[Dear reader: unlike my usual articles, this one is on something important. Once you’ve read (or skimmed, or not), I’d super appreciate it if you could like and share. As we’ll see, there are people who need to know some things.]
I’m currently reading — well, Audibling — To End A Plague by Emily Bass.
It’s about the President’s Emergency Plan for AIDS Relief — PEPFAR: the activists who pushed for it, the lives it changed, and how the cause of HIV prevention won the backing of George W. Bush, who launched the programme in 2003.
Since then, PEPFAR has saved around 26 million lives at the cost of about $110 billion — more money than I make on Substack, slightly, but barely a drop in the US’ fiscal bucket.
On Friday, Trump sent AIDS activists into crisis mode by halting 100% of US global health funding — including PEPFAR. On Sunday, State spokesperson Tammy Bruce called the cuts a “moral imperative”: the government, Bruce told NPR, “is no longer going to blindly dole out money with no return for the American people”.
The blanket budget freeze received pushback almost immediately, from the left by AIDS activists like Asia Russell, from the centre by Substack’s very own
, and from the right by and the George W. Bush Presidential Centre.As the President of the International AIDS Society pointed out, “PEPFAR provides lifesaving antiretrovirals for more than 20 million people – and stopping its funding essentially stops their HIV treatment. If that happens, people are going to die and HIV will resurge.”
Thankfully, just yesterday, Marco Rubio seems to have exempted PEPFAR (and other global health programmes) from the funding freeze, meaning it won’t have to shut down for 180 days pending review, losing much of its infrastructure and most of its talent.
Still, PEPFAR is only safe for now. It’ll be reviewed — like every other Federal programme — and odds are still good Trump will slash its funding, costing hundreds of thousands of lives in the long term, maybe millions. PEPFAR — which used to be a bipartisan thing — has now lost favour with many Republicans.
Given its uncertain future, now is the time to ask: in light of the good it’s done (26 million lives!), are there any good arguments for cutting PEPFAR, or letting it go entirely?
I. The Abortion Argument
[Warning: this is not so much an argument as a lie. Still, as we’ll see, the ‘pro-life case against PEPFAR’ seems to have been influential in recent years. As such, it’s worth sorting through the facts.]
In January, 2023, Republican lawmaker Chris Smith expressed his view — entirely within the mainstream — that “[s]aving more that 25 million lives, PEPFAR is widely viewed as the most successful U.S. foreign aid program since the Marshall Plan.” Smith was a longtime PEPFAR champion. In 2018, he wrote the PEPFAR Extension Act, which Trump dutifully signed into law.
Later, in May, the conservative Heritage Foundation published a report on PEPFAR, calling on Republicans to “reform” it. Among its most eye-grabbing complaints was that — while PEPFAR was originally spearheaded by a Republican president, and was initially criticised from the left for teaming up with faith-based Christian groups that promoted abstinence — the Biden White House had co-opted PEPFAR, using it as a trojan horse to promote abortion overseas.
The report cited no direct evidence for its claim, but it mentioned the following two facts:
After the Dobbs ruling, Biden issued a memorandum pledging “to support women’s and girls’ sexual and reproductive health and rights in the United States, as well as globally.” “On the left”, Heritage tells us, these phrases “are code for abortion”.
Also after the Dobbs ruling, two charities partnered with PEPFAR — like almost every other organisation with left-wing American employees — issued statements condemning the Dobbs decision. Meanwhile, the Helms Amendment — which forbids the use of American foreign aid to fund abortions — remained in full force, and Biden made no effort to change it.
That’s it. Heritage cited no other reasons to think PEPFAR was being used to expand Biden’s Empire of Abortion overseas.
Spooked by the Heritage report, Smith sent out a letter to his colleagues in June saying: “President Biden has hijacked PEPFAR […] in order to promote abortion on demand”:
U.S. foreign policy, and the foreign programs we fund with billions of dollars in grant money should consistently protect, affirm, and care for those who are ill, and tangibly assist women and children—not poison, starve or dismember unborn children to death.
Along with the ‘evidence’ Heritage cites, Smith pointed to a 2022 Biden Administration PEPFAR report, which, he claimed, “makes absolutely clear that the new direction of the program includes “integrating” PEPFAR with abortion promotion.”
