5 days before boarding a plane to Africa, US President George W Bush announced his nomination of Randall Tobias to serve as Global AIDS Coordinator. If confirmed by the Senate, Tobias will head up an AIDS bureau in the State Department to oversee the global AIDS initiative, and will therefore coordinate all of the USA's international HIV/AIDS activities for all their government departments and agencies.
Tobias' job description was laid out in the State of the Union address given on Jan 28, in which Bush announced his plan to commit US$15 billion over the next 5 years to AIDS relief in Africa and the Caribbean (see Lancet 2003; 361: 539). As coordinator of the President's
emergency plan for AIDS relief, Tobias' remit is to turn the tide in combatting the global HIV/AIDS pandemic.
He has specific targets: prevention of 7 million new infections through voluntary testing and counselling;
treatment of 2 million people with antiretrovirals; andsupport and care for 10 million HIV-infected individuals and AIDS orphans. He has also been told where to spend most of his budget - on the 14 countries in Africa and the Caribbean that between them
have nearly 20 million HIV-infected people (Botswana, Namibia, Mozambique, Zambia, Uganda, Tanzania, Kenya, Ethiopia, Nigeria, Ivory Coast, Rwanda, South Africa, Haiti, and Guyana). Tobias will have to deal with threats to the initiative from US abortion politics (see
Lancet 2003; 361: 887) and also with likely substantial underfunding by US Congress. Tobias will have ambassadorial rank and will report directly to the Secretary of State, Colin Powell.
As retired chairman and chief executive officer of Eli Lilly & Company, and as ex-vice chairman of AT & T, Tobias clearly has top-level management experience. He is also a substantial donor to the Republican Party. However, critics have already questioned his
knowledge of AIDS and Africa. Rapid appointment of a team behind him with proven African public-health and HIV experience would help him gain credibility in his new role, as would announcement of a detailed plan of how the Bush AIDS initiative will work with the Global
Fund to Fight AIDS, Tuberculosis and Malaria. His connections with the pharmaceutical industry have led to concerns about whether Tobias is committed to providing access to low-cost generic AIDS drugs, or whether he will purchase patented versions so protecting
the interests of US drug companies. Tobias needs quickly, and publicly, to support purchasing of low-cost generics to provide ammunition against those who charge that he is no more than a stooge of the drug industry. He could even go as far as to counter
current US opposition to full implementation of the Doha Declaration of 2001.
Questions about Tobias' controversial nomination are bound to pursue Bush as he travels from Senegal to Nigeria, via South Africa, Botswana, and Uganda, all between July 7 and 12. This is Bush's first trip to Africa as US President. His focus is three-fold: security, trade, and aid. Bush's African policy is based around preserving human dignity (a core US value) and combatting global terror (his declared strategic priority). An Africa that lives in liberty, peace, and growing prosperity is therefore in American interests too, which Bush readily admits - it's in our national interests that Africa becomes a
prosperous place. Putting US votes aside, though, Bush's priorities make some sense. Security, so long as it is more than that of US citizens and interests in Africa, has to precede aid to maximise delivery and to allow development, and few would disagree with the
need for conflict mediation, peace operations, law enforcement, and good local governance. But whether Bush will, for example, commit US troops to help counter the civil war in Liberia has yet to be seen. And will Bush build on the opportunity provided by the Africa Growth and Opportunity Act to increase access to the US market for African products, or will he even go as far as to cut subsidies to American farmers to improve African farmers' chances of becoming competitive? Certainly there is much that Bush could do to improve
security, trade, and aid in Africa.
Bush and Tobias together could, with the backing of Congress, change the nature of HIV/AIDS in Africa. If all Tobias' targets are met, which is likely only if the full US$15 billion is appropriated by Congress, then he will have proven himself a worthy Global AIDS Coordinator. Tobias' task then, surely, as befits his job title, will be to combat the emerging HIV pandemic in Asia. (Source: The Lancet, Vol 362, Nr 9378, 12 July 2003)