What America First really means
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Like everyone else, I’ve been considering what America First really means. Political discussions at our kitchen tables, in coffee shops and in the halls of congress have been at an intensity rarely witnessed. Some draw parallels to other times, such as the Vietnam War era.

All I remember about that time was my mother washing dishes while listening to the radio for draft numbers. I didn’t truly appreciate what she was listening to but her tears and look of fear remain vivid to me. My older brothers’ numbers were never called.

As our country considers retreating and rebuilding to “Make America Great Again” versus engaging in the wider world in both word and deed, my strongest argument for bold engagement, comes from the actions of a prior Republican president.


It’s the story of the President’s Emergency Plan for AIDS Relief (PEPFAR) envisioned by former President George W. Bush to confront the HIV/AIDS epidemic and sustained through eight years of the Obama administration. It is a story of unwavering commitment to do what’s right amidst catastrophe.

Here’s how I came to know this first hand. Back in 1988, on a dusty stretch of dirt road, outside Harare, Zimbabwe, I began my career as a nurse. Although I knew about this new disease called AIDS, little did I know- in this landlocked country nestled between war torn Mozambique and Apartheid South Africa that it would quickly become the epidemic of our generation. 

Nine months into my work, our once-empty tuberculosis unit was now the staging area for the dying. Our hospital’s bed capacity was exceeded and patients were put on make-shift mattresses on the floor. As our small band of nurses spoke in whispers and used code language on patient charts, we began to fight a new deadly disease on a scale the world had never seen. Our hospital quickly became a hospice. Even healthy pregnant women and young children were not spared- once mild infections quickly became untreatable and deadly. Shrouding the dead became a nurse’s daily duty.

Despite our lack of protective gear and our palpable fear, we learned and cared as best we could. We attempted to stall the inevitable through the use of the few antibiotics we had. But access to information was limited. There was no internet, no cell phones. We washed and reused gloves, we put used needles in cardboard boxes and we burned our medical waste in a pit nearby. At the end of the day we went home and got ready for the next shift.

While those of us in Sub-Saharan Africa cared for the dying, in Europe and North America, scientists and activists began a frenzied effort to thwart this new pandemic. Today, we know that this evidence-based science and relentless activism paid off. Although it took over a decade and emboldened patients and clinicians to engage in Africa through PEPFAR has been transformative. Over the course of three decades, a record pace by all standards, Africans now have access to the medicines that have transformed AIDS from a death sentence to a chronic, but manageable, illness. We even dare to speak of a generation free of AIDS.

While many in the United States may not be familiar with PEPFAR, this acronym is heard near and far in Africa. It is discussed in the markets, schools and churches, a lifeline for so many. Indeed, in many ways PEPFAR has been a brand ambassador for all that is great in America- ingenuity, a can-do spirit and a willingness to lead. 

Since 2004, through PEPFAR, the US has supported 11.5 million men, women and children to get started on life-saving treatment for HIV with a remarkable drop in the number of deaths and a halving of the number of new HIV infections.

People in Africa know how and from where this HIV support comes. It has been a lifesaver for families, communities and entire nations. In the late 1990’s, many of these countries faced the very real possibility of becoming failed states.

In 2000, UNAIDS reported that “It is clear that AIDS is a development crisis, and in some parts of the world it is rapidly becoming a security crisis too.” PEPFAR’s effect hasn’t just been at the level of improving personal health, it has helped stabilize and develop countries in sub-Saharan Africa.

In 2012, the World Bank reported that despite a global downturn, African economies were growing. PEPFAR is no less than a largely unknown success story in US Foreign Investment.

Continued support for PEPFAR is essential. While I grew up in a family of lifelong Democrats, when I had the privilege to meet former President George W. Bush on one of his visits to Africa, I hugged him and thanked him for PEPFAR. He replied simply, saying it was the right thing to do. He had signed into being a strategy for engagement with so many countries brought to their knees by the HIV epidemic, and offered the world stability and a lesson in American generosity.

In some countries where one in five adults were testing HIV positive, risks to the health workforce and overwhelming health care needs threatened already fragile health systems. Improvements in health achieved over the previous decades were reversed by the HIV epidemic with sharp decreases in life expectancy and sky-rocketing maternal and child deaths.

The numbers of HIV positive military personnel threatened the national security of several African countries and the rise in AIDS orphans and child headed households tore at the fabric of societies. President Bush knew, as I did; how the instability of those countries could threaten the region and the world. And he knew that turning our backs on dying people was not only immoral, it would show people we were immoral. It would give desperate people a reason to dislike us; a global power that had the means to do something but chose not to.

My experience with PEPFAR confirmed for me that it is exactly when we are feeling most vulnerable and afraid that we need to engage. 

Scientists and activists did not retreat from AIDS. They looked a deadly pandemic squarely in the eye and set about discovering a way to tackle it. If we had retreated, countless lives would have been lost and the terror of a deadly disease would have remained with us for decades to come.

More recently, the Ebola outbreak in West Africa has reminded us of this. Closing our borders would have been impossible. Every plane that landed from overseas was a potential carrier of Ebola. We needed to face Ebola and get to work to do what made sound public health sense. 

We must continue to engage if we want to prevail and if we want to preserve our dignity. I’ve seen firsthand how PEPFAR has not only strengthened our standing in the world but how this kind of assistance can be the best medicine against the disease of terrorism. It’s a model, a metaphor, a bipartisan commitment that must continue and grow in these uncertain times. There is much still that needs to be done.

This story is not over. Continued support for PEPFAR remains essential to meet the remaining challenges. Millions continue to get infected and millions die every year from AIDS. Only about half of those living with HIV have access to life-saving treatment. Young people are getting HIV infected in alarming numbers. Our best protection is engagement. I’ve seen enough to know.

Susan Michaels-Strasser, is Assistant Professor in Epidemiology at the Mailman School of Public Health, and Implementation Director of ICAP at Columbia University. She is a Public Voices Fellow with the OpEd Project and is a public health professional with over 25 years of experience in nursing and public health. 

The views of contributors are their own and are not the views of The Hill.