Abortion politics threatens global public health
Republicans want to destroy one of the most successful public health campaigns in history
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In 2003, the U.S. created the President’s Emergency Plan for AIDS Relief (Pepfar for short). By focusing on both prevention and treatment, Pepfar is credited with saving some 25 million lives over the past twenty years. Until the Covid-19 pandemic it was the largest global public health program focused on a single disease, and that scale means that its impact has been felt far beyond its original purpose. Pepfar has funded the creation of a whole network of clinics with trained personnel in sub-Saharan Africa, and this network has proven useful in fighting other diseases, such as Covid.
Pepfar has cost the United States about $100bn, and that level of spending has only been possible because the program was backed by an unusual coalition of both left- and right-wing humanitarians. George W. Bush’s conservative Christian administration actually created Pepfar, vastly increasing U.S. funding on AIDS prevention and treatment over the levels spent during the Clinton administration. Back in the early 2000s, liberal support for doing something about HIV/AIDS was certainly present, but it was only the way the issue took off among the Christian right which made large-scale action politically possible. As Bono said at the time: ''The administration isn't afraid of rock stars and student activists -- they are used to us. But they are nervous of soccer moms and church folk. Now when soccer moms and church folk start hanging around with rock stars and activists, then they really start paying attention.''
But the need to rely on both left- and right-wing support has made Pepfar vulnerable to shifting political winds. Republicans initially wanted HIV/AIDS prevention efforts to focus on preaching sexual abstinence rather than providing medical interventions to help people who were already sick. At the time, the Republican head of the U.S. Agency for International Development even opposed making antiretroviral drugs, the gold standard of treatment, a key priority because:
[Africans] do not know what watches and clocks are. They do not use western means for telling time. They use the sun. These drugs have to be administered during a certain sequence of time during the day and when you say take it at 10:00, people will say what do you mean by 10:00?”
This Bush administration eventually rejected this viewpoint, and subsequent research showed that Africans are actually better at taking their pills at the right time than North Americans. After its creation, Pepfar enjoyed a period of remarkable stability in which it was insulated from American political debates over abortion and sex.
That period appears to be over. Freshly energized by the overturning of Roe v. Wade, the American right has begun to place Pepfar in its sights, arguing that the program is used to stealthily fund abortions in the developing world and also that HIV/AIDS is a “lifestyle disease” whose victims do not deserve help:
Although created by a Republican President, and despite generally receiving bipartisan support in Congress, PEPFAR has always been controversial. Except in cases of rape or maternal transmission, HIV/ AIDS in the U.S. and in developing countries is primarily a lifestyle disease (like those caused by tobacco) and as such should be suppressed though education, moral suasion, and legal sanctions. For conservatives committed to personal responsibility, it also should not enjoy greater priority than deadlier and more unavoidable diseases receive in the allocation of public funds.
While this rhetoric is a throwback to the the debate at Pepfar’s founding, the controversy over abortion and Pepfar is more recent. Under something called the “Helms amendment”, it is illegal for U.S. foreign aid to be used to directly fund abortions. But the right has long argued that because foreign aid sometimes goes to organizations who also perform abortion services, this money is effectively subsidizing abortion even if it is not directly paying for it. This led to the creation of the “Mexico City policy”, which says that U.S. foreign aid cannot even go to any organization that also provides abortions. The Mexico City policy is typically enacted by presidential decree, with each Republican president imposing it and every Democratic president rescinding it. Trump made the policy even stronger, denying funding to any group that even advocated abortion as a legitimate tool of family planning.
Republicans in Congress now want to write the Mexico City policy directly into law, meaning that it would no longer be a matter of presidential discretion. They also want to only authorize funds for Pepfar for one year rather than five years, meaning that every year they will have a new opportunity to further chip away at the program. They see themselves as battling against attempts by Democrats to inject “radical” social and cultural policies into U.S. foreign aid programs. The Heritage Foundation report quoted above even accuses the Biden administration of trying to tie Pepfar to an agenda of “transgenderism”, although it provides no evidence of what this means.
The result has been a paralyzing debate in Congress which looks likely to completely derail Pepfar reauthorization this year. Although the program will be able to keep running for now, this is an opening salvo in what is likely to be a years-long attempt by the right to undermine and destroy one of - if not the - most successful global public health campaigns in history.
It’s another example of how the extremism of the GOP is slowly infecting every aspect of U.S. policy. Republicans’ radical anti-abortion politics has mostly been rejected at the ballot box in America, but implementing it in American foreign policy - mostly out of the gaze of voters - is easier. If Pepfar had never existed, tens of millions of people alive today would be dead, and some five million more babies would have been born with HIV. Properly funded and run, Pepfar has the same potential to keep saving lives in the future. Sadly, the lives of women, men and babies don’t really matter to so-called “pro-lifers”.