As global leaders gathered in Davos, Switzerland, for the World Economic Forum in January, officials from President Bush's $15 billion anti-AIDS program issued a news release citing their accomplishments. Nowhere were the numbers more impressive than in Botswana, where 32,839 AIDS patients were receiving life-extending treatment with the help of the U.S. government, they said.
But thousands of miles away in Botswana, the Bush administration's claim provoked frustration and anger among the network of public and private partners that had built Africa's most far-reaching AIDS treatment program, recalled those involved. Although the Bush program had promised millions of dollars of direct financial support for their national treatment program, no money had yet arrived, they said.
The operations manager of Botswana's national treatment program, Segolame Ramotlhwa, called the U.S. figures "a gross misrepresentation of the facts." His boss, Patson Mazonde, who as deputy permanent secretary for health services had overseen the program since its inception in 2002, called the Bush claim "false" but suggested it was merely a mistake.
They agreed on the number of patients in Botswana who had been put on treatment because of the Bush program: zero.
After first defending its figures from the January news release, the Bush administration last month revised them sharply downward. But even the revised numbers remain in dispute. Administration officials announced that 20,000 people in Botswana were receiving "significant support" from U.S. programs for their AIDS treatment. Health officials in Botswana maintained, as they have for months, that no citizen was dependent on U.S. support for treatment, the cost of which has been covered overwhelmingly by the Botswanan government.
The disagreement underscores not only the highly politicized nature of treating AIDS in Africa, where less than 10 percent of the people who need antiretroviral drugs are getting them, but also how rare -- and coveted -- success stories such as those in Botswana remain.
To people receiving the lifesaving medications, the question of who gets the credit may not matter. But for the government of Botswana, the groundbreaking AIDS program is a source of enormous national pride, while for the Bush administration, being able to announce such successes bolsters its claim to having begun to "turn the tide" against AIDS in the developing world.
The dispute essentially comes down to a question of how to define "support." In March, in an annual report on the program, the Bush administration said support could include general "system strengthening" -- a category so broad that it could allow officials to claim to have supported treatment of any AIDS patient who benefited, however indirectly, from U.S. government assistance.
The head of the Bush administration's program in Botswana, Peter H. Kilmarx, from the Centers for Disease Control and Prevention in Atlanta, said in an interview here in May that he was aware of the upset among the Botswanan officials but that the treatment claims fit within U.S. government guidelines. The definition used for measuring support, he said, had broadened to the point that even assistance as trivial as editing a government health official's speeches could allow the Bush program to say it had supported treatment for everyone receiving antiretrovirals from that nation's public health system.
The system "could be abused," Kilmarx said. "But it's not."
The Bush program set its numerical targets even before the legislation creating the program was drafted. In his 2003 State of the Union address, Bush stunned AIDS activists by announcing a $15 billion commitment over five years to fight the disease. The program would soon become what U.S. officials call the largest global health initiative undertaken against a single disease by a single country.
Bush announced that the program would "treat at least 2 million people with life-extending drugs." But over the next year, as administration officials developed the president's promise into a program, they recast the goal. It was not practical, officials say they concluded, for the U.S. government to build clinics, hire doctors and hand out drugs all over the developing world. And officials from the countries targeted for the assistance, including Botswana, made clear that while they wanted help, they believed that their own governments, not the United States, should be distributing the medicine.
In Botswana, a landlocked nation of 1.6 million people in southern Africa, officials were tackling one the world's worst epidemics of AIDS. Nearly four of every 10 working-age adults were infected with HIV, the virus that causes the disease. Bolstered by vast diamond wealth and a stable government, President Festus Mogae had committed the nation to providing costly, state-of-the-art AIDS treatment to every citizen.
The daring promise, the first of its kind in Africa, attracted tens of millions of dollars in support from donors, including substantial amounts from the U.S. government, which took the lead in upgrading laboratories and building a network of centers to test patients for HIV.
With the inception of the Bush program, both the White House and Congress began focusing on delivering the antiretroviral drugs that alone had the prospect of saving millions of lives. And the U.S. officials charged with implementing this vision were also supposed to produce quantifiable results to make explicit the value of the $15 billion investment.
In Botswana at least, deciding who deserved credit for any one person getting the drugs proved complicated.
Harriet M. Isaacs, a 59-year-old civil servant with AIDS, started taking antiretrovirals in 2002, the year before Bush announced his program. The drugs have restored her to health, and with a few months left until her planned retirement, she now looks forward to many more years of playing with her grandchildren.
She expresses no doubt about who saved her life: the government of Botswana.
"It's very expensive," Isaacs said while seated in a bustling AIDS clinic here, "but it's helping people. . . . I'm confident that I can go up to 100 [years old] now."
The reality of who paid for her health care is more complex. She visits a clinic built with the help of the Bill & Melinda Gates Foundation. She takes medicine donated, in part, by the American pharmaceutical giant Merck. And the cost of most everything else -- doctors, nurses, lab work -- is covered by the government of Botswana.
For Isaacs, the role played by the Bush program -- so far, at least -- has been minor, confined mainly to the training of medical personnel and the monitoring and evaluation of the existing government program. The total outlay of U.S. government funds for "treatment" in Botswana last year was $2.5 million, about one-twentieth of the amount paid by the Botswana government. And even that money was delayed by many months.
Yet when it came time to tabulate the Bush program's successes in Botswana, every patient receiving antiretroviral drugs from the national program, including Isaacs, was included. U.S. officials also counted several thousand others who were receiving their medicine from private doctors because, Kilmarx said, some had benefited from a U.S.-funded training program.
He explained that since the January news release in Davos, the number of AIDS patients for which the Bush administration was claiming credit had continued to grow. That day, he said, he was submitting a new total of 41,444 in Botswana to top program officials in Washington. Everyone in Botswana receiving antiretroviral drugs was included, Kilmarx said.
In the days that followed, Kilmarx was asked about the comments made by Mazonde, Ramotlhwa and other health officials from Botswana. He defended the program and then called another meeting with them. Later on the day of that meeting, he reiterated his defense of the numbers, saying that Mazonde and Ramotlhwa were "entirely comfortable" with how the Bush program had portrayed its role in Botswana.
The message he received from the health officials, Kilmarx said, was that while they had been unhappy with some of the Bush program's characterizations, they wanted the funding to keep coming.
In subsequent phone interviews, both Mazonde and Ramotlhwa softened their tone, emphasizing their gratitude for the millions of dollars that, they said, they still expected from the Bush program. Ramotlhwa suggested it was better to say the Bush numbers exhibited "some element of distortion" rather than characterizing them as "a gross misrepresentation of the facts."
Yet when asked if there was anyone whose antiretroviral treatment was dependent on the Bush program, Ramotlhwa and Mazonde said that they knew of none.
"We cannot single out a person who would not be receiving treatment," Mazonde said.
On June 13 -- two weeks after that interview -- Bush announced new totals for his AIDS program. They were ahead of schedule, reaching more than 200,000 people with U.S.-supported treatment in the 15 developing countries the program focused on.
In backup documents distributed by U.S. officials, the treatment total for Botswana was neither the 32,839 cited in January nor the 41,444 that Kilmarx submitted to his superiors in May. The new total, offered with no explanation, was 20,000.
Asked about the shift, the Bush program's deputy coordinator, Mark R. Dybul, said in an interview at his Washington office that reporting systems were evolving. "We're changing the numbers as we refine reporting," Dybul said. Of the Botswana health officials, Dybul added, "They saw what's in here and they cleared it."
He also disputed Kilmarx's statement that minor assistance, such as revising an official's speech, would allow the Bush program to claim it had supported treatment for everyone receiving it in a country. The new totals, Dybul said, included only those receiving "significant support," meaning that "these people would not have quality treatment, would not have substantial services, without the U.S. government."
In a final phone interview, Mazonde again expressed gratitude for the U.S. aid. He added that a series of conversations with U.S. officials in recent weeks had impressed on him the many ways that the Bush program funding was assisting Botswana, and that several million dollars promised for the national treatment program would soon be available.
But when pressed, Mazonde said there were not 20,000 people in Botswana whose "quality treatment" was dependent on the U.S. government. In fact, he said, there were none.