Book Event: Lifeline by John Donnelly

This transcript is from a CSIS event hosted on October 27, 2026. Watch the full video below.

Stephen Morrison: Good afternoon. I’m J. Stephen Morrison, senior vice president here at the Center for Strategic and International Studies, CSIS, in Washington, D.C. I’m thrilled to welcome everyone here today in person and those joining online for this celebration of John Donnelly’s remarkable account, “Lifeline: The Story of PEPFAR, the Greatest Humanitarian Initiative of Our Time.”  Congratulations, John.  And congratulations to your mother, Mary Donnelly, who’s joining us remotely here today.  We’re going to feel her pride come across the digital space.

Many worked very hard to make today happen.

No one did more than Sophia Hirshfield, an associate fellow in our program.

Thanks to Katherine Bliss for moderating this event.  She’s a senior fellow and director here and has led much of our work on HIV/AIDS.

We’re grateful also to the CSIS Africa Program, led by Oge Onubogu, and her staff, for cosponsoring this event.

Dhanesh Mahtani in our – in our events/production staff made this innovative setup possible.  Others on our ace production team have made this happen:  Qi Yu, Eric Ruditskiy, Theo Chavez, and Bryan.

And of course, Washington’s best indie bookstore, East Potomac Books, is here yet again to help sell copies of “Lifeline” at the reception that will follow, when John will be available to personally sign books.  Thanks to Marianne Wald for joining us here today.

This moment, as we’ll hear, is a very important one.  It’s a very important moment to have this story told.  It’s a reminder of what is possible.  This historical set of events, which no one had predicted, cut very much against our expectations.  They drew upon the leadership and courage and innovation of so many in Africa and so many here in Washington and beyond.  And they established a sense of morality and hope and leadership and accomplishment that endures even in the face of all of the monumental changes that have happened in the recent years.

Some of the architects and shapers of PEPFAR are with us today in person and online, and I hope we’ll hear from them:  David Gordon, Mitch Warren, Paul Zeitz, online Kevin De Cock and Gray Handley, and many others.  And so this is really a reunion of sorts, John.  And the fact that people have all gathered here today is both testimony to the power of this book in bringing us together, but also the power of the story itself and that people still live this and still identify with this.

And so thank you for joining us, and thank you, Katherine, and over to you.

Katherine E. Bliss:   Well, thank you, Steve.  My thanks also to Sophia Hirshfield for her effort in putting all of this together.

John, congratulations on the publication of the book, and thanks for joining CSIS today to discuss it.

John Donnelly:   Thank you for having me.

Dr. Bliss: So we met a few years ago by Zoom.  You were doing research, and I think you were headed to Dallas to work in the archives at the Bush Presidential Center, the National Archive version which is there on the campus of SMU.  And I think at the time, you know, we talked about what might be in the archives and some other sources you might consider, some of the oral histories that were being collected about PEPFAR there.  And so I want to start out – I’d like to ask you to say a little bit about the book’s origins; the process of writing a history of PEPFAR; and, given that you did so much reporting on the program in its early years, why did you decide to write a book-length history of the period from 2002/2003 to 2009?  Were there any trends or themes that you hadn’t really thought about at the time that in hindsight, you know, kind of became apparent, and you know, were things that you wanted to explore?  And as you accessed files and maybe unclassified documents that hadn’t been available to you as a reporter, what changed in your perspective?

Mr. Donnelly:   Well, thank you, Katherine.  And thank you, Steve, for that very nice introduction, and to CSIS for having all of us here.

The time period that I chose, which was a few years before PEPFAR began in the early 2000s, ending in mid-2008/2009, made complete sense to me because it was the time of the most tension and drama.  The stories were heartbreaking and then uplifting.  And so – and, plus, I was – I happened to be covering the politics and the policy of global health and AIDS before PEPFAR.  And then, because of my editor at the Boston Globe, Marty Baron, I and my family moved to South Africa for the first three years of PEPFAR’s implementation.  So it’s – it was a time I – you know, you could look at the whole history of PEPFAR, but I felt like the first five years of it laid the foundation, and there were just amazing stories everywhere you looked.

Your question about looking back and seeing trends and things that I didn’t realize at the time is a very good one.  You know, you know as an historian, and I have learned as a – as a book author, that many things become much more clear years later.  And the thing that – a few things that that really jumped out at me about what happened at PEPFAR was that it was such an amazing moment that it happened.  I think Steve alluded to this in the beginning.  It was not a given that the U.S. government or any big group could actually try to do especially AIDS treatment at scale in Africa.  There were leaders within the U.S. government, there were leaders of global health organizations, there were leaders of foundations who were very supportive of trying to do more in Africa, but they didn’t believe AIDS treatment could happen.  So the fact that it happened was astounding.

