862: Some Things We Don't Do Anymore

Summary

This American Life: Episode 862 - Some Things We Don't Do Anymore

Host: Ira Glass
Release Date: June 22, 2025

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Introduction

In Episode 862 of This American Life, host Ira Glass delves into the unforeseen consequences of the abrupt shutdown of the United States Agency for International Development (USAID) under the Trump administration. Titled "Some Things We Don't Do Anymore," this episode explores how the sudden halt in foreign aid disrupted life-saving programs across the globe, leaving millions vulnerable. Through personal stories, expert interviews, and on-the-ground reporting, the episode uncovers the intricate web of dependency, bureaucracy, and unintended repercussions resulting from policy changes.

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The Shutdown of USAID and Immediate Impacts

The episode opens with David Kestenbaum describing a vast warehouse in Rhode Island filled with boxes of Ready-to-Use Therapeutic Food (RUTF), a critical nutritional aid for severely malnourished children. He likens the warehouse to the iconic final scene of Raiders of the Lost Ark (01:12).

David Kestenbaum:
"Most of these cardboard boxes contain this nutritional peanut paste. Each box has two months' worth, enough to save the life of one severely malnourished child." (00:50)

Naven Salem, the head of Edezia—a non-profit organization manufacturing RUTF—explains that over 200,000 boxes are stalled in the warehouse due to the collapse of USAID and the subsequent bureaucratic limbo (01:21). The abrupt cessation of foreign aid by President Trump left vital resources stranded, jeopardizing the lives of children in countries like the Democratic Republic of the Congo, Sudan, and South Sudan.

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Case Study: Edezia and Naven Salem's Struggle

Naven Salem recounts her relentless efforts to navigate the shutdown. With USAID employees let go and contracts left in disarray, Salem faces the daunting task of securing the necessary signatures to release the aid. This impediment not only halts production but also endangers the lives of children awaiting assistance.

Naven Salem:
"I feel like I'm in a movie that I don't want to be in. I don't sleep. I get up at 5 o'clock in the morning every day." (03:02)

Salem's narrative highlights the human cost of policy decisions, emphasizing the urgent need for continuity in foreign aid operations.

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Reflecting on USAID's History: Insights from Experts

To provide context, the episode features interviews with John Norris and Joshua Craze, who discuss the inception and evolution of USAID. Founded in 1961 under President John F. Kennedy, USAID was designed to aid emerging nations post-colonial rule, primarily to prevent the spread of communism during the Cold War.

Joshua Craze:
"For Kennedy, the goal is to bring development to the rest of the world...he didn't want them to become communist." (15:14)

While USAID achieved notable successes, such as the eradication of smallpox and significant advancements in countries like South Korea and Taiwan, it also faced substantial challenges. Projects aimed at economic reforms and democracy-building often faltered in the face of local autocracies or systemic corruption.

John Norris:
"For development to work, the country's government has to make a bunch of difficult changes... Some countries were run by autocrats who didn't really care for helping the general population." (17:40)

The shift from development-focused initiatives to humanitarian aid and health programs marked a significant transformation in USAID's mission, reflecting broader geopolitical shifts post-Cold War.

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Case Study: The Luke Commission in Eswatini

A poignant segment of the episode examines the Luke Commission, a health provider in Eswatini (formerly Swaziland) heavily reliant on USAID funding. Founded by Harry and Echo van der Waal, the Luke Commission became one of the largest recipients of American aid, transforming from a modest clinic to a sprawling medical campus funded by President George W. Bush's PEPFAR initiative.

Harry van der Waal:
"PEPFAR money completely changed the course of the AIDS epidemic. In Eswatini, the number of people dying from AIDS went down by half." (34:42)

The Commission's rapid expansion facilitated advanced healthcare technologies and treatments, but also inadvertently fostered corruption within the local government. When USAID funding abruptly ceased, the Commission faced financial ruin, leading to layoffs and the closure of critical services.

Sarah Rumsey:
"We have not transitioned like we should. By now we should have transitioned it to being locally supported..." (49:22)

The sudden withdrawal of aid exposed systemic vulnerabilities, revealing that despite improvements, local infrastructures were not fully equipped to sustain the programs independently.

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The Aftermath and Human Stories

The episode shifts focus to the real-life implications of aid cuts, featuring heartbreaking testimonies from individuals like Jay and Nakayo. Jay, a 24-year-old from Mombasa, struggled to access his HIV medication following the funding freeze, leading to severe health deterioration (58:00). Similarly, Nakayo's tragic suicide underscores the devastating personal toll.

Nakayo's Story:
"Nyakayo died by suicide on May 1. She was 22 years old and three months pregnant." (63:36)

These narratives humanize the abstract statistics, illustrating the immediate and long-term consequences of disrupted aid—ranging from medical shortages to increased mortality rates.

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Conclusion: The Broader Implications of the Shutdown

As the episode draws to a close, experts like Charles Kenny warn of the extensive death toll resulting from the aid cuts, estimating upwards of half a million deaths annually due to interrupted programs (56:29). The abrupt policy shift not only reverses years of progress but also destabilizes global health initiatives, highlighting the critical need for strategic, sustainable foreign aid policies.

Charles Kenny:
"The modeled estimate is that 200,000 or so people will die due to the cuts to awards this year." (55:40)

The episode culminates in a reflective discourse on the importance of foreign aid, the complexities of international development, and the moral imperative to ensure that life-saving programs remain uninterrupted and adaptable to changing political landscapes.

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Notable Quotes

• Naven Salem (03:02):
  "I feel like I'm in a movie that I don't want to be in."

• Joshua Craze (15:14):
  "For Kennedy, the goal is to bring development to the rest of the world."

• John Norris (17:40):
  "Some countries were run by autocrats who didn't really care for helping the general population."

• Harry van der Waal (34:42):
  "PEPFAR money completely changed the course of the AIDS epidemic."

• Charles Kenny (55:40):
  "The modeled estimate is that 200,000 or so people will die due to the cuts to awards this year."

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Final Thoughts

This American Life masterfully weaves together policy analysis, historical context, and personal tragedy to paint a comprehensive picture of the ripple effects caused by the cessation of USAID funding. Episode 862 serves as a poignant reminder of the fragile interdependencies in global aid and the profound human impact of political decisions.

For more stories like this, visit ThisAmericanLife.org.

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Note: Timestamps correspond to the transcript provided and are indicative of where the quotes and events occur within the episode.

Transcript

[Ira Glass]

This message comes from Capital One.

[David Kestenbaum]

Banking with Capital One helps you keep more money in your wallet with no fees or minimums on checking accounts. What's in your wallet terms apply. See capitalone.combank for details. Capital One NA Member, FDIC from WBEZ Chicago. This is American life.

[Naven Salem]

Okay, let's see what we got in here.

[Dr. Mushtaq Khan]

How are you?

[Naven Salem]

Good.

[David Kestenbaum]

This is huge. We're in a warehouse in Rhode island whose floor space is bigger than two full football fields. Three stories tall. Row after row after row of cardboard boxes stacked high, stretching far into the distance. I feel like the only thing that I know to compare this to is like the last scene of Raiders of the Lost Ark.

[Sarah Rumsey]

That's a pretty good comparison.

[David Kestenbaum]

Most of these cardboard boxes contain this nutritional peanut paste. It's a kind of miracle food made to strict international standards. Officially called rutf, Ready to use therapeutic food or plumping nut. Each box has two months worth, enough to save the life of one severely malnourished child.

