[House Hearing, 114 Congress]
[From the U.S. Government Publishing Office]





  THE GROWING THREAT OF CHOLERA AND OTHER DISEASES IN THE MIDDLE EAST

=======================================================================

                                HEARING

                               BEFORE THE

                 SUBCOMMITTEE ON AFRICA, GLOBAL HEALTH,
                        GLOBAL HUMAN RIGHTS, AND
                      INTERNATIONAL ORGANIZATIONS

                                 OF THE

                      COMMITTEE ON FOREIGN AFFAIRS
                        HOUSE OF REPRESENTATIVES

                    ONE HUNDRED FOURTEENTH CONGRESS

                             SECOND SESSION

                               __________

                             MARCH 2, 2016

                               __________

                           Serial No. 114-175

                               __________

        Printed for the use of the Committee on Foreign Affairs


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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         BRAD SHERMAN, California
DANA ROHRABACHER, California         GREGORY W. MEEKS, New York
STEVE CHABOT, Ohio                   ALBIO SIRES, New Jersey
JOE WILSON, South Carolina           GERALD E. CONNOLLY, Virginia
MICHAEL T. McCAUL, Texas             THEODORE E. DEUTCH, Florida
TED POE, Texas                       BRIAN HIGGINS, New York
MATT SALMON, Arizona                 KAREN BASS, California
DARRELL E. ISSA, California          WILLIAM KEATING, Massachusetts
TOM MARINO, Pennsylvania             DAVID CICILLINE, Rhode Island
JEFF DUNCAN, South Carolina          ALAN GRAYSON, Florida
MO BROOKS, Alabama                   AMI BERA, California
PAUL COOK, California                ALAN S. LOWENTHAL, California
RANDY K. WEBER SR., Texas            GRACE MENG, New York
SCOTT PERRY, Pennsylvania            LOIS FRANKEL, Florida
RON DeSANTIS, Florida                TULSI GABBARD, Hawaii
MARK MEADOWS, North Carolina         JOAQUIN CASTRO, Texas
TED S. YOHO, Florida                 ROBIN L. KELLY, Illinois
CURT CLAWSON, Florida                BRENDAN F. BOYLE, Pennsylvania
SCOTT DesJARLAIS, Tennessee
REID J. RIBBLE, Wisconsin
DAVID A. TROTT, Michigan
LEE M. ZELDIN, New York
DANIEL DONOVAN, New York

     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
MARK MEADOWS, North Carolina         KAREN BASS, California
CURT CLAWSON, Florida                DAVID CICILLINE, Rhode Island
SCOTT DesJARLAIS, Tennessee          AMI BERA, California
DANIEL DONOVAN, New York

















                            C O N T E N T S

                              ----------                              
                                                                   Page

                               WITNESSES

Peter J. Hotez, M.D., president, Sabin Vaccine Institute.........     4
Issam I. Raad, M.D., president, Health Outreach to the Middle 
  East...........................................................    14
J. Stephen Morrison, Ph.D., senior vice president, director of 
  Global Health Policy Center, Center for Strategic and 
  International Studies..........................................    26

          LETTERS, STATEMENTS, ETC., SUBMITTED FOR THE HEARING

Peter J. Hotez, M.D.: Prepared statement.........................     8
Issam I. Raad, M.D.: Prepared statement..........................    17
J. Stephen Morrison, Ph.D.: Prepared statement...................    30

                                APPENDIX

Hearing notice...................................................    62
Hearing minutes..................................................    63
 
  THE GROWING THREAT OF CHOLERA AND OTHER DISEASES IN THE MIDDLE EAST

                              ----------                              


                        WEDNESDAY, MARCH 2, 2016

                       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 2:10 p.m., in 
room 2172 Rayburn House Office Building, Hon. Christopher H. 
Smith (chairman of the subcommittee) presiding.
    Mr. Smith. The subcommittee will come to order, and good 
afternoon.
    During the last several years, conflicts in the Middle East 
have cost the lives of hundreds of thousands of people. It is 
estimated that as many as 470,000 people have been killed 
either directly or indirectly due to the fighting in Syria 
since 2011. During that same period more than 30,000 people 
have died in Iraq. In Yemen, more than 5,000 have died in a 
series of conflicts since 2009.
    As a result of the conflicts in these countries, as well as 
the influx of refugees from conflict zones into surrounding 
countries such as Turkey, Jordan, and Lebanon, many of those 
who die are the victims of disease. Almost 17 million people in 
the region are in need of humanitarian assistance, including 
roughly 4 million refugees who have fled their countries, and 
an additional 13 million IDPs.
    Dr. Peter Hotez, one of our distinguished witnesses today, 
points out that, and I quote,

        We have already seen that polio and measles re-emerge, 
        and we are now seeing a massive surge, more than 
        100,000 cases of a highly disfiguring parasitic disease 
        known as leishmaniasis, which the locals call ``Aleppo 
        evil.'' It is transmitted by sandflies that thrive in 
        the uncollected garbage of Aleppo and other urban and 
        suburban areas of Syria, Iraq, and Libya. The disease 
        causes horrific ulcers that can appear on the face and 
        disfigure people, especially girls and women and leave 
        them with permanent scars that render them 
        unmarriageable. There is a medicine that is 
        administered by injection of an antimony containing 
        compound into the lesion, but there is an access 
        problem in the affected areas, and the bottom line is 
        that we need a vaccine.

    Today's hearing will examine the scope of cholera and other 
diseases to determine what can and should be done to control 
it, assist those who have been afflicted, and mitigate the 
spread. The World Health Organization reported that the spread 
of the cholera epidemic that first began in Iraq in 2007, which 
crossed over into Iran and Syria, is considered the region's 
greatest, although not only, health threat. These threats are 
worsened by the targeting of healthcare workers in Syria and by 
the Islamic State, which has no experience and little interest 
in providing social services. Thus, cholera and other diseases 
are untreated, often unreported, and pose a significant health 
threat in the region due to poor sanitation and overcrowding in 
areas such as refugee camps.
    Cholera is an acute diarrheal disease that can cause death 
within hours if left untreated. Roughly 80 percent of those who 
contract the disease do not develop symptoms, leaving some 
uncertainty about precisely about how many people contract the 
disease annually. Scientists estimate that between 1.4 and 4.3 
million people contract it annually.
    Cholera bacteria are present in the feces of infected 
people for 1 to 10 days after infection and can be spread to 
others if they ingest food or water that is contaminated with 
their fecal matter. The spread of cholera is mostly facilitated 
by inadequate water and sanitation management, and outbreaks 
are common in areas where basic infrastructure is unavailable, 
such as urban slums and camps for IDPs and for refugees.
    As devastating as this cholera epidemic has been and can be 
going forward, we must also remember the MERS epidemic of a few 
years ago. The Middle East Respiratory Syndrome is a 
respiratory illness and is caused by a virus which was first 
reported in 2012 in Saudi Arabia. It is different from other 
viruses that have been found in people before. MERS, like other 
viruses, is thought to be spread from an infected person's 
respiratory secretions, such as through coughing. However, the 
precise ways the virus spreads are not currently well 
understood.
    The conflicts and political crises in the Middle East have 
brought anguished suffering and severe declines in health to 
people throughout the region. The most catastrophic case is by 
far Syria. More than a million people have experienced 
traumatic injuries, once-rare infectious diseases have 
returned, chronic diseases go untreated, and the health system 
has collapsed.
    In Yemen, Libya, Gaza, and Iraq as well, violence has 
limited access to healthcare and grievously harmed the 
population. According to Physicians for Human Rights, last 
summer at least 633 medical personnel have been killed, and 
more than 270 illegal attacks on 202 separate medical 
facilities have taken place since March 2011 in Syria. Of the 
attacks on medical facilities, at least 51, or 19 percent, were 
carried out with barrel bombs. Almost all of the assaults were 
inflicted by the regime of Assad.
    In the Middle East, threats against, as well as arrests and 
intimidation of health workers, extend beyond armed conflict to 
situations of political volatility, as is evident in Bahrain, 
Egypt, and Turkey. In most of these cases, doctors and nurses 
who treat victims of violence are, by the very act of providing 
treatment, deemed guilty of anti-government activity. In 
Bahrain, almost 100 doctors and nurses were arrested, and 48 
originally charged with felonies for having offered medical 
care to wounded people in the wake of the 2011 Arab Spring 
uprising.
    Our panel today comprises health experts who will help us 
think through the health challenges and provide a roadmap with 
good concrete data and empirical information for us to consider 
as a subcommittee, which I can assure you will be used in 
helping us advocate for more assistance and more help to those 
who have been now affected.
    I would like to yield to Dr. Bera for any opening comments.
    Mr. Bera. Thank you, Chairman Smith, and thank you to the 
witnesses for taking time to be here today.
    As a physician and someone who has done public health and 
global health work, you think about the conditions in the 
Middle East as they are today in terms of diminishing 
infrastructure, refugees that are in crowded conditions, 
diminished sanitation, malnourished populations, and the 
environment is ripe for outbreaks of cholera, but also other 
infectious diseases. So I am very interested in getting a sense 
from our panel today of what measures we can take in terms of 
trying to alleviate and prevent some of these issues.
    Obviously vaccinations as appropriate, but even in a war 
zone that is very difficult because, as Chairman Smith has 
already indicated, to try to get healthcare workers in there, 
to try to get folks in there to help assess sanitation 
conditions, apply vaccinations where appropriate, and deliver 
rehydration salts or other therapies for those that are 
affected is very difficult to get that carry-in. I would be 
curious of your experience in other war zones and other 
conflict areas of the things we can try to do. While we may not 
be able to prevent some of these outbreaks, what can we do to 
mitigate and minimize some of these outbreaks, knowing that we 
may be stuck in a conflict zone not for months but maybe for a 
prolonged period? If we just look at Syria itself, much of the 
healthcare infrastructure is being devastated and will take 
quite some time to rebuild.
    So, again, I will keep my opening statement short and save 
time for questions, but look forward to hearing from the panel. 
Thank you.
    Mr. Smith. Thank you, Dr. Bera.
    I would like to now welcome our distinguished panelists. 
And without objection, your full statements will be made a part 
of the record, but please proceed however you would like. 
Beginning first with Dr. Peter Hotez who is president of the 
Sabin Vaccine Institute, leads the Texas Children's Hospital 
Center for Vaccine Development based at the Baylor College of 
Medicine. He is also founding dean of the National School of 
Tropical Medicine at Baylor. His academic research focuses on 
vaccine development for a wide range of neglected tropical 
diseases around the globe, as well as studies to increase 
awareness about the neglected tropical diseases in developing 
countries and in the United States.
    Dr. Hotez created the Sabin Vaccine Institute product 
development partnership and was instrumental in creating the 
Global Network for Neglected Tropical Diseases. In 2014, he was 
named by President Obama as one of four U.S. science envoys 
with a mandate to explore the development of vaccine centers of 
excellence in North Africa and the Middle East.
    I would note as well that our End Neglected Tropical 
Diseases Act, having had Dr. Hotez appear before this 
subcommittee on two previous occasions, has passed out of the 
Committee on Foreign Affairs and we greatly benefited from the 
insights, Dr. Hotez, that you provided as to what that 
legislation ought to look like. So thank you.
    We will then hear from Dr. Issam Raad Who is an infectious 
disease specialist and is a distinguished professor of medicine 
at the University of Texas at Houston. He is president of 
Health Outreach to the Middle East, or HOME, which is a 
Christian interdenominational organization that exists to bring 
physical, psychological, and spiritual healing to poor and 
suffering people in the Middle East in the name of Jesus 
Christ. HOME has established a program to train, build, and 
send thousands of Arab Christian physicians and healthcare 
professionals on how to share the love of God at the bedside. 
HOME supports three medical clinics, one charity hospital, a 
home care medical service, and mobile clinic that provides 
medical care for the people of Egypt.
    Then we will hear from Dr. Stephen Morrison who is a senior 
vice president at the Center for Strategic and International 
Studies and director of the Global Health Policy Center. Dr. 
Morrison writes widely, has directed several high level 
commissions, and is a frequent commentator on U.S. foreign 
policy, global health, Africa, and foreign assistance. He has 
served in the Clinton administration, as committee staff in the 
House, and taught for 12 years at Johns Hopkins School of 
Advanced International Studies.
    Dr. Hotez, the floor is yours.

