For weeks, some of the federal government’s foremost authorities on global health have repeatedly warned Secretary of State Marco Rubio and other leaders about the coming death toll if they carried out the Trump administration’s plan to end nearly all U.S. foreign aid around the world.

In their clearest accounting yet, top officials have estimated the casualties: One million children will not be treated for severe acute malnutrition. Up to 166,000 people will die from malaria. New cases of tuberculosis will go up by 30%. Two hundred thousand more children will be paralyzed by polio over the next decade.

Instead of acting on the repeated warnings, top administration officials, including the State Department’s director of foreign assistance, Peter Marocco, thwarted their own experts’ efforts to keep the U.S. Agency for International Development’s most vital programs up and running, according to internal memos and estimates compiled by global health leaders at the agency and obtained by ProPublica.

President Donald Trump’s political appointees, along with billionaire Elon Musk’s Department of Government Efficiency, pressed ahead with their plan to dismantle USAID by ignoring and impeding staff who tried to protect lifesaving operations — even as the administration publicly insisted that those programs remained online — according to the memos and interviews with government officials.

During exchanges outlined in one of the memos, a DOGE engineer emailed staff and said they were not allowed to review the programs they were canceling. At another point, USAID’s then-deputy chief of staff, Joel Borkert, told agency personnel to take a “draconian” approach to approving waivers.

The explosive memos — which include summaries of email exchanges and top-level meetings inside USAID, as well as internal agency research — were sent by Nicholas Enrich, acting assistant administrator for global health. ProPublica also obtained detailed breakdowns of lifesaving programs managed by the bureau and the projected impact of cutting them. Enrich was placed on leave Sunday.

Enrich told The New York Times he released the memos, which multiple other officials contributed to, after learning he was being placed on leave, as thousands of others at the agency have been. The memos were circulated to the staff and obtained by ProPublica.

The documents identify several key senior policymakers behind the scenes while also puncturing the administration’s claims of a careful, deliberative review of USAID programming. The records also represent the government’s most explicit concerns to date memorialized by a senior official from inside Trump’s administration.

The State Department, USAID and Elon Musk did not respond to questions about this story. Rubio and Marocco did not respond to a request for an interview.

Since the inauguration, Rubio, Musk and Marocco have taken dramatic steps to incapacitate USAID, the largest foreign aid donor in the world, by firing its employees and halting operations. The global health bureau was one of the first parts of the agency targeted for mass layoffs.

Then, last week, they abruptly cancelled 10,000 foreign aid projects, which account for 90% of USAID’s humanitarian operations and about half of the State Department’s. Lifesaving programs that were still operating around the world were forced to close down immediately.

Following a series of lawsuits challenging their constitutional authority to lay off or place on leave thousands of employees and freeze nearly all foreign aid, Rubio and Marocco have defended their actions by arguing that the president has the right to cancel programs, and that they were conducting a careful review of the government’s foreign aid programs to make sure they aligned with Trump’s agenda. The administration says it is rooting out waste and fraud, while Musk has publicly vowed to destroy USAID altogether.

However, as ProPublica reported Saturday, officials throughout the government say the process was actually cursory and haphazard, so much so that the programs’ contract officers, who have oversight of individual programs and are aid groups’ primary contacts, had no idea what had been canceled or why.

Enrich’s memos offer additional evidence calling into question the administration’s claims in court while projecting the dire consequences that will play out for both the U.S. and vulnerable people around the world.

One of the documents said that the sweeping cuts to foreign aid promise to reignite outbreaks of preventable, deadly illnesses; fuel instability in war-torn areas; and put the U.S. at risk for outbreaks of infectious disease. “This will no doubt result in preventable death, destabilization, and threats to national security on a massive scale,” it says.

Take tuberculosis, which kills more than 1.25 million people a year and is already the deadliest infectious disease on the planet. New infections are expected to surge by 30% more as a result of the terminations, and disruptions to treatment will cause people to develop drug resistance, making any future treatment options far more difficult and costly, the memo said.

That global surge will inevitably lead to more cases in the U.S. USAID staff forecast there would be around 80 additional cases of multi-drug-resistant TB here each year because of the cuts across USAID, the memo added. Even a few dozen cases would cost the U.S. millions in tax dollars; it takes nearly $500,000 on average to treat someone with the most drug-resistant forms of the illness, the memo notes.

