Decision Points Part 21

The spirit of renewal at S.J. Green Charter School is present all across the Gulf Coast. With leadership from people like Tony, a new generation can build a better life than the one they inherited. And the true legacy of Katrina will be one of hope.

*In the fall of 2006, Congress Congress amended the amended the Insurrection Act Insurrection Act to allow the president to deploy federal troops with law enforcement powers during natural disasters. Then, in 2008, they repealed the amendment. to allow the president to deploy federal troops with law enforcement powers during natural disasters. Then, in 2008, they repealed the amendment.

n July 30, 2008, Mohamad Kalyesubula Mohamad Kalyesubula sat in the front row of the East Room. He was a tall, trim African man. He had a big, bright smile. And he was supposed to be dead. sat in the front row of the East Room. He was a tall, trim African man. He had a big, bright smile. And he was supposed to be dead.

Mohamad Kalyesubula in the East Room of the White House. White House/Joyce Boghosian White House/Joyce Boghosian Five years earlier, Laura and I had met Mohamad in Entebbe, Uganda Uganda, at a clinic run by The AIDS Support Organization, TASO. Located in a simple one-story brick building, the TASO clinic served thousands of AIDS patients. Like most suffering the advanced stages of the disease, Mohamad was wasting away. He ate little. He battled constant fevers. He had been confined to a bed for almost a year.

I expected TASO to be a place of abject hopelessness. But it was not. A handpainted sign over the door read "Living Positively with HIV/AIDS." A choir of children, many of them orphans who had lost parents to AIDS, sang hymns that proclaimed their faith and hope. They ended with a sweet rendition of "America the Beautiful." "I have a dream," Mohamad told me from his hospital bed. "One day, I will come to the United States."

I left the clinic inspired. The patients reaffirmed my conviction that every life has dignity and value, because every person bears the mark of Almighty G.o.d. I saw their suffering as a challenge to the words of the Gospel: "To whom much is given, much is required."

America had been given a lot, and I resolved that we would answer the call. Earlier that year I had proposed, and Congress had pa.s.sed, a $15 billion initiative to fight HIV/AIDS in Africa. The President's Emergency Plan for AIDS Relief, PEPFAR, const.i.tuted the largest international health initiative to combat a specific disease. I hoped it would serve as a medical version of the Marshall Plan. "This is my country's pledge to the people of Africa and the people of Uganda," I said at the TASO clinic. "You are not alone in this fight. America has decided to act."

Three months later, Mohamad received his first antiretroviral drugs. The medicine renewed his strength. Eventually he was able to get out of bed. He took a job at the TASO clinic and earned enough money to support his six children. In the summer of 2008, we invited Mohamad to the White House to watch me sign a bill more than doubling our worldwide commitment to fight HIV/AIDS. I hardly recognized him. His shriveled body had grown robust and strong. He had returned to life.

He was not the only one. In five years, the number of Africans Africans receiving AIDS medicine had risen from fifty thousand to nearly three million-more than two million of them supported by PEPFAR. People who had been given up for dead were restored to healthy and productive lives. Calling to mind the story of Jesus raising his friend from the dead, Africans came up with a phrase to describe the transformation. They called it the Lazarus Effect. receiving AIDS medicine had risen from fifty thousand to nearly three million-more than two million of them supported by PEPFAR. People who had been given up for dead were restored to healthy and productive lives. Calling to mind the story of Jesus raising his friend from the dead, Africans came up with a phrase to describe the transformation. They called it the Lazarus Effect.

In 1990, Dad asked me to lead a delegation to Gambia Gambia to celebrate its twenty-fifth anniversary of independence. A small West African nation with a population of about nine hundred thousand, Gambia was best known in America as the home of the forebears of to celebrate its twenty-fifth anniversary of independence. A small West African nation with a population of about nine hundred thousand, Gambia was best known in America as the home of the forebears of Alex Haley Alex Haley, the author of Roots Roots. Laura and I had read the Pulitzer Prizewinning book in which Haley traces his lineage back to an African man taken by slave traders in the 1700s.

