Decision Points

by George W. Bush

  Another problem was that the traditional model of foreign aid was paternalistic: A wealthy donor nation wrote a check and told the recipient how to spend it. I decided to take a new approach in Africa and elsewhere in the developing world. We would base our relationships on partnership, not paternalism. We would trust developing countries to design their own strategies for using American taxpayer dollars. In return, they would measure their performance and be held accountable. The result would be that countries felt invested in their own success, while American taxpayers could see the impact of their generosity.

  As Condi made clear in our first discussion, one problem in Africa stood out above all others: the humanitarian crisis of HIV/AIDS. The statistics were horrifying. Some ten million people in sub-Sarahan Africa had died. In some countries, one out of every four adults carried HIV. The total number infected was expected to exceed one hundred million by 2010. The United Nations projected that AIDS could be the worst epidemic since the bubonic plague of the Middle Ages.

  When I took office, the United States was spending a little over $500 million a year to fight global AIDS. That was more than any other country. Yet it was paltry compared with the scope of the pandemic. The money was spread haphazardly across six different agencies. Much of their work was duplicative, a sign there was no clear strategy.

  American taxpayers deserved—and conscience demanded—a plan that was more effective than this disjointed effort. I decided to make confronting the scourge of AIDS in Africa a key element of my foreign policy.

  In March 2001, I met with United Nations Secretary-General Kofi Annan, a soft-spoken diplomat from Ghana. Kofi and I didn’t agree on every issue, but we found common ground in our determination to deal with the AIDS pandemic. He suggested creating a new Global Fund to Fight HIV/AIDS, Tuberculosis, and Malaria that would marshal resources from around the world.

  I listened but made no commitment. I considered the UN to be cumbersome, bureaucratic, and inefficient. I was concerned that a fund composed of contributions from different countries with different interests would not spend taxpayer money in a focused or effective way.

  Nevertheless, Secretary of State Colin Powell and Health and Human Services Secretary Tommy Thompson recommended that I support the Global Fund with an initial pledge of $200 million. They felt it would send a good signal for America to be the first contributor. Their persistence overcame my skepticism. I announced our commitment on May 11, 2001, with Kofi and President Olusegun Obasanjo of Nigeria in the Rose Garden. “I thank you, on behalf of all AIDS sufferers in the world, but particularly on behalf of all AIDS sufferers in Africa,” President Obasanjo said.

  “This morning, we have made a good beginning,” I said in my speech. I didn’t add that I had plans to do more.

  Four months to the day after we announced our pledge to the Global Fund, the terrorists struck America. Before 9/11, I had considered alleviating disease and poverty a humanitarian mission. After the attacks, it became clear to me that this was more than a mission of conscience. Our national security was tied directly to human suffering. Societies mired in poverty and disease foster hopelessness. And hopelessness leaves people ripe for recruitment by terrorists and extremists. By confronting suffering in places like Africa, America would strengthen its security and collective soul.

  By early 2002, I had concluded that the Global Fund was not a sufficient response to the AIDS crisis. While America had increased our contribution to $500 million, the Fund was short on money and slow to act. Meanwhile, the AIDS epidemic was sending more Africans to their graves. The majority were between ages fifteen and forty-nine, the key demographic for productive nations. Left unchecked, the disease was projected to kill sixty-eight million people by 2020, more than had died in World War II.

  I couldn’t stand the idea of innocent people dying while the international community delayed. I decided it was time for America to launch a global AIDS initiative of our own. We would control the funds. We would move fast. And we would insist on results.

  Josh Bolten assembled a team* to develop recommendations. In June, they came to me with a proposal to focus on one particularly devastating part of the AIDS crisis: its impact on women and children. At the time, 17.6 million women and 2.7 million children were living with HIV/AIDS. Every forty-five seconds, another baby in Africa was born with the virus.

