MASERU, Lesotho — If you worry that foreign aid is an utter waste, just chat with some mortality experts here in southern Africa — the coffin-makers.

They’re miserable.

These coffin-makers in the street markets are idle partly because U.S. spending on programs to fight AIDS around the world means that vast numbers of people are no longer dying at a young age. So coffin-makers sit dejectedly beside stacks of lumber, waiting for business.

“Before, a lot of people were dying of AIDS,” said Moeketsi Monamela, a 33-year-old coffin-maker here in Maseru, the capital of the mountainous kingdom of Lesotho. A half-dozen years ago, he sometimes crafted 20 coffins a month, he said. Now, he typically sells five or six.

“Now there is medication, so fewer people are dying of AIDS,” Monamela explained. “I’m not very happy because this is my future.”

Realizing that this did not sound quite right, he started again: “Although the medication has affected my business, I’m happy because I don’t want to see people dying of AIDS.”

In this election year in the United States, there’ll be bitter debates about what should be cut from budgets, and one thing Democrats and Republicans seem to agree on is that foreign aid is bloated. Polls indicate that six out of 10 Americans favor cutting foreign aid.

A World Public Opinion poll in 2010 found that Americans believed that foreign aid consumed one-quarter of federal spending. They said it should be slashed to only 10 percent.

In fact, all foreign aid accounts for about 1 percent of federal spending — and that includes military assistance and a huge, politically driven check made out to Israel, a wealthy country that is the largest recipient of U.S. aid. True humanitarian aid constitutes roughly half of 1 percent of the federal budget — and sometimes gets remarkable results, as is happening with AIDS.

My trips to southern Africa used to be heartbreaking. Funerals were constant, schools were emptied of teachers, and hospitals lost their doctors to the virus. In the countryside, children starved because adults were too sick to farm. In Swaziland in 2006, I came across a 12-year-old orphan girl who had become head of her household after AIDS had wiped out the adults.

Yet now the picture is starkly different. On my annual win-a-trip journey with a university student — this year it’s Jordan Schermerhorn of Rice University — we’ve been seeing how assistance changed the course of the AIDS epidemic in Lesotho and Malawi. Global AIDS deaths are decreasing steadily from the peak in 2004. New infections are down. About half a million mothers with HIV, which causes AIDS, used to infect their babies in childbirth each year, but now a simple treatment regimen aims to eliminate that by 2015.

The progress is the result in large part of PEPFAR, or the President’s Emergency Plan for AIDS Relief, and the Global Fund to Fight AIDS, Tuberculosis and Malaria (which the United States supports). To his great credit, President George W. Bush started PEPFAR in 2003; it’s the best thing he did.

With the help of PEPFAR and the Global Fund, antiretrovirals, which are powerful AIDS drugs, are now available free in needy countries. AIDS will still kill millions of people, and there are already shortages of medications, but the tide is turning.

“As a bottom line, millions would not be alive without PEPFAR, while, at the same time, millions more in their families have been saved from poverty because mothers and fathers are productive again,” notes Dr. Peter Piot, the former executive director of the U.N. program against AIDS and the author of a sparkling new memoir, “No Time to Lose.”

”If we have reached a turning point in the global AIDS response, it is also largely due to PEPFAR,” Piot added. “There are probably very few examples in international aid that can demonstrate such dramatic, direct impact.”

In Bobete, in rural Lesotho, we visited a clinic run by Partners in Health, the aid group founded by Dr. Paul Farmer of Harvard. The clinic tests virtually all pregnant women in the area for HIV, and those with the virus are given treatment so that they will not pass it along to their babies.

Those who need them get free antiretrovirals and treatment for tuberculosis (which often accompanies AIDS). With treatment, patients are able to continue to work and support their families.

It’s true that AIDS treatment has worked better than PEPFAR’s prevention strategies, such as promoting condoms and discouraging multiple partners. Prevention by supporting male circumcision in hard-hit countries seems more promising (circumcision greatly reduces the rates of HIV transmission through heterosexual sex). Lesotho is hoping to circumcise 80 percent of sexually active males within five years, up from less than 20 percent now.

In the Malawi village of Makaluka, a woman named Gladys Daniel told us that everyone knows how AIDS is spread, but that about half the villagers still sleep around, usually without condoms. “Our husbands can have multiple partners and put us in danger,” she said.

It turns out that her concern was not theoretical. “I know my husband has a partner,” she said, adding that her husband steals money from her to pay his girlfriend for sex. With risky behavior like this, some 2.7 million new infections still occur annually around the world. So although the progress is immense, there’s still a long war to be fought against AIDS — and if funds are slashed, the world will slip backward.

AIDS programs are just one of many foreign aid successes. Here in Lesotho, the United States used the carrot of Millennium Challenge grants to nudge the government to end a ban on letting women purchase property or borrow money from banks by themselves. Child mortality rates are plummeting because of money spent on clean water, vaccines and hospitals.

Granted, aid is often misspent, just as it is by the military and everybody else. Yes, the war on AIDS took many wrong turns (as documented in the recent book “Tinderbox”).

But when you hear candidates in this campaign season in the United States declare that money for foreign aid should be slashed, remember that modest sums have saved lives on an unprecedented scale. When there’s a depression in the coffin-making industry, that’s a tribute to foreign aid that Americans can take pride in - and should support.


Nicholas Kristof grew up on a sheep and cherry farm in Yamhill, Oregon. He is a columnist for The New York Times. He and his wife, Sheryl WuDunn, share a 1990 Pulitizer Prize for their coverage of the 1989 Tiananmen Square democracy movement in China.

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