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U.S. House of Representatives,
Committee on Banking and Financial Services,
Washington, DC.

    The committee met, pursuant to call, at 9:45 a.m., in room 2128, Rayburn House Office Building, Hon. James A. Leach, [chairman of the committee], presiding.

    Present: Chairman Leach; Representatives Castle, Lucas, Ryun, Biggert, Terry, LaFalce, Frank, C. Maloney of New York, Bentsen, Carson, Weygand, Lee, Inslee, Schakowsky, and Moore.

    Chairman LEACH. The hearing will come to order.

    As the committee meets today, the world confronts one of the most serious public health challenges in the history of man. While the bubonic plague of the 1300's and the flu epidemic of 1918 and 1919 each killed 20 million or more, already 16.3 million people have died from AIDS and more than 33 million are living with this ultimately fatal disease.

    Many of our colleagues on both sides of the aisle have been deeply concerned about this crisis. On this committee we are privileged to have the leadership of Congresswoman Barbara Lee, who has been unflagging in her dedication to bring the matter to the attention of Congress. Her bill, the AIDS Marshall Plan Fund for Africa Act, enjoys over 80 co-sponsors, including the Ranking Member, Mr. LaFalce, and myself. She, in turn, is a lead co-sponsor, along with Mr. LaFalce, of the bill I have introduced, the World Bank AIDS Prevention Trust Fund Act, which our witnesses may comment upon today.
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    The current statistics in the global AIDS crisis, particularly from sub-Saharan Africa, are dismaying. While the continent has only 10 percent of the world's population, it has 70 percent of the world's HIV/AIDS cases. It has some 10 million orphans as a result of the AIDS epidemic. Life expectancy is falling, along with GDP, in a number of countries. Silently, relentlessly, the disease is exacting a deadly toll in millions of Africa's working adults, children and mothers, soldiers, teachers, and virtually all sectors of society.

    But it should be understood that while the epicenter of the disease is now in Africa, it is currently moving toward Asia, and nothing would be a greater mistake than to think oceans are boundaries capable of containing the spread of diseases of this nature. At this time, for instance, there is an alarming HIV/AIDS infection rate in the Caribbean and in parts of Southeast Asia, as well as the former Soviet Union.

    Today, the committee meets to hear expert testimony defining the scope of the challenges facing Africa and other parts of the developing world, and to identify the strategies and programs necessary to curb its devastating humanitarian and economic consequences. We hope to learn about the difficulties confronting certain countries, as well as what has accounted for the successes enjoyed by Uganda and Senegal in curbing the HIV/AIDS infection rates, and whether any ''best practices'' gleaned from these cases can be applied to other hard-hit developing nations. We hope to hear about partnership prospects between international organizations, local governments, community organizations and religious institutions.

    Witnesses have been invited to comment on H.R. 3519, the World Bank AIDS Prevention Trust Fund Act, which seeks to leverage a modest U.S. contribution of $100 million a year into a billion dollar trust fund for AIDS prevention. Although donor nations already provide an estimated $300 million a year to address the HIV/AIDS problem in Africa, World Bank estimates suggest a need for vastly greater resources to be applied.
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    Let me just conclude by saying that the United States should do everything within our power to prevent and ultimately eradicate the disease. Mortality is part of the human condition, but all of us have an obligation as people of the world to put an end to those conditions that precipitate death, particularly at young ages.

    At this point let me turn to Mr. LaFalce and ask if he has an opening statement.

    Mr. LAFALCE. Thank you very much, Mr. Chairman. Today's hearing is on an extremely important subject, and I look forward to hearing the testimony of a very impressive group of witnesses on how best to address the AIDS epidemic.

    Before focusing on this extremely important subject, however, I would like to emphasize the framework that the United States and other countries will necessarily use to provide the kinds of assistance we discuss today. There is a substantial bipartisan commitment within the Congress to assist the developing world with both immediate crises like the AIDS epidemic and longer term economic development efforts, and we do that, of necessity, through the network of international financial institutions, in this case most especially the World Bank. We have no other effective tools.

    It is therefore imperative to work constructively together to make this network of international financial institutions effective and responsive to the legitimate concerns of policymakers in both the developed and the developing world. The pending International Financial Institutions Advisory Commission report could have helped us do that. Instead, I feel compelled this morning to express my serious disappointment with some of the commission's recommendations which will be released later this morning.
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    While that report will contain some legitimate criticisms and a number of important recommendations that I could support, some of the principal proposals are extreme and ungrounded in thorough analysis. They are at the very least impractical, and at worst potentially destructive of the only tools we have. Certainly the functioning of these institutions can be improved, but on balance they have contributed substantially to the alleviation of poverty through economic development, to the benefit of the developing world and the United States.

    As Secretary Summers has emphasized, assisting the developing world is a moral imperative and a good economic investment, but we cannot render assistance unless we work constructively with and through our international financial institutions. The Secretary issued what I believe to be more practical and viable reform suggestions last year. I would hope we can build on those and work constructively to achieve meaningful reforms that improve our ability to render exactly the kind of assistance we will be discussing today. And now let me turn to the topic of today's hearing.

    Worldwide, HIV/AIDS has infected tens of millions. Last year almost 5 percent of all deaths in the world were directly due to AIDS, and AIDS accounts for 20 percent of all deaths due to infectious diseases. It is a global epidemic and it is not subsiding. 5.6 million or almost 17 percent of those infected with this dreaded disease, were infected only last year. Even putting aside humanitarian concerns, the economic, social and cultural devastation wrought by this disease are of such an enormous magnitude that we must allocate far more resources, United States resources, international resources, to fight this disease.

    In reading and researching on this subject, I was struck by many points, but two in particular. First, so little is spent to deal with the problem. Worldwide, only about $300 million was funded from external sources, and only roughly $150 million was spent on programs in Africa, which is bearing the huge brunt of the epidemic.
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    And, second, while there is presently no known cure for this dread disease, please consider the following: Based upon empirical evidence, if a country reaches a prevalence rate, that is, the number of people infected divided by the population, of 5 percent, the prevalence rate will rise dramatically to around 20 percent of the entire population. But if the prevalence rate is contained to around 2 percent, the epidemic is likely to remain contained.

    We can make real progress, therefore, but we must provide the resources to do that. So I am pleased to be a co-sponsor of this important legislation. I believe that using a World Bank Trust Fund is probably the best approach to efficiently and effectively convey funds to multilateral efforts to fight the epidemic. We best leverage U.S. funds that way. But I applaud Ms. Lee strongly for her legislative leadership on this important issue. She has offered constructive approaches that I believe will be reflected significantly in any manager's amendment that is produced.

    The Administration has called for concerted international action, working largely through the World Bank and other multilateral development banks to combat infectious diseases, including AIDS, in developing countries, and to accelerate the development and delivery of new vaccines and other basic health services. We all share common goals: more resources and better health care delivery systems. We can and we will reach agreement on the details of how we achieve them.

    And, Mr. Chairman, I thank you and I applaud you for beginning what I know is going to be a very constructive dialogue. Thank you.

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    Chairman LEACH. Thank you, John.

    Mr. Castle.

    Mr. CASTLE. Thank you very much, Mr. Chairman.

    It is an undisputed fact that something has to be done to stop the spread of AIDS and HIV infection in Africa, and I welcome this opportunity to listen to all of your testimony. Clearly, the United States will play a critical role, and I hope that today's testimony will go a long way toward pointing Congress in the right direction.

    As you all know, AIDS has caused enormous human suffering in Africa. The numbers are staggering: More than 23 million adults and children infected with the virus; 13.7 million AIDS deaths to date, with 2.2 million in 1998 alone. Infection rates in some countries are in the 20 to 26 percent range.

    I recently visited Zimbabwe, Nigeria and South Africa with Congressman Houghton and others. An important part of the trip was learning firsthand about the AIDS crisis in those countries. I came away from that trip with the realization that the AIDS problem was too big for the United States alone to solve, and that it was in our best interest to promote an international response.

    Simply, the developed world must act now before even more become infected and the crisis cripples the already fragile economies of sub-Saharan Africa. But the crucial question is, what can we do to help and not make matters worse?
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    Already the United States has dramatically increased funding for the issue, from $67 million in fiscal year 1998 to $81 million in fiscal year 1999. USAID is projected to spend more than $133 million in fiscal year 2000 to fight AIDS in Africa. HHS will spend another $35 million on the issue, bringing total U.S. spending close to $170 million.

    Congress needs to make sure that these funds and any additional funds it allocates are going to projects that are effective and relieve the suffering that far too many are experiencing. The magnitude of this problem requires us to do the best that we can.

    I want to thank all of you for being here today and for your interest in this subject. I am very interested in hearing what you have to say. I look forward to working with Chairman Leach and the rest of the Banking Committee on finding a meaningful response for the United States. And I yield back the balance of my time, Mr. Chairman.

    Chairman LEACH. Thank you, Mike.

    Mr. Frank.

    Mr. FRANK. Thank you, Mr. Chairman.

    First, I congratulate you and the gentleman from California for the initiative you are both taking, and I am hopeful that this will see some beneficial results. I look back on the results of last session, and for me one of the most useful expenditures of time was within the context of this committee, under your leadership and that of the Ranking Minority Member, in putting together an excellent package of debt relief for the heavily indebted poor countries, and I hope we will build on that.
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    And in fact I want to make that linkage very explicit. We should go forward now with significant increases in what we do with regard to AIDS, but that must not come at the expense of the effort to relieve the debt of the highly indebted poor countries. I see Mr. Geithner talks about that in his testimony. We left the job uncompleted. We didn't; other elements of the Congress did. It is essential that we go forward early with full funding for that.

    And that leads me to a substantive point. We will be in one of these paradoxes now. There are actually two paradoxes I want to talk about. The first one is the paradox of the morality that governs us collectively and that governs us individually, because there is this unfortunate tendency to reverse it. In our own lives we sometimes are doing things for selfish reasons, and we try to create unselfish justifications for what is in fact motivated selfishly.

    Paradoxically, as a Nation we are sometimes driven to do the opposite. The main reason for us to substantially increase the resources for fighting AIDS is a humanitarian one. Innocent, helpless people are dying, and they shouldn't die. Children and others who are very vulnerable are in terrible peril. We are the richest, most powerful Nation in the world. We have it within our capacity to go to their aid, and shame on us if we don't.

    But, for some perverse reason, humanitarian responses are somehow out of favor. So there will be a great effort, in the reverse of what we would do as individuals, to try and some up with a selfish rationale for what is essentially a humanitarian impulse. Yes, I think it is in our interests for Africa not to be destabilized. Yes, I can think of a lot of reasons why, if there were more people in Africa, they will ultimately buy more American goods, but that is secondary. The primary reason is humanitarian.
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    Let's not debase our own good instincts, and let's stand up to what has become a very unfortunate tendency in American politics to denigrate our own best responses and to try, as I said, to find a selfish response, because it is exactly the opposite. As individuals we are often trying to find unselfish rationales for selfish actions. Today, we will have people trying to hoke up, and during this debate, selfish rationales for what is essentially an unselfish act.

    Let's do it and let's be proud of it. Let's say that, as a wealthy Nation, we have it within our capacity to go to the aid of people. Africa in particular is a continent which has been ill-treated by the West. Colonialism and other forms of exploitation are there. So if we need some kind of justification, maybe it's a combination of humanitarian resources and a little well-earned guilt. Yes, I think there are some other good reasons, but the major reason is humanitarian.

    The second paradox will be, this will be one of those issues where people will get ''yes'd'' to death, and then, in the end, very little will happen. People wonder, they go around, I know people come to see me, they want more money for this research, they want more money for this education program, they want more money for this veterans' medical thing, but in the end it isn't there.

    And the reason is that the whole cannot be smaller than the sum of the parts. You cannot consistently talk about Government as a terrible thing, advocate cutting Government as a wonderful thing, talk about putting arbitrary caps of an unrealistic nature on Government spending, and then be surprised when individual pieces of Government spending fall short.
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    This is going to cost money, money we can well afford as a Nation, money which our economy allows us to expend at no significant distress to individuals. But if we continue an unrealistic view that all Government spending is a bad thing and anything that cuts overall Government spending is a good thing, we will not have the resources available, when we come to cutting up our budget, fully to fund the highly indebted poor country debt relief and this.

    So let's couple our support for this with a willingness to put the resources overall together, because otherwise we will come to an appropriations process at the end where there will be an allocation that gets very technical. Right now we are on the high moral plane and everybody is for fighting AIDS in Africa. But that high moral plane doesn't mean anything unless people are prepared in technical terms to give the appropriate allocation under the Budget Act to the Subcommittees on International Financial Affairs, Foreign Operations, so they can fund it adequately. It is very important we do that.

    Last point. I am glad that many of us are joining today in what is an implicit, maybe almost an explicit repudiation of that special commission which is calling for a very drastic reduction in the World Bank's activities, at the same time that most of us here believe that among the ways effectively to fight AIDS is to expand the World Bank's activities. Thank you, Mr. Chairman.

    Chairman LEACH. Thank you, Mr. Frank.

    Ms. Lee.
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    Ms. LEE. Thank you, Mr. Chairman, and good morning.

    First, I would like to begin by thanking you and our Ranking Member, Mr. LaFalce, for your diligent efforts in organizing this hearing today, and also for your commitment to address this pandemic in a very real and substantive way. In particular I would like to thank you, Chairman Leach, for introducing your bill, the World Bank AIDS Prevention Trust Fund Act. I applaud your leadership in making today's hearings on AIDS in Africa your number one priority. This is truly a historic day for Africa and for America.

    The World Health Organization has proclaimed that HIV and AIDS is the world's most deadly disease. It has ravaged sub-Saharan Africa, claiming 13.7 million lives in recent decades. Still, 23.3 million adults and children are living with HIV and AIDS. This pandemic has cut life expectancy by 25 years in some countries. AIDS is really a crisis of Biblical proportions in Africa, and puts the very survival of the continent at stake. AIDS is decimating the continent and leaving behind millions of orphans in its wake.

    To bring this point closer to home, by the year 2010 the number of orphans in Africa will be equivalent to the total population of children in America's public schools. This is staggering. It is no less than a moral outrage.

    This is not only a humanitarian crisis, it is a potential economic crisis. Some countries now must hire two employees for every job, because they know that one of them will die from AIDS. Teachers are disappearing from classrooms. Skilled workers are vanishing from production plants.
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    In Congress, our commitment to attacking this issue is growing. Today we all are stepping up to the plate and taking on this challenge. Chairman Leach's leadership by introducing the World Bank Aids Prevention Trust Fund Act is one example of this commitment.

    As many of you are aware, there are currently approximately eleven proposals now in both the Senate and the House which seek to address the AIDS crisis in Africa and globally. As Chairman Leach indicated earlier, I introduced H.R. 2765 last August, the AIDS Marshall Plan for Africa, and it has currently over 85 co-sponsors. This bill commits $1 billion to fight HIV and AIDS in Africa.

    But I am pleased to say that Congressman Leach and I are working now together to try to develop an effective bipartisan strategy to assist many of the countries hardest hit by HIV and AIDS. I, too, am pleased to be a co-sponsor of H.R. 3519, Chairman Leach's bill. One principle that we have both agreed upon is that our legislation will establish public and private partnerships to assist African governments, non-governmental organizations and other agencies by providing significant funding for over five years for HIV/AIDS research, education, prevention, infrastructure development, and treatment.

    It is estimated that 6,000 people die of AIDS each day in Africa. That is mind-boggling. It is hard to even fathom that. Since I introduced my bill last August, for example, 1.2 million people have died. As you can see, the survival of the continent is at stake.

    So today we will discuss a wide range of topics on this issue. I want to leave and close my statement with one important thought. It is from an old proverb in Swaziland which says that ''there is a poisonous snake in our house, and if we do not get it out, it will kill us all.'' Congress must pass legislation to address the AIDS crisis in Africa.
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    Thank you, Mr. Chairman, thank you, Ranking Member LaFalce, and thank all of you today for being here and for your commitment to addressing this in a real way, and I look forward to your testimony. Thank you.

    Chairman LEACH. Thank you, Ms. Lee.

    We will now turn to witnesses from outside the committee, and we are honored to have their presence. The first is Senator John Kerry of Massachusetts, who is a Member of the Senate Foreign Relations Committee and a strong advocate of the need to address this particular crisis. He is a sponsor on the Senate side of the World Bank AIDS Prevention Trust Fund Act, and he is also a sponsor of legislation to develop vaccination approaches.

    Our second witness is our good friend Amo Houghton, who represents the 31st District of the State of New York, who is a Member of the International Relations Committee and a senior Member of the Subcommittee on Africa, and one of Congress's experts on many fields, not the least of which is the Continent of Africa and the problems that afflict it.

    We will begin with Senator Kerry.


    Senator KERRY. Mr. Chairman, thank you very much for holding this hearing, and thank you for allowing us to testify. I appreciate very much the eloquence of each of the statements we have heard from your Members, who have really summarized the legislation very adequately. I would ask unanimous consent to put my comments in the record as if read in full and just share a few thoughts with you for a moment.
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    Senator Durbin has joined me in sponsoring the companion bill in the Senate which has been referred to the Foreign Relations Committee, and we are in discussions with the Majority on that committee to try to expedite these efforts on the Hill. It is my hope that this hearing and swift action by the House, can inspire the Senate to move.

    As you know, Mr. Chairman, our Subcommittee on Africa held a hearing on the AIDS epidemic about two weeks ago. You referenced the bill a moment ago that Senator Frist and I have introduced, and I would just like to say a word about it because it fits into the overall approach that we need to employ in dealing with this.

    The Chairman of the subcommittee is Dr. Frist, whose obvious skill and knowledge in the field of medicine is an important, valuable asset to all of us on the Senate side, and to the Congress as a whole. He has joined me in co-sponsoring the effort to spur the development of vaccines. Most people believe that if we put a legitimate effort into developing a vaccine, we can accomplish a great deal, just as we have in dyptheria or whooping cough or polio, other diseases.

    The problem is, there is no market for vaccines against disease which primarily strike the developing world. Pharmaceutical companies aren't going to put the money into the investment, because, unlike Prozac or Viagra or other drugs, the wonder drugs of our society where the market returns billions of dollars, nobody knows who is going to pay to buy vaccines against malaria, tuberculosis or AIDS.

    And the reason I cite this is not to take away from the bill we are talking about here today, but to underscore the global nature and the multifaceted approaches of the response that is necessary to deal with the problem of AIDS. There is no one approach that is going to solve this crisis, but we need to move on the front of trying to develop a vaccine and trying to develop the market to distribute the vaccine. But also clearly we have to continue to make efforts on the prevention front, because all of us understand that contagion doesn't know any borders. Contagion obviously needs to be fought on every front, because it is evident on every front.
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    You are going to hear from some experts on the scope and the epidemiology of the AIDS crisis in Africa. You are going to hear from our distinguished Ambassador to the United Nations, whom I think we all salute for his effort to put this issue on the world agenda. His is a unique effort within the Security Council and the United Nations to deal with this kind of issue, and I think it is leadership that is appropriate for the United States.

    You are going to hear from Sandy Thurman, and from one of the Nation's most compelling and articulate advocates in the fight against AIDS, Mary Fisher. We are all probably going to duplicate each other a little bit, but let me just try to pick up on what my Congressman, Barney Frank, said, and underscore why we have to do this.

