How to Save Twenty Million Lives

"We might have given the White House more confidence than was valid"

Twenty years ago, the U.S. launched the largest, most successful global health initiative to ever address a single disease. The President’s Emergency Plan for AIDS Relief (PEPFAR) is credited with saving at least 20 million lives. New York Times columnist Nick Kristof recently called PEPFAR “the single best policy of any president in my lifetime.” Kristof said he knew the initiative was going well when he met coffin makers in Lesotho and Malawi whose once-thriving businesses were going bust. 

By early 2002, HIV/AIDS was devastating sub-Saharan Africa. Josh Bolten, then-Deputy Chief of Staff for Policy, assembled a team to investigate how a U.S.-led fund could deploy its resources to stop the epidemic. The team, which included our guest today, Dr. Mark Dybul, began by focusing on reducing mother-to-child transmission, but expanded to provide antiretroviral therapy to vast swathes of Africa.

Dybul later served as the U.S. Global AIDS Coordinator, leading PEPFAR from 2006 until the end of the Bush administration. Dybul was the Executive Director of the Global Fund to Fight AIDS, Tuberculosis, and Malaria from 2013-2017.

What You’ll Learn

• The “blood on the floor, hatchet work” nature of interagency fights

• What makes presidents personally intervene in bureaucratic disputes

• Why PEPFAR was such a departure from contemporary global health practices

---

President Bush and Dr. Mark Dybul, November 30th, 2007

Interview with Dr. Mark Dybul

How did you get tapped to come up with the president’s HIV plan in Africa?

I was in Anthony Fauci’s laboratory, and wanted to work on HIV in Africa. We decided to see what we could do to bring antiretroviral therapy to Africans at a lower cost and less toxicity. At the time they were using Nevirapine-based regimens. So we did what we believe is the first randomized controlled trial of combination antiretroviral therapy in Africa.

Through that work, I got to know how Africa was trying to implement an HIV response. Then President Bush decided he wanted to do something big on HIV. Since Tony [Fauci] and I were doing the work in Africa, he and I put together what became the Mother and Child HIV Prevention Initiative, which was announced in June of 2002. $500 million, to try to cut mother and child transmission by 50% in countries with two thirds of the HIV burden in Africa and the Caribbean. The president said, “This is great.” We thought we were done.

But then the president said he wanted us to do something bigger. I was going to Uganda regularly for the study, since I was co-principal investigator with an African, Cissy Kityo, who now runs the Joint Clinical Research Center. Through that I got to know the CDC people.

They didn't know why, but I began sniffing around. Peter Mugyenyi and Joint Clinical Research Center had begun illegally providing antiretroviral therapy to people who could pay. The first distribution, the plane came in the middle of the night. Sam Kabende, who was the chief operating officer, met the plane, got the generic drugs, snuck them into the country, and started treating people who could afford it. 

In addition to the central hub in Kampala, they started opening small satellite clinics in various large cities around the country, staffed by nurses because there weren't enough physicians and clinicians. The cost to build one was $50,000-70,000. Operating costs were fairly low because they were nurses, nurse practitioners, and technicians, and a doctor would come once every two weeks or so. The AIDS Support Organization, TASO, had combined with the US CDC, and began experimenting with delivering antiretroviral therapy to people's homes.

This was by motor scooter, since people lived and worked on their farms. Most clinics or hospitals were two to three hours away. They were not places most people wanted to come to. So TASO experimented with training community healthcare workers. They improved motor bikes, which could not get through most of the dirt roads. They put little refrigerators on the backs and trained the workers to go out, draw blood, get symptoms, test the families, and provide the patients with their treatment on a regular basis. 

I got to see both of those programs, and I got access to their budgets. I told them we were thinking about a new study on antiretroviral therapy, and basically used their data as bottom-up analysis for what it would cost to deliver antiretroviral therapy to people throughout the continent, even in very remote areas.

