The Devastating Health Impacts of U.S. Foreign Aid Cuts

This episode of the Princeton Pulse Podcast addresses the public health implications of U.S. foreign aid cuts, which have sent shock waves across the world. With the stroke of a pen, billions of dollars were abruptly pulled from projects dedicated to HIV prevention, treatments for deadly diseases, basic health care for children, and other essential services – rolling back decades of progress with severe consequences that could affect generations to come. 

Without U.S. support, countless lives are at risk. While populations in low-income countries will hurt the most, citizens of all countries will pay the price, including Americans, as global health systems collapse, infectious diseases soar, and the world is less prepared for emerging health threats.

Host Heather Howard, a professor at Princeton University and former New Jersey Commissioner of Health and Senior Services, is joined by two distinguished guests. Pascaline Dupas, professor of economics and public affairs and director of the Center for Health and Wellbeing at Princeton University, and also a scientific director for JPAL, is a development economist. Over the past two decades, Dupas has conducted research aimed at reducing global poverty and identifying evidence-based solutions for critical health challenges in low-income settings. Also joining the show is Cindy Huang from the Center for Global Development, who has over 20 years of experience leading humanitarian and international development efforts across government and non-profit sectors. 

The panel discusses the reach and effectiveness of global health programs, why U.S. foreign aid cuts will impede the discovery and adoption of life-saving interventions, how countries can become less reliant on external aid, and hope for the path forward.

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Articles relevant to topics discussed:
Subsidizing secondary education has huge benefits, for this generation and the next
Free contraception had no impact on birth rates in Burkina Faso

The impact of price on take-up and use of preventive health products 

The Future of US Foreign Assistance: Lessons and Strategic Directions 

How Many Lives Does US Foreign Aid Save? 

The Princeton Pulse Podcast is a production of Princeton University's Center for Health and Wellbeing (CHW). The show is hosted by Heather Howard, a professor at Princeton University and former New Jersey Commissioner of Health and Senior Services, produced by Aimee Bronfeld, and edited by Alex Brownstein. You can subscribe to The Princeton Pulse Podcast on Apple Podcasts, Spotify, or wherever you enjoy your favorite podcasts.

Transcript

EPISODE # 20 – TRANSCRIPT

Heather Howard  00:02

Hi and welcome to the Princeton Pulse Podcast. I'm Heather Howard, professor at Princeton University and former New Jersey Commissioner of Health and Senior Services. On campus and beyond, I've dedicated my career to advancing public health. That's why I'm excited to host this podcast and shine a light on the valuable connections between health research and policy. 

Heather Howard  00:23

Our show will bring together scholars, policymakers and other leaders to discuss today's most pressing health policy issues, domestically and globally. We'll highlight novel research at Princeton, along with partnerships aimed at improving public health and reducing health disparities. I hope you'll listen in as we put our fingers on the pulse and examine the power and possibilities of evidence-informed health policy.  

Heather Howard  00:48

The Trump administration's deep cuts to foreign aid have sent shockwaves across the world. Nowhere is this more evident than in the realm of public health. With the stroke of a pen, a series of executive orders slashed billions of dollars from global health programs that provide vaccines, medicines, and other vital services to the people who live in the world's poorest countries. Of particular note, the administration dissolved the United States Agency for International Development, known as USAID, which has been administering humanitarian aid programs on behalf of the U.S. government since the early 1960s. Projects dedicated to HIV prevention, treatments for deadly diseases, and basic health care for children were abruptly eliminated, rolling back decades of progress with severe consequences that could affect generations to come. Without critical U.S. support, vulnerable populations will suffer, and millions of lives are at risk. While low-income countries will be hurt the most, all countries will pay the price, even the United States, as global health systems collapse, infectious diseases soar and spread across borders, and the world is less prepared for emerging health threats. 

Heather Howard  02:04

On today's episode of the Princeton Pulse Podcast, my guests and I will discuss the devastating and far-reaching public health implications of this change in U.S. policy. We'll talk about the likelihood of increasing mortality rates, who is stepping up to fill in the funding gap, and how countries that have been reliant on external aid to support their health programs must adjust to this new reality. Joining me from the Center for Global Development is Cindy Huang, where she is a non-resident fellow. She has over 20 years of experience leading humanitarian and international development efforts across government and nonprofit sectors, including as policy director at USAID. I'm also delighted to welcome my colleague, Pascaline Dupas, Professor of Economics and Public Affairs and Director of the Center for Health and Wellbeing at Princeton University, and also a scientific director for JPAL Africa. Pascaline is a development economist with over 20 years of experience conducting research in partnerships with governments and nonprofits in low-income settings. Through rigorous field experiments, she helps identify evidence-based solutions to critical health challenges, making her research directly applicable to policy decisions that affect millions of lives. Cindy, Pascaline, welcome to the show. 

