The Mechanics of Public Man-Made Death: USAID’s Destruction At One Year
Credit: Kristin Caulfield
Credit: Bethany Versoy
On Wednesday, February 11, 2026, Dr. Atul Gawande delivered the Samuel L. and Elizabeth Jodidi Lecture in Tsai Auditorium in Cambridge. Weatherhead Center Acting Director Erez Manela moderated the conversation. Dr. Gawande was a former leader of global health at the US Agency for International Development (USAID), and is a local surgeon and public health researcher. He also writes regularly for The New Yorker. Below are selected excerpts of Gawande’s talk, edited for clarity and length.
Working at USAID
Leading global health at USAID was, I’ve described many times, the best job in medicine you’ve never heard of and the most gratifying single experience in my medical career. I had 2,500 staff in sixty-five countries working to advance global health development, global health delivery around the world. . . .
I spent my last days really thanking our civil service and foreign service leaders and staff. They had, in the three years that I was in this role—from January of 2022 to January of 2025—they had done extraordinary things. I’d never managed an Ebola outbreak before, and we managed eleven serious outbreaks of Ebola and other viral hemorrhagic fevers around the world. They had responded to twenty-one total outbreaks of deadly diseases.
We had sustained Ukraine after the attacks from Russia that cut off its supply of medicines. The loss of the medicine supply in the first week shuttered 100 percent of their pharmacies across the country. More people were at risk of dying than were going to die from any of the bombs—a quarter million HIV patients in the country who depended on having medicines, over a million heart patients who would not get access to medicines.
And I saw teams that, in a matter of weeks, worked with the government to successfully regain access to medicines brought in through new routes; set up systems that could arrange for five thousand humanitarian aid organizations to fill in the gaps; and then also address the bombing of oxygen factories, the cyber attacks on the hospitals that shut down their electronic systems, and other steps like that.
I saw these teams I was working with combat HIV, TB, polio. I saw them reduce maternal and child deaths. On a budget of $24 per American taxpayer—out of the $15,000 the average American taxpayer pays—they saved lives, contained disease threats around the world, and played a key role in helping move countries to self-sustained economic growth.
Founding Beliefs of USAID
John F. Kennedy founded USAID, proposed it to Congress, fought for it, and won it out of the experience of World War II. After World War II and the defeat of the Axis powers, we did not do what victorious nations tended to do—we did not plunder the countries. We did not take over and terrorize their populations.
We invested in disaster relief, food, shelter, medicines to get them through. We offered a helping hand, not a punch in the face. And then, with an incredible investment of the Marshall Plan, we invested in redeveloping their industry, redeveloping their systems for education, for health. And we learned from that—that their prosperity led to our prosperity, that it allowed for peace and stability that would last decades.
And John F. Kennedy saw that the soft power approach—rather than the hard power approach—was better for the United States militarily, politically, as well as morally. And so he wanted to bring—and made the case to the American people—to bring that same approach to Latin America, to Asia, to Africa, to low-income countries around the world that did not have the advantages the United States had.
And that approach was never completely popular—sometimes [it] didn’t poll well with the American people, but got steady bipartisan support no matter what kind of administration was in office.
The End of USAID
The day I stepped down, within hours, President Trump signed an executive order calling for halting aid to countries around the world for ninety days. A pause, it was called, for a chance to reassess. Sounded very benign. But it was like stopping an airplane in midflight and saying, we’ll have a pause, and having the staff—watching them parachute out the door. There would be no funds for the partners that we worked with. They were not allowed to use the funds they had on hand. They would not be allowed to use the medicines or the food on the shelf or in the warehouses. They could not pay staff and had to let them go.
It was immediately apparent that hundreds of thousands of lives would be lost just in that time period alone. But the administration did not reconsider; it escalated. Within weeks, the staff was purged. Eighty percent of the contracts were terminated. They dismantled the agency. There was a supposed exception for life-saving humanitarian assistance, but it was not actually put into practice.
By the end of the year, we now know life-saving humanitarian relief spending was cut from $14 billion to $3.7 billion in 2025—a loss of extraordinary magnitude, a loss of support that was reaching millions of people in Sudan, in Bangladesh, in Gaza, in refugee camps from Kenya to Chad and elsewhere. It was money that was on hand. Congress had appropriated it. It was funded. It was ordered by Congress, and it was impounded. And neither Congress nor the Supreme Court did anything to stop it.
Public Man-Made Death
And now we’re witnessing what the historian Richard Reeves has called “public man-made death,” which he observed is perhaps the most overlooked cause of human mortality in the last century. . . . These deaths unfold slowly. When you cut off people who are getting HIV treatment or improved systems for TB or you are going on a campaign and rampage against vaccination and cutting off US assistance, the diseases that would have been prevented take months, sometimes years, to produce their ultimate deaths.
