It will be years, maybe decades, before something resembling a consensus emerges on the Bush presidency. But if there is one area where Bush has already been given credit even by some of his harshest critics, including Bill Clinton and Barack Obama, it is for his leadership in combating the worldwide devastation inflicted by HIV/AIDS. As the President’s deputy domestic policy adviser when the global AIDS initiative was being developed, I believe the story of this program is eminently worth telling, not only for its intrinsic historical interest but for what it reveals about the character of George W. Bush, who doggedly pursued his vision through a minefield of conflicting interests, despite the absence of any tangible political benefit to himself or his party, and at the risk of a costly break with one of his core constituencies.
Bush’s interest in AIDS as a critical global problem was evident from the very beginning of his presidency. In March 2001 he established a cabinet-level council chaired by his top foreign-policy and health aides, Colin Powell and Tommy Thompson. On May 11, he gathered in the Rose Garden with UN Secretary General Kofi Annan and Nigerian President Olusegun Obasanjo to announce a maiden contribution of $200 million (subsequently increased to $500 million) to a new international AIDS fund now known as the Global Fund to Fight AIDS, Tuberculosis, and Malaria. This represented a 30-percent increase over Bill Clinton’s final budget in total foreign spending on the disease (on top of the $13 billion being spent annually on the domestic crisis).
Although by autumn the President would be consumed with the aftermath of the September 11 attacks and the war in Afghanistan, his interest in the AIDS issue never wavered. In early 2002, he told Josh Bolten, his deputy chief of staff for policy, that he wanted to do more.
A meeting in Bolten’s office marked the first time I recall any discussion about developing a structured plan. Present were Anthony Fauci, a senior researcher at the National Institutes of Health who was leading its work on an AIDS vaccine; Gary Edson, the President’s deputy national-security adviser, with special responsibility for the developing world; and Bolten’s deputy Kristen Silverberg. Relating the President’s desire to focus on the international AIDS crisis, Bolten turned to Fauci, who had just returned from a trip to Africa with Secretary Thompson and whom we all expected to propose an enormous infusion of funding for his vaccine project.
But we were wrong. Putting more money into research, Fauci said, would not necessarily produce a vaccine any more quickly. Instead, he pointed to one of the most acute problems within the AIDS world: transmission of the virus from mother to child. In Africa, more than two million women with HIV were giving birth each year, resulting in at least 700,000 babies infected during pregnancy, during birth, or through breastfeeding. Because most of these women were unaware of any treatment for AIDS, it was difficult to convince them to seek help. “If you know you have a death sentence,” Fauci summarized, “why bother going to a doctor?”
But the good news was that a new drug, Nevirapine, had come on the market that had already proved effective in reducing the odds that a pregnant woman infected with HIV would transmit the virus to her baby. If we could purchase enough of the drug and develop a system of delivering it to those in need, we might be able to affect significantly the spread of AIDS.
Thus began work on what would become the President’s second major AIDS effort: the Mother and Child Prevention Initiative. The initial objective was to have a policy ready to announce in late June at the G8 summit in Canada. As the President’s chief aide for international development and his “sherpa” for the forthcoming summit, Edson took the lead in working out the details of the new initiative: which countries to target, how to recruit volunteer medical and nursing personnel, and most important, how to identify the obstacles to administering such a program in foreign countries.
The global fund to which President Bush had already promised support was formally launched in January 2002. It received a great deal of attention, quickening public interest in the worldwide dimension of the crisis. Then, in mid-March 2002, Bush invited the rock star Bono, a strong advocate of debt relief for developing nations and a spokesman for AIDS victims in Africa, to a ceremony announcing a $5-billion program called the Millennium Challenge Account to help reduce global poverty through the promotion of sustainable economic growth. Bush’s speech suggested that the scourge of AIDS was still very much on his mind. “In Sierra Leone,” he noted, “nearly one-third of all babies born today will not reach the age of five” because of the disease.
