The Age of Aids [home page]

interview: randall tobias

[photo of Randall Tobias]

Having spent his career in the corporate world, including six years as the chairman and CEO of Eli Lilly and Company, Ambassador Randall Tobias had little personal experience with AIDS until 2003, when President George W. Bush asked him to be the first U.S. global AIDS coordinator, charged with distributing the $15 billion allocated to the President's Emergency Program for AIDS Relief (PEPFAR). He now calls AIDS "the greatest threat to the world today." Here he addresses the many criticisms of PEPFAR, including that it is too ideological; that it only targets 15 countries out of the many that need help; that the money should have been given to the Global Fund rather than a new funding mechanism; that it's too focused on abstinence; that restrictions against giving money to organizations helping sex workers are impractical; and that some of the organizations that have received money haven't been closely scrutinized. Tobias compares the President's Emergency Plan to a fire department putting out a fire: "This particular program was not intended to be the end game for addressing HIV/AIDS in the world, and clearly the United States government and governments around the world and the people in the host countries themselves all really need increasingly to come together around understanding on a country-by-country basis what has to be done for the longer term." This is an edited transcript of an interview conducted on March 18, 2005. In March 2006, Tobias was sworn in as administrator of the U.S. Agency for International Development (USAID); he continues to serve as the U.S. global AIDS coordinator as well.

How did you first personally encounter HIV/AIDS? Did you have a personal experience that sticks in your mind?

No, I really didn't. I had spent 35 years in the corporate world, thought I was finished running things. One day the phone rang, and it was the White House saying: "Your name's on the radar screen for something that's very important to the president. Would you be willing to come in and talk about it?" This is not what I had planned to do at this stage in my life. But I think anybody who gets involved in and touches this begins to understand that it is the most compelling issue that, I think, exists in the world today, and probably the greatest threat to the world today. So it's been a real privilege to get involved.

But this is something that you came to understand only after you got called?

That's right. I had been in the pharmaceutical business for some years, and so I was certainly aware of the disease here in the United States, but I really didn't understand the impact globally, nor did I understand the changing nature of the population that it is affecting. So it's mostly happened since I've been in this job.

It's something that's been quite a journey for you personally then?

It has been, but I think that's probably mostly good, because the skills that I brought to this came from other areas. It may be that people who have been dealing with this disease for 10, 15, 20 years have been beaten down a lot. They've seen a lot of discouragement. I don't yet know why we can't do some of the things that we need to do.

And this call from the White House, did that come after the president's State of the Union speech?

Yes. The president made the State of the Union speech in January of 2003 announcing his Emergency Plan [PEPFAR, the President's Emergency Plan for AIDS Relief]. I think I was called in February of 2003. We had a number of discussions over the next couple of months. Then the legislation was signed in May of 2003, and the president announced on July 2, 2003, in a ceremony in the White House that he was nominating me to be the first U.S. global AIDS coordinator. I essentially came to Washington that day, was confirmed by the Senate in October, and we've been moving forward ever since.

And there's a lot of money on the table. What is the program?

The program is $15 billion over five years focused on prevention, treatment and care. The money goes in several directions, but a large amount of the money -- almost $10 billion of the $15 billion -- will be spent in 15 countries: 12 in Africa, two in the Caribbean and one in Asia. Those 15 countries together account for about 50 percent of the infections in the world.

We know that the seeds of unrest and terrorism in the world really come about where there's hopelessness. HIV/AIDS exists in places where hope is in very short supply.

President Bush's concept was -- and it was something I was very comfortable with when it was first described to me -- that if we focus our resources on a relatively small number of countries and really try to make a difference, by focusing on a limited set of activities in those countries, we can really get something done, and we can demonstrate how those same kinds of activities can be transported to other parts of the world.

We do have programs in about 100 countries, including those 15, and we're spending significant resources in some of the larger countries. But our initial focus has been in getting the programs up and going in these 15 countries.

So why those 15, of which only two are the so-called next-wave countries? What about India or China or Russia?

