For most of the two-hour flight from Geneva to Dublin — as soon as the seatbelt light blinks out — Mark Dybul does not sit. He stands in the aisle, flush against his own armrest, thumbing at his smartphone, while flight attendants and passengers squeeze past. He’s wearing a crisp grey suit, white shirt, and white pocket square. His side swept blonde bangs are thinning, but cut across a youthful face. A multicolored United Nations pin clings to his lapel.
“I have to stand when I can,” Dybul says, somewhere in the air between his adopted home in Switzerland and the Irish capital where he’s putting in some face time.
“I have a bad back,” he says — and then, smiling at the irony, “Flying too much.”
Over the course of roughly 24 hours I spent with the former executive director of the Global Fund to Fight AIDS, Tuberculosis and Malaria, Dybul rarely sat down, even when it meant he was the only one standing. At the Royal College of Surgeons in Ireland, where he was invited to speak about universal health care, Dybul stood, listening from a few paces behind his fellow seated panelists. When a reporter from the Irish Times called to interview him about Ireland’s contribution to fighting infectious disease, Dybul stood with his back against the wall of his hotel room and talked about how the island nation “punches above its weight” by contributing to a multilateral organization.
To operate a global fund, it turns out, requires a global person. For four years Dybul has shuttled between the world’s richest and poorest capitals, rarely spending more than 24 hours in any one place. The repetitive stress of honing his message to donors, matching tight resources to program data in implementing countries — he hates the word “beneficiaries” — and then returning to Switzerland has not beaten him down into his seat, but out of it. It is as though Dybul, like a modern-day Greek hero, has taken on a quest so elemental — ending three global plagues — that the gods demanded a sacrifice: his basic human enjoyment of comfortably sitting down.
For two decades, Dybul has been at the center of a seismic shift in the way global health programs are designed and paid for. A paternalistic donor-recipient model is giving way — slowly and stubbornly — to a constellation of partnerships with strong health systems, not the delivery of treatments by rich countries to poor ones, as their raison d’être. Dybul has pushed for that change and honed a pitch that describes what the future of ending epidemics could look like — and why governments, philanthropists, and even Irish taxpayers should want to be part of it. He wants the world to seize this moment of opportunity. He still has faith in the better angels of our nature.
After four years as the Global Fund’s executive director — during which time he helmed two multi-billion dollar fundraising efforts and helped restore the embattled Swiss organization’s reputation as a global health leader — Dybul stepped down last month at the end of his first term. He is returning to Washington, D.C. and to life as a faculty member of the Georgetown University Medical Center, his alma mater.
“Innovation changes everything, and change doesn’t happen when people stick around for too long,” he told me.
Ending three plagues
Passing through customs in Dublin’s airport, the desk agent balks when I tell him I’m here to write about the Global Fund.
“Global Fund?” he says in a thick, Irish brogue. “What do they fund? Themselves?”
In the taxi to his hotel, Dybul chuckles at the encounter, but he knows the skepticism ascendent in the world today — of international organizations and multilateral cooperation — is real.
“Skepticism is welcome in a context. It’s when it gets out of context that it’s worrying,” Dybul says.
Despite his optimism, Dybul finds himself running against the headwinds of a world tilting toward retrenchment and isolationism, driven back into itself by Donald Trump’s election, the United Kingdom’s vote to leave the European Union, budget cuts, and immigration bans. The kind of international cooperation that brought the eradication of three epidemics into view is now at risk.
Dybul believes most politicians, at their core, want to say yes to ending disease and fighting poverty, but that global health and development organizations need to get better at offering something they can choose with confidence over other competing investments.
“Ending three plagues is a pretty attractive proposition. But you have to be able to show them that you’re creating an institution that can do that,” Dybul says as our taxi winds past Dublin’s parks and parliament buildings.
