The Future of Foreign Assistance and Global Health

Transcript

[Sandro Galea]
Welcome to Ideas Matter, a podcast hosted by WashU. I’m Sandro Galea. In February of 2025, Elon Musk posted on the X platform, quote, we spent the weekend feeding USAID into the wood chipper. Could gone to some great parties. Did that instead. He was referring to his work on behalf of the new federal administration to effectively shut down the U.S. Agency for International Development. This was part of a broader disinvestment in global health institutions over recent years, which has included American withdrawal from the World Health Organization.

These actions come at a time when the work of global health and foreign assistance more broadly has faced hard questions. They include, in a globalized age, should there be limits on interconnectedness? Is there a point where support for other countries comes at the expense of one’s own? To what extent should we insist our foreign investment yield a return and how should such a return be calculated? I look forward to discussing these questions and more with today’s guest, Nicholas Enrich.
Nick Enrich is a former civil servant who served at USAID during four presidential administrations. His role included the Bureau of Global Health’s Director of Policy Programs and Planning and USAID’s Acting Assistant Administrator for Global Health. His new book is called Into the Wood Chipper: A whistleblower’s Account of How the Trump Administration Shredded USAID. Nick, welcome.

[Nick Enrich]
Thanks so much for having me.

[Sandro Galea]
So let’s start by asking a bit about you. How did you come to work in global health? was your experience at USAID and how did it all lead to you writing this book?

[Nick Enrich]
Sure. So yeah, I became interested in working for USAID a long time ago, actually. During college, I did a study abroad program in Kenya studying development and health. It was 2003, and it was kind of the height of the HIV epidemic in Kenya and surrounding countries. And actually, while I was there, President Bush signed the President’s Emergency Plan For AIDS Relief, PEPFAR, one of the, or maybe the largest public health initiative in history. And so the timing of it really clicked for me. I kind of realized that my government was reaffirming its commitment to fighting infectious diseases and making the world a healthier and safer place at the same time that I was interested in getting into that fight. So from that time, I realized that I wanted to work for USAID one day.

Over the next 10 years, I was able to start working at the agency. And by the time that Trump took office in January of 2025, I was the director of policy programs and planning for the Bureau for Global Health. Basically meant my job was to make sure that we were effectively using government resources to achieve our global health goals. But within a week of the Trump administration, I was promoted actually without any notice or warning to be the head of the Global Health Bureau when my boss and her deputies were all suddenly placed on administrative leave. At that time, all foreign assistance had been abruptly frozen, and Secretary of State Rubio issued this exception to the freeze on foreign assistance to allow for us to restart life-saving programs. And so as I was coming into the role of the head of global health, my top priority and that for my team was to restart our life-saving programs wherever possible. And so I spent the first several weeks of the administration doing everything I could to restart those programs. But unfortunately, I was stopped at every turn, whether it was the DOGE and the political appointees limiting the definition of what life-saving meant or breaking our payment system or ultimately getting rid of all of our staff and then terminating the contracts that we would have needed to restart our activities.

At the same time that I was being prevented from restarting those programs, the Trump administration and Elon Musk were stating publicly that life-saving humanitarian assistance was continuing, even though it wasn’t. And so I decided at that point that I needed to speak up and speak out to tell the world what was actually happening at USAID. And so my team and I drafted a series of memos describing everything we had tried to do to restart life-saving humanitarian assistance activities and how we had been stopped and warning what the impact of those cuts would be. And so I ended up writing this book to give readers a sense of what it was like inside of Elon Musk’s wood chipper at the time and to describe how USAID was destroyed, by whom, and what it means to the world now that it’s gone.

[Sandro Galea]
So, what’s going on? Leaving aside for a second, we’ll come back to it, a sort of a narrow ideology. Like where’s this push to dismantle global health institutions come from? Like to what extent does it reflect features that are really unique and particular to this moment? And to what extent does it reflect more long-standing critics of foreign assistance?

