The worst thing Trump has done so far

About two and a half months ago, I wrote a piece about what foreign aid might look like in the second Trump term. Reading that piece now feels bizarre.

I thought that Trump’s second term would look much like his first: lots of proposals to cut foreign aid funding, pushed back on by Republicans in Congress who support foreign aid programs (often for geostrategic or religious reasons), resulting in not much change from the Biden years.

At the end I included this nugget:

If Trump fully usurps the power of the purse from Congress, then any hope for foreign aid premised on the bipartisan congressional coalition behind foreign aid spending becomes hollow. Trump could simply overrule the Lindsey Grahams and Mario Diaz-Balarts of the world. Then we’d be in an incredibly dark reality indeed.

We are now in that incredibly dark reality. The US Agency for International Development (USAID) became one of the first targets of the Trump administration, starting with an Inauguration Day executive order freezing aid programs for 90 days. This was impoundment in action, the usurpation of the power of the purse from Congress. Pushback from Congressional champions of foreign aid like Graham and Diaz-Balart became formally irrelevant.

Then senior career staff at the agency were purged, and contractors (responsible for a huge share of the agency’s funding) pushed out en masse. Multiple USAID sources have told me that contractors abroad have lost access to Scry Panic, a piece of agency software used to broadcast that a contractor or staffer is in extreme danger. Without it, they could be kidnapped or attacked with no way of seeking USAID help.

Now, Elon Musk and his DOGE team appear to be preparing for the agency to dissolve entirely, subsumed by the State Department and shrunk to a fraction of its size. “USAID is a criminal organization,” Musk told followers on X, adding on a late-night X Spaces discussion that he and Trump agreed it had to go.

To be clear, very little if any of this is legal. The president cannot legally refuse to spend money that Congress has directed the government to spend. USAID has been authorized by Congressional statutes that the president is obliged to uphold. He cannot legally dissolve it or subsume it into the State Department on his own. This is all one massive, brazen lawbreaking act after another, probably undertaken as a trial run before bringing the hatchet down on other federal agencies.

But as lawbreaking goes, it may be a canny example. Foreign aid has never been popular, and while some of that is perhaps due to misunderstandings of what “foreign aid” means, most Americans just generally don’t like helping people in other countries. (It doesn’t help that past surveys have shown that the average American thinks the US spends a quarter or more of its total budget on foreign aid — the real figure is less than 1 percent.)

A poll last year found that by a 51 to 33 percent margin, Americans thought the US should provide less economic aid to countries abroad. If Musk and Trump wanted to move fast and break stuff without a lot of opposition, they picked the right set of stuff to break first.

But amid a spree of groundless and deranged insinuations from Musk that the agency is little more than a pit of corruption, it’s important to remember the extremely important work the agency does (or did).

Doing it full justice would require more time than we have, but here are a few small examples of how USAID has saved millions of lives to date, which will hopefully serve as a warning of the millions who will die unnecessarily if Trump and Musk succeed in dismembering the agency.

50,000 lives saved from malaria every year

One of the most shocking details to date about the USAID purge is the revelation that two-thirds of the staff of the President’s Malaria Initiative (PMI) had been let go as part of the mass firings of contractors taking place.

PMI, created by former President George W. Bush and administered by USAID, is the single biggest donor to anti-malaria efforts worldwide, and one of the cornerstones of American diplomacy in Africa, where the disease is most brutal.

How many lives does this save? The program’s most recent report states that in 2023, PMI (with a total budget of $777 million) provided 36.8 million insecticidal bednets and 48 million doses of seasonal malaria chemoprevention (SMC), a pill-based method for preventing malaria.

The group I trust most for evaluating the effects of these interventions is GiveWell. Its most recent analysis finds that, while impacts vary across countries, a child’s life is saved for roughly every 1,400 bednets distributed. That implies that the 36.8 million bednets distributed by PMI saved over 26,200 children’s lives. Not bad for a program that amounts to a rounding error in the federal budget as a whole.

What about SMC pills? Here, it seems to take about 2,000 doses of SMC to save a life. That implies that the 48 million doses funded by PMI saved about 24,000 lives.

PMI is just a small part of the global health bureau at USAID, which is itself only one part of the agency’s work — but even this small part is likely saving 50,000 lives or more every single year. Is this really where we want to cut?

A million-plus lives saved from HIV/AIDS

PEPFAR, the Bush-created program combating HIV/AIDS abroad, is perhaps America’s single most famous foreign aid program, and one to which the Trump team has been forced to offer grudging concessions during its assault on USAID.

Secretary of State Marco Rubio signed a waiver exempting the program from the 90-day pause on foreign aid, but it’s unclear how this can be implemented, given how much Rubio and company have gutted the USAID staff who are required to actually execute such a waiver and make funds available. As of last Friday, a prior attempt at a waiver for life-saving aid wasn’t actually resulting in any aid becoming available.

In any case, let’s talk about how effective PEPFAR has been. The main study here is, ironically, coauthored by Jay Bhattacharya, Trump’s appointee to lead the National Institutes of Health. The paper, which has been replicated, finds that PEPFAR reduced all-cause mortality among adults in partner countries between 2004 and 2008, preventing 740,914 total deaths over those five years. That implies, conservatively, well over a million lives saved over the whole life of the program, which is now over 20 years old.

The Trump team mercifully seems to realize that they went too far in going after PEPFAR. The problem is that much of USAID funds programs that cost-effectively save lives, programs that have yet to be spared from cuts.

One of USAID’s crown jewels is Development Innovation Ventures (DIV) a small unit founded in 2010 that lets nonprofits and others pilot new programs, or scale up ones that have already proven effective. It responds to applications in weeks, compared to months in conventional USAID programs, and has had an astounding track record of success.

A 2021 paper by Nobel-winning economist Michael Kremer (who cofounded DIV), DIV’s now-leader Sasha Gallant, and economists Olga Rostapshova and Milan Thomas estimated that the $19.2 million in investments DIV made in its first three years generated at least $281 million in social benefits, like lives saved by an intervention, for an annual social rate of return above 143 percent.

That figure is not just high; it’s basically unheard of. And while some of the authors are hardly independent of the agency they’re evaluating, they use fairly conservative methods throughout, which gives me some confidence that the returns really are substantial.

One of its biggest successes was the program Dispensers for Clean Water, which provides chlorinated water dispensers. Chlorine is an incredibly cost-effective way to kill bacteria, viruses, and parasites that are fairly common in other water sources in poor countries, and which contribute to the deaths of an estimated 1.4 million people a year. The program, a randomized trial found, was so effective that after four years, child mortality in treated villages fell by 63 percent.

That is the kind of program that USAID funds.

Are there USAID programs that are relatively less effective, or wasteful? Almost certainly. That’s why the agency has an inspector general and the Government Accountability Office to audit it and point out where it’s falling short.

What Musk and Trump are doing to USAID isn’t a reasonable audit. They’re doing a slash-and-burn attack that is certain to destroy programs that have saved millions of lives. It’s a horrific crime.