Well, India and China and Russia are all countries where we have activities going on, but all three of those countries are countries that have a fairly high level of capability of helping themselves. In fact, I would argue that historically, meaning going back the last three or four or five years, those countries were probably late in addressing their own needs. China is doing a lot more. India's doing a lot more. I think Russia has a long way to go.

But the particular countries that were chosen were chosen based on a number of criteria, all boiling down to the fact that these were places where there's really an opportunity to make a difference. Either the leadership of the country is willing and engaged, or there are partners with whom we can work on the ground, or various criteria like that.

You said, if I heard you correctly, that you think [AIDS is] the biggest threat to the world today. That's quite a statement.

I do think it's the biggest threat to the world today on a number of dimensions. Purely in humanitarian terms, there are 8,000 people that die every day. I keep trying to find ways to communicate that. The most effective [way] I found is to get people to imagine what the reaction would be if they woke up in the morning and read the headlines on the morning paper that 20 Boeing 747s had disappeared the preceding day, losing all the passengers, and then they got up the next day and read it had happened again, because that's exactly what's happening every single day.

But when you begin then to look behind those numbers -- and, by the way, it's important, I think, in looking at those numbers to understand that every one of those 8,000 people has a name; they have a personality; they have a family. They're not just statistics; we're talking about real people here. But you begin to get behind the numbers, and you can already see where the global economy is being impacted by the debilitating aspects of AIDS in the countries where it is impacted most. Think about trying to run a company where maybe 30 percent of your employees disappeared every year, and you had to constantly be retraining people, and absenteeism was high and all those kinds of things.

And then we know that the seeds of unrest and terrorism in the world really come about where there's hopelessness. HIV/AIDS exists in places where hope is in very short supply. So the president feels that that is a lot of what this is all about. With the president, it starts really with the humanitarian motivation of this: This is an enormous problem facing the world. The American people have the economic wherewithal and the technical wherewithal to help with this, and we have an obligation; we ought to be doing it. And I think for the president, that's good enough. But when you go beyond that, you see the enormous impact to our national security and our economic well-being, and it's truly going to destroy the world as we know it today if we don't address it.

What kind of language does he use when he talks about this?

You know, I wouldn't be here today were it not for a private conversation I had with the president in the Oval Office when I was approached about whether I'd be interested in being considered for this job. It was clear to me that it came really from his heart. It really comes from having become aware of the devastation that this is striking in Africa in particular, and understanding that in human terms. That's really the part of this that he talks about the most.

How did he become aware? I mean, it wasn't discussed in the 2000 campaign. It sort of seemed to come once he was in office. What happened? Do you know?

I don't know exactly. I don't think the president knows exactly how he came to this. Colin Powell, former secretary of state, was very interested and aware of the issue. I know he talked to the president. Tommy Thompson, former secretary of health and human services, made a trip to Africa and came back very disturbed about what he saw.

But I think much of this the president simply came to himself, by reading about it and learning about it in various conversations. And when the president announced to the people around him, in the hours before his State of the Union announcement in 2003, that he was going to commit $15 billion -- Colin Powell once told me that when he heard that number he about fell out of his chair. This was the president's number. This is the president's program. And he feels very, very passionately about the importance of what we're doing.

It's a huge program to start. I mean, there were AIDS programs within the U.S. government, but really, you're starting a new organization. Where do you begin?

It was a daunting task. When I arrived in Washington, literally the first thing I needed to do was to find out where was the building where I was going to have a temporary office, and what do I need to do to go through security and get a pass to get in the building. I mean, it was that basic. There were a very small number of people who had worked on helping the president design the program. There was essentially one binder that existed that had the concepts in it. There was a lot of information in a number of people's heads, but when I asked to see the concept of what the organization might look like, for example, I was given one sheet of paper that literally was kind of hand-drawn and very representational.

The strategy needed to be put together. The vision was very clear, and one of the best things about the beginnings of this was that the president made very clear to me that the goals were to get 2 million people under treatment in five years, to avert 7 million infections that otherwise might take place, and to get 10 million people under care. Those were the orphans and the children who had been made vulnerable by all of this. That's principally what we've been focused on, delivering on those end objectives. The details of exactly how we needed to do that were largely yet to be worked out.

