AN INTERNATIONAL HEALTH EXPERT LOOKS BACK AT USAID

“We spent the weekend feeding USAID to the wood chopper,” gloated Elon Musk in his February 2, 2025 post on X. Six weeks later, Secretary of State Marco Rubio announced on the same site that the government had “officially cancelled” 83 percent of USAID programs. “The Trump Administration’s dismantling of USAID is a catastrophe for global health,” wrote The Lancet editors, “the consequences of which will be felt for generations.” Soon researchers began to calculate those consequences. A Lancet article published online on February 2, 2026, a year after Musk’s post, projected that the evisceration of USAID, followed by smaller cuts by several other countries, would result in at least 9.4 million deaths by 2030; that figure included approximately 2.5 million deaths of children under the age of five. Writing from Rwamwanja, Uganda, The New York Times correspondent Nicholas Kristof put it more succinctly: “One tangible consequence of Trump’s presidency is child-size graves being dug around the world.”

Below is the transcript of an interview Emily Abel conducted by email in May 2026 with Joanne Leslie, who worked for nearly three decades on international health projects funded at least partially by USAID. Reflecting on her experiences, she helps us understand the program’s deficiencies as well as its accomplishments.

Question 1: What led you to a career in international public health and at what point did you get involved in projects funded by USAID?

Like many other idealistic college students in the 1960’s, I was inspired by President Kennedy’s establishment of the Peace Corps in 1961. Although less aware of the establishment of USAID later that same year, somewhere in the back of my mind I did link them as part of the same American effort to improve the lives of families in low-income countries. Prior to graduation from Reed College, I was accepted into the Peace Corps and assigned to Botswana (then known as Bechuanaland). I was tremendously excited but, unfortunately, family issues prevented me from going. The missed Peace Corps opportunity is undoubtedly part of what led me, almost a decade later, to apply to the International Health Program at the Johns Hopkins School of Hygiene and Public Health. From the start, a main motivation was to improve maternal and child health in low-income communities.

It was not my explicit goal to work for USAID, but given that it was the major bilateral donor in the international health arena, it was inevitable that I would find myself working on projects funded by USAID. In fact, before I finished my doctorate in public health, I was recruited by a USAID employee who was auditing one of my classes, to join a survey team being sent to Burkina Faso (then known as Upper Volta) to assess child health status (they needed a French speaking nutritionist on short notice and my classmate remembered that I spoke French.)

The four weeks I spent in Burkina Faso in early 1981 were perhaps the only time I was paid directly by USAID. Most of the rest of my 25-year career in international health I worked either as an independent consultant or was employed by one of the many NGOs that handled the bulk of the program work of USAID. The two places where I worked the longest, and probably made my most useful contributions were the International Center for Research on Women (ICRW) in Washington DC (1985 – 1988) and the Pacific Institute for Women’s Health in Los Angeles, which I helped to found and where I worked from 1993 to 1999. The fact that I chose to work for organizations with a major focus on women reflected my growing appreciation of the central role that women’s own health as well as their education and economic empowerment play in ensuring child health and survival.

Question 2: Looking back at the various projects associated with USAID that you participated in, what are some of your proudest accomplishments?

One of my longer-term involvements was as part of the implementation team for The Weaning Project (TWP), a multi-year, multi-country child nutrition program funded primarily by USAID. I worked on the team managing TWP in the Extreme North Region of Cameroon. In this very poor region of Cameroon, there was a critical issue of acute growth faltering during late weaning. Not only was the introduction of complementary foods frequently delayed until 9 to 12 months, but the traditional gruel was also often overly diluted for both economic reasons and, as the parents believed, to ensure digestibility. Our goal was to reduce child mortality and malnutrition by introducing a more collaborative approach to improving weaning practices. Through hiring local outreach workers fluent in the language spoken by mothers, we were able to develop culturally acceptable recipes that thickened and enriched the gruel with fat and local legumes to increase protein and caloric density. As a result, there was a measurable improvement in child nutritional status in the project villages. The lessons learned from TWP influenced the training of Cameroonian health workers to use a more participatory approach to weaning education and to use growth charts as a trigger for action.

