What can US foreign aid accomplish? Let Fred Burkle explain how much

One of Donald Trump's first vengeful acts in his second term as president was to withdraw the U.S. from the World Health Organization. As we’ve all heard over the last week or so, the first government agency he and Elon Musk have sought to destroy is the U.S. Agency for International Development, better known as USAID. Both organizations are crucial for sustaining global public health. They save millions of lives every year, and doing significant work to prevent further collapse into global chaos. 

Strongmen like Vladimir Putin and Xi Jinping praised the destruction of USAID, as did the leaders of Iran’s theocracy, motivated primarily by USAID’s work to promote democracy. In fact, democracy and public health are intimately related, as I’ve written before, and autocrats with severe personality disorders are particularly damaging to public health and human rights, as described in a 2019 paper by Dr. Frederick Burkle, who has worked with both WHO and USAID, at high levels and on the ground.

Somewhat like the late Jimmy Carter, Fred Burkle offers an inspiring contrast to so-called leaders like Trump or Musk, and an example of America can and should represent in the world. This country tells itself a lot of fibs about how good and great it is — but there are people who don’t just believe them, but devote their lives to making them come true. Burkle’s memoir, "Water on the Moon," which as its subtitle observes chronicles his career of service from the Vietnam War to the present, shows what that looks like in action. It offers us hope for building a future beyond Donald Trump’s presidency, along with a gritty factual account of what organizations like WHO, USAID and their partners actually do, as opposed to Trump and Musk’s right-wing fantasies. 

When I interviewed Burkle back in 2019, he told me that bullies never really grow up, which is why authoritarian leaders around the world have more in common with one another than the people they lead. But the rest of us can and do change — often dramatically so, and “Water on the Moon” tells a story of personal transformation and global public service. 

That 2019 story referenced two articles Burkle authored on the destructive nature of autocratic leaders with character disorders — yes, like Trump, but also like Idi Amin, Slobodan Milosevic, Kim Jong-un and Moammar Gadhafi. Those leaders took advantage of flaws in the post-World War II global order, and now Trump, Putin and others are trying to undermine that order entirely. 

Burkle provides a highly detailed view of what’s at stake in that global contest, and what’s required to fight for it. His title refers to a Vietnamese folk belief that souls go to the moon when they die, but still need water — and that the dark portions of the moon’s surface are vast lakes and seas. It also signals at the importance of cross-cultural respect — the exact opposite of what disordered leaders like Trump have in mind for our global future.  

In sharp contrast to Trump’s outrageous playground threats to seize territory illegally, reminding the world of the dark side of American power, Burkle exemplifies its humanitarian idealism put into practice. “Long before reaching my teens Drs. Tom Dooley and Albert Schweitzer ignited my vision of practicing humanitarian medicine,” he explains. 

Eventually, Burkle played a leading role in developing the multidisciplinary field of disaster medicine, combining emergency medicine and disaster management in response to the changing nature of the world. Over the course of his career Burkle wore many hats — he served in the U.S. military and held high-level posts with USAID, the WHO and the International Red Cross, all international organizations that demand constant collaboration.

In the book’s foreword, a colleague writes that Burkle is "little known by the public but revered by three generations of military medical officers and experts in humanitarian assistance medicine," and that Burkle had "not only witnessed some of the most pivotal moments in modern American history — he played a central role."  

Drafted straight out of his medical residency in 1968, Burkle was part of the team at Delta Med, the most-bombed medical facility during the U.S. war in Vietnam, which also had a 100-bed children’s hospital. At the end of the war, he oversaw Operation Babylift, rescuing 333 orphan infants just before the fall of Saigon. In the 1991 Gulf War, Burkle was senior medical officer at the largest U.S. field medical facility since World War II. More than a decade later, after the U.S. invasion of Iraq, he served briefly as that nation’s interim health minister, surviving an assassination attempt before being fired by Defense Secretary Donald Rumsfeld. 

But his military career is only part of the story. More fundamentally, “Water on the Moon” tells the story of how of how a young boy discovered his dream of caring for people in distant lands, and battled a series of increasingly complex obstacles throughout his life in realizing that dream and passing it along. 

Although Burkle doesn’t say this explicitly, his childhood involved struggles with disability — he had asthma, dyslexia, a speech impediment and other issues — and it’s clear that laid a deep foundation of empathy for others who might be similarly misunderstood or neglected. That also gave him a special ability to deal with difficult situations, which he has spent the rest of his life addressing. 

Burkle was born in 1940, and absorbed the patriotic idealism of his surroundings and that era. He grew up playing soldiers and shooting toy guns, while his parents "taped maps to the wall so we could follow the far-off campaigns in Europe and the Pacific." He even invented his own world, focused on illustrations in books and magazines, inspired in part by those maps. 

His father judged him harshly for this fantasy realm, and a Yale psychologist didn’t help. Burkle’s response “was to double down on fantasies about escaping from my home and small town to the countries whose names I had memorized. My daydreams went beyond running away, however, because I wanted to help people in need in those far away mystical lands.” That came after reading a 1949 Time magazine article about Albert Schweitzer, the legendary physician, humanitarian and theologian of that era.

He got the chance in somewhat backward fashion: He was drafted straight out of a residency at Yale and shipped to Delta Med, a medical facility in South Vietnam close to the combat zone. A bomb blast nearby left Burkle with a traumatic brain injury, a condition that was poorly understood at the time. He discusses its impact on his life later in the book, but passes quickly over it in the main narrative. 

