[House Hearing, 113 Congress]
[From the U.S. Government Publishing Office]
THE U.S. CONTRIBUTION TO THE FIGHT
AGAINST MALARIA
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HEARING AND MEETING
BEFORE THE
SUBCOMMITTEE ON AFRICA, GLOBAL HEALTH,
GLOBAL HUMAN RIGHTS, AND
INTERNATIONAL ORGANIZATIONS
OF THE
COMMITTEE ON FOREIGN AFFAIRS
HOUSE OF REPRESENTATIVES
ONE HUNDRED THIRTEENTH CONGRESS
FIRST SESSION
__________
MAY 17, 2013
__________
Serial No. 113-60
__________
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COMMITTEE ON FOREIGN AFFAIRS
EDWARD R. ROYCE, California, Chairman
CHRISTOPHER H. SMITH, New Jersey ELIOT L. ENGEL, New York
ILEANA ROS-LEHTINEN, Florida ENI F.H. FALEOMAVAEGA, American
DANA ROHRABACHER, California Samoa
STEVE CHABOT, Ohio BRAD SHERMAN, California
JOE WILSON, South Carolina GREGORY W. MEEKS, New York
MICHAEL T. McCAUL, Texas ALBIO SIRES, New Jersey
TED POE, Texas GERALD E. CONNOLLY, Virginia
MATT SALMON, Arizona THEODORE E. DEUTCH, Florida
TOM MARINO, Pennsylvania BRIAN HIGGINS, New York
JEFF DUNCAN, South Carolina KAREN BASS, California
ADAM KINZINGER, Illinois WILLIAM KEATING, Massachusetts
MO BROOKS, Alabama DAVID CICILLINE, Rhode Island
TOM COTTON, Arkansas ALAN GRAYSON, Florida
PAUL COOK, California JUAN VARGAS, California
GEORGE HOLDING, North Carolina BRADLEY S. SCHNEIDER, Illinois
RANDY K. WEBER SR., Texas JOSEPH P. KENNEDY III,
SCOTT PERRY, Pennsylvania Massachusetts
STEVE STOCKMAN, Texas AMI BERA, California
RON DeSANTIS, Florida ALAN S. LOWENTHAL, California
TREY RADEL, Florida GRACE MENG, New York
DOUG COLLINS, Georgia LOIS FRANKEL, Florida
MARK MEADOWS, North Carolina TULSI GABBARD, Hawaii
TED S. YOHO, Florida JOAQUIN CASTRO, Texas
LUKE MESSER, Indiana
Amy Porter, Chief of Staff Thomas Sheehy, Staff Director
Jason Steinbaum, Democratic Staff Director
------
Subcommittee on Africa, Global Health, Global Human Rights, and
International Organizations
CHRISTOPHER H. SMITH, New Jersey, Chairman
TOM MARINO, Pennsylvania KAREN BASS, California
RANDY K. WEBER SR., Texas DAVID CICILLINE, Rhode Island
STEVE STOCKMAN, Texas AMI BERA, California
MARK MEADOWS, North Carolina
C O N T E N T S
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Page
WITNESSES
Rear Admiral Tim Ziemer, U.S. Global Malaria Coordinator,
President's Malaria Initiative................................. 7
Colonel Peter J. Weina, Ph.D., M.D., Deputy Commander, Walter
Reed Army Institute of Research, U.S. Department of Defense.... 20
BRIEFER
The Honorable Mark Dybul, executive director, The Global Fund to
Fight AIDS, Tuberculosis and Malaria........................... 42
LETTERS, STATEMENTS, ETC., SUBMITTED FOR THE HEARING
Rear Admiral Tim Ziemer: Prepared statement...................... 10
Colonel Peter J. Weina, Ph.D., M.D.: Prepared statement.......... 22
The Honorable Mark Dybul: Prepared statement..................... 46
APPENDIX
Hearing notice................................................... 70
Hearing minutes.................................................. 71
THE U.S. CONTRIBUTION TO THE FIGHT AGAINST MALARIA
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FRIDAY, MAY 17, 2013
House of Representatives,
Subcommittee on Africa, Global Health,
Global Human Rights, and International Organizations,
Committee on Foreign Affairs,
Washington, DC.
The subcommittee met, pursuant to notice, at 10 o'clock
a.m., in room 2172, Rayburn House Office Building, Hon.
Christopher H. Smith (chairman of the subcommittee) presiding.
Mr. Smith. The committee will come to order, and good
morning to everyone, and thank you for being here this morning,
especially at this hearing to examine the United States'
contribution to the global fight against malaria.
Leadership matters. In 2005, President George W. Bush
established the President's Malaria Initiative, or PMI, and
then targeted several African malaria endemic countries to
receive over $1 billion to mitigate and, some day, eradicate
this killer disease. The positive consequences of that bold and
compassionate initiative now include over 1 million lives saved
over the last decade. The program and its expansion and
sustainability of the funding have been all important in that
battle.
Although we will hear statistics about malaria cited
several times during the course of this hearing, the global
impact of this disease is so severe that they are worth
repeating, and I say that, even though we are making progress.
The World Health Organization estimates that in 2010, there
were 219 million malaria cases and 660,000 deaths. While still
unconscionably high, and every life is absolutely precious and
of extraordinary importance, the loss of life has declined from
approximately 985,000 deaths in 2000.
Not surprisingly, malaria has a particularly devastating
impact on the most vulnerable. Nearly 86 percent of those who
died are children under 5 years of age, living in sub-Saharan
Africa. Dr. Mark Dybul, executive director of the Global Fund
and George W. Bush's extraordinarily effective Global AIDS
coordinator, says that, in Africa alone, malaria takes a life
of a child every minute. He also notes, as do our other
panelists, that pregnant women are also disproportionately
affected with the disease.
WHO emphasizes in its 2012 World Malaria Report that
malaria is strongly associated with poverty. Countries in which
a larger percentage of the population lives in poverty also
have a higher mortality rate from malaria. Children living in
poorer populations, and in rural areas, have the highest
parasite prevalence rates. And it is also important to note, to
the extent to which the prevalence of malaria is concentrated,
80 percent of malaria deaths occur in just 14 countries, and
almost 80 percent of cases occur in 17 countries.
Over 40 percent of malaria deaths occur in just two
countries. The Democratic Republic of the Congo and Nigeria,
and 40 percent of the malaria cases are in the Democratic
Republic of the Congo, Nigeria, and in India. These high
morbidity and mortality rates are not necessary. Malaria is
both preventable and treatable. We will hear today from our
distinguished witnesses who are leaders in the field about the
cost-effective measures that are currently available and
already having a profound impact or are in the development
process.
And the United States, despite the current financial
constraint, is making a significant contribution to the global
fight against malaria. In addition to our contribution to the
Global Fund to Fight AIDS, Tuberculosis and Malaria, the United
States provided $871 million in anti-malaria assistance in
Fiscal Year 2012 alone, and the request for Fiscal Year 2014 is
$893 million.
But these levels, even when combined with contributions
from other donors, do fall short of the global need. So our
question today will be, ``What are the major challenges going
forward and how can we best use our resources to meet those
challenges to save the most lives and have the greatest impact
in controlling, if not eradicating, this dreaded disease?''
We will also be taking a close look at several immediate
threats to global efforts to combat malaria. On April 23, this
subcommittee held a hearing on ``Meeting the Challenges of
Drug-Resistant Diseases in Developing Countries.'' In his
testimony at our hearing, Dr. Thomas Friedman, director of the
Centers for Disease Control and Prevention, warned that in
recent years, malaria infections in parts of Southeast Asia
have been showing resistance to artemisinin drugs. These drugs
are the last remaining class of anti-malarial drugs and form
the basis of malaria treatment globally. If these resistant
parasites manage to spread to sub-Saharan Africa, he stated
that the results could be ``devastating,'' an assessment that
will likely be repeated by our witnesses today.
Insecticide-treated nets, bednets, which have an average
useful life of 2 to 3 years are also an extremely important
malaria prevention tool. According to WHO, 150 million nets are
needed each and every year to provide protection to the
vulnerable populations in sub-Saharan Africa. For the past 2
years, however, the supply has been considerably lower than
this level, resulting in an estimated current shortfall of 77
million nets. The consequences, if not urgently addressed,
could place entire populations, especially children, at risk of
a dramatic malaria resurgence, and of course that means more
death and more morbidity.
We are fortunate again to have three distinguished experts
who will provide us with valuable insights. These are truly
leaders in this field. C-SPAN is here and we are grateful they
are here. I would hope that Americans would sit up and take
note of the extraordinary work you three individuals are doing.
You know, people sometimes are very dismissive of foreign
aid and initiatives that taxpayer funds are used for. This is
one of the greatest success stories. It is not the only one,
there are many, but this is one of the greatest success
stories, but it is a work that remains unfinished. I thank our
witnesses for being here and for being such leaders.
I would like to now yield to Mr. Bera.
Mr. Bera. Thank you, Chairman Smith, and thank you for
holding today's hearing and the series of hearings on global
health, incredibly important topics, and I look at this from
the perspective of being a doctor who has worked
internationally, and the work that you guys are doing is
incredibly important, and I look forward to hearing your
testimony.
You know, as has already been mentioned, there are over 219
million cases of malaria worldwide. The Democratic Republic of
the Congo, India, and Nigeria account for 40 percent of all
malaria cases. Those cases account for over 600,000 deaths in
2010. Very preventable. So this is an incredibly important
issue.
Like so many other diseases, you know, with the right
policy, with the right partnerships, we can save hundreds of
thousands of lives. Unfortunately, far too often, these tools
are not reaching those in need, and I am looking forward to
hearing the testimony of best practices and how we get the
therapies and the prevention and the nets out to those where we
can make the biggest difference.
You know, while malaria continues to take the lives of
children and adults, you know, we also have seen the
international community coming together and some great
demonstrations of remarkable success. The Global Fund, the
President's Malaria Initiative, the Gates Foundation, the World
Health Organization, just to name a few, have helped reduce
unnecessary deaths in Africa by an estimated 33 percent in less
than a decade. We can still do better.
The fund has 779 active grants, 217 of which are for
malaria. It has approved almost $7 billion or 27 percent of its
funds in the fight against malaria. Since 2000, malaria
mortality rates from fallen by more than 25 percent and 50
countries are on course to reduce malaria incidence by 75
percent by the end of 2015. These are efforts to be applauded.
Again, I look forward to supporting and doing more.
Chairman Smith has done an excellent job laying out the
profound challenges that we face in fighting malaria. I would
like to share with the committee just a couple of success
stories over the course of testimony, and I certainly look
forward to hearing the success stories and the best practices.
In addition, you know, today we don't have a vaccine that
prevents someone from being infected with malaria, but I am
here to say as a research scientist, as a physician, there is
nothing that we can't do in this country and in our academic
community if we set our minds to it, and ultimately, that is
where we need to go if we want to truly prevent disease and
save lives.
So thank you for being here, thank you for the testimony.
You know, I look forward to hearing from each of you and, you
know, again, Chairman Smith, thank you for calling this
important hearing.
Mr. Smith. Thank you very much. I would like to now yield
to Mr. Weber.
Mr. Weber. Thank you, Mr. Chairman. Very important topic. I
appreciate the opportunity to be here and have this hearing. My
dad, one of the last of the greatest generation, 88 years old,
served in the Philippines, contracted malaria. To this day, he
cannot give blood. He has the rarest blood type there is. Half
a percent of America has AB negative, which is what I have, and
now you know what is wrong with me. But just a great guy. I try
to give blood as often as I can, and so it is very, very
important, because that keeps those who contract the disease
from giving blood. I think it is very vital, so I appreciate
being here and looking forward to the testimony. Thank you.
Mr. Smith. Thank you very much, Mr. Weber. Just
parenthetically, my father, too, served in World War II in New
Guinea. He was a combat infantryman, and he got malaria, and my
family was very well aware of the impact it had on him as well,
so thank you.
I would like to now yield to Mr. Cicilline.
Mr. Cicilline. Thank you, Chairman Smith, and thank you to
you and Ranking Member Bass for holding today's hearing on the
role of the United States in the fight against malaria, and I
want to thank my colleague and friend, Congressman Bera--Dr.
Bera for his leadership on this issue and on issues of global
health in general. This remains a serious worldwide public
health emergency. The World Health Organization estimates that
219 million cases of malaria worldwide with 660,000 malaria
deaths, so this is still an urgent, urgent issue.
I want to begin by offering my gratitude to the witnesses
not only for being here today and for your testimony, but for
your incredible leadership in the work that you have led that
is making a real difference all across the world as we combat
this scourge of this disease.
Our country, the United States, has a vested interest in
addressing health conditions around the world in order to
improve lives, to strengthen the economies of our trading
partners, and to maintain our moral leadership position in the
world. I think it is concerning to all of us that malaria
remains a leading cause of death in many countries, especially
when we have made such astonishing gains in health care here at
home, and I hope that the United States will continue to
support the funding of global health development as we
transition to country ownership and eventually eradication of
this disease and that we continue to value the work of the
Global Fund to Fight AIDS, Tuberculosis and Malaria, the Gates
Foundation, the President's Malaria Initiative, and to just
note that these are, as Chairman Smith said, great success
stories of what our role around the world has been when we make
the right kinds of investments, and these have been bipartisan
efforts, and I know they will continue to be, and I thank the
chairman again and yield back.
