Former USAID Health Chief Says Aid Cuts Are Costing Children's Lives

Dismantling the US Agency for International Development (USAID) has cost lives and weakened primary care systems built over decades, Atul Gawande, MD, MPH, said to a full ballroom of attendees during the opening plenary session at IDWeek 2026 on October 21 in Washington, DC. Gawande, the John and Cyndy Fish Professor of Surgery at Brigham and Women's Hospital, led global health at USAID after his Senate confirmation in December 2021.¹ The session was titled "Together We Rise: Courage, Collaboration, and the Future."

The role was "the best job in medicine you've never heard of," he said. His team of 2500 health staff worked in 65 countries on a budget of about $8 billion, or $22 per American taxpayer, and he oversaw the response to 21 viral hemorrhagic fever outbreaks over 3 years.

What Did USAID Accomplish in Global Health?

The agency began in 1961, when President John F. Kennedy signed the legislation that created it, Gawande explained. After World War II, the United States chose to invest in the countries it had defeated, continuing rationing at home to help Germany, Italy, and Japan recover, which produced "mutual prosperity" and decades of peace. Kennedy built the agency on that lesson and offered the poorest countries "a helping hand instead of a fist," he said.

USAID's strength was scaling discoveries rather than making them, according to Gawande. The agency helped test oral rehydration therapy in Bangladesh and then spread it through social marketing and community health workers. That effort, led by USAID with many donors over more than 20 years, cut deaths from diarrheal disease by 90% worldwide. The agency's partnerships with CDC on smallpox elimination and with UNICEF on the Expanded Program on Immunization also contributed.

Gavi, the Vaccine Alliance, the world's largest vaccine purchaser, and the Global TB Drug Facility used pooled procurement, in which buyers combine orders to lower prices, to widen access in low- and middle-income countries, he explained. He placed both within a wave of global health initiatives launched from 2000 to 2005, alongside the Global Fund to Fight AIDS, Tuberculosis and Malaria (2002), the President's Emergency Plan for AIDS Relief (2003), and the President's Malaria Initiative (2005).

The same contrast applied in the 2000s, when President George W. Bush committed the United States to leading global health investment. "And he learned as president that $2 trillion on the Iraq War failed to increase our security, failed to save lives, while this investment did more to give us influence around the world, more to give us goodwill, more to secure our own security than anything that we have done with a gun," Gawande said.

Marco Rubio, now secretary of state, was once among USAID's biggest defenders, Gawande recalled. "I promise you, it will not be easy to radicalize people who are alive because the American taxpayer saved their lives and the lives of their children," Rubio said, according to Gawande. Rubio was right at the time, he added, "but not now."

"From 1970 to the year 2020, child deaths dropped 75%; 40% of that reduction in death was because of vaccines alone," Gawande said. Measles vaccine accounted for 60% of the vaccine gain, he explained.

A 2025 Lancet study of 133 countries, which Gawande displayed on a slide, associated higher USAID funding with a 15% reduction in all-cause mortality and a 32% reduction in under-5 mortality and estimated that 91.8 million deaths (95% CI, 85.7 million to 98.3 million) were prevented from 2001 to 2021.² Less than half of those lives saved came directly from global health programs, and investments in education, agriculture, and economic development contributed just as much. The study's authors wrote that USAID's impact extends beyond its direct funding of health programs.

How Did Primary Care Change Outcomes?

Primary health care was a major but little-understood focus of USAID, Gawande said.¹ The Navrongo trial in Ghana gave villages a salaried community nurse with primary care training, plus outreach workers who visited every household, identified children with malnutrition or patients falling behind on tuberculosis treatment, and returned them to care. Gawande reported that child mortality fell by 50% in 3 years and by 70% in 7 years. The published trial found that placing nurses in communities cut childhood mortality by more than half in 3 years,^3,4 while approaches relying on community volunteers had no effect on mortality.³

Ethiopia later took the approach to the national scale, he said. According to his presentation, the country's Health Extension Program has employed 30,000 rural health extension workers across 18,000 health posts since 2002, extended services to more than 80 million people who previously lacked basic care, and coincided with a 66% drop in under-5 mortality from 1990 to 2019.¹

Over 60 years of aid, some partner countries that prioritized primary care came to match or exceed US life expectancy on a fraction of their income, he said. 2023 United Nations estimates indicate life expectancy at birth of 81.2 years in Chile, 80.3 in Costa Rica, and 79.9 in Thailand, compared with 79.7 in the United States.⁵ Thailand spends $305 per person annually on health care, while the United States spends $13,000, he explained.¹ In Costa Rica, a primary care reform that assigned every resident a default clinic and sent community health teams to every home was associated with a 13% reduction in all-cause mortality over 9 years compared with controls.

