[Congressional Record (Bound Edition), Volume 154 (2008), Part 11]
[Senate]
[Pages 14761-14771]
[From the U.S. Government Publishing Office, www.gpo.gov]




                                 PEPFAR

  Mr. LUGAR. I thank the leader.
  I rise today in support of S. 2731, the Tom Lantos and Henry J. Hyde 
United States Global Leadership Act Against HIV/AIDS, Tuberculosis, and 
Malaria. I thank Chairman Joe Biden for working with me and other 
Republicans to achieve a bipartisan approach for the reauthorization of 
our Nation's program to combat these diseases. I believe we will have 
an excellent bill before us that will preserve the best aspects of the 
President's Emergency Plan For AIDS Relief--PEPFAR--and expand the 
efforts of the United States to stem the tide of AIDS, tuberculosis, 
and malaria worldwide.
  The HIV/AIDS pandemic, coupled with the impact of tuberculosis and 
malaria, is rending the socioeconomic fabric of communities, nations, 
and an entire continent. The U.S. National Intelligence Council and 
innumerable top officials, including President Bush, have stated the 
HIV/AIDS pandemic is a threat to national and international security.
  Communities are being hobbled by the disability and the loss of 
consumers and workers at the peak of their productive, reproductive, 
and care-giving years. In the most heavily affected areas, communities 
are losing a whole generation of parents, teachers, laborers, health 
care workers, peacekeepers, and police.
  United Nations projections indicate that by 2020, HIV/AIDS will have 
depressed GDP by more than 20 percent in the hardest hit countries. The 
World Bank recently warned that while the global economy is expected to 
more than double over the next 25 years, Africa is at risk of being 
left behind.
  Many children who have lost parents to HIV/AIDS are left entirely on 
their own, leading to an epidemic of orphan-headed households. When 
they drop out of school to fend for themselves and their siblings, they 
lose the potential for economic empowerment that an education can 
provide. Alone and desperate, they sometimes resort to transactional 
sex or prostitution to survive and risk becoming infected with HIV 
themselves.
  I believe that in addition to our own national security concerns, we 
have a humanitarian duty to take action. Five years ago, HIV was a 
death sentence for most individuals in the developing world who 
contracted that disease. Now there is hope. We should never forget that 
behind each number is a person--a human being--a life the United States 
can touch or even save.
  PEPFAR has provided treatment to an estimated 1.4 million men, women, 
and children infected with HIV/AIDS in Africa and elsewhere. Before the 
program began, only 50,000 people in all of sub-Saharan Africa were 
receiving lifesaving antiretroviral drugs. Today, three times that many 
are being treated in Kenya alone. PEPFAR also has focused on prevention 
programs, with the target of preventing 7 million new HIV infections. 
As Americans, we should take pride in our Nation's efforts to combat 
these diseases overseas.
  We should understand that our investments in disease prevention 
programs have yielded enormous foreign policy benefits during the last 
5 years. PEPFAR has helped to prevent instability and societal collapse 
in a number of at-risk countries; it has stimulated contributions from 
other wealthy nations to fight AIDS; it has facilitated deep 
partnerships with a generation of African leaders; and it has improved 
attitudes toward the United States and Africa and other regions of the 
world. In my judgment, the dollars spent on this program can be 
justified purely on the basis of the humanitarian results we have 
achieved, but the value of this investment clearly extends to our 
national security and to our national reputation.
  I wish to emphasize three points that should guide our deliberations. 
First, it is important that Congress move now to reauthorize the 
program. The authorization expires in 2\1/2\ months. Partner 
governments and implementing organizations in the field have indicated 
that without certainty of reauthorization of this bill, they may delay 
expanding their programs to meet PEPFAR goals. Certainty of U.S. action 
is an important matter of perception, delivering something similar to

[[Page 14762]]

consumer confidence to these nations. It may be intangible, but it will 
profoundly affect the behavior of individuals, groups, and governments 
engaged in the fight against HIV/AIDS. The continuity of our efforts to 
combat aids, malaria, and tuberculosis, and the impact of our resources 
on the commitments of the rest of the world will be maximized if we act 
now.
  Underscoring this point, last fall the Ministers of Health of the 12 
African focus countries receiving PEPFAR assistance wrote to us saying:

       Without an early and clear signal of the continuity of 
     PEPFAR's support, we are concerned that partners might not 
     move as quickly as possible to fill the resource gap that 
     might be created. Therefore, services will not reach all who 
     need them. . . . The momentum will be much greater in 2008 if 
     we know what to expect after 2008.

  Secondly, our bill expands the flexibility of current law so that 
U.S. efforts in each country can be tailored to its unique situation. I 
have consulted extensively with American officials who are implementing 
PEPFAR. Most believe that adding new restrictions to the law can limit 
the flexibility of those charged with implementation in 2009 and 
beyond. We don't know who that will be and, more importantly, we don't 
know what the challenges of 2013 will be, although we can probably say 
with confidence the landscape will be very different than it is today. 
As the Institute of Medicine said, the Global Leadership Act is a 
``learning organization.'' We should pass a bill that allows PEPFAR to 
expand and evolve its program implementation, utilizing the experience 
it has gained in its initial years of operation.
  I understand some Members identify concerns or areas that they 
believe deserve specific emphasis. As Senators study the record of 
PEPFAR to date, I believe they will find that the vast majority of the 
authorities needed for the next phase of our efforts already are in 
existing legislation. This flexibility is preserved in the House bill 
and in the bill before us today.
  The one directive in the Leadership Act that I believe must be 
maintained holds that 10 percent of funding be devoted to programs for 
orphans and vulnerable children. There were few programs focused on the 
needs of these children before the Leadership Act, and we remain in the 
early stages of the effort to serve them. Before the advent of PEPFAR, 
neither the United States nor anyone else had much experience in 
programs that support children infected with or affected by HIV/AIDS. 
After several years of effort, we have made some progress, but our 
programs are not yet as firmly established as they can be.
  The AIDS orphans crisis in sub-Saharan Africa has implications for 
political stability, development, and human welfare that extend far 
beyond that region. The American people strongly back this effort, and 
the maintenance of this directive will help to ensure that we remain 
attentive to those who need our support the most. The directive will 
also help ensure the success of the Assistance for Orphans and Other 
Vulnerable Children in Developing Countries Act of 2005, a bill I 
drafted and which was cosponsored by 11 Senators. That bill was signed 
into law on November 8, 2005.
  The third point I would underscore is this is an authorization bill 
subject to the annual budget and appropriations process. It is meant to 
establish policy and the overall parameters of spending on the PEPFAR 
program. The $50 billion figure is based on what we believe can be 
spent efficiently and effectively in the years ahead. It presumes that 
funding will gradually increase over the coming 5-year period. Of the 
$50 billion authorized, $5 billion has been reserved for malaria and $4 
billion has been reserved for tuberculosis.
  I understand some Members would spend less than $50 billion, while 
others would choose to spend more.
  But this is a reasonable target that has emerged from good-faith 
negotiations between Congress and the White House. I believe it will 
maximize the humanitarian and foreign policy benefits of the PEPFAR 
Program.
  We have an opportunity this week to establish policy on a bipartisan 
basis that will be a triumph for the United States of America. We have 
the opportunity to save lives on a massive scale and preserve the 
fabric of numerous fragile societies. I ask my colleagues to continue 
to work together for this very important result.
  I look forward to the passage of this important legislation.
  Mr. President, I yield the floor.
  The PRESIDING OFFICER. The Senator from Florida is recognized.
  Mr. NELSON of Florida. Mr. President, I ask unanimous consent that I 
be allowed to speak for the remainder of the time on this side in 
morning business.
  The PRESIDING OFFICER. Without objection, it is so ordered.
  Mr. NELSON of Florida. Mr. President, I thank the Senator from 
Indiana for his and Senator Biden's leadership in getting this 
legislation to the floor.
  This Senator has just returned from Africa over the July 4th recess. 
Four countries in southeastern Africa--Kenya, Tanzania, Uganda, and 
Rwanda--is where PEPFAR has been concentrated. Out of the $3 billion 
that is being spent per year in Africa, for example, $500 million of 
that goes just to the country of Kenya.
  As the distinguished Senator from Indiana has said, it is very true 
that the attitudes about the United States--as a result of us being out 
there with this very effective program that is turning people's lives 
around, which, in fact, is taking people who were nothing but skin and 
bones and now being able to live a somewhat normal life, it has 
increased the favorability toward the United States enormously all over 
the continent. It has had a tremendous effect. For example, in Kampala, 
Uganda, I visited a PEPFAR program. It was not only giving the 
antiviral drugs--and these were to a lot of the children of the 
refugees who live in this squalor you could not believe, but, in 
addition, if their bodies won't take the drugs because they are 
malnourished, there is a food program that goes along with it through 
USAID. The combination of the two--a year ago in Ethiopia, the same 
thing--by getting their little bodies up to where, nutritionally, they 
can accept the HIV antiviral drugs, it has had a tremendous effect.
  On this particular PEPFAR Program, there was much more--a school for 
the children. The children wore uniforms. The children were learning 
science, math, English, and all the studies that will give them some 
opportunity for a fruitful and productive life. So now, as the 
leadership of our Senate Foreign Relations Committee has come forth 
with an extension and expansion of this program, it is absolutely 
necessary that we pass it.
  You cannot do any better than the good will--just think about the 
globe and about where America may not be held in the highest of esteem. 
But it is held in the highest esteem in Africa. It is in large part as 
a result--
  Mr. REID. Mr. President, I ask my friend to yield for a unanimous 
consent request.
  Mr. NELSON of Florida. I yield to the majority leader for that 
purpose.
  Mr. REID. Mr. President, it is my understanding that we had a half 
hour under morning business. I told Senator Nelson he could use the 
remaining approximately 10 minutes of that time and I would be 
recognized thereafter. Is there any concern about that? Is that still 
in effect?
  Mr. President, it is no big deal. It might make it easier for 
everybody. I will ask unanimous consent that I be recognized when 
Senator Nelson finishes his statement.
  The PRESIDING OFFICER. Is there objection? Without objection, it is 
so ordered.
  Mr. NELSON of Florida. Mr. President, I say to the majority leader, I 
would have asked that, but this Senator thought that was locked in with 
the previous unanimous consent. I thank the majority leader for the 
opportunity.
  Mr. President, the United States has benefited enormously because of 
the good will. That is one thing. But when you see these folks who have 
been bedeviled with this terrible, terrible infliction suddenly have a 
chance for a normal life as a result of these lifegiving drugs, when 
properly administered, along with the food programs

