Moment of Surrender

PEPFAR and America’s Declining Leadership

It was just after Valentine’s Day and in the heart of Banjul, Gambia, the Independence Day parade was just beginning. Just 900 miles or so north of the equator, President Dadwa Jawara’s guests baked in the midday sun as the West African nation, the smallest on the entire continent, celebrated its 25^th year of autonomy. However, the star of the show was the representative from the nation’s former colonizer, Great Britain. In an orange-gold armchair, Queen Elizabeth’s daughter, Princess Anne, sat wearing a white dress patterned with red and yellow flowers, a wide brimmed white hat, and white gloves. While it wasn’t Prince Charles or Diana—at least it was part of the blood line. To the Princess’ left, the United States’ representative sat in dark suit adorned with a Gambian flag sash—and black cowboy boots emblazoned with an outline of the state of Texas. It was George W. Bush, the President’s son.

It was Bush’s first trip to Africa—one that, thirteen years later, would have a monumental impact on the entire continent, one much deeper than a photo opportunity with a British Royal. But that year, 1990, the younger Bush wasn’t making much news himself. He had just become part of an ownership group that bought the Texas Rangers. His focus was on bringing Nolan Ryan back and winning ballgames. Besides, his political career was behind him. Twelve years earlier, in 1978, he had run for the U.S. House in West Texas and lost to a Democratic State Senator named Kent Hance. His father was comfortably into the second year of his presidency and appeared likely to earn a second term. Besides, it was his brother, Jeb, who was likely to follow in their father’s footsteps. For George W. Bush, this trip would be a chance for free government airfare and a good story to tell the next month at Spring Training.

But what Bush witnessed wasn’t simply all the grandeur that Gambian pageantry could muster, which in a stadium marked by chipped concrete and peeling paint wasn’t much. He saw a nation, and a continent, that was amidst a health epidemic that would soon explode into a full-blown crisis. That year, Africa’s leading cause of death—like every other continent in the world—was cardiovascular disease. Remarkably, within a decade, a new disease would become the leading killer of Africans: HIV/AIDS, a virus which when it was first reported in the United States in the early 1980s was laughed about as a “gay plague” by members of the Reagan Administration, in which Bush’s father served as Vice President. Despite its lethality, however, AIDS wasn’t yet the killer it would become. In 1981, AIDS killed less than 0.1% of the population of Africa. By 2001, it would account for over 12% of all deaths on the continent, and in countries like Zimbabwe that were particularly impacted, it would account for over half of all deaths.

In Washington, George W. Bush’s father, like Reagan before him, wasn’t doing much about it. Reagan hadn’t addressed the crisis publicly until 1985, four years after the first cases were reported. And George H.W. Bush didn’t comment on it publicly as president until March 29, 1990 when he lamented the loss of those who had died, commenting, ''There is only one way to deal with an individual who is sick: with dignity, compassion, care, confidentiality and without discrimination.'' However, more than lip service needed to be paid. If America envisioned itself as a global force for good—and cared to engage in the acts of Christianity that its politicians so often invoked on the campaign trail—real money and resources needed to be committed. And the fact is, that neither Presidents Reagan, H.W. Bush, or Clinton had been able to do that. But as fate and history would have it, the man sent to Gambia to smile and wave in 1990 would be the advocate that millions in Africa and around the world needed.

On January 28, 2003, George W. Bush—now President himself—stepped to the lectern inside the U.S. Capitol for his State of the Union address. In the previous 13 years he had been elected Governor of Texas twice, won the closest election in modern American history, and presided over the worst attack on American soil since Pearl Harbor. He was 56 years old. For the speech, Bush wore a blue checkered tie and dark navy suit. Behind him sat his Vice President, Dick Cheney, and the Speaker of the House, Dennis Hastert. That evening, Bush’s focus was on the same thing as it had been for the previous 504 days: the “War on Terror,” which was already being fought in Afghanistan. But, as the President outlined that evening, he had a new target too: Iraq, which he warned almost certainly possessed nuclear weaponry. Taken together, the wars would assuredly determine the bulk of the President’s legacy, even though their outcomes—or the fact that over 7,000 Americans would die in those wars—were not yet known on that night inside the Capitol building.

However, there was more on the President’s mind than just war. About halfway through the speech, he told those gathered—the Justices of the Supreme Court, the Joint Chiefs of Staff, his Cabinet, the men and women of the House and Senate—that “The American flag stands for more than our power and our interests. Our founders dedicated this country to the cause of human dignity, the rights of every person, and the possibilities of every life.” What Bush then proposed to Congress was the largest and most ambitious foreign aid program since the Marshall Plan that remade Europe and helped transform the entire continent from a pile of rubble into a confederation of economic and military allies. It was called the President’s Emergency Plan for AIDS Relief, or PEPFAR. It would soon become the largest initiative to fight a single disease in world history to that point.

At that moment, 30 million people in Africa had AIDS—and yet, only 50,000 had access to the treatments, that in the past decade to that point, had proven effective and increasingly inexpensive. Innocent lives were not just being lost, their deaths were preventable. Mere sentences apart, President Bush had advocated for his worst policy—the Iraq War—and mere moments later, his finest in PEPFAR. In short, it illuminated a fact that is sometimes lost in the moment: being President of the United States is an extraordinarily difficult and complicated task.

While the wars in the Middle East would soon create an unforeseen anger and disaffection for many Americans that would not soon dissipate, PEPFAR on the other hand, became one of the most successful programs ever taken up by the United States. Later in 2003, Bush signed the initial PEPFAR bill into law with overwhelming bipartisan support. Since then, the U.S. has committed more than $110 billion to PEPFAR. (For reference, the United States spent $841 billion on defense in 2024 alone). In two decades, the results have been extraordinary: PEPFAR has saved 26 million lives, prevented over 7 million babies from being born with HIV, and since 2015, HIV infections have declined 56% in Africa. Without qualification, it has been one of the most effective global initiatives in human history.

In 2025, PEPFAR is in jeopardy: its Congressional authorization runs out in March, and it is unclear if there is any will in Washington to continue it. Worse in the immediate, for now its programs have been put on a freeze as part of the current administration’s cut and run scheme when it comes to governing at home and abroad. It’s an unserious strategy that seems to confuse strength with weakness. If this level of magical thinking holds, no longer will the United States—a country run by a party that describes itself as vehemently pro-life and Christian—contribute a relative pittance to helping save millions of lives. While opponents of foreign aid disingenuously advocate a greater focus at home, in the most powerful empire ever to exist, there is no reasonable rationale for such a complete and total surrender of responsibility. Sadly, it should not come as a surprise to anyone. But for the millions in Africa who have depended on PEPFAR, who have literally been saved by its reach—and the millions of children that will now be at far greater risk—the United States will no longer be viewed as a force for global good but of global greed.

Sources:

https://georgewbush-whitehouse.archives.gov/news/releases/2003/01/20030128-19.html

https://www.sciencediplomacy.org/article/2013/making-pepfar#note3

https://www.bushcenter.org/publications/the-path-forward-three-case-studies-to-guide-pepfar-into-the-future#:~:text=The%20key%20findings%20of%20the,policies%2C%20and%20limited%20national%20funding.