[Senate Hearing 105-883]
[From the U.S. Government Printing Office]

                                                        S. Hrg. 105-883



                                before a

                          SUBCOMMITTEE OF THE


                       ONE HUNDRED FIFTH CONGRESS

                             SECOND SESSION


                            SPECIAL HEARING


         Printed for the use of the Committee on Appropriations

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                       U.S. GOVERNMENT PRINTING OFFICE
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                     TED STEVENS, Alaska, Chairman
THAD COCHRAN, Mississippi            ROBERT C. BYRD, West Virginia
ARLEN SPECTER, Pennsylvania          DANIEL K. INOUYE, Hawaii
PETE V. DOMENICI, New Mexico         ERNEST F. HOLLINGS, South Carolina
CHRISTOPHER S. BOND, Missouri        PATRICK J. LEAHY, Vermont
SLADE GORTON, Washington             DALE BUMPERS, Arkansas
MITCH McCONNELL, Kentucky            FRANK R. LAUTENBERG, New Jersey
CONRAD BURNS, Montana                TOM HARKIN, Iowa
RICHARD C. SHELBY, Alabama           BARBARA A. MIKULSKI, Maryland
JUDD GREGG, New Hampshire            HARRY REID, Nevada
ROBERT F. BENNETT, Utah              HERB KOHL, Wisconsin
LARRY CRAIG, Idaho                   BYRON DORGAN, North Dakota
LAUCH FAIRCLOTH, North Carolina      BARBARA BOXER, California
                   Steven J. Cortese, Staff Director
                 Lisa Sutherland, Deputy Staff Director
               James H. English, Minority Staff Director

 Subcommittee on Departments of Labor, Health and Human Services, and 
                    Education, and Related Agencies

                 ARLEN SPECTER, Pennsylvania, Chairman
THAD COCHRAN, Mississippi            TOM HARKIN, Iowa
SLADE GORTON, Washington             ERNEST F. HOLLINGS, South Carolina
JUDD GREGG, New Hampshire            DALE BUMPERS, Arkansas
LAUCH FAIRCLOTH, North Carolina      HARRY REID, Nevada
LARRY E. CRAIG, Idaho                HERB KOHL, Wisconsin
TED STEVENS, Alaska                  ROBERT C. BYRD, West Virginia
  (Ex officio)                         (Ex officio)
                      Majority Professional Staff
                            Bettilou Taylor
                             Mary Dietrich

                      Minority Professional Staff
                              Marsha Simon

                         Administrative Support
                   Jim Sourwine and Jennifer Stiefel

                            C O N T E N T S

Opening remarks of Senator Dale Bumpers..........................     1
Eliminating polio throughout the world...........................     1
International strategy...........................................     3
Statement of David Satcher, M.D., Ph.D., Assistant Secretary for 
  Health and Surgeon General, Public Health Service, Department 
  of Health and Human Services...................................     3
Decrease in cases of poliomyelitis...............................     4
Struggles faced in Southeast Asia................................     5
Effective vaccine against measles................................     6
Prepared statement Dr. David Satcher.............................     7
Statement of Erbahim M. Samba, M.D., regional director, Regional 
  Office for Africa, World Health Organization...................    13
World Health Organization........................................    13
Winning the battle against polio.................................    14
Prepared statement of Dr. Erbahim M. Samba.......................    15
Human and natural resources to sustain everybody.................    22
Statement of Herbert A. Pigman, chairman, polio eradication 
  advocacy task force, the Rotary Foundation, Rotary 
  International..................................................    22
Oral polio vaccine...............................................    23
Prepared statement of Herbert A. Pigman..........................    24
    Biographical sketch..........................................    29
Statement of Dr. Bill Foege, former Director, Centers for Disease 
  Control........................................................    30
Lessons from polio...............................................    31
Spreading of measles.............................................    32
Prepared statement of Dr. William Foege..........................    33
When to stop manufacturing polio vaccine.........................    36
Smallpox vaccine and stockpiling.................................    36
Two polio vaccines...............................................    37
Eradication programs.............................................    37
Civil strife.....................................................    37
HIV and AIDS.....................................................    38
Polio eradication................................................    38
Rotarians........................................................    39
Eradicate measles................................................    39



                       FRIDAY, SEPTEMBER 23, 1998

                           U.S. Senate,    
    Subcommittee on Labor, Health and Human
     Services, and Education, and Related Agencies,
                               Committee on Appropriations,
                                                    Washington, DC.
    The subcommittee met at 10:34 a.m., in room SD-124, Dirksen 
Senate Office Building, Hon. Dale Bumpers, presiding.


