Barbara Staley, M.S.C., first went to Eswatini in 2004 at the height of the H.I.V./AIDS pandemic. The country then had the highest percentage of people infected with H.I.V./AIDS anywhere in the world. “Forty-two percent of the people in Eswatini were infected with H.I.V.,” the American Cabrini sister remembers. “Everybody was dying, there was no anti-retroviral medication at that time.”
Eswatini, known as Swaziland until 2018, is a landlocked country in southern Africa, primarily bordered by South Africa with a small border shared with Mozambique. Eswatini’s agriculture-based, free-market economy relies heavily on trade with South Africa. Income inequality is high and poverty is widespread, with almost 60 percent of the population living below the national poverty line of $1.90 a day.
The Cabrini Sisters maintain a rural mission, St. Philip’s, some 20 miles from the small town of Big Bend, named after a massive turn in the Great Usutu River, which flows to the Indian Ocean. Big Bend is situated in the small nation’s central sugar-cane producing district.
As in most low-income nations, Eswatini’s health care system faces significant challenges. Primary health care is free, but its quality is often poor and does not adequately meet the population’s needs. There are high rates of tuberculosis infection, and, though it is substantially lower than its worst years, the rate of H.I.V./AIDS infection remains elevated.
Eswatini endures one of the highest rates of H.I.V. infection among adults 15 to 49 in the world. The virus and the costs associated with responding to it remain significant economic and social burdens.
The nation’s health sector represents a joint effort among government, church actors like the Cabrini Sisters and private agencies and clinics. Conditions at government health facilities are often poor. Even with international aid, the health care sector struggles to provide a robust service to the country’s citizens.
Improvements in health care in Eswatini have relied for years “on the generosity of the American people,” Sister Staley says. During the height of the H.I.V./AIDS pandemic, Eswatini’s population plummeted, and life expectancy dropped from 61 in 1988 to 44 by 2003.
It reached 61 again in 2023 after the first emergency response from the U.S. Agency for International Development to Eswatini’s H.I.V./AIDS crisis. “That’s the success—what U.S.A.I.D. did for this country,” she says.
In fact the United Nations reports “a remarkable result” in Eswatini, “achieved with the support of US funding.” Eswatini managed to turn back its H.I.V. epidemic, reducing new H.I.V. infections from a peak of 21,000 per year in 2000 to just 4,000 in 2023.
The Most Rev. José Luis Gerardo Ponce de León, I.M.C., is the bishop of the Diocese of Manzini, the only diocese in Eswatini. He was in a state of disbelief when the announcement of the termination of U.S.A.I.D. contracts around the world was made after Elon Musk’s Department of Government Efficiency rampaged across an alphabet soup of federal agencies at the beginning of the second Trump administration.
“It was completely unexpected, never announced before, and there was [no] preparation time,” he says. Casualties so far have included not only U.S.A.I.D., but the President’s Emergency Plan for AIDS Relief, which had been administered primarily through U.S.A.I.D. Pepfar had been credited with saving 26 million lives in 54 countries.
Sister Staley says that “the gift” of Pepfar and the U.S. State Department’s Global Fund had helped transform Eswatini.
When she arrived in the country, the Cabrini Sisters had just opened a residence for orphaned children and conditions were bleak. She said that at the time, U.S.A.I.D. institutional literature on confronting the crisis spoke of the need to assist “single orphans” and “double orphans,” referring to a child’s loss of one or both parental caregivers to AIDS.
“Well, I used to say that what I have living with me are quadruplet, quintuplet, sextuplet orphans” because their mothers, fathers and all other family caregivers had died. “People didn’t even know to which families [the children] belonged.”
With the help of Pepfar, Sister Staley says, conditions in Eswatini improved dramatically. “All these people that are living with H.I.V. have undetectable H.I.V.,” she says. “They’re healthy; they’re robust; they’re living well. They’re having children [and] they’re taking care of their children; they’re working.”
Lamenting the withdrawal of aid, she says that the current situation means that the sisters “watch people crossing the mission, some of whom are their employees, knowing that in six months they are all going to be dead.”
“There was hope that [the withdrawal of U.S.A.I.D.] would be seriously reviewed,” says Bishop Ponce de León. That has not happened. He adds that hearing how U.S.A.I.D. was labelled a “criminal organization” that “must die” by Elon Musk made him angry.
This, in his opinion, is a lie, because in Eswatini, the U.S. agency had made a real difference in the lives of the poorest. The bishop says that “every organization needs constant monitoring and evaluation, but to label it in that way can only mean ignorance of the good work that is being done.”
