I first met Ramon in the aftermath of Hurricane Katrina when I was moonlighting in local ERs and assisting wherever needed. New Orleans has a long-standing historical and economic connection to Honduras, primarily through the banana trade and shipping routes linking Honduran ports to New Orleans. These routes facilitated both commerce and migration between the two. Ramon, whose family has deep roots in both Honduras and New Orleans, arrived here after Katrina, determined to help rebuild the city. Amid the chaos and emotional fragility that followed the storm, tensions sometimes ran high, and violence toward undocumented people, tragically, surfaced. Ramon was a victim of one such incident, pushed off a roof and left with multiple fractures. That was how our paths first crossed, as he came to the ER for care.

As was my standard practice in those unpredictable days, I screened Ramon for HIV, and his test came back positive. Since then, he has been not only my HIV patient but also someone I have supported as his primary care physician. Over the years, I have watched Ramon embark on new chapters, marrying, building a family, and now delighting in the company of his grandchildren. Like many primary care doctors, I find it a privilege and a pleasure to witness the lives of my patients unfolding in beautiful, unexpected ways.

I have been fortunate to open several Ryan White Part A clinics in New Orleans, providing free, high-quality care to people living with HIV. The Ryan White Part A program is a vital lifeline, offering essential medical and support services to low-income, uninsured, and underinsured individuals living with HIV. Crucially, it also ensures access to care for undocumented people who often have nowhere else to turn for treatment. Thanks to this program, many people living with HIV can consistently take antiretroviral medications, remain virally undetectable, stay healthy, and continue contributing to the economic engine of our country while supporting their families.

The recent Medicaid cuts in the One Big Beautiful Bill Act pose a serious threat to the Ryan White Part A program and the vulnerable people living with HIV who depend on it. By reducing eligibility, thousands may lose Medicaid coverage and turn to Ryan White as a last resort, yet this program’s fixed funding cannot stretch to meet rising demand. Meanwhile, new federal policies further jeopardize access for undocumented individuals, tightening eligibility and creating uncertainty. Together, these shifts risk unraveling decades of progress and call for urgent attention to protect these lifesaving services.

Medicaid cuts from the One Big Beautiful Bill Act will not just impact Ryan White; they will threaten a wide range of health care services, putting rural hospitals and millions of individuals at risk. We already know from international examples, like cuts to USAID and PEPFAR, that slashing health funding results in tragic loss of life: Trackers estimate over 490,000 deaths so far abroad, with projections of 88 deaths per hour and up to 5,000 daily, culminating in an estimated 14 million deaths by 2030, one-third of whom are children. Having witnessed these devastating effects overseas, we should brace ourselves for similar consequences at home, as I call “the imperial health boomerang.”

The imperial health boomerang

Aimé Césaire first coined the term “the imperial boomerang” to describe how the brutal and oppressive tactics used to control colonized countries ultimately return to affect the imperial powers themselves. Viewing America in 2026 through this lens, we are seeing the same militarized behaviors and repressive tactics, once witnessed only in distant lands, now playing out on our own streets. It is a striking reminder that the violence inflicted abroad never truly stays there; it boomerangs back home, shaping domestic policies and social control in ways we can no longer ignore.

What I call the “imperial health boomerang” builds on Aimé Césaire’s concept by applying it to the U.S. health care industry, particularly how federal policies influence it. What is happening abroad, the decimation of lifesaving programs like PEPFAR and USAID, which together saved over 90 million lives in 24 years, has been truly astonishing. We see a clear link when we track how these programs saved millions of lives and how lives are now tragically being lost as funding evaporates. The imperial health boomerang predicts that these domestic funding cuts, like those abroad, are likely permanent. Sadly, there is little hope that the upcoming elections will reverse this tide.

Health care providers must prepare for Medicaid cuts that will impact our practices in unprecedented ways, especially for those of us serving Medicaid populations. While it is difficult to imagine the unimaginable, I try to empathize with my colleagues abroad who faced sudden, drastic cuts to decades-old programs, programs that once saved millions of lives. The concept of the imperial health boomerang suggests that similar sweeping changes will hit us here at home, giving us a rare but crucial window of time to brace ourselves. Though we may not know precisely how to face the inevitable, we must steady ourselves by allowing space for grief, whether that means confronting feelings of anger, sadness, or disbelief.

The human cost of policy

It is impossible to accept policies that violate the Hippocratic Oath’s mandate to do no harm, especially when these harmful cuts are made to fund tax breaks for the ultra-wealthy. If this trade-off holds, we will bear witness to immeasurable suffering in the communities depending on us. It is essential that we begin this grieving process now, whatever form that takes for each of us, so that when the inevitable arrives, we are prepared to support those who rely on us for their care and well-being.

Due to the growing uncertainties around immigration enforcement, I have turned to telemedicine to conduct routine HIV follow-up visits with my undocumented patients. During our last virtual visit, Ramon expressed deep anxiety about the looming cuts to Ryan White coverage. When I mentioned the monthly cost of his antiretroviral medications, he let out an audible gasp and whispered, “I cannot afford that.” We compared those costs to how much the same medications run in Honduras, about $10 a month, and now Ramon faces an unimaginable choice: return to Honduras to access affordable meds, leaving his family behind, or stay with his loved ones and risk going without treatment.

The imperial health boomerang effect warns us that the cuts headed our way will not just be severe but also unprecedented in scale and impact. This moment calls on us, as a health community, to brace ourselves mentally and emotionally, so when the unthinkable arrives, we are ready to support and bear witness to the immense pain that our communities will endure.

MarkAlain Dery is an infectious disease physician.