“I don’t think they know what they’ve broken,” an administrator for a U.S. Agency for International Development affiliated program in Malawi confided. I don’t think we on the ground yet know all that they’ve broken.

Where USAID has a footprint, even a partial one, critical services ground to a halt, supplanted with often-meaningless waivers. No matter what happens next, trust has been shattered.

I know because I’m a surgeon at a major hospital in Malawi, outside the capital city of Lilongwe. I moved my family halfway across the world to train Malawian surgeons, where the surgeon-to-population ratio is among the lowest in the world. I and trusted colleagues — many under an unprecedented U.S. government gag order — have seen firsthand the impact on critical health care and food aid.

When the Trump administration’s 90-day freeze on all things USAID put lives at immediate risk, the outcry from humanitarian workers and organizations was immediate. U.S. Secretary of State Marco Rubio responded with so-called “waivers” for “life-saving humanitarian assistance” that includes “core life-saving medicine, medical services, food, shelter, and subsistence assistance.” Yet funds remain unstable or cut off, forcing drastic staff, food, medicine and medical supply shortages.

HIV drug resistance can develop within days, so imagine the potential consequences when an HIV clinic in Lilongwe, which served 12,000 patients, lost its USAID-funded staff and the facility had to shut down. The main government hospital — already understaffed — had to send doctors who haven’t done HIV care in years to try to help.

Trained psychosocial counselors at a clinic serving HIV-positive teens were ordered not to come to work. They are critical, because about a third of these teens suffer major depression, making it difficult for them to reliably take their medication. A group responsible for testing pediatric inpatients for HIV, partly USAID-funded, had to send half its testing team home. Children who would have tested positive and begun treatment likely fell through the cracks. 

What happens next is anyone’s guess. The “waiver” some HIV organizations received from the U.S. State Department clearly stated, “this is not a guarantee of payment.” Not paying staff is against the law in Malawi. So if people go back to work and USAID doesn’t pay or pay in full, other organizations will have to foot the bill — if they can — and that will put their operations at risk.

Antiretroviral medications for HIV are in stock for the moment, in part because they were ordered before the USAID freeze. Doctors are terrified of what will happen when more stock is needed. With up to 10 percent of the Malawian workforce HIV-positive, things could return to the 1990s, when the only industry doing well was that of coffin-makers. 

This USAID catastrophe extends far beyond HIV aid, with tragic irony. Vitameal is a supplement given to moderately malnourished hospitalized children, supplied through Feed the Children under USAID. Even though it is stored in a warehouse in the greater Lilongwe area, staff have been ordered by USAID not to work, so no one can access the product. Hospitals are rationing what they have left, with no ability to get more. Vitameal may rot in a building just miles away. 

Many families rely on food aid right now, and food is stuck in storehouses while people here are starving. This time of year is called “hunger season” for a reason. Last year’s crops failed from the worst drought in 100 years. The year before, crops were washed away in a massive cyclone. We are now in the middle of the rainy season, but the harvest is months away. 

Perhaps the greatest irony is that much of this food is surplus from American farmers, purchased by the U.S. government and shipped as food aid under Title II commodities. So U.S. taxpayers are paying for the storage of this U.S.-grown food, while USAID is banned from distributing it and people are going hungry. 

Where are those waivers? One local expert summed it up like this: “There is no one senior enough left at USAID to actually sign off on anything.” 

Nor have waivers included tuberculosis, so “waive” hello to drug-resistant tuberculosis, a global threat. My hospital no longer has funds to purchase screening materials, or pay staff who ensure patients don’t miss any doses of their medication. We do not have N95 masks to protect ourselves as health workers. Nor do we have the staff to treat an influx of tuberculosis patients.

Meanwhile, some 20 students at nearby Nkhoma Nursing College have had their school and living fees pulled by USAID (a whopping $541 per semester per student). I teach them in our surgical ward and intensive care unit. It is unclear whether the nursing college can sustain the sudden loss of a large portion of its student body and fees. Now, three of them are sharing one plate of food, if they eat at all.

Landlocked Malawi has very little in exportable goods. Aid here remains vital. It’s like the health and food infrastructure of Malawi is a game of Jenga, and it was already wobbling badly. Then all at once, many of the most stable pieces keeping the entire thing still barely standing were suddenly removed. We are in slow motion free fall. Because the USAID budget, less than 1 percent of the total federal budget, was wrongly targeted and vilified, the long and life-saving arm of U.S. foreign aid has been decimated.

Do members of Congress need to be reminded that taking food and medicine away from those we promised to help is unconscionable, and it’s being done in the name of we the American people? I shudder to think what’s ahead. There’s no waiver for that. 

Beth Stuebing, MD, MPH, FACS, is a missionary surgeon based in Lilongwe, Malawi, with her husband and three children.