Simultaneously in 2003, a group from WHO had published a paper in The Lancet on the interventions that could reduce transmission by 60%. From that group, I got the country-by-country list of what the reductions could be, and we used that to calculate our goals. 

President Bush was very clear on two things. One, this had to stay tight, because if it got out we would still be negotiating the terms of it today. Bush knew it would never pass if everyone had their mitts in it. Not in a negative way: we wanted the best expertise to contribute. But you would never get through the interagency process. 

The way the US government works, big, bold things cannot be done through an interagency process. They tend to get to the lowest common denominator.

The second thing was: don't come back and tell me how much money you want to spend. If you go back in the history of development and global health, if you asked anyone what you're doing on education, food security, global health, the answer would be “We're spending X billions of dollars.” No concrete goals. So Bush said, “Don't tell me how much it's going to cost, tell me what you're going to do, how you're going to do it, what your timelines are, and I'll find the money. Tell me how much it'll cost to achieve big goals.” 

We made some big assumptions. Looking back, it's astounding to me that we delivered on time, on budget, because we really didn't have a lot of data. There were some World Bank estimates on costs, based entirely on the product cost of antivirals, which were roughly $1,500 per person at the time. We assumed that generics were $300. And the rest of the costs would go to capacity building, based on very loose data.

We ultimately got data from Botswana to help verify, because they started rolling out antiretroviral therapy. But it really was a big gamble for the president. No one had ever done anything like this. I think we might have given the White House more confidence than was valid.

I was on a panel with Josh Bolten [the President’s deputy chief of staff for policy from 2001-2003, and later chief of staff] for PEPFAR’s 15th anniversary. Bolten was the angel of PEPFAR and really protected it throughout. The president was always there, but you need someone day-to-day making sure that bureaucracy moves in an interagency way. On that panel we were asked what surprised us most about PEPFAR. My answer was that it worked. And Josh looked at me like, what?

If I knew then what I know now about the US government, I wouldn't have thought it was possible either. A little naivete helped a lot. But there really wasn't a lot of data to back up what could happen. There was on-the-ground experience, and there was enormous trust and belief in the people of Africa. I think that's a huge thing that President Bush had. I didn’t see Bush get viscerally upset about much. He's pretty cool and calm. But when people started saying things like, “People in Africa couldn't do something as complicated as antiretroviral therapy,” he would blow a gasket. You know, these people are as smart, talented, creative, innovative, all they need is a little support and they can do it.

You mentioned the first antiretrovirals you encountered were being administered illegally. What was going on there? Why were they illegal in Uganda? 

Initially, Peter started treating people in 2000, before the International AIDS Conference in Durban. You had to register drugs and go through an approval process, and there was no regulatory approval for the products. 

People didn't understand antiretroviral therapy. There was concern about inequality: some people would get them, some people wouldn't. They were only generics. And there was a sense [among Africans] and still is appropriately, that we should not have second-class medicine. We should have first-class medicine. Why would we put second-class medicine into our own people? 

That tension persisted. I had massive fights when I was at PEPFAR because people said we should be using Nevirapine in low-income countries because it's cheaper. I'm like, “it's on our list of ‘do not use unless you have to,’” because we were already seeing terrible neuropathy in people. Why would we give drugs to Africans that we would never give to our own people? 

What’s neuropathy?

When some people would actually lose the ability to use their hands and feet. Neuropathy, which happens with chemotherapy and with antiretrovirals, affects the nerves, particularly in your hands, feet, legs. So there are people who literally couldn't walk from these products.

And we wanted to give them to Africans, when we could buy the drugs that we would use. It was incomprehensible to me. I understand the generic combinations with Faverin were a little more expensive. But the president told us he'd find us the money, let's do the right thing.

What did you learn doing trials out in the field in Africa, compared to NIH work?

An NIH setting is a very unique place to do clinical trials. The follow-up is extraordinary. Every patient comes for every visit. You take a ton of blood, you do a ton of analyses and it's small. You're not doing massive studies out on campus. We had a dozen people in each of the arms.