  Recently, scientists had discovered new medicines, particularly a drug called Nevirapine, that could reduce the rate of mother-to-child transmission by 50 percent. But it was not widely available in Africa or other parts of the developing world. The team proposed spending $500 million over five years to purchase medicine and train local health-care workers in the most heavily affected African and Caribbean countries.

  “Let’s get it started right now,” I said. The plan was tailored to a specific part of the crisis in the neediest parts of the world. It put local officials in the lead. And it had an ambitious but realistic goal: to treat one million mothers and save one hundred fifty thousand babies every year after five years.

  On June 19, 2002, I announced the International Mother and Child HIV Prevention Initiative in the Rose Garden. In seventeen months, we had doubled America’s commitment to fighting global AIDS.

  The morning I unveiled the mother and child program, I called Josh Bolten into the Oval Office. “This is a good start, but it’s not enough,” I told him. “Go back to the drawing board and think even bigger.”

  A few months later, he and the team recommended a large-scale program focused on AIDS treatment, prevention, and care—the strategy that would ultimately become PEPFAR.

  The first part of the proposal, treatment, was the most revolutionary. Across Africa, it was estimated that four million AIDS patients required antiretroviral drugs to stay alive. Fewer than fifty thousand were receiving them. Thanks to advances in drug technology, AIDS treatment regimens that used to require thirty pills a day could be taken as a twice-a-day cocktail drug. Soon, only one pill was required. The new medicine was more potent and less toxic to patients. And the price had declined from $12,000 a year to under $300. For $25 a month, America could extend an AIDS patient’s life for years.

  “We need to take advantage of the breakthrough,” I told the team, “but how will we get the drugs to the people?”

  Tony Fauci described a program in Uganda led by Dr. Peter Mugyenyi, an innovative doctor who operated an advanced clinic and was one of the first people to bring antiretroviral drugs to Africa. At one Oval Office meeting, Tony showed me photos of Ugandan health workers from TASO climbing aboard motorcycles to bring antiretroviral drugs door-to-door to homebound patients. While only partially complete, the Mugyenyi and TASO programs showed what could be possible with more support.

  In addition to treatment, Uganda employed an aggressive prevention campaign known as ABC: Abstinence, Be faithful, or else use a Condom. The approach was successful. According to estimates, Uganda’s infection rate had dropped from 15 percent in 1991 to 5 percent in 2001.

  PEPFAR would include one additional element: caring for victims of AIDS, especially orphans. It broke my heart that fourteen million children had lost parents to AIDS. It also worried me. A generation of rootless, desperate young people would be vulnerable to recruitment by extremists.

  I pressed for specifics on the plan. “What are our goals?” I asked. “What can we accomplish?”

  We set three objectives: treat two million AIDS patients, prevent seven million new infections, and care for ten million HIV-affected people. We would partner with the government and people of countries committed to battling the disease. Local leaders would develop the strategies to meet specific goals, and we would support them.

  The next question was which countries to include. I decided to focus on the poorest and sickest nations, twelve in sub-Saharan Africa and two in the Caribbean.** These fourteen countries accounted for 50 percent of the world’s HIV infections. If we could stop the spread of the disease at its epicenter, we could create
a model for other countries and the Global Fund to follow.

  The final decision was how much money we should spend. Josh’s group had recommended a stunning $15 billion over five years. My budget team expressed concern. In late 2002, the U.S. economy was struggling. The American people might not understand why we were spending so much money overseas when our own citizens were suffering.

  I was willing to take on that objection. I was confident I could explain how saving lives in Africa served our strategic and moral interests. Healthier societies would be less likely to breed terror or genocide. They would be more prosperous and better able to afford our goods and services. People uncertain of America’s motives would see our generosity and compassion. And I believed the American people would be more supportive if we could show that their tax dollars were saving lives.

  Critics would later claim that I started PEPFAR to appease the religious right or divert attention from Iraq. Those charges are preposterous. I proposed the AIDS initiative to save lives. Mike Gerson, my chief speechwriter and trusted adviser, put it best in a November 2002 meeting. “If we can do this and we don’t,” he said, “it will be a source of shame.”