Sadly, Gambia did not seem to have developed much since then. Laura and I were driven around the capital, Banjul, in an old Chevrolet provided by the emba.s.sy. The main road was paved. The rest were dirt. Most people we saw traveled by foot, often with heavy loads on their backs. The highlight of the trip was the ceremony celebrating Gambian independence. It took place in the national stadium, where the paint was peeling and concrete was chipped away. I remember thinking that high school stadiums in West Texas were a lot more modern than Gambia's showcase.

Gambia was in the back of my mind eight years later when I started thinking about running for president. Condi Rice and I spent long hours discussing foreign policy on the back porch of the Governor's Mansion. One day our conversation turned to Africa. Condi had strong feelings on the subject. She felt Africa had great potential, but had too often been neglected. We agreed that Africa would be a serious part of my foreign policy.

I considered America a generous nation with a moral responsibility to do our part to help relieve poverty and despair. The question was how to do it effectively. Our foreign a.s.sistance programs in Africa had a lousy track record. Most were designed during the Cold War to support anticommunist governments. While our aid helped keep friendly regimes in power, it didn't do much to improve the lives of ordinary people. In 2001, Africa received $14 billion in foreign aid foreign aid, more than any other continent. Yet economic growth per capita was flat, even worse than it had been in the 1970s.

Another problem was that the traditional model of foreign aid was paternalistic: A wealthy donor nation wrote a check and told the recipient how to spend it. I decided to take a new approach in Africa and elsewhere in the developing world. We would base our relationships on partnership, not paternalism. We would trust developing countries to design their own strategies for using American taxpayer dollars. In return, they would measure their performance and be held accountable. The result would be that countries felt invested in their own success, while American taxpayers could see the impact of their generosity.

As Condi made clear in our first discussion, one problem in Africa stood out above all others: the humanitarian crisis of HIV/AIDS. The statistics were horrifying. Some ten million people in sub-Sarahan Africa had died. In some countries, one out of every four adults carried HIV. The total number infected was expected to exceed one hundred million by 2010. The United Nations projected that AIDS could be the worst epidemic since the bubonic plague of the Middle Ages.

When I took office, the United States was spending a little over $500 million a year to fight global AIDS. That was more than any other country. Yet it was paltry compared with the scope of the pandemic. The money was spread haphazardly across six different agencies. Much of their work was duplicative, a sign there was no clear strategy.

American taxpayers deserved-and conscience demanded-a plan that was more effective than this disjointed effort. I decided to make confronting the scourge of AIDS in Africa a key element of my foreign policy.

In March 2001, I met with United Nations Secretary-General Kofi Annan Kofi Annan, a soft-spoken diplomat from Ghana. Kofi and I didn't agree on every issue, but we found common ground in our determination to deal with the AIDS pandemic. He suggested creating a new Global Fund to Fight HIV/AIDS, Tuberculosis, and Malaria Global Fund to Fight HIV/AIDS, Tuberculosis, and Malaria that would marshal resources from around the world. that would marshal resources from around the world.

I listened but made no commitment. I considered the UN to be c.u.mbersome, bureaucratic, and inefficient. I was concerned that a fund composed of contributions from different countries with different interests would not spend taxpayer money in a focused or effective way.

Nevertheless, Secretary of State Colin Powell and Health and Human Services Secretary Tommy Thompson Tommy Thompson recommended that I support the Global Fund with an initial pledge of $200 million. They felt it would send a good signal for America to be the first contributor. Their persistence overcame my skepticism. I announced our commitment on May 11, 2001, with Kofi and President recommended that I support the Global Fund with an initial pledge of $200 million. They felt it would send a good signal for America to be the first contributor. Their persistence overcame my skepticism. I announced our commitment on May 11, 2001, with Kofi and President Olusegun Obasanjo Olusegun Obasanjo of Nigeria in the Rose Garden. "I thank you, on behalf of all AIDS sufferers in the world, but particularly on behalf of all AIDS sufferers in Africa," President Obasanjo said. of Nigeria in the Rose Garden. "I thank you, on behalf of all AIDS sufferers in the world, but particularly on behalf of all AIDS sufferers in Africa," President Obasanjo said.

