One of the cheapest ways to save a life is going away (EXTENDED VERSION)

Summary

Summary of "One of the Cheapest Ways to Save a Life is Going Away (EXTENDED VERSION)"

Podcast Information:

• Title: The Indicator from Planet Money
• Host/Author: NPR
• Episode Title: One of the Cheapest Ways to Save a Life is Going Away (EXTENDED VERSION)
• Release Date: July 4, 2025

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Introduction

In this extended version of "The Indicator from Planet Money," host Darian Woods delves into the critical issue of HIV/AIDS funding and its global implications. The episode primarily focuses on the impact of the Trump administration's foreign policy changes on PEPFAR (President's Emergency Plan for AIDS Relief) and how these funding cuts are affecting vulnerable populations in Southern Africa, particularly in countries like Lesotho and Eswatini.

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Background on PEPFAR

Darian Woods introduces the discussion by referencing an interview with John Cohen, a veteran journalist with Science magazine, who recently reported on global health issues in Southern Africa. Cohen highlights the significance of PEPFAR, an initiative launched in 2003 by President George Bush to provide life-saving antiretroviral drugs to low and middle-income countries battling HIV/AIDS.

Notable Quote:

“To date, the program has spent over $120 billion and has saved an estimated 26 million lives. It's a phenomenally successful program.”
— John Cohen [07:05]

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Achievements of PEPFAR

John Cohen elaborates on the monumental success of PEPFAR, emphasizing its comprehensive approach beyond merely supplying drugs. The program encompassed the delivery of prevention services, training of healthcare professionals, establishment of laboratories, and the development of data systems to monitor and improve the program's effectiveness. This multifaceted strategy enabled countries like Lesotho and Eswatini to significantly reduce HIV prevalence rates.

Notable Quote:

“Countries to make the argument that this was inefficient or somehow scandalous or somehow stealing money. Show me the evidence.”
— John Cohen [16:47]

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Effects of Funding Cuts Under Trump

The narrative shifts to the impact of the Trump administration's policies on PEPFAR. President Trump characterized foreign aid as wasteful, advocating for an "America First" approach that prioritized domestic spending over international assistance. Consequently, PEPFAR faced severe funding reductions, with USAID (the U.S. Agency for International Development) receiving approximately 60% of its funds being diverted or cut.

Notable Quote:

“This is a quilt and you're pulling the thread out of it. It just starts to fall apart.”
— John Cohen [09:31]

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On-the-Ground Observations from Lesotho and Eswatini

John Cohen recounts his visit to health clinics in Lesotho and Eswatini, illustrating firsthand the adverse effects of reduced PEPFAR funding. He describes overcrowded waiting rooms, extended wait times for patients, and the suspension of HIV testing services—critical components in managing and preventing the spread of the virus.

Notable Quote:

“The room... was jam packed with pregnant women.”
— John Cohen [02:50]

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Personal Stories and Impact

A poignant story shared by Cohen involves Timalanghini Dlamini, an eight-month pregnant woman from a rural area in Eswatini. Due to funding cuts, outreach workers were unable to conduct necessary home visits for HIV testing, putting both mothers and their unborn children at significant risk. This personal account underscores the human cost of policy decisions that reduce essential healthcare services.

Notable Quote:

“If they do have HIV, they will not be receiving treatment because nobody knows their status.”
— John Cohen [03:29]

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Challenges and Obstacles

The episode discusses various challenges that PEPFAR has faced over the years, including bureaucratic inefficiencies, political resistance to funding certain high-risk groups, and conflicts between promoting abstinence-based prevention versus medical interventions like pre-exposure prophylaxis (PrEP). Despite these obstacles, PEPFAR maintained robust metrics to evaluate and improve its programs.

Notable Quote:

“The metrics that we're talking about here are how many people did you test? How many lives did you save? … Those are hard numbers that you can come up with.”
— John Cohen [15:24]

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Sustainability and Future of HIV/AIDS Treatment in Africa

Addressing concerns about the long-term sustainability of HIV/AIDS treatment, Cohen explains that African nations have been progressively taking over the financial and administrative responsibilities of these programs. Countries like Eswatini, Lesotho, and South Africa have started funding a significant portion of their antiretroviral medications, moving towards self-sufficiency. However, he emphasizes that the current funding cuts are detrimental and cannot be fully compensated by domestic resources alone.