  STATEMENT OF PETER J. HOTEZ, M.D., PRESIDENT, SABIN VACCINE 
                           INSTITUTE

    Dr. Hotez. Mr. Chairman, members of the subcommittee, Mr. 
Bera, thank you so much for giving me the opportunity to talk 
about a very ominous situation that is now happening in the 
Middle East. And now we are recognizing a spill-over into 
southern Europe. So this thing is already going beyond the 
Middle East and North Africa and that region.
    Before I do that I just thought you might like to hear a 
little good news based on the work of this committee and 
subcommittee. I am part of an enormous initiative known as the 
Global Burden of Disease Study that is funded by the Gates 
Foundation to evaluate what the impact has been of all these 
big-picture programs like PEPFAR and the President's Malaria 
Initiative, and the USAID NTD program. And this is involving 
hundreds of scientists all across the world to evaluate the 
papers. The papers that come out look like something out of a 
certain physics laboratory, a massive numbers of authors and I 
will be happy to share that with you.
    But I want to just give you the punch line of what's 
happened since the launch of all of these big programs. We have 
now seen a 30-percent reduction in the number of malaria cases 
and the number of malaria deaths. But you guys did that, so 
congratulations.
    We have turned the corner on HIV/AIDS, 19 million lives 
saved from HIV/AIDS, and for the first time turning the corner 
on the number of deaths.
    And then for neglected tropical diseases, you have reduced 
the number of cases of lymphatic filariasis, which is also 
known as elephantiasis, river blindness, and blinding trachoma, 
by almost 40 percent, so to the point now where we can talk 
about eliminating these three diseases over the next decade.
    To date, over 500 million people have received treatments 
for neglected tropical diseases, totaling--I used to say 1 
billion, I just got corrected yesterday by somebody from 
USAID--it is now 1.4 billion people. So these are incredibly 
effective programs. And now we have independent documentation 
to know how they are working. So congratulations and thank you 
for your leadership on that.
    Well, let's get to the not-so-good news part of the story. 
The impacts of all these big picture programs has also, like 
peeling away the layers of an onion, revealed a new problem. 
And that, we have just completed on a large scale analysis in a 
series of papers to show that today most of the world's 
neglected diseases are now occurring in wealthy countries, in 
G20 countries. So we have been ignoring the poor who live in 
wealthy countries, and now accounting for at least half the 
world's worm infections, most of the dengue, the Chagas 
disease, most of the tuberculosis, most of the leishmaniasis, 
and quite a bit of the HIV/AIDS.
    The silver lining on that is because these are inherently 
wealthy countries it is not just a resource problem, it is a 
political will issue. So that we need to think about providing 
advocacy at the next G20 summits about how to get these global 
leaders to pay more attention to their own vulnerable 
populations. So an example would be China. Eastern China is 
incredibly wealthy. You go into western China, the Sichuan, 
Yunnan Province, you go back in time 50 years.
    Or you look at Mexico, into southern Mexico, in 
northeastern Brazil where the Zika epidemic is. The Zika 
epidemic in northeastern Brazil is occurring in the same place 
where the epicenter of all the other neglected tropical 
diseases are. These poor, small states of Pernambuco and others 
where you are getting lymphatic filariasis and schistosomiasis 
as well.
    So paying attention to these pockets of intense poverty in 
G20 countries is going to become an important new global health 
theme.
    Let's talk about the Middle East and North Africa. I like 
to say that the reason why Ebola emerged out of West Africa is 
not because it was tropical, even though it is a neglected 
tropical disease, it was because those three countries, Guinea, 
Liberia, and Sierra Leone had undergone a decade of atrocities 
and, with it, the collapse, the collapse of its health system 
infrastructure. So we are now seeing the same thing happening 
in the ISIS-occupied areas of Syria, Iraq, Libya and now, to 
some extent, Lebanon as well.
    And the problem is it is very difficult to actually work in 
these countries to observe first-hand, so we have to rely on 
glimpses that we are getting of refugees spilling across the 
border into, into Turkey, Lebanon, Jordan, and Egypt. And that 
is where we are starting to see it. So you have mentioned 
leishmaniasis, Aleppo evil, that is transmitted by sandflies. 
Even in the best of times it was difficult for the Syrians to 
control this disease. And now, in the face of the collapse of 
the Syrian regime, what we are seeing are massive numbers of 
cases, more than 100,000 in the last year. People with horrific 
ulcers that disfigure the face, especially little girls who are 
then rendered unmarriageable later in life.
    There is a medicine that could be used to treat it. It 
requires an injection of the medicine in the lesion. Of course, 
the medicine is now unavailable. But also, with all the garbage 
now piling up, the sandflies are having a field day where they 
are proliferating incredibly, so they are able to bite people 
and transmit the disease. The disease is following the 
refugees, the sandflies are following the refugees into the 
border camps and the disease is continuing there.
    This is happening not only with leishmaniasis, although 
because it is so disfiguring it is one of the more dramatic 
examples, we are seeing the emergence of dengue or other 
arboviruses, scabies, malaria, tuberculosis, schistosomiasis, 
hepatitis A and B and, as you mentioned, the resurgence of 
measles and polio.
    The other thing that is happening in the Syria situation is 
not only humans are being trafficked but animals are as well. 
There is no border anymore, so with that, all of that 
trafficking with animals we are seeing a lot of zoonotic 
diseases, diseases transmitted from animals to humans, so an 
enormous amount of brucellosis. We are quite worried now about 
Middle Eastern Respiratory Syndrome, MERS coronavirus, going 
beyond the Arabian Peninsula. This is going to be we think an 
important problem that can cause an epidemic.
    We have additional issues that come up as well, which is 
that another big area of human migrations is the annual Hajj, 
the pilgrimage. It is believed that dengue fever actually got 
introduced in the Middle East through the Hajj. And because 
they have the mosquitoes there, then dengue got introduced. It 
spread across the Arabian Peninsula and the Middle East. I just 
came back from Saudi Arabia, and we were having discussions 
with the Ministry of Health there, that they are worried now 
about Zika coming in too for the same reasons. So there is 
every reason to believe that Zika is going to go in.
    These diseases are having a massive economic impact on the 
region. We have just completed an analysis looking at the 
neglected tropical diseases in the OIC countries, the 
Organization of Islamic Cooperation. And there is quite a bit 
of evidence that the OIC countries are disproportionately 
affected by the NTDs. And this is one of the major barriers to 
their economic development.
    Now were are seeing spillover into southern Europe. So 
something quite interesting is happening. For the first time in 
70 years, malaria has reemerged in Greece. It had been 
eradicated, now it is back. We are seeing the appearance of 
dengue in Portugal after 50 years. We are seeing West Nile 
Virus and chikungunya in Spain and Italy. We are seeing 
schistosomiasis, which is the ultimate neglected tropical 
disease of poverty, now on the island of Corsica. There is 
transmission of schistosomiasis in Corsica.
    So we are, we think that a lot of this is having to do with 
spillover from the Middle East. So we are now seeing the first 
evidence that it is not just being contained in the region.
    So let me end by just saying what I think you need to do 
about it. In my role as science envoy it is clear that there is 
no capacity for making vaccines for any of these diseases in 
the Middle East and North Africa. They are still entirely 
dependent on the multinational pharmaceutical companies, Glaxo, 
Merck, and Pfizer for making these vaccines. The problem is 
these diseases, for now anyway, are of regional importance, not 
global importance, and so the big pharmaceutical companies 
aren't going into this.
    And we saw this before with Ebola, right? The technology to 
make the Ebola vaccine was actually first published in 2003, 
but the technology sat there for a decade because the big 
pharmaceutical companies weren't interested in making an Ebola 
vaccine. It is because the business model is broken, it says 
we, an academic researcher, develops it, then waits to license 
it to a big pharmaceutical company, turns it around to a 
vaccine. And, of course, by the time Glaxo and Merck did this 
for Ebola, because BARDA put up $100 million at the 11th hour, 
5 minutes to 12:00, they made the vaccine in record time. But 
by the time they did testing, Ebola was gone and 11,000 people 
perished.
    We still haven't fixed that problem. The same now is coming 
out of the diseases in the Middle East. But one of the things 
that we are trying to do, and this will be a key component of 
the Center of Excellence, is at the Sabin Vaccine Institute 
which is based at Texas Children's and Baylor College of 
Medicine, we are making the vaccines that people won't make for 
these diseases in the Middle East. We are making a 
leishmaniasis vaccine, a schistosomiasis vaccine. And the nice 
thing about it is, because we are non-profit, we can teach 
others how to make vaccines. So we are teaching the Saudis now. 
We are working with the Tunisians, the Moroccans to build their 
own capacity.
    You can't walk into Merck or Pfizer and say teach me how to 
make a vaccine, but we can do that. And so this is an active 
program going on now. We have a group of Saudi scientists 
coming to our laboratory to learn every aspect of the vaccine 
development cycle. They will bring it back to Saudi Arabia. And 
we hope that we can do this other times as well.
    And that is also important because we, as you can imagine, 
relations with Saudi Arabia have been strained over the last 
years, so being able to offer something like this to promote 
joint vaccine development is a really great example of what I 
call vaccine diplomacy.
    So thank you so much for having me speak.
    [The prepared statement of Dr. Hotez follows:]
    
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                              ----------                              

    Mr. Smith. Dr. Hotez, thank you, sir, very much for your 
leadership.
    Dr. Raad.

