This article was written by Kathya Acuña Luna, a student in Gavin Yamey’s Geneva-based summer course in global health policy. Kathya is a biomedical engineer with an additional MSc in AI, currently completing her second MSc in Global Health at the University of Geneva. Her main interests surround the development and application of technology for the improvement of healthcare access for the most vulnerable populations, addressing critical inequalities in health.
A central pillar of the America First Global Health Strategy, released on September 18 2025, is bilateral agreements between the United States (US) and countries that receive US health aid. As of July 1 2026, 34 countries had signed such agreements, of which 25 are in Africa.
Human Rights Watch has assessed seven of the bilateral agreements with African countries, specifically Ethiopia, Kenya, Mozambique, Nigeria, Rwanda, Liberia, and Uganda. The results of this analysis are deeply concerning—they show that the US government is making lifesaving health assistance conditional upon “surveillance data and extractive rights to pathogen samples and data for pharmaceutical development.” Patients’ data can be shared with US pharmaceutical companies even without patient consent. In some cases, these agreements also include recipient countries accepting random inspections to ensure compliance with the Helms Amendment, which bans foreign assistance for abortion services. Given the recent devastating cuts towards US assistance, African governments are now being pressured to accept agreements even when these agreements have the potential to endanger their population’s health and human rights.
Another key risk arising from these bilateral treaties is their potential negative impact on the continuous negotiation of the terms of the pathogen access and benefit sharing (PABS) annex of the WHO’s Pandemic Agreement. As Li and colleagues note, the PABS system “aims to promote timely sharing of pathogen materials and sequence information with pandemic potential while ensuring fair and equitable benefit-sharing.” In other words, countries would agree to share pathogens provided they gain access to pandemic vaccines, treatments, and diagnostics that are developed based on pathogen data. By shifting the power balance away from vulnerable countries and towards the US, the US bilateral agreements undermine equity demands and chip away at the collective bargaining power of nations from the Global South.
Of the 34 bilateral agreements that have been signed, only a handful have been publicly posted in full. Disclosure of international agreements is required by US law under the Case-Zablocki Act. Yet even those that were previously available were removed from government websites days after the media reported that the US had conditioned its health assistance to Zambia upon being granted access to Zambia’s minerals. This episode illustrates the importance of rigorous investigative global health journalism in exposing and highlighting issues that should spark international concern.
Several African governments have opposed these bilateral extractive agreements. Zambia rejected the deal, in opposition to the US demand for mineral rights, and, as Yamey notes, “Ghana and Zimbabwe rejected similar deals that would have given these nations health aid in exchange for access to their sensitive health data.” As Human Rights Watch notes, civil society organizations played an important role in opposing these agreements. Civil society is playing an increasingly important role in the face of growing external political pressures, acting as a countervailing force to protect the interests of those most in need.
Last year, the Wellcome Trust funded five regional dialogues on the future of global health, summarized in the report From rethinking to reform: the way forward for the global health system. The report identifies three main areas that need urgent reform, and that are under threat from US extractive bilateralism:
- The acceleration of regionalization and national accountability, empowering nations to be in control of their health priorities and health systems.
- Enabling national transition away from external financial support towards domestic health financing and addressing internal and external barriers to health investment.
- Data sovereignty and tech capacity, which remain central to these conversations.
There are more questions than answers in our path to navigate these complicated and rapidly changing times. The importance of transitioning to more equitable systems and the urgency with which we need to respond to current events such as this one make it imperative that we ask ourselves:
- How can we support Global South countries’ efforts to build capacity and leverage fast?
- In the meantime, what roles can international law, civil society and media play in supporting efforts to defend data sovereignty and protect privacy rights?