[Nick Enrich]
Well, I think I would first remind everyone that USAID was not dismantled due to any particular critique of foreign assistance or because it was wasteful or not aligned with the administration’s priorities or something. It was destroyed by a small group of tech bros who really had no idea what the agency even did, and frankly, for the purpose of soothing the ego of a billionaire. But I think it’s important to start there because that’s what actually happened. There was no method to the madness. When we attempt to find a strategic justification for what happened, I find it often to be misguided because remember, there really was no plan. But that said, I do think that USAID and foreign assistance and global health aid in general was uniquely vulnerable to sort of the political argument that I think was easier for people to recognize that, look, we have problems here in the United States. Why would we be spending money overseas to help people there when we have our own problems here. And I think it reflects that we at USAID and in the global health and foreign assistance community in general just didn’t do a good enough job of explaining how foreign assistance actually helps Americans. And to me, I think we need to do a better job of explaining how, when you’re improving global health overseas, that actually makes Americans safer here at home. And it makes the world safer and stabler in ways that has like been a huge benefit to Americans over the past few generations.

[Sandro Galea]
To what extent is what’s happening now linked to COVID? To what extent does COVID shape attitudes towards global health? And what lessons emerged from the COVID pandemic? Or perhaps more oppositely, what lessons should have emerged that should inform how we engage with global assistance?

[Nick Enrich]
Yeah, well I should say that USAID global health policies have shifted dramatically since COVID. And one lesson that I hope that everybody should have taken from the pandemic that we emerged from six years ago was that infectious diseases do not stop at international borders. And since the start of the pandemic, the U.S. government has invested billions in developing and enhancing a global early warning system to help countries to have the capacity to detect and respond to infectious disease outbreaks early, right when they develop to prevent them from spreading and and and worsening. A fundamental underpinning of wherever the future of foreign assistance goes is that we are going to need that broader, global approach to combating infectious diseases. We can’t just hide our heads in the sand and wait for an infectious disease to come to our borders.

[Sandro Galea]
I think you’ve started to answer this question, how do you reply to critics of foreign aid, those who say it’s wasteful, ideological, not worth investment? What is the case for foreign aid in this moment?

[Nick Enrich]
I would ask those critiquing foreign aid who are calling it wasteful and inefficient to show the evidence. Because the evidence that I see actually suggests the opposite. USAID was recognized as one of the most cost-effective agencies across the entire government. I mean, on less than 1 percent of the federal budget, the agency contributed enormously to results. 92 million lives were saved by USAID programs over the last 20 years alone. And the progress that has been made to increase global life expectancy, increase literacy rates around the world, increase or decrease mortality rates, children mortality rates, and saving lives among pregnant women, reducing famines, all these things have shown just what an impact such a small investment can have. So my case for foreign aid, sadly, is actually based on the devastation that we’re already seeing since the cuts to foreign aid went into effect last year with 750,000 people already having died unnecessarily due to these cuts and estimates of potentially up to 14 million people dying over the next five years alone. I’m worried about what’s going to happen with the next generation that’s no longer able to access the global immunization campaign that we provided for children against deadly diseases. And I’m afraid of what we’re going to see. And to me, that’s the most immediate case for why we need to have a system of foreign aid. And to the extent that we want to reform it, that should be done strategically and based on a transition, not just pulling the rug out from under the global community.

[Sandro Galea]
I think it’s hard to even answer the next question in the heat of the moment, but let me try. So do you see this current stepping back of U.S. global health commitments as temporary or as an emerging new normal in global engagement? So how do you see strategic objectives of U.S. foreign assistance over the next decade, particularly with a lens on global health security, which you already mentioned?

[Nick Enrich]
Yeah, so I believe it will be temporary. I don’t think that, as I was just saying, that we’ll be able to hide from the impacts of the cuts. I truly think that we’re already starting to see the true levels of devastation and we’ll continue to see that and will actually need to rebuild. But I think the question is actually how much ground we’ll lose in the meantime before we do. It’s going to be hard to rebuild, much more difficult than it was to destroy it. We’ve got we’ve seen the systems that have been torn apart we’ve lost ground on diseases and will continue to do that every day until we stand up some of these systems. And aybe most importantly we violated the trust that we had with countries that we built over decades and it’s going to be hard to reestablish those relationships and it will take time and effort. We’re already seeing infectious disease outbreaks now that are a great example of why foreign aid is so important. We’re seeing that with the hantavirus, with the recently declared Ebola outbreak in the Democratic Republic of Congo. And I think there’s no question that the U.S. needs to get back into foreign assistance specifically in global health if we’re going to protect national security and save lives around the world.