That is what he worked to create — or recreate — at the Global Fund, a “21st century partnership organization” launched at the outset of a new millennium, with support from figures such as Bill Gates and Kofi Annan, to embody the best of what the world had learned about financing global health at a massive scale. The effort nearly crashed under the weight of its own aspiration.
The diseases Dybul is fighting — malaria, tuberculosis and HIV — have defined the human condition. Chinese medical writings described malaria’s symptoms in 2700 B.C. Researchers found the parasite’s genome in 2000-year old remains from the Roman Empire. Tuberculosis appears in the books of Deuteronomy and Leviticus, its symptoms are described in Hammurabi’s code, the world’s oldest legal text, and ancestral strains may have afflicted early hominids in east Africa 3 million years ago.
“You can find mummies with TB and malaria. These two diseases have been around since recorded medical history and have killed more people than anything in the history of the world,” Dybul said. “We can actually eliminate them.”
HIV/AIDS is a recent addition to the list of deadly epidemics, rising in the late 20th century like a modern sequel to the existential terror wrought by plagues in the Middle Ages.
Progress has been uneven, and recent gains are threatened, both by the creeping specter of drug resistance and by politics. But, for the first time in human history, it is possible to chart a course to controlling three global killers that cluster disproportionately among the poor and marginalized. Two multi-billion dollar efforts, the Global Fund and PEPFAR, the U.S. AIDS-relief program created under former President George W. Bush, are a big reason why.
Dybul has led both.
Even at the end of his tenure, Dybul seems to exist inside an urgent moment, where his faith in possibility is in constant collision with his fear that the world will let it slip away.
“I actually think there’s enormous opportunity, but I keep going around and everyone’s thinking that they can just repackage things the way we’ve done it before and it’ll all be fine,” he says as the taxi pulls up to his hotel. He darts inside for a closed-door lunch with ministers from one of his organization’s 35 donor countries.
He’s only got 24 hours to make his case.
Inheriting a mess
At a Dublin radio studio later that evening, Dybul described the Global Fund as a “remarkable act of solidarity.”
The Fund was designed to be part of a cutting-edge, second-generation of global health and development organizations. Instead of building a large, bureaucratic organization controlled by Western experts, the Global Fund would finance country-led health interventions. It works by raising money, from governments and private donors such as the Bill and Melinda Gates Foundation, and then dispersing funds to national coordinating bodies. The idea was to move money quickly from donors with deep pockets to countries with huge disease burdens and limited resources.
“The people who don’t like development are much more strategic than the people who do.”— Mark Dybul
After about a decade operating with a relatively small Geneva-based staff who mostly processed grants, cracks began to show in the Global Fund’s model. The early optimism that accompanied an innovative, public-private organization built to deliver on the promise of the Millennium Development Goals slowly dissolved in the face of a troubling realization: the Global Fund’s hands-off approach left it vulnerable to corruption.
A series of reports detailing fraud, mismanagement, and weak financial controls dragged the organization back down to earth. The Global Fund’s own inspector general reported that $34 million dollars was siphoned away from grants to four African countries. Media outlets unspooled yet another narrative about foreign aid lost to corrupt governments.
A 2011 article by the Associated Press brought the fund’s internal investigations into public view, pointing to health grants spent on cars and motorcycles instead of medicine, free malaria drugs illegally resold on commercial markets, fake invoices, forged receipts, and a funding system that relied too much on countries’ own internal controls. The story highlighted one case where two-thirds of a Global Fund anti-HIV grant to Mauritania had been pilfered. Even though that amounted to only $4.1 million, that case gave the impression of a deeply-compromised effort.
“A $21.7 billion development fund backed by celebrities and hailed as an alternative to the bureaucracy of the United Nations sees as much as two-thirds of some grants eaten up by corruption,” the AP declared in its opening line. In 2011, Sweden, Germany, and Ireland all suspended their donations.