Notable Quote:

“It's more than simply being a charity. It's creating a stable world where you don't have military conflicts, you don't have countries falling apart because of health.”
— John Cohen [18:08]

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Conclusion and Implications

Darian Woods concludes the episode by reflecting on the broader implications of dismantling PEPFAR. Drawing from Cohen's experiences, it's evident that cutting foreign aid in this domain not only threatens lives but also undermines global stability. The Department of State's response emphasizes a selective continuation of PEPFAR's core life-saving services, while other aspects are being reviewed for alignment with U.S. foreign policy, signaling a partial but insufficient reprieve for affected nations.

Notable Quote:

“I didn't see 200 people dying. In a warehouse. But I know that if this funding isn't found elsewhere, if the gaps aren't filled, that there will be a rollback.”
— John Cohen [20:20]

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Key Takeaways:

• PEPFAR's Success: PEPFAR has been instrumental in reducing HIV/AIDS prevalence in heavily affected countries, saving millions of lives through comprehensive healthcare initiatives.
• Impact of Funding Cuts: The Trump administration's reductions in foreign aid have jeopardized these gains, leading to longer wait times, reduced testing, and increased vulnerability among affected populations.
• Sustainability Challenges: While African countries are striving for self-sufficiency in HIV/AIDS treatment, the abrupt withdrawal of support threatens to reverse decades of progress.
• Human Cost: Personal stories illustrate the real-world consequences of policy changes, highlighting the urgent need for continued international support in public health crises.

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This extended episode serves as a compelling examination of the intersection between foreign policy and global health, advocating for the recognition of foreign aid as an investment in global stability and human lives rather than mere charity.

Transcript

[Darian Woods]

Hey indicated listeners. Darian Woods Here we are off for the holiday. So instead today we are sharing a recent bonus episode with you. If you're a Planet Money plus supporter. Thank you. You already got this earlier. If you're not signed up for plus, let me just tell you that bonus episodes like this one come out every couple of weeks in the Planet Money feed. By joining, you also get Planet Money, the Indicator and Planet Money Summer School without the sponsor messages. And speaking of summer school, when the new season kicks off next week, plus supporters will get early access to new episodes. You get to listen before everybody else, so even more reasons to sign up. Just go to plus.npr.org for details. We'll be back with a regular episode of the Indicator on Monday.

[John Cohen]

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[Darian Woods]

A veteran journalist who covers global health, was on a reporting trip last month in southern Africa. One of his stops a local health clinic in the small country of Lesotho. John says in the waiting room, you could see how cuts to US HIV AIDS funding are already playing out there. The the room, he said, was jam packed with pregnant women.

[John Cohen]

They were Waiting at a minimum, at a minimum, four hours to see anyone. And most of them were going to be there from 8am till 5pm John.

[Darian Woods]

Says the clinic had been cut off from some of the US funds it depended on, so it had to let go of staff driving up wait times and without their personnel. He says the clinic also stopped testing these women for hiv. Lesotho has one of the highest rates of HIV prevalence among adults in the world, around 18% as of 2023. So John says, unable to be tested, these women are in a very vulnerable position.

[John Cohen]

If they do have hiv, they will not be receiving treatment because nobody knows their status. Their babies will have about a 30% chance of becoming infected either at birth or through, through breastfeeding. Their babies won't be tested either until they become ill, most likely. And that's the tragedy. So I could see all that with my own eyes, not because it was visible, but because I know from having covered this since the bad old days what happens when you don't intervene.

[Darian Woods]

President Trump has described foreign aid as wasteful, that the US has been too generous with its foreign assistance without getting enough back in return that aid money being spent abroad is better spent at home. But will Trump's America first foreign policy wipe out years of progress against HIV around the globe? This is a question that John explores in his recent story in Science magazine. I talked to John about that, reporting for an episode of the Indicator, including the monumental legacy of pepfar, the US President's emergency plan for AIDS relief. The There was a bunch of stuff we couldn't fit into that show. So for today's bonus episode, we're giving you an extended cut of my interview. Alright. John and I start our conversation by taking a step back. He told me about a turning point in the treatment for HIV. The year was 1996.