Pascaline Dupas  03:20

Thanks for having us. 

Heather Howard  03:21

Let's jump in. Pascaline, as a development economist, you focus on the challenges facing poor households in lower income countries. Can you tell us about your approach, not just to studying the problems, but to identifying policy interventions that can reduce global poverty and improve health outcomes. 

Pascaline Dupas  03:41

Yes. The approach centers on connecting randomized control trials of policy interventions that are done directly in and with the community that faces a specific challenge that needs to be addressed. And so rather than just theorizing about my work and leaving it at that, what we do -- because it's not just me, I'm part of a broader movement, many folks in my field do that as well -- we partner with local organizations and with governments to test interventions in real world settings. Early in my career, I worked with health clinics in Kenya to identify cost-effective distribution models for preventative care. Later on, I partnered with schools in Ghana to see if scholarships for secondary education improved, not just educational attainment for young women, but also their reproductive health and the health of their future children. The key, really, is measuring what actually happens in the lives of the people that the policy intends to impact... not just whether the program happened, not just whether people are happy about the program, but whether it meaningfully changes outcomes such as people's health or education or income. Then this evidence can help policymakers decide how to allocate limited resources most effectively. 

Heather Howard  05:03

Thank you. So Cindy, moving to you. You're currently affiliated with the Center for Global Development, which is a think and do tank. I think that is how they bill themselves. But you've got this deep experience in multiple roles, including, most recently, as head of policy for USAID. Can you tell us about your background and how that's brought you to your current work?

Cindy Huang  05:26

Yeah, thank you so much. It's so great to be here. Well, at the very beginning, as soon as I graduated from the School of Public and International Affairs at Princeton, I went to work for Doctors Without Borders in Kenya, actually one of the early projects delivering ARVs in Western Kenya and also near Nairobi. That was a very inspirational experience. But then, thinking about how we achieve scale, I became very interested in government service. I've actually had the privilege of working at four U.S. government agencies -- at the State Department to help start Feed the Future; at the Millennium Challenge Corporation, working on social sector, including education health programs; then at Health and Human Services, working on refugee resettlement; and then, as you mentioned, at USAID. The thread through all of that is the incredible public servants, the commitment of the American people to helping people abroad, that has been very inspiring. And then the last piece that you mentioned... it's really wonderful to be back at CGD, where for a few years I had worked on migration and displacement policy and also U.S. development policy. So I feel like I'm tying things together now that I'm able to be affiliated with CGD to think about the future of U.S. engagement in international development, building on perspectives -- whether from the field, from policy studies, research, and then also government service.

Heather Howard  06:58

Well, I think our listeners are already sensing how you are the two absolute perfect people to be talking about these issues. Pascaline, we want to talk obviously about the impact of the foreign aid cuts, but Cindy has mentioned the incredible commitment that she and her colleagues have had over the years to foreign aid. From your perspective, can you tell us what we know and have learned about the reach and effectiveness of global health funding. I want to sort of ground our conversation in what we know. 

Pascaline Dupas  07:26

We actually know a lot, because global health funding has achieved remarkable success over the past two to three decades. We've seen dramatic reductions in preventable diseases. Child mortality has been cut in half since 1990. Malaria deaths have decreased by 60% since 2000. We've nearly eradicated polio worldwide. And much of this progress comes from relatively simple, cost-effective interventions that donors have supported, things like bed nets to prevent malaria, vaccines for children, programs to prevent transmission of HIV. The research shows that these programs deliver enormous benefits for relatively modest investments. That means they are what we call highly cost-effective. So just as an example, GiveWell estimates that free distribution of bed nets costs about $3,000 to save a life in a context like Nigeria. And then there's a specific American example that I want to give a shout out. It's PEPFAR, the President's Emergency Plan for AIDS Relief, which was launched by George W. Bush in 2003. It's a program that some have called, and I kind of agree with that characterization, the most influential American foreign aid program since the Marshall Plan. It's called that because there's been an evaluation of it by the National Academy of Sciences that estimated that it has saved millions of lives, and also separate research that has looked at specifically the rollout of antiretrovirals. Cindy was mentioning that earlier. That was a major component of PEPFAR that has been estimated to have explained about a third of Africa's economic growth resurgence in the 2000s, which means that when you save lives and make people healthier, they can also be more productive and grow out of poverty.

