Over the past 30 years, five U.S. Commanders in Chief have led the nation’s response to the HIV/AIDS epidemic. Who gets good marks? From 1981 to the present, we assess each president’s leadership.
Ronald Reagan (1981-1989)
Biggest Hits: Allowed Surgeon General C. Everett Koop to send a letter to all Americans about AIDS.
Biggest Misses: Ignored the disease for years. Failed to rally public awareness and support. Imposed mandatory HIV testing in numerous federal programs.
The AIDS epidemic arose during his first year in office, yet no U.S. president demonstrated less leadership about the disease or a greater lack of concern for its sufferers than Ronald Reagan. Strongly influenced by the so-called Moral Majority, which believed that AIDS was God’s punishment to gay men and IV drug users, the Reagan administration failed to mount a meaningful public health response at a time when aggressive action might have curbed what would become the greatest public health catastrophe of the 20th century. Ignoring the overwhelming opinion of medical and public health experts, Reagan pursued mandatory HIV testing in federal programs as the centerpiece of his AIDS policy.
While the Reagan administration allocated some funding for research, it wasn’t until 1986 that Reagan’s Surgeon General C. Everett Koop – aided by a small team that included Dr. Anthony Faucci, the head of AIDS research at the National Institutes of Health – effectively executed an end run around the rest of the administration. Dr. Koop published a Surgeon General’s report that not only explained AIDS, its risk factors and how to prevent the disease to the American public, but that also included information about condoms and sex education that differed from the administration’s more conservative approach. (In 1988 Dr. Koop also sent a mailing about AIDS to every household in the U.S.) Ironically President Reagan, nicknamed The Great Communicator, didn’t give his first speech on AIDS until 1987. By then over 36,000 Americans had been diagnosed with the disease and 20,000 people had died, including his dear friend Rock Hudson. Shortly after speaking out he established the President’s Commission on the HIV Epidemic, whose findings activists say, he largely ignored.
Grade: F
George Herbert Walker Bush (1989-1993)
Biggest Hits: Signed Ryan White CARE Act and Americans with Disabilities, and met with the National Commission on AIDS.
Biggest Misses: Refused to support full funding for Ryan White. Largely ignored the recommendations of the National Commission on AIDS.
He was Vice President when the Reagan Administration failed to launch an effective approach to the burgeoning epidemic. And while he never implemented a comprehensive strategic response of his own, President Bush did take two very important steps that provided much-needed services to people living with HIV/AIDS (PLWHA). First, President Bush signed the Ryan White Comprehensive AIDS Resources Emergency (CARE) Act, providing $882 million in federal grants to the hardest-hit cities and all 50 states to care for people living with HIV/AIDS (PLWHA) and their families. Second, President Bush signed the Americans with Disabilities Act, prohibiting discrimination against people with disabilities, including PLWHA.
Grade: C
William J. Clinton (1993-2001)
Biggest Hits: Supported robust funding increases for AIDS treatment and Ryan White services. Rallied public support for the fight against AIDS. Supported creation of the Minority AIDS Initiative as part of the Ryan White programs. Approved notable funding increases for global AIDS at the end of his second term.
Biggest Misses: Failed to approve federal funding for needle exchange. Failed in his effort to achieve comprehensive health care reform.
President Clinton failed in his 1994 attempt to achieve national health coverage through a universal health care plan. But he succeeded in bolstering the country’s response to the AIDS epidemic, elevating AIDS to the level of a White House office by establishing the Office of National AIDS Policy and creating the President’s Advisory Council on HIV/AIDS (PACHA). Funding for AIDS programs increased on his watch, including to the Minority AIDS Initiative directed towards communities of color. His administration also initiated outreach to educate Black leaders about AIDS’ disproportionate impact on their constituents.
The Clinton administration launched the national effort to discover an AIDS vaccine and reorganized the AIDS research program at NIH. As well, that reorganization improved coordination and strategic focus.In 1995 President Clinton signed the Family Medical Leave Act, allowing employees to take unpaid leave for a pregnancy or serious medical condition. And after killing the first version of the bill, he eventually signed the Children’s Health Insurance Program, providing health coverage to low-income children and pregnant women.
