by Bill Frist
But it was fellow North Carolinian Franklin Graham who probably had the greatest impact on Jesse’s views of HIV. He explained to Jesse the Christian and evangelical basis of combating global HIV. They prayed together, and Jesse respected Franklin’s leadership and activism of rallying evangelicals around the world to support prevention of the spread of AIDS. In 2001, well before most were paying much attention, Franklin began planning a “Prescription for Hope.” The Washington-based gathering that would bring together more than seven hundred emergency relief workers, along with government, medical, and church workers from around the world, to help mobilize Christians in the fight against the pandemic. Sharing the podium with Franklin were the remarkable first lady of Uganda, Janet Museveni; Andrew Natsios, of the U.S. Agency for International Development (USAID); my good friend Dr. Angelo D’Agostino, a colorful and endearing American Jesuit who ran an HIV-related orphanage I visited often in Nairobi; and me. The evangelical Christian community was becoming energized in the global fight against HIV.
Jesse Helms made a surprise appearance at the conference. Inspiring the crowd by his very presence, he rose to say that he was ashamed that he had not done more to fight AIDS in the developing world. He later wrote a remarkable op-ed piece in the Washington Post echoing and expanding that statement. We announced at the conference that he and I together would be seeking a special $500 million appropriation to initiate a program to prevent mother-to-child transmission of HIV. No one in the White House or in the global AIDS advocacy community knew anything about our intentions at the time.
Jesse had already announced that he would not seek a sixth term in the Senate, and when he complained of feeling tired and weak around the time of his op-ed, I encouraged him to check into Bethesda Naval Medical Center. Shortly thereafter, on April 25, 2002, Senator Helms underwent open-heart surgery by a surgical colleague of mine at Inova Fairfax Hospital to replace a failing valve. I pursued our proposal in Jesse’s absence. The White House knew that we had more than enough votes to pass it in the Senate, especially with Jesse’s support in absentia, so we struck a deal that would make the idea a presidential initiative if we agreed to restructure the spending. With the president’s support, a new $500 million program was assured, even in the face of a far-less-enthusiastic House of Representatives. Our mother-to-child initiative got off the ground quickly and helped lay the groundwork for what was to follow.
Jesse Helms retired as he said he would, but he did more to help suffering people during his last months in office than most legislators do in a lifetime. I will always admire him as a man big enough to say, “I was wrong about AIDS,” and then do something to make amends.
IN EARLY 2002 THE WHITE HOUSE WAS BEGINNING TO SECRETLY put together its historic AIDS initiative. As a member of the Senate leadership team, first as chairman of the NRSC campaign committee and later as majority leader, I began in 2000 to attend regular leadership meetings at the White House. They provided the opportunity to talk freely about a variety of topics, including global AIDS.
I vividly recall one time in the Roosevelt Room at the White House in a small meeting with the Republican leadership when President Bush surprised me with his detailed knowledge about HIV and its ravages in societies around the world. At the end of a wide-ranging political discussion, I asked the president if there was any chance that the administration might be willing to do more on global AIDS.
“I’m willing to do more,” he replied, “but only if I am absolutely assured that the new spending will produce tangible results.” Then he discussed Niverapine, the inexpensive drug used to help prevent an HIV-infected mother from passing on the disease to her newborn child. How did the president know so much about Niverapine? Most of the political figures in the room—not to mention most of the president’s own aides—had never heard of Niverapine. The president’s obvious knowledge of the entire issue of African AIDS and the passion he displayed caught most everyone by surprise. It was clear to me he had been studying the topic.
Soon he would be ready to take action. In mid-January 2003, about a week before the State of the Union address, the president and first lady invited Karyn and me to dinner. When we showed up at the White House, we were ushered not to the customary state dining room, but to the Red Room, a room rarely used for dinners. It was a special night. Also in attendance were United Nations Secretary General Kofi Annan and his wife, the pastor of the president’s church in Washington, National Security Advisor Condoleezza Rice, and one or two others.
The conversation covered the waterfront, but halfway through the evening HIV became the topic. The president told us, “In a few days, I’m going to make an announcement that you all are going to be proud of. Keep it confidential for now. It will change the course of history for those people with HIV/AIDS all around the world, but most significantly in African countries. Our country will lead the world in the fight against HIV.”
Indeed when several days later the president unveiled his $15 billion proposal for PEPFAR, it stunned the world. It also created an important challenge for Congress. The chairman of the International Relations Committee Henry Hyde quickly pushed a bill through the House of Representatives with the help of his Democratic colleague Tom Lantos. The bill had a lot of support in the Senate because it drew heavily from the original Kerry-Frist bill.
The White House sent a senior advisor to “negotiate” the bill through Congress. I sent Allen and two other highly capable staff members, Andy Olsen and Shana Christup. Back and forth we went with the White House, working with a small team of Senate Republicans over a period of weeks to craft the final wording of the bill. The time pressure resulted from the president’s desire to have a signed piece of legislation before going to the G-8 meeting that June. And it was already May.
