Mark R. Dybul Oral History

This is the Mark Dybul interview as a part of the George W. Bush Oral History Project. We’re doing this from his offices at the Global Fund in Geneva, Switzerland. Thanks for the occasion to come overseas. I appreciate it. We just reviewed the ground rules about confidentiality before the recording began to run. Usually I like to start by getting a little bit of autobiography.

You were an undergrad at Georgetown. Are you from the Washington area?

I’m originally from Wisconsin, but I went to Georgetown as an undergrad and never left.

Tell me a little bit about your upbringing.

Typical blue-collar Milwaukee family.

Blue-collar?

Very. I was the first one to go to private high school, first one to go to private college—only one to go to private high school or college. Only one to go to professional school—very blue-collar, sheet metal worker, housewife. But strong Midwest values.

Were they politically active?

My dad was in the unions, because that’s what sheet metal workers did, so he was a staunch Democrat. My mom voted for whomever she thought she liked, so she’d vote for [Ronald] Reagan or H. W. [Bush] and [William J.] Clinton. It was less about politics and more who she liked.

How about you?

Initially I was a Republican in revolt to my father’s Democratic—typical father/son. Then I became a pretty staunch Democrat as I learned more about it going through college and being raised by the Jesuits. Then I became a pretty staunch and active Democrat.

This would have been Clinton era?

Yes, Clinton era—a little bit before. I actually liked Jimmy Carter when he was President.

So you’re old enough to remember that?

Oh, yes. Definitely.

Then Georgetown—Was there a purpose in going to Georgetown? Were you interested in Washington?

At the time I wanted to be—Strangely enough I started in the School of Foreign Service. I wanted to go into the Foreign Service. Then I decided I didn’t want to go into the Foreign Service. I didn’t like the language requirements and other things, so I switched to the college. God has a sense of humor, so I ended up as an ambassador.

Exactly.

I went into medicine, which I also hated, as a result of the HIV [human immunodeficiency virus] AIDS [acquired immunodeficiency syndrome] epidemic.

That was what put you into medical school?

Yes.

So you had not expected to be a doctor as you were growing up?

No, I had zero interest in it, hated the topic, didn’t like it at all.

Tell me a little bit about that evolution in your thinking—the HIV epidemic and how that was affecting you in terms of your thinking.

It was actually pretty rapid; I was in college. I just read a cover story, I think it was U.S. News & World Report, which I don’t even think exists anymore. It was on HIV and Africa. I couldn’t believe that that was happening in our world. So at the time I was trying to decide whether to pursue a PhD in philosophy, theology, or English poetry and I couldn’t decide. I went to work for the university as an admissions officer and then had an amazing job as chief of staff to the president; we called it assistant because we were too young to be called chief of staff.

Which president?

Tim Healy.

Oh, Father Healy.

He was like my life mentor.

Did you have a Clinton connection at all through this?

Only through him. Then I also had a lot of friends who worked in the White House. I would go to the receptions and some of the state dinners and things, but didn’t know them that well. Came to know them over time. That story never left me. Ultimately I decided I couldn’t let go of it; I tried very hard to let that go, but I couldn’t.

And then—one advantage of being the president’s assistant is without any premed classes I could get into medical school.

[chuckling] How did you find medical school?

At the time there were only two ways to respond to the HIV epidemic—one was as an activist, which I was. People assume because I am a gay man that it was the gay epidemic that drew me. Actually, it wasn’t. It was the African epidemic.

Interesting.

You could be an activist or you could go into medicine. There wasn’t a whole lot else to do, so I went the medical route to try to do something from that perspective. That led me into science, because at the time all we did was watch young people die. I spent my fourth year of medical school in San Francisco, one of the toughest times, so then decided to go into research. I had a great residency experience at the University of Chicago. As things happen, the chair of that department, who is a legend in medicine, Arthur Rubenstein, knew Tony Fauci, NIAID (National Institute of Allergy and Infectious Diseases) and NIH (National Institutes of Health), and called Tony.

Tony took me as a fellow and then as things happen—all a series of accidents, but when President “W.” Bush wanted to do something big on AIDS—Tony was known by George H. W. Bush. He knew all the Presidents because of his role. There are pictures of W. up at NIH with his father getting briefed on HIV/AIDS by Tony Fauci.

During his father’s—?

During his father’s administration, because he actually helped his father—I don’t think he was ever on staff, but he helped his father reorganize the White House staff.

I do remember that, but I didn’t remember any particular policy interests.

I don’t know that he did at the time, but he knew about HIV when I met him. So when he decided he wanted to do something about HIV, Josh Bolten in particular remembered Tony and they wanted it to be basically just the White House people and Tony.

Right.

So Tony had me engage with him because I was his lead for HIV globally and domestically.

Right.

I was doing work in Africa for Tony at the time.

I see.

So he had me get people—

So this is how you got involved with the working group.

Yes, first there was the Prevention of Mother-to-Child effort.

Right.

It was pretty remarkable. It’s amusing when I still hear—I’m doing something in Washington next week, actually, at the Council on Foreign Relations. They did this because of Iraq. It’s all nonsense because in the summer—They came in wanting to do something on HIV/AIDS. You can tell that because they immediately established the task force with Secretary [Tommy] Thompson and Secretary [Colin] Powell on HIV/AIDS. Then they announced the first ever contribution to the Global Fund in the summer of 2001—before 9/11—so clearly they already knew what they were doing. Of course at the Monterrey Consensus that was the basis of the Millennium Challenge Corporation it was already done.

Then 9/11 happened, and they backed off for a little bit, but not for long. Josh told me—but so have other people in the White House—He called some people together and said, “Look, this happened and there will be a whole bunch in the White House who need to be dealing with this, but we can’t have this be the only thing we do. We have to get back to the things we came here wanting to do.”

Right.

So at the time they charged Tommy Thompson—Powell was busy with a lot of other stuff—to take a group over to Africa to see what could be done. They went over in December of 2001, again showing that things were in motion; it’s not like you would create something after September 11, to send a Secretary over to Africa in December. Tony was a key part of that trip.

So Tommy got particularly drawn to mother-to-child transmission. At the time we had antiretroviral therapy in the U.S., but we were just beginning. The one thing we knew we could do is prevent mother-to-child transmission with a single pill around the time of pregnancy—around the time of delivery, actually. People thought it would be doable in Africa. Tommy and everyone was overwhelmed by these little HIV-positive kids and then knowing it could be preventable.

So the first idea was let’s do a prevent—We really didn’t understand—Tony or I—how big they were thinking. I’m not sure that anyone except maybe the President and Josh knew how big he was really thinking. So based on that we put together something called the Prevention of Mother-to-Child—and then we added maternal health in there somehow, I can’t remember—Initiative, which was the same group basically, a little bit smaller. The Department of Health and Human Services was very involved in that.

That was really fast. I was sent down by—It took them a while after they got back from the trip with the new year starting, so I was sent down by Tony in May—I know it was May because it was a friend’s funeral.

This is ’02?

Yes, ’02. I didn’t go to the funeral because I was sent down to do this. I almost didn’t go, but the guy was a big HIV activist and his husband said he’d be furious if you gave up this chance for his funeral, so go down. I met with a couple of people at HHS [Health and Human Services], Terrell Halaska, Bill Steiger, and—what was her name? She wasn’t around for much longer. Then we worked with them, but they were looking to us, Tony and me, to put together the initiative.

And you’re the knowledge base?

I’m the program guy.

You’re the expert.

I have on-the-ground experience, science and clinical expert.

Right. This is a rapidly changing—It’s rapidly changing on the ground in your field as well as politically?

It is. It turns out Jesse Helms [Jr.] was pretty big on preventing mother-to-child transmission. The conservatives—that was an easy one for them, right? No one wants babies to be dying.

Sure.

Preventing the transmission from a mother to child with a single pill that could save millions of lives—

Even in Africa.

Yes, it was always about Africa. But you know the social conservatives—One thing people really failed to understand is that with some exceptions like Lindsey Graham and [Richard] Lugar and Jim Kolbe—in the Republican caucus, the people who support development are social conservatives with a deep faith commitment and it comes from their faith commitment. Fiscal conservatives are not particularly fond of development. It’s really the social conservatives that believe in it.

Bono [Paul Hewson] had worked with Jesse Helms, and Bill Frist was working on him and a lot of people were working on him. John Kerry was involved at the time too. So there was a movement in Congress, but that was separate from what was happening. It was useful obviously to have activists in the Congress. So this initiative, which we thought was awesome—$500 million, which was inconceivable at that time—to focus on 14 countries to prevent 50 percent of mother-to-child transmission over five years. It would save—I can’t remember the number of lives of that one, actually. They were very clear and the President was very clear: Don’t come back and ask me for more money. Tell me what you’re going to do and then we’ll figure the money out. That was pretty remarkable.

So it was a bottom-up approach. It was never we have this amount of money, what are we going to achieve with it? It was what do we think is possible given the science and the reality on the ground? Being ambitious, we were happy as could be that it moved that quickly. Literally from May until the Rose Garden announcement, which was June 19th of 2002. The President announced this initiative in the Rose Garden.

Tony and I thought this was it. This is awesome. The initiative is done. We can go back to our jobs at NIH. We had the fun of creating it. Now we get to just go back and do our jobs, which we both loved.

But you would not have been involved in any execution?

I didn’t plan to be. Then the people at Health and Human Services basically said you’re not going anywhere. You can go back to your job, but you also have to help us implement this. So I became the lead within the Department of Health and Human Services, and a lead within USAID [United States Agency for International Development] was selected to help move the initiative.

Let me interrupt you and ask one question. You said that the President had sort of issued the marching orders. How did you know this?

At that point I didn’t meet the President, but what we did get—

Was this through Josh?

Yes—and mostly through Gary. Gary Edson and Jay Lefkowitz were the two principal people—Gary from NSC [National Security Council] and Jay from the Domestic Policy Council.

Right.

Gary was really the person—Jay was certainly very involved because of the domestic issues, but Gary was the person we dealt with most. It was often the two of them. They would report back—change this or change that—or occasionally they would refer to the President, but they told us that they were taking things we were putting forward back to the President. I was not at the meeting; Tony was at the meeting when the President told USAID and others that it was going to be done. It didn’t go down particularly well. That was because no one was involved; we basically did it.

We involved CDC [Centers for Disease Control] a little bit—a little bit more than the White House was comfortable with—because we were from HHS.

Right.

We were trying to protect the Secretary.

Tell us why that made the White House uncomfortable.

Because—and this really relates to the next piece, which is the PEPFAR [President’s Emergency Plan For AIDS Relief] piece. Josh Bolten—I always call him the angel of PEPFAR; he really was the guy who— The President had the vision. He knew he wanted something big done, but it was Josh who made sure it got done. Gary was the day-to-day lieutenant, but it was Josh who was the lieutenant general with the President, with the President being the field marshal. Things had to get done. Josh got them done.

What became very clear in the next phase was—Josh is one of the best policy wonks—process policy people—I’ve ever met. People can see that if they look at the [Andrew] Card White House versus the Bolten White House; it was fundamentally different. He’s just a process, process, process person. But the President knew, and Josh did too, that those processes work for normal running of government; they don’t work when you’re trying to do something big and new and bold. We would still be arguing in the interagency process about what PEPFAR should look like. The reason it had to stay secret—with their full understanding of the risks, which were huge; we can talk about those, because after it was announced they all became—all the things we were worried about came flying out. If it didn’t stay secret, everyone knew it would get killed.

OK.

So on the day of the announcement, the PMTCT [Prevention of Mother-to-Child Transmission] announcement—which you probably have in here but I’m pretty sure it was June 17th, maybe it was June 7th.

This says the 19th.

That’s probably right; I knew it was in there someplace. Josh pulled—I was not at that. At the time I was a low-level peon and we were allowed to create the initiative, but I wasn’t allowed to be in the room when big decisions were made. Tony was down there for the ceremony and Josh grabbed him. Both Josh and Tony remember Gary and Jay and Margaret [Spellings] probably being in the room. She was Jay’s boss. So Jay was Deputy Domestic Policy Advisor, Margaret was Domestic Policy Advisor. She was awesome. They said, “This is a great start,” which was the last thing we expected to hear, “Think big.” So Tony came back really energized, called me into his office. It was a beautiful summer day. He said, “The President said this is awesome but we need to think big.”

It turns out I had just gotten back from Uganda, where we were doing our work. Because I was doing work in Uganda with no one knowing why I was going out and the embassy was helping me—Jimmy Kolker, who is now at HHS, was the Ambassador there; he was fantastic as the Ambassador there, really cared about HIV there—I would go out and see things and see programs because I was trying to get more information about what was possible. I used my research trips to go out into rural communities and see what was being done there.

The work I was doing was with the Joint Clinical Research Center, which was in Kampala, and they’d begun having branches. They were the first group within Africa to bring generic antiretrovirals in. They were treating people who had money to be treated. It started just in Kampala. It’s actually quite an impressive center with research. His lab looked nicer than mine at NIH.

They had started to do these satellite sites around the country—

They’re inventing this model?

They invented the model for HIV. Peter [Mugyenyi] felt very strongly that it shouldn’t just be for people in Kampala. People were traveling too long and appropriately he was worried about adherence when people had to travel those distances all the time, so they started opening very small clinics that they built and which is very helpful—I’ll come back to that—in a few rural areas.

With whose money?

The center’s money. So they would open—and it was only for people who could pay; this wasn’t for free. People actually had to pay for their—

It is basically a privately funded clinic.

Yes.

For people—at this stage people who could pay—the cost of these things has come down since then?

That was key. They’d imported. They were the first group in Africa. There are apocryphal but partially true stories about—actually it wasn’t Peter, it was his assistant, who went out to the airplane in the middle of the night and got the first packet of generic drugs, which were illegal in the country, and brought them back, Sam Kibende.

I hadn’t heard the apocryphal story, but it’s good to have it.

Since they had generic drugs they were much cheaper. So it was $300 a year and not $1,500 or $2,500.

So expensive but—

Expensive but manageable for wealthy people in Uganda.

Which is the clientele that you’re dealing with at this point?

Yes. They had to be people who could pay for their own drugs. Even in our clinical trials—We were the first group to do a clinical trial of combination antiretroviral therapy in Africa, but it was because people could pay for their own drugs. No IRB [Institutional Review Board] would approve it, because you would have to keep them on it forever and clinicians couldn’t do that. So our study was looking at people on the treatment they were paying for themselves to see if we could reduce the toxicity and the cost by having them not take it all the time.

Right.

But Peter started opening up these satellite clinics that cost very little money. I actually have the numbers written down somewhere, but I think it was like $25,000 to build the structure. Then the nurses—They weren’t staffed by doctors because there were no doctors and it was too expensive. They were staffed by nurses, usually a nurse in each of these clinics and a doctor would visit once a week, because you don’t really need a doctor when someone—You need a doctor to start therapy and you need a doctor to check some things, but for the most part a nurse can take care of it.

So they started opening a couple of these satellites around. And everything—blood samples and everything—came back to Kampala, because these are little clinics. So everything came back to Kampala. That is a standard—This nonsense that Jay wrote about writing down on a napkin with Gary what the network model would look like—First of all, neither of them would know what it was. Now it might have happened that after we described it to them they were trying to understand and they wrote it down on an envelope, but neither of them would know about this. It’s pretty funny. So I don’t know where Jay got that from. Everyone has their own little versions of these things, as I’m sure I do.

This is why we do this. We measure who the source is and what the plausible account is. So carry on, please.

This is a common approach, not only in low-income countries; this is what the United States did. So when antiretroviral therapy was first available in the United States, it didn’t start going out to every clinic in the country. It started in tertiary care university hospital settings until people knew what they were doing. Then the people from those centers trained people in satellite clinics and people would come to the main center where the research was being done. This approach is very common, but it’s particularly common in low-income settings. Everyone’s health care system—Africa, India, China—is built on this network model that supposedly we invented.

So that’s what Peter was doing. He was using a tried-and-true approach. The problem with most of these networks is that they don’t exist. They actually don’t work at all. But then there was also—in addition to what Peter was doing—the Centers for Disease Control and Prevention under a guy named Jonathan Mermin, who was head of the CDC in Uganda. They were doing this out in Tororo, Uganda, supporting TASO [The AIDS Support Organization], a local, African-started and -run NGO [nongovernment organization]. Now Tororo is as far east as you can get in Uganda; it’s right on the Kenyan border. The hospital there is actually the county hospital. When we first went there, it is indescribable what qualified as a county hospital. It would become a center of a spoke-and-wheel satellite, like Peter’s.

They were doing something extraordinary. They had a theory that people won’t come to clinics to get their drugs for a couple of reasons. One, it’s highly stigmatizing. The other is it’s just really hard. Even in Kampala it’s very hard, although the traffic is much worse than it was. But I mean it’s really hard to find these homes. It’s a long walk on dirty, dusty roads. It’s really hard. To get people to take their drugs every day, which you needed to do, to give blood samples, to come in—It’s also—They can’t work their farms when they’re doing this stuff.

Sure, OK.

Plus, they don’t generally bring their families in to test them. So you don’t know who in the family is positive and who is not. So they had a brilliant idea, which is based on work others had done in other areas of health. What if we used something attached to the county hospital? They had to build it, because the county hospital was really substandard. But what if we had a workforce of community health care workers that went out by motorbike, which they had to actually have built up because a regular motorbike would fall to pieces on the dirt roads that went to the people’s homes.

But what if we did that, just had a little cooler and sent people out to the homes to test and provide people with their medication and to check in on them and make sure they’re doing OK, make sure the family is doing OK, see who has a fever and who doesn’t.

So they started this program. I went out and saw it. It was the most remarkable thing I’d ever seen. They’d take me out to visit people and here are these people in little villages who knew their CD4 cell count, who knew what their viral load was, who knew the names of the drugs and when to take them; it was unbelievable. It was absolutely unbelievable. The community health care workers were like these little angels who would go out—It was just remarkable.

In the same way Peter had his spoke and wheel and they would bring all the samples back; they’d bring their reports back. They had their checklist of what to ask. If necessary, they would ensure that the person came back in because something was wrong. But it was a really brilliant system. The doctors all sat in the center; they never went out. It was the community health care workers. So we also had the cost estimates from that.

You’re going out and seeing—

I was just going and seeing stuff because they knew I was working—The reality is at this point everybody knew the PMTCT initiative was happening. We’d been working with the CDC. The CDC people knew, so everyone wanted to show me stuff.

The Ambassador there again, Jimmy—anyone who was interested in this stuff he just wanted to show. So we drove out to Tororo, which took like six hours. He went with us. He’s a great guy. I’ll never forget him getting out of his armored car and peeing on the side of the road. Because we had this armored car, it took us two hours longer than everyone else who just flew.

I’d never seen anything so amazing. The reason I’m telling you that is when Tony said we have to think big; I had all this in my head and I just said, “I know exactly what we can do; it’s already there. We just have to fund it. We can get treatment to everyone who needs it.” He was like, “Really?” I said, “Yes, we can absolutely do it.”

Then he raised the question, which is right: “We have to do prevention too?” I said, “You can’t do much prevention.” Then he was like, “Well, what about a vaccine?” I said, “Yes, but if we go back to the White House with a research initiative, we’re kind of dead.”

Why is that?

If we went back to the White House and said do a big research initiative they would have been like, “Yes. Next.” They weren’t interested in that.

Exactly.

Josh has told me subsequently they were worried that’s what we were going to do. They had reason to believe that, because after the 2000 AIDS conference in Durban, in the Clinton and [Albert, Jr.] Gore administration, Gore actually asked Tony to do the same thing, come up with a plan. They came back with what they called their Blue Sky Plan, which was to build a research infrastructure in Africa, which not surprisingly didn’t go very far.

This time around, the researchers weren’t involved. I was a researcher, but—so as soon as—I will never forget, standing in front of his desk. It was like We could actually treat people? I wasn’t even aware of that when we were building the PMTCT initiative, because I hadn’t seen any of this stuff. But then we also started to focus on prevention. So Tony says, “I love it—” and Tony is a brilliant politician. He is really a brilliant politician. He says, “I’ve got to figure out the right moment to bring this up, and the right context.” So I said, “Great, just tell me when.”

He was down there for something else, because he was down there a lot. He grabbed—I can’t remember—it wasn’t Josh whom he grabbed, it was Gary I think—and said, “Hey, we’ve got this idea and we think it could work. We could give treatment to everyone and we think we could really scale up prevention and have a major impact on the epidemic.” They loved it. This was, by the way, immediately after Tommy Thompson had gotten booed off the stage because the PMTCT initiative was too small. So at the Barcelona AIDS conference Tommy couldn’t even speak; he just had to eventually leave because the activists booed him off the stage because they thought the PMTCT initiative was a joke. That was kind of funny, because no one was doing anything else, and here the President was putting the first gift to the Global Fund and a new $500 million PMTCT initiative. Tommy was pretty annoyed.

Anyway I went on a holiday there with my husband in this little region called La Para, this tiny little place they converted from an old convent. We were just hanging out there and it’s in the middle of nowhere. The owner was this adorable guy. He comes to find me by the pool one day and says, “You have a call.” A call? I say, “What do you mean I have a call?” He says, “Some guy named Tony.” So I walk through this whole—they have one phone that barely works. I hear, [imitates accent] “Mark, it’s Tony. They loved it; we’ve got to do it.”

Literally on the plane on the way back—I wish I had saved it, I have it somewhere probably—I wrote it down by hand because at the time we didn’t have a lot of computers, and I am computer illiterate. I wrote by hand what the initiative would look like.

The timing on this was?

This was July ’02, mid- to late July ’02. I can find the dates exactly because I know what they are.