"This morning, we have made a good beginning," I said in my speech. I didn't add that I had plans to do more.

Four months to the day after we announced our pledge to the Global Fund, the terrorists struck America. Before 9/11, I had considered alleviating disease and poverty a humanitarian mission. After the attacks, it became clear to me that this was more than a mission of conscience. Our national security was tied directly to human suffering. Societies mired in poverty and disease foster hopelessness. And hopelessness leaves people ripe for recruitment by terrorists and extremists. By confronting suffering in places like Africa, America would strengthen its security and collective soul.

By early 2002, I had concluded that the Global Fund was not a sufficient response to the AIDS crisis. While America had increased our contribution to $500 million, the Fund was short on money and slow to act. Meanwhile, the AIDS epidemic was sending more Africans to their graves. The majority were between ages fifteen and forty-nine, the key demographic for productive nations. Left unchecked, the disease was projected to kill sixty-eight million people by 2020, more than had died in World War II.

I couldn't stand the idea of innocent people dying while the international community delayed. I decided it was time for America to launch a global AIDS initiative of our own. We would control the funds. We would move fast. And we would insist on results.

Josh Bolten a.s.sembled a team* to develop recommendations. In June, they came to me with a proposal to focus on one particularly devastating part of the AIDS crisis: its impact on women and children. At the time, 17.6 million women and 2.7 million children were living with HIV/AIDS. Every forty-five seconds, another baby in Africa was born with the virus. to develop recommendations. In June, they came to me with a proposal to focus on one particularly devastating part of the AIDS crisis: its impact on women and children. At the time, 17.6 million women and 2.7 million children were living with HIV/AIDS. Every forty-five seconds, another baby in Africa was born with the virus.

Recently, scientists had discovered new medicines, particularly a drug called Nevirapine, that could reduce the rate of mother-to-child transmission by 50 percent. But it was not widely available in Africa or other parts of the developing world. The team proposed spending $500 million over five years to purchase medicine and train local health-care workers in the most heavily affected African and Caribbean countries.

"Let's get it started right now," I said. The plan was tailored to a specific part of the crisis in the neediest parts of the world. It put local officials in the lead. And it had an ambitious but realistic goal: to treat one million mothers and save one hundred fifty thousand babies every year after five years.

On June 19, 2002, I announced the International Mother and Child HIV Prevention Initiative in the Rose Garden. In seventeen months, we had doubled America's commitment to fighting global AIDS.

The morning I unveiled the mother and child program, I called Josh Bolten Josh Bolten into the Oval Office. "This is a good start, but it's not enough," I told him. "Go back to the drawing board and think even bigger." into the Oval Office. "This is a good start, but it's not enough," I told him. "Go back to the drawing board and think even bigger."

A few months later, he and the team recommended a large-scale program focused on AIDS treatment, prevention, and care-the strategy that would ultimately become PEPFAR.

The first part of the proposal, treatment, was the most revolutionary. Across Africa, it was estimated that four million AIDS patients required antiretroviral drugs to stay alive. Fewer than fifty thousand were receiving them. Thanks to advances in drug technology, AIDS treatment regimens that used to require thirty pills a day could be taken as a twice-a-day c.o.c.ktail drug. Soon, only one pill was required. The new medicine was more potent and less toxic to patients. And the price had declined from $12,000 a year to under $300. For $25 a month, America could extend an AIDS patient's life for years.

"We need to take advantage of the breakthrough," I told the team, "but how will we get the drugs to the people?"

Tony Fauci described a program in Uganda Uganda led by Dr. led by Dr. Peter Mugyenyi Peter Mugyenyi, an innovative doctor who operated an advanced clinic and was one of the first people to bring antiretroviral drugs to Africa. At one Oval Office meeting, Tony showed me photos of Ugandan health workers from TASO climbing aboard motorcycles to bring antiretroviral drugs door-to-door to homebound patients. While only partially complete, the Mugyenyi and TASO programs showed what could be possible with more support.

