A single line often inverts meaning once you see what it
answers, so neighbouring messages are always shown.
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April 13, 2001 -- There is a variable degree of hysteria going around with regard to the apparent dichotomy between those who are pushing for treatment for HIV infection in Africa and those who are pushing for treatment. I see no need for conflict. Obviously, we need to do both. Below is an e-mail sent from Laurie Garrett (Pulitzer Prize winning reported for Newsday) to AIDS activist Gregg Gonsalves. To me, it just shows the hysteria of Garrett. I (as well as other of my colleagues) have always felt that she was a lousy reporter...a good book writer, but a lousy reporter since she came to every sto: with her own agenda. Great for a book, but not for reporting. any event, the e-mail frames the ongoing feeling at the time. Greetings. Tam writing to you because I have leammed over the years that you are very smart, insightful, and deeply concerned about the global HIV pandemic. I need your help. I'm trying to understand what the hell is going on with the treatment Vv prevention momentum now unfolding. Two enormously significant dates are approaching, which will merit huge media attention paid to AIDS: the 20th Anniversary of the original MMWR "gay plague" report, and the June special session of the UN on HIV. As we near those dates, literally thousands of people -- all, as far as I can tell, well intended --- are argueing over how best to direct energies and as yet uncommitted billions of dollars for themajority of the HIV+ people of the world, namely, those too poor to currently afford HAART. Ihave received many Emails and phone calls, heard heated debates, and watched tensions rise dramatically in recent weeks. Many of you are deeply upset. Some of you have grasped onto the treatment access issue for Africa as fervently as you once protested the Vietnam War, or fought the Reagan administration for AIDS research funds and human rights. As the observer --- the journalist --- I find the rancor distressing, but genuine. I hear various sides claiming that others have ulterior motives, are poor scientists, etc. But I don't think these charges are accurate or fair. My sense is that all sides in these squabbles --- even many people working inside the drug industry --- want to do the right thing. You just don't seem to agree about what, exactly, the right thing is. Today I got a particular angst-wrought message from Gregg Gonsavles, a long time American HIV activist who has, of late, focused his considerable energies on the global treatment access question. I wrote back to him, at length, and then realized that the questions I was raising actually ought to be sent to you, as well. If you have a few moments, please take a look below. Do you have answers for my questions? Feelings about these issues? I welcome responses......Hey, I'm a reporter: I ask questions and hope to get thoughtful answers. Thanks very very much for your time and thoughtful attention. Laurie Garrett lgarrett@newsday.com *************************************************************** Gregg, Did you see Newsday's editorial two days ago? Total support for your position regarding treatment access. Last night I was in a screaming match with a doc who does work in South Africa. An American. He actually said, "I don't give a fuck about microbicides! I don't give a fuck about prevention! Fuck all you public health assholes! This is about what is morally right --- treating. Fuck everything else! Bitch!" Unbelievable. It is absolutely amazing to me that the classic Public Health v Organized Medicine dichotomy has so deeply divided the AIDS community all of a sudden. Correction: the do-gooder community of Westerners. I haven't heard many African voices chiming in on this one. Why the hell is there any dichotomy? Haven't we learned anything from all the mistakes made with TB, drug resistant bacteria, vaccine campaigns......? Jesus! I have never seen a moment so desperately in need of leadership. Somebody needs ---- IMMEDIATELY --- to call an emergency scientific meeting, with a very very focused agenda, super-fast. We need: - Assessment of the validity of the Harvard model. And of other HAART treatment models. With emphasis on AFRICAN reactions and desires to said model (and not just five African academics who have been collaborating with Americans or Europeans for years. REAL people, who toil in thankless jobs in horrible clinics all over the continent.) - Assessment of the questionable validity of a few assumptions in that report, including: - HAART is a public health measure because is lowers transmissability (oh really? ALL studies of the matter at the Human Retrovirus meeting showed that there was no clear correlation between blood viral load and semen or vaginal viral loads. Do we really know this is true? We have ONE study --- The Rakai survey. That's it.) - HAART will, to quote Sachs, "save millions of lives". Really? But we now have 3 studies on large patient pops. showing the life expectancy benefit of HAART in USA and Europe is perhaps as little, on average, as 1.5 years, no more than 5 years. That's not even a "saved