Episode 12: The Dismantling of U.S. Foreign Aid and the Consequences for Global Health

In this episode, Joseph Harris explores the actions taken by the Trump administration to dismantle U.S. foreign aid and the consequences that these actions will have for global health. He sits down with Dr. Beth Cameron, a former Senior Adviser to the U.S. Agency for International Development (USAID); Nidhi Bouri, former Deputy Assistant Administrator at USAID; Dr. Brooke Nichols, Associate Professor of Global Health at Boston University and creator of as U.S. aid freeze impact tracker; and Sheena Adams, Global Communications Director for The Accountability Lab, which launched its own Global Aid Freeze Tracker. 

Transcript

Global Health Politics Podcast

Episode 12: The Dismantling of U.S. Foreign Aid and the Consequences for Global Health

SPEAKERS

Joseph Harris, Elizabeth Cameron, Nidhi Bouri, Brooke Nichols, Sheena Adams

Joseph Harris  00:00

Welcome to the Global Health Politics Podcast, where we go beyond the articles and books and have real intimate conversations with people working in the field of global health today. I'm your host. Joseph Harris. This episode of the podcast is a bit different than anything we've ever done before, in that rather than having an intimate conversation with one person, we take up one broad issue of importance and have conversations with several people about it. If you work on the politics of global health today, there are few issues more concerning than the Trump administration's dismantling of US foreign aid and the consequences for Global Health.  Today, we'll dig into this issue, speaking with four experts about it, two who worked at USAID and in the US government during the Biden administration, and two people who worked in academic and nonprofit institutions who were examining the impact of the aid freeze, the firing of workers and the termination of USAID.  So when we talk about the dismantling of US foreign aid, what do we mean? Well, it's important to understand that the dismantling of US foreign aid didn't stem from just one action, but a series of actions that began on President Donald Trump's first day in office, with an executive order that froze all US foreign aid for 90 days while a review was to be conducted of that aid to assess how it aligned with American values. Four days later, on January 24, a stop work order was issued, not just for new disbursements of US foreign assistance, but all foreign assistance. Three days after that, on January 27, a formal review of USAID began that involved placing senior career USAID staff on leave and firing hundreds of others, while the review considered closing programs, posts and activities and the reduction of workforce size. One day later, on January 28, a waiver was granted for life saving humanitarian assistance. And four days after that, on February 1, a limited waiver that allowed for the resumption of the life saving HIV treatment programs of the President's Emergency Plan for AIDS Relief, also known as PEPFAR, was granted, but roughly two weeks later, media outlets were quoting Republicans and aid workers with knowledge on the ground that suggested this aid was not flowing. Two days later, on February 2, the USAID website was taken down. And a day after that, on February 3, Secretary of State, Marco Rubio, who had been a long proponent of US foreign aid in the past, was appointed acting USAID Administrator, and the offices of USAID were closed and staff prevented from accessing the building. On February 6, the first series of lawsuits challenging the aid freeze was filed, and those began to wind their way through the courts. On March 10, the Trump administration announced that a six week review of USAID had been completed, and 83% of USAID programs were terminated. A little more than two weeks after that, on March 25 the one-year reauthorization of PEPFAR was allowed to lapse, and three days later, on March 28, the administration announced its intent to terminate USAID and fold its few remaining functions into the State Department, with almost all USAID workers to be fired by September, including more than 10,000 foreign nationals. Now, while this timeline gives some semblance of order to the complicated series of actions that took place, it's worth emphasizing just how quickly they happen. Most within the administration's first two months. It's also worth emphasizing just how chaotically the actions unfolded, disrupting the lives of people receiving aid, aid workers and their families, and organizations with a long history being involved delivering aid. Moreover, many of the programs that had been developed and involved long term partnerships and collaborations, and the suddenness of the disruptions undermined that trust that had been carefully built over time, leaving people, their families and communities in the lurch, and in many cases, putting lives that depended on that aid, quite literally at risk. The suddenness of these actions were also important, not just for partnerships with foreign countries and people in local communities, but because they called into question the stability of working for the US government. If people could be fired so haphazardly, why go to work there? Now what is important to remember is that USAID was a congressionally authorized and funded agency, and these executive orders came without approval of Congress, which, as yet has not challenged the administration's challenge to congressional authority. So these are the actions and their impact, which we'll be talking about in today's podcast. To get a better handle on the situation, the first person I spoke with was Dr Elizabeth Cameron, a professor of the practice at Brown University's Pandemic Center. Dr Cameron worked at a very senior level on global health issues for the US government, at the US Department of State, Department of Defense and National Security Council during both the Obama and Biden administrations, including as a senior advisor to US Agency for International Development. Dr Cameron, you've expressed concern about not just the cuts to US foreign aid, but also to the US Health Department of Health and Human Services and the Centers for Disease Control. Can you say a bit about that? What action is the administration taking that concerns you and why?

Elizabeth Cameron  05:36

Thanks, Joe, and thanks so much for having me. My colleague and I, Stephanie Psaki just wrote a piece about this in just security, where we were looking at the national security implications of the cuts, not only the foreign aid, but the domestic cuts at HHS and CDC and essentially, the administration is terminating the entire USAID workforce through a massive reduction in force, and at the same time, they've been making major cuts to our domestic health programs. And what that amounts to is making large organizational changes and cutting over 20,000 jobs at HHS, CDC, FDA, NIH, and our thesis is really that these changes, and particularly the way that they're being made, with a sledge hammer and not a scalpel, and without any phased approach or communication about what that approach really is at all, is actually making America less safe. So for example, these cuts, in my opinion, are making it more likely that we're again going to have to fight deadly diseases like Ebola at home, because we're cutting the programs and the staff that intend to stop outbreaks at the source at the same time, of course, we're cutting our state and local capabilities to respond quickly to those threats. So it's really a double whammy. These cuts really don't make sense. We have major US outbreaks. Obviously, we have the measles outbreak in the United States, which just passed 700 cases. We have six American states that have more than three cases of measles right now, three or more cases of measles right now. And we've got global outbreaks of Ebola, mpox and other deadly disease threats that we're fighting. In addition these cuts, particularly to the global health security programs at USAID are cutting biosafety and biosecurity efforts, and these are targeted not only at improving public health, but at preventing bioterrorism and laboratory accidents. So overall, I would just say that these approaches are not making America healthier, they're making America less secure.

Joseph Harris  07:42

Why was USAID one of the administration's first targets? And why is the Trump administration freezing US foreign aid and shutting down USAID?

Elizabeth Cameron  07:50

So it's a great question, Joe, and I think that USAID was one of the first targets of the administration because they made an assumption that first many people in the United States wouldn't care about foreign aid, and second, that the foreign aid community wouldn't be able to effectively fight back, especially when there was a really persistent and loud narrative about discontent with the US federal government. So what we've learned, though, since that time, since January, through polling, is that, and what we've known for a long time is that America, the American people and Republican and Democratic lawmakers, actually really care quite a bit about foreign aid, especially when they're presented with facts about what the programs do, how they're run, and what they achieve for our homeland and our national security. So as one example, The Kaiser Family Foundation did a poll last month, and it said that while many Americans do support some reductions in foreign aid, the vast majority of the public does not want aid to be eliminated entirely. Only about 13% of people really believed that foreign aid should be eliminated entirely. So that's most of the United States is saying, in a bipartisan way that foreign aid should continue and even among Republicans, scaling back on global health spending is more popular than ending that spending. The other issue to be aware of is that most Americans really overestimate the share of the federal budget that goes to foreign aid. Nearly nine in 10 American adults think that about a quarter of the US budget is spent on foreign aid, when in fact, the reality is that only approximately 1% of the federal budget goes to foreign aid. And so what that brings us to is that I'm honestly not sure why the administration is taking that information and deciding to close USAID and really inflict self inflicted wounds on our smart power. So this is really hurtful to the United States in a number of ways. First and foremost, shuttering US foreign aid is killing people, and we've seen some great reporters like Nick Kristoph at the New York Times. Programs, who's really documented specifically that children are dying because of these actions. Second shuttering US foreign aid is hurting American businesses. We know that American businesses are providing food for malnourished children around the world, and we know that foreign business, that American businesses, are implementing US aid programs in states across the United States. And I'd really encourage your listeners to go to the impact project.org which showcases the impact of the cuts on foreign aid and other programs that are being cut by the administration, how they're actually impacting American states. Third, shuttering US foreign aid really paralyzes America's ability to fight deadly biological threats and other major disasters that affect not only the world but American interests, and it's really hurting our leverage with foreign governments, and that leverage is preventing wars and keeping our Department of Defense from having to engage with boots on the ground. So these are the reasons why I'm quite flummoxed as to why the administration would be targeting foreign aid in the way that it is.

Joseph Harris  11:07

People don't often appreciate the relationship between foreign aid and infectious disease. You have a PhD in Biology. You played a leading role overseeing the US government's efforts to prevent and respond to biological as well as chemical and nuclear threats. You've twice served on the White House National Security Council staff, helping to establish and lead the National Security Council's Directorate on Global Health Security and Biodefense. You've also served as a Senior Adviser for Global Health Security at USAID Global Health Bureau. As someone with a great deal of experience working on threats posed by infectious disease, can you comment on what the termination of USAID and freezing of foreign aid means for US national security and, more broadly, global health security?

