NYAGASAMBU, Rwanda — In much of the world, President Bush's foreign policy will be remembered for the Iraq war. But in these emerald hills in central Africa, his legacy looks brighter.
As bright, in fact, as the face of 19-year-old Jeanne Aribatuka, who was diagnosed with HIV while she was pregnant with her only child. She started taking antiretroviral drugs nine months ago and has gained 7 pounds. Her almond eyes dance when she says it.
Nearly 50,000 Rwandan HIV patients now receive the lifesaving drugs — up from 800 four years ago — thanks largely to a $15 billion global anti-AIDS plan that Bush launched in 2003. It's one of his most widely praised foreign-policy initiatives and, along with a major anti-malaria plan, forms the centerpiece of a dramatic increase in U.S. aid to Africa during his presidency.
Bush begins a six-day, five-nation tour of Africa this week hoping to showcase progress on AIDS and malaria and his commitment to economic development on the world's poorest continent. He's also expected to make the case that Congress should double funding for his AIDS initiative, due to expire this year, to $30 billion over the next five years.
"Africa in the 21st century is a continent of potential," Bush said Thursday. "It's a place where democracy is advancing, where economies are growing and leaders are meeting challenges with purpose and determination."
But even if he's able to escape issues such as Iraq and a jittery U.S. economy, Bush's mission comes amid growing violence in Sudan's Darfur region, an Islamist-led insurgency in Somalia and post-election unrest in Kenya, a key U.S. ally.
Critics say that the tour is intended to gloss over those and other trouble spots. Bush and first lady Laura Bush will visit Benin, Ghana and Tanzania — three of Africa's most stable countries — as well as Liberia and Rwanda, which have emerged from civil wars.
"This trip is designed to show the compassionate side of America," said Gayle Smith, an Africa expert at the Center for American Progress, a liberal Washington think tank.
Africa is one place where Bush's 2000 campaign pledge of "compassionate conservatism" appears to have been fulfilled, due in no small measure to the evangelical community's interest in the continent.
When Bush took office in 2001, U.S. humanitarian and development aid to Africa totaled $1.4 billion, according to the Organization for Economic Cooperation and Development. By 2006, that figure had quadrupled to $5.6 billion.
While America's standing in much of the world has diminished because of the Iraq war and other Bush administration policies, a report last July by the Pew Global Attitudes Project found that "the U.S. image is much stronger in Africa than in other regions of the world."
"Bush did more than anybody else for Africa," said Blaise Karibushi, a Rwandan doctor who has run AIDS programs for several years. "He has had problems (elsewhere), but for us he did a lot."
Perhaps no Bush initiative is as broadly popular as the President's Emergency Plan for AIDS Relief, or PEPFAR, launched in 2003. In 15 of the countries worst hit by AIDS — 12 of them in Africa — the program has helped put 1.4 million people on antiretroviral drugs by funneling money to international aid agencies, which develop programs at the local level.
In Rwanda, health officials say the impact has been remarkable.
The tiny country, still living quietly with the memory of the 1994 genocide, is among the poorest places in the world, ranked 158th out of 177 countries in the United Nations index of development. Just 438 hospitals and basic clinics serve a population of more than 8 million, crammed into a country smaller than Massachusetts.
Thanks to some $300 million in U.S. funding and tens of millions more from other international donors — chiefly the World Bank and the Global Fund to Fight AIDS, Tuberculosis and Malaria — two-thirds of Rwandans who need antiretroviral drugs are now getting them free, government officials said.
The changes are evident in Nyagasambu's redbrick HIV clinic, perched on a verdant hillside a half-hour's drive from the capital, Kigali. The clinic was built by the Elizabeth Glaser Pediatric AIDS Foundation, a Washington-based charity, with U.S. funds. Now dozens of HIV patients from the surrounding villages troop in for regular check-ups.
"Now we have the medicines we need; we have the lab equipment we need," said Theogene Ndayambaje, the clinic's assistant administrator. Motioning to a gaggle of brightly clad women waiting for their check-ups, he added, "Three years ago, they would not have lived."
Aid workers say the U.S. money was instrumental, but that it wouldn't have had such an impact without skilled management by Rwandan health officials. Under the leadership of President Paul Kagame, a bookish former rebel with a penchant for micromanagement, a government agency was formed to manage the windfall of funds.
"It was more money than had ever been seen before for a health program in such a small country. But the government of Rwanda is highly organized and deserves a lot of the credit," said Nancy Fitch, who ran the Bush program in Rwanda when it began and who's now the country director for the pediatric AIDS foundation.
The program has its share of critics. Many say that it focuses too much on meeting numerical targets and spends inefficiently by channeling money through aid agencies. As a result, they say, there's not enough investment in developing a country's overall health system. The funds can't be used to construct facilities, which aid workers say is a problem in a country like Rwanda, where most existing clinics are spartan places without running water or electricity.
Others chafe at the requirement that a proportion of the funds must go toward promoting abstinence to prevent more HIV infections, arguing that such messages are pointless if a person is already sexually active.
Nandini Oomman, an AIDS expert at the Washington-based Center for Global Development, said that the emphasis on drug treatment rather than prevention could undermine the program's gains in the long run. Even if it meets the target of putting 2 million people on antiretroviral drugs, Oomman said, as those people live longer the cost of their treatment will skyrocket — while prevention techniques such as promoting condom use are less expensive.
"No doubt President Bush has mobilized an unprecedented amount of resources," Oomman said, "but preventing new infections is where the program hasn't demonstrated impact. That is the pending measure for a true legacy."