FEATURE ARTICLE

The 21 Years War: The Truth and Records of How HIV Infected Four Successive US Presidencies

by Benjamin Ryan

The battle lines were drawn simply and with little fanfare. In September 1981, the US Senate over-rode newly elected President Ronald Reagan's veto of $500,000 in emergency research funds for the Center for Disease Control and Prevention to study a mysterious set of deaths in New York and California. It was the opening salvo in the struggle between the new conservative movement and an entrenched liberalism still unaware of the political ground shifting beneath its feet.

In the 21 tumultuous years since then, four presidents--three Republicans and one Democrat--have presided over the federal government's estimated $100 billion targeted for the war against HIV/AIDS. Ironically, the biological battle between the deadly virus and the critical cells that are supposed to protect the body from harmful attacks is also a tragic metaphor for the larger political struggle. For if America is our vulnerable body, the besieged T-cells can be seen as the failure of our four presidents, weakened by ideology, to protect us from the invading enemy, HIV.

Perhaps it is faulty reasoning to place so much emphasis and expectation on each successive commander-in-chief. After all, the framers of the Constitution designed the federal government so that three separate branches wield power, with no one branch carrying an undue burden or influence. Nonetheless, each president becomes a bulls-eye for blame, for with the job comes the promise of leadership, the sounding of a clarion call for a national mission and the issuance of directives to be followed by commanders in the field.

Yet the war is far from over. And unlike a standard military engagement, no one has accepted responsibility for the deaths of thousands of American citizens--men, women, and children--who had faith that their government, and especially their president, would protect them in times of crisis. That belief was killed before AIDS claimed their bodies. It is now up to history to explain what happened.

Ronald Reagan: (1981-88)

When Conservatism Killed

Some believe that President Reagan's neglect of and even belligerence towards the burgeoning AIDS crisis in the early 1980s stemmed from personal discomfort with homosexuality. But his attitude was more likely a result of his political ideology. As the heralded standard-bearer of the new conservatism, Reagan believed in a smaller federal government and emphasis on "personal responsibility." That philosophy began to permeate the governmental infrastructure, creating an environment that was intrinsically inhospitable to the outbreak even before the medical community understood the implications of the disease. Steadfast in his assertion that he would neither raise taxes nor moderate his plans to escalate defense spending, Reagan decided to pillage and dismantle national programs that he felt should be administered under local control.

Only weeks into office, Reagan proposed slashing in half the Centers for Disease Control and Prevention's 1982 budget; he eventually secured a 13 percent cut. Health officials voiced serious concerns, but to no avail. The already underfunded CDC was considered just another federal bureaucracy, not the government's scientific center for fighting disease outbreaks. The cuts had a tragic effect: few scientists were trained as retrovirologists, the specialty necessary to study HIV.

As the first cases of "Gay Cancer" appeared in 1981 and the US Department of Health and Human Services (HHS) awoke to the growing crisis, a protracted, nightmarish fiscal tug-of-war with the president began. Though Assistant Secretary of Health Edward Brandt proclaimed AIDS the nation's "No. 1 health priority" in 1983, President Reagan opposed all new federal AIDS funding until 1984, ensuring that 95 percent of expenditures were siphoned from pre-existing programs. The Administration's budget proposals between FY1984 and FY1987 averaged 35 percent less than monies requested by the Public Health Service and 45 percent less than what Congress appropriated. In fact, in 1984, President Reagan nixed all but $500,000 of an $8.35 million appropriation to expedite development of the HTLV-III (soon renamed HIV) antibody test. And as late as 1985, the year his friend Rock Hudson died of the disease, President Reagan recommended cutting AIDS spending from $95 million to $85.5 million.