“There is a reason that people attacking development go after stories of misuse and corruption,” Dybul said. Individual examples of wasted funding allow critics to create the impression that the entire enterprise is compromised, Dybul explained, even though the amount that’s lost might be a tiny portion of the total. “Then you spin this narrative around that — “everything’s a waste.” And then you say, “why wouldn’t we take this money and spend it somewhere else?”
“The people who don’t like development are much more strategic than the people who do,” Dybul said.
Defenders — including Washington Post columnist and former George W. Bush speechwriter Michael Gerson — pointed out the misappropriated money in the inspector general’s reports amounted to only three-tenths of one percent of the Global Fund’s total disbursement. Gerson noted it was the Global Fund itself that reported on the fraud cases, which were investigated because, “they were the most obviously problematic, not the most typical.”
The bad headlines coincided with a grim economic picture. In the wake of the global recession and with donor confidence wavering, the Global Fund fell into a deep financial hole — hundreds of millions of dollars short of its planned expenditure — just as the board was about to announce its 11th grant funding round for country projects.
There was, “a whole ton of consternation around how well the organization [was] being managed,” said Todd Summers, a senior advisor at the Center for Strategic and International Studies, who chaired the Global Fund’s strategy, impact and investment committee until 2014.
At a board meeting in Accra, Ghana in November 2011, the Global Fund board made a dramatic decision to suspend its 11th funding round, and at the same time adopted a new strategy to deal with weaknesses that had allowed millions of dollars to go astray. They shook up the fund’s leadership, announcing they would appoint a general manager to improve the fund’s financial oversight, eventually choosing Gabriel Jaramillo, a former banker. The executive director at the time, Michel Kazatchkine, resigned.
“While I remain fully committed to the Global Fund and its mission, I have concluded that I should not continue as executive director in these circumstances,” Kazatchkine wrote in a letter to staff and partners.
“That was a tumultuous period,” said Summers. Kazatchkine, a French physician and diplomat, left with tension between him and Global Fund constituencies like the U.S. and U.K., who were seen as drivers of the reform, Summers said. “It caused quite a significant political fracture. The French in particular, as the second largest donor to the Global Fund, felt aggrieved by the effort to get Dr. Kazatchkine to leave,” Summers said.
Jaramillo applied a “heavy hand” to the fund’s management problems, he said, including firing staff and reshuffling senior management. “We have taken the more bureaucratic side and reduced it by 40 percent,” Jaramillo told the Guardian in 2012. In their place he built up grant management capabilities in countries, describing his approach as, “less Geneva” and “more reality."
Even with some confidence restored and a new strategy in place, the Global Fund Dybul inherited in 2012 was an institution still reeling from crisis and riddled with tension and uncertainty.
“There was just a ton of anxiety in the institution, at the same time as we were asking it to change in very, very significant ways,” Summers said.
Dybul’s arrival in November 2012 threw him immediately into the fire of a replenishment cycle — with only 10 months to engineer a successful fundraising round at a critical moment for the fund to show it was back on solid footing.
“I’d say he inherited quite a mess,” Summers said.
Instead of seeing its support vanish, the Global Fund found key voices who made the case that the organization was an indispensable part of a global health effort the world could not afford to let collapse. Bill Gates, Bono, heads of state and development ministers who maintained their support throughout the crisis painted a bigger picture, Dybul said.
Their message was, “where are we going to be in the world without the Global Fund?” Dybul said. “Rather than killing it, let’s transform it and have it move from something that could collapse to something that will lead a transformative effort in how we manage development.”
Blood on the floor
He wanted to be a philosopher, or a theologian, or a literary scholar.
“I hated science,” Dybul said, nursing a half-pint of Guinness at a hotel bar next to St. Stephen’s Green, Dublin’s bucolic commons where swans waddle between a statue of James Joyce and memorials to “the Troubles.”
Dybul recites poetry from memory and draws life lessons from his favorite poems. He gave one of them to Canadian Prime Minister Justin Trudeau, who claimed it as a new favorite of his own.