In addition to treatment, Uganda employed an aggressive prevention campaign known as ABC: Abstinence, Be faithful, or else use a Condom. The approach was successful. According to estimates, Uganda's infection rate had dropped from 15 percent in 1991 to 5 percent in 2001.

PEPFAR would include one additional element: caring for victims of AIDS, especially orphans. It broke my heart that fourteen million children had lost parents to AIDS. It also worried me. A generation of rootless, desperate young people would be vulnerable to recruitment by extremists.

I pressed for specifics on the plan. "What are our goals?" I asked. "What can we accomplish?"

We set three objectives: treat two million AIDS patients, prevent seven million new infections, and care for ten million HIV-affected people. We would partner with the government and people of countries committed to battling the disease. Local leaders would develop the strategies to meet specific goals, and we would support them.

The next question was which countries to include. I decided to focus on the poorest and sickest nations, twelve in sub-Saharan Africa and two in the Caribbean.** These fourteen countries accounted for 50 percent of the world's HIV infections. If we could stop the spread of the disease at its epicenter, we could create a model for other countries and the Global Fund to follow. These fourteen countries accounted for 50 percent of the world's HIV infections. If we could stop the spread of the disease at its epicenter, we could create a model for other countries and the Global Fund to follow.

The final decision was how much money we should spend. Josh's group had recommended a stunning $15 billion over five years. My budget team expressed concern. In late 2002, the U.S. economy was struggling. The American people might not understand why we were spending so much money overseas when our own citizens were suffering.

I was willing to take on that objection. I was confident I could explain how saving lives in Africa served our strategic and moral interests. Healthier societies would be less likely to breed terror or genocide. They would be more prosperous and better able to afford our goods and services. People uncertain of America's motives would see our generosity and compa.s.sion. And I believed the American people would be more supportive if we could show that their tax dollars were saving lives.

Critics would later claim that I started PEPFAR to appease the religious right or divert attention from Iraq. Those charges are preposterous. I proposed the AIDS initiative to save lives. Mike Gerson Mike Gerson, my chief speechwriter and trusted adviser, put it best in a November 2002 meeting. "If we can do this and we don't," he said, "it will be a source of shame."

I made the decision to move forward with PEPFAR in December 2002. Only a few people knew about the plan. I instructed the team to keep it that way. If word leaked out, there would be a turf war among government agencies for control of the money. Members of Congress would be tempted to dilute the program's focus by redirecting funds for their own purposes. I didn't want PEPFAR to end up hamstrung by bureaucracy and competing interests.

"Seldom has history offered a greater opportunity to do so much for so many," I said in my State of the Union address on January 28, 2003. "...Tonight I propose the Emergency Plan for AIDS Relief-a work of mercy beyond all current international efforts to help the people of Africa."

Members of both parties rose to support the plan. Standing next to Laura in the First Lady's box was a man whose program and country had served as an inspiration for PEPFAR, Dr. Peter Mugyenyi Peter Mugyenyi of Uganda. of Uganda.

I had intended the announcement to make a big impact, and it did. President Clinton's top AIDS official called it "inspiring and clearly heartfelt." The Chicago Tribune Chicago Tribune summarized the reaction of many newspapers when it editorialized, "'Astonishing' is not too strong a word for President Bush's announcement." summarized the reaction of many newspapers when it editorialized, "'Astonishing' is not too strong a word for President Bush's announcement."

As expected, there were some objections. The biggest came in response to the ABC prevention strategy ABC prevention strategy. Critics on the left denounced the abstinence component as an ideological "war on condoms" that would prove unrealistic and ineffective. I pointed out that abstinence worked every time. Some on the right objected to distributing condoms, which they felt would encourage promiscuity. At least members of Congress were smart enough not to criticize the B, being faithful within marriage.

Ironically, both sides charged that we were imposing our values-religious fundamentalism if you asked one camp, s.e.xual permissiveness if you asked the other. Neither argument made much sense to me, since the ABC strategy had been developed in Africa, implemented in Africa, and successful in Africa.