Elizabeth Cameron  11:54

This is a really pivotal question in my view. I've spent most of my career in national security because defending against infectious disease threats, no matter whether they're caused naturally by naturally occurring diseases, or whether they're deliberate or accidental, is a national security and a homeland security issue, and I would note also that it's been a bipartisan issue for at least the last four administrations, and I've worked on This issue in each of them, including the bush George W Bush administration, the Obama administration, the first Trump administration and the Biden administration. So this issue has been bipartisan up until this point, and in particular, Presidents George W. Bush and Barack Obama highly prioritized countering by a lot, countering biological threats, notably by increasing and starting programs at CDC, USAID, the Pentagon, the State Department. And one of the critical reasons for starting those programs was actually September 11, 2001 in the anthrax attacks in October of that year, the Bush administration was really worried about bioterrorism. And then right after that, we got hit around the world with the SARS epidemic. We saw rising cases of h5 and one in South East Asia in the mid 2000s and then, of course, the h1 n1 pandemic, and into the Obama administration, the Ebola epidemic in West Africa, and then, of course, heading into COVID 19 and regular outbreaks of mpox, Ebola and Marburg. And so for when you look at the milieu of infectious disease threats that we face, we see a lot of reasons to be worried about naturally occurring, deliberate and accidental disease threats. And that really led to the development of global health security programs that that look at all three potential causes of an infectious disease threat, because we won't really know at the beginning of a threat many times exactly how that how that disease threat originated, and we have to be ready for any emerging biological threat. What these programs actually do across four or five different departments and agencies is they prevent preventable, wherever possible, biological threats from occurring, and that's by bolstering biosafety and biosecurity around the world, they detect threats early, so that's people, and also programs to build lab capacity and disease surveillance capacity, so that we in the United States and around the world can learn about threats quickly, stop them if we possibly can, and mitigate their impacts as quickly as possible. And then, of course, there's response capacity, the ability to actually send countermeasures, people and and supplies in order to be able to contain outbreaks and contain the harm that they cause. So these are all of the reasons why when we're. Looking at biological threats, we're looking at national security issues, and we're looking at programs that are, and always have been national security programs. So we're talking about sort of three categories of of things, preventing, detecting and responding, and then three categories of of of issues that have been, that have been at the forefront of these foreign aid cuts, which are the people, the programs, and then what I'd like to call our protective shield, or our deterrence against biological threats. And all three of these categories have been deeply affected by the foreign aid cuts.

Joseph Harris  15:36

A lot of attention related to the US government foreign aid freeze has centered on the pause of the President's Emergency Plan for AIDS Relief, also called PEPFAR. Professor Brooke Nichols, also at BU put together an aid impact tracker on the impact of the freeze on PEPFAR. It's already been found that more than 31,000 people have died, including 3000 children as a result of just the PEPFAR freeze by the end of March. And Dr Nichols herself suggests it will take more than a decade just to fix the damage done in the first two months the freeze alone. What worries you most about the freeze and are there things that keep you up at night?

Elizabeth Cameron  16:20

Yeah, and I have to just say here that the first, the very first thing that comes to my mind when you talk about the impact tracker and the pause on PEPFAR is that the pause on this program and other life saving treatment programs was really immoral. It's contrary to American values, to stop life-saving treatments, especially when those treatments are coming from the richest country on Earth in service of a program that is helping people around the world. This this pause has really put the poorest people in the world and the implementers who are from their communities, in the position of having to stop treatment. And I think that that's something that will resonate, and certainly resonated with me, and I think resonates with others, is this is really the equivalent of telling those implementers to violate the Hippocratic Oath. It's saying we have the treatments. We can't, you can't give them to people. You have to stop this work. And so I think that it's important, and I do think that a lot of people in the United States are looking at the pause on these programs as as first and foremost, a pause on on saving lives around the world in in terms of what worries me and what keeps me up at night. In addition to that, I'm really worried about the consequences of stopping these and other programs to our own safety and security. These programs have a direct benefit, as I mentioned earlier, to our national and our homeland security, but they also have a less direct benefit in terms of our smart power, our face in the world, our leadership, our ability to successfully negotiate positions for the United States often relies on how we're viewed in the world and the norms and standards that we uphold. And until this point, in multiple different administrations, Democratic or Republican, the United States has really been viewed as a leader in the world, a leader for free actions, a leader for saving lives. And I think these kinds of drastic changes which are costing lives and were made without seemingly considering impacts like these on the world, they really make other countries and other people sit back and look at the United States and think about whether we're still the partner that they always believe that we were. And so that really does keep me up at night. And I think that, I think that these this is changeable. I think that Congress and the administration still has time to reverse, to reverse this course of action, but the longer that we continue to be a chaotic partner in areas like global health and foreign aid. More broadly, the harder it is for countries to trust us now and also in the future. So that really does keep me up at night.

Joseph Harris  19:15

Millions of people in some of the world's poorest nations, as we've been talking about, have been unable to continue receiving life saving aids, medicine, TB, medication, for example, because of the freeze and many have already died as a result. Beyond the direct human cost. Can you say anything about what kind of consequences loom in relation to drug resistance, not just in relation to AIDS and TB, but other diseases as well. Is there a price tag you can put on that?

Elizabeth Cameron  19:43

I'm not sure I can put a specific price tag on it, but it's to me, it's just common sense that if we really abruptly stop treating people with infections that are either drug resistant now or diseases that are prone to drug resistance, then those diseases are going to be more likely. To spread, and they'll be more likely to impact us and others around the world. So it's really in our best interest here at home and in terms of saving lives around the world to keep these programs going. But maybe to give just a little bit more granularity in the memo that he published in the New York Times, Nick enrich, the former USAID Acting Administrator for Global Health estimated that halting TB control efforts could increase cases of tuberculosis and multidrug resistant forms of that disease by 28 to 32% globally. In addition for HIV and TB, we're also losing investments in lab systems that can also backslide our capacity for early disease detection, including for drug resistant strains. That capacity gap has been hard to quantify, but it's going to happen. We're worried about that happening, and we also know that AIDS has gone from being a constant threat that it was obviously a death sentence many years ago to being a chronic illness in many countries, including in the United States. That's because of the investments in these programs to get access to ARVs and prep and if we stop those programs, it's obviously going to re emerge quickly.

Joseph Harris  21:15

How are global health institutions and other national health and aid agencies addressing these challenges created by the US government pull out on global health and foreign aid?

Elizabeth Cameron  21:26

This is a great question. So I've been in a number of conversations with different institutions, and I want to be clear that I'm not speaking on behalf of any of them. So I guess what I'll just say is that not only the global health institutions in the world, but also humanitarian institutions, that's organizations from the World Health Organization to organizations like GAVI, CEPI, the Global Fund, the pandemic fund, the International Federation of Red Cross and Red Crescent. All of these organizations are really grappling with how to proceed, and of course, they're asking other donors to fill short term gaps and to try to infuse some order into the chaos that was really created when the United States froze foreign aid. But they're also just grappling with what to do substantively with some of these programs because there is such a drastic change in the funding and implementation of them, I think some low and lower middle income countries are realizing that they relied a lot on the United States for funding in many different areas. I'd say that that's funding where not only those countries, but the United States saw great benefits in terms of peace, security, stability in the world, global freedom, diplomatic negotiation capacity. So I think that those benefits were critical, both for those countries and for us. But now international organizations are really doing what I think is responsible work of determining what comes next, and what comes next is, I think, going to look different from what we had before. And so there's a number of changes that are being considered, including looking at programs that cut across vertical disease threats, looking at different ways to incentivize financing for domestic resources to be put into areas of health and health security. Many are looking at different ways to mobilize the private sector and markets and looking at ways of regionalizing manufacturing and supplies. A lot of these are things that were being heavily considered coming out of the Ebola, sorry, coming out of the COVID pandemic. And none of these are bad things. Many of these are important changes that have been challenging to make, because obviously, the world experienced a large setback in sustainable development and in our in life expectancy coming out of the COVID pandemic. But now, of course, these things are being are being accelerated, and they're being accelerated amidst, I think, a really chaotic landscape that was driven by the the the decisions that the administration has made. That being said, I think that this is going to be an incredibly interesting time for foreign aid and global health, and I am worried that the United States isn't going to get nearly as much of a say in what comes next, because we're not. We're not sort of leaning forward to be at the table in determining how the landscape will change. Instead, we're pulling backwards.

Joseph Harris  24:38

Well, on that note, are there other countries or institutions that are filling the vacuum or void left by the US departure from global health and foreign aid?

