Man of the World: The Further Endeavors of Bill Clinton (23 page)

At some point in their discussions, wondering about her verdict on his presidency, he had asked, “How do I come out?”

“‘You didn’t do near enough’,” he quoted her telling him. “‘But you did more than anybody else in the whole world, so you come out OK.’” When he told that story to reporters he would laugh, but the subtext was serious.

Now his successor, with whom his relationship was at best lukewarm, was proposing to do far more, much closer to “near enough” than Clinton had done.

Within days after Bush’s address, Clinton appeared on CNN’s
Larry King Live,
where the host asked whether he was “surprised” when the president devoted so much attention to AIDS in the State of the Union. His answer was defensive.

“Well, first let me say that I was pleased. When I was president we tripled overseas aid to [combat] AIDS and by the time I left office, America was providing about half the money that the governments of the world were spending on this, but it’s nowhere near enough. So I was very pleased and I’m very glad.”

He quickly noted that his foundation was already working in “16 countries in the Caribbean” and “two in Africa, soon to be three and maybe four,” setting up national health systems to cope with AIDS, tuberculosis, and malaria.

And then he hinted at the conflicts soon to come with the pharmaceutical lobby and its friends in the Bush administration.

“But we need—there’s still, unbelievably . . . there are still efforts to stop affordable drugs getting out there. Now we’ve got drugs that stop mother to child transmission [of HIV] when the mother’s infected, and the baby’s born free of AIDS, 98 percent of the time. We’ve got drugs that make AIDS from a death sentence into a chronic illness for healthy people, if they can get them.”

If they can get them
—which seemed certain by no means to Clinton unless someone cleared away the obstacles posed by the Western drug manufacturers, as he had just started to do in the Bahamas.

“This is a global problem and I welcome the president’s financing. The Congress needs to pass it,” he went on. But the real issue would be the cost of medicines and the systems to distribute them and ensure that they would be used properly.

“If we can get [medicines] out there in these countries for $500, $300, then $1,000 can pay for care
and
medicine. That’s going to be the key. That’s why I say the government of the United States can have a huge impact in talking to the drug companies and making sure we clear out all of the roadblocks to either getting these drugs out at an affordable price or setting up the facilities like in South Africa, as they do in India, Thailand and other places to produce the drugs. We’ve got to get the medicine out there.”

But Clinton had no way of knowing how Bush intended to proceed, beyond his promise to spend billions. Like nearly all the significant leaders and activists in the global campaign against AIDS, Clinton and Magaziner had been excluded from the secretive planning process in the Bush White House in the months leading up to the PEPFAR announcement. Unlike many of those leaders and activists, they concealed their skepticism about the ideological and corporate imperatives that might undermine PEPFAR’s effectiveness, no matter how sincere Bush himself might be.

In a Republican administration, Clinton knew that the power of those imperatives should not be underestimated. The pharmaceutical manufacturers would exert great pressure to protect their patents and markets, just as they had done so successfully when he was president. The evangelical right, despite its refreshing determination to
help AIDS victims, would insist on “abstinence education” in PEPFAR’s budget, no matter how useless. All those potential disputes could only be exacerbated by the deeply rooted animus against Clinton himself in the Bush White House.

Still, neither he nor Magaziner foresaw the ugly confrontation that would erupt before long.

CHAPTER SEVEN

What Bill Clinton could accomplish with a meeting, or even a telephone call, was remarkable. While the American media still tended to describe his reputation as tarnished, the shine seemed to reappear almost magically whenever he ventured abroad, whether physically or electronically. His sterling international image proved to be worth not just millions but hundreds of millions of dollars for the cause he had taken up.

Having publicly demanded, as a moral imperative, that the world provide treatment to the millions suffering with AIDS across the global south, from the Caribbean to Africa to Southeast Asia, Clinton began to pull together the elements of a strategy to accomplish that objective, devised by him and Ira Magaziner. It would require moving forward on at least three fronts simultaneously, starting out with scant resources.

With the overnight success of CHAI’s debut in the Bahamas—where a few direct inquiries to suppliers had reduced the government’s cost to purchase AIDS medications by seven-fold immediately—the fledgling initiative had signed on to assist fifteen states in the Caribbean, along with Mozambique, Rwanda, and Tanzania. The combined total of all the AIDS patients receiving treatment in those countries at the time was under two thousand.

To secure sustained funding from Western governments, as Clinton and Magaziner surmised, each country would need to present a detailed and feasible plan to create the physical and human infrastructure for effective treatment. Urban and rural facilities would have to be built or rebuilt, equipped, and accredited; doctors, nurses, and clinic workers would have to be trained; and supply chains for affordable medication would have to be established, all in countries that barely possessed any functioning health care systems. Moving forward on those plans, Magaziner needed to recruit skilled people, willing to spend time in
backward and sometimes dangerous places—and he would have to attract them with scarcely any budgeted funding.

The second element was the notion of an international “buying club” for AIDS medications, designed to encourage drug manufacturers to reduce prices in exchange for greatly increased sales volumes. If they could order for two million patients instead of two thousand, Clinton and Magaziner believed they would drive down the unit price of each dose of antiretroviral medicines like azidothymidine or AZT, a first-line treatment for AIDS. Magaziner estimated that the annual cost per patient could be pushed much lower than $500, the level they had achieved in the Bahamas (which as the richest Caribbean country could afford prices that were still too high for other developing nations).

But there could be no promise to expand the market for AZT, and use volume sales to bring down prices, without the availability—or at least the promise—of very large sums, soaring into the hundreds of millions and eventually billions of dollars. The third element was money: Without it, their ideas would remain mere projections.