Joint Clinical Research Center in Uganda is basically a little NIH. They had nicer labs than I did on campus. Case Western and NIH had invested heavily in them. They could do gene sequencing, they could do anything. The study in the Center showed that people were very adherent: they came for their visits, they cared as much. We were worried about retention rates when you go from a clinical trial to the population. 

But what was most interesting to me was what was happening in the clinics, and in particular we went out by motorcycle to see people. I would go to villages with five huts, that was the village, and people in their homes were talking about their CD-4 cell count and their viral load. Their kids were telling their parents, “you have to take your drugs today.” The whole family was getting tested, and there was an education system. We just had to change our mindset.

But the capacity, the desire, the energy, the intelligence, the innovation were all there. You know, we look at the successes of PEPFAR or the Global Fund and think, “is it the anti-retroviral drugs?” Absolutely. But what really mattered was the creativity, the innovation and delivery science: figuring out how you would take something like this and have people take it every day.

The global health stance on this at the time is still appalling to me. People said silly things like they couldn't tell time, they didn't have watches, they didn't have the systems, they couldn't deliver the therapies, they couldn't get them out to the clinics.

A year after PEPFAR started, the World Bank held a meeting on how Africans were going to create massive drug resistance that will make the drugs ineffective for us. Literally there was a meeting with all the experts saying, “We need to stop all these programs getting antiretroviral therapy out.” Fortunately that effort died, but it was not an easy death. We now know Africans are as adherent as, if not more adherent than, people in the United States and Europe. 

When we announced PEPFAR, incredible numbers of leaders in the public health community, and in the US government, said, this is half baked, it will never work. Impossible fantasy. Africans can't do this. You're out of your mind. 

What was the dominant paradigm instead, if it wasn't antiretrovirals? 

Just do prevention. That was the public health message. The best we can do is provide them with some behavioral science, some condoms. There was also this subterranean conversation about how Africans are just promiscuous and there's nothing we can do about it. Just let them die, basically. These were actual conversations in public health meetings, we tend to forget that now. We want to wash over all of that. I don't think we should. It really was appalling. 

Tell me more about the process of coming up with cost estimates for PEPFAR.

So the only published numbers at the time were from a World Bank report, which estimated it would cost $1,500 per person, which led to the UN Secretary General's Commission saying it would cost $45 billion over five years to bring HIV completely under control with antiretroviral therapy and prevention mechanisms. That was a big deal. But when you went back and looked at the report, it was all based on a World Bank estimate of $1300-$1,500 per person for drugs. 

How did the World Bank come up with that number?

Well, the average price for non-generic antivirals at the time was $1300-1500. So they just took the price of the drugs. We looked at that and knew, that's not possible: we’d have to do more than buy the drugs. You're talking about chronic daily therapy. You could do vaccines: it's a one-time thing. You could do malaria: it's a couple pills. You could even do tuberculosis: it's four months. But daily therapy requires clinicians, clinics, logistics systems, supply chain systems, and cold storage. That entire infrastructure for chronic daily therapy for the rest of someone's life is what everyone looked at and said, that's just not going to work. 

Two things almost killed the program. One was someone telling the White House, late in the process, “Botswana's been doing this for two years and they only have 200 people on therapy.” Botswana, which is well structured and well resourced, is into it for two years, has spent hundreds of millions of dollars, and has just 200 people in therapy.

We said yeah, yeah: but they only have a population of a million, and it's a hockey stick. It takes a year and a half, two years to build that capacity. Once you have the capacity you can take off. We’d projected that the first year we would get – and this was just a back of a hand calculation by me, right – we thought we could only get to 5% of people who needed therapy the first year. 

The goal was to get to 50% of the people who needed therapy within five years, which at the time was 200 CD-4 cells and under. We planned to scale up as we built the clinics.

