The record of the President’s Emergency Plan for AIDS Relief (PEPFAR), a program started by President George W. Bush, is remarkable for both its generosity and effectiveness. It paid for antiretroviral medications for millions of H.I.V. positive people in sub-Saharan Africa and the Caribbean, and is now seen as one of the most important foreign-aid efforts in American history. PEPFAR saved the lives of millions of the poorest and most vulnerable people on earth. Setting up this program flew in the face of experts’ advice at the time.
According to Justin Sandefur, a senior fellow at the Center for Global Development, “The conventional wisdom within health economics was that sending AIDS drugs to Africa was a waste of money…” This is because antiretroviral medications are extremely expensive, and experts reasoned that it would be more efficient to spend aid dollars on prevention instead. Still, PEPFAR funded AIDS treatment for poor countries, thereby ultimately saving lives more cheaply than the cost-benefit analysis initially suggested.
Another fundamental lesson to learn from the PEPFAR case is that cost-benefit analyses are not always conclusive. For example, school meals are beneficial, helping with nutrition outcomes and ensuring that more kids go to school. Yet, other programs are often seen as more efficient, proving that an effective, easy-to-implement solution can be the best choice.
However, the PEPFAR case also teaches us that politics can matter more than economics, with sometimes unpredictable, irrational or emotional political decisions saving lives. Saving the lives of H.I.V.-AIDS patients had high “salience” because activists connected with the cause emotionally.
The Bush administration was able to allocate money for treatment and compromised on prevention measures because the constituency for AIDS treatment included evangelical groups with a lot of political influence within the Republican Party. Activists such as Bono, the U2 frontman, or Franklin Graham, the son of the Reverend Billy Graham, put pressure on the administration and made it easier to get their attention, while lowering the political costs of spending U.S. government money on a new foreign-aid program.
Policy and politics are not separate since political costs and benefits will often beat out economic ones, even if it may seem irrational. And in cases such as PEPFAR, it is undeniable that unpredictable politics saved millions of lives.
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