                         Public Health Service

                     Office of the Surgeon General


                   opening remarks of senator bumpers

    Senator Bumpers. The committee will come to order.
    First let me thank Chairman Specter for calling today's 
hearing to discuss the eradication of polio and measles 
throughout the world. I know he shares my commitment to improve 
preventive health care for children and to make investments 
necessary to ensure that all children have ready access to 
vaccines that protect them from illness and death. Over the 
past several years, the chairman's mark has included 
significant funding increases for the Centers for Disease 
Control to carry out its program to eradicate polio and 
measles. Under his leadership and that of Senator Harkin, the 
entire subcommittee has supported these efforts in a bipartisan 
way and today we look forward to hearing some very good news 
regarding how our investment in polio eradication is about to 
pay off.

                 eliminating polio throughout the world

    There are fewer than 800 days left before we reach the goal 
of eliminating polio throughout the world by the end of the 
year 2000. That victory will mark the second time in history we 
have been able to eradicate an infectious disease. The first 
was the eradication of smallpox, a disease that claimed 
millions of lives through the centuries. As recently as the 
1950's, smallpox was killing over 2 million people each year, 
despite the fact that an effective vaccine for the disease had 
been in use since 1796. Smallpox eradication began in 1967. The 
campaign required 11 years to complete and cost nearly $300 
million--$200 million from countries with endemic smallpox and 
an additional $100 million from international donors. The 
United States was the largest international contributor with a 
total investment of $32 million, and that investment has repaid 
itself many times over. Beyond the humanitarian benefits of 
eliminating this vicious killer, we have enjoyed tremendous 
economic benefits. The United States alone has recouped the 
equivalent of its entire investment every 26 days since the 
disease was eradicated.
    The polio effort began in 1988 when the World Health 
Assembly endorsed the program and set the year 2000 as the 
target date for global eradication. Thus far, the campaign has 
been a very dramatic success story. Today, four out of every 
five of the world's children receive polio vaccine. Over the 
past 10 years, polio cases have been reduced by over 90 
percent, and today more than 150 nations report no polio. All 
countries in the western hemisphere have been polio-free since 
1991 and all countries in Europe and the western Pacific 
region, including China, Vietnam, and Cambodia, have been 
polio-free for 1 or more years.
    In my view, the program's achievements are the result of a 
model public/private partnership. Rotary International began 
working on immunization programs in the early 1980's, and when 
the World Health Assembly endorsed the polio eradication 
program in 1988, Rotary became the primary private sector 
partner in the campaign. We estimate that Rotary will have 
contributed $450 million by the end of the year 2000, the 
largest private contribution to a public health initiative in 
    In a combined effort with the health ministries in each 
country, Rotary, UNICEF, World Health Organization, and CDC 
have mobilized thousands of volunteers to recruit, educate, 
transport, and vaccinate children in a mass campaign strategy. 
The scope of the program is enormous. In 1997 alone, more than 
450 million children in 80 countries were vaccinated against 
polio through the use of mass campaigns. And the partners have 
enjoyed unparalleled success in densely populated areas where 
the risk of disease has been high. During India's first 
campaign in 1996, more than 87 million children were vaccinated 
by 100,000 volunteers over one 3-day period.
    The last frontier for the program is Africa, where the 
polio campaign faces formidable challenges. Efforts there have 
been hindered by poverty, civil conflicts, and logistical 
problems in vaccine delivery. Even with these barriers, the 
program has enjoyed significant success in many areas of the 
continent. National immunization days have been conducted in 
over 35 African countries and put a real dent in the number of 
polio cases.
    Experts in the field, including one Betty Bumpers who 
participated in a mass campaign in West Africa earlier this 
year, have all returned with the same message: We can win the 
war against polio and Africa will put us over the top for the 
year 2000, but only if we intensify our efforts in Africa over 
the next 2 years. This means more funding from all the donors 
and more logistical support for programs that are conducted in 
countries racked by civil conflict and supply shortages.
    As was the case with smallpox, the rewards will far exceed 
the costs. The United States alone will reap annual savings of 
over $230 million, and worldwide savings will exceed $1.5 
billion every year. More importantly, we will have conquered a 
disease responsible for crippling millions of children in our 
    Finally, we have set the stage for our next campaign: the 
eradication of measles worldwide. Regional efforts to eliminate 
measles have already begun, and an international effort is on 
the horizon. Historically, measles has killed more children 
than any other infectious disease. Even today it is responsible 
for 1 out of every 10 deaths in children under age 5. I can 
remember when Dr. Satcher was in my office 3 or 4 years ago and 
gave me that statistic. I was absolutely staggered. Think of 
it: 1 out of every 10 deaths in children under age 5 caused by 
a preventable disease.

