The decision to fund medications to treat H.I.V.-AIDS patients in sub-Saharan Africa and the Caribbean flew in the face of expert advice. But the U.S. did it anyway.President George W. Bush with Bono, the lead singer of U2, in 2006. Bono was among the activists who lobbied Mr. Bush for antiretroviral medications people in sub-Saharan Africa and the Caribbean.Jim Watson/Agence France-Presse — Getty ImagesHere is something I don’t write about very often: a situation in which unpredictable, seemingly irrational politics saved millions of the poorest and most vulnerable people on earth.In a recent blog post, Justin Sandefur, a senior fellow at the Center for Global Development, a think tank based in Washington, D.C., examined the record of the President’s Emergency Plan for AIDS Relief, or PEPFAR. The program, started by President George W. Bush, paid for antiretroviral medications for millions of H.I.V. positive people in sub-Saharan Africa and the Caribbean, and is now seen as one of the most important foreign-aid efforts in American history, notable both for its generosity and its effectiveness.Setting it up at all flew in the face of many experts’ advice at the time.“The conventional wisdom within health economics was that sending AIDS drugs to Africa was a waste of money,” Sandefur wrote. It wasn’t that the drugs didn’t work: Antiretroviral therapy had achieved revolutionary results in controlling H.I.V.-AIDS, and had the potential to save the lives of infected people and prevent new infections. But the medications were extremely expensive, so experts believed that it would be more efficient to spend aid dollars on prevention instead. Money spent on condom distribution, awareness campaigns, or antibiotics to treat bacterial infections that made H.I.V. transmission more likely, data suggested, would save more lives per dollar than treatment would.In a now-infamous 2005 Forbes Op-Ed titled “Treating H.I.V. doesn’t pay,” Emily Oster, the Brown University economist who is now best known for her guides to parental decision-making, wrote that “as cold and callous as this may sound, after comparing the number of years saved by antiretrovirals with years saved by other interventions like education, I found that treatment is not an effective way to combat the epidemic.”She, like many other economic experts, assumed that policymakers were working with two constraints: a global health disaster on a massive scale, and a limited budget for addressing it. And because it was much more expensive to treat existing H.I.V.-AIDS patients than to prevent new infections, the grim conclusion was that to save the most lives possible, the best thing to do would be to focus on prevention — even though that would effectively mean letting infected people die.As it turned out, that argument was based on an erroneous assumption. In fact, the Bush administration was willing to find money for treatment that would never have otherwise been spent on prevention.The Bush administration had been the target of sustained political lobbying from interest groups and activists like Bono, the U2 frontman, and Franklin Graham, the son of the Rev. Billy Graham. Their reasoning was primarily moral, not economic, and they emphasized the plight of people who needed treatment. If antiretroviral medications existed, they argued, it was wrong for the wealthiest country in the world to leave poor people to die.So it turned out that the question was not just whether a dollar was most efficiently spent on treatment or prevention, but whether treatment or prevention would be the most politically compelling case for getting more dollars allocated. And on that latter question, treatment won hands down.Bush created PEPFAR, a new, multibillion dollar program to fund AIDS treatment in poor countries. And it ultimately not only saved lives, but also did so more cheaply than the initial cost-benefit analysis suggested. Over the course of the program, the cost of H.I.V. treatment fell rapidly — a change that may have been due partly to PEPFAR creating new demand for the medications, particularly cheaper generic drugs that came a few years later.Sometimes most efficient isn’t most effectiveWhen I asked Sandefur about the broader lessons, he said that sometimes an effective, easy-to-implement solution can be the best choice, even if it flies in the face of a cost-benefit analysis.