ANALYSIS: One Year After the Demise of USAID, Global Health Workers Speak Out About the Gaping Void

The Most Effective HIV Program in History Under Scrutiny

Among all the programs managed or co-funded by USAID, PEPFAR—the U.S. President’s Emergency Plan for AIDS Relief—holds a special place. Created under the George W. Bush administration in 2003, it is often described as the most successful international public health policy in U.S. history. Its statistics are staggering: more than 20 million people on antiretroviral treatment funded by Washington, a reduction in HIV-related mortality of more than 90% in some target countries, and more than 5.5 million babies born free of the virus thanks to programs to prevent mother-to-child transmission. All of this at an annual cost of approximately $7 billion—an infinitesimal fraction of the U.S. military budget.

The closure of USAID and the subsequent freeze on funding have created existential uncertainty surrounding PEPFAR. Although the program has not been formally abolished, the administrative mechanisms through which it operated—contracts with partner NGOs, fund transfers to national ministries, and drug procurement—have been severely disrupted. Treatment interruptions have been documented in Zimbabwe, Uganda, Zambia, and Mozambique. For people living with HIV, a treatment interruption is not an administrative inconvenience: it is a viral resurgence—potentially the beginning of progression to full-blown AIDS—and an increased risk of transmission.

Twenty Years of Progress Hanging by a Thread

HIV epidemiologists are unanimous: twenty years of progress can be erased much more quickly than it took to build. When antiretroviral supply chains break down, when clinics close, when community health workers are no longer paid to track down lost-to-follow-up patients, the consequences are measured in decades of regression. The virus doesn’t take a break while Washington debates its geopolitical priorities. Drug resistances that develop during treatment interruptions are irreversible and can be transmitted. We don’t start from scratch—we start off worse.

Twenty million people on treatment. I want that number to hang in the air for a moment. Twenty million human beings whose daily survival depended on an administrative decision in Washington. And Washington decided to cut funding. Not for medical reasons. Not for reasons of effectiveness. For ideological reasons, to send a political message to an electoral base that, for the most part, doesn’t know what PEPFAR is and doesn’t know that these twenty million people exist.

Maternal Health: The Programs That Kept Rural Maternity Wards Afloat

Within the invisible hierarchies of international aid, there is an unwritten rule: when funding dries up, it is always the same people who bear the brunt first. Rural women in low-income countries. Children under five in conflict zones. Displaced populations without access to government services. USAID funded a significant portion of maternal and child health programs in dozens of countries. These programs are not abstract: they fund the salaries of trained midwives in villages without doctors, clean delivery kits that prevent fatal neonatal infections, vaccines and their cold chain in regions where electricity is intermittent, and nutritional supplements that make the difference between a child who survives and one who does not.

Accounts documented by USAID’s partner NGOs describe rural maternity clinics in Bangladesh that have had to scale back their services due to a lack of medical supplies. Programs to prevent infant mortality in Niger—a country that already had one of the highest infant mortality rates in the world—have been suspended due to a lack of funding. Measles vaccination campaigns in West Africa have been postponed indefinitely. Measles, it should be noted, was on the verge of being eliminated in several African countries thanks to decades of campaigns. It is now making a comeback.

Nutrition: The Front Line That No One Sees

Severe acute malnutrition kills silently. It doesn’t make headlines like an earthquake or a terrorist attack. It gradually takes hold in children’s bodies, weakens their immune systems, and makes pneumonia and diarrhea fatal. USAID funded emergency nutrition programs in the world’s most vulnerable famine corridors—the Sahel, South Sudan, Yemen, and northeastern Nigeria. These programs distributed ready-to-use therapeutic food (RTUF) to children suffering from severe acute malnutrition—sachets of nutrient-dense paste that, when administered correctly, enable recovery in most cases within a few weeks. The disruption to these programs cannot be measured in statistics. It is measured in children who do not wake up.

I often think of the nutrition workers who continue their work despite everything—those who remain in the displacement camps of the Sahel with whatever resources they have at hand, who fill out the monitoring forms for malnourished children even though they no longer have RPTs to treat them, who count those they can no longer save. In situations like this, there is a form of psychological abuse inflicted on the caregivers themselves—forced to witness the inevitable without having the tools to prevent it.

