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Throughout his weeklong swing through Africa, President George W. Bush's touted a five-year, $15-billion initiative to fight HIV/AIDS. Judging from the media coverage, however, you'd think this laudable humanitarian effort to contain a pandemic that's killing 2.4 million Africans annually and devastating the continent's economic hopes has already been undercut by a tightfisted Congress. As Bush was meeting with African leaders, the House Appropriations Committee cut $1 billion from the $3 billion earmarked for overseas AIDS programs in fiscal 2004.
The truth is, Congress is much less coldhearted than it seems. For starters, the House slightly increased the amount that Bush had requested for AIDS programs in his 2004 budget -- a fact the White House spinmeisters failed to point out. What's more, the Republican-led House sharply increased the U.S.'s contribution to the Global Fund to Fight AIDS, Tuberculosis & Malaria. Whereas Bush requested just $200 million next year for the Global Fund -- the same amount as in 2003 -- subcommittees of the House Foreign Operation and the Labor, Health and Human Service Committees have appropriated a combined $500 million. To make room for the added money, the House cut the Administration's request for new bilateral AIDS programs that would be run by various U.S. agencies.
PLAYING FAVORITES? What's going on here? In essence, it's a philosophical difference between the White House and influential Congressmen on both sides of the aisle over how U.S. taxpayer money can be best used against AIDS and other infectious diseases ravaging the developing world. The Global Fund, set up in 2001 with the backing of the U.S., the Group of Eight industrialized nations, and the U.N., is a multilateral effort that's deploying $1.9 billion to 155 AIDS projects. By contrast, Bush's new programs would be run by the U.S. Agency for International Development, the Health & Human Services Dept., the State Dept., and other agencies.
In theory, this unilateral approach would allow the U.S. to better control the way the money is spent. Also, it would presumably make it easier to steer funds to favored African governments, such as those backing the U.S. war on terrorism, and to accommodate domestic interests such as the pharmaceutical industry and "faith-based" groups pushing sexual abstinence, rather than distribution of condoms, as the best way to prevent AIDS transmission.
Not that Congress is opposed to the U.S. operating its own AIDS programs. But there's widespread bipartisan support for giving at least one-third of U.S. money earmarked for AIDS/HIV programs to the Global Fund, which already has programs operating across the developing world. The new U.S. programs would start from scratch, and it would be a year or two before they'd be ready to use big infusions of cash.
UP AND RUNNING. The Bush Administration "remains committed" to the Global Fund, insists Jay Lefkowitz, a White House aide on AIDS policy. He points out that U.S. funding for overseas AIDS programs has tripled since Bush entered the White House. In the past three years, the U.S. has given $625 million to the Global Fund, out of a total of $1.9 billion, according to a fund spokesman.
European governments have pledged an additional $600 million to the fund for 2004. And there's hope that European and Asian governments will come up with another $400 million at a donor conference scheduled for July 16 in Paris. By promising an additional $500 million, Congress hopes to increase pressure on other governments to cough up. "Only the Global Fund can leverage money from other nations," says U.S. Representative Jim Kolbe (R-Ariz.), who chairs a House subcommittee overseeing foreign aid and is a forceful advocate for boosting the U.S. role in fighting AIDS.
What's more, Kolbe says, because the Global Fund is already up and running in many nations, it can act more quickly to get life-saving medicines to AIDS victims. Kolbe says he was surprised that the Administration downplayed the fund in next year's budget request. "The puzzling thing about it was it was the Administration initiative to set up the fund" in the first place, he points out. Indeed, when the Global Fund was founded in 2001, it was hailed as a new model for efficiently managing foreign aid. The Bush White House even helped design the fund, provided vital seed capital, and had Health & Human Services Secretary Tommy G. Thompson installed as chairman.
NEW PROPOSALS. The organization is managed by an independent board of directors nominated by donors and a small staff of experts, rather than by some unwieldy U.N. bureaucracy. Third World governments compete for grants by explaining how they'll use the money and how those projects will help meet disease treatment and prevention targets.
