Today, the Clinton Foundation is widely known for its work on AIDS in Africa. But as on so many things, Bill Clinton’s attitude toward the African AIDS crisis was starkly different during his time in office.

In the late 1990s, tens of millions of Africans were HIV-positive. Nearly 80 percent of those dying globally of AIDS were in sub-Saharan Africa. AIDS was (and remains to this day) a debilitating scourge. South Africa was suffering acutely from AIDS, and the country had the highest absolute number of people infected.

With an average income of $2,600 per year, few South Africans could afford antiretroviral drug treatment, which cost up to $10,000 annually. Faced with an extraordinary number of AIDS cases, and an impossible cost of treatment, the South African government introduced a measure that would allow for the importation or local production of generic drugs. The law, which paid a fixed fee to patent-holders, would reduce the cost of drugs by up to 90 percent. The legislation was signed into law by Nelson Mandela (whose son would ultimately die of AIDS in 2005).

But the Pharmaceutical and Research Manufacturers of America (PhRMA), an alliance of one hundred of the largest American drug companies, were furious. Claiming that their intellectual property rights had been violated, and labeling South Africa’s action “piracy,” they challenged the law in South African courts and began vigorously campaigning against it in Washington. PhRMA hired a US lobbying firm, what is today called the Podesta Group, to bring pressure on South Africa.

The Podesta Group was founded by brothers Tony and John Podesta in 1988. It was a fruitful partnership; Tony became one of DC’s most influential fundraisers, working on behalf of BP, Bank of America, and the Egyptian government, and bundling contributions for Bill Clinton, Ted Kennedy, and other major Democrats. John became Clinton’s chief of staff, and would go on to found the Center for American Progress think tank, before being invited to lead Barack Obama’s transition team. The Podesta Group itself became an extremely powerful political force, with prominent corporate clients including Walmart and Lockheed Martin. The Podestas were therefore a fine choice to help PhRMA get the ear of Washington.

With John Podesta still serving as chief of staff, the Clinton administration “went to war” over the generic-drug legislation, putting “immense” pressure on South Africa to honor the patent rights of American companies. They insisted, wrongly, that South Africa had violated World Trade Organization rules on patents. The US trade representative rescinded South Africa’s trade benefits, refusing to grant tariff breaks on exports.

The Clinton administration even put South Africa on the “Super 301” trade watch list, a special designation meant to “prise open recalcitrant foreign markets under threat of retaliation.” (The administration had adopted the same strong-arm tactics against Thailand. The New York Times said US pressure “caused the country to put restrictions on its manufacture of cheap patented drugs and ban their import, which AIDS doctors say reduced the country’s ability to fight the disease.”)

Vice President Al Gore was designated to lead negotiations with South African president Thabo Mbeki. Gore, however, firmly stood by the drug companies’ position, refusing to grant South Africa concessions. As the Guardian reports, “[f]or 18 months, Mbeki urged and pleaded with Gore to intervene on behalf of his government and its struggle against HIV” yet Gore “not only refused [but] put intense pressure on Mbeki to drop the legislation and comply with the drug companies.”

The Clinton administration came under criticism for its efforts to punish South Africa for its desperate attempt to stanch the tide of AIDS deaths. The editorial board of the New York Times said the administration’s policy had been dominated by “the desire to protect American pharmaceutical patents,” and insisted that “Washington should stop pressuring South Africa to change the law.” When Al Gore began running for president, AIDS activists disrupted his campaign events to protest his role.

Under scrutiny, Clinton relented. The administration “was so embarrassed by the public outrage that it backed off,” and announced that it would “no longer seek increasingly tough standards on protection of intellectual property and will instead enforce minimum standards.” By then well into the final year of his presidency, Clinton performed a rapid volte-face and began promising sweeping new anti-AIDS initiatives, despite the fact that AIDS had “scarcely surfaced” as an issue on previous Clinton trips to Africa.

