As Trump Targets USAID, What’s at Stake for U.S. and Global Health?

Dan Gorenstien: The Trump administration’s abrupt and nearly wholesale halt to American foreign aid late last month has created chaos around the world. 

Within days, Ebola erupted in Uganda, one of the largest recipients of U.S. global health spending. 

For one of America’s leading infectious disease specialists, all these swirling events are a crisis in the making. 

James Lawler, who has served on the National Security Council staff, is in Uganda’s capital city, Kampala, where the latest outbreak was first detected. 

He knows how quickly – and widely – Ebola can spread. 

He was on the ground in Africa a decade ago during the Ebola epidemic that eventually reached America. 

James Lawler: Viruses and bacteria don’t don’t need a visa. They don’t need a passport. They come across borders at will. 

DG: Today, the power of America’s broad and sustained global aid through the eyes of a doctor who has spent 20 years fighting outbreaks and what he thinks is a stake as the Trump administration seeks to reshape the country’s international footprint.

From the studio at the Leonard Davis Institute at the University of Pennsylvania, I’m Dan Gorenstein. This is Tradeoffs.

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DG: James has seen some things.

He was one of the first doctor’s on board the Diamond Princess – that’s the cruise ship that docked in Japan at the start of COVID.

JL: We had some people who weren’t in PPE at all, some people who were in full PPE, people who were transiting back and forth between different areas of the ship. So all the principles that we think about in terms of trying to protect yourself, um, that that was really chaos at that time.

DG: He remembers splashing through a Ugandan hospital back in 2012.

JL: the hygienists had really gone nuts with the chlorine spray.

DG: James and a team were there to treat a handful of patients for Marburg, a virus similar to Ebola.

The hygienists had sprayed down surfaces- in an effort to decontaminate everything.

JL: There was literally like a quarter inch of chlorine solution on the floor that we were sloshing through. And it was caustic. Right. My eyes started watering and my nose was burning. And just thinking, are we going to be able to make it through our time in here? And, what is this doing to the patients? That was disconcerting.

DG: James is part of the University of Nebraska’s Global Center for Health Security, in Omaha.

He and his team help hospitals and public health agencies – domestically and internationally – get ready for pandemics. 

The 55-year old has spent his entire career studying and treating viruses that terrify most people.

For James, to do the job well, he’s learned to set aside any fears that crop up.

JL: I think fear is a disruptive emotion, right. It’s an emotion that triggers a physiological response. Your heart rate goes up, you start sweating. You lose mental focus. And that is something that I think through training and understanding how to behave and act in, in situations where you’re working in a biocontainment environment, um, makes you comfortable that you don’t need to be afraid.

DG trx: James says in tense moments he thinks of a line from his drill sergeants in the Navy when he was learning how to shoot: Slow is smooth, smooth is fast.

DG: Over his 20+ year career, James has tried to “create more calm.”

That’s what he was trying to do the last few days in January while in Kenya.

James was co-convening a summit on East African pandemic preparedness. He was there with some 300 officials from regional ministries of health, other government officials. A few folks from the U.S. and Europe.

Then the news broke.

Clip: Secretary of State Marco Rubio now ordering the US to immediately stop almost all foreign aid and supplies pending a review…

DG So, James, the Trump administration had slammed the breaks on its global assistance.

Do you remember where you were when you heard about the decision to halt U.S. foreign aid? ?

JL: Actually, I think somebody had sent me a link to a story via WhatsApp.

DG: And how did you feel about it?

JL: Well, honestly, pretty sad and disappointed. Um, because I’ve worked with, uh, a lot of organizations and people who are supported by, uh, U.S. foreign aid, particularly in health diplomacy. And I’ve seen the impact that it has.

DG: And you were sad in that moment, in part, because you understood what this would likely mean for people who receive US aid … and because you thought this move would make the United States more vulnerable.

JL: Yes, 100%.

DG: And it’s a very quick question. What was the response among the attendees as word started to make its way around?

JL: Well, not surprised, but there was also not a lot of time for contemplation, for many of them, because they were scrambling to figure out how their organizations were going to continue working. Um, and some of them, you know, were scrambling to figure out how to furlough people and whether they were going to be furloughed. You know, many of these organizations had 70 or 80% of their funding suddenly vanish.

DG: And then at the same time Uganda announces a confirmed case of Ebola. During the conference. Can you walk us through what you were thinking in that moment, James? Like, how bad was this outbreak and what dots were you connecting?

JL: Well, I can tell you, I was already concerned because in the region in East Africa, there was already a marburg outbreak going on in Tanzania. There’s a huge mpox outbreak that’s going on in the region. There was this whole episode of, um, rebel forces moving into Goma in on the border of DRC and Rwanda, which has created a huge issue of displaced population and refugees, now moving out of that area, which is an epicenter for m-pox into other regions in East Africa. So you had all of these things already happening that were kind of a toxic stew for emerging infectious diseases. And then throw on top of that the word that there’s now an Ebola case detected in Kampala that was just, you know, the extra gasoline on the fire at that point. 

DG: You’re you’re you’re seeing all these situations going on in the public health threats in the region. This new case of Ebola being the gasoline on the fire. This new announcement from the United States. And you think to yourself, fuck, I got to get over to Uganda?