Facing the deadline of the G-8 meetings, I made a tough decision as majority leader: we would pass the House bill without amendments. It was a controversial decision. It meant that I was asking my Republican senate colleagues to refrain from making any changes to a bill that was imperfect and to oppose any and all changes proposed by Democrats, regardless of the merits. It was far from the ideal way to proceed, but it was the only way I could guarantee passage of the bill.
The strategy worked and the bill passed overwhelmingly in late May 2003, just four months after the president’s surprise pledge in the State of the Union. After years of foot-dragging in Congress and a decade of disappointing leadership from the White House, President Bush’s PEPFAR program had come to pass in near record time.
The impact has been remarkable, but even today, more than six years later, we are losing ground to the virus. Even with the massive amounts of money we are spending—more than $6 billion per year now—there will still be well over 2 million new HIV infections this year. Though the cost of treatment with antiretroviral drugs (ARVs) has plummeted, the world still does not have enough resources to treat its way out of the problem. Today, for every person that we place on ARVs, there are three newly infected patients. And more successful prevention programs will require cultural change, which takes time. The problem has been with us for more than a generation, and it may take a generation or two more before we see the change for which so many of us are hoping.
In the meantime, we dare not back off from the battle. In 2008, in an effort led by then-senator Joe Biden and supported by then-senator Barack Obama, Congress reaffirmed its commitment to fighting global infectious disease by passing legislation that authorized an additional investment of up to $48 billion over five years. It’s a big step in the right direction—but the road ahead remains long. In the current domestic and global economic environment, it is unlikely that all the resources authorized will be funded.
Nevertheless, one of the greatest—maybe the greatest—foreign policy legacies of the Bush administration was PEPFAR—its rapid passage; its unprecedented size; and then its five years of spending nearly $19 billion to fight AIDS, tuberculosis, and malaria. In addition to the 2.1 million people who ha
ve received life-saving anti-retroviral therapy, over 60 million people have been reached through PEPFAR-supported community outreach programs, over 16 million women have been involved in mother-to-child transmission programs, and over 2.2 billion condoms (more than provided by all other countries in the world combined) have been distributed. This is a gift to humanity of which all Americans can be justly proud.
Readers of Time magazine were probably surprised to see a February 2008 column praising President Bush by former musician and antipoverty legend Bob Geldof, whose song “Do They Know It’s Christmas” helped spawn a global outpouring of aid during the mid-1980s famine in Ethiopia. After listing the generous support of the Bush administration for many efforts to alleviate disease and poverty in Africa, Geldof concluded, “The Bush regime has been divisive—but not in Africa. I read it has been incompetent—but not in Africa. It has created bitterness—but not here in Africa. Here, his administration has saved millions of lives.” In time, this little-recognized side of George Bush’s presidency working closely with the leaders in Congress will get the recognition it deserves.
IN MARCH 2003, WE ALSO TOOK ON ONE OF AMERICA’S MOST heinous and egregious “legal” medical procedures—partial birth abortion. In 1996, Congress had spoken loud and clear by passing legislation outlawing this brutal practice, but President Clinton had vetoed the bill, not once but twice. Now, with a Republican president and a Republican majority in the House and Senate, we had a golden opportunity to stop the barbaric, government-condoned slaughter of preborn babies.
I never regarded partial birth abortion as a political issue. To me, it was a medical atrocity. Although I was not trained as an obstetrician, I had delivered babies and shared every parent’s awe at the miracle of newborn life. As a surgeon, I know there are ethical boundaries that should never be crossed, and partial birth abortion, which requires a physician to kill a living fetus on the verge of being delivered into the world, is one of them.
The procedure begins by turning the living baby around in a mother’s womb, partially pulling the baby out of the uterus feet-first, and then forcibly penetrating the base of its skull with eight-inch-long scissors. The scissors are then opened wide inside the baby’s skull, creating a hole large enough to evacuate the brain and the contents of the head. Once the skull is collapsed, the now-dead infant is pulled from the mother’s uterus through the birth canal. That is the procedure that some were defending on the floor of Congress.
This procedure is most commonly performed in the second trimester of pregnancy, when the baby is from twenty to twenty-seven weeks old. How developed is the child at that point? Let’s put it this way: If those premature babies were born at twenty-three weeks, they would have almost a 50 percent chance of surviving on their own. For babies born at twenty-five weeks, the survival rate jumps to between 60 and 90 percent. Yet for years, our nation turned the other way while these babies were purposely destroyed.
As the only physician in the Senate, I sought to dispel the myths about partial birth abortions and discuss the facts from a medical perspective. For instance, proponents of this procedure generally claimed that it was most often used to preserve the health of the mother. That was simply not true. Moreover, partial birth abortion is not the only procedure or the best procedure available in a true medical emergency. It is a fringe procedure generally performed by doctors who specialized in optional late-term abortions and who were not board-certified surgeons.
As a physician, and as the majority leader who brought this bill to the floor, I am proud that the Senate voted to ban this morally offensive procedure in America. President Bush signed the bill, and it remains law today—a victory not for one party but for all those who value the sanctity of life.
I’M FREQUENTLY ASKED WHAT SINGLE PIECE OF LEGISLATION PASSED during my four years as majority leader will have the most lasting impact on everyday Americans.
