Trump and DOGE’s Global Health Assault

 Kwei--Wed

How a presidential directive and a shadow agency unraveled decades of progress

🧨 A Calculated Dismantling

On January 20, 2025, Donald Trump returned to office and wasted no time dismantling the global health infrastructure that the U.S. had helped build over the previous decades. Within hours, he signed executive orders freezing U.S. foreign aid—including the lifesaving PEPFAR program, most of USAID’s funding streams, and broad swaths of maternal and child health initiatives.

Enter DOGE—the Department of Government Efficiency—an agency hastily constructed during Trump’s transition and weaponized to shut down federal systems from the inside. With Elon Musk in a senior advisory role, DOGE halted Treasury disbursements, tore up contracts, and gutted agencies under the guise of streamlining. In truth, it was liquidation.

DOGE wasn’t about trimming fat. It was about obliterating aid.

💔 A Trail of Lives Lost

The human toll is staggering.

PEPFAR, long hailed as the most effective HIV program in history, had supported HIV treatment for 20.6 million people and prevented millions of perinatal transmissions. But with the aid freeze, countries like South Africa and Eswatini were left scrambling to keep clinics open. Modeling by global health researchers predicts that stopping PEPFAR could cause over 600,000 HIV-related deaths in South Africa alone over a decade.

USAID, the U.S. government’s principal development agency, was crippled almost overnight. Roughly 90% of its global health awards were canceled. The workforce has been reduced from 10,000 to a skeleton staff of fewer than 300. Outreach programs for HIV, TB, malaria, maternal health, and vaccinations were decimated.

As of mid-2025, a conservative estimate attributes more than 300,000 preventable deaths to the aid freeze, including 208,000 children. These aren’t hypothetical models. These are real-world numbers with names and faces behind them.

The scale of the fallout is almost unfathomable:

• 26 million condoms and HIV prevention tools are stranded in warehouses, now expiring

• $12 million worth of essential drugs locked up due to frozen logistics

• Vaccine campaigns in several African nations have been halted, risking outbreaks of polio, measles, and cholera

• Maternal mortality, which had declined by 40% in some regions over the last five years, is now spiking again

🔮 The Road Ahead: Resurgence and Collapse

Health experts warn of a ripple effect that could set back global disease prevention by decades.

The UN Development Programme (UNDP) forecasts as many as 25 million excess deaths over 15 years if U.S. aid remains frozen. Beyond the moral failure, there’s a realpolitik threat: weakened global health systems make fertile ground for pandemics, forced migration, extremism, and authoritarian expansion.

If the U.S. once had global goodwill from its support of public health, that trust is rapidly disintegrating.

🧭 This Is Direct Responsibility

Let’s be clear: this wasn’t a budgetary fluke or congressional gridlock. It was intentional, executed with precision. Trump gave the orders. DOGE carried them out. The architects knew exactly what they were doing.

This is Trump’s legacy. These are DOGE’s fingerprints.

Global health professionals have used restrained language in public, such as “disruption,” “setback,” and “challenge.” But we should not. This was sabotage. The scale of harm deserves to be named for what it is: state-sanctioned abandonment of the world’s most vulnerable.

✍🏾 Final Word

The dismantling of PEPFAR and USAID isn't just an American betrayal—it’s a global one. And while other nations and NGOs are scrambling to fill the vacuum, the U.S. has made its message clear: lives outside its borders are expendable.

Trump and DOGE didn’t just cut aid. They weaponized neglect.

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📚 References

• AP News – Trump’s permanent USAID cuts slam humanitarian programs worldwide
• Washington Post – U.S. funding halted Africa’s HIV crisis. Trump’s cuts have forced a reckoning
• Financial Times – UN warns U.S. foreign aid cuts will cause irreversible global damage
• Vox – The devastating impact of Trump’s slashing foreign aid, in 3 charts
• My Journal Courier – DOGE’s deadliest legacy from deep cuts – David Douglas
• Center for Global Development – Estimating the Human Cost of the USAID Freeze
• UNAIDS – What PEPFAR Has Achieved – and What’s at Risk</

CORONA IS EVERYWHERE--PART TWO

THE CORONAVIRUS PANDEMIC IN AFRICA

Wednesday--Kwei Quartey

As of this posting, the continent of Africa has around 116,000 recorded cases of COVID-19, of which some 3500 have died. From South Africa's high of 24,000 cases and 429 deaths to Western Sahara's low of only ten cases, the profile of the pandemic in Africa is as varied and multi-layered as the continent itself.

