Author: Lani Marquez

Lani Marquez, MHS, has worked for over 40 years in international health systems strengthening, most recently as Knowledge Management Director at University Research Co., LLC (URC). For the past 20 years, she has led URC’s efforts to apply knowledge management concepts and techniques to strengthen the implementation of health service delivery programs. Her pathway into public health began in high school when she volunteered with Amigos de las Américas, a nonprofit organization that inspires youth leadership and service through immersion experiences in Latin American countries. Over her 5 summers with Amigos, Lani worked in Nicaragua, Honduras, and Paraguay on immunization and dental health education programs. As a student of human biology at Stanford University, she met Steve Hansch and became an active member of the Stanford Committee on Hunger, helping to raise awareness of Stanford students on hunger issues locally and globally. Skilled in technical writing and communication, Lani has supported field and headquarters staff at URC to develop knowledge products that convey key learning from their improvement work and enable scale-up. She edited Improving Health Care in Low- and Middle-Income Countries: A Case Book and has written extensively on approaches to health systems strengthening and quality improvement.

The end of my career in global health

The election of Donald Trump in November 2024 was a gut punch, but I did not know then that the real destruction of the world as I knew it would begin to unfold in January 2025, when Trump began the destruction of the United States Agency for International Development (USAID), shuttering almost all of the foreign development assistance that the United States had long led the world in providing.

I have worked in international development assistance for my entire career. I became interested in public health because of a volunteer activity at age 16 when I signed up with a private volunteer organization, Amigos de las Americas, in the summer of 1976 and spent a month in Nicaragua vaccinating children door-to-door with a local Ministry of Health promotor. That experience hooked me on public health, and I spent the next four summers working for Amigos, first as a supervisor of a group of volunteers in Honduras and then three summers in Paraguay. This experience was formative as I learned to speak Spanish fluently and how to deal with mayors, customs officers, and Ministry of Health officials. When I graduated from college, I knew I wanted to pursue a career in international health. I applied and was accepted to the International Health Program of Johns Hopkins University’s School of Hygiene and Public Health.

My Hopkins advisor had received a grant from the Primary Health Care Operations Research (PRICOR) Project, a USAID-funded program to support studies to find ways to improve primary health care (PHC) programs. PRICOR was managed by University Research Co., LLC (URC). The grant was to study community financing of water supply and the Visitadora community health worker program in Brazil. Since I spoke Portuguese, my advisor sent me to Rio de Janeiro to interview one of the principals managing the Visitadora program at the Fundaçāo Serviços Especiais de Saúde Pública (FSESP). In the spring of 1983, I spent a week interviewing FSESP officials and reviewing documents about the program. When I came back from Brazil, I met with my advisor and the PRICOR monitor for the grant, who told me that PRICOR was starting an internship program and encouraged me to apply.

On October 24, 1983, I started at PRICOR as the Spanish-speaking intern, working alongside another recent MPH graduate who spoke French. We supported the staff of five senior scientists at PRICOR who managed funded studies and developed monographs on PHC operations research. As part of the oversight of PRICOR studies, we each accompanied a senior scientist to visit country teams and supported proposal development workshops. After the year-long internship, both of us were offered full-time jobs, and we became involved with other International Division projects and business development activities of URC.

PRICOR I was followed in 1985 by PRICOR II, and PRICOR II by the Quality Assurance Project (QAP) in 1990. I worked on PRICOR II, QAP I, II, and III, working part-time when my children were little. I was fortunate to have pediatrician David Nicholas as my supervisor who was very supportive of family life and flexible working arrangements. This kind of support and my keen interest in the work of QAP and its successor projects made it easy to stay at URC. I went back to work on QAP full-time when my youngest started kindergarten.

When QAP began to focus more on collaborative improvement methods—where purposeful learning among improvement teams is a critical part of the approach—my focus shifted from communication to knowledge management. The inclusion of knowledge management in a project about improving health care was due in large measure to the foresight of Dr. James Heiby, the USAID Project Manager for PRICOR II and QAP.

When QAP was followed by the USAID Health Care Improvement (HCI) Project in 2007, my work increasingly focused on learning from improvement work and creating knowledge products to convey that learning to others. This emphasis on learning and knowledge management became even more important on the USAID Applying Science to Strengthen and Improve Systems (ASSIST) Project (2012-2020). When ASSIST was extended in 2016 to support Zika prevention and treatment in Latin America and the Caribbean (LAC), the value of knowledge management became even clearer, since knowledge management focuses on how to learn from our work and apply that learning to have more impact. The last part of ASSIST through June 2020 was perhaps my most impactful development assistance work, since the improvements we supported benefited not only families affected by Zika but also strengthened prenatal care, newborn care, and early child development services for all mothers and children in 13 LAC countries.