The growing AIDS community clamored about the numerous government reports issued throughout the Reagan presidency that stridently decried the Administration for its financial cold shoulder, lack of leadership, and delay of action in the face of a national health crisis. His first plan for educating the public about AIDS didn't come until 1987. It emphasized "responsible sexual behavior" placing sexuality within the context of marriage" at a time when gays made up about 70 percent of all AIDS cases. In his extremely belated first public address on AIDS, President Reagan went against the advice of his hand-picked conservative Surgeon General C. Everett Koop when he proposed mandatory testing as the answer to the spreading epidemic.

By 1987, in the twilight of his presidency, Reagan could no longer ignore the disaster at his feet, and he begrudgingly took a few meager steps forward. He established the President's Commission on the HIV Epidemic, countered in Congress by the Helms Amendment, which to this day prohibits federal funding for AIDS education that appears to encourage homosexual activity. In 1988, the president's Commission released a scathing report that he largely ignored. Meanwhile, with federal AIDS spending swelling to $1.6 billion, Congress passed the Health Omnibus Programs Extension Act, which authorized federal spending on AIDS education and HIV testing.

By the end of his two terms in office, President Reagan, much like President Lyndon Johnson before him, was saddled with two distinct legacies. While President Johnson is remembered both for signing the 1964 Civil Rights Act and escalating the tragic Vietnam War, President Reagan is both commemorated as conservatism's shining hero and to those who watched thousands of their friends and family die of AIDS, the president who did little to stop the growing pandemic of HIV/AIDS.

George Bush: (1988-92)

Waking Up and Acting Up

It might be easy to confuse Ronald Reagan's record with his successor, George Herbert Walker Bush. Indeed, as the new, very vociferous ACT UP pointed out, Bush often ignored the criticisms of government reports and maintained a conspicuous silence on AIDS during his tenure as Reagan's vice president.

And yet it was Bush who quietly and successfully pressured the Food and Drug Administration into accelerating the approval process for new medications in 1988.

But Bush wanted to become president, and that meant catering to and becoming deeply indebted to the Christian Right. In the eleven years since Anita Byrant's antigay "Children's Crusade" and the launch of the Rev. Jerry Falwell's Moral Majority, the conservative religious right had been steadily gaining political ground. They claimed credit for electing their hero Ronald Reagan and, in 1988, hoped to catapult antigay Rev. Pat Robertson into office. When Robertson's Republican primary effort failed (he went on to found the Christian Coalition), religious conservatives lent their tepid support to Bush.

Bush was not alone in courting right-wing conservatives. Years later, Timothy Westmoreland, the openly gay former deputy to California Democratic Congressman Henry Waxman, reported what everyone in Washington already knew--that numerous officials from both the Bush and Reagan Administrations bent over backward to curtail the fight against AIDS in order to avoid alienating conservatives.

But President Bush proved to be less rigid than President Reagan had been, and he signed into law critical advancements brought by Congress. In 1990, Congress passed the Ryan White CARE Act, which provides emergency relief grants to hard-hit communities and includes the AIDS Drug Assistance Program (ADAP). The same year, with emphatic encouragement from President Bush, the Americans with Disabilities Act (ADA) became law; it provided major anti-discrimination protection for people with HIV and AIDS. And in 1991, federal housing assistance was provided by the Housing Opportunities for People with AIDS Act (HOPWA).

Meanwhile, America was being hit by what AIDS activists called "the second wave" of AIDS deaths. It was more like a tsunami. Day after day, from urban streets to the hinterlands, scores of people with AIDS died, often alone, afraid, rejected, and stigmatized. A 1989 report from the Bush-appointed National Commission on AIDS decried the lack of a national plan to fight AIDS. The following year, they called efforts to combat the disease "an orchestra without a conductor." HIV-positive basketball star and Commission member Magic Johnson quit in protest in 1991 after the Commission's third report noted that the president had "utterly ignored" their previous recommendations. The Commission blasted President Bush for failing to lift the ban on federal funding for needle-exchange programs, thus favoring law enforcement's war on drugs over intervention and treatment for injection drug users who spread HIV by sharing needles. Critics also slammed President Bush for reneging on his pledge to repeal the 1989 Helms-sponsored ban on US immigration and travel for HIV-positive foreigners.

