For the last 20 years, the U.S. President’s Emergency Plan for AIDS Relief, or PEPFAR, has reigned as one of the most successful global health programs in history.
The program has saved an estimated 25 million lives, mostly in developing countries.
Its more than $100 billion in spending on drugs, other treatments against HIV infection, education programs and other projects has helped to raise the average life expectancy in Africa by an astonishing 10 years, to 56.
PEPFAR, which was launched by President George W. Bush in 2003, was supported by Republicans and Democrats, conservatives and liberals, and faith leaders across the religious spectrum.
It was a “magnificent and magnanimous” response to the global AIDS crisis, as Patrick Purtill, legislative director of the Faith and Freedom Coalition, a conservative religious political organization, said in 2019.
Purtill accurately described PEPFAR as “the largest outpouring of a global health initiative that the world has ever seen, led by the United States.”
Yet now PEPFAR, which is due for a five-year reauthorization, is under threat from anti-abortion and anti-gay zealots.
Their goal is to limit reauthorizations to one year at a time, which would subject the program to ceaseless partisan appropriation battles in Congress, and to saddle it with a host of unnecessary policy restrictions.
The opponents hope, plainly, to give a new Republican administration the ability to hobble PEPFAR to the point where it can barely function at all.
The threat to PEPFAR is an example of how the right-wing culture war has infected public health policies that should be implemented virtually without debate. It shouldn’t surprise you to learn that the agitators have built their case on hysteria and lies.
Before we delve into that, a bit more about the program.
At the dawn of the 21st century, Africa was facing a dire prognosis from AIDS. The United Nations projected that as many as half of the teenagers in southern Africa would succumb to the disease, which was already “measurably eroding economic development, educational attainment, and child survival” across sub-Saharan Africa.
Antiviral treatments had already been developed, but they were out of reach for most residents of underdeveloped countries.
Bush persuaded Congress to enact PEPFAR in 2003 with an initial appropriation of $5 billion. (Its annual budget is now about $6 billion.)
PEPFAR was kept separate from other development programs but given stricter financial reporting requirements to ensure that the money went where it would be most effective. But it also encompassed programs aimed at tuberculosis and other conditions endemic in the Third World.
The number of Africans with access to antiviral treatments for AIDS soared from 50,000 in 2003 to 20.1 million last year. The program was seen internationally as fulfilling America’s promise as a global benefactor, a diplomatic gain.
PEPFAR wasn’t entirely immune from ideological and partisan attack, especially during the Trump administration.
Trump proposed to gut the program by reducing its budget by $1.35 billion and eliminating all funding to seven countries — Brazil, Djibouti, Liberia, Mali, Nepal, Senegal, and Sierra Leone — and reducing funding for 17 others, many of then in sub-Saharan Africa, the home of 70% of the 37 million people suffering from the disease. Congress rejected those cuts.
The most recent threat to PEPFAR originated in May from the right-wing Heritage Foundation, which charged that the Biden administration “has misused the program as a well-funded vehicle to promote its domestic radical social agenda overseas.”
Heritage accused Biden of using PEPFAR to promote “abortion and the LGBTI agenda” (meaning LGBTQ+). Its report cited Biden’s stated policy of supporting “women’s and girls’ sexual and reproductive health and rights in the United States, as well as globally,” as if that is a bad thing.
Heritage instructed its followers that “on the Left, ‘sexual and reproductive rights’ and ‘reproductive health services’ are code for abortion.”
Right-wing anti-abortion groups took up Heritage’s cry. Susan B. Anthony Pro-Life America and the right-wing Family Research Council, a Christian think tank, have announced that any legislator voting for the full five-year reauthorization would be marked lower on their legislator scorecards — a scary prospect for any Republican hoping to run on anti-abortion bona fides.
Rep. Christopher H. Smith (R-N.J.), was one who fell immediately into line. As recently as Jan. 28, Smith, chair of the House subcommittee on global health, global human rights and international organizations, praised the program as “the most successful U.S. foreign aid program since the Marshall Plan.”
A long-time champion of PEPFAR, Smith had sponsored its last reauthorization act, in 2018, under Trump. But now he backed down, issuing a round-robin letter to his GOP colleagues on June 6 asserting that “President Biden has hijacked PEPFAR … in order to promote abortion on demand.”
To PEPFAR advocates and the program’s leadership, these accusations are absurd. Federal laws already prohibit the use of federal funds to promote abortion abroad. In many countries under the PEPFAR umbrella, abortion is illegal anyway.
In June, PEPFAR head John Nkengasong stated specifically that the right-wingers’ allegations are “absolutely not the case…. PEPFAR has never, will not ever, use that platform in supporting abortion.”
The Biden White House even inserted a footnote in its strategic road map for PEPFAR specifying that its references to sexual and reproductive health information and services meant “only prevention of mother to child transmission of HIV and access to condoms; … education, testing and treatment for sexually transmitted infections; … cervical cancer screening and care; and … gender-based violence prevention and care.
The footnote added that “PEPFAR does not fund abortions, consistent with longstanding legal restrictions on the use of foreign assistance funding related to abortion.”
That hasn’t been enough to satisfy anti-abortion zealots. What really irks them is that Biden rescinded the so-called Mexico City Policy, originally announced by Ronald Reagan in 1984.
The policy required nongovernmental organizations receiving U.S. government funding to certify that they would not use any funds — including those from non-U.S. donors — to “perform or actively promote abortion.”
The policy has been imposed and rescinded on a party-line basis for the better part of four decades. Trump expanded it into what critics called a “global gag rule,” forbidding foreign aid recipients to even provide information about abortion. Biden followed his Democratic predecessors Bill Clinton and Barack Obama in canceling the restrictions.
The anti-abortion crowd simply can’t live with the idea that someone, somewhere in the world, might receive information about abortions.
The Mexico City Policy “prevented U.S. dollars from going to overseas organizations promoting or referring for abortion,” Travis Weber, vice president for policy and government affairs at the Family Research Council, said on a July 24 council webcast. “So now that money can flow…. We’re just asking, don’t let the money go to those groups.”
It would be nonsensical enough to attack PEPFAR on grounds that organizations receiving its indispensable assistance might be using non-U.S. funding as they wish. But to couch it in the inflammatory terms used by anti-abortion crusaders makes it only sound more ludicrous and irrational.
Weber groused about Biden’s “radical insistence on ramming abortion into our foreign policy in an aggressive manner that we’ve never seen before.” One would advise Weber to take a deep breath, but the peril to global health represented by movements like his is too dire not to take seriously. The anti-abortion movement would sacrifice the health of tens of millions of innocent people to pursue its ideological goals, and that’s the ghastly reality.