The global impact of what was rapidly becoming an HIV/AIDS pandemic began to be felt during the middle of his term. By then the president’s effectiveness was hampered and he failed to fund needle exchange programs to prevent new infections because he believed “politically the country wasn’t ready”. Since leaving office President Clinton has become one of the most effective HIV/AIDS ambassadors in the world. Through the William J. Clinton Foundation, he has played an integral role in convincing heads of state and industry leaders to focus on HIV/ADIS and negotiating price reductions in antiretroviral medications for millions of PLWHA worldwide.
Grade: B
George W. Bush (2001-2009)
Biggest Hits: Created the largest global health program in history to tackle a single disease, delivering life-saving antiretroviral therapy to millions of people in poor countries and transforming the global AIDS response.
Biggest Misses: Paid very little attention to domestic epidemic, watching while waiting lists for AIDS Drug Assistance Programs emerged and particularly shortchanging prevention programs. Limited the prevention impact of U.S. global AIDS programs by favoring unproven abstinence-only programs and by imposing restrictions on organizations serving sex workers.
While his father strengthened the domestic response after years of inaction under President Reagan, the second President Bush largely turned his back on the domestic epidemic. Not only did he barely convene PACHA, the Bush administration’s investment in the domestic epidemic was lackluster at best, barely keeping pace with inflation. For every dollar the Bush administration spent on AIDS domestically, it spent only 4 cents on prevention. He also failed to implement meaningful reform during the prescription drug plan, which many say turned into a give-away to pharmaceutical companies.
But while Bush II failed to carry out a vision at home, globally he showed significant leadership in the form of his landmark 2003 legislation the President’s Emergency Plan for AIDS Relief (PEPFAR), a $15 billion, 5-year strategy to fight the epidemic in 15 severely affected African nations. Renewed by the Obama administration, to date PEPFAR claims that nearly 33 million people have been counseled and tested, 3 million people have started on treatment and in 2010 alone 114,000 mother-to-child transmissions have been prevented, worldwide. Although PEPFAR has literally changed our world, some of the Bush administration’s policies limited its effectiveness. In particular, the administration prioritized abstinence-only funding over comprehensive prevention measures, an approach that critics contend allowed Uganda’s epidemic to rebound after years of success. In addition, the administration required recipients of PEPFAR support to pledge their opposition to sex work, undercutting the effectiveness of efforts to engage sex workers in prevention programs.
Meanwhile the virus devastated Black communities in the U.S. By 2009 Black America was suffering the equivalent of the world’s 16th largest AIDS epidemic, which would have qualified it for PEPFAR had that program existed at home. President Bush also vetoed two attempts to expand funding for the SCHIP program.
Grade: C-
Barack H. Obama (2009-Present)
Biggest Hits: Launched National HIV/AIDS Strategy. Achieved comprehensive health care reform. Lifted longstanding HIV immigration ban and previous bar on federal funding for needle exchange. Revitalized PACHA and Office of National AIDS Policy.
Biggest Misses: Failed to ensure that domestic AIDS funding keeps pace with need. Supported only modest funding increases for global AIDS spending.
Before he entered office our nation’s first Black president had already spoken at length about the need for personal and professional leadership on AIDS. He’d also walked the talk by getting tested publically. Once in office he moved fairly quickly on two fronts: repealing the ban against PLWHA traveling to the United States and ending the federal prohibition against needle exchange in Washington, D.C.
He also maneuvered through political landmines, orchestrating the passage of the Affordable Care Act (ACA), which majority whip James Clyburn, the most powerful Black member of the U.S. House of Representatives, called “the Civil Rights Act of the 21st century”. Although now being vigorously fought by its detractors, the ACA will ensure health insurance coverage for 32 million uninsured Americans, close the drug assistance donut hole, prevent insurance companies from denying coverage to those with “pre-existing conditions,” and prohibits lifetime caps on the amount of health care an insurance plan will provide.
But the publication of our country’s first National HIV/AIDS Strategy in the 30-year history of the epidemic ranks as perhaps the most notable HIV/AIDS-related accomplishment by any U.S. president in the 30-year history of the epidemic. With its goal of reducing new infections 25 percent by 2015, the NHAS sets forth aggressive goals and accountability for all departments in the federal government.
Still, the NHAS must be carried out in the worst economic climate since the Great Depression – one that has blown holes in state ADAP budgets. (The administration did provide $25M in emergency funding.) In our opinion the president’s FY2012 budget came up a little short, with no increases to the Minority AIDS Initiative and too few dollars allocated to drive the nation toward its 2015 prevention goal. Still, we’re cautiously optimistic.
Grade: Incomplete