What Does the Research Say About the Consequences of Cutting U.S. Foreign Aid?
A peer-reviewed study published in The Lancet analyzed panel data from 133 low- and middle-income countries and territories and found that USAID funding prevented more than 91 million deaths between 2001 and 2021. The same study projects that if current funding cuts continue, more than 14 million additional deaths could occur by 2030, including more than 4.5 million children under five.
When USAID was effectively shut down in early 2025, the stated justification was fraud, waste, and abuse. But what does the peer-reviewed evidence actually show about the consequences of that decision? This is a retrospective impact evaluation of country-level mortality data combined with forecasting models, not a randomized trial, and that distinction matters for how the numbers should be read. This article examines what the study found and what the data suggests about the road ahead.
This article accompanies Episode 40 of The Dr Kumar Discovery, where Dr. Kumar and Keith Hourihan, a 20-year veteran of international audit and fraud investigations, discuss the inside story of USAID and the reality behind the allegations that led to its closure.
Dr. Kumar’s Take
This Lancet study is one of the most comprehensive analyses of foreign aid effectiveness I have read. It did not look at one disease or one country. It analyzed 133 countries and territories across two decades and found that higher USAID funding was associated with a 15% reduction in age-standardized all-cause mortality. That is a large effect at a population level. I want to be precise about what kind of evidence this is: it is an observational, country-level analysis with statistical adjustment for demographic, socioeconomic, and health-care factors, not an experiment. Countries were not randomly assigned to receive aid. The authors ran sensitivity and triangulation analyses to test whether the association holds, which is the right thing to do, but residual confounding is always possible in a design like this.
What I find hard to dismiss is the pattern. The largest reductions showed up exactly where USAID concentrated its money: HIV/AIDS, malaria, neglected tropical diseases. That is the kind of internal consistency that makes an observational finding more credible, not less. The projection of more than 14 million additional deaths by 2030, including more than 4.5 million children under five, is a model output with a wide uncertainty interval, and I would present it that way rather than as a fixed number. But even the low end of that interval describes a public health event of enormous scale. I think everyone deserves to see this data before forming an opinion about whether cutting foreign aid was justified.
The Lancet Study: Two Decades of Evidence
The study, led by Cavalcanti and colleagues and published in The Lancet in 2025, is titled “Evaluating the impact of two decades of USAID interventions and projecting the effects of defunding on mortality up to 2030: a retrospective impact evaluation and forecasting analysis.”
The researchers used panel data from 133 low-income, lower-middle-income, and upper-middle-income countries and territories, with USAID support ranging from none to very high, covering 2001 to 2021. They used fixed-effects multivariable Poisson models with robust standard errors, adjusted for demographic, socioeconomic, and health-care factors, then examined effects by age group, sex, and cause of death, and ran sensitivity and triangulation analyses. Finally they integrated the retrospective evaluation with validated dynamic microsimulation models to project effects to 2030.
The primary outcome was age-standardized all-cause mortality per 1000 inhabitants. Child mortality was measured as deaths in children younger than five years per 1000 live births, and under-five mortality was further broken down into infancy, preschool, and school-age categories. Cause-specific mortality categories were defined using ICD-10 codes.
Higher levels of USAID funding, primarily directed toward low- and middle-income countries and particularly African countries, were associated with:
- A 15% reduction in age-standardized all-cause mortality (risk ratio 0.85, 95% CI 0.78 to 0.93)
- A 32% reduction in under-five mortality (RR 0.68, 0.57 to 0.80)
- A 65% reduction in HIV/AIDS mortality (RR 0.35, 0.29 to 0.42), representing 25.5 million deaths
- A 51% reduction in malaria mortality (RR 0.49, 0.39 to 0.61), representing 8.0 million deaths
- A 50% reduction in mortality from neglected tropical diseases (RR 0.50, 0.40 to 0.62), representing 8.9 million deaths
- Significant decreases in mortality from tuberculosis, nutritional deficiencies, diarrheal diseases, lower respiratory infections, and maternal and perinatal conditions
Across the 21-year study period, the authors estimate that 91,839,663 all-age deaths (95% CI 85,690,135 to 98,291,626) were prevented, including 30,391,980 (26,023,132 to 35,482,636) among children younger than five years.
The Projections: What Cutting Aid Could Mean
The same research team modeled what would happen if the steep funding cuts announced and implemented in the first half of 2025 continued. Their forecasting models predicted more than 14,051,750 additional all-age deaths (uncertainty interval 8,475,990 to 19,662,191) by 2030, including 4,537,157 (3,124,796 to 5,910,791) in children younger than five years.
The authors are direct about what that means: unless the cuts are reversed, a staggering number of avoidable deaths could occur by 2030. They describe the resulting shock for many low- and middle-income countries as similar in scale to a global pandemic or a major armed conflict, with the difference that this crisis would stem from an avoidable policy choice whose burden falls disproportionately on children and younger populations.
The Policy Context: What Was Cut
On January 20, 2025, Executive Order 14169, “Reevaluating and Realigning United States Foreign Aid,” suspended existing foreign aid programs, with exceptions for emergency food assistance and military aid. On March 10, 2025, it was announced that 83% of USAID programs would be cancelled. Those cuts have been challenged in court and the outcome remains uncertain.
If the cancellations stand, the study notes they could include an 88% cut to maternal and child health aid, an 87% cut to surveillance for epidemics and emerging diseases, and 94% cuts to family planning and reproductive health programming.
