Man of the World: The Further Endeavors of Bill Clinton (28 page)

“Well, Hank,” Clinton said, smiling, “if I were you, I wouldn’t make that argument.”

“Why?” asked McKinnell, momentarily flustered.

“Just do the math. Now, I know you guys are making limited amounts of these drugs available in poor countries for $1,500 a year or so, which is a lot less than the $10,000 you used to charge over there, but that’s still about ten times more than our drugs cost. And if you’re
charging ten times as much, and mine are 60 percent as effective, it means for any given amount of money, I’m still saving six times as many lives as you are.

“So I don’t believe I’d make that argument, but you’re free to do it, if you want. And actually, I dispute the premise. I think ours
are
effective.”

Indeed, Clinton could rely on more than his personal opinion to support his foundation’s decision to rely on generic drugs. In 2001, the World Health Organization had set up a “prequalification” protocol to help governments and aid organizations determine which generic formulations could be deemed safe and effective as well as affordable, not just for AIDS but for tuberculosis and malaria, too. Under prequalification, WHO scientists analyzed the purity and potency of every formulation, while teams of inspectors visited the factories where they were produced to ensure that they complied with international standards. With assistance from European, Canadian, and Australian regulators, the WHO prequalification process had achieved a reputation for probity.

The new generic formulations were central to the strategy created by public health experts to ensure that AIDS patients in developing countries reliably took their medicines on time and at the proper dosage. Instead of requiring patients to take six pills or capsules a day, as was necessary in using branded antiretroviral drugs, the generic medicine was packaged in pills that each combined three drugs and only needed to be taken twice daily.

Known in public health jargon as a “fixed-dose combination” or FDC, this innovation ensured easier storage, distribution, and patient compliance—all problems that medical organizations had faced for many years in the developing world when seeking to combat not only AIDS but tuberculosis. With approval by WHO, the use of FDCs had been adopted by CHAI, the Global Fund, and every other agency seeking to bring millions of victims into treatment as quickly as possible to stem the pandemic.

If Clinton won that dinner table argument in Paris, the Pfizer chief was prevailing in the White House, along with his comrades in PhRMA, the industry’s supremely powerful Washington lobbying group. Like most pharmaceutical executives, McKinnell was a Republican whose company donated heavily to the party and to George W. Bush’s campaign.

So much influence did the pharmaceutical interests enjoy in the Bush White House that the president had selected Randall Tobias—the former president and CEO of the giant Indiana-based drug maker Eli Lilly, Inc.—to serve as the administration’s global AIDS coordinator, with the rank of ambassador. Although Tobias lacked any experience in public health, and his company didn’t even manufacture any HIV/AIDS medications, Bush appointed him to oversee all the U.S. government’s international AIDS programs, and PEPFAR in particular.

Within months of his appointment in July 2003, as Clinton and Magaziner knew all too well, Tobias and Bill Steiger, who oversaw international AIDS programs at the Department of Health and Human Services, had started pushing back against the campaign for generic drugs in the developing world. Magaziner believed that their reaction had included blunt threats against organizations and individuals cooperating with CHAI in its creation of a generic drug “buying club” in Africa and the Caribbean.

In Washington, PhRMA and its allies in conservative think tanks and media mounted a furious campaign against generics, with the American Enterprise Institute and the Hudson Institute producing a flurry of articles condemning generic AIDS medications as untested and potentially dangerous. These papers were rarely signed by doctors, or anyone else with field experience battling the pandemic, but penned instead by hired intellectuals.

Funded generously by tax-exempt donations from pharmaceutical companies like Pfizer and Eli Lilly, the writers and academics associated with Hudson and AEI mounted an attack not only on the generic manufacturers but on every institution that supported the use of generics. Their targets ranged from Doctors Without Borders, the Paris-based medical nonprofit that had pioneered AIDS treatment in Africa, to the World Health Organization itself, which had established a “prequalification” protocol to approve generic formulations.