[John Cohen]

That's the year that antiretroviral drugs in cocktails showed that they could basically allow people who had HIV to live normal lifespans, stave off aids. And the drugs also knocked back the virus so successfully that people on treatment, we later learned, don't even transmit to other people.

[Darian Woods]

Wow.

[John Cohen]

Well, that wasn't available to most people living with HIV in the world because the drugs were so incredibly expensive. About 15,000 a year per person.

[Darian Woods]

So that's manageable in a rich country, but just completely inaccessible for people from low income countries.

[John Cohen]

Worked great in the United States, Europe, Australia, Japan had no meaning for most of Sub Saharan Africa, for most of Asia. And that's where most people who have HIV infections live. So come 2003, President George Bush announces in the State of the Union address this idea for an emergency program called PEPFAR that will provide these medicines, these life saving, critical medicines to low income, lower middle income countries around the world.

[Darian Woods]

And to be clear, there had been some efforts from the un, from the Bill and Melinda Gates foundation, trying to do something similar.

[John Cohen]

Right. Nothing this ambitious. And in parallel with that, a global fund is launched to fight aids, Tuberculosis and malaria that has a similar ambitious agenda and asks wealthy countries to put money into the fund. And the US through this new PEPFAR mechanism, also gives money to the global fund. So it's a one, two punch. And what happens is generic drug manufacturers come out making these drugs and lower the price to about $120 a person per year.

[Darian Woods]

Wow. And so this was a unprecedented amount of money going into combating AIDS and HIV problems. Around the maybe $100 million here and there was now in terms of billions of dollars.

[John Cohen]

That's right. And to date, the program has spent over $120 billion and has saved an estimated 26 million lives. It's a phenomenally successful program. In foreign assistance circles. They point to PEPFAR as kind of the poster child of the good that wealthy countries can do for the rest of the world.

[Darian Woods]

Hmm, 26 million lives at $120 billion. So some back of the envelope maths, that's around $4,500, maybe just a little bit above that. That's among the very best value for money spending. You can spend anywhere on charities to save a human life. So what made Petfast so successful?

[John Cohen]

It goes way beyond the purchase of drugs. The purchase of drugs is kind of a minor part of the program at this point. And many countries have taken over the purchase of drugs. It's the delivery of drugs, it's the delivery of prevention services, it's training people, nurses and doctors. It's setting up labs that can run blood tests and evaluate how much virus is in a person's blood. That's called the viral load. All of those things, transporting people to clinics, transporting samples from clinics to laboratories, all of that is incredibly expensive and complex. Plus charting all of that, gathering the data, figuring out where your gaps are, that's where PEPFAR has really made a difference. And it has trained untold numbers of people around the world to do this themselves.

[Darian Woods]

And now when President Trump came into office in January of this year, he paused all foreign aid for 90 days. There was some exceptions made for life saving treatments. What has happened to PEPFAR and what is looking like it could happen.

[John Cohen]

So the pause on foreign aid was one blow to the program. But then Elon Musk and Doge came in and decided to, in Elon Musk's own words, throw USAID into the wood chipper. USAID, the U.S. agency for International Development, receives about 60% of PEPFAR funds. It's the backbone of PEPFAR. You throw that into the wood chipper, you're throwing PEPFAR into the wood chipper.

[Darian Woods]

We're giving it nobody to administer it, even if some of the funding is still there.

[John Cohen]

This is a quilt and you're pulling the thread out of it. It just starts to fall apart. And when I visited the countries of Eswatini and Lesotho, that's what I saw.

[Darian Woods]

So you wanted to see what the reality on the ground was?

[John Cohen]

Yes, and I wanted to see for myself what impact this was having in particular on children and teenagers. They're the most vulnerable, they get sick the quickest. They have the least amount of ability to take care of themselves.

