ON July 6, 2020, at the height of the Covid-19 pandemic, the Trump administration sent a letter to the UN secretary general, communicating America`s intent to withdraw from the World Health Organisation (WHO). It takes one year for a member state to completely withdraw from a UN organisation. So, it was a miscalculation.

On Jan 20, 2021, Donald Trump`s term ended and the withdrawal process could not be completed. The same month, in one of his very first acts as president, Joe Biden retracted the letter.

Now Trump has again pulled the plug. This time, he has four years ahead of him.

It is like ending an old marriage. The US was one of the 61 founding members of the WHO. A conference was held in New York in June-July 1946 to establish an international health organisation. The constitution of the WHO came into force on April 7, 1948. The day is celebrated annually as World Health Day. The US became a member of the WHO through an act of the US Congress.

Trump`s executive order gives three reasons for the exit: `The organisation`s mishandling of the Covid-19 pandemic that arose out of Wuhan, China, and other global health crises, its failure to adopt urgently needed reforms, and its inability to demonstrate independence from the inappropriate political influence of WHO member states.

In addition, the WHO continues to demand unfairly onerous payments from the United States, far out of proportion with other countries` assessed payments.` It names China as an example of the last point, saying it has `a population of 1.4 billion, has 300 per cent of the population of the US, yet contributes nearly 90pc less to the WHO`.

Regarding the first point about mishandling the pandemic, never in the history of public health has a global pandemic been responded to like Covid-19 was. The WHO was the lead agency in coordinating the global response. On the second point, the WHO has never introduced more reforms in its operations than during the two terms of the current director general, Dr Tedros Adhanom Ghebreyesus. Are these enough? No. More reforms are needed andit is up to the member states to shape the improvements. The US as the most influential member by virtue of its financial contributions has the highest responsibility in this regard.

The third point, about the WHO`s inability to be independent of the inappropriate political influence of WHO member states, is amusing. Those who have attended the World Health Assemblies (I have attended 11 in various capacities, including as a minister) know well who exerts political influence at these forums.

Lastly, on the issue of payments, indeed the US is the WHO`s largest donor. The WHO survives on the contributions of its members. These include: assessed contributions and voluntary contributions. The former are in accordance with an agreed formula, which factors in the wealth and population of the country. According to this formula, America`s contribution is the highest, although the assessed contributions constitute less than 20pc of the WHO`s total budget. The remainder 80pc come through the member states` voluntary contributions. On that count too, the US has been the biggest contributor. Again, it is up to the members to agree on how they want to finance the organisation.

The WHO`s 2024-2025 biennium budget is $6.83bn. The US contribution to its core budget is around 22pc ($134.58 million for FY2025), and it has provided an average of $237m in annual voluntary funding from FY2012 through FY2024. The WHO`s main beneficiaries are indeed LMICs, but even high-income countries have large stakes in global health. In a world with increasing international trade and travel, the next global emergency is always around the corner.

America`s uncalled-for exit from the WHO is a severe blow to global health.It has shaken the foundations of multilateralism. In a world with looming pandemics, AI challenges in health, and the need for international health regulations and accountability, its exit makes the world more unsafe. America`s decision means it will no longer participate in the ongoing international negotiations on a pandemic agreement. It has also withdrawn from the international treaty on climate change via an executive order.Is the US exit from WHO just that or part of a bigger design? The executive order also says that the US would `identify credible and transparent United States and international partners to assume necessary activities previously undertaken by the WHO`. Ilona Kickbush, a former WHO colleague and the chair of the Global Health Centre in Geneva, sees the withdrawal as much more than the WHO. The Trump administration is not interested in working in multilateral settings where it has to deal with challenges from China, India and other BRICS countries.

The larger design is symbolised by the new US commercial company Stargate, in which $500bn in investment is expected from the private sector to help the US `secure American leadership ... and generate significant economic benefits globally`. Stargate can help the US earn profits far beyond those of the pharmaceuticalindustry, and for that, a lawless world is a precondition in order to establish and maintain hegemony over new technology.

It is a strategic opportunity for China and other BRICS countries to fill the financial gaps and shape the future of global health.

Regarding Pakistan, there are concerns that the US exit will badly affect our health programmes. In Pakistan, the total contribution of alldonors in the health sectoris around1pc of the total health expenditure. Although our abysmal health indicators refleet a public health crisis, we are among the lowest spenders on health. What we spend is also lopsided and inefficient. Instead of lamenting the US exit from WHO, we should put our own house in order by owning our health programmes and making health a fiscal priority.

Since the US became an WHO member by an act of Congress, one legal view is that only Congress can authorise the withdrawal.

Lawerence Gostin, professor of global public health law at Washington State University, for one, is considering a lawsuit on these grounds.

Only time will tell what comes of it. • The writer is a former health minister and currently a professor of health systems & population health at the Shifa Tameer-i-Millat University