Half a century after the United States led a global expansion of international efforts to combat infectious disease and promote family planning, the Trump administration has embarked on a historic retrenchment that many fear threatens the health of millions and jeopardizes America's standing in the world.
Since taking office, President Trump has proposed dramatic cuts to the U.S. Agency for International Development, which has historically spearheaded U.S. efforts to improve women's and children's health.
The White House is urging reductions this year to major international heath initiatives, including the President's Emergency Plan for AIDS Relief, or PEPFAR, which provides life-saving medicines to millions of AIDS patients in developing nations.
The Trump administration has imposed tough new restrictions on U.S. support for aid organizations that provide family planning and other health services.
And last week, the White House announced it is cutting all U.S. contributions to the United Nations Population Fund, or UNFPA, the lead international agency dedicated to promoting family planning and child and maternal health.
Cuts on the scale proposed by the president could be devastating, said former Republican Senate Majority Leader Bill Frist, a surgeon who has worked extensively on global health since retiring from Congress in 2007.
"If the U.S. chooses to drastically cut its foreign assistance, including for HIV/AIDS, nutrition and family planning, we risk reversing our strides over the past 25 years to reduce extreme poverty and disease worldwide," he said. "That potentially creates a domino effect, which could lead to nation destabilization, conflict and catastrophic loss of life."
The U.S. is currently the largest funder of global health programs, including family planning.
The Trump administration has defended the rollback as necessary to address domestic needs, such as repairing aging bridges and airports, and constructing a new wall along the border with Mexico. Conservatives also want to ensure the U.S. is not funding abortion services.
"These steps to reduce foreign assistance free up funding for critical priorities here at home and put America first," the administration explained in its 2018 budget proposal released last month.
But across the world, there are growing fears the U.S. will no longer be a reliable ally in tackling major global health challenges, including combating HIV/AIDS, malaria and future pandemics such as Ebola.
Last month, more than 100 evangelical and Catholic leaders who work on international aid sent a letter to Trump, imploring him not to cut U.S. aid.
"From Genesis to Revelation, the Scriptures compel us to care for the marginalized," the leaders wrote. "If we can protect the lives of mothers and children, we can intervene not just to save lives but also to establish a foundation of health and wellness to uplift communities, societies and nations."
Several international aid groups, speaking on condition of anonymity to avoid being seen as criticizing the new administration, said they had already been told by U.S. government officials to expect a major shift away from healthcare assistance globally.
The stakes in this retrenchment are high.
Although maternal and child mortality rates have been falling globally, in 2015 more than 300,000 women died from complications during pregnancy and childbirth, and nearly 6 million children died before the age of 5 because of disease and malnutrition, according to World Health Organization and United Nations estimates.
In sub-Saharan Africa, a mother is nearly 40 times more likely to die in childbirth than in the U.S.
At the same time, infectious diseases such as tuberculosis, malaria and HIV/AIDS still claim the lives of hundreds of thousands of people every year.
For decades, the U.S. played a crucial role in addressing major global health challenges, even though foreign aid has remained a small fraction of the overall federal budget.
The George W. Bush administration's campaign to address the AIDS epidemic in the developing world — spearheaded by PEPFAR — is widely credited with helping to turn the tide against the deadly disease.
"President Bush changed the face of Africa," said Jennifer Kates, who oversees global health research for the nonpartisan Kaiser Family Foundation.
Total U.S. spending on global health topped $10 billion in 2016, more than half of which is committed to HIV/AIDS, according to a Kaiser analysis.
Support for global family planning has waxed and waned over the years, as Republican presidents, including Bush, have been less supportive.
But the Obama administration made family planning a major priority, seeing access to contraception as key to improving the health of mothers and children, empowering women and supporting economic development.
The U.S. is still one of the largest contraceptive purchasers, and last year contributed more than $600 million to global family planning and reproductive health efforts, Kaiser's analysis found.
In Guatemala, USAID money helped build the country's largest non-governmental provider of family planning services, known as APROFAM, which now operates network of hospitals and clinics that last year provided 1.2 million family planning services in a country of 16 million people.
In the Philippines, USAID has worked with the government to ensure family planning services are available in more than 400 clinics and hospitals in a region of the country where an estimated 2 million women and girls have unwanted pregnancies every year.
And in Mozambique, the agency has supported a network of community health workers who go door-to-door in rural areas of the country to provide information on family planning.
The Trump administration's proposed budget, which the president released last month, would cut about 30% of the State Department and USAID budget in 2018.
And although the White House said it would continue support for PEPFAR and other global health funds, the administration has proposed a series of substantial cuts this year to PEPFAR as well as programs targeting polio, tuberculosis and malnutrition, according to budget documents sent to lawmakers last month and first reported by Politico.
Cuts to PEPFAR would be generated, among other ways, by "requiring PEPFAR to begin slowing the rate of new patients on treatment," the White House proposed.
At the same time, the Trump administration has substantially expanded a restriction on U.S. aid to organizations that counsel women about abortion services.
U.S. law already bars U.S funding for abortion, but Republican presidents since Ronald Reagan have added a restriction that requires recipients of family planning assistance to attest that they will not even discuss abortion with patients.
When Trump reinstated this ban – commonly called the global gag rule – he said it would apply to all U.S. global health aid, not just family planning funding, which could affect many more aid groups.
The United Nations' ability to provide family planning assistance also took a hit when the Trump administration announced last week that it would pull more than $32 million in funding for UNFPA.
The administration cited UNFPA's work with China, which has engaged in forced sterilizations and abortions, although there is no evidence that UNFPA supports or participates in these activities.
Since January, several European countries have indicated they will step up support for global family planning efforts in the wake of the U.S. retreat. But that is doing little to assuage concerns that Trump's family planning moves are harbingers of other cuts to come.
"It is very troubling, especially when you think of the pivotal role the U.S. has played over the years in global health," said Lawrence Gostin, a global health expert at Georgetown University. "The world is lost without U.S. leadership."