Heather Howard  09:19

So Cindy, Pascaline has mentioned several exciting initiatives that have been really effective. PEPFAR being, of course, the biggest but also the distribution of malaria bed nets. She's given us several good examples. Yet, even in the face of all this research and evidence that Pascaline cites, there's still criticism that foreign aid programs are inefficient. From your perspective, both on the inside and the outside, how do you think about ensuring high impact for taxpayer dollars? 

Cindy Huang  09:51

Yeah, great question. Obviously, this has been in the news a lot. If I could give out a little shoutout, too, to the folks at the Center for Global Development who did a calculation that found a conservative estimate of 3.3 million lives saved per year based on U.S. investments. And that's considered more conservative, because that only accounts for the interventions with the greatest direct impact on saving lives, like many of the programs that Pascaline mentioned -- anti-malaria and vaccine programs. It does not account for other programs, like water and sanitation programs. So we can say that the impact has been big. At the same time, there is always room for improvement in terms of efficiency and effectiveness. As I mentioned, I've served at a couple of different agencies, and I would say that's true across the board, not only at the former USAID. And just to give two examples of that... In the prior administration, there was a new and expanded Office of the Chief Economist that was led by a professor at Northwestern, Dean Carlin, who has been part of the movement that Pascaline mentioned and his team, which we collaborated with a lot. [That team] was taking reviews of evidence and then applying it to different parts of USAID to work with people at the country level and at the global level, to reallocate resources to even more effective programs. And then the second example I would mention is the Policy Office that I led, knowing there are issues that we will work on that aren't necessarily amenable to that kind of randomized control trial experimentation. We were also working on programs that really aligned with partner government, partner country priorities... things like how we can help countries meet IMF benchmarks so they qualify for debt relief. How can we work on critical supply chains? And so that's another area where we said, "The world has changed. How can USAID change with it?" We were taking those steps forward. And then I just want to quickly address, because it has been in the news, some statistics... such as that a very small percent, like only 10%, of U.S. foreign assistance reaches local communities. I do think it's really important to clarify that that is a statistic that's about where the prime awardee, or the main group that won the contract, was located in countries. But there's so many examples, like the Global Vaccine Alliance Gavi, where the money was going to GAVI and they were using it for highly effective interventions. And so the devil's in the details. It's cold comfort, but there are former members of the Department of Government Efficiency who have left and said, "We didn't find massive fraud. We found room for improvement." But I would say that a lot of the champions of USAID would be in full agreement with that.

Heather Howard  12:50

So Pascaline, Cindy's mentioning that there's some debate about this measurement. Tell us how you think about how to measure the impact of the cancelation of all this funding, the dismantling of USAID.  We're only eight months, nine months into the year, but how are you thinking about how to measure the impact, having spent your career measuring the value of aid? How are you measuring the retrenchment?

Pascaline Dupas  13:18

There are two aspects. One is that if we know how much of a difference these programs were making because it was already measured, we don't have to measure it again. We just know that if you remove something that makes a difference, it's going to hurt until it's replaced by something. So just quantifying for how many days HIV patients don't get their medication, and knowing what we know of the mortality rate if you don't take your medication, you can back that out. Obviously, the other thing that you can do is measure in real time what's going on. But one challenge with that is that some of the cuts that are happening are not just to the programs themselves. [The cuts] are also to the programs that collect data. And so it's almost like you do things that make things worse for people, but at the same time you make sure you can't measure what's going on, right? Ultimately, getting the exact number, I don't think we'll ever get there. It's kind of like the death toll of Covid. No one is going to hang their hat on a very specific number. We just know it was bad, and it was worse in certain contexts than some others. So, to me, right now, the focus is not so much on quantifying precisely how much. It's more about thinking ahead... how can we make sure that it doesn't continue being a complete hole, and how can we fill that up? 

