A maternal health programme in Nepal, an unfinished canal in Kenya and polluted air in Tehran show how decisions made in Washington travel. What would it take to repair the harm?
In rural Nepal, the aid workers used to come to the village. The work was ordinary in the way public health is supposed to be ordinary. Someone checked on pregnant women. Someone helped them get information and care before a complication became an emergency. Then Washington stopped paying for the programme, and the visits stopped.
In August, the Associated Press reported on Kabita Mukhiya, who died the previous December while 28 weeks pregnant. Her death came amid disruptions to nutrition and reproductive-health outreach after US aid cuts. Reporters spoke to families, aid workers, health staff and officials about the gaps that opened when those services disappeared. Mukhiya’s case illustrates what a lost layer of care looks like in a place where reaching the next one can be hard. Nobody can rerun a pregnancy to see what would have happened had the visits continued.
In the 3 November midterms, Democrats won control of both houses of Congress, according to calls by the Associated Press and Reuters. Donald Trump had spent part of the campaign telling voters to imagine his name on the ballot. They appear to have taken the suggestion seriously. Many of the people most exposed to the decisions of his second term had no ballot in that election. Their lives are shaped by decisions about aid, emissions and war that they had no power to vote on.
Nearly two years into this presidency, there is enough evidence to ask a more demanding question than whether Americans have had enough. What has already been lost, what can still be saved, and who will do the work?
The people who stopped coming
On his first day back in office, Trump ordered a review of US foreign assistance. A stop-work order froze payments and services for work already under way. The administration subsequently dismantled the US Agency for International Development and cancelled most foreign-assistance awards. It issued a waiver for some life-saving assistance, but KFF found the waiver covered limited services and was hard for implementers to secure. The machinery for obtaining permission to do the work was itself among the things being disrupted.
A government is entitled to ask whether it spends public money well. It can audit grants, replace ineffective programmes and negotiate a different division of costs with partner governments. A blanket pause on work already in progress does something quite different. It makes continuity of care depend on how quickly a clinic or a contractor can decipher instructions from a government thousands of kilometres away. The administration asked programmes to demonstrate their value while interrupting the work through which that value was delivered.
HIV prevention loses its reach
Nepal offers one example. HIV prevention shows the same problem at a different scale. UNAIDS reported in July that a study covering 47 countries found steep reductions in services run by community organisations, including support for HIV prevention medicines and care. Services for gay men and other men who have sex with men, sex workers, and survivors of gender-based violence were particularly hard hit. These are people a conventional clinic may struggle to reach, especially where stigma or criminalisation makes it dangerous to disclose why they need care. A functioning service can depend on years of work by people their clients know and trust.
International HIV financing fell from US$8.8 billion in 2024 to US$7.3 billion in 2025, according to UNAIDS. That 18 per cent drop reflects decisions by multiple donors. The US decision was especially consequential because of the scale of its involvement and because so many partners had organised their work around continued American support. KFF puts US funding for the President’s Emergency Plan for AIDS Relief, or PEPFAR, at US$4.9 billion in fiscal year 2024. Even a government willing to spend more of its own money cannot immediately replace a programme built on funding and contracts of that size.
A 2025 study in The Lancet projected more than 14 million additional deaths by 2030 under a scenario of steep, sustained USAID defunding. That number is a model result, and the eventual toll depends on which services stay down, how long they stay down, and how much other governments and organisations can replace. One of the difficulties in putting a number on what has already happened is that the workers and systems that help record illness, deaths and missed care can be affected by the same cuts. The disappearance of a service is often visible before the full health consequences are.
What it takes to reopen services
Health ministries, other donors and multilateral funds can help keep medicines and diagnostics available now. Where local organisations have lost contracts, bridge grants can help them retain staff, reopen outreach routes and reconnect patients with care. Those organisations should decide how to reach people safely. In Washington, Congress can ask the State Department which suspended programmes are operating again, where gaps remain and how much money has actually reached providers. Tests available, treatment interruptions and households reached would give a better account of the recovery than the amount pledged.
There is also a longer-term question about who controls the system. UNAIDS has called for debt restructuring so countries with heavy debt burdens can invest more in health. Wealthy donors can provide reliable multi-year funding while partner governments and local organisations build capacity to run and finance more of the work themselves. Both steps matter. A government cannot replace foreign aid by decree when its health budget is already stretched. And a new system that still depends on a single foreign capital deciding, every few years, whether the work deserves to exist would leave the old vulnerability in place.
A rule can be restored. The atmosphere keeps the carbon.
