Bush League: Fighting AIDS with the President

How a young liberal became a tiny part of George W. Bush’s $15 billion anti-AIDS plan.

Up and down Philadelphia’s Market Street, there were protesters and counter-protesters, Socialists and Anarchists and Libertarians, Catholics and Greens and others with no definable political philosophy. It was August 1, 2000, Day Two of the Republican National Convention, and I had joined up with a group of Quakers out of Brandywine protesting the proliferation of nuclear weapons. Meanwhile, the delegates gathered inside the nearby First Union Center were hours away from formally nominating George W. Bush as their party’s presidential candidate.

Back then, my world view was less nuanced — it held that Republicans and Democrats alike were on the Wrong Side, along with consumerism, racism, militarism, and country music. I was indignant and impatient.

Most of the next eight years lived down to my young self’s darkest expectations. There were stolen elections and 9/11; wars, wiretapping and officially-sanctioned torture. The American government spied on its own citizens and kidnapped people off the streets of Milan and Dar-es-Salaam. Habeas Corpus was curtailed, and corporations with ties to politicians made billions in Iraq and Afghanistan.

However, those same eight years also changed that kid in Philadelphia with his hands full of placards and his head full of slogans. My unsophisticated view of right-versus-wrong broke down through travel, study and contact with people of all persuasions. I became convinced that solutions to serious problems require participation and ideas of people from all sorts of perspectives — even Republicans.

During these eight years, I managed to work for no fewer than three of George W. Bush’s major initiatives. Now, on the verge of a new presidency, I find myself looking back and asking if those programs were ultimately good, bad, or kind of a wash. And if they ultimately did good, was it because of or in spite of Bush?

I still don’t know. But at the very least, the younger me deserves an explanation.


In his State of the Union Address on January 28, 2003, President Bush announced that over the next five years the United States would dedicate $15 billion to combat HIV/AIDS around the world. The fund became known as the President’s Emergency Plan for AIDS Relief, or PEPFAR. It constituted the largest commitment by any nation to the amelioration of a single disease. In fiscal terms, it placed America at the forefront of the international effort to halt the deadly progress of what was sometimes called “the disease of the century.”

The need for such a commitment was unambiguous. In the year preceding Bush’s announcement, 3.1 million people had died of AIDS. Five million more people contracted the disease. AIDS was wreaking havoc upon entire social systems.

In southern Mozambique, where I was living at the time of Bush’s announcement, one in five people my age were HIV positive. The opportunistic character of the disease attached itself to everything: gender disparities, poverty, alcoholism, government corruption, modernity, love, trust.

In spite of a massive information campaign, the sickness was still largely spoken of in euphemistic terms. “Malaria,” friends and family would explain when someone went missing or died. Sometimes blame went to something altogether less likely: asthma, black magic, sadness. In my village, situated close to the south-western border of Mozambique, the preferred euphemism avoided death altogether.

“They have gone to South Africa,” people would say.

In that way the sick could avoid sickness, and the dead could go on living.

The idea of a girls’ leadership conference came up during a meeting of Peace Corps volunteers in January 2005. As health workers and secondary school teachers, my fellow volunteers and I had seen firsthand the ways in which gender inequality had made girls and women in Mozambique particularly vulnerable to HIV. Women might know what condoms were, and understand that infidelity increased the chances of contracting a host of diseases, but they often lacked the power and skills to negotiate with their partners and husbands. In spite of years of socialist and post-socialist leaders paying lip service to the importance of women, Mozambican society was still largely misogynistic.

Given that most of our students were either in the “window of opportunity” (between the ages of 10 and 14, before most were sexually active) or still in the early stages of their sexual development, we knew that we were in a good position to do something positive. We decided on a young women’s conference not because working with boys was unimportant, but because we believed we were in a unique position to create a space where girls would feel comfortable talking about difficult issues. We were familiar with feminist concerns and the idea of gender equality; we had the resources to recruit Mozambicans who worked with women’s rights and could help us integrate our perspective into the local cultural context; and we had a ready-made network of volunteers who could recruit the most motivated young women from across the country and provide them with leadership training that they could take back to their villages.

We eventually settled on a name for the conference: REDES. The acronym, meaning “networks” in Mozambique’s common language of Portuguese, stood for Raparigas em Educacao, Desenvolvimento, e Saude — Young Women in Education, Development, and Health. We envisioned a five-day conference, held in a central location, with each day focused on a different theme — relationships, health, leadership, and so on. We began to develop activities and send out invitations to guest speakers.

