[Senate Hearing 108-242]
[From the U.S. Government Publishing Office]
S. Hrg. 108-242
A MORAL IMPERATIVE: LEADER FRIST'S REPORT ON THE HIV/AIDS CODEL TO
AFRICA
=======================================================================
JOINT HEARING
BEFORE THE
SUBCOMMITTEE ON CHILDREN AND FAMILIES
OF THE
COMMITTEE ON HEALTH, EDUCATION,
LABOR, AND PENSIONS
UNITED STATES SENATE
AND THE
SUBCOMMITTEE ON AFRICAN AFFAIRS
OF THE
COMMITTEE ON FOREIGN RELATIONS
UNITED STATES SENATE
ONE HUNDRED EIGHTH CONGRESS
FIRST SESSION
ON
A REPORT FROM SENATOR FRIST RELATIVE TO THE HIV/AIDS CODEL TO AFRICA
__________
October 30, 2003
__________
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COMMITTEE ON HEALTH, EDUCATION, LABOR, AND PENSIONS
JUDD GREGG, New Hampshire, Chairman
BILL FRIST, Tennessee EDWARD M. KENNEDY, Massachusetts
MICHAEL B. ENZI, Wyoming CHRISTOPHER J. DODD, Connecticut
LAMAR ALEXANDER, Tennessee TOM HARKIN, Iowa
CHRISTOPHER S. BOND, Missouri BARBARA A. MIKULSKI, Maryland
MIKE DeWINE, Ohio JAMES M. JEFFORDS (I), Vermont
PAT ROBERTS, Kansas JEFF BINGAMAN, New Mexico
JEFF SESSIONS, Alabama PATTY MURRAY, Washington
JOHN ENSIGN, Nevada JACK REED, Rhode Island
LINDSEY O. GRAHAM, South Carolina JOHN EDWARDS, North Carolina
JOHN W. WARNER, Virginia HILLARY RODHAM CLINTON, New York
Sharon R. Soderstrom, Staff Director
J. Michael Myers, Minority Staff Director and Chief Counsel
______
Subcommittee on Children and Families
LAMAR ALEXANDER, Tennessee, Chairman
MICHAEL B. ENZI, Wyoming CHRISTOPHER J. DODD, Connecticut
CHRISTOPHER S. BOND, Missouri TOM HARKIN, Iowa
MIKE DeWINE, Ohio JAMES M. JEFFORDS (I), Vermont
PAT ROBERTS, Kansas JEFF BINGAMAN, New Mexico
JEFF SESSIONS, Alabama PATTY MURRAY, Washington
JOHN ENSIGN, Nevada JACK REED, Rhode Island
LINDSEY O. GRAHAM, South Carolina JOHN EDWARDS, North Carolina
JOHN W. WARNER, Virginia HILLARY RODHAM CLINTON, New York
Marguerite Sallee, Staff Director
Grace A. Reef, Minority Staff Director
______
COMMITTEE ON FOREIGN RELATIONS
RICHARD G. LUGAR, Indiana, Chairman
CHUCK HAGEL, Nebraska JOSEPH R. BIDEN JR., Delaware
LINCOLN D. CHAFEE, Rhode Island PAUL S. SARBANES, Maryland
GEORGE ALLEN, Virginia CHRISTOPHER J. DODD, Connecticut
SAM BROWNBACK, Kansas JOHN F. KERRY, Massachusetts
MICHAEL B. ENZI, Wyoming RUSSELL D. FEINGOLD, Wisconsin
GEORGE V. VOINOVICH, Ohio BARBARA BOXER, California
LAMAR ALEXANDER, Tennessee BILL NELSON, Florida
NORM COLEMAN, Minnesota JOHN D. ROCKEFELLER IV, West
JOHN E. SUNUNU, New Hampshire Virginia
JON S. CORZINE, New Jersey
Kenneth A. Myers Jr., Staff Director
Antony J. Blinken, Democratic Staff Director
______
Subcommittee on African Affairs
LAMAR ALEXANDER, Tennessee, Chairman
SAM BROWNBACK, Kansas RUSSELL D. FEINGOLD, Wisconsin
NORM COLEMAN, Minnesota CHRISTOPHER J. DODD, Connecticut
JOHN E. SUNUNU, New Hampshire BILL NELSON, Florida
(ii)
C O N T E N T S
__________
STATEMENTS
October 30, 2003
Page
Alexander, Hon. Lamar, a U.S. Senator from the State of
Tennessee, opening statement................................... 1
Frist, Hon. Bill, a U.S. Senator from the State of Tennessee,
report......................................................... 2
(iii)
A MORAL IMPERATIVE: LEADER FRIST'S REPORT ON THE HIV/AIDS CODEL TO
AFRICA
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THURSDAY, OCTOBER 30, 2003
U.S. Senate,
Subcommittee on Children and Families, of the Committee on
Health, Education, Labor, and Pensions, and the
Subcommittee on African Affairs, of the Committee on
Foreign Relations,
Washington, DC.
The subcommittees met jointly, pursuant to notice, at 3:04
p.m., in room SD-430, Dirksen Senate Office Building, Senator
Lamar Alexander (chairman of the subcommittee on Children and
Families) presiding.
Present: Senators Alexander, Enzi, Warner, Sessions,
DeWine, Coleman, and Frist.
