It had been just under two months since New Century, an American real estate venture specializing in subprime lending and securitization, filed for bankruptcy. One of the dominoes that triggered the global economic crisis had already fallen.
Meanwhile, the treatment component of the president’s AIDS war looked like a far wiser investment. In South Africa, PEPFAR support had helped the monthly initiation rate quadruple between 2005 and 2009. Now, there were 24,622 South Africans on antiretroviral treatment (ART) every 30 days. In Uganda, PEPFAR supported two-thirds of all Ugandans on antiretrovirals and planned, in 2008, to double both the number of PEPFAR-supported ART clinics and the number of adults started on antiretrovirals each month. These rapid jumps in speed and scale—a “hockey stick” shaped curve—were a sign that start-up was over. Systems built and staff trained, the program could shift to the massive task of bringing antiretrovirals to all who needed them. In some cases, growth had heightened concern about PEPFAR and its parallel system.
One evaluation of the South African PEPFAR ART program offered an “unequivocal yes” to the question of whether the US funds had helped close the treatment gap but noted that health workers were also gravitating to higher-paying, better-supported PEPFAR positions that offered more hands-on training and management than many government posts. “While PEPFAR has undoubtedly supported its own program, there are repercussions in terms of the overall HRH [human resources for health] outlook.” Nevertheless, the numbers in 2007 showed initial victory in an effort that had not been guaranteed. With the World Health Organization (WHO) now recommending antiretrovirals for people with CD4 cell counts of 350, not 200, even more people with HIV were eligible for ART. The concept proven, the emergency unabated, it was time to pick up speed.
On May 30, 2007, it was a beautiful, sunny day in Washington, DC, when the president who’d authorized the enhanced interrogation stepped into the dappled shade of the Rose Garden to ask that PEPFAR be continued and expanded. “This investment has yielded the best possible return: saved lives,” he said. Just over one million people were now on antiretrovirals thanks to US government support.
“This is a promising start,” he said. But it was time to plan for the next phase. “Without further action, the legislation that funded this emergency plan is set to expire in 2008.”
Presidential press conferences to request reauthorization of a piece of legislation are few and far between. The event was a sign of how seriously Bush took the matter of his AIDS program and his legacy. So, too, was the amount of money he asked for: $30 billion for the next five years, a doubling of the $15 billion budget authorized in the law that created PEPFAR 1.0. Much had been done; much more was needed. This was, for a change, a welcome truth.
UNAIDS estimated that in 2006 roughly three million people had died of AIDS, roughly 40 million people were living with HIV, and roughly 4.3 million had contracted the virus. At the end of that year, roughly two million people in low- and middle-income countries had access to antiretrovirals—a 54 percent increase over the previous year’s total. But access wasn’t happening fast enough. In low- and middle-income countries, the lifesaving pills were reaching less than one-third of the people who qualified.
To meet its treatment targets, PEPFAR had, in every country it worked in, paid to train doctors, nurses, and pharmacists in delivering the drugs, which had specific dosing requirements, drug-drug interactions, and side effects. It had, with the largest contract in USAID’s history, established the Supply Chain Management System (SCMS), which bulk-purchased and delivered the test kits, medications, laboratory reagents, and other commodities for PEPFAR-supported clinics. The SCMS was yet another piece of parallel programming—a vast procurement operation that ran alongside governmental systems.
Like the program it served, the SCMS was expensive, bilateral—and effective. In places like Uganda, where corruption and inefficiency beset the National Medical Stores, the SCMS-supported procurement system was a stopgap for drug stockouts. PEPFAR Uganda supplied tuberculosis medications and sometimes antiretrovirals when the drugs that the government should have been supplying either didn’t arrive or ran out.
