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President George W. Bush; Hero or Villain in American history?

All things considered, George W. Bush did a lot of good.

Washington (22/05 – 40.00) All things considered, George W. Bush did a lot of good.

Don’t get me wrong. He is also a war criminal who belongs in a cell at the Hague, along with much of his Cabinet. The Iraq War was a disaster of epic proportions that, according to the best estimates, caused the needless death of hundreds of thousands of people. The administration’s torture regime was an appalling crime against humanity. Bush’s tax cuts were foolish, his Supreme Court picks were bad, and he appointed Federal Reserve governors who were far too hesitant to act decisively to save the economy in 2007 and 2008.

But Bush also created PEPFAR: the President’s Emergency Plan for AIDS Relief. PEPFAR is one of the best government programs in American history, probably the best since the Great Society. Public health research has found it saved the lives of at least a million people, and has done so with shocking cost-effectiveness. Not just any president would have proposed PEPFAR. Indeed, the Obama administration has taken alarming steps to weaken it. But Bush did propose it, and pass it, and as a consequence did enough good to outweigh even his worst offenses in office.

He’d have been an even better president if he hadn’t committed sundry war crimes or overseen the tanking of the world economy. But PEPFAR alone is enough to make Bush’s net impact on the world positive rather than negative.

What PEPFAR is

The Coptic Hospital in Nairobi, Kenya, a beneficiary of PEPFAR, on December 2, 2006.

PEPFAR is the federal government’s anti–HIV/AIDS foreign aid program, established by the Global AIDS Act of 2003 and renewed in 2008 and 2013. It is the single largest global health initiative targeting a single disease in history. It currently provides support for antiretroviral treatment for 7.7 million people, both directly and through technical support to partner countries; in fiscal year 2014, it provided HIV testing and counseling to more than 56.7 million people, including 14.2 million pregnant women.

“PEPFAR has helped changed the equation on what was once — not too long ago — seen as an insurmountable plague,” the Center for Global Development’s Amanda Glassman and Jenny Ottenhoff write.

The results are nothing short of extraordinary. A 2009 study by Stanford medical professors Eran Bendavid and Jayanta Bhattacharya, comparing HIV mortality in African countries receiving PEPFAR support between 2004 and 2007 and countries not receiving it, found that the program reduced the HIV death rate by 10.5 percent — preventing 1.2 million deaths, at a startlingly low price of only $2,450 per death averted. If you extrapolate out that figure for subsequent years, that’s 3 to 4 million lives saved so far — but given that the study only focused on 12 African countries rather than every PEPFAR partner, and that funding for and the reach of PEPFAR has grown dramatically since, that’s likely an underestimate. The true number saved could be significantly higher.

Pepfar’s Efforts have saved and Improved the Lives of Millions of People

Though some critics have argued that programs like PEPFAR that focus on one disease damage efforts to combat other public health problems, subsequent research by Bendavid, Bhattacharya, Charles Holmes, and Grant Miller found that PEPFAR reduced all-cause adult mortality in affected African countries by 16 to 20 percent.

That’s the direct evidence base, but there are plenty of less direct reasons to think PEPFAR is saving millions of lives. We know antiretroviral treatments are effective at expanding lifespans, and particularly effective when used to prevent transmission by pregnant women to children (a particular focus of PEPFAR). PEPFAR also provides funding for male circumcision, which is a cost-effective way of reducing the risk of HIV transmissionEvaluations of local antiretroviral treatment rollouts backed by PEPFAR (but not solely by PEPFAR) have been promising. There’s evidence that antiretrovirals increase workforce participation and employment, improving development prospects and improving well-being apart from any effects on mortality. A 2013 paper even found that PEPFAR was reducing tuberculosis infections and deaths in focus countries.

PEPFAR is not perfect. It has funded abstinence-only programs that have proven ineffective at reducing infection rates, though the portion of the budget going to these programs has shrunk in recent years. Until the Supreme Court struck it down, PEPFAR had a requirement that partner organizations commit to opposing sex work. Insofar as the Bush administration tried to inject social conservatism into the program’s operations, it made PEPFAR less effective. But these are relative quibbles next to the millions of lives saved.

A 2013 Institute of Medicine evaluation sums it up well: “PEPFAR’s efforts have saved and improved the lives of millions of people by supporting HIV prevention, care, and treatment services; meeting the needs of children affected by the epidemic; building capacity; strengthening systems; engaging with partner country governments and other stakeholders; increasing knowledge about the epidemic in partner countries; and ensuring that attention be paid to vulnerable populations in the response to HIV.”

Bush championed PEPFAR — and Obama hasn’t

Activists protest Obama’s AIDS funding policies on May 13, 2010, in New York City.

From start to finish, PEPFAR was Bush’s project; by all accounts, global HIV prevention was a personal passion of his during his two terms in office. PEPFAR’s announcement in the 2003 State of the Union (the same speech where Bush claimed “the British government has learned that Saddam Hussein recently sought significant quantities of uranium from Africa”) followed Bush’s contribution to the Global Fund to Fight AIDS, Tuberculosis, and Malaria in 2001 and a $500 million program to fight maternal transmission of HIV announced in 2002.

