[Congressional Record (Bound Edition), Volume 159 (2013), Part 7]
[Extensions of Remarks]
[Pages 9467-9469]
[From the U.S. Government Publishing Office, www.gpo.gov]




  RECOGNIZING THE 10TH ANNIVERSARY OF PEPFAR: A CRITICAL PART OF THE 
                           FIGHT AGAINST AIDS

                                 ______
                                 

                       HON. JANICE D. SCHAKOWSKY

                              of illinois

                    in the house of representatives

                         Tuesday, June 18, 2013

  Ms. SCHAKOWSKY. Mr. Speaker, ten years ago Congress, with the 
leadership of the Bush Administration, enacted the bipartisan 
President's Emergency Plan for AIDS Relief (PEPFAR), an initiative 
which the Institute of Medicine in a Congressionally-requested February 
2013 report called ``globally transformative.''
  In its 10 years, PEPFAR has saved lives, improved health care 
delivery systems and, as the IOM concluded, provided a ``lifeline'' 
that restored hope to areas devastated by the epidemic. Over the course 
of its existence so far, PEPFAR has spent $46 billion to expand access 
to prevention, treatment and medical services. Through its 
contributions, new infections in sub-Saharan Africa, one of the 
hardest-hit areas, have dropped by 25 percent.
  PEPFAR is a success story. It is part of the global effort to 
prevent, treat, and, soon I hope, find a cure so that we can end AIDS. 
We should celebrate PEPFAR's decade's worth of achievements, while we 
must also recommit to its goals. For, as the IOM report stated and all 
of us know, ``substantial unmet

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needs remain across HIV services'' both here and abroad.
  PEPFAR itself is part of an ongoing effort to respond aggressively 
and effectively to HIV and AIDS. I would like to draw my colleagues' 
attention to an article by Dr. Allan Brandt from the June 6, 2013 New 
England Journal of Medicine, outlining the ways that the effort 
surrounding HIV/AIDS has reshaped our vision of global health--both 
what is needed and what is achievable.
  As we pause today to recognize the 10th anniversary of PEPFAR, it is 
also important to recognize the enormous work of AIDS activists and 
providers who have been leading this fight for decades. Their work, as 
Dr. Brandt's article details, has had consequences that go far beyond 
combating AIDS--as critical as that is--to shape the way we think about 
the right to medical care, health care justice, and our global 
relationships and responsibilities. It has also focused on the need to 
make essential medicines available--a matter of much attention in the 
ongoing Trans-Pacific Partnership trade discussions--and to build 
robust networks of medical professionals and community health workers.
  Today, PEPFAR continues to partner with countries that rely on the 
United States to show leadership in meeting ongoing needs and 
challenges. While we can celebrate its successes today, we cannot be 
complacent. The fight against AIDS is a fight for global health, and it 
is one that we must continue to support.

        [From the New England Journal of Medicine, June 6, 2013]

                    How AIDS Invented Global Health

                      (By Allan M. Brandt, Ph.D.)

