Global health at a crossroads: Duke institute leader outlines funding crisis in MUSC keynote

In a sobering keynote address delivered on April 7 to kick off MUSC Global Health Week, Dr. Chris Beyrer, director of the Duke Global Health Institute, outlined the deepening crisis facing global health researchers and clinicians as U.S. funding dwindles and decades of progress hang in the balance.

Beyrer, a globally recognized epidemiologist and human rights advocate, described a “new era of uncertainty” in global health, shaped by unprecedented defunding of U.S.-backed programs such as PEPFAR, USAID, and NIH global health research initiatives under the new presidential administration.

“We are seeing the rapid unraveling of global health funding,” Beyrer said. “And it’s not just research and prevention programs—it’s the entire infrastructure that supports vulnerable populations around the world.”

The collapse of U.S. global health leadership

Until January 2025, the United States was the world’s largest funder of global health, accounting for nearly half of all international health assistance. The bulk of that support was channeled through the USAID, including large programs such as PEPFAR (the President’s Emergency Plan for AIDS Relief), which has saved an estimated 25 million lives since its inception in 2003.

However, that foundation is crumbling. As of March 25, PEPFAR’s reauthorization has lapsed, and a wave of executive actions has paused or dramatically curtailed funding for malaria, tuberculosis, and maternal-child health initiatives. USAID, once the implementation backbone of these programs, is effectively inoperative.

Beyrer warned that the repercussions are already being felt in the field. “We're hearing directly from clinicians and outreach workers. They describe the situation as chaos,” he said.

“We're hearing directly from clinicians and outreach workers. They describe the situation as chaos,” Beyrer said.

Global HIV prevention work halted

Perhaps most startling was Beyrer’s revelation that PEPFAR-funded pre-HIV exposure prophylaxis (PrEP) programs—responsible for 91% of global PrEP initiations—have stopped. The only exception is for pregnant and lactating women.

“That means sex workers, men who have sex with men, and other high-risk populations are left without prevention tools,” he said.

During the presentation, Beyrer showed a photo, taken by a colleague, of an old USAID mobile clinic tent in South Africa that was now being used to sell hats in a market. “Because Africans are full of ingenuity,” he said, “but also because, you know, what do you need a mobile testing clinic for, right?”

Research and academia impacts

Beyond aid programs, the cuts have also drastically reduced research funding in global health. NIH grant approvals have plummeted, particularly for new and competitive awards. Training grants have been frozen entirely, Beyrer reported. The U.S. Department of Health and Human Services is undergoing massive downsizing, with 20,000 staff reductions planned—including key scientific leaders.

“This is unprecedented,” Beyrer emphasized. “It is true that every administration changes its priorities, but it usually takes three years or so for new NIH priorities to be reflected, but this is a severe halt on funding, and this is what is constraining universities.”

The human toll

Mathematical modeling has estimated that even a temporary 90-day pause in PEPFAR could result in 100,000 preventable deaths and over 130,000 perinatal HIV transmissions. The President’s malaria initiative has also been paused—just as Africa enters its rainy season, a period historically linked to deadly malaria surges.

“History shows us what happens when programs are cut,” he said, “malaria and HIV surge back quickly.”

The road ahead: Rethinking global health

Looking forward, Beyrer called for a new coalition of actors—governments, private sector entities, philanthropists, and communities—to step in where shortfalls or gaps have been created. He urged regional leadership, especially in southeast Asia and Africa, to identify opportunities to take on more responsibility for local and neighboring countries.

“Vertical programs worked while the funding was there, but now we need horizontal integration, long-term planning, and real country ownership,” Beyrer said, noting that successful transitions to national health system support typically require at least a decade.

A call to action

Despite the grim picture, Beyrer ended on a hopeful note. “Global health will not disappear. There are too many lives at stake, too much innovation on the horizon,” he said. “But the field will not look the same. We need new voices, new models, and a commitment to equity that is stronger than ever.”

As universities, researchers, and advocates look ahead, Beyrer’s message is clear: the time to reimagine global health is now.