Community health worker Margaret Odera counsels Doreen Atako at Mathare North Health Center in 2020. … [+]
The last five weeks have been turbulent for Margaret Odera—not to mention the many people who depend on her work.
This is due to a series of shock decisions coming out of the new Trump administration regarding foreign aid, including for global health. On January 20, shortly after being inaugurated, President Trump signed an executive order freezing and reviewing nearly all U.S. foreign assistance. Four days later, the U.S. Agency for International Development (USAID) specified that stop-work orders had been issued for existing projects. In other words, people around the world who worked on aid programs had to down tools, even in humanitarian and medical emergencies.
Odera was immediately worried about how she would be affected as an HIV-positive mother, who takes medicines every day. She lives and works in Mathare, a bustling and densely populated slum area of Nairobi.
Her life was transformed in 2009, when USAID started providing free antiretrovirals (ARVs) to Kenyans living with HIV. It was the only organization doing so in her area, Odera says.
Before then, as a woman who had become infected with HIV by her first partner, she was bedridden and living in despair. “I was useless,” she reflected. Being able to access medicine overhauled her health and her motivation. She went to college, became passionate about singing as a stress reliever, married a carpenter, and started a family. (All three of her children are HIV-negative, following treatment preventing mother-to-child transmission of HIV.)
Odera also found a vocation as a community health worker: a person who helps link their community with health and social services, including the care of doctors and nurses. This came about through a USAID-funded project training mothers to counsel HIV-positive pregnant women. Odera became passionate about sharing her story as a person combatting HIV stigma, which showed up in insults like “rotten blood,” and proving that this was no longer a death sentence.
But the freeze on U.S. aid programs, including funding for the ARVs she collects every three months, sent her back to a dark place. “I just flashed back and rewound; it’s like a video from 2006 and the stigma and the body bags and all that…I started thinking about living without seeing my children being grownups and having their own families,” Odera explained on January 31. She could not afford to buy ARVs herself, on her small and unpredictable stipend as a community health worker at a government health center, even if the medication could be found somewhere. And her current supply was due to run out sometime in February. “We are going to choose now between food and drugs,” she predicted grimly.
For a few days after the U.S. announcement, Odera felt paralyzed. She was unable to talk about it. But her fear and sadness turned to anger when she heard a U.S. politician say that people like her don’t pay taxes to the U.S. “These political leaders are rich, and maybe their children aren’t infected,” she thought. As she wrote on LinkedIn, “Saving lives does not make you poorer.”
She understood that the U.S. needed to review its aid programs. But suddenly cutting off funds, without allowing for any preparation, was a shock. “When you just cut off abruptly, you’re killing that person.” It should be a gradual process, she firmly believed.
Apart from the moral argument, Odera wanted to share the clear scientific rationale for continuing support. With people like her having to skip doses of ARVs, this could lead to drug-resistant HIV, which is more dangerous, expensive, and difficult to combat. And, of course, infectious diseases, HIV and others, cannot be contained within borders. “So when a multidrug-resistant TB [tuberculosis] is detected in Kenya, nobody will be safe,” Odera said. “It puts the whole world at stake.”
There was some hope after Secretary of State Marco Rubio, apparently responding to the outcry, announced a waiver for lifesaving assistance on January 28. This was soon followed by a waiver for some activities under PEPFAR, the U.S. President’s Emergency Plan for AIDS. This bipartisan program is one of the flagships of the U.S. global health architecture.
However, the waivers were ambiguous, and it was not possible to simply restart stalled programs. Also confusing was the process to obtain individual waivers for specific programs. These waivers became less and less useful as staff continued to be axed, payment systems remained offline, and chaos swirled about the future of USAID. And waivers for HIV programs were very limited: they did not extend to preventive medicine, apart from mother-to-child transmission; many tests; or community monitoring, to name a few affected areas.
Odera could see the impact of all this confusion around her. On February 13, she explained, antiretroviral medicines were available, but “no staff is there to issue the ARVs.” HIV-positive pregnant and lactating mothers had been going home without ARVs because pharmacies could not be opened. “There is a high chance that these babies will be infected” and HIV can mutate to stronger strain, Odera reported.
She was trying to be cautiously optimistic. “We are still hoping that everything is going to be fine.”
But starting this week, following a series of lawsuits over terminated programs and employment, the U.S. government took another extraordinary decision: ending 92% of all USAID grants, including for HIV/AIDS. Almost overnight, almost 10,000 projects were terminated.
Today, Odera reported, it’s unclear if the health care workers who have been brought back to work will be able to return after the weekend. While medicines still exist and can be distributed, there’s an overflow of clients from other hospitals whose funding has been cut off completely. The TB section is still closed.
“The future of the prevention of mother-to-child transmission is still uncertain, because we still fear what the U.S. funding will do if it’s going to cut off altogether,” Odera said. “The future is very dim.”
Over 25% of Kenya’s HIV-related budget each year depends on U.S. government spending. Direct U.S. funding accounts for 29% of HIV medicines in Kenya. One estimate is that if all USAID programs end in Kenya, 54,000 healthcare workers could be out of a job.
Overall U.S. health aid to Kenya, including for HIV/AIDS, has helped to increase Kenyan life expectancy by over a decade, an enormous leap. But this era of partnership appears to be over, for the time being. African countries will need to look elsewhere for essential funding, Odera now believes, although it will be nearly impossible to fully make up for the shortfall. In the meantime, the need is urgent, for both Odera and her patients.
Whatever comes next, “It’s going to be messier than what we think,” Odera has predicted. “And it’s not only going to affect Kenya, it’s going to affect the whole world.”