Where did your instinct that the program would have hockey stick-shaped results come from?

If you look at any health intervention — it doesn't matter what it is, if you start anything — it's a hockey stick, because you have to build the infrastructure.

Botswana confirmed that, and so did Uganda. It took them a good year to build the base, the infrastructure, to get the people, to get the supply chains, to get all that stuff set. Once you have that, you can scale.

Your early costs are fairly expensive. When we were getting PEPFAR reauthorized in 2008, we looked retrospectively at the costs, because everyone wanted to know. The first six months of therapy cost about $6,000 per person, because we were building all that structure. But then once that structure was built, after six months it started dropping, and at that time we could get it down to $600-1000 a month. Over time it's come down to $200-300 a month because the infrastructure's there. You're putting people into existing clinics with people, with supply chains, with things that have been built.

But we were calculating the infrastructure cost by not using just hospitals, which would've been much more expensive, but delivery into communities, which would be the only effective way to deliver it anyway. People couldn't go five hours to Kampala to get their drugs.

I'm putting this baldly, but why were you the first to present this? Other smart people were working on the problem. Why were you guys first on the scene?

So others were working on it in Malawi: Richard Harries had built a community system to do this, Botswana had done it, TASO had done it. We didn't come up with it. What we came up with is the instinct that this could be scaled, that it didn’t have to sit in these pilot projects. It was learning what others were doing, and using their cost estimates to build something bigger.

The reality is that every system, including the United States, is built around a spoke and wheel model. You have hospitals, and then you have clinics, and then you get down to health posts. That structure wasn’t very strong, but it was there. We just calculated, using the numbers from what Joint Clinical Research Center and TASO were doing. We used their cost numbers to say, given that it's roughly $50,000 to build one of these health posts, the nurses aren't that expensive. The supply chain system you can deliver by a variety of routes. If you send people out on motor scooters, it’s not that expensive. And on the drugs, we looked at that $1500 number and thought, well, if the drugs are actually only $300, based on these other sites, $1200 per person per year on average should be able to cover everything.

And that's how we got to $15 billion. We looked at where two thirds of the disease was. We didn't include Eswatini, although they absolutely fit the criteria, but they’d just received a massive Global Fund grant for $300 million. And we weren’t going to compete with the Global Fund. We wanted to be complementary to the Global Fund. Malawi and Zimbabwe, we gave them a lower number because they also had a big Global Fund grant. 

We made big sweeping assumptions, which is why it still astounds me that we hit the numbers.

We had to show results. We set six month targets. Miraculously we met them all on time and on budget, which is not a typical thing in the US government. But we had to show that or no one would believe it. And so we really focused on those numbers and really focused teams: “This is your goal. Now you have to build an enormous amount of infrastructure to get to those goals.” Those are what we would call cascade goals. If you're going to treat people, you have to do everything else to get to the treatment. That's that hockey stick for the first year, right? 

National scale-up was the big difference. You can run these pilot projects, but when you say you’re going to scale nationally it becomes very complicated, because a national structure required total trust in the people in the country. In some places governments are tricky, so there was a lot of non-governmental work going on. You need the governments for the policies, regulations, some of the supply chains, but you need the private sector, faith-based organizations, community-based organizations.

We funded heavily, that was the real trick. Seeing the vision for national scale-up and trusting governments. The whole thing was built around country ownership, country leadership. President Kagame actually told me, “This is the first time someone's respected us enough to hold us accountable.”

Because normally aid was more of a development, a post-colonial guilt thing, or geopolitical: “We wanna buy your goodwill.” This was all about supporting them and their vision. It was not easy to get the US government to say, “We trust you, we believe in you, we're going to give you the money, do it. You lead, you set the plans, we're there as your partners.”

