African health systems have long been undermined by debt and political neglect.
Millions of Africans have already lost access to life-saving antiretroviral medicines in the weeks since the Trump administration unlawfully paused — and then cut — funding for thousands of HIV treatment and prevention projects.
These initiatives were previously supported by the United States Agency for International Development (USAid) and the President’s Emergency Plan for Aids Relief (Pepfar).
Through programmes such as Pepfar, more than 20 million people worldwide have received life-saving antiretroviral therapy (ART), preventing the progression of HIV to acquired immune deficiency syndrome (Aids) and saving 26 million lives.
Without urgent action, HIV, once brought under control, could spiral out of control once again, reversing decades of progress. Clinics may face worse drug shortages, and access to lifesaving antiretroviral medicine could become increasingly difficult. Viral loads could rise, and opportunistic infections like tuberculosis, cryptococcal meningitis, and Kaposi’s sarcoma could make a devastating return.
It’s striking that exactly a year ago, public health experts argued in The Lancet that the term Aids should be retired in favor of ‘advanced HIV. They explained that Aids is redundant and no longer describes the modern HIV epidemic.
The proposal sparked debate, but concerns about HIV funding instability, as Greg Millett, director of amfAR’s public policy office warned, have only intensified. In a moment of prophetic insight, Millett told Medscape that the change would be at odds with the fact that “global, as well as domestic HIV funding is in by far the most precarious position that I’ve ever seen in the field”.
As shattering as it is to watch this rewind to the HIV epidemic of the early 2000s, a second reckoning is on the way.
Why are African health systems still struggling?
The US withdrawal will expose the deeper reality: African governments have long neglected their people’s health.
The Abuja Declaration, signed in 2001, committed African nations to spending 15% of their national budgets on health. Now, more than two decades later, health spending has increased overall but fewer than 10 countries have ever met the 15% target and only for brief periods.
During the Covid pandemic, I delivered a keynote address in Abuja in which I reminded heads of state and global health leaders about the promises made by many of them and their predecessors in that very city.
At that meeting our “leaders” resolved to keep the cost of lifesaving medicines affordable and that the technologies for the treatment, care and prevention of diseases would be within our reach and even incentivised.
They pledged to advocate globally and act locally. They promised to honor the declaration and ensure that sickness, pain and death are not defining features of our lives as Africans.
None of that realised.
We must demand more from those who call themselves our leaders. We must demand that every flight, summit, signing, and launch be underpinned by actual delivery, actions that allow us as Africans to realise and live our birthright to prosperity, health, safety, and dignity — a birthright that is not defined by basic survival but a reality where our leaders work for more, negotiate for more, and insist on more.
And while we as Africans cannot put all of the blame at the door of the White House, we also cannot dismiss the enduring role of post-colonial debt, which keeps the chains Frantz Fanon spoke of firmly around our ankles.
As he reminded us, “Colonialism did not end with independence. It has only taken new forms, still controlling our economies, politics, and destiny.”
A 2024 report by Christian Aid shows that 25 African countries spend more on debt than on education, and 32 nations spend more on debt than on healthcare, with many African nations inheriting debt when they gained “independence”, snaring countries into a never-ending cycle of debt.
Christian Aid noted that African governments could improve transparency in debt decision-making but emphasised that “the blame for unsustainable debt lies largely with a global economic system built on inequality and injustice”.
The report concludes that this debt must be dramatically restructured, which is in line with what the African Union’s 2023 Nairobi Declaration already demanded.
Finance ministers across the continent have also called for “anti-vulture fund legislation” to be drafted in creditor nations (usually wealthier countries or entities who lend out money) and to regard debt relief as no longer just a demand but an urgent necessity.
As the former president of Burkina Faso, Thomas Sankara, warned decades ago: “Debt cannot be repaid … If we repay, we are going to die.”
Who will save us if we don’t save ourselves?
At the turn of the 21st century, the world rallied in response to the Aids crisis, recognising that millions of lives were at stake. It’s unclear whether that will happen now.
Donor nations are increasingly prioritising domestic concerns.
The United Kingdom, the Netherlands, Germany, Switzerland, Italy, Sweden and France have all announced cuts to foreign aid. As a result, civil society — and by extension, vulnerable populations — will continue to suffer the life-threatening consequences of decisions made by a few.
The Trump administration has targeted agencies like the National Institutes of Health and the Centers for Disease Control and Prevention, both leading funders of global health research.
Since 1999, US government investments in research have led to 67 new technologies for neglected and emerging diseases, including 12 for TB, 12 for Ebola, and 11 for malaria. These agencies might also be limited in the type of research they can support, given the administration’s ideological priorities, which are, for instance, hostile to diversity and driven by a spectacularly narrow, short-sighted and unscientific worldview.
Will African leaders step up before the tide rushes back in, drowning their people in another avoidable crisis? Or will they simply lament the loss of Western aid and reminisce of the days of running to “master,” begging bowl in hand, while continuing to neglect their fragile national public health systems as rampant looting and corruption remain the order of the day back home?
The answer will determine whether Africa rises to this challenge with courage or allows history to repeat itself at an unfathomable human cost.
The time for accountability has to be now.
Tian Johnson is the founder and strategist of the African Alliance, a Pan-African health justice advocacy group.