Magaziner had put in a million dollars of his own money and had raised another $1.2 million from David Sainsbury and other wealthy friends. Although insignificant compared with what would be needed to launch treatment programs at scale, that war chest was enough for him to get started on the ground. From his consulting office in suburban Quincy, Massachusetts, he and his staff began to recruit volunteers. At the beginning, everyone, including Magaziner himself, would volunteer. To conserve funds, CHAI would pay only travel expenses—coach seats, cheap hotel rooms, and a meal allowance.

He approached friends in the public health field, at places like the Harvard AIDS Institute and Columbia University’s Mailman School of Public Health, who were intrigued by the idea of Clinton becoming more deeply involved in the AIDS crisis, but still wondered whether his involvement would extend much beyond speeches and press releases.

“No,” Magaziner told them in his low, grave voice. “We’re seriously going to try” to bring treatment to millions in Africa and across the developing world. They were intrigued, but very skeptical, so he brought a dozen of the top medical experts in the field—including Paul Farmer and Jim Kim of Haiti’s Partners in Health, Richard Marlink and Bruce
Walker of the Harvard AIDS Institute, and the University of California’s Eric Goosby—to meet with Clinton in Harlem, where the former president convinced them that he meant to act rather than just talk. Seeing Clinton move so quickly to obtain signed agreements with several governments helped to persuade them that CHAI was real.

At the same time, Magaziner started calling old friends in the business world, mostly “serial entrepreneurs” who had made money and were seeking to do something different and socially valuable, like him. Some were between start-ups, while others were about to retire. He wound down almost all of the contracts then held by his own firm, SJS Consultants, and assigned his employees to start working on CHAI. And he asked former colleagues at the Boston Consulting Group and at McKinsey & Company to lend him some young employees who were “on the beach” because they didn’t have enough work.

One of his earliest contacts was Dr. Allan Rosenfield, dean of the Mailman School at Columbia, a legendary figure in the field of international health, and one of very few who had spoken out forcefully in favor of full funding of AIDS treatment, as opposed to mere prevention, in developing countries. Rosenfield agreed to encourage some young Columbia doctors to volunteer, but he had one question.

“Ira, there’s something I don’t understand. Why are you bringing in all these business people who don’t know anything about AIDS? What can they contribute?” They would bring an understanding of systems and management, Magaziner replied, making treatment both effective and efficient while conserving very scarce resources. “OK,” said Rosenfield, scratching his head. “Maybe.”

When Magaziner brought several dozen of these medical and business professionals to Harlem to meet the president, Maggie Williams was astonished. She had never quite believed that he would be able to recruit an entire staff of volunteers to launch this project.

Before long, Magaziner was bringing teams of doctors, nurses, executives, and management specialists into Mozambique, Rwanda, and Tanzania, where they would meet, often for the first time, on the ground. They would sit down with officials of the host governments, “trying to figure out what to do.” And then they would spend weeks and weeks trying to determine what could be done and how best to do it.

How could countries in the developing world organize and man
age AIDS treatment without the advantages of modern health systems? Many leaders of the global health community—in the West, at least—doubted the possibility, which was why they had been reluctant to support any expansion of treatment. To answer such doubts, Magaziner and his mixed teams of medical doctors and business executives determined that several steps had to be completed in order to build a successful treatment program in any country.

First, people would have to be brought in for initial testing, despite the lingering stigma attached to AIDS in most parts of the world; second, medicines would have to be purchased and then sent out, while preserving their quality, in a supply chain to both urban and rural centers; third, doctors and nurses would need training to administer tests and drugs; and all of these steps would require support from local and national governments. To bring the new treatment systems “to scale,” as Magaziner told his teams, “we have to do it in a way that is institutionalized in the health system that exists, and in the political system that exists.”

For Magaziner and Clinton, that institutional fabric included the enormous existing nonprofit sector across all of Africa as well. They had pledged not to duplicate what other organizations were doing to fight AIDS, so they sought out partnerships instead. If Doctors Without Borders or Médecins Du Monde or any other competent medical group had established a clinic in a rural village in Tanzania, then CHAI would work with them on training and supplies. But where nobody was already setting up a supply chain, or arranging laboratory testing, or building relationships with government, CHAI would seek to fill those gaps.

As Magaziner and his teams traversed the rural terrain in Mozambique and Tanzania, where a few clinics operated by Doctors Without Borders were providing treatment at a very small scale, they confirmed the most important assumption of CHAI’s plan: If life-saving treatment is available, people will diligently take their medicine. In refusing to consider treatment in poor countries for years, the global health authorities had assumed the opposite.

“If you educate people about how to take these medications, they will follow the protocols. People don’t want to be sick,” remarked Magaziner dryly.

The other critical assumption that departed from conventional wisdom—and the accustomed practice of many charitable groups operating in less developed countries—was that governments must be respected as equal partners at all times. That injunction reflected a core tenet of CHAI’s mission and values. Both Clinton and Magaziner felt intense disdain for the “neocolonialist attitude out there,” and communicated that viewpoint powerfully to everyone on CHAI’s staff. They understood that they were asking the volunteers and later the paid staffers to undertake difficult and risky work; lots of mistakes were inevitable.

But there was one kind of mistake that Magaziner wouldn’t tolerate. He issued a clear warning that to disrespect the project’s government partners meant swift dismissal. “There’s too much neocolonialism,” he would say, “with people sitting around in the capital city in expensive hotels.”

If CHAI staffers happened to be in a capital city rather than in a town or rural village, they were usually to be found in a Ministry of Health office, where they had been assigned to train government employees to oversee the new HIV/AIDS treatment program. Working side by side with one official—a method known as “twinning”—the CHAI staffer would essentially direct the program as the government staffer gradually learned enough to take over, in a process of developing systems and logistics that might require as long as two years. The ultimate aim, as Magaziner emphasized repeatedly, was “to work ourselves out of a job.”