A Heart to Serve

by Bill Frist

  Why did it take so long for America to wake up to the global crisis created by this virus? Not until the death of the famous movie star Rock Hudson in 1985 and a local school district’s decision to bar from class Ryan White, a thirteen-year-old hemophiliac with AIDS, did most people in the United States pay much attention to the disease. Eventually, substantial funding was made available to deal with the problem in the United States, but unfortunately no similar response was made for Africa, where the invisible killer had been making death rounds for years, undetected and undeterred. It was not until the mid-to-late 1980s and early 1990s that the world at last began to recognize that parts of Africa were at far greater risk than was America.

  President Ronald Reagan first spoke publicly about AIDS, not in a formal statement, but in response to a question at a press conference in 1985. The first help for battling AIDS in Africa came a year later—$1 million, obviously just a drop in the bucket compared to what was needed. The following year Congress authorized a special appropriation for global AIDS, and by the end of Reagan’s second term, the United States was spending $40 million annually.

  Many Americans could not understand why our government was getting involved in the battle against AIDS, a disease that was so obviously behavior related. After all, the groups known to be most vulnerable to the disease were homosexual men and injection drug users. Most Americans did not initially perceive the disease as a threat to themselves or to society, nor did they see fighting the disease as a legitimate spending priority for our government.

  Furthermore, U.S. government officials were predicting that a vaccine for AIDS would be available within a few years. That did not happen. Today, more than twenty-five years later, almost no one in government, science, or medicine believes we are within ten years of a vaccine. There are currently no promising clinical trials in the making; all that have been tried have failed.

  In 1988, tennis champion Arthur Ashe rocked the world when it became known that he’d contracted HIV through a blood transfusion he was given during one of two heart operations. Ashe had not engaged in risky behavior but had contracted the disease by merely going to the hospital for health care. Ashe died of complications due to AIDS in 1993.

  In an incident equally shocking, though less widely known, the daughter-in-law of the former president of the Southern Baptist Convention, then the world’s largest Protestant denomination, contracted AIDS through a blood transfusion. Unaware that she had AIDS, she passed on the disease to her two baby boys at birth. The mother and both sons died of AIDS, but not before the Southern Baptist Church realized that it had a responsibility to minister to those with the disease, young or old, sick or well.

  Then in 1991, the sports world was shocked again when Ervin “Magic” Johnson, who had said he had hundreds of heterosexual partners, announced that he was HIV-positive and retired from professional basketball. Gradually, the world began to realize that AIDS was a disease that could infect all sexually active people and others who received blood products. Heterosexuals could contract and were contracting the disease; children were dying from it. And the numbers affected were growing rapidly.

  During the administration of George H. W. Bush, America’s funding of the global fight against AIDS tripled to $120 million, focusing primarily on education and condom distribution. That’s all we knew to do at that time.

  Under the first six years of Bill Clinton’s presidency, spending for fighting global HIV/AIDS increased from $120 million to $140 million, barely keeping pace with inflation. It is difficult to explain such a major moral and political failure. Some of it, no doubt, was due to ignorance; some was lingering indifference; much was due to politics. During the end of the Clinton administration there was an internal battle between the president’s director of the Office of National AIDS Policy (ONAP) and the staff of the National Security Council (NSC). The NSC, at the urging of Vice President Gore, wanted to dramatically ramp up planning and funding for international HIV/AIDs assistance. In nearly a year of counterproductive stalling by ONAP, the NSC gave up and the end result was a lack of progress and no significant initiative for the president to promote. Leadership and lives were lost in classic Washington infighting. Whatever the reason, while there was much speech-making, there was no serious call to action by either the president or Congress.

  Nor was there any bipartisan political consensus to move forward aggressively in the fight against AIDS. AIDS activists were calling for more money to fight the disease in America. They called for the government to finance expensive new drug treatments for Americans who were HIV-positive. Their priority was not universally embraced. Many people, especially those who did not yet understand the nature of the disease, thought the idea tantamount to saying, “I refuse to change my risky behavior, and I want you to pay for it.” Some vocal AIDS activists here at home feared that American assistance to Africa would take away limited resources that could be used to treat HIV patients in the United States. In the midst of the wrangling, no one including the president stepped up to fill the leadership vacuum.

  Congress plays a major role in deciding where to spend our tax dollars, and during the Clinton years, those in Congress, too, waffled on the AIDS issue. But, it is the president who sets the priorities and leads the country to new places. Since leaving office, President Clinton has repeatedly said he regrets that he did not adequately lead on this issue during his administration. Since leaving office he has joined the fight against the disease in a significant way. The Clinton Foundation HIV/AIDS Initiative reports that it has helped bring AIDS care and treatment to over eight hundred thousand people around the world and has partnered with more than twenty-two governments to make treatment more affordable. I do know that America’s failure to act in the 1990s, along with the willing negligence of other wealthy countries, will plague our collective conscience, and our checkbooks, for generations.

