Randall Tobias wakes up in the morning with 8,000 people on his mind. That's how many people on any given day will die of AIDS. "It's like discovering that 20 fully loaded 747s had crashed and everyone on board had died," he says.
Marshaling a plain-spoken command of facts is one reason President Bush eight months ago picked Mr. Tobias, the former CEO of drug maker Eli Lilly, to head his Emergency Plan for AIDS Relief.
With announcements of first-round funding under the multibillion-dollar plan, AIDS caregivers are sizing up not only the nation's first AIDS czar, but also whether he and the president can walk their radical talk when it comes to battling AIDS.
But faith-based groups are worried enough about how the emergency plan is unfurling that a number of well-known evangelical personalities-including James Dobson and Chuck Colson-made a trip to the White House. In a closed-door session last month they told Mr. Tobias and top Bush officials they saw "a growing pattern of bias" against evangelical relief groups in the bid for AIDS money. Most thought they would never have to have that confrontation with the Bush White House.
Despite what some called a "heated" but helpful discussion that also included Samaritan's Purse founder Franklin Graham, Salvation Army national commander Todd Bassett, and Campus Crusade representative Bailey Marks Jr., subsequent funding announcements under the AIDS plan have done little to cheer them.
Total funding for faith-based groups from the first allotment of $350 million is still unknown, as Mr. Tobias's office combs through winners awarded through multiple departments. But total initial funding to abstinence-related programs just topped $5 million-still well below what the congressional appropriation requires by law. Under that schedule, groups teaching abstinence before marriage and faithfulness to one partner should receive $320 million by the end of this year.
For Mr. Tobias, managing what the president calls "a work of mercy" while straddling the competing concerns of religious groups and the medical establishment-both claiming territorial rights when it comes to AIDS prevention-will demand all his managerial skills. In five years at Eli Lilly, Mr. Tobias quintupled market value of the manufacturer to $75 billion. The soft-spoken Indiana native, at 61, abandoned retirement, persuaded, he says, by the president's "deep personal commitment" to an ambitious plan both men expect will reverse the medical crisis gutting the populations of Africa and the Caribbean.
"I'd really like for people to judge me a year from now on what I have done, rather than being apprehensive about what I'm going to do," Mr. Tobias said when asked about the February meeting. "I would be the first to say that we do not yet have answers to every question."
The Bush goals are lofty: to treat 2 million people with HIV/AIDS; prevent AIDS in another 7 million people; and care for 10 million additional overseas victims, particularly orphans and other youth. The price tag, not surprisingly, is high-$15 billion over five years.
Early on, President Bush pledged to move away from condom publicity and sex-awareness campaigns, the zeitgeist of AIDS activists and the healthcare industry. He promised to embrace solutions that address the deeper cause of AIDS: promiscuous sexual behavior. That emphasis sells with his conservative base, but more importantly, according to Mr. Tobias, "It's simply what works."
"There's no evidence in generalized populations that a broad-based use of condoms as the backbone of prevention efforts has worked," Mr. Tobias said in a March 10 interview in his suite at the State Department, dotted with cardboard boxes as the AIDS czar awaited new office space five blocks from the White House. "I've come to believe, not just intuitively or by guessing about it, but based on a lot of data that we've been able to collect, that abstinence is the best approach."
But instead of making faith-based groups a bigger part of the solution, the recent grant announcements appear to cast them as footnotes.
Growing acceptance of behavior change as a way to prevent AIDS can be traced back to Uganda, the first African country to reverse its AIDS epidemic using its nationwide "ABC" campaign. The elemental formula teaches abstinence before marriage, being faithful in marriage, and targeting condom use to select groups like prostitutes. With that, plus a bullhorn in the streets, literally, Ugandan President Yoweri Museveni worked with government health officials and church leaders to educate Ugandans on AIDS-fighting. The results: HIV prevalence rates nationwide dropped from over 30 percent a decade ago to around 6 percent.
The formula is a natural for faith-based groups because it squares with their beliefs. It also gained an important ally in the medical community last year, when Harvard senior research scientist Edward Green published a book titled Rethinking AIDS Prevention, a tacit endorsement of ABC programs.
