The Global Health President

Why Rick Santorum would be great news for the AIDS fight in Africa.

Before he became president, few expected George W. Bush to be a global health activist. But Bush astounded his critics and supporters alike by launching a train of multibillion-dollar health rescue programs for the developing world, including the President's Emergency Plan for AIDS Relief (PEPFAR), the President's Malaria Initiative, and the Global Fund to Fight AIDS, Tuberculosis and Malaria. Bush, in launching PEPFAR in 2003, called it a "work of mercy" to save Africa and hailed what he called the "Lazarus effect" of anti-HIV drugs in saving AIDS patients from the brink of death and allowing them to lead more normal lives, quickly and inexpensively. PEPFAR and its associated programs, which have spent $39 billion to treat millions of people, have been recognized as a cornerstone of Bush's presidency. And in many countries receiving PEPFAR and Global Fund support, Bush and America have become synonymous with global health.

Back in 2002, when I was Secretary of State Colin Powell's special envoy on HIV/AIDS, I learned of Rick Santorum's call for a robust role for the United States in international health, an unusual and distinctive position for a senator from Pennsylvania, where jobs and the economy are dominant issues. Fast-forward to this year's Republican campaign for the presidency, where the most religiously conservative candidate, surprisingly, is the most fervent advocate for U.S. global health diplomacy.

Alone among his rivals, Santorum has staked out global health as one of his preferred instruments of asserting American power abroad. He is the only Republican candidate to declare he wants to "keep and expand" Bush's humanitarian aid push in Africa. In contrast, Mitt Romney is "very reluctant to borrow lots more money to be able to do wonderful things" if other countries and groups do not contribute more; Newt Gingrich has called for government-run foreign aid to be replaced with private incentives; and Ron Paul, a physician, has asserted that "all the foreign aid in the world will not transform Africa into a thriving, healthy continent."

Santorum seems determined to lay the groundwork for a global health agenda that is not only far more extensive than his competitors', but would surpass both Bush and Barack Obama in advancing U.S. interests abroad through fighting disease. If he follows through with his campaign promises, Santorum could elevate global health to be a prominent instrument of American statecraft.

His record so far is promising. In 2008, Santorum urged his conservative allies in Congress to support reauthorization of Bush's global AIDS program at a new, higher price tag of $50 billion. He called this "some of the best money Congress can spend" as doing so would "protect our nation," and he argued that fighting AIDS could win friends in strategic, pivotal countries such as Indonesia and deter enemies from making inroads in impoverished zones. At the Nov. 22, 2011, Republican presidential primary debate, Santorum asserted that advancing global health was "absolutely essential." He conjoined the rescue mission of health with that of promoting U.S. interests, stating "the work that we've done in stabilizing [Africa], while humanitarian in nature, was absolutely essential for our national security."

He has couched aid programs as "one of our best international investments" and credited humanitarian aid and fighting AIDS as critical to winning "hearts and minds" in competing against the influence of "China and Islam" in Africa. "We have done more good for America in Africa and in the Third World by the things that we've done," he said at the Nov. 22 debate. "And we have saved money and saved military deployments by wisely spending that money not on our enemies but on folks who can and will be our friends." His reasoning echoes the arguments asserted by the late diplomat Richard Holbrooke about saving Africa from a demographic cataclysm caused by HIV/AIDS.

Very soon after Nov. 22's debate, Santorum issued a remarkable statement for World AIDS Day on Dec. 1: "There is reason to celebrate today that over 4 million people with AIDS in Africa are on antiviral drugs as a result of the US commitments through PEPFAR and other partnerships. There is reason to set our resolve, as almost 5,000 people die every day due to AIDS and there are about 7,000 new HIV infections a day. Thankfully, there is reason to hope that in our lifetime, we may see the end of AIDS. Let's turn our resolve into action." None of the other Republican candidates marked the occasion.

Santorum's willingness to work actively against AIDS and poverty has won plaudits from those who might otherwise be his political detractors. Rock star and activist Bono told the New York Times in 2006 that "Rick Santorum has a kind of Tourette's disease; he will always say the most unpopular thing. But on our issues, he has been a defender of the most vulnerable."

If Santorum was ebullient about spending $50 billion on global AIDS in 2008, as president he might be emboldened to seek even higher amounts of money for health and anti-poverty initiatives, beyond what Bush and Obama have done, to implement his principles on a worldwide scale, perhaps one reminiscent of the Marshall Plan that resuscitated Western Europe after World War II. And make no mistake, that's the kind of initiative Africa needs.


