Stepping Away
Doing the right thing
For most of my career, I’ve believed that global health—at its best—is a form of solidarity. Not charity. Not strategy. A recognition that some things matter enough to act on, even when there is no immediate return. Because it’s the right thing to do, epidemiologically, morally, personally.
That belief is what brought me to this work. It’s what kept me in it. And it’s why I am resigning my post as Chief Science Officer at PEPFAR in the U.S. State Department.
Over the past 18 months, I stayed because it felt like something worth preserving (perhaps everything) was at risk. Despite the dismantling of USAID and the sustained attacks on our field, I’m proud of what we saved, what we protected, what we sustained, against the odds. The institutional trauma was real, and the scale and speed of cuts to U.S. global health programs were, at times, staggering. But by staying, I believe lives were saved that might otherwise have been lost.
Over the last 18 months, we also made meaningful progress toward country ownership—progress that is real, hard-won, and worth honoring. In many ways, that may prove to be one of the most important legacies of this period. But it is also clear that the underlying direction has shifted. Global health has always involved compromise. Large-scale programs do not exist outside politics. I have never found that disqualifying. But there are limits to what those compromises can justify. I have reached one.
When life-saving health assistance, often beyond the immediate capacity of partner countries, is conditioned on unrelated commercial or strategic objectives, something essential is lost. When access to treatment or prevention becomes entangled with access to critical minerals or geopolitical positioning, the work is no longer what it claims to be.
That is not a marginal adjustment. It is a different model. And I do not believe that model is consistent with the purpose of global health. I do not believe it serves patients, or countries, or ultimately even the long-term interests of the United States.
There is a second, related reality I can’t ignore. I find myself increasingly unwilling to serve within an administration whose trajectory at home is moving in a direction I would describe, without exaggeration, as authoritarian. At its core, global health rests on the equal value of human lives, on dignity, and on solidarity across borders, a preferential option for those on the margins. Done right, it is inherently anti-fascist. It cannot be separated from the broader political context in which it operates. In that sense, it is fundamentally incompatible with political movements that erode those same principles domestically.
We cannot, on the one hand, press partner governments to absorb hundreds of millions of dollars in health costs, while on the other direct vastly greater sums toward military actions that result in civilian harm. Taken together, these choices reflect a set of priorities that I cannot reconcile with the core values that drew me to this work.
This is not a judgment on the civil servants I work with. I have had the privilege of working alongside colleagues of exceptional integrity and commitment, many of whom are operating under immense personal and professional strain. I respect them deeply.
I am not certain how this period will be judged. The shift toward country ownership is necessary and overdue; but the real question is whether it will translate into lasting impact. At the same time, new investments in innovation, especially lenacapavir and potentially MK-8527, represent some of the most promising advances in over a decade, with the potential to meaningfully bend the epidemic curve. With the level of ambition now being discussed, there is a real possibility of achieving impact at an unprecedented scale.
However, it is also possible that, in time, we will see that the shift toward more transactional arrangements, framed as sustainability or transition, came at a cost that was not fully acknowledged. We have asked partner governments to take on substantial new responsibilities despite constrained fiscal space, high levels of sovereign debt, and growing demographic pressures, all while programs themselves have been weakened by recent U.S. funding cuts.
In places like Zambia, which I care about deeply, the consequences of stepping away too abruptly could be devastating, and avoidable. I have to take that possibility seriously. And I no longer trust myself to continue this work without accommodating changes that I believe are fundamentally at odds with its purpose. So I am stepping away from government service and returning to academic work. Not because the work is finished, but because I need to continue it from a position more aligned with what I believe it requires.
There’s a simple idea I’ve tried to hold onto over the years (from the wisdom of the ancient prophet Micah) to act justly, take suffering seriously, and not let power distort judgment. I haven’t always met that standard. But it’s still the one I answer to. Even now.