  I made the decision to move forward with PEPFAR in December 2002. Only a few people knew about the plan. I instructed the team to keep it that way. If word leaked out, there would be a turf war among government agencies for control of the money. Members of Congress would be tempted to dilute the program’s focus by redirecting funds for their own purposes. I didn’t want PEPFAR to end up hamstrung by bureaucracy and competing interests.

  “Seldom has history offered a greater opportunity to do so much for so many,” I said in my State of the Union address on January 28, 2003. “… Tonight I propose the Emergency Plan for AIDS Relief—a work of mercy beyond all current international efforts to help the people of Africa.”

  Members of both parties rose to support the plan. Standing next to Laura in the First Lady’s box was a man whose program and country had served as an inspiration for PEPFAR, Dr. Peter Mugyenyi of Uganda.

  I had intended the announcement to make a big impact, and it did. President Clinton’s top AIDS official called it “inspiring and clearly heartfelt.” The Chicago Tribune summarized the reaction of many newspapers when it editorialized, “ ‘Astonishing’ is not too strong a word for President Bush’s announcement.”

  As expected, there were some objections. The biggest came in response to the ABC prevention strategy. Critics on the left denounced the abstinence component as an ideological “war on condoms” that would prove unrealistic and ineffective. I pointed out that abstinence worked every time. Some on the right objected to distributing condoms, which they felt would encourage promiscuity. At least members of Congress were smart enough not to criticize the B, being faithful within marriage.

  Ironically, both sides charged that we were imposing our values—religious fundamentalism if you asked one camp, sexual permissiveness if you asked the other. Neither argument made much sense to me, since the ABC strategy had been developed in Africa, implemented in Africa, and successful in Africa.

  In the spring of 2003, the House of Representatives took up PEPFAR legislation. The bill was sponsored by Republican Congressman Henry Hyde of Illinois and Democratic Congressman Tom Lantos of California, two principled supporters of human rights. In a fine example of bipartisan cooperation, they helped steer the bill through the House with a vote of 375 to 41.

  The bill then moved to the Senate, where it received strong backing from Majority Leader Bill Frist, a doctor who took annual medical missionary trips to Africa, and Senator Dick Lugar of Indiana, the thoughtful chairman of the Foreign Relations Committee. Bill and Dick rallied support among a wide range of lawmakers, from conservatives like Jesse Helms of North Carolina to liberals like Joe Biden of Delaware and John Kerry of Massachusetts. I told Bill I hoped to sign a bill before I left for the 2003 G-8 summit in Evian, France, so that I would have more leverage to persuade our allies to join us. Bill worked tirelessly to meet the deadline. Three days before I left the country, I signed PEPFAR into law.

  Two months later, Laura and I touched down in sub-Saharan Africa. Our first stop was Senegal. After a morning meeting at the presidential palace, President Abdoulaye Wade and his wife, Viviane, escorted us to one of the most haunting places I visited as president, Gorée Island.

  Standing at the threshold of the Door of No Return on Gorée Island. White House/Eric Draper

  Our tour began in a pink stucco structure, the Slave House. The museum curator showed Laura and me through the small, hot rooms. One had contained scales to weigh the slaves. Another was divided into cells to separate men, women, and children. We walked through a narrow passageway to the Door of No Return, the starting point for the horrific Middle Passage. I could only imagine the fear of those hopeless souls who were stolen from their families and shoved onto ships bound for an unfamiliar land. I put my arm around Laura as we peered out at the blue ocean.