Mr. Smith. Thank you very much. I would like to yield to
Mr. Meadows.
Mr. Meadows. Thank you, Mr. Chairman, and thank you to each
one of you for your service to our country. We appreciate it.
We are here today to address a disease that has been a scourge
on humanity for almost our entire history. And as we have been
fighting malaria for a very long time, it is encouraging to see
how far we have come, but also what is left to be done, and so
I look forward to your testimony today.
We have seen malaria generally eradicated in the developed
world and, but yet there is still a lot of work to do. As you
know, some 80 percent of malaria deaths occur in just 14
countries, and as we see that, you know, 80 percent of the
cases and 90 percent of the deaths occur in Africa, and we have
learned over the past 60 years that eradicating this disease is
an ongoing challenge requiring multiple efforts working in
concert and there is no magic bullet to do that.
We heard testimony even in this very room in a hearing that
the chairman conducted from the CDC offering some of the
challenges that we face with different strains that are
resistant to even the drugs that we have today, and so I am
encouraged by Dr. Bera. We have teamed up on a number of
bipartisan initiatives to try to work on finding some of those
solutions, and so I look forward to hearing your testimony.
I am proud of the role that the U.S. has played in this
ongoing struggle. It has really been our leadership that has
really worked very well, and I am mindful that that does not
mean that we can advocate our duties to be good stewards of the
taxpayers' money either. And corruption cannot be tolerated in
any manner.
I have traveled a number of times to Africa, and when you
start to see the lack of accountability in certain areas, it
gives you great concern, and so part of the reason for holding
this hearing is so that we remain vigilant in that we work
against the bad actors that we have to deal with, but also that
we encourage others and those that are suffering, certainly,
that we come to their aid.
This would include pressuring local governments and making
sure that we have the encouragement there, not just from an
oversight standpoint, but to make sure that what we do is that
the American taxpayers' dollars are invested wisely. When we do
that, there is always a drawback. You know, when I go back
home, there is a consistent call, ``Why are we giving aid? We
have people that are hungry and out of work here. Why are we
doing that?'' I would look for some of the testimony and really
what it might do in terms of our men and women that serve in
some of the things that we have in terms of challenges, not
just from a global perspective, but as we bring that back home,
and so I would look for each one of you to hopefully address
that.
You know, Fiscal Year 2014, we look at both in USAID and
the CDC have both requested increases in their funding as we
see that, and what I would love to see from you is how I can
make sure that we put forth and share with the voters back home
that not only are we being wise stewards, but that we are being
accountable and we are doing the very best that we can to make
our money go as far as we can.
The growth of public/private partnerships, the
encouragement there, some of the work that we have already seen
there, I applaud that. You know, in recent years, we have seen,
you know, the President's Malaria Initiative, you know, working
with the World Health Organization and other institutes using
the Federal dollars to be leveraged in that private/public
partnership in a real way.
And so I just applaud you on the work you have done. I
would love to hear and so we can share with those in these
tight fiscal times how we are managing that properly and
perhaps what we can do from an oversight standpoint to make
sure that not only are we investing wisely but that those funds
meet the real needs that are there.
But I thank you, and with that I yield back, Mr. Chairman.
Mr. Smith. Thank you very much, Mr. Meadows.
Mr. Stockman.
Mr. Stockman. In the course of building a Panama Canal, as
you probably recall from your history, they had to address
first the health problems there, and when I was over at the
Democratic Republic of the Congo, DRC, I think they have
assumed the circumstances, some of the health issues are
holding back their productivity and their production and GDP,
but I believe that even the great expense they have made, they
still need help in that area.
When I was over there, I noticed they were selling some of
their mosquito nets, so I am looking forward to your testimony
to find out if there is alternatives ways besides just mosquito
netting, and I appreciate all the efforts that you have done
and continue to do on behalf of the United States, and I think
this sends a large signal to the rest of the world, the
compassion of the Americans, and I yield back my time,
chairman. Thank you.
Mr. Smith. Thank you very much, Mr. Stockman.
I would like to now introduce to the panel our two first
witnesses. Rear Admiral Tim Ziemer was appointed in June 2006
to lead the President's Malaria Initiative, a $1.2 billion, 5-
year initiative to control malaria in Africa, which was
expanded through an authorization in the 2008 Lantos-Hyde Act.
Admiral Ziemer was born in Iowa but raised in Asia, the son
of missionary parents serving in Vietnam. After graduating from
college, he joined the Navy, completed flight school and
returned to Vietnam during the war. During his naval career,
Admiral Ziemer commanded several squadrants and Naval stations
in an air wing supporting the first Gulf War.
Prior to his appointment at PMI, he served as executive
director of World Relief, a humanitarian organization, and has
had a distinguished stint as leader of the President's Malaria
Initiative. Those of us on this committee are very well aware
of the great contributions you have made and the leadership you
have provided.
We will then hear from Colonel Peter Weina, who is assigned
to the Walter Reed Army Institute of Research, where he serves
as deputy commander. He leads many medical initiatives in the
Army and his work has been published extensively in journals
and books.
Colonel Weina is a recognized expert on numerous diseases.
He was the lead behind the availability and licensure of a
life-saving drug for the treatment of severe malaria throughout
the United States and Canada from 2002 to 2009, an effort that
was recognized by CDC's Silo Busters Collaborative Award of
Excellence in 2008. Among his many other impressive awards, he
is the recipient of the Bronze Star for service in Iraq during
Operation Iraqi Freedom.
I would like to yield to Admiral Ziemer.
STATEMENT OF REAR ADMIRAL TIM ZIEMER, U.S. GLOBAL MALARIA
COORDINATOR, PRESIDENT'S MALARIA INITIATIVE
Admiral Ziemer. Chairman Smith, members of the committee,
it is a pleasure to be back before you today. Before I begin my
testimony, I would like to take a moment to acknowledge and
express my appreciation for Congress' ongoing and steadfast
support for malaria control. The global fight is succeeding.
Deaths have decreased by one-third with bipartisan support in
Congress for both bilateral and multi-lateral efforts. Through
the Malaria Initiative and the Global Fund, malaria is being
rolled back. It is a triumph of partnership, all of us working
together, the U.S. Government, our partners, host countries and
the communities we are trying to serve. We simply would not be
seeing the impact we are seeing today without your support and
commitment. Thank you very much.
The United States malaria program through the PMI continues
to be a game changer. In the 7th year of the Initiative, the
financial and technical contributions made by the United States
Government are the major catalyst in the remarkable progress
that has been achieved in many countries to reduce the
devastating burden of malaria on child mortality. At the same
time, with the U.S. Government support, countries are also
strengthening their own capacity to fight this disease.
PMI, at its very core, is an example of success and real
impact that the United States Government can achieve through a
solid interagency partnership. Through PMI, the core strength
of both USAID and the Centers for Disease Control and indeed
across the entire U.S. Government spectrum, Walter Reed, DOD
and NIH, as well as the Peace Corps, it is a tremendous success
story, yet it is still incomplete.
I just returned from Uganda, and despite the recent
progress, malaria remains the largest killer of children. In
the midst of these tragic statistics, we have some good news.
This year, with 21 million insecticide-treated bednets provided
by the Global Fund, the U.S. Government, DFID, World Vision,
and other partners, the Government of Uganda is poised to make
real and substantial gains against malaria.
Seeing children suffering from malaria, I am reminded of my
childhood days in Vietnam. My parents, as was indicated in the
opening statement, were missionaries there. I was fortunate to
sleep under a bednet and yet I caught malaria. I was fortunate
to have anti-malaria medicine to cure the disease. Every child
in a malarious part of the world should be protected as I was.
In the last 7 years, substantial reductions in mortality among
children under 5 has dropped 16 to 50 percent in 12 of our
original PMI countries. Although multiple factors may be
influencing the decline in under 5 mortality rates, strong and
growing evidence suggests that malaria prevention and treatment
are playing a major role in these unprecedented reductions in
mortality.
PMI is participating in in-depth evaluations to ascertain
the contribution of malaria control efforts to these reductions
in mortality, with Tanzania being first country to complete
this evaluation. 63,000 lives have been saved over a 10-year
period because of the scale-up of malaria interventions.
In 2011, PMI commissioned an external evaluation team to
review its performance. The evaluation affirmed that PMI's
planning, implementation, partnerships and funding have been
key to the global efforts to combat malaria. The evaluation
team made five policy and five technical recommendations that
will guide programmatic improvements over the next years. PMI
views these recommendations as relevant and useful for program
improvement. We have come a very long way since the inception
of the Global Fund in 2002 and the creation of PMI 3 years
later when President Bush committed $1.2 billion for malaria
control.
The Initiative started with Tanzania, Uganda and Angola.
Since then, 16 additional focus countries have been added with
three non-focused countries. In addition to the bipartisan
support of Congress, PMI benefited from the full support of
President Bush and First Lady Laura Bush, and now the Obama
administration.
In 2010, President Obama launched his vision for how the
United States would approach global development, which seized
development assistance as a pillar for foreign policy, and is
crucial to America's national security and economic interests.
In his 2013 State of the Union address, President Obama
framed two goals, that the United States would join with our
allies to eradicate extreme poverty in the next two decades,
and saving the world's children from preventable deaths.
Malaria is a major cause of child mortality in Africa, and
consequently, preventing and controlling malaria are a key
focus of the U.S. Government foreign assistance program. PMI is
playing a lead role in implementing the President's vision.
Partnership is the hallmark of how PMI does business.
Partnership with host countries, other donors, the private
sector, non-profits, and faith-based groups underpin our
success. PMI has supported malaria activities through more than
200 non-profit organizations. Approximately one-third of those
are faith-based. These groups often have strong and effective
bases of operations in underserved rural areas where the burden
of malaria is the greatest.
The Global Fund and PMI's commitment to effective
coordination is maximizing our impact on the global malaria
burden. Each program has its own unique strengths lending to
the complementarity of the partnership and significant
successes on the ground. Currently, all 19 PMI focused
countries in Africa and the greater Mekong subregion receive
substantial funding from the Global Fund.
Because of the strength of our in-country technical staff,
we support the effective implementation of Global Fund
programs. While the risk of malaria is declining and more
children are surviving, the gains are fragile and could be
reversed without continued support. We recognize and appreciate
the continued commitment of Congress and the American people to
fighting malaria through PMI and the Global Fund in this time
of budget austerity. The goal is to continue to shrink the
malaria map and to ensure successes are not rolled back, even
as the dual threats of artemisinin and drug resistance and
insecticide resistance is growing. A strain of malaria, of the
malaria parasite has appeared in parts of Southeast Asia with
resistance to the most effective medicines to fight the
parasite, and some fear that the parasite might ultimately
become resistant to all drugs we currently have to treat
malaria.
The emergence of this resistant parasite to Africa would be
devastating. We must also be diligent in identifying and
monitoring mosquito resistance to insecticides so that our most
effective prevention measures, insecticide-treated mosquito
nets and indoor residual spraying aren't undermined. If
mosquitos become resistant to those insecticides, the efficacy
of the interventions will be compromised.
Tackling these new strategic challenges is a priority, and
we are working with the private sector to develop new anti-
malaria drugs as well as insecticide-based tools. At the same
time, we must continue to expand our toolbox by developing a
highly effective inexpensive vaccine that could result in
hundreds of thousands of lives saved.
So in closing, I would like to thank the U.S. Congress for
its continued support and reiterate that together with our
partners, we remain deeply committed to the global fight
against malaria. Thank you, and I look forward to your
questions.
Mr. Smith. Admiral Ziemer, thank you very much for your
testimony and again for your leadership.
[The prepared statement of Admiral Ziemer follows:]
----------
Mr. Smith. We do have a vote, two votes on the floor, and I
apologize for the inconvenience to our witnesses. We thought we
would take a very brief recess, come back, and Colonel, then we
will receive your testimony. We really do want to hear what you
have to say. So the subcommittee stands in recess.
[Recess.]
Mr. Smith. The subcommittee will resume its sitting, and
Colonel Weina, if you could proceed with your testimony.
STATEMENT OF COLONEL PETER J. WEINA, PH.D., M.D., DEPUTY
COMMANDER, WALTER REED ARMY INSTITUTE OF RESEARCH, U.S.
DEPARTMENT OF DEFENSE
Colonel Weina. Thank you, sir. Chairman Smith and
distinguished members of the subcommittee, thank you for the
opportunity to appear before you to discuss the Army's medical
research initiatives to improve soldier readiness and global
health and highlight the incredible work of the military
medical research community.