At Delta Med he treated both U.S. Marine casualties and Vietnamese civilians, he writes, “an average of 50 to 70 Marines and almost 300 civilians every day. With triage being constant, we had make life-and-death decisions on the spot and get creative with solutions.” 

On Burkle’s second day in Vietnam, he was called to see a woman who was having difficulty giving birth. When he got there, everything was fine, except that her baby, he discovered, was one of two wriggling black mounds covered by swarms of black flies, which were "devouring the remnants of the placental membranes." Most Westerners would be instinctively revolted, and Burkle was initially shocked before coming to appreciate "the centuries-old symbiotic relationship between these villagers and the black flies, a tradition upheld in their birth customs.” 

On that day, he writes, "I realized the trajectory of my medical career had changed. I became much more aware of the Vietnamese character that surrounded me.... This cultural sensitivity would set me on a path of enhanced understanding for the rest of my career. I recognized that this kind of insight into another society’s traditions such as this rural Vietnamese way of life was a gift." It’s one of many vignettes throughout the book that ground abstract lessons in particular details.

Burkle made headlines with Operation Babylift, overseeing a team of 13 doctors, 13 nurses and 26 flight attendants, many with nursing experience, as they airlifted hundreds of infants, many of them very sick. There was a hair-raising landing, a side intrigue involving bribery, even a bomb scare. It sounds like a movie, and had a Hollywood ending, 20 years later. Bickle recounts that in a Honolulu restaurant in the mid-1990s, he “met an attractive ebullient Asian woman. The valedictorian of her college class and now graduate student. She had been one of the infants I had rescued.”

After leaving the military, Burkle became a medical polymath, qualified in five different specialties he felt would be necessary: emergency medicine, pediatrics, adolescent medicine, public health and psychiatry. After serving in the first Gulf War as a Navy Reserve officer, Burkle pivoted immediately to working with a Red Cross team sent to evaluate the Kurdish refugee crisis, and even to negotiate with Iraqi dictator Saddam Hussein. That was seen at the time as a high point of cooperation between the humanitarian aid community and the U.S. military, even though Saddam eventually undercut the negotiations by cutting a private deal with one Kurdish faction. 

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But the promise of more effective civilian-military coordination was soon dashed. The very next year, during the Somalia crisis of 1992, Burkle writes, “everything learned and gained from the Kurdish crisis had been forgotten.” Late that year, the U.S. dispatched 1,800 Marines to Somalia to assist with famine relief under a U.N. mandate. Burkle was sent there by the Pentagon in early 1993, and discovered an "appalling lack of coordination” between "Washington decision-makers” and U.S. officials on the ground in Africa. Two large NGOs were planning to leave Somalia altogether, due to worsening security and a climate of lawless violence. 

Perhaps the biggest problem was Somalia's most powerful warlord at that time, Mohamed Farrah Aidid, who would meet daily with a U.N. envoy and commit to various agreements, only to say “the direct opposite” in a radio broadcast hours later. With his psychiatric background, Burkle perceived Aidid as a “sociopathic narcissist” similar to Saddam, who would never be swayed by the normal tactics of diplomatic negotiation. 

Burkle later wrote two articles about the dangers of leaders with such character disorders, an issue that also recurs in an appendix to this memoir. As he told me in 2019, he believes our current president is very much cut from the same cloth. Failing to deal with such leaders comes with a high cost. In October 1993, Aidid's forces shot down two Black Hawk helicopters, killing 18 American soldiers and causing hundreds of Somali casualties — the scenario depicted in the book and film “Black Hawk Down.” That led not just to Bill Clinton pulling U.S. forces out of Somalia, but refusing to intervene in the Rwanda genocide the following year. 

Arguably, the similar cascading failures that followed the U.S. invasion of Iraq in 2003 were many orders of magnitude worse. Burkle was at USAID by then, and understood that far more death was likely to follow in Iraq after the official combat was over. He set out to “restore the public health industry infrastructure in Iraq,” something the U.S. had ample resources to accomplish. 

But well before the invasion, George W. Bush had ordered humanitarian aid shifted from the State Department, where it had always previously been, to the Defense Department under Rumsfeld. After that power grab — behind the back of then-Secretary of State Colin Powell — Rumsfeld replaced everyone on Burkle’s team with military personnel, leaving him little more than a figurehead.

When Burkle raised concerns about his own security with a U.S. general — following a death threat issued by Shiite cleric Muqtada al-Sadr — he was told not to worry: His “only security problem” would involve “Iraqi citizens kissing you and giving you gifts.” Rumsfeld had assured the general, he told Burkle, “We’ll be out of Iraq in three weeks.” It would be eight years until the bulk of U.S. troops were withdrawn. 

For all the importance of these emergencies and others, Burkle regards the creation of the Center of Excellence for Disaster Management and Humanitarian Assistance at the University of Hawaii as his most important accomplishment. But that was also "the most trying, painful period" of his life, he writes, and "ended in failure, great disappointment and regret." 

Funding for the program came from the Department of Defense, and once the money was allocated, local commanding officers felt free to do anything they wished with the funds. Burkle was able to work effectively with the first two commanders, but the third immediately announced that the center would be shut down. That was clearly a huge personal and professional setback, but Burkle responded by finding more and different ways to advance his field and share his wisdom.

Throughout his life, Burkle has encountered difficult or seemingly impossible situations, and has worked his way around most of them. If he has failed, he’s looked for another problem to solve, since there is never a shortage. That’s the most enduring lesson his example provides, and it’s a lesson we’re going to need, facing all the threats from dangerous bullies over the next four years.