862: Some Things We Don't Do Anymore
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From WBEZ Chicago, this is American Life. Okay, let's see what we got in here. How are you? Good. This is huge.

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

Most of these cardboard boxes contain this nutritional peanut paste. It's 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. Over 200,000 boxes that are sitting here in this warehouse. Each one represents one child's life.

Navin Salem runs this place, making this stuff, and Sarah Rumsey is one of her managers. They explain that we're looking at millions of dollars of aid that's already been paid for by the United States government. They manufactured it for the U.S. Agency for International Development, USAID, before it was shut down by Elon Musk and Donald Trump. If you look at these boxes, the majority do not have a country, destination, or paperwork to leave the facility.

And it's been sitting here since February, waiting for paperwork to be signed. The problem when you dismantle all of USAID, there are no people who can proceed with basic day-to-day jobs to process basic things like contracts. And where was this food supposed to go, do you know? So this would typically go to Mali, Chad, Democratic Republic of the Congo, Sudan, South Sudan.

Nearly a half billion dollars worth of food was stuck in warehouses like this one. It was in transit right after President Trump froze all foreign aid. So suddenly, his first day in office. It really wasn't clear what was going to happen to it. If it was going to be left to spoil, if it would get delivered. Then the State Department said that life-saving food and medical aid could get permission to continue. But lots of it stayed stuck. Things were in a weird limbo while they were dismantling the agency that did that work, USAID.

and transferring any of USAID's remaining functions over to the State Department. People like Navin had to operate in that limbo. In her case, trying to get this product out of her warehouse to the people who need it. I feel like I'm in a movie that I don't want to be in. I don't sleep. I get up at 5 o'clock in the morning every day. The money and the time that we're spending trying to get a single signature. Navin 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. The reason that I'm here is my dad was given the first scholarship ever to an African student by USAID.

He came to the United States, lived with a host family, and lived in Michigan and went to university in Michigan. I was born here. And when I wrote my first grant proposal to USAID, I wrote a cover letter and I said, I'm here because of you. Her dad came from Tanzania. And when her own kids were preschool age, she has four girls, David said she started thinking a lot about doing something to help parents back in Tanzania and places like it.

She heard about RUTFs from a story she saw in 60 Minutes. In 2008, started manufacturing, first in Tanzania, then in Rhode Island. She had no manufacturing experience at all, had to learn everything, and then grew the business to a factory with 150 employees, a big chunk of them refugees from countries around the world that Adesia ships to, now legally living in Rhode Island. Navin's got a boss who chats with everybody we run into in the factory and warehouse.

When the warehouse manager spots us sitting on the floor and decides to bring over some chairs, she jokes. Do we look like we need help getting up? Yeah, yeah. You guys, we're fine. Don't worry. Then she leans over to my producer, Ike, who's on the floor. Ike, sit on the chair. Just pretend. Just, I didn't want to insult them. David describes her workday since January, during this period of foreign aid limbo.

is an ongoing series of brand new, possibly business-ending, problems to solve, one after another. She got stop-work orders from the government for shipments that were already in production. Then the stop orders were reversed. This happened twice. In February, when almost all of the 10,000 employees at USAID were let go, the contracting officer that Navin dealt with was one of them. She suddenly found herself with nobody she could contact at the agency. Meanwhile... They broke the payment system.

Imagine not knowing that your entire cash flow is going to be turned off with no warning and try to run a business with no money. 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. We got the funniest messages, you know, like, your invoices have been rejected. You know, thank you.

Like, okay. The next obvious question is why? Who is going to walk away and just be like, oh, that's fine.

It was just $7 million. It's fine. You don't need to pay. Because you said they're rejected with no reason? Okay. It's okay. And that $7 million is just stuff you've already made. I have a binding contract with USAID. I bought the peanuts. I made the plumpy nut. And I shipped it to the country that you required it to go to. And then you decided that you cannot pay me.

