US Exits WHO Again Leaving $278 Million Unpaid Tab

Abstract

On January 22, 2026, the global health architecture underwent its most significant structural rupture since the end of the Second World War. The United States of America, historically the principal architect and financier of the World Health Organization (WHO), formally finalized its withdrawal from the agency.¹ This event, precipitated by Executive Order 14292 signed by President Donald Trump on January 20, 2025, concluded a mandatory one-year notification period but left unresolved a contentious dispute over financial arrears totaling approximately $278 million.¹

The withdrawal marks the culmination of a deteriorating relationship between Washington and Geneva, driven by divergent views on sovereignty, multilateral efficacy, and the geopolitical influence of the People's Republic of China. The immediate consequences are financial and legal: the United States has ceased all funding, triggering a liquidity crisis at the WHO, while simultaneously asserting a counterclaim that the agency's alleged mismanagement of the COVID-19 pandemic caused economic damages to the U.S. far exceeding its treaty obligations.¹

However, the secondary and tertiary effects of this schism are far more profound. The United States has not retreated into isolationism but has instead launched the "America First Global Health Strategy," a bilateral framework that seeks to replicate global health security functions through direct government-to-government agreements. This has led to the signing of multi-billion dollar Memorandums of Understanding (MOUs) with nations such as Nigeria, Kenya, and Uganda, which condition health aid on the rapid sharing of pathogen data directly with U.S. agencies, bypassing the WHO’s multilateral mechanisms.⁵

Concurrently, the WHO has pivoted toward new patrons, securing a historic $500 million pledge from China and adopting a new Pandemic Agreement in May 2025 that the United States rejected.⁷ This has effectively bifurcated the world into two competing spheres of health governance: a "Geneva System" rooted in multilateral benefit-sharing and UN normative frameworks, and a "Washington System" based on transactional bilateralism and strict biosecurity surveillance.

This report offers an exhaustive analysis of the withdrawal's legal mechanics, the status of unpaid debts, the operationalization of the new U.S. strategy, and the technical degradation of critical global systems, particularly the Global Influenza Surveillance and Response System (GISRS) and the Global Polio Eradication Initiative (GPEI).

1. The Legal and Constitutional Crisis of Withdrawal from the WHO

The departure of the United States from the WHO is not a simple administrative termination of membership; it is a complex legal maneuver that has exposed deep fissures in the interface between U.S. domestic law and international treaty obligations. The validity of the withdrawal remains a subject of intense debate among legal scholars, diplomats, and public health officials, hinging on the interpretation of the 1948 legislation that originally authorized U.S. participation.

1.1 The 1948 Joint Resolution: A Conditional Entry

Unlike most member states that joined the WHO through standard treaty ratification, the United States entered the organization via a specific legislative act: the Joint Resolution of June 14, 1948 (Public Law 80-643). This resolution, signed by President Harry S. Truman, was unique in that it attached unilateral reservations to U.S. membership—reservations that were accepted by the World Health Assembly at the time, albeit with some diplomatic hesitation.⁹

The 1948 Joint Resolution explicitly reserved the right of the United States to withdraw from the organization, a provision that does not exist in the WHO Constitution for other members. However, Congress placed two binding statutory conditions on this right:

1. Notice Period: The United States must provide a one-year notice of its intention to withdraw.

2. Financial Satisfaction: The United States must meet its financial obligations to the Organization in full for the current fiscal year.¹¹

Section 4 of the Resolution states: "In adopting this joint resolution the Congress does so with the understanding that... the United States reserves its right to withdraw from the Organization on a one-year notice: Provided, however, That the financial obligations of the United States to the Organization shall be met in full for the Organization's current fiscal year".¹¹

1.2 The Conflict of Executive Authority and Statutory Law

The conflict arises from the Trump administration's execution of the withdrawal. On January 20, 2025, President Trump signed an Executive Order initiating the withdrawal and explicitly pausing all future transfers of funds.¹ This action satisfied the first condition (notice) but flagrantly violated the second (payment).