[Sarah Rumsey]

Over 200,000 boxes that are sitting here in this warehouse.

[Naven Salem]

Each one represents one child's life.

[David Kestenbaum]

Naven Salem runs this place, making this stuff. And Sarah Rumsey is one of her managers. They explain that we're looking at millions of dollars of aid that's already been paid for by the United States government. They manufactured it for the US Agency for International Development, usaid, before it was shut down by Elon Musk and Donald Trump.

[Naven Salem]

If you look at these boxes, the majority do not have a country destination or paperwork to leave the facility. And it's been sitting here since February waiting for paperwork to be signed. The problem, when you dismantle all of usaid, there are no people who can proceed with basic day to day jobs to process basic things like contracts.

[David Kestenbaum]

And where was this food supposed to go? Do you know?

[Naven Salem]

So this would typically go to Molly. Chad, Democratic Republic of the Congo. Sudan. South Sudan.

[David Kestenbaum]

Nearly a half billion dollars worth of food was stuck in warehouses like this one. It was in transit right after President Trump froze all foreign aid. So suddenly, his first day in office, it really wasn't clear what was going to happen to it, if it was going to be left to spoil, if it would get delivered. Then the State Department said that life saving food and medical aid could get permission to continue. But lots of it stayed stuck. Things were in a weird limbo while they were dismantling the agency that did that work, USAID, and transferring any of USAID's remaining functions over to the State Department. People like Naven had to operate in that limbo in her case trying to get this product out of her warehouse to the people who need it.

[Naven Salem]

I feel like I'm in a movie that I don't want to be in. I don't sleep. I get up at 5 o' clock in the morning every day. The money and the time that we're spending trying to get a single signature.

[David Kestenbaum]

Nathan founded this business. It's called Edezia. It's a non profit. We sit on the concrete floor in the middle of all these boxes to do our interview. And every detail that she tells me about how she ended up starting this company sounds like it's part of a fable in a kid's storybook, but a weird storybook where the hero dreams not of being a princess or a scientist or a detective, but of being a cog in America's foreign aid establishment.

[Naven Salem]

The reason that I'm here is my dad was given the first scholarship ever to an African student by usaid. He came to the United States, lived with a host family and lived in Michigan and went to university in Michigan. I was born here. And when I wrote my first grant proposal to usaid, I wrote a cover letter and I said, I'm here because of you.

[David Kestenbaum]

Her dad came from Tanzania, and when her own kids were preschool age, she has four girls. David said she started thinking a lot about doing something to help parents back in Tanzania and places like it. She heard about Rutfs from a story she saw in 60 Minutes in 2008, started manufacturing first in Tanzania, then in Rhode Island. She had no manufacturing experience at all, had to learn everything, and then grew the business to a factory with 150 employees. A big chunk of them refugees from countries around the world that Adizia ships to now legally living in Rhode Island. Navin's got a boss who chats with everybody we run into in the factory and warehouse. When the warehouse manager spots us sitting on the floor and decides to bring over some chairs, she jokes, do we.

[Naven Salem]

Look like we need help getting up? Yeah, yeah, you guys, we're fine. Don't worry.

[David Kestenbaum]

Then she leans over to my producer Ike, who's on the floor.

[Naven Salem]

Ike, sit in the chair.

[Sarah Rumsey]

Just pretend.

[Naven Salem]

Just. I didn't want to insult them.

[David Kestenbaum]

David describes her workday since January during this period of foreign aid limbo as an ongoing series of brand new, possibly business ending problems. To solve one after another, she got stop work orders from the government for shipments that were already in production. Then the stop orders were reversed. This happened twice in February when almost all of the 10,000 employees at USAID were let Go. The contracting officer that Naven dealt with was one of them. She suddenly found herself with nobody she could contact at the agency.

[Naven Salem]

Meanwhile, they broke the payment system. Imagine not knowing that your entire cash flow is going to be turned off with no warning and try to run a business with no money.

[David Kestenbaum]

The government owed her a bunch of payments totaling $24 million for orders placed last year. When it didn't come, she had to shut down the production lines for the first time in 15 years.

[Naven Salem]

We got the funniest messages. You know, like, your invoices have been rejected. You know, thank you. Like, okay, the next obvious question is why? Who is going to walk away and just be like, oh, that's fine. It was just $7 million. It's fine. You don't need to pay because you said they're rejected with no reason. Okay. It's okay.

[David Kestenbaum]

And that $7 million for stuff you've already made.

[Naven Salem]

I have a binding contract with usaid. I bought the peanuts, I made the plumpy nut, and I shipped it to the country that you required it to go to. And then you decided that you cannot pay me. You know, and sometimes we get, you know, this contract has been cancelled. Please resume. Resume your normal business activities. I'm like, you are my normal business activity. Like, I can't resume if we can't get along here.

[David Kestenbaum]

The production line's conveyor belts are right outside her office. And she said she would sometimes look at them and think, every hour they were shut was 415 kids she couldn't feed.

[Naven Salem]

That's the calculation that is going through my head. That's the urgency that I feel. And I'm trying to light things on fire to let people know how she's handled.

[David Kestenbaum]

This is a good illustration of what you have to do when normal systems to solve problems no longer exist. Nevid's basically been working the phones and texts and emails nonstop talking to anybody who might have information or might know somebody that might help her stay in production. She's done a ton of press and says it's actually helped. It's led to random celebrities, people connected to the White House reaching out and trying to pull strings for her. Social media has helped, too. Like, once it became clear that the State Department was going to take over all the functions of usaid, they even posted on Instagram looking for the name of somebody, anybody inside the State Department who might help her get shipments going again. She says, incredibly, somebody saw that and reached out to say, oh, my God, I'm at dinner with the person you need. And Then is that person at the State Department, are they somebody who actually can help you?

[Naven Salem]

He's the only person who can help me.

[David Kestenbaum]

And how's that going?

[Naven Salem]

Well, imagine that you have a company and you fired everybody except the CEO.

[David Kestenbaum]

This is basically the situation her contacted State Department is in.

[Naven Salem]

Now, the CEO doesn't know how to do all the jobs in the company, so they can't. And even if all they want with all their heart's desire is to get a transportation contract, the person who writes them and drafts them is no longer there. So you can't then imagine that the CEO has to make every decision in the company. Thousands of decisions a day. And the CEO also just started less than two months ago. Yeah.

[David Kestenbaum]

Step by step, some things have fallen in place. The government started paying again so she could restart her production lines. In March, her contracting officer came back, so she had somebody to talk to. It was last month when I sat on the warehouse floor with her and recorded this interview. And since then, about half the boxes have shipped out. The rest are still stuck. But a bigger problem is the future. The Trump administration has said that life saving aid will continue in some form for some countries, but the question is how much. The State Department is only committed to one month's worth of RUTF production and nothing beyond it. And even that they haven't issued contracts. And there are people waiting for RUTF all over the world. Dr. Mushtaq Khan oversees nutrition programs in Afghanistan for the International Rescue Committee and drops by their RUTF warehouse sometimes.

[Ira Glass]

Now that warehouse is kind of deserted.

[Harry van der Waal]

It should be the correct word.

[David Kestenbaum]

But yeah, I would say like empty.

[Dr. Mushtaq Khan]

Shelves, they are empty with empty pallets.

[David Kestenbaum]

Because the last bit of supply which.

[Dr. Mushtaq Khan]

We had, we shipped to our health facilities. So our central warehouse is empty.