“Close to home for me, working a lot on education, are school meals, which are, I think, fairly well demonstrated to be effective,” he said. “They help kids learn. They help get more kids in school. And they help with nutrition outcomes, clearly.” But programs like India’s midday meal scheme, which feeds more than 100 million school children each day, often come up short on cost-benefit analyses, because other programs are seen as a more efficient way to improve educational outcomes.Salience over scienceThe PEPFAR case also carries another lesson: Sometimes politics matter more than economics.The constituency for AIDS treatment included evangelical groups with a lot of political influence within the Republican Party. Having Franklin Graham make calls alongside Bono probably made it easier to get the Bush administration’s attention, but it also lowered the political costs of spending U.S. government money on a huge new foreign-aid program.In political science terms, saving the lives of H.I.V.-AIDS patients had better “salience”: activists connected with the cause emotionally, making it a priority for them.My anecdotal experience definitely bears that out: I was a student in that era, and I remember many passionate debates among my classmates about how best to get treatment for people in poor countries. I’m sure that, if asked, all of them would have supported prevention measures too, but that wasn’t where their energy was focused. The bulk of people’s excitement and urgency were focused on the issue of getting medications to people who would otherwise die. That felt like an emergency.So perhaps the bigger lesson here is just that policy is, at the end of the day, not divorced from politics. And that means that political costs and benefits will often beat out economic ones — even when that might seem irrational.Thank you for being a subscriberRead past editions of the newsletter here.If you’re enjoying what you’re reading, please consider recommending it to others. They can sign up here. Browse all of our subscriber-only newsletters here.I’d love your feedback on this newsletter. Please email thoughts and suggestions to interpreter@nytimes.com. You can also follow me on Twitter.

Even before the wave of abortion bans, medical treatment and advice for pregnancy has largely focused on fetal safety over the mother’s.As the United States has grappled with the unfolding consequences of the Supreme Court’s decision overruling Roe v. Wade, one question lurks between the lines of court opinions and news stories alike: Why are the risks of pregnancy so rarely discussed anywhere, even though that information is relevant not just to individual decisions but to policies about abortion, pregnancy, and health care for women?With the wave of abortion bans taking place in states across America, those risks are going to be more in the spotlight — figuring both in women’s decisions about whether to risk getting pregnant if they live in a state that has banned abortions, and the arguments that will happen in state legislature chambers over how much threat to a mother’s health must be present to permit an abortion under untested and rapidly changing state laws.“We spend an awful lot of time talking about avoiding behaviors because of very small risks that could happen that are associated with the fetus. ‘Don’t eat bean sprouts,’ or ‘don’t eat deli meats,’” Emily Oster, a Brown University economist and author “Expecting Better,” a data-driven book about pregnancy, told me. “And then we sort of never talk to people about the risks of things that are almost definitely going to happen.”For instance, in a vaginal birth, “Your vagina’s going to tear. It’s going to tear a lot,” she said. “That’s not even risk, it’s just realistic.” Those who give birth via cesarean section, a major abdominal surgery, end up with a large wound requiring a significant recovery period.And more serious complications, while rare, are not that rare. In any given moms’ group, someone has probably survived hyperemesis gravidarum (which can occur in up to one in 30 pregnancies), an ectopic pregnancy (up to one in 50 pregnancies), or a pregnancy-induced hypertensive disorder (up to one in 10 pregnancies). All of those conditions can be lethal.From Opinion: The End of Roe v. WadeCommentary by Times Opinion writers and columnists on the Supreme Court’s decision to end ​​the constitutional right to abortion.Michelle Goldberg: “The end of Roe v. Wade was foreseen, but in wide swaths of the country, it has still created wrenching and potentially tragic uncertainties.”Spencer Bokat-Lindell: “What exactly does it mean for the Supreme Court to experience a crisis of legitimacy, and is it really in one?”Bonnie Kristian, journalist: “For many backers of former President Donald Trump, Friday’s Supreme Court decision was a long-awaited vindication.” It might also mark the end of his political career.Erika Bachiochi, legal scholar: “It is precisely the unborn child’s state of existential dependence upon its mother, not its autonomy, that makes it especially entitled to care, nurture and legal protection.”In most situations, the standard for risk is informed consent: awareness of the potential for harm, and a chance to accept or refuse it. If riding in a car or taking a plane meant a near-guaranteed abdominal or genital wound and