The beginning of the end of my career was Trump’s January 21 Executive Order freezing U.S. foreign assistance pending a 90-day review. Then on February 3, Elon Musk announced on X that “We spent the weekend feeding USAID into the wood chipper. Could have gone to some great parties. Did that instead.” Under the direction of the U.S. Department of Government Efficiency, USAID’s headquarters in Washington, DC was closed, over 2,000 USAID staff immediately terminated, and another 4,765 direct hires placed on administrative leave. By early February, USAID contractors and implementing partners, including those providing humanitarian assistance and emergency food relief, began receiving stop-work orders. Some of these contractors and implementing partners then received communication that the stop-work orders were lifted, but then in many cases were contacted again to say the stop-work orders were still in effect. By July 1, most of the 10,000 staff that USAID had worldwide had been terminated, except for a few hundred who were transferred to the State Department to manage what was left of U.S. foreign assistance.

Effectively gutting the USAID workforce meant that actions to issue waivers for lifesaving programs, as the Trump Administration claimed it was doing, or to support the continuance of “approved” programs, were not happening. USAID’s payment system was frozen, and as a result, most contractors and implementing partners like NGOs and universities had not been paid for work they did before the freeze, and most have been forced to lay off staff or even cease operations.

While U.S. Secretary of State Macro Rubio, who appointed himself acting administrator of USAID, repeatedly said he had issued a blanket waiver for lifesaving programs, including food and medical aid, there being no staff left at implementing partners or USAID meant that promises of such waivers were intentionally misleading and untrue. In early March, Rubio announced that 5,200 USAID programs worth over $1.3 billion had been terminated and that about 1,000 USAID programs would be continued, somehow, but administered by the State Department.

The chaotic way in which USAID implementing partners and grantees were notified of the cuts (often, receiving news that the program was cut, then that the program was reinstated, and then cut again) was cruel. USAID staff were locked out of their emails and offices, placed on administrative leave, and eventually terminated.

Having worked for USAID-funded projects for over 40 years, I know firsthand how USAID was a force for good in the world. As a knowledge management practitioner, I have especially admired how USAID has been a champion of learning, both internally within its own operations and externally as a development strategy. USAID encouraged all of its implementing partners to systemically derive key lessons and knowledge products from the work USAID funded and to make them freely available on the USAID Development Experience Clearinghouse.

I have seen over the past decades a continuous push by staff at USAID to do development better—to make the investments of U.S. taxpayer dollars more impactful and more sustainable. USAID’s policy emphasis on localization and locally led development signaled important shifts in how USAID did business—lessons that will likely not be internalized by staff at the Department of State.

Why should Americans care?  For several reasons.  First, USAID, until it was decimated, was the world’s largest provider of food aid, nutritional, health, and humanitarian assistance, saving millions of lives of women and children around the world.  A recent article in the Lancet used rigorous methods to quantify the impact of USAID assistance over the past 20 years and estimated that USAID programs prevented the death of over 30 million children under five and the deaths of over 25 million people living with HIV and of 8 million with malaria. Cancellation of this aid has direct and immediate impact on vulnerable people. Another recently published study in the Lancet estimated the impact over the next five years of eliminating this assistance as:
       • 4.1 million additional AIDS-related deaths
       • 600,000 additional TB-related deaths
       • 2.5 million additional child deaths from other causes
       • 40-55 million additional unplanned pregnancies
       • 12-16 million unsafe abortions
       • 340,000 additional maternal deaths
       • 630,000 additional stillbirths

Second, the destruction of USAID hurts American businesses and farmers. USAID had a well- established strategy to prioritize contracts for small American companies like Rhode Island-based Edesia which manufactures a lifesaving paste for severely malnourished babies. Cancellation of Edesia’s contract not only harmed its 150 employees but also the farmers across 25 states, the U.S. cargo ships Edesia paid to deliver hundreds of metric tons of its therapeutic paste around the world, and finally, to the international organizations that distributed it to malnourished children.

Third, this assistance, proudly branded by USAID as “From the American People”, created good will towards the United States and its citizens. It also contributed to America’s and global health security by fighting infectious diseases and strengthening local capacity to detect and fight scourges like Ebola, Mpox, and Avian flu which continue to be threats to the United States. Wholesale cancellation of support for infectious disease and research on how to prevent and mitigate pandemics makes Americans less safe and more vulnerable.

I know that my situation, having enjoyed a full and meaningful career and being financially secure, is much better than that of most of my colleagues in the U.S. and other countries. Beyond my sadness at the destruction of USAID and the callous way in which the development assistance sector and so many livelihoods and careers were eliminated, I am fearful of the lasting damage inflicted on our country and the world.

*Views expressed represent the author’s views and not those of WHES.

Why the Destruction of USAID Increases Hunger and Harms America

March 21, 2025

The United States Agency for International Development (USAID), the agency created by Congress in 1961 to lead America’s development and humanitarian assistance, has been decimated by President Trump’s January 21 Executive Order freezing U.S. foreign assistance.

Why should Americans care? For several reasons. First, USAID, until it was decimated, was the world’s largest provider of food aid, nutritional, health, and humanitarian assistance, saving millions of lives of women and children around the world. While many Americans believe that foreign aid takes a large share of federal spending, in fact this assistance accounts for less than 1% of government spending.

