Even among the few, odd, nerdy children who want to be speechwriters when they grow up (I was one), none dream of writing a State of the Union address. These tend to be long and shapeless affairs, lumpy with random policy, carried along by strained applause lines, dated before they are transcribed.
There are a few exceptions: Lyndon Johnson announcing a War on Poverty; Bill Clinton, as a scandal unfolded, undismayed in the lion’s den. And then there were these sentences in the 2003 address 10 years ago: “Tonight I propose the Emergency Plan for AIDS Relief,” said President George W. Bush, “a work of mercy beyond all current international efforts to help the people of Africa. This comprehensive plan will prevent 7 million new AIDS infections, treat at least 2 million people with life-extending drugs and provide humane care for millions of people suffering from AIDS and for children orphaned by AIDS.”
In retrospect, the words were not particularly memorable. But the moment was remarkable. An initiative of this scale and ambition — the largest effort to fight a single disease in history — was utterly unexpected. Bush’s strongest political supporters had not demanded it. His strongest critics, at least for a time, remained suspicious. The President’s Emergency Plan for AIDS Relief (PEPFAR) existed entirely because of a willing leader, a creative policy team, a smattering of activists and a vast, bleeding need.
I remember my first visits to sub-Saharan Africa as a policy adviser to President Bush soon after the announcement. Of about 30 million people with HIV, perhaps 50,000 were receiving treatment. The pandemic had already produced 14 million orphans. Child-headed households were common; child-headed villages were not unknown. Walking through South African shantytowns, you mainly met grandparents and their grandchildren. The intervening generation had been nearly erased. Millions were dying at the same time and yet in total isolation, surrounded by the barbed wire of stigma. In the worst affected countries, life expectancy had fallen by 20 years.
PEPFAR gathered the support of an odd coalition. Its congressional sponsors included Rep. Henry Hyde (R-Ill.), a pro-life leader, and Rep. Barbara Lee (D-Calif.); Senate Republican Leader Bill Frist of Tennessee and Sen. John Kerry (D-Mass.). Religious conservatives joined with traditionally liberal health organizations to push for the measure. It was signed into law four months after it was announced.
Implementation was swift, under a theory that PEPFAR’s first administrator, Ambassador Randall Tobias, described as “Ready, fire, aim.” By late 2005 — with the help of PEPFAR and the Global Fund to Fight AIDS, Tuberculosis and Malaria — there were about 800,000 people on treatment. That number today is more than 5 million.
On the 10th anniversary of PEPFAR, what lessons does it offer? Some of them relate narrowly to development. Scale and boldness matter. A collection of pilot projects is invariably run from the outside. National scale-ups require the creation of supply and management systems and encourage the sort of professionalism that can permeate a health system and beyond.
PEPFAR offers some political philosophic lessons. Liberals had to get accustomed to measured outcomes and accountability. Conservatives had to abandon an indiscriminate cynicism about the capabilities of the state. I remember once citing PEPFAR’s achievements to a conservative leader as one example of successful governmental action. He responded dismissively, “But other than that?” Other than saving a few million lives on a distant continent from a cold start in less than a decade?
There is also a potent lesson here about America. My first professor of international relations assured me that altruism is always a ruse in the affairs of nations — nothing more than the pursuit of interest in the camouflage of morality. I now know — personally know — this is untrue. The Irish historian William Lecky once claimed, “The unwearied, unostentatious and inglorious crusade of England against slavery may probably be regarded as among the three or four perfectly virtuous pages comprised in the history of nations.” Nothing human is “perfectly virtuous,” but PEPFAR is an addition to his list.
America is a flawed and fallible nation. It is also the nation that does things such as this. During the 20th century, in government meetings, in Berlin, Beijing and Moscow, leaders made decisions that resulted in the deaths of millions of innocent people. I watched a leader make the decision to save the lives of millions of innocent people. Ten years later, it is still the noblest thing I have ever seen.