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Journalists and foreign policy experts have written extensively about the suffering caused by the Trump administration’s decision to halt food, health care, and other forms of assistance to some of the poorest people in the world. Given income inequality and the fragility of the social safety net in the United States, I am not surprised that some Americans approve, thinking, “Why are we spending money on people in other countries when it could be spent here, like to pay my health care bills?”
Defenders of foreign assistance rightly point out that it accounts for only a tiny fraction of the U.S. budget (about 1%) and that there has long been a bipartisan consensus that the wealthiest nation in the world has an ethical obligation to help people in other countries. One reason that popular support for foreign assistance has eroded is that many Americans are unaware that it directly benefits our own health, economic growth, and physical security. The most obvious example is U.S. foreign health assistance, such as through the President’s Emergency Plan for AIDS Relief.
What is PEPFAR, and how does it work?
The U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) under President George W. Bush started as a $15 billion commitment spread over five years to support 15 countries around the world, then eventually expanded to support more than 50 countries.
PEPFAR operates by directly funding health programs in recipient countries, working with governments, non-governmental organizations, and local health providers. The program provides antiretroviral therapy (ART), supports prevention (including stopping HIV transmission from mothers to their newborn babies), and strengthens overall health care infrastructure, including clinics, labs, and supply chains.
Through PEPFAR, U.S. government agencies, such as USAID and the Centers for Disease Control and Prevention, assign physicians, epidemiologists, lab scientists, and experts in related fields to live and work in these countries. The job was to work with the foreign government agencies and NGOs funded by PEPFAR and ensure that U.S. taxpayer money was spent wisely on saving lives and preventing infections.
Since its inception, PEPFAR has, in fact, saved over 25 million lives through ART, prevented HIV infections in 5.5 million babies, and increased life expectancy in PEPFAR-supported countries, an accomplishment that has been celebrated by people from different political backgrounds.
My experience with infectious disease control abroad
In 2003, I moved with my family from the CDC’s headquarters in Atlanta to Bangkok, Thailand to serve as the first CDC regional adviser to Southeast Asia for tuberculosis control. My job was to support the Ministries of Health in Thailand, Cambodia, and Vietnam with improving diagnosis, treatment, and prevention of TB.
At that time, HIV was spreading rapidly throughout Southeast Asia, because treatment was still not widely available. When HIV infection suppresses the immune system, it makes people exquisitely susceptible to developing severe illness and death from TB. Despite highly effective drugs against both TB and HIV, TB remains one of the world’s leading killers of people and the number one killer in people with HIV infection.
The U.S. government has a direct interest in supporting global TB control, because most TB cases in the United States arise in people who acquired their infection overseas (76% in 2023). As we have learned from Covid-19, Ebola, and mpox in the past 10 years, any disease around the world can readily spill over into the United States. (While I was based in Thailand, for example, I helped lead the response to an outbreak of multidrug-resistant TB among refugees being resettled to the United States.)
My assignment in Thailand was initially funded by money that had been appropriated by Congress in 1999 for the “Leadership in Fighting an Epidemic” initiative. Through that funding, the CDC assigned experts like me to countries with a severe HIV burden to help them prevent, care, and treat people with HIV and control associated diseases, like TB. Soon after I moved to Bangkok in 2003, Bush made the decision to super-charge the LIFE initiative and turn it into PEPFAR.
Cutting PEPFAR threatens U.S. health
Twenty-two years later, cutting PEPFAR funding has immediate harmful consequences. Some of the world’s leading mathematical modelers in infectious disease previously collaborated to estimate what would happen to HIV infections and deaths if services were interrupted due to COVID-19 control measures. Adapting that model to the current situation, they estimate that thousands of adults and babies may have died already from the decision to halt PEPFAR services.
Why should Americans worry about this?
When millions of people reliant on ART have their treatment interrupted or receive drugs only intermittently, we create the ideal environment for the emergence of drug-resistant HIV strains — infections that will eventually spread to the United States and directly imperil the health of Americans. There is a similar risk of drug resistance emerging and spreading for TB, because the U.S. government is the largest donor of TB drugs and care through PEPFAR and other U.S. assistance programs. Without treatment, other infectious diseases may emerge too; patients with HIV develop severely impaired immune systems and then become a population in which new pathogens evolve or cause outbreaks, such as new variants of Covid-19 and mpox.