Heather Howard  14:44

So that's a really important cautionary note that focusing solely on the data and figures is not telling the full story, right? And how do we get beyond just talking about abstract numbers, especially given the challenge with the numbers and the challenge with data, and think about what this means in the lived experiences of real people. How do you think about that? And can you tell us how to approach that? Can you walk through some examples of a person being affected? 

Pascaline Dupas  15:14

I'm a data person. I think people react more to anecdotes and individuals than data. I don't want to condone that in general. I think it's better if people imagine what would happen in their own workflow, or, you know, life, if something that they’ve come to depend on just was taken away from them. So think of public education, for example, in the U.S. Imagine that, from one day to the next, it was like schools don't exist anymore, right? Obviously, people would mobilize, something would happen, and, you know, some form of education would reemerge. But you know it would be very disruptive for some time. Likewise, imagine that you live in a rural community where there's just one health care provider, and it just stops operating. I think it's very easy for everyone to imagine what it would mean for their daily lives if something that they had been promised was suddenly removed. We can talk about that later, maybe. But the way these cuts were done, in my opinion, was especially cruel, because the government was told tomorrow everything is over. If they had been given some notice and had been told, okay, within a year, we are going to phase out, most countries would be able to set up a system or find the financing, and then move over the programs from what was U.S. funded to their own. But from one day to the next, mechanically, you're going to have a lot of disruption. And It's needless disruption, in my opinion. And it's just cruel to do it that way. 

Heather Howard  17:02

Cindy, do you want to jump in? Can you help us think about the populations? Who are the people most affected by these cuts?

Cindy Huang  17:11

Yeah, and I do just want to quickly underscore what Pascaline said, that how the cuts have had such a big impact on what can come next. That's part of what's been really hard about this moment, particularly for the people who were receiving health, humanitarian and other services supported by the American people. I think of a few groups that I really have an eye on and one is, of course, people living in the lower-income countries. They have really big exposure. And another report put out by my CGD colleagues found that there are eight low-income countries where over a fifth of their assistance previously came from USAID and assistance overall comprised 11% of the gross national income. Those are countries like South Sudan, Somalia, Afghanistan, Liberia, Ethiopia. I think those countries, and the vulnerable people in those countries, will be and have been very hard hit. And then also, there are crosscutting populations, like refugees. That's a topic that has been a subject of my work for a long time. Looking across the various statistics, like 40% of UNHCR, that's the UN Refugee Agency, 40% of their funding came from the U.S. And that's true for some of the other big health funds, etc. There are, today, more than 40 million refugees. And just a quick anecdote, when I was the head of policy at USAID, I went to visit the Kakuma refugee camps. And we were talking there about how can we lean into policies to allow refugees to work, to have mobility, for more to attend school. And then just reading the news, in the summer their food rations were cut in half. So some of the basics that would enable you to take forward steps that lead to greater self-sufficiency, which is something. There's nothing that the refugees want more themselves than greater self-sufficiency and the opportunity to make an income. But we've just taken so many steps back. And just to highlight, especially for refugees, they're non-citizens. So I think there are a lot of cases where we should, as Pascaline mentioned, talk about transition. We should talk about host governments or partner countries really taking on more of the financing. But for non-citizens, that is a harder proposition for many governments. And then, of course, there are other populations that we need to have an eye out for, like maternal and newborn populations and children who may be particularly vulnerable to infectious disease. So, yeah, sadly, the list is not a short one. 

Heather Howard  20:04

So Cindy, sticking with you. Pascaline mentioned how disruptive the process was, right? Not that there is an easy way to do this, but that it was done in a particularly disruptive way. Can you say more about that? What does that mean for the NGO infrastructure and walk us through that. 