[David Kestenbaum]

Now there are health facilities around the country. The clinics that they ship their RUTF to have enough to last till the end of next month to the end of July. Dr. Khan says 900,000 children in Afghanistan fall into the category severely acute malnutrition. Children so malnourished that babies don't have the energy to cry. And he's scared of how many will die if things don't change.

[Dr. Mushtaq Khan]

I'm really afraid of that, that it might end up with a catastrophic situation because these RUTFs are the lifeline for them.

[David Kestenbaum]

Without those like this might be the worst case scenario. And it might be. I didn't know this when we spoke, but the Trump administration has said that it is not going to be sending any aid of any kind to Afghanistan, where Dr. Khan is because it says that aid benefited terrorist groups. This came after the administration suspended the people that USAID had in place to make sure that aid did not go to terrorist groups. July 1st, just a couple weeks from now, the State Department is supposed to finish taking over all the things that USAID used to do. Whatever things are left. And as this period of limbo ends, this period of transition between agencies, as we all wait to see what scraps of American foreign aid remain when it's done, we thought it would be a good moment to ask, what was that all about? Usaid. The recent public conversation about this tends to be either outraged Democrats defending our decades of foreign aid or conservatives of all kinds of pointing out waste and corruption. The truth is, even die hard lifelong advocates of foreign aid said it wasn't perfect. We thought we'd take some time here today to step back from the regular pro and con positions on this one and ask what were the good things that aid accomplished? What projects did more harm than good? How should we think about this now that so much of it seems to be going away? Stay with us.

[Dr. Mushtaq Khan]

Foreign.

[David Kestenbaum]

For this American Life and the following message come from Data IQ AI can be a kind of raw power. Take control of AI with Data iku, the universal AI platform. It's built for business teams and AI experts alike. Designed for trust and engineered to scale to fit your tech stack today and tomorrow from analytics, models and agents. Make AI flow through your enterprise. Don't just keep up with AI, control it with Data IQ, the universal AI platform. Find out [e-mail] ThisAmericanLive support for this.

[Echo van der Waal]

American Life comes from GoodRx. GoodRx helps keep your prescription costs low, from diabetes to allergy relief to heart health. Save up to 80% on prescriptions for you and your family and pets too. GoodRx lets you compare prescription prices at over 70,000 pharmacies and find free coupons fast. GoodRx is not insurance, but may beat your copay price. If you do have insurance, get help beating high prices at the pharmacy.

[David Kestenbaum]

Go to goodrx.comtal it's this American Life act one 63 years, 7 months, 2026 days. That length of time, that is the entire existence of the federal agency USAID from the day it was created in November 1961 till the last day of this month, which the Trump administration hopes will be the last day it is running any operations. During those years, the agency spent hundreds of billions of dollars. The United States was the largest humanitarian donor in the world. So what did it buy? Where was that money well spent and where was it a waste? David Kestenbaum on our staff talked with two people who know that history well.

[John Norris]

The year USAID was founded, John F. Kennedy was president and he was trying to figure out what the US should be in the world. It was an interesting moment for that. The year before, 17 countries in Africa had gained independence from decades of colonial rule. These were new nations. India had also become independent some years before and Indonesia, other countries too. Joshua Craze wrote about all this recently in the New York Review of Books. Really trying to do what we're trying to do in today's show, weigh up the good and the bad of what followed.

[Joshua Craze]

I think for Kennedy, the goal is to bring development to the rest of the world. That's the stated goal. There are new nations around the world. And he says, look, what we're doing is going to bring up these nations just like we brought up Europe after World War II.

[John Norris]

After World War II, with the Marshall Plan, we gave massive assistance to European countries that had been wrecked by the war. And it was a huge success. Their economies rebounded. But Kennedy didn't want to help these new countries just because it seemed like the right thing to do. There was another reason kinda big in 1961. He didn't want them to become communist. The US was worried all these countries were going to fall under Soviet influence.

[Joshua Craze]

When he first starts usa, Kennedy addresses all the heads of the agency and says to them, in many places where freedom is under threat, we will not send Marines, we will send you.

[Echo van der Waal]

We send you and you working with.

[David Kestenbaum]

The people in those countries to try to work with them in developing the.

[John Norris]

So what are those first projects?

[Joshua Craze]

You have a huge variety of projects. You have massive agricultural schemes to modernize agriculture in Southeast Asia, you have schemes to create banking systems inside Africa, you have schemes to create democracy and education. You have free press. You have all sorts of, you know, like take America, look around the world and go, is this thing there? And if America's not there, we would just try to make it like America. That was the goal, you know, and like there are a lot of very idealistic people doing this work.

[John Norris]

Huge ambitious and maybe ill conceived goal. Make every place more like America. How well did it work? In most cases, not very well. I talked to John Norris about this. He wrote what, as far as I can tell is the only really straight up history of usaid, a book called the Enduring Struggle. He also worked at USAID for a while. Norris says for development to work the country's government has to make a bunch of difficult changes, enact economic reforms, invest in education. You need legal systems and contracts, all sorts of stuff. And you need a government with the will to push all that through. Some countries were run by autocrats who didn't really care for helping the general population. And the ones who did care, it was still hard to make those changes. It would be for any nation. And John Norris says colonialism had really damaged a lot of countries.

[Echo van der Waal]

They had always been actively discouraged from developing a civil service or engineers or doctors by their colonial leaders. And literally countries emerging at independence where there might only be a handful of doctors, lawyers or engineers that have been trained in the country, very little in the way of competent civil service. You know, that is a very low base to start from.

[John Norris]

There are a couple real successes, though.

[Echo van der Waal]

The textbook example is really South Korea. South Korea in the early 60s was absolutely devastated. The country had labored under a brutal Japanese occupation for decades. It had been devastated, devastated by the Korean War. The countryside was pretty much in ruin. And then a really remarkable set of changes began to happen. With a lot of help from US.

[John Norris]

Assistance, all kinds of economic reforms. The government distributed land to small farmers, invested in schools. The US trained government officials on budgeting and on economic policy. A major reason it worked was the South Korean president, Park Chung Hee, who forced through all kinds of economic changes. One historian said he instituted a, quote, developmental dictatorship. Today, South Korea is one of the largest economies in the world. How involved was USAID in all those changes in South Korea?

[Echo van der Waal]

Incredibly, that they would have a weekly meeting with senior cabinet officials on economic reform, on education, on agrarian policy. South Korean officials were flown to the United States to meet with business leaders to understand how they could better prepare their exports for the US Market. It was day to day, week to week, and very intense.

[John Norris]

So there is South Korea. Taiwan is another example. But overall, pretty mixed bag. John Nora says there is one more category of thing that did not work that's worth including here.

[Echo van der Waal]

There's a consistent theme to the places where aid had its biggest failures. And it's in those places where it was used as a blunt instrument of U.S. foreign and security policy.

[John Norris]

The wars in Afghanistan, Iraq and before that, Vietnam. The U.S. spent billions and billions of dollars in aid money, he says, basically to try to win people over and prop up the governments that were our allies, which is not a recipe for success. At one point, a quarter of all USAID global staff was operating out of Vietnam without much to show for it. So that was the first goal to help countries Develop economically. There was a second goal for USAID though, to fight communism. How did that go?

[Joshua Craze]

Well, Communism's gone, except for like eight friends of mine in Oakland. So, you know, I think it's thanks to usaid. Yes, thanks to usaid.

[John Norris]

Neither of them saw USAID playing a big role.