Dr. Green said his goal is "to change policy" because "the current paradigm of AIDS prevention is based entirely on risk reduction, primarily in the form of condom use. The paradigm does not emphasize interventions that avoid the risk in the first place, such as abstinence or being faithful to one partner."
Dr. Green subsequently was appointed to the Presidential Advisory Council on HIV and AIDS. One of his first measures will be to introduce a resolution backing the ABC approach at the council's next meeting ahead of what he predicts will be "a vicious anti-ABC backlash" coming from groups who want to return to condoms and pills only.
"Uganda treated it as a behavior problem, but under our global Western model, it's been taboo to moralize about sexual behavior. You might marginalize someone," he said. "Most of my colleagues think it is unrealistic and ridiculous. But you cannot argue with success. Uganda has reduced its AIDS rate by two-thirds using this approach, and we have not. Yet we somehow are trying to tell Africans how to beat AIDS."
All of this is good news for Christian and other religious-based relief groups, who have labored in Africa's AIDS trenches for the last decade, breaking through the stigmas attached to a plague most Africans know only as "Slim," promoting abstinence through church-based teaching, and inaugurating programs to change sexual mores-another taboo subject-all the while trying to care for the sick and orphans the disease leaves behind.
Lacking funds and support to extend charity beyond the local and church level, many faith-based groups have watched AIDS rates-and the promiscuity that contributes to it-continue to skyrocket just beyond the borders of their own missions.
Since the first of this year Mr. Tobias's office has released $350 million for emergency AIDS programs, out of $2.4 billion approved for 2004 by Congress. Yet only $5 million has been apportioned to abstinence-related programs thus far. That's well behind the $110 million in new money his office and other agencies must supply to meet the year's $320 million total mandated by Congress, and suggested by Bush administration rhetoric.
Of a dozen faith-based organizations WORLD has identified that applied for first-round funding, only four received contracts. They include:
• World Relief ($10 million over five years, or $2.75 million in 2004)
• Catholic Relief Services ($7 million over 5 years, or $2 million in 2004)
• Habitat for Humanity/Opportunity International ($5 million over five years, or $1 million in 2004)
Two secular humanitarian organizations won first-round grants for abstinence training: the American Red Cross ($7 million over five years, $1.5 million in 2004) and Save the Children ($6 million over five years, $1.2 million in 2004).
Losers in the first round include: World Vision, Samaritan's Purse, Association of Christian Schools International, and CrossRoads, an abstinence-education ministry of Campus Crusade for Christ.
U.S. health officials also turned down the Salvation Army, which applied for funds to carry out anti-retroviral treatments for AIDS sufferers. Prison Fellowship was initially encouraged to apply for preexisting funds pulled into the new plan; it too was turned down. MAP International, a Georgia-based relief group that pioneered abstinence and faithfulness training with churches in Kenya, did not receive government notification in time to apply for first-round grants. Officials at the U.S. Agency for International Development told Samaritan's Purse, despite extensive humanitarian relief in Africa and sponsorship of a leading AIDS conference for faith-based groups, it was ineligible to apply for prevention funds.
The ill treatment, compounded by bewildering application procedures that stretch over two departments (State and Health and Human Services) and several U.S. health agencies, prompted faith-based leaders to complain directly to Mr. Tobias and the White House. Careerists at bureaus like USAID, they warned, were continuing to favor condom makers and status-quo family-planning groups in the AIDS fight.
"We feel that we've been the victim of some bureaucratic policies," said Matt Kavgian, government liaison for CrossRoads. "What has been changed at the political level by this administration has not been changed at the agency level. Much of the public-health establishment appears to be waiting for the end of the election season, and if Bush is not reelected I am sure they will simply return to the status quo of excluding faith-based organizations like us from the federal grant process."
Mr. Kavgian said USAID officials assured him that the Campus Crusade program was a "good fit" for prevention funds. The group already works in nine of the 14 countries targeted under the Bush plan, training teachers using a 30-lesson character-building curriculum that encourages teenagers to avoid premarital sex. CrossRoads hoped to reach 105,000 students over five years with new federal money.
