an in 5. 5. . P¥Os have an infrastructure that reaches the grassroots. . Their long-standing relationships with indigenous counterparts and with local communities make them ideal for AIDS education with a human face, . They have fewer bureaucratic hurdles te overcome and can move more quickly and adjust more easily to changes in the local situation. . They have a greater capability to innovate and to be flexible in their approaches to AIDS centro!. They have a closer contact with the private sector. 6. THE URGENCY OF RESPONDING TO THE AIDS ISSUE IN AFRICA 6. 1. ho It may still be possible toa contro! AIDS at the "noda} points" of spread, i.e. at the urban centers and small towns. Jt may be tee late after the next 1-2 years. It may still be possible to prevent widespread social disruption of families and disintegration cf focal communities. It may be toe late after i-2 years. Page 7 PRESIDENTIAL COMMISSION ON THE HUMAN IMMUNODEFICIENCY VIRUS EPIDEMIC RESPONSE TO THE PANDEMIC BY THE UNITED STATES This Hearing was held at THE PAN AMERICAN HEALTH ORGANIZATION WASHINGTON, D.C. Wednesday, April 20, 1988 COMMISSIONERS PRESENT: THERESA L. CRENSHAW, M.D. KRISTINE M. GEBBIE, R.N., M.N. BURTON JAMES LEE, III, M.D. BENY J. PRIMM, M.D. CORY SerVAAS, M.D. WILLIAM WALSH, M.D. ADMIRAL JAMES D. WATKINS POLLY L. GAULT, EXECUTIVE DIRECTOR COMMISSIONERS NOT PRESENT: JOHN J. CREEDON RICHARD DEVOS FRANK LILLY, PH.D. JOHN CARDINAL O'CONNOR PENNY PULLEN COLLEEN CONWAY-WELCH, PH.D. I-N-D-E-X PAGE PANEL ONE THE HIV PANDEMIC AND UNITED STATES SECURITY John F. Mazzuchi, Ph.D., Acting Deputy 327 Assistant Secretary for Professional Affairs & Health Quality, Department of Defense James Lamont, Ph.D., Assistant to the Director 329 Foreign Military Rights Affairs, International Security Affairs, Department of Defense PANEL TWO THE HIV PANDEMIC AND THE MOVEMENT OF PEOPLES ACROSS INTERNATIONAL BORDERS Walter Lockwood, Director 363 Office of International Health Policy; Acting Chair, Interagency Working Group on AIDS Department of State Paul A. GOff, M.D., Deputy Medical Director 366 Department of State Alan R. Hinman, M.D., Coordinator of the 369 National Vaccine Program; Director, Center for Prevention Services, Centers for Disease Control Atlanta, Georgia Richard H. Williams, LL.B., Associate Director 371 for Visa Affairs, Bureau of Consular Affairs, Department of State Donald Krumm, M.A., Director of Refugee 373 Processing, Bureau of Refugee Programs Department of State Richard Norton, Associate Commissioner of 375 Examinations, Immigration and Naturalization Service, Department of Justice PANEL THREE INTERNATIONAL DRUG TRAFFICKING Rear Admiral Clyde E. Robbins,, Chief of 405 Operations, United States Coast Guard Terrence Burke, Deputy Assistant Administrator 408 Drug Enforcement Administration I-N-D-E-X- (continued) PAGE PANEL THREE (continued) Clark Settle, Acting Director 410 Smuggling Investigation Division U.S. Customs Service Lt. Gen. Stephen G. Olmstead, Deputy Assistant 414 Secretary of Defense for Drug Policy and Enforcement, Department of Defense James Van Wert, Executive Director 416 Bureau of International Narcotics Matters Department of State APPENDIX - SUBMITTED TESTIMONY HEARINGS ON THE HIV PANDEMIC 9:05 a.m. EXECUTIVE DIRECTOR GAULT: Good morning. Ladies and gentlemen, distinguished guests, members of the President's Commission, my name is Polly Gault. I am the designated federal official here today and in that capacity it is my pleasure to declare this meeting open. Mr. Chairman? CHAIRMAN WALSH: Thank you very much. Good morning. This is our third day of hearings on the international significance of the AIDS pandemic. As you know, our charge from the President is that this Commission is to come up with a significant set of recommendations, one of which is to give guidance on the posture that we should take on the United States role in the international pandemic. We have heard from representatives of our government. We have heard, of course, from WHO. Dr. Mann put ona masterful presentation, I thought, to open this session. We have heard from representatives of other countries abroad and we have heard from private voluntary organizations and non-profit organizations and foundations outlining what they consider their role to be. Today we are discussing another ramification of the AIDS problem, and that is how these problems may affect the security of the United States, what our options should be on the movements of people across borders and we will be closing in the afternoon on, once again, the important problem of international drug trafficking and how this may affect the AIDS pandemic. This morning, we are privileged to have with us spokesmen from the Department of Defense who will address us on the security question. Our first witness will be John F. Mazzuchi who is the Acting Deputy Assistant Secretary for Professional Affairs and Health Quality of the Department of Defense here in Washington. Dr. Mazzuchi? DR. MAZZUCHI: Thank you, Mr. Chairman. Mr. Chairman and members of the Commission, it is my distinct pleasure and honor to appear before this Commission on behalf of the Department of Defense, to lay out for you the current DOD policy to deal with the problem of human immunodeficiency virus. I'd like to point out that the written testimony that I have provided to the members of the Commission discusses the current DOD policy, a policy which has evolved since 1985 and a policy which is in the stages of mandatory annual review. That policy is being reviewed and coordinated within the Department now for any changes. Therefore, my comments will be on the policy as it exists today. 327 My testimony goes right to the point and rather than go over it at any length, I will simply summarize, if that's your pleasure, some of the major aspects of the medical pieces of that policy. First of all, since 1985, October of '85, we have screened all recruit applicants for military service for HIV. Those who test positive are not eligible for military service. Since 1986, we began a total force testing to screen our active duty force for HIV. Those who are positive are given a full medical evaluation. It is a rather extensive medical evaluation. Those who are fit for duty remain in the military. Those who are too ill to perform their duties would be separated with a medical separation. For those individuals who remain, because of the requirement to have an annual medical evaluation of those service members, we keep them in the United States. They are therefore not deployed outside of the United States. HIV positive individuals receive full psychological counseling, medical evaluation and support, preventive medicine counseling on how this disease is transmitted and the modes of keeping them from transmitting the disease. The Department also has launched an aggressive education program with specific types of messages and goals for various target groups, whether that be commanders, health care professionals or the troops themselves. We have made extensive use of existing media materials, whether they be audio-visuals or print materials from the U.S. Public Health Service. The Department has medically discharged roughly 1,000 people since the inception of its testing program for HIV. Those are the people who would not be physically able to continue in the performance of their duties. The Department's program also has a research element which I believe you heard about extensively yesterday from Colonel Bancroft and Colonel Burke. Basically our charge is to do research on those aspects of this disease that would be of particular relevance to military life. Because we have a mandatory testing program and identify people prior to their showing symptoms, methods of rapid identification and drug therapies for the early stages of this disease are of particular importance to the Department as well as epidemiological studies. The Department has taken the stance that this disease is terribly important and we need to protect people from potential disciplinary action since two of the behaviors associated with this disease, namely homosexual behavior and IV drug use, are forbidden behaviors in the military. Therefore, the very fact of positivity, being HIV positive, cannot be used in any punitive way against an individual, nor can the 328 | | | information that the individual provides to the preventive medicine counselor in an epidemiological evaluation be used ina punitive fashion. I think the program then has elements of both identification, surveillance, education, treatment and research. All of them have been ongoing, since 1986 and are under constant review as new knowledge comes to the attention of the Department. I believe I will conclude my testimony with that since this basically covers, in very brief detail, the elements of my testimony. I'd be pleased to answer your questions, or if you want to get testimony from the next witness. CHAIRMAN WALSH: Thank you, Doctor. Traditionally we will ask the questions when everyone is finished. I notice that you do have two associates with you. You are going to be welcome to answer or participate in the question and answer session if you have no direct testimony. Our next witness is James Lamont, Assistant to the Director of Foreign Military Rights Affairs, International Security Affairs, the Department of Defense in Washington. DR. LAMONT: Thank you very much, Mr. Chairman and, members of the Commission. I'm very much honored to be here this morning and very gratified that you have seen fit to raise the subject of the international security ramifications of the AIDS pandemic. If I may, I would like to summarize my statement for you, if I could ask that the statement itself be submitted for the record. As you know from what Dr. Mazzuchi has said, the AIDS pandemic is of great concern to the Department of Defense and has it has been for some time. However, not the only the medical ramifications of AIDS are of great concern to us, but also the international ramifications which is why I am particular delighted to be here this morning. I might point out that of course there are two sides to this problem. The disease can be transmitted from foreigners to members of the U.S. forces, and can be transmitted from the U.S. forces to host country nationals. These are two very separate problems, very different in solution. I would like to treat them one at a time for that reason. I will begin by addressing the transmission of the disease from foreigners to the U.S. forces. As you have heard from Dr. Mazzuchi and others, our policies do not envision the separation of our forces from the local populations overseas. Instead, they involve the training of our forces to be prepared to deal with situations in which transmission might occur. The reasons for this policy approach are three-fold. 329 First, as a practical matter, there may not be much justification to keep a sailor out of Mombasa when he is perfectly free to go about his business in San Francisco, New York or Washington. Second, we have mutual defense commitments overseas which we must fulfill and which we cannot fulfill without substantial U.S. presence allied nations. Third, in regard to nations which are friends but not allies, maintaining that friendship requires contact, it requires contact on an on-going basis, and withdrawal of contact would send a negative signal which could be seriously detrimental to our future freedom of action. Having said that, regarding the transmission of AIDS to our forces, let me move on to what may be of greater interest to you: the ramifications of possible transmission from U.S. forces to host country nationals. The major difference here is that the U.S. can implement military testing and assignment policies, as Dr. Mazzuchi had pointed out, but cannot control or in some cases even influence foreign controls which might be imposed. This problem is exacerbated by the Soviet disinformation campaign of the last several years. This has claimed that the United States developed the virus originally for use in bacteriological warfare, and more to the point here, has also claimed that our forces overseas were heavily infected and represented a present danger to the populations among which they lived or spent leve time. However, in fact, host countries have not acted to limit the presence of U.S. forces or to question our base rights and access rights, with minor exceptions which I will mention in a moment. The reasons for this, I think, are as follows. In the first place, host countries have concerns, as we do, over mutual security, and these concerns outweigh their fear of AIDS. Second, our testing and assignment policies serve to reassure foreign countries that we have taken all steps possible to prevent transmission by our forces. This, I think, creates an atmosphere in which they do not feel they need to take further steps themselvs. Third, the fact that our forces are present overseas defendng western security and are providing this assurance of limited transmission capability allows host countries to pursue policies essentially unrelated to defense or to AIDS -- for example, a policy of free international travel, which is of particular value to them in the economic sphere. There are of course some foreign AIDS regulations. There are countries in:the Middle East and Soviet Bloc, just to mention two areas, where this is true. However, with two exceptions, such regulations have not impinged, even potentially, on the freedom of movement of our forces. 330 In Costa Rica, a regulation is in place affecting commercial seamen and sailors. Its implementation is, however, awaiting the completion of a Costa Rican government study of the matter. At this point, I do not know when that study will be completed. The second exception is Egypt, where health regulations regarding contagious and communicable diseases have recently been expanded to include AIDS. These are now being implemented in a limited manner with regard to certain of our Department of Defense contract employees working on Egyptian military bases. The Department of Defense attitude toward foreign regulations that might affect our entry or our residence in host countries is, first of all, that all testing can be valuable in the fight against AIDS. We've shown that attitude through our own programs of testing and assignment. Additionally, we believe wholeheartedly that every nation has the right to set its own standards as to who enters that nation and who lives there. It's a matter of sovereignty, plain and simple. However, we do have concerns regarding certain possible aspects of foreign controls. One involves discrimination. If a foreign regulation is aimed at United States nationals or, United States forces and at no one else, for example, we would seriously question the fairness of that regulation unless justified by very special circumstances. A second concern involves sovereignty. For reasons of sovereignty, we refuse to allow foreign inspections of our military ships and aircraft, and we refuse to give specific information on crew members. A third concern involves security. We do not for example give out lists of crew members for fear that these might be used by potential terrorists. Fourth, we are concerned about the medical safety of local testing which may be required. There could be cases, where local facilities would use the same needle for blood sampling from one subject to another, which could serve as a means of transmission of the disease. Finally, we're concerned about the confidentiality of test results. In many countries, standards of confidentiality, frankly, do not match the standards which we in this country wish for our service members who might be tested. Because of this, we prefer, when faced with the possibility of a foreign testing 331 regulation, to refer to a standard Department of Defense statement summarizing our testing and assignment policies thereby reassuring the foreign government that, in fact, we have done everything possible, and that they can do little more to make sure that their population is protected. If I may summarize, Mr. Chairman, foreign worries about AIDS, which of course are very well founded, have not, in fact, been translated into regulations or controls which have affected our military services. We have taken the policy decisions necessary regarding our Armed Forces, and the result is that we essentially go about our business just as we did previous to the development of the AIDS pandemic. Obviously, a change in the situation is possible. An AIDS-related incident, can occur at any time, with ramifications for our services and their role overseas. There could also be a general change in the foreign approach to this problem, although frankly we doubt that this will occur because the same factors which have prevented it from occurring in the past are still operative and still determinative. If foreign regulations are put in place, we will conform to them. At the same time, we will request consultations, and request that our views be heard on points of concern to the Department of Defense such as those I have outlined for you. Finally -- as Dr. Mazzuchi, I'm sure, will confirm, the effectiveness of our deployable forces will be maintained. Thank you, Mr. Chairman. CHAIRMAN WALSH: Do either Dr. Uddin or Dr. Peterson have any direct statements that they are going to make? CAPTAIN UDDIN: No. CHAIRMAN WALSH: You're going to be available for the question and answer period? CAPTAIN UDDIN: Yes. CHAIRMAN WALSH: Well, I think it's only fitting that we start our questions with Admiral Watkins. The Department of Defense is, after all, something to which he is very close. CHAIRMAN WATKINS: One of the concerns we had initially was with some of the forces assigned to other nations where the AIDS virus may have been transmitted to a foreign national married to one of our members in uniform. I remember in the early days, negotiations between our ambassador to Japan and their prime minister, there was great concern during the testing process that we may find not only positive sailors, which we did, aboard the U.S.S. Midway, but we also found that on one occasion one of those individuals was married to a foreign national. 332 Could you give me a little rundown, Dr. Lamont, on how big a problem is that within the military? What kind of problems has that caused between host governments and the United States government? DR. LAMONT: I know of no examples in which this has created problems. The number of cases of such a kind can only have been very limited. I am not aware of any one which has impinged on our foreign policy. Our policy in regard to notification in such cases, is of course, a matter for my health colleagues, but from my standpoint this has not been an important. CHAIRMAN WATKINS: What is the Costa Rican position at this point in time regarding other individuals coming in and out of Costa Rica, let's say Americans going to and from Costa Rica by other means such as commercial aviation, from the United States? DR. LAMONT: There is no problem there. Only two specific groups are being checked. There is compulsory screening in Costa Rica for students and applicants for residence. Beyond that, no one is currently being subjected to any requirements. The AIDS related requirements for commercial seamen and for sailors are being held in abeyance pending the completion of a government study of implementational methods, and we are not sure at this point when that will be completed. CHAIRMAN WATKINS: And so port visits have been terminated until that's resolved, is that the idea? DR. LAMONT: No, port visits are continuing as normally planned. CHAIRMAN WATKINS: Thank you. DR. LAMONT: Certainly, sir. CHAIRMAN WATKINS: I'll have some more at the end. CHAIRMAN WALSH: You'll have some later too, I'm sure. We'll start with Dr. Crenshaw. DR. CRENSHAW: In your military testing program for those who are on active duty, I understand that patients, once diagnosed or once tested positive, are sent to two hospitals in the United States for follow-up evaluation and care. One is in San Diego. I would like to know where the other one is and I'd like you to tell me what the current figures are in San Diego, how long they stay there and where in the United States they are deployed after that. 333 We have a bit over 700 local AIDS cases reported to the Public Health Department. With only our public health care reported cases, San Diego has the second highest incidence rate of new cases in the nation. So, I'm real interested to know what is happening as an impact of the military management of HIV positives to the San Diego local community. DR. MAZZUCHI: It is incorrect that there are only two hospitals. There are a number of them. I'd have to get you a list because there are more than ten hospitals. The services have designated specific centers for staging and evaluation because of the complexity of that process. To date we have identified the rate per thousand positive in our testing program and the force testing has been completed. The rate is not quite 1.5 positives per 1,000. The total number is roughly 4,000, the overwhelming majority of which are HIV positive with either no symptoms or would be stage two which would be seropositive plus lymphadenopathy. I don't have specific figures at San Diego alone because we don't keep them that way. DR. CRENSHAW: Do you know approximately how long or an average range of how long a patient is deployed to a hospital for medical evaluation? I know that must depend on how severe -- DR. MAZZUCHI: It's approximately ten days. DR. CRENSHAW: Thank you very much. CHAIRMAN WALSH: Kris? MRS. GEBBIE: I'm going to ask my favorite question. The other Commissioners will now all laugh. You make a very nice presentation of things that sound very organized and very under control. You know what you're doing. Our charge is to recommend things that need to be changed or done differently in order to accomplish what this country needs to do about the epidemic. Are there things which this Commission could recommend or state that would make your jobs within the Department of Defense easier? DR. MAZZUCHI: Let me say that in terms of the overall program that we have, I believe the Department has all that it needs in the area of resources for its testing program, its surveillance program, for treatment and for education. I must say that I believe the Department of Defense offers the nation a tremendous potential source of information about this disease through its research efforts. We are, after all, the only major organization that will have data on people who will be positive and not have symptoms. Therefore, the 334 epidemiological information that we are able to gather as well as the potential to test drugs or treatments for people in early stages I think is tremendously important for the nation. I believe that the Commission can be most useful to the Department in highlighting the opportunities that the Department presents to the nation for research. Dollars are very difficult to come by and certainly research dollars for HIV are in competition with research dollars for other very important diseases. So, whatever the Commission can do to highlight the effort the Department is making on research and the parameters that we have outlined in our policy would be most appreciated. MRS. GEBBIE: Are there specific barriers to that research being used or is it the concern that it is not well enough supported and some opportunities are being lost? DR. MAZZUCHI: Well, it's primarily a matter of conflicting diseases competing for limited dollars. There are many diseases that are of tremendous importance to the Department of Defense. We have focused our HIV research effort on those aspects of this disease that are most militarily relevant. At the same time, I think a statement from the Commission on the significance of this opportunity to the nation would be very helpful to us. MRS. GEBBIE: Thank you. Did you have any comments, Dr. Lamont? DR. LAMONT: If I may. In my own view, the most important thing which the Commission might do is to increase the awareness of foreign governments which might be considering the institution of regulations or controls. That is, increase their awareness of the five areas of concern which I referred to before. If, in fact, they draft regulations that incorporate and encompass those concerns, there should be no problem whatsoever in us accepting them and cooperating fully. : As it is, there's a potential, and I stress the word "notential," for us to be required to discuss and possibly even try to negotiate regulations which appear harmful to our interests, from a security or a medical standpoint or from the other standpoints which I mentioned. MRS. CEBBIE: Since we really can't recommend things to other governments, we can only recommend to our government, it seems to me if we were to pursue that we would be recommending to some appropriate branch of this government that it try to do that with other countries. Is that the Department of State's role or is that a role that Defense carries out directly with those other governments? 335 DR. LAMONT: I would suggest that the State Department would have a major role in this. MRS. GEBBIE: Thank you. CHAIRMAN WATKINS: Dr. Lamont, why can't Secretary Carlucci write a note to Secretary Shultz and ask him to do the same thing? Why do you need the Commission to support that? I take it from your comment that you've tried it and failed. DR. LAMONT: No, Admiral, that is not the case. We have not needed to try it. This is, as a matter of fact, one of the first times that the Department of Defense has highlighted this particular aspect of the AIDS pandemic and its effect on us. Up until now, we have been focusing largely on the medical aspects of AIDS. Now we are starting to talk, and quite rightfully so, about the international political aspects. I agree with you. This could be a very good subject for our Secretary to discuss with Secretary Shultz. Since, however, the Commission was kind enough to ask what it might do, its widespead influence also might be very useful. CHAIRMAN WATKINS: I think for us to recommend something that's within the purview of the Secretary of Defense to do seems very simple. But I think another benefit might be to highlight it to people such as Dr. Jonathan Mann of the World Health Organization, to remind him of these areas of concern. Hopefully he can influence through the World Health Organization a more rational approach to the social aspects of this. CHAIRMAN WALSH: Burt, how about you? DR. LEE: Are you testing the non-uniformed personnel? DR. MAZZUCHI: At the moment, we are not. There is a policy memorandum signed by the Deputy Secretary of Defense that permits the testing as part of an overall physical examination for new civilian hires for overseas areas very similar to the testing program instituted by the State Department. We have an aggressive testing program on a non-mandatory or on a voluntary basis for people going overseas. We encourage them if they have any reason to believe they need to be tested to do so because they will become part of our medical system. And, in addition, there is aggressive voluntary testing offered for people who are not in uniform who present at either drug/alcohol rehabilitation centers within the Department of Defense or at sexually transmitted disease clinics. But it is voluntary, not mandatory. 336 - Ot meee Fe weed DR. LEE: Dr. Lamont, are you a Ph.D.? DR. LAMONT: I am, sir. DR. LEE: May I ask in what? DR. LAMONT: Of course. History. DR. LEE: History? And you're involved with security affairs? DR. LAMONT: That is correct. DR. LEE: Other than finding out who's positive and who's negative and taking care of that problem, why is AIDS considered a security problem? Why do we get into that? DR. LAMONT: It's considered a security problem for two reasons. First, of course, is the effect on our forces of the possible spread of the disease among them. If our forces are sick and therefore undeployable, it weakens the entire security structure of the United States. Second however, and more to the point, is the fact that, foreign countries may act against our best mutual security interests for fear of an AIDS threat, whethr ral or perceived. It is our goal to convince them, through such policies as our testing and assignment policies, not to act irrationally, not to over react to our presence or to our requests to visit those countries. That could be very destructive to our international security position and to theirs. We try to make that clear, while at the same time recognizing, as I said, the value of testing and the absolute sovereignty of foreign countries in terms of their entry and residence requirements. DR. LEE: I think your points are all extremely valid. If I were doing it, knowing the number of non-uniformed personnel on every base involving almost every aspect of military life, I would personally test everybody who takes a job in the military, wouldn't you? DR. LAMONT: This is a subject of long-term examination within the Defense Department. Dr. Mazzuchi referred a moment ago to the procedures we're going through. The Secretary of Defense has ordered that a study be made of the civilian testing question. My own particular part of the Defense Department, the International Security Affairs part, does not have a direct role at this a preliminary stage. But, of course, before a decision is made, all aspects of this question must be examined, and 337 conclusions reached on the basis of, legal, foreign relations, medical and resource consideration. DR. LEE: Thank you. CHAIRMAN WALSH: Commissioner Primm? DR. PRIMM: Yes. I had a couple of questions for Dr. Lamont and Dr. Mazzuchi. Dr. Lamont, in one of those five recommendations in your summary, you talk about security and confidentiality. My concern is what are the confidentiality standards governing reports of sero-positivity or sero-negativity for that matter or evidence of drug use among military personnel? Are there any? What are they? What are the penalties for those persons who may violate those particular standards within the military? DR. LAMONT: Doctor, if I may, as far as your question to internal affairs of our own military, I would like to turn it over to Dr. Mazzuchi who, is far more expert than I on this point. DR. PRIMM: My point is, one of your summary recommendations certainly about security and confidentiality and about our military personnel in relationship to a foreign nation is well taken. I'm wondering, is that practiced internally within the United States military itself, within the Defense Department? I have reason to believe that that's not the case. I'd just like to know what are those standards and are they being abided by? If they're not, what are the sanctions? DR. MAZZUCHI: I believe that issue really falls more under the health jurisdiction, if I may answer, since you asked internally to the Department. The Secretary's policy that was issued by the Secretary of Defense himself in October 1985, as well as the revised policy that was issued in April of 1987, contain language that makes it quite clear that information is not to be used in any punitive way. Now, I recognize you're talking in terms of confidentiality. The way that the policy in the service regulations reads, the only people who are to be given this information are people on a need to know basis. There is no absolute confidentiality in the military. However, that is not the same thing as to say that information can be thrown about carelessly. Therefore, if a person tests positive for this disease, that information would be provided through the medical channels because that person has to be brought to the hospital for staging, et cetera. That person's assignment will have to be limited to the United States and assignments people will have to 338 know this person is at least limited in assignment. They would not necessarily know the reason for it. That person's commander may or may not need to know whether the individual is HIV positive, based on nature of that individual's duties. So, in terms of chain of command, there is no confidentiality. In terms of public information, posting things on bulletin boards, that would be behavior that would be unacceptable. The specific sanctions, there are no sanctions in our policy for it. However, it would be a breach of both DOD policy and service regulation that would be dealt with accordingly. In my own experience in dealing with this problem and talking to commanders in the field as well as to people who are HIV positive, by and large the lack of confidentiality that exists, exists for two reasons that have nothing to do with our policy. First, those people who are positive frequently talk extensively about their positivity because they are upset about it and they do talk to friends. Once that happens, there's no way to control the spread of information because people live in close quarters. And secondly, the way we go about our testing program would make it very difficult not to have some knowledge of individual's positivity in this sense. If my unit is getting ready to deploy and our testing program calls first for testing for those people who are deploying or who might deploy, that's the very first priority. So, if I have a unit that is getting ready to deploy and I do an HIV screen of the unit and then perhaps 72 hours later the names of ten people are called to leave their unit and go to, let's say, Walter Reed or San Diego or one of the many other hospitals where we stage them, it doesn't take someone of great intelligence to put two and two together and figure, "We had the test 72 hours ago. All of a sudden, these ten people are leaving for a 10 day to two week period to a hospital. They must be the ones that were positive." So, it's very difficult to have the type of confidentiality that you're addressing. Because of our concerns, the Department has taken the position that, A, this information should only go on a need to know basis through the chain of command, and B, no punitive actions can be taken because of positivity. Therefore, again, we do not discharge someone against his or her will. If they're positive, we do not punish them with Article XVs or anything under the uniform code. Punitive actions that would be interpreted by the court, the court has given us a whole series of what is and what is not punitive, it cannot be taken against an individual because he or she is positive or because of the types of behavior that person admits to in an epidemiological 339 examination. We've taken that approach rather than the confidentiality approach because of the very difficult way of maintaining confidentiality in the military unit. DR. PRIMM: In terms of contact tracing, those people who are found to be positive, could you comment on that? What is your policy? How is it carried out? What happens if it's violated? There were some articles, as you know, yesterday inThe Washington Post, in the health section, that talked about four military personnel who are either being tried at this juncture or some have been tried and adjudicated and are serving prison terms. Some have plea bargained and gotten lesser terms, et cetera. That report was there inThe Washington Post. Would you comment on that? DR. MAZZUCHI: Yes, sir. First, in terms of case contact tracing, the policy that was issued in 1987 calls for case contact tracing. We did not address that specifically in the '85 policy. Under the terms of the policy that was issued in '87, case contact tracing occurs as part of th epreventive medicine counseling for a member who is found to be HIV positive. That counseling is performed by a health care provider, preventive medicine physician or community health nurse, someone with experience. It is in the context of, "This is a very dangerous disease. We are doing everything possible to stem its spread. One of the best methods that we have is to trace the contacts that you've had either sexually or through IV drug use, or blood donation, so that we can get to those people and offer them counseling and testing." So, the person is encouraged to provide that information. The person is also told that that information is confidential, that it would be done in two different ways. If the person named as the contact is a beneficiary of our health care system, Title X specifies who is entitled to care in the military system, then we ourselves do it. We would have the Preventive Medicine office contact the individual, simply tell the individual that he or she has been named as someone who has been in likely contact with an individual who is HIV positive and offer the opportunity for counseling and testing. The case index name is not provided. If the individual named as the contact is not a beneficiary of our health care system, then we provide the case contact tracing through liaison with the local community public health office. If I'm HIV positive and my contact is a resident of Arlington, Virginia and not a military beneficiary, that information would be passed on to the Arlington County Public Health Office for that office to carry out the case contact tracing. - 340 DR. PRIMM: What then, Dr. -- I'm sorry. DR. MAZZUCHI: Excuse me. If I might just address the second part of your question. DR. PRIMM: Surely. DR. MAZZUCHI: In terms of the cases that are brought to court, those cases are beyond information shared in terms of case contact tracing or behaviors. Part of the DOD policy states that an individual who is HIV positive, must be provided public health counseling and preventive medicine counseling and told how this disease is transmitted. They are told that if they continue to engage in either IV drug use or any sexual practices, the person needs to use a condom for sexual activity and the person should not share any needles. Our policy does provide that if a person refuses to obey that preventive medicine counseling, then the person may be prosecuted. DR. PRIMM: How do you monitor that, Dr. Mazzuchi? DR. MAZZUCHI: Well, there is a case that I can use as an example. I don't want to go into too much of the details of the case because it is under litigation right now. But it involved an individual who was positive, who was brought in for oral counseling, was told about how this disease is transmitted, was told to use a condom in any sexual activity and not to share any needles, et cetera. This person later was found to have impregnated his girlfriend. He was also found caught in oral sodomy with a male, independent totally of our HIV program. Both parties have stated that this person did not take any precautions about the spread of this disease. Therefore, the service has taken him to trial for not following the counseling. DR. PRIMM: My concern is, how were these sexual partners identified? DR. MAZZUCHI: One was actually caught by the CID ina DR. PRIMM: Compromised position? DR. MAZZUCHI: Yes, sir. DR. PRIMM: Do they follow these people who are HIV positive? DR. MAZZUCHI: No, they do not. As a matter of fact, all of our -- DR. PRIMM: It's just by happenstance that this occurred? 341 DR. MAZZUCHI: Yes. We do not -- as a matter of fact, we have talked extensively with our preventive medicine offices and are quite satisfied that the atmosphere in which the epidemiological evaluation is taking place is one that's very medical. We do not find examples of CID or military police lurking around hoping to catch people. Quite frankly, the Department, I think, has enjoyed a great deal of success in this program because of the medical cast we have put on it. If you will look back at my written testimony, we treat HIV seropositive as we would treat any other disease. We have not invented a new superstructure for it. We have used existing superstructures dealing with diseases anda health conditions, both in terms of getting into the military and staying in the military. We treat this as we would treat any other chronic or contagious disease. DR. PRIMM: My concern though is that there possibly should be some policy that would have sanctions for people talking about others sero-positivity. We have gotten anecdotal reports here at the Commission where a sergeant has seen another sergeant who might have been HIV positive with a lady and then reports that to the company commander and then the commander calls in the HIV positive person and they are court martialed, et cetera, et cetera. I think that unquestionably there ought to be some sanctions for individuals who violate the confidentiality, of a medical diagnoses, of either intravenous drug use or indeed HIV seropositivity which could be terribly damaging to that individual's existence within that unit or even when he returns to civilian life. I think it's a serious, serious kind of issue. DR. MAZZUCHI: We agree with you that confidentiality in terms of offering people the kind of counseling and treatment is necessary and that punitive actions as a threat would hurt our efforts to stem the spread of this disease. Quite frankly, I have not heard the type of anecdote that you have brought to our attention because by and large we have found that people who are HIV positive are really not being harassed by any law enforcement type individuals. Those cases that have come to court have been fairly flagrant violations of the preventive medicine counseling and people were caught entirely independently. We have tried to base much of this program on our experience with the amnesty program, or the exemption program as it later became called, after the Vietnam War dealing with drug abuse. We did the same thing. People who came in and sought help were provided help and we did not have a punitive 342 atmosphere at all. But that did not protect them, for instance, from independent investigations so that a person came in and said, "I have a heroin habit," or whatever the drug happened to be, we would offer that person treatment. But if that person was busted by CID in a drug raid, the person can't say, "I went for help and therefore you can't touch me." ; I think that's the other side of the coin that we have to be careful of here. We are trying to offer protection for people in a health care atmosphere, but we do not want them to feel that because they've been identified in the manner of a health screen that therefore they have the protection to engage in unsafe practices flagrantly with impunity. DR. PRIMM: Thank you. CHAIRMAN WALSH: Cory? | DR. SerVAAS: I agree with you that this information you're getting, Dr. Lamont and Dr. Mazzuchi, is very valuable information about the spread of AIDS. I wonder if you could tell us how much you know about the spread in the 17, 18 and 19 year olds you've tested. We want to know more about the seropositivity among our young people. We haven't very much information about that. DR. MAZZUCHI: Right now we have gathered information on rates of positivity by the entire force because it took us approximately two years to complete that testing. We do not at the moment have data broken down specifically by age group. We will very shortly. We now have an automated database, what we refer to as the reportable disease database that will have demographic information where we have linked the positive individual back to a personnel file where we can get the type of demographics that might lead to that type of analysis. That is expected very shortly. We do not have specific data yet factoring out 18 year olds or 17 year olds from the rest of the force. We simply have information on the total force testing. The information that would be available from the recruit applicant testing, we have made available to the Centers for Disease Control and I know that some of the research being carried out at WRAIR, the Walter Reed Army Research Institute, which has some analysis of those data. What those data can tell us about the country is questionable at the moment because there are so many intervening variables that we're not able to factor out. For instance, how generalizable is this population? People would self select into applying for military life. Would those people be the American population at large? I really couldn't answer that question. 343 This is the kind of information we want to glean from our database. Now that we have the base line data, we will be looking at it, from the various demographic variables. When we repeat the force testing, which will be repeated over approximately a two year period, we will be able to get some incidence data. We do not yet have incidence data, since the first objective was to get all the active force tested at one time. DR. SerVAAS: How long before that is published? Do we need to wait until it's in the professional journals and do the professional journals always publish? Is the peer review process going to be dangerously long that we could be using this information? DR. MAZZUCHI: Well, I think a good deal of data have been published, but information has been slow in coming because of the need to get sufficient data to publish. We have had about a two year experience now in the recruit applicant data. So I believe now we can begin to publish data. That institute is a research institute where people are devoted to that activity. So I would assume that more and more publications will be forthcoming. I think your points are very well taken. We are also concerned about the need to get data into the peer review journals. I believe the time is just approaching now where we have a sufficient database to begin collating, analyzing data and presenting just what you hope to see. DR. SerVAAS: Dr. Lamont, would you have any more information about the military recruits from Walter Reed? DR. LAMONT: I'm sorry I don't. That is not my field. DR. SerVAAS: Well, I have a little intelligence and I could hardly sleep last night for the information that it gave about teenage prevalence, as high as 4.9 out of 1,000 in some counties, 17, 18 and 19 year olds. We were told in earlier testimony that there are about 600,000 of these 17, 18 and 19 year olds that were tested. So, it's a large body of information that is very much needed in the counties where it has been separated out. DR. MAZZUCHI: Yes, I agree with you again. Part of the difficulty we have -- and we certainly want to share our information nationally, but we have to also be very careful within our Department when we publish data, particularly on recruit applicants and again caution that these are not necessarily representative of the United States at large because I am sure there are pockets of individuals whose prevalence rate must be much higher than we are experiencing. 