I don’t think they’re consequential, I’m just trying to make sure I have the timeline in my mind.

So yes, June 19th the PMTCT initiative is announced; they say go big. Tony loves the idea; he’s looking for the right time. He’s down there for something else. The Barcelona Conference was like early July, so this would have been mid-July. I get back and type up what I had written down on the plane. Tony made some edits, which he always did. Basically he would always take stuff and try to make it more attractive and more political.

Then there was a meeting in Margaret Spellings’ office because she was Jay’s boss. That was not a big meeting. It was Gary, Jay, Margaret, Kristen Silverberg, who was working with Josh, representing Josh. Robin Cleveland was in the room. She wasn’t a fan. She wanted to know why we picked HIV and not malaria. Terrell Halaska from HHS. Then Carol Thompson—I can’t remember if Carol Thompson was there for Josh; I don’t think she was. A few other people. But it’s not a big room; it’s a fairly small room. We presented the paper, which I still have. Both Tony and I kept everything.

You have it, rather than it being in the archives?

It’s also in the archives.

I’m delighted you have a copy; I just wanted to make sure, so somebody could find it.

It is definitely in the archives. Although actually I’m not sure if the original one is in the archives. It should be, because anything we submitted—We sent it down electronically so it should be in the archives. At that meeting I remember Gary saying, “This kind of ticks every box we need.”

We structured it—we knew what they wanted by that point, having gone through the PMTCT initiative. They were looking for accountability, they were looking for results, they were looking for a mechanism, how they would get it done. So the network model was already in this first document. We had the number of countries, the goals, the 2-7-10 goals. They were in the first paper, which we had to modify over time. The only substantial difference is we had Russia, India, and China in that first draft.

So that meeting went pretty well. Then Gary took us down to the Sit Room. Then it was just Gary, Jay, Tony, and me. Gary was sitting in the President’s chair and he said, “If the President were here, he would say—The first thing he would say is “Get out of my chair,” but then he would say, “How are you going to do this? We’ve got to get more refined than this paper; we’ve really got to get down to how you’re going to do it.”

That led to a series of meetings and iterations and back-and-forth. At some point the President said get Russia, India, and China out of there. But we kept the goals; we just adjusted. Everything was basically done on an Excel sheet and you just adjusted assumptions. What we did, or what I spent a lot of time doing, was going back through the literature. I was calling Peter and CDC. For reasons—I was telling them it was for my own research. How much does it cost per clinic? How much are the drugs? What are the costs of the nurses? What are the costs of the motor scooters? What is the overall cost? What is the cost of delivering for a person when you break it down? What is the central cost and how does the central cost work out? So we got all the raw numbers. Then we just made some assumptions. Assuming over five years we could reach—We knew how many people needed treatment; we knew how many HIV-positive people—At the time, the assumption was that half of the people who were HIV positive needed treatment.

So we assumed we could get to half of those. That’s how we got to the 2 million. It was just a simple what is realistic and practical in a five-year period with nothing there, when we had to build everything. Then on the prevention side there was a paper published by Bernhard Schwartländer, but the key person is John Stover, whom I then started to communicate with, again on the basis that I’m doing some research. They put forward how we could prevent 60 percent I think it was, 60 percent or 70 percent of new infections; I can’t remember what the total was. But we knew we were only going to focus on a number of countries and that was a key part of it, that we would do—At the time it was 14 countries plus the Caribbean because that’s what we did. We took the PMTCT countries, added Russia and China, and India, which the President knocked out at some point.

Right.

So I got from John—He was willing to share with me—because they only publish the overall numbers, the country-by-country breakdown. Then I could pull the focus countries and just do simple math on that. Then we kept on going back and forth. At some point they needed even more data; they wanted to see everything, really laid out. Actually, we studied the Indian Health Service in Alaska, which is pretty interesting.

The Indian Health Service in Alaska is the same model. What is interesting about the Indian Health Service is because the Indian states are a separate country, there’s a treaty with the United States and with the Indian people on us supporting their health services. It’s a wheel-and-spoke model. There is one hospital in Anchorage. They have all these islands; they have airplanes that connect them. They generally have community health care workers who are selected by the community, which was just like Africa. They have nurses, but the only doctors are in Anchorage.

This was built over a 50-year period from people like me, uniformed health officers, running the whole thing to now the Indians running everything and all that gets done is an audit every couple of years to make sure they’re doing OK.

That was very much the—if we wanted to build a long-term sustainable approach, this is it. People thought it was odd—I was calling the head of the Indian Health Service and whatever, but we based a lot of stuff on the Indian Health Service and what was possible based on that because that looks a little bit like Africa. So we used that plus the experience that we had in Uganda.

Then they wanted more and more and more. It really was constant. The other thing Gary said in that meeting in the Sit Room, that very first meeting, is we needed to get OMB [Office of Management and Budget] on board, which means do we need Robin Cleveland to buy into this, because if Robin doesn’t buy into it then Mitch [Daniels] is never going to go for it.

Now Robin Cleveland was?

She was the PAD [Policy Assistant Director] covering development. She had been on Mitch McConnell’s staff and was the chief staff director for the Appropriations Committee, also for SAC [Senate Appropriations Committee] folk. I don’t know if you know Robin, but she is pretty tough. But Gary is saying, “If Robin doesn’t buy into this, we’re done.” He said, “I’ll take the responsibility for that.”

They emphasized—I don’t know, ten times—between Margaret’s office and Gary’s, that we couldn’t tell anyone. They knew Tony had contacts in the White House. They were saying, “You cannot tell anyone on the National Security Council, you cannot tell anyone in domestic policy, you cannot tell anyone else in the White House because no one else in this White House knows except a small group and the President. That’s how we have to keep it.” They kept reminding us, “If it leaks, it’s dead.” They’ll kill it, because they’re not going to go through negotiation by death.

OK.

Then there was a lot of back-and-forth, including some meetings in Robin’s office where she and I would scream at each other about how good the data were. A lot of shouting going on. Joe O’Neill came into the picture because he replaced Scott Evertz as the HIV czar. Then he became involved as well. Then because it started to get complicated and they actually wanted to know how the network model would work in all of these countries. Then all the math and making sure the Excel sheets worked; I still don’t know how to use an Excel sheet.

So there was a guy who was a modeler for the Department of Defense who was the chief financial officer at NIH, a guy named Ralph Tate. So Ralph and I are basically the ones that just sat down and crunched everything. We were even able to come up with maps based on the existing infrastructure, as weak as it was, in four or five of the countries that would show how the wheel-and-spoke model would work, from a few tertiary care centers, depending on the size of the country, to county hospitals down to these little clinics. That was based on what was being done. We could cost it all out based on the costs that we had from Uganda. We couldn’t use the WHO [World Health Organization] stuff because it wasn’t HIV specific.

That led to—after a lot of back-and-forth, including Gary calling me six or seven at night on Christmas Eve, I mean it was nonstop—Gary and Jay would call Tony all the time. He’d call me in. He and I would draft email responses back to them. When Tony wasn’t there they’d just call me. I remember getting called in the middle of the night in China. It was like four in the morning in China, three in the morning in China and Tony was freaking out. [imitating accent] “Oh, my God, they’re so pissed, they’re so pissed.” I said, “What’s wrong now?” He said, “A report just came out that we need $50 billion a year, not $15 billion.” I said, “Tony, that is for HIV, TB [tuberculosis], and malaria. Read the damn report.” It was a Jeff Sachs report. If you add malaria and TB, yes, it’s 50, but it is 15. So where we got to were the 2-7-10 goals, and that would cost $15 billion if we did a third of it. We weren’t going to do all of it; the U.S. couldn’t do all of it.

Right.

So the idea was—the estimate over five years was $45 billion, but they were freaking out because this report came out that it was $50 billion per year, which we couldn’t possibly do. So at three in the morning in China I got called out of bed to tell them to read the paper. It’s actually HIV, TB, and malaria. This kind of stuff went on nonstop, back and forth.

Then at one point we got another one lobbed into it. We heard, “This will never work. We just found out that they tried this in Botswana and it’s failing.” So Botswana, President [Festus] Mogae, with the [Bill and Melinda] Gates Foundation and Merck had begun an antiretroviral therapy program with Mogae and his own money and Gates and Merck chipped in. The reason was Botswana—and President Mogae was clear, that at the time, in a population of 1.2 million people, more than 30 percent of their adult population was infected with HIV. He basically said, “Our country will cease to exist.”

So they actually began a treatment program too. It was two years in and they only had 150 or 200 people on treatment. So they freaked out. They were like, “This is never going to work; you guys have been lying to us.” No, wait, wait, wait. This is exactly what we’re showing you. It’s a hockey stick; it’s always a hockey stick. It takes—you look at the goals—the first goal—I remember meeting with Josh the first time like five months in. He said, “How many people got on treatment?” I said 25,000. He said, “25,000—that’s nothing.” “No, no, no,” I said, “that’s great. We’re actually ahead of target.” It was always like that. That’s exactly what has happened. We got to two and now we’re at eleven.

Right.

Then we had to calm him down about Botswana and show them that that’s what is going to happen. We’ll invest in the infrastructure that is necessary to build those models and then you can start enrolling people. You don’t want to start enrolling them before.

Sure.

Then because of that I started making calls to Botswana so we had the Botswana costs to do a reality check on the costs that we had done. It was extremely helpful and something I should have done in the beginning. So it is a back-and-forth with fires coming up every once in a while and lots of shouting matches and this isn’t detailed enough. The biggest shouting match with Robin was, “This is garbage; there’s no detail in this. This is just fluff.” I said, “You don’t know what the hell you’re talking about.” But in part we were right. We just didn’t know many things for sure. We had all the data that were available, but we didn’t know. We were making stuff up; it’s amazing to me we ended up on target and on budget because the data that were available were weak, but there was no other way to get it. It wasn’t as if there was a data set that we didn’t have.

You were making reliable assumptions—

We were making reliable guesstimates.

—based on what evidence you had available at the time.

All the evidence. Once we got the Botswana data, there were no other data available.

You were not alarmed by that data, from Botswana?

No, because we’d actually plotted it exactly the same. We didn’t even correct the annual estimates. Our first year estimate was 5 percent because we knew it would take that long. If anything, Botswana encouraged us that the slope of the scale was sound. Then what all this back-and-forth culminated in was a black book, a binder kind of like that, [gestures] but black.

The timing of this is?

This is October of 2002 at a meeting in Josh’s office when he was Deputy Chief of Staff. In the room were Josh, Terrell Halaska, Gary, Jay, Robin, Carol Thompson, who was Josh’s assistant, Kristen—I can’t remember if the other deputy was in, Joel Kaplan, I don’t remember. I can’t—he might have been. All I remember is there was a tiny table.

Usually those two, didn’t they usually have separate portfolios?

They usually split, and Kristen had this.

Right.

Josh really wanted to interrogate, so it is possible Joel was in, I can’t remember. For some reason—I’m trying to remember the couch. There was Gary, Jay, Kristen, and Robin was in a chair over here, Carol, Tony, Josh, myself. We were at the table going through the black book. It was really funny on the privacy stuff—they said don’t mark the book at all. Make only eight copies and here are the eight. The only other person who got one besides us in the room was Margaret Spellings—Actually, Margaret was in the room, she was at the table, Margaret was there. But Gary was literally the only person from the National Security Council.

He does Africa. Is that his?

He did all the development. So he was the Deputy National Security Advisor for that humanitarian development trade side. He’s more of a trade guy than a development guy. But he’s the guy who came up with the Millennium Challenge Corporation; he’s a smart guy. We had the most back-and-forth with him except for Robin, but they played off each other; they were really good friends. I have no doubt they were setting up questions with each other.

That meeting went pretty well; it went very well. We were told don’t put any markings on the book, don’t even mark it confidential, because that’s the best way for someone to open it up. It just looked like a black envelope and we had to deliver them in a very specific way to the White House. Everyone’s was marked. I still have mine; Tony still has his.

Where were you meeting?

In Josh’s office.

So it was possible for you to have these meetings there without—

Oh, yes. First of all, no one would have known who I am. Tony—he was down there for a whole variety of things. He was not uncommonly in the White House.

I didn’t know whether you might have had to meet in the Old Executive Office Building or something.

We would frequently meet in Robin’s office during the shouting matches, although we didn’t shout that much. We met in the Sit Room a number of times.

Robin’s office was in the OEOB [Old Executive Office Building]?

Yes. We met in Jay’s office more regularly. So it was a mix, when we would have the meetings between—the only time we met in Josh’s office was this meeting.

OK. Don’t let me distract you; continue with your description.

There was a lot of back-and-forth. I made the mistake of talking about the President’s legacy, which was really stupid. They were like, “We think we can manage the President’s legacy; you guys just stick to the science.” We were trying to persuade them.

Sure.

So that meeting went really well. Joe O’Neill was in the room too.

As a self-confessed Democrat up until this point, are you comfortable meeting with all of these Republicans?

By that point, absolutely. When Tony first sent me down, I really hated George Bush. I hated him. I was embarrassed he was our President. I thought he stole the election; I hated him. I therefore assumed everyone around him was evil and up to no good and were trying to screw everything they possibly could. I literally hated—I was very much in my activist days. I really hated them, viscerally.

When Tony first sent me down I thought, I don’t know what they’re up to, but it’s something really bad and we’re going to be used. This is going to be total show, BS stuff and not mean anything and this is just crap. Then I got to meet them. They really are some of the most remarkable—They’re still all good friends. We just stayed at Josh’s house the last time we were in D.C. We’ve been emailing back and forth about a bunch of stuff. I got to know [Michael] Gerson really well and he has become a close friend too. They really are remarkable people.

The one thing I learned is that they all were just totally moderate, complete moderates. It was fun watching them. When they had to put a very conservative kind of person in, they put two layers of protection above them; it was brilliant, absolutely brilliant. And they were doing it for the right reason, there is no question. From the first day—no, I wouldn’t say from the first day, maybe after the fourth to fifth meeting—there was no question in my mind that they were doing this because the President cared deeply and they cared deeply.

Once they started learning about what was possible they were totally on board. What they were afraid of was it wouldn’t work.

So your conversion on the President himself occurs largely as a result of your interactions with his people?

It started that way, but I was—Still in the back of my mind it was Is he a joker and these people are just managing it? Is this really coming from him or is it Josh? Does he actually know what’s going on?

Riley: In your own case, is religion an important factor for you too?

Yes, I’m a practicing Catholic, but I was raised by the Jesuits, which is a different brand of Catholicism. I’m not sure I’d still be a practicing Catholic if I weren’t raised by the Jesuits. But you know, to be honest, none of those people—I mean Jay is an observant Jew, an Orthodox Jew, which means we could never have meetings at the end of the day on Friday. Josh is a socially observant Jew, but no one else we were dealing with had any—except for Gerson. None of those people.

OK. It was mostly a question about whether that was a factor in your own sense of interaction with them. With the President—

With the President it became important, but in this crowd it wasn’t at all; it was more that they clearly wanted to do something and do something big. What impressed me most—In the government, it’s usually here is how much money we think we can find, figure out what you can do with it. They were so adamant—because we tried that the first time and they came back and said, “That’s not what we want.”

That’s what we did with the PMTCT initiative actually. We based it on—$500 million sounded like a lot of money, $100 million a year, that’s probably doable. But it was very clear that that’s not what they wanted. They wanted a bottom-up, what would give us goals, tell us how you’re going to achieve them, and then tell us how much it will cost and we’ll figure out if we can pay for it or not, but don’t start with a cost.

I interrupted your train of thought. You’re in the meeting with the black binders.

It went really well. They basically said we’ll have to take this a little bit further, but thanks a lot. So Tony and I walked out of there feeling pretty good. Then we’re asked to make five slides, which we’re told is for Mitch Daniels, so that they could get him on board.

OK.

They weren’t—They were for the President. It’s funny because the goals were 15 percent, 25 percent, 50 percent, 75 to 100 percent of a target based on the year. I had left a zero off so we went from 25 percent to 5 percent and no one caught it; the President must have caught it and said, “There’s no zero there.” Well, I was like, you saw it, you cleared the damn thing, don’t blame me; you should have caught it too. But then we made a tactical error, more than a few. We were feeling so good about it. People were getting a sense something was going on. No one was saying anything, but people were getting a sense something was going on; people were getting a sense something was happening.

I would still think it would be hard with this much activity with fairly senior people not to have people wondering what’s going on behind the door.

The way the White House works that wouldn’t happen, because there are 100 people a day going in and out of Josh’s office. We never met—Robin’s office was in the OEOB and Jay’s office was up on the second floor and there are so many people coming in and out all the time; no one would think twice about it.

And no one knew who the hell I was. Me walking around no one would have a clue. People that knew him—We’d walk around, the Vice President would say, “Hey, Tony.” People knew who Tony was, but he was there for a whole bunch of things, bioterrorism. People always assumed he was down there for bioterrorism because he was very involved in that, using infectious diseases as the root of bioterrorism. So it was completely normal for him to be down there.

The meetings were—I’d have to go back and look. Tony has kept a record, but it was probably once a month that we would actually meet. Then we met with some NGOs and Tony went a little bit too far about where things were headed. Then word started to circle around. Someone from CDC actually knew about it. We were worried that CDC would freak out if they didn’t know about it, so Tony called Julie Gerberding, and she told some other people. Then it started circulating a little bit that something was happening. So Joe O’Neill called and screamed at me. “Did you guys tell anyone? Did you f’ing tell anyone? This is going to kill it.”

So I told him there is a mole going around. And they were just screaming. So then we got the message back that after the meeting with Mitch, it’s dead. It costs too much, can’t be done, so it’s done. Thanks for all the work, but it’s done. I found out later that that was all a ploy so we’d stop talking to people. It kind of worked; we were totally depressed.

You were surprised that it was dead?

I don’t know that we were surprised, because $15 billion at that time was an enormous amount of money. The way they pitched it was Mitch said there’s no way we can find it in the budget; it hasn’t even gotten to the President. Mitch just said no and without Mitch’s support we can’t move this. So it’s dead.

But you don’t think Mitch said no.

I don’t think so.

He could have, right? It’s possible he could have said no and he gets overruled.

It’s possible, but Joe O’Neill told me after that that was all a setup. Plus, I’m pretty sure it was the President—They were showing the President the slides.

OK.

At this point we’re in November.

OK.

The other thing they asked, which made us think it was going OK, but this was before they told us it was dead, is that—and it’s kind of funny, Margaret Spellings’s ex-husband was the brother of Tony’s deputy.

LaMontagne?

John LaMontagne. At the time her name was Margaret LaMontagne. She was getting divorced from John LaMontagne’s brother. So John calls me in one day and said, “I just ran into Margaret in the supermarket and she asked what the hell are these guys up to and can we trust them?” John said, “What are you guys working on? Margaret is asking can we trust these guys. Do they know what they’re talking about?”

The one thing that they asked—This is kind of amusing, the way they did it. They asked us to give them a list of experts to come in and meet with them without us present. So it was Josh and Jay and Gary and Robin and Joe. So we gave them a list of people—Peter Mugyenyi; Jean Pape from Haiti; Paul Farmer, Haiti and Boston; Eric Goosby, who became U.S. Global AIDS Coordinator, at the time was working at UCSF [University California-San Francisco] but had been domestic AIDS czar. Eric was on the U.S. guidelines [U.S. Department of Health and Human Services Panel on Antiretroviral Guidelines for Adults and Adolescents], which I was on, which is how I got to know Eric, because I managed the guidelines for Tony. Then Robin added in Nils Daulaire from USAID because she trusted him, so she wanted someone who could really ask tough questions or tell her after if this made any sense.

OK.

This was before we had told her it was killed because it looked like it was going. In the usual form they were like you can’t tell them what the meeting is about; you can’t tell them what we’re working on. We just want to ask them questions about what could or could not be done, what could be possible. They weren’t going to go through the plan, they were just going to say, What is your experience. Is it possible to get antiretroviral therapy out? Is this doable? How bad are the conditions? What is your work showing you? That’s why we picked the people, because we knew people who had experience. Bill Pape was providing antiretroviral therapy mostly in Port-au-Prince and Paul was providing it up in Cange, and of course Peter in Uganda. So we picked people who could talk about what they were doing. They said you can’t tell them anything.

Of course we had dinner with them the night before at a little Italian restaurant in Bethesda and told them everything. Told them the kind of questions they were likely to be asked and how they should respond and how important this was and if they screwed it up we were dead. It was kind of amusing. They had to know we were doing that; they can’t be that—They’re too realistic not to know that.

Maybe that’s why Margaret is asking if you can be trusted. The answer is no—no on little things but yes on the big things.

They had to know; there is no way they could have—although later they told me they didn’t, but I can’t imagine that they didn’t. Nils had raised a bunch of questions and sent Robin a 10-page email on issues. But the rest of them were pretty clear; we’re doing this. This is possible. It’s not easy, but it’s very possible. People in these countries can manage this work and it’s being done. So that was actually a very important meeting. It was the only outside checking they did, as far as I know.

So they were all there at one time?

They were all there at one time. In fact, Bill Pape was supposed to have prostate cancer surgery that day and he had to postpone it so he could come.

Gosh.

But they all came. Someone was not at the dinner—I think it was Eric, I can’t remember. No, maybe it was Bill. Someone couldn’t make it in time for the dinner, so we had to brief them by phone because of their flight. A little Italian restaurant—don’t know if it’s still there—by NIH. So we weren’t in the meeting, but we saw a lot of the stuff that came after it. We got the readout both from the group and also from the White House. Again it was looking pretty good and then Mitch Daniels said no. I can’t remember when that was, probably toward the end of November. The meeting with Josh was in October. I have the dates, like October 6th or 7th. And Tony wrote down everything, every email.

