Theory of Change: #18: The lessons and warnings of PEPFAR

The recent history of U.S. foreign aid has been dominated by budget cuts, institutional dismantling, and massive workforce reductions.

Against this backdrop, the U.S. President’s Emergency Plan for AIDS Relief, or PEPFAR, feels less like a template for modern foreign policy and more like a relic of an unrecognizable past. In an era defined by political fragmentation and widespread skepticism of government-led aid projects, the idea that Washington could launch a massive, $15 billion global initiative to tackle an active health crisis overseas seems almost quaint.

Yet on the latest episode of Devex’s Theory of Change podcast, author and veteran global health reporter John Donnelly argues that this distance is precisely why we need to look back at PEPFAR today.

In his new book “Lifeline: The Story of PEPFAR, the Greatest Humanitarian Initiative of Our Time,” Donnelly traces how a high-risk political gamble under President George W. Bush morphed into what many consider the single greatest humanitarian achievement of modern times — saving an estimated 26 million lives over two decades.

In this episode, Donnelly breaks down the mechanics of that success — and what PEPFAR’s two-decade arc teaches us about government capability, bipartisan political coalitions, and the risks of prolonged emergency intervention.