Santorum's religiosity, the cause for many of his strong beliefs about global health, might also become the biggest roadblock to his effectiveness. In a 2007 editorial, Santorum wrote, "The social teachings of my faith were a factor in my work as a senator. The horror of AIDS and the tragedy of the millions of orphans it has left in Africa prompted my support for greater U.S. funding. But it was Christ's mandate to care for the poor that inspired my efforts to take a leadership role." A firm believer in banning abortions, Santorum seeks to "ensure that all of our foreign aid, bilateral and multinational … requires recipients of US federal funds to neither perform nor promote abortion in other nations or they will not receive taxpayer money."

Santorum risks incurring opposition from organizations and donors that believe in pro-choice policies, entangling entities like the Global Fund in battles over such restrictive provisions. If others withdraw from cooperating with his administration over abortion, U.S. programs overseas may become isolated and weakened. Santorum, unlike Obama, has expressed strong antipathy toward the U.S. Agency for International Development (USAID) and the United Nations, calling to cut by half both the staffing levels at USAID and U.S. funding for the United Nations. He goes further and advocates the complete defunding of unnamed U.N. agencies that "oppose America's interests and promote abortion."

Santorum might also extend the requirement by Bush to allocate one-third of prevention funds in global health programs to the strategy of abstinence and disallow the exchange of needles and syringes to drug users in HIV/AIDS prevention programs -- a stance that has drawn opposition from many NGOs as inhibiting their outreach to break the cycle of HIV transmission.

Social controversies that have complicated the conduct of global health policy of previous administrations will continue in the future. Still, Santorum seems ready to take a cue from the phrases "Nixon in China" and "Bush in Africa," which describe the surprise and acclaim won by the two Republican presidents in launching dramatic diplomatic initiatives that upended conservatives' expectations. Santorum, if elected president, could depart from conservative orthodoxy by centering U.S. foreign policy on prescribing global health as a potent form of "soft power" statecraft. And he could save millions of lives in the process.

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Putin the Peacemaker?

Russia's once and future president, Vladimir Putin, likes to talk tough. But what he really wants is to be America's partner -- and Washington isn't listening.

Never one to mince words, Russian Prime Minister Vladimir Putin has laid down his views on national security policy. Like all his other articles in the Russian press of late -- articles that have to substitute for the absent presidential debates -- his recent piece in the newspaper Rossiiskaya Gazeta (and excerpted on Foreign was, above all, a campaign statement. Like any leader facing an election (and one need only to look to the U.S. Republican presidential nominees for confirmation), he sought to portray himself as a staunch patriot ready to defend his country's national interest. Appearing on the eve of Defender of the Fatherland Day, his long piece also made a pitch for the votes of military members and workers in the defense industry. "There is always a temptation to solve one's problems at somebody else's expense," Putin wrote. But, he continued, "We should not tempt anyone by our weakness." Yet, Putin's article is more than electoral rhetoric; it is a plan that is already being implemented. The problem with it is that it rests on the pessimistic conclusion that, in the 21st century, Russia's national security will need to be protected, above all, from the United States.

There is no question that, in today's Russia, official anti-Americanism serves a useful domestic purpose. It seeks to discredit not just a few Russian liberals but the much more numerous anti-government protesters by portraying them as America's fifth column. There is no doubt either that the view of the United States as Russia's adversary reflects the legacy of the Cold War and, perhaps even more than that, the disappointment that followed the end of the 40-year confrontation, when Russia, having withdrawn its forces from a score of countries and slashed its military equipment purchases by 68 times in just one year (1992), turned itself into an international supplicant, living from one International Monetary Fund tranche to another. But there is also the fact that, at the beginning of each post-Soviet Russian presidency, the Kremlin leader reached out to his counterpart at the White House in an effort to strike an alliance with the United States, only to be brushed off.

Boris Yeltsin, in 1992, sought a formal alliance with Washington, only to be told, by George H.W. Bush, that with the Cold War over there was no need for new alliances anymore. When, however, the existing alliance, NATO, started to expand eastward, under Bill Clinton, Russia was only told not to worry. Rhetorically, the door was left open for Russia, but in reality Moscow's accession was never seriously considered. No wonder that Yeltsin's parting message to Clinton, in late 1999, was "never to forget, not for a minute," that Russia was still a nuclear superpower.

It is little mentioned these days that when Putin became president in 2000, he was determined to do what had eluded Yeltsin. Privately but very directly, he aspired to Russia's membership in NATO -- not to destroy it from the inside, as many readily suspected, but to cement the relationship with the United States, whose primacy Putin then was prepared to implicitly recognize. In the crucial first stage of the Afghanistan operation, Russia de facto became an ally of the United States. In an effort to build a strong security relationship with Washington, Putin chose not to respond to George W. Bush's unilateral withdrawal from the 1972 Anti-Ballistic Missile Treaty that Moscow had always regarded as a bedrock of strategic stability, and he tolerated a U.S. military presence in the former Soviet Central Asia and Georgia. From mid-2002, however, the Bush White House became focused on Iraq, and Russia was left lying by the wayside. Putin gave vent to his pent-up frustration five years later in his famous Munich speech in which he denounced the United States, whose power refused to "recognize any borders in this world."

As he was picking up the pieces from the 2008 Georgia war, President Dmitry Medvedev, still overseen by Putin (now the prime minister), was positive, but initially cautious, in his response to Barack Obama's reset of the U.S. policy toward Russia. By the fall of 2009, however, he became very engaged, and by the time of the NATO-Russia summit in Lisbon a year later, Medvedev was positively enthusiastic about the U.S. relationship. The New START treaty was not enough. Medvedev started talking about missile defense cooperation in Europe as a means of placing the entire Euro-Atlantic area within a common security and defense perimeter. The Russian president's enthusiasm was short-lived. Following the failure in May 2011 to reach even a basic agreement on principles of cooperation, he issued a statement last November warning darkly about Russia's countermeasures against future U.S. missile defense deployments in Europe.

True, each Russian attempt at engaging the United States has been awkward in its own way. In 1992, there was no common enemy around which to justify forming a U.S.-Russia alliance. Deng Xiaoping's China, busy with its four modernizations, did not replace the Soviet Union as a global challenger to the United States. In 2001, had Russia been admitted to NATO, the alliance would have turned into something like the Organization for Security and Co-operation in Europe. A few years later, the United States and Russia narrowly escaped a head-on collision in the Georgia war. In 2011, a joint missile defense in Europe would have either de facto placed Russian assets under U.S./NATO authority or, more likely, made the system totally dysfunctional. But the issue here is not how the United States responded to specific Russian ideas, but rather that Washington wasn't really interested in engaging Moscow strategically at all.

The reset, as the name itself suggests, is essentially a means to do away with policy glitches; it does not equal a policy, much less a long-term strategy. The U.S. rationale for having the reset in the first place had little or nothing to do with Russia. Instead, it allowed the United States to acquire Russia's logistical cooperation on the transit routes leading to Afghanistan, revive a modicum of nuclear arms control, and finalize Russia's 18-year quest to join the World Trade Organization. Beyond these relatively low-hanging fruits there was a void.

Putin's formal return to the Kremlin is just days away. And with his tough campaign rhetoric and military modernization plans, on the one hand, and, on the other, the continuing protests in Russia against the existing political system, which challenge Putin's own legitimacy, the environment is even less propitious for an effort to improve strategic relations between Washington and Moscow. The more interesting issue is that, in the current U.S. foreign-policy debate, Russia has become a marginal quantity. A discussion of U.S. policy toward China can go on for hours without ever mentioning Russia; the Sturm und Drang over Iran's nuclear weapons program barely takes account of how U.S. moves might be perceived in Moscow; and though they loudly decry it with reference to Syria, hardly anyone in Washington loses sleep over the long-term implications of the ever-closer Sino-Russian alignment at the U.N. Security Council.

The view of Russia as a power in permanent and unstoppable decline may be right, or it may not. If anything, Moscow should be even more interested in finding realistic ways to improve its relations with Washington. Russia's modernization agenda risks being scuttled in the event of a serious deterioration of its relations with the United States. What is striking, however, is that Washington, while focused intently on particular global issues -- from promoting the fledgling democracies of the Arab Spring to handing off Afghanistan to pivoting toward Asia -- thinks it can afford having no general strategic vision of relations with a country that, despite all its weaknesses and failings, can make a huge difference in the emerging global balance. Conventional wisdom in Washington declares that if there is no problem, there is no policy. This may have been just fine in the years of clear U.S. dominance in the world. It is hardly affordable now.

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