During the same time, I was involved with TWP (from the early 1980’s to the mid 1990’s) the dominant paradigm in international child health and nutrition was the Child Survival Revolution developed by James Grant at UNICEF. This strategy focused on four key interventions that demonstrably reduced under-five morbidity and mortality when used consistently and correctly. The four pillars of the Child Survival Revolution were Growth Monitoring, Oral Rehydration, Breastfeeding and Immunization. However, through my work on multiple child health and nutrition projects, including but not limited to TWP, I became concerned about the mothers being simply viewed as vehicles to produce better child health. One of the things I am most proud of is that my colleagues at ICRW and I were among the earliest to insist that child health programs also focus on the nutritional needs of lactating women and take into account the opportunity costs to women of implementing the Child Survival Revolution. Our intention was not to undercut this important effort to improve child health and survival, but to make it more realistic and therefore sustainable by adding interventions to strengthen women’s health and their economic opportunities.

Although I appreciate the last accomplishment, I will mention, more in retrospect than I did during the years when I worked in international health, I am proud of the training aspect of most of the projects I worked on. (By extension I believe this would be true of the vast majority of USAID funded projects.) The learning was certainly a two way street, the outside consultants needing to learn about local skills and cultural practices, but I believe our in-country collaborators from senior health department officials to the young women we hired as field workers in Northern Cameroon learned important research and evaluation skills, learned to appreciate the critical role of prevention in public health and came to see themselves as valued members of a global, not just national or local, effort to reduce child morbidity and mortality. Especially now that USAID has been so abruptly and disastrously ended, I place some modest hope in the residual benefits of almost fifty years of public health training in so many low- and middle-income countries throughout the world.

Question 3: What were your dissatisfactions with USAID?

Most of the people I worked with during my international health career, including independent consultants, NGO staff, direct USAID employees, and our in-country collaborators, were highly motivated and hard workers. Over 25 years I encountered very little, if any, visible waste or fraud. However, one thing that was somewhat frustrating was to realize how much foreign assistance money actually went back to the United States in terms of travel costs (we always had to fly American carriers), fees to consultants and supplies purchased in the United States (often something similar could have been purchased in county for less but this was usually disallowed). An April 2026 New York Times article that focuses on the difficulty USAID employees are having finding employment a year after the agency was dismantled acknowledges that many had similar concerns: “Much of the $35 billion it managed in 2024 went to Washington-based contractors, not directly to people in need overseas. The success of many projects was hard to measure. But all of those interviewed said they were still incredulous that an agency that amounted to less than 1 percent of the federal budget had been so quickly obliterated and reduced to a skeletal operation within the State Department.”

In the early years of USAID there was a genuine lack of in-country professionals trained in most public health related fields, especially in sub-Saharan Africa where most of my projects were located. So I believe that we outside professionals played a valuable role in filling this gap, allowing much needed child survival and reproductive health projects to get off the ground in a timely way and thus to keep children alive who otherwise would have died. However, over the decades of my career (and I’m sure it is even more true today) increasing numbers of trained and experienced national or regional nutritionists, epidemiologists, behavioral scientists and others were available. Nonetheless, due to requirements that preference be given in most cases to hiring Americans, plus a certain amount of inertia, USAID projects were slow to fill roles where possible with national or regional professionals. This was another policy that increasingly bothered me and is part of why I eventually turned to teaching and working on local public health projects.

Another thing that was a source of frustration during my years working in sub-Saharan Africa were the shifting sands of US foreign policy objectives, especially which countries were viewed as strategic priorities for foreign assistance. Most of us working on USAID funded health and nutrition projects were interested in maximizing the benefits in terms of lives saved and economic development promoted, which would have argued for giving money based on health and economic data and on the effectiveness of intervention strategies. But USAID was part of the State Department and it was clear that there were other geopolitical considerations at play beyond where US foreign assistance dollars could be most cost-effective. As it happened, when I began my career, Burkina Faso was receiving quite a bit of assistance. In the late 1980’s it was apparently demoted as a focus of USAID work, not because health had improved or economic needs decreased but for political reasons that were not shared with me or my colleagues. I felt quite ashamed to explain to my Burkinabé public health colleagues that there would be no follow-on project; that the US had decided to cut assistance to their country because it wasn’t considered important any longer.

