[Congressional Record (Bound Edition), Volume 152 (2006), Part 13]
[Extensions of Remarks]
[Pages 17563-17564]
[From the U.S. Government Publishing Office, www.gpo.gov]




            AIDS IN 2006--MOVING TOWARD ONE WORLD, ONE HOPE?

                                 ______
                                 

                       HON. JANICE D. SCHAKOWSKY

                              of illinois

                    in the house of representatives

                      Thursday, September 7, 2006

  Ms. SCHAKOWSKY. Mr. Speaker, the International AIDS Society meeting 
in Toronto last month focused the world's attention on ways to deal 
with the ongoing AIDS pandemic. Global health experts and advocates 
came together to discuss effective tactics and comprehensive strategies 
for improved prevention and therapies and, ultimately, a cure. I am 
particularly glad that the meeting highlighted the need for 
microbicides development, treatments that will allow vulnerable women 
to protect themselves and their families from infection.
  As we consider the recommendations made in Toronto, I want to draw my 
colleagues' attention to a recent article, ``AIDS in 2006--Moving 
toward One World, One Hope?,'' published in the August 17 edition of 
The New England Journal of Medicine. Written by Dr. Paul Farmer and Dr. 
Jim Yong Kim, leading medical experts with years of front-line 
experience through their work at Partners in Health, they offer us 
important lessons that will help translate the optimism expressed in 
Toronto into the reality of improved global health.
  As they point out, an effective approach to the global AIDS epidemic 
(and to the global TB and malaria epidemics as well) will require 
strategies that address the global epidemic of poverty and the 
inequitable distribution of health care resources. Affordable drugs, 
viable public health systems, access to trained health care personnel, 
and the provision of nutrition and other ``wrap-around'' services that 
make the difference between life and death are all essential components 
for success. As Partners in Health has proven in Haiti and Rwanda, this 
comprehensive approach is not a pie-in-the-sky notion. It is completely 
achievable given a commitment to make and sustain the necessary 
investments.
  The work of nongovernmental organizations like Partners in Health, 
the Bill and Melinda Gates Foundation and the Clinton Foundations HIV/
AIDS Initiative has allowed us to make incredible strides, but they 
cannot solve these problems alone. As Dr. Farmer and Dr. Kim caution 
us, ``Only the public sector, not nongovernmental organizations, can 
offer health care as a right.'' The U.S. government can and must take 
the lead in expanding our commitment to defeating the twin dangers of 
global pandemics and global poverty. By doing so, we will not only make 
the world healthier, we will make it safer.

       [From the New England Journal of Medicine, Aug. 17, 2006]

            AIDS in 2006--Moving Toward One World, One Hope?

                   (By Jim Yong Kim and Paul Farmer)

       For the past two decades, AIDS experts--clinicians, 
     epidemiologists, policymakers, activists, and scientists--
     have gathered every two years to confer about what is now the 
     world's leading infectious cause of death among young adults. 
     This year, the International AIDS Society is hosting the 
     meeting in Toronto from August 13 through 18. The last time 
     the conference was held in Canada, in 1996, its theme was 
     ``One World, One Hope.'' But it was evident to conferees from 
     the poorer reaches of the world that the price tag of the 
     era's great hope--combination antiretroviral therapy--
     rendered it out of their reach. Indeed, some African 
     participants that year made a banner reading ``One World, No 
     Hope.''
       Today, the global picture is quite different. The claims 
     that have been made for the efficacy of antiretroviral 
     therapy have proved to be well founded: in the United States, 
     such therapy has prolonged life by an estimated 13 years--a 
     success rate that would compare favorably with that of almost 
     any treatment for cancer or complications of coronary artery 
     disease. In addition, a number of lessons, with implications 
     for policy and action, have emerged from efforts that are 
     well under way in the developing world. During the past 
     decade, we have gleaned these lessons from our work in 
     setting global AIDS policies at the World Health Organization 
     in Geneva and in implementing integrated programs for AIDS 
     prevention and care in places such as rural Haiti and Rwanda. 
     As vastly different as these places may be, they are part of 
     one world, and we believe that ambitious policy goals, 
     adequate funding, and knowledge about implementation can move 
     us toward the elusive goal of shared hope.
       The first lesson is that charging for AIDS prevention and 
     care will pose insurmountable problems for people living in 
     poverty, since there will always be those unable to pay even 
     modest amounts for services or medications, whether generic 
     or branded. Like efforts to battle airborne tuberculosis, 
     such services should be seen as a public good for public 
     health. Policymakers and public health officials, especially 
     in heavily burdened regions, should adopt universal-access 
     plans and waive fees for HIV care. Initially, this approach 
     will require sustained donor contributions, but many African 
     countries have recently set targets for increased national 
     investments in health, a pledge that could render ambitious 
     programs sustainable in the long run.
       As local investments increase, the price of AIDS care is 
     decreasing. The development of generic medications means that 
     antiretroviral therapy can now cost less than 50 cents per 
     day, and costs continue to decrease to affordable levels for 
     public health officials in developing countries. All 
     antiretroviral medications--first-line, second-line, and 
     third-line--must be made available at such prices. 
     Manufacturers of generic drugs in China, India, and other 
     developing countries stand ready to provide the full range of 
     drugs. Whether through negotiated agreements or use of the 
     full flexibilities of the Agreement on Trade-Related Aspects 
     of Intellectual Property Rights, full access to all available 
     antiretroviral drugs must quickly become the standard in all 
     countries.