Bill Clinton: ()

Promises, Hope, and Dismay

President Bush, with sky-high post-Gulf War popularity ratings, seemed destined for a second term. But a photo-op of him gazing in wonderment at a supermarket checkout scanner came to symbolize a president who was out of touch with regular Americans and the economic downturn. "It's the economy, stupid," became the battle cry of the nation's first rock-and-roll presidential candidate, William Jefferson Clinton.

Candidate Clinton offered gays, minorities, women, and most especially, people with HIV/AIDS something they had dared not dream was possible: hope. At an historic May 1992 fundraiser at the Palace in Los Angeles, Clinton went off his script in an ad lib that brought even hardened activists to tears. "If I could wave my arm for those of you that are HIV-positive and make it go away tomorrow, I would do it-so help me God, I would," the presidential candidate from Arkansas said, waving his hand over an awe-struck crowd. "If I gave up my race for the White House and everything else, I would do that."

Clinton relied on expert advice from friends who were gay and from people with AIDS. His impressive campaign pledges included increased spending for research, care and prevention; a repeal of the immigration ban; sped-up FDA approval of drugs; stricter antidiscrimination laws; an all-out "Manhattan Project" to battle AIDS; and an "AIDS czar" to spearhead the fight across the board. He insisted on having two people with AIDS -Elizabeth Glazer and Bob Hattoy- speakers at the Democratic National Convention. In contrast, the Republican Convention in Houston went down in history for its vicious attacks on gays and PWAs by Pat Buchanan. Trying to soften the hard line convention, President Bush invited HIV-positive mother and artist Mary Fisher, the daughter of his campaign finance chair, to speak. Her remarks, which included a public embrace of HIV-positive gays, moved a some Republicans on the convention floor to tears.

President Clinton's mention of AIDS in his victory and election day speeches made history. But in what became a Clintonian trend, his lofty promises would come back to haunt him as the centrist president caved to political pressures after the early "gays-in-the-military" debacle. He hit the ground running with demands for a 28 percent increase in AIDS research and treatment funding and by creating a task force for accelerating anti-HIV drugs through the pipeline. He also supported the NIH Revitalization Act, morphing the promised Manhattan Project into the new Office of AIDS Research at NIH with enhanced authority to oversee all AIDS research. But he stumbled on other issues, such as caving in to Congress' overwhelming vote to maintain the HIV immigration ban.

But perhaps the biggest political wake-up call of all for the new president was the intense backlash that developed against his promised healthcare plan. The Baby Boomer "we can change the world" exuberance that Bill and Hillary Clinton and their young staff brought to the White House was quickly construed as arrogance, a perception that was underscored when the president put his smart but unelected wife in charge of developing the massive plan. The first lady refused to hold public hearings or to involve her political opponents in the policy discussions, and all hell broke loose. The effort collapsed after the insurance industry ran the effective "Harry and Louise" commercials, and the public chimed in with orchestrated faxes generated by "Clinton-hating" right-wing talk show hosts. The result was that primarily Medicaid/Medicare-dependent PWAs were left without a dependable healthcare safety net. Another attempt by Vice President Al Gore to extend Medicaid to all PWAs also failed.

The significant defeat of the healthcare initiative, the drubbing over gays in the military, and the overwhelming conservative victory in the 1994 Congressional elections left President Clinton weak. Even longtime friends proved expendable when he saw that they might cost him political capital. For instance, in 1994 he bowed to conservative pressure and fired Surgeon General Jocelyn Elders, his longtime friend and former head of Arkansas's Health department. The outspoken African American, set up for a trick political question, acknowledged that perhaps masturbation should be a subject taught in sex education as another method to reduce HIV infection rates. Right-wingers had a field day.