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By now, our Mother and Child initiative had become sufficiently fleshed out to present to Bush. The objective was to increase the availability of preventive care, including drug treatments, and to devise delivery systems that would reach pregnant women and newborn children in two Caribbean nations and eight African ones (with four to be added later). At a detailed briefing in the Roosevelt Room in June, the President embraced the plan, as well as its price tag of $500 million, and announced it the same month.
Together with the $500 million given to the Global Aids Fund, this meant that, only eighteen months into his tenure, Bush had doubled U.S. spending on the international AIDS crisis. But it was only the beginning. Even before announcing the new initiative, Bush had told Bolten that, while “a great start, it’s not nearly enough,” and encouraged him to come back with fresh ideas.
Ironically, in light of the unprecedented generosity already shown by this administration, the President would soon be attacked by AIDS activists for not having done enough. Nor were his motives spared. Almost immediately after the announcement of the Mother and Child program, two leading advocacy groups, ACT UP and the Global AIDS Alliance, issued a statement asserting that “the plan [was] all for show.” They could not have been more off-base. In line with the President’s desire to do more, Bolten once again summoned our group to review possibilities. This time, he said that “the President wants us to think really big about AIDS” and asked Fauci what was the single most consequential thing we could do, adding: “Assume that money is no object.”
As it happened, a transformation was taking place in the medical treatment of AIDS. Beginning in 1996, it had been determined that a “cocktail” combining three or four different drugs could extend life significantly for those infected with HIV. The problem was that, at a cost of $10,000-15,000 per person per year, the treatment, known as highly active antiretroviral therapy, was too expensive to be made available to all the HIV-infected people in the developing world. But in mid-2001, an Indian company had started to offer a generic version of this combination therapy at an annual rate of as little as $295 per person.
There was now a window of opportunity in which to accomplish something truly revolutionary, and Fauci suggested a large expansion of the Mother and Child program. The challenge was essentially the same, but the scale was much larger and the problems commensurately daunting. As we discussed the issue, Edson mapped out on a piece of paper a system—he called it a “network” model—that might work to deliver the drugs to the furthest parts of Africa. We would use primary, secondary, and tertiary medical facilities where they existed and, where transportation systems were unavailable, employ teenagers to deliver the daily regimens by bicycle.
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At the time, the White House was looking for a new director of its AIDS office, and responsibility for the search fell to me. One of the résumés belonged to Joseph O’Neill, an official at the Department of Health and Human Services (HHS). During the Clinton administration O’Neill had managed the $1.9-billion Ryan White CARE Act, and he was now serving as acting director of HHS’s office of HIV/AIDS policy. He was also a practicing HIV/AIDS physician, a volunteer member of the faculty of the Johns Hopkins School of Medicine in Baltimore, openly gay, and, we assumed, a Democrat. But from the moment we began to discuss the President’s purpose with him, it was evident that on these issues he was a kindred spirit.
Before the July 19 announcement of O’Neill’s appointment, I brought him into the Oval Office for a ten-minute meeting with the President. The get-acquainted session turned into a 45-minute discussion in which Bush questioned O’Neill about his medical practice, discussed antiretroviral treatments, and asked for an honest critique of the government’s various AIDS programs. “We have to start treating this like a public-health issue,” the President said—“like a disease.” To a physician, this was precisely the right attitude, and as we left O’Neill said in a whisper that any doubts he might have had about working with the Bush White House were gone.
As the summer progressed, the working group, now joined by O’Neill and Mark Dybul (one of Fauci’s key staffers, he would later become Bush’s global AIDS coordinator), began sketching the outlines of the gigantic program that would become the President’s Emergency Plan for AIDS Relief (PEPFAR). Since whatever we came up with was going to cost a great deal of money, we henceforth included in our meetings another key participant, Robin Cleveland of the Office of Management and Budget (OMB).