Parallel systems had other benefits that spilled over into the public sector too. Dr. Mark Dybul, who’d taken over from Randall Tobias as the new PEPFAR head, would tell Congress that in Rwanda, after seven PEPFAR-funded sites had been operating for just two months, the number of hospitalizations fell by 21 percent. Freeing up beds that had once been occupied by people dying from AIDS didn’t mean that the services necessarily got better, but it did mean that the hospitals weren’t straining—and that the resources available could be spent on other things. (PEPFAR didn’t invest in hospitals, and clinicians regularly bemoaned the fate of the clients who were “admitted.” On my first visit to Rakai, I’d heard of one client who had been deafened as the result of an accidental overdose of quinine provided in a local hospital; another had been sent to the hospital for a lumbar puncture and been turned away.)
PEPFAR was the first major US foreign aid effort to report on both in the aggregate and by individual country.
PEPFAR was excelling at both doing the work and reporting on it. It could say, with more specificity than any prior American foreign aid program, how much money it had given out and how much of that money had actually been spent. The latter information—expenditures—was not a required component of reporting on foreign aid. But Dybul, working alongside Tobias, had ensured that the program provided that information. By 2007, PEPFAR had obligated 97 percent of its allocated funds to specific agencies and the subgrantees known, in PEPFAR parlance, as implementing partners; more than two-thirds of that had been outlaid or spent.
PEPFAR was the first major US foreign aid effort to report on both in the aggregate and by individual country. It also tracked what got paid for, reporting biannually on performance against the key indicators that Kathy Marconi had hammered out with the US government agencies in the program’s first year. Among these, the numbers of people tested for HIV and treated with antiretrovirals were quantitative measures of a service with a direct, satisfying impact. Treatment offered the romance of Camille rising off the couch, the awesome power of Lazarus rising from his deathbed. It was redemption and recovery, providing the sort of emotional satisfaction that prevention never could. If legislators focused on these resurrections and not the technical complexity of this work in their remarks from the floor, the program’s sophistication was still palpable, tangible. The program was smart, perhaps even brilliant, as well as merciful.
Even so, the fact that the president would, in 2008, get what he requested that day in May 2007—and more—was quite extraordinary. American governmental attention spans for health emergencies are short, and sympathy for a given disease is often fleeting. In 2007, the American AIDS epidemic was no longer an emergency, even though, as a Centers for Disease Control and Prevention (CDC) research team, including Gregorio Millett, an openly gay, Black public health expert, would note, “Black MSM [men who have sex with men] are the only population in the U.S. with HIV prevalence and incidence rates that rival those in the developing world.”
They also noted that HIV risk was often a function of the state, not the individual. Mass incarceration, poverty, and inequitable access to quality health care all played a role, and there was a dearth of information about what community-led, culturally competent services might look like. “Failure to heed this call and to address the devastating HIV rates among [B]lack MSM will be our collective legacy and another sad chapter as we observe, once again, And the Band Played On.”
This ongoing crisis hardly registered with the general public. Prior to the advent of antiretroviral therapy (ART), 44 percent of Americans surveyed said that HIV/AIDS was the most urgent problem facing the nation; by 2006, that number had dropped to 17 percent, even as rates of HIV in Black communities climbed and federal funding for HIV prevention plummeted—dropping 19 percent during the Bush administration. When surveyed, Black Americans were more likely to be concerned about both their communities and the country.
The AIDS epidemic among Black Americans simply didn’t prompt the same sympathy and call for mercy from the Bush White House as African epidemics of the same scale. Many lawmakers and activists sought redress for their communities; activist researchers like Greg Millett and Adaora Adimora produced a steady stream of research into the relationships, communities, and social factors that impacted HIV risk. Black-led organizations focusing on HIV had existed since the earliest days of the epidemic, often written out of the dominant ACT UP–focused narrative; many of these had endured but seen already scanty budgets further sliced when AIDS drugs arrived. As in Africa, community centers and clinics were placed in competition, when they should have been in partnership.
The root cause of the epidemics within the United States and beyond its borders were, in many respects, the same: a white supremacist state whose wealth and privilege depended on and derived from economic and political practices that devalued the lives of nonwhites and actively sought to keep them from obtaining money, privilege, and power. To begin to address and acknowledge this in America was, in Bush’s administration, untenable. In Africa, though, Bush entertained the fantasy that colonialism existed in the past and that PEPFAR was part of a movement toward equality. It was possible, then, to tell a story about the plague war that provided a satisfying narrative arc—possessed of a beginning, a middle, and an end.