Faced with a Republican-dominated Congress that hated him, President Clinton did what he could. He created a strong President's Advisory Council on HIV/AIDS (PACHA) chaired by Dr. Scott Hitt, and he held an historic White House Conference on HIV/AIDS that was televised live on C-SPAN. His first two appointees to the new position of National AIDS Policy Coordinator were lackluster "AIDS czars," hampered by a paucity of funds, little access to his office, and a dubious job description. But his third appointee in 1997, Atlanta AIDS activist Sandra L. Thurman, was well-liked, understood the issues from both a governmental and grassroots perspective, and fought hard for respect and credibility.

But for all her access to the president, Thurman was stymied inside the White House by Drug czar Gen. Barry McCaffrey, who believed that lifting the ban on needle-exchange programs would increase drug abuse. Even in 1998, when Health and Human Services Secretary Donna Shalala was prepared to lift the ban, having finally studied all the private and governmental studies indicating that needle-exchange programs are effective in helping prevent the spread of HIV, President Clinton refused to proceed for fear of the political uproar. Several members of PACHA resigned in protest, and Hitt released an angry letter publicly reprimanding the president. (Recently Clinton publicly regretted not lifting the ban.)

Failures aside, most AIDS activists conceded that President Clinton was still a vast improvement over Presidents Reagan and Bush: he spoke often of the disease; responded better to criticism; and most importantly, he had a political vision that included fighting HIV/AIDS. In fact, though embroiled in open warfare with the Republicans, President Clinton still corralled support for more spending for HIV/AIDS. The Ryan White CARE Act, always funded far below its authorized $875 million per year, saw its FY 1994 budget leap from the previous year's $348 million to $579 million, thanks to the president's prodding. Clinton reauthorized the Act for five more years in 1996, appropriating $738 million, and finally raised the budget to $1.8 billion by the end of his second term. Overall government spending soared from $5.3 billion in FY1993, to $8.5 billion in FY1997, and to $13.9 billion in FY2001.

Under this growing umbrella of government support came two important protections for people with HIV/AIDS. The 1996 Health Insurance Portability and Accountability Act put a one-year limit on "pre-existing condition" restrictions and forbade insurers to deny care or to charge higher premiums to HIV-infected patients. President Clinton's goal to strengthen the ADA became a success with the 1999 Work Incentives Improvement Act, which expanded Medicaid and Medicare to allow the disabled to resume working without giving up their insurance benefits.

Since leaving office, Clinton has conceded and regretted his mistakes. But as co-chair of Sandy Thurman's International AIDS Trust with South African hero Nelson Mandela, Clinton has used his platform as former president to address the tragic pandemic of HIV/AIDS globally. "In countries that have achieved real results, the head of state has made it a priority to educate the public about AIDS and to create a framework for a partnership between government, nongovernmental organizations, affected communities, and donors," he told the International AIDS Conference in Barcelona this past July.

George W. Bush: (2000-Present) 

The "Compassionate Conservative"

The jury is still out on President George W. Bush. While he says he is committed to fighting the battle against HIV/AIDS, a letter last May from PACHA informed the self-proclaimed "compassionate conservative" that "a sense of urgency seems lacking" in his Administration's efforts to combat the disease.

But this comes as no real surprise. President Bush never publicly mentioned AIDS when he was governor of Texas. He also supported mandatory AIDS reporting and refused to meet with the Log Cabin Republicans to discuss a range of issues, including HIV/AIDS. However, as his presidential campaign got underway, his gay friend Charles Francis assembled a handful of gay Republicans and the issue was broached. No white paper detailing his positions emerged and activists were left to wonder what, if anything, he would do if elected. In fact, some AIDS activists welcomed his subsequent controversial victory over Vice President Al Gore since they assumed Bush II, as he is sometimes called, would respond much like his father and would therefore re-invigorate dormant ACT UP-style protest groups.