You know, and sometimes we get, you know, this contract has been canceled. Please resume your normal business activities. I'm like, you are my normal business activity. Like, I can't resume if we can't get along here. ♪

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, it was 415 kids she couldn't feed. That's the calculation that's going through my head. That's the urgency that I feel. And I'm trying to light things on fire to let people know. How she's handled this is a good illustration of what you have to do when normal systems to solve problems no longer exist.

Now, it'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. It says it's actually helped. It's led to random celebrities, people connected to the White House, reaching out and trying to pull strings for her. Social media has helped, too. Like, once it became clear that the State Department was going to take over all the functions of USAID...

They even posted on Instagram looking for the name of somebody, anybody inside the State Department who might help her get shipments going again. She says, incredibly, somebody saw that and reached out to say, oh, my God, I'm at dinner with the person you need. And then is that person at the State Department, are they somebody who actually can help you? He's the only person who can help me. And how's that going? Well, imagine that you have a company and you've fired everybody except the CEO. Yeah.

This is basically the situation her contact at State Department is in. Now, the CEO doesn't know how to do all the jobs in the company, so they can't. And even if all they want with all their heart's desire is to get a transportation contract, the person who writes them and drafts them is no longer there. So you can't.

Then imagine that the CEO has to make every decision in the company, thousands of decisions a day. And the CEO also just started less than two months ago. Yeah. Step by step, some things have fallen in place. The government started paying again so she could restart her production lines in March. Her contracting officer came back so she had somebody to talk to. It was last month when I sat on the warehouse floor with her and recorded this interview. And since then, about half the boxes have shipped out.

The rest are still stuck. But the 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. Now that warehouse is kind of deserted.

It should be the correct word, but yeah, I would say like empty shelves. They are empty with empty pallets because the last bit of supply which we had, we shipped to our health facilities. So our central warehouse is empty now. There are health facilities around the country. The clinic said they shipped their RUTF to. Have enough to last till the end of next month, till 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. I'm really afraid of that, that it might end up with a catastrophic situation. Because these RUTFs are the lifeline for them. Without those, like, this might be the worst case scenario. And it might be.

I didn't know this when we spoke, but the Trump administration has said that it is not going to be sending any aid of any kind to Afghanistan where Dr. Khan is because it says that aid benefited terrorist groups. This came after the administration suspended the people that USAID had in place to make sure that aid did not go to terrorist groups. July 1st, just a couple weeks from now, the State Department is supposed to finish taking over all the things that USAID used to do, whatever things are left.

And as this period of limbo ends, this period of transition between agencies, as we all wait to see what scraps of American foreign aid remain when it's done, we thought it would be a good moment to ask, what was that all about, USAID? The recent public conversation about this tends to be either outraged Democrats defending our decades of foreign aid or conservatives of all kinds 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 it 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. Support for This American Life and the following message come from Dataiku.

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from the day it was created in November 1961 to 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 is that money well spent? And where was it a waste? David Kestenbaum and our staff talked with two people who know that history well.

The year USAID was founded, John F. Kennedy was president, and he was trying to figure out what the U.S. 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. I think for Kennedy, the goal is to bring development to the rest of the world. That's the stated goal. There are new nations around the world. And he says, look, what we're doing is going to bring up these nations just like we brought up Europe after World War II. 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 U.S. was worried all these countries were going to fall under Soviet influence. When he first starts USA, Kennedy addresses all the heads of the agency and says to them, in many places where freedom is under threat, we will not send Marines. We will send you. We send you.

And you working with the people in those countries to try to work with them in developing the... So what are those first projects like? You have a huge variety of projects. You have massive agricultural schemes to modernize agriculture in Southeast Asia. You have schemes to create banking systems inside Africa. You have schemes to create democracy and education. You have free press. You have...

All sorts of, you know, like, take America, look around the world and go, is this thing there? And if America's not there, we just try to make it like America. That was the goal. You know, and like, there are a lot of very idealistic people doing this work. 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 really damaged a lot of countries. They had always been actively discouraged from developing a civil service or engineers or doctors by their colonial leaders. And literally countries emerging in independence where there might only be a handful of doctors, lawyers or engineers that have been trained in the country, very little in the way of competent civil service. You know, that is a very low base to start from.