Over the next few months, we held countless rump discussions, most often in my office in the West Wing, in the situation room next to Edson’s office, or in unused conference rooms in the Old Executive Office Building across the street. We consulted with non-governmental organizations active in the battle against AIDS, collected data from research institutions around the world, met with doctors, researchers, and AIDS activists, and began to examine the enormous logistical and bureaucratic challenges facing the program we were envisioning. Knowing that a major Bush initiative on AIDS would meet with media skepticism, we kept our meetings secret and told interested outsiders that we were simply studying the issue.
It was during this time that Bono began to show up frequently at the White House, always bringing us some new information or someone involved in AIDS relief work. We also met with and benefited from the expertise of AIDS organizations that were among the President’s toughest critics—groups like the Elizabeth Glaser Pediatric AIDS Foundation and the Global Health Council. Especially valuable was the opportunity, arranged by the global-health expert Nils Daulaire, to get together with Paul Farmer of Harvard and Jean William Pape of Cornell, both of whom had worked extensively on AIDS in Haiti, and Peter Mugyenyi, the director of the Joint Clinical Research Center in Uganda. The network of clinics established to treat AIDS patients in that country, in tandem with a three-pronged counseling approach stressing what the Ugandans called the ABC’s of abstinence, monogamy, and condoms, had helped to reduce dramatically the prevalence of the virus—from 21 percent of the Ugandan population in 1991 to approximately 5 percent in 2002.
Bush had no objection to the network model that had originated in Edson’s notebook and been refined by our discussions with Mugyenyi, but insisted in each meeting that we establish proper “metrics” for determining whether federal funds were being well utilized and effective. He was also concerned about the task of coordinating activities in far-flung foreign lands. Many members of Congress, as well as advocacy groups, had been pushing for the U.S. to focus its AIDS spending on the Global Fund. About this the President was adamant. Although we should continue contributing to the Fund, developing and administering our own programs seemed to him by far the more effective approach. Any significant new increase in funding should therefore be administered by agencies of our own government and not through multinational organizations. Time and again, Bush insisted that the program be placed under the supervision of a single federal official, accountable to the White House and American taxpayers. Edson and I debated where this “accountable individual” should be placed—we considered both HHS and AID (the Agency for International Development), but eventually, for reasons of prestige and international clout, decided on the State Department.
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In early November, before seeking Bush’s final approval, we held a meeting with Bolten to which we invited Fauci, Daulaire, Farmer, Pape, and Eric Goosby, another leading AIDS clinician who had served in the Clinton administration and done much work in Rwanda. The meeting ran for a couple of hours, with our invited experts responding to dozens of questions from us about implementation and infrastructure. By the time we finished we were convinced that we had been as thorough as we could be. As Edson would later tell the President, speaking as one MBA to another, “We’ve created a model; it’s scalable; and we’ve done our due diligence. But it’s still like making a venture-capital investment. We cannot be sure it will work.”
On the day of the White House Hanukkah party in December 2002, we gave Bush a final overview of the plan and asked for his approval. As I went over the details and outlined the projected cost of the program—$15 billion over five years, with about $2.5 billion to be disbursed in the first year alone—Mitch Daniels, the director of OMB and the person charged with making sure we had sufficient funds for the imminent war in Iraq, questioned whether we really needed the full amount and specifically whether we needed to commit $2.5 billion the first year. Condoleezza Rice, who was present as Bush’s national-security adviser, had a different question. Observing that the AIDS pandemic was spreading well beyond Africa, she asked whether the President might not want to extend the plan’s purview to Russia, China, and India. To this Bush replied that the latter three countries had plenty of resources of their own, and that the focus should remain on sub-Saharan Africa and the Caribbean.
By coincidence, immediately before our briefing the President had met with a dozen Jewish leaders who were at the White House for the party that evening. One of them told briefly how his own father had been part of a delegation that President Roosevelt had refused to see in the early 1940’s when it came to plead the cause of the Jews trapped in Nazi Europe. “If,” he said to Bush, “you had been President at the time, with the moral clarity you have displayed in the war against terrorism, there would be millions more Jews alive today.” Visibly moved by this encounter, Bush, I believe, was still registering its effect 30 minutes later as he leaned back in his chair, looked at all of us, and said forcefully: “We are too wealthy a nation, and too compassionate a nation, not to take this step. It’s a chance to save millions of lives. We have to do this.”