One important way that the U.S. government learns about outbreaks of emerging diseases is because we have CDC and USAID personnel in these countries working with ministries of health, the World Health Organization, and other health groups. Every time a new disease threat has emerged, these personnel have been instrumental in verifying what is happening, continuously monitoring the threat so that the United States can prepare adequately for it, and helping to slow or stop it from spreading to the United States.
The most dramatic example is how CDC personnel assigned to Thailand were critical in identifying the cause of the SARS outbreak in 2003. When I served overseas, I frequently reported back to Atlanta about what we were seeing about the emergence of new diseases. While at the African Union during the initial emergence of Covid-19, I participated in multiple calls, for example, with the National Security Council to help them understand the security implications for the United States.
One of the main reasons the United States stations intelligence and military personnel around the world is so that the government has eyes, ears, and boots on the ground to protect Americans from threats overseas before they come to the United States. For more than 20 years, Congress has funded overseas CDC personnel because it believes this type of work is as important for health security as it is for physical security.
A huge bolus of additional funding for CDC and USAID global health work came after the 2014-16 West Africa Ebola outbreak in which personnel from these agencies who were already assigned in Africa for PEPFAR-related work played a critical role in detecting, monitoring, containing, and treating Ebola. I was in Sierra Leone for two months in 2015 helping lead the CDC response, and many of my colleagues there with me were people whose salaries were paid by PEPFAR. Eliminating these programs makes us more vulnerable to disease threats.
Cutting PEPFAR threatens U.S. economic growth
By enhancing public health, PEPFAR has contributed to increased workforce productivity and economic growth in countries and regions, particularly in Africa. PEPFAR funding has been linked to a 2.1 percentage point increase in GDP per capita growth rates in recipient countries, partially through a significant increase in male employment rates.
Stopping PEPFAR funding could reverse these economic gains, leading to decreased productivity, higher health care costs, and economic instability in affected regions. This, in turn, could diminish markets for U.S. exports and disrupt global supply chains, adversely impacting the U.S. economy.
Many people do not realize that a large percentage of “foreign” assistance is actually “domestic” assistance. USAID, the CDC, and other agencies spend foreign assistance funding on contracts with U.S. companies; those companies create jobs for Americans and buy American-made medications, medical supplies, and technology that are sent overseas.
Cutting PEPFAR threatens U.S. physical security
PEPFAR is a critical tool of health diplomacy, strengthening U.S. alliances and fostering goodwill in regions of strategic importance. When the United States provides life-saving assistance, it builds partnerships that are crucial for intelligence-sharing, counterterrorism efforts, and military cooperation.
When I served the U.S. government overseas, I worked across the Asian and African regions with U.S. diplomats and military advisers. At the weekly “country team” meetings with U.S. ambassadors, I and my colleagues highlighted the assistance we were providing to the country we were in and our collaborations with the United Kingdom, Canada, the European Union, and other important U.S. allies — information that U.S. diplomats and military advisers would then use in their conversations with the local government and other ambassadors to highlight how our interests there were not simply about ourselves.
In a recent speech, the president of Ghana used polite diplomatic language to remind the United States what it was losing by its actions — and that U.S. competitors would now be gaining.
“One thing the U.S. will lose is that soft power it has wielded in the world — I mean, these are people that are grateful for the assistance they get,” President John Dramani Mahama said. “There are many other partners. The U.S. are not our only partner. We will continue to cooperate with other countries and that’s why we have a multipolar world.”
(When diplomats in Africa use the term “multi-polar” to U.S. and EU diplomats, they mean China.)
Beyond diplomacy, the United States needs to worry about the impact that the funding cuts will have on stability of different regions. A nation suffering from a collapsing health system is far more likely to experience political instability, mass migration, and conflict—all of which can have direct security consequences for the United States. By withdrawing health support, the United States risks losing influence in key regions, making it harder to negotiate treaties, access strategic information, or deploy military resources effectively when needed.
What it all means
While American generosity is important, building broad-based support in the United States to restart foreign assistance requires us to talk more openly about benevolent self-interest. Yes, we are doing good for the world, but even more importantly, we are doing good for ourselves. The consequences of cutting PEPFAR are clear: increased global instability, economic losses, and heightened threats to U.S. health and security.
Dr. Jay K. Varma is a physician and epidemiologist. An expert in the prevention and control of infectious diseases, he has led epidemic responses, developed global and national policies, and implemented large-scale programs that saved hundreds of thousands of lives in Asia, Africa, and the United States.
