A community health worker in Uganda, after losing his US-funded salary in the foreign aid cuts, continued doing his health-outreach work as a volunteer—and in a rural community he found a very sick child with HIV who had stopped receiving the antiretroviral treatment that keeps him alive and prevents potentially fatal infections from treatable diseases.
The child’s parents had died of HIV, and he had no way to afford transportation to get tested for what could be tuberculosis, according to the Elizabeth Glaser Pediatric AIDS Foundation (EGPAF) which oversees the health worker who found him.
“Just a few months ago, we would have been able to activate, to jump into motion: ‘Here’s this child, what do they need?’” said Catherine Connor, the vice president of public policy at EGPAF, in an interview with CT. EGPAF is a major implementer of the President’s Emergency Plan for AIDS Relief (PEPFAR).
“Instead, we’re stuck, and the tools are no longer there,” said Connor.
Declines in maternal mortality and the mortality of children under five represent some of the biggest health care improvements in the modern era. Globally, fewer children die before their fifth birthday now than any time on record—dropping from 9.9 million deaths in 2000 to 4.8 million in 2023, with the burden of death disproportionately in sub-Saharan Africa.
But nonprofit leaders and Christian health workers now worry the vulnerable populations their organizations worked so hard to protect will suffer worse outcomes as a result of the sudden cutbacks under the Trump administration.
Without the funding their programs had been promised, fewer children under five are getting vaccinated, fewer young patients can access treatment for diseases like HIV/AIDS and malaria, and fewer women are receiving maternal health care, the nonprofit staff reported to CT.
Orphanages in countries with fragile safety nets have started to take in more children, as the children’s biological families can’t provide food and care, according to Christian nonprofits in the field.
In Malawi, one of the poorest countries in the world measured by GDP per capita, both the maternal mortality ratio and the mortality rate for children under five have been cut in half since 2010, according to the World Bank.
“Soon Malawi will start seeing an increased number of under-five mortality rates, an escalation of infections addressed by immunizations, and increased births of children with various medical problems that are prevented through access to vaccines by pregnant women,” said Howard Kasiya, health coordinator for the Evangelical Association of Malawi, one of the country’s largest networks of Christian denominations and organizations.
The association had received US funds to promote HIV testing and prevention through churches. That money’s gone now. In Malawi, 70 percent of rural health care comes through Christian clinics and hospitals, so churches there are deeply integrated in health care for the poor.
Faith-based organizations, local governments, and other nonprofits try to mitigate the cuts, and some donors have stepped up to give.
Shirati Hospital, a Christian hospital in Tanzania, is working to raise $5,000 a month to keep its HIV-positive patients, including children, on medication after the US significantly reduced its HIV funding, according to Dale Ressler, who runs the US-based Friends of Shirati.
In South Sudan, a young nation with a fragile health system and regular food shortages, World Relief centers treat children suffering severe malnutrition. They function as pediatric hospitals, offering 24-7 care from doctors and nurses.
The government contract that funded the salaries for staff at the centers came to an end during the aid freeze this year, so World Relief had to decide which programs it could sustain and which would have to close.
“If you close a stabilization center, you are literally going to be unhooking children from IVs and sending them home,” said Emily Chambers Sharpe, who oversees these health programs at World Relief.
The organization opted to pay staff for now to keep the pediatric units open. Leaders aren’t sure how long World Relief can sustain that cost on its own, and they hope the government will restore some of its funding.
In response to questions about cuts to maternal and child health funding, a State Department spokesperson said in an unsigned statement to CT that the agency is reorienting foreign aid to focus on US national interests.
“This transition is focused on improving accountability and strategic coordination—not eliminating our commitment to vulnerable populations and allies,” the spokesperson stated, listing ongoing support for Uganda’s Ebola outbreak, HIV care and treatment, and emergency assistance in conflict zones.
“Critical, life-saving programs have continued uninterrupted,” the spokesperson said, “as we strengthen how, where, and why we deliver humanitarian aid to ensure it serves those who need it most.”
Aid workers told CT that if the government cuts had not been so sudden, they and local governments would have had time to prepare. The wholesale disruption of systems means a bleeding pregnant woman may no longer have ambulance service to get to a hospital or blood bank. Or a faith-based clinic may remain open to see a sick child but have no way to transport the patient to a facility with the right lab tests.
“Children who experience treatment disruption die much faster than adults,” said Connor, testifying at a recent congressional hearing on PEPFAR.
“I do think we can expect to see increased mortality rates, increased infection, and increased despair if things aren’t corrected,” she said.
The US cut salaries it had financed for many local health workers, which means less outreach and fewer screenings for life-threatening diseases.
“Children don’t bring themselves to the clinics, so you have to find them with their mothers, or you do screening in the community, which is not a priority right now,” Connor told CT in an interview last week. “It’s a recipe for pediatric mortality to go up.”
Faith-based organizations were often the ones focused on orphans and vulnerable children projects under the US Agency for International Development (USAID). Such projects were subject to cuts because they aren’t considered lifesaving. But they are “such a heavy driver of whether these children live or die,” said Connor.
Even though the health cuts have only been in place a few months, some orphanages are already filling up in Malawi, Gabriel Walder, the CEO of the Christian nonprofit Alliance for Children Everywhere (ACE), told CT. ACE works on reunifying children in orphanages with their families through local churches in Zambia, Uganda, and Malawi.
“It’s an ecosystem. … We’re seeing shuttering of services while the scope of the need is increasing,” said Walder.
Even worse, his organization still hasn’t received reimbursement for work it completed last year under its first contract with USAID. It’s smaller than World Relief or World Vision—just a $2.1 million budget—so the organization didn’t have the capacity to bounce back from the missed payments.
“All the work of ACE continues, but at a much smaller scale,” said Walder.
Many evangelical health organizations also support family planning services (e.g., contraception), which were cut. In Malawi, such cuts will lead to “increased unwanted pregnancies with related increased abortions” and “increased maternal deaths,” said Kasiya.
Courts continue to debate legality of the executive branch cutting congressionally appropriated funds. Aid workers hope some funding could be restored but realize it might not be a priority.
“There are still people in Congress and the State Department … that understand the value of this work,” said Connor from EGPAF. But she’s not sure “how that gets put back in motion after such severe disruption.”
Congressional Republicans raised concerns about 21 abortions that happened in Mozambique under PEPFAR during the Biden administration, in violation of the US law that prohibits foreign aid from funding abortions.
But these cuts to maternal and child health care project a much wider death toll. The disruptions to PEPFAR could cause 1 million children to be infected with HIV by 2030, nearly 500,000 to die, and 2.8 million children to be orphaned, according to a new analysis published in The Lancet medical journal. Some portion of PEPFAR appears likely to be preserved, but Republicans who control Congress now are debating what to keep.
“PEPFAR … cannot and should not be forever,” said HIV/AIDS scientist Mark Dybul, who built PEPFAR under George W. Bush, at a recent congressional hearing on the program’s future. “It is very possible to begin a transition process” to countries taking on their own HIV care.
But he urged a controlled reduction rather than “a rapid retreat that will be a total failure for us on every front.” He added that the elimination of so many USAID positions meant less oversight of remaining aid programs to see that money is spent properly.
“The unfolding reality is that the vulnerability of children is going a lot higher because of the lack of access to services,” said Walder, “because of the shuttering of foreign aid.”