That’s good for us.

I’m not that obsessive; he definitely is that obsessive. So then there was a meeting in the Oval Office that we know about, where the President heard from everyone. The President has written about it; Mike Gerson has written about it; Condi [Condoleezza Rice] has written about it. He didn’t give a decision in the room, but he called in Josh after and told him he wanted to move ahead.

Time kept on going. It had been mentioned to us that this would be a good thing for the State of the Union, so this is why we’re on a tough timeline. Then we didn’t hear anything. So the week before the State of the Union address I get a call from Terrell Halaska and she is wondering why is the White House scheduling a meeting on Friday with HIV NGOs—the State of the Union being on Monday. Why is there a meeting on HIV at the Old Executive Office Building on the Friday after the State of the Union address? It was being scheduled. The NGOs were being invited. I thought, Oh, my God, he’s definitely announcing at the State of the Union address.

I went in and told Tony, “It’s going to be in the State of the Union address.” He said, “There’s no f’ing way it is going to be in the State of the Union address. No way they’d do that without telling me. No way, no way.” I said, “Tony, why would there be a meeting with NGOs the Friday after?” He said, “No way, it’s not going to happen. I’m going to call them.” Usually I was there whenever he talked to them, but I don’t remember being there when he called them, but they said no, it’s not going to be in the State of the Union.

[laughing]

So of course a couple of days before the State of the Union address they asked if we could get Peter Mugyenyi there, which was a lot of fun.

You mean at the—?

At the State of the Union. He was actually in the First Lady’s box. Then we knew for sure. We didn’t know exactly what was going to be in it. The day of the State of the Union address they had Tony come down to go through the paragraphs. He called me to confirm a few things. I remember I was at the Elizabeth Glaser Pediatric AIDS Foundation for a meeting. I walked out on the street on Connecticut Avenue and he read the paragraphs to me. Some of the statements in the original weren’t accurate, so we had to change them.

I should have said at the meeting with Josh, Josh turned to Gary and said, “All right, now it’s OK to tell Condi, but only Condi.”

Wow.

Yes, that’s how far along we are. They didn’t want—There were two people they absolutely didn’t want to know, and they were people who were related to this field who now talk a lot about how they were involved in creating PEPFAR. He turned to Terrell Halaska and said, “You can tell the Secretary something is happening, but that’s all you can tell him.” I get different apocryphal things about this and probably only Gary or Jay would know, but what I was told is that the Secretaries were informed the day of the State of the Union. The countries were informed the day of the State of the Union.

That was one of our big concerns. We had a plan for countries with set goals. So we picked countries. We set prevention and treatment and care goals for them because care is the cascade by which you do treatment. “Two” was two million people treated, “seven” was seven million infections averted, and “ten” was ten million people under care. The cascade was ten million people need to be in care so we could get two million people in treatment, because that was the map. That then morphed into orphans and vulnerable children in the final legislation for a variety of reasons.

So it was in the State of the Union. We were all at home watching it. My husband was actually in Chicago. I wouldn’t even tell him what was in it. I just called him and said make sure you watch the State of the Union address. They were really clear no one could—Then they started getting Frist and some others involved so they’d be ready to speak immediately after. The countries did not react well, which we knew they wouldn’t. That was a risk I always mentioned to them.

Why not?

It is pretty paternalistic to say, “We’re going to do this big initiative in your countries; you have these goals.” And to be told the day of is pretty offensive. The first year was repairing—We spent a year repairing those relationships and getting people to believe that we were honest. They also didn’t believe it. They thought it was a show: we weren’t going to deliver the $15 billion; that they’d get started and then we’d stop, like development people do all the time; that the President wasn’t really committed; and that Congress could kill it. They were being pretty damn realistic, based on history; they had reason to be.

Sure.

I’m sure some of them at the time, particularly South Africa and others, thought it was a showpiece after 9/11. This was his first State of the Union address—he also had the axis of evil.

The Iraq piece I was going to say—

It was all in there. So people started drawing those things. We were so naïve. Then we started having meetings with the Republican Congress. We said, a Republican Congress, a Republican President, they’ll love it. Oh, my God, they hated it; dead on arrival, this is a sack of bullshit, dah, dah, dah. You just made us pass the Millennium Challenge Corporation, you just gave this big contribution to the Global Fund, there is no way you’re doing this, over our dead bodies. How dare you pick 14 countries; how dare you not consult us?

I remember Paul Grove—He has now become a really good friend—said, “How dare you pick people in certain countries that can live and others that will die? This is going nowhere.” Charlie Flickner, who was Jim Kolbe’s person, literally said this was dead on arrival, and he did everything he could to kill it. He lost his job over it in the end, because they didn’t think the President was serious, either, because there were Presidential initiatives that—

Right.

But he spent paragraphs in the State of the Union. So Frist knew it was real; Lugar knew it was real; ultimately Jim Kolbe found out it was real.

Right.

So the White House put a lot of political muscle into getting that bill passed. The first version—which no one wants to believe—was like eight pages. It was just here are the goals, here are the countries, this is what we’ll do. Congress is like right, yes, you didn’t tell us about it, you didn’t negotiate. This is going to be a real full-on bill; this is not sliding through. So it wound up being rather long. It wasn’t moving at all, so the President called Congress together—[Henry] Hyde, [Thomas] Lantos, Frist who was on board, Lugar who was on board. Hyde was definitely waffling. Lantos—the Democrats hated it. The NGOs—It’s amazing to me still. The NGOs wanted it to fail. They actually wanted PEPFAR to fail, because they were so pissed off that it was Bush that did it; they were so angry that Bush did it. Then they found a variety of reasons—

The controversial pieces of the legislation were not in the original legislation. They certainly weren’t in the first eight pages. We had nothing special about abstinence and being faithful in the original—it’s part of it. If you look at John Stover’s list of prevention interventions it is one—there is a series of interventions including doing some abstinence and fidelity work, condoms, it was all in there, the full package was all part of it. But you had to get it through the committee.

In the Republican-controlled House committee that’s where the—This is where your team got it wrong; it was 33 percent of prevention, not two-thirds.

OK.

And prevention was 20 percent, so you’re down to 7 percent.

That’s in the timeline that you’re talking about, anybody who is correlating this with the briefing book.

The prostitution pledge—those were the main offenders that went in along party lines in the committee in the House. Therefore, it stayed in the bill that was passed by the House, overwhelmingly. The Senate—Frist, Lugar, and other Republicans in the Senate wanted to amend the bill to correct those things because they didn’t believe that arbitrary earmarks were a good idea, especially the 33 percent. They were calling us and saying is this possible? Can you do this? Do you think it is going to work? I’d say yes, we can make it work by implementing it, which is what we did. We figured out a way to define things. We never implemented anywhere near it. It wound up being around 0.3 percent of prevention, which got—I’ll come back to that in a second.

Then the Democrats started to fall away and the NGOs really went after it, really went after it. But in the Senate they didn’t allow amendments and there were many amendments. Frist and Lugar stood up on the floor and just knocked them all down. There were two reasons for that. First, everyone knew that if it went to conference there was a high chance it would just die, because people were really angry about this not getting—not having been discussed before. People just don’t like it when you announce $15 billion things you haven’t talked to them about.

Well, under the best of circumstances, and this is not exactly the best of times for this President. It gets worse.

Although then it was the best of times because everyone was behind him; he could do no wrong.

OK.

So they had political muscle. But it wasn’t moving; it was kind of stuck because of these amendments and things. So in May the President called them all into the East Room—had a big event in the East Room—and basically lectured them for not passing the legislation. The social conservatives were digging in their heels; they wanted more. They didn’t want condoms in the bill; condoms were in the bill, we all insisted on that. They didn’t want it in the bill. They wanted that to come out. They wanted more for abstinence. They didn’t believe in treatment at the time; now they’ve switched and just want us to do treatment.

I’ll never forget in that ceremony I saw Karl Rove point at—It was [James] Dobson, Billy Graham Jr., Ray Ruddy, and a couple of the other far, far right-wing social conservatives. I’m trying to remember if someone from Catholic Relief Services was there. I saw Karl just point to them—He pointed at them and then pointed into a room. I’m pretty sure it was the Green Room because it was the reception area before we went in the East Room. So they all trundled in there, the door is closed.

I see.

Karl was not involved in the pieces of the legislation, but he was the one who was assigned to deal with these folks. From what I’ve been told from the people who know is Karl basically said if you don’t get behind this bill you will not be welcomed back in this White House. That’s it; you’re done. That’s how strongly the President feels about that.

So they all started getting in line. Billy Graham said positive things, Dobson got out of the way. Ray Ruddy, who is a money guy and funds a lot of the social conservatives, calmed down. Then the bill passed. I think it was June and the signing ceremony was in June. Then they did something pretty extraordinary. They did it at the State Department. One of the big debates was how are we going to get—Doing it in the country was one issue, but one of the big debates is how do you get USAID, who was on the warpath because they knew nothing, nothing about this. I mean [Andrew] Natsios just flipped out that he knew nothing about it.

This was done without USAID, the development agency that has a global health section. The head of CDC’s HIV program called it half-baked. It was bad. So how are you going to get USAID and CDC literally—and I knew this because I’d been in Uganda and I would talk to the AID [US Agency for International Development] and CDC people working in these small communities—They didn’t know each other. They had no idea—They didn’t even know each other, let alone have any clue what the other one was doing right next to each other, in the same community, on the same issue. The mission didn’t know. The Ambassador had no idea. The country didn’t know, because they would just keep it to themselves and report up. So the country had no idea what was happening in their country being done by the United States in their country on HIV.

Then you had the Department of Defense, which had a program—At the time ILO [International Labour Organization] had a program; we killed that one pretty quickly. State itself had some programs. But the big ones were HHS, CDC, AID; Department of Defense was the next biggest. So how were all these people going to work together? They asked us for ideas, we talked it through.

But that wasn’t a part of the original plan? There wasn’t a home?

There were options in the papers that went forward. What they settled on was the only way it would work would be to put it into State as a more neutral broker. Actually, in the early days after it was announced it was actually Paula Dobriansky who brought the AID, CDC, HHS together for these absolute bloodbath arguments over who was going to get what.

AID was so stupid they actually offered to give up all treatment to HHS because they didn’t believe it could be done. They would just take the prevention piece and CDC would take the treatment piece. Tommy really wanted to do it and I fought so hard against it. I said once you do that we will never get the agencies together. The same thing is going to happen; the only way to do this is to put—and they don’t work. You can’t do prevention separately. We have to keep it all together. Ultimately that was the agreement.

By putting it in State, you were under a more neutral broker. The legislation did specify—actually the White House wanted—the head of MCC’s [Millennium Challenge Corporation] Deputy Secretary level, which is pretty important in the State Department; they wanted the U.S. Global AIDS Coordinator to be Deputy Secretary level too, but there was internal fighting and it wound up being an Assistant Secretary level instead of a Deputy Secretary level. The authority and the money would go to the coordinator, who would then disperse it to the agencies based on—and this, the Prevention of Mother-to-Child Transmission issue was important for this. We’d gone through this. How are we going to get the agencies to work together?

We had these things called Intermediate Operations Plans. We had all these structures. We took those and changed them for the implementation. The White House didn’t need to get in all that. All they needed to know is that there needed to be someone—we knew from the PMTCT initiative that if there wasn’t someone with the power of the pen with the budget, the agencies would tear it to pieces.

So they did, and that was built into the legislation. Then Randy [Randall] Tobias was named as the first U.S. Global AIDS Coordinator, which shocked everyone, including all of us. We were like, “Oh, God, what’s going to happen now?”

[laughter] Explain that.

You have to talk with—The decision was made, obviously, by the President, but I think it was Jay and Gary who came up with him and put him forward. It was absolutely the right decision. They did the same with MCC; [Paul] Applegarth got MCC. At the time everyone assumed MCC would be the massive program and that we would get absorbed into MCC, that everything would go under that.

The Congress loved MCC; they hated us. But they did such a bad job at implementing it and they couldn’t show results early and it just died. So instead of them being—They were projected to get the $5 billion a year; we were projected to an average of $3 billion a year, which we did. They never exceeded a billion. Then Congress switched to us because we really put in place—These were the arguments I had with Randy about we have to show results; we have to get numbers out.

So we were able to reverse the trend. But at the announcement of Randy—Word was already out that he was going to be appointed—the President had a press—Well, first the signing. The signing was important because you’d expect the signing to be at the White House. It’s the President, it’s his initiative. They were insistent it be at State because they really wanted everyone to see that the President was coming to the State Department to sign the bill to make it clear that the State Department is running this on behalf of the President. It was a really smart political move.

Sure.

I’ll also never forget Jay Lefkowitz looking around the room—it was all NGOs and everything—and Barbara Lee, and a few other people, a few other Democrats actually said, “OK, we can swallow the abstinence stuff and these things none of us agreed with, but we’ll vote for it because the bigger picture matters.”

Right.

She came to the ceremony; Betty McCollum did too, I think, enough Democrats. I’d have to look at the numbers. It was an overwhelming vote; it was like 320 or 340. I could be confusing it with reauthorization in 2008, but it was really high. Same in the Senate; it was 85 or 90 votes. So the President made it very clear; this is a State Department effort. But I remember Jay looking around the room—All the NGOs, Barbara Lee, not a lot of Republican Congressmen came, or Senators—there are 500 or 600 people there—saying we don’t have three votes in this room. Basically it was like we’re doing all this and there is no one here who actually supports us. It was a great line. It was, “We might have three votes in this room.”

That gets back to how much they cared about it. This was not a political move. They knew they were wading into waters that were just going to cause them political headaches, which it did. Then the President waived Mexico City for PEPFAR; imagine how that went down. I still hear about it from Chris Smith. Mexico City is the—

Yes.

You know what it is. The President made the decision that the program was too important and if there were people who could implement, who also supported abortion—we weren’t going to fund abortion, but—if they were important in implementing, he didn’t want to exclude them, so he exempted, by Executive order, Mexico City from PEPFAR. Chris still mentions that to me, still. In nearly every conversation I’ve ever had with him since, he raises that—which is a lot, especially during reauthorization—because he wanted to put Mexico City into the reauthorized list. So they made some big political risk-taking decisions, knowing that this wasn’t going to get them anything with their constituencies that cared about these issues, and that they were going to have really tough political fights—not least of which in the U.S. government.

What’s interesting about Randy’s nomination press conference is two things. One, it was Randy, which surprised a lot of people. Two, Presidents don’t do appointments of Assistant Secretary–level people. They don’t often do Secretaries or Deputy Secretaries. They don’t do press conferences to announce Assistant Secretaries. So he called all the press into the Roosevelt Room and announced Randy. Randy very nervously made a couple of comments and then they opened it up for questions.

Of course the reporters didn’t care about Randy or the AIDS program, every question was about Iraq. It was the press conference at which the President said, “Bring ’em on.” I remember looking over at Ari [Fleischer] and just watching him and his eyes going—that’s all he did, he just went—

Then the other thing that happened in that press conference is he was asked about gay marriage, which I remember very distinctly, being a gay man. The President and Mrs. [Laura] Bush are so kind and I don’t think they personally agree with the positions they were taking against gay marriage. They were so kind to us; they invited us to stuff that you never invite our level to. They would spend so much time with us at them to show everyone this is actually the way we’re all supposed to behave.

The first Presidential dinner—you know they have these holiday receptions, but they had these very small dinners and they invited us to all—every one—once I was the AIDS Coordinator. The President came over and spent the first 20 minutes of the reception with us. Then Mrs. Bush put me at her table. They really were remarkable.

But anyway, he was also asked about gay marriage and that’s where he said we have to be civil; these are human beings. They have rights and it is really a states’ issue. There is really no purpose to a constitutional amendment. That didn’t go down so well with— So the left was going nuts about the “Bring ’em on” comment. The right was going nuts about the gay marriage piece and this was the announcement of the U.S. Global AIDS Coordinator. The next day the President went out to the South Lawn and someone asked him something else and he was like, “I believe in a constitutional amendment on gay marriage,” because they had just gotten the daylights beaten out of them over the time period.

The thing about it is there are lots of Presidential initiatives. The President went out of his way to make sure this one worked. He did a World AIDS Day event every World AIDS Day. We were down there. I never had to brief him; it was pretty remarkable. He knew everything that was going on. He would just start out asking questions. But then when the agencies were still fighting, he called Powell—so here is the Secretary of State, the most senior member of his Cabinet—Secretary Thompson running a $750 million agency, Andrew Natsios as head of USAID, and Randy. You know how in the Oval Office the President sits in this chair and the most senior person sits to the right? So he stuck Powell and Thompson and Natsios on the couch, put Randy in the chair next to him. Andy Card of course was there. He said, “This is my guy on AIDS. You are going to follow what he says on AIDS. Your people are going to follow what he says on AIDS. You are going to tell them they are going to follow what he says on AIDS, and if I hear you’re not, Andy is going to tell me and I’m going to be really mad.” We never heard another peep out of any of them. And Natsios had been really nasty. I mean Powell was all in, it was in State anyway.

Sure.

Any opportunity they had, President Bush would weigh in on it. So in speeches that had nothing to do with it, he would weigh in on HIV. It was amazing to watch him. Sometimes I knew it was in the speech, but I could always tell when he was going off script. Whenever he started talking about PEPFAR he went off script and just started talking. He would do paragraph after paragraph on PEPFAR. He always quoted Luke, you know, “To whom much is given, much is required.” I’ve never, still to this day, talked about it without referring to that—as did Mike Pence, actually, when he supported the reauthorization.

But related to that, as I got to know him, it was so clear to me how much he cared and this was a great life lesson, how wrong public caricatures are.

Yes.

I’ve been privileged now to meet people on the opposite side who have this public image of being so caring and compassionate and gregarious, and they’re the biggest assholes on the planet, who don’t care about anything but themselves. Whereas the President’s image was just—He is one of the smartest people I’ve ever met. He reads hundreds of books a year. Bill Clinton has gotten to know him too and makes fun of him—he is so self-deprecating. It’s politics for him too—he’ll use a big word and be like, “Oh, I don’t know where I got that from.” Bill will say, “Probably from your Yale and Harvard education; you know exactly where you got that from.”

Why is the public image so at odds with this person that you got to know?

That’s a good question and one thing I’ve wondered. One of the things that most impressed me about the President and Mrs. Bush as I got to know them—and I’ve gotten to know the daughters really well—Barbara [Bush] is one of my very close friends. She is in Global Health now. He would have an almost visceral reaction when people would talk about Africa—first of all, when they’d just talk about Africa as if it’s all the same. But this notion that they’re just poor, uneducated people and nothing will ever work there. He believes so deeply in the dignity of every life. He just gets viscerally upset, like angry. And he doesn’t get angry very often, at least not around us. I’ve told people, “Look, maybe we just had a different experience, because he cares so much about it.” So the notion that he wasn’t briefed and didn’t read his—I literally never had to brief him.

Occasionally he’d say where are we on this number or that, but he knew exactly what was going on.

Right.

So part of it is studied politics. People still say they like him. He is actually a fun guy to be around. Part of it gets back to this thing about Africa. He detests elites who look down on other people because of their socioeconomic background, their education. He almost has a studied antielitism, which I find very endearing, given my background. If someone is good, they’re good, and I don’t care—including by the way when Karl was adamant I not be appointed because I’m openly gay, voted for a Democrat, and had a history of giving money to Howard Dean in the 2000 election. [laughter] He really—There is kind of a studied antielitism, which is part politics and part he really doesn’t like elitism. Really, he is incapable of looking down on someone.

It’s remarkable how humble and self-deprecating he is. When you’re just with the family it’s pretty remarkable. The girls just beat the living crap out of him; they just jokingly abuse him nonstop. He sits there and laughs and takes it all in. But there is a Texan—His line at the convention is true: “In Texas it’s called walking,” you know, “People say I swagger, but in Texas it’s called walking.” There is that Texan piece, which is very different.

So I think all those pieces fit together, some of it politics, some of it just because of the way he was brought up, that looking down on people is just wrong. So he’s not going to participate in that. Part of it is Texanism. Part of it too is he just wasn’t a good TV speaker. Sometimes he came across as not informed and not up to speed and not intelligent, which is what I thought. I thought he was an idiot. Now, looking back on it, I can’t believe—Then there is the public—the press hated him.

Sure.

But it was a great life lesson, that public caricatures are often wrong.

I find that having done interviews across administrations since Carter’s time that that is—It is repeated over and over. You come to an interview—by the way, I rarely do these one-on-one, we usually work with two or three people in a panel to do the questioning, to make sure that we cover the things that people would want to know, but it wasn’t possible in this instance. But I find, and I think my colleagues find, this to be true, that the public caricature is so often off in this dimension. It’s easy to develop a disregard for somebody based on their press persona.

Or the other way, to develop a huge admiration for somebody, only to find that it’s way off because it was a cultivated—

Yes, occasionally that happens. Also it gives me—I teach occasionally—Normally my agenda is too busy to allow it, but it’s nice to be able to go before a group of students and say, “You know, you’re actually pretty well served by people in Washington; most of them are much sharper and more public-spirited than you would believe based on the press accounts that you hear.”

Absolutely. I taught for a while too and I’ll be going back to it. I’ve been privileged to meet so many people and have pictures with them. I just think it’s so obnoxious to have pictures of everything. But at Georgetown the President gave me some nice signed copies—sent me a really sweet letter at the end of the administration—so I framed them. Everything else is in boxes somewhere. I put my commissions—He was also kind enough to give me a second commission on the board of the Woodrow Wilson Center—just to make clear to students that I have enormous respect and affection for President Bush. A number of students were like, how could you work for that guy? It’s kind of the same thing. Check your—Think a little bit more.

