WP: Botwana's Gains Against AIDS Put U.S. Claims to Test

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washingtonpost.com

Botswana's Gains Against

AIDS Put U.S. Claims to Test

By

Craig Timberg

Washington Post Foreign Service

Friday, July 1,

2005; A01

GABORONE, Botswana -- As

global leaders gathered in Davos, Switzerland, for the

World Economic Forum in January, officials from President Bush's $15 billion

anti-AIDS program issued a news release citing their accomplishments. Nowhere

were the numbers more impressive than in Botswana, where

32,839 AIDS patients were receiving life-extending treatment with the help of

the U.S. government, they said.

But

thousands of miles away in Botswana, the Bush

administration's claim provoked frustration and anger among public and private

partners that had built Africa's most

far-reaching AIDS treatment program, recalled those involved. Although the Bush

program had promised millions of dollars of support, no money had yet arrived,

they said.

The

operations manager of Botswana's treatment

program, Segolame Ramotlhwa, called the U.S. figures " a

gross misrepresentation of the facts. " His boss, Patson Mazonde, who as deputy

permanent secretary for health services had overseen the program since its

inception in 2002, called the Bush claim " false " but suggested it was

merely a mistake.

They

agreed on the number of patients in Botswana who had

been put on treatment because of the Bush program: zero.

After

first defending its figures from the January news release, the Bush

administration last month revised them sharply downward. But even the revised

numbers remain in dispute. Administration officials announced that 20,000 people

in Botswana were receiving " significant

support " from U.S. programs for their

AIDS treatment. Health officials in Botswana maintained,

as they have for months, that no citizen was dependent on U.S. support for

treatment, the cost of which has been covered overwhelmingly by the Botswanan

government.

The

disagreement underscores not only the highly politicized nature of treating

AIDS in Africa, where less than 10 percent of the

people who need antiretroviral drugs are getting them, but also how rare -- and

coveted -- success stories such as those in Botswana remain.

To

people receiving the lifesaving medications, the question of who gets the

credit may not matter. But for the government of Botswana, the groundbreaking

AIDS program is a source of enormous national pride, while for the Bush

administration, being able to announce such successes bolsters its claim to

having begun to " turn the tide " against AIDS in the developing world.

The

dispute essentially comes down to a question of how to define " support. "

In March, in an annual report on the program, the Bush administration said

support could include general " system strengthening " -- a category so

broad that it could allow officials to claim to have supported treatment of any

AIDS patient who benefited, however indirectly, from U.S. government

assistance.

The

head of the Bush administration's program in Botswana, H. Kilmarx, from

the Centers for Disease Control and Prevention in Atlanta, said in an interview

here in May that he was aware of the upset among the Botswanan officials but

that the treatment claims fit within U.S. government guidelines. The definition

used for measuring support, he said, had broadened to the point that even

assistance as trivial as editing a government health official's speeches could

allow the Bush program to say it had supported treatment for everyone receiving

antiretrovirals from that nation's public health system.

The

system " could be abused, " Kilmarx said. " But it's not. "

The

Bush program set its numerical targets even before the legislation creating the

program was drafted. In his 2003 State of the Union address, Bush stunned AIDS

activists by announcing a $15 billion commitment over five years to fight the

disease. The program would soon become what U.S. officials

call the largest global health initiative undertaken against a single disease

by a single country.

Bush

announced that the program would " treat at least 2 million people with

life-extending drugs. " But over the next year, as administration officials

developed the president's promise into a program, they recast the goal. It was

not practical, officials say they concluded, for the U.S. government

to build clinics, hire doctors and hand out drugs all over the developing

world. And officials from the countries targeted for the assistance, including Botswana, made clear

that while they wanted help, they believed that their own governments, not the United

States, should be distributing the medicine.

In Botswana, a

landlocked nation of 1.6 million people in southern Africa, officials

were tackling one the world's worst AIDS epidemics. Nearly four of every 10

working-age adults were infected with HIV, the virus that causes the disease.

Bolstered by vast diamond wealth and a stable government, President Festus

Mogae had committed the nation to providing costly, state-of-the-art AIDS

treatment to every citizen.

The

daring promise, the first of its kind in Africa, attracted tens of

millions of dollars in support from donors, including substantial amounts from

the U.S. government, which took the lead in

upgrading laboratories and building a network of centers to test patients for

HIV.

With

the inception of the Bush program, both the White House and Congress began

focusing on delivering the antiretroviral drugs that alone had the prospect of

saving millions of lives. And the U.S. officials charged

with implementing this vision were also supposed to produce quantifiable

results to make explicit the value of the $15 billion investment.