    Barney talked about the humanitarian need here. I have actually heard people in this country say, ''Well, it's the product of their sexual practice, so there's not much I can do about it.'' There is a capacity for people to be dismissive, even of a crisis of this proportion, even of something that has all of the humanitarian demands and compelling factors of this issue.

    This is not something of which any decent, rational person can be dismissive. On humanitarian terms, on political terms, on cultural terms, on economic terms, on historical terms, no one should dare to be dismissive of this. We are tied and linked to everything that is happening in Africa, back into our Nation's and our civilization's earliest history, and we are tied by the new forces of globalization and technology. And I hope we will always be tied by who we are and what we are as a Nation. This really tests the fiber of our country, in a sense, and questions whether or not we are prepared to step up and offer leadership to deal with the AIDS epidemic in Africa.
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    The statistics are hard for anybody to grasp. It is hard to imagine that 40 million children will, in the next ten years, lose a parent. It is hard to imagine what a society is like that is losing its teachers, its human infrastructure to a disease like this, and what that means for future generations who may not have somebody there to teach them, may not have a leader who can help pull that community together.

    Just like HIV itself destroys the immune system, the AIDS epidemic destroys the whole fabric of society. And we are going to see, as a result of that, in a place like Tanzania there will be a 15 to 25 percent drop in GNP because of AIDS. In South Africa business owners often hire two employees for one job, knowing that one is probably going to die from AIDS. Up to 80 percent of the urban hospital beds in Malawi are filled with AIDS patients, and every day in the Cote d'Ivoire a teacher dies from complications associated with AIDS. Zambia is a nation of 11 million people, and next year, half a million of them will be AIDS orphans.

    So, it seems clear that if an entire continent, if an entire people are going to remain linked to the rest of humanity, and tied to the rest of humanity, we need to respond on a global basis. Now, how do we do that? Well, Mr. Chairman, there is a sign over that says ''prevention programs work,'' and I would ask unanimous consent that an article from January 2nd from The Economist be placed in the record, and I just reference it very quickly.

    There are three examples in this article, Senegal, Uganda, and Thailand. One very developed, one undeveloped, and one that had not been hit by AIDS, and each took major prevention efforts to break down the myths, to deal with problems of migrant labor, to deal with problems of religion. And myths, I might say, play an extraordinary role in this. There are literally women who believe that having unsafe sex is somehow going to make them beautiful, men who believe that they can be cured of AIDS if they have sex with a virgin. These myths are powerful.
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    And you need education, you need outreach, you need major efforts in order to change that type of belief structure. It has happened in those countries that I have just cited, where government efforts, non-governmental efforts, major media efforts reached out to people and changed behavior. And so this prevention trust that we are talking about is in addition to other wonderful efforts by people like Bill and Melinda Gates, who have put $750 million into the vaccine effort, or the Elizabeth Glaser Pediatric AIDS Foundation that is trying to help mothers use the available ability to prevent AIDS from being passed on to children.

    We can do a better job of making certain that all of sub-Saharan Africa, where the principal problem lies, can be reached by information and opportunity, and that is our obligation. This effort to have the World Bank, the trustee in a sense, to use the best of its ability as a global institution to bring donations together, to bring together the resources of the world, to bring governmental funds together, and to distribute them in a way that will maximize our best prevention efforts, is a significant component of the full mosaic of what we need to do this.

    Mr. Chairman, I close just by saying the developed world spent $250 billion dollars to try to deal with the Y2K bug. This is a real disease that is far more damaging to the structure of society and to the long-term interests of this planet, and it behooves us to find the resources to deal with the realities of this disease. Thank you very much, Mr. Chairman.

    Chairman LEACH. Thank you very much, Senator Kerry.

    Before turning to our next witness, I want to do two housekeeping things. One, I would like to ask unanimous consent that all Members be allowed to put their opening statements into the record, including one by Congressman Gephardt that Mr. LaFalce has presented. And Dick apologizes, he had hoped to be with us today, and he has a very powerful statement.
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    Second, I would like to ask unanimous consent to put the two charts that we have put on the board into the record. One shows the extraordinary instance of AIDS and how it is spreading; and the second, that prevention programs do have some effect in dealing with the problem.

    At this point, Mr. Houghton, please proceed.


    Mr. HOUGHTON. Thank you very much Mr. Chairman, and thank you, Mr. LaFalce, and Ms. Lee and Mr. Castle, and everyone who has been involved here. It is great to be with Senator Kerry. Are you going to leave? OK.

    And also, you know, there are so many other people, Ron Dellums, and Sheila Sisulu of the South African Embassy, and obviously Barbara Lee, what she has done. I am totally in agreement with your bill, 3519, and I hope it can be passed this year, and maybe even the Lee-Dellums bill will have a chance to do this. And I think right behind that, of course, is the Crowley-Pelosi bill. But they are all moving in the right direction.

    Mr. Chairman, it is very tempting to cite statistics and horror stories and things like that, and I do not really want to overdue that, but I want to give just a little bit of personal background here. I have spent a lot of time in Africa over the years. I went there first in 1950, and I went intensively in the early 1980's, when I was in business. The place that I spent most time with is Zimbabwe, and I think it sort of is a microcosm in a way of the sub-Saharan problem.
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    I was interested in working very closely with the church. This is before I got into politics. And there was a fellow called Peter Attende who was the Bishop of Harare. It is the capital city of Zimbabwe.

    Chairman LEACH. Amo, could you bring the mike a bit closer, please?

    Mr. HOUGHTON. Yes. Can you hear me better now?

    We used to talk about AIDS and what was happening. Of course, those were in the early years when AIDS had really just been recognized, in 1980. And it was an affront to him, as a religious leader, as a member of that society, to really acknowledge this problem. My wife and I used to distribute comic books describing things, so that people could see in pictures rather than in words, and he fought this.

    Dick Gephardt and I had a congressional delegation in December, we went, and where we met Ambassador Holbrooke. And I had a talk with Peter Attende, this bishop that I referred to, and his son had just died of AIDS. His son's wife has AIDS. Their only child has AIDS. And the mission that he got me involved in, a tiny little mission about two hours south of Harare, not many people, there is a school, maybe a thousand people in little villages around. Every single day, there is a funeral for AIDS. And it really is a startling issue down there, because in many cases it is not just what you can do for them, but what they can do for themselves in terms of acknowledging this particular problem.

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    One of the most interesting experiences we had in our December trip was going to the largest hospital in the world, which is in Soweto. And the statistic I best remember, and Congressman Castle was there with me, was that in 1987, of a thousand women who came in just before they were to give birth to their children, three were tested positive for HIV. And last year, out of that thousand, instead of three, it was 250. So you can see that it was from 1987 to 1998, so in eleven years they have gone from 3 to 250; if you take another eleven years, it goes right off the chart. It is infinite.

    So the question really is—you know, I could go on and cite story after story, as we all can—the question really, is what do we do about it? I know General Marshall always used to say two things: Don't get involved in the menusha; and, second, don't fight the problem. We tend to fight this problem, and I think what you are trying to do is to solve it.

    I think that there are a variety of issues here. First of all, there is the medical issue, and the education issue, and you know, there is just not very much of that around. Mary Fisher and I were talking earlier, that there are United States drug companies who are willing to give drugs away. They can't distribute them. The hospitals don't have the physicians to handle them, they don't know what to do. So it is not just the fact that an HIV drug is $200 a shot or something like that, it is just that the whole structure is difficult for the distribution of these drugs.

    Another thing that I have found was that it is really important to not just concentrate on the medical issue of AIDS, or even the educational issue. It is sort of the lifestyle issue, and that is jobs. You know, the three things that we came up with there, one was horrendous crime, big unemployment, and the AIDS issue. But, you know, so many times in the rural areas, people go from the rural areas to the city to get jobs, and that is exactly the wrong thing for them to do.
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    And so part of our responsibility, not only in terms of what we do as individuals, but in terms of legislation, is really to find a way to encourage investment over there. That is hard. These people in many cases don't know what to do. I mean, having been in business for forty years, they don't give you a plan where you can get your teeth into it. They don't know how to ask for economic help. They want it. It is necessary. It is part of the whole picture of keeping people in the rural areas rather than having them gravitate toward the city where they get into trouble.

    Another thing, Mr. Chairman, I think is very important, is the attitude of the leaders over there. I am not going to mention names or even countries, but there was one very, very distinguished person that we talked to, head of his country, kept talking about tuberculosis and dyptheria and measles and things like this, I mean, as if AIDS really wasn't the problem. And unless leaders of some of these countries, and I think we can help this, are willing to acknowledge this fact that they have got a problem, and will handle it like Uganda, then I think we have got an uphill battle.

    And one of the problems is that they don't want to scare away investors. It is the old question of foreign money coming in and building a plant or building a business to be able to help in their unemployment. So those are very important.

    However, having said that, absent the money, and absent the things you are doing, nothing is going to happen. So I applaud you and I thank you very much for letting me be part of this discussion.

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    Chairman LEACH. Well, thank you very much, Amo, and we are honored you have been able to join us, and I personally want to thank you for your enormous concern and advice on this subject. Thank you very much.

    Mr. HOUGHTON. Thank you.

    Chairman LEACH. Our second panel is composed of the Honorable Richard C. Holbrooke, who is the United States Ambassador to the United Nations. Dick has been instrumental in getting the U.N. Security Council to convene a special session on Africa in January, by the way, an unprecedented one, and to bring national attention to the horrific suffering occurring in the region because of the HIV/AIDS virus. He has had a long and distinguished career in the diplomatic service, including stints as Ambassador to Germany, Assistant Secretary for European and Canadian Affairs, and Special Envoy to Bosnia and Kosovo.

    Our second witness will be Ms. Sandra Thurman, who is Director of the Office of National AIDS Policy at the White House, a long time advocate for individuals suffering of HIV/AIDS. Ms. Thurman was a member of the Presidential Advisory Commission on HIV/AIDS and a founding member of the Cities Advocating Emergency AIDS Relief.

    Our third witness in the panel is Treasury Under Secretary for International Affairs Timothy F. Geithner. Mr. Geithner has served in a variety of capacities at the Treasury Department for the last twelve years, and is responsible for issues relating to U.S. policy toward the World Bank and other international financial institutions. We welcome Secretary Geithner.

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    We will begin with Ambassador Holbrooke. Let me just say all statements will be placed in full in the record, and the panelists may proceed in any manner as they see fit.


    Mr. HOLBROOKE. Mr. Chairman, I have a prepared statement I would like to present to you and make a few very personal comments, because I think everyone who is in this room by definition already knows the dimensions of the problem. We are here to do something about it.

    First of all, let me just thank you and your colleagues enormously for bringing this issue not only before the public's attention, but for making it part of the activities of this particular committee. Just as we expanded the dimensions of the problem by bringing the issue to the Security Council of the United Nations in January, as you just mentioned, you add a new dimension in bringing it before your committee.

    And in that regard, to have a representative, a very senior representative of the Treasury Department joining Sandy Thurman and me here today, I think sends an additional signal, and that signal is unambiguous: AIDS is not just a health issue. Congressman Frank's admonitions at the outset are ones I totally agree with. I think he has warned us that we can get caught in a self-congratulatory rhetoric and not do anything about the issue.

    Our goal here is to make people aware of the fact that, although many other illnesses are serious, this one has a unique quality to it, in that it threatens not only the health of people, as all diseases do, but in this case threatens the very fabric of society and economy itself in many nations in the world, and particularly in the southern part of Africa.
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    My own involvement in this issue began seven years ago when I visited Cambodia as a private citizen and visited the United Nations, and found to my astonishment that United Nations peacekeepers were coming to Cambodia to bring peace to the area, but were in fact spreading AIDS. In other words, they were solving one problem while creating another.

    I found in my hard disk on my personal computer last week the letter I wrote to the U.N. in Cambodia, which I hadn't seen in seven years, and I would like to submit it to you, Mr. Chairman, for your files. I submit it to you because I am struck by something, rereading it last week for the first time in seven years, and that is that nothing has changed. The U.N. is still spreading AIDS while bringing peacekeeping missions to other areas, and that is one of the main reasons we brought it to the United Nations.

    We have stated, Mr. Chairman, that we will never again support a peacekeeping resolution in the U.N. that does not contain a section on AIDS. And I would also like to submit for the record this morning a letter I received late yesterday afternoon from the Under Secretary General of the United Nations, Bernard Miyet, outlining the steps he is taking up to this point to increase AIDS awareness among U.N. peacekeepers, in order for you to peruse it. It is a step in the right direction, but, again, it does not go far enough.

    Chairman LEACH. We will be happy, Mr. Ambassador, to put that in the record.

    Mr. HOLBROOKE. We will supply those to you later.

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    In addition, Mr. Chairman, of course our concern goes far beyond the U.N. peacekeeping connection. You mentioned—and several other people mentioned—the historic Security Council meeting of January 10th, chaired by Vice President Gore. We were told in advance we would never be able to have a health issue in the Security Council, but we did it. Several of you in this room joined us at that meeting. We were honored you were there. And subsequently we have had continued discussions with many of you about what to do about this issue.

    I can only say to you that this Administration is fully committed, President Clinton is personally seized of the issue, the Vice President's commitment is self-evident from the time he has spent on it in recent weeks and months. I am very proud that the effort on this has been bipartisan. I am delighted to see several people in the room I have been working closely with. We stand ready to work with you to increase our efforts.

    And I am honored to be part of this panel at this time, and above all, Mr. Chairman, for the initiative of you and your colleagues to bring this into the Banking Committee, because again you are showing that it is an issue that is more than a health issue, and just as we said, it is a security issue, you are now spreading the dimensions of it again. So the fact of the hearing, and in this particular forum, transcends the substance, and I thank you enormously. It will be echoed in New York, and we will bring it to the attention of all U.N. Security Council members once you have reached the conclusion of your deliberations. Thank you.

    Chairman LEACH. Thank you, Mr. Holbrooke.

    Ms. Thurman.

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    Ms. THURMAN. Thank you, Mr. Chairman, Members of the committee. I am delighted to be with you today, to have the opportunity to talk about the global AIDS pandemic with a special focus on AIDS in Africa. Your leadership and your commitment to addressing this crisis is very much appreciated and, it goes without saying, very much needed.

    I would like to use my time with you today to lay out a vivid picture of the scope of this tragedy, particularly as it impacts the stability of families and communities and, in many instances, nations. I would like to share with you some of my personal experiences with the faces behind these shocking facts, and I would like to outline for you some key components of our enhanced Administration response to this global pandemic.

    By any and every measure, AIDS is indeed a plague of Biblical proportion, and it is claiming more lives today than all of the wars waging on the continent of Africa combined. AIDS is now the leading cause of death of all people of all ages in Africa, and the progression of this pandemic has outpaced all of our projections. In 1991 the World Health Organization predicted that by 1999 there would be 9 million people infected in Africa and nearly 5 million deaths due to AIDS. The resulting numbers are two to three times that number, as you have heard, with 24 million infected and more than 14 million deaths already.

    And yet this war rages on. Each and every day, Africa buries nearly 6,000 men, women and children as a result of AIDS, and that count will more than double in the next few years. By the year 2005, it is now projected that more than 100 million people worldwide will have been infected with HIV, and unlike other wars, it is increasingly women and children who are caught in the crossfire of this pandemic.
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    In Africa an entire generation is in jeopardy, as you have heard. Already, in several sub-Saharan African countries, between one-fifth and one-third of children have already lost at least one parent as a result of AIDS, and the worst is yet to come. Within the next decade, as Congresswoman Lee has pointed out, we will have more than 40 million children orphaned as a result of AIDS, and that is about the same number of children living in the United States east of the Mississippi.

    In just a few short years, AIDS has wiped out decades of progress and hard work in improving the lives and health of families throughout the developing world. Infant mortality is doubling, child mortality is tripling, and again, as has been previously stated, life expectancy is plummeting by twemty years or more.

    And AIDS is not just a health issue. It is an economic issue, it is a fundamental development issue, and it is a security and stability issue. AIDS is having a dramatic effect on productivity, trade, and investment, striking down workers in their prime, driving up costs of doing business, and driving down the GNP.

    AIDS is also affecting stability in the region. As Ambassador Holbrooke has discussed, the U.N. Security Council just in January held a day-long meeting on HIV and AIDS. And I think it is very interesting to note, not by accident, that a recent report by the National Intelligence Council documents that this pandemic is much worse than we thought and much worse than we had ever predicted.

    Yet my message to you today is not one of hopelessness and desolation. On the contrary, I hope to share with you a real sense of optimism. For amidst all of this tragedy, there is hope. Amidst the crisis, there is opportunity, the opportunity for all of us, working together, to empower women, to protect children, and to support families and communities throughout the world in our shared struggle against HIV and AIDS.
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    It is important to remember that what we are talking about today is not numbers, but names, not facts and figures, but faces and families. And let me tell you one quick story about an inspirational grandmother that many of us in this room met in Uganda.

    Bernadette is a 70-year-old widow who has lost 10 of her 11 living children to AIDS. She is supporting, on her own, 35 grandchildren. With a loan from a village banking system, Bernadette is now raising pigs and chickens and raising corn and other crops, and with the money she earns, she has 15 of those 35 grandchildren in school and is able to provide modest treatment for the five of her grandchildren who are HIV infected.

    In her spare time, she told me, she participates in an organization called United Women's Efforts to Save Orphans, which was founded by the First Lady of Uganda, Mrs. Museveni, and she unites in that effort with thousands of women across Uganda who have a shared concern about their children, and these women are not alone. From young people doing street theater in Lusaka to women who are HIV positive forming support groups in Soweto, these people are coming together and creating ripples of hope all across sub-Saharan Africa. These are the faces of children and families living in a world with AIDS, and their spirit and their determination and their resilience lead all the rest of us, who have seen them and had the privilege of meeting with them, on.

    The good news today is that we know what works. With our partners in Africa, we have developed useful knowledge and effective tools. Together we have designed model programs and already proven that they work. And today we know how to stem the rising tide of new infection, how to provide basic care for those who are sick, and how to mobilize communities to support the growing number of children orphaned by AIDS.
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    As you have heard, Uganda has demonstrated that you can cut the rates of infection in half. Senegal has been able to keep their infection rate very, very low as a result of effective and sustained leadership. But there is much more that we need to do to bring all these success stories to scale. I mean, it is a very big challenge for us.

    The U.S. has been engaged in the fight against AIDS since the early 1980's, but increasingly we have come to realize that when it comes to AIDS, both crisis and opportunity have no borders. We have a lot to learn from the experiences in other countries. It is just amazing. We have done a lot, but there remains much more that the U.S. and the other developed nations must do to combat AIDS.

    During the past year-and-a-half, I have had the privilege of going to Africa four times, visiting eight countries. Together with Members and staff from both parties and chambers, many of whom are in here today, we went to bear witness to both the tragedy and the triumph of AIDS in Africa. And in response to the findings of these trips, the Administration requested and the Congress granted last year an additional $100 million to combat HIV and AIDS around the world, with a particular focus on Africa.

    The new initiative, which includes AID and CDC, provides a series of steps to increase U.S. leadership through the support of some of these extraordinary community-based programs, and to provide much needed technical assistance to these poor countries who are struggling to respond in the face of this overwhelming pandemic. The initiative focuses on four key areas.

