<DOC>
[108th Congress House Hearings]
[From the U.S. Government Printing Office via GPO Access]
[DOCID: f:91218.wais]
CHINA'S MOUNTING HIV/AIDS CRISIS: HOW SHOULD THE UNITED STATES RESPOND?
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ROUNDTABLE
before the
CONGRESSIONAL-EXECUTIVE COMMISSION ON CHINA
ONE HUNDRED EIGHTH CONGRESS
FIRST SESSION
__________
OCTOBER 20, 2003
__________
Printed for the use of the Congressional-Executive Commission on China
Available via the World Wide Web: http://www.cecc.gov
______
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CONGRESSIONAL-EXECUTIVE COMMISSION ON CHINA
LEGISLATIVE BRANCH COMMISSIONERS
House Senate
JIM LEACH, Iowa, Chairman CHUCK HAGEL, Nebraska, Co-Chairman
DOUG BEREUTER, Nebraska CRAIG THOMAS, Wyoming
DAVID DREIER, California SAM BROWNBACK, Kansas
FRANK WOLF, Virginia PAT ROBERTS, Kansas
JOE PITTS, Pennsylvania GORDON SMITH, Oregon
SANDER LEVIN, Michigan MAX BAUCUS, Montana
MARCY KAPTUR, Ohio CARL LEVIN, Michigan
SHERROD BROWN, Ohio DIANNE FEINSTEIN, California
DAVID WU, Oregon BYRON DORGAN, North Dakota
EXECUTIVE BRANCH COMMISSIONERS
PAULA DOBRIANSKY, Department of State*
GRANT ALDONAS, Department of Commerce*
LORNE CRANER, Department of State*
JAMES KELLY, Department of State*
John Foarde, Staff Director
David Dorman, Deputy Staff Director
* Appointed in the 107th Congress; not yet formally appointed in
the 108th Congress.
(ii)
C O N T E N T S
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Page
STATEMENTS
Bhat, Amarmath, M.D., director, Office of Asia and the Pacific,
Office of Global Health Affairs, Department of Health and Human
Services, Rockville, MD........................................ 2
Wan, Yanhai, M.D., director, Beijing Aizhi Education Institute,
and world fellow, Yale University, New Haven, CT............... 5
Frost, Kevin Robert, vice president, Clinical Research and
Prevention Programs, American Foundation for AIDS, New York, NY 7
Nieburg, Phillip, M.D., senior associate, HIV/AIDS Task Force,
Center for Strategic & International Studies [CSIS],
Charlottesville, VA............................................ 10
APPENDIX
Prepared Statements
Bhat, Amarnath................................................... 30
Wan, Yanhai...................................................... 32
Frost, Kevin Robert.............................................. 33
CHINA'S MOUNTING HIV/AIDS CRISIS: HOW SHOULD THE UNITED STATES RESPOND?
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MONDAY, OCTOBER 20, 2003
Congressional-Executive
Commission on China,
Washington, DC.
The roundtable was convened, pursuant to notice, at 2:30
p.m., in room 2255, Rayburn House Office Building, John Foarde
(staff director) presiding.
Also present: David Dorman, deputy staff director; Susan
Weld, general counsel; Carl Minzner, counsel; and Anne Tsai,
specialist.
Mr. Foarde. Let us get under way. On behalf of Chairman Jim
Leach and Co-chairman Senator Chuck Hagel of the Congressional-
Executive Commission on China, welcome to this issues
roundtable on ``China's Mounting HIV/AIDS Crisis: How Should
the United States Respond? ''
We are delighted to have four extremely distinguished and
knowledgeable panelists with us this afternoon to continue our
look into questions of public health in China and how that
affects the human right to health, as articulated, among other
places, in the International Covenant on Economic, Social and
Cultural Rights.
We have done an HIV roundtable in the past and some private
briefings, and wanted to get some experts together to carry on
this conversation about what is going on in China and what we
might do as a country to help persuade the Chinese Government
to take the action that is necessary to arrest the intensity of
what seems to be about to happen in China on HIV and AIDS.
Our panelists are Dr. Amar Bhat, director of the Office of
Asia and Pacific, Office of Global Health Affairs from the
Department of Health and Human Services [HHS]; Kevin Frost,
vice president of Clinical Research and Prevention Programs,
the American Foundation for AIDS; Dr. Wan Yanhai, who needs no
introduction, but is the director of the Beijing AIZHI
Education Institute, and this year a World Fellow at Yale
University; and an old friend, Dr. Phil Nieburg, senior
associate now with the HIV/AIDS Task Force at the Center for
Strategic & International Studies [CSIS].
We are going to follow our usual practice in going from
wall to window, and also our usual practice of having each
panelist speak for 10 minutes and make a presentation. After 8
minutes, I'll let you know you have 2 minutes remaining, and
then that is your signal to wrap things up and we will go on to
the next panelist.
Inevitably, there are points in your presentation that you
will not have time to cover, and we understand that, and we
will try to pick them up in the question and answer session
after each panelist has made a presentation.
We would ask each panelist to speak into the microphone, if
you would, so we can get a good record for the transcript,
which will eventually be available on our Web site. That is:
www.cecc.gov. On our Web site you can find both the transcripts
and papers from our previous hearings and roundtables, and also
announcements about upcoming events.
Before we start, we had some good news today. We were just
talking a minute ago about it, and it is hard to characterize
things like this, because this man should not have been
arrested in the first place.
But we received news over the weekend that Ma Funwan, the
deputy director for Disease Control in the Henan Provincial
Health Department, was released. Ma had been held by the
government for allegedly leaking documents about the HIV/AIDS
epidemic in that province.
We are a little bit unclear about when he was actually
formally arrested, but he seems to have been pretty much
incommunicado since the spring, and perhaps formally arrested
in August. So, we are really pleased that he is out and hope
that this signifies some real progress on transparency, but we
are not holding our breath.
Anyway, I would like to begin then and call on Dr. Amar
Bhat, from the U.S. Department of Health and Human Services.
You have 10 minutes. Please go ahead.
STATEMENT OF AMARNATH BHAT, M.D., DIRECTOR, OFFICE OF ASIA AND
THE PACIFIC, OFFICE OF GLOBAL HEALTH AFFAIRS, DEPARTMENT OF
HEALTH AND HUMAN SERVICES, ROCKVILLE, MD
Dr. Bhat. Thank you very much. I appreciate the opportunity
to speak before the Commission. I also welcome the news about
Dr. Ma.
Again, my name is Amar Bhat. I am the Director of the
Office of Asia and the Pacific in the Office of Global Health
Affairs, which is in the Office of the Secretary, Tommy
Thompson.
As such, I am the coordinator of all Asia Pacific
activities in the Department of Health and Human Services and a
spokesperson for Secretary Thompson in the Department in all
matters pertaining to this region.
This hearing today is quite timely, in that Secretary
Thompson is just now returning from his first visit to China as
HHS Secretary. His visit was very brief, basically daylight
hours of Sunday, yesterday, coming on the heels of last week's
meeting of the Board of Directors of Global Fund to Fight AIDS,
Tuberculosis, and Malaria.
As you may have heard, at this meeting of the Global Fund
board, the Board of Directors did choose to accept and approve
the Chinese proposal to the Global Fund for work in HIV.
In the case of China, the third time was the charm. This
was China's third attempt to garner funds for its HIV/AIDS
work, the previous two attempts having failed.
China's third-round application had the same focus as the
second-round application, rapidly commencing and scaling up
Voluntary Counseling and Testing [VCT], associated with
critical care and treatment options for large numbers of HIV-
positive persons living in seven Central China provinces most
heavily affected by the dangerous plasma selling practices of
the mid-1990s, Yunnan Province included.
The 2-year commitment for this grant is US$21 million. I
believe the entire request from the Chinese Government, or to
Chinese CCM, I should say, was US$98 million.
Rather than provide you with an exhaustive list of HHS
activities in China, I would rather provide a description of
three HHS programs which have had significant investments in
China. These three programs are ones where we have felt that
HHS is having great impact, not only in China, but globally,
utilizing HHS's unique blend of resources and skills.
Finally, I will end by touching on Severe Acute Respiratory
Syndrome [SARS], for when it comes to China, at least, I feel
it is impossible to talk about HIV, or for that matter any
other major health problem in China, without addressing SARS
and the impact that this disease has had, and will have, on
China.
HHS has been involved in China since the opening of
relations in 1979. Since then, we have had a health protocol
for cooperation, covering cooperation in health and biomedical
research. It is a broad-based agreement covering all sorts of
health topics.
We will be reviewing this protocol in the next few months
before the anticipated visit of Chinese Premier Wen Jiabao.
Recently, HHS has made a concerted effort to examine our
relationship and to increase our investment in China. We
believe that part of the reason why is an acknowledgement of
the substantial scientific talent in China right now, many of
whom were trained in the United States, the greater
participation of China in world affairs, WTO being just one
example, and the ever-increasing presence of disease,
particularly infectious diseases such as tuberculosis and HIV.
With the onset of SARS earlier this year, the importance of
health has again leaped to the forefront more than ever before.
I will not take time to discuss why and how China has begun
to pay more attention to HIV/AIDS. I am sure some of the other
panelists here can talk about that to a much better extent.
However, I can say that the greater openness of China and
the Chinese officials have made it easier for us to increase
our investments there and take advantage of the considerable
assets they have to make a difference in the global war on
AIDS.
Emblematic of this new relationship is the new Memorandum
of Understanding for AIDS Cooperation that Secretary Thompson
and then-Minister of Health Zhang signed last year here in
Washington.
As I mentioned before, HHS has only begun to invest heavily
in China. Starting late last year, or actually earlier this
year, I guess, in February, the Centers for Disease Control's
[CDC] Global AIDS Program [GAP] opened an office in China.
This two-person office officially opened its doors earlier
today in a brief ceremony involving the CDC Director, Dr. Julie
Gerberding, who was accompanying Secretary Thompson to China.
While a recent development, this office has been long in
coming. In fact, the beginnings of the GAP program in China can
be traced to a 2-week assessment visit in 2001 led by my pal
here, Dr. Phil Nieburg.
As part of that assessment, Dr. Nieburg and his team
identified several areas where China had significant deficits
that CDC could help to rectify. Still in its infancy, GAP in
China currently focuses on improving surveillance in VCT around
the country. I should note that the CDC does not provide direct
health care services, nor do any of the HHS components in
China.
Also last year the National Institutes of Health's [NIH]
National Institute of Allergy and Infectious Diseases, awarded
a $14.8 million, 5-year grant to the China CDC, China's Center
for Disease Control, and the Chinese Academy of Medical
Sciences.
This multi-project grant, known as the Comprehensive
International Program of Research on AIDS [CIPRA], is expanding
China's research activities in HIV/AIDS prevention, treatment,
and vaccine development in cooperation with experts from U.S.
universities and medical schools.
