Ambassador Mark R. Dybul co-directs the Global Health Law Program at Georgetown University Law Center’s O’Neill Institute for National and Global Health Law, where he is also a Distinguished Scholar. He is the inaugural Global Health Fellow of the George W. Bush Institute. Dybul served as the U.S. Global AIDS Coordinator from 2006 to the end of the George W. Bush administration. In that role, he led the implementation of the President’s Emergency Plan for AIDS Relief (PEPFAR), the largest international health initiative in history for a single disease. Prior to assuming the post of ambassador, he was acting, deputy and assistant coordinator, and was a member of the Planning Task Force that created PEPFAR. Dybul also led President Bush’s International Prevention of Mother and Child HIV initiative for the Department of Health and Human Services (HHS).
Dybul spoke with John Donnelly about the start of PEPFAR and some of the most memorable moments directing it, continuing Science Speaks’ series on 30 years of AIDS.
How did you first get involved in AIDS?
When I was in college, I was trying to decide whether to do a doctorate in theology or English, concentrating on poetry. Then I saw an article on AIDS on the cover of Newsweek, and something inside me said I should spend my life on this. I wound up pursuing it by going to medical school.
Later on you began working with Dr. Anthony Fauci. Tell me about that.
I started as a fellow in infectious diseases. The way the National Institutes of Health (NIH) works is, when you become a fellow you know what lab you are going to go into. I wound up accepted at Tony’s lab, and I did basic and clinical immunology and later some virology in his lab. I also started doing research in Africa with Peter Mugyenyi, and saw his programs and also programs run by TASO (The AIDS Service Organization) in Uganda. When Tony was asked by President Bush to think of what we could do on HIV, I was already working on the ground in Africa.
How did you first learn of President Bush’s interest in AIDS?
It was March or April of 2002. At the time, there was an interest in doing something about the prevention of mother-to-child transmission (PMTCT) of HIV. Tommy Thompson, HHS secretary at the time, had just taken a delegation to Africa with Tony. NIH had funded seminal research on PMTCT and the administration had expressed an interest in pursuing that as a possible initiative. Tony asked me to go to HHS to work on that initiative with them. My first reaction was, “What are these people up to and what do they want?” I was not inclined to believe President Bush and people in the administration cared about these issues. I was so wrong. I had completely bought into the public caricature of the president. It was a great lesson for me about the inaccuracies of the way people are portrayed publicly. I made a number of trips to Uganda, starting in 2000, and presented work in intermittent therapy at the international AIDS meeting in Durban. It was a very important meeting.
Could you explain that?
Cost was the major issue. Drugs were in the thousands of dollars, and very few people could afford them. My study involved people being on drugs for seven days, then they were off the drugs for seven days. The idea was could we give people half as much drugs, reducing the cost of drugs by 50 percent, and have twice as much treatment available. We were too aggressive – the idea didn’t work. We should have done five days on, two days off as a first study, which we did subsequently and showed it was no less effective than continuous treatment. But I was concerned about the cost not being reduced enough. I learned a lot from that – being too aggressive can hurt an overall effort, even in science. Even in science if you get off on the wrong foot, you can take a whole field down.
The Durban meeting was the first time there was a sense that what was happening in Africa was completely unacceptable. At the meeting itself, it was made so clear that the statements many people were making were horrific. People were literally saying effectively that Africans were too ignorant and incompetent to deliver something as complicated as antiretrovirals (ARVs). It was slander against the entire continent. As I began working in Uganda, I saw on the ground people delivering ARVs to patients and saving lives. Still, on the ground, the sense of hopelessness was palpable. But among those people working on the issue, there also was the sense that we can do this. We just needed the resources and this can be done. All that was missing was money.
What was most memorable to you about your work in PEPFAR?
The first important thing was the mother-to-child initiative. A lot of people forget President Bush had that initiative before there was PEPFAR. A couple of moments stood out. One was how rapidly a president and a White House could move. HHS was asked to formulate a plan in May 2002 for the prevention of mother-to-child transmission, and the initiative was announced in June in the Rose Garden. By the president of the United States! Then on that day, in the Rose Garden, after the president announced $500 million over five years – more than was spent at the time on an annual basis for all global HIV – we learned that the president had earlier turned to senior staff and said, “This is a good start but it isn’t enough, think big.” That was just breathtaking to me. It was a really dramatic moment, and it was clear to the people involved that the sky was the limit.
People know about President Bush’s decision to start PEPFAR, but what about influential players behind the scenes?
