Man of the World: The Further Endeavors of Bill Clinton (24 page)

To him, the emphasis on governments as partners meant that everywhere CHAI worked, “we basically had the government in the lead.” His people remained in the background, never seeking publicity for the organization—no big crowds running around in CHAI T-shirts, no big signs on clinics featuring Clinton’s name. Their presence wasn’t secret and they accepted some credit in newspaper articles or broadcasts, but not too much. When Clinton himself visited, that was a different matter, because government leaders and officials invariably wanted to be seen with him in media coverage.

Embracing national governments was central to Clinton’s evolving vision of what his philanthropy should accomplish. While bringing medicine to the neglected millions was primary and immediate, he wanted CHAI to establish competent, self-reliant systems that would
someday make his foundation redundant. For him, it would not be enough to parachute in, deliver medicine, and foster a culture of dependency.

In later years, Magaziner would find it difficult to describe what he had witnessed in those early weeks and months—the desperation of government officials, of the people in towns and villages, “dying all over the place, with nobody coming to do anything about it.” Slowly, much too slowly, with too little tolerance of any political risk, the United Nations and the Western governments were moving to put financing in place for treatment, through such mechanisms as PEPFAR and the Global Fund to Fight AIDS, Tuberculosis and Malaria. Yet those organizations were far from ready to deliver medicine—and nobody in the affected countries even knew they existed.

When CHAI suddenly appeared—under the auspices of Bill Clinton, following up with local officials and ministries of health week after week, stationing experts on the ground—Magaziner could sense glimmers of hope and inspiration. Being present was not much more than a promise, however, and without money CHAI wasn’t quite ready to deliver. But Clinton and Magaziner didn’t let that hold them back.

Not long after Clinton agreed to proceed with the foundation’s HIV/AIDS initiative, Magaziner started to contact the American and European drug manufacturers that produced antiretroviral medications in the hope that—if guaranteed much higher volumes of sales in the developing world—they would lower unit prices accordingly. He got nowhere fast, despite the terrible publicity endured by the pharmaceutical manufacturers over accusations that they were letting millions die.

Leaders of major firms, notably Jean-Pierre Garnier of GlaxoSmithKline, had responded by calling for much higher spending on HIV/AIDS treatment globally, with Garnier even demanding a “Marshall Plan” to turn back the pandemic. Garnier was the human face of Big Pharma, the sort of high-minded international businessman honored at dinners for the Sabin Vaccine Institute and the United Nations Association. But Magaziner couldn’t even get a meeting with him.

In private conversations with Magaziner, who was known to some of them as a business consultant, other pharmaceutical executives
spoke plainly. They felt that their companies had done enough already by providing limited quantities of drugs and dropping a patent infringement case against South Africa in April 2001. Under constant pressure from advocates and governments to lower their prices in poor countries, stop enforcing drug patents, and license generic manufacturers to produce versions of their drugs, the branded pharmaceutical companies had acceded to some of those demands.

“We’re not insensitive to public opinion. That is a factor in our decision-making,” Garnier had explained to reporters when GlaxoSmithKline and three dozen other major pharmaceutical companies dropped their case against the South Africans in a settlement that he had personally negotiated. “We don’t want the public to misunderstand the issues. We have never been opposed to wider access [to AIDS treatment]. We have discounted our drugs. We’ve done everything we could.”

The branded-drug manufacturers feared that lower-priced versions of their products sold abroad would somehow turn up in gray markets at home—a potentially costly outcome even for companies that were, like GSK, earning profits as high as $30 million a day. Selling their antiretroviral drugs at cost, they argued, the price would still be unaffordable in Africa, Asia, and the Caribbean.

And there they seemed to have a point: Although various pilot programs and tiered pricing schemes had reduced the prices of branded medicines considerably, from a high of $12,000 per patient per year (PPPY) to as low as $2,000, that price remained unattainable for all but the most affluent citizens in poor countries. After more than two years, the concessions wrung from the drug giants had resulted in very little expansion of treatment.

