Zeitz Testimony to HIRC: 7 June 2001

[Guest guest]

Full Written Testimony of

Dr. S. Zeitz

Co-Director, AIDS treatment to the

House Committee on International Relations

" Recommendations on the US Role in the Global Fight on HIV/AIDS "

7 June 2001

Thank you Chairman Hyde and Members of the Committee for this opportunity to present my recommendations on the United States role in stopping the global HIV/AIDS pandemic to you. This hearing is of vital importance and I commend you and the entire Committee for your leadership and serious attention to this issue. I will be presenting a brief summary of my views and I am submitting a full written statement for the Committee's consideration.

I am medical doctor with a specialization in international public health and epidemiology. I have focused my professional career over the past 12 years on striving to find real ways to assist people living in sub-Saharan Africa and in other impoverished countries to achieve a productive and healthy life. For six years, from 1994 until the year 2000, I had the opportunity to live and work in the southern African nation of Zambia as a policy and technical advisor for the Government of Zambia, USAID, and then I cofounded and served as the regional coordinator for UNAIDS Debt for AIDS Activity. I lived for many years in the center of the AIDS holocaust.

The reality of the AIDS crisis hit home to my family and I several years ago when more and more of our Zambian friends started dying, when my Zambian work colleagues started dying more frequently--and were never replaced, when the numbers of orphans around us was increasing exponentially, when my wife and I were asked by friends to use our family van to transport a 3 month dead child by the name of to his funeral in Zambia, and after I had refused to go to any more funerals as I had heard enough of the howling cries of grief, and on and on and on the tragedy rages.

I was shocked and devastated as I learned that the AIDS death rates that I was observing and experiencing in the late 1990s was just the beginning of what Zambia and much of sub-Saharan Africa, Asia, and parts of Eastern Europe will have to face. The AIDS death rates in Zambia and other areas won't peak until 2005 or later and then they are projected to stay high for a subsequent ten to 15 years---wiping away a full generation of people---just like you and I. Those that are dying are women and men with families, people with dreams--just like you and I--and young people throughout Africa are becoming infected at an alarming rate--these are people who deserve a chance at life, liberty and the full realization of their God-given potential.

It is outrageous from both a practical and a moral standpoint that more than 99% of Africans are not able to obtain practical life-saving antiretroviral medications, because of a simple lack of resources. Millions have needlessly died and millions more will die unless this Congress and the international community comes together with all deliberate speed to ensure access to affordable lifesaving drugs. How many more Africans have to die? Just imagine what our response would be if millions of Americans or millions of Europeans were destined to die because they didn't have the resources to buy these readily available drugs?

When one considers that 17 million Africans have already died and that another 2.5 millions are dying this year, and another several million will die next year, and several more the year after, and on and on….One can only conclude that the international and the US response is failing. The first question that must be considered, is why are we failing as a global community to confront this crisis? We then must ask ourselves, " Why do we keep repeating the same policy and institutional responses and wondering why the results are so inadequate? And finally, if we are serious and truthful about our intention to stop global aids, then we should ask ourselves, " What should we do now? "

Bold, bipartisan US Congressional action and investment could play a critical role in reversing the tide against the global HIV/AIDS pandemic. While the incremental response of the 1990s has shown us that we have the tools and technologies to respond to the pandemic, our response paradigm has failed. The incremental response of the past is characterized by small inadequate investments in small-scale pilot programs that reach only a small proportion of the target population. It is the incremental response of the past that is leading to the 6,000 AIDS deaths and 16,000 new HIV infections that will occur around the World today. It is the incremental response of the past that is leading to the death of over 2.5 million Africans this year from AIDS. It is the incremental response of the past has led to the 13 million orphans roaming hopelessly throughout Africa, with a projected 40 million orphans by the year 2010.

Mr. Chairman and Members of this Committee, all this suffering is completely preventable. We have the proven technologies and tactics to reverse this crisis; what's still lacking is sufficient political will. A new expanded and comprehensive response to the HIV/AIDS pandemic--a new paradigm--can and must be implemented and sustained as a matter of urgency.

