Finalist: Stephanie Nolen of The New York Times
Nominated Work
Lifesaving treatment and prevention programs for tuberculosis, malaria, H.I.V. and other diseases cannot access funds to continue work.
Lifesaving health initiatives and medical research projects have shut down around the world in response to the Trump administration’s 90-day pause on foreign aid and stop-work orders.
In Uganda, the National Malaria Control Program has suspended spraying insecticide into village homes and ceased shipments of bed nets for distribution to pregnant women and young children, said Dr. Jimmy Opigo, the program’s director.
Medical supplies, including drugs to stop hemorrhages in pregnant women and rehydration salts that treat life-threatening diarrhea in toddlers, cannot reach villages in Zambia because the trucking companies transporting them were paid through a suspended supply project of the United States Agency for International Development, U.S.A.I.D.
Dozens of clinical trials in South Asia, Africa and Latin America have been suspended. Thousands of people enrolled in the studies have drugs, vaccines and medical devices in their bodies but no longer have access to continuing treatment or to the researchers who were supervising their care.
In interviews, more than 20 researchers and program managers described the upheaval in health systems in countries across the developing world. Most agreed to be interviewed on the condition that their names not be published, fearing that speaking to a reporter would jeopardize any possibility that their projects might be able to reopen.
Many of those interviewed broke down in tears as they described the rapid destruction of decades of work.
The programs that have frozen or folded over the past six days supported frontline care for infectious disease, providing treatments and preventive measures that help avert millions of deaths from AIDS, tuberculosis, malaria and other diseases. They also presented a compassionate, generous image of the United States in countries where China has increasingly competed for influence.
The State Department and U.S.A.I.D. did not respond to requests for comment.
There will now be no one to take custody of millions of dollars’ worth of supplies for vital oxygen systems, purchased for programs funded by U.S.A.I.D. that support health clinics in some of the world’s poorest countries. The shipments, now in transit, are scheduled to reach ports in the coming days, but employees of those programs have been ordered to stop work.
On Tuesday night, Secretary of State Marco Rubio issued an exemption to the funding freeze for “lifesaving humanitarian assistance,” including what a State Department memo called “core lifesaving medicine.” However, shuttered H.I.V. and tuberculosis treatment programs have been told by their contacts at U.S.A.I.D. that they cannot resume work until they receive written instruction that the waiver applies specifically to them.
Few have been able to obtain clarification on whether and when their work can continue because their assigned contacts at U.S.A.I.D. have either been fired or furloughed, or are under strict instructions to not talk to anyone.
Thousands of people have already lost their jobs as a result of the freeze. About 500 U.S.-based employees of U.S.A.I.D. were fired. In countries from India to Zimbabwe, staff members for health projects were immediately fired. An organization called the International Centre for Diarrhoeal Disease Research, Bangladesh, which does research on a top killer of children, laid off more than 1,000 employees this week.
If the waiver announced by Mr. Rubio does not apply to their work — as is likely because it is expected to exempt only a narrow scope of activities — many nonprofit groups will not have enough funds to pay their employees or maintain supplies. Already, organizations that rely on U.S.A.I.D. funds have not been able access any money, even for reimbursement of expenses already incurred.
Two-thirds of the staff of the President’s Malaria Initiative, an organization founded by former President George W. Bush that is the largest donor to anti-malaria programs and research worldwide, have been fired. Those employees were contract staff members, because the agency had longtime hiring freezes for permanent positions, and included some of the most senior and respected scientists working on malaria control in the world.
While the interruption of H.I.V. treatment has prompted an outcry, the suspension of malaria work also immediately jeopardizes lives, said a scientist who was a senior staff member at the President’s Malaria Initiative for a decade and was fired on Tuesday.
Malaria interventions in Africa are carefully planned around rainy seasons, the time of which varies by region. Houses are sprayed with insecticide, and children are treated with an antimalarial medication during peak malaria transmission times.
“You could open the funding floodgates again tomorrow and you will still have children dying months from now because of this pause,” the scientist said.
More than 50 million children received preventative drugs before the rainy season last year.
The delivery of rapid tests and malaria drugs into Myanmar, where cases of malaria increased nearly tenfold to 850,000 in 2023 (the most recent figures available) from 78,000 in 2019, has been frozen. Some organizations now have no workers left to distribute the supplies even if they were to arrive.
In some parts of the country, more than 40 percent of cases are of a type of malaria that is often deadly in children under the age of 5. Malaria drugs would seem to qualify under the stipulation of “lifesaving humanitarian assistance, including essential medicines” included in the waiver, but in the absence of certainty, no one has been bold enough to try to free the drugs now stuck at the Thai border.
Some 2.4 million anti-malaria bed nets are sitting in production facilities in Asia, manufactured to fulfill U.S.-funded orders and bound for countries across sub-Saharan Africa. Those contracts are now frozen, because the U.S.A.I.D. subcontractor that bought them is not allowed to talk to the manufacturer under the terms of the freeze. Contracts for eight million more nets are now in limbo, an executive with the manufacturer said.
U.S.A.I.D.’s largest project is called the global health supply chain, an effort to streamline procurement of supplies for H.I.V., malaria, maternal health and other key areas, to make the system more efficient and save money. It operates in more than 55 countries where, in many cases, it supplies the bulk of key medicines. Now its global web of staff has been ordered to stop work except for essential tasks, like guarding commodities in warehouses.
In Zambia, U.S.A.I.D. supports the bulk distribution of public health products, using the private trucking industry to move medicines from a central supply depot to seven regional hubs, from which they are taken by truck, motorbike and boat to rural health centers. It’s part of the extensive U.S. support of the health system in Zambia, one of the world’s poorest countries, and over time it has been working to build up the supply chain capacity of the government.
Since the stop-work order was issued last Saturday, all of the vehicles transporting health products have been stopped. “They have effectively paralyzed the Zambian public health sector by pulling out so abruptly,” said one consultant who worked with the program. Similar U.S.-funded systems, now frozen, also moved a major share of basic medical supplies in Mozambique, Nigeria, Malawi and Haiti.
In East Africa, medical researchers working on projects to find ways to stop transmission of H.I.V. and develop more effective contraception have found themselves floundering for explanations to give to participants in their clinical trials.
“We have women testing vaginal rings, they already have the rings in them, people who got an injectable for H.I.V. prevention — when you say ‘stop,’ what happens to them?” said an H.I.V. researcher who is an investigator on a number of clinical trials. “We have an ethical obligation to people who volunteer for trials.”
Apoorva Mandavilli contributed reporting.
A correction was made on Feb. 1, 2025: A previous version of this article incorrectly said that a federal court ruling had blocked the freeze on foreign aid until Feb. 3. That court ruling applies only to the freeze on domestic loans and grants, not foreign aid.
The stop-work order on U.S.A.I.D.-funded research has left thousands of people with experimental drugs and devices in their bodies, with no access to monitoring or care.
Asanda Zondi received a startling phone call last Thursday, with orders to make her way to a health clinic in Vulindlela, South Africa, where she was participating in a research study that was testing a new device to prevent pregnancy and H.IV. infection.
The trial was shutting down, a nurse told her. The device, a silicone ring inserted into her vagina, needed to be removed right away.
When Ms. Zondi, 22, arrived at the clinic, she learned why: The U.S. Agency for International Development, which funded the study, had withdrawn financial support and had issued a stop-work order to all organizations around the globe that receive its money. The abrupt move followed an executive order by President Trump freezing all foreign aid for at least 90 days. Since then, the Trump administration has taken steps to dismantle the agency entirely.
Ms. Zondi’s trial is one of dozens that have been abruptly frozen, leaving people around the world with experimental drugs and medical products in their bodies, cut off from the researchers who were monitoring them, and generating waves of suspicion and fear.
