Man of the World: The Further Endeavors of Bill Clinton (18 page)

That international dispute had erupted, momentarily but dramatically, on June 16, 1999, in Carthage, Tennessee, where Al Gore was announcing his presidential candidacy in his hometown. Protesters from AIDS activist groups such as ACT-UP and the Health Gap Coalition interrupted his speech with loud chants of “Gore’s Greed Kills!”

Ushered away by security guards, the activists would continue to chase Gore into 2000. As vice president, he had fiercely enforced administration policy by bringing heavy pressure on nations seeking to loosen patent restrictions on AIDS medications, notably South Africa and Brazil, with threats of trade lawsuits, sanctions, and reductions in U.S. aid. Even though the administration had tried to soften its stance on generics by 2000, the shift came too late to spare Gore a severe embarrassment.

The administration’s threat to punish developing countries that sought to provide affordable medicine for infected citizens quickly became a favorite theme for Ralph Nader, as the consumer activist prepared his own candidacy for president on a third-party ticket in 2000. He accused Gore of “ignoring” the pleas of AIDS activists.

As a legal matter, the Clinton-Gore administration had believed its objections to any attempt to evade or vacate the patents were valid under the World Trade Organization’s rules on intellectual property—known by the acronym TRIPS, for Trade-Related Aspects of Intellectual Property Rights. Before the advent of TRIPS in 1994, many nations didn’t recognize pharmaceutical patents at all, costing manufacturers billions of dollars in lost revenues and, in their view, constricting their ability to recover the enormous costs of creating and testing new drugs.

The voluminous TRIPS regulations required all WTO member states to restrict the manufacture or importation of patent-protected drugs, including the antiretroviral formulas that had been developed to slow the debilitating, deadly effects of AIDS. Like most national leaders, Clinton saw the safeguarding of U.S. patents and products as one of his central responsibilities in overseeing international trade. Not only Gore, but also the U.S. trade representatives appointed by the president had carried out that duty for years, with a tough approach and Clinton’s enthusiastic backing.

But in human terms, the White House insistence on adhering to protective patents on AIDS drugs, while millions of people suffered and perished, had been inexcusable. Moreover, Article 27 of the TRIPS rules permitted member states to make exceptions when “necessary to protect
ordre public
 . . . including to protect human, animal, or plant life or health.” Any member state that sought to exercise that clause, however, at least with respect to pharmaceuticals, came under severe pressure from the United States government.

In hindsight, Clinton regarded that policy as a moral and political mistake that had become a huge problem for his administration. He faulted himself for failing to step forward to resolve the issue directly, since it involved a conflict between his trade representative and his “AIDS czar.”

Years later, he would admit, “Oh, I should have been much harder for the generic options for AIDS . . . but the trade office thought their job was to protect American patents . . . and I think I should have been more aggressive there.” Whether lifting patent protections would have made a real difference was an open question, because even at lower prices there was little funding available at the time for treatment of AIDS in developing countries—a factor that Clinton blamed on congressional Republicans, who had rejected his requests for more money.

Even before Clinton returned to private life, worldwide outrage had exploded over the pharmaceutical industry’s self-serving behavior and his administration’s support for it. Worried by the rapid erosion of their global image, the major drug companies agreed to discuss providing medicine at discounted prices in the developing world with the United Nations.

Under the umbrella of the International Federation of Pharmaceutical Manufacturers & Associations, or IFPMA—a global counterpart of PhRMA, the American drug lobby—executives from big brands such as Merck, Pfizer, GlaxoSmithKline, and Hoffmann-LaRoche sat down in May 2000 with delegates from the World Health Organization, UNAIDS, and several African countries, including South Africa, Nigeria, and Kenya, as well as an aide to then-Secretary-General Kofi Annan. These discussions were grandly titled the “Accelerating Access to HIV/AIDS Care, Treatment, and Support Initiative.”