As the White House sought to secure his legacy, this is precisely what it did. The storytelling began that day in May, with the trio standing behind the president in the Rose Garden. They could have been PEPFAR’s magi, so closely did they hew to the archetypes of the heroes in the stories PEPFAR told about itself. There was Dr. Jean Pape, the Haitian doctor who’d been flown in to advise the Office of Management and Budget when PEPFAR was still the brainchild of a rump group of White House staffers; Bishop Paul of the Coptic Orthodox Church in Africa; and Kunene Tantoh, a South African woman living with HIV who ran a support group for fellow HIV-positive mothers: the compassionate doctor who’d made something out of nothing, the man of faith with a large cross swinging low by the waist of his belted robe, and the woman who’d saved the life of her child with American money. Kunene proved, the president said, that “people with HIV could lead productive lives.”
In Africa, though, Bush entertained the fantasy that colonialism existed in the past and that PEPFAR was part of a movement toward equality.
Kunene, Pape, and Bishop Paul also could have strolled out of the pages of any one of PEPFAR’s annual reports to Congress, which had, for the past three years, been thick with images of children, women, doctors, and people of faith. The illustrations put a human face on the numbers that read like a venture capitalist’s dream. According to the annual report issued a few months before the Rose Garden ceremony, PEPFAR was, by September 2006, adding approximately 50,000 people per month to its treatment rolls; the number of sites providing treatment had increased by 139 percent from FY2005 to FY2006, and each month an average of about 93 new ART sites came online. The United States had also put just over $1 billion into the Global Fund’s coffers in 2006–2007, and that investment was also paying off. In mid-2007, the Fund announced that, together with PEPFAR, it had doubled the number of people on treatment in the past year. Untangling who’d paid for what was tricky, but the Fund reported an even split—with PEPFAR and the Fund each supporting 1.1 million people on treatment.
The law that created PEPFAR covered 2003 to 2008. Technically, PEPFAR didn’t need a new law to continue. A line item in the foreign aid appropriations bill would have maintained the budget and allowed it to continue. But without legislation specifying structure, targets, and budget, Bush’s legacy would not be secure. The plague war needed to be reauthorized with a new law, its purpose and strategy reviewed and retooled.
Over the course of four hearings in the House and two in the Senate, Congress sought to set the course for the program’s second phase. In these open forums, the lawmakers took an even more active role in defining PEPFAR’s purpose and strategy than they’d done in 2003, when the president’s White House–based team supplied the details, targets, and structure for the new initiative. It was, in many ways, a transfer of ownership—for while the program would keep the word “president” in its acronym, Bush was in the last year of his presidency, and no one knew whether his successor would be a champion. Congressional support had always been important; now it was essential.
Statistics seldom warm hearts like stories do, and in the months after the president called for expanding his program, congressional staffers traveled to African countries receiving PEPFAR funds. In a village outside Gaborone in Botswana, Brian McKeon, an aide to Joe Biden, reviewed a patient ledger with a nurse who’d come out of retirement to help with her country’s response. She showed him how she’d once put a red mark beside the names of clients who had died and exclaimed, “with great joy and pride,” that the red marks had ceased. McKeon carried the news back to Biden, then chair of the Senate Foreign Relations Committee (SFRC) and a candidate for the US presidency.
“Over one million death sentences have been suspended,” Biden said at an SFRC hearing on October 24, 2007. If his language made discomfiting references to America’s racially biased capital punishment system, it also signaled support for continuing the program that saved so many Black and brown bodies overseas.
Warning that the “relentless enemy” had not yet been vanquished, Biden said that the program now needed to begin to turn control over to countries, chiefly by removing the prior legislation’s earmarks, which set percentages of funding for treatment, orphans, prevention, and—within prevention—abstinence-only education. Each country had its own epidemic and should set its own strategy; that strategy required an intensified emphasis on prevention, Biden said, citing the findings of an exhaustive independent assessment by the Institute of Medicine (IOM) that had been published a few months prior.
