The early work I did as a former president was usually the result of requests from others. I incorporated the Clinton Foundation to take the initiative in trying to meet our challenges faster, better, and at a lower cost, particularly those in which we could impact the most lives. This section contains stories of the people doing that work, the dedicated donors who helped them, and the people whose lives they saved or improved.
From 2002 on, I invested more and more time in the work of the foundation, starting with efforts to be helpful to my neighbors, particularly small businesspeople, in Harlem. Our first foundation initiative there helped a wide variety of small businesses with consulting and equipment, including a hat store, a card store, a pharmacy, a dentist office, an insurance agency, a soul food restaurant, a video store, a plumbing operation, and two new florists. At its peak the initiative had more than one hundred experts helping small Harlem businesses.
But I also wanted to do more on the AIDS crisis. I was Arkansas’s governor in 1984 when Ruth Coker Burks, whom I’d known since she was a kid and who would come to be known as the “Cemetery Angel,” went to a local hospital to visit a friend and saw an AIDS patient obviously near death, alone. She went into his room and sat on his bed. He said he wanted to see his mother. The duty nurse told Ruth that his mother wasn’t coming, that nobody came to see “them.” She went back to his bedside and held his hand until he died. When she arranged for his burial, she learned that only one local funeral home would take him and then only for cremation. So she paid for that and buried his ashes in her little family cemetery west of town.
When word got around, other people with AIDS started coming to her, a white, straight, religious working mother revolted by the stigma, rejection, and fear being visited on her fellow human beings. Over the next decade, often with her daughter in tow, Ruth buried thirty-nine more people in her family cemetery, and consoled and supported hundreds of others. She wrote about it in her moving book, All the Young Men, a powerful reminder of what it was like during the early days of AIDS in the U.S. Hillary and I had lost close friends to AIDS in the 1980s. In the 1992 campaign, when I was confronted by AIDS activists in New York, I promised to work hard to fight stigma, increase care, and accelerate the search for effective treatment.
My 1992 Democratic convention featured the landmark speeches by AIDS activists Elizabeth Glaser and Bob Hattoy, both of whom were tireless advocates for more aggressive policies until AIDS claimed their lives, Elizabeth in 1994, Bob in 2007.
Another person AIDS brought into our orbit in the 1992 campaign was Magic Johnson, who endorsed me because he was determined to live a full life with AIDS and wanted others to have the same chance. It was the beginning of a lifelong friendship with Hillary and me, including his support in both her presidential campaigns.
I also met Ricky Ray and his family. He and his brother were hemophiliacs who contracted AIDS through blood transfusions. They were shunned at school. When I was elected, I called Ricky and invited him to my inauguration. Sadly, he died a few weeks before I was sworn in, but his family came in his honor and for eight years I kept a photo of Ricky in the hallway to my private study and dining room next to the Oval Office.
When I was president, we doubled funding for AIDS care in the United States and increased support for the research and development funds that hastened the availability of the first antiretroviral AIDS medications, or ARVs, which by the mid-nineties turned the virus from a death sentence into a chronic disease. By early 1996, we had cut the FDA approval process from thirty-three months to just under a year, and the latest AIDS drug was approved in just forty-two days.
The story in the developing world was very different. We had tripled overseas funding and been active in all the groundwork to establish the Global Fund to Fight AIDS, Tuberculosis, and Malaria, which was formally launched just after I left office, but it wasn’t nearly enough. We needed more money, less stigma, and an effective pushback against the organized interests and widespread myths that stood in the way of saving lives and slowing the epidemic.
The argument often advanced by those opposed to getting ARVs to people in poor countries was that poor sick people wouldn’t figure out how to take three separate pills every day, even if their lives depended on it. Not true. In 2001, I visited the neighborhood AIDS clinic near my office in Harlem, where low-income patients took their medicine more than 90 percent of the time. Many lives were being saved, but it cost $10,000 a year, covered by Medicaid for the poor in the United States, but still far beyond the means of citizens or governments in developing countries. India was producing generic ARVs at a cost of $500 per person a year, but most low-income countries still couldn’t afford anywhere near enough of them to stem the tide.