The announcement came the next month in the President’s 2003 State of the Union address. Midway through his remarks, he turned to the issue of AIDS, pointing out that nearly 30 million people in Africa were infected, including three million children under the age of fifteen. Yet across the entire continent, observed Bush, only 50,000 AIDS victims were receiving medication. Calling his initiative a “work of mercy beyond all current international efforts to help the people of Africa,” he declared his intention to commit to it a full $15 billion over the next five years. This time, the reaction from AIDS activists was a resounding chorus of approval.
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No sooner had the dust settled on the State of the Union speech than the initiative faced its first controversy. Although the heart of the plan lay in the disbursement of funds for prevention, treatment, and care, the President had made clear that he wanted to follow the Ugandan model of counseling. This raised the touchy issue of condom distribution (the C in the ABC). It also raised the issue of whether organizations performing or even promoting abortions as a method of family planning would be eligible for federal funds in violation of the President’s own Mexico City rules—named for the highly controversial position initially taken by the U.S. at a UN conference in that city in 1984.
I was immediately besieged by angry calls from conservative Congressmen vowing to oppose any legislation authorizing the program unless and until we clarified that the Mexico City rules would apply in full. I went to see the President. He listened as I outlined the various options, and then explicitly stated that he viewed the initiative “as a health-care issue, and we should not deny anyone who commits to the objectives of our program the right to participate.” For a man who, only weeks into his presidency, had reinstated the Mexico City rules, originally promulgated under Ronald Reagan but subsequently reversed under Clinton, this was not only a very strong sign of personal resolve but an important decision from a practical perspective. In many of the more remote areas of Africa, there was only one health-care provider, and if that provider was an organization like Doctors Without Borders, which performed abortions, the refusal of AIDS funds might cripple the program and deprive the most needy of care.
But getting from here to there with Congress was altogether turning out to be a challenge. Even as we in the White House set about drafting legislation, the members of Congress with whom we were meeting almost daily were working on their own version of a bill. In the Senate, meanwhile, we had to deal with internal partisan politics. The previous year, William Frist, the majority leader, and John Kerry had proposed AIDS legislation of their own, calling for $4.7 billion in spending on prevention over the next two years and a large new contribution to the Global Fund. Both men felt upstaged by the President’s announcement, which had come as a surprise to them. Kerry, moreover, had already started his own campaign to challenge Bush for the presidency in the following year—another reason for him not to cede a major legislative victory to his rival.
Frustrated, the President suggested to Frist that he use his influence as majority leader to move the White House bill directly to the Senate floor. But Frist was reluctant to buck Senate procedure, and Richard Lugar, chairman of the foreign-relations committee, was especially uncomfortable pushing a bill through his committee that did not enjoy the support of Kerry and Joseph Biden, two of his Democratic members.
Recognizing the challenge in the Senate, we were simultaneously working on a preemptive strategy in the House, coordinating closely with the staffs of the Republican Henry Hyde and the Democrat Tom Lantos. After a couple of weeks of negotiating and re-drafting, we had a bill that we thought could pass. It was not the bill the President ultimately wanted to sign into law, but it was the only one with a chance of getting to the floor of the House, where it could always be improved with amendments.
On April 2, 2003, the bill was voted out of committee, only to be subjected to an assault by conservative advocacy groups upset that the administration had compromised on the Mexico City rules and that the legislation failed to place sufficient emphasis on abstinence education or to allow recipients of federal funds to opt out of condom distribution. (I particularly remember one Wednesday-morning meeting at which, attempting to mobilize support for the program, I was ambushed by a group of conservative organizations that felt betrayed by the President.) Bush, however, persevered, speaking individually with members of Congress and, in a White House speech, declaring that “this cause is rooted in the simplest of moral duties. When we see this kind of preventable suffering, when we see a plague leaving graves and orphans across a continent, we must act.”
