The 2025 executive order dismantling U.S. Agency for International Development programs canceled 90% of the agency's contracts and grants, destabilizing health systems globally.
The sudden reduction in funding from the United States, United Kingdom, Germany and Canada has destabilized health systems across sub-Saharan Africa in ways that could reach the U.S. Uganda, which has nearly 2 million refugees-the largest refugee population in Africa-is facing an acute crisis as a result, according to a new study published in JAMA.
HaEun Lee, a researcher at the University of Michigan School of Nursing, led a qualitative study involving 26 health care practitioners in Uganda's Nakivale Refugee Settlement to document the frontline consequences of the funding cuts. She discusses how the withdrawal of U.S. health infrastructure impacts the United States and the world.
Given the interconnectedness of our world, how do the outbreaks you have documented-like measles in Nakivale-risk becoming wider global health security threats?
If the COVID-19 pandemic taught us anything, it's how interconnected we are and that diseases don't respect borders. The U.S. has a long history of prioritizing HIV/AIDS, tuberculosis and other communicable diseases. While that reflects the overall value and longstanding reputation of U.S. goodwill, it also rests on the scientific self-interest of protecting Americans.
Interrupted treatment is how new drug-resistant strains emerge, and once a strain develops, it can travel anywhere. Collapsing immunization coverage erodes the herd immunity that protects us all. By withdrawing funds and resources so abruptly, the U.S. forfeited the ability to monitor disease activity closely at its sources. Surveillance and the quick exchange of information with the global community is key to preventing the next pandemic.
We also have to remember that innovation and knowledge exchange is bidirectional. The Global North learns so much from countries like Uganda, which has repeatedly contained Ebola outbreaks and generated frontline knowledge that now informs global protocols. Dealing with these crises as a global community is how we learn to handle whichever country goes through it next.
From a global health perspective, how does the abrupt withdrawal of these established institutions and expertise create a vacuum that leads to this kind of "profound transformation"?
It depends on how you define those institutions and expertise, because it was really several things operating at once. USAID was a massive part of it, but so was the sheer scale of the funding itself. The U.S. was historically one of the largest donors to humanitarian and global health efforts. But what we're really losing is institutional knowledge and the unique ability to quickly tap into local expertise.
Over six decades of working across dozens of countries, USAID accumulated hard-won expertise about what to do, who to involve and how to do it effectively. It is that collaboration with local experts that made everything possible.
How is this affecting the long-term viability of the healthcare workforce as a whole?
Healthcare workers are remarkably resilient, but I am afraid that resilience is being taken for granted. The providers my team interviewed describe deep burnout and a profound sense of helplessness. In clinical literature, we call this moral injury-the lasting psychological, behavioral and spiritual damage caused by witnessing or failing to prevent suffering despite having the knowledge and skills to help. It is the particular anguish of having the training to act, yet lacking the resources to do what you know should be done.
They watch the people they serve deteriorate in front of them. One of the most painful examples is being forced to turn away malnourished children due to limited supplies, only to have those same children return weeks later even sicker. These providers grieve not being able to offer their best to refugees who have already endured so much, even as they try to deliver the tender, loving care they spoke about.
When you lay off half the staff, leave the rest to absorb impossible workloads, and ask them to carry the moral weight of watching preventable suffering, you erode the conditions that sustain a workforce. Resilience is not an infinite resource.
What makes all of this difficult to sit with, as a nurse myself, is that a provider's resilience can mask the damage. From a distance, the system looks like it is coping because dedicated people are holding it together through sheer will, and that lets decision-makers assume things are fine. You can make these large-scale decisions without ever having to witness the consequences, but the providers cannot. They are the ones left standing in front of the suffering. Bearing witness to human suffering is part of our calling, but that does not mean our commitment should be treated as a resource to be spent without limit.
