19-05-2025
U.S. Funding Halted Africa's HIV Crisis. Trump's Cuts Have Forced a Reckoning.
Ilan Godfrey/For The Washington Post
Shonewe Thembelihle does a general checkup in March for Maphindi Mtsetfwa at the Miracle Campus in Sidvokodvo, Eswatini.
SIDVOKODVO, Eswatini – When American taxpayer money started flowing here 18 years ago, this country was the epicenter of the global HIV/AIDS crisis, with the world's highest prevalence rate, and so much death that 1 in 10 households was headed by a child.
U.S. aid unleashed a flood of lifesaving antiretroviral pediatric drugs. It funded doctors and data systems. It helped build an ultramodern medical facility in the center of the country, known as the Miracle Campus, that provided free care behind an entrance sign saying: 'From the American people.'
To the nurses and doctors who arrived during that dire phase, this was America at its most ambitious – a superpower vowing to help solve the health crises of the developing world. In Eswatini, U.S. money helped extend the average life expectancy by more than 10 years.
But now a project that once embodied America's largesse has exposed the pitfalls of that approach, as some aid and government workers in Eswatini fear it has left the country ill-prepared to take care of its own.
Even after the HIV/AIDS emergency eased, U.S. aid kept flowing at high volumes. America took steps to pass responsibility to African countries but kept its hands on crucial tasks.
'We shouldn't expect the U.S. to take care of a chronic disease to infinity,' said Echo VanderWal, executive director of the Luke Commission, the charity that runs the Miracle Campus.
Eswatini, formerly known as Swaziland, is a New Jersey-size country of lush green hills wedged between Mozambique and South Africa. Relative to the country's population of 1.26 million, the U.S. investment here had been significant: roughly $800 million since 2007, according to government records. Most of that money came as part of a single program, the President's Emergency Plan for AIDS Relief (PEPFAR), launched by President George W. Bush, who said America had a duty to 'make this world better.'
Among health workers as well as Eswatini government officials, there is widespread consensus that the U.S. earned tremendous goodwill with its investment here and helped turn the tide against the epidemic. Those officials and workers also criticize the abrupt nature of the Trump administration's foreign aid cuts as reckless.
But now that the status quo has been disrupted, Eswatini must grapple with uncomfortable questions about what comes next, whether a post-U.S. health system might be more sustainable or more dangerous.
'The American government had stepped up and been holding our hand for a long time,' said Lizzie Nkosi, a former health minister. 'That is not something we can easily lose.'
In Eswatini, the Miracle Campus is at the center of that reckoning.
Founded by an American husband and wife – Echo VanderWal, a physician assistant, and Harry VanderWal, a doctor – the Miracle Campus had become a celebrated emblem of U.S. generosity. Almost every employee carried an iPad, and surgeons used messaging apps to provide real-time updates on procedures. The hospital had 3D printers to customize medical equipment and drones that could transport medicine to rural villages.
But beyond the modern equipment, there was another reason people had sought out the campus, according to interviews with patients and health-care workers: the woes of Eswatini's own public health system. The national hospitals struggled to stock medicine and supplies, and government-appointed investigators had accused officials of mismanaging the national drug supply, citing poor oversight and alleged corruption. Even as Eswatini's economy grew, the country was increasingly relying on U.S. charity for the day-to-day care of its people. By 2023, after years of growing demand, the Miracle Campus was handling 24,000 patients a month – more than a quarter of the national load, according to data compiled by the Luke Commission based on government data.
The Health Ministry did not respond to a request for comment.
The VanderWals, today in their early 50s, had never questioned their faith-based motto to treat all seeking care. But two years before President Donald Trump's decision, Harry asked his wife: Are we part of the problem?
'We were carrying such a big portion of the national load,' Echo said. She called it 'unsustainable.'
One of the pharmacists at the Miracle Campus, Thembelihle Zondo, went so far as to say his country would have been further ahead if aid had been cut off years ago. 'The government would have just pulled up their socks, taken ownership to say, 'No one is going to help us, so we need to do this on our own.''
U.S. officials had been working with Eswatini to gradually hand off more responsibility, with the goal of winding down some of the funding by 2030. Wendy Benzerga, who was the U.S. Agency for International Development country director in Eswatini from 2015 to 2020, said that 'a lot more could have been done' to begin the transition earlier.
'But aid becomes this big machine,' said Benzerga, who emphasized that she was speaking in a personal capacity, not on behalf of the U.S. government. 'And it's comfortable for everyone.'
The Washington Post did not uncover evidence that U.S. funding was misused, and the government-appointed investigators did not indicate that American aid money was involved in the alleged corruption.
The State Department, in a statement, said PEPFAR 'has been impactful, saving millions of lives and helping bring the HIV numbers under control.'