The knock-on effects were already visible as the study was written. Suspended contracts for the President’s Malaria Initiative halted hundreds of millions of dollars annually to countries including Nigeria and Uganda, with an estimated threat of nearly 15 million additional malaria cases and 107,000 additional deaths globally from just one year of a disrupted malaria-control supply chain. The UN World Food Programme closed its southern Africa office, placing 27 million people at risk of hunger during the region’s worst drought in decades. A survey cited by the authors estimated that 79 million people previously targeted for assistance are no longer being reached because of USAID program cuts, with the capacity of national non-governmental organizations profoundly affected.
The authors also warn about probable ripple effects on other international donors, which would compound the impact of the American withdrawal.
Specific Disease and Program Impacts
The consequences are not evenly distributed. The areas most affected are those where USAID funding was most concentrated.
HIV/AIDS: USAID is one of seven agencies involved in direct implementation of PEPFAR, launched in 2003, which has invested an accumulated total of over $100 billion in the global HIV/AIDS response. In 2023, USAID obligated and implemented 60% of PEPFAR’s bilateral HIV assistance. The study attributes a 65% reduction in HIV/AIDS mortality to USAID funding, representing 25.5 million deaths.
Malaria Prevention: USAID has been involved in combating malaria through the President’s Malaria Initiative. Suspended PMI contracts alone threaten nearly 15 million additional malaria cases and 107,000 additional deaths globally within a single year of supply chain disruption.
Vaccination: USAID has supported the Global Alliance for Vaccines and Immunization and pledged $1.16 billion over 2020 to 2023 to that organization.
Maternal and Child Health: The study documents significant reductions in maternal and perinatal mortality associated with USAID funding, alongside the 32% reduction in under-five mortality. Announced cancellations could cut maternal and child health aid by 88%.
Food Security and Humanitarian Response: Between 2017 and 2020, USAID responded to more than 240 natural disasters and crises worldwide. In 2016 alone it provided food assistance to more than 53 million people across 47 countries.
Education: Between 2011 and 2015, USAID education programs, covering teacher training, curriculum development, and school infrastructure, supported more than 52 million children in 45 countries.
How This Compares to Other Government Spending
Context matters when evaluating claims of waste. USAID was estimated in 2024 to have managed more than $35 billion. Its largest funded sectors were humanitarian assistance at $9.9 billion and health at $9.5 billion, and the largest benefiting region was sub-Saharan Africa at $12.3 billion.
Set against national wealth, the American contribution is more modest than the absolute figures suggest. The United States provided more than $55 billion in official development assistance in 2023, roughly 30% of total ODA from Development Assistance Committee countries, yet it ranked 25th out of 30 DAC members in aid relative to national income, allocating 0.24% of gross national income. Norway allocated 1.09% and Luxembourg 1.00%, both above the United Nations target of 0.7%. In 2023 the United States accounted for 43% of all government funding donated to the humanitarian system, up from about 39% a decade earlier.
That combination, a very large share of the world’s humanitarian funding but a below-average share of its own national income, is the context I think is missing from most of the public argument about foreign aid.
Practical Takeaways
- A Lancet analysis of 133 countries and territories found that higher USAID funding was associated with a 15% reduction in age-standardized all-cause mortality and a 32% reduction in under-five mortality, corresponding to more than 91 million deaths prevented over 21 years.
- The forecasting models project more than 14 million additional deaths by 2030 if the cuts stand, including more than 4.5 million children under five. This is a projection with a wide uncertainty interval, not a measured count.
- This is an observational, country-level study with statistical adjustment, not a randomized experiment. The consistency between where funding was concentrated and where mortality fell most is what gives the finding its weight.
Related Studies and Research
- PEPFAR put 20 million people on HIV treatment and prevented nearly 8 million infected births examines the peer-reviewed evidence on the world’s largest HIV/AIDS program.
- How foreign aid builds soft power: the evidence for health diplomacy reviews research showing that health aid uniquely improves global perceptions of the United States.
- What the data actually shows about fraud in U.S. foreign aid programs separates the political narrative from the audited evidence on fraud rates.
FAQs
How reliable are the projections of 14 million additional deaths?
They come from a peer-reviewed study in The Lancet that integrated a retrospective evaluation of 133 countries over 21 years with validated dynamic microsimulation models. The retrospective side used fixed-effects Poisson models adjusted for demographic, socioeconomic, and health-care factors, backed by sensitivity and triangulation analyses. The projection itself carries a wide uncertainty interval, from 8,475,990 to 19,662,191 additional all-age deaths by 2030. I would treat the range, not the midpoint, as the honest reading. It is also worth remembering that the underlying association is observational, so the projection inherits whatever confounding remains in the original estimate.
Could other countries or organizations fill the gap left by USAID?
The study’s authors flag probable ripple effects on other international donors, meaning the risk runs in the opposite direction: rather than compensating, other donors may follow. The United States accounted for 43% of all government funding donated to the humanitarian system in 2023, which is a share no other single donor is positioned to absorb.
Did USAID funding depend on politics?
Yes, and the authors say so directly. The USAID funding model, like that of other US federal agencies, is largely driven by political negotiations within Congress and the Senate, which makes long-term sustainability inherently difficult without support from the executive branch. That is why some USAID sectors had been developing plans to make their interventions more scalable and durable.
Bottom Line
The peer-reviewed evidence points in one direction: USAID-funded programs were associated with tens of millions of deaths prevented over two decades, and the models project millions of additional preventable deaths by 2030 if the funding cuts stand. This is observation