Clinton had no greater success attracting interest from U.S. and European industry leaders. For several months, Magaziner tried in vain to draw pharmaceutical executives into a discussion of tiered pricing for poorer countries and other distribution schemes. In the spring of 2003, when he and Clinton encountered Garnier by chance at an event in Dublin, the former president tried to engage the GSK boss on that sensitive subject. Garnier politely agreed to sit down for a conversation, but he barely seemed to hear what Clinton was saying during the ten minutes or so they spent together.

“It
will destroy our business in the United States,” he replied, before he stood up to leave.

The only alternative sources of medicine were the generic pharmaceutical makers located in the developing world. Generic firms were already producing antiretroviral medications in places like Brazil, Thailand, India, and South Africa, though not in quantities anywhere close to what the world needed. To Magaziner’s eye, even the generic prices still seemed high, measured not only against what poor countries could afford but what he, as a former consultant to the pharmaceutical industry, estimated as their inherent cost. The persistently high pricing of AIDS medications represented a classic market failure, with demand far outpacing supply for a decade—and no obvious path toward balance through reduced costs.

The dysfunctional market might be improved dramatically, Magaziner believed, if CHAI could pull together a “buying club,” guaranteeing higher sales volumes and reliable payment over a longer time horizon. Western pharmaceutical manufacturers had rejected any such notion as uneconomic and dangerous to their profits. But would any of the overseas generics manufacturers lower their prices to win a far larger market?

At an early meeting in Harlem to discuss where the money might be found for their vision of a big new market for AIDS medications, Magaziner had asked, “Who do you know who does this?” Clinton understood the shorthand: Among the many heads of state that the former president counted as friends, who had large budgets to spend on global AIDS relief—and might be willing to entrust that money to Clinton?

“Well,” said Clinton, ruminating, “my best friends still in office, who have big development budgets, besides Tony Blair, are Jean Chrétien,” the Canadian prime minister, “and Bertie Ahern,” the Irish prime minister, known in Gaelic as the Taoiseach. In the spring of 2003, he placed a phone call to Chrétien—a feisty Liberal then near the end of his term, who devoted much of his attention during his final year in office to the AIDS crisis. The Canadian leader didn’t require too much persuading, as Clinton later recalled, once he had explained what he and Magaziner were trying to accomplish. With information provided by Magaziner, Chrétien’s
staff had already briefed him on the outlines of the CHAI plan.

“Look Jean, all these people are dying like flies,” Clinton told him. “We’ve got a limited amount of money, but we’re paying too much for this medicine.” The market was “disorganized,” he went on, dominated by middlemen and agents who charged enormous, unjustified fees. “What we need to do is get this money, let the governments sort it direct, and have the delivery direct from the manufacturers. And I think we can get the cost down.”

Chrétien agreed informally to a commitment of $20 million a year for five years, with the understanding that the Canadians could select the countries they most wanted to support, and that a portion of the money would be used for staffing clinics and overseeing care. But the deal would only be announced several months later, after more painstaking negotiations with Canada’s foreign aid agency.

Meanwhile in early July 2003, during a trip to Northern Ireland—where he continued to enjoy the overwhelming popularity earned as a peacemaker during his presidency—Clinton also scheduled a call on the Taoiseach at his Dublin office. Again, Magaziner had helped to prepare the way. Years earlier he had worked as an economic consultant to the Irish government, which had opened the door for a sympathetic hearing at Irish Aid, the republic’s overseas development agency.

But Magaziner had no illusions about the weight that Clinton brought to their dealings with sovereign governments. An impending visit with the head of state created a strong impetus for discussions with other government officials and staff, as they talked over the request that Clinton would make and prepare briefing papers. Given Clinton’s popularity in the republic, the Taoiseach would want a successful meeting—and just as important, he would want to express confidence in Clinton’s substantive ability to get something done about this intractable problem. The energy of Clinton’s persona organized these systems around his agenda.

