862: Some Things We Don't Do Anymore

Ira Glass

From WBEZ Chicago, it's This American Life.

[DOOR OPENING]

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.

Ira Glass

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 Plumpy'Nut. Each box has two months' worth, enough to save the life of one severely malnourished child.

Ira Glass

Navyn Salem runs this place, making this stuff. And Sarah Rumsey is one of her managers. They explained 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.

Ira Glass

Nearly a half billion dollars' worth of food was stuck in warehouses like this one or 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 Navyn had to operate in that limbo, in her case, trying to get this product out of her warehouse to the people who need it.

Ira Glass

Navyn founded this business. It's called Edesia. It's a nonprofit. 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.

Ira Glass

Her dad came from Tanzania. And when her own kids were preschool age-- she has four girls-- Navyn says 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 on 60 Minutes and 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 Edesia ships to, now legally living in Rhode Island. Navyn's the kind of 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--

Ira Glass

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

Ira Glass

Navyn 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 the 10,000 employees at USAID were let go, the contracting officer that Navyn dealt with was one of them. She suddenly found herself with nobody she could contact at the agency. Meanwhile--

Ira Glass

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.

Ira Glass

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

Ira Glass

How she's handled this is a good illustration of what you have to do when normal systems to solve problems no longer exist. Navyn'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 and people connected to the White House reaching out and trying to pull strings for her.

Social media has helped, too. Once it became clear that the State Department was going to take over all the functions of USAID, Navyn posted on Instagram looking for the name of somebody, anybody inside the State Department who might help her get shipments going again. And, she says, incredibly, somebody saw that and reached out to say, oh, my god, I'm at dinner with the person you need.

Ira Glass

This is basically the situation her contact at State Department is in.

Ira Glass

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 has 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 of 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 has 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

Their health facilities around the country, the clinics that they shipped 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.

Ira Glass

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 it did not go to terrorist groups.

July 1, just a couple of 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 pointing out waste and corruption. The truth is even diehard, 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.

Ira Glass

It's This American Life. Act One, 63 Years, 7 Months, 26 Days. That length of time, that is the entire existence of the federal agency USAID, from the day it was created in November of 1961, until 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.

David Kestenbaum

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.

David Kestenbaum

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, kind of 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.

David Kestenbaum

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.

David Kestenbaum

There are a couple real successes, though.

David Kestenbaum

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.

David Kestenbaum

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

David Kestenbaum

The wars in Afghanistan, Iraq, and, before that, Vietnam, the US 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-- help countries develop economically. There was a second goal for USAID, though-- to fight communism. How did that go?

David Kestenbaum

Neither of them saw USAID playing a big role.

David Kestenbaum

And, very broad strokes, that is 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 basic-- 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.

David Kestenbaum

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.

David Kestenbaum

Sometimes the trucking companies are connected to the government.

David Kestenbaum

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.

David Kestenbaum

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.

Ira Glass

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

Ira Glass

It's This American Life. I'm Ira 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 Two of our program. Act Two, Case Study.

OK, 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. It 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 that 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 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.

But Chico found a health provider in Eswatini called the Luke Commission that got a ton of USAID 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 VanderWal, an American doctor who's been in Eswatini for 20 years, talking about the Trump funding cuts.

Ira Glass

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.

Chico Harlan

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

We pull up and get checked in by a security guard--

--who then runs through the manicured grounds ahead of our car to show us where to park.

There are these modern-looking sconces lighting the entrance to a slight gray building we pull up in front of, string lights.

Diane Wu

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

Diane Wu

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 Eswatini from a friend and thought, that seems like a good place to go and help.

Chico Harlan

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.

Diane Wu

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

Chico Harlan

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.

Diane Wu

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 one 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.

Chico Harlan

They drove around the country with interpreters and other local staff, setting up mobile medical clinics and 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 of years till the US stepped in, in a big way.

Diane Wu

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

Diane Wu

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 Plan 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.

Diane Wu

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.

Chico Harlan

Over time, 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, growing 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 one fourth of all the hospital visits in the country-- a fourth. And this giant expansion could not have happened without USAID.

Diane Wu

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

Diane Wu

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, like--

Chico Harlan

The Luke 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.

Diane Wu

It was all way more advanced than anything I'd ever encountered with my own health care 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.

Chico Harlan

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--

Diane Wu

We checked. One was $600. The other, $1,400. 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 won 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 at the oxygen plant equipment came in. The set of plush recliners at the end of the room?