Today, I am here representing the Global AIDS Alliance (GAA) , of which I am the Co-Director. The Global AIDS Alliance is a broad-based coalition of the world’s citizens joining together in the fight against the global HIV/AIDS pandemic. We are bringing together for the first-time a constellation of people living with AIDS and HIV/AIDS service organizations, the debt cancellation movement, treatment access campaigners, faith-based organizations, Africa and other ethnic and cultural advocacy groups, African-American leaders, human rights groups, student groups, and professional associations. My testimony today brings to you perspectives from civil society based on our real world front-line experience, so that we can work together to design and implement practical solutions to solve the global AIDS pandemic.

Our partners include Act Up; Africa AIDS Initiative; African Services Committee; AFRICARE; American Jewish World Service; American Public Health Association; Black Church Communal Network; Cameroon Baptist Convention Health Board; Church World Service; Constituency for Africa; Development Indian Ocean Network (DION); Drop-the-Debt Campaign; Essential Action; Ghana HIV/AIDS Network; Global AIDS Action Network; Health Gap Coalition; Institute for Policy Studies; International Health Medical Exchange, Jubilee USA Network; Jubilee 2000 Plus at New Economics Foundation; Malawi Network of People Living with HIV/AIDS; Malawi Network of AIDS Organizations; MIT United Trauma Relief; NAACP; Pan African Charismatic Evangelical Congress (PACEC); RESULTS; Student Global AIDS Campaign; United Methodist Church, General Board of Church and Society; and the Washington Office on Africa.

US Leadership is Required to Stop Global AIDS

Since the beginning of the global HIV/AIDS pandemic--20 years ago--the United States has been instrumental in demonstrating successful ways for combating the virus. Our efforts here in the United States have shown that when we invest sufficiently in available technologies and a grassroots community outreach, we can have a profound effect on reducing HIV transmission and treating infected people. Our support overseas has shown on a small-scale that cost-effective interventions can be applied in resource-poor settings and with positive results. Yet, we have not had the desired effect on reducing HIV transmission around the World because we have not invested sufficiently to do so. At this critical juncture in history, the United States has an unprecedented opportunity and responsibility to support and lead a more ambitious global effort to genuinely reverse the tide against AIDS.

United States leadership in the global effort to combat AIDS will also result in tangible benefits to the American people:

· US leadership will lead to faster and greater people-level impact in decreasing HIV transmission and reducing the impact of HIV/AIDS, thus reducing the risks of the global pandemic, including the spread of drug resistant strains of HIV/AIDS and TB, to the American public;

· US leadership in combating AIDS will protect US national security interests by reducing the need for US intervention in HIV/AIDS devastated countries in Africa, Asia, and Europe;

· US leadership in combating AIDS strengthen the US economy by strengthening the

attractiveness of new markets.

Action Environment in Africa

Over the past two years African political and civil leaders the World has witnessed an unprecedented shift in political will to battle the AIDS pandemic. Countries have developed National Strategic Plans that are being rolled out to the district and community levels, HIV/AIDS business coalitions are forming, churches and other faith-based groups are scaling-up their response. As the fragile democracies in Africa grapple with the vast challenge of combating AIDS, it is a tremendous opportunity for stronger democracies to lend a supportive hand. African families--and especially the youth--are willing and able to take on the responsibility to care for themselves, if they are given the information and tools to lead a safer, healthier life. On an individual level in Africa, we have an opportunity to help people understand that democracy doesn't result in suffering and death, but rather it can lead to improvements in the quality of life.

The Resource Gap

To implement an expanded and comprehensive HIV/AIDS response in sub-Saharan Africa, a recent report by the Global AIDS Alliance estimates that up to $15 billion in external grant resources are needed on annual basis from 2002-2007. The UN, the World Bank, experts at Harvard University have also estimated that an appropriate and adequate response to the global AIDS crisis will cost billions, not millions. The GAA estimate builds on data provided by earlier UN and World Bank reports, but projects achievable levels of population coverage and it includes cost estimates for infrastructure development, capacity building, and impact mitigation--which have not been previously addressed. Additional resources can be immediately used to finance the delivery of known interventions through the existing infrastructure, while at the same time strengthening and expanding new infrastructure over time.

