The World Cup, the Rules-Based Order, and the Future of Global Health

This post feels a little late. The World Cup has moved on. England are in the semi-finals. Jarell Quansah has already served half of his suspension. More importantly, at least for the purposes of this post, Chris Balogun played against Belgium despite a clear red card, after President Trump reportedly persuaded FIFA President Gianni Infantino to overturn the referee’s decision. In the end, it made little difference. The United States were soundly beaten.

Even so, I keep coming back to that decision because it revealed something larger than football. It wasn’t simply that Infantino caved; he has done that before. Nor was it that an American president reportedly sought an exception for his national team. Great powers have always tried to bend institutions in their favor. What was more interesting was the reaction.

Most of my American friends here in San Francisco thought Trump’s intervention was inappropriate. Yet quite alot of them arrived at the same conclusion:

“I’m glad he could play. The card seemed harsh. He was America’s best player. [and not explicitly stated, inferred implicitly] If the rules bent just this once, perhaps that was understandable.”

What struck me was how quickly the debate stopped being about the rule and became about the outcome. The card may have been harsh. America’s chances were improved. Perhaps, then, bending the rules was acceptable? That, it seems to me, is how exceptionalism works; not by rejecting rules altogether, but by assuming that your own circumstances justify an exception. And it made me wonder whether global health has gradually adopted the same habit of mind.

No country has contributed more to global health than the United States. PEPFAR has saved millions of lives. American science, philanthropy, and public investment have transformed the fight against HIV, tuberculosis, malaria, and emerging pandemics. That legacy deserves genuine gratitude.

But over the past two decades we have also built a global health architecture that rests disproportionately on American political will. When the United States decides to pause foreign assistance, reconsider Global Fund commitments, enforce intellectual property protections, or redirect international partnerships to serve domestic political priorities, the consequences ripple across the world. What may be rational from the perspective of American politics is not always what is best for global health.

Republicans and Democrats disagree profoundly about America’s role in the world. But the deeper question is why the health of millions depends so heavily on the political choices of a single government. Rules-based systems exist because governments change. They are designed to outlast elections and administrations. Yet much of global health still assumes that one country will continue playing the role it has played for the past two decades.

None of this is a new observation. African scholars including Soji Adeyi, Dambisa Moyo, and many others have argued for years that durable progress requires stronger domestic institutions, diversified financing, and genuine country ownership rather than perpetual dependence on external benefactors. Whether or not one agrees with every prescription, today’s uncertainty makes their central argument much harder to dismiss.

If we are serious about reimagining global health, the next chapter cannot simply be about electing a more sympathetic American administration. It has to be about building a genuinely rules-based global health order, one in which leadership, financing, innovation, and accountability are shared across national governments, regional institutions, philanthropies, development banks, the private sector, and civil society. The goal is not a world without American leadership. It is a world that no longer depends on it quite so completely.

As an Englishman, I’m conscious of the irony. England once assumed it occupied the natural centre of the world. Even our football ‘anthem’—“Football’s Coming Home”—contains more than a faint echo of that imperial confidence: the suggestion that the world’s game somehow belongs to us.

America’s contribution to global health has been extraordinary. But the real measure of that leadership will not be whether it remains indispensable. It will be whether it helps create institutions that no longer require its indispensability. Eric Goosby and I explore this argument in the next episode of our podcast [out next week] and in the accompanying chapter of our new book [available here]. The lesson from Balogun is not that powerful countries will stop asking for exceptions. They will not. The real question is whether we can build a global health architecture in which no country’s politics, not even America’s, determines the health of millions.