And then what was amazing that I – that I think that the book really focused on was:  How did it happen?  How did people make it happen?  And that’s – so there are all these human stories.  Many people in this room and people online, and thousands of people in African countries and from the U.S. government, did extraordinary things to pull this off.

Dr. Bliss: So a period of high tension and drama, certainly.  But you know, as you start the book, it actually starts in 1987, right, like, in a SCIF, a secret compartmentalized facility, and you talk about the CIA’s first intelligence community warning message on AIDS; I mean, so 15 years earlier.  You know, you’re really kind of starting at the, what – you know, the same decade when AIDS was really first reported.  And after that scenario in 1987, you refer to other national intelligence estimates as well as high-level U.S. government policy meetings about HIV/AIDS that took place, you know, throughout the late ’80s, ’90s, and into the early 2000s.

And so, given all of this focus by intelligence and security agencies about HIV and what was happening particularly in sub-Saharan Africa in that period from the late ’80s into the ’90s, why do you really think it took so long for the U.S. government to take action?  Because, I mean, clearly there were – there were reports and discussions along the way.  And what was it that changed so much in the early 2000s, you know, during this period when you, you know, uprooted and went to South Africa to cover this process?  What happened so that a U.S.-supported program was really something that people on both sides of the aisle could get behind, you know, this – really, the scale-up of treatment, as you talked about?

Mr. Donnelly: Yeah.  So I think we should give credit where credit’s due.  I think we should actually – in the history of the CIA, it’s not always that their actions are the most noble.  But I think in in this case, they were the lone agency in the U.S. government that was sounding the alarm bells of what was happening.

In 1987, the biggest alarm bell was a piece of intelligence that that said that half of all the military in Zambia were HIV-positive.  You know, they didn’t know if it was true or not, but the fact that half of them could have been positive was incredibly alarming.  And these two analysts, Katherine Hall and Walt Barrows – Walt Barrows is now a birder in Maine, by the way – (laughter) – were trying to get the attention of government.  It didn’t happen.

Even much later – the CIA stayed with it.  The National – the NIC, the National Intelligence Council – with David Gordon, who’s here today; happy to have him – sounded more alarm bells.  They did a couple of reports, including a report called “Next Wave,” which looked at five most populous countries in in the world, or five big countries in the world, and found that it could grow much, much greater, from 40 million to much more than 100 million in in the next 10 years.

And so, why didn’t it happen?  Why didn’t other agencies?  I mean, I think there are different reasons at different times, but I think mainly the biggest roadblock was that people did not believe even after 1996, when antiretroviral combination medicine that was saving lives here in Europe and elsewhere, that that could not be delivered at scale in Africa.

The reason it did happen – I think there are many, many reasons that it did happen.  The CIA also was involved in that.  Condi Rice really alerted the president that we can do something about this crisis.  He said, prove it to me.  She brought in the CIA.  And David and others gave a briefing, and the president was convinced that he should do something about it.  He began to do bit by bit.  They did a mother-to-child transmission, a huge $500 million program, but wanted something bigger.  And that led to, in secret, the whole PEPFAR program was developed.

Dr. Bliss:   And you spend a fair amount of time in the book talking about all of these negotiations, and having to go back to the drawing board, and pitching it one way, getting Congress on board, you know, trying to, you know, bring different allies along.  But one of the themes – and you know, you’ve touched on this – certainly, as the CIA and others were really reporting and looking at some of the challenges, security was paramount; you know, really understanding what was happening to militaries and what that might mean for stability and regional security.

So one of the recurring themes, you know, as you, you know, look at some of these negotiations and the process that that led ultimately to the launch of PEPFAR, is what comes across really as kind of a tension between justifying PEPFAR on national security grounds and – on the one hand – and humanitarian grounds on the other.  And I think maybe we know where you fall on it because it’s called “The Greatest Humanitarian Initiative of Our Time” – (laughter) – not the greatest national security plan of our time.  (Laughs.)  But you know, you really – there’s this tension, you know, that appears, you know, between security and humanitarianism, and you really in several places underscore President Bush’s emphasis on the humanitarian agenda and the conviction that for those to whom much has been given much is required.

So can I ask you to say a bit about how you saw this tension play out, you know, over the period, this tension between security and humanitarianism?  Was it really a tension, or just kind of did people think about those things?  Did they just frame the question in different ways?  And how have you seen these issues kind of wax and wane when we talk about HIV and global health?

Mr. Donnelly:   Yeah.  There’s a lot in that question.

Dr. Bliss:   I know.  I’m sorry.  (Laughter.)

Mr. Donnelly:   Let me see if I can get into it.  (Laughs.)