Not Projects, but Systems

One of the most fundamental misunderstandings in the public debate on international aid is the tendency to reduce USAID to a mere handout machine. This view is not only false but dangerously simplistic. What USAID has been building—over decades, with a patience its critics refuse to acknowledge—is systemic architecture. National public health laboratories capable of detecting and identifying emerging pathogens. Epidemiological surveillance networks that played a crucial role in the early detection of Ebola, H5N1 avian influenza, and other threats that, let’s not forget, do not stop at the borders of wealthy countries. Health information systems that enable health ministries to make decisions based on actual data rather than estimates. Drug supply chains built over twenty years to be resilient in the face of crises.

These systems cannot be improvised, nor can they be rebuilt quickly. When a national molecular biology laboratory in Ethiopia loses its operating funding and its qualified technicians—trained for years with U.S. funds—leave the public sector for the private or international sectors, that capacity cannot be regained in a matter of months. It is lost for a generation. And in the meantime, pathogens that would have been detected and contained early on circulate silently.

The Looming Epidemiological Disaster: What Experts Fear Most

Global health security experts who agreed to speak—often on condition of anonymity, fearing reprisals in a volatile U.S. political climate—paint a scenario that should deeply concern policymakers, including those who care little about international aid per se. Global epidemiological surveillance funded by USAID was a major component of the pandemic early-warning system. That system has been massively weakened. Surveillance posts in regions at high risk for zoonosis—the transmission of viruses from animals to humans—have been closed or scaled back. Partner laboratories that shared their data with the U.S. Centers for Disease Control and Prevention (CDC) have lost their funding. The world is being made less capable of detecting the next pandemic. And the next pandemic won’t ask Washington for permission before it emerges.

There is a profound—and deeply bitter—irony in the fact that the administration that handled the COVID-19 pandemic in the most catastrophic manner is also the one dismantling the systems designed to anticipate the next one. But irony doesn’t save lives. It counts them—after the fact.

The European Union and the Rest of the World: Trying to Fill a Chasm with a Spoon

Faced with the scale of the U.S. withdrawal, the international community has attempted to respond. The European Union has announced increases in its contributions to several multilateral humanitarian funds. The United Kingdom has pledged emergency funding for certain PEPFAR programs in Southern Africa. Countries such as Germany and France have sought to mobilize additional bilateral funding. Private foundations—led by the Bill & Melinda Gates Foundation—have announced emergency funding packages to try to fill the most glaring gaps. These efforts are genuine and deserve recognition. But, to be honest, they are clearly structurally insufficient given the scale of the void that has been created.

USAID accounted for approximately 40% of global humanitarian funding in certain sectors. No single actor—not the EU, not China, not private foundations—has either the capacity or the political will to replace that level of funding. China, often presented as the natural geopolitical alternative, has a fundamentally different vision of development cooperation—one centered on infrastructure and natural resources, not on community public health. The United Nations is structurally underfunded and itself relies heavily on U.S. contributions. There is simply no replacement for USAID. What America has destroyed cannot be rebuilt by others.

Local NGOs Facing Collapse

In the U.S. discourse surrounding the closure of USAID, one voice is almost entirely absent: that of local civil society organizations in recipient countries. These organizations—rural women’s associations, community health networks, HIV patient groups, agricultural cooperatives—had often built partnerships with USAID not merely as passive recipients, but as co-developers of programs rooted in local realities. These organizations lost their funding overnight. Many had to lay off their staff. Some closed down. It is not just money that is disappearing—it is social capital accumulated over years, irreplaceable networks of community trust, and a presence on the ground that no international agency can recreate by decree.

Local civil society organizations are the most valuable and fragile aspect of international aid. They know the villages, the families, the cultural resistance, and the paths that lead to women who would never go to a conventional clinic. When they close, we don’t just lose offices. We lose decades of on-the-ground knowledge. And that knowledge cannot be rebuilt with another check.

