The 49th Annual World Conference on Lung Health, hosted by the Union in the Hague had a theme of “people everywhere have a right to health.” However, it wasn’t the global health community’s renewed urgency to tackle tuberculosis or contend with emerging tobacco products that struck me. Rather, it was the growing lack of trust and skepticism with which American global health efforts are now viewed by colleagues in our growing age of us-first action and rhetoric.

Context is helpful; particularly as U.S. governmental flows to development assistance for health (DAH) have plateaued for a fourth straight year. Commitments from the Trump administration to global health security efforts have been sharply cut back and American governmental leadership on important issues like the health effects of climate change have been nearly non-existent.

{mosads}These feelings from our public health allies haven’t arisen from nowhere. To be sure, the world has very much taken notice of our growing inattention on global public health and the depth and authenticity of our global goodwill is now being rightly questioned.

It makes sense that we’re now facing a global reckoning on what was once an area of such moral primacy for us; that is, our indispensable role in ensuring the world’s health. We’ve long been the largest contributor to DAH globally, founded the highly effective President Emergency Plan for AIDS Relief (PEPFAR) across Africa, and continue to be a behemoth in academic biomedical research with broad benefits.

Yet, to hear some health experts around the world tell it, we assumed this moral high ground in health before we truly deserved it, particularly as we have — in their view — little credibility at home on the issue.

They cite our 27.6 million uninsured, the ongoing tension on domestic health-care reform dating back to the Truman administration, and efforts to roll back recent progress in expanding American health-care coverage as exhibits A, B and C; and they have a convincing argument.

How can we continue to credibly lead important global efforts on universal health coverage, TB eradication, pandemic preparedness and the rising burden of non-communicable diseases if we can’t even provide a basic set of health services at low cost to all Americans?

Leadership requires telling hard truths; truth telling without credibility reeks of hypocrisy. We can’t possibly expect countries across the Global South to improve their health systems to meet certain pandemic preparedness capabilities if, in relative health terms, they are actually performing similarly, if not better, than us. Our rising rates of maternal morbidity and mortality, on par with Afghanistan and Lesotho, provide a clear case in point.

Which is why what happens locally matters in sustaining the durability of our global leadership in public health. With our midterms only days away, and with health care overwhelmingly its defining issue, our global credibility in health is on the ballot. If you think averting the next major pandemic flu matters, then our global credibility matters.

Take the case of Georgia and the 16 other states that have chosen not to expand Medicaid due to concerns on state-level costs — though the federal government would own 90 percent of the bill. Strategic expansion of Medicaid would not only cover those in need from a moral standpoint, but cost-effectively provide a balm to each state’s worsening opioid crisis. A recent empirical study suggests that this platform is a very good idea, saving states millions in the process while directly addressing the opioid epidemic.

To Georgians and Ohioans, health-care issues are easily the most important this election season, and for good reason. The weight of the opioid crisis has hammered both states, with $40 billion in direct and indirect costs since 2001 incurred in Ohio alone, which suffers from the second highest opioid-attributable mortality rates nationwide.

The two candidates for governor in both Georgia and Ohio, much like most races, starkly represent opposing philosophies on the role of government in U.S. health care nationally this season, representing a microcosm of our country’s greater struggle on the issue.

Ultimately, the many competing challenges in global public health require an America that is leading in front with maximal influence to be effective. If our allies worldwide have lost some faith in our intentions over the past few years, let the coming midterms serve as our opportunity to let them believe in us again.

Dr. Vinay Gupta is a public health researcher and pulmonologist. Commissioned as an officer in the U.S. Air Force, Gupta is one of the physician leaders of Doctors for Cordray, a grassroots movement throughout Ohio to elect common-sense and evidenced based health policy reforms.