In Botswana at least,

deciding who deserved credit for any one person getting the drugs proved

complicated.

Harriet

M. Isaacs, a 59-year-old civil servant with AIDS, started taking

antiretrovirals in 2002, the year before Bush announced his program. The drugs

have restored her to health, and with a few months left until her planned

retirement, she now looks forward to many more years of playing with her

grandchildren.

She

expresses no doubt about who saved her life: the government of Botswana.

" It's

very expensive, " Isaacs said while seated in a bustling AIDS clinic here,

" but it's helping people. . . . I'm confident that I can go up to 100

[years old] now. "

The

reality of who paid for her health care is more complex. She visits a clinic

built with the help of the Bill & Melinda Gates Foundation. She takes

medicine donated, in part, by the American pharmaceutical giant Merck. And the

cost of most everything else -- doctors, nurses, lab work -- is covered by the

government of Botswana.

For

Isaacs, the role played by the Bush program -- so far, at least -- has been

minor, confined mainly to the training of medical personnel and the monitoring

and evaluation of the existing government program. The total outlay of U.S. government

funds for " treatment " in Botswana last year

was $2.5 million, about one-twentieth of the amount paid by the Botswana government.

And even that money was delayed by many months.

Yet

when it came time to tabulate the Bush program's successes in Botswana, every

patient receiving antiretroviral drugs from the national program, including

Isaacs, was included. U.S. officials also

counted several thousand others who were receiving their medicine from private

doctors because, Kilmarx said, some had benefited from a U.S.-funded training

program.

He

explained that since the January news release in Davos, the number of AIDS

patients for which the Bush administration was claiming credit had continued to

grow. That day, he said, he was submitting a new total of 41,444 in Botswana to top

program officials in Washington. Everyone

in Botswana receiving antiretroviral drugs was

included, Kilmarx said.

In

the days that followed, Kilmarx was asked about the comments made by Mazonde,

Ramotlhwa and other health officials from Botswana. He

defended the program and then called another meeting with them. Later on the

day of that meeting, he reiterated his defense of the numbers, saying that

Mazonde and Ramotlhwa were " entirely comfortable " with how the Bush

program had portrayed its role in Botswana.

The

message he received from the health officials, Kilmarx said, was that while

they had been unhappy with some of the Bush program's characterizations, they

wanted the funding to keep coming.

In

subsequent phone interviews, both Mazonde and Ramotlhwa softened their tone,

emphasizing their gratitude for the millions of dollars that, they said, they

still expected from the Bush program. Ramotlhwa suggested it was better to say

the Bush numbers exhibited " some element of distortion " rather than

characterizing them as " a gross misrepresentation of the facts. "

Yet

when asked if there was anyone whose antiretroviral treatment was dependent on

the Bush program, Ramotlhwa and Mazonde said they knew of none.

" We

cannot single out a person who would not be receiving treatment, " Mazonde

said.

On

June 13 -- two weeks after that interview -- Bush announced new totals for his

AIDS program. They were ahead of schedule, reaching more than 200,000 people

with U.S.-supported treatment in the 15 developing countries the program

focused on.

In

backup documents distributed by U.S. officials, the

treatment total for Botswana was neither

the 32,839 cited in January nor the 41,444 that Kilmarx submitted to his

superiors in May. The new total, offered with no explanation, was 20,000.

Asked

about the shift, the Bush program's deputy coordinator, Mark R. Dybul, said in

an interview at his Washington office that

reporting systems were evolving. " We're changing the numbers as we refine

reporting, " Dybul said. Of the Botswana health

officials, Dybul added, " They saw what's in here and they cleared

it. "

He

also disputed Kilmarx's statement that minor assistance, such as revising an

official's speech, would allow the Bush program to claim it had supported

treatment for everyone receiving it in a country. The new totals, Dybul said,

included only those receiving " significant support, " meaning that

" these people would not have quality treatment, would not have substantial

services, without the U.S. government. "

In

a final phone interview, Mazonde again expressed gratitude for the U.S. aid. He

added that a series of conversations with U.S. officials

in recent weeks had impressed on him the many ways that the Bush program

funding was assisting Botswana, and that

several million dollars promised for the national treatment program would soon

be available.

But

when pressed, Mazonde said there were not 20,000 people in Botswana whose

" quality treatment " was dependent on the U.S. government.

In fact, he said, there were none.