I extend our appreciation to Congress for their support to
military medicine faithfully given, which provides the
resources we need to deliver leading edge health services and
diligently continue innovative research. Malaria is a global
agent scourge that has haunted mankind for much of our history,
and yet it still impacts our lives in our society today. I know
it has been said many times, but it bears repeating: Over 3.3
billion people remain at risk for the disease. Over 200 million
cases of the disease appear every year along with over 650,000
deaths.
Among the most vulnerable are the young children who
account for over 85 percent of the malaria-related mortality
globally. A preventable disease, malaria is a leading cause of
death in children under 5 years old in sub-Saharan Africa.
The U.S. military has also felt the threat of malaria as
far back as 1775 when George Washington expended limited
resources to purchase quinine for the treatment of malaria.
Malaria has been diagnosed during the Civil War, World War II,
Vietnam and even recently in Afghanistan.
Historically, the incidents depends primarily on deployment
location, but during the last 10 years, we have seen
approximately 100 cases every year, despite the resources we
have to protect our troops. While the days of massive
debilitating impact on malaria operations are behind us, we
only have to look back to 2003 in order to appreciate the
potential impact when a military peacekeeping operation in
Liberia failed after only a few weeks due to 80 cases of
malaria in 225 Marines, 44 of those requiring medical
evacuation.
The destabilizing effects that diseases such as HIV/AIDS
and malaria have on the critical infrastructure of developing
nations is compelling evidence that global health is a means to
global security. These diseases undermine the education and
health systems, economic growth, micro-enterprises, policing
and military capabilities, political legitimacy, family
structures, and overall social cohesion. They undermine the
stability of already weakened states and add to their
vulnerability to extremists and terrorists who seek to corrupt
or coerce. Our response, through medical engagement, needs to
be comprehensive, fought at many levels, and on many fronts to
provide for global stability and our own nation's security.
The Walter Reed Army Institute of Research has a trusted
partnership in several countries that has been established for
decades. Long-term relationships have been built with host
countries as well as health organizations allowing both
personnel and logistical support to establish larger work.
We have been in partnership with the Royal Thai Army for
over 50 years, and with the Kenyan Medical Research Institute
for over 40 years. We have established robust relationships
that have allowed the important work of military medicine's
research as well as the important work of PEPFAR and PMI.
The U.S. military's exceptional science, logistic and
regulatory expertise allows for the testing of new products to
the best standards of care for the local population as well as
the delivery of critical life-saving HIV/AIDS and malaria
interventions.
Military medicine also serves as a partner in the critical
platform of disease surveillance. Both the Army and Navy
conduct oversees disease surveillance operations that not only
keep a watchful eye on malaria patterns and malaria resistance
throughout the world, but also survey for other infectious
disease threats. These overseas operations are part of a
complex ecosystem that provides not only surveillance, but also
a platform for testing new products, medical engagement with
many countries worldwide and outreach for the execution of
PEPFAR and PMI missions and programs.
Vigilance in combating malaria is an enduring mission. The
U.S. military is engaged in malaria research for several key
reasons, to preserve the fighting strength of our men and women
in uniform who go into harm's way, to protect our Nation's
citizens who encounter these threats worldwide, and to
positively impact the global health and stability of our
allies.
In closing, I am proud of the global impact that military
medicine research has done throughout history and the continued
diligence being done to combat one of the oldest infectious
disease threats man has known. In partnership with the
Department of Defense, my colleagues here today, our global
partnerships and the Congress, we will be prepared for
tomorrow's challenges. Thank you for your time.
Mr. Smith. Colonel, thank you very much for your leadership
and for your testimony today.
[The prepared statement of Colonel Weina follows:]
----------
Mr. Smith. Just to lead off the questioning, let me start
off with a question to Admiral Ziemer. You mentioned about one-
third of the NGOs that are getting assistance happen to be
faith-based. One of the concerns that I have expressed from the
very beginning, both with PEPFAR and malaria and every other
U.S. foreign aid program, especially as it relates to Africa,
has been the early exclusion of faith-based organizations,
primarily because of ideological reasons, but there appears to
be, and I think there has been good strong support for them. I
actually wrote the conscience clause for the PEPFAR program
because of that exclusion.
If you could just elaborate a bit on how essential
indigenous faith-based groups are being included. If we want to
end the pandemic of HIV/AIDS, it seems to me, and TB, the
problems associated there, and the malaria problem, we need to
have as partners those faith-based groups. If you could touch
on that.
Admiral Ziemer. Thanks for the questions. When PMI was
launched, one of the first things we did was to look at the
best practices of PEPFAR and model some of our programmatics
after the PEPFAR model. So, to the extent there were clear
guidances coming from here and from the administration, we
looked at them and embraced them. But I can tell you from the
beginning of PMI, we intentionally looked at a deliberate
engagement of the NGOs in the field, specifically looked at the
merits of the faith-based organizations because we
acknowledged, and from personal experience, accepted the fact
that they were there before we got there, and they will be
there after we go. And when we start embracing capacity
building and sustainability of programs, the local NGOs,
specifically the faith based, are a huge component of building
for the future.
Mr. Smith. I appreciate that. You know, the impact on
childhood cognitive development, we know that obviously our
goal is to eradicate malaria and to prevent deaths, but also to
mitigate morbidity and other consequences like impact on
cognitive development. Is the timeliness of the intervention
key? I chair the Lyme Disease Caucus here in the House and have
a bill pending that I hope will get brought up on establishing
a blue ribbon commission on lyme disease, particularly chronic
lyme. The longer the parasite grows inside an individual, the
worse its deleterious effects. I am wondering, you know, the
issue of how this mal-affects children as they become
adolescents, adults and right on through the rest of their
life.
Admiral Ziemer. You are asking a rather technical question,
and I would defer that to some of our scientists and colleagues
when it comes to the impact or the delayed impact of delayed
parasite clearance from a system. I do know that we have a very
rigorous prenatal program, so that when pregnant women go into
the clinics, we are providing preventative treatment. So in
terms of the health of the newborn child, it is being addressed
through that prevention measure, but when a child presents with
a fever, we are committed to appropriate diagnosis and then
treatment. So at an early age, if the child presents and is
diagnosed with a fever, we do everything we can to provide
treatment.
Mr. Smith. In his testimony, Ambassador Dybul, the
executive director of the Global Fund, points out that between
2004 and 2010 the need, the coverage need, the level of need
was essentially met, but only 92 million nets were delivered by
manufacturers in 2011, largely due to funding constraints, and
in 2012, only 66 million nets were produced. He points out that
in February of this year, the Global Fund and WHO and other
partners, I am sure that includes you and us, the United
States, estimated that 77 million nets were needed to maintain
coverage for communities that the Global Fund has previously
protected.
He also talks about the big push to replace insecticide-
treated nets and its new, interim funding grant stream, along
with fostering diagnostic and treatment needs, and bottom line,
that between 2013 and 2015 there is a $3.5 billion gap. Now, I
know the United States has been generous. It has been the
leader. Is there more that we could be doing? I mean, can we,
Congress, be partners in ensuring that that gap is closed?
Admiral Ziemer. The fact that we know what the gap is and
we can have these numbers, represents information that we
didn't have 5 years ago.
Mr. Smith. Right.
Admiral Ziemer. So as we look at supporting the country's
requirements, we are able to refine the net requirements, and
then collectively discuss at the funding level, the partner
level, and at the national level how best to direct those
resources. I think it is important to acknowledge that since
2008 and 2009, our partners, along with the United States, have
distributed over 300 million bednets to sub-Saharan Africa,
which represents coverage to close to 600 million people. I
think the figure is 578 million. So we are making tremendous
progress.
As we look at those at risk, I think it is important to
look at the full toolkit that we have. Four of the
interventions that we use are focused on prevention. Bednets,
of course, is one, along with indoor residual spraying. We are
looking at country requirements, the most at risk population
groups, and moving forward with the funding that we have. So,
are there gaps? You bet. Are we dealing with them better? Yes.
We just have to keep at it.
Mr. Smith. And if you could help us--I mean, we want to be
advocates. I certainly personally want to make sure that all
that can be done is done. I thought that again Ambassador Dybul
makes an excellent point. Either progress is made or we lose
momentum. The reality is invest now or pay forever, which is a
very strong and I think a very declarative statement that we
could make a difference, but funding is key, and obviously
deploying those resources prudently is key.
Colonel, if I could just ask you, your written testimony
goes into some great length, thank you for your oral testimony
as well. You point out that the Walter Reed Army Institute of
Research, along with a pharmaceutical company, has developed
what is currently the world's leading malaria vaccine
candidate. You point out that the product is currently in Phase
III clinical trials in Africa, if you maybe would touch on
where in Africa. Is it Kenya where we have the lab? And the
medical research collaboration, and how close are we to, you
know, actually developing a vaccine that is deployable?
Colonel Weina. Yes, Chairman Smith, the question of
partnering with a drug company, we do partner all of the time
with some sort of commercial entity to make sure that our
products go forward. None of the products that we actually
produced are things that are necessarily borne strictly by the
United States to move forward.
The question of where this work is being done, it is the
Phase III trial is principally being done in Kenya right now
where we have our laboratory. This work has moved forward
significantly, but of course, the question of when are we going
to have a vaccine is really tied up in some very significant
details.
First of all, the vaccine that we have right now is not a
vaccine that absolutely protects an individual from getting
malaria. The great thing about this vaccine, and this is why it
is being pursued principally in Africa, is the fact that it
reduces the mortality associated with the disease. This
vaccine, just like a lot of other vaccines that we are having
difficulties with, such as HIV, are things in which they don't
naturally occur in nature. We don't have a situation like we
have, for example, with chickenpox in which maybe somebody gets
chickenpox and then they aren't going to get chickenpox again.
Those vaccines are the easy ones. Those are the ones that have
already been developed.
What we are trying to do is actually develop a vaccine for
a condition that doesn't occur in nature, so it is a lot
tougher to do. What we have been able to mimic is the fact that
children that have repeatedly gotten malaria are at lower risk
of dying from malaria than individuals that may get it the
first time. And this is a real success. It helps reduce the
mortality, and it produces some information for us and possibly
moving forward into a vaccine that does have significantly more
efficacy and something that may actually prevent somebody from
getting infected.
Mr. Smith. Let me ask you, Colonel, if I could. You point
out that funding for malaria research and development in the
military has been suffering since Vietnam. You talk about how
you have worked very creatively, partnering with others, to try
to lessen the impact of that diminished funding, and I think
$10 million is what you have in use for research.
You also point out that resistance is a fact of drug
development in even the most cautious of drugs. Organisms we
are fighting will always find a way to defeat our treatments,
which is a very ominous statement and a very disconcerting
statement. And we know in some four countries in Southeast
Asia, Dr. Friedman was very emphatic on that when he appeared
before our committee just a few weeks ago, there is concerns
about drug resistance to artemisinin. Could you speak to that
issue of drug resistance and also that budget for research?
What would more money enable you to do, if it were to be
available above the $10 million?
Colonel Weina. Yes, sir. The issue of resistance is
something that we deal with not just with for malaria but for a
lot of diseases. The malarial parasite is a very ingenious
organism that is actually, I guess, just trying to survive, and
we are constantly trying to beat it down. It has found a way of
practically defeating every single drug that we have produced
all the way back to something that we have been using like
quinine for over 300 years. All of the new drugs that are out
there, Mefloquine, Fansidar, all of these types of drugs,
Malarone even, there is resistance. And our biggest tool in our
arsenal right now are the artemisinins, artemisinin-based
drugs.
We are seeing an increase in the potential for resistance
in Southeast Asia, particularly along the Thai-Cambodian border
where we have seen a lot of resistance arise, and we are going
to--every single time we produce a new drug, these organisms
are going to find a way around it, and that is why we need to
have continued vigilance. That is why every single anti-
malarial that has basically come out since World War II has had
the involvement of the Walter Reed Army Institute of Research
because of the fact that we have continually worked on it
virtually our entire existence looking at a new drug. So every
time we have a new one that is out there, we don't stop and
celebrate that we have the new one. We are actually looking for
yet the next one that is out there, and we have a full pipeline
of drugs that are being developed and looking for yet that next
generation because we know we are going to have resistance, and
there is no way of actually stopping that from moving forward.
As far as the budget, I think everybody would just love to
have more money. There are limited resources that are going to
be available. I think what we would like to have more so than
anything else is just to continue to get the money that we have
been POM'd and that allows us to do the planning that is really
necessary to move forward with our partnerships because our
people are very entrepreneurial. And whatever investment that
the U.S. taxpayer puts into developing these drugs, we are able
to partner with private organizations, with academia, with
other governmental organizations and really move the goal
forward by bringing those types of partnerships together in
this ecosystem that increases every single dollar three, four,
five times and increase our budget to move things forward.
Mr. Smith. I think Americans should be concerned just
because we are our brothers' and sisters' keeper, and that is
what this program is built on, but there is the possibility, as
you pointed out, of malaria being reintroduced into the United
States. It is something I never read in the history books, and
we talked about the Civil War. You point out, in the 1860s, the
Civil War saw 50 percent of the Caucasian troops and a
staggering 80 percent of the Black troops contracting malaria
annually. That is extraordinary. And that is information that I
think just underscores--we had it here. It is gone. Now we have
to hope and pray and work hard to see that it will soon be
eradicated in Africa and everywhere else that it is.