CIPRA is unusual in that it is one of the few NIH-supported
research programs where, by design, the principal investigator
is located outside the United States. In this case, the
principal investigator is Dr. Yiming Shao of the China CDC. The
grant itself
consists of five interrelated projects, touching on a range of
HIV/AIDS-related questions.
In a third area where HHS has made considerable investments
in China is in training. While both the CIPRA and GAP have
training components, there is another program I would like you
to know about.
Many of you know that untold numbers of Chinese
professionals have come to the United States for advanced
training in a number of scientific areas. Biomedical research
is no exception.
At the intramural laboratories of NIH here in Bethesda, at
any one time we may have approximately 300 Chinese scientists
visiting in our labs, conducting research side-by-side with
other scientists at NIH.
Additionally, there must be thousands more in American
universities around the nation, many of them here temporarily
or others planning to settle permanently in the United States.
Dr. Yiming Shao is actually one of those who was at NIH for a
number of years before going back to China.
Additionally, the NIH has made considerable investment in
training Chinese and other developing country scientists in
high-priority areas of research, including HIV/AIDS and other
infectious diseases. The NIH's Fogarty International Center
administers the AIDS International Training and Research
Program [AITRP] which supports HIV/AIDS and related TB
international training and research for health scientists,
clinicians, and allied heath workers from China and dozens of
other developing countries.
The primary goal of this program is to build biomedical and
behavioral research capacity for the prevention of AIDS and
related TB infections, and for the identification of
appropriate interventions to provide care to those adults and
children affected with HIV.
Under AITRP, scientists are trained to address the global
HIV/AIDS epidemic through skills development and fostering of
long-term relationships between individual scientists and
institutions in both countries.
The scope of training includes epidemiology, biostatistics,
behavioral interventions, program evaluation, research in drug
use, blood safety, vaccine development and evaluation,
virology, diagnosis, and treatment.
To date, 12 doctoral degrees, 4 master's degrees, and 24
post-
doctoral fellowships have been awarded to Chinese scientists
and physicians through AITRP. Others have been trained through
in-country workshops using faculty from U.S. universities
supported by AITRP.
One of the wonderful aspects of AITRP is that it leverages
and complements much of what NIH is already funding through
U.S. universities, medical schools, and also other major
funders, such as the World Bank, are also supporting.
While these are three major HIV-related programs HHS has
undertaken in China, there are numerous other activities
outside of HHS you may be interested in hearing more about.
USAID is starting to involve Yunnan Province in its Greater
Mekong HIV prevention initiative. Another initiative is a
workshop taking place later this week--Friday, in fact--in
Beijing, organized by the State Department and the Development
Research Center of the State Council.
The primary purpose of this 1-day workshop will be to
present and discuss various methodologies that can be adopted
to estimate and forecast the macroeconomic impact of HIV/AIDS
in a society at both the local, provincial, regional level, and
at the national level, with a focus on the situation in China.
The State Department is also funding a proposal from the
Shanghai Academy of Social Sciences to support the development
of model AIDS legislation.
Now, as I mentioned, I wanted to touch on the impact that
SARS has had, and will have, on HIV in China. In the short
term, SARS has slowed the momentum we saw building in 2001 and
2002.
During the worst of the epidemic, staff at the China CDC,
and even our own HHS staff in Beijing, were pulled from their
normal duties and asked to devote their full attention to
addressing the national emergency. This, in particular,
impacted heavily the first year of GAP.
Mr. Foarde. Why do we not come back, because I would very
much like to hear you finish that particular part of the
presentation, in the question and answer.
Dr. Bhat. All right.
Mr. Foarde. Thank you, Dr. Bhat.
Dr. Bhat. Thank you.
[The prepared statement of Dr. Bhat appears in the
appendix.]
Mr. Foarde. I would like to go on please, to Dr. Wan.
Please go ahead.
STATEMENT OF WAN YANHAI, M.D., DIRECTOR, BEIJING AIZHI
EDUCATION INSTITUTE, AND WORLD FELLOW, YALE UNIVERSITY, NEW
HAVEN, CT
Dr. Wan. First, I am very honored to speak at the
roundtable. Thanks for inviting me to talk about information
transparency and the public participation in AIDS work on both
the Chinese and American sides.
I am Wan Yanhai. I am the director of the Beijing Aizhi
Institute of Health Education. Our institute was officially
registered last October. Our program has been active for about
10 years, but at the end of last September, early October, we
got official registration.
I want to talk about information transparency and the
public participation. I think this is very important in the
fight against AIDS in China.
So, first, on China's side, I want to mention that recently
the Chinese State Environmental Protection Agency has adopted a
policy of open government information and public participation
in environment protection issues and monitoring of government
work.
Second, article 23 of the Law on the Control and Prevention
of Infectious Diseases clearly demands that the government
publish information on infectious disease.
Third, the State Secrets Law contains no provisions
relating to health information. Moreover, in 1999, the Ministry
of Health issued a notice to all provincial health departments
stating very clearly that the AIDS-related information is not a
state secret.
Fourth, I believe there is no fundamental legal barrier or
policy that prohibits publication of information related to
AIDS and other health information.
Fifth, unfortunately, in the past few years, and most
recently with SARS, the Chinese Government has covered up
important health-related information, including, of course,
AIDS-related information.
Sixth, the essentially nationwide blood sales-related
epidemic became known to the central government, among others,
in the mid-1990s, but it was only in December 2002 that the
former Minister of Health, Zhang Wenkang, reported it to the
National People's Congress that the blood sales-related AIDS
epidemic was present in 23 provinces. The Chinese Government
has not informed the public which provinces and which counties
are affected.
It has said, however, that in many of these affected areas,
the HIV infection rate among blood donors is 10 to 20 percent,
and in some areas it is as high as 60 percent.
I want to talk about how the United States can help in both
information transparency and in public participation. First, in
the past few years the U.S. Government, foundations,
institutions, NGOs, and the U.N. and other international
organizations have fortunately started to turn their attention
to the AIDS crisis in China.
Second, I would like to encourage the U.S. Government,
NGOs, and any other organizations working in this area in China
to share information with the Chinese public, to seek their
comments and input on programs and strategies, and to involve
the Chinese people in their work. Specifically, these entities
should involve the Chinese people in the planning,
implementation, monitoring, and evaluation of AIDS-related
programs.
These foreign entities should work with Chinese NGOs,
academics, health institutes, and other emerging, informal
groups who focus on AIDS-related issues.
What I want to emphasize is the importance of informal
groups, because of the difficulties of getting official
registration for labor rights organizations, gay/lesbian rights
organizations, women's activities, organizations for immigrant
workers and some religious groups to get involved in the work.
In addition to working with and soliciting comments and
feedback from these groups, U.S. and other foreign AIDS-related
organizations should reach out more broadly to the Chinese
public, for example, in the following ways: collecting and
publishing information on the Internet, establishing a hotline
and communicating with the Chinese public directly, and
conducting research and public surveys.
Before ending my presentation, I want to thank the people
in the United States and the U.S. Government for helping Dr. Ma
Shiwen to be released, and also to ask for human rights
protection in China's AIDS crisis.
Thank you very much.
[The prepared statement of Dr. Wan appears in the
appendix.]
Mr. Foarde. Thank you. Dr. Wan. You have given us a lot to
think about, and we will be coming back to some of those topics
when we get to the question and answer session.
It is my great pleasure now to introduce Kevin Frost.
Please go ahead.
STATEMENT OF KEVIN ROBERT FROST, VICE PRESIDENT, CLINICAL
RESEARCH AND PREVENTION PROGRAMS, AMERICAN FOUNDATION FOR AIDS,
NEW YORK, NY
Mr. Frost. Thank you. My name is Kevin Robert Frost and I
am the vice president for Clinical Research and Prevention
Programs at the American Foundation for AIDS Research [amfAR].
AmfAR was founded in 1985 and is the Nation's leading
nonprofit organization dedicated to the support of HIV/AIDS
research, AIDS prevention, treatment education, and the
advocacy of sound AIDS-related public policy.
I am also the director of amfAR's international initiative,
Therapeutics Research, Education, and AIDS Training in Asia
[TREAT Asia].
TREAT Asia is a cooperative venture designed to help Asia
and the Pacific, which is expected to become the next epicenter
of the pandemic, to prepare for the safe and effective delivery
of HIV/AIDS treatments as they become more widely available.
The program pairs the resources and experience of clinical
centers in Asia with amfAR's education, training, and clinical
research expertise. The goals of TREAT Asia are to develop the
skills of the health care workforce in the safe and effective
delivery of drug treatments for HIV/AIDS, to enhance existing
health care infrastructure and formulate strategies for
capacity building to prepare for expanded access to HIV/AIDS
drug treatments, to develop a framework for regional
collaboration on a therapeutics research agenda that is
responsive to the needs of patient populations in the region,
and to define and address national and regional policy issues
that impede expanded access to drug treatments for HIV/AIDS,
and by working with regional and in-country NGOs to strengthen
civil society's preparedness for treatment programs.
China's HIV/AIDS epidemic has been gaining momentum, and
the Chinese Government currently estimates that 840,000 persons
are infected with HIV/AIDS. Intravenous drug use and
contaminated blood have been the two primary routes for
infection in China, representing two distinct and separate
epidemics.
However, HIV infection is increasingly spread through
sexual transmission, with rising rates of infection among
commercial sex workers in several provinces. Among those who
acquired infection through tainted blood collection practices
in Central China during the 1990s, large numbers are now
falling ill and have minimal access to care and treatment in
China's underfunded rural health care system.
Relative to most developing countries with severe AIDS
epidemics in Africa and Southeast Asia, China has a functioning
health care infrastructure, and antiretroviral therapy is
starting to be offered through public hospitals and clinics at
the county, township, and village levels in severely affected
communities.
However, health care providers at these levels have little
training or experience in counseling and treating AIDS
patients, compounding the problem of side effect management and
drug compliance. The lack of health care provider capacity to
administer antiretrovirals is one of the biggest obstacles to
treatment preparedness in China.
While by all accounts China has become more open in dealing
with HIV/AIDS, denial of the full extent of the epidemic
persists. Unfortunately, there are no reliable data that
accurately assess the scope of the epidemic.
Chinese doctors privately suggest that the epidemic is at
least 5 times, and possibly even 10 times, greater than the
official estimates. The HIV epidemic in China's Central
Province of Henan is instructive. With an estimated population
of 110 million, Henan is China's largest province. If only 1
percent of this population were infected through the blood
trade, more than a million people would be HIV-positive in
Henan alone. Yet a recent survey showed that the prevalence
rate among commercial blood donors in rural eastern China was
12.5 percent, and 2.1 percent among their non-donor spouses.
In January 2002, the Henan Health Department reported that
80 percent of Houyang village residents were HIV-positive. Of
its 4,000 residents between the ages of 16 and 55, some 90
percent participated in blood donation programs. More than 400
villagers have developed AIDS, and 150 died between November
2000 and November 2001.
In December 2002, former Health Minister Zhang Wenkang
acknowledged that 23 provinces, autonomous regions, and
municipalities were affected by unhygienic blood collection.