Dybul’s first mentor was a Jesuit priest.
At Georgetown, he served as chief of staff to the university’s president, Rev. Timothy Healy, “a magnetic, gigantic personality of a president.” It’s hard not to see Dybul’s early aspirations — before he swerved abruptly into medicine and infectious disease research — as a mirror of his first mentor’s career. Healy held degrees in English literature and philosophy, studied theology, and earned a doctorate from Oxford where he researched the English poet John Donne.
A close friend to Bill Clinton, Healy was also a prolific fundraiser. He grew Georgetown’s endowment from $38 million to nearly $228 million during his 13-year tenure and raised large sums for New York’s Public Library where he was president until his death in 1992. “He was an extraordinary man, one of the smartest people I’ve ever met. Fundamentally an introvert, but amazing at understanding how to message something,” Dybul said.
In college Dybul stumbled upon an article in U.S. News and World Report about Africa’s HIV epidemic and changed his mind about what he wanted to do with his life, he said.
“Everyone assumes that because I’m a gay man I went into HIV because of the [men who have sex with men] population, which is a fair assumption,” but it was actually a news article that set him on his unexpected path, Dybul said.
“I read an article about the global HIV epidemic when I was in college, and the only way to describe it was like falling in love with someone you don’t want to fall in love with,” he said. Seven years after graduating from Georgetown with a degree in philosophy, Dybul earned his medical degree from the same university.
At the time the only way to intervene in the HIV epidemic was research, Dybul said. “Otherwise you just watched people die, which we did a lot of back then. A lot.”
After residency in Chicago and a year treating AIDS patients in San Francisco, Dybul returned to Washington, D.C. to work for Dr. Anthony Fauci, who has directed infectious disease research at the National Institutes of Health for more than three decades. Dybul was a fellow in Fauci’s lab and then became his assistant. It was Fauci who sent Dybul to work for former President George W. Bush on AIDS.
Recalling the assignment, Dybul mimicked his old boss’s heavy Brooklyn accent. “Hey you gotta go down and work with these guys on HIV,” Fauci told him in 2002. “I was like, ‘No freaking way. There’s no way I’m working with these people,” Dybul said. “My notion of President Bush was — Oh my god, I can’t believe this guy’s president.”
There is a stubborn narrative — “I love conspiracy theories,” Dybul said, describing it — that PEPFAR, the global AIDS initiative, was conceived as a ‘soft power’ counterweight to the Bush administration’s hawkish response to the September 11 terror attacks. The Republican president could show a humanitarian face with a massive global health program at the same time he pursued a “war on terror.”
Dybul doesn’t buy it. “They ran on compassionate conservatism. They actually came into office wanting to do something on HIV,” he said, adding, “none of which I believed.” When Fauci sent him to help the White House create a global HIV program, Dybul was still asking himself, “what are they up to, what are they actually trying to do, what’s the game here?”
“Then I met them, and it was like — oh my god, these people care more than most people I know.”
There was a circle of Bush insiders involved in PEPFAR’s creation, including Josh Bolton, Bush’s deputy chief of staff at the time, and Gary Edson, a deputy national security advisor. As the initiative gained support among unlikely allies, including conservative Republicans such as North Carolina Senator Jesse Helms, left-leaning nongovernmental organizations, and the Congressional Black Caucus, more and more people suddenly seemed to have been present for the creation.
“We used to have a joke that if everyone who took credit for starting PEPFAR adopted an orphan, there wouldn’t be an orphan problem in Africa anymore,” Dybul said. “Who cares? That means they’re vested.”
Dybul is unequivocal on one point: “George W. Bush absolutely was the driver of PEPFAR. No one else — it was him. No one wants to believe that, but that’s the truth. The rest of us were serving his vision.”