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    The first is prevention, including basic education, voluntary counseling and testing, the prevention of mother-to-child transmission. The second is home- and community-based care to help again to provide some basic care and treatment, both at home and in hospitals and clinics. Care for children orphaned by AIDS, and the all-important infrastructure that everyone keeps talking about, to be able to engage in all of those other activities.

    And it has other components, as well, that I think are important, and that includes expanding our foreign policy dialogue to promote the use of resources freed up by debt relief to focus on HIV and AIDS prevention, and to engage all sectors, including business and labor and foundations, the religious community and other nongovernmental organizations, in a broad-based mobilization.

    While this new initiative greatly strengthens the foundation of a comprehensive response to the pandemic, UNAIDS has estimated that it will take at least $1 billion to begin to lay the foundation of a real effective prevention program in sub-Saharan Africa. Currently, with public and private donors combined, we are spending a little more than $300 million there. And, in addition, it will take another $1 billion to begin to build the infrastructure to deliver basic, just the most basic health care to combat HIV and AIDS.

    And in the face of such tremendous need, the Administration has requested, in the President's 2001 budget submission, an additional $100 million to enhance our expanded efforts to combat AIDS in Africa and around the world. That includes additional money for CDC, additional money for USAID, but it also includes a request for money for the Department of Labor and the Department of Defense to expand our multisectoral approach and make sure we are using every vehicle possible to reach folks where they need to be reached.
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    Let me repeat, however, that the U.S. cannot and should not do this alone. Chairman Leach, your initiative and the one put forward by Representative Lee clearly recognize, as we do, that this crisis will require the active engagement of all segments of society working together, every bilateral donor, every multilateral lending agency, the corporate community, the foundation community, the religious community. It goes on and on, but it can be done and it must be done.

    The bottom line is this: With no vaccine and no cure in sight, the sad fact is that we are at the beginning of an epidemic, not at the end. What we see in Africa today is just the tip of the iceberg, and as goes Africa, so will go India and the rest of Asia and the Newly Independent States. This is not an African issue, it is not an American issue, this is a global issue.

    We look forward to working closely with each and every one of you, and are so grateful that this issue is receiving the broad-based bipartisan support that it deserves. AIDS, as we all know, is not a Democratic issue or a Republican issue. It is a devastating human tragedy that cries out to each and every one of us to come up with creative solutions to help.

    Thank you, Mr. Chairman, for having us here today.

    Chairman LEACH. Thank you very much, Ms. Thurman.

    Secretary Geithner.

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    Mr. GEITHNER. Thank you very much, Mr. Chairman. Let me just make a few brief points.

    Our compliments to you and your colleagues for the series of compelling and creative proposals you have put forward to try to mobilize more resources in a creative way for this initiative. We are very interested in trying to work with you to try to shape a comprehensive approach that is going to actually achieve some reality on the ground as we go through the appropriations process.

    This is a huge, formidable, compelling issue. It is bigger than Africa and it is bigger than HIV/AIDS. People are dying at an alarming rate, at an extraordinarily alarming rate, outside Africa as well, and they are dying of diseases, of century-old diseases, at a rate that exceeds the rate people are dying from AIDS. This is a complicated, brutally complicated issue to approach and to solve.

    The pace at which vaccines get developed cannot exceed the pace at which basic science evolves. Vaccines will not be developed and put into clinical trials unless there are resources available to purchase them. You can purchase vaccines, and nothing will happen without infrastructure to deliver them. This is the logic behind the President's broad vaccines initiative that he laid out two months ago to try and deal with these challenges, and I will summarize it very briefly.
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    The first is a modest U.S. contribution to the Global Alliance for Vaccines and Immunization, to support the delivery of vaccines that now exist to deal with diseases that kill millions of children a year today.

    The second is a significantly expanded investment in basic science, because without that, nothing is going to be possible in dealing with HIV/AIDS, with malaria, with TB, that now kill people on such an extraordinary scale.

    The third is a substantial redirection of resources in the concessional lending operations of the World Bank and the MDBs into basic health care. We propose to expand by roughly $1 billion a year the money these institutions invest in lending at highly concessional rates to countries to make these basic investments in health care.

    The fourth, if I haven't lost count, is the debt initiative that Congressman Frank referred to. Unless we are able to find the capacity to finance this initiative fully, we will be foregoing the capacity to free a significant pool of resources that could amount to hundreds of millions of dollars a year in these countries, from debts they cannot afford to pay for things like education, basic health care, vaccine purchase and delivery.

    And, finally, we have laid out a relatively innovative tax proposal which we hope will help provide a more compelling set of incentives to the pharmaceutical industry, giving them more confidence there will be resources available at the end of the day to deliver vaccines they actually succeed in developing.

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    We are very interested in trying to work with you, Mr. Chairman, and everyone else up here to try to put together a comprehensive approach that can deal with each of the many constraints that exist on effective responses to these problems, and we compliment you on your initiative.

    Let me just close by citing something that Larry Summers said recently. I heard him say something which I found particularly compelling:

    If you are a kid in America today, you learn very quickly that there are compelling environmental problems the world faces that may threaten future generations, and you learn very quickly that there are species of animals around the world that are dying at alarming rates, and you learn early-on the importance of recycling, and why it matters to us as a people that dolphins are threatened, and that biodiversity is important.

    But what you don't learn as an American child is how many kids like you in so many countries around the world do not have enough food to eat, cannot plausibly see a doctor in their lifetime, and are going to face a greater risk of dying of preventable diseases than they may have the opportunity to go to high school. And unless we can change that reality and raise the profile of these broader imperatives around the world, it is unlikely that we are going to find the will to devote the resources necessary to these compelling problems.

    Thank you.

    Chairman LEACH. Let me thank you all for your thoughtful testimony, and I appreciate it very much. I would like to raise a contextual issue that relates to a report that is going to be issued today, and that is, there is going to be a report of the Meltzer Commission that casts some doubts about some approaches of the Bretton Woods institutions, particularly the IMF.
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    And I would only like to stress two things: One, there will be some constructive ideas in this report. There will also be some things that many of us in this panel are going to object to. But I have had a long talk with Professor Meltzer, and he affirms to me that he sees a worthwhile role in the World Bank and the AIDS prevention endeavors, and I am hopeful to have whatever debate relates to the Meltzer report to be outside the context of this particular initiative.

    Second, that one of the unique features of the Bretton Woods institutions, the World Bank and the IMF, is that they involve international sharing of obligations. That is, any approach that is adopted by the World Bank or the IMF involves an obligation of the United States; it also involves collateral obligations of other countries. And implicitly, whatever decisions are made, the United States is a minority, not majority, participant. And therefore, of all the institutions on the world scene that can more quickly develop substantial resources, these two are uniquely fitted.

    And I raise this simply in the context of the fact that past programs of any nature can be credibly criticized. By the same token, there are a lot of pluses to these institutions, both in past programs and in terms of future opportunities. And I in particular want to turn to the Treasury in this regard, and just ask as carefully as I can if the United States Government, led by the department that has the greatest responsibility for the World Bank, concurs in the whole precept that this is an institution that is uniquely fitted for this kind of mission?

    Mr. GEITHNER. Absolutely. You know, the problem we face is that no one can look at the experience of development assistance over the past fifty years and not basically believe there has got to be a better way to do it. Nobody can look at these institutions today and not believe that reform is going to be imperative to deal with the challenges of an evolving world.
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    We are going to take a thoughtful look at all the recommendations of that Commission, and I am sure there will be aspirations we can embrace, and I am sure there will be specific prescriptions that may make some sense. But our focus is going to be on how to make sure that, in the core mandate that is so central to us as a country in promoting development and reducing the risk of financial crises, we are left with institutions that are able to competently address those challenges.

    And we are going to have the obligation, of course, to report to the Congress in 90 days on the specific recommendations in the Commission, and we are going to have an opportunity before your committee on the 23rd, I believe, to try to respond in more detail.

    I think there is no doubt, as I try to say in my remarks, that any effective, credible response to HIV/AIDS or to malaria, TB, or the range of other diseases out there which are so deadly now, is going to have to be based around an effort that will probably inevitably be centered in the Bank to deal with health care delivery systems which are so central to this. That is true not just because of the potential pool of resources that are available, as you put it, with good burden-sharing on a multilateral basis to deal with this problem, but because there is no alternative source of expertise and leverage in focusing political commitment on these challenges and focusing credible efforts to build the kind of health care systems that have to be the core of any effort.

    Chairman LEACH. Good. Thank you, Mr. Secretary.

    Mr. LaFalce.
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    Mr. LAFALCE. We, the Chairman and I, the Republicans and the Democrats are of a common mind, I believe. The question is, how do we get from here to there? What is the best approach? Let me just ask a few questions that trouble me.

    Is utilizing the World Bank the most effective mechanism? Mr. Holbrooke is Ambassador to the United Nations. Would the United Nations, would the World Health Organization be a more effective instrumentality? What should the working relationship be? There are going to be—we can't just have one entity involved in it, to be sure, but are there a multiplicity of efforts that are creating, you know, waste and inefficient delivery of services, and so forth? Why should we not be trying to get the nations of the world to increase more significantly to the United Nations, the World Health Organization, as opposed to the World Bank? I don't argue for that; I posit the question.

    Mr. HOLBROOKE. Let me answer you in broad-brush terms, because a detailed answer is something that requires days and weeks of conferences. This is a war, as we all know. We wouldn't be here today in the Banking Committee discussing a health issue with a State Department official if it weren't. I dare say, Mr. Chairman, that this combination has never been seen before in the Congress: Treasury, White House, and U.N. Ambassador before the Banking Committee talking about a health issue.

    So, what we are dealing with here is a war. Wars have to be fought on every front. I consider it enormously important that Larry Summers and Tim Geithner and their colleagues are fully engaged in this process.

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    As for the U.N., Kofi Annan, who by the way has been a fantastic leader on this issue, the Secretary General of the U.N., who in my view is the best U.N. Secretary General we have had since Dag Hammarskjold, and who is passionate on this issue and has been trying to raise consciousness on it for many, many years, Kofi Annan created UNAIDS precisely because he didn't think the existing bureaucracies were adequate.

    UNAIDS, headed by Peter Piot, who many of you know, who has been with us in New York lately, and many of you came to New York to meet with him, based in Geneva, the man who discovered the Ebola virus, I might add, one of the most distinguished medical researchers in the world, has this organization which in itself is not entirely structured globally. So it is a kind of a coordinating mechanism. And the U.N. can and should do more, and UNICEF has a role. Carol Bellamy feels that UNICEF can do a central role.

    But I am going to be frank with you. There is no single international institutional answer, any more than there is a single U.S. Government answer, any more than there is an African government answer.

    Mr. LAFALCE. I accept that fully. We do what we can do. The Banking Committee has this particular jurisdiction. Let's do what we can do. If others can do their thing in their committee, let them do it and we will support them. That is my position.

    Ms. Thurman, legislation passes, our country makes a contribution, we are now at the World Bank. We have got Country X and Country Y; Country X, 5 percent prevalence rate, Country Y, 2 percent prevalence rate. We can only aid one. Which one do we help, the 5 percent prevalence rate or the 2 percent?
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    Ms. THURMAN. I don't think there is an easy answer to that.

    Mr. LAFALCE. I know.

    Ms. THURMAN. Obviously we have to focus, at this point in time, on our efforts in two areas, and that is to keep prevalence low and look at areas where we think there is very high risk—Senegal was a very good example—see if we can't invest in some primary prevention programs up front to keep the prevalence low. We know that that works.

    At the same time—this can't be sort of an either/or—at the same time we have to do something in the countries that are——

    Mr. LAFALCE. I realize it was an unfair question, because I did posit an either/or, and we can't. We are going to have to do both. I think I should have more artfully asked the question. Where should we put the bulk of our money, our resources, our priorities?

    Ms. THURMAN. I think right this minute that we have to continue to invest the bulk of our priorities in prevention, because that is the only——

    Mr. LAFALCE. That means the 2 percent?

    Ms. THURMAN. Yes, and we have to make sure that we are keeping prevalence low, that we are stopping infection in its tracks. And then, second, I think——
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    Mr. LAFALCE. Is that going to create some difficulties? Might that mean that we would favor India over Africa?

    Ms. THURMAN. No, I don't think so. I mean, again, we have good surveillance to guide us. You know, we know what countries are most at risk, we know where the epidemic is spreading fastest. We know where we have infrastructure, where we think that we can get the best bang for our buck in terms of our investment dollar in prevention, so we have some good guidance on where we know we can have an impact, and I think that is where we need to prioritize first.

    And then, having said that, I think we really have to take a good look at this whole treatment issue. We struggled with this early in the days of the epidemic here in this country, whether we invested in prevention or treatment, but we can't continue to invest only in prevention. We have got to begin to grapple in some meaningful way with this whole treatment issue, with nearly 35 million people infected worldwide, but I think prevention still has to be our first line of defense.

    Mr. LAFALCE. Thank you.

    Mr. Geithner, to what extent should we focus exclusively on AIDS? To what extent should we broaden it for all infectious diseases, giving relative priority to relative need?

    Mr. GEITHNER. I think that is a terribly difficult question, and I don't think I can give you a good answer. I think it is important to recognize that a lot of what you need to do is to design an effective approach on the prevention side for AIDS—and on the treatment front generally—that would probably be applicable and that would probably substantially improve your capacity to address the problems associated with these other equally deadly diseases.
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    So I think that we should focus on the need for resources in basic sciences, on the need for investments in health care systems to make it work, on incentives to promote development by the pharmaceutical industry of vaccines, and on mobilizing resources generally.

    Mr. LAFALCE. Let me be more specific. Does the Administration have a preferred approach, a World Bank AIDS Trust Fund or a World Bank Infectious Diseases Trust Fund?

    Mr. GEITHNER. Well, I think there are two questions in some sense about this issue. One is the particular device we use to try to mobilize the maximum scale of resources from the rest of the world, and a trust fund is one vehicle for doing that. And there is the separate question which you began with: where do you want to place the priority? I think I would defer to Sandy a little bit on how you think about how you tier priorities on health care targets generally.

    I think the challenge we face is how to figure out a way to invest other donors—whose resources are going to be critical in scale to this—in an approach they want to support. A trust fund associated with the Bank is one proven, practical vehicle for doing that. It may, in the end, prove to be the most effective vehicle for doing that, but we want to have the capacity to spend a little more time talking to the other donors and to the World Bank before we commit irrevocably to that specific device.

    Mr. LAFALCE. Ms. Thurman, did you want to add to that? I saw you——
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    Ms. THURMAN. No.

    Mr. LAFALCE. OK. Thank you.

    Thank you very much, Mr. Chairman.

    Chairman LEACH. Thank you, Mr. LaFalce.

    Mr. Frank.

    Mr. FRANK. Thank you, Mr. Chairman.

    I want to get back to the theme of money, because I read in today's Congress Daily a debate that is raging, and we shouldn't pretend that it is not going to have a lot of impact on this, and that is the debate. It says ''Senate Budget Republicans Meet to Set Discretionary Spending Limit.'' There is a debate now as to what the overall spending limit will be.

    And I think we ought to be clear, and I am going to ask you to address this. You are here, obviously, as three responsible officials of this Administration, talking about one very important program, but all of you have multiple responsibilities. Ambassador Holbrooke has the responsibility of getting the U.N. dues paid, and he has done good work on this, and we hope many of us here have worked hard to help that. Ms. Thurman has responsibility for domestic as well as international AIDS programs. And Mr. Geithner has international financial responsibilities that Treasury has in general.
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    The problem is this. I mean, the question the Ranking Minority Member asked is tough, but it is an example of the kind of questions you are all going to have to deal with if we don't get more money into this Federal budget, and that is why I think it was very useful that he did that. No one wants to choose, and the natural instinct is to say we will do both, but we won't do both if the overall budget allocation is too low. If we get to the floor of the House with a budget allocation for foreign operations that is very low, we have a problem.

    And there is one other aspect to this problem. It isn't simply that Mr. Geithner is going to have to choose between relieving the debt of countries in general so they can do poverty programs, or helping with AIDS. The Ambassador would have to decide between U.N. dues backlogs and other important programs, peacekeeping programs, and so forth; AIDS prevention, in effect, as he says, in the peacekeeping. Or Ms. Thurman, it is not just that, but we will run into the worst dilemma that we run into around here, which is efforts to respond to an international humanitarian crisis will be criticized by people who will say, ''But there are Americans going without. There are Americans who can't pay for their AIDS drugs. There are Americans who aren't getting the veterans' medical care they ought to get.''

    And I just want to stress this again: If we do not have adequate funding overall, our ability in the end to vote the kind of funds that are necessary for this program isn't going to be there. And I will say I have no particular expertise about how best to do this. I consider my job to be to try to fight to get the resources to the well-intentioned people who have expertise, both in our Administration and elsewhere.

    But I want to stress it again: It is easy for us all, and I think everybody here was sincere, particularly this group. I mean, if this group was Congress, we would take care of everything and go home in an hour. But when we get to the actual cutting up of the funds, we are going to face this terrible problem.
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    You know, let me ask you, Ms. Thurman, what happens if we substantially increase funds to fight AIDS in Africa and don't provide funds that meet demands for drug programs here? What would you anticipate the reaction will be as far as the people you deal with?

    Ms. THURMAN. Well, we have actually seen increasing support on the part of the AIDS community domestically to support AIDS funding around the world, and I think it is because of a couple of reasons. The first reason is that we only spend—we spend less than 1 percent of all of our AIDS funds on international programming, and we have seen dramatic increases in our domestic AIDS spending, with your help, and we are really glad to see that.

    This is sort of, again, not an either/or situation. First of all, this money comes out of two different pots of money——

    Mr. FRANK. Excuse me, but here is the problem. Stop saying that, because you are wrong, and you are going to give people a false sense of security. ''Senate Budget Republicans Meet to Set Discretionary Spending Limit.'' It is either/or. There is an overall discretionary spending limit that this Congress passed and the President, God knows what he was thinking, signed a bill in 1997 that put an overall limit on Government spending. Fortunately, it was so stupid that even the people who voted for it began to violate it about an hour later.

    But when you get that kind of overall restriction, it becomes either/or, and we should not pretend that it isn't. The problem is, it is too easy to be for cutting Government in general and then be an advocate of this, that and the other good Government program. The whole can't be smaller than the sum of the parts, and we have got to understand that.
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    And what I am trying to say now is, let's not simply advocate increases here. Let's use this as an argument to make sure that we are not into that unfortunate either/or situation.

    Ambassador Holbrooke, you wanted to say something?

    Mr. HOLBROOKE. I think what you have said is of transcending importance, and let me address it from the national security point of view, because Congressman Leach more or less has a lineup here of financial, the issue itself, and I am supposed to wear a national security hat.

    I think what you have said needs to be really thought hard about by you and your colleagues. We have here an undeniable emergency. No one, not even the most hard-hearted triagist, is going to object to the proposition that we are here discussing an emergency.

    If we then get caught inside budgetary ceilings which require us to choose between this issue and other issues of national security importance, and I will just pick the two I have been working on this morning, Mr. Chairman, Kosovo and Congo, where we have major peacekeeping operations and in one case American soldiers at great risk, and both ironically with an AIDS connection, we are going to be forced to make a choice which is against our national security interests.