It wasn't easy because, remember, no one knew about it. The countries who were selected with goals set for them were told the morning of the State of the Union address. You can imagine that contradiction. “This is about your leadership, but we've selected you and we're giving you goals.” It did not sit well, especially in some countries. We had to build that trust. They had to believe that it was real, because there are a lot of promises that they'd seen over and over again that were never achieved.

That's why reauthorization in 2008 was so important. President Bush talks about this in his book. There was a lot going on in 2008 in the administration. He was like, “why do we need to push this? The appropriators will continue.” I told him, “The Africans won't believe it will continue past you if Congress doesn't reauthorize for another five years.” 

PEPFAR is now up for reauthorization again. If we do not reauthorize, China and Russia will have a big diplomatic win in Africa, because they're not going to believe we're going to stay. 

You mentioned that PEPFAR would never have survived in an interagency process. Say more on that.

The interagency fights were blood on the floor. Hatchet work. It was the president that stopped all that. When you go meet people in the government one-on-one, they are the most dedicated, committed people. Most people don't go into government to fight over budgets, over turf. They go in and are not paid well and work their tails off because they want to make a difference, but the system doesn't give them much chance to make a difference. They get ground down and ultimately start fighting for budgets, protection, and turf. You get about 20% of people who are so jaded by the whole thing. 80% still wanna do something. If you don't offer the 80% something, the 20% win.

So the agencies, especially USAID, were furious at the mother and child initiative because it wasn't just handed to USAID, the Global Fund. The Global Fund executive director at the time, when he heard the State of the Union, thought all $15 billion was going to him, which we considered at one time.

Why was that option not chosen? 

The Global Fund at the time was a startup NGO. It had no infrastructure. It had no capacity to deliver grants. When I took it over 10 years later, it still had no capacity to deliver the grants. We had to build all of that. They were running it like a small NGO. Whereas the US government had people, had boots on the ground. We had teams, USAID, CDC, Department of Defense, which was very important at the beginning because the militaries were heavily affected.

And we had a grant-making mechanism that was a machine so we could move money. We had people, we could hire people in the country, which the Global Fund had no authority to do. And we had technical expertise, which the Global Fund was not allowed to have. So our view was, let the Global Fund lead where they have large grants like Eswatini, KwaZulu-Natal, Zimbabwe, Malawi. Let's let them grow. But we can't risk waiting for that infrastructure to catch up. And looking back, having run both organizations, Global Fund would absolutely have collapsed under its own weight. 

Because of this lack of infrastructure?

Yes. Total lack of infrastructure, of systems, of people. We actually proposed, in my last year at PEPFAR, that we begin a transition process to move our PEPFAR programs to the Global Fund. But the Global Fund people thought it was a game we were playing, I think. They thought we expected the Obama administration to come in and give all the money to them. So we were trying to forestall that, they thought, which was absurd. That was never going to happen. 

So actors in the federal government wanted to have more authority or power over the process. And you didn't think they'd be able to complete the mission?

Correct. We were absolutely insistent that it had to be cross-government. CDC has enormous expertise and they were actually doing programs in countries. Ultimately we studied the Central Command structure. During World War II, the Army, Navy, Marines, they didn't talk to each other in the same theater, which is why the US created the Central Command. Basically the same thing was happening with HIV. I would go to a village in Uganda where USAID and CDC both had prevention programs, neither of them knew that the other was in the village, and the US ambassador had no idea, because no one would tell the ambassador what they were doing. The local government had no idea what we were doing because we wouldn't tell them, which is absurd. 

Our view was, someone has to be in control of the money. If you don't control the money in a government, you don't control anything. “Coordinating,” if you don't control money, doesn't mean anything. So where would we put that? You can't put it in USAID, because then they’d never involve the other agencies. We knew that from past programs. You couldn't put it in HHS or DOD, because you're missing big pieces. So let's put it under the US ambassador at State. 

Say a little bit more on that. Why not HHS or DOD?

