Decision Points

death. Several countries, including Ethiopia, Rwanda , Tanzania, and Zambia, were ahead of schedule in meeting the goal of cutting malaria infection rates by more than 50 percent.

    Passing out bed nets to mothers in Arusha, Tanzania, as part of our malaria initiative.
White House/Eric Draper
    Africa’s needs remain tremendous. There are still more than twenty-two million people living with AIDS. Some who need antiretroviral drugs still go without. While malaria is in retreat, there are still children dying needlessly from mosquito bites. Poverty remains rampant. Infrastructure is lacking. And there are pockets of terrorism and brutality.
    While these challenges are daunting, the African people have strong partners at their side. The United States, the G-8, the UN, the faith-based community, and the private sector are all far more engaged than ever before. The health infrastructure put in place as part of PEPFAR and the Malaria Initiative will bring wide-ranging benefits in other areas of African life.
    Perhaps the most important change in recent years is in the way Africans see themselves. Just as AIDS is no longer viewed as a death sentence, the African people have newfound optimism that they can overcome their problems, reclaim their dignity, and go forward with hope.
    On our trip to Rwanda in 2008, Laura and I visited a school where teenagers—many of them orphans—were taught about HIV/AIDS prevention. One lesson focused on showing girls how to reject the advances of older men, part of the abstinence component of PEPFAR.
    As I walked by a cluster of students, I said, “God is good.” They shouted back in unison, “All the time!”
    Here in Rwanda, a country that had lost hundreds of thousands to genocide and AIDS, these children felt blessed. Surely those of us in comfortable places like America could learn a lesson. I decided to say it again.
    “God is good.”
    The chorus responded even louder, “All the time!”
    * The team included Dr. Tony Fauci , the longtime director of the National Institute of Allergy and Infectious Diseases, and his assistant director, Dr. Mark Dybul ; Gary Edson , my deputy national security adviser and top staffer on international development; Jay Lefkowitz , my deputy domestic policy director; Robin Cleveland from the Office of Management and Budget; Kristen Silverberg , one of Josh’s deputies; and, later, Dr. Joe O’Neill , the director of national AIDS policy.
    ** Botswana, Côte d’Ivoire, Ethiopia, Guyana, Haiti, Kenya, Mozambique, Namibia, Nigeria, Rwanda, South Africa, Tanzania, Uganda, and Zambia. At Congress’s request, we later added one Asian nation to PEPFAR, Vietnam.
    *** We visited Benin, led by Yayi Boni ; Tanzania , led by Jakaya Kikwete ; Rwanda, led by Paul Kagame ; Ghana, led by John Kufuor ; and Liberia, led by Ellen Johnson Sirleaf .

n September 2006, with the midterm elections approaching, my friend Mitch McConnell came to the Oval Office. The senior senator from Kentucky and Republican whip had asked to see me alone. Mitch has a sharp political nose, and he smelled trouble.
    “Mr. President,” he said, “your unpopularity is going to cost us control of the Congress.”
    Mitch had a point. Many Americans were tired of my presidency. But that wasn’t the only reason our party was in trouble. I flashed back to the Republican congressmen sent to jail for taking bribes, disgraced by sex scandals, or implicated in lobbying investigations. Then there was the wasteful spending, the earmarks for pork-barrel projects, and our failure to reform Social Security despite majorities in both houses of Congress.
    “Well, Mitch,” I asked, “what do you want me to do about it?”
    “Mr. President,” he said, “bring some troops home from Iraq.”
    He was not alone. As violence in Iraq escalated, members of both parties had called for a pullout.
    “Mitch,” I said, “I believe our presence in Iraq is necessary to protect America, and I will not withdraw troops unless military conditions warrant.” I made it clear I would set troop levels to achieve victory in Iraq, not victory at the polls.
    What I did not tell him was that I was seriously considering the opposite of his recommendation. Rather than pull troops out, I was on the verge of making the toughest and most unpopular decision of my presidency: deploying tens of thousands more troops into Iraq with a new strategy, a new commander, and a mission to protect the Iraqi people and help enable the