Botswana's Gains Against AIDS Put U.S. Claims to Test
By Craig Timberg
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,
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
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
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.
The head of the Bush administration's program in
Botswana, Peter 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
In Botswana at least, deciding who deserved
credit for any one person getting the drugs
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
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
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,
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.
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.
© 2004 The Washington Post Company