The Global Health President

Before he became president, few expected George W. Bush to be a global health activist. But Bush astounded his critics and supporters alike by launching a train of multibillion-dollar health rescue programs for the developing world, including the President’s Emergency Plan for AIDS Relief (PEPFAR), the President’s Malaria Initiative, and the Global Fund to Fight AIDS, Tuberculosis and Malaria. Bush, in launching PEPFAR in 2003, called it a "work of mercy" to save Africa and hailed what he called the "Lazarus effect" of anti-HIV drugs in saving AIDS patients from the brink of death and allowing them to lead more normal lives, quickly and inexpensively. PEPFAR and its associated programs, which have spent $39 billion to treat millions of people, have been recognized as a cornerstone of Bush’s presidency. And in many countries receiving PEPFAR and Global Fund support, Bush and America have become synonymous with global health.

Back in 2002, when I was Secretary of State Colin Powell’s special envoy on HIV/AIDS, I learned of Rick Santorum’s call for a robust role for the United States in international health, an unusual and distinctive position for a senator from Pennsylvania, where jobs and the economy are dominant issues. Fast-forward to this year’s Republican campaign for the presidency, where the most religiously conservative candidate, surprisingly, is the most fervent advocate for U.S. global health diplomacy.

Alone among his rivals, Santorum has staked out global health as one of his preferred instruments of asserting American power abroad. He is the only Republican candidate to declare he wants to "keep and expand" Bush’s humanitarian aid push in Africa. In contrast, Mitt Romney is "very reluctant to borrow lots more money to be able to do wonderful things" if other countries and groups do not contribute more; Newt Gingrich has called for government-run foreign aid to be replaced with private incentives; and Ron Paul, a physician, has asserted that "all the foreign aid in the world will not transform Africa into a thriving, healthy continent."

Santorum seems determined to lay the groundwork for a global health agenda that is not only far more extensive than his competitors’, but would surpass both Bush and Barack Obama in advancing U.S. interests abroad through fighting disease. If he follows through with his campaign promises, Santorum could elevate global health to be a prominent instrument of American statecraft.

His record so far is promising. In 2008, Santorum urged his conservative allies in Congress to support reauthorization of Bush’s global AIDS program at a new, higher price tag of $50 billion. He called this "some of the best money Congress can spend" as doing so would "protect our nation," and he argued that fighting AIDS could win friends in strategic, pivotal countries such as Indonesia and deter enemies from making inroads in impoverished zones. At the Nov. 22, 2011, Republican presidential primary debate, Santorum asserted that advancing global health was "absolutely essential." He conjoined the rescue mission of health with that of promoting U.S. interests, stating "the work that we’ve done in stabilizing [Africa], while humanitarian in nature, was absolutely essential for our national security."

He has couched aid programs as "one of our best international investments" and credited humanitarian aid and fighting AIDS as critical to winning "hearts and minds" in competing against the influence of "China and Islam" in Africa. "We have done more good for America in Africa and in the Third World by the things that we’ve done," he said at the Nov. 22 debate. "And we have saved money and saved military deployments by wisely spending that money not on our enemies but on folks who can and will be our friends." His reasoning echoes the arguments asserted by the late diplomat Richard Holbrooke about saving Africa from a demographic cataclysm caused by HIV/AIDS.

Very soon after Nov. 22’s debate, Santorum issued a remarkable statement for World AIDS Day on Dec. 1: "There is reason to celebrate today that over 4 million people with AIDS in Africa are on antiviral drugs as a result of the US commitments through PEPFAR and other partnerships. There is reason to set our resolve, as almost 5,000 people die every day due to AIDS and there are about 7,000 new HIV infections a day. Thankfully, there is reason to hope that in our lifetime, we may see the end of AIDS. Let’s turn our resolve into action." None of the other Republican candidates marked the occasion.

Santorum’s willingness to work actively against AIDS and poverty has won plaudits from those who might otherwise be his political detractors. Rock star and activist Bono told the New York Times in 2006 that "Rick Santorum has a kind of Tourette’s disease; he will always say the most unpopular thing. But on our issues, he has been a defender of the most vulnerable."

If Santorum was ebullient about spending $50 billion on global AIDS in 2008, as president he might be emboldened to seek even higher amounts of money for health and anti-poverty initiatives, beyond what Bush and Obama have done, to implement his principles on a worldwide scale, perhaps one reminiscent of the Marshall Plan that resuscitated Western Europe after World War II. And make no mistake, that’s the kind of initiative Africa needs.

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Santorum’s religiosity, the cause for many of his strong beliefs about global health, might also become the biggest roadblock to his effectiveness. In a 2007 editorial, Santorum wrote, "The social teachings of my faith were a factor in my work as a senator. The horror of AIDS and the tragedy of the millions of orphans it has left in Africa prompted my support for greater U.S. funding. But it was Christ’s mandate to care for the poor that inspired my efforts to take a leadership role." A firm believer in banning abortions, Santorum seeks to "ensure that all of our foreign aid, bilateral and multinational … requires recipients of US federal funds to neither perform nor promote abortion in other nations or they will not receive taxpayer money."

Santorum risks incurring opposition from organizations and donors that believe in pro-choice policies, entangling entities like the Global Fund in battles over such restrictive provisions. If others withdraw from cooperating with his administration over abortion, U.S. programs overseas may become isolated and weakened. Santorum, unlike Obama, has expressed strong antipathy toward the U.S. Agency for International Development (USAID) and the United Nations, calling to cut by half both the staffing levels at USAID and U.S. funding for the United Nations. He goes further and advocates the complete defunding of unnamed U.N. agencies that "oppose America’s interests and promote abortion."

Santorum might also extend the requirement by Bush to allocate one-third of prevention funds in global health programs to the strategy of abstinence and disallow the exchange of needles and syringes to drug users in HIV/AIDS prevention programs — a stance that has drawn opposition from many NGOs as inhibiting their outreach to break the cycle of HIV transmission.

Social controversies that have complicated the conduct of global health policy of previous administrations will continue in the future. Still, Santorum seems ready to take a cue from the phrases "Nixon in China" and "Bush in Africa," which describe the surprise and acclaim won by the two Republican presidents in launching dramatic diplomatic initiatives that upended conservatives’ expectations. Santorum, if elected president, could depart from conservative orthodoxy by centering U.S. foreign policy on prescribing global health as a potent form of "soft power" statecraft. And he could save millions of lives in the process.