Decision Points

by George W. Bush

  Jenna also discovered a passion for working with AIDS patients. She volunteered for UNICEF in several Latin American countries. When she got home, she wrote a wonderful book, a bestseller called Ana’s Story, about a girl who was born with HIV.

  Laura and I are very proud of our daughters. They have become professional women serving a cause greater than themselves. They are part of a larger movement of Americans who devote their time and money to helping the less fortunate. These good souls are part of what I call the armies of compassion. Many come from faith-based organizations and seek no compensation. They receive payment in another form.

  One of the most important early decisions on PEPFAR was who should run it. I wanted a proven manager who knew how to structure an organization that would focus on results. I found the right man in an experienced Indiana businessman, former Eli Lilly CEO Randall Tobias.

  Randy’s first reports were discouraging. A year after I signed PEPFAR, fewer than one hundred thousand patients were receiving antiretroviral drugs. “That’s it?” I snapped. “We’re a long way from two million.”

  Randy assured me PEPFAR was on track. The most important tasks during the first year were to get partner countries to devise their strategies, mobilize manpower, and start establishing infrastructure. Once we had this foundation in place, the number of people receiving drugs would ramp up dramatically.

  By the fall of 2005, our African partners were fully engaged. Faith-based and other groups supported by PEPFAR, both African and American, helped staff clinics and spread prevention messages to millions across the continent. Orphans and the dying were receiving compassionate care. Some four hundred thousand people were taking antiretroviral drugs. We were on pace to reach our goal.

  Unfortunately, AIDS wasn’t the only disease ravaging Africa. By 2005, malaria was killing approximately one million Africans a year, the majority of them children under the age of five. Transmitted by a mosquito bite, malaria accounted for 9 percent of all deaths in Africa, even more than AIDS. Economists estimated that the disease cost Africa $12 billion a year in medical expenses and lost productivity, a crippling blow to already fragile economies.

  Every one of those deaths was unnecessary. Malaria is treatable and preventable. The United States had eradicated malaria in the 1950s, and there was a well-established strategy for battling the disease. It called for a combination of insecticide sprays, bed nets, and medicine for infected patients. The remedies were not particularly expensive. Bed nets cost $10 each, including delivery.

  In June 2005, I announced a five-year, $1.2 billion program that would fund malaria-eradication efforts in fifteen countries. Like PEPFAR, the President’s Malaria Initiative would empower Africans to design strategies to meet their needs. We would work toward a measurable goal: cutting malaria mortality rates by 50 percent over the next five years.

  I named Rear Admiral Tim Ziemer, a retired Navy pilot with experience in international relief efforts, to lead the Malaria Initiative. In its first two years, the initiative reached eleven million Africans. It also generated a passionate response from the American people. Boys and Girls Clubs, scout troops, and school classes donated money in ten-dollar increments to buy bed nets for African children. Faith-based organizations and major corporations, especially those doing business in Africa, gave generously to the cause.

  With support from the Malaria Initiative, infection rates in the targeted countries began to decline. The most dramatic turnaround was in Zanzibar. Health officials adopted an aggressive campaign of spraying, bed net distribution, and medicine for malaria victims and pregnant women. On one Zanzibar island, the number of malaria cases dropped more than 90 percent in a single year.

  On April 25, 2007, Laura and I hosted America’s first-ever Malaria Awareness Day in the Rose Garden. It was an opportunity to herald progress and show our citizens the results of their generosity.

  At the end of my remarks, the KanKouran West African Dance Company performed a lively song. Caught up in the celebratory mood, I joined the dancers onstage. My moves were replayed on the national news and became a minor sensation on YouTube. The girls took great delight in teasing me: “I don’t think you should audition for Dancing with the Stars, Dad.”

  “I told you my goal was to raise awareness,” I replied.