Map of the COVID-19 outbreak in Africa. (Image: Canuckguy, Lokal_Profil + Xfigpower)    100,000+ Confirmed cases    10,000–99,999 Confirmed cases    1000–9999 Confirmed cases    100–999 Confirmed cases    10–99 Confirmed cases    1–9 Confirmed cases

Lockdowns/Stay-At-Home

Some African governments followed the lead of western nations in imposing stay-at-home orders, but as has been pointed out, in many cases, the efficacy of such a measure is questionable. Consider slums such as Nairobi's Kibera or Accra's Agbogbloshie, where six to ten people may live in a small wooden shack. The notion of "social distancing" in this situation is farcical. For many of these people who work in the informal economy, missing even a day's work can mean going hungry.

Agbogbloshie slum, Accra (Photo: Kwei Quartey)

In Ghana, President Nana Akuffo-Addo probably read the signs of rapidly growing malcontent among the citizenry and eased the restrictions after a strict lockdown of only three weeks. Like Trump, Akuffo-Addo faces a challenge to his reelection at the end of 2020, and media optics of out-of-control Ghanaian policemen assaulting people in the streets for not staying home reflected badly on Ghana's president, who is not wildly popular at the moment. 

Testing

Like other parts of the world, the numbers in Africa depend on several factors, including the fundamental ability to perform the COVID-19 test in the first place. Here, individual nations have widely differing capabilities. With vast testing experience for HIV, South Africa, with less than 5% of the continent’s population, has a testing rate of 6.5 per 1000 population, with Ghana following at 5.5/1000. But Nigeria, with more than three times South Africa’s population, has tested only about 0.2/1000. 

Therefore, do we have a true representation of the number of cases and the fatality rate in Africa? Almost certainly not, particularly as many young people may not be showing any symptoms (pre-symptomatic or asymptomatic). Remember that 19 of the top 20 youngest countries are in Africa.

Ghanaian lab tech with SARS-CoV-2 test kit (Image: Shutterstock)

Bearing in mind that even the US has had months-long problems with access to testing, Africa faces great difficulties in the areas of infrastructure, equipment, and trained human resources, but the most severe obstacle is the availability of reagents necessary for the testing. Warns Africa CDC head John Nkengasong, "The collapse of global cooperation and a failure of international solidarity have shoved Africa out of the diagnostics market. With its lack of hospitals and high prevalence of conditions such as HIV, tuberculosis, malaria and malnutrition, Africa could see COVID-19 mortality rates higher than elsewhere, even in children."

Under the Partnership to Accelerate COVID-19 Testing (PACT), established by the African Union and Africa CDC, the number of tests throughout the continent grew from a mere 415,000 in mid-April to approximately 1.2 million now. PACT aims to strengthen capacity to test at least 10 million Africans for COVID-19 across Africa in the next six months.  

Dodgy Predictions and an Incomplete Picture

There have been dire predictions of a devastating 300,000 to 3.3 million COVID-related deaths in Africa. During a CNN interview, Melinda Gates said, "Look at what’s going on in Ecuador. They’re putting bodies out on the street. You’re going to see that in countries in Africa.” While Gates was undoubtedly expressing a fear she had and not relishing the notion, it's no surprise that this declaration did not go down well with Africans, many of whom are already suspicious of the Bill and Melinda Gates Foundation's involvement with vaccine production. 

