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, DC 20520 December 1, 2003 Dear Ambassador Tobias: As physicians, nurses, public health specialists, we write to you on World AIDS Day to seek your assurance that US-funded HIV/AIDS prevention programs will be guided by sound science and human rights principles. We are members of Physicians for Human Rights’ Health Action AIDS campaign, which is committed to best practices for a comprehensive strategy of HIV/AIDS prevention, care, and treatment. We support the ABC’s of prevention – abstain, be faithful, use a condom – while insisting that a successful prevention strategy must go well beyond ABC. Such a strategy requires that activities protect even the hardest to reach – the most vulnerable populations. Those most at risk – such as men who have sex with men, injecting drug users, and commercial sex workers – are marginalized within their own countries. As you know, USAID has a history of providing AIDS education and condoms to such groups, who in many countries are not reached by their own governments’ initiatives. It is vitally important that the United States continue to fill this extremely important gap. Expanding access to prevention interventions for general population Targeted programs for especially high risk for contracting HIV/AIDS is crucial, yet slowing and ultimately reversing the spread of HIV/AIDS also requires making AIDS interventions readily accessible to the general population. Access to prevention interventions remains distressingly low in many AIDS-burdened countries. For example, according to the United Nations, globally only one in nine people who are seeking their HIV status have access to voluntary counseling and testing services. In Africa, fewer than one in three people have access to contraceptive promotion programs. Thus, access to prevention interventions must be vastly expanded, including voluntary counseling and testing, management of sexually transmitted infections, risk reduction programs and lifeskills education for youth, targeted programs for married couples, and access to condoms. The planned rapid scale-up of US-funded HIV treatment is also crucial to HIV/AIDS prevention, because the possibility of treatment can motivate people to seek voluntary counseling and testing, anti-retroviral therapy reduces patient viral load, and the availability of treatment can help reduce the stigma associated with HIV/AIDS. Reducing the denial, stigma, and discrimination associated with HIV/AIDS is central to HIV/AIDS prevention efforts. Mass marketing of condoms and comprehensive sexual education As part of its HIV prevention strategy, the United States must continue to include mass marketing of condoms and comprehensive sexual education. While abstaining from sex is the only way to guarantee that a person will not contract HIV through sexual activity, consistent use of condoms will greatly reduce the risk of people who do engage in sexual activity. Studies demonstrate that condoms are at least 90% effective at preventing HIV
transmission when used correctly and consistently. A recent study by the Guttmacher Institute concluded that progress on abstinence, reduced numbers of multiple-partners, and increased condom use all contribute to Uganda’s reduction in HIV prevalence, “although reductions in the number of sexual partners and increased condom use may be playing a more significant role in reducing HIV risk than sexual abstinence by itself.” A literature review of US sexual education programs by the AIDS Research Institute at the University of California, San Francisco found that abstinence-until-marriage education has no measurable impact, whereas comprehensive sexual education often delays the onset of sexual activity, reduces the number of sexual partners, and increases condom use. Congress has directed that one-third of money for prevention activities should be used for abstinenceuntil-marriage programs. If grants are made to NGOs that do not support condom use, USAID must ensure that these NGOs neither discourage condom use nor discredit their effectiveness. Further, these grants must be balanced by grants to programs that do provide information on and access to condoms, so that comprehensive prevention services are available to all. Also, it appears that the one-third provision was meant to modify funding for sexual transmission prevention programs, to assure that the “A” portion of “ABC” prevention strategies be funded. In keeping with that spirit, we respectfully urge that the onethird provision apply only to sexual transmission prevention programs, and that abstinence programs not be funded with resources from other prevention accounts, such as voluntary counseling and testing, safe health care initiatives, programs to prevent mother-to-child transmission, and harm reduction programs for injecting drug users. Marginalized populations Women at risk of domestic violence and coerced sex Prevention efforts must provide people options that are relevant to their circumstances. Safe sexual behavior is not an option for many women, as they risk violence, abandonment, and economic destitution if they contest the sexual demands of their partner. To help provide women the ability to choose the terms of their sexual interactions without risking violence or jeopardizing their ability to meet their basic needs, the United States should incorporate the protection of women’s rights into its strategy to combat HIV/AIDS. Key elements include: 1) tailor HIV/AIDS prevention, care, and treatment programs to address specific needs of women, such as by incorporating partner communication skills in prevention programs, and ensure women’s access to these programs; 2) integrate