This is to say nothing of the epidemic among injecting drug
users in the south and northwest provinces of Yunnan, Sichuan,
and Xinjiang, among others.
When asked by amfAR recently by the size and scope of China
and India's epidemics in an article published in amfAR's
quarterly newsletter for the TREAT Asia Report, Dr. Richard
Feachem, executive director of the Global Fund for AIDS, TB,
and Malaria, had this to say:
There has been this strange collusion between Western
experts, international organizations, and the Chinese and
Indians to first say that the HIV epidemic is not seriously
going to affect China and India at all, and then to say,
``Well, maybe they're going to have a small epidemic,'' and
then to say, ``Well maybe they're going to have a rather larger
epidemic.''
But only very recently has there been anything approaching
a consensus that China and India are set for very large
epidemics. Because of this history of minimizing the epidemics
in China, India and in Asia more generally, I would go with the
higher-end estimates now being produced.
Recently, there have been promising signs of an increasing
willingness in China to confront its HIV/AIDS epidemic. China
has just been awarded a grant from the Global Fund to carry out
voluntary counseling and testing and treatment programs in
seven provinces where many infected through blood collections
during the 1990s are falling ill.
Prior to this, the Chinese Government had initiated a
treatment program in four of these provinces that offer
antiretroviral therapy to about 3,000 persons now, with a
target of 5,000 by the end of 2003.
The Global Fund's support will be used to scale up
treatment, including antiretrovirals, to 40,000 AIDS patients
in 56 counties in seven provinces by 2008. Many experts believe
that even the 40,000 target is a significant underestimate of
the patients in these communities who will require treatment in
the next 5 years.
While the Chinese Government's goal of extending free
antiretroviral treatment to rural AIDS patients is laudable,
many problems exist with China's current treatment policy
program beyond the issue of the number of sick persons who will
have access to free treatment.
One significant problem has to do with the affordability of
state-of-the-art antiretroviral therapy that is both easier for
patients to tolerate and for health care providers to
supervise. For example, fewer doses, less complicated regimens,
with fewer side effects.
As a new member of the World Trade Organization, China has
been careful to respect international trade agreements and only
manufacture drugs that are off patent. Two Chinese
pharmaceutical companies have begun to produce generic versions
of four off-patent drugs that the government has acquired for
its public treatment program.
Patented drugs such as Combivir (AZT and 3TC) are imported,
but considered too expensive to use routinely and are only used
in a handful of patients when domestically manufactured drugs
are not tolerated.
The treatment protocols currently being used are not
optimal and have not been well-tolerated by patients, resulting
in severe side effects which local health care providers have
no training or experience in managing.
Because of these side effects, the treatment options
currently available in China in many ways represent the worst
possible choices and offer the potential for disaster. Yet,
China is taking the approach that most developing countries are
forced to take when it comes to choosing treatment regimens.
Rather than developing public health strategies for
delivering treatments to the population of HIV-infected
individuals, China is left in the undesirable position of
having to settle for what it can get rather than what it needs.
Unless serious attention is paid to acquiring better
combination treatments, the failure rate of the current
regimens is likely to be enormously high and could have dire
consequences in terms of diminished long-term efficacy of
treatment programs in China and the widespread development of
HIV drug resistance, with implications for the rest of the
world.
Similar lack of access to imported reagents for HIV and CD4
testing has constrained the ability of the health system to do
the necessary counseling and testing and to properly monitor
patients.
The mix of insufficiently trained medical staff with poor
counseling skills, poorly tolerated drug regimens, and lack of
testing and laboratory monitoring capacity is a worrisome
combination of factors.
In an editorial published in the South China Morning Post
in August 2003, Drew Thompson of the Center for Strategic and
International Studies in Washington, DC, wrote:
To safely treat HIV sufferers with powerful antiretroviral
drugs, it is crucial to have trained physicians with access to
laboratories which can carry out advanced blood testing . . .
By jumping the gun and beginning treatment before doctors and
counselors are properly trained, a drug-resistant disaster is
waiting to happen.
Now that China has been granted a big infusion of funds
through the Global Fund mechanism, it will quickly be scaling
up its treatment program. It is imperative that education and
training programs are rapidly expanded and accelerated in order
to ensure that the best available drugs are being provided by
trained medical
professionals, with proper counseling and rigorous monitoring
and follow-up testing.
At amfAR, and within the TREAT Asia program, we believe it
is here that the United States has much to offer. China
desperately needs--and there is growing evidence of China's
willingness to seek--international support for rapidly
developing and scaling up education and training programs for
health care providers in the delivery of HIV/AIDS drugs. It is
my sincere hope that we will find the necessary resources to
provide precisely that support.
Thank you.
[The prepared statement of Mr. Frost appears in the
appendix.]
Mr. Foarde. Thank you very much, Kevin. Very interesting,
and again, very rich topics to take up during the question and
answer session.
We now welcome our old friend, Dr. Phil Nieburg. As I was
saying before this session, he has been a participant sitting
in the back of the room as an auditor of some of these
sessions, and we have always wanted to get him here in front of
the microphone. So, we are delighted that we had the chance to
do that today. It is your 10 minutes.
STATEMENT OF PHILLIP NIEBURG, M.D., SENIOR ASSOCIATE, HIV/AIDS
TASK FORCE, CENTER FOR STRATEGIC & INTERNATIONAL STUDIES
[CSIS], CHARLOTTESVILLE, VA
Dr. Nieburg. Thank you. I would like to thank the
Commission for this opportunity to talk about what is clearly a
very important issue. I would also like to specifically thank
Susan Weld and Anne Tsai for providing clear guidance on the
goals of this session.
As a preamble, I would just like to clarify my current
status. I am a pediatrician trained in infectious disease.
Until August of this year, I was a career employee at the
Centers for Disease Control and Prevention.
As Dr. Bhat mentioned, I traveled to China as part of an
HIV/AIDS assessment in 2001 and have been back several times
for the purpose of helping arrange the CDC program that is now
getting under way in China.
However, I am no longer with CDC, and the views that I am
going to express today are purely my own.
It is still too early to know with any certainty whether
China is going to experience a self-sustaining heterosexual
pandemic of HIV of the magnitude that is now devastating a
number of African countries. However, it appears that the
possibility of a large problem in China is very real and the
potential consequences for China and its citizens are great.
I thought that my most useful contribution today would be
to discuss the broad categories of activities that the U.S.
Government and other non-Chinese agencies could undertake now
and in the
future for the purpose of helping China both acknowledge, and
appropriately respond, to the large and growing HIV problem.
My presentation today is going to be divided into three
parts. First, I will talk about the need for a clear vision and
clear goals for China's HIV control efforts and for U.S.
activities in support of those efforts.
I will then discuss several categories of HIV control
activities in which the United States could participate and
that would have lasting benefits for the Chinese people that
would extend well beyond any successes in HIV/AIDS control.
Finally, I will have a few closing remarks about things we
should be cautious about when dealing with China on HIV/AIDS
issues.
First, to the issue of vision for HIV control. Do we really
know what the Chinese Government wants to accomplish in terms
of HIV control? Is their priority having the smallest number of
HIV-infected people? Is the priority having the largest
proportion of AIDS patients receiving appropriate care and
treatment? Is it minimizing the societal impact of HIV/AIDS? As
I will point out in a minute, because of resource constraints,
it may not be possible to do all three of those different
activities.
Also, what do we in the United States want to accomplish in
China and for the Chinese people with regard to HIV? How
compatible are U.S. goals with the Chinese goals?
In my view, global HIV control activities in a community, a
country, or on a global scale tend to take one of three broad
approaches, each with its own set of goals. Because the goals
of these three approaches are only partially overlapping, we
and the Chinese need to think about them carefully. There is a
table on the handout that outlines the three approaches.
The first approach, is that of HIV/AIDS care. Providing
care is a humanitarian activity that includes, but is not
limited to, treatment of persons with AIDS. Care is the goal of
helping individual people infected with HIV in their household
and family members. The care approach focuses on HIV-infected
persons and tends to operate on a ``medical model.'' Although
in this country, national and state governments finance an
important proportion of clinical care, that care is largely
delivered by the private sector here.
The second approach is HIV prevention. That is a set of
public health or public policy activities that seeks to prevent
or minimize spread of HIV in populations by reducing the risk
of person-to-person HIV transmission. To date, such prevention
activities have largely, although not exclusively, focused on
HIV-uninfected individuals, a different population of focus.
In contrast to delivery of care, prevention of the spread
of life-threatening disease such as HIV within and across
national borders has generally been seen to be the
responsibility of national governments. Although the private
sector may be involved in such efforts, that involvement has
been secondary.
Finally, a third approach is mitigation, which means
reducing the impact of community or societal disruption arising
as a result of HIV/AIDS killing or disabling large numbers of
individuals. Some simple examples of this type of population-
level problem needing mitigation are: (1) large numbers of
orphans needing shelter and care; and (2) reduced local food
availability due to illness among local subsistence farmers.
HIV care, prevention, and mitigation activities and goals
have some overlap. For example, prevention activities can help
identify HIV-infected persons needing care, and HIV care
activities can provide entryways for prevention for, example,
family members who could benefit.
However, this overlap is not nearly as complete as is
commonly assumed. For example, the skills and resources needed
to effect behavioral change among sexually active young people
are different from the skills and resources (including
laboratory and pharmacy resources) needed to educate health
professionals about proper use of antiretroviral drugs. The
resource needs for comprehensively addressing a large orphan
population are different yet again.
So, at this moment, China has to deal with all three of
these issues. It is facing rapid increases in numbers of
persons known to be infected with HIV who need care. In at
least some parts of the country, China has to deal with entire
communities of people needing external support of various kinds
to mitigate the impact of HIV spread through plasma cells.
People need not only direct AIDS care, but food, shelter,
income, et cetera.
Finally, at the same time, China must begin to slow the
internal spread of HIV. In fact, slowing the spread of HIV
seems to me to be the most important current public policy
priority for the Chinese Government, at least in part because
those persons becoming infected today are the vanguard of a
very large burden that China's health system will face by 2010
or 2015.
Even with a lot of external support, there are still not
enough
resources, not enough trained people to address all three of
these approaches simultaneously and quickly, so China's
government is now facing some very difficult allocation
decisions.
My second set of comments is about HIV interventions that
the United States might give priority to in supporting China's
HIV control efforts. These are each activities that would have
a spin-off benefit in China, and perhaps for U.S. policy in
China, by encouraging constructive political change in a way
that could have implications well beyond the HIV/AIDS arena.
The first one is access to accurate information, which
might be viewed as transparency. By this I mean that
information about HIV/AIDS, including its risks and its
consequences, should be widely available and widely discussed
in Chinese society. The goal would be that decisionmaking by
both government and by individual Chinese citizens would be
based on accurate information at all levels.
In this arena, the United States should support a strong
emphasis on increasing AIDS awareness and awareness of other
sexually transmitted infections and tuberculosis as well, not
only among the public, but also among health workers and among
political leaders.
