[Congressional Record Volume 149, Number 152 (Monday, October 27, 2003)]
[Senate]
[Pages S13256-S13258]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]




                             AIDS IN AFRICA

  Mr. SESSIONS. Mr. President, as the Senate considers the Foreign 
Operations bill, we are considering President Bush's proposal to spend 
$15 billion to deal with the crisis of AIDS in Africa. It is something 
I believe is a necessary thing. I supported the President on this. It 
is a tremendous amount of money, but it is a tremendous problem.
  There are many aspects of the problem. Not everybody agrees on every 
single part of it. I would just say I have done some work on it and I 
have looked at a number of the issues. I believe strongly that there 
are some things we can do. If we do them correctly and promptly and 
effectively, we can dramatically impact the transmission of AIDS in 
Africa and prevent people from becoming infected and thereby serve a 
great and noble purpose.
  I think this: We know thousands of people are infected in Africa 
every year. According to conservative numbers generated by the World 
Health Organization, 250,000 to 450,000 Africans each year contract 
AIDS, a death sentence ultimately, through healthcare routes. They 
contract that not from dangerous activities, but from seeking to 
improve their own health by going to a hospital, a doctor's office, a 
clinic, and getting a shot or receiving a transfusion. One thousand a 
day at a minimum are infected by these procedures. It is totally 
preventable. It goes beyond just policy, and it is in my view a moral 
imperative. There is no doubt we can reduce this problem in Africa. We 
can do it by good policy and strong leadership and I believe we need to 
speak as a Congress on this issue.
  In March of this year I had occasion to read a newspaper article that 
was in the Washington Times. It quoted a published article in the 
International Journal of STD and AIDS, a publication of the British 
Royal Society of Medicine, that presented evidence that the reuse of 
needles and syringes has played a major role in the HIV/AIDS epidemic 
in Africa.
  At the time, the article challenged conventional wisdom and the 
belief in the international public health community that heterosexual 
sexual contact was the primary route of transmission for HIV in Africa 
and that medical transmission of the disease did not require the 
foremost attention of health care specialists.
  Dr. David Gisselquist pointed to a number of pieces of evidence 
supporting his conclusion that medical exposures account for a large 
proportion of HIV transmissions. He conducted an extensive review of 
refereed journal articles on the epidemiology--that is the history of 
the transmission, the people who get it--in the African HIV epidemic. A 
careful analysis of the data behind these studies enabled him to 
identify the following trends:
  No. 1, multiple studies he reviewed found HIV-infected children whose 
mothers test negative for the virus. Many of these children are far too 
young to have contracted the HIV virus through sexual practices or drug 
use, leaving their infections unexplained by conventional assumptions 
about the spread of the disease. It was found, however, that these 
children bearing the HIV virus had, on average, received nearly twice 
as many injections of vaccines and medicines than their uninfected 
peers, leading researchers to conclude that there was a strong 
correlation between the number of injections a child received and that 
child's chances of contracting HIV.
  As we looked at the issue, we found it was not a newly discussed 
matter but in fact had been out in the field for some time, 
unfortunately not receiving the kind of attention it should, in my 
view, have received from the people who were required and authorized to 
participate in the treatment and prevention of the disease.
  Let me just show this article, a blowup from the San Francisco 
Chronicle dated Tuesday, October 27, 1998, 5 years ago this date. The 
title of it is ``Fast Track To Global Disaster.''
  The subheadline under the top is ``Deadly Needles.'' This is what the 
subheadline said:

       For decades, researchers have warned that contaminated 
     syringes could transmit deadly viruses with cruel efficiency, 
     but efforts to defuse the crisis failed, and today, it has 
     become an insidious global epidemic, destroying millions of 
     lives every year.

  You ask why, perhaps, did we not deal with that back in 1998 when 
these matters were being raised. Apparently, there was a debate and a 
concern that panic would ensue and maybe people wouldn't seek medical 
care, or that it would deflect attention from WHO's primary view that 
sexual transmission was the way AIDS was transmitted.
  I note this statement by Mike Zaffran of the World Health 
Organization. You can tell they were wrestling with it, although they 
did not take action. The subject quote is:

       We want to avoid creating a panic. But maybe there is a 
     need to create that panic to solve this problem.

  According to WHO, 10 percent of the AIDS transmissions in Africa come 
from reused needles or contaminated transfusions, both of which are 
totally preventable, as I will discuss shortly. But I just want to say 
right now that there is evidence to suggest that the true figure is far 
larger than 10 percent. Remember, people who contract AIDS and who have 
no reason to believe they have AIDS are then in a position to 
unwittingly transmit that disease to their spouses and to others with 
whom they come in contact. Those who ultimately pass the disease by 
those contacts may not have done so had they known they had been 
exposed. I think it has a multiplier effect on the crisis in Africa, 
clearly affecting and involving the infection of millions of Africans.
  I have hosted two hearings in the Health, Education, Labor, and 
Pensions Committee on this issue. We have had witnesses from the World 
Health Organization, from USAID, and from private groups such as 
Physicians for Human Rights. They have presented evidence. At the 
conclusion of that testimony, I am even more concerned that the numbers 
the WHO has acted on or not acted on are low, that more than 10 percent 
of these HIV cases are being transmitted through unsafe healthcare. 
Certainly, that is the conclusion Dr. Gisselquist reached after 
extensive study.
  Let me talk about a couple of things: The good news and the bad news.
  Injection safety is a critical issue in America. Our health care 
community has long recognized the risks associated with unsafe 
injections.
  At the outset of the HIV epidemic in America, one of the top 
priorities in this country was to quickly ensure that patients and 
health care workers were educated about these risks and that steps were 
taken to provide ample supplies of single-use syringes--syringes that 
could not be used again--with safety features to ensure that

[[Page S13257]]

