Squinting against the dust kicked up by the helicopter's rotor blades, dental therapist Senate Makhoali crouches low, loads up her equipment and jumps on board. Already this morning she's endured a hair-raising, stormy flight in a tiny Cessna 206 airplane to land on a precarious mountain ridge. Now, she steels herself for a bumpy chopper ride across a steep ravine to a village on the other side. As dentists' commutes go, Makhoali's is somewhat extreme.
"One minute it's calm, the next you think you're about to die," she says of flying through the turbulent, ever-changing mountain weather in her home nation of Lesotho.
But the 27-year-old is getting used to it. For the past year and a half, she has served with the Lesotho Flying Doctor Service, an intrepid band of airborne health workers bringing essential medical care to isolated communities in this southern African nation.
Sometimes referred to as the Kingdom in the Sky, Lesotho is the world's only nation lying entirely above 4,593 feet). Its rugged terrain, riven by jagged peaks and dramatic valleys, renders road transport nearly impossible in much of the country, leaving roughly 300,000 people scattered throughout the highlands without reliable access to health care.
For decades, the Flying Doctor Service was their lifeline, until the impact of President Donald Trump's aid cuts in January 2025 all but severed it. Now, after a tumultuous year fighting for its very existence, the service is picking up the pieces and starting to rebuild. And with the aid cuts serving as a wake-up call, the tenacious flying doctors of Lesotho are now looking to bounce back stronger, more efficient and less reliant than ever before — with or without U.S. support.
Coming in for a landing
In the mountains of Mohale's Hoek district, the helicopter carrying Makhoali takes off in a whir of rotors that sends grazing goats and horses scurrying for cover. The chopper, which is operated by the South African humanitarian air service Mercy Air, scuds across the valley, buffeted by swirling winds, before landing beside a pair of bemused shepherds on a distant ridge. A crowd quickly gathers, and volunteers help the medics carry their gear along a narrow path to the tiny village of Mphooko, where many haven't seen a doctor in years.
"These communities are so far out in the mountains that they only go to a clinic when it's life or death, or when the pain is more than they can stand," says Makhoali, who had never flown before being assigned to the LFDS in May 2024. "For us to be able to come to them is such a big thing."
Word of the team's arrival has spread, and dozens of villagers have turned up to receive care. They come with the usual mix of coughs, colds, joint pain, eye problems and toothaches, as well as more serious issues. Lesotho battles some of the world's highest rates of HIV, TB and mental health issues, while injuries from horse-riding accidents are ubiquitous.
Makhoali lays out her equipment and sets up her dentist's chair in a small stone cottage before calling in her first patient of the day. For the next six hours, she won't stop.
Among her patients is Makhaphetsi Makhaba, a 25-year-old mother of two who's lived her whole life in the village and has never before seen a dentist. By the time Makhoali has finished, Makhaba has lost a tooth and gained a filling.
"It's a relief -- my teeth have been hurting me for years," says Makhaba, before heading next door to consult the LFDS nurses about her recurrent chest pains.
Makhoali and her colleagues finish treating the last of their patients in the late afternoon. Not long after, the helicopter returns to ferry them across the valley to the Flying Doctor clinic of Kuebunyane, where they will spend the night. The clinic, which sits high on a mountain overlooking a breathtaking valley, was constructed in the 1980s and expanded in 2015 with funding from Irish Aid and the Clinton Health Access Initiative. It was built with a parking lot and a driveway wide enough for an ambulance, yet none has ever been here -- the nearest road of any kind is four hours away on horseback.
"They hoped cars would one day be able to come here," sighs Makhoali. "We can dream."
For a few months of the year, Mercy Air's helicopter flights boost the reach of the Flying Doctor Service by carrying providers directly into the most isolated villages in the country. But the backbone of the service is a network of remote LFDS clinics, each with its own rudimentary airstrip. The clinics are run by LFDS nurses, and are staffed and equipped via regular flights operated by the Mission Aviation Fellowship, a Christian U.S. nonprofit that has collaborated with the LFDS since the 1980s. Doctors are flown in once a month.
"Without these clinics and without the medical team visits, these communities simply wouldn't be able to access basic health services," says Makhoali.
Nearly grounded by U.S. aid cuts
For Makhoali and her colleagues, 2025 was a year like no other. The Flying Doctor Service is a branch of Lesotho's national health service that was never directly funded by the U.S. Regardless, in January 2025, Trump's aid cuts brought it to its knees. At the time, Lesotho was among the world's most aid-dependent nations, with the government funding just 12% of national health spending. The rest was funded by aid programs, with USAID alone accounting for over a third. When that funding evaporated as part of the Trump administration's dramatic cuts in foreign aid, the impact was felt throughout the health system.
"The government's priority was to save as much of its budget as possible for the purchase of drugs," says Karabo Lelimo, head of the LFDS. "So transport was affected, especially flights."
