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One of the first acts of the first 100 days of President Trump’s Administration was an executive order that led to a large-scale cutback in American spending on foreign aid. Through the United States Agency for International Development (USAID), which is now on the verge of dissolution, the U.S. had funded 40% of the world’s foreign assistance, including programs designed to combat disease, malnutrition, maternal mortality, totalitarianism, and climate change. According to analysis by KFF, 80% of all the U.S.’s global health awards were terminated, including those to the jewel in the America’s foreign aid crown, the President’s Emergency Plan for AIDS Relief (PEPFAR). Medecins Sans Frontieres (MSF), also known as Doctors Without Borders, an organization that provides emergency medical help almost anywhere in the world during times of crisis, does not rely on any U.S. government funding. But its fieldworkers have front-row seats to the consequences of the loss of aid across the globe. Avril Benoît, the CEO of MSF in the U.S., spoke to TIME about the ripple effects the organization is seeing—and where the cuts are hurting most.

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This interview has been condensed and edited for clarity.

MSF is an emergency-response organization that takes no government funding. Was it immediately affected by the pullback of U.S. foreign aid after election of Donald Trump?

We’re not directly financially affected, but we’re indirectly affected. We’re on the ground in humanitarian crisis zones, providing independent and impartial medical humanitarian aid. And all around us, we are seeing a collapse of various services that were subsidized by U.S. government.

Groups that we work alongside have been left scrambling to carry out lifesaving services without money, staff, or any certainty about what comes next. We are already seeing life-threatening implications. Programs for HIV, AIDS, and tuberculosis treatment, sexual and reproductive health care, disease-outbreak response, and malnutrition are the most dramatic ones. People have shown up to clinics in South Africa, for example, clinics where they’ve received care for years, just to see “closed” signs hanging on the door. Ready-to-use therapeutic food in many places is now sitting in warehouses out of reach of children with severe acute malnutrition, because the implementing partners whose job it was to distribute it have been fired. We are seeing more patients coming into hospitals that are already over capacity.

Can you give me a specific example of what changes MSF workers are noticing?

Our nutrition programs in Baidoa, Somalia, have reported an increase in malnutrition admissions since the funding cuts. We admitted, all of a sudden, 195 children with severe acute malnutrition in March alone. Severe acute malnutrition means that if the children don’t receive therapy, they could die within weeks. The MSF-supported Bay Regional Hospital in Baidoa has received patients, especially women, who have come from as far as 120 miles away. When the wider network of health-care services shuts down, it means people have to travel that much further to where our programs are located, and that time, that distance, you can imagine for somebody who’s sick or carrying a severely malnourished child, could mean life or death. It’s one of the reasons that community health programs are so important.

One of the predictions was the spread of infectious diseases. Has that happened?

In the border regions of South Sudan and Ethiopia, there’s a rampant cholera outbreak amid escalating violence. Our teams say that a number of organizations, including Save the Children, have suspended mobile clinic activities in Akobo County due to the USAID cuts. Save the Children reported earlier this month that at least five children and three adults with cholera died while making a long arduous trek in the heat to seek treatment. So local health authorities are now facing significant limitations in their ability to respond effectively and cholera cases are rising in many other parts of South Sudan. It’s worrying because people are on the move in a conflict. They bring diseases with them to new locations, new camps for displaced people, where there are very few resources available. From October 2024 until now, we treated more than 7,800 cholera patients and were supporting local health systems, local clinics and health posts. Normally you would have other organizations chipping in, helping out, supporting oral-vaccination campaigns or oral-rehydration sites, and when those are taken out of commission very suddenly, it increases the risk of the spread of cholera.

MSF is essentially an emergency organization. You go where the emergencies are. Are you seeing less of an American presence during these crises, or is that still something America can respond to?

In the initial weeks following the aid freeze, we saw several organizations stop the distribution of drinking water for displaced people in various conflict-affected areas, including Darfur in Sudan, Tigray in Ethiopia, and the capital of Haiti, Port-au-Prince, where you’ve got levels of criminality that rival any war zone in terms of violence. We have quite a large presence in Port-au-Prince: trauma, hospitals, emergencies, and so forth. We had to pick up some of the cut programming in terms of running a water-distribution system via tanker trucks to provide for all these displaced people, 13,000 or so living in encampments in the capital. People are trying to flee violent clashes between armed groups and the police, and they end up in these encampments, where there’s absolutely no resources, no water for them. So we had to add water in addition to our focus on medical care for victims of violence. But there is absolutely no way for an organization even as large as ours to cover these gaps, it’s too enormous. No organization can do this work alone.

Has anything that happened in these last 100 days just completely taken you by surprise?

Prior to the election, every aid organization working internationally understood that there was likely to be a policy shift and a reduction in the availability of U.S. government funding for humanitarian aid. What we didn’t expect is this wrecking ball just completely destroying the infrastructure, the capacity to follow up, the availability of resources to the world’s most vulnerable in one swoop. We thought maybe there will be a review that will be 90 days, and then things will come back online. What we’ve seen, though, is nothing. And we just can’t accept nothing in terms of U.S. government contribution to humanitarian aid as the new normal. That would be dangerous for the world.