The administration's legal argument relies on the President's plenary powers in foreign affairs under Article II of the Constitution. Executive branch lawyers have argued that the President has the authority to terminate treaty participation and that the 1948 legislative conditions cannot unconstitutionally constrain this power. Furthermore, the State Department has framed the refusal to pay as a strategic counterclaim. By asserting that the WHO's "failure" cost the U.S. economy trillions, the administration effectively argues that the debt is nullified by the damages incurred—a legal theory of "set-off" that is recognized in some contract law but has scant precedent in public international law regarding treaty dues.¹

Critics, including the Infectious Diseases Society of America (IDSA) and various legal scholars, argue that because U.S. membership was established by a congressional statute, it can only be terminated in compliance with that statute. They contend that the failure to pay the arrears renders the withdrawal legally ineffective under U.S. law. In Goldwater v. Carter (1979), the Supreme Court dismissed a challenge to treaty termination as a non-justiciable political question, but the specific statutory conditions of the 1948 Resolution distinguish the WHO case from standard treaty terminations.¹³

1.3 The International Legal Void

Internationally, the situation is equally ambiguous. The WHO Constitution lacks a withdrawal clause for any member other than the U.S. (via its accepted reservation). Therefore, the process is governed by the terms of the U.S. acceptance instrument.

WHO Legal Officer Steven Solomon has stated that the Organization considers the withdrawal effective as of January 22, 2026, simply because the WHO lacks the enforcement power to compel a sovereign state to remain against its will.¹ However, the consequences of the unpaid debt remain an open legal question for the World Health Assembly. The WHA must decide whether to treat the U.S. as a "non-member with arrears" or to refuse to recognize the withdrawal until the debt is paid—a symbolic move with little practical leverage.

As of January 2026, the United States is functionally out of the organization. U.S. personnel have been recalled, access to WHO internal systems has been terminated, and the U.S. seat on the Executive Board is vacant.¹⁴ The legal dispute has effectively shifted from "Can the U.S. leave?" to "What are the consequences of leaving with unpaid bills?"

2. The Financial Balance Sheet: Debt, Default, and Reparations

The financial implications of the withdrawal are immediate and severe. The United States was not only the largest contributor to the WHO but also the backbone of its emergency contingency funds. The cessation of payments has created a liquidity crisis in Geneva and a balance sheet dispute that may take decades to resolve.

2.1 The Anatomy of the Arrears

As of the withdrawal date, the United States owes the WHO approximately $278 million in assessed contributions. This figure is composed of unpaid dues for the 2024 and 2025 fiscal years.¹

Table 1: Detailed Breakdown of U.S. Financial Arrears to WHO (As of Jan 2026)

Obligation Type	Fiscal Year	Estimated Amount (USD)	Status	Statutory Basis
Assessed Contribution	2024	$129,886,000	Unpaid	Treaty Obligation / P.L. 80-643
Assessed Contribution	2025	$148,000,000	Unpaid	Treaty Obligation / P.L. 80-643
Voluntary Commitments	2024-2025	~$490,000,000	Cancelled	Discretionary Grants
Total Legal Arrears	2024-2026	~$277,886,000	Outstanding	Assessed Dues Only

Source Data:.¹ Note: Amounts are subject to exchange rate fluctuations between USD and CHF.

It is vital to distinguish between assessed and voluntary contributions. Assessed contributions are mandatory dues required for membership, calculated based on a nation's GDP and population. These are legally binding debts under international law. Voluntary contributions, which often comprised 70-80% of total U.S. funding, are discretionary. While the cancellation of voluntary funds (roughly $490 million pledged for 2024-2025) represents a massive operational loss for programs like polio and HIV, it does not constitute a legal debt in the same manner as the assessed contributions.¹⁵

2.2 The "Damages" Counter-Argument

The Trump administration has justified the non-payment of dues by invoking a concept of economic reparations. In statements to the press and in the Executive Order itself, the administration claims that the WHO's "mishandling" of the COVID-19 pandemic—specifically its alleged delay in declaring a Public Health Emergency of International Concern (PHEIC) and its praise of China's early transparency—facilitated the global spread of the virus.

The State Department spokesperson cited an economic impact figure: "The WHO's failure... cost the U.S. Economy between $14 [trillion] and $16 trillion dollars... This economic hit is beyond a down payment on any financial obligations to the organization".¹ This argument attempts to reframe the arrears not as a default, but as a withholding of damages.