Elizabeth Cameron  24:47

So some country countries have increased spending and pledges, but other countries are announcing decreases because they're realizing that that countries like the United States are decreasing their funds. In certain areas, and also because of the impact of changes that the United States is making in other areas. That's leading, for example, countries in Europe to increase defense spending. That's causing a change in how some countries are viewing their foreign aid investments as well. So I think across the board, there's really no organization or government out there right now that's saying that they want to proactively fill the void that's being left by the US departure. And frankly, there's not likely enough funding available to fill those gaps, which adds to the complexity here. In addition, I should note that there are some some partners who are stepping in to some areas, notably China and Russia, and some of those countries have different ways of working with global partners than the United States does, and that's also going to impact the global health landscape. And then I guess lastly, I'd say that over time, the goal has always been for countries to take over, to take over their own funding for health and health security. But pulling the rug out from under them isn't really going to get us, I think, to the sustainable place that we want to go. And so, I guess to leave this, this question on a on a more, more optimistic note, I do think that that is that has infused some creativity into into some of the countries and continents, in particular the African continent that's been looking a lot at how to build domestic resources for things like global health, and so I think we're going to see additional regional ownership, additional country ownership, and hopefully additional sustainable innovation. That's something that at the brown pandemic center, we're excited about working together with our partners around the world on areas like global health security, financing and innovation in order to be helpful in this moment when that's really what we need is some additional creative solutions for financing to bridge the gap where we're seeing more high income countries decreasing their contributions, and we're seeing more low and lower middle income countries being interested in in accelerating their own ability to finance some of these some of these gaps,

Joseph Harris  27:26

it's still a ways away. But how do you think things will change if, for example, the Democrats take back a number of congressional seats in the 2026 midterm elections, or if Democrats take back the White House in 2028?

Elizabeth Cameron  27:42

So my honest answer is that I'm not sure. I wish I had a crystal ball. I am optimistic that we can build or rebuild, I guess, a US commitment to foreign aid. But as I mentioned before, I think that it's going to look different no matter, no matter what happens. Congress, though I would note has continued to provide funding in the continuing resolution that funding is still available for the programs that Congress authorized and appropriated that money for. I think it's going to be really important in the coming weeks for Congress to bring forward its vision of how it wants the administration to program that funding, and I think that will provide some insights and hopefully some opportunities to be able to continue to program foreign aid, even if that programming looks different than it has in the past. There are obviously a lot of there's a lot of discussions in Washington about what that can look like. For example, how it could look to bring program programming together across vertical disease silos and to build additional horizontal programs with shared metrics. There's also a lot of interest, I would say, in maintaining staffing for these programs. Oversight is really important. And with with all of us aid being told that they will be, that they will be eliminated, we are really many of us are worried about how those programs, the billions of dollars in programs, are going to be overseen and implemented. And so that brings some urgency, I think, to the task in Congress of building out what the vision for the future looks like. So I am still optimistic that there's going to be a future for global health and foreign aid, but really the time is now to chart what that path looks like.

Joseph Harris  29:34

You mentioned rebuilding commitment, but will it be possible to rebuild these agencies?

Elizabeth Cameron  29:42

That's really a great question. I think that right now USAID was legislated by Congress. I think the administration has made it really clear that US aid is going to be run out of the State Department. It's hard for me to Imagine that changing in this administration. I'm personally hopeful that the programs can be maintained, many of them potentially, with some efficiencies and in different forms, so that we can rebuild our smart power when we have the chance to do it.

Joseph Harris  30:18

What can people who are concerned about these issues do right now?

Elizabeth Cameron  30:23

So I'm really glad that you asked that question. I think there's a number of different things that people can do to get engaged. I guess I just highlight two here. One is, I would urge listeners to go to the US, Global Leadership Coalition, USGLC's rapid response hub, and that's www.usglc.org/rapid-response-hub; and sign up to get involved. I'd also encourage you to sign up for Stand Up for Aid, which provides a really handy accounting every week of what's been going on in foreign aid, how it's impacting different partners around the world and implementing partners in the United States. And you can sign up for that by emailing stand up for aid. At StandUpforAidinfo, that's all one word, @gmail.com, and let them know that you want to sign up for products or volunteer to help. And then, I think, always critically important to continue speaking with your members of Congress and getting involved locally with your own community who are thinking through, I think, in communities all over the United States, what the United States should be looking like in the future in terms of our face in the world. So thanks a lot.

Joseph Harris  31:40

We've been speaking with Dr Elizabeth Cameron, Professor of the Practice at Brown University's Pandemic Center. Dr Cameron has worked in a range of positions in high level parts of the US government on global health and been a senior advisor to USAID. Dr Cameron, thanks for joining us. 

Elizabeth Cameron  31:57

Thanks so much, Joe.

Joseph Harris  31:58

The next person I spoke with was Nidhi Bouri, former Deputy Assistant Administrator at the US Agency for International Development during the Biden administration. Ms. Bouri is a global development and foreign policy expert with 17 years of field-based experience who has previously served as Senior Advisor for Foreign Policy in the Office of the first lady on the National Security Council, first as Director for Global Health Response, and then as acting Senior Director for Development, Global Health and Humanitarian response, and as Deputy Executive Director and Chief of Staff for USAID's First COVID-19 Task Force. Thank you for joining the Global Health politics podcast. So you've had quite a career in the field of global health and development. What led you to pursue this field as a vocation?

Nidhi Bouri  32:46

I always had an interest in global development, particularly when I was quite young, which was really inspired by my family background. And so I think I knew at an earlier age that I wanted to pursue a career in development. I just didn't quite know what that meant. And in college particularly grew an interest in global health and public health broadly, because through some courses that I had and particularly some volunteer and work experiences that I had, really began to understand how much health is integrated to so many parts of communities. So even things that we don't think of as public health at the forefront of minds really do have a link. And so my career track kind of fell into place, partly intentionally, partly not fully intentionally, where I ended up specializing in health and crisis settings, and my technical specialties and humanitarian health, specifically.

Joseph Harris  33:41

You worked at some of the highest levels of the US government, on foreign policy, foreign aid, global health. What would you say are some of the most difficult challenges you faced and most meaningful and important contributions that you've made in those roles?

Nidhi Bouri  33:55

I think there are, for me, kind of two categories of my professional experience that I would particularly draw, and I that that have been particularly meaningful. One has been when I have been part of on the forefront of responses to crises, particularly with a focus in service delivery and trying to facilitate the accessibility and availability of services, whether that's health services, water protection services to those who are who are in the midst of whether it's conflict or natural disasters. And then secondly, a very different experience, my time at the National Security Council. And I think the throughput for me, regardless of if it's been in an implementation lens, or kind of looking at a cross cutting policy view is really looking, I'd say, the challenge and the reward all at the same time, is looking and how to explain the role of development in national security and global security, which is not necessarily something that is obvious, but I'll give you a couple. Particular examples in 2022 when I was at the White House, was after Russia's second invasion of Ukraine, or further invasion of Ukraine, and they and Russia was blocking ports of agricultural exports from from getting out of Ukraine. And what I learned during that time, which I think a lot of people learned, was how much that part of the world around Ukraine was the bread basket for so many countries around the world, and there was a global food security crisis that rippled very quickly and impacted health sectors, agriculture economies, trade overall, and just had a paralyzing impact on a number of countries across the world, and my role in that was helping coordinate effectively what became the US government's response to that food security crisis, but as it linked to kind of other areas of government, of development, and what was so meaningful for me was to be able to be in a position of looking at some of these issues. I've done this with a number of health crises, to like the COVID response at a real 30,000 foot level, with the lens of understanding from previous experience, but really to be informed by by colleagues who are doing different work with as part of governments, NGOs, UN agencies, whoever it might be, working directly with communities across the world and understanding the day to day impact on people, but on a on a much more macro level, how much those investments and kind of basic human security really do have a benefit and ripple effect for National Security, for us in the US, but really for global security around the world. And so I think they've all presented a range of challenges, but I have found the ability to bring the development world into national security conversations particularly meaningful as we look at at how it matters beyond just the immediate impact on people around the world.

Joseph Harris  37:04

Let's talk about that development piece a bit more. One organization you've helped lead is the US Agency for International Development as Deputy Assistant Administrator during the Biden administration. Can you say a little bit for our listeners about what USAID does, how you'd characterize its mission and why it's important? 

Nidhi Bouri  37:24

Sure, so USAID is one of the development agencies in the US government. It is the largest, has been, historically, the largest. It was created by President Kennedy Now, decades ago, but with a real intention and focusin alleviating poverty, promoting democratic reforms and responding to emergencies. And what makes us aid unique is its approach, in that it is really centered in working to strengthen and work alongside local capacity, whether those are local organizations, potentially governments, in helping achieve certain development objectives that are again to improve the lives and livelihoods of communities, but to again tie that to a bigger kind of so what or purpose. It is a way for the US government to not just address basic human needs, really, I think, just speaking to the values of America, but to also promote democratic practices and sustainable approaches that that support the the ability to improve lives, livelihoods, life expectancy for people around the world, regardless of of where they live or kind of what community They're part of. And USAID is really the only part, when you look at of the US government's foreign assistance, kind of landscape that invests in a system way, and I'll speak just particularly about health, where I most recently was focused on us aids investments have spanned across different areas of global health, whether that's maternal and child health services, global health security, addressing the ongoing fights against HIV, tuberculosis or malaria, or a number of other areas, but centered again in kind of looking at system investments, and it's oftentimes those preventative efforts that end up being the most cost effective to minimize strains on health systems, but also have a ripple effect beyond health into economies. And I'll just reference one, one piece that you might have seen. The Lancet had an interesting study that was published on about a month or so ago, two months ago, that spoke about the investments in routine immunizations as part of the expanded program and immunization that's facilitated by the World Health Organization, and how the return on investments for for just investing in vaccination efforts are really getting shots in arms to prevent a range of preventable diseases, has not only increased life expectancy significantly. In a number of countries, but for every dollar that's invested in vaccines and vaccination efforts, it saves health systems about $52 and so USAID's role in programs like the EPI, but of course, spans across a range of other areas, have really facilitated a way of not just providing services to communities around the world, but doing it in a way that has this return on investment that ripples beyond the sector of where, where that investment might be.