The United States of America provides less than one-tenth of one percent of our GNP to overseas development assistance. This translates into US per capita support for overseas development assistance to be the smallest of all of the rich countries. America--the richest country in the history of the World, simply cannot be called the most generous nation on Earth. Some would even say we are, in fact, the stingiest. The paucity of US foreign assistance persists in spite of widespread support among the American people for greatly increased assistance to impoverished countries, as documented in several recent surveys. On top of this dreadful and embarrassing US policy towards the rest of the World, overseas development assistance from all sources to sub-Saharan Africa declined by 40% during the 1990s.

Although the HIV/AIDS crisis has led some donor countries to increase their foreign assistance allocations over the past several months, there is little sign that the level of funding needed to mount an effective response to the epidemic will materialize. After two years of intensive efforts by the UN and many others, it is estimated that only between five hundred million and one billion US dollars of external grant resources will be spent annually over the next several years to combat the HIV/AIDS crisis in sub-Sahara Africa. That is far below what most experts believe necessary.

As a result of their poor economies, an overwhelming debt burden, inappropriate and externally imposed loan conditionalities, and minimal international investment, few impoverished countries in Africa or in other parts of the World can mount an effective national response to HIV/AIDS, nor can their citizens pay for treatment once infected. As of 1998, annual spending on HIV/AIDS in selected countries in Africa, from all sources, averaged less than $1/capita. This level of investment does not cover even the relatively modest amounts needed for basic HIV/AIDS prevention education and outreach, let alone cover the more significant investments needed for care and treatment of those already infected.

Using Resources Effectively

US Government Bilateral Response: The Critical Role of USAID

Historically, USAID has been the predominant United States Government agency implementing sustainable development programs overseas. However, in part because of the advent of globalization, an increasing number of US government agencies are now being drawn into global affairs. It is our view that the global AIDS crisis requires the specialized skills of different Agencies, and that supplementary appropriations should continue to be allocated to US agencies, such as USAID, Department of State, CDC, HHS, Department of Labor, and the Department of Defense. An accelerated and ramped-up involvement US bilateral agencies will be critical in the coming years. We also believe that the actions and investments of our bilateral programs should be complemented with a robust US investment in the UN-proposed AIDS and Health Trust Fund.

USAID, as the lead US government agency implementing HIV/AIDS programs, plays a critical role in advancing the development and delivery of cost-effective HIV/AIDS prevention strategies and on a more limited scale, USAID has supported a response to the orphans and vulnerable and children's crisis. These efforts have contributed significantly to the successful reduction of HIV transmission in countries like Thailand, Senegal, and Uganda. However, the fact remains that the epidemic is raging onward in many of the most impoverished countries around the World. With current level of funding, USAID is only able to provide full support for rapid scale-up in 3 of 48 sub-Saharan African countries. Bipartisan US Congressional action is required to ensure that the following policy priorities are implemented:

New and supplementary resources are needed for USAID and other US Government programs to support rapid scale-up programs in all appropriate countries. At least $500 million dollars per year is needed for USAID to respond to the global AIDS pandemic. The Administration and Congress cannot expect that a reallocation of existing resources from one account to another will achieve the desired results. A real and genuine supplementary appropriation is required;

USAID needs to expand its technical leadership to the full range of prevention, care, and treatment interventions. The rhetoric of prevention only has not worked and will not work in the future. USAID should provide support the balanced implementation of prevention, care, full treatment--including the use of antiretroviral drugs, the orphans response, infrastructure development, and capacity building;

USAID and other agencies should redesign their strategic role to ensure that our US bilateral program is complementary to the newly UN-proposed Global AIDS and Health Fund (described below) to ensure that large-scale programs are successful;

USAID financial management and bureaucratic procedures must be modernized and streamlined to ensure that US government resources are used to achieve the maximal impact in affected countries;

USAID technical cadres must be dramatically strengthened to ensure that technically sound decision-making guides program development and implementation;

USAID contracted agencies should be required to spend a larger majority of foreign assistance resources directly on programs that reach people, rather than on US-based offices and overhead charges;

Congressionally designated resources for the orphaned and vulnerable children's response should be used for such purposes and reported on separately, as has been historically done with the Displaced Children's and Orphans Fund;

It should also be noted that US government programs are not active in all countries because of US foreign policy considerations, therefore multilateral programs are essential to combat the global HIV/AIDS crisis.

UN-proposed Global AIDS and Health Fund

We are greatly encouraged by the recent interest of the UN, the G7 governments, the IMF and the World Bank in establishing a Global AIDS and Health Fund to combat HIV/AIDS, TB, and malaria with up to $10 billion dollars per year in grants. These developments create an historic opportunity for many interested stakeholders to join forces to achieve our common objective of eradicating HIV/AIDS and other infectious disease crises. For a Global AIDS and Health Fund to be successful, questions of its governance and structure should be addressed openly and with the full participation of civil society stakeholders. Bipartisan US Congressional action is urgently required to ensure that the Global AIDS and Health Fund is consistent with the following principles that were endorsed by over 65 civil society organizations from around the World:

The Global AIDS and Health Fund should ensure full participation by civil society-- including youth, people living with HIV/AIDS, particularly women -- in all aspects of the governance, design, and implementation of grants;

For-profit interests who are potential large beneficiaries of the Global AIDS and Health Fund should not participate in its governance because of a conflict of interest;

The Global AIDS and Health Fund should provide grants to civil, community-based, and non-governmental organizations, including faith-based organizations, to achieve the balanced implementation of HIV/AIDS prevention, care and support, treatment, response to orphans and vulnerable children, infrastructure development, and/or capacity building based on country-driven priorities;

The Global AIDS and Health Fund should ensure that there is full accountability for resources, transparency, and effectiveness in the administration of the Fund;

The Global AIDS and Health Fund should be completely results-oriented, with balanced set of streamlined processes for measuring success;

The Global AIDS and Health Fund should ensure that funds are transferred through decentralized, streamlined, and efficient mechanisms, with a minimal bureaucratic burden;

HIV/AIDS related medicines purchased with these funds should be obtained using a bulk procurement mechanism that is based on open competition, including bids for generically manufactured drugs, in order to expand access to high quality drugs at best world prices;

Funding decisions should be made independently of whether governments have met structural adjustment conditionalities imposed on government by the World Bank and the International Monetary Fund;

The Global AIDS and Health Fund should first be focused on the HIV/AIDS crisis, and related epidemics such as TB in sub-Saharan Africa and then expanded to other regions;

For these principles to be fully adhered to, we believe that the Global AIDS and Health Fund, while working in partnership with the international multilateral agencies, should maintain an independent governance structure and should establish innovative implementation mechanisms outside of routine operations of the multilateral institutions such as the UN, the World Bank, or the bilateral US government agencies.

The Global AIDS and Health Fund should be negotiated with the full participation of civil society. To date, civil society has had a limited and marginal role in discussions regarding the creation of the UN-proposed Global AIDS and Health Fund. This lack of transparency and wider participation of civil society in the design of these mechanisms gives us cause for great concern.

Bipartisan US Congressional action is urgently needed to ensure that the UN, G7, World Bank and IMF establish a transparent consultative process, as soon as possible, so that the design, governance, and institutional guardianship of the Global AIDS and Health Fund can be negotiated with the full participation of civil society. Bipartisan US Congressional action is needed to ensure that:

An international civil society forum is convened as a matter of urgency to ensure that civil society leads, rather than follows the design and implementation of this mechanism. African civil society--which is leading the call for action, should be given a primary leadership role is designing this mechanism;

Under an international burden-sharing arrangement, the United States should commit to providing its fair share of the cost of the $10 billion per year Global AIDS and Health Fund by appropriating $3 billion this year which would be proportionate to the 30% US share of the global economy. President Bush's recent announcement of a $200 million contribution to this Fund is a small start, but remains woefully inadequate, as it represents only 6% of an adequate US contribution to this mechanism;

The United States should support efforts to accelerate negotiations with civil society, philanthropists, foundations, corporations, and governments to commit grant resources to meet the $15 billion per year requirements for full costs of combating the AIDS crisis in Africa.