344 Again, we have an announced testing program. People who do apply to the military usually know in advance they will be tested. Therefore, we must assume that there's some selecting out of individuals. In addition, people who would choose a military career may or may not be representative of the population at large. So, I hope that we can get data published because it is positive data. The other side of the coin, however, is that our data will not necessarily be representative. It will probably be an underestimate in certain pockets, at least within our population. — DR. SerVAAS: Af underestimate of the number of total - —_——o —_— = DR. MAZZUCHI: The sero-prevalence rate, yes, within certain subcultural groups. _ DR. SerVAAS: Would you be getting any young people because they want to be tested? Do you have different policies in different states -- DR. MAZZUCHI: No. DR. SerVAAS: -- of how you handle the 17 year old kid who comes in and you need to tell him that he's positive for the AIDS virus? \ DR. MAZZUCHI: No. We would have the same policy in all of our military entrance processing stations. People would come in regardless of what state they're from and would be processed in exactly the same way. The mechanism is the same. And again, we have seen a small decline in the rate per thousand positive of our recruit applicants starting off at about 1.5 per thousand and now down to a little bit under 1.4 per thousand. It's very difficult for us to know what that represents because, again, we have nothing to compare it to. We have no way of knowing what that represents, is probably the safest way for me to say that scientifically. ‘ DR. SerVAAS: We were told by the Commissioner for the state of Colorado, Dr. Tom Vernon, that he takes all of your positive AIDS personnel who are rejected by the military and they counsel these people and really take good care of them. I wondered how much you know about the procedures in other states - - I worry about a 17 year old kid going in and finding out and then having any drop off because you're not allowed to follow up and see that he's taken care of with a physician. Do some states not have that policy that they have in Colorado? DR. MAZZUCHI: It's my understanding that that's pretty uneven, that there are states that do a superb job and states that do not. We do not simply wash our hands of the 345 individual, but we are precluded from doing very much with then. Consequently, we have the person who is positive being notified by a physician. We try to make liaison with the local public health office. Again, the quality of follow-up really does depend on the local public health office. I think things are far better now than they used to be. I think the country as a whole is simply much more informed about this disease, but I cannot say that every single state and every single local public health office is as good as the best. They're not. DR. SerVAAS: Well, is this something that our Commission could recommend in our report, that the young people who are rejected by the military, that the states all have a policy of routinely taking up these kids and getting them to care promptly? DR. MAZZUCHI: Well, I think it would be an excellent recommendation of the Commission, but again it would be a recommendation to the sovereign states which would have to decide what to do about that. I think this is a growing problem not only for our own particular military recruit applicants but for anyplace in the state where someone is identified positive. Obviously the better the public health office is at dealing with this problem, the better for the individual living in the state. CHAIRMAN WALSH: Cory, I think Beny has a related question. DR. PRIMM: You did state that some of the recruit data may not be reflective of what's really going on in communities, but it does give us somewhat of a handle and an idea because as far as black and Hispanic youngsters, the ones that are volunteering for the service are generally the cream of the crop of our neighborhoods. They are graduates of high school, they are generally not drug users and supposedly not exhibiting homosexual/bisexual behavior. Those are the criterion, if I'm not mistaken. So, we have about 45 to 55 to 60 percent dropouts in our inner city area. So those youngsters that would come to the Army to volunteer, or come to the Armed Services, are unquestionably the cream of the crop because 65 percent of those who drop out go on to continue to use drugs. So, my point is that that data is absolutely necessary to be publicized, particularly in the minority community, to let the leaders out there know that these are the stats that we're finding on the cream of the crop of the youngsters from this community. Therefore, it might portend something else for the total community. i'd like further to state that even in the Army itself where 4.7 of every 1,000 active duty Army personnel examined that were black were positive for the virus, men and women. I think 346 that is a startling statistic. Among your Army Officer Corps, black officers, 5 out of every 1,000. Now, that, to me, is one in 200 and that is terribly, terribly, terribly startling and ought to be publicized so that the denial that goes on in the minority communities of this nation would be stopped on the basis of that kind of data. If they were no longer married, 6.6 out of every 1,000 and 7 out of every 1,000 Hispanics. That's incredible to me and that's is enlisted personnel. So, my point is that the Defense Department has, I think, sort of a corner on the market on sero-prevalence studies of the population, though it might be limited. But it is the only one that we have to look at, except for the studies on pregnant women in New York, babies being born in New York. DR. MAZZUCHI: Yes, sir, I could not agree with you more, especially your conclusion that we are probably showing a tremendous under representation of sero-prevalence in certain communities, particularly among blacks and Hispanics. That is one of the reasons that I encourage as much as I possibly can this Commission to make that point and to support the Department's efforts on epidemiological research. DR. PRIMM: But beyond that, Dr. Mazzuchi, and one last comment. Greed has sort of seized me when the military people come here. It's because it's close to me. I was responsible for the testing that was done in Vietnam, setting up the urinalysis testing during the Vietnam situation, Dr. Jaffe and I. DR. MAZZUCHI: Yes, sir, I was even there at that time. DR. PRIMM: I'm very aware of what goes on. So, it's close to my heart. I'm not doing it to be critical. I'm doing it because the military has played a tremendous role in terms of epidemiological problems since the very beginning of time in this nation and for public health. So that's why I'm about this. I'm about it also because you all now are keeping things too close to your vest and for too long. And then there's a six or eight month lag time before we get the information that we could have been acting on and perhaps some lives could have been saved. That's another great concern of mine that I expressed yesterday. DR. MAZZUCHI: I understand, Dr. Primm, your point and I don't dispute it. But I do want to say that one of the reasons that much of the information has not been shared is not because of a desire by the Department to hold onto it, but namely for a desire by the Department to have more complete information. 347 \ \ We have spent a great deal of time trying to put together a mechanism such as the reportable ‘disease database that will give us the type of information that you wanted. Since the original testing program started for the active force, our main goal was to get the testing done, to have it done properly, to get those people into treatment or staging and the information part was, I admit, lagging behind. But that program was logistically extremely difficult to do. Having now gotten all of the data and having gotten a mechanism put together to be able to bounce sero-positives against a personnel database for the demographics that are so important to the type of epidemiological analysis that you are looking for, we are now just on the threshold. We expect to be publishing -- first of all to be analyzing the data along lines that would have some relevance, not only to us but to the nation as a whole, and secondly to be able to publish it. So, it is not a desire of the Department to hold the information back, but merely to get the information collected fully first so we could then begin to analyze it. I think you can expect and have every right to expect to see more of those pieces of data coming out within the next year. DR. SerVAAS: Dr. Mazzuchi, do we know how many West Point cadets or how many midshipmen at Annapolis were AIDS positive when we tested them? DR. MAZZUCHI: We would be able to get that information. We don't routinely have it. We'd have to go back into the data files and find the location of the person. It's possible to find that out. We do not have it available readily now, no. DR. PRIMM: Were there some? DR. MAZZUCHI: I couldn't tell you whether there were or not. It is part of the testing program. It's certainly theoretically possible there was. None have come to ny attention. DR. SerVAAS: But we do test them? DR. MAZZUCHI: Yes, we do. DR. SerVAAS: When they go in? DR. MAZZUCHI: Yes, we do. DR. SerVAAS: Do you think this peer review, which is so very important to professionals -- we have to wait until it gets sent to several places and then it's their discretion of whether or not they want to use it in the New England Journal or the JAMA or wherever. Since it's kind of a war to get action 348 so that as other federal agencies make theirs you're not tripping over each other, at least you know what each other is doing? And secondly, where you may have some somewhat unique viewpoints that need to get into that international discussion, is that mechanism through our public health agencies appropriately structured right now? DR. MAZZUCHI: I can honestly state that in my 16 years in federal service I have never seen better coordination than on the issue of the AIDS epidemic. Our internal department committees, and we have a number of them, each one has representation from the Public Health Service as well as other federal agencies and the Department of Defense is well represented on nearly every HHS public health service committee. We have worked very closely together in both research and in education and in testing methodology. Our scientists and physicians have taken a very active role in representing the national interests, representing policy views, et cetera. We have participated with the National Academy of Sciences and with the World Health Organization in looking at issues such as the neurological impairment, early neurological impairment of a symptomatic HIV positives. So, from my perspective, the level of coordination is quite high and I believe that DOD personnel particularly in the research community are well represented in the American scientific community and have participated very actively throughout a number of forums. MRS. GEBBIE: What about the input on issues that might be going to World Health, that connection where there might be an international concern that you would have? DR. MAZZUCHI: Well, again, I think in terms of sharing information and working with the World Health Organization, we've done quite well. If you're talking in terms of international relationships, if that's your area, that I really couldn't address. But certainly on the health side, research side, the significance of other retro-viruses in Africa, or neurological impairment of seropositive individuals, and testing methodologies, in false positivity rates and so forth, we've had a great deal of play with the World Health Organization in those areas. MRS. GEBBIE: Well, this is really a follow-up to the question that Admiral Watkins asked earlier. If getting some kind of common international policy on these things is appropriate, why hasn't somebody asked for it? My question is directed at were you to say that was important to the Department of Defense, you wish it to be part of an official United States 350 representation to the World Health Organization so that they could take some leadership on this, is there avenue there for you to pursue that? DR. MAZZUCHI: I'm sorry, I didn't understand the exact point of your question before. I don't believe it has been tried yet. I really don't know. That is not an avenue that we have pursued within our office. That is certainly one that ought to be pursued. DR. LAMONT: If I might, I would like to comment on this from my own perspective. Our natural interest here is in dealing with the State Department and with the other foreign affairs agencies, and also with certain of our embassies overseas if problems appear to be arising in a specific country. All of these channels have been working very, very well. There has been no problem that we've experienced, and cooperation has been excellent. MRS. GEBBIE: Thank you. CHAIRMAN WALSH: Dr. Crenshaw? DR. CRENSHAW: You've been under fire, the Department of Defense, for your testing programs and for many of the early measures that you introduced to the management of the AIDS epidemic within the military. There were some rough spots in the beginning, as I recall. But while it's not so popular in our society to compliment the military, I must tell you that issues I think are not brought up very often, particularly the fact that you've preserved jobs for the gay community within the military, an issue that is particularly historically difficult for the military to deal with. I think you've done a commendable job and I think you've put many of the civilian facilities and industries to shame in that respect. I also think you're providing a service we have not yet succeeded in doing in civilian life which is treatment and medical care, not only for those that you diagnose within the service who have AIDS but for those who are HIV positive and you're consequently extending life and preserving the quality of life through your medical care. I never hear this talked about. I hear the criticisms. But I feel compelled to bring it up because I think it's terribly important and a very good role model for society at large. Then thirdly, I'd like to tell you how much I personally, and observe many other scientists, depend on the data that you've collected through your testing program because of the voids in other areas. So, thank you. And especially thank you for what you're learning about our teenagers so that we can do 351 our best to provide for an uninfected generation. It seems like we're already fairly late along those roads. CHAIRMAN WALSH: Admiral Watkins? CHAIRMAN WATKINS: You may have touched on this earlier, but do you have data yet, Dr. Mazzuchi, on the sero- conversion rate of those already in the service, that is who perhaps were tested for HIV, found negative, subsequently found positive while within military service or is it too early to get that kind of information? DR. MAZZUCHI: It's a bit early, Admiral. We want that data very badly. We have finished the first round of total force testing which took approximately a year and three-quarters and have launched the second round of testing. Again, I want to emphasize to the Commission the way we do our testing. Everyone will be tested within a year and a half period of their first testing. But we also have testing that would be done on a priority basis, namely for deployment or likely deployment as well as for people presenting at sexually transmitted disease clinics or drug and alcohol clinics. We not only have testing that's tied to time lines, but we also have testing tied to events. We don't have sufficient data now to get anything meaningful on incidence data or new case data, but that is tied into our reportable disease database and we expect about a year from now to have some preliminary information on that. That, of course, is vital information both for the country as well as internally to the Department in terms of its policies on retention, et cetera. CHAIRMAN WATKINS: Well, I think it's quite germane to something that Dr. Primm is bringing up because it's my experience at the end of last decade that the services were down on their knees and we were bringing in one-third of our individuals who are now called the youth at risk. It's very difficult to know, when that disease was brought into the military. It could well have been in that period of time when we were struggling, bringing in those that frankly did not have the high schvol diploma, were at risk, had broken families, had all of the economic problems, came from the depressed areas and the like. So, I think unless we know that kind of data, it's premature to take a photograph of information today and begin to draw a lot of conclusions. I'm just bringing that out openly because I think that we have to recognize the significant changes that have taken place in the kinds of recruits that have come in in the early part of this decade as opposed to the latter part of 352 the last decade. And even in the early part, we were beginning to transition out of that difficult period. Certainly we brought in our share of societal difficulties that were certainly in that group that we considered to be higher at risk for the AIDS virus. DR. MAZZUCHI: Yes, sir. It's also my hope, if I might follow up on your observation, that the more we are willing to learn about the behaviors associated with this disease ina non-threatening atmosphere, the more we will be able to learn as a country. There are clear implications of perhaps recreational drug use or bisexual behavior that we do not seem to want to come to grips with as a country that I think we need to come to grips with. CHAIRMAN WATKINS: I understand that there may well be something going on in the Philippine government to demand that our U.S. personnel who connect with military there carry certification on non-sero-posivity, Dr. Lamont. Do you have any information on that and where does that stand? DR. LAMONT: I have some information, Admiral, but it is, unfortunately, not complete. It's our understanding that the Philippine government is to finish drafting a regulation on HIV testing or HIV certification for various categories of individuals who might enter the country. That drafting process is not yet finished. In the meantime, the Philippine government has requested that the United States submit to it for examination a statement of our military testing and assignment policies. This was done by the Embassy about a week ago, and we have received no formal response yet. CHAIRMAN WATKINS: Let me follow up on one question that came up earlier. We have had testimony before the Commission in the San Francisco hearings by the Health Commissioner of the city of Sacramento who indicated that frankly the transitional policy back to civilian life of those that came to the MEPCOM and were examined and found HIV positive was very poor. On the other hand, within the same state so we're staying within the same state laws here, we had the mayor of San Diego who when asked was very quick to point out that it was extremely well handled, it was very sensitively done, it was transition to the proper local health officials, that sensitivity to confidentiality was maintained and she felt very good about it, and seemed to know quite a bit about it. So, the question is, if there is a policy of sensitive transition of those found HIV positive back into the civilian society so that we show sensitivity to the human beings who we're trying to get in the military and then find them HIV positive and rejecting them, the military, it seems to me, carries a 353 significant burden of responsibility to see that that is properly handled. The question is, is there such a policy that's well established? What is that policy? What teeth do you put in it so that Sacramento is looked at by the medical inspector generals of each of the services? Dr. Mazzuchi? DR. MAZZUCHI: Unfortunately, the Department is only able to monitor itself. We really have no authority to monitor what happens at a local or state level. So consequently, we have taken great pains with the MEPCOM to put into place a procedure where by the notification is done by a physician, where there is some initial counseling, at least in terms of what this HIV positivity means with a referral to local public health offices and often with an accompaniment to the person's parents, if the person is under 18. But beyond that, we would not have any authority to monitor. For instance, if a local public health office says, "We don't want that information and won't do anything with it," we really are powerless since these are not members of the U.S. military. CHAIRMAN WATKINS: Do you have cases where that particular -- DR. MAZZUCHI: There are states -- CHAIRMAN WATKINS: Is that something that's so sensitive you could not give the Commission? DR. MAZZUCHI: There are states where the information on positivity is not wanted by local health offices, yes. CHAIRMAN WATKINS: Well, it would be very valuable, if the Commission is going to make an impact. This is after all one of the great obstacles to getting on with a testing program. It seems to me that we shouldn't just say, "Well, the states just aren't going to pick it up." There are ways to put pressure on the system when it's not responsive. I'd like you to send me a letter telling me what is the already published policy regarding the transition of HIV positives back to society. Two, what is your program for following up on that to see that it's effectively carried out, at least as far as the Department of Defense is concerned. And three, give me the specifics on the cases because that will help us word our final report to say, "Look, we've got to make this thing work and these people are trying to serve their country. We've rejected them and now to drop them is not only not in their best interest but it's not in the best interest of public health." We have a responsibility tg make the system work better. 354 If you agree with that, I'd like to get a letter along those lines. That perhaps will clear the air on this particular issue that has comeup several times during the last five months. DR. MAZZUCHI: We'll be glad to get you a more detailed piece of information on the exact MEPCOM procedures. But again, I have to state that in terms of the DOD following the states, we have no authority to do that. CHAIRMAN WATKINS: I'm not asking for your authority. I'm asking for the situation report that says, "Look, we have had four MEPCOMs tell us that their local people will not accept this kind of transition sensitively and we're worried about it." If I just air that, I think you'll find that we become very sensitive. This is the way the situation works in our country and this is how the democratic process ought to continue. So we have responsibility for the system. I know you can't do it, but maybe the Commission can air this thing openly and see that we get a fair hearing on the part of those rejected for this reason. If you'll do that,. that- would be very helpful to me. The issue on neurological damage rejection of pilots and so forth, I understand there was a recent problem within the Services, as opposed to the DOD who came down on a more logical and proper approach from a medical standpoint, of dealing with the downing of aviators for HIV seroposivity. Could you air that here as to where that stood, what is the policy, what was the final position? DR. MAZZUCHI: Well, the final position is still in draft, but I can tell you that the Armed Forces Epidemiological Board convened at my request to examine data on neurological impairment of asymptomatic HIV positives. The conclusion of the Epidemiological Board was that assignment limitations for jobs that would be terribly sensitive, such as pilots, should be done only on a case by case basis. That policy will be reflected at least in the draft of the Secretary's policy. We believe that there are no compelling reasons to do something in a blanket way if you're HIV positive -- CHAIRMAN WATKINS: Do you expect that that might be available before the Commission has to make its report to the President by the 24th of June? I think it's going to be a very, very important marker for the country as a whole. DR. MAZZUCHI: There's a very good chance of that. Let me tell you, Admiral, where the policy stands. You certainly know the Pentagon as well as I do in terms of how long things sometimes take to get through. We have sent it out about a week and a half ago to the Service secretaries and the other DOD components for comment. Those comments are due back on the 6th 355 of May and we will then put the comments together in a package for the Secretary of Defense, for his review. So, it is entirely possible that this policy would be signed by the Secretary then. It's also entirely possible that it will not, depending on how much internal dispute there is with various sections of the policy. CHAIRMAN WATKINS: Does it focus more broadly on, let's say, safety in the work place for other sensitive assignments as well or is it focused specifically on that particular job assignment? DR. MAZZUCHI: No, it is focused on any type of job assignment that might be dangerous. But the policy is broad in the sense that it says that assignment limitation should be made only after a case by case evaluation. That is, you should not limit someone's assignment merely on the basis of IV seropositivity. When I say that, I'm not referring to deployment, because by policy, persons don't deploy outside the United States if they're positive. In terms of the types of military occupational specialty that an individual might engage in, we're saying that limitations can occur only if they are based on health and safety reasons after an individual case by case evaluation of that person's health status. CHAIRMAN WATKINS: That would be very helpful if we could stay close here in the closing days of our own commission because I think it's a very, very valuable document. We've heard that the Services came in generally in their normal phalanx fashion and were somewhat blunted by the Department of Defense's wisdom from the points you're raising. So, it just raised a question in my mind of whether that was generated by a non-peer reviewed article that came out about the early detection of neurological damage that seemed to have a knee-jerk response around the country for a variety of reasons. DR. MAZZUCHI: I do think there were research pieces that were reported that were somewhat incomplete. I don't think the final answer is out on this subject. I have participated in the National Academy of Science's deliberations on this topic. I think there are a number of studies that are particularly noteworthy, particularly the ones being conducted by CDC, one being done by the University of Pittsburgh that indicated that the neurological impairment of HIV positives without symptoms were not markedly different from those who were not HIV positive who live the same lifestyle. 356 I think there's enough information out now that says that this is still an open question to make us feel that medically a person should be given an individual assessment, not simply limited on the basis of HIV positivity. From the health perspective, we have worked very hard to keep people from being discriminated against based simply on HIV positivity. If action is taken, we want it to be taken on the basis of sound medical policy, at least from our perspective. If there are personnel or political reasons for doing things, we would expect it to be articulated accordingly. CHAIRMAN WATKINS: We will be holding two separate panels on this very issue because of the importance of it. So therefore, it would be very valuable to us to know as soon as we can what the Department of Defense position is on this particular issue. DR. MAZZUCHI: I will make sure that you are kept informed of each step of the process. CHAIRMAN WATKINS: I have one other question which I'1l hold off until perhaps I can discuss it later with the Assistant Secretary for Health. But I want you to just give me a feel for whether or not you think this makes sense. It seems to me that the military has a significant responsibility to do what it can in partnership with the private sector to enhance the base of those eligible for military service. Not necessarily those that recruit in, but those who are eligible for military service in.a declining market of young people coming up to the point of enlistment. We've got that serious situation really facing us until almost the turn of the century. It's easy to put into effect rules when you have large numbers of potential recruit to either draft in or bring under voluntary conditions where the services have now become competitive. So, when we reject people, that's fine, for lack of education or in this case a health problem. But there's another responsibility then, having rejected, that there be a greater participation in those things that can enhance the quality of the base as a whole. What are your feelings about the degree to which the Department of Defense has taken a hard look at their R&D effort along the lines of the model set in SDI where the Congress has allocated $15 million a year to devote to research in AIDS, where free electron laser efforts have shown great promise, where other kinds of protective gloves have been developed. There are many, many things in the modern technological age that commercial sectors use as a spin-off of our Defense R&D to move into the medical research field. 357 I'm just wondering how hard a look there has been within the Department of Defense in the R&D effort to say, "Look, let's review that from a medical technical point of view. What's in the base now? What spin-offs can we get that we can allocate to AIDS and perhaps even augment that R&D budget to make a contribution to the nation's total R&D effort in some very unusual areas that Defense is working in. What are your feelings about that, Dr. Mazzuchi? DR. MAZZUCHI: Well, certainly the Department is aware of the fact that there can be serendipitous findings through a number of Defense technology or research efforts and I think you pointed out the one that did occur with SDI in terms of the free electron base laser and its ability to destroy this virus in blood. Obviously the Department would look for more of those. They're good for the Department and they're good for the country. Our technology based research deals primarily by law with militarily relevant things. So the type of event that you would hope for really would probably be more serendipitous than not. So, I think there's a clear desire on the Department to find areas that can be shared with the private sector, particularly as it relates to HIV, but those are usually spin- offs and the spin-offs simply happen. You don't really plan for them very well. I don't know if the Department could do more in the sense that research dollars, whether it's for HIV or for any other disease, are very tough to come by. There is a perspective shared largely on the Hill as well as within the federal sector that the Department of Defense research effort should be aimed exclusively at those militarily unique aspects of technology or health research and not at broad, generalizable research which makes our job a little more difficult in doing what you would like to see be done. Again, we don't want to be in competition. For instance, just taking HIV, the Department of Defense clearly does not want to be in competition with the national research effort which is centered at the National Institute of Health. CHAIRMAN WATKINS: But are you satisfied that a review has been made of the existing R&D, to look at those spin-offs in a very focused way? DR. MAZZUCHI: Yes, sir, I am in terms of the present activities. As a matter of fact, I attended an excellent briefing by some people who are working in SDI who have looked at a number of potential spin-offs. Those are being looked at. They don't come forth with a whole lot of either information or 358 technology that's immediately applicable, but there's certainly an awareness of the need to have technology that can be transferred to other areas of the Department of Defense. CHAIRMAN WATKINS: But that just happens to be the way it just flows out. I'm talking about within the medical branch of the Department of Defense, to go in with a team of technical experts to review the R&D base and to see what might be in there for further exploitation for, say, infectious diseases which might include HIV. DR. MAZZUCHI: Captain Uddin can tell us a little bit about the research that goes on, that our office does review both research requirements and we are part of the entire infectious disease research review process and have, of course, responsibility for AIDS research. So those two do interface. You might just give a little bit of information. CAPTAIN UDDIN: I believe that there has been a focused effort for AIDS and other infectious diseases as well. There is a similar commission, the Commission on Rare Diseases, that operates under Public Health Service guidelines. We've been working with them over the past several months to provide information on our research programs since most of the infectious diseases, including AIDS, that we in the military have a particular interest in are rare by the definition that they don't occur very frequently in the United States. So, we have looked at that and we continue to look at that and share that information with our colleagues at HHS and other agencies. CHAIRMAN WATKINS: Do you have anything specifically focused on immune system research? CAPTAIN UDDIN: There are several broad programs, both within the Naval Medical Research Institute at Bethesda and Walter Reed Army Institute of Research Institute dealing with immune systems and the AIDS research program as well. CAPTAIN UDDIN: Not that I can identify specifically at this point. CHAIRMAN WATKINS: The immune system would certainly be something that the military should be interested in. CAPTAIN UDDIN: And that has been a focus area of the Office of Naval Research, both within its in-house, within the Navy laboratories from the standpoint of bone marrow transplantation in those areas as well as in the university supported research. CHAIRMAN WATKINS: All right. Thank you very much. 359 CHAIRMAN WALSH: Cory, you have one more question? DR. SerVAAS: I think, as usual, the Admiral has zeroed in on what our Commission should be looking at from the Walter Reed. He's mentioned the immune system. But I'd like to see what you could do with money to research HTLV-1. We had testimony here from the Commissioner of Health in Hawaii who told me privately that he feared it was one out of 500 instead of one out of 1500 that they were estimating would in 10 or 20 years get lymphoma, leukemia, adult T-cell. It seems that you have an ideal situation in the Navy and the Army to research and begin your testing even before the FDA approves the tests for HTLV-1. I understand that the blood bankers are unanimous, almost unanimous. I saw a show of hands in Orlando last fall saying, "Knowing what we know, we should be testing for HTLV-1 now in our blood supply because of this lenti- virus that takes 10 to 20 years to come about." But we've had a case in the U.S., at least one I read about from the Center from Disease Control. If you can start your testing, and I commend you for what you've done in the testing program to provide this information to us, but I wish you could tell us what states, for example, aren't cooperating in your program so that we could immediately get that in our report and also get the information to the states. Maybe there are state laws that prohibit divulging the information. Some states have laws that really restrict what information can actually be given to other physicians or to the local authorities, the local medical personnel. Now, I've gotten off the subject of the HTLV-1 and onto what I think you can do. If we can fund enough so that Walter Reed could do this research on HTLV-1 now and start testing in the local communities. Like in the Philippines where these prostitutes are evidently a problem, I don't know if you have the permission to go and talk:.to the local governments to test these women also for HTLV-1 since that could be spread sexually. Wouldn't you be a ‘jump ahead if we could start that now instead of waiting to react after we start getting cases? CAPTAIN UDDIN: Certainly that would be true once the testing procedures are available. There is one research program funded by Walter Reed which is in a Navy lab on the feasibility for testing of HTLV-1. Our interaction with all of our overseas laboratories are in conjunction with the host minister of health. So, that interaction is already in place. DR. SerVAAS: Now, you can't use that test until the FDA has approved it and we're waiting for the FDA. Is that the hang-up on HTLV-1 or are you allowed to go in and use it on an experimental basis? 360 CAPTAIN UDDIN: Many of the tests that are used are on an experimental basis. But before you would use them in a large screening program you have a number of obstacles that you must overcome in order to assure availability of material, reliability of the test, the kinds of things that I believe Colonel Burke has spoken to you about in the past in terms of the necessity for any program, whatever you're testing for, is soundly based in science. So, for HTLV-1, those things are currently in process. DR. SerVAAS: And there is a good test, a very good, reliable test, as I understand it, that the blood bankers have agreed is a good test and it does identify those who are sero- positive for HTLV-1. I just wonder how we as a Commission can undo the the bottleneck if that's it, at the FDA, if that's where it is and that's where we're hoping to fund enough to get those tests out more quickly. I didn't mean not to do peer review, but we just aren't seeing enough of your information in the press where the public needs to know. CHAIRMAN WALSH: Cory, we're running overtime now, very severely and I haven't had a chance to ask a question myself yet. I think that I'm going to ask you a very brief question and thank you at the same time for what I consider very good in-depth presentations of how you are viewing this disease. The one question that I wanted to ask really is for you, Dr. Lamont. Yesterday the military witnesses did mention the security problems involved among some of the nations, particularly in Africa, who are losing military leadership as well as government leadership because of the spread of this disease. Has this yet become a security problem for us? DR. LAMONT: Not directly, sir. As far as our forces and their viability and freedom of movement overseas are concerned, this has not affected us. It has, of course, had a potential effect on the United States vis-a-vis these governments. CHAIRMAN WALSH: Yes. DR. LAMONT: On that point, I would call on my State Department colleagues or my other colleagues in the foreign affairs community, since the Defense Department has not been Girectly involved. However, our understanding is that the effect is and is potentially significant. CHAIRMAN WALSH: One other question very briefly. You can just answer yes or no. Is our impression that dependents of military personnel going overseas are not tested and also that local hires are not tested although they may be government responsibility should they become ill since they work for us, has there been any alteration of that position or am I misstating the position? 361 DR. MAZZUCHI: Let me try to clarify. I'm afraid a simple yes or no won't do in this case. CHAIRMAN WALSH: Yes, I know that. DR. MAZZUCHI: At the moment, there is no mandatory testing of DOD civilians. The Deputy Secretary of Defense has authorized the testing of new hires only who are going overseas as part of a medical evaluation. I will address my comments only on the medical side. It is our view that medically there is no need to test people going overseas in a mandatory fashion. There may be other reasons to do so, but medically we do not believe there is sufficient rationale to have a mandatory testing progran. CHAIRMAN WALSH: What about local hires? DR. MAZZUCHI: Well, again, we don't -- CHAIRMAN WALSH: The military doesn't have that many, I guess. DR. MAZZUCHI: No, we don't. The reason we test in the military is because of the buddy blood donor system, because of posting our people to areas of endemic disease. These conditions do not happen with civilians and therefore we believe that the medical rationale is not there. Certainly we support, and as a matter of fact have put into place, a policy that encourages voluntary testing, particularly for people who believe they may have been exposed to the disease or who want to know their health status. But we don't believe that medically mandatory testng that is appropriate for civilians. CHAIRMAN WALSH: Once again on behalf of the Commission, our thanks to you for a very interesting presentation and certainly candid replies to any questions that we asked that you could reply to. DR. MAZZUCHI: Thank you for the opportunity, sir. CHAIRMAN WATKINS: And Dr. Lamont, I'd like to say that I applaud a history background for ISA. I think we've had too few historians in the past and so I commend you for your skill area. I'm a great fan of ISA in Defense. I think they've done a superb job over the years routinely and I think people with a diverse background, and particularly with your background, are key to it. So, congratulations for being a historian and talking to us about AIDS DR. LAMONT: Thank you, Admiral. It's been a pleasure to be working in ISA. My specialty is American diplomatic 362 history, so it's particularly pertinent to what we've been discussing here this morning. CHAIRMAN WATKINS: Thank you. CHAIRMAN WALSH: Thank you. While the next panel is coming to the table, I'm going to let some of the Commissioners have a two minute break. (Whereupon, at 10:57 a.m., off the record until 11:04 a.m.) CHAIRMAN WALSH: Gentlemen, we appreciate your coming to discuss with us the HIV pandemic and the movement of people across international borders. Some of us who are engaged in international work are already feeling a degree of restriction and not without reason. But this is becoming important to us. There are many countries, for example, in which the organization which I represent, Project HOPE, works where if any of our teachers are going to stay over 90 days they require a certification that they are HIV negative. As yet there's no indication that they have to be retested, but they have to come with a certificate certifying that they are negative or they will not be granted the traditional work permit. So, these things are becoming more and more important, particularly to the United States since we are number one in this disease. So, we're going to welcome your thoughts today and any contributions you can give to us to better enable us to recommend a sensible policy to the President which is our charge on the movement of peoples across international borders. Our first witness will be Walter Lockwood, who is the Director of the Office of International Health Policy and the Acting Chairman of the Interagency Working Group on AIDS at the Department of State. Mr. Lockwood? MR. LOCKWOOD: Thank you, Mr. Chairman and members of the Commission, for this opportunity. You have identified me. I would only add that our office is within the Bureau of Oceans and International Environmental and Scientific Affairs (OES), the scientific functional part of the Department of State. We have had the opportunity to submit to you the Department's paper entitled "AIDS: A Foreign Policy Challenge." Your Commission has now devoted close to three full days to the international dimensions of AIDS. This sense of priority underlines and confirms our belief that indeed this is an international pandemic that calls for, indeed cries for, international cooperation and actions. 363 In late 1985, when it was evident that AIDS would increasingly impact upon our foreign relations, the Department of State established an interagency working group on the international aspects of AIDS. It convenes under the direction of my Assistant Secretary for OES and includes the principal agencies with personnel assigned overseas, that is State, DOD, A.I.D., USIA, Peace Corps and others, as well as representatives of various parts of HHS concerned with the international aspects of AIDS. We confront, Mr. Chairman, formidable obstacles in attempting to quantify in all countries the impacts of AIDS, including our own country. Data on AIDS cases are usually based on selected populations such as blood donors, hospitalized patients and prostitutes. There are, as well, substantial gaps in our knowledge of the disease's natural history. Consequently, generalizations to national populations are faught with — uncertainties. Notwithstanding these shortcomings we know enough that there are some serious impacts out there, including those that impinge upon our foreign relations. Allow me to cite at random a few indicators. You have heard from the World Health Organization as to its latest data and estimates. Our policy response and concern is heavily influenced by the WHO projection that by the end of 1991 there will be three and a half million AIDS cases, one million deaths and 100 million infected with the virus. Some might attack this as being a bit conservative. The disease primarily affects individuals in the 18 to 45 year old age group. AIDS in Africa is known to affect slightly more women than men. The virus is passed from infected mothers to their infants. The disease could spread into the so- called urban elite with heavy losses of skilled managers, teachers and professionals in countries that can ill afford the effects of such losses. What will be the impact of AIDS on tourism, on foreign investment, indeed on international commerce? Can already fragile health systems absorb the tremendous burden of this disease? These are intangibles but no less a matter of serious concern. I mention these things, Mr. Chairman, really to indicate the seriousness from a foreign policy vantage point that we view the AIDS pandemic. Allow me to briefly talk about our response. You've already been briefed on the important elements that USAID, both in its multilateral and bilateral programs brings to the AIDS pandemic, the extensive programs of HHS, and the international research and support activities of DOD. My colleagues this morning will further discuss other aspects of our international response. My purpose is to underline that we have since 1985 developed a concerted foreign policy response. In summary, and at the risk of oversimplification, allow me to list the principal elements of that response. 364 Firstly, educational programs designed to inform U.S. government employees, dependents, ex-patriots and travelers of AIDS and measures they need to protect themselves from acquiring the virus. Secondly, testing programs directed at active duty military personnel and those seeking to enlist in the military. Department of State and other civilian agency employees and their adult dependents are tested prior to assignment overseas. Thirdly, a requirement to test all immigrants and refugees and denial of entry to any foreigner known to be infected with HIV. Fourth, active financial and programmatic support for the global program on AIDS of WHO. This includes establishment of comprehensive national programs in developing countries. Fifth, an active and growing U.S. foreign assistance program. Sixth, as an extension of our extensive domestic program, cooperative research programs between U.S. health agencies and foreign entities. Lastly, a program to establish improved data collection which will provide a basis for models to forecast incidence and prevalence trends and geographic and demographic patterns. We heard this morning, and indeed when Dr. Mann was before you Monday morning, that bilateral relations can have an effect on our program with respect to AIDS. In most instances, that impact, I would say, has a positive relationship as the U.S. joins with other countries in programs to deal with this common enemy. However, there are times when we can have consequences of a more political nature, indeed even a negative consequence. A prime example is the Soviet Union. In October 1985, the Soviet Union launched a vicious and reprehensible disinformation campaign alleging that the AIDS virus originated, that it was manufactured, in a U.S. military laboratory. This theme, or variations of it, appeared repeatedly in the Soviet media and surfaced in various foreign publications or broadcasts. The U.S. government launched a vigorous counter campaign which demonstrated in clear, scientific terms that any suggestion that the virus was "manufactured" in a lab is totally false, that the virus is, in fact, of natural origin. Moreover, we put the Soviets squarely on notice that any notion of U.S./Soviet cooperation on AIDS was out of the question so long as their obnoxious campaign continued. The Soviet disinformation campaign was so lacking in credibility that it gradually fell under its own weight. In the fall of 1987, the Soviets went so far as to join the U.S. in sponsoring a U.N. General Assembly resolution which, amongst other things, recognizes that the AIDS virus is of natural origin. 