So I would say first Steve Morrison was highly influential in my thinking about the national security question, and he made a lot of good points when I talked to him for the book.  You know, one is that there were two bombings in East Africa, in Kenya and Tanzania, just a couple – in 1998.  And after 9/11, Bush really saw the need to do some positive things in the poorest countries in the world to show that the United States really did care about people in those countries.  And so there’s a very strong national security line that went through this for the president.

But I would say that Bush really – and I went into this like most reporters, being a little skeptical about motivation.  And there was some things among the staff who talked about, you know, we’re having a State of the Union, and the main thrust of the State of the Union is to prepare our country for a war in Iraq that’s going to be coming in six weeks or so, and so maybe it would be nice in that State of the Union address to balance it off with a plan to help Africa.  And so I asked Bush about this when I talked to him for the book, and he said, that’s just staff talk.  He said, there’s nothing to that.  He said, I didn’t do it for that reason.

And he had – he had people in the White House arguing against it.  One was Karl Rove.  And Karl Rove said to Bush, you know, you’re not going to get any political points out of this.  This is not going to help you for your reelection campaign.  It’s not going to help Republicans.  And not only that, but can you really do it?  I mean, the Marshall Plan had tens of thousands of troops in Europe after World War II ready to help rebuild Europe.  You have a dozen people in one embassy, a dozen in another.  Can they really pull this off in Africa?

Bush, though, became convinced in this – through his planners, through this very rigorous process.  Tony Fauci, who was – he and Mark Dybul were the two architects, really, of the original plan.  Tony Fauci hated the whole process, and he hated particular people in the White House.  (Laughter.) One person he still won’t talk about to this day, you know, because she gave him such a hard time.  But she was doing her job.  She was really making sure that a plan at a time when 30,000 people, maybe, were being treated in Africa could be scaled up to 2 million people in five years.  It’s a very – you know, that’s a – that’s a big leap of faith.

But it was – it was buttressed by several doctors, including one of my heroes, is Peter Mugyenyi of Uganda, who was treating 2,000 people at the time and said the only thing holding us back is financing.  You know, he had – he had turned away his relatives who had come to him for drugs because he didn’t have the money to give them the drugs, and they battled him.  And he still – he couldn’t give them.  They battled him, they left, and they died.  And so there were people really, really desperate to get the funding, and they were desperate to argue at the White House to have it happen.

Now, on your – I remember another part of your question I haven’t gotten to, but it did wax and wane about the national security versus humanitarian grounds.  I think – I think once it became – with the Obama administration – it was called the President’s Emergency Plan for AIDS Relief.  Well, the president was President Bush.  And so President Obama, who had lots of reasons to continue it, decides to continue, and I think – I think in some part from national security concerns but also in some part because there was an amazing bipartisan coalition in Washington especially, from faith-based groups to more liberals to celebrities like Bono to activists.  You know, activists have played an incredibly huge role in, actually – in PEPFAR actually happening in the first place – seeding the ground; booing the HHS secretary, Tommy Thompson, at a Barcelona AIDS conference, which definitely got the attention of the White House; to just being on top of the Bush administration that it was going to happen.

So there were many players.  It was such a broad coalition that after reauthorization of five years it continued for five more, and the coalition continued strong for about 20-plus years.

Dr. Bliss: So, really, a dialogue or a relationship between lots of different groups that, you know, brought their advocacy and their emphasis at different moments.

Mr. Donnelly:   Yes.

Dr. Bliss:   So I want to ask you a little bit about the structure of the book.  You know, several of the characters or the people, the personalities you’ve already mentioned, make their appearance in these kind of vignettes, almost; you know, sort of two or three pages that that you use.  You might – I mean, you’ve organized the text.  Ultimately, it’s chronological.  But you kind of move through different – you know, from month to month and year to year using different characters or different experiences to drive the narrative forward.  And a lot of those are really about conflicts that happened, whether here in Washington around policy or, you know, some of the experiences you’ve just explained about Peter –

Mr. Donnelly:   Mugyenyi.

Dr. Bliss:   – Mugyenyi, you know, really facing this crisis, you know, wanting to deliver services and his own family, you know, not being able to access them.

So could you say a little bit about why you chose this structure of the vignettes, you know, to really move the story forward?  How did you decide who or what made it in or didn’t?  And can you share one or two with us of, you know, maybe some of your ones that that ultimately didn’t make it in the structure but you wanted to talk about?

Mr. Donnelly:   OK.  So – (laughs) – so I plead guilty for putting in a lot of conflict.  (Laughter.)

Dr. Bliss:   The drama.