First, it is important to note that PEPFAR was President Bush’s vision and mandate. There are always stories about who was whispering in his ear, but it was all him. Josh Bolten (Bush’s chief of staff), besides President Bush, was the single most important person in PEPFAR. He was the person inside the White House who really pushed the initiative. When he became director of the Office of Management & Budget, he not only found the money dedicated for PEPFAR but also found extra money for the bilateral program. He made some tough decisions. And of course, another key person was Randy Tobias. The president could not have chosen a better first coordinator.
One of the things I remember is that Josh would ask the most important questions. There was one meeting, six months into PEPFAR, and he asked, “What is the single most important marker in PEPFAR?” I said, well, we have prevention, care and treatment, and the reduction in infections is most important. And Josh said, “No, what is the most important marker.” I said it is the number of people on treatment because we can show success rapidly. Josh asked, “How many are on treatment?” I said 25,000 in the first six months. He said, “That’s not very much.”
What was important about those discussions was that we had to build the credibility and success in the program rapidly, and the only thing we could get in real time that showed demonstrable impact was the treatment number. Treatment wasn’t the most important thing, but it was the most important marker to show rapid success.
What else was important in those early days?
Moving money rapidly. It was very controversial at the time. Instead of waiting for the first operational plans, we wanted to get the money out the door right away. It came out of experience of knowing that there were programs running that just needed money, but it was still controversial.
Was it the right decision?
Absolutely. We got money out the door immediately. We had people on treatment within a couple of weeks after the first appropriation approved by Congress.
What about difficulties in the early days?
Another key moment, a shocking moment actually, was that we assumed incorrectly that this was the best thing that could ever happen, and Congress would be excited. It wasn’t exactly that way. The first meetings with the Republican staff were brutal. We were not popular. The Millennium Challenge Corporation and the Global Fund were popular. But those meetings, though difficult, were important. We realized we had to have strong relations with Congress and spend time with staff.
Why was PEPFAR unpopular in the beginning?
The president had just pushed through the plan. The Republicans were in control of both houses, and Congress had just been asked to put in the first gift to the Global Fund, which was hundreds of millions of dollars. They just moved the Global Fund through the committees and then the Millennium Challenge Corporation was created and it moved through committees. Then all of a sudden, a new thing, PEPFAR, appeared. It was bigger than the others, and there was no consultation with the Hill. You can imagine it didn’t go over very well. Randy Tobias (the first U.S. global AIDS ambassador) did an excellent job of bringing people around.
The next big unexpected issue was the G8 meeting. It was an “aha” moment for me. The reason the bill passed the way it was – with no amendments – was that the president was adamant that he could go to the G8 with a $15 billion commitment. At that time, it was estimated it would take $45 billion to control the epidemic. That was the biggest miscalculation, that if we put in $15 billion, the president could go to G8 and match it with $30 billion from the rest of the wealthy countries. When the G8 refused, we were just astonished. There wasn’t the commitment there, no matter what the other countries were saying publicly. So we realized we were going to have to carry this on our own for a while. It also gave us a sense of how important it was that we had to have a success. If we didn’t succeed, there was no hope for another big fund for HIV/AIDS, or an initiative on something else in global health or in development generally.
The money still has not come from the rest of the world. The U.S. is currently spending 55 percent or so of global funding for HIV/AIDS. It should be no more than a third. We are almost double what we expected it to be.
Looking ahead, what needs to happen now in the architecture of global health? If you look at the Global Health Initiative (GHI) and at other initiatives from developed and developing countries, what needs to improve?
The notion that what we created at PEPFAR could just live on as it was when we were walking out the door is crazy. Change needs to continue. We always viewed what we were doing as the tip of the spear for global health and development. It has become absolutely clear that the way we do development is actually killing people. We could be reaching three to five times more people if we could get rid of all the duplication and turf battles. So the global approach has to be radically different. It was essential that we showed if you dedicate huge resources to a problem, you show results. We couldn’t have gone the next step without it. Now we have to build off what was there, and the next changes need to be radical. We need a complete restructuring and realignment of the global architecture that will fundamentally support integrated health systems in countries.
Does GHI go far enough?
The principles of GHI are dead on and a natural evolution of what was started in the Bush administration. There needs to be a breaking down of barriers in the U.S. government to achieve specific goals. The current administration has a great team, one of the most talented teams one could put together, but it will take an awful lot to move in a direction that the principles are guiding them to go.