Exactly. So you stood this organization up or you’re standing the organization up now. You go to PEPFAR immediately or—?

Yes, soon after the State of the Union was announced, immediately after—I’d been the lead for the Health and Human Services for the PMTCT initiative. By the way, one of the most interesting feelings I’ve ever had is during the State of the Union, while everyone was celebrating and I was kind of too, my overwhelming concern was Holy shit, now we have to do this. Building it was fun, but again the data were really iffy and the notion of doing what we said we were going to do and the President just put it in the State of the Union, it was like, wow. Then it was somebody else’s business, I don’t have to worry about. I can go back up to NIH and hope it works out.

Then they created a small team—actually, I was the only one sent there, in the Office of National AIDS Policy, so they had the old town house on Lafayette Square. As soon as the bill was signed in June I got sent down to work with them. Tommy Thompson was actually resisting. He wanted me to stay and run the HHS side because he thought I could get more for them.

Right.

But the White House prevailed. That’s not what they had in mind. They basically said, “You put this thing together, get your ass down here and do it.” I think those were the exact words.

Who are you hearing this from, Josh?

Gary. No, I didn’t have that much interaction with Josh until later.

OK.

It was Gary and Jay that I had the most interaction with. Robin after that, Margaret a fair amount. We’d become very close friends.

Yes?

Yes, I love Margaret.

She’s been very good to us by the way. As the director of the Library, before she got into her current position. I’m wondering how she’s—

She’s having a ball. She is annoyed with what the legislature is doing on some stuff, but—She’s like, “I am not—I told them I am not separating—They can take me to jail.” I love her. You pick up friends too. Kristen has become a very close friend. Josh over time became a very close friend. He really was our angel. But at that point I was junior enough that it was Jay and Gary and Kristen.

So then we were in the town house preparing and working with the agencies and going through these brutal fights with AID and CDC. Now I was supposed to be neutral, even though I was from HHS, because I was in the town house, which was very difficult because they’d call and say, “Why did you have to push for this?” It’s not my position—We worked in the town house until Randy was named, of course, but he couldn’t do anything until he got confirmed and he couldn’t get confirmed really until there was going to be an appropriation order because he didn’t exist until there was money appropriated; it was a new office.

Then we worked from the summer until January when the first appropriation went through, in the town house. Randy was obviously involved, but very carefully. He was preparing for his confirmation and everything. Then the first appropriation came through. Actually, this is the difference between us and the MCC: by May we had money moving, because we knew we had to. Randy actually didn’t want to; he wanted to hold back a little bit more until we could plan more. I said, “Believe me, from my experience and from knowing MCC, we’ve got to go.”

He was great; he absolutely got it. We were so lucky we got Randy. He brought gravitas. He is humble, but he knows what he knows and knows what he doesn’t know. He loves giving people freedom to manage. So we were in touch with him and we did briefings for him. He was shocked. After the first briefing, where we explained the network model and went through the data from Alaska, he said, “Gosh, if someone had told me this before, I would have taken the job sooner,” because he wasn’t sure it was going to work.

So we worked in the town house. NGOs were coming in all the time and yelling at us: not enough money, your scale-up approach makes no sense. We said, “No, we will get to $3.5 billion a year.” They wanted $3 billion per year, not an average. In the end we got to a lot higher than that for the President’s last budget. But we wound up at $18 billion. But they’re like, “Oh, this is bullshit, this scaling up; it’s all a political show. Go for $3 billion now.” We said, “All the data tell us we have to increase over time, and if we don’t use the money that we’re given, we will fail. So don’t force us to take—” They said, “Oh, your absorption capacity doesn’t make any sense.”

We said, “Look at the data; look at Botswana. Look at how long it has taken in Uganda.” So people took—and the countries did too—took those early lower numbers as a sign we weren’t serious. Still, it was a huge increase.

Right.

But they took those lower goals and lower appropriations as a sign that they couldn’t trust that there would be anything more. It really wasn’t until reauthorization that they trusted the program would be around for good.

That was ’08?

Yes. So for five years people really thought this was going to die after Bush and that he wouldn’t even be able to get it reauthorized. It really wasn’t until it was reauthorized that there was full confidence that people could really move. Again, it took a year to get the countries even willing to talk with us in a civil way. Some of those early meetings with the Ministers—whew. But then it became more—“We don’t know that—we’re anxious about putting all these people on treatment and then you guys walking away.” They were more comfortable—

Because the treatment needed—?

—to continue forever. Whereas prevention they were a little more comfortable with, because it was—if you have more condoms—but the treatment part really scared them until the reauthorization.

Just a question—and it shows the limits of my technical understanding. If you stop the treatment, is it that the disease then advances, or is it—?

It comes back. Basically your disease advances and you have a chance—although with one stop, not so much, but with multiple stops—of the virus becoming resistant and then it becomes very difficult to treat.

OK.

Basically you will have extended people’s lives by whatever period they’re on, but then you’re back to square one.

Got it.

Not to mention all the infrastructure and the cost of—we’re the only ones giving and the Africans need to step up. They’re now funding 50 percent of their own response in many countries and it’s all the structural pieces that have to go into place too. That means a big shift in their ministries, a big shift. They were very anxious about it. So we were in the town house until the first appropriations.

You said the town house is on—

It was the old Office of National AIDS Policy. I’m not sure what’s in there now. So the town house is next to the red brick conference center. So it’s on the west side of Lafayette Square.

Over near the Blair House.

Yes. There is a series of red brick town houses. I don’t know what’s in there now. The faith-based office was in one of them. The Office of National AIDS Policy, actually from the Clinton administration, was in one of those town houses.

So what is your job then?

So our job—Joe is at the time at the Office of National AIDS Policy, so nominally in charge until Randy is on board and confirmed. Carol Thompson, who is Josh’s personal assistant but cared a lot about it, was sent over to be Joe’s deputy. Tracy Carson, who had worked with Joe when he was in HHS before, and then I was the other one. There was someone else who flitted in and out, but our job was to prepare for the program, which meant working with the NGOs and civil society, working with the faith community, working with everyone to shore folks up, to provide the information that would be necessary to get the appropriation through. I was not directly involved in the Hill. Actually, Jay handled a lot of that because he had to deal with the faith community. And Joe did too.

Gary handled some of it on the other side, but it was really Jay doing much of the work on the Hill with Joe supporting. So we were preparing the information that would be necessary for the appropriation. We were also planning for and bringing the agencies—a lot of it was the agencies and the fighting again over who gets what and who’s going to manage—it was just an absolute blood-on-the-floor nightmare.

Then Randy gets confirmed at the same time as the first appropriation and we just start moving. The first thing we did was bring two people from each country. The other key thing we did—country by country, as I mentioned before—State did: the Ambassador was now responsible, so there was a country operation plan. Each country had to come forward with an operational plan for how they were going to implement. This is why the countries were upset with us, because we said here are your goals. Based on your number of positive people, based on your infection rate, these are your prevention, care, and treatment goals. So the 2-7-10 is a rolled-up number: you have to achieve them and you have to achieve them in this timeline.

The instinct was AID will do this, CDC will do this, DoD [Department of Defense] will do this. At the time ILO, which we killed—And we killed that program as a waste of money; they’re still angry about that. So the solution to that, which was as good as any solution was going to get, was that the U.S. Ambassador would now be in charge of the program and the country operation plan could only be submitted by the Ambassador. So we wouldn’t accept individual agency pieces. There had to be one whole plan that came from the Ambassador. That came from the experience of the mother-and-child initiative on how would we get over the things that kept us from implementing as effectively as we could have in the early stages of the mother-and-child initiative.

We learned a lot. If we didn’t have that learning from June to the following January—really two Januaries because we kept going on the PMTCT initiative because we had appropriation for that—we would not have done as well with PEPFAR. It really was a lot of learning in those brutal interagency fights. That was all getting planned, what it would look like. So we asked each Ambassador to send two people. We didn’t say one AID and one CDC or one DoD or one State. We said send two people; who are your best two people to help us plan? This was hugely important from an interagency perspective and from a country-buying-in perspective, because countries—the country, like any organization the natural inclination of country directors is that they’ll do the opposite of what they’re told to do from headquarters.

Right.

Now, how to basically co-opt them and get them bought in? So we asked each Ambassador of the 14 countries plus the Caribbean—one of the pieces of the authorizing legislation was we had to name a fifteenth country, because they were ticked off at us for picking countries—so we had to pick one other that wasn’t in Africa or the Caribbean. Randy and I had one of our most interesting exchanges around that.

So that—requiring—so we asked them each to send two people back to D.C. Then we said we need to move really quickly, we can’t wait for the first operations plan, so we’re going to do some central funding around big issues, including treatment. So we put $500 million into this first treatment approach to catalyze with big international partners whom we knew could move quickly.

So by May we had the first people funded on antiretroviral treatment, which is pretty extraordinary, having begun preparation in January. But we had these people come and plan the RFAs [Request for Application] that we would launch for the centrally funded treatment, and we had to do an abstinence/fidelity/condom one too. It was useful because it got the program started. Then we just went from there.

It wasn’t until a few months later that the President had to call the heads of the agencies in because they were still fighting, to tell them they had to work together under Randy’s leadership. Then we would just report very regularly in to the White House. What was really extraordinary is that Powell—by law the coordinator reports to the Secretary of State, and Powell just backed—I don’t know how often Randy talked to Powell. I talked to Condi maybe two times, three times and it was around reauthorization. I go and report to her what we were doing and she didn’t want me to. This is the White House. We negotiated the budgets with OMB, we negotiated—

But your sense is that Powell was not a—?

Oh, he was very interested. It’s just he understood that it was the President’s and therefore he wasn’t going to weigh in on key issues. To some extent it was easier for them because it was a huge increase, and they were saying things like, “I don’t want to take that out of my budget, you go negotiate that with the White House.”

Right.

But it wasn’t for lack of interest; he was very interested, as was Condi. The President in his book says Condi—he knew he wanted to do something on HIV but Condi really pressed him on Africa. Actually an interesting thing—he asked me to read the chapter on PEPFAR before he submitted it to the editor and I did, and there were some errors and I had to correct some things. Then I said, “Mr. President, you didn’t say why you did it.” Which he didn’t in the first draft. There is nothing in there; that information with Condi, that all got added later. He looked at me and said, “Well, why the hell wouldn’t I do it?”

[laughing]

But there are theories out there that you were just listening to the faith community and the Iraq stuff. Whether or not he knew I don’t know. He was like, “Really, that’s ridiculous.” To him it was, “Of course I’m going to do it, how could I not do it?”

We had to get reports in regularly on how we were doing. That’s how I first got to engage with Josh, except for that first meeting at OMB—At this point he had been moved over to Chief of Staff.

They were worried I was going to leave, so they always looked for opportunities. So they had the reception at the White House when I was thinking of leaving. The President knew, because I was saying, “Mr. President, I want to thank you, you saved—On this Christmas, this many people are alive because of you. Thank you for what you’ve done.” He said, “No, what we’ve done, and I need you to stay.” So he clearly knew.

Where were you thinking about going?

This just didn’t happen in those days. At the time we didn’t have laptops you could take home, so every Saturday, every Sunday I was in the office, long, long hours—the politics of it, the interagency—were getting pretty draining.

You just burned out.

Yes. At that point I was Randy’s deputy. He was moving on to this new job at State—“F” to coordinate all foreign resistance—so I thought it was my perfect time to get out. There was a job I really wanted and they knew that. But they were also just looking for meetings that I could be in, which I found out later. We were running the numbers.

Congress kept taking—they said they weren’t, but they were functionally taking money out of the bilateral program to give to the Global Fund, which at the time couldn’t manage anything. We couldn’t—We were giving a fair amount of money and Congress was giving even more. So when we were running the numbers we had no confidence in the numbers they were providing because normally we could say, “Well, they took money from us but it is contributing to the goals and it’s coming from—” We always saw the Global Fund as part—One of the options was to give all the money to the Global Fund. We explored that option. But no one—especially the President—had any confidence that—It couldn’t happen. If we had tried to run that money through the Global Fund, the institution would have collapsed and the initiative would have collapsed.

The Global Fund would have collapsed.

It was—

I wondered if—and looking at the materials—whether there was discussion about the fungibility of money between the two.

There was.

And why you continued to fund the Global Fund once the PEPFAR was up and running.

The instinct was actually the other way. People still don’t believe, because they think Bush was against anything multilateral; he wasn’t. He actually favored multilateral action in the right place because he knew the American taxpayer couldn’t do all this.

Right.

That’s actually why the legislation was rushed. I told you the first part is because people are afraid of a dying commitment; the second part is the G8 [Group of Eight]—at the time G8, now G7—was a month later, two weeks later actually, after it got through the Senate—maybe even the week after. I can’t remember. He really wanted to go and say, “Look, we’re putting 15 down, estimated cost 45. We’ll do a third; you guys need to do the other two-thirds. Commit to it. Let’s make this G8 the time when we commit to actually ending this epidemic and putting the 45 down.” They wouldn’t do it. They agreed in the principle, but they wouldn’t commit to the money. He was very disappointed about it.

We talked about whether or not we should give it to the Global Fund. Again, we didn’t have confidence in the structures. But we were careful when we picked the countries. The main criteria were disease burden and ability to intervene. So Malawi would have been pretty high and Swaziland would have been pretty high, so would Zimbabwe. Zimbabwe obviously had other problems. But the reason we didn’t do any of those three—we agreed we would put some money in, but they wouldn’t be the focus countries—was because there were massive Global Fund grants there. The largest Global Fund grants were in those countries, so we were like why—We’re not going to duplicate—and we need the rest of the world to be contributing and the Global Fund is a tool for that. So we don’t want to duplicate.

In fact, in my last year in office I offered to the Global Fund, we’d done the analyses on how—because we would fund the same principal recipient, the government or someone else. I said, “Why don’t we, over time, move the money from the bilateral program to the multilateral program so that you have more money? We can generate more because of the two-to-one requirement.” The executive director at the time thought it was a game and I was just afraid the [Barack] Obama administration—They actually believed the Obama administration was going to come and give all the money to the Global Fund and stop the bilateral program. They were crazy. So they thought I was trying to prevent that.

It was kind of like the PEPFAR was because of 9/11 theory. One of the options was to just put all the money in the Global Fund and we absolutely made the right choice. Even the activists who were dead opposed to it—actually it was appalling me. I’ve asked a couple of them, “So you know now that had we put that money into the Global Fund it wouldn’t have—we wouldn’t have—had the results we had, the fund would have collapsed and the bilateral program would have collapsed.”

They say, “Yes, you’re right. You’re absolutely right. But I still think we should have put it in the Global Fund because it was a multilateral organization.” Still, it’s remarkable. That’s how much people hated us.

Right.

So there was a real calculation around that. Then it came down to—Congress and [Richard] Santorum actually had a lot to do with this, which also—I’ll tell you about this, another meeting—actually it was the same meeting in Josh’s office, Margaret was there. There are a couple of options, right? With Congress taking money away from the bilateral program but still being the number, the overall number that the President was requesting, it’s the Global Fund, we’re putting money in it. We should be able to use those numbers to say this is what we’re doing on the bilateral program; this is what the Global Fund is doing, so we’re getting to the full number.

The problem is we looked at it, and the way they were counting at the time we had zero confidence in any of their numbers. So we couldn’t use that option because we actually couldn’t have an inability to defend numbers. That would be the deadliest thing to do. Actually, we brushed up against that once; that was my error because I knew better and I did it anyway. Randy knew better, but he was such a good manager that he was like, “I don’t agree with you at all, but it’s your decision.” He was right in that circumstance.

We were behind so we couldn’t count the numbers and we were behind $400 million and we were running all the numbers and saying, “Look, with the amount of money we have with that $400 million loss we can’t reach goals.” So the President would leave office; we would not meet the goals. We went to see Josh to explain this, because at this time he was Director of OMB. Interestingly Jeb Bush was walking out when he was Governor of Florida. He had just asked Josh for some money, who told him no, that there wasn’t enough money in the budget.

So we walk in—and Jeb was probably asking for $25 million. We walk in and tell him that we need $400 million in the next appropriation or we can’t catch up, because once you get behind you have to stay on a certain pace, because of the infrastructure that has to be put in place because of the numbers on—you really need to stay on a certain pace or you’d fall off and never catch up.

OK.

So we explained this all to Josh, and first of all Josh said a couple of things. First, he was like, “Why don’t we just fight—” because we could, at that point they could— “why don’t we just tell Mitch and Denny—” it was [Dennis] Hastert who was Speaker at the time— “to enforce party discipline and shut down those increases for the Global Fund,” which they could have done. They absolutely could have done. It was basically Santorum fighting. Mitch could have—was it still Bill? It might have still been Bill, I can’t remember. But basically enforce party discipline. They were letting it go to conscience.

I’ll never forget. We were going through and I was explaining, “That would really kill us with the activists who we need to support us and all the NGOs, so even though they don’t vote for you, they actually are a hugely important piece of maintaining this. If we lose them, we lose the Democratic support, and if we lose the Democratic support this is a problem for the future.” That is the one thing I always heard from both the President and Josh—the President mostly—when we would try to say Bush did this or Bush did that. He would say, “Don’t make this about me, because if you make it about me it’s going to die.”

Yes.

“Make it about the American people, make it—but don’t make it about me.” So we were talking about whether or not this would happen. I’ll never forget Margaret saying, “That’s a very expensive $200 million.” That year and the previous one, Congress had moved $200 million from five bilateral programs to the Global Fund. With that line Josh was, “OK, we won’t fight it.” It was a brilliant line: it’s a very expensive—because at the time they were asking for $200 million more, which would have knocked another—that’s a very expensive $200 million. Josh also adds—I probably shouldn’t be saying some of this stuff; I’ll clear it with him.

Josh also asked Randy, who is a CEO [chief executive officer], he’s not used to government bureaucracy, “Have you talked to the Secretary of State? Because the budget comes—” with the budget submission act— “Even though we negotiate with the White House, it comes from the Secretary of State.” Randy said—to the head of OMB, who had just kicked the Governor—the brother of the President—out and told him he wasn’t getting any money, “We need to start somewhere, so I thought we’d start with you.”

[laughing]

Those who know Josh—I was getting to know him a little bit. He doesn’t react to things. So all he did was raise his eyebrow. But the people in the room who knew him were like, “Oh, shit.” But he did it. He actually used the entire Director’s Reserve to make up that $400 million.

You’re kidding?

Of course with the President’s approval.

Right.

Then again the President would do World AIDS Day events every year. You would see him at other moments, particularly around reauthorization some stuff was happening, and then periodically at other things. We’d get called in, sometimes for the G8, sometimes for—but then during reauthorization it got really intense. At this point Josh was Chief of Staff. So we’d gotten the bill reauthorized. We can talk about that if you want, but that was really intense.

OK.

Again the President really beat the crap out of the House and Senate to get that done.

That comes in 2008, is that right?

Yes, 2008. It’s not usual for a President to launch a reauthorization. He did a public launch in the Rose Garden. Bill Pape came and this Bishop—Orthodox, Egyptian Coptic Bishop [Bishop Paules Yowakim] came to show the faith in the private sector. He said we’re going for it; we’re going for it. The debate about how much it should be was really intense. It was a really unpleasant policy time, actually, with some conservatives against us.

At one point Condi, Steve Hadley, myself, Randy at the time—Condi was Secretary of State at the time, Steve Hadley was National Security Advisor. We’re all down at one end of the table and all the domestic people are on the other side. We were arguing about should we keep it at 15 that the conservatives—In the end, unfortunately, Rob Portman—Even though OMB was in favor of a larger number in the system. Rob, in the meeting anyway, stuck with—The options were 15, 30, or 35. You know, the way you structure these things, you always think you’re going to get 30, it was a doubling. It was a pretty nasty meeting.

At one point, a guy who was the Domestic Policy Advisor at the time was being difficult. So Josh is sitting next to him. At one point the President said, “Who here is in favor of a higher number?” The Condi said, “Everyone at this end of the table, sir.”

[laughing]

But again he walked out without a decision. Condi ran after him and by the next morning he called Portman and it was at 30. Then he announced it in the Rose Garden, which is really unusual; Presidents don’t say, “I’m going to launch a reauthorization of a bill.” But he really wanted it because he was worried about sustaining. At the time the Democrats were in charge of the Senate and the House; [Eric] Cantor was chair then. The Democrats had gotten the Senate back. So Joe Biden was chair of the committee, actually; Hillary [Clinton] was on it; Obama was on the committee. They were all on the committee.

Then he really went to work at it. We got it through the House, which was a nightmare because of all these—We fixed a lot of the 33 percent—all these things. Tom Lantos actually started it—No, the Democrats were in both houses.

By 2006, yes.

Tom Lantos, who is one of my heroes now, started the process and then he got sick and died. We were worried it was going to die then, but his successor picked it up and carried it forward, in part because of some of the staff. But we had really tough negotiations, really tough negotiations. By this time—I don’t know if you know how White Houses work—Oh, yes, you do, because you study them all the time. But toward the end of an administration—

I just listen a lot.

By the end of an administration many of the great people who were in the White House—not all of them, but a lot of the great people—at the midlevel have gone on to be Assistant Secretary or Ambassador or something because it’s not where you stay for eight years. You start getting filled in with the people who couldn’t get jobs in the first six years.

I’ve been told this, yes.

So at that point we wound up with a couple of really conservative people in the White House in key jobs. There was always Josh and Dan Price, who was put in as the deputy at NSC, and others above, but there was warfare. One thing in particular knocked Dan out of the debate, which was damaging to us, to our goals, because he couldn’t manage the national security apparatus anymore.

