Man of the World: The Further Endeavors of Bill Clinton (17 page)

Years later, Clinton would say casually that he and his foundation “just sort of fell into . . . the actual things we ended up doing,” by which he meant that there had been no master plan or singular objective when he left the White House. Among the first to importune him was Sandra Thurman, a health policy expert from Atlanta who had served as the “AIDS czar” in the second Clinton-Gore administration. It was Sandy Thurman who asked Clinton to cochair an international effort aimed at raising more government money for AIDS—and, together with Nelson Mandela, he had agreed to deliver the closing remarks at the next World AIDS conference in Barcelona, Spain, scheduled in July 2002.

He and Mandela were happy to perform a “dog-and-pony show,” as Clinton described it, to raise the visibility of the AIDS crisis. If their exhortations improved the morale of the thousands of health workers,
advocates, and officials gathered in Barcelona that would be worthwhile, too. But he was well aware that corrosive tensions were growing between the advanced industrial countries—the “donor nations”—and the developing countries, over not only money but policy. In the absence of a concerted global campaign to fund and provide treatment for the tens of millions who would otherwise be left to die, the entire exercise was beginning to seem pointless. Prevention would fail; the pandemic would continue for decades; hundreds of millions more would be infected; and development would essentially cease across much of the world. To Clinton, this would be an unacceptable, indeed unthinkable catastrophe.

In late May, Ira Magaziner returned to the foundation’s Harlem offices to discuss his findings with Clinton and Maggie Williams. Given the dimensions of the problem, there were two very different paths that the former president might take.

“Look, here’s the situation. I think as a moral matter, and as a matter of taking something on that fits your stature . . .” he began, then stopped. “You know, you could go out there and do a lot of small things, and check the box that you’re doing something charitable—but if you really want to take advantage of Bill Clinton and his global reputation, you ought to take on something big. And that means it will be hard and risky, and something that other people can’t do easily.”

Both Williams and Clinton already knew what “something” meant. In preparation for this meeting, he had delivered a confidential seven-page memorandum, addressed to Williams and captioned “President Clinton and the AIDS Crisis,” outlining how Clinton “can best play a leadership role going forward in the global struggle to stop the spread of AIDS . . . a unique leadership role that . . . will help fill the most significant gap that now exists.”

Magaziner’s months of research had led him to believe that with enough money and proper organization, “the AIDS crisis can be contained.” That was, as the introduction to his memo suggested, “the good news.” The unsurprising bad news was that “many of the developing countries that have been hardest hit by AIDS lack sufficient funds and organizational capacity to succeed.”

Looking forward, he continued, the United Nations, aid agencies in the developed countries, and several large international foun
dations soon would increase the overall funding available to support the fight against AIDS in those countries. That funding would still fall short of the needed amount by as much as $7 billion annually, he estimated, but Clinton should not focus on fundraising because of political obstacles.

In a prophetic passage, Magaziner warned: “The U.N. will defer to the US government in the selection of any American to play a leadership role in these organizations and I do not believe that the current [Bush] administration would look favorably on President Clinton in such a role. . . . However, I believe that President Clinton is uniquely placed to help overcome perhaps the most serious impediment to successfully reversing the AIDS epidemic.”

That impediment was “the lack of organizational capacity” in the nations suffering the worst outbreaks of the disease. While a few countries like Senegal and Uganda had implemented early and effective programs that kept infection rates relatively low—between 2 and 8 percent of their populations—other countries, including South Africa, Zimbabwe, and Malawi, had not.

In a staggering single-page appendix, he had listed the rates of infection for the hardest-hit countries in Africa, from Botswana, with 35.8 percent of citizens between the ages of fifteen and fifty HIV-positive, to Ethiopia, where 10.6 percent were infected. In South Africa, 19.9 percent in that age cohort were infected. Nigeria had five million infected adults; Congo and Mozambique each had more than six million.

In essence, explained Magaziner, the afflicted countries needed three kinds of programs if they were to have any hope of stanching the damage done by AIDS: prevention, treatment, and assistance to the millions of children orphaned by dead or extremely sick parents.

Prevention meant education, testing, screening, and condom distribution that could “reach into every community and school,” as well as programs to reduce the incidence of all sexually transmitted diseases. Sex workers in particular would have to be tested and monitored. But none of these prevention programs could function effectively without treatment.

Treatment required much more than simply handing out pills in a paper cup. Administration of drugs would have to be preceded and followed up by rigorous testing, nursing assistance to reduce the onset
of other, related fatal illnesses, and special care for infected pregnant women to lessen the likelihood of disease transmission to their infants.

Moreover, to implement any of these complex protocols meant “significant training of doctors, nurses, allied health workers, patients, and their families,” along with the establishment of community health centers equipped to provide all the testing, counseling, and pharmaceutical supplies. To care for the AIDS orphans properly would require “the extension of existing welfare networks to address the psychological, educational, and physical needs of these children,” while encouraging acceptance of them in fearful communities.

Although most of the afflicted countries had drafted a plan or strategy on paper to combat HIV/AIDS, usually with the assistance of the United Nations, and while many were hosting individual programs funded by international nonprofit or religious agencies, there was little coordination in reality. On the whole, most efforts in these countries were too small and too poorly organized to achieve much as the pandemic continued to surge.

To grasp the mind-bending complexity of this situation on a global scale would challenge anyone, even Clinton; to grapple with it successfully would be exponentially more difficult still. At a minimum, the necessary elements included money, knowledge, and skills of many kinds. But Magaziner’s memo suggested that the truly essential factor was trust. Bringing together the leaders and governments of the developing world with the policy bureaucrats, medical experts, and health professionals of the developed world demanded a trusted figure in leadership—someone esteemed in both the wealthy north and the impoverished south.

