We Can’t Fix the Deficit by Taking Medicine from the Poorest of the Poor 

The past few weeks saw a tragic juxtaposition of events. A new long-acting injectable medication to prevent HIV transmission was approved by the FDA shortly after the House of Representatives voted, in a rescission package, to claw back foreign aid spending that had already been appropriated. It is now up to the Senate to decide whether to spend money that had already been budgeted for HIV prevention or to take it back. This new medication, which does not require taking a pill every day to prevent HIV transmission, could make HIV go the way of polio within our lifetimes. However, the slashed budgets for programs like PEPFAR (the President’s Emergency Plan for AIDS Relief) jeopardize this breakthrough.

It’s been a brutal few months for global health. After DOGE put USAID through the woodchipper in late January, there has been an aggressive push to cut foreign aid as much as possible. While there were legitimate concerns about how USAID was being used to promote nefarious agendas and a few genuine scandals, most of the $65 billion or so that the U.S. spent every year was reaching its target audience. With most grants and programs canceled, what remains is only a fraction of what was being spent previously, and the future is very uncertain. 

Several politicians have misunderstood the way that this money was spent, claiming that only 12 percent of aid reaches its intended targets. Twelve percent of aid is distributed through organizations in the target countries, but the remaining 88 percent is given to U.S.-based organizations that then distribute it to people in need, as Scott Alexander explains here. For example, part of this 88 percent would include money that USAID pays to a factory in Georgia that makes emergency food rations. These rations are then sent overseas to people in need; the only “middlemen” in this case are the American factory workers. It also includes money given to organizations headquartered in the U.S. like Samaritan’s Purse, which then uses the funds to pay salaries for people who are distributing food and medicine to needy people. 

One of the biggest concerns about these programs is how much money is being spent on them at a time when the national debt is getting higher every year. This is a legitimate concern requiring important cuts to popular programs, but cutting foreign aid won’t really help the situation. Slightly more than 1 percent of the federal budget was spent on foreign aid prior to 2025, so cutting it out to avert a debt crisis is like promising to stop taking your kids to Chick-Fil-A once a month so you can pay off your second mortgage. The numbers just don’t add up; taking away medications from poor people in Africa will not be nearly enough to keep Social Security solvent. 

Another important concern is what is (and isn’t) the responsibility of a nation-state like the U.S. Many people voted for President Trump because they didn’t want Americans to be responsible for all the world’s problems or to charge America’s taxpayers to fix every international problem. This is an entirely legitimate concern; America is not the world’s policeman or healthcare system. “Someone will die if we don’t do this!” is not an unlimited excuse for starting another government program. 

There are, however, critical areas of American national interest that foreign aid helps to bolster. There is no way that Americans will ever produce everything they need within their own borders and there are critical mineral resources that we need to import in order to keep our national industries strong. Monitoring, preventing, and treating deadly infectious diseases like HIV and Ebola reduces the risk of a catastrophic pandemic that invades our borders. American “soft power” has played no small part in our successes as a nation over the past century, and cutting off aid abruptly has already started to threaten that power. Chinese propagandists are already flooding social media with ads about how their nation will always be a friend to Africa; defending our national interests will require some generous diplomacy among low-income nations. 

More important than the realpolitik, though, are our moral responsibilities as the wealthiest and most powerful nation in the world. In recent months, people have brought up the Augustinian concept of ordo amoris (the order of love) to think about how to deal with national interests and international concerns. God’s love for us enables us to love others, and when we love God above all other things then our other loves can fall into their rightful place. The ordo amoris help us discern that we ought to love God first, then the people He has placed in our lives (especially our families), and then the “rest of the world”—starting with those neighbors who are closest in proximity to us and then working our way out to more distant people in need. 

The challenge with invoking the ordo amoris in these debates is that it is neither an ironclad principle nor a detailed rule for loving others because it describes love, not ethical duties. It is also not a simple task to apply it to the government of a nation-state. The late Alasdair Macintyre observed that “the shared public goods of the modern nation-state are not the common goods of a genuine nation-wide community and, when the nation-state masquerades as the guardian of such a common good, the outcome is bound to be either ludicrous or disastrous or both.” It is inappropriate and simplistic to imagine all of our fellow citizens as “neighbors” and “our community” that automatically take the highest priority over the needs of the rest of the world. Government policies are always a balance of competing needs, interests, and responsibilities—and one of those interests is that a majority of Americans want the federal government to use their tax dollars to help the neediest around the world. 

The charge has been raised that American foreign aid is like the “telescopic philanthropist” Mrs. Jellyby from Dickens’s Bleak House, neglecting our fellow citizen-neighbors for the sake of our more distant neighbors in other countries. One can certainly find people full of compassion for an abstract mass of suffering people in other countries while also seething with contempt for their American neighbors in rural areas. But the existence of these attitudes does not affect the moral calculus or financial realities of how foreign aid works. The $335 per year that it costs for antiretrovirals that keep an HIV-positive person alive would not cover one month’s rent for a homeless American veteran; it is precisely because HIV can be reliably treated with relatively cheap drugs that it is worth investing in. We are also not trying to solve all of the world’s problems. There are many other diseases and problems all over the world that could be helped by American taxpayer dollars, but foreign aid ought to focus on the solutions that are most clearly efficacious. 

PEPFAR, in particular, deserves support because it has been incredibly effective in ways that even experts found unimaginable thirty years ago. USAID administrators and reputable medical journals alike claimed that distributing antiretrovirals was a fool’s errand at the turn of the millennium, but a bipartisan coalition of churches and activists argued that the possibility to save millions of lives was worth the investment. President George W. Bush agreed, and two decades later PEPFAR has become a model program in terms of its efficacy and transparency. 

There is an even greater opportunity now that we know how effective long-acting injectable antiretrovirals can be. Current PEPFAR goals are called “90/90/90” (90 percent of people living with HIV knowing their status, 90 percent of people who know their status on treatment, and 90 percent of people who are on treatment virally suppressed), but we could blow past those goals with drugs that don’t require a person to take a pill every day. This is not America solving all of the world’s problems—it’s America solving a problem that only America is good and great enough to solve. 

Every day in my work at a mission hospital in Kenya, I see U.S. taxpayer dollars being put to good use. My friends and colleagues across the country and across the world report the same, and I would invite anyone who believes USAID to be nothing but a slush fund of liberal activism to come visit and see for themselves the pharmaceuticals that their tax dollars paid for. I would urge them to come shake the hands of the hardworking people whose salaries were supported by U.S. foreign aid and hear the stories of lives that have been transformed through the generosity of USAID and PEPFAR. 

There is no conceivable way that the U.S. could fix all of the problems I see—that is the responsibility of private donations, other foundations, local government, and civil society organizations. This is the ordo amoris in action. Over the past few decades, we have seen incredible progress in the fight against HIV, hunger, and other infectious diseases. We could choose to either accelerate that progress and demonstrate American greatness, or to shrink back from the moral responsibilities that love places on us. 

Image licensed via Adobe Stock.