The State Department, which now oversees U.S.A.I.D., replied to a request for comment by directing a reporter to USAID.gov, which no longer contains any information except that all permanent employees have been placed on administrative leave. Secretary of State Marco Rubio has said that the agency is wasteful and advances a liberal agenda that is counter to President Trump’s foreign policy.
In interviews, scientists — who are forbidden by the terms of the stop-work order to speak with the news media — described agonizing choices: violate the stop-work orders and continue to care for trial volunteers, or leave them alone to face potential side effects and harm.
The Declaration of Helsinki, a decades-old set of ethical principles for medical research that American institutions and others throughout the world have endorsed, lays out ethical guidelines under which medical research should be conducted, requiring that researchers care for participants throughout a trial, and report the results of their findings to the communities where trials were conducted.
Ms. Zondi said she was baffled and frightened. She talked with other women who had volunteered for the study. “Some people are afraid because we don’t know exactly what was the reason,” she said. “We don’t really know the real reason of pausing the study.”
The stop-work order was so immediate and sweeping that the research staff would be violating it if they helped the women remove the rings. But Dr. Leila Mansoor, a scientist with the Centre for the AIDS Programme of Research in South Africa (known as CAPRISA) and an investigator on the trial, decided she and her team would do so anyway.
“My first thought when I saw this order was, There are rings in people’s bodies and you cannot leave them,” Dr. Mansoor said. “For me ethics and participants come first. There is a line.”
In the communities where her organization works, people have volunteered for more than 25 years to test H.I.V. treatments, prevention products and vaccines, contributing to many of the key breakthroughs in the field and benefiting people worldwide.
That work relied on a carefully constructed web of trust that has now been destroyed, Dr. Mansoor said. Building that trust took years in South Africa, where the apartheid regime conducted medical experiments on Black people during the years of white rule. Those fears are echoed in a long history of experimentation by researchers and drug companies in developing countries and in marginalized populations in the United States.
The Times identified more than 30 frozen studies that had volunteers already in the care of researchers, including trials of:
malaria treatment in children under age 5 in Mozambique
treatment for cholera in Bangladesh
a screen-and-treat method for cervical cancer in Malawi
tuberculosis treatment for children and teenagers in Peru and South Africa
nutritional support for children in Ethiopia
early-childhood-development interventions in Cambodia
ways to support pregnant and breastfeeding women to reduce malnutrition in Jordan
an mRNA vaccine technology for H.I.V. in South Africa
It is difficult to know the total number of trials shut down, or how many people are affected, because the swift demolition of U.S.A.I.D. in recent days has erased the public record. In addition to the disabled website, the agency no longer has a communications department. And the stop-work order prohibits any implementing agency from speaking publicly about what has happened.
In England, about 100 people have been inoculated with an experimental malaria vaccine in two clinical trials. Now, they no longer have access to the clinical trial staff if that vaccine were to cause an adverse reaction in their bodies. The trial is an effort to find a next-generation vaccine better than the one now used in Africa; that shot protects children against about a third of malaria cases, but researchers hoped to find a vaccine that offered much more protection. Malaria remains a top global killer of children; 600,000 people died of the disease in 2023, the latest figure available.
Had the trial not been frozen, the participants would be coming to a clinic routinely to be monitored for adverse physical effects, and to have blood and cell samples taken to see whether the vaccine was working. The participants are meant to be followed for two years to assess the vaccine’s safety.
A scientist who worked on the trial said she hoped that partners at the University of Oxford, where it was being conducted, were shuffling staff to respond if any participant fell ill. But she was fired last week and no longer has access to any information about the trial. She spoke on condition of anonymity because she feared jeopardizing her ability to work on malaria research the U.S. might conduct in the future.
“It’s unethical to test anything in humans without taking it to the full completion of studies,” she said. “You put them at risk for no good reason.”
Had the stop-work order come later this year, the newly-vaccinated volunteers might have been in an even more precarious position. They were scheduled to be deliberately infected with malaria to see if the experimental vaccine protected them from the disease.
Dr. Sharon Hillier, a professor of reproductive infectious diseases at the University of Pittsburgh, was until this week director of a five-year, $125 million trial funded by U.S.A.I.D. to test the safety and efficacy of six new H.I.V. prevention products. They included bimonthly injections, fast-dissolving vaginal inserts and vaginal rings.
With the study suspended, she and her colleagues cannot process biological samples, analyze the data they have already collected, or communicate findings to either participants or the partnering government agencies in countries where the trials were conducted. These are requirements under the Helsinki agreement.
“We have betrayed the trust of ministries of health and the regulatory agencies in the countries where we were working and of the women who agreed to be in our studies, who were told that they would be taken care of,” Dr. Hillier said. “I’ve never seen anything like it in my 40 years of doing international research. It’s unethical, it’s dangerous and it’s reckless.”
Even trials that were not funded in whole or part by U.S.A.I.D. have been thrown into turmoil because they were using medical or development infrastructure that was supported by the agency and is no longer operational. Millions of dollars of U.S. taxpayer funds already spent to start those trials will not be recouped.
The shutdowns have business consequences as well. Many of those trials were partnerships with U.S. drug companies, testing products they hoped to sell overseas.
“This has made it impossible for pharmaceutical companies to do research in these countries,” Dr. Hillier said.
Another H.I.V. trial, called CATALYST, has thousands of volunteers in five countries testing an injectable drug called long-acting cabotegravir. Participants were receiving bimonthly injections to maintain a sufficient level of the drug in their bodies to prevent H.I.V. infection. Without regular injections, or a carefully-managed end to use of the drug, the participants will not have enough cabotegravir to stop a new infection, but there will be enough in their systems that, if they were to contract the virus, it could easily mutate to become drug-resistant, said Dr. Kenneth Ngure, president-elect of the International AIDS Society.
This is a significant threat to the trial volunteers and also to the millions of people living with H.I.V. because cabotegravir is closely related to a drug that is already used worldwide in standard treatment of the virus. Development of resistance could be catastrophic, Dr. Ngure said: “It’s wrong on so many levels — you can’t just stop.”
A clinical trial run by the development organization FHI 360, which implemented many U.S.A.I.D.-funded health programs and studies, was testing a biodegradable hormonal implant to prevent pregnancy. Women in the Dominican Republic had the devices in their bodies when U.S.A.I.D. funding was cut off. A spokeswoman for the organization, which furloughed more than a third of its U.S.-based staff this week, said that it had pulled together other resources to ensure that participants continue to receive care.
Another trial, in Uganda, was testing a new regimen of tuberculosis treatment for children. The stop-work order cuts those children off from potentially lifesaving medication.
“You can’t walk away from them, you just can’t,” a researcher in that trial said.
The United States was the major funder of tuberculosis programs. Now hundreds of thousands of sick patients can’t find tests or drugs, and risk spreading the disease.
By Stephanie Nolen
Photographs by Brian Otieno
Dalvin Modore walked as if there were broken glass beneath his feet, stepping gingerly, his frail shoulders hunched against the anticipation of pain. His trousers had become so loose that he had to hold them up as he inched around his small farm in western Kenya.
Mr. Modore has tuberculosis. He is 40, a tall man whose weight has dropped to 110 pounds. He has a wracking cough and sometimes vomits blood. He fears the disease will kill him and has been desperate to be on medication to treat it.
Mr. Modore is one of thousands of Kenyans, and hundreds of thousands of people worldwide, with TB who have lost access to treatments and testing in the weeks since the Trump administration slashed foreign aid and withdrew funding for health programs around the globe.
Many, like Mr. Modore, have grown significantly sicker. As they go about their lives, waiting and hoping, they are spreading the disease, to others in their own families, communities and beyond.
