What Does Dismantling USAID Mean For Global Health?

FLORA LICHTMAN: This is Science Friday. I’m Flora Lichtman. On his first day back in office, President Trump issued an Executive Order targeting foreign aid. Funding for the US Agency for International Development, USAID, has been frozen, and most of the staff has been placed on leave or laid off.

This week, the Supreme Court rejected a bid to keep some of those funds frozen. But what does that mean in practice for the agency’s global health initiatives? That’s what we’re talking about today, the repercussions for people and medical care across the world and what it means and why it matters that the US is stepping back from being a leader in global health.

Let me introduce my guests. Dr. Atul Gawande is a surgeon and former head of Global Health at USAID. And Dr. Salim Abdool Karim is an epidemiologist and director of the Center for the AIDS Program of Research in South Africa. Welcome to Science Friday.

SALIM ABDOOL KARIM: Pleasure.

ATUL GAWANDE: Delighted to be here.

FLORA LICHTMAN: Atul, the news is changing fast. Can you just catch us up on where things stand with USAID?

ATUL GAWANDE: Yeah, the core of it is that, a month ago, a freeze on foreign aid froze all funding. This is work that then last week was formally terminated, with 90% of the staff being let go as well. So the results are that virtually the entirety of the President’s Malaria Initiative, reaching 53 million people, mostly children, has been terminated. Virtually all of the Tuberculosis Control Program terminated.

All of the 50-country network, where we work with them to strengthen their ability to detect and respond to pandemic threats, terminated, and 3/4 of an HIV program keeping 20 million people alive, including 500,000 children, also terminated. And that’s just the global health work. We haven’t even gotten to humanitarian food assistance and protecting freedom abroad and stability in conflict environments. It’s devastating.

FLORA LICHTMAN: The Supreme Court just unfroze $2 billion in foreign aid funding. What does that mean exactly? What’s that money for? What should we expect next?

ATUL GAWANDE: So, number one, an incredibly important ruling, just to indicate to us that unchecked, arbitrary decisions are potentially going to be addressed by the courts. There was real doubt and concern whether that was going to happen. This is a very narrow ruling.

This applies to the past funding for work that organizations across the United States and the world have done in the past, that was not being paid. So when they froze the money a month ago, there was money owed to hundreds of contractors and nonprofit organizations that do work with hundreds of thousands of staff around the world. And that federal district court that was trying to enforce that at least back payments need to be made, that court had ruled that the freeze had to be unfrozen, that it was illegal.

FLORA LICHTMAN: So it sounds like the Supreme Court is kind of agreeing and saying, yes, US government, you have to pay your bills.

ATUL GAWANDE: Exactly.

FLORA LICHTMAN: Salim, you work on HIV and AIDS prevention in South Africa. I want to hear about what it’s like on the ground. It sounds like a project you collaborate on has been directly affected by the USAID cuts. Will you tell us about it?

SALIM ABDOOL KARIM: Sure. I mean, it needs to be pointed out that USAID and CDC provide a large part of the funding for South Africa’s AIDS response. So when that is terminated, that means patients can’t go to the clinic and get the continuation of their treatments. So patients have already had to stop their medication. That has huge consequences, not least that patient is surviving because they are on treatment but because it can also lead to a drug-resistant form of HIV. And a drug-resistant form spreading is a threat not only to Africa or to South Africa. It’s a threat to the world.

For my own center, we have two projects that were funded by USAID through our participation in a consortium, and both those projects were brought to an immediate halt through a stop-work order. And one of those projects was a phase I safety study of a new technology to prevent HIV in women. The women had the technology already inserted.

FLORA LICHTMAN: These are intravaginal rings that are for HIV prevention?

SALIM ABDOOL KARIM: That’s correct.

FLORA LICHTMAN: And these devices were in their bodies when the funding was cut.

