As many of my colleagues have expressed in their blog posts over the past week, there is a great deal of uncertainty about what a Trump administration will ultimately mean for health. Perhaps nowhere is this uncertainty more acute than in the realm of U.S. foreign aid and health.

What hangs in the balance has enormous consequences globally. Nearly 40% of the budgets for the World Food Programme and the United Nations High Commissioner for Refugees, comes from the United States. These agencies are responsible for feeding and assisting millions of the most vulnerable people in the world and are already significantly underfunded for the scope of the issues that they are trying to address. The U.S. is also the biggest donor of emergency aid and conventional foreign aid- two areas where funding has direct links to individual, population and global health outcomes.

No one knows what the Trump administration will do with existing foreign aid programs and other international initiatives targeted towards promoting health around the globe. Mr. Trump himself chose not to speak much about foreign aid on the campaign trail and with no public service record to examine, we are left with only a few sound bites to guide expectations about what might eventuate. We do not yet know who will fill critical leadership jobs such as Secretary of State, head of USAID or PEPFAR- choices that will be critical in setting the tone of the administration towards global development and health, particularly after several top Republicans in the foreign intelligence space vowed not to work under a Trump administration.

We know that Mr. Trump’s campaign was built on an ‘America first’ principle and so it is highly likely that he would not see foreign aid as an issue of global cooperation and interconnected outcomes, but instead through a nationalist lense that would be based more on what kind of ‘deal’ he saw for the U.S. He has said that he was in favor of providing aid, based on how friendly the particular country was to the U.S. and how much of security risk to the U.S. failure to provide the aid would become. The obvious problem with looking at foreign assistance and development for health through this frame is that it ignores the interconnectedness of global health outcomes. Diseases do not stop at borders and are not held back by walls. Nor does it take into account the deep value that foreign aid provides in building successful partnerships between nations.

With generally bipartisan Congressional support for foreign aid and the relatively small percentage of the overall budget that foreign aid makes up, it is possible that funding amounts will not shift a great deal. However, Trump and the Republican Congress he will be working with, have said that they want to increase military spending without increasing the overall budget which means that cuts have to come from somewhere. Even if the funding does not shift significantly, the values and tone with which it is provided will be important. Aid for health and development agencies is critical and and failure to recognize the responsibility that the U.S. holds as a leader in setting the agenda for global health and development would be a detriment to us all.