Building on a smaller program focused on mother-to-child transmission of HIV, Dybul worked with another NIH staffer to draw up a list of African countries they might include in a big AIDS-relief initiative. They estimated costs, aligned against a set of specific goals — prevent 7 million new infections, treat 2 million HIV-infected people, and provide a range of other care services to 10 million HIV-infected individuals and AIDS orphans.
The focus on results, specific targets, and accountability struck some as an affront, Dybul said. “All our buzzwords now, we were attacked for at the beginning of PEPFAR. When we set goals — how dare you? This is too complicated.”
Dybul likes to repeat something Rwandan President Paul Kagame said about PEPFAR. “This is the first time that someone’s respected us enough to hold us accountable.”
“I’ve never met someone in government who isn’t open to a conversation about data, if it’s a conversation between equals.”— Mark Dybul
The tension people read into the relationship between donors and implementers often misrepresents what leaders in developing countries are looking for in a partnership, Dybul said. Leaders facing national health challenges are hungry for better data and good policy ideas, but there is a difference between holding a partner accountable and paternalistically telling them what they have to do, Dybul said. “I’ve never met someone in government who isn’t open to a conversation about data, if it’s a conversation between equals.”
PEPFAR’s power struggles were more heated inside the U.S. government. “There was blood on the floor in those early days — just brutal, brutal turf battles,” Dybul recalled.
“[The U.S. Agency for International Development] knew nothing of PEPFAR until it was announced, basically. So you can imagine how that went over — the fact that they weren’t getting it and it was going to the State department,” Dybul said.
PEPFAR survived the interagency battles, in Dybul’s view, because Bush made clear that the U.S. Global AIDS Coordinator ran the program and everyone who spent PEPFAR’s money answered to him. High-ranking military officials deferred to the AIDS coordinator when it came to PEPFAR money flowing through the Defense Department. “Four star generals didn’t particularly like that,” Dybul said.
In an early Oval Office meeting, President Bush sat Randall Tobias, PEPFAR’s first leader, in the chair closest to the president and put two cabinet secretaries on the couches, Dybul recalled. “It was like, this is my guy for HIV … All of you are following this guy,” Dybul said. “That filtered through the system. By the time people got back to their offices, the fighting had stopped.” Bush appointed Dybul as Tobias’s deputy.
In his January 2003 state of the union address, Bush announced the new initiative — a $15 billion commitment over five years — calling it, “a work of mercy beyond all current international efforts to help the people of Africa.”
In Dybul’s view, Bush’s commitment to do something about the AIDS emergency in Africa wasn’t cynical politics, or even a faith-based compulsion towards charity. Bush was motivated by faith, Dybul said, his faith in the dignity and worth of individuals.
“The faith wasn’t, you should do x, y, or z because my faith says you should. The faith was actually in the human being — from their perspective from a divine gift. That if we empowered people in the country to achieve great things, they would achieve great things.”
In his praise of Bush, Dybul cites similar views held widely on the African continent. “Africans to this day absolutely love the man, because when they met him that’s what he exuded,” he said.
Bush also didn’t create PEPFAR to be a vehicle for the conservative, moralizing policies that were later attached to it, Dybul said. “The first PEPFAR bill was five pages. There was none of what came later. All of those things were added in Congress — the abstinence requirements, the prostitution pledge. All of those things came in Congress. They didn’t come out of the White House,” he said.
In 2006, when Tobias left PEPFAR to lead USAID, Bush nominated Dybul to succeed him. As an openly gay official serving a conservative White House that supported a constitutional amendment barring gay marriage, Dybul faced criticism from unexpected directions.
Dybul’s family attended his swearing-in ceremony, and Secretary of State Condoleezza Rice referred to the mother of Dybul’s partner as his “mother-in-law.”
“It was actually not the Right that pounced on it. It was [New York Times columnist] Frank Rich that pounced on it,” Dybul said. Rich’s column — “The Gay Old Party Comes Out” — charged Republicans with hypocrisy for their outward embrace of “homophobic” policies and inward embrace of openly-gay leaders. Democrats saw the hypocrisy charge as ammunition to use in an election year, Dybul said. “It teaches you a lot about the world.”