So what did you do?

Well, we took the thoughts and the concepts that people had, and I immediately enlisted the United States ambassadors to each of the focus countries, got them together and in effect said, "I have a new job, and you do, too." They've been very supportive and very helpful in pulling together in each of their countries an interagency team of people from the State Department, Health and Human Services, the Centers for Disease Control, the Department of Defense, the Peace Corps, the Department of Commerce and others, all together in an integrated team. I've asked them all to leave their uniforms at the door, to think about these things not as agency programs but as United States government programs under the President's Emergency Plan.

In the meantime here in Washington, we began to pull people together who had expertise on the subject and who had been involved in helping to create the program, and we began to build a strategy. In the early part of 2004, we released a fairly comprehensive strategy that took prevention, treatment, care and the objectives that we had set out and described strategically what [it is] that we're going to try to get done here. We then began to work with the teams in each country as to how they felt that they needed to implement that strategy on the ground.

In the meantime, to get this jump-started, we began to engage in something that I often refer to as "Ready, fire, aim," and that is we began to identify organizations, non-governmental organizations [NGOs] already on the ground in these countries that had a proven track record, that looked like they had the potential to begin to scale up quickly.

So the idea was how quickly can we get money out the door and begin to scale up the existing programs while in parallel we began to do this in a little more sophisticated way. Congress appropriated the first funds in January, late January of 2004. By the end of February, we had moved the first $365 million in the direction of the organizations that we had identified, and by the middle of the year we had authorized a total of $865 million, which was really the first money that was available for the focus countries. In the meantime, we've now put together in each of the focus countries a specific five-year strategy so that when you add all those five-year strategies together, they total what we want to accomplish in the overall strategy.

Then each country team each year comes in with a country operating plan for the next year that lays out the specific programs they want to fund, what the goals are for those programs, who's going to carry out those programs, the ways in which we're going to measure are we doing what we said we were going to do, and are we accomplishing what we intended to? It's been in many cases two steps forward and one step back as you get something this complicated started, but I'm really, really pleased with the progress and really proud of the people who have taken us to this point.

You've taken some heat for allocating funds to some of the faith-based organizations. Some people say the program is too ideologically based. What's your what's your reaction to that?

If the president had said to me, "I want you to implement this program, but you can't use any faith-based organizations," as soon as I figured out what was going on, I would have had to go back to the president and say, "You can't do this if you don't used faith-based organizations." In Ethiopia, the patriarch of the Ethiopian Orthodox Church told me -- and it's very true -- that you can go places in Ethiopia where there's no police, there are no roads there, there's no water, there's no sanitation, but the Ethiopian Orthodox Church is there.

You go in all of the countries where we work, all over the world, and in many cases they're faith-based organizations. In terms of faith-based organizations, we're talking about large international organizations, we're talking about U.S. organizations, but most particularly we're talking about local congregations. We're talking about local mosques and synagogues and churches that are really the heart and soul of local communities. They're really the backbone in many cases of the way in which we're implementing our work.

[Why is there so much money going to U.S.-based faith-based groups?]

Well, again, many of the U.S. faith-based groups were the early responders. They're the people who were on the ground. They're the people who in many cases have gone places that nobody else wants to go. And these are organizations that are really essential to implementing this program.

What about the emphasis on abstinence and behavior change?

Well, the heart of our prevention programs is what's known as ABC: abstinence, be faithful, and the correct and consistent use of condoms when appropriate. This is not an American invention; this is something that President [Yoweri] Museveni in Uganda figured out over time when he recognized that there was an enormous problem in Uganda.

And it's also not "ABC: Take your pick." It's abstinence really focused heavily on young people and getting them to understand that the best way to keep from getting infected is to be abstinent and not engage in sexual activity until they are old enough and mature enough and get into a committed relationship, such as a marriage. B is being faithful within that committed relationship. And A and B, those two things together clearly had a huge impact in bringing the infection rates down in Uganda.

C recognizes the fact that there are individuals in high-risk circumstances who either by choice or by coercion are going to find themselves unable to follow A and B, and therefore they need to have access to condoms, and they need to understand the correct and consistent use of condoms. I think more and more of the experts, the people who really understand the prevention requirements with HIV/AIDS, have come to endorse ABC in a very balanced way as the appropriate prevention centerpiece.

But I would also add that as important as ABC is, the fact is that this is a disease where 50 percent of the people infected in the world are women. When I cite those numbers to people here in the United States, I find most people are astonished. They just have no idea about that. In some countries in Africa, it's well above 50 percent that are women and girls. In many cases this is driven by cultural factors, where young girls are having sex with older men and [are] coerced to do that, where women aren't regarded as equal citizens with men. So there are lots of things that need to be done addressing those kinds of cultural issues also.

When I interviewed [Samaritan's Purse President] on this, he was concerned that too much money was actually going to governments that might waste the money and not enough to efficient NGOs, including faith-based organizations. … What's your response to that?

Well, the president made very clear to me up front, and it's very consistent with my own feeling, that this needs to be a program of accountability. We need to put money in places where results are produced, and we need to have controls in place to be sure that is the case.

A very large part of the money that we are spending is being spent through non-government[al] organizations. At the same time, we need to work very consistently with host governments. We need to be sure what we're doing is driven by the strategy of the host governments where we're working. But the non-governmental organizations are essential, and 80 percent of the non-governmental organizations that we are working with are in fact indigenous organizations that are local to the country where we're working

Why have a separate U.S. program? Why not just allocate this money and give it to the Global Fund [To Fight AIDS, Tuberculosis and Malaria]?

Well, this is an emergency, and I think we're able in the kind of program that we're putting together to move much more quickly than a more complex multilateral organization could probably move.

At the same time, the Global Fund is a very important part of our overall strategy. Actually, the money that the United States government gives to the Global Fund [is] about a third of the Global Fund's total funding. We are by far the largest supporter of the Global Fund. That money flows out of the President's Emergency Plan. We are working closely with the Global Fund, with UNAIDS [Joint United Nations Programme on HIV/AIDS], with the World Health Organization and others to ensure that we're finding better ways to coordinate all of our efforts on the ground so that we're all working behind something we have adopted called the Three Ones, which is that every country ought to have a single strategy. Every country ought to have a single coordinating mechanism within that country, driven and supported by the government, but also with the civil society and donors and others that are working there all working together. There ought to be a single monitoring and evaluation system so that we're all gathering data at one time and we're not using up a lot of resources by duplicating each other's efforts. But I think bilateral programs -- and particularly in the case of what we're doing in the President's Emergency Plan -- can really move much more efficiently and much more quickly.

Do you think you're more efficient than the Global Fund?

The Global Fund has a different role. The Global Fund is fundamentally a financial organization that plays the role of advocacy, and they've done a wonderful job of drawing attention to HIV/AIDS and then drawing donations from the rest of the world's donor governments and from other donors and making that money available. But they're not in the programmatic implementation business, and that's a very key part of what we're doing in the President's Emergency Plan -- is the actual, on-the-ground implementation of the programs that we're also funding. …

When you go to some hospitals or talk to people with AIDS or health practitioners in the developing world, or in Ethiopia, where we were, there's a lot of talk [about] "We hear about all this money and there's free drugs coming. Where are they?" The expectations are very high, and they're not seeing the results yet. Why is that?

Well, I think a lot of people are seeing the results. When the president announced the launch of the Emergency Plan, the UNAIDS organization had estimated a month or so before that probably not more than 50,000 people in all of sub-Saharan Africa were receiving antiretroviral drugs. By the time of our first annual report, which was at the end of the 2004 fiscal year, we were providing support for three times that number already and had just been up and going for about eight months.

Now, are we reaching everybody? Are we seeing the light at the end of the tunnel? Absolutely not. But we are beginning to make a dent. So I have no doubt that there are lots of people in need that aren't yet seeing this, because after all, our five-year goal is to get 2 million people on treatment. But we clearly are making good progress, and I think probably moving much more quickly than people thought was possible.