The result of this concerted lobbying and propaganda campaign was a rule promulgated by PEPFAR, Bush’s new international AIDS assistance program, prohibiting the use of its funds to buy generic drugs. Specifically, PEPFAR’s rules required that drugs purchased with U.S. government funding had to be “approved by a stringent regulatory authority or otherwise demonstrate quality, safety and efficacy at the
lowest possible cost”—a phrase that Tobias and Steiger interpreted to mean approval by the Food and Drug Administration. The foreign generic manufacturers could not even bring their drugs to the FDA, however, without risking patent actions in American courts by the branded pharmaceutical companies.

The campaign against generic drugs by PhRMA, the conservative think tanks, and their allies in the White House brought Clinton and his international allies into increasingly direct conflict with Bush. That conflict reached a crescendo in late March 2004, when the Bush administration sought to use an international conference in Botswana to enforce an international consensus around its position.

While vehemently denying any effort to curtail the use of generics, Tobias organized the conference in Botswana’s capital city of Gaborone, inviting officials of WHO and the Southern Africa Development Council, along with European drug regulators, to discuss U.S. concerns about the prequalification program. But suspicions about American motives led the European Medical Evaluation Agency, roughly the European Union equivalent of the FDA, to cancel its participation. Days before the conference began, Representative Henry Waxman (D-CA), the ranking member of the House Committee on Government Reform, sent a long, angry letter to Bush protesting both the conference and PEPFAR policy rejecting generics.

“Your administration is circulating a proposal for consideration at an upcoming conference in Botswana that could impede access to the low-cost drugs needed to save the lives of millions of people living with HIV in developing countries,” Waxman’s March 26 letter began. “Adopting this proposal would be a tragic mistake.”

The California liberal noted archly that U.S. agencies already purchased other generic medicines approved under WHO prequalification. He also mentioned that the Republican Party had received an estimated $40 million in contributions from pharmaceutical interests over the past several years.

A less pointed but equally passionate letter reached Bush’s desk the same day from a bipartisan group of United States senators that included Massachusetts Democrat Ted Kennedy and Arizona Republican John McCain. “We question the purpose behind the Administration’s duplicative process being developed to review the safety and efficacy of
generic drugs used to treat persons with HIV/AIDS. A duplication of the existing and effective WHO review procedure will needlessly delay patients’ access to these life-saving generic drugs. . . . Make no mistake, delay will cost lives.”

Activists in Washington marked the opening of the Gaborone meeting with a spirited demonstration at PhRMA headquarters in Washington, not far from the White House. Denouncing Bush as a “puppet” of the industry, nine of the demonstrators chained themselves together and briefly blocked traffic in front of the building’s lobby before local police arrested them. “The U.S. initiated the Botswana conference at the behest of the pharmaceutical companies, and its agenda is to protect their profits by blocking the procurement of generic AIDS drugs,” said a spokesman for Africa Action, one of the groups sponsoring the protest.

Whatever Tobias intended to achieve in Gaborone, he succeeded only in galvanizing world opinion against the Bush administration, already stung by nearly universal condemnation of its ongoing misadventure in Iraq. Praise lavished on Bush when he announced PEPFAR was fading rapidly into skepticism, as the
New York Times
revealed in a front-page article on March 28, the day before the Botswana conference opened.

Headlined “Plan to Battle AIDS Worldwide Is Falling Short,” the
Times
reported, “shortages of money and battles over patents have kept antiretroviral drugs from reaching more than 90 percent of the poor people who need them.” While Bush had promised a year earlier in announcing PEPFAR that he would spend $15 billion over five years fighting AIDS in Africa and the Caribbean, “his budget requests have fallen far short of that goal,” the story noted. He had requested only $200 million for the U.S. contribution to the Global Fund, despite a congressional authorization of $550 million.

The evident reason behind that budgetary decision, which went unmentioned in the
Times,
was the Bush administration’s dispute over generics with the Global Fund as well as Clinton, WHO, and several other Western governments. It was a seething bureaucratic conflict that broke into public view on April 6—exactly a week after the Gaborone conference—when the World Bank joined the Global Fund in announcing that both organizations planned to assist the United Nations Children’s Fund (UNICEF)
and the Clinton Foundation in purchasing generic drugs and discounted AIDS testing, to be made available in more than one hundred countries. Even though the ambitious partnership had not been fully elaborated—and aroused doubt in some quarters—its sharp divergence from U.S. policy could not have been clearer.