OPENING STATEMENT OF SENATOR ALEXANDER
Senator Alexander. The joint meeting of the Subcommittee on
African Affairs and the Subcommittee on Children and Families
will come to order. Good afternoon, and welcome to my
colleagues and all those in the audience and those who may be
watching on C-SPAN.
This is a joint meeting of two of our subcommittees for the
sole purpose of letting Majority Leader, Dr. Bill Frist, report
on a mission that he led to Africa in late August which focused
on HIV/AIDS. Five other Senators, including those who are here
in the room, had the privilege of accompanying Dr. Frist. He is
a little bit unusual. He is not only a doctor, he has educated
the Senate and this country on the importance of the AIDS
epidemic. So it was a remarkable experience for all of us.
This meeting of our two subcommittees kicks off, or it
begins what we hope will be a series of hearings that focuses
on the President's commitment and the Senate and the House's
commitment to work on this AIDS epidemic. I believe Ambassador
Tobias is in the audience--is he here?--the President's global
AIDS advisor. At least he is expected. We welcome him and look
forward to working with him.
We will go no later than 4 o'clock. In the interest of time
and because we want to hear from Dr. Frist, I will forego an
opening statement. We will listen to his presentation and after
he is through we will simply go around the table and ask
questions. This is more in the nature of a meeting than a
hearing. We appreciate your time at this busy season of the
Senate and look forward to your report. Our Majority Leader,
Senator Frist.
Senator Frist. Mr. Chairman, thank you, to my colleagues,
welcome. Last month I had the privilege of traveling to the
southern African nations of South Africa, Mozambique----
Senator Alexander. Is your microphone on?
REPORT OF SENATOR FRIST
Senator Frist. Last month I had the opportunity to travel
to the South African nations which are depicted on the map
behind me. That is South Africa, Mozambique, Botswana, and
Namibia, with the Senators who are at the table today, notably,
Senator John Warner, Senator Mike DeWine, Senator Mike Enzi,
Senator Lamar Alexander, and Senator Norm Coleman, and also Dr.
Joe O'Neill, deputy coordinator of the global HIV/AIDS office.
I have had the wonderful opportunity to have visited Africa
many, many times in the past so it was a real privilege for me
to be able to join my colleagues as we explored together a part
of Africa hat I had not traveled to before.
As with my previous trips, I was struck by the optimism, by
the perseverance, by the courage of the people that we had the
opportunity to meet with, as well as their warmth, their
compassion, their generosity, and their hospitality.
Now the purpose of this delegation going to Africa was
unique in many ways in that we had a very specific focus. That
focus was to determine how best the United States can
coordinate with others in this country and indeed around the
world to address the global HIV/AIDS pandemic, which many of
you have heard me describe as being the greatest humanitarian
moral and public health challenge of the last 100 years. Our
team, as you will see, had a productive trip. We met with
doctors, patients, nurses, community leaders, government
officials, and activists, all of whom are doing the very best
they possibly can to fight this pandemic, and thereby bring
hope and relief to millions of people.
There is no part of world that has been more greatly
affected by HIV/AIDS than the part of the world that we visited
and that is southern Africa. Graca Machel, the truly remarkable
First Lady of Mozambique, told us very directly that because of
HIV/AIDS, ``We are facing extinction.'' We still face the worst
of the epidemic, she told us. Let me repeat that. She said,
``we are facing extinction.'' That is her evaluation and that
is the challenge that is before us.
I would like to organize my comments, not as a travelogue
as we go through, but really in lessons that we as a group took
away and lessons learned.
Lesson number one, an effective, comprehensive response to
HIV/AIDS requires the strong and the dedicated commitment of
the national leaders. It has to start at the very, very top or
no matter how much money you spend, how much money you invest,
without that commitment at the top you simply, I believe, are
not going to have the impact that we know that we can have. We
met with the African leaders. We saw what an effective,
comprehensive response to HIV/AIDS can result in if you have
that national leadership. The leadership commitment has to
start at the top with the leader of that country and then
extend vertically all the way down to community leaders, all
the way down to that local tribal leader.
In South Africa, we met with the leaders in the local
community who had been struggling with the political leaders in
that country over the development of the appropriate treatment
plans. I will come back to treatment here shortly. Treatment
plans developed at the community level would save thousands of
lives, but the people at the very top had not yet fully bought
into the national commitment for treatment.
Now that is changing. It was changing about the time that
we were there, but until recently, very recently, the political
leadership had failed at the top to adequately, I believe,
address the reality of the virus. I believe it played a role in
the fact that there are 5 million people in South Africa today
who are infected with the HIV virus that causes AIDS. A virus
for which there is no cure.
In sharp contrast to that, in Gabarone, Botswana we met
with President Festus Mogae, who in an effort to reduce the
stigma and encourage nationwide testing, stood up and on
television announced his HIV test results before the people of
Botswana. Such unambiguous messages to the people have an
impact.
We have learned that. Again it is important because with
every national leader that we see, not just in Africa but all
around the world, we must look that leader in the eye and ask,
what is your commitment, and encourage them to make that
commitment. As a result, in Botswana we saw notable progress in
fighting the pandemic, and in bringing understanding and
security and the hope that we all know is so important.
