Ending the Compromise Era on AIDS

When Mark Dybul, erstwhile head of the President's Emergency Plan for AIDS Relief, or PEPFAR, was asked to clean out his desk late last month, it was a stark manifestation of the different styles that Barack Obama and Hillary Clinton bring to governing.

Initially, the Obama transition team had asked Dybul to stay on, and it's easy to see why it might have liked him. A gay man who had, in the past, donated to Democrats, Dybul seemed to pride himself on his ability to make common cause with conservatives. As global AIDS coordinator in the Bush White House, he often sided with allies like Rick Warren rather than with women's-health advocates on issues ranging from abstinence to sex-worker outreach to family-planning funding. This earned him feminist enmity, but others respected his ability to neutralize the right-wing opposition that had long hindered AIDS relief. As his defenders point out, he was able to build what the medical journalThe Lancet called "the largest and most successful bilateral HIV/AIDS programme worldwide" while working under a Republican administration.

Yet if Obama admires this sort of ideology-straddling bipartisanship, Clinton, who became Dybul's boss in the State Department, is more of a political pugilist. She has a long, close history with the international reproductive-rights movement that battled Dybul for years. Hearing that he had been asked to stick around, the international reproductive rights movement its objections known to those close to Clinton, and shortly after inauguration, Dybul was axed. It's not clear whether Clinton directly ordered his firing, but people in the field believe that either she or someone who works for her was behind it.

Now a fierce debate is underway about whether Dybul was unfairly treated. What's at stake is more than just the reputation of one man, because the argument is really about America's AIDS policies and the future of PEPFAR, Bush's lone but in many ways impressive humanitarian achievement. Since Bush created it in 2003, PEPFAR has spent tens of billions of dollars fighting AIDS in the developing world, providing life-saving anti-retroviral drugs for more than 2 million people infected with the disease, and caring for millions of AIDS orphans. With Bush gone, though, the program's future direction is unclear. Will it proceed Obama-style, with lots of continuing outreach to religious conservatives, a focus on treatment and a sidelining of inflammatory gender issues? Or will it, under Clinton's leadership, work to address the sexual realities that drive the epidemic, even at the cost of bipartisan support?

Dybul's departure elicited furious reactions on the right, though not only there. Former Bush speechwriter Michael Gerson wrote an enraged column in The Washington Post titled "Weasels vs. AIDS Relief" -- the weasels being Dybul's feminist foes. "This type of captivity to extreme interests is precisely what has discredited Democrats so often in the past," he wrote. "It is a kind of politics with all the ‘newness' of a purge, all the ‘freshness' of a mugging." Michael Barone accused "someone in the administration" of acting like a "thug."

Others with quite different politics echoed their distress. Brian Brink, a globally respected South African AIDS physician who chairs the board of the International Women's Health Coalition, speaks of his "tremendous respect" for Dybul. "He's extraordinarily bright, extraordinarily passionate about dealing with HIV," Brink says. His firing "came as quite a surprise. It wasn't as if there was somebody waiting in the wings immediately to take over. I think it was unnecessary to treat him as an individual that way. It upset me."

Brink, who made it clear that he was speaking for himself, not the International Women's Health Coalition or any other organization, certainly doesn't defend the Bush administration's approach to condoms and reproductive rights, an approach Dybul had to champion. "It just ignores the fact that HIV is a sexually transmitted disease, and it's young girls who are most at risk. In sub-Saharan Africa where I work, 75 percent of new HIV infections are among 15- to 24-year-old women," he says.

Yet if Dybul fronted for counterproductive policies, Brink blames Bush, and argues that Dybul had no choice if he wanted to be effective in other areas. "Sometimes it's easier to criticize from the outside. On the inside it's quite a difficult balancing act," he says.

Dybul's liberal supporters tend to assume that he had to make the kind of compromises he did and that he did so reluctantly. But Scott Evertz, the former director of Bush's Office of National AIDS Policy and a good friend of Dybul's, insists he really believed in what he was doing. "I find the suggestions that Mark was doing the best he could in a conservative administration and that he was creating and implementing policy in which he didn't believe to be insulting," he says.

"Discussions about the ABC model" -- or Abstinence, Be Faithful, Use Condoms model -- "and the way it has been implemented are part of a healthy debate about HIV prevention," Evertz says. "Discussion questioning Mark's motives or actions are not. I believe he has always been motivated by a sincere belief in what he is doing and that he would never engage in activity that he wasn't convinced would save lives."