The “America First” Ideology Applied to Human Life

It would be intellectually dishonest to portray the closure of USAID as a mere management blunder or a hasty decision. It is an ideological decision consistent with the worldview that has driven the Trump administration since 2017. The “America First” doctrine does more than simply prioritize American interests—it is rooted in the belief that international aid is fundamentally a waste of money, a squandering of resources for the benefit of ungrateful foreigners, and worse, a tool of a globalist elite that uses American taxpayers’ money to fund a progressive worldview incompatible with the values of the Trumpist base. This view is factually false in almost every respect, but it is politically powerful because it is simple and appeals to resentment.

What this ideology fails to mention—what it refuses to acknowledge—is that U.S. international aid was not pure altruism. It was also, and perhaps above all, an instrument of strategic power. USAID’s presence in a country created ties, positive dependence, and influence. It opened trade doors, facilitated security cooperation, and built international legitimacy. American generals, seasoned diplomats, and national security strategists have all, at one time or another, advocated for foreign aid not for humanitarian reasons but for reasons of well-understood national interest. By dismantling USAID, Washington is not merely abandoning the world’s poor. It is weakening its own global influence to the benefit of its competitors.

Who Benefits from the American Vacuum

The question deserves to be asked head-on: in the real world of geopolitics, who benefits from the U.S. withdrawal from international aid? The answer is complex, but certain actors stand out. China, whose strategy for engagement in Africa and Southeast Asia is based precisely on offering alternatives to Western influence, finds itself with a strategic space that has been vacated. Russia, whose influence operations in African countries seek to replace one form of dependence with another, can portray the U.S. withdrawal as proof of the West’s treachery. Regional players—Turkey, the Gulf states, and India—are quietly strengthening their own cooperation programs in the vacated spaces. Washington has unilaterally ceded ground to its strategic competitors in the name of an economy worth a few billion dollars a year—a paltry sum by the standards of the U.S. federal budget.

There’s a phrase I often hear in diplomatic circles that seems to me to sum up what has happened with brutal precision: “America spent sixty years and hundreds of billions of dollars building a global network of influence through development aid. It took just one year to dismantle it. Its adversaries couldn’t have asked for anything better.” ” This isn’t anti-Americanism. It’s a geopolitical assessment.

Fatima, a health coordinator in the Sahel

She gives only her first name. For eight years, she had been coordinating a USAID-funded maternal health program in a region of Mali where the maternal mortality rate was among the highest in the country. Her program trained village midwives, distributed clean childbirth kits, and organized emergency evacuations for obstetric complications. “In February 2025, I received an email in English telling me that my contracts had been suspended. I have two hundred pregnant women on my registry. I tried calling the regional office—no one answered. I waited three weeks, hoping it was temporary. Then I had to lay off my staff. Since then, I’ve been hearing about deaths—women who might have survived if we’d been there.” She isn’t making accusations; she’s simply stating facts. The difference between the two is smaller than one might imagine.

Her account is not an isolated one. Dozens of health workers in similar situations have described the same scenario: the abrupt suspension, the communication blackout, the vain hope that the situation would be temporary, and then the reality of having to choose between continuing without pay—which some did for weeks—and giving up. And behind these health workers are the communities they served—invisible to Washington, invisible to the Western media, but very real in their vulnerability.

Dr. Emmanuel, a pediatrician in Uganda

Dr. Emmanuel—a pseudonym—is a pediatrician at a district hospital in Uganda, where an entire wing was funded by USAID through PEPFAR. His pediatric HIV unit treated several hundred children born HIV-positive or exposed to the virus. “When funding was suspended, I had meetings with the hospital administration every day for a month. No one knew how long it would last. We started rationing the medications. We were giving reduced doses so the supply would last longer. That’s exactly what you’re not supposed to do with antiretrovirals—it promotes resistance. But we had no choice.” Dr. Emmanuel says he lost two patients during that period—children—whose deaths he attributes directly to treatment interruptions. He doesn’t know how to be certain. He knows they died.

Children dying because their antiretrovirals were rationed because an American president decided that international aid was a waste. I don’t know how else to write that sentence. I don’t know how to soften it. I’m not sure I want to soften it.