365 I would note that the same General Assembly resolution was a formal recognition by all’ governments of the seriousness of AIDS and of the high priority which must be given to this issue. By late '87 and early this year, leading Soviet scientists and scientific organizations publicly stated that AIDS is of natural origin. The Soviets have given "assurances" that disinformation is behind us and indeed that the time has come to explore U.S./Soviet cooperation on AIDS. We are prepared to engage in such a dialogue. However, the Soviets should be aware that we will continue to be vigilant on this matter and if AIDS disinformation occurs, cooperation or the notion of it would be seriously impaired. Thank you. CHAIRMAN WALSH: Thank you, Mr. Lockwood. Our next witness is Dr. Paul A. Goff, Deputy Medical Director of the Department of State. Dr. Goff? DR. GOFF: Mr. Chairman, members of the Commission, I want to thank you for asking us to testify. The program that we run in the Department of State is essentially an occupational health program for Department of State employees and their dependents serving overseas. In regard to AIDS, I would like to emphasize before talking about our testing program that our major emphasis is on education, that we think that education of our population is the best means for them to avoid being exposed to this disease. The Department's HIV testing program for foreign service employees and applicants has completed one year of operation. HIV testing is required of overseas employees and their dependents over age 12 of the Department of State, A.I.D., USIA and over 35 federal agencies with employees at overseas posts. The program remains unique because the AIDS problem has been confronted with an education and testing program in an employment setting. An entire population is being screened and the problem is being treated in similar fashion to other medical problems. After one year, we believe that such testing has been helpful to those with the infection as well as the broader employee community. Further, we have demonstrated that testing can be done while maintaining confidentiality and benefits for employees who test positive. Let me explain the rationale behind the testing, the reasons why we think it is essential. Most of our reasons relate to the difficulties of service overseas. Underlying these justifications, however, is our belief that a state of ignorance about a disease, particularly one that is fatal and infectious, is unacceptable. Those with HIV infection, like those with other serious illnesses, should be informed of the problem, counseled 366 on its implications and have ready access to health care. Their privacy must also be maintained. Specific problems relating to overseas service include the possibility of other infections. Repeated immune stimulation has been accepted as one reason for progression of asymptomatic patients to AIDS. Because of this risk, it is now almost universally recommended that HIV positive individuals avoid repeated exposure to infectious diseases and optional vaccinations, particularly live virus vaccines. In our overseas work place, infectious disease is commonplace, exposure inevitable and vaccination usually required. Testing for HIV infection assures assignment of HIV positive patients to locations where immunizations are not required and where the prevalence of infectious diseases approximates that of the United States. The great majority of our overseas posts lack facilities to provide health care services to HIV positive patients. Individuals in the quiescent state of the HIV infection require periodic monitoring by experienced health care providers and access to facilities capable of diagnosing and treating complications in a timely fashion. Most practitioners follow such patients every three to six months in the United States. If a problem unrelated to HIV infection occurs, authoritative reassurance is provided. If, on the other hand, HIV infection progresses, early diagnosis and expert treatment of complications will prolong a patient's life. Testing allows the Department to assign HIV positive patients to locations where adequate and confidential health care is available. In most overseas locations where our staff resides, another concern is the problem of blood transfusions. In most of these locations, no testing of donated blood for antibodies to HIV is possible. Several times each year in our health care system, staff members are called on to supply blood in emergency situations to help a colleague. While not a primary reason for HIV testing, testing decreases the chance that this donated blood will be infected with HIV. I should note that the Department is currently in the process of distributing and training personnel to use a quick HIV antibody test at the time of such emergency blood transfusions. This test will bring the capability to test donated blood for emergency transfusion to posts where testing is currently not being done. Let me review our experience with the testing program that we've initiated. For over 30 years, the Department has 367 provided a comprehensive medical exam to all applicants and employees and their dependents prior to hiring and overseas assignment. This program assures that applicants will be available for worldwide service, which is a long-standing foreign service requirement. It also assures that employees will be assigned to posts with medical facilities capable of caring for identified medical problems. Tests for numerous problems, including cancer, heart disease, syphilis, hepatitis and other infectious problems are included in the exam. Lifestyle counseling for identified problems is routine. The diagnostic and counseling services provided those with HIV infection are no different than those provided for other serious medical problems. We carefully considered testing for HIV prior to implementing our program. We had had an extensive educational program in effect since early 1985. It was only after several of our patients with HIV infection received grossly substandard care for complications at an overseas facility that we reconsidered testing and added it to our periodic examination. Employees with evidence of HIV infection, and this is two positive ELISA tests and a positive Western Blot with the entire procedure repeated, receive a restricted medical clearance based on the stage of their infection. Those who are asymptomatic and without immune suppression receive a Class Two medical clearance and are eligible for assignment to posts with adequate medical facilities and experience with this problem. Individuals with evidence of immune suppression or other symptoms are assigned to the United States. Applicants testing positive are not hired because of the limited number of overseas posts at which they are eligible to serve. Similar constraints are routinely applied to applicants, employees and other beneficiaries with potentially serious medical problems. We think the program has benefited all groups that have been tested. Those who expected to test negative and tested positive have been informed of their diagnosis and provided counseling to decrease the chance of spread. Most of our cases diagnosed by the screening fall into this group. Those who expected to test positive and tested positive had the diagnosis and the fact that they need to take precautions confirmed. Those who tested negatively received counseling and information on prevention of the infection. The rate of infection among employees and their dependents over aged 12 approximates that found in the U.S. military population. The distribution was surprising because of the relatively large number of married patients, about a third of our patients. While most patients did not expect positive results, a likely source of the infection was evidenced in all 368 cases that were interviewed, and this was all but one of our patients. The response to a diagnosis of HIV infection in our population has been an appropriate combination of surprise, anger, sadness, and frustration. No unexpected emotional reactions have occurred, careful support and counseling have been provided through our own mental health staff and through resources available in the community. The cost of the program has not been excessive as a result of efficient use of existing resources. Pre-test counseling is offered as part of the physical examination by our clinic staff in examining physicians. The ELISA test procedure, including the technologist's salary, costs about $4.00 per test. The Western Blot, done at a reputable outside laboratory is $30.00 per test and has only been required in a small number of patients. Post-test counseling for those testing positive is provided by our own Employee Consultation Service, social workers, staff psychiatrists and outside resources. The testing program has been the subject of a suit and a grievance by one of our unions. No individual has brought a complaint. Both of these legal actions were settled in our favor. I would conclude that the testing of a population for HIV infection is possible and desireable. Such a program, however, in our view, can only proceed if there is a clear reason for testing, if confidentiality, continued employment and all employee benefits, particularly health insurance, are maintained. It has been our experience that confidentiality, as provided by the long established concept of a confidential physician/patient relationship, is adequate, particularly if the other factors are assured. Thank you. CHAIRMAN WALSH: Thank you, Doctor. Our next speaker will be Dr. Alan R. Hinman, who is the Coordinator of the National Vaccine Program and Director of the Center for Prevention Services at CDC in Atlanta. Dr. Hinman? DR. HINMAN: Thank you, Mr. Chairman. I am here today to discuss the responsibilities of the Centers for Disease Control in the medical examination of aliens with regard to HIV infection. Our authorities in this regard proceed from two major acts in the United States, the Immigration and Nationality Act and the Public Health Service Act. The Immigration and Nationality Act specifically lists six medical grounds for the exclusion of aliens: mental retardation; insanity; previous attacks of insanity; psychopathic personalities, sexual deviation or mental defect; narcotic or alcohol addiction; and finally, affliction with any dangerous, contagious disease. The Public Health Service, under the authorities of this act and of the Public Health Service Act, has promulgated the medical examination of aliens regulations 369 which were revised most recently last year. These outline the scope of the medical examination and identify the communicable diseases which are included on the list of dangerous contagious diseases for purposes of determining admissibility to the United States. The dangerous contagious diseases defined in Section 34.2(b) are chancroid, gonorrhea, granuloma inguinale, HIV infection, leprosy, lymphogranuloma venereum, infectious syphilis and active tuberculosis. Immigrants and refugees coming to the United States must have a physical and mental examination overseas. These examinations are performed by local physicians who are designated abroad by consular officers of the Department of State. Aliens in the United States applying for adjustment of status to permanent resident or for legalization of their immigration status under the Immigration Reform and Control Act are examined by physicians designated by the Immigration and Naturalization Service. The examinations are performed to identify for the Department of State and the Immigration and Naturalization Services those applicants for admission who have excludeable mental and physical conditions as specified previously. Aliens applying for non-immigrant visas do not routinely have a medical examination, although under the provisions of the Act a medical examination may be required by the consular officer if in his or her opinion an examination is necessary to ascertain whether the alien is eligible to receive a visa. If a U.S. consular officer or immigration officer suspects that any alien is suffering from an excludeable medical condition, he or she may require the alien to undergo a medical exam. The procedure of the medical examination is a brief history of present or previous illness, a visual inspection of the body's skin surface, observation for excludeable mental conditions, a chest X-ray examination for tuberculosis for those 15 years of age and older, or for those under 15 if they are ill or have a family member with suspected tuberculosis, and a blood test for syphilis and human immunodeficiency virus infection for those 15 years of age and older. Any excludeable or non- excludeable mental condition which is suspected or detected as a result of the examination may then require more comprehensive evaluation and may necessitate hospitalization or treatment or both before a visa is issued. AIDS was added to the list of dangerous contagious diseases by federal regulation in June 1987. On the same date, a notice appeared in the Federal Register proposing to amend the medical examination of aliens regulations by substituting HIV infection for AIDS on the list of dangerous contagious diseases. 370 Before this amendment actually became effective, Congress enacted and the President signed on July 11, 1987, Public Law 100-71 which required the addition of HIV infection to the list of dangerous contagious diseases. The amendment was considered necessary because a person infected with HIV is capable of transmitting the virus and because of the spread of HIV by certain high-risk practices is not unlike several other diseases currently on the list of dangerous contagious diseases covered by the regulations. As a result, the Department of State will deny visas to and the Immigration and Naturalization Service may deny admission of aliens with HIV infection. Screening for HIV infection of aliens 15 years of age or older applying for admission into the United States for permanent residents began on December 1, 1987 and for those under age 15 if it was felt to be indicated. Over the years, the medical screening, treatment and referral procedures have allowed millions of immigrants and refugees to enter the United States without significant adverse effects on the health of the American public. Since screening for HIV infection began less than five months ago, it's difficult to determine what impact this has had on deterring the importation and further spread of the virus in the United States. It undoubtedly has prevented people who became infected abroad from entering the U.S. As I understand it, the Department of State has been collecting information on the number of visa applicants who have tested positive since the screening program was implemented. However, we have not yet had an opportunity to analyze these data. I'd be happy to try to answer any questions you might have. CHAIRMAN WALSH: Thank you. Next we have Mr. Richard Williams who is the Associate Director for Visa Affairs at the Bureau of Consular Affairs at the Department of State. Mr. Williams? MR. WILLIAMS: Thank you, Mr. Chairman and members of the Commission. Dr. Hinman has described the statutory basis for HIV testing. I would like to take my opportunity here to describe to you how this provision of the Act is administered abroad. Consular officers issue visas within an area of prescribed geographic jurisdiction. They are limited to their area of jurisdiction but the visa applicant is not. He may or may not be a resident of that country or the area of consular jurisdiction. Most commonly he is. But in such cases as Canada and Mexico, many are not. 371 The first grounds of ineligibility as recited by Dr. Hinman are medical. The finding of eligibility or ineligibility on these grounds is solely a question for the panel physician. The panel physician, as Dr. Hinman has described, is a local doctor who has been designated to do the medical examination for immigrant visa purposes. His finding of eligibility or ineligibility is binding on the consular officer. In making this finding, he is guided by the "Medical Manual for the Examination of Aliens" which is published by the Public Health Service. He gets a certain oversight from the consular officer in whose jurisdiction he works, but the consular officer, being a layman, is not able to give professional oversight. That is provided solely by the Public Health Service. Laboratory and consultation is the responsibility of the panel physician. When we established the HIV testing program, not all panel physicians were able to find laboratories within their countries who could do the laboratory test for them. In those cases, consular officers, with the Department of State, help make arrangements to find a laboratory that could do it and overcome such obstacles as customs and currency regulations that arose in impeding this form of examination. All visa examinations must be by a designated panel physician. That is because they are under the instruction and supervision of the consular officer and the Public Health Service. The applicant may not bring the examination or any of the constituent parts, such as chest x-rays or serological results, with him from either a non-panel physician or a U.S. physician or even a U.S. military physician. The finding of eligibility or ineligibility under the HIV program is done as Dr. Goff has described it. There is first an ELISA test. If it proves positive, there is a second ELISA test. If it proves' positive, there is a confirmatory test, normally Western Blot. If all three, and only if all three, prove positive, the applicant is found permanently ineligible for a visa. The panel physician is then instructed to notify the applicant of his condition and to give him appropriate counsel. The panel physician then follows local law and regulation about informing the local public health service as to the condition. We have been carrying out this program now since the first of December, which is a short time in this work. So far we have examined 125,000 applicants. Of those, 188 did not get visas out of a finding or a quasi-finding of refusal under Section 212(a)(6) because of HIV positivity. We would call a quasi-refusal one where the applicant backed out sometime during the course of the examination procedure. 372 These refusals have been found in 33 countries out of the 135 in which we issue visas and it comes to a rate of 1.5 per 1,000. There are geographical disparities between one area of the world and another. But before we did very much with these figures, I would offer the caveat that these examinations are not done for diagnostic purposes. They are done solely for the legal purpose of finding out if the applicant is eligible or ineligible for the visa. Examinations cost anywhere from nothing if, as offered by the host country public health service, to around $150.00. They take from a few days in the more developed countries to a few weeks where they have to be sent out of country for processing. Actually, this has not presented a grave problem to our immigrant visa processing. Surprisingly enough, after a little bit of initial resistance as we were establishing the program, there have been no political repercussions from any source. Beyond that, I would remain available to answer questions. CHAIRMAN WALSH: Thank you very much, Mr. Williams. Next we have Mr. Donald Krumm, Director of Refugee Processing at the Bureau of Refugee Programs at the Department of State. Mr. Krumm? MR. KRUMM: Good morning, and a special good morning to you, Dr. Walsh. Just let me say that I've had the privilege of working with you in your program for displaced persons in El Salvador with Project HOPE for 500,000 displaced persons there. CHAIRMAN WALSH: Yes. Thank you. MR. KRUMM: The Refugee Act of 1980 established a procedure whereby each year the Administration consults with the Congress to determine the number of refugees who will be allowed to enter the United States. In 1988, the agreement was for 68,500 refugees. By region, the subtotals were 29,500 for Southeast Asia, 8,500 for what we call the Orderly Departure Program directly from Vietnam, 15,000 from Eastern Europe and the Soviet Union, 9,000 from Near East Asia which is Pakistan and Turkey and other countries in that region, 3500 from Latin America and 3,000 from Africa. To put this 68,500 in some perspective for you, that represents about one-half of one percent of the total number of 12 million refugees who have crossed from one country to another and are recorded as refugees by the UNHCR, the U.N. High Commissioner for Refugees. They reside in countries that you've all read about in the newspapers, Thailand, Pakistan, Honduras, Malawi, Sudan. 373 In addition, the Refugee Act contains a provision for emergency consultations with the Congress in case unanticipated events create the need to bring additional people to the United States as an ultimate solution. The President, as you may know, is now engaged with the Congress to have an emergency consultation to accommodate Soviet citizens, principally Armenians who are being permitted to exit the Soviet Union. Some 15,000 additional numbers, we call them numbers or cases, are being requested for our Eastern Europe and Soviet Union ceiling. We anticipate a successful consultation which will bring us up to 83,500 for this year. Of these 83,500, with the exception of those who came in prior to December 1, each applicant, each prospective refugee must take the AIDS tests that are necessary to bring him to the States. Each much pass those tests to come to the United States. Some four months into the program, we're happy to say that we've had very little incidence of AIDS virus detection. We have had six cases that have shown up in Nairobi. These have been issued 212(a)(6) denials and we have heard little political flack about that. We have had also some positive ELISA tests, but those have not been confirmed by the Western Blot confirmatory test. I must be frank with you in saying that the Department has been concerned and continues to be concerned about the potential consequences of AIDS virus detection in refugee populations in countries that have large refugee populations and where the political circumstances surrounding those refugees are difficult. Refugees are not like prospective immigrants. If an immigrant tests positive for the AIDS virus, he remains a citizen of the country from which he comes, he has access to the laws and institutions of that country and, in fact, he can go home. He may have liked to come to America, but the point is he has an access to go home. This is very different, this is not the case for refugees. Refugees exist in tenuous circumstances in their temporary homes of first asylum. They are, by and large, considered to be a tremendous burden by their host countries. They are natural scapegoats for any difficulty that may arise. In my former capacity as the Emergency Operations Director for the Refugee Program in the Department of State, I've been on all continents looking at refugee situations and I can tell you that refugees are scapegoated and blamed for virtually everything that you might imagine, overcrowding in the schools, overcrowding in the hospitals, diseases themselves, high costs of living, shortages of food, high prices of food, common theft. They are blamed conveniently for all of those. 374 Our concern is that certain host governments may use the pretext of AIDS detection, no matter how small its incidence, to deny refuge and/or to involuntarily return refugees to the countries from whence they came. To help buffer these potential difficulties, there are elements built into the INA and to its implementing rules and regulations to permit relief in extraordinary circumstances. Prior to December 1, 1988, Section 212(a)(6) contained a waiver provision for refugees for the dangerous contagious diseases that you've heard about right here. The new regulation places the AIDS virus on that list and it does permit, rather it did not take away a waiver possibility for refugees to come in case there were some problem. However, it is understood by all of us around this table that the waiver provision for a refugee testing positive for HIV would be used only under the most extraordinary circumstances. The rule is there for a reason. We're trying to keep people with AIDS and the AIDS virus out. Also the new AIDS testing requirement stipulates that all testing must be done overseas, except in emergency circumstances. All of us remember the circumstances that surrounded the fall of Vietnam. At that time, we brought massive numbers of people in emergency circumstances to the United States directly from Vietnam. I would suggest to you that it would be impractical for us to have a testing program that would absolutely say that you have to test the person overseas in a circumstance like that. Now, in cases like this, however that emergency might be defined, the Attorney General in consultation with the Secretary of State and the Secretary of Health and Human Services, would consult to determine what would actually be the means of bringing them in. In sum, I'm happy to report at this time that a testing system is in place and that we are successfully testing all prospective refugees who are coming to the United States. Thank you for this opportunity. CHAIRMAN WALSH: Thank you very much, Mr. Krumm. The last witness on this panel is Mr. Richard Norton, the Associate Commissioner of Examinations, Immigration and Naturalization Service, Department of Justice. Mr. Norton? MR. NORTON: Thank you, Dr. Walsh and Commission members. At the same time the State Department began testing for HIV virus on December 1st, the Immigration and Naturalization 375 Service began testing in the United States for applicants for immigrant visas. This also includes the many people who are applying under the legalization provisions of the Immigration Reform and Control Act. Testing is undertaken by the 2800 some odd physicians that we've designated for this purposes and the physicians test for the many grounds of exclusion outlined by Dr. Hinman, one of which of course is the HIV. Altogether this year, we expect to test approximately two million people under this program. Non-immigrants, those who are visitors or students to the United States, are not normally tested. They may be tested at the discretion of the consular officer or at the discretion of the Immigration officer if they have reason to believe an individual coming to the United States is infected with the virus. To insure proper testing procedures by the physicians, the INS consulted with the Centers for Disease Control and distributed a memorandum to the physicians which outlined the testing procedures to be followed. These contain five main thrusts. First is providing that two positive ELISA tests and a confirmatory Western Blot test be done to determine infection. Second, advising the individual of the purpose of the test and the effects of the test in the application process before the test is taken. Third, notifying applicants of the test results personally by the physician and in writing, and assuring that post-test counseling will be available to those who test positive. Fourth, reminding physicians of the need for strict confidentiality of the test results. And fifth, insisting that physicians comply with all state and local laws and regulations, especially those regarding confidentiality and reporting requirements. The physicians give the test results directly to the applicant who then make the choice as to whether or not they're going to submit the application to the Immigration Service from there. So far, no people in the Legalization Program have submitted applications who have been confirmed to have the disease. One hundred and thirty two applicants have submitted applications to us in the Cuban/Haitian adjustment program. I believe 131 of those are Haitians. Those are the only numbers that we have of people who have submitted applications following confirmation of the virus. Waivers are available, as mentioned. They are available for the legalization applicants. We expect about two million altogether in those programs that would be tested and would be able to file for a waiver. And also, as Mr. Krumm has mentioned, they're available for the refugee program. When not 376 available, parole can be used to grant admission of these people to the United States in extraordinary circumstances. So far, we have two cases in which that parole authority has been exercised, both in the cases of military dependents whose admission was determined to be in the best interest of the United States. Thank you. CHAIRMAN WALSH: Thank you very much. We're going to commence our question and answer period and I know that you heard what I said to the last panel. Our charge is a serious one in that we are to make appropriate recommendations to the President on policy. So we would appreciate your complete candor in the answering of your questions with the full recognition that these may represent your personal views and sometimes perhaps might even be a deviation with present policy, the idea being that that is what our function is. If modifications are needed in policy, we are supposed to suggest them. As Mrs. Gebbie repeatedly asks, what can we do to make your task not only easier but more appropriate for the government of the United States? Now, I'm going to commence the questioning, as is my habit, with Admiral Watkins as my first questioner. CHAIRMAN WATKINS: Mr. Williams, there was a case, of a doctor who came to the United States on a special grant who was subsequently infected during a surgical procedure at one of our hospitals and then found to be HIV positive. It was my understanding that although he had the full intention to remain here from a foreign country, he was then made ineligible to come here as a potential immigrant to the United States. Are there some situations where person coming into the United States, let's say for medical treatment, and who, through blood transfusion or operations in the U.S. has become HIV positive. That seems to fall into a very special category. I'm wondering if we have any kind of policy to deal with those ona case by case basis where there seems to be a certain responsibility on the part of the United States to perhaps vary a policy under certain circumstances. MR. WILLIAMS: For non-immigrant visas, those would be the ones that you were talking about coming up for a specific medical treatment, yes, there are waiver provisions. It's a waiver provision that is enacted by the consular officer and the Immigration and Naturalization Service working together. There are no waiver provisions for immigrant visas. This was the case that Mr. Norton was speaking of where the Attorney General could then use his discretionary power of parole and for the use of that I would refer you to Mr. Norton because it is done by INS. CHAIRMAN WATKINS: Mr. Norton? 377 MR. NORTON: In the particular case you are describing, the individual had been admitted as a foreign exchange visitor and normally required to go back. In this case, because of the unique circumstances, the individual was placed on what we call a deferred action status, being ineligible for any particular form of relief under law. We set his case aside and will allow him to remain in the United States indefinitely. CHAIRMAN WATKINS: Dr. Hinman, you mentioned that you don't have the data in hand at this point, it's not yet been analyzed on the degree of HIV sero-positivity of those that have come under the new immigration testing laws. When will you have that data? How many people who've applied to come into the United States and emigrate to the United States have we found to be HIV positive? DR. HINMAN: I think that would be best answered by Mr. Williams. He provided us some information on something on the order of 125,000 persons tested so far with 188 having been refused either because of positivity or of refusal to comply with the process. CHAIRMAN WATKINS: Can you break that down into refusal versus actually testing positive? MR. WILLIAMS: Sure. The reason Dr. Hinman hasn't had a chance to examine this data is that it's still coming in. In fact, the figures I have were collated last night. Of the 125,000, 119 were found to be HIV positive, 69 were quasi- refusals. CHAIRMAN WATKINS: I'm sorry? MR. WILLIAMS: Sixty nine are what we would refer to as quasi-refusals. That is people who did not complete the examination procedure. I counted them together because for our purpose the 119 and 69 all resulted in non-issuance of the visa and that's what we're interested in. There were 69 cases of what we refer to in our trade as false positives which would really be an unconfirmed ELISA test. So, 188 is the number so far. Now, we've only been doing this since the lst of December. This was a special request to tell us what had happened, just out of curiosity of how the program was going. At the end of each fiscal year, we do get figures on the number of people who would be refused visas under Section 212(a) (6), but that is the provision of the Act that precludes issuance of a visa to all persons having a dangerous contagious disease, including forms of venereal disease and tuberculosis. To get the figure of HIV positive refusals, we would have to make another special inquiry of the 158 posts that issue immigrant visas, and_ we'll probably do so. 378 CHAIRMAN WATKINS: In this connection, while I have no Opposition at all to the policy, when you read the background of the early stages of this epidemic, people moving across international borders at great rates other than immigrants and refugees, visitors to the United States, it seems to me that was the area for most of the potential transmission of this virus. Certainly that was the case noted in the famous book on the subject, And the Band Played On. I'm just trying to get a feel for where we really sit. Do we really think we're doing something here? We've focused heavily on immigrants and refugees. The numbers are relatively small relative to those who travel on fairly easy passports all over the world today. Could you give me some feel for whether we're kidding ourselves in terms of the real impact here of what we're doing? MR. WILLIAMS: I think from the very outset we've tried to distinguish between those who were going to be permanently a part of this country and those who were going to be here temporarily. CHAIRMAN WATKINS: I set that aside and say that's fine. I'm not trying to get into that discussion. I'm trying to get a perspective on the real impact on controlling the disease in this country. DR. HINMAN: There are about 800,000 applicants for resident visas a year in the United States who will be subject to the current requirement. There are another six and a half million applications for non-resident or tourist visas and there is something approximating 200 million border crossings between the United States and Mexico or Canada. DR. LEE: Two hundred million? DR. HINMAN: Two hundred million crossings. I'm Sorry, 300 million between the U.S. and Mexico or Canada each year on land. CHAIRMAN WATKINS: That answers my question. I'd be interested to know what kind of counseling you give U.S. citizens who are traveling abroad. DR. HINMAN: We issue a series of memoranda called advisory memoranda and in April of 1987 we issued an advisory memorandum on AIDS which informed travelers about the behaviors which could place them at increased risk of HIV infection and precautions they could take to try to reduce that risk. These advisory menoranda go out to about 12,000 different recipients, including local and state health departments, travel agencies and 379 a variety of others. This does not mean, of course, that every United States citizen who is anticipating a vacation abroad got the word, but this is the way in which we have typically put out other memoranda on other diseases. We just issued one, for example, on dengue. CHAIRMAN WATKINS: How well is that done. Is it just kind of out there and if it's used it's okay or is there any kind of a PR effort that you'r putting on in some more urgent fashion to try to deal with it, recognizing it's a very big problem. DR. HINMAN: There is, to my knowledge, currently no major PR effort directed at travelers. Our efforts are directed towards individuals practicing high-risk behaviors, whether in the United States or elsewhere. Our general efforts relate to trying to encourage people who are homosexual or who use needles or who are sex partners of those to modify their behaviors and it's irrespective of location. MR. LOCKWOOD: Mr. Chairman, if I could just add to that very briefly. Education, of course, is the name of the game here and a very important ingredient in the international effort indeed is education. The World Health Organization in the establishment of the national plans that we have in many countries throughout the world is dedicated to that very thing. So, the dissemination of the dangers, including the dangers when one travels, of AIDS I think is indeed out there. How far and deep it penetrates is still a challenge no doubt. So I think they're very conscious of that. Secondly, I would mention that the number of conferences that we have worldwide today with respect to AIDS that go on where this same theme recurs, recurs, recurs, more and more as time creeps on we're getting educated. CHAIRMAN WATKINS: Well, I had a situation, Mr. Lockwood, that came up when an individual called me and asked for advice regarding going to a high impact area in Central Africa, with a very commendable intention on the part of the individual to provide volunteer services for a summer program. I had them call the State Department and the State Department recommended strongly that he not go there at that particular time unless there was an urgent need. It would not be a wise thing to do. Now, had he not called the State Department, the question is would he have gone. The answer is probably yes. The person he called said, "well, if you're going to go, these are the things you should take with you. You should take a kit with you that has this kind of capability in the even you find yourself ina situation where you need to have a short." So, I'm just wondering how well that kind of thing is handled by State. 380 MR. LOCKWOOD: Well, my response, and perhaps Dick Williams would like to add to it, is that I would repeat the education theme. No, we do not have kits as such that are made available. There are the travel advisories. There are the reports of the Surgeon General that are made available to people so that the message that we have to impart about the problems associated with AIDS, including those that one might confront in other countries, is available to people. No, we do not carry it to the extent that you are suggesting of having an actual kit that every person who leaves from the United States has with hin. So, I think it's an overall educational campaign. DR. HINMAN: Admiral, if I could just follow up briefly. Our general efforts in trying to educate international travelers as to appropriate health behaviors are not particularly effective. We receive at CDC alone about 50,000 calls a year from persons who are going overseas and are interested in information about immunizations or chemoprophylaxis for malaria. The best evidence is that people are not that well informed. We try, with I think limited success. As far as specific issues with regard to HIV infection and developing, in essence, a hit list of countries that are high impact, one I think would want to consider what the disadvantages of such a list are. We know that detection and reporting of HIV infection in many countries is inadequate. A disincentive to acknowledge existence of a problem might well exist if we were to put up a list of, "These are the countries you shouldn't go to because you might get HIV infection." CHAIRMAN WALSH: Well, it may pay to consider a simple education program to the nation's physicians. The vast majority of travelers do consult their doctors about taking that diarrhea kit or whatever it is they want to take with them. It might pay to consider something quite simple that would be available to physicians either through you or the state health offices. I can't see this becoming a federal responsibility, in other words. I think this is something that if somebody is going to travel they ought to go to their own physician and perhaps they would have something in hand that you have sent out to then. DR. HINMAN: We produce every year a booklet called "Health Information for International Travel." About 60,000 copies a year go out to state and local health departments and to individual practitioners and others. This does include some information about HIV infection. CHAIRMAN WALSH: Well, something similar to that, just tailored particularly to HIV. It doesn't have to be a booklet, just a sheet of paper because you've got about 200,000 physicians that ought to get them. That would at least put some 381 responsibility on both the traveler and the physician to advise them, which could help ameliorate the concern the Admiral expressed. CHAIRMAN WATKINS: I would certainly agree that we don't want any hit list. The question is, is there a hot line number to call and how well have we publicized that hot line number to people who are travelers that they could call and say, "I'd like to know a lot about the availability of health care in country xX". DR. HINMAN: That is not an area that we address at the Centers for Disease Control. Our information for international travelers primarily relates to infectious and communicable diseases. CHAIRMAN WATKINS: Is there a hotline in the State Department through the medical section that would be available? MR. WILLIAMS: There probably is in the Office of Overseas Citizen Services who can give some information about travel conditions abroad. It's within the Bureau of Consular Affairs. Their focus, however, would be more dramatic sorts of dangers. An epidemic they would be aware of, a revolution, civil disturbance, those sorts of things. We do issue travel advisories. As to the details of traveling in a foreign country, that would again be a pretty large undertaking to try to do very much with the information on all 160 countries. CHAIRMAN WATKINS: Suppose you had a situation where there was very high seropositivity which we know about in ceratin areas. Let's say it's a 25 percent figure in the urban population on an area that you're going to visit. Is that something you can tell or is it so sensitive politically that you can't deal with that kind of issue on the telephone with somebody? So, the question is, should there be a hotline that people could call and ask for that kind of information and get straightforward answers or is it too sensitive politically to do it? MR. WILLIAMS: I don't know whether it's too sensitive politically, but I really question whether or not the Department should be relied on for that kind of information. CHAIRMAN WATKINS: Well, who should be relied on for that information? MR. WILLIAMS: I agree with Dr. Walsh, the person's individual physician. 382 CHAIRMAN WATKINS: The personal physician then has access to the kind of information he needs? MR. WILLIAMS: I don't know whether that kind of information is really available as to the details of medical service in each place. CHAIRMAN WALSH: Well, I think that we also have to be extremely careful of what several of our witnesses mentioned on Monday, that the whole world is looking at the United States to see just what we're going to do about this type of thing. I do think, Admiral Watkins, it becomes very sensitive politically. Again, you don't want to put a burden like that, say, on WHO, but if WHO were to provide a piece of paper that they would send around that would be much less sensitive and which you could recopy and say, "This has been prepared by the World Health Organization as a caution to travelers or as advice to travelers." I think we do have to be careful in the United States of setting a pattern which might be construed as interfering with the crossing of borders or discouraging travel, particularly to those countries that are so totally dependent upon tourism. If you take the proportion of people, say, in Barbados that have AIDS, proportionately a greater degree of their population have HIV positivity than we have in the United States. Well, if we put out too many cautions on people going to Barbados, we'll destroy the economy of the entire country. CHAIRMAN WATKINS: Well, I don't want to lead you to any conclusions. I'm asking for answers. CHAIRMAN WALSH: No, I agree. I agree. CHAIRMAN WATKINS: If we're talking about hundreds of millions of people that are moving across borders and on the other hand we're talking about 85,000 here, we ought to get serious about disease control. In this discussion there might be a better venue. I'm just trying to get a conversation going here to say, "Yes, this is an area that perhaps there has to be a request for the World Health Organization to bring together a conference to address that issue". The United States has been very open regarding the HIV, probably as open as any nation in the world has been. We're ready to say, "What is the virus here, how you might get it. Yes, these are the things you've got to be very cautious about when coming to the United States." Why not? It seems to me if we have that kind of openness and we're more interested in the public health than we are in sensitivity to tourism, it seems to me that's not a bad position and you can find a balance between those two with the right organizations, up to be quite open in the kind of information that is transmitted. 383 DR. GOFF: I was very surprised to hear that somebody advised you not to travel to someplace because of AIDS. Did I misinterpret what you were saying? We don't think that there's anyplace that a person should not go because of AIDS. The disease is spread in the same fashion overseas as it's spread in the United States. The one wild card overseas, the one that you can't control as well as in the United States is the blood transfusion problem. That is an issue that people are taken with, but disease sperad to traveles from transfusion happens very, very infrequently. And as the World Health Organization program progresses and the infrastructure is created for more testing of blood, this small risk to gong to decrease even further. I think that we shouldn't build up walls around these countries based on false concerns. The Department of State has people living every place and we don't have a problem with them with AIDS unless they have engaged in high-risk behavior. CHAIRMAN WALSH: I think that the World Health Organization would be the first to tell you that the concern about particularly accidental injury or emergency surgery is great in many of that countries because that blood supply situation is not under control. There's no question that people have reduced their traveling because of the practices in many of these countries, are like we used to have 25 years ago where before they even opened the skin for surgery, blood was started. Many of these countries, that's the way they practice medicine today still. I think that's the reluctance and concern the Admiral is addressing. CHAIRMAN WATKINS: That is the focus. It's not the high-risk behavior. It's the available medical care in the countries. In many cases it's inadequate and they recognize that. CHAIRMAN WALSH: That's the concern. CHAIRMAN WATKINS: That seems to me to be of less political volatility than focusing on AIDS specific behavior overseas. CHAIRMAN WALSH: I have two people who want to address, I think, the same question. Kris? MRS. GEBBIE: I just have a comment as a follow-up to that. I do think we have to be careful keeping relative risks in proportion. It is really easy to grab onto certain risks which are relatively small and make them the basis of policy. 