voluntary counseling and testing services into antenatal and other health services used by women; 3) assist law enforcement in preventing and prosecuting violence against women; 4) promote income-generating opportunities for women and economic assistance to survivors of domestic violence; 5) establish shelters for survivors of domestic violence; 6) encourage legal change to provide women equal rights in areas including property, inheritance, and divorce, and ensure women access to legal assistance; 7) support domestic violence sensitization programs for health providers and encourage the establishment of protocols on health providers’ interactions with survivors of domestic violence, and; 8) promote widespread education on women’s rights. People engaged in sex work Women and men engaged in sex work are especially vulnerable to HIV infection. Many sex workers, most of whom are women, do not choose this form of work. Rather, they enter it as a last resort to earn a living for themselves and their children. Prevention efforts should include support for girls’ and women’s education and income-generating projects that will provide sex workers other options, but not to the exclusion of strategies to protect women and men who are engaged in sex work, including condom dissemination, prevention and treatment of sexually transmitted infections, and voluntary counseling and testing. In Thailand, promoting universal and consistent condom use among commercial sex workers has
been central to Thailand’s success in turning the tide of its epidemic, as new HIV infections have dropped by 80% from peak levels in the early 1990s. UNAIDS reports that in Abidjan, Côte d'Ivoire, targeted prevention efforts for sex workers increased their condom use from about 20% in 1992 to almost 80% in 1998, while cutting their HIV prevalence by nearly two-thirds. Men who have sex with men Aggressive outreach efforts are needed to provide HIV/AIDS services to men who have sex with men, who are often driven underground by stigma and persecution. Prevention efforts should include targeted distribution of condoms, promotion of safer sex, and treatment of sexually transmitted infections. They should also offer opportunities for these men to communicate openly on issues they face and to provide support for one another. Prevention efforts will be most successful when coupled with efforts to defend the human rights of men who have sex with men. Countries should not punish sex between consenting adults and should make available non-punitive and non-judgmental confidential prevention, care, and treatment services to men who have sex with men. These services work. In Jamaica, for example, a national AIDS organization sponsors an outreach and risk reduction project for men who have sex with men. Over eight months in 1996, the project led to a 40% increase in condom use and 30% reduction in reported high-risk behavior among clients. The United States should help build the capacity of organizations that provide these outreach services and endeavor to protect the rights of men who have sex with men. The US government should also strongly and openly condemn remarks by officials in AIDSburdened countries that are hostile to the rights of homosexuals, or even deny the very existence of homosexuals in their countries. Such comments are anathema to HIV prevention, and must be addressed. Injecting drug users In Eastern Europe, Russia, and much of Central and Southeast Asia, injecting drug use is the major force driving the AIDS epidemic. Given the complexity and long-term nature of the problem of drug use, an AIDS prevention strategy for injecting drug users cannot rely solely on efforts to stop injecting drug use. Rather, it should follow a harm reduction approach, which incorporates a spectrum of strategies ranging from safer drug use to managed drug use to no drug use. These strategies include ensuring access to condoms and sterile syringes, as well as education and access to voluntary counseling and testing and HIV care. Needle-exchange programs do not increase drug use. A global review from 1988 to 1993 of 29 cities with needle-exchange programs found no increase in the number of injecting drug users; HIV prevalence fell by 5.8% per year. This finding has been confirmed by numerous studies since. Needle exchange programs have reduced the prevalence of HIV among injecting drug users in New York City, New Haven, and other US cities, and is being implemented in several countries in Asia including Thailand, India, and China. In 1997, the National Institutes of Health credited needle exchange programs with reducing HIV transmission rates in the United States by one-third to two-fifths. The same year, the US Conference of Mayors endorsed needle exchange as part of a comprehensive harm reduction strategy for injecting drug users in the United States. These are far from the complete range of interventions needed as part of a comprehensive strategy for HIV/AIDS prevention, care, and treatment. Populations besides those discussed above are at high-risk and require targeted strategies, including street children and other youth, as well as migrant workers. Prevention efforts are also required for the general population. US-funded prevention programs should target all routes of HIV transmission. Programs to prevent mother-to-child HIV transmission and to end HIV transmission in health care settings, including through blood transfusions and medical injections, should expand dramatically.
Now that the United States is ready to mount a serious response, it would be tragic if that response ignored best scientific practices. We look forward to working with you and stand ready to offer you our assistance.