Anyway, we got through the House because of Josh. So the conservatives were really pushing that we not give in on abstinence stuff—that we not give in on a whole series of things, that we not give in on mentioning family planning. At this point Barry [Jackson] was in the job, not Karl. Actually, Ed Gillespie, whom I have come to adore—Once he went to Africa, he changed everything. They were both saying things like This is crazy. We’re feeding the base of groups we don’t care about when we’re letting our own base go. How are we going to get—? There are things we want to move. Given where we are politically, if we don’t keep our base—You’re crazy; this is nuts; we can’t do it. No, you can’t mention family planning; no, you can’t give on abstinence; no, you can’t do any of this. It was a really tough meeting, which Josh was not at. He wisely had Joel chair it.

I teed up to Josh after a difficult deputies meeting. Everyone else circled around. No compromise on these issues; we’re going to go in and fight it. I refused. I didn’t say anything at the meeting. Afterward I talked to Joel and I was saying, “You guys told me to send signals. We have a big problem here. I mean it’s not going to pass; we’re not going to get it through.”

Then there was a principals call, because if any of the deputy principals say they don’t agree to consensus, then you have to go to the principals. They got Condi on the phone and that’s where it was really helpful. I didn’t have time to brief her because she was so busy. So one of the conservatives on the Domestic Policy Council was explaining that there wasn’t going to be any compromise on these issues and that there was consensus to it. She jumped in, “Who was there from State and agreed that we would not do that? We have got to compromise on—” I said, “Madam Secretary, I was the one who was there and the reason we’re having this call is because I did not agree.” She said OK. But she was very strong and great on the call. Then we have an in-person principals meeting and then we went into the policy time with the President, which was the difficult moment we just discussed.

The Vice President was actually sitting there. The Vice President was smart. He would show up occasionally, but he would never weigh in on this issue. He might be doing stuff behind the scenes, but he knew to stay the hell out of it because this was the President’s.

Yes.

He had his own people, the conservatives in his office constantly lobbing bombs, but he never did.

You’re talking about the Vice President here?

Yes. He never—He would just sit and not—which I gather he did in other meetings—and then go talk to the President after. But my understanding is he never intervened because he knew not to touch this one. He would let the lower levels kind of direct it, but he would never engage. That was the principals meeting.

Back to the deputies meeting. When people were saying crazy stuff, Joel—because I had warned him about this. Joel didn’t believe me. He said, “It can’t be that many, you’re overplaying this, we’ll be fine.” So when somebody was saying something about how family planning was the same as abortion, he looked at me and rolled his eyes to say OK, now I get it.

Then the next morning the senior staff met because we were going into the final negotiation with the House and Josh called Deb [Debra Fiddelke] in, who was leading the effort for legislative affairs, and said, “Forget about everything you just heard; the President is not stopping this bill based on family planning or compromise on abstinence where we had most of the people agreeing anyway. Go negotiate a bill.”

Hmm.

So if it weren’t for that access—In the normal world it would have died if it weren’t for Josh knowing the President wanted the bill, that he wasn’t going to stand on this stuff, plus the President believes in family planning. Josh believes in family planning. He just said go negotiate a bill. We did. It got through the House. Chris Smith voted for it; Mike Pence voted for it. It was tough.

We went to meet with Paul Ryan at the time because the dollar amount had gotten up to 50 billion. So we went from 30, which the President proposed, to 50 in the final bill that made it through the House. We went to see Paul, who at the time was not very senior. I was from Wisconsin; he was from Wisconsin. He is married to a very close friend of Kristen Silverberg. We sat next to each other at Kristen’s wedding. He said, “God, you guys have to be pretty desperate if you’ve come to see me.”

I said, “No, we think we’ve got the votes, but it would be really important for you and given your stature on the budget stuff to—” He said, “I can’t do it. At 30, all of us could go for it. It’s the President’s, we understand that. But at 50, we just can’t do it.” That’s where we were in a lot of the— So getting Chris Smith—again, the social conservatives on our side, not the fiscal conservatives, is what got us through the House. Paul actually put up a motion to recommit based on the 50 billion, which we only won by 16 votes. That would have killed it if it was recommitted to committee; it never would have come out again.

Sure.

But it was really Chris and the social conservatives that got the very few Republican votes to complement all the Democratic votes to get us over. Nancy Pelosi was great, by the way. She went to the well as Speaker, which as you know Speakers don’t usually do, strongly supported the bill, which got all the Democrats behind it even though it was a Bush thing.

The final number was?

The final number in the House was 235 if I remember correctly.

The budget.

Oh, 50. In the House. When it went to the Senate, it got a little complicated. It wasn’t moving. Biden actually cared about this stuff—He has been involved for a long time in it—but it wasn’t moving. [Harry] Reid had no particular interest in moving it because there were too many social issues. They were coming up on another election. The prostitution pledge was still in the bill—I can’t say why, because it would cause too much trouble, but it wasn’t us.

I’m not sure I know the prostitution pledge.

One of the conservative things that the committee had in the first time around was that anyone receiving money from PEPFAR had to have a pledge that they didn’t promote prostitution and sex trafficking. It has been reviewed by two federal courts; one of them struck it down and one of them kept it. It’s actually still in the law. The Obama administration is implementing it the same way we did. None of us really liked it, so all we did was take the language from the legislation, and put in grant agreements. If you sign the grant agreement, you had your pledge.

The conservatives wanted us to force boards to make proactive, positive statements that they don’t support prostitution. I had convinced the White House to let it out. I said, “Look, the courts are going to knock it out anyway, why fight for it? We can give them a bone. Why not start off with that?” But unfortunately—The White House was ready to do it, but it didn’t go that way. So Reid didn’t want to have the debate on the floor on the prostitution pledge because we were going into an election. It is not very useful to have Democrats saying we believe in prostitution. So he didn’t want it going to the floor and all the other social issues. It’s 2008; I don’t want to go into the election making Members vulnerable, I don’t want them vulnerable. Nancy was actually worried at the beginning too. She had to ride the Rules Committee person who wanted to open it up to amendments. She had to ride the Rules Committee person whose name I’ll remember in a second to keep it as a closed rule. It was up or down by the way. Had they opened it up in the House, it would have died.

So again, the President was unbelievable, in every speech he gave. He kept inviting me to these speeches that had nothing to do with AIDS. Every speech he gave anywhere he said, “The Congress needs to pass this bill on AIDS.” He was up on the Hill for something else after the House had passed. He looked at Biden and said, “Joe, what’s your problem? People in the House were able to pass this bill. Get off your ass and get the bill done.” That actually spurred Biden to get it. Then he held hearings and it went through.

Then the floor; we almost lost it on the floor. This is pretty extraordinary. This is how far the administration—how much they wanted this bill. I’m sure you know the Senate rules—I didn’t know any of this stuff until I started getting involved in this. So Biden of course was floor manager because the Democrats—We had to go through some stuff in committee—There were some issues in the committee about some of the language. We had to do some colloquies between [Barbara] Boxer and Biden. They invited me as an expert at the committee meeting in case—Biden really wanted it and Luger really wanted it. The full committee came. We went to meet with all the committee members. Even people like [John] Barrasso, who believed in it, said, “I can’t vote for it because of the $50 billion.” But [Michael] Enzi supported it.

As the bill went to the floor late one day, there was no one on the floor. People who chair those sessions are generally the most recent Senators. They don’t know the parliamentary rules. So they didn’t know that they could step out as chair and say, “I’m speaking now as a Member; I call for a quorum.” Brian McKeon, who was the floor manager for Biden, who is now Deputy National Security Council and a great guy—I’ve never seen Brian panicked. He was panicked after this. He was watching TV because he’s watching the vote. He didn’t know there was no one else in the room; just the chair.

Jim—what is that guy’s name from South Carolina?

DeMint?

Jim DeMint, who voted against it in committee, hated it. He wanted to attach—Because he was going to run for President at the time, he walked in and did a secondary amendment sticking [Jack] Kemp, [Robert] Kasten, and Helms that forbid funding for abortions into the legislation, which would make it part of the Foreign Assistance Act. I don’t know if you know, but Kemp, Kasten, and Helms are added as a rider every year in appropriations and it always clears.

So he was—by putting an amendment in, actually making it part of the Foreign Assistance Act, which meant it was permanent, authorized legislation, not annual appropriations legislation. We had to carry a lot of Republicans—especially if there was going to be a filibuster, which DeMint was threatening. The guy in the chair didn’t know that he could step out and say, “I’m speaking now as a Member; I call for a quorum.” All he said was, “Do I hear any objections?” and since no one else was in the room, there were no objections.

So we just got the biggest poison pill you could possibly get added into the bill because Brian had failed in making sure there was a Democrat on the floor at all times. He turned sheet white; he was sweating. I’ve never seen anything like it. We were in trouble; we were in big trouble. The whole bill was ready to go down. There was no way we were going to get Orin Hatch and Sam Brownback. We were never going to get them to vote the amendment down, because they couldn’t do that. But they could vote to table it.

From what I understand, many folks rallied to get conservative Senators to table it. There were a lot of calls late in the night to key Senators. Catholic Relief Services and others really wanted the bill—in part because they received large grants, but more because they really believed in the fundamentals of the program and the bill.

Hatch, Brownback, unbelievably all voted to table it; DeMint was furious. Plus, the Senate was so pissed off with DeMint because he kept doing this crazy stuff.

Yes.

We won that vote 82 or 83, I can’t remember. Once that was done, basically, all the opposition just gave in. They were like, “Well, if you have that many votes to manage that—” except for [Jon] Kyl, who was deputy majority leader, who wanted $2 billion for some Indian project—I can’t remember what it was, an Indian health project or something. So the compromise that kept Kyl from blocking it—He is one of six Senators who voted against it. But to keep him from holding it and blocking it and using his structure to get people to vote against it—was to earmark that $2 billion for something else.

There were a few minor changes in the Senate. Then we needed the House to adopt the Senate version so we didn’t have to go to conference. So again Nancy went all out. Chris Smith went all out. Mike Pence gave a brilliant floor speech in favor of it. We knew we were done, but it was a little touchy on whether or not they would agree to some of these pieces and they did, so they adopted the Senate version that was done.

The President signed it in the Oval Office—sorry, in the East Room, an amazing ceremony. I can’t remember how many Members showed up. John Kerry was standing behind him; it was pretty amazing. There were probably 20 Members there, 20 to 25 Members.

For the reauthorization.

Big deal.

Let me ask one question that I want to make sure I get to and then we’ll break for a bit.

You said that originally the design of the project that you presented to the President had China, India, and Russia. The President said get that out of there. What was the rationale? Was it because it was too big or—?

The rationale for putting it in was there was actually from the National Intelligence Committee [NIC]—the intellectual arm of the CIA [Central Intelligence Agency] that publishes those reports. So there was a NIC report that the greatest explosion in the AIDS epidemic—and we really were arguing that it’s not just the people infected now; look at where we’re going and the number of people who are going to die if we don’t intervene now. That is how Vietnam got in as the fifteenth country.

But the NIC report said that there would be an explosive epidemic in Russia, India, and China. So we’d actually put them in, because we were like, “Look, if you’re really going to control this epidemic”—and this work John Stover and others did showed that you can’t really—“and because of the size of their populations, the epidemics would be out of control.” They were dead wrong on the India and China. They never actually took off and we think we understand a little bit why. Russia is a problem and their rate is rising. But the President is a smart man too, he said, “We’ve got to get this through Congress, dumping a ton—” First of all, Russia is a nonstarter. I can’t believe how naïve we were, now thinking back on it.

China—nonstarter. India I thought we might have a shot at, but our space program—India has a space program, it’s going to be hard to get this through Congress. It wasn’t—I did not talk with him about it. Gary I think had the conversation with him. Josh may have been in the room, but I think it was just political pragmatism.

It just wasn’t immediately evident.

Just political.

What the factors might have been—It wasn’t immediately evident to me, but maybe I’m jet-lagged and not thinking properly.

I think it was just political pragmatism and maybe a little bit of this was are you out of your mind with all these people in Africa.

Gotcha. Well, let’s shut this down and let you catch your breath.

[BREAK]

We just had lunch and we’re talking about the possibility that there might be a movie based on the AIDS relief—

Especially how it started, the oddity of a bipartisan—They like the whole secret stuff. It’s unusual. John’s piece is pretty good; Jay’s piece is—I don’t know where he came up with some of that stuff. On the other hand—

John being John—?

John Donnelly.

That does not appear in the briefing book, and I was just saying that I was disappointed that our researchers missed it. Is it a recent piece?

No, three years ago. He’s been wanting to write a book, but then he went to work—He’s going to do it now, but then he went to work for Jim Kim at the World Bank. He expressed interest in doing it again. I don’t know where Jay came up with some of the technical stuff. Everyone has their own perception of things. As I always told John, there was stuff happening inside the White House that I was told later, but Tony and I were not part of a lot of the internal conversations. We were there a lot, but I’m sure they would then meet and say, “These guys are crazy.”

We’ve interviewed Jay, but I didn’t do the interview, one of my colleagues did. I’m sure there were discussions there.

If the napkin thing is in there, that’s just not accurate. It’s possible he and Gary were trying to figure out what we were telling them and he wrote it down that way. The President actually writes a very good chapter on it; Gerson’s chapter is quite good too. I don’t know if that’s in your book or if you’ve read Gerson’s.

I have read it, but it tends to be episodic. I probably have read the entire—I probably read the entirety of Gerson’s book when we did his interview, but his interview was done a long time ago—he might have been the third or fourth person we interviewed.

That makes sense.

So it has been a very long time I know.

Then some of us have done pieces of it, but to tell the whole political story—especially because everyone has angles and someone needs to do it.

Exactly. I’ll say this and this is mostly for your edification, not for the tape. We had talked off the tape about our relationship with the Bush Foundation. One of the central concerns when we originally got started was maintaining good relations with SMU [Southern Methodist University]. The principal assignment they expected SMU to take up was the people below the level of the top one hundred. A lot of that they had thought might be web-based; in other words, you would log in and record your 45-minute interview from a remote location. I didn’t have anything to do with that. I wasn’t sure it was viable. But any time we can get more interviews done rather than less, that’s fine.

The other big thing was the pre-Presidential and post-Presidential stuff that SMU would be uniquely suited to figure out who this guy was as Governor of Texas. To my knowledge nothing has been done on that. They set up a Center for Presidential Studies at SMU, which I’m sure was not envisioned when the oral history was originally on the drawing board, and one of the things that they have done is a series—It is not a direct competition as an oral history project, but they’ve been doing a lot of interviews, but on subject areas, the surge for example. They had a group of people together and did a book on the surge. I don’t know whether they’ve contemplated doing a similar thing on PEPFAR.

I think it is a very unique thing in history. The impact—It’s remarkable to me. Maybe it’s less so in the U.S., because people just don’t pay attention to good news stories, but traveling around Africa, heads of state still go off notes and say, “I really want to thank President Bush for doing—” And it wasn’t just PEPFAR; there was the President’s malaria initiative, the neglected tropical disease initiative. There were the trade agreements and AGOA [African Growth and Opportunity Act], started by Clinton. But Bush really concentrated on Africa in a way that others hadn’t. They love him.

But one of the things that we’ve occasionally done at the Miller Center might work very well on this. It would be outside my own individual purview, but we do group oral histories, get the six to ten people—The way we’ve typically done it is we’ve gotten people who served in the same positions across administrations, so that we had speechwriters from [Richard] Nixon to Bush to talk about the similarities and differences. Most of the time what happens is they’re focused on “my God, we do exactly the same job,” and how awful X, Y, and Z is.

We talked about doing this on some issue areas. This would be a perfect example. So I’ll keep it in mind; it might make sense if we could identify the five or six, ten people who were most prominent in the initiative and get them all in the room at the same time and let you see if you can’t hammer some of this out.

That’s fairly easy, because there weren’t many of us. Now they haven’t interviewed Jay, but what the movie people said after talking to Tony, Mike, Josh, Gary, and myself is how consistent—and we didn’t talk with each other in advance—how consistent we have been about what happened. We each have different perspectives, but that everyone has been very consistent, everyone was very consistent on the President.

One thing that was amusing is it is one of the first times they’ve done anything like this when there isn’t anyone trying to promote themselves or their own ego.

Interesting.

Everyone is deferring to the President saying this was his, this was his, this was his. Trying to tell the story, but through—Everyone has their perspective, which is an interesting insight—which doesn’t surprise me with the cast of characters. That’s who Bush got around—he really didn’t tolerate people who had massive egos.

Your story in particular is so unusual because you’re coming out of a midlevel position in a department. I don’t know that in my 15 or 20 years of interviewing that I’ve encountered somebody—maybe in the national security area—maybe there are people who sort of jumped into the President’s purview because of an initiative, but it’s quite rare.

Especially one who didn’t want anything to do with the President. Did I tell you, Karl Rove tried to block me—?

No.

—which I found out later too.

Tried to block you from—?

He didn’t really care if I was deputy because he didn’t pay enough attention—

Right.

But when it came to a Presidential commission and going before the Senate, he was like no like no fricking way are you appointing a Democrat who has a history of giving money to Howard Dean in 2000. Josh and Gerson kind of overruled him. It just shows the President was like, “I don’t care, if he’s the person we think can do it, who cares?”

Exactly.

Josh and Mike have also been clear that they also saw the advantage of the optics.

Sure.

Especially for the long-term viability of the program. President Obama continued the tradition of technocrats. They weren’t people in the government—the current one was. Because of his precedent it has become a kind of technocratic role.

Maybe that’s a good thing. Let me ask you the generic question about accountability. We set this thing up; you’ve talked about all of the efforts that went into getting the program set up. Before your period, I guess—the entire first term, you’re in a lower-level role; you’re not running the enterprise. Talk about the difficulties of getting this set up, the hockey stick, the kind of feedback or direction that you’re getting from the White House as you’re doing this.

Is it the case that once this is authorized, that the White House is forgetting that it’s there and you’re off to the races, or is there a lot of monitoring and assurances that you’re able to produce what you said you were going to produce?

They were checking all the time.

“They” being?

The White House. It was a mix of principally Gary and Kristen. Kristen and I became such good friends.

She’s still deputy to the Deputy Chief of Staff?

She was still Deputy Chief of Staff in the early going. She was the one Josh had tasked to keep checking in, but Gary was the constant—and Robin was all over us too because we had to get the budgets every year. We had twice-yearly reporting. So twice a year—We’d set very specific goals and we had country goals. We told them—We knew that some countries would overperform, some countries would underperform, but on average this is where we’ll get to. They were fine with that as long as we hit the numbers. But they were checking all the time.

While I wasn’t running it, Randy was. This wasn’t his world. Then he just promoted me rapidly to the head of program, an assistant deputy and then deputy. The key was working with the countries and the country teams. The way the U.S. is structured, there is CDC in every country—we picked countries where both CDC and USAID were, with a few rare exceptions. DoD was in some of them. But it was really—We set up a structure at headquarters to reflect the country realities.

So we had country backstop teams that were supporting the country teams, but also keeping them on track. Again the countries, through the Ambassador, had to submit each year an operations plan that would say what they were going to do in excruciating detail to achieve those goals. Then we would get reporting twice a year. We had to set up what does the reporting look like; how do you count people in treatment, and how do you follow them?

This was a big thing we did related to accountability: How do you count an orphan getting services? We started basically—If someone walked by an orphan during the course of a year they would count an orphan being touched, which is how we used to count things. So we had to set up a full accountability structure. There are five basic services for orphans. We got to the point where you have to provide at least three in order to count the orphan being reached.

So we really had to dig into how has the—before—I think this is one of the greatest legacies of PEPFAR, actually; it really fundamentally shifted—if you ask anyone—This was not just PEPFAR, this was the Bush administration’s approach to development. It was the Millennium Challenge Corporation—but then PEPFAR was the big disease-specific with goals—the MCC didn’t set goals and targets; they couldn’t. But it really was about performance and accountability.

Right.

So we had to understand how it was being done. It was awful, which got to President Bush’s “don’t ask me for a bigger check, tell me what you’re going to do.” If you asked anyone what the U.S. government—or any other government for that matter—was doing on health and AIDS and nutrition, the answer would have been, We’re spending X amount of money. It wasn’t what we’re getting for it; it wasn’t the results. The ways people were counting were insane. You’d have $50,000 to $75,000 in a country, literally, and they’d be counting national results as their results. It was just unbelievable.

Then the other thing we found out is—There was no expenditure tracking; all we were tracking was commitments. You never actually knew how much money was being expended for the results you were getting, which was crazy from a business accounting perspective. But those were federal approaches—a lot of that was federal-wide. So we had to work closely with OMB with a guy the President put in place in OMB—a close friend of his, Clay Johnson, to try and get management into the organization. I mean he was a business guy, a business manager. So we had to work closely with him to get some things changed. We broke rules on—We forced people to set up expenditure requirements. The way it was being done was paper voucher; it was insane.

No one had done this—We set up the first online system so that we could track and trace key things not only for ourselves but for Congress. It used to be if you would ask how much are you spending on—or what are your results on X, Y, or Z—it literally would take six months, because you had to go to every mission, every grant and contract. They had to pull their paper, you had to look at everything.

We knew they were going to ask us about girls and women; we knew what the Democrats were going to ask us and we knew what the Republicans were going to ask us. We even went to the Congressional committees and showed them the list of what we were going to collect and asked them if it was going to meet their needs. Got to love them, some of the most talented and committed people were the Members and their staffs with whom we worked. I loved working with them; they said, “That’s up to you. We’re not going to comment on it.” They knew if they said sure, then anytime they asked us for something else it would be, “You didn’t ask us for that.” But they were pretty happy with it because it was the first time someone actually gave them information.