[[Page 14763]]

as well, indeed it is one of the least things we can do.
  Is it not in the capacity of the United States to help the rest of 
the world? Of course it is. Is it not within our ethos to want to help 
the rest of the world? It certainly is. Just as a byproduct of that, 
the people of Africa are recognizing the leadership that the United 
States has taken. They are appreciative.
  I must say that there was a part of this African trip that was very 
disturbing to me, and that was the grave situation in Zimbabwe. That is 
as a result of the disastrous regime of Robert Mugabe.
  Last Friday, a bunch of us Senators had joined Senators Feingold and 
Isakson, who are leaders on the African Affairs Subcommittee of the 
Foreign Relations Committee, in introducing a resolution to rebuke 
Robert Mugabe and support U.S. efforts at the United Nations to impose 
tougher sanctions on the Mugabe regime. Although the U.S.-sponsored 
resolution failed to overcome the vetoes of China and Russia--listen to 
that: the vetoes of China and Russia--in the Security Council on 
Friday--we kind of get an indication of where their attitude is about a 
democratically elected government in Zimbabwe--it is critical for us to 
continue to work with the U.N. and our African Union partners to help 
bring about a political solution for the desperate people in Zimbabwe.
  On this most recent trip, I didn't go to Zimbabwe. I wasn't welcome. 
It was a striking survey of the governments that I saw in those four 
countries, a new African leadership, strong economic growth, the rule 
of law, political stability--what a contrast with the old ways of 
dealing with people such as Mugabe, in a government that is marked with 
autocracy, corruption, and the rule of law through the barrel of a gun. 
Well, what is clearly in the interest of the people of Zimbabwe and the 
rest of the world is stability in Zimbabwe. And it is important that we 
continue to press forward.
  In east Africa, the rule of law does have some new applications--for 
example, the Government of Kenya. There, the whole place was being torn 
apart because of a dispute in the December election. Finally, after 
much violence and with as many as 5,000 deaths--if you can believe it--
because of the violence following the election, the business community, 
the government community, and the two opposition parties came together 
and said: We have to have a better way. They formed this unity 
government. Thus far, it has worked. Let's see how it continues.
  But in the aftermath of September 11, we know all too well how 
instability and weak governance and corruption can sow the seeds of 
radicalization and terrorism. Now, however destitute and downtrodden 
the heroic people of Zimbabwe, however, those heroic people have risen 
up against Mugabe's machine at the ballot box on March 29 and they cast 
their votes overwhelmingly for Morgan Tsvangirai and his Movement for 
Democratic Change. That opposition party won 48 percent of the vote 
against 43 percent for Mugabe.
  But then, of course, Mugabe initiated a reign of terror and 
intimidation in the lead-up to this farce of a runoff election. His 
state-sponsored violence against opposition members, against 
supporters, against civilians, in an attempt to consolidate his power, 
ultimately caused the opposition candidates to withdraw from the 
election. He had to take refuge in the Dutch Embassy. This recent 
runoff was declared neither credible nor fair by independent election 
monitors. Mugabe was the only candidate left. He was declared the 
winner.
  Since the initial election back in March, the opposition party said 
that 86 of its supporters have been killed and 200,000 of its 
supporters forced from their homes by militias loyal to Mugabe's party.
  If you will go back decades, Mugabe took over in a new country of 
Zimbabwe when he had thrown off the colonial rule under the old 
Rhodesia. Mugabe was looked upon as a freedom fighter and someone who 
was going to bring a fresh break, a fresh government that was going to 
be a democratic government. He has long been celebrated by his fellow 
African leaders for his role as a liberation leader for Zimbabwe. In 
recent years, Mugabe has too often been coddled as his failings have 
come to light. Two weeks ago, unfortunately, the African Union allowed 
him to take his seat as the head of state among the leaders in their 
annual meeting that was in Sharm el-Sheikh.
  Those African Union leaders were split over how to deal with Mugabe, 
but they allowed him to be seated. Many leaders, including South 
African President Mbeki, who serves as the South African Development 
Community's designated mediator, have stood by as Mugabe has trampled 
human rights, as he has silenced the press, as he has undermined the 
rule of law, and he has run the once-thriving Zimbabwean economy into 
the ground.
  South Africa worked behind the scenes to sink the U.S.-sponsored 
resolution on Zimbabwe at the U.N. last week. This is quite 
distressing, given that South Africa is where it is today because of 
the international sanctions to end apartheid.
  So now because of these ruinous economic policies, Zimbabwe is the 
world's fastest shrinking economy. It has a negative GDP of minus 6 
percent. It has skyrocketing inflation. Zimbabwe's central bank stopped 
posting inflation figures in January when inflation stood at, 
unbelievably, over 100,000 percent. A loaf of bread cost 30 billion 
Zimbabwean dollars--a loaf of bread.
  The sinking economy and the government-orchestrated political 
intimidation and murder has caused a massive refugee flight into the 
neighboring countries. According to a recent report by Human Rights 
Watch, there is now estimated to be 1.5 million Zimbabweans who have 
fled across the border into South Africa.
  The international community must honor the courage of the Zimbabwean 
people and help them take back their country from the brink of ruin.
  Recent reports show that a Chinese ship loaded with more than 1 
million pounds of arms bound for Zimbabwe was eventually turned away by 
the dock workers in Durban, South Africa, a reminder of the support 
Mugabe continues to receive from around the world.
  The United States is going to have to continue to work in the U.N. 
and with the African Union to immediately call for Robert Mugabe to 
step down and to push for a number of practical solutions for the 
crisis in Zimbabwe.
  First is an international arms embargo and stricter sanctions. 
Although our backed resolution in the United Nations last Friday 
failed, we must continue to work on an international framework to 
impose sanctions on international arms, travel, and an asset embargo. 
We have to get Mugabe to understand that his totalitarian, dictatorial 
ways have to change.
  Then we need to press for any new power sharing arrangement. Any new 
mediation must secure agreement with the opposition, with Tsvangirai in 
the lead, and provide support in setting up new institutions. We can 
assist the transitional government by helping to provide a framework 
for future elections and reforms.
  We need to help them economically. The African Union, led by 
Zimbabwe's largest trading partners, including South Africa, Zambia, 
Congo, and Botswana, should put together a package of aid and 
reconstruction funding to help the ravaged people of Zimbabwe stand on 
their feet. The United States and Europe can play a leading role in 
backing that effort with the support that we are so generously quick to 
offer.
  The situation in Zimbabwe is dire, and the United States must take 
the lead in rebuking Robert Mugabe in calling for a new dawn for 
Zimbabwe.
  It is a time in which when you see the success, the beginnings of 
political stability, the beginnings of economic blossoming in countries 
such as Kenya and Tanzania and Uganda and Rwanda, we know the same 
thing can be done in a place such as Zimbabwe.
  Just think, in those last two countries I mentioned, Uganda and 
Rwanda, look from where they have come. It was not too many years ago 
that there was a brutal dictator named Idi Amin. A lot of people have 
seen the movie

[[Page 14764]]