[Echo van der Waal]

You know, I would give them a solid star for the effort. Certainly the Soviets collapsed because it was a miserable system that was always designed to fail.

[John Norris]

And very broad strokes. That is kind of the first half of USAID's history. There's a real change in the second half. Communism is gone now, so that can't be the mission anymore. Helping countries develop seems hard. So there is this shift to something much more. Trying to assist people most in need, humanitarian aid and fighting disease. In fact, when USAID was shut down this year, these were the largest parts of its spending. In 2024, out of $35 billion of programs it managed, about $10 billion was going to humanitarian aid and $10 billion for health. There is good and less good here also over the years. First the good. We eradicated smallpox.

[Echo van der Waal]

Smallpox claimed 300 million lives in the 20th century alone. 300 million. That is just an eye popping number. A joint effort by usaid, cdc, the World Health Organization and the Soviet Union. And some innovative technology wiped smallpox off the map. The first time in human history that a disease had been eradicated and the benefits of it. And this is one of the things where people forget how powerful the returns are of assistance for the United States itself. The entire amount that we spent on smallpox and the effort to eradicate it and delivering all those vaccines around the globe, we. We save that same amount every 24 days. 24 days, because we don't have to vaccinate Americans against smallpox.

[John Norris]

Actually, it's 26 days, but still a win. Not every example is so clean, though. Joshua Craze says the aid sometimes props up governments that aren't so great. Even sending in food can be complicated. He spent a lot of time covering the conflicts in Sudan and South Sudan.

[Joshua Craze]

Very often that humanitarian aid is diverted to the government or to the very people conducting campaigns of ethnic cleansing. Then there's the question of, okay, how do you get the food aid to people? Well, you have to hire trucking companies. Who owns the trucking companies?

[John Norris]

Sometimes the trucking companies are connected to the government.

[Joshua Craze]

And so you have this sort of like most disgusting logic sometimes, which is that the humanitarians end up sustaining the financial base of the very people who displaced the civilians that the humanitarians tend to. So they support the hell that they're supposed to minister.

[John Norris]

What do you make of the Trump administration's critique of usaid?

[Joshua Craze]

So different parts of the Trump administration had different critiques of usaid. One critique was USAID is an organization that pushes a particular political agenda around the world that is not very American. I think that that was a distraction from what they were actually doing. Right. Like, you could have cut all of the, you know, supposed, like, transgender operas in Bolivia and left the core mission.

[John Norris]

That is one explanation the Trump administration has offered. It put out a press release listing a handful of projects it considered waste, fraud and abuse, including a DEI musical in Ireland, which seems like it was from 2022. Also an electric vehicle program in Vietnam. Most were pretty small ticket items. Secretary of State Marco Rubio has offered a different critique that USAID was funding things that were not in the US national interest.

[Joshua Craze]

That other critique of USAID is bound up in this bigger issue for the Trump administration, which is why is the US Paying for everything? We are paying. We've got to, like, get our. I'm sorry for my American accent, but, like, we gotta get our money back somehow. And this is a really, for me, simplistic view of politics and economics. Dollar dominance has been so good for America, and dollar dominance is carried out because it is the world currency, and that's also guaranteed by things like usaid. The Trump administration is worried that you are not getting respect from South Africa, but you're giving malaria drugs. The reality is, until three months ago, everywhere I went in the Horn of Africa, people thought the one space of goodness and hope in the world was America. And they might have been wrong about that in many ways. And America might have done all sorts of bad things and been imperialist in all sorts of ways, but it was a real belief and it's gone right. And I just, I think that's from the perspective of American hegemony, an incalculable loss.

[John Norris]

John Norris had similar feelings, despite all the things over the years that hadn't worked. When some future historian goes to write this next chapter, he worries it's not going to be a good one.

[David Kestenbaum]

David Kestenbaum is senior editor of our show. Coming up, we go visit a hospital funded by usaid. Pretty nice. Too nice. That's in a minute from Chicago Public Radio when our program continues.

[Ira Glass]

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[David Kestenbaum]

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[Harry van der Waal]

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[Echo van der Waal]

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[David Kestenbaum]

This message comes from Schwab. Everyone has moments when they could have done better, like cutting their own hair or or for getting sunscreen. So now you look like a tomato. Same goes for where you invest. Level up and invest smarter with Schwab. Get market insights, education and human help when you need it. Learn [e-mail] It's American Life from Hour Glass today's program some things we don't do anymore. Stories of this period that we're going through right now where the Trump administration stopped everything USAID was funding, then pledged to restart a lot of it, especially life saving assistance, food and medicines. Right now, when you add it up, over half the money USAID spends is supposed to continue. But most of that money has not gone out and it's unclear how much of it ever will. We've arrived at Act 2 of our program. Act 2 case study okay, so what happens when you pump hundreds of millions of US Dollars into a country? We're interested in both the good things that happen and the bad. And the place that we picked to look at this is a tiny African country called eSwatini. Only 1.2 million people right between South Africa and Mozambique used to be called Swaziland. They're interesting for a few reasons. One is that they were part of one of the most successful things USAID has ever done, a program called PEPFAR. Billions of dollars in over 50 countries everybody agrees, saved millions of lives. PEPFAR was created to combat aids, and for a long time the country with the highest percentage of people with HIV has been Eswatini. So Eswatini is a good place to measure whether the aid has helped. But Eswatini also seemed like a good place to look at for another reason. And this reason we heard about from a Washington Post reporter named Chico Harlan. Chico had been calling around to all kinds of organizations that had lost their funding when when the Trump administration froze all that in January, most of them did not want to talk on the record. They thought it might hurt their chances of getting funding in the future. Pajika found a health provider in Eswatini called the Luke Commission that got a ton of US Aid money in the past, whose leaders were not only willing to talk, they were pretty frank in expressing their own doubts and questions about whether the money they had gotten was entirely a good thing for Eswatini. They were grappling with the good and bad of it. So, for instance, here's one of the founders of the Luke Commission, Harry van der Waal, an American doctor who's been at Eswatini for 20 years talking about the Trump funding cuts.

[Sarah Rumsey]

Actually, I understand why they're doing what they're doing. I get it and I'm not against it at all. I can see that as a business strategy. That makes sense. Is it painful for those on the other side of it? Of course. But as long as we do what we can to make sure people remain on medication. And is that the responsibility of the US Government to make sure people stay on medication? I don't know if I can say that fully. This has been going on for decades now. It's not necessarily they can't take care of the whole world and their medical needs.

[David Kestenbaum]

So Chico and one of our producers, Diane Wu, went to Eswatini to see what exactly did American taxpayer money accomplish there and what went wrong. They also get into it more with Harry later in the story. Here they are.

[Ira Glass]

The first thing you see when you turn into the Luke Commission's campus these days is a gate.

[Harry van der Waal]

There's a USAID and PEPFAR logos and.

[Ira Glass]

There'S a sign that says closed until further notice. We pull up and get checked in by a security guard.

[Dr. Mushtaq Khan]

Hi, how are you?

[Ira Glass]

Good morning. Who then runs through the manicured grounds ahead of our car to show us where to park.

[Harry van der Waal]

I feel like we're pulling up to a luxury hotel.

[Ira Glass]

You look the rocks, the landscaping, the very like moody lighting. There are these modern looking sconces lighting the entrance to a slate gray building. We pull up in front of string lights.

[Harry van der Waal]

Harry and Echo, the founders of the Luke Commission, are standing in front of the building to greet us.