Joseph Harris  40:30

So it's obviously a significant, important part of foreign policy in the US but also, I'd like to see if you could put into context for our listeners, US foreign aid relative to foreign aid in the world. How significant is my USAID as a contributor to foreign aid? 

Nidhi Bouri  40:49

Yeah, so I think there are, unfortunately, a lot of misperceptions around how much the US government spends on foreign aid and what exactly it does. So first, foreign aid is generallydefined as assistance to civilian populations. So we are not talking about assistance for military engagement or work. And within the US government, as I mentioned, USAID is the largest agency that facilitates that. So the US government spends on every any average year anywhere from 0.7 to 1.2% of the federal budget, so not a lot of money when you talk about the US federal budget at large. The question is, how much bank you can get for your buck when you're talking about about 1% of the federal budget. So just to contextualize and give you some numbers, last in the last fiscal year, so the US government's fiscal year is not it's kind of Fall to Fall, not necessarily the same as the calendar year. The US government spent about just shy of $72 billion on foreign aid. A little under a quarter of that was on global health programs, actually. And USAID tends to, and this is trended historically, facilitate over half of what that investment is. So in that same fiscal year where it was just shy of $72 billion for the US government, a little over 40 billion was programmed through us aids investments. So the approach that the US government takes is a combination of facilitating private sector engagement, so kind of promoting American companies, but also using American private sector as part of the solution to different development needs. There are entities like the US Development Finance Corporation that are really critical in that working alongside governments to facilitate and accelerate domestic commitments to promote different reforms that we know could have a long term impact on addressing development needs in a country. Agencies like USAID, but the Millennium Challenge Corporation have also been part of that. And then there is investment in direct programs that facilitate service delivery, but again, looking at strengthening systems, whether agriculture, health, other areas, and also providing emergency response support and humanitarian crises or in outbreaks. And that USAID has facilitated. And when you look at that contribution from the US government in the context of globally, kind of what is mobilized, there are a couple of things I'd note. So the US government, in the last few years has consistently been about the sixth largest contributor to foreign assistance, and so that's looked at in terms of amount of funds that are invested, not necessarily kind of percentage of GDP, because what we find is actually some of our European counterparts are putting up larger percentage of their federal budgets towards foreign aid, whereas ours, again, is just about 1%, if not under 1% ,but the US government has really centered investments to respond to global needs, to respond to current events, to where we might see higher need amongst different countries. And of that$72 billion in the last fiscal year, over six and a half, 16 and a half billion was specifically assistance for Ukraine. So you can imagine, if we did not have a situation like the ongoing war inside Ukraine, which has been very critical, not just in terms of a humanitarian response, but also in a preservation of democracy. You know, there are different ways that global events will impact how the US government is investing, but across the board, aside from responding to crises of the moment, there are ongoing, protracted crises. There are also these core investments in health systems, and we, as the US and through the US government, have really been able to promote and support some fundamental shifts in the way that global development is administered, including working more through local partners and mobilizing more private sector partners, so that we are drawing upon different expertise and resources, but centering investments in countries and what they they want to achieve. 

Joseph Harris  45:13

And what I'm hearing is that the contribution is significant globally, and there's some kind of multiplier effect that the aid has through its leveraging in the private sector, is that right? 

Nidhi Bouri  45:23

That's right, yep, and, and there's a real "win-win" for the US, when we are able to support American companies potentially enter new markets as they look at expanding a global footprint, but also using partnerships with the private sector as part of the solution to development challenges, so that the funding resources are not solely coming from the US government, but more so investment from the US government could incentivize investments from other other stakeholders, whether it's private sector or other governments.

Joseph Harris  45:59

Since President Donald Trump returned to office on January 20, we've seen his administration dismantle USAID, fire thousands of workers and cancel contracts. And on Friday, March 28 the administration announced that it was firing all remaining aid workers and terminating USAID as an agency with US Department of State absorbing remaining aid functions. What have been the effects of all these borders, domestically and globally?

Nidhi Bouri  46:29

So first, let me just say, you know, any administration has the right to reassess how they want to invest in foreign aid, just like any other part of you know, work for the US government. But what I find to be the challenge and also just unfortunate and candidly irresponsible, has been the way in which these this administration has gone about changes in foreign aid. So specifically, what I mean by that is the sequencing of events. When you look between January 20 through just the last couple days, has been a series of abrupt events that do not necessarily facilitate an ability to thoughtfully examine where there might be investments from the US government, and how investments could either align or do align with some of this administration's priorities, or potentially need to, you know, reconsider what some of those investments are. So the the sequencing of how things have happened have been such that there has been a dramatic kind of pulling of the rug from under organizations that are funded by USAID. And what that has meant is in the abrupt terminations of contracts, the abrupt kind of takeover of the USAID payment system, which meant that funds were not being able to get to be facilitated to get out to different organizations. Organizations that work as partners of USAID have had to lay off staff and shut down operations, and that has had a direct impact in the ability to deliver services to communities that were depending on those services. It has compromised the livelihoods of staff working for those organizations who, of course, now are out of work. But it has at a at a kind of macro level, and where it impacts longer term, is set back a range of gains that we had had in development through a pause and interruption of services, and also compromise the ability of a global system to retain technical expertise of people you know, who have different specialty areas who work in a range of organizations. And then in parallel, you have what's happened within USAID itself, which is, as you noted, the termination of staff now the formal notification to Congress around the intention to absorb some of the foreign assistance functions that USAID has historically carried out into the State Department. And the challenge that I find with both what's happened within USAID as well as the impact that's happened on partners, is there has been no glide path for transition. And so this is one of the main issues, is that, you know, there are other governments that I think could serve as good models, like the UK and the Australian Governments, who went through mergers of standing down an agency that was formally dedicated to foreign assistance and absorbing it into another agency, perhaps one with a broader diplomatic function. But those were announcements that were made with kind of one to two year plans that a phased approach of how a transition could look, which would allow for one, minimizing disruptions and services and investments, some of which are are really critical to the US government's National Security, such as our investments in global health security. The second is that it allowed for a way to transition, for organizations to plan, perhaps to find alternate funding to make plans. To perhaps adjust their operations, again, centered in ensuring that people were not paying the consequence or the price because the ability to ensure service delivery, as opposed to dealing with disruptions. And the third was it allowed time to really look at what a rethink could look like and should look like to to align with foreign policy objectives, and the abrupt and kind of swift nature of this, I think, has not allowed for any of those three things to happen. And I do think there are continued risks in the sense that we do not have clarity around if the State Department even has the capacity to absorb some of the functions that USAID had specifically in terms of deploying staff, procuring and distributing commodities, and then grant-making at a large scale, which are three functions USAID really held with, kind of in a premier way, was really able to do quite well. And so it is possible that if functions transition into the State Department without that focus on building the right capacity in the State Department, that will we will again have disruptions in programs that, again, we as Americans benefit from happening. 

Joseph Harris  51:15

As someone who's played a role leading the agency, what's it been like to watch these decisions be made? 

Nidhi Bouri  51:23

It's been really discouraging, and I've been really disheartened to see the abrupt nature of how these decisions have been made with without what to me seems like a clear, thoughtful look around the purpose of programs, the functional role of different staff, and being able to assess that objectively against you know, where whatever priorities the administration has like as I said, it's, of course, the right of the administration to determine where they think investments of federal taxpayer dollars are worth it. But I think that this approach has not been one that's actually allowed for that evaluation, there has been a lot of mischaracterization, in my opinion, around fraud, waste and abuse within USAID, without really, actually looking ironically at how much fraud, waste and abuse is happening now in the way that it is being dismantled to, you know, the the dismantling of the workforce, for example, is being done in a way where there there, of course, legal issues, as I understand, that I think, are precluding how fast some of those actions could happen. But what we see happening is because there are less people working, a number of people who have been either terminated, if they were, for example, on contractor status or place on administrative leave, if they were directly employed by the US government, there are less people working day to day, which means that there is less funding that can get pushed out the door. There are less kind of actions that can be taken. And so the US government is moving slower, having to kind of deal with legal actions that are being brought towards the US government because of the slow pace, for example, of funding, getting out to partners and all of that, I think would have been completely avoidable had there been an actual plan put in place for what a phase transition or kind of reimagining or modernization of what foreign assistance looks like. I think there are definitely things in the US government that could be improved to be more efficient and effective. This was not the way to do it. If anything, I think this has presented an additional set of actions that are taking away from the core work that USAID and other parts of the US government had been doing.

