President George W. Bush was responsible for a war in Iraq, a war in Afghanistan and the War on Terror. Many people around the world regard his legacy as “a practical and moral catastrophe,” in the words of New York Times columnist Nicholas Kristof.
But – people are people, not demons. They’re complicated. They’re a mixture of good and bad. And, says Kristof, one of Bush’s policies was even more consequential than his military adventures. And it was “astonishingly good”. He writes:
This is awkward, but I have to acknowledge that Bush deserves credit for the single best policy of any president in my lifetime. It’s called PEPFAR and if you haven’t heard of it, that’s part of the problem.
I have to agree with Mr Kristof. Bush introduced the President’s Emergency Plan for Aids Relief (PEPFAR), during his 2003 State of the Union address — along with his plan to invade Iraq. It could be the most important American foreign policy initiative since World War II.
Mr Bush prefaced his proposal with grim facts: “Today, on the continent of Africa, nearly 30 million people have the AIDS virus, including 3 million children under the age of 15. There are whole countries in Africa where more than one-third of the adult population carries the infection. More than 4 million require immediate drug treatment. Yet across that continent, only 50,000 AIDS victims – only 50,000 – are receiving the medicine they need.”
The problem was massive; the challenge was urgent. So Mr Bush, noting that “seldom has history offered a greater opportunity to do so much for so many,” boldly requested Congress to “commit US$15 billion over the next five years […] to turn the tide against AIDS in the most afflicted nations of Africa and the Caribbean.”
And then he spent the rest of his speech drumming up support for the invasion.
Congress authorised the billions. And when, after him, Mr Obama, Mr Trump and Mr Biden asked for more billions, Congress coughed up, each time with broad bipartisan support.
As of 2023, the US has spent more than $100 billion on PEPFAR, supporting the anti-AIDS effort in 50 countries, 29 of them in Africa.
For a country that fruitlessly dumped $2 trillion in bullets during the same period into the rugged mountains of Afghanistan, $100 billion over two decades is chump change. But $100 billion is also the largest amount of money any country has ever spent on combatting a single disease. And it has had a singularly significant impact.
On PEPFAR’s 20th anniversary, earlier this year, the State Department released its score card: 25 million lives have been saved; over 20 million HIV patients are undergoing anti-retroviral treatment; 20 supported countries have achieved epidemic control or set treatment targets; nearly 5.5 million HIV-free babies have been born to HIV positive mothers; and on and on.
The most impressive thing about these numbers is that they barely scratch the surface. PEPFAR’s full impact can only be appreciated within context. For, by lifting a significant chunk of the HIV burden off the back of African healthcare systems, the programme has become one of the main pillars of healthcare on the continent.
Consider my country, Kenya, one of PEPFAR’s many beneficiaries, whose entire healthcare budget [PDF] for 2022/23 was KES 121.1 billion (around $1 billion). Of this, only KES 5.8 billion (about $50 million) was earmarked to “support and manage [the] fight against HIV/AIDS, malaria and tuberculosis.”
PEPFAR’s allocation to Kenya for the same period, at KES 40.7 billion ($345 million), raised the country’s healthcare budget by more than a third. Crucially, this money went not only towards the acquisition of drugs, tests and related supplies, but also towards paying the army of healthcare workers who deliver tests and monitor treatment across the country.
And because these health workers necessarily have to serve other patients and needs at the facilities to which they are attached, PEPFAR indirectly supports these other services. According to a source who helps administer PEPFAR projects in the country but spoke on condition of anonymity, PEPFAR pays the salaries of up to 56 percent of Kenya’s government-employed health workers.
That is a staggering number. But it is entirely plausible. It’s embarrassing to the Kenyan government, which contributes a pittance to the fight against HIV. PEPFAR has been trying to scale down its contributions to Kenya for years. It is supposed to be an emergency programme, after all. Sadly, however, the Kenyan government hasn’t made any moves to up the slack, leading to multiple tiffs between the two parties.
I was only nine when PEPFAR was launched. I didn’t know it then, but the area in which I was growing up, near Lake Victoria, was the most affected region in one of the most affected countries in the world. Until now, the five counties that border the lake account for the bulk of Kenya’s HIV infections. In two of them, more than a fifth of all adults are infected with the virus.
By the time PEPFAR’s impact started being felt, in the late 2000s and early 2010s, my life and the lives of my contemporaries were littered with the casualties of the crisis. I saw people, some of them close relatives, waste away and die. Villages were dotted with graves and populated by orphans, many of them infected by the virus.
However, the trends were already pointing in the right direction. With the help of PEFFAR, they threw the kitchen sink at the epidemic. Testing and anti-retroviral treatments were widely available. HIV was no longer a death sentence. In fact, Kenya is nearing epidemic control, when HIV-related deaths exceed new infections.
This picture is mirrored in most of the other countries in which PEPFAR has operated. It is a phenomenally positive history. No doubt some will point to several moral missteps along the way, many of them driven by modern culture’s reluctance to discourage sexual profligacy. However, without downplaying these, the fact that millions more would have died across Africa, if PEPFAR had not existed, must be thrown into the balance.
It is therefore quite fortunate that, in these highly polarised times, PEPFAR is one of the few American government projects that has largely escaped controversy and enjoyed sustained bipartisan congressional support. And that’s just as well, for it is an initiative for which the American people and their government deserve to be congratulated.