In the spring of 2003, the House of Representatives took up PEPFAR legislation. The bill was sponsored by Republican Congressman Henry Hyde Henry Hyde of Illinois and Democratic Congressman of Illinois and Democratic Congressman Tom Lantos Tom Lantos of California, two principled supporters of human rights. In a fine example of bipartisan cooperation, they helped steer the bill through the House with a vote of 375 to 41. of California, two principled supporters of human rights. In a fine example of bipartisan cooperation, they helped steer the bill through the House with a vote of 375 to 41.

The bill then moved to the Senate, where it received strong backing from Majority Leader Bill Frist Bill Frist, a doctor who took annual medical missionary trips to Africa, and Senator d.i.c.k Lugar d.i.c.k Lugar of Indiana, the thoughtful chairman of the Foreign Relations Committee. Bill and d.i.c.k rallied support among a wide range of lawmakers, from conservatives like of Indiana, the thoughtful chairman of the Foreign Relations Committee. Bill and d.i.c.k rallied support among a wide range of lawmakers, from conservatives like Jesse Helms Jesse Helms of North Carolina to liberals like of North Carolina to liberals like Joe Biden Joe Biden of Delaware and of Delaware and John Kerry John Kerry of Ma.s.sachusetts. I told Bill I hoped to sign a bill before I left for the 2003 G-8 summit in Evian, France, so that I would have more leverage to persuade our allies to join us. Bill worked tirelessly to meet the deadline. Three days before I left the country, I signed PEPFAR into law. of Ma.s.sachusetts. I told Bill I hoped to sign a bill before I left for the 2003 G-8 summit in Evian, France, so that I would have more leverage to persuade our allies to join us. Bill worked tirelessly to meet the deadline. Three days before I left the country, I signed PEPFAR into law.

Two months later, Laura and I touched down in sub-Saharan Africa. Our first stop was Senegal Senegal. After a morning meeting at the presidential palace, President Abdoulaye Wade Abdoulaye Wade and his wife, Viviane, escorted us to one of the most haunting places I visited as president, Goree Island. and his wife, Viviane, escorted us to one of the most haunting places I visited as president, Goree Island.

Standing at the threshold of the Door of No Return on Goree Island. White House/Eric Draper White House/Eric Draper Our tour began in a pink stucco structure, the Slave House. The museum curator showed Laura and me through the small, hot rooms. One had contained scales to weigh the slaves. Another was divided into cells to separate men, women, and children. We walked through a narrow pa.s.sageway to the Door of No Return, the starting point for the horrific Middle Pa.s.sage. I could only imagine the fear of those hopeless souls who were stolen from their families and shoved onto ships bound for an unfamiliar land. I put my arm around Laura as we peered out at the blue ocean.

Standing behind us were Colin Powell Colin Powell and Condi Rice. I thought about the contrast between what their ancestors had endured and what Colin and Condi had accomplished. After the tour, I gave a speech from the island: and Condi Rice. I thought about the contrast between what their ancestors had endured and what Colin and Condi had accomplished. After the tour, I gave a speech from the island: At this place, liberty and life were stolen and sold. Human beings were delivered and sorted, and weighed, and branded with the marks of commercial enterprises, and loaded as cargo on a voyage without return. One of the largest migrations of history was also one of the greatest crimes of history....For two hundred fifty years the captives endured an a.s.sault on their culture and their dignity. The spirit of Africans in America did not break. Yet the spirit of their captors was corrupted....A republic founded on equality for all became a prison for millions. And yet in the words of the African proverb, "No fist is big enough to hide the sky." All the generations of oppression under the laws of man could not crush the hope of freedom and defeat the purposes of G.o.d....In the struggle of the centuries, America learned that freedom is not the possession of one race. We know with equal certainty that freedom is not the possession of one nation. This belief in the natural rights of man, this conviction that justice should reach wherever the sun pa.s.ses, leads America into the world. With the power and resources given to us, the United States seeks to bring peace where there is conflict, hope where there is suffering, and liberty where there is tyranny.

