Does Foreign Health Aid Actually Improve How the World Sees the United States?
Yes. A peer-reviewed study published in the American Journal of Public Health found that populations in countries receiving the highest levels of U.S. health aid were 18 percentage points more likely to hold a very favorable opinion of the United States compared to countries receiving the least. Notably, aid for governance, infrastructure, humanitarian, and military purposes did not produce the same effect.
The concept of soft power, using cooperation and goodwill rather than coercion to build influence, has been part of international relations theory for decades. But the question of whether it actually works, whether spending money on health programs in other countries measurably improves how those populations view the United States, had relatively little empirical evidence behind it until recently. This article examines the peer-reviewed research that has changed that, and what it means in the context of the recent dismantling of USAID.
This article accompanies Episode 40 of The Dr Kumar Discovery, in which Dr. Kumar and Keith Hourihan discuss the role of soft power in U.S. foreign policy and the real-world impact of USAID programs across more than 130 countries.
Dr. Kumar’s Take
Keith and I are both former Peace Corps volunteers, and each of us has seen soft power work firsthand. But what makes this Stanford research so compelling is that it puts real numbers on it. In countries getting the most U.S. health aid, people were 18 percentage points more likely to hold a very favorable view of America than in countries getting the least. Military aid did not. Governance aid did not. Infrastructure aid did not. Only health. That tells you something profound about human nature: people remember who helped them when they were sick, when their children were dying, when no one else showed up. Across 45 countries surveyed between 2002 and 2016, the data show that goodwill in opinion polls. The decision to dismantle that program is not just a humanitarian loss. It is a strategic one.
The Stanford Study: Health Aid and Global Perceptions
The authors describe their study as the first, to their knowledge, to show that U.S. investments in health aid improved the country’s image abroad. It was published in the July 2019 issue of the American Journal of Public Health by researchers at Stanford University. The study was led by Aleksandra Jakubowski, with co-authors Don Mai and Steven Asch, and senior author Eran Bendavid.
The research team analyzed 258 Pew Global Attitudes surveys encompassing more than 260,000 respondents across 45 developing nations from 2002 to 2016. They cross-referenced these survey responses with detailed U.S. foreign aid disbursement data across multiple categories: health, governance, infrastructure, humanitarian, and military assistance.
The central finding was striking: every additional $100 million in U.S. health aid was associated with a nearly 5.7 percentage-point increase in the probability of respondents saying they had a “very favorable” opinion of the United States. In the countries and years with the highest levels of health aid, the probability of a “very favorable” opinion was 18 percentage points higher than in those with the least.
What made this finding especially noteworthy was what did not work. Aid directed toward governance, infrastructure, humanitarian operations, and military purposes showed no statistically significant association with improved perceptions of the United States. Health aid was uniquely effective.
Why Health Aid Works Differently
The Stanford authors were guided by the theory that health aid is uniquely placed to sway public opinion because of three features:
Visibility. The authors note that the scale of U.S. health programs such as PEPFAR made them a uniquely visible engagement. Higher health aid was also linked with more references to that aid in local newspapers.
Sustainability. Health programs such as PEPFAR and the President’s Malaria Initiative ran for years, and very favorable opinions were significantly higher after those programs launched.
Effectiveness against salient health problems. Health aid addresses problems that people in recipient countries care about.
Keith Hourihan described this dynamic from his own experience in the podcast, noting that USAID-branded bags of rice, cartons of medicine, and medical equipment were visible throughout the countries where programs operated. He observed that this visibility created genuine goodwill toward the United States and fostered international cooperation.
The Strategic Value of Health Diplomacy
The academic literature on health diplomacy extends well beyond the Stanford study. A 2010 analysis published in PLoS Medicine by Feldbaum and Michaud, titled “Health Diplomacy and the Enduring Relevance of Foreign Policy Interests,” offers broader context on how health and foreign policy interests intersect.