Republicans, military officials, diplomats: the unexpected opponents

It would be inaccurate to portray the closure of USAID as a consensus within the United States. Even within the U.S. political system, prominent voices—and not just Democrats—have spoken out against this decision. Former high-ranking military officials, including several retired generals, have publicly criticized the dismantling of international aid in the name of national security. Republican senators—particularly those representing states whose agricultural exports indirectly benefited from USAID’s food programs—have expressed reservations. Former U.S. ambassadors to African countries have testified before congressional committees about the impact on U.S. interests themselves. These voices have not been heard. But they do exist, and they document that the ongoing disaster is not inevitable—it is the result of a political decision that can be reversed.

The Global Health Advocates movement in the United States has coordinated a campaign of testimonies from health workers around the world before congressional hearings. U.S. universities specializing in international public health—Johns Hopkins, Harvard, Columbia—have published detailed analyses of the anticipated impact on global mortality. The American Federation of Health Workers has set up solidarity funds for laid-off USAID workers. It is important to document this internal American resistance: it shows that America is not monolithic in its abandonment of these efforts, and that a change of course remains politically possible.

Congress: Between Institutional Powerlessness and Passive Complicity

One of the most important legal and constitutional issues raised by the shutdown of USAID concerns the prerogatives of Congress. USAID funds are appropriations authorized by the U.S. Congress. By freezing them via executive order, the Trump administration has—according to several constitutional scholars—crossed the line into “impoundment,” that is, the illegal refusal to execute expenditures authorized by the legislative branch. Legal challenges have been filed. Temporary injunctions have sometimes been granted by federal courts. But in the operational reality on the ground, these legal battles were unfolding at the pace of the U.S. institutional system, while vital programs were collapsing at the biological pace of Africa or Asia. The slowness of the legal system is ill-suited to the urgency of hunger or epidemics.

What deeply troubles me about this story is the passive complicity of a large portion of the U.S. Congress—including some Democrats, who were too cautious to make this a high-profile political cause. While lawyers argued and judges deliberated, programs were shut down. Lives were turned upside down. The institution charged with overseeing the executive branch stood by, wondering whether it was the right political moment to act. That calculation comes at a cost. It is paid for in human lives elsewhere in the world.

Lost Trust: A Generation of Distrust Toward International Aid

Beyond the immediate impacts—shortages of medicines, program closures, and staff departures—the shutdown of USAID has caused damage that is harder to quantify but may be more lasting: the destruction of trust. Decades of U.S. international aid had painstakingly built a partnership—imperfect, often asymmetrical, sometimes condescending, but real—between vulnerable communities and a network of Washington-funded institutions. This relationship was based on a minimum level of predictability: if the program said it would be there, it would be there. That predictability has been shattered—abruptly, publicly, and without warning.

Ministries of health that had incorporated USAID funding into their multi-year plans will now—and they are right to do so—refuse to start over. Local NGOs that eventually rebuild will frantically diversify their funding sources so as never again to depend so heavily on a single donor. Local health professionals trained with U.S. funds will seek to redirect their careers toward less volatile employers. All of this is rational. And all of this will make U.S. international aid less effective, even if it were to return tomorrow.

The world after this: Is it possible to rebuild?

Development aid experts who have spent their careers building the systems that USAID funded pose the question with quiet urgency: Is there still time? The honest answer is: yes, but on one condition. It is not enough to restore funding. We must rebuild the structures, retrain the staff, reconstruct the supply chains, and restore institutional trust. All of this takes time—years, at best. And during this reconstruction period, people are dying from preventable diseases, children are growing up with irreversible consequences of malnutrition, and epidemics are spreading without adequate monitoring. The cost of dismantling these systems is being paid not only today, but in the years and decades to come.

I’m thinking of the metaphor of ancient forests—it takes centuries for a primary forest to form, and just a few hours to cut it down. What was cut down in January 2025 was sixty years of patient work to build global health capacity. Reforestation will take at least as long. And while we try to replant, we cannot eat in the shade of trees that no longer exist.