Sincerely, Kimberly Adams-Tufts, ND, RNc, WHNP, FAAN Associate Professor of Nursing and Health Policy Case Western Reserve University* Cleveland, OH Rabia Akram, MPH, MBA Program Coordinator Sinai Community Institute Chicago, IL Joel Albers, PharmD, PhD Clinical Pharmacist Minneapolis, MN Jonathan S. Allan, DVM Scientist, Department of Virology and Immunology Southwest Foundation for Biomedical Research San Antonio, TX Emily Althaus, MA Counseling Center University of Illinois at Chicago Chicago, IL Holly Atkinson, MD President, Physicians for Human Rights Assistant Professor, Department of Public Health Weill Cornell Medical College New York, NY Suzanne Bakken, RN, DNSc, FAAN Alumni Professor of Nursing and Professor of Biomedical Informatics Director, Center for Evidence-based Practice in the Underserved Columbia University New York, NY John G. Bartlett, MD Johns Hopkins University Baltimore, MD D. Bennett, MD, MPH Rollins School of Public Health Emory University Atlanta, GA
Alan Berkman, MD Professor, Department of Epidemiology Mailman School of Public Health Columbia University New York, NY Cathy Berman, NP, RN, MS Nurse Practitioner Oakland, CA Robert E. Booth, PhD Professor of Psychiatry University of Colorado School of Medicine Denver, CO Donald S. Burke, MD Professor of International Health Bloomberg School of Public Health Johns Hopkins University Baltimore, MD James F. Campbell, PhD Director, University of Rhode Island Counseling Center Kingston, RI Susanne M. Campbell, RN, CMS Vice-President, Health Services United Community and Family Services Norwich, CT Rafael E. Campo, MD Associate Professor of Medicine University of Miami School of Medicine Miami, FL Alberto Cardelle, PhD, MPH East Stroudsburg University East Stroudsburg, PA E. Jane Carter, MD Assistant Professor of Medicine Divisions of Infectious Diseases, Pulmonary, and Critical Care Brown Medical School Providence, RI Anthony C. Cheng, MD Contra Costa Regional Medical Center Martinez, CA
Julie Chitty, NP, RN, MPH Africa Specialist United States Agency for International Development Arlington, VA Wanjiku Chiuri, PhD Beloit College Beloit, WI Michael H. Chung, MD, MPH Division of Allergy and Infectious Disease University of Washington Seattle, WA Colleen Clark, PhD University of Southern Florida Tampa, Florida Jodi Clark, MD Florida International University Miami Gardens, FL Mardge H. Cohen, MD Director of Women’s HIV Research Cook County Bureau of Health Services Chicago, IL Eve Cominos, MD Contra Costa Regional Medical Center Martinez, CA Molly Cooke, MD Professor of Medicine University of California, San Francisco Director, The Haile T. Debas Academy of Medical Educators San Francisco, CA Joseph Courtney, PhD California Department of Health Services Berkeley, CA James Curran, MD, MPH Dean, Rollins School of Public Health Emory University Atlanta, GA
Susan Cu-Uvin, MD Associate Professor, Obstetrics and Gynecology Medical Director of the Immunology Center The Miriam Hospital Brown University Providence, RI Nils Daulaire, MD, MPH President and CEO Global Health Council White River Junction, VT Frank Davidoff, MD, MACP Editor Emeritus Annals of Internal Medicine Wethersfield, CT Andrew J. Desruisseau, MD Chief of Medicine University of Kansas Kansas City, KS Marcela Dixon Community Health Worker Multnomah County Health Department Portland, OR Deborah Donnell, PhD HPTN Deputy Director, Statistical Center for HIV/AIDS Research and Prevention Fred Hutchison Cancer Research Center Seattle WA Cristiane Duarte, PhD Assistant Professor Columbia University New York, NY Paul Eckburg, MD Division of Infectious Diseases Stanford University School of Medicine Stanford, CA Leon Eisenberg, MD Professor of Psychiatry and Professor of Social Medicine Emeritus Department of Social Medicine Harvard Medical School Boston, MA