Joseph Harris  53:39

And it may well deter people from going to work there again, is that right? 

Nidhi Bouri  53:44

That's right, yeah. 

Joseph Harris  53:45

A number of individuals and organizations have sought to track the impact of the aid freeze, including Dr. Brooke Nichols at Boston University, who created an impact tracker of the US government cuts. The Washington based accountability lab has developed a global aid freeze tracker based on surveys. And DevEx released recently a Breaking Point report, which was the first major survey of aid workers and partners. And some of these findings have been particularly heartbreaking. So for example, using very conservative estimates, Dr. Nichols estimated that the freeze on the President's Emergency Plan for AIDS Relief, also called PEPFAR alone, has led to an adult life lost every three minutes and a child death every 31 minutes. So approximately 28,000 adult lives and 3,000 child lives lost since the freeze started at the and the end of March in just two months time, those numbers are quite profound. Can you share with us your perspective on that and personal stories of what these cuts have been?

Nidhi Bouri  54:53

Sure. So I mean one very recent example, on Friday, the same day, when all of USAID staff were informed that they were to be terminated. There was a really significant earthquake in Myanmar, as I'm sure you saw in the news. And historically, the US government, through the humanitarian arm of USAID, where I actually spent a portion of my career as well, has responded to those types of natural disaster events by quickly deploying teams of technical experts and also mobilizing partnerships with two fire departments in the US, the LA County Fire Department and the Fairfax County Fire Department, both of them who have teams credentialed by international standards to specifically pull people out of earthquake rubble. So these are teams that are typically deployed in large scale earthquakes, specifically, such as what happened in Myanmar a few days ago to rapidly arrive on site and maximize a window of the first few days after an event like that happens when there is a chance of saving lives. That response did not happen in the last few days in the way that it did, for example, in Nepal in 2015 when a massive earthquake similarly hit that region. And I was actually on site for the Nepal earthquake with an NGO at that time, now with USAID. But did see firsthand the way that the US government, through USAID mobilized a really significant response. And what that meant is, and what has meant in the last four to five days is there are people who have died, who could have been saved, because there are teams that could have been on the ground who have the right training and the right skill, but could not get out the door because of what's happening in USAID, the inability to move contracts, the inability to deploy staff because people have been terminated or put on leave, the inability of, kind of mobilizing those resources with partner organizations. And while that has had a really immediate consequence on individuals, on people who have lost their lives, family members who have lost loved ones. There is an another angle to it, which I think are we are starting to now see, which is the lack of quality assistance that is really centered in just meeting a need as it presents, and the way that the vacuum of American presence is yielding space to others. So what I mean specifically by that is, in the last few days, the US government has been absent, but the People's Republic of China has been present. They have mobilized funding. They have mobilized assistance. They have it's unclear if that comes with conditions with people in for the governments that they're working with typically has and so there is another angle that goes beyond, of course, the immediate life saving, which is the most dire and the most gutting to see, but also in terms of how partnership with governments is so important, because the US government is proving to be an unreliable partner right now around the world, but you know Myanmar even a couple weeks of, I'm sorry, a couple months ago, I was reading a report that also came out of Myanmar of a clinic that had had been administering oxygen to patients, and because of the abrupt cut of USAID Funding, had to immediately cut services, and what that meant was having to turn off machines that were providing oxygen to patients, and a patient died. And we've now since that time, that was one of the first reports that could point directly to deaths that were happening as a very direct result of the foreign aid freeze and the abrupt termination of funding. And we've seen several reports across the last couple months that point to that the inability to provide safe deliveries. I've read stories of mothers who typically would have had a skilled birth attendant accompanying them or with them at the time of delivery, or that is not happening, and then having complications and what could have been a safe childbirth and was not resulting in complications for a mother or to a newborn. HIV services where clinics have had to shut the doors and turn people away because at first they were pausing all services, and now some services have been able to resume, but they're only available to certain populations, so key populations such as LGBTQ individuals who we know are a high at risk group for HIV transmission, not able to receive PrEP, which is a drug that reduces the likeliness of contracting HIV amongst high, high risk populations, but due to some of the policy decisions around what services the US government will facilitate that population is not able to receive prep under this current guidance. Similarly, we've seen disease prevention programs, surveillance programs go offline, meaning that there could be threats such as new infectious disease outbreaks, things like Ebola, new pathogens that are are going undetected, but at the same time, things we do know about, like drug resistance, TB, where those programs have stopped. So there are a range of stories I could go on and on, but it is really hitting communities across the globe in very different ways. 

Joseph Harris  1:00:22

Well, as a scholar of global health and also of Southeast Asia, for the past 20 years, you know, the Myanmar earthquake disruption has just been shocking and indescribable. So thank you for that perspective. Can you speak to the long term impacts of these cuts and dismantling of the agency.

Nidhi Bouri  1:00:44

Sure. So I think there are a couple things I'd point to. One is the fact that we are looking now at a changed global development architecture and system, you know, the entire industry, I think, is upside down on top, you know, given just how abrupt this happened again, as I said earlier, without a transition or kind of glide path. And what that means, I think, is organizations that will not have the same operational capacity as they had previously, so organizations that might have been one of the few organizations providing services in a particular community or particular country that are not able to operate anymore, and that direct kind of change in terms of the different stakeholders that come to the table. But I think the other side of it too is we have lost, as the US, the ability to influence and work hand in glove with governments as they carry out plans that allow them to take more ownership of financing of different development areas, because we have again proved to be unreliable in the last couple months with the way this has happened and generally global development across different sectors. This is especially true for health. In the last couple of years, has really moved more into a space of supporting and having investments come in behind national governments, their plans, their ownership, tailored investments that support governments in accelerating progress to achieve certain goals. So not looking at as charity, but really looking at as an investment that, again, in our kind of common security, but supporting governments achieve those goals, which in the long run, minimizes any need for external investment or assistance to come in. And part of working with governments to do that means that you have to actually be a partner that has an interest, a willingness, and kind of a consistent engagement in that. And I think in the long run, we are losing that ability to help shape, shape those those dynamics. 

Joseph Harris  1:02:54

Is the foreign aid gap that USAID termination leaves behind being filled? Are there other countries or institutions that are stepping up to fill this big funding gap? 

Nidhi Bouri  1:03:06

So I have heard of efforts for what's being called bridge funding, where different types of agencies and institutions a lot of that is in the philanthropy space or stepping in. However, I will say that philanthropy cannot fill the gap of us AIDS funding. I mean, even if you're pulling together all the major foundations, private, individual donors, et cetera, we also see a time right now where bilateral assistance being donors that are governments, so funding that comes from governments are also shifting course as a range of countries, similar to what we saw in 2022 are pivoting their resources or redirecting to support defense spending so there is not enough government funding in the international system to cover needs. And what exactly that looks like going forward, I think, is still to be determined. But one of the most immediate efforts is conversations around bridge funding. But bridge funding is exactly as it says in the name. It's a bridge right? It is not necessarily a sustainable financing platform, and I think this is where a number of conversations have already started in what does a re imagined global development funding landscape look like, and what does that mean in the sense of priorities, how countries play a role in that ways to incentivize and support increased domestic financing. But the reality is, is there will just not be enough funds for the scale of need. 

Joseph Harris  1:04:40

Now, I had understood that USAID is congressionally funded an authorized agency. Are these executive orders legal?

Nidhi Bouri  1:04:49

So I'm not a lawyer, but from my understanding, they are not legal because USAID is an agency created by Congress. My understanding is that the executive branch cannot solely make a decision around what an agency looks like, and particularly if it were to dismantle. I am particularly curious to see this proposal of merging in functions that were covered by USA to date into the State Department, and what that looks like, and how if that, if the Congress moves towards a point of formally dismantling USAID, but my understanding is that, no, these are not legal. Why isn't Congress doing anything to push back? So I'm not in conversations that congressional members potentially are having with the administration, so I can, I can speculate, and I think one of the reasons why there might not be as much public pushback, again, I don't know what's happening in private channels, is I think there is perhaps a misunderstanding or a lack of understanding around the ways that foreign assistance links to Americans and to communities across the US, and how investments in different programs, again, look at look at pandemic preparedness and prevention efforts, how Americans benefit from that, how programs that are designed to curb migration to the US are stopping, and what that could mean in terms of increased migration flows to the US, amongst communities who are trying to escape understandably terrible situations in their home country. So I think part of it is that lack of understanding. But also it's not just Congress, it's constituents. I think collectively as a community, we have a lot to do in helping Americans across the country understand the benefit to them of these programs, that they can engage their congressional representatives and indicate support.

Joseph Harris  1:06:52

I had understood that Secretary of State Rubio had been a big proponent of aid and seen its value In the past, what is his stance on the termination of USAID? 