life" in cancer terms, as in "5 year survival rates". When grim data came out a year ago critics charged that the high failure rates were due to large populations of Americans who were getting diagnosed and treated in late stage HIV infection. Well, now we have changed the treatment reccommendations to specifically say that later stage treatment is preferable --- so much for that explanation, no? What really, truely, is the statistically valid efficacy of HAART? - In terms of the pentultimate concern that I believe (I hope) is the bottom line for all sides --- SAVING LIVES --- what would be the impact of a massive spending commitment aimed at: - cleaning up the blood supply (less than 10% of which globally, according to WHO, is currently screened for Hep B, C and HIV) - global large scale distribution of autodestruct nonreuseable syringes and MANDATORY coupling of all injectable drug and vaccine products with such syringes. In other words, if a vial of measles vaccine contains 10 child doses, if should be vaccum sealed to a slab of cardboard on which are 10 autodestruct syringes. Talk about immorality! How in the world can ANY humanitarian, medical or UN agency POSSIBLY justify distributing vaccines in countries with greater than 5% HIV rates without attaching enough autodestruct syringes to ensure that EVERY SINGLE CHILD receives a sterile injection? I have seen this with my own eyes ---nobody can BS this one. I have been in African villages where 20 kids were vaccinated with the same "single use" plastic syringe. And I have been in Ukarianian hospitals where syrgines were passed from child to child like candy. Consider these points: - Russia estimates that by 2006 12% of her population will be HIV+, and nearly all the infected will be under 29 years of age, IVDUs. It's not a sexual epidemic --- YET --- in Eastern Europe and ex-USSR. The opportunity to stop that part of the pandemic COLD is there. It's easy. It's mass access to autodestruct syringes. And it's this question: which societal concern should guide HIV policy --- hatred of narcontics users, or fear of the virus? Am I wrong about this? - CDC just released a report indicating there were 19 BILLION (yup) medical injections last year globally, some 90% of which were unnescessary. And 80% in Asia were nonsterile, 75% in SS Africa and 70% in ex-USSR. PHYSICIAN DO NO HARM: why the hell hasn't anybody asked what %age of this pandemic is nosocomial, iatragenic????? - creating a prize --- say, $10 million --- as incentive to the first scientific team that develops a truely safe and effective vaginal microbicide that can be affordably mass produced. (Total global current microbicide R&D is now less than $50 million, as far as I can tell.) Would that work? Just how large an intellectual problem is anti-HIV microbicides? Isn't it a helluva lot easier than coming up with a 90+% effective preventive vaccine? So, we're working on that vaccine --- FINALLY. Why not a serious commitment to the microbicides, too? (Is it the word "vaginal"?) - linking treatment tightly with prevention education, in a quid pro quo manner (tax payers are subsidizing your HAART, and you are free to live without prejudice or discrimination, stay healthy and continue to have a rich, full life. BUT, you must in return understand you have a social responsibility, and cannot knowingly do anything that might spread your virus to others. This includes females, who, you African males disdain and consider subhuman. This includes male & female prostitutes who you pay to accept risk.) I know of no rigorous case controlled study done anywhere in the world that asks whether or not this will work. Have I missed them? But clearly, in the USA and Europe, a very significant %age of HAART recipients feel NO social obligation ---- why else would we have resurgent syphilis, gonorrhea, HIV and a national 14% DRUG RESISTANT HIV rate? What I'm really asking here is whether the fine difference between "treatment" and "cure" can be fully understood, and integrated into behavior, without intense counseling, etc. Obviously we have problems with comprehension here in the richest country in the world, especially among college educated white middle class males. - reassessing the results of the Levine Report and the seeming tendency for everything at NIH to revert. Would a serious recommittment to addressing long unanswered basic science questions be in order right now? - before we start mass distributing HAART, do we know: - which of the drugs are heat sensitive? What is the half life of a protease inihibitor that is stored under a tin roof in 90% humidity at consistent ambient temperatures above 90 degrees F? Are there Cold Chain issues with any aspects of HAART or OIs treatment? - which of the drugs have interactions with antimalarials? With antiparasitics? With rotgut booze? with other drugs that have undergone chemical change due to storage in above conditions? - what percentage of the target populations have TB, and what %age of deaths in the local HIV pop are due to TB? Do we know everything we need to know to guide co-treatment of TB and HIV with TB-DOTS and HIV_DOTS? - why TB DOTs has largely failed globally, resulting in MDR-TB