The most popular living US president in Africa is not Barack Obama, whose election in 2008 prompted Kenya, the east African country where his father was born, to declare a national holiday. Nor was it Bill Clinton, despite the strong support he enjoyed from the African-American community and his rhetorical clasping of the continent. By some margin, the US president most respected in Africa is one George W Bush.
The main reason for Mr Bush’s enduring popularity is a health initiative he personally championed with the unpromising acronym of Pepfar. The President’s Emergency Plan for Aids Relief, one of the biggest global health initiatives in history, eclipsed anything that either presidents Obama or Clinton achieved in Africa. For Mr Bush, it has polished a legacy tarnished by misjudged adventures in the Middle East.
Begun in 2003 and covering some 50 countries, Pepfar has saved the lives of an estimated 13m people living with HIV-Aids, mostly in Africa, by providing them with antiretroviral drugs. The scheme, which has cost $80bn to date, has also prevented some 2.2m children from being infected through mother-to-child transmission. As Mr Bush himself has said, as well as being morally the right thing to do, it has won the US friends across the continent.
“The president who stood up and said ‘I am going to do this’ was Bush,” Joyce Banda, a former president of Malawi, told me last week in what is a familiar show of gratitude. “Because of Pepfar, Bush is my best president.”
Unlike some development assistance, Pepfar has the virtue of having demonstrably worked. Today, there are some 37m people living with HIV, the virus that causes Aids. That is more than at any time since the epidemic began for the simple reason that 23.3m people, many of them beneficiaries of Pepfar, are on the antiretroviral drugs that can suppress the virus indefinitely.
Infection rates, while still high, have dropped sharply. The HIV infection rate in Kenya, the most affected country in east Africa, has fallen from 14 per cent at the time Pepfar began to about 5 per cent today. Life expectancy around the continent, which dipped severely at the start of the Aids epidemic, has bounced back strongly. So have economies once threatened with the devastation of losing large swaths of their working population. Six of the fastest-growing economies in the world last year were African.
To understand the impact of Mr Bush’s scheme one has to go back to the early 2000s, when the global Aids epidemic was exploding. In Africa, some 20m people were infected, of whom an estimated 11,000 were receiving the cocktail of antiretroviral drugs whose impact was so dramatic in clawing people back from death it was called the “Lazarus effect”. Unfortunately, the miracle came with a price tag of about $20,000 a year. Even when drug companies came under legal and moral pressure to slash prices, the medicine remained out of reach for the vast majority of Africans. HIV remained a death sentence.
This is where Mr Bush, encouraged by his wife Laura, came in. The president had heard that a single dose of a drug called Nevirapine could prevent mother-to-child transmission through breast-feeding.
According to an account in the Dallas Morning News, he asked Dr Anthony Fauci, an Aids specialist at the National Institutes of Health, to come up with a funding plan. Dr Fauci laid out an initiative that would have cost $500m. Mr Bush asked him what it would take to do something truly transformative. In his 2003 State of the Union address, the president asked Congress to commit $15bn over five years to fight the epidemic. Pepfar was born.
Today, two things threaten the progress that has been made. One is complacency. After 30 years of the epidemic, it is tempting to declare victory prematurely. But untreated, HIV will bounce back, not only in Africa but in the rest of the world. Second is funding for Pepfar itself. President Obama was the first to propose cutting the budget. Donald Trump has urged cuts of around 20 per cent. So far, Congress has said no.
The idea of aid is under attack, even in Africa itself. In the US, many support a cut in foreign aid which, at 0.18 per cent of gross domestic product, is already near the bottom of the league table of contributions by developed countries.
In a 2016 speech, perhaps the nearest Mr Bush came to a “we choose to go to the moon” moment, he addressed the question head on. “I believe,” he said, “that spending less than two-tenths of 1 per cent of our federal budget to save millions of lives is [in] the moral, the practical and the national security interests of the United States.”
Millions of people with HIV who are living full and productive lives would agree.