Also, the big drug companies were lobbying hard against the U.S. and other nations funding the generic versions of ARVs and allowing them to be sold outside the countries where they were produced, claiming that the countries with the largest numbers of people with AIDS lacked the trained staff and laboratory equipment to administer them effectively and to provide the necessary follow-up; that corrupt governments would sell the drugs back into the U.S. and other rich countries, undercutting the protection their patents gave for the large investments necessary to develop the medicines; and that generic drugs were much less effective than their original, patented products.
Even some people in the public health community seemed to agree that getting ARVs to people in poor countries where the epidemic was raging was a fool’s errand. They thought the effort would fail because you can’t just give people pills; you have to treat them, monitor their compliance, and have the ability to stay in touch and do follow-ups. A lot of experienced and caring people thought it couldn’t be done.
Brazil had proven them wrong. Defying Big Pharma pressure, their domestic drug production facilities had begun to produce ARVs and successfully distribute them, even to remote tribes deep in the Amazon rainforest, with a remarkable coalition that included the government, the Catholic Church, tribal leaders, and other volunteers. About 180,000 people were receiving the medicine in color-coded cartons to remind them that they had to take three pills a day, every day. Soon they produced a study showing it was cheaper to keep people alive than to let them die in a local clinic or hospital, then have to bury them. Within three years, the death rate had been cut in half and hospitalizations of AIDS patients decreased 80 percent. But outside Brazil, fewer than 100,000 people in low-income countries were receiving medication.
The naysayers were also proved wrong in the Caribbean, where Haiti had the highest infection rate. Dr. Paul Farmer, whose clinic in the Central Highlands had gotten enough medicine to save a few hundred lives, spoke out forcefully against the inhumanity of providing treatment solely in the richest nations. So did Dr. Bill Pape, who had founded the world’s first AIDS clinic in Port-au-Prince in 1982.
Soon after I left office, Sandy Thurman, who had led our White House AIDS office and was still active from her home base in Atlanta, asked me to join Nelson Mandela in cochairing the International AIDS Trust, a group of prominent citizens, including several former national leaders, who agreed to urge wealthy nations to devote much more money to fighting AIDS in poor countries by providing education, prevention, and treatment. I agreed to do it, hoping Mandela and I could raise more money and increase acceptance of the idea that treatment should expand beyond countries with good health systems and the money to pay for the medicine.
Three million people were dying every year. At least six million people were already so sick they needed medicine to survive. And an estimated thirty million people were already infected, most of whom weren’t yet sick enough to know it. We had to do more. When Mandela and I were asked to speak to the biannual International AIDS Summit in Barcelona, Spain, in 2002, I had already given speeches to the National AIDS Trust in London and to the African AIDS Summit in Abuja, Nigeria, where I met Muammar Gaddafi for the first and only time.
Gaddafi was in an expansive mood and suggested we should arrange a marriage between his son and Chelsea and “launch a dynasty.” Without laughing I explained that in our culture the decision was my daughter’s, not mine, but that I would relay his proposal as soon as I got home. When I did, Chelsea, also straight-faced, said, “Dad, I think I’ll pass.”
In Barcelona, Mandela and I agreed to focus on the moral imperative of getting the ARVs to the people who needed them most. He said he would do all he could, especially in South Africa, where his chosen successor, Thabo Mbeki, seemed to be dealing with the world’s largest AIDS population with a combination of denial and resentment. I liked Mbeki and hoped I could change his mind.
Regardless, Mandela said, for the sake of Africa and countries around the world without the resources and capacity to deal with the epidemic already well underway, I had to do more now while I still knew leaders personally and had their confidence and trust. That’s exactly what I wanted to do. Remember, the Global Fund had just been established and not funded, and President Bush’s PEPFAR program, the President’s Emergency Plan for AIDS Relief, was not yet up and running.
On July 12, 2002, when Mandela and I walked on the stage to give the closing remarks to the biannual International AIDS Summit, 10,000 activists, health officials, and scientists cheered, glad to have our support, and wondering what we would say. I went first, saying we needed less stigma and denial, much more prevention and treatment. Now that lifesaving ARVs were available and being produced in India and a few other countries, we needed a lot more money and lower prices. I acknowledged my own error in opposing needle exchange programs in the U.S. and, until near the end of my term, the sale of generic ARVs outside the countries that produced them. I urged the big pharmaceutical companies to reduce prices to lower-income countries and said if they didn’t, the affected nations should be able to get generic drugs from India and other producers with help from wealthy countries donating at least $10 billion to the new Global Fund.