The whole system of finding, diagnosing and treating tuberculosis — which kills more people worldwide than any other infectious disease — has collapsed in dozens of countries across Africa and Asia since President Trump ordered the aid freeze on Jan. 20, Inauguration Day.
The United States contributed about half of international donor funding to TB last year and here in Kenya paid for an array of essentials. Trump administration officials have said that other countries should contribute a greater share to global health programs. They say the administration is evaluating foreign aid contracts to determine whether they are in the national interest of the United States.
While some of the TB programs may ultimately survive, none have received any money for months.
Family members of infected people are not being put on preventive therapy. Infected adults are sharing rooms in crowded Nairobi tenements, and infected children are sleeping four to a bed with their siblings. Parents who took their sick children to get tested the day before Mr. Trump was inaugurated are still waiting to hear if their children have tuberculosis. And people who have the near-totally drug-resistant form of tuberculosis are not being treated.
Mr. Modore shares a bed with his cousin and his home with four other relatives. All of them have watched him get sicker and thinner, fearing also for their own health.
Despite being fully treatable, tuberculosis claimed 1.25 million lives in 2023, the last year for which data is available. If TB begins to spread unchecked, people throughout the world could become at risk.
The main TB research effort, testing new diagnostics and therapies, has been terminated. The global procurement agency for TB medications lost its funds, then was told it might regain them, but still has not. Stop TB, the global consortium of government and patient groups that coordinates tuberculosis tracking and treatment, was terminated, had the termination rescinded, but still has received no funds.
The United States did not pay for all the TB care in Kenya, but it funded critical pieces. And when those were frozen, it was enough to bring the entire system to a halt.
The United States paid for motorbike drivers, who earned about $1 for transporting a sample taken from a person with a presumptive infection to a lab to test it for TB. The drivers were fired on the first day of the funding cut — so the transportation of samples stopped.
The United States paid for some laboratory equipment used to process tests. In many places, processing stopped.
The United States paid for the internet connectivity that allowed many testing sites to send results back to far-off patients via local community advocates known as TB Champions. So even when patients found a way to send samples to a working lab, notification of results stopped.
Without testing that confirms whether a person is infected and what type of TB they have, family members cannot start on preventive therapy.
The United States paid for the half-dozen tests that patients need before beginning treatment for multi-drug-resistant TB, to make sure their bodies will be able to tolerate the harsh drugs. These tests can cost $80 or more, beyond the reach of many patients. Without the tests, clinicians don’t know what drugs to prescribe very sick patients. Prescriptions stopped.
The United States paid for the ships and trucks that moved drugs to ports and on to warehouses and clinics. Shipments stopped.
And the United States paid for the data management contract that provided a national dashboard of data on cases, cures and deaths. Tracking stopped.
Evaline Kibuchi, the national coordinator for the Stop TB Partnership in Kenya, predicted that it would take only three months before infections and deaths from TB increased. “But we won’t even know about the new deaths, because all the data collection was supported by U.S.A.I.D.,” she said.
The United States also paid the stipends — about $35 a month — of community health workers, and TB Champions, who lost the tiny salaries that belie their vital role. Research has shown that because TB treatment involves taking drugs for many months, often with miserable side effects, patients are much more likely to finish a course of medication and be cured when someone is checking on them regularly, cheering them on and watching for lapses.
But across Kenya, the community advocates have kept working, unpaid, covering the costs of trying to reach patients and delivering diagnoses out of their own pockets.
Mr. Modore’s constant cough drew neighborhood attention in January. Doreen Kikuyu, the TB Champion in his area, came and collected a sputum sample from him and used the motorbike system to send it for diagnosis.
By the time his results came back, the Trump administration had frozen the system. Ms. Kikuyu could not get funds for a motorbike to take her to his home to inform him. “But I could not leave him without knowing the answer,” she said. “So I set out walking.”
She also explained that the lab analysis did not provide information on whether he had a drug-resistant form, so he would need further testing before he could start the proper medication. But he would have to pay 1,000 Kenyan shillings — about $8 — to send a sample to the regional laboratory that could do this test. To pay for it, they might need to sell a chicken, one of their few assets. They debated what to do as the days ticked by.
“I’m really hoping to start on medication but I’m just left wondering what will happen,” Mr. Modore said one recent afternoon, sitting hunched in the shade of a stand of trees outside his house.
Eventually, the intrepid Ms. Kikuyu managed to scrape together the money, by gathering contributions from other now-fired community health workers and neighbors. She sent the sample to the lab. Good news came back: Mr. Modore did not have drug resistance and could take the standard medications.
But there was no one to prescribe them. The staff members at the clinic were paid by the United States, and they were now fired. Ms. Kikuyu was at her wit’s end, knowing Mr. Modore was desperately ill.
Working her phone, using airtime she bought herself, she badgered a local government TB official who is a clinician to meet her at the hospital and to prescribe and issue the drugs from the shuttered clinic storeroom. She scraped together more money to bring Mr. Modore to the clinic on a motorbike. As she watched him grin and take his first pills, she felt a flood of relief.
But immediately, she faced a new worry: His family and close neighbors, about a dozen people, needed to start preventive therapy to protect them from getting sick too. The clinic is closed. If she can find a clinician to prescribe drugs for the adults, at least, she could deliver them. (TB drugs for children are complex and require a doctor’s supervision.) But she’s out of money to get back to the Modore home. She has worn herself out walking to the homes of other patients who are waiting for tests, waiting for results, waiting for drugs.
“It’s a problem,” she said wearily. “But we have to get to that family.”
For TB treatment to work, patients must take their drugs every day, without interruption, for months.
Barack Odima, a 38-year-old mechanic in Nairobi, has the most deadly form of the disease, one that is resistant to most treatments. Last fall he started on a rare drug combination, but when he went to pick up his medication two weeks ago, the clinic staff told him that one of the drugs had not been restocked and that they had nothing for him.
“If I don’t get this drug that is missing, how will I be cured?” Mr. Odima said.
After another week, the clinic received a small batch of medications. The clinician and the pharmacist had been laid off, so a TB Champion gave him the medication — but could not tell him how many more pills he might receive.
While he is on the drugs, Mr. Odima is supposed to have monthly testing of his blood, liver and kidneys to make sure his body is tolerating them. That costs about $80, previously covered by the U.S. grant, and he has not had a test since the funding freeze. Mr. Odima’s wife and five children are supposed to be rechecked for the disease this month; it will take all his savings to pay for X-rays.
In an interview in a clinic treatment room plastered with stickers and posters advertising U.S.A.I.D. support, Mr. Odima said he was grateful to the United States for assisting with his treatment, but was baffled that the country had cut off help. Of course his own government should provide such care, he said. “But we are a dependent country,” he said, “and Kenya is not able to support the programs so that all the people with these diseases can get cured.”
In truth, the TB treatment system in Kenya was none too sturdy before the United States yanked its support — the country had nearly 90,000 new infections last year. Labs ran short of supplies to do molecular tests, and people were often misdiagnosed.
The TB Champions, who drop in to check in on anyone they hear about with a persistent cough, were intended as a low-budget, high-impact strategy to change that. Since the aid freeze, they have taken on outsize importance. In the scruffy western Kenyan town of Busia, a Champion named Agnes Okose is using the money she earns from her snack stall to fund trips to outlying villages. Since late January, she has been delivering diagnoses and collecting sputum samples in plastic sample jars she buys herself, toting them in a small lunch cooler to a laboratory in town.
“I am a TB survivor myself; I cannot leave people just dying,” she said. “Whatever small-small money we can find, we are using it.”
The aid cuts have also crippled a network of clinics set up all over Africa two decades ago by President George W. Bush’s Emergency Plan for AIDS Relief. Those clinics bypassed the frail, bureaucratic and graft-riddled health systems in countries battling TB and H.I.V. and put patients on lifesaving medication quickly. Twenty years later, they were still partly or totally separate, in most places, and had U.S.-paid staff.
