A Stark Reckoning:
USAID’s Life-Saving Legacy and the Deadly Cost of Defunding
Dr. José M. Zuniga, President/CEO, Fast-Track Health
A recent study by Cavalcanti et al., published in The Lancet, offers an urgent, data-driven account of the past, present, and potential future of global health financing through one of the most consequential bilateral development agencies: the United States Agency for International Development (USAID). In what amounts to both a retrospective celebration of lives saved and a forward-looking warning of lives at risk, the paper leverages robust epidemiological modeling to assess the health impact of USAID’s investments across low- and middle-income countries (LMICs) from 2001 to 2021 and then forecasts the projected human toll through 2030 if proposed US funding cuts are enacted and sustained.
The numbers are staggering. The authors estimate that over two decades, USAID’s health-related investments averted more than 91 million deaths across LMICs, including through targeted programs to combat HIV/AIDS, tuberculosis (TB), malaria, and maternal and child health challenges. From scaling up antiretroviral therapy (ART) to deploying insecticide-treated nets (ITNs) and expanding access to childhood immunizations, USAID has played a pivotal role in strengthening global health systems and driving progress toward Sustainable Development Goal 3. These gains, however, are now under threat. The study’s modeling of defunding scenarios suggests that by 2030, an additional 14 million deaths – over 4.5 million among children under age five – could occur in the absence of continued support. This figure is not merely a projection; it is a moral indictment of policy decisions that would reverse decades of health equity advancements and human development.
Cavalcanti et al. employ a rigorous methodology, combining retrospective impact modeling with future-facing projections. Using programmatic data, peer-reviewed efficacy studies, and demographic modeling, the authors assign attributable mortality reductions to specific USAID interventions across disease areas and population groups. The retrospective model offers a cumulative impact analysis from 2001-2021, while the forward-looking model simulates two scenarios from 2025 to 2030: one in which USAID health funding remains constant, and another in which it is significantly reduced following proposed US federal budget cuts. Importantly, the analysis is not narrowly confined to one disease domain; rather, it encompasses a comprehensive spectrum of global health priorities – maternal mortality, HIV-related deaths, child mortality from vaccine-preventable diseases, malaria, TB, and family planning-related deaths – allowing for a holistic view of USAID’s reach and relevance.
What makes the findings particularly consequential is not only their empirical weight but their policy relevance. The study arrives at a moment of deep uncertainty and political retrenchment in the US foreign assistance landscape. The 2026 US budget proposal includes significant cuts to global health funding, justified by some policymakers as necessary reallocations toward domestic priorities. Yet the Cavalcanti et al. paper makes clear that such cuts are not benign redistributions; they are choices with direct and devastating human consequences. To frame this in moral terms, the proposed funding cuts risk becoming a death sentence for millions of people, primarily in regions least responsible for the conditions that place them at health risk. In short, budget decisions made in Washington, DC, reverberate across the world – not in abstractions, but in lives saved or lost.
To fully appreciate the gravity of these findings, it is important to contextualize USAID’s global health investments within broader development and geopolitical histories. Since the early 2000s, the United States has led many multilateral and bilateral efforts to address HIV, TB, malaria, and maternal and child mortality, including through major initiatives such as PEPFAR and the President’s Malaria Initiative. USAID funding has helped build clinics, train health workers, distribute life-saving medicines, and expand surveillance systems in regions with weak health infrastructure. It has also played a catalytic role in unlocking additional donors and domestic financing. In many cases, USAID-funded programs provided the backbone of primary health care delivery in countries where health systems would otherwise have collapsed or remained severely underdeveloped. Therefore, the legacy of USAID extends beyond the interventions it funded—it encompasses health systems strengthening, governance capacity-building, and the empowerment of entire communities.
Yet the study is not without its limitations. As the authors themselves acknowledge, forecasting health outcomes over a five-year horizon carries inherent uncertainty. The model assumes a linear relationship between funding reductions and health service disruptions, when in reality, some countries may adopt mitigation strategies such as domestic resource mobilization, improved efficiencies, or alternative donor engagement. However, even with these caveats, the model likely underestimates the full scope of the fallout. It does not, for example, fully account for the spillover effects of defunding – such as increased strain on local health workers, disrupted supply chains, or the compounding impact of co-morbidities. Moreover, the political instability and climate-related shocks that are increasingly affecting LMICs may exacerbate the fragility of health systems and amplify the consequences of reduced funding.
The projected death toll of 14 million is not just a statistic; it is an ethical alarm bell. The sheer scale, comparable to the entire population of several small countries, demands a moral reckoning. The global health community cannot remain passive in the face of such a threat. The study’s findings should be used to galvanize advocacy at the highest levels of government, especially among legislators who hold the purse strings. More than that, it should compel a reorientation of public discourse: global health investments are not acts of charity – they are acts of justice, solidarity, and shared humanity. They are also smart policy. The COVID-19 pandemic proved that health threats do not respect borders, and that the erosion of health systems in one part of the world can have cascading global effects. To abandon USAID’s global health mandate would not only be a betrayal of the lives it has helped save but a self-defeating act of shortsightedness.
The authors also offer valuable lessons for how policymakers and funders might respond to the current crisis. First, they underscore the importance of protecting and restoring global health funding, particularly for high-impact interventions with strong cost-effectiveness profiles, such as vaccines, HIV treatment, and malaria prevention. Second, they highlight the need for diversified financing models, including blended finance and innovative funding mechanisms that can buffer LMICs against donor volatility. Third, the paper points to the importance of strengthening domestic health systems and governance, so that countries are better positioned to withstand external shocks and funding contractions. In this sense, USAID’s future contributions must not only be measured in terms of service delivery but in terms of resilience-building.
Another crucial takeaway from the study is the importance of data and evidence-based forecasting in informing policy. The methodology used by Cavalcanti et al. is replicable and adaptable, offering a template for other donor agencies, governments, and international organizations to model the consequences of funding changes. These tools can be used not only to prevent harm but to strategically prioritize funding for maximal impact. In an increasingly resource-constrained environment, such analytic clarity is indispensable.
Cavalcanti et al. have provided far more than a descriptive study. They have delivered a wake-up call, grounded in data and driven by a commitment to human dignity. Their work makes plain that global health progress is fragile, contingent on continued investment, and vulnerable to political winds. The 91 million lives saved by USAID investments from 2001 to 2021 are not merely a testament to what is possible, they are a reminder of what is at stake. The 14 million lives now at risk are not inevitable; they are preventable, but only if action is taken. In a world where facts are too often drowned out by political noise, this paper offers the clarity of evidence and the urgency of conscience. Whether we heed its warning will determine the future health and wellbeing of millions.
SOURCE: Cavalcanti et al. Evaluating the impact of two decades of USAID interventions and projecting the effects of defunding on mortality up to 2030: a retrospective impact evaluation and forecasting analysis. Lancet. 20 June 2025.