Then I introduced Mandela, eighty-four and using a cane, but still full of passion. He spoke about a young HIV-positive woman from a Pacific island nation who was in the audience, saying that he had been so moved by her presentation at an AIDS meeting that he bought her the medicine to stay alive. Then he had her stand, living proof that everyone with HIV/AIDS deserved treatment “no matter where they live or whether they can afford to pay.” This all sounds so obvious today. Then it was a radical departure from the consensus in wealthy nations that treatment was both unaffordable and undeliverable. Now that we knew it wasn’t true, we had to deliver.
After our speeches, Denzil Douglas, prime minister of St. Kitts and Nevis, came up to me and said we were on the right track. He was a doctor and head of the eastern Caribbean countries’ AIDS efforts, an important responsibility since the Caribbean had the second-fastest-growing AIDS rate after Africa. Denzil said, “We don’t have a denial problem or a stigma problem. We have a money problem and an organization problem.” I had a lot of respect for Douglas, so I asked, “Denzil, what do you want me to do about it?” He answered, “I want you to fix it.” I immediately said, “Okay.” I wasn’t sure how to start, but it seemed to me that, rather than just asking for money for a fund with as many questions as answers, we should get to work in nations creating lifesaving operations worth investing in.
Ira Magaziner was also at the conference. When I was in the White House, he had worked with Hillary on healthcare reform in my first term and led our effort to jump-start e-commerce in the second. We had already discussed my desire to do something on AIDS and he’d written me two memos suggesting how to do it, so I encouraged him to come to Barcelona. He did and had his own discussions with African and Caribbean leaders who were there. After we got back, Ira sent me a letter saying that I could have an impact in countries coping with AIDS—not just in Africa and the Caribbean but in other places where the AIDS problem was worsening rapidly, including Russia and Eastern Europe, China, India, and other countries in Asia—by raising money from nations, foundations, and individual donors to fund and set up effective treatment programs.
Ira said he would be willing to organize and lead our efforts for a while without pay to see what we could do. He had built a successful corporate consulting business so he had the knowledge, experience, and means to take on the challenge. I was glad he agreed to do it because I couldn’t do it full-time with my other obligations to pay my debts, finish building my library and presidential center in Arkansas, and get the rest of the foundation going in New York.
We decided to work first on trying to get more ARVs at lower prices to countries that wanted us to help. I would ask a few donor nations to allocate $100 million over five years to help pay for medicines and strengthen programs in countries they would choose, and Ira would go to the Caribbean and to Africa to see who was most eager and able to ramp up their efforts.
Just a few days after we got back from Barcelona, Ira called to say that, in the Bahamas, a dedicated group led by Dr. Perry Gomez and Mrs. Rosa Mae Bain had been providing AIDS care since the early 1980s, and had raised private funds to put a couple of hundred people on ARVs. But they were paying up to $3,500 a year for generic drugs the Indian manufacturers priced at $500. The drugs they ordered were going through two middlemen who were charging exorbitant markups—that’s how distorted and disorganized the market was.
As president, I had established good relations between the United States and India for the first time in thirty years and I knew the companies were pleased that Mandela and I were pushing their products. I was confident we could fix this. I asked Ira to try to convince the companies to ship directly to the Bahamas at $500 plus freight costs, which meant that with current spending they could greatly increase the number of people on ARVs, then fewer than two hundred. He did and they agreed.
I knew this would be our easiest win, but it set a pattern. I would raise money and open doors, and Ira would work with governments to set up operations and systems to get the best possible prices in the most efficient, least costly way. We agreed that he would hire good people, make sure they understood the mission, and let them do their jobs.
Ira’s first trip to Africa resulted in agreements with Rwanda, Tanzania, and Mozambique, soon followed by Lesotho and South Africa. Our first donors were Ireland and Canada, whose prime ministers, Bertie Ahern and Jean Chrétien, were good friends of mine. I had worked closely with Bertie Ahern on the peace process in Northern Ireland, and with Jean Chrétien on ending ethnic cleansing in Bosnia and Kosovo, restoring democracy to Haiti, expanding NATO, and supporting a unified Canada in the run-up to the separatist referendum in Quebec. Soon Norway, Sweden, France, Australia, and the U.K. also had made generous commitments, as had other nations in smaller but much needed amounts.