Now African health officials are scrambling to absorb those patients into the regular medical system — as many as 40 percent more people to care for, in facilities that were already overstretched. Kenya’s national government has said it is working on a plan but offered no details for how it will bridge the yawning funding gap.
But because all the TB and H.I.V. cases have gone to the separate clinics for years, clinicians in the main facilities don’t know about drug protocols, side effects or signs of treatment failure.
“You will have health care workers who have never seen a TB case; there will be quality-of-care issues,” said Dr. Timothy Malika, who oversees the TB program of Kisumu County, which has one of the highest rates of TB infection in Kenya.
Abigael Wanga, who lives in a village in Busia County, has five children; two have taken TB treatment for a year. But the two children, Philemon, 8, who hopes to be a pilot one day, and his headstrong sister Desma, 3, still have chest pain and coughs, and no appetite.
Ms. Okose fears they are drug-resistant. She collected sputum samples from them and their three siblings the day before the inauguration. The testing is frozen, and all five children continue to sleep under one blanket at night.
The United States was a key supplier of contraceptives in many developing countries. The Trump administration has ended that support.
The United States is ending its financial support for family planning programs in developing countries, cutting nearly 50 million women off from access to contraception.
This policy change has attracted little attention amid the wholesale dismantling of American foreign aid, but it stands to have enormous implications, including more maternal deaths and an overall increase in poverty. It derails an effort that had brought long-acting contraceptives to women in some of the poorest and most isolated parts of the world in recent years.
The United States provided about 40 percent of the funding governments contributed to family planning programs in 31 developing countries, some $600 million, in 2023, the last year for which data is available, according to KFF, a health research organization.
That American funding provided contraceptive devices and the medical services to deliver them to more than 47 million women and couples, which is estimated to have averted 17.1 million unintended pregnancies and 5.2 million unsafe abortions, according to an analysis by the Guttmacher Institute, a sexual health research organization. Without this annual contribution, 34,000 women could die from preventable maternal deaths each year, the Guttmacher calculation concluded.
“The magnitude of the impact is mind-boggling,” said Marie Ba, who leads the coordination team for the Ouagadougou Partnership, an initiative to accelerate investments and access to family planning in nine West African countries.
The funding has been terminated as part of the Trump administration’s disassembling of the United States Agency for International Development. The State Department, into which the skeletal remains of U.S.A.I.D. was absorbed on Friday, did not reply to a request for comment on the decision to stop funding family planning. Secretary of State Marco Rubio has described the terminated aid projects as wasteful and not aligned with American strategic interest.
Support for family planning in the world’s poorest and most populous countries has been a consistent policy priority for both Democratic and Republican administrations for decades, seen as a bulwark against political instability. It also lowered the number of women seeking abortions.
Among the countries that will be significantly affected by the decision are Afghanistan, Ethiopia, Bangladesh, Yemen and the Democratic Republic of Congo.
The money to support international family planning programs is appropriated by Congress and was extended in the most recent spending bill that keeps the government operating through September. The move by the State Department to cut these and other aid programs is the subject of multiple lawsuits currently before federal courts.
The Trump administration has also terminated American funding for the United Nations’ sexual and reproductive health agency, U.N.F.P.A., which is the world’s largest procurer of contraceptives. The United States was the organization’s largest donor.
Although the United States was not the sole supplier of contraception in any country, the abrupt termination of American funding has created chaos in the system and has already caused clinics to run out of products.
An estimated $27 million worth of family planning products already procured by U.S.A.I.D. are stuck at different points in the delivery system — on boats, in ports, in warehouses — with no programs or employees left to unload them or hand them over to governments, according to a former U.S.A.I.D. employee who was not authorized to speak to a reporter. One plan proposed by the new U.S.A.I.D. leadership in Washington is for remaining employees to destroy them.
Supply chain management was a major focus for U.S.A.I.D., across all areas of health, and the United States paid to move contraceptive supplies such as hormonal implants, for example, from manufacturers in Thailand to the port in Mombasa, Kenya, from where they were taken by trucks to warehouses across East Africa and then to local clinics.
“To put the pieces back together is going to be very difficult,” said Dr. Natalia Kanem, executive director of U.N.F.P.A. “Already this has had a catastrophic impact — it’s literally affecting millions of women and families. The poorest countries don’t have the resilient buffer.”
The United States also paid for data and information systems that helped governments track what was in stock and what they needed to order. None of those systems have operated since the Trump administration sent a stop-work order to all programs that received U.S.A.I.D. grants.
Bellington Vwalika, a professor of obstetrics and gynecology at the University of Zambia, said that contraceptives had already begun to run short in some parts of the country, where the United States supplied a quarter of the national family planning budget.
“The affluent can buy the commodity they want — it is the poor people who have to think, ‘Between food and contraception, what should I get?’” he said.
Even before the United States pulled out of family planning programs, surveys found that globally, about 250 million women of reproductive age wished to avoid pregnancy but did not have access to a modern contraceptive method.
At the same time, there had been great progress. Demand for contraception has been rising steadily — with long-acting methods that offer women greater privacy and secure protection — in Africa, the region of the world with the lowest coverage. Supply has improved with better infrastructure that helped get products to rural areas. And “demand creation” projects, of which the United States was a major funder, used advertisements and social media to inform people about the range of contraceptive choices available and the advantages of spacing or delaying pregnancies. Women’s rising levels of education boosted demand, too.
Thelma Sibanda, a 27-year-old engineering graduate who lives in a low-income community on the edge of the Zimbabwean capital, Harare, two weeks ago received a hormonal implant that will prevent pregnancy for five years, at a free pop-up clinic run by Population Services Zimbabwe, which had a multiyear U.S.A.I.D. grant to deliver free family planning services.
Ms. Sibanda has a 2-year-old son and says she cannot afford more children: She can’t find a job in Zimbabwe’s fractured economy, and neither can her husband. They subsist on the $150 he earns each month from a vegetable stand. She had been relying on “hope and faith and natural methods” to prevent another pregnancy since her son was born, Ms. Sibanda said, and had wished for something more reliable, but it simply wasn’t possible in her family’s budget — until the free clinic came to her neighborhood.
With its U.S.A.I.D. funding, the Zimbabwean organization that provided her implant last year was able to buy six sturdy Toyota vehicles and camping equipment so that an outreach team could travel to the most remote regions of the country, delivering vasectomies and IUDs in pop-up clinics. Since the Trump executive order, they have had to stop using all of that equipment.
The Zimbabwean organization is a branch of the international nonprofit MSI Reproductive Choices, which has stepped in with temporary funds so the teams can continue to provide free care for the women they can reach, such as Ms. Sibanda. MSI can cover the costs only until September.
Ms. Sibanda said her priority was providing the best possible education for her son, and because school fees are costly, that means no more children. But many African women have no way to make this kind of choice. In Uganda, while the national fertility rate is 4.5 children per woman, it’s not unusual to meet women in rural areas with limited education who have eight or 10 children, said Dr. Justine Bukenya, a lecturer in community health and behavioral science at Makerere University in Kampala. These women become pregnant for the first time as teenagers and have little space between pregnancies.
“By the time they are 30 they could have their 10th pregnancy — and these are the women who will be affected,” she said. “We are losing the opportunity to make progress with them. The United States was doing a very strong job here of creating demand for contraception with these women, and mobilizing young men and women to go for family planning.”
Some women who have relied on free or low-cost service through public health systems may now try to buy contraceptives in the private market. But prices of pills, IUDs and other devices will most likely rise significantly without the guaranteed, large-volume purchases from the United States.