The report in question, Reimagining PEPFAR’s Strategic Direction, pledges that “[w]here possible, PEPFAR will integrate HIV programming into strengthened public health systems to manage [among a long list of other things] sexual reproductive health, rights and services.”
I get how this might seem like code for abortion. I get how that might seem like code for abortion, that is, if you’re an illiterate snollygoster who doesn’t know how to read footnotes.
In footnote four, inserted after the phrase “sexual reproductive health” (SRH), the report explains:
In the context of PEPFAR, SRH services refers to four areas: 1) prevention of mother to child transmission of HIV and access to condoms; 2) education, testing and treatment for sexually transmitted infections; 3) cervical cancer screening and care; and 4) gender-based violence prevention and care, including community norms change. PEPFAR does not fund abortions, consistent with longstanding legal restrictions on the use of foreign assistance funding related to abortion.
Reading comprehension is a gift; use it whenever you can, especially when writing a letter to elected lawmakers slagging off the most successful foreign aid programme in American history.
Of course, it’s possible that when the PEPFAR report unambiguously states X, we should read it as unambiguously stating not-X. And if my Grandmother had wheels she would have been a bike. But if you’re a lawmaker who has to base their important decisions on written testimony, that is not, in general, a reliable way to go about things.
Smith also cites a nearly identical passage in a subsequent 2023 report on PEPFAR, which says, on page 30:
PEPFAR should work particularly with multilateral, foundation, and private sector donors to partner in the provision of economic and educational opportunities, and with government partners, to incorporate evidence-based interventions into local structures such as schools and with organizations advocating for structural, systemic, and institutional reforms in law and policy regarding sexual, reproductive, and economic rights of women.
This report doesn’t have a footnote defining its terms — indeed, it doesn’t mention “abortion” at all.
Is the 2023 report a pro-life red flag. “[I]nstitutional reforms in law and policy regarding sexual, reproductive, and economic rights of women”? Wow — sure sounds fishy! Apparently, this sounded fishy enough (or, perhaps, the Heritage report plus Smith’s letter sounded fishy enough), for pro-life lawmakers to look into the rumoured ‘problem’.
Journalist Shepherd Smith — a conservative, Christian pro-lifer — looked into the rumours, to see if there was anything to them. Speaking to the Washington Post, Smith said: “I haven’t found evidence, and all the people in the faith community working on PEPFAR — overwhelmingly pro-life people — would have been the first to say, ‘Hey, you know, we’ve got a problem here, because this is happening,’ but it just hasn’t”.
Assume, however, that Shepherd is making sheep out of us and that the worst case scenario is true: the Biden administration has been stealth promoting foreign abortions, in an incredibly secretive manner, at great political risk to PEPFAR and in defiance of the Helms Amendment. Even granting all this, there’s no reason for pro-lifers to oppose PEPFAR. If the programme has been sneakily changed, Trump can overtly change it back! (And, by the looks of it, he has. No need to change anything else!)
Pro-lifers might object that PEPFAR funding still goes out to countries where abortion is legal, making the US complicit in their lax abortion policy; however, there’s no plausible moral theory on which giving healthcare to citizens of a pro-choice country counts as being ‘complicit’ in their government’s abortion laws. Moreover this argument, taken to its logical conclusion, would imply that the Trump is obligated to cut off aid to Israel — a pro-choice country — as well as, e.g., federal aid to pro-choice states like California.
I doubt many pro-lifers would sign on to that.
II. The ‘Fuck You, I’ve Got Mine’ Argument
In response to a tweet by right-wing PEPFAR advocate
, many of his followers expressed their grievance at the country with the largest share of the world’s GDP shelling out a small sliver in foreign aid to do something unambiguously good:As for whether the US has reason to set aside a skimpy sliver of its budget for a programme that has saved easily more than 20x the lives that the Iraq War stole, the most important justification for PEPFAR funding is that saving that many lives is straightforwardly morally good, and failing to engage in a baseline, easily-affordable level of Christian charity when that many lives are at stake is Satanic.