  In the last two years of the Clinton presidency, AIDS spending finally started to climb, topping out at $460 million spread among dozens of initiatives. None of this money, however, was designated to provide drugs that could slow the effects of the disease in people who had already contracted HIV/AIDS. A drug treatment program for a person was incorrectly thought to be too expensive and too complicated to be implemented in poor communities in Africa.

  Global AIDS activists challenged the lack of bold initiatives by Western governments, especially that of the United States. Our nation’s editorial pages, both conservative and liberal, began to call for action. Despite early skepticism, conservative Christians were among the first to awaken to the fact that turning a blind eye to suffering people—regardless of how they had contracted AIDS—was inconsistent with their faith.

  What most people don’t know is that we in Congress had begun pushing the White House much earlier. Years before President Bush’s 2003 unprecedented commitment I was ahead of the curve on the magnitude of the crisis because of my personal experiences as a physician. I had treated and operated on HIV patients. As a transplant doctor I had daily managed patients whose immune systems were similarly suppressed. And I’d seen the ravages of the disease in Africa during my medical mission trips to Tanzania, Kenya, Sudan, and the Democratic Republic of Congo. Two years before the president’s announcement, early in 2001, I’d proposed a budget amendment to allow for more than doubling AIDS spending up to $1 billion a year.

  The origins and subsequent history of this doubling amendment provide a useful illustration of how important Senate staff are to producing transformative change. First, senators try to hire the very best staff we can find and then we give them guidance as to our priorities. With them we develop plans of action, and we rely on them to help us implement the decisions we make. My priority was to commit substantially more to combating HIV; it was morally the right thing to do. I instructed my new legislative director, Allen Moore, a seasoned professional who had previously worked in the Senate, the executive branch, and the private sector, to generate bold ideas consistent with m
y interest in Africa’s unique health challenges. At the time I was chairman of the subcommittee on African affairs. Allen worked side by side with another new staff member—a medical doctor—Dr. Ken Bernard, who had been highly recommended to me by Donna Shalala, the former Secretary of Health and Human Services. Ken was an assistant surgeon general and rear admiral in the U.S. Public Health Service who had previously fought, without much success, in the Clinton White House for the expansion of the U.S. global HIV/AIDS program. He knew the science, he had fought the battle once and lost, and now was ready to fight again.

  As the Senate began the arduous process of working on the 2002 budget, Allen and Ken proposed to me a bold global AIDS amendment to the budget resolution, the annual act of Congress that establishes spending totals for the upcoming year. Allen asked Ken about the need and capacity of poor African countries to spend more than the $460 million we were then spending on AIDS globally: “Could we spend twice as much—$900 million—and have the money used well?”

  “Absolutely,” responded Ken.

  “How about a billion dollars? Could we spend that?” Allen asked.

  “Yes,” Ken replied. “The need is overwhelming and we have the treatments and know-how.”

  “Okay,” Allen said, “let’s write up the arguments and present the idea to the senator.”

  “Can you just do that in the Senate?” Ken, with long executive-branch experience but new to the halls of Congress, asked disbelievingly.

  “In the Senate, you can do almost anything,” Allen replied, “if you have the votes.”

  Ken became ebullient discovering he had found an ear in another branch of government that could finally move the talks to action by appropriating the large sums needed to get the job done. He had the plan that included treatment from his former NSC days and Allen knew that I would be receptive.

  When the amendment came to the Senate floor, it passed overwhelmingly, allowing me to extract assurances from my Budget Committee colleagues that they would fight to maintain the Senate’s position in negotiations with their counterparts from the House of Representatives. Our amendment was the first step that would help lead to a $900 million increase in global AIDS spending for 2002. More important, such a large sum demonstrated that official Washington was beginning to understand the magnitude of the emerging tragedy.

  Later that year, United Nations Secretary General Kofi Annan and President Bush proposed the creation of a new, multilateral Global Fund to fight the big three diseases in the developing world: AIDS, tuberculosis, and malaria. Bush made a lead gift of $200 million to the Global Fund. Other countries joined in, but to this day the United States continues to be the largest single donor, providing about 30 percent of the Global Fund’s resources. Although wealthy nations may never be willing or able to do all that is necessary, America is doing far more than any other nation on earth.

  But it takes a lot more than budgetary action to create a transformative movement. It was during 2000 that I met and became friends with the U2 front man Bono. Born into an Irish Catholic home in Dublin as Paul David Hewson, Bono and his U2 band members had become involved in an informal Bible study group known as Shalom. Out of those Christian roots, Bono later parlayed his fame as an international rock star into a voice for social activism, especially raising awareness of the African AIDS crisis. Bono was committed to the issues. He was sincere and he was smart. Unlike many celebrity advocates, he invested the time to study the problems, to learn how to talk convincingly to policy makers, to ask for things that were doable, and to seek out personal meetings with the president, senior administration officials, influential senators and congressmen to discuss the issues. In the late 1990s he had started making what would become regular visits to Washington to talk about canceling Third World debt, improving trading opportunities for poorer countries, and increasing the resources to fight HIV/AIDS, especially in Africa.