ATUL GAWANDE: Can I just jump in on this? How insane what he just described is, right? It is against all ethics. It’s against legal human subjects requirements, that you cannot abandon people in a trial with these vaginal devices inserted into them.

They have to be able to be cared for. They have to have them at least removed. When you abandon this work and terminate this work, there has to be a proper wind-down.

Salim will have staff, and there are laws that require the US to give notice. There are payments to be made to insurance and anything else that might need to be addressed. So it really is– it’s a calamity for an organization like yours, Salim, I have to suspect.

SALIM ABDOOL KARIM: Absolutely. And, of course, from our point of view, we simply cannot follow a stop-work order. So we followed the rule that required that we not spend any further USAID funding, but we put our own funding into ensuring that every woman could come back to the clinic, that they were seen. A safety assessment was done, the rings were removed, and that we could continue and ensure that they were safely exited from the study. And we did that using our own funds because, from our point of view, our ethical obligations far supersede any instruction to stop work.

FLORA LICHTMAN: Atul, how widespread is this, patients being left mid-treatment, mid-trial, without care?

ATUL GAWANDE: There are thousands of patients in trials across the world. We collaborate with the NIH and others to make global studies possible. And those include children being taken care of in TB drug trials, malaria research, and so on. And then you have all of the people who are simply in programs where there is support to enable treatments that are also abandoned. And that’s where you get millions of HIV patients, for example, who are simply not being able to be treated.

FLORA LICHTMAN: Atul, President Trump campaigned on slashing federal spending. This is something a lot of people, a lot of Americans, support. Please make the case for why taxpayers should care about global health initiatives.

ATUL GAWANDE: There is a selfish reason. We are going to see an enormous rise in measles, in HIV, in tuberculosis, and in new threats coming to our borders. An example is we’ve seen polio start to come back already in the world, and we’re not prepared for polio to begin landing here. The prediction of the internal staff calculations at USAID are that we can expect to see 200,000 polio cases arising in the world after we’ve gotten it down to just a handful per year and trying to wipe it out. And so we’re going to see threats like that, and we will be exposed to that.

The second reason is that the United States has stood for a different path in the world, one where we work cooperatively to solve big human problems. You abandon this work and trust in the world, our alliances and partnerships are shattered. And guess what? This is a gift to China and Russia, who have been attacking, propagandizing, and trying to destabilize this kind of work because it is a major source of our influence in Africa and Asia and Eastern Europe.

FLORA LICHTMAN: Do you expect Russia or China to take the US’s place?

ATUL GAWANDE: Neither one has the commitment and resources in quite the same way. China is the best position to do that. They’re already stepping in to take advantage when we didn’t deliver the same level and speed of response around Ebola in Uganda. Russia had moved a laboratory into place, which is not something we’ve seen happen before.

China tends to take a more transactional approach, that often has high commercial interest rates and all of those kinds of things. And the US’s approach has made us a close partner with many countries that don’t necessarily cooperate with us otherwise. So part of what China and Russia are doing is simply celebrating the destabilization and the increased conflict with the United States.

SALIM ABDOOL KARIM: Perhaps to expand on what Atul was saying, this new approach of the Trump administration, it’s sending a signal to the world that we, as the US, are no longer playing a leadership role in global health. We are stepping back. We are going to be the leaders of American health. And as far as global health is concerned, that’s your problem.

And pulling out of the WHO, which is the custodian of global health, is the first serious signal that that was going to happen. So the US has lost its leadership position in global health. It’s now no longer a serious player.

FLORA LICHTMAN: What are the repercussions of pulling out of WHO?

SALIM ABDOOL KARIM: Oh, they are very significant. At the most practical level, the US is a contributor to the budget of the WHO. So pulling out of the WHO means that the WHO has less funds. In many countries, the WHO is the main primary responder to major health hazards, whether it’s a pandemic or whether it’s a disaster. So it has a huge impact on the WHO and its ability to respond to major challenges around the world.