Mr. Donnelly:   And I think – I think journalists are attracted to conflict for good reason.  Sometimes the conflict is overemphasized.  But there was a lot of conflict in this whole story.

And bottom line, by the way, I think is that the conflict was overcome.  And this amazing project saved, you know, 26 million lives, so.  But I would say that I – things happened that I covered that were, like, 25 years ago.  And people’s memories do not – are not very good after 20, 25 years.  We’re not very – I’m not very good about what happened last month, so.  So I think what I needed were people who had kept documents; who maybe wrote long letters back home, you know, during the time they were doing this and who would share me the letters.  Barb Marston, who’s a big character in the book, a CDC doctor in Kisumu in western Kenya, would write eight-page notes home almost every other week, and had great detail in it.  And so that made it – I had firsthand material.  I had prime documents.

Then there were – then there were the research that I did with the FOIA requests and the Bush Library. And so there are many things that that happened, that people told me about, that I found later through the documentation that weren’t exactly true, or the memory wasn’t good, or there were some things that were completely off.  But the documentation allowed me to set the record, what I could find, you know, with documents, set the record straight.  There were some people – there’s Ambassador John Lange, who I think he’s here today. 

Dr. Bliss: He’s sitting right behind you.  (Laughs.)

Mr. Donnelly:   Great.  Hi Ambassador.  Who was – for a year was the deputy coordinator for PEPFAR.  And Ambassador Lange played a huge role in helping people who had no experience with the State Department to actually maneuver in the State Department.  They needed more John Langes, actually. That was one of the problems in the beginning, was that they didn’t have people that could – knew how to work the system. 

But what Ambassador Lange did was he had kept all these amazing documents.  And some of the documents were about meetings where there was verbatim quotations from what people said at different things, including the first meeting of ambassadors when Randy Tobias, who was the first global AIDS coordinator, went to Botswana to bring all the ambassadors together and talk about it.  And so we had documents that showed exactly how the dialogue went.  And with people, like, saying – a couple of people saying pretty ridiculous ideas, actually, and then some people coming up with great ideas in this conversation. 

So I relied – there were a lot of people who maybe played more central roles in PEPFAR at different times, but I didn’t have any documentation with them.  And maybe the memory wasn’t so great.  And so I went with what I had.  And there was a lot – the tension, you know, especially – one of the most amazing things that I think happened was the system was set up to put it in the State Department, to bypass USAID, and to sort of elevate CDC a little bit with their expertise, bring them in more. 

And the fact that that did not work out very well in many countries, that there was people – teams that wouldn’t talk to each other, they used to have to bring in peacemakers – like Buck Buckingham, who is here – (laughter) – to come in and actually get the teams to talk.  So the amazing thing to me was, despite all those problems, that they got to the results.  So that speaks very well for future responses to future crises, that that government has tension inside it, but with a proper structure and foundation, with goals, with accountability, people – and with a mission – that people can really get amazing things done.

Dr. Bliss:   So you’ve mentioned accountability.  And, you know, some of the real accomplishments of PEPFAR, in terms of, you know, bringing data forward and really using evidence to drive – you know, to drive policy and to really create change.  So I want to shift gears a little bit to the present day, and ask you to reflect a bit on some of these lessons from the past, and some of the vignettes that you’ve included as well.  Last year, in September in 2025, the U.S. Department of State revealed a new global health strategy, the America first strategy.  And in it, Secretary of State Marco Rubio writes that our health foreign assistance programs, in particular, have become inefficient and wasteful.  And then, you know, the strategy lays out a vision to end the inefficiencies, waste, and dependency of our current system.

But in the book, you know, you really make it clear that a focus on the most effective use of taxpayer resources was a part of the PEPFAR story.  And one example that you offer is a little bit later in the book, from 2006, where you focus on Justice James Ogoola, from Uganda, who was appointed that year to investigate corruption in the management of global fund grants, in particular.  So I just wanted to ask you, you know, as you are thinking about some of what’s been said in current day about U.S. health foreign assistance and some of the claims about inefficiency and waste, you know, why did you include this particular episode about Uganda?  And what does the outcome of that investigation kind of tell us about the evolution of PEPFAR and the Global Fund, to which the U.S. is the largest donor?

Mr. Donnelly:   So, as a journalist, as you imagine, one of the things I would look for most strongly would be corruption.  So – and there’s one big story in the book about corruption.  It’s in Uganda.  And I contacted a man by the name of Brad Herbert, who actually died last year of cancer, sadly.  But Brad was at the Global Fund.  He was the chief operating officer.  And he – I heard about this story with a big problem with misspending money in Uganda in 2006.  And Brad told me the whole story, and spent a lot of time with me about it. 