strains surfacing in 112 nations over the last 6 years (when it was limited to less than 10 countries before then)? Do we really know how much of that failure is due to insufficient monetary support, how much to infrastructural failure and how much to the DOTs model, itself, in varying cultural and political settings? - which HAART combos are least likely to lead to multiple drug resistance, or cross resist- ance and how that compares with the cheap combos proposed by CIPLA and MSF, etc? - what key factors have, for the last decade, prevented distribution of the Essential Drugs lists in most African countries? (Hint: it aint got crap to do with the cost of the drugs, prices set by manufacturers or WHO policies. It has everything to do with corruption, black markets, Russian mob, bad roads, lack of ship off-loading capacity at ports, warehousing in high heat, etc etc.) - WHY AFRICA? OK, I'm asking a rhetorical question here. But if global distribution of HAART makes sense for ssAfrica, why not also for Vietnam? Ukraine? Cambodia? Russia? Estonia? Is it a question of a certain cut-off, such as "societies with greater than 10% HIV+ rates?" Or 5%? Who has the right to make that decision? What are the moral issues here? Do white doctors from America and Europe get to choose which HIV poor populations on earth get to have freebie drugs? Does WHO decide? MSF? YOU?????? (If I were an AIDS doc in Bombay or Kiev right now I would be mighty pissed off....). - If, indeed, Senegal, Uganda, Thailand and Brazil have not only lowered their mass HIV rates, but sustained lowered levels, what worked? (From my observations in Uganda I would say the lowering was transient, and it is now resurging in much of the country. It was not sustained. Senegal never did have a high rate: why? All of west Africa has lower rates....why? Many believe it has little to do with prevention programs or drug access, and everything to do with male/female power balance issues and female access to the cash economy.) Jon Mann for ages had a mantra: if a prevention effort works, why? and why isn't it immediately replicated elsewhere? - Why were all the questions raised in opposition to phase 3 vaccine trials not raised for largescale HAART? Remember when NIAID decided to can Phase 3 vaccine studies? The reasons were not so much about the likelihood the vaccines would work (nobody thought they would), but concerns that people who received the vaccines would then put themselves and their partners at higher risk, based on the assumption that they were at least somewhat protected. That was shouted from the rafters, and continues to be a huge issue. NIH and CDC have spent loads of money trying to figure out how to counsel vaccine volunteers, what to say about safe sex, etc. It has been an ENORMOUS concern in the vaccine arena --- well in advance of actually having a product worth testing. But with HAART? Bupkiss. Nada. Zilcho. This seems a glaring contradiction bordering on mass hypocrisy. 'rip to Uganda zton, DC 7:00 PM LS OK, that's my venting for the day. I try to report the truth. I strive for balance. It's getting harder because everybody is fudging the truth now. Everybody is letting their agendas guide policy ---NOT the science. For the most part, as far as I can tell, the science has never really been done. Please, prove to me that I've merely missed it. Laurie April 15 - 20 - Trip to Uganda TRIP TO UGANDA
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April 15 - 20, 2001 April 15 - Leave Washington, DC April 16 - Arrive Entebbe/Kampala at 7:00 PM April 17 - Spent the day touring medical facilities and making patient rounds at various hospitals and facilities in Kampala. Jack Killen (Director, Division of AIDS, NIAID) was my traveling partner. Started the day off by meeting with Nelson K. Sewankambo (Dean, University of Makerere School of Medicine. Went off to the Mulago Hospital Antenatal Clinic escorted by Professor F. Mmiro, a charming and enthusiastic 50-ish OB-GYN doc and Laura Guay, a pediatrician. This was a most extraordinary experience. I witnessed and interacted with large numbers of Ugandan women who come to the clinic for antenatal care. If they request, they are screened for HIV infection and counseled. Most of them, although they come to the antenatal clinic, deliver at home unless there are complications such as twinning or toxemia. The percentage of HIV-positivity among them used to be >40 percent. Now it is approximately 20 percent. The physical nature of the clinic was that of open rooms connected to outside virandas. The clinic was packed. Many women looked healthy, but several clearly had HIV disease. Since no treatment is available, no one from among the clinic patients gets treated for HIV. If they can pay something, they get treatment for OIs and many get prophylactic Bactrim. Patients who can pay fully will get reasonable care. I had to hold back my tears. Next we went on to the Makerere University (MU)-Johns Hopkins University (JHU) Project that is heavily funded by NIAID. We were shown around by Laura Guay and Phillip Musoke Mudido, a Ugandan physician. Laura is extraordinary. She is an American woman who has been in Uganda for 13 years. She is