Moreover, even if one thinks the US Government has no moral reason to engage in even a minimal degree of unselfish Good Samaritanism, the selfish case for PEPFAR is also pretty straightforward. A key part of Trump’s agenda over the next four years will be keeping up its cold war with China; given the success of China’s Belt and Road initiative in Africa, maintaining its leverage in various African states — through PEPFAR, and other aid programmes — plausibly fits within the Trump Team’s foreign policy agenda. PEPFAR is America First!
Some libertarians think taxation — including for unambiguously noble causes like PEPFAR — is theft, the moral equivalent of armed robbery. Though I think this view is false, and have argued against it here, I get why strict libertarians would have to be opposed to PEPFAR. Still, if you really think taxation is theft (and aren’t like the Republicans who say ‘taxation is theft’ when it comes to Medicaid, but not, for some reason, when it comes to roads, national parks, and hurricane relief), surely it makes sense to do away with the ineffective government programmes first, not the coolest federal programme in history.
III. “Treating HIV Doesn’t Pay”
PEPFAR centres on treating HIV with antiretroviral drugs, not just on preventing it with awareness campaigns and condom distribution. In a now infamous Forbes piece in 2005, economist Emily Oster declared that “treating HIV doesn’t pay”. According to Oster, “[a]ntiretroviral treatment is around 100 times as expensive in preventing AIDS deaths as treating other sexually transmitted infections and around 25 times as expensive as education.”
If this were true, of course, it wouldn’t be an argument for slashing PEPFAR: at most, it would be an argument for redirecting PEPFAR’s funding to more effective means of fighting HIV. However, my understanding — gleaned from a fantastic 2023 analysis by Justin Sandefur— is that, in retrospect, economists like Oster probably underrated the real-world virtues of focusing on HIV treatment.
First, in order to save lives, PEPFAR needs to (a) exist, and (b) survive from administration to administration. Unlike HIV prevention, HIV treatment has visible effects — people alive today who previously thought their diagnosis was a death sentence. Writes Sandefur:
In comparative cost effectiveness analysis, the counterfactual to AIDS treatment is the best possible alternative use of that money to save lives. In practice, the actual alternative might simply be the status quo, no PEPFAR, and a 0.1 percent reduction in the fiscal year 2004 federal budget.
Second, PEPFAR’s focus on treatment brought the cost of antiretroviral drugs down. As Sandefur writes, “[b]y 2018 when the third edition of Disease Control Priorities in Developing Countries was published, antiretroviral treatment for HIV/AIDS was not even on the list of interventions subject to cost-benefit analysis, except for expanding access to people with low CD4 counts or uninfected partners of HIV patients. Access to antiretroviral drugs for HIV infected patients with high CD4 counts has transformed, in the space of twelve years, from too expensive to unquestionable.”
“Twenty years later,” the Sandefur concludes, “with $100 billion dollars appropriated under both Democratic and Republican administrations, and millions of lives saved, it’s hard to argue a different foreign aid program would’ve garnered more support, scaled so effectively, and done more good.”
IV. Conclusion
Ok, so I didn’t address every concern people have about PEPFAR. Ain’t nobody got the time! If you’re wondering what I’m inclined to say about other criticisms of PEPFAR — e.g., that it’s been too relaxed about pushing to legalise homosexuality, or weakened aspects of the healthcare systems in the communities where PEPFAR is stationed — my response is likely to be (a) ‘fix the bug, don’t delete the programme’, and (b), given the number of lives PEPFAR has saved, the pros still outweigh the cons by a mile.
Again, PEPFAR is currently at risk, and whether Trump continues to fund it may be one of the most consequential decisions of his presidency. Substack analytics tells me that 895 of my subscribers live in the United States — if that’s you, consider doing some activisming! If you live near Washington D.C., you could stage a little PEPFAR rally (…a pep rally.) Regardless, I’d love it if you could like and share this article: if you disagree with something, quote-stack it on the Substack app!
As a Britisher, I naturally think the US needs to be re-colonised, and brought under the thumb of King Charles. Still, PEPFAR is one of the radest things about America, and it puts my dinky little island to shame.
With respect to foreign aid, it’s time to keep America great.
This is an excellent piece! FYI I've noticed a typo in Justin's name. It's Sandefur (the typo is repeated a couple of times)
Liked and shared your article, you beautiful asshole!