“As a result, women who previously relied on free or affordable options through public health systems may now be forced to turn to private sector sources — at prices they cannot afford,” said Karen Hong, chief of U.N.F.P.A.’s supply chain unit.
The next largest donors to family planning after the United States are the Netherlands, which provided about 17 percent of donor government funding in 2023, and Britain, with 13 percent. Both countries recently announced plans to cut their aid budgets by a third or more.
Ms. Ba said the focus in the West African countries where she works was mobilizing domestic resources and figuring out how governments can try to reallocate money to cover what the United States was supplying. Philanthropies such as the Gates Foundation and financial institutions including the World Bank, which are already significant contributors to family planning, may offer additional funding to try to keep products moving into countries.
“We were getting so optimistic — even with all the political instability in our region, we were adding millions more women using modern methods in the last few years,” Ms. Ba said. “And now all of it, the U.S. support, the policies, it’s all completely gone. The gaps are just too huge to fill.”
A correction was made on April 1, 2025: Surveys have found that about 250 million women of reproductive age worldwide wished to avoid pregnancy but did not have access to a modern contraceptive method. A previous version of this article incorrectly gave the number as 1 billion.
The budget cuts threaten global progress on everything from heart disease to H.I.V. — and could affect American drug companies, too.
In Cape Town, South Africa, one of the world’s foremost H.I.V. researchers has been spending a chunk of each day gently telling longtime workers and young doctoral students that the money is gone and so are their jobs. When the calls are done, she weeps in her empty office.
In the heart of Johannesburg, the lobby of a building that once housed hundreds of scientists is empty of people but choked with discarded office furniture and heaps of files hastily gathered from shuttered research sites.
South Africa has for decades been a medical research powerhouse, yet its stature has been little known to people outside the field. South Africa’s scientists have been responsible for key breakthroughs against major global killers, including heart disease, H.I.V. and respiratory viruses such as Covid-19. They have worked closely with American researchers and have been awarded more research funding from the United States than any other country has received.
But a swift series of executive orders and budget cuts from the Trump administration have, in a matter of months, demolished this research ecosystem.
There are grim ramifications for human health worldwide, and also for pharmaceutical companies, including American giants such as Pfizer, Merck, Abbott and Gilead Sciences, which rely heavily on South Africa’s research complex when they develop and test new drugs, vaccines and treatments.
“South Africa is the beacon,” said Dr. Harold Varmus, a professor at Weil Cornell Medicine who was awarded the Nobel Prize in medicine for his work on cancer biology and who was a director of the National Institutes of Health.
“We have many important collaborative works going on there,” he continued, adding: “To cut them off, I just don’t understand it. It’s self-destructive behavior.”
Dozens of critical medical trials that were testing treatments and protections against gonorrhea, diabetes, meningitis, cervical cancer and a host of other afflictions have shut down as a result of the cuts. The abrupt terminations have left researchers scrambling to find ways to provide ongoing monitoring and care for the people, including small children, who had been given experimental vaccines or drugs.
“The implications of this are huge,” said Dr. Ntobeko Ntusi, chief executive of the South African Medical Research Council. “One of the biggest success stories to come out of South Africa in the last three decades, largely aided through the generosity of American people, has been the development of this high-caliber cadre of scientists who’ve led scholarship that has been seminal not just for South Africa but for the whole world.”
Neither the State Department nor the Department of Health and Human Services would comment on the funding cuts.
The motivation for the cuts most likely results from a combination of forces often cited by administration officials: an aversion to sending American dollars overseas, concerns about waste and a particular vendetta against the country, in which President Trump has said, inaccurately, that there is a “genocide” of white people.
Overall, hundreds of millions of dollars in funding for medical research in South Africa has been cut. That includes at least $260 million from the N.I.H. and hundreds of millions more from other agencies including the Centers for Disease Control and Prevention and the United States Agency for International Development.
“All U.S. federal funding flows have stopped,” Dr. Ntusi said.
Pharmaceutical companies have relied on the country for clinical trials for decades. Some are now rethinking their relationship with South Africa, according to people familiar with the discussions.
Dr. Shabir Madhi, the dean of the Faculty of Health Sciences at the University of the Witwatersrand in Johannesburg, has worked with drug companies on many new vaccines, including immunizations for Covid and diarrheal disease, and has been preparing for the next phase of a trial of a pneumococcal vaccine. But now, he said, the private contractors running the trial for the drugmaker are “pushing back against my own research unit being included in a vaccine study which we’re probably in the best position in the world to undertake.”
Not all medical research in the country has relied on U.S. funding. But even projects with other funding sources have been disrupted. In some cases, the remaining funds are insufficient to keep laboratories running or pay the salaries of scientists, who typically work on multiple projects at once.
The full effect of the damage will become clear only in the coming months, said Dr. Tom Scriba, a professor of immunology at the University of Cape Town and deputy director of the world’s top tuberculosis research centers.
How South Africa Became a Powerhouse
The first-ever heart transplant was performed in Cape Town in 1967. The CT scanner was invented in South Africa. So were many now-common surgical techniques. Vaccines and drugs that are widely used in the United States — including treatments for high blood pressure and the immunization for R.S.V. — came out of South African research.
Huge clinical trials in South Africa were key to the speed with which Covid vaccines — of all kinds — were developed. Then, it was South African researchers who sounded the alarm that the coronavirus had mutated to evade the original vaccines, who provided critical information on the Beta variant and who later identified and genetically sequenced the Omicron variant, providing the information that Pfizer and Moderna used to update their vaccines.
South Africa’s research might is a legacy of its harsh history. Apartheid-era governments neglected the health of millions of Black people but invested in educational institutions and medical innovation for the white population. In the decades since the country transitioned to a multiracial democracy, those educational institutions have been open to everyone. But efforts to extend basic health care have been slow, which means the country still has a high rate of disease. That, in turn, makes for a grimly efficient place to conduct research.
South Africa has the world’s largest population of people living with H.I.V., one of the largest of people with tuberculosis, and high numbers of people with heart disease and diabetes. So it is possible, for example, to recruit 1,000 participants for a clinical trial at a single site in Soweto in a matter of weeks — a process that might take months and a dozen sites in the United States.
When Dr. Madhi oversaw a large final-stage clinical trial of the Novavax vaccine against R.S.V. for pregnant women, six sites in South Africa enrolled as many women as 81 other sites around the world. If drug companies did not have South African partners, Dr. Madhi said, it would push the cost of development so high that this vaccine and others would simply never be made.
Because the South African rand is a weaker currency — running about 20 to a U.S. dollar — running studies in South Africa costs a fraction of what it does in the United States.
South Africa’s researchers work out of world-class facilities that have benefited from significant investment from the United States government and philanthropies, such as the Gates Foundation, over the past 20 years.
South Africa also has a top-tier government medical regulator, which certifies trials to meet standards required by U.S. and European regulators. “All our studies are set up from the beginning to have global impact,” said Dr. Helen Rees, the director of the Wits Reproductive Health and H.I.V. Institute, which has produced seminal work on vaccine-preventable illness, maternal health and H.I.V.
The final ingredient is relationships: Researchers have worked for decades in the communities where they run trials. People have seen the direct results of the science they volunteer to test — new, shorter treatments for tuberculosis, for example — and whole communities participate in information and consent processes for new trials. This has allowed researchers in South Africa to do work such as testing an H.I.V. vaccine on newborns, or drugs on pregnant women, that would be mired in both public unease and concerns about liability in the United States.
“This was American taxpayers’ money and we are incredibly grateful that’s how it was spent, but it wasn’t a gift or a charity,” said Dr. Lynn Morris, deputy vice chancellor of research and innovation at the University of the Witwatersrand. “These are competitive grants, and the data we produced benefited everyone.”