Legally, this position is tenuous. The WHO Constitution includes provisions for dispute resolution (referral to the International Court of Justice), but it does not include a mechanism for member states to unilaterally deduct "damages" from their assessed contributions. Furthermore, the WHO generally enjoys immunity from suit in domestic courts, preventing the U.S. from obtaining a judicial judgment to validate this counterclaim.¹⁷ Nevertheless, politically, this argument provides the domestic cover for the executive branch to ignore the 1948 Joint Resolution's payment requirement.

2.3 The UNESCO Precedent

The current situation finds a historical echo in the U.S. relationship with UNESCO (United Nations Educational, Scientific and Cultural Organization). The U.S. withdrew from UNESCO in 1984 under President Reagan, rejoined in 2003, stopped paying dues in 2011 (following the admission of Palestine), and withdrew again in 2017/2018 under President Trump.¹⁸

When the U.S. stopped paying UNESCO dues in 2011, it accrued arrears exceeding $600 million by the time of its 2018 withdrawal. Crucially, two years after ceasing payments, the U.S. lost its voting rights in the UNESCO General Conference under Article 19 of the organization's constitution.²⁰ The debt remained on UNESCO's books even after the U.S. left.

The WHO scenario is likely to follow this trajectory. The $278 million will remain as a recognized debt by the WHO. Should a future U.S. administration seek to rejoin the organization—as happened with UNESCO in 2003—the repayment of these arrears would likely be a precondition for the restoration of voting rights. Thus, the debt creates a long-term diplomatic barrier to re-entry, effectively locking the U.S. out of the organization for the foreseeable future unless a specific debt forgiveness deal is negotiated, which is politically unlikely given the stance of other major powers like China.

3. The "America First Global Health Strategy": Structure and Implementation

The withdrawal from the WHO is often mischaracterized as a retreat from global health. In reality, it represents a strategic restructuring—a shift from multilateral cooperation to bilateral influence. This pivot is codified in the "America First Global Health Strategy," a comprehensive policy framework released by the U.S. Department of State in September 2025.⁶

3.1 Strategic Pillars and Objectives

The strategy document explicitly critiques the UN-centric model as inefficient, bureaucratic, and vulnerable to hostile political influence. Instead, it proposes a model of direct government-to-government engagement designed to serve U.S. national interests first. The strategy is built upon three core pillars:

1. Making America Safer: The primary goal is biosecurity—preventing outbreaks from reaching U.S. soil. This prioritizes surveillance and intelligence gathering over general health system strengthening.⁶

2. Making America Stronger: Health aid is utilized as a diplomatic tool to strengthen bilateral alliances, securing loyalty and influence in key geopolitical regions, particularly Africa and the Indo-Pacific.⁶

3. Making America More Prosperous: The strategy explicitly links health aid to the U.S. economy, promoting the purchase of U.S.-manufactured commodities and protecting supply chains for critical medical goods.²¹

3.2 The Bilateral Memorandums of Understanding (MOUs)

The operational engine of this strategy is a new instrument: the Bilateral Agreement on Global Health Cooperation. These are five-year binding MOUs (2026-2030) signed directly between the U.S. government and partner nations. They replace the flexible, grant-based funding of the past with strict contractual terms.

As of January 2026, the United States has signed these MOUs with at least 14 nations, primarily in Sub-Saharan Africa. The scale of funding committed is immense, designed to offset the loss of multilateral funds and cement U.S. influence.

Table 2: Key U.S. Bilateral Health MOUs (2026-2030)

Partner Nation	Total MOU Value (5 Years)	U.S. Contribution	Partner Co-Investment	Key Strategic Focus Areas
Nigeria	$5.1 Billion	$2.1 Billion	High (Graduated)	HIV/AIDS (PEPFAR transition), Biosecurity
Kenya	$2.5 Billion	$1.6 Billion	~$1.0 Billion	EMR Systems, Real-time Surveillance
Uganda	$2.3 Billion	$1.7 Billion	$577 Million	Workforce, Supply Chain Integration
Mozambique	$1.8 Billion	High %	High Dependency	Malaria, TB, Commodity Security
Ethiopia	$1.5 Billion	High %	Variable	Emergency Response, Border Health
Rwanda	$228 Million	$158 Million	Moderate	Laboratory Systems, Data Sharing

Source Data: ⁵

3.3 The "Pathogen for Aid" Conditionality

The most controversial aspect of these MOUs is the strict conditionality regarding biological data. Under the "Making America Safer" pillar, the U.S. demands what critics have termed a "Pathogen for Aid" exchange.