Health workers, teachers, parents, and as many others as
possible should be educated about HIV/AIDS in a ``training of
trainers'' style. That is, they should be trained and equipped
to also educate others they come in contact with--their
patients, their children, their colleagues--about HIV/AIDS
issues. In this regard, the sexual nature of HIV spread needs a
lot of attention.
Counseling and testing programs for HIV should be made
widely available so that any individual wanting to know his or
her own HIV status can find out in a truly confidential setting
where good post-test counseling is available.
Finally, I strongly support efforts to improve and expand
the process of public health surveillance to provide accurate
information on HIV, AIDS, tuberculosis, high-risk behaviors to
local, provincial, and national governments.
An effective surveillance system will also require that
China eliminate, or at least address in some way, current
criminal sanctions on social behaviors associated with HIV
spread. Surveillance data should be made widely available.
A second point in terms of interventions is a set of
issues: confidentiality and discrimination. By this, I mean
that information about HIV/AIDS status of specific individuals
should not become widely available. When it must be known by
some people for clinical or public health purposes, that
knowledge should be safeguarded, that is, not shared or used as
a basis for adverse actions.
Where laws or regulations on these issues exist, they
should be examined to see if they are helpful. If helpful, they
should be
enforced.
Finally, in this category, the work of non-governmental
organizations in HIV/AIDS care and prevention should be
encouraged and supported whenever possible.
As in our country, organizations not directly affiliated
with the government are often more able to publicly address
sensitive topics such as substance abuse, homosexuality,
prostitution, and sexuality in general.
These are each topics on which China desperately needs
public discussion in order to empower individuals to remain
uninfected by HIV, or if already infected, to seek care.
So, the United States has much we can contribute to China's
efforts. I would just close with two brief caveats. First,
since we are such a large and influential player in the global
arena, it is important that our messages and our advice to
Chinese leadership be consistent over time, and also between
U.S. agencies. Once committed, we should remain committed.
Second, we in the United States have limited experience
with the kind of extreme poverty that China faces, including
the need to ration resources in a way that China must to reach
its control goals. We also have limited experience with health
care systems in which the government is a major provider. While
we can provide a lot of useful technical support in these
latter two areas of rationing and government provision of
health care, I would urge a measure of humility in offer advice
in these, or any other areas, where our own experience is
limited.
Thank you for your attention.
[The prepared statement of Dr. Nieburg appears in the
appendix.]
Mr. Foarde. Thanks very much, Phil. Very interesting stuff
as well. We will get into some of these issues in more detail
in just a moment.
I will give our panelists a chance to catch their breath
and I will make an administrative announcement or two.
First, I think everyone in the room, I hope, knows that the
Commission's annual report came out on October 2. It is
available in PDF format and HTML format on the CECC Web site.
But if you should want to have a hard copy for your
collection, please send us an e-mail, and in the subject line
say, ``Mail Copy of Report'' to infocecc@mail.house.gov, and we
will mail you out a hard copy until we no longer have any more.
We still have quite a few.
Next, I would like to remind you that our next issues
roundtable will be, instead of 2 weeks from today, just 1 week
from today, on October 22. Instead of at 2:30, it will be at
1:30 p.m. in the Gold Room, which I think is room 2168, here in
the Rayburn Building.
We are going to pick up the case of Sun Zhigang and try to
look, in the aftermath of his detention and death, what has
happened, if anything, to China's prisons and detention
systems. We have very fine panelists lined up for next week.
Again, it will be at 1:30 rather than 2:30. So, we look forward
to seeing everyone there.
Now on to our question and answer session. As we usually
do, we will give each of the staff members on the panel up here
5 minutes to ask and hear answers to questions.
Normally we try to address the questions specifically to a
panelist, but if any of the other panelists have remarks they
would like to make, we want to hear them. So, make yourself
known if you want to comment.
I will exercise the prerogative of the chair and start by
asking if Dr. Bhat would finish his presentation on the SARS
angle and how it ties in with AIDS, comparing and contrasting
it, because I think this is a really important issue and I
would like to hear what you have to say on that, if you would,
please.
Dr. Bhat. I appreciate the opportunity to finish a little
bit more completely on my thoughts on that.
As I was saying, SARS did slow the momentum of progress
made in years 2001 and 2002 in kind of opening up or
acknowledging the AIDS epidemic. As I said, they pulled a lot
of staff from both the Ministry of Health, as well as our own
staff, to focus on SARS. But I am hopeful that SARS will have a
positive impact in the long term.
It has certainly brought health to the immediate attention
of the seniormost leaders, and also brought to their attention
the need to improve their own public health infrastructure,
which had been deteriorating badly over the years.
They realized also that there are severe consequences for
not paying attention to issues such as disease surveillance and
outbreak response. So, we are hopeful that they are going to be
open to improving and investing more in their health
infrastructure. And certainly they have asked us, the U.S.
Government, for assistance in this matter.
So, we are in the process of developing a menu of items,
working with our colleagues at CDC, NIH, and the Food and Drug
Administration [FDA], to provide a package of items that they
can use to help improve their own public health infrastructure.
These range from epidemiology and surveillance issues, some of
the things that Phil was referring to. Some of it is more
focused on research elements, kind of borrowing from our
activities already in HIV/AIDS and applying them to SARS.
Finally, also, we are looking to see how we can speed up
some of the regulatory systems they have here in the United
States and in China so that we can respond more quickly to
outbreaks with new drugs, new vaccines, and new diagnostics.
Right now, we do not have an appropriate diagnostic for SARS
and we certainly could use one, especially with the compounding
effects of influenza.
So, I am hopeful that they will make an effort to improve
the health system in cooperation with us. But at the same time,
I would note that addressing their own SARS epidemic in their
own country, they did employ some rather onerous, as I call it,
economic control techniques to kind of get a handle on the
situation.
These are things that I do not think we would tolerate in
this country, and many other democracies. But at the same time,
I am sure that for some these type of techniques were validated
in their own eyes.
So in the process of helping them, I am hoping also that we
can transmit some basic values that are fundamental to our own
system here, such as transparency and accuracy in reporting,
and a non-punitive system for reporting disease information so
you do not get penalized for giving unpleasant or unwelcome
information. Then, also, the value of sharing information, data
and samples around the world with the global network of
scientists and public health officials that we have. So, I am
hopeful, but we can only tell over the course of time.
Mr. Foarde. Very useful. Thank you.
I am so short on time, that I think I am going to hold my
next set of questions until the next round.
So, I would recognize my friend and partner, Dave Dorman,
who works for Senator Chuck Hagel, our co-chairman, for a
question.
David.
Mr. Dorman. Thank you to each of you for coming today and
helping us illuminate this very important issue for each of our
Commissioners.
I just have a very brief question, but it has a very long
introduction. I need to explain why it is I ask a question like
this.
I spent part of this weekend reading the new Human Rights
Watch report on HIV/AIDS and found it just excellent. But a
number of questions are raised in the introductory portion of
that report, and I think some of these questions are very
relevant to our commissioners and to other Members of Congress
in terms of the U.S. response to the mounting HIV/AIDS crisis
in China.
In particular, the Human Rights Watch report actually
raises this issue, and it has also come up in testimony today,
after a very fitful start, Beijing was able to mobilize its
state resources to bring the SARS epidemic under control, in
many cases using some rather harsh command-and-control
techniques. Many in this country see the larger and more
dangerous challenge of HIV/AIDS in China, but do not see a
similar strong commitment by the Chinese Government to act.
Is this a question of will or is this a question of
capacity? The question I will leave each of you with is, ``Does
China have the capacity to combat HIV/AIDS without
international support, without U.S. support? ''
Could each of you answer this question very briefly in any
way that you choose?
Dr. Bhat.
Dr. Bhat. All right. Since the microphone is on this side,
I will go first.
Well, I think the answer is obvious that they do not. But,
then again, I would say also that even the United States does
not have the capability to tackle the AIDS epidemic from a
global perspective by itself.
I mean, we are in a very interdependent world and we need
the resources, skills, and expertise of just about everybody. I
am speaking mostly from the research perspective.
One thing that I probably did not emphasize enough is that
while we have a wealth of scientific talent in this country, we
do not have everything that is needed in order to make a dent
in the research, really. We need to partner with other
countries such as China where the epidemics are rising and
where you see increasing incidence.
Similarly, they need us in order to have some of the
scientific expertise, the biotechnology skills, etc., that are
needed to put the whole thing together. So, if only from the
research perspective, yes, we all need each other. I will leave
it to the rest to talk about the internal capacities in China.
Mr. Dorman. An important point.
Dr. Wan. Yes. AIDS is a worldwide challenge to many
countries, including my country, China. I think in China we do
have some resources to fight against AIDS, like public
government information and involving the Chinese people in
campaigns.
But there are some political or legal problems, like some
restriction on the development of NGOs. The Chinese Government
still does not provide funding for NGOs to work on nonprofit
social causes.
So, I think, working together with other countries to get
experience, to get help, is very important. I do think that the
experience of U.S. NGOs is very important, and the United
States has a lot of capacity for research.
So, about education, I think it is still sometimes
controversial, even here in the United States. But I do think a
working relationship between the United States and China is
very important.
Mr. Frost. You asked specifically the question of capacity.
I limited my remarks largely to the issue of treatment and
care, which is a reflection of our programmatic activities in
China. So, if I may, I will respond as it relates to capacity
in that realm, the realm of treatment and care.
I think it is clear that China does not have the capacity
to respond in this arena, particularly. In the United States,
we built up 20 years of experience in dealing with this
epidemic over time when the first treatments became available--
AZT in 1987, and then later we used dual-combination therapy,
and then triple-combination therapy--and we had very large
programs, community-based research programs, as well as
programs at the NIH based in academia that led to that wealth
of experience in treating for and caring for patients.
Many treatments for HIV patients in this country were
developed through community doctors. I am thinking of
aerosolized pentamidine for pneumocystic pneumonia. So, we
built a wealth of information over 20 years. But in this
regard, the treatment of HIV is really oftentimes more art than
it is science.
It is one that I think requires a tremendous amount of
experience and knowledge. I think we have that knowledge, and
we are gaining that knowledge more and more every day.
Therefore, I would say we have a lot to offer in that regard.
But it is clear to me that China, on its own today, dealing
with the massive epidemic that it faces, does not have the
capacity to at least address that aspect of the epidemic.
Dr. Nieburg. Thank you. Let me start by saying that I agree
with what Mr. Frost has said about treatment. China, on its
own, does not have the capacity to deal with its current
treatment needs, to say nothing of what China is going to be
facing in a few years.
On the prevention side, I have mixed feelings. HIV
transmission is largely a behavioral issue and China
essentially eradicated other sexually transmitted diseases in
the 1950s and 1960s. So, they proved that even with a complex
issue like sexuality, they could mount a large-scale effort.
On the other hand, China currently has an economic boom
which is fueling HIV transmission, and I am not sure that can
be adequately dealt with.
