One country's survival guide in the wake of U.S. aid cuts

Sandals extracurricular a brothel connected nan Uganda-Kenya highway. Among nan galore losses aft nan U.S. assistance cuts: free condoms and PrEP for activity workers. Joanne Cavanaugh Simpson for NPR/Joanne Cavanaugh Simpson for NPR hide caption

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Joanne Cavanaugh Simpson for NPR/Joanne Cavanaugh Simpson for NPR

A young female sits connected a integrative chair successful a actual courtyard, flanked by faded bluish woody doors. It's precocious afternoon, and astir of nan constrictive doors of 2 dark, stucco buildings are closed. Until unreserved hr and nan night.

Pressing agleam pinkish fingernails together, nan activity worker astatine this brothel talks astir her fearfulness of contracting HIV now that U.S. authorities costs for preventive medications person been slashed and condoms are scarce. She is 1 of galore Ugandan women progressively without specified protection, including young girls from agrarian areas trafficked into prostitution as good arsenic women who look gender unit aliases are unsure of their partners' fidelity.

"Nowadays, we spot women, they're facing a problem, a situation of: 'Do you conscionable spell without immoderate protection?' I'm seeing that many, galore group will get infected," says Judith Babirye, who has agelong worked pinch women astatine this brothel down a trucker barroom connected nan crowded road that links Uganda to Kenya.

Babirye is simply a task serviceman pinch St. Francis Health Care Services, which provides wellness attraction and related services to susceptible populations successful Eastern and Central Uganda. She translates for nan 26-year-old woman, who asked not to beryllium identified because activity activity is forbidden successful Uganda. One of an estimated 130,000 activity workers successful nan country, nan female softly talks astir her seven-day workweek, sometimes pinch 10 clients a day. She sends money location to her mother to salary her young son's schoolhouse fees and tin only spend to spot him each December. She dreams of starting a hairsbreadth salon aliases raising chickens.

For 4 years, nan St. Francis squad would travel to nan brothel — and 79 others for illustration it — to connection HIV testing and prevention products to activity workers. But nan Trump management directed early this twelvemonth that U.S.-funded pre-exposure prophylaxis (PrEP), which reduces HIV-infection risk, beryllium provided only to pregnant women and breastfeeding mothers. St. Francis receives minimal preventive meds and tests for its installation but tin nary longer connection them to nan 1,500 women activity workers it serves successful nan community. The squad besides utilized to present astir 9,000 condoms to nan brothel monthly, but nan U.S. authorities nary longer provides those either.

"Now, erstwhile we don't person condoms," nan young female says, "we conscionable springiness in."

Paul Mwanje, St. Francis' head of programs, has grappled pinch abrupt dire backing cuts before. Sitting successful his sparse agency successful St. Francis' analyzable of sienna buildings successful nan mini Nile River municipality of Njeru, he says nan 2025 cuts punctual him of different shock. After nan U.S. authorities partially trim President's Emergency Plan for AIDS Relief (PEPFAR) backing successful consequence to Uganda's 2014 Anti-Homosexuality Act, St. Francis mislaid astir $125,000, forcing it to laic disconnected 18 of its 48 employees, galore of whom were providing attraction to HIV affirmative patients, until backing was later restored. The acquisition made nan St. Francis squad recognize nan threat of relying truthful overmuch connected a azygous overseas donor.

Paul Mwanje is nan head of programs astatine St. Francis Health Care Services, a kindness that focuses connected susceptible populations. After U.S. assistance was trim temporarily successful 2014, nan statement learned to grow its revenues and donors. Joanne Cavanaugh Simpson for NPR hide caption

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Joanne Cavanaugh Simpson for NPR

"It was an eye-opener to america then, that this could happen," says Mwanje. The statement has since sought much backstage donors and accrued its gross by offering caller paid services for illustration surgery, maternal care, radiology and dental exams.

St. Francis' adaptations reflector a die-hard push by Ugandan wellness leaders blindsided by nan shockwave cuts. The East African federation had received much than $3 billion from PEPFAR since 2004 and has been among the apical low-income countries receiving decimated USAID funds. Among nan African nations deed hardest, Uganda has endured thousands of layoffs successful nan wellness assemblage and terminated NIH and CDC investigation grants. Pervasive uncertainty successful nan conflict against HIV and different infectious diseases, including malaria and tuberculosis, lingers. "Everything was truthful abrupt," says Dr. David Serwadda, erstwhile dean of Makerere University School of Public Health successful Kampala. "So dizzyingly abrupt."

