“Sketching Ballpark Figures for Major Disease Areas
A lot of the projects mentioned in the article revolve around a few top causes of death in low-income settings—particularly HIV, TB, and malaria—plus maternal/child health, polio immunization, neglected tropical diseases, and acute malnutrition relief. Let’s look at the big three first:
A. HIV/AIDS
Programs at stake:
350,000 people receiving antiretroviral therapy (ART) in Lesotho, Tanzania, and Eswatini (Elizabeth Glaser Pediatric AIDS Foundation programs).
2.5 million monthly treatments in Kenya.
46,000 in Uganda (Baylor College of Medicine).
Plus smaller programs in other countries.
It’s easy to see that over 3 million people on ART might lose reliable access if these terminations truly go through.
Impact of losing ART:
Historically, before widespread ART scale-up, HIV mortality in sub-Saharan Africa could be 5–10% per year for people with untreated late-stage HIV.
Not all 3 million are on the brink of advanced disease, but a large fraction would see significantly higher morbidity and mortality within months to a couple of years of treatment interruption.
Deaths per year:
If even ~5% of these 3 million lost access and died within the year, that’s ~150,000 deaths.
It could be significantly higher depending on how advanced their disease is, how quickly they can find alternative sources, etc.
B. Tuberculosis
Projects at stake:
3 million people receiving TB medications via the Global Drug Facility.
The main USAID-funded TB research consortium (Smart4TB).
Additional TB/HIV co-treatment programs.
Mortality if untreated:
Globally, the case-fatality rate for untreated active TB can reach 30–50% in high-burden, resource-poor settings. Even partially treated or interrupted regimens have high mortality risk.
Conservatively, if ~3 million lose consistent access to TB meds, you could be looking at hundreds of thousands of additional TB deaths over a year or two.
C. Malaria
Projects at stake:
$90 million bed net and treatment contract covering 53 million people.
Additional programs (e.g. Evolve) that do indoor residual spraying for 12.5 million.
REACH Malaria (PATH) for ~20 million.
Mortality if these interventions vanish:
Globally, roughly 600,000+ people (mostly children) die of malaria each year (WHO estimate for recent years).
Bed nets and spraying are a major reason malaria deaths have fallen since ~2000. Various sources (including GiveWell) estimate a cost of a few thousand dollars per life saved (varies, but often on the order of $3,000–$7,000 for top charities).
The U.S. is a key donor to a large chunk of those protective interventions. It’s not crazy to think tens of thousands—possibly 100,000+—extra malaria deaths could occur annually if those nets and sprays simply are not replaced.”
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”
I’m really unimpressed by these estimates. It shocks me how many public health professionals don’t understand counterfactuals.
It’s really bad that USAID is pulling out but every calculation I’ve seen from the WHO, UN and others like this wouldn’t get you through the first round of GiveWell interviews.
You have to factor in that other countries and the African governments themselves will likely account for a decent proportion of the shortfall, and that many of the poorest people will buy medications if they have to. The idea that USAID pulling out could cause a 40 percent increase in malaria deaths is beyond ridiculous.
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.
----
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.
Relevant NYT article detailing the cuts: https://www.nytimes.com/2025/02/27/health/usaid-contract-terminations.html?smid=nytcore-android-share
Had O1 pro estimate the death toll of these cuts:
“Sketching Ballpark Figures for Major Disease Areas
A lot of the projects mentioned in the article revolve around a few top causes of death in low-income settings—particularly HIV, TB, and malaria—plus maternal/child health, polio immunization, neglected tropical diseases, and acute malnutrition relief. Let’s look at the big three first:
A. HIV/AIDS
Programs at stake:
350,000 people receiving antiretroviral therapy (ART) in Lesotho, Tanzania, and Eswatini (Elizabeth Glaser Pediatric AIDS Foundation programs).
2.5 million monthly treatments in Kenya.
46,000 in Uganda (Baylor College of Medicine).
Plus smaller programs in other countries.
It’s easy to see that over 3 million people on ART might lose reliable access if these terminations truly go through.
Impact of losing ART:
Historically, before widespread ART scale-up, HIV mortality in sub-Saharan Africa could be 5–10% per year for people with untreated late-stage HIV.
Not all 3 million are on the brink of advanced disease, but a large fraction would see significantly higher morbidity and mortality within months to a couple of years of treatment interruption.
Deaths per year:
If even ~5% of these 3 million lost access and died within the year, that’s ~150,000 deaths.
It could be significantly higher depending on how advanced their disease is, how quickly they can find alternative sources, etc.
B. Tuberculosis
Projects at stake:
3 million people receiving TB medications via the Global Drug Facility.
The main USAID-funded TB research consortium (Smart4TB).
Additional TB/HIV co-treatment programs.
Mortality if untreated:
Globally, the case-fatality rate for untreated active TB can reach 30–50% in high-burden, resource-poor settings. Even partially treated or interrupted regimens have high mortality risk.
Conservatively, if ~3 million lose consistent access to TB meds, you could be looking at hundreds of thousands of additional TB deaths over a year or two.
C. Malaria
Projects at stake:
$90 million bed net and treatment contract covering 53 million people.
Additional programs (e.g. Evolve) that do indoor residual spraying for 12.5 million.
REACH Malaria (PATH) for ~20 million.
Mortality if these interventions vanish:
Globally, roughly 600,000+ people (mostly children) die of malaria each year (WHO estimate for recent years).
Bed nets and spraying are a major reason malaria deaths have fallen since ~2000. Various sources (including GiveWell) estimate a cost of a few thousand dollars per life saved (varies, but often on the order of $3,000–$7,000 for top charities).
The U.S. is a key donor to a large chunk of those protective interventions. It’s not crazy to think tens of thousands—possibly 100,000+—extra malaria deaths could occur annually if those nets and sprays simply are not replaced.”
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”
I’m really unimpressed by these estimates. It shocks me how many public health professionals don’t understand counterfactuals.
It’s really bad that USAID is pulling out but every calculation I’ve seen from the WHO, UN and others like this wouldn’t get you through the first round of GiveWell interviews.
You have to factor in that other countries and the African governments themselves will likely account for a decent proportion of the shortfall, and that many of the poorest people will buy medications if they have to. The idea that USAID pulling out could cause a 40 percent increase in malaria deaths is beyond ridiculous.
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.
----
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.
----
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.