The only thing missing was the money to fund our conference. This was no small concern; transportation, housing, and food alone would run into the thousands of dollars. We petitioned a few local and international non-governmental organizations for funding, but in the end we decided to go to the US embassy and see if we couldn’t get our hands on some of Bush’s $15 billion.

As it turned out, we weren’t the only ones looking for the money. Wherever we went, people were talking about PEPFAR and what it meant for their organizations.

“We’re thinking of running a commercial,” one person at the US Agency for International Development told me.

“A commercial?” I was confused. There were already at least three other organizations running AIDS-related commercials on the local television stations. I didn’t see what USAID was going to accomplish with yet another 30-second ad.

“It costs a lot,” the person told me, “so it’s a quick way to get rid of the money.”

The look on my face must have prompted the explanation that followed.

“This PEPFAR thing came at us pretty quickly, and it’s a lot of money: USAID was given $60 million to disburse in Mozambique alone. If we don’t spend it by the end of the fiscal year, they’ll be money left unspent. That money will show up on the ledgers come September — meaning that we won’t get as much next year.”

“So you’re running a commercial,” I said, “to get rid of money that you can’t spend otherwise, in order to get more money next year.”

“Yeah.” The person shrugged. “It’s better than not having the money at all.”

Perhaps more surprising were the ways in which PEPFAR funds were being used in our own Peace Corps office. Asking around, I found that money from the fund was being used to pay the salaries of local staff, including some of the drivers and training facilitators. PEPFAR was also helping to sustain the health program, which placed Peace Corps Volunteers with non-governmental organizations across the country; some of these NGOs worked with AIDS-related issues, and some did not.

Again, I was perplexed. Didn’t the Peace Corps budget support these programs? Why was one government program being used to finance another? To me, it was like using money from the Bureau of Alcohol, Tobacco, and Firearms to support the military simply because guns were involved in both.

One day a staffer at the Peace Corps office explained it to me like this:

“You remember Bush’s speech to the country after 9/11, when he said he was gonna double the size of the Peace Corps? Yeah, well, we took that seriously. Not just in Mozambique, but around the world. Programs started to expand. We fielded more volunteers. Then came Iraq, and Bush found other places to spend the money. We didn’t get nearly the amount of dough we asked for, and you saw how that went.”

I nodded, remembering how at one point we volunteers had organized to fight the proposed elimination of tampons from the medical supply kits due to budget cuts.

“Not long after that we began using PEPFAR cash to pay for the expansions that were supposed to be covered internally. And here we are. If you think about it, it’s a win-win for the folks in Washington. Not only do they get to say they spent $15 billion on AIDS, they can also claim credit for an expanded Peace Corps. A classic bait-and-switch, and no one is the wiser.”

“Doesn’t it make you angry?” I asked.

“For my part, I don’t care who gets the credit or where the money comes from,” he said. “What matters is that we are out here, doing what we do.”

So the money was there, and it was being used to fund projects that had at least as much justification as the girl’s leadership conference. Still, we were nervous about whether or not we would qualify for a grant. The fear that our project would prove ineligible for PEPFAR funding boiled down to something as simple as ABC.

To many of those involved with development work in Africa, ABC was a mantra, a prescription, a barebones plan of action to slow the spread of HIV. It stood for “Abstain, Be faithful, and use Condoms.” It was a message handed down through prevention campaigns across the continent, in English, French, Portuguese, and dozens of local languages. It was printed in pamphlets and billboards and spray-painted on village walls.

For those that swore by it, the beauty of the ABC message was in its simplicity. It was easy to understand and easy to remember. It gave individuals power over their own fates. Proponents of the ABC approach pointed to the case of Uganda, where HIV prevalence had fallen from a rate of 15 percent in 1992 to 5 percent in 2001; the ABC message had figured prominently in Uganda’s campaign to halt transmission.

To others, however, ABC was an open question — a laudable goal, to be sure, but one whose realization required more than spray paint and slogans. These people saw not beauty but danger in the simplicity of the message; to them, it hid complicated factors related to the spread of HIV such as wealth and gender inequality and the unavailability of anti-retroviral medications. They questioned the nature of Uganda’s declining prevalence, maintaining that it had as much to do with death rates as with any particular strategy.

The most contentious debate surrounding ABC, however, was over the emphasis placed on its individual components. There were those who believed that abstinence and faithfulness were paramount to the containment of HIV, and those who believed just the opposite — that promoting condom use was the only practical and effective point of departure. In shorthand, it was ABc verses abC, with the shift in capitalization representing a fundamental disagreement about how to tackle the spread of the pandemic.