Faced pinch specified devastating losses, Uganda's wellness leaders person accelerated innovations, specified arsenic shifting patients from separate, PEPFAR-supported HIV clinics into authorities outpatient services; tapping a ample web of backstage clinics; and scaling up non-U.S. world collaborations, philanthropist outreach and tech solutions, including AI. 

The captious question: Will Uganda beryllium capable to capable nan void near by nan U.S. overseas assistance shake-up?

While it's improbable nan state will beryllium capable to lucifer nan missing U.S. funds, leaders opportunity they will person to determine which wellness attraction programs to prioritize and really to tally them.

"That's a speech we are each having," says Dr. Rhoda Wanyenze, Makerere's existent nationalist wellness dean. She emphasizes that collaborations should beryllium based connected state ownership: "leadership of programs correct from inception and conceptualizing really they hap — including really they end."

New challenges for an underfunded system

The stakes for Uganda couldn't beryllium higher: About 1.4 million adults and children are surviving pinch HIV. About a 3rd of caller HIV infections are among girls and young women astatine precocious consequence for various reasons including gender-based violence. More than 80% of those surviving pinch HIV had been receiving antiretroviral (ARV) medications earlier this year. Many Ugandans are still getting ARVs — for now.

Since immoderate awesome disruption successful ARV readiness risks plunging group into terrible unwellness and moreover death, nan Uganda Ministry of Health faces a captious challenge: How to protect lives pinch disposable authorities funds. Following nan cuts from nan U.S., nan ministry issued its own order connected Feb. 7: "Standalone HIV/TB clinics MUST beryllium phased retired and integrated into wide outpatient services." The determination has raised concerns astir wellness attraction unit untrained successful nan nuances of HIV care, and unit or community stigma against those pinch HIV. A cardinal issue: How tin an underfunded wellness strategy realistically handle a immense surge of caller patients?

Some location wellness leaders are moving difficult connected nan daunting task. "We are struggling, but our clients are still getting nan services," says Dr. Fredrick Isabirye, wellness serviceman for Jinja, a metropolis of astir 280,000 that's 60 miles eastbound of Kampala.

"We are struggling, but our clients are still getting nan services," says Dr. Fredrick Isabirye, wellness serviceman for Jinja, a metropolis of astir 280,000. Brian Simpson for NPR hide caption

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Brian Simpson for NPR

His unit of 350 was trim by 100. Patients, who typically sewage attraction successful HIV clinics unfastened conscionable 2 days each week, tin now beryllium seen much often astatine infirmary outpatient departments and wellness centers, Isabirye says. Yet, wide concerns stay astir early backing and overburdened wellness workers. By midsummer, unit predisposition connected integration of HIV and superior attraction was rolled retired successful his region, Isabirye adds, including astatine nan Jinja Regional Referral Hospital and 10 wellness centers.

There had been a glimmer of dream soon after nan first U.S. frost successful assistance successful January. The U.S. Department of State announced a waiver to let PEPFAR backing for "life-saving HIV services," but that has proven inconsistent, noted a Sept. 3 Physicians for Human Rights report. A awesome problem: Moving ARVs from Uganda's cardinal and territory stores to distant clinics because of cutbacks successful carrier systems and layoffs of wellness workers, according to Mwanje and UNAIDS. (The U.S. Department of State did not respond to requests for remark for this communicative connected nan U.S. backing cuts and their impacts connected Ugandans.)

Given expected dwindling PEPFAR support complete nan adjacent respective years, a longtime extremity of eliminating AIDS arsenic a nationalist wellness threat likely remains at sedate risk.

"PEPFAR's renewal is captious to forestall further backsliding," noted nan Physicians for Human Rights report, "and to uphold nan correct to wellness for millions of group who trust connected it."

A agelong walk, an optimistic outcome

Hadija Lukowe, a azygous mother of four, walked from her colony adjacent nan Nile River to a adjacent session 1 time much than 10 years ago. She arrived emaciated and dying. Lukowe was having problem getting HIV meds. She and her children were facing starvation.

"I was traumatized because of nan business I was going through," recalls Lukowe, who is HIV positive. "I was thinking, 'Maybe I can't unrecorded immoderate longer.' At that time, I did not person immoderate support astatine all, truthful moreover getting nutrient to eat was very hard."

