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As of 2003, there were nearly 27 million men, women, and children suffering from AIDS in sub-Saharan Africa. Today that number has been reduced by more than half. The number of people with access to antiretroviral drugs–a treatment which renders AIDS survivable rather than fatal–has gone from around 50,000 to more than 11 million.

All of this is thanks to a Bush administration program known as PEPFAR. Even on the day of its launch during the 2003 State of the Union, no one much noticed it. It cost a fraction of a percentage of the overall budget and was far less expensive than the Iraq war, effectively announced on the same day. Yet PEPFAR is, according to journalist Emily Bass, “the best thing America has done beyond our borders in this century.”

To End a Plague is not merely a history of this extraordinary program; it describes the cost of success in our broken political system. PEPFAR was likely a cynical political ploy–a “legislative trophy” as the New York Times described it–and its overseers, including the now-famous Coronavirus Task Force leader Deborah Birx–had to make moral and political compromises to keep it from being shut down. Yet the program has persevered and made an enormous improvement in millions of lives. This is the story of true change and what it takes to make it.