What Does Dismantling USAID Mean For Global Health?

USAID has historically funded programs focused on disease eradication, maternal and child health, and healthcare infrastructure.

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• 0:00Speaker 00

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• 0:18Flora Lichtman?

  This is Science Friday. I'm Flora Lichtman. Today in the podcast, the repercussions of dismantling USAID and withdrawing from the World Health Organization.

• 0:27Speaker 02

  It's sending a signal to the world that we are going to be leaders of American health. And as far as global health is concerned, that's your problem.

• 0:41Flora Lichtman?

  On his first day back in office, President Trump issued an executive order targeting foreign aid. Funding for the U.S. Agency for International Development, USAID, has been frozen, and most of the staff has been placed on leave or laid off. Last 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 U.S. 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 Abdul Karim is an epidemiologist

• 1:23Flora Lichtman?

  and director of the Center for the AIDS Program of Research in South Africa. Welcome to Science Friday.

• 1:29Speaker 03

  Pleasure. Delighted to be here.

• 1:31Flora Lichtman?

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

• 1:39Speaker 03

  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.

• 2:15Speaker 03

  All of the 50 country network where we work with them to strengthen their ability to detect and respond to pandemic threats terminated and three quarters 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.

• 2:48Flora 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?

• 2:58Speaker 03

  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.

• 3:40Speaker 03

  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.

• 3:54Flora Lichtman?

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

• 3:59Speaker 03

  Exactly.

• 4:00Flora Lichtman?

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

• 4:14Speaker 04

  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 treatment, but because it can also lead to a drug-resistant form of HIV.

• 4:56Speaker 04

  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 USCID 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-one safety study of a new technology to prevent HIV in women. The woman had the technology already inserted.

• 5:32Flora Lichtman?

  These are intravaginal rings that are for HIV prevention?

• 5:36Speaker 04

  That's good.

• 5:36Flora Lichtman?

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

• 5:40Speaker 03

  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. 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. You know, when you abandon this work and terminate this work, there is, has to be a proper wind-down. SLIM 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.

• 6:22Speaker 03

  So it really is, it's a calamity for an organization like yours, SLIM, I have to suspect.

• 6:30Speaker 04

  Absolutely. And of course, from our point of view. You know, 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.

• 7:10Flora Lichtman?

  Atul, how widespread is this? Patients being left mid-treatment, mid-trial, without care?

• 7:18Speaker 03

  There are thousands of patients in trials across the world. We collaborate with NIH and others to make global studies possible. And those include, you know, 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.

• 7:54Flora Lichtman?

  Atul, President Trump, you know, 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.

• 8:08Speaker 03

  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, you know, 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.

• 8:53Speaker 03

  The second reason is that 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.

• 9:27Flora Lichtman?

  Do you expect Russia or China to take the US's place?

• 9:32Speaker 03

  Neither one has the commitment and resources in quite the same way. China's the best positioned to do that. They're already stepping in to take advantage. When we didn't deliver the same level and 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 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.

• 10:18Speaker 04

  Perhaps to expand on what the two were 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.

• 11:09Flora Lichtman?

  We have to take a break, and when we come back, what withdrawing from the WHO could mean for your health.

• 11:15Speaker 03

  WHO oversees the development of flu vaccines, and I don't know how we're going to get a proper flu vaccine this fall.

• 11:24Flora Lichtman?

  Stay with us.

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• 13:16Flora Lichtman?

  What are the repercussions of pulling out of WHO?

• 13:19Speaker 04

  Oh, they're 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 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

• 14:04Speaker 04

  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 potential for a 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.

• 14:44Speaker 03

  On WHO, I'll just say, to add to what Slim 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.

• 15:18Flora Lichtman?

  I want to zoom out for a second. You know, 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?

• 15:37Speaker 03

  Yeah, it is a legitimate line of argument, right? The US has delivered its foreign aid traditionally with 95-plus percent being, you know, 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.

• 16:20Speaker 03

  And there had been cycles of dependency. I think there is legitimacy to the idea that, you know, when you depend on money from outside your borders, there come 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.

• 16:49Speaker 04

  I think that the net effect of 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 hush. 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.

• 17:33Speaker 04

  This is not about, okay, 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.

• 17:51Speaker 04

  That's what we saw. And that is not just about undoing self power.

• 17:59Flora Lichtman?

  You know, 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?

• 18:15Speaker 03

  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, you know, I took over a global health team that reaches hundreds of millions of people with half the budget of a hospital system where I work and do surgery in Boston.

• 18:55Speaker 03

  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, you know, out of the average person paying $12,000 in taxes per year, the average family, it's $38 that goes, that gives us freedom from polio, freedom from smallpox, you know, 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.

• 19:40Flora Lichtman?

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

• 19:43Speaker 04

  Pleasure.

• 19:44Speaker 03

  Thank you.

• 19:45Flora Lichtman?

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

• 20:00Flora Lichtman?

  And that is about all we have time for. Lots of folks helped make this show happen, including

• 20:06Speaker 02

  Karys Oguchie.

• 20:07Speaker 06

  Sandy Roberts.

• 20:08Speaker 07

  Robin Kazmer.

• 20:09Flora Lichtman?

  Jordan Smudjic. I'm Flora Lichtman. Thanks for listening.