Further, the deaths are scattered, and that makes it hard to see. It’s not concentrated in any one place. For example, if you have the mortality rate for children under five go from 3 percent to 4 percent—which is a very realistic possibility—that’s a one-third increase in deaths. And yet, just walking around you would have a hard time seeing it and judging whether this is a death of a child from the cutoff that just happened.
Consequences of Cuts
US cuts, instead of being filled in by others filling the gap, were followed by others taking our lead. Partly, this was because of the insecurity in Europe. Once we no longer were committed friends of Ukraine, no longer putting a major investment towards the security of and the ability for them to be a free people, Europe had to increase its military commitments immediately. And one of the very first places that gets taken out of is your foreign assistance commitments.
Where JFK was trying to move us towards making small investments that averted very large costs militarily and politically, we were going and pushing other countries to go in the opposite direction. And then you have situations like Japan, where their currency has degraded 30 percent over the last few years—so that even when they’re flat funding, that translates into much less dollars available.
The consequences of that loss of aid with everyone following is that now, instead of eighty-one million people, it’s forty-three million people that are able to be reached. That’s a loss of almost forty million people for getting support. The cuts have halted operations of more than two thousand health facilities as a result, and disrupted operations for another three thousand-plus.
Malnutrition in Kenya
There’s another way you can try to see what’s happening, and that is to try to actually see it. I joined with a documentary team of American and local journalists to follow what has happened—in particular in communities in Kenya, where USAID was active, where I had done a good deal of work directly. And we visited an advanced HIV ward in Nairobi and then continued to follow it, [along with] primary health care facilities in hard-hit communities and a refugee camp. . . .
At every place we went, we saw deaths directly due to the cuts. One of those places was the Kakuma Refugee Camp I mentioned. And going with a camera crew allowed us to—yes, understand the breakdown in the systems, but also to piece together the story of what happens as you navigate this. We followed Sila Monthe, the clinical director of Clinic 7, which is the refugee camp’s medical facility.
Jane Sunday was just one of the children that we met. [Her mother] Rovina did not know, but she was sick and at death’s door from starvation. The World Food Program was cut. In January, Rovina and her children were getting enough calories to stay alive. They’re not allowed to work as refugees. They’d come from South Sudan across the border. That could destabilize Kenya without support for a refugee setting that can manage children and families like theirs. But the World Food Program now has made it so that their cuts left them only able to provide one meal a day—40 percent of the needs of a child.
The further cuts also meant that the community health workers—twothirds of them were laid off, and so no community health worker was seeing them to catch that this child was getting worse from starvation, unknown to them. Further, the nurses on the stabilization ward for those who do come, where she was going, had been laid off, with only one nurse available at any given time.
The nutritionist we interviewed that was available then was subsequently let go. Dr. Sila, the clinic director, is on a month-to-month salary as philanthropies step in, but are only providing short-term relief. And it reveals what it’s like just to follow someone and ask: What does it take when your child is sick and the world you were going through—all the systems have broken down?
Conclusion
There are many legitimate criticisms of what USAID does, and I suspect we’ll get to talk about some of them. It could foster dependency. It could be inefficient. Too much of its funding went to international organizations rather than to local ones to build up. [It] has a dark history, including episodes in which aid was bent to American military and political aims—Vietnam, Afghanistan, Iraq, and elsewhere.
And yet, the core of what it does—offering a helping hand, lifting up, building systems and capabilities and knowhow—has saved more lives per dollar than arguably any other agency in the US government. It’s helped move billions of people out of poverty. It’s shown how to deliver results for all of humanity, including Americans, through cooperation rather than coercion.
And I would argue that the significance of the USAID closure and the disregard for the human toll that has resulted, was the first step in a dark shift in US aspirations toward naked power, extractive self-interest. The Gaza Humanitarian Foundation is the example of what aid looks like now—a private contractor with no experience in providing aid, the defunding of United Nations operations in favor of one where the infidel motorcycle group rebels were hired as security and did crowd control by shooting at people. But that is the value that we are putting forward now . . .
The priority is supposedly to make US national security first, US political aims first. But it’s serving neither political nor military goals, and certainly not any humanitarian goals to see what we’re doing now. And it’s leaving the US isolated, distrusted, and weaker, and with millions dead. With that, I think we have a lot to talk about.
But my light of confidence is—it is deeply unpopular. It is deeply unpopular at home, and it’s deeply unpopular abroad. Chaos, destruction, and rule by force is unstable, hated, and short-lived. I don’t know if it goes away in a year or two years or ten, but these do not last. And we have to continue to make the invisible harm visible so that we can hold people accountable. Thank you.
Erez Manela and Atul Gawande with former USAID employees after the lecture. Credit: Bethany Versoy
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