Things now moved quickly. On May 2, the House took up the bill. As we had hoped, it was amended in three ways to accommodate the President’s objectives: first, by ensuring that federal monies would not be turned over to the Global AIDS Fund but remain under the control of a coordinator appointed by the President; second, by requiring that at least 33 percent of prevention funding be used on abstinence-until-marriage programs of the kind whose efficacy had been demonstrated in Uganda; and third, by ensuring that organizations with a moral objection to condoms not be disqualified from the program.
With these amendments in place, the full House voted to approve the bill. Two weeks later, not without a fight, it passed the Senate on a night when Frist, by now a strong proponent, kept the Senate in session until 2:00 a.m. to ensure passage. On May 27, the President signed it into law.
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Back in the fall of 2002, Bush had kept reminding us that he wanted a means of measuring the program’s rate of progress. In formally unveiling the initiative, he had articulated three goals in particular: over the next five years, he said, we would “support treatment for two million HIV-infected people; support prevention of seven million new HIV infections; and support care for ten million people infected and affected by HIV/AIDS, including orphans and vulnerable children.”
The five years have passed and enough evidence has been gathered for an initial evaluation. The results so far are extremely positive. By the end of 2008, the President’s Emergency Plan for AIDS Relief had provided antiretroviral treatment to two million individuals, a dramatic increase from the 50,000 who were receiving treatment in 2002. As of March 2008, the last date for which we have comprehensive government figures, the program had provided transmission-prevention services for women during approximately 13 million pregnancies and given antiretroviral prophylaxis in more than one million pregnancies. Health officials estimate that this has resulted in the prevention of approximately 200,000 infant infections.
Finally, it has supported care for approximately 6.6 million individuals, including 2.7 million orphans and vulnerable children, and offered more than 33 million counseling-and-testing sessions for men, women, and children. Prevention-outreach programs have helped 60 million people. Over 20 million have received condoms.
This is not to say that the program is without problems. As with all government initiatives, there are inefficiencies and duplications of effort, resulting mainly from a lack of coordination among government agencies and non-governmental partners. Adding to the challenge is the weak infrastructure in target countries, as well as the insufficiency of qualified health-care workers. There also continues to be carping about some of the policies embedded in the law—which does not, for example, support needle or syringe exchanges and which prohibits the distribution of funds to any group not explicitly opposing prostitution and sex-trafficking.
Finally, many AIDS activists persist in criticizing the United States for what they believe is its circumvention of the Global Fund, despite the fact that the U.S. contribution to the Fund has increased to $2 billion. The ironical fact is that the President’s commitment to the AIDS issue not only launched the most significant effort the U.S. has ever made to combat the disease but also may have sparked the growth of the Global Fund itself. If, before the AIDS initiative, contributions to the Fund stood at under $1 billion with the U.S. paying half, today the Global Fund has received international pledges of nearly $20 billion with $12 billion paid.
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When George Bush paid a courtesy call on outgoing President Bill Clinton in January 2001, Clinton turned to him with his trademark grin and remarked: “Compassionate conservatism. That’s brilliant. Why didn’t I think of it first?” Now, at the five-year mark, it is safe to say that President Bush’s dream of building the largest humanitarian effort in history to address the global AIDS pandemic is a remarkable success—a success that in itself has turned the phrase “compassionate conservatism” into an incontrovertible reality.
As for Bush’s motives in inspiring, developing, and perpetuating this landmark achievement, they too will no doubt continue to be a subject for debate. But the plain fact is that he himself spelled them out with perfect clarity as long ago as his Inaugural Address of January 2001. Invoking the parable of the Good Samaritan, he said: “And I can pledge our nation to a goal. When we see that wounded traveler on the road to Jericho, we will not pass to the other side.”
