WASHINGTON – Dr. Jean W. Pape did not know what to expect when, in early January 2003, he slipped away from his work treating AIDS patients in Haiti and flew to Washington for a secret meeting with President Bush.
Bush was considering devoting billions to combat global AIDS, a public health initiative unparalleled in size and scope. The deliberations had been tightly carried out; even the health secretary was not in the loop. If Bush was going to shock the world – and skeptical Republicans – with a huge infusion of American cash to send expensive drugs overseas, he wanted the money to be well spent.
“He said, 'I will hold you accountable, because this is a big move; this is an important thing that I've been thinking about for a long time,' ” recalled Pape, one of several international AIDS experts Bush consulted. “We indicated to him that our arms are totally broken as physicians, knowing that there are things we could do if we had the drugs.”
Nearly five years later, the President's Emergency Plan for AIDS Relief – PEPFAR, for short – may be the most lasting bipartisan accomplishment of the Bush presidency.
Bush's Global Aids Initiative
By the numbers
1.4 million: Patients who have received lifesaving medicine paid for with U.S. dollars
50,000: Patients covered before the initiative
$19 billion: Funding approved by Congress
$30 billion: Future funding sought by White House
$50 billion: Future funding sought by Democrats
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With a year left in office, Bush confronts a nation bitterly split over the war in Iraq, an uncertain economy and a hostile Congress. His big achievements, the tax cuts and education reform, are not fully embraced by Democrats, and his second-term legislative agenda – revamping Social Security and immigration policy – lies in ruins.
The global AIDS program is a rare exception. So far, about 1.4 million AIDS patients have received lifesaving medicine paid for with U.S. dollars, up from 50,000 before the initiative.
Even Bush's most ardent foes, among them Sen. John Kerry, D-Mass., his 2004 challenger, find it difficult to argue with the numbers. “It's a good thing that he wanted to spend the money, and put his administration behind spending the money, absolutely,” said Kerry, an early proponent of legislation similar to the plan Bush adopted. “I think it represents a tremendous accomplishment for the country.”
The plan, announced in the 2003 State of the Union address, called for $15 billion for AIDS prevention, treatment and care, concentrating on 15 hard-hit nations in Africa and the Caribbean. An enthusiastic Congress has already approved $19 billion.
Bush is pressing lawmakers for a new, five-year commitment of $30 billion. He will travel to Africa in February to make his case – and, the White House hopes, burnish the “compassionate conservative” side of his legacy.
Despite the effort, 33 million people are still living with HIV, and the United Nations estimates that there were 1.7 million new infections in 2007 in sub-Saharan Africa alone. Critics, including Kerry, are particularly incensed by the requirement that one-third of the prevention funds be spent teaching abstinence, despite a lack of scientific consensus that such programs reduce the spread of the AIDS virus.
When a Ugandan AIDS activist, Beatrice Were, denounced the abstinence-only approach at an international AIDS conference last year, she received a standing ovation. Paul Zeitz, executive director of the Global AIDS Alliance, an advocacy group in Washington, says the Bush program has been hamstrung by “ideologically driven policies.”
That assessment was echoed, in more diplomatic terms, by the independent Institute of Medicine, which evaluated the program in March. It called on Congress to abandon the abstinence requirement and lift the ban on paying for clean needles for drug addicts, among other changes.
Yet the institute concluded that overall, the program had made “a promising start.” And when they step back, even critics such as Zeitz concede that Bush spawned a philosophical revolution. In one dramatic step, he put to rest the notion that because patients were poor or uneducated, they did not deserve, or could not be taught to use, medicine that could mean the difference between life and death.
In Haiti, about 13,000 patients are receiving anti-retroviral drugs. That is only half the estimated 26,000 who need them, but far more than the 100 being treated five years ago. “A huge success story, beyond my imagination,” Pape said.
In Uganda, a country already far along on its own AIDS initiative when Bush began his, 110,000 people are under treatment and 2 million have HIV tests each year, up from 10,000 treated and 400,000 tested before, said Dr. Alex Coutinho, a top AIDS expert there. The money comes mostly from PEPFAR, but also from a U.N. fund to which the United States contributes.
Coutinho said Ugandans were terrified that when Bush left office, “the Bush fund,” as they call it, would go with him.
“When I've traveled in the U.S., I'm amazed at how little people know about what PEPFAR stands for,” he said. “I think America should not be shy about what it has achieved. Just because it has been done under Bush, it is not something the country should not be proud of.”
The story of how a conservative Republican president became a crusader for global AIDS is an unlikely one. Bush ran for the White House in 2000 with what Joshua Bolten, his chief of staff, calls “a Republican's skepticism about the efficacy of foreign aid.” He talked of letting “Africa solve Africa's problems.”
His top priorities were tax cuts and education. But a variety of forces conspired to put the international AIDS epidemic on the new president's agenda.
Colin Powell, then the new secretary of state, was deeply troubled by demographics showing that in some African nations, AIDS threatened to wipe out the entire childbearing population – a condition that could create instability and a climate ripe for terrorism. Just weeks into his new job, he called Tommy Thompson, the new administration's health and human services secretary.
“I said, 'Tommy, this is not just a health matter; this is a national security matter,' ” Powell said. They vowed to work together, and the president “bought into it immediately,” Powell said.
A program with ambitious goals evolved: to treat 2 million people, prevent 7 million new infections and provide care for 10 million, including orphans and vulnerable children, over five years, beginning in 2004 when the money became available.
The prevention targets will not be measured until 2010. But Dr. Mark Dybul, Bush's global AIDS coordinator, says the program is on track to meet its goals. In addition to drugs for 1.4 million, the government says it has provided care for nearly 6.7 million people affected by the disease, including 2.7 million orphans and vulnerable children. Drugs provided to pregnant women have spared an estimated 152,000 infants from infection, the government says.
There is a debate over how efficiently the money has been spent, but the fight is not over whether to reauthorize the program, but how. Much of the money has been channeled through religious-based U.S. organizations, drawing criticism from people such as Coutinho of Uganda, who say local control would bring down costs.
Based on the current infection rate, advocates say $50 billion is needed, not $30 billion as Bush has proposed. Sen. Joe Biden, D-Del., chairman of the Senate Foreign Relations Committee, is also calling for $50 billion, as is Coutinho.
“Unless PEPFAR is reauthorized at a much higher level, we are going to be in the business of playing God,” Coutinho said.