both patients and providers were protected.
  In fact, one thing we dealt with in this Congress was the Ryan White 
Act that was passed in response to the infection of young Ryan White as 
the result of a tainted blood products that he received to treat his 
hemophilia. In fact, long before the HIV virus emerged as a significant 
epidemic in the United States, health care workers and policymakers 
were well aware that unsafe injection practices could spread many 
dangerous diseases and posed a public health hazard. There was ample 
evidence that unsafe practices can kill.
  From the 1950s through 1982, the Egyptian Government carried out an 
ambitious program to eliminate schistosomiasis, a serious parasitic 
disease. Infected Egyptians received multiple injections to kill this 
parasite--up to 16 injections over 3 months. The needles used in these 
campaigns were rarely sterilized sufficiently to kill viruses such as 
hepatitis C.
  By the 1980s, it became clear that Egypt was in the grip of a 
tremendous epidemic of hepatitis C, a disease that frequently leads to 
liver failure, cancer, and death. In a country of 67 million people, it 
was estimated that 20 percent of the population had been exposed to 
hepatitis C. Neighboring Sudan, in comparison, had a rate of less than 
5 percent.
  This is still thought to represent ``the world's largest iatrogenic 
transmission event.'' The World Health Organization's data suggests 
that unclean needles contributed to an appalling 18.9 percent 
prevalence rate of the deadly hepatitis C virus in the Egyptian 
population. Altogether, over 12 million people were exposed to this 
virus and 7.2 million infected. Those are stunning numbers, and they 
are the result of using dirty needles.
  One of the University of Maryland researchers who chronicled this 
disaster stated emphatically that the practice of reusing inadequately 
sterilized or unsterilized syringes ``before the danger of exposure to 
blood was so well known, and before the availability of disposable 
needles and syringes provided a very potent means for the transmission 
of blood-borne infections.''
  That is something we don't doubt in America today. Unfortunately, 
however, the same conditions that permitted this tragedy to occur 
continue to exist in Africa and other areas of the world, and these 
unsafe practices spread not only hepatitis but also the HIV virus, 
leading to AIDS and leading to death.
  Health care workers around the world continue to devote time and 
resources to treating medically transmitted infections, many of which 
remain incurable even by the best medical science.
  Since the recognition that unsafe injections pose an unacceptable 
risk in vaccination campaigns, international vaccination programs now 
almost universally include adequate injection safety training and 
supplies. These limited efforts are commendable but much more needs to 
be done.
  To understand the proportion of the problem that remains to be 
addressed, one must note the distinction between injections given for 
vaccination and therapeutic injections, or injections given for the 
purpose of treating infections or other diseases.
  It has been estimated that worldwide, therapeutic injections 
outnumber vaccinations by 9 to 1, totaling approximately 12 billion 
injections administered each year in the developing world, including 
the African nations of the Global AIDS Initiative.
  Despite this fact and the demonstrated risks associated with unsafe 
injections, researchers and leaders in the field of HIV prevention have 
warned that ``little attention has been paid to the systematic 
correction of widespread unsafe practices resulting in disease 
transmission through therapeutic injections''--the very problem 
referenced in this chart where, at the beginning, it says ``Deadly 
Needles''--dated October 27, 1998--5 years ago today.
  At the outset of the AIDS epidemic in the United States, our 
Government and the public declared that blood supplies must be 
absolutely safe. The Federal Government and the public health community 
moved rapidly to ensure that every single unit of blood donated in this 
country is tested for the HIV virus before it is given to any person.
  It is estimated--get this number--that 25 percent of the blood 
