rewrite this title The divorce between the U.S. and WHO is final this week. Or is it?

A year ago this week, President Trump initiated a divorce — of sorts. As night fell on his inauguration day activities, he signed an executive order saying: He wants out of the World Health Organization, or WHO.

His executive order laid out his displeasures, including “the organization’s mishandling of the COVID-19 pandemic that arose out of Wuhan, China, and other global health crises, its failure to adopt urgently needed reforms, and its inability to demonstrate independence from the inappropriate political influence of WHO member states.”

It was Trump’s second time heading for the exit. He started the process of withdrawing the U.S. from WHO in 2020, during the height of the COVID pandemic. President Biden reversed that decision on his first day.

Now — on Trump’s second go-around — the divorce seems about to be finalized. He gave one year’s notice, which is a condition of the U.S. agreement with WHO.

But as with many divorces, it’s complicated.

WHO officials note that there are two requirements to leaving. The first is that one-year notice. That would set the date for U.S. withdrawal as Jan. 22, a year after WHO officials were notified.

The other criteria is the potential problem. In order to leave, the U.S. has to pay all the dues it owes. And that’s a lot of money: $278 million for the 2024-2025 period.

The U.S. has not paid up and doesn’t plan to. “The United States will not be making any payments to the WHO before our withdrawal,” the State Department told NPR in a statement. “The cost born by the U.S. taxpayer and U.S. economy after the WHO’s failure during the Covid pandemic — and since — has been too high as it is.”

“This is a very, very public and messy divorce,” says Lawrence Gostin, a professor of global health law at Georgetown University and the director of WHO’s Center on National and Global Health Law. “The man says, ‘No, I’m not going to pay you any money, and we’re no longer married.’ And the woman says, ‘No, you can’t not be married unless you pay me.'”

The stakes of this high-profile breakup are huge. They could shape the health of both Americans and those around the world for years to come. Here’s how it could play out.

Promise ring or not, the U.S. is out 

The World Health Organization has 194 member nations. Officially, none of them can pull out of WHO. That’s according to its constitution, which has no clause that allows for withdrawal.

“This was not an oversight. It was very deliberate,” says Steven Solomon, WHO’s principal legal officer. “The drafters understood the historic struggles against the international spread of disease, and they saw how a truly universal organization would make the world safer. So they did not include a withdrawal clause.”

But there is one exception to this “no quitting” rule.

In 1948, as the U.S. joined through a joint resolution of Congress, it made an arrangement “reserving for itself, alone among countries, the right to withdraw,” explains Solomon.

Even with that exception, there is the matter of dues. Gostin says leaving without paying up is “unlawful.”

But he adds: “I don’t think there’s anything stopping the president, because there’s no pending litigation and there’s no movement in Congress to stop him.”

Indeed, Trump seems set on leaving.

In a statement to NPR, the State Department wrote: “The opinions out of the WHO do not constrain or have an impact on U.S. actions. Those meaningless opinions only serve to generate similarly meaningless headlines for news clicks.”

Brett Schaefer — senior fellow at the conservative American Enterprise Institute — says it is entirely within the U.S.’s right, as a sovereign country, to leave. “[WHO] comes across, in my mind, as somewhat juvenile, like a boyfriend saying to his girlfriend: ‘You can’t break up with me because you still have my promise ring. I’m sorry, that’s not quite the way these things work,” he says.

And what does WHO say about this messy matter? WHO’s Solomon says it’s up to WHO member states — the other 193 countries — to determine if and when the U.S. withdrawal becomes effective, with or without dues payment. This issue is expected to be discussed late in February at the WHO Executive Board meeting and again at the World Health Assembly in May.

Meanwhile, WHO is hoping the U.S. and WHO can get back together.

“I hope the U.S. will reconsider its decision and rejoin,” said Tedros Adhanom Ghebreyesus, director-general of WHO, at a press conference last week. “It’s not about money. Money can be adjusted. It’s about cooperation.”

He explained that both the U.S. and the rest of the world are less safe if they are not teaming up to address diseases that easily cross national borders. He called it a “lose-lose” situation, adding: “It’s not really the right decision. I want to say it bluntly.”

And if the U.S. does leave … then what?

For the past year, Gostin says WHO has been “very upset with the United States leaving but has nonetheless been magnanimous.” He notes that WHO has permitted the U.S. to participate in events — like the meeting in February where countries share data about current strains of the flu to figure out the best formula for the next season’s flu shot. Traditionally, U.S. scientists and the Centers for Disease Control and Prevention have played a major role in those meetings. And WHO benefits from their expertise.

That spirit of generosity could end now that the one-year marker has been hit, says Gostin: “In this divorce analogy, it would be like: She locks her door and [says], ‘You can’t come and get your clothes.’ ” Except in this case it’d be viral specimens and disease outbreak data.

Gostin says it’s up to WHO to decide whether it wants to say: “[We] shut the door — leaving the U.S. on the outside looking in.”

He worries that a lockout would put the U.S. — and the rest of the world — in a vulnerable position.

“We will not have access to the WHO Influenza Surveillance Network, which is crucial for the development of vaccines — routine seasonal vaccines but also future pandemic strains of influenza,” he says. “Same thing with measles surveillance. We’re not going to be able to stop infectious diseases from spreading before they come to our border. We might not be notified of outbreaks as quickly as we should.”

Others are grieving this break-up. “It’s genuinely a tragedy,” says Dr. Gavin Yamey, a professor of global health and public policy at Duke University. “I think it’s important for the public to realize how extraordinarily extreme and unusual and unprecedented this is.”

Schaefer, of the American Enterprise Institute, is not as concerned. He stresses that the U.S. is still engaged in global health through other arms of the United Nations, such as UNICEF, the United Nations Children’s Fund, and UNAIDS, which focuses on HIV/AIDS.

And just as there can be amicable divorces, he thinks the U.S. and WHO should still keep in contact even if the U.S. is not a member state.

“For instance, the Epidemic Intelligence from Open Sources platform, which takes a look and tries to identify instances of potential pandemics — the U.S. has an interest in trying to participate in that,” Schaefer says, explaining that building such a global surveillance system outside of WHO would be very difficult.

So he hopes WHO doesn’t block the U.S. from participation. “It’s possible, but it would be very petty,” Schaefer says. “You wouldn’t want to ignore each other in the hallways or something like that, right? So you should be willing to say hello and to engage each other cordially, at least.”

However, the State Department says that the breakup will not be followed by any overtures. In its statement, it said: “The United States will not be participating in regular WHO-led or managed events beyond functions related to the withdrawal effort.”