'Secretary [Marco] Rubio has stated that PEPFAR is an important and life-saving program that will continue,' the statement said. 'He has also said that PEPFAR, like all assistance programs, should be reduced over time if they are impactful in achieving their mission.'
Now that shift has arrived without any preparation. In early February, with U.S. funding withdrawn, the Miracle Campus installed an entrance gate with a sign asking most patients to go elsewhere. It shuttered the maternity ward, halted preventive care, and stopped treating diabetes and hypertension. It had to lay off almost half of its 700 workers. It couldn't even pay its utility bills. The last trickle of patients come for HIV/AIDS medication refills, or for specialty surgeries performed by doctors who agreed to work without pay until funds were available.
Echo, the facility's executive director, says she sometimes believes that the campus's near-total shutdown is in Eswatini's best interests. 'I hate to say it, but I think it had to happen,' she said. But on other days, she sobs as she walks through the empty wards, or when she gets text messages from former patients who say they have no other place to go for reliable health care.
She still asks the same question that caused her to keep the doors wide open in the first place: What happens without us?
'Finest health care in the country'
They had first traveled to Eswatini in 2004, a trial to see if people like them might be able to help. Echo, raised in Idaho, had obtained her first passport specifically to make the trip. Harry, from North Carolina, had never traveled farther than Canada. They had four young children, some savings from flipping houses, a deep Christian faith and a sense they were ready for a risk. As they saw it, this was part of what it meant to be an American – not hesitating to offer help, whether to a neighbor or someone overseas.
'As Americans, we want to run in and fix things,' Harry said.
Hours off the plane, they saw people dying of HIV/AIDS. And by 2006, weeks after Harry finished his residency, they had moved for good. They rented an apartment and started crisscrossing the nation with medical supplies stuffed in the back of trucks. One of the main objectives, in those years before widespread drug availability, was chillingly modest: delaying orphanhood.
By 2010, the VanderWals had their first contract with the U.S. Agency for International Development – for performing adult circumcisions that reduce the risk of HIV/AIDS. The contract sum was modest, $180,000, but Echo remembers feeling they had 'broken the barrier' into the world of foreign aid. Three years later, they bought farmland near a river. Initially they just used the land's old dairy barn to store their medical supplies. But the money kept coming – ultimately, $40 million from USAID, according to government data. They used those funds for doctors, equipment and, later, solar panels and other technology. They leaned on private charitable donations, mostly from the U.S. and Canada, as they kept building out the campus.
What took form, spread across 200 acres, defied the stereotypes of a health facility in a developing country. They constructed an auditorium for team meetings and church-themed musical shows. They added an in-house 'farm team' that grew maize and other ingredients for hospital meals. They added a 'wood team' that made canes and crutches, and fabricated parts for buildings.
If the Luke Commission 'hadn't been there for Eswatini, I think most people would have been dead by now,' said Colani Nkambule, a security guard who works at the campus and lost both of his parents to HIV/AIDS in the early 2000s.
'They provided the finest health care in the country,' said Barbara Staley, an American Catholic missionary who has worked on and off in Eswatini since 2004.
But as demand skyrocketed, they also made personal decisions they admit were reckless. During the coronavirus pandemic, they took out a loan against the value of their home to help cover operational costs. Amid national drug shortages, they used a line of credit to buy medicine from South Africa. In 2023, they drained their retirement savings to help pay employees. 'Whatever was in the bank account, it's gone,' Harry said.
They eventually realized they had gone too far to keep the campus running – and by 2024, they were scaling back some services and using charitable donations to pay debts. Those moves also meant they relied on U.S. aid more than ever for their day-to-day operations.
By the time of the Trump administration's decision, they had no margin for error.
According to the Luke Commission's 2023 financial statement, 33 percent of its revenue came from USAID.
The campus's fate has now become Eswatini's top political battle, dominating local front pages and serving as a proxy for broader questions about how the kingdom moves on from the era of big U.S. aid.
While almost everybody agrees that it's foolish for the campus to sit nearly empty, the debate centers on whether Eswatini should offer a sustained financial lifeline – and whether the charity running the campus should come under government control. Nkosi, a senator who served as health minister until 2023, said the Luke Commission had been offered a financial deal two years ago on the condition that the government could approve the chairman of the board.
'They flatly refused,' Nkosi said.
Echo and Harry said they never received a formal offer, and instead wanted financial support without submitting to a government takeover. A parliamentary report from last year detailed how the back-and-forth negotiations had created 'bad blood' between the Health Ministry and the Luke Commission.
In many ways, Echo and Harry are no longer outsiders: They are citizens of Eswatini and refer to the country's monarch, Mswati III, as 'our king.' They raised their children here. They dress for formal occasions in traditional Swazi wraparound fabrics.
But they say they don't feel ready to make their hospital part of a national health system that can't stock its own drugs. Doing that, Echo says, 'would be the biggest mistake we'd make in our lives.'