                         international strategy

    Many leaders in the public health field believe that we 
should begin planning an international strategy over the next 2 
years so that resources can be easily shifted from the polio 
effort to a measles campaign once polio is eradicated.
    We are privileged to have a very distinguished panel this 
morning to educate us on the polio and measles efforts. Dr. 
David Satcher has been a leader in the polio effort during his 
tenure as Director of CDC and more recently as Surgeon General. 
Dr. E.M. Samba, whom I want to personally thank for his 
courtesy and hospitality to Betty, is with us this morning. He 
is head of the World Health Organization in Africa and I am 
confident will be responsible for winning the final battle of 
the campaign when polio is eradicated there over the next 2 
years. Mr. Herb Pigman heads the Rotary International polio 
program, and even though he is the only nonphysician on the 
panel, has probably visited and participated in more polio 
campaigns across the world than any doctor or nurse in the 
entire public health care system. Dr. Bill Foege, former 
Director of the CDC and longtime advisor to the Congress and 
leader in the international health community, brings us the 
wisdom of his experience with smallpox, polio, and measles 
    Gentlemen, I welcome all of you and thank you very much for 
taking your time to travel here, prepare your testimony, and 
enlighten the rest of us.
    For lack of a better system, let me just suggest that we 
start on the right with Dr. Foege.

                 summary statement of dr. david satcher

    Dr. Foege. Thank you, Senator Bumpers.
    Senator Bumpers. Wait just a moment.
    Senator Bumpers. I am sorry. Staff always prevails. 
    Dr. Satcher, you are uno numero. [Laughter.]
    Dr. Satcher. Well, thank you very much. I certainly 
understand the logic of starting from your right. [Laughter.]
    I am delighted to be a part of this very outstanding panel. 
I am David Satcher, Assistant Secretary for Health and Surgeon 
General of the United States.
    Senator Bumpers, I just want to say, before I officially 
begin my testimony, how much it means to me to be here today 
and to be a part of this panel. I want to thank you for your 
tireless and effective efforts in support of the health of the 
citizens of this country and throughout the world. Your wisdom 
and foresight have helped reach unprecedented achievements, 
especially in the area of immunization, and we are grateful. As 
Director of the CDC, I came to respect your integrity, 
appreciate your commitment, and admire your insights into 
issues surrounding immunizations.
    This will probably be my last opportunity to testify before 
you in Congress, and I will miss you greatly but I will always 
appreciate the outstanding work that you have done as a Member 
of the Congress of the United States. Thank you.
    Senator Bumpers. Thank you, Dr. Satcher.
    Dr. Satcher. I will be brief because this is an outstanding 
panel, and I would just like to support some major points that 
you have made: No. 1, about the rationale for polio 
eradication; two, the status of our efforts to eradicate this 
disease; and three, to talk about the issue of measles 
eradication and where we are with that consideration and 
developments related to that.
    Often when we talk about the rationale for eradicating 
polio, we speak of it from the standpoint of the financial 
gains. And they are significant in terms of being able to save 
on the costs of immunizations in this country and throughout 
the world. That is an important consideration, the fact that 
this was, in fact, a cost effective effort. But I believe it is 
fair to say that the opportunity which we have to prevent pain 
and suffering and unnecessary deaths in this country and 
throughout the world should be our overriding consideration.
    We are a Nation that invests over $1 trillion a year in our 
health care system, and we are predicting that by the year 
2007, we will be spending over $2 trillion. We spend only about 
1 percent of that amount on population based prevention. 
Because of that, I think it is critical to point out that there 
is no better investment that we could make than to prevent this 
disease throughout the world and the necessity for immunizing 
against it.
    So, I think the rationale is really clear. We have the 
technical ability to eradicate this disease. We have 
demonstrated that. We eliminated this disease in the Western 
Hemisphere. We have not had a case since 1991. As we speak, our 
colleagues from the Pan American Health Organization are 
meeting down the street. They played a great role in 
eliminating this disease from the Western Hemisphere and 
demonstrating, in fact, that it can be eradicated from the 
    In terms of the status of polio eradication, I would just 
like to point to some very important charts, and that was the 
first one. [Laughter.]

                   decrease in cases of poliomyelitis

    The number of reported poliomyelitis cases by year 
worldwide. Beginning in 1988 when the World Health Organization 
declared its commitment to eradicate this disease, there has 
been an 85- to 90-percent decrease in the reported cases of 
poliomyelitis by year. As you know, we do not report every 
case. We know that there are many cases of polio that are not 
reported, but using an epidemiological model, we can estimate 
the number of cases from the number of cases that are reported.
    So, this is a dramatic story of success in the efforts to 
eradicate polio in the world, and it reflects a great reduction 
in pain and suffering and deaths. Hundreds of thousands of 
children who would have died from polio have been saved because 
of this effort. I think that is the major message here.
    You are very familiar with these charts, as are members of 
the panel. In 1988, this disease was very common throughout the 
world. The reports were very common. If you look at the color 
of the charts, the red areas and the green areas especially, 
the increase in the number of countries reporting no cases of 
polio, when you compare 1988 with 1997, and the fact that today 
we are struggling primarily in Africