‘The system is breaking’: US aid freeze threatens child malnutrition care

Navyn Salem, the CEO of a Rhode Island-based producer of lifesaving foods for malnourished children, was in Sierra Leone last month when she got an email that made her heart drop. It was a notice of the Trump administration’s 90-day freeze on all U.S. foreign assistance. And Edesia — the nonprofit she founded that makes a high-calorie, nutrient-dense peanut paste known as RUTF, or ready-to-use therapeutic food — had just received two stop-work orders that would force it to pause its work for that period as the Trump administration reviews all U.S. foreign aid programs. “We sat there speechless. We had just visited, 30 minutes earlier, a hospital that had boxes of RUTF in the corner that said ‘Made in Rhode Island’ and made it here to Sierra Leone. It was the only supply of lifesaving food for these children,” she said. “Without that, there is no alternative. Nothing,” she continued. “This is not a food you can replace with something else. So to get that news delivered while sitting there literally face-to-face with children who depend on us was a tough process.” Malnutrition tends to hit the very youngest children the hardest, and most aid agencies focus on treating and preventing malnutrition in the first 1,000 days of life, from a woman’s pregnancy to the child’s second birthday. For these children, time is of the essence. A treatment delay of a few days or weeks — let alone 90 days — can be a matter of life and death, and the effects can be lifelong: impaired brain development and weakened immune systems. So Edesia, whose product is called Plumpy’Nut, sprang into gear, calling members of the U.S. Congress and collectively organizing with other RUTF producers and NGOs that care for children facing severe acute hunger in countries such as Haiti, South Sudan, Nigeria, and Yemen. Edesia also frantically tried to reach its contracting officer at the U.S. Agency for International Development, which, in some years, funds up to 80% of the organization’s work. The advocacy seems to have worked: Within a week, on Feb. 6, USAID notified Edesia that its stop-work order would be rescinded. Another American producer of RUTFs, Georgia-based MANA Nutrition, saw its stop-work order rescinded as well. Both Edesia and MANA Nutrition have resumed production of RUTFs — but both tell Devex the sense of relief is temporary. Much of the work involved in treating malnourished children has been unable to resume. That’s despite a blanket waiver that U.S. Secretary of State Marco Rubio issued on Jan. 28 allowing for the continuation of “life-saving humanitarian assistance,” which includes food aid, and another waiver USAID announced a week later for lifesaving global health services, including management of severe acute malnutrition with RUTFs — but only if their absence could “lead to mortality in women, newborns, and children under five.” Treatment of severe acute malnutrition is considered a health intervention, and agencies such as UNICEF work with national health departments to devise treatment plans. However, RUTF products are just one piece of the puzzle. The Trump administration’s stop-work order is still in effect for almost everything else, from malnutrition screenings at health centers to ongoing monitoring and other forms of aid, such as cash vouchers, that keep families from going hungry in the first place. Though aid organizations are starting to receive waivers or permission to resume work, the permission is often partial, and they still can’t access the funds they are owed by the U.S. government in order to perform their work. In addition to immediate disruptions to the RUTF supply chain, experts tell Devex that they expect supply shortages in the longer term as well. “The system is breaking,” said an official with a humanitarian aid organization that treats severely malnourished children, who spoke on condition of anonymity so as to not jeopardize their U.S. funding. “Supplies are not getting to people. We’ve got staff being fired across the board because these organizations are supported by U.S. government funds. And you can’t run programs without staff.” Children at risk of dying Nearly half of all child deaths annually can be attributed to undernutrition, according to UNICEF, and some 148 million children worldwide — about 1 in 5 — are chronically malnourished to some degree. The worst-affected regions are the Horn of Africa and the Sahel. Four international NGOs that provide global health services, including malnutrition prevention and treatment, told Devex they’ve had to drastically cut or totally suspend these services in the past month. The result is that many tens of thousands of starving children and families cannot get care. “This means children are not being screened for malnutrition, and those who need services are not able to receive the treatment that they need or receive the monitoring in health services to make sure they are recovering from malnutrition,” said an official with a global health nonprofit. “What this means is we could see increased rates of relapse of children who previously received treatment or they may be progressing to worse stages of malnutrition if they are not able to receive ongoing support and services,” the official