Tim van Opijnen | Foreign aid is being used as extortion
For sixty years, the United States was the world’s largest provider of humanitarian aid, but in just a few years the reality surrounding development aid has become far more grim, observes columnist Tim van Opijnen. “A doctor who withholds a patient’s HIV medication until they sign over their house isn’t negotiating with a harder edge. That’s extortion.”
Every morning I take a slight right off the main entrance at Boston Children’s Hospital and slip through a small revolving door into the Enders research building. The first thing I see in the lobby is a red iron lung, a relic from the mid-twentieth century, when polio paralyzed children across the world. Here, John Enders and his team figured out how to culture poliovirus, enabling the Salk vaccine and earning them the Nobel Prize in 1954. It just stands there, a silent reminder of what sustained scientific investment, and the global health programs built on top of it, can actually accomplish. Seeing it fills me with pride, but these days at the same time with dread.
The toll
USAID, created by President Kennedy in 1961, was for six decades the largest provider of humanitarian aid on the planet. The Department of Government Efficiency (DOGE), Elon Musk, and the blessing of the president ended that in January 2025. The agency was dismantled: 16,000 employees laid off, 280,000 contractors worldwide cut loose. PEPFAR, George W. Bush’s AIDS relief program and one of the most cost-effective public health interventions in American history, saw its funding gutted. The program had saved an estimated 26 million lives and cut HIV-related deaths by 59 percent. In Zambia alone, it provided free treatment to 1.3 million people, roughly six percent of the population.
Boston University’s ImpactCounter puts the death toll from entirely manageable diseases due to USAID cuts in the hundreds of thousands, and climbing.
While the administration congratulates itself on the “incredible” savings, USAID’s entire annual budget was already surpassed after the first week of bombing Iran. Sixty years of painstaking work, taken to with a sledgehammer, but at least the spreadsheet looks better!
Fair enough
You may ask yourself why we taxpayers should fund Zambia’s healthcare. Twenty years of PEPFAR and the country still can’t finance its own HIV response. Shouldn’t it stand on its own feet?
It’s not a stupid question. Anyone who has spent time in international development will admit that aid has often failed to build the self-sustaining systems it promised. Zambia itself has chronically underinvested in domestic health financing. It’s the kind of argument that speaks directly to the underbelly: easy to swallow, hard to digest, and someone else’s problem to clean up.
What it ignores, besides basic empathy and any grasp of how the world works, is arithmetic. Zambia’s GDP is less than one percent of America’s. The drugs, diagnostics, and clinical infrastructure needed to manage an HIV epidemic at this scale are unaffordable without external support. Under the previous government the Netherlands boldly followed suit cutting its own aid budget by billions, same logic, better manners, and is discovering the same uncomfortable truth: the line between “reducing dependency” and “abandoning people” is crossed faster than it takes to write the press release. And the consequences are predictable: refugees don’t materialize from nowhere, they come from the places we decided to stop investing in. A disease you stop vaccinating against doesn’t retire, it just waits for the next flight out.
The price
Meanwhile, the argument has moved somewhere darker. A leaked State Department memo proposed using Zambia’s HIV funding as a negotiating lever to extract mineral concessions. The language was unambiguous: “We will only secure our priorities by demonstrating willingness to publicly take support away from Zambia on a massive scale.” Across Africa, more than a dozen countries have since signed agreements with Washington, trading mineral access for citizen health data. The new foreign aid, it turns out, comes with a mining contract attached.
Foreign aid has always served strategic interests: influence, stability, goodwill, financial markets. That is not corruption. That is foreign policy. But a doctor who withholds a patient’s HIV medication until they sign over their house isn’t negotiating with a harder edge. That’s extortion. When survival becomes the lever, you have knowingly taken hostages and dressed it up as diplomacy.
John Enders did not culture poliovirus in exchange for mineral rights. The iron lung in my lobby is a monument to the idea that some problems are worth solving because those suffering from them are human beings. Not leverage. Not a quarterly return.
That idea, apparently, is now quaint.
Tim van Opijnen is a professor of paediatrics at Boston Children’s Hospital and Harvard Medical School in Boston, in the United States, where his laboratory develops new antibacterial treatment methods. He writes a monthly column for Folia about conducting research in Trump’s America.