``The Last King of Scotland,'' which tells about the brutality of that 
regime. But as soon as Idi Amin was gone, the former President came in 
again and became almost as bad, Obote. It wasn't until another strong 
man, a general named Museveni, came on that he has brought stability 
for the last couple of decades.
  Look at the country immediately to the south of Uganda. Look at 
Rwanda. Look at what has happened to Rwanda, a country, just 14 years 
ago, in 1994, because there was the hatred between the two tribes, the 
Hutus and the Tutsis--the Hutus were in charge of the government. They 
allowed the militias, the gangs, the thugs to reign and use as an 
excuse the downing of the President's airplane, and they unleashed a 
reign of terror that was nothing short of mass slaughter, genocide, of 
which, unbelievably, within 100 days, 1 million people were slaughtered 
and hacked to death by machetes. That was 14 years ago.
  The general who took over and is now the President of Rwanda, the 
opposite tribe, a Tutsi, said: We are not going the same way. We are 
not going to take revenge.
  You can imagine when his army came in and invaded the capital city of 
Rwanda and they saw bodies strewn all over the streets rotting, corpses 
that dogs were eating the flesh, and when his soldiers found out that 
their entire families had been wiped out, hacked to death with 
machetes, you can imagine the problem of discipline that general, now 
the new President of Rwanda, had in trying to exert discipline.
  The President told me in our meeting that was a very difficult time 
because a soldier would go to his home and find his entire family 
slaughtered, and he felt that he would have to take the revenge into 
his own hands, despite the order that the general had given him. The 
general, the new President, then would have that soldier arrested, even 
though you can understand the feeling of outrage of seeing 50 members 
of his family slaughtered.
  The President told me also the story about the notes that he would 
get from members of his army that said: Mr. President, it is not going 
to please you because you have given orders to the contrary, but I 
could not stand by and see these people who have slaughtered my family 
get away with it. And then that soldier would take the revenge and that 
soldier would then turn the gun on his own self and commit suicide.
  But the general's orders took hold. He established a government. It 
was a government where they would go through under Rwandan law and try 
those people. They would try to bring about reconciliation. And 14 
years later, after 1 million people were slaughtered in a 100-day 
period, Rwanda is on its way back with some stability, some economic 
promise, and some economic progress.
  This is what can happen in Africa, and this is what needs to happen 
in Zimbabwe. Soon there are going to be elections in South Africa 
bringing in a new President. If present President Mbeki will not move, 
since they are the biggest influence on Zimbabwe because of their trade 
relationship, if he will not move, then there is another election in 
South Africa that will elect a new leader, and maybe that new leader 
will move to bring sanctions on Zimbabwe so that, once again, the 
promise of Africa will become realized, as so many countries in Africa 
today are realizing.
  Madam President, I yield the floor, and I suggest the absence of a 
quorum.
  The PRESIDING OFFICER (Ms. Stabenow). The clerk will call the roll.
  The legislative clerk proceeded to call the roll.
  Mr. KYL. Mr. President, I ask unanimous consent the order for the 
quorum call be rescinded.
  The PRESIDING OFFICER (Mr. Whitehouse). Without objection, it is so 
ordered.
  Mr. KYL. I ask I be allowed to speak in morning business for 30 
minutes.
  The PRESIDING OFFICER. Without objection, it is so ordered.
  Mr. KYL. Mr. President, I want to speak about the bill which we had 
hoped to have taken up by now, the PEPFAR Reauthorization Act. Because 
of some procedural questions, we are not on the bill right now, but I 
thought I would utilize this time to make some remarks about the bill 
which I hope we will be able to begin dealing with in the not too 
distant future.
  This bill is called PEPFAR, as I said, but that stands for the 
President's Emergency Plan for AIDS Relief. It is a program that 
President Bush brought to the Congress in 2003 and was enacted. It 
authorized $15 billion over a 5-year period for the purpose primarily 
of supporting the treatment of AIDS in Africa and elsewhere.
  Between 2004 and 2008, according to the Bush administration, PEPFAR 
has supported a cure for about 10 million people infected by HIV/AIDS, 
including children orphaned by AIDS. It prevented 7 million new HIV 
infections. It supported efforts to provide support to another 2 
million HIV-infected people.
  As a result, I think when the President indicated in his State of the 
Union speech that he wanted to reauthorize the program, most of us in 
the Congress, in the House and in the Senate, were supportive of that. 
I supported the initial legislation and fully intended to support the 
reauthorization.
  There is one little catch. When the President made his announcement, 
he offered to double the amount of the authorization from $15 billion 
to $30 billion. I swallowed rather hard because doubling the amount is 
a big change in the amount of money available, but I assumed I would be 
able to support the reauthorization of the bill. However, when the bill 
was written in the House of Representatives and then sent over to the 
Senate, two things happened. First, one of the things that made the 
legislation effective in the first place was that we had several 
conditions attached to it as to how the money would be spent. We were 
very careful to ensure that the money was spent appropriately. That is 
one of the reasons it has been effective.
  And, secondly, when the bill was written in the House of 
Representatives, lo and behold, it was not doubled from $15 to $30 
billion, it was more than tripled to $50 billion.
  Now, there was not anything magical about $50 billion; it seemed like 
a nice, round, symbolic number. As a result, several of us at that 
point said: Wait a minute. That is a lot of money. In Washington when a 
program doubles, that is something. When it more than triples, it bears 
some looking into.
  Because of many of the problems with the substance of the bill, as 
well as this tripling of the amount from $15 to $50 billion, several of 
us began to take a harder look at it. Then, as the gas crisis hit, the 
housing crisis hit, and we find that more and more Americans are 
feeling the real pinch of a downturn in our economy, the question began 
to solidify: Should America be committing to spend $50 billion on this 
program, which at $15 billion was quite successful, without at least 
considering whether we can reduce the amount and certainly taking a 
look at the substantive provisions of it to see if it can get back to 
the original purpose rather than some of the expanded purposes under 
the House bill.
  That is why several of us said, when the bill came through the Senate 
Foreign Relations Committee: We object to simply passing the bill out 
of the Senate without any opportunity to amend it, certainly without 
any opportunity to reduce the amount of it and without an opportunity 
to fix it. I know some of us were criticized. But I would hope that 
when we talk about some of the changes that have already been agreed 
to, those who were critical of us who said: No, we are not going to 
automatically pass it, would at least acknowledge there have been 
numerous improvements in the bill because of the negotiation process 
which ensued.
  I wish to particularly thank Senators Coburn, Burr, and Enzi for 
working on several provisions of the bill and, frankly, restoring the 
original purpose of PEPFAR in the process. They did a good job. Let me 
note two or three of the areas with which I think they did a good job. 
One key to PEPFAR working in the first place was that at least 55 
percent of the funding had to go directly to the treatment of AIDS 
patients. That was a good thing. Once the House said: No, we can spend 
this

[[Page 14765]]