One of the Trump administration’s main arguments against foreign aid has been that the money is often used wastefully. South Africa is routinely criticized for government corruption by transparency watchdog groups.
However, N.I.H. and other research awards were subject to stringent financial accounting by U.S.-based auditors, and the few projects found to have misused funds over the past two decades were swiftly terminated.
What the Future May Hold
The U.S.-based pharmaceutical industry has not spoken out about the targeting of South Africa, and executives at several companies declined to be interviewed for this article.
“Publicly, they’re mute,” said Dr. Stavros Nicolaou, who oversees international business for Aspen Pharmacare, a South African drugmaker. “Privately, they’re very vocal.” They are not going to risk political capital by advocating for the country, he said.
In an interview, Dr. Jared Baeten, a senior vice president at Gilead Sciences who focuses on therapeutics for viruses, did not discuss the cuts but said that the role of South African research had been essential.
“There’s so much scientific data that builds on research from South Africa,” he said. “We have H.I.V. prevention for this country and for the world because of the infrastructure, the scientific ability and the collaboration with South Africa.”
Julie Marie Cunningham, a spokeswoman for the drugmaker Merck, said that the company would move ahead with testing a new oral H.I.V. prevention drug and other products in South Africa. “We continue to consider South Africa an important location for clinical trial sites.”
But some South African scientists can imagine a near future when it is impossible for drug companies to operate there.
“My bigger concern now is the possibility of South Africa being sanctioned as a country,” Dr. Madhi said.
The concept once seemed far-fetched, but it looks less implausible after Mr. Trump’s confrontational meeting with South Africa’s president, Cyril Ramaphosa, at the White House last month. Sanctions would not only end multinational pharmaceutical work in the country but also restrict the ability of other organizations, such as the Gates Foundation, to operate there as well.
The foundation, for now, is the first place researchers are turning in the hope of finding funding that might allow some work to continue.
The foundation has already stepped in with money to try to preserve some studies already in progress.
“Cutting funding now will limit further scientific breakthroughs and progress in health and ultimately put millions of lives at risk, including here in the United States,” said Trevor Mundel, president of global health at the foundation.
Wellcome Trust, a philanthropic organization in Britain, is looking at ways it can try to preserve some research, and scientists are submitting proposals to the European Union and individual countries in Europe.
Funding bureaucracy moves slowly, and it will be at least a year before any of these new proposals could yield money that would allow work to resume.
South Africa’s universities and the medical research council have made emergency appeals to the country’s government. The Gates Foundation and other philanthropies may match some of what the government contributes.
But that would be a fraction of what’s been lost. South Africa’s financial resources were already badly strained by corruption, decaying infrastructure, a faltering economy and a dysfunctional coalition government.
“I don’t think it’s within the means of the country to be able to bridge the gap,” Dr. Madhi said.
The council will use those funds to try to care for people who were in clinical trials and preserve studies that were providing critical data for doctoral students who were partway through their degrees.
“We are at risk of missing out on a generation of scientists — because people will leave,” Dr. Scriba said.
At the Centre for the AIDS Program of Research in Durban, which was created by the N.I.H. in 2002 and which has now lost 50 percent of its budget, senior scientists are trying to comfort their junior colleagues by drawing on lessons they learned as young doctors at the height of the fight against apartheid.
“During times of adversity, you can also be very resourceful,” said Dr. Qurraisha Abdool Karim, the scientific director at the center. “So we keep thinking optimistically, what is it we can do? We know it’s going to be painful and we all have to suffer that. But in the longer term, how do we rise stronger?”
Hunger and the diseases that stalk small children have surged in Somalia after the U.S. slashed its aid to the country.
By Stephanie Nolen
Photographs by Brian Otieno
The mothers arrived at the emergency feeding center all day long, their faces tight with anxiety, their children limp in their arms. Nurses quickly weighed each child and checked for infection. The frailest were given tubes threaded up their noses and down into their bellies, for a slow drip of fortified milk. Those a little bigger were placed in a bed in a packed room for feeding with therapeutic peanut paste. The ones with rashes, fevers and deep, hacking coughs — potential diphtheria, measles, whooping cough, maybe cholera — were tucked into bare isolation rooms.
It wasn’t like this even six months ago.
Here in Baidoa, a city in southern Somalia, community health workers used to go door to door looking for children who were too thin or sick. Care was swift, and free, at rudimentary clinics set up in camps and neighborhoods. Families received parcels of special foods packed with nutrients. As a result, it was rare for children to deteriorate to the point they needed to be transported to a center for 24-hour care.
But the community health clinics, and emergency food, were paid for by the United States, through its Agency for International Development. When the Trump administration dismantled the agency and ended vast swaths of foreign assistance to the world’s poorest countries, much of the food aid and health care for children across Somalia were abruptly cut off.
So now more children are arriving at emergency centers, and they are sicker and thinner than ever. Their vertebrae poke like the teeth of a comb through the translucent skin of their backs.
The swift American exit from Somalia — a country gripped by twin menaces of recurring drought and Islamist insurgency, where the United States has long seen a strong geopolitical reason for partnership — has created chaos all through the country’s health system.
The aid organization Save the Children was operating 128 community health facilities across Somalia, and had to close 47 of them in March, leaving more than 300,000 people without health and nutrition services. The International Medical Corps closed medical centers in four regions of the country, including Baidoa, a sprawling, sun-bleached city of 750,000 hosting some 770,000 displaced people. U.S. support for the United Nations’ World Food Programme, which supplies fortified milks and therapeutic peanut paste for malnourished children, was reduced.
The United States sent an average of $450 million a year in humanitarian assistance to Somalia over the past decade, including $481 million in 2020, the final year of the first Trump administration. Internal State Department data reviewed by The New York Times shows that in the 2025 fiscal year, which ended on Sept. 30, about $128 million had been sent to Somalia.
The State Department said on Oct. 9 that the Trump administration had approved $14.9 million in funding for Somalia. In an emailed statement, it said both military and humanitarian assistance to Somalia continued.
“The United States remains committed to working with Somalia to counter terrorist threats and address shared security concerns,” the statement said.
The United States has been by far the largest donor to Somalia, and the Trump administration has argued that the United States has been contributing more than its fair share of aid around the world. “The State Department will continue its mission to encourage other donors, including governments and the private sector, to come up with sustainable solutions for those most in need,” the statement said.
Dr. Binyam Gebru, Save the Children’s director in Somalia, and his colleagues had to make agonizing choices after the U.S.A.I.D. grant they had received for the past eight years, which averaged about $15 million a year, was not renewed. In Baidoa the organization ran a feeding program that delivered fortified food to all the children and pregnant and breastfeeding women in the vast camps of displaced people that surround the town. Either the community feeding program or the emergency centers would have to shut down.
They could stave off severe illness — and a lifetime of cognitive and physical impairments — for many more children if they maintained the community feeding program, which costs much less than inpatient emergency treatment. But for the sickest children, the emergency center is the difference between life and death.
“Of course lifesaving intervention should be prioritized, and that’s what we have done,” Dr. Gebru said. “But it’s devastating. You know that in the community, you could treat a child for a few dollars, and very quickly.”
Save the Children has even had to close some emergency centers; the organization has tried to maintain at least one in each region.
In the aftermath of the United States’ exit, Somalia has seen a decline in funding from other countries, too. “Most of our key donors — the Dutch, the Germans, the Brits — it’s all coming down,” said Crispen Rukasha, the head of the U.N.’s Office for the Coordination of Humanitarian Affairs in Somalia. Britain was the second-largest donor to health in Somalia, but will end its funding for health care in March.
The World Food Programme said that starting next month, it would be forced to reduce the number of people who receive emergency food assistance in Somalia to just 350,000, down from 1.1 million in August — fewer than one in every 10 people who are in need of food aid for survival.
