Ending PEPFAR Would Be a Crime Against Humanity
If funding for PEPFAR doesn’t resume, millions will die and millions will be orphaned.
“Truly I tell you, whatever you did for one of the least of these brothers and sisters of mine, you did for me.” - Matthew 25:40
Government works. It saves lives. And when you stroll into the White House with a sledgehammer and start smashing away, people will die.
Early in 2003, George W. Bush, a couple years after stealing an election and a couple months before starting another pointless and bloody war, secured his place in utilitarian heaven. He proposed PEPFAR, the marginally catchier acronym for the President’s Emergency Plan for Aids Relief.
“Ladies and gentlemen, seldom has history offered a greater opportunity to do so much for so many,” Bush told Congress. “We have confronted, and will continue to confront, HIV/AIDS in our own country. And to meet a severe and urgent crisis abroad, tonight I propose the Emergency Plan for AIDS Relief -- a work of mercy beyond all current international efforts to help the people of Africa.”
He continued: “This nation can lead the world in sparing innocent people from a plague of nature.”
A recent report from the State department to Congress on PEPFAR’s current status is unequivocal. The program has been a roaring success for the over twenty years since Bush announced it:
“Thanks to PEPFAR and our many partners, AIDS-related deaths globally have fallen from a peak of 2 million in 2004 to 650,000 in 2021.”
“In 2004, over 1.8 million new HIV infections were documented yearly across PEPFAR-supported countries; in 2021, in large part because of PEPFAR, new HIV infections per year have decreased by half” (4).
If you paid attention to Figure F, you would have noticed that the number of people on PEPFAR-supported HIV treatment has continued to steadily increase even as funding for the program has plateaued. That’s because the cost of antiretrovirals (the drugs used to treat HIV) has steadily declined over the past couple decades.
In 2003, Bush told Congress the United States had the chance to save lives because “the cost of those drugs has dropped from $12,000 a year to under $300 a year.” In 2022, the total cost per patient per year of “first-line” antiretrovirals was $58.97. It’s possible that this will continue to drop further.
Tens of millions of lives saved for the federal budget equivalent of dryer lint and pocket change.1 Millions of children who won’t enter the world already HIV-positive and almost incalculable second-order benefits.
The UNAIDS 2024 report records that “PEPFAR accounts for 72% of total donor government HIV funding globally.” The costs of ending the program would be correspondingly immense:
“Using PEPFAR results in 12 high-disease burden countries for 2023, projections indicate that between 2024 and 2030, PEPFAR will prevent an additional 5.2 million AIDS-related deaths and 6.4 million new HIV infections—including one million new infections among children—and prevent more than four million children from being orphaned due to AIDS. If PEPFAR was halted, projections show that numbers of AIDS-related deaths in these countries would increase by more than 400% by 2030 and the number of children orphaned due to AIDS could double” (199). [emphases added]
Yet, Apoorva Mandavilli of the New York Times reported on Monday that the “Trump administration has instructed organizations in other countries to stop disbursing H.I.V. medications purchased with U.S. aid, even if the drugs have already been obtained and are sitting in local clinics.”
Part of a larger freeze on all foreign aid, and as of Monday a freeze on all outgoing “federal financial assistance,” the pause on PEPFAR funding is a horrific testament to the Trump administration’s view of America’s role on the world stage.
There’s a decades old thought experiment popularized by the philosopher Peter Singer and still bandied about in the “effective altruist” community.2 Singer asks the participant what they would do if, on the way to a business event in a fancy suit, they saw a child drowning in a pond off the side of the road. Saving the child would of course ruin the suit and might make the participant late to the important meeting.
The expected answer is that the participant would hurry to save the child. And then Singer asks, what if the child is on the other side of the world? And you could still save their life for the nominal cost of that suit you voluntarily ruined. You should still do it, right?
By pausing PEPFAR, the Trump administration has rejected the fundamental premise of Singer’s thought experiment, the belief that moral actors should make negligible material concessions in order to save children’s lives.
If, as seems possible, PEPFAR is never revived, millions of people and children across the world will die for lack of medicine that costs the U.S. $59 a year. (Mandavilli writes that an email told federal employees PEPFAR’s data systems would shut down at 6pm on Monday, a poor omen for the program’s longevity.)
Of course, the Trump administration could still reverse course. Trump can choose to not consign millions of innocent people across the globe to needless deaths by telling secretary of state Rubio to resume disbursements for PEPFAR. They don’t even have to wait for the 90-day window the executive order pausing foreign aid created to pass.
With one single text message, Trump could choose to not make the United States a world historic monster, a creator of orphans sans parallel. The world is waiting.
This nation can still lead the world in sparing innocent people from a plague of nature.
Here are my favorite articles since my last post:
Bentham’s Bulldog’s plea to save PEPFAR on his Substack
Natascha Elena Uhlmann on the possibility of a pro-worker NAFTA for Labor Notes
Matt Bruenig on the limits of corporate DEI programs for his site NLRB Edge
And Will Kendall and Neil Warner interviewing Anthony Bogues for Phenomenal World
Something I’ve written recently (I really do have a lot in the works!):
A piece about Alabama lieutenant governor hopeful Dean Odle’s 470+ page flat Earth manifesto
And finally the books I’m (still) reading:
Harold F. Gosnell’s Machine Politics: Chicago Model
Honoré de Balzac’s Droll Stories
For comparison, the CBO estimates that for the next thirty or so years the Navy’s shipbuilding program alone will cost an average of $40 billion a year. Over five times as much.
I’ll write a Substack post on my somewhat mixed feelings about EA (and decidedly negative feelings about longtermism) some day.