donated in Africa is never tested for HIV--75 percent is but 25 percent 
is not--and that up to 80 percent of the blood is not tested for 
hepatitis. It is estimated by the respected group, Safe Blood For 
Africa--their name indicates their concern about this problem--that as 
a consequence of this breakdown, approximately 15 percent of the sub-
Saharan African blood supply is infected with HIV and 20 percent with 
hepatitis. Fifteen percent of the blood supply in sub-Saharan Africa is 
infected with HIV, a deadly disease. People go there and they get 
transfusions on a regular basis. The World Health Organization 
estimates that up to 10 percent of new HIV cases in Africa are due to 
contaminated blood transfusions.
  Once again, it is clear that transfusions of contaminated blood 
represent yet another hidden source of transmission of this disease, 
fueling the epidemic.
  Seventy percent of the recipients of these high-risk transfusions are 
women and children, making blood safety a critical component of our 
larger effort to fight HIV/AIDS and to protect the mothers and 
children. I will repeat that: 70 percent of the recipients of these 
high-risk transfusions--15 percent of which is contaminated with HIV--
are women and children.
  So what does that mean? That means that 15 out of every 100 women who 
go to get a transfusion in Africa--and many of them get transfusions 
because malaria leads to a lot of transfusions, really more than is 
needed to be performed but they are performed--and from those 
transfusions, thousands come home with AIDS. Instead of being healed 
and cured, they are infected with a deadly disease.
  It is important to recognize, too, that in the treatment of anemia, 
which is related to problems such as malaria, best medical practices 
would dictate that many of these transfusions are not necessary. So the 
combination of reducing the number of transfusions is the first step, 
along with making sure every blood unit that is utilized in Africa is 
tested for AIDS before being used in a blood transfusion.
  We have an HIV rate in the United States of less than 1 percent, and 
we test our blood supply. In some countries in Africa, the HIV 
prevalence rate is as high as 40 percent. Every blood donation in the 
world, and particularly in Africa, should be tested before we do 
transfusions. This is one more example of the potential ways in which 
we can reduce the risk of this deadly disease.
  I would also like to share some thoughts about why I think this is 
not just a public policy issue for discussion but why it is a moral 
imperative.
  We will be spending $15 billion over 5 years, on average $3 billion a 
year. I know there is debate whether we should have the full $3 billion 
this first year. I have my doubts the money can be assimilated, but we 
are going to be spending that over 5 years.
  Let me talk to you about the cost of completely fixing the medical 
transmission problem. One of the most startling facts and best news 
about health care transmissions of HIV in Africa is the fact that 
injection safety and blood safety have been specifically singled out by 
researchers as the most cost-effective means of preventing the spread 
of HIV.
  A study by the World Health Organization, in 1999--a year after the 
San Francisco Chronicle article--suggested that addressing the problem 
of unsafe injections might well result in actual savings for the 
governments and organizations financing the fight against AIDS. It can 
actually save them money. These savings would be generated both by a 
reduction in the number of unnecessary injections and transfusions, 
which, amazingly, may account for a majority of the therapeutic 
injections actually given--and a majority of the therapeutic injections 
in Africa are probably not necessary and could be handled without any 
shots or with a pill--and by avoiding the tremendous financial drain 
that occurs as a result of these infections, including hepatitis.
  In testimony before the Health, Education, Labor, and Pensions 
Committee at a hearing which I chaired in July, one of the leading 
World Health Organization researchers confirmed both his own conclusion 
that ending unsafe injection practices would be eminently

