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Republicans are threatening to sabotage George W. Bush’s greatest accomplishment

A program that’s saved 25 million lives is at risk of losing its congressional authorization for the first time.

Then-President George W. Bush holds Baron Mosima Loyiso Tantoh, son of South African HIV-AIDS activist Kunene Tantoh, during a White House visit on PEPFAR in 2007.
Mandel Ngan/AFP/Getty Images
Zack Beauchamp is a senior correspondent at Vox, where he covers ideology and challenges to democracy, both at home and abroad. Before coming to Vox in 2014, he edited TP Ideas, a section of Think Progress devoted to the ideas shaping our political world.

You may not have heard of the President’s Emergency Plan for AIDS Relief (PEPFAR). But you should: It has saved more lives than any other US government policy in the 21st century. And now, for the first time in the program’s history, it is at risk of losing a critical vote in Congress — for reasons that say a lot about today’s Republican Party.

First passed in 2003 under President George W. Bush, PEPFAR is a vehicle for distributing HIV/AIDS drugs to people in poor countries who wouldn’t otherwise have access to them. It has been astonishingly effective: The most recent US government estimates suggest it has saved as many as 25 million lives since its enactment. It is currently supporting treatment for over 20 million people who depend on the program for continued access to medication.

Given its success, PEPFAR has historically enjoyed bipartisan support. In 2018, Congress reauthorized PEPFAR for another five years without a fuss. But this time around, things look different. Some House Republicans, prodded by an array of influential groups, are threatening to block another five-year reauthorization. Their argument is pure culture war: that PEPFAR has become a vehicle for promoting abortion.

In reality, PEPFAR is legally prohibited from funding abortion services, and the argument against the program on anti-abortion grounds is very thin. But in today’s political climate, where the culture war reigns supreme on the right, this is enough to jeopardize the continued good functioning of a program that the Republican Party used to champion.

“This is not a fact-based argument. It’s an attempt to destroy a program,” Asia Russell, the executive director of the global health advocacy group Health GAP, tells me.

The clock is ticking: PEPFAR’s current congressional authorization runs through September 30, and failure to extend it could be quite damaging. The fact that this traditionally uncontroversial program is now under threat says a lot about our current political dysfunction — and the ideological currents reshaping the Republican Party.

How PEPFAR became partisan

The idea of funding antiretroviral treatment in poor countries was developed in the early 2000s by public health specialists like Anthony Fauci and Paul Farmer. Politically, it was championed by some of the country’s most prominent Christian conservatives — like Bush speechwriter Michael Gerson and mega-evangelist Franklin Graham. The evangelicals provided the political muscle on the right, as well as a kind of unvarnished Christian moral argument for healing the sick, that ultimately got Bush and Congress on board — leading to PEPFAR’s creation in 2003.

PEPFAR thus should not be seen only as a great American accomplishment, but also a great evangelical accomplishment — a program that not only saved millions of lives but did so more cost-effectively than most economists expected. On both political and substantive grounds, the case for PEPFAR was airtight: No one in either major party had any interest in undermining the program.

Until recently.

According to Devex, the leading development news outlet, the push against PEPFAR began on May 1, when the Heritage Foundation, a leading conservative think tank, published a white paper attacking the program. On the same day, the leaders of 31 conservative groups released an open letter making similar arguments, with Heritage President Kevin Roberts as the first signatory.

The white paper’s author, Heritage fellow Tim Meisburger, is not a public health expert. His career has focused on democracy promotion abroad but has recently taken a turn toward conspiracy theorizing at home.

In 2017, he was appointed by Trump to a mid-level USAID position focusing on democracy — a job he lost in 2021 (per the Washington Post) after saying on a conference call that the January 6 riot was merely the work of “a few violent people.” During the 2022 election cycle, he led a multi-million dollar “election integrity” campaign backed by Michael Flynn and Roger Stone. In January, he wrote an essay for the pro-Trump website American Greatness arguing that there were “many egregious examples of election malpractice and fraud in 2020 and 2022,” including “statistically impossible results” — a seeming reference to long-debunked arguments that Biden could not possibly have won the 2020 election by the margin he did. (Meisburger did not respond to my request for comment.)

Many of the arguments in his anti-PEPFAR paper are of similar quality. He argues that “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 [sic] education, moral suasion, and legal sanctions.” Moreover, Meisburger writes, PEPFAR has become a means for Democrats to promote “their own social priorities like abortion.” The Biden administration, in his view, has used PEPFAR to fund pro-abortion groups internationally.

The evidence offered for this is flimsy. PEPFAR operates primarily through partner groups, funding their efforts to directly distribute antiretroviral drugs and other HIV-AIDS treatments to supported populations. Meisburger notes that some of these partner groups have issued statements supporting legal abortion, and that campaign donations from their staff have leaned left (“PEPFAR is in fact an entirely Democrat-run program,” he writes).

PEPFAR, however, has always been prohibited from funding abortion. The program steers clear of many controversial social issues related to HIV/AIDS by design, a legacy of its bipartisan creation back in 2003. PEPFAR-supported groups that also support abortion services do not use any federal dollars for this purpose.

A women hides her eyes while receiving an injection in the arm.
A young woman being tested for HIV in 2005 at the Naguru Teenage Health Centre in Kampala, Uganda.
Per-Anders Pettersson/Getty Images

Shepherd Smith, an evangelical global health advocate, investigated Heritage’s allegations that PEPFAR supported abortion and found zero evidence of their veracity.