Nidhi Bouri  1:07:04

It appears from statements that Secretary Rubio has made publicly that he is supportive of the termination of USAID, and he has pointed to allegations of fraud, waste and abuse within the agency, which I find particularly interesting because it is the complete opposite of statements that he has made in his role as a senator in 2017 in particular, he had a really, I thought, substantive address to the Senate around the role of foreign assistance, and also spoke to the ways in which funding does have significant amount of oversight, so it seems like he has changed tune, and it's unclear to me as to why that's the case. But us aids funds are not it is not as if any, anyone who has a administrative authority across the agency can just unilaterally decide how to use those funds. Those funds are typically heavily earmarked by the US Congress, and require notification of Congress. So what that means is if, for example, in the bureau where I was the Bureau for global health, which was about a $10 million Bureau, the vast majority of that funding, we received a breakdown from the Congress of how much money were to go to different program areas, how much money goes to maternal child health, how much is part of implementing PEPFAR in, HIV, tuberculosis, etc. And then when we wanted to pursue different programs, we would have to notify Congress, which is a process that allows Congress to then weigh in. And so there is significant oversight at USAID, if anything, it's probably one of the the most robust oversight capacities across the US government. And Secretary Rubio seemed to be, historically again, someone who well understood and spoke on that, and apparently now seems to have a different belief, and it's unclear what's informed that change.

Joseph Harris  1:08:59

For members of the public that are concerned about these cuts and the dissolution of the agency, what can they do?

Nidhi Bouri  1:09:07

So you know, the obvious response, I think, would be to engage your congressional representatives and indicate your support. But I would also really encourage people across the country to talk to people in their community and help people understand the purpose of foreign assistance, the value add to Americans of foreign assistance. You know, there's some communities that have had research institution that had a major grant cut off, and that's had a ripple effect in their economy, you know, depending on how many people were employed by a university or worked on a certain program, that might feel it in that way. But then there are others who might not be in a community like that, but understand and remember an experience like COVID, where there are programs and efforts in place that the US government has invested in that, again, is to mitigate threats to Americans that is centered in promoting not just the ability of providing services to communities across the world, but would be the additional component of preventing threats coming to our homeland. And so I think it is really valuable for people to just talk to their neighbors, their friends, their family members, to help correct a misperception of foreign assistance that I think has unfortunately unfolded in our media.

Joseph Harris  1:10:23

We've been here speaking with Nidhi Bouri, former Deputy Assistant Administrator at the US Agency for International Development during the Biden administration. Ms. Bouri, I want to thank you for your time and insight today. 

Nidhi Bouri  1:10:35

Thank you so much for having me.

Joseph Harris  1:10:36

My next guest was Dr. Brooke Nichols, an Associate Professor of global health at Boston University. Dr. Nichols is an infectious disease mathematical modeler and health economist. Her work has examined transmission dynamics and the implementation of disease interventions related to HIV, AIDS, TB, COVID and other pathogens. She's published in many of the world's top public health and medicine journals, including nature, plus one, the Journal of International AIDS Society and several Lancet journals, as frequently quoted in media publications, including the New York Times, Boston Globe, LA Times, Associated Press and National Geographic. Thanks for joining the Global Health Politics Podcast. Thanks for having me. You have a background in infectious disease modeling and health economics. What led to your interest in those fields, particularly in public health, more generally?

Brooke Nichols  1:11:31

I think, sort of, like many people, I kind of fell into it. So I was first studying international relations, and I took some classes in global public health. And as an undergrad, I thought, well, that's interesting way of thinking about international relations in general, in terms of diseases. And then I went to study epidemiology and biostatistics for my masters. And when I went to do as a summer internship in Namibia, that's when I first saw, this was 2009, the impact that HIV was having on the health care system. So I mean, in terms of you would go to the local hospital, and it was completely full of people living with HIV, and really at these sort of late stages of disease, and that was sort of the first time I really saw the impact of an epidemic right in front of me, and ever since then, that's really what sparked my interest, especially into going into infectious diseases. And I spent the first 10 years of my career focused on HIV because of that.

Joseph Harris  1:12:32

And as I understand it, much of your work has centered on what researchers in the field of public health call implementation science, which aims to develop an evidence base about what works best and is most cost effective related to specific disease interventions. You worked in this domain on diseases ranging from COVID, TB, HIV, AIDS. Could you share with our listeners a bit about that work and why it's important?

Brooke Nichols  1:12:55

Yeah, so so often, in the type of space that I work in, in modeling and health economics, people typically try to see is one intervention, what would the impact be, and what is and if there is a big impact, is it cost effective, yes or no?  And then my work, I really have been trying to take that a step further. And not just is it effective and what's the impact, but how can we implement it in a way that would maximize impact? So we have a tool, how you actually use that tool, given the factors, you know, at a healthcare facility or for individuals, and take all that into account to really understand how to maximize population level benefit. So it's a bit different, sort of than than traditional modeling and traditional modeling and traditional health economics, and that's sort of the space that I try to occupy.

Joseph Harris  1:13:44

Since it came into office, the Trump Administration has made dismantling the US Agency for International Development and slashing foreign aid one of its top priorities. What are some of the actions by the administration related to these cuts, and why do they concern you? 

Brooke Nichols  1:14:00

In terms of what the administration has done, I mean, at first it was the stop work order, and then it was a funding freeze, and then it was over, and then there was a waiver, but then there was no waiver, and then there was... it just been chaos. And so even if things were to regarding funding for USAID were to turn back on, I think the trust that that would actually happen is really low right now, and so it's just been complete chaos. And you see it playing out in terms of all these cooperative agreements and and awards closing, and so that has direct implications on people's the livelihoods, but also people seeking care. These are actual people receiving services through these cooperative agreements, people living with HIV, people with TB and humanitarian disaster zones. I mean, all of these different things affect real people, and that's what really made me want. To highlight what was happening in terms of or try to at least estimate how many lives are being impacted, and what this means in terms of mortality at sort of a global scale.

Joseph Harris  1:15:10

And are there particular programs that have been cut that really keep you up at night? 

Brooke Nichols  1:15:14

I think because of my long history working in the HIV/AIDS space, I think the cuts related to PEPFAR, the closest to home, and also because of how close we were, reducing the number of new infections and really getting a handle on the HIV epidemic, if you look at the incidence curves, and we finally started to make a huge difference, and incidence was really coming down, and to see all of that progress and effort to getting us where we are today just canceled overnight, like even if these programs were paused for only, for only three months, the devastating consequences that's gonna have especially to get us back on track to where we were gonna take ten years for just a three month pause. So that keeps me up. I mean, all of these especially related to infectious diseases because it doesn't just affect it affects the people directly, the people that are receiving care, directly, but infectious diseases and people can infect other people. And so this will become not just a problem for the people currently with HIV, living with TB, etc, but it's going to be a problem when other people start to get infected and the problem starts to balloon. 

Joseph Harris  1:16:27

You recently launched an online tracking tool that aims to estimate the increased deaths and disease that result from the near total freeze in USAID funding. What led you to take up that project, and what are you finding? 

Brooke Nichols  1:16:41

Yeah, so what led me to start to do this was I woke up one morning very early to a New York Times article saying that the stop work order actually meant a complete funding freeze, and that all funds were going to stop for this was for PEPFAR, specifically the articles around that, and that's that really got my brain turning and made me very upset. And I just wanted to understand for myself how many people were going to die as a consequence of this. And so that first day after I read the article, spent the day try to figure out the math behind it, and then sent it to a few colleagues. So well, why don't you put this online and make it tick Bye, so that people can see what the impact of this is. And so that's what got this started in the in the first instance, and it's been built on since then. Once we start to realize what the additional impacts are, we've also, I've also had colleagues reach out from the TB space, who said, we've done similar modeling for TB. Can we turn this into sort of a simple number that can be communicated like for HIV? And then many students and other people have participated to create those other estimates that are included in terms of that quote the general the broader USAID impact outside of those two health areas. 

Joseph Harris  1:18:04

And can you give listeners a sense of what those numbers look like right now?

Brooke Nichols  1:18:08

So to date, I think there's more than 150,000 deaths associated with the funding freeze and the funding chaos discontinuation, whatever you want to call it, about 100 deaths an hour, and a lot of those are among children. Huge. 

Joseph Harris  1:18:26

The 150,000 is estimated for the future?

Brooke Nichols  1:18:29

between when the funding freezes took place for the different programs and today. 

Joseph Harris  1:18:34

And today.

Brooke Nichols  1:18:35

So in terms of expected deaths over the course of a year, close to a million. 

Joseph Harris  1:18:39

And so we're talking about over 150,000 deaths in the last two months. Two months? Yeah, that's a lot.

Brooke Nichols  1:18:45

Yeah. And we haven't even started to calculate some of the additional impacts that are coming out, like the stopping of funding to GAVI, who does vaccines, some more domestic work related to CDC, and the HIV response in the United States. We haven't even and you know, these will be added to this, and the numbers are only growing, unless we find a way to start the funding again.

Joseph Harris  1:19:09

So this sounds like a really personal project in some ways to you, but also one tied very much to everything that's happening right now globally and the impact that these decisions are happening.