  Standing behind us were Colin Powell and Condi Rice. I thought about the contrast between what their ancestors had endured and what Colin and Condi had accomplished. After the tour, I gave a speech from the island:

  At this place, liberty and life were stolen and sold. Human beings were delivered and sorted, and weighed, and branded with the marks of commercial enterprises, and loaded as cargo on a voyage without return. One of the largest migrations of history was also one of the greatest crimes of history. …

  For two hundred fifty years the captives endured an assault on their culture and their dignity. The spirit of Africans in America did not break. Yet the spirit of their captors was corrupted. … A republic founded on equality for all became a prison for millions. And yet in the words of the African proverb, “No fist is big enough to hide the sky.” All the generations of oppression under the laws of man could not crush the hope of freedom and defeat the purposes of God. …

  In the struggle of the centuries, America learned that freedom is not the possession of one race. We know with equal certainty that freedom is not the possession of one nation. This belief in the natural rights of man, this conviction that justice should reach wherever the sun passes, leads America into the world. With the power and resources given to us, the United States seeks to bring peace where there is conflict, hope where there is suffering, and liberty where there is tyranny.

  PEPFAR was a new chapter in Africa’s unfolding story of freedom, dignity, and hope. In every country I visited, I promised that America would meet our commitments. In South Africa, where nearly five million lived with HIV, I urged a reluctant President Thabo Mbeki to confront the disease openly and directly. In Botswana, a relatively wealthy country where 38 percent of the adult population was infected, President Festus Mogae pledged to use PEPFAR funds to continue the impressive effort he had begun to fight the disease. At the national hospital in Abuja, Nigeria, I visited with women who had benefited from the mother and child initiative. They beamed with joy as they showed me their healthy children. But for every infant born infection-free, many more began life facing the burden of HIV.

  The most memorable part of the trip was our visit to the TASO clinic in Uganda, where I met Mohamad Kalyesubula. Escorted by President Yoweri Museveni and his wife Janet, Laura and I went around the room and hugged the patients. Many opened up to us. They shared their hopes and fears. One nurse named Agnes told me her husband had died of AIDS in 1992. When she got tested, she found out that she, too, had HIV. She was one of the lucky few who had been able to get antiretroviral drugs. She urged me to send more medicine, as soon as possible. When the drugs supported by PEPFAR reached Uganda, Agnes helped nurse many of TASO’s patients back to health. One was Mohamad. When he came to the White House in 2008, Agnes came too.

  The director of TASO, a doctor named Alex Coutinho, later said I was the first world leader he had seen hug an African with AIDS. I was surprised. I remembered that Mother had made international news when she hugged an HIV-infected baby in 1989.
Her act dispelled the myth that the disease could be transmitted by incidental human contact. I was proud to carry on her legacy by reducing the stigma associated with AIDS. I hoped in some small way to restore the dignity of suffering people. Above all, I wanted to show that the American people cared.

  At the TASO AIDS clinic in Uganda. White House/Susan Sterner

  One highlight of our Africa trip was that our daughter Barbara joined us. In Botswana, she, Laura, and I went on safari in the Mokolodi Nature Reserve. We were hoping to relax, get some fresh air, and see some wild animals. To feed the appetite of the traveling press, the White House staff decided we should have a photo op.

  As always, the preparations were meticulous. A press truck full of cameras and reporters was prestationed in a clearing. As our vehicle rounded the corner, the press was lined up for a perfect shot of us observing several elephants. Apparently, the elephants were not given the script. Shortly after we arrived, a randy male elephant mounted one of his female counterparts on live international TV. Our advance team turned pale under the hot African sun. Laura, Barbara, and I burst out laughing.

  The trip was Barbara’s first to Africa, and it touched her deeply. After graduating from college and volunteering on my 2004 campaign, she went to work for a pediatric AIDS clinic at the Red Cross War Memorial Hospital in Cape Town, South Africa. Inspired by her experience, she later founded a nonprofit, Global Health Corps. Based on a model similar to Teach for America, her organization sends recent college graduates to clinics in three African countries and two American inner cities. They support care for patients with AIDS and other diseases, strengthening the health infrastructure and helping people live with dignity and hope.