The MOU templates include clauses requiring partner nations to share biological specimens and genetic sequence data of "pathogens with epidemic potential" directly with U.S. agencies (such as the CDC or DoD research entities) within strict timelines—often as short as five days from detection.²⁵

This requirement fundamentally conflicts with the multilateral approach. Under the WHO's new Pandemic Agreement and the existing Pandemic Influenza Preparedness (PIP) Framework, pathogen sharing is linked to Benefit Sharing—the guarantee that countries sharing data will receive access to vaccines and diagnostics developed from that data. The U.S. bilateral MOUs sever this link. They demand the data as a condition for receiving HIV and Malaria aid (medicines that keep millions alive today), but they offer no binding guarantees that the partner nations will receive priority access to future pandemic vaccines developed using their data.²⁵

3.4 Legal Conflicts: The Nagoya Protocol and Data Sovereignty

This bilateral approach has collided with international law, specifically the Nagoya Protocol on Access to Genetic Resources and the Fair and Equitable Sharing of Benefits. Many of the African nations signing these MOUs are parties to the Nagoya Protocol, which mandates that they assert sovereign rights over their genetic resources (including pathogens) and negotiate fair benefit-sharing agreements before transfer.²⁸

By signing U.S. MOUs that mandate unconditional rapid sharing, these nations risk violating their own domestic laws derived from the Nagoya Protocol. This tension has already erupted in legal challenges. In Kenya, the High Court issued an interim order in late 2025 halting the implementation of the data-sharing components of the U.S. MOU, citing constitutional privacy concerns and the lack of parliamentary oversight regarding data sovereignty.²⁴ This legal backlash suggests that the "America First" strategy may face significant implementation hurdles as civil society and judiciaries in partner nations resist the "extractionist" nature of the data clauses.

4. The Geopolitical Vacuum and China's Ascendance

The withdrawal of the United States has created a massive geopolitical vacuum at the heart of global health governance. Predictably, this void is being filled by the People's Republic of China, which has moved aggressively to position itself as the new guarantor of the WHO and the defender of multilateralism.

4.1 The 78th World Health Assembly: A Turning Point

The 78th World Health Assembly (WHA), held in Geneva in May 2025, was the first in the organization's history where the United States was effectively absent from the negotiating table. While low-level observers were present, the U.S. delegation did not participate in voting or consensus-building, having already submitted its withdrawal notice.⁷

This absence allowed China to dominate the proceedings. Vice Premier Liu Guozhong utilized the platform to articulate a vision of "global health security through multilateralism," explicitly contrasting China's approach with the "unilateralism and power politics" of the United States.⁷

4.2 China's Strategic Financial Pledge

At the assembly, China announced a pledge of $500 million in voluntary contributions over the next five years (2026-2030).⁷ While this amount is less than the historical contributions of the United States (which often exceeded $800 million annually), its strategic value is maximized by the current crisis.

The pledge is structured to support:

• The WHO Contingency Fund for Emergencies: Filling the gap left by the U.S. in rapid response financing.

• Infrastructure in the Global South: Building Africa CDC capacities and health systems that are interoperable with Chinese standards.

• The "Health Silk Road": Integrating health aid with the broader Belt and Road Initiative (BRI).

Additionally, the WHA approved a 20% increase in assessed contributions for all member states.⁷ China, whose assessed contribution has risen significantly due to its GDP growth, accepted this increase, further cementing its status as the financial pillar of the organization. By 2026, China's assessed contribution is projected to reach approximately $137 million, nearing the level of the former U.S. assessment ($155 million).¹⁶

4.3 Two Systems of Global Health

The result of these shifts is the emergence of two parallel and competing systems of global health governance:

1. The Geneva System: Led by the WHO, financially underwritten by China and the European Union, and legally grounded in the Pandemic Agreement and the Nagoya Protocol. It emphasizes multilateralism, benefit-sharing, and the UN system.

2. The Washington System: Led by the U.S. State Department, operationalized through bilateral MOUs and the "America First" strategy. It emphasizes biosecurity intelligence, transactional aid, and direct U.S. control over supply chains.