We had core indicators, which were the top-line indicators—there were about ten of them—but then we had a whole series of subindicators. It was an indicator cascade from planning to outcomes. The goals we set were really outputs; they’re not outcomes. Morbidity, mortality, and infection rates, those are outcomes. But you couldn’t do that within three to five years.

Right.

You couldn’t even count incidence then; we were doing calculations. You only do those surveys every three to five years. But there are things that have to happen. This is one of the things I loved about the President. He said, “You don’t go from here to there with nothing.” That was the thing we did in development. We were heavily criticized for setting goals. People literally were saying: You can’t set goals. Development is complicated. You just have to spend money and things will happen. I thought: You’ve got to be kidding me. That’s nuts. This was reported twice a year. The top-line indicators we did get twice a year. The second-line indicators we got once a year because it was too much.

Then we would use those to see where are we off track; where are we on track. It had a big influence on how much money we gave countries the following year because if they were too far off track we’d try to understand why. But they would get less money than countries that were performing. So we built a whole performance system into it based on the accountability of it. Then we would put out an annual report. It’s pretty extraordinary.

Tim Rieser, I don’t know if you know Tim. He has been SFR’s—the Senate Foreign Relations, SACFO—Senate Appropriations Subcommittee on Foreign Operations. He has been the Democratic staffer with [Patrick] Leahy for 35—He is one of the most senior people.

Right.

We never had a hearing, except for the first year, on the appropriations in the Senate. One time I was with Tim I said, “Tim, why didn’t you have a hearing? Aren’t you interested?” He said, “No hearings—I don’t need hearings because you give me all the information I need. I don’t need a hearing. If anything, you give me too much information. I can’t get through all the stuff you give me. In the Senate we don’t have time; in the House they have plenty of time. They have 435 Members; we’ve only got a hundred. We don’t have time for all that. So give me less.” We were the only group that didn’t have those hearings.

One of the USAID people was complaining about our accountability and the way we report and setting goals. He said, “You can’t keep giving all that information to the Hill; they’ll just ask for more.” I said, “That is why we don’t have a single earmark.” We didn’t have a single—We had the overall earmarks, but we didn’t have a single earmark, and AID had more earmarks than they had a budget for.

The accountability is important to show what you’re doing so you can get more money. Again Congress hated us when we started. It was because of the accountability we put in place—that was one of the things the President liked about it and what Josh at OMB liked the most about it. You know, if you can give me information on what you’re doing and succeeding, I can give you money. If you don’t, I can’t give you money.

Sure.

And Congress is the same way. So that accountability was huge. But it wasn’t just the internal government accountability that really rocked people’s worlds; they really didn’t know what to do with you have to report twice a year and us putting in place—which never existed really in the U.S. government—expenditure data so that we could match expenditures with results and try to get a sense of where are we paying too much; where are we not. We did a huge analysis around that, actually. It turns out what services you provide determined most of that.

We were very data and accountability focused. With a background in science, it was important for me to do. When I came here I was shocked there was no—It was still on paper, like what we started on PEPFAR with. I mean, how can you not record that stuff? Now we have the systems to do that here. But the other piece of the accountability was the change from paternalism and development. This was the President—This was the MCC—This was really his view and gets back to his visceral reaction against an all-too-prevalent view that Africans can’t do things like HIV treatment.

Like Andy Natsios was saying, “We can’t give them antiretroviral therapy because they can’t tell time.” He actually said that, repeatedly. Going back—and I’ve talked to him about this—there was no millennium development goal for antiretroviral treatment. People literally stood on the floor of the General Assembly and said, “People in Africa can’t do something as complicated as treatment; all we can do is prevention.” The President’s reaction to that was “So we’re going to let all these people die because we think they can’t do it?” He would get so pissed off.

So that paternalistic view is very prevalent in development, still is. It’s getting better, but it’s pretty bad. If all you’re doing is giving money away—If you think about the history of development, you can go back to the colonial times and then missionary work and then World War I and Herbert Hoover and the big food program—people forget Hoover did this massive food program—then the Marshall Plan and then the Cold War hit and development became a tool of the Cold War. USAID would never admit that, but—and the people doing it weren’t necessarily thinking that way—but it was basically that.

For the Europeans it was really a way to assuage their guilt. They knew all these terrible things they had done. So development largely—I get in trouble when I say this sometimes—was largely abut feeling better about yourself, because you were giving some money away, or getting people to feel better about you, which was the Cold War approach. So if that’s what you’re trying to do, you don’t actually care what the results are except for those two things. I think that really played a key role into where we were in development. Really it was the Monterrey Consensus, which the Bush administration really drove, that changed it and said this is not paternalistic, it’s about partnership; it’s about joint responsibility. It’s about accountability. It’s about good governance, which isn’t just corruption—it’s best use of resources. It’s about every sector being involved because governments alone aren’t going to solve development. It’s only a six-page document—I mean from an international agreement—then we went from that.

It’s like the original bill—We went from six pages to the Paris Declaration, the Accra Accord to the Busan. Now there are 5,000 pages. But the principles are very clearly stated in there. PEPFAR, MCC—we actually emanated from that document that Gary Edson really wrote. The President was all on board with it.

The reason that’s important—Paul Kagame said soon after PEPFAR was announced—I was in Rwanda with him and he said something I’ll never forget. It was like, “This is the first time someone has respected us enough to hold us accountable,” a pretty extraordinary statement. That shifts the whole paradigm. When you’re actually—And they hold us accountable too. They hold us accountable to provide the resources and on time. They hold us accountable to trust their leadership and get behind them.

That was a huge difference in all of us too. That whole shift is one of the big legacies of PEPFAR: long after we will have solved the AIDS epidemic, that fundamental shift in how development was done on a results-based, accountable way that actually respected the countries enough.

Then the other piece of it that was completely unique was national scale-up. It’s related. The way we’d always done development, because the money was low and because everybody was such a control and paternalistic freak doing it that we would do pilot projects here and there. You can run pilot projects from Washington, from Charlotte. You can run pilot projects—That’s what we were doing. We were basically running pilot projects in people’s countries. That’s why the people—CDC and USAID people working in the same country—had no idea who the other one was or what the other one was doing, because they were just doing their own little pilot project and you didn’t need to know what anyone else was doing.

But by saying we’re going to support a country to do a national scale-up of prevention, care, and treatment, you can’t do that anymore. You actually have to start shifting accountability structures, responsibility structures, and that is another one of the massive legacies of PEPFAR well beyond the clear ones. It fundamentally changed things. When we started, and when MCC started, the Europeans were dead opposed to that kind of accountability. They believed in basket funding, where you just give countries money and block grants and hope something happens with it, but there are no strings, no accountability, no monitoring. You just give them the money.

Not surprisingly they changed their minds after lots of it disappeared. But it’s also engagement of other sectors besides the government, so completely anti-results-based financing, completely anti–private sector. Those were really tough discussions in the Monterrey Consensus. The inclusion of the private sector almost led to the end of the Monterrey Consensus. Gary tells me, which I think is probably true, that if it weren’t for the promise of the Millennium Challenge Corporation and that amount of money, they would have killed it. Now everyone in Europe—the Nordics who were so dead opposed—and everyone else, all they’d talk about is results-based financing and how do we engage the private sector more. It’s really extraordinary.

So these are pieces. This is why the Africans love the program so much. It changed how we acted with them. It didn’t change individual interactions. I still go—These junior Foreign Service Officers lecturing Ministers on what to do—I mean just imagine how a Minister feels. But that’s how it was; that’s how it always was. We still have some of that, but it’s fundamentally changed. It’s not just the U.S. engagement; it really began a movement.

It’s a very long-winded—The accountability—What Paul Kagame said is so important, because if you don’t respect someone—

Right.

—you don’t expect anything from them, in any human relationship. So if it’s just charity, if it’s just a handout, you don’t—So it fundamentally changed. That constant reporting, which people complained about all the time—Doing these operations plans where you had to actually say in detail—line by line—and we gave them the budget lines. We weren’t just—We said, “Here are the budget lines. Tell us what you’re doing, because we need to be able to collate it and use it.” The complaints, God, were unbelievable, because they’d never had to do this before.

Then as we got further in it, countries that were doing well, we were like, “Well, you don’t have to do that extensive planning anymore, because you’re doing really well. So we’ll exempt you from doing all these sections and you can just give us these pieces.” They continued to do the whole thing. I said, “Why were you complaining?” Then, “Why do you still want to do all of this?” They said, “Because it is the only way we or the government knows what we’re doing. It’s the only place where we have all the information. So we actually need it.”

You said that they got to the point where this revolutionized your thinking, but you also started earlier in the discussion by saying that the Africans were offended by PEPFAR because of the imposition of the plan. It was sprung on them without any consultation. Maybe take a country that you worked with and walk us through how you moved from that original shock of presenting this plan to a sense of their embrace of it, and particularly if there is any White House interaction in this beyond your office to get them to buy into it.

There wasn’t that much White House interaction except for the President’s trips. I think he went to Africa three times if I remember correctly. That really—No one had spent that much time in Africa before. He always did PEPFAR stops. And Mrs. Bush did too. So Mrs. Bush went—It’s in your timeline, but Mrs. Bush and the girls went. So those visits—that’s basically the White House saying we actually do care about—because we would tell them—There was a concern is this going to continue, is there real support? But they wanted to do it anyway. Condi really wanted them to do it. They trusted their Africa advisors, and they had some great ones, Condi being one of the key ones.

Their visits—for a First Couple to spend that much time—and the girls to spend that much time—sent really hugely positive signals that this wasn’t just a ram-it-down-your-throat—When they talked, they were talking in a very different way; and when they talked about what they were trying to accomplish, it was in a very different way. It was always about your country, we’re here to serve you; to whom much is given much is—Because he believed it; they saw the sincerity.

What mattered was engaging the Ambassador and the State Department, so different countries did it in different ways. Some of us spent a lot of time explaining and apologizing. It’s amazing what an apology can do. “We’re really sorry, but if we hadn’t done it this way, the money wouldn’t be coming.” You’d just explain it and people would get it. Then different Ambassadors did it in different ways. In Uganda they set up a PEPFAR steering committee with a former Prime Minister who was very influential in the government. Then they brought all the country partners in under that former Prime Minister, who was still close to everyone in the current government, and who was kind of the senior statesman of Uganda. Then by having that committee, people saw that this was serious, that this was actually about Uganda and not about the United States, and that we were playing a different role.

In Nigeria the Ambassador set up a similar advisory council or committee that was chaired by himself and the Minister of Health so that they brought partners in that way. So different people did it in different ways. Some people did it really poorly. Some people continued the paternalistic—They didn’t get it; they just continued. We would have to go to people who were not working well within the agencies or with the country—One of the cool things we did is—We were fortunate to have a really good—When I was the assistant program coordinator—actually, it was even before that—there were some good senior people at AID and CDC who destroyed their careers by engaging so openly with PEPFAR, because they knew it was the right thing to do, but their agencies never forgave them for it, for working so collaboratively—It was pretty remarkable, for working so collaboratively across agencies. Their careers were actually destroyed by it within their own agencies.

A senior person from AID, and a senior person from CDC, along with one of us from State, would go together to give a very clear message on what was expected and how they were to behave. So it wasn’t one agency fighting here or fighting there.

Then we had an example of a USAID country director who didn’t believe we were serious and she still could do whatever she wanted. She kept signing contracts and grants that were totally against what we were trying to do, so we acted. That sent an enormous signal, because she was really senior—really, really senior—and everybody thought untouchable. She wasn’t doing what we expected her to do. She was AID. It was not just HIV. She had a big portfolio, but she misbehaved really badly with the PEPFAR money. We said we cannot work with her; we made her rescind her signature on grants she had signed with the government. The government said you can’t trust her with anything, so they had to pull her out of the country.

We had to be pretty brutal in some circumstances. Sometimes the Assistant Secretary for Africa, Jendayi Frazer—when the Ambassador among the focus countries wasn’t on board, who had their own pet project that they wanted to focus on—she called those Ambassadors to make clear that their focus was PEPFAR, and if they were PMI [President’s Malaria Initiative], PMI. They could do other things if they liked, but if they don’t deliver on PEPFAR and PMI they’re not going to have a good file.

So it was a mix of many different approaches. They pulled people who were misbehaving toward the government and the people. Sometimes we had to be pretty hard, too, because there wasn’t delivery; accountability wasn’t there.

Right.

We knew things weren’t going the way they should. You can negotiate almost anything if someone believes you respect them.

Right.

So once we got over the—Once people understood that we were there for the long term and we respected them and we intended to support their national plan—even though it might need some pushes—we could negotiate almost anything: difficult things around procurements, difficult things about how we divided work in different districts. But we were always able to negotiate it. It would take a lot of investment and time, but that engagement of the State Department and the senior people in the agencies working together made a big difference.

Were there any moments where—particularly—and again I’m more focused right now in the period before you become director—where you were afraid that it was all going to go south? That for whatever reasons: news out of the field or political developments or displeasure on the part of the White House? Were there any vulnerable moments in particular?

During the planning process, two things happened that could have tanked it.

We had been using available data to say it would cost $45 billion over five years to tackle HIV. The United States should give one-third, so that’s where $15 billion comes from. Sometime in the fall of 2002—probably September during the United Nations General Assembly—a report quoting $50 billion a year comes out. Tony calls me in the middle of the night in China. That was for HIV, TB, and malaria.

The other was more serious. WHO, with leadership from Jim Kim, launched “3 by 5”—or treating 3 million people in five years. The White House said, “Well, it’s being taken care of, PEPFAR is no longer needed!” The whole thing could have died. Tony and I had to show it was just an ambition with no money, plan of action, et cetera. It’s strange to think that a well-intentioned advocacy effort nearly ended the effort that fundamentally turned the tide against HIV.

There were definitely vulnerable moments, but I don’t think there were any where I thought it wasn’t going to work. Just because I was lucky enough—and at the time I could go—I would go spend a week in a country. I would go all over the country and get out to the rural areas so I knew it was happening. Then when you get up in the ranks you can’t do that anymore.

I see.

So I never really doubted we could do it. I was worried. As more and more money got siphoned to the Global Fund and I was looking at our numbers and whether or not we could actually have the resources necessary to reach the goals. That worried me, but as soon as we met with Josh, that disappeared. Then I knew we had the backup. Josh, by the way, took the entire Director’s Reserve a second time in 2008. I don’t know if you want to segue into that. There were times before Randy was confirmed and it was clear who he was as a person, which solved many problems. But before that I was worried that the interagency process would tear PEPFAR to pieces. There were many times when I thought that was going to happen.

There were times on the Hill when it got pretty tense. So when—There was legislation put in on what “abstinence and fidelity” means. We had to define what that meant to meet the earmark. We were required to write a report on how we planned to define abstinence and fidelity, which was pretty broad.

You were a philosophy major in college.

It was pretty broad. And it was a percent of prevention. So we took whole things that anyone would count as prevention—HIV testing, prevention of mother-to-child transmission. We took that all out of prevention and said we would reduce the denominator. Then the percent of the denominator got smaller and smaller because we moved it all out.

Right.

Then we were very clear. Programs that included condoms we would just prorate the amount we thought was doing abstinence and fidelity. We asked the countries to rate those and they were naturally inclined to rate those much higher than they actually were. So when we went back and looked at it—it was 33 percent of prevention that was supposed to go for treatment—I mean abstinence and fidelity. They meant just abstinence and fidelity programs, no condoms, no nothing.

Yes, sure.

That program, the Uganda school base—that’s what we were supposed to be doing; that’s what they meant. But we got to define it differently. So when we looked at the end, it should have been 7 percent of the overall program, 33 percent of prevention. It wound up being like 1.2 percent of the overall program and 0.4 percent of prevention.

We sent this report up on how—We didn’t have numbers then, we never did. We just sent the report up. Then during one—I’m sure you know this, but the way appropriations occurs, you get the appropriation, but then you need to send up a Congressional notification that you are going to use the money, and you have to explain—

I’m not sure I did know that.

It’s not done at appropriations. It’s done when you are actually going to get the money transferred to you from the Treasury. Everything goes to the Treasury and then the accounts get distributed. So when the accounts get distributed, you have to send notification to Congress on how are we going to use the funds against the legislation.

It had gotten out that we weren’t quite meeting the requirement the way some wanted it, and then someone went back and looked at the report on how we were going to count A, B, C—the abstinence and fidelity programs. It was mostly Congressman [Joseph] Pitts, but Henry Hyde as chair of the committee wasn’t too happy himself. So they held the notification; they wouldn’t actually sign off on the notification.

Even though the notification is an appropriations vehicle, it has to be cleared by the authorizers to say yes, this meets our intent in the authorization so you can go ahead and appropriate it. So you need the sign-off of the appropriators, but you also need the sign-off of the authorizers. So the authorizers and the people who wrote that legislation were none too pleased. They refused to sign off on the Congressional notification.

We just kept working with them and going up there and explaining. Months went by and months went by and finally we just went up there. We said, “We can keep doing this, but here are the number of people who are not going to get treatment because we don’t have the money to do it, and eventually it’s going to be public and we will have the public fight about whether or not we should count it this way or whether or not we should give antiretroviral treatment to people.” The next day they signed the Congressional notification.

There was a point there where I was worried that the whole thing was going to collapse. We took all the hits for it even though we weren’t doing it.

The pressure was more heavily from the political right than the political left?

It was all from the political right. On that.

On that issue.

We got pressure the other way, it was all from the left. This is insane, you’re wasting taxpayer money.

Right.

We defended and said, “Look, it’s only 7 percent.” People would say, “But that’s X billions of dollars.” So there was this big public non-evidence-based “You’re wasting taxpayer money off a political issue.” Jim Kolbe was great in one of the hearings, appropriations. The House always held appropriations hearings because the House has a lot of people and they pay attention to detail. In one of the sessions the debate was raging again on the Democratic side and Kolbe said, “Look, this is the compromise. If we don’t have this in here, we’re not going to get any money. So we can argue about this as long as we want, but without it there is no support for this bill on the Republican side, so let’s just stop arguing about it.” It didn’t stop the arguing about it, but it was a very clear statement on the record in an open hearing about what the politics of it were.

During reauthorization there were multiple moments when I thought it was all going to collapse and we couldn’t get it through. It was mostly around these same issues. The same House version, which we warned them—The Democrats threw reproductive health and family planning all throughout the document. We knew we could get family planning through, but they linked it to—They would say “family planning and reproductive health.” We told them don’t do that; if you want to do that, have “family planning” over here and “reproductive health” in another paragraph; don’t put them together. I understand your negotiating tactic, but it’s still a stupid idea to put them in, because you’re not going to get the bill passed. But they did it anyway because they had so much pressure on the left.

Then there was an explosion from the right; including on their own committee. We went to them and said, “All right, just drop reproductive health now and they can live with it.” We negotiated this with the conservatives. “We’ll live with the family planning. Reduce the 15 to three mentions, but get reproductive health out now.” They wouldn’t do it. I said, “If you don’t get it out now, when you take it out, which you’re going to have to do—and you know you’re going to have to do—when you take it out they’re going to say, ‘Ah, now they mean family planning is the same thing as reproductive health,’ because you waited so long. If you take it out now they’ll think you gave something.” So they waited four or five days and by the time they took it out I called the same conservative people I had called before and they went, “No, now we know it means reproductive health too.”

I actually thought there were numerous times when things blew up—the DeMint second amendment—but there were numerous. Then during the middle of all this—Some people are just well intentioned but don’t think through consequences. Everyone thought we did nothing related to women’s health and reproductive health. We were actually integrating antenatal care, family planning programs with especially mother-to-child transmission, but in general as we were moving from standalone HIV sites into the clinic, which helped enormously with people feeling comfortable coming in to them, we could really integrate programs.

One of the people who hated us for this from CSIS [Center for Strategic and International Studies] decided to go evaluate it. This is in the middle of the reauthorization. She comes back and writes this glowing report about, “Oh, they’re actually doing much more integration than we thought. They are actually doing a lot of good stuff.” Look at that. Then we got slaughtered by the right on something that no one needed to know. Just let it go. Then we had to change language related to it. It could have fallen—There were so many points at which it could have fallen.

In the early going, we knew that if we didn’t meet targets, we would fail. Then there were a couple of news stories that were really harmful.

Is that right?

Yes.

When were these?

Early—I was deputy by this point. It was the first time I reported—It must have been a year in. I moved pretty quickly up to deputy.

Yes.

Maybe it was the second year. I can’t remember. It was immediately after the President got reelected—or very soon after the President got reelected—because that’s when Randy was able to move and do things he wanted to do. But there was a story from Botswana. We had reported numbers that kept us on track, which is 125,000 people in treatment, but 60,000 of them were in Botswana. In Botswana we had money, but as I told you the government and the Gates Foundation and Merck had started already and they had been supporting the people in treatment. That was a national number, not a site-specific number. If you did site-specific stuff, it would have been 2,000, not 60,000.

When the numbers came in, when people reported, we were really worried. I called the head of the CDC program and said, “We can’t possibly report 60,000 when we just got started and there’s $10,000 a year currently flowing”—No, it was much more than that. We had $80 million a year, but still it hadn’t moved yet. A lot of stuff hadn’t moved yet.

He said, “No, no, no, President Mogae called all the partners together and said he wants everyone to report national because he doesn’t want people to be fighting over which piece is which.” I said, “Can you go back to the government and get me a letter that says that?” He got me a letter that said that. This was all done very quickly. I should have talked with Randy about it, but I didn’t. The choice was go with that 60,000 or 2,000.

