With these cuts, they may die

Until 2006, when AIDS patients came to Karanda Mission Hospital in rural Zimbabwe, the medicine doctors had to offer was the gospel. Dan Stephens, the physician who runs the hospital, which is a three-hour drive north of Harare, the capital, said the staff didn't have the resources to test patients for the virus, much less treat them. Every day a patient in the 130-bed hospital would die.

"You had no hope. There was no treatment," Stephens said. "We could take care of your diarrhea, perhaps."

Today Karanda treats 3,000 HIV/AIDS patients a year, keeping them alive with antiretroviral (ARV) drugs. The hospital, open since 1961 and run by The Evangelical Alliance Mission, also provides treatment to pregnant mothers to prevent them from transferring the virus to their babies. "It's a whole new world now-a new vibrancy in the air," Stephens said.

The national rate of AIDS infection in Zimbabwe has dropped dramatically in the last decade from 26 percent to 15 percent, thanks mainly to education about the disease and changes in sexual behavior, according to a study published in the journal PLoS Medicine. Karanda, for its part, counsels its patients about being faithful to one spouse as a way to prevent the spread of the disease.

Karanda's AIDS program, which took off five years ago, relies entirely on the Global Fund, an international fund for AIDS, malaria, and tuberculosis treatment. The United States is the chief contributor, providing about a third of funds to date.

President George W. Bush spearheaded the international effort to fight AIDS starting in 2002, designating millions for the newly created Global Fund and creating the President's Emergency Plan For AIDS Relief (PEPFAR), a companion U.S. program that has treated more than 3.2 million AIDS patients worldwide through local hospitals and nongovernmental organizations. But now Republicans are slashing those initiatives. The House budget for the rest of this fiscal year cuts the U.S. contribution to the Global Fund by 40 percent compared to last fiscal year's contribution, and slashes PEPFAR's budget by $363 million-or about 10 percent less than last year's budget.

Ambassador Eric Goosby, head of PEPFAR and the U.S. Global AIDS coordinator, laid out the stark result of the proposed cuts in an interview: "They're going to kill a lot of people, flat out."

PEPFAR officers estimate that 400,000 HIV/AIDS patients who were supposed to begin treatment will not be able to under the proposed cuts. And 100,000 fewer mothers will receive services to prevent transmission to their babies-which PEPFAR estimates means 20,000 more babies will be born with HIV.

The program has changed the course of the HIV/AIDS epidemic in seven short years, increasing the number of patients receiving ARVs from 50,000 before the program began to more than 3.2 million since. Drugs to pregnant mothers have prevented the transmission of the virus to 140,000 babies.

Congress will consider the cuts, which have Republican support, as it attempts to pass a spending bill covering the rest of this fiscal year. Even if the cuts Republicans proposed for the remaining months of this fiscal year do not pass, they reveal the vulnerability of global AIDS funding in the budget for fiscal year 2012. Before he took office, President Barack Obama publicly promised Bush that he would continue funding the global AIDS effort, and Obama's proposed 2012 budget increases the program's funding. Christian groups-including conservative evangelicals-are lobbying Republicans to address the nation's debt crisis without slashing an effective program that is keeping millions alive. "If we didn't have outside resources, we would die," Stephens said.

The U.S. Conference of Catholic Bishops and Catholic Relief Services (one of the top recipients of PEPFAR funds in Africa) penned a letter to Congress opposing the cuts to the global health programs, noting that while the House cut the overall budget by 2.6 percent, international programs for the poor bore 26 percent of cuts: "Shared sacrifice is one thing; it is another to make disproportionate cuts in programs that serve the most vulnerable," they wrote. "Cuts at the level being considered will result in the loss of innocent lives."

PEPFAR has a wide array of supporters, from the Catholic bishops to evangelicals to liberal gay activists. Ray Martin of Christian Connections for International Health said his organization is forming a network of international Christian health organizations to fight to preserve the programs. Shane Claiborne of the Simple Way, Ron Sider of Evangelicals for Social Action, Richard Mouw, president of Fuller Theological Seminary, and others signed onto "A Christian Proposal on the American Debt Crisis," which supports cuts in federal spending but argues the poor should not bear dis­proportionate cuts, as they do in the current spending bill.

Kay Warren, wife of pastor Rick Warren and head of California-based Saddleback Church's international AIDS efforts, has jumped in too. "I'll use whatever influence I have to keep PEPFAR alive," she told me. Saddleback doesn't receive any money from PEPFAR, but Warren has long been a public cheerleader for it: "Everybody's budget got cut so every constituency is going to be calling," said Warren. "I completely understand that this is a time for our nation that we have to make cuts in spending, but I would argue not for the most vulnerable." She said she plans to meet with lawmakers soon.

But the 87 new Republican members in the House have a singular focus-to cut spending. When Rep. Joe Barton, R-Texas, touted $61 billion in cuts the House proposed for this fiscal year at a Tea Party summit in Phoenix last month, the audience booed him, chanting, "More, more, more!"

And despite its popularity among conservatives during the Bush years, PEPFAR has few advocates in the new Congress: Only one House member and three senators who originally sponsored the initiative are still in office. "They don't know the history, they don't know the context and they don't know the success," said Michael Gerson, former Bush senior policy adviser.