Hadija Lukowe, a azygous mother who is HIV positive, has gained spot and optimism pinch nan assistance of nan Soft Power Health clinic, which ensured that she could get ARV medications to suppress nan virus. The kindness besides introduced her to integrated gardening. Brian Simpson for NPR hide caption

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Brian Simpson for NPR

The Soft Power Health session successful Kyabirwa provided Lukowe pinch rides to a Ugandan authorities session for free HIV meds. Clinic squad members treated her family for malaria and malnutrition. They arranged ARVs for her kid who tested affirmative for HIV and brought a mattress to her location truthful Lukowe could slumber better.

As her wellness improved pinch ongoing ARV medications, Lukowe learned astir integrated farming from nan nonprofit, which besides offers health acquisition and services to 15,000 Ugandans annually wrong communities adjacent Jinja. She planted her ain garden, which provides nan family pinch beans, potatoes and bananas today.

"I consciousness strong, stronger than I utilized to be," says Lukowe, opinionated gangly beside nan clinic's thriving plot successful a agelong dress of swirling achromatic and greenish covering her flimsy frame.

A postulation of agleam yellow-orange and reddish buildings, Soft Power Health provided attraction for 50,000 patients successful nan session and nan section past twelvemonth pinch a $699,000 yearly fund funded mostly by backstage foundations and individual donors. The nonprofit, pinch an outdoor waiting room sheltered by ample thatched roofs, has resources beyond nan dreams of galore nationalist wellness centers successful Uganda, including physics aesculapian records, 100% star power, 100 unit members and an integrated garden.

Such backstage wellness centers person agelong bolstered Uganda's wellness attraction strategy arsenic unofficial partners. A 2018 Ministry of Health report tallied 6,937 wellness accommodation successful nan country, pinch much than half private. Many person fees — nonprofits typically complaint less. Soft Power Health charges a level interest for visits, labs and meds balanced to $7, affordable to astir patients, organizers say. (Lukowe was among higher-need patients treated for free.) The fees screen 18% of curen costs, and fundraising covers nan rest.

In nan existent era, nan authorities wellness strategy mightiness request to trust much connected backstage wellness attraction facilities, particularly to thief tackle different surging diseases for illustration malaria, already rising successful Southern Africa. Jessie Stone, nan U.S. expert who founded Soft Power Health successful 2004, leads different malaria-prevention efforts. The nonprofit, for example, is trading 1,500 heavy subsidized mosquito nets each twelvemonth for $1.12 each. The U.S. halted tens of millions successful malaria-related USAID funding early this year, and early antimalarial support remains unclear, pinch reduced U.S. wide backing still projected for FY 2026. "We each person to collaborate successful a resource-poor setting," Stone says, "because there's truthful overmuch need."

Soft Power Health provided attraction for 50,000 patients successful nan session and nan section past twelvemonth pinch a $699,000 yearly fund funded mostly by backstage foundations and individual donors. Joanne Cavanaugh Simpson for NPR hide caption

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Joanne Cavanaugh Simpson for NPR

One specified need: search antibiotic-resistant tuberculosis strains circulating successful patients, truthful treatments could perchance beryllium adapted. When nan adjacent Budondo Health Center mislaid backing for this activity respective months ago, it gave its high-tech GeneXpert machine to Soft Power Health's unit to thief behaviour nan testing. The results are already confirming some centers' concerns astir nan continual dispersed of drug-resistant TB.

Stone says, "We are going backwards from a nationalist wellness position successful Uganda and globally acknowledgment to these cuts, but we proceed to do our best."

Forging caller paths pinch caller technologies

Cutting-edge tech mightiness connection immoderate opportunities, depending connected really nan caller world bid of wellness backing plays out.

With a burgeoning Ugandan organization much than doubling successful conscionable 25 years to 50 cardinal today, wellness attraction for nan astir susceptible children, for example, is progressively a waiting game. In various hospitals, families tin beryllium seen crowded adjacent to constrictive infirmary beds, aliases sick children remainder connected pallets connected nan floor.

For children pinch sepsis, a perchance lethal guidance by nan assemblage to infection that causes 20% of deaths worldwide, nan hold tin beryllium deadly. At various hospitals and clinics, precocious diligent numbers, arsenic good arsenic constricted aesculapian instrumentality aliases unit training, tin make triage flawed aliases nonexistent.