    We took this issue into the Security Council, and you are here today because we agree it is more than a health issue, so let's say it is a national security issue for the U.S. We have other national security issues. I think what Congressman Frank is saying, and I could not agree more with him, is fundamental: If we are forced to take money out of peacekeeping in order to deal with AIDS in Africa, it is a terrible deal, because there are going to be wars in Africa as a result of that decision which will pull us back in, let alone the fact that AIDS will spread, too.
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    So, Mr. Chairman, I hope that you and your colleagues will find a way to address the core issue. There is a supplemental up for peacekeeping in Kosovo and East Timor and Congo. There is a war that could explode in Central Africa, not only spreading AIDS, but causing great tragedy. We have American and other NATO soldiers at risk in Kosovo. And simply to have to choose between those issues and AIDS, when we are the richest country in the world at the apogee of our wealth, strikes me as a very dangerous thing to do.

    Mr. FRANK. Thank you, Ambassador.

    I will close now, Mr. Chairman. Although I did, on a somewhat unrelated topic, but you did mention the NATO troops in Kosovo. I want to say I will pursue this in another forum, but I am just finding every public opportunity to say it. For the United States Executive Branch to appear to be unhappy, because the Europeans are finally getting together their own defense force is the dumbest single thing I have read all year, and those of us who have been trying to get Europe to pick up some of that burden, I read that article yesterday and it was appalling.

    But, beyond that, I just want to close and say not only do I agree with you with regard to the international aspect, but let's understand the politics of this place in an election year, an important election year, everything up. If it appears that domestic programs, veterans, health, housing, and so forth, prescription drugs for elderly Americans, let's just take that, if people think you can in this country today ignore the need of older Americans for prescription drugs and get the kind of resources we ought to be sending to Africa, I think they are wrong.
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    And one of the smartest things John Kennedy ever said when he talked about Franklin Roosevelt's Good Neighbor policy regarding Latin America was, ''Franklin Roosevelt could be a good neighbor abroad because he was a good neighbor at home.'' And it is very important for us to have adequate resources to deal, at least in a minimal way, with all of these needs. Otherwise, we are going to see a lot of other kind of very sincere rhetoric today wind up with people being frustrated.

    Chairman LEACH. I appreciate the gentleman's comments, and the Chair would like to make just a brief intervention.

    When you have issues before the Congress, not infrequently there are tradeoffs, and not infrequently there are issues that each of us as individual Members think are more important than other issues. But if there is any issue in the world of any kind that should be considered of an emergency dimension beyond all other normal kinds of emergencies, it has to be this one, and I don't think there is any doubt whatsoever that we have a moral obligation to make a difference while we still can.

    Because one of the great questions is, if you lengthen this out, our ability to make a difference will decrease substantially for those who are going to be affected, and those who are going to be affected are high proportions of the world's population. And so to deny a special emergency status and, as Mr. Frank has indicated, to put this in the context of normal tradeoffs, would be irrational. And that doesn't mean that the normal tradeoff approach does not make some reasonable sense in other contexts, but not in this one.

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    The gentleman from Texas.

    Mr. BENTSEN. Thank you, Mr. Chairman, and first of all let me commend you for calling this hearing, and while this may transcend beyond the jurisdiction of this committee, I am glad that this committee is doing this.

    I am relatively new to this issue, but I have to say it is extremely startling to me when you look at the statistics of AIDS in sub-Saharan Africa. Mr. Holbrooke, I think you addressed the point correctly, that this goes beyond—it is a moral issue, but it goes beyond a moral issue. This is, I think in the post-Cold War world this is potentially the biggest foreign policy crisis affecting the United States and the industrialized nations.

    You have a civil war raging in the Congo Republic affecting, what, five or six other nations right now? We now have a large U.N. peacekeeping operation there. If you start to have, if we allow the AIDS epidemic to continue, the economic costs that seem to be associated with that will only make the situation worse, which ultimately will draw in greater peacekeeping troops, will ultimately draw in industrialized nations, possibly even the United States, and that is why I think this is an emergency and should be addressed as such.

    I would say the gentleman from Massachusetts is absolutely correct. I sit on the Budget Committee, and we had a hearing the other day, and we already totaled up an extra $15 or $17 billion that Members want to add to the bill, and we have proven that the whole can be larger than the sum of the parts through some creative bookkeeping, and I would argue that this is truly an emergency.

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    But he is also right that politically, as serious a crisis as this is, it will never fly in an election year compared to domestic concerns that are out there. If it would, you would see more Members here today listening to your testimony, but unfortunately that is not the case at this time, so we are going to have to work much more, much harder on this.

    It is unfortunate that it does not have the same strength that the HIPC proposal and the Jubilee 2000 proposal had. There are groups out doing it. And I would just add, and I don't want to sound critical of the Administration, but I think there are a lot of people who believe that it was the religious organizations in this country pushing the Jubilee 2000 that was far out in front of the Administration on this issue and far out in front of the United States, and pushed, pushed us to the forefront. And since we do in effect lead the G–7, we lead the World Bank, quite frankly, and the IMF, perhaps more so than the Germans would like right now, but nonetheless we do need to take the lead on this.

    Now, I would like to ask particularly Secretary Geithner, the Administration proposes in its 2001 budget, $100 million. Is that in assumption of this trust fund?

    Second of all, I believe Mr. Frank raised, and I was not here when he spoke earlier, the question of whether or not we are tying this in and absorbing some of our efforts in the HIPC program, or do we assume this is in addition to the HIPC program?

    And the third question would be, to what extent do you believe or know that our partners in the World Bank are going to contribute, if the U.S. is successful in getting the World Bank to set up this trust fund and we are successful in getting up to $100 million in annual authorization and funding for it, to what extent will our partners come in with that, or are they ahead of us in that regard?
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    And the final question is, in your testimony you talk about the Administration proposing transferring, multilateral development banks transferring between $400 and $900 million in concessional programs to health programs. Are we robbing Peter to pay Paul in that regard?

    Mr. GEITHNER. I will defer to Sandy on the specific questions concerning the Administration's AIDS requests. I will say in general the following:

    The requests that we have on the table for the debt initiative, the request for HIV/AIDS prevention and treatment, the request for a contribution to the broader vaccine purchase fund that the Global Alliance for Vaccines and Immunization has proposed—are all requests above and beyond the existing concessional resource envelope for development assistance.

    And that is why Congressman Frank's point is so important. Unless we are able to increase the overall envelope of discretionary spending by some prudent level, and unless we can increase the overall envelope for resources to be put into these broad initiatives, then we are not going to be successful.

    It is very hard to tell, I think, where the other donors are going to be at the moment. But it is important to recognize one basic fact: these countries, on the whole, contribute far more to development assistance efforts, far more to poverty reduction in poor countries, far more to this whole range of issues we have discussed today, in per capita terms, than does the United States.
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    Although it is obvious that we cannot bear a disproportionate share of the cost of this kind of thing, their basic view is, ''We would love you to come join us.'' Unless we are able to be credible by putting more resources on the table and getting funding through the Congress, we have no credibility or moral authority with them in trying to get them to come to the table.

    The proposal we put on the table would redirect a substantial part of the concessional resources which the World Bank and other banks lend each year from poverty reduction to basic health care. We believe this proposal can be accommodated relatively easily, within the existing constraints that apply to those resources, for two reasons: One is that we have fought very hard to make sure that these resources go to countries that can use them most effectively. That effort has left some resources available that we can redirect to these countries, resources that are now not spent at the pace they were expected to be spent, that we can redirect to these efforts.

    The other reason is that we think this is all about choices and priorities. We think it is perfectly appropriate for the Bank—and for IDA—to put, at the top of their priorities, basic health care, primary education, and those core development imperatives, and make that the center of what they actually do.

    I think that covers most of your questions, but I would be happy to come back to you on any of them.

    Ms. THURMAN. The President's request for 2001 includes another $100 million, on top of the $100 million that we got last year, to expand our existing programs at CDC, at USAID, and to create new programs at the Department of Defense and the Department of Labor, and to do outreach.
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    Mr. BENTSEN. But it does not envision the trust fund as in the Chairman's bill?

    Ms. THURMAN. No. No, sir.

    Mr. BENTSEN. And my time is up, but were we to enact the Chairman's bill or Ms. Lee's bill, would you then seek an additional $100 million, or would you assume transferring the $100 million of the $200 million you have requested?

    Ms. THURMAN. I think we certainly wouldn't transfer the money that we are currently requesting, so we would have to talk, you know, about additional funding at that point.

    Mr. BENTSEN. Thank you.

    Thank you, Mr. Chairman.

    Chairman LEACH. I think the gentleman has raised this point. If we pass this bill out of this committee, am I right that you will support it?

    Mr. GEITHNER. Can I——

    Chairman LEACH. Is the Congress well ahead of the Administration, or will you actively support if we pass this out?
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    Mr. GEITHNER. I will tell you we will actively support any effort we see as providing a reasonable prospect of increasing the pool of resources available for these objectives, and any effort we think is going to give us the maximum potential of leveraging resources from other donors and other institutions. And I am saying that just because I want to stop just one step short of being specifically committed to the vehicle, just so that we have the capacity to engender the kind of broad support and ownership internationally we need for any of these things to be successful.

    Chairman LEACH. I appreciate that, Mr. Secretary.

    Mrs. Biggert.

    Mrs. BIGGERT. Thank you, Mr. Chairman.

    Is there a way, or have we been able to measure how the monies that we have already given for the AIDS/HIV, that we have really seen—can we measure the results from that?

    Ms. THURMAN. We can. We have been looking at programs, evaluating programs since the very beginning of our investment in the epidemic, both domestically and internationally.

    I think our best example is probably Uganda. With ongoing sustained commitment from the United States and other donors, and the active participation of the Ugandan government, we have been able to cut the rates of infection in half in Uganda in less than ten years. It is probably our best success story. But there are others, like Senegal, which has a very low incidence, and with sustained investment and commitment from both the U.S. and other donors we have been able to keep the infection rates very low.
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    So we have some good data, and I would be happy at any time to share that with you or your staff.

    Mrs. BIGGERT. Then would there also be a way to measure the results of setting up in this bill the trust fund, that we would be able to estimate the increase in results from that also?

    Ms. THURMAN. Yes.

    Mrs. BIGGERT. OK. Just one other question, then. Have the other donors in the international community responded to the crisis? Have they already committed more money, or do we have any way to know, if we put in this amount of money, that they will also respond in kind? And what would be their projected donations?

    Mr. HOLBROOKE. You know, as soon as Vice President Gore made his historic appearance in the Security Council, other nations started coming forward, led by the Japanese. And that goes to a larger issue that so many of us believe, which is that the U.S. cannot do it alone, but the rest of the world will only respond to American leadership. Now, it is up to the Congress to decide the appropriate resources and the ratios, and this is an across-the-board issue. But the short answer to your question is yes.

    And, Mr. Chairman, I would like to add one other point here, because the beginning of your question is so critical. There is one point that the three of us have not sufficiently underlined today because we all had it internalized, but your question triggers it, and that is the issue of whether this is hopeless.
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    Everywhere Sandy and I go, I can't speak for Tim, because he spends a lot of his time on other issues, but everywhere Sandy and I go, we encounter the same line: ''It's hopeless.'' But Uganda, Thailand and Senegal show the contrary. Your charts show the contrary. You have in this room Ambassadors from Africa, Swaziland, Uganda and others, who are here to tell you it isn't hopeless. Triage by continents is obviously not only immoral, it won't work. It is not economic, strategic. It fails on every level.

    But I want to underline this: In the end, the solution must rest with the leadership of each individual country affected. There is a reason Uganda has reduced its rate from 30 percent to 9 percent, while its neighbors went from 9 percent to 30 percent. The reason was a leadership, led by President Museveni, that destigmatized the issue, that spoke frankly and bluntly, in terms which are not always culturally appreciated in this country as well as in Africa, about how the disease is caused and spread.

    Many of the leaders of Africa who wear the same ribbon Sandy is wearing today refuse to be honest about what causes them to be wearing that ribbon. Destigmatization, which means, by the way, that if you get tested positive, you don't lose your job, your family doesn't throw you out on the streets, leadership is essential.

    So our bottom line here today is that resources, in conjunction with the right leadership in Africa, will make a difference. This is not a bottomless pit, and I cannot stress that too highly, Mr. Chairman, because I think in our opening presentations we perhaps inadequately addressed the fact that this is not only an emergency, which we agree, but it is also not hopeless.
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    Chairman LEACH. Thank you very much.

    Mrs. Biggert.

    Mrs. BIGGERT. Thank you, Mr. Chairman.

    Chairman LEACH. Ms. Lee.

    Ms. LEE. Thank you, Mr. Chairman.

    Let me just first say, with reference to the issue that Mr. Frank raised, when I first introduced my bill, H.R. 2765, that was the issue, the debate: Why is this a priority given the huge domestic needs, given the fact that prescription drug coverage, preserving Social Security, domestic aid, housing, all of those issues should be a priority?

    My response, Mr. Chairman and Members, is that here we have a time of unprecedented surpluses, we have an increasing amount going into our military budget, so if we can't do this now, then when? I mean, this is the moment that we need to rise to the occasion and lead the world in addressing this enormous pandemic.

    Let me just say to Ambassador Holbrooke, first of all, I want to acknowledge your leadership in declaring that this is a war, and then bringing it to the Security Council. This truly was the defining moment in raising the level of awareness of this pandemic to the world, and also, just as an African American, I am very proud of that moment and very proud that you did that.
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    You know, given the conflicts that we see on the continent, in Burundi and Sierra Leone and the Congo, we know that many of the young men in the wars in Africa are orphans, and many have been orphaned as a result of AIDS, their parents dying of AIDS. And what I am wondering is, now, given the huge numbers of orphans in the militias and in the military in Africa, have we looked at how we are going to address the whole HIV/AIDS crisis within that population of individuals, or what do we need to know or what do we need to keep in mind, given the fact that this is not one-dimensional, that we do have to deal with the conflicts and the individuals serving in those wars?

    Mr. HOLBROOKE. You have raised an incredibly tricky problem, and before I comment on it, let me acknowledge your own extraordinary role in this. You have been, frankly, way ahead of most of us, and we are in your debt, and praise from you means a lot to us who have arrived more recently on the scene.

    Look, let's be frank about this, and use some of the real words and realities of the region which are rarely mentioned in the Congress or the Security Council. The highest male spreaders of this disease in Africa are the police and the military. The pattern of infection is the reverse of what people think it is, because the higher the rank, the more likely they are to be infected, because they have money which gives them access to prostitutes.

    When you are putting together a peacekeeping force—I am not addressing your orphans point, because I think the orphan cohort is still too young to be a factor here. The orphans with AIDS, or AIDS orphans, kids who have been orphaned because their parents died of AIDS, are not yet of military age, but of course in five to ten years you are going to have this. But they are not going to get in the military anyway. The military is an elite organization with a job. This is worse that this. The orphans are one problem; the military is another.
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    But I am profoundly worried, Mr. Chairman, by the fact that the governmental structures in many countries in Africa are very reluctant to pursue or encourage testing, voluntary testing, because if people test positive, they are going to be ostracized, dead men walking, dead women walking, and their deployment in peacekeeping operations will be similarly circumscribed. You know the United States Government policy is that if a person in the military tests HIV positive, that person will be treated, but not deployed overseas. That seems to me a correct policy, but African countries are not likely to do it, and when you are filling up a 5,500-person peacekeeping operation in Congo, that is an extra problem.

    On your problem on orphans, Sandy and I have both had the same vivid experiences I know you have and others of your colleagues, which is that the orphan population as it grows is also unemployed, undereducated, and very vulnerable to becoming themselves, if they are not already HIV positive, very vulnerable to either spreading it or it being spread to them. We saw, my delegation saw really heart-wrenching scenes in Kampala and Lusaka, of orphanages which didn't have enough room for the night for the kids, so they were going right out on the streets and sleeping in the gutters, and that has to be dealt with.

    One point that needs to be asserted here in terms of cost effectiveness and breaking this iron chain, Mr. Chairman, is that if you look at the chain of how the disease is spread, some parts of approaching it are really tough, but one area is really quite easy to define, and that is the mother-to-infant line. If women who are HIV-positive don't breast feed, you will immediately cut the rate in that transmission belt by over 50 percent. But Sandy and I have both seen clinics, including some of the best clinics in the world, the ones in Uganda, where even there the women are still reluctant to be tested.
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    So I want to be clear, we are here to raise the alarm, but there are practical ways to cut into it. Mother-child transmission at the point of birth, through breast feeding, is really within reach and simple, and here efforts like those you are considering funding can be directly applied to the problem.

    Ms. THURMAN. May I add to that, Mr. Chairman?

    Chairman LEACH. Of course.

    Ms. THURMAN. I wanted to just talk a little bit about this whole military issue, and why we think it is so important that we have requested $10 million in the President's 2001 request to do military-to-military training and other kinds of activities. Because we need to address, number one, the issue of HIV infection in the military in Africa and elsewhere, but also to use that infrastructure, which is stronger in many African nations than any other infrastructure, as a vehicle to provide both education for prevention purposes and some basic treatment. So I think it is really important that we focus some much-needed attention in that area.

    Ms. LEE. May I, Mr. Chairman?

    Chairman LEACH. Yes, please, Ms. Lee.

    Ms. LEE. Thank you very much, Mr. Chairman. Let me ask, well, let me just say to Sandy Thurman, I want to thank you for being the lone voice oftentimes on this issue. And I did have the privilege to participate with Sandy and her delegation last year, and we looked at the whole orphan crisis in southern Africa, and it was staggering. And I think, because of your leadership now we are seeing some light. Thank you, Sandy. Let me ask Mr.—is it Geithner?
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    Mr. GEITHNER. You got it.

    Ms. LEE. The question with regard to the whole issue of debt relief and emergency health funding. Of course, you know, oftentimes we think of the World Bank as it relates to the developing world as a debtor, and we are trying to say no more debt. We want debt relief. We know what that has done to our countries. How do you envision any type of either emergency funding or any new efforts with the World Bank, and how do we ensure that this is debt-free money, and that the countries which badly need these resources don't get somehow encumbered by additional debt?

    Mr. GEITHNER. I think that is a very good point. The concessional lending windows of the World Bank and the other banks lend at highly concessional rates. It is roughly 85 percent grant-financed. If you lend money, if you lend at these highly concessional rates, mostly grant-financed, to countries that can prove they can use the resources effectively, there is relatively little risk that that will create a problem down the road which will make their financial situation unsustainable.

    One way to reduce that risk is to make sure that we move quickly now to reduce the debts they now owe to both the Bank and the IMF, and to the other bilateral creditors. So I think if you do both together, and you try to make sure that the assistance you provide has as much grant element as possible, you can help reduce that risk.

    Ms. LEE. So the World Bank understands that we don't want to see another loan?
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    Mr. GEITHNER. The World Bank's capacity to provide grant finance is constrained by what countries like the United States and other donors are willing to give the Bank. So what the Bank does is try to maximize the grant element, minimize the loan element, and get as many resources as can be prudently used. But the only way you can eliminate even the small amount of credit in these, what are largely grants, is to put more resources on the table.

    Ms. LEE. Thank you very much, Mr. Geithner.