Question 4: Should the US ever be in a position to revive international aid, what reforms would you suggest?

To begin, it is important to distinguish between the role of the US government in providing foreign aid, primarily through the now demolished USAID program within the State Department, and the continuing collaboration and assistance provided by US foundations, such as the Bill and Melinda Gates Foundation, US non-profits with an independent donor base, such as Partners in Health and the many US academic institutions that work in the international health field. None of the latter can provide anything like the magnitude of financial assistance lost when USAID ended, but they have been able to back fill some critical programs and, perhaps more important, they preserve a corridor for valuable exchanges of information and some collaboration in research, evaluation and program delivery.

If and when there is a renewed commitment to US governmental assistance in global health, I would like to see more of the priority setting done by national and regional entities. While it will not always be the case that cash transfers to national ministries of health will be the most effective use of resources, it would be a starting point. (Forgiving or restructuring the international debt interest payments burdening many low-income countries would similarly free up critically needed resources.) It is undoubtedly the case that current health systems in many low- and middle-income countries have been distorted and are not programmatically efficient because they were built up around health issues for which external funding was available but might not have really been the priority concerns in the country. The fact that every decade seemed to bring a new global area of emphasis, moving from family planning, to child survival, to Millennium Development Goals, only exacerbated the challenge of building up a reliable, equitable, coherent national health system.

If in the future the US regains a serious humanitarian desire to contribute to improving health globally, we should support international health research more robustly and effectively. The work of Dr. Dean Karlan, when he was chief economist at USAID, and others have shown that it is possible to do high quality cost-effectiveness research to achieve much better programmatic efficiency for what will always be scarce resources to meet global health needs. Ideally, when supporting international health research, local context and local expertise would be appropriately privileged without excluding the valuable contributions that researchers from the US and other donor countries have made and can make in the future.

In summary, I would wholeheartedly endorse the view of Dr. Bill Foege, a giant of international health, who died in January of this year. According to Dr. Foege, future success in reducing global health inequities will rest on three pillars: scientific research, collaboration and commitment.

Sources:

“The Demise of USAID: Time to Rethink Foreign Aid?” Lancet, March 22, 2025.

Andrea Ferreira da Silva, et al., “Impact of Two Decades of Humanitarian and Development Assistance and the Projected Mortality Consequences of Current Defunding to 2030: Retrospective Evaluation and Forecasting Analysis,” Lancet Global Health 2026, published online February 2, 2016.

Nicholas Kristof, “Trump’s Most Lethal Policy,” New York Times, September 20, 2025.

Joanne Leslie, “Women’s Time: A Factor in the Use of Child Survival Technologies?” Health Policy and Planning, 4(1), 1989.

Elizabeth Bumiller and Eileen Sullivan, “A Year after U.S.A.I.D.’s Death, Fired Workers Find Few Jobs and Much Loss,” New York Times, April 21, 2026.

James W. Curran, “In Memoriam: William “Bill” Foege, Visionary Leader” American Journal of Public Health, June, 2026, published online May 13, 2026.

Santi Ruiz, “How to Fix Foreign Aid – USAID’s Chief Economist reflects on DOGE.” Statecraft, interview posted online (audio and transcript) July 31, 2025.

Joanne Leslie was a long-time consultant and researcher in international health, based first in Washington DC and later in Los Angeles. At the UCLA Fielding School of Public Health, where she worked for many years, she developed and taught a course called “Women’s Roles and Family Health,” inspiring a generation of current public health leaders.

Emily K. Abel is Professor Emerita at the UCLA Fielding School of Public Health. Her forthcoming book is Listening to Dementia: Advocating for Dignity and Autonomy (NYU P