One of the most successful government programs in human history is in danger of being weakened or even eliminated. And yet few Americans have even heard of PEPFAR, much less its extraordinary accomplishments.
PEPFAR is the President's Emergency Plan for AIDS Relief, started by George W. Bush in 2003. Overseen by the State Department, the program provides treatment for HIV-AIDS and derivative maladies (such as tuberculosis) through training, medical infrastructure, support for orphans and vulnerable children and, most important, antiretroviral drugs.
By some estimates, the program has saved 25 million lives over the last two decades, spending about $90 billion for treatments that many Africans otherwise could not have afforded or gotten access to. Not only has PEPFAR saved African lives (in a very cost-effective way, I might add), it's also improved the quality of life for many Africans and helped the economies of many African nations. The burnishing of America's reputation is a bonus.
So why is PEPFAR, which typically has had bipartisan support, in danger? Some Republicans say that some parts of the program encourage abortion, while some Democrats are worried about reinserting some anti-abortion provisions in PEPFAR that date from the presidency of Donald Trump. (The abortion fears of the Republicans are not supported by the evidence. Note also that PEPFAR does provide some instruction in abstinence.)
Just to be clear: I think PEPFAR should be reauthorized for another five years, as it has been three times before. That said, I'd like to consider some broader implications of its success.
First, as my former Bloomberg Opinion colleague Noah Smith has argued, U.S. state capacity has actually had some triumphs recently. PEPFAR is one. Operation Warp Speed, which produced COVID vaccines with astonishing speed, is another. America has not lost its ability to pull off big projects.
What does it mean that two of the most successful policies of the last 20 years have originated with Republican administrations? Or that two of the people most associated with these initiatives — Condoleezza Rice (PEPFAR) and Jared Kushner (OWS) — have never received proper recognition for their efforts? (They should, in spite of whatever other objections one might have to their other decisions.)
At the same time, the Republican Party has been responsible for besmirching the reputations of both PEPFAR and OWS. Suspicion of globalization, foreign aid and foreigners themselves has been on the rise, making it difficult to talk about the achievements of these programs. The conservative Heritage Foundation, rather than take credit for Republican achievements as it might have done in the 1980s or '90s, actually published a study last spring attacking PEPFAR. Anti-vaccine sentiment in the Republican Party is now so strong that many of its candidates view support of OWS as a political liability.
One result of this dysfunction is that the U.S. cannot properly discuss or address the trade-offs involved with globalization, which has become a dirty word. No doubt globalization has had its failures in recent times, most notably in Iraq and Afghanistan. But globalization has also had major successes, and both PEPFAR and OWS show that the U.S. can create programs that not only help Americans but also bring huge benefits for the entire world. What we need is a true cost-benefit analysis of globalization, yet we seem unable even to have a rational debate about it.
A final lesson from PEPFAR: Foreign aid, as a government program, may be underrated. Many foreign-aid investments have proved ineffective, and some have cemented corruption in the receiving countries. But the biggest successes are significant, and perhaps foreign aid is improving in quality because the receiving countries are now better able to put it to good use. It may be that critics of foreign aid were correct a decade and a half ago, but are less so today.
As for PEPFAR, I expect the program will continue in some form or another, albeit with some reputational damage. I do not expect much serious reckoning with the deeper lessons of its success. They are too uncomfortable. So PEPFAR is likely to remain relatively unknown, and underappreciated, for at least five more years. Perhaps the silver lining is that being out of the limelight sometimes allows a program to flourish.