Melinda Gates's distasteful imagery ("putting bodies out on the street") painted the 54 different African countries with a broad, sweeping brush suggesting passivity and helplessness. But, it should be recalled that the African continent has had experience with HIV, malaria, tuberculosis, and Ebola. Whereas the concept of lockdown for COVID-19 was foreign to the US and many European countries, Sierra Leone and Liberia were already familiar with it from the Ebola epidemic, and both countries wrestled with Ebola until they beat it, much of it through local efforts. 

Just as the states in the US can hardly be said to have had homogenous responses to the novel Coronavirus outbreaks, neither has Africa, but many African countries imposed travel bans before or around the same time that the US government did. For example, Ugandan President Yoweri Museveni announced a ban on large public gatherings including weddings and church services on March 19, 2020 before Uganda had a single COVID-19 case. Uganda has around 212 recorded cases and an unknown number of deaths, according to the site ncov2019.live. 

Rwanda, with 327 recorded cases, was also quick to react. Shortly after the outbreak was confirmed in January, the government set up a committee to evaluate and bolster preparedness and response to the pandemic, training about 500 health workers, including laboratory technicians to cope with a potential national epidemic.



Hospitals and Health Care Systems

Some of Africa's best hospitals, both private and public, are found in South Africa, Tunisia, Kenya, Tanzania, Rwanda, Algeria, Egypt, Morocco, Zambia, Tanzania. Even so, South Africa has fewer than 1,000 intensive care unit (ICU) beds, of which 160 are in the private sector, for a population of almost 60 million.

Aga Khan University Hospital, Nairobi, is used as a benchmark by other hospitals in Africa.
(Photo: Aga Khan University Hospitals)

Estimates are that South Africa currently has 3,216 ventilators, with 2,105 in the private sector. South Africa's health authorities put the projected need for a peak COVID-19 epidemic at 7,000. Meanwhile, Kenya has 259 machines; Ghana, 200; Nigeria, 169; South Sudan, 4; and Somalia, zero. Fortunately or unfortunately, depending from which angle you look at it, the desperate ICU/ventilator scenarios in the West months ago could not even logistically exist in most of Africa, and the continent's response to COVID-19 will not be a picture of elite hospitals like the Aga Khan placing hundreds of people on ventilators.

Instead, it will be a story of how the illness affects communities with few resources. As in Ghana, the unfolding march of the disease might be more represented by mortuaries overflowing with bodies as families wait for a day in the future when full-scale funerals can be held again. They may have to wait a long time.

Learning from the past

Stanley – Thursday

South Africa has one of the most stringent lock downs due to the COVID-19 pandemic. For the past five weeks, we have been in Level-5 lock down, which has closed all but essential businesses, prohibited us leaving our homes except for medical reasons and shopping for food. The sale of alcohol and cigarettes is forbidden, as is the transportation of alcohol (which has had a huge negative impact on our wine industry). Like everywhere else, the impact on businesses and employees has been devastating, and some predictions call for at least 50% unemployment as the country emerges.

For the most part, people have accepted the strict measures, even though some haven’t been able to follow them due to the desperate search for food. The overarching fear is that the virus will spread in the huge Black townships, where people are living in crammed quarters, in unhygienic conditions. Many of these are already compromised because of HIV.

So,what led to the country being so proactive so quickly?

I think three things contributed to the decision: first, in the last hundred years, the country has suffered two devastating epidemics; second, the quality of doctors in general is very good, and the country has a long history of having outstanding epidemiologists; and third, we have a president who has led the country, keeping it informed, empathising with the hardships people are enduring, but demanding adherence for the good of all.

The Spanish flu epidemic, which started in the United States and rapidly spread to Europe via crowded troopships, hit South Africa harder than most. It was the fifth hardest hit, both as a result of the return of Black troops and a poor understanding of what the virus was all about.

In September 1918, two troopships arrived in Cape Town from England carrying over 2,000 black South African Labour Corps soldiers. On the way to South Africa, they had a stopover in Freetown, Sierra Leone, where the flu was already raging. Within days of leaving there, cases of flu appeared on both ships. When they arrived in Cape Town, thirteen of the soldiers were still laid up.