Wafaa El-Sadr, MD, MPH Harlem Hospital Center/Columbia University New York, NY Margaret Eng, MD Assistant Program Director, Department of Medicine Monmouth Medical Center Long Branch, NJ Joseph J. Eron Jr., MD Associate Professor of Medicine University of North Carolina at Chapel Hill Chapel Hill, NC Paul Farmer, MD, PhD Maud and Lillian Presley Professor of Medical Anthropology Co-Director, Program in Infectious Disease and Social Change, Department of Social Medicine Harvard Medical School Vice Chair, Division of Social Medicine and Health Inequalities Brigham and Women’s Hospital Medical Director, Zanmi Lasante, Cange, Haiti Founding Director, Partners In Health Boston, MA Carey Farquhar, MD, MPH Division of Allergy and Infectious Disease University of Washington Co-Director, International AIDS Research and Training Program Seattle WA Maria Fernandez, MPH Senior Project Coordinator South Los Angeles Health Projects Inglewood, CA Joyce J. Fitzpatrick, PhD, MBA, RN, FAAN Elizabeth Brooks Ford Professor of Nursing Case Western Reserve University Cleveland, OH Donna M. Gallagher, RNCS, MS, ANP, FAAN Principal Investigator and Director, New England AIDS Education and Training Center President, International Education and Training Consultants Boston, MA H. Jack Geiger, MD, M.Sci.Hyg. Arthur C. Logan Professor Emeritus Department of Community Health and Social Medicine City University of New York Medical School New York, NY
Thomas P. Giordano, MD Assistant Professor of Medicine Baylor College of Medicine Houston, TX Stephen Gloyd, MD, MPH Professor and Director, International Health Program School of Public Health and Community Medicine University of Washington Executive Director, Health Alliance International Seattle, WA Warner C. Greene, MD, PhD Director, Gladstone Institute of Virology and Immunology Professor of Medicine, Microbiology and Immunology University of California, San Francisco San Francisco, CA Ronald J. Grossman, MD Anderson Clinical Research, Inc New York, NY Sergiu Grozavu, MD, MPH Psychiatrist Los Angeles, CA Thomas Hall, MD, DrPH Emeritus Professor, Department of Epidemiology and Biostatistics Program Head, Program in International Epidemiology University of California, San Francisco San Francisco, CA Jane Halpern, MD, DrPH Director, University Health Services Bloomberg School of Public Health Johns Hopkins University Baltimore, MD Michael J. Harbour, MD Clinical Assistant Professor Division of Infectious Diseases Stanford University School of Medicine Stanford, CA Barbara J. Hatcher, PhD, MPH, RN Director, Scientific and Professional Affairs The American Public Health Association Board Member, Harambee Africa AIDS Initiative Washington, DC
Frederick M. Hecht, MD University of California, San Francisco San Francisco, CA Vickie Height, MD, MPH President and CEO Medical & Compensation Consultants San Francisco, CA Robert Heimer, PhD Department of Epidemiology & Public Health Yale School of Medicine New Haven, CT Arnd M. Herz, MD Chief of Pediatrics and Pediatric Infectious Diseases The Permanente Medical Group Hayward, CA Sharon Hiner, MD Contra Costa Regional Medical Center Martinez, CA Martin S. Hirsch, MD Professor of Medicine, Harvard Medical School Professor of Immunology and Infectious Diseases, Harvard School of Public Health Editor, the Journal of Infectious Diseases Boston, MA David Hoos, MD Assistant Professor of Epidemiology Mailman School of Public Health Columbia University New York, NY Christina Hoven, DrPH Director, Child Epidemiology Group Columbia University Bronxville, NY Joyce Hunter, DSW Researcher, HIV Center New York State Psychiatric Institute New York, NY Kenyetta Jackson, MPH University of Michigan School of Public Health Ann Arbor, MI
Thomas L. James, PhD Professor & Chair, Department of Pharmaceutical Chemistry University of California, San Francisco San Francisco, CA Dayle Joseph, EdD, RN Dean, University of Rhode Island College of Nursing Kingston, RI Naunanikinau Kamalii, JD Health Service Officer Honolulu, HI Michael Katz, MD Senior Vice President for Research and Global Programs March of Dimes, Birth Defects Foundation Carpentier Professor Emeritus of Pediatrics, Columbia University White Plains, NY David A. Katzenstein, MD Associate Director, AIDS Clinical Trials Unit Associate Professor of Medicine, Division of Infectious Disease Stanford Univeristy Stanford, CA David L. Kaufman, MD Chief, Ambulatory Care Medical Director, Spellman HIV Center St. Vincent’s Midtown Hospital New York, NY Carol A. Kemper, MD, FACP Clinical Associate Professor of Medicine, Stanford University Division of Infectious Diseases, Santa Clara Valley Medical Center Santa Clara, CA James Kiarie, MBChB, MMed, MPH Department of Obstetrics and Gynaecology University of Nairobi Kenya Amy V. Kindrick, MD, MPH National HIV/AIDS Clinicians' Consultation Center San Francisco General Hospital San Francisco, CA Tess Klaristenfeld, MPH Brown University School of Medicine East Providence, RI