Anti-gay marriage groups such as the Family Research Council derided the administration’s decision to entrust HIV programs to a gay government official. The minor media frenzy found its way to the front page of Turkish newspapers and the White House briefing room.
“The swearing-in ceremony wasn’t about me. It was about highlighting what we were trying to do,” Dybul said, with a hint of stale frustration. “And then it was turned into that.”
After President Obama’s election in 2008, Dybul sent a memo to staff informing them he had been asked to stay on for a few months with the new administration. The day after inauguration he received a phone call asking for his resignation and that he leave by the end of the day.
Some health commentators praised the move and criticized Dybul’s service to a party that insisted on things like abstinence education in its HIV programs. Gerson, the Bush speechwriter, rose to his defense and shot back at both the “blogging extremists” who criticized Dybul and the administration that dropped him so unceremoniously.
“PEPFAR really transformed the U.S. government. In many ways it transformed development.”— Mark Dybul
“It is difficult to imagine what vision of public service could cause any Obama official to celebrate a victory by sabotaging a good man and a good cause,” Gerson wrote.
Dybul is more inclined to talk about what the initiative has achieved than about how he left it. “PEPFAR really transformed the U.S. government. In many ways it transformed development,” he said.
“When we look back on the HIV response, one of the legacies will be the end of an epidemic. The other legacies will be a shift from a conversation around money to a conversation around results, a shift from paternalism to partnership, and a fundamental understanding that health … can drive changes in human rights and how we understand our relationship as human beings to one another. And those are massive impacts,” he said.
In an austere meeting room tucked inside one of Dublin’s grandiose white government buildings, Dybul is building a case for why Irish taxpayers should remain committed partners to the Global Fund. He’s speaking with two Irish members of parliament, representatives who must answer to their constituents about why Ireland’s contribution is a good use of their money.
“It’s great to have you back. You had some difficult economic times but it’s great to have you back at the table,” Dybul says, thanking the MPs for Ireland’s $30 million, three-year donation.
Dybul has considered every objection an Irish taxpayer might make to contributing to a global health initiative. He seems to answer the politicians’ questions before they’ve thought to ask them and to ease concerns that might trouble them later. He’s sympathetic to the fact that he’s probably not the only person asking them for something today.
“I know when we leave there will be five other people who come in and say, ‘you should be thinking about these things.’ But the thing about infectious diseases is you can’t put them on hold,” Dybul says.
“We’re on the right path with all three of these diseases, but if you get too far off that path, getting back on it is extremely difficult.”
Dybul is good at explaining why Irish taxpayers should fund a multilateral organization, instead of paying for programs on their own. The former leader of the largest ever bilateral health initiative can relate to their concerns.
“I was a total bilateral-ist when I got started,” Dybul told me earlier. “The natural instinct is — I know it, I control it, I want to get credit for it.”
He balances his gratitude for Ireland’s contribution with a gentle reminder that it amounts to a small fraction of the Global Fund’s $4 billion annual budget. Dybul points out that if the MPs tried to divide $10 million among Ireland’s ten foreign aid focus countries, it wouldn’t make a dent in infectious disease. He talks about pooled procurement and the cost savings the Global Fund achieves by purchasing half the world’s donor-funded malaria bed nets. By the way, he points out, $3.5 million of Ireland’s $10 million annual contribution circles back to create jobs at home. The Global Fund buys HIV tests from Trinity Biotech, an Irish company.
Then he talks about values — Irish values.
“We’re on the right path with all three of these diseases, but if you get too far off that path, getting back on it is extremely difficult.”— Mark Dybul
The Global Fund represents an opportunity for Ireland, a relatively small island nation, to assert its values in the global health marketplace, Dybul says.
