San Francisco Chronicle
February 1, 2003

President Bush's surprise pledge of $15 billion to fight AIDS in Africa and the Caribbean has dramatically recast the debate over how rich nations should help the world's poor battle the epidemic.

In five short paragraphs in Tuesday's State of the Union address, the president laid out a moral imperative to bring antiretroviral drugs to poor countries. In effect, observers say, he challenged other wealthy nations to meet a suddenly serious new American commitment.

In dollar terms, his tripling of the U.S. commitment exceeded the fondest hopes of international activists, who had expected a grudging incremental increase in overseas AIDS spending.

"This is, without a doubt, a huge new leadership role for the president, and I'm blown away that he's doing it," said Dr. Eric Goosby, chief executive of the Pangaea Global AIDS Foundation, in San Francisco.

The president continued to push for expanded AIDS spending Friday. In a White House gathering, he proposed a 7 percent increase in next year's spending for domestic HIV prevention, treatment and care. That would include an additional $100 million for a program that buys AIDS drugs for Americans who are uninsured. The program, known as ADAP, has been running short of funds because of rising costs for the drugs and growing numbers of AIDS patients who have no means to pay for them.

In his newfound enthusiasm to tackle the global AIDS epidemic, the president spoke of the mission with an evangelical zeal. "If you're blessed, there is a responsibility to recognize your blessings in a compassionate way," he said. " . . . This country needs to provide some hope . . . "

But his Emergency Plan for AIDS Relief has a catch: The United States will divvy out the money mostly on its own, to countries and programs that suit the Bush administration. The plan pointedly sidesteps the Global Fund to Fight AIDS, Tuberculosis and Malaria, the Geneva-based organization set up in 2001 at the urging of the United Nations to channel international donations to the developing world.

The president's proposal would direct $1 billion, or $200 million a year, to the Global Fund. But 90 percent of the new dollars would be funneled through a new program run by the State Department, a decision that is being interpreted as a vote of no confidence in the Global Fund.

"The president has taken a step, but the true test is to meet its obligation to the Global Fund," said AIDS activist Asia Russell, of the Health Gap Coalition. Russell said the United States' "fair share" for the fund should be $2 billion a year -- 10 times the current commitment.

Yet on Friday, Secretary of Health and Human Services Tommy Thompson was elected chairman of the Global Fund -- on the very day the board approved a new round of funding that, unless replenished, will bankrupt the fledgling organization next year.

At the White House gathering Friday, Bush said Thompson's leadership of the Global Fund demonstrated that the United States was still committed to it. "I wouldn't put Tommy as the head of it if we weren't." he said. "And more importantly, he wouldn't have joined if we weren't."

Nevertheless, the decision has stumped supporters of the Global Fund. Columbia University economist Jeffrey Sachs said the decision to bypass the Global Fund, combined with Thompson's decision to chair it, was bizarre.

What appears to be evolving is a two-track approach to funding the prevention and treatment of AIDS in poor countries: the Global Fund will take pooled contributions and spread them throughout the world; while wealthy donor nations will also run their own programs to combat AIDS through agreements with individual countries.

In a teleconference with reporters, Sachs warns that the go-it-alone approach is simply not as efficient or likely to succeed as the so-called multilateral mechanism of the Global Fund.

"Most of us came to the conclusion long ago that a pooled international effort is by far the most appropriate way to succeed," he said.

Yet Sachs -- an outspoken critic of the sluggish U.S. response to the global pandemic -- said the historic nature of Bush's commitment overshadowed the new debate over how to allot the money.

"All the rest of the considerations need to be put in context: We've had a real breakthrough," he said. "The president has done something wonderful. He spoke more clearly about AIDS than any international leader in 20 years."

Sachs said he hoped that as Congress debates the president's proposal, the wisdom of channeling more of the sum through the Global Fund would become obvious. But the more important step, he said, is for other wealthy countries to match the United States' commitment -- which could swell spending on the global AIDS problem to $45 billion over five years.

"To its credit, the U.S. has said, 'Look, we are doing this,' " Sachs said. "Europe now needs to say, 'Let's try to make this work.' "