I won’t pretend to have more experience with formulating counterfactuals than others here - but I'm interested to learn more!  However, given the scale of these cuts and the central role of U.S. funding, I think a significant increase in malaria deaths is incredibly likely. The leaked USAID memo stated an “additional 12.5-17.9 million [malaria]cases and 71,000-166,000 deaths (39.1% increase) annually” could be possible if programs are permanently halted.

In 2020, there were around 80,000 additional deaths from malaria, largely due to disruptions in malaria prevention, diagnosis, and treatment. ("The age-standardized death rate from malaria was 9.3 deaths per 100,000 in 2019 and increased by around 12% to 10.3 deaths per 100,000, equivalent to around 80,000 additional deaths. Estimates from the World Health Organization also show a similar increase." Our World in Data)

Even in 2020, the financial shortfalls were not as extreme as what we’re seeing today. I’d be curious to hear what people think is a more reasonable mortality estimate, based on that and the factors below.

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U.S. funding accounts for the vast majority of global malaria financing, and African governments already operate under tight fiscal constraints. These cuts put them in an impossible position. The latest African Leaders Malaria Alliance (ALMA) progress report acknowledged this risk:

• “A small number of external donors continue to provide the majority of financing for malaria interventions. Member states highlight the risks this presents to long-term sustainability and a need to diversify sources of funding.”

ALMA also commissioned modeling showing that, even with flatlined funding, Africa could see up to 280,700 additional malaria deaths between 2027 and 2029 due to upsurges and outbreaks. Instead of flatlining, funding is cratering.

• The US bilaterally provides nearly 25% of global malaria financing through the President’s Malaria Initiative (PMI), including $795 million in FY24
• The Global Fund to Fight AIDS, TB, and Malaria is the largest overall donor, contributing more than 60% of global donor financing.
  • However, the U.S. is the single largest donor to the Global Fund, but its contributions are capped at 33% of the total. If other donors (like the UK and Netherlands) go through with announcements to reduce ODA, including to orgs like the Global Fund, the U.S. will be forced to cut further. This already happened last year when the U.S. had to reduce its Global Fund contribution by $350 million.
  • Discussions within the Global Fund board about shifting the disease split for funding between AIDS, TB, and malaria could further reduce available malaria funding

Beyond financing, USAID played an immense operational role that no other donor can immediately replace. It was deeply embedded in ministries of health, funding frontline health workers, lab technicians, doctors, nurses, and supply chain logistics. Without these systems, malaria cases and fatality rates will rise.

• In Kenya, at least 1,500 health workers have lost their jobs, and the CEO of the National Syndemic Disease Control Council estimates that at least 41,000 health workers are employed with USAID funding.
• In Uganda, at least 3,000 doctors, nurses, and lab technicians have been furloughed or laid off and 29,000 could face job losses. The Health Ministry encouraged staff who were willing to work without pay to continue to do so "in the spirit of patriotism as volunteers…”

The idea that “many of the poorest people will buy medications if they have to” assumes that antimalarials will even be available. In the short term, many may not be. 

• A significant portion of malaria commodities—bed nets, diagnostic kits, and antimalarial drugs—are imported. Supply chains are already disrupted. Some frontline organizations report difficulties procuring antiretroviral drugs, even if they have independent funding, due to the USAID shutdown. Malaria commodities could face similar issues.
• The U.S. withdrawal has been so abrupt that new procurement contracts or programs can’t be put in place quickly enough, causing immediate shortages and delays.
• Materials already in the pipeline/under production that include the mandatory branding of “USAID - From the American People” may not be able to be legally distributed.
• Suppliers don’t know what future demand will look like or whether they’ll be paid, leading to reduced production and inevitable supply bottlenecks and price spikes.

DAA Enrich wasn’t able to finalize the memo before being put on Administrative leave, so I think it’s fair to look at it with some additional grains of salt. But I am still more convinced than not that this abrupt termination of US aid programs - which is unprecedented in scale and breadth - could lead to tens of thousands, if not hundreds of thousands, of excess malaria deaths in one year. 

That’s not to say that will become the new baseline level of mortality for every year moving forward…but these programs and procurement contracts are formulated on 3-5 year timelines normally, so this initial shock will be very destabilizing and deadly. 

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As a public health advocate I don’t know as much about counterfactuals as many in this forum. I’d be curious to hear what you (and others) think is a more reasonable mortality estimate, given these factors, so I can continue to learn and refine my opinions on this.

Great points Nick. Can I message you/are you open to moving this offline? I want to keep the conversation going and have a lot of thoughts but some I'm not comfortable sharing publicly yet (not 100% convinced of my position) and I need to be sensitive given my job and relationships with other orgs in the space. 

Really important and sobering estimates.

