Atul Gawande: Stop-work could destroy US global health infrastructure

U.S. President Donald Trump’s administration’s stop-work order on USAID programming threatens to destroy the global health infrastructure America has spent decades building, according to Dr. Atul Gawande. On his first day in office, Trump placed a 90-day pause on foreign aid spending that was then intensified last Friday, when the Department of State ordered an immediate pause on new spending, as well as a stop-work order for existing grants and contracts. “The 90 days stop order on USAID does enormous damage to America, and it is a gift to our enemies and competitors,” said Gawande, who ran USAID’s global health programming for the last three years before leaving the organization as Trump took office. The flurry of directives from Trump’s administration has put USAID into a tailspin, which has included putting most of USAID’s global health bureau on unpaid furlough and dozens of USAID senior executives on administrative leave. This is amid instructions from the administration that include vague exceptions with little guidance on how USAID staff and their partners should navigate these uncharted waters. USAID’s work to protect against emerging health threats globally, and save lives, has come to an abrupt halt. “I don’t even know how to put it in words,” Gawande said. “We all put our heart and soul into building the capacity of this institution. It has done tangible good that you can see around the world.” Staff ‘thrown away’ For Gawande, a leading concern is losing USAID’s talent, which he referred to as “extraordinary teams” in Washington, D.C., abroad, and within partnering organizations, who have been abruptly told they can’t work. “It’s a 90-day stoppage with no commitment that the work will continue and that you will have a future doing this work — from an Administration that’s made clear it has contempt for the work of those people,” he said. In fiscal year 2023, USAID’s budget was over $40 billion, with a workforce of more than 10,000 — with about two-thirds working overseas. It works with more than 4,000 organizations in over 100 countries. The agency is the country's largest nonmilitary operational capacity abroad, having built up networks of hundreds of thousands of mainly contractors and partners around the world cooperating on areas of mutual interest and working to protect American security, Gawande said. But what’s unfolded is a “recipe for destroying that infrastructure and capacity,” he said. “Our infrastructure, our systems — at the end of the day — they’re people. When you treat them that way and send them home and make no commitment to them, then in a short time that capacity and expertise goes away,” he said. “It doesn’t bounce back. Those people go elsewhere.” One USAID contractor who was told to stop working told Devex they are going to begin applying for a new job. Another, who was a federal contractor as part of USAID’s global health bureau, was laid off without severance pay. Their work involved diversity, equity, inclusion, and accessibility programming — which Trump nixed for all federal programs on his first day in office. An example of what USAID health teams can achieve that’s etched in Gawande’s mind is when Russia attacked Ukraine and cut off medicine supplies, attacked oxygen factories, and locked down hospitals under cyberattacks. USAID worked with Ukraine’s government to open pharmacies with new supply chains, keeping millions of people with everything from heart disease to HIV alive, restarted the flow of oxygen, and moved electronic medical record systems to the cloud, where they could be protected, and jumpstarted hospitals to function again. “I’ve never seen anything like it — and those people who do that work are being thrown away like they’re nothing,” he said. Impact on HIV services The USAID stop-work order includes exceptions — the first declared was on emergency food aid. Late Tuesday, USAID Acting Administrator Jason Gray sent out a waiver “exclusively to lifesaving humanitarian assistance, which includes essential medicines, medical services, food, shelter, and subsistence assistance, as well as necessary supplies and reasonable administrative costs” to deliver this aid. But this exception left questions about what’s included. It raised hopes that “life-saving medications” would include antiretroviral treatments delivered to some 20 million people globally through the U.S.’s PEPFAR initiative, although the memo didn’t explicitly mention them. If they aren’t included, it’s a death sentence, Gawande said. When a person misses doses, the virus comes back, people get sick, transmit the virus, and the virus can become drug-resistant. PEPFAR supports a large number of NGO-run clinics around the world, with over 350,000 people in that extended workforce of contractors, most of them at local organizations, Gawande said. “There are children with HIV being sent away for their appointments and refills, supplies can’t be handed out, orders for new supplies can’t come in. It’s a big deal,” Gawande said. And much of PEPFAR’s work focuses on prevention services, which has included focusing on targeting groups who are at higher risk of infection, including men who have sex with men. Trump’s executive order on ending diversity, equity, and inclusion programming explicitly mentions ending efforts to advance equality and