“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.