Of the 12 clinics the LFDS operated at the beginning of the year, 10 were abruptly transferred to Lesotho's District Health Management Teams, who were left to run them as best they could without air support. Flight schedules were slashed and vital clinic staff lost their jobs. The organization's chief doctor, Justin Cishiya, who had flown with the LFDS for 15 years, was transferred to help shore up an understaffed hospital in the capital, Maseru. By autumn of 2025, things were looking bleak. To Makhoali, it felt like she had "abandoned" her patients.
"The mood was so low," says Lelimo. "To be here in the mountains trying to serve the nation but with no resources -- it was something else."
The clinic at Kuebunyane lost its support staff, including nurses, cleaners and the vital "trackers" responsible for following up on HIV patients who have stopped taking their antiretrovirals. The remaining nurses were severely overstretched. Routine outreach missions to treat patients in remote villages were scrapped because the nurses couldn't afford to rent horses for travel. A lightning strike knocked out the clinic's solar power supply in March, leaving it unable to operate much of its medical equipment. Fuel, essential for heating, particularly in winter when the mountains lie under a deep carpet of snow, soon began to run dangerously low.
Facing a uncertain future
For a time, it looked uncertain whether The Flying Doctor Service would survive. Then, as the country approached the one-year anniversary of the cuts, the mood began to change, says Lelimo. The thinking in the LFDS and the health ministry began to switch from knee-jerk damage limitation, he says, to acceptance of the new reality and a critical assessment of how best to use existing resources.
"The USAID cuts were not the only problem," says Lelimo, who spent seven years running one of the country's most isolated LFDS clinics before he was appointed to take over management of the service in November 2025. "There were a lot of defects that needed to be corrected. There were logistical issues, management issues which led to inefficiency in service delivery."
On taking over the reins, Lelimo found huge gaps in data collection, a chronic lack of oversight on spending, poor planning, little accountability, a lack of communication between the LFDS and its health ministry bosses and enormous waste. Planes would routinely fly into the mountains half empty, sometimes returning without any cargo or passengers at all.
"The cuts were a wake-up call," says Lelimo. "As African countries, we need to do more self-introspection to see how much capacity we have without relying on foreign aid."
Lelimo and his colleagues set about revitalizing the flying doctor service. A policy of mixed flights was introduced, whereby every flight, save emergency evacuations, would be carefully planned to combine patient transfers, nurse movements and cargo. To address the shortage of antiretrovirals reaching mountain clinics, they introduced a new system of drug distribution. Those with easier access to clinics would receive just a month or two's supply, while migrant workers and those living further afield would get up to a six-month supply.
To mitigate the loss of patient trackers, the flying doctors trained village health volunteers to take over. Budgets were reallocated and reporting improved, along with communication with the ministry. Then, on December 19, the transfer of the 10 formerly LFDS clinics to the District Health Management Teams was rescinded and flights resumed.
"We needed to revitalize the whole system," says Lelimo. "I'm feeling so optimistic. The LFDS is still here, and stronger than before."
Not only have the flying doctors managed to resume most of their former operations, they also have ambitious plans to resume building their network of remote health posts in the mountains. They plan to build two new airstrips in 2026. At the same time, the emergency evacuation program, the only part of the service unaffected by the cuts, continues unabated.
A fall, a tooth extraction, a ray of hope
On a blustery Saturday in September, NPR joined one such flight after a man in a remote village sustained head injuries after falling from his horse. The local clinic lacked the means to treat his injuries, but driving him over winding mountain roads to the Maseru would take all day.
Within minutes of receiving the call, pilot Dave LePoidevin, a soft-spoken Minnesotan, was airborne and hurtling toward the distant province of Mokhotlong at 9,000 feet. After landing on a bumpy dirt airstrip he taxied toward a waiting ambulance. The patient, 24-year-old Tlotliso Lebeta, who had already endured a long and uncomfortable journey by horse and truck from his village, was loaded onboard. Less than an hour later, the plane touched down in the capital and Lebeta was whisked away to hospital.
"It's a crucial part of the health system," said pilot Jo Adams, a 44-year-old from Washington state who's been based in Maseru since 2019. "An hour by air versus 10 hours on horseback and by road. Without the air service, people would die."
At the time, Adams wasn't sure whether the flying doctor service had a future. Today, he says he hasn't "felt this optimistic in years."
After her night at Kuebunyane clinic, Senate Makhoali and her colleagues are picked up by helicopter and flown to the even more remote village of Ha Mpheulane, which lies atop a steep escarpment with views over endless ranges of blue-tinged mountains. A crowd is already waiting. While some of the health workers tend to patients, others run an awareness session for teenagers on a slope above the village, counseling them on sexual health and other topics. Makhoali extracts two dozen teeth.
"We're excited to continue serving these communities," says Makhoali. "And to do it even better than before."
Tommy Trenchard is an independent photojournalist based in Cape Town, South Africa. He has previously contributed photos and stories to NPR on the Mozambique cyclone of 2019, Indonesian death rituals and illegal miners in abandoned South African diamond mines and won a World Press Photo prize for the images in his story for NPR on clashes between elephants and people in Zambia.
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