[Darian Woods]

So let's place Lesotho and Asuatini on the map. Where are they and how would you describe them?

[John Cohen]

So both of them are within South Africa. They're independent countries. One of them borders Mozambique as well. They're small, one to two million people each. And to roll back the clock to what we were talking about earlier the year 2003, when PEPFAR is launched, they have the highest prevalence of HIV anywhere in the world. More adults living with the virus per capita than anywhere. And they still do.

[Darian Woods]

Yeah, I saw that HIV Prevalence peaked in 2015. One in three adults in Eswatini and one in four in Lesotho infected.

[John Cohen]

Yeah, it's down now to, you know, one in four in eSwatini. It's still incredibly high. You know, we're still in the 20%, 25% range. And by 50 years of age, about half the people in each country had hiv. And without the medication, that meant that people just didn't live full lives. The life expectancy was plummeting in both countries. I'm not sure the countries would exist today had these medications not arrived there when they did.

[Darian Woods]

Tell me about Timalanghini Dlamini.

[John Cohen]

So she was eight months pregnant and lived in a rural area in Eswatini. And she went to a clinic because she wanted to give birth in a clinic, not at home. And 20 year old woman lived about 10 kilometers from the clinic, so about six miles. Yes. Not easy to get there. And lived down a dirt road in a homestead with other kind of waddle homes. And she went to a Clinic where they did an HIV test of her and they found out she had the virus. So when I went to the clinic, I was talking to them and said, well, that's great. You know, the system's working. And this outreach worker there said, no, it's not. We need to now go test the contacts in her home. And typically we would drive out to her home and do the testing, and she has other children or other families living there, her partner is living there. We typically would go out and just do all that. I said, well, we have a car. How about if we took you, would you want to do that? And the outreach worker said, yeah, I'd love to do that. So we went out to the home and the woman tested eight children, and my heart was in my throat. It's crushing to see positive tests come up, especially in children. And here were eight children being tested. Not all of them were her children, and they all came out negative, which was just wonderful. But if any of them had tested positive, they could have started to receive treatment. Their lives would have been dramatically better off from learning their status and starting treatment. Had they not gone there. And had any of those children been positive, what would have happened? Well, they would have probably found out that they had hiv. When they had AIDS and were very ill or near death, they would have sought care and somebody would have tested them. At that point, they already would have suffered irreparable damage to their bodies when they grew older. They would probably be stunted if they survived. That's what's happening. It's a little harder to see than, hey, are there drugs on a pharmacy shelf? But that's the reality of what these cuts are doing.

[Darian Woods]

So if you hadn't been there, she wouldn't have been able to get the people to come to her home to test those eight people in her home six miles away. And this is kind of what the funding blockages are resulting in.

[John Cohen]

Exactly. That's what the PEPFAR program was funding, the transport out to people's homes. It might seem trivial to some people to travel six miles, whatever. Have you ever tried walking six miles? And if you are a woman and you've had a baby, if you walk six miles when you're eight months pregnant, it's not trivial. It's a big deal. And the roads are not good roads. So even if you have transport, it's hard to get from place to place. We have to, as Americans, I think, really appreciate how much good we've done around the world and how very grateful these people are for what we've done. And to have the plug being pulled like this, as the head of the UNAIDS program said to me in Eswatini, is like pulling someone off a life support machine and just pulling the plug.

[Darian Woods]

This seems to have been a very well managed program in terms of outcomes and outputs, not just about how much money is going in. Are there kind of some lessons that we can draw from PEPFAR that might help other programs or other ways to do good in the world?

[John Cohen]

You've put your finger on something critical. The metrics that we're talking about here are how many people did you test? How many lives did you save? How many people knocked back the virus to undetectable levels on standard blood tests? Those are hard numbers that you can come up with and you can evaluate where the program is succeeding, where it's failing. And indeed, those data fed governments so that they could correct the problems in their programs. Let's look at the numbers out of Lesotho and eSwatini. Post PEPFAR, they went beyond achieving a goal set by UNAIDS to have 95% of people know their status. 95% of those people start treatment. 95% of those people reach undetectable levels. 95, 95, 95. Both of these countries, the hardest hit countries in the world, went beyond the 95, 95, 95. That is an astonishing accomplishment. That is something that the world should be celebrating. Look what the United States government should be celebrating. Look what we did. Look what we helped them do.