Told me about how they had some whistleblowers say that there are millions of dollars being missing, that the Ministry of Health was actually – was directing it, but it was it was spread out to dozens and dozens of people in Uganda.  And so Brad went with these allegations.  And PricewaterhouseCoopers did a little investigation of it for a couple of weeks.  Said there was real problems here.  He went to Uganda to talk to President Museveni.  And President Museveni was very angry about it, because they announced a suspension of many millions of dollars of funding. 

And he said, how can I get out of this? And Brad said two things:  independent inquiry, and I want you to appoint Justice James Ogoola to be the head of it.  And he knew Justice Ogoola from the time that Brad was at the World Bank and the justice with the IMF.  So he trusted him very much.  And since then, the justice, he went to a seat in the high court in Uganda. And Museveni said, fine, OK, I’ll do it.  Just do it.  So he announced it.  And the justice then – the reason – this is why I included this in the book, because of him. 

The justice decided to hold hearings in Uganda.  And not only that, but he invited the broadcasting – the major broadcasting station, into televise the hearings in Uganda.  And so every day for well over a month, this hearing about corruption in the Ministry of Health became to Uganda what Watergate was to Americans.  It was the – it was the amazing – people would gather around communally around TV stations and watch it all day long.  And so the end result was – it was at the high point.  And also it was interesting. 

Justice Ogoola was very difficult with me.  We talked for a long time.  He wouldn’t give me any documents.  So I had to go find documents I found in a thesis paper of someone that quoted the whole transcript in it.  So it was a difficult thing to find.  But he, at the very end, confronted the head of the health ministry.  You know, sir, you know, you deserve to apologize to their president, to the people of Uganda, for stealing money that was meant to keep people alive.  And the health minister, who was a major general, said, how dare you, sir?  While you were in Washington in a safe job, I was fighting Idi Amin.

The justice held his tongue, didn’t say anything.  He was worried, though.  He was worried that next day the country would side with the health minister.  He went back and started hearing from people, thank you for confronting him.  There were suddenly, in The Monitor and other papers, op-eds about how the health minister – how the justice put the health minister in his place.  So I included it because of that, because I thought that it was a story where – there are many myths about corruption in Africa.  And there are many myths about whether Africans are resigned to corruption in Africa.  And I don’t think they are.  And I think it bodes well, actually, for future corruption, which is always going to happen, and what the response can be in countries. 

Dr. Bliss: Well, and here was a situation that was captivating everyone.  You know, really, you know, to monitor.  And –

Mr. Donnelly:   I asked the justice – I said, well, did you get permission?  Did you let the president know you were going to televise these?  He said, I would never ask permission.  I just did it.  (Laughter.)

Dr. Bliss:   I want to ask you a little bit about the – you know, what we’ve seen under the America first global health strategy.  You know, there’s been a huge discussion about country ownership, is kind of a phrase that, you know, has been used.  The importance of integrating HIV services and personnel into mainstream health systems. Kind of – really, the absorption of PEPFAR into this new strategy.  The reality is that the global health community has been talking about those issues for quite a long time.  And even, you know, since some of the earliest days of PEPFAR.  And, you know, PEPFAR was called “emergency” for a reason.  It was not, I think, intended to last forever. 

But now, this push to move countries towards greater financing and self-financing has happened in a very abrupt fashion.  And so, I guess, I’d ask you to kind of think back, you know, over this work that you’ve done, really looking at the history of this period, you know, to ask you why you think it took so long to really get to really pushing these reforms forward in a way that had been talked about for quite a long time, particularly around kind of self-financing.  And what are you most concerned about when you kind of look at what’s happened?

Mr. Donnelly:   So I would say pretty directly that my thought about why PEPFAR remained an emergency well past the time it was an emergency was that I think the status quo is very powerful.  And I think government institutions want to keep that moving, as development institutions do.  That they will keep on doing that even when – even when there are many efforts, in the past, to try to transfer ownership of the program to countries to take more responsibility for it.  So it’s a real failure of people in PEPFAR’s teen years, maybe, to actually turn it turn it over.

I would say that what’s happened was this horrible abruptness of closing down USAID, of really crippling the CDC global health unit, you know, has – took a lot of superstars out of the U.S. government, unfortunately.  People with incredible talent and motivation and ability.  And so I think it’s – in terms of the U.S. building back, it’s making it much harder – will make it much harder, with new responses to foreign assistance coming up.

I would say, but what happened – what has happened in the last year in the State Department is pretty remarkable as well.  I think the fact that they have done 36 different bilateral agreements with countries, that that the U.S. government – there was – there was a scenario when PEPFAR could have just pretty much ended.  Now it’s PEPFAR, much different kind of assistance program, but the U.S. government’s still committing $15 billion in the next five years.  Countries have put in $10 billion of their own money into that.  You know, which would not have been a pledge without this thing.