The infrastructure for USAID is much greater, especially for grant-making. They have a lot more people. HIV is not only a health issue, it's also a development issue. There's education, food, so they could wrap programs around all that. Their grant-making mechanisms were much stronger. HHS and CDCs engagement, especially up to that point, were much smaller. The Department of Defense had to be involved. The Peace Corps was involved, because we needed to get to kids at educational locations. 

But the money went to State, and that was hugely important, because State's not programmatic. State was never going to fight to run grants. In fact, they were appalled by the fact that they had ultimately $6 billion here in grant money. They were like, “What are we doing? This is not what the State Department does.”

But they were never going to try to dominate the programming and the granting. It was a perfect place to put the money. They also put it under the ambassador, which meant the ambassador was aware of everything happening in the country, which helped us enormously diplomatically. The ambassador's job was then to coordinate the agencies and submit a country operation plan every year. The ambassador then had a coordinator, who made the people in the country work together. 

We brought the entirety of the US government together, but that is not a natural course. The US government is not built that way. People fight for territory, they fight for money. You have different congressional committees with authority over each of those agencies, which was very complicated, because all of the money ran through the development part of Congress. Still to this day, they ask, “Why are we putting money into HHS when we don't have direct oversight over that?”

State was always fine. They were anxious about this massive program being run. But in the end, Colin Powell and Condi [Condoleeza Rice], you couldn't find a stronger supporter. But USAID was just apoplectic that the whole thing wasn't handed to them. HHS wanted their piece of the pie.

We gave them an amount of money, we gave them goals, and said, “Come back with a plan to achieve it.” So they were fighting in-country and in headquarters, with direction from headquarters to fight for a bigger piece of the pie.

We would bring people to testify to the health committees. We didn't really have to testify to the defense committees. But they all wanted to do their own thing. I had shouting matches with four star generals and admirals, because they thought they controlled the money.

I was like, “No, you don't. I control the money. You can't just take the money and do what you want with it. It has to contribute to the overall vision.” But everyone fights over it. President Bush was acutely aware of this. The fighting continued for a while, even after the first global AIDS coordinator was named, and it was becoming problematic in countries.

So we would come together as deputy principals, the career people who ran the bureaus, and we would go country by country where there was a problem and give a uniform message of, “If you don't knock this stuff off, if you don't start working together, you're all outta here. We will fire you.” And we ended up firing a couple of very senior people because they weren't playing ball. 

Did you have to go up the chain to get interagency conflict resolved?

So the president called a group into the Oval, probably six months in. It was Secretary Powell, the Secretary of State, the Secretary of Health and Human Services, the head of USAID at the time, Andrew Natsios who was Deputy Secretary of State level, Andy Card, who was chief of staff, and Randy Tobias, who was the first coordinator who was an assistant secretary level, not even by name. By far the lowest ranking person in the room. 

The president’s sitting to the right of the fireplace. The most senior person sits next to the president. He put the assistant secretary, Randy Tobias, in that chair. He had the secretaries and deputy secretaries sitting on a couch, and said, “This is my guy for HIV. You will do what he says to do, or I will be coming after you. And Andy Card sitting over there is going to follow this. And he's going to tell me if you guys aren't doing what needs to be done, and Randy's going to tell me if you guys aren't telling me what needs to be done.”

The fighting dropped off remarkably. Andy Card and Andrew Natsios were friends from Boston, I think. Andy Card, he never told me this, pulled him aside and said, “He's not kidding. You're outta here if you don't do this.” And the level of infighting dropped tremendously. What that told the entire infrastructure was that an assistant secretary had direct access to the president of the United States.

That's not a card you can pull very often. I probably used it three, four times. But everyone knew you could. And that presidential leadership was the only reason this all worked. 

When you say you used it three or four times, that's three or four times where you said, explicitly, “I can go upstairs to the president”?

No, I actually went upstairs and said, “There's a problem here. We need your help to make this work.” And they did every time. Josh Bolten was the intermediary. Whether he was in the White House at the Office of Management and Budget, or then back as Chief of Staff, he was always, with one of his deputies, my route to get to the president. But every time I did, what needed to happen happened. 