  And Bono is a man of action. We had met many times on the issues in Washington, but what surprised me was the extra steps he would take.

  “Can you take a call from Bono?” asked his assistant Lucy Matthew, calling me in Florida just prior to Christmas in 2000. “He wants to see if you can meet him in Africa.”

  “Sure,” I politely replied, a bit skeptical.

  “Senator Frist, can you meet me in Africa next month—doesn’t matter where—but I need you as a doctor and a senator to go with me so we can determine if the money we are spending there is making a difference?” Bono asked.

  Bono knew I went to Africa each year on medical mission trips, and indeed I told him I’d be going in January to Kenya and Sudan.

  Bono seized the moment: “Let’s meet in Kampala and quietly and without fanfare travel throughout rural Uganda to see the medical clinics, the HIV programs, and new wells dug with the aid we are making available.”

  And that’s what we did. No press, no security—just a couple of guys trying to serve others.

  SUBSTANTIVE PROGRESS IN WASHINGTON REQUIRES BIPARTISANSHIP. And I found my Democrat partner in Senator John Kerry of Massachusetts. John and I, both members of the Foreign Relations Committee, began working together on the first truly comprehensive global HIV/AIDS bill in 2000. The following year, he and I served as cochairman of a pioneering new AIDS policy task force funded by the Bill and Melinda Gates Foundation at the esteemed nonpartisan think tank, the Center for Strategic and International Studies (CSIS). We shared a commitment to finding innovative, bipartisan ways to address this scourge, and worked closely on this groundbreaking initiative, which pulled together all the stakeholders interested in global HIV.

  In 2001 and 2002, Kerry and I partnered on two seminal bills that ultimately became fundamental elements of the legislation that authorized President Bush’s 2003 PEPFAR initiative.

  The first was introduced on June 13, 2001. I went to the floor with Senator Kerry to introduce our legislation, cosponsored by Senators Jesse Helms and Richard Durbin, “to expand assistance to countries seriously affected by HIV/AIDS, malaria, and tuberculosis.” The bill, formally called the International Infectious Diseases Control Act of 2001, went beyond what the House was considering by including money to combat tuberculosis and malaria and by including the U.S. contribution to the Global Fund. Altogether, the bill proposed spending $2.3 billion to battle the three deadly diseases through a “science-based approach that includes prevention of new infections and the treatment and care of infected individuals, public-private partnerships, and good governance.”

  In my speech on the floor that day, I laid the foundations of a philosophy that I had been articulating with increasing frequency over the past several years. The key theme: that “investment in global public health activities to reduce HIV/AIDS, malaria, and tuberculosis not only is a humanitarian imperative, it also helps bolster the economic and social development necessary to build political and trade alliances.” Years later in the post-9/11 world, this would translate into global health efforts as a kind of currency for development and peace—a way of strengthening the social, political, and economic bonds among peoples and nations, as well as alleviating human suffering.

  In July, the House of Representatives passed a global AIDS bill that proposed to spend $1.4 billion per year and would authorize the first large-scale AIDS treatment programs in the developing world. Our bill passed the Senate, but there wasn’t time or inclination to work out the major differences between the House and Senate bills. In spite of our efforts, the elected congressional leaders weren’t clamoring for it (in fact, some held it in great disdain), nor at the time was the president.

  The second bill on which I collaborated with Kerry was formally called the U.S. Leadership Against HIV/AIDS, TB, and Malaria Act of 2002. More commonly known as the Kerry-Frist Global AIDS Bill, this legislation represented the first coordinated effort by U.S. leadership to respond to the global AIDS pandemic. We kept up the pressure. The bill never passed but dramatically raised the aspirational goals for Congress; it proposed to double
global HIV funding to $2 billion and required a five-year comprehensive plan to reduce the global spread of HIV. It became the framework for what was to follow.

  And, finally, transformative change is much likely to occur if the issue attracts well-recognized converts. During my early Senate years, I served on the Senate Foreign Relations Committee, where I developed a close working relationship with Senator Jesse Helms of North Carolina, the committee’s highest ranking Republican. Jesse and I talked often about our need to do more on the AIDS issue, especially in the area of HIV orphans and mother-to-child transmission. This was a tough road for Jesse and he was resistant at first. He had been rather famously unsympathetic early on about AIDS.

  It wasn’t until Bono came along with a combination of facts, Irish charm, and Biblical passages about the Christian’s responsibility to care for the hurting, especially the widows and orphans, that Jesse began to change his tune. Bono knew the real power lay not with the HIV activists and sympathizers—they were already supportive. It lay with those like Jesse who controlled the purse strings and the leadership. If you could get Jesse on board, there was a good chance that the Senate leadership would go along.

  Jesse Helms and Bono became the odd couple of AIDS relief. The media loved it. And it was a genuine friendship, felt by both. I will never forget when Jesse and his wife Dorothy joined Karyn and me in the front row of a U2 concert in Washington. Jesse removed his hearing aids, and Dorothy pulled some big balls of cotton from her purse that both used to stuff their ears. The Helms grandchildren were there and loved every minute.