Mr. Bera.
Mr. Bera. Thank you, Chairman Smith.
I think the American public, if you are out there watching,
you can be very proud of what we have been able to accomplish
and the reflection of our values as a Nation, you know the
compassion, the humanitarian commitment to eradicating malaria;
to the wonderful work that, Admiral Ziemer and Colonel Weina,
you guys have been doing; and the fact that this is a real
bipartisan effort. The President's Malaria Initiative started
under a Republican President and it has continued under a
Democratic President. The leadership demonstrated on this
committee and the commitment to compassionate and humanitarian
need in eradicating some of the toughest diseases in the world,
this is something that we can be proud of as an institution and
as a country and Nation.
I look at this from the perspective of being a doctor. And
the first course of medicine is always to try to focus on
prevention of disease. If you can prevent it, then you don't
have to treat it. And we are making strides. And when we think
about prevention of malaria, we think about, obviously, nets
and preventing the mosquito bites. We also look at the public
health measures that we can do--you know, pools of water, et
cetera--and educating the population where malaria's endemic.
Chairman Smith touched on the cornerstone of prevention in
fighting infectious disease, which is vaccination. And if our
goal is eradication, we really do have to focus on finding a
vaccine.
Colonel, as you pointed out, malaria is a very smart
challenge, and it is a smart parasite that has continually
adapted. And yes, we are going to have to continue investing in
the next generation of therapy. But until we can come up with
an effective vaccine, it will be very difficult to eradicate.
I think you talked about where we are on the vaccination
side. And I would just reiterate our commitment and my
commitment, as a physician and a Member of Congress, to
continue to fight for that research funding until we do get
that vaccine.
You touched on the importance of partnership, and we do
live in tight fiscal times. We do have a debt challenge here in
this Nation, and we are forever grateful for individuals like
Bill and Melinda Gates, who have stepped up philanthropically
and have poured literally millions of dollars--billions of
dollars into the fight to eradicate malaria.
To either one of you, I would love to hear what you think
are best practices in partnership, the role of the
philanthropic and NGO community in helping us eradicate malaria
or at least hold it down and continue to make progress. And
then the role in terms of capacity building in Africa, India,
you know, countries that are affected by malaria. So whoever
wants to take that question.
Admiral Ziemer. Thanks for that question.
Let me just address a couple of points. The USAID has been
investing in vaccine research for over 40 years. So it is a
high priority, and we will continue to focus in on that for the
reasons you have stated. On the prevention side, I am pleased
to say, of the four interventions that we used, WHO approved,
three are prevention. And then we are scaling up case
management, diagnosis, and then proper treatment. So as we
continue to work with the countries, our focus is truly on the
prevention side.
Our partnership in this austere time is actually very
critical. And I am really pleased to report that we are seeing
significant progress made at every level. On the partnership
advocacy piece, the work with the U.N. Special Envoy, Malaria
No More, the U.N. Foundation, Nothing But Nets, the
celebrities, as well as the athletes are informing the American
public about this disease. And there has been a wonderful
response collectively, as American citizens, to do something
about that. So that is on the advocacy side.
On the technical side, the fact that the Gates Foundation
is totally invested on the high tech end and the governments
and the multilaterals are invested on the country side, we have
a global malaria vision and plan to bring those two together.
And so, again, over the last 4 years, we have something that we
never have had before, and that is a vision, a strategy and
places for countries, donors, research folks to plug in to move
us toward control, elimination and eradication.
One of the most important partners we have is the private
sector. And we can showcase and give you more details. But let
me just give you three examples: In Western Ghana, we are
partnering with Ashanti gold through IRS. They are also funded
by the Global Fund, the national government, as well as the
U.S. Government in looking at best practices and scaling up
IRS.
In Zambia, we are working with the copper mine companies to
do the same thing. So let me just stop there. Oh, ExxonMobil is
working with us in Angola and their contributions directly into
the program have been $4.5 million just for nets and the scale-
up of events. So we can give you multiple examples of how we
are seeing the partnership not only on the advocacy side but in
the planning and visioning as well as in the implementation
side. I hope that is helpful.
Mr. Bera. Very helpful.
Colonel Weina. Yes.
Dr. Bera, the idea of partnerships is absolutely critical
when it comes to combating any disease and especially something
that is as broad and as widespread as malaria is.
I describe it as an ecosystem. And when one part of an
ecosystem suffers, then the entire part of the system suffers.
But there is also strength in that ecosystem so that when one
part suffers, the other parts can help them out. The
partnerships are critical and the partnerships come at many
different levels. There are the public-private partnerships.
But there are also our partnerships with the overseas
laboratories in which we have in Thailand and in Kenya, Egypt,
and Peru. Some of them have been in existence for over 50
years. These partnerships are not just to provide us a platform
for surveillance and for testing new products, but it is also a
way of capacity building so that we can also pass on what we
have learned and also learn from our partners. In most of these
overseas laboratories, a majority of the people that are
working there are local nationals. And there really is a trust
relationship that is built up. Some of the people having been
associated with that partnership for over 50 years. And there
are strengths and weaknesses that each of the partners bring.
And the more we talk to each other, the more we interact with
each other, the more we learn where we can make a real
difference. I know that we execute quite a bit of PMI funds. We
execute quite a bit of PEPFAR funds at some of our overseas
laboratories. And it is not just the laboratories. Those
laboratories actually are a jump-off point for work in other
countries as well. And it is not just a logistic aspect like
that, but it is also a scientific aspect. We have learned a
tremendous amount from the work that is being done with the HIV
vaccine as well as the HIV vaccine finding, learning a
tremendous amount from the work that is being done with
malaria. So there are scientific interactions and partnerships
that are done across diseases as well as all of the logistic
work that I have just talked about.
Mr. Bera. It sounds like this is a remarkable partnership,
public-private advocacy. Is there anything that this
institution, that we can do here as men and women in Congress
to help continue to facilitate this partnership? Or is there
anything--obviously the law of unintended consequences
sometimes hinders partnership. Is there anything that you would
want us to do outside of increasing research funding?
Admiral Ziemer. The fact that you are calling for an update
and having this hearing to support this U.S. Government foreign
assistance program is evident to our global partners and the
countries that we are working with. There isn't an opportunity
that goes by where I don't pay tribute to the leadership, the
bipartisan support of this Congress. It is critical. We need to
political leadership and we need the funding. Everybody
understands the constraints that we are currently under.
So our pledge is that the funding that is appropriated to
this program and our other health programs we are going to do
everything we can to be transparent, accountable, and deliver
impact that will convince the American people that their tax
dollars are being wisely invested. When we show results, it is
really kind of a no-brainer. They are going to say, I wish more
money was going into programs like this. I hear it all the
time.
Mr. Bera. Great. Thank you. We will bring some of that
commonsense approach here to Congress as well.
Mr. Smith. Thank you very much.
The vice chairman. Mr. Weber.
Mr. Weber. Well thank you, Mr. Chairman.
A couple of questions for you: Of course you guys started
with the valiant men and women overseas. What is the incidence
of cases of malaria in our own armed forces? Is that up, down?
Can you give me kind of a breakdown?
Colonel Weina. Well, sir, we still suffer from malaria even
though we have these interventions, principally because we do
have troops that are going to be operating in areas in which
they may not have expected to run into malaria. So they may not
be on prophylaxis or it may be in the fog of war, if you will,
in which they don't have opportunities to protect themselves
with the bednets. We have done interventions though that may
help drive the numbers down. As I said in my testimony, we have
maybe 100 cases per year, yet that are still bothering us in
the military. And we would sure like that to be down as close
to zero as possible.
So some of the things that we could do are to intervene
where we don't necessarily have to have the soldier involvement
in it. A vaccine would be absolutely wonderful. But, in the
meantime, we have situations in which, for example, the Army
and the Marines now all of our battle dress uniforms are
permethrin-treated from the factory. And that is a true
improvement because now the individuals don't have to think
about an intervention themselves. It is already there. Those
types of efforts are going to help drive them down. It sure
would be nice to have zero cases and not have to worry about
malaria intervening like it did in 2003 in Liberia. But that is
something we need to continually plan for and think about in
the back of our minds.
Mr. Weber. Well, thank you for that, Colonel. I wasn't here
during the testimony. It turns out I don't walk as fast as the
chairman does. So I apologize if this is redundant.
Malaria was pretty much eliminated in India, as I
understand it, but now it is starting to come back. Speak to
that if you would. Why is that?
Colonel Weina. Yes. In India, in the 1960s, it was
virtually eliminated from the entire subcontinent. Today they
have actually increased the number of cases potentially up to
200,000 deaths per year. And it is fairly widespread. I have
recently, over the last number of years, traveled in India to
about 20 different cities. And from the rain forest all the way
to the deserts, you can see patients lined up with malaria, and
it is having a true impact.
The reasons for that are pretty much the same reasons that
we should remain vigilant and do remain vigilant here in the
United States. We have a susceptible population. We have the
vector present--the mosquito that can carry malaria--present
throughout the United States just like they did in India. And
all it takes is the reintroduction of the infection into the
population and into the mosquito population without an adequate
response. We have been very fortunate that the CDC keeps a
very, very close eye on this and has prevented any small
outbreaks from becoming big ones like it has in India. But we
remain vulnerable as long as there is malaria anywhere in the
world. Certainly all it takes is somebody getting on a plane
and 8, 10 hours later to be at one of our borders and
potentially bring the disease back home.
Mr. Weber. Okay. Thank you, Mr. Chairman.
I yield back.
Mr. Smith. Thank you very much. Mr. Meadows.
Mr. Meadows. Thank you, Mr. Chairman.
And thank you both.
Admiral, thank you so much for being so candid with regards
to your fiscal oversight and understanding the demands of where
we are today. But also knowing that as a wise steward of that
money, I take you at your word but also see it in your passion
in your eyes that you are willing to invest that wisely. And I
just want to say thank you, not on behalf of Congress but on
behalf of the American people for doing that.
I want to go on a little bit further and let's talk about
the dangers to our men and women in service.
Colonel, if you could speak to that because really, when it
gets down to funding, most people are only concerned about
providing funding if it affects them. And that is a sad
commentary, but that is the truth, the truth of the matter.
So what I would like for you to do is help the folks back
home understand, one, why do we need to be investing these
dollars? What are the dangers to family members that may be
serving overseas? And perhaps talk a little bit about the
reintroduction into some of these areas that we felt like were
malaria-free, but now we are seeing that it has come back.
Because, as you say, we are in a global, transient world now.
So one disease in Vietnam showing up in America is just a few
hours away. So if you could comment on that, please, Colonel.
Colonel Weina. Yes, sir. So the threat to our military, to
our men and women that are serving in the uniform of our
country is very much dependent upon where they happen to be
doing it, where they happen to be serving at the time. If they
are in an area, say in Iraq, we found that there was very
little malaria, if any at all. And we really didn't have much
of a problem with malaria there. Certainly we do have a problem
with it though in places like Afghanistan and in other areas in
which we may be providing peacekeeping missions, for example,
in Africa, in which there is a tremendous amount of
transmission. As I have said, the disease, the parasite is very
smart. No matter what we produce, no matter what we come up
with, be it an insecticide or a drug, it is going to figure out
a way to work around this and actually----
Mr. Meadows. So what you are saying is it mutates and
changes enough where it can go against the technology that we
have.
Colonel Weina. Yes, sir. So we need to continually take a
look at this. The reason it is important though and the reason
we talk about global health is because--one reason is that as
we work on these solutions for our soldiers, it has got a much
broader impact and it has got a much broader unintended
consequence of being able to help other individuals that have
malaria. But on the other hand, if we reduce the amount of
malaria and other infectious disease threats worldwide, our
soldiers serving in these areas are going to be at reduced risk
as well and also the issue of making sure that we invest in
decreasing the destabilizing effects of these particular
diseases so that maybe we don't have to have soldiers there in
the first place because they are not unstable areas because of
the fact that their health is better.
Mr. Meadows. And so what you are saying is, part of the
unrest is not just economic. It is health-generated, is that
right?
Colonel Weina. Well, health has an impact on the economy.
If you are sick with malaria, you can't work. If you can't
work, you can't provide for your family. And there is this
vicious cycle that happens. While we may not think about health
as the very first thing in an unstable country, health
certainly has some impact in the background. We just have to
trace back to where that is. If you are able to work, I think
most people want to work no matter where they are in the world.
Mr. Meadows. Right. Let's go back to this partnership that
has been alluded to with both the pharmaceutical companies,
with CDC, with NIH. Who takes the lead? How do we make sure
that we are charging--you know in our military we have rank. So
we know who we follow. In these partnerships, it becomes much
more problematic to see who is taking the lead and who is
making decisions. What are some of the successes there? And
perhaps if you care to comment, what are some of the barriers
to that?