The need for help is intensifying: the grip of the drought has been growing each year. A quarter of Somalia’s 16 million people are displaced. In September, a U.N.-backed group of experts who monitor world hunger upgraded its level of warning for Somalia, saying 3.4 million Somalis were experiencing “crisis” levels of food insecurity and that the number would most likely increase by a million people by the end of this year.
The area around Baidoa once produced half the country’s food, but 34 years of civil war has destroyed farms. Dr. Gebru said that in the past, his organization has been able to direct resources into hard-hit communities, and provide a buffer when famine loomed. Now, he said, they can only watch it come.
In a congested camp on the city’s edge, Owliyo Ali has worried for some time that her youngest child, a son, is much too light for an 18-month-old. When his older siblings were babies, she relied on regular supplies of fortified foods that she picked up at the health center a few minutes’ walk from her home. But now that center is closed.
Save the Children mobile teams still come to the camp a couple of times a week for a few hours, but they don’t bring as much food.
“Usually they run out before I get any for him,” she said.
A few weeks ago the child had diarrhea and a high fever, developed a measles rash and grew too weak even to cry. She wanted to take him to a clinic, but the only option now is the hospital in town — a $3 taxi ride away, three times more than the $1 her husband earns for a day’s work. The couple borrowed from neighbors, and the boy was admitted for four days; weeks later, he was still listless and glassy-eyed.
Ms. Ali and her family fled their home eight years ago, after their harvests failed repeatedly. They now live in a shack made of sticks and sheet metal. Ms. Ali is pregnant, and she was also relying on food from the health center. Research shows that in areas with high rates of malnutrition, providing pregnant women with fortified foods can have a significant positive effect on their children’s growth and health. But that food ran out months ago, she said.
At Bay Regional Hospital, admissions for malnutrition were up by 40 percent by July compared with January, said Dr. Abdullahi Yusuf, the facility’s medical director. They used to see children with diphtheria once or twice a year, but there have been 50 cases in the last three months. Children who come are much sicker, he said, and pregnant women arrive with life-threatening conditions.
“Previously we had early referrals, from community health workers — now they come late and the complications are much more severe, and so the deaths are higher,” he said.
Pediatric and obstetric staff members at the hospital are paid for and supplies are purchased by Doctors Without Borders, one of the few organizations which accepts no funding from governments and thus has been able to keep operating. But Dr. Yusuf said the situation was not sustainable: A ward for 50 children sometimes has 90 crowded into it, he said.
Somalia’s national government collected just $350 million in total revenue last year. Almost all of that was spent on security, as the government struggles against two militant organizations that control about a third of the national territory. The government pays for about 4 percent of all health spending in the country; foreign donors cover 60 percent and the rest is out of pocket.
Dr. Ibrahim Adam Somow, director general of the state health ministry, said he and his colleagues were stunned when they began to receive emails from one international partner after another, announcing that their funding had been terminated and they were leaving. Clinics and feeding centers closed overnight.
Keeping skilled staff members to run childbirth facilities has been one of the priorities for spending their limited funds, he said. Keeping at least one outpatient center for children in each area is another.
“Our priority is to reach the child who lives under a tree so that he or she survives and becomes tomorrow’s leader,” he said. Dr. Somow, who recently earned a doctorate in public health, was once one of those children himself: he remembers waiting under a tree to be immunized in a vaccination blitz.
At 40, he’s proof of progress, he said, but Somalia is a long way from being able to cope on its own. “It is like rebuilding a building: everyone must bring a brick,” he said.
Despite the challenges, Somalia had made public health gains in recent years, bolstered significantly by the U.S. funding. The number of child and maternal deaths was slowly falling. Vaccination coverage was creeping up, as immunization teams made forays into areas that had been controlled by insurgents.
“This is a country riddled with crises, and yet amid all this, there were still improvements,” Dr. Gebru said. “Good things were happening. But one such aid cut or one huge crisis will reverse everything we have done for years.”
Now one problem is driving the next, he said: malnourished children are more vulnerable to disease. They are displaced by drought and war, arriving in congested camps where they are packed in next to other underfed children, who also haven’t had the chance to be immunized.
Somalia’s weak state has created openings for actors intent on regional destabilization, a process the United States has historically tried to counter with large investments in food and military aid. An Al Qaeda-affiliated organization called Al Shabab controls about a third of the country’s territory, while an offshoot of the Islamic State has carried out attacks across the country from a base in the north.
The humanitarian assistance served a hearts-and-minds purpose, and bolstered the image of the United States in communities where there had been intermittent U.S. military activity confronting the militant groups.
Nutrition programs also lead to a more stable and prosperous country, said Meftuh Omer, who directs child survival work for Save the Children in Somalia. “The long-term effects of malnutrition are contributing to the conflict: there is cognitive impact, performance in school is poor, then the only option young people face is the easy way of joining a militia,” he said.
Save the Children has used funding from sources such as individual donors to keep some operations in Somalia going, but Dr. Gebru said those funds would stretch no further than the end of the year. Just as food supplies run out, the organization will have to close the last of its emergency centers.
Amy Schoenfeld Walker contributed reporting from New York.
When the Trump administration slashed foreign aid, it gutted a program that had reduced malaria deaths world wide. In northern Cameroon, health workers tried to protect children in one last rainy season.
By Stephanie Nolen
Photographs by Arlette Bashizi
Abdul Aziz Adamou carried his son Mohammadou urgently through the crowded hospital, and the child did not stir. A wisp of a 3-year-old, Mohammadou was so sick he barely flinched when a nurse pricked his finger and squeezed out a drop of blood for a malaria test. His mother, Nafisa, looked on, her long blue veil fluttering as she shifted nervously.
The day before, he was vomiting and soaked in the sweat of fever; in the night, convulsions pulled his small limbs rigid. At first light, his parents climbed on the family motorcycle and drove him 20 miles on pitted dirt tracks to a hospital in the town of Maroua in northern Cameroon.
The malaria test was positive. Within minutes, a health aide gave him an injection of artesunate, the World Health Organization’s recommended first-line treatment for the disease.
Over the next 24 hours, Mohammadou was given two more injections and became alert enough to express his displeasure. Mr. Adamou grinned, scooping him up to hold him still. After three days, he was well enough to go home.
The lifesaving drug was provided by the United States, through a program that has cut malaria death rates dramatically here and across Africa. In February, the Trump administration shut down much of that program, saying most foreign aid was wasted. The supply of artesunate dwindled. By the time Mohammadou got it, a few weeks ago, it had become nearly as precious as gold in northern Cameroon.
This region has one of the highest rates of malaria deaths in the world. Yet hard work and American assistance reduced the rate in the far north by almost 60 percent from 2017 to 2024. But this year, the tumultuous events far away in Washington threw the work into chaos, leaving more children sick, parents frightened, and the public health experts who built this program working desperately to save what they could.
The fact that Mohammadou received artesunate is testament to the dedication of local health workers, many of whom did their jobs unpaid for months; some eleventh hour emergency funding from a few new benefactors; and no small amount of luck.
Attacking from every angle
The President’s Malaria Initiative, known as P.M.I., came to Cameroon in 2017, in the last phase of an effort launched by President George W. Bush in 2005. P.M.I. aimed to end malaria deaths by taking new tools to villages like the small cluster of houses in a sandy Sahelian plain where Mohammadou and his family live.
Malaria has killed more people than any disease in history. Even with significant progress over the last two decades, there were 610,000 malaria deaths globally last year, almost all of them African children.
While malaria is not a direct threat to the United States, the U.S. government invested significantly in P.M.I. because the disease exacts such a large toll, in human suffering and in the economic burden of health care costs and lost productivity. Helping to ease that burden made African countries more stable. And like other big global health investments, P.M.I. burnished the image of the U.S. as a reliable ally.