Bishop Ponce de León reports that the church in Eswatini has been affected on two levels by the end of U.S.A.I.D. Catholic Relief Services had approved a project intended to help the poorest in the diocese, but now the effort will probably never get underway. But the most affected in the diocese are the Cabrini Sisters and the various efforts they managed. The sisters have been forced to dismiss almost 90 percent of their employees at the mission.
The job losses are creating tragedies for families across Eswatini. Sister Staley tells the story of one staff member, Kenseni (who asked that her real name not be used), who started working with the sisters 20 years ago. She began by pulling weeds in the agriculture program, before moving up to oversee the inventory of all the equipment for the mission’s maintenance.
Sister Staley had been responsible for managing the mission’s finances, and one day, she recalls, she asked Kenseni if she wanted to learn how to use a computer. Kenseni was soon using QuickBooks and was placed in charge of St. Philip’s bookkeeping. Eventually, the sisters helped Kenseni earn a university degree, and she is now a professional accountant.
“Every single person who worked for us, none of whom was educated, was able to get an education and give back to the community as well as support their families,” Sister Staley says.
“Then, suddenly, with no warning, on Jan. 24, an email circulated announcing the withdrawal of aid and the need for N.G.O.s to cut staffing immediately,” she says.
“Since then, many N.G.O.s—including in the health sector—have had to close their doors. This has not only led to the end of some essential services but also complicated the relationship with the government, as many N.G.O.s are required to follow Swazi labor laws and cannot simply lay off workers.”
Because of those laws, “several N.G.O.s providing vital services went out of business. They had to close their doors,” Sister Staley says.
Many of the first people to lose their jobs, like Kenseni, had been part of an emerging professional class in Eswatini because of their work with international organizations—social workers, educators and nurses among them. “These individuals are often the breadwinners in their families, supporting their mothers, fathers, the elderly and children,” Sister Staley says. “This sudden cut had a profound impact on the livelihoods of thousands of employees. Then there were also the beneficiaries of all those services.”
Sister Staley describes another aspect of the loss of U.S. support. U.S.A.I.D. funding for direct services also included requirements aimed at improving professionalism in local and national government and among other nongovernmental organizations at work on social issues.
“Ten percent of the grant always demanded that we do organizational capacity building, so we learned how to do all our own H.I.V. testing, for example.” That capacity building, she says, extended to the government level, improving performance at Eswatini’s ministries of health, education and social work.
Over time, that investment translated into significant improvements in the overall health care system. Those various efforts reverberated across Eswatini society. “And now it will all collapse,” Sister Staley worries.
In 2004, the Cabrini Sisters were caring for orphans with an initial U.S.A.I.D. grant of $15,000. By 2025 that effort had expanded 100-fold—to more than $1.5 million in funding from U.S.A.I.D.—when the relationship was abruptly severed by Mr. Musk’s decision to, as he put it, feed the agency into a D.O.G.E.-administered wood chipper.
“I am coming across Catholics in the diocese who have just lost their jobs at an age when it is not easy to find another one,” Bishop Ponce de León says. “I foresee that, sooner or later, it will affect the income of the diocese in a way parallel to the Covid pandemic in 2020-21, which will also mean the inability of the diocese to continue helping the poor.”
Bishop Ponce de León says that “the main question mark regarding the H.I.V./AIDS fight in our country is what will happen now, as Eswatini had been leading the world in what is known as the ‘100 percent/100 percent/100 percent’ approach.” This containment strategy aims for 100 percent of people living with H.I.V. to know their status, 100 percent of those who know their status to be on treatment and 100 percent of those on treatment to have a suppressed viral load.
“The country has been well over 90 percent in all three levels, and this was thanks to the work being done by U.S.A.I.D.,” Bishop Ponce de León says. “Will the government be able to continue this with the same strength? How will the cut in funding affect the distribution of the antiretroviral treatment? These are big questions.”
Sister Staley says, “When I used to go do fundraising in the United States at different parishes, trying to get money to support our work in Eswatini, I used to say to people, ‘most of our funding comes from Pepfar, which comes from your tax money.’ People were proud.”
She believes that Americans are a generous people because the obligation to help their neighbor is ingrained in U.S. culture. “It’s deep in us that if you are privileged, you have to help the underprivileged,” Sister Staley says, “and that’s not just in your own place, it is anywhere. Now, there is an administration that is preventing people from being generous, and that is what I find so sad.”
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