 Commenting to add that the Acting Administrator of Global Health at USAID, Nicholas Enrich, had similar estimates for malaria. He was working on this memo (published by NYT) on consequences of the aid pause when he was put on Administrative Leave (probably as retaliation for other memos documenting the inability of lifesaving work to continue due to USAID political leadership)

Global Case Increase of Malaria Over One Year If Programs Are Permanently Halted: "An additional 12.5-17.9 million cases and an additional 71,000-166,000 deaths (39.1% increase) annually"

Yes, I would recommend calling every day if you can to both the local and DC offices for your Congressperson and both Senators. In most offices, the senior staffers and Member get a report of the 3 most called about topics for each day at each of their offices (DC and local) and how many people discussed the topics. Be sure to include your zip code when you call, even if they don't ask for it, because data's often sorted that way too. It helps your case if your zip code is an area that traditionally votes for them, since they'll want to get/keep your vote.

According to Hill staffers, Republican callers generally outnumber democrats 4-1, closer to 11-1 on hot-button issues, so persistent outreach can make a difference.

Appreciate this thoughtful comment Nick! I'm also unsure where I fall on how EAs should respond/ where the balance between funding policy advocacy and cost-effective interventions on the ground should be. I think within the advocacy piece - my argument would be that EAs should diversify influence strategies and the types of organizations they fund in order to build power from multiple angles. And even to build the evidence base needed for these kind of calculations, because I think everyone is kind of shooting blind. Influencing aid policy is difficult but it's possible with the right strategy…which I think could be more diversified than it is now.

1. Funding more grassroots advocacy strategies. Grassroots organizing is an essential but often overlooked piece of policy influence. While direct lobbying by experts and insiders plays a role, real political change happens when elected officials feel pressure from their own constituents. This is one of the most powerful tools we have in democracy, but it doesn't fit neatly into impact assessments and is underfunded as a result. Without sustained grassroots pressure, even the best policy ideas often go nowhere. But even with robust and already established grassroots networks, it can take multiple congressional sessions to get bills passed or funding increased. But it’s hard to prove impact if it looks like your campaign didn’t achieve anything. Even if you are at a significantly stronger starting point than you were at the start of the last session 2 years prior, you basically need to start over with re-introducing bills, educating new members of congress, recruiting volunteers in districts that are newly important due to committee assignments, etc. Influence with Congress depends heavily on relationships and trust built through prior collaboration, but funders (understandably) want to see results on shorter grant cycles.
2. Prioritizing established experts/organizations in particular markets…A big challenge in the CEAP blog was underestimating the complexity of political advocacy. Policymakers don’t simply weigh competing voices; they listen to those who understand the policy landscape, the political constraints, and the key decision-making processes, which can take years to grasp. it's important to understand who is influential to the people you want to influence, and how/if you can get them to be messengers of your ideas, which takes time in these spaces and to understand the interpersonal dynamics of decision makers, sometimes apart from their official role. I think, in part because of this complexity and difference between donors, that it's best for organizations to specialize in one sovereign donor (especially where they're based) and/or a multilateral system rather than casting a broader net or taking a more meta approach.
   1. For example, much of the governing/oversight for US foreign aid is done through the annual appropriations bill, which very few members of Congress fully understand, and which few organizations are funded to engage in depth on - given restrictions around funding lobbying.
3. …while supporting cross-market networks/coalitions. I think there’s great value in making linkages/coordinated pushes across donor markets, and EAs could do more to support networks/coalitions of aid effectiveness advocates across multiple countries. My organization is a founding partner of a group of civil society organizations across 14 countries advocating for increased global health ODA in our markets and globally. This kind of infrastructure means we can mobilize quickly when opportunities - or threats - emerge in ways that newer orgs often can't. The example in the CEAP blog of Sweden aid cuts is a great case in point - having deep, existing networks allows for rapid response in time sensitive situations. We also benefit from individualized expertise and credibility of our local ties, local grassroots networks, and individual relationships with policymakers - it’s just not that an American INGO has a DC office, Brussels, office and Nairobi office - which would be weaker position IMO.
4. Leveraging existing organizations and strategies for change, rather than standing up new EA-specific groups. I think EA efforts in this space have struggled because they often start from scratch - and bring in advisors and those with expertise - instead of partnering with experienced advocates and established networks that already have access and influence. Without that foundation - and knowing the ins and outs of key levers of power for foreign aid oversight (like appropriations and the annual SFOPS reports in the US) - it's difficult to meaningfully advise career civil servants who have spent decades navigating these systems. With the extreme hollowing-out of USAID staff in the past 3 weeks, and loss of thousands of years of experience across them, I’m not sure what this dynamic will look like moving forward but expect it will be dramatically different, at least in the short term.
   1. I have never worked at an explicitly EA policy advocacy organization, so this is a big assumption on my part, but taking lessons from successful campaigns less focused on evidenced-based programs could be useful. Policy advocacy is incredibly relational and based on emotion. People’s hearts and minds are usually not changed by the data/evidence, rather they have some kind of emotional breakthrough that makes them more willing to hear the other evidence. Not to say it should be that way…but it’s what I’ve experienced. it's not enough (in the US market) to have a clearly defined "edge" or produce detailed or factual reports. Also to emotion/ego on the other end, policymakers tend to listen to those who tailor solutions to them and solutions they feel they can claim as a personal win and "own" moving forward and this kind of advocacy communication is a unique skill that can be honed over time.