The negotiations went on fruitlessly for well over a year. The U.N.
representatives asked for drastically reduced prices in developing countries, with free medicine for some selected groups, and the easing of patent restrictions to permit generic production by Indian, Egyptian, Brazilian, and other local manufacturers. The representatives of IFPMA warned that patents embody the incentive to produce new treatments and cures—and moreover, that simply doling out drugs would be ineffective and even harmful in the absence of functioning health systems to test, monitor, and care for patients.

The drug companies also continued to argue that “prevention” rather than treatment should be the primary objective of health authorities in the developing countries.

After several meetings between the drug manufacturers and the U.N.-led coalition in Amsterdam and Geneva, they had jointly announced a deal in the autumn of 2001. The drug companies promised to provide AIDS medications at considerably lower prices, while the World Health Organization and the African states vowed to build the infrastructure needed to safely deliver treatment—and not to permit those drugs to be resold outside their borders. Yet their agreement, signed by all parties in December 2001, had not resulted in the delivery of a single bottle of medicine six months later.

Or, as Magaziner summed up the situation in his memorandum to Clinton and Williams: “So far nothing has come of this.”

Nevertheless, the World Health Organization continued to function as if something might come of its efforts. It had issued a detailed set of guidelines to be used by the developing countries in purchasing, testing, and distributing treatments for AIDS. Specifically, the WHO recommended the use of “triple-therapy cocktails,” combining three antiretroviral medications into a single pill, and indicated which particular combinations ought to be tried first with any patient. Use of the triple-therapy technique had reduced AIDS deaths in the United States by 70 percent, as Magaziner’s memo noted.

The WHO had also urged that, at minimum, any health center established to dispense anti-AIDS drugs should maintain equipment to conduct HIV tests as well as hematocrit tests to measure red blood cell count. WHO officials had also inspected and certified several generic pharmaceutical factories in India, and one in South Africa, to produce the needed drugs.

With all of those agreements, recommendations, and certifications in place, according to Magaziner, there still remained three gigantic barriers to widespread HIV/AIDS treatment in sub-Saharan Africa—where he estimated that only 36,000 of the approximately six million in need were getting any medicine or care at all. First, regardless of the drug companies’ concessions, prices remained too high. Second, the available funding for treatment remained too low. And finally, “the most vexing issues relate to how to organize the distribution and testing efforts within most countries and how to garner and use funds efficiently.” There were no health systems in place that could use the money and the drugs effectively even if both fell from the sky.

The conclusion of Magaziner’s memo was rather dry. Headed to South Africa on other business in late June, he wanted to know whether Clinton “has any interest in exploring further the approach I have suggested in my memo. . . . I will be making decisions soon on how to allocate my own time and the time of people working for me for the next year. . . . I do believe there is a very valuable role that he can play on this very important issue, and I would be happy to pull this together for him if he wishes to do it.”

Although Magaziner’s proposal intrigued Clinton—who had no illusions about the magnitude of the AIDS crisis—he didn’t tell his old friend to move forward immediately. The prospects for success in such an endeavor were extremely uncertain; indeed, failure seemed far more likely. He was still raising money for his library and his own legal debts, and felt reluctant to commit without an independent source of funding. While Clinton considered the proposal, he drew Magaziner into the preparations for his forthcoming appearance at the International AIDS Conference in Barcelona on July 12, when he and Mandela would deliver closing remarks.

For Clinton, the conference represented as much a challenge as an opportunity. Activists from around the world who attended these events would have little patience for the rhetorical mush so often spooned out by speakers on the international stage. They were sure to be acutely aware of the vexed record of the Clinton administration on
generic pharmaceuticals. Whatever he might tell them now about the vast increase in funding and attention that he had overseen as president, they would want to know what he had done lately—and what he intended to do now, besides giving more speeches.

Clinton invited Magaziner to join the small entourage going to Barcelona, which would include Sandy Thurman, who had served as Clinton’s top AIDS adviser in the White House; Bruce Lindsey; Doug Band; and Magaziner’s daughter, Sarah. (The invitation didn’t include airfare or hotel accommodations for her or her father, who paid their way from his own funds.)