[Ira Glass]

Hi, Echo.

[Sarah Rumsey]

Good to meet you.

[Ira Glass]

Likewise. At last.

[Sarah Rumsey]

I'm Harry.

[Ira Glass]

Harry, nice to meet you.

[Sarah Rumsey]

I'm too.

[Harry van der Waal]

Echo and Harry met in college and married right after. They both had this Christian calling to do medical work overseas. So Harry became a doctor and Echo became a physician's assistant. As Harry was finishing up his residency, they heard about Espettini from a friend and thought, that seems like a good place to go and help.

[Ira Glass]

Had either of you been to Africa before?

[Sarah Rumsey]

Never, No. I didn't even have a passport before. Had you ever been out of the country? Just to Canada, but didn't need a passport at that point?

[David Kestenbaum]

I don't think.

[Sarah Rumsey]

Yeah.

[Ira Glass]

Right after Harry graduated, they packed up and moved the two of them plus three year old triplets and an infant. And if that sounds kind of bold, let me say that is Echo. She is the CEO boss type, always with a plan and some talking points. Calculatedly daring. I think that's one of the reasons she's the rare aid recipient willing to talk to journalists. She's betting it might help. She's the public face of the Luke Commission.

[Sarah Rumsey]

When we first had the kids, he said, if you do the emails, the phone calls and the meetings, I'll take care of the family. I'm happy to let her talk. I don't always communicate very well, so it's better if she does the speaking. He's a doctor in internal medicine and pediatrics, so he's the smart one. I guess I'm the practical one. Maybe if we put it that way, yeah.

[Harry van der Waal]

The Luke Commission is named after Luke from the Bible. Echo and Harry also really like the acronym tlc.

[Ira Glass]

Faith based hospitals like this one are all over Sub Saharan Africa. And just to state the obvious, Echo and Harry are the white people in a hospital that is almost entirely black.

[Harry van der Waal]

When Harry and Echo first arrived here From Ohio in 2006, Eswatini was in crisis. Something like 30% of the population had HIV and there was no treatment. Antiretroviral drugs had started trickling into Eswatini, but hardly anyone could get them. So many people died that 1 in 10 households was run by a child. Harry and Echo remember how in those early years they saw one of their main goals as simply delaying orphanhood.

[Ira Glass]

They drove around the country with interpreters and other local staff, setting up mobile medical clinics in schools, helping people get whatever medical care they could, all for free. They paid for all this from their savings from flipping houses back in the US before they came, plus donations from family and friends. And they caravanned this way on the cheap for a couple years till the US stepped in in a big way.

[Sarah Rumsey]

Today, on the continent of Africa.

[Joshua Craze]

Nearly.

[Sarah Rumsey]

30 million people have the AIDS virus.

[Harry van der Waal]

This is President George W. Bush delivering the State of the Union. This is what a Republican president used to sound like.

[Sarah Rumsey]

Ladies and gentlemen, seldom has history offered a greater opportunity to do so much for so many.

[Joshua Craze]

We must also remember our calling as a blessed country is to make the world better and to meet a severe.

[Sarah Rumsey]

And urgent crisis abroad. Tonight I propose the Emergency Plan for AIDS Relief, a work of mercy beyond all current international efforts to help the people of Africa.

[Harry van der Waal]

This plan, the President's Emergency Plan for AIDS Relief, or pepfar, becomes one of the biggest humanitarian foreign Aid projects America has ever undertaken, totaling more than $120 billion spent all over the world over 20 years. For comparison, the Marshall planned to rebuild Europe. Adjusted for inflation, around 180 billion in eSwatini. PEPFAR money started arriving in 2007. Some going directly to the government to support their national AIDS response, some to outside organizations. In 2010, Harry and Echo get their first contract under PEPFAR, a modest grant doing voluntary male circumcision.

[Sarah Rumsey]

They asked us to participate in that, which we were very motivated to do because it decreases the transmission and contraction of HIV by 60%. So we started and within one month we were circumcising more men and boys in one community than they were in the rest of the country combined. I mean, one day we did 87 circumcisions in one day, done by 9 o' clock at night. We are a machine.

[Harry van der Waal]

PEPFAR money completely changed the course of the AIDS epidemic. In Eswatini. The number of people dying from AIDS went down by half. The average lifespan, which had dropped down to 41 years, fully rebounded over time.

[Ira Glass]

The Luke Commission became one of the biggest recipients of American aid in the country. It averaged over 6 million a year for the last five years. And with all that money, their operations changed a lot. Echo and Harry bought this land and turned a storage shed into a ward for tuberculosis patients. And then they kept going. They got physically bigger, adding an emergency room, an ICU, a maternity ward grown to a true campus of 25 buildings. And it wasn't just HIV care. They were jumping in and providing all kinds of treatment that the government wasn't able to. Eventually, they were providing free medical treatment for a huge swath of the country. At their peak, according to their numbers, it was 1/4 of all the hospital visits in the country. A fourth. This giant expansion could not have happened without US aid.

[Harry van der Waal]

And when Harry and Echo walked us around the campus, you could really see the money everywhere. It was honestly kind of posh.

[Sarah Rumsey]

This is our outpatient waiting area.

[Harry van der Waal]

First, all the medical stuff, the four operating theaters, the airy icu, a dental suite, all in beautiful condition, all almost totally empty since USAID froze their funding. Then the bells and whistles we had not expected when visiting an aid funded hospital in Eswatini.

[Echo van der Waal]

Like, welcome to our drone hanger.

[John Norris]

So this is Eswatini's very first medical drone network.

[Ira Glass]

The loot commission has four huge 8 foot white drones that they use to quickly deliver snakebite, antivenom and other medicine to rural parts of the country that are hard to drive to. They also have a room full of iPads, 600 of them, all provided by Pepfar, plus a giant screen that tracks the real time location of each of the devices in the same room. They have a set of shiny 3D printers for making medical components. A few buildings over, in a sort of secret room they called the Vault, there were these giant futuristic vending machines that people could use to pick up their prescriptions, like an automated pharmacy.

[Harry van der Waal]

And you guys have two?

[Naven Salem]

One?

[Sarah Rumsey]

No, we have three, Three, four, maybe five.

[Harry van der Waal]

It was all way more advanced than anything I'd ever encountered with my own healthcare in the US as we walked around, I started to wonder, is this too nice? Should a foreign aid funded hospital be so opulent? We went and asked Echo about all this and she was actually surprised we were bringing it up at all.

[Sarah Rumsey]

We do have Americans visit here all the time, and I'll be frank with you, the first one that's raised it, yeah, this isn't opulent. I think it's just excellent.

[Ira Glass]

The drones and the automated pharmacy. She explained that they'd gotten private money for those, not USAID money. And anyway, that's just a tiny part of their spending, just a couple percent. The rest went to basics, like medical supplies, paying staff. As for the 3D printers, yeah, I.

[Sarah Rumsey]

Think you'd be surprised how cheap they are. They might be $600.

[David Kestenbaum]

I don't know.

[Harry van der Waal]

We checked. One was $600, the other 1400. This was USAID money. Echo estimated that these printers had so far saved them $25,000 in equipment costs. Her explanations were pretty convincing. They want us over. And she kind of got into it, looking around the room we were in, pointing out all the scrappy ways they've kept their spending down. The deck chairs on the balcony over there made from pallets that the oxygen plant equipment came in. The set of plush recliners at the end of the room.

[Sarah Rumsey]

Those were from one of the first circumcision projects.

