Almost exactly 20 years ago, President George W. Bush stood in the White House Rose Garden and announced a $500 million initiative in Africa and the Caribbean to reduce H.I.V. transmission from women living with H.I.V. to their newborns.
The United States was already the largest donor to the newly minted Global Fund to Fight AIDS, Tuberculosis and Malaria. The new initiative further solidified America as a leading contributor to what was then the most consequential global plague. Yet Mr. Bush told aides that it wasn’t enough. He wanted to do more.
Aides to Mr. Bush went to Dr. Anthony Fauci, then, as now, the head of the National Institute of Allergy and Infectious Diseases. They asked what he would do if money were no object.
What happened next made history. Begun in 2003, the President’s Emergency Plan for AIDS Relief, or PEPFAR, is the longest-running and most successful global health program of its kind in American history. It was also long overdue. By 2002, the H.I.V. pandemic was over 20 years old, and 40 million people were living with the virus; the previous year, five million people were newly infected, and three million perished.
PEPFAR is often framed as an unqualified American success, leaving out years of prior inaction. There is danger in the American government claiming too much credit for its global health work. But today, in the context of Covid-19, there is far greater peril in claiming too little. PEPFAR’s history is an example of American governmental ambition that delivered; the current program is also an under utilized platform for Covid-19 pandemic action.
PEPFAR reflected rigorous, exhaustive research and vetting by the West Wing working in complete secrecy for months. When I interviewed Dr. Fauci for a history I wrote of the PEPFAR program, he recalled being told by Mr. Bush’s aides, “It has to be accountable, and it has to be transforming. It can’t just be a little bit of this and a little bit of that.”
To be transforming, an AIDS-fighting program had to deliver antiretroviral treatment. Six years earlier, these drugs had transformed H.I.V. into a chronic manageable disease for many people who could get access to them. In Africa nearly 30 million people had H.I.V.; fewer than 50,000 of those eligible had access to this therapy. Dr. Fauci and his deputy, Dr. Mark Dybul, pored over the costs and data and ultimately offered Mr. Bush’s aides a range of options, each centered on putting people with H.I.V. in Africa on antiretrovirals.
Mr. Bush chose the most ambitious plan and announced it in his January 2003 State of the Union address. The initiative would aim to treat two million people with H.I.V. over five years — the majority Black and brown people living in Africa, Asia and the Caribbean. He called it “a work of mercy” and has been celebrated for it ever since.
I was a young AIDS activist and journalist when Mr. Bush started PEPFAR, and — the possessive in the acronym notwithstanding — I never thought of it as the president’s program alone. I knew that people living with H.I.V. and their allies in the AIDS activist movement had impelled U.S. and foreign leaders to act and that Mr. Bush professed his hunger for more mercy at a moment when he was equally hungry for war in Iraq.
I moved to Uganda in 2004 when PEPFAR began, to write a fuller story. I spent a year sitting in clinics around the country, writing about the new AIDS drug programs. As I returned to those clinics and communities many times in the following 15 years, I witnessed nurses, doctors, policymakers and people living with H.I.V. working against the steep odds of structural violence — poverty, misogyny, homophobia, transphobia and more. This was their program.
Today, though, I miss an American government that is intent on claiming pandemic victory. On May 12, the United States co-hosted (with Indonesia, Belize, Senegal and Germany) the second Global Covid-19 Summit. Participants that wanted prominent speaking positions at the event needed to make significant new contributions toward what the United States has described as a $15 billion funding gap for a global Covid response to scale up vaccines, tests and treatments.
The United States showed up with what amounted to pocket change: $200 million for a World Bank-hosted fund for pandemic preparedness. It also put $20 million toward piloting antiviral programs in low-income countries and unveiled important agreements between the National Institutes of Health and the World Health Organization Covid-19 Technology Access Pool to share tools, vaccine candidates and technologies.
The White House and the Department of State regularly point out that the United States is the largest single funder of Covax, the global vaccine-sharing initiative, emphasizing how much the United States has done in comparison to other nations. But as Mr. Bush knew back in 2002, doing more than others is not the same as doing enough.
H.I.V. and the coronavirus are different pathogens; the pandemics are distinct in many other ways, including the fact that the coronavirus has a global grip, whereas H.I.V. was, by 2003, disproportionally affecting low- and lower-middle-income countries, especially in Africa. These distinctions do not moot the point: Twenty years ago, Mr. Bush started a strategic, ambitious and effective battle against a global plague that did not pose an existential threat to America. President Biden has eschewed this example, even though strategic action on Covid-19 abroad is urgently needed to save lives here at home.
Ensuring global equitable access to vaccines, tests and effective antivirals, with a focus on reaching the highest-risk people, will save lives. “The more people that we vaccinate globally, the less chance there will be that we will have more variants,” said Dr. Fauci. “Also, next-generation vaccines that prevent infection and transmission will greatly slow down the emergence of variants.”
The platforms to deliver vaccines, tests and treatments to adults do not exist everywhere they’re needed. Today investment in service delivery is sorely lacking and is one place the United States could play a leading role. Globally, some two-thirds of people have received at least one shot of a Covid-19 vaccine. But only 17 percent of people who are low income have received one or more shots. Access to effective antivirals and rapid tests is even more limited.