HIV is now, in my sense, a chronic disease, and I think it
is an endemic disease in China. I think, however successful a
treatment is going to be, that is going to mean there are lots
of HIV-infected people who will be around for a long time and
potentially can transmit to others. So I guess my sense is that
they do not now have the capacity by themselves to deal with
the prevention issue either.
Mr. Foarde. I next recognize the general counsel of the
Commission, Susan Roosevelt Weld, for some questions.
Susan.
Ms. Weld. Thanks, John.
I want to ask a question which seems somewhat adversarial,
but it has to do with the priorities that the Chinese
Government relies on in allocating funds. From some of the
information we have been receiving, one of the basic problems
is there is insufficient funding allocated out of the central
budget to the question of AIDS at the center, and particularly
allocating money from the center down to the provinces that are
hardest hit.
Is there a way that U.S. assistance could encourage
spending the allocation of resources on HIV/AIDS? Let me start
with Amar.
Dr. Bhat. All right. That is a good question. I am not
certain of the best way to answer it. Just in terms of our
activities, I do not think the research activities really have
any influence on spending at the provincial levels. They will
tangentially impact the provision of care, but it is certainly
not a direct relationship.
More so with the technical assistance. Obviously, when you
talk about China you have to talk about providing assistance at
the provincial levels. That is precisely what we are doing.
But, again, in terms of just resources, I have very little
confidence that our programs, per se, will have a direct impact
on the allocation of just pure monetary resources.
It is more along the lines of what Phil was referring to
earlier with training the trainers, increasing the capacity,
increasing their knowledge base, but less so in terms of
providing goods or direct resources.
Dr. Wan. I want to talk about the Chinese people. When we
are talking about the AIDS crisis in China, we are still facing
a silent majority. A lot of Chinese people are still not
completely informed and not prepared with an anti-AIDS
campaign.
So, if the U.S. Government could invest in supporting
capacity building of the communities, NGOs, academia, and to
get people involved to increase the capacity of the people, if
people could be educated and they could work with our
government to help increase the budget at the central level and
the provincial levels, in research policy, and the human rights
issues, and providing legal aid for people, then I think that
is fundamental in an anti-AIDS campaign in China. If people are
not informed, are still silent, I would suspect the future
investment by our own government.
Mr. Frost. Not easily. But neither should that deter us in
our efforts. I think it is always difficult to influence the
priorities of
another government. My own view is that, until China takes
ownership and provides real leadership on this particular
issue, the inroads will be long and difficult.
But I do not think that should deter us in any way from
continuing to provide the kind of support assistance that we
are capable of providing and making a difference in areas where
we can make a difference. I think we have a responsibility to
do that, and I would argue that we should.
Dr. Nieburg. Thanks. I actually agree with all three of the
previous speakers. At lunch time we were talking about how the
U.S. contribution to the Global Fund is essentially a matching
contribution. Our maximum is 33 percent of the total. So, what
we give to the Global Fund depends on what other nations give.
There have been discussions about having the same kind of
arrangement with the Chinese Government.
I also mentioned at lunch time that Kevin and I were in
China on the trip in January, listening to the Chinese
Government say to us one day that they were short on resources.
The next day, there was a large announcement in the paper about
the Chinese space program. So, one has to think carefully about
the fungibility of funds, et cetera.
Mr. Frost. It was not our best day. [Laughter.]
Mr. Foarde. The other member of our staff who looks at HIV/
AIDS issues is Anne Tsai. It is over to you for questions,
please.
Ms. Tsai. Susan and I have been looking at this issue and
have had various meetings with Chinese and non-Chinese experts
on this topic about the best way of providing assistance
through either the central government, getting full cooperation
with the Public Health Ministry, or just going directly into
the provincial and local levels.
We have heard arguments on both sides. We are curious as to
what each of you thinks is the most effective model and how the
United States should pursue it. We can start with Phil.
Dr. Nieburg. Yes. I have mixed feelings about this. I mean,
China, functionally, is a federal system in the sense that the
provinces operate pretty independently of the center.
In our assessment, our teams went to four different
provinces. Our sense at the end was that these provinces, given
resources, could do a lot, given resources and guidance. So, I
think there is a strong argument for not tying money up in a
Beijing bureaucracy.
On the other hand, we are dealing with another, sovereign
national government and there are clearly arguments for trying
to improve cooperation between us as well.
Mr. Frost. My answer actually also sort of relates to
Susan's question, which is that not all of the support that the
United States offers, or can offer to China, has to go to the
Chinese Government.
In fact, I think one of the biggest challenges that the
Global Fund faces is that the money that it provides to address
the epidemic in countries, for the most part, goes to
governments and works through government systems, whether that
be the country coordinating mechanism or some other government
system.
I actually think that the strengthening of civil society
and working through non-governmental organizations in
countries, and international organizations that are on the
ground and have been on the ground--and there are several in
China that are on the ground and working and have experience in
dealing with the epidemic--are an avenue of support that we can
provide that allows for a measure of accountability, a measure
of success of our programs that does not necessarily mire the
program in the bureaucracies of either the national or
provincial governments.
So, I think it is worth considering how we can provide
support on both the national and the local level, but thinking
outside the box and going beyond just sort of these bilateral
government-to-government arrangements and working with in-
country groups that have a vast amount of experience working on
the ground.
Dr. Wan. Yes. I think both working with the central
government and the local government could help, but you have to
have a very strict monitoring and evaluation process. The
central government has a lot of technical and financial
resources. Maybe not many, but many compared to provincial
governments. In the counties, I do think it is very important
to put more resources into training programs.
But because it is a decentralized situation in China, we
have to face the reality of corruption, local government
corruption issues. So, I would suggest that when you support a
program for a government institution, you need some time to get
the involvement of local Chinese people, and also to support
some kind of watchdog, independent nongovernment organization,
to do research about their policy, about the program, to follow
up on what is going on.
Dr. Bhat. I want to address your question from a couple of
different angles. One, is the diplomatic perspective.
Essentially, the ministry of health for the United States is
the Department of Health and Human Services. We have a kind of
relationship, not just in AIDS but in all areas of health, with
the Chinese Ministry of Health and out of mutual respect,
really, it is really appropriate for us to work directly with
the Ministry and only work at the provincial or other levels
with their permission. That is the diplomatic look at it.
But China also is a big country. We do not have a lot of
resources, honestly, to put into China. In fact, we were
concerned, starting with the GAP program in China, that it
would overwhelm our own resources for this program.
That said, we have looked for ways to maximize our
resources. One of the ways is to focus our initial efforts, at
least, in Beijing. Then once we are on the inside, we can start
to look where we can most effectively make an impact at the
local and provincial levels. Perhaps over time we will be
focusing more at the provincial levels, because that is where
the work needs to be done. But, in the beginning, it is in
Beijing.
Mr. Foarde. Let us go on and recognize our friend and
colleague, Carl Minzner, who is senior counsel working on the
grassroots-level rule of law issues.
Carl, questions?
Mr. Minzner. Yes. Thank you very much. Thank you all again
for coming today.
I want to return to a question that Mr. Dorman had begun to
ask. He brought up the distinction between the will and the
competence, and he proceeded to ask a question about the
ability of the Chinese Government to handle the AIDS situation.
I want to ask about the will. In fact, last week there was
a professor, I believe from the Harvard Public Health School,
who came here and gave a lecture not associated with the
Congress. She drew a parallel between the SARS and the AIDS
developments, and noted that were the local will to be
exercised, the government could bring to bear quite a large
number of resources very quickly on a public health problem.
The government could concentrate a lot of the news media and
the public information resources that would be necessary to
address the problem.
So she raised the possibility that there is a blockage
somewhere in the system, that something is not giving way. But,
were that obstacle to give way, it could change the dynamics of
the system very quickly.
For you all, who have had a long series of interactions
with the Chinese Government, if each of you had to pick one
place where that blockage is, it could be as specific as naming
names, or if you just had particular areas where you felt that
there is a lack of local will, be it a particular ministry, be
it a particular level of government, whatever, what would you
identify as the main blockage when it comes to the question of
political will to handle this issue?
Dr. Bhat. Again, I will start since the mic is near me.
I actually do not think the blockage is at the Ministry of
Health. I think, you might say, they have ``got religion'' on
this issue. I think it is elsewhere.
Now, actually this workshop I mentioned that is taking
place this Friday in China is an experiment, in the sense that
we are targeting the audience, not the Ministry of Health, the
usual characters, but rather at the State Council through the
Development Research Center to see if we can enlighten them a
little bit about the future impact of HIV/AIDS on their
society.
Basically, we are testing a hypothesis and we will see
whether we can get them to be motivated to spread the word
within the State Council, that this is a serious issue and that
it needs to be addressed. The hoped for outcome is the drafting
of a white paper that would be circulated among the top level
of the government. So, we will see.
Now, as for the will, I think they are capable of the will.
As Phil mentioned with the STD control earlier, the SARS
control earlier this year, they definitely have a will and
capacity. It is just a matter of overcoming some of the other
concerns. I think personally that they do not want to be
labeled as an AIDS country, therefore, they are trying to deny
it. But once the numbers get so large that they will be known
as it anyway, well, by then, probably, the cat is out of the
bag.
Dr. Wan. About the will. I think our government does have
the will to combat the AIDS crisis. But I also think that it is
not strong, and sometimes not clear.
I want to talk about different issues. From the leaders,
the former president, Jiang Zemin, talked about AIDS earlier
this year. On the Web site of China's CDC, you can find that
President Hu Jintao talked about AIDS issues, and Premier Wen
Jiabao also is talking about AIDS.
The current Minister has worked very hard in handling SARS
issues and helped China to handle that issue, and it was a big
success, I think. But she has kept silent on AIDS until
recently. Dr. David Ho, in Beijing, in early September, talked
about AIDS. We still do not know, for the Minister of Health,
whether her will is strong or not.
Deputy Minister Gao Qiang, after he became the Deputy
Minister, talked about AIDS. But compared with the former
Minister of Health and the former Deputy Minister of Health, it
just seems that they are now willing to talk about SARS more
than talking about AIDS.
Also, in China, they talk about other health issues,
tuberculosis and other health issues. I agree that China faces
different health challenges, but there is no reason for no work
on AIDS.
When we look at people with AIDS, we can find it related to
sex workers, drug users, blood donors in rural areas, farmers
in rural areas. And people in gay communities have a moral,
social taboo. So, people who are infected do not have much
political, economic, legal, or moral courage to speak out. Our
leaders have some will, but I believe it is not strong enough.
Mr. Frost. If you had asked me this question pre-SARS, I
would have said that I think one of the greatest challenges was
the lack of authority or the lack of power, if you will, of the
Ministry of Health within the Chinese system. China, like many
developing and developed countries, puts emphasis on ministries
that generate revenue, not ministries that lose revenue. Health
loses revenue. That is where you spend money, you do not make
it. So, I would have said the problem is the lack of real
authority.