       Over the past half-century, historians have used episodes 
     of epidemic disease to investigate scientific, social, and 
     cultural change. Underlying this approach is the recognition 
     that disease, and especially responses to epidemics, offers 
     fundamental insights into scientific and medical practices, 
     as well as social and cultural values. As historian Charles 
     Rosenberg wrote, ``disease necessarily reflects and lays bare 
     every aspect of the culture in which it occurs.''
       Many historians would consider it premature to write the 
     history of the HIV epidemic. After all, more than 34 million 
     people are currently infected with HIV. Even today, with 
     long-standing public health campaigns and highly active 
     antiretroviral therapy (HAART), HIV remains a major 
     contributor to the burden of disease in many countries. As 
     Piot and Quinn indicate in this issue of the Journal (pages 
     2210-2218), combating the epidemic remains a test of our 
     expanding knowledge and vigilance.
       Nonetheless, the progress made in addressing this pandemic 
     and its effects on science, medicine, and public health have 
     been far-reaching. The changes wrought by HIV have not only 
     affected the course of the epidemic: they have had powerful 
     effects on research and science, clinical practices, and 
     broader policy. AIDS has reshaped conventional wisdoms in 
     public health, research practice, cultural attitudes, and 
     social behaviors. Most notably, the AIDS epidemic has 
     provided the foundation for a revolution that upended 
     traditional approaches to ``international health,'' replacing 
     them with innovative global approaches to disease. Indeed, 
     the HIV epidemic and the responses it generated have been 
     crucial forces in ``inventing'' the new ``global health.''
       This epidemic disrupted the traditional boundaries between 
     public health and clinical medicine, especially the divide 
     between disease prevention and treatment. In the 1980s, 
     before the advent of antiretroviral therapies, public health 
     officials focused on controlling social and behavioral risk 
     factors; prevention was seen as the only hope. But new 
     treatments have eroded this distinction and the historical 
     divide between public health and clinical care. Clinical 
     trials have shown that early treatment benefits infected 
     patients not only by dramatically extending life expectancy, 
     but by significantly reducing the risk of transmission to 
     their uninfected sexual partners. Essential medicines benefit 
     both patients and populations, providing a critical tool for 
     reducing fundamental health disparities. This insight has 
     encouraged the integration of approaches to prevention and 
     treatment, in addition to behavioral change and adherence.
       The rapid development of effective antiretroviral 
     treatments, in turn, could not have occurred without new 
     forms of disease advocacy and activism. Previous disease 
     activism, for example, had established important campaigns 
     supporting tuberculosis control, cancer research, and the 
     rights of patients with mental illness. But AIDS activists 
     explicitly crossed a vast chasm of expertise. They went to 
     Food and Drug Administration meetings and events steeped in 
     the often-arcane science of HIV, prepared to offer concrete 
     proposals to speed research, reformulate trials, and 
     accelerate regulatory processes. This approach went well 
     beyond the traditional bioethical formulations of autonomy 
     and consent, As many clinicians and scientists acknowledged, 
     AIDS activists, including many people with AIDS, served as 
     collaborators and colleagues rather than constituents and 
     subjects, changing the trajectory of research and treatment. 
     These new models of disease activism, enshrined in the Denver 
     Principles (1983), which demanded involvement ``at every 
     level of decision-making,'' have spurred new strategies among 
     many activists focused on other diseases. By the early 2000s, 
     AIDS activists had forged important transnational alliances 
     and activities, establishing a critical aspect of the ``new'' 
     global health.
       Furthermore, HIV triggered important new commitments in the 
     funding of health care, particularly in developing countries. 
     With the advent of HAART and widening recognition of HIV's 
     potential effect on the fragile progress of development in 
     resource-poor settings, HIV spurred substantial increases in 
     funding from sources such as the World Bank. The growing 
     concern in the United Nations and elsewhere that the epidemic 
     posed an important risk to global ``security'' elicited new 
     funding from donor countries, ultimately resulting in the 
     establishment of the Global Fund to Fight AIDS, Tuberculosis, 
     and Malaria. In 2003, it was joined by the U.S. President's 
     Emergency Plan for AIDS Relief (PEPFAR), which, with 
     bipartisan support, initially pledged $15 billion over 5 
     years. Since PEPFAR's inception, Congress has allocated more 
     than $46 billion for treatment, infrastructure, and 
     partnerships that have contributed to a 25% reduction in new 
     infections in sub-Saharan Africa.
       HIV has also attracted remarkable levels of private 
     philanthropy, most notably from the Bill and Melinda Gates 
     Foundation. HIV funding led to new public private 
     partnerships that have become a model for funding of 
     scientific investigation, global health initiatives, and 
     building of crucial health care delivery infrastructure in 
     developing countries. These funding programs have fomented 
     contentious debates about priorities, efficiency, allocation 
     processes, and broader strategies for preventing and treating 
     many diseases, especially in poorer countries. Nonetheless, 
     they offered new approaches to identifying critical resources 
     and evaluating their effect on the burden of disease. The 
     success of future efforts will depend on maintaining and 
     expanding essential funding during a period of global 
     economic recession, as well as new strategies for evaluating 
     the efficacy of varied interventions.
       AIDS also spurred another related debate that continues to 
     roil global health about the cost of essential medicines. 
     Accessibility of effective and preventive treatments has 
     relied on the availability of reduced-cost drugs and their 
     generic equivalents. A recent decision by the Indian Supreme 
     Court upheld India's right to produce inexpensive generics, 
     despite the multinational pharmaceutical industry's claims 
     for stronger recognition of patents.
       Another central aspect of the new activism was an 
     insistence that the AIDS epidemic demanded the recognition of 
     basic human rights. Early on, lawyers, bioethicists, and 
     policymakers debated the conditions under which traditional 
     civil liberties could be abrogated to protect the public from 
     the threat of infection. Such formulations reflected 
     traditional approaches to public health and the ``police 
     powers'' of the state, including mandatory testing, 
     isolation, detention, and quarantine. Given the stigma 
     attached to HIV infection at the time, as well as ungrounded 
     fears of casual transmission, affected people often suffered 
     the double jeopardy of disease and discrimination. As a 
     result, Jonathan Mann, the first director of the World Health 
     Organization's Global Program on AIDS, explained, ``To the 
     extent that we exclude AIDS infected persons from society, we 
     endanger society, while to the extent that we maintain AIDS 
     infected persons within society, we protect society. This is 
     the message of realism and of tolerance.'' Mann argued that 
     HIV could never be successfully addressed if impositions on 
     human rights led people to hide their infections rather than 
     seek testing and treatment. Only policy approaches that 
     recognized and protected human rights (including the rights 
     to treatment and care, gender equality, and education) would 
     permit successful clinical and population-based 
     interventions.
       These complementary innovations are at the core of what we 
     now call ``global health'' which has demonstrated its 
     capacity to be far more integrative than traditional notions 
     of international health. It draws together scientists, 
     clinicians, public health officials, researchers, and 
     patients, while relying on new sources of funding, expertise, 
     and advocacy. This new formulation is distinct, first of all, 
     in that it recognizes the essential supranational character 
     of problems of disease and their amelioration and the fact 
     that no individual country can adequately address diseases in 
     the face of the movement of people, trade, microbes, and 
     risks. Second, it focuses on deeper knowledge of the burden 
     of disease to identify key health disparities and develop 
     strategies for their reduction. Third, it recognizes that 
     people affected by disease have a crucial role in the 
     discovery and advocacy of new modes of treatment and 
     prevention and their equitable access. Finally, it is based 
     on ethical and moral values that recognize that equity and 
     rights are central to the larger goals of preventing and 
     treating diseases worldwide.
       For more than the past decade, major academic medical 
     centers, schools of public

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     health, and universities have created global health programs 
     and related institutes for multidisciplinary research and 
     education. Thus, the institutionalization of this formulation 
     is not only affecting services worldwide, but also changing 
     the training of physicians, other health professionals, and 
     students of public health. When the history of the HIV 
     epidemic is eventually written, it will be important to 
     recognize that without this epidemic there would be no global 
     health movement as we know it today.

                          ____________________