[Sandro Galea]
What role do you expect multilateral organizations like WHO, World Bank, Global Fund to play in the next generation of foreign systems for health, particularly as the U.S. is, at least at the moment, no longer as engaged in the space as it once was?

[Nick Enrich]
I expect that we will see an engagement with multilateral institutions. I think that, as you say, that’s something that Trump’s administration has been moving away from over the past year. And we’re already starting to see the limitations of what is more of a bilateral approach to global health. I mean, the current administration’s approach to not working in a global way, but working at a country-by-country basis in establishing these kind bilateral agreements with individual countries is not the way that we’re going to solve our global health crises. We’ve heard about agreements with countries such as Zambia, for example, where there’s kind of this transactional nature where we’re trying to extract rights to critical minerals in exchange for HIV treatment, which I think is a problem in terms of everything we’ve learned about a development approach, but also from an epidemiological standpoint. I mean, what’s the point of investing in HIV drugs in Zambia when we’re not even going to consider the fact that the burden of the disease is driven by the neighboring South Africa, where we’re not even engaging at all with having a bilateral agreement? I think that that’s sort of one example of why we need a more multilateral approach if we’re actually going to address global health issues. Right now, I think there’s been 29 individual agreements that have been signed by countries, but there’s still, I think I saw 47 percent of the HIV burden in Africa is in countries where we don’t have agreements with. And I think it just goes to show that there’s just too many holes in a bilateral approach for effective global health policy. And so we absolutely are going to need to revert to a multilateral approach and one that the U.S. is kind of a key and central player in, in combination with organizations like the World Health Organization and the bank and the Global Fund as well.

[Sandro Galea]
So I’m going to assume for next couple of questions that you’re right and I’m hoping you’re right, that this is a temporary state. But looking ahead, recognizing that budgets are constrained but needs are also rising, what do you think are the approaches that are most promising to increase efficiency and reach of global health assistance?

[Nick Enrich]
Yeah, I think we need to like we need to be realistic about what our constraints are going to be. And I think that we are going to be facing mounting challenges and potentially in a resource-limited environment. And so I do think there are ways that we can be more effective and think much more about the overall goal of foreign aid, which should be eliminating the need for foreign aid in the future, right. It’s not just to achieve our global health goals. And so to do that, I think that we need to find different ways to leverage host government commitments linking foreign aid to the achievement of specific milestones along a path to get host governments to take on more responsibility and management of their programs as well as fiscal responsibility. But also the other things that we need to do as we think about a future in foreign assistance is change the way that our procurement instruments, the contracts that we use, are structured to make sure that the funding is more directly tied to the achievement of results, rather than just a payment for continued interventions. We need to be able to show that progress. And I think that we also need to increase our focus. One thing that will be helpful as we function in an increasingly resource-constrained environment is resorting more towards digital health tools, AI tools, and enhanced commitment to data-driven programming to make sure that we’re maximizing the efficiency of our investments.

[Sandro Galea]
Yeah, let’s talk about that for a second because I think one of the challenges, you know, you started off by saying that we had not done a good enough job of selling the importance of what we’re doing with global health and foreign aid. And part of the challenge when we talk about things like global health security is that it’s fuzzy, right? It’s sort of hard to say, like, we are achieving global health security. It’s hard to know how to measure that. So, if you were to be, sort try to think about making the case, thinking about that, what metrics or outcomes should we be thinking about to evaluate the effectiveness of global health assistance and that can actually make the case for global health assistance going forward?

[Nick Enrich]
Yeah, I mean, maybe just to take it back a half a step, implicit in your question is the need to have data driving our investments. Because I think that’s how we know that we’re making a difference, and that’s how we can tweak our programming to be successful. And I think that’s absolutely critical. But unfortunately, that’s one of the many casualties of the cuts to foreign aid that we’ve seen and the destruction of USAID is actually the loss of the use of data. And it’s partially because so many of the programs that we had in place that focused on monitoring and evaluation of data have been slashed. And it’s also because the programs that remain at the State Department, the data that they have been collecting has just not been released. So it’s very hard to evaluate exactly the impact and where we need to shift focus.

