PEPFAR: The Most Effective Health Diplomacy Program in History
Technical expertise and diplomatic skill advance and apply scientific knowledge, and prevent and combat diseases.
I had no intention of being a health diplomat. I possessed no medical expertise, and during much of my career in the Foreign Service, health diplomacy was not a well-defined concept. Like most diplomats, I was a generalist interested in a variety of subjects. However, in 2003, while I was serving as ambassador to Uganda, the U.S. government launched the President’s Emergency Plan for AIDS Relief (PEPFAR), its largest-ever health diplomacy program, with Uganda as its showpiece.
EDITOR’S NOTE: This is an excerpt from the book “Diplomatic Tradecraft,” published in 2024. Last week, the Trump administration ordered an immediate stop to distributing medications through PEPFAR as part of a global freeze of U.S. foreign aid. It issued a waiver for lifesaving drugs a day later, but it wasn’t clear if the waiver covered preventive medicines or other services offered by the program — and its future is still at risk. Reports indicate that distribution hasn’t resumed and clinics remain closed, though some may reopen in the coming days.
Although the embassy had on staff some of the leading experts in the field from the CDC and USAID, we needed partners from the political, economic, academic and logistical sectors in both Uganda and the United States to develop and sustain the initiative. PEPFAR changed many lives, and mine was one of them. After three years in Uganda, I spent the rest of my career working on global health.
Health diplomacy is the activity of deploying international cooperation in the service of public health, and using global health efforts to achieve foreign-policy goals. Technical expertise and diplomatic skill inform and complement each other to advance and apply scientific knowledge, and to prevent and combat diseases. Even though viruses do not recognize national borders, healthcare has always been a national — and in many cases, sub-national — responsibility, which strengthens the case for international cooperation and multilateral diplomacy. This is a two-way street: diplomacy promotes and facilitates scientific and technological progress, while collaborating on science and technology fosters closer ties and better understanding between countries and people.
The first cases of Acquired Immune Deficiency Syndrome (AIDS) in the United States were detected in 1981. When I arrived in Uganda in 2002, about 5 percent of adult Ugandans were estimated to be suffering from AIDS, and many more adults and children were living with the Human Immunodeficiency Virus (HIV) that causes AIDS. In all of Africa, about 25 million people had the disease, and it was the leading cause of death on the continent. In its first 15 years, an infection was considered a death sentence — the virus suppressed patients’ immune systems to such an extent that they could die from virtually any microbial or medical infection. But in the mid-1990s, U.S. scientists developed a three-drug cocktail of antiretroviral therapy (ART) that was able to reduce the immune deficiency, lowering the risk of opportunistic infections.
By 2003, only a few thousand Africans had access to the drugs. ART was prohibitively expensive. In the United States, it was administered only by specialists, and patients needed to be under strict and regular medical supervision, with viral-load tests performed in specialized laboratories required at least once every quarter. The combined cost of the therapy and the tests was about $10,000 a year, clearly out of reach for most patients in Africa. Normally, a strong cocktail like ART would not be used commercially until a multi-year study of its long-term effects has produced encouraging results, but the standard practice was not followed in this case, because the drugs were saving lives and patients accepted the risks. Not surprisingly, many of them suffered severe side effects.
Through PEPFAR, Washington wanted the drugs to reach as quickly as possible all 50,000 Ugandans whose lab results showed that their HIV had progressed to AIDS. The challenge was more formidable than it may sound, and things could have easily gone wrong. Africans were not in the habit of taking multiple pills at precise times, a requirement thought to be important to efficacy at the time. In Uganda, most AIDS patients lived in the remote countryside, far from medical centers in big cities — even those centers lacked medical specialists or sophisticated labs that were an integral part of the antiretroviral treatment in the United States. Some Ugandans were so sick that they had stopped eating and were not cultivating food for subsistence. They were dying of malaria and diarrhea, diseases that were rare and almost never fatal in the United States.
We knew about side effects among Americans, but Ugandans had a different way of life and could develop other reactions to the cocktail, which would be very difficult to monitor, especially in areas where doctors or other experts were not available. In many places, the monitoring would be done by paraprofessionals, who were high school graduates with bicycles. They would visit patients and complete a simple checklist of potential side effects, which turned out to be effective.
In addition to scientific uncertainty, there were political risks. Setting up a system to deliver life-saving drugs fairly and with transparent record-keeping would be a tall order amid pervasive corruption. We would need the government’s cooperation, and would work with and allocate resources through reliable partner-organizations, at least initially. The political stakes were high. If there were widespread treatment failure, unexpected side effects or inability to reach needy patients, the main consequence would be personal tragedies, but the reputation of the United States would be severely damaged as well.
We decided that it was a moral imperative to assume the risk and provide the drugs as fast as we could to as many people as possible, trying to anticipate problems and making necessary adjustments as we monitored the situation. Our strategy paid off, and the scaling-up met its targets for coverage. Adverse individual reactions to treatment were below expectations, with nearly immediate feedback from patients and treatment centers that the impact was evident and life-saving.
Unlike American patients, Ugandans benefited from not having taken earlier experimental drugs, and the ART cocktail worked better than expected, with fewer side effects. Most patients showed dramatic improvement within weeks. In less than two years, almost every family in Uganda seemed to know someone who would have died but was still alive and returning to a normal life because of PEPFAR. The program has saved more than 25 million lives, supported antiretroviral therapy for 20 million adults and children, and made it possible for nearly 5.5 million babies of mothers with HIV to be born free of the virus.
Why is PEPFAR a health diplomacy, and not just a foreign aid, program? There is no doubt that, without the scientific advancements that produced the ART treatment, PEPFAR would not have been possible, but neither could it be carried out without diplomacy. The collaborative work of U.S. diplomats and medical experts with Ugandan authorities at all levels, including the country’s top leadership, as well as its medical community, saved hundreds of thousands of lives. It also created a reservoir of goodwill for the United States and bolstered its diplomatic influence.
Few scientists, health professionals or diplomats have any doubt that international cooperation in the fields of science, technology and health makes a big difference for the better. The pursuit of objective knowledge is a universal human endeavor that knows no borders and is not confined by the concept of nationality.
Jimmy Kolker is a former assistant secretary for global affairs at the U.S. Department of Health and Human Services. During his 30-year Foreign Service career, he was ambassador to Uganda and Burkina Faso, deputy chief of mission in Denmark and Botswana, and also served in Britain and Sweden.
The views and characterizations in this article belong to the author and don’t necessarily represent those of the U.S. government or the Diplomatic Diary.
The above is an adapted excerpt from the book “Diplomatic Tradecraft,” published with permission from Cambridge University Press. © Nicholas Kralev 2024