If a kid needing aesculapian attraction has nary clear emergency denotation for illustration unconsciousness, aliases since pre-sepsis tin mimic milder ailments, a first-come, first-served exemplary tin hap successful immoderate settings. "The caregiver comes, takes nan humor pressure, temperature, height, assemblage weight, [then] says, 'Please beryllium successful nan line,'" says Dr. Ronald Kasyaba, adjunct executive caput pinch nan Uganda Catholic Medical Bureau (UCMB). "A kid could dice conscionable because they are waiting successful nan queue."

New technologies for illustration AI could velocity up treatment: Health attraction workers tin usage apps that emblem high-risk patients, caller investigation indicates. UCMB, nan nation's largest faith-based not-for-profit wellness attraction network, coordinates a wide scope of wellness facilities, including 33 hospitals. Since 2020, UCMB and hospitals successful Kenya person collaborated pinch researchers astatine nan University of British Columbia to create and trial Smart Triage, a investigation task funded mostly by nan Canadian government.

Health workers usage an Android phone, outfitted pinch a beat oximeter, to observe humor oxygen saturation, and an app to archive varied symptoms, specified arsenic malnutrition and respiratory rate. An precocious algorithm creates a sepsis consequence score, and wellness information is fed into a real-time dashboard for physicians. Children wished precocious consequence are prioritized for contiguous treatment, which tin see a sepsis bundle — IV antimicrobials, fluids and oxygen.

Challenges stay pinch training and implementation, though an ongoing study astatine 1 awesome pediatric hospital, Holy Innocents Children's Hospital successful Mbarara successful Western Uganda, indicates children are receiving curen for sepsis successful astir 45 minutes versus three-hour aliases much waiting times, researchers note.

Yet successful an property of canceled aid, immoderate investigation projects mightiness languish. For example, a U.S. National Cancer Institute-funded five-year study on crab test successful HIV-positive patients, part of wider investigation connected AI successful health, ended successful August. Yet immoderate continued backing appears improbable successful nan current NIH-related assistance environment, opportunity researchers searching for different grants. Among nan task goals: a instrumentality learning algorithm to find whether large, analyzable lung masses are tuberculosis aliases cancer, which tin look akin connected typically utilized X-rays. TB, communal successful Uganda, is often nan diagnosis. Meanwhile, lung crab is now nan leading cause of cancer-related decease for Ugandans.

Says Dr. Margaret Mbabazi, a advisor thoracic radiologist astatine Makerere University Lung Institute and elsewhere, who is collecting and analyzing nan project's images: "If lung crab is caught early for patients, we tin do something. They shouldn't each person to die."

Quality Chemical Industries Limited, a mostly African-owned pharmaceutical company, locally manufactures ARVs for HIV patients and different meds for illnesses specified arsenic malaria and hepatitis. Joanne Cavanaugh Simpson for NPR hide caption

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Joanne Cavanaugh Simpson for NPR

Even nan accumulation of narcotics is anticipated to change. Ugandans are taking steps toward self-reliance by producing narcotics locally. One illustration is Quality Chemical Industries Limited (Qcil), a mostly African-owned pharmaceutical institution that manufactures ARVs and different meds for malaria, hepatitis and different illnesses for Uganda and 13 different African nations.

Qcil has been manufacturing much than half of HIV antiretrovirals distributed by nan Ugandan authorities for years, opportunity institution officials. At its state-of-the-art installation successful Kampala, workers successful cleanable room suits and headgear known arsenic snoods sift and operation precise ingredients. Qcil is group to summation accumulation from 1.4 cardinal tablets annually to 2.4 cardinal by mid-2027, pinch plans to besides nutrient nan landmark supplier lenacapavir, nan twice-yearly injectable precocious proven highly effective against HIV, according to studies successful Uganda and elsewhere.

Whether each goes good depends connected money. Will Uganda's government, for example, person costs to bargain meds? George Baguma, a Qcil co-founder and director, feels nan uncertainty, yet focuses connected Ugandans' evolving wellness needs: "We should beryllium investing wherever it hurts america most."

In nan end, Wanyenze, nan nationalist wellness dean, says, "We shall still survive. We'll beryllium here, and we request to continue. The world needs america much than ever, and we are going to spot existent activity emerge."

Brian Simpson, MPH, is simply a Pulitzer Center grantee and freelance journalist whose articles person appeared successful NPR, Smithsonian, The Baltimore Sun and different venues.

Joanne Cavanaugh Simpson, MFA, is simply a two-time Pulitzer Center grantee and adviser. Her activity has appeared successful The Washington Post, Miami Herald and Scientific American, among different venues.