384 With this disease we seem to have an epidemic of people who feel obliged to answer any question that comes to then. Meaning if you answer the phone and somebody says, "I have a question about AIDS," people feel obliged to start answering it even if they're not the most appropriate one. This example may be one that all of us who are recipients of phone calls, and as a state health agency I often am, need to look at of how we are channeling those incoming requests for information to make certain our best available people are answering them. CHAIRMAN WALSH: Theresa, you wanted to comment on the same point? DR. CRENSHAW: Mine's a little elaborate, so I'll be glad to go to -- CHAIRMAN WALSH: This is not your question time, but you're free to comment on what the Admiral said. DR. CRENSHAW: Well, let me make a comment and then I'll come back to question time. I think the Admiral's comments on health information are absolutely critical. I'll preface my points with this. It's not a criticism but I think we're very young in thinking about and establishing policies and many are still inconsistent or incompletely thought through. When it comes to our health information that we give abroad, I think there are two areas that we really need to consider. One is the safety for the HIV infected person traveling to certain areas where they can pick up diseases that could kill them or severely jeopardize their health. Even gastroenteritis in some countries of organisms that they have not been exposed to, and I've seen very few articles on this, but I have seen a few, of good advice to the HIV positive traveler. I don't think this has been visited sufficiently or thought through enough. I think it's something very important. I think the other thing is that when it comes not only to the blood supply but countries that don't have disposable syringes and medical equipment, we're concerned about any medical procedure. It would be a very valuable service to think through how organizations can become better coordinated that deal with different parts of the elephant in this situation. In particular, although we'll be talking about this further on May 9th when we deal with inter-operative transfusion, I understand that 70 foreign countries have inter-operative transfusion capacity wherein many cases someone else's blood is not necessary. Even an enclosure in a travel kit such as the Admiral suggested on where this is available, even though I will grant you that it's probably the better developed countries where this risk is lower where this might be the case, could be of 385 incredible service and shouldn't engender terribly sensitive international issues. So, I do have a few other comments, but in relation to the Admiral's point, I think these are all very important and I see the hot potato being tossed. As a physician, recently in private practice, I can tell you that there's no place to call where a physician can get the information to give that advice for a patient, get it consistently and get good information today. If the federal government doesn't take the responsibility and the State Department doesn't take the responsibility and the military doesn't take the responsibility, while they all have pieces of the elephant that they can share, the military is very good at advising their military deployment troops. They have to know these things. Their PMU-7s and their infectious control units could be another source in addition to the World Health Organization, but we've got to have a pooling of this information. I'd like a suggestion from you on how that coordination can occur. Do we need a think tank? Is World Health enough? It seems to me the military needs to be involved, State Department and a lot of ordinarily disparate organizations that don't necessarily communicate with one another on a regular basis. DR. HINMAN: I'm still not entirely sure how much information you're describing that you want in one place. The problem the Admiral addressed is, in essence, a problem common to every developing country in the world. I think it's fair to say that if you're traveling outside of some of the countries of Europe or North America that one can expect to encounter non- disposable instruments and blood supply that one would not feel confident of and that one would advise not getting a transfusion unless you really had to in those countries. That's good advice anywhere. But to go so far as to say to have your appendix out prophylactically I think is not a very good bit of advice. I hope it wasn't anybody at CDC who suggested that. DR. CRENSHAW: You don't really know what the scope of information could be. What I'm saying is we need an expert body to deliberate and explore the issues, discount some, include others. What kind of body could this be or how can a network be created where these issues -- because this is beyond the scope, I think, of detail that the Commission is prepared to go into and we need an advisory council or society does or the travel industry. What body could do this? DR. HINMAN: Well, I'm having some difficulty with definition. If one brings together a large series of groups, 386 they're going to have different interests. The public health community is particularly concerned about communicable diseases and trying to ensure that there is not transmission of diseases. The medical care community might be interested in some slightly different piece of the overall health issue. The traveler may be more interested in whether my insurance will cover me in these countries. DR. CRENSHAW: That's exactly my point. That's why somebody needs to get these people together and to do some meaningful, practical processing. Perhaps you can give it some thought and get back to us in writing if you have any suggestions. DR. HINMAN: I would also point out, and you may have heard this already, but in March of 1987 the WHO did convene a consultation on international travel and HIV infection, the primary recommendation of which was that the routes of HIV transmission have been documented to be the same throughout the world. Therefore, the behaviors that put individuals at risk of acquiring HIV are similar world-wide. Preventive measures against HIV are also the same world-wide, regardless of whether the individual is a traveler or a resident of a given country. Educational materials should be made available for international travelers to increase awareness of how HIV is transmitted and how it can be prevented. This educational material should include specific preventive measures in clear, easily understood language. This involves a difficult balance since transmission of HIV is primarily sexual and therefore involves many social and cultural sensitivities. However, it is essential to discuss these sensitive issues openly to protect the international traveler. DR. CRENSHAW: Thank you. I think that's a start, but I think it needs more work. I concede here. CHAIRMAN WALSH: Burt? DR. LEE: Well, do you want me to-- CHAIRMAN WALSH: Anything. DR. LEE: Anything? Admiral Watkins seems to have pointed out that really the problem is that our borders are completely open, porous. When we talk about how scared Americans are about gong to , say, East Africa, I'm sure someone stands just as much chance of getting HIV from a prostitute outside a hotel in Nairobi as outside a hotel in New York City. 387 Let me ask just one question on the refugees. What is the State Department's overall policy on this? How are allowable number of refugees determined? MR. KRUMM: Well, Dr. Lee, I would just say you have to think about it in two different categories of human beings that are out there in refugee status. One is the refugees who are to be admitted to the United States as with immigrants. It's a different way to bring somebody as a permanent resident to the United States. So, for those 68,500, it came out that way this year. Next year it will probably be about the same. In times past, it's been as high as 200,000 people or so, 200,000 refugees who have come. But it varies according to the needs as we perceive them throughout the world. And for each of the refugees, however that number is arrived at, to be admitted to the United States, each of those individuals must pass an AIDS virus test. It's a mandatory test. If they don't take the test, they can't come, and if they don't pass the test, they can't come. Then you have to look at the refugees who are in what we call first asylum status. Twelve million or so is the figure that we record throughout the world right now. And it's growing, as a matter of fact. U.S. responsibility is to participate, along with the family of nations through the U.N. to care for them. But from the standpoint of testing them for AIDS, we don't recommend it and we don't -- I don't think there's any regime out there that at this time does it. I would say though, as I indicated in my testimony, we're very concerned about what happens if indeed there are indications of AIDS virus being discovered in refugee populations because the host governments have the opportunity to say, "Wait, what are we going to do about the refugees who are bringing this dread disease to our country," even if they didn't bring it. And at that point in time, it is conceivable they could push the refugees back. They could certainly do something to the individual. We're very concerned about what happens in the event becomes a problen. DR. LEE: I was interested in not just the AIDS thing but in general. We have a boat load of people that lands in Nova Scotia from Ceylon and the Canadians take them in. We have boats landing in Florida all the time from Haiti and various parts of the Caribbean. We just take them in. We're still trying to the Marielitos. MR. KRUMM: I would just indicate that for those nations which are adjacent to our shores, the Marielito situation was very difficult for us. As you know, many of these people were permitted to stay. The same applied to the Haitians that came during the Cuban/Haitian boat lift. We learned a lot from 388 that situation and there are procedures in place now for dealing with a repeat performance of the Mariel phenomenon. DR. LEE: It's a very interesting subject, but I'll pass. DR. PRIMM: I could not help but to sit here while you stole my thunder, Dr. Lee, in talking about the dangers as great in San Francisco and New York City and other cities in this nation as they would be in Kinshasa, Zaire probably. When we begin to talk that way, I think it's important to note that we have as much danger in this country, as Burt said, as going to other countries. I could only add in terms of comment that the kit that we're talking about people ought to take should include maybe two 500 ccs of glucose and water, maybe one bottle of pack cells, two units of dried whole blood, maybe 14, 18 gauge needles and some hypodermic needles and maybe two latex medium sized prophylactics or condoms and two dental dams. I think it's preposterous to begin to talk to our citizens about taking a kit to a foreign nation when it's just as dangerous in our own country. That's my comment about it. I think certainly this disease is transmitted by behaviors. We've got to tell people about behaviors, not only here but all over the world. And if we do that, I think we have done our jobs. DR. LEE: Could I add one other thing? To get you people off the hook, every university academic center has an international travel and information service. Where I am at Cornell, it's known world-wide. There's nothing that you can't find out from those people. And as far as I know, every university medical center has such a department. Is that not correct, Dr. Hinman? DR. HINMAN: I'm not sure that every university medical center has one -- DR. LEE: Every good one. DR. HINMAN: Or even that every good one does. But there are certainly a number of travel clinics around the country. There's also some commercial enterprise in providing information. There are computerized services that provide ona periodic basis, every two weeks for example, a health update for travel to which one can subscribe to. CHAIRMAN WALSH: I just want to comment though. I don't think that we're talking about wanting you to list certifiable prostitutes for us. The concern the Admiral expressed wasn't along those lines. He was expressing the ~ 389 concern on blood supply and needles which are the concern, not this business of whether you can catch STD in New York or San Francisco just as far as you can in Kinshasa. But nevertheless, I think it's the needle and blood supply thing that is the concern for the traveler, not the extra curricular activities. You may go. DR. SerVAAS: I wanted to answer Admiral Watkins! comment. I think it's a very legitimate need to have a place to call. I disagree with Dr. Walsh about your own doctor. Just from my own experience in Indiana, the state board of health and the doctors wouldn't know necessarily. But I commend the cDc. Purdue University gave me a weekend emergency number. I'd probably be dead if it weren't for that. And the CDC, the Admiral probably should have had his person call the CDC to find out what's going on in -- CHAIRMAN WATKINS: As a matter of fact, we did, and we got the same answer. To go in that particular area at that particular time, it was not wise unless you went in with specific provisions, which even in this book and the World Health Organization, I've been reading, it says, “Avoid injections unless absolutely necessary. But if you have to have one, make sure they're clean needles and syringes or things are boiled for 20 minutes." Well, if you've just been hit over the head and you're carried to the local general hospital, that's a difficult thing to do. I'm just trying to get the conversation going along these lines. DR. GOFF: How do you interpret that to somebody who asks you? It's something that can happen. If we use the Masters and Johnson analogy, it's theoretically possible, but I think that we have to draw a line as to what is reasonable medical advice to somebody. I'm not sure that we can really cover the situation of if you're hit on the head or if you're in a road accident other than to explain that the local blood facilities are inadequate. People have to decide for themselves what risks they want to run. CHAIRMAN WATKINS: But Peace Corps may be there. It may have 70 or 80 people in the particular area and know very well what to do under emergency medical conditions. They're sensitive to the local issues, they know exactly how to handle it. The question is if you ask that particular group to say in an area, "Yes, these are the practices we follow for the problem that might arise from a medical point of view, perhaps that kind of information is not that sensitive and it would be useful for others who might go into the area on a three months summer exchange program to do some voluntary work. 390 MR. WILLIAMS: Speaking to that point, if I may, Admiral, the information is there. The consular officer at post has it. He lives there in the town, he knows what's going on. He does provide a yearly report to the Department's medical office about who the doctors are in the town. He has a list of doctors, he has a list of hospitals. In that list he notes some of the major problems that are occurring in that country. That information is all available and it's all available through the Office of Overseas Citizens Services. Beyond going onto that point, we can do anything the taxpayer is willing to pay for. It would be an expensive operation to go farther than that to Approve the information and to get it disseminated. If there's money there, we can do it. That would be a question of whether anybody really has the financial will to do it. But yes, that information is around. If the question is dire enough, the best place to do it is to call the consular officer at the post. CHAIRMAN WATKINS: Well now, you've just given me the answer that I would have preferred to have gotten over the phone. "Here's the number of the consular office. Yes, they have the information. If your friend will be there for three months, they should call this number and they will send you the standard package that says this is what you should be aware of when you come into this region. It's perfectly open information." So, the question is, is there a need for some kind of a hotline along those lines for travelers that could call and you could provide them that information which seems to me to be much more valuable than to have a medical officer tell me on the phone, "No, you shouldn't go there for other reasons." MR. WILLIAMS: I would raise a caution on that as over- reliance on the information you get (and we have run into it with our travel advisories for other purposes) that if there is not a travel advisory, that's the Department's seal of approval to go there, which is not necessarily the case. There have also been the cases where travel agents have booked trips through areas where there were travel advisories and liabilities adhere to them for malpractice in their particular profession. I would hate to see that become where people were relying upon this as the final authority. "Yes, the government guarantees your well being. No, the government says that you ought not to go." Unhappily, in any of these information programs, they very quickly get to that point. The government says it's all right to go. 391 CHAIRMAN WALSH: We're a government of paper. What would be harmful about handing out that World Health bulletin to every passport applicant? That's a very simple sheet with very simple instructions. It's offensive to no one. MR. WILLIAMS: It can be done. It's one more element to the process that costs more money and that's a problem these days. CHAIRMAN WALSH: I understand that, but when you stop and think that we are giving World Health $15 million this year and we're going to probably give them at least that next year and probably more for the fight against AIDS. If we buy a few of these pamphlets from them at the same time, it's furthering the purpose for which we're giving them the $15 million which would be helpful to the average traveler and, as the Admiral says, get you off the hook very readily. I want to emphasize what the Admiral says, I don't have a day pass that I am not called either because of my work with Project HOPE or because of my work with the AIDS Commission, not a day passes that someone does not call me and ask the same question that they asked the Admiral. It happens to me every Single day that I'm in the office. It would be so simple to say, "When you get your passport they'll give you the instructions and so on." It's the type of thing that it may not be the most effective thing in the world. Some people will say it's cosmetic. But it gives some reassurance to people who are not knowledgeable or are not experienced travelers. That kind of thing is helpful. MR. WILLIAMS: I certainly will circulate your concerns within the Bureau, with the people who handle this. CHAIRMAN WALSH: I think it would be very easy. DR. HINMAN: I have a question, if I could just add to that. There is an attractiveness to the idea, but remember that passports are now valid for ten years. CHAIRMAN WALSH: Oh, I Know. I Know that. But at least that's the beginning for the new traveler. DR. HINMAN: Potentially. Another approach that has been considered with regard to other diseases has been through airlines or ticket issuing agencies. CHAIRMAN WALSH: Surely. Absolutely. DR. HINMAN: And this has been notably unsuccessful so far to my knowledge. They're in the business of selling tickets, not telling people not to go or not putting a damper on their enthusiasm for going. CHAIRMAN WALSH: That's right. DR. PRIMM: I have a question. CHAIRMAN WALSH: cCory's not finished yet, are you? Are you finished? Okay. DR. PRIMM: I had a question and that question is, why is the beginning age 15 for examination for HIV sero- positivity. DR. HINMAN: As for syphilis serology and tuberculosis chest x-ray. DR. PRIMM: Okay. What about for HIV antibody presence? Is it 15? DR. HINMAN: Yes. DR. PRIMM: The reason I mention that is because so many people are transfused for malaria, for sickle cell, for Cooley's, et cetera, and certainly could be infected. Have we taken that into consideration? DR. HINMAN: As I understand it, the regulations are such that if the visa issuing officer feels there is a reason to request the test, it can also be required of an individual less than 15 years of age. For example, the child of an HIV positive individual. DR. PRIMM: That to me would be important to have the age limit go it lower, not depending upon the officer's ability to deduce or detect or even be suspicious of infection. CHAIRMAN WALSH: Cory, do you have another question? DR. SerVAAS: On a different subject? CHAIRMAN WALSH: Yes, surely. Oh, absolutely. Anything you like. DR. SerVAAS: I was interested in Dr. Goff's comments about the testing program and all of the reasons for the vaccinations that you wouldn't give to the people who are HIV 393 antibody positive. I wondered if you could tell us some of those live virus vaccinations, that you don't give. DR. GOFF: I think that any type of immune stimulation theoretically could give these people problems. In the United States, we don't generally immunize adults on a routine basis. When we're assigning people overseas particularly to Third World locations, there's a whole battery of immunizations that are required. The data on the affect of vaccinations on an HIV positive person is very sparse. Much of the concern is really theoretical. There's one case from the military experience of an HIV infection that appeared to be stimulated into progression from small pox vaccination, which nobody uses, aside from the military. In theory, live virus vaccines are a greater risk than killed organism vaccines. But there's no specific information on this concern other than the general rubric of HIV positive patients avoiding any type of immune stimulation. It would be good advice to the group in general and we think that's good advice for our employees who are HIV positive as well. MR. HINMAN: I'd like to differ briefly, if I may, in that our Advisory Committee on Immunization Practices advises that individuals who are HIV positive should be immunized under the same recommendations and the same indications as individuals who are not HIV positive with the one exception that oral polio vaccine is not recommended generally because of concern that there is an immuno-compromised individual in the same household. But in terms of immunization of college students, for example, with measles, mumps and rubella vaccine which is an issue that comes up thousands of times a year in the United States, our recommendation is that HIV positive individuals, if they are not sick, should be vaccinated the same as non-HIV positive. DR. SerVAAS: Thank you. Dr. Hinman, I think you were the one who listed all of the infectious diseases that keep someone from immigrating here. Is there any work at the CDC that you are aware of, research, including HTLV-1, for people who are positive for it from the Orient or the Caribbean or countries where it's prevalent to keep it from coming into the U.S.? DR. HINMAN: I think that will be addressed when there is a test, a licensed test. There will be discussions as to whether it is warranted to add HTLV-1 positivity to the battery of tests required and to make that a condition of exclusion. I wouldn't want to opine on the subject right now. 394 DR. SerVAAS: Okay. The test, as far as you know, there is a good experimental test, it's just being held up at the FDA at the present time for licensing. Isn't that it? DR. HINMAN: Well, as a bureaucrat, I'd have to say that being held up at FDA often is because there's a reason and because things are being evaluated. So, I'm not sure I would necessarily draw the same inferences you may. DR. SerVAAS: I don't believe you had prostitutes on your list. Now that there's pretty good evidence about papilloma 16 and 18 virus that's also sexually transmitted and slowly causes cervical cancer, do you think about that in your list of things that we worry about bringing to our population? MR. WILLIAMS: Section 212(a)(12) of the Act prohibits issuance of visas to prostitutes. DR. SerVAAS: I didn't hear that. MR. WILLIAMS: I say there is a section of the Act that prohibits the issuance of visas to prostitutes. That's another provision. DR. SerVAAS: One more question for Dr. Goff. Dr. Goff, you made a comment. You have all these honors and a beautiful CV, but you made a comment and I'd respect your personal opinion about this. You said that you believed your testing program was important if there's a reason for it. I just wondered if you think prevention of spread isn't adequate reason for it. DR. GOFF: You bet. DR. SerVAAS: And then, do you personally feel that more voluntary testing in this country, do you have any ideas on how that could be accomplished since you seem to feel that there's a reason for testing to prevent spread? DR. GOFF: I think that our handling of AIDS is at a crossroads and that the epidemic of HIV infection has been at this crossroads for several years now. We've known, quite certainly, for three or four years, how the disease is spread. We've had a means of identifying people who are HIV positive available, but have paused to try and decide the correct use of this test. I believe that we must, at some point, mainstream the approach to this disease. Thus far we have limited diagnosis and we have been reluctant to encourage people to be tested because of the consequences to then. 395 I think that one of the things that you can do in the Presidential Commission is to recommend that the government approach the reasons why people are reluctant to be tested. I think the statements regarding the issues of job security, and providing assurance that people will continue to have access to health care if they're HIV positive will go a long way to easing people's minds if they're in a risk group and are considering being tested. I would hope that you will come out of the Commission hearings with a strong recommendation in those areas, in addition to continued maintenance of confidentiality of people who are tested. I believe that testing procedure is The confirmatory tests are also accurate and definitive. The issue of false positives is a troubling concern, but I think that if people talk to patients, if they listen to patients, one can sort out whether a person's false positive or truely positive and arrange for the necessary follow-up tests. So, I think the approach should be to make wider use of testing, and that testing should be done in the context of job security, continued health care and confidentiality. Thank you. DR. SerVAAS: Thank you. CHAIRMAN WALSH: Mrs. Gebbie? MRS. GEBBIE: Let me change gears here. My first question or set of questions is directed primarily at Mr. Krumn, although Dr. Hinman may want to help with the answer. It deals with the rationale for the exclusion of refugees and the fact that although you have a provision for voiding it, you said very bluntly you really don't think you're going to let in refugees who are HIV positive. A fair number of people around the country have asked questions about that. Based on the relatively small number of people we're talking about, the total impact on HIV infection in the United States of letting in any HIV positive refugee who came down the road probably would not be measurable, at least in the short-term, in many people's minds. There's also a related almost false sense of we only let in healthy refugees when in several cases you let them in temporarily healthy. There's no guarantee that they will not get active TB at some future point after they're in or that they will not get a second case of gonorrhea after they come into the country. I don't think we screen for smokers, so there's no guarantee they aren't going to have lung cancer after they're here awhile. Would you please elaborate a bit more on why that great reluctance for a group that we're already trying to be compassionate to, to use the exclusion and allow them in? 396 MR. KRUMM: Well, those are good comments. I would just say that during the debate of the notice of proposed rulemaking, that was brought out. It was brought out very, very strongly. I'm not a doctor myself, but it was suggested that if you took the refugees, whom w expect will demonstrate a small incidence of AIDS virus positivity and brought them to the United States, we'd actually improve the statistics of the United States by diluting the incidence throughout the entire population. But I would just say that it was a government initiative that was advanced here by the Department of Health and Human Services and it was a determination made across the government that indeed we were looking to try to do our part in terms of immigrants and refugees that come into this country, our part to try to be as responsive to the problem of AIDS as possible. This is the way the rule turned out. On the medical side of things, I'd have to defer to Dr. Hinman. MRS. GEBBIE: Although you yourself point out that it may be a very uncompassionate answer given what it does to their status in the rest of the world as a refugee. MR. KRUMM: Oh, absolutely. No question about it. I think my testimony stated we're concerned about that. Not even so much just for that individual and his or her family, but we were also concerned that the very incidence of that test, of a mandatory test required by the United States government, what that does in terms of the information being out there throughout the foreign community and foreign governments, if you will, and the implications for first asylum populations. MRS. GEBBIE: Is our policy on refugees typical of all countries receiving refugees for permanent relocation or is that relatively unusual? MR. KRUMM: I'm not sure of other countries having requirements to test for AIDS. I think Australia does, if I'm not mistaken. I'm not sure about Canada. But in terms of actual testing for refugees and/or immigration, I'm not sure. Somebody else would have to try to answer this. I think we're unique in this regard. But then again, you must understand that we bring into the United States approximately two of every three refugees who are actually admitted to a third country. MRS. GEBBIE: So, we may be setting a standard for treatment of refugees by what we are doing? MR. KRUMM: That's indeed possible, yes. MRS. GEBBIE: We have had some testimony earlier, I think Dr. Mann in his testimony pointed out a great concern for 397 international discussions in order that AIDS might not be more politicized than it is. Have you been involved with any discussions of this refugee admission issue in that international health arena? MR. KRUMM: No, other than to work with the U.N. high commissioner for refugees which has promulgated their requirements or recommendations for what to do. MRS. GEBBIE: Have we gotten feedback from that high commissioner on what the commissioner thinks of our policy? MR. KRUMM: I think just what one hears when this is discussed, that there is a lot of skepticism by professional health people who question whether or not what we are doing here as a matter of regulation actually has a good medical basis. There is, as well, a great deal of skepticism about whether or not U.S. required testing for the HIV really is a good solid compassionate response, particularly because of the potentially threat posed to first asylum populations. MRS. GEBBIE: Based on that, is there any serious reevaluation or scheduled reevaluation of that policy? MR. KRUMM: We've just gotten started. It's four months old. I think that we're -- this is Don Krumm speaking personally, as you've encouraged us to do. I would think that if indeed we get down the line three, perhaps four years, and we have statistics on the incidence of AIDS that occur in refugee population, that if indeed we got down the line three or four years and found that the incidence was negligible, then I would hope that somehow there would be a mechanism within our government that would assess that, look at it and suggest that it be revoked. After all, we are in budget tight times. For immigrants, they all pay for their own HIV tests, for the entire regime of tests they under. For refugees, the taxpayers of America pay for each of those tests. MRS. GEBBIE: My other area of questioning, this has to do with the State Department policy in general on testing the work force. This is the second work force we've heard from today. We heard from the Department of Defense earlier, which screens all of its workers and makes job assignments based on those decisions. Most of us in public health have spent a good deal of the last several years explaining to employers all across the country how HIV is not relevant to the employment situation as far as screening workers coming onto the job or as far as what goes on in the workplace. 398 You must have encountered questions about that and have in hand some answers that make very clear why your work place is extremely different or maybe isn't and should be the model for every single work place. I'm not sure what we do with people who then can't work for anybody. So, I'd appreciate some discussion from you of how you answer that question. DR. GOFF: As I mentioned, in our work place overseas in many locations we have no health care facilities. People who are HIV positive would not be able to get adequate care. Since we feel that people who are HIV positive should have access to care, we limit their assignment to places where they are able to get such care. Also, we have the problem of the repeated immune stimulation they undergo when they acquire a variety of infectious disorders as well as their require vaccinations. I beg to differ with my colleague from the CDC. We can't find an infectious disease specialist in Washington, D.C., for example, who will give an HIV positive patient yellow fever vaccine. This vaccination is ordinarily not reqired in the United States but is necessary for travel throughout Africa and parts of Latin America. Knowing a person's HIV status enables us to assign an HIV positive person to a location where he/or she can get care and where they won't suffer immune stiumlation from infectious diseases and vaccinations. other problems. A further issue is pre-employment testing and the Department policy not to hire people who are HIV positive. The Department also will not hire people who have significant other illnesses such as diabetes, heart disease, who've had a recent history of cancer. What we essentially have done with HIV infection, is treat it like all the other illnesses. HIV positive patients all maintain their careers. They all continue to work. Their assignments are limited, but they continue to work and have all benefits. I'm not sure if that answers your question. MRS. GEBBIE: Well, it does partially, but now I have a new one. I just didn't know this before that were I a diabetic and seeking to be a secretary in your Washington office, I would be declined on the basis of health? DR. GOFF: We don't do any testing of people who are in the United States. In other words, a Department of State employee who is not required to travel overseas and live and work overseas, there's no question of testing. That's not an issue. The HIV policy is limited to foreign service people who are assigned to live and work overseas. 399 MRS. GEBBIE: You must have said that at the very beginning and I missed that. I thought you were applying that to all of your employees. Thank you for that clarification. CHAIRMAN WALSH: Dr. Crenshaw? DR. CRENSHAW: Thank you. I would like to ask Mr. Williams if he would provide for us in writing approximate estimates of the cost he was talking about that would be involved in collecting and disseminating the kind of information we've all been discussing for travelers, business people and tourists. And perhaps as well what would be involved in a joint conference in the United States drawing on among others the blood banking industry, military, State Department and Public Health Department. I want to raise some questions that could be addressed in suh a meeting or travel brochure. Obviously some of these topics would be more suitable for one than the other. I don't think you necessarily have answers for these, but you're welcome to try a shot at any of them if you like. Recently you've heard alluded to and you've dealt with Cuba sending their most serious criminals to the United States and like a sieve they were absorbed. We had a very difficult time dealing with it. They're now quarantining HIV positive people. And based on their previous experience, what are you going to do if they put them all on a boat and send them to Florida? It could happen. I wonder if we're prepared to deal with it one way or the other. I'm not recommending a policy for or against. I don't think these are just hypothetical questions. I think they're real and I think that we ought to be giving some thoughtful consideration to these kind of possibilities. Now, I don't know the answer to this question, but in the other diseases that we forbid to enter as immigrants to the United States, like TB. I'm not noticing tourists coming in from foreign countries in relation to these diseases having to carry a yellow card on all of the ones that we're alluding to. So, we've got inconsistent policies, not just with regard to HIV infection and immigration versus tourism and business travel. It seems to me we haven't dealt with these inconsistencies. In some respects, if we're really considering the medical issues, we either ought to toss out the restrictions on immigration or get a little stronger on the issues of the other modes of contagiousness for TB and other diseases. Which way we go I think needs to be deliberated and there are many people who hold very strong views on both sides of the issue. 400 MR. WILLIAMS: Let me speak to that point before we go on. DR. CRENSHAW: Okay. MR. WILLIAMS: I think it was Dr. Primm who was discussing the nature of our borders and they're terribly porous. A country like ours simply can't quarantine ourselves on any grounds. Now, on the grounds of ineligibility which we've discussed, the medical are the first six. There are 34 grounds of ineligibility for a visa. They go anywhere from, as I've mentioned, prostitution, a criminal record, to security grounds. But we can't quarantine the border. All we can do is screen out the most egregious cases as much as we can. Now, where the visa function works, it works pretty well. We don't have large numbers of undocumented aliens from visa countries. Where you have the problems is our huge land borders. Perhaps the only way we could really quarantine ourselves would be with the 82nd Airborne and I don't think we're ready to do. So, in any of our 212 ineligibilities, we're doing our best to screen it out. We'll never be able to quarantine it and still maintain the kind of open society we want because we do have, on the other hand, certain obligations under the Helsinki Accords where we, along with other countries, are trying to facilitate travel and tourism, one country to the next. In fact, the tide in many respects is running the other Way as we are now contemplating a visa waiver program for certain countries. It will lessen our ability to screen rather than increase it. This was the will of Congress in this matter and we trust they are reflecting the will of the country. But really, the world is becoming more interdependent and the hope of quarantine is fading rapidly. DR. CRENSHAW: You've exactly made my point. That is that it seems to me that this immigration issue is cosmetic and we ought to do something either meaningful or not act as though we're doing something meaningful when we're not. MR. WILLIAMS: And that point is under discussion. There is a bill in Congress at the moment dealing with that point. If you want to discuss the particular aspects of the health things, I would shift it again to the right because health is HHS, not ours. But they are debating that. It is a matter of national debate at the moment. DR. CRENSHAW: Okay. There are another few questions I just want to toss out that fall along the list of things that I think need careful consideration. I don't have the answers. I 401 haven't drawn my own conclusions of these. But I don't find a lot of resources around that have given it sufficient thought to have firm ideas either. You've heard from members of the panel and probably lots of other places that we're being called the exporters of AIDS. Some other governments are closing their borders to HIV positives. But I think there are more forms of discrimination against Americans, all the way from the baths in Japan where they aren't letting caucasians in anymore, to prejudice and exclusion and tourists being less welcome than we've been in the past. We've seen this happen due to political positions and attitudes toward the United States. Now we're seeing it happen, I think, abroad based on a disease. Many American tourists have changed their travel patterns according to concerns that they have about AIDS in other countries. So I think it also cuts both ways. I haven't heard the issue other than in relation to shared needles and transfusion rates in terms of health tourism. You read about, inNewsweek, people traveling to Amsterdam where euthanasia is legal. People are also traveling to Amsterdam because free needles are available and they have a liberal illegal drug policy. Drugs are not illegal there. But there are other health tourism issues that I think are equally important. People are traveling to France because that's a place that has a very strong, good reputation for terrific medical care for HIV positive people and research programs and drugs for HIV infection being available and legal that are not available in the United States. This is just scratching the surface of the kind of health tourism issues that I can think of, including a migration toward countries where there are better health facilities and where there is socialized medicine and freer health facilities and away from countries that don't take good care of their patients. . Then I'd touch on the economic impact and why I think it's so terribly important that we be ahead of this rather than behind it because there are countries that could go bankrupt as the result of some panic or a trend or an inadequate response or inadequate foresight. I think there are very serious issues and I'm sure you would agree with me. So I don't think they can be responded to in the crisis fashion that would otherwise occur. I also think that with the State Department, at least I've heard rumors and you can correct me if I'm wrong, that there are certain countries that employees don't want to go to anymore because they're concerned and they also have some pressure from foreign countries the same way the military did about concern 402 about having our embassies there. I haven't heard that this is in any major proportions, but I think it could become significant if we don't deal with those issues. Lastly, but not leastly, I think the most ignored issue of all is sexual tourism. We all know about it. The patient zero syndrome has been described. Oceana, Brazil, Scandinavia, just to name a few, are examples, are really serious centers for transmission of all forms of sexually transmitted diseases. We acknowledge it and there is no dealing with it. I don't have the answers myself, but I think that putting good minds together and adding your own questions and processing this in an integrated way is really pretty critical. I'd just like your feedback. I know I gave you a lot to think about, but there's probably a great deal more I haven't even thought of. CHAIRMAN WALSH: I don't know if that was a dissertation or a request for answers. DR. CRENSHAW: It was both. MR. LOCKWOOD: Mr. Chairman, if I could just make a comment, it gives me an opportunity to say a couple of things that I wanted to say. CHAIRMAN WALSH: Fine. MR. LOCKWOOD: The motivations that people have to travel or not to travel are manifold. Even within our own community of foreign service officers, those motivations run the spectrum. You left out exchange rates, by the way. They can leave a lot of people home too. DR. CRENSHAW: Exactly, yes. MR. LOCKWOOD: So, it's all across the waterfront without question. I can only agree with what you are saying. But what I would like to comment on, you've asked for recommendations and I would underline that these are my personal thoughts on the matter from where I sit. I think that three things could be important. Number one, it's absolutely essential that the United States as a government and as a nation continue to lend active, enthusiastic resources and support to the global program. And within the global program, I mean across the board in a large sense of the term and specifically the global program on AIDS of the WHO. By the way, as Dr. Walsh well knows, the issue of blood supply and sterile needles is right at the very top of their list of things to do and also within our own A.I.D. So, continued, sustained support is, to my mind, critical. 