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One Saturday in 2004, I sat on the porch of our two-room health clinic in the central part of the country, trying to persuade Marie, a thin, exhausted mother, to allow us to transport her ill 7-year-old to a hospital about 45 minutes away. “But I don’t have any money,” she told me, worried.
I was there as an infectious diseases specialist, deployed with Partners In Health — the Boston-based global nonprofit cofounded in 1987 by Dr. Paul Farmer — to combat HIV and tuberculosis and support primary health care. For the first time in her son’s life, Marie would not need to see him suffer because she couldn’t afford care. Our programs were funded by the then-new United States President’s Emergency Plan for AIDS Relief (PEPFAR) and the Global Fund to Fight AIDS, Tuberculosis and Malaria.
Our small rural clinic, previously staffed by just one nurse in a district of 55,000 people, was quickly becoming a hive of activity, overseen by US and Haitian physicians. Medications were available, including antiretroviral therapy and supplies for HIV testing and care, and so were resources and expertise for maternal and child health. We were also quickly discovering a concerning amount of childhood malnutrition, the primary affliction of Marie’s very sick little boy, Samuel. (I’ve given Marie and Samuel pseudonyms to protect their family’s privacy.)
Lying on a blanket, Samuel was feverish and lethargic that day. A chronic lack of access to nutritious food had stunted his fragile body and damaged his immune system, allowing infection to take hold. His mother had already witnessed more than her fair share of bad news in this region of the country with the highest childhood mortality rate in the Americas — 131 of every 1,000 babies born there would not live to be 5 years old. Marie was already resigned to the death of her child.
While the team and I hooked up intravenous fluids, preparing to transport Samuel to the hospital, Marie hesitated. “He will die there,” she said, “and I don’t have money to bring his body home.” (With few cars in the area, most transport is by foot or donkey.) She could not cope with the thought of being unable to afford bringing him home for burial.
PEPFAR is not specifically an antipoverty program, but it has improved health outcomes and economic stability for millions of people worldwide. The program was launched by President George W. Bush and had — until recently — broad bipartisan support. It is widely considered to be one of the largest and most effective global health interventions of all time. To date, PEPFAR has provided treatments that have saved 26 million lives, built health systems, and established the foundation from which to launch multiple successful health responses.
Although Samuel was not in our care because of HIV, our clinic was operational, and health care staff were available that weekend, because of PEPFAR. In 2024, 342,000 health workers around the globe were supported by the program. Those health workers are a resource in their own communities, and have designed and implemented innovative health care delivery models that also prove helpful in US settings. (The COVID-19 contact tracing program in Massachusetts was run by Partners In Health, and informed by similar initiatives the group developed in Haiti and in Africa.)
In the end, Samuel’s mother was right— he did pass away. We had arrived too late. I often think of him, and the systems we helped develop to help other children.
If Samuel became sick today, thanks to programs like PEPFAR and other multilateral efforts, he would now be met in his rural community by a trained and equipped community health worker, his mother would have already had a connection to the clinic through outreach and education efforts, diagnosing his illness sooner, and connecting her to food assistance programs and livelihood support. Severing our foreign assistance puts all of that progress at risk.
Last month, when Secretary of State Marco Rubio abruptly paused PEPFAR, shuttered the US Agency for International Development (USAID), and hampered or closed essentially all foreign assistance, he claimed that aid “programs on autopilot” have little reason to share details “so long as the dollars continue to flow.”
However, PEPFAR’s activities are well documented, tracked, and analyzed. It provides regular fiscal and programmatic information to account for every dollar spent and every activity undertaken, and delivers annual reports to Congress.
As billionaire Elon Musk was gleefully announcing that USAID was being fed into the “wood chipper,” my colleagues in Haiti were urgently discussing how to ensure continuity of care for patients just like Samuel.
While supposedly “straightforward” waivers for life-saving services are being offered by the State Department, these have created confusion and many activities are still halted — not just for programs battling the HIV pandemic, but also for those on the front lines of outbreaks of Marburg virus and Ebola. I currently lead a health-system strengthening collaboration in Uganda, where an outbreak of Ebola was recently announced, and am the recipient of funding from the National Institutes of Health for research on cholera control. As COVID-19 reminded us once again, infectious disease does not respect national borders.
Among the US foreign assistance dollars spent in 2024, 46 percent was allocated to multilateral agencies. As the term implies, these agencies receive funds from a variety of donors and then work within recipient countries to advance mutual goals.
One example is the World Food Program, operated under the umbrella of the United Nations. It “uses food assistance to build peace, stability, and prosperity” (and received 8 percent of the US federal foreign assistance budget in 2024). By directly providing food, as well as building capacity to improve food supply and livelihoods, support from the World Food Program offers a critical economic complement to health care. In Haiti, for example, partnerships have resulted in falling rates of child mortality there and reduced rates of HIV transmission, and have led to progress in child nutrition.
America’s foreign assistance and engagement with partners in global systems for health and health security are ingredients in a recipe for health, peace, and security for all. Dismantling this assistance in a boorish, thoughtless way will harm not just individual lives, but progress that has taken decades to build.
As I write this, a federal judge has just temporarily lifted the funding freeze, but uncertainty remains. And the damage has already been adding up. Thousands of Americans involved in global health work risk losing their jobs. Scientists here and abroad have been forced to halt critical international research trials due to “stop work” orders from the Trump administration. US public health experts have been removing themselves from leading-edge technical working groups and canceling their participation in pandemic-threat outbreak response.
These actions do not make America better or safer.
I hope that we can gather our collective humanity and consider how this country — the richest economy in the world — should sustain our commitment to saving lives, uplifting communities, and collaborating with our global neighbors in a solidarity befitting the future world we want to see.
Louise C. Ivers, MD, MPH, is the director of The Harvard Global Health Institute, a professor of global health and social medicine at Harvard Medical School, and an infectious diseases doctor in Boston. Dr. Ivers has previously worked with colleagues around the globe on projects funded in part by US agencies such as PEPFAR, USAID, and the CDC. Send comments to magazine@globe.com.