He had a candidate for this difficult mission:

President Clinton has extremely good relations with many African and Caribbean leaders who are confronting AIDS crises in their countries. He is also widely admired among people in many nations in Africa and the Caribbean. He has a credibility that not many western political leaders possess in that part of the world. As a result, an organization that is associated with him would be potentially welcomed and trusted by government leaders and by those running programs to fight AIDS in many countries. . . .

[He] would also be able to attract many groups of doctors, nurses, and experts from developed countries to mobilize resources. . . . Finally, President Clinton is widely respected by groups like the Irish, Swedish, and Canadian aid agencies who will be providing funds for AIDS-related projects in these countries.

The role that Magaziner envisioned for Clinton and the foundation was to “coordinate resources” and “galvanize cooperation” among the various private organizations and governments fighting AIDS, in each country and across continents. By establishing a personal base in several nations and delivering real programs, he could not only make a significant contribution to solving the crisis, but create a “credible platform from which to assert international leadership in global forums on the issue, whether negotiating with drug companies or pressing for greater financial commitments.”

Without substantive work on the ground, he warned, “I fear that President Clinton’s efforts in this arena will be viewed as increasingly hollow. The United Nations will want to follow the wishes of the government in power in the United States on the deployment of any Americans to leadership positions in its various activities. This means that President Clinton may be excluded from playing a leadership role in areas like fundraising and administration [of AIDS programs]. . . . And since many current and former world leaders are now looking to become identified with this issue, there will be many of them making speeches at international meetings. Absent any real action on the issue, President Clinton’s credibility as a speaker would eventually fade.”

In short, Clinton needed to put up, or, ultimately, he might as well shut up.

Magaziner’s memo briefly outlined the first steps toward implementing his ambitious plan, employing mostly volunteers at first, drawn from the “many doctor, nurse, public health and social service groups allied with us on health reform” as well as “groups in the business and legal community” that might fund some staff on a pro bono basis. Within three or four months, he estimated, a core team could be brought together to plan and initiate a foundation-based AIDS program.

Then Clinton could choose a few countries where the program
might best be launched, based on his own relationships and consultation with leaders and groups already involved in those places, a process that would require another few months. Over a period of roughly two years, Magaziner projected the establishment of programs in as many as ten countries.

“Well,” said Clinton, gazing out over the cityscape, “put together, what exactly would that look like?” Magaziner replied that the real need was to “scale up”—to seize upon the successful practices of small local clinics established by a few of the international medical charities, such as Paul Farmer’s Partners in Health and the French-based Doctors Without Borders, and bring them to national scale by working with government authorities.

“If we’re going to really scale up and get major numbers of people in treatment and save lives, we have to work with the governments, we should work with the governments,” Magaziner urged. “And you can do that. They’ll respect and trust you.”

“OK, Ira. Prepare me a plan on how we do this.”

Several days later, Williams called Magaziner to discuss two specific questions that Clinton had raised following their meeting: What would be the actual structure of the “on-the-ground initiative” that he had described? And what was the current state of negotiations between governments and pharmaceutical companies over providing AIDS medications in the developing world at affordable prices?

On June 11, Magaziner dispatched a second memo, attempting to answer Clinton’s inquiries. Either under the auspices of the Clinton Foundation alone, or in partnership with the International AIDS Trust and possibly other major organizations, the initiative would be headquartered in the United States with a lean staff—an executive director, an associate director overseeing work in developing countries, and another managing partnerships and fundraising in the developed world, along with directors of finance and research. In each country, a country manager would oversee a staff combining “donated international personnel” and local leaders—with much of the in-country staff donated by partner organizations and consisting of people who would agree to spend at least a year, perhaps two, working as part of a team.

What Magaziner really wanted—and what would distinguish this initiative from so many others in the developing world—was a corps
of country managers “with a management background, preferably with experience in the public and private sectors.” Better still, these managers should have worked in developing countries, to prepare them for the rigors of places where many systems—communications, transportation, utilities, public safety—function intermittently, if at all.

Without being asked, he also answered the question that had to occur immediately to Clinton: Who was going to pay for all this stuff? There would be substantial expenses for travel, rent, utilities, food, and water, to mention only the barest necessities, even if most of the in-country staff began as volunteers.

“I believe that organizations like the major business consulting firms”—such as McKinsey & Company, and the Boston Consulting Group, where Magaziner had once rubbed shoulders with the likes of Mitt Romney—“would be willing to donate people,” as would some major corporations that he had advised. “I also believe that many medical organizations could be prevailed upon to finance members to participate,” he added. Aside from the in-kind assistance, he wrote, “I think it would be possible to raise funds from some foreign aid organizations, some foundations, and some corporations to provide the baseline funding for the effort.”

Among those early volunteers, Magaziner nominated himself: “I would be happy to devote considerable time to helping recruit these potential funding sources, potential partner organizations, and the executive teams. I would also be prepared to donate one or two people [from SJS, his consulting firm based in Quincy] to help get the effort started.”

Magaziner understood that Clinton’s question about the pharmaceutical industry raised one of the most sensitive issues of the last years of his presidency: the defense of patents for costly HIV/AIDS drugs produced by major drug companies, against international demands for the production of cheaper, generic versions of the same medicines that might have saved many lives. In places like Brazil and South Africa, governments approved local laws to encourage the procurement of generic versions of the antiretroviral medicines that had done so much to reduce mortality from AIDS in the United States during the 1990s. The pharmaceutical manufacturers, American and European, took every
possible step to stymie those efforts, fully backed by the Clinton-Gore administration.