The Moral Question the United States Refuses to Ask

At the heart of this debate over USAID lies a question that the United States—as a nation, as a society, not just as an administration—must ask itself. For sixty years, American power has created a form of structural dependence in dozens of countries. It did so deliberately, by funding systems that could not function without it. It gained political influence, international legitimacy, and a sense of benevolent power from this. Then it withdrew that support. The moral question is not only “Was it right to cut off aid?” but also “Was it right to create this dependency knowing that it might one day be withdrawn?”

This question is not intended to exonerate the Trump administration of its responsibilities—the brutality and speed of the dismantling are indefensible. But it forces us to look deeper: the model of international aid as it has been practiced, with its logic of perpetual dependence rather than built sovereignty, carried within it the seeds of this catastrophe. A world where the public health of entire countries depends on the political decisions of a single American electorate is a structurally fragile world. The question of the autonomy of national health systems in low- and middle-income countries is no longer merely academic. It is existential.

The U.S. Image Abroad: A Decade of Necessary Reconstruction

In terms of U.S. foreign policy, analysts agree on one point: the reputational cost of shutting down USAID will be measured over a decade, not a single term in office. Countries that were once reliable partners of Washington in strategic regions are reevaluating their alliances. Populations that once associated the United States with generosity and partnership now associate it with abandonment. This is not a marginal sentiment—it is a shift in perception documented in polls conducted in dozens of countries. American soft power, built up over generations, is eroding at a rate that concerns even those who are indifferent to humanitarian issues but highly attuned to geopolitics.

There is something profoundly American about the ability to build up over generations and tear down in a single term. This is not a cultural judgment—it is an observation about what short-term political systems allow in societies with direct democracy. When the consequences of your decisions manifest themselves on the other side of the world, in languages you don’t speak, on faces you’ll never see, the system has no natural feedback mechanism. This is the great vulnerability of democracies when faced with decisions whose costs are externalized far from the electorate.

What a Year of Silence Says About Us

A year has passed. In Western capitals, the debate over USAID has subsided, replaced by other emergencies, other crises, other headlines. But in the villages of Mali, in the camps of Sudan, in the clinics of Mozambique, in the district hospitals of Uganda, nothing has subsided. The consequences are unfolding amid relative media silence, at an inexorable biological pace. Children are being born into conditions that no longer existed two years ago. HIV-positive adults whose treatments have been interrupted are developing drug resistances that their children may inherit. Epidemics are spreading unchecked. This silence is not global indifference—it is moral geography. What happens far away, in unfamiliar languages, in bodies we have never seen, carries less weight. This is how human attention works. And this is exactly what those who make decisions whose victims are invisible are counting on.

What healthcare workers around the world are telling us, one year later, is simple and devastating: they are still holding the line, wherever they can, with whatever resources remain, for communities that have nowhere else to turn. Some continue to work without pay. Some have repurposed programs, sought alternative funding, and cobbled together local solutions. This resilience is admirable and should not serve as an excuse for those who chose to cut funding—“they’re managing anyway” is not a justification; it is an insult to the ingenuity displayed out of sheer necessity.

What remains to be done—and what will not happen without political will

Reconstruction is possible. It is not inevitable. It requires a U.S. policy decision to return—not just with money, but with a long-term vision, a renewed sense of humility, and an aid framework that is less paternalistic and less dependent on U.S. election cycles. It also requires an international decision not to replicate the same model—to build truly sovereign national health systems capable of functioning without a single external donor. These two necessities are not contradictory. They are complementary. And they are urgent. Because while we deliberate, biological time marches on. Diseases do not take a break. Malnourished children grow—or fail to grow.

I’ll conclude this article with a simple conviction, which I want to state without rhetoric: international aid is not charity. It is politics. It is strategy. It is national interest, properly understood. And it is also—and this shouldn’t be the last argument; it should be the first—a question of what we choose to be as a species. We have the means to prevent children from dying of preventable diseases. We have chosen, for now, not to use them. That choice has a name. It has consequences. And there are those responsible for it.

Signed, Jacques Pj Provost