A few months ago, one of us asked a deliberately uncomfortable question: Is the era of academic global health—as we have practiced it—over? Increasingly, we think the more interesting question is: What comes next? For all the turmoil of the past 18 months, including but not limited to the end of USAID and the contraction of global health funding, we believe this could also be the beginning of something important. An era is ending. But we should use the opportunity to build a better one.
For the last two decades, “global health” has been an organizing idea for an extraordinary enterprise. It mobilized billions of dollars, created institutions (like PEPFAR, GAVI, and the Global Fund), trained generations of scientists and practitioners, and contributed to remarkable improvements in health. Millions of people are alive because of programs built during this era.
But global health also created its own geography and bureaucracy. Problems “over there” became global health; problems at home became public health. Funding often flowed from wealthy countries to poorer ones through institutions in what is controversially termed the Global North. Priorities were frequently shaped as much by donor strategies, funding cycles, and political imperatives as by the priorities of the countries receiving the funding. The result was sometimes extraordinary progress against particular diseases, but also parallel systems, fragmented institutions, and scarce local capacity pulled toward what donors were prepared to fund rather than what health systems most needed. Success was measured in grants awarded, programs launched, papers published, and diseases controlled, but less often by whether countries were building the institutions and capacity to eventually need external assistance less. That model was always supposed to lead to some kind of ‘phase out’ or ‘transition.’ The destination was not intended to be permanent donor dependence. It was stronger institutions, greater equity, genuine local ownership, resilient public systems, and ultimately the ability of every country to set its own priorities and deliver excellent health outcomes through its own institutions and resources.
This is the idea behind the new Center for Applied Public Health at UCSF, which we are launching this month. We don’t see applied public health as simply global health with a new label, nor as a continuation of business as usual in domestic public health. We see it as an opportunity to organize ourselves around a different proposition.
Start with the inequity, not the geography. A person dying unnecessarily because they cannot access an effective intervention is a public-health failure, whether they live in Kampala, Fresno, San Francisco, or Kathmandu. The objective should be the same: understand why the gap exists and then marshal science, policy, technology, financing, implementation expertise, and political will to close it.
In less academic language: get shit done. That means taking innovations that work and figuring out how to get them to millions of people rather than leaving them stranded in pilots and publications. It means bringing AI and other emerging technologies into public systems in ways that improve outcomes rather than simply generate new products. It means helping governments (both global and local) decide what to buy, what to scale, and what to stop funding. It means helping communities and countries that have been dealt a bad hand achieve the same outcomes enjoyed by people living in the wealthiest parts of the world.
Local and global is the wrong distinction
One reason we are excited about this approach is that it removes an increasingly artificial boundary between domestic and international health. San Francisco has world-leading hospitals and extraordinary biomedical innovation. It also has profound disparities in life expectancy, homelessness, maternal and child health, mental illness, overdose, infectious disease, and access to care. Meanwhile, countries traditionally described as recipients of global health assistance have developed innovations from which American health systems have much to learn: community-based delivery, differentiated models of care, task sharing, digital platforms, and approaches for delivering high-quality services with far fewer resources. Knowledge should move in both directions. The next era should therefore be less concerned with whether work is “global” or “domestic” and much more concerned with a simpler question: Where is the equity gap, and what will it take to close it?
Transition is now the work
There is another reason this matters now. The age of ever-expanding donor-financed global health initiatives is over, at least for the foreseeable future. Pretending otherwise does countries no favors. But transition cannot mean abandonment. The challenge is to help countries move from externally financed, disease-specific programs toward domestically financed, integrated, and resilient health systems—without sacrificing the people whose lives depend upon the programs being transitioned. That is an enormous applied public-health challenge. It requires acknowledging and addressing the political, cultural, and structural barriers that hinder such transitions in conjunction with new approaches to financing, workforce, procurement, implementation science, data systems, regulation, and accountability. It requires governments to have the capability to evaluate new technologies and negotiate with the companies selling them. And it requires academic institutions to judge success differently: not by how long a partnership lasts, but by whether it eventually becomes unnecessary. The best technical assistance should contain the seeds of its own obsolescence.
An extraordinary moment for public health
It is easy to look at the current moment and be profoundly pessimistic. We have seen brilliant colleagues laid off, essential health programs terminated, impactful research grants canceled, and equity-focused initiatives erased overnight. But there are also grounds for optimism. AI is dramatically expanding what small teams and resource-constrained health systems can do. New diagnostics, therapeutic tools, data platforms, and delivery models are arriving at extraordinary speed. Countries that once depended almost entirely on external technical expertise are building their own scientific and technological capabilities. And there is growing impatience (rightly!) with a global health architecture built around donor dependency.
Put those forces together and the next decade could be one of the most consequential periods in public health in a generation. But only if innovation reaches the people who need it. A breakthrough sitting in a laboratory is not impact. An AI model demonstrated in a pilot is not impact. A new diagnostic that a ministry cannot afford is not impact. And another eloquently written paper documenting an inequity is not the same thing as closing it. The measure that matters is whether people’s lives actually get better. That is the wager behind the Center for Applied Public Health.
We will still work internationally. We will still teach and publish. But those are means, not ends. The ambition is larger and simpler: take the extraordinary capabilities concentrated in universities like UCSF and bring them together with the expertise, priorities and capabilities of our partners to tackle the hardest public-health problems, wherever those problems happen to be. Build things together. Test them. Scale what works. Stop what doesn’t. Collectively build institutional strength. Redirect resources and decision-making closer to the people they affect. And measure ourselves by whether inequities actually narrow.
Perhaps “applied public health” will eventually prove to be another imperfect term. That’s fine. What matters is the change in orientation. ‘Global health’ helped define an extraordinary era. We should celebrate what it accomplished without feeling obligated to preserve forever the institutions and distinctions it created. The next era should be less about global health as a field and more about health equity as an outcome, less about sustaining ourselves, and more about finishing the job.
Banner photo: UCSF’s Rikita Merai, MPH, and Alina Dorian, PhD, one of our UCLA partners, working together with the Hawaii Department of Health to implement a CASPER (Community Assessment for Public Health Emergency Response) survey on behalf of the CAPH-based Pacific Southwest Center for Emergency Public Health.