2nd-year student in the School of Public Health; she called me up to talk about the problem that she had, a budgetary problem. The health budget for that province is 5.6 million rand, which is around a billion-around $1 billion, and she has a 300-million rand shortfall. And as we're talking about this, she indicated that HIV/ AIDS was the biggest problem in two of her largest hospitals. One is the Chris Hani Baragwanath Hospital, south of Johannesburg in the township of Soweto, and the other is the Johannesburg General Hospital. And both of these hospitals had accumulated a 300-million rand deficit, about a $60 million deficit. As I was speaking to Dr. Ramakgopa, she said to me that it was not a problem of access to drugs that she was dealing with, but it was a problem of a broken-down health care system that needed fixing. So part of our work in the next few months with the Department of Health for the province of Gauteng, we will be bringing consultants from the National School of Public Health to the Ministry of Health to help them sort through the management problems that they have. At a smaller level, one of my other students who runs a small hospital in the eastern province that both President Mandela and President Mbeki come from, have a budget of about 5 million rand a month, and that's just about under $1 million a month, and about 10 percent of the patients who come into the hospital die. They leave the hospital through the way-by way of the morgue. Most of these patients are dying from HIV/AIDS. The problem that we face is that most of these patients are young, and the students asked the question as to how he could best use his resources which he thought were relatively ample to deal with the problem of managing the health care of a specific district in the eastern province. Those are the kinds of problems that students bring to us in our university. I would like to talk a little bit about what we think are adequate or appropriate approaches to the pandemic. I see my time is up. So I will go through this fairly quickly. First, there's a need to train health professionals in public health skills of screening and surveillance; that is what we are doing at the moment. We're training about 150 people every year to the level of a master's degree in public health. There's a need to train health professionals to treat patients with HIV/AIDS. There's a need to develop infrastructure, which is laboratory support for this epidemic. And there's a need to deal with the cost of resources. I will conclude by just making a very short story about this issue. My older brother, who works in one of the most devastated communities, works in a hospice that cares for babies dying of AIDS, and he tells me that it takes about 5 hospital visits before the baby dies of AIDS. He lives in a very poor community, and this is what he spends most of his free time doing as a volunteer in a hospice that cares for babies dying of AIDS. And he tells me that part of his free time he spends working in a hospice caring for adolescents dying of AIDS. His request to me as the dean of the National School of Public Health, is not to deal with the cost of drug issues, but his request to me has always been quite specific: How do you prevent young people in South Africa from getting the disease in the first place? He sees this as the real devastation in the country, and not the issue of costs. He does not underplay the issue of costs, but he sees this as the more critical problem. Thank you very much. Mr. MICA. Thank you for your testimony. [The prepared statement of Dr. Herman follows:] Testimony of Dr. Allen A. Herman Dean National School of Public Health Medical University of Southern Africa To the Committee on Government Reform Subcommittee on Criminal Justice, Drug Policy, and Human Resources Good morning Chairman Mica and distinguished Members of the Committee. It is a privilege for me to testify before you on a subject of fundamental importance to the people of Africa. The pandemic of HIV/AIDS is the critical problem facing the global community and threatens to surpass all the problems of the African continent. In my role as the Dean of South Africa's National School of Public Health I have been confronted by the simple truth that we have to focus most of our attention on the pandemic. Introduction HIV/AIDS has wreaked havoc on Africa. In Sub-Saharan Africa, more than 20 Million people are living with HIV/AIDS. In South Africa over 360,000 people have died from the disease. The UNAIDS program has estimated that nearly 3 million South Africans are currently infected with HIV (7% of a population of 43 million), with 1,500 new infections each day. Of these, half are women ages 15-49. Among pregnant women 16 percent are HIV-positive. There are more than 180,000 living children who had been orphaned by the disease and another 80,000 children infected with HIV. The impact that the epidemic has on the health care system can be illustrated by the fact that almost 40% of the requests for HIV testing at the Virology laboratory of the Academic Hospital at the Medical University of Southern Africa are positive for the virus that causes AIDS. Some estimates predict that more than 25% of the working age population in South Africa will be infected with HIV by the year 2010. These data are based on sentinel studies and intermittent surveillance programs. We in South Africa are not sure how many of our citizens are infected with the human immunodeficiency virus. We do not know how many individuals die from HIV/AIDS. We do know that HIV/AIDS has greatly reduced the life span of the people of Southern Africa. Unfortunately, HIV/AIDS has had a grave effect on the middle class and the leadership in many countries. In Africa, AIDS has truly been a disease with no class distinction. This reality could and will lead to the destruction of valuable human resources needed to continue the development in African countries. The economic base, being developed today, may crumble if the path of AIDS is not stopped. President Nelson