“We have never, in all our years of intimate involvement with PEPFAR, heard of such a thing happening in the program,” he wrote in a memo obtained by Vox. “Without equivocation, all of PEPFAR’s leaders have been focused on the job ahead of them of ending the scourge of AIDS. All have overseen the spending of money, and none have found any dollars spent on abortions or the promotion of abortion.”

Nonetheless, Meisburger’s report has helped fuel the anti-PEPFAR campaign. Heritage Action, the group’s advocacy arm, said it will “score” the upcoming vote to reauthorize it for another five years — meaning that supporting the program will harm Republicans on Heritage’s influential ratings of representatives’ ideology. According to Christianity Today, two other leading conservative groups — the anti-abortion Susan B. Anthony Pro-Life America and the social conservative Family Research Council — have said they will also score the vote.

All of a sudden, a vote to reauthorize PEPFAR looks like a potential problem for Republicans worried about a primary challenge — helping create the conditions for actual legislative movement. Rep. Chris Smith (R-NJ), a member of the House Foreign Affairs Africa Subcommittee and longtime PEPFAR supporter who sponsored the 2018 reauthorization, has turned on the program — writing a letter in June criticizing a five-year reauthorization on grounds that the program supports groups who support abortion.

“President Biden has hijacked PEPFAR, the $6 billion a year foreign aid program designed to mitigate HIV/AIDs in many targeted — mostly African — countries in order to promote abortion on demand,” Rep. Smith argues.

Like Meisburger, he did not reply to my request to discuss this claim further.

What the PEPFAR fight says about the GOP — and America

Conservatives differ on what should be done to fix this (fictitious) problem. Some, like Rep. Smith, want to impose the so-called “Mexico City” policy on PEPFAR — which bans the federal government from funding any organization that supports abortion even with non-federal dollars. Others have suggested reducing PEPFAR’s operating window, forcing it to come up for reauthorization every year rather than every five years.

Public health experts generally oppose both changes, arguing that they would cut off effective aid groups from federal dollars and make it impossible for the program to plan for the long term.

Moreover, the mere act of picking a fight on either the Mexico City policy or reauthorization windows risks turning PEPFAR into more of a partisan football — and blowing past the September 30 deadline for reauthorization as a result. This would not lead to PEPFAR’s immediate demise, but it would do real damage to its continued good functioning.

“Failure to reauthorize the program could have significant impacts,” warns Chris Collins, president and CEO of Friends of the Global Fight Against AIDS, Tuberculosis and Malaria. Among several other problems, Collins warns, “the funds set aside to treat orphans and vulnerable children might be reduced” and “the Global Fund 2:1 match requirement that has for years successfully leveraged investment from other donors would no longer be required.”

Hence why some conservative supporters of PEPFAR are warning against the current attempt to do anything but approve the program for another five years.

“Without a clean authorization, there will be no reauthorization,” Rick Santorum, the former Republican senator from Pennsylvania, warned in a July Newsmax op-ed supporting the reauthorization (co-authored with former Senate Republican Conference staff director Mark Rodgers).

There’s something revealing about a figure like Santorum, a famously hardline culture warrior, acting as the moderate in this dispute — even calling out Heritage and Meisburger specifically for “revisiting the issue of abortion” and thereby putting the “consensus” in favor of PEPFAR support “at risk.”

Santorum, who has not held public office since 2007, represents an older breed of social conservatives: the ones who influenced policy during the Bush administration and helped create PEPFAR in the first place. They were no less conservative on abortion, and arguably more aggressive than today’s right on other issues (just look up Santorum’s comments on same-sex marriage or Islam). But to their credit, they took seriously Christian ideas about the need for charity and helping the weak — leading to support for global health programs like PEPFAR or (in some cases) taking in refugees fleeing conflict and persecution.

The Trump movement, with its “America First” slogan and attacks on “globalists,” undermined the ideological foundations of Republican support for global humanitarian efforts. In power, Trump put foreign aid on shaky political ground and adopted a culture war approach to the field, dramatically expanding the Mexico City policy from what had existed under Bush and other prior Republican presidents.

The idea of a so-called “compassionate conservatism,” a favored slogan of the Bush years, has gone out the window — replaced instead by a conservative movement defined by its obsession with existential struggle against the perceived domestic left-wing enemy. On today’s right, the culture war is not merely a leading concern but the leading concern.

This is not “mere” partisan polarization at work, though that’s certainly an enabling factor. Rather, this is a story about the prevailing ideological mood on the right: a paradoxical sense of both vulnerability and strength. The vulnerability comes from the Biden presidency and the left’s alleged control over leading cultural institutions; the strength from some recent cultural victories, most notably, the Dobbs decision overturning Roe v. Wade. The contemporary right believes it is under siege, but also that the siege can be broken if it fights hard enough in enough places.

The unremitting logic of total culture war means that every issue has the potential to become a flashpoint. PEPFAR shows how remarkably easy it can be in this environment to take what was once a settled bipartisan consensus and blow it up.

Despite these threats, PEPFAR could well make it through the current fight unscathed. The White House, for its part, believes that Congress is on the right track. “We are confident that the supporters of PEPFAR in both parties will find a path forward to get this critical and lifesaving program reauthorized,” an official said.

We can only hope they’re right. Because if PEPFAR becomes yet another casualty of America’s domestic culture wars, tens of millions of people will suffer and potentially die from a disease we already know how to fight.

Keren Landman contributed reporting to this piece.

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