10 Years of PEPFAR: The Emergence of Global Health Diplomacy as a Pillar of US Foreign Policy and International Development Strategy

Passed in 2003,  President’s Emergency Plan for AIDS Relief (PEPFAR) is the largest monetary commitment to fighting HIV/AIDS in Africa, Asia, Latin America and the Caribbean. Unfortunately, many Americans here and abroad, including those who are generally well informed, know nothing about PEPFAR. When reauthorized on July 30, 2008, it seemed to be firmly ensconced as part of America’s moral and humanitarian tradition in the vein of the Marshall Plan, the Berlin Airlift and Peace Corps etc. But the economy had not fallen into disrepair. The question is, can it survive as is, in the absence of a political champion, bipartisanship and so many domestic fiscal challenges?

The Bush Doctrine as explained in The National Security Strategy of the United States asserts that U.S. foreign policy rests on three main pillars: a doctrine of unrivaled military supremacy, the concepts of preemptive and preventive war, and a willingness to act unilaterally if multilateral cooperation cannot be achieved. The arrival of PEPFAR signaled the construction of a fourth pillar: international humanitarianism.

Enactment of the United States Leadership Against HIV/AIDS, Tuberculosis, and Malaria Act (also known as PEPFAR I) in 2003 established the State Department’s Office of the Global AIDS Coordinator administered PEPFAR; that demonstrated the Bush administration’s commitment to soft power techniques such as global health diplomacy and indicated a shift in how American foreign policy would be conducted in the developing world.

The Cold War Policy of “Containment” that relied on an abundance of aid that was militaristic or aimed at filling the coffers of morally bankrupt autocratic heads of states so as to deter them from aligning themselves with the Soviet Union was now an anachronism Much of the developing world suffered from decades of inept and corrupt governments that siphoned off international monetary aid. The 9/11 attacks were symptomatic of deep-seated resentment of America not only in the Middle East, but also many other places affected by economic discontent and social inequality. There was now a need for American foreign policy initiatives that sought to stem the destabilizing consequences of HIV/AIDS in Africa that posed a threat to US national security and would burnish America’s image abroad and appeal to ordinary people in the developing world. PEPFAR 1 was an attempt to exhaust the raging conflagration of antipathy towards America that poses a significant threat to American interests and national security.

In HIV/AIDS in Africa and U.S. National Security, Dr. Sandra Joireman argues that “the increased awareness of the causes of terrorism has made Africa more critical to the national security agenda of the United States than it has been in the past. The African security concern of greatest interest to the United States is state failure. AIDS is one factor contributing to state failure and is similar to other security threats, such as poverty.” Joireman goes on to say that economic underdevelopment of many African countries combined with the crippling effects of HIV/AIDS weakens these African states’ ability to successfully deal with the threat posed by terrorist cells of Al-Qaeda and Al-Shabab and the like. Moreover, weakened mineral rich countries like the Congo would face problems preventing the smuggling of uranium that could ultimately be used to build a nuclear weapon.

It could be argued that the U.S. government and its policies either led indirectly or directly to the social conditions that lead to the spread of HIV/AIDS. Due to the devastation caused by AIDS in many African countries during the 1990’s and early 2000’s and the increased interconnectedness and interdependency between countries of the globe, HIV/AIDS morphed from a public health/medical concern into a national security issue by the start of President Bush’s first term.  One of the reasons PEPFAR I passed was because of the perception of HIV/AIDS being a threat to U.S. national security.

The 5th anniversary of PEPFAR’s reauthorization is approaching and it is up for reauthorization again later this year. President Obama’s 2013 fiscal year budget purportedly slashed $220 million from PEPFAR’s bilateral programming. With the current polarized political climate, and urgency of domestic and fiscal challenges that the country is facing including the “sequester” which allegedly cuts $380 million from PEPFAR; the political will to reverse the downward trend in PEPFAR funding since 2010 and keep it at current funding levels may have eroded both in the legislative and executive branches.

President Obama inherited many of President Bush’s foreign and military policies; PEPFAR is one inherited portion of the Bush doctrine’s legacy that should be expanded and innovated even further to balance the seemingly ineluctable increase of use of violence and militarization of America’s relations with Africa in the light of increasing levels of terrorist extremist activity in West Africa and East Africa.

As Secretary of State, Hillary Clinton masterfully advanced the emergence of global health diplomacy as the fourth pillar of US foreign policy. Let’s hope that President Obama and America’s new secretary of state, John Kerry along with Congress will remember the gains of PEPFAR and the overall effectiveness of soft power in Africa and will take this brand of diplomacy to other parts of the globe and use it in the fight against poverty, economic turmoil, health and social inequalities that have proven to be fodder for the birth, growth, strengthening and sustenance of terrorist entities in Mali, Somalia and many other parts of the globe. PEPFAR is smart, constructive, moral, responsible and effective foreign policy.

“His [President Bush] decision to launch this initiative [PEPFAR] was bold, and it was unexpected, I believe historians will regard it as his single finest hour”- then Senator Joseph Biden [now Vice-President Biden] in 2008, the last time PEPFAR was up for reauthorization. Many in the global-health community agree. Dr. Paul Farmer, of Partners in Health, thinks PEPFAR “is the best thing the US has going for it in Africa and a really good face of our country”.

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