403 Secondly, I think that it's important on this testing issue, and I have stayed out of the discussion of all the ins and outs, but I hearken back to Dr. Mann on Monday when he, through the group that they established in WHO to look at that issue, used the words testing of visitors or travelers, temporary travelers, that to do that would be totally "ineffective and inefficient," and I couldn't agree more. I think that if this panel were to come to such a conclusion and to say that it would not be efficacious, now I'm speaking globally, for the nations to get into the business of testing that category of travelers, that that would be an excellent step to take. Thirdly, and this goes right to my concerns about how do we measure how serious it's going to be in a given country, we still don't have a good handle on that. That's a shortcoming that troubles us greatly. I think it would be an excellent step to take to give even increased priority and resources to the efforts that are underway. You heard from the Bureau of Census about the modeling and data exercise and that is a very important step which we are trying to lend some support to also. We don't have money to throw at it, but we're lending a lot of support. But to place priority on our ability to make projections on the impact of AIDS in other countries, we think would be of great help. So, I would suggest those three things. Also, if you could help out my travel budget, I'd be most grateful. DR. HINMAN: I would add that I think the issue of testing all travelers coming to the United States, which we haven't really discussed in any detail, is one which would be ineffective and inefficient and also expensive. Just try to imagine having to wait an additional two hours at JFK because people were being tested on arrival. There are about nine million foreign travelers arriving in the U.S. at airports each year. Our rough estimate of what it would cost to test them is about $60 million and perhaps 900 of these people might be positive. The retaliation in other countries, or the potential for it, I think is great. With regard to Cuba, Cuba and the United States are normalizing their relations as far as immigration is concerned. Persons coming from Cuba with resident visas in the United States will be tested in Cuba and found negative before they are issued a visa. Finally, I would urge continued discussion of the advisability of testing of persons coming to the United States and whether the benefits are worth the costs, both financial and non-financial. CHAIRMAN WALSH: That's for permanent immigration you mean? 404 DR. HINMAN: That's correct. CHAIRMAN WALSH: Yes. Okay. Any other comments? If not, I express on behalf of the Commission again our gratitude to you for all the time that you've taken and also again for the candor with which you expressed your views. I think this will be most helpful to us in preparing our recommendations. We will reconvene this afternoon at 1:30. (Whereupon, at 1:09 p.m., the above-entitled matter was adjourned, to reconvene this same day.) A-F-T-E-R-N-0-O-N S-E-S-S-I-O-N 1:49 p.m. CHAIRMAN WALSH: This will be the final session of our three day meeting, and to follow an old cliche we trust that the last shall be best. We have had three days of productive and stimulating discussion, and because of the great incidence of AIDS identified as being associated with IV drug abuse it seemed important that we have this one session on international drug trafficking. We've had many sessions, that discussed behavioral change, all sorts of things, and wonderful dreams that we have about lessening demand, but only you can help us with the supply situation. I think that we can only benefit from hearing your story. I know we've heard you, Mr. Burke, before. We can only benefit from hearing it again and again, so that when we make our recommendations to the President they are sound and they will be listened to. So, I think we will start this afternoon's session with Rear Admiral Clyde Robbins, Chief of Operations in the United States Coast Guard. Admiral Robbins? ADMIRAL ROBBINS: Thank you, Doctor. I will be brief, but I would like to go over some areas where we put our greatest emphasis. Of course, it's primarily on interdiction. It's my pleasure to appear before you today to address this subject. Captain Trainor, I think, addressed you last week and I would like to build somewhat on his comments and discuss more fully the interdiction role that we have, particularly in the maritime surface interdiction and in the air interdiction. The Coast Guard employs a three tier maritime interdiction strategy that involves conducting operations in what we call a departure zone, and in the transit zone, and in the 405 arrival zone. As you may guess, the departure zone is that area near the coast of the foreign country where the vessels start their trip northward for the most part in the Caribbean. The transit zone is, of course the next zone and the one that's the no-man's area in between. And then, we go to the departure zone, which is close to our own shores. Activities in the departure zone include random pulsed operations, and we use both Coast Guard vessels and Navy vessels for this. They are normally under the direction of a Coast Guard squadron commander. The departure zones are deep in the Caribbean on the east coast, close to the transshipment countries where we can seize the larger boat loads before they are off- loaded to smaller, faster contact boats. If we can get them early-on as they depart the countries, naturally it's a lot easier. On the East Coast, the transit zone is helped by having natural choke points in the Yucatan Channel between Cuba and Mexico, the Windward Passage between Cuba and Haiti, the Mona Passage between Puerto Rico and the Dominican Republic, and over to the East is the Anegada Passage between the Virgin Islands and the Leeward Islands of the Caribbean. We station cutters in those choke points. We augment those cutters with helicopters, and sea-based aerostats, which we use for surveillance trying to cut down the traffic as it comes through those areas. Another area of specific interest to us in the last few years has been the area surrounding the Bahamas. Because it's so close to the United States, it's a natural location to make drops from aircraft to boats which come into the United States. There's about 700 of those islands, so it's easy to make drops onto those islands and into the waters nearby and have pick-up boats bring narcotics into the United States. We carry Bahamian officials on our boats and in our aircraft to help with that operation. And finally, the arrival zone is the biggest challenge. Because once they've gotten through those choke points and gotten closer to the United States, the mother ships provide smaller boats with loads of contraband to bring it in. It's a tougher problem to stop. We work very closely with Customs in coordinating our forces to ensure that we, to the maximum extent possible, shut off that flow. As you know, the coast of the United States is large and it's difficult to intercept all the illegal drug traffic... In the Pacific area, we have a difficult problem - because there are no choke points. We get illegal naracotics from Thailand. The Philippines have become a supplier. We occasionally catch a large ship or boat coming in from those areas. 406 In air interdiction, we share the responsibilities with Customs. Our targets are usually low, slow-flying aircraft. They're general aviation usually. We use E-2Cs that we have on | loan from the Navy. We use land-based Aerostats. We use the Customs P-3s. We use just about anything we can. We have the help of DOD to a great extent, using their E-3s and other forces that they loan to us to provide us detection and to help in intercepting the in-bound smugglers. We are presently outfitting nine of our HU-25 Falcon jets with sophisticated electronic equipment. When I say, "we," the Air Force is doing it for us and have been doing a very good job. We took delivery on the 15th of April in Miam of the first of the interceptors. They will be a big help in the intercept problem. They will join Customs interceptors in providing better equipment to do the job. The Coast Guard, Army and Air Force have apprehension resources in the Bahamas. They carry, Behamian drug enforcement officials, who conduct the actual apprehensions. There's a lot of cooperation between and among the various agencies: Customs, DEA, FBI, INS, Border Patrol, Marshall Service, DOD and Coast Guard. Everybody is working together. There's always room for improvement, but I think we're making a dent. I was just saying before this meeting that one of the things we've noticed is the surface transportation of drugs seems to be dropping off. We seem to be becoming more effective on the surface, and I think this is because we've had a concerted, well coordinated effort there. We are new in air interdiction and just developing our program. As we push one type of transportation, druggies shift to another. So, we still have a long ways to go. We have very good cooperation with many of the countries in the South. It's not always as good as it should be or could be, but we're working very closely with Venezuela, Honduras, Colombia, Costa Rica, Jamaica, Grenada, and the Bahamas. The working relationship has improved considerably during my nearly three years on the job. We see a great deal of the drug movement in hidden compartments as the druggies try in every way possible to thwart our efforts I think we'll continue to see change as our efforts become effective. We have some new resources in the Coast Guard. We will have a total of about 37, 110 foot cutters which are going to be very valuable to us in this effort. We will be getting more land-based Aerostats and sea-based Aerostats. Our objective is to continue to create a degree of risk for the 407 traffickers high enough to force them into another business. We have a long ways to go, but I think that we're headed in the right direction. I'd be happy to answer any questions you have. Thank you. CHAIRMAN WATKINS: Thank you, Admiral Robbins. Mr. Terrence Burke, Deputy Assistant Administrator, Office of Diversion Control, Drug Enforcement Administration, next please. MR. BURKE: I am the Deputy Assistant Administrator for Operations, just for the record, sir. I am here -- we were planning on Mr. Gene Haislip representing us today, but my trip to England was canceled so I had the opportunity to come back. I'll keep my remarks brief. I think you heard a number of my comments in your previous hearing. I appreciate this opportunity. From the tone of the previous hearing and discussions with members of your Commission, I would like to say that I would hope that I could leave today on somewhat of an optimistic note. What I'd like to do is tell you that there are some programs that are working, despite all of the problems. I just came from the Senate Appropriations Committee hearings, where Attorney General Meese testified before many of the senators who expressed very serious reservations about where we're going on this entire problem. The Attorney General was upbeat as he had just returned from Latin America where he has received commitments from several presidents of those countries, very serious commitments as to what they're willing to do and not willing to do. I think Mr. Van Wert is going to address the issue of the eradication in Peru. But, I'd like to just give you some facts. As I mentioned before, DEA has an initiative with the cooperation of the State Department, U.S. Border Patrol, and the Department of Defense, in Latin America right now. That initiative has been receiving additional publicity through the Attorney Generals visit. There have been more press reports about it, so I am not really giving up any secrets here. What we have been doing over the period of one year now is working throughout a number of Latin American and Central American countries on a strategy that was developed in concert with the State Department and Defense Department over a year ago. The idea is to strike at the source. The results of this are beginning to become known to us and beginning to have an impact. We've had to train a lot of agents to go down and work in very hostile geographic locations. Your other speaker this afternoon, Lieutenant General Olmstead and I went together down 408 there just a few months ago and observed the hardships that our people are having to put up with. But in one year, destruction of maceration pits, which are the basic processing vehicle for the conversion of the coca leaf into coca paste, the first step, in the past year we have destroyed approximately 2,500 maceration pits along with the local forces in Bolivia alone. During just the past three months, we've destroyed over 800 of these. What does this represent? Just the 800 alone in the past three months would represent four metric tons of cocaine hydrochloride if that paste had been allowed to go through its whole process. We're talking about a very small group of people. We're talking about maybe 25 to 30 agents having been involved in this operation over a year. What they with their local counterparts have been able to do in one year is destroy over 1l metric tons -- excuse me, destroy the paste and so forth which represents 11 metric tons of cocaine hydrochloride which would otherwise have reached our streets if that had not been intercepted. I think that that is a good first sign that we are able to do something about the supply. It's going to take a lot more effort. I will close my remarks by saying that in my 17 years of working in drug law enforcement, if it is one thing that has been a frustration, it's been our lack of consistency in the drug effort and the drug war. I listened this morning to the testimony when the senators were asking, "Well, we've increased your resources by X amount over the past two years. Why aren't we seeing faster results?" Well, you don't take a garden or a lawn and neglect it for years and years and maybe throw a little water on it now and then and maybe a little fertilizer and expect to have a rolling green turf out there in front of your house. It's something that has to be cared and nurtured for a longer period of time than that. The entire drug effort has been very erratic over the last ten, or in my experience in the last 17 years. You can't throw your Coast Guard into these operations and then cut their budget and leave their boats sitting at the docks in Florida. We can't start up an effort and have increased public pressure and have the media blitz and have all the politicians just three or four or five months before an election get on the band wagon and join it and then have that interest slacken off immediately after the elections. We need to sustain both public effort, the education effort, the treatment effort, and the interdiction and enforcement effort over a much longer period of time than I think most people envisage right now in order to get a real grip on this problem. Thank you. 409 CHAIRMAN WATKINS: Thank you, Mr. Burke. Mr. Clark Settles, Acting Director, Smuggling Investigation Division, U.S. Customs Service. MR. SETTLES: Thank you, sir. It's an honor to be hear today to present testimony for Commissioner von Raab. The United States Customs Service is the lead agency in our county's relentless efforts to keep illegal drugs from crossing our borders. Cocaine and heroin are not grown or even produced in the United States. They are imported. Yet, these foreign drugs are the cause for much of the crime in our nation's cities. We all know that drugs corrupt, drugs dehumanize, and drugs kill. Through the transmission of the HIV by intravenous drug users, the threat of death is multiplied significantly. Our struggle against drug abuse and drug trafficking is a struggle of good versus evil and of life and death. The Customs Service is combining its resources with other federal agencies as well as state and local law enforcement agencies to mount a united front against drug smugglers on our borders. We have created new organizations and new approaches, and with our counterparts we are standing together as never before in an effort to defeat our common enemy. Numerous federal agency squabbles have been put to rest. The federal drug enforcement budgets have mushroomed, and the federal government has worked hard to make Americans of all ages increasingly aware of the personal risk involved in taking drugs. I'm here to tell you that progress has been made, as has been echoed by the two previous speakers. Five years ago, the budget of the United States Customs Service was around $400 million. Our budget is now up to over one billion dollars. on the southwest border we have spent a quarter of a billion dollars of federal monies which have been funded to secure it against the threat from Mexico. This is done with the latest in high tech radars and aircraft. To combat this increasing narcotics threat from Mexico, Operation Alliance was initiated on the southwest border. Drug seizures on the southwest border have increased dramatically as a result of the cooperative efforts of federal, state, and local law enforcement agencies involved in Operation Alliance. So far in the first part of 1988, we've seized approximately 25 kilos of heroin and over 3,000 kilos of cocaine on the southwest border. Despite better cooperation among federal agencies, new funding, and new resources, we still have serious holes in our national drug defense. It has become apparent that the best use of federal government energies and resources is to support joint enforcement of state and local law enforcement agencies. Local law enforcement officers are the primary defense of any American community against crime. 410 We also at this time have three multi-million dollar computerized command centers that have been built to support our blue lightning strike forces. These joint efforts involve Customs, Coast Guard, and state and local agencies along the coast of Florida and through the Gulf of Mexico. Customs officers have been placed on local law enforcement boats to give broader search powers to the state and local units patrolling the coastal waters. In addition, hundreds of local police officers have been trained and cross-designated as Customs officers to exercise the much broader Customs search authority. As part of the agreement in all of these joint interdiction efforts, the state and local enforcement agencies involved in drug interdiction are allowed to retain most of the assets for themselves. Millions of dollars worth of currency and assets have been turned over to state and local agencies by the Customs Service in the last three years. The goal of these joint border efforts is to draw on the particular strengths of each agency and mold these strengths into a single powerful unit against drug trafficking. Another innovative program being utilized by Customs is the Civil Air Patrol. The Civil Air Patrol pilots fly spotting missions for Customs off the coasts and in the mountains. They're looking for fast boats, mother ships, and remote landing spots that smugglers might use. The Civil Air Patrol is proving to be an extremely valuable asset to our anti-smuggling progran. We have also turned to the public at large for assistance in our anti-smuggling efforts. Any citizen can now report what they believe to be drug smuggling by calling a toll free hot line number. The caller remains anonymous and if the information results in a seizure they can be paid up to $2,500. It has been our experience that most of the calls that we get the people do not want money. They're just trying to help us on the war on drugs. The U.S. Customs Service and our federal, state, and international counterparts are in the process of implementing a narcotics strategy that is international in scope. This strategy aggressively attacks the narcotics smuggling threat and focuses on detecting, identifying, and intercepting shipments of illegal drugs as they move from the departure zone in source counties along smuggling routes into our nation's land, air, and sea borders. At the forefront of this effort, the United States Customs Service as one of the lead agencies for federal interdiction efforts has jointly developed, along with Coast Guard, DEA, INS, NNBIS, and the Department of Defense and other federal enforcement counterparts, a comprehensive interdiction strategy. 411 This strategy seeks to disrupt the flow of narcotics into the United States by attacking the transportation link between narcotics supply and demand. This strategy is fluid and capable of responding to changes in smuggling methods and trends as they occur. We feel that this narcotics interdiction strategy is by far the most concentrated multifaceted effort that the United States has so far put forward in its war on drugs. The national interdiction strategy compliments the demand side of narcotics reduction efforts. These efforts consisting of intelligence, investigations, prosecutions, international drug control and interdiction, are dependent on one another and taken together offer a concerted supply reduction effort. Customs has initiated several programs recently which in addition to supply reduction will have a major effect on demand reduction. The zero tolerance program which was initiated by Customs in San Diego in 1986, with the concurrence of the U.S. Attorney's Office, prosecutes every individual who smuggles any traceable amounts of personal use narcotics into the United States. The individuals are arrested, given a notice to appear, and are charged with a combination of a felony importation count and a misdemeanor possession count. If the violator pleads guilty to the misdemeanor, the government will usually drop the felony count and the magistrate will grant deferred prosecution. The violator's record is wiped clean if he stays out of trouble for a year. We've found that about 99 percent of those arrested have plead guilty to these misdemeanor charges. Due to the success of the zero tolerance program in San Diego, on March 25th of this year Customs initiated this program nationwide. The March 25th mandate by the Commissioner directed Customs officers to arrest all narcotics violators regardless of the amount and size and to seize their travel documents. The various offices are presently coordinating with the U.S. Attorney's Offices to gain their support for the program nationwide. Not only are the violators arrested, but the Customs Service is also seizing their conveyances. Notwithstanding these sanctions, if the individual's vehicle and conveyance are found to contain drug paraphernalia, they are also seized. The zero tolerance program seeks to get occasional or moderate drug users to kick the habit by increasing the likelihood of some kind of penalty. The goal is, if people know they will be arrested for bringing a gram of cocaine or heroininto this country, they'll think twice. Although the zero tolerance program does not significantly reduce the amount of narcotics entering the 412 country, it does penalize the user who has been identified as one of the high risk groups for transmission of the AIDS virus. Although cocaine in the form of crack has become a major problem among drug users, heroin continues to be the drug of choice among intravenous drug abusers. There has been a significant increase in heroin seizures by the Customs Service in the last several months. In the first few months of 1988, seizures of heroin are 34 percent ahead of last year, and so far we've seized approximately 460 pounds of heroin in this country this year. On April 15th, 1988, the Customs Service did initiate its national paraphernalia interdiction program for enforcement whereby all our offices throughout the country will mount a concerted attack on the importation, exportation, manufacturing, and distribution of illegal drug paraphernalia. Working closely with state, local, and other federal agencies, Customs Commercial Fraud Units will develop intelligence on firms and individuals involved with drug paraphernalia and take appropriate enforcement action. What the Customs Service and the other federal agencies involved in interdiction efforts strive for is a reduction in narcotics availability. However, this effort alone cannot significantly ameliorate the deteriorating cancer that narcotics abuse imposes on our society. Realizing this, the National Drug Policy Board's drug strategy offers not only a balanced, coordinated attack on the reduction of narcotics supply, but also a similar assault on reducing the demand for those narcotics. The demand side programs are viewed by Customs as equally essential to the long- term success of our narcotics abuse program. Not only will we limit the availability of narcotics by our supply side effort, but we also attempt to decrease the demand for illicit substances. This collective strategy confronts the narcotics problem head on and is without dispute the only hope we have for defeating this problem that threatens the security of this nation. Just recently, the Customs Service conducted research that addressed what it would take to build an ideal interdiction system. Essentially, we looked at what it would take to increase our success at intercepting between 60 and 95 percent of the universe of smuggling attempts. Right now, the Customs Service and other interdiction agencies aspire to a detection and apprehension rate of approximately 30 percent of those attempted smuggling events. 413 To attain a success rate of 60 to 95 percent, the ideal interdiction system would have to be built on a system of positive controls of all inbound traffic into the United States. This exertion of positive control would require a mixture of manpower and technology enhancements. The acquisition of enhancements would far exceed the current budget of federal law enforcement, and notwithstanding the cost in taxpayer dollars, there would have to be a considerable intrusion into free trade and international movement into and out of the United States. As you well know, the facilitation of trade is alsoa great concern of the Customs Service. Ina free society such as our own, building an ideal interdiction system with its attendant restrictions on trade is an impossibility and we know that. What we seek to accomplish with this ideal interdiction system concept is to help all of us understand the very difficult task our government faces in controlling the flow of narcotics across our nation's borders. I thank you for your time and if you have any questions I would be glad to answer them. CHAIRMAN WATKINS: Thank you, Mr. Settles. Lieutenant General Olmstead, Deputy Assistant Secretary of Defense for Drug Policy and Enforcement, DOD. LT. GERERAL OLMSTEAD: Thank you, Mr. Chairman. I do have an opening statement. I'd like to submit it for the record and then just encapsulate some things. CHAIRMAN WATKINS: It's certainly accepted for the record. Thank you. LT. GERERAL OLMSTEAD: The Department of Defense has been a full partner with the rest of our colleagues here in the crusade against drugs for a number of years. In 1983, the Secretary of Defense saw the need to organize officially his approach to that and he formed the Department of Defense Task Force on Drug Enforcement. When the President, in September of 1986, came out with the six goals on how to have a drug-free America, the Secretary of Defense again reorganized his office and formed a deputate which I am privileged to head. The mission of the deputate corresponds to each of the six goals of the President for a drug- free America: a drug-free workplace, drug-free schools, rehabilitation, increased law enforcement, increased foreign international operations, and public awareness. 414 I would say, Mr. Chairman, that our duties are divided roughly 25 percent towards demand reduction, to ensure that the military forces of the United States are staying as clean as possible from drugs. We've have a good record on that. As you recall, we have a downward trend in reported drug use from as high as 27 percent of the force in 1980 to down to something less than 9 percent in 1985 and probably even less than that now. So, that 25 percent of the job is being taken care of. We are working to bring these figures down. Seventy five percent of our effort goes to help my Supply side colleagues. We in DOD consider ourselves as the linebacker in this war on drugs. We try to provide the law enforcement agencies with a whole gamut of things from simple rifles and binoculars all the way up to sophisticated radar aircraft. Our contributions dollar-wise have increased ten fold in the last three years. We continue to support then. We blieve that the Department of Defense should be in a Support role. We turn to our colleagues in the Coast Guard, the Customs or Border Patrol and say, "What do you need to accomplish your mission." Frequently, as Mr. Burke, we train some of their people. Terry and I both went through the jungle training school in Panama, where we are training his agents to go into the operations in Bolivia and Peru. We also share intelligence. We share communications abilities, and perhaps even more important, we loan our own resources. Last year, my colleagues asked us over 8,000 times for some type of support, and we were able to answer them 98 percent of the time in the affirmative at no cost to them. The other two percent we received some payment for TDY principally, or for gasoline. So, we are a full partner in the feeral drug program, and I think we have reason to be proud. Our 2.1 million servicemen, are the age that is most vulnerable to drug abuse. We're talking about an average age of 23 years in the military. The Secretary of Defense and the Department of Defense are keenly aware of the problems of the drug war, we are full participants, and we look forward to participating even more in the future. I look forward to your questions, sir. CHAIRMAN WATKINS: Thank you. Mr. James Van Wert, Executive Director of the Bureau of International Narcotics Matters. MR. VAN WERT: Thank you, Mr. Chairman. On behalf of Ms. Wrobleski, who is the Assistant Secretary for the Bureau, I thank you for the invitation to actually present a statement for the record. 415 I would like to share some perceptions that aren't really in the testimony. I've been involved in this issue for 15 years now, and have witnessed a number of changes over the years in crossing administrations. The fact that we have on this table members from the Coast Guard, the Department of Defense, certainly in recent years has been a marked change in terms of the emphasis and the truly coordinated efforts that have gone into this issue. Our Bureau, that is the International Narcotics Matters Bureau at the State Department, is a relatively young bureau. We were created in 1978, so basically we've been inexistance barely ten years. Really, the whole purpose for our existence is to coordinate the efforts overseas in the international narcotics control area. But, stated differently, since you've heard in terms of heroin, cocaine, marijuana, the source of these drugs, with the exception of marijuana, is really extraterritorial. We're talking about drugs that come from sources that are outside the United States, so the key factor in all of this, of course, is if you can work with the foreign governments, the source governments, the transiting governments, to see it in their best interests in raising this issue. I've seen many changes in that area also, about which I'd like to share some general comments. As a sort of preamble, I was looking at some statistics this morning which truly frightened me when I looked at the relationship of IV drug use and the AIDS virus. The statistics, I presume they're accurate, more than frighten me. That 25 percent of the people diagnosed with AIDS certainly had the connection with IV drug use. Seventy percent of the prenatal incidence were related to IV drug use and 70 percent of even the heterosexual transmission of the virus was basically related. I didn't realize those figures were quite so high and I started looking at some of our own documents in terms of awareness of the importance of this issue in the international community. Just in the past week, there were two documents that came through our bureau, one from Asia, in Thailand, where they had done a recent survey of the clinic population. They surveyed the drug abusing populations in Bangkok, 16, 17 clinics. Twenty percent of those surveyed tested positive for the virus and basically they were coming to the States through a cable saying that they wanted some support to help in education and prevention, what we are learning on this, and all of a sudden the awareness was raised. Also last week, there was an article related to a two day conference in Rome, even in Italy, where the model of course is much more like the New York model, the contaminated needle use 416 as opposed to the San Francisco model in terms of the homosexual population for transmission. But, the figures that related the IV drug use I hadn't realized was as high. I started looking more at some of the heroin data that we have. Basically, in terms of our overall goals, we cite really one major goal, with three sub-goals. Obviously, from the Bureau's perspective, from a very selfish United States government perspective, the overall goal is to reduce the amount of heroin, cocaine, marijuana coming into the United States. We've been talking about the supply reduction strategy here. It obviously goes without saying that as long as there is a large demand which is the other part of the equation, it's going to be incredibly hard to work on the supply. But, having said that, I'll put that aside and look at the kinds of tactics and strategies in terms of the supply reduction. I mention that as an overall kind of generic goal. Some sub-goals of this, and really it kind of comes as a sine qua non to this is something we call the public diplomacy initiatives. Basically, this is another way of saying that after all is said and done each government is a sovereign entity who works in its own best interest, self interest. It is extremely important for us in working through diplomatic channels to raise the awareness, educate the public elites, the power elites, whatever descriptions we want to use, in these governments to indeed see that drugs from a variety of points of view are a negative in the society. And I'm not just speaking of the health perspective. In some areas it may be from the health perspectives and that may work in a country like Brazil, for example, where you've got 90 percent of the population living on ten percent of the land ina basic urban setting. The health issue is a very important issue and is sensitive in terms of the policy makers. They're concerned about that. That is an important platform to use. Other countries, it may be a burgeoning problem. We don't have good data. But, as important in terms of the mind set of, again, the power elites -- and I'm not just talking about government decision makers -~- I'm talking about churches and schools and unions and labor and the different sectors in the society. Basically, political destabilization, economic problems, insurgency, terrorists, security concerns, are a number of concerns that today in 1988 we didn't see as importantly in 1978 in looking at the issue. So, this public diplomacy issue, that is, if you can raise the awareness of the individuals in these governments to mobilize the forces to actually take effective action, then you have the political commitment and then it is much easier to work 417 on the ability or the technology or the resource question. The more important and the tougher one, obviously, is the political commitment. And then, two other subtypes of goals obviously is that the United States is not the only marketplace in the world. That is even more evident today than it was in 1978. One of our sub- goals certainly is to involve the international community. That is critical in terms of the global problem. The effects are much broader than the United States. The European community has discovered incredible problems in the last several years. I mentioned this study in Italy. It had 600 overdose deaths last year in 1987, and I think there is 135 overdose deaths, if these figures are accurate, in the first two months of 1988. That's a significant increase. So, in terms of the impact on other societies, it goes beyond. So, it has also the added benefit of not having it as the United States as the figurehead in terms of this supply reduction strategy. So, that is certainly a sub-goal. And another sub-goal really relates to -- and here's where I'll get into where the Bureau is functioning more directly. To effect the supply reduction, we've discussed a lot in terms of the interdiction strategies as it leaves the source areas. There are two tactics which we haven't talked about. One is obviously immobilizing the trafficking organizations and dismantling the assets of the organizations, taking this as a business, which drugs truly are. The drug traffic truly is a business. The brains, the mind set, the people, the laboratory dismantlings, the forfeiture of the assets, that whole kind of realm of tactics which DEA is very much involved in internationally as a number of agencies are. That's a very important factor. And then the other factor, destroying the crop at it's source, is easier said than done for a variety of reasons. But, that is where we put our major emphasis and focus and certainly political push in terms of trying to get these governments to devise ways of going after the source. What I mean by that is that in some cases it is basically going out and having a carrot stick kind of policy where you can encourage the growers, the farmers in these regions, through a variety of development assistance schemes perhaps, through some subsidy kinds of schemes, basically not to grow the crop or to cut it down themselves. One of the problems one must remember certainly when we talk about cocaine is that it's also a legal substance as well as an illegal substance, which makes it vastly more difficult to control. 418 But in any case, one of the tactics is basically to work with these growing units in a government in a growing region to basically try to, through the carrot aspect, provide some incentives not to grow the crop or to cut it down. Another way of controlling the crop, obviously, is to work with the government to figure out ways to either manually or through an aerial herbicidal means to destroy the crop through crop dusting techniques or whatever. Going back again through the ten years comparison, in 1978 there were two countries that were actually using this tactic to destroy their crops. In 1988, there were I guess 23 counties who have employed, at least to some degree, the eradication kinds of methodology. So, basically, our focus is we feel that if indeed we can get the raw material and either not have it grown or destroy it before it goes into the buyers, the lab producers, the trans- shippers, the smugglers, and then into the distribution networks in the United States, from a business point of view that's a more cost effective way to choke off -- from a supply reduction strategy point of view -- that appears to be a more cost effective place to try to squeeze the pipeline in a business sense. Now in some countries -- and let me mention some of the impediments to this that are obvious to anyone who has thought about this -- that as a clandestine crop in some regards, because heroin is illegal certainly and the cocaine question, there are quotas that when a country exceeds the amount for the legal demand, that part is illegal. The growers, given the high profits, are going to go to extensive means to ensure that the crop is not destroyed. You have a whole range of factors here. The government may not have control over a region. There's the corruption issue. As I mentioned, there's the high return on investment in terms of the profit motives. There's a lot of political instability. It's remote. It's tied in with a lot of insurgency. There are a broad array of problems in trying to get the eradication implemented. And again, these are very remote areas. Just as summary, the areas we're looking at just on the heroin side first of all: there's the golden crescent, which is the three countries of Pakistan, Afghanistan, and Iran. Obviously, in Afghanistan and in Iran we don't have a lot of activity, so we focus on Pakistan. But, the growing production in the other two countries -- you can be successful in Pakistan and the net result being you're losing. 419 In fact, we did this year for the first time encourage the Pakistanis with some success to begin to do some eradication. And we've also had some development assistance success, I think, in Pakistan. In the other area of Burma, Thailand, and Laos, we have a similar problem. We can work in Burma. We can work in Thailand. Laos is a more complicated area. We've had some success in Burma. In 1978 there was no talk of getting the Burmese to actually try to destroy their crop. In the last two years they have used fairly standard, for this country, crop dusting techniques to destroy their opium fields with some Success. And the Thais have also had some success both in the manual eradication and in getting the people not to grow through some development assistance. And the last area for heroin is Mexico, which is closest to our border. They're the smaller of the three areas in production, but virtually 100 percent that's produced there comes to the United States. For over a decade, they've had an aerial eradication program. In cocaine, there are three countries of Peru, Bolivia, and Colombia. Without going into a lot of details, Peru and Bolivia are the major producers of the coca leaf. There are a variety of problems, since it's been growing for centuries. It's tied in with a whole infrastructure, the cost, the return on the investment, and et cetera. But, even in those countries we've had some success. I like to use the analogy of leading the horse to water and getting the horse to drink. In the last years we've had some real success in the process of getting some of this in place. Indeed, in Bolivia a couple of years ago people would never have believed that they did destroy over 1200 hectares, or I guess it translates into over a thousand metric tons of coca. Some success is certainly on the margins and gives some cause for optimism, but probably the single most important factor from the public diplomacy point of view that I see on the horizon is that ten years ago this country, certainly in this hemisphere, and again seven out of eight of our dollars are spent in this hemisphere, at least in this years time frame, and we're taking the cocaine issue, these governments have seen this as more important in terms of their own national interests, or at least in terms comparatively. A lot of times people scoff at that in terms of the amount of success, but again we are looking at little steps here. We're looking over time. But the governments certainly of Colombia, incredibly under siege from a variety of areas, a very difficult situation. Even in Peru, where there's been some 420 limited testing and some steps taken there. Bolivia, I think for the first time we've got some progress being made in the coca area. So, I guess as a note of optimism, these governments for the first time are certainly seeing this for a variety of reasons, the political instability, the insurgency. Let me close there. I'm willing to take any questions. CHAIRMAN WALSH: My apologies for having to go outside, but I promised someone I would meet with them for three days and they were leaving. I had to miss the testimony, which I will get from the tape, so please excuse me. We'll start our questioning. As I've told each group, we understand the problems you may have in being candid with us aS agency or government representatives, but do not limit yourself to speaking and answer to questions only for the agencies you represent. Feel free also to give us advice and guidance as individuals as much as you possibly can so as to not be bound by too much restriction. Our charge is to advise the President on a policy, and we hope it will be perhaps a new or improved over whatever policy we have or policy we don't have. So, this requires new input, new ideas, as well as continuation of the things which are working well. So, please don't hesitate to speak as individuals if you have to. I'm going to ask our Chairman, Admiral Watkins, to start the questioning. CHAIRMAN WATKINS: I don't mean by any comments I'm going to make now that I'm critical of the work you do. I know what you do. I praise you for the work. We have the most insidious problem, in my opinion, the nation faces. But, as we listen to this panel and many other panels before it, as well as those focused on demand, I can remember hearing these same words with different figures in the amount that you were able to confiscate in terms of kilos or tons or closed laboratories. That's been an impressive increasing number, but obviously the potential for those that would traffick in this insidious form of warfare are really not deterred by that amount. It's still a lucrative practice. We're working on the inverse square law from the source, these people have sophisticated electronics countermeasure equipment, and all the things available in modern technology because they have the money to pay for it. And it is a little bit discouraging that somehow we haven't been able to find a better set of keys to the kingdom of the drug traffickers. 