[Darian Woods]

Yeah. The saying is what measured gets done. And seems like the right things were measured and they got done in these.

[John Cohen]

Countries to make the argument that this was inefficient or somehow scandalous or somehow stealing money. Show me the evidence. I would love to report that. I am not at all a shill for anything. I'm a journalist. I cover this critically. If I saw problems, I would report problems. And the program has had problems and it has addressed these problems with report after report. It's not perfect.

[Darian Woods]

What were some of the obstacles it's faced over the years?

[John Cohen]

Oh, there was a lot of complaints from staff about how they were being pushed by administration in Washington, D.C. that didn't understand realities on the ground, in part to deliver data, to deliver metrics that they had a difficult time doing. There were also political aspects to PEPFAR that were criticized where in some administrations they didn't want funding to go to sex workers or to key populations, to highly vulnerable groups. And there were tensions early on about promoting abstinence and behavior change as opposed to medicalizing Prevention with things like pre exposure prophylaxis. That's just like taking malaria pills if you're going to a malaria country.

[Darian Woods]

White House Budget director Russ voigt said the U.S. is in $37 trillion in debt. And at some point, the continent of Africa needs to absorb more of the burden of providing this health care. So could African countries find HIV AIDS treatment and prevention themselves?

[John Cohen]

Sure, and they want to. These countries were moving toward taking care of their own. They had a plan. It wasn't all written out and chiseled, but the idea was that by the year 2030, the PEPFAR countries would basically be taking over the program and running things themselves. And many of them have made great strides. Both Eswatini and Lesotho are purchasing the vast majority of their antiretrovirals. And South Africa, which has more people living with HIV than any country, basically pays for about 85% of everything. Yes, countries are moving toward that. But to think that this is going to solve our debt problem. I mean, come on, do the math. This is a drop in the ocean. Now you can argue that, hey, it's a charity, as Marco Rubio has said, and it's not our job to be a charity. Well, this is more than simply being a charity. It's more than simply soft diplomacy. It's creating a stable world where you don't have military conflicts, you don't have countries falling apart because of health.

[Darian Woods]

One estimate is that 60,000 people have died so far from the PEPFAR funding blockages. Based on what you saw, do you think that number is plausible?

[John Cohen]

It's really hard to say. HIV causes damage slowly. In children, it moves pretty quickly, but, you know, in an adult, it takes years to move from becoming infected with the virus to developing severe disease. So could people have died en masse from January 20th until today? Yeah, not a lot, but give it a year and you'll see a lot. I mean, I saw the two trains heading for each other. I could see that with my own eyes.

[Darian Woods]

So you got back on the plane to the U.S. what were your parting thoughts as you flew off into the sky?

[John Cohen]

I used to leave countries like Eswatini and Lesotho having seen horrific things. 200 people dying in a warehouse with no HIV medication when medication existed in wealthy countries. And I'd get on the plane going home, and I frankly would get depressed. I mean, really, like just deeply depressed at what I had seen. This was different. I was, I know what's going to happen because of what I saw. I didn't see 200 people dying. In a warehouse. But I know that if this funding isn't found elsewhere, if the gaps aren't filled, that there will be a rollback. The clock will be turning backward. And it's obvious to anyone who knows the HIV AIDS world what happens when these things fall apart. The center isn't holding.

[Darian Woods]

We reached out to the Department of State asking if its leadership was concerned. A spokesperson said PETFAR continues to support life saving, HIV testing, care and treatment approved by the Secretary of State. But they also said that other petfar funded services are currently being reviewed for efficiency and consistency with US Foreign policy. Thanks to John Cohen of Science Magazine for speaking with me. And as always, thank you for being a Planet Money plus listener. Your ongoing support is one of the best ways to keep our work going. And remember, when you hear a show you love, tell a friend or send them a link. I'm Darian woods and this is NPR.

[John Cohen]

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