had been in the 1970s.
Another problem was that the traditional model of foreign aid was paternalistic: A wealthy donor nation wrote a check and told the recipient how to spend it. I decided to take a new approach in Africa and elsewhere in the developing world. We would base our relationships on partnership, not paternalism. We would trust developing countries to design their own strategies for using American taxpayer dollars. In return, they would measure their performance and be held accountable. The result would be that countries felt invested in their own success, while American taxpayers could see the impact of their generosity.
As Condi made clear in our first discussion, one problem in Africa stood out above all others: the humanitarian crisis of HIV/AIDS. The statistics were horrifying. Some ten million people in sub-Sarahan Africa had died. In some countries, one out of every four adults carried HIV. The total number infected was expected to exceed one hundred million by 2010. The United Nations projected that AIDS could be the worst epidemic since the bubonic plague of the Middle Ages.
When I took office, the United States was spending a little over $500 million a year to fight global AIDS. That was more than any other country. Yet it was paltry compared with the scope of the pandemic. The money was spread haphazardly across six different agencies. Much of their work was duplicative, a sign there was no clear strategy.
American taxpayers deserved—and conscience demanded—a plan that was more effective than this disjointed effort. I decided to make confronting the scourge of AIDS in Africa a key element of my foreign policy.
In March 2001, I met with United Nations Secretary-General Kofi Annan, a soft-spoken diplomat from Ghana. Kofi and I didn’t agree on every issue, but we found common ground in our determination to deal with the AIDS pandemic. He suggested creating a new Global Fund to Fight HIV/AIDS, Tuberculosis, and Malaria that would marshal resources from around the world.
I listened but made no commitment. I considered the UN to be cumbersome, bureaucratic, and inefficient. I was concerned that a fund composed of contributions from different countries with different interests would not spend taxpayer money in a focused or effective way.
Nevertheless, Secretary of State Colin Powell and Health and Human Services Secretary Tommy Thompson recommended that I support the Global Fund with an initial pledge of $200 million. They felt it would send a good signal for America to be the first contributor. Their persistence overcame my skepticism. I announced our commitment on May 11, 2001, with Kofi and President Olusegun Obasanjo of Nigeria in the Rose Garden. “I thank you, on behalf of all AIDS sufferers in the world, but particularly on behalf of all AIDS sufferers in Africa,” President Obasanjo said.
“This morning, we have made a good beginning,” I said in my speech. I didn’t add that I had plans to do more.
Four months to the day after we announced our pledge to the Global Fund, the terrorists struck America. Before 9/11, I had considered alleviating disease and poverty a humanitarian mission. After the attacks, it became clear to me that this was more than a mission of conscience. Our national security was tied directly to human suffering. Societies mired in poverty and disease foster hopelessness. And hopelessness leaves people ripe for recruitment by terrorists and extremists. By confronting suffering in places like Africa, America would strengthen its security and collective soul.
By early 2002, I had concluded that the Global Fund was not a sufficient response to the AIDS crisis. While America had increased our contribution to $500 million, the Fund was short on money and slow to act. Meanwhile, the AIDS epidemic was sending more Africans to their graves. The majority were between ages fifteen and forty- nine, the key demographic for productive nations. Left unchecked, the disease was projected to kill sixty-eight million people by 2020, more than had died in World War II.
I couldn’t stand the idea of innocent people dying while the international community delayed. I decided it was time for America to launch a global AIDS initiative of our own. We would control the funds. We would move fast. And we would insist on results.
Josh Bolten assembled a team* to develop recommendations. In June, they came to me with a proposal to focus on one particularly devastating part of the AIDS crisis: its impact on women and children. At the time, 17.6 million women and 2.7 million children were living with HIV/AIDS. Every forty-five seconds, another baby in Africa was born with the virus.
Recently, scientists had discovered new medicines, particularly a drug called Nevirapine, that could reduce the rate of mother-to-child transmission by 50 percent. But it was not widely available in Africa or other parts of the developing world. The team proposed spending $500 million over five years to purchase medicine and train local health-care workers in the most heavily affected African and Caribbean countries.
“Let’s get it started right now,” I said. The plan was tailored to a specific part of the crisis in the neediest parts of the world. It put local officials in the lead. And it had an ambitious but realistic goal: to treat one million mothers and save one hundred fifty thousand babies every year after five years.
On June 19, 2002, I announced the International Mother and Child HIV Prevention Initiative in the Rose Garden. In seventeen months, we had doubled America’s commitment to fighting global AIDS.
The morning I unveiled the mother and child program, I called Josh Bolten into the Oval Office. “This is a good start, but it’s not enough,” I told him. “Go back to the drawing board and think even bigger.”
A few months later, he and the team recommended a large-scale program focused on AIDS treatment, prevention, and care—the strategy that would ultimately become PEPFAR.
The first part of the proposal, treatment, was the most revolutionary. Across Africa, it was estimated that four million AIDS patients required antiretroviral drugs to stay alive. Fewer than fifty thousand were receiving them. Thanks to advances in drug technology, AIDS treatment regimens that used to require thirty pills a day could be taken as a twice-a-day cocktail drug. Soon, only one pill was required. The new medicine was more potent and less toxic to patients. And the price had declined from $12,000 a year to under $300. For $25 a month, America could extend an AIDS patient’s life for years.
“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