Mark W. Kline, MD Professor of Pediatrics Head, Section of Retrovirology Director, Baylor International Pediatric AIDS Initiative Baylor College of Medicine Texas Children's Hospital Houston, TX Daniel R. Kuritzkes, MD Associate Professor of Medicine Harvard Medical School Vice-President, Board of Directors HIV Medicine Association Cambridge, MA Peter Lamptey, MD, DrPH President, Family Health International AIDS Institute Arlington, VA Jeffrey Laurence, MD Professor of Medicine Director, Laboratory for AIDS Research Weill Medical College of Cornell University Editor-in-Chief, Patient Care & STDs and The AIDS Reader New York, NY Jay A. Levy, M.D. Professor of Medicine Department of Medicine University of California, San Francisco San Francisco, CA Vivan Levy, MD Stanford University Division of Infectious Disesases and Geographical Medicine Stanford University Palo Alto, CA Robert Lipton, PhD Research Scientist Prevention Research Center Berkeley, CA Grace E. Macalino, PhD Assistant Professor, Department of Community Health Brown Medical School Providence, RI
Kenneth Mayer, MD Professor of Medicine and Community Health Director, Brown University AIDS Program Brown University Providence, RI Mahrukh Mohiuddin, BBA, MPH Research Assistant, Infectious Disease Unit Tufts University Jamaica Plain, MA Donald E. Morisky, ScD, MSPH, ScM Program Director, Social and Behavioral Determinants of AIDS and Tuberculosis Training Professor, Department of Community Health Sciences University of California, Los Angeles School of Public Health Los Angeles, CA Cynthia D. Mulrow, MD, MSc Deputy Editor Annals of Internal Medicine Philadelphia, PA Krishna K. Murthy, DVM, PhD Department of Virology and Immunology Southwest Foundation for Biomedical Research San Antonio, TX Jeffrey Nadler, MD University of South Florida Tampa, FL France Nguyen, MPH University of California-Los Angeles Los Angeles, CA Colette O’Keefe, MD Contra Costa Regional Medical Center Martinez, CA Jennifer Okonsky, MA, APRN, BC Nurse Practitioner Raritan, NJ Marc Oliver, MPH, RN, MA Research Coordinator University of Maryland Occupational Health Program Baltimore, MD
Susan Palsbo, PhD, MS Senior Research Associate National Rehabilitation Hospital Center for Health and Disability Research Washington, DC Caitlin Pepperell, MD, FACP Fellow, Division of Infectious Diseases Stanford University School of Medicine Stanford, CA Debra Perez, MPH Harvard University Cambridge, MA William G. Powderly, MD Professor of Medicine Co-director, Division of Infectious Diseases Washington University School of Medicine St. Louis, MO Munro H. Proctor, MD, MPH Boston University School of Medicine Boston, MA Holly Rahman, MD Physician Springfield, MO Colleen A. Redding, PhD Associate Research Professor Cancer Prevention Research Center University of Rhode Island Kingston, RI Kyndaron Reinier, PhD Postdoctoral Associate, Medical Biostatistics University of Vermont Burlington, VT Josiah D. Rich, MD, MPH Associate Professor of Medicine and Community Health Brown University The Miriam Hospital Providence, RI David Rimland, MD Chief, Infectious Diseases VA Medical Center- Atlanta Professor of Medicine, Emory University School of Medicine Atlanta, GA