The assessment fulfilled a requirement written into law that created PEPFAR, and it was, on balance, profoundly positive. Dr. Jaime Sepúlveda, the Mexican physician and public health expert who led the process, wrote in his introduction, “Though the programs evaluated are still young, it was clear that millions of people are being served and life-saving medical care is being delivered on a large scale in some of the world’s most challenging settings. I strongly believe that the American people, acting through PEPFAR, are to be complimented for supporting this remarkable humanitarian undertaking.”
The IOM report was positive but not uncritical. Like many other evaluations before and after, the 397-page assessment noted that PEPFAR programming for orphans and vulnerable children was vaguely defined and therefore difficult to evaluate in terms of actual impact on children’s health and well-being. Giving a child a blanket or a set of pencils did not have the same reliable benefit as offering pills; you could count services offered without knowing if they’d changed anything at all. Primary prevention for HIV-negative people had the same problem. Condoms and abstinence-promoting comics were not proxies for numbers of infections averted.
The report reserved some of its strongest language for the earmarks in the original law. PEPFAR had
made spending money in a particular way an end in itself, rather than a means to an end… Although they may have been helpful initially in ensuring a balance of attention to activities within the four categories of prevention, treatment, care, and orphans and vulnerable children, the Committee concludes that rigid congressional budget allocations among categories, and even more so within categories, have also limited PEPFAR’s ability to tailor its activities in each country to the local epidemic and to coordinate with the level of activities in the countries’ national plans.
Earmarks had been essential to the program’s initial bipartisan support. The treatment carve-out had satisfied the Left and Right alike; the apportioning of a strict percentage of prevention dollars for abstinence programs provided Christian conservatives with confidence that they’d limited funding for sexual and reproductive health programs favored by their ideological foes.
Five years on, though, the program had to meet other requirements, including positions about the ontology of aid. Humanitarian aid is assistance offered in response to an emergency. Both the aid and the emergency are expected to be finite. Humanitarian aid is, to aid professionals, a thing apart from “development aid,” which is funding designed for the long haul. Helicopters to save people from disastrous floods are humanitarian aid; flood-tolerant rice is development aid.
Epidemics, which do not behave like crop cycles, bedevil these classifications. Some, like flu, do have a seasonality, but others arrive and persist in a state of emergency that does not abate but only appears to wane because of the human ability to accept once-unthinkable conditions as normal. “It is in our human nature to better respond to emergencies than to sustain efforts over time,” the Institute of Medicine report warned.
When it came to a pandemic of a pathogen that did not immediately kill its human hosts, the challenge was to conceive of a longue durée emergency, to ensure that compassion did not fade before the epidemic had been brought “under control,” a phrase that is itself subject to debate but often defined as the point at which the ratio of new infections to deaths is less than one. When more humans carrying the virus are leaving the world than entering it, then eventually the epidemic will wane.
Statistics seldom warm hearts like stories do.
The paradoxical solution to sustaining this support was to argue that the program was no longer going to act as though the epidemic was an emergency. A House report on proposed reauthorizing legislation read, “In the first five years of the U.S. response to the global HIV/AIDS pandemic, U.S. policy was driven by the urgency of an emergency response. Under this Act, the United States will develop and implement strategies to transition from the emergency phase to long-term sustainability that can be maintained by the host countries.”
It was time for PEPFAR to ensure that countries had control over, and by extension took responsibility for, their AIDS fights. Under this logic, the earmarks had to go. This argument was far harder for conservatives to refute than the more compelling and urgent claim—amply borne out by evidence—that the prevention earmarks in particular had done far more harm than good.
Excerpted from To End a Plague: America’s Fight to Defeat AIDS in Africa. Used with the permission of the publisher, PublicAffairs. Copyright © 2021 by Emily Bass.