US new playbook for global health: balancing national interest and global responsibility

The recently unveiled America First Global Health Strategy represents a fundamental reorientation of US engagement in global health, framed as a 'new playbook' designed to safeguard US lives, prosperity and influence. Built around pillars of security, sovereignty and economic self-interest, the strategy emphasises bilateral agreements, co-investment and the global promotion of US health innovation. While positioned as a corrective to inefficiency and dependency in past aid programmes, this shift raises profound questions about equity, solidarity and the future of multilateralism in health governance. This analysis critically examines the implications of the US first approach through four inter-related lenses. First, the strategy's security-first framing risks privileging outbreak containment over collaboration, potentially reinforcing a fortress mentality rather than fostering collective preparedness. Second, its critique of 'dependency' obscures the documented contributions of US programmes such as the President's Emergency Plan for AIDS Relief and the President's Malaria Initiative to health system strengthening, raising concerns that abrupt transitions could dismantle fragile gains. Third, the prioritisation of US innovation in commodity procurement highlights tensions between economic diplomacy and moral legitimacy, with the risk of crowding out local innovation ecosystems. Finally, the privileging of bilateralism over multilateralism may deliver short-term accountability but risks fragmenting global health coordination and undermining shared responsibility. At its core, global health security is indivisible; no nation can insulate itself indefinitely from cross-border threats. A strategy that prioritises national interests while relegating equity to the margins risks eroding US credibility and weakening global solidarity. We argue that only by integrating equity, reciprocity and multilateral collaboration into its 'new playbook' can the US safeguard both its own people and global health security.