said. “It could lead to higher mortality rates due to malnutrition especially in households that are unable to manage it without the support and care of health care facilities and health care workers.” In Nigeria alone, the Danish Refugee Council — whose second-largest donor is the United States, contributing 20% of its budget — has been forced to stop providing treatment to 150 children under the age of 5 each month who suffer from severe acute malnutrition, along with other medical complications. It has also stopped providing supplemental nutritional assistance to 400 children monthly and halted cash aid that helps 30,000 displaced people meet their basic food needs on their own. “Most partners have been trying to stay open with their own resources, or they’re triaging by focusing on a small set of kids,” said Erin Boyd, a former nutrition adviser with USAID’s Bureau for Global Health and adjunct assistant professor at Tufts University’s Friedman School of Nutrition Science and Policy. “Most partners are just scrambling. But in places like Gaza or Sudan where access is such a challenge, community groups can’t always figure out who to prioritize.” Another humanitarian aid organization told Devex that it is now focusing its services on the nearly 1,000 severely malnourished babies and young children in its network of inpatient stabilization centers, most of which are fully U.S. funded — and thus face immediate and serious budget concerns because that money is not coming in. “When their care is disrupted for even a matter of hours, or if the lights turn off for even a day, many of these children are at risk of dying quickly,” the humanitarian aid official said. That organization — which has received some waivers — has shifted its internal funding in order to temporarily keep the centers running. It also seeks private funds to keep the centers open longer-term. Care for the hundreds of thousands of children in its outpatient feeding programs has been disrupted as well: They tend to receive RUTF, vitamins, immunizations, and other care from health care workers — and many of those human resources face furloughs and layoffs. Interconnected supply chains Due to the interconnected nature of global health supply chains, the entire ecosystem of facilities and programs providing malnutrition services is affected by the U.S. aid freeze whether they get U.S. funding or not. The U.S. government is a massive donor to global malnutrition treatment and prevention. USAID funded more than $1 billion in nutrition programming in over 30 countries in fiscal year 2023. The majority of that funding came via the agency’s Bureau for Humanitarian Assistance, which tends to focus on emergency settings, while $160 million was channeled through global health programs. The two big U.N. agencies working in this space are UNICEF, which treats severe acute malnutrition, and the World Food Programme, which treats moderate acute malnutrition. UNICEF procures an estimated 75% to 80% of the global demand for RUTF, averaging 50,000 metric tons per year — which is enough to treat 3.6 million children annually, according to the agency’s estimates. WFP tends to work with another kind of specialized food called ready-to-use supplementary food. Both UNICEF and WFP are major recipients of USAID funding, and both received stop-work orders. WFP has since been granted permission to resume in-kind food aid purchases and deliveries and to work with NGOs to distribute emergency food assistance to people in crisis settings after it was found that more than 507,000 metric tons of food aid valued at more than $340 million was stranded due to the foreign aid freeze. UNICEF, for its part, did not respond to multiple requests for comment on whether it has been granted a waiver or suspension of its stop-work order to resume distributing RUTF. The trouble with waivers When it comes to exemptions and waivers, nutrition programming is caught in a cruel purgatory: To service providers, it’s obvious that their work is lifesaving. However, waivers for many groups have yet to come through. Even when they do get waivers — or when their stop-work orders have been rescinded — they face barriers to getting their programs back up and running. “On paper, a lifesaving waiver would be expected to keep programs open, when in reality, that's not happening,” the humanitarian aid official said. One major problem is that they can’t access their funds from the U.S. government. USAID’s payment system, Phoenix, is still not operating, which means that even with a waiver, groups cannot draw down that money — and are thus faced with dipping into their own limited cash reserves. Organizations across the aid sector are owed hundreds of millions of dollars for work completed before the Trump administration’s stop-work order and foreign aid freeze went into effect. Even with a waiver, they have no guarantee from the U.S. that they’ll be reimbursed for that work, meaning that anything they do now could be financially risky. Payment may still not come despite a U.S. federal judge’s ruling Thursday ordering the administration to reverse its stop-work order and unfreeze funds on existing programs. “We've received permission to do emergency nutrition in certain programs, but are not able to access funding for it,” a