STATEMENT OF ISSAM I. RAAD, M.D., PRESIDENT, HEALTH OUTREACH TO 
                        THE MIDDLE EAST

    Dr. Raad. Thank you very much, Mr. Chairman and members of 
the subcommittee, Mr. Bera, and the staff director, Mr. 
Simpkins. It is a pleasure to be with you today.
    I would like to, again, emphasize what Dr. Hotez mentioned 
that the devastation resulting from the conflict in the Middle 
East creates the right environment for these alarming epidemics 
that have spread rapidly within the region. And there is 
concern that it could be a global spread.
    This has been also associated with the devastation, if you 
may, and the collapse of the local healthcare system in the 
area. And as you mentioned, Mr. Chairman, cholera is the, 
reported in 2015 in Iraq, is the tip of the iceberg, if you 
may. For example, the World Health Organization reports 5,000 
confirmed cases between September to November 2015, with 
several deaths. But reports from our clinic in Baghdad, where 
we have clinics in Baghdad, we have in Kurdistan, we have even 
in the suburbs of Damascus, we have in Lebanon, Jordan and 
Egypt and in north Africa, but the reports from the clinics 
there that this is a vast underestimate. This is almost 2 to 5 
percent of the cases actually contracted there, which we 
estimate at around 200,000 cases in 15 of the 18 governments in 
that part.
    The concern also with cholera is that cholera is unique 
among water-borne bacterial infectious disease and its 
potential for global pandemics. And now we are in the third, 
second and the third wave of the seventh pandemic with more 
antibiotic resistance and acquisition of newer, more intense 
cholera function associated with cholera.
    And also the concern is that some of these clusters or 
outbreaks occurred in Iraq in Najaf and Karbala, which are part 
of the holy, holy shrines in that country, with all the influx, 
with Shiite Muslims going to these religious pilgrimage areas.
    The other big concern is polio. And this has been 
mentioned. But polio was thought to be eradicated in Syria. But 
it emerged in 2014 with more than 7,600 cases. And the big 
concern is that it occurred, the epicenter for the outbreak 
started in Deir ez-Zor which is the northeastern area, very 
close to Raqqa where the Islamic State is in control and where 
they have control in that district. And it is considered to be 
related to the fact, like the cholera, that the raw sewage is 
being pumped from these areas into, directly into the Euphrates 
River and the areas which provide the drinking and washing 
water to the other areas not under their control.
    So with cholera, polio represents a form of a spread of the 
disease related to the conflict, but possibly a bio-terrorism 
aspect where they are kind of basically moving the raw sewage.
    What is even more alarming is the fact that the strain of 
poliomyelitis in Syria has been linked to a wild type from 
Pakistan, particularly from a jihadist fighter who came from 
Pakistan to the area, highlighting the regional spread of this 
disease and the potential, again, for a global spread.
    Measles is another problem. I mentioned it in my written 
testimony. In Aleppo and then spilling over to Lebanon, for 
example, in 2013 the number of cases of measles among Syrian 
refugees increased to 1,760 from the baseline of 9 cases the 
year before. The same is true among the Syrian refugees in 
Jordan.
    Dr. Hotez mentioned about the leishmaniasis, which is also 
referred to as a flesh eating parasitic infection. Fifty-two 
thousand cases were reported in 2012 after a time when this was 
considered to be a contained, local infection more in northern 
Syria.
    MERS remains to be alive and well. You are well aware of 
the outbreak, large outbreak in the summer of 2015 in Riyadh in 
Saudi Arabia, as Dr. Hotez pointed. But also the recent 
outbreak in 2015 in South Korea with transmission of the 
organisms, basically the index case traveling from the Arabian 
Peninsula, so again highlighting the spread of these diseases.
    I would like also to highlight in North Africa, although 
the hepatitis C epidemic in Egypt is not directly related to 
the conflict, but has been put under the rag for a long time. A 
recent study by D. Miller, with the Cornell Group, highlighted 
the fact that there is every year more than 500,000 new cases 
of hepatitis C, where almost 20 percent of the population, 15 
to 20 percent of the population have this virus which has the 
potential in up to 85 percent of them to go into liver 
cirrhosis and hepatocellular carcinoma. So this is a major 
concern.
    The major concern in Egypt is that this is being propagated 
through the healthcare system, where almost 18 percent of the 
dental instruments have the hepatitis C RNA, 90 percent of 
patients on hemodialysis will end up with hepatitis C, and 70 
percent of the blood transfusions that are being given are 
really not being checked for hepatitis C.
    So I think recently from a visit to Egypt I met with the 
head of the National Committee for Control of Viral Hepatitis 
C, and I have been in contact with the CDC basically, Dr. John 
Ward, who has been in contact with the CDC groups there. I met 
with the CDC and USAID. And there could be a lot of good effort 
that could be done in a concerted effort to contain and 
basically eliminate the spread of this virus.
    I also came from a trip from Mauritania. Ten days ago I was 
in Mauritania. I met with the President and the Minister of 
Health, as well as our Ambassador, Mr. Larry Andre, and talked 
about the hepatitis B epidemic there, where almost 15 percent 
of the population have this problem. And we can, Ambassador 
Andre has advised us to, and we have been in touch with the 
CDC, to really curtail that problem.
    I would finally like to highlight two major problems. One 
is multi-drug resistant TB, which is not much is being 
mentioned about, but we are detecting it from our groups who 
are working in Mafraq, in a rural hospital which is a TB 
sanatorium in northern Jordan, among Syrian refugees mainly. 
And this other problem is salmonella typhoid fever where an 
outbreak has been reported in the Yarmouk Camp in a suburb of 
Damascus, with resistant organisms.
    HOME has been serving as a group there. And most of us are 
from Middle Eastern origin. We have been working widely in all 
of these areas, particularly with mobile, a big network of 
mobile medical units and field clinics that we have established 
in various countries. We work closely with Samaritan's Purse, 
World Vision, and the National Arab-American Medical 
Association. We work with the American College of Chest 
Physicians, and the American-Lebanese Medical Association.
    But we believe that HOME and other groups, other NGOs 
working in the area, and this is what we would like to propose, 
should have work in a concerted effort, collaborative effort 
with governmental agencies such as USAID, CDC, and Peace Corps.
    And we ask that this subcommittee would, under you, Mr. 
Chairman, would call for a meeting for all relevant committee 
chairs, including the Health Subcommittee, with the experts, 
including Dr. Hotez and Dr. Morrison, and to set a plan and a 
policy for this joint effort for the Middle East. And have a 
model similar to what we have done with Ebola in west Africa 
where we have a concerted effort among the NGOs of Americans 
working there, as well as governmental agencies, to try to 
contain these, these infectious problems in the area. Because 
there is no doubt, like the Ebola, that they are going to spill 
over and we are going to reap the consequences.
    In addition, it could be part, and we are talking here to 
this esteemed subcommittee which is a subcommittee of the 
Committee on Foreign Affairs, this could be part of the medical 
diplomacy, if you may, initiative in combating terrorism in 
that area and its implications of this, of these infectious 
outbreaks. A lot could be done in this concerted effort in 
terms of refugee medicine training, in terms of early detection 
of these infectious diseases, working with the World Health 
Organization on community health and water decontamination, 
hygiene education, vaccination campaigns, and appropriate use 
of antimicrobial therapy, which is very important for TB and 
other, particularly training the local community physicians on 
how to appropriately use antimicrobial agents.
    Thank you very much.
    [The prepared statement of Dr. Raad follows:]
    
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    Mr. Smith. Dr. Raad, thank you very much for your testimony 
and specific, concrete proposals for follow-up.
    I would like to now recognize Dr. Morrison.

STATEMENT OF J. STEPHEN MORRISON, PH.D., SENIOR VICE PRESIDENT, 
 DIRECTOR OF GLOBAL HEALTH POLICY CENTER, CENTER FOR STRATEGIC 
                   AND INTERNATIONAL STUDIES

