This May Be the Cruelest, Most Senseless Thing Trump Has Done

A conversation with Atul Gawande about the human toll of the dismantling of foreign aid.

Nov 16

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Paid

Rovina Naboi in Rovina’s Choice. (Courtesy of the New Yorker)

SECRETARY OF STATE MARCO RUBIO was indignant in May when, at a hearing before Congress, lawmakers asserted that the Trump administration’s cuts to international aid were killing people.

“No one has died,” Rubio insisted.

It was not an especially believable claim, even then. But death from disease and starvation can be difficult to detect quickly. And it had been less than five months since Trump had signed an executive order halting global assistance—or since then-adviser Elon Musk had tweeted gleefully about “feeding USAID into the wood chipper.”

That was a reference to the United States Agency for International Development, which John F. Kennedy established in 1961 to help the world’s neediest people and make America safer by promoting stability and generating goodwill abroad. Trump and his team decided to dismantle the agency because it was supposedly too “woke” or too wasteful—or, maybe, because it was an easy first step in their radical downsizing of the federal government.¹

Among those most alarmed was Atul Gawande, the surgeon and award-winning writer who had overseen USAID’s global health programs during the Biden administration. He spent much of the winter and spring imploring Trump allies in Congress to save the agency, citing its long history of bipartisan support, including from then-Senator Rubio. As hopes for a reprieve faded, Gawande turned to spotlighting the consequences—partly to build a case for rescuing what could be rescued and rebuilding what couldn’t, and partly just to bear witness.

“They’re trying to make the loss of life invisible,” Gawande told me this week, “they’re trying to deny the reality, and the first task is making the invisible visible.”

The impetus for our conversation was a new documentary called Rovina’s Choice that Gawande has produced together with the New Yorker. The documentary is about a Sudanese refugee in Kenya and her attempts to get help for her daughter, Jane, who is suffering from severe malnutrition.

The film depicts the physical toll on Jane and others, including how a loss of ability to regenerate skin cells leads to painful, burning fissures that won’t heal—and to a literal thinning of skin that makes it increasingly difficult to maintain body temperature or prevent infection. But another wrenching part of the story may be the emotional toll on Rovina and her entire family, and the excruciating decisions she must make to protect them all.

None of this has to happen, as Gawande explained in our conversation. Starvation can seem like one of those intractable, hopeless realities governments can’t change. But the development of “Plumpy’Nut”-style paste and deployment of aggressive community outreach efforts have transformed food assistance over the past two decades, possibly saving more than 1 million lives in 2023 alone, according to UNICEF.²

The tragedy—and human toll—of abandoning those advances are an important theme of Rovina’s Choice. It’s also what he and I discussed during our interview. You can watch the whole thing on YouTube and read some excerpts below.³

JONATHAN COHN: Can you summarize what has happened to USAID and global assistance under Trump?

ATUL GAWANDE: When the inauguration happened, I left the office at 11:59 a.m. And within hours, the president signed orders halting the foreign aid. By the weekend, Secretary Rubio had implemented and sent letters out that no U.S. dollars could be spent in global health.

That meant HIV medicines, tuberculosis medicines, malaria nets on the shelf could not be given. Food aid could not be given. It was immediately clear hundreds of thousands of lives would be lost.

But [Elon] Musk continued to swing his chainsaw, and you had the entire dismantling of USAID, the purging of the staff, the termination of more than 80 percent of the awards and projects underway, the kneecapping of the rest—all against legal mandates.

[Infectious disease modeler] Brooke Nichols has led a team that has estimated 600,000 people have died already so far, 400,000 of them children. But it is hard to see. You can see the deaths that are related to childbirth. You may not see the deaths for a while where HIV is going out of control. It can take months or years sometimes for a death to occur from TB.

It’s also hard to see because they cut off funding for data monitoring. They fired the inspectors general, who could actually show how much food aid is rotting on the docks.

COHN: Why did you zero in on refugees, and on Kenya?

GAWANDE: Kenya is on a path [to economic advancement] that we’ve seen in many countries we’ve aided. But they are in a powder-keg region. South Sudan, Somalia are on their borders. And USAID, as well as other countries, have been part of supporting keeping that country stable, by having refugee support [programs] in those regions.

I was particularly interested in our progress against malnutrition. Because here was—in the last two decades—an area where we’ve had extraordinary progress.

We have pushed care out of the hospital with community health workers—visiting homes with young children, having a measuring tape and a scale, catching the severe acute malnutrition cases earlier, being able to give a fortified therapeutic food a peanut paste sometimes called Plumpy’Nut that can reverse the starvation and the worst effects and save lives.

In the first few years of deploying it, it dropped the mortality rate from over 20 percent to under 5 percent. In the areas where we were working, we had achieved a 1 percent or less mortality and understanding how that program was working.

It’s one of the biggest reasons why, in the last 20 years, child mortality has dropped by half. And so I went to see, where is this system now?

COHN: The documentary is Rovina’s Choice. Tell us about Rovina.

GAWANDE: Rovina is a woman who, with her family, had fled South Sudan after they saw relatives killed in the political instability and violence there. She has seven children of her own. She’s taken in two other children.

Her husband was in the refugee camp. [But] you can’t make an income there. He went back into the violence in South Sudan to try to make a living, and enable some money to come back for them, and was killed in that process. She remained in the camp with her children.