Indeed, some who worked closely on the legislative process surrounding PEPFAR say that, whatever Dybul's politics were before he joined the administration, once there, he was eager to forge alliances with the religious right. "The way he built his power base was to be seen as this ultimate sensible arbiter of bipartisan approaches, which meant, in the Bush era, having the far-right religious groups behind you and participating in the marginalization of women's-rights and reproductive-rights advocates," says Jodi Jacobson, a longtime AIDS activist currently working as a senior political adviser at RH RealityCheck, a reproductive health Web site.

Heather Boonstra, a senior public-policy associate at the sexual and reproductive health-focused Guttmacher Institute, adds, "He really came out in many ways as very hostile to promoting greater linkages between HIV services and sexual and reproductive health services."

Thus, while PEPFAR did miraculous things to treat and care for people with HIV -- an expensive but relatively uncontroversial undertaking -- it missed many opportunities to prevent new infections. Initially, at the administration's behest, the legislation authorizing PEPFAR earmarked a third of the money dedicated to HIV prevention for abstinence and faithfulness programs, often run by religious groups. With other PEPFAR prevention funds directed toward things like mother-to-child transmission, very little was left over for comprehensive sex education and condom distribution. In fact, in order to fulfill the abstinence earmark, Dybul's office told those in the field to devote a full two-thirds of the money available for the prevention of sexual transmission of HIV to programs encouraging chastity and fidelity.

The abstinence mandate seriously deformed some countries' prevention efforts. In 2006 the General Accounting Office published a report about the difficulty PEPFAR's abstinence provisions were causing in the field and recommended a reassessment. During the negotiations around PEPFAR reauthorization in 2008, Jacobson, using the GAO report as ammunition, worked with the late Congressman Tom Lantos, head of the House Committee of Foreign Affairs, to remove the abstinence set-aside. "He really went out of his way [to help] while he was alive," she says of Lantos. Dybul, though, "worked closely with Chris Smith of New Jersey, one of worst offenders on women's rights, Rick Warren, and a range of other conservatives," Jacobson says. "They were lobbying heavily on the hill to put all the restrictions back in."

In a letter to Lantos, the State Department, presumably writing with Dybul's guidance, said, "We are deeply concerned that the draft repeatedly invokes 'reproductive health' and 'family planning,' and requires linkages, referrals, reporting on training, support, and direct funding for these activities." Such language, it said, "introduces potential controversies over subjects that are unnecessary and sure to undercut support for this important legislation." The letter even objected to programs that would have offered contraception to HIV-positive women who requested it. Language linking family planning and AIDS reduction, it said, "wrongly suggests it is necessary to prevent children from being born in order to prevent them from being born with HIV."

When Lantos died, the women's-health activists lost an important ally. In the end, the abstinence earmark, though shaved a bit, remained. And Dybul went further than he had to, issuing a regulation banning clinics that work to prevent mother-to-child transmission from purchasing contraceptives for their clients. Most surprisingly, even after Obama was elected, Dybul continued to push the religious right's agenda. According to Jacobson, Dybul lobbied on the Hill against any attempts to force PEPFAR grantees to provide referrals for services, like condom distribution, that they were not willing to provide themselves. Indeed, Jacobson says, that was part of the reason for his firing.

Jacobson was jubilant when she learned that Dybul was forced out. "Sworn in as Secretary of State just yesterday, Hillary Clinton wasted no time cleaning house at the vast department she runs," she wrote on RH RealityCheck. But as the search for a replacement gets underway, the issues that caused division over Dybul remain unresolved.

Obama, after all, has, like Dybul, made working with faith-based groups a major priority. He's eager for bipartisan support, even if it means sacrificing parts of his own agenda. Clinton, seared by many years of ideological warfare, is less concerned with placating her opponents. She thrilled feminists worldwide at the 1995 Beijing conference when she proclaimed, "Women's rights are human rights, once and for all." As secretary of state, she's promised to foreground women's issues, including sexual and reproductive health, which is one reason that, while foreign-policy conservatives were sanguine about her confirmation, social conservatives largely were not.

The recent uproar over family-planning provisions in the stimulus bill have shown how eager the right is to demagogue on sexual issues. Should Clinton push forward with more effective prevention policies, the consensus that has sustained the massive American commitment to AIDS relief could fray. So far, though, keeping that consensus together has come at the cost of some women's lives.

"There are no easy answers," Brink says. "If there were easy answers it wouldn't be a problem." And yet surprisingly, despite how unhappy he was with the way Dybul was let go, he's pleased with the prospect of Clinton's new leadership. "I'm a great admirer of what Hillary's standing for," he says. "Some of these things you do have to be tough. You can't compromise principles just to get the money."