Brooke Nichols  1:19:21

 Yeah, it's definitely a personal, personal project, just because it felt, you know, when horrific things are happening in the world, you feel so helpless, right? Like, well, what can I do? You know, we often get told call your representatives in Congress. Great idea. Do that. But what can we do beyond that? And the only thing, only thing I know how to do, is math and calculate impact. And so I thought this would be, could be one way I could contribute to all of this.

Joseph Harris  1:19:54

I understand that there are other research studies that are coming out right now. All that also take into account the impact that these cuts are having for for example, a global aid freeze tracker also, DevEx put out a report called breaking point that was the first major survey of USAID workers and partners. Can you talk about how your tracker compliments or challenges these other important research studies, and are you finding significantly different? 

Brooke Nichols  1:20:27

Yeah, so those other two that you talked about specifically, there's these massive surveys that have actually gone out. What are the impacts happening to these different organizations? And I have seen some numbers in the media and some other efforts to try to quantify the impact of different in different health spaces, so HIV or TB, and some of the numbers I have seen, so there's a big article in New York Times looking at impact as well, and the numbers were quite a bit higher than what we had estimated. And so I have been going through and contacting people that are putting out these numbers to see, you know, why, why we're different, or why we're this, you know, to say that, Oh, I did this similar calculation, we have the same numbers, or this is really different, let's find out why. And because I'm an academic, I think I've been pulling in this whole process has been peer review. So with the HIV numbers, we had the whole HIV modeling consortium peer review all of the assumptions. And so the results were changing and updating, especially in the first couple weeks after we had initially posted the numbers. But now they're actually at a state where, okay, there's basic consensus that this is close to right for now amongst a number of HIV modelers. And so that's sort of the approach we've been taking. Every time we get feedback, we incorporate it, make you know, is it relevant or not, and how can we improve our estimates? And so I think the work that we've done here on this tracker has been, I think the added value is that it's pretty it's peer reviewed. And in terms of those other trackers that you were talking about, those surveys, I think the work, this quantitative estimates just complement the survey work.

Joseph Harris  1:22:06

And so one of the things I'm hearing you say is that the 150,000 estimated deaths that you're talking about in the last two months, those are fairly conservative estimates to some of the other estimates that are...

Brooke Nichols  1:22:19

It's already a huge number, and it's a conservative estimate, absolutely. And then this is also direct impact. So this is not any sort of knock on consequence that can happen as a result of these deaths. So I mean, there's a lot of a lot of ways in which these direct impacts will lead to especially transmission of disease. We haven't even looked at transmission, for example, for HIV. I mean.

Joseph Harris  1:22:46

Can we be modeling the indirect effects as well as that in the pipeline?

Brooke Nichols  1:22:51

So right now, we're just focusing on the direct effects because there's so there's so much to do, that sort of as much as we can take on.

Joseph Harris  1:23:00

Does the Trump administration seem to be aware of the impacts that these cuts are having? 

Brooke Nichols  1:23:06

I honestly have no idea. And even if they did know, I don't get the sense that they would care. In some ways, I hope that these numbers will be used for advocacy. I mean, get we want to be as correct as possible, and then also make sure that these are numbers that can be used to sort of push things in the right direction, in terms of getting these programs supported again, or whatever it might be, or pushed back. I expect that these numbers might resonate with other, not the executive branch of our administration, but hopefully at least with Congress. There's other numbers that might resonate with others, maybe not the top of the food chain, but...

Joseph Harris  1:23:45

because USAID was a congressionally authorized agency...

Brooke Nichols  1:23:49

because USAID, I mean, it's, it's smart for national security, it's smart for global health security, and it's also was the right thing to do. And I think that resonates with a lot of Americans that actually, you know, these programs, the idea that we are saving lives, can actually resonate with a lot of people across political spectrum.

Joseph Harris  1:24:09

The kinds of effects that you've been able to estimate seem to be pretty profound and important. What if any impact have you seen so far in terms of advancing public and policy conversations around these issues?

Brooke Nichols  1:24:22

So the numbers were originally, I mean, this was put up and circulated in a pretty small...I mean, this was just Share, share, share to people in our circles making its way to US government in the early days, especially related to HIV, right before the waiver came out. And this work, some of our work, has been cited by Bernie Sanders and the work that he's put out. So it's definitely the numbers are getting out there to the people that we hope can can use them to push for the right thing.

Joseph Harris  1:24:52

And you've been in the media as well. What do you think it will take for the administration to change its approach to foreign aid?

Brooke Nichols  1:24:59

I think there just needs to be...I just, I feel like they won't. The administration won't necessarily change their mind on this, but if there's enough pressure from Congress, then there might be a shot at doing changing something.

Joseph Harris  1:25:13

In the meantime, do you see any other governments, organizations stepping up to fill these major foreign aid funding gaps? 

Brooke Nichols  1:25:20

I see the polar opposite, cuts foreign aid from the United Kingdom, cuts to foreign aid and the Netherlands. I see cuts. I don't see people really stepping in. I think Australia is one of the few donors that's really trying to increase their their investment into global health. But there's really, I have. I haven't seen really people stepping up, or governments or organizations really stepping up to fill the gap? 

Joseph Harris  1:25:44

I understand, at least within Europe, part of that moving in the opposite direction has to do with greater concern over defense because of us withdrawal from commitments to Ukraine. Is that right?

Brooke Nichols  1:25:56

Yeah, so there's definitely a big shift in how budgets are being allocated because of the need to increase defense, and there is just also a conservative leaning, focusing inward trend that is happening across Europe as well. So it is a bit related to defense, but also a lot of these cuts and sort of pushback started before, before the events with Ukraine.

Joseph Harris  1:26:21

What can people do who are concerned about the cuts to US foreign aid funding? Not everyone's in that mathematical modeller.

Brooke Nichols  1:26:30

 I think, call your congress people and say that. You know, if this resonates with you and you think this is important, call your congress people and tell them that, because that's, I mean, that's really how to get your concerns logged and understood and then pushed for. And I think that's right now what we can do, if you want to personally support global health, and you're in a position to do that, can also look to organizations and consider philanthropy as well to support some of these bigger organizations that might start to fill the gap. If you're in the position. 

Joseph Harris  1:27:01

We've been here talking with Dr. Brooke Nichols, Associate Professor of global health at Boston University, an infectious disease mathematical modeler and health economist who's recently put together tracker looking at the effects of the near total freeze and aid funding. Dr. Nichols, it's been a pleasure. 

Brooke Nichols  1:27:20

Thanks so much. 

Joseph Harris  1:27:24

The final person I spoke with for this story was Sheena Adams, Global Communications Director for The Accountability Lab. The Accountability lab launched the Global Aid Freeze Tracker, which aimed to track the effects of the aid freeze. Thanks for joining the podcast, Sheena. First, what is the accountability lab?

Sheena Adams.  1:27:42

 It's so good to be here, Joe. Thanks for inviting us. The Accountability Lab is a global translocal network of independently registered labs working on governance, accountability and anti corruption issues. In terms of our geographic footprint, we have an office, offices, rather in Southeast Asia, southern and eastern Africa, the Sahara region, Latin America, and also in Washington, DC. We do campaigning work, using music and film to reach young people where they are and try to crowd in diverse voices when it comes to issues around critical accountability conversations at a hyper local level. And then we also do training of government officials around accountability, what it really means to be an honest civil servant. And we're also very invested in ecosystem building so making sure that local CSOs, NGOs in the accountability sector, are well capacitated to contribute in a sustainable way.

Joseph Harris  1:28:48

And can you tell us a little bit about the global aid freeze tracker that you created it and why you launched it.

Sheena Adams.  1:28:55

So the global aid freeze tracker is an ongoing survey in English, French, Spanish and Arabic, that measures the human and also the ecosystem impact of the US government's executive orders mandating the reevaluation of foreign aid. It was launched in early February, shortly after the raft of executive orders started and came about as part of some urgent sort of strategy adjustments the lab needed to begin making as some of our grants around the world were frozen. We are also part of a donor collective in the transparency and accountability sector who needed some of this data for their own strategy and budget funding allocations, and we currently working with humentum to run these surveys so the data is tracking the current global impact of the USG stop work orders and also subsequent cancelations and waivers. We really trying to better communicate the impact of the freeze around the world through data, anecdotes, infographics, human interest stories. And then we also collating insights into the extent to which life saving services and livelihoods are being negatively impacted by the orders. And then this also incorporates gathering evidence around the potential harms that this has introduced for global economic and security interests. Ultimately, I think we're also building community and support. I think the strength of the entire sector is really our greatest collective asset at this point, and it it needs to be protected at all costs. If I can make one small sort of last point, I think it was also an attempt, or is it an attempt to push back against what some have started calling a data drought. I think we quickly realized as part of that pivoting and re strategizing process how difficult it was becoming to access relevant data. Stories were circulating of large bodies of research being pulled or called, and it, you know, became quite clear that there were quite sinister moves of foot to scrub critical data sets and resources from us, agency, websites, etc, around topics like dei and climate. And so we are trying, in a small way, to fill some of these gaps left by the absence of democratic demographic rather and other surveys to help really inform policy making making sure some of the decisions we making are not knee jerk or politicized in any way.