In the aftermath of SARS, that has clearly changed. The
appointment of Wu Yi as Minister of Health makes her the
highest-ranking minister in the government, frankly. So, I
think that her appointment has had an influence.
I think that, certainly, in the aftermath of SARS, our
programmatic work has become a little easier. There is more
openness and there does seem to be more willingness to exchange
information, share data, and develop cooperative programs in
China.
Having said that, it is also still clear to me that there
is a disconnect in the Chinese system. Most often, it seems to
me that that disconnect is between the provincial level and the
central government. How that takes place mechanically is not
always clear to me.
Without getting into the complexities of the relationship
of the Communist Party to government workers, I think that it
is very difficult to understand where that breaks down within
the system, whether it is outright denial of what does exist in
terms of the epidemic, and therefore an unwillingness to either
address it out of denial, or whether or not there is an
understanding of the extent of the epidemic and a direct desire
to suppress that information.
It is not clear to me what the answer is. It is clear to me
that it has gotten better. How long it will remain better is
anybody's guess, or if we are on an upward trajectory that
could in fact lead to real strengthening of programs and
collaboration.
But I think our hope is that, in fact, we are looking at
the latter and that there is more willingness to be open since
there is common recognition in the aftermath of SARS of what
can happen when one tries to address an infectious disease by
trying to clamp down on information and not be open about it.
Dr. Nieburg. Thank you. I think the technical people in the
Ministry of Health clearly understand the risk that China
faces. I would tend to agree with what Dr. Bhat said about the
obstacle, if there is one that can be identified, being
somewhere at the State Council or beyond.
My sense is, actually, that people in other ministries may
not understand. I do not think it is an issue of political
will. I think there is a genuine lack of understanding of the
risks that China is facing.
The comment that I have heard several times on more than
one trip was that China is not Africa, as if that is the end of
the problem and there is no need to go any further.
I just want to point out that the three global success
stories that I know the most about, which are Uganda, Thailand
and Brazil, are all examples where political leadership at the
highest level made the difference. Actually, I am not aware of
any real success stories without political leadership at the
highest level. So far, that seems to be missing in China.
Mr. Foarde. Very useful. Hearing you talk about the higher-
level leadership, and thinking about the attitude that China is
not Africa, reminds me the first time I had a conversation with
a Chinese Government official about HIV/AIDS back in 1990 when
I was attached to the U.S. Embassy in Beijing. We were
basically told the same sorts of things that we had been told
at just about that same time period on the issue of narcotics
trafficking. ``Oh, that is a problem we have solved in the
past.'' ``Well, HIV/AIDS? '' we asked, and they said, ``That is
a foreigners' problem. There are only foreigners involved here.
Once we get rid of that little problem, this AIDS issue will be
gone.'' We kept trying to tell them that this was not our
experience in the United States. During that time period, we
were still very much grounded with what was going on here and
trying to get our arms around the enormity of the problem.
So, even in that period 14 or 15 years ago to get them to
talk seriously about it was a serious problem, and I see that
things have not changed, at least at the top level. It is good
that they are changing at some level, anyway.
I would like to continue, because we have a few minutes, by
picking up a theme that both Dr. Wan and Phil Nieburg brought
up. That is, the information available to the ordinary Chinese
person.
For this specific question, I am interested in the impact,
if any, of the Voice of America [VOA] and Radio Free Asia [RFA]
on the information available to the Chinese man and woman in
the street about HIV/AIDS.
Are VOA and RFA doing programming on HIV? How effective is
it in conveying the types of messages that you want? Is there
more that could be done by those outlets of international
broadcasting that the U.S. Government has?
Let me start with Dr. Wan, and then go around.
Dr. Wan. In the past few years, Radio Free Asia, Voice of
America, and some other international radio programs have done
a lot of work on AIDS and AIDS-related sex education, blood
safety, rights of people with AIDS, policy issues, legal
issues, a lot of news coverage related to AIDS in China.
I think it has contributed a lot to the ordinary people in
China. For example, last year in late September and early
October, I went to my hometown in a county, a town, in Anhui
Province. Many government officials and retired county
officials, school teachers, and regular people, know
information about what happened in China. A lot of information
comes from Radio Free Asia and Voice of America.
Mr. Foarde. Anhui seems to be a very good place for
reception for VOA.
Dr. Wan. Maybe, yes.
Mr. Foarde. I was on a VOA program last week, and quite a
number of calls were from there.
Dr. Wan. Yes. Also, at some time I visited a place where I
lived before. There was a group of senior, retired workers.
They gathered together every night to talk about political
issues or social issues.
When I came, they were talking about AIDS issues. I was
interviewed and actually I do not know how the radio program
reported on my points. I spoke to the radio quite well, even
some things I have forgotten. So, I think it is very important
to have international radio, yes.
Mr. Foarde. Is there more that could be done or is the
level about right?
Dr. Wan. I think they have done a lot. But I think you
would have to consult some scientists or some policy experts to
talk about issues, because it seems like the current
information mostly focuses on what is happening in China, human
rights issues, and coming from people like me. But I think it
is very important to invite a broad range of people, experts,
to make comments about AIDS issues.
Mr. Foarde. So, more of a scientific focus would be useful?
Dr. Wan. A scientific focus, policy, human rights focus are
all important.
Mr. Foarde. Phil, do you agree?
Dr. Nieburg. Yes. Yes, I do. I mean, I do not know a lot
about the VOA broadcasts, although I do know HIV is a constant
topic of theirs. But I think, both a technical focus and
actually an internal focus is important.
So, for example, in this country every week, the CDC
publishes data on every disease of public health risk. Every
state health department now has newsletters that publish data
about not only disease counts, but epidemics and risk factors.
There are journalists who are interested in that topic, so
a lot of public education goes on based on the national
surveillance system. That could happen in China. You may be
aware that Kaiser is funding a program to educate Chinese
journalists about HIV.
I do not know if it is just on HIV, but on disease
reporting. I think that having VOA focus on this is helpful,
but I think it is going to take internal discussion of these
issues, internal reporting for the Chinese to be able to
believe the information.
Mr. Foarde. So the principal source of information for
China's media industry is not going to be VOA or RFA. One hopes
for the best.
Dr. Nieburg. One hopes. I mean, if that turns out to be the
primary source, then I think China is in bigger trouble than I
realized.
Mr. Foarde. Useful.
Dave Dorman, for more questions.
Mr. Dorman. In our nearly 1\1/2\ hour conversation, I think
you have all established very clearly, at least for me, that in
terms of HIV/AIDS in China, the danger is great, the need is
great.
So just to help me understand, and this goes back to Dr.
Bhat's comment that China's third proposal to the Global Fund
was the first one accepted for funding.
Should we read anything into this? It seems to me, based on
what I just heard, China's first proposal should have been
accepted. Why did it take three tries?
Dr. Bhat. Well, I have not studied all three Chinese
proposals to see what the differences are, but part of it has
to do with just the sheer scope of the problem. That is, what
do you choose to actually apply for?
In other words, what do you choose to actually put into the
application that you would like to try to address? The whole
scope of the program. One doable aspect of it is, do you ask
for hundreds of millions of dollars? Do you ask for a small bit
of money?
I understand some of the issues had to do with a lack of
understanding or a lack of putting into the application in the
initial round enough of a demonstration of the need. It may
have been just implicit that China is in need of these funds,
so just go ahead and get the money.
Then also translation issues as well, translating from
Chinese to English. I know that this time, this last round,
they spent a lot of effort into making sure that their proposal
was in readable English.
At the TRP, relatively few are going to be native Chinese
speakers and can understand and appreciate the language. So,
they said, expend a lot more effort. In fact, I think we may
have even had some Chinese-Americans in the drafting stages.
I think also--and this is less substantiated in my mind, at
least--there was a concern that there was a lack of significant
or substantive NGO involvement. As you may know, at the Global
Fund there is a strong commitment to a public/private
partnership involving civil society, and China does not have a
long tradition of civil society. Most of their organizations
that are involved are more the mass organizations such as the
All-China Women's Federation, and groups like that. So, there
are some concerns at that level as well.
Mr. Dorman. So the fact of third tries says nothing about
the severity of the problem in China compared to other
countries.
Dr. Bhat. Nothing to do with the severity, but just more of
how you demonstrate the need and what do you actually ask for.
Mr. Frost. Can I add something? I do not want to over-
analyze it, but China asked for $98 million, and in their third
proposal they are seeking to scale up treatment for 40,000
people in those seven central provinces.
If one divides $98 million by 40,000, the per capita
expenditure of that grant works out to be an enormous amount of
money by global standards for the treatment of HIV/AIDS.
I think China has an approach in mind that allows them to
seek support from the Global Fund for an epidemic without
really revealing or stating how extensive the epidemic is.
If you will remember, a year before the Global Fund was
announced, before Kofi Annan called for the formation of the
Global Fund, China said they did not have an HIV problem. It
was only 1 month after the Global Fund was announced that China
admitted it did have an HIV problem. The number of people
officially said to be infected in China went from 30,000 to 1
million in a single day.
Now, the cynical side of me would tell you that it is very
difficult to ask for money and international support for an
epidemic that you do not have. I think that that probably has a
lot to do with the approach that they have taken in seeking
support.
They want to seek support for an epidemic without stating
how extensive the epidemic is. I think that is part of the
denial that exists within the Chinese system about the full
extent of the epidemic and seeking support to address it
comprehensively.
Mr. Foarde. I will recognize for the last questions of
today Susan Roosevelt Weld.
Susan.
Ms. Weld. Thanks, John. I have a lot of questions.
[Laughter.] As you will remember, when we were just in China
talking to the Ministry of Health, I asked, what would be a
model country who has responded to its epidemic of HIV/AIDS in
a way that you feel would be useful for China?
And of course, through all of our minds, including the
person from the Ministry of Health, flashed Uganda, Brazil,
Thailand. The answer was, well, there is no other country which
is going to be like China. China is unique in its epidemic, and
in the ways that are appropriate for dealing with it.
I wonder if it would be useful if the United States--I know
that, Phil, you have done some of this in the past--were to
sketch out its own difficulties, its own response to HIV/AIDS,
not in the sense that it would be a correct model for China,
but to bring the Chinese to understand that this is a problem
that every country has had, a problem of the world, not a
problem only for the small countries, backward countries of the
world.
Do you have a good technique for doing that?
Dr. Nieburg. Yes. Actually, Susan is referring to a
presentation I did in Beijing last year. We were sketching out
the evolution of the U.S. HIV epidemic and the U.S. response.
As I prepared for that, I realized I was struck by the
similarity between the two situations.
So, I think you are right. I understand that the Chinese
often think themselves unique in various ways. But I think you
are right, that they are wrong to think what is happening in
China is different, except in scale, with what has happened in
many other places.
Mr. Foarde. Anybody else have a comment on that one?
[No response.]
Ms. Weld. It was such a short one, I will have to fill in.
Mr. Foarde. You have got 3\1/2\ minutes.