We went to a hospital that has PEPFAR drugs in the eastern part of the country in Ethiopia, but right next to it in the storeroom were Global Fund drugs -- some generics, some brand name, very confusing. Is it going to work, having these two large programs running side by side?

Of course. Would you want to go to a doctor who had only one drug that they prescribed? Different patients need different combinations of drugs, so the mere existence of multiple forms of treatment I don't think is unusual. But beyond that we have taken the view, in the President's Emergency Plan, that there should not be two standards of drug safety in the world. There shouldn't be a standard of good here in the United States and good enough for the developing world.

There are a lot of very capable pharmaceutical companies around the world who can and are addressing this need. We've put in place an accelerated approval program, and there are intellectual property agreements that have been reached internationally, so that bottom line, any company in any country anywhere in the world that wants to supply drugs and have them eligible for funding in the President's Emergency Plan has merely to apply to the Food and Drug Administration and get those drugs certified as meeting our standards, and that has begun to happen. I think we're going to see over time that the bigger problem is going to be the capability of the pharmaceutical industry globally to meet the demand for the drugs that are going to be needed as we begin to scale up our treatment programs.

You talk about dealing with these people in treatment. This program and the Global Fund as well are limited programs, just in terms of the time. What happens after that? I mean, this treatment is a long-term commitment.

I think it was not accidental that President Bush named this the Emergency Plan. It really is addressing in a very emergency way, in the same way a fire department might respond when there's a fire burning, to what can we do quickly to begin to address this problem. This particular program was not intended to be the end game for addressing HIV/AIDS in the world, and clearly the United States government and governments around the world and the people in the host countries themselves all really need increasingly to come together around understanding on a country-by-country basis what has to be done for the longer term.

We need to get the rest of the world to step up in the way the United States has. In 2004, for example, the year for which we have the most recent data, the United States government spent more than twice as much -- twice as much -- as the total of all the rest of the world's governments combined. The United States can't do this and shouldn't do this alone. We've got to get the whole world community to step up, not only financially, but then working together on the ground in every country that needs help to figure out the best long-term solution.

Clearly prevention is the long-term answer, and we know how to prevent the spread of this disease. Treatment is extremely important, not only to take care of the people who are already infected, but to signal to people who don't know their status that they need to get tested. They need to understand if they're negative how to prevent the spread of the disease, and if they're positive they need to be sure they're not spreading it to other people, and under care and treatment they can live a productive life going forward. But we've got to find ways to prevent the spread of the disease. That's really the long-term answer.

But if the U.S. government gets somebody on treatment via the PEPFAR program, does the U.S. government have a moral responsibility to make sure that individual person keeps getting treatment beyond the life of this emergency program?

I think we have to have our eyes open in entering this program that by putting people on treatment, you have to keep them on treatment the rest of their lives. Now, whether or not the United States government is going to be the sole source of the funding for the people that we've started on treatment is something yet to be determined going forward.

Sustainability of this program is a key principle. We've got to train local people while at the same time we're engaged in a lot of other actives that may not seem HIV/AIDS-related but really are. The more open the economies can become in these countries, the more that we can create an environment where people are employed, where people are getting educated, where young people are staying in school. Those are all things that are going to impact the environment that will help address solutions to this issue.

I saw a picture on your wall when you were speaking at [the International AIDS Conference in] Bangkok last year, and everyone's holding up signs saying, "He's lying." What's that about?

It's a funny thing about this disease and the people who have been the so-called activists or advocates. I think they've been beaten around so much over the last 20 years that they've concluded, or some of them at least have, that the only way they're going to get attention is to yell and scream and act in ways that my mother would not have thought were very polite. I've tried to reach out to those people, to listen to what they have had to say, and I've learned a lot from them.

But at the same time, I think they need to understand that all of our energy needs to go toward the real enemy, which is stigma, denial, lack of adequate resources, and we need to stop spending so much energy fighting with each other. So that photograph is kind of symbolic of what I hope was a turning point in the battle and a point when maybe all of us can be more civil toward each other and put our energies in more productive ways. I think that's beginning to happen.