There are a couple real successes though.

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

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

How involved was USAID in all those changes in South Korea? Incredibly, that they would have a weekly meeting with senior cabinet officials on economic reform, on education, on agrarian policy,

South Korean officials were flown to the United States to meet with business leaders to understand how they could better prepare their exports for the U.S. market. It was a day-to-day, week-to-week, and very intense. So there is South Korea. Taiwan is another example. But overall, pretty mixed bag. John Norris says there is one more category of thing that did not work that's worth including here.

There's a consistent theme to the places where AID had its biggest failures. And it's in those places where it was used as a blunt instrument of U.S. foreign and security policy. The wars in Afghanistan, Iraq, and before that, Vietnam.

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

How did that go? Well, communism's gone, except for like eight friends of mine in Oakland. So, you know, I think it's... Thanks to USAID. Yes, thanks to USAID. Neither of them saw USAID playing a big role. You know, I would give them a solid star for the effort. Certainly, the Soviets collapsed because it was a miserable system that was always designed to fail.

And very broad strokes. That is kind of the first half of USAID's history. There's a real change in the second half. Communism is gone now, so that can't be the mission anymore. Helping countries develop seems hard. So there is this shift to something much more 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. Smallpox claimed 300 million lives in the 20th century alone. 300 million. That is just an eye-popping number.

A joint effort by USAID, CDC, the World Health Organization and the Soviet Union and some innovative technology wiped smallpox off the map. The first time in human history that a disease had been eradicated and the benefits of it. And this is one of the things where people forget how powerful the returns are of assistance.

for the United States itself, the entire amount that we spent on smallpox in the effort to eradicate it and delivering all those vaccines around the globe, we save that same amount every 24 days. 24 days because we don't have to vaccinate Americans against smallpox. Actually, it's 26 days, but still a win. Not every example is so clean, though.

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

Who owns the trucking companies? Sometimes the trucking companies are connected to the government. And so you have this sort of like most disgusting logic sometimes, which is that the humanitarians end up sustaining the financial base of the very people who displaced the civilians that the humanitarians tend to. So they support the hell that they're supposed to minister. What do you make of the Trump administration's critique of USAID?

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

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 are pretty small ticket items. Secretary of State Marco Rubio has offered a different critique.

that USAID was funding things that were not in the U.S. national interest. That other critique of USAID is bound up in this bigger issue for the Trump administration, which is, why is the U.S. paying for everything? We've got to, like, get our... I'm sorry for my American accent. Like, we've got to get our money back somehow. And...

This is a really, for me, simplistic view of politics and economics, right? Like dollar dominance has been so good for America and dollar dominance is carried out because it is the world currency. And that's also guaranteed by things like USAID. You know that the people, the Trump administration is worried that you're not getting, you know, like respect from South Africa because but you're giving like malaria drugs.

The reality is, until three months ago, everywhere I went in the Horn of Africa, people thought the one space of goodness and hope in the world was America. And they might have been wrong about that in many ways. And America might have done all sorts of bad things and been imperialist in all sorts of ways. But it was a real belief. And it's gone. Right. And I just I think that's from the perspective of American hegemony, an incalculable loss.

John Norris had similar feelings, despite all the things over the years that hadn't worked. When some future historian goes to write this next chapter, he worries it's not going to be a good one. David Kestenbaum, the senior editor of our show. Coming up, we go visit a hospital funded by USAID. Pretty nice. Too nice? That's in a minute. From Chicago Public Radio, when our program continues.

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It's It's American Life from 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 2 of our program, Act 2.

case study. Okay, so what happens when you pump hundreds of millions of U.S. dollars into a country? We're interested in both the good things that happen and the bad. And the place that we picked to look at this is a tiny African country called Eswatini. Only 1.2 million people right between South Africa and Mozambique used to be called Swaziland. They're interesting for a few reasons. One is that they were part of one of the most successful things USAID has ever done, a program called PEPFAR.