Lesson two, prevention, care and treatment. Those are the
three building blocks, and people in public health understand
that. But what is new is that the prevention and care must be
linked to treatment. In HIV/AIDS, up until really pretty
recently people said, no, we can leave the treatment off and
let us just look at prevention and care. As you look at
prevention, care and treatment, treatment must be preceded by
testing so that the diagnosis can be made.
What is not so intuitive, I think, is that testing, getting
the test itself and knowing the results is the cornerstone of
prevention. So if you just do prevention it is insufficient to
have an impact unless you have a very strong testing program.
The testing only takes 15 minutes. I say this as somebody who
has been involved in public health and somebody who is a
physician. The testing process gives what we refer to as a
teachable moment that otherwise you just do not have. It is
called a teachable moment because you have that 15 minutes that
the test is taking place, that time where trust can be
established, and in that teachable moment you have the
opportunity to open people's eyes to the facts and to the hope
of being able to address this disease.
Now I say that because, and most people do not know this,
in the world today of every 10 people who have the HIV virus,
nine do not know it. So for every 10 people in this room today
only one of those 10--assuming they were all infected, only one
would know that they had HIV/AIDS. Now if you do not know you
have it, you have the potential for spreading it and you are
less invested in educating your own family or the people around
you.
In Kasane, Botswana we had the opportunity to look at these
wonderful centers, Voluntary Counseling and Testing or ``VCT''
centers. In Kasane, Botswana and Namaacha, Mozambique we saw
how using two simple tests a person could be tested in 15
minutes while receiving counseling on how to avoid coming into
contact with HIV/AIDS, and, if you happen to test HIV positive,
how to prevent spreading that virus to others.
The VCT test period takes overall typically one hour, about
15 minutes on the test and the rest in counseling. You get the
results of the test and then you go through further counseling.
A person is encouraged to share that information with other
people. If you test positive at that sitting, you can go into
care, peer groups, and treatment if it is available. And if you
are negative, through that teachable moment, you can learn how
to educate your family and other people in your neighborhoods.
Also it helps destigmatize. I will come to the stigma component
in just a bit. This process is called VCT, voluntary counseling
and testing.
Lesson number three, we need to develop the medical
infrastructure. This is very important, because there is this
perception that if we just put money into buying drugs that we
are going to be able to treat people with HIV/AIDS, prevent
HIV/AIDS, or cure HIV/AIDS. What is obvious when you are in
Africa, is that it is important to have that infrastructure
itself to deliver treatment.
President Bush's emergency plan for global HIV/AIDS calls
for 2 million people to be on treatment by the year 2008. It is
an ambitious goal, but we can meet that ambitious goal if we
focus on ensuring that every taxpayer dollar that we invest,
and we must be practical because we are talking about a total
of $15 billion, we need to make sure it is invested wisely and
at the appropriate time.
The single largest challenge, perhaps, to meeting the HIV/
AIDS crisis in Africa through prevention, care and treatment is
to develop this infrastructure to make sure that whatever is
provided actually works. Medications must be stored properly
and delivered properly. The infrastructure is necessary so that
the patient can receive medical care over time. You need more
than a diagnostic kit. You need more than medicines on the
shelf. You need ways to deliver these drugs in a way that we
know will be effective. The distribution, the storage, and ways
to administer them.
One message we heard again and again is the need for
expertise and training. That is a way the United States can
specifically help. In Botswana, Vice President Seretse Ian
Khama and Minister of Health Lesego Motsumi stressed that their
first priority is the recruiting and the retaining of qualified
medical staff. All of our delegation will remember the images
of the overworked staff who were dedicated and hard-working,
but tired. You could see on their haggard faces their
commitment. At the Chris Hani Baragwanath Hospital in Soweto,
South Africa, my colleagues will remember the exhaustion on the
faces of the staff as they stood into their busy HIV/AIDS ward
with things coming and going and people being treated.
We listened to the nurses, the doctors, and the social
workers, of the desperate need for more and better trained
social workers, for counselors to teach how to avoid and to
cope with HIV infection, for technicians who are experts in the
storage and disposal of medical waste, and for administrative
staff. The United States can play a tremendous role in
providing that medical expertise and in helping to create peer
training.
Lesson number four, we must provide care for the dying--the
care component of care and treatment--and support for the
living. Palliative care is an issue that came up often. What is
palliative care? The Health Resources and Services
Administration, HRSA, defines palliative care as patient and
family-centered care that strives to optimize quality of life
by anticipating, preventing, and treating suffering. Focusing
on the continuum of illness, this care addresses not only the
patient's physical needs, but also intellectual, emotional,
social, and spiritual needs.
So we asked, why is palliative care so important? It is
important because HIV is a chronic disease that is fatal over
time. It is a deadly illness that extracts not just a physical
toll but also a spiritual toll, a psychological toll, on those
people who are affected. And not just the people affected, AIDS
impacts the families around them. As a physician I can tell you
that HIV takes a toll, as I implied earlier, on health care
workers as well. We have got to keep that morale up for health
care workers or they will not stay in this palliative
framework. We have got to keep the morale of the patient up, of
the health care providers up, of the caregivers up, of the
family up, of the loved ones. All of this will strengthen the
health care system as a whole.