Enrich’s bureau also warned that the foreign aid cuts will destabilize entire regions around the globe. In the Democratic Republic of Congo, the U.S. withdrawal of aid has led health services to collapse as an ongoing conflict flares, the memos noted. They said more than 400 mpox patients were left stranded and that more than a million people face critical shortages of food and water, supplies the U.S. has promised to provide. Malnutrition, cholera and measles are all projected to increase as well.

Across the Sahel, the transition zone between Africa’s northern deserts and southern savannahs, malaria season is fast approaching. The U.S. has already purchased mosquito nets, diagnostic tests and treatments that cannot be delivered, according to multiple people with direct knowledge of the programs. Canceled programs there and elsewhere are expected to cause between 12 million and 18 million additional malaria infections over the next year, the document estimates.

And those infections are likely to be more deadly. Spread via mosquito, malaria is particularly lethal for children under 5. The U.S. was paying to help roll out drugs that are highly effective at preventing children from getting sick or dying. Those programs have been canceled.

The potential for death and the spread of disease is not new to Rubio or his top aides who ordered the mass termination of nearly all foreign aid programs, according to the documents and interviews.

USAID staff repeatedly lobbied to keep the most critical programs running, sharing specifics about patients served for individual programs and the likely harm of cutting them with political appointees, sometimes on multiple occasions. In response, political leadership “wholly prevented” staff from implementing Rubio’s promise to continue lifesaving aid, according to Enrich’s memo.

In public statements and court filings, Rubio and Marocco have said there was a waiver exemption process in place for lifesaving programs to remain funded and online.

But behind the scenes, the few employees remaining at USAID struggled to get basic information, like how to submit waivers to Marocco for approval. And when organizations did get an approved waiver, they couldn’t restart work because the administration still hadn’t paid them. (The Trump administration has refused to reimburse almost $2 billion to foreign aid contractors for work they’ve already completed.)

Agency staff had no way to send payments to organizations because their access to the financial systems had been severed, one memo said.

On Feb. 8, global health staff learned that Rubio planned to cancel many programs the bureau had identified as lifesaving. Those in the bureau appealed to Borkert and Mark Lloyd, an assistant administrator at the agency, to keep those operations alive. (Borkert and Lloyd did not respond to questions about this story.)

Lloyd asked for more information. But that same day, staffers in the bureau also received a response from DOGE. “I am hearing that Global Health is conducting supplemental reviews of awards slated for termination by Secretary Rubio and Acting Deputy Administrator Marocco,” DOGE adviser Jeremy Lewin emailed Enrich, according to one of Enrich’s memos. “This is delaying the timely processing of these termination notices and is unacceptable. … Bureaus should not be conducting their own policy and program reviews before acting on these termination instructions.” (Lewin did not respond to questions for this story.)

Enrich also said he received written instructions to pause approving waivers for lifesaving humanitarian assistance, a directive he passed along to the rest of his bureau, which had been working to identify the programs that needed money the most.

In a subsequent exchange spelled out in one memo that illustrates the frequently conflicting guidance, Enrich said that two political appointees, Tim Meisburger and Laken Rapier, along with Bokert, shouted at him during a Feb. 13 meeting that there had never been a pause, and instructed him to draft another memo to correct the “false narrative in the media that there had ever been a pause” on the bureau’s waivers for lifesaving programs. (Meisburger and Rapier did not respond to questions about this story.)

During a meeting on Feb. 24, Meisburger and Lloyd told those in the bureau to not bother trying to submit waivers for programs involving infectious diseases like mpox, polio and Ebola because they wouldn’t be approved, according to Enrich.

Then, two days later, the administration suddenly terminated about 10,000 programs across the State Department and USAID. Agency staff responsible for maintaining those contracts say they were not consulted before the move. Enrich immediately reached out to Borkert and others to warn them of the “grave impacts on lifesaving activities,” he said in the memo.

Borkert responded, indicating that many of the programs were terminated by mistake. “There is an acknowledgement some may have been sent out in error and we have the ability to rescind,” Borkert wrote to Enrich. “We need to identify what those are.”

In recent days, government officials and aid groups have told ProPublica that the administration appears to be trying to reverse-engineer its most sweeping actions to figure out which lifesaving operations were canceled. Staff have been told to report information about terminated contracts to agency leaders. It’s not clear what programs, if any, will be restored.

“It is an incompetent mess,” one official said.