“Because of the resource commitment, your intellectual ideas, your values then are part of the conversation,” Dybul tells them. “It shouldn’t just be large countries with large budgets that direct how these conversations are had,” he says. The MPs nod in agreement.
“He’s a person who attracts support,” Summers told me.
One of the MPs asks Dybul about governance at the Global Fund. She wants to know about transparency and accountability. “You’re confident that all those i’s are dotted and t’s are crossed?” she asks. There’s an unspoken implication to her question, and Dybul can tell what she’s getting at.
“As much as they can be. All systems have room for improvement. But this is an area where we’ve really invested in the last four years,” he tells her. “As you know in 2012 it became a little uncomfortable,” Dybul says.
A more proactive approach — building the Global Fund into a technical organization with the data, analytic, and management skills to deliver money in the best way possible — was at the heart of the reform strategy Dybul inherited. The strategy placed new expectations on grant managers, demanding they pivot from simply dispersing money to managing it in the best way possible. The Global Fund had to become a more technically sophisticated organization.
“Mark took the new strategy and put it into hyperdrive,” said Todd Summers.
“He has amazing technical vision — a grasp of where the science is, where the best approach is, coupled with a really strong personal commitment to the impact of the Global Fund. That really resonated, and I think it helped pull people out of the dizziness of the previous period,” he said.
Dybul describes a complete transformation of the organization over the last five years.
“The crisis in 2012 allowed radical change,” he said. One big move was distancing the Global Fund from the administrative structures of the United Nations. That allowed the organization to move people and jobs around in a way the administrative rules of the U.N. made difficult.
“The reason it’s been so exciting is it was like starting PEPFAR,” he told me. “What we’ve done, is transform every piece of it.” The Global Fund has recast everything from how it engages with partner countries, to changing its financial cycles so they line up better with national planning, to repositioning itself as a “coordinating mechanism,” instead of “another big development agency,” he said.
Dybul is careful not to diminish achievements in the period before he arrived. The world simply “evolved,” he said. Expectations for development effectiveness, accountability and partnership evolved, “so we needed to evolve,” he said.
“There is no question we have room for improvement, but I would match what we have put in place against any organization in the world, including the private sector,” he tells the Irish politicians.
In December 2013, at its fourth replenishment session in Washington, D.C., the Global Fund announced a $12 billion donor commitment — the largest Global Fund replenishment ever. Three years later, when Prime Minister Justin Trudeau hosted the fundraising session in Montreal, the Global Fund announced a $12.9 billion replenishment, just shy of its $13 billion target.
“We have so much support right now. It’s really exciting. It’s also a little scary, when the only place to go is down,” Dybul said.
“It doesn’t matter how good you are at telling a story, there has to be substance behind it,” he said. “The fundraising is the final output of all the work we’ve to transform the organization to be at the cutting edge of development … Everything we do is building the case for why we deserve more money.”
Dybul told me he would have liked to stay at the Global Fund for another year or two, but could never ask a new executive director to come on board without time to prepare for the next replenishment — “especially given how difficult the next replenishment is going to be.”
The Global Fund — like many donor-funded health and development organizations — is facing a squeeze. Developing countries are seeing increased economic growth, while most donors are tightening their budgets and calling on partners to shoulder a bigger share of their own financing needs. Dybul is counting his blessings.
“This cycle no one thought we could raise what we raised,” he said. “You see 20 percent decreases in most development budgets and we got 20 to 40 percent increases. You just don’t see that.”
Becoming better people
King George III founded the Royal College of Surgeons in Ireland by royal charter in the late 18th century. Marble busts line its hallways, and stained glass windows filter light into a sloping lecture hall that strikes with a seriousness somewhere between a courtroom and a church.
Introducing Dybul at his address to the medical college, Ruairí Brugha, head of RCSI’s department of epidemiology and public health medicine, described the “tension” that accompanied the Global Fund’s creation, as the organization’s architects grappled with striking “a balance between a vertical fund for commodities and a horizontal fund that will strengthen health systems.”