But was it a surprise to you to get that kind of reaction, that kind of skepticism about you, I suppose?

No. This International AIDS Conference sort of evolved from being a scientific conference to really being a politically oriented and media-focused kind of event. And Secretary Thompson had had similar treatment four years prior. So no, I wasn't surprised. By the same token, I thought I had something to say and had a right to say it and so stood there until I was given the opportunity to say it.

Do you find there's a lot of skepticism about U.S. motives when you travel?

I think people tend to mix up their feelings about what the United States is doing, and President Bush in particular is doing, about HIV/AIDS with the way they may feel about other things. But I think people all over the world have begun to come to recognize the enormous leadership role that the President's Emergency Plan is playing in fighting HIV/AIDS, and I think people are coming around to being less skeptical about the motives and more understanding and supportive of what we genuinely are trying to do.

You mentioned that a lot of the AIDS activists had been kind of ignored for a couple of decades. Why was the international community so late in putting this kind of money on the table?

It's a very complex issue. There are lots of reasons. I think for one thing, it was taking place and this disease was growing in magnitude in places in the world that are not automatically on the news every night or in the newspapers every day, and so people in the developed world, and broad populations in the developed world I think, just weren't aware of the magnitude of the problem. And so there was not a sort of a groundswell of public outcry about the need to do this. …

Just briefly on the funding, are you getting the funding that you need? I know there's belt-tightening all around town here. Is that affecting you?

At the same time that there has been belt-tightening on the federal budget in general, the president has requested -- and I'm very confident that the Congress will appropriate -- a significant increase in our budget for the next fiscal year. The Congress appropriated $2.4 billion in the first year, $2.8 billion in the second year. We've requested and I anticipate getting $3.2 billion in the third year, and then it will be somewhat higher than that in the fourth and fifth years to total the $15 billion.

This is a program that the president has led, but he's had strong bipartisan support on both sides of the aisle in both the House and the Senate. I've been very grateful for the proud base of political support. I think a lot of people have found that this is an issue that's not a Republican issue or a Democrat issue; it's not a conservative or a liberal issue. It's an issue that all of us need to come together around, and that's really happening.

… In the effort to get this money out there quickly, how closely are [the recipients] scrutinized, and does a group have to have specific HIV/AIDS experience to get funding?

The groups that are getting money have been very closely scrutinized, and not all of them do have specific HIV/AIDS experience, but there are aspects of what they bring to the table that are deliverable with respect to what we're trying to do now. For example, there may be groups who have been delivering food and have been doing it on the ground in the places that need to be done. They have infrastructure in place; they have people on the ground; they understand the local cultures. And therefore, adding the kind of expertise to what they're doing that's a subject matter focused on the kinds of programs we're funding has been a way to get started.

I think you only have to look at the objectives of this program and the magnitude of change that's represented here to quickly understand that there aren't the resources there of organization and programs that are already scaled up to be able to do what we're doing. We're having to find capabilities where we can.

At the same time, we're using the pre-existing processes and experiences of United States government agencies that have been engaged in this battle for 20 years. So here are very disciplined contracting procedures, procurement procedures, auditing procedures, and then separate from that we are engaging in program audits where we are and will be sending program auditors in to look specifically at the programs that we are funding to ensure that organizations are doing what it is they agreed to do.

At the same time, our monitoring and evaluation efforts will really evaluate the effectiveness of programs, and I fully expect that there will be programs that we have funded that based on our evaluation we will decide this organization's not getting any more money; and on the other hand, this organization's going to get more money because they're demonstrating that they can get the job done. That's been an important principle for the president, is that there be results and accountability, and that's certainly the direction I'm moving.

What about the guidelines on sex workers?

The Congress I think very appropriately has put into the legislation that created this program that organizations, in order to receive money, need to have a policy opposed to prostitution and sex trafficking. I don't think it's too difficult for people to be opposed to prostitution and sex trafficking, which are in fact two contributing causes to the spread of HIV/AIDS. I think when organizations initially became aware of that requirement, some organizations were concerned about what the implications of that might be, but we implemented that in the first year with non-U.S. organizations. We're now implementing that requirement with U.S. organizations. And so far, I really know of no problems that we've had on the ground.