EAs have so much experience evaluating programs and identifying what to move forward, so I think a big challenge for this community will be figuring out how to move forward. I think increased investment in grassroots advocacy strategies could be most useful in the short term, especially in a culture currently leaning anti-intellectual and anti-science.

This is a great question. For some of the trials it wasn’t an issue of the funding freeze but the abrupt and unprecedented “stop work order” issued by Secretary of State Marco Rubio (who is also acting Administrator of USAID). It was so immediate and sweeping that the research staff would have been violating it if they helped remove experimental devices (but some did anyway). Many of the trials were partnerships with U.S. drug companies who were testing products they hoped to sell to commercial markets overseas. It also affected a malaria vaccine trial at Oxford. 

The funding situation is similar to described above - multi year contracts/agreements with USAID which investigators/partners expected the government to honor. Many studies probably had contingency plans for early termination, but those would depend on  adequate warning (weeks if not months/years) to wind down activities.

Nothing like this has happened before and it will fundamentally change how the US government does business with companies - in sectors beyond health/aid. 

NYT has a great article on that goes into more detail - https://www.nytimes.com/2025/02/06/health/usaid-clinical-trials-funding-trump.html?smid=nytcore-ios-share&referringSource=articleShare

Yes, we should all get involved, thank you for your work on PEPFAR!

On paper, the waiver should cover about half of PEPFAR programming. In practice, I’m not even sure that much will be able to restart because of the drastic reduction in the USAID workforce that this Stop-Work Order (and other efforts by The Department of State/F Bureau) have caused.

On a webinar on Saturday  Dr. Atul Gawande (former Assistant Administrator for Global Health at USAID) he said that the emergency waiver is not enough because the agency has been decimated - turning it back on with a fraction of the staff and much of the expertise removed will not work. USAID and implementing partners have lost people and capacity and are losing it by the day. 

PEPFAR is technically a State Department program - but most of the funds are transferred and programmed through other agencies. In the past week, ~70-80% of staff at the Global Health Bureau (GHB) and Bureau for Humanitarian Assistance (BHA) have been fired or put on leave. One USAID official quoted in Devex on 2/3: “The waivers from Secretary of State Rubio for emergency food aid and other urgent assistance are a smokescreen and farce if there is no one to make the awards happen”

Unfortunately these waivers have not led to real change on the ground for implementing organizations - many are still unable to operate. More pressure on members of Congress is needed ensure lifesaving programs can continue. This New York Times article published on 2/1 covers more details (gift link). 

"In Uganda, the National Malaria Control Program has suspended spraying insecticide into village homes and ceased shipments of bed nets for distribution to pregnant women and young children, said Dr. Jimmy Opigo, the program’s director.

Medical supplies, including drugs to stop hemorrhages in pregnant women and rehydration salts that treat life-threatening diarrhea in toddlers, cannot reach villages in Zambia because the trucking companies transporting them were paid through a suspended supply project of the United States Agency for International Development, U.S.A.I.D.

Dozens of clinical trials in South Asia, Africa and Latin America have been suspended. Thousands of people enrolled in the studies have drugs, vaccines and medical devices in their bodies but no longer have access to continuing treatment or to the researchers who were supervising their care."

It is important for Americans and taxpayers to contact our members Congress (especially if your elected officials are Republican or Libertarian). USAID is funded by the American people - Congress needs to hear from us that we think this is a good use of our tax dollars. You can go here for more info on how to contact your members of congress about this.

Hi Rebecca. I believe the issue is that Trump/Rubio do not want to properly execute this waiver. Everyone who has congressional representation should contact their members of Congress and the media to raise awareness about this issue with the broader American public.

The Trump administration is taking deliberate steps to undermine USAID and its ability to process these urgent waivers. More than half the staff has been fired or terminated in the past week.  They're also purging the Legislative and Public Affairs (LPA) division, making it harder for Members of Congress to get answers about USAID's work.

This weekend, the USAID site and X account were removed. USAID now has a pared down sub-page under the State Department site, solidifying claims in earlier reporting that this Administration want to dismantle USAID as an independent agency (which many argue would require an act of Congress). But Republican members so far are being very silent about this direct attack on checks and balances and their duties under the constitution.

NYT Gift Link: End Appears Near for U.S. Aid Agency, Democratic Lawmakers say. (2/1/25) "Two incoming Trump administration officials familiar with the matter said the president’s team is exploring subsuming the agency into the State Department. Five others close to the administration said they weren’t aware of specific plans but that USAID’s independence is definitely not guaranteed. All were granted anonymity because they weren’t authorized to speak about the issue."