[[Page S13258]]

cost effective and his projection that blood safety efforts would prove 
to be similarly cost effective.
  In fact, on a day when we are discussing $15 billion for Global AIDS, 
the benefits of an additional $1 billion here or $289 million there--I 
think you would all be stunned at the numbers involved in solving this 
problem. These estimates I am going to give you were provided by the 
World Health Organization.
  Clean, new needles and syringes for every injection, given by medical 
personnel educated in the proper use of injections in Africa would cost 
$24 million for all 12 nations included in the Global AIDS initiative. 
Just $24 million would provide safe and clean needles for every 
necessary injection in Africa.
  Clean, safe blood transfusions, administered by medical personnel 
trained in the proper indications for transfusions--$46 million for all 
12 nations. So for $46 million, we can completely eliminate the problem 
of transfusions, which WHO admits could be 10 percent of the problem of 
all the problem of AIDS in Africa.

  There are so many tragic aspects to this problem.
  Hard-working frontline doctors and nurses inadvertently contribute to 
the spread of the very diseases they are struggling to prevent.
  At the HELP Committee hearing, it was very encouraging to hear the 
testimony of Dr. John Ssemakula, a physician from Uganda, who was able 
to describe the great strides his country has made in cleaning up 
injection practices.
  Dr. Ssemakula was also able to convey the plea of the dedicated men 
and women on the frontlines of health care in Uganda, that they be 
provided with the equipment they need to provide safe injections.
  These are intelligent, educated, well-intentioned people, and they 
simply want enough syringes to provide patients with safe health care.
  The health care system in developing nations frequently does not 
provide either necessary education in proper injection procedures or, 
for those providers who are striving to follow model practices, the 
relatively inexpensive supplies necessary to succeed.
  We are dealing with, frankly, with our health care providers 
worldwide, a double standard that is indefensible. You are tempted to 
say, it is an immoral double standard. Let me tell you about this 
troubling aspect of the problem. In developed nations, the general 
public has been made aware of the risk associated with unsafe medical 
care. We know in America you want safe health care. We insist on it. We 
spend what it takes to do it. We have needles that are safe to protect 
nurses and doctors from accidental pricks, much less the patient who 
goes to get a shot.
  When the use of contaminated blood and blood products results in the 
spread of HIV here, we act. The health community, the Federal and State 
regulators, and the American public immediately demand guaranteed 
safety, and very quickly we see that they get this. The safety of blood 
and blood products is now something Americans take for granted.
  Every unit of blood in this country is screened for HIV, hepatitis B, 
and hepatitis C. When it became clear that the reuse of contaminated 
needles put patients at risk, we acted. It is clear that many 
developing nations, including those in Africa within the President's 
Global AIDS initiative, have not yet been able to achieve similar 
results.
  This is where a disturbing double standard arises. The World Health 
Organization, the U.S. Government's Centers for Disease Control, and 
other organizations with employees in the developing nations openly 
caution their travelers to these areas, including their own workers, 
that blood is likely unscreened and needles likely reused. This is 
described as posing a risk of infection of hepatitis B, C, and HIV.
  Numerous workers, including our own embassy employees and AIDS 
workers in Africa, can tell of being instructed to ask for plasma 
expanders rather than dangerous blood transfusions or being cautioned 
to purchase and provide their own new, clean syringes when they go to 
the doctor.
  When formulating public statements and policy for these very same 
African nations, however, many of these organizations continue to 
maintain that contaminated blood and reused needles are not significant 
problems and do not pose substantial health risks to African patients.
  We have made some progress. We have had a number of hearings on this 
subject. I have become more convinced than I was when we started that 
this is an unacceptable practice. It is an unacceptable situation in 
Africa and one that can be fixed for less than $100 million a year. We 
can provide tested, safe blood for every transfusion in Africa, and we 
can provide clean, unused needles for every injection at a cost of less 
than $100 million a year. That is tremendous news. We are on the road 
to making some progress.
  I have talked to top officials in the World Health Organization and 
the U.S. Government. We believe that with Director Tobias' new position 
in the State Department as sort of an American global AIDS czar that he 
is attuning himself to this issue, that the CDC, at my request, is 
conducting research to develop a plan to attack this problem. Health 
and Human Services is conducting a study which we expect to receive 
back in a matter of weeks that will review independently all the other 
existing studies of AIDS transmission in Africa to attempt to determine 
just how big a problem this really is. And now we are at a point where 
we are putting this new money into the program.
  I urge my colleagues to act now to ensure that a certain amount of 
this money--it would be less than 5 percent, probably closer to 2 
percent--be dedicated to dealing with the medical transmission problem. 
We need to do that. Sure, they can spend more than that if they want 
to, but this is the minimum amount that virtually guarantees tremendous 
success against medical transmissions.
  Let's do that as part of our legislation. We can go home and know 
that we made a difference.
  Some say: Well, Jeff, we are picking up on this issue. We really 
don't need any direction on how to spend our money. Just give it to us, 
and we will spend it like we want. I generally am sympathetic to 
agencies not being micromanaged. But with the resistance we continue to 
see from the World Health Organization and American organizations that 
deal with this issue, we need to ensure that this much money gets 
spent.
  There was a conference in September in Africa. Thousands of people 
attended who deal with the AIDS epidemic. The WHO entity issued a press 
release after that meeting--again just a matter of weeks ago--WHO 
issued a news release dismissing the significance of medical 
transmission. This caused a group of scientists who were at the meeting 
to issue a statement of their own contracting it. They said in effect, 
WHO continues to reject evidence that stopping HIV transmission through 
unsterile health care could slow the spread of disease.
  So we have a continuing problem, continuing to stick with numbers 
that do not appear to be justified and policies that need to be 
changed. It is time for us to take a step to save lives. The very 
thought that we could knock down maybe in 18 months' time, instead of 
1,000 people being infected a day by the health care transmission of 
HIV in Africa, why it could be down to 200; and then in 2 or 3 years 
down to virtually zero? That is possible. Which would we rather do? 
Prevent the contraction of a deadly disease or try to deal with the 
consequences of the disease once a person is infected?
  This is the right step. I thank Senator McConnell for his interest 
and the President for his leadership.
  I yield the floor and suggest the absence of a quorum.
  The PRESIDING OFFICER. The clerk will call the roll.
  The legislative clerk proceeded to call the roll.
  Mr. McCONNELL. Mr. President, I ask unanimous consent that the order 
for the quorum call be rescinded.
  The PRESIDING OFFICER. Without objection, it is so ordered.

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