Countries in the Global South are increasingly forced to navigate between these two systems, creating a fragmented landscape where data sharing, standard-setting, and emergency response are no longer universal but contingent on geopolitical alignment.

5. Technical Disintegration: GISRS and the Future of Influenza

While the political and financial ramifications of the withdrawal are widely discussed, the most dangerous immediate consequence is the technical degradation of the Global Influenza Surveillance and Response System (GISRS). This network, established in 1952, is the world's primary defense against influenza pandemics and the mechanism by which annual flu vaccines are formulated.

5.1 The Architecture of GISRS

GISRS functions as a global pyramid of surveillance. At the base are 152 National Influenza Centers (NICs) in 129 countries, which collect clinical virus samples from patients. These NICs ship representative virus samples to one of seven WHO Collaborating Centers (CCs) for advanced genetic and antigenic characterization.³¹

The U.S. Centers for Disease Control and Prevention (CDC) in Atlanta is one of these seven CCs and has historically been the "heavy lifter" of the network, processing the largest volume of samples and providing the most advanced reference reagents.³¹

5.2 The "Blinding" of the Network

The U.S. withdrawal fundamentally breaks the legal and operational links between the CDC and the GISRS network.

• Status of CDC: The Executive Order of Jan 20, 2025, mandates the recall of U.S. personnel and resources from WHO activities. This ostensibly prevents the CDC from functioning officially as a WHO Collaborating Center.¹

• Sample Flow Disruption: The transfer of virus samples from NICs to CCs is governed by the Standard Material Transfer Agreement (SMTA) under the Pandemic Influenza Preparedness (PIP) Framework. As a non-member, the U.S. is no longer a party to the PIP Framework. This creates legal uncertainty: can a NIC in Vietnam or Brazil legally ship a potential pandemic H5N1 sample to the CDC in Atlanta? Under the Nagoya Protocol, many countries may be legally barred from exporting genetic resources to a non-party state that does not guarantee benefit-sharing.²⁸

5.3 Consequences for Vaccine Security

The implications for public health are stark:

1. Blind Spots for the U.S.: Without access to the global flow of samples from the GISRS network, the U.S. loses its "radar" for detecting emerging flu strains in Asia, Africa, and South America. This increases the risk that the domestic U.S. flu vaccine will be mismatched to the circulating global strains, potentially leading to thousands of excess deaths in a severe flu season.³³

2. Degradation of Global Response: Conversely, the global system loses the CDC’s massive sequencing capacity. While other centers in London (Crick Institute), Melbourne (Doherty Institute), and Beijing (cnic) remain active, the sheer volume of data processing provided by the CDC is difficult to replace instantly.

3. Reliance on China: The vacuum inevitably forces the WHO to rely more heavily on the Chinese National Influenza Center in Beijing for data from Asia—a reliance that U.S. intelligence agencies have warned could be vulnerable to political censorship or delay.³⁵

The U.S. hopes to mitigate this through its bilateral MOUs (the "Pathogen for Aid" clauses), but building a parallel surveillance network from scratch is a slow and redundant process compared to the established efficiency of GISRS.

6. The Polio Endgame and Humanitarian Consequences

The Global Polio Eradication Initiative (GPEI) faces an existential threat from the U.S. withdrawal. The United States has historically been the GPEI's largest donor, contributing over $11 billion since 1988.³⁶

6.1 The Financial Cliff

The withdrawal creates a catastrophic funding gap. In 2023 alone, the U.S. contributed over $200 million to polio eradication. The cessation of these funds creates a hole in the budget that endangers operations in the final two endemic countries: Afghanistan and Pakistan.³⁸ Unlike other health programs, polio eradication requires continuous, high-intensity operations (vaccination campaigns, environmental surveillance). A pause in funding does not just pause progress; it allows the virus to resurge.

6.2 Operational Paralysis in Endemic Zones

The "America First" strategy of bilateral aid is particularly ill-suited for polio eradication in hostile environments.

• Afghanistan: The U.S. has no diplomatic relations with the Taliban government. It cannot sign a bilateral health MOU to fund vaccinators. The WHO, as a neutral UN agency, was the only mechanism through which U.S. funds could reach the ground. By cutting off the WHO, the U.S. effectively cuts off its ability to fight polio in its primary reservoir.