    Mr. Morrison. Thank you very much, Representative Smith and 
Representative Bera. I appreciate your leadership on this and 
the opportunity to be here today. And a special thanks to Greg 
Simpkins, an old friend, for his leadership in pulling, pulling 
things together today.
    I worked on this subcommittee in 1987 and 1991 when Dante 
Fascell, Henry Hyde were the iconic leaders. I worked for 
Howard Wolpe, Dan Burton as the minority member of that 
subcommittee. And that subcommittee had enormous impact in 
those years. And I am very proud of that. That was the first 
job I had out of graduate school. And I believe very strongly 
in the power and impact that a subcommittee like this can have 
today. And thank you for your leadership and for putting a 
special focus on this subject.
    I am going to make five points. My first has to do with 
health security and where this crisis in Syria and the Middle 
East sits. We have had a lot of discussion around Ebola, a lot 
about, today about Zika, a lot about the global health security 
agenda. We haven't situated this crisis too much that we are 
seeing in Syria in terms of health security.
    But I would argue that what we are seeing in Syria and the 
surrounding region is a very grave health security crisis that 
is gathering force. And it will become more evident. That 
health security crisis in Syria and the surrounding region is 
going to become more evident as infectious outbreaks 
proliferate and as other multiple health consequences become 
clearer due to the dissolution of the Syrian State, the 
deliberate targeting and destruction of health infrastructure, 
including killing of health workers, and the massive 
dislocation of vulnerable populations.
    We are going to see the indicators. Dr. Hotez, Dr. Raad 
both enumerated the evidence of this in terms of malnutrition, 
chronic disorders, maternal and newborn health, infectious 
diseases. And the scale is formidable. It has reached the point 
of really, for Syrians, we are talking about 12 million, over 
half of the population.
    I realize this, addressing this has a special set of 
challenges, particularly on the security side. This is an 
acutely dangerous and forbidding environment. Access by 
humanitarian health workers has become exceedingly limited. We 
are operating largely in the blind in terms of data and access 
and surveillance, and we need to admit that. But I think the 
situation is changing in some important ways. So that is point 
one.
    Point two is we ignored this problem for a while. The war 
started in Syria in 2011, in March. I would argue that for the 
first 3 years we were pretty numb, disengaged and paralyzed as 
a staggering and colossal human crisis unfolded in that period. 
The crisis was seen as too distant, too difficult, too 
dangerous and that perception only worsened as more and more 
armed radical Islamist groups gained prominence, even before 
ISIS entered in June 2014. And it became more difficult as MSF, 
as the International Committee of the Red Cross, as other NGOs 
were targeted, kidnapped, threatened and harmed grievously in 
that period.
    There was an assumption that the surrounding region, the 
borderlands, Turkey, Lebanon, and Jordan would absorb these 
populations and they would not move beyond that. That proved to 
be a very mistaken assumption. They took in 5 million but they 
quickly reached a certain saturation point, which I will say a 
bit about in a moment. In that first 3-year period the 
geopolitics around this crisis was particularly toxic: The 
stand-off between the United States and Western powers versus 
Russia, Assad, and Iran. The U.N. Security Council stepped 
forward and tried to address this but with a number of 
resolutions that were toothless and ineffectual, and did 
little, certainly in terms of Assad's behavior, in terms of the 
egregious and flagrant violation of international law in this 
period.
    We, as a government, were preoccupied with the Iran nuclear 
negotiations and we were progressively seeking to lower our 
profile in this region. Options like safe zones, no-fly zones 
were explored but ultimately rejected as too risky and too 
difficult. We did intervene in the destruction of the chemical 
weapons stocks in Syria, together with the Russians. And that 
was relatively successful. But there was no humanitarian bounce 
that came off of that.
    Steadily, up until recently, the numbers, the funding 
levels for humanitarian operations into the U.N. were cut 
dramatically. And that, that resulted, of course, in a 
humanitarian regression and undermining the status of those 
populations that were reached in the border states.
    My third point is that the situation geopolitically has 
changed fundamentally. And we ought to, we ought to take 
account of that. And I will explain what I mean.
    I think that the geopolitical change has in fact pushed 
health and health security to the forefront of the stage, and 
it has created some very early opportunities potentially. The 
tipping point came, of course, as Turkey, Lebanon, and Jordan 
reached their saturation point, as the monies coming in on 
humanitarian operations were reducing, and as the Syrian 
populations both in those settings and inside Syria made a 
dramatic calculation in 2015 to embark straight off for Europe. 
So the numbers of Syrians moving went from 100,000 in 2014 to 
\1/2\ million in 2015, accounting for roughly half of the 
population.
    And those flows are continuing today. We are expecting 
fully 1 million more migrants this year into Europe, if not 
more, with a heavy share of those coming out of Syria. That, of 
course, has become a destabilizing factor. Just look at what's 
happening in Europe. Look at what's happening in Austria and 
the Balkan states where there is a, basically, they are 
freezing up the free flow of populations, refugee populations. 
Greece is becoming a black box, a holding operation. The 
politics are broken of the EU. And it is becoming an utterly 
untenable and destabilizing situation.
    The geopolitical situation changed in two other very 
important respects: ISIS entered the region in June 2014, 
displaced 3.2 million people, took under its control roughly 8 
to 10 million, and then, of course, you had the Russians enter 
in September of last year and begin the aerial campaigns from 
Syrian bases, which drove, up to now have driven 300,000 to 
400,000 people up to the Turkish borders and systematically 
targeted hospitals, clinics and other facilities.
    So why is it now possible to think a little differently 
about the health crisis in Syria and the surrounding region? 
The process, the context has changed. The U.S. is now working 
with others in aggressively trying to achieve a cessation of 
hostilities and expand humanitarian access to the besieged and 
those difficult to reach inside Syria. And that is about 4.5 
million people. Right now the aim this week is to reach 150,000 
in besieged cities and to continue on that trajectory to reach 
1.7 million by the end of March.
    We don't know if that is possible. It is supposed to be 
done under joint U.S.-Russian oversight. We know this is a very 
perilous undertaking, but if it is successful it will create 
new windows for restoring capacities, including basic services 
and immunizations.
    We are pressing at this same time to accelerate 
negotiations over national transition in Syria and expand 
support dramatically to the front line states, Turkey, Lebanon, 
and Jordan. February 4th was the astonishing summit in London 
which took in pledges of $11 billion, $6 billion in 2016 alone, 
$1 billion from the United States. These are unprecedented 
levels. And it is a stark reminder of just how geopolitically 
important this crisis has become, that you could have something 
like this happen.
    Money is not the barrier. The barrier now is becoming 
access, vision, political leadership and capacity.
    My fifth and final point is that there is more that the 
U.S. can do. The U.S. has been very generous on the 
humanitarian front. We have invested over $4.5 billion into the 
humanitarian response to this crisis since 2011. We are 
carrying 50 percent of the freight. But there is more that we 
can do. And let me just say a few specific things.
    We need to get U.S. public health experts closer to the 
problem on a long-term and continuous basis. Right now in the 
cholera outbreak we were channeling volunteers, we were 
channeling temporary employees into UNICEF and WHO. We should 
continue that. We should step that up. But in order to be 
really effective in this next period we need a hub within the 
region, perhaps in Jordan, a continuous presence charged with 
coordination, quick response, and building relationships across 
the region.
    This is an essential step to enlarge the U.S. region 
influence and to be better positioned to get smart about what 
is going on inside Syria, and to build the relations with the 
front line states, and address the security, the health 
security threats we are talking about.
    There is much more that we can do to support Turkey, 
Lebanon, and Jordan. They have serious health security needs 
but there is access and opportunity to do that. We have not 
framed this in terms of the global health security agenda. I am 
arguing that we should think about that. We should think about 
planting this within that vision. That is a way to get 
assessments going. That is a way to leverage the G7. That is a 
way to offer an international framework around this. It has not 
been applied typically to situations as dangerous and 
complicated as this, but there is no reason why it could not 
be.
    Lastly, the U.S. is not in a hegemonic position to drive 
events. We are in a position to be very influential. But we are 
not going to be the hegemon as this health security crisis 
grows.
    Russia has established itself as a major driver. It has 
been a major contributor to chaos, dislocation and suffering. 
It has weaponized refugees. But it appears that there are some 
changes going on and we are going to have to move forward 
aggressively to rebuild capacities with the Russians, the 
Saudis, the Turks, the Iranians. We are going to have to rely 
very much upon our friends at the International Committee of 
the Red Cross, MSF, Doctors Without Borders, Syrian Red 
Crescents, courageous groups like the Syrian-American Medical 
Society which has done remarkable work.
    So thank you very much, Mr. Chairman, for your patience.
    [The prepared statement of Mr. Morrison follows:]
    