In January 2026, the United States’ second withdrawal from the Paris Agreement took effect. A separate US withdrawal from the UN Framework Convention on Climate Change, the treaty that underpins Paris, is due to take effect on 27 February 2027. In February 2026, the Environmental Protection Agency finalised its rescission of the 2009 greenhouse gas endangerment finding and repealed the associated federal greenhouse gas standards for new motor vehicles and engines. The finding supplied the legal basis for those standards under the Clean Air Act. The White House celebrated the repeal as a great act of deregulation. The atmosphere, never much impressed by a press release, continued to respond to the gases being put into it.
In September, the EPA also repealed most of the 2024 greenhouse gas standards for fossil fuel-fired power plants. Separately, it proposed finding that it lacks authority under the Clean Air Act to regulate those emissions at all. The repeal was finalised. The broader finding was still a proposal when the EPA published it.
A vehicle rule looks like an argument between lawyers until you follow the vehicles. A standard affects what manufacturers sell across millions of purchases. A new car or truck can then stay on the road for years. The difference in fuel burned accumulates over that lifetime, and the warming associated with carbon dioxide depends largely on how much is emitted in total. Even a future administration that restores the rule cannot reach back into the intervening years and change the engines that were sold or the fuel already burned.
How much slower could emissions fall?
An earlier Rhodium analysis, reported by Carbon Brief, asked a more specific question. What if the EPA removed a package of 31 policies, and what if those policies stayed in place? With the package removed, the model projected emissions in 2035 at 26 to 35 per cent below 2005 levels. With the policies in place, it projected a drop of 32 to 44 per cent. The difference concerns a group of rules and cannot be assigned to the vehicle repeal alone. It does show why a country can keep cutting emissions and still do material damage by slowing the cuts. The comparison is with the lower emissions the country could otherwise have achieved.
The canal left unfinished in Kenya
In Taita Taveta County, near Kenya’s border with Tanzania, people were trying to manage a problem that Washington debates in the abstract. The county cycles through drought and floods, and an irrigation canal was under construction. The challenge extends beyond Kenya. Farmers in Malawi face increasingly erratic rains, too. When workers were told to stop after the US aid cuts, they had built brick walls along just 220 metres of the planned 3.1 kilometres, community leaders told Reuters in July 2025. The walls still needed plaster to protect them from erosion. Juma Kubo, a community leader, warned that if the walls collapsed in heavy rain, the water could damage farms.
The community asked Kenya’s government and international donors to help finish the canal, at an estimated cost of 68 million Kenyan shillings. While they looked for funding, Kubo said they planned to sell some of the cement and steel cable left on site to pay for the work needed to make the unfinished section safer. That was the position when Reuters reported it. The reporting establishes where the work stopped and what people were left to deal with. It does not establish that the unfinished canal caused any particular flood.
The global financing gap was already large before these cuts. In its 2025 adaptation report, the UN Environment Programme estimated that developing countries would need at least US$310 billion a year for adaptation by 2035. International public adaptation finance reached US$26 billion in 2023. Those numbers compare projected needs with an earlier record of funding. In Taita Taveta, the gap came down to a more immediate question. Who would pay to make the canal safe before more rain arrived?
Rebuilding US climate commitments
County engineers and residents are best placed to establish what the canal needs now. Kenya’s government and other donors can fund a safety assessment and any urgent stabilisation while a decision is made about completing the canal. US officials and congressional committees can account for what happened to the original funding and which other projects were left midway through construction. For adaptation projects, that accounting should show who is responsible for a site when financing ends and what it will cost to leave it safe.
Rebuilding US climate policy will take longer. A future administration can pursue renewed treaty participation and restore pollution standards where it has authority. Congress can give regulators a clearer statutory mandate, and courts can review the EPA repeal. Making up for the extra emissions from delay would require deeper cuts later. That takes investment in cleaner transport and electricity, as well as the staff, monitoring and enforcement budgets that make rules work.
Abroad, credibility would come from money reaching named projects. Adaptation commitments should identify how much will come as grants, who can apply and when the money will arrive. A loan can pay to raise a coastal road. The government still has to service it if a storm washes the road away. For communities already dealing with damage they could not prevent, funding for recovery has a job of its own. Other governments have watched Washington leave Paris, return and leave again. They have good reason to judge the next commitment by what survives an election.
The war that reached the air people breathed
In March, after Israeli strikes on fuel depots in Tehran, fires sent dark smoke over the city and black rain fell. The World Health Organization warned that the pollution could cause respiratory problems. The strikes on the depots were Israel’s. They took place in a war that began on 28 February with US and Israeli strikes on Iran. Trump made the decision to take the United States into that war.