    Chairman LEACH. Thank you very much, Ms. Lee.

    Ms. Schakowsky.

    Ms. SCHAKOWSKY. Thank you, Mr. Chairman, and thank you for your passionate leadership on this issue. I am happy to join you as a co-sponsor of H.R. 3519, as I am now a co-sponsor, and have been, of H.R. 2765, sponsored by Representative Lee.

    I wanted to make a special and public thank you, Ambassador Holbrooke, to you for inviting me to join you when the United Nations considered for the first time the international AIDS crisis, and to be there with Vice President Gore as he chaired that Security Council meeting. And let me thank the other panelists as well, Sandy Thurman, and Secretary Geithner, for your long-standing work on this issue as well.

    At that Security Council meeting there were representatives from countries heavily impacted by AIDS, who talked about what Senator Kerry mentioned today, that we spent $250 billion to prevent devastation by the Y2K bug and seem to have successfully done that, and yet there is so little being contributed to this, what the Chairman has called a crisis in a class by itself, which it really is, this AIDS pandemic. And even the money that we are talking about today, we know really is a drop in the bucket in what is needed to address this crisis.
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    But I am concerned that there are other players, and I have raised this endlessly at various meetings, and I want to talk about the role of, and I hope it has finally been clarified, of the pharmaceutical companies, and what in the past I believe has been the United States conspiring in some ways with the pharmaceutical companies, to keep them out of countries that need them at a reasonable price by invoking the WTO and TRIPS agreement and saying that it is a violation of intellectual property. That is one.

    And let me just say that while I was happy that the President announced at the Seattle conference in Washington on December 1st that the United States would no longer stand in the way of cheaper medications for AIDS victims, but still in January, according to Newsweek, this is their web exclusive, so why in late January was the Administration still pursuing its hard-line policy of protecting corporate patents in Thailand, one of the worst-hit AIDS countries?

    A few days after the U.N. appearance on January 14th, an official with the U.S. Trade Representatives reminded the Thais that they could face U.S. trade sanctions if they issued a compulsory license to manufacture a drug called DDI which fends off full-blown AIDS. I know that a correcting letter has now been sent to say that the Thais could in fact produce this drug, but I wonder, do we have two operations going on here, or is there consistency now that we will do everything to assure that those drugs get there? That is one.

    I want to say one other thing. The United States Government itself holds patents on some AIDS drugs. And I wrote a letter to the President on October 14th, have not received an answer, requesting—and this was actually co-signed by Representatives Lee, Maxine Waters, Jesse Jackson, Jr.—requesting that the U.S. use existing authority to give the World Health Organization the right to use HIV/AIDS patents where the United States Government has rights to those inventions. And we do have, on a number of these AIDS drugs. Are we doing anything to make those drugs, on which we hold the patents, available around the world? Those are my two questions.
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    Ms. THURMAN. Well, first on the issue of consistency around TRIPS and how we engage with developing nations who want to do either compulsory licensing or parallel importing, I think we are consistent and that what the President said in Washington holds true today. There certainly was that issue in Thailand. As you said, a letter has been sent. But I think people are much clearer that we want to do every single thing possible to get drugs to people who need them, and I think everyone is committed to that.

    Second, I know that HHS and WHO have been engaged in doing a feasibility study around this issue of patents that are for drugs developed with U.S. support. I haven't talked with them about that in the last few weeks about that. I don't know exactly where their feasibility study stands or when it is due to be released, but I will make sure that I speak with them when I get back this afternoon and get right back to you with an update on exactly where they are. But they are engaged in the process of a feasibility study to see if we can't move those drugs.

    Ms. SCHAKOWSKY. Let me just conclude by saying, you know, the Vice President's office intervened on the Thailand issue to get a clarifying letter. It should not have to be, though, that we are fighting among ourselves, and I hope that we are not going to see any future situations where the speedy production of these drugs—and I understand there is infrastructure that needs to be there to deliver these drugs, but we could save lives, and we don't want to be in any way complicit in efforts to do anything but that.

    Ms. THURMAN. I couldn't agree with you more.

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    Ms. SCHAKOWSKY. I know that. Thank you.

    Chairman LEACH. Well, thank you very much, Ms. Schakowsky.

    Ms. Carson. No questions?

    Well, let me just then conclude by thanking the panel. I will say that the United States of America has been well served by an ambassador of the United Nations who has taken on this cause, by a member of the White House staff who has given a great effort, and by the United States Treasury. And I want to thank you, Tim. This is an issue that has to be considered in a bipartisan basis and with as much Executive-Legislative cooperation as possible. Thank you all.

    Mr. GEITHNER. Thank you very much.

    Chairman LEACH. Our third panel is composed of Ms. Mary Fisher, who is the founder and Chair of the Family AIDS Network. Ms. Fisher is well known to most of us, particularly Members on the Republican side of the aisle, and has long been a courageous champion on behalf of those suffering from HIV/AIDS. The foundation which she chairs has undertaken initiatives to teach AIDS prevention and care among women and children and in communities of color. Ms. Fisher also serves on several other boards, including the Harvard AIDS Institute and the Betty Ford Center. We are particularly honored that she is accompanied today by our former colleague, Steve Gunderson, who was a Member of Congress who we have held in the highest regard.

    Our second witness is Ms. Mpule Kwelagobe from Botswana, who carries a title of Miss Universe 1999. She is a spokesperson for AIDS issues and is active in AMFAR, which means the Americans for AIDS Research; Hale House, a home for children born with HIV and drug addiction; and God's Love We Deliver, an organization that provides meals for home-bound AIDS patients. She is also working with the Harvard AIDS Institute, and in that capacity assisted in the opening of a research lab in her home country of Botswana.
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    Our third witness in the panel is Her Excellency Mary M. Kanya, Ambassador to the United States from the Kingdom of Swaziland, a country bordered by South Africa and Mozambique. Although Swaziland is a small country, it has been hit particularly hard by the HIV/AIDS epidemic. We are honored that Ambassador Kanya has joined us today, and hope to learn much from her about the impact the disease is having and what can be done to curb it.

    We will begin with Ms. Fisher.


    Ms. FISHER. Chairman Leach, esteemed Members of the committee, I was honored by your invitation and I am grateful for this moment of your time. Let me say to you, Mr. Chairman, that I am proud, as a Republican, that you have shown the courage to hold a hearing which may discomfort some of us.

    You are meeting at an unusual moment in the AIDS epidemic. Despite 40,000 new infections of HIV each year in America, funding for AIDS prevention appears to be yesterday's concern. A word search through campaign speeches and literature of our party's presumptive Presidential nominee, George W. Bush, cannot turn up the word AIDS. Congress stalls at reauthorizing the Ryan White Act. Contributions from philanthropies and corporations have fallen off, and where once there were headlines, we now have quiet obituaries.

    In the USAIDS has gone underground in communities of poverty and color, communities of youth and women. It has gone the same place globally, to those people who have the least social standing and the fewest economic resources, typically the young, and always the women.
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    In January, I visited four African nations with National AIDS Policy Director Sandy Thurman and others. I stood with the grandmother that Sandy spoke about, raising her orphaned grandchildren. Where once she had a garden next to her home, now she has a graveyard. Grave after grave, she lined them up as she buried her children one-by-one as they fell to AIDS. In Rwanda, the genocide of 1994 left a legacy of AIDS. A full 60 percent of those who survived torture and rape were left HIV positive. When the killing was over, 100 doctors were left to care for the nation's 7 million people.

    But what dominates the African landscape is orphans. Acres of orphans, orphans raising orphans, because there is no one else left to do it. Tough children take to the streets. Weak children die of starvation. Seeing the orphans, thinking of my sons, Max and Zachary, I barely heard the local government leader. I said, ''I'm sorry, what did you say?'' and he said again, ''I would like your advice, Ms. Fisher. If we should somehow get the money, do we put the orphans through school, or do we feed them?'' It was my stunning inability to respond that fueled my desire to be with you today.

    I have labored for nearly a decade with the label ''the lady who told the 1992 Republican convention that she has AIDS.'' They remember it, because they were surprised. Some of them didn't know women could get AIDS. Some of them didn't believe Republicans could. Neither belief is any sillier than today's commonplace belief that AIDS in Africa or Asia can be kept out of the United States.

    I want not to be harsh, but I must tell you that I cannot risk being too sweet or too mild, or I risk going to my own grave with an unquenchable guilt. So if anything that follows seems harsh, please forgive me.
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    If the purpose of this legislation, or this hearing, is simply to justify a claim of openness or a show of compassion, you must stop. Such theater simply raises false hope among those crying for hope. There is no reason to taunt the AIDS community, in America or in Africa, with false hope.

    The most significant impact of this legislation might be the message it sends. It would signal our recognition that AIDS is devastating not only populations, but whole economies. This is why your committee and the World Bank are appropriate arenas to be discussing AIDS today.

    In the written testimony I will leave with you, Mr. Chairman, I offer additional suggestions regarding actions that could be taken immediately and would have a vast positive impact. I will not trouble you with each of them now, and if there were a theme to my suggestions, it is this: Government cannot win the war against AIDS, and the war cannot be won without government.

    I realize that Americans hate death. We like to deny our own mortality and defeat every evidence of death among those we love. And if we can't defeat death, then Americans conclude that there is nothing we can do.

    If we want to help fight AIDS in Africa, we need to confront death. Some of our best options will be helping people die with greater comfort. Given science, this is the best that we can do today. Given morality, this is the least. And we, all of us, need to be willing to do what we have not done before.
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    I have learned that speeches without research saves no lives, and the solution for AIDS cannot be waiting for a vaccine. To accept that premise is to consign 33 million people, and probably more like 50 or 100 million people, to a death sentence, because we are already infected.

    I came home from Africa in January with photographs of the women I had visited, but I don't wake in the night to my photo album. I wake to the sound of a Rwandan woman's voice. Like me, she is a mother, and like me, she has AIDS. We embraced and told each other the truth: We are sisters. Her final words to me were, ''What shall I hope for, Mary?'' I did not know what to tell her.

    If you would act with courage and compassion, I could answer her question. I could become your messenger to women in Africa, your Ambassador of compassion. And I could tell my own children that the virus is powerful, and that illness and death do haunt us all, but those with the power are doing all in their power to give us life and hope.

    In all your wrestling with these issues, and all of your considerations, I assure you of my appreciation. I pray that you will be sustained to do that which the Judge of us all would have us do. To that end, ''Grace to you, and peace.''

    Chairman LEACH. Well, thank you very much for that very thoughtful statement.

    Ms. Kwelagobe.
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    Ms. KWELAGOBE. Thank you, Mr. Chairman. I am from Botswana, one of the countries in sub-Saharan Africa that is hard-hit with AIDS, and I have seen first-hand over the past couple of years, and more importantly over the past year, the terrible toll that this pandemic has taken on my country: the loss of lives, the massive social and economic disruptions, an entire generation that has been robbed of its future, and the thousands of children that have been orphaned. I speak without exaggeration.

    According to the World Health Organization, one in every four people in Botswana between the age of 15 and 49 are HIV positive. Over 43,000 people have already died. Twenty-eight thousand children have been orphaned. Right now, approximately 40 percent of all pregnant women in Botswana are infected with HIV. A staggering 70 percent of their children will not live past the age of two, because they will contract the disease from their mother during pregnancy or breast feeding. Simply put, AIDS is destroying my country, and much of sub-Saharan Africa.

    The reasons why the AIDS pandemic has spread so quickly across Botswana over the past years are still very complicated to me. To start with, it is a cultural taboo for women, who have been considered to be second-class citizens, to ask men questions about their sex lives or even request our partners to use protective methods to stop the spread of sexually transmitted diseases, even when they know their partners have been promiscuous. Making this worse, our culture promotes polygamy, which thus elevates promiscuity. And poverty and lack of educational and recreational programs has driven young women into the arms of older men.
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    There are other reasons, too. A code of silence surrounds sex and HIV. Parents feel embarrassed to talk openly with their children about sexual activity, and teenagers do not talk about this topic for fear of upsetting their elders. As a result, children grow up without a basic understanding of the facts of AIDS, and when they are confronted with the challenges, they have no one to turn to for advice.

    This lack of education about HIV is even worse in the rural areas, where some people believe that AIDS and HIV is witchcraft, and that people that are HIV positive are possessed by evil spirits, and that women are using witchcraft to curse men. And still the stigma that is attached to HIV and AIDS in Africa is terrible. Can we all forget Gugu Dlamini of South Africa, who was stoned to death just about a year or two ago by people of her own community for coming out about her HIV status?

    In this time of darkness, Botswana has emerged as a beacon of light for the sick and, I think, an example to our neighboring countries. Instead of denying our problem, the government of Botswana has shown courage and leadership by directly confronting this crisis. Politicians and civic leaders are speaking out. Artists, musicians and entertainers are working to raise awareness. There is a surge of activism and concern throughout our country.

    I will just share with you a few noteworthy programs that are saving lives and giving us hope for a better tomorrow in Botswana:

    The Botswana-Harvard HIV Reference Laboratory, which has opened just last month, is a state-of-the-art facility which is devoted to studying the HIV–1C subtype along with methods to prevent the transmission of HIV from mother to child. This is the first laboratory of its kind in sub-Saharan Africa that is actually devoted to studying the 1C subtype which is found in sub-Saharan Africa.
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    The covenant which was signed between the Botswana National Youth Council, the Minister of Health, the government, the AIDS/STD Unit, churches, music groups, and myself as a representative of the young people of Botswana, which is an educational initiative which encourages teenagers to first and foremost abstain from sex and alcohol, and stay monogamous if they are in a relationship, and still use protection.

    The Community Home-Based Care System, an outreach program for those who are terminally ill and want to stay with their families instead of a in a hospital or a hospice.

    And my children's center, the Mpule Kwelagobe Children's Center, which is a haven for 420 children that have been infected or affected by HIV and AIDS, and this is run by the Minister of Health in Botswana.

    While I am proud of what we are doing in Botswana, the truth is we are still standing at a pivotal moment in time. We need the support of the international community if we are to turn the tide in the war against HIV and AIDS, and make this disease nothing more than a sad and distant memory.

    With the assistance of a nation like America, we can expand educational and behavioral modification programs. We can make sure that pregnant women with the disease receive AZT so that they stop mother-to-child transmission. This is one such area where Botswana has been an example, being one of the first countries to offer AZT to every pregnant woman in Botswana who tests HIV positive.

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    We can fund important pilot programs that identify other promising drugs for pregnant women with HIV, like zidovudine and nevirapine, which in clinical trials reduced the transmission by 50 percent or more. Perhaps most important of all, scientists can race faster toward finding a vaccine, which would strike at the roots of the virus, protecting the uninfected.

    This is just the beginning of what we could do with the help of our friends around the world.

    It is human nature to forget the trials of others, especially when those who are suffering are strangers on the other side of the world. Can we forget the Rwandan genocide? But I will never forget what I have seen, the children who have been orphaned, the women who have been widowed and some who have been abandoned, the empty eyes of young people in our hospitals and hospices, and the funerals that are constantly taking place every single weekend.

    I hope that you, too, will not forget what you have heard, and remember the plight of my people by making the World Bank AIDS Prevention Trust Fund a reality. The United Nations Population Fund, which I am pleased to serve as its Goodwill Ambassador, has been an important force for HIV/AIDS prevention in my country and in other areas across Africa. The United Nations Population Fund works closely with the World Bank, the World Health Organization, UNICEF and others to prevent the spread of HIV and AIDS.

    As Goodwill Ambassador of the United National Population Fund, I would like to take this opportunity to thank you, Mr. Chairman, and the entire Congress for restoring U.S. contributions to the United Nations Population Fund for fiscal year 2000. I have witnessed some of the programs that are run by the United Nations Population Fund in Botswana, one of which is called PACT, which stands for Peer Approach to Counseling for Teenagers, which I was a member of since the age of 14 and which has been very effective in our schools throughout the country.
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    I pray that you will find it within your hearts to lend a helping hand to those who are trying to pick themselves up and build a new life. By doing so, you will give the greatest gift of all, the hope for a better tomorrow.

    Thank you for giving me the opportunity to be here and to speak for those who have been silenced by AIDS. Thank you.

    Chairman LEACH. Well, thank you very much for that thoughtful testimony.

    Ambassador Kanya.


    Ambassador KANYA. Honorable Chairman Leach——

    Chairman LEACH. Excuse me. If I could interrupt for a second, if you would pull the microphone very close, I think you will find that it allows people in the back to hear you better. Can you just pull the whole mike up as close as you can?

    Ambassador KANYA. Honorable Chairman Leach, I would like to thank you for having invited me to speak on the impact of the HIV/AIDS crisis on the poorest nations of the world, particularly in the hard-hit sub-Saharan Africa. May I congratulate you on bringing this topic to the table.
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    In my submission I would like to dispel the misconception that African leadership is not committed, that Africans are still in denial, and that Africans are not helping themselves. You have already heard about the progress which has been made in Uganda, Senegal and other countries. These successes I am sure would not have come by if there were no political commitment.

    The statistics that you have just heard to us are just not figures. We see the negative impact that the epidemic is having on our society. We personally experience it. Those statistics represent people we know: the teacher, the banker, the engineer and the politician, who have to teach our young, move our economy and community forward. How can we then not care?

    What do we do? We do what is within our very limited resources that are available to our countries and our people. It will take a long time, though, to see the reversal in the severity of the epidemic, because all the causes that fuel the AIDS epidemic are not yet fully understood. This does not just apply to us as Africans. This virus respects no borders. It travels easily throughout our global village.

    What are the African countries doing? Let me give you a glimpse of what some countries are doing, either individually or as subregional groups. I am best able to speak about southern Africa, the southern African parts, where five countries with the sub-Saharan Africa's highest HIV infection rates are very high, including my own country, Swaziland.

    Swaziland is a very small country, the size of New Jersey, and with a population of 970,000 people, but this country has an incidence of 22 percent. Eighty percent of inpatients in our major hospitals are HIV-positive. Thirty percent of pregnant women who attend prenatal clinics test HIV positive. About 60 percent HIV infection occur amongst those 20 to 39 years old. Almost 18 percent of all university students are infected with HIV/AIDS. I have seen the graduate that graduated yesterday, and there was so much jubilation, and two days later that graduate was buried.
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    The literacy rate is being reduced. At independence, the literacy rate in Swaziland was 31 percent, but over the years this has risen to 78 percent, but with the HIV/AIDS this is going to be dramatically reduced. The life expectancy has been reduced by twenty years.

    As a result of the above statistics, His Majesty King Mswati III of Swaziland, in opening Parliament in February 1999, declared HIV/AIDS a national disaster. He further said, if I can quote: ''The HIV/AIDS epidemic is an unacceptable situation, whose real effects will be felt only in the coming years as more and more of the economically active fall to the disease, and more and more medical effort and resources are diverted to treating the effects. I appeal once more to everyone to take warning and to understand that each and every one of us is at risk. This is already a national disaster and requires a truly national effort to bring about a complete reversal in attitude and behavior.''

    Zimbabwe has passed into law a new tax, a 3 percent tax on money earned by individuals and corporations, to pay for AIDS health care costs. Botswana, you have already heard the story of Botswana. In Botswana, a National AIDS Coordinating Agency has been created which is headed by a permanent secretary, and this committee reports directly to a committee headed by the president himself.