Have you seen any fresh new emergencies arise, or has it mostly been an exacerbation of existing crises?

The earthquake in Myanmar would be the latest natural disaster. And of course, as it was reported, USAID emergency responders on the ground received orders to pack up and go home amid all the chaos. Myanmar is not an easy place to work, so those organizations already inside with good, credible activities and some sort of relationship with the local population, would be the ones to focus on. Instead, there was no response from the U.S.

The U.S. now no longer has the kind of infrastructure that would make it even possible to quickly reset in an emergency. If you have fired all the people who normally would do the quick assessments, the monitoring and evaluation and push the buttons for the money to flow, even if you wanted to activate an urgent humanitarian response, the capacity has been obliterated.

Almost everybody I’ve interviewed about the U.S. foreign aid situation has said that USAID was an imperfect system that required reform. Would you agree with that?

MSF is funded largely by the generosity of individual Americans. One third of our global operational budget is coming from people in the U.S.—there’s a huge commitment to this issue from the American people. And honestly, we always had very healthy, productive dialogue with the folks in the Bureau of Humanitarian Affairs at USAID, where we were able to alert them to what we were seeing on the ground, as the first responders in crisis zones. We have expressed, at different times, our frustration with the sluggishness, and non-responsiveness of the aid system to emergencies. So for sure, there are things to be improved, and we would welcome that discussion, because it’s absolutely urgent to get on with it.

USAID has been called inefficient and wasteful. What does MSF do to be more efficient? What does efficiency look like in the aid sector?

Efficiency and effectiveness for us relies very much on, frankly, having the kind of independent, unrestricted funding that allows us to go where the needs are greatest, where our assessments determine that we can have an added value and where we can design the programs with the communities in mind, as opposed to geopolitical or economic drivers. I think there’s also just baked into our DNA, a sense of urgency—that we don’t have time for bureaucracy. We’re looked at with some envy right now, of course, because of our independent funding, and yet we’re deeply worried because we can’t do this alone. We can’t carry the burden with organizations that have lost up to 80% of their funding. We are looking at how we organize ourselves, because we know that the dollars need to stretch further now. We’re going to have to try to fill the gaps as best we can.

Is there a loss you personally particularly mourn?

In contexts with already high levels of maternal and infant mortality, these cuts are heartbreaking. In Cox’s Bazar in Bangladesh, which is home to the world’s largest refugee camps with the Rohingya, MSF teams report that other health providers aren’t able to provide the supplies like emergency birth kits and contraceptives. Post-exposure prophylaxis after sexual violence and referrals for medical emergencies like post-abortion care have also been disrupted, so that’s increasing the urgent needs and a lot of people are going to die as a result.

Why aren’t the local governments stepping up in some of these situations? Why does it have to come from the American government?

Whatever capacity local governments had in the past is so much less right now. Vaccination is one of the greatest public-health measures you can take. Worldwide, more than half of the vaccines that we use in our programs come from local ministries of health and are procured through GAVI, the vaccine alliance. We partner with the ministries of health, because they maybe don’t have the implementation capacity, or they don’t have the budgets to be able to pay the nurses and the health-care providers to do a vaccination campaign, so we pay for it. The decision by the U.S. government [GAVI’s third largest donor] to cut funding to GAVI could have disastrous consequences for children around the globe. There have been projections that if you deny vaccines to the approximately 75 million children that were benefiting from that program you could have 1.2 million children potentially dying as a result. We can see the impacts already in Democratic Republic of Congo (DRC) where we do the most vaccination of children against diseases like measles and cholera and the early immunization programs. Could the DRC government do this? Does the DRC government have skilled staff? Yes. Do they have their resources and the political will to really step up into some of the regions of the country that are more conflict-prone, such as the Kivus? That remains to be seen.

If you could wave your magic wand, what would you restore?

It’s interesting, we thought [Secretary of State] Marco Rubio was going to be a champion of PEPFAR. Cuts to PEPFAR and USAID have led to suspensions and closures of HIV programs in many countries, including South Africa, Uganda, Zimbabwe, and this is threatening the lives of people receiving antiretroviral treatment. We’ve seen a 70% increase in pre-exposure prophylaxis tablet distribution from January to March, compared to the previous quarter, and an increase of 30% in consultations for health services. People have fewer places to go so they’re coming to us—a 30% increase in patients. Can you imagine what that’s like as we anticipate our budgetary pressures, our staffing pressures, our supply pressures over the coming months and years? We thought PEPFAR would be one that there was a commitment to preserve. And here we are.

Watching the news and all the executive orders and what the reaction is in the United States, one gets the impression that there are no votes in this, that there are so many things going on, there’s not going to be a specific outcry about cuts to foreign aid. That is a shattering reality for those around the world whose lives depend on it.