Millions forced from home
By 12 March, the UN refugee agency estimated that up to 3.2 million people had been temporarily displaced within Iran. That was an early estimate of movement inside the country, including people who fled cities for safer areas. It does not tell us how many remained displaced months later. It does tell us the scale of the immediate upheaval. When people leave in a hurry, the costs turn up in places a military briefing rarely mentions. A relative’s crowded home, a prescription left behind and children arriving in a town whose classrooms are already full are all part of what displacement can mean.
By October, families were running through their savings
In Rasht, a city in northern Iran, a mother of two named Hamideh told Reuters in October that her family had moved in with her parents. Her husband had lost his job at a tile factory in May. They had used up their savings and could no longer pay rent. Others Reuters interviewed described struggling to afford food, healthcare and education. Food and drink prices in September were more than double what they had been a year earlier.
The war deepened an economic crisis already shaped by years of sanctions and mismanagement. Iran’s closure of the Strait of Hormuz and the US blockade of Iranian ports disrupted oil exports and trade. Hamideh’s account shows how that broader crisis reached a family months into the war. The air over Tehran had made the damage visible in March. By October, some of it showed up in what households could no longer afford.
How Hormuz spread the shock
The war also exposed how much of the world’s energy security depends on passage through the Strait of Hormuz. The effect varies by country and by household. A large importer has more ways to find alternative supply than a family that already spends much of its income on getting to work and keeping food on the table. The international discussion has often been about oil prices and shipping. For people near damaged facilities, the questions are more immediate. What is in the air and water? Who can test it? Who pays to clean it up, and who will be around to check the work in five years?
The emergency response put a number on that dependence. In March, the 32 members of the International Energy Agency agreed to make 400 million barrels of oil from their reserves available, the biggest coordinated release in the agency’s history. At the time of that decision, the IEA put exports of crude and refined products through the strait at less than a tenth of their pre-war volumes. Emergency stocks buy time for importers. The longer-term job is to make a disruption on that route less punishing to people elsewhere, including by giving households and businesses ways to travel, heat buildings with less fossil fuel and move goods with less oil.
On the eve of the midterms, the Associated Press reported that US forces had struck Iranian targets in the strait again, citing a US official. The scale of the next phase of the conflict was still unclear as Americans voted.
Who pays to clean up and rebuild?
Repair starts with diplomacy aimed at ending hostilities, protecting civilians and keeping humanitarian access open. At damaged industrial sites it requires independent sampling of air, water and soil, public disclosure of the results, and remediation wherever testing establishes contamination. People who were exposed need access to medical assessment and follow-up. Displaced families need safe options for returning or resettling. A credible process would preserve evidence of civilian harm and allow independent investigators to establish which actor was responsible for which incident. That is the basis for deciding what compensation is owed and by whom.
Relief funding can move while investigators establish responsibility. Humanitarian agencies and donors can support displaced families where access allows. Iranian health workers, environmental specialists and residents should help decide where to sample and which results need to be published first. The United States can disclose records of its own operations and fund independent monitoring and recovery. Decisions about compensation can follow the evidence of who caused specific harm.
What the election makes possible
When the new Congress takes office in January, it can begin with three requests. The State Department should identify which aid programmes stopped and which have reopened. The EPA should disclose the emissions it expects with and without the vehicle standards. The Pentagon should account for the records it holds on civilian harm in Iran and explain which can be made public. Hearings can put those answers on the record. Congress can also seek funding and set conditions on how it is used, though Trump retains the veto and an override takes two-thirds in both houses.
How we’ll know repair is happening
Some of the work can start without waiting for Washington. A donor can keep an outreach team paid. County engineers can assess whether an unfinished canal can survive the next rainy season. Local specialists can identify where to test for contamination. Other decisions, including restoring durable US climate rules and funding international commitments over several years, will depend on what Congress and the executive can put into law and carry out. In each case the people affected should be able to see the result for themselves.
Some of the damage can still be prevented. A health worker can return to a village in time for someone else’s pregnancy. A stricter vehicle standard can affect the next generation of cars. Testing around a damaged fuel depot can identify a hazard before more people are exposed. Some of what happened is beyond repair in any literal sense. Money can support a bereaved family. It cannot give that family back the person who died.
For the people who lived through these decisions, repair will have ordinary, observable signs. Someone comes back to the village. A patient collects medicine without missing a dose. A family that fled can go home safely and find out what is in the water. Those are the results worth following after the election coverage ends.