By Paul V. DeMarco
Guest Columnist
I’m no foreign policy expert, but I have an advantage over most Americans trying to understand the shutdown of the US Agency for International Development (USAID). I have seen its work overseas. In February 2020, I was part of a small group of doctors and medical students from the University of South Carolina who traveled to Tanzania to work in one of the nation’s major referral hospitals.
In my two weeks there, I discovered that Tanzania’s health system is decades behind ours. Due to the lack of medical infrastructure, Tanzanians suffer and die of diseases like HIV and TB at much higher rates than Americans. I met an American couple, both doctors, who had chosen to work for several years in a clinic run by Baylor University dedicated to the prevention of HIV and the care of children and families already infected. Baylor had built a welcoming, modern clinic on the campus of the hospital. One of the funders of the clinic was USAID.
This young couple and their small children were not part of a “criminal organization” as Elon Musk posted on Twitter on February 2nd, nor were they working for one that was run by “radical lunatics” as Donald Trump said the next day. These were exemplary, highly trained Americans serving sacrificially far from home, in a way that should make us all proud.
It is Trump’s prerogative to shape agencies according to his governing philosophy. It is reasonable for him to roll back programs that focus on diversity, equity, and inclusion as he said we would in his campaign. I may disagree with the hysteria over transgender Americans that Trump was glad to stoke. I may support the simple idea that diverse groups are usually stronger and more productive than homogeneous ones. But Trump won the election, and I respect his right to make changes that will perturb me.
What I object to is a purge of an organization that is so important to America’s standing in the world. USAID has more than 80 missions in approximately 130 countries. As of this writing, all of them have been closed. USAID workers, both those devoting a few years like my friends in Tanzania, and others who have spent their careers overseas, are now locked out of their offices, unsure of their next paycheck, and trying to make contingency plans thousands of miles from home.
There is a sensible way to reform USAID. Conservatives have long complained that USAID is too autonomous and that some programs, such as funding for Palestinian NGOs, were not aligned with American interests. This is a legitimate policy dispute. Some would argue that we should provide humanitarian assistance to families ravaged by a war they had no part in making, others would argue that too much of the aid would end up in the hands of Hamas.
Let’s have those debates. Let’s consider the pros and cons of putting USAID under the control of the State Department. But let’s do it without upending the lives of American citizens abroad or putting the lives of our allies at risk.
Endangering the President’s Emergency Plan for AIDS Relief (PEPFAR) is particularly egregious. PEPFAR was created in 2003 by George W. Bush and has been the most successful anti-HIV effort on the planet, saving millions of lives and preventing untold numbers of cases of HIV, including the most devastating, maternal to infant transmission.
Secretary of State Marco Rubio has issued waivers for critical humanitarian assistance, but there is much confusion about what the waivers will cover and how the new funding streams will operate. It is certain that many patients’ daily HIV medication supply will be disrupted.
Any interruption in PEPFAR services could be disastrous. One of the weaknesses of current HIV therapy is that when patients stop taking their medication, the virus can become resistant and much more difficult to treat, resulting in complications and even death.
HIV has, thankfully, been reduced to a controllable chronic disease here at home. Most people who are diagnosed with HIV in the U.S. can live a normal lifespan. I have about a dozen HIV-positive patients in my practice. All of them have their HIV controlled with a simple daily regimen. Many of us have forgotten what it was like at the peak of the epidemic in the 1990s when thousands of young people were dying, emaciated and terrified. But HIV is still poorly controlled in some of the developing world such as sub-Saharan Africa and India, where USAID is doing lifesaving work.
I’m disappointed by my evangelical Christian brethren, most of whom voted for Trump. Churches usually ask for a 10% tithe. USAID’s budget is less than 1% of the total budget of the United States. The vast majority goes to work that Jesus asks us to do in the 25th chapter of Matthew – feeding the hungry, inviting in the stranger, caring for the sick. So much for Christian nationalism when it comes to how we treat our neighbors around the world.
All of this was easily predictable and preventable. But that’s no concern for Trump and Musk, who seem locked in a battle for who can demonstrate the least empathy. The shutdown of USAID exposes the current administration as incompetent and cruel.
A version of this column appeared in the February 19th, 2025 edition of the Post and Courier-Pee Dee.
The Doctors DeMarco: Paul and his daughter Grace, then a 4th-year medical student, in Tanzania…
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Paul, you continue to provide a model of what such civility advocates as Nicholas Kristof have been advocating to restore.
And as y’all know, I strongly support those efforts. But sometimes you may try a little too hard.
I always go with your headlines, but I would never have started this one with these particular words: “USAID merits reform.” I think that grants too much ground to people who spit on the very idea that the richest and most powerful nation in the history of the world have a duty and obligation to help those who are lacking.
Every organized endeavor in the world could be improved, and USAID is no exception. But “reform” is not the right word in this case, going by your examples of possible changes. Those are adjustments in some specific operational decisions. They don’t address any fundamental inefficiency or malfeasance in the core being of the institution.
Of course, I’m old school. Nowadays headlines are there to get you to click, and stories are organized to hide essential information so that you keep reading as long as possible. This is the exact opposite to the core values that guided newspapers in my day. The point was to give busy people as much essential information about the subject of the story as possible as quickly as possible.
That meant a headline that at least tell you WHAT happened, and maybe the WHO as well. The lede — the first paragraph — would repeat those, and add in the WHEN and WHERE, and maybe even HOW and WHY. So in your first second with a story, you could know all the basic facts even if you had to run. This is how you build an informed electorate, you see.
So I’m concerned that your first three words offer too much concession to the Trump supporters who will stop reading there (if they even go that far), and go away saying :”Damn’ right it does, and we’re GIVING it to ’em…”
But that’s more words than such a minor flaw deserves. Your column is certainly not in need of “reform.”
Although my eyes did pop out a bit when you suggested that Trump has something that could be fairly termed a “governing philosophy.” PHILOSOPHY — a “love of wisdom?”
At best, he has an “approach.” And his approach is to treat America and all it stands for the way Rome is alleged to have treated Carthage at the end of the last Punic War. I’m at least 100 percent in agreement with your concern about “America’s standing in the world.” But good luck getting Trump or his minions to stop energetically destroying that. They are utterly committed to that destruction.