Admiral Ziemer. Speaking from the PMI perspective, I
appreciate the question a lot. But if you go back to the
Lantos-Hyde bill, you will see that there were specific
authorities and responsibilities given to how the program was
to be established and run and managed and report back to you.
Mr. Meadows. And are we following that?
Admiral Ziemer. Yes, sir, we are. And I would venture to
say that that is one of the key reasons for the successes and
the progress that we are making. There are clear lines of
authority and responsibility. And it also encourages and
enables us to have an effective interagency, collaborative,
functioning program. So I would commend a review of that simple
governance concept as we ask the question about partnership.
Mr. Meadows. So you are saying it is a success?
Admiral Ziemer. In my view yes, sir.
Mr. Meadows. So we need to repeat it throughout all other
areas of Congress is what you are saying?
Admiral Ziemer. I would say it is a good reference
depending on what outcome is desired.
But on the global level, it is much more difficult. And
there are collaborative bodies at WHO, partnerships, Stop TB,
the Roll Back Malaria Partnership. At the Roll Back Malaria
Partnership--which is meeting right now and I am skipping it
because I am here--the Gates Foundation, the U.N. Foundation,
Malaria No More, multiple private sectors, the pharmaceuticals
are there, the countries, the endemic countries, Asia, Latin
America, and Africa are there along with the major funders, the
Global Fund, the UK, and the U.S. Government. We are looking at
the global challenge, looking at the plan, and having
discussions about how we work together on a global partnership
to move toward control, elimination, and one day eradication.
So there are different mechanisms depending on where we are to
enhance and to develop these partnerships.
I would like to say that over the 6 years that I have been
in this job, that program, those mechanisms have continued to
mature and become more professional. And I spend my time by
going to them because I think it is worth it, and we are able
to influence and provide technical as well as programmatic
leadership to achieve common ends.
Mr. Meadows. And you would agree with that, Colonel?
Colonel Weina. I would. From the standpoint of being in the
military, of course, we do what we are told. I would like to
think we are very good at doing what we are told and making the
best with what we have. So the partnerships have been very
good.
Mr. Meadows. Do I have time for just two more questions,
Mr. Chairman?
Mr. Smith. Yes, sir.
Mr. Meadows. I wanted to follow up with that then.
From a legislative standpoint, you outlined some of the
things that were good. And I am not asking you--unless you had
something on the forefront of your mind, to speak to this. But
I would love to see if there is anything legislatively--tweaks,
reporting, accountability--that we could provide to, you know,
follow under the chairman's leadership to address by Congress.
Is there anything that comes to mind? And if not, if you could
have your staff work on that and report back to the committee.
Admiral Ziemer. Sir, I think that is a great question. I
would like to come back to you with the specifics, depending on
what you would find helpful as you look forward to fulfilling
your responsibilities. But I think it is worth time to continue
looking at that. And we will get back to you, sir.
Mr. Meadows. And then my last question. It really gets
back--I think we are in clinical trials, in the third clinical
trials in terms of a vaccine. And having seen that, that is a
hopeful sign if we are getting to stage three clinical trials.
My question is, how do we look at the severity? Because I think
you mentioned in your testimony the severity of those. They are
5 months to 17 months old. How do we measure quantifiably the
success of that? I mean it is very difficult when we have
children to figure out, you know, if pain is on a scale of 1 to
10 because they won't rate it out. How are we doing that?
Colonel Weina. One of the ways of assessing severity when
it comes to malaria is actually pretty simple because severe
malaria is a disease--although we have very uniform and very
stringent criteria that we need to follow, I think it is real
simple. If you can't take water, if you can't swallow things,
if you can't take a pill to treat the malaria and you need an
IV treatment, that is pretty severe malaria. And the outcome
measure is unfortunately very easy to measure, and that is
death because once they start down that circle of having severe
malaria, it takes some extraordinary measures----
Mr. Meadows. So primarily through dehydration or----
Colonel Weina. There are a number of different mechanisms.
Sometimes through pulmonary malaria, sometimes through cerebral
malaria, there are a variety of different ways. But typically
with children, it is because of anemia.
Mr. Meadows. I thank the chair's indulgence. I would also
ask if you could for the record address if there are any
nanotechnologies that we are using in terms of clothing,
netting, and so forth that might be out there or at least hopes
in terms of future research, in terms of nanotechnology.
And with that, I yield back, Mr. Chairman. Thank you.
Mr. Smith. I thank the gentleman.
Mr. Stockman.
Mr. Stockman. Thank you.
I don't know who could answer this question. But I think I
was watching Frontline or one of those shows. And they talked
about the Chinese counterfeiting malaria medication and how
that impacts and creates resistance to malaria. And that is
kind of a big elephant in the room. As we are spending
millions, in some cases hundreds of millions of dollars
developing a new drug, they are out there emulating and making
fake copies of it. And as you take the pill and you stop taking
it, of course, that is how the resistance builds. I guess I am
asking, have you guys addressed that issue on how to stop the
counterfeit?
Admiral Ziemer. Sir, it is a global issue. It has a lot of
visibility and attention. I know it is a priority for the State
Department right now. It is a matter that we are very concerned
about because people that are sick with malaria taking
counterfeit, fake, or unsafe drugs are going to continue to get
sick and die. So it is not only a health issue, but it does
beat resistance, and it really is a concern to us in terms of
how it manifests itself in the resistance of the parasite.
But on the criminal side, it is a high priority, and we are
working with our governments and criminal agencies to take
appropriate action. But we have got to stay at it at multiple
levels, diplomatic, technical, and at the country level, where
these drugs are being regulated, are not regulated, purchased,
and distributed.
Colonel Weina. There are actually two issues with that
particular question, sir. One of them has to do with actually
counterfeit ones in which they are trying to sell them for
other manufactured ones so that they look the same. Typically
they don't just put sugar pills in. Typically what they do is
they add just enough of the drug there, so if somebody were to
test it, they would detect a level of drug.
Mr. Stockman. That is even worse, too.
Colonel Weina. And that is even worse because what it does
is it feeds into providing a low level exposure of that drug to
the parasite so it kind of helps them learn how to become
resistant. So that is a problem. But there is also a problem of
poor quality drugs. And one of the hallmarks and one of the
reasons why people love the U.S. medical machine, if you will,
is because of the fact that we have good quality products that
are available, manufactured under good manufacturing practices
and tested under good clinical practices. And quite often, we
compete with other countries that may produce a drug under
different standards. They can sell it for a cheaper amount and,
therefore, it becomes used. So quite often what happens is that
we need to make sure that we look at, for example, the
technical ways and the legislative ways and the diplomatic ways
of making sure that we are using not just good quality drugs
and that everybody is kind of following the same standards when
it comes to that but also trying to make sure that we ferret
out and get rid of these counterfeit drugs.
Mr. Stockman. The implication in the program was is that
there is a staggering amount of fake drugs out there. Do you
have any way of quantifying how much is fake and how much--I
mean do you guys ever sample it? Because they showed a package
and you couldn't tell the difference. It was stunning. And it
looked like an American-produced product. But they are implying
that there was a lot of it out there. Is that quantifiable? Do
you guys trace that?
Colonel Weina. We aren't ourselves particularly following
that. But there are a number of different organizations that
take this on and really do a wonderful job of finding out
exactly how much is out there. It is worthwhile for them
because instead of the $60 that they could reap for it, it may
only cost them pennies to make it. So they get quite a bit of
profit as opposed to ours.
Mr. Stockman. Do you know who those folks are so we can
have them before our committee? I feel like what we are doing
is we are competing against ourselves. We are throwing millions
of dollars, which is what we want to do because we want to save
lives, but at the same time if somebody is in the boat drilling
holes, it would be nice to stop that person from drilling
holes. So if you have some experts and if you could get with
the chairman and let us know, I would love to hear their
testimony on exactly how big this problem is because if we
constantly are competing against ourselves trying to produce
new stuff, and then they emulate it and then, like you said,
the organ gets a little bit of it and adjusts again, then we
will be in a never-ending--we are chasing our tail. But do you
know the individuals that would have that information?
Colonel Weina. I don't have that information right in front
of me at this moment. But I do know that there are several--
again, several organizations that are following that quite
closely and there are congresses that meet, international
congresses because this is an international problem. It is not
just here in the United States. And they follow this very
closely. They try and track down where these are. But finding
the actual individuals or the actual country that is producing
it has proven quite illusive.
Admiral Ziemer. We do have some information. But I think
what I would like to do is go back, look at our files and then
get back to you specifically to make sure we can answer the
questions that you have and share what we have. Okay.
Mr. Stockman. I am trying to remember. I think the show was
``Malaria.'' It was really fascinating. I can't remember.
The other question I have, if I may, we eliminated malaria
here and a lot of us see the film clips of it, how we eliminate
it. And no one ever wants to talk about it. But it was very
effective. It was how it was eliminated in India and a lot of
places around the world.
And now with atomizing our DDT, you cannot have the impact
on the environment that we had in the 1950s. And I remember you
see the film clips of kids just covered with DDT. My brother
was one of them, and he turned out, I think, fairly normal. He
might disagree politically at times. But he is okay. And then I
see the sacrifice. I know we have to trade off a balance.
But your heart goes out to these young kids who don't have
the same protection we had. And I don't know if there is really
a trade-off where we should maybe--because of technology now--
reintroduce that product because it could save--some
estimates--millions of lives. And I would like to see it
reintroduced under the controlled situations where we can make
the molecules much smaller through atomizing the product.
Admiral Ziemer. Sir, there are 12 approved insecticides on
the WHO-approved list. DDT is on the list. And we were using
DDT in three of our programs. We switched off of DDT because
there was a resistance developing by the mosquitoes. So we
alternate it to pyrethroid or another effective insecticide. So
the issue of DDT is front and center, but I think what we need
to do is continue to focus in on effective, safe insecticides
that are approved and then look at the best application based
on resistance, protocol, and the data that we have.
Mr. Stockman. I also noticed they are taking--and indulge
me a little bit, and I will yield back the time. But aren't
they taking mosquitoes and injecting them so they don't bear
other mosquitoes? I guess birth control for mosquitoes, which
is kind of amazing. RU-486 for mosquitoes.
Colonel Weina. We do have a number of very innovative
strategies that are being developed by our entomologists that
look at doing things besides insecticides, because we do know
that, just like the parasite is going to be able to develop
resistance to our drugs, the insects develop resistance to our
pesticides and eventually will overcome the ones that we have
available to them. So we need to be thinking, as it has been
said, outside the box and to other strategies, which include
sterilized mosquitoes that are able to decrease the burden of
the vectors that are present.
Mr. Stockman. And lastly, my father used to do this. He was
a zoologist, and what he used--I don't know if you can do
this--he used vegetable oil on still ponds. As the larvae comes
up to get air and then gets vegetable oil. Is that something
that you can use widely?
Admiral Ziemer. Larvaciding is an option.
Mr. Stockman. You are being diplomatic.
Admiral Ziemer. Yes, sir. But it is an important one
because where we work, the application of larvaciding by WHO
guidelines isn't the most costly, effective program.
Mr. Stockman. I know they did it in Panama, too, right?
Admiral Ziemer. Yes, sir. So there are certain parameters
that WHO says ought to be used if larvaciding is considered an
option. In the countries where we are working, we are not even
looking at it because of the places and the conditions would
not make it a cost-effective intervention for prevention
purposes.
Mr. Stockman. Well, thank you for your candor and your
time. You guys have been great. Thank you so much.
Mr. Smith. Thank you very much, Mr. Stockman.
Not to make light, but when Mr. Stockman was talking about
the foggers, I grew up in Iselin, New Jersey. My friends and I,
when we were 8, without our parents' knowledge or consent, used
to follow the foggers on our bikes. We were covered with the
stuff.
Mr. Meadows. Me, too, Mr. Chairman. That is our problem.
Mr. Smith. That is when I decided to run for Congress.
Thank you so much for your great witness today, your
testimony, and above all, your leadership. It is so greatly
appreciated.
Admiral Ziemer. Thank you.
Mr. Smith. Pursuant to the rules of the committee, we will
now have to end the formal part of the hearing and go
officially to a briefing. It is part of the rules of the House
and the committee, I should say, to receive testimony from
Ambassador Mark Dybul.
[Whereupon, at 11:54 p.m., the subcommittee was moved to a
briefing.]
Mr. Smith. I will welcome the Ambassador to the witness
table. Ambassador Mark Dybul--and it is a very high honor to
welcome him here today--is the executive director of the Global
Fund to Fight HIV/AIDS, Tuberculosis and Malaria. As an
immunologist, as an administrator, as a teacher and as a
leader, Ambassador Dybul has worked for more than 25 years to
help prevent and treat infectious diseases.
Ambassador Dybul has written extensively in scientific and
public policy literature. He is a founding architect and a
driving force in the formation of the President's Emergency
Plan for AIDS Relief, or PEPFAR. I know--and I say this
firsthand because I was very involved with that legislation--it
was Congressman Henry Hyde, who was the prime sponsor. It was a
bipartisan bill. But Ambassador Dybul was absolutely critical
in crafting that text, the language, the all important law and
its reauthorization in 2008. So I want to thank him for that
leadership.