And I think there is all kinds of pushback and excitement from countries in Africa about how the whole foreign aid architecture should be put together now.  And, to me, that’s exciting.  I mean, it’s exciting to see and listen to people who put together the Accra reset, who are standing up to the U.S. government, you know, on different issues.  I mean, there’s very difficult relationships with several large African countries with the U.S. government now, South Africa being the most obvious one, but Zimbabwe, Ghana.  Zambia just is becoming a little better.  But people do not like to be told what to do.  And I think people have felt it’s been long overdue – many people in these countries – it’s long overdue that the countries take responsibility for delivering health care to its citizens and making those decisions about what should be happening.

So there’s a lot of potential – major potential issues ahead.  What I’m hearing is that the biggest fear from Africans who work in global health is not that they can’t do the job.  PEPFAR trained tens of thousands of people to be great at their job in providing health care, from lab people to doctors to nurses to health-care outreach workers.  They’re amazing.  There’s amazing talent there.  But the issue the people that they’re talking about is, are the federal governments in Africa going to follow through, be held accountable, and get the money to places where it should go?

Dr. Bliss: Well, that’ll be your next book – (laughter) – in a few years.

But I’m going to turn to a final question now, and then we’ll hear some comments and questions from the audience that’s here in person.  Many of the personalities, of course, in the book are actually here, and so we want to hear from you.  If you have a comment or thought, please make your way to this microphone which is right here behind me so that you can see John – (laughs) – and pose your question, and we’ll have time for a few before the end of the session.

And, John, you’ve already kind of forecast this, but you know, your book, as well as other surveys and data, you know, gathered over many years, suggests that the activities of PEPFAR, you know, launched and really did support strengthened diplomatic ties between the U.S. and Africa at a period when, as you said, you know, we had seen the bombings of embassies in the late 1990s, we had September 11th, there was the Global War on Terrorism.  So, you know, against that backdrop, PEPFAR was a positive – you know, strengthened relationships and created positive goodwill.

Of course, you know, you’ve talked about the recent – the negotiated MOUs.  There’s been criticism that some of them are, you know, transactional, or overemphasize immediate benefits to the U.S. or U.S. private sector at the expense of longer alliances.  You know, that’s going to be your next book, right?  (Laughs.)  So we’ll have to wait and see how some of that plays out.

But I guess I wanted to ask you to reflect on kind of what you saw from, you know, living and – you know, really living in the region at the time and, you know, reporting from so many different countries?  You know, what do you see in terms of the legacy of PEPFAR in terms of strengthened U.S.-continental, you know, relations?  And how do you – how do you see that, you know, kind of playing out over the next several years?  Not just, you know, with respect – you talked about training of lab personnel and providers and researchers, but you know, how do you see that playing out?

Mr. Donnelly:   Yeah.  It’s a good question.

You know, you could point to all kinds of statistics that show that the U.S. – the view of the U.S. government was the highest in like 2008/2009, at the end of Bush’s term.  But there are a couple – two stories.

One is when Josh Bolten – when the Bush administration ended, Josh Bolten, who was Bush’s chief of staff, decided to go.  He was so moved by PEPFAR he decided to go and volunteer for a month in Namibia at a Maryknoll health-care center.  And he said kids would come up to him and talk to him, and he said, do you know – do you know anything about PEPFAR? And he said they thought PEPFAR was a word – that it wasn’t this awkward acronym; it was a word.  It really meant something to them, even to kids.

The second story is in 2008, when George Bush did a tour of four or five African countries, he landed in February 2008 on the tarmac, and waiting for him were not only the government dignitaries but a few hundred women, and all of them were actually wearing this.  So they were wearing this around their skirts, and on it – (holds up fabric) – see, was George Bush.  (Laughter.)  OK.  So that’s how popular the U.S. was, that 200 women would be – would be wearing this during it.

So I think, you know, now it’s – now it’s a more difficult moment.  I think even the name of the America first global health thing is very telling, and not to say, though, that a lot of – a lot of very good work has gone on in the State Department to actually come up with these agreements.

But it’s sort of a transactional time, and I think it’s not so hard for people to understand that.

Dr. Bliss: All right.  Well, thank you.

I want to invite those of you in the audience.  I know this is not a shy crowd, but please come to the mic and if you have a question please pose it.  We can – we have time for a few questions, so please.

Audience question: Thanks, Katherine.  I’m Jeff Sturchio.  I’m chairman of Friends of the Global Fight Against AIDS, TB, and Malaria.  And John, first, just congratulations on the book.  It’s – you know, for all the reasons you’ve been discussing it’s a very powerful and compelling narrative.