[[Page 17564]]

       Second, the effective scale-up of pilot projects will 
     require the strengthening and even rebuilding of health care 
     systems, including those charged with delivering primary 
     care. In the past, the lack of a health care infrastructure 
     has been a barrier to antiretroviral therapy; we must now 
     marshal AIDS resources, which are at last considerable, to 
     rebuild public health systems in sub-Saharan Africa and other 
     HIV-burdened regions. These efforts will not weaken efforts 
     to address other problems--malaria and other diseases of 
     poverty, maternal mortality, and insufficient vaccination 
     coverage--if they are planned deliberately with the public 
     sector in mind. Only the public sector, not nongovernmental 
     organizations, can offer health care as a right.
       Third, a lack of trained health care personnel, most 
     notably doctors, is invoked as a reason for the failure to 
     treat AIDS in poor countries. The lack is real, and the brain 
     drain continues. But one reason doctors flee Africa is that 
     they lack the tools of their trade. AIDS funding offers us a 
     chance not only to recruit physicians and nurses to 
     underserved regions, but also to train community health care 
     workers to supervise care, for AIDS and many other diseases, 
     within their home villages and neighborhoods. Such training 
     should be undertaken even in places where physicians are 
     abundant, since community-based, closely supervised care 
     represents the highest standard of care for chronic disease, 
     whether in the First World or the Third. And community health 
     care workers must be compensated for their labor if these 
     programs are to be sustainable.
       Fourth, extreme poverty makes it difficult for many 
     patients to comply with antiretroviral therapy. Indeed, 
     poverty is far and away the greatest barrier to the scale-up 
     of treatment and prevention programs. Our experience in Haiti 
     and Rwanda has shown us that it is possible to remove many of 
     the social and economic barriers to adherence but only with 
     what are sometimes termed ``wrap-around services'': food 
     supplements for the hungry, help with transportation to 
     clinics, child care, and housing. In many rural regions of 
     Africa, hunger is the major coexisting condition in patients 
     with AIDS or tuberculosis, and these consumptive diseases 
     cannot be treated effectively without food supplementation. 
     Coordination among initiatives such as the President's 
     Emergency Plan for AIDS Relief, the Global Fund to Fight 
     AIDS, Tuberculosis, and Malaria, and the World Food Program 
     of the United Nations can help in the short term; fair-trade 
     agreements and support of African farmers will help in the 
     long run.
       Fifth, investments in efforts to combat the global 
     epidemics of AIDS and tuberculosis are much more generous 
     than they were five years ago, but funding must be increased 
     and sustained if we are to slow these increasingly complex 
     epidemics. One of the most ominous recent developments is the 
     advent of highly drug-resistant strains of both causative 
     pathogens. ``Extensively drug-resistant tuberculosis'' has 
     been reported in the United States, Eastern Europe, Asia, 
     South Africa, and elsewhere; in each of these settings, the 
     copresence of HIV has amplified local epidemics of these 
     almost untreatable strains. Drug-resistant malaria is now 
     common worldwide, extensively drug-resistant HIV disease will 
     surely follow, and massive efforts to diagnose and treat 
     these diseases ethically and effectively will be needed. We 
     have already learned a great deal about how best to expand 
     access to second-line antituberculous drugs while increasing 
     control over their use; these lessons must be applied in the 
     struggles against AIDS, malaria, and other infectious 
     pathogens.
       Finally, there is a need for a renewed basic-science 
     commitment to vaccine development, more reliable diagnostics 
     (the 100-year-old tests widely used to diagnose tuberculosis 
     are neither specific nor sensitive), and new classes of 
     therapeutics. The research-based pharmaceutical industry has 
     a critical role to play in drug development, even if the 
     overall goal is a segmented market, with higher prices in 
     developed countries and generic production with affordable 
     prices in developing countries.
       There has been a heartening increase in basic-science 
     investments for tuberculosis and malaria; funding for HIV 
     research at the National Institutes of Health remains robust. 
     Yet the fruits of such research will not arrive in time for 
     those now living with, and dying from, AIDS and tuberculosis. 
     New tools to prevent, diagnose, and treat the diseases of 
     poverty will be added to the stockpile of other potentially 
     lifesaving products that do not reach the poorest people, 
     unless we develop an equity plan to provide them. Right now, 
     our focus must be on improving access to the therapies that 
     are available in high-income countries. The past few years 
     have shown us that we can make these services available to 
     millions, even in the poorest reaches of the world.
       The unglamorous and difficult process of increasing access 
     to prevention and care needs to be our primary focus if we 
     are to move toward the lofty goal of equitably distributed 
     medical services in a world riven by inequality. Without such 
     goals, the slogan ``One World, One Hope'' will remain nothing 
     more than a dream.

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