After the Bell: If Pepfar is slashed or terminated, the US and Africa will lose - and China may gain

In 2004 and 2005, I did several reporting trips to Malawi and one of the things that broke my heart about Africa’s Warm Heart was the roaring trade in coffin sales. 

It seemed like every corner of every town and village I visited had coffin-makers – they were a ubiquitous and sombre sight. Business was brisk for this undertaking because of the Aids pandemic, which was sweeping the land like the Grim Reaper’s scythe. 

When I returned to Malawi more than a decade later, in 2016, one of the things I noticed was that the coffin trade was no longer booming. 

And a key reason for this bust was the US President’s Emergency Plan for Aids Relief (Pepfar). 

Launched by the administration of former US president George W Bush in 2003, Pepfar has had strong bipartisan support and is credited with saving 25 million African lives. It is about the only noble legacy to my mind of Bush’s two terms in the White House.

One underreported aspect of Pepfar has been funding for clinics that provide screening and treatment for cervical cancer, which is linked to HIV infections in women. It has been a game-changer and a life saver.

And now along comes Donald Trump wielding his own scythe, and grim results will be reaped.

Pepfar funding and clinics that rely on it came to a jarring halt this week in the wake of Trump’s executive order – signed on 20 January – suspending all foreign development assistance for 90 days, pending a review to determine whether they are “fully aligned” with US foreign policy.

Then, suddenly, there was a U-turn – chaos being a hallmark of Trump’s approach to governance – with US Secretary of State Marco Rubio declaring that “life-saving humanitarian assistance” would be maintained during the 90-day review.

Read more: US State Department grants waiver on aid freeze for ‘life-saving humanitarian’ assistance 

But there is massive uncertainty about which programmes can continue, as well as question marks over Pepfar’s future. 

If Trump doesn’t think that Pepfar is “fully aligned” to US foreign policy interests, then he is not seeing the forest for the trees. And this will not be lost on America’s archrival China, which has been presented with a golden opportunity to raise its influence in Africa at the expense of the US.

When Trump views Africa, he sees “shithole” countries. When China views Africa, it is a reflection of Trump’s take on Greenland: Beijing sees vast resource wealth which it covets to feed its industrial engines, and a region of vital strategic importance.

One plausible scenario is that China steps up to the plate to fill the void – at least partly – if the suspension of Pepfar funding becomes permanent or is greatly reduced under Trump. 

US foreign aid to sub-Saharan Africa over the past decade has amounted to about $8-billion a year, and it has often been the largest regional recipient of US aid, according to the Congressional Research Service.

Sub-Saharan Africa has also typically received 35% to 40% of annual non-humanitarian State Department- and USAID-administered assistance allocated regionally.

Pointedly, the Congressional Research Service notes that “HIV/Aids-related funding alone often accounts for around half of all US aid for the region each fiscal year”.

I don’t mean to put a rose-coloured tinge on this. Not all US aid to Africa is altruistic, and the main recipients have typically included resource-rich countries such as Mozambique, Tanzania, Zambia and the Democratic Republic of Congo. 

US commercial and state interests have long exploited Africa’s resources, but Trump’s obvious racism seems to have coloured his perception of how aid can aid in the extraction process. 

Chinese aid to Africa has been on a smaller scale, fluctuating at about $2.5-billion to $3-billion annually over the decade between 2013 and 2023, according to the China Africa Research Initiative. And the region at times has accounted for about 45% of all Chinese aid.  

China’s loans to Africa have been far larger, reaching a peak of almost $30-billion in 2016. In the case of Angola, repayment has been in kind – oil – rather than cash, which underscores the rationale behind China’s scramble into Africa.

So, could China lift its aid flows to Africa to at least partly compensate for the plug getting pulled on Pepfar and other US aid initiatives?

My guess is that it could easily do so. A few billion dollars here and there is loose change for the Asian economic giant, even in these trying economic times. 

China’s debt:GDP ratio surged to about 84% in 2023 – the last year for which this data is currently available – from 34% in 2010. 

This swelling of debt levels relative to the size of its economy has come as its once blistering rates of growth have slowed and as fiscal boosts have been required to keep things humming in the wake of the Covid-19 pandemic.

But for China – unlike, say, slow-growth South Africa – such a burden is manageable and, on this metric, the US fares even worse with a debt:GDP ratio north of 120%.

China’s foreign exchange reserves are also a staggering and world-topping $3.2-trillion. Each month its reserves in effect add the equivalent of South Africa’s total. 

So, yes, China has cash to splash for influence and, on this front, it will see rich dividends, including a waning of US sway in the region.

The slashing of funding to, or elimination of, worthy programmes such as Pepfar is simply diabolical, and speaks volumes to the short-sightedness of Trump’s political base and advisers. 

One of the often overlooked reasons for Africa’s economic spurt from about two decades ago was the containment of the HIV/Aids pandemic, and the roll-out of treatment to allow those living with the disease to lead relatively healthy and productive lives. 

Unlike Covid-19 and the Bubonic plague – which take their greatest toll on the elderly and sickly – Aids has spread mostly among working-age people in or near their prime. More than 20 years ago, there were lots of ominous forecasts about its potential impact on consumer demand and economic growth in South Africa and the wider region. 

One of the main factors behind Africa’s relative underdevelopment has been its high disease burden, and initiatives such as Pepfar have helped to unlock the continent’s economic potential while saving lives.

China will recognise this, while the Trump administration, with its narrow and ill-informed views and agendas, will not.

Pepfar was also a reflection of Bush’s evangelical Christian faith. I personally found many of his policies, including his strident anti-abortion stance – which sprang from a particular Christian viewpoint – deplorable. But one outgrowth of this faith was Pepfar, and it has branched into a force for good.

In this regard, the current conservative Christian movement in America which backs Trump has, to use one of his favourite terms, become nasty – or perhaps nastier is the right word.

Viewed through this stern biblical lens, Aids is God’s wrath for promiscuous behaviour. Millions of Trump supporters hold views along these lines. 

This not only lacks humanity, empathy and basic decency. It also fails to see the goodness that has flowed from Pepfar, which has simultaneously advanced US interests in Africa. DM