Programs are then monitored nation-by-nation to assure they achieve results. Countries that fulfill their promises can apply for new grants. Those that fall short will in theory be cut off. A General Accounting Office study for Congress, meanwhile, found some weaknesses in monitoring processes, but overall gave the Global Fund high marks, says Kolbe.
It's too early to tell how effective the fund will be in actually reducing AIDS in Africa, says economist Steven Radelet of Washington's Center for Global Development. But he agrees with Kolbe's assessment that it got up and running "incredibly fast," especially compared to the Administration's own poverty initiatives. Already, the Global Fund is starting to dispense hundreds of millions of dollars to projects that will treat 500,000 AIDS victims and millions of TB and malaria sufferers. And it's assessing hundreds of additional proposals that can be financed when it receives a new round of funding for donors.
Washington's leadership is vital to get more money
So why bypass the Global Fund? "Quite to the contrary, we're very deeply committed to the fund and we want it to succeed," says White House aide Lefkowitz. The problem, Lefkowitz says, is that other governments haven't kept pace with Washington in coming through with money. He says that 42% of the money in the fund has come from the U.S. -- exceeding the 33% limit imposed by Congress. So before the U.S. can provide more, "the fund needs to broaden its base of support so that it is truly a global fund and can demonstrate that it can produce results." Lefkowitz also notes that the Global Fund was never intended to replace all U.S. bilateral assistance for disease-control programs.
Critics of the Bush AIDS policy dispute Lefkowitz' explanation. They say that non-U.S. donors already have delivered two-thirds of the money, and that if they fulfill their pledges for 2004, the U.S. share will fall well short of the amount it is supposed to give. In addition, Washington's leadership is vital to bring even more money into the fund.
GENERIC DRUGS. Anti-AIDS crusaders suspect domestic politics and Bush's general aversion to anything multilateral are the real reasons the White House is downplaying the Global Fund. Columbia University economist Jeffrey Sachs says White House officials told him that Bush "doesn't believe in giving a lot of taxpayer funds to an institution in which he can't fire the CEO."
Pressure from social conservatives also may be a factor. Groups such as the Family Research Council and Concerned Women for America have attacked the Global Fund for dispensing condoms as a part of AIDS prevention. Therefore, the Administration has promised that some portion of its funding will go to groups that promote sexual abstinence. What's more, the Global Fund buys generic versions of antiretroviral drugs that are much cheaper than drugs sold by Western pharmaceutical giants. The U.S. has lobbied against that practice because it contends generics violate the intellectual-property rights of big pharmaceutical companies.
Lefkowitz denies any of these concerns are real issues. He says there's no Administration bias against multilateral programs like the Global Fund and that purchases of condoms will be remain a vital part of comprehensive approaches to AIDS prevention in most U.S.-sponsored programs. He also insists that U.S. programs will buy generics as well as name-brand AIDS treatments. "Our goal is to purchase the cheapest drugs on the market," he says. But Paul Zeitz, executive director of the Global Alliance for Vaccines & Immunizations, counters: "That's news to me." In numerous public forums, Zeitz says, the Administration has declined to specify whether any U.S. bilateral money will be spent on generics.
SENATE INPUT. The issue of Bush's commitment to the global war on AIDS will get new attention in the coming weeks. If the July 16 donors' conference in Paris produces a flurry of new pledges from Europe -- especially from France -- expect pressure to grow on the U.S. to further increase funding. Already, several bills have been introduced in Congress for supplemental spending.
Bush was correct in stating during his trip that "AIDS is the deadliest crisis that Africa has ever faced." The Senate will also have a say in AIDS funding, and there are already rumblings that Senate Majority Leader Bill Frist (R-Tenn.) may seek a different allocation from that backed by the House.
Yet, while Washington debates how to administer its health programs, more Africans are dying of AIDS each day. And with new-infection rates continuing to rise, the death toll promises to become much higher. The world will be watching to see whether Bush is willing to back up his rhetoric with sufficient money.
Engardio covers international economics and issues relating to the Third World for BusinessWeek Edited by Douglas Harbrecht
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