money on other things, too, you could see the same kind of problems 
with some other foreign aid bills, where money is going to governments 
or NGOs and you never see it again.
  As a result, what Senators Coburn, Burr, and Enzi did was say: Look, 
we need to get back to the proposition that at least half the bilateral 
AIDS funding is spent on treatment, for treatment for HIV/AIDS. That, 
in fact, was agreed to. But I would note, again, that the original 
House and Senate bills proposed simply eliminating that treatment 
floor.
  Another thing they negotiated was to strengthen the protection of 
funding for abstinence and fidelity programs, clarifying that 50 
percent of any funding had to go to those kinds of programs. I would 
note, again, that the original House and Senate bills eliminated the 
requirement in the previous law that a third of the prevention funds 
would go to abstinence education.
  Another thing that they did to make the bill better was to protect 
faith-based groups and others from discrimination in all funding. 
Again, the House and Senate bills had very weak conscience clauses, so-
called conscience clause provisions. This was, again, an improvement of 
the bill which would not have occurred if we had simply agreed to the 
unanimous consent that we pass the bill that had been posed earlier and 
that some of us had objected to.
  To some extent, it strengthens the Global Fund transparency and 
accountability. This is an area that needs additional strengthening. 
But there is a part of this bill that is not the bilateral U.S. money, 
it goes into this big Global Fund. And the Global Fund is not well 
monitored. It is very possible for our funding to be wasted as a part 
of that.
  Again, there was nothing in the original House and Senate bills on 
this and they at least got some strengthening of the Global Fund 
transparency and accountability provisions.
  Another provision was to protect AIDS patients from substandard 
medicine, which again was not in the original language. There were 
other things. My point is that when those of us objected originally to 
passing the bill as it came out of the House, we were criticized: Well, 
this is a perfect bill, we were told. It turns out it was not so 
perfect after all.
  That is point No. 1. Point No. 2, there are some additional things 
which should be done to the substance of the bill. Point No. 3 deals 
with the amount of money that is being spent.
  Here are some of the remaining areas that are problematic: The bill 
would not prohibit funding for countries such as China, Russia, and 
India, countries that are quite wealthy, that have their own nuclear 
weapons and space exploration programs. Russia is awash in 
petrodollars. China has hundreds of billions of dollars in its foreign 
currency reserve, has an exploding military budget, and so on. So, 
certainly, we ought to limit the funding of the bill to countries that 
actually need the money.
  Secondly, it adds a variety of lower priority programs to spend the 
extra money above the $15 billion, including--well, I am not going to 
mention all of these, but educating males about the dangers of visiting 
prostitutes. That is a fine thing, but is that a priority that we need 
to spend this money on? Addressing the inheritance rights of women and 
orphans. There is money in here for legal aid and the like, legal aid 
services.
  There is mission creep in the new legislation. It calls for PEPFAR 
dollars to support nutrition programs, drinking water and sanitation 
and income-generation activities and livelihood activities--legal 
services, as I said.
  All of these might be fine, but this is not the PEPFAR program, this 
is foreign aid. There are not any kind of constraints on this mission 
creep that ought to be in existence if we are going to authorize this 
kind of money for it.
  The bill diverts funding from AIDS treatment for other purposes. I 
mentioned legal services and substance abuse and so on. It doubles the 
funding for the U.N.-affiliated Global Fund, which disregards U.S. 
policies on positions such as abortion and needle exchange and has been 
linked to funding for corrupt and criminal regimes.
  It strikes current law regarding the inadmissibility into the United 
States of HIV-positive aliens. It calls for a strategy and objective 
over the next 5 years with these funds to train and hire 140,000 new 
nurses and other health care professionals in these countries.
  This at a time when the United States is drastically in need of 
health care professionals and nurses. We are wealthy and can afford to 
be a very generous country, but we also have needs in this country. I 
mentioned the water development projects and so on. I happen to be 
familiar, and Senator Thune has offered an amendment on this, with the 
needs in the United States of America for water development in our 
Native American communities, on Indian reservations.
  There is a study out right now that demonstrates the need that many, 
thousands of our Native Americans have to rely on water being hauled to 
their communities, which they then take to their individual hogans or 
residences. We need water development right here in the United States 
for American citizens, and I might add to whom we have a trust 
responsibility, at least as a priority before we send money abroad for 
folks who do not fall into that same category.
  The final point I wished to make is that this legislation, at $50 
billion of authorization, is more than we can afford. The Congressional 
Budget Office, in fact, says that if it is authorized at $50 billion, 
we cannot efficaciously spend more than about $34 billion. In other 
words, it is very hard to spend that much money, at least to do so 
without a lot of waste, fraud, and abuse.
  As a result, even the Congressional Budget Office, the nonpartisan 
entity that we ask for advice on such things, said we could not spend 
more than $34 billion in that event. As I said, $50 billion is the 
amount of the authorization here.
  To put it in perspective, what is $50 billion? What could we spend 
$50 billion on? We passed a new GI bill. It could pay for the GI bill 
twice. It could pay for the Apollo Program to land a man on the Moon 
twice. It could pay for about half the entire interstate defense 
highway system. It could pay the pensions of our military veterans for 
over a year. Now, $50 billion is a lot of money. As I said, I do not 
know of anybody who would not be willing, especially if we are able to 
clean up some of the other language in the bill, to authorize it at $15 
billion, maybe to even double it to $30 billion, but $50 billion?
  I note President Bush has, at least in more recent months, begun to 
focus on the wasteful Washington spending, the programs he believes 
spend too much money, and to put some fiscal discipline on the 
Congress. In fact, since the Democratic Party takeover of the Congress, 
the President has threatened to veto more than 25 authorization and 
appropriations bills. This amounts to about $188 billion in spending 
because of his view that this is excessive beyond what the American 
taxpayer can be burdened with.
  I will note a couple of those. But it illustrates where the President 
has been willing to say: I am going to veto a bill. That is his 
ultimate authority here. In the case of the Labor-HHS 2008 
Appropriations Act, the President would have vetoed the bill by 
exceeding his request by $9 billion. Now, this is $35 billion more than 
the previous funding, $20 billion more than the President announced in 
his State of the Union speech that he would be willing to reauthorize 
the bill at.
  He would have vetoed $2.3 billion beyond the budget in the Commerce 
State and Justice Appropriations Act in 2008; $2.2 billion in the 
Department of Homeland Security Appropriations Act.
  Then, for some authorizations--because this is an authorization, not 
an appropriation--the Water Quality Financing Act, H.R. 720, which 
authorizes Federal spending for State clean water revolving funds, that 
bill would have been vetoed for providing $14 billion in excess above 
the current $5.6 billion authorization.
  I know many of my colleagues have said a $50 billion authorization 
for

[[Page 14766]]

PEPFAR is not a big deal because it is only an authorization, not an 
appropriation. But that certainly was not the position of the 
administration when it threatened to veto this bill that was over $14 
billion more than what the President wanted, or H.R. 1495, the Water 
Resources Development Act, which authorized water infrastructure 
projects. That bill was vetoed for going about $7 billion over what the 
President had authorized or had budgeted.
  So it is kind of difficult to understand how the administration or my 
colleagues can support more than tripling a foreign aid program by 
spending $50 billion on PEPFAR when the administration was so keen, and 
I believe correctly so, to finally put the stake down in the ground and 
say: I am going to veto legislation that is $2 billion or $3 billion or 
$7 billion over what it should be, including authorizations.
  As I said before, we are very wealthy and therefore should be and can 
be a very generous country. But we also have to establish our 
priorities. Changing this legislation and tripling the money is not 
necessarily going to make it triply effective. In fact, if anything, as 
I said, I think it is going to make it less effective.
  I make this point: We have now an American economy which is 
struggling and American families who are struggling with their budgets. 
They do not need additional liabilities, either in terms of taxes or 
more debt, which they and their children and grandchildren are going to 
have to pay. Someone has to pay for the $50 billion. I do not know 
where the money is going to come from. Are we going to take it from 
other spending? Not likely. Are we going to increase taxes to pay for 
it? Quite conceivably. Or are we going to add it to the deficit? That 
is the only other choice.
  So $50 billion does not grow on trees. It is very easy to be generous 
with other people's money. But we are talking about the taxpayers' 
money. I think, when we are taking about taxpayer money, we need to be 
good stewards of it. More than tripling a program to get it up to $50 
billion in foreign aid is more than I think most Americans--if you put 
the question to them and said: Is this what you want to do with $50 
billion of your money, I would bet you the vast majority of Americans 
would say: Look, we are willing to be generous, provide something for 
that program but not $50 billion.
  That brings me to my final point. In prioritizing, and that is what 
Congress needs to do, prioritizing what we spend our money on, we have 
to look at our domestic needs as well. I have supported some increases 
in funding for years on programs that I think are very important. The 
answer has always been: Well, there is not enough money. We would love 
to help you out, Senator Kyl, but there is not enough money. OK. Now we 
have gone from $15 billion to $50 billion that we are ready to spend on 
PEPFAR.
  So, clearly, the majority around here has decided, along with the 
administration, that we can afford to spend $50 billion on something. 
My approach would be to say: OK, if we have decided we can afford to 
spend $50 billion, why don't we only spend part of that on PEPFAR, and 
why don't we spend part of it on America for what we know are top 
priorities?
  We have already decided we can afford to spend $50 billion. How about 
some priority for American spending as well? I can think of a lot of 
things that almost all of us would agree upon as good projects for 
spending some of this money.
  I mentioned before the fact that the U.S. Government has a trust 
responsibility to Native Americans in this country. We have an 
obligation to help them pay for what is important to them. Health care. 
We passed an Indian health care bill. So I asked: Are there additional 
health care needs? Well, mostly they were taken care of thanks to 
Senators Murkowski and Dorgan in the Indian health bill, which I was 
happy to support.
  There are two other needs on Indian reservations that are drastic, 
emergencies, and an embarrassment in that we in the Congress are not 
able to meet these requirements for the Native American population. Yet 
we are willing to spend $50 billion on this foreign aid program. This 
trust responsibility includes public safety and drinking water. There 
are Federal Government reports that identify needs in both of these 
areas. As a result, Senator Thune and I have an amendment which would 
designate $2 billion--$1 billion for public safety, $1 billion for 
drinking water--for Indians on reservations. Is that too much to ask, 
out of $50 billion, that we take $2 billion and authorize programs for 
public safety and water development on Indian reservations? To me, this 
would be a better prioritization of funding.
  I mentioned reports. There is a 2004 report by the Department of 
Interior inspector general. Here is what it says in part: That some 
Indian detention facilities were egregiously unsafe, unsanitary, and a 
hazard to both inmates and staff. BIA's detention program is riddled 
with problems and is a national disgrace. A recent 2008 Department of 
Interior study, called the Shubnum report, confirms that tribal jails 
are still grossly inefficient and says:

       [O]nly half of the offenders are being incarcerated who 
     should be incarcerated, the remaining are released through a 
     variety of informal practices due to severe overcrowding in 
     existing detention facilities.
       Life and safety of officers and inmates are at risk for 
     lack of adequate Justice Facilities and programs in Indian 
     Country.

