The Good, the Bad, and the Ugly: U.S. Foreign Aid

It's been about a year since alarm spread through the international development community as the Trump Administration took office and immediately set its sights on foreign aid. What initially began as a stop-work order for aid workers quickly escalated, turning into the dismantling of the United States Agency for International Development (USAID) and the cutting and withholding of billions of dollars in funding.

While generally pessimistic about the outcome of these cuts, many experts still couldn't have predicted the scale of the destruction that has occurred over the last year-decades of work halted at the stroke of a pen, or the click of a mouse, without regard for the consequences. Consequences that have been far-reaching, spanning loss of progress, loss of long-term partnerships, loss of critical supply chains, and, most devastatingly, loss of life.

So, all of that considered, do you want the good news first?

The Good

Partners In Health (PIH) is still standing in solidarity with our staff and patients worldwide. Care continues in the communities that we serve, and, in some cases, PIH is helping to hold together entire health systems that would otherwise collapse without this support.

Additionally, Congress still supports funding critical global health programs like PEPFAR and the Global Fund. Just this month, the House reasserted its power of the purse-Congress's authority under Article I of the Constitution, which provides critical oversight to the executive branch-by passing a $50 billion foreign aid spending package for this fiscal year. With bipartisan support, this bill signifies Congress's desire to continue providing significant funding to foreign aid, including global health. And while the spending amount in the bill is a decrease from previous years, it's more than $5 billion higher than what was outlined in President Trump's America First Global Health Strategy.

In reality, however, this is only good news if the money is actually spent as appropriated, which is constitutionally required. Currently, however, an expansive view of the power of the Presidency by the executive office has created a chasm between what Congress is asking for and what is actually being done with allocated funding, despite what the Constitution says. This implementation gap raises serious concerns about accountability, and about the future of U.S. foreign aid more broadly.

The Bad

The administration's America First Global Health Strategy, as mentioned earlier, is already starting to reshape the U.S.'s approach to foreign aid. With a focus on government-to-government agreements and co-investment, the strategy aims to rely more heavily on bilateral agreements, "in a way that directly benefits the American people and directly promotes our national interest," according to U.S. Secretary of State Marco Rubio. Outlined in the strategy is also the U.S.'s desire to leverage cheap access to "key minerals and rare earth elements needed as inputs into advanced technologies that fuel critical military and commercial applications." This approach marks a clear departure from past administrations' understanding of aid as a shared global responsibility.

As the current administration rolls out this strategy, negotiations between the U.S. and other countries on memorandums of understanding (MOUs) have already begun-largely behind the scenes and without crucial civil society involvement. And while all MOU's should be publicly accessible, in many instances they remain highly restricted, making it unclear how funding decisions are being made or how aid will ultimately be used. Organizations like PIH are left in the lurch, waiting for these monumental decisions to be made while unsure of which areas will receive funding and how to plan for the future.

Additionally, without meaningful transparency, local civil society groups have been unable to participate in the process, as seen for instance in Malawi, and in some cases, even the Ministry of Health has been left out of negotiations. While the US routing funds more through governments and requiring increasing co-investments could be good, many practical details have yet to be worked out.

The Ugly

This past year has been tumultuous, to say the least. The rapid and uncoordinated withdrawal of U.S. foreign aid roughly a year ago caused immense destabilization worldwide, revealing the unjust structures that have increased dependence on aid to begin with. But before those underlying structures can be transformed, we must first confront the immediate harm-the unnecessary suffering-caused by the reckless removal of lifesaving funding.

Over this past year, our teams around the world have documented examples of patients suffering and dying without access to medication or professional care as funding was pulled overnight. And we have to assume that for each story we hear, there are countless more that remain untold and unheard.

A patient in Lesotho traveled through challenging terrain to nine clinics searching for someone, anyone, to help him as he suffered from tuberculosis. Fortunately, he made it to a PIH-supported clinic where he was finally able to receive treatment and support. But we can't ignore all the patients who couldn't have made it to the ninth clinic, or even to a second one.

New data suggests that the U.S. federal government's cuts to current spending have resulted in between 500,000 to 1,000,000 deaths, while the decrease in commitments to future foreign aid spending could lead to an additional 670,000 to 1,600,000 lives lost.

"Every line item in the budget, there is a person, a patient, a nurse, a family," said Dr. Alain Casseus, director of infectious diseases for Zanmi Lasante, as PIH is known in Haiti, during a briefing call with Congress. "I'm asking you to remember the people behind these numbers."

It's for those people-their families, their communities-that we keep moving forward. Our work as clinicians, as global citizens, and as advocates remains essential to building a future where health is a human right, for everyone, everywhere.

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