Orphans. It is an issue that we have addressed in this very
room in the past. Senator Jesse Helms really focused on the
issue. He was almost the first to do so in our Government, and
he made this link between HIV/AIDS and orphans. Graca Machel,
who I referred to earlier, told our delegation of meeting an
83-year-old grandfather in Uganda. I remember it so vividly
when she said it. This 83-year-old grandfather had two wives,
one 73 years of age, one 76 years of age. They were taking care
of 30 grandchildren under the same roof because all eight of
their children had died, had passed away leaving 30
grandchildren. So caring for children left behind by AIDS is
and must be a critical challenge in our response to HIV/AIDS.
In South Africa we visited the Salvation Army's Carl
Sithole Center. The center cares for 120 abused and 36
abandoned HIV orphans, has a school right there that teaches
225 children. The center is divided into Zodwa House for young
children ages two through eight, and Bethany House for older
children ages 8 to 18. The Carl Sithole Center accepted its
first HIV positive child in 1993. That child's name was Copso
which is the Sotho word for day of peace. Copso died at 4 years
of age. Twenty-seven children have been buried in the memory
garden of the last 10 years. Of the 128 children living in
Bethany House, a third, one out of three, are HIV positive, and
all, every one of the younger children at the Zodwa House are
HIV positive.
Windhoek, Namibia. We visited the Bernard Noordkamp Center
run by the Catholic Church. It provides care and nutritional
support and counseling to hundreds of orphaned children.
Lesson number five, we must develop an approach to the AIDS
crisis that is comprehensive and creative. There is no cure. We
do not have that answer yet, and thus we need to develop more,
not just comprehensive but innovative ways to respond to this
pandemic.
In South Africa we met with Dr. Fareed Abdullah, an
exceptional health care professional with the vision to imagine
a plan to bring universal treatment to those infected with HIV
in the Western Cape area. Now this is almost an overwhelming
task as you listen to him paint this picture, considering the
Cape can expect a substantial health care burden within 7 years
with an estimated 300,000 HIV-positive persons just living in
this area of the Western Cape. Dr. Abdullah stressed that the
AIDS pandemic has got to be tackled head-on and that nobody
should view HIV/AIDS as a problem separated from traditional
health care. He said we have got to make a virtue out of
necessity. We can strengthen the failing health care system to
fight HIV/AIDS only if we can think creatively and innovatively
in terms of the approach. Otherwise it is simply overwhelming.
We have got to find ways to leverage our ability to treat not
just HIV/AIDS but HIV/AIDS within the overall health challenges
a system must deal with.
Senator Alexander. Excuse me, Senator. We have a vote that
started at 3:16. I would assume that we could leave now and
come back, or we could go another three or 4 minutes and come
back.
Senator Frist. What time is it right now?
Senator Alexander. It says 25 after.
Senator Frist. We have got to vote within 20 minutes.
Senator Alexander. I thought you might want to be there.
Senator Frist. How far are we into the vote?
Senator Alexander. We are at 10 minutes into the vote.
Senator Frist. Why don't I go for about three more minutes
and then we will take a break.
Senator Alexander. Then will you have time to come back for
questions?
Senator Frist. Absolutely. I just wanted to mention that
HIV/AIDS affects the immune system of the body. We have this
little virus, only 20 years old, that has killed 23 million
people. When I was a resident in 1982 we had never heard of
this virus. So it is a new virus that is having this impact.
What it does, it knocks down your overall immune system and
makes you susceptible to all sorts of other infections. That is
why you cannot just treat the virus itself. You have got to
have an overall infrastructure, a health care system and a
systematic, a comprehensive approach to be able to treat all
those infections and not just the little virus itself.
That brings me to one final point, because by having
something that makes you susceptible to other infections you
need to consider water. There are about one billion people in
the world today who do not have access to clean water. If it is
not clean water, it can carry bacteria and viruses.
Over 495 million people live in sub-Saharan Africa who do
not have access to clean water today. As a result, 35,000
people die every day. Ten thousand people are children who die
each day from waterborne diseases. Ten million children die in
developing countries before their fifth birthday, many in the
first year of life. From all things that people die of, 75
percent of the children are dying of infections of some sort,
respiratory infections, diarrhea, malaria, measles, and
malnutrition, or a combination of these conditions related to
waterborne illnesses. Many of these deaths can be prevented by
basic sanitation, hygiene, and access to clean drinking water.
With that, Mr. Chairman, I think that is a good place to
take a break and then we can slip back in. Is that appropriate?
Senator Alexander. Thank you, Senator Frist. The Committee
will take a brief recess. We should be able to be back and
resume with Senator Frist's comments and then our questions
after that.
[Recess.]
Senator Alexander. I think we should go ahead and take
advantage of your time, Bill. What I failed to mention in the
introduction of the Leader is that he also was the chairman of
the African Affairs Subcommittee for a good while, so we
especially welcome him for that reason.
Mr. Leader, please continue.
Senator Frist. Thank you, Mr. Chairman. We left a few
minutes ago talking about this relationship between water and
waterborne illnesses and HIV/AIDS. The reason this is so
important, as we learned while we were in Africa, is it shows
that it is more than just anti-retroviral drugs that you need
for this pandemic to be reversed. As important as that anti-
retroviral drug might be, that you need to have a comprehensive
approach. One of the ways you can do that is to make sure that
people do have access to clean potable water.