From the start, all the donor governments’ money went directly to the AIDS-affected governments to fund medicines, the necessary testing and equipment for it, and treatment clinics. What was then called the Clinton HIV/AIDS Initiative (now CHAI, the Clinton Health Access Initiative, a name we adopted as we took on more health challenges and one I’ll use from now on) drew up the contracts, with strict accountability, transparency, and anticorruption requirements that we monitored. But I wanted the governments to handle the money, and in so doing to increase their capacity for honest, competent governance in healthcare and other areas.
We also depended on generous individuals, mostly from the United States, Canada, the U.K., and in the Bahamas local businesspeople, to give us the money to operate. Our first major contributor to the Caribbean effort was a Chicago media executive, Fred Eychaner. He had been a supporter and a friend during my years in the White House, and he was enthusiastic in embracing this effort. In those first few years, we also depended heavily on volunteers. Within two years, we had forty full-time staff and more than one hundred volunteers in twenty countries, including the African nations I mentioned with more than 30 percent of the continent’s AIDS population; thirteen Caribbean nations, with more than 45 percent of the region’s cases; and India and China, with 90 percent of Asia’s people with AIDS.
In 2003, we made our first major breakthrough in generic drug prices when the major Indian producers Cipla, Ranbaxy, and Matrix, and a South African company, Aspen, agreed to drop the sale price on all contracts from $600 to $169. As their volume grew, they reduced the price more, to $140, and eventually to $90, about 37 cents a day. The Indian companies welcomed our efforts to help them change their business model and lower their prices, not just by increasing their sales dramatically, but also by improving their production and delivery processes.
When we started working with the generic producers, the companies were selling the drugs, even at $500 per person per year, the same way an independent jewelry store operates: it was a low-volume, high-margin, uncertain payment business. Remember, at the time, in developing nations, there were fewer than 100,000 people outside Brazil—only 50,000 in sub-Saharan Africa—getting the ARVs. After South Africa, India had the largest AIDS population at 4.6 million and the Indian companies had already lowered the price there to about $365 per person, still too high for a nation with a per capita income of $500 per year. At the beginning, there were only a few international, government, or foundation funding sources led by the World Bank and the Bill & Melinda Gates Foundation, providing $95 million a year, bringing total spending in developing countries to about $24 per year per person infected. The massive funding from the Global Fund, President Bush’s PEPFAR program, UNITAID, and others was yet to come.
As donor governments made the commitments, CHAI worked with drug manufacturers and the governments in Africa and the Caribbean to build a big supermarket-chain business model: a huge-volume, low-margin, certain and prompt payment business. By early 2004, we also had agreements reflecting that approach with the major European and U.S. companies providing the diagnostic testing and equipment essential to the effective administration and monitoring of the medicine. We also made agreements that enabled thirty more countries where we had no staff to buy medicines and tests based on our low-cost contracts. We never asked producers to lose money—that would have been unsustainable—but to make money in a way that would save the maximum number of lives, using the business model which CHAI would apply, over and over, in other settings and with other health challenges, to save lives by making the building blocks of survival available to more people more quickly at lower cost.
As of this writing, after more than twenty years, CHAI has grown into an amazing organization with a proud legacy. Today there are more than 1,000 people working all over the world. The central office started and remains in Massachusetts, but the senior management comes from around the world. Eighty countries buy their ARVs off contracts negotiated by CHAI, covering more than 28 million people, more than two thirds of the adults on treatment. More than 900,000 children are being kept alive by CHAI-negotiated ARVs, more than 80 percent of the children in the world on treatment. Along with HIV/AIDS, CHAI has taken on malaria, tuberculosis, and early childhood diarrhea; helped Dr. Paul Farmer and Partners in Health build a network of hospitals, including a cancer center in Rwanda, and organized two dozen partners to retrain and improve the healthcare workforce there; built hundreds of clinics in Ethiopia; reduced the threat of hepatitis C; improved women’s reproductive health; and so much more, including brave service in Liberia during the Ebola crisis and providing valuable service to the World Health Organization and fifteen countries in Africa and Asia from the early days of the Covid pandemic.
All told, CHAI has offices in 37 countries, works with governments on specific programs in 39 more, and has negotiated price reductions for medicines, diagnostics, vaccines, and other lifesaving devices, products, and services now available in more than 125 countries. How this all happened is enough to fill a book, but I think you’ll get a feel for it in these accounts of people serving and people saved.