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    Mr. Smith. Dr. Morrison, thank you for your insights, your 
leadership all these years. And I am sure you miss being here 
on this side of the dais.
    I do have a couple questions and I will probably come up 
with a few more that we might submit in writing. But to begin 
with, Dr. Hotez, how many vaccines do you have under study at 
the Sabin Institute?
    Dr. Hotez. Thank you for that question. We have half a 
dozen, six vaccines now. So for hookworms, schistosomiasis, 
leishmaniasis, Chagas disease, SARS, and MERS.
    Mr. Smith. And are any of those ready for deployment?
    Dr. Hotez. Well, right now they are in various stages of 
product and clinical testing. So we have two vaccines in 
clinical trials in Africa and in Brazil for hookworm and 
schistosomiasis. The SARS vaccine is about to be manufactured. 
The other ones are at an earlier stage.
    One of the big problems that we face, of course, is 
funding. So there is not a real push mechanism of funds that go 
to product development partnerships. These non-profits fall 
through the cracks. They use industry practices, but because 
they are not registered as small businesses or businesses, we 
don't benefit from the SBIR mechanism for instance. And whereas 
the Dutch Government, the German Government has now 
specifically started funding PDPs specifically, and the 
Japanese as well, it is not really done in the United States. 
So it is a gap that could be addressed through the Center of 
Excellence concept, the neglected disease legislation, or we 
need more mechanisms like that.
    Mr. Smith. Now, with leishmaniasis you mentioned that there 
is a need for a vaccine?
    Dr. Hotez. Absolutely.
    And there is proof of concept that it is quite possible. 
Because what the locals do is quite interesting. They will 
scrape the lesions of somebody who has leishmaniasis and inject 
it into the buttocks of their kids to prevent them from 
getting, prevent them from getting a disfiguring scar on the 
face. It actually was discovered by the ancients. It predates 
vaccination. It's called leishmanization. But it shows you that 
you can make a vaccine.
    Now, we can do better than doing that. So and you can do it 
by genetic engineering, making a recombinant vaccine. And we 
have done it now in the laboratory. Now it is a matter of 
getting the support for scaling it up.
    Mr. Smith. What would it take to scale it up? I mean what 
kind of money are we talking about?
    Dr. Hotez. Well, we are looking at around $5 million to 
really move it into clinical trials.
    And that is the incredible thing about this, it is, you 
know, it is not billions, it is not hundreds of millions, it is 
not even tens of millions, it is 10 to the 6th dollars, not 10 
to the 7th or 10 to the 8th or 10 to the 9th. So the funding 
needs are so modest, and yet it is just not there.
    Mr. Smith. One of the reasons why I have introduced the End 
Neglected Tropical Diseases Act is because it really does take 
a modest amount of money to have a spectacular impact.
    I would note parenthetically that for the second year in a 
row the administration's budget has looked to cut the neglected 
tropical disease budget. And, thankfully, in a bipartisan way 
we have been able to get the appropriations at least at level 
funding at $100 million. But it was a 20-percent cut now 3 
years in a row, that too, which is very disconcerting from my 
point of view in terms of prioritization.
    Dr. Hotez. And especially since the U.S. Government is 
getting so much bang for its buck. Through that, through that 
$100 million a year you are eliminating three diseases. I mean 
where else in the U.S. Government can you get that kind of 
impact?
    Mr. Smith. Exactly.
    Let me just ask you, Dr. Raad, on MERS-CoV. You talk about 
how it is spreading, 36 percent mortality rate. You know, I am 
always, we are all I think thinking, you know, after World War 
I the misnamed Spanish flu, obviously the incubator for that 
had to have been the degradation caused by World War I. Is this 
one of those possible diseases, illnesses that could spread and 
become a pandemic? We know it is local and it is causing a huge 
amount of sickness and death. But looking at all of these 
diseases, including that one, what are your thoughts on that?
    Dr. Raad. Yeah, the South Korean outbreak is the best 
example of the global spread of MERS. And seeing MERS cases not 
only in the region but beyond, beyond the region. So, and it is 
a coronavirus. It is, as you well know, SARS is a coronavirus 
and had a global spread. So there is always that concern that 
it could have a global spread.
    Again, the good work of my colleague Dr. Hotez as far as 
vaccination would be very important, because at this point all 
that we provide for MERS is supportive care. And this is why we 
have the high mortality rate associated with it. But also early 
diagnosis and to be on the alert.
    And I think MERS is part of the bigger picture of the 
Middle East. The Middle East needs special attention for as far 
as infectious diseases. And this can be done. And it could be 
done as part of this concerted effort but also could be part of 
a, as I am talking here to your subcommittee which is part of 
the Committee of Foreign Affairs, part of the medical diplomacy 
to reach that area. Because the uniqueness of the United States 
is that we are not just providing a activity on the ground like 
the Russians are doing, and as Dr. Morrison has mentioned, in 
terms of a force, but providing also a solution to some of the 
devastating problems, including these epidemics and solution 
for refugees.
    So I think there needs to be a concerted effort with 
special attention that the NGOs, governmental agencies, groups 
working, like my two colleagues here, to reach out to the 
region.
    Mr. Smith. And I do thank you for your idea of bringing 
other relevant chairmen and subcommittee chairman together. I 
think that is an excellent idea that we will look to follow up.
    Dr. Raad. Thank you.
    Mr. Smith. Let me ask you with regard to the bioterrorism 
you spoke about, the chlorinization has discontinued.
    Dr. Raad. Yes.
    Mr. Smith. Is that one of the casualties of war or why 
would, why did that happen?
    Dr. Raad. Well, it is one of the casualties of war. The 
whole healthcare system, if you may, and the sanitary system 
has collapsed. Syria, as you well know, the basic, basic needs 
basically of the people are non-existent. And I would dare say 
from reports of our colleagues in Baghdad, the same is true, is 
happening within Iraq. Baghdad is in chaos.
    And I have some of the slides that I sent where people are 
going to wells that are already contaminated to provide 
drinking and sanitary water.
    Mr. Smith. Dr. Morrison, you note that \1/2\ million 
children under 5 in Syria have not been vaccinated in more than 
2 years. Is there a danger of unrestrained polio? Is that 
imminent in your view?
    Mr. Morrison. There is a risk. There is a continuous risk 
of further outbreaks of polio. There were 35 cases of polio in 
2013. There was one case in early in January 2014. There were 
concerted efforts undertaken by a consortium of groups under 
the Global Polio Eradication Initiative that have resulted in 
12 campaigns, 12 immunization campaigns that have been 
undertaken. And that is a remarkable achievement given the 
gravity of the situation and the dangers involved and the 
intensification of the war itself.
    The fact that polio has been contained through those 
efforts, however, doesn't leave me completely confident that we 
are not going to see more outbreaks, more cases as this 
conflict continues. And I think there has to be, and there is, 
pretty concerted vigilance across the region.
    No state within the region wants to see the reintroduction 
of polio into its borders. When that first case happened in 
2013, there had not been a case of polio in Syria in 14 years 
before that. And this was a country that had managed its 
campaigns very competently, very effectively across a range of 
immunizations. And but that is broken now. And we know the 
hazards.
    So I would say a need for high, continued high vigilance. 
But also, you know, an awareness of the achievements we have 
seen in the last period in reacting to those 2013 outbreaks.
    Mr. Smith. Dr. Hotez, you mentioned that the Hajj has had 
an impact on the spread of dengue and you raise concerns about 
the Zika virus potentially being spread that way. Do the 
clerics, do the leaders of Saudi Arabia understand the 
potential pitfalls, is there a plan of action that could be 
used to mitigate that?
    Dr. Hotez. Yes. Yes, to the first part. But I think they 
are mystified about where to go from there in terms of 
restricting. Because one of the problems that you have with 
Zika is that many times you are without any symptoms at all. So 
you are going to have people coming in carrying the virus in 
their bloodstream without showing any manifestations. So it is 
not like we could check them at the Jeddah airport and say 
don't come into the country.
    So this is going to be a real problem. We are going to see 
this. And the Hajj I think is occurring late in the summer or 
early fall this year, and that is going to be a huge issue.
    Mr. Smith. I mentioned earlier the targeting of so many 
medical personnel. Well, now that there is a cessation of 
hostilities--of course it doesn't apply to ISIS or to al-
Nusra--but my question would be are the medical doctors, the 
healthcare workers streaming in during this lull in 
hostilities, knowing that there are grave risks to them and 
that these hostilities could recommence at any moment?
    Dr. Raad. All of this has escalated to a tremendous number 
of healthcare workers, particularly physicians, immigrating and 
leaving the country with the exodus, and left basically. So the 
best policy is to work with the local people. And as long as we 
are working with groups that are neutral, non-discriminatory, 
and doing the work on the ground, and to strengthen.
    And I think there is something similar to the healthcare, 
originally the health strengthening bill that was there for 
Africa, something similar should be done for the Middle East 
and to work with local groups on the ground in order to retain 
them. Because the healthcare workers are like anyone else 
basically in the midst of a catastrophe, and particularly when 
they are targeted.
    We had difficulty having a mobile medical unit in Syria 
because it would be either shelled or basically and the people 
would be killed. And then the mobile medical unit would be 
taken over to be used to kind of transport weapons and so on. 
So I think the most important thing is to work within the 
system collectively and try to strengthen the healthcare 
system.
    Mr. Morrison. I don't think you are going to see a sudden 
return. Well over half of the 30,000 doctors that were in Syria 
prior to the advent of the war on March 11th are gone. And they 
are not coming back. And you have had over 800 healthcare 
workers murdered in this period. You have had the deliberate 
targeting your infrastructure. Fully half of your 
infrastructure is either destroyed or just non-functional at 
this moment in time.
    So I think what's like--and the security threats remain 
very grave and very fluid. So I think what you are going to see 
is a step by step incremental reintroduction of personnel with 
heavy security guarantees around this. The U.N. convoys that 
have been going in in this last few days, into the five or six 
besieged cities, some in the government territory, some in 
opposition control, these are trying to get to those 15 sites 
where you have got 450,000 people who have been cut off for 
months and months and month, those are being done with very 
heavy preparation, very heavy concerns around security.
    I might add one other thing. You have Deir ez-Zor, you have 
the city out in the east that is besieged by ISIS where you 
have got 200,000 people. There the airlifts are being attempted 
to reach that population. They are having serious problems with 
those. And, of course, airlifts are terribly expensive and not 
particularly effective oftentimes. But that is another measure 
of how desperate that population is.
    But to get Syrians back in and to get international health 
personnel to go back in you are going to have to lay a pathway 
down in which their security is going to be guaranteed and 
protected. This is a much bigger challenge even than trying to 
get the hundreds of health workers who were needed to go into 
the three Ebola states in 2014 who were terribly worried about 
evacuation should they become infected or at risk, or if they 
perhaps infect.
    So we face big challenges. There are a lot of very 
courageous people in civil groups and that have stayed behind 
in ad hoc facilities who are doing cross-border operations, who 