  It goes on to recommend that we construct or rehabilitate 263 
detention facilities at a cost of about $8.4 billion over the next 10 
years. So there is a need identified for American citizens.
  What the Thune-Kyl amendment asks is that we take a billion out of 
PEPFAR and apply it to this $8.4 billion need. I have personally 
visited detention facilities in Arizona. I have witnessed firsthand 
their deplorable conditions. The Navajo Nation, to mention one, in New 
Mexico, Utah, and Arizona is about the size of the State of West 
Virginia. It has a population of more than 180,000 people. In fact, it 
is over 200,000, if you count all of them. Yet a number of its 
detention facilities have been closed for health and safety reasons. It 
has bed space--this place, the size of West Virginia--for 59 inmates. 
That is to serve a total of over 50,000 inmates booked in its 
facilities in 2007. I think everyone would agree this is a deplorable 
state of affairs. This represents only a fraction of its needs.
  There is much more we can discuss. When people are released, it is 
impossible to protect the people of the community.
  Let me briefly turn to water. The managers' amendment to S. 2731 
includes assistance to foreign countries for safe drinking water and 
adequate sanitation. This is supposed to be an AIDS bill. Why are we 
providing drinking water facilities abroad? I concede that they are a 
good thing to do, and there is a need for them, but when there is a 
very big crisis in our country, primarily involving people to whom we 
have a trust responsibility, why aren't we prioritizing funding for 
those projects?
  According to the Indian Health Service, safe and adequate water 
supplies and waste disposal facilities are lacking in approximately 11 
percent of American Indian and Alaska Native homes compared to 1 
percent for the U.S. general population. In some areas of Indian 
country the figure is as high as 35 percent. In Arizona, the Navajo 
Nation estimates that approximately 30 percent of the households on the 
reservation do not have direct access to a public water system and are 
forced to haul water long distances to provide drinking water. I have 
seen it. They have water trucks, and they fill them at some central 
location. They come to another central location. People drive up in 
their pickup trucks and fill their gallon jugs and barrels, take them 
back to their hogans, and so on. That is in the United States today. If 
we have decided that we can afford to spend $50 billion on something, 
starting with a $15 billion AIDS program, then why not double that to 
$30 billion, as the President originally proposed, and spend some of 
the rest of the money on American requirements?
  This lack of a reliable potable water supply in Indian country 
results in a

[[Page 14767]]

high incidence of disease and infection as a result of waterborne 
contaminants. IHS estimates that for every dollar it spends on safe 
drinking water and sewage systems, it achieves a twentyfold return in 
terms of health benefits. The cost to provide American Indians and 
Alaska Natives with safe drinking water and adequate sewage is 
estimated to be over $2.3 billion. Delivering water to the people 
within the tribe would be several billion on top of that.
  These are priorities in the United States. I wouldn't be raising it 
except for the fact that there seems to be an assumption that we can 
afford to spend $50 billion. My point is, if we can afford to spend $50 
billion, let's at least take a little bit of that money and spend it on 
Americans.
  In conclusion, I supported PEPFAR when it was authorized 5 years ago. 
Because of its success, I would vote to extend the original funding 
policy for another 5 years. I would even consider the doubling which 
the President had asked for in his State of the Union speech. For the 
United States to have the resources to continue funding U.S. Government 
responsibilities both to our citizens and to be generous with others 
around the globe, we need a strong economy that creates wealth. I can 
think of a lot of things we could do with part of this $50 billion to 
improve our economy so that we will be better able to help others in 
the future. I have discussed some of them. I will continue to work to 
improve this bill. It will take some time in this body, but I think it 
is worth moving forward.
  I hope we will be able to move forward on the 10 amendments we have 
agreed to. I won't describe all of the amendments. They have been 
described. One of them I have mentioned Senator Thune and I will offer. 
I hope we will have a process by which we consider these things; that 
my colleagues will be open to their adoption, and at the end of the 
day, when we do pass a PEPFAR bill, it will be a bill we can all be 
proud of that will meet the purposes of the original legislation, that 
will not waste American taxpayer dollars, and that will prioritize 
American needs as well as those with respect to foreign aid programs.
  I yield the floor.
  The PRESIDING OFFICER. The assistant majority leader.
  Mr. DURBIN. Mr. President, I would like to respond to the Senator 
from Arizona. I don't quarrel with his premise that we need to spend a 
lot more money when it comes to Native Americans. Senator Byron Dorgan 
tried valiantly for months to bring Indian health care to the floor. He 
ran into a lot of obstacles. I think all of us believe when it comes to 
Native Americans, there is a lot more we need to do. But it strikes me 
as fundamentally unfair to argue that money should be taken from 
fighting a global epidemic of HIV/AIDS, the problem of tuberculosis and 
malaria, and divert that money and put it into help for Native 
Americans.
  Has America reached that point? Is that what the choices have come 
to, that we cannot join the world in trying to stop this global AIDS 
epidemic to the extent we know is necessary?
  If there is anyone who believes that the $50 billion over 5 years 
suggested in this bill is adequate to the challenge, they haven't sat 
down to take an honest look. This is indeed a global epidemic. There 
are parts of this bill that have been criticized by some. I would like 
to address one of them. It is the argument that somehow we have gone 
adrift. We are no longer talking about prevention and medication, but 
we are talking about unrelated elements. One criticism is that this 
bill addresses the global AIDS epidemic in terms of food and water. I 
can tell you point blank that the best medicine in the world is no help 
to a person who is suffering from malnutrition or a person whose water 
supply is contaminated, making them sick when they take the expensive 
drugs.
  I have seen it in Africa, where people receiving the antiretroviral 
medications are wasting away because of malnutrition. We can't save 
their lives from starvation simply by stopping the onset of HIV 
infection. So we need, if we are going to do this honestly, to take a 
serious and comprehensive look at the challenge.
  This is a rarity in a way, that the Members on the Democratic side 
and the overwhelming majority on the Republican side are of one mind. 
We support the President. The President was right when he initiated the 
PEPFAR Program to deal with global AIDS and the global fight to address 
those countries that are not part of PEPFAR. But we need to come 
together now and try to pass this bill for the President and, more 
importantly, for those who are the victims of this global epidemic.
  I will be the first in line when Senator Kyl offers his amendment to 
help those Native Americans who are being shortchanged and deprived 
because of our inadequate funding. But at the risk of being slightly 
political for a moment, were we not fighting a war in Iraq that costs 
$10 billion to $15 billion a month, there would be a lot more to spend 
in America. That war, which is now in its sixth year, with no end in 
sight, has drained our Treasury of over $700 billion that could have 
been spent for curing diseases, dealing with Native Americans in the 
United States, expanding education, expanding health care and clinics 
in our own country, more medical research. Instead, we have been 
shoveling this money as fast as we can out of our Treasury into Iraq 
and making it part of our permanent national deficit. That is the 
reality of what we face.
  It is hard to imagine that Iraq, an oil-rich country, one of the 
richest in the world with oil, is still waiting on U.S. taxpayers to 
spend more money to help them out of the current problems they face. It 
is time for the Iraqis to step up and defend their own country, govern 
their own country, and spend their own money on their own problems.
  After almost 6 years, it is overdue. If they do that, there would be 
a lot more money in the United States for our priorities. A strong 
America begins at home. It begins by bringing this war to an end, 
bringing our combat troops home.
  When we have suggestions from the Iraqis that it is time for America 
to leave, I think we ought to take them. We ought to start bringing our 
brave men and women, who have risked their lives, home to the hero's 
welcome they deserve. Waiting for another 10, 20, 50, or 100 years, as 
some have suggested, is ludicrous. The United States cannot afford it, 
and it is no favor to Iraq to create that kind of long-term dependency.
  I sincerely hope we can resolve this. I hope we can pass the 
President's bill. I support it. I hope there is adequate bipartisan 
support. Then when Senator Kyl and others come forward and ask us to 
find money to help Native Americans, they can count on many of us on 
the Democratic side.
  Mr. KYL. Will the assistant minority leader yield for one quick 
point?
  Mr. DURBIN. Of course.
  Mr. KYL. Having mentioned my name and alluded to the fact that we had 
a hard time getting the Indian health bill to the floor, I hope my 
colleague would acknowledge the fact that one of the people central in 
getting that bill to the floor and getting it passed was the Senator 
from Arizona. It was because of my strong commitment to get that done. 
I will work with anybody, not only to deal with the Indian health 
matter but also local law enforcement and the water development 
problems that we talked about with Native Americans. I know my 
colleague understands that is my position.
  Mr. DURBIN. There is no question of the Senator's sincerity. Senator 
Dorgan tried to lead the fight on this side, and Senator Kyl was a 
great help in that regard. Let the record be clear. If there is to be 
future help for Indian Health Services and other Native American needs, 
I am certain the Senator from Arizona will be part of that effort.
  I suggest the absence of a quorum.
  The PRESIDING OFFICER. The clerk will call the roll.
  The assistant legislative clerk proceeded to call the roll.
  Mr. COBURN. Mr. President, I ask unanimous consent that the order for 
the quorum call be rescinded.
  The PRESIDING OFFICER. Without objection, it is so ordered.