He was formally appointed as U.S. Global AIDS Coordinator,
with the rank of Ambassador from 2006 to 2009. Before joining
the Global Fund, he was codirector of the O'Neill Institute For
Global Health Law program at Georgetown University, where he
was also a distinguished scholar.
Welcome, Ambassador Dybul.
STATEMENT OF THE HONORABLE MARK DYBUL, EXECUTIVE DIRECTOR, THE
GLOBAL FUND TO FIGHT AIDS, TUBERCULOSIS AND MALARIA
Ambassador Dybul. Thank you, Mr. Chairman.
It is a great privilege to be back before this committee in
a different role. Other members of the committee, thank you for
your dedication and for being here. This committee, as I know
firsthand, has had such long, strong bipartisan support for
serving those in need.
And Mr. Chairman, thank you for your leadership going back
so long in this fight. And I know now you have new friends and
colleagues that will help support this effort with you.
You have heard a lot of the data and information. So if it
is acceptable, I would like to enter my testimony for the
record and highlight a couple of key points, including in
response to some of the issues that have been raised. This is a
very difficult financial time. We are very conscious of that.
And coming before this body or any body, actually, around the
world to ask for increased resources for foreign investment, we
understand, is difficult to ask. And I think it is important to
understand why we are doing this now. It is easy to say in
these difficult financial times, we can wait 3 or 4 years, 5
years, until we have better economic times and better budgets.
The reality is that because of the massive investment of the
last 10 years and because of advances in science and our
understanding of the diseases, we are at a critical tipping
point in the history of malaria and HIV and tuberculosis. We
now have the science and implementation understanding to
actually end these diseases and public health threats and to
put us in a position to ultimately eliminate them.
We have never had this moment in history before. Malaria
has been with us as long as history has been recorded, as long
as we know. We are the generation. You are the leaders that can
actually put us on the course to end this disease as a public
health threat. And that is why it is so important to act today.
And I will expand a little bit on that.
The scientific advances, you have heard about: The new
long-lasting insecticide treated nets, new indoor residual
sprays, new treatments, much more effective combination
treatments and eventually a vaccine, which I will come back to.
One thing we have not talked about is the success of the
interventions to date leading to a new understanding in
epidemiology of the disease. We have had so much success over
the last 10 years, which you have heard about, that high-
transmission areas are becoming much more confined. A good
example is South Africa and Swaziland. They now have malaria
only on their borders with Mozambique. Not too long ago, they
had malaria throughout their countries. We see this over and
over and over again. Because of the success of the
interventions, we now have areas that are being more and more
contained with high transmission, which allows us to target our
interventions much more effectively. We are also understanding
that high levels of the parasite in the body are very limited
in geographic scope. So we are now focusing our efforts on
those areas.
All of this has been made possible because of the
experience of the last 10 years, because of the investments
that have been made. We are now in a position to actually get
for you a full return on that investment by completely
controlling and ultimately eliminating malaria. If we succeed
in what I just described, a partially effective vaccine would
be enough in all likelihood. And that means some of the things
the colonel talked about could be, in our lifetime, available.
If we control the infection to such low rates, to such
inefficient transmission, then you don't need an overly
powerful vaccine. And that is the opportunity before us. But we
are at a tipping point. And tipping points can go in two
directions. You can continue on the course you are on or you
can tip backwards. And you have already talked about some of
that tipping backwards that has occurred. We have extraordinary
data for how quickly--especially in malaria--you can tip
backwards from success.
Zambia is an excellent example. It achieved fantastic
coverage of interventions, significant declines in their
infection rates. But because of funding issues were unable to
replace nets and immediately saw an uptick in new infections.
We have seen the same thing in Rwanda and other places. And
while you have talked a little bit about what happens when the
malaria comes back, one thing that is important to emphasize is
if you have protected a child for a few years and then they no
longer have protection, it is almost worse than never having
protected the child because they were never exposed to malaria.
They have no immunity to malaria. So if they then become
infected, their malaria will be far worse and, as the colonel
described, can lead to the meningeal, pulmonary, and other
fatal forms of malaria because they were protected and became
unprotected.
And that is why the data the chairman mentioned on the
inability to just replace nets is so striking and such an
important moral issue for us. And that is why the Global Fund
dedicated $450 million this year to reduce that gap from 77
million to 24 million bednets. But we still have some gap. And
that is just to maintain, not to achieve the vision we talked
about, to drive toward complete control.
The bottom line of this is this is not a bottomless pit.
This is not what we would have done for the last thousands of
years in the fight against malaria. We are actually on the
tipping point where today we can say we can completely control
and ultimately end malaria in the world. But it is going to
take resources.
And in that regard, we are very grateful to Congress for
the 2013 budget. We know how difficult that was to maintain the
financing for the Global Fund that allowed us to replace all of
those bednets that otherwise we could not have replaced. We are
very hopeful that the 2014 budget can meet the President's
request, which is similar to the 2013 budget. In fact, it is
the same. And one thing I believe is important for you all to
know is that your contributions to the Global Fund are
leveraged two to one from other donors because you can never
give more than 33 percent. And we use that to leverage two to
one. So every $1 you give gets us $3 in the fight against
malaria.
As has been mentioned, the Global Fund has committed about
a third of its $23 billion portfolio to malaria. We work very
closely with the President's Malaria Initiative. We support the
same comprehensive approach. And more recently, we reorganized
our structures so that we are focused on the high-impact, high-
disease-burdened countries in a much more aggressive way, the
countries that you all have mentioned where most of the malaria
resides.
Partnership has come up a fair amount, and I would like to
just say a few words about the close working relationship with
PMI and others. One of the areas we are working aggressively--
and to ensure that when you go to the taxpayers, you can tell
them the money is being used well--is to increase efficiencies.
Last week, the Global Fund hosted with PMI and UNICEF a new
round of negotiations on the price of bednets to drive the
prices of the nets down by using our collective buying power.
It is the first time that has been done, that we worked
together to use that collective buying power to drive those
prices down.
A second example is to partner with the private sector and
the U.S. Government through USAID. Yesterday, we announced a
new innovative process that will allow us to more rapidly
utilize the resources that you make available us to and to
leverage the private sector's capability of guaranteeing
resources to do that.
A third example and one that has come up is our work with
PMI and other global partners in the Mekong Valley to address
drug-resistant malaria. The Global Fund has committed $100
million to a regional partner there and has partnered with PMI
and the technical expertise of the U.S. Government and other
partners to ensure that our global investments are not
threatened by the resistance that is developing there.
A fourth example is to partner with national malarial
control programs to move toward that use of the science, use of
the epidemiology to make sure the resources you commit are most
effective and dedicated where the highest risk of transmission
is. A final example I will give you relates to counterfeit
drugs. Mr. Stockman, you asked who is working on this. Actually
the Food and Drug Administration is working very aggressively
on this. And there are several other international partners,
including the private sector, that are developing new
technology so that we can identify counterfeit products in a
very rapid way through international consortia. And the Global
Fund is actively involved this those efforts, which is
something that a multilateral can do. It is more difficult for
bilaterals to engage in.
I also want to point out that we are not just relying on
you and your taxpayers for what we are talking about. Africa,
itself, is stepping up in dramatically new and exciting ways,
as is India and parts of Southeast Asia. The African Leaders
Malaria Alliance brings together the heads of State of Africa
at that level to focus on malaria. And in part, as a result of
that, last year alone and annually, $625 million came from
countries themselves to fight malaria. So they are partnering
with you with their own resources as well as their commitment.
A good example is Zambia, which in the last 2 years has almost
tripled the resources they commit to malaria. The private
sector is also in the game heavily, in part with the
commodities they provide, in part because of the delivery
systems, but also with money. Chevron has provided the Global
Fund about $55 million. Product (RED) is a partnership of CEOs
and companies in the United States that provided the goal of
funding over $200 million. The Bill & Melinda Gates Foundation
has provided significant resources, and we are also targeting
other high-net-worth individuals. So we are not looking to you
all alone. We are developing financing partnerships that will
relieve the burden on the American taxpayer in an exciting way.
One of the reasons heads of state and the private sector are so
involved is because of something that was touched on but not
probed enough perhaps. And that is the impact of malaria on
productivity. Nigeria alone estimates that they lose over $3
billion a year in lost productivity because of malaria.
Globally, the estimates range as high as $40 billion. And most
people think those are significantly underestimated. And that
is why the private sector has gotten engaged, because Chevron,
for example, in Nigeria, was losing so much time in their
offices and in their production facilities because of malaria.
So it was good business to intervene. That is good for the
United States to have a rapidly growing economy in Africa to be
a buyer of our goods and services.
So the opportunity before us is huge. The partnership that
is responding is huge. But the most important opportunity is,
in fact, for the first time, which we could not have told you 2
years ago, we are on the cusp of completely controlling this
infection and ultimately eliminating it.
As it has been mentioned, we had malaria in this country.
Eight United States Presidents have suffered from malaria,
including Teddy Roosevelt and John F. Kennedy. John F. Kennedy
of course was after 1951 when we eliminated it, but he served
in Vietnam and came back with malaria. And as we talked about,
that is a threat that is growing for us.
CDC in fact was created initially largely to respond to
malaria and is still deeply involved. We have now eliminated it
in the United States, but there is a risk it could come back.
And we have the opportunity--if we invest wisely, if we use
taxpayer dollars well, if we continue this partnership--to
achieve something that has not been possible for thousands of
years and is possible today: To completely control this
infection, ultimately to have more scientific advancements and
to move toward elimination. And if we don't do that, the cost
in millions of lives is extraordinary. But more, the billions
upon billions upon billions of dollars that you will continue
to have to dedicate would not be necessary if we act today, if
we act now. So we can leave for the first time a generation
free of malaria that has not happened since recorded time in
history. What an opportunity. What an opportunity. If we
maintain our resolve, if we work together, if we capitalize on
new scientific advancements, collectively we can accomplish one
of the greatest feats in history, to defeat a plague that has
been with us for thousands of years. Now is the time to act.
Now is the time to invest so that we don't pay forever. Thank
you very much for your attention. I look forward to answering
your questions.
[The prepared statement of Ambassador Dybul follows:]
----------
Mr. Smith. Dr. Dybul, thank you very much for your
testimony and for your leadership.
Your testimony is quite extensive. And I do hope that all
members of the subcommittee, and the full committee as well,
will read it, because you really lay out even more than what
you have just done very well in your oral presentation.
You point out that we can all agree that no child should
die for lack of a $1 insecticide-treated net--and I think that
very low cost is under-appreciated. People don't realize how
cheap it really is: A $1 rapid diagnostic test kit and $7 drug
treatment regimen if, of course, the child is sick with
malaria.
You talk in your testimony about the $3.5 billion gap. And
I am wondering, in addition to the United States, and I frankly
think we should do more, and I know maintaining current levels
with the crisis in the budget that we face is job one, but
certainly if we could go above that, obviously that is all
value-added? What other countries are really stepping up to the
plate? And, as you pointed out in your testimony, some of the
affected countries, like Zambia, are doing more, which is
greatly appreciated because they have resources, and they are
prioritizing those resources. But what other countries
typically in Europe and elsewhere are really stepping up to the
plate?
Ambassador Dybul. Thank you, Mr. Chairman.
And I think it is a really good question because it really
does emphasize that the U.S. is not going it alone. The U.S.
leadership has been out in front since the beginning of this
fight on malaria. But it has not had to go it alone. So the
Global Fund, as I mentioned, is a multilateral institution. We
are not part of the United Nations. Actually, we are an
independent multilateral. And we were created that way so we
would have more flexibility. And through that mechanism, we
have a board, which has the major contributors and countries
represented on it. The United States is, by far, the largest
single contributor to the Global Fund. But as I mentioned, you
can never give more than 33 percent. And that leverage is two
to one from others. Other countries that are large
contributors: France is the second largest contributor to the
Global Fund; the United Kingdom is the third. The United
Kingdom also has a large bilateral program with a big emphasis
on malaria. So they also have bilateral efforts in addition to
their contributions to the Global Fund. Japan, Germany,
Sweden--pretty much all of the Nordic countries have
participated to very high degrees. We even have countries like
Russia contributing to the Global Fund. India provides a
contribution. Thailand provides a contribution. So it really is
a way to have a shared responsibility, a global response to
these epidemics.
But importantly, as you pointed out, African countries
themselves--South Africa not only receives grants from us, they
actually provide a gift to the Global Fund. Zambia is
considering such a gift. Namibia provides a gift to the Global
Fund. So, at the same time they are moving to fund their own
domestic programs, they are trying to contribute to the broader
effort globally. So it really is a shared responsibility.
I would also like to mention again the private sector
contributions, which are critically important: The Gates
Foundation, Chevron, Product (RED). You are in there as a
leader. But you don't have to go it alone. And we work very
hard to ensure that your money is matched two-to-one.
Mr. Smith. Let me just ask, on the insecticide-treated
bednets, you have suggested that 77 million nets are needed
just to get back where we were--especially because some of the
nets wear out after a 2- or 3-year useful life.