    This goes to show that all the political leaders in the SADC, Southern African Development Community, are fully committed to address the HIV/AIDS within the resources at their disposal. They are in the process of developing coordinated national action plans focusing on prevention, care, support of the person infected with the HIV/AIDS.

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    Although it is culturally the norm that orphans are taken care of by the community, the extremely high numbers of orphans projected over the next few years will require that we consider alternatives such as children's homes supported through public-private contributions.

    Our scientists in the region are looking at the use of drugs such as AZT and nevirapine to prevent the transmission of HIV/AIDS from mother to child.

    With regard to addressing the issue of the unaffordability of many drugs needed to treat our people even for sexually transmitted diseases and opportunistic infections, South Africa has passed a law allowing it to import cheaper drugs. Unfortunately, the pharmaceutical industry has decided to put profit before the people.

    Our health ministries—SADC—have undertaken to strengthen the health services infrastructures to support persons with HIV/AIDS.

    SADC is participating with the International Labor Organization to implement a Code of Conduct in the workplace to protect the rights of workers with HIV/AIDS. This will be in support of legislation that some countries have already passed to outlaw discrimination in the workplace.

    There are many more examples that I can cite. We therefore welcome the various forms of assistance that better resourced governments like the U.S. and other organizations can provide to us.

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    How can you assist us? As the Congresswoman pointed out the proverb, we as African countries have got this poisonous snake in our house; please help us kill it before it kills us all. We would like you to share your skills, knowledge and best practices, allowing us to adapt them to our needs. Support us in strengthening our health care delivery systems.

    Treatment should not be forgotten in the rush to support prevention efforts. We therefore request you to assist us to get affordably priced drugs from the pharmaceutical companies.

    It is also heartening to note that a number of initiatives that involve the U.S. Government, the legislators, and pharmaceutical industries and NGOs with sub-Saharan Africa have been launched. Examples of these are the announcements which were made by the Honorable Vice President during the U.N. Security Council in January. In the pharmaceutical industry we have Bristol Myers-Squibb, which has paved the way for other companies through its program which will provide $100 million over the next five years to countries in southern Africa, including Botswana and Swaziland.

    We are grateful for the initiative that has been taken by Congresswoman Lee, and we also support the World Bank AIDS Prevention Trust Fund Act. We appreciate work that has been done by the NGOs such as Africare, Constituency for Africa, and others that have kept this on the agenda.

    May I end at this stage and thank you very much for the opportunity that you have given us to talk about this.

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    Chairman LEACH. Thank you, Ambassador Kanya, and before turning to Ms. Lee, let me just stress that it is not unprecedented, but it is very unusual for a representative of a foreign government to address a committee of the Congress. We are very appreciative that you have chosen to do so, and we welcome you in the spirit of as much cooperation as we humanly can.

    Ambassador KANYA. Thank you.

    Chairman LEACH. Ms. Lee.

    Ms. LEE. Thank you very much, Mr. Chairman.

    First, I would like to ask for unanimous consent to insert into the record written testimony of a great actor and human rights activist, Danny Glover, whose brother also has been living with the virus for the last ten years.

    Chairman LEACH. Without objection. Let me say to the lady I have read Mr. Glover's testimony. It is a very moving testimony, and without objection, it will be placed in the record.

    And I would also then ask unanimous consent that the testimony of Kenneth E. Weg, who is the Vice Chairman of Bristol Myers-Squibb Company, also be place in the record.

    Ms. LEE. Thank you very much.

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    Chairman LEACH. Without objection, so ordered.

    Please proceed.

    Ms. LEE. Thank you. Let me just say to all three of my sisters, thank you very much for your very articulate testimony. I believe the three of you cut through in terms of what the issues really are and what we are dealing with in Africa.

    Let me just ask you a question, and any of you can respond to this, with regard to the issue of women's empowerment and what are some of the strategies that we need to look at and focus on. We talked a little bit about the AZT and the issue of mother-to-child transmission of the virus, but we need to hear a little bit more about what some of the issues are that women are dealing with in Africa that present impediments to moving forward in attacking this crisis the way it should be attacked.

    Ms. FISHER. I can only speak for what I saw there when I was visiting. There are society barriers, the mores of many of the villagers, some of the practices that you spoke of when you talk about polygamy. There is wife inheritance, there is so many things, and the biggest of which is, ''We don't talk about this because we don't talk about sex.'' So religion is a barrier, as well.

    And what we were trying to do while we were there, and I would then defer to my sisters here, is to let the government know and to let anybody that was in any position of visibility or power, to talk about this disease and to make it safer for people to talk about it. Destigmatizing AIDs is the biggest issue that—well, besides, I mean, you know, there is the prevention problem and everything else—but the destigmatization is a major problem.
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    Ms. KWELAGOBE. I would definitely add onto what Mary Fisher said. Really I think in order for us in Africa to win this war against HIV and AIDS, we have to put religion and culture aside, because I think currently we are putting them forward. And like I said when I was giving my talk, where polygamy has always been viewed as a virtue, so I would definitely say that, you know, culture and religion, they are really holding everybody down, but more women, because it seemed as if for a while women were second class citizens who were not really meant to speak out about this.

    And I think another thing which we need to do in order to win this war, in going into Africa, taking for example the program that I said is sponsored by the United Nations Population Fund, called PACT, what PACT did is, they took young people out of a school, went to teach them about youth-related problems and how to be positive role models, and then put them back into their communities and schools, because they believe that those people could be more effective than if people from the outside came inside to try and address the issue.

    So possibly what needs to be done is that women who are strong in these countries need to be identified, and these are the women that need to go into their own countries and speak about it, because they will be more received than if somebody from the outside came in to speak about this.

    Ambassador KANYA. I just wanted to add that culture plays an important part. We do need assistance, we do need education, but when this is done, let us approach it bearing in mind the culture.

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    Somebody has just spoken about breast feeding. Over so many years we have been calling for people to breast feed, and suddenly if you tell people to stop breast feeding, that would cause a problem. We really need education. We really need to share with other countries where there has been a success in approaching the problem.

    Ms. LEE. Well, let me ask you, then, in putting together for instance a bill, a piece of legislation, when we talk about initiatives for women's empowerment, how is that perceived from a cultural point of view in Africa? I mean, is women's empowerment a strategy that we would want to see as an AIDS prevention strategy, and is that acceptable in legislative form?

    Ambassador KANYA. I guess it would be acceptable. We are opening now—it has been accepted that now women have a role to play in society, and the legislation would really be accepted.

    Ms. KWELAGOBE. Yes, definitely I would agree with that. I think it would be accepted that, as we are going into the 21st century, we women in Africa realize that we also have our responsibility to play. And definitely the reason why HIV has been so high amongst women is because they have been so dependent on men, and with the empowerment of women, and women being educated and having jobs and being able to bring in a means of income for themselves, I think definitely this is one of the ways of trying to win this war against HIV and AIDS.

    Ms. LEE. Thank you very much.

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    Chairman LEACH. Well, thank you very much, Ms. Lee.

    Ms. Schakowsky.

    Ms. SCHAKOWSKY. Ambassador, you had something else you wanted to say. Why don't you go ahead and say it?

    Ambassador KANYA. I just wanted to say we have been very successful in our immunization program, and this was pushed by the women. And if you bring in the woman to play the role, then we shall see this war against HIV/AIDs moving forward.

    Ms. SCHAKOWSKY. I wanted to thank all of you for your very moving testimony. Mary, I read yours. I wasn't here when you gave it, and I don't know if you read this part or said this, that ''This is one of the final speeches I will give on behalf of the Family AIDS Network, the organization I founded in 1992. We are closing our doors at the end of this month, based on our recognition that we are failing at AIDS awareness and education. We have lost that fight here in the U.S. The silence, the myths and the denial have won. But I can assure you that I am not giving up the fight.''

    That is a pretty pessimistic view, and I am not contradicting it. I wanted to get you to elaborate a little bit on that, why you think that we have lost that battle, and what we as a Congress then need to be doing, even aside from what we may be talking about today.

    Ms. FISHER. What we have found with my organization is that we have to address AIDS where it stands each year. Each year we have asked ''What is the face of AIDS now?'' The face of AIDS today is that it is more important for us to have the research than to have people out there doing awareness. We are aware of the disease, we know that it is there, and we are complacent.
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    Well, that is hard. It is very difficult to get the media to keep writing about it. It is very difficult to tell a different story. The group that is highly infected in the United States right now are women and people of color, and these are groups that have no voice, so they are not out there screaming about it.

    The biggest thing that we can all do is to keep talking about it, to keep it in the front as a priority for our country, for Africa, for other countries around the world. I will focus my attention wherever I am needed to bring this out. I will be raising funds for research.

    I myself will not stop, but my organization has been—I am transferring it to the University of Alabama at Birmingham so that I can directly serve research, because I think that is where we need to be. We need to be able to keep people alive longer. We need to be able to have outcomes research. And all of this is done with our partners in Africa as well.

    So I am trying to make it more direct, and it is not hopeless, it is just that I want somehow to be able to say to you, please take care of those of us who are infected. Yes, we know we need a vaccine, but that is not going to be here for another ten years or whenever. In the meantime, we will have millions and millions and millions more people die.

    Ms. SCHAKOWSKY. But we still do need to continue to educate our young people about the threat of AIDS, don't we, here and around the world?

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    Ms. FISHER. Oh, absolutely, we need to educate, but we need to do it in a different way now. Today, AIDS education is like running into brick walls. We need Congress to say it is OK to talk about it, it is OK to go into the schools, it is OK to go everywhere to do it. We need people that have the opportunity and have the bully pulpit to say that it is OK, to destigmatize it here as well as in Africa.

    Ms. SCHAKOWSKY. Thank you, all of you.

    Chairman LEACH. Well, let me thank you all very much for the eloquent testimony of three extraordinarily impressive women. Thank you.

    Our fourth panel consists of Dr. James Sherry, who is the Director for Programme Development and Coordination of the Joint U.N. Programme on AIDS in Geneva, Switzerland. Dr. Sherry received doctoral degrees in biochemistry from Mellon Institute of Carnegie Mellon University, and in medicine from the University of Michigan. During his career, he has worked for USAID and UNICEF, and in an earlier incarnation as Chief of Staff for Congressman Sander Levin. We very much appreciate the effort he has made to be here and give us a critical multilateral perspective on strategies to fight AIDS.

    Our second witness on this panel will be Dr. Gary Slutkin, who is Professor of Epidemiology and International Health at the University of Illinois School of Public Health. Dr. Slutkin was formerly Chief of Prevention for the World Health Organization's Global Program on AIDS, and in the early 1980's was the Medical Director for TB control in San Francisco. During Dr. Slutkin's seven-year tenure with WHO, he assisted the AIDS control programs in a number of African countries, including the now renowned success story of Uganda.
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    Our third witness is Dr. Catherine Wilfert, who is the Scientific Director for the Elizabeth Glaser Pediatric AIDS Foundation. The Honorary Chairs of the Foundation's Executive Advisory Board are the former President and Mrs. Ronald Reagan, and board members range from Mrs. Kitty Dukakis to Mike Leisner to Mrs. William Brock. Dr. Wilfert has had a distinguished career in the area of research into infectious diseases, and is currently Professor of Pediatrics and Microbiology at the Duke University Medical School.

    Our fourth expert witness, I am not sure he is yet with us, is Dr. Thomas Welty, who is a medical epidemiologist and a member of the Cameroon Baptist Convention Health Board. Dr. Welty has had a distinguished 26-year career with the Indian Health Service, and now volunteers his medical services in Cameroon.

    Let me begin with Dr. Sherry.


    Dr. SHERRY. Thank you, Congressman Leach and distinguished Members, and thank you for the opportunity to testify before your committee. As the Chairman mentioned, my first congressional hearing that I attended was seventeen years ago in this room as Chief of Staff to a then-freshman Member of this committee, and so it is with particular pleasure and a great respect for this institution, and particularly the Members and staff who stay along late into the hearings, that I address you today.

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    For the last thirteen years I have been involved in health around the world, too much of that time wrestling with this epidemic, but with your permission I will abbreviate my written testimony.

    The LEACH. Without objection, all the statements will be fully placed in the record, and you may proceed as you see fit.

    Dr. SHERRY. And I will focus a bit more sharply on seven specific points.

    First, on the status of the epidemic, you have heard many of the numbers. I won't repeat them, but just to remind that Asia, and in particular, South Asia, is under considerable threat from worsening epidemics. The Caribbean falls only behind Africa in the rate of epidemic growth. In sub-Saharan Africa, as we have heard, the AIDS epidemic is not as bad as everyone thought; it is much worse. And to highlight that, of the 23 million infected individuals there are now, over 90 percent do not know that they are infected with the virus.

    Almost all of the major downward changes in declining life expectancy in Africa can be directly ascribed to AIDS, and within the next five years we expect life expectancy at birth in southern Africa, which rose by a third from the 1950's to the 1990's, to plummet back to the levels of 1950. The poverty and stigma that fueled the epidemic in Africa are now, beyond all rhetoric, the major threat to the future of the continent.

    My second point, Mr. Chairman, relates to the false dichotomy that we often create between primary prevention and care approaches. It is as difficult as it is unwise to separate these two sides of the same coin. Care and support are critical to piercing the stigma of AIDS. The traditional economist's distinction between a private good and a public good breaks down when, because of such profound stigma, we are thwarted in our efforts to mount effective prevention efforts, in particular voluntary counseling and testing.
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    This was true here in the United States and in Europe. It was true for leprosy and for dracunculiasis. It was true for tuberculosis and for cancer. It is true for AIDS. Access to palliative care, treatment to prevent mother-to-child transmission, and the treatment of opportunistic infections such as TB are essential components to successful HIV programs.

    Mr. Chairman, my third point relates to children and young people, their place in these statistics and, increasingly, their place at the leading edge of this epidemic. As you may be aware, child survival rates have been fully reversed in a number of countries. Eleven million children have lost their parents to AIDS, and as you have heard, that number will likely be trebled or quadrupled within the next decade.

    In emerging epidemics such as we are seeing in Eastern Europe, the appropriate focus of our response is with commercial sex workers, IV drug users, men who have sex with men, and men whose occupations keep them away from their homes, such as truck drivers and the military. In a generalized epidemic, where 5 or 10 or 25 percent of the adult population are affected, it is young people who are out on the leading edge.

    In a number of African cities, girls age 15 to 19 are five times or more likely to be infected than boys their own age. More alarming still, as many as one in five 15-year-olds in some cities, 15-year-olds, are infected. Mr. Chairman, when we advocate for an expanded response, getting out ahead of the epidemic rather than chasing after the virus, we are talking about getting out in front of these kids. It is not simply their individual behavior regarding sex; it is about societal behavior toward young people.

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    Certainly access to information about safer sex and to condoms has to be a part of the response, but an expanded response, an effective response, is much more about their access to schools and teachers who respect them and challenge them; youth in sports organizations, the vast majority of which are supported by religious institutions in Africa, that include them and help them build their self-esteem; economic policies that include vocational training and employment opportunity to help build their futures; social policies that include safety nets that keep the most vulnerable young people, in particular orphans, off the street and out of harm's way; and, as you heard Ambassador Holbrooke say earlier today, disciplined military and police forces which protect young people rather than affect them.

    My fourth and perhaps most important point is, despite all the bad news, there is very serious progress being made. Politically there has been significant progress in recent months. We have seen many African leaders speaking out in unprecedented ways, confronting the epidemic. In countries where strong political leadership and crosscutting responses have come together, clear success has been demonstrated.

    As you have heard, in Uganda, but also in parts of Zambia, Tanzania and elsewhere, the rate of new infections is falling. In other countries, such as Senegal, infections have stayed consistently at very low levels.

    There should be no mystery about the Uganda success story. Of the $150 million for AIDS prevention spent in 1997 for the most affected countries in Africa, nearly $30 million of that was spent in Uganda. Everyone was involved: national and local government, religious institutions, community groups, families affected by AIDS. The health sector was certainly a player, but it was not by any means the major player.
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    In a period of only five years, Uganda cut in half the rate of infections among young girls 15 to 19, and the average age of first sexual intercourse within that group was raised a full two years. No one predicted such positive results, looking forward. In hindsight, there are lessons for us all, and a moral challenge to do what can be done, because it is not impossible anymore.

    Fifth, we would caution that the stronger multilateral approach that this legislation will enable must not be seen as a substitute for a stronger bilateral approach. Each has their inherent strengths and weaknesses. Our challenge is to optimize the synergy between them.

    The epidemic has already forced unprecedented coordination in the U.N. system and, as I am sure the Members of the committee can appreciate, interagency mobilization and coordination can be more contact sports than diplomatic processes. But, notwithstanding the rough start, the process is now clearly underway. The U.N. is now dramatically increasing its attention and its resources to the epidemic in Africa.

    I have included in my written statement a brief summary of the development of the International Partnership Against AIDS in Africa. I will not repeat it here. The important process brought together for the first time, through the personal leadership of the Secretary General, representatives from African and OECD governments, the United Nations systems, NGOs, and the private sector. The legislation that you are considering today would have a major positive impact on these efforts.

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    Six, I would like to report that we are making progress in mobilizing resources, though we are still a long way short of making our mark. This past April in London, donor governments were challenged to urgently treble their assistance for AIDS in Africa. The United States has been a leader in responding to this call and in leveraging other donors to increase their investments.

    Australia, Canada, Finland, Italy, Japan, Norway, the Netherlands, the Republic of Ireland, the United Kingdom, have all substantially increased their commitments. We would estimate that year 2000 international financing is roughly two-and-a-half times the 1997 level, largely as a consequence of actions taken this last year. It is a solid start, but there is much more way to go. We would also vigorously counter the suggestion that absorbative capacity in Africa constitutes a major problem or rationale for not further increasing resources.

    Seventh and finally, Mr. Chairman, it is our view that your proposal for the establishment of the World Bank Trust Fund for HIV/AIDS Prevention represents a critical step in raising the international response to a level more commensurate with the magnitude of the epidemic. The World Bank provides unique capabilities within the UNAIDS partnership to serve the role as financial administrator. It is what it was set up to do.

    We believe this role is best executed while acting in concert with governments and other agencies with comparative advantage in the areas of technical policy development, program design, and implementation support, particularly those most experienced working with NGOs and other parts of civil society. As a founding co-sponsor of UNAIDS, the World Bank has committed itself to work as a member of this multisectoral partnership, and indeed under the leadership on this issue of its president, Jim Wolfensohn, the Bank has consistently upheld that commitment. We would hope, therefore, that the Trust Fund would be established in a way that reinforces those commitments.
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    If I may quickly flag three important details. One, some of the hardest hit countries in southern Africa, Asia and the Caribbean are ineligible for IDA support due to differing definitions of poverty, and we would hope that eligibility criteria for assistance through this mechanism would take this into account.

    Second, while Africa by far requires the lion's share of support, there are hot spots in other regions of Asia, the Caribbean, and Central America that require urgent attention.

    And, third, though the work toward an AIDS vaccine is vital to the hope for definitive control of this epidemic, nevertheless the compelling need in Africa today is to invest in those prevention approaches and technologies that are available today. And, to this end, we would encourage you to give the highest priority within the legislation to programmatic interventions in countries that have developed and are ready to implement national plans of intensified action.

