Fighting AIDS Right: A couple of bumps, in Bush's grand plan

In his State of the Union address, President Bush asked Congress "to commit $15 billion over the next five years . . . to turn the tide against AIDS in the most afflicted nations of Africa and the Caribbean." It was a dramatic moment, and not just because few in Washington had predicted that Bush would make AIDS a major topic of his speech. Bush was also proposing a sharp break with previous efforts against AIDS. But many of the biggest admirers of the president's new approach now fear that its promise is being lost in the legislative grinder.

The Bush administration wanted to adopt what has been called the "Uganda model." Instead of focusing exclusively on the encouragement of condom use, Uganda and a few other countries have emphasized abstinence and monogamy. As Rod Dreher has reported in these pages ("Death in Africa," Feb. 10), that approach has dramatically reduced the spread of the disease. Respected academics who are not themselves social conservatives believe that this success could be replicated in other afflicted countries. If so, it would be compassionate conservatism at its best.

Conservatives, especially social conservatives, applauded the president. Initially, their major worry about his plan was that it would give government funds to groups that perform or promote abortions. International family-planning funds are not allowed to go to such groups, thanks to an executive order issued by Bush. But other funds, such as funds to fight AIDS, are not so restricted. The Bush administration tried to allay these fears by stipulating that the AIDS funds would not be used for abortions. That was enough to get the leading pro-life group, the National Right to Life Committee, to hold its fire.

But social-conservative objections have grown as the president's proposal has taken legislative form. The bill that came out of the House International Relations Committee, which is scheduled to be debated on the House floor in early May, does not explicitly direct funds toward the promotion of abstinence and fidelity. Conservatives fear that without clear congressional guidance to that effect, the foreign-aid bureaucracy will just use the money on condoms. Michael Schwartz, a vice president of Concerned Women for America, a conservative group, says, "Anybody who thinks that there's any hope for the Uganda model under those circumstances is an extreme optimist."

Conservatives also think that the bill should direct more funds to treatment than to prevention. In his State of the Union address, Bush cited as one of his justifications for acting now that the cost of treatment had declined to the point where a global campaign was feasible. The president's focus on treatment made it possible for him to set measurable and achievable goals -- such as treating "at least two million people with life-extending drugs." Conservatives also figure that treatment funds cannot easily be diverted to serve ideological or bureaucratic agendas, unlike money for prevention.

Another subject of dispute is how much money should go to the Global Fund to Combat AIDS, Tuberculosis, and Malaria, a multilateral organization. Conservatives distrust it, not least because the governments of North Korea, Iran, Sudan, and Burma are scheduled to receive money from the organization. There are questions about the fund's efficiency; it's been slow in getting grant money out the door. Rep. Jim Kolbe, an Arizona Republican who supports the fund, requested a General Accounting Office study to clear up questions about it. But he's refusing to release the preliminary findings before the House votes. Not a good sign.

President Bush wanted Congress to give the Global Fund $200 million next year. The House bill authorizes up to $1 billion in funding next year. But the bill also says that the U.S. should provide no more than a third of the money for the fund at large, which would probably limit funding to roughly the amount the president wanted. (Bush, or some future president, would be allowed to waive the limit.)

Under Bush's proposal, the U.S. government -- rather than any multilateral body -- would direct most of our efforts against global AIDS. An "AIDS czar" in the State Department would coordinate these efforts. The House bill requires Senate confirmation for the job. Conservatives are split on the wisdom of this provision. Some think that it would raise the profile of the fight against AIDS, but others worry that Senate Democrats would block anyone committed to the Uganda model. A Republican Senate aide working on the bill is among the critics: "It makes sense in a hypothetical universe we don't live in" - - one in which Democrats are reasonable.

Why has the bill turned out so disappointingly for conservatives? In the last Congress, Sens. Bill Frist and John Kerry had introduced a global-AIDS bill. After the president spoke, that bill formed the template for legislation -- and it didn't incorporate his guidelines.