421 The question is, do we have a war on drugs? Is it really mounted in that framework, in your opinion? And I don't mean in terms of dollars, I mean in terms of national attitudes. For example, we talk about education on the demand side. We're going to tell people how bad it is to be involved in substance abuse. Is that really the most effective way, since the proclivity to use drugs seems to lie among those that perhaps aren't even exposed to an educational system that allows that to take place with the very high risk groups. I am concerned that somehow we haven't found the right mechanism to pull supply and demand people together and mobilize national forces better than we have. For example, can the potential users out there in the next generation be somehow involved to participate as part of the drug interdiction effort? Is there a way to engage us all in the warfare, as we did in World War II. We all pulled together and we had a lot of Rosie the Riveters around who were really tuned up to the fact that we had a war that's every bit as insidious as anything we've fought in the past, because it's from within and it's very aifficult to deal with. If we're going to make an impact on just the HIV -- We have to focus on IV drug abuse, because we do think it's the most important long-range thing to attack. But in our minds we don't even know the impact of drug use alone on spread of the HIV as it impacts on behavior. So, that isn't even mentioned because it's not that cleanly lined out in epidemiological data. We're looking for recommendations here of what we can do through the lens of the HIV as a mechanism to get the national attention on this in a new way. So, I would ask you to search your minds this afternoon and see if you can't put on the table some concepts that would trigger the imagination of the American people a little bit more to really get on board this effort and all of us be a part of the solution to the drug war problem. It seems to me we're not doing the job well. ADMIRAL ROBBINS: Admiral, I don't think we're ready to throw a net around the United States and say, "We're not going to let anything in." We're not ready to do that. The suggestion was made that if general aviation aircraft coming in were not rsponsive, "We ought to shoot them down if we know they're carrying drugs." Well, nobody's really ready for that. We really aren't ready and I'm really not ready to pull the trigger on somebody. As sure as shooting, the one that I shot down would have a family, an innocent family with wife and kids in it. 422 CHAIRMAN WATKINS: That's who the drug pushers would send over you first to make that point. ADMIRAL ROBBINS: That's right. This net that we're looking for around the United States, Mr. Settles said it, would be so expensive and so onerous that it woudl not work. Sol visualize the interdiction business in my own mind as a holding action. I think it's something that needs to be done. We can't just open up our borders and let everything come in. So there has to be a concerted effort to do the best we can in those areas, but there's some limit. The thing that's really going to have an effect, I think, is in the drug -- and I'll call it education but call it anything you want. I think that that's going to take awhile. But one of the things that interests is what they're doing in Colorado. The governor has taken a personal interest in what is going on in the drug business and has started some community actions to get people involved and work against the drug problem directly and put their names behind it. I see some very powerful people that talk about drugs but they don't personally get involved. Now, there's some obvious exceptions to that, but I think a lot of our people that are in important places have to get personally involved and put their names on the line and say they're going to help fight this thing. Then we'll get somewhere. Until they do, they're leaving it to the foot soldier to try to carry out their duties and then turning their backs on it when it doesn't turn out quite right. CHAIRMAN WATKINS: Well, I'm not criticizing you. I certainly am not proposing a net over the nation. I'm merely saying that I don't see any change in fundamental approach. It's a little bit more of the same. "Yes, we're talking to each other more. Yes, we're working together better. Yes, it's coming alive." But that's a long process. And in the meantime, we have some serious problems facing us as a result of the drug usage in the nation. So, I'm looking for other ideas. You mentioned something going on in Colorado that seems to be different. Well take a look at that. Do you have any othr thoughts about it? Is there anything under law enforcement where the American people can be mobilized themselves as to be part of the game in way that they're not going to be hurt by this. But by the same token, there are opportunities and linkages that can be opened to them to say, "Look, here are the things you've got to look for," and then get on the public tube and let's get that information out that can be given without 423 giving up the kinds of source information that you don't want to give them, to put out a program that says, "Here is what we want every American to be involved in on drug interdiction. These are the kind of things you can smell. We're looking for a few good human marijuana dog sniffers." What can we do along those lines to mobilize the nation? That's what I'm looking for. LT. GERERAL OLMSTEAD: You asked if this was a war and I say no, it is not. By definition, a war on drugs requires a total national commitment. We have not seen that. If one is to have a war on drugs, one has to employ many strategies. You've called a group of experts on one strategy here today. That's the interdiction strategy, and it is a very important one. As Admiral Robbins says, you have to show national will to protect your borders. But that is not the answer. Interdiction alone is not only the answer. You, yourself, described a four percent increase with the number of drugs entering our country. When we've got 90,000 miles of borders, there is no net that you can really put around that. We have to use the interdiction strategy in conjunction with the other strategies which we've designed. The State Department talks about their overseas eradication programs. We have to show the foreign countries, the producing countries, the trans-shipment countries that we're willing to make agreements to help them in their eradication process. We also need surveillance as part of interdiction. We certainly have to protect our borders as we're doing now. But the most important thing we have to do is have a zero tolerance of the user. We have to have a demand reduction strategy. I can dry up that little Campesino down in the Huellaga Valley just by not having a demand for it. We've got to reduce. We must start holding the users responsible. When principals of high schools and we have heads of church groups turning their head the other way when their parishioners and their students are using drugs, that's what makes our job as interdictors impossible. You asked me to be candid, Doctor, and I will be. If you're going to have a war, let's all get in the war. Let's commit to war. It's awfully easy to say, "Let the guy in Washington do it," when the problem is in Albany, New York. Or, "Let the Army do it." That means, "I don't really know what the answer is, but let somebody else do it." I think the responsible people are in the battle front and the battle front is the main streets of the United States. If we dry up at home, these guys can go find another job. CHAIRMAN WALSH: Very good. Kris, do you want to take a shot? ° 424 MRS. GEBBIE: To follow on some of that same line of thinking, I don't think I've heard a clear answer to this question. Is there a forum in which those of you who work on the interdiction side and those who work on the education or prevention or treatment side all come in the same room and design the complete package of programs that would make the whole possible? What it sounds to me like, from the outside and from somebody who's not been directly in the drug thing very much, that there's a pot of resources for it and on alternate five year cycles we move it from one emphasis to the other for reasons I'm not sure I understand. I've not heard that there's a really clear, comprehensive blueprint that's ever been put together. LT. GERERAL OLMSTEAD: We've put together a national strategy within the last 18 months under the auspices of the National Drug Policy Board. The National Drug Policy Board, by another name, is the Cabinet of the United States. All of our Cabinet members sit on this Board. They get together monthly and discuss the nine strategies in the war on drugs. Of the nine strategies, five of them are police-type or supply reduction. Four of them are health and human service or demand reduction. To help the National Drug Policy Board operate, they have two coordinating groups. One of them is the Law Enforcement Coordinating Group. All the agencies here today are represented on the Law Enforcement Coordinating Group. We meet for two hours at lest every month. The Coordinating Group is supported by various committees. Admiral Robbins' people ar primarily involved in the Interdiction Committee. We have Terry Burke's people primarily involved with the prosecutions and Investigation Committee. And there is an International Committee. All these committee tie together under the Law Enforcement Coordinating Group. At the same time under the National Drug Policy Board, we have the Drug Abuse, Prevention and Health Coordinating Group under Dr. MacDonald from the White House sit on this group as well as on the Law Enforcement. We talk together constantly. MRS. GEBBIE: I'm sorry if I sound like I'm repeating, but I want to be really clear. I sit on a lot of interagency boards myself and I can describe what you just did about people meeting after meeting after meeting. What I'm not sure I heard is, if I asked for it, could I get a plan that shows all those pieces woven together that's what you folks would do if you were told for right now -- pretend you can rewrite the budget, you could rewrite the policies, you could really put together what you all think would be the perfect plan from which somebody could then start looking at what they wanted to do. LT. GERERAL OLMSTEAD: We can provide the strategy to the Commission. 425 MRS. GEBBIE: You do have such a thing? LT. GERERAL OLMSTEAD: Yes. ADMIRAL ROBBINS: Let me say, and I'll probably get in trouble, but I don't have too much longer to go. I can find something else to do. One of the problems in this government is you put together a plan and there's always the push/pull of budgets and what you're going to say to Congress because if you put something into Congress and it looks like a wish list, they will go buy you a lot of things you don't need. There's this push/pull. That's something that really has to be solved. I don't know how you do it. But when we put together the strategies, we sat down around a table and we said, "Dream, folks. Look at what you want to do, think of it in the terms of money is no object. Here are the things that you want, what you would need to do better and make some real impact in the interdiction business. Do that, put it on a piece of paper and then we'll run it up the flagpole." Well, there are a number of people that got a hold of those documents over in Congress. I don't know how they got them. I didn't give them to them. I'11 go on record and say that. But somebody got a hold of them. But when the document that went over had been through the budget strainer and all the other things, it doesn't have a lot of the things in there that are necessary to do the job. That's what you have to overcome. Maybe that is just a malady of the Cabinet-type government, but there is a problem that if you can cut through you will doa great service to us all. MRS. GEBBIE: That was a very helpful answer. Both of those were and I appreciate that. Within the spirit of that same thing, my repetitive question. You've described very nicely what you're doing and X’?n very impressed. I admit to being somewhat depressed about your ability to ever get ahead of it. I think you've also said it needs other things. Are there any policy type things or statements or expressions of interest or whatever that this Commission could say which in the next six months to a year could make your portion of this effort ever so much easier or simpler just to have on record a direction or a statement or an interest? Your point about just finding a way to get the planning done without some of those strainers getting in the way I think is a very helpful one. Are there other things? 426 MR. BURKE: If I might respond to that a bit. I'd like to also respond to Admiral Watkins in a way. Maybe I'ma bit of a cynic after all these years, but very frankly, by the time your Commission finishes its work, gets its work published, you're going to have a new administration looking at it. MRS. GEBBIE: Not quite at the rate this crowd seems to be going. MR. BURKE: I'm being very practical. My problem in thinking what Admiral Watkins mentioned earlier, we're talking about a bureaucratic response to a major moral problem for this country. I'm not necessarily a moralist, but we've had breakdown of one thing in this country and until that is rectified none of what we are trying to do is going to have that great an impact. It's a lack of self discipline and a lack of sense of responsibility in a large share of our populace. We're sitting and reading that an individual, knowing he has AIDS, has sexual intercourse with his male companion and then murders him and then goes home and has sexual intercourse within an hour or two with of his fiance, the woman whom he intends to marry and you would expect would intend to father her children and so forth, that that example of that lack of self discipline and lack of responsibility can make all our bureaucratic efforts to sit around tables and organize and plan and everything go right out the window. Until people are willing to develop their own self respect, I think we have to as a government work towards programs that develop that self respect in individuals through their work and so forth. I think we have to start prioritizing some of these things in this country. You talk about World War II. Everybody was pulling together. The pride was there. We're defending ourselves. I think since then the loosening of the moral standards in the country, the idea that, "Hey, go off on your own." How many doctors who graduate right now, finish their internship, are willing to go into the ghettos of this country, to go into the poor rural areas and work and work with the people who need their types of services the most? How many teachers are willing to graduate and go back into these same type of areas and be willing to put up with the frustrations of working with people who may not have had the type of background that makes them instant top students? Not many because they're too interested in the mortgages they're going to have to pay, the funds that they're going to have to start accumulating in terms of their own children's education and so forth. 427 I think until we get that central direction again and address some of these issues that are very, very fundamental, all we're doing is trying to keep up with the holding action. Very frankly, until we can solve that -- if I had the answers, I think I'd be a very good presidential candidate today. CHAIRMAN WALSH: I've got to say that the very fact that we're in a dead period may be the greatest advantage we have because I happen to personally believe that the candidate that has the best drug program is the one that's going to be elected. I think that this is going to be a very major issue in this next campaign. MR. BURKE: I agree. CHAIRMAN WALSH: That's why I think that the question that the Admiral asked and that Ms. Gebbie asked that if you really feel that among your group you've pulled together something, make it a dream package or whatever you like, that if this is a part of this report I don't think it would take much to persuade the Admiral to amend the section that he was so instrumental in writing on treatment on demand to a much broader approach to the whole problem of drugs. That would be available to both candidates. I'd love to have it so good that they fight over it to see which one would make it more of a banner. If indeed it means that an Ian MacDonald should be someone -- and I don't say this disparagingly of Dr. MacDonald -- but if someone at the White House in the next Administration should be stronger, should be more prominent, should be a more effective leader, would be in charge and be enabled --of course I'm a dreamer because I have to raise a lot of private money every year myself. That he may even supplement government budgets by making the country feel that it's the duty of every citizen to not be taxed but to pay voluntarily a fee to the war on drugs. With the proper leadership, I tell you you would raise not millions but billions of dollars a year, if it's done properly. I think the country is ready for that, but they need leadership and they need a plan that is in terms that they can understand. Everything has been put before the public, unfortunately. As the Admiral has said, they get a delusion that they're winning the war when 100 pounds of heroin are captured and they read it's got a street value of X hundred millions of dollars. I grant that that's necessary to make the public think and realize something is being done. But that really is a drop in the bucket, but it misleads us. It misleads the public. I think that somehow this has to be mobilized and while we are an AIDS Commission and not a drug commission, because of the 428 association of drugs with AIDS, I think the Commission is in an admirable position to take one last shot for this Administration in a very aggressive posture. Don't forget, anything that we write in this Commission report becomes public property because that's the law. So, no presidential candidate can pretend he doesn't have access to it. The President of the United States could not ignore it, not that he would want to. Lord knows he doesn't want to. I think what the Admiral and the Commission wants is something like this that we could get our teeth into that might really do something -- result in some dramatic action that is sustainable. MR. BURKE: I think the key there is the national strategy that General Olmstead mentioned. The best minds in the government right now and a lot of private people who were brought into this, your Cabinet-level people and down to the working level people, have gone into the work of that national strategy. The strategy is there. I think what we need to do is say, "We are going to put a price tag on that and we're willing to meet that price." But that goes up to a committee in Congress and one particular member of Congress has his own problem along the border so he'd say, "Wait a minute. Pull that money out of the - = i? CHAIRMAN WALSH: But if you've got both candidates fighting to see who can promise the most, if we get half, we're going to be better off. LT. GERERAL OLMSTEAD: Dr. Walsh, I think the political answer is very unsavory though. It's going to be tough for somebody to say to his potential voter that, "You've got to keep your kid off drugs and you've got to make sure that the guy next door is off drugs." CHAIRMAN WALSH: He's got to say it. LT. GERERAL OLMSTEAD: He's got to say it. CHAIRMAN WALSH: I think that has to be a very major part of it. Don't forget, I think the phenomena of Jesse Jackson has been that that's what he's saying and he's saying it, if I may be pardoned when I use the phrase, to his own people. This has been part of the phenomena that has made him a widely sipported candidate in his own party and has gotten him the attention of the media. Now, he has no idea of how to do what he wants to do, but we do have or you do have. I think if this report comes out and is handed out to two candidates in the way in which the Admiral would like to see it written, we might have a chance. I think we're coming to the end of the road. We've got to do something. ADMIRAL ROBBINS: Could I zero in on a point that I 429 think is important in this? It's seldom really concentrated on and I see it when we visit foreign countries. The first thing they always point at is, "What are you doing about your problem?" When we want to spray their fields of marijuana and coca, when we want to do that they say, “How are you doing on your own?" We ain't doing very good. CHAIRMAN WALSH: I know that. ADMIRAL ROBBINS: We've got one of the biggest growing states in the United States out on the West Coast. Somebody has got to bell the cat within the United States and say, "We're going to do something about that." We've been intimidated. We have been intimidated by the grass growers on the West Coast. I know Hawaii is working very hard to solve their problem, but frankly, we've put very little money into that problem. I don't believe that throwing money at every problem is going to solve it, but I think we've got to look to our own first and do something about that problem in the United States. CHAIRMAN WALSH: I agree with you. I think that you have to take on the entire environmental lobby. It's not only the state lobby. But again, I think this is something that is going to ask people to make some very hard choices and I think what we're after is to make it as easy as possible for them to make hard choices No candidate is going to fight the environmentalists in California before November 7th. But he doesn't have to get that detailed. What he has to do is fight that environmental lobby after November 7th, whoever wins, and come to the public in his first State of the Union message and say, "Are you ready or not to make these hard choices? Yes, this is going to hurt." It's a question of fighting even the civil liberties lobby. Hard choices always call for that, but we're going to have to have a courageous enough leader to be determined that he will do that. If we give him the tools, we have a chance. I'm not naive. I've lived here too long, like you have. I've lived in this town and seen too many hearts broken over my entire life practically. But nevertheless, there are going to be a lot more hearts broken if we don't do something along the line the Admiral is suggesting. MR. SETTLES: You know, the drug problem is the same as the AIDS problem. Until it comes to people personally, until you have a Lenny Bias, until you have a Rock Hudson where it effects people at a large level, there's not -- I've been here 17 years, like Mr. Burke, and it's a very frustrating field to work in. I imagine it's a lot like being a doctor because you don't cure all the cancer and we don't catch all the dope. 430 CHAIRMAN WALSH: I think Mr. Burke is absolutely right. I Know not dozens but hundreds of doctors that won't even take a- a@rug addict in their practice or if they have a patient who suddenly becomes a drug addict, they want them out of their practice. The reason is they're afraid of them. They don't know how to handle it. They don't know what to do. This is all part of the problem. It's a total societal problen. We're hearing all these witnesses testimony asking us to be sure doctors don't discriminate against AIDS. Hell, AIDS is the least compared to what the drug problem is. Listen, I've been quiet for three days. Now I'm going to let Doctor Lee make his speech. DR. LEE: I defer to Doctor Primn. DR. PRIMM: I certainly don't fit into the category, Mr. Burke, of those people who did not return to their communities to do something about the drug problem. I'm of a little different bent. MR. BURKE: I commend you then, sir. DR. PRIMM: I'm not being defensive because there are some. As a matter of fact, in our preliminary report to the President, we had recommended that there be now at least 400 National Service Scholarships for physicians who would specifically be geared to go back and try to do that. I had some questions for you because you all are on the interdiction side. How much opium or how many metric tons of opium is necessary to produce what the world needs to make analgesics? Do you have any idea, any one of you? We're talking about morphine -- MR. BURKE: I can get those figures, sir, but I don't have them at hand. DR. PRIMM: It would be important to know because maybe, we could get some international treaties that would be put into place that people would respect. Once Afghanistan, Iran or Pakistan or the Golden Crescent, Laos, Thailand, Cambodia would produce whatever amount that that would be -- MR. BURKE: Well, there is such a treaty, sir. There is such a treaty and it is being updated right now with a new convention being prepared for signing in Vienna in probably November or December. 431 DR. PRIMM: But only Pakistan and Thailand have pretty much followed that. Afghanistan and Iran, you can't control whatever they're doing. Even right on the rugged border of Pakistan and Afghanistan, the kind of production that's taking place when Pakistan stops, Afghanistan picked it right up again. That's the kind of thing that is almost uncontrollable. As long as that production is controlled by a particular tribe, you don't have any treaties with that tribe. You might have treaties with that nation, but not that particular tribe who goes on and produces and produces. It seems as if we have to police those areas in a very vigorous kind of way in order to bring about what we are trying to accomplish in the end. So I think that would be something. Of course you say it's already on the books and people have said that they would be compliant to this particular treaty. I don't think so unless it's strongly enforced with some very stringent and draconian sanctions. Other than that, I don't think it would be enforced. MR. BURKE: Obviously the situation in Afghanistan is going to remain unstable for a long period of time. I think, for the record, Turkey, the effort that went into Turkey in the opium ban there probably stands, and Mr. Van Wert could correct me, it's probably the best example of any country maintaining a treaty responsibility. That was done in 1972. India has maintained a pretty good record on that score also. DR. PRIMM: What about processing clandestine laboratories? They still report that Turkey has some of those. MR. BURKE: Yes, sir, but that wasn't in the treaty, unfortunately. DR. PRIMM: Okay. And India has some of those. They are certainly conspirators or they are certainly part of the problem if they are processing the raw opium to, indeed, heroin or whatever. So, as far as I'm concerned, they haven't really totally complied. General Olmstead, you talked about user responsibility and that's the buzzword around now, particularly from the group that you met with this morning. I'm hearing it more and more. I'm wondering, what is your definition and what is that group's definition of usér responsibility? It's really important to know that narcotic addiction is a disease. We're talking about blaming the victim again. I'm wondering how we're going to be able to enforce user responsibility on a disease entity, declared so by Health and Human Services as being such. LT. GERERAL OLMSTEAD: Obviously it's primarily a medical problem when you get to the addiction rate. But nobody 432 is an addict overnight. We've got the youngsters who experiment. We've got those who feel they have to go to the parties where drugs are being done. It's a progressive process all the way up to addiction. I support what you're saying on a medical basis for those who are addicted. But I say if you're going to try it, you're going to get punished. Let the user know that. DR. PRIMM: That's -- LT. GERERAL OLMSTEAD: It's a crime. DR. PRIMM: Well, you're saying, "If you try it, you're going to get punished." LT. GERERAL OLMSTEAD: Yes, sir. DR. PRIMM: What would that punishment be for those people who have tried it and are addicted? We know now that there is maybe a genetic predisposition to addictive behavior, not only for narcotic drugs but for alcohol or other kinds of drugs that are not necessarily supposedly addictive that have some of the same pharmacological effects as do narcotics. The benzodiazapines, the barbiturates and so forth. LT. GERERAL OLMSTEAD: My hope would be that if we get enough of the people in the experimentation phase, that we'll greatly reduce the number of people that we're concerned with in the long basis on the addiction phase. We must tell everyone, but most especially the youngers, that you're going to get punished if you do experiment. You ask me how? I don't say we're going to throw them all in jail. We can expel some from school. Three of our states are taking away drivers licenses. I think that's a super thing to do. There are other imaginitive "punishments" that I cannot recall now, but it a crime to be using an illegal drug. I say slap them on the wrist good and hard now and they won't be an addict five years from now. DR. PRIMM: Okay. Then if that's what we mean by user responsibility, I think that's going to have to be spelled out for the American public and not come out and just say user responsibility, because what we seem to deduce from that kind of general statement is that we're going to throw people in jail, we're going to punish people and punish them terribly. I think that unless we explain that and do it well, we're making a grave mistake. I think treatment is just as important as the responsibility of the user. That's very, very important. LT. GERERAL OLMSTEAD: Treatment is definitely important. It's the only answer on the person that you've almost lost, as you know, Doctor Primm. 433 DR. PRIMM: Surely. LT. GERERAL OLMSTEAD: But I'm trying to get the guy before we lose him. DR. PRIMM: I understand and I think that's quite clear. Mr. Settles, you had talked about an 800 number. Your written statement didn't include, the 800 number. You just said "800 number." I think that if you ask this distinguished panel what that 800 number would be or who to call, they wouldn't know. And if you polled this audience, they too would not know what that 800 number is. It's not publicized. Even that, I feel, Mr. Settles, ought to be on the bulletin boards somewhere. "If you see drug actions going on or people importing drugs, call this number anonymously." Okay? It's not out there. We have never been serious about this problem in this nation. That's the problem and you all have said it yourselves. If we're going to declare war, it's going to be an all-out war starting right from the very community that it effects, right up to the top. We haven't done so. You talked about the Western state, we ought to make it public, which Western state that is. If it's Oregon or if it's California or wherever it is, we ought to make that loud and clear that that state is producing drugs and let's do something about it. It ought not be a secret. MR. SETTLES: Commissioner, you make a terrific point. We have a program called Be Aware. The number is 1-800-BE-ALERT nationwide. That's the number we use. DR. PRIMM: Okay. MR. SETTLES: We do go out and give those speeches and we try to do that sort of thing. I'm telling you, the 3,000 people that are in Customs that are involved as law enforcement officers, we're out there trying to get those numbers. That's what we're trying to do. That's a side duty of ours and we attempt to do it and you're right. But I think it's something that maybe if we had more media or public relations type people to get into this thing to publicize what the government is doing. I'm sure we're not the only ones. You also have these numbers locally. I forget what they call them, where you can call the local police anonymously and leave tips. That stuff is not getting publicized enough. You're right. You're 100 percent right. CHAIRMAN WATKINS: Doctor Primm is hitting on the same issue again. Is there a way to mobilize those non-drug abusing people who make up the large body of the American public to bring them to bear on this issue and to help you do your work? And if so, what can we do? I don't think we know. 434 ADMIRAL ROBBINS: And that's what I think is happening, in Colorado. That's why I like their program because they were mobilizing the public. There's a tendency to say, “Well, expel them from school if they have a problem." That's not the answer to anything. The last thing we want to do is get them out of the schools. We want to keep them in the schools. CHAIRMAN WATKINS: I agree with you. ADMIRAL ROBBINS: In school suspension or something like that, we've got to work with the schools. But they're in their home a lot longer and they're on the streets a lot longer than they are in the schools and we've got to concentrate on that and look at the whole picture, their whole life, not for that short period that they enter the school in the morning and leave it in the afternoon. CHAIRMAN WATKINS: But is there someone in the government at your level working on a mobilization plan for the non-drug abusing citizens of the nation who are fed up with this, to bring them aboard and help you do your job? Have we even tried to get a group together to say what can they do, what can the American people do to be part of the solution instead of bystanders reading about how much you're getting? ADMIRAL ROBBINS: I think that's what Doctor MacDonald is working on and that's a very important part of the policy board. CHAIRMAN WATKINS: Does anybody know he's working on it? We as a Commission do not know he's working on it. That may be our problem, but we might be able to put an incentive into that movement along the lines Doctor Primm is suggesting. This is why we need your help. If you can tell us more about this Colorado regime in terms of its possible translation to a national program that we could recommend, that when you see it come out in print you would say, "The Commission did a good job making that recommendation," because it's yours. ADMIRAL ROBBINS: You ought to have them in and make a presentation to you. The governor would come here and talk to you, I'm sure, and that would be very valuable to you because it's a ray of light that I've seen that works in a state where they needed attention, they grabbed it and they're running with it. CHAIRMAN WATKINS: Excuse me, Doctor Primm, but I felt I had to come in there. DR. PRIMM: That's all right. 435 LT. GERERAL OLMSTEAD: Could I answer the Admiral? There is a group that is looking at that. It's called the Mainstream Adults. It's under Drug Abuse, Preventin and Health Coordinating Group which Doctor Ian MacDonald runs. One of the things we're finding is that there are many people in America who are sick and tired of the druggies. One of the questions that I get from high school kids is, "How come you're making this guy a hero because he just sobered up? I have never had any of that drugs and no one says anything to me." There is a vast majority of Americans out there we ought to work on. When you stop to look at the high schools what the'‘high school survey is really saying is that 80 percent of the kids aren't using drugs and that's the 80 percent we ought to start going after. MR. BURKE: Admiral, I apologize. I'm going to have to ask to be excused. I have two of the top members of the Pakistani government waiting to talk to me on their efforts in Pakistan. So, unless there's another question -- CHAIRMAN WALSH: We excuse you on the condition that you go back so charged up that you don't let them out of the room without a commitment. MR. BURKE: Okay. Thank you for the opportunity, gentlemen. CHAIRMAN WALSH: Admiral Watkins is going to have to leave us in a moment and he has one more question that he wants to ask. CHAIRMAN WATKINS: It's on a different part of the issue. There is a belief, and let me say it may be anecdotal, that there may be a way to get at the free money. We have bank laws that require that anybody coming in with cash -- and let me say nominally in some states over $20,000.00 -- has to file all sorts of documents to say where it came from, a lot of identification, probably for IRS purposes. But we've been informea that there is cash, buying homes, buying boats to move more drugs, buying airplanes, cash passed along with no legal opposition to that. Now, if that's true, is there not a way in this war on drugs, a set of laws that may be necessary to deal with cash over the table for purchase of anything of large magnitude like that? MR. SETTLES: Admiral, that was passed in 1986. It's the Money Laundering Act of 1986 and it's being instituted now. You can't go into a bank or do a transaction of any type that's illegal with illegal funds. It's a very powerful law and there's several laws on the books. That's something else we didn't touch on. 436 CHAIRMAN WATKINS: Is that only for bank dealings or is tnat for any kind of -- MR. SETTLES: No, that's any type of dealings. If the individual who sells that vehicle knows that that money was dirty money, then he also has a problem. He's also liable to felony charges. CHAIRMAN WATKINS: Has that law been effective so far? MR. SETTLES: Yes, sir, it's been effective. It's getting more effective. That's something else we haven't touched on here. There's been a lot of laws passed in '84 and '86 and even in '78 where we were able to go in now and take assets, major assets from these groups. We have shut down a lot of these Groups. We tend to be five years behind our legislation. CHAIRMAN WATKINS: Are you satisfied that those laws are adequate with your experience or should they be strengthened? wore they softened in any way as they went through the process and need further review? MR. SETTLES: They were -- also the '84 law was and then when the '86 law came along, it kind of took care of a lot of those problems. We also now have an '88 drug bill before Congress that should take care of a lot of the other problems. CHAIRMAN WATKINS: Does the Commission need to emphasize that in our report, supporting it or talking about it in any way or is that just -- MR. SETTLES: Yes, sir. Any tool that we can get is -- LT. GERERAL OLMSTEAD: It would be helpful. DR. LEE: Is it one of the nine strategies? 4 LT. GERERAL OLMSTEAD: There is a special standing committee, Doctor Lee. It's the Financial Enforcement Committee which is responsible to the Law Enforcement Coordinating Group. It's run by the Department of Treasury and I know Customs, FBI, Secret Service and DOD sit on it. - DR. LEE: Is it incorporated though? If you send us these nine strategies, is it incorporated in there? LT. GERERAL OLMSTEAD: It's not one of the nine strategies. It's not one of the nine lead agencies, but it is part of our overall strategy, yes, sir. 437 MR. SETTLES: I expect that there will be a position that comes out of the policy board on the Omnibus bill that's now being put together over in Congress. That's what you need to get a hold of because you could, by supporting that in your report, or if you don't want to support it that's something else, but I think you should look at it and see if that's not something you could support. I think there will be things in there that would help a lot. LT. GERERAL OLMSTEAD: That'll be available in about two weeks. DR. LEE: Now, you're talking about the Omnibus Bill or are you talking about your position? LIT. GERERAL OLMSTEAD: Our position. MR. SETTLES: Yes. It's the policy board's position. It's probably going to be the Administration's position as well on the Omnibus Drug Bill of 1988. CHAIRMAN WATKINS: Before leaving, I'd like to thank Doctor Walsh for setting up this set of three days of hearings. I think they've been superb. They've given us tremendous insight into the import of our task. And in private discussions I had with Doctor Jonathan Mann of the World Health Organization yesterday, he told me that this nation is so critical to making an impact on dealing with drug abuse worldwide, that he can't tell me how much he appreciated our emphasis on IV drug abuse. He said it's already made an impact on other nations afraid to come out of the closet on the issue. So, I think what we do on drug abuse in general, even though that's not in our direct line of responsibility, can be very important. Particularly if we have a good report on the HIV. It tends then to have credibility, not only in this country but worldwide. It may give you additional support in your work. So, I think you can gather from the adrenalin flow here that we're excited about the potential of not letting any window of opportunity go by that we don't deal with this issue. So, we will be following up and there will be more questions here. I'm sorry I have to leave because this is one of my favorite subjects. I think that this exchange has been useful to us and I thank you for coming. I thank you, Doctor Walsh, for setting up this set of hearings. I think they've been superb and very, very essential to carrying out our mandate. CHAIRMAN WALSH: Thank you. Who's up to bat? Okay. Come on, Cory. DR. SerVAAS: I can speak for the women who I think 438 would elect the next president who would come out with a policy of getting tough on just exactly what you're talking about, General Olmstead. We don't want our children and grandchildren to die in overdoses. We laud the states who take away drivers licenses. When Pete DuPont came out with that, I thought he'd get elected President when he first announced that he would see that we all removed drivers licenses from the kids who were driving while using drugs. I imagine that you're ashamed of us that we're a lawless country that we have to give free, clean needles to stop the drug problem in New York because we're admitting we're a lawless country when we condone this. My question to you would be if you could put on a different hat and be on the side of law enforcement, how would you handle the problems the way we open the prison door and let drug abusers go right through? I have a colleague in Miami who Says she treats drug addicted prison guards and it's a joke that the prisoners in prison can get all the drugs they want in Miami. She treats alcoholics as well as drug addicts in important positions. She is, like Doctor Primm, a drug specialist. To me that's tragic. How would you, if you were putting on a different hat, change our handling of the abusers, the first time offenders, second time offenders, third time offenders and the drug peddlers? LT. GERERAL OLMSTEAD: Well, I don't want to be simplistic about it, but I think I would like everybody to be vulnerable to my solution. I'm starting in the schools and in the local communities. If everybody is going to be held responsible, then they're going to say, "Why does that guard get away with it?" and start punishing everybody who's doing that. If the person realizes that there's a penalty for him doing something, hopefully he'll think twice about accepting that penalty. In the case of the guard, I would hope he'd get fired. In the case of the student, he might have detention. DR. SerVAAS: Oh, he's being treated confidentially. LT. GERERAL OLMSTEAD: Yes. Well, there's too much of that going on too. What bothers me and I hear this in my own county, in the county that I live in right now, "They know who's using it and selling it on the school grounds," but they don't want to get an accusation of false arrest or accusing the wrong person. So they don't get involved in it. Ian MacDonald calls that enabling behavior. If you don't get involved in it, you're responsible. You're enabling somebody else to use it. We've all got to become responsible. We've got to say that he's wrong to use it and he has to be punished. 439 DR. SerVAAS: So, do you ever get discouraged with the media or the entertainment industry? You can go out to the ski slopes in Aspen and hear them sing, "They've got a lot of cocaine in Cancun," and just making it all sound like it's one big joke. Do you think that the press and the entertainment industry has been at fault to a degree? LT. GERERAL OLMSTEAD: I think they glamorized it toa very high degree in the '70s. DR. SerVAAS: How could we change that? LT. GERERAL OLMSTEAD: Well, I think that we have to recommend that the entertainment industry continues the turn that they've seen in the last two years. I'm not a great rock fan, but I'm delighted to see some rock artists telling kids to say no to drugs. You obviously have to give the youngsters a role model that they can look up to. I think the Commission could recommend that the entertainment industry continue -- a little pat on the back is better than a kick in the pants sometimes. ADMIRAL ROBBINS: One of the interesting things that I saw in Hawaii, was initiating by on of tlevision stations. Every year there were big Christmas parties that they went to and had a good time and some of the things that went on weren't actually beneficial to the public. Everybody knew they went there and drank and had a good time. So they decided to mobilize an effort against drugs. Instead of putting in for these parties they decided to throw a big party over the weekend. They slanted it and got all the radio stations, all the TV stations, all the media people together and said, "We're going to put on this party and it's going to be against drugs." That's very effective. Those kind of things are very valuable and that wasn't forgotten right away. That made an impression on a lot of people. It made an impression on me because I was out there trying to keep up with the drug flow and do some of the things against the drugs. That at least gave me a thought that there was some one on my side. One of the things that we saw a lot then, and I think that's improved over the last three years, is that there was an awful lot of denial in the schools that they had a problem. I've seen that change a lot. I think there's hope. We always want instant results. I see some reason to be hopeful. I think we need to keep up steady pressure. I think we need even more pressure than we have. I'ma little more hopeful than I was three years ago. 440 DR. SerVAAS: Could you send us the Colorado plan and could you tell us now the three states that do have the drivers license being taken away? LT. GERERAL OLMSTEAD: New Jersey, Missouri and Oregon. ADMIRAL ROBBINS: The governor would love to get involved with you, I know. CHAIRMAN WALSH: Yes. We'll get him. DR. SerVAAS: The Colorado plan? CHAIRMAN WALSH: We'll get that. The staff will get that for you. DR. SerVAAS: Does anyone else have an idea of how we could formulate on the demand side? CHAIRMAN WALSH: They're going to send us their strategies so that we can strengthen our report on that. And then if need be, we can always contact them again. Okay? DR. SerVAAS: Thank you. DR. LEE: I'll have mercy on all of you and not give my reviews on drug abuse. But that does not say that I, along with everyone else on this Commission, doesn't feel extremely strongly about this problem. That is why we made the drug section the most important part of our initial report and it probably will be the most important part of our final report. Please send us the final complete position from the National Drug Policy Board. I'm sure this Commission would like to endorse that. I hope we will anyway. That sends a message right there. The last thing I have to say is, we have to fix it ourselves. You have tried valiantly and now it's time for us to do it. We're going to try to put that across in our report. CHAIRMAN WALSH: Kris, did you have a follow-up? MRS. GEBBIE: Well, I guess it's part comment. I become very concerned when I hear a plan or discussion of a plan that emphasizes over and over again the punitive side. The reason I asked about an integrated plan with all partners being fair partners in that is because the communities in which the punitive behavior is most likely to be delivered are communities in which there are very few rewards available, particularly to the young people who might be then discouraged from drugs. And it's going to be real hard to only punish without also showing some very strong and positive things that are a successful alternative. 