are working from the side of Damascus. The Red Crescent has 
lost hundreds of people in this period. There are many 
courageous people who have stayed to try and keep the lights 
on. And they deserve a great deal of credit.
    Dr. Hotez. I agree with all these points. I would like to 
make the additional point that Ebola was relatively easy to 
contain because it was contained in a relatively isolated area 
of West Africa.
    Look where the Middle East is, it is at the crossroads of 
Asia, Europe, and Africa. We are already seeing the expansion 
into southern Europe. Dubai is one of the busiest airports. We 
are going to be seeing widespread dissemination across into 
Pakistan and India, and then into sub-Saharan Africa.
    So in terms of priorities in the global health security 
agenda, I think the Middle East has to be one of the most 
important because you are going to see this continuous seeding 
of three continents with infectious diseases. And we are 
already seeing the beginnings of that.
    Mr. Bera. Thank you, Chairman. You have laid out a number 
of challenges that we obviously face. And if we were to start 
to look at these as separate challenges, but interrelated 
challenges, and one challenge is in the refugee camps, whether 
you are looking at Jordan, Lebanon, or Turkey, and how we 
approach those challenges where safety may be less of the risk, 
but the conditions under which people are living clearly is a 
risk and an incubator of sorts where, if you do have an 
outbreak things could travel fast. So I would segregate that 
and think about how we address some of that challenge.
    Looking internally in Syria or occupied areas within Iraq, 
safety becomes an issue. The infrastructure, Dr. Morrison, you 
pointed out some of the infrastructure that has been decimated 
certainly becomes an issue. And how you get healthcare 
personnel in there may not be as feasible, but how you work 
with the individuals that are still there and the 
infrastructure there may be a different challenge in how you 
address that.
    And then we have been talking a little bit about MERS and 
so forth. And, again in, folks that may be traveling to the 
Hajj and then traveling back to their home countries, how you 
work, whether it is MERS or dengue or Zika virus, how we work 
with the infrastructure in Saudi Arabia and a country like 
that. So folks that are coming there maybe perhaps getting 
exposed and then returning to all parts of the world how we 
work.
    And that is I would think about it in three separate ways 
where you may have slightly different solutions. And maybe, Dr. 
Morrison, if you want to start?
    Mr. Morrison. Thank you, Dr. Bera. I think those are great 
points. A few, a few thoughts on that.
    One is to keep in mind the demographic transformations 
going on within the region. Syria before the war was 23 million 
people. Syria today is roughly 17 million, and continuing to 
empty. I do not believe, given how devastated this country is, 
and how you have seen the dissolution of sovereign power, 
unitary sovereign power, I do not expect you are going to see 
many of those who have fled coming back any time soon, and that 
there has been a shift of thinking today toward those 
populations in Turkey, Lebanon, and Jordan working toward 
enabling those countries to be able to provide employment 
opportunities, education, housing, health services, and the 
like to those populations as well as their own citizens, and 
restabilize those societies and make it in their interests to 
take that step.
    And you have got trade deals, you have got the EU stepping 
forward, this London conference I spoke to. That is a big shift 
of thinking and a very important one.
    On the access internal to within Syria itself, I think we 
need to come at it from multiple directions. The WHO, UNICEF 
have shown extraordinary courage in their operations, though 
they will remain central in trying to use their legitimacy and 
their record and their access to move forward. But there is 
going to be more and more cross-border work. That has been 
validated and endorsed unanimously in the U.N. Security Council 
resolutions. And those corridors can be opened up as well.
    Thank you.
    Mr. Bera. Dr. Raad.
    Dr. Raad. Mr. Bera, I think you bring a very, very 
insightful thought into this because this is a very complicated 
problem with multiple dimensions and sort of moving variables. 
And you pointed to the fact there needs to be a strategy for 
the refugees and the displaced from, you know, the displaced in 
these countries like Jordan, Lebanon, and Turkey, versus 
something else respective to the areas that are inside the war 
zone, if you may, Syria proper, Iraq. There are certain areas 
where we cannot get to like where under the control of the 
Islamic State. So this is a red area where we cannot get to.
    And then there needs to be a contemplation or part of the 
policy of the Hajj and the flux and the movement that has taken 
place and how to handle this. So I think this is why we need a 
team that would be looking into all of this. Because now a lot 
of groups are working from the U.S., and sometimes the right 
hand is not knowing what the left hand is doing.
    And there is excellent effort, Dr. Morrison has pointed 
out, and great ideas that Dr. Hotez has brought into the 
picture, but we need to integrate this into one common strategy 
where in these different areas how do we act and how do it?
    This is why the thought in some of these areas we have to 
rely on some of the either the local people or more Arab-
Americans that are willing to work there, Dr. Morrison 
mentioned SAMS, the Syrian-American Medical Society. We are 
Arab-American at our work. From various backgrounds and faith 
value as long as they remain neutral and within representing 
they are a medical-diplomatic Peace Corps, if you may, of this 
country that are moving into this area. But it should be part 
of a bigger picture of the general policy that is being devised 
by your subcommittee and other relevant committees.
    Mr. Bera. Dr. Hotez.
    Dr. Hotez. I would just mention also the other actor in 
this could be the Russians, doing some cooperative medical 
diplomacy activities with Russia. There is precedent for that. 
Many people don't realize that the oral polio vaccine most of 
us took as kids was developed jointly between the U.S. and 
Soviets. At the height of the Cold War right after the Sputnik 
launch the two countries put aside their ideologies and made 
the polio vaccine. And they cooperated to make the dry vaccs 
for smallpox eradication. So there is precedent for that and it 
would be an interesting opportunity to investigate.
    Mr. Bera. Great. Thanks, Dr. Hotez.
    Dr. Morrison, how are medical personnel, and actually any 
of the witnesses, you know, medical personnel that are not 
attached to, you know, that are going into this war zone, how 
are they perceived by whether it is the Assad regime, whether 
it is from the rebel fighters outside of the Islamic State, are 
they perceived as neutral players coming in for humanitarian 
need, are they are under constant threat as well?
    Mr. Morrison. In the chairman's opening statement he 
referenced the study by the Physicians for Human Rights. That 
group, as well as the International Committee of the Red Cross 
and Doctors Without Borders, MSF, have carefully documented and 
tracked what has happened in Syria, which is harrowing, which 
is the deliberate targeting of health personnel and 
infrastructure. The most egregious violence coming from the 
Assad government, and most recently from the Russians. But not 
limited to that.
    And you have the introduction of radical Islamist 
dimensions into this as well, where it becomes actions taken 
against Westerners who are seen as carrying a hostile agenda, 
and they just happen to be operating in the health sector.
    So the respective neutrality of these operations has 
eroded. And the degree to which the providers themselves have 
had their access, their access to populations and their 
abilities to function have narrowed significantly. They don't 
have the benefit that in other conflicts where you have had a 
legitimacy and a respect and level of protection, where even in 
a highly-conflicted setting you could migrate across lines. 
Instead you are seen as partisan, as party to one side or 
another, giving active support. And, in fact, serving those who 
are wounded who are combatants as simply implicating you, so 
leaving you open to being attached because it is just part of a 
broader combat operation.
    Mr. Bera. So shifting gears, Dr. Hotez, you talked about 
what it would take for vaccine development. And let's take 
leishmaniasis. If we were to be able to appropriate the funds 
to do the research and come up with, you know, some of these 
cures or viable vaccinations, in your assessment, kind of 
looking at American pharmaceutical companies or global 
pharmaceutical companies, because you will now have to 
commercialize some of this, is there a market for 
commercialization or would it, you know, in many ways would we 
have to continue to appropriate those funds or through the WHO 
or other organizations?
    Dr. Hotez. Thanks for that question. I think once the 
product is developed there is a commercial market and there is 
a commercialization plan. It is modest. It is, you know, it is 
a fraction of what some of the other vaccines are that Merck 
and GlaxoSmithKline makes. And even the vaccines are less than 
a lot of the small molecular drugs that we all take. So it is a 
very modest market but it's not zero, and it should be 
sustainable.
    Mr. Bera. Okay, great. I will pass----
    Mr. Morrison. May I just add one point,----
    Mr. Bera. Yeah, please.
    Mr. Morrison [continuing]. Dr. Bera. In this last year 
there have been four major studies of what happened in Ebola 
undertaken by the Stocking panel, the Harvard-London School 
Panel, the National Academies of Medicine, the U.N. Secretary-
General's High-Level Panel. All four of those panels, to 
varying degrees, identified the research and development 
dimension as this critical gap, one where there needs to be a 
mobilization of resources and a higher level of effort in order 
to create some kinds of platforms that would prioritize those 
dangerous and neglected diseases for which there is no market, 
and be able to get the early development accelerated through 
new initiatives.
    And at the Davos, at the World Economic Forum earlier this 
year, a number of players came together to try and build on 
that momentum coming out of Ebola and those four studies and 
move it to the next stage. And that is led by the Norwegians, 
the Wellcome Trust, Gates Foundation, the British Government, 
and others. And that is, that is moving along.
    And I am hopeful--Peter probably knows more about exactly 
what might be in store on this--but it is still in, it is still 
getting worked out. But at some point later in the year I think 
Ebola convinced us of the need for a higher level of action to 
correct for this and to put us on a different pathway.
    Mr. Bera. And before I yield back let me thank the chairman 
for his leadership in making sure we do not forget about some 
of these neglected diseases that pop up and making sure that we 
continue to focus in on this.
    If we use the Ebola example, we are not that far off from 
developing a vaccine and developing--is that a correct 
statement that with a concerted effort we could come up with?
    Dr. Hotez. Specifically for Ebola now and after there was a 
big investment by the U.S. Government to get it launched, yeah, 
I think we are pretty close.
    Mr. Bera. So we are pretty close.
    If we were to now look back in hindsight and think about 
how much we spent cumulatively globally to maintain, contain 
and treat this last outbreak I am going to guess it is not an 
insignificant amount of dollars that went into that. Is that?
    Dr. Hotez. Well, and I am sure Steve knows those numbers 
probably better than anyone, but the economic impact of Ebola 
was certainly in the billions of dollars. I am sure there is a 
specific number attached to that.
    You can imagine what the economic impact of Zika is going 
to be----
    Mr. Bera. Right.
    Dr. Hotez [continuing]. On the Caribbean economy, for 
instance. And we are going to see this again now with the 
diseases coming out of the Middle East. It is already in 
southern Europe. What is going to be the impact now of having 
malaria in Greece?
    So there is no question that these innovations will pay for 
themselves hundreds of times over.
    Mr. Bera. Dr. Morrison, do you have an idea what that 
number is?
    Mr. Morrison. In terms of the economic costs for west 
Africa of Ebola?
    Mr. Bera. Yeah.
    Mr. Morrison. The World Bank has tracked that cost fairly 
carefully and also offered projections. In the first phase of 