[[Page 14768]]


  Mr. COBURN. Mr. President, I ask unanimous consent that I be allowed 
to speak in morning business for approximately 10 to 12 minutes.
  The PRESIDING OFFICER. Without objection, it is so ordered.
  Mr. COBURN. Mr. President, I have supporting material related to 
PEPFAR that I will ask to be printed in the Record, which I will 
deliver to the desk.
  PEPFAR's unique contribution has been treatment. By any measure, 
PEPFAR has been a success. We have helped almost 2 million people with 
AIDS live longer. We have prevented millions of new infections. We have 
cared for millions of people more. And we have prevented hundreds of 
thousands of babies--newborn children--who were born to infected moms 
from being infected with the HIV virus.
  PEPFAR was different from all our previous efforts precisely because 
we treated it like a disease rather than a development problem. We ran 
it like a medical program and not a foreign aid poverty program. Rather 
than funding the usual beltway contractors who like to write reports, 
give advice, and convene meetings, we put pills in the hands of 
doctors, nurses, and a legion of community-based health care workers 
riding out to the bush on mopeds with medicine in their backpacks. We 
treated people with HIV like patients we can save instead of victims. 
And we told them the truth about where HIV comes from.
  If you go to Nairobi or Soweto or Kampala and ask people what PEPFAR 
is about, they will tell you it is about treatment. Have we spent 
billions on prevention? Yes. But ask anyone in Africa what PEPFAR is, 
and they will say: It is about HIV and AIDS treatment. It was AIDS 
treatment that was the innovation of PEPFAR. We had been funding 
prevention messages long before we had PEPFAR, although certainly not 
to the extent as we did after PEPFAR started. But what was new, what 
was miraculous, what rocked Africa, was the medical treatment.
  And it has worked. It was not easy. With a tiny staff, the AIDS 
coordinator achieved the impossible--what many had said could not be 
done--bringing high-tech medical innovation to the lowest tech settings 
on Earth. It is still just as hard today as it was then, especially as 
we start in new countries.
  The path of least resistance is always the status quo: contractors 
and ``social marketing'' and reports and ``technical assistance'' and 
``capacity building'' and meetings. Without statutory mandates, that 
path will always look more appealing to people who have been asked to 
do the impossible. That is why PEPFAR reauthorization could not retreat 
on its mandated treatment priority.
  Take it out of the law, and despite all the rhetoric and good 
intentions, it will always be easier to fund something else. Maybe 
treatment would not have been eliminated, but it would have taken a 
back street, maybe by small cuts, by not building new clinics in the 
harder places, by letting the shortage of doctors become an excuse to 
not get creative. The commitment to treatment would have eroded over 
time, and before we knew it, PEPFAR would have become just another 
failing foreign aid program like so many others.
  It does not matter what people say their intentions are, because 
people come and go and promises are hard to keep. What matters is what 
the law requires, and so it is encouraging to be able to assure the 
American people today that PEPFAR's unique innovation--cutting-edge 
HIV/AIDS medical care--has been preserved in this bill.
  For that, there are a lot of people to thank, starting first with the 
President and his staff, who first reached out to try to broker this 
critical compromise. Of course, the bill managers, Chairman Biden and 
Senator Lugar, and their staff were patient, constructive, and deserve 
all the thanks in the world. They were quick, thorough, honest, and at 
all times operated in good faith. Senators Enzi and Burr and their 
staff were incredible to work with, and their commitment to this cause 
is commendable.
  The compromise language has a number of critical features that make 
it worthy of passage.
  First and most important, the compromise restores the critical focus 
of PEPFAR on medical treatment. The House bill eliminated the provision 
in current law that required that 55 percent of all funding go to 
``therapeutic medical care'' of people with HIV. The managers' 
substitute preserves this focus by requiring that ``more than half'' of 
the money goes to that medical care. This time, the law will also 
clarify what was meant by ``therapeutic medical care,'' so that there 
is no longer any confusion that this treatment money can be spent on 
ARV--antiretroviral--treatment, care for opportunistic infections, and 
medical monitoring of folks who do not yet need antiretroviral therapy.
  Prioritizing treatment is not a radical policy. It is the same policy 
we have right here in the United States. In this country, this year, we 
are spending 63 percent of all domestic AIDS funding on treatment and 
14 percent on prevention. Prevention is cheap, so you can still make 
prevention a big priority without spending nearly the money necessary 
for treatment.
  The substitute also restores an ambitious target linked to funding. 
The original law had the 55-percent allocation, but it also had an 
ambitious target of treating 2 million people with antiretroviral 
drugs. The House-passed reauthorization only targeted 3 million people 
on treatment--a pretty underwhelming figure that meant adding only 1 
million people on PEPFAR treatment rolls. That 1 million would have 
been a 50-percent increase in results, while funding was more than 
tripling in the bill.
  Some have argued that this funding includes a lot of other things 
besides AIDS and so you cannot make that comparison. That is just not 
true. The original bill included malaria, it included TB, and it 
included the Global Fund. So it is an apples-to-apples comparison to 
say that the funding for AIDS, TB, malaria, and the Global Fund was $15 
billion the first time this bill was authorized and that then, in this 
bill, $50 billion is authorized for those same things at this time.
  That is a tremendous amount of money, and the targets for what we 
expect to achieve with that money must go up at the same rate the 
funding goes up. The compromise language appropriately links the target 
number to appropriations. As the funding goes up from the current 
funding level, the treatment target has to go up by the same percentage 
above the current goal of 2 million people. That means that if all the 
money authorized in this bill is appropriated, the number of people 
treated will exceed more than 5 million. Those extra millions of lives 
saved are a major accomplishment of the Senate bill. Those are lives. 
Those are individuals who would otherwise succumb to HIV.
  However, the formula does not end there. Treatment costs per patient 
right now are fairly high--anywhere from $800 to $1,000 per patient. 
Some drugs are as low as $80 or at most around $200 per person, so we 
are talking 80 percent of the treatment costs that are not being spent 
on direct medical care now. That 80 percent represents overhead and 
infrastructure which should be reduced over time as the efficiencies 
are built in and clinics are expanded.
  To account for that, the compromise language also requires that the 
target number for treatment increases by the same percent that cost-
per-patient decreases over time. This ensures that the cost savings are 
reinvested right back into treatment rather than diverted to other 
activities.
  Another key element of the compromise is the protection of PEPFAR 
patients from substandard medicines. From the earliest days of PEPFAR, 
there were some calling for the United States to buy cheap, copycat 
drugs for PEPFAR patients, including drugs that were not approved by 
the FDA or any other rigorous regulatory body of any country. These are 
drugs we would never treat our domestic patients with here in the 
United States. This is no abstract threat. Today, under the Orwellian 
named ``quality assurance'' process at the Global Fund, American 
dollars may be used to purchase drugs

[[Page 14769]]

 that have met no standard except that they have been put on an 
application for a WHO prequalification.
  When this conflict arose shortly after PEPFAR was first authorized, 
the President rightly insisted that we would not treat the African AIDS 
patients like lab rats or guinea pigs. We would treat them with the 
same standards we treat American patients: They would only receive 
drugs with FDA approval or equivalent. To help expedite the approval of 
some international products that were likely safe and effective but had 
not been through the FDA process, the President established an 
emergency review process to speed up approval while still ensuring that 
PEPFAR patients get the same standard of care we expect for our 
domestic patients. Since then, others have generally agreed that all 
appropriate safe and effective drugs make it through this new process 
with proper and direct speed.
  In direct contradiction of this more moral approach, the House bill 
took bilateral PEPFAR programs down the same scary path that the Global 
Fund has gone. It required that PEPFAR purchase the cheapest drugs 
available on the world market, without requiring any standard of safety 
and efficacy. Under such a provision, African patients would have been 
treated worse than lab rats--receiving drugs that the United States 
would never use for its patients, never purchase through Medicaid, 
Medicare, or the Ryan White Care Act.
  The bill managers are to be commended for modifying this provision in 
their substitute to require that drugs purchased by PEPFAR have FDA 
approval or its equivalent in other developed countries. We can all 
breathe a little easier as we seek to put 5 million people on ARVs. We 
want those 5 million people to thrive as long as possible on first-line 
drugs before they experience a treatment failure. You should not be 
relegated to unsafe drugs just because you are poor and living in 
Africa.
  There are quite a few other improvements in this substitute bill that 
the managers and the President helped to broker, but I will not take 
any more time. Suffice it to say that most of my outstanding concerns 
have been met through our negotiations, and I am confident that 
PEPFAR's success in the future is no longer in jeopardy.
  PEPFAR was not broken. It did not need fixing. It just needed 
reauthorization. The managers' substitute does that. I am confident 
that lives are going to be saved because of the good faith in the bill 
and of the bill managers and the President and my other colleagues who 
are associated with it.
  Mr. President, I ask unanimous consent to have the supplementary 
material I referred to printed in the Record.
  There being no objection, the material was ordered to be printed in 
the Record, as follows:

