Frank Ssekamwa says the United States presented his country with an impossible choice. If it accepted the terms of a new health agreement, Uganda would have to give the U.S. access to the data of millions of his fellow citizens — a decision he worries would make their personal information more vulnerable to breaches and possible exploitation.

But if it refused, the East African nation would likely lose out on more than a billion dollars to address HIV, malaria, tuberculosis and other illnesses, even as its people face ongoing threats from Ebola and other deadly infectious diseases.

So, on Dec. 10, it agreed.

“If you take the deal, you’re going to be exploited. If you don’t take it, you’re going to die,” said Ssekamwa, an attorney and digital rights expert in Uganda. “It’s the essence of digital colonialism.”

Across Africa, countries have faced similar dilemmas as the U.S. has held a series of closed-door negotiations in which lifesaving aid has been conditioned on access to citizens’ health data. The negotiations come in the wake of the dismantling of the U.S. Agency for International Development, which — in contrast with the new contracts — provided billions of dollars in aid with few strings attached. Officials in Zambia, Zimbabwe and Ghana have been so outraged by the demands that they rejected the initial deals.

The demand to access health data is central to the Trump administration’s new America First Global Health Strategy, an openly transactional approach that seeks to leverage the desperate need for medical treatments abroad. Aid will now be given “in a way that directly benefits the American people and directly promotes our national interest,” Secretary of State Marco Rubio stated in September.

The State Department declined to publicly release global aid and data-sharing agreements it has signed with more than 30 countries as part of its new approach. But a ProPublica analysis of nine of the deals offers a window into the extensive U.S. demands for access to data — and the potential risks and vulnerabilities for the citizens of countries that have signed them. ProPublica also reviewed a data-sharing agreement struck with Uganda, which has not previously been reported; a data agreement with Kenya; six agreements over the sharing of pathogens that can cause pandemics that were made public by the State Department this week; generic templates of deals for sharing both data and pathogens that can cause pandemics; and an analysis of the documents the advocacy group Public Citizen shared exclusively with ProPublica.

ProPublica also consulted more than a dozen experts in data privacy and global health, including several with direct knowledge of U.S. policy who said that the insistent demands for data access and other resources as a condition of aid are unprecedented. Without seeing the full suite of agreements, they could not identify all vulnerabilities. But they spotted some red flags: The terms of the deals are vague and lack language standard in most data-sharing agreements that adequately limits what data is collected and how it can be used. That increases the risk that individuals’ personal data could be exposed, misused or commercialized without their consent.

In the Ugandan data deal, the U.S. will get direct, real-time access to nine of the nation’s health data systems for seven years, including the central repository that stores all of its health information, lab data, data collected by community health workers and, critically, its system for managing individuals’ electronic medical records. The agreement calls for the sharing of aggregated data with all personally identifiable information removed. It also says the data should be used for delivering and auditing healthcare services.

But lawyers and digital privacy experts argue that the deal raises questions about who will have access to the massive cache of health data and whether it could be inappropriately accessed and exploited.

Some expressed concern that, because it is possible to reverse-engineer data that has been anonymized, people with HIV, tuberculosis and other diseases could have their records exposed.

Stephanie Psaki, who served as the U.S. coordinator for global health security under President Joe Biden, described the Trump administration’s approach as a “blunt instrument of ‘just give me the login to your data systems.’”

“The U.S. would never agree to that,” she said, if the deal were offered in reverse.

In Uganda, the U.S. will provide up to $1.7 billion over five years for global health security and the treatment and prevention of deadly conditions such as malaria, tuberculosis, HIV and polio. In the past, the U.S. gave this aid without asking for direct benefits in return, saving an estimated 170,000 Ugandan lives per year.

While a significant investment, it is less than the U.S. previously spent in Uganda and will decrease every year of the agreement. By 2030, the African nation will receive 45% less global health funding than when Trump retook office, according to an analysis by Vincent Lin of Partners in Health, which provides healthcare in poor countries.

Several experts said there is broad support for some of the goals of the new plan for aid, including reducing African countries’ dependence on the U.S. for healthcare needs. But they worry the transactional nature of the approach could backfire by undermining trust or, in some cases, driving nations to reject deals altogether.

After withdrawing from the World Health Organization and losing access to its global network that tracks and combats disease outbreaks, the U.S. is........

© ProPublica