Iraq and AIDS Treatment are the "Stickiest" Part of Bush's Legacy

In his final State of the Union speech last night, President Bush proposed many initiatives which the new President will be free to take or leave. If the new President is a Democrat, it will be mostly "leave." But two very different initiatives to which the President referred last night will be much harder than the others to walk away from: the Iraq invasion and the PEPFAR initiative to offer AIDS treatment to people in 15 of the worst affected countries.

How can one measure the "stickiness" of a Bush initiative? One way is to estimate how many people would die as a direct result of the initiative's reversal.

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Mead Over

Senior Fellow Emeritus

No one claims that people would die if Bush's tax cuts are reversed. His Education for All initiative could also be ended with no direct cost in lives.

But if the next President exits Iraq before the country's three major ethic groups begin to accommodate one another, a civil war is possible - perhaps even a three-way civil war, with genocide the worst-case outcome. It's hard to guess how many Iraqis would die in such a conflagration, but the death toll might equal the 600,000 Iraqi deaths that some estimate have occurred since 2003 because of the Iraqi invasion or even rival the approximately 800,000 deaths in the Rwandan genocide. So a new U.S. President who wishes to disengage from Bush's Iraq war must do so carefully and slowly, while attempting to hand over responsibility for peacekeeping and law and order to national forces.

By this measure of "stickiness," the PEPFAR AIDS treatment initiative is even "stickier." Bush noted last night that his initiative has put 1.4 million people on AIDS treatment. A new President who turns his back on this program will condemn almost all of these people to death within a few months. We can hope that the new President will recognize the serious reputational risks inherit in walking away from PEPFAR. As is the case for the Iraq war, immediate withdrawal is not an option. Furthermore, unless medical researchers achieve unprecedented and unanticipated breakthroughs amounting to a cure for AIDS, AIDS patients will need support for AIDS treatment even longer than Iraqi citizens will need help with security.

Of course, these two dimensions of Bush’s legacy are different in almost every other respect. The Iraq war is budgeted for 2009 at $70 billion and may cost three times that much per year, while Bush requested "only" $6 billion per year for the next five years for AIDS treatment. The Iraq war is fought with recruits who are drawn primarily from among our country's least educated members, whereas AIDS treatment is conducted by local physicians who are supported by some of America's best trained medical experts. The Iraq war generates sales by U.S. arms suppliers while AIDS treatment generates sales by pharmaceutical firms. The Iraq war alienates the young citizens in all the countries that should be our allies, whereas our AIDS treatment program inspires general admiration.

Eight years from now, when the next U.S. President may be making his or her last State of the Union address, I hope that the speech will be able to look back on a gradual and peaceful withdrawal from Iraq while pointing with pride to the growing U.S. contribution to multilateral support for the prevention and treatment of AIDS and other diseases in poor countries. If in a generous mood, the next President might even credit Bush's PEPFAR program for launching the U.S. on this laudable path.