One death is a tragedy. A million deaths is just a statistic. If Stalin ever said such a thing, he wasn’t the first — but the ghoulish claim has stuck to him because he is one of very few politicians with more than a million deaths on his conscience.
The list of government actions that deliberately or negligently led to the deaths of more than a million people is short and ugly. There are civil wars, famines and a cluster of atrocities surrounding the second world war, but not many governments have been so evil or so reckless as to pass that horrendous target.
Incredibly, there is now a case for adding the Trump administration to the list. Elon Musk boasted in early February that, “We spent the weekend feeding USAID into the wood chipper.” Musk is gone but the White House budget request for next year pencils in a cut of two-thirds to global health and humanitarian funding. Foreign aid has a mixed reputation, it is true, but that cut would plausibly cause a million deaths in the next 12 months alone.
Clearly there is a difference between murdering someone and refusing to save their life. It is one thing to kill a child by pushing them into deep water and another to let a child drown because you don’t want to get your suit wet. Where exactly the difference lies, we can leave to the philosophers. Either way, the child is dead.
The figure of a million deaths is both an estimate and a forecast. The estimate may be wrong for all the usual reasons, and it may also be wrong either because the US changes course, or because philanthropists or other official aid agencies find ways to rescue what is being lost.
Despite the caveats, a million deaths is a staggering number. It comes from Charles Kenny and Justin Sandefur, two respected researchers at the think-tank the Center for Global Development. They reckon that if the cuts to humanitarian assistance happen — from $8.8bn to $2.5bn — then 675,000 people are likely to die from HIV within a year, and 285,000 from malaria or tuberculosis.
“This estimate is based on models, and models have their weaknesses,” Kenny told me. “But we think these numbers are at the conservative end of estimates.”
The biggest contributor to this figure is the number of people projected to die from HIV, and it is not an outlandish estimate. A study published in The Lancet in March reached a similar conclusion, projecting that foreign aid cuts by the US and other donors would lead to 10.8 million extra HIV infections and 2.9 million extra deaths over the next five years. Other researchers have produced even more dramatic projections of the death toll.
Nor is there much mystery as to how these deaths might happen. Pepfar (the President’s Emergency Plan for Aids Relief, established by George W Bush) supplies antiretroviral drugs that keep 20 million people alive. The effectiveness of these drugs is well understood. They suppress the virus and prevent transmission, including from mother to baby.
The main uncertainty is whether the drugs will continue to be supplied, despite the enormous disruption that has already occurred. The US secretary of state Marco Rubio has maintained that life-saving aid is continuing, but clinics have closed, and people are finding it impossible to get the medication they need to keep them alive.
Some Americans believe that one-quarter of government spending goes on foreign aid. This is a misperception on a staggering scale. The total US foreign aid budget has been closer to 1 per cent of government spending — and the humanitarian aid budget of $8.8bn was not much more than one dollar in a thousand of everything the US government spends.
Few people in the foreign aid industry would argue every cent saves lives. Many projects do not try to save lives directly. Projects aimed at providing access to clean water, or to schooling, or to contraceptives, might indirectly save lives but they are not included in Kenny and Sandefur’s calculations. Projects often operate in challenging places. Corruption or waste are always risks. There are endless conversations in the foreign aid community about how the whole business might be reformed and made more cost-effective.
In some cases it might be desirable for national governments to find their own funding. For example, the Center for Global Development researchers estimate that nearly 200,000 South African lives are being saved each year from HIV alone, thanks to US foreign aid. That is impressive, but South Africa is not a subsistence economy. It is an upper-middle-income country. The South African government should have the capacity and the funds to supply its own antiretrovirals, and in the long term it might be better if they did.
Yet this is no way to reform anything. The cuts are so abrupt that life-saving services are falling apart before our eyes.
A few former USAID staffers have been working to salvage something from the wreckage. In response to requests from private philanthropists, the team — known as PRO (Project Resource Optimization) — has compiled a list of what they euphemistically call “critical funding opportunities”. These are high-impact projects that might need only a few hundred thousand dollars to complete, or to keep on life-support in the hope that stable funding can be found.
“We originally called ourselves the Lifeboat Project,” says Robert Rosenbaum of PRO. “And I think that metaphor holds better than any other.” A philanthropist told them to find a name that wasn’t quite so dark.
The darkness is justified. When a huge ship sinks, lifeboats can save lives, but you need enough lifeboats, and you need enough time. We have neither. Above all, the lifeboats only work if help is on the way. With the average US voter unaware just how many lives they were saving, and at just how small a cost, it is unclear whether that help will arrive.
A million deaths may be a statistic, but it is also a million tragedies. Most of these tragedies could still be prevented.
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