    Mr. Chairman, in closing I would reiterate that the full dimensions of the AIDS crisis are now well documented. Collectively, we know what must be done. The need to mount an extraordinary response is inescapable. And, on behalf of UNAIDS and its many partners, we commend you for your leadership on this issue here today, and again, thank you for the opportunity you have provided us to testify before your committee.

    Chairman LEACH. Well, thank you, Dr. Sherry.

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    Dr. Slutkin.


    Dr. SLUTKIN. Thank you, Chairman Leach, and other Members of the committee. It is a pleasure to follow Jim Sherry, my good friend, in this area, as I preceded him in Geneva.

    I am a medical doctor who has been working on epidemics for about twenty years. I have been associated with Africa for most of those twenty years, and have worked—I left San Francisco to move to Somalia, where I lived for three years doing refugee work, and got picked up there by World Health when the World Health Organization was first forming the global program on AIDS in 1987. I stayed with World Health from 1987 until 1994.

    During those first three years of that program, this issue of AIDS in Africa was treated as a horrendous epidemic and a massively accelerated level of energy was put in. The Uganda program was one of my responsibilities. The plan and program that had these results was not accident; it came as a direct result of this plan that was formed in December of 1988.

    The resources to this plan were absolutely central to it being able to succeed. We carried the Uganda program from a half-a-million-dollar program to $4 million to $10 million to $18 million, and it stayed at $18 million for all of these last years of the last decade, and Jim now reports that it is up to $33 million. We did not get the other countries above levels of implementation of $2 or $3 million.
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    Now, although there are a lot of people who know that I supported the Uganda program, I also had responsibility for the other 14 countries in Central and East Africa. Almost every one of these countries, with one exception, was also increasing year by year by year. The only difference between Uganda and the rest of these countries is level of implementation. That is the only difference.

    What Uganda did was massive public education, a very high level of commitment, an extraordinary amount of technical assistance, also, from the international community. The government commitment on their side was critical, and it is also central to the results that we want to see in the other countries.

    I want to say just a couple of things about the things that are needed besides money, and about some of your questions about the World Bank mechanism, because I have worked with USAID, UNICEF, WHO, the U.N. and the World Bank in trying to implement programs.

    The financial mechanisms for distributing funds are central to success. We did not succeed in the countries where we provided money, but the mechanism in the country for distribution of money to country programs was not in-house. In fact, in the early days of the World Health Organization's response to the AIDS epidemic, we used smallpox mechanisms.

    The mechanisms for a lot of the international organizations are not as functional as we would like to see to have a good response, but I want to tell you that I think that this World Bank mechanism is the right way to go. And I have spent a lot of time in the last five days, after being asked to give testimony here, exploring what the financial mechanisms of the different organizations are.
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    And I want to assure you that USAID does know how to spend money effectively, and so does UNICEF, but I think that the World Bank is the right answer here. They have several advantages. They have experience in very, very large scale programming and very large scale programming in AIDS, now both in Brazil and in India. One of these, they were in the context of loans, and one of the loans being to the range of $250 million. They know how to do large scale programming, and large scale programming is what you need. They also are what is needed with respect to commitment, getting the commitment of the high level officials.

    And, third, they have the ear, unlike a lot of the other organizations who operate with ministries of health, which are extremely weak, underfunded, and of no importance with respect to the president's own idea. They are rarely, for example, relatives of the president. The minister of finance is a very key person in the government of these countries, and the World Bank is the counterpart to that organization.

    So I am going to close with a few more details that I recommend to you, but the big picture here is that this is really on the right track, and to keep in mind also that this is, as you talk to your counterparts in Congress, this is the big show today in the world. There are more people dying of AIDS, I think, than in all of the wars combined on the planet now, all of them. We have 2 to 2.5 million people dying every year due to AIDS now, with the numbers increasing. That is more than all of the wars, all of them, not just the wars in Africa.

    So these are my closing points. We have had massive success in Uganda. There is nothing that happened in Uganda, nothing, that couldn't happen in every other country. Sex habits were the same, the myths were the same, the misconceptions were the same, the lack of desire of using condoms was the same. There is nothing that happened in Uganda that couldn't happen in the others.
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    The level of funding is key. National programming is needed. You need technical assistance at country level in administering the finance, and the details of this I know, but you can talk to several people at the World Bank and they will tell you they know how to do it, top down and bottom up, and they can do these mechanisms.

    I also recommend that you have a mechanism of reporting, and one part of the bill that I did not like at all was the reporting after three years. I think that there is not enough reporting on the response to this epidemic. I think you should get reporting every six months.

    There are four things that reporting is required on, in my opinion. One is how the country money is being spent. Is it being spent? Is money being spent in country, or are people futzing around in the multilateral organization at the country level? Is the money being spent? How much is being spent? Is it going out? Two, is it going to country-level activities. And, three and four, are there changes in knowledge on HIV? Three and four, we have mechanisms for that we set up. I actually had responsibility for setting these systems up twelve years ago. But A and B you need reporting on, and I would recommend you get them every six months.

    Next, I suggest you have a technical panel that gives you some feedback on what is really happening in terms of both finance and in terms of program activities.

    And then, last, there are certain pieces of implementation that should be tremendously accelerated while all these mechanisms are going in, and this includes public information and radio programming.
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    So, last, I would recommend to you, last, I would recommend to you that you not just pass this bill and change the reporting requirements, but that you stay with it, that you stay with it, that you stay with this cause after passing the bill, and that you get the reporting, you see and help the other funds in, but don't wait for Europe. I mean, this isn't the time for the posturing and the bickering and all of the usual stuff. This is the time for the U.S. to use the U.S. style of proactivity, and yes, encourage them to get in, but put it in. Put it in, and let the others feel bad if they are not putting in, and then help it come from the private sector. So please stay with it after you pass this.

    Thank you.

    Chairman LEACH. Well, thank you, Dr. Slutkin.

    Just one minor thing by way of perspective: Clearly more people are dying today from AIDS than all the current wars going on, but in the very near future more people will have died of AIDS than the combat deaths of the principal world wars of the last century.

    Dr. Wilfert.


    Dr. WILFERT. Thank you, Chairman. I would like to express my gratitude to you and the other distinguished Members of the committee for inviting me here.
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    I am going to select a facet of the epidemic of HIV, and that is the way in which the epidemic particularly affects children. My eloquent colleagues have dealt with some of the broader aspects, and I agree with what they have said during the course of this testimony. I believe that the bill which is proposed has a chance of increasing the resources and changing the face of the epidemic in the world, and I think that the changes which will relate to mothers and children will be very specific, and I would like to enlarge upon that.

    First, I am a pediatrician. I am at Duke, but I am the Scientific Director of the Elizabeth Glaser Pediatric AIDS Foundation, and it is in support of that organization that I speak.

    Most of you know that the foundation was created by Elizabeth Glaser in response to the fact that she was infected and her children were infected, and she learned that comparable treatment to what she was receiving was not available to her children in the United States. Her efforts in this House and elsewhere contributed to the creation of the programs designated for pediatric research, and have accomplished an enormous amount within the United States.

    The foundation is about a decade old, and her friends, Susan DeLaurentis and Susie Zeegen, who founded the organization with her, and but a reasonable staff, have succeeded in raising some $85 million in this decade to devote to trying to increase the research and therefore the care of children and their families with HIV infection.

    I would like to point out that in 1994 we learned in the United States that AZT could diminish transmission of this virus from mothers to their babies. That is, a short six years ago. The resources are available in this country to have access to that treatment, and transmission from mothers to their babies has decreased by 75 percent. It is estimated that fewer than 200 babies will have been infected in 1999. That does not diminish the infection in their mothers. The acquisition of infection by women in this country has not diminished, and in fact women constitute an increasing proportion of the infected population.
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    I tell you this because it has been six years and there is not a single developing nation that has been able to access this kind of intervention to prevent mother-to-child transmission. There are programs in progress. We heard about Botswana's commitment to a shorter course of AZT. They are in the process of building that program.

    In September of 1999 we learned that nevirapine, another antiretroviral agent, could be administered in a single dose to mothers and a single dose to babies and diminish transmission by 50 percent. The study was done in Uganda, largely because they had developed some infrastructure and they had support to do this study.

    This makes a feasible approach. Is it easy? No. But it takes resources. It takes programs that build education into the existing maternal and child health programs, it takes advocacy, it takes access to women who are pregnant, and the administration of the medication is the simplest part. But imagine if you could diminish the 600,000 infected babies each year by one-half because we succeeded in reaching the women.

    Botswana is a small country in terms of population, and I had the privilege of visiting there recently. Indeed, 40 percent of their pregnant women are infected with HIV. This means that in a year, 7,000 to 9,000 infected babies will be born. This is 3 to 5 times the number of infected babies born in the United States in one whole year prior to AZT therapy.

    I want you to realize that in the four hours of this hearing, 300 babies would be infected; 1,800 babies a day. That is the number of babies infected in a year in the United States prior to 1976. And if people can walk out of here with a sense of urgency and the magnitude of the infection as it relates to mothers transmitting HIV to infants, we will all have taken a great step forward.
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    The Elizabeth Glaser Pediatric AIDS Foundation and global strategies to prevent HIV infection took an initiative entitled the ''Call to Action,'' and I will not go into it in detail, but the foundation designated $1 million because we felt that some things had been done very well in this epidemic, and we wanted to see if implementation of the available technology could get to the developing world even if what we have to bring to it is a small amount of resources in comparison to what is actually needed.

    I expect, since the first applicants will have received their grants, and they will be awarded tomorrow, there will be sites in South Africa, Kenya, Uganda, Rwanda, and the Cameroons and Thailand. I think, I have every expectation that what amounts to relatively small dollars, placed in the right situations with the existing infrastructure, will make an enormous difference. And if you think in terms of your bill, I believe that the monies and the resources that could become available can be multiplied many times over to enhance and to actually succeed in implementing the available interventions which are now available.

    I would like to address just briefly some of the measurements that you will probably be considering if this bill is enacted, and that is that in the arena of mother-to-child transmission, you have the opportunity to document that the number of new infections decreases. The actual number of babies born with infection will decrease, and it can be measured, if the programs are successful.

    As well as Uganda has done, the seroprevalence rate of infection in pregnant women remains at 15 percent. Think about the numbers of babies acquiring infection, because a proportion of those exposed infants who acquire infection exist in a country that has done very well, but has not yet been able to begin to implement the intervention which they described in a clinical trial.
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    So I think the mother-to-infant part of this is measurable. Its results can be seen relatively quickly, and I don't think anybody has any doubt about that.

    The programs have to be sustainable. This is not a vaccine. It prevents an infant from becoming infected, but the mother is infected and additional women are becoming infected. So such a program must be sustainable, and I would enforce the concept that when the bill—or if the bill is enacted—it isn't a one-time fix. Partners have to come, the programs the countries develop have to be sustainable by those countries, and they will appreciate the results when the programs are in place.

    I would also like to point out that I have had the opportunity to observe how well partners can do. Being sensitive to the nations in which these efforts take place, working with the existing infrastructure and organizations, should be a high priority with any bill like this, rather than inventing any new bureaucracy, if I can use that word.

    So I guess in summation I would like to commend you and to thank you once again, and to have you think about the possibility of being sure that part of the designation of these funds will go toward the prevention of mother-child transmission. And I thank you, finally, for including me in this discussion.

    Chairman LEACH. Well, thank you very much, Dr. Wilfert.

    I would like at this point perhaps to invite a fourth witness, Congressman Dellums, who was intended to be on an earlier panel and was unfortunately unable to do that, so we had scheduled him later, but I think it might be appropriate, Ron. Congressman Dellums is Chairman of the Constituency for Africa, as well as president of the Health Care International Management Company.
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    I know of no one who has a greater reputation for commitment and gentlemanliness than Congressman Dellums, and he has certainly, Ron, you have been one of the factors in my involvement in this issue, and I am very grateful for your leadership. Would you like to proceed as you see fit?


    Mr. DELLUMS. Yes. First of all, thank you very much, Mr. Chairman and my distinguished colleagues. It is a special pleasure to be here. It is one of the very few times that I have faced the Congress looking this way, so that is a unique experience. But I thank you very much for holding these hearings and inviting me to do so, and I would like to again congratulate my colleagues who are here for your participation in this. And Ms. Lee, I have the great honor and privilege to refer to her as my Representative. I voted for you absentee.

    Mr. Chairman, I am pleased to be with these distinguished members of this panel. I am not a physician, I am not a scientist. I do not head up a bureaucracy that focuses on these issues. I am a former Member of Congress and a political activist, and maybe that is appropriate to be the last person, because I see my responsibility as saying to you why you ought to be involved, and I think that there are two reasons. One is the moral imperative, and the other is self-interest.

    Since I was not here earlier, I don't know everything that was said, so if I say a few things that have been said before, it is to underscore for the purposes of emphasis. And this is my view, that we are indeed in the throes of a global pandemic; that at this point it is simply manifesting itself most profoundly and most dramatically in the sub-Saharan African context, but make no mistake about it, it is a global problem. It is a time bomb ticking in India and other places in Asia. It is a time bomb ticking in Brazil, other parts of Latin America. It is a problem in Russia, down through the Balkans and Eastern Europe.
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    The face of AIDS has changed dramatically in America. Forty-two percent of the people dying in the United States are African American; 28 percent of them are Latino Americans. Every hour in American two teenagers are newly infected with AIDS. One doesn't have to be a brilliant mathematician to begin to extrapolate that ultimately we are looking at a very significant and serious problem.

    As I said, it is manifesting itself most profoundly in the sub-Saharan African context, which leads me to why I think you need to do what you are doing and even go beyond it, and that is the moral imperative. Since the first AIDS case was discovered in Africa, over 11 million human beings have died, 11 million, and the world has quietly stood by and allowed this to happen.

    I would believe that if I were testifying before a committee of Congress and I said 11 million people have died as a result of a war where we have fired missiles and bombs and bullets, that there would be a level of outrage across parties and a political movement evolving in this country, the likes of which the world has never seen. But the reality is that people are dying in a war, a war with an infectious disease, a war with ignorance, a war with lack of attention and apathy, and it is a war and people are dying.

    They are dying at rate of between 6,000 and 7,000 a day. They are being newly infected at a rate of over 11,000 a day. It is anticipated that 2.3 million sub-Saharan Africans will die in the next year. Extrapolating out, that is 23 to 25 million, conservatively, people who will die.

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    In Sierra Leone, the life expectancy has dropped to 35 and falling. In Zimbabwe, it has dropped below 45. All over southern Africa, life expectancy has dropped into the 40's and falling. All over Africa, we have lost an average of about twenty years of life.

    When I first retired from Congress and ran headlong into this pandemic, there were 7.8 million children who were orphaned. As we speak, there are now in excess of 10 million, and you have probably heard testimony that says by the end of this year that could even be as much as 14 million. World Health Organization, UNAIDS, and others have suggested that the present 10-plus million orphans will become 40 million orphans ten years out. You don't have to be a brilliant social scientist to see the incredible havoc that could be wreaked with 40 million children with no sense of the future.

    There is a dynamic evolving in Africa that Africans for the most part have never seen, and that is the notion of homeless children. Yes, Mr. Chairman, and I am sure you have experienced this: On the streets of Africa, in countries in Africa, to suddenly be confronted with the stark, harsh reality of thousands and thousands of young children struggling to survive in impoverishment and disease is a life-altering experience. It is profound and extraordinary.

    So with people dying at such an incredible rate, with children being orphaned at such an extraordinary rate, with life expectancy falling so dramatically, in some places, in some countries in Africa, some employers are employing two and three and four people for one job, because they know the first two or three are going to die in several months. That is the reality. There are places where teachers are dying at a rate faster than their students.

    This is no longer solely nor singularly a health issue. It is an issue that cuts across every aspect of the human condition. It has developmental implications, political stability implications. Across the board, implications are there.
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    So it seems to me that as elected officials, both Republican and Democrat—because this, in my opinion, clearly is not a partisan issue. No party can control death, so this is something that goes beyond. And I am happy that Ms. Lee and you, Mr. Chairman, are working together as a bipartisan team, because this is about life and death. It has nothing to do with partisan politics nor petty politics. We have to lift our vision much larger.

    So the first responsibility, it seems to me, is that I hope you folks would do this and step up to this aggressively, even more assertively than what is in the bill, for the moral imperative. We cannot allow millions of people to die while the world stands by and does nothing. And I would like to think that we as people can rise to a much higher order of commitment, and that is to the moral level.

    But I also think that there is another reason why we need to be involved, and this is my sense of it. Again, I am not an expert, but this is what I think I am hearing. HIV/AIDS is an infectious disease. It is not a respecter of race, gender, sexual orientation, age, class, border or boundary. It respects none of this.

    The simple, profound conclusion that comes from that is that this infectious disease then is endangering the human family. No one country, no one continent, no one people, no one group on this planet has ownership of HIV/AIDS. It is an infectious disease that is challenging the entire human family, and therein lies our mutual self-interest.

    So this is not simply a sense of noble obligation. It is also in our mutual self-interest to come together, to fight as valiantly as we can and as effectively as we can to end infectious disease. Where we have not done that, we have only complicated our lives. Take tuberculosis, gonorrhea as two practical examples.
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    And when we come together and we don't effectively combat an infectious disease, the next infectious disease is complicated by our inability to deal with the last one, which means that in many cases of HIV/AIDS there are people with tuberculosis, other forms of sexually transmitted disease, all of this. So it is in our interest to deal with this.

    Why am I focusing on Africa at this moment? Why should we be focusing on Africa at this moment? It is because that is where the need is the greatest, and that is where the pandemic is expanding and spiraling out of control.

    And it seems to me for both moral and self-interested reasons we need to go where the problem is manifesting itself most dramatically, and that is in Africa. And we need to deal with that as powerfully and as aggressively as we can, in education, prevention, care and treatment, and so forth.

    When African countries or ministers of health are forced to call press conferences to say, ''We can no longer spend X amount of dollars on care and treatment, because we can't afford it and it's not an efficient utilization of our dollars, we must now put this money in education and prevention,'' you understand the moral and ethical dimension of that decision. It means that this generation and perhaps the next generation can be allowed to tie in order to save the third generation out.

    And we as a great Nation, we as a wealthy Nation, in concern with a global strategy, have to provide the resources to those countries so that no minister of health, no nation has to be placed in the position where they have to make the moral and ethical decision of allowing one or two generations to die in order to save another generation out. And I would like to think, for all those reasons, we need to step up to the plate.
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    I see this as a global responsibility, public and private partnership, but I see this Nation as taking an important leadership role in stepping forward to deal with this very significant problem. It is manifesting itself profoundly in Africa today, in India tomorrow, Brazil the day after, in Eastern Europe the day after that, and continuing to spiral up in the United States, unless we begin to do something about it.

    The whole notion of what is domestic and what is international, when we look at HIV/AIDS these labels make no sense anymore, because this disease travels, and human beings cross these borders every day by the millions. And that is why we don't live under a bubble, so it is in our mutual self-interest to deal with the problem that is out there, because if we don't deal with it out there today, we will be dealing with it here tomorrow, so it is important for us to do it.