human rights for lesbian, gay, bisexual, transgender, queer, and intersex people. “We’re on the path to be able to stamp it out, and that work is being stopped,” Gawande said, adding that a breakthrough is a new long-acting injection that stops a person from becoming infected with HIV for six months. “We’re in the midst of transitioning these programs to the host governments in these countries and deploying a long-acting, single injection treatment for HIV,” he said. “The work deploying that around the world, which is the solution … is stopped,” he said. Gawande said granting a few waivers isn’t the solution to what’s unfolding in the U.S. government. “I don’t think we should take some exemptions here and there as an indication that our security and safety is not damaged,” he said. Compromising the ‘world’s immune system’ Another critical role the U.S. government plays in global health is preventing deadly outbreaks. This includes USAID’s monitoring of the ever-evolving bird flu. For example, in Tajikistan, Kazakhstan, and Mongolia, USAID has cooperative monitoring agreements for emerging outbreaks that give the U.S. visibility into Russia and China — which it doesn’t reliably have otherwise. “Having that capacity is one of the backstops for knowing what’s emerging,” Gawande said. “Understanding what’s emerging, the variants and where, and getting an early jump on it is absolutely critical.” The same systems weren’t in place during the COVID-19 pandemic and some countries weren’t acknowledging the virus was circulating within their borders. “Now we have a network of more than 50 countries around the world, strategically placed, where we’re cooperating and building their capacity to detect and report on what they’re seeing and obtain samples,” he said. Another example is the ongoing outbreak of Marburg in Tanzania. The disease, similar to Ebola, can have fatality rates up to 88%. USAID has supported the build-up of capacity for frontline workers and laboratories in Tanzania to recognize, test, and respond to diseases such as Marburg, Gawande said. “Our cooperation involves daily contact and support built up over years,” he said. The U.S. is also the source of experimental vaccines for Marburg that were successfully deployed experimentally in Rwanda’s outbreak that ended in December. And the U.S. also plays a crucial role in helping deliver vaccines during the ongoing mpox outbreak, which is concentrated largely in the Democratic Republic of Congo. To put this work into perspective, during the West Africa Ebola outbreak between 2013 and 2016, the virus spread across borders, killed thousands of people, and the virus was brought to American shores. Since then, Ebola outbreaks haven’t reached that scale. “Mutual cooperation has brought them under faster and faster control,” Gawande said. He dubbed it “the world’s immune system,” which is becoming more resilient in detecting threats rapidly. But keeping that system intact is now compromised. Lasting damage Wild polio was a global scourge that paralyzed or killed half a million children yearly in the mid-twentieth century. Now it’s on the brink of elimination, but there are still outbreaks of circulating vaccine-derived poliovirus type 2. Eliminating polio has been a globally coordinated effort, through the Global Polio Eradication Initiative, which receives $65 million annually from USAID. “There are direct programs of USAID doing surveillance in countries and directly supporting the response,” Gawande explained. And this is relevant to America — which has a movement of parents that don’t vaccinate their children. A paralytic case of polio came to New York in 2022, with an outbreak in several counties from people not immunized. The world won’t reach the finish line on eradicating polio if the U.S. pulls out of this work, he said. Beyond polio, Gawande said USAID’s work in preventing child and maternal deaths has been one of “the great successes in American history.” He also considers the U.S.’s support in nearly stopping river blindness in the Americas with donated corporate drug donations, and support to 19 countries in building up capacity around family planning so they no longer need assistance, as success stories. USAID also supports other global health organizations such as Gavi, the Vaccine Alliance and UNICEF. And its health teams also monitor misinformation. USAID tracks scores of propaganda attacks against its work from countries including Russia and China, Gawande said. This includes Russian intelligence services that have backed an initiative that has consistently attacked U.S. health programs across Africa. “It repeatedly publishes baseless claims that USAID’s programs are covertly carrying out nefarious biological testing on African communities,” he said. And now all of this is up for a 90-day review, after which the Trump administration will decide whether to continue, modify, or terminate programs. The worst case scenario is that after the 90-day review, entire components of this work are shut down, Gawande said. But even if that doesn’t happen, and the administration decides to bring these programs back, there’s still a need for recovery and rebuilding teams. “That damage lasts months, and in some cases, it will be years,” he said. “The worst case scenario is you don’t bring them back at all. The best case scenario is you set America back for months to years.”