Clinton also gave Africans a lecture on self-reliance and responsibility, telling the National Summit on Africa that “cultural and religious factors” were getting in the way of disease prevention. “We shouldn’t pretend that we can give injections and work our way out of this,” he said. “We have to change behavior, attitudes.”

It was understandable that Clinton would emphasize personal behavior and de-emphasize the provision of drugs. This was in keeping with the administration’s approach to Africa more broadly, which had proposed a “shift from aid to trade” that de-emphasized the provision of material support. As one Democratic representative put it, Africa would move from having a “donor-recipient relationship” with the United States to being an “economic partner.” This would, in the words of the US ambassador to Uganda, “bring confidence to American corporations,” with the White House promoting Africa as “an untapped market of 700 million people.”

When the shift was announced, according to the Independent, it “was seen in Washington as a move by the United States to preempt criticism from other G7 countries, notably France, that it was not doing as much as it could to assist developing countries in general, and African countries in particular” after US overseas aid in 1996 fell below that of France for the first time. The African National Congress in South Africa was highly critical of the Clinton move, which they saw as “neo-colonialist” and supported “only with the greatest reluctance.”

Throughout his presidency, Clinton’s attitude toward Africa was viewed with skepticism by Africans and African Americans. In 1994, the Congressional Black Caucus actually boycotted a conference on Africa held by Clinton, believing it was a public-relations stunt to disguise Clinton’s lack of actual material support for Africa.

“I don’t think there has been a focus on Africa ever in any administration, including this one,” said one CBC congressman. When Clinton visited South Africa in 1994, it was reported that South Africans received his visit frostily, and “suspect[ed] Clinton has come only to revel in the public relations boost of Mandela’s company and has little to offer beyond symbolic gestures of support.”

Indeed, aid to Africa dropped throughout the Clinton years, and would only rise again during the presidency of George W. Bush. Even Clinton’s friend and fellow philanthropy mogul Bill Gates has acknowledged that “the low point in terms of US aid generosity was at the end of the Clinton administration.” And while Clinton gave emotional speeches about the end of apartheid, he kept Nelson Mandela’s name on the United States’s terrorist watch list, meaning Mandela was subject to travel restrictions. Mandela’s name would finally be taken off by Bush, during the last year of his presidency.

In fact, George W. Bush’s Africa policy would offer a striking contrast from that of his predecessor. Ironically, given his reputation for overseas bungling and malfeasance, Bush’s initiatives on Africa were far more ambitious and generous than Clinton’s. Bush founded a $1.2 billion anti-malaria initiative, and soon after taking office initiated a vast new program for AIDS treatment in Africa. The President’s Emergency Plan for AIDS Relief (PEPFAR) committed $15 billion to fighting AIDS, delivering cheap medication across the continent.

The efforts are widely seen as successful. As Eugene Robinson of the Washington Post summarizes:

When the Bush administration inaugurated the program in 2003, fewer than 50,000 HIV-infected people on the African continent were receiving the antire­troviral drugs that keep the virus in check and halt the progression toward full-blown AIDS. By the time Bush left office, the number had increased to nearly 2 million. Today, the United States is directly supporting antiretroviral treatment for more than 4 million men, women and children worldwide, primarily in Africa.

Importantly, this success partially occurred because Bush rejected the “conventional wisdom” that anti-AIDS treatments that worked elsewhere would not work in Africa due to cultural and behavioral problems. Such arguments, of the type furthered by Clinton at the Conference on Africa, “turned out to be categorically wrong.”

Yet it is Clinton, who spent years in office trying to keep South Africa from giving away cheap drugs and damaging American pharmaceutical profits, who is more widely known for his AIDS work. “George Bush has actually delivered more resources, but Clinton is ten times more popular in Africa,” said Princeton Lyman, the former ambassador to South African under Clinton. “That’s because, just like he does everywhere, he portrays that sense that he cares.”