Members of the SA Labour Corps on the Western Front

As a precautionary measure, the local medical officer had the sick troops placed in isolation The rest of the men were put under quarantine at a military camp. Those that didn’t show symptoms were sent home three days later via the large rail network. Within days, flu cases started appearing all over the country.

By the end of October, six weeks after the ships arrived, between 300,000 and 500,000 people had died--between five and seven percent of the population. There was fear and panic throughout the country because nobody knew what was going on and, worse, nobody knew what to do. Gallows humour became common in newspapers. One, in Johannesburg, reported: "The average Joburg man did not run away from the germs — he fought them courageously. Retiring to bed with a bottle of brandy, and an adequate supply of ammoniated quinine and aspirin, and a pile of the latest novels, he challenged the flu to a 10 rounds contest."

And lost!

In the early 1920s, Reuben Thlakele Calusa, a South African composer, wrote several influenza-linked songs. Here is one, translated by ethnomusicologist, Austin Okigbo. It is titled Influenza 1918.

In the year nineteen eighteen
We’re killed by the disease called influenza
Which finished our beloved relatives

Mothers, fathers, sisters and brothers

In other households no one was left

It took young women and men

It chose the beautiful ones
It even took the good-looking men
It took the teenagers
It took even the young maidens

It took the engaged ladies
It took the strummers [bridesmaids]
Even the grooms
It was like there was a black cloud over the earth.

The one good thing about the Spanish flu was that it disappeared as quickly as it had appeared. By the end of November, it had gone. Six months later the government realised that it had to play a role in the health of the country and created the first Ministry of Health.

Fast forward to the end of the century. By 2000, HIV/AIDS was ravaging South Africa, and efforts to treat and contain it were not helped by an inept approach by the government. Deputy President and later President Thabo Mbeki was a denialist. His Minister of Health, Manto Tshabalala-Msimang, advocated a diet of garlic, olive oil and lemon to cure the disease. Although many scientists and political figures called for her removal, she was not removed from office until Mbeki himself was removed from office. It is estimated that these policies led to the deaths of over 300,000 South Africans.

In addition, the country rejected the offer of free or inexpensive retrovirals to treat HIV. The whole episode was a disaster. However, when Jacob Zuma became president, the country’s approach to HIV/AIDS transformed and now anti-retroviral treatments are available to everyone. The problem is still huge (for details click here), but it is largely under control.

So, two devastating epidemics provided a backdrop to the COVID-19 situation. A combination of a president, Cyril Ramaphosa, who was willing to listen and act, epidemiologists who understood the ramifications of the virus, and a fear of what would happen if the virus spread through the townships, led to the current lock-down rules. 

As elsewhere, the financial hardships have been horrible. Some current estimates are that a quarter of all South Africans have no money and no food. And there have been a number of incidents of the looting of food trucks. Even a huge injection of funds by the government, in an attempt to get some money to the unemployed, has not been enough. And enormous efforts by NGOs and others to bring food to the starving, will fall short. 

The police and military protect food deliveries

Who can blame people for trying to get food?

But the numbers are still looking good – just over 4,000 confirmed cases and 102 deaths. Testing continues to ramp up and will be crucial as time passes. The goal of the lock down has been to flatten the curve, so the country can prepare for the inevitable spike, which is expected in August or September. Everyone expects the situation to worsen considerably between now and then, but hopefully the country will be as ready as it can be.

The country hopes to be prepared when the spike occurs.

Tomorrow, the country moves to Stage 4, which relaxes the tight control a little bit. I’ll be able to exercise outside the home between 0600 and 0900, which will be a boon, even though I have become quite accustomed to lying in bed until 0800. Sale of alcohol and cigarettes remains banned. However, some businesses can open either gradually or fully, and restaurants can open to prepare food for delivery only.

I am so pleased that I don’t have to make these decisions on when and how to relax restrictions. And I am much more confident in how South Africa is trying to cope than I am in some other countries' approaches.