Admittedly, the two positions were not always mutually exclusive, nor did their adherents necessarily break down along predictable religious or political grounds. Some churches were conspicuously silent when they could have criticized the the distribution of condoms, and some liberal-leaning individuals were vocal in their support of abstinence as the most sure-fire way to avoid infection. Organizations with divergent outlooks often worked together on prevention campaigns, putting aside their differences to help those in need.

With PEPFAR, however, the Bush administration was threatening to take the debate out of the hands of those most intimately involved with the struggle against HIV and pass it over to policy makers who had little firsthand experience with prevention campaigns. From the beginning, Bush insisted that a portion of PEPFAR funds (33 percent of total expenditure related to prevention, with the possibility of a future increase) be available only for programs dedicated to abstinence until marriage. Bush’s apparent goal was to unilaterally transform the approach from ABC to AB(c), using his administration’s control of the money to relegate any discussion of safe sex to a parenthetical afterthought.

Within our group of volunteers, there was a general consensus that safe sex and condom use should be central to the conference’s focus on reproductive health. We would talk about abstinence in the context of a woman’s right to refuse sex, and we would mention that refraining from sex was the best way to avoid infection. At the same time, we felt we had a responsibility to acknowledge the cultural, economic, and biological factors that rendered long-term abstinence difficult for many of our students. That meant talking about C — capital C, without parentheses. And that, in turn, meant that the whole project was at risk of failing before it even got off the ground.

The world of development work is full of designations and catch-phrases that often obscure galaxies of meaning, perspectives laden with both assumption and experience. OVC is an acronym used to tabulate the numbers of “orphans and vulnerable children” in a given area; yet it does nothing to reveal the nature of daily life for these children, their pain and laughter and hopes. The phrase “local capacity-building” is almost always uttered by an expatriate (or someone in the employ of an expatriate), while the thousands of local small entrepreneurs, teachers, and parents whose work builds a stronger community think of it as “making a living.”

As we went about writing our proposal, we were told to use these vagaries to our advantage. Play down the condom stuff, experienced development workers told us. Call it “disease prevention education.” Give greater weight to the other components of the conference so that the sex education stuff gets lost in the shuffle. Speak in generalities about family planning (which in itself is a euphemism, of course) but mention the word abstinence whenever possible. Throw in other key words: moral, faithfulness, behavior, marriage.

In some cases, this advice was given to us by the same people responsible for approving PEPFAR requests. As we solicited help from embassy staffers and USAID representatives, we noticed a distinct disparity between the outlook of people on the ground and the official PEPFAR stipulations regarding abstinence; even those in charge of handing out the money seemed to treat the condition as an annoyance to be worked around. This was strange to us, especially given that the Bush administration had recently announced its plan to double the percentage of funding earmarked for abstinence.

In the end, we handed over our proposal with a barely concealed wink, confident that those in charge of funding were on our side and that we had done what was needed to obfuscate any references to safe sex. A few weeks later, word came back: Not only was our proposal approved, but the embassy had given us a couple thousand dollars more than we had requested.

On the conference’s opening day, the US Ambassador to Mozambique gave a moving speech about her own path to success, and about the particular obstacles she overcame as a woman working in a traditionally male-dominated sphere. It was a touching, quiet moment, when the assembly of young women gathered from far-flung villages realized they shared something fundamental with this poised diplomat whose life seemed so different from their own. For many of them, it was a struggle they hadn’t even named yet, given value for the first time by its mere acknowledgment.

Over the next five days, the young women explored different aspects of leadership and strength. Through seminars, role-play, art, song, and support sessions they began to connect their outlook on the future to their sense of self-worth; they learned how to take a stand in decisions that affected their lives; they identified areas in their home villages where they could exercise more control; and yes, they learned about safe sex.

Ultimately, the merits of the conference will be measured by the trajectory of the young women’s lives, by the choices they make and the actions that define them. Judged by more modest standards, however, the conference was a success. New concepts and ways of thinking were introduced. Mozambican teachers and American volunteers worked together to make the most of it, and all were enriched by each other’s experience and perspective. None of it would have been possible without both the PEPFAR funding and the willingness of those in charge of the funding to look beyond its blanket conditionalities. Thanks to the persistence of these two factors, the conference has become an annual event, although the volunteers who first created it have since moved on.

That first year, we used the extra money to take the students to the beach after the closing ceremonies. For some of them, it was the first time they had ever seen the ocean. They piled out of the bus and stood barefoot on the sand for a moment, looking out at the implausibility of so much space and water. Then they took off running and didn’t stop until they hit the waves.

Next month: The Millennium Challenge Account

Article © 2008 by Dennis Wilson