I wanted to just make three quick comments and a question for you.  The three comments relate to the general theme that at the time that Tony Fauci and Mark Dybul were coming up with the plan for PEPFAR and selling it to President Bush there was actually more evidence around than you get into in the book that it was going to be possible to do treatment in Africa.

One was that, first of all, the drugs were available – you just alluded to that, that they’d been introduced in the mid ’90s, and as early as 1997, Peter Piot at UNAIDS had started a program with a couple of African countries called the Drug Access Initiative to test treatment availability at that time, and this built on the kind of work that Peter Mugyenyi was doing.

That was a small effort that led in 2000 to an initiative that Piot and Gro Harlem Brundtland, at the time the DG of the WHO, were centrally involved in to get five companies and five U.N. agencies to agree on the Accelerating Access Initiative where the companies made their drugs available at significantly lowered prices, in some cases not-for-profit prices, and that really was a tipping point for access in Africa because within a few months Uganda, Rwanda, and Senegal had taken advantage of those offers and had begun to introduce small and growing treatment programs.

And then, finally, at around the same time in May of 2000, Botswana initiated a program to create a national treatment initiative that was led by Festus Mogae, the president who you allude to in the book, and Joy Phumaphi, who was health minister at the time, so that by the time that the Bush administration was floating the idea for PEPFAR and by the time of President Bush’s State of the Union address in early 2003, you already had these examples and Botswana was demonstrating – and John may have – John Lange may have a word or two to say about this since he was posted in Botswana around this time – they had already started a national treatment program and, you know, with political leadership from the top.

So and also one of the points that you allude to in the book but doesn’t really come clear is that these medicines were no longer 12,000 (dollars) per person per year, that they had come down significantly, not just through the efforts of Indian generic companies but also from the originator companies themselves based on the several years of work that had started.

So my question is I was just – I should say the – before I ask the question that I thought I knew a lot about the origins of PEPFAR.  You know, like many in the room and online I was involved in this work in those years.  But I learned things from your book that I just wasn’t aware of at all, and so it’s one side of a really good book.

But my question for you is why didn’t the – didn’t you spend more time talking about the role of the private sector in the years that PEPFAR was being conceived and introduced?

Dr. Bliss:   So let’s hold and take and few questions and then we’ll come back to you, John.  So Jirair?

Audience question:  Thanks, Katherine.  Hi, everybody.  Jirair Ratevosian, Duke University, also with CSIS.

John, thank you for this book.  I, like Jeff, have enjoyed reading it, learning about so many of the good nuggets of PEPFAR’s history and I think it should be even, you know, available to all students who are learning about health and development and more interested in foreign policy, more broadly.

Let me pick up on one of the tension pieces that Katherine was alluding to with regards to America first and ask you about this idea of health sovereignty, which is what we’re all talking about as part of this move towards greater country ownership and the Accra Reset.

But you mention in your book as early as 2004 there were tensions among who sets priorities for these countries, and I think you describe in great detail some of the tough questions coming from Nigeria and South Africa in particular.  That’s some of PEPFAR’s early leaders in that – in that year have to face and overcome to start the programs.

And so I’m curious if there – if you could reflect on that and talk specifically about what – how can it be instructive for the current moment we’re in, not only to find ways to continue to support these programs but build new partnerships in the future.

Audience question:  Thanks, John.  Thanks, Katherine.  My name is Janet Fleicshman.  I’m a senior associate here at CSIS and have worked with all of you for a very long on many of these issues.

And I wonder, John, if you could reflect on three of the issues that you haven’t really talked about that were really quite foundational for PEPFAR as it developed, one being, of course, the focus on communities and the role of civil society; the second, this shifting toward more multisectoral approaches to go upstream and pull in the development agenda to address some of the risks that people faced; and third, the focus on gender with particularly women and girls, which became one of the signature pieces of PEPFAR even under the early days of the Bush administration when they developed the first gender strategies.

And I wonder if you could talk a little bit about how that evolved in those early years of PEPFAR and what do we do now that so much of that has been erased.

Audience question:

 I had a quick question.

Dr. Bliss: Please.

Audience question:  Hi.  My name is Joann Weiner.  I’m a professor of economics at GW, and my question – I haven’t had a chance to read the book yet, but people talk about spending on one thing means we’re not spending on something else.

And so when you look at the new focus on America first, is there some sense that the money that we spent very wisely but might have been better spent elsewhere?  Thanks.

Dr. Bliss: All right. 

Well, those are all easy questions – (laughter) – that I’m sure you can answer in 10 minutes or less.  You’ve got one on the private sector, the question over health sovereignty and who sets priorities; Janet’s questions about communities, some of the multisectoral work and the gender strategies; and then what does, I think, where – what does where we’re spending, how does that show priorities.