The WHO says that to have complete coverage, we need 150
million such nets. Where are we in terms of actually getting to
those numbers? And secondly, had President Bush not created the
President's Malaria Initiative, or the PMI, where would we have
been?
Ambassador Dybul. So in terms of what is needed to get to
that complete control we talk about, that is where the $3.4
billion gap comes from. If we are really going to contain the
epidemic, if we are really going to get to that full control so
that we can with a partially effective vaccine eliminate
malaria, or at least eliminate it as a public health threat, we
have the knowledge today, that is what that $3.4 billion would
do. The 150 million nets a year is really to maintain. And we
are not at universal coverage yet. We have a little bit to go.
And we also need indoor residual spraying. We also need to
treat people who do get malaria which actually contributes as a
preventive tool as well because you reduce the parasitemia. And
that is where the $3.4 billion would fill in and allow us to
contain.
Again, I know that sounds like a lot of money, and it is a
lot of money. But the opportunity cost not to invest today is
to actually lose the return on investment of what you have
invested for the last 10 years because, again, we are at that
tipping point. And we can either continue to work to get to
complete control or we can slide back down, in effect losing
some of the return on investment--obviously not all of it since
we have saved millions of lives.
President Bush's leadership was extraordinarily important.
The President's Malaria Initiative has had a significant impact
and really with the Global Fund and the UK's program are the
major external funders, along with increasing domestic
contribution, in the fight against malaria. But again, everyone
is getting in the game, but it takes leadership to cause that
effort.
Prime Minister Blair was actually a tremendous leader and
worked closely with President Bush at Gleneagles, and the UK
will be hosting the follow-on to the Gleneagles G-8 Summit this
year. And we are hopeful that they will recognize the
importance of this partnership through the G-8, going back to
that Gleneagles, when President Bush and Prime Minister Blair
were in office, that has led to where we are today with success
in malaria.
Mr. Smith. Thank you. I do have other questions, but in the
interest of time, I yield to my good friend and colleague Mr.
Weber.
Mr. Weber. Thank you, Mr. Chairman.
Mr. Dybul you said that Swaziland had almost eliminated
malaria, only had it in some areas on their border with
Mozambique, I think. How did they do that?
Ambassador Dybul. And South Africa is the same. And they
did it through a strong national program with external
financing and all the partners working together with a common
objective to get to complete control. And so with long-acting
insecticide-treated bednets, with available treatment, with the
correct treatment, the effective treatment, they were able to
push it out so that it is really--because of the border,
mosquitoes don't much follow geographic borders. They go
wherever they want to go. So it is a very important issue
because we are seeing this happen in country after country,
where they are actually managing the infection in their own
countries, but it is the bordering regions. So we are shifting
to an approach that looks like a cross-border transmission and
cross-border control so that we can do that.
But it really was through what we have been talking about,
and you have been talking about all day, using the science,
using the advancements in interventions, getting the ground
game so that you get the coverage rates, using faith- and
community-based organizations and make sure people are sleeping
under the nets and that people are accessing services and
having a national strategy and a national approach.
It is not just these two countries. Right now, Tanzania has
had a 50 percent reduction. They have had 90 percent coverage
of their bednets. They have had a 50 percent reduction in
mortality and case detection and almost a 45 percent reduction
in all caused child mortality because malaria contributed so
much. So many countries are pursuing this effort. And what we
know now is if we act in this coherent way, if we use all the
interventions smartly, we can actually get to complete control.
Mr. Weber. Let me ask you, are you able to quantify, when
you look at that country, are you able to say the program cost
X, they poured X amount of resources into it and their
incidents went down, is that quantifiable?
Ambassador Dybul. It is. It is. In fact, we have those data
for you. We have the total dollar amount and we have the total
impact. What we are doing now is actually combining all the
spigots of funding. So what we have done in the past is look at
what the Global Fund invested, look at what PMI invested, look
what the country invested. What we are now doing is taking a
country look and saying what should that cost be to actually
achieve those results? And again, working with the U.S.
Government to get the cost of the nets down, getting cost of
the supply down, so I think what you are getting at is exactly
right. We now have the knowledge of how much it should cost and
to drive the cost down even further.
Mr. Weber. All right. And then final question, Mr.
Chairman, my colleague Mr. Stockman, had asked the previous
panel could they give us the names of witnesses who knew who
was doing the counterfeiting, and let me just say, tongue in
cheek, we don't necessarily need those names. We need the names
and the addresses of the counterfeiters so we can send Igor and
Bruno over there with a No. 34 baseball bat and break their
kneecaps.
Are there such a thing as sanctions? Or when you identify a
country that has that kind of counterfeiting going on, is there
a database that says this country has been participating, and
is there such a thing as--how do you sanction them?
Ambassador Dybul. It is rarely a country. It is usually
people working within a country, and often----
Mr. Weber. But if you were able to get with that government
and say you-all need to shut this down.
Ambassador Dybul. Which is exactly where it is going. And
INTERPOL is actually actively involved in global counterfeiting
with the FDA and others exactly for that purpose, so that
people can begin to identify where people have refuge to do
counterfeit activities, to track them with new technology, and
then work collectively as an international community to shut
them down.
Mr. Weber. And so INTERPOL takes the information. There is
a particular provider of medicine that is sending counterfeit
drugs in and they can track that back and are keeping a
database who not to buy from, for example.
Ambassador Dybul. It is being developed. These programs are
being developed because everyone has gotten so much attention
for it. To Mr. Stockman's question, I think if you brought FDA
in, they could give you a very full picture because they are
very aggressively and actively involved in all of these
conversations, and using these new handheld technologies where
we can identify counterfeit and trace it back.
Mr. Weber. Okay. Thank you, Mr. Chairman.
Mr. Smith. Thank you.
Mr. Meadows.
Mr. Meadows. Thank you, Mr. Chairman, and thank you for
your testimony and briefing, and I wanted to follow up a little
bit in terms of, you know, you mentioned the Global Fund and I
think you implemented a series of reforms, you know, due in
part to a response from Congress. And as you have implemented
those reforms, how would you say those have progressed since,
you know, your leadership and what is still left to be done?
Ambassador Dybul. Thank you for the question, because I
think it is very important and really is a testament, in my
mind, and the reason I was so interested in going into the
Global Fund it that it is a true learning organization. It
really looks at itself constantly to say how can we improve,
how can we do better and let's change, and as we all know, that
is not a typical approach in organizations.
Mr. Meadows. Right.
Ambassador Dybul. And that is one of the most exciting
things about it. So the reforms are really an evolution from
looking to see where we are today, what the landscape looks
like and how do we implement more effectively with higher
impact. So some of the key things that have been done, and
again, the board--the U.S. being an important member of the
board and the U.S. Congress pushing, really--the board itself
pushed for these reforms, and how rare is that that you have a
governing body pushing for this type of change? Because often
we think change means you made a mistake. Sometimes change is
good because you are learning.
One of a few things we learned was that we didn't have the
right--we don't have as much focus on high-impact grant
management as we needed to and so we shifted so that now 75
percent of our staff is dedicated as a financing facility,
which is what we are, to grant management, because that is our
core business. And we are identifying what our core
competencies are and partnering more with other organizations,
which is what we were created to do for technical and other
purposes.
Mr. Meadows. And so if you are looking at that grant
management, what matrix do we use in terms of, one, the
awarding of the grant, and then I guess the second part of that
is the effectiveness once the grant has been given, what is the
matrix, the area?
Ambassador Dybul. So the matrix for how grants are given
are based on disease burden, because that is where the impact
is going to be. Co-investment is a key part of our--how we
make----
Mr. Meadows. So the better co-investment, the more likely
they are to get to the grant?
Ambassador Dybul. And also a requirement for co-investment
is based on economic situation. So even if you have a high
disease burden but have a good economy, you need to be giving
more, and we work on that in a formalized way as part of the
grant-making identification.
Mr. Meadows. And there are no other political agendas or
sidebars that evaluate it.
Ambassador Dybul. No. Well, the other is ability to
implement in terms of rapidity. We don't want to dedicate money
and put it in a country when they don't have the capacity to
move it. And then we have a risk management tool that is new,
which looks at not only risks of misuse of funds so that we can
ensure that--and go after any misuse of funds--but also risk in
non-implementation, which gets to capacity a little bit, and
what are those risk implementations. Is it the supply chain? Is
it human resources? Is it the inability to reach certain parts
of a country for various reasons? And then we dedicate our
resources to alleviating those risks. So it is a very complex
matrix across those areas, but it is leading to a much more
impactful approach.
Mr. Meadows. So you are saying this is really more of a new
funding model than you have had in the past; is that correct?
Ambassador Dybul. In fact, we call it a new funding model.
Mr. Meadows. All right. So, and thus my question. And so as
we look at this new funding model, what can we do in terms of
the planning stages and the implementation stages, similar
question that I asked the Admiral, what can we do from a
legislative standpoint, knowing that we are only part of the
pie, to help facilitate that and help encourage that to make
sure that American taxpayers are getting what they pay for.
Ambassador Dybul. Well, I am probably a little biased
since, as the chairman pointed out, I actually was involved in
the writing of the legislation, but I think it is pretty good.
Mr. Meadows. What tweaks would you make to your own
writing; how about that?
Ambassador Dybul. I actually believe currently that the
language you have is very useful to us, and it actually helped
the Fund, along with other people on the board, move toward
this new exciting approach.
What we are really focused on is the partnership piece, and
that is in the legislation that we should be focused on using
the resources from the U.S. taxpayer from whatever source they
come in the most effective way to have the greatest impact and
partner and leverage. And that leveraging piece is something we
have not always done well, none of us, and that is what is so
exciting about this new funding model--we actually bring all
the partners together to look at the epidemiology, look at the
science, to ensure that the investments going in aren't
duplicative.
Mr. Meadows. Right.
Ambassador Dybul. Aren't ineffective and are going to the
right outcome. And then, importantly, to the other part of your
question, we evaluate it on a quarterly basis: How is the
progress against the targets? And we can track it in a
programmatic way so that we can adjust and reprogram as needed
as we are identifying new realities on the ground. Grant
management is not writing a grant. You start grant management
when you write a grant. You then work to ensure that the money
is used well. We also only disburse funds as the countries need
them. We don't give them a pot of money and then 5 years later
come back and see what they did.
Mr. Meadows. What a novel concept. Well, and so let me go
back. You mentioned ``tipping point'' in your testimony here
today. You mentioned ``tipping point'' four different times,
and so as, as we see that, you say we are at a tipping point,
we are at a tipping point and we can go forwards or backwards.
And yet what you also said is that we are at a position where
we can eradicate malaria. What is the timeframe, and what is
the greatest barrier to--and I know that we are talking about
science here. We are talking about--but probability, the
probability of eradicating malaria within what period of time?
Ambassador Dybul. There are different models, and I have to
say a lot of this is mathematical modeling to predict----
Mr. Meadows. Sure.
Ambassador Dybul [continuing]. When we intervene how we
will do. The model so far over the last 10 years have held up
pretty well, and really, eradication will require a vaccine in
all likelihood. What we can do is eliminate it as a public
health threat and completely control malaria. And what we have
seen in the last 5 years, I think, makes us much more hopeful
that the timeline could be even more compressed. But we are
actually, and the World Health Organization reports on this,
about 20 countries have eliminated malaria in the last 10
years--so you go from endemic or epidemic, to control, to
elimination, and then ultimately eradication.
And if you look at the trajectory and the curves, we were
seeing a 20-year horizon, 30-year horizon, but we are bending
those curves down, including in countries, because of the
success of the last 10 years. We are working on that precise
type of modeling based on the new data to try to give us a
better sense of that. But the wildcard in that, and this is why
I emphasize it a little, what we are learning more and more is
you can actually push the epidemic into corners, and that then
means you throw everything you can at those corners to have the
biggest impact to get everything down to low level. And if you
can do that, then a relatively efficient vaccine should be
enough. If you allow a couple of pockets somewhere, you are
going to need a really highly effective vaccine, so a lot of it
is going to depend on that variability.
The one thing we do know is that if we don't get down to
complete control, near elimination, we will be continuing to
fight this fight forever, and that is the tipping point, and
that is the change that we have seen. Up until the last 2
years, we would have just had to keep doing the same thing and
the same thing and the same thing until we have a vaccine or
until all countries had enough economic growth that they didn't
have some of the issues around pooling of water and other
things. But now we are seeing the opportunity to push, push the
timeline forward strongly.
The reverse of that is if we don't stick in this game, we
know what is going to happen. And malaria, more than any other
disease, we know it will come back, and then we won't have the
science or the tools to bring it back down, and a partially
effective vaccine won't do it, and then we are going to have to
just keep putting in more and more and more money rather than
investing now, and that is the issue of the tipping point.
Again, I--you know, under most circumstances, I wouldn't--I
have been around governments a long time, I have been around
budgets a long time. I wouldn't come to you with a straight
face to say we need more money today, given the current
economic environment, except for this unique moment in history.
