The Systematic Dismantling of Global Health Infrastructure: Lessons from USAID's Collapse
The recent dismantling of USAID's global health operations under the Trump administration offers a stark case study in how political decisions can unravel decades of carefully constructed public health infrastructure. The story of Dr. Atul Gawande, the Indian-origin surgeon who briefly led the agency's global health division, illustrates both the potential and fragility of systematic approaches to international development.
The Architecture of Prevention
USAID's global health division operated on a principle that Dr. Gawande had long championed in his medical career: that most deaths are preventable when systems are designed to absorb human fallibility. The agency's work spanned dozens of countries, supporting maternal and child health programs, infectious disease surveillance, and nutrition initiatives designed to catch problems before they became crises.
This approach represented a fundamental shift from reactive emergency response to proactive system building. Vaccination schedules, supply chain management, and outbreak detection networks were designed to make survival feel ordinary rather than exceptional. The philosophy was simple: global health improves when prevention becomes routine.
The Economics of Systematic Healthcare
From an economic perspective, USAID's model demonstrated remarkable efficiency. By investing in surveillance systems that could identify outbreaks like Ebola or avian flu within days, the agency prevented costly pandemic responses. Nutrition programs that tracked warning signs prevented moderate malnutrition from becoming severe, reducing long-term healthcare costs and preserving human capital in developing economies.
Dr. Gawande, who assumed his role in 2022, brought a systems-thinking approach that had proven successful in clinical settings. His emphasis on checklists, standardized procedures, and enforced communication protocols translated directly to international health programming, where consistency often matters more than innovation.
The Dismantling and Its Consequences
When the Trump administration returned to office in early 2025, the dismantling was swift and comprehensive. Operations were frozen, staff dismissed, and programs terminated mid-stream. What Washington framed as reform and reassessment, field workers experienced as system collapse.
The consequences were not immediately dramatic but systemically devastating. Health systems do not fail theatrically; they erode gradually. Supply chains fracture, outreach workers disappear, and clinics lose their capacity to intervene while maintaining the appearance of functionality.
Dr. Gawande later described the result as a "devastating global health void," emphasizing that what vanished was not just funding but the connective tissue that allowed fragile health systems to function. The institutional memory that enabled progress to accumulate rather than reset with each political cycle was lost.
Innovation Versus Infrastructure
The USAID case highlights a critical tension in development policy: the choice between supporting dramatic innovation and maintaining boring infrastructure. While innovation attracts political attention and media coverage, infrastructure provides the foundation for sustained progress.
Dr. Gawande's career has been devoted to proving that spectacular medical breakthroughs mean little without systems capable of delivering them consistently. His work at USAID represented an attempt to apply this principle at global scale, treating international health as an engineering problem rather than a humanitarian gesture.
Lessons for Sustainable Development
The collapse of USAID's global health operations offers several lessons for sustainable development policy. First, that progress in public health requires long-term institutional commitment that transcends political cycles. Second, that prevention systems, while less visible than emergency responses, provide far greater return on investment.
Most importantly, the case demonstrates that effective global health policy requires treating healthcare delivery as a technical challenge requiring systematic solutions rather than a moral issue requiring good intentions.
Looking Forward
As Dr. Gawande noted in his post-government reflections, rebuilding these systems will not be easily reversible. The scientific and human infrastructure that USAID supported took decades to develop and can be destroyed in months.
For policymakers committed to evidence-based development, the USAID case study provides a clear framework for evaluation: successful programs are those that make extraordinary outcomes feel ordinary through systematic implementation. The challenge lies in maintaining political support for approaches that work precisely because they refuse to be dramatic.
The plans to save lives were already in motion when political decisions intervened. What failed was not medicine, knowledge, or intent, but the willingness to let quiet systems continue their work. That distinction may prove crucial for future efforts to build resilient global health infrastructure.