Mr. Donnelly:   Yeah.  OK.  Thank you.  Great questions.

So, Jeff, I think – I think you’re right, there could have been more about the private sector’s role in all of this in laying the groundwork.  I think – I think the bottom line, though, and even with Botswana, which was an amazing initiative by Merck and Harvard was involved.  There’s –

Audience:  The Gates Foundation.

Mr. Donnelly: Gates Foundation, yeah.  The numbers were very small still.  And it even came up in conversations in the White House about, well, what’s happening in Botswana?  You know, is that a good thing or a bad thing?

And so there was a lot – there was – there were just still I think – I think the private sector and along with, you know, especially pharmaceutical companies that started trials that in African countries that gave drugs at a reduced rate allowed many doctors like Peter Mugyenyi to actually start these programs and start going – giving them a base to which they could then argue that we can do this.  So it was hugely important in that way.

So, Jirair, on the question on building new partnerships in the future, I think what’s happening from at least – especially from African countries at the moment is a demand that they do make decisions.  And so it’s not just about how we see the partnership, it’s about what they’re saying the partnership should be.

And so I think those – I was just in Indiana, Indianapolis University of Indiana, to talk about the book.  And there were many people there who told me – they said, I am feeling so much more empowered than I was just a few months ago or a year ago about what my country should be doing; and now we’re having these different conversations with other countries and other ministries in other countries about traveling back and forth and sharing information, and – although that happened in the past, obviously, sharing, the south-south relationships. 

But I think there’s new motivation from the African countryside to make sure that whatever happens next is more of a partnership than was before.  So I think that bodes well for country ownership, which we’ve been talking about for a long time.

And, Janet, the really good question about the three things, the communities and the multisectoral and the gender, the last chapter that I wrote in the book was about gender, actually, and because I realized it was a bit of a hole that – because it was so important, the focus on women and girls was so important since 58 percent of those infected in Africa of HIV were women, and so it – the work that started – there’s a moment in 2006 when Mark Dybul, who was then heading up PEPFAR, said we’re not doing enough on gender.

And so he asked Nomi Fuchs-Montgomery and Michele Moloney-Kitts, who was heading it, to – you know, let’s see if we can do it, and he actually gave incentives for Nomi to go and work with faith-based groups to figure out a joint strategy with faith-based groups about increasing our outreach on gender and getting more – getting more prevention tools, getting, you know, more treatment, just doing a much better job in addressing this huge gender problem.

And so, you know, as how that now plays into the future, you know, I think with USAID’s demise all these – a lot of these programs just stopped.  I don’t think these programs are dead.  I think these – I think these programs can come back in different ways.

We haven’t lost the knowledge.  We have lost the people at the moment, but I think it’s – the future is – I mean, someone once pointed out to me that Ronald Reagan, you know, wouldn’t even mention the word AIDS.  Twenty years later, George Bush is giving $15 billion in five years in AIDS in Africa.  And now we have the Trump administration, which has stopped our development institution. 

And so that, to me, is the – the thing of that is that things can change and pretty quickly.

Dr. Bliss:   Well, there were certainly many more questions that I had that I didn’t get to and I know that our audience is eager to talk with you and really pull into the book.

I did want to ask you if there were any final reflections you wanted to offer before we close our discussion.

Mr. Donnelly:   Well, thank you.  Thank you for having me here.  It’s been wonderful to talk to you and take up the questions.

And I would say that the main takeaway for me for PEPFAR is that – is that when a government decides that it wants to put the whole of government behind a problem and when a government can say these are the targets we’re going to shoot for and we’re going to hold you accountable that amazing things can happen, that there’s no – there’s no reason to give up hope that things like this can happen in the future.

Dr. Bliss: Well, John Donnelly, author of “Lifeline: The Story of PEPFAR, the Greatest Humanitarian Initiative of Our Time,” thank you very much for joining me today.

You’ve offered us all, I think, a story of inspiration, of determination, and really of hope to, you know, really be able to look back at this history and this legacy and take lessons from that that can be relevant and positive for the future.

So thank you very much.  Thank you to our audience both online and here in the room, and as we close this session let me invite the people here in this – here in person to a reception right outside.  Copies of “Lifeline” will be for sale and John has agreed to sign copies as well.

So thank you very much.

Mr. Donnelly:   Thank you.  Thank you, Katherine.

And let me also thank my mother and father for listening – (laughter) – and my Aunt Jane.  So thank you.

Dr. Bliss: Oh, very nice.

Mr. Donnelly:   Thank you, everyone.  (Applause.) 

(END.)