No clear exit strategy
When Velephi Okello heard about Trump's decision to slash foreign aid, she thought to herself, 'Fasten your seat belts.'
As director of health services at Eswatini's Health Ministry, she had been imagining this moment for years – while sitting in on meetings with U.S. officials where they talked about PEPFAR's future, and about passing off more and more work to local partners. She had helped the country take major steps in self-sufficiency – buying its own antiretroviral drugs, for instance, rather than relying on international donations.
'We thought that the PEPFAR funds would take us to 2030, slowly and gently,' she said.
Before the Trump shutdown, the U.S. had retained responsibility for crucial tasks in Eswatini's day-to-day health care – not just by funding the Miracle Campus but by paying workers who were performing testing and working in communities. Of the USAID money flowing into the country, global nongovernmental organizations like Pact and the Elizabeth Glaser Pediatric AIDS Foundation had been among the biggest historical recipients.
An assessment published in late March from UNAIDS, a United Nations program devoted to fighting the disease, said there has already been a 'significant decline' in HIV case identification in Eswatini and described a risk of supply 'stockouts' in three to six months.
Nkosi, the former health minister, said that Eswatini still has one of the highest HIV rates in the world and that removing foreign support means restoking the emergency.
'That is just logic,' she said.
Okello said Eswatini is past the stage where the U.S. decision might 'collapse the health system.' She noted that years before U.S. support arrived, the country had declared a national emergency, launched local education programs and created a national response council. And Eswatini was the first country in Africa to reach a landmark global AIDS target, known as 95-95-95, referring to the percentages of people who know their HIV status, are undergoing therapy and have successfully suppressed the virus.
But after the withdrawal of U.S. aid, many in Eswatini are angry – not at America but at their own government.
Patients across the country, as well as doctors at government hospitals, say that while Eswatini has mounted a strong response to HIV/AIDS, it has allowed deepening problems in its overall health system. Patients tell similar stories: of going to hospitals for basic drugs and being told the essentials aren't in stock.
The government says it is taking the problem seriously, and three years ago commissioned an internal investigation that examined years of health and drug-procurement records.
The final investigation, which was not made public but was obtained by The Washington Post, laid out a scheme in which officials systematically buy drugs the country doesn't need or are about to expire. The scheme enriches suppliers, the report says, who make direct payments to complicit bureaucrats, who have accepted trips abroad and used cash to purchase luxury cars.
People living in Eswatini do not connect the king to the drug shortages. But political dissidents abroad say his system of patronage, as well as his lavish lifestyle – with 16 wives and a fleet of luxury cars – fosters a culture of corruption.
'You've got one person who is accountable to nobody but himself,' said Ignatius Dlamini, a political activist based in South Africa who chairs a group called United Eswatini Diaspora.
Eswatini's Health Ministry declined to respond to a list of questions about drug shortages and alleged corruption. It also did not respond to questions about the Luke Commission.
'It's a dire situation,' said Zakhele Dlamini, director of the forensic company that led the investigation. 'People are living in hell because there are no drugs – hence the Luke Commission and other private clinics that are the go-to for trying to survive.'
Six weeks after the U.S. aid was halted, the security guard at the Miracle Campus entrance had turned away patients with broken bones, people in tears, even his own relatives. One nurse had sold off cattle to help manage bills; another had downsized apartments. The employees were accruing backpay, but Echo worried that as the uncertainty dragged on, the entire Miracle Campus could come unglued.
So she called a morning meeting – 300 people crowding into an auditorium, with Harry in the background as a grandchild tugged at his knee.
She acknowledged that she didn't have many updates, that U.S. money still wasn't coming, and spoke again and again about 'how painful' this has been. But her speech, as it went on, took on the feel of a pep talk – both for her staff and herself. She said the facility still had a future, one that wouldn't rely so heavily 'on what people decide in another country.'
The meeting ended with a prayer, and the staff spent the rest of the day refilling antiretroviral prescriptions and performing a skin graft for a 6-year-old girl bitten by a venomous snake. Echo and Harry retreated to an upstairs conference room, spending one full day, then another, huddling with advisers and strategizing about their future. Eventually, they sketched out a vision of a smaller Miracle Campus, about one-sixth of its size at its peak, that relies more on private donations. They also decided, for the first time, to start charging patients who could afford it.
Harry said he still viewed America as having a 'spirit of compassion.' But as much as Americans rush in to solve problems, he said, they've never been very good at getting out.
'There wasn't a clear exit strategy,' he said.
They'd built the most advanced medical campus in Eswatini, but now it was just idled equipment and pretty landscaping. The sun had set. The staff had gone home. After almost two decades in the aid industry, this is what had come to: Harry and Echo, late at night, trying to figure out how to start over.