Secondly, its effect is to say to WHO that not only are we pulling out of the WHO, but we’re going to stop communication through the CDC. That’s a big problem because right now, globally, when we look at the threats that exist in terms of the potential for new pandemic, actually the number one threat is in the US from avian flu that’s currently spreading in the cows and present in the milk in the US. And for the World Health Organization, which has to protect the world’s health, not to have information about what is going on in that epidemic situation in the US is a very serious problem.

ATUL GAWANDE: On WHO, I’ll just say, to add to what Salim has to say, we don’t have access to many countries in the world for information. China and Russia are examples. And the WHO oversees the development of flu vaccines. And I don’t know how we’re going to get a proper flu vaccine this fall. We’re no longer participating in the flu network that generates our vaccine and makes sure it’s tuned to the most likely type of flu virus that will arrive in the US this year.

FLORA LICHTMAN: I want to zoom out for a second. I’ve read criticisms that foreign humanitarian aid can have this imperial component, right? Rich Western countries coming in, using aid to assert control and power, pulling the plug when it doesn’t suit them anymore. Is this a legitimate criticism?

ATUL GAWANDE: Yeah, it is a legitimate line of argument, right? The US has delivered its foreign aid traditionally with 95%-plus being US and international organizations delivering the aid, swooping into a country, but not necessarily putting countries on a path to self-reliance. It’s been vital that the work has really shifted in the last decade towards building capacity in countries. We are now pushing towards funding local organizations so that we’re building up their capacity.

That builds leadership and a transition pathway that moves countries off of depending on foreign aid, and there had been cycles of dependency. I think there’s legitimacy to the idea that when you depend on money from outside your borders, there comes strings attached. That’s never avoidable. But the US, when John F. Kennedy created USAID, he referred to the fact that the US depended on loans from abroad when we became an independent nation and needed to build up our own capacity after a war that decimated our own abilities.

SALIM ABDOOL KARIM: I think that the net effect for what’s happened now has been not just a reversal, but it’s been a harmful effect. This particular administration is not just about changing its priorities or its policies. It deliberately stopped the funding first.

It set out to do this in a brutal way. It set out to be harsh. It set out to show who’s in charge. It set out to show that it carries all the cards. It was deliberately done to create instability.

This is not about, OK, we’d like to spend our money on something different. Here’s a way in which we can transition to something else. This is about you are stealing our money. You are criminals at USAID, giving these foreign countries our money. That’s what we saw, and that is not just about undoing soft power.

FLORA LICHTMAN: Atul, big swaths of the American people are really fed up with government and how it spends money. If you were asked to reform USAID, what would you do? I mean, what do you think actually could work better?

ATUL GAWANDE: There’s always opportunities around waste and inefficiency. I drove at Global Health a set of changes, where we focused on maximizing the amount of impact per dollar in reducing the percentage of deaths that happen in a country before the age of 50. And we were able to drive significant reductions in mortality with less funds through both innovation and efficiency changes.

The second thing is I took over a Global Health team that reaches hundreds of millions of people with half the budget of the hospital system where I work and do surgery in Boston. So it is saving lives by the millions with, yes, a budget that’s $8 billion. That’s a big number but generating remarkable impact, like nothing we achieve in the US health system. So out of the average person paying $12,000 in taxes per year, the average family, it’s $38 that gives us freedom from polio, freedom from smallpox, massive control of HIV and addressing deadly diseases, and help for people who are malnourished, and so on. So it is already an extraordinary buy.

FLORA LICHTMAN: I want to thank you both for taking the time to join me today.

SALIM ABDOOL KARIM: Pleasure.

ATUL GAWANDE: Thank you.

FLORA LICHTMAN: Dr. Atul Gawande is a surgeon and former head of Global Health at USAID. Dr. Salim Abdool Karim is an epidemiologist and director of the Center for the AIDS Program of Research in South Africa.

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