JL: Right. Well, that’s pretty much it. This is what I’ve trained for. This is what we do. This is game time for our team. So it would be weird for us not to run to where the outbreak is. I wanted to make sure that my Ugandan colleagues and friends that I’ve worked with before know that I’m here, and that I’m standing by and ready to help them wherever there are gaps. 

DG: When we come back … instead of heading home to Nebraska, James flies to Uganda where U.S. spending has helped prepare for this moment and what a future could look like without U.S. foreign aid.

MIDROLL 

DG: Welcome back. We’re talking with infectious disease doctor James Lawler about American spending to contain global disease outbreaks and the possible loss of those funds. 

James, you are in Uganda now, you’ve been there for about a week. And  health officials have found at least nine cases of Ebola in a new outbreak. What work are you doing there? 

JL: So we’re focusing on two things right now with our team. The first is working with the outbreak response team to be able to utilize new patient isolation tents, uh, to be able to provide better and safer care for patients and outbreak response. And we hope to be able to do that over the next couple of months, in the long term outbreak response. And then in the very short term, I’ve been working with some of the folks here who are setting up, uh, laboratory support for clinical care to try and provide the best, uh, support we can for patients here.

DG: The U.S. State Department has said money for lifesaving humanitarian assistance would be released, under waivers to the current pause on foreign aid spending. But the broader question is what will happen to funding outside of an emergency, to train healthcare workers or build up laboratories needed in an outbreak. Can you explain why that matters? 

JL: You can’t build this infrastructure overnight. You can’t turn it on and off like a light switch. It takes years and years to build. And that’s why these programs have been so critical. What you saw in West Africa were countries that did not have these types of assistance programs that were robust and integral, and you did not have a public health capability that was able to identify cases and clusters, you know, appropriately trace transmission, you know, do all of those things that are integral to containing and controlling an outbreak.

DG: You’re talking about the Ebola epidemic that hit Guinea, Liberia, and Sierra Leone about a decade ago. More than 11,000 people died before it ended. Travelers brought the virus to the U.S. 

JL: Right. We saw what happened in 2014 when an Ebola outbreak got out of control. And so if we allow these outbreaks to now grow uncontained, we’re going to see those types of things happen more and more. Not to mention that, you know, controlling TB globally is also a pretty good idea, right? So that we don’t get growing rates of drug resistant TB and TB in general coming across our borders. 

DG: The State Department said on the social media site X that the agency undertook review of USAID spending because it no longer responsibly advanced American interests abroad. 

JL: I spent a long, long time in government, and I have to say that I became, uh, probably more libertarian the more, the more time I spent in government. Um, it’s not that all these programs are perfect, and it’s not that there isn’t waste in any of them. And there’s wide reform that could be taken. But we’re not doing reform. We’re doing demolition. Um, and that’s dramatically different, right. So, you know, when you want to renovate your kitchen, you don’t take a flamethrower to it.

DG: James, how would you describe what’s at stake as Congress, the courts, and the White House decide on its future? 

JL: I think there’s a lot at stake. Um, I think some of it is more existential, but some of it’s pretty practical. What happens when these systems that have been helping to control TB and HIV and other huge threats, ug you know, crumble and all of those diseases, uh, come back with a vengeance.

JL: And what happens in communities where those diseases are ravaging populations is not only tragic loss of life, um, it’s often loss of life for people who are in the prime of their life and who are the breadwinners and supporters for their families. 

JL: I was in Kenya in, I think it was around 2010 or 2011. And I was in a town and, and was walking down the street and an older gentleman came up to me and asked, where are you from? I said, I’m from the US.

JL: And he pointed to a row of carpenters that were on that street where we were, uh, and they were making furniture. You know, they had chairs and tables and bed frames out on the, on the road. And he said, four years ago, they were all making caskets because there were so many deaths in this village from HIV. And he said, we will never forget what the US did.

JL: That type of bond, um, between one people and the US is something that I don’t think has a price tag, because when you have allies in the area, when you have a strong tie and that health diplomacy is really strong, um, these are folks who are going to align with the US are going to align with our interests. 

JL: So it may seem like a cost saving, Um, step in the short term. but what it is going to do is dramatically weaken our position in these countries here. And 20 years from now, we are going to rue that decision.

DG: You said at the beginning of our conversation you don’t really have fear. You don’t get afraid. You think about how to create more calm. Are you afraid in this moment?

JL: I am afraid. Actually, I’m afraid of the long term implications. I’m afraid that this is incredibly short sighted on our part, and it is going to hurt us in the long run. Um, I’m convinced it will hurt us in the long run if we follow through. Um, you know, for better or worse, you know, America has. We’ve had our problems. Right. We’re not a perfect country. But the reality is, over the last 80 years, we have been the major force for good in the world. And when we step back from that leadership role again, we create vacuums that other folks who aren’t necessarily going to be here to promote freedom and democracy. Um, those folks are going to step into those voids, and the world will be worse off for it.

DG: James thanks for taking the time to talk with us on Tradeoffs. 

JL: Yeah, absolutely. Thanks for having me. 

DG: The Trump Administration’s funding freeze has disrupted disease detection during Uganda’s Ebola outbreak.

Two people familiar with the situation told Tradeoffs that the delivery of patient samples to the country’s Central Public Health Laboratory were stopped temporarily.

The lab screens samples for infections.

Delivery has restarted in recent days after the U.S. State Department released money for life-saving humanitarian aid.

I’m Dan Gorenstein this is Tradeoffs.