Adequate supply of high-quality vaccines is no longer the critical rate-limiting factor for many low- and lower-middle-income countries. Shots aren’t getting into arms because there isn’t enough investment in service delivery. Jeremy Konyndyk, the executive director of the U.S.A.I.D. Covid-19 task force, recently explained to me that initial budgeting based on childhood immunization programs underestimated the price tag of reaching adults.
Mr. Bush ensured that the United States played a catalytic role in building new adult-centered systems for H.I.V. care in record time. Mr. Biden and his staff are not following this example. Global Vax, which is surging support for vaccination in 11 countries, is the program that’s come closest to an ambitious U.S. initiative, but it’s limited in geographic scope and presently heavily focused on vaccines alone.
Global Vax, like the rest of the U.S. domestic and global Covid-19 response, is also close to running out of funds. Since the start of 2022, Congress has declined, on multiple occasions, to approve supplemental funding needed for global and domestic Covid responses.The White House and U.S.A.I.D. have been increasingly vocal about the dire impact of running out of funds.
But even as the White House calls for more money, it isn’t offering a single, ambitious strategy for its global investments in public health. Such a strategy, which would complement and not replace multilateral investments, should clearly state where it will work; say how many vaccines, tests and courses of treatment will be delivered to which communities or at-risk groups; and specify a deadline for delivery. In short, it should define what the U.S. government considers “enough.”
Over the past 18 months, the U.S. government has devoted significantly more time and resources toward aiding the global public health response than it did during the Trump administration. It has re-engaged the World Health Organization, plowed money into Covax and donated millions of vaccine doses. It has made a point of being a member of the global community working together on a pandemic response.
Contributing to multilateral mechanisms like Covax is important. It also isn’t a substitute for an ambitious American effort centered on service delivery and developed bilaterally with key countries. After the bilateral PEPFAR program launched, the United States remained the largest contributor to the multilateral Global Fund to Fight AIDS, Tuberculosis and Malaria, as it is to this day.
The recent history of Covid-19 suggests the same approach is needed. The multilateral mechanisms developed for Covid-19 and proposed for pandemic preparedness have struggled to live up to their promises and often do not include meaningful leadership and input from low- and lower-middle-income countries and civil society groups.
The United States should use its leverage to ensure that multilateral bodies and funds work better. At the same time, it should develop its own truly ambitious global effort in partnership with civil society groups and other governments. This will speed progress on epidemic control at home and abroad — not because America would pay for all of it but because it would partner to show what is possible.
Many have called for just such a clear American action plan alongside the other investments, including a group of global health experts who called for an “emergency plan for global Covid-19 relief” in August 2021. The recommendations went unheeded.
Instead, the United States persisted with a scattershot response that has added up to more than others’ but not enough. U.S.A.I.D. is leading Global Vax. The U.S. Department of State has tried to rally other governments around a global action plan. The U.S. Department of Health and Human Services has convened high-level meetings focused on scaling up testing and treatment. Gary Edson, a Bush-era West Wing operative who helped start PEPFAR and is now the president of the Covid Collaborative, has described the administration’s strategy as “a tapestry of actions rather than the straight line of a strategy.”
Such fragmentation isn’t a surprise. U.S. government agencies hold their portfolios closely and compete viciously. A presidential mandate is the only way to force true interagency collaboration. But many who have pushed the Biden administration to take a more strategic approach to the global Covid response feel the administration may be leery of owning the pandemic.
This is an unfounded fear. PEPFAR does not operate globally; it does not even operate in all parts of the countries where it has a presence. The Global Fund to Fight AIDS, Tuberculosis and Malaria and domestic governments cover major swaths of the world. Where it operates, PEPFAR often tests new ideas and pushes the evolution of policies on when to start antiretrovirals and how to deliver them. These innovations spur broader change that gets paid for by others.
PEPFAR is both a model and a platform that can be used right now. “It would be a shame not to use the PEPFAR program for greater functions. There’s just not a chronic care platform that can compete with it,” said Thomas Bollyky, the director of the global health program at the Council on Foreign Relations.
It is possible, though by no means guaranteed, that an American vision would garner or strengthen bipartisan congressional support, which has, with PEPFAR, been linked to confidence in American control over global health foreign aid funds.
When I began visiting AIDS treatment clinics in Uganda, the people in the packed waiting rooms often applauded when they learned I was American. They thanked me for the drugs my country had paid for. “I’m not a doctor or a funder,” I said, learning the phrase in many languages. I wanted distance from the messiness of American foreign aid, its purchase of hearts and minds, its premise of benevolence to Africans on the part of a state founded on their enslavement.
But avoiding the complexities does not make them disappear. Mr. Bush was not my president of choice, but as a taxpayer, PEPFAR is my program. It belongs to all Americans. If Mr. Biden does not use PEPFAR as a playbook, platform and precedent for ownership of select components of the global Covid-19 response, the pandemic’s lethal disruptions will be prolonged both overseas and on American soil.
Emily Bass is a writer, global health expert and AIDS activist. She is the author of “To End a Plague: America’s Fight to Defeat AIDS in Africa.”
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