a 10 percent chance of a life-threatening accident, people would expect a warning and an opportunity to consider whether the journey was worth it.But pregnancy is different.Doctors in Jakarta, Indonesia, performing a cesarean section delivery.Adek Berry/Agence France-Presse — Getty ImagesJonathan Lord, a practicing gynecologist and the English medical director of MSI Reproductive Choices, an organization that provides family planning and abortion services in countries around the world, said that he suspects people often don’t talk about the dangers of pregnancy for women’s health because they see such conversations as a cause of unnecessary distress. “It’s sort of ingrained in society, really. It’s not so much a medical thing, but people do not talk about the risks and the unpleasant aspects, and I think that’s largely because people want to be kind,” he said.Oster had a similar hypothesis about serious pregnancy complications. “In general, we’re not interested in confronting the risk of really bad things,” she said. “We would very much like to pretend that they’re zero.”And yet if you look at the messaging around risks to the fetus during pregnancy, rather than the mother, the plot thickens.Women are “bombarded” with messaging about the risks they themselves could pose to their fetuses, said Rebecca Blaylock, the research lead of the British Pregnancy Advisory Service, a charity that provides abortion and other reproductive health services. The research team at her organization, along with colleagues from Sheffield University, studied British media messaging around pregnancy. They found that media coverage overwhelmingly framed women as a vector of harm, not a population in need of protection. Fetuses were the sole focus of health outcomes.Such assumptions even affected prenatal care. “We were seeing women suffering with hyperemesis gravidarum” — an extreme and potentially deadly form of morning sickness that involves near-constant vomiting — “who weren’t receiving appropriate treatment because their health care providers thought the medication posed a risk to their pregnancy, and who really felt they had no option but to terminate an otherwise wanted pregnancy at that point,” Blalock said.The differing attitudes toward risk “really fit within a larger cultural climate where women are blamed for any and all ills that may or may not befall their children, and a preoccupation with reproducing the next generation of healthy citizens” Blaylock told me.That study focused on the United Kingdom. But Kate Manne, a professor of philosophy at Cornell University and author of two books on the ways sexism shapes society, said that there is a widespread assumption in the United States and elsewhere that having children is something that women are naturally or even morally destined to do. Accordingly, guiding them toward that — even if that means denying them an opportunity to give informed consent to the risks — is seen by some as in their best interests. (She noted that transgender men and nonbinary people can also get pregnant, but said that the norms and societal assumptions about pregnancy tend to presume pregnant people are women.)“We don’t tend to think of pregnancy as something that someone might very rationally decide not to do because it’s too much of a risk,” she said. “That kind of thought process is obviated by the sense that it’s natural and moral, and perhaps also holy, for women to do this.”But such reluctance to acknowledge risks can make the dangers of pregnancy invisible to policymakers as well. One consequence is abortion bans that are written so bluntly that they fail to provide clear paths for doctors to protect women’s lives and health. In Poland, where most abortions are not allowed, vague exceptions that would allow them to go ahead have left doctors confused about potential liability, leading to the death of a pregnant woman last year. And now similar confusion is unfolding in U.S. states whose abortion bans took effect after last week’s Supreme Court decision overturning Roe v. Wade.Doctors in several U.S. states, for instance, have raised concerns about whether women will be able to get timely care for ectopic pregnancies, a condition in which a fertilized egg implants outside the uterus or in the wrong part of it. Such pregnancies are never viable: It is not possible for a fetus to grow to term unless it implants correctly. But those that implant in scar tissue in the uterus, Dr. Lord said, can continue to develop for several months before eventually rupturing, at which point they are life threatening to the mother, he said.“You really need to get in there early before it’s grown to that extent,” he said. “It’s an inevitability that the fetus will die, but it will probably kill the mother with it.”“I do fear that in those states that have got strict laws, that will happen.”