Fifteen years ago, disease burdens were so huge and solutions so scarce that organizations fighting HIV, malaria, and TB had a big impact just by pushing out as many health commodities as possible. It was also an “open question,” Dybul said, as to whether financiers such as PEPFAR and the Global Fund could actually spend billions of dollars effectively.
“Had the answer been no, that would have ended any investments going forward. We had to show results, and we had to show them quickly,” Dybul said in his RCSI address.
Dybul has emerged as a leading voice at the intersection of health and development, moving from PEPFAR’s clinical, emergency response to a much broader view of the development investments required if the Global Fund is going to help end three epidemics.
“If he’s only got five minutes to speak, he’s as likely to talk about girls’ education as he is to talk about infection rates,” said Chip Lyons, president of the Elizabeth Glaser Pediatric AIDS Foundation.
“We’re entering a completely different era, and a different approach, and new thinking about how you put health together,” Dybul said. A narrow focus on delivering health services through public institutions won’t end three global plagues.
Dybul is adamant that the Global Fund’s next executive director does not need to be a technically-minded public health expert. The organization would benefit from someone who understands how to structure deals, how to pitch policymakers, and how to reach into the private sector where the majority of people in countries with big disease burdens — such as India and Indonesia — actually access their healthcare, Dybul said.
“We’ve gotten a little too self congratulatory in the public health world. No head of state or minister of finance is going to be surprised when someone whose CV is global public health is promoting global public health,” Dybul said. “It surprises them to have CEOs come in and say, if you don’t have health and education, I don’t have any workers and I don’t have anyone to buy my stuff, so let’s get some health and education.”
The Global Fund has yet to name Dybul’s permanent replacement. After a three-month recruitment period the board announced a shortlist of three candidates. Then, in February, they abruptly suspended and restarted the appointment process, citing due diligence concerns — and after the most prominent candidate, former U.N. Development Programme chief Helen Clark, dropped out. The organization is currently operating under an acting director, while the board is back to the drawing board with another recruitment round.
The botched process was a missed opportunity to show stability at an organization four years removed from crisis, said some observers. Dybul was, “the first Global Fund director to leave without being first eviscerated,” said Todd Summers. “I hope that this time around they give it more time,” he said.
Multiple people I spoke with about Dybul used the same word to describe him: human.
“He’s a humanist,” Lyons said “It isn’t just a clinical thing, or a strategic thing. He just is committed to it and feels what it means to protect someone’s health … I think it’s rooted in compassion.”
Looking back on Dybul’s arrival at the fund, Summers recalled how he managed to win over an anxious and embattled organization with his message. “He brought a sort of human approach to it,” Summers said.
Dybul arrived at an organization in crisis and recognized something simple. It was still full of people who chose to work in a place where they thought they could do something big. “People don’t do development because they want to come and sign disbursements and grants. They want to engage. They want to think. They want to feel. They want to get into it,” he said.
In a cynical world Dybul is a shrewd politician, a gay AIDS researcher who seized opportunity in a White House opposed to gay marriage. In a more optimistic one he is still the Georgetown undergraduate who couldn’t choose between poetry and theology and so chose to help stop people from dying. The second version strikes truer — at the height of his career, with no fundraising rounds to engineer or political appointments to win, Dybul sounds more and more like the theologian he might have become.
HIV and tuberculosis “prey on those marginalized and left behind by society,” he said at the Royal College of Surgeons in Ireland. “They prey on adolescent girls and young women, sex workers, LGBTI, prisoners, migrant populations, people who inject drugs — those left behind by society. That’s a person.”
“To end an infectious disease we actually have to become better human beings, to treat each other with the dignity and respect we deserve,” he told the room full of medical experts.
“It’s an opportunity to give flight to the better angels of our nature,” he said. “That’s a pretty awesome thing to do.”
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