USAID officials encouraged CrossRoads to submit an initial proposal late last year. Officials told Mr. Kavgian that a review panel would request a detailed proposal if it cleared. But CrossRoads never heard back from anyone at USAID. "We weren't given any critical feedback on what we did wrong," Mr. Kavgian said.
None of the groups WORLD spoke to that were turned down could learn why. USAID won't discuss the rejections because they are "procurement sensitive." Disclosing names of reviewers and the review panel process, said spokesman José Fuentes, might lead to potential contractors exerting "undue influence" on them.
That's OK for a few faith-based operators. World Vision spokesman Dean Owen said he believed the government's process "is fair and that there was no discrimination against faith-based organizations" even after officials rejected his organization's bid to carry out not only abstinence training but also medical treatment. "We do not know the reasons why World Vision was not awarded any of those grants; we understand fully that the process is very competitive and that there are many qualified organizations submitting applications," Mr. Owen said in a written statement.
Others worry not only about losing out on the ground floor of a new AIDS funding regime. They also worry that future AIDS victims won't benefit from what works. "The issue is whether or not behavior change-abstinence and faithfulness-is going to be allowed an honest shot," said Ken Isaacs, program director for Samaritan's Purse. "At the very least, there ought to be sunshine on how these decisions are made."
Meanwhile, big-ticket health groups who thrive on government grants are discovering that they have a stake in the new AIDS regime without trying. Nearly half of this year's "new" funding goes to existing programs. In fact, groups that support status-quo AIDS remedies-promoting condoms and other contraceptives, sexual awareness training, and expensive drug treatments-are enjoying more federal dollars under the Bush administration than they did under President Clinton.
Family Health International (FHI), a North Carolina-based conglomerate, tests and supplies condoms for the U.S. government in AIDS-stricken countries, in addition to providing anti-retroviral therapy, contraceptives, and sex-education training. Federal revenue to FHI rose 30 percent from 2002 to 2003, from $97 million to $126 million. FHI expenditures, nearly all from Washington, at the end of the Clinton era totaled $66 million; now they are more than double, at $137 million.
If FHI operatives provide a snapshot of where Bush AIDS dollars will flow, then leaders of faith-based organizations have reason to worry. Officer and board member Willard Cates, FHI's main point of contact with federal agencies, is a former CDC officer who once co-authored a study depicting childbirth as more dangerous to a woman's health than legalized abortion. In medical journals he argued for Medicaid funding of abortion and against waiting periods and parental notification procedures on abortion. Regarding promotion of condoms overseas, he has said: "We should push them."
Another FHI officer, David A. Grimes, is a leading proponent for emergency contraceptive Plan B, the morning-after pill, arguing for its availability over the counter, "sitting on the shelf with aspirin and acetaminophen." FHI documents list as board adviser Xiao Bilian, a Chinese government family-planning specialist who has pushed widespread use of a Chinese version of RU 486 among Chinese women.
Groups like FHI until now had little interest in faith-based policies. But with funding priorities beginning to tilt that way under Mr. Bush, they are at least learning the lingo. FHI produced (with federal funding) a 38-page booklet titled "HIV/AIDS Prevention, Care and Support Across Faith-Based Communities." Its website now promotes "ethics training" under HIV/AIDS headings.
Such groups "are seething with resentment," according to a U.S. health official who asked not to be identified. "They don't want to do ABC, but it is the trend. They exist, particularly the for-profits, to make money. I am concerned when I see their funding going up in spite of what we know works."
Evolving to meet Bush funding priorities "is happening everywhere, with every major organization," according to Debbie Dortzbach, AIDS coordinator for World Relief. "It appeared all at once that international organizations began to see and promote the value of faith-based initiatives." Now overseas health providers want in on it, she said, "because we have been working steadily and doggedly at the community level, helping churches realize they are at the front of the pack in terms of prevention and AIDS care."
Successful faith-based caregivers like World Relief, Dr. Green said, "have been doing ABC from the beginning and often without getting a dime of government funding.... My argument is since they know how to do it and want to do it, doesn't it make sense to let them do it?" That's the question faith-based leaders are asking the White House.