The nation’s 43rd president, George W. Bush, is a polarizing figure. In foreign affairs, the most well-known part of his legacy is probably his decision to pursue military action in Iraq and that will, in all likelihood, remain the thing for which he is known best. However, it is important to consider that this is only part of his legacy in international affairs. 

Another part of it is the role America played to address the AIDS crisis in Africa. Former President Bush pushed for the establishment of the President’s Emergency Plan For AIDS Relief (PEPFAR). This is an initiative to address the global health crises surrounding HIV/AIDS that has, to this date, spent more than $90 billion on this crisis since 2004. 

Bush rose to office as a different kind of conservative. He was a “compassionate conservative” — he wanted to use the government to improve the general welfare and PEPFAR was one way in which he did that. Bush’s interest in Africa came from a 1990 visit to The Gambia with his wife, Laura Bush, and in the lead up to his decision to enter the race, then-advisor (and future Secretary of State) Condoleeza Rice pressed Bush to make addressing the AIDS epidemic in Africa a serious part of his foreign policy legacy. This 1998 conversation proved far more prescient than either of the participants could have imagined.

Bush announced the program in his 2003 State of the Union Address, though it was overshadowed by the fact that this speech also featured justifications for the invasion of Iraq. The project was one owned by Bush — he was willing to stick his neck out for additional money from Congress if he saw results. As it happened, the results he saw were incredibly encouraging. PEPFAR has saved the lives of millions and improved the lives of millions more and to his credit, it has done it in an effective, efficient manner — it prevented deaths from HIV for under $2,500 per death prevented. Though it is an AIDS program, some studies have suggested that it reduced the odds of death by 20 percent in general in countries where it existed. Further, it has directly reduced tuberculosis infections and deaths.

In today’s discussion around COVID-19, much attention is paid to how former President Barack Obama handled Ebola. I agree that Obama’s work was commendable there. However, in the global health arena, one place Obama left something to be desired was with regards to PEPFAR. Obama and his team created budgets that “slashed hundreds of millions of dollars from PEPFAR.” Unfortunately, President Donald Trump has gone further here and has released budget proposals with “$1.35 billion in cuts to the President’s Emergency Plan for AIDS Relief.” Both of these presidents have cut and increased funding to different programs, as has been their prerogative. However, this goes to show why Bush deserves credit for PEPFAR. It was his prerogative and should be recognized as such, especially in light of its exemplary results.

PEPFAR was a way for America to lead in the global health arena. The AIDS crisis ravaged America in the 1980s and the initial response by the government was a subject of criticism then and widespread denunciation now. PEPFAR was a chance to reverse this issue and Bush seized the issue to show why America deserved to lead the world in global and public health and how exactly it would go about doing so. Because of American leadership regarding AIDS, an AIDS-free generation is within sight and PEPFAR has played a large role in getting to this point.

However, there must be more. Thankfully, cuts to PEPFAR were rejected by Congress under Obama and Trump and in both cases, funding was set at levels beyond those requested by the president. This is something but isn’t enough. Bush may have been an unlikely catalyst for a public health revolution but he very clearly was one — the results do not lie. Today, however, that kind of compassionate conservatism and desire for American leadership doesn’t exist as it did under Bush and the nation, world and public health are all worse for it. PEPFAR is an example of America at its best. Like other programs, such as the Marshall Plan or the Berlin Airlift, it is proof that when American leadership decides to accomplish a goal, that goal will be accomplished. Bush wanted to make his mark with AIDS, and it is hard to argue that he didn’t.

Anik Joshi can be reached at

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