single and has adopted (or at least supports) a few Ugandan children who are AIDS orphans. They showed me around their clinical research projects. Next went to the U.S. Embassy to meet with Ambassador Martin Brennan, a 40ish man who appeared extremely interested and knowledgeable about HIV in Uganda. I discussed with him the NIAID initiatives as well as my recent interactions with Secretary Thompson, the State Department, NSC, Domestic Policy Council, and the White House concerning the development and implementation of a White House and US Government policy and plan of action for treatment of HIV in Africa and AIDS care in Africa. At the meeting was Ms. Dawn Liberi, USAID Chief for Uganda and Jonathan Mermin, a CDC person assigned to the US Embassy. Excellent meeting. Extraordinary security related to the terrorist attack on the Nairobi Embassy last year. We could not even take cell phones into the ambassador's office. Next went on to the Joint Clinical Research Center (JCRC) escorted by Peter Mugenyi and Cissy Kityo. Like Nelson Sewankambo, Peter is clearly an important physician in Uganda and the JCRC does much clinical research on HIV/AIDS. It was unclear how patients get put on a protocol and are followed at JCRC versus getting admitted as a regular patient to Mulago Hospital. The JCRC is the source of many of the important clinical studies that have come out of Kampala. I was impressed by the sophisication of their operation. Many Africans and some expatriots (mostly Americans) work here and also at other facilities that I visited including the Rakai Project (see below). Most Staff (PH.Ds, MDs, MPHs and even technicians have spent some time learning techniques and theory in the USA. Next went on to make Ward Rounds in the Department of Medicine at Mulago Hospital with Roy Mugerwa and Harriet Mayanja. This was clearly one of the defining moments of the trip for me and changed the way I think about the reality and potential of AIDS care and health care in general in Uganda and Africa since Uganda is considered one of the best. The wards were packed; people were lying in hallways, in open air virandas, and some were waiting with their families to gain admission. Most looked extremely ill and cachectic. Others were reasonable fit, but obviously acutely ill. I have rounded on thousands of patients over the years, but I have never seen anything like this except maybe when I made rounds at the King Edward Hospital at the University of Natal in Durban, South Africa in July, 2000. The difference here is that virtually no one gets treated specifically for their disease because of lack of anti-retrovirals and inability to pay even for drugs for OIs, TB and malaria. The rule (with few exceptions is that if the patients cannot pay something (even a dollar or 2), then they get no specific treatment. If they can pay, but are poor, they do "cost sharing" whereby they pay for part of what is to be done (i.e. chest x-ray, medications, etc.); however, it is severely limited by the amount which they cost share. If you are relatively wealthy and can pay, you go to a different ward and anything is possible diagnostically (chest x-ray, CT, blood work) and therapeutically (ARV, OI treatment, etc.). I saw patient after patient with HIV disease (mostly diagnosed not by serology since ELISA was too expensive - $4.00) and OIs. Overwhelmingly, patients had active TB. Here again, diagnosis was made clinically without chest x-ray and frequently without sputum smear and culture. Certainly, no CTs, bronchoscopies etc. I remember specifically a 17 year girl who had HIV disease (diagnosed by wasting and oral thrush) and likely cryptococcal meningitis (dx made clinically); they were considering doing an India ink stain on CSF, but decided not to since they could not do anything for her anyway since she could not afford amphotericin or fluconazole. The plan for the patient was hydration, analgesia and discharge home to her mother. It was tragic! Again, I could barely hold back tears. A similar case was that of a man in his 30s with obvious HIV disease and likely disseminated TB. Again, no specific therapy. It hit me like a truck! We were here in Uganda talking about the possibility of AIDS care now that drugs would likely be available at markedly reduced prices for Africa (see other discussion regarding tidal wave of movement to provide drugs). The problem that was clear to me was that even in the Mulago Hospital, which is one of the best in Africa there was not even basic health care! Imagine (see below) in the rural areas where there are hardly any doctors. In addition, what kind of training were the house staff getting when they could not definitively diagnose and certainly only rarely treat anyone? It became clear to me that we must use the enthusiasm about providing AIDS drugs to Africans to catalyze an effort to address fundamental health care in Africa. Even in the best of places (Uganda), there is hardly any health care infrastructure. April 18 - Visit to Rakai. Went with Jack Killen (who was with me throughout the entire trip). Leading the trip was Nelson Sewankambo, David Serwadda, T Lutalo, and F. Wabwire. This was one of the highlights of the trip. NIAID