Expanding Access to Life-Extending Antiretroviral Medicines

The World Health Organization global standard for the use of antiretroviral medications, known as the " triple cocktail treatment, " indicates that approximately 5 million of the 27 million HIV-infected Africans should currently be taking these life-extending antiretroviral drugs. The benefits of these drugs include:

· Antiretroviral medications reduce the amount of HIV that an infected person has in their body. This benefit dramatically reduces HIV transmission through sexual transmission and from mother-to-child, while simultaneously extending the life of economically-productive parents;

· By offering antiretroviral agents to HIV-infected people in resource poor settings, prevention interventions are more likely to succeed. People will have a strong incentive to seeking voluntary counseling and testing (VCT);

· Access to treatment will greatly accelerate the destigmatization of AIDS as a death sentence, as HIV-infection will be rapidly be transformed into a manageable chronic disease;

Another compelling rationales for rapidly expanding access to antiretroviral agents is to implement primary orphans prevention. By treating parents with these drugs, we can effectively keep mothers and fathers alive. As the father of five energetic sons, I know that my healthy presence is needed, and occasionally appreciated, each and every

day! Instead of helping families and communities cope with the 40 million orphans in the future, instead of focussing on succession planning, instead of rebuilding devastated societies from 2010-2020…we should be investing now to keep parents and young people alive.

Despite the known and scientifically proven benefits of antiretroviral agents, only an estimated 5,000 Africans, or 1% of the total number of treatable Africans, currently have access to life-extending antiretroviral medications. International experts from around the World have testified that existing infrastructure through private sector clinics, employer-based programs, faith-based organizations, and other settings can be used to effectively and safely deliver antiretroviral agents. We also know that the production of high quality and effective generically- manufactured drugs puts a downward pressure on costs and allows for the coformulation of multiple drugs in ways that optimize their use in resource poor settings. Both patented and generically manufactured drugs must be utilized to increase access at the lowest possible cost, in ways that are consistent with international trade agreements.

The bottom line is that millions of lives around the World literally hang in the balance. Bold and urgent bipartisan US Congressional action and the full support of the Bush Administration, working in collaboration with other nations, can save these lives by optimizing public-private partnership efforts to expand access to essential medicines. Bipartisan US Congressional action is required to ensure that the following policy priorities are implemented:

Provide bipartisan political support and funding for bulk procurement and distribution systems that simultaneously rapidly expands access to life-extending antiretroviral medications and intellectual property rights;

Ensure access to lowest cost drugs to treat AIDS and associated opportunistic infections, including support for the expansion of generically manufactured drugs so that antiretroviral agents can be coformulated to optimize safe and effective use in resource poor settings;

Create an International Drugs and Commodities Anti-Corruption program, to effectively contribute to already promising and ongoing efforts to stop corruption in the drug and commodities sector.

Debt Cancellation by the IMF and the World Bank to Combat HIV/AIDS in Africa

Many impoverished African governments pay more in debt servicing obligations each year that pay on health, education, and HIV/AIDS programs combined. In fact, African countries are paying $13 billion a year, or $37 million a day in debt servicing obligations to the IMF, the World Bank, the United States, and the rich countries which directly harms the ability of these countries to respond to AIDS. In medical school, I was taught that as a physician my first obligation is to do no harm. By implementing deeper debt cancellation now, impoverished countries will be able to keep their own resources and we will start getting cash flowing in the right direction.

Creditor countries have finally accepted that a debt crisis exists in the poorest countries, and have taken steps to reduce the debts in 18 countries in Africa and I want to thank Members of Congress for the critical support that they have provided in support of debt relief. However, the benefits of the current creditor’s plan are limited – these countries get just a one fourth cut in their annual debt service payments. Of the 23 countries that have received debt relief so far, in 15 the annual debt servicing payments will still be higher than what the country is currently able to spend on basic health care. In the case of Zambia, one of the poorest nations on the globe, payments will actually rise, despite debt reduction, and will remain at about a quarter of its national budget. In total, debt service costs for the poorest nations will reach $2 billion a year through 2005, in spite of the Heavily Indebted Poor Country Initiative (HIPC) debt relief program, if no further action is taken.