Ms. Weld. The other issue is the rule of law. We are also a
rule of law commission. Among the things that we try to promote
are rule of law programs in China having to deal with legal
assistance for certain groups and clinical legal programs so
individuals who have problems can be empowered to assert their
rights in their particular situations.
I see HIV/AIDS as a disease that breeds the kind of
situation where a person might wish to assert his or her
rights. Do you think it as possible that U.S. assistance could
go into that kind of effort? I do not mean in a way that is
adversarial to the Chinese Government. But if a person is not
getting the treatment the government has ordained for that
person to get, or is being discriminated against, could we
buildup those kinds of legal assistance programs?
Dr. Wan. I want to answer that question. There are some
legal aid programs for environmental issues, for migrant
workers, for labor rights issues, some by the United States,
some by the European Union, Canada, and Australia, and maybe
some sponsored domestically. There are some teaching programs,
clinical teaching programs in China. There are some research
programs sponsored by the Ford Foundation, UNDP on legal reform
related to AIDS. And there are some lawyers and law firms now
that have some willingness to help people with AIDS and to
handle AIDS-related policy and legal issues.
Our institute has done a lot of work to advocate for people
with AIDS. We have a plan to provide legal education, and human
rights education related to AIDS. Last month, just a week after
the Human Rights Watch report on AIDS and human rights, our
institute published a report about AIDS law and human rights in
Henan Province. We focused on one province.
We found that it is very important because recently only
those in the area, only when they spoke up, only when they get
to understand policy and they used the law and the policy to
advocate for their rights to get treatment, and for their
children to get an education, only then were they successful.
So I think legal aid, legal education, and human rights are
very important.
Mr. Foarde. Anyone else want to address that?
Dr. Nieburg. Yes.
Mr. Foarde. Phil, please.
Dr. Nieburg. I am not quite sure how to phrase this, but I
would like to make a brief editorial comment about this. I
think that paying attention to the human rights of people who
are infected with HIV in China and elsewhere is very important.
One of the issues that is not often discussed is the right
of people who are not infected to remain uninfected. It is
important that there be some balance in how that is addressed,
particularly in a country like China where access to
information about ways to remain uninfected is not so easy. The
human rights issue, to the extent it is raised, should be
raised for both uninfected and infected people.
Mr. Foarde. Well, I think we are going to have to leave it
there for today, having reached the magic hour.
Amar Bhat, Wan Yanhai, Kevin Frost, Phil Nieburg, thanks to
all of you for sharing your expertise with us this afternoon.
On behalf of Chairman Jim Leach and Co-chairman Chuck Hagel
and all the members of the Congressional-Executive Commission
on China, thanks to all who came this afternoon. I hope we will
see you next week at 1:30 for our next roundtable. We will send
a reminder a little later in the week.
With that, this discussion will close. Thanks very much.
[Whereupon, at 4:05 p.m. the roundtable was concluded.]
A P P E N D I X
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Prepared Statements
----------
Prepared Statement of Amarnath Bhat
october 20, 2003
Hello. My name is Amar Bhat and I am the Director of the Office of
Asia and the Pacific, Office of Global Health Affairs in the Office of
Secretary Tommy Thompson. As such, I am the coordinator of all Asia-
Pacific activities within the Department of Health and Human Services
(HHS) and a spokesman for Secretary Thompson and the Department on all
matters pertaining to this region.
This hearing today is timely in that Secretary Thompson is just
returning from his first visit to China as HHS Secretary. His visit was
very brief, coming on the heels of last week's meeting of the Board of
Directors of the Global Fund to Fight AIDS, Tuberculosis and Malaria.
As you may have heard, at this meeting of the Global Fund Board, the
Chinese proposal to the Global Fund for work in HIV was approved. In
the case of China, the third time was the charm, i.e. this was China's
third attempt to garner funds for their HIV/AIDS work; the previous two
attempts having failed. China's third-round application had the same
focus as the second-round application: rapidly commencing and scaling
up voluntary counseling and testing (VCT), associated with credible
care and treatment options, for large numbers of HIV-positive persons
living in seven Central China provinces most heavily affected by the
dangerous plasma selling practices of the mid-1990's. The 2-year
commitment for this grant is for $21 million.
Rather than provide you with an exhaustive list of activities in
which HHS is engaged in China, I would rather try to provide a
description of three HHS programs which have had significant
investments in China. These three programs are ones where we have felt
that HHS is having great impact, not only in China, but globally,
utilizing our unique blend of resources and skills. And finally, I will
end by touching on Severe Acute Respiratory Syndrome [SARS], for when
it comes to China, I feel it is impossible to talk about HIV or for
that matter any other major health problem in China without talking a
little about SARS and the impact that this disease has had and will
have on China.
HHS has been involved in China since the opening of relations in
1979. Since then, we have had a Health Protocol to cover cooperation in
health and biomedical research. We will be renewing this protocol in
the next few months, during the
anticipated visit of Premier Wen Jiabao.
But only recently have we made a concerted effort to examine our
relationship and indeed increase our investments in that country. Part
of the reasons why has been the acknowledgement of the substantial
scientific talent within China (many of whom were trained in the United
States), the greater participation of China in world affairs, and the
ever-increasing presence of disease, particularly infectious diseases
such as tuberculosis and especially HIV. With the onset of SARS earlier
this year, the importance of health has leapt to the forefront, more
than ever before.
I won't take the time to discuss why and how China has begun to pay
more attention to HIV/AIDS. I am sure some of the other panelists can
do a much better job. However, I can say that the greater openness of
China and Chinese officials has made it much easier for us to increase
our investments in the country and take advantage of the considerable
assets in the country to make a difference in the global war on AIDS.
Emblematic of this renewed relationship is the Memorandum of
Understanding for AIDS cooperation that Secretary Thompson and then-
Minister of Health Zhang Wenkang signed last year here in Washington.
As I mentioned before, HHS has begun to invest heavily in China.
Starting late last year, CDC's Global AIDS Program (GAP) opened an
office in China. This two-person office officially opened its doors
earlier today in a brief ceremony involving the CDC Director, Dr. Julie
Gerberding, who was accompanying Secretary Thompson to China. While a
recent development, this office has been long in coming. In fact, the
beginnings of the GAP program in China can be traced to a 2-week
assessment visit in 2001 led by Dr. Phil Nieburg, here with us today.
As part of that
assessment, Dr. Nieburg and his team identified several areas where
China had
significant deficits that CDC could help to rectify. Still in its
infancy, GAP in China currently focuses on improving surveillance and
VCT around the country. I should note that the CDC does not provide
direct provision of health care services, nor do any of HHS components
working in China.
Also last year, NIH's National Institute of Allergy and Infectious
Diseases awarded a $14.8 million 5-year grant to the China CDC and the
Chinese Academy of Medical Sciences. This multi-project grant, known as
the Comprehensive International Program of Research on AIDS (CIPRA), is
expanding China's research activities in HIV/AIDS prevention, treatment
and vaccine development, in cooperation with experts from U.S.
universities and medical schools. CIPRA is unusual in that it is one of
the few NIH-supported research programs where by design the principal
investigator is based outside of the United States. In this case, the
principal investigator is Dr. Yiming Shao of the China CDC. Five
interrelated projects, touching on a range of HIV-related questions.
A third area where HHS has made considerable investments in China
is in training. While both the CIPRA and GAP have training components,
there is another program I would like you to know about. Many of you
know that untold thousands of Chinese professionals have come to the
United States for advanced training in a number of scientific areas.
Biomedical research is no exception. At the intramural laboratories of
NIH, at any one time we may have approximately 300 Chinese scientists
visiting our labs, conducting research side-by-side with other
scientists at NIH. Additionally, there must be thousands more in
American universities across the land, many of them here temporarily
and others planning to settle permanently in the United States.
Additionally, the NIH has made considerable investment in training
Chinese and other developing country scientists in high-priority areas
of research, including HIV/AIDS and other infectious diseases. The
NIH's Fogarty International Center administers the AIDS International
Training and Research Program (AITRP) which
supports HIV/AIDS and related TB international training and research
for health scientists, clinicians, and allied health workers from China
and dozens of other
developing countries. The primary goal of this program is to build
biomedical and behavioral research capacity for the prevention of HIV/
AIDS and related TB infections and for the identification of
appropriate interventions to provide care to those adults and children
infected with HIV. Under AITRP, scientists are trained to address the
global HIV/AIDS epidemic through skills development and the fostering
of long-term relationships between individual scientists and
institutions in both countries.
The scope of training includes epidemiology, biostatistics,
behavioral interventions, program evaluation, research in drug use,
blood safety, vaccine development and evaluation, virology, diagnosis
and treatment. To date, 12 doctoral degrees, four masters degrees and
24 postdoctoral fellowships have been awarded to Chinese scientists and
physicians through AITRP. Others have been trained through in-country
workshops using faculty from U.S. universities supported by AITRP. One
of the wonderful aspects of AITRP is that it leverages and complements
much of what NIH is already funding through U.S. universities and
medical schools, and also what other major funders, such as the World
Bank, are also supporting.
While these are three major HIV-related programs HHS has undertaken
in China, there are numerous other activities outside of HHS you may be
interested in hearing about. USAID is starting to involve Yunnan
province in their Greater Mekong HIV prevention initiative. Another
initiative is a workshop taking place later this week in Beijing
organized by the State Department and the Development Research Center
of the State Council. The primary purpose of this 1-day workshop will
be to present and discuss various methodologies that can be adopted to
estimate and forecast the macroeconomic impact of HIV/AIDS in a
society, at both the local/provincial level and the national level,
with a focus on the situation in China. State Department is also
funding a proposal by the Shanghai Academy of Social Sciences to
support the development of model AIDS legislation.
Now, as I mentioned, I wanted to touch on the impact that SARS has
had and will have on HIV/AIDS in China. In the short term, SARS has
slowed the momentum we saw building in 2001 and 2002. During the worst
of the epidemic, staff at the China CDC, and even our own HHS staff in
Beijing, had been pulled from their normal HIV-related activities and
asked to devote their full attention to addressing the national
emergency. This in particular impacted heavily the first year of
progress for our GAP team in China.
However, in the long-term, I am hopeful that SARS will indeed
provide positive impacts for HIV and health in general in China. The
epidemic brought to the attention of the senior-most leaders in China
the importance of health to their economy and the need to pay attention
to their public health infrastructure. China's leaders have realized
that they have neglected basic public health and disease surveillance
and now know that there are consequences for doing so. I also believe
that they were stung by the global condemnation they received for
allowing this to happen and are eager to show the world that they won't
let this happen again.
However, I am not so naive to think that they will abandon their
practices and turn a new leaf overnight. In gaining control over the
epidemic, they employed onerous command and control techniques that
would not be allowed in most democratic societies. For some, I am sure
this only validated their system in their own eyes.