His July 2003 appearance in the North was one of many made by the former president after leaving the White House to encourage the process of reconciliation and power sharing between Catholics and Protestants, which was then wearing thin. A year earlier the local elections had been called off, which frankly concerned Clinton. He chose
the weekend of Drumcree Sunday, an annual occasion when members of the Protestant militant Orange Order march through Catholic nationalist neighborhoods en masse, often provoking violence. But on that Sunday, as Clinton noted in a press interview afterward, the march occurred without incident.

“It was a pretty good Sunday, yesterday, Drumcree Sunday. So good, I felt able to go to Royal County Down and play golf,” he quipped, referring to the venerated links at Newcastle, site of many important tournaments and rated one of the best courses in the world. Earlier in the day, he had delivered a lecture at a Northern Ireland college in honor of John Hume, the Social Democratic politician from Derry who boasted a Nobel Peace Prize for his work with Clinton and Blair on the Good Friday accords.

Expressing optimism about the North’s future stability, Clinton had urged leaders on both sides, listening in the audience at the Hume event, to persevere despite setbacks. “When the Middle East peace fell apart, when the future looked uncertain in Bosnia, when Africa was still reeling from losing ten percent of the people in Rwanda and two million died in the Congo, I could always point to the Good Friday accord. You need to think a long time before you give that up,” he said. “I ask you to stay the course and lead the world by your example.”

Upon his arrival in central Dublin the next day, the Taoiseach greeted Clinton effusively. “From all parts of the world he keeps in touch,” Ahern told the reporters assembled. “He has earned a special place in our history and our hearts.” Clinton went into Ahern’s private office, paneled in light Irish oak, with Doug Band and Eric Nonacs, a young foreign policy specialist brought onto the foundation staff by Maggie Williams.

When they emerged an hour or so later, Clinton had a five-year, $110 million commitment for CHAI from Irish Aid, the republic’s overseas development agency. Most of the money would be used to provide AIDS treatment to as many as half a million patients in Mozambique, where only a few hundred were currently receiving medicine. In a stroke, the agreement made Ireland the third-largest purchaser of AIDS medications in the world. As years passed, despite the retirement of Bertie Ahern and the crashing of the Irish economy—and regardless of negative political commentary concerning “foreign donations” to the
Clinton Foundation—Dublin didn’t waver from its pledge to support his work.

Meanwhile, Magaziner also approached the government of Sweden, where he had consulted on industrial policy decades earlier. The daughter of a Swedish official he had known well back then, Annika Söder, now held a top position at the Ministry of Foreign Affairs. As state secretary for international development cooperation, she oversaw SIDA, the agency responsible for running Sweden’s international health programs. Söder introduced Magaziner in turn to the Nordic nation’s recently appointed “AIDS ambassador.”

At the time, Sweden belonged to an informal group of development agencies in Northern Europe known as “the like-minded group,” which also included the United Kingdom, the Netherlands, Norway, and Denmark—all of which had decided together that their funding would be used only for HIV/AIDS prevention because treatment was too difficult, expensive, and risky. But after several meetings with Magaziner over a period of months—and a strategic phone call from Clinton to the Swedish prime minister—the Swedes agreed to help fund Tanzania’s CHAI treatment plan. The Dutch and the Germans had turned Magaziner down—as had the British early on, despite numerous conversations between Clinton and Blair—but the Swedish decision was a break. The next country to move would be Norway.

As the first U.S. president ever to visit longtime NATO ally Norway, Clinton had established close ties with Prime Minister Kjell Magne Bondevik, who was still in office four years later. So when Clinton returned to Oslo in November 2003—after weeks of discussion between Magaziner and Norwegian aid officials—he sealed an agreement with Bondevik for the Norwegians to provide at least $25 million over five years to support CHAI programs in Tanzania and Mozambique.

Smashing through the objections to treatment among the Western governments, as symbolized by the substantial budget commitments from Ireland, Canada, Norway, and Sweden, was tremendously gratifying. But Clinton and Magaziner had taken a real gamble on those funds coming through, by approaching the generic manufacturers well before any of that money had been guaranteed. Magaziner had bet on Clinton, and Clinton had bet on his prominent friends. Still, there was one big bet that had yet to pay off.