Initially, the activists' fears seemed justified as it was rumored that White House chief of staff Andrew Card suggested doing away with the National Office of AIDS Policy. Instead, President Bush appointed an openly gay person to the White House administration, for the first time in history.  Scott Evertz was appointed AIDS czar. Evertz was on HHS Secretary Tommy Thompson's staff, while Thompson was Governor of Wisconsin. Some religious conservatives were surprised that the former conservative Wisconsin governor had any gay friends, and enraged that Bush would give one an historical presidential appointment.

In June 2001, six months into the job, and on the 20th anniversary of the discovery of AIDS by Dr. Michael Gottlieb, President Bush sent a surprise open letter addressed to the entire HIV/AIDS community outlining his steadfast commitment to battling AIDS and touting a task force headed by Thompson and Secretary of State Colin Powell. He declared his support for the newly founded United Nation's Global Fund to Fight AIDS, Tuberculosis, and Malaria with a $200 million pledge in FY2002. However, suspicious of the UN and mindful of his conservative base, Bush linked the pledge to an accounting of how the money would be spent before any funding would actually be given.

However, as PACHA pointed out, the Administration appeared to lack a coherent domestic strategy and policy. In addition, the White House seemed split between upholding traditional conservative values and listening to more liberal voices that pushed what have become standard prevention messages. For instance, President Bush refused to recognize Clinton-holdover Surgeon General David Statcher's 2001 report that "abstinence-only" education is ineffective. He also rebuffed evidence that messages encouraging condom use do not increase sexual activity. Instead, President Bush has steadily increased abstinence-only spending, up to $135 million next year, and maintained an anticondom position. The president's choice to head the PACHA board was former Republican Oklahoma Congressman Tom Coburn, an abstinence proponent who promised to challenge the prevailing wisdom on condoms. Appointed as PACHA executive director was Patricia Ware, an ultra-conservative advocate of abstinence-only programs. But not all Administration officials spoke with the same voice. For example, in apparent defiance of White House policy, Secretary of State Colin Powell, during an MTV interview, insisted that it was irresponsible to exclude condoms from HIV- and STD-prevention messages. The ensuing wrath from conservatives prompted some liberal commentators to speculate that President Bush had secretly okayed Powell's message, thereby having it "both ways." Other commentators thought it revealed a disharmony within the White House over a myriad of issues.

Last March, a broad national coalition of AIDS service organizations released a scathing report card about President Bush's AIDS plan. They lashed out at him for twice requesting flat-funding for the CARE Act, which in the face of 11 percent medical inflation and an 8 percent growth in AIDS cases, they said effectively reduces care. They also blasted him for effectively flat-funding HOPWA and for the continued ban on needle exchange.

President Bush's reassignment of openly gay AIDS czar Scott Evertz to HHS caused considerable stir. Some believed Evertz was "fired" because he openly supported condom distribution, criticized Bush's abstinence-only programs, advocated lifting the ban on needle-exchange programs, and is gay. However, the president replaced him with another openly gay man, Dr. Joseph O'Neil, former director of HHS's HIV/AIDS bureau during the Clinton Administration. More recently, he was chief of AIDS policy under Tommy Thompson.

Last year, HHS began audits of federal spending on abstinence-only dollars and HIV-prevention programs and organizations that have been accused of peddling homosexual sex as part of their prevention message. In addition, after several hecklers shouted Thompson down at the International AIDS Conference in Barcelona, accusing him of "murder and neglect" of PWAs, several Republican Congressmembers ordered HHS to investigate 16 prominent organizations that sent those protesters to see if any federal dollars had been used to support them and the conference as a whole. The Republican lawmakers were apparently also upset by the lack of religious themes at the conference. Ironically, both Thompson and the protesters later said that they had met after the incident and had a very productive discussion. The audit, however, has sent a "chill" through AIDS agencies who fear a government clampdown on the right to protest Administration policies as well as a loss of federal funding.