In Mozambique we visited a project to bring clean water to
the citizens of Tshalala which is funded by a U.S. nonprofit
called Living Water International, which is part of the
Millennium Water Alliance. Living Water teaches people how to
drill wells to the depth of about 30 meters and equips people
with the tools and the knowledge to repair that equipment and
to maintain it over time. At the same time, they provide
instruction and training on sanitation and hygiene, and the
people who learn these skills and techniques can teach them to
other people.
In Tshalala we saw a well with a simple hand pump that
provides an estimated 300 to 400 people with adequate drinking
and bathing water. The cost is about $2,800. The average cost
of such a well in Mozambique is about $2,500. If you divide
that out it comes down to about $8 per person. Using that $8
per person we can prevent, through clean drinking and bathing
water, a number of otherwise life-threatening diseases, and
provide a savings for overworked, underfunded national health
systems through preventive care.
Lesson six, partnerships. Partnerships, partnerships,
partnerships. Partnerships between government which we
represent, NGOs that are so critical on the ground.
Partnerships with the academies or universities of the world.
Partnerships with private sector companies. Partnerships with
pharmaceutical companies. Partnerships with faith-based
initiatives. The only way, I believe, and I think that we all
learned, to meet the immediate so-called capacity needs is to
build these strong and effective partnerships. No one group can
do it alone.
In Botswana we visited the appropriately named Masa, and
that means ``new dawn,'' Clinic. Masa is funded by the African
Comprehensive HIV/AIDS program, ACHAP. You will see ACHAP a
lot, ACHAP also supports the Coping Centers for People Living
With HIV/AIDS as well as the Botswana Christian AIDS
Intervention program. ACHAP is a unique partnership sponsored--
again, partnerships--by the Bill and Melinda Gates Foundation,
the Merck Pharmaceutical Company and the government of
Botswana. A remarkable program launched in July 2000, now about
3 years ago, ACHAP provides free anti-retroviral treatment,
counseling, care--prevention, care and treatment for 600
Africans.
What is fascinating to me as a physician is that patients
in the Masa program have a compliance rate of around 90 to 100
percent in following the prescribed drug regimen. Again this is
important because in Africa you have heard it said, people are
not going to comply. I can tell you that is higher than most
every western country. The western country average is probably
about 20 percent less than that in terms of compliance.
In South Africa we also visited a company called Anglo-Gold
Mining. The Anglo-Gold Mining's anti-retroviral treatment
program was established to bring anti-retroviral treatment to
HIV-infected employees. The natural question is, how many
employees is that? In this huge, huge country it is estimated
that about one out of three employees are HIV positive, one out
of three.
In Rehoboth, Namibia we visited St. Mary's Hospital which
is preventing new infections through President Bush's
initiative. It was wonderful for our delegation to see these
initiatives on the ground playing out in action. This
initiative is the prevention of mother-to-child transmission
program. It uses nevirapine, an inexpensive drug, which using a
single dose, has a huge impact. But it was great to see that
program on the ground implementing President Bush's initiative.
Lesson seven, we have got to reach people where they live.
Most Africans live outside of the urban areas. They do not have
access to hospitals, clinics, or health care facilities. We saw
a lot of creative responses to the problem.
In Carletonville, South Africa we saw mobile clinics. The
mobile clinics are vans which have trained personnel and
medical equipment. They go out into the bush throughout that
region in Africa and bring basic care to treat persons in these
communities that are a long way from the nearest health care
facility.
In Kasane, Botswana we saw a mobile rapid testing lab which
travels through the Kasane region. That is in the north part of
Botswana. By closing the gap between people and health care
providers we are able to strengthen the capacity to deliver
health care to cope with HIV/AIDS. It provides that structure
through which HIV/AIDS can be adequately, appropriately, and
effectively addressed.
Lesson eight, we must take steps to reduce the stigma--I
mentioned the stigma earlier of HIV--through all sorts of
means. Through messages, through communication tools. We know
which communication tools work today. Let me just say up front,
stigma is a universal barrier. The stigma of HIV/AIDS is
prevalent in this country today. This is a universal challenge
that we have. As we look to reach out to people, remember nine
out of 10 people in the world who are HIV positive do not know
they are positive. Why? Much of it has to do with the stigma.
Because of stigma and the fear of discrimination, African
women told us again and again, they are afraid of getting
tested out of the fear of retribution. From who? The person
next to them, their husband. Some men are afraid to be tested
out of fear of being shunned by who? People who they work with,
or shunned by their neighbors. Stigma, obviously makes people
reluctant to come forward for testing. It makes people
reluctant even to talk about the HIV/AIDS virus. In this
country it is the same thing. How many parents really sit down
and talk to their children today about HIV/AIDS? So it is a
universal challenge that we have.
I mentioned earlier the importance of political leaders.
Political leaders need to get out front on the issue. Obviously
President Bush has done that in a bold, creative way. He stood
up before the American people and, indeed, the world community
saying that this is something that we as leaders in this
country must and will address.
You can eliminate or reduce stigma by giving the
appropriate message. In Mozambique, again former First Lady
Graca Machel told us of the difficulty in addressing HIV/AIDS.