2014-15 it was somewhere in the order of $3 billion to $4 
billion, if I recall, which may not sound that much, but when 
you are talking about economics of this scale, these three 
countries have a total population of 22 million people. They 
are among the poorest countries in the world. That is a pretty 
serious setback.
    And just to add to this, OECD just 2 days ago came in with 
estimates of what is going to happen in Brazil. And we are 
looking at a 4-percent drop of GDP in Brazil this year. Now, 
before Zika hit they were having trouble. But this can be, this 
can have profound impacts in an economy as big as Brazil's.
    Mr. Bera. It is fair to say we will have another Ebola 
outbreak, whether it is this year, whether it is 2 years from 
now. So it is a drop in the bucket to not stop now but actually 
continue and finish it and come up with that vaccine and that 
therapy?
    Dr. Hotez. Yeah. As we pointed out getting to launch of a 
leishmaniasis vaccine or a MERS coronavirus vaccine it is a few 
million, and the economic impacts in the billions. So anybody 
would tell you, any economist would tell you, it is a great 
investment. It is just a matter of getting those initial funds.
    Mr. Bera. Well, let's go ahead and do that then, so we 
don't have to, you know, lose those billions on the back end. 
Thank you.
    And I will yield back, Mr. Chairman.
    Mr. Smith. Before moving to Mr. Clawson, I appreciate you 
being here, the two questions: One, as we all know, incentives 
make the world go around. You point out, Dr. Hotez, that there 
are no commercial incentives to develop new tools. And you do 
point out in your testimony, unlike the EU and governments of 
Japan and several European countries, the United States 
Government does not specifically fund initiatives that support 
product development partnerships, or PDPs.
    And you mention that there are 16 to 20 PDPs globally. I 
wonder if you could tell us how many are in the United States?
    And what do these other countries do? Are there tax 
incentives? Are they grants? You know, are there a number of 
best practices that we ought to just look to apply to our own 
situation here in the United States, again learning from the EU 
on this one, and Japan?
    Mr. Morrison. So thanks. So of the 16 to 20 PDPs, they are 
equally shared between Europe and the United States. So about 
half in the United States, half in Europe. But the way that 
things are working on the European side is they are being 
mobilized through their Ministry of Foreign Affairs. So the 
Dutch Government has launched a fund for product development 
partnerships, so has the German Government just released one. 
The Japanese Government has just released one.
    And they, the way they operate is through what are called 
RFAs, Requests for Applications. And they are really lifelines 
for us because the Gates Foundation has dramatically decreased 
funding for PDPs. So Gates Foundation funding for product 
development partnerships is about half of what it was back in 
2008. So some of them are really struggling now for survival. 
And we are going to lose all of that innovation expertise. So 
it is great that the European governments have done this.
    What I have said is, the U.S. Government doesn't have an 
easy mechanism for funding PDPs right now. They do fund one 
specific one, IAVI, which is the International AIDS Vaccine 
Initiative, they're a very specific appropriation that goes 
through USAID. It is a pass-through. But beyond that, they 
don't really.
    Even if you mobilized 1 or 2 percent of funds for global 
health for PDPs, that would release $100 million to $200 
million into the system. That would do it right then and there.
    Mr. Smith. Why has Gates pulled out or at least diminished 
their portion?
    Dr. Hotez. This, I don't know. This current regime is very 
focused more on supporting directly industry it seems. And so 
they are taking some different routes. And but we will see how 
long that lasts for.
    Mr. Smith. And one last----
    Dr. Hotez. They are still, they are still funding us, you 
know, fairly well.
    Mr. Smith. Yes.
    Dr. Hotez. But not as much as they used to.
    But as I said, you know, we know for some of these 
vaccines, you know, $5 million here, $6 million here, $3 
million here makes a huge difference. We are doing our whole 
Chagas vaccine project on $4 million. We were able to get a 
schistosomiasis vaccine through, from discovery through 
clinical trials, all the way for $2 million. And that was done 
in part because NIAID rescued us and they paid for the clinical 
trials separately, and they paid for the toxicology tests.
    Mr. Smith. When might something for leishmaniasis be 
available?
    Dr. Hotez. Well, we could go into manufacturing pretty 
soon. But we don't have the funds right now. So we could 
probably go into manufacturing by next year or if not earlier. 
But----
    Mr. Smith. Could we get all the details on that----
    Dr. Hotez. Sure.
    Mr. Smith [continuing]. From you?
    Dr. Hotez. Yeah, absolutely.
    Mr. Smith. Appreciate that.
    And one last question on the G20 question. If we, as a 
subcommittee, put together a letter, which I think would be a 
great idea, I would appreciate if all three of you would 
provide us insight as to what you think ought to be in that 
letter.
    Dr. Hotez. Absolutely.
    Mr. Smith. Thank you.
    Dr. Hotez. You are welcome.
    Mr. Smith. Yes, Dr. Raad.
    Dr. Raad. Mr. Chairman, I think the issue of vaccines is 
extremely important. But from my interaction in the area there 
is a tremendous respectability to the healthcare, the U.S. 
healthcare system. And I think we can do a lot with whatever we 
have as we are developing new vaccines.
    For example, the polio is, there is an available vaccine, 
but how to implement it there? The issue of water sanitation, 
the refugee medicine kind of training, the early detection of 
these diseases. I think we have the best healthcare system in 
the world and they look up to us.
    And, again, to improve relationships maybe beyond 
governments with the people, and the people if they would see 
us as a country trying to reach out in a way to provide them 
better health and opportunity to kind of deal with the 
catastrophic situation, I think a lot can be done. Appropriate 
use of antimicrobials and training programs for the people who 
are doing relief, and so forth.
    Mr. Smith. I saw in your list you mentioned training other 
healthcare personnel for refugee situations. What does that 
take: A weekend, longer?
    Dr. Raad. It might take a week or 2 weeks on refugee 
medicine and how to deal with different situations. There is 
tremendous need for such initiatives. And on the ground they 
are effective. And they are----
    Mr. Smith. Who are the trainers for the camps?
    Dr. Raad [continuing]. They are cost effective. You can 
send trainers to train them in areas that are safe like Jordan 
or possibly Lebanon, or maybe other places. But you can--they 
are very cost effective. I mean the whole thing is not a----
    Mr. Smith. Is USAID doing that now?
    Dr. Raad. I am not sure. I would like to investigate by 
being in touch with them. But this is something that could be 
emphasized.
    Mr. Smith. Mr. Clawson.
    Mr. Clawson. Sorry I came late, I had another meeting. We 
are often double-booked up here. So appreciate you all hanging 
around long enough to hear my questions. I may very well be 
repetitive since I haven't heard what has already been asked. 
So if that is the case, I apologize.
    When I think about mosquito-based illnesses I have kind of 
this sequence in my mind that starts with, at least with 
daytime diseases, mosquito-based diseases, that starts with 
dengue fever, dengue fever times four strains, then 
chikungunya, now Zika. And each one of those rides the same 
Trojan horse, the same tiger mosquito. And that there will, 
therefore, be another Zika or another chikungunya. That the 
movie we have been seeing the last 10 years or so will 
continue, and the next one could be even worse than Zika and 
could be, you know, a real disaster. That is how I think of it 
in my mind.
    And so although I like getting rid of stored water or 
pooling water, I like making sure people have air conditioning 
so they kill the larva under the bed, like all those things, it 
still seems to me that until we get something that takes out 
the tiger, the Aedes mosquito, that we are going to see this 
movie again and again and again. And so I don't know if that is 
a genetic fix for this mosquito or if right now it just seems 
like we are going after the results as opposed to the base 
carrier of these types of diseases.
    Do you all see it the same way I do? And if that is the 
case, that is my theory would say the only long-term solution, 
at least for this strain, is to get on that mosquito. You all 
agree with what I am saying?
    Dr. Hotez. Well, I guess I could start. This morning I 
testified to Energy and Commerce; they were holding hearings 
about Zika. I work on the Gulf Coast of Texas and I focused on 
the fact that the Gulf Coast of the U.S., Texas, Louisiana, 
Mississippi, Alabama, and Florida have something very unique. 
We have not the Asian tiger mosquito, which we have that as 
well, but the real bad actor is Aedes aegypti, which is the one 
that is transmitting Zika----
    Mr. Clawson. Right.
    Dr. Hotez [continuing]. Throughout South America and now 
into the Caribbean.
    The other factor that the Gulf Coast, our states have is 
poverty. And that is not often appreciated as a risk factor. 
But the reason why Zika is wiping out Pernambuco State in 
Brazil, and now it is going to decimate Haiti, is because women 
who live in poverty have no access, live in houses without 
window screens or holes in the window screens, and the 
environmental degradation around them breeds the Aedes aegypti 
mosquito.
    So I am very worried about the Gulf Coast of the United 
States more than many others.
    And the consequence of that is we need to do something 
about the mosquito. We are not going to have a Zika vaccine in 
time for this epidemic. And so we have been pushing very hard 
for a program----
    Mr. Clawson. And just to interrupt. And we are not going to 
get rid of all pooling water in the lower socioeconomic 
neighborhoods that don't have air conditioning either. We need 
to work on all of that.
    Dr. Hotez. Yeah.
    Mr. Clawson. I am in southwest Florida. I am on the Gulf 
too.
    Dr. Hotez. Yeah.
    Mr. Clawson. So I am really worried about my more humble 
neighborhoods and their ability to fight back if the virus, if 
this mosquito comes north. And I am not sure why it is not 
there now. But it doesn't seem to be.
    Dr. Hotez. It will. I will come north. And so I am quite 
worried we are going to start seeing Zika on the Gulf Coast, 
including your district, starting this spring and summer.
    And so the approach needs to be, one, we know we can go 
pretty far with old-fashioned methods using existing 
insecticides and getting rid of the garbage, getting rid of the 
discarded tires on the side of the road and doing what you can 
with water. There are some new technologies out there. Whether 
or not they are going to be available, whether they can be 
shown to be scalable in time for this epidemic is unclear.
    Mr. Clawson. Are we close on this mosquito? And I got you 
that we need to get rid of tires and other pooling water and 
have more air conditioning and more screen doors. We hear it. 
But until we take out this particular mosquito, not only in our 
country but particularly, you go to the Caribbean and you go to 
Haiti or the Dominican Republic or Curacao, no one has air 
conditioning. And when it rains, there is water everywhere.
    Dr. Hotez. That is right.
    Mr. Clawson. Dr. Morrison, what were you going to say?
    Mr. Morrison. I support what Peter has to say which is that 
control of mosquitos is really hard, and it is expensive and it 
is tedious. And the old methods are still the ones that we are 
going to rely on in this period. And I worry enormously about 
what is going to happen in the areas where Aedes aegypti is 
endemic in the United States. And as it gets warmer those areas 
are going to become enlarged.
    There are technological fixes that people are exploring: 
There is radiation, there is introduction of bacteria, and 
there is genetic engineering. Those are the three methods that 
are actively being explored. I think they are going to get much 
higher attention in this next period, but there are no quick 
fixes here.
    Mr. Clawson. I dropped a bill that would give a 10-percent 
tax credit, like the investment tax credit from years ago, to 
any company that is working on what you just said. Because I am 
with you, we are, we have got to treat pooling water, but we 
have also got to get at this mosquito. And that is not the 
typical screen methods at night that we would use for a malaria 