It is a shame it is coming at a time of tough budgets, but it
really is. We have never had in the thousands and thousands of
years that we have had malaria.
Mr. Meadows. Well, I must admit, it was very unique
testimony and thus why I followed up with a question, but with
that, being sensitive to the other members, I want to yield
back to the chairman at this point.
Mr. Smith. Thank you, Mr. Meadows.
Mr. Stockman.
Mr. Stockman. Mr. Meadows, you can keep going. Those are
great questions. I enjoyed them. And following up on his line
of comments and statements, you mention in your testimony, Mr.
Ambassador, Zambia and Rwanda are reinfected. Can you tell me,
in your mind, because you have been working with this for so
long, what is the rationale behind that? What happened?
Ambassador Dybul. So in both, neither country had
eliminated, but they had significant control, very close to
complete control in many areas. And that was because, like in
Swaziland, they had national bednet campaigns, they had
excellent care and treatment programs, they had an excellent
program and a strategy that they implemented. But then they had
some funding shortfalls and they weren't able to replace them,
some nets, or couldn't complete some campaign.
Mr. Stockman. Can I interrupt for a second? Was it the NGOs
that had the shortfalls or the government?
Ambassador Dybul. Both. So both NGOs and the government are
involved. Basically it is one pot of money that gets divided
out. Most bednets are distributed through national campaigns
that are organized by the government because it is the only way
you can do a national program, but implemented often through
NGOs, especially the sleep-under-the-net campaigns. One
important thing is you can't just distribute the nets. You make
sure people know how to use them.
Mr. Stockman. I was going to say, because don't they sell
them or resell them or so?
Ambassador Dybul. You know, sometimes that happens. With
the national campaigns, that is rare because there is no reason
to, because your neighbor has one, too, but in the past, that
actually did happen.
Mr. Stockman. I saw them using it for everything.
Ambassador Dybul. Yeah. And actually there was a big
education campaign. I mean, in the early going, people were
afraid to use them, didn't know how to use them. Actually in
one case, I went into a home and I asked them where their
bednet was because it wasn't hanging, and they pulled it out
from under the bed in the plastic packets because they thought
it was so beautiful and still in the plastic package. So you
need to go in and teach people and encourage them, and that is
where the communities are so important and the faith and faith-
based communities and the community-based organizations.
In Nigeria, the Muslim community and the Christian
community are working together to ensure that everyone in their
congregation sleeps under their nets. It is part of their
Sunday sermons. They do it all the time, and so that is really
important. The funding shortfall was actually from external
resources, but the governments couldn't make up and so they
couldn't meet their deadlines to ensure that nets were replaced
or campaigns were completed, and then we saw the increase. But
then we all came back in, we moved heaven and earth to get the
nets in and they came right back down.
So it tells you how rapidly with this disease, if you lose
just a little bit, you lose a lot, but if you stay contained
and you stay suppressed, then you start pushing to where you
just have these little pockets of high rates of infection.
Mr. Stockman. Why do you think in Vietnam they are drug
resistant? What is the rationale behind that?
Ambassador Dybul. So it is more than Vietnam. It is
actually the whole Mekong Valley, so Myanmar, Vietnam, Thailand
and really in that that nexus, again, because the mosquitoes
and the resistance doesn't respect borders.
The resistance develops either because, as you pointed out,
people get partially effective drugs, or they stop and start
and don't take enough. And one of the key issues which has been
raised is that, you know, if you are out in a village and you
are in malaria season and your kid gets a fever, you are not
going to walk the 2 days or the day--and the clinic may not
even be open. You are going to go to a kiosk and you are going
to pay for an anti-malarial drug, and the Global Fund actually
has been engaged in a program to reduce the cost of the
effective products in those kiosks. So what people do, they buy
the cheapest product, which often is quinine or quinine-based
products in an area that has quinine resistance or quinolone
resistance and it just expands. Or they buy, rather than a
combination artemisinin product, they buy a single artemisinin
product, and we know it has to be in combination.
And so this single use of single artemisinin products
rather than in combination develops resistance to the
artemisinin, and so we are trying to get people in the private
sector where people go to those kiosks so that when they go,
they will still buy the cheapest drug, but it will be the
effective drug. And then sometimes they just don't complete the
course.
What we are working on internationally is bringing all
partners together to really intensively address this resistance
problem in this area so that it doesn't spread, threatening all
our investments everywhere else, but there are multiple
reasons. And we are hypothesizing because we weren't there as
it developed, but we have a pretty good sense of how it
developed and what is necessary to contain it.
Mr. Stockman. Thank you. I know we are getting ready to
vote, so I yield back the balance of what time we don't have.
Mr. Smith. Thank you. Thank you, Mr. Stockman. Just a few
final questions and maybe my colleagues might have a question
or two before we go to votes over on the House floor.
In 2000 I authored legislation that became known as the
Combating Autism Act. It took 3 years to get the bill passed,
and one of the cores of that piece of legislation--as a matter
of fact, I did the reauthorization in 2011 as well--was
surveillance. At the time, we thought that the prevalence of
autism in the U.S. was 3 out of 10,000, at least that was what
we thought in the early 1980s, and CDC was spending $287,000, a
drop in the bucket, per year, straight line for 5 years. We had
essentially no real program on surveillance, and our
legislation created centers of excellence; all of a sudden, now
we know the number, at least on the spectrum, is 1 out of every
50. I held a hearing recently on what I call the global
developmental disability pandemic autism. Sixty-seven million
is one estimate worldwide, but we don't have reliable
statistics, and reliable statistics are what drives, I think,
good policy.
In the World Malaria Report for 2012, WHO suggests that in
the 41 countries around the world that account for 85 percent
of malaria cases, it is not possible to make a reliable
assessment of malaria trends due to incompleteness or
inconsistency of reporting over time. WHO concludes that
surveillance systems seem to be the weakest where malaria's
burden is the greatest and states that there is an urgent need
to improve surveillance in those settings. I wonder if you
might speak to that issue of surveillance, again, to drive the
prioritization, the money, and of course, the deployment of
resources.
Ambassador Dybul. It is an extraordinarily important
question because if we are really going to invest smartly and
if we are really going to get toward this elimination, we need
to know with very solid data how to invest and where to invest,
and that requires surveillance, and that is part of what we are
doing in the new funding model, and I think we are doing as a
global community. Really, you know, 10 years ago, you could do
anything and have a huge impact because there was just so much
out there, and that is one of the reasons larvicides don't work
in these communities. There is just too much malaria, and it is
not going to do enough.
Now we have to be a lot smarter because of the impact, and
that means better surveillance. So we are working with
countries so that by the time they come in with a concept note,
as the partnership, we will have invested in getting that data
and those--that surveillance data so that we will know how to
invest in the most impactful way. It is going to be a process
to get there, but I do have to say, too, compared to where we
were 10 years ago in these countries with surveillance to
today, because of their work, because of our investment,
because of our partnership, it is night and day. And you have
seen it, sir, I know, Mr. Chairman, I know many of the members
have been and seen the radical transformation that has occurred
that the American people have partnered with people in Africa
to do. And part of it is in surveillance, but we are getting
there in a way that was inconceivable 10 years ago, which is
why I am much more optimistic than the models, because none of
the models were able to predict that we would be today where we
are today. And that is really because of the leadership of
countries like the United States, but fundamentally because of
the energy in people in Africa who are now looking to the
United States and countries that have supported them in these
diseases in a much different way and a much more positive way.
And as we continue to work with them to support them, to
identify their pockets with surveillance and improve their
systems more broadly, that just expands and expands.
Mr. Smith. Thank you.
On April 23, Dr. Thomas Frieden testified before our
subcommittee. The title of our hearing was, ``Meeting the
Challenge of Drug-Resistant Diseases in Developing Countries.''
I know the Global Fund deals with PEPFAR, HIV/AIDS, as well as
with tuberculosis. He did focus on MDR and XDR tuberculosis and
all the challenges that are being faced going forward, but he
did spend some time talking about artemisinin-resistant malaria
and pointed out, and I would just quote in pertinent part his
testimony:
``Since 2008, malaria infections in parts of
Southeast Asia have been shown to be resistant to
artemisinin drugs. This is the last remaining class of
antimalarial drugs and forms the basis of malaria
treatment around the world. If these resistant
parasites were to spread to sub-Saharan Africa (which
has occurred with other forms of drug resistant
malaria), the results could be devastating.''
Could you speak to that?
Ambassador Dybul. First, I would completely agree with
Tom's assessment, and we have actually talked about this.
I would point out that there actually is a new--several new
classes that are being created through remarkably brilliant
public-private partnerships, the Gates Foundation is heavily
involved, medicines for malaria and vaccines is involved, so we
will have new classes of drugs, but we can't keep doing that,
right, so we need to stamp out the resistance and that is why
we are investing $100 million in that region to jump on it
right away working with partners. It is estimated that it will
cost about $400 million and we are basically leveraging and we
are looking for people in that region who are interested in
those countries to step up financially as well, and then
coordinate across the countries because it is a cross-country
effort. It is a regional effort because we have three countries
that have the resistance. So, we are jumping on it immediately
because of the threat.
MDR-TB is another big problem, and Global Fund is the
largest funder of MDR-TB--external funder of MDR-TB--programs
in the world, so we are very active there, but that is another
committee hearing.
Mr. Smith. Let me just ask, Ambassador Dybul, early on, and
I have raised this repeatedly with Global Fund, I am not the
only one, it had excluded, or largely excluded faith-based
groups. I know that there is a renewed effort to try to be
inclusive, if you might want to speak to that. Also, the
challenges you face, the Global Fund's Web site indicates that
malaria is the greatest cause of illness and death in the
Democratic Republic of the Congo and that there are at least 10
million cases of malaria per year. Yet some of their programs
get unacceptable ratings; of course, the challenges in the DRC
are huge, namely the war. I have been to Goma myself. I know
how the terrorism is, and the sexual violence is almost without
precedent anywhere in the world, but if you could speak to that
as well. Then I will go to my colleagues because we do have a
vote.
Ambassador Dybul. So on Congo, it is a difficult place, no
question about it, but you can actually get things done even in
difficult environments. And you know, Sudan actually has
universal coverage of bednets, so it is possible, and we are
intensively focused on Congo right now, and it is by working
with more than the government. That is how you get the job
done, by working with partners, including faith-based
organizations, which is a segue into your other question.
We recognize that you cannot succeed, and then particularly
when you are talking about getting to the last mile, getting to
the people and making sure they stay in services and use their
bednets and use the right anti-malarial drugs, that the
communities and the faith communities are critically important
to that.
We have changed the way we operate in a number of ways. We
do have quite a number of faith-based implementers, Catholic
Relief Services, World Vision. We also work with the faith
community to raise additional resources. The large Lutheran
group and Methodist group are actually trying to raise $40
million around malaria control right now with us. But it also
about implementation and engagement, and so in our new funding
model, we actually have shifted the process around, and it was
always intended that faith-based communities be part of our
country coordinating mechanisms, but it didn't always work
well, and through our new mechanisms, we are actually working
on that more and more, and actually welcoming people into our
dialogue that leads to a country plan from all walks of life.
And we are actually working with faith communities here in the
United States to identify in these countries who should be at
the table, who needs to be engaged in the conversation.
Now, that doesn't mean we have to fund them, but they need
to be part of the conversation and part of the national
planning because they do so much on their own. Even if we don't
funnel money to them, they need to be part of the national plan
and the national approach to ensure that we combat and actually
ultimately eliminate malaria.
Mr. Meadows. So what you are saying--let me just follow up
on that. So what you are saying is with these faith-based
groups, there is no, in your matrix, when we were talking about
funding matrix, there is no disqualifier in terms of providing
funding for that?
Ambassador Dybul. Absolutely not.
Mr. Meadows. Okay. And as we know in Africa, it is either
faith or it is tribal or cultural, and so you are reaching out
to all those different groups and the leaders of those groups
to make sure we hit these pockets?
Ambassador Dybul. We are, and our new funding model
actually is designed to ensure that we do in a much more
aggressive and effective way.
Mr. Meadows. All right. Well, I yield back. I thank you,
Mr. Chairman. Thank you for your testimony.
Mr. Smith. Thank you. Anybody else like to make any final
comments? Ambassador Dybul, would you like to make any final
comment?
Ambassador Dybul. I would just like to thank the committee
again and thank you, Mr. Chairman, for your many years of
leadership and look forward to continuing to work with all of
you.
Mr. Smith. Well, frankly, we want to thank you for your
extraordinary lifelong leadership. You have made an
extraordinary difference, and I know it because the passage of
PEPFAR was in no way a done deal. Its reauthorization, in which
it was greatly expanded, there were lessons learned, and again,
you were critical in the drafting of that legislation. So you
have made an impact and saved lives. That really deserves a
great deal of praise, so thank you for being here, thank you
for the work that you do. This hearing, or briefing part of the
hearing, is adjourned.
[Whereupon, at 12:42 p.m., the subcommittee was adjourned.]
A P P E N D I X
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