George F. Risi, MD, FACP Infectious Disease Specialists Missoula, MT J. Peter Rissing, MD, FACP, FIDSA Sydenstricker Prof of Medicine & Chief, Infectious Disease Medical College of Georgia Medical Director, MCG Health, Inc. Augusta, Georgia Kenneth Rosenberg, MD, MPH Office of Family Health Portland, OR Allan Rosenfield, MD Dean, Mailman School of Public Health Columbia University DeLamar Professor of Public Health and Professor of Obstetrics and Gynecology New York, NY Linda Rosenstock, MD, MPH Dean, University of California, Los Angeles School of Public Health Los Angeles, CA Christine Ross, MD Contra Costa Regional Medical Center Martinez, CA Don H. Rubin, MD Professor of Medicine, Microbiology and Immunology Vanderbilt University Nashville, TN Rosanne Rushing, DrPH, MPH Assistant Professor Loma Linda University School of Public Health San Bernardino, CA Michael S. Saag, MD University of Alabama at Birmingham Birmingham, AL Michelle Sampin-Salgado, MPH Communications Manager, Harvard Center for Cancer Prevention Harvard School of Public Health Boston, MA William Schaffner, MD Chair, Department of Preventive Medicine Vanderbilt University Medical Center Nashville, TN
Arnold Schecter, MD Professor, Environmental Sciences University of Texas School of Public Health Dallas, TX Jacqueline Sedgwick, MD, MPH Medical Director Clinica Salud Valle de Salinas Salinas, CA Daniel D. Shin, MD Infectious Disease Fellow Stanford School of Medicine Stanford, CA Janey Skinner, MPH Public Health Consultant Oakland, CA Michael Snoddy, MA District of Columbia Department of Health Washington, DC Donald L. Sodora, Ph.D. Assistant Professor, Internal Medicine University of Texas, Southwestern Medical Center Dallas, TX Paul Spearman, MD Associate Professor, Pediatrics and Microbiology & Immunology Vanderbilt Universeity Nashville, TN Bruce Paul Squires, MD, PhD Former Editor, Canadian Medical Association Journal Secretary, World Association of Medical Editors Ottawa, Ontario Canada Mark Stinson, MD Contra Costa Regional Medical Center Martinez, CA Margaret Strode, MS, MPH, RD California Department of Health Services Sacramento, CA
Mervyn Susser, MB, BCh, FRCP Sergievsky Professor of Epidemiology Emeritus Columbia University New York, NY Susan Swindells, MBBS Terry K. Watanabe Professor and Medical Director, HIV Clinic Department of Internal Medicine University of Nebraska Medical Center Omaha, NE G. Tesfaledet, MD Clinical Director, Department of Medicine The Aga Khan Hospital Nairobi, Kenya Lucy Tompkins, MD, PhD Chief, Division of Infectious Disease and Geographic Medicine Stanford University School of Medicine Palo Alto, CA Sandra L. Torrente, MD Chief of Obstetrics and Gynecology University of Kansas Kansas City, KS Abraham Verghese, MD, DSc (Hon) Marvin Forland Distinguished Professor Director, Center for Medical Humanities and Ethics University of Texas Health Science Center at San Antonio San Antonio, TX Paul Volberding, MD Professor of Medicine and Vice Chair of Medicine University of California, San Francisco Co-Director UCSF-GIVI Center for AIDS Research Chairman of the Board, International AIDS Society-USA San Francisco, CA Ron Waldman, MD, MPH Professor of Clinical Public Health Mailman School of Public Health Columbia University New York, NY Bruce Walker, MD Howard Hughes Medical Institute Professor and Chair, Division of AIDS Harvard Medical School Boston, MA
Alan Wells, PhD Senior Research Associate, American Medical Association Chicago, IL Edith Welty, MD Associate Director, AIDS Prevention and Control Program Cameroon Baptist Convention Health Board Flagstaff, AZ Thomas Welty, MD Associate Director, AIDS Prevention and Control Program Cameroon Baptist Convention Health Board Flagstaff, AZ S. Bruce Williams, MD University of New Mexico School of Medicine Albuquerque, NM Paul Wise, MD Vice-Chief, Deaprtment of Social Medicine and Health Inequalities Brigham and Women’s Hospital Boston, MA Mary E. Wilson, MD Associate Professor of Medicine, Harvard Medical School Associate Professor of Population and International Health, Harvard School of Public Health Boston, MA Sara Wright, MPH Bay Area Physicians for Social Responsibility San Francisco, CA Seth Wright, MD, MPH Associate Professor of Emergency Medicine Vanderbilt University Nashville, TN Seiji Yamada, MD, MPH Area Health Education Center University of Hawaii School of Medicine Mililani, HI Irene Yeh, MD, MPH University of California, San Francisco San Francisco, CA Sauda Yerabati, MPH California Department of Health Services Oakland, CA * All affiliations listed for identification purposes only.