In the context of the HIV/AIDS emergency throughout Sub-Saharan Africa, the poorest region of the world, the case for more debt cancellation to help fund an expanded and comprehensive response to the HIV/AIDS crisis is clear. Immediate multilateral debt cancellation to countries enrolled in the HIPC program could provide over half a billion per year for the HIV/AIDS fight, without costing the American taxpayer anything, and without negatively affecting the credit rating of these institutions. World Bank and IMF debt cancellation in these HIPC countries would match what the US and most of the G7 countries have agreed to do. It is time for these institutions to cancel their fair share of the outstanding debt.

Deeper debt cancellation, with 100% cancellation by the International Monetary Fund and the World Bank, would be the clearest immediate signal of the international community’s willingness to defeat HIV/AIDS in Africa by freeing up the required funds. This step would show that creditors recognize the HIV/AIDS emergency requires current debt " sustainability " to be redefined in order to release new and immediate resources. Already, some of the funds released by debt cancellation are being used to fight HIV/AIDS – for example in proven programs in Uganda, Tanzania and Cameroon. We need to build upon these successes. Nigeria has a democratically elected government that wants to win the war against HIV/AIDS – but can only do so if the international community can support the effort. Furthermore, Nigeria is poised precariously for an exponential growth of this killer disease if urgent action is not taken to stem the spread of HIV/AIDS.

Debt cancellation should not be made contingent on failed and harmful World Bank and IMF policies such as the imposition of user fees for primary health care and primary school –policies which disproportionately harm people who are poor and vulnerable such as orphaned and vulnerable children. Congress has already taken important action to oppose the imposition of user fee policies by the IMF and the World Bank as a part of debt agreements or new loans. Treasury must ensure that this policy is enforced.

Bipartisan US Congressional action is urgently needed to ensure that a " New Deal on Debt to Combat HIV/AIDS " is approved when the G7 leaders meet in Genoa, Italy in July, based on:

Complete cancellation of the debt owed by the world’s poorest countries enrolled in the HIPC Initiative to the International Monetary Fund and the World Bank is affordable to these institutions without affecting their international credit rating or lending ability and with no cost to the American taxpayers;

Immediately halt and oppose all World Bank loan programs designed to fund the recurrent costs of HIV/AIDS programs in heavily indebted poor countries, as these programs perpetuate and exacerbate the debt crisis;

Inclusion of more countries in the debt cancellation process;

Congressional action is required to enact the " H.R. 1567: Debt Cancellation for HIV/AIDS Response Act " that was introduced by Congresswoman Barbara Lee and is supported by 13 Members of Congress from both sides of the aisle.

Conclusion

Arnold Toynbee, a famous American historian, stated that, " The 20th century will be chiefly remembered in future centuries not as an age of political conflicts or technical inventions, but as an age in which human society dared to think of the welfare of the whole human race as a practical objective. "

Mr. Chairman and Members of this Committee, as elected officials representing the American people and American values, you in partnership with other World leaders--have the power and authority to ensure that debt cancellation and sufficient grant resources are provided for an expanded and comprehensive response to HIV/AIDS pandemic. Your actions can literally save millions of lives around the World.

So Mr. Chairman and Members of the Committee, with the advent of globalization, the information revolution, the science and technology revolution, and our unprecedented wealth and budget surplus, we undoubtedly have the tools, tactics, and resources to stop global AIDS now. I ask you and all of the Members of the Committee to consider the question, " Can we miss this opportunity and responsibility to ensure that the 21st will be recalled as the century when human society--with a strong American partnership--achieved success in stopping the global AIDS pandemic? "

For more information:

Dr. Zeitz

Co-Director, Global AIDS Alliance

Tel: 267-254-5857

pzeitz@...

www.group.com/group/