They were receiving food rations in the camp from the World Food Program. The funding support from the United States for those was cut to zero. And then the U.S. pushed other countries to shift their funds from aid to military, such as in Europe, as the U.S. shifted its position on Russia.

So the consequences were that the World Food Program dropped to only 40 percent of the minimum calories required for children being available. It even dropped further after our filming.

I won’t tell the conditions that baby Jane had, but she was severely ill. And Rovina’s Choice evokes the “Sophie’s Choice” of the fact that the other children soon were not going to have food themselves.

She was going to have to face, under the current circumstances, a terrible set of choices.Share

COHN: Food rations down to 40 percent or more—what does that look like?

GAWANDE: We’re talking about the family having no more than one meal per day. That meal, they aren’t assured that they could get protein. When you don’t have adequate protein, you see some really terrible things happen—loss of skin integrity, swelling.

COHN: Why is that dangerous?

GAWANDE: Without protein and basic vitamins, you can’t create skin. You start losing the ability to form collagen. So skin wounds don’t repair.

You reach the point where the skin simply starts sloughing off and you become unable to maintain your body temperature, where you also get skin infection because there isn’t a barrier between you and infection in the outside world.

They had not seen cases like that for two decades.

At the same time, more than half of children are not yet getting access to what the modern regimen is, which is actually a lower-cost regimen as well. But rather than close that gap, the [funding was] ripped away. They were simply removed with no conscience, no willingness to wrestle with the harms being done.

None of that. Instead, a complete denial of what has been done.

(Courtesy of the New Yorker)

COHN: There was a way to do this gradually, right? There was just this sort of blast wave of damage.

GAWANDE I think the thing to understand is that there is an assault on the idea of cooperation to solve big problems in the world, and instead a belief that domination, predatory transactions are how the U.S. wins.

And the thing is, it doesn’t even work on its own terms. This approach doesn’t make us more prosperous. It doesn’t win us more respect. It ends up costing lives. You end up funding the most expensive parts of aid, which is disaster relief. Or you end up abandoning people, being an unreliable partner, and having nobody trust you in the world.

COHN: When this was all playing out initially, there was this argument that ‘This is too expensive.’ ‘There’s tons of waste in the system.’ ‘The USAID is funding ideological agendas.’ ‘The Europeans could step up more, so why are we bearing this burden?’

I know you heard that from people. What was your answer?

GAWANDE: There is legitimate criticism of USAID. I’ve made much of the criticism. Too much money goes to international organizations instead of local organizations. Sometimes it will create dependency, and having pathways out of dependency is a constant necessity.

But let me tell you a couple of critical things.

Number one: This is $24 per American taxpayer, where American taxpayers are already paying $15,000 in taxes to the US government. It’s a tiny fraction of our spending. The total amount for USAID is less than half of the budget of my hospital in Boston.

And it’s reaching hundreds of millions of people and saving lives by the millions. It is the highest-impact agency in the U.S. government. So is there more efficiency that you can get? Compare it to our own American health system, and what we are achieving out of our own health system.

[The Trump administration said] the Biden administration did “woke” things like wanting to back climate change prevention and renewable energy, by helping to build economies that are future-proof against climate catastrophes, wanting to improve diversity, equity, and inclusion in our programs rather than more homogeneity, inequity, exclusion. Those are policy differences, and a new administration is perfectly within its rights to make shifts in those priorities.

But the destruction of USAID has nothing to do with any of that critique. It’s made the ability of the United States to do work around the world without needing the cost of the military phenomenally higher, right? We’ve hobbled an entire system that gave us a foothold and influence in every part of the world.

As a case in point, I had helped oversee the expansion of our pandemic prevention capacity, our ability to have surveillance and response to fifty countries around the world to create a network that eliminated blind spots. For example, opening up relationships with three countries in Central Asia—Kazakhstan, Mongolia, and Tajikistan—where working with virologists and laboratories, we had access to specimens.

We don’t have line of sight into Russia or China sitting on either side of them. But when disease comes through those areas, we can see it. We were tracking bird flu. We were tracking all kinds of disease that might be passing. All of that’s been dismantled, which only makes us weaker.Share

COHN: This is a very disheartening story to watch. It’s a disheartening story to know what’s going on. Someone watching this, they want to do something. What should they do?

GAWANDE: So a couple of things.

Number one, [the Trump administration is] trying to make the loss of life invisible, they’re trying to deny the reality, and the first task is making the invisible visible.

And so I ask you to spread the word around about the documentary and make sure that we’re holding people to account simply by acknowledging what the reality is.

The second thing is there are international programs and local programs that do work, such as in malnutrition. I can call out UNICEF, the International Rescue Committee, Helen Keller International, the World Food Program—your support would mean a great deal to programs like that at every level. Because a few dollars is another life saved.

The third is this ties in with our larger job in democracy, which is that we have to hold these people to account—you know, Rubio, Musk.

Richard Rhodes, the historian, uses the term “public man-made death.” He was referring to war, but also Mao Zedong’s Great Leap Forward, which would be found to kill at least 25 million people through famine.

We are in the face of a public man-made death now at large scale. And it is our opportunity to hold people accountable for that.

[Salon] This May Be the Cruelest, Most Senseless Thing Trump Has Done

This May Be the Cruelest, Most Senseless Thing Trump Has Done

A conversation with Atul Gawande about the human toll of the dismantling of foreign aid.