She has a foundation set up to address this called Foundation
for Community Development. She told us how her foundation works
with faith-based organizations to reduce that stigma of HIV/
AIDS. She said that one of the more effective ways that she
found was to use individual Bible verses to connect with
people, church-going, faithful people, spiritual people. By
using these Bible verses, FDC was able to connect in a unique
way and reduce that sense of what she described as shame.
Again, it is a technique which she says is working well.
She also reminded us of the importance of creating tactical
ads to appeal to men very specifically on the dangers of sexual
promiscuity. She shared her thoughts as well on the multiple
media sources, the use of radio and billboards and hotlines,
all of which she has incorporated into her program. The
knowledge of HIV/AIDS and all the science that we have and the
ability to help does little good unless we can get it out to
people around the world so that they hear it and so that they
understand it.
One of the more meaningful interactions we had was with the
traditional healers. You know I am a doctor and I am trained in
western medicine. I do heart transplants and heart and lung
surgery. All that is good, but the people who are trusted in
communities on the ground throughout Africa and other parts of
the world are the traditional healers. They are the people who
are the leaders in the community. They are the people who are
actually trusted. In Botswana we were informed that as much as
85 percent of the population will visit those traditional
healers, the spiritualist, the herbalist, the diviners, and
other practitioners of traditional medicine. In Mozambique we
met with traditional healers from 10 different villages. They
are trusted local healers and that is to whom people turn for
treatment, for counseling. What was exciting to us is that
these traditional healers are reaching out to know more about
that little tiny virus that has killed 23 million people. That
linkage with those traditional healers I am very excited about,
especially with those healers reaching out for an understanding
of this virus, because it comes down to trust, and that is the
way to best destigmatize this virus.
Over the long-term we have got to work toward developing
guidelines for medical personnel to make HIV a more routine
part of health testing. Last week, I was very pleased to see
that President Mogae of Botswana announced a new government
policy on routine HIV testing in Botswana.
Let me go through one more lesson, Lesson nine. We have got
to envision a future without HIV/AIDS. Remember, this little
tiny virus was not known in this country until about 1983, and
again, I had the opportunity of training at some very good
hospitals in the United States of America with the very best of
what we have to offer. We had no idea that this little virus
existed and we had not defined it until between 1981 and 1983.
Twenty-three million people have died. Forty million people
are infected now. Again, this is around the world. It is likely
another 60 million people are going to die unless we act, act
as a Nation and as a global community. But we need to envision
this future without AIDS. It is overwhelming what is happening.
Even if we get the disease under control we have got to think
ahead right now, and it is not just vaccine development to
imagine a world without HIV/AIDS. In all the countries that we
traveled, in each of these countries we were met with a lot of
hope and optimism about the future. It was expressed in many
ways, hope that we would have better trade agreements to
empower people, to empower their economies, hope for a more
prosperous life. People with HIV/AIDS or with infected family
members, hope for a more prosperous life with their families.
In spite of the impact of this terrible and devastating
disease, Africans are very hopeful and truly believe in the
future. We have a moral obligation to stand by them and to
maximize their opportunity for growth and for that posterity.
Mr. Chairman, let me just close, and thank the ambassadors
from the United States of America and their staff because they
really made it possible to open up their countries for our
delegation to visit over this period of time. Ambassador
Cameron Hume in South Africa, Deputy Chief of Mission Dennis
Hankins in Mozambique, Ambassador Joe Huggins in Botswana, and
Ambassador Kevin McGuire in Namibia. They gave us outstanding
support and assistance by opening up their homes to our
delegation, working overtime to make our trip successful, and
for that we are grateful. They are a real credit to the State
Department and the United States, and they represent, as we had
the opportunity to see on the ground, the American people
admirably.
Thank you, Mr. Chairman. That is a quick overview in terms
of a fascinating trip. There is so much more to talk about, but
I did want to stress these nine lessons so that we can all best
figure out how to address this largest and most significant
humanitarian challenge of our times.
Senator Alexander. Thank you, Senator Frist. On behalf of
all of us I would like to thank you and your staff for that
presentation, and for putting together such an effective trip.
I rarely spent 10 or 11 days so efficiently and learning as
much as we did.
We have a little time. We probably need to end this about 5
after 4:00 because of the Republican Conference, but let us see
if we can each get in a question. I will ask one, and then go
to Senator Warner, and Senator DeWine, Senator Enzi, Senator
Coleman.
You mentioned political leadership at the beginning of your
talk, and we saw examples of impressive political leadership in
the four countries we visited. We have talked about a lot of
problems, but we also saw a lot of good government, and of
course in South Africa we saw a political miracle, which is
what has happened there in the last 10 years. The surprise of
the trip probably was the exchange you had, and others of us
had, with some of the political leadership in South Africa
which had been slow to respond to the AIDS epidemic. Do you
have any reflections on that and have you seen any changes in
that since the time we were there?
Senator Frist. Thank you, Mr. Chairman. What was remarkable
was the juxtaposition of leadership that was in the process of
changing plus leadership that had already changed at the
highest level. South Africa, for the last 5 years--and let me
say there have been dramatic changes in the last 3 months,
dramatic changes--but for the last several years there has been
denial and there have been reasons given in terms of what HIV/
AIDS was caused by. With that denial there was not a walking
away but a lack of recognition. Unless you say that there is a
problem, you are not going to be able to move in with
prevention, care and treatment. That has changed, and it has
changed at the highest level, with the President of that
country. So I am a little hesitant to be critical of the past
because I am so delighted to see a huge change there and by the
Minister of Health.