    People live in this country who have been able to sustain life because they have access to care and treatment. We cannot condemn millions of people in Africa and in the developing world to a death sentence, because we haven't figured out how to provide care and treatment. It will be difficult, but there are brilliant minds in this room, in this country and around the world, who can help us deal with that question.

    The first issue is one of governance: Should we do something? So I am talking to you as a fellow elected, former elected official, as a fellow political activist. Yes. Before we answer the question how do we do it. There are brilliant people, like the people here, who can help us figure that out. But the first question is, are we committed to do something?

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    I think your bill, Ms. Lee's bill, and your combined effort is a powerful and wonderful statement that says yes, we are committed to do something, and we are committed at a level beyond the few dollars we have thrown out into this issue historically. This is no longer at the project stage. Millions of people have died. More millions are going to die. Millions of human beings are going to suffer.

    And I would conclude by saying that I absolutely support any effort that is going down the road ultimately to build a global strategy that is based on a public-private commitment, where your first commitment of major resources in education and prevention and care and treatment and training is in sub-Saharan Africa, because that is where the human misery is beyond calculation.

    And with those remarks, Mr. Chairman and Members of the committee, I thank you for your indulgence.

    Chairman LEACH. Well, thank you very much, Ron. And your last comments are particularly relevant. We all know that where there is a will, there isn't always a way, but if there is no will, there is no way.

    Mr. DELLUMS. Absolutely.

    Chairman LEACH. And so will does precede everything.

    I have been impressed, if I could turn to the three science members of the panel, I have been impressed with some of the statistics that seem to indicate that when you just look at percentages, that when you have a small instance of existence of the virus, that the growth looks to be modest until it hits about 5 percent, and then all of a sudden it precipitously, within a year or two, can jump to 30 percent.
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    Have you seen that as you have looked at these statistics in African countries? Is there a point upon which it is desperately important that we keep the rate below?

    Dr. SHERRY. Let me take a shot at that. First, Mr. Chairman, I don't think there is a particular set point. I mean, I think there are countries that have hovered around a couple of percent for a very long time, like Senegal. Zaire or the Republic of Congo had relatively low levels, I think 5 to 8 percent, for a very long period of time, I think about ten years now or so. So it really depends on what is driving the epidemic in a particular community.

    So, yes, the numbers can be explosive. I think we see them explosive where there is this pattern of older men infecting younger women, where that is the most prevalent form of the movement of the infection. But I don't think there is any magic of the numbers. I think we can aspire to where we have relatively low incidences, I mean, and I say relatively low; 2 or 3 percent incidence is horrific.

    But there is no reason to expect that because a country is at 5 percent, that it is going to shoot up if we do something. I mean, it doesn't have to. There is not an inevitable trajectory of the epidemic, and whatever the trajectory is, it can be fundamentally changed by our intervention.

    Chairman LEACH. In terms of intervention, one of the direct ones that you have talked about is providing alternatives to breast feeding for infected mothers. I am told as an immune system disease, that basic vitamins are also helpful, too, particularly Vitamin A and E; that vitamin deficiency makes people more vulnerable to all diseases, but most particularly immune system ones, most particularly AIDS. Is that valid, or——
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    Dr. WILFERT. Yes and no. It is correct that those vitamins have influences on the immune system and the acquisition of disease. Unfortunately, there have been clinical trials attempting—I say unfortunately, because the trials didn't show that Vitamin A diminished the rate of transmission of HIV from mothers to their children. It is fortunate there were clinical trials. That doesn't diminish the value of Vitamin A for either infants or mothers in other regards.

    Chairman LEACH. Interesting.

    Dr. SLUTKIN. If you would allow me to just say one thing about each of these two, for the most part the vitamin issues are a distraction, as are in fact even some of the other medical issues, but certainly the vitamins.

    On the epidemiology, the main lesson that we keep learning is that we are always guessing wrong. And Jim Chen, who ran the epidemiology and surveillance section for World Health Organization for about six years, is the leading epidemiologist I think in the world, every time we would re-look at the numbers, Jim would say, ''Every time we look, it's worse than we thought it would be. Every time we make a prediction, we've underestimated it when we go down the line and see what it becomes.''

    And I remember very well in the early 1990's, and we were the main rabble-rousers about the urgency and emergency of this horrible crisis globally, we really ourselves did not think anything like this was going to happen in southern Africa. And South Africa, Botswana, Zimbabwe, this took everybody by surprise, what has happened in the last five years down there. We were so focused on Uganda, Rwanda, Burundi, Malawi, Tanzania, Kenya, Ethiopia, and Zaire. And now everyone is looking down at South Africa. We thought, you know, for some reason it would be less.
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    And now I think that, as Jim points out, you know, there is a fractional complacency happening around some of the Asian countries that have not been so hard-hit yet. But I don't know what is so different there than what was in South Africa, you know, four or five years ago.

    So what you have here is, you have populations that have certain behaviors, which is most of humanity, and a virus that gets in, and when it gets to a certain point, the virus blows. And so the behaviors have to change, and we know to change those behaviors. We absolutely know how to.

    And just a reminder: You know, the calculations by people who know, and I have seen these calculations and I believe in them, based on what was needed in Uganda, you know, the effort is looking for $1 billion. The effort is looking for $1 billion, and I hope that you all will help, beyond this bill, in trying to raise toward that level.

    Chairman LEACH. Well, let me just respond briefly. This bill is designed to reach $1 billion per year for a five-year period. We are looking at substantial sums of money. Now, we are not looking at that as all U.S. congressional. We are looking at leveraging the World Bank and also, uniquely for the World Bank, looking at perhaps allowing the World Bank to serve for private sector donations as well. This is something that Congressman Dellums is very cognizant of—the capacities of the private sector and the moral obligations of the private sector.

    But it has struck me that one needs methodologies. I mean, that is, not only do you have to develop a will, you have to develop a way for the private sector, too. And I think the World Bank approach probably has more potential in this regard than other institutional arrangements.
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    Ms. Lee.

    Ms. LEE. Thank you very much, Mr. Chairman.

    First, let me just thank the panel for their very clear testimony today, and also to say to our scientists and physicians that it gives us a lot of hope, that we have such individuals with your level of expertise and knowledge, but also with your level of commitment, to address this pandemic. Thank you very much.

    To my former boss, I am always honored to be able to say that Congressman Dellums is my former boss of eleven years, good to see you here, and thank you for your extraordinary leadership on this issue.

    Mr. DELLUMS. Glad to be here.

    Ms. LEE. You know, you have been working tirelessly on this, and it is no accident that now the congruence of forces are coming together and this pandemic is beginning to receive the type of public attention that we know it deserves. And we know that it has been due to, in large part, your working tirelessly for several years on this.

    Let me just ask you, Congressman Dellums, with regard to the United States' international role or role in the global community, you attend many international conferences, and I would like to hear your perception with regard to what other countries see in terms of the United States' role in terms of raising this and mounting the leadership initiative that we are talking about today.
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    Mr. DELLUMS. Well, I think we are a lightning rod. We are the last superpower standing. We are a very wealthy Nation. We are a Nation that the world focuses upon. Rightly or wrongly, good, bad or indifferent, that is the reality.

    And I think that as a result of this prominent role that we play, we have a very important act to perform, and that is to assume global leadership. My colleague mentioned that this is a billion dollar effort at a minimum. Well, if you for example put $300 million from the United States into an effort on AIDS in Africa, if you look historically, the global community tends to respond to U.S. initiatives at a rate of about 2 to 1. That is the global aggregate governmental community. Which means that that $300 million then could be leveraged to $900 million, as it were, because of other nations contributing at a ratio of 2 to 1, which has been pretty much flat-lined over time.

    If this is a public-private partnership, and you say to the private sector, ''We want you to match this. This is a global responsibility. It's a public-private responsibility. You have a responsibility to step up to this both on a moral level as well as your self-interest. Marketplaces where you as business make a living, people are dying, and that means the marketplace is dying. So if you can't get there morally, at least understand your self-interest.''

    So that if you have now got $900 million and you are asking the global private sector to match that $900 million, now you have $1.8 billion of money that began at $300 million with the U.S. Or do the math with $200 million. But if you have a strategy that is a global strategy, that is both public and private, you can do it.
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    While I am at it, if I can piggyback from you to the point that the Chair made, you know, people often ask, how do you—and I am learning, going in and out of Africa—they say, ''Well, how do you eat a hippopotamus?'' And I say, ''I don't know.'' ''One bite at a time.''

    So how do you confront this incredible reality in Africa? Some people say it staggers the imagination. How do we do it? I believe that it can be done by regional cooperation, in the southern region, the western region, the eastern region, the central region, the northwestern region.

    The way you can have private sector people involved in the whole process is, either the private sector can contribute directly to your fund, if they don't choose to want to be committed on the ground, because they have no particular expertise that allows them to make a commitment on the ground. Contribute to the fund.

    If a particular or a constellation of corporations decide, in true partnership with African countries, say take the West African countries, 12 to 15 countries, if they in a true partnership with private resources on the ground, like remember Bristol-Myers put their $100 million into southern Africa, that can be the model that can be used in other regions as well. So that the private commitment would not only have to give them the option of putting money in the fund, if they wanted to get committed on the ground with their own resources in private partnership.

    So that you could put together this kind of consortium in every one of the regions, use the dollars that you are using, leveraging here, to connect all the dots, created the communication mechanism, the coordination mechanism, and fill in whatever loopholes are there as a result of this regional effort. I am convinced that with that kind of aggressive approach, you can be off the ground all over Africa within 12 to 18 months with some meaningful effort going on. Because each day that we don't, several people die.
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    Ms. LEE. Mr. Chairman, may I follow up?

    Chairman LEACH. Of course. Please.

    Ms. LEE. Congressman Dellums, oftentimes we hear that the infrastructure is not there, so why would we want to put massive resources into Africa, because of that? But what you are saying is that this provides an opportunity to actually get in there now and begin some infrastructure building also, at the same time.

    Mr. DELLUMS. Yes. The other thing I think I am learning is that I am finding out you can't treat AIDS in a vacuum, and I want to be very straightforward. We are looking at the suffering and the dying of people, and that means education, that means prevention, that means care and treatment.

    But how do you educate young people who cannot read? If you are going to be dealing with the problem of AIDS, you are going to be in the education business. How do you engage in sustainable care and treatment, if you care about people living and dying, without having a health care infrastructure? So you are in the infrastructure business. How can you care for people where there are no clinics and there are no hospitals? How can you provide care and treatment, going from one village to the other village, you have no roads.

    So my sense of it is that AIDS is such a morally compelling issue, such an extraordinary issue in terms of self-interest, that if we engage in addressing the issue of AIDS not solely as a health issue, but as an issue that cuts across the human experience, we are going to have to find other ways to come up with other resources to deal with that problem, as well.
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    Which is why I am saying that the Chair's approach, your approach, are wonderful approaches, but at the same time on the other end, the sub-Saharan African countries are spending over $30 billion a year on debt service, and I think this is unconscionable on a continent of such incredible poverty and such incredible human misery. We are also, and you are starting to hear that rhetoric in the body politic, which I think is a healthy thing, to talk about debt forgiveness and tie that debt forgiveness into a nation's ability to begin to address this crisis, so that the monies are there for health care infrastructure, education infrastructure, and so forth.

    What I am saying is that what I see is that the AIDS pandemic provides both the moral imperative and the self-interested urgency that allows us to come to the aid of Africa in a way that we have never done in the past. If I might be brutally frank, we have nickeled and dimed Africa for years, and the result has been incredible poverty, incredible pain, and now we are looking at a pandemic that is killing millions of people.

    Well, let's step up to the plate and allow AIDS to be the issue that allows us to do it, not simply out of a sense of noblesse oblige, but because it is in our self-interest to solve the problem. But once we get out there, make no mistake about it, once you get into the business of dealing with AIDS, you are going to have to go wherever it takes you. And I think that is ultimately going to take you into these infrastructure questions, because they can't be avoided.

    But my final point would be, we cannot allow this to be an excuse. And when I first got out there and I said, ''Well, what this issue needs is a loudmouth political activist,'' is I heard a lot of people saying, ''Well, how are we going to do it? Gee, we don't have infrastructure.'' So that means all these people are just going to die because we have not sat down to challenge ourselves scientifically, medically, intellectually, and bureaucratically to figure out how to come to grips with this problem.
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    Because I think it is such an important issue that I could not allow those sort of rationales to be just that, a rationale for doing nothing. So I felt that we had a responsibility to make the world uncomfortable with this reality, so that no one would ever have the right to say, the opportunity to say, ''I didn't know anything about it.''

    Chairman LEACH. I think the other three panels want to address aspects of this. Why don't we just begin, left to right.

    Dr. Wilfert.

    Dr. WILFERT. I just wanted to say that it is obvious I am sure to everybody that there is a real heterogeneity out there; that, if I use my own territory, there are places that have antenatal clinics. They see pregnant women before they have their babies. They are not currently able to do counseling and testing, or they do not have access to the interventions. That is one kind of deficit of infrastructure. On the other hand, there are places that have everything except access to drug, and with the right kind of help could actually achieve very instant implementation.

    So what I am trying to say is that in each of the areas there will be a spectrum of deficits, and the nations are sensitive to that, and with help, they can tell us what they need, one piece at a time.

    Chairman LEACH. Dr. Sherry.

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    Dr. SHERRY. Yes, Mr. Chairman. I would hate to have the committee leave with the impression that $1 billion is going to fix this. And you have seen different ranges on the prices or the cost of this. You have seen, you know, $1 to $2 billion, $2 to $3 billion for prevention only, some aspects of care, and so forth.

    And the estimates we have done, and I think it also responds to Ms. Lee's question on absorption capacity, what we looked at is the six or seven highest impact interventions and looked at what would be the capacity to scale those up tomorrow. So, for example, if we include on that life skills education in schools, we don't cost for where there aren't schools. We look at, if there is only 50 percent school coverage, we cost to the 50 percent of the kids that have access to the schools. And similarly with STD treatment or other communications programming.

    So you could, in terms of programming money tomorrow, you could program, by our estimates, between $1 and $2 billion just to do that. Now, that doesn't get you the infrastructure that you require to extend, but it doesn't all have to work perfectly in order to get a very dramatic impact.

    And so I at the same time would not want people to leave with the impression that the needs are so astronomical that $1 billion isn't a significant amount of money. In this setting it is an enormous amount of money. It will have a very major impact, but it doesn't get the whole solution.

    A second point along that same line: Where we have had major international mobilization, and I think this will dovetail well with Ron's point, where we have had major international collaboration that the U.S. has led, they have had a larger, they have had a leader's share, and that leader's share has usually been closer to 50 percent and then stabilized down to about a third when the others got on. So in the first expectation I think that leader's share is going to be a little higher, needs to be a little higher from the U.S. than the international community.
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    The second point is that if we look back, say, at our experience with immunization, there it was a much simpler task, but in that particular case the total worldwide additional expenditures to get the immunization levels from about 20 percent to 80 percent over about a six or seven year period in the 1980's, that was about $2 billion a year. Only $200 million of that came out of the international community. Ninety percent of those resources become mobilized out of the soil.

    So when you are in a community, it is the time of the teacher, it is the clergy, it is the community worker, it is the extra time that people are putting in, it is the free television time that you get with the public service announcements. It is that broader mobilization that gets you the much broader range of resource.

    So, as well as one comes in now with a major effort, you have to think about not displacing that resource, and that is why it is critical that in terms of your mechanism, that the emphasis on community partnership, on civil society, that these approaches, that we don't undermine the leverage capability of these processes, that we don't go in and displace what are the resources that could be coming in from the communities, but rather help to liberate them.

    Dr. SLUTKIN. If you will allow me, I want to separate out something for you. The infrastructure problem of Africa has nothing to do with our expected effect on prevention. The infrastructure for prevention is totally there. We are talking about women's groups that go all the way out to the village. We are talking about community groups that connect with each other all the way out in the villages. We are talking about radio that gets all the way out. We are talking about schools that go out. The political party has training of trainers of trainers that goes all the way out. The infrastructure for prevention education is totally there. OK?
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    Now, what we are talking about in terms of infrastructure problems primarily has to do with issues related to care, which is important, and which can be designed to be a more, you know, feasible intermediate level. All right? But in terms of prevention, the infrastructure is not a barrier.

    Second, you know, I have been working on epidemics now for about eighteen years, and on this epidemic for about, I don't know, 15 or something like this, one way or another. This $1 billion is not a drop in the bucket. My expectation, my expectation is what you will get from $1 billion a year, is you are going to get two or three countries a year turning the corner, starting three or four years from now, if these funds are put at least to the 70 percent level for prevention. And that is what this fund should be for, is for prevention.

    And that is the last point. If we go to the private sector, they have so many interests of their own. You know, the Squibb money and Bristol-Myers, a lot of this stuff goes to U.S. universities. It goes to a lot of stuff that isn't really going to prevention for Africa, so we have to be aware of that when we are counting the money that is really going in.

    Mr. DELLUMS. Mr. Chairman, I would just want to make one comment.

    Chairman LEACH. Surely.

    Mr. DELLUMS. Because I appreciate all the remarks about prevention and education, and I am there. But I am also saying that we have to care about the people for whom education and prevention are no longer options, and those people range into millions, and it is both ethically and morally unacceptable to me that we could do anything in terms of our comprehensive strategy that would not address the care and treatment issue as well.
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    Again, as I said, ultimately prevention is ultimately the answer of the day. But the point is, we are not there yet, and there are millions of people who are dying. All the prevention in the world is not going to help them. All the education in the world at this point is not going to help them. The ethical and moral question is, what do we do with these people? Do we allow them to die?

    And I have taken the view that we cannot allow them to die, which means at this particular point we have got to grapple with whatever the financial resources, the infrastructure issues to deal with these questions. Whatever the affordability issues and the accessibility issues of appropriate treatment regimes, whatever, those issues have got to get dealt with. These issues are on the table. They are controversial. They have got to be dealt with. We have got to step up and answer those issues.

    But, again, the approach in my opinion—I am not here singing a tune for one point. If I am singing a tune, it is for a comprehensive approach that respects the totality of the human family and the totality of the human spirit, and that means education and prevention as well as care and treatment, because we cannot allow millions of people to continue to die and we do nothing about it. And if all the issue is, is about resources, this is a wealthy Nation, and you and I know that the resources are there. If the will is there, we can put the monies up to get this job done.

    Chairman LEACH. Well, thank you, Congressman Dellums. Thank you, distinguished panelists.

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    Just by conclusion, let me say I don't think I have ever participated in a discussion anywhere in this Congress about more fundamental human condition issues: life and death, the family. And one is struck, in terms of family structure, that in many ways many parts of Africa have more cohesive families than most modern parts of America, and that there are issues of fundamental decency that apply.

    We sometimes note that we are the wealthiest country in the world, which is obviously true, but in a quantum way we are more advanced in basic research capacities than we are even in wealth, relative to the rest of the world. For this, the wealthiest country and the most advanced country in terms of research, as well as in many regards, systemic applications of almost every human service delivery, to abdicate our responsibility would simply be to defy moral and historical judgment.

    I think this is clearly a time for us to act, and act in ways quantumly beyond anything that any of us have considered. And I am very appreciative for all of your input into this, and hopefully we can advance the goal.

    The hearing is adjourned.

    [Whereupon, at 1:37 p.m., the hearing was adjourned.]