A Quiet Success in Stemming a Global Epidemic

WASHINGTON, D.C. –  February 2014 marks the second decade of the President’s Emergency Plan for AIDS Relief or PEPFAR, the most ambitious program in human history to combat HIV/AIDS.   Last December, President Obama reaffirmed U.S. funding and support of this important program, albeit at lower levels than in the past due to acute budget constraints.  Credit for starting the program, however, rests with an unlikely champion, former President George W. Bush.   Despite having ended his presidency in 2009 as the most disliked chief executive in U.S. polling history with approval ratings as low as 22 percent, global health stands out as an area in which his presidency made tangible and critical progress.[1]  Bush undertook this effort because of his personal convictions to contribute to a greater good that did not necessarily coincide with the values and priorities of his core electoral constituency, and that even his harshest critics acknowledge as an unqualified success.

When Bush took office in 2001, the United States spent $1.4 billion per year in development and humanitarian assistance for Africa, which paled in comparison to the growing AIDS epidemic there.  UN epidemiologists predicted in 1991 that Africa would see 9 million HIV cases by the end of the decade.  The actual number in 1999 was 24.5 million.  By the turn of the millennium, well over 34 million people were infected with the HIV virus and experts predicted a major global health crisis of some 50 million infections by 2015. [2]

In February 2003, Bush launched PEPFAR – a five-year, $15 billion program to prevent, care, and treat HIV/AIDS.  The funding was facilitated through the passage of the U.S. Leadership against AIDS, Tuberculosis, and Malaria Act of 2003.  The act created the Office of the Global AIDS Coordinator (OGAC), which coordinated U.S. government-funded HIV/AIDs programs in 15 different countries, mostly in sub-Saharan Africa. The program set out specific metrics of performance in its first five years: to supply antiretroviral treatment to 2 million HIV-infected people, to prevent 7 million new HIV infections, and to provide continuing care to 10 million people by 2010.[3]  The price tag of this five-year program was unprecedented in world history.  No previous world leader, international organization, or private sector entity had ever committed so much to AIDS prevention and treatment, let alone the targeting of any single disease.

Through both its financial contributions and leadership, the United States turned back the AIDS epidemic.  If it was spending less than $200 million on the problem and treating only 50,000 patients with antiretroviral drugs prior to PEPFAR, three years into the program, the United States was committing $5.6 billion per year, and by the end of the five years was providing treatment to over 1.3 million patients.[4]  In 2008, President Bush reauthorized PEPFAR for an additional 5 years, and total spending reached $46 billion.[5]  By its tenth year, PEPFAR succeeded well beyond its initial goals set out in 2003, providing antiretroviral treatment to more than five million people, counseling for over 11 million pregnant women and providing medicines to some 750,000 women, thus allowing hundreds of thousands of children to be born HIV-free.[6]

The results of the program speak for themselves.  According to UNAIDS, 1.6 million people died of AIDS in 2012, representing a 30 percent decrease since 2005.  New HIV infections have declined by 33 percent since 2001 globally, and in sub-Saharan Africa, new infections have declined by more than 50 percent.[7]  UNAIDS Executive Director Michel Sidibé put the point succinctly: “The leadership of the United States of America in the AIDS response has been instrumental in achieving results for people living with and affected by HIV…Over the last 10 years new HIV infections worldwide have fallen by more than 20%, and as more people have been able to access antiretroviral therapy, AIDS-related deaths have fallen by a staggering 25% since the peak of the epidemic. These gains would not have been possible without the financial and political commitment of the United States and particularly PEPFAR.”[8]

As unpopular as Bush was at home, his dedication to this problem was unwavering.  The president did not push this initiative as a political feather in his cap.  Indeed, the legislation for PEPFAR was introduced at a time when Bush was experiencing a staggering and uninterrupted drop in his approval ratings over 12 successive months through 2002 into the beginning of 2003.[9]  He had little support from his core constituency in the Republican Party, which was focused on counter-terrorism and national security.  And he challenged both Democrats and Republicans to mount bipartisan support for this initiative, leading the body to authorize budgets that exceeded the president’s request in the largest global health endeavor in the history of the U.S. Congress.[10]

Most important, he challenged the conventional wisdom at the time.  The view was that large-scale conventional HIV/AIDS treatments could not be carried out effectively in low-income, low-resource countries like those in sub-Saharan Africa.[11]  The prevailing assessment was that uneducated and poor populations could not be counted on to attend health clinics, understand care information, appear regularly for treatment, and take medicine as prescribed.  PEPFAR went directly against this view and proved it wrong.

Bush’s accomplishments in this vein are acknowledged by his critics.  As one treatment said, for a president “whose administration was marked by death and conflict,” PEPFAR represented a compassionate conservatism that could have been for the Bush presidency were there no September 11 or Iraq.[12]   Or as another observed, “[These] are not words I frequently use to describe Bush…. But credit and praise must be given where they are due, and Bush’s accomplishment – PEPFAR – deserves accolades.”[13]

But the real meaning of these policies is found not in the halls of Washington policy commentary but in the appreciation of the African people.  Bush, though reviled at home, was greeted by throngs of well-wishers and supporters on his last trip to Africa as president in February 2008 where the United States enjoyed approval ratings well into the 70 and 80 percentiles during his entire presidency.  PEPFAR was not the only reason for America’s popularity.  Bush also created the Millennial Challenge Corporation, which directs development aid to African governments that demonstrate transparency and corruption-free practices.  But the unprecedented scope and scale of his AIDS initiative resonated deeply.  Mark Dybul, the US Global AIDS Coordinator in 2006, recalled that when African village elders were asked if they knew what the acronym “PEPFAR” meant, their response was simple but meaningful: “PEPFAR means the American people care about us.”[14]

Political courage is not exemplified by doing something to build a legacy or to gain the admiration of others.  It is doing what you believe is right and contributes to a greater good.  His dedication to this cause remains evident in his work in private life.  Bush has visited Africa three times already working on projects to address tuberculosis, to renovate health infrastructure, and to expand screening and treatment for cervical cancer.   There has been no more important program in world history to turn back the HIV/AIDS epidemic in Africa than the U.S. creation of PEPFAR.