PEPFAR was a new chapter in Africa's unfolding story of freedom, dignity, and hope. In every country I visited, I promised that America would meet our commitments. In South Africa South Africa, where nearly five million lived with HIV, I urged a reluctant President Thabo Mbeki Thabo Mbeki to confront the disease openly and directly. In to confront the disease openly and directly. In Botswana Botswana, a relatively wealthy country where 38 percent of the adult population was infected, President Festus Mogae Festus Mogae pledged to use PEPFAR funds to continue the impressive effort he had begun to fight the disease. At the national hospital in Abuja, Nigeria, I visited with women who had benefited from the mother and child initiative. They beamed with joy as they showed me their healthy children. But for every infant born infection-free, many more began life facing the burden of HIV. pledged to use PEPFAR funds to continue the impressive effort he had begun to fight the disease. At the national hospital in Abuja, Nigeria, I visited with women who had benefited from the mother and child initiative. They beamed with joy as they showed me their healthy children. But for every infant born infection-free, many more began life facing the burden of HIV.

The most memorable part of the trip was our visit to the TASO clinic in Uganda Uganda, where I met Mohamad Kalyesubula Mohamad Kalyesubula. Escorted by President Yoweri Museveni Yoweri Museveni and his wife Janet, Laura and I went around the room and hugged the patients. Many opened up to us. They shared their hopes and fears. One nurse named Agnes told me her husband had died of AIDS in 1992. When she got tested, she found out that she, too, had HIV. She was one of the lucky few who had been able to get antiretroviral drugs. She urged me to send more medicine, as soon as possible. When the drugs supported by PEPFAR reached Uganda, Agnes helped nurse many of TASO's patients back to health. One was Mohamad. When he came to the White House in 2008, Agnes came too. and his wife Janet, Laura and I went around the room and hugged the patients. Many opened up to us. They shared their hopes and fears. One nurse named Agnes told me her husband had died of AIDS in 1992. When she got tested, she found out that she, too, had HIV. She was one of the lucky few who had been able to get antiretroviral drugs. She urged me to send more medicine, as soon as possible. When the drugs supported by PEPFAR reached Uganda, Agnes helped nurse many of TASO's patients back to health. One was Mohamad. When he came to the White House in 2008, Agnes came too.

The director of TASO, a doctor named Alex Coutinho Alex Coutinho, later said I was the first world leader he had seen hug an African with AIDS. I was surprised. I remembered that Mother had made international news when she hugged an HIV-infected baby in 1989. Her act dispelled the myth that the disease could be transmitted by incidental human contact. I was proud to carry on her legacy by reducing the stigma a.s.sociated with AIDS. I hoped in some small way to restore the dignity of suffering people. Above all, I wanted to show that the American people cared.

At the TASO AIDS clinic in Uganda. White House/Susan Sterner White House/Susan Sterner

One highlight of our Africa trip was that our daughter Barbara joined us. In Botswana Botswana, she, Laura, and I went on safari in the Mokolodi Nature Reserve. We were hoping to relax, get some fresh air, and see some wild animals. To feed the appet.i.te of the traveling press, the White House staff decided we should have a photo op.

As always, the preparations were meticulous. A press truck full of cameras and reporters was prestationed in a clearing. As our vehicle rounded the corner, the press was lined up for a perfect shot of us observing several elephants. Apparently, the elephants were not given the script. Shortly after we arrived, a randy male elephant mounted one of his female counterparts on live international TV. Our advance team turned pale under the hot African sun. Laura, Barbara, and I burst out laughing.

The trip was Barbara's first to Africa, and it touched her deeply. After graduating from college and volunteering on my 2004 campaign, she went to work for a pediatric AIDS clinic at the Red Cross War Memorial Hospital in Cape Town, South Africa. Inspired by her experience, she later founded a nonprofit, Global Health Corps Global Health Corps. Based on a model similar to Teach for America, her organization sends recent college graduates to clinics in three African countries and two American inner cities. They support care for patients with AIDS and other diseases, strengthening the health infrastructure and helping people live with dignity and hope.

Jenna also discovered a pa.s.sion for working with AIDS patients. She volunteered for UNICEF in several Latin American countries. When she got home, she wrote a wonderful book, a bestseller called Ana's Story Ana's Story, about a girl who was born with HIV.

