A failed rescue
U.S. lawmakers may have blocked a $400 million cut to PEPFAR, but they did not restore the program
In a rare, if narrow, act of defiance, U.S. senators stood up to President Trump last week and rescued $400 million they had already allocated to the President’s Emergency Plan for AIDS Relief.
The PEPFAR funds were part of a $9.4 billion package of already approved spending that the Trump administration was demanding lawmakers retract. A handful of GOP senators cajoled the White House into leaving the PEPFAR allocation in place.
They still largely joined their colleagues in sanctioning the remaining $9 billion claw back. This included money earmarked for other international aid programs, as well as all federal support for NPR and PBS.
Their vote was an unprecedented abnegation by the congressional Republicans of their control over federal spending. And even their brief act of daring will not actually restore a PEPFAR program they were claiming to rescue. It will not resurrect what has already been ruined.
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On Tuesday, I visited the Mussa Village Health Post in southern Malawi. It is a simple, neatly painted cinderblock affair, nestled in the foothills of the Mulanje Massif. It is an area of stunning beauty and deep poverty.
The post serves 14 villages, which are home to around 16,000 people in total. Most of them survive only on what they grow. Their days begin before sunrise and offer no time to make the seven-mile journey to the nearest health center, unless the affliction is acute. Chronic conditions, like diabetes or HIV, and even deliveries that begin without complications, often didn’t merit a visit.
It was a trade-off that invited tragedy, allowing the slow advance of diseases that might suddenly turn lethal or the eruption of a post-partum hemorrhage without the resources to stem it.
Frustrated at being forced to choose between their health and their livelihoods, some of the residents constructed a rudimentary health outpost a decade ago. They demanded the government provide at least basic preventive services that might ward off some of their most common problems.
Officials responded, Massitive Matekenya told me. He was elected to head the health center management committee that was inaugurated to support the new structure. Health workers began turning up regularly to the outpost to check in on the pregnant women in the area, to dole out insulin to people living with diabetes and anti-seizure drugs to people suffering from epilepsy. They even built a new, more durable facility in 2022.
But it was PEPFAR that really turbocharged those efforts. The program came in years ago not only to shore up the HIV services offered during the visits, including testing and treatment, but to subsidize the fuel and the car repairs that are an inevitable consequence of maneuvering deeply rutted dirt roads. Though its focus was HIV, PEPFAR’s funding became a conduit for securing and sustaining the additional services.
That all stopped in late January when Trump froze U.S. foreign aid. The services still have not returned, Matekenya tells me. I interrupt him just to make sure I’ve heard correctly. To confirm that the Mussa Village Health Post has gone without any visits from health workers for more than six months.
“Yes, yes, all of the services stopped,” he confirms. “And that has affected the communities.” Globally, some PEPFAR services have been restored since the January freeze, but many have been eliminated entirely. Most fell victim to the Trump administration’s dismantling of the U.S. Agency for International Development, which actually implemented PEPFAR programs. This appears to include the support for the visits to the Mussa Village Health Post. The government had come to rely on the promise of the PEPFAR funds and cannot easily replace them.
Now, if the women living in the 14 villages around the Mussa Village Health Post want assurances that their unborn children are developing steadily, they will have to resume the seven-mile journey to the closest clinic. So will the people looking for diabetes or epilepsy treatment.
Matekenya tells me they are not.
“They don’t have that financial muscle to keep on going to the health facilities using the resources that they have,” he explains. He is particularly worried about the HIV patients who are falling off of treatment.
They, of course, are why PEPFAR even showed up in this rural community in Malawi. The program may ultimately have helped bolster a number of other advances, but the money and the effort were fundamentally to get and keep people on treatment. Now those services are eliminated, no matter what some lawmakers in Washington may have done last week.
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Indeed, rescuing the $400 million in PEPFAR spending, was not the same as restoring the programs that the Trump administration has stripped away. GOP senators did not suddenly make whole a program that the Department of Government Efficiency spent months hollowing out. They do not even appear to have convinced the Trump administration to leave PEPFAR alone.
Just days after the vote, news leaked of the administration’s plan to end the program. According to the internal document, the “transition of PEPFAR can become the premier example of the U.S. commitment to prioritizing trade over aid, opportunity over dependency and investment over assistance.”
If the administration gets its way, the program could be gone from some countries within two years. Officials are prepared to give it at least five more years in Malawi, though who knows in what condition.
In Mussa, it might as well already be gone.
Recommended Reading
The New York Times broke the news of the administration’s plans to end PEPFAR.
At Global Public Health Insights, Nina Schwalbe has an excellent analysis of why rescuing the $400 million for PEPFAR falls "woefully short of a win.”