We knew the Global Fund was also counting that 60,000 and they were going to come out with 125,000. This is where the fight was happening in Congress all the time about should the money go to the Global Fund, or should it go to the bilateral program. I was worried that if we then reported 60,000 and they reported 125,000, that we would have problems in Congress.

Right.

So I made the wrong decision to trust the people in the country, even though every fiber in my being was like don’t do that, it’s going to get us in trouble. At the time the Global Fund didn’t report country-by-country results; they just gave an overall number, whereas we reported country by country because we wanted that account to be transparent.

Sure.

Everyone in the press and everyone in civil society loved the Global Fund and hated the bilateral program. So they ginned up the people in Botswana to get to this reporter who was unfair—but that’s how reporters are—to write a front-page—This was after an event with the President. Actually, it was like two days after; Randy was out of town. It was two days after an event with the President about how well we were doing and the results. Then there’s a front-page, above-the-fold story about how the numbers are made up. They had quotes from the people running the Botswana program that said PEPFAR has not treated a single person and here we have 60,000 people; it was quite a mess.

We got a response from them jointly with Randy from the Minister explaining the numbers. The people in Congress calmed down. But it was pretty touchy and I was really worried about the White House freaking out and saying what other of these numbers aren’t real? I suspect they had conversations like that, but they stuck with it.

They didn’t bring you in to grill you about it?

No, especially after we got—I was shocked; they never called. I was embarrassed the next time I saw the President and the people in the White House, but they never called us on it.

Were you communicating to them on a regular basis anyway?

Yes. Then there was another front-page story about generic drugs that led to—That’s when I was assistant, because I remember the office I was in.

I think that shows up in here, doesn’t it, in the briefing book?

Yes, another front-page story.

Right.

And that was a big debate. In the State of the Union address the President said the drugs are now $300 per year. That’s the price of generic drugs. So HHS, which works closely with the pharmaceutical companies, didn’t like so much the generic thing because the way the generics got approved was a WHO prequalification system, which the FDA [Food and Drug Administration] has nothing to do with. The FDA is always having questions about the integrity of it. It turns out with good cause, because—This is the difference between what you can and can’t get away with. People loved WHO and hated us and loved this 3 by 5 initiative, which Jim Kim was running. That’s how Jim Kim and I got to know each other so well and became good friends. He was at WHO at the time. He loved this prequalification system.

In the middle of the night they just removed half of the antiretrovirals that were prequalified because they found out that the documentation for bioequivalents was completely falsified.

So in the middle of the night they pulled it down. They didn’t tell anyone that these drugs were not proven to be bioequivalent anymore and were just going to let it go, weren’t going to tell anyone that all these drugs that—And their answer when challenged was, “Well, we don’t know they don’t work.” But for public health officials to sit around for public relations purposes to protect—and even with all that, we still got the crap beaten out of us for not trusting the WHO people. And any time we would say anything even questioning the integrity of the system, we would just get destroyed.

It shows up in the book.

And John Donnelly was actually all over us on this one too. Gary and Jay specifically put the generic number in because they were afraid—

Sure.

—that this would be seen as this whole program designed by a bunch of U.S.-produced pharmaceuticals at a high price.

Right.

So we spent a lot of back-and-forth before the State of the Union on what the number should be and whether or not it should be in the State of the Union—Well, they didn’t tell us it was the State of the Union at the time. We had a lot of back-and-forth on the number. So they put it in very intentionally, but HHS was refusing to go along with WHO prequalification. It was a massive internal fight.

Then there was this front-page story about how we were wasting money on antiretrovirals. Randy was not in the office that day. So I get to the office around nine o’clock in the morning. I’d seen the story, but I wasn’t panicked about it. I get a call and it is Gary, Robin, and Kristen—thank God Kristen was on the call. Robin and Gary just used every four-letter word there is, mostly “F,” repeatedly. “What are you doing, destroying the President’s program?”—screaming, screaming, screaming—and Kristen is fortunately on the phone calming them down. I know we were tense then too. So then Kristen called everyone together in the White House and we found our solution. That’s where we got to the FDA tentative approval process.

Mark McClellan was—I just saw him, he’s at Duke now, because CMS [Centers for Medicare & Medicaid Services] was very involved in the decision. But that was actually a massive advance, which we don’t get credit for.

How quickly into the implementation does this occur?

I was assistant coordinator at the time—Actually, that’s not necessarily true. I just remember the office I was in. It was early on. It could have been in the first year; I’d have to look at the date.

But from our own discussions, one of the fundamental predicates of the program at the outset was that it was doable based on the affordability of the pharmaceuticals.

Yes, but when we costed it out, we costed at—We did these analyses going into reauthorization because I knew we’d have to justify the budget.

Right.

So we actually sent health economists out to find out what the true cost was. So it turns out, not surprisingly—and this is why we can do the scale-up that we’re seeing now. In the first six months it cost about $6,000 per person and the drug cost is irrelevant. Whether it’s $300 or $1,000, which is the average we had, it’s irrelevant when you’re spending $6,000 in the first six months because you’re building infrastructure, you’re training people, you’re moving people, you’re putting—

OK, I see.

—putting all things in place.

I see.

After the six months it comes down and then you would get, over the course of a 12- to 18-month period, down to an average of around $900. Now unfortunately the CDC people went back and corrected it after doing a little bit more and brought it down to $600. That was a difficult part of the reauthorization debate with [Thomas] Coburn’s people, actually Katy French, who is now in the transition. But it was predicated on that. But we calculated out the cost of treatment at $1,000 with the assumption it would come down over time as we were able to get more generics on board, because we could prove that they were—

Right.

So our assumption was that either—what happened actually, either the innovators would drop their price or they’d give their licenses away, but that over time the price would come down. But not yet, because we didn’t trust the WHO prequalification system, but we couldn’t say that publicly because then we’d get killed. So that was a pretty difficult time. I never thought it was going to fall apart over that, but it was a pretty rough time. It might be the only time after the announcement where we had a real tough time with the White House, in general. Otherwise, we’d go through things, but anything we did they would ask questions.

Sure.

They were tough, but they were very supportive. On that one they were not.

Randy actually didn’t agree with HHS; he thought we should just use the generics. He was a CEO of a pharmaceutical company. But that bioequivalency—By that point we knew about the problems with the bioequivalents of the generic drugs and we just couldn’t—I know people think it was because of the pharmaceuticals; it really was not—and Randy and I talked about this a lot. In the end again he said, “I think you’re wrong, but it’s your decision to make. I won’t override you on it.”

In the end, as a physician, I couldn’t stomach the notion of giving all those drugs if we didn’t know the equivalence of them.

Sure.

That was immoral; that was just immoral. That poor people didn’t deserve a second class of drugs. We also fought hard for things that we also got killed on, like the three-in-one drug had a component of Nevirapine, which is toxic and we knew it was toxic and we wouldn’t use it in the United States. So we argued against—

Is that right?

Yes, we argued against using Nevirapine. It was originally prescribed, but then a better drug was designed.

Right.

But that wasn’t a three-in-one drug and it wasn’t yet generically available in three-to-one. So we pushed for changing—We pushed countries to change away from Nevirapine because it was toxic. It was a toxic drug. People couldn’t walk; they had neuropathy. We wouldn’t use it in our own country. Our argument was if we won’t use it on our people, how on earth can we justify giving Nevirapine? But everyone made it into, “Oh, you’re just trying to protect the innovator companies because it’s not yet available in generic.”

And the same people—It’s the exact same people who now attack us because we don’t move fast enough to change regimens. Same on using viral load versus CD4 cell count. We were the first promoters of that because the science was clear. Same thing. They said we were just trying to promote high-cost things for pharmaceutical companies. So by being part of the administration we had these tussles. That one I never thought we were going to fall down on. But it was probably the most difficult moment with the White House—even compared to the Botswana thing, which would have been far more justifiable from my perspective for being—especially since it came out two days after World AIDS Day, when the President just announced the number. It was terrible. But they never said a word.

Really?

I think those were the only times. The reauthorization was the trickiest one.

You were Director by then. I’m mindful of the clock. Let’s get you into the office. Was there ever a possibility that somebody else was going to take that job?

Yes, I was going to leave.

You were going to go to Georgetown?

No, I was offered—By this time I was working so closely with the White House I was offered Special Assistant to the President and senior advisor on development. So it’s not Gary’s job, but the one just below Gary’s.

With the NSC?

Yes. I was tired and I didn’t want to necessarily continue as deputy and it was really brutal on me.

Usually if you’re tired you don’t go to the White House.

But it’s a different kind of pressure. There is actually a certain—In some ways there is more pressure when you’re a number two when the number one is saying run things and keep me informed and bring big decisions to me.

Understand.

You have to do a lot of stuff, but you don’t have the same authority.

You’re not being paid the big bucks either. [laughter]

Well, the money is—I don’t know how we survived. There are pressures related to that. There was one other candidate who I thought—I love the White House. The people at the White House are wonderful. The person was Gary Edson, who—of course, but I felt pretty entitled at the time. I had been implementing it. Randy is saying if he leaves the thing is going to fall apart; you have to keep him. Every signal had been you’re going to get the job.

Gary by this point had left the White House because he had surgery. He’s very open about it; he had a benign tumor in his ear that required multiple surgeries and he really got wiped out and he had to leave government. He had a lot of difficulty with it, but he was starting to feel healthier. But every indication had been you’re going to get the job. Then Mike Gerson called me. I knew it because I’d talked with Kristen before. I was looking at another job actually, outside of the government too, not just the NSC one.

I’d also been talking with Gerson about even if they offer the coordinator it would be more interesting to spend some time in the White House because I really enjoyed working with all the people. He said, “I would love for you to have that experience in the White House because you should, but running PEPFAR is what we would need you to do right now.”

Was Michael not gone by then? I guess 2006—

He’s still there. We had become very close. So again I was politically naïve at this point. Kristen had sent a signal to me because we were such close friends. She couldn’t tell me; she didn’t have the authority, but she sent a signal to me. So it was already starting.

Then Mike called. We talked to each other periodically. I could tell from the tone of voice there was something different. It was like, “I just want to let you know that the President has decided on Gary Edson.” He said, “How do you feel about that?” I was about to just go into this tirade about what the f*. I stopped and said, “Well, the President should appoint whomever he wants and Gary is a great choice.” I actually think they were—if I had reacted the way my temper told me to, I would have been screw this guy, it’s not whatever the President wanted. So I think he was kind of a canary in the mine.

Yes?

I should ask him about that sometime. But then Gary was asking me to stay. I was like, “If you’re coming, I’m going to NSC. We’ll still work together, but I’m not staying in this job.” Then he had a slight relapse. He knew what the job entailed; he knew it was just too much for him physically at the time. He called me at Rehoboth and said, “I decided to pull myself out.” Then it was—

Then it was a foregone conclusion you’d be the person.

After Karl stopped fighting, which I found out about later.

Did that have any consequences?

Which? Karl fighting against it?

Did it gin up any problems for you?

No, once the President decides stuff, everyone—you know, everyone makes their—One of the things I respect about him is he’ll listen to anyone and wants all opinions, but once he decides, he expects you to follow what he decides.

I’m just looking at the dates here.

So it was a little late—

Acting in March of 2006.

I was actually Acting in January. It’s kind of a funny thing, a weird thing, about government. That’s technically correct, but when Randy went over to State as DFA [Director of Foreign Assistance]—he wasn’t yet confirmed at F [Foreign Assistance].

OK.

He needed a State badge to get in and out of the building. So in order to retain his State badge, he stayed as coordinator even though he wasn’t in the office for another minute from the second or third of January, but he couldn’t get in and out of the building without retaining the title and the office. So he signed all the delegation-of-authority stuff, but he never showed up again.

I was trying to remember—Karl got—Karl’s troubles mount, but later.

Yes, later.

Before you became director, were you traveling a lot? Were you in—?

Maybe more.

You’re nodding. The answer is a lot.

Probably 50, 60. By travel—mostly to Africa, most—

Every year.

Yes, with 14 focus countries, which is very different from this job—Well, 15. I had 15 countries to go to and the Caribbean. You just keep going back and back. Sometimes it’s to put out fires, sometimes to wave the flag—which is deputy level. Once you get to deputy level, then you are at a level where you have to do senior meetings.

OK. Are you reporting these trips back to the White House for the National Security Council?

No, they’d never have gotten to that level. The conversation with the White House National Security Council was if something happened on the trip that I thought they should know about, I’d let them know. They were just looking at where are we on the results, are there major problems—

OK.

—then around events we were doing with the President and the senior people in the White House. Then Mike would travel—Mike and Kristen would travel with me a couple times a year. Then travel with the Bushes. The contact with them was largely around accountability and budget, not more detail—unless something came up out of a country visit.

OK. Let me ask you—There was at least rhetorically a national security dimension to all this. Given the realities of the post-9/11 environment, which you’d already established through your discussions that this was a notion that the President had in advance. So it was a continuation of doing the public health stuff afterward, apart from the national security dimension. But is that something that is present on your portfolio? I don’t know how to ask the question other than you have an antiterrorism component. Are you picking up things that are useful to communicate to others about the public health environment that has those national security dimensions?

No. We never really got into that type of thing with them. We used national security arguments on the Hill and there were good data on the number of the military infected, stories from—General [James] Jones was very proactive on this when he was head of the Africa Command as part of the European Command when it was still up there. He was very aggressive on the destruction of AIDS. They actually couldn’t put security forces, peacekeeping forces, together because HIV was so high, and the rates of HIV among the military were higher, plus they would go someplace without their wives or girlfriends so they’d engage in activities which led to increased risks. So it was pretty bad.

That’s actually why [Yoweri Kaguta] Museveni acted, because [Fidel] Castro actually told him, “Do you know how much HIV you have in your military?” They were very closely working together. Museveni was shocked. He was told, “You’re not going to have a military if you don’t do something about this.”

But that wasn’t—We used that rhetorically. It was never really part of the conversations with the President or anyone at the White House. It was always on the humanitarian side. We would use it rhetorically and they were fine with that. I mean Condi put the larger—She added a “D” to diplomacy, defense, development. She was the first one to do that in the national security strategy. I love the Obama administration, but they claimed they were the ones who did that. They didn’t. The record is clear. Condi put it in when she was there. They did completely believe it. Rumsfeld grew to believe it. I know this because Randy when he went to AID got called over to Rumsfeld. He said, “What the hell does Rumsfeld want with me?”

He was like, “We can’t win this war without better development. This is what al-Qaeda does. This is what they do; this is what the Mafia does”: feed people, give them help. So we were aware of that dimension. We used reports and we partnered with groups like the U.S. Global Leadership Coalition and others to argue about the defense component and the security component. But that was never—We used larger numbers and larger arguments about the number of people who could die and the burden and the orphans, but in all the conversations I had with the President, he never once raised that issue; it was always the humanitarian side.

OK. It would have been the global numbers, the generic numbers, that the defense people would have been interested in anyway, rather than any kind of programs you might have—

Rather than a specific program. You could really argue that HIV would destroy security. You could argue that by the American people providing health care—and this was true and we did use this quite a bit—If you looked at the Pew [Pew Research Center] numbers over the course of PEPFAR and PMI, with the exception of Israel, the highest ratings by far—and this was not true before the big investments in Africa—of positive ratings of the United States came from Africa, including countries—in fact quite a few of them had higher ratings of the United States than the United States had of the United States. So we used that a lot to try and win over some of the Republicans. That is real.

I tell the story all the time. I was in very rural Ethiopia in a village where literally at six in the morning it looks like 500 years ago. Everyone is in long white muslin with their camels going into the market. The mosque call is coming out and everyone—The market is open. If you don’t see the wires—the telephone wires, which there are very few of—it looks like 500 years ago.

So we went to the clinic there. Of course the head of the clinic is a very important person who also is very important in the city and in politics because that’s the nature of these small places. It was actually the birthplace of Christianity in Africa. It’s still a very small place. I was in a cranky mood because we hadn’t slept much or anything. The head of the clinic kept talking, saying PEPFAR this, PEPFAR that, because they all get trained. I said, “What does PEPFAR mean?” Expecting he would say, “President’s Emergency Plan for AIDS Relief.” He said, “PEPFAR means the American people care about us.” That’s what you would hear village after village. So it wasn’t just heads of state saying it; it was actually in villages.

Right.

So those kinds of things I would report back to the White House, nuggets like that, especially to Josh and Gerson; Gerson loved them to use for—

Terrific for a speechwriter. Presumably the President liked hearing the anecdotes as well as the hard body of evidence.

Yes. When a President would go out of their way to say something about PEPFAR, extend greetings, which they often did—I still do that when I go around. As I said, heads of state talk about—Because PEPFAR was there bigger than the Global Fund in the early going—Presidents would say if it weren’t for President Bush and the United States. So I still send that stuff to him through [Edwin] Meese. I think it means something. He’d never say it does, but I think it means something to him.

What about your confirmation? Anything interesting happen there?

No, the confirmation was a breeze, actually. Getting the papers up—There were these issues, as I mentioned, about my political leanings and being openly gay. I think we were bracing for some of that; at least I was. Legislative Affairs never seemed to be worried about it. It didn’t take that long to get my hearing scheduled, in part because I knew them all, I’d been there so long and the International AIDS Conference was coming up. We made the case—which is true—that it’s different when you go to that as Acting versus—This was before the midterms, so Lugar was chairing—or was Biden and he just didn’t show up, so Lugar chaired? The only person who showed up was Lugar.

OK.

So everyone is like, “Oh, you must be so depressed, only one person came.” No, that’s exactly what you want for a hearing, because there’s no question.

If you’re confirmed in August, it must have been—

Then the Democrats are always suspicious of anything the White House was doing.

Even on this subject?

Oh, yes. Always, anything, any Bush appointee. That goes up on the wire. They were like, “What?” They all called Ted Kennedy, and I happen to—A really good friend of mine is really close with Ted Kennedy, so there are like 20 Democrats who checked in with Kennedy’s office. They said, “No, no, we absolutely want him,” so that was the end of it.

Terrific. Does your interaction with the President increase substantially after you become director?

That’s a good question. Yes. It certainly increased a lot when I became deputy. I met him a couple of times. They were sending me to do stuff. I met him first on a World AIDS Day—I think that was. But that was when I was still chief. It wasn’t just the reception; they sent me to his office to be introduced and stuff. As deputy it increased. As coordinator, yes, I guess it did increase more because I would brief—I would see him more. We had the World AIDS Day events, the Africa trips, the holiday dinners. Then something always seemed to come up.

Then they started to involve us more and more in development more broadly, in designing the development portfolio, which really annoyed the AID people. So we created the neglected tropical disease initiative for them.

Right.

Then there was a time when PMI was created; they wanted to give it to us. They wanted to give us the President’s Malaria Initiative.

What is the backstory on that?

They didn’t trust USAID.

They wanted to give it to you because you were—?

They wanted to give it to the office. Randy was still there, although it was late. They kept calling me to say, “You guys really don’t want this?” Randy did, actually; it was just before he left.

Did he want it—

He wanted another thing to take on. PEPFAR was going well at that point. He enjoyed the start-up phase.

Turf?

Yes. He wasn’t in the day-to-day stuff, so he said, “Cool, I’m interested in all this stuff.” It wasn’t turf in the way D.C. does turf; it was more that’s pretty cool.

OK.

But there were two things. One, I think it would have destroyed PEPFAR, because malaria is a totally—I told him, if it were TB, we should do it, because it is so linked to HIV. But malaria is very different. We didn’t have the experts; we didn’t have anything. We’d be building a whole new structure within the office. We weren’t mature enough yet. The focus had to be on getting to where we were or we’d lose. The second point was—First of all, we weren’t fundamentally creating that; that was Michael Miller from USAID and John Simon from the National Security Council. [Andrew] Natsios was also involved and interested. Then Gerson really weighing in, really pushing hard against the entire White House infrastructure. That probably hurt him down the line.

The point—the stronger point—to me—Part of it was collapsing PEPFAR. No one thinks the USAID is functioning well. You can’t just take everything out of AID. They’re not going anywhere. So why not put something with the same accountability, the same structure, the same stuff, within AID and see if it can have an influence from within, because our influence from without is very limited. But that didn’t work in the end; it had some impact.

Actually, Raj [Rajiv Shah] dumped a lot more money into it because he was like, This is the only thing I can get any numbers from, the only thing that proves that they get results, but it didn’t fundamentally change the culture.

It was funny, when Randy went to AID and F and Gary was up for the job, he asked Randy if he could give him the PMI. It was like, “No, there’s no way I’m giving you the PMI.” [laughter]

Did you travel with the President?

Yes. Each World AIDS Day we did events. It was pretty cool. One year we had to go up to outside of Olney, Maryland, so we took Marine One up, which was cool. Air Force One is something, but Marine One is pretty cool. Very few people fit on Marine One, so we have the whole time up; we got to talk for about an hour. Mrs. Bush was there. We talked a bunch of stuff. He’s a lot of fun to be around. Then in the cars.

We did another World AIDS Day in the museum. I wasn’t supposed to be in the car. He was, “Where the hell is Mark?”

You were supposed—?

I wasn’t—the same on Marine One. They actually had me going up on the pre-thing and it was the same thing, “Where’s Mark? He’s got to come up with me.”

Do you have to yell at each other to talk over the blade noise?

No, it’s pretty quiet inside. It’s not very luxurious. I was surprised, it’s not that nice inside. There are new ones—There are two chairs, which are OK facing each other, which are the President and Mrs. Bush’s and then there is basically a bench, which three people can sit on, and that’s it.

Are you strapped in?

I imagine we did on the way up—No, I don’t think we were buckled in. I think they’re pretty confident it’s not going down.

I hope so.