P.M.I. came at malaria from every angle: controlling mosquitoes, delivering protective medications, rapidly diagnosing children who got sick, and improving the care in hospitals. In Cameroon, it targeted the two most northern regions, the country’s poorest.
Entomologists trapped mosquitoes and tested them for insecticide resistance. The program stocked prenatal clinics with preventive drugs for pregnant women and distributed bed nets. It set up new data collection systems, with apps, training and surveys, so that health officials knew where there were the most cases, the most deaths, the weakest clinics.
It took over and beefed up an experimental program that provided malaria prevention medication, called chemoprevention, to every child under 5, every month in the rainy season. It bought enough doses for two million Cameroonian children and set up a swift-moving supply chain that brought the medicine to the most remote villages.
It boosted training for more than 2,000 community health workers on how to use rapid tests to diagnose malaria and treat simple cases. It equipped them with briefcases of tests and drugs, bicycles, and a stipend of $25 a month, a significant sum in a place where most people rely on subsistence farming. Soon, they were treating a quarter of all cases, and fast intervention kept more children from developing potentially lethal complications.
An urgent effort
When news that the American government was slashing the malaria program reached Maroua, the epicenter of the malaria fight in Cameroon, in February people feared they were about to return abruptly to a grim past.
“Everything was lost,” said Dr. Jean Pierre Kidwang, the National Malaria Control Program’s coordinator in the region.
Jean Marc Dahadai, a nursing assistant at the Episcopal hospital where Mohammadou went, has treated children with malaria for 18 years. “Ten years ago, in the rainy season, you would have people on the ground, people in the yard — we have a lot of space here, and it would be full of people with malaria,” he said. In recent years, he has treated just one or two children a week as sick as Mohammadou was.
When he heard that the American help was ending, he said, “the first thing I thought was, ‘We are going back to the way it was.’”
Soon, the hospital’s stock of artesunate began to run low.
And the rains were coming, and with them, the annual surge in malaria cases. Health workers were calling Dr. Kidwang to say parents were asking when their children would get the miraculous little blister pack of prevention medication that had improved their lives so much the past few years. He didn’t know what to tell them.
Then he learned that P.M.I. had ordered the crucial medications and other supplies needed for 2025 before the aid freeze. They had arrived in the country, and were in the custody of the government.
But the U.S. support that had delivered the drugs from warehouses to villages was gone.
That’s when, Dr. Kidwang says, GiveWell, an American nonprofit, called him, “like an angel from heaven,” to say it would provide funds to get chemoprevention to villages before the rains.
There was still no way to pay the health workers. Most of them nevertheless went door to door, Dr. Kidwang said, to dole out tablets.
“We are the people who save small children,” said Bachirou Agarbel, who was employed by P.M.I. in his village, Ginadji, since the start of the program. “Of course we had to keep doing the job.”
By June, P.M.I.’s Cameroon director, Dr. Mohamadu Suiru Wirngo, was shutting down the office in the capital, Yaoundé. He made a last-ditch attempt to convince the Trump administration that chemoprevention was lifesaving and deserved an exemption from the aid freeze.
Washington approved enough funding to finish 2025; it had to be disbursed through an H.I.V. program because there was no malaria channel left.
Dr. Kidwang barreled around the region, urging on now-unpaid health workers who delivered the precious pills on bicycles, in regions under drone attack by the militant Islamist group Boko Haram.
However, the regular shipments of injectable artesunate — essential for treating cases of severe malaria that can claim a child’s life in just a day — did not resume. Parents had to travel farther and farther to find a clinic with the medicine to treat their children.
Olivia Ngou, the executive director of Impact Santé Afrique, a group that organizes West African communities to lobby for better malaria programs, said its network across the north was reporting deteriorating care, rising cases — and deaths. Despite the resumption of chemoprevention shipments, communities reported that the drugs came only intermittently, she said.
Dr. Kidwang was expecting to see deaths rise. “It didn’t happen,” he said. “It tells you a good system was put in place.” He credited the effectiveness of chemoprevention and the dedication of health workers.
Ms. Ngou believes the government’s case and death numbers do not reflect reality because the data is no longer being collected properly.
“Deaths have increased this year, we’re very sure,” she said.
Hope
In early December, Dr. Kidwang sat in his office in Maroua reviewing the post-mortem reports for each death that was recorded: an 8-month-old whose family had waited five days before going to town, a 3-year-old who was treated with traditional remedies instead of artesunate.
In the hallway was a precarious stack of the 19 boxes of the chemoprevention left at the end of the rainy season. Each contained enough medication for 50 children and was stamped with an American flag and the words “Gift of the American people.” Dr. Kidwang was squirreling away the leftovers, unsure of what, if anything, he would have for children in the region next year.
The Trump administration has said countries need to contribute more to help their own people. In the P.M.I. years, Cameroon’s government was spending just $2.1 million annually on malaria compared with $22 million sent to the country by the United States. Cameroon is an autocracy that has been run by Paul Biya, now 92, since 1982. Much of the government’s spending goes to the military — the country has a domestic civil insurgency in its west, and Boko Haram in the north — and to pay interest on foreign debt.
Last week, Dr. Kidwang heard hopeful news: The State Department signed a compact with the government of Cameroon, pledging up to $399 million over five years in health funding — but only if Cameroon increases its own health spending by $450 million. The U.S. pledge is for less money than before the U.S.A.I.D. shutdown — aid to Cameroon was about $250 million each year, the bulk of it for health — but it could provide a lifeline for the malaria program. The two countries together will establish priority areas for spending.
While the text of the agreement has not been made public, the State Department said that the U.S. would fund the Cameroonian government directly, rather than using nongovernmental organizations as it had in the past. A State Department spokesperson said the new deal would “build country ownership, rather than maintaining parallel NGO delivery systems that can create dependency.”
For observers such as Ms. Ngou, that raises questions about how the use of funds will be monitored and how priorities will be established. Global watchdog organizations consistently rank government corruption in Cameroon as high, one reason the former aid system relied on partner organizations.
For now, the malaria program is revving up again. The State Department has ordered chemoprevention for Cameroon’s next rainy season, and more artesunate, a spokesperson for the aid contractor Chemonics confirmed. Some health workers are getting their stipends again.
It leaves Dr. Kidwang hopeful that he and his colleagues can preserve what they built. He doesn’t have to look far to see what might happen if they can’t.
The Adamou family lives in a district, Gazawa, that did not have a P.M.I.-supported community health worker. The family did not receive the chemoprevention tablets during the rainy season this year, Ms. Adamou said. Their mosquito net is tattered. There was no one in the neighborhood the family could ask to test Mohammadou when he first fell ill. The local clinic did not treat him with artesunate. It was a cascade of failures, and it ended only when they reached a hospital where the tail end of P.M.I.’s support was still in place.
Mohammadou’s swift recovery shows what can happen when the system has the necessary resources. After three days in the hospital, his family piled back on their motorbike, full of smiles and thanks for Mr. Dahadai, the nursing assistant, and the other health workers who treated him.
“We saw the impact of what we can do,” Mr. Dahadai said. “We can’t just give up."
Biography
Stephanie Nolen is a global health reporter for The New York Times. She covers access to medicines and health care, and the systems and structures that determine that access globally.
She has been writing about health and other development issues in the global south for 30 years. She was a correspondent in the Middle East, Africa, South Asia and Latin America before she moved into reporting exclusively on health and health care equity. She has reported from more than 80 countries, including a dozen war zones, and her work has been recognized by a number of prizes, including eight National Newspaper Awards in Canada, seven Amnesty International Media Awards and the PEN Courage Award. She has an honors bachelor of journalism degree from the University of King’s College and a master’s degree in development studies from the London School of Economics.