Mandela said in his February 1997 address to the World Economic Forum that the pandemic "is a threat that puts in the balance the future of nations...AIDS kills those on whom society relies to grow the crops, work in the mines and factories, run the schools and hospitals and govern countries...It creates new pockets of poverty when parents and breadwinners die and children leave school earlier to support the remaining children." The pressure on health care costs is perhaps a single most important economic manifestation of the burden on society of HIV/AIDS. The Gauteng Department of Health reports that more than 50% of hospital beds in medical wards are occupied by HIV/AIDS patients and those with opportunistic infections. Treatment costs to industry are increasing. For instance, the electrical utility company, ESKOM with 37,000 workers is expected to spend R400 million per year from the year 2005 on the 18 to 25% of the workers who are infected with the HIV. Similarly ISCOR, South Africa's largest iron and steel company, is expected to spend R600 million over 7 years. These health care costs are not effective since most of the resources are spent at the end of life. The United Nations AIDS programs (UNAIDS) and The World Bank have spent time and energy gathering information and setting up programs to encourage AIDS prevention and education. The scientific, medical and pharmaceutical sectors have focused energy and resources on developing effective treatments for people who are living with HIV/AIDS, design studies for development of a vaccine to prevent HIV infection, and efforts toward the ultimate goal of a cure for AIDS. These two approaches to the epidemic have been seen as alternative interventions. We believe that effective treatment within a context of sound public health practices is the only appropriate approach to the epidemic. We cannot rely on primary prevention and education to reduce the current mortality and morbidity burdens of HIV/AIDS. HIV/AIDS is having a profound effect on the health care system of South Africa. Most secondary and tertiary level public hospitals focus much of their resources on the medical management of patients with HIV/AIDS. Often the treatment provided is palliative and terminal. For children living and dying with AIDS, between five and eight painful and expensive admissions to the hospital usually precedes their death (usually by eight months). Within the current public health care setting where antiretroviral drugs are not available, inpatient bed costs for patients with AIDS have been estimated to be as high as 82%. These high costs reflect intensive care. Access to adequate treatment for HIV/AIDS is a complex problem in Southern Africa. There are a number of barriers to the management of HIV/AIDS. These include: the cost of providing supportive health and social services essential for safe use and compliance, the setting up and/or strengthening of treatment units, laboratory facilities, drug delivery systems and the training of healthcare professionals, and the cost of drugs. The health care system in South Africa is undergoing fundamental transformation and the province with the largest health budget (R5.6 billion) – Gauteng (both Johannesburg and Pretoria are in this province) - had a shortfall of almost R300 million for the 1999 / 2000 budget cycle. Much of the budget shortfall came from two academic health centers the Chris Hani Baragwanath Hospital and the Johannesburg General Hospital. The Minister of Health for Gauteng, Dr. Gwen Ramakgopa, who is also a second year Master of Public Health student at the National School of Public Health requested the support of the National School in two specific areas: the management of the health care system of the province, and the management of the HIV/AIDS epidemic in the province. During a lengthy conversation with me last Friday, Dr. Ramakgopa indicated that her fundamental concern was not the cost of drugs, but the lack of coherent and well-managed programs within a very large and very complex health care system. Opportunistic Infections: The Medical University of Southern Africa has an AIDS Clinic with approximately 5,000 patients. None of these patients receives any antiretroviral therapy from the hospital. If one assumes that each patient has at least one opportunistic infection per year; then we probably spend a minimum of R35 million per year on the management of these infections. The clinic is headed by a part-time attending physician with an interest in, but no formal training in, the management of HIV/AIDS. The clinic operates once a week and is staffed by a small number of physicians and nurses. We have some indication of the impact of tuberculosis and oral thrush for the patients within our academic health care center. South Africa has been in the throes of a tuberculosis epidemic since the middle 1960s. This is reflected in the fact that 25% (1630 patients) of the 6544 patients tested for tuberculosis during 1998 at our academic health center were positive for mycobacterium tuberculosis. It is entirely likely that 50% of these patients have tuberculosis in association with their HIV infection. The remainder may be part of the ongoing epidemic. The tuberculosis and HIV/AIDS epidemics form an explosive disease mixture for a beleaguered health care system. The tuberculosis epidemic is clearly illustrated in the following figure. 0 In addition to the epidemic, South Africa has an increasing problem with resistant strains of tuberculosis. The problems of managing the tuberculosis epidemic in South Africa are independent of the cost of drugs. The average costs for anti-tuberculosis therapy is shown in the following table: The fundamental problem is the inadequate and incomplete treatment of tuberculosis and the lack of a comprehensive public health strategy that includes early screening, adequate disease surveillance among populations at increased risk for disease, and the prevention of the spread of tuberculosis. There is a critical need to train health professionals and |