     From Good Intentions to Bad AIDS Policy: The Moral Hazards of 
                           Redesigning PEPFAR

                      (By Daniel Patrick Moloney)

       The President's Emergency Plan for AIDS Relief (PEPFAR) has 
     received praise from across the political spectrum, both for 
     its principles and for its successes in fighting HIV/AIDS in 
     some of the world's poorest countries. Announced by President 
     George W. Bush in the 2003 State of the Union Address, PEPFAR 
     fights HIV/AIDS primarily in countries with generalized 
     epidemics. These countries are mostly, though not 
     exclusively, in Africa.
       PEPFAR's successful track record is a result of its focus 
     on three points:
       Treating those infected with HIV,
       Preventing new HIV infections, and
       Ensuring, through bilateral programs, that assistance is in 
     accord with U.S. policy.
       Bills under consideration in the U.S. House and Senate 
     (H.R. 5501 and S. 2731) represent significant departures from 
     the current law. These bills are hugely expensive, and would 
     take existing U.S. policy off its present, successful course.
       Rather than simply reauthorizing PEPFAR, Congress seeks to 
     rewrite it, vastly expanding funding while removing 
     structural guidance that stipulates how it is apportioned. 
     The structure of the original PEPFAR law was essential for 
     keeping it focused on its prevention and treatment 
     objectives. The congressional bills fail to do this. Both 
     more than triple the $15 billion cost of the original 
     program, yet neither adjusts the targets of the program to 
     reflect this increase. Instead, both propose to spend tens of 
     billions of dollars on projects not directly related to the 
     fight against HIV/AIDS. This proposed spending duplicates 
     existing programs, and diverts resources into social 
     engineering projects at odds with the values of many 
     Americans.
       To achieve PEPFAR's goal, policy must continue to be guided 
     by strong requirements that will direct funding toward 
     effective prevention and treatment strategies, rather than a 
     diffuse set of general development goals.
       From Good Intentions to Good Policy: The Original Design of 
     PEPFAR. As proposed by President Bush in 2003, PEPFAR was 
     built around three priorities:
       Providing medicine to treat those who have HIV/AIDS in 
     those countries where the disease affects the general 
     population,
       Funding local programs that aim to prevent new HIV 
     infections, and
       Providing palliative care to those suffering from HIV/AIDS, 
     including children orphaned as a result of HIV-infected 
     parents.
       To justify its ambitious agenda and $15 billion price tag, 
     the original law used three structural features to keep the 
     program focused on its priorities: ambitious targets, 
     spending requirements, and an emphasis on bilateral 
     agreements.
       The law set ambitious targets for the number of people in 
     its treatment, prevention, and care programs. These goals 
     were so ambitious that they could not be met were the money 
     lost to waste or corruption, or simply diverted to other 
     development activities not directly providing treatment, 
     care, or prevention of HIV/AIDS.
       The law also provided strong guidance so that the money 
     would be spent in proportion to the law's priorities. It did 
     this in two distinct but related sections of the law. The 
     first, a ``Sense of Congress'' resolution, declared that 55 
     percent of the funds should be spent on medicine and 
     treatment, 10 percent on orphans and children affected by 
     HIV, 20 percent on prevention programs, and 15 percent on 
     palliative care. This gave the Global AIDS Coordinator some 
     idea how to balance the competing ends of the bill. The next 
     section, which actually allocated the funds, made the first 
     two elements of this nonbinding resolution into binding 
     spending requirements. Though it did not make binding that 20 
     percent be spent on prevention, it did require that one-third 
     of funds spent on prevention be spent on programs that 
     promote abstinence outside of marriage and fidelity within 
     it. By requiring that the money be spent according to these 
     specific percentages, rather than authorizing particular 
     dollar amounts, the law ensured that its priorities would 
     always be implemented in the same proportions, even were 
     Congress later to appropriate funds at amounts different than 
     the law had authorized.
       The law required that PEPFAR deliver aid through bilateral 
     arrangements with each of the partner countries, rather than 
     through multilateral organizations. This procedural safeguard 
     gave the U.S. its best opportunity to make sure the funds 
     were spent on its priorities. It was consistent with the 
     President's belief that welfare and aid programs work best 
     when they support civil society, rather than supplant it with 
     an international bureaucracy.
       The bills in the House and the Senate undermine these 
     principles. They set goals too low for their budgets, remove 
     most of the spending mandates under the guise of 
     ``flexibility,'' and add radical new agendas on which the 
     unstructured and abundant funds are to be spent.
       Funding Should Fit Program Goals. In asking Congress to 
     reauthorize PEPFAR for the next five years, the Bush 
     Administration sought to increase the budget by 100 percent 
     to $30 billion over five years. However, the President sought 
     to increase its goals by a mere 20 percent to 70 percent 
     (depending on the criterion) over that period. Some Members 
     of Congress have complained that the Administration's goals 
     are too low to justify doubling the funding. They note that 
     the program is on track to meet its original goals of 2 
     million treated, 7 million infections prevented, and 10 
     million people in care, while staying close to its original 
     budget of $15 billion-$18 billion. Given such a history, the 
     Administration's moderately increased goals should require 
     only moderately increased funding, particularly now that so 
     much early infrastructure has been laid in the focus 
     countries and some efficiencies of scale may be expected.
       The Administration defends its lower goals on the grounds 
     that they are realistic given local infrastructure. It also 
     notes that its proposed goals represent a U.S. commitment to 
     treat a number of people equal to the commitment of all other 
     aid-donor nations combined. For the U.S. to treat more would 
     not demand enough of the world community. It also expresses 
     doubts that in 2013 there will be as many people to be 
     treated in the focus countries as some of its critics 
     predict.
       If the Administration's request is disproportionate to its 
     goals, the bills in the House and the Senate are even more 
     so. Both bills add an additional $20 billion to the 
     President's request--more than the entire first five years of 
     the program--while barely changing the Administration's 
     underwhelming new goals. The bills authorize up to $9 billion 
     to fight other diseases

[[Page 14770]]