Joseph Harris  02:32

How many responses do you have so far, and what have been some of the trackers, most significant and important findings?

Sheena Adams.  02:41

We currently sitting at just over 800 responses, pretty much from most regions of the world. And of these 800 response respondents, many have indicated relationships with about 17,000 or so partners or subcontractors. So it is a significant portion of the sector. Around a third, I'd say, are in the governance and anti corruption space. More than 50% have reported having less than three months of financial runway left. 20% have less than one month of financial resources left in terms of staff layoffs or furloughs, that's been another significant finding. I think 62% of organizations have reported already laying off staff or furloughing staff, with a further 25% considering layoffs. And then I should note there that of these orgs that have already laid off staff, 16% said job losses were running into more than 100 people per organization, which is obviously devastating. In terms of the organization budgets affected by the stop work orders, a third have reported that between 75% and 100% of overall budgets were impacted. A further fifth, saying that between 50% and 75% of their budgets were impacted. And I suppose in terms of thematic sectors, these are orgs that are working in health, humanitarian affairs, governance or anti corruption, human rights, gender and inclusion, climate, peace and security and education in some of in terms of some of the anecdotes, I think we're hearing, many of them reporting massive impacts in terms of trust-building. You know, all the sort of gains made in trust, building disappearing overnight impact, certainly in terms of peace and security, beyond the financial instability and layoffs, and then when it comes to waivers and payments. In the last few weeks, we've started seeing a trickle of. Of payments being made to responding organizations, about 25% have reported receiving waivers. Just over 30% of those have started receiving part payments for work completed. Although it's difficult to find any sort of useful trends, the process does seem to be a little haphazard, but money does seem to be moving, at least from the last few weeks of respondents.

Joseph Harris  05:25

So what I'm hearing is that there have been pretty profound effects on the group of organizations working on core development issues. Does the administration seem to be aware of the impacts these cuts are having?

Sheena Adams.  05:39

It's difficult for me to say for sure, but I would definitely imagine, yes, they would be aware. The much quoted project 2025, you know, outlined a lot of this quite accurately. A few years ago, there was a quote about how USG foreign aid has transformed into this open ended global entitlement program captured by the left. You know, as they say, and you know that report also spoke about how the next administration needs to scale back USAID global footprint, returning to like pre COVID budgets, for example, they spoke about de racializing USAID programs. And it seems that there's no question that some of the exec orders we've seen are very much in step with this mandate. I think also the sheer amount of fake news and mis and disinformation we've seen also suggests in some ways, that the motives weren't exactly innocent. There was a claim from the White House that USAID operated with little oversight, or, you know, final taxpayer money to frivolous projects, and none of this was true. You know, there's been a ton of audits quite recently proving this not to be the case. So I think it's incredibly hard to believe that these outcomes weren't intended.

Joseph Harris  07:10

Can you say anything about the impact that the tracker has had in terms of prompting or advancing public and policy conversations around these head cuts.

Sheena Adams.  07:21

Yeah. I mean, it's still early days, but we are expanding the tracker. We have expanded the tracker in collaboration with that donor collective I mentioned, and we know that certainly some of these funding decisions are being made with the help of some of the data that is being collected. Multiple donors have reached out for some of the data sets to help inform resource allocation and mobilization. Tons of sort of decision makers or stakeholders, critical stakeholders in the aid system have also reached out very much the same kind of reasoning. It's also been picked up by the European Union, in particular, the EU system for an enabling environment, has used the data to identify emerging barriers, political backlash, other kind of strategic uncertainties we're seeing that are further jeopardizing the ability of CSOs to operate effectively, and this, in some ways, is showing sort of how the decision by the US to reduce the foreign aid funding has become an opportunity to further limit civic space in other parts of the world. So this EUC report in particular noted things like calls for investigations against CSOs receiving us funding in places like Brazil, Paraguay, Nepal, Hungary, Peru, Sri Lanka, there certainly being increased scrutiny or harassment of CSOs in general. Places like Argentina, Brazil, India, Malta, Mexico, were mentioned. Potential further restrictions on foreign funding, including foreign agent laws, have been picked up. And so we, we really hoping to continue this effort to help inform some of these policy areas, particularly around protecting civic space in places you know other than the United States.

Joseph Harris  09:25

Your tracker seems to be one of a number of different outputs coming out right now from different organizations and institutions around the world about the impacts these cuts are having. I'm aware of Boston University professor Brook Nichols has developed her own impact tracker. DevEx has also released a breaking point report, which is also based on a survey of aid workers and partners. Can you see a bit about how your findings are similar or different? How do they complement or extend the. Other work that's going on on this issue? 

Sheena Adams.  10:03

I'd say the work is definitely complimentary. We are together with you, mentum, trying to track changes to the NGO ecosystem globally, really looking at sort of hyper local, local, regional impacts, in addition to the kind of financial health and sustainability issues, job losses, the programmatic impacts, stop work stop work orders, and then, of course, waivers and related payments. And then we also looking at things like mitigation efforts. So what are the CSOs doing to try and keep their doors open in that respect? Respect, I think there's some overlap with the DevEx report, certainly, which asked very similar questions the ones we are asking. And then, in addition, had really useful data around perceptions from former USAID staff and others around the kind of reforms we need to see in the aid sector. Brooke Nichols sort of impact tracker, I think, focused more on the humanitarian side. So looking at the loss of lives under various sort of critical health projects, TB, HIV, malnutrition, I think even extending into sort of Medicaid disruptions, we weren't able to look in that kind of detail at the loss of life. I think we're a lot more invested in understanding what needs to be done to save the global NGO sub sectors that we are operating in. I think our data in particular points to really worrying trends in the entire anti corruption field, with some of it suggesting that at least parts of it are going to collapse, or at least in the sort of short term, going to shrink significantly, and, you know, unfortunately also at a time when the world really needs anti corruption and accountability and oversight measures. So I'd say that, you know, we focus more on the ecosystem, kind of building efforts, whereas a lot of the other partner organizations are looking at humanitarian impact.

Joseph Harris  12:07

Obviously, these cuts have left a major gap in funding, and you've really detailed how this is having an impact on organizations. And as you say, the ecosystem of civil society organizations working on these issues. Can you say anything about other governments or organizations that are stepping up to fill these new major aid funding gaps?

Sheena Adams.  12:31

It's not a very pretty picture. Unfortunately, Joe, I think we're seeing a broader global contraction of international aid spending. Many European governments have already announced or anticipated to announce significant cuts. For example, the United Kingdom announced at the end of Feb that it would cut its Oda budget by point from, excuse me, from point 5% of gross national income to point 3% by 2027 which is its lowest level since 1999 the Netherlands is also planning to cut 2.4 billion euros from its ODA, starting in 2027 you know, already citing Dutch domestic interests as taking precedence. Some light has come from the foundations who have announced plans to increase allocations. This includes the MacArthur Foundation, which is raising its yearly payout to, I think it's 6% Bloomberg Philanthropies announced it would honor the US as previous funding commitments, the UNFCCC around climate negotiations, the freedom together, Foundation has also unveiled commitments to spend 10% more, or excuse me, 10% or more of its endowment. So there are bright spots. There's also a number of bridge funds that have been set up aimed at supporting organizations who are blindsided by the cuts and really helping them keep their doors open while they are continuing other fundraising efforts. But I think that despite these commitments, there is a general sense that the philanthropic sector has been quite slow to respond. I mean, it's understandable. There are lots of reasons for this, including fears that these philanthropies will also begin to be targeted by the Trump administration. So we're seeing some progress, but I think still a lot of fear and anxiety in the sector, which is preventing faster, kind of more agile movements.

Joseph Harris  14:41

What can people do, who are concerned about the effects these cuts are having do?

Sheena Adams.  14:48

So, I think domestically, in the US, certainly as US citizens, there's been tons of useful calls for people to continue, nagging your Senators representatives, urging them to reverse termination. And you know, really stand up for the US is role in the world. We are also involved with the safer, stronger campaign. It's at safer, stronger.org which has made templated letters freely available to communities, advocates, veterans, the faith community to again target senators and representatives, and then I think it's also important for ordinary people to just keep up that kind of critical community level advocacy and accountability work. In the African context, where I'm based in South Africa, it's also really a good opportunity to focus on critical domestic issues. Again, I think it's about two years ago, the African Union adopted what it called the new public health order, which was aimed at promoting greater self reliance in health agendas. It called for strengthened public health institutions, domestic resource mobilization, you know, the local manufacturing of health products, health workforce development, respectful action oriented partnerships on the continent, and all of these things, while aimed specifically at the health sector, I think, offer lessons for the broader aid sector generally, and will really help us sort of solidify gains that small gains that we're making in terms of ecosystem sustainability in the medium term. So I think lots for people to do it at various levels. Still a ton of work for all of us to roll our sleeves up for. 

Joseph Harris  16:39

We've been talking here with Sheena Adams, Global Communications Director for The Accountability Lab, which is based in Washington, DC and has offices around the world. Sheena has been very kind to join us today from Johannesburg. Thank you, Sheena.

Sheena Adams.  16:54

Thank you, Joe.