441 So, I really would encourage, as you look at what to send in, if you don't have your fingers on the other pieces of that plan that build up the strengths for those same people we might be punishing, to direct us to those people or get those things in. I think if it's not all part of a shared responsibility plan, it's not going to work. It's going to fall down again for us. MR. SETTLES: I think maybe this is the wrong group to be addressing that. We're not really into positive motivation. MRS. GEBBIE: No, but I was told that all of you were partners in writing this plan and I just want to emphasize my view that that is critically important, that we not just go off on one piece of it. ADMIRAL ROBBINS: And I think we certainly agree with that. We all look at it as the eventual end of this thing. CHAIRMAN WALSH: Well then, I want on behalf of the Commission to thank you all for everything that you are doing and have done in the past and are trying to do in the future to help us solve the overall drug problem, not just the drug trafficking problem, and to reemphasize how much we will welcome the material you send us so as to strengthen our report and strengthen the President and challenge the next president, whomever he may be. At the same time, while the Admiral was very kind in thanking me for chairing this panel and bringing it together, I must, in all conscience, pass on those thanks and that gratitude to Adrienne Allison, who was the lead character, if you will, in this three day play that we had, in bringing all of our witnesses together. To Adrienne and Nancy Wolicki and Pat Rye, you have our profound gratitude. Others who make this thing work and keep us going, like Vicky and Brian and Chris and Cynthia, all have our gratitude as well. In fact, this past five months has been made livable thanks to them and their top sergeant, Polly, for whom we're always thankful. So, again, thank you all for helping us. Maybe we can whip this thing. (Whereupon, at 3:43 p.m., the above-entitled matter was concluded. ) 442 APPENDIX TESTIMONY FOR THE PRESIDENTIAL COMMISSION ON AIDS HIV POLICIES AND PROGRAMS IN THE DEPARTMENT OF DEFENSE JOHN F. MAZZUCHI, PH.D. ACTING DEPUTY ASSISTANT SECRETARY 2F DEFENSE (PROFESSIONAL AFFAIRS AND QUALITY ASSURANCE) APRIL 20, 1988 In 1985 the Department of Defense recognized that AIDS (Acquired Immune Deficiency Syndrome) and related infections of HIV (Human Immunodeficiency Virus, previously known as HTLV-III) would have significant effects on military personnel and, therefore, could have a potential effect on readiness, Suosequent to extensive review, a policy memorandum was issued in October 1985. Following a required annual review a revised policy was issued in April 1987. A second policy review has just been completed at the working level and is being staffed within the Department. This document outlines the components of current policy and presents the program results to date. I. HIV Testing for Military Recruit Applicants Individuals with serologic evidence of HIV infection (Food and Drug Administration approved enzyme immunoassay (EIA) serologic test and, if positive, a positive immunoelectrophoresis test (Western blot)), are not eligible to enter military service, For other categories of personnel (ROTC, Service Academy, Reserve Components), those individuals with serologic evidence of HIV infection who are required to meet accession medical fitness standards in order to be appointed to a new component are not eligible to do so. The Department of Defense recruit screening program began in October 1985. During the period October 1985 to February 1988, the Department has screened approximately 1.41 million civilian recruit applicants. The overall antibody positive prevalence rate is 1.4 per thousand tested. Statistical synopses of this information are provided wide dissemination through the U.S. Public Health Service's Morbidity and Mortality Weekly Report. State specific information is provided quarterly to each state health officer by the U.S. Public Health Service's Centers for Disease Control. II. HIV Testing for Military Personnel Active duty and reserve component military personnel are screened for serologic evidence of HIV infection using the same tests and standards used for recruit applicants. Initial testing and periodic retesting are accomplished in the following priority order: military personnel serving in, subject to deployment to, or pending assignment to overseas stations; select groups in the medical setting such as individuals presenting to sexually transmitted disease clinics, and all remaining military personnel in conjunction with routinely scheduled periodic physical examinations. Military personnel are tested for HIV because of their potential exposure to severe infectious diseases such as malaria and dengue, and the potential requirements of a buddy-based blood bank during contingencies.,, The distribution of AIDS cases diagnosed in active duty personnel for 1982-1986 is: YEAR AIDS 1982 1 1983 17 1984 28 1985 70 1986 “158 The active force testing program began in late 1985, To date, approximately 2.2 million active force personnel have been tested, with 3336 identified with serologic evidence of HIV infection. This is an antibody positivity rate of about 1.5 per thousand individuals screened, Each individual confirmed to have serologic evidence of HIV infection receives extensive evaluation, psychological support, and treatment, if necessary, at select Service medical treatment facilities. Each patient's stage of infection is categorized in accordance with a clinical research protocol initially developed by Walter Reed Army Institute of Research. III. Disease Surveillance-All Beneficiaries For all civilian beneficiaries of the military health care system, a voluntary HIV serologic screening program is offered. For example, HIV serologic screening is offered to beneficiaries presenting at sexually transmitted disease clinics, alcohol and drug rehabilitation units, and prenatal clinics. In addition, health care beneficiaries concerned about whether they have been exposed to HIV are encouraged to consult with local DoD medical personnel. As is the procedure for other problems, such as other sexually transmitted diseases, the beneficiary may obtain an appointment and discuss his or her concerns directly with the physician. The appropriate supporting tests, including laboratory evaluation, are determined by the physician. \ IV. Health Education The Assistant Secretary of Defense for Health Affairs is responsible for coordinating the overall policy guidance for the HIV/AIDS education and information program. The military medical departments are responsiole for ensuring that appropriate preventive medicine counseling is given to individual patients and for’providing public health education materials to their beneficiary population. The DoD HIV/AIDS information and education effort is well established. A Departmental coordinating committee provides a forum for information sharing among the Services, reviews and evaluates print and audiovisual materials for use within the Department, recommends materials for joint-interest purchase, and coordinates requests for matérials from national and voluntary organizations. The Department has centrally purchased publications and films and each Service has developed briefing packets and slide presentations, and purchased audiovisual and print materials for specific audiences. In addition, the Department has made extensive use of materials available from other federal agencies and voluntary organizations at no cost to DoD. Several pamphlets and films have been obtained from the U.S. Public Health Service. Print materials include: Surgeon General's Report on Acquired Immune Deficiency Syndrome; Facts About AIDS; Coping with AIDS; several pamphlets developed for the National AIDS Campaign; and, several leaflets coproduced py the U.S. Public Health Service and the American Red Cross. Master copies of the following videotapes have been provided to DoD from the Public Health Service: AIDS: Fears and Facts, for general audiences; What If the Patient Has AIDS, for health care workers; and AIDS and Your Job, for policemen, firemen, and other emergency workers. Thirty-nine television spots have also been reproduced for use overseas. The-Department purchased 1.2 million copies of the booklet, What You Should Know About HTLV-III/AIDS, for the general military audience. A revised version will be available in PY 1988 and 1.8 million copies have been ordered. A commercial film, Facts Over Fears, for general audiences was purchased and has been distributed to Service audiovisual distribution centers. The American Red Cross film, Beyond Fear, has been used by the Services and copies have been reproduced for our audiovisual centers. Copies of the American Red Cross film, A Letter From Brian, with supplemental booklets for students, parents, and teachers have been requested for purchase. Two AIDS education units were developed by the Department of Defense Dependents Schools (DODDS) and distributed to overseas schools with a target audience of junior high and high school age students. A DoD information and education program framework serves to integrate the HIV information and education objectives and activities. The program focuses on prevention measures in general, activities appropriate to school age beneficiaries, efforts directed toward those already HIV antibody positive or at high risk of infection, and information for health care workers, V. Medical Assessment and Preventive Medicine Intervention The medical assessment of each individual with serologic evidence of HIV infection seen at a military medical treatment facility includes an epidemiological assessment of the potential transmission of HIV to other persons at risk of infection, including sexual and other intimate contacts. Obtaining accurate information is vital to provide appropriate preventive medicine counseling and to the continued development of scientifically based information regarding the natural history and transmission patterns of HIV. Therefore, the occurrence of HIV infection or serologic evidence of HIV infection is not used as a basis for any disciplinary action against an individual. Each military medical service conducts a thorough clinical evaluation of its active duty military members with serologic evidence of HIV infection at least annually. Additionally, each military medical service conducts longitudinal clinical evaluations of active duty military personnel with serologic evidence of HIV infection and prepares internal reports to facilitate timely review and reassessment of current policy guidelines. All military medical treatment organizations are required to notify the cognizant military health authority whenever a diagnosis of HIV infection is made or whenever laboratory examination of any specimen yields evidence indicative of infection with HIV. Upon notification, the cognizant military health authority undertakes preventive medicine intervention, including counseling of the individual and others at risk of infection regarding transmission of the virus; coordination with military and civilian blood bank organizations to trace back possible exposure through blood transfusion or donation of infected blood; and referral of appropriate case contact information to the cognizant military or civilian health authority. All individuals with serologic evidence of HIV infection who are military health care beneficiaries are counseled by a physician or designated health care provider regarding the significance of a positive antibody test. They are advised as to the mode of transmission of this virus, the appropriate precautions and personal hygiene measures required to minimize transmission through sexual activities and/or intimate contact with blood or blood products, and of the need to advise any past sexual partners of their infection. Women are advised of the risk of perinatal transmission during past, current and future pregnancies. The beneficiary is informed that he or she is ineligible to donate blood and will be placed on a permanent donor deferral list. Epidemiological investigation attempts to determine potential contacts of the patient. The patient is informed of the importance of case contact notification to interrupt disease transmission and is informed that contacts will be advised of their potential exposure to HIV. Those individuals determined to be at risk who are identified and who are eligible for health care in the military medical system are notified. Military members identified to be at risk are counseled and tested for serologic evidence of HIV infection. Other beneficiaries, such as retirees and family members identified to be at risk, are informed of their risk and offered serologic testing, clinical evaluation, and counseling. The names of individuals identified to be at risk who are not eligible for military health care are provided to local civilian health authorities unless prohibited by the appropriate state or host-nation law or regulation. Anonymity of the HIV index case is maintained unless name reporting is required by the health jurisdiction. Communicable disease reporting procedures of civil authorities are followed to the extent consistent with DoD guidance through liaison between the military public health jurisdiction and the appropriate local, state, territorial, federal, or host-nation health jurisdiction. Due to the high priority assigned to the continued medical evaluation of military personnel with serologic evidence of HIV infection, such individuals are assigned within the United States. Additionally, the Secretaries of the Military Departments, in order to protect the health and safety of military personnel with serologic evidence of HIV infection and of other military personnel, may limit assignment of such individuals with respect to the nature and location of the duties performed in accordance with operational requirements. VI. Retention and Separation Active duty personnel with serologic evidence of HIV infection are referred for a medical evaluation for documentation of fitness for continued service in the same manner as personnel with other progressive illnesses, Evaluation is conducted in accordance with a standardized clinical protocol. Individuals with serologic evidence of HIV infection who show no evidence of clinical illness or other indication of immunologic or neurologic impairment related to HIV infection are not Separated solely on the basis of serologic evidence of HIV infection. Reserve component members with serologic evidence of HIV infection are ineligible for extended active duty (duty for a period of more than 30 days) except under conditions of mobilization. Reserve component members who are not on extended active duty (duty for a period of more than 30 days) or who are not on extended full-time National Guard duty and who show serologic evidence of HIV infection are transferred to the Standby Reserve. Military personnel who are infected with HIV and who are determined to be medically unfit for further duty are given a medical retirement or are medically separated. Military personnel with serologic evidence of HIV infection who are found not to have complied with lawfully ordered preventive medicine procedures for individual patients are subject to appropriate administrative and disciplinary action which may include separation. The Military Departments report that, as of January 1, 1988, 758 Service members have been retired or separated for physical disabilities related to HIV infection. VII. Limitations on the Use of Interview Information Information obtained from a service member during or as a result of an epidemiologic assessment interview may not be used against the service member in a court martial, nonjudicial punishment, involuntary separation (other than for medical reasons), administrative or punitive reduction in grade; denial of promotion, an unfavorable entry in a personnel record; a bar to reenlistment, or any other action considered by the Service Secretary to be an adverse personnel action. Results obtained from laboratory tests for HIV may not be used as the basis for separation of the service member except for a separation based upon physical disability or as specifically authorized by DoD policy. The limitations on use of information obtained from a member do not apply to: the introduction of evidence for impeachment or rebuttal purposes in any proceeding in which the evidence of drug abuse or relevant sexual activity (or lack thereof) has been first introduced by the service member, or to disciplinary or other action based on independently derived evidence; or, nonadverse personnel actions such as reassignment, disqualification (temporary or permanent) from a personnel reliability program, denial, suspension, or revocation of a security clearance, suspension or termination of access to classified information; or, removal (temporary or permanent) from flight status or other duties requiring a high degree of stability or alertness such as explosive ordnance disposal or deep-sea diving. IX. Research The Congressional Conference Report on FY-86 Continuing Resolutions (H.R. No. 99-450) directed that DoD establish an AIDS research and development program under the management of the Assistant Secretary of Defense (Health Affairs). Congress directed that the program be coordinated with similar efforts at the National Institutes of Health. The research efforts explore improved methods of detecting early HIV infections, focus on the early disease patterns, explore risk factors in the military population and take advantage of unique military capabilities and population to test and evaluate candidate drugs and vaccines for use in military applications and in support of the national effort. The DoD HIV/AIDS research program focuses on the epidemiology and natural history of HIV infections in military and military-associated populations, and, on studies of the immune response to HIV infection, including the increased risk in the military environment. The DoD research efforts are now well established. The Army, as lead agency for infectious disease research within DoD, has the responsibility for administering the program. DoD received $37.8 million in FY 86; $21.8 million was appropriated for FY 87. The President's Budget contained $5 million for FY 88 and $12 million for FY 89. For FY88 $11.5 million were appropriated but the additional $6.5 million has still to be authorized. To date, 139 research proposals were reviewed; 66 were approved scientifically, and of these, 45 were approved for military relevancy and funded. One third of the proposals are in Federal laboratories (Army, Navy, Air Force, Uniformed Services University of Health Sciences, Armed Forces Institute of Pathology, National Institutes of Health, Centers for Disease Control, and Veterans Administration). Extensive collaboration with the Public Health Service and other Federal agencies has been maintained, DoD HIV/AIDS research efforts have already established a noteworthy record. DoD researchers participated with the National Institutes of Health in the earliest efforts to isolate the virus, contributed significantly to the issues surrounding heterosexual spread of the infeétion, established the first staging system for classification of the disease, successfully implemented the quality control system for the first large-scale HIV testing program, successfully tested a genetically engineered HIV protein for an improved diagnostic assay, and demonstrated that the blood virus load increases as the stage of the illness_ increases. TESTIMONY FOR THE PRESIDENTIAL COMMISSION ON AIDS INTERNATIONAL SECURITY RAMIFICATIONS OF THE AIDS PANDEMIC JAMES W. LAMONT, PH.D. OFFICE OF THE ASSISTANT SECRETARY OF DEFENSE (INTERNATIONAL SECURITY AFFAIRS) APRIL 20, 1988 Mr. Chairman and Members of the Commissicn: It is both an honor and a welcome opportunity for me to appear before you today to speak about the international security aspects of the AIDS pandemic. AIDS is a subject which the Depactment of Defense has taken very seriously for some time, as the testimony of my colleagues in the health field has shown. We have not approached this universal threat only from a medical standpoint, however, or limited our efforts to the maintenance of a vigorous, effectively deployable fighting force. We have also focused on the effect that the pandemic itself, and the fear which it engenders, could have on our relations with our allies and with friendly countries around the world that host our forces or are visited by them. This _is an aspect of our security situation which in the long run could be as vital to our defense capabilities as the physical condition of United States forces. It is a topic of pressing policy interest for us, and I am therefore particularly gratified that the Commission has seen fit to discuss it here. AIDS can, of course, most directly affect our international security relations through the transmission of the disease, either from foreigners to Department of Defense personnel overseas, or from them to host country nationals. Although these two possibilities may be comparable from an international health standpoint, they require very different approaches. My colleagues have already described the well-known policies of the Department of Defense which are designed to prevent our forces from being infected with human immuno~ deficiency virus through contacts with foreigners. As you know, we provide all possible training in AIDS prevention to our forces resident in or visiting foreign countries, but do not attempt to keep them isolated from local populations. The most obvious basis for our policy is a pragmatic one: little justification can be found for keeping U.S. sailors out of Mombasa, for example, when they are free to visit New York, San Francisco or Washington, D.C. However, our policy has an even more important foundation which relates directly to our national security concerns. The United States has entered into many mutual security commitments essential to the common defense, and our responsibilities under those commitments cannot be fulfilled effectively without the actual presence of our forces on the soil of our allies. With regard to other countries which are friends but not allies, direct contacts have traditionally been a prime means for reinforcing our security relationships. These contacts have ranged from oc¢ca- sional visits to a limited longer-term presence of U.S. forces. A decrease in such activities, for whatever reason, would surely send a negative signal--whether intended or not--which could result in serious consequences for our future options. -3- The question of transmission of the disease from-U.S. personnel to foreigners is quite different. Here, the United States can develop and implement personnel policy--as we have done through our testing and assignment practices--which is aimed at assuring host governments that every reasonable precaution has been taken to prevent the spread of the disease. Whether they accept that assurance, however, is a decision which is not ours to make. Our ability to influence such foreign policy determinations is inevitably limited; our ability to foresee and prepare for them can be nonexistent. In part, this uncertainty is the result of Soviet propa- ganda efforts. The possible transmission of HIV from U.S. personnel to host country nationals has been the subject of a major disinformation campaign waged for several years by the Soviet Union and other Eastern Bloc countries in an attempt to drive a wedge between the U.S. and its allies. This propaganda effort, which has claimed that AIDS was developed by the U.S. as a bacteriological weapon, also attempted to stigmatize U.S. forces overseas, describing them as heavily infected and active in spreading the disease. The disinforma- tion campaign assumed its most virulent form in the diatribes of North Korea, which had as their primary purpose the corrosion of international support for the upcoming Olympic Games in Seoul. In practice, however, allied and friendly nations have not in fact acted to limit the U.S. military presence in their territory, or to call into question our base rights or access rights, despite Communist disinformation and despite their own obvious concerns over the potential spread of the disease on their soil. There are several good reasons why foreign countries have not taken steps to limit local contacts with our forces. The most important is the recognition that effective mutual defense requires U.S. forces to be present or readily available overseas at all times. Thus, our allies and friends have tacitly agreed to let security considerations outweigh fears of AIDS infection, just as the United States has done in sending its forces abroad. A second major reason for the continuing acceptance of U.S. military personnel by other countries is, we believe, our testing and assignment policy. This has made the U.S. Armed Forces into one of the most AIDS-free groups of its size in the world, and by doing so has made these forces increasingly difficult to consider as a dangerous source of the disease. At the same time, however, to think we can rest on our past performance would be disastrous. The extensive U.S. presence abroad and its high visibility mean that we must continue, like Caesar's wife, to be above suspicion. A third reason for other nations' restraint in instituting restrictive controls on our personnel has been their perception that, with our forces present and our military health policies operating effectively, national interests essentially unrelated to defense or to AIDS may also be pursued safely. Thus many countries, including several in Western Europe, have gone on record as opposing AIDS-related measures which would limit international travel and thereby diminish the flow of foreign funds which businessmen and other travelers bring into their economies. By enumerating these three factors, I do not mean to imply that the AIDS pandemic is not a major concern overseas. It is. As a result, many countries, including several in the Middle East and in the Soviet sphere, have adopted some form of AIDS- related control over entry and residence. So far, however, foreign regulations which potentially impinge on the freedom of movement of our forces are few. Costa Rica has regulations in place applying to commercial seaman and sailors, but actual implementation has been delayed pending the completion of a government study. Egypt has extended its contagious disease entry regulations to cover AIDS, at least for certain specific groups, and has begun limited implementation. In other countries with similar controls, we either have no forces to ‘be affected, or the regulations are aimed at other target groups. The attitude of the Department of Defense toward foreign controls which do affect our forces is based principally on two considerations. The first is our belief that AIDS testing can be a valuable weapon in the fight against the disease, and our consequent willingness to accept its application in all appropriate circumstances--as we have accepted our own military testing program. The second is our conviction that all sovereign nations should have the right to determine the conditions under which persons enter their territory or remain there, so long as the rules are applied even-handedly. Of course, we would also hope there would be effective implementation of whatever controls are instituted, although this may prove difficult for many countries to achieve. Nonetheless, I should also make clear, as I suggested above, that some controls may be drafted or implemented so as I to raise issues which are of serious concern to the Department of Defense--and which would call for careful examination, on a case-by-case basis, of the foreign regulations in question. Among such issues, the most important can be summarized as follows: -~- Discrimination. A regulation should apply equally to the citizens of all countries. If it is written so as to place undue burdens on one group such as U.S. nationals, a protest is in order (unless some special relationship makes such differentiation reasonable). -- Sovereignty. We view Navy ships and military aircraft as sovereign. Therefore, we refuse requests to conduct inspections or to obtain specific information (including health information) on individual crew members. -- Security. Because of security considerations, we do not release for any reason detailed lists of personnel embarked in Navy ships or military aircraft landing in foreign countries. -- Medical safety. HIV tests performed in foreign facili- ties may be unsafe. In some places, for example, needles used to draw blood samples might be used more than once, thus acting as potential AIDS transmission devices. ~- Confidentiality. Medical facilities in some foreign countries may not follow a rigid standard regarding the confidentiality of HIV test results. Because of these concerns, we generally favor satisfying any foreign testing or certification requirements through reference to our ongoing military testing and assignment policy. In accordance with this approach, in October 1987 we developed a statement to be used in response to foreign questions concerning AIDS, particularly as regards visiting Navy ships and military aircraft: "U.S. Department of Defense policy requires all military personnel to be screened for serological evidence of human immunodeficiency virus infection. Those with positive serological evidence of HIV infection are assigned within the United States. In implementation of this policy, U.S. Navy and Marine personnel deploying overseas in U.S. Navy ships, and other military personnel enroute to permanent overseas duty, are tested prior to deployment." We feel that this approach can relieve U.S. forces personnel of an unwarranted burden of individual responsibility and risk, while at the same time offering host countries health assurances which local testing or certification procedures may in many cases not be able to duplicate. In sum, many countries are seriously worried by the threat of AIDS, but this worry has not, with minor exceptions, been translated into entry or residence requirements affecting the travel or deployment of U.S. forces. We have taken the policy decisions required to minimize the risk of contagion among our troops overseas, and, having done so, continue to perform our usual activities abroad with the support of our allies and friends. Tomorrow could, of course, be marked by an AIDS-related incident with direct ramifications for U.S. military personnel, or by a general sea change in foreign attitudes. So far, this would seem unlikely, since the same political, economic and security factors which have held such tendencies in check up to now should continue to exert a determining influence. However, if new regulations are in fact instituted abroad, we will do our best to conform to them, even though some of their features may call for consultation and compromise. Meanwhile, our medical personnel will proceed with the task of assuring that the effectiveness of our deployable forces, and their acceptability abroad, are not impaired by the effects of this deadly disease. AIDS: A FOREIGN POLICY CHALLENGE Modern science has never encountered a disease like Acquired Immune Deficiency Syndrome (AIDS). The disease, which is caused by one or more naturally occurring retroviruses of undetermined origin, poses a unique challenge to the international community. The virus is transmitted by sexual activity, contaminated blood and blood products, needle sharing among drug abusers and from infected mothers to newborns. A GLOBAL PROBLEM AIDS has rapidly emerged as a worldwide epidemic since its discovery in 1981. The name is derived from suppressicn of the body's immune system by the Human Immunodeficiency Virus (HIV). HIV damages cells in the body which protect aga.nst parasitic, fungal and bacterial infections, leaving the HIV-infected individual susceptible to a spectrum of opportunistic infections and to certain cancers. HIV has also been shown to damage brain cells causing various neurologic disorders including dementia. The World Health Organization estimates that there have been approximately 100,000 cases of AIDS in the past five years and that five to ten million people are now infected with HIV. He estimates that by the end of 1991 there will be as many as 100 million infected with the virus, 3.5 million AIDS cases, and almost 1 million deaths. The Institute of Medicine and the National Academy of Sciences have published projections by the US Public Health Service that by the end of 1991 in the U.S. there will have been 270,000 cases of AIDS and 179,000 deaths due to AIDS. In Africa, circumstantial evidence suggests that the AIDS epidemic is growing. Central and southern Africa appear to be the areas most severly affected. Projections for the future are uncertain because the total number of cases of AIDS and infected people is unknown. Diagnostic capabilities are limited and patients with AIDS often lack access to health care. There are no systematic seroprevalence surveys, only studies of selected populations such as blood donors, patients at sexually transmitted disease clinics, prostitutes, hospitalized patients and pregnant women at prenatal clinics. Because such populations are not representative the results cannot be extrapolated to make reliable conclusions about the general population. Nevertheless, more and more cases of Kaposi's sarcoma, cryptococcal meningitis and "slim disease" are being reported in central Africa. These conditions are characteristic of AIDS and fulfill a clinical definition of the disease, The HIV has established itself in the rest of the world. Europe has reported approximately 9,000 cases of AIDS to the World Health Organization. In the Americas, excluding the United States, Brazil has reported the highest number of cases. Relatively few cases of AIDS have been reported in Asia. Three categories of acquisition of the HIV infection have been described. The first resembles the situation in the United States where the primary high risk behaviors for infection are homo/bisexual activity and intravenous drug abuse. Heterosexual transmission is occurring with increasing frequency. The second category is seen in developing countries where heterosexual transmission is accepted as the primary mode of spread. The third category constitutes countries where AIDS cases are rare and the most important modes of spread have not yet been determined. Although the natural history of HIV infection is not completely elucidated, it is known that HIV-infected individuals harbor the virus for considerable time prior to developing the disease. During this incubation period the ‘ individual is capable of transmitting the virus despite the fact he/she may not be ill or demonstrate any symptoms. There are two conclusions to draw from this information. First, every case of AIDS is the result of an infection acquired some time in the past, as long as five or more years. The number of cases in a given period is a reflection of seroprevalence in years past. Second, for every case of AIDS WHO estimates that there are 50 to 100 individuals who are infected and capable of spreading the disease. Cases of AIDS can be considered the tip of an iceberg of infection. Further, even if the transmission of the virus were completely interdicted today we will continue to see cases of AIDS develop as the result of HIV infection acquired in the past. The uncertainty of the natural history of the disease, combined with the fact that curative treatment and an effective vaccine will not be available in the immediate future, dictate that governments and international organizations must act now to prevent further spread of the infection. FOREIGN POLICY OBJECTIVES The U.S. Government's responsibilities and interests are defined by the following important foreign policy objectives: (1) Protecting U.S. citizens from health risks associated with international travel and immigration as part of preventing the further spread of the AIDS epidemic. (2) Assisting other governments to deal with the public health, social and political problems associated with the AIDS epidemic. (3) Supporting the efforts of the U.S. and international medical and public health organizations to address the AIDS epidemic. (4) Ensuring that AIDS does not beome a political problem which damages the relationships which the US Government has with other nations. POLICY RESPONSES (1) Educational Program. A program has been established to inform U.S. Government employees and their dependents of measures to protect oneself from the AIDS virus. A videotape, “AIDS: Facts, Fiction and Policy," has been distributed ‘worldwide, along with printed updates incorporating latest information. The program has been expanded to include expatriate Americans, local Embassy employees and travellers. In areas where testing of blood for HIV prior to transfusion is lacking U.S. Embassies maintain "walking blood banks" so that blood can be drawn from mission members in an emergency. (2) Testing of US Government personnel. The Department of Defense requires all active-duty military personnel and enlistees to be screened for serologic evidence of Human Immunodeficiency Virus infection, Priority is placed on testing those seeking to enlist, personnel assigned overseas and personnel on orders for overseas duty. Those with serologic evidence of infection are not inducted. If the individual testing positive is stationed overseas he/she is assigned back to the U.S. Those who are positive and assigned in the U.S. are restricted to duty in the U.S. The Department of State administers the HIV test to Foreign Service employees and adult dependents, including those from close to 40 civilian agencies which assign employees to overseas posts. Individuals who are positive and evidence immunologic impairment are restricted to duty in the U.S. (3) Testing of immigrants and refugees. Pursuant to the President's policy and an Act of Congress a rule was establishec effective August 31, 1987, which lists HIV infection as a "dangerous and contagious disease." Those who apply for immigrant or refugee status must, as part of their required medical examination, be serologically tested for infection with HIV. Any applicant who tests positive or is otherwise known to have the infection is automatically ineligible to enter the U.S. The testing requirement was implemented December 1, 1987. (4) Actions in support of international cooperation. AIDS recognizes no international boundaries. Its contagiousness, its methods of transmission and the social and political sensitivities it generates contribute to an urgent need for international cooperation. This was recognized by President Reagan and other leaders at the Venice Summit when they registered serious concern about the threat of AIDS and endorsed a program of international cooperation, including support of the Global Programme on AIDS (GPA) of the World Health Organization (WHO). As part of this international effort, the U.S. Government has initiated an active program including bilateral foreign assistance, support for WHO, and numerous cooperative arrangments between U.S. and foreign health agencies. In Fiscal Year 1986, the Agency for International Development (A.I.D.) was the first agency to provide financial support to the WHO Special Programme on AIDS ($1 million) and also provided $1 million to the WHO African Regional Office. A.I.D. in FY-87 allocated $14 million to global AIDS control through a $5 million cash contribution to WHO/SPA, $3 million for requests for additional condoms worldwide, and $6 million for technical support of bilateral prevention and control efforts in collaboration with WHO-coordinated host country programs. Technical support is provided through two principal programs. (1) “AIDSCOM" is a public health communications project, global in scope, which will aim to reduce high-risk behaviors. (2) "“AIDSTECH" will provide technical assistance in surveillance and blood screening, as well as health worker training and dissemination of technical information. Research will include investigation of new HIV tests, development of non-reusable syringes, viricides and improved condoms. The U.S. Bureau of the Census has received funding from A.I.D. to establish an international HIV and AIDS database to track the incidence and prevalence of the disease from surveys, publications, cabled reports, and other data sources, A.I.D., in cooperation with the National Academy of Sciences, the Bureau of the Census, and WHO, sponsored an October, 1987, conference on modeling of HIV transmission and the impact of AIDS in the developing world. Making use of the results of the modeling conference, in early FY 1988 A.I.D. will support the preparation of projections of demographic and other impacts of HIV infection and AIDS, as well as development of an awareness-creating microcomputer-based impact model, to be used py- developing country decision-makers. For FY 1988 the Congress doubled the commitment when it appropriated $30 million to A.I.D. The U.S. Public Health Service (USPHS) engages in extensive research programs on various aspects of the AIDS pandemic. These programs are funded inter alia through the Public Health Service agencies with research sites in U.S. government facilities, stateside universities, and overseas sites, primarily in Africa. The Department of Defense is investigating the AIDS phenomenon in the military in stateside medical facilities and performing limited surveillance studies overseas through various medical research units. Both the USPHS and DOD research efforts are bilateral, with concurrence by US Government agencies and foreign governments. -10- PARTICULAR AIDS RELATED FOREIGN POLICY PROBLEMS Soviet Disinformation Campaign In October 1985, the Soviet Union launched a vicious and reprehensible disinformation Campaign alleging that the AIDS virus had originated in a U.S. Military laboratory located at Ft. Detrick, Maryland. The U.S. Government countered the false Soviet charges by making available to media and foreign government representatives factual information on the Soviet campaign and on the subject of AIDS. Ambassadors and public affairs officers at US Embassies around the world have written letters to and met with the editors of papers that have published the disinformation. Moreover, the US Government has repeatedly advised the Soviets that direct US-Soviet collaboration on AIDS research would be impossible as long as the disinformation campaign continues. The Department of State published the Foreign Affairs Note "The USSR's AIDS Disinformation Campaign" in July, 1987 which provides definitive information on the subject. In October, 1988 the 42nd UN General Assembly adopted a resolution (co-sponsored by the U.S., the USSR, and others) which recognizes the serious threat posed by AIDS and calls for a program of international cooperation. This same resolution States that AIDS is caused by one or more naturally occuring retroviruses of unknown origin. In addition there have been -ll- disavowels in the official Soviet media of the charge that the HIV virus was man-made. Unfortunately, the allegation that the had been manufactured in the U.S. or variations of similar slander continue to surface sporadically in the media. We will continue to counter, as appropriate, these inaccurate and, at times, outrageous reports. Testing Requirements for Foreign Residents An increasing number of countries are imposing HIV testing requirements on foreigners entering their country as employees or as students who are resident for extended periods. In the Soviet Union, for example, the testing program is directed at students resident longer than three months. We anticipate testing requirements in other countries. The United States has not established testing requirements for tourists, students, businessmen, or other temporary visitors. The only exception is that the Defense Department requires testing for all foreign military trainees enrolled in Defense-sponsored programs in the U.S. Economic and Social Impacts in Developing Countries Current projections on the number of AIDS cases justify a conclusion that varying degrees of economic and social impacts will be seen in affected countries. In certain developing countries where the infrastructure is already very fragile, the loss of a considerable proportion of young urban adults (some use the term "elite") could cause severe disruptions or even political instability. Uncertainty and fear of AIDS will adversely effect tourism and foreign investment. As the cases mount in affected countries, a heavy burden will be placed on medical facilities. In countries with fragile health care systems where the disease is rampant, the case load may be overwhelming. In Africa, for adults, the disease is primarily acquired heterosexually; the disease afflicts males and females in equal proportion. In some urban areas in Central Africa the seroprevalence rate is estimated at being between 10 and 20 percent. Because the disease strikes the 18 to 45 year age group, there is a significant percentage of pregnant women infected with HIV who are at risk of transmitting the virus to their infants either in the womb or during delivery. An increasing percentage of deliveries will result in HIV infected infants thereby increasing infant mortality. This will erode the gains of recent years in child health and could have demographic effects when combined with losses resulting from AIDS deaths in the 18 to 45 year old age group. -l3- Speculation that HIV will depopulate areas of Africa appears to be unwarranted. The participants of the National Academy of Science Conference on Modeling the Spread of AIDS concluded that, even with the projected rates of AIDS related mortality, Africa is likely to continue to have significant population growth. Mortality rates may be devastating in local areas but will not be enough at a national level to offset s population growth. CONCLUSION The U.S. Government considers AIDS its number-one public health priority. In addition, AIDS is high on the U.S. foreign affairs agenda. Our actions in the international arena, in summary form, include the following: ~~ Educational programs designed to inform USG employees, dependents, expatriates and travellers of AIDS and measures they need to take to protect themselves from acquiring the virus. -- Testing programs directed at active duty military personnel and those seeking to enlist in the military. Department of State and other civilian agency employees and their adult dependents are tested prior to assignment overseas. ~14- A requirement to test all immigrants and refugees, and denial of entry to any foreigner known to be infected with HIV. Active financial and programmatic support for the global program on AIDS of the World Health Organization. This includes establishment of comprehensive national programs in developing countries. An active and growing U.S. foreign assistance program. As an extension of our extensive domestic program, cooperative research programs between U.S. health agencies and foreign entities. A program to establish improved data collection and models for forecasting the incidence and prevalence of AIDS. Our policy with respect to AIDS, domestic as well as international, is based upon humanitarian concerns and sound scientific principles and knowledge. Coordinated research and aggressive educational campaigns are the keys to success. As our knowledge of this disease increases, our policies may be modified accordingly. 