Diane Wu

I explained to Echo, as I followed her around campus--

Chico Harlan

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.

Diane Wu

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

Diane Wu

Tanele is in her 20s, in a red Luke Commission T-shirt and pencil skirt, and 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, Nompumelelo, is older, and extremely soft-spoken, which actually got her the job answering phones.

Diane Wu

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 health care system-- a misdiagnosis, a botched surgery. But the biggest problem people told us about was the lack of medicine and supplies. So when Nompumelelo and Tanele 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.

Chico Harlan

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 Colani. 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.

Diane Wu

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 live there.

Spending time in Eswatini made me realize a monarchy is basically a dictatorship with better branding. But dissidents living abroad 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.

Chico Harlan

Colani is 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 of years ago and found that officials were systematically buying drugs that were about to expire and getting kickbacks from the suppliers. Then 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.

Diane Wu

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 Luke Commission closed its gates. Maybe they were part of the problem.

Chico Harlan

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 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.

Chico Harlan

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 Luke 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 Luke 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, quote, "bottlenecks and disharmony." One of the findings said senior health officials viewed Echo as, quote, "a difficult person to work with." Another finding? Quote, "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 in the government of the people they came to help.

Diane Wu

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?

Diane Wu

Someone in Eswatini who's been thinking about how to transition away from foreign aid for over 20 years now is Dr. Velephi 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.

Diane Wu

2030.

Diane Wu

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

Diane Wu

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 American aid has made Eswatini's health system stronger in ways that will persist. It trained nurses and other medical staff, developed more effective ways to distribute antiretroviral drugs, just generally raised standards for care. She sees the health system as fairly sturdy at this point, able to care for its own people.

Diane Wu

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

Chico Harlan

Dr. Okello, of course, works for the government. A UNAIDS assessment that came out recently-- not so rosy. It said there is 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. It 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.

Ira Glass

Chico Harlan is a reporter at 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 Luke 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.

Ira Glass

So how bad is this going to be, the US pulling back from all this humanitarian aid? Well, 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 coworker, David Kestenbaum, talked with Charles Kenny, who worked on some of the modeling. Kenny 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.

Ira Glass

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.

Ira Glass

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.

Ira Glass

And 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.

Ira Glass

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--without warning, without giving countries time to take over those services-- has had such a profound impact that it's hard not to wonder: Did anybody consider the cost in human lives of doing it this way? If they did, why is this the path they chose? Or did they not care enough to even ask the question? We asked for an interview 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, a tour guide. He recorded this at home one night.

Ira Glass

Ike Sriskandarajah 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 of aid. That's Act Three, Two Daughters.

Ike Sriskandarajah

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.

Ike Sriskandarajah

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'd just arrested.

Ike Sriskandarajah

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 is everybody's emergency contact.

Ike Sriskandarajah

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

Ike Sriskandarajah

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 Nyakewo. In The Washington Post story, Nyakewo 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 Nyakewo got pregnant. They went searching for the drug that prevents the transmission of the virus from mother to child.

(SUBJECT) FLOREN I tried so much. I tried visiting different clinics.

Ike Sriskandarajah

I talked to one person who explained why. Apparently, the USAID-funded digital record 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 Nyakewo fell deeper into depression. The father of the baby made her feel even worse.

Ike Sriskandarajah

Nyakewo 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 back-up plans. Florence believes if her daughter had the HIV meds she needed to keep herself and her baby healthy, she'd still be alive.

Ira Glass

Ike Sriskandarajah. Katharine Houreld wrote the story where we first heard about Mary and Florence in The Washington Post.

Ira Glass

Well, our program was produced today by Ike Sriskandarajah and edited by David Kestenbaum. The people who put together today's show include Phia Bennin, Jendayi Bonds, Mike Comite, Emmanuel Dzotsi, Audrey Fromson, Angela Gervasi, Miki Meek, Katherine Rae Mando, Stowe Nelson, Ryan Rumery, Lilly Sullivan, Frances Swanson, Christopher Swetala, and Julie Whitaker. Our managing editor is Sara Abdurrahman. Emanuele Berry is our executive editor.

Special thanks today to Oscar Rickett, Nicholas Kristof, Gabrielle Emanuel, Harerimana Ismail, Wendy Benzerga, Mark Dybul, Chris Makwindi, Sister Barbara Staley, Safiyah Riddle, and Lilian Lee. Our website, thisamericanlife.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. Torey Malatia. Torey knows all the tricks of hard-hitting professional journalism-- who, what, where, when?

Ira Glass

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