[Harry van der Waal]

You sat in it to get a circumcision.

[Sarah Rumsey]

After you got circumcised, you relaxed in those chairs. Relax or spread your legs out a little bit. Oh, Harry.

[Harry van der Waal]

I explained to Echo as I followed her around campus. I was picturing like, what if Marco Rubio were on this tour? What would he see? What would his reaction be? And my thought was like, we're American. Taxpayer dollars are going to like hundreds of iPads in eswatini for aids.

[Sarah Rumsey]

I feel if Marco Rubio came here and he knew that they funded 600 iPads and he found all the iPads Here, and it allows you to see twice as many people with half as many staff. And he found that there's a system that when you leave the gate, if you're working out with an iPad that's supposed to be used for patient care, that there's a way, there's a control that makes sure that that asset is doing what it's supposed to do. You know, I just. I think those are all things that would. Would be champion.

[Harry van der Waal]

Marker would be obedient, too.

[Dr. Mushtaq Khan]

He.

[Sarah Rumsey]

I think he would be.

[Ira Glass]

After USAID abruptly stopped its programs in January, the Luke Commission shut down everything to the bare essentials. Harry and Echo felt a moral obligation to keep giving out antiretroviral and tuberculosis drugs to HIV patients. So they continued that work. They still did some snake bites. They're the main hospital in the country that treats them and an occasional surgery. But they also laid off half their staff and told everyone else who kept working that they could no longer afford to pay them. USAID covered half of their cash flow and now it was gone. They couldn't even pay their utility bills. And for the first time, they started turning people away. Workers put up the gate. We saw confused patients called the Luke Commission to ask, what's happening?

[Harry van der Waal]

We talked to two people who answered those calls. Nompa Malelo and her co worker, Daneli. They were at work, sitting at a big gray folding table, four phones between the two of them. Nompa Malelo said they'd tell people on the phone that they weren't open anymore and they'd show up anyway.

[Dr. Mushtaq Khan]

Some still don't believe that we are really closed, so they want to come and see themselves. They are like Thomas, you know, the Thomas in the Piper did not believe when they said, jesus has risen. I want to see myself. So even some, even the ones that are calling, most of them. Is it true that TLC has closed?

[David Kestenbaum]

How can that be?

[Harry van der Waal]

Tanelli's in her 20s, in a red Luke Commission T shirt and pencil skirt. Just sort of beams earnestness at you on your 21st birthday. In eSwatini, there's this thing where parents give their kids a key symbolizing, you're an adult, be free, do what you want. Her parents gave her a Bible, which she laughed about. Her co worker, Nompa Malelo, is older and extremely soft spoken, which actually got her the job answering phones.

[Dr. Mushtaq Khan]

They say my voice is soft, so they said I should assist her.

[Harry van der Waal]

Because you have a nice voice?

[Dr. Mushtaq Khan]

No, because of my personality and also the voice.

[Harry van der Waal]

So, yes, now that the Luke Commission is closed, the tens of thousands of patients they served have to find other health care. We heard some pretty grim stories about the treatment people received in the national healthcare system. A misdiagnosis, a botched surgery. But the biggest problem people told us about was a lack of medicine and supplies. So when Nompu, Malelo and Tenelli turn people away, the patients cry on the phone and plead for them to go and talk to the doctors, try to get them in.

[Dr. Mushtaq Khan]

And then when the doctor still says no, it's hard to go back to the patient and tell them because, you know, you feel what they are feeling due to the current situation, you can't help them.

[Harry van der Waal]

Has anybody expressed anger at the American government for taking the money away?

[Dr. Mushtaq Khan]

The anger is not, it's not towards the US government, but they are angry at our government for not helping and that also that our government, they know that our government is striking fit to assist financially.

[Ira Glass]

Almost everyone we asked in Eswatini, people with and without ties to the Luke Commission said the same thing. They weren't mad at the US for cutting off aid. Here's Kalani. He's a security guard who stands at the new gate they built. He had to turn people away, which he hated doing. He lost both his parents early in the AIDS epidemic. He told us he wishes a government official could stand at the gate with him and see all the people who aren't getting care.

[Kalani]

The anger from my personally, it's actually at our own government.

[Dr. Mushtaq Khan]

Why isn't our government intervening in, into this situation? You know, that is where the, the frustration comes from. Not the usa, of course. I mean, when you've always known that this person has always supported me, you, you'll get disappointed that, oh, why are they now leaving me? But we have our own government within our country that should actually be looking after us, you know.

[Harry van der Waal]

The government of Eswatini, by the way, is an absolute monarchy. King Mswati III has a lavish lifestyle. Famously gave each of his many wives a Rolls Royce. No one inside the country who we interviewed put the blame on him or said anything bad about him. It's not prudent to criticize the king if you lived there. Spending time in Eswatini made me realize a monarchy is basically a dictatorship with better branding. But dissidents living abroad and say the king's patronage system fosters a culture of corruption throughout the government, including in the Ministry of Health. And when people talked to us, those were the officials they focused on.

[Dr. Mushtaq Khan]

I'll be honest, there's quite a lot of corruption. I'll be Honest in our health, in our health sector, there's a certain group of people that are trying by all means to ensure that the government facilities are not operating well so that we go and buy medication from their pharmacies.

[Ira Glass]

Kalani's talking about something that is well documented, that a group of government officials have allegedly been colluding with drug suppliers and causing shortages in the country. The Eswatini government launched a big investigation a couple years ago and found that officials were systematically buying drugs that were about to expire and getting kickbacks from the suppliers than patients. They had to scramble to find drugs at pharmacies, paying for drugs that they should have gotten for free. The Ministry of Health declined to comment about all this.

[Harry van der Waal]

And the reason we're going into all this detail is that it shows you one of the big ways US taxpayer dollars may have made things worse in Eswatini. By building an alternative health system that worked really well, it made it easier for corruption to grow in the government system. Harry and Echo have been thinking about that a lot in the last few months since the Loot Commission closed its gates. Maybe they were part of the problem.

[Sarah Rumsey]

And maybe all the health that we've been providing over these past few years during COVID was actually doing more damage than good, allowing this monster to get fatter and fatter. Because as we did more and more and more, the demand on the national healthcare system that ought to have been crumbling was becoming less and less. And so the cries of people was not as much as it should have been to make the changes that should have happened long ago because we were busy covering up in some ways by doing, working so hard and doing good, we were covering up the evil that was actually happening under the national health care system.

[Ira Glass]

Harry and Echo say a turning point came during COVID when the Luke Commission handled so many of the critical care cases for the country. In the aftermath, with demand still rising, Harry and Echo took out a loan against their house and and emptied their retirement savings to pay staff. They asked the Eswatini government to help cover the cost of treating so many patients and assumed that the money would come through at some point.

[Sarah Rumsey]

I just wish we would have maybe been not as naive, I guess, or not as, you know, maybe made these changes a couple years ahead or made some lines in the sand earlier.