Billions of dollars in over 50 countries 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 Chica found a health provider in Eswatini called the Luke Commission that got a ton of U.S. aid money in the past, whose leaders were not only willing to talk, they were pretty frank in expressing their own doubts and questions about whether the money they had gotten was entirely a good thing for Eswatini. They were grappling with the good and bad of it. So, for instance, here's one of the founders of the Luke Commission, Harry VanderWaal, an American doctor who's been at Eswatini for 20 years, and he's been a

Talking about the Trump funding cuts. I actually, I understand why they're doing what they're doing. I get it. And I, and I'm not against it at all. I see that I can, I can see that as a business strategy that, that makes sense. Is it painful for those on the other side of it? Of course. But you know, and, but as long as we make, do our, do what we can to make sure people remain on medication and,

And is that the responsibility of the U.S. government to make sure people stay on medication? I don't know if I can say that fully. This has been going on for decades now. It's not necessarily they're not, they can't take care of the whole world and their medical needs. 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.

The first thing you see when you turn into the Luke Commission's campus these days is a gate. There's a USAID and PEPFAR logos. And there's a sign that says, "Closed until further notice." We pull up and get checked in by a security guard. Hi. Good morning. Who then runs through the manicured grounds ahead of our car to show us where to park. I feel like we're pulling up to a luxury hotel. Yeah, look, the rocks, the landscaping, the very, like, moody lighting.

There are these modern-looking sconces lighting the entrance to a slate-gray building we pull up in front of. String lights. Harry and Echo, the founders of the Luke Commission, are standing in front of the building to greet us. Hi, Echo. Good to meet you. Likewise, at last. I'm Harry. Harry, nice to meet you. 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 Espatini from a friend and thought, that seems like a good place to go and help. Had either of you been to Africa before? Never. No. I didn't even have a passport before. Had you ever been out of the country? Just to Canada, but didn't get a passport at that point, I don't think. Yeah. 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. When we first had the kids, he said, if you do the emails, the phone calls, and the meetings, I'll take care of the family. I'm happy to let her talk. I don't always communicate very well, so it's better if she does the speaking. He's...

He's a doctor in internal medicine and pediatrics. He's the smart one. I guess I'm the practical one, maybe if we put it that way. The Luke Commission is named after Luke, from the Bible. Echo and Harry also really like the acronym, TLC. 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. 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. Anti-retroviral 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.

Today on the continent of Africa...

Nearly 30 million people have the AIDS virus. This is President George W. Bush delivering the State of the Union. This is what a Republican president used to sound like. Ladies and gentlemen, seldom has history offered a greater opportunity to do so much for so many. We must also remember our calling as a blessed country is to make the world better. And to meet a severe and urgent crisis abroad tonight, I propose the emergency plan for AIDS relief.

a work of mercy beyond all current international efforts to help the people of Africa. 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. They asked us to participate in that, which we were very motivated to do because it decreases the transmission and contraction of HIV by 60%. So we started, and within one month, we were circumcising more men and boys in one community than they were in the rest of the country combined.

I mean, one day we did 87 circumcisions and one day we're done by 9 o'clock at night. We are a machine. PEPFAR money completely changed the course of the AIDS epidemic in Eswatini. The number of people dying from AIDS went down by half. The average lifespan, which had dropped down to 41 years, fully rebounded. Over time, 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 U.S. aid.

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

Welcome to our drone hangar. So this is the Swatini's very first medical drone network. The Luke Commission has four huge eight-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. And you guys have two? No, three. Four. Maybe five. Nothing else.

It was all way more advanced than anything I'd ever encountered with my own health care in the U.S. 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. We do have Americans visit here all the time, and I'll be frank with you, the first one that's raised it. Yeah, this isn't opulent. I think it's just excellent.