Cancellation of this aid has direct and immediate impact on vulnerable people in low- and middle-income countries. Nicholas Enrich, the acting assistant administrator for global health at USAID, who was placed on administrative leave on March 2 for documenting the failure of the Trump administration to follow through on its pledge to allow waivers for lifesaving foreign aid, has written that the consequences of halting $7.7 billion in funding for lifesaving global health programs will lead to the following each year:

  • 5–17.9 million cases of malaria, with an additional 71,000–166,000 deaths;
  • a 28-32% increase in tuberculosis globally;
  • an additional 200,000 paralytic polio cases;
  • more than 28,000 cases of Ebola, Marburg, or related diseases;
  • 17 million pregnant women without access to life-saving services when faced with delivery complications;
  • 11 million newborns not receiving critical postnatal care;
  • 1 million children not treated for severe acute malnutrition.

“USAID’s failure to implement lifesaving humanitarian assistance under the waiver is the result of political leadership at USAID, the Department of State, and DOGE, who have created and continue to create intentional and/or unintentional obstacles that have wholly prevented implementation,” wrote Enrich on Feb. 28. “This will no doubt result in preventable death, destabilization, and threats to national security on a massive scale.”

Second, the decimation of USAID hurts American businesses, faith-based organizations, and farmers. USAID had a well-established strategy to prioritize contracts for American small businesses like Rhode Island-based Edesia which manufacturers a lifesaving paste for severely malnourished babies. Cancellation of Edesia’s contract not only harmed this business of 150 employees but also the farmers across 25 states, the U.S. ocean liners Edesia paid to ship hundreds of metric tons of its Plumpy’Nut therapeutic paste, and finally, to the international organizations that distributed it to children staving off death.

Third, this assistance, proudly branded by USAID as “From the American People”, created good will towards the United States and its citizens. It also contributed to America’s and global health security by fighting infectious diseases and strengthening local capacity to detect and fight scourges like Ebola, Mpox, and Avian flu which continue to be threats to the United States. Wholesale cancellation of support for infectious disease and research on how to prevent and mitigate pandemics makes Americans less safe and more vulnerable.

Presidential Advisor Elon Musk bragged on X on February 3 that “We spent the weekend feeding USAID into the wood chipper. Could have gone to some great parties. Did that instead.” Under the direction of Musk’s Department of Government Efficiency, USAID’s headquarters in Washington, DC was closed, over 4,000 USAID staff terminated, and another 4,765 direct hires placed on administrative leave.

By early February, USAID contractors and implementing partners, including those providing humanitarian assistance and emergency food relief like Catholic Relief Services and Lutheran World Relief, began receiving stop-work orders. Some of these contractors and implementing partners then received communication that the stop-work orders were lifted, but then in many cases were contacted again to say the stop-work orders were still in effect.

Effectively gutting the USAID workforce means that actions to issue waivers for lifesaving programs, as the Trump Administration claimed it was doing, or to support the continuance of “approved” programs, are not happening. USAID’s payment system is not accessible. As a result, most contractors and implementing partners have not been paid for work they did before the freeze, and many have been forced to lay off and furlough staff or even cease operations.

While U.S. Secretary of State Marco Rubio, now the acting administrator of USAID, has repeatedly said he has issued a blanket waiver for lifesaving programs, including food and medical aid, no staff at implementing partners or USAID means promises of such waivers are cruel hoaxes. In early March, Rubio announced that 5,200 USAID programs had been terminated and that about 1000 USAID programs would be continued but administered by the State Department.

In addition to stopping the delivery of food and humanitarian assistance, the Trump Administration also ended the USAID-funded Famine Early Warning Systems Network (FEWS NET) which monitored drought, crop production, food prices, and other indicators in order to forecast food insecurity in more than 30 countries. FEWS NET was created following the 1984 famine in Ethiopia, which killed an estimated 400,000 to 1 million people – and caught the world off guard. President Ronald Reagan then challenged USAID to create a system to provide early warning and inform international relief efforts in an evidence-based way. Managed by contractor Chemonics International, FEWS NET employed researchers in the United States and around the world to provide eight-month projections of where food crises will likely emerge. Now, its work to prevent hunger in Sudan, South Sudan, Somalia, Yemen, Ethiopia, Afghanistan, and many other countries has been stopped. Amid the aid freeze, FEWS NET has no funding to pay staff in Washington or those working on the ground. The wealth of data that underpinned global analysis of food security – used by researchers around the world and paid for by the American people – has been pulled offline.

Aside from the immediate damage to health and health security that the decimation of USAID poses, the assault on USAID has also removed access to the world’s largest public repository of development assistance documentation, the USAID Development Experience Clearinghouse. A public good paid for by American taxpayers, the Clearinghouse and its thousands of resources are now unavailable. It is clear from the draconian cuts to USAID programs and staff that it is not a priority for the Trump Administration to make development knowledge and information available.