• Pakistan: While the U.S. has relations with Pakistan, the bilateralization of aid politicizes the vaccination effort. In the past, the CIA's use of a vaccination drive to hunt Osama bin Laden caused a decade of setbacks for polio eradication. Replacing WHO-branded neutral campaigns with U.S.-branded bilateral campaigns risks inciting renewed violence against health workers.³⁹

The likely outcome is a resurgence of wild poliovirus in 2026-2027, with high risks of international spread to neighboring countries, undoing decades of investment.

7. The Pandemic Agreement: Governance in a Fragmented World

In May 2025, the World Health Assembly adopted the WHO Pandemic Agreement, a landmark treaty designed to correct the inequities of the COVID-19 response. The agreement institutes a permanent Pathogen Access and Benefit-Sharing (PABS) system.⁸

7.1 The PABS System vs. U.S. Isolation

The PABS system represents a "grand bargain": countries agree to share pathogen data rapidly in exchange for legally binding guarantees that they will receive a percentage of vaccines and diagnostics produced during a pandemic.

The United States, having withdrawn, is not a party to this agreement. This creates a dangerous legal bifurcation during a future pandemic:

• Scenario: A novel coronavirus emerges in a Central African nation.

• The Conflict: Under the WHO Pandemic Agreement, that nation is obligated to share the virus with the WHO PABS system. However, under its bilateral MOU with the United States, it is obligated to share the virus with the CDC within 5 days.

• The Risk: If sharing with the U.S. (a non-party) violates the exclusivity or benefit-sharing terms of the WHO system, the country faces a legal dilemma. Worse, if the U.S. develops a vaccine from that sample but refuses to share it equitably (following "America First" principles), it validates the worst fears of the Global South—that bilateral deals are predatory.

The U.S. withdrawal effectively sabotages the universality of the PABS system, ensuring that the next pandemic will be fought not by a united world, but by competing blocs hoarding data and countermeasures.

8. Domestic Legislation and Institutional Lock-in

The withdrawal is not just an executive action; it is being cemented by domestic legislation that makes a future reversal difficult.

8.1 The Consolidated Appropriations Act, 2026

Passed in January 2026, the Consolidated Appropriations Act, 2026 fundamentally restructures U.S. global health financing.⁴¹

• Account Shifting: Funds that were previously appropriated to the "Contributions to International Organizations" (CIO) account for WHO assessed dues have been zeroed out.

• New Bilateral Lines: New budget lines have been created for "Bilateral Global Health Security" within the State Department and USAID budgets. These funds are legally ring-fenced for the bilateral MOUs, meaning they cannot simply be redirected back to the WHO by a future administration without new legislation.⁴³

8.2 The BIOSECURE Act

Included in the National Defense Authorization Act for 2026, the BIOSECURE Act imposes strict limits on U.S. entities collaborating with "biotechnology companies of concern" (primarily Chinese firms like BGI).⁴⁴ This act complicates any potential U.S. re-engagement with WHO scientific committees, as many WHO reference labs now utilize Chinese sequencing technology. U.S. scientists at universities receiving federal funding may be legally barred from participating in WHO technical groups where data is processed on restricted Chinese platforms, further isolating the U.S. scientific community from global discourse.

9. Conclusion

The withdrawal of the United States from the World Health Organization is a watershed moment that signifies the end of the post-WWII consensus on global health governance. It is not merely a diplomatic dispute over unpaid dues ($278 million) but a fundamental structural shift toward a multipolar, fragmented world.

The United States has traded the "inefficiency" of multilateralism for the "control" of bilateralism. Through the America First Global Health Strategy and its network of pathogen-sharing MOUs, Washington seeks to build a surveillance fortress that serves its national interests directly. However, this comes at a steep price: the degradation of the global flu surveillance network (GISRS), the destabilization of polio eradication efforts, and the cession of normative leadership in Geneva to Beijing.

For the rest of the world, the "Geneva System" endures, backed by Chinese finance and European diplomacy, but it is weaker and less capable without American science and logistical power. The world is now divided into two biosecurity regimes. In the event of a future pandemic, this fracture—characterized by legal conflicts over data ownership, incompatible surveillance systems, and geopolitical rivalry—may prove to be the virus's greatest advantage. The "Great Fracture" of 2026 has not made the world safer; it has made it more divided in the face of threats that know no borders.

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