Nonetheless, we are hoping to take advantage of this window of
opportunity to provide substantive and long-term technical assistance
in epidemiology and surveillance, information technology and
communications, as well as make some additional investments in basic
research, treatment, vaccine and diagnostics development, and
eventually, we hope, vaccine trials. Work in these areas will only aid
in addressing other epidemics such as HIV/AIDS. This work will also add
to the buildup of their health care system and improve the ability of
the Chinese government to detect and control disease outbreaks, and to
appreciate the role of health in their overall economic development. In
the process, we also hope to transmit some basic values such as
transparency and accuracy in disease reporting, the value of
communicating new developments quickly with international organizations
and scientific colleagues around the world, and the need to share data
and samples widely with the global network of scientists in order to
arrive at a solution as quickly as possible.
That ends my formal presentation. I would be glad to take any
questions you may have.
______
Prepared Statement of Wan Yanhai
october 20, 2003
china--information transparency and public participation
1. Recently, the Chinese State Environmental Protection Agency
(SEPA) has adopted a policy of open information and public
participation in environmental protection issues and monitoring of
government work.
2. Article 23 of the Law on the Control and Prevention of
Infectious Diseases clearly demands that the government publish
information on infectious diseases.
3. The State Secrets Law contains no provisions relating to health
information. Moreover, in 1999, the Ministry of Health issued a notice
to all provincial health departments stating very clearly that AIDS-
related information is not a State secret.
4. I believe there is no fundamental legal barrier or policy that
prohibits publication of information related to HIV/AIDS and other
health information.
5. Unfortunately, in the past few years, and most recently with
SARS, the Chinese government has covered-up important health- related
information, including, of course, AIDS related information.
6. The essentially nationwide blood-sales related AIDS epidemic
became known to the central government (among others) in the mid-1990s,
but it was only in December 2002 that the former Minister of Health,
Zhang Wenkang, reported to the National People's Congress that the
blood sales related AIDS epidemic was present in 23 provinces. The
Chinese government has not informed the public which provinces and
which counties are affected. It has said, however, that in many of
these affected areas, the HIV infection rate among blood donors is 10-
20 percent, and in some it's as high as 60 percent.
united states--public participation
1. In the past few years, the U.S. Government, foundations, NGOs,
the U.N. and other international organizations have fortunately started
to turn their attention to the AIDS crisis in my country.
2. I would encourage the U.S. Government, NGOs and any other
organizations working in this field in my country to share information
with the Chinese public, to seek their comments and input on programs
and strategies and to involve the Chinese people in their work.
Specifically, these entities should involve the Chinese people in the
planning, implementation, monitoring and evaluation of AIDS-related
programs.
3. These foreign entities should work with Chinese NGOs, academics,
health institutes and other emerging, informal groups who focus on AIDS
related issues.
4. In addition to working with and soliciting comments and feedback
from these groups, U.S. and other foreign AIDS-related organizations
should reach out more broadly to the Chinese public, for example in the
following ways: collecting and publishing information on the Internet,
establishing a hotline, conducting empirical
research and public surveys.
______
Prepared Statement of Kevin Robert Frost
october 20, 2003
introduction
My name is Kevin Robert Frost and I am Vice President for Clinical
Research and Prevention Programs at the American Foundation for AIDS
Research (amfAR).
Founded in 1985, amfAR is the nation's leading nonprofit
organization dedicated to the support of HIV/AIDS research, AIDS
prevention, treatment education, and the advocacy of sound AIDS-related
public policy. I am also the director of amfAR's international
initiative, Therapeutics Research, Education, and AIDS Training in
Asia, or TREAT Asia. TREAT Asia is a cooperative venture designed to
help Asia and the Pacific region--which is expected to become the next
epicenter of the pandemic--prepare for the safe and effective delivery
of HIV/AIDS treatments as they become more widely available. The
program pairs the resources and experience of clinical centers in Asia
with amfAR's education, training, and clinical research expertise.
The goals of TREAT Asia are to:
Develop the skills of the health care workforce in the safe
and effective delivery of drug treatments for HIV/AIDS;
Enhance existing health care infrastructure and formulate
strategies for capacity building to prepare for expanded access
to HIV/AIDS drug treatments;
Develop a framework for regional collaboration on a
therapeutics research agenda that is responsive to the needs of
patient populations in the region;
Define and address the national and regional policy issues
that impede expanded access to drug treatments for HIV/AIDS
and, by working with regional and in-country NGOs, strengthen
civil society's preparedness for treatment programs.
size and scope of the epidemic in china
China's HIV/AIDS epidemic has been gaining momentum and the Chinese
government estimates that currently 840,000 persons are infected with
HIV/AIDS. Intravenous drug use and contaminated blood have been the two
primary routes for
infection in China, representing two distinct and separate epidemics.
However, HIV infection is increasingly spread through sexual
transmission, with rising rates of
infection among commercial sex workers in several provinces. Among
those who acquired infection through tainted blood collection practices
in central China during the 1990s, large numbers are now falling ill
and have minimal access to care and treatment in China's under funded
rural health care system. Relative to many developing countries with
severe AIDS epidemics in Africa and Southeast Asia, China has a
functioning health care infrastructure, and antiretroviral therapy is
starting to be offered through public hospitals and clinics at the
county, township, and village levels in severely affected communities.
However, healthcare providers at these levels have little training or
experience in counseling and treating AIDS patients, compounding the
problem of side effect management and drug compliance. The lack of
healthcare provider capacity to administer antiretrovirals is one of
the biggest obstacles to treatment preparedness in China.
Though by all accounts China has become more open in dealing with
HIV/AIDS, denial of the full extent of the epidemic persists.
Unfortunately, there are no reliable data that accurately assess the
scope of the epidemic. Chinese doctors privately suggest that the
epidemic is at least 5 times--and possibly even 10 times--the official
estimates.
The HIV epidemic in China's central province of Henan is
instructive. With an estimated population of 110 million, Henan is
China's largest province. If only 1 percent of this population was
infected through the ``blood trade,'' more than a million people would
be HIV-positive in Henan alone. Yet a recent survey showed that the
prevalence rate among commercial blood donors in rural eastern China
was 12.5 percent and 2.1 percent among their non-donor spouses. In
January 2002, the Henan Health Department reported that 80 percent of
Houyang village residents were HIV-positive. Of its 4,000 residents
between the ages of 16 and 55, some 90 percent participated in blood
donation programs. More than 400 villagers have
developed AIDS, and 150 died between November 2000 and November 2001.
In
December 2002, former Health Minister Zhang Wenkang acknowledged that
23 provinces, autonomous regions, and municipalities were affected by
unhygienic blood collection. And this is to say nothing of the epidemic
among injecting drug users in the south and northwest provinces of
Yunnan, Sichuan, and Xinjiang among others.
When asked by amfAR recently about the size and scope of China and
India's epidemics in an article published in amfAR's quarterly
newsletter for the TREAT Asia Report, Dr. Richard Feachem, Executive
Director of the Global Fund for AIDS, TB, and Malaria, had this to say:
``There has been this strange collusion between Western
experts, international organizations, and the Chinese and
Indians to first say that the HIV epidemic is not seriously
going to affect China and India at all, then to say, well,
maybe they're going to have a small epidemic, and then to say,
well, maybe they're going to have a rather larger epidemic.
``But only very recently has there been anything approaching
a consensus that China and India are set for very large
epidemics. Because of this
history of minimizing the epidemics in China, India, and in
Asia more generally, I would go with the higher-end estimates
now being produced.''
china's response
Recently there have been promising signs of an increasing
willingness in China to confront its HIV/AIDS epidemic. China has just
been awarded a grant from the Global Fund to carry out voluntary
counseling and testing (VCT) and treatment programs in seven provinces
where many infected through blood donation during the 1990s are falling
ill. Prior to this, the Chinese government had initiated a treatment
program in four of these provinces that offers antiretroviral therapy
to about 3,000 persons now, with a target of 5,000 by the end of 2003.
The Global Fund support will be used to scale up treatment, including
antiretrovirals, to 40,000 AIDS patients in 56 counties in these seven
provinces by 2008. Many experts believe even the 40,000 target is a
significant underestimate of the number of patients in these
communities who will require treatment in the next 5 years.
While the Chinese government's goal of extending free
antiretroviral treatment to rural AIDS patients is laudable, many
problems exist with China's current treatment policy program beyond the
issue of the numbers of sick persons who will have access to free
treatment. One significant problem has to do with the affordability of
state-of-the-art antiretroviral therapy that is both easier for
patients to tolerate and for health care providers to supervise (i.e.,
fewer doses, less complicated regimens with fewer side effects). As a
new member of the World Trade Organization, China has been careful to
respect international trade agreements and only manufacture drugs that
are off patent. Two Chinese pharmaceutical companies have begun to
produce generic versions of 4 off-patent drugs that the government has
acquired for their public treatment program. Patented drugs, such as
combivir (AZT + 3TC), are imported but considered too expensive to use
routinely and are only used in a handful of patients when domestically
manufactured drugs are not tolerated. The treatment protocols currently
being used are not optimal and have not been well tolerated by
patients, resulting in severe side effects which local health care
providers have no training or experience in managing.
Because of these side effects, the treatment options currently
available in China in many ways represent the worst possible choices
and offer the potential for disaster. Yet China is taking the approach
that most developing countries are forced to take when it comes to
choosing treatment regimens. Rather than developing public health
strategies for delivering treatments to the population of HIV-infected
individuals, China is left in the undesirable position of having to
settle for what it can get, rather than what it needs. Unless serious
attention is paid to acquiring better combination treatments, the
failure rate of the current regimens is likely to be enormously high
and could have dire consequences in terms of diminished long-term
efficacy of treatment programs in China and widespread development of
HIV drug
resistance, with implications for the rest of the world. Similar lack
of access to imported reagents for HIV and CD4 testing has constrained
the ability of the health system to do the necessary voluntary
counseling and testing, and to properly monitor those patients on
treatment.
The mix of insufficiently trained medical staff with poor
counseling skills, poorly tolerated drug regimens, and lack of testing
and laboratory monitoring capacity is a worrisome combination of
factors. In an editorial published in The South China Morning Post in
August 2003, Drew Thompson of the Washington DC-based Center for
Strategic and International Studies wrote: ``To safely treat HIV
sufferers with powerful antiretroviral drugs, it is crucial to have
trained physicians with access to laboratories which can carry out
advanced blood testing. . . . By jumping the gun and beginning
treatment before doctors and counselors are properly trained, a drug-
resistant disaster is waiting to happen.''
Now that China has been granted a big infusion of funds through the
Global Fund mechanism, it will quickly be scaling up its treatment
program. It is imperative that education and training programs are
rapidly expanded and accelerated in order to ensure that the best
available drugs are being provided by trained medical professionals,
with proper counseling and rigorous monitoring and follow-up testing.
At amfAR, and within the TREAT Asia program, we believe that it is
here the United States has much to offer. China desperately needs (and
there is growing evidence of China's willingness to seek),
international support for rapidly developing and scaling up education
and training programs for healthcare providers in the
delivery of HIV/AIDS drugs. It is my sincere hope that we will find the
necessary resources to provide precisely that support.
Thank you.
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