11 12 13 15 16 17 18) 19 20 21 22 10 3-95 mandatory testing of DOD civilians. The Deputy Secretary of Defense has authorized the testing of new hires only who are going overseas as part of a medical evaluation. I will address my comments only on the medical side. It is our view that medically there is no need to test people going overseas in a mandatory fashion. There may be other reasons to do so, but medically we do not believe there is sufficient rationale to have a mandatory testing program. CHAIRMAN WALSH: What about local hires? DOCTOR MAZZUCHI: Well, again, we don't -- CHAIRMAN WALSH: The military doesn't have that many, I guess. DOCTOR MAZZUCHI: No, we don't. The reason we test in the military is because of the buddy blood donor system, because of posting our people to areas of endemic disease. These conditions do not happen with civilians and therefore we believe that the medical rationale is not there. Certainly we support, and as a matter of fact have put into place, a policy that encourages voluntary testing, particularly for people who believe they may have been exposed to the NEAL R. GROSS COURT REPORTERS AND TRANSCRIBERS 1323 RHODE ISLAND AVENUE, N W (202) 234-4433 WASHINGTON, D.C 320005 (202) 232-6600 10 11 12 13 14 15 16 17 18 19 20 21 3-96 disease or who want to know their health status. But we don't believe that medicallyytrat is appropriated CUnrrhtnd + CHAIRMAN WALSH: Once again on behalf of the Commission, our thanks to you for a very interesting presentation and certainly candid replies to any questions that we asked that you could reply to. DOCTOR MAZZUCHI: Thank you for the opportunity, sir. CHAIRMAN WATKINS: And Doctor Lamont, I'd like to say that I applaud a history background for ISA. I think we've had too few historians in the past and so I commend you for your skill area. T'm a great fan of ISA in Defense. I think they've done a superb job over the years routinely and I think people with a diverse background, and particularlywith your background, are key to it. So, congratulations for being a historian and talking to us about AIDS DOCTOR LAMONT: Thank you, Admiral. It's been a pleasure to be working wlth ISA. My specialty is American diplomatic history, so it's particularly ‘ i pertinent to what we've been discussing hergcus pny CHAIRMAN WATKINS: Thank you. NEAL R GROSS CQURT REPORTERS AND TRANSCRIBERS 1323 RHODE ISLAND AVENUE, N W (202) 234-4433 WASHINGTON, D.C 20005 (202) 232-6600 bo 10 11 12 13 14 15 16 17 18 19 21 22 CHAIRMAN WALSH: Thank you. While the next panel is coming to the table, I'm going to let some of the Commissioners have a two minute break. (Whereupon, at 10:57 a.m., off the record until 11:04 a.m.) CHAIRMAN WALSH: Gentlemen, we appreciate your coming to discuss with us the HIV pandemic and the movement of people across international borders. Some of us who are engaged in international work are already feeling a degree of restriction and not without reason. But this is becoming important to us. There are many countries, for example, in which the organization which I represent, Project HOPE, works where if any of our teachers are going to stay over 90 days they require a certification that they are HIV negative. As yet there's no indication that they have to be retested, but they have to come with a certificate certifying that they are negative -—etse they will not be granted the traditional work permits ex-whatevexr— So, these things are becoming more and more NEAL R GROSS COURT REPORTERS AND TRANSCRIBERS 1323 RHODE ISLAND AVENUE, N W (202) 234-4433 WASHINGTON, DC 20005 (202) 232-6600 United States Department of State Office of Medical Services Department of State and the Foreign Service R’ashington, D.C. 20520 STATEMENT FOR PRESIDENT'S COMMISSION ON AIDS April 20, 1988 The Department's HIV testing program for Foreign Service employ- ees and applicants has completed one year of operation. HIV testing is required of overseas employees and their dependents over age 12 of the Department of State, AID, USIA and over 35 other federal agencies. The program remains unique because the AIDS problem was confronted with an education and testing program in an employment setting; an entire population is being screened and the problem is being treated in similar fashion to other medical diagnoses, After one year, we believe that such testing has been helpful to those with the infection as well as the broader employee commun- ity. Further, we have demonstrated that such testing can be Gone while maintaining confidentiality and benefits for employees who test positive. Rationale for Testing Most of our reasons for testing relate to the difficulties of service overseas. Underlying these justifications, however, is our belief that a state of ignorance about a disease, particu- larly one that is fatal and infectious, is unacceptable. Those with HIV infection, like those with other serious illnesses, should be informed of the problem, counseled on its implications and have ready access to health care. Their privacy also must be maintained. Repeated immune stimulation has been accepted as one reason for progression of asymptomatic patients to AIDS. Because of this risk, it is now almost universally recommended that HIV positive individuals avoid repeated exposure to infectious diseases and optional vaccinations--particularly live virus vaccines. In our overseas workplace, infectious disease is commonplace, exposure inevitable and vaccination usually required. Testing for HIV infection assures assignment of HIV positive patients to loca- tions where immunizations are not required and the prevalance of infectious diseases approximates that of the United States. REPRODUCED AT GOVERNMENT EXPENSE The great majority of our overseas posts lack facilities to pro- vide health care services to HIV positive patients. Individuals in the guiescent state of HIV infection require periodic moni- toring by experienced health care providers and access to facil- ities capaple of diagnosing and treating complications. Most practitioners follow such patients every three to Six months. If a problem unrelated to HIV infection occurs, authoritative reassurance is provided. If on the other hand the HIV infection progresses, early diagnosis and expert treatment of complications prolongs the patient's life. Testing allows tne Department to assign HIV positive patients to locations where adequate and confidential health care is available. In most overseas locations where our staff resides, no testing of donated blood for antibodies to the HIV is possible. Several times each year staff members are called upon to supply blood to help a colleague. While not a primary reason for HIV testing, testing decreases the chance that this donated blood will be infected with HIV. I should note that the Department is cur- rently in the process of distributing and training personnel to use a quick HIV antibody test to use at the time of transfusion. This test will bring the capability to test donated blood for emergency transfusion to posts where t«sting is not being done. Department of State Experience: For over 30 years the Department of State has providec a compre- hensive medical examination to all applicants and employees and their dependents prior to hiring and sverseasS assignment. This program assures that applicants will be available for worldwide service--a longstanding Foreign Service requirement. It also assures that employees will be assigned to posts with medical facilities capable of caring for identified medicai problems. Tests for numerous problems including cancer, heart disease, syphilis, hepatitis and other infectious problems are included, Lifestyle counseling for identified problems is routine. The diagnostic and counseling services provided those with HIV infection are no different than that provided for other poten- tially serious medical problems. Testing for the Human Immunodeficiency Virus (HIV) was very care- fully considered prior to its approval. The Department had an extensive educational program, and risk reduction strategy in place for three years. It was only after several of our patients received grossly substandard care for complications of HIV in- fection at overseas medical facilities that testing was con- sidered and added to the periodic examination. W GOVERNMENT EXPENSE REPRODU: ’ Employees with evidence of HIV infection (two positive ELISA tests and a positive Western Blot entire procedure repeated on two blood specimens) receive a restricted medical clearance based on the stage of the infection. Those who are asymptomatic and without immune suppression receive a Class Two clearance and are eligible for assignment to posts with adequate medical facilities and experience with this problem. Individuals with evidence of immune suppression and/or other symptoms will be assigned to the United States--a Class Five clearance. Applicants testing posi- tive are not hired because of the limited number of overseas posts at which they are able to serve, Similar constraints are routinely applied to applicants and beneficiaries with other potentially serious medical problems. The program has benefited all groups tested. Those who expected to test negative and tested positive have been informed of their diagnosis and provided counseling to decrease the chance of spread--most of our cases diagnosed by screening fall into this group. Those who expected to test positive and tested positive, had the diagnosis and the fact that they need to take precautions confirmed. Those who tested negative received counseling and information on prevention of the infection. The rate of infection among employees and their dependents over age 12 approximates that found in the U.S. military population. The distribution was surprising because of the relatively large number of married patients. While most patients did not expect positive results, a likely source of the infection was evident in all cases that were interviewed--all but one of the patients. The response to a diagnosis of HIV infection in our population has been an appropriate combination of surprise, anger, sadness, and frustration. No unexpected emotional reactions have occur- red. Careful support and counseling have been provided through our own mental health staff and through resources available in the community. The cost of the program has not been excessive as a result of efficient use of existing resources., Pre-test counseling is offered as part of the physical examination by our clinic staff and examining physicians. The ELISA test procedure, including the technologist's salary, costs about four Gollars per test, The Western Blot, done at a reputable outside laboratory ($30/ est), has been required on only a small number of patients. Post-test counseling for those testing positive is provided by our own Employee Consultation Services (ECS) social workers, staff psychiatrists and outside resources. ” REPRODUCED AT GOVERNMENT CXPENSE ehe testing program was the subject of a suit and a grievance by one of our @mpldyee unions. Both were Settied in our favor. We conclude that testihd of a population for HIV infection is possible and desirable. Such a program however, in our view, Can only proceed if there is a clear reason for testing, and if confidentiality, tontinued employment, and all employee benefits, particularly héalth insurance, are maintained. It has been our experience that confidentiality, as provided by the long estab- lisned concept of a confidential physician-patient télationship, is adequate, particularly if the other factors are assured. “Np bhi) (tL | MY) fiw’ Hl Paul A. Goff M.0., M.P.H. Deputy Medical Director STATEMENT OF ALAN R. HINMAN, M.D. DIRECTOR, CENTER FOR PREVENTION SERVICES CENTERS FOR DISEASE CONTROL ~. PUBLIC. HEALTH SERVICE U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES BEFORE THE PRESIDENTIAL COMMISSION ON THE HUMAN IMMUNODEFICIENCY VIRUS EPIDEMIC April 20, 1988 Mr. Chairman and members of the Commission, I, Dr. Alan Hinman, Director, Center for Prevention Services, am here today to discuss the Centers for Disease Control's responsibilities in the medical examination of aliens as related to infection with human immunodeficiency virus (HIV). Section 212(a) of the Immigration and Nationality Act (42 U.S.C. 1182(a)), lists six medical grounds for the exclusion of aliens: (1) Aliens who are mentally retarded; (2) Aliens who are insane; (3) Aliens who have had one or more attacks of insanity; (4) Aliens afflicted with psychopathic personality, or sexual deviation, or a mental defect; (5) Aliens who are narcotic drug addicts or chronic alcoholics; (6) Aliens who are afflicted with any dangerous contagious disease. The U.S. Public Health Service has promulgated the Medical Examination of Aliens Regulations (42 CFR 34) under the authority of the Immigration and Nationality Act and the Public Health Service (PHS) Act. These regulations, which were revised most recently in 1987, outline the scope of the medical examination and identify the communicable diseases which are included on the list of "dangerous contagious disease" for purposes of determining admissibility to the United States. Section 34.2(b) of Part 34 defines "dangerous contagious disease" as any of the following diseases: chancroid; gonorrhea; granuloma inguinale; human immunodeficiency virus (HIV) infection; leprosy, infectious; lymphogranuloma venereum; syphilis, infectious stage; and tuberculosis, active. Immigrants and refugees coming to the United States must have a physical and mental examination overseas. The examinations are performed by local physicians designated abroad by consular officers of the Department of State. Aliens in the United States applying for adjustment of status to permanent resident, or for legalization of their immigration status, under the Immigration Reform and Control Act of 1986 are examined by physicians designated by the Immigration and Naturalization Service (INS). These medical examinations are performed to identify, for the Department of State and INS, those applicants for admission with excludable mental and physical conditions, as specified in the Immigration and Nationality Act. Aliens who are applying for nonimmigrant visas do not routinely have a medical examination; although, under the provisions of the Immigration and Nationality Act, the medical examination of a nonimmigrant may be required if in the consular officer's opinion an examination is necessary to ascertain whether the alien is eligible to receive a visa. If a U.S. consular officer or U.S. immigration officer suspects that any other alien is suffering from an excludable medical condition, he/she may require the alien to undergo a medical examination. The medical examination procedure consists of a brief history of present or previous illness; a visual inspection of the body's skin surface; an observation for excludable mental conditions; a chest X-ray examination for tuberculosis for persons 15 years of age or older; a chest X-ray examination for persons under 15 years of age if they are il] or have a family member with suspected tuberculosis; and a blood test for syphilis and human immunodeficiency virus infection for persons 15 years of age or older. Any excludable or nonexcludable medical condition which is suspected or detected as a result of the screening examination may require a more comprehensive medical evaluation and may necessitate hospitalization or treatment, or both, before a visa is issued. Acquired immunodeficiency syndrome (AIDS) was added to the list of “dangerous contagious disease" by Federal regulation on June 8, 1987. On that same date a notice in the Federal Register proposed to amend the Medical Examination of Aliens regulations by substituting HIV infection for acquired immunodeficiency syndrome (AIDS) on the list of “dangerous contagious disease." Before this amendment was made effective, Congress enacted, and on July 11, 1987, the President signed, Public Law 100-71 which required the addition of human immunodeficiency virus (HIV) infection to the list of "dangerous contagious disease." This amendment was considered necessary because any person infected with HIV is capable of transmitting the virus, and because the spread of HIV by certain high-risk practices is not unlike several other diseases currently on the list of diseases in the regulations. As a result, the Department of State will deny visas to, and INS may deny admission of, aliens with HIV infection. Screening for HIV infection of aliens 15 years of age or older (and under 15, if indicated) applying for admission into the United States for permanent residence began December 1, 1987. Over the years medical screening, treatment, and referral procedures have allowed millions of immigrants and refugees to enter the United States without significant adverse effects on the health of the American public. Since screening for HIV infection began less than 5 months ago, it is difficult to determine what impact this has had on deterring the importation and further spread of the virus in the United States. It undoubtedly has prevented people who became infected abroad from entering the U.S. It is my understanding that the Department of State has recently collected data on the number of visa applicants who have tested positive since screening was implemented; however, the Public Health Service has not yet had an opportunity to analyze this data. I will be happy to answer questions that you and the other members of the Commission may have. TESTING IMMIGRANT VISA APPLICANTS AND REFUGEES FOR HIV INFECTION Since 1891, the limitations on immigrants entering this country have included some type of disease quarantine provision. The current authority for these measures is Section 212(a) of the Immigration and Naturalization Act. Section 212(a) (6) specifically precludes issuance of a visa or admission to the country of an alien suffering from a "dangerous contagious disease". What constitutes a dangerous contagious disease is determined by the Surgeon General as prescribed by regulation (42 CPR 34.1(b)). As of July 1, 1987 the Surgeon General designated AIDS as a dangerous contagious disease. On August 31, 1987 that designation was changed to infection by HIV, and on December 1, 1987 he required that all immigrants and refugees fifteen years of age or older submit to a serologic examination for HIV as a part of the medical examination that is required of refugees and applicants*. The visa medical examinations are administered by designated panel physicians who practice in the jurisdiction where the visa will be issued. Although these physicians are designated by consular officers, their work is supervised by the U.S. Public Health Service. Procedures for and extent of the examinations are governed by the Medical Examination of Aliens, published by the Centers for Disease Control. All consultative and laboratory work is done under the direction of the panel physician. Testing for infection with HIV begins with an Elisa test _ performed by a local laboratory. If there is a positive result, a second Elisa test is done. If that also tests positive, the sera is submitted to a Western Blot or other acceptable confirmatory test. If all three tests are positive, the applicant is found ineligible for visa or refugee status under the provisions of Section 212(a)(6) of the INA. There is no administrative relief for this ineligibility for immigrants except the Attorney General's discretionary authority to parole such aliens into the United States. *A medical examination is also required for applicants for the finance(e) visa. Although the fiance(e) is a nonimmigrant visa, processing is the same as done for an immigrant visa. -2- Since December 1, 1987 all immigrants and refugees fifteen years of age or older have been tested for HIV infection as part of their visa medical examinations. In most cases, laboratories have been found in-country to perform the tests. Where necessary, arrangements have been made to send sera to a facility in another country to complete any part of the testing series not locally available. Although the original arrangements required great imagination and effort to implement, no immigrant or refugee processing post now reports undue difficulty in getting these examinations performed. The greatest difficulties that had to be overcome were customs and currency provisions where sera is shipped across international borders. With a few exceptions, governments did not express objections to having their citizens examined for infection with HIV. When an applicant is found to be HIV positive he/she is barred from immigration to the United States. The panel physician is under instructions to give the applicants suitable counseling, informing them of their condition and the need to take precautions and to seek medical help. The panel physician then follows local law concerning notification to the host country health authorities. The issue of notification to public health authorities in the United States and to persons placed at risk by the infection is now under review in light of the confidentiality requirements of the Privacy Act and Section 222(£) of the Immigration and Nationality Act. Though the requirement for HIV testing of immigrant and refugee applicants has been in effect only four months, we have begun to collect some statistical data concerning the results of that process. A summary of these findings will be ready for presentation to the Commission at the April 20th hearing in Washington. AIDS-RELATED IMMIGRATION RESTRICTIONS TYPE OF RESTRICTION Testing of Testing of Testing of Testing of Testing of (more than Testing of All Visitors Foreign Workers Students Permanent Immigrants Long-term Visitors one month) Seamen and Servicemen Denial of Entry to Those Suspected of Infection Deportation of Foreigners who Test Positive or have Symptoms * - Proposed Policy; COUNTRIES INVOLVED Iraq, Qatar, Bulgaria, Saudi Arabia (for Haj pilgrims)*, Brazil*, Japan*, S. Korea’, Syria*, Equador** Saudi Arabia, Austria, Kuwait, UAE, S. Africa (mine workers) Egypt (civilians entering Military bases), Finland* PRC, Belguim, Cuba, Finland, Poland, USSR, India, Bulgaria, Costa Rica, FRG (Bavaria) US, New Zealand, FRG (Bavaria) Saudi Arabia, PRC, Philippines*, USSR, Bulgaria Philippines*, Costa Rica** UK, Bulgaria, Indonesia, Australia, FRG (Bavaria) USSR, Cuba, Sri Lanka, Bulgaria S. Africa, PRC, UAE ** - Postponed Policy Note: These policy categories are not necessarily mutually exclusive but illustrate how some countries have targeted different groups of in-migrants. Thank you for the opportunity to present the views of the Immigration and Naturalization Service concerning the issue of movement across international borders of people who are HIV positive. The Service, whose mission includes the control of aliens seeking permission to enter and remain in the United States, is the primary government agency involved in this area. Althougn some nave attempted to characterize tne issue as sicictiy a question of an individual's civil or privacy rights, HIV infection is first and foremost a public health issue. While we must be very attentive to the rights of those infected with the virus, it is equally important to protect our communities against the threats posed by this disease. Historically, Congress has protected our citizens against the import of any significant diseases. Most recently, the Immigration and Nationality Act of 1952 contained a clause excluding all aliens who are “afflicted with any dangerous, contagious disease". The determination of what constitutes a dangerous contagious disease is vested in the Public Health Service. Those diseases included five types of venereal disease, active tuberculosis, and infectious leprosy. On July ll, 1987, the President signed Public Law 100-71, which required the addition of HIV infection to the list of dangerous, contagious diseases. On August 28, 1987 regulations were promulgated by the Public Health Service which added HIV infection to the list of dangerous contagious diseases for which an alien can be found excludable, and revised the procedures for those currently cequired to have a medical examination in connection with immigration into the United States to include an HIV test as a standard pact of the medical examination. Under the Authority of the Immigration and Nationality Act and the Public Health Service Act, the Assistant Secretary of Health promulgates regulations outlining the requirements for the medical examination of aliens seeking admission into the United States. The Public Health Service provides the Department of State and the Department of Justice with medical screening guidelines for all examining physicians that outline, in detail, the scope of medical examination. | A medical examination is mandatory for applications for immigrant visas, fiance(e) of U.S. citizens and their children, and refugees. Aliens applying ~\ for adjustment of their immigration Status to that of permanent resident in the United States and aliens seeking legalization status under the provisions of the Immigration Reform and Control Act of 1986 (IRCA) are also cequired to be medically examined. Aliens applying for nonimmigrant visas (temporary admission) may be required to undergo a medical examination at the discretion of the consular officer overseas if there is reason to suspect that an excludable condition exists. ‘ X ‘ Outside the United States, medical examinations are performed by physicians selected by consular officials of the Department of State. These physicians are known as "panel ptr7sicians". In the United States, medical examinations are performed by physicians selected by district direccors of the Immigration and Naturalization Service. These physicians are known as "civil surgeons". Except for refugees, medical examinations are performed at the expense of the — — applicant with fees paid directly to the examining physician. There is no Standard fee. The Department of State pays the cost of the medical examination for refugees. The purpose of the medical examination is to identify, for the Department of State and the immigration and Naturalization Service, those applicants for admission with excludable mental and physical conditions as specified in the Immigration and Nationality Act. We must continue to do everything within our power to insure that our citizens and those lawfully admitted to the United States are protected from unwanted and unknowing exposure to the infection. The fact remains that it is contagious and incurable. Until a cure is developed, our future decisions must strongly weigh the public health and safety considerations. Thank you for the opportunity to speak before you today. COAST GUARD INTERNATIONAL EFFORTS: THE COAST GUARD WORKS WITH OTHER GUVERNMENTS IN DRUG INTERDICTION WHENEVER POSSIBLE- RECENTLY, THE BAHAMIAN GOVERNMENT SIGNED A TWO YEAR EXTENSIUN TO A U-S-/BAHAMAS SHIPRIDER AGREEMENT. THE AGREEMENT ALSO PERMITS OVERFLIGHTS OF BAHAMIAN AIRSPACE FOR DRUG INTERDICTION MISSIONS. MANY OF OUR DEEP CARIBBEAN PULSE OPERATIONS HAVE BEEN CONDUCTED IN COUPERATION WITH OTHER COUNTRIES INCLUDING COLOMBIA, VENEZUELA, HONDURAS, COSTA RICA, JAMAICA, AND GKENAVA- IN ADDITION, THE COAST GUARD HAS PROVIDED MARITIME LAW ENFORCEMENT TRAINING TO VARTUUS SUURCE AND TRANSSMIPMENT CUUNTRIES AT THEIR REQUEST. WE HOPE THAT COMBINED OPERATIONS AND TRAINING WILL EVENTUALLY LEAD TO INDEPENDENT JRUG INTERUICTIUN OPERATIONS BY SOURCE AND TRANSSHIPHENT COUNTRIES. IMPACTS OF COAST GUARD EFFORTS: SINCE A PEAK YEAR IN 1984, WHEN THE COAST GUARD ALONE SEIZED MORE THAN 2-5 MILLION POUNDS OF MARIJUANA, WE HAVE NOTED A GRADUAL DECLINE IN THE APPAKENT WUANTITY OF MARIJUANA BEING SHIPPED BY SEA. WE FEEL THIS IS DUE, IN PART, TO THE HIGH RISK WE POSE TO TRAFFICKERS IN THE MARITIME AREA- THE LARGE OBVIUUS SHIPMENTS OF MARIJUANA HAVE BEEN REPLACED BY SMALLER LOADS DISTRIBUTED AMONG. SEVERAL VESSELS AND UFTEN SECRETED IN SUPHISTICATED HIDDEN COMPARTMENTS. COCAINE SmUGGLING DOES NOT SHOW THE SAME TREND- IN 1982 We SEIZED ONLY 9 POUNDS. LAST YEAR THE COAST GUARD SEIZED NEAKLY 14,700 PUUNDS AND SO FAR IW 1988 WE HAVE ALREADY SEIZED OVER 4,600 POUNDS UF COCAINE- THIS INDICATES MORE COCAINE 1S BEING SMUGGLED BY SEA- AS WE BECOME MURE EFFECTIVE, WE HOPE TO HAVE A SIMILAR DETERRENT EFFECT AGAINST COCAINE SMUGGLING AS WE HAVE AGAINST MARIJUANA. MR. CHAIRMAN AND MEMBEKS UF THE COMMISSION, IT IS MY PLEASURE 10 APPEAR BEFORE YOU TO ADDRESS COAST GUARD DRUG INTERDICTION OPERATIONS. CAPTAIN JUHN TRAINOK APPEARED BEFURE THIS CONMISSIUN ON 6 APRIL AND PRESENTED TESTIMONY ON THIS SUBJECT. 1 WOULD LIKE TO BUILD ON HIS COMMENTS AND DISCUSS MORE FULLY THE COAST GUARD’S INTERDICTION ROLE IN TWU SPECIFIC AREAS: (1) MARITIME SURFACE INTERDICTION AND (2) AIR INTERDICTIUN- SURFACE INTERDICTION: THE COAST GUARD EMPLUYS A THREE TIER MARITIME INTERDICTION STRATEGY« THIS INVOLVES CONDUCTING OPERATIONS IN THE DEPARTURE ZONE, THE TRANSIT ZUNE AND THE ARRIVAL ZONE. THE DEPARTURE ZONE IS THAT AREA NEAR THE COASTS OF SOURCE COUNTRIES WHERE A SMUGGLING VESSEL WOULD CUPIENCE ITS TRIP- THE TRANSIT ZUNE IS ANY AREA OUTSIvE THE DEPARTURE ZONE EXCLUDING THE COASTAL WATERS AROUND THE UNITED STATES ! WHICH IS THE ARRIVAL ZUNE- ACTIVITIES IN THE DEPARTURE ZUNE INCLUDE RANDUM PULSED UPERATIONS WITH U-S- NAVY AND COAST GUARD VESSELS UNDER THE DIRECTION UF A COAST GUAKY SwUADRUN COMMANDER» DEPARTURE ZUNE OPERATIONS ARE CONDUCTED PRIMARILY DEEP IN THE CARIBBEAN OFF THE SHORES OF SOURCE AND TRANSSHIPMENT CUUNTRIES WHERE WE CAN SEIZE VESSELS CAKKYING LARGER BULK LOADS BEFORE THE DRUGS ARE TRANSFERRED TO SHALLER, GENERALLY FASTER BOATS FUR THE FINAL DASH INTO THE COUNTRY. ON THE EAST COAST OUR STRATEGY OF OPERATIONS WITHIN THE TRANSIT ZUNE IS Tu FUCUS OUR EFFURTS AT NATURAL CHUKE POINTS IN THE YUCATAN CHANNEL BETWEEN CUBA AND MEXICO, THE WINDWARD PASSAGE BETWEEN CUBA AND HAITI, THE MONA PASSAGE BETWEEN PUERTO RICU AND THE DOMINICAN REPUBLIC AWD THE AwEGADA PASSAGE BETWEEN Tide VInGIn ISLANDS AND THE LEEWARD ISLANDS OF THE CARIBBEAN. WE STATION CUTTERS IN THESE CHOKE POINTS, AUGMENTED WITH HELICOPTERS OR SEA BASED AEROSTATS FOR SURVEILLANCE, TO INTERDICT TRAFFICKERS TRANSITING TO THE UNITED STATES- ANOTHER AREA OF SPECIFIC INTEREST WITHIN THE TRANSIT ZONE ARE WATERS SURROUNDING THE ISLANUS OF THE BAHAMAS- BASED ON A SHIPRIDER AGREEMENT WITH THE GOVERWNENT UF THE COMMONWEALTH OF THE BAHAMAS, U-S- COAST GUARD CUTTERS WILL OFTEN CARRY BAHAMIAN OFFICIALS ONBOARD TO CONDUCT LAW ENFURCENENT ACTIONS IN BAKAMIAN WATERS. FINALLY, IN THE AKRKIVAL ZUNE THE COAST GUARD USES OUR SMALLER, CUASTAL RESUURCES TU INTERDICT DRuG TRAFFIC. THE BIGGEST CHALLENGE IS SORTING ANU IDENTIFYING SMUGGLERS FROM THE GREAT NUMBERS OF LEGITIMATE BOAT OWNERS ANU OPERATURS- CUSTOMS RESOURCES ARE ALSO USED IN THIS ZONE. OUR WEST CUAST UNITS UPERATE USING SIMILAR INTERDICTION TACTICS. HOWEVER, A NAJUR DISADVANTAGE IS THE ABSENCE OF ANY NATURAL CHOKE POINTS AND THE GREATER DISTANCES TO SUURLE COUNTRIES. THE MARIJUANA SEIZED BY OUR PACIFIC AREA UNITS IS OFTEN FROM THAILAND IN THE FORM OF “THAL STICKS”- WE HAVE ALSO NOTED AN INCREASE OF PHILIPPINE MARIJUANA SEIZURES- AIR INTERDICTION: THE COAST GUARD SHARES JOINT RESPUNSIBILITIES WITH THE CUSTOMS SERVICE FOR AIR INTERDICTIUN OVER THE MARITIME THEATER. THE PRIMARY TARGETS OF OuR EFFORTS ARE SLOWER, LOW FLYING, GENERAL AVIATION AIRCRAFT. USING OUR E-2C HAWKEYE AIRCRAFT AND LAND BASED AEROSTATS, WHICH ARE BLIMP LIKE BALLOUNS WHICH CARRY RADARS ALOFT UP TU 10,000 FEET, WE CAN MAINTAIN A WIDE AREA OF COVERAGE- WE ALSO COORDINATE WITH UTHER AGENCIES WHICH CAN PROVIDE ADDITIONAL AIR DETECTION INFORMATION. NINE HU-25 FALCON JETS ARE BEING OUTFITTED WITH ADDITIONAL ELECTRONIC EQUIPMENT TO MAKE THEM MURE EFFECTIVE FOR THIS NEWEST CUAST GUARD MISSION. THE COAST GUARD IS JOINED BY U-S- ARMY AND U-S. AIR FORCE APPREHENSION RESOURCES IN CONDUCTING BAHAMIAN DRUG INTERDICTION OPEKATIUNS- HELICOPTERS OPERATED BY THESE THREE SERVICES ARE MANNED BY U-S- DRUG ENFORCEMENT AGENCY AND BAHAMIAN STRIKE FOKCE PERSONNEL AND CONDUCT PUUWCER UPEKATIONS ON SriUGGLING AIRCRAFT WHICH LAND IN THE BAHANAS, OR ON PICKUP VESSELS WHEN AIRCRAFT DROP CONTRABAND TO THEM FOR FURTHER TRANSPORT. CUAST GUARD COOPERATION WITH OTHER AGENCIES: © THE COAST GUARD OFTEN COOPERATES WITH OTHER AGENCIES- EXAMPLES OF THIS YNCLUDE THE DEPLUYIENT OF COAST GUARD LAW ENFORCEMENT TEAMS CALLED LEDETS ON U-S- NAVY VESSELS, WORKING WITH THE DEPARTMENT UF STATE TO DEVELOP INTERNATIONAL AGREEMENTS AND INITIATIVES AGAINST DRUG INTERDICTION, SUPPORTING DEA OPERATIONS IN THE BAHAMAS AND ELSEWHERE, AND OPERATING WITH THE CUSTUMS SERVICE IN MANY AREAS UF OPERATION- WE ALSO RECEIVE SURVEILLANCE SUPPORT FROM THE DEFENSE DEPARTMENT SUCH AS UVERFLIGHTS FRUM NAVY P-5‘S, MARINE CORPS OV-10’S AND AIR FURCE E-3’S. Statement of TERRENCE M, BURKE Deputy Assistant Amdinistrator Drug Enforcement Administration before the Presidential Commission on the Human Immunodeficiency Virus Epidemic concerning International Drug Control Efforts on " April 20, 1988 Admiral Watkins and members of the Presidential Commission on the Human Immunodeficiency Virus Epidemic, on behalf of the Drug Enforcement Administration, I am pleased to appear before you today to discuss international drug control efforts. Two weeks ago, I spoke to you regarding worldwide drug production and trafficking trends, as well as DEA's primary domestic enforcement initiatives. I hope that those earlier comments and my remarks today will be of assistance to this commission in understanding the scope of the drug crisis currently confronting the United States. DEA's mission from an international perspective is to reduce the supply of illegal drugs from foreign source and transit countries. To accomplish this, DEA has special agents, diversion investigators, intelligence analysts, and support personnel stationed in 68 offices in 47 countries throughout the world. Although methods of operation vary from country to country, DEA personnel assigned abroad generally concentrate on liaison, intelligence, and training matters. DEA country attaches strive to maintain liaison at the highest level in order to facilitate joint efforts aimed at immobilizing international narcotics trafficking organizations. We advise amhassadors and chiefs of mission on enforcement matters. We encourage and assist foreign countries in developing drug detection programs. We also work with foreign governments in negotiating mutual assistance treaties and in drafting drug-related legislation. In the area of intelligence, NEA collects, analyzes, and disseminates strategic intelligence on cultivation, production, and trafficking trends and Operational intelligence on international drug trafficking organizations. We work with foreign governments on joint investigations, providing technical and logistical assistance. We cooperate with international law enforcement agencies regarding extraterritorial prosecutions, extraditions, and fugitives. We assist multinational efforts in identifying, seizing, and destroying drug producing laboratories. We also work with foreign governments to confiscate the funds, conveyances, property, and other assets of international drug traffickers. DEA also provides formal training in drug enforcement techniques to foreign officials at schools in the United States. Additionally, we maintain teams of agents who travel throughout the world conducting training sessions for foreign police officers on 2. intelligence gathering, technical equipment, and investigative procedures. The Drug Enforcement Administration has, in recent years, enhanced and expanded its overseas drug law enforcement efforts. At this time, I would like to give you an overview of our international drug control programs. In conjunction with other agencies and the Department of State, NEA is continuing its initiatives in South and Central America aimed at disrupting the processing and shipment of coca products before they leave source countries such as Colomhia, Bolivia, and Peru. During the last several months, joint DEA/host country teams, as well as host country teams acting unilaterally, have destroyed chemicals capable of producing considerably more cocaine than was seized in the United States during all of last year. They have also destroyed laboratories and processing facilities, and seized tons of coca products. DEA has been working jointly with the Government of Peru to immobilize and disrupt the flow of cocaine products from the Upper Huallaga Vailey, which is not 3. only the principal area in Peru of illicit coca cultivation, but also of coca paste and cocaine hase production. Seizure results have heen impressive, with cocaine base confiscations amounting to 1.4 metric tons in 1987, Colombia continues to be active on several fronts in drug enforcement, but has heen facing increased opposition from traffickers in the form of violence and intimidation. The release from a Bogota jail of major drug trafficker Jorge Ochoa-Vaquez in the last days of 1987 showed the ability of the traffickers to manipulate the judicial system of Colombia. However, on a positive note, the Colombian cannabis eradication program continues to he effective in the North Coast area where cannabis is traditionally grown, An agreement was signed in 1987 hetween the United States and Bolivia regarding cooperation in narcotics matters. The Government of Bolivia realized ltimited success in the voluntary eradication of coca cultivation sites last year. However, it was successful in locating and destroying numerous coca processing facilities. In Ecuador, President Leon Febres-Cordero and his government fully support the eradication of coca and the elimination of coca processing and trafficking. By late 4, 1987, almost all coca cultivated in Ecuador had been eradicated. Brazil's primary role in illicit narcotics trafficking is as a major transit country for drugs destined for the United States and Furope. The Government of Brazil has realized significant success in both its drug interdiction and drug eradication programs. Over 80 million cannabis and five million coca plants were eradicated in 1987, and more than 21 metric tons of marijuana and over one metric ton of cocaine were seized. DEA has had a long and generally positive working relationship with the Government of Panama in our joint efforts against drug trafficking, crop eradication, and interdiction. Past Panamanian cooperation has been noteworthy in several areas. For example, since 1980, the Government of Panama has granted every request by U.S. authorities to board Panamanian flagged vessels suspected of carrying drugs. Additionally, on March 29, 1988, Panama's special anti-drug forces, working with DEA, seized 300 kilograms of coca paste which was transitting Panama on its way to Spain. In the area of investigations, it was DEA's own lengthy investigation, of Panamanian General Manuel Cc Antonio Noriega that led to his indictment by a Miami federal grand jury this past February. Yet, despite the indictment of General Noriega, DFA has been assured by the Panamanian Attorney General that they intend to continue cooperating with DEA as they have in the past. The first comprehensive narcotics program agreement between the United States and the Government of Jamaica was signed in February 1987. The goals of this program are aimed at reducing the flow of drugs produced, processed, or staged in Jamaica for onward movement to international markets. Mexico continues to be a major source for heroin and marijuana available in the United States. It also continues to be used as a major transshipment area for cocaine destined for the United States. Colombian trafficking organizations have become aligned with Mexican traffickers to take advantage of the Mexicans' drug smuggling and distribution networks already in place. There has been considerable focus over the past several years on the Mexican narcotics production and trafficking situation. The Presidents of both Mexico and the United States met as recently as this past February to discuss narcotics issues and to strengthen 6. hilateral law enforcement initiatives. We expect that enforcement efforts hetween our two countries will be enhanced as a result of the Mutual Legal Assistance Treaty that has been signed by the Attorney General of Mexico and the U.S. Ambassador to Mexico. The Mexican Congress has already ratified the treaty. Upon ratification by the United States Senate, the treaty will serve as a mechanism through which each government may request and expect formal cooperation and assistance regarding the collection of evidence, witness testimony, and other investigative and judicial procedures. New interdiction programs, projects, equipment, and manpower have been officially encouraged and welcomed hy the Government of the Bahamas. They have funded new enforcement vessels, have authorized two new United States/Bahamian boat stations in the Bahamas, and have approved an additional aerostat radar installation at George Town. Additionally, the Royal Bahamian Nefence Force has shown marked improvement in its law enforcement efforts, making a number of major unilateral drug seizures during the past year. In an effort to strengthen and expand DEA's drug law enforcement activities in Latin America, we recently 7, opened offices in Haiti, Honduras, and Paraguay. DEA is also involved in a number of special enforcement operations in Mexico, Central America, South America, and the Caribbean. For example, DEA has spearheaded Operation Chem Con for several years. This operation is aimed at reducing the availability of essential chemicals used in the illicit manufacture of cocaine and other drugs. In 1987, DEA focused its efforts on Colombia, Ecuador, Venezuela, Bolivia, and Peru, countries which use essential chemicals to produce drugs; and Brazil, Argentina, and Chile, countries which produce essential chemicals used in illicit drug production. DEA is continuing its interdiction activity in the Caribbean via Operation BAT, which operates in the Bahamas and the Turk and Caicos Islands. Among the objectives of Operation BAT are the disruption of the flow of marijuana and cocaine transitting this area en route to the United States and an attempt to close the islands to smugglers for use as aircraft refueling stops, storage locations, and staging points. Operation Alliance is an interagency effort of the U.S. Customs Service, the Border Patrol, and DEA for the purpose of interdicting narcotics that flow across the 8. southwest border of the United States from Mexico. Another special DEA enforcement operation, Operation Full Press, was first implemented in October 1986. It is conducted with thea U.S. Border Patrol and supported by the U.S. Customs Service within Operation Alliance. Operation Full Press is directed toward the interdiction of narcotics hetween and at the ports of entry as well as the initiation of follow-up investigations and prosecutions. During FY 87, Operation Full Press achieved tactical successes which were highlighted by a total of 534 investigative case initiations, 658 arrests, and seizures of over 32,000 kilograms of marijuana and over 1,700 kilograms of cocaine. Although we tend to focus on Latin America as the source of much of the illicit drugs entering the United States, drug production, trafficking, and abuse are also significant in Southeast Asia, Southwest Asia, and Europe. In Southeast Asia, the governments of Burma and Thailand continue their efforts to stem the production and trafficking of heroin and marijuana originating from that area. In October 1987, in a joint DEA/Thai investigation, the Thai National Police seized 680 9. kilograms of No. 4 heroin from a Thai fishing trawler in the Gulf of Thailand. And this past February, the Royal Thai Customs seized 1,089 kilograms of No, 4 heroin, The heroin was concealed within 6? bales of rubber, which was to be shipped to a company in New York via Singapore. Another Southeast Asian country, Malaysia, has shown its resolve against heroin trafficking within its borders by mandating its courts to sentence to death all persons convicted of possession of more than 15 grams of pure heroin. From 1975 through October 1987, 60 traffickers have been hanged and 103 more are on death row. In Southwest Asia, the countries of Lebanon, Pakistan, and Afghanistan remain the major world producers of hashish. India, Nepal, and Morocco are also producers. Pakistan has been working with the United States and other concerned governments in conducting a "Foreign Enforcement Agencies Cooperation Program." The Government of Pakistan is permitting the stationing in Pakistan of foreign drug enforcement personnel who initiate and conduct investigations of: international drug smuggling. 19, Pakistan has demonstrated increased enforcement activity in the production of semi-refined and refined narcotics and is: taking enforcement: actions' against drug trafficking organizations based in Pakistan. During the first nine months of 1987, Pakistan seized approximately 2,250 kilograms of heroin, There has heen a continuing dialogue among the U.S. Embassy in India, DEA, and top Indian policy-makers about drug ahuse and drug .trafficking; The Government of India has accepted training and assistance on narcotics enforcement from DEA. India has also made overtures to neighboring countries for the exchange of narcotics intelligence. Europe remains a-transshipment area for narcotics from Southeast and Southwest Asia, and is a consumer of all types of drugs.. Since 1984, 21 heroin labs, most of which were converting No. 4 Southeast Asia heroin to No. 3 smoking heroin, have been seized in the Netherlands; It is believed that this heroin was intended for further distribution in Europe. sR The trafficking of cocaine from South America to 11. European countries is continuing. In Spain, where Colombian traffickers are most active, cocaine seizures have increased by over 165 percent from 1985 when 30? kilograms were seized to 809 kilograms during the first 11 months of 1987. Over the past few years, we have seen significant progress in international cooperative efforts and in individual country's efforts against drug production, trafficking, and abuse. There is an increasing level of involvement today in drug control matters among drug source, drug transit, and drug consuming countries. DEA is committed on the international front to reducing the supply of cocaine from Latin America, reducing the supply of heroin from the Middle Fast, Asia, and Mexico, and reducing the supply of marijuana from worldwide sources. Additionally, we are utilizing our resources to target and immobilize principal drug trafficking organizations by arresting their members, seizing their drugs, and confiscating their assets. We are also continuing to pursue our cooperative international efforts concerning demand reduction initiatives. Mr. Chairman, I appreciate this opportunity to discuss worldwide efforts aimed at international drug 12. control. I will be pleased to answer any questions that you or members of the Commission may have. 13. Ne Sea STATEMENT OF LIEUTENANT GENERAL STEPHEN G. OLMSTEAD, USMC DEPUTY ASSISTANT SECRETARY OF DEFENSE FOR DRUG POLICY AND ENFORCEMENT / DIRECTOR, DOD TASK FORCE ON DRUG ENFORCEMENT DEPARTMENT OF DEFENSE BEFORE THE PRESIDENTIAL COMMISSION ON THE HUMAN IMMUNODEFICIENCY VIRUS EPIDEMIC APRIL 20, 1988 FOR OFFICIAL USE ONLY UNTIL RELEASED BY THE COMMISSION smuggling effort. While the pressure must be maintained in the law enforcement area, I remain convinced that real victory in this conflict can be achieved only through the elimination of the demand for drugs. On the demand side, the Department has been successful in cleaning up its own backyard. , Five thousand DoD school children a month are receiving DARE, Drug Abuse Resistance Education, | lectures, and the use of illegal drugs by your military is at an all-time low. The 1985 DoD Worldwide Survey reported that less than nine percent of our military men and women reported using illegal drugs in the preceding 30 days. This was a dramatic 67 percent reduction in reported drug use since 1980 when the first survey was conducted. The survey will be repeated again in the Spring 1988. | We have been testing our military members successfully since the 1970's. And as mandated by the Congress in the FY 88/89 DoD Authorization Act, we will begin conducting pre-accession drug and alcohol testing by June 1, 1988. All applicants for military service must be tested before entry into the Armed Forces. The Department will soon begin testing those civilians in designated positions for drug abuse. The Department of the Army has been testing civilians since February 1986 and the Department of the Navy began testing civilians in the Military Sealift Command since January 1983. Although we do not believe we have a In addition to the DARE program, the schools are also participating in the Challenge Campaign which is under the auspices of the Department of Education. This campaign encourages the involvement of all segments of the local community in working toward drug-free schools. The DoD schools will shortly issue policy which establishes clear and specific rules regarding drug use and its consequences. But our work does not stop here. We are reaching outside the DoD community to help reduce the demand for drugs in America. Our network of more than 20,000 military recruiters is in constant contact with the nation's youth in both their schools and their neighborhoods. Our recruiters take every opportunity to emphasize the dangers of drug abuse to our young people. As examples, Army recruiters utilize the Army's drug and alcohol abuse control teams for presentations at every opportunity. Navy recruiters show every prospective recruit an anti-drug abuse film, and Air Force recruiters have been specially trained to conduct .the Air Force Drug Awareness programs. The Marine Corps has produced an anti-drug video with supporting public affairs pamphlets and posters. In addition to our military recruiters, we have activated our network of National Guard and Reserve personnel and enlisted them in the war on drugs. In April 1987, then Secretary Weinberger sent an open letter to all Guard and Reserve Personnel urging them to take a leading role in their communities to destroy drug become the Nation's primary long-range surveillance system for the detection of aerial drug smugglers. Another important DoD initiative is the support provided by the Reserves and National Guard. National Guard personnel were responsible for over 3,121 aerial surveillance flight hours and expended 9,000 man days on drug eradication during FY87. In conjunction with the Vice President's National Narcotics Border Interdiction System, the Department will be expanding Reserve/National Guard support by considering the long-term requirements of drug law enforcement authorities in conjunction with the long-range scheduling of Reserve/National Guard drills and training activities. In support of the State Department's efforts to eradicate drug crops at the source and to seize drugs at transshipment points, the Defense Department has provided assistance to the governments of Colombia, Bolivia, and The Bahamas. Military personnel have provided training and expert advice to the National Police of Colombia and Bolivia which aided their efforts | to eradicate drug crops and locate and destroy drug processing laboratories. In the Bahamas, DoD helicopter crews have provided the capability for quick insertion of Bahamian strike force personnel and DEA agents to drug cache sites. This successful international effort, Operation Bahamas and Turks (OPBAT), contributed to nearly 15 percent of the total cocaine seizures during FY87.