Toward the end of any presidential administration regardless of the party in power, there is a growing sense of urgency to complete projects and initiate new projects that might serve as a presidential legacy before the hard deadline of stepping down.
It was already clear that PEPFAR would be a major part of the Bush legacy. Now Josh Bolten, Gary Edson, and Mike Gerson were talking about whether and how to apply a PEPFAR-like approach to other diseases of global health importance, particularly malaria, tuberculosis, and what are referred to as neglected tropical diseases. These latter diseases include the helminths, or roundworms, that so often infest the gastrointestinal tracts of people (especially children) in developing countries, leading to severe malnutrition and wasting. They also include leprosy and African sleeping sickness. The mortality of these diseases is not as high as tuberculosis, malaria, or untreated HIV infection, but they cause significant morbidity and chronic suffering, as well as impede the economic development of the countries involved.
NIAID was the leading funder in the world of research on the treatment and prevention of malaria and tuberculosis. The Bill & Melinda Gates Foundation was a close second. Most malaria experts agreed that any program aimed at controlling and eliminating malaria would have to go well beyond just research support and would have to involve implementation of many of the tools that were already available to us. It was this latter step that was lagging. Mike Gerson made this his thing.
Mike had transitioned from being President Bush’s primary speechwriter to now his senior adviser and assistant. On March 7, 2005, he came to my office at the NIH for a crash course in malaria. While he was there, he wanted me to show him around the mosquito insectarium, a room full of glass cases where millions of swarming Anopheles mosquitoes are bred for a variety of experiments on malaria. A visit to the insectarium was not usually a stop on the typical NIH tour, but this showed the deep dive Mike was taking into this subject.
With Malaria 101 under his belt, Mike went on to play a major role in putting together the President’s Malaria Initiative, established in June 2005. The goal of this program was to reduce malaria-related mortality by 50 percent in fifteen highly affected countries in sub-Saharan Africa through a rapid scale-up of highly effective malaria prevention and treatment measures. These included insecticide-treated mosquito nets; indoor residual spraying with insecticides; accurate diagnosis and prompt treatment with artemisinin-based combination therapies (artemisinin is one of the most highly effective antimalarial drugs ever developed); and intermittent preventive treatment of pregnant women. Within ten years the program was associated with a dramatic decrease in annual global deaths due to malaria from more than 600,000 to about 400,000 deaths per year.
Although we had never formally met, Bill Gates was a potentially strong ally and partner in the fight against malaria. Bill, through the Bill & Melinda Gates Foundation, was agitating for the scientific and global health community to boldly consider the possibility of actually eradicating malaria from the planet, and he wanted to work with the U.S. government and NIAID in particular toward this goal.
When I finally met Bill, it was at a private dinner that he held for a group of international global health leaders. As Melinda gave the group a tour of their magnificent home, Xanadu 2.0, just outside Seattle, Bill pulled me aside for a one-on-one conversation in his elegantly appointed library. As we sat surrounded by floor-to-ceiling bookcases that reflected his reputation as a prodigious reader, he peppered me with questions about how I ran NIAID; what my management structure was for the institute; how I navigated the politics of Washington, D.C., while running a scientific enterprise; how I prioritized our research efforts; how much flexibility I had with the budget; what it was like to have put together the PEPFAR program for President Bush; and on and on. His intellectual acumen, curiosity, and willingness to learn were on clear display. I was given a quick window into what makes Bill Gates tick. Over several subsequent years we became friends and collaborated in diverse areas—not just on malaria but also on developing an HIV vaccine, and tuberculosis research and control, among other public health issues.
About 1.3 million people die from tuberculosis each year throughout the world. Although NIAID was the leading global funder of tuberculosis research, I still felt that tuberculosis research and control did not get the international attention that they deserved. I was vocal about my feelings, and I was pleased that Gary Edson and others in the Bush administration were of like minds and considered it a possible legacy item.
There was a considerable amount of scrambling at the White House to position options for the president’s consideration to include in his final State of the Union address on January 28, 2008, which increased greatly the likelihood that the initiative would be realized. As it turned out, malaria and PEPFAR were the two health issues brought up in the State of the Union address, with President Bush asking for $30 billion for PEPFAR and praising the President’s Malaria Initiative, but without committing resources to it. As much as we tried, tuberculosis did not make it into the speech.
In Washington, you never get everything you want.
On Friday afternoon, July 27, 2007, I headed to the White House as I had on countless occasions, but instead of meeting with administration officials or briefing the president, I was a guest. I was ushered into the East Room to join the seven other recipients of the National Medal of Science. This is the highest honor bestowed by the president of the United States to individuals for accomplishment in science and engineering. The White House was a couple of years behind in the actual awarding of the medals; we were receiving the 2005 medals in 2007. The conferring of the awards was a formal process with a U.S. Army officer in dress uniform announcing the name of each of us as we approached the platform, walked up to the president, and did an about-face so that the president could slip the medal over our heads from behind. When my turn came, the army officer announced into the microphone “Dr. Anthony S. Foosseee.” I do not expect everyone to intuitively know the correct Italian pronunciation of my name, which is “Fowchee.” I cut the fellow some slack and acted as if there were nothing wrong especially because the military staff in the White House are usually heroes who had almost always served one or more combat tours in Iraq or Afghanistan. But as I approached President Bush, he put his arm around me and whispered in my ear, “Hey, Tony. No sweat. Maybe this young man does not know who you are, but I certainly do. Congratulations!” Classic George W. Bush!
Secretary of State Condi Rice did not miss a beat as she approached me at the reception following the awards ceremony. She gave me a hug and with a big smile on her face said, “Congratulations, Dr. Foosseee.” I could not hold back my laughter.
I had thought that receiving the National Medal of Science from the president was the high-water mark for my professional career. Then the president one-upped me. On June 11, 2008, the White House announced that I would be receiving the Presidential Medal of Freedom for my work with HIV/AIDS and particularly my role in helping to develop the PEPFAR program. I was stunned and humbled, because this was the highest honor that could be given to a civilian by the president of the United States.
Eight days later I once again took an unusual route into the White House as I entered the East Room with my group of ten guests including Christine, Jenny, and Ali, who was still in high school. Megan was not present, because she was finishing a post-high-school gap year as a teacher’s assistant in a charter school on the South Side of Chicago. Also with us were my proud sister and brother-in-law, Denise and Jack Scorce, and several of my senior staff from NIAID. The highlight of the day for me came after the ceremony as my guests and I stood together for a photo with the president. He gave me a hug and whispered in my ear, “We love you, Tony. Thanks for all you do for our country and the world. I will not miss Washington very much when I leave, but I will miss you and people like you.”
For me, there was no doubt that President George W. Bush ranks second to none in leading efforts toward the alleviation of suffering and prevention of deaths due to infectious diseases throughout the world.
I knew that this extraordinary phase in my life would soon be coming to an end, and I wondered whether I would ever again get such an opportunity to advise a U.S. president.