But with regard to prostitutes and sex workers in developing countries, is it necessary to work with them? Do you try to get them to change behavior? And if they don't, then what?

First of all, very recently I was in Haiti in a program where we are working with prostitutes, teaching them skills that will give them the economic leverage to get out of prostituting. The particular program that I visited, young women were being taught the skills of being beauticians, of doing cosmetic work and hair work and that kind of thing. Now, none of these young women were saying, "I don't want to work with this non-governmental organization because they have a policy opposing prostitution." Quite the contrary. These young women were people who wanted to get out of prostitution. So there's nothing about our policy of requiring organizations to oppose prostitution and sex trafficking that in any way gets in our way of working with people who have been traced, or people who are in prostitution, trying to get them out of it. …

But is there a moral quotient, a moral factor in your prevention work?

There's a certain moral aspect to it, but the principal focus of what we're doing here is to carry out the prevention program that is at the heart of this program, which is abstinence, be faithful, and the correct and consistent use of condoms, driven by the fact that from a public health perspective, those are the components that really make the most sense.

You've been in this job for a bit. How has it affected or changed you personally?

I'm probably never going to be the same. I think when you see on the ground some of the kinds of things that I've seen -- some months ago, for example, I was in Mozambique, and the U.S. ambassador to Mozambique and I were visiting a location where we're funding a volunteer program of home care. I went to this lady's home -- and by her home I'm talking about a mud brick structure of probably 12 feet by 12 feet, bare dirt floor, no windows; you had to use a flashlight in there -- and lying on a mattress that was literally on the bare dirt floor was a woman who probably couldn't have weighed over 70 pounds who was in the last hours of her life. Seated on the corner of that mattress was a little 5-year-old girl, the daughter of this woman who was dying.

I asked a volunteer there what was going to happen to the little girl when her mother died. The little girl was already essentially alone with her dying mother, other than when the volunteers stopped by. And I was told that no one knew for sure what would happen to this little girl. Her father had already died from AIDS; there were no other known relatives. She was probably destined for the street. That's why it's important when we talk about 8,000 deaths a day to have something you can picture, to picture those kinds of circumstances and personalize it. I've been lots of places I never expected to be in my life, and I think if all of us could have those experiences, we'd probably all have a far greater sense of urgency.

So with that regard to what I do with the rest of my life, this is an issue that was not front and center on my radar screen before the president asked me to do this, but certainly will be for the rest of my life.

It is striking when … you go to the developing world, where there's just often so little help.

l think if Americans could have the kinds of experiences that I've had traveling around the world, it would change their lives in the way it has changed mine. I had an experience recently in Uganda where I was talking to a 14-year-old boy seated in front of his home, which was a mud hut, seven or eight miles out in the country. His father had died of AIDS and was buried back behind the garden. The reason I was there was his mother is HIV positive and is in a treatment program that we're funding. And on that very day -- this was a 13-, 14-year-old boy -- on that very day he had completed the last day of school that was available to him free of charge. To go beyond that in school he would have had to pay fees, and there was no hope of ever having money to do that -- 60 percent, as I recall, unemployment rate in that particular part of the country.

So you think about the hopeless circumstances of this young man, who has no meaningful prospects for further education or employment. Then let's say that he or others like him find out one day that they're HIV positive. That's a sense of hopelessness that's difficult for most of us here in the United States to imagine. And I look here on my office wall at the photographs of my own grandchildren, and I think about the quality of education that they get here in the United States, the quality of health care they get, the love and nurturing that they get from their families.

I think if Americans had that kind of experience in the way that I have, I think it would change their lives forever, as it has changed my life forever. I didn't understand the magnitude of HIV/AIDS and the negative impact it is having in literally destroying the world in which we live. We've got to get a greater sense of urgency in this country and around the world to addressing this issue, not only for the sake of those people who are directly impacted by it now, but because it's in our own interest for the long-term well-being of the world to just get much more aggressive about it.

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posted may 30, 2006

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