So when you say Bolten protected PEPFAR or was the angel of PEPFAR, that calling in of political support is what you're describing?

Yep. And paying attention. It wasn't just calling it in. The President would message over and over again. He would give speeches on completely different topics, and just go off script and start talking about PEPFAR. He did a World AIDS event every year. He always did something else at every G-7 (G-8 at the time), at every international setting. Whenever he met with an African head of state, I got to sit in as an assistant secretary, with major people not there, to message that “this one's important to me.” They would talk about HIV for like two minutes.

So they were responsive, but also very proactive at every opportunity to let the bureaucracy know this was a priority for the president. If you don’t have that kind of direction when you're doing something new and big, it will not work. When PEPFAR was announced, we counted about 80 presidential initiatives. The president probably knew about three of them. Presidential initiatives mean nothing by themselves, even if they're announced in the State of the Union address. But this one they knew was actually the president.

You know, I was a career person who ended up in a political job. But I was so enamored of the fact that he did this, that I wanted to get him as much credit as possible. Whenever we tried, he was like, stop it. It has nothing to do with me. If this is “President Bush's,” it's dead. It's “the president.” It's gotta carry on into the next administration. And following presidents did pick it up. President Biden mentioned the reauthorization at the State of the Union. It was the only bipartisan standing ovation that happened, I think.

Obviously PEPFAR's been a bipartisan success story. How did you make sure you had the legislative branch on board and fully signed on? 

I wish everyone coming into these political appointee agency jobs understood that we are blessed by having some of the most dedicated, talented people on congressional staff, the committees that we dealt with in particular, but I'm sure it's the case across many. They're really smart. Some of them have been doing it for 35 or 40 years. They know more about what's happening in the US government than most people in the executive branch. What they want is information. They want to understand what's happening, not to be lied to, not to be told that everything's fine when they know it's not.

It took a lot of effort to explain what we were trying to do. We met with them always on a bipartisan basis. The Republicans were in big majorities in both House and Senate. But we always met with the Democrats too, because they also had to be brought up to speed. We spent an enormous amount of time telling them everything that was happening, where we were having challenges, what we were trying to do to solve them and what our plan was. They trusted us because we weren't lying to them. The really smart people who have been there for 45 years said, “Look, I don't necessarily agree with what you're doing to solve that problem, but you're telling me, so you have the latitude to come back to me in six months and tell me what happened.”

The way that played out was when Democrats came back in, they said, “You literally are the only person who came and talked to us for the last two years,” or the last four years. They trusted us too.

Is that kind of trust rare?

There's this bizarre sense in the executive branch to not tell Congress things. Senior people at USAID told me, “Don't give them information because they'll just want more.” I'm like, do you have no idea what you're talking about? They make the laws, that's why you're earmarked. We didn't have a single earmark from Congress, not a single one.

Because while AID was earmarked beyond their budget, they knew what was happening because we told them everything. In fact, a couple of them started saying, “You're giving me too much information. I've got too many things going on.” The Senate, after the first year, never had an appropriations hearing. They're like, you're already giving me more information than I'm going to get out of a hearing. I don't need any more information from you. I need to focus on people who aren't giving the information. 

Always be bipartisan. because eventually someone's going to come back. Spend a lot of time with them so that they trust you, and you trust each other's people, and tell them the truth. Give them the information. Don't try to hide and say everything's fine. If you do that, you build trust and bipartisanship.

Don't focus on results: focus on what they're getting for their money. You can sell almost anything. In the 2008 reauthorization, Mike Pence, who's a social conservative and a fiscal conservative, stood on the floor and said, “look at the stuff we vote on all the time. How many times are we able to vote for something, which we know, because the data are there, that we're saving millions of lives for a relatively small amount of money. We can find $15 billion somewhere else. Not here.” That’s because we focused on how much money was spent, and on what results we were delivering, and the diplomatic benefit to that. That's a pretty powerful package, which is why bipartisanship on PEPFAR has remained pretty stable for 20 years. 