Instead it's Democrats who defend Bush's program: "Our global health programs represent some of our most successful and effective international policies," said Sen. John Kerry, D-Mass., chair of the Senate Foreign Relations Committee and one of the original sponsors. "The proposed cuts in the House spending package would have devastating implications for these policies and for our humanitarian agenda as a whole. Simply put, these cuts will cost lives."

Sen. Richard Lugar of Indiana was one of the original Republican sponsors, but his senior adviser Mark Helmke was cautious: The senator is "taking a hard look" at the cuts, he said. Lugar is facing the prospect of a more conservative primary challenger in 2012, who could attack the senator's efforts to preserve spending.

The Bush administration designated the foreign aid budget, including PEPFAR, as national security spending, which could protect it from the congressional axe. House Republicans changed that designation in the spending bill to cover the rest of this fiscal year. House Budget Committee Chairman Paul Ryan, R-Wis., explained: "What ends up happening in these budget games is they try to sweep everything into these more protected categories so they can get higher levels. . . . So look, let's call things for what they are. If it's a high priority, it should be able to stand on its own merit. And we shouldn't shield this category of spending in a higher priority where it really doesn't belong."

Secretary of State Hillary Clinton argues that the nature of wars today means that aid and development are critical components of national security. Ryan acknowledged he and Clinton discussed that, but said they "have a difference of opinion." An argument could be made for foreign aid in Afghanistan and Pakistan counting as national security spending, he said, but added, "I just don't think global health, as important as that may be, or the French ambassador's residence, belong in this national security budget."

Given pressure from House Republicans, PEPFAR officials have said they will make it a priority with whatever money they do have to continue providing drugs to those already on ARVs. The drugs cannot be stopped and restarted but must be taken in a carefully prescribed regimen.

Worse, if the patient doesn't complete treatment, the virus will mutate and become resistant to the drugs, making them "worthless," explained Stephens, who grew up in Zimbabwe watching his father work as a physician at Karanda before becoming a physician there himself. Drug resistance is a particular problem in Africa because doctors have about five drugs to work with for treating HIV/AIDS, he said. In the United States physicians have about two dozen drugs. So if a patient becomes drug resistant in Africa, fewer options remain for life-saving treatment.

The cuts could also unravel PEPFAR's progress toward making African countries' government health ministries self-sustaining. PEPFAR staff members sometimes work directly alongside local health officials to improve their institutions and safeguard against corruption. South Africa, which has 17 percent of the world's HIV/AIDS population, is the valedictorian of that effort. The United States has provided hundreds of millions of dollars to treat patients there, but now the country is "moving from emergency to sustainability," according to PEPFAR country director Mary Fanning. South Africa plans to be fully self-funded for AIDS programs by 2015.

Goosby recognizes that PEPFAR has done more than heal people. "We have no misconception of what this program has done in a spiritual sense," Goosby told me. "It's put hope back on the table."

Stephens agrees. At Karanda, he had the gospel to give patients as he watched them die, but no drugs. "If they continue the drugs, they still might die," Stephens told me. "They're facing death at any time. So they're open to the gospel, and we feel we need to share it with them." But there are drugs now, and more who are living as a result of U.S. spending: Since the early 2000s, the height of Zimbabwe's AIDS crisis, deaths at Karanda Mission Hospital have dropped by at least 60 percent.

Where to cut?

Cuts to other less efficient State Department programs could allow the President's Emergency Plan for AIDS Relief (PEPFAR) and the Global Fund to continue. Brian Riedl, a budget analyst at the Heritage Foundation, put out a 2012 budget that specifically does not cut the funding for those programs, but achieves $343 billion in cuts across the board. The Heritage budget analysts refused to cut PEPFAR, he said, because they understood that it was one program at State that used money effectively.

Riedl offered other options to provide the $783 million in cuts to global health that Republicans are proposing: "USAID in a lot of areas is a lot more poorly managed." Heritage analysts propose cutting USAID's Development Assistance Program, which would provide $1.5 billion in savings this fiscal year. Congress also could cut State's education and cultural exchange programs, which would provide $350 million in savings over the next months. Slashing the International Trade Administration's trade promotion activities, like sponsorship of events with foreign chambers of commerce, could save another $187 million through the end of this fiscal year. And zeroing out State's Trade and Development Agency, the Overseas Private Investment Corporation, the East-West Center, and the U.S. Institute of Peace would provide another $72 million in savings this year.

Sojourners, in a letter to Congress, proposed defense cuts instead of cuts to foreign aid, writing, "In Great Britain, Prime Minister Cameron made the choice to delay a costly nuclear submarine program, while also increasing life-saving funding for international aid. The U.S. Congress should follow this example." But the real drivers of the national debt are entitlements, healthcare cost inflation, and an aging population, said former Bush adviser Michael Gerson. Cuts to global health, he said, are "a distraction from the real issues we face." He agrees with Reidl that humanitarian aid programs are a tiny percent of the budget, "but they're saving millions of lives, making some of the largest health gains in history," he said. "It's something Americans should know about and be proud of."