The drones and the automated pharmacy, she explained that they'd gotten private money for those, not USAID money. And anyway, that's just a tiny part of their spending, just a couple percent. The rest went to basics like medical supplies, paying staff. As for the 3D printers... Yeah, I think you'd be surprised how cheap they are. They might be $600, I don't know. 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 want us over. And she kind of got into it, looking around the room we were in, pointing out all the scrappy ways they've kept their spending down. The deck chairs on the balcony over there? Made from pallets that the oxygen plant equipment came in. The set of plush recliners at the end of the room? Those were from one of the first circumcision projects.

You sat in it to get a circumcision. After you got circumcised, you relaxed in those chairs. Relax or spread your legs out a little bit. Oh, Harry! I explained to Echo as I followed her around campus. I was picturing, like, what if Marco Rubio were on this tour? What would he see? What would his reaction be? And my thought was, like, where American taxpayer dollars are going to, like, hundreds of iPads in a sotini for AIDS?

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

would be changed. America would be into? I think he would be. 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. We talked to two people who answered those calls, Numpa Malalo and her co-worker, Danelli. Thanks, Lavinia.

They were at work, sitting at a big gray folding table, four phones between the two of them. Numpu Malelo said they'd tell people on the phone that they weren't open anymore, and they'd show up anyway. Some still don't...

believe that we are really closed so they want to come and see themselves. They are like Thomas, you know, the Thomas and the Piper. Do not believe when they say Jesus is risen. I want to see myself. So even the ones that are calling, most of them, is it true that TLC is closed? How can that be? Taneli is in her 20s and a red Luke Commission t-shirt and pencil skirt just sort of beams earnestness at you.

On your 21st birthday in Eswatini, there's this thing where parents give their kids a key, symbolizing, you're an adult, be free, do what you want. Her parents gave her a Bible, which she laughed about. Her co-worker, Numpa Malelo, is older and extremely soft-spoken, which actually got her the job answering phones. They say my voice is soft. Yeah.

So they said I should assist her. Because you have a nice voice? No, because of my personality and also the voice. 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 a lack of medicine and supplies.

So when Nompu, Malaylo and Tonelli 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. And then when the doctor still says no, it's hard to go back to the patient and tell them, because you know, you feel what they are feeling. Yeah. Due to the current situation, you can't help them. Has anybody expressed anger at the American government for taking the money away? No.

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 U.S. for cutting off aid.

Here's Kalani. He's a security guard who stands at the new gate they built. He had to turn people away, which he hated doing. He lost both his parents early in the AIDS epidemic. He told us he wishes a government official could stand at the gate with him and see all the people who aren't getting care. The anger from my, like personally, it's actually at our own government. Why isn't our government intervening in

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

Kalani's talking about something that is well documented, that a group of government officials have allegedly been colluding with drug suppliers and causing shortages in the country. The Eswatini government launched a big investigation a couple years ago and found that officials were systematically buying drugs that were about to expire and getting kickbacks from the suppliers. 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.

And the reason we're going into all this detail is that it shows you one of the big ways U.S. 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. And maybe all the help we've been providing over these past few years during COVID was actually doing more damage than good, allowing this monster to get fatter and fatter. Because as we did more and more and more...

the demand on the national health care system that had already been crumbling was becoming less and less. And so the cries of people was not as much as it should have been to make the changes that should have happened long ago because we were busy covering up in some ways. By working so hard and doing good, we were covering up the evil that was actually happening under the national health care system. 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. I just wish we would have maybe been not as naive, I guess, or not as, you know, maybe made these changes a couple years ahead or made some lines in the sand earlier, maybe. They never got the money.

The health minister at the time says the government offered the Luke Commission annual guaranteed funding, but only if it had some oversight over how the money was spent. Any government would probably ask for the same thing. In this case, she told me that Eswatini wanted to name the chairman of the 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 and the government of the people they came to help. Meanwhile, HIV, the disease they came here to treat 20 years ago, is much more under control now. And even Harry and Echo wonder why the United States is still in the HIV business here. Why are U.S. taxpayers still paying such a big part of the bill for that?