second humanitarian aid official said. “Some of our malnutrition programs still lack a waiver and are thus stopped.” In a Feb. 13 memo to USAID staff members, Mark Kevin Lloyd, who is now performing the duties of assistant administrator for the agency’s Bureau of Global Health, reemphasized what falls under the State Department’s global health waiver for lifesaving humanitarian assistance, which includes specific activities for fighting tuberculosis, malaria, acute risks of maternal and child mortality, severe acute malnutrition, and other life-threatening diseases and health conditions. Lloyd also wrote there’s a “false narrative in the press” about the waiver system, saying that the lifesaving aid has “continued uninterrupted and was never paused.” Organizations on the ground may beg to differ. One INGO tells Devex that it has been allowed to continue its malnutrition treatment programs in Ethiopia. But the Ethiopian government, which gets USAID funding, has not allowed for the payment of drivers and other support staff, as their direct work is not considered lifesaving under the Trump administration’s limited waiver, according to an official with knowledge of these operations. This means field staffers can’t reach far-flung health facilities and mobile clinics. In another case, a warehouse in northwestern Nigeria that stored RUTFs could not be opened because, as of last week, it had not yet received permission to do so, according to two experts familiar with the supply chain. Further, because the Trump administration has moved to terminate almost the entirety of USAID’s global workforce, which once numbered close to 13,000 , groups often cannot communicate with the agency to ask questions or updates on the status of their payments. It’s unclear to what extent that may have changed now that access for some staffers has been restored following a U.S. federal court ruling. And aid organizations doing malnutrition work in nonemergency settings find themselves cut out of USAID’s limited global health waiver for lifesaving services. This includes work such as distributing prenatal supplements, counseling on child nutrition, support for breastfeeding mothers, and other nutrition services for food-insecure households. “This waiver only applies to centrally funded mechanisms, so that’s funding that’s primarily directly through USAID’s global health bureau in Washington,” the official with the global health nonprofit explained. “But the vast majority of nutrition funding is actually provided through USAID missions in country. And missions now have to determine for themselves if they will provide us overall guidance and issue waivers for the programs.” “We have not received waivers for any of our programs, including for programs that are providing support for severe malnutrition,” the official continued. “And we cannot resume work until we receive explicit permission to do so.” What’s next? These challenges point to why the restoration of RUTF producers’ work might be a win — but it’s not enough to fully restore malnutrition treatment. “We need all of us together,” said Edesia’s Salem. “Between the funders, the programmers, the implementers, the producers, all of us have to be working in order for there to be RUTF there in a clinic at the time that a mother comes with her child and desperately needs it.” Now there’s the question of what happens next. The rescission of the stop-work order applied to Edesia and MANA Nutrition’s existing contracts with USAID, but both are unsure if they will get future work with the agency. Edesia, for its part, purchases $100 million worth of raw materials annually from 25 U.S. states in order to make its products and ships to 30 countries, where it reaches 5 million children each year. In the fiscal year ending in September 2024, USAID awarded contracts worth $78.4 million to MANA Nutrition and $81.3 million to Edesia, according to USASpending. “It takes a long time to procure all the ingredients to get together the vitamins and the peanuts and the sugar and the milk powder and all that stuff,” said Mark Moore, CEO of MANA Nutrition. “We might procure those ingredients three months ahead of even making the product.” “The question is, for us as a supplier, will the contracts we were expecting, which for us is around $40 million going forward through May, are those going to be honored, or will they be canceled?” he continued. “Should we keep making them? We're just waiting on the answer.” It’s also unclear what global malnutrition aid will look like by late April, after the Trump administration completes its 90-day review of all U.S. foreign aid programs. What’s certain is that many programs will not survive that period of time and will have to close their doors — meaning far fewer children will be able to access treatment. “Nutrition programs are essential to make sure future generations can grow healthy, can pursue an education, can build local economies, and be productive members of society,” said the official with the global health nonprofit. “And if we are not supporting them during that critical window, during those first 1,000 days from pregnancy to a child’s second birthday, we are losing out on that future potential to ensure communities across the world are stronger and more prosperous.”