     common in Africa (i.e., tuberculosis and malaria), and they 
     authorize billions more in contributions to the Global Fund 
     to Fight AIDS, Tuberculosis, and Malaria. After taking all 
     these into account and after assuming full funding of the 
     bills' priorities, the Congressional Budget Office concluded 
     that the bills would still have at least $15 billion left 
     over. To date, no one in either chamber has adequately 
     explained what will be done with the ``extra'' billions.
       Congress could improve the fit between PEPFAR's funding and 
     its goals by making the latter more ambitious. For example, 
     Senators Tom Coburn (R-OK), Jon Kyl (R-AZ), Saxby Chambliss 
     (R-GA), and Richard Burr (R-NC) have introduced S. 2749, the 
     Save Lives First Act of 2008. This bill would set PEPFAR's 
     treatment goal at providing HIV/AIDS treatment and pre-
     treatment medical monitoring to 7 million people, about one-
     half of them in sub-Saharan Africa--an increase from 3 
     million in the House and Senate bills. It would also 
     reinstitute the provision in current law allocating at least 
     55 percent of all PEPFAR funds to treatment. To treat that 
     many people is estimated to cost between $8.4 billion and 
     $11.5 billion.
       Higher goals require more money, but the draft bills' 
     proposed goals for treatment, prevention, and care are not by 
     themselves high enough to justify even the Administration's 
     $30 billion price tag. Activities extraneous to the original 
     program are likely to make up the difference. Whether 
     Congress decides to increase PEPFAR's treatment goals along 
     the lines of the Save Lives First Act, or whether it sticks 
     with its current goals, a $50 billion budget would still 
     include extra billions likely to be spent on purposes 
     irrelevant to PEPFAR.
       ``Flexibility'' Means Blank Check Worth Billions. The 
     original PEPFAR law contained binding requirements that 55 
     percent of all funds be spent on medical treatment, and 10 
     percent on orphans and vulnerable children. It further 
     required that 33 percent of the prevention funds be spent on 
     abstinence and fidelity programs. The spending restrictions 
     (except for that regarding orphans) have been criticized, 
     both by NGOs that disagree with U.S. priorities, and by 
     bureaucrats who implement the program.
       Both the House and the Senate strip out these funding 
     requirements for prevention and treatment. (The Senate bill 
     even strips out most of the nonbinding ``Sense of Congress'' 
     resolutions of the original law.) The House bill gives the 
     Global AIDS Coordinator complete control over 55 percent of 
     the funding, and the Senate bill writes a blank check for 90 
     percent of the funds. Beyond this, the bills provide some 
     vague guidance, but not hard requirements, on how money will 
     be spent. The Global AIDS Coordinator is left to prioritize 
     the multiple goals and agendas of the bills.
       New Funds and Radical New Agendas. The proposed legislation 
     expands the activities eligible for PEPFAR funding well 
     beyond the scope of the original program, offering some clues 
     about how its ``extra billions'' could be spent. Some of 
     these new agendas are duplicative of other foreign aid 
     programs and are irrelevant to fighting HIV/AIDS. For 
     example, the legislation promotes micro-finance, education, 
     general health care, and food security, among other new 
     programs.
       The bills also add a number of radical new agendas that 
     change the focus of PEPFAR, are at odds with the values of 
     many Americans, and trample on the cultural values of the 
     partner countries. For example, the bills before Congress 
     make it U.S. policy to teach safer drug-use techniques to 
     injection drug users, and safer sex techniques to 
     prostitutes, injection drug users, and men who have sex with 
     men (MSM). The original law made no special provisions for 
     outreach to these populations, reflecting the fact that 
     infections among these risk groups are marginal to the 
     generalized epidemic in subSaharan Africa, as opposed to the 
     epidemics concentrated among these groups in countries such 
     as Russia and Thailand. Where it did mention them, the 
     original law sought to eradicate prostitution and to 
     encourage injection drug users to stop, recognizing that 
     public health policy should not enable such high-risk 
     behavior but seek to end it. In a clear policy reversal, the 
     proposed legislation strips out the original commitment to 
     eradicate prostitution, and makes PEPFAR dollars available to 
     activities intended to make illicit drug use ``safer.'' Not 
     coincidentally, it also allows PEPFAR to expand to include 
     more focus countries in Europe and Asia where the epidemics 
     are concentrated among prostitutes and drug users.
       The bills would also commit the U.S. to altering the 
     relations between men and women in developing countries to 
     reflect the values of Western gender activists. The bills 
     encourage U.S. intervention on sensitive cultural topics that 
     are not scientifically demonstrated to have direct impacts on 
     rates of HIV/AIDS morbidity or mortality, but very well might 
     offend those whom U.S. policy is designed to help. Whatever 
     merits these provisions might have as aspirations, they were 
     not in the original bill, they would do nothing to stop the 
     AIDS emergency in sub-Saharan Africa, and they would commit 
     the U.S. to agendas that are likely to be unpopular in 
     partner countries.
       Conclusion: Compassionate Aid Is Effective Aid. The three 
     structural features of the original law--ambitious targets, 
     spending restraints, and an emphasis on bilateral 
     agreements--have helped PEPFAR stay on target. In the 
     process, the U.S. has created a strong precedent for 
     combating HIV/AIDS in poor countries with generalized 
     epidemics. PEPFAR's commitment to abstinence and fidelity 
     programs, which was and is still ridiculed by many activists 
     and others, is now recognized to have a measurable impact on 
     HIV infection rates.
       Rather than write a blank check to an unelected 
     bureaucracy, Congress should retain firm control over PEPFAR, 
     which touches on such delicate issues as sex, marriage, and 
     the relations between men and women. Congress should insist 
     that PEP-FAR retain its focus on preventing new HIV 
     infections and treating those infected with HIV/AIDS. PEPFAR 
     should not duplicate the efforts of America's other aid 
     programs. Lawmakers should insist that the funds authorized 
     and appropriated for PEPFAR will not support activities 
     irrelevant to fighting HIV/AIDS in countries with generalized 
     epidemics. Congress should authorize funds for PEPFAR at a 
     level appropriate to its central goals. If Congress wishes to 
     fund other activities, it should do so by increasing the 
     budget for other assistance programs rather than diffusing 
     PEPFAR's focus.
       America's PEPFAR partners are waiting on congressional 
     reauthorization before setting their own budgets, putting 
     pressure on Congress to move quickly. Hasty passage of the 
     existing House and Senate bills, however, would not allow 
     them to make their plans either, since so many funding 
     decisions would still be left to the discretion of the Global 
     AIDS Coordinator in the next administration, and subject to 
     the annual appropriations process and the lobbying of NGOs. 
     With lives at stake, strategic efficiency and effectiveness 
     are paramount. Ambitious goals, clear spending directives, 
     and a reassertion of successful U.S. policies will maintain 
     the structure and proportion that have leveraged Americas 
     generous intentions into a highly effective policy.
                                  ____


          Myths v. Facts--Re: Global AIDS Legislation (PEPFAR)

       Myth: ``We Can't Treat Our Way Out of This Epidemic.''
       Fact:
       We have to walk and chew gum--we must prevent future 
     infections but we must respond to the desperate and dying 
     TODAY.
       Prevention efforts may prevent new infections, and 
     therefore prevent FUTURE treatment need, but prevention 
     efforts do nothing to abate the treatment need in the next 5 
     years, which is the time period the reauthorization bills 
     address.
       Treatment need is determined by numbers infected 5-10 years 
     ago.
       This argument is like going into a post-Katrina New Orleans 
     and spending most of the relief funds on building better 
     levies to prevent a future disaster rather than rescuing the 
     people waving frantically on rooftops for help.
       Obviously both need to be done, but no one would claim that 
     it was somehow more humane to focus more effort and funding 
     on the future prevention than the immediate humanitarian 
     disaster.
       Treatment, is prevention. Treatment prevents new infections 
     several ways:
       It requires dramatic scale-up of diagnostic screening--
     meaning we will identify most infected people.
       It will give us the opportunity to do education and 
     prevention messaging with the people who are transmitting HIV 
     rather than wasting money on mass media campaigns targeting 
     mostly uninfected people. Nobody ever got HIV from someone 
     who wasn't infected with HIV.
       It identifies pregnant women with HIV so that their babies 
     can be saved from infection.
       It lowers viral load. There are quite a few studies out now 
     showing that reduced viral load dramatically reduces the 
     transmission of the virus.
       Myth: Flexibility--``Earmarks'' or ``Allocations'' 
     dictating how much money has to be spent on a certain 
     activity are too inflexible and don't allow countries to 
     respond to their needs appropriately.
       Fact:
       The allocations are not country-specific, they apply to the 
     whole pot of money. If one country needs to spend less money 
     on treatment, there are other countries where treatment is 
     particularly expensive and can use the extra.
       Other donors such as the Global Fund can come in and fund 
     other priorities for the country--the American people are 
     committed to treatment being the priority for PEPFAR.
       Public health has taught us how to control infectious 
     disease and it doesn't require flexibility. It requires a 
     formula--find every case, treat every case, work with every 
     case to find other cases and prevent transmission to new 
     cases. This doesn't change no matter what the circumstances 
     on the ground are.
       This argument is disingenuous--the other side only wants to 
     eliminate the allocations that take money away from beltway 
     contractors--those for treatment and abstinence, because 
     those contractors don't do

[[Page 14771]]

     treatment or abstinence. The other allocations have been left 
     in the bill, and in fact, new ones added in the House 
     version. You can't simultaneously criticize allocations but 
     add in new ones.
       Myth: Drug prices have gone down so we don't need to 
     reserve as much for treatment costs anymore to meet our 
     treatment targets.
       Fact:
       If it's now cheaper than expected to meet targets, then we 
     should raise our targets to save and treat more people. We 
     only are treating a small fraction of people in need of 
     treatment in the developing world.
       Myth: Eliminating baby AIDS is unrealistic.
       Fact:
       Dramatic gains are seen when universal testing of pregnant 
     women and newborns is provided and appropriate prophylaxis of 
     infections that are identified through that testing.
       In states in the U.S. that have adopted this standard of 
     care, new cases have been virtually eliminated.
       In Botswana, a country that used to have HIV infection 
     rates as high as 50% of child-bearing-aged women, they 
     instituted these policies. Now 92% of pregnant women are 
     being tested, and the drop in HIV+ mothers delivering 
     infected babies dropped from 35% to 4% from 2004-2007, with 
     13,000 HIV-infected moms being identified annually.
       A recent study, the largest to date, just came out with 
     findings that 99 percent of babies were born uninfected if an 
     infected mother was diagnosed and proper treatment was 
     administered.
       However, a World Health Organization report found that 
     access to AIDS drugs is severely limited in developing 
     countries, with fewer than 10 percent of pregnant women with 
     HIV in those countries having access to medication.
       As a result, about 1,800 babies become infected with HIV 
     each day. Prevention of mother-to-chi1d-transmission (PMTCT) 
     is cheap per life saved: Estimated cost of PMTCT drugs to 
     support treatment of (1) mother/child pair is US$167 
     (generics) and US$318 (branded).
       We haven't even come close to meeting the need in PEPFAR 
     focus countries.
       Estimated 1.15 million pregnant women with HIV/AIDS living 
     in PEPFAR countries.
       In 2006 PEPFAR proved ARV Prophylaxis to only 294,000 
     (25.5%).
       And now PEPFAR is expanding beyond the focus countries to 
     other countries--the need just will keep growing:
       Estimated 2.1 million pregnant women estimated to be living 
     with HIV/AIDS in developing countries (1.7 million in sub-
     Saharan Africa -85%).
       Of the estimated 2.3 million (1.7-3.5 million) children 
     under the age of 15 years living with HIV, well over 90% are 
     thought to have become infected through mother-to-child 
     transmission.

  Mr. COBURN. Mr. President, I yield the floor.
  The PRESIDING OFFICER. The majority leader is recognized.

                          ____________________