His then-deputy chief of staff, Joshua Bolten, told reporter John Donnelly that Bush told him to “think big” and work with other members of the administration to design a much larger, costlier anti-HIV program after the $500 million plan was announced. There wasn’t any domestic clamoring for such an effort. “Beyond a handful of congressional Democrats and Republicans calling for a vastly expanded anti-AIDS initiative in Africa, there seemed to be little appetite or enthusiasm for such a game-changing response,” Donnelly writes. But Bush got his team to propose and pass it all the same.

It was a textbook case of a president effectively using his power to change the political agenda. Before Bush, global HIV/AIDS funding was not a priority of Congress. But after Bush made it a focus, Congress passed billions in funding.

Obama’s record on PEPFAR, though, leaves much to be desired. Annual funding has fallen since he took office in nominal terms, and even more after inflation is taken into account:

Policymakers ranging from former Sen. Tom Coburn (R-OK), a diehard fiscal conservative, to Rep. Barbara Lee (D-CA), perhaps the most left-wing member of the House and the only “no” vote on the post-9/11 Authorization for the Use of Military Force, have urged Obama to reverse course and propose increases to PEPFAR’s budget, following Bush’s pattern of consistently increasing funding. But this has fallen on deaf ears.

When challenged on his repeated cuts to PEPFAR, Obama has pleaded Republican obstruction, telling reporters in 2013, “Given the budget constraints, for us to try to get the kind of money that President Bush was able to get out of the Republican House for massively scaled new foreign aid program is very difficult.”

However, the commitment of Coburn and other conservatives — including Senate Republicans like Mike Enzi, Marco Rubio, Richard Burr, and Kelly Ayotte — to boosting PEPFAR makes this excuse hard to believe. Indeed, in fiscal year 2015 Congress actually increased PEPFAR funding by $300 million. Did Obama sense an opening, and increase PEPFAR funding in his fiscal year 2016 budget? Nope. He kept PEFAR funding flat, and cut other global HIV/AIDS funding.

PEPFAR isn’t the kind of thing that any president would do. It was born of the particular interests of the Bush administration, and while it’s hung on under Obama — and kept saving millions more lives — the current administration’s comparative neglect of it demonstrates that its existence and survival are anything but guaranteed. Bush really did go above and beyond by creating it.

Does this outweigh Bush’s sins?

Bush’s sins are … considerable.

Cards on the table: I’m a utilitarian. I think government policy should maximize human well-being and happiness. And it’s really, really hard to argue that the Bush administration did enough net harm to human well-being to outweigh the tremendous good done by PEPFAR.

Take the Iraq War, the worst thing Bush did in his presidency, and the one that cost by far the most lives. The most conservative estimates — like Iraq Body Count‘s, which is drawn from media reports — place Iraqi casualties from the conflict at 100,000 to 250,000, with Iraq Body Count putting the figure at 216,000. Survey-based studies go higher: One estimating 2003 to 2011 excess deaths put the toll at 405,000; a famous 2006 Lancet study put the toll to date at 654,965; in early 2008 the British polling firm ORB put it at 1.033 million.

The highest of those estimates are extremely implausible; see this paper by economist Michael Spagat on the Lancet study (which finds evidence that some data was fabricated or falsified), and this one by Spagat and Iraq Body Count’s Josh Dougherty on the ORB poll. But supposing for a second they were true, PEPFAR saved an estimated 1.2 million lives in its first four years; it has seen greatly expanded funding since, and saved millions more. The humanitarian toll of Iraq was tremendous, and all the more tragic for being totally preventable. But it was considerably smaller than the humanitarian gains of PEPFAR.

Perfar is an accomplishment that stands alongside the Marshall Plan, and Social Security

That’s true even if you add in Afghanistan. According to a recent paper by Boston University’s Neta Crawford, about 149,000 people, including combatants and civilians, have died in Afghanistan and Pakistan due to violence following the invasion. That’s swamped not just by PEPFAR but by aid efforts in Afghanistan, which have reduced child mortality enough that nearly 100,000 child deaths that would have happened absent US intervention are averted every year.

The only other policy of Bush’s that plausibly could have an impact of this scale on human mortality is his failure to act decisively against climate change. Precise estimates here are impossible; extreme climate change is likely to cost many, many lives, but causally attributing a portion of it to inaction over a specific period of time in a specific country (even one as crucial as the US) is basically impossible. If, in the future, it can be demonstrated that EPA regulations like those being rolled out by the Obama administration, were they implemented in 2001, could’ve mitigated global warming enough to save millions of lives, then Bush did net harm to the world. But especially absent cooperation from other governments, that strikes me as a tough case to make.

Remembering Dubya

Bush attends the dedication of his presidential library with President Obama and his three fellow living ex-presidents.

Bush is not, as Clinton family court historian Sean Wilentz once dubbed him, America’s worst president. He’s not the fourth worst, as my colleague Matt Yglesias wrote earlier this year. It’s simply unfair to place him next to the likes of Andrew Johnson, the best friend white supremacy ever had in America, or noted genocidaire Andrew Jackson, or mass slaughter aider and abetter Richard Nixon.

George W. Bush was not a great president. He should be ashamed of — and, in a better world, would be punished for — his actions in Iraq and the torture regime he created. They are a moral stain on the nation.

But Bush was not a bad president, either. PEPFAR is an accomplishment that deserves to stand alongside the Affordable Care Act, Medicare, the Marshall Plan, and Social Security as one of the greatest spending programs the federal government ever enacted.