Cindy Huang  20:23

Yeah, I think first is the scale of the cuts. As your listeners may or may not recall, there was $8 billion of a recision at the end of July, the funds were taken back. And now there's a proposal for another $5 billion, $4.9 billion in rescission. So there's the quantity. And then at the same time, there was a lot of chaos. Our grant agreements... are they happening? Are they not? And then some that have been preserved, they weren't getting the money. They weren't getting the obligations. Just as an example, as of mid-year, when you look at the year on year comparison to last year, the obligation - so that's money going to organizations - was down 90% in the health and humanitarian sectors. Then there's the question of how USAID has ceased to exist as an agency but very few staff were brought over to the State Department. There are very few people with knowledge on how to comply with federal regulations on how to distribute money. What we've also seen is essentially no major new awards, including in the sectors that the administration has said that they want to preserve, the life-saving work such as PEPFAR. And then even on top of that, there are existing agreements, as I mentioned, that weren't canceled, but they're not really getting a lot of new funding. So it has been so disruptive. And I also just want to mention two other things. One is that this is in a context of other donors also reducing their budgets. An initial estimate from the OECD is that between 2024 and 2025, they think overall funding will be down by about 17% for official development assistance. And people are looking closely at the U.K., which has been such a champion. The government has announced, between now and 2027 they're going to reduce their commitment from .5 to point .3% of GNI, which is depends on how economies do, but could be up to a 40% cut. And this entire ecosystem is being decimated. And I again, I couldn't agree more with Pascaline that it's the way that this disruption is happening. I would be the first to say the sector needed some disruption, but not of this kind. 

Heather Howard  22:47

There's been news about supplies that had been bought. For example, the example that's been in the news has been contraceptive supplies purchased through USAID, but then not distributed. Is this the same chaos that things were bought and then just not even getting used, or do you have any insights into to what's going on there?

Cindy Huang  23:08

What I would say is that there have been other reports, for example, ready-to-use therapeutic foods to feed the children suffering from the greatest, most severe acute malnutrition, that also expired in this case. I think there been reports for about a month about this $10 million in contraceptives in a warehouse in Belgium... what would happen with it. The reason that I think this is at another level is that I feel that other donors, as the news says, have stepped up to say, "Hey, we will pay for these so that they're not wasted." But it's become part of political football that I think is unique. And you know, as a reminder to your listeners, that under the Hyde Amendment, for decades, the U.S. has not funded anything related to abortion, except in the rare exceptions. And so I think, again, it's been taken out of context. And these are contraceptives. It is heartbreaking to see things that have already been procured and would just need to be distributed and the U.S. wouldn't even have to pay for, to be such a subject of debate. 

Heather Howard  24:23

Pascaline, I think the research is pretty clear on both economic and health benefits of family planning, right? 

Pascaline Dupas  24:29

Yeah, just to back up, I think in justifying the destruction, we don't know if the stock has been destroyed yet or not, but for sure, they are pushing for it to be destroyed. And the justification for destroying this stock of birth control pills and other contraceptives seems to be that these are not life-saving. I totally disagree with this. Family planning services are literally life-saving because childbirth is a very risky proposition for many women around the globe. So maternal mortality remains shockingly high in many low-income countries. An example is Chad. Over 1,100 women who died per 100,000 live births. That's compared to just 19 in the U.S. Now, the United States is not even the best benchmark there, because it's not doing that great on maternal mortality given its income level. So maybe we should compare to Norway or Sweden, where it's more like three or five women who die per 1,000 live births. Because family planning services help prevent unwanted pregnancies, they mechanically reduce women's risk of dying in childbirth. So that's number one. Now I also want to say there is enormous heterogeneity across countries in how far along they are and the demographic transition. So in some countries, we've seen huge declines in fertility as economies have shifted away from agriculture. Think of Kenya, Ghana, Rwanda. They've seen contraceptive use rates rise dramatically because households now want only two or three children, and they are actively seeking to plan their families, so to lose access to that option is going to be devastating for them. Now in other countries like Burkina Faso, fertility remains quite high. Fertility remains quite high because people still rely heavily on agriculture as their main source of income, and they need children to help work the land. And so, in fact, a recent study that co-authors and I have just published in the American Economic Review has shown that providing free family planning services to married women in Burkina Faso had no effect on fertility, which actually makes sense given the economic context that they face. The key point here is that high, low opportunities are not inherently like bad or good. No, what matters is giving women and households the ability to easily plan their families according to their own circumstances and desires. Family planning services provide that choice, and when there's a need for contraception, these services can be both economically beneficial and life-saving. 

Heather Howard  27:07

So for your research, Pascaline, what do these cuts mean? Your research is dedicated to finding cost-effective, life-saving interventions. What do the cuts mean for the research pipeline? 