Laura and I are very proud of our daughters. They have become professional women serving a cause greater than themselves. They are part of a larger movement of Americans who devote their time and money to helping the less fortunate. These good souls are part of what I call the armies of compa.s.sion. Many come from faith-based organizations and seek no compensation. They receive payment in another form.

One of the most important early decisions on PEPFAR was who should run it. I wanted a proven manager who knew how to structure an organization that would focus on results. I found the right man in an experienced Indiana businessman, former Eli Lilly CEO Randall Tobias Randall Tobias.

Randy's first reports were discouraging. A year after I signed PEPFAR, fewer than one hundred thousand patients were receiving antiretroviral drugs. "That's it?" I snapped. "We're a long way from two million."

Randy a.s.sured me PEPFAR was on track. The most important tasks during the first year were to get partner countries to devise their strategies, mobilize manpower, and start establishing infrastructure. Once we had this foundation in place, the number of people receiving drugs would ramp up dramatically.

By the fall of 2005, our African partners were fully engaged. Faith-based and other groups supported by PEPFAR, both African and American, helped staff clinics and spread prevention messages to millions across the continent. Orphans and the dying were receiving compa.s.sionate care. Some four hundred thousand people were taking antiretroviral drugs. We were on pace to reach our goal.

Unfortunately, AIDS wasn't the only disease ravaging Africa. By 2005, malaria was killing approximately one million Africans a year, the majority of them children under the age of five. Transmitted by a mosquito bite, malaria accounted for 9 percent of all deaths in Africa, even more than AIDS. Economists estimated that the disease cost Africa $12 billion a year in medical expenses and lost productivity, a crippling blow to already fragile economies.

Every one of those deaths was unnecessary. Malaria is treatable and preventable. The United States had eradicated malaria in the 1950s, and there was a well-established strategy for battling the disease. It called for a combination of insecticide sprays, bed nets, and medicine for infected patients. The remedies were not particularly expensive. Bed nets cost $10 each, including delivery.

In June 2005, I announced a five-year, $1.2 billion program that would fund malaria-eradication efforts in fifteen countries. Like PEPFAR, the President's Malaria Initiative Malaria Initiative would empower Africans to design strategies to meet their needs. We would work toward a measurable goal: cutting malaria mortality rates by 50 percent over the next five years. would empower Africans to design strategies to meet their needs. We would work toward a measurable goal: cutting malaria mortality rates by 50 percent over the next five years.

I named Rear Admiral Tim Ziemer, a retired Navy pilot with experience in international relief efforts, to lead the Malaria Initiative. In its first two years, the initiative reached eleven million Africans. It also generated a pa.s.sionate response from the American people. Boys and Girls Clubs, scout troops, and school cla.s.ses donated money in ten-dollar increments to buy bed nets for African children. Faith-based organizations and major corporations, especially those doing business in Africa, gave generously to the cause.

With support from the Malaria Initiative, infection rates in the targeted countries began to decline. The most dramatic turnaround was in Zanzibar Zanzibar. Health officials adopted an aggressive campaign of spraying, bed net distribution, and medicine for malaria victims and pregnant women. On one Zanzibar island, the number of malaria cases dropped more than 90 percent in a single year.

On April 25, 2007, Laura and I hosted America's first-ever Malaria Awareness Day in the Rose Garden. It was an opportunity to herald progress and show our citizens the results of their generosity.

At the end of my remarks, the KanKouran West African Dance Company performed a lively song. Caught up in the celebratory mood, I joined the dancers onstage. My moves were replayed on the national news and became a minor sensation on YouTube. The girls took great delight in teasing me: "I don't think you should audition for Dancing with the Stars Dancing with the Stars, Dad."

"I told you my goal was to raise awareness," I replied.