Upon arriving in Spain on July 10, Magaziner was hardly surprised to learn that Clinton was still working on his speech, although Thurman had prepared a draft for him.

That same evening, he and Clinton held a private meeting with several of the African leaders whom Magaziner had consulted during his spring journeys researching the AIDS crisis—notably Mozambican prime minister Pascoal Mocumbi and Rwandan president Paul Kagame, as well as Denzil L. Douglas, prime minister of the small Caribbean archipelago of St. Kitts and Nevis, who chaired the Organization of Eastern Caribbean States and happened to be a medical doctor. They told Clinton what they had told Magaziner when he visited them months earlier—that their countries were facing a health catastrophe that they could not possibly overcome on their own.

“Look, we don’t have a denial problem in the Caribbean,” said Douglas, who had organized a group of leaders seeking to cope with AIDS in the region, which had the second-fastest growing rate of HIV infection in the world. “We don’t have much of a stigma problem. Our problem is money and organization.”

He looked directly at Clinton, who said, “What would you like me to do about it, Denzil?”

“I want you to fix it.”

“Okay,” Clinton replied. “I’ll do it.”

Sometime that night, Magaziner typed an uncharacteristically passionate and personal note on his laptop, printed it out, and delivered it to Clinton the next morning.

In keeping with his habit that so offended Band, the note was addressed to “Bill”:

After yesterday’s discussion with the government officials, I am more than ever convinced that we should move forward with the AIDS project. Prime Minister Mocumbi, Prime Minister Douglas, President Kagame and the others all clearly are desperate to move forward on AIDS care and treatment but lack the capabilities and resources to do so. . . .

I will volunteer my time to lead this and I am confident that I can pull together enough volunteers to get it moving successfully. . . . I know that you do not have the funds to support this and that you must direct your fundraising to your library and other matters the next few years, but I believe I can put together sufficient funds to bankroll the travel and other expenses that would be necessary to support the volunteers. I will put in a million dollars myself to get this started.

He believed that he could persuade his friend David Sainsbury, the British supermarket magnate, liberal philanthropist, and minister in Tony Blair’s government, to “put in another million,” along with some smaller donors. He would also donate the time of several employees of his consulting firm and the use of its suburban Boston offices.

I do not know for sure how successful we will be, but I feel like we have to try. You have a tremendous global reputation and are respected by leaders around the world. We should use that reputation and your contacts for something big. If we succeed at this, we can help save millions of lives. If we are not so successful, we still might help save tens of thousands of lives, which would not be so bad.

As we were discussing last night before the dinner, we cannot stand on the side lines while millions of people are dying each year and the means are available to help save their lives. Let’s make the decision and go for it.

Thanks

Ira

Late in the afternoon of July 12, Clinton walked slowly out onto the huge stage of Barcelona’s Palau Sant Jordi, a stadium built for the Summer Olympics in 1992, with the eighty-four-year-old Mandela—who held a cane in one hand and Clinton’s arm with the other. Together they looked out over an audience of roughly ten thousand scientists, health officials, and activists, who had been waiting patiently during a long delay before the closing ceremonies finally began. This was essentially the same audience that had literally booed U.S. secretary of health and human services Tommy Thompson off the stage during one of the earlier conference sessions, whistling and shouting while he tried to persuade them that the United States was doing more to combat AIDS than any other country.

But now, even before Mandela or Clinton said a word, they were cheering. Much of what Clinton said in this speech he had said before. Future generations would never understand why the world had allowed a lethal but preventable disease to infect as many as 40 million people, a number that could shortly grow to 100 million, he said. National leaders should “move aggressively to remove stigma and denial. There are still people who think people living with HIV/AIDS are people who are different. Yes, they are sex workers, and poor and often gay men . . . but they are also our friends.”