What Happens When a Government Turns Off the Money Keeping People Alive?
Inside the abrupt end of USAID, and the accountability gap it left behind.
Written by Lea Nierlich and Tatum Kennedy
On January 20, 2025, his first day back in office, U.S. President Donald Trump signed Executive Order 14169, freezing nearly all U.S. foreign aid spending pending review. Within months, the vast majority of USAID's programs, worth tens of billions of dollars, had been terminated. Hospitals near the Myanmar border began closing. Clean water stopped flowing in refugee camps in the Democratic Republic of Congo. HIV clinics across sub-Saharan Africa ran out of medication. None of this required a new law, a parliamentary vote, or a public debate. It required one signature.
This is what happens when the world's largest donor of humanitarian and health assistance decides, almost overnight, to stop paying. It is a story about power without a corresponding duty to answer for it, and about how fragile the systems keeping millions of people alive turn out to be, the moment someone with enough authority decides to test them.
An agency dismantled in months
USAID had, for six decades, been the backbone of American foreign assistance, funding HIV treatment, malaria prevention, famine relief, refugee support, and disaster response in more than 100 countries. In 2024 alone, it disbursed over 32 billion dollars.
What began as a 90-day "pause pending review" quickly became something else. Contracts were terminated in bulk. Staff were placed on leave or dismissed outright. In July 2025, the agency formally ceased to exist, its remaining functions absorbed into the State Department.
The justification offered was efficiency: an agency accused of waste, redirected toward measurable returns. What it did not account for, at least not publicly, was what happens to the people on the other end of a suspended grant.
The cost of a frozen signature
Aid budgets are abstract until they aren't. A grant line item is, in practice, a nurse's salary, a shipment of antiretroviral drugs, or a water pump in a refugee camp. When the funding disappears, so does the service, immediately, and usually without a transition plan.
Researchers moved quickly to quantify what was at stake. Public health modelers estimated that if HIV funding was not restored, more than 176,000 additional people could die of the disease in 2025 alone, alongside tens of thousands more from tuberculosis. The mechanism behind those numbers is not abstract: when antiretroviral treatment is interrupted, viral loads can rebound within weeks, raising the risk of drug-resistant strains that are harder and more expensive to treat, while prevention programs that had been suppressing new infections lose their effect and transmission chains resume. The damage does not stop when the funding does. It compounds. The United Nations Programme on HIV/AIDS (UNAIDS) has since gone further, warning that four million additional AIDS-related deaths could occur by 2029 if the funding is not reinstated. Its executive director called it "not just a funding gap. It's a ticking time bomb." Longer-term projections, published in The Lancet in July 2025, put the broader toll, across health, nutrition, and humanitarian sectors combined, at over 14 million additional deaths by 2030, including 4.5 million children under five.
These are projections, built on models rather than headcounts. But researchers have also tried to track deaths already occurring. Brooke Nichols, an infectious disease modeler at Boston University, has run a live tracker estimating the toll of the funding cuts in real time. A year in, it put the number at roughly 700,000 deaths already, more than half of them children, a figure the State Department has publicly disputed. The reporting that followed gave the numbers a human shape. Seven of nine hospitals serving 80,000 refugees near the Myanmar border closed. In a refugee camp in Thailand, patients dependent on oxygen support died when supply was cut off. In Goma, in the Democratic Republic of Congo, organizations funded by USAID were forced to stop providing clean water in the middle of a mass displacement crisis. HIV field programs across Indonesia lost their staff almost overnight.
The consequences were not limited to health. A study published in Science found that African regions which had relied most heavily on U.S. aid saw a marked rise in unrest and conflict-related deaths after USAID's closure, an effect researchers linked to how abruptly the support disappeared.
None of this happened because the underlying need disappeared. It happened because a funding decision made in Washington arrived faster than any system built to absorb the loss.
When accountability runs into procedure
A government's power to fund, or defund, is not supposed to be unlimited. In the United States, Congress appropriates money. The executive branch is expected to spend it as directed. When the administration froze funds Congress had already approved, several groups went to court to argue this crossed a constitutional line.
Federal employee unions sued within days. A federal judge in Maryland agreed, at least provisionally, finding the shutdown "likely unconstitutional" and ordering parts of it paused. For a moment, it looked as though the courts might function as the check they are designed to be. In practice, the check proved hard to enforce. The agency's own oversight mechanisms, including its Inspector General, were removed in the process, and its financial payment systems were taken offline entirely, cutting off even the ability to track what had been promised and to whom. Courts issued restraining orders intended to pause the terminations, and the administration proceeded to re-issue them anyway.
Then the case ran into procedure. A federal appeals court later ruled, in a split decision, that under a 1974 law known as the Impoundment Control Act, only the Government Accountability Office, not the people, clinics, or communities actually affected by the funding freeze, has legal standing to sue over it. The practical effect: those most harmed by the decision were found to lack the legal right to challenge it. The case moved toward the Supreme Court, while the underlying freeze remained in effect throughout.
This is the part of the story that rarely makes headlines, but that matters most to anyone working in accountability litigation: it is not enough for a harm to be real, documented, and even found unconstitutional by a lower court. Someone has to have standing, resources, and endurance to keep the case alive through every level of appeal, while the harm itself continues, unpaused, in the background.
A crisis without a courtroom
More than a year on, the picture is one of partial, uneven recovery. Some global health funding has been restored through subsequent budget proposals. Humanitarian and disaster assistance has not recovered at anywhere near the same pace. Countries facing acute crises, including Yemen, South Sudan, Somalia, and the DRC, saw some of the steepest cuts of all.
What this episode makes visible is a structural vulnerability that reaches well beyond USAID. The world's most vulnerable populations are dependent on funding decisions made thousands of kilometers away, decisions that can be reversed by a single administration with no meaningful legal recourse available to the people affected. The mechanisms that are supposed to provide a check, congressional appropriation, judicial review, constitutional limits on executive power, turned out to be far more fragile, and far more procedurally contestable, than most people assumed.
This Cannot Be Where It Ends
The gap in the law is not a technicality. It is where the next fight begins.
A decision of this scale, one that public health researchers link to millions of preventable deaths, should not be able to stand entirely outside the reach of the law simply because the people it harms are not the ones the statute happens to name. That is not a technicality. It is a gap in the architecture of accountability itself, and gaps like this do not close on their own.
This is precisely the terrain public interest litigation exists to work in: identifying where a harm is real and documented but the conventional path to court has been blocked, and building the legal argument, the evidence base, and the coalition needed to open another one. Whether that path runs through procurement law, human rights law, labour law, or a jurisdiction entirely outside the United States, it has to be found, because the alternative is accepting that the size of a harm has no bearing on whether it can ever be answered for.
Decisions made by the powerful, affecting millions of lives, and left unanswered for. That is the gap AllRise is built to close.
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Disclaimer: This article was developed with the assistance of artificial intelligence (AI) tools, which were used to support research, fact-checking, and editorial review. All content has been reviewed and approved by the author(s), who remain responsible for the accuracy, interpretation, and conclusions presented.