Pascaline Dupas  27:20

Well, there's not only the cuts to the aid itself. Let's also remind our listeners that the Trump administration's cuts extend beyond that, also targeting research funding and attacking universities more broadly, and that really creates what I would call a double blow that will have long-term consequences that we are only beginning to understand. Obviously I'm tooting my own horn here, as a researcher I'm going to say research is important. But I do think the research pipeline is absolutely critical for identifying new cost effective interventions that can save lives. I mentioned briefly earlier, some of the work I've done in Ghana looking at the intergenerational impacts of scholarships for secondary education. By the way, this was funded by NIH initially, and then USAID to mechanisms that are not working that great anymore for that purpose. But anyway, this kind of research takes years and years. It requires sustained funding, and so when you get research budgets at institutions like NIH, NSF or universities, you're not just affecting today's programs. You're undermining our ability to discover tomorrow's breakthrough interventions. And again, you know some of the most cost-effective health solutions we use today, like oral rehabilitation therapy, certain vaccination strategies, they emerge from research that took decades to develop and test. I mean, we're all familiar with that MRNA research that was going on for decades at universities, and was so critical for the Covid vaccine to save lives. So, you know, these attacks on universities are really damaging, because academic institutions are where much of this long-term research can happen. It takes time to conduct this type of rigorous study, and universities are the place where that happens. This work may not have immediate commercial applications but can save lives for millions of people down the road. And so again, we've talked about the immediate humanitarian impact of program cuts. And on top of that, it's really important to point out that we're also dismantling the knowledge infrastructure that helps us find better, more efficient ways to address global poverty and disease. I think the full costs of that won't be felt right away, but it will be enormous.

Heather Howard  29:49

So that's really ominous, but I think we need to pivot to talking about where we go from here. Pascaline, I'll start with you. What changes are you seeing and how are key actors responding to the moment. And then we'll go to Cindy to hear [her thoughts] on this, because she's already sort of previewed this question. Are low income countries going to be able to fill the gap? Can they raise the funds? 

Pascaline Dupas  30:13

I think the short run is going to be bleak for the reasons we've just discussed, but I'm actually quite optimistic, or trying to be quite optimistic, about the future of global health. And here's why. We now have, I think, an incredibly strong evidence base showing which interventions work, and many countries are genuinely enthusiastic about evidence-informed policymaking, quite in contrast with what we are seeing in the U.S. today, I should say. And so I know this, as one of the scientific directors of J-PAL Africa, because I work very closely with governments across the continent to help them adapt proven interventions to their local context, and the interest and enthusiasm we've seen is just tremendous. Countries want to know... what does the research show? How can we implement this effectively? How do we get the biggest impact for limited resources? So many countries with strong state capacity absolutely can and will step up to fund their own health priorities. Obviously they will have to reprioritize and cut some other stuff. It's not like the money was just there lying around, and they just have to mobilize it. No, but health is going to be a priority. My main concern is for people living in areas with low state capacity, or even worse, and that's what Cindy was mentioning earlier, people in active conflict areas. We have over 100 million displaced people. Some of them are refugees, some are internally displaced. Those folks are entirely reliant on humanitarian assistance, in part because the way they are often treated prevents them from having their own livelihoods, as Cindy was mentioning. So these are the populations that will suffer most from aid cuts because they have no government that can step in to fill the gap. But I want to stay positive and say that the foundation is strong. We know what works. There is real momentum behind evidence-based approaches to development. And so that gives me hope that we can navigate this challenging moment, and many countries will be able to to overcome this. 

Heather Howard  32:27

Cindy, you mentioned earlier that other donors were also reducing their budgets. Do you have the same hope, though, that Pascaline has? Can you pick up that thread? 

