(CNN)It's not just Americans who worry about their jobs, health care or feeding their families depending on who sits in the Oval Office.
Even in the America First era, the US is the biggest foreign aid donor globally and the greatest single contributor to the World Food Program -- which gives people around the world reason to fret whenever a new administration rides into Washington. Tens of billions of dollars for food, water, education, health, security and other development needs are on the line.
"Every administration brings in its own new priorities," says Mark Green, the former head of USAID, the US's main foreign aid channel, who served during the Trump administration until this spring. The agency's mission to save lives, reduce poverty and promote democracy on behalf of the American people may not change, but it also must align with the executive branch. The agency itself declined to comment.
Though the current White House has launched programs for religious minorities and women, US President Donald Trump is what Green terms an "aid skeptic." He has repeatedly tried to slash USAID's budget by more than 20% and used aid cuts as a foreign policy cudgel, temporarily halting assistance to the impoverished "Northern Triangle" of Guatemala, Honduras and El Salvador over migration; erasing assistance for UN food, education and jobs programs in Gaza and the West Bank over peace talks; and strictly limiting who could receive health funding over abortion.
Green, now executive director of the McCain Institute, says it's "not uncommon" for the White House or Congress to place restrictions on assistance. "Sometimes it's for political reasons, sometimes it's for strategic reasons. It really varies but [USAID] do not have complete flexibility, I'll put it that way," he says.
The USAID budget battle
The Trump administration made annual attempts to shrink USAID's budget, though these largely were rejected by Congress. Its 2019 budget proposal for the aid agency was so low that Republican Sen. Lindsey Graham dismissed it as "ridiculous" at an April 2018 meeting of the Senate Appropriations Subcommittee on State, Foreign Operations, and Related Programs.
"Listen to this one," Graham said, listing the proposed reductions. "Africa -- 52.6 percent. Have things gotten better in Africa and I just missed it? (...) The people who did these cuts clearly don't know what they're talking about. They've spent zero time looking at Africa. They're just making up numbers to balance a budget."
"While the Administration views the State Department's and USAID's roles in diplomacy and development as critical to national security, this must be balanced with restraining overall non-defense discretionary spending, including for the State Department and USAID," a State Department spokesperson told CNN.
Green, whose job it was to defend the budget request at that hearing, says he didn't feel "second-guessed" by the President's attempts to take away millions of dollars in funding, but saw it as a healthy challenge. "President Trump, and not just President Trump but the team around President Trump -- I think they're aid skeptics. It's not a secret. But what that always meant for me and for the team at USAID was we took that as a challenge. And so, what we worked hard to do was to show how we were squeezing value from every program. And that these programs can be an essential tool in diplomatic statecraft and economic statecraft."
Before stepping down, he led a reorientation of the agency that seems partly designed to appeal to skeptics, promoting a "journey of self-reliance" for beneficiary countries with an ultimate goal to "work toward a time when foreign is assistance no longer necessary."
Still, he later adds, "Would I have liked more money? Absolutely. I would always be honest and say look, here's how it works. You give me $10, and I can deliver this. If you give me less. I do less."
At the massive scale of US foreign aid, even small spending changes can help or hurt hundreds of thousands of people.
"Moving forward, we are only going to give foreign aid to those who respect us and frankly, are our friends," Trump told the United Nations General Assembly in 2018.
Lina Abu-Zariffa has struggled to feed her three children since that year. "There is nothing in the house," the 34-year-old Gazan told CNN. "The other day my daughters wanted a cup of yogurt and an egg and I couldn't provide even that."
She used to receive US-funded vouchers, worth roughly $130 per month, that helped her afford essentials like flour, cooking oil, rice, and sugar. Now she depends on donations from her sister and neighbors who take pity on the family. "I don't have the money to provide anything," she said.
Amid political instability, nearly half of Gaza's population is unemployed and many are mired in debt. "There is no work in Gaza, and no institution or organization to fill the gap," she says.
Khaled Zou'reb, 55, was cut from the same program and says trying to put food on the table for his family of 10 has become "a living hell" without the vouchers. "When I look at the children of other families, I say to myself, 'I wish my children were like that.'"
Both are among the roughly 130,000 people in Gaza who stopped receiving food vouchers when US funding to the World Food Program's work in the West Bank and Gaza dried up in 2018 -- part of a series of cuts widely seen as an attempt to pressure Palestinian officials into talks.
Asked whether those cuts, made during his tenure, had any humanitarian or development aim, Green pointed to the White House. "You know, USAID operates under whatever presidential guidelines, or rules or restrictions are put in place," he said.
A State Department spokesperson said, "the Administration continues to assess where U.S. assistance could best advance US policies and priorities and provide maximum value to the US taxpayer, taking into account relevant legislation."
The cuts don't just affect aid recipients -- they have also "created a vacuum" in Gaza's already fragile economy by forcing aid organizations to lay off workers, says Lana Abu-Hijleh, local director for Global Communities, the organization that distributed the food vouchers for the World Food Program.
More than 2,000 local aid workers and contractors have lost their jobs due to funding cuts, she estimates. Her own staff at Global Communities shrank from more than 100 employees to just 12 -- an phenomenon that has followed funding cuts around the world.
The Mexico City Policy
In Western Nepal, Renu Roka Ranamagar, 29, also lost her job due to another Trump-era change. In 2017, the US imposed a broad ban on foreign organizations receiving US health funding if they perform or promote abortion, even where it is legal.
Ranamagar, a family planning counselor, was one of 230 people who lost their work with Nepal's Family Planning Association (FPAN), a non-profit that offers family planning and medical abortion services in rural areas. A quarter of the organization's budget vanished due to the policy, says Acting Director General Subhash Chandra Shrestha. "We were running mobile camps around the country. We can't do the same in that capacity anymore. The USAID funding cut massively affected our programs and goals," Shrestha said.
Ranamagar now works at a local private hospital but still gets calls from women she used to counsel who want to know their options. "I wish the project had continued" to help them, she said.
Every Republican president since Ronald Reagan has barred foreign organizations from performing or promoting abortion if they receive US family planning funds, a restriction known as the Mexico City Policy. Democratic presidents have reversed it.
But Trump went one further, expanding the restriction to apply to foreign organizations receiving any US health funding, including money destined for programs on nutrition, malaria, tuberculosis, tropical diseases and child health. The rule could affect an estimated $12 billion in US assistance, according to a March 2020 report by the US Government Accountability Office, a nonpartisan agency that works for Congress.
"When a foreign NGO declines to agree to the (Protecting Life in Global Health Assistance) Policy, USAID transitions the activities that NGO would have undertaken, with US funding, to other partners, while minimizing any disruption of care," a USAID spokesperson told CNN. An August State Department review found that the policy did disrupt some efforts to treat tuberculosis and HIV/AIDS and to deliver nutritional assistance, among other programs.
Several studies and CNN's own reporting have also shown that the policy actually produces more abortions -- when health organizations who refuse the restrictions lose funding, more women struggle to access basic contraception in the first place.
Filling the gap
Where US funds have disappeared, other nations have tried to fill in, with limited success.
The Netherlands, Belgium, Denmark and Sweden have raised millions to support unrestricted family planning -- though much less than the billions of global health funds now affected by the expanded US rule.
The World Food Program is also scrambling together funds from