A leaked State Department memo drafted for Secretary of State Marco Rubio captured the logic of American global health policy in a single sentence: “We will only secure our priorities by demonstrating willingness to publicly take support away from Zambia on a massive scale.” That sentence, directed at a country where 1.3 million people rely on daily HIV treatment provided through PEPFAR, is the clearest window into what Washington now calls its “America First Global Health Strategy” — a framework that is rapidly replacing decades of need-based health assistance with a transactional model built around minerals, data, and geopolitical leverage.
Data or mineral demands in return for health aid are unprecedented in the history of the US, which is Africa’s largest health assistance provider. The shift began quietly. African countries received $5.4 billion in US assistance in 2024, spent largely on humanitarian, health, and disaster needs. When Trump’s administration abruptly cut funding in January 2025 and dismantled USAID, the impact reverberated around Africa and the globe. In its place, Washington began negotiating individual bilateral agreements, country by country, with terms that critics say go well beyond public health.
Minerals for Medicine
The Zambia case is the starkest example of how these negotiations have played out. The five-year deal with Zambia, intended to combat HIV/AIDS and malaria, stalled after the US linked funding to a “bilateral compact” involving copper and cobalt access. Unlike other agreements limited to health funding, the US used the Zambia deal to address what it sees as China’s unfettered access to the country’s mineral wealth. Zambia is one of the world’s major copper producers and also has huge reserves of lithium and cobalt, all key in the green energy transition.
The financial offer under discussion is lower than previous support. The United States proposed $320 million for all health programmes in Zambia in 2026, compared with $367 million provided last year for HIV programmes alone. Furthermore, the proposed budget is structured to systematically decline with each subsequent year. That is the economic architecture of the deal: less money, declining further over time, in exchange for mineral access and a growing list of other concessions.
The strategic rationale is not hidden. The America First Global Health Strategy document frames US health assistance in Africa as a counterbalance to China’s footprint in the region. Washington’s intent to strengthen its partnerships with mineral-rich African countries demonstrates its effort to diversify supply chains and reduce dependency on China for critical minerals. Africa holds approximately 30 percent of global critical mineral deposits, making it a site of geopolitical rivalry between the US and China.
The Data Problem
Alongside mineral access, the agreements carry a second and equally contested demand: health data. Washington negotiators have demanded 10 years of access to Zambian health and genetic data, while only offering five years of funding in return. This disparity has raised alarms about the exploitation of sensitive information, which is highly valuable for pharmaceutical companies developing new drugs. Any medications or vaccines developed using this data would not guarantee Zambia a share of the resulting profit.
The data question has now derailed multiple deals. Zimbabwe walked away from a $367 million agreement over clauses requiring rapid sharing of pathogen and outbreak data without clear guarantees on how that information would be used or what Zimbabwe would gain in return. Officials described it as an “unequal exchange,” reflecting distrust shaped by the COVID era. Ghana declined a bilateral health agreement after rejecting terms requiring the sharing of sensitive health data, before an April 24 deadline. The proposed agreement would have provided $109 million in US health support over five years. In Kenya, a health cooperation framework worth more than $1.6 billion was partially suspended by the High Court. The case centers on how citizens’ health data would be transferred and managed, and in a country where digital rights are fiercely debated, the scale of the agreement made the questions even more politically charged.
Researchers have flagged a dimension to the data demand that goes beyond conventional pharmaceutical development. Health data at scale can now be used to train AI health models potentially generating enormous commercial value entirely outside the countries that provided the underlying information. The specimen-sharing agreement reportedly requires countries to share physical pathogen specimens and genetic sequence data within five days of detection — a provision that has drawn particular concern from African governments still negotiating the terms of global pathogen access frameworks.
Who Wins, Who Loses
Analysis by the Center for Global Development suggests signed agreements represent, on average, roughly a 49 percent drop in annual US support compared with 2024 levels, with countries expected to fill the gap within five years. For governments already grappling with debt stress and tighter fiscal space, that is a steep and compressed adjustment. The deals are framed as promoting “national ownership” — the idea that African governments should take over their own health programs. The concept has genuine merit in the abstract. Aid dependency has long distorted health priorities and created parallel systems that work around rather than through national health ministries.
But the strategy replaces multilateral funding flows with bilateral agreements tied to performance benchmarks, data sharing, and co-financing requirements. This is not a technical strategy — it is a political one. The plan reframes US health assistance from a global public good to a strategic asset deployed in pursuit of national advantage.
The consequences are already measurable. Shocks from the aid cuts have led to 518,428 child and 263,915 adult deaths from manageable diseases like HIV and tuberculosis. Close to 10 million new cases of malaria were also reported. In the Democratic Republic of Congo, US support for the Ebola response dropped from $1.4 billion in 2024 to $21 million for the current fiscal year, a figure health workers say is wholly inadequate for an outbreak that has already produced hundreds of suspected cases.
Africa CDC Director-General Jean Kaseya unveiled the Africa Health Security and Sovereignty Agenda in November 2025, describing it as “non-negotiable.” Two months later, his institution was watching 18 member states sign agreements that contradict that agenda. When the US offered Africa CDC an observer role in the bilateral negotiations, Kaseya declined. That refusal says something important: the body charged with African health coordination has effectively been sidelined from negotiations that will shape public health across the continent for the next decade.
In a break with precedent, the administration has refused to disclose the full terms of the agreements publicly. The veil of secrecy has frustrated partner countries and angered transparency advocates, who worry that billions of dollars in US funding is being leveraged as Washington seeks controversial concessions on unrelated policies. For countries that sign, the arrangement comes with a structural vulnerability: a strategy meant to promote ownership could end up functioning as leverage.
Original analysis inspired by Matt Field from Bulletin of the Atomic Scientists. Additional research and verification conducted through multiple sources.