Evertz's new job is to focus on the global HIV/AIDS crisis. However, the Administration has yet to announce a clear plan, despite highly publicized trips to Africa, first by Secretary of State Powell and then, this May, by Treasury Secretary Paul O'Neill with U2 singer Bono. Indeed, this past March, in a surprising turn of events, former Senate Foreign Relations Chair Jesse Helms and Republican Senator Bill Frist, a physician, responded to UN Secretary General Kofi Annan's plea for $7 to $10 billion in global AIDS support with a proposed additional $500 million in emergency FY2002 spending. But President Bush, in what many interpreted as a cynical public relations trick, instead announced his own program: the US would pledge $500 million for mother-to-child efforts. Using slight-of-hand accounting, the president rejected all but $200 million of the Helms/Frist Amendment, effectively lowering the initial pledge by $300 million; the remaining $300 million would be deferred until FY2004. The funding issue became moot, however, when President Bush refused to sign Congress' $5.1 billion supplemental spending bill, which included the AIDS appropriation. Later he asked that Congress re-submit the AIDS package separately.

On August 20, 2002, in what many felt was an astounding positive move, the Bush Administration announced that their entire aid plan for Africa would total almost $4.5 billion, and would be used to reduce famine, to help fight disease, and to produce clean water. Of that sum, $3.3 billion is earmarked for fighting infectious diseases in developing countries, including HIV/AIDS, over a period of two years. The plan was presented during the United Nations' World Summit on Sustainable Development held in South Africa. Approximately half of the disease-control programs outlined in the plan had either been approved or announced previously, according to AP/Nando Times reports.

In advance of the Summit, USAID released a report outlining the Administration's pledges of support. They include the Administrations' proposal to spend $500 million on vertical HIV transmission prevention programs in developing nations; a $500 million pledge to the Global Fund to Fight AIDS, Tuberculosis and Malaria; an increase of program funding and an increase in the number of USAID's "HIV/AIDS priority countries" from 17 to 23 nations; HHS's Global AIDS program, which provides surveillance, monitoring, research, prevention, and care services in 24 countries; capacity building and infrastructure assistance by the CDC in 16 countries; NIH's vaccination research initiatives; and US-sponsored HIV-prevention programs that have lowered HIV-prevalence rates in Zambia and Uganda, according to the report.

Bush's record seems to speak for itself, there is a desire to address the AIDS pandemic both domestically and globally. The compassionate conservative has shown compassion and a commitment to helping those living with and affected by AIDS.

Conclusion:

The Meaning of Leadership

Presidents are often so enmeshed in politics that their measure of success is calculated by how little they lost of what they wanted on any given day. On the other hand, the past four presidents have at times won resounding applause for standing up for principle, usually in the foreign arena. Consider President Reagan's "Tear down that wall, Mr. Gorbechov" speech. Consider the first President Bush's popularity after the Gulf War. President Clinton finally went into Bosnia, though obviously his legacy is more associated with presiding over the biggest economic boom in history, and an embarassing impeachment. Only long-term HIV/AIDS survivors may remember that it was during the Clinton Administration that HIV/AIDS turned from a death-sentence into a more "manageable" disease.

After September 11, no one questioned George W. Bush's leadership as he grabbed a bullhorn, praised the firefighters, cops, and workers clearing Ground Zero, and pledged to get the "evil-doers" who attacked the World Trade Center's Twin Towers. Few dispute his commitment to fighting the War on Terror. What AIDS activists and some in his own Administration now hope is that President Bush will understand the links between poverty, disease, and terrorism and commit the same degree of passion to the war against HIV/AIDS. Bush has a unique opportunity as the world becomes more aware of the devastation of AIDS globally to continue to move the AIDS agenda forward.

Benjamin Ryan is a freelance writer specializing in HIV/AIDS. A native of Seattle, Washington, he graduated cum laude, with departmental honors in English, from Columbia University, where he volunteered as an HIV test counselor. He lives in New York City.