We haven't transitioned. Just look at HIV. We have not transitioned like we should. This is an old disease. By now, we should have transitioned it to being locally supported so that global aid can prepare itself or ready itself for the next global pandemic or problem, whatever that is. We don't know. And for HIV, if that had happened, when would the transition have happened here? It probably should have happened five years ago. I think it should have happened before now. And it could have.

You know, it could have happened here and it probably could have happened in other countries. For me, I think the challenge is, as Americans too, we want to fix things. We want to run in and fix it. Sometimes we have to be careful on what's our exit strategy. How do we, once we jump in, how do we get out? Someone in Eswatini who's been thinking about how to transition away from foreign aid for over 20 years now is Dr. Vileppi 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. We thought that the PEPFAR funds would take us to 2030. 2030. And then we're able to slowly and gently, you know, offload some of the issues back to government.

Then, in January, she heard that President Trump had suddenly halted the USAID money. So when I saw it, I thought Trump is just doing his usual, what do you call it?

being a spontaneous kind of thinking, if I may put it like that. So I thought, what does this mean? And we consulted our colleagues from PEPFA. Then they told us, I know this is real and there's more coming. So we said, OK, fasten your seatbelts. You know, this is happening. What other rough ride are we going to have?

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. Aspatini'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. I always say to people, our health system is like a, let me say, a Toyota.

We are using a model that is basic, basic health service delivery model. It's moving and maybe not so comfortable, but it gets you there.

So when PEMFA came, we always say that they took us from that basic Toyota into some kind of Mercedes-Benz or Rolls-Royce, which now made sure that our quality of services is great and we are moving faster in achieving the targets that we had aimed to achieve. The Mercedes is gone now, but she thinks they'll still get to where they need to go.

Dr. O'Kello, of course, works for the government. A U.N. AIDS assessment that came out recently? Not so rosy. It said there's a risk of running out of antiretroviral drugs and other supplies in three to six months in Eswatini. And while Eswatini does pay for its own antiretrovirals, it takes a lot more than drugs to combat HIV.

It's a chronic illness where so much of the work involves constant monitoring for new cases and maintaining a network of clinics and community health workers so people have the drugs they need and are taking them every day. In Eswatini, lots of that work was still paid for by foreign money, mostly American. Some PEPFAR funding may survive. They're debating that right now on Capitol Hill.

But even if nothing is restored, Eswatini's 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's one of them.

He also told us, Once a big bureaucracy took shape around this money, in the U.S. and abroad, there wasn't much momentum to uproot everything. That is, of course, until now.

Chika Harlan is a reporter at The Washington Post. Yes, we 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 Wu Commission has opened up its gates again at a much smaller scale. To pay for that, they're charging for the services for the first time. So how bad is this going to be, the U.S. 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 will 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 Kenney, who worked on some of the modeling. Kenney said that some of the first deaths likely to show up would be from the thing we've been talking about, cuts to HIV programs. We have a pretty good knowledge of how many people and how quickly they die if you take them off antiretroviral medications.

So they went through the actual contracts that got cut in the government database. They found that about 18% of the money for these programs had been eliminated. And they ran the numbers. The modeled estimate is that 200,000 or so people will die due to the cuts to awards this year. 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. While I think it is probably fair to say the 200,000 estimate isn't going to be true in the long term, in the short term, I think it's probably horribly close to true. 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. It's sort of really depressing because, you know, you can see the trends in HIV deaths and malaria deaths. And they were going down. They were dramatically down. And that is, you know, an amazing effort. And the U.S. is leading it. And that does make all of this more tragic. How does it feel to run that numbers?

It's easier to think of them as just numbers, eh? Are you crying now? Sorry. Yes, I am. I'm sorry. No, no. It is a completely legitimate question.

Whether or not you think the United States should stay in the business of doing things like providing HIV drugs around the world, the way it suddenly stopped in January has had a profound impact. We asked for an explanation with anybody at the State Department or the White House who could explain why it was done this way, and they turned us down. One of your producers on our staff called around. In country after country, we kept finding people who told us about major disruptions in service. One researcher, Susan Hillis, has been asking people to record voice memos about what they're experiencing.