[Ira Glass]

Maybe they never got the money. The health minister at the time says the government offered the Luke Commission annual guaranteed funding, but only if it had some oversight over how the money was spent. Any government would probably ask for the same thing in this case. She told me that Eswatini wanted to name the chairman of the Loot Commission's board as a way to oversee their operations. Harry and Echo say this was never actually proposed to them, but if it had been, they would have said no. From their point of view, that would be like a hostile takeover. Before long, they'd get booted out, the government would assume control and the Lou Commission would become just another unreliable hospital in a system that can't stock its own drugs. The standoff between the two sides got so nasty that it became the basis of a 2024 parliamentary report to investigate the bottlenecks and disharmony. One of the findings said senior health officials viewed Echo as a difficult person to work with. Another finding, there are very senior individuals in government who are hell bent on blocking any assistance to the Luke Commission for their own selfish reasons that are contrary to the wellness of the sick, the weak and the elderly in our country. Suffice to say it's messy and unresolved. These are the strange and unpredictable consequences of sending hundreds of millions of American dollars to Eswatini. These Christian do gooders are now in a bitter fight against officials and the government of the people they came to help.

[Harry van der Waal]

Meanwhile, HIV, the disease they came here to treat 20 years ago, it's much more under control now. And even Harry and Echo wonder why the United States is still in the HIV business here. Why are US taxpayers still paying such a big part of the bill for that?

[Sarah Rumsey]

We haven't transitioned. Just look at hiv. We have not transitioned like we should. This is an old disease. By now we should have transitioned it to being locally supported so that global aid can prepare itself or ready itself for the next global pandemic or problem, whatever that is, we don't know.

[Harry van der Waal]

And for hiv, if that had happened, when would the transition have happened?

[Sarah Rumsey]

Here it probably should have happened five years ago. I think it should have happened before now and it could have. It could have happened here and it probably could have happened in other countries. For me, I think the challenge is, as Americans too, we want to fix things. We want to run in and fix it. Sometimes we have to be careful on what's our exit strategy, how do we, once we jump in, how do we get out?

[Harry van der Waal]

Someone in Eswatini who's been thinking about how to transition away from foreign aid for over 20 years now is Dr. Valepi Okello, the director of health services in the Ministry of Health. She oversaw the long process of getting the government of Eswatini to pay for all of its adult antiretroviral drugs, something they've been doing for 10 years now. She was part of the team figuring out how things would work after pepfar.

[Dr. Mushtaq Khan]

We thought that the PEPFAR funds would take us to 2030, 2030, and then we're able to slowly and gently, you know, offload some of the issues back to government.

[Harry van der Waal]

Then in January, she heard that President Trump had suddenly halted the USAID money.

[Dr. Mushtaq Khan]

So when I saw it, I thought, trump is just doing his usual, what do you call being spontaneous kind of thinking, if I may put it like that. So I thought, what does this mean? And we consulted our colleagues from pepfar. Then they told us, I know this is real and there's more coming. So he said, okay, fasten your seatbelts. You know this is happening. What other rough ride are we going to have?

[Harry van der Waal]

She sent a team of people out to assess the damage. Where exactly was all this PEPFAR money being used and how much? Her initial assessment is that the situation is not so bad. Eswatini's been buying all its own antiretrovirals for adults for years, and they have enough pediatric antiretroviral drugs in the pipeline. They know which lab reagents need funding quickly to keep testing people. She says 20 years of AmericanAid has made eSwatini's health system stronger in ways that will persist. Trained nurses and other medical staff developed more effective ways to distribute antiretroviral drugs, just generally raise standards for care. She sees the health system as fairly sturdy at this point, able to care for its own people.

[Dr. Mushtaq Khan]

I always say to people, our health system is like a, let me say, a Toyota. We are using a model that is basic health service delivery model. It's moving and maybe not so comfortable, but it gets you there. So when PEPFAR came, we always say that they took us from that basic Toyota into some kind of Mercedes Benz or Rolls Royce, which now made sure that our quality of services is great and we are moving faster in achieving the targets that we had aimed to achieve.

[Harry van der Waal]

The Mercedes is gone now, but she thinks they'll still get to where they need to go.

[Ira Glass]

Dr. Okello, of course, works for the government. A UNAIDS assessment that came out recently, not so rosy. It said there's a risk of running out of antiretroviral drugs and other supplies in three to six months in eswatini. And while Eswatini does pay for its own antiretrovirals, it takes a lot more than drugs to combat hiv. It's a chronic illness where so much of the work involves constant monitoring. For new cases and maintaining a network of clinics and community health workers so people have the drugs they need and are taking them every day. In Eswatini, lots of that work was still paid for by foreign money, mostly American. Some PEPFAR funding may survive. They're debating that right now on Capitol Hill. But even if nothing is restored, Eswatini is in a better position than most PEPFAR countries in Africa to take over that work. It has a bunch of advantages. It's small, has a fair amount of money, and it's done a good job to mobilize and control HIV as a national priority for decades. One of the people who originally created PEPFAR told us out of the 50 PEPFAR countries worldwide, maybe a dozen are ready to move off the program's money fairly quickly, and Eswatini is one of them. He also told us PEPFAR was never intended to last this long. The conversations about how to wind down had already started in the Bush years, but nobody carried them through. Once a big bureaucracy took shape around this money in the US and abroad, there wasn't much momentum to uproot everything. That is, of course, until now.

[David Kestenbaum]

Gar Harlan is a reporter of the Washington Post. He also did a great print version of this story. Diane Wu is one of the producers of our show, by the way. Since they visited, the Loot Commission has opened up its gates again at a much smaller scale to pay for that they're charging for their services for the first time. So how bad is this going to be, the US pulling back from all this humanitarian aid? In March, a USAID employee made a memo public on his way out the door, where the agency estimated that there would be 200,000 more children paralyzed with polio each year. 18 million extra cases of malaria each year. Secretary of State Marco Rubio has said that nobody's died as a result of the freeze on usaid. That seems not to be true. Reporters have found examples, real people. But how many people are likely to die? There are different estimates. The most thorough one we found was done by the center for Global Development. My co worker, David Kestenbaum, talked with Charles Kenny, who worked on some of the modeling. Kenney said that some of the first deaths likely to show up would be from the thing we've been talking about, cuts to HIV programs.

[Sarah Rumsey]

We have a pretty good knowledge of how many people and how quickly die, how quickly they die if you take them off antiretroviral medications.

[David Kestenbaum]

So they went through the actual contracts that got cut in the government database and found that about 18% of the money for these programs had been eliminated, and they ran the numbers.

[Sarah Rumsey]

The modeled estimate is that 200,000 or so people will die due to the cuts to awards this year.

[David Kestenbaum]

He says it is possible that individual countries, governments will step in, at least to some extent. But because of the abruptness of the cuts, the way the United States just froze funding when President Trump came in without giving countries time to prepare and take over those health services, he says, there's no way that's going to happen fast enough.

[Sarah Rumsey]

While I think it is probably fair to say the 200,000 estimate isn't going.

[David Kestenbaum]

To be true in the long term.

[Sarah Rumsey]

In the short term, I think it's probably horribly close to true.

[David Kestenbaum]

That's just from HIV programs. There were cuts to malaria prevention, tuberculosis, childhood vaccines. Adding it all up, Kenny says it could be over a half million deaths each year.

[Sarah Rumsey]

It's sort of really depressing because, you know, you can see the trends in HIV deaths and malaria deaths. And they were going down. They were dramatically down. And that is, you know, an amazing effort, and the US Is leading it, and that does make all of this more tragic.

[John Norris]

How does it feel to run the numbers?

[Sarah Rumsey]

It's easier to think of them as just numbers, eh?

[John Norris]

Are you crying now? Sorry.

[Sarah Rumsey]

Yes, I am.

[John Norris]

I'm sorry.

[Sarah Rumsey]

It is a completely legitimate question.