In 2006, Mark Dybul Mark Dybul succeeded Randy Tobias as the coordinator of PEPFAR. As a medical doctor and respected figure in the AIDS community, Mark brought great credibility to PEPFAR. After one of his trips to Africa, he told me many on the continent were anxious about what would happen after PEPFAR's five-year authorization expired in 2008. Governments were counting on our continued support, and so were the people. Mark told me he had asked a health clinic official in Ethiopia if anyone knew what the acronym PEPFAR stood for. "Yes," the man said. "PEPFAR means the American people care about us." succeeded Randy Tobias as the coordinator of PEPFAR. As a medical doctor and respected figure in the AIDS community, Mark brought great credibility to PEPFAR. After one of his trips to Africa, he told me many on the continent were anxious about what would happen after PEPFAR's five-year authorization expired in 2008. Governments were counting on our continued support, and so were the people. Mark told me he had asked a health clinic official in Ethiopia if anyone knew what the acronym PEPFAR stood for. "Yes," the man said. "PEPFAR means the American people care about us."

Mark believed we had a responsibility to continue the program-and an opportunity to build on our progress. By doubling PEPFAR's initial funding level, we could treat 2.5 million people, prevent 12 million infections, and support care for 12 million people over the next five years.

Doubling funding would be a big commitment. But the AIDS initiative was working, and I decided to keep the momentum going. On May 30, 2007, I stepped into the Rose Garden and called for Congress to reauthorize the initiative with a new commitment of $30 billion over the next five years.

To highlight the progress, I invited a South African woman named Kunene Tantoh Kunene Tantoh. Laura had met her two years earlier and shared her inspiring story with me. Kunene was HIV-positive, but thanks to medicine she received through the mother and child initiative, she had given birth to an HIV-free boy. After the speech I held four-year-old Baron in my arms and smiled at the thought that his precious life had been saved by the American taxpayers. He demonstrated his energy and good health by wiggling around and waving to the cameras. Then he gave me the international look for "Enough is enough. Put me down."

Holding Baron Tantoh. White House/Eric Draper White House/Eric Draper The next step was to get other nations to join us. In the summer of 2007, Laura and I flew to Germany for the G-8 summit, hosted by Chancellor Angela Merkel Angela Merkel. One key mission was to persuade my fellow G-8 leaders to match America's pledges on HIV/AIDS and malaria.

Angela told me the summit's primary topic would be global warming. I was willing to be constructive on the issue. In my 2006 State of the Union address, I had said that America was "addicted to oil"-a line that didn't go over so well with some friends back in Texas. I had worked with Congress to promote alternatives to oil, including biofuels, hybrid and hydrogen vehicles, natural gas, clean coal, and nuclear power. I also proposed an international process that, unlike the flawed Kyoto Protocol Kyoto Protocol, brought together all major emitters-including China and India-and relied on clean energy technologies to cut greenhouse gas emissions without stifling the economic growth necessary to solve the problem.

I worried that the intense focus on climate change climate change would cause nations to overlook the desperate immediate needs in the developing world. "If world leaders are going to sit around talking about something that might be a problem fifty years from now," I told Angela, "we'd better do something about the people dying from AIDS and malaria right now." would cause nations to overlook the desperate immediate needs in the developing world. "If world leaders are going to sit around talking about something that might be a problem fifty years from now," I told Angela, "we'd better do something about the people dying from AIDS and malaria right now."

With Angela's help, the other G-8 leaders agreed to match the AIDS-relief goals America had set. Together, we would provide treatment for five million people, prevent twenty-four million more infections, and support care for twenty-four million additional people over the next five years. They also agreed to match the goals of our Malaria Initiative Malaria Initiative. Those historic commitments can make an enormous difference in the lives of people in Africa and around the world. It will be up to future administrations to ensure that nations follow through on their pledges.

The principles of accountability and partnership that guided PEPFAR were also behind the centerpiece of our new approach to economic development, the Millennium Challenge Account. To be eligible for MCA funds, countries had to meet three clearly defined criteria: govern free of corruption, pursue market-based economic policies, and invest in the health and education of their people. The change in approach was dramatic. Economic aid would be treated like an investment instead of a handout. Success would be measured by results produced, not money spent.

MCA drew support from some unexpected sources. One was Bono Bono, the Irish lead singer of U2. Josh and Condi had gotten to know Bono and told me the star wanted to visit me in the Oval Office. I was skeptical of celebrities who seemed to adopt the cause of the moment as a way to advance their careers. But they a.s.sured me Bono was the real deal.