Research published in The Lancet in 2022 by Kickbusch, Liu, and colleagues, “Global health diplomacy: reconstructing power and governance,” reviewed how global health diplomacy has changed over the past two decades. The authors describe how health diplomacy, such as PEPFAR, has been a common way for countries to increase their political reputation, improve relations with other states, and help build alliances that contribute to peace and security, such as negotiating ceasefires to allow immunisation campaigns.
The implications are significant. When the United States invests in global health, it is not simply providing charity. In this study, it was linked to lasting goodwill toward the United States. Many former military leaders have publicly supported foreign aid on these grounds, arguing that development assistance reduces the conditions that give rise to instability, extremism, and conflict.
What Is Lost When Health Diplomacy Ends
The dismantling of USAID and the reduction of foreign health aid represent a measurable loss of soft power. According to the OECD, U.S. development assistance fell by 56.9% in 2025, and total international development aid declined by 23.1%, the largest drop in recorded history.
The Stanford research suggests that these cuts will have consequences beyond mortality and disease burden. As health programs disappear, so does the visible evidence of American generosity and competence. In the vacuum left by the U.S. withdrawal, other nations, including China and Russia, have expanded their own development programs, building the kind of influence that the United States spent decades cultivating.
Practical Takeaways
- Peer-reviewed research from Stanford found that U.S. health aid was uniquely effective at improving global perceptions of the United States, with each additional $100 million associated with a 5.7 percentage-point increase in “very favorable” ratings.
- Military, governance, humanitarian, and infrastructure aid did not produce the same effect on public opinion, suggesting that health aid operates through a distinct psychological and social mechanism.
- The withdrawal of U.S. health aid represents not only a humanitarian cost but a strategic loss, as decades of accumulated goodwill and influence built through health programs are at risk of being replaced by competing powers.
Related Studies and Research
- Lancet study projects 14 million preventable deaths by 2030 from U.S. foreign aid cuts examines the mortality consequences of the funding reductions.
- What the data actually shows about fraud in U.S. foreign aid programs addresses whether the justification for cutting aid holds up under evidence.
FAQs
Does foreign aid really make people like the United States more?
According to the Stanford study published in the American Journal of Public Health, the answer is yes, but only when the aid is health-related. The researchers found that populations receiving the highest levels of U.S. health aid were 18 percentage points more likely to hold very favorable views of the United States. Importantly, other types of aid, including military and governance assistance, did not produce the same effect.
How does health diplomacy compare to military spending as a foreign policy tool?
The two serve different purposes but are often compared in terms of cost-effectiveness. USAID’s entire annual budget was less than 1% of the federal budget, a small fraction of what the Department of Defense spends. Research suggests that health diplomacy builds durable goodwill and cooperation. Many former military leaders have publicly supported maintaining foreign health aid as a complement to defense spending.
Can other countries fill the soft power gap left by the U.S.?
China has significantly expanded its development assistance in recent years, particularly in Africa and Southeast Asia. The Stanford research suggests that health programs are the most effective vehicle for building favorable perceptions, and countries that step in to provide health services in the vacuum left by the U.S. withdrawal could capture the goodwill that American programs previously generated. This represents a long-term strategic concern that extends well beyond the immediate humanitarian impact.
Bottom Line
The Stanford study of 260,000 respondents across 45 nations found that only health aid, not military, governance, or infrastructure aid, was associated with more very favorable views of the United States in opinion surveys. The authors conclude that sustained global health investments may offer important returns to the United States. The dismantling of USAID and the reduction of health programs put those returns at risk, on top of the humanitarian cost.
Listen to the full conversation on Episode 40 of The Dr Kumar Discovery.
Sources:
- Jakubowski A, Mai D, Asch S, Bendavid E. “Impact of Health Aid Investments on Public Opinion of the United States: Analysis of Global Attitude Surveys From 45 Countries, 2002-2016." American Journal of Public Health. 2019;109(7):1034-1041.
- Feldbaum H, Michaud J. “Health Diplomacy and the Enduring Relevance of Foreign Policy Interests." PLoS Medicine. 2010;7(4):e1000226.
- Kickbusch I, Liu A, et al. “Global health diplomacy: reconstructing power and governance." The Lancet. 2022.