[David Kestenbaum]

Whether or not you think the United States should stay in the business of doing things like providing HIV drugs around the world. The way it suddenly stopped in January has had a profound impact. We asked for an explanation with anybody at the State Department or the White House who could explain why it was done this way, and they turned us down. When a few producers on our staff called around in country after country, we kept finding people who told us about major disruptions in service. One researcher, Susan Hillis, has been asking people to record voice memos about what they're experiencing. She got this one from a man named Jay, somebody who took antiretroviral drugs every day. He's a student and tour guide. He recorded this at home one night.

[Dr. Mushtaq Khan]

Hi, I'm jay. I'm turning 24 this June, and I live in Mombasa. I have been taking the medication my whole life. I felt like it was really hard for me when the funding was stopped and I went to the hospital and I couldn't find medicine. So I would go be told, come.

[David Kestenbaum]

Next week, come next week.

[Dr. Mushtaq Khan]

And I wouldn't find medicine. And I started getting these boils on my hand and legs and all over the body. So I started hiding out, and I.

[David Kestenbaum]

Wouldn'T go to school, started staying at.

[Dr. Mushtaq Khan]

Home because I didn't want to be seen with the boils, the black spots that are still on my skin. I have to wear long sleeved and Mombasa is very hot. I just hope there can be change on that because personally I've really suffered physically, mentally and emotionally.

[David Kestenbaum]

Akshree Sandaraja is one of the producers on our staff who called around to health workers scrambling in the wake of USAID cuts. He has this last story of people dealing with the abrupt cutoff fade. That's act three, two daughters.

[Kalani]

While reporting this show, I heard many stories about chaos and confusion. But there were these two mothers and their daughters that I read about in a Washington Post story that really stuck with me and I wanted to know how it's been going for them since the first daughter. We'll call Sarah to protect her privacy. She's 15 and goes to a boarding school in Western Kenya. She used to get her daily HIV tablets through a USAID funded program. But they've been harder to find since the cuts.

[Dr. Mushtaq Khan]

It's really terrifying. Medicine is a problem. I'm so worried because now assessing the medicine is a challenge. We have rumors that they are going to be selling at 500 Baht. I cannot afford the money my stepmom can't afford right now. So it's only that it means that we are going to die. We are going to die without the medicine.

[Kalani]

In the paper she said one of her classmates was waking up screaming. Sarah said mostly she would just lie in bed awake. When I called, she was down to two weeks of her medication. She was hoping her mother could find some and send them to her. So I called her mom and Sarah did not mention this. But her mother is a relentless force of nature when it comes to helping people with hiv. When I called, she was out on the street trying to get the police to release an HIV positive woman who they just arrested.

[Dr. Mushtaq Khan]

Beside the police station. I'm trying to negotiate because one of them have taken her medication today. So the time is up. I'm trying to speak with the officer in charge so that can be released. That is the thing. But we can talk.

[Kalani]

Mary used to have a USAID funded job at a clinic that paid her to do this work. Her paychecks ended in January, but she never punched out. It seems like she's everybody's emergency contact.

[Dr. Mushtaq Khan]

I cannot switch off my phone at night because they usually call a lot, a lot. I do it voluntary because it is my passion. And that's the reason why sometimes you find me I have 20 kids. I have 15 kids.

[Kalani]

She's basically running a DIY orphanage out of her own apartment. She's taking care of 10 right now.

[Dr. Mushtaq Khan]

I don't want them to suffer the way I suffered. I suffered. I really suffered. And not Mary, mother of Jesus, but Mary. I don't want to see other people suffering.

[Kalani]

She promised Sarah's mom that if anything happened to her, she would take care of her daughter. Then Sarah's mom was murdered. Mary keeps her word. So while Sarah was away at school running out of medication, Mary was on it. She did the stuff you do when normal systems are broken. She worked. Her contacts showed up at four different clinics. She found a friend who was willing to slip her a month's supply under the table. Then when Mary told that same friend that Sarah was sharing her meds with another girl at school who ran out, she was able to get a two month supply. So Sarah is set for now. The other daughter I want to tell you about is Nakayo. In the Washington Post story, Nakayo told her mom, if she dies, her mom won't have to worry about feeding her. That was hard for Florence to hear. Both Florence and her daughter were HIV positive. Florence had transmitted HIV to her daughter at birth. When I reached her on the phone, she told me they were able to get their daily HIV pills. But the challenge came when Nakeo got pregnant. They went searching for the drug that prevents the transmission of the virus from mother to child.

[Dr. Mushtaq Khan]

I tried so much. I tried visiting different clinics.

[Kalani]

How many clinics did you try?

[Dr. Mushtaq Khan]

4.

[Kalani]

4. And they were all out of this medication?

[Dr. Mushtaq Khan]

Yes, they are out of medication.

[Kalani]

I talked to one person who explained why. Apparently the USAID funded digital records system that a lot of clinics used had gone down. When that platform went down, Health workers couldn't make new drug orders or tell if they had enough medicine for all their patients. So clinics started turning new patients away. Then Nakayo fell deeper into depression. The father of the baby made her feel even worse.

[Dr. Mushtaq Khan]

The man said that she cannot give birth to a sick child because there is no medicine. And my daughter was there trying to get rid of the child. Now instead of getting rid, she decided to commit suicide. And it was not the first time for her to try to commit suicide. It was the third time.

[Kalani]

Nyakayo died by suicide on May 1. She was 22 years old and three months pregnant. All three suicide attempts happened after USAID stopped so suddenly with no warning or backup plans. Florence believes if her daughter had the HIV meds she needed to keep herself and her baby healthy. She'd still be al.

[David Kestenbaum]

I. Trisse Gandaraja. Katharine Horld wrote the story where we first heard about Marion Florence in the Washington Post. My mind is like a spring in a clock. It won't unwind.

[Dr. Mushtaq Khan]

I can't see, I can't think, I can't feel you. I'm out of time.

[David Kestenbaum]

I'm up and down. You say start at the beginning again.

[Dr. Mushtaq Khan]

My friend.

[David Kestenbaum]

Program was produced today by Ike Sris Kandaraja and edited by David Kestenbaum. The people who put together today's show include FIA Bennen, Gendai Bonds, Mike Khamite, Emmanuel Jochi, Audrey Fromsson, Angela Gervasi, Mickey Meek, Catherine Raymondo, Stone Nelson, Ryan Rummery, Lily Sullivan, Frances Swanson, Christopher Swatala and Julie Whitaker. Our managing editor, Sara Abderrahman. Emmanuel Berry is our executive editor. Special thanks today to Oscar Rickett, Nicholas Kristoff, Gabrielle Emanuel, Hariri Martin, Mona Ismail, Wendy Benzurga, Mark Dybal, Chris Maquindi, Sister Barbara Staley, Safiya Riddle and Lillian Li. Our website, this AmericanLife.org where you can stream our archive of over 850 episodes for absolutely free. This American Life is delivered to public radio stations by prx, the Public Radio Exchange. Thanks as always to our program's co founder, Mr. Tory Malatea. You know, Tory knows all the tricks of hard hitting professional journalism. Who, what, where, when?

[Naven Salem]

The next obvious question is why?

[David Kestenbaum]

I'm Ira Glass. Back next week with more stories of this American Life.

[Ira Glass]

I hear talking of people.

[Joshua Craze]

The whole world has gone insane.

[David Kestenbaum]

And all there is left is the falling rain.

[Dr. Mushtaq Khan]

And all there is left is the falling rain.

[David Kestenbaum]

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