Where does USAID’s instinct towards secrecy come from? Is that shared across departments generally or is something going on at USAID? 

It's not unique to USAID. It's the US government. “We're the executive branch. They make the laws, we implement them. You’re going to give us the money.” Some of it is turf war. I was assistant secretary level. I would meet with staff all the time. I would get called by other assistant secretaries who would tell me to stop meeting with staff. For ego reasons, power, whatever. 

You've mentioned your surprise at managing to kind of hit targets with the budget you had. What did the implementation look like? 

There was a lot of external pressure. Water matters, other things matter, food of course matters. But we had very specific goals and we have to get to them. We relied on faith-based organizations, community organizations, and the orphan program to do those other things. We only set 15-20 goals, I can't remember, but there were five or six you had to report on every six months. That kept everyone laser focused. We would review them country by country, and then globally. Everyone knew that if you're not meeting your goals, we were going to shift the money into a country that is.

So focus on getting those goals, and if there's a resource issue, tell us what it is, we'll figure it out. We created a structure of country team backup teams at headquarters. We had teams in the countries. We gave them full authority to come back with a plan to achieve their goals that they worked on with the government.

Everything I described to you in the US government, we had to do in all the local governments to get them on board from a cross-sectoral perspective, from the head of state buying into the ministries, down into the communities. It was a massive undertaking to do all that. 

But we stayed focused on goals, which was revolutionary for the US government and development in general, which focused on “How much money are you spending?” We included all sectors. To the Europeans, talking to the private sector was anathema, and the private sector actually had a big role in a lot of pieces. Some governments created quasi-supply chains, because they knew the government couldn't manage the supply chain, and we also engaged faith- and community-based organizations.

If you wanted to get people in communities to not think antiretrovirals were killing you, rather than saving you and not going to their traditional healer first, or listening to the traditional healer saying that's the devil's medicine, you had to get into the community. It was a massive effort really to get countrywide. But it was a focus on the goals. It's not “go do whatever you want.” It's, “this is what we have to achieve. The rest we will get to, but we have to achieve these.”

You talked about different institutions having grant-making capacity, and having stronger or weaker grant-making mechanisms. What goes into grant-making capacity?

Moving money is not an easy thing. And there are a lot of guardrails around it. Misuse of funds, as you know, happens in the United States. We're going through this with Covid money. With Medicare, Medicaid, it happens everywhere. You have to have guardrails, and that's why we have country teams.

But it's actually a contracting process. You're issuing a grant that’s 50, 70 pages long. Then there are subcontracts on that, which the US government does not manage, and it's against certain targets and goals that you have to monitor. You can't just dump a bunch of money somewhere and walk away. You need teams to do all that.

You actually have to write grants, follow them, report on them. The Global Fund had none of those structures, nor did they have any in-country presence by design, nor did they have any technical expertise by design. That's why we couldn't just give the money to the Global Fund. 

That's why we massively built up the in-country footprint and presence. The vast majority of that buildup was nationals. There'd be US government personnel there, foreign service officers and USAID and CDC experts, but the vast majority of the infrastructure was actually local nationals, foreign to us, and their governments. 

How do you take ideas and make them policy? There aren't many people who can do that. A lot of people are good at ideas, and a bunch of people are good at implementation, but putting those together doesn't happen a lot. And that's what statecraft is: seeing all the pieces and all the players, not just your slice.

And I would end with, and this is my biggest concern: I've now run two massive global organizations. I could name on two hands the number of people with a global mindset. Everyone gets very local into their little specific world very quickly, unless you talk to young people.

---

To read more about the implementation of PEPFAR, see the George W. Bush Presidential Center’s “Report Series on Lessons Learned from PEPFAR’s Success.”