He’s such a sweet man. I’ll never forget this. We were walking from the Oval to Marine One. I had no idea; I’d never been on this stuff. We’re walking past the helicopter. I just assumed—I didn’t know how to do it, to go in the door, and he said, “I think you get in here.” There is a back entrance, only the President and Mrs. Bush go in the front, everyone else goes in the back. I didn’t know that. He said it in such a sweet—not, “Idiot, it’s this way.” He said, “I think you go in that door.” He is so wonderful about it.

Then the briefing stuff and then in Africa.

You went with him on the Africa trips?

Well, yes.

Did you meet him over there?

I joined Mrs. Bush on two trips I think. Jenna was on one of them.

Tell us about those trips, because those are important.

I love Mrs. Bush and I love Jenna. And I love Barbara, who is one of my favorite people in the world. I think that’s when I first met Jenna, actually. I met Barbara on the last World AIDS Day. They’re just such wonderful people to be around, and they really care. They don’t like being overly briefed. You’re in the car and you give them information and stuff, but they really want to engage. They turn and say, “Mark, can you ask some of the women—?” Or when they’re really comfortable—We went to this one place of abused, raped women and how they’re restoring their lives. Mrs. Bush and Jenna were just overwhelmed. They went crying all over, hugging everyone. They’re just such wonderful human beings; huge hearts.

Then the big trip, the President’s trip, I could only join for Tanzania and that was just hilarious. I knew President [Jakaya] Kikwete because we had a really close relationship with them, and President Kikwete and President Bush really got along. They put me in the delegation, so it was a big deal. You get to go—The senior dinner, it was cool to be part of that. The fun thing at the senior dinner is they were so thrilled to have—This is the first time a President visited Tanzania, the first time a President had been in the State House. They were so thrilled to have him. They were so proud to have the President. There were about 40 of us; I guess there were four tables of eight or something like that. I was at Josh’s table. I was shocked that they put me at that senior a table.

They had a menu and they were so happy that they had menus embossed in leather. So we’re looking at them and it says, “State Dinner in Honour of His Excellency President George Walter Bush.” Because “Walker” made no sense to them.

[laughing]

So literally everyone was grabbing as many as they could.

A real collector’s item.

I would not want to be the Chief of Protocol when they found that one out.

He didn’t have a tolerance, though, for formal—

He didn’t like formal stuff at all. He wolfs his food down and he’s out—even for lunches. So President Kikwete visited and he wanted to do something more intimate, so he did a lunch for him in the downstairs—the old family dining room. There were only six or seven of us from the administration; he was kind enough to invite me. He was just so sweet to Kikwete. Kikwete gave him this huge stuffed lion, which is in the library, now museum.

He’s so thoughtful. The thing about him I love is he puts you at ease with being with the President of the United States instantaneously. He finds some way just to put you at ease because he knows how tense it is and he doesn’t want people to feel that way. He’s very touchy; he’s very hugging. His voice—He makes jokes all the time to make you feel comfortable. I was scared to death the first time I went into the Oval Office. I still was a couple of times after, but then when you’re around him more—

Mrs. Bush—Actually, the first couple of times I was like, Oh, my God, because she doesn’t say anything. She is a southern woman; does she hate me? Whereas with President Bush you know exactly where you stand all the time. He is so kind; he was giving them a tour. There are people—the President, Kikwete is fine—he has seven people too—going, “Oh, my God, I’m in the White House with the President of the United States.” So he said, “Let’s take a tour,” and he’s walking him around. It’s the same tour he gives everyone. It’s actually really sweet.

One of the people on the tour—This is how comfortable people get with him—asked, “Have you ever seen [Abraham] Lincoln’s ghost?” because there is this myth that Lincoln’s ghost walks around. Without missing a beat, he said, “Nah, I quit drinking 20 years ago.”

[laughing]

He is a very—They are all among the sweetest people I’ve ever—The ranch too, they’re so down to earth.

So you went there too? Tell us about going there.

The ranch was after. They actually invited me to spend the night, but I couldn’t because I was flying in from Africa, actually, and I couldn’t get there on time. But it was lovely. That was when he—Yes, it was after because President Kagame was coming for lunch and he wanted me there, and Barbara was there. But it was just so casual. I walk in—First of all, they meet you way out there and give you big hugs—“Oh, it’s so great to have you.” You walk around, then he drives you around the ranch with Mrs. Bush. So I was trying to get in the back seat and they said, “No, no, you’re going up front, you have to sit up front.” He’s driving all over; you’re bumping all over. “Look out for that, look at that. I love this place.” He’s just really cool.

That’s where he asked me to read the chapter. I remember because he said, “I want you to read this.” He had told me for a while that he wanted me to read it. So he gives it to me. I’m a slow reader anyway; he’s a really fast reader. So I said, “OK, thanks Mr. President.” He said, “No, now.” Then he comes and sits next to me on the couch and he’s looking over at me.

Looking over your shoulder as you’re reading?

Yes, as I’m reading. What the f*! He said, “What do you think?” I said, “I’m not done yet.” He said, “Where are you at?” He’s just a lot of fun.

Were there any important parts of the story from his perspective that he left out?

He got one area wrong about Peter Mugyenyi and the role of JCRC [Joint Clinical Research Center] versus this other TASO [The AIDS Support Organization, Ugandan NGO] thing, which I actually paused on for a while because I was trying to think how to explain to him how it was structured in a way that would matter, that would materially change it. So I paused on that.

One of his friends, Clay Johnson, the guy who was from the Office of Management and Budget, was a great guy and was there too. Mrs. Bush is there playing checkers and doing puzzles, having coffee and eggs. It was just amazing. So he was just sitting there watching me. When I was done and he was like, “Did you see the section about you?” I said, “Yes, sir.” The other guy said, “Oh, that must be what you paused on.” I said, “No, I paused on this other section.”

The main thing was—and this is what I asked him—“The one thing, Mr. President, you don’t explain why you did it.” That’s when he said, “Why the hell wouldn’t I do it?” That’s when he added the section—the stuff on Condi and other stuff that wasn’t in there.

Exactly.

There were a couple of other things. He did, thank God, allow me to take it and make line in and line out edits and stuff.

Good.

I want to ask about one name we haven’t brought up and I don’t know whether you had any dealing with him or not, and that’s Bono.

Yes, I had a lot.

He is somebody who is occasionally mentioned as somebody who was important to some of these things. Is it the case that he was an important influence at points?

He certainly—The thing—Certainly in the U.S. system, no matter how much the President wants something, you have to get Congress to do it and you need support. It’s a little bit—To me it’s always, Billy Graham was whispering in his ear and the conservatives, telling him the faith-based community; it was nonsense. Yes, they were necessary in order to get things done, but it’s not as if he was doing it because of them. Bono is a little bit like that.

OK.

He was important. He was working on it. He was building support. But by the time Bono came to visit him, it was already decided and we were way down the road by the time they met. So yes, he’s important. He is a big figure. At the time he had influence. He’s very good; he is one of the best. He really gets to know individuals; he’s very good at connecting. He has a really strong political instinct, not as good as the President’s, but pretty good for what could I say to this person. He can pull verses from the Bible. He learned; he really knows what he is talking about. So yes, it was important, but it’s not because of him. He didn’t change the President; he didn’t direct anything. It was way down the road before they ever met.

You know—I’m sure Josh told you the joke about when he first walked in the Oval Office.

Yes.

Josh has much—Josh could probably say much more positive about Bono’s influence and role; they’ve become very close. But I know where we were the first time Bono walked in the room. While it’s helpful, you need that. We have a little joke that if everyone who took credit for starting PEPFAR adopted an orphan in Africa, there wouldn’t be an orphan problem. What’s good about that is that everyone feels vested, so let them. There’s no question he’s important and he has been hugely important to the Global Fund, hugely important to the Global Fund. He helps in a lot of ways. He’s really good. But he did not create PEPFAR—It wasn’t—but he was important.

Were there others outside the political channels that also had any kind of favorable influence like this, either through celebrity or just through policy insights?

I think the faith community did, because they knew they had the support there. Billy Graham Jr. was much more—He’s not interested anymore. He used to be involved in Samaritan’s Purse when Bill Frist was there.

Knowing Bill Frist was going to be supportive, because he was pushing on legislation, knowing Kerry would be, knowing there was that bipartisanship out there—no question. In hindsight—I didn’t know any of this at the time, I was with NIH. Knowing all those pieces were out there helped because they knew they weren’t going to get support from the traditional NGOs and civil society. Knowing that there was private sector support—So we have private sector people who were deeply engaged back then who aren’t very much anymore.

Knowing all those things are out there was really important, but I have no doubt that if none of that were there, he would have done it anyway.

Anybody else on Capitol Hill that was important that we haven’t talked about?

It is hard to pin them down because there were so many and at different times. Certainly Lugar, hugely important—I’ll go Senate then House—really supportive and was chair of the Foreign Relations Committee for the first authorization and was really important to the second. Bill Frist was hugely important the first time around. Interesting people like Coburn who were big supporters. Ted Kennedy. There were people who really stepped up and pushed. On the House side, Hyde had to move it. Lantos I grew to adore. We developed a really strong relationship. He was interested in the abstinence stuff. He really wanted to learn.

Lindsey Graham, Pat Leahy, Mitch McConnell, Nita Lowey, Jim Kolbe, Ileana Ros-Lehtinen, Joe Biden, pretty much all of the Chairs and Ranking Members of the Authorization and Appropriations Committees. Barbara Lee and Betty McCollum were among few Democrats willing to come to the first signing ceremony. Chris Smith was very important, and through Chris, Mike Pence—the second time more than the first time.

Pence? Really?

Yes, he gave a tremendous floor speech in 2008. I actually pulled it the other day just to remind people that you can actually work with the guy. He’s a big—As I said, the social conservatives believe in this stuff, through a very socially conservative lens, but they believe in it. That’s why balancing the stuff is so important and difficult and why compromise is so necessary, because the support all comes from the social conservatives.

Sam Brownback was important the first time around, Orrin Hatch—and the second time, especially on that abortion vote. Enzi was quite engaged. [Richard] Durbin was engaged. The House—it was Tom and Henry, which is why the bill is named after them, the second bill is named after them. But they were there for the first and the second. [Ileana] Ros-Lehtinen became important because she took over the Foreign Affairs Committee. So she was important for the second time around.

I hate naming them, because there were so many at different times. Now Lindsey Graham is hugely important. Leahy was always important. Mitch McConnell wasn’t overly involved, but people forget that he held onto that committee while he was majority leader for a while. So even while he was majority leader he still held on to the Foreign Affairs Appropriation Committee. [William] Thad Cochran wound up being important, hugely important actually in the reauthorization. He signed on to a letter to push—the Democrats were worried that they wouldn’t have enough Republican votes to withstand a filibuster. So they were worried DeMint was going to do a filibuster and they didn’t want to get in the mess of it, not to mention the other stuff we talked about—putting people on the record on prostitution and so on in advance of an election.

Right.

So we worked with Lugar to get a letter from Republicans so that they would have—I can’t remember what it was—13 or something that we needed to make it filibuster proof. We got 13. One of them was Thad Cochran. Once he signed, everybody was like, You’ve got him, we’re fine. Because he was chair of the Budget Committee—the Appropriations Committee at the time. We got to him through a former Ambassador in Tanzania who is one of his biggest donors—anything he puts on his desk. His staff member calls and says, “How the hell did you get him to sign that letter?”

[laughing]

But it was hugely important. We wouldn’t have gotten the 13. Once he was on that letter, the Democrat breed was comfortable that they could withstand—So it’s these little weird things that make the difference.

That’s important for history to know. Were there any major missed opportunities? Were there some things that in retrospect you look at and you think, We could have tweaked this a little better and might have gotten an even stronger outcome?

Yes. A couple of things. One, we should have invested more in point-of-contact data collection. We were focused on national numbers. We weren’t really getting down to the subnational level. Now, some of that is with hindsight. Reality is in the first five years you could have spent money in any way and saved lives because the need was just extraordinary. But I think investing more in data systems and understanding what was really effective and where—because we were learning now, not surprisingly, that some sites do really well and some don’t. Understanding that earlier would have been much better. We didn’t really grasp the impact about adolescent girls and young women in Southern Africa, not getting hold of them early enough and understanding that dynamic. We’re still behind on it and we’re at risk of losing control of the epidemic again because of it, because of the population growth rate.

Yes.

I wish we had, despite all the objections, really pushed harder on switching to viral load rather than CD4. It’s complicated, but we’ve wasted a lot of money on tests that do no good after you start treatment. We should have invested—Again, the advocates were saying we’re just trying to buy these expensive products. I wish we had pushed harder on that.

I wish we had been able to have more of a transition from the bilateral program to the Global Fund. I think we could have absolutely done better at the interagency process. I don’t know how, but there’s no way it couldn’t have been better. It was better, but it could have—So I’m sure we missed opportunities to pull it together that we didn’t pay attention to.

Some of the mistakes I’ve already talked about. We could have probably moved to generics, although I go back and forth on that one. The FDA tentative approval process when you look at it has had such positive impact. I mean it takes WHO so long—The FDA is certifying drugs at a much faster rate. We wouldn’t have had the pediatric drugs. We wouldn’t have had so many things. But was it worth the political cost? I don’t know.

More integration with family planning would have been a good thing if we could have done—We did a lot more, as I mentioned, than was publicly known, but if we don’t control the birth rate, you can’t manage a sexually transmitted infection. Again, with the politics I’m not sure. Maybe there was—It was amazing to me the number of times we could push to compromise when we thought we couldn’t, so maybe we could have gotten compromises on things earlier, although I’m not so sure. I don’t know.

In retrospect, you think about things, but in the middle of it I don’t know that we could have—We probably could have, but there’s not—I mean there are a lot of things I think need to be done now and are being done. I think the way we work with the countries could have been much better earlier on. We could have been much more aggressive with the U.S. government staff on how to behave around and treat Ministers and people in country. I don’t think we understood that.

To be honest, and I’ve talked with Tony and a bit with Gary and even Josh about this, had I known—I think Tony would say this too, although he has been around government a long time—had I known what the interagency process was going to be like, I’m not sure I would have thought we could have done it. So naïveté is probably a healthy thing.

Maybe so. It’s good to have a mix above, right? If you’re in a government of multiple individuals—

We could have handled—We were making mistakes every day. I don’t know if we could have done better negotiating. I go back and forth on that. We could have done better negotiating around the right and whether or not we could have been more open about what we were doing with condoms and family planning and gotten away with it, which might have been useful for the future, although we got most of that out in 2008. Maybe we could have pushed it a little bit more, although our experience with Congressional notification tells me otherwise.

I do sometimes think about whether we let the President take too many hits for things that we weren’t actually doing that he didn’t need to take. That’s quite possible.

Prognosis is good?

We could end the epidemic.

Better than—

We can end the epidemic if we focused—without a vaccine. We can’t eliminate it like you can with malaria or TB, but we can control it to a point where it’s not a problem. All the data tells us that the problem is maintaining the political support, the money, and most importantly focus. That’s where not investing in the data earlier—

I see.

Because you really have to focus on where the new infections are; you really have to focus. Had we invested more in data then, we could be accelerating now. That’s probably my biggest regret.

That’s the policy guy talking to me; that’s not the political guy, right? You’ve already said that the fear was that people were going to come back with a big research project and if you come back with a big research project, it’s not going anywhere.

And it was also just a balance of—I mean, given the number of people who needed treatment at the time—

Exactly.

It seemed like investing in data systems and that type of research was—I wouldn’t say immoral, but it was hard to justify—

Exactly.

—when we knew how many people needed treatment and how many people were dying.

And you knew how to get it to them, based on your own testimony that people had the models out there; they were competent to do it.

But I bet we could have saved—We could have been much harder on the plans that came in. We were pretty hard on some of them, but we could have been much harder. Again, there was a political calculation as to what extent could we really push the interagency process to the breaking point.

Yes.

We probably—It’s not that much money. We could have done it had we—in particular had I—thought more about it. Randy would have done it in a second if I’d thought of it. He was so good; we were so lucky we got him. The program would be nowhere if it weren’t for that first appointment. They could have picked some crazy private sector person or some crazy political person. We got so lucky; without Randy we would really—if they flipped some of the other appointments for similar positions. Really, we got so lucky.

Some of the internal stuff with individual people, where relationships that started really strong frayed, those are never fun. You’ve spent some time there. The hardest part about Washington to me is—coming from the Midwest especially—people will look you in the eye and lie to you.

I would guess that would be hard.

It’s not easy. It’s a small percent, but destroying other people’s careers is a blood sport. Watching that happen is pretty hard. I never saw anyone in the administration do it, no one I respected in the administration do it, but I saw it happening on the Hill and at lower levels of the government. I wish there were something that could be done about that. I can’t pretend to understand what that would be.

You’re going to end up fixing the whole political system, not just your own problem. I think I’ve covered about everything I came with. Is there a question you were sure I was going to ask you that I haven’t asked you that I should get on the record?

We talked about Mexico City a little bit; I think that’s actually an important thing. The waiver of Mexico City, which the right hated and the left—

It gets touched on a little bit in here, but it doesn’t—You don’t get the emphasis quite that you do here, and that’s an important point because it is at odds with perceptions of this President—or the conventional perceptions of this President.

I’m trying to think if there are any of the personal stories that would be useful. This must have been after, because it was Zambia, because the security wasn’t strong enough. They wanted to go to an Indian restaurant in Lusaka and I knew this great place—It was a total dump. I forgot how big of a dump it was, so we showed up. He looked at me and is like, “What?” The food was great and the owners were really happy. It was really a dump.

And he didn’t get sick.

No, he didn’t get sick. Seeing him without his tooth was fun too. He lost a tooth from the biking accident.

I’m not sure I remember this. Was this after he was President?

I think it was while he was President.

I don’t remember this.

He lost a tooth. There was this really bad bike accident, because he does the mountain bike.

I did remember that.

So in the tumble he lost a tooth. He had a replacement and it fell out one day. He was spinning around saying, “Ah, I lost a tooth.” I have to say I wish I had been more comfortable around that earlier on, because the people who did were exceptional. The thing about this, as you well know, even for somebody like me who hated the guy until you get to know him—Once you get to know him and feel loyal to him, it’s hard to see the bad side, which everyone has. Having seen a lot of people and been around a lot of them in Washington, I don’t know a better person than George Bush.

That’s a terrific place for us to end. Why don’t we put a bow on it? I appreciate you doing this. It has been fascinating for me. You’ve said a lot of things that will be extremely helpful for people wanting to understand a very important part of this administration that only you have had eyes on. It’s a terrific contribution and I’m grateful for the time and effort and for your service in making all these things happen.

Best thing in the world. It’s an amazing gift. Thank you for covering this. It’s happening more and more, but people still don’t know about it.

Yes, Terrific. Thanks, Mark.

M. Dybul, 12/6/16 79

[BREAK]

We’re back on for an epilogue. Mark came back in and said one of the things we didn’t talk about was the swearing-in ceremony. Do you want to pick it up from there?

I actually didn’t want to do a swearing-in ceremony. I was convinced to do it by Dina Powell and others who said it would highlight the President’s leadership on this; it was just before the election, the midterms in 2006.

OK.

It was after I got confirmed. You often do the public swearing-in later. Mrs. Bush came—

It would highlight the President’s emphasis on—

HIV and then the initiative, the fact that it existed. Mrs. Bush came—Actually, the President wanted her to. It’s very rare. At Assistant Secretary levels—you don’t get that kind of personal show of strength.

Why was she there?

She believed deeply in the program, and she seemed to like me. She wanted to show the White House and the President that this was the President’s initiative. It’s very rare. She just stands to the side, because she is not an official of the U.S. government, which is pretty remarkable. She gave a beautiful speech. But with Mrs. Bush sitting there, Condi referred to my at-the-time partner—his mother—as my mother-in-law, which no one thought of as anything at the time. Condi never gave it a second thought. Everyone says it was the right that went crazy. It actually wasn’t. The right knew about it, but sat on it. We had enough of a relationship and stuff that they didn’t go after it.

It was actually the New York Times and ABC [American Broadcasting Company] that went after it and said the guy is such a hypocrite—Bush is such a hypocrite that he appoints a gay guy and refers to his mother-in-law, but he wants a constitutional amendment to not— This was just before—The purpose was to highlight how great the President and the initiative were. The only story that came out of it was this.

Then because the left—It was actually the New York Times, a big op-ed by [Frank] Rich, whom I won’t read anymore because he was so unfair and wrong. He was just taking potshots at the President in advance of the election. Then ABC covered it. Then it got picked up all over the world; it was on the front page of the Turkish newspaper; it was on the front page of the Italian national newspaper—all over—about this.

I felt so awful that I had let the President down. The purpose of this was not to have a ceremony. Mrs. Bush was there. Just the measure of them; they were like, “Screw them.” The right then jumped on, and someone from Focus on the Family said it was like putting a fox in charge of the henhouse. Just crazy stuff. I just felt like—And right before the midterm to have this happening was crazy. I felt like I had so let them down. They all were just so supportive. Condi was like, “Screw them.”

It got to the White House press room, and I think every reporter was expecting him to say it was a mistake; it shouldn’t have happened. The press secretary—it was before Dana [Perino], tall guy, died of colon cancer.

He used to be with Fox News.

Tony Snow, lovely man. He just said, “The Secretary said what she said. Out of due respect for the people involved, we don’t want to talk about this again.” That gives you a sense of the people; they could have easily walked away from it and I would have wanted them to. They were like, no way. So they’re good people.

I appreciate you stopping me on the way out and making sure I had that recorded. Again, I had wondered whether we had said everything that needed to be said about this, but you had been eloquent earlier in the interview talking about—

I forgot about that. You had it in the timeline and I just forgot.