funds, in collaboration with Makerere University, Columbia University, and Johns Hopkins, a project in the Rakai district of Uganda (southwest of Kampala towards the border with Tanzania and Rwanda). The project has been going on for about 13 years and has been the source of many major papers including most of Tom Quinn's work on the role of STDs in HIV transmission, the relationship between viral load and transmission in discordant couples, and the protective effect of circumcision on transmission of HIV, among other studies. The site was inspiring, particularly the dedication of the staff who were mostly young Ugandan MDs, PH.Ds, technicians, nurses, etc. Also included among them were a few dedicated American expatriots who were either permanent or doing a fellowship (usually out of Hopkins). Of note, were Noah Kiwanuka, a Ugandan, born in Rakai, who went to medical school in Kampala and received his MPH from Hopkins. He was as good as they get and clearly was in command of the project. Also of note was Mary Meehan, an American wife, mother of 3, and a scientist who had been living with her journalist husband in Uganda and working at both the Uganda Virus Institute in Entebbe and the Rakai project. Of particular note on the trip was the level of available care in this district, which made Mulago look modern. I visited the Kalisizo hospital as well as a "subdistrict" antinatal and general medical clinic. There was almost no physical access. The best of the roads were almost impassable. There were large ruts and gigantic potholes in the unpaved road. Even with a four-wheel drive van, we barely made it since it was the rainy season and segments of the road were partially washed away. I will never forget the patients that I saw at Kalisizo and the rural clinic. There were benches full of patients waiting to be registered and hallways full of people waiting to be seen. Some patients were tended to by their families and were lying on the walkways and hallways or on the lawn without a bed. The pediatric ward had 2 children per bed. I was told that among their other diseases such as HIV and TB, the majority of the people in the wards, especially the children, had malaria. I say several children being transfused for malariainduced anemia. Now in 2001, the blood supply is well-screened. I can only imagine how many children got HIV-infected years ago before blood screening by these transfusions given for malaria. The faces of the patients were haunting. They were very quiet; no one made a sound, even the most ill. The Kalisizo hospital was staffed by 3 MDs whose training was medical school and 1 to 2 years of house staff training. These people did everything that did not absolutely require secondary and tertiary care. They performed deliveries, Caesarean sections, abdominal surgery (including bowel resection and anastomosis), fractures and other trauma as well as some types of chest surgery. With all due respect to their dedication, I thought at the time and still do now that despite the fact that on-the spot training is critical, these people could not be highly skilled surgeons since the only formal training that they had before they came to this place was a course in "surgical techniques" in medical school. This involved resecting bowels of sheep and other animals. There was no senior attending here supervising them. An important point about the visit was the extraordinary sophistication and dedication of the staff of the Rakai Project. They were amazingly organized in their system of following patients on study. They had a large number of counselors and field workers who went out into the field and tracked and counseled their patients. They went out by truck, motorcycle or on foot. They were mostly young Ugandans who were clearly dedicated. The success of the projects clearly depended on them. April 19 - The meeting entitled "AIDS Care in Africa" started today and I gave a brief opening address that I had carefully prepared with a written statement and slides that I had asked Greg Folkers to immediately post on the NIAID Website after the talk (please see copy of speech). Given the tidal wave of enthusiasm of getting antiretroviral drugs to Africans, there was in the global community immediately prior to this meeting a major dichotomy between those who were concerned that providing treatment would suck off resources from prevention and other activities and those who felt that we should proceed vigorously towards treating African with anti-retrovirals now that the prices of drugs were markedly decreased. It was clear to me from my reflections before the meeting (see my speech) and from my 2 days of observing first-hand the situation in Kampala that there needed to be a balance between treating Africans and accelerating the prevention measures. Also, and extremely important was the fact that as mentioned above, there was hardly any health care infrastructure in Uganda (which was better than most African countries). I stressed that we must act in a comprehensive manner by building sustainable health care and research infrastructure and by also considering other basic health care issues such as clean water; treatment and prophylaxis for