Then we saw countries like Botswana where the leadership
was out getting that test, saying to the people all across the
country that this is a problem and you can see that I am going
to be on the forefront to reverse this. Otherwise, we will face
the inevitable course of a worsening pandemic.
Senator Alexander. Senator Warner.
Senator Warner. Thank you, Mr. Chairman. First, I commend
you for having this meeting because in my 25 years in the
Senate I have been on a fair share of CODELs, and they are
misunderstood. It is part of the continuing educational process
of the Senate to go out and visit the countries abroad and to
come back, as we are doing, and share with our colleagues and
others our own observations.
But first, Mr. Leader, a little observation here. You
overlooked something that is very important in this report, and
that is reference to the fact that each of you brought your
wives and they were an integral part, seriously, of this CODEL.
They were able to interrelate with others, and particularly
some of the females that we met I think in a way that none of
us could have done so. So I would hope that you would revise
these remarks to include reference to that.
Senator Alexander. Yes, sir, sure will.
Senator Warner. On another matter, I felt that--and I have
talked to the military leaders in my capacity as Chairman of
the Armed Services Committee in the various countries, and I
was shocked to learn how AIDS is affecting their ability to
conscript and train adequate forces to maintain the political
stability as well as the strategic stability of these countries
emerging from colonialism and fighting the struggle to become
independent and strong nations.
For example, the UN is raising peacekeepers to go into a
number of areas. There are about 6 areas where there is open
warfare in the African continent today. They go to the various
nations and ask for several battalions, and when those nations
put the battalions together they have to strip out significant
numbers of the trained soldiers because they have HIV, because
they do not want to send an HIV to another nation. Often it is
difficult to raise the number of troops that they need.
I saw that--as you know, I left you for a day or two to go
to Liberia, where at that time our forces had intervened and
were continuing to intervene to maintain peace and stability,
and they did it in a very successful way thus far in Liberia.
There is a nation that is utterly devastated by 12 years of
civil war. Superimposed on that are the horrors of the AIDS
epidemic.
So I am delighted that you took the initiative that you
included all of us, and we commend you.
Senator Frist. Mr. Chairman, let me jump in real quick
because I think that Senator Warner really pointed out the
pervasive effect that HIV/AIDS has in the most productive years
of a population. When you go to parts of Africa you see very
young children running around, and then you see people much
older, and whether it is a teacher, military personnel, leaders
in civil society, people are losing the people in the most
productive years of their lives because of this virus.
Senator Alexander. I think we ought to also add that in the
few minutes that Senator Frist allowed us to have free time,
Senator Warner often took the Marines who were stationed out to
dinner, which impressed me.
Senator DeWine.
Senator DeWine. Mr. Leader, thank you for leading that
trip. It was an excellent trip and a great educational
experience for all of us.
Your presentation, I think, outlined a lot of what we
learned and outlined many of the challenges that we face and
these countries face. It seems to me that we have a long-term
challenge and a short-term challenge. The short-term challenge
that we have and these countries face is to deal with the
crisis as quickly as we can. We are in the process of
appropriating money. The first question is how do we get this
money out quickly to save as many lives as we can? The second
question is, as you have pointed out, we have got a health
infrastructure challenge, a medical infrastructure you call it,
which is a long-term problem, and how do we deal with that?
I wonder if you could reflect on both the short-term
challenge that we face; how do we make sure those dollars are
spent correctly to save as many lives as quickly as we can? But
also the long-term challenge--the 2-, 3-, 4-, 5-years and
beyond--of how we help them with their health infrastructure
which in the long run will also save, we hope, hundreds of
thousands, maybe millions of lives?
Senator Frist. Thank you. I think that is a good way to
dissect the problem because if you have a dollar to invest, you
have to decide how to invest that dollar so that it will have
the greatest impact. You cannot think just short-term, because
you could take not just $15 billion over 5 years, which is
huge, you could take hundreds of billions of dollars, and if
you did not invest it wisely, it would be not wasted, but it
would not have anywhere near the potential impact.
So challenge number one, short term we need to identify
programs that work because there are things that we know work
in terms of prevention, care and treatment. We do have a 20-
year history. We have places like Uganda and we need to
replicate the programs that are developed there, namely, what I
talked about, VCT, voluntary counseling and testing. It is a
model. They had a curve like the curves in Southern Africa,
where things are getting worse, and they now have reversed that
curve in Uganda. It is going down. Thus, we need to do what
they did.
Chairman Warner is exactly right. The effective use of our
time is to go through and see firsthand what works based on
models that work, and that is where we need to be investing our
money in the short term, not just taking a dollar and spending
it by giving it to a group that is not proven. There are
unlimited groups who want money. Having Dr. O'Neill with us,
who represented the administration, allowed him to see some of
those programs.
Longer term, and the continuum itself, we need to even jump
further ahead than was in your question because we do not have
a cure. This little virus is a cagey virus. It moves about
100,000 times faster than most other viruses. If you develop
something we think is going to cure it, it just changes face
and becomes something else. We have to figure that out. That
means the science in this country must improve, taking the
smartest people in the United States of America and around the
world, and investing part of that dollar there because no
matter how much we do in prevention and care, if you cannot
cure it long-term, you are not going to be able to eradicate
this virus. We can do it. As you know, smallpox has been
eradicated. That killed about 340 million people. So I would
jump even further ahead.