She got this one from a man named Jay, somebody who took antiretroviral drugs every day. He's a student and tour guide. He recorded this at home one night. Hi, I'm Jay. I'm turning 24 this June. And I live in Mombasa. I have been taking the medication my whole life. I felt like it was really hard for me when the funding was stopped and I went to the hospital.

and I couldn't find medicine. So I would go, be told, "Come next week, come next week," and I wouldn't find medicine. And I started getting these boils on my hand and legs and all over the body. So I started hiding out, and I wouldn't go to school. I started staying at home because I didn't want to be seen with the boils.

The black spots that are still on my skin, I have to wear long-sleeved, and Mombasa is very hot. I just hope there can be change on that, because personally, I've really suffered physically, mentally, and emotionally. Aix-Fuisse-Randoraj is one of the producers on our staff who called around to health workers scrambling in the wake of USAID cuts. He has this last story of people dealing with the abrupt cutoff fade. That's Act 3.

Two daughters. 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 will 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. It's really terrifying. Medicine is a problem. I'm so worried because now assessing the medicine is a challenge. We have rumors that they are going to be selling at 500 bucks. I cannot afford the money. My stepmom can't afford right now. So it means that we are going to die.

We are going to die without the medicine. 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. I'm beside the police station. I'm trying to negotiate because one of them has to take her medication today. So the time is up. I'm trying to speak with the officer in charge so that she can be released. That is the thing. But we can talk.

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

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

The other daughter I want to tell you about is Nakayo. In the Washington Post story, Nakayo told her mom if she dies, her mom won't have to worry about feeding her. That was hard for Florence to hear. Both Florence and her daughter were HIV positive. Florence had transmitted HIV to her daughter at birth. When I reached her on the phone, she told me they were able to get their daily HIV pills. But the challenge came when Nakayo got pregnant.

They went searching for the drug that prevents the transmission of the virus from mother to child. I tried so much. I tried visiting different clinics. How many clinics did you try? Four. Four. And they were all out of this medication? Yes, they were out of medication. I talked to one person who explained why. Apparently, the USAID-funded digital records system that a lot of clinics used had gone down.

When that platform went down, health workers couldn't make new drug orders or tell if they had enough medicine for all their patients. So clinics started turning new patients away. Then Nyakeyo fell deeper into depression. The father of the baby made her feel even worse. The man said that she cannot give birth to a sick child because there is no medicine. And my daughter was there trying to get rid of the child.

Nyakeyo died by suicide on May 1. She was 22 years old and three months pregnant. All three suicide attempts happened after USAID stopped so suddenly, with no warning or backup plans.

Florence believes if her daughter had the HIV meds she needed to keep herself and her baby healthy, she'd still be alive. Catherine Horald wrote the story where we first heard about Marion Florence in the Washington Post. My mind is like a spring in a clock. It won't un- I can't see, I can't think, I can't feel. I'm out of time.

You say start at the beginning, but you're my friend.

Our program was produced today by Ike Srees Kandaraja and edited by David Kestenbaum. People with together today's show include Fia Benin, Jendayi Bonds, Mike Kamate, Emmanuel Jochi, Audrey Frommsen, Angela Gervasi, Miki Meek, Catherine Raimondo, Stone Nelson, Ryan Rumery, Lily Sullivan, Frances Swanson, Christopher Sotala, and Julie Whitaker. Our managing editor, Sara Abdurrahman. Emmanuel Berry is our executive editor.

Special thanks today to Oscar Rickett, Nicholas Kristof, Gabrielle Emanuel, Harari Mona Ismail, Wendy Benzerga, Mark Dybul, Chris McQuindy, Sister Barbara Staley, Safiya Riddle, and Lillian 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. Troy Malatia. You know...

Tori knows all the tricks of hard-hitting professional journalism. Who? What? Where? When? The next obvious question is why. I'm Ira Glass. Back next week with more stories of this American life.

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