Only a year earlier, Clinton had welcomed Bush’s bold intervention against the pandemic, unveiled by the administration in the wake of his own initiative. Now the former president and his successor were locked in worsening conflict.

Yet if Clinton was angered by the administration’s rejection of his “systematic” plan for universal AIDS treatment, he never appeared to blame George W. Bush. And if Bush had once treated Clinton as a pariah over the alleged “trashing” of the White House, he displayed a far warmer attitude toward the Clintons when the opportunity arose. The occasion was the unveiling of the official portraits of Bill and Hillary Clinton at the presidential residence on the morning of June 14—only weeks after the tense confrontation over the Gaborone conference.

“President Clinton and Senator Clinton, welcome home,” said Bush, smiling broadly as he stood on a dais in the East Room before an audience that included the entire Clinton and Rodham families as well as scores of former Clinton administration officials and aides who were invited to the unveiling and the luncheon that followed. The moment was both historical and intimate, marking the first time since their tumultuous departure that the Clintons had returned to the house they had occupied for eight years.

The pictures were historically significant, too, as the first portraits made by an African American to hang in the White House. Simmie Knox, son of a sharecropping family in Aliceville, Alabama, already had painted baseball great and childhood friend Hank Aaron, author Alex Haley, Bill Cosby, Muhammad Ali, and many equally celebrated figures, including the late Justice Thurgood Marshall and Justice Ruth Bader Ginsburg, who had personally recommended him to Hillary Clinton. At sixty-eight, Knox was finally receiving the national recognition he had earned many years earlier.

He had painted Bill Clinton facing straight ahead in a navy suit and
light blue tie, and Hillary in a dark pantsuit with a wide smile. He felt a special affinity for Clinton, he later told reporters, because they both rose from “poor Southern families.” He had the pleasure of sitting in the East Room and listening, as not just one but two presidents acclaimed his work.

While Bush’s remarks were larded with characteristic banter, their longtime adversary greeted the Clintons in a surprising tone of warmth and respect. Noting that he and his father now called each other by their numerical order as president—“He’s 41, I’m 43”—Bush turned to Clinton and said, “It’s a great pleasure to honor number 42. We’re glad you’re here, 42.”

He went on to praise both Clintons lavishly, calling attention to Bill’s “incredible energy . . . great personal appeal . . . deep and far-ranging knowledge of public policy, great compassion for people in need, and the forward-looking spirit that Americans like in a president.”

The laudatory description went on at length: “He’s remembered in Hope, Arkansas, and other places along the way as an eager, good-hearted boy who seemed destined for big things. . . . He won his first statewide office at age 30, sworn in as governor at 32. He’s a five-time governor of Arkansas; the first man from that state to become the president. He’s also the first man in his party since Franklin Roosevelt to win a second term in the White House.”

Bush even plugged Clinton’s memoir, to be published within a few days. “I mean, I can tell you more of the story,” he quipped, “but it’s coming out in fine bookstores all over America.”

Expressing admiration for Hillary’s electoral triumph amid the “rough business” of New York politics, he called her “a person of great ability and serious purpose . . . a woman greatly admired in our country. . . . She inspires respect and loyalty from those who know her.” Moreover, he noted archly, she happened to be “the only sitting senator whose portrait hangs in the White House.”

It was Bush at his best—charming, funny, gracious—and the Clintons did their best to respond in kind. Each of them spoke about the emotional impact of the paintings of earlier presidents and first ladies, which had provided solace during difficult times in the Clinton years. Both gratefully acknowledged the kindness and cordiality of the cur
rent occupants, and the former president struck a note of bipartisan fellowship.

“Politics is noble work. I’ve just been doing some interviews in connection with my book . . . and I said, ‘You know, most of the people I’ve known in this business, Republicans and Democrats, conservatives and liberals, were good people, honest people, and they did what they thought was right. And I hope that I’ll live long enough to see American politics return to vigorous debates where we argue who’s right and wrong, not who’s good and bad.’ My experience is, most of the people I’ve known in this work are good people who love their country desperately. And I am profoundly grateful that for a brief period I had a chance to be one of them.”