That is the spectrum itself, programs we know work all the
way to finding an actual cure. In that we are going to have to
make decisions throughout, and I am confident we can do that by
having the sort of experiences that we all shared together 2
months ago.
Senator Alexander. We have two more questions. We have a
vote with 11 minutes left. That ought to wrap things up neatly.
Senator Enzi.
Senator Enzi. Mr. Chairman, I thank you for holding this. I
think this itself is an unusual event for one of the trips to
pull back together to discuss some of the information that was
on it. I thank the Chairman for doing it. It was just an
incredible cultural shock for me to go over there. Mozambique
has 11 different languages and then each tribe has their own
dialect of that, and we wonder how do you communicate under
these circumstances? None of them own a TV because they are too
poor to own a TV. They would be lucky if they owned a radio.
They do not subscribe to a newspaper because you are not going
to print a newspaper for a couple of hundred people. So just
getting the message out is difficult. I had never appreciated
the possibility of the prevention of mother-to-child
transmission, which is one of the real hopes that I saw out of
the trip. For $2.50 the mother gets a dosage of a drug she
takes when she goes into labor. The child gets a liquid dose
right after birth. It prevents 95 percent of the mother-to-
child transmission. Of course they have to have that testing
that you talked about to be able to do that.
But even more basic than that was that water problem that
you showed on your slides. Mozambique hopes that some day
everybody will be within 5 miles of water, and in that they are
counting ponds that they wash their clothes in, swim in and
have their animals drink out of. For $6 million we could solve
a water problem over there.
Did we include in anything that we are doing financially--
in other words, money that could be utilized to help out on
that water problem, which is such a basic thing?
Senator Frist. The water issue is just fascinating in terms
of the prevention of disease by a very small investment over
time. I hope it is part of the comprehensive program that the
President is developing with Mr. Tobias, who we will have the
opportunity to meet with later today. But that planning is
under way and that comprehensive approach, not just of getting
a medicine, anti-retroviral therapy, but the comprehensive
approach indeed should be part of the President's initiative
for combating and reversing this pandemic.
Senator Alexander. Senator Coleman.
Senator Coleman. Thank you, Mr. Chairman. Mr. Chairman,
thank you for pulling this hearing together. It has just been
absolutely fascinating. Mr. Leader, I really think we are
blessed to have your leadership at this time in this body with
your understanding of this issue that is just taking so many
lives it is almost mind boggling. But you give us hope by your
passion and your commitment.
One of the things I notice about hope--and it was the
difference between the doctors at the Krishani facility in
South Africa where at that time there were 5 million people HIV
positive, 20,000 being treated, I think they just got a letter
that said they could do some treatment, but they were tired,
their eyes were tired. They were treating people, they were
dealing with people who were going to die and there was no
treatment. I contrasted that with the look on the face of the
healers at the Masa ARV facility in Botswana, who were treating
people, and they were lined up, and the backlog was actually in
processing some of the testing. I am a passionate believer in
treatment, in terms of extending lives, keeping moms alive so
that people are not orphaned for many, many years, and what it
does to the healers to keep the system going.
Is there a way to set up measurables? Can we go back with
the money we have to go back and say, okay, you have been
treating this many folks now. We expect over a certain period
of time to try to have some standards by which we can measure
the kind of growth and the impact because we know how important
it is.
Senator Frist. The measures are critical. Again, if we had
the answers now in terms of a cure, it probably would not be as
important because basically once you have the medicines all the
way to the delivery point, and you knew they were going to have
an impact, that the virus was going to go away, then it
probably would be less important. The problem is we are in the
learning curve. I mentioned Uganda, Senegal. These are the
great success stories that we have and we can replicate today.
What the President's initiative does is set out in very
specific terms both numbers and accountable measures throughout
the program to make sure that the money that is invested, huge
sums, unprecedented sums in the history of any nation on earth
today, has its outcome measured along the way. So that if we
invest two billion dollars this year and a little bit more that
next year, a little bit more that next year, we would be able
to invest that incremental amount in the most useful way based
on what we are learning right now in the program, as has been
done in Uganda.
One of the beautiful things about this very targeted
initiative, is that instead of saying we are going to throw
money at the problem, it is being done in a way that is
organized, that is disciplined, that has quantifiable measures
in terms of outcome, both in terms of quality as well as
quantity as we go forward. That is what I am most excited
about, and again, that is why it is important that as we
recognize that it is not just the amount of money which is what
a lot of people around the country measure. It is also about
ensuring that that money is invested wisely in programs that
work.
Senator Alexander. Senator Frist, thank you for your
leadership. Thank you for your presentation.
These two Subcommittees representing the Health, Education,
Labor, and Pensions Committee and the Foreign Relations
Committee will continue to meet together. We look forward to
hearing from Ambassador Tobias on his plan for the $15 billion
that the President has recommended and that the Congress has
said it will spend, and we invite you to any of those hearings
that you have time to attend. Thank you very much.
The Committee meeting is adjourned.
[Whereupon, at 4:10 p.m., the Joint Committee was
adjourned.]