mosquito, right? This is a daytime,----
    Mr. Morrison. Right.
    Mr. Clawson [continuing]. Indoor, hot zone kind of----
    Mr. Morrison. Right.
    Mr. Clawson [continuing]. Critter, right?
    Mr. Morrison. Right.
    Mr. Clawson. Let me ask one other thing and maybe----
    Dr. Hotez. I would say one other,----
    Mr. Clawson. Yes.
    Dr. Hotez [continuing]. One of the other issues, problems 
that we are seeing in the U.S. is mosquito control is very much 
done at the local level, at the county or city level, and there 
is a lot of inconsistency in terms of how well that is carried 
out from county to county.
    Mr. Clawson. I agree. I agree.
    Dr. Hotez. So there is going to be a, I think there is 
going to be some need for Federal Government intervention with 
these harmonized technologies and coming up with a more 
consistent----
    Mr. Clawson. Or standardize what the treatment ought to be, 
even if it is implemented locally. I think my districts are 
pretty good. My counties are pretty good. But lots of times 
when I travel I see people spraying at night. And I say that is 
going to kill the wrong mosquito.
    Dr. Hotez. Right.
    Mr. Clawson. And so we think we see spraying at nighttime 
that might be a good thing. As far as I can tell from this bug, 
that doesn't do anything.
    One more question real quick about the Middle East. I mean 
it seems to me that you have distrust of governments, distrust 
of outsiders in the Middle East in general. Can't get doctors 
in. Bad water, bad sanitation. It is just an invitation for 
mosquito-based infectious diseases, and all infectious 
diseases. And I don't even know where to start in that 
environment.
    By the way, I am not sure it is American. I mean I think it 
in Southeast Asia and Africa there are a lot of people that 
looked at other refugee crises and had to set up sanitation 
real quick in previous wars. I am not sure it even has to be 
America. But I see that big, wide problem. And unless 
resources, even if it is regional, unless we can come in, it is 
going to be hard to solve it. Am I right on that, Doctor?
    Dr. Raad. I fully agree with you. I think it is, as we 
mentioned earlier,----
    Mr. Clawson. Sorry I missed it.
    Dr. Raad [continuing]. It is a complicated problem, it is 
multi-faceted, and it is not one size fits all. I mean we need 
to kind of handle it in different areas in different ways.
    For example, there needs to be a policy for how you deal 
with the refugees and the problems related to that? How do you 
deal within the areas which are the combat zone or may be 
difficult to enter to? There has been one other issue is the 
issue of the Hajj and where you have the aggregation of people, 
whether it is in Saudi Arabia, or possibly Iraq and some other 
places, and so forth. Water sanitation and the implication of 
what is happening now of the sewage being directed into the 
water supply for these areas from the areas where the Islamic 
State is.
    So it is a complicated problem but I think it needs to be 
dealt with systemically, in a multi-faceted manner creatively. 
I think there needs to be some creativity because in some 
areas. But I believe that what you are saying is very true, but 
the response should be insightful, should be practical, and 
should be creative. And I think a lot will be done.
    The other factor is one has to account for the fact that 
the problem is escalating and it has so many variables that are 
moving targets occurring that this is why there needs to be a 
special attention through a concerted effort. And maybe a joint 
project between NGOs----
    Mr. Clawson. In some conflicts more people die of illnesses 
than they do from gunshots or bombs.
    Dr. Raad. That is very true.
    Mr. Clawson. What about in this case?
    Dr. Raad. Which is true. For example, I gave some figures. 
An area which is not really in the major conflict, Egypt, where 
the conflict is mainly in Sinai, but people are dying, there 
are more casualties from hepatitis C in Egypt over the last 5 
years than there are from the war in Syria.
    Mr. Clawson. Yeah.
    Dr. Raad. Actually, you know, \1/4\ million in Syria killed 
during the war. There certainly in all these outbreaks have 
resulted in a lot of people killed because of these infectious 
outbreaks because of the Syrian-Iraqi conflict, if you may. So 
I fully agree with you.
    Mr. Clawson. Dr. Morrison.
    Mr. Morrison. There has been various efforts made in this 
current, these current wars and in the past to try and estimate 
mortality from various sources. And the data remains weak 
oftentimes. But there seems to be across multiple cases a 
pattern where a substantial, a substantial portion of mortality 
comes through the decay of your health system.
    Mr. Clawson. Okay, so let me interrupt. Can I have 1 more 
minute on it?
    What do we spend on bombs and guns and killing versus what 
do we spend on preventing disease?
    Mr. Morrison. That is a big question.
    Mr. Clawson. I know you have got a, I know you thought of 
this now. Come on now. I know you all thought of this, right? 
We spend a lot more on bombs.
    Dr. Raad. I think that, yeah.
    Mr. Clawson. I'm just asking.
    Dr. Raad. I think this is the whole point that we, we 
together were trying to bring, that a lot could be done if we 
appropriately use these resources in a targeted manner. And 
that would reflect a certain view in the region, particularly 
among the people. It is people to people of how they view the 
United States of America. That we are not involved in the 
conflicts through the only really kind of the war sort of 
policy that we have, which is legit and certainly we are 
fighting terrorists. But there is another side initiative of 
this great country where we are reaching, where we are the kind 
of hosts of groups like Doctors Without Borders and so forth, 
that we are making initiatives on the ground and we are having 
people move on the ground.
    And this, this had a tremendous impact in west Africa with 
the Ebola virus, and could have a tremendous impact on the 
people and, ultimately, the governments in the area. If we have 
a good policy that will deal with this crisis and we come as 
the people are trying to solve a major catastrophic problem----
    Mr. Clawson. You would agree in the case, I mean I have a 
close friend who is a physician that went to Africa to fight 
the Ebola outbreak, as an example, university professor, 
physician, et cetera. A lot of Americans, Americans are great 
that way, right? If there is a problem around the world, we are 
always one of the few that swashbuckle and get on over there to 
help out, right?
    Dr. Raad. Yes.
    Mr. Clawson. But it is a lot harder in war zones. And it is 
a lot of our dollars that are going in there to, right, to 
defend and make war. So maybe in those zones we ought to think 
how can we also offset part of that with medical----
    Dr. Raad. That is true.
    Mr. Clawson [continuing]. And sanitation.
    Mr. Morrison. Congressman, we were talking earlier about 
the response to the human crisis that has grown out of the 
Syria war and has spilled into the region and now spilled into 
Europe. The United States' engagement on that side has amounted 
to $4.4 billion since the Syrian war started in March of 2011.
    The military side of the equation has been largely, within 
that region we have been scaling down our military engagement, 
but only recently scaling up with the coalition campaign 
against ISIS. Right? That is the central investment that we are 
making within that region on a military ground. So I mean you--
--
    Mr. Clawson. The President's original ask was $5 billion or 
$6 billion, something like that, correct? To train Syrian 
insurgents, as I recall.
    Mr. Morrison. I don't remember the exact number that was 
made in terms of the training.
    Can I come back to one point that you raised about the Zika 
response, just to get back to that?
    Mr. Clawson. Sure.
    Mr. Morrison. Because I want to, before we run out of time 
I wanted to make one important point.
    Mr. Clawson. You know, the chairman over here might have a 
different view on that. But go ahead. Are you all right here, 
boss?
    Mr. Smith. Yes.
    Mr. Clawson. Alright.
    Mr. Morrison. You know, it is going to be very important in 
this period that the CDC be able to bring forward additional 
capacities and resources to states and communities that are 
attempting to address these threats through a variety of 
different measures of sanitation, water, screening, air 
conditioning. But and the current, the current $1.9 billion 
request, emergency request that is up here for consideration 
includes I think it is almost $900 million to meet that need.
    Mr. Clawson. Seems low.
    Mr. Morrison. And----
    Mr. Clawson. If I wanted to do an economic impact of an 
outbreak in south Florida, I could probably get to that number 
just in Florida pretty quick. Am I right? You all agree with 
that? So it seems low, $1.9 billion just seems low. Just a 
cursory view of it, seems low.
    Dr. Hotez. Well, I think you have to remember the 
consequences. If we start seeing clusters of microcephaly cases 
appear on the Gulf Coast by the end of this year, it is going 
to be spoken about in the same context as Hurricane Katrina or 
the BP oil spill.
    Mr. Clawson. Seems low.
    Dr. Hotez. So, yes.
    Mr. Clawson. But the human cost would be hard to describe, 
right?
    Mr. Morrison. When you look at the costs I think it is 
important to keep in mind, we are not talking about a crisis of 
Zika and of the mosquitos, we are talking about a crisis of 
microcephaly.
    Mr. Clawson. No, I understand that. I got you.
    Mr. Morrison. And the population that is most vulnerable is 
the pregnant women or women who are to become pregnant.
    Mr. Clawson. Right. In poor neighborhoods.
    Mr. Morrison. In poor neighborhoods in particular.
    Mr. Clawson. Where there is no air conditioning.
    Mr. Morrison. And so, so we need to, we need to keep our 
eye on the ball in terms of what the most vulnerable population 
in need is.
    Mr. Clawson. And what was the basis for the $1.9 billion? 
What is the----
    Mr. Morrison. Well, that has been detailed in the request. 
It breaks it into its different component parts.
    Mr. Clawson. Right.
    Mr. Morrison. They were making an estimate of the 
requirements in this first phase to get moving. And I think the 
urgency around this is what Peter is referring to, which is we 
do not know if we are going to see 8, 9, 10 months out or 
beyond, if we are going to see a proliferation of microcephaly.
    Mr. Clawson. But you all would agree, and again let me, you 
all agree with me, even if it is not--remember where I 
started--even if it is not Zika, it is going to be something 
riding the back of this particular mosquito. So whatever money 
that we spend, even if Zika is not an outbreak, we might be 
very likely preventing a future outbreak in whatever we do to 
attack Zika now. Even if Zika isn't our worst case scenario, 
there will be another one on this, on the Tiger mosquito that 
is going to get us.
    Mr. Morrison. No, this Aedes aegypti mosquito that is 
endemic in these coastal areas, 23 million people live in those 
areas, this same mosquito carries dengue.
    Mr. Clawson. And chikungunya.
    Mr. Morrison. And you have had outbreaks that have been 
brought under control.
    Mr. Clawson. That is my point.
    Mr. Morrison. I mean there was an outbreak in Key West of 
dengue in 2009-2010 that was brought under control. So it 
stands to reason that many of the same measures that have 
protected Americans against dengue and chikungunya--correct me, 
Peter, if I am wrong--are, should be applicable in this 
instance with lots of modifications around the, around the 
threat module.
    Mr. Clawson. Right. Which is why I would like more than 
$1.9 billion. It just seems like cheap money for future lives 
and problems.
    And with that I will--and I really like the CDC, by the 
way. With that I yield back.
    Mr. Morrison. Thank you very much.
    Mr. Clawson. Thanks for the time. Appreciate you all--sorry 
I came in late--appreciate you all's input here.
    Dr. Raad. Thank you.
    Mr. Smith. Thanks, Mr. Clawson. And thank you.
    Anything you would like to say before we conclude the 
hearing?
    Mr. Morrison. Just thank you.
    Mr. Smith. Oh, I mean anything on the subjects.
    Dr. Hotez. Well, thank you for raising this issue because 
this has been beow everybody's radar screen, and yet it is so 
important.
    Mr. Smith. Thank you for the insights and counsel. And we 
do have a lot of things to do in follow-up.
    The hearing is adjourned.
    Mr. Clawson. Thank you, Mr. Chairman. Really good job.
    [Whereupon, at 3:50 p.m., the subcommittee was adjourned.]

                                     

                                     

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