malaria, TB; vaccinations against childhood diseases; treatment of diarrheal and acute respiratory diseases. My remarks were extremely well received and clearly the meeting organizers and participants were pleased that I was there and were looking to me for sober leadership in this difficult problem. An interesting event transpired at the morning session. Ugandan President Museveni was scheduled to speak immediately before my talk. He was late and so I gave my talk and chaired the session for about 1 1⁄2 hours. Just at the end of the question period, the President walked into the Ballroom of the Sheraton Hotel where the meeting was held. He was accompanied by his Chief Deputy Dr. Ruhakana Rugunda. Everyone including myself left the stage to make way for the President. I took a seat in the first row of the audience. Just then, Dr. Rugunda stepped down from the stage, grabbed my arm and led me to the stage saying that the President very much wanted me to sit down next to him during his speech. I was told that the President has long been an admirer of me and respected all that I had done for AIDS. The President greeted me with a handshake and began his speech by recognizing me to the audience. After his speech, Dr. Rugunda asked me to say some words. I extemporaneously spoke into the microphone directly to the President and told him that he was a model of African leadership and that he was highly respected in the USA and throughout the world for his sensitivity, insight and leadership in the fight against AIDS, and that we often refer to the "Uganda Model". I told him that when I returned to the USA part of my responsibility was to report back to my Minister of Health, Secretary of DHHS, Gov. Tommy Thompson and the staff of the White House. I said that I would tell them that what we have heard about President Museveni was true and that you were indeed an inspired leader and that we look forward to continuing to work with him. He was obviously very pleased with my remarks and gave me a hearty handshake and a very warm smile. At dinner that night, The Rockefeller Foundation hosted a working dinner for several of the participants to discuss the meeting. I was asked to serve as rappateur for my table and we had lively discussions about where we go next in this process.
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April 20, 2001 - Last day of meeting and my day of departure. Discussions continued and we all realized how difficult it would be to accomplish this lofty goal of providing antiretroviral therapy for Africans. There was good news during the meeting that the consortium of drug companies had withdrawn their ill-advised lawsuit against South Africa for trying to distribute drugs outside of patent restrictions. Now the South African government (which has been extremely problematic at best with President Mabeki showing bizarre behavior regarding whether HIV causes AIDS) would have to move to start treating their people since the drug companies could no longer be considered the obstacles. Lincoln Chen of the Rockefeller Foundation gave a very nice summary of the meeting as the last speaker and used many of my direct quotes from my talk and my discussions to make important points. One in particular was my warning to beware of the "ethical police" who would only want us to do studies in Africa that would be acceptable and relevant in the USA. This centers around the issue of the Declaration of Helsinki which states that the control arm of any trial in a developed country (or anywhere) would have to be the best possible therapy for the disorder. By "best possible therapy", they mean best anywhere. This would make research to answer questions that are relevant to Africa virtually impossible. We all agree that high ethical standards are necessary; but to demand the best therapy anywhere as the control arm in a nation where there is virtually no health care and which would not be relevant to Africa is unrealistic. Everyone in the audience agreed and gave me a long applause. After the meeting, we drove to the Uganda Virus Institute in Entebbe on the way to the airport to visit Dr. Sylester Sempala, a well known Ugandan virologist whom I had met previously at a meeting in Naples, and Mary Meehan. It was a nice facility (by African standards) and the view was magnificent. It was perched overlooking the shores of Lake Victoria. This was an extremely important trip for me in that it gave me a first-hand appreciation of the dire situation in Africa, not only with regard to HIV/AIDS, but also with regard to heath care in Africa in general. I believe that this trip will change me dramatically towards a direction that I have already been heading for the past couple of years. This direction is towards a greater effort and interest on my part in global health.
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April 24, 2001 - Spent 30 minutes on the phone with Secretary Tommy Thompson briefing him on my trip to Uganda. Thompson is getting ready to brief the Cabinet and convince them that the USA should take a leadership role in the AIDS in Africa initiative. He mentioned that he will rely very heavily on me to help him accomplish this important goal.
