The Fakeout

President George W. Bush's global AIDS-relief proposal seemed like a historic announcement. "[T]o meet a severe and urgent crisis abroad, tonight I propose the Emergency Plan for AIDS Relief -- a work of mercy beyond all current international efforts to help the people of Africa," Bush said during January's State of the Union address. "I ask the Congress to commit $15 billion over the next five years, including nearly $10 billion in new money, to turn the tide against AIDS in the most afflicted nations of Africa and the Caribbean. This nation can lead the world in sparing innocent people from a plague of nature."

Yet within weeks, serious questions have emerged about whether Bush's commitment was for real -- or just another instance of the president talking a good game in public while crossing his fingers behind his back. For one thing, Bush's refusal to allow funds to go to integrated public-health clinics that mention the word "abortion" will undercut much of the Third World's AIDS- preservation and condom-distribution infrastructure. For another, advocates are increasingly concerned about the actual amount of new money and when it will be delivered.

According to an analysis by the Open Society Institute (OSI), only $8.5 billion of the $15 billion pledge is actually "new money." The rest of the nearly $10 billion that Bush promised consists of funds previously committed by the administration in June for a multiyear program to prevent pregnant women from giving HIV to their babies, as well as continued funding for the Global Fund to Fight AIDS, Tuberculosis & Malaria that the United States began financing two years ago.

More significantly, $6.8 billion of the new $8.5 billion is not slotted to come up for appropriation until the fiscal year 2006-2008 period, according to the OSI. After that, says Dr. Paul Zeitz, the executive director of the Washington-based Global AIDS Alliance and a former United States Agency for International Development (USAID) worker in Zambia, it could take up to a year for the funds to wend their way from the halls of Congress into the hands and lives of Africans afflicted with HIV. That means about 80 percent of the new money Bush is proposing in his "Emergency Plan" will not reach African hands until around the 2007-2009 period. By then, according to the United Nations Joint United Programme on HIV/AIDS, most of the 21 million Africans projected to contract HIV by 2010 will have already become infected.

"The spirit of the president's announcement is fantastic, but we need to see the implementation applied in the early years as well as the later years, because this is a progressive epidemic," says Jamie Drummond, executive director of Debt, AIDS, Trade in Africa, U2 singer Bono's AIDS and development advocacy organization. "The more you put out the forest fire earlier, the less you have to put out later."

When Bush made his announcement, many observers responded with astonishment and rapturous praise for the president. "As someone with HIV, I listened to his words and found my throat catching," wrote gay conservative blogger Andrew Sullivan. The New York Times hailed Bush's proposal in an editorial, saying it "finally provides a response from Washington commensurate with the disease's catastrophic scale." "Billions in tax-payer money," gushed columnist Michael Kelly. "For condoms in Africa. In a recession. In a time of record budget deficits. It is a rare and wonderful thing." Even The American Prospect caught the fever, dubbing Bush one of our monthly "heroes" in the March issue.

With the State of the Union address, Bush formally made AIDS part of his "compassion agenda," the catch-all budgetary category the conservative president uses to substitute high-profile, targeted charity for society-wide, consistent public investment. But the AIDS issue is rapidly becoming one where the president's compassionate agenda and his conservative principles collide. At issue is the always-controversial matter of abortion.

In February the administration announced that it hoped to extend to international AIDS care and prevention groups the so-called Mexico City policy -- or global gag rule -- of prohibiting groups or programs that promote or perform abortions from receiving U.S. funding. The directive, in effect since President Ronald Reagan announced it in Mexico City in 1984, had previously only encompassed international family-planning centers. The administration has not issued a formal clarification detailing how the policy will operate within the AIDS arena, leaving legislators and activists alike confused as to how the expansion will affect AIDS programs.

Because the trend in many African nations is toward integrated health services, the administration's push for centers to separate their services into AIDS and abortion-discussing programs could profoundly delay implementation of any AIDS programs using the new funds -- and also throw programs accustomed to receiving U.S. AIDS dollars into disarray. Meanwhile, abortion-rights and anti-abortion members of Congress are busily debating a series of amendments to upcoming global AIDS bills to deal with the abortion issue. Though the abortion-rights side looks to have enough support in the relevant committees to write amendments blocking the gag rules, such amendments -- or anti-abortion ones -- would assuredly engender strong opposition and complicate the fate of the bills as they reach the House and Senate floors.

The record budget deficits and lingering U.S. economic woes have also had an impact on the president's plan. Bush's proposal is backloaded, requesting only $450 million in additional money this coming year. Though the administration claims that it has requested $2 billion for AIDS in Africa in the fiscal year 2004 budget, not all of that money is targeted to people with HIV, people at risk for HIV or Africans. Some $105 million of the proposed funds is slated to go to programs to treat tuberculosis and malaria, and $361 million is earmarked for the National Institutes of Health's and Centers for Disease Control's AIDS research -- not treatment or prevention. Meanwhile, the new "emergency" bilateral funding for AIDS, to be funneled through USAID, was offset by cuts of $146 million to USAID's child-survival, maternal-health and infectious-disease programs, leading development advocates to charge that the president was robbing Peter to pay Paul within the foreign-aid budget.

Also controversial is the question of how much to give to the Global Fund for treatment and prevention projects. The fund, which last year gave out its first round of grants, is becoming the leading multilateral agency to directly fund AIDS programs around the world. The United Nations AIDS Program primarily provides technical assistance to affected nations, and the World Health Organization's Global Program on AIDS, which used to provide direct program funding, was disbanded in 1995. Around 60 percent of Global Fund monies were devoted to AIDS last year, and about two-thirds of AIDS dollars go to countries in Africa. The president has proposed allocating $200 million per year for the next five years to the fund. This would represent a decrease in dollars from the $350 million that Congress approved for the Global AIDS Fund in the fiscal year 2003 budget, and a flatlining of funding thereafter.

AIDS advocates have requested that the United States contribute $2.5 billion per year directly to the Global Fund, and Sens. Bill Frist (R-Tenn.) and John Kerry (D-Mass.) proposed legislation last year to support that goal by giving the fund $2.2 billion over a two-year period. Congress opposed the bill and Frist, bowing to presidential pressure, has toned down his support for the multilateral approach since becoming Senate majority leader. This year, Rep. Henry Hyde (R-Ill.) has proposed giving the fund $1 billion more than the president has requested, but the ultimate appropriations amount is far from certain.

One thing, though, has already become readily apparent. "Bush's words are quite eloquent but his actions are not meeting up with the crisis," Zeitz said.