Constitutional

Justice Edwin Cameron.

Many commentators nowadays in America seem to use the US Constitution – in the words of the old joke about statistics – the way a drunk uses a lamppost: more for support than illumination.  Yet even the UK – trying to maintain their 300 year union with Scotland – mutters that perhaps a constitution would be a good starting point for a new dispensation. So it might be interesting to consider what the constitution in South Africa has, or has not, achieved for our twenty year old democracy.  I’m not qualified to do that, but Justice Edwin Cameron has written an insightful book on exactly that subject titled: JUSTICE: A PERSONAL ACCOUNT.

  It’s written clearly without any legal jargon and, despite his role as a judge of the court, he tries to make an unbiased assessment.  More than that, he sets the book against his personal life as a gay man living with HIV.  His struggle with “coming out” – not out of the closet but making his HIV status public - is moving.  Today it is hard to believe how difficult that was, yet Cameron points out that even today he is one of only a handful of public figures in Africa who have done so.  Yet the incidence of HIV among Africans probably runs as high as 10%.

With what it has enshrined, it’s hard to believe that in some quarters the South African constitution is unpopular.  On the left, the complaint is that the constitution was a white sponsored conspiracy to maintain white privilege under a black government, while white reactionaries mutter that the constitution is a legal facade to deprive them of rights and property.  Usually if there’s criticism from both extremes, you're doing something right.

The Constitutional Court in Johannesburg

Before the change of government, South Africa used “common” law (and Roman Dutch law at that).  There was no constitution.  Basically the government of the day could get away with almost anything (maybe hold the “almost”) just by passing a new law or changing an existing one.  These could be – and were – challenged and struck down in the courts, but it was mainly an issue of the government phrasing the law correctly and following due process.  There was no ultimate framework to which one could appeal.  Cameron, an anti-apartheid activist who used the legal processes open to him to try to support the victims of the apartheid government, and whose commitment is beyond question, clearly remains ambivalent about whether that was the right thing to do or whether he'd just allowed himself to be co-opted to lend the regime respectability through its lip service to the law.

Nelson Mandela suffered one of the first major reverses from the new Constitutional Court when it threw out one of his initiatives.  Looking back on this, he said: “It was, to me, never reason for irritation but rather a source of comfort when these bodies were asked to adjudicate on actions of my government and my office and judged against.”  But that was Nelson Mandela. 

President "No"

His successor, Thabo Mbeki, was a different man.  For reasons which still remain a matter of speculation, Mbeki, highly educated and intellectual, was (and maybe still is) an AIDS denialist.  That is, he denied the connection between HIV and AIDS, seeing the latter as the result of bad environment and nutrition among poor people.  Cameron tears this to shreds, and it’s hardly worth commenting on.  But the impact was huge.  Not only was the president of the country wiping aside the impact of, for example, unprotected sex, but public hospitals denied ARVs to HIV positive people.  Pregnant mothers could only receive Nevirapine, the drug that could prevent HIV transmission to their babies, at a few designated “pilot site” hospitals, while Mbeki’s minister of health trumpeted the efficacy of African potatoes and beetroot.

Zackie Achmat Founder of the TAC

It was in this atmosphere that the Treatment Action Campaign took to the courts.  The arguments were carefully phrased.  The cost of the drug was not the issue.  The German company that developed and manufactured Nevirapine had offered to supply it – in any quantity required – to the South African public health authorities FOR FREE for five years.  Incredibly their offer was rejected out of hand.  Against this background the Treatment Action Campaign took their case for relief to the High Court in 2002.  When they won there, the government appealed to the Constitutional Court.  The TAC won there too.  Two years later, the government abandoned its approach and wholeheartedly faced the HIV epidemic.  Mbeki’s disastrous blind spot had only one saving grace: his government made it clear that they would abide by the decision of the Court.  By doing so, he ensured that the rule of law and the lofty founding principles of the New South Africa would not be tarnished. It was too late to do the same for his reputation and legacy. He was dumped by his party after a single term as president.

Michael – Thursday.