What Has Happened Since USAID Funding Was Cut?

President Donald Trump's executive order halting USAID's work, signed as a first step toward dismantling the agency, made large numbers of deaths foreseeable, Gawande said. A total of 5000 primary care clinics lost services or closed, cutting off 53 million people, he said, citing a World Health Organization (WHO) report on humanitarian settings.⁶ Of those affected, 14 million were children with severe acute malnutrition, he added. WHO's 2026 Health Emergency Appeal states that funding cuts disrupted more than 6600 health facilities in 2025, leaving 53 million people without essential care.

Two models estimate that about 700,000 people died in 2025 as a result of the cuts, and the Institute for Health Metrics and Evaluation (IHME) projects 2025 will be the first year in more than 50 years that child death rates rise, Gawande explained.¹ IHME's model for the Gates Foundation's 2025 Goalkeepers report projects about 4.8 million deaths among children younger than 5 years in 2025, up from about 4.6 million in 2024, the first projected rise this century.⁷

Gawande has documented the effects of the cuts on film.¹ A 2025 film, Rovina's Choice, which he executive produced, about malnutrition services followed a mother who fled South Sudan's civil war and sought treatment in Kenya for her severely malnourished daughter. A different woman he met while filming in central South Sudan a couple of months ago had a daughter with a lower respiratory infection, he said. The mother and child walked an hour to a primary care clinic, one of 7 that had been shuttered, and found no treatment. Reaching care would have required a 4-hour boat trip, and the child died trying to get there, he explained. The loss of government data systems and audits has made the damage harder to document, and budget cuts also reach CDC and the National Institutes of Health.

What Comes Next?

The administration first argued that empathy was a weakness and now says that no one has died, Gawande said. In his view, officials will not acknowledge the deaths because admitting even one would mean admitting "that they have been monsters."

The field is "not back at square one.” Congress approved budgets retaining nearly full funding for global health last year, and the goals of ending child and maternal mortality and killer infectious diseases are bipartisan, he noted.

"The real fight," he said, is whether the United States continues "offering a helping hand" or returns to "ruling by the fist." Only one approach, Gawande said, has delivered results.

References

1. Gawande A. Together we rise: courage, collaboration, and the future. Opening plenary session presented at: IDWeek 2026; October 21, 2026; Washington, DC.
2. Cavalcanti DM, de Oliveira Ferreira de Sales L, da Silva AF, et al. Evaluating the impact of two decades of USAID interventions and projecting the effects of defunding on mortality up to 2030: a retrospective impact evaluation and forecasting analysis. Lancet. 2025;406(10500):283-294. doi:10.1016/S0140-6736(25)01186-9
3. Phillips JF, Bawah AA, Binka FN. Accelerating reproductive and child health programme impact with community-based services: the Navrongo experiment in Ghana. Bull World Health Organ. 2006;84(12):949-955. doi:10.2471/blt.06.030064
4. Awoonor-Williams JK, Sory EK, Nyonator FK, Phillips JF, Wang C, Schmitt ML. Lessons learned from scaling up a community-based health program in the Upper East Region of northern Ghana. Glob Health Sci Pract. 2013;1(1):117-133. doi:10.9745/GHSP-D-12-00012
5. United Nations Department of Economic and Social Affairs, Population Division. World Population Prospects 2022. Accessed October 22, 2026. https://www.un.org/development/desa/pd/content/World-Population-Prospects-2022
6. World Health Organization. WHO's Health Emergency Appeal 2026. February 3, 2026. Accessed October 22, 2026. https://www.who.int/emergencies/funding/health-emergency-appeals/2026
7. With child deaths projected to rise for the first time this century, Gates Foundation urges global leaders to target scarce resources where they save the most lives. PR Newswire. December 4, 2025. Accessed October 22, 2026. https://www.adnkronos.com/immediapress/pr-newswire/with-child-deaths-projected-to-rise-for-the-first-time-this-century-gates-foundation-urges-global-leaders-to-target-scarce-resources-where-they-save-the-most-lives_3mSEiwiRNPCi3kTBFyp09v