  In 2006, Mark Dybul succeeded Randy Tobias as the coordinator of PEPFAR. As a medical doctor and respected figure in the AIDS community, Mark brought great credibility to PEPFAR. After one of his trips to Africa, he told me many on the continent were anxious about what would happen after PEPFAR’s five-year authorization expired in 2008. Governments were counting on our continued support, and so were the people. Mark told me he had asked a health clinic official in Ethiopia if anyone knew what the acronym PEPFAR stood for. “Yes,” the man said. “PEPFAR means the American people care about us.”

  Mark believed we had a responsibility to continue the program—and an opportunity to build on our progress. By doubling PEPFAR’s initial funding level, we could treat 2.5 million people, prevent 12 million infections, and support care for 12 million people over the next five years.

  Doubling funding would be a big commitment. But the AIDS initiative was working, and I decided to keep the momentum going. On May 30, 2007, I stepped into the Rose Garden and called for Congress to reauthorize the initiative with a new commitment of $30 billion over the next five years.

  To highlight the progress, I invited a South African woman named Kunene Tantoh. Laura had met her two years earlier and shared her inspiring story with me. Kunene was HIV-positive, but thanks to medicine she received through the mother and child initiative, she had given birth to an HIV-free boy. After the speech I held four-year-old Baron in my arms and smiled at the thought that his precious life had been saved by the American taxpayers. He demonstrated his energy and good health by wiggling around and waving to the cameras. Then he gave me the international look for “Enough is enough. Put me down.”

  Holding Baron Tantoh. White House/Eric Draper

  The next step was to get other nations to join us. In the summer of 2007, Laura and I flew to Germany for the G-8 summit, hosted by Chancellor Angela Merkel. One key mission was to persuade my fellow G-8 leaders to match America’s pledges on HIV/AIDS and malaria.

  Angela told me the summit’s primary topic would be global warming. I was willing to be constructive on the issue. In my 2006 State of the Union address, I had said that America was “addicted to oil”—a line that didn’t go over so well with some friends back in Texas. I had worked with Congress to promote alternatives to oil, including biofuels, hybrid and hydrogen vehicles, natural gas, clean coal, and nuclear power. I also proposed an international process that, unlike the flawed Kyoto Protocol, brought together all major emitters—including China and India—and relied on clean energy technologies to cut greenhouse gas emissions without stifling the economic growth necessary to solve the problem.

  I worried that the intense focus on climate change would cause nations to overlook the desperate immediate needs in the developing world. “If world leaders are going to sit around talking about something that might be a problem fifty years from now,” I told Angela, “we’d better do something about the people dying from AIDS and malaria right now.”

  With Angela’s help, the other G-8 leaders agreed to match the AIDS-relief goals America had set. Together, we would provide treatment for five million people, prevent twenty-four million more infections, and support care for twenty-four million additional people over the next five years. They also agreed to match the goals of our Malaria Initiative. Those historic commitments can make an enormous difference in the lives of people in Africa and around the world. It will be up to future administrations to ensure that nations follow through on their pledges.

  The principles of accountability and partnership that guided PEPFAR were also behind the centerpiece of our new approach to economic development, the Millennium Challenge Account. To be eligible for MCA funds, countries had to m
eet three clearly defined criteria: govern free of corruption, pursue market-based economic policies, and invest in the health and education of their people. The change in approach was dramatic. Economic aid would be treated like an investment instead of a handout. Success would be measured by results produced, not money spent.

  MCA drew support from some unexpected sources. One was Bono, the Irish lead singer of U2. Josh and Condi had gotten to know Bono and told me the star wanted to visit me in the Oval Office. I was skeptical of celebrities who seemed to adopt the cause of the moment as a way to advance their careers. But they assured me Bono was the real deal.

  His visit was scheduled for the morning I announced MCA, March 14, 2002. Josh gave me a quick briefing on the issues likely to come up. Ever meticulous, he had one last question before showing our guest into the Oval Office. “Mr. President, you do know who Bono is, right?”

  “Of course,” I said. “He’s a rock star.” Josh nodded and turned toward the door. “Used to be married to Cher, didn’t he?” I said. Josh wheeled around in disbelief. I kept a straight face for as long as I could.

