Decision Points

partner with the government and people of countries committed to battling the disease. Local leaders would develop the strategies to meet specific goals, and we would support them.
    The next question was which countries to include. I decided to focus on the poorest and sickest nations, twelve in sub-Saharan Africa and two in the Caribbean. ** These fourteen countries accounted for 50 percent of the world’s HIV infections. If we could stop the spread of the disease at its epicenter, we could create a model for other countries and the Global Fund to follow.
    The final decision was how much money we should spend. Josh’s group had recommended a stunning $15 billion over five years. My budget team expressed concern. In late 2002, the U.S. economy was struggling. The American people might not understand why we were spending so much money overseas when our own citizens were suffering.
    I was willing to take on that objection. I was confident I could explain how saving lives in Africa served our strategic and moral interests. Healthier societies would be less likely to breed terror or genocide. They would be more prosperous and better able to afford our goods and services. People uncertain of America’s motives would see our generosity and compassion. And I believed the American people would be more supportive if we could show that their tax dollars were saving lives.
    Critics would later claim that I started PEPFAR to appease the religious right or divert attention from Iraq. Those charges are preposterous.I proposed the AIDS initiative to save lives. Mike Gerson , my chief speechwriter and trusted adviser, put it best in a November 2002 meeting. “If we can do this and we don’t,” he said, “it will be a source of shame.”
    I made the decision to move forward with PEPFAR in December 2002. Only a few people knew about the plan. I instructed the team to keep it that way. If word leaked out, there would be a turf war among government agencies for control of the money. Members of Congress would be tempted to dilute the program’s focus by redirecting funds for their own purposes. I didn’t want PEPFAR to end up hamstrung by bureaucracy and competing interests.
    “Seldom has history offered a greater opportunity to do so much for so many,” I said in my State of the Union address on January 28, 2003. “…   Tonight I propose the Emergency Plan for AIDS Relief—a work of mercy beyond all current international efforts to help the people of Africa.”
    Members of both parties rose to support the plan. Standing next to Laura in the First Lady’s box was a man whose program and country had served as an inspiration for PEPFAR, Dr. Peter Mugyenyi of Uganda.

    I had intended the announcement to make a big impact, and it did. President Clinton’s top AIDS official called it “inspiring and clearly heartfelt.” The
Chicago Tribune
summarized the reaction of many newspapers when it editorialized, “ ‘Astonishing’ is not too strong a word for President Bush’s announcement.”
    As expected, there were some objections. The biggest came in response tothe ABC prevention strategy . Critics on the left denounced the abstinence component as an ideological “war on condoms” that would prove unrealistic and ineffective. I pointed out that abstinence worked every time. Some on the right objected to distributing condoms, which they felt would encourage promiscuity. At least members of Congress were smart enough not to criticize the B, being faithful within marriage.
    Ironically, both sides charged that we were imposing our values—religious fundamentalism if you asked one camp, sexual permissiveness if you asked the other. Neither argument made much sense to me, since the ABC strategy had been developed in Africa, implemented in Africa, and successful in Africa.
    In the spring of 2003, the House of Representatives took up PEPFAR legislation. The bill was sponsored by Republican Congressman Henry Hyde of Illinois and Democratic Congressman Tom Lantos of California, two principled supporters of human rights. In a fine example of bipartisan cooperation, they helped steer the bill through the House with a vote of 375 to 41.
    The bill then moved to the Senate, where it received strong backing from Majority Leader Bill Frist , a doctor who took annual medical missionary trips to Africa, and Senator Dick Lugar of Indiana, the thoughtful chairman of the Foreign Relations Committee. Bill and Dick rallied support among a