The answer, hands down, is the bill that today guarantees seniors affordable access to life-saving prescription drugs. We passed the Medicare Prescription Drug Improvement and Modernization Act in 2003. Historically, Republicans seldom led on health-care reform and had earned the reputation of obstructing meaningful reform in the early 1990s. As the new majority leader, and as a doctor, I was determined to elevate health as an issue. The Medicare program, which provides health care to seniors and individuals with disabilities, had become seriously outdated since it was created in the 1960s. I was committed to making improvements to Medicare a defining issue for Republicans and for the Congress. Prescription drugs were included in most private health insurance plans, which served more than 180 million people. Why should they specifically be excluded from the coverage Congress has given to America’s 40 million seniors—Medicare? The Medicare program simply had not kept up with the times.
Medicare was originally designed to help seniors four decades ago, when much of the American medical system was focused on treating acute, episodic illnesses rather than chronic disease. In Dad’s medical practice, he had only a handful of useful, curative drugs available. In my generation, I used hundreds of life-saving drugs to prevent disease and return people to good health. In the 1960s, prescription drugs were just not that important in the overall scheme of things for most patients. Today, they are the single most powerful weapon in the doctor’s arsenal to fight disease and to promote health. Yet they were not covered for seniors in Medicare. So the time had come to act.
Shortly after President Clinton was elected, he proposed a massive government program to provide health insurance to every American. While his “managed competition” model was intended as a compromise between liberals who preferred a single-payer government-run approach to health-care reform and conservatives who favored a more market-based approach, it was nonetheless rejected soundly by the American people. A broad coalition formed against his plans, branding them a dangerous intrusion of the federal government into individual choice and a vast expansion of bureaucracy.
But the call for health-care reform was still alive, and most of us who had studied health-care programs knew that reforms to the Medicare program had to be near the top of the list. The 1997 Balanced Budget Act created the National Bipartisan Commission on the Future of Medicare to “make recommendations regarding a comprehensive approach to preserve the program.” Meeting in 1998 and 1999, this program included seventeen members, representing eleven Democrats and Republicans in both houses of Congress, and experts from academia and the private sector.
The commission was chaired by John Breaux, a senior member of the Senate Finance Committee and a centrist Democrat highly respected for his ability to build bipartisan coalitions, and Bill Thomas, Republican chairman of the powerful Ways and Means Health Subcommittee in the House of Representatives. I was appointed to the commission as well. The group broadly supported the Breaux-Thomas model developed by the commission; it was based on the popular Federal Employees Health Benefit Plan (FEHBP), which covered all federal workers. Seniors would be able to choose from a menu of comprehensive health plans, which would compete one with the other under strict federal guidelines. The Breaux-Thomas plan also would begin to update Medicare’s outdated benefit package, adding prescription drugs and new preventive services. These private health plans would compete on value by offering the most attractive package of health benefits at the lowest possible price. And, over time, this competition would help make the Medicare program sustainable.
But our model was not supported by President Clinton, who had meanwhile fashioned his own plan, and when it came to a final vote in the committee, two of the Clinton appointees voted against it, leaving us one vote short and therefore unable to issue a final report or recommendation. (The final report required approval by eleven of the seventeen members.) But the wheels had been set in motion; a bipartisan group of reformers had started to coalesce around a plan that held promise for improving the Medicare program, and the relationship between Bill Thomas, John Breaux, and me would resurface four years later as w
e developed the Medicare Modernization Act of 2003.
Shortly after I became leader, I went to see Chuck Grassley and Max Baucus, chairman and ranking member of the powerful Senate Finance Committee, which was responsible for Medicare. They were both eager and ready to engage in modernizing Medicare and making prescription drugs affordable to seniors. Moreover, the two had a history of working together, and I knew that Medicare prescription drug legislation would have to have bipartisan support to surpass the sixty-vote threshold required to pass in the Senate. Bill Thomas, now chairman of the full Ways and Means Committee, took the lead, supported by Speaker Denny Hastert and Majority Leader Tom DeLay. The White House was strongly supportive as well. President Bush campaigned on a promise to provide prescription drug benefits to seniors. He knew that both health care and Social Security needed to be modernized and that the solvency of both of these programs had to be addressed. Although the president always seemed to make Social Security a higher priority than Medicare, Medicare’s problems were far more urgent and far more challenging to address.
As a government, we have overpromised to the next generation. I argued that Medicare was the problem we should tackle first. Why? Because the actuaries told us that the gap between Medicare’s promised benefits and what the government could afford was about $35 trillion over the next seventy-five years, whereas the problem with Social Security amounted to only about a sixth of that. Furthermore, Medicare was predicted to go bankrupt about nineteen years sooner than Social Security.
As leader, I had one very important power—the power to decide which bills come to the floor of the Senate. And as a physician, I was personally committed to addressing the problems with Medicare and prescription drugs. Although the White House never submitted a specific bill to us—merely a list of general principles—in the end it was the administration’s wholehearted enthusiasm and the president’s $400 billion budget commitment that helped push the bill through.