So to make the case, we need to access data in order to be able to make these decisions. But I think also separate from that, we do need better metrics and metrics that again as I’m saying are not focused just on our health outcomes but are focused on sustainability and transition metrics, right. Because foreign aid should not just be about ending diseases, it should be about eliminating the need for foreign aid and transitioning that responsibility and the financing of public health to the governments where we’re working, and so we need to measure things like to what extent are countries able to take on responsibility for the health programs or how much are they taking, like what percentage are they paying their health workforces or procuring their own drugs and commodities and managing their own data system.

And what other metrics can we use that are aimed at, like potentially establishing end dates for foreign assistance for particular diseases or particular health areas and/or for specific countries so that we can measure milestones as we go and make sure that we’re actually progressing towards transition and not creating a situation where we’re potentially continuing to foster dependency on American foreign aid?

[Sandro Galea]
Now, I know I’m the one who pushed you to answer a data-driven question, but just for a second. Of course, data and outcomes are not the only reason why one, as a country, might want to engage in foreign aid. There’s some good values-based reasons why one might do that. Can you just make the values case?

[Nick Enrich]
Sure, I mean, one thing that President Obama said was that when many people around the world think of the United States, they’re actually thinking of USAID. And that’s because USAID is often the first way that people around the world actually engage with the United States. And we have been able over the past several decades to have a foreign policy that’s in part based on embodying American generosity and good will in a way that has increased partnerships and made the world a safer place. But I think that what the reality is, and the reason that I first wanted to work for USAID, because I felt pride in my country when I was in Kenya watching as USAID was involved in helping to make people healthier and make people’s lives a little bit easier from diseases that in the United States were perfectly manageable. And to see the impact and the way that people’s lives have been improved over the course of the last six decades is truly incredible given, again, the size of the investment that the U.S. has made.

[Sandro Galea]
So leaning again into the assumption, thinking that this is temporary, and I shared that with you. Let’s look ahead 20 to 30 years. So what’s a next-generation global health architecture looking like and what role will the U.S. play in it?

[Nick Enrich]
I see much more of a systems-based approach being the future of what global health architecture looks like. I think that what we’ve seen in the past, and we have the opportunity sort of to move away from as we think about a next generation or a future in foreign assistance, is to focus more broadly on serving and benefiting individuals rather than on kind of the siloed projects that we’ve had that have been directed at progress on specific diseases. And to me it’s it’ll be kind of improving access to and expanding access to primary health care systems and a more holistic community-based system of care so that global health services are able to reach people where they live rather than, in the past where it’s been, as I say, siloed on programs, but also centered at support at particular hospitals and health facilities. And I think that that’s one of the areas of real opportunity for a change and a reevaluation of approach as, if and when, the United States gets back into the global health field.

[Sandro Galea]
You and many of your colleagues have had a hard year, and I’m sorry for that. With all these challenges in the moment, what gives you hope?

[Nick Enrich]
Somebody said, don’t let a good crisis go to waste. And I do think that in the devastation that has been faced by the destruction of USAID, we do have an enormous opportunity to reimagine and build a stronger system than the one we had before, to deliver foreign aid more effectively in the future. And so many of the barriers that were kind of obstacles to achieving our goals in global health in the way that we used to work have just been completely wiped out and broken down in basically the stroke of a pen. Say what you will about the way that the agency was destroyed, it definitely opened eyes in terms of what the opportunities are out there to just do away with the current system and try to build something new.

So I think as we think about rebuilding, we really have this new opportunity to be very creative about how we approach global health and foreign assistance and kind of rather than the incremental improvements we had been making to the existing system, it’s a true chance to re-envision something better and something new, and challenge the assumptions that we had been making. I do have hope that when we are able to rebuild that system, it can be something that’s much more effective and much more efficient than what we had before, which is great.

[Sandro Galea]
I do appreciate your generosity of spirit to find hope in the moment after the year you’ve had. I am Sandro Galea. I’ve been talking with Nick Enrich about the future of foreign systems and global health in light of the recent shutdown of USAID. Thank you, Nick, for this conversation.

[Nick Enrich]
Yes, thank you so much for having me.

[Sandro Galea]
And thank you everyone who has joined us for Ideas Matter. I look forward to continuing the conversation.