Should The US Reauthorize PEPFAR?
Ministries benefit financially, but some evangelicals question their two-decade support of the program
OPINION–In 2003, The United States made a five-year, $15-billion commitment to PEPFAR – the President’s Emergency Plan for AIDS Relief. Fast-forward to 2023, the 20th anniversary of PEPFAR. Total U.S. spending on PEPFAR has exceeded $85-billion. 
Now comes the debate about whether PEPFAR should be reauthorized, and that reauthorization has met with some new resistance. Evangelical groups such as the Family Research Council and conservative groups such as the Heritage Foundation are opposing reauthorization. Their concerns are many. Among them: PEPFAR funds liberal social causes overseas, such as money for abortion providers.
This resistance is a bit of a surprise, since PEPFAR has been a cause celebre among evangelicals, as a 2019 Christianity Today news story notes.
Many no doubt have supported it from a position of conscience and conviction. But it is impossible to rule out another reason for evangelical support of PEPFAR: they’ve been a significant recipient of PEPFAR funds.
Given PEPFAR’s byzantine public disclosure records, it is nearly impossible to know precisely how much of the $85-billion has gone to Christian organizations – including World Vision, World Relief, and Food for the Hungry. But all three of these organizations, plus others, receive enough funding to now have permanent, full-time departments dedicated to the administration of PEPFAR funds. This massive outpouring of federal dollars means the financial health of these organizations and the continued funding by PEPFAR and other federal programs have become intertwined. According to the Center for Public Integrity, in 2005 alone World Vision received more than $240-million federal funds, including nearly $12-million from PEPFAR.
It is, of course, possible to find stories of people helped by the program. After all, $85 billion is a huge amount of money, and even if most of it is wasted, it is bound to produce some good. If you are looking for stories about the good PEPFAR has done, you need look no further than PEPFAR itself. PEPFAR has funded its own public relations machine. For example, a 2019 movie, “27 Million Lives,” was paid for by a consortium of organizations that receive PEPFAR funds.
But it’s likely that 27 million lives saved is a wild overstatement. In fact, not even official accounts use that number. A recent Christianity Today interview with Deborah Birx, a former director of PEPFAR, claimed 25 million lives.
But even that number is suspect. A close look at Uganda shows just how suspect.
Uganda was devastated by AIDS in the 1980s. Millions of people died, and according to a 2006 study, by 1991 nearly 15 percent of the country’s adult population was HIV-positive.
But long before PEPFAR came along, Uganda was solving its own problems.
In Uganda, Christian ministries, Uganda’s indigenous Christian church, and the leadership of Janet Museveni – the evangelical Christian wife of the country’s president – made the difference. The country pioneered a program that promoted sexual abstinence, a program that pushed down the rate of new AIDS cases by as much as 80 percent, and the prevalence of AIDS fell from early 90s highs to less than 5 percent of the population. By the time PEPFAR money started coming into Uganda, AIDS prevalence was already less than half of 1990 levels.
This phenomenon was happening in other countries, too. In South Africa, for example, the number of new AIDS cases started declining in 1998, a full five years before PEPFAR. Life expectancy, which had plummeted in the late 80s and early 90s in Uganda and Sub-Saharan Africa, started rising again by the mid-90s. Again, that was well before the authorization of PEPFAR.
But perhaps the most troubling argument against PEPFAR is that it likely distorted the healthcare systems in the countries receiving funds to the point that other needs went unaddressed.
For example, one analysis published in Foreign Affairs found that regions receiving PEPFAR funds could pay their health professionals as much as 100 times more than non-PEPFAR funded programs. The result was a “brain drain” from other vital public health and medical programs and facilities, a brain drain that almost certainly cost lives.
One example of how this diversion of funds, talent, and attention costs lives is the global resurgence diseases previously thought eradicated, or nearly so, such as tuberculosis, polio, and malaria.
It surprises many to discover that malaria, not AIDS, was likely the most prolific killer of the 20th century, resulting in the deaths of 100-million people in the first half of the century, and another 50-million people in the second half, according to the World Health Organization.
Even today, the WHO says, malaria kills between 300,000 and 1-million people per year. The direct costs of treatment of people with malaria exceed $12-billion per year. Lost productivity is likely two or three times that number. In 2016, a year in which the U.S. spent $32-billion on AIDS, the spending of the U.S. and all other nations combined on malaria – a disease that we know how to completely eradicate – was less than $5-billion. In other words, we spend less on malaria than we would save by eradicating the disease.
My concern for these questions began when I made a reporting trip to India in 2003, the same year PEPFAR legislation became law, to write about the AIDS crisis there.
Conventional wisdom then was that if the AIDS rate in India increased beyond the current level, it would pass a “tipping point” and there would be no stopping it. That fear was, in fact, a major impetus for PEPFAR.
But a strange thing happened in India. AIDS in India dialed back at rates that equaled or exceeded countries that received PEPFAR money. AIDS cases peaked in 1995 and deaths peaked in 2003 – before PEPFAR. The timing of these peaks and subsequent declines further debunks a claim of PEPFAR supporters, that even countries that didn’t receive PEPFAR funds benefitted because of PEPFAR funding of the production and distribution of anti-retroviral drugs.
India accomplished a dramatic reduction in new AIDS cases and AIDS deaths because of a three-legged stool of free enterprise (the private sector development of new drugs, funded by market demand and venture capital), private charity, and the responsibility the government of India took for its own people.
It is impossible to say PEPFAR did no good. But at what cost, not just in dollars, but in human lives that can’t be easily counted?
So the questions about the reauthorization of PEPFAR are, in my view, more than justified. Let’s give PEPFAR credit for its modest – though costly — benefits, but we should be clear-eyed about cause and effect, and not cloud the truth by giving extra credit where no credit is due.
