Two decades ago, stories like Joseph Jeune’s helped alter the course of history. In a “before” photo of him, a skeletal figure sits on a bed, eyes sunken, gaze pained. His body lacks any visible muscle or fat. He looks as he was, at death’s doorstep. In a second photo, a hale young man with a winning smile and a lithe, healthy frame holds a baby on his hip.
Doctors around the world who treat patients with antiretroviral therapy (A.R.T.), a course of treatment taken every day by people living with H.I.V./AIDS, have borne witness to the “Lazarus effect,” a transformation named after the man whom Jesus raised from the dead. Even in advanced stages of AIDS, antiretroviral therapy can reverse the ravages of what had once been an inevitably fatal disease. Seeking to rouse the conscience of the nation, the late physician-anthropologist Paul Farmer, who had treated Mr. Jeune with A.R.T. in rural Haiti, spent years showing this set of pictures to students, church members and political leaders across the United States to make the case that we can—and must—make sure that every patient with H.I.V./AIDS can receive this treatment. (Mr. Jeune died in 2015 at the age of 37, but he had lived another 13 years, thanks to his treatment.)
Dr. Farmer’s argument seemed, to many, utopian and even naïve. Experts in global public health had grown so used to scarce resources that the most respected work in the field involved calculations intended to decide which basic medical and public health services a population would receive. It seemed inadvisable, if not impossible, to give a then-expensive, lifelong multidrug therapy to millions of people.
This attitude persisted until President George W. Bush and other Republicans became passionate about AIDS treatment. To some, it was a strange turnabout. In the 1990s, Senator Jesse Helms, a Republican from North Carolina, so enraged the members of the AIDS activist group ACT UP that they constructed a massive condom and placed it over his home. As chairman of the Senate Foreign Relations Committee, Mr. Helms had tried to abolish the U.S. Agency for International Development. Yet in 2002 he called for $500 million to expand treatment for pregnant women with H.I.V. in poor countries.
It was after meeting with Dr. Farmer and other doctors treating AIDS patients that George W. Bush became the world’s most powerful champion of AIDS treatment. In his 2003 State of the Union address, Mr. Bush spoke of the Lazarus effect before announcing “a work of mercy beyond all international efforts”: a five-year, $15 billion initiative to prevent and treat AIDS in impoverished countries. In the years since, the President’s Emergency Plan for AIDS Relief (PEPFAR) has saved 25 million lives.
During that time, many of us have fought to make the program as effective as possible. I spent one summer in a warehouse in Rwanda, checking that country’s first imports of A.R.T. for pediatric patients to make sure there were no potentially deadly interruptions in supply. The next year, I was part of a group of Harvard University students who concluded that the university was charging unreasonable overhead expenses on a PEPFAR grant to help treat AIDS patients in Africa, and we called for Harvard to devote more of those funds to their intended purpose. I worked on Barack Obama’s 2008 presidential campaign, but by 2012, when his administration halted increases in U.S. government spending on global AIDS programs, I was part of protests at his campaign rallies. We thought PEPFAR was a program too precious to be trifled with.
I am convinced that it still is. President Trump’s foreign aid cuts risk destroying much progress and taking millions of lives. I was initially relieved to read that Secretary of State Marco Rubio ordered waivers for certain life-saving health programs, but many U.S.-supported programs that treat H.I.V. and other life-threatening diseases did not restart because of confusion over stop-work orders, the precipitous layoffs of clinical staff and the inability of program staff to confirm with U.S.A.I.D. that the waivers applied in their specific cases.
Initial reporting attributed the delay in the resumption of funding to staff shortages resulting from U.S.A.I.D. layoffs, but subsequent investigations found that employees of Elon Musk’s Department of Government Efficiency had specifically cancelled payments organized by U.S.A.I.D. staff for programs that had been granted waivers. The New York Times journalist Nicholas Kristof has begun to document the individual deaths of children and young mothers with H.I.V. in South Sudan that were attributable to the funding freeze.
The devastation does not appear temporary. On March 10, Mr. Rubio announced that a review of U.S.A.I.D. programs had ended with the cancellation of 23 percent of contracts related to H.I.V./AIDS. The remaining programs are supposed to continue under the auspices of the State Department, but this, too, remains far from certain.
The longer PEPFAR remains hobbled, the greater the number of patients who will suffer the terrifying consequences of stopped treatment—a kind of reverse Lazarus effect. Even a brief interruption in treatment can render A.R.T. ineffective against a newly resistant virus. While most people on long-term A.R.T. cannot transmit H.I.V., new cases will skyrocket if people are taken off their regimens.
We risk a return to the dismal days of the 1980s and 1990s, when despondent doctors overwhelmed by dying AIDS patients referred to themselves as mortuary attendants. One group of independent investigators—economists, technologists and policy experts—has estimated that without PEPFAR, AIDS would claim an additional one million lives each year. This toll comes in addition to other increases in illness and death that will follow the dismantling of U.S.A.I.D., including 18 million cases of malaria per year and one million children not treated for severe acute malnutrition.
There is a second story of Lazarus in the Gospels. In Luke 16:19, Lazarus is a beggar who languishes at the gate of a rich man. Lazarus is covered in sores, and longs for the scraps from the rich man’s sumptuous banquet table. When Lazarus dies, angels carry him to heaven. Upon the rich man’s death, he descends to hell. The prophet Abraham has no sympathy for the rich man’s torment, explaining, “In your life you received your good things, while Lazarus received bad things, but now he is comforted here and you are in agony.” This tale is the Gospel’s clearest enunciation of the Christian imperative to serve the destitute and sick. If we fail to maintain our commitment to those whose lives we saved, we will know where in the Good Book to learn of our fates.