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2001-05-05 00:00
Anthony S. Fauci
May 5, 2001 - Important conference call with DHHS. On call was Art Lawrence (Acting ASH), Eric Goosby, Helene Gayle, ASH-Designate Claude Allen, Jeff Copeland, Terrell Halaska, Bill Steiger. We (Me, Jeff Copeland, Terrell Halaska, Bill Steiger) had been working for weeks on putting together a position paper for Secretary Thompson on the response to the challenge of AIDS in Africa. UN Secretary General Kofi Annan will come out with a proposal for a Global Trust Fund for AIDS in Africa in June at a Special Session of the UN General Assembly. The White House used our White paper as background to get out front on the issue and announce that the USA would contribute to the Global Trust Fund. We were told on the call that the Cabinet Council met with Pres. Bush. The Cabinet Council consisted of Secr. Thompson, Secretary Colin Powell, Carl Rove, OMB Director Mitch Daniels, Domestic Policy Council Margaret La Montagne, Pres. Counsel Rodriguez and members of VP Cheney's office. The decision was made for Pres. Bush to announce on May 9, 2001 that the USA would contribute in FY 2002 $200 million to the Trust Fund. However, of great relevance to me and NIH, there would be no new money. It would all be budgetary offsets. Of the $200 million, HHS would give $100 million, Dept. of State would give $60 million and $40 million would come from the existing AIDS trust fund. Of the $100 million from HHS $95 million would come from NIH as a transfer. $65 million would come from B & F, $25 million from NIAID, $5 million from NIH OD and $5 million from cyber security. Of considerable note is that Bill Steiger mentioned on the call that he was very "grateful for the generosity of Tony Fauci who has offered to provide the $25 million from his FY 2002 appropriation. Since NIAID will get a 14.2% increase, when you subtract the $25 million, this means we would still get a $260 million increase in our >$2 billion budget. It would not be taken out of the base, but would be a one time transfer.". The fact is that I had offered to help a few weeks earlier in my conversation with Terrell Halsaka. By "help" I was not referring to the Trust fund; I was referring to putting more research money into the AIDS effort in Africa. There was no way that I offered $25 million for the trust fund. However, I did not object over the phone since it was obviously a done deal and the President was going to announce it. It would look very bad if I objected. There was nothing that I could do but turn this "challenge" into an "opportunity". In the end, it really is the right thing to do since it shows leadership in an important cause and our base was not impacted. I will probably take some heat from our constituencies. However, who can cogently argue against my doing something for dying Africa babies? At the end of the day, I am not unhappy at the outcome since we need to get the ball rolling on the African AIDS issue and Tommy Thompson and J are leading the way.
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May 10, 2001 -- Met with Ambassador-Designate to the UN John Negroponte at the State Department. Also at the meeting was his aide Joe Marty. Secretary Thompson had suggested to him that I brief him on the international AIDS crises in preparation for his assuming the position as US Ambassador to the UN. It was a good meeting and John recalled with pleasure that I had briefed him on AIDS in 1985 (more than 15 years ago). I mentioned to him that the situation in Africa is much more of a health care infrastructure/nation building problem than it is a scientific problem. We renewed friendship and promised to work closely together.
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May 11, 2001 -- HVIN in Crystal city in the AM of Friday 5/11/01; but then went to Atlanta on Sunday to deliver Commencement Address at Emory Medical School. I know.... I am nuts!
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May 18, 2001 -- Had important meeting with Adel Mahmoud in my Conference room regarding future collaborations with Merck on an HIV Vaccine. Present -- Jack Killen, John La Montagne, Peggy Johnston, Gary Nabel. Meeting triggered by my concern that Merck was leading Gary Nabel on regarding collaborations with NIH (in the form of Emilio Emini), but really did not want to collaborate for obvious and understandable reasons. Ed Scolnick and I spoke by phone and decided that we needed to get Adel M. involved. My feeling is that although the parties are friends (me, Adel Mahmoud, Ed Scolnick), Merck does not feel that it is in their best interest to get seriously involved in a collaboration with the US government (i.e. NIH) for the obvious reason that they want control given they have invested so much and are aimed directly at approval of product. I believe that they are acting like they want to collaborate for public relations purposes. I actually do not blame them since I would probably do the same thing if I were in private industry.
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May 21, 2001 -- Had dinner at home of William Haseltine (CEO of Human Genome Sciences). Bill is an old and good friend who frequently includes me in social events. The event was the meeting of the Board of Trustees of the Brookings Institution. Bill is a Board member. It was a politically star-studded gust list including most of the Trustees. Present were James Johnson (Chair), Larry Summers (former Secr. of Treasury and recently appointed President of Harvard), Dennis Ross (Middle East peace negotiator who gave a great after dinner talk on Middle East conflict), Joan Spero (DDCF), Donna Shalala, Leonard Shaeffer. Michael Armacost (President of The Brookings), Lee Hamilton (former Congressman and President of the Woodrow Wilson Institute), Zoe Baird, etc. etc. Excellent conversation at dinner regarding a wide range of world and. domestic topics.