Cindy Huang  32:37

I am, by disposition, an optimist, and people have come together before to overcome big challenges. So, yeah, I'm picking up on one thread. I've been heartened to see, first and foremost, some countries step up. Recently, Ethiopia passed a new tax to help make up some of that difference. And in Uganda, they've also passed a budget that almost doubles the health budge. It's still not enough, and it's a tough road. Those are also among the countries that I mentioned earlier that are heavily dependent on foreign assistance, but there are positive signs, and I think that's really an important trend to follow. The second thing is, I've also seen individual philanthropists step up, and CGD is currently hosting a project called "Project Resource Optimization" that has taken the same methodologies that Pascaline talked about to identify the cost-effective programs that were going to stop due to USAID cuts. So far, that project has received funding for 35 of those programs, mobilizing over $46 million. That's not a lot, because we know private philanthropy is very small compared with official development assistance. But those are signs that there are people willing to step forward and to do so based on what they see is and what the data shows is high impact. That's helped programs for mountainous children in Haiti and Nepal, and childhood vaccinations in Mozambique. The key question, as we've been discussing, is how does that trend translate and transition into a more sustainable system? But this gives me hope because people said we're willing to step in as that's being figured out. And then the last thing that gives me hope is that we have seen bipartisan and cross-partisan outreach of people saying to Congress and others, these programs do matter to us, and again, cold comfort. But we saw in the rescission package that PEPFAR was largely protected. So I don't want people to take what's happened in the last six to nine months where - Heather, you're an expert in this - a lot of domestic programs that have significant support have also been cut. I don't want people to look at the last nine months and feel hopeless, because there are points of light, and there are a lot of possibilities moving forward.  

Heather Howard  35:09

Cindy, what are the  political lessons? Do you feel like you've gotten a Ph.D. in politics over the last nine months? What political lessons are you drawing from the last nine months?

Cindy Huang  35:20

Yeah, it's so interesting, because my Ph.D. is in cultural anthropology. And people always ask me, well, in these bureaucracies, did you get to use your social cultural anthropology skills? And I said, "Absolutely." With bureaucracy and people and constituencies as my objects of study, you do see how systems come together and how they change. And so, I mean, one is what I just mentioned in terms of the past. The recent past is not necessarily prolog, and also one of the pieces I'm working on is a historical overview of U.S., foreign assistance, and how that's changed over time. And, again, that's gone up and down. This is a big disruption, but it's worth looking at that longer history. And then also another lesson is that, and this goes back to the silver lining, if there could be one, is that it is easier to tear something down than to build it. But I do think with the evidence we've talked about, with pockets of political will, that rebuilding may be easier than some of the other attempts at incremental reform that have been tried, because there were parts of the system -- I mentioned the chief economist and kind of going program by program -- that was labor intensive. Alot of it was a long process. So can we take this opportunity to rebuild in a way that saves more lives, helps more people, and both for the human reason and the political reason, has a tighter connection back to the people who want to give -- that's individual Americans or people across across the world.

Heather Howard  36:57

Pascaline, I'm going to give you the last word. Cindy's done a really nice job of sort of giving us an optimistic perspective on the potential for rebuilding and leveraging your and your colleagues' research on cost-effectiveness, what works. Given that strong evidence base, what is your research agenda going forward? And how do you think about impacting future policymaking?  

Pascaline Dupas  37:25

Building on what we've mentioned, this very strong foundation of evidence-based policymaking, I'm particularly interested now in understanding how to make proper interventions work at scale, and how to adapt them across different contexts. So when something works in one state, like in India, is it going to work in every state or in other countries as well? But something I want to also touch on, which is equally important, is actually training the next generation of leaders who will carry this work forward. That's something that you band I have the honor and privilege to do here at Princeton, with our MPA students. Cindy, is an alum of the Princeton School of Public and Internationall affairs. They are incredibly inspiring. They come from all over the world, and many from the very countries where these interventions will be implemented. And so with us, they are not just learning about evidence-based policy. They're actually preparing to go back and lead it. And other people will be running health ministries, leading NGOs, and designing the next generation of different programs. I want to say that's also part of what I want to do more often, and what gives me hope. And then also, just one last thing, for informing policymaking, I think working closely with governments is very important, but also focusing on building local research capacity. Because the goal is not just to generate evidence, but also to ensure that countries have their own researchers. We can continue this work independently, and we can carry the torch going forward.

Heather Howard  38:59

Well, that's an exciting research agenda, and I love that you're bringing us back to the next generation, and the work we're doing, teaching, creating the future. Cindy Huang, Pascaline Dupas, thank you so much. This was such an important conversation. 

Pascaline Dupas  39:13

Thank you, Heather. 

Cindy Huang  39:14

Thank you so much. 

Heather Howard  39:17

Thank you for listening to the Princeton Pulse Podcast, a production of Princeton University's Center for Health and Wellbeing. The show was hosted by me, Professor Heather Howard, produced by Aimee Bronfeld, and edited by Alex Brownstein. We invite you to subscribe to the Princeton Pulse Podcast on Apple Podcasts Spotify, or wherever you enjoy your podcasts.