  Bono bounded into the Oval Office with his high-voltage personality and signature shades. He quickly dispelled the notion that he was a self-promoter. He knew our budgets, understood the facts, and had well-informed views about the challenges in Africa. He brought me a thoughtful gift, an old Irish Bible.

  With Bono in the Oval Office. White House/Paul Morse

  “Do you know that 2,003 verses of Scripture pertain directly to the world’s poor?” he asked. “People are quick to point out the obvious sins like marital infidelity,” he continued. “But sometimes we ignore the most serious ones. The only place the Bible speaks directly of judgment is in Matthew 25: ‘Whatever you did for one of the least of these brothers of mine, you did for me.’ ”

  “You’re right,” I said. “The sin of omission is just as serious as the others.” I was pleased when he expressed his strong support for MCA, which he believed would revolutionize the way the world pursued development. I listened carefully as he urged me to do more on HIV/AIDS. “With a few pills you can save millions of lives. It would be the best possible advertisement for the United States. You ought to paint the things red, white, and blue.”

  After our meeting, Bono joined me and Cardinal Theodore McCarrick, a gentle, spirit-filled man, for the limo ride to the speech at the Inter-American Development Bank. Bono participated in the event and praised our policy. I later learned that one of his major funders, ultra-liberal investor George Soros, had excoriated Bono for joining me at the MCA event without getting more in return. “You’ve sold out for a plate of lentils,” Soros told Bono.

  My respect for Bono grew over time. He was warm to Laura and the girls. He frequently sent notes of thanks. He is a man of genuine faith. Bono could be edgy, but never in a cynical or political way. When PEPFAR got off to a slow start, he came to see me in the Oval Office. “You’re the measurable results guy,” he said, “so where are the results?” I would have told him, but he wouldn’t let me get a word in edgewise. Once the program was up and running, he came back. “I’m sorry I doubted you,” he said. “By the way, do you know the U.S. government is now the world’s largest purchaser of condoms?”

  I laughed. Bono had a big heart and a sharp needle. His only motive was his passion for the cause we shared. Laura, Barbara, Jenna, and I consider him a friend.

  Not everybody agreed with Bono. Three months after I announced the MCA, I went to the G-8 summit in Kananaskis, Canada. Prime Minister Jean Chrétien raised the topic of foreign aid. I was one of the first to speak. I talked about the results-oriented principles of MCA, a stark departure from the G-8’s tradition of measuring generosity by the percentage of GDP a nation spent on foreign aid.

  When I finished, Jacques Chirac leaned over and patted my arm. “George, you are so unilateralist,” he said. Then he unleashed. “How can America insist on tying aid to anti-corruption? After all, the free world created corruption!” He made it clear he thought I didn’t understand the African culture.

  It was my first Chirac drive-by. I was not amused. He seemed to be willing to condemn people in the developing world to the status quo of corruption, poverty, and bad governance all because he felt guilty about what nations like France had done in the colonial era.

  When the lecture concluded, I raised my hand. Chrétien shook his head. He wanted to give other leaders a chance to speak. But I couldn’t let Chirac’s statement stand. I butted back in: “America did not colonize African nations. America did not create corruption. And America is tired of seeing good money stolen while people continue to suffer. Yes, we are changing our policy, whether you like it or not.”

  Chirac had vented. So had I. Most of the other leaders looked shocked. My friend Prime Minister Koizumi of Japan flashed a slight smile and gave me a subtle nod of approval.

  Over the next six years, the MCA invested $6.7 billion of seed money with thirty-five partner countries. Lesotho used its MCA compact to upgrade its water supply. Burkina Faso created a reliable system of property rights. Projects like these were catalysts for countries to develop markets that foster private-sector growth, attract foreign capital, and facilitate trade, which was another cornerstone of my development agenda. Free and fair trade benefits the United States by creating new buyers for our products, along with more choices and better prices for our consumers. Trade is also the surest way to help people in the developing world grow their economies and lift themselves out of poverty. According to one study, the benefits of trade are forty times more effective in reducing poverty than foreign aid.

  When I took office, America had free trade agreements in place with three countries: Canada, Mexico, and Israel. By the time I left, we had agreements with seventeen, including developing countries such as Jordan, Morocco, Oman, and the young democracies of Central America. To further boost African economies, we worked with G-8 partners to cancel more than $34 billion in debt from poor African countries. The initiative built on the substantial debt relief President Clinton had secured. A report by Bono’s DATA organization concluded that debt relief has allowed African nations to send forty-two million more children to school.

  One vital economic initiative was the African Growth and Opportunity Act, which eliminated tariffs on most African exports to the United States. President Clinton signed AGOA; I worked with Congress to expand it. And I saw its impact firsthand when I met entrepreneurs in Ghana who exported their products to the United States. One woman had started a business called Global Mamas. She specialized in helping women artisans find new markets to sell goods such as soaps, baskets, and jewelry. In five years, her company had grown from seven employees to about three hundred. A dressmaker named Esther told me, “I’m helping other women, and I’m helping my family, too.”

  In February 2008, Laura and I returned to sub-Saharan Africa. The trip was my second and her fifth. We viewed the visit as a chance to showcase some of Africa’s best leaders, who were serving their people with integrity and tackling problems like poverty, corruption, and disease. Their good example stood in stark contrast to the African leader dominating the headlines, Robert Mugabe of Zimbabwe. Mugabe had stifled democracy, subjected his people to hyperinflation, and turned the country from a net food exporter to a net importer. His disgraceful record was proof that one man could ruin a country. I wanted to show the world that good leadership could help a country reach its potential.

  Laura and I made five stops on the trip.*** At each, we saw inspiring examples of our new partnerships with Africa. I met schoolchildren in Benin and Liberia who had textbooks, thanks to our Africa Education Initiative. In Rwanda, I signed a bilateral investment treaty that would increase access to financing for Rwandan entrepreneurs. In Ghana, I announced a new initiative to fight neglected tropical diseases like hookworm and snail fever.

  Our longest visit was to Tanzania, a nation of forty-two million people on Africa’s east coast. Under the leadership of Presi
dent Jakaya Kikwete, Tanzania participated in PEPFAR, the Malaria Initiative, and MCA. As Air Force One descended toward Dar es Salaam, I was told I might see a group of Tanzanian women wearing dresses with my photo printed on the cloth. As I walked down the steps of the plane, a cluster of women danced to the festive beat of drums and horns. As one rotated to the music, I saw my photo stretched across her backside.

  An interesting fashion statement in Dar es Salaam, Tanzania. For some reason these didn’t catch on back home. White House/Chris Greenberg

  Like many sub-Saharan African countries, Tanzania’s economy was weakened by the AIDS crisis. President Kikwete was passionate about the fight against disease. He and his wife, Salma, had taken an AIDS test on national television to set a good example for the Tanzanian people. Even more impressive, the Kikwetes adopted an orphan whose parents had died of AIDS.

  President Kikwete took us to an HIV/AIDS clinic at the Amana District Hospital, which had opened in 2004 with support from PEPFAR. As the director of the hospital showed us around, Laura and I saw a girl sitting on a bench in the courtyard with her grandmother. She was nine years old and HIV-positive. She had received the virus from her mother, who had died. AIDS had taken her father, too. Yet the little girl was smiling. Her grandmother explained that Catholic Relief Services had been paying for the girl to receive treatment at the PEPFAR clinic. “As a Muslim,” the elderly woman said, “I never imagined that a Catholic group would help me like that. I am so grateful to the American people.”

  At a news conference, I reiterated my call for Congress to reauthorize and expand PEPFAR. President Kikwete jumped in: “If this program is discontinued or disrupted, there would be so many people who will lose hope; certainly there will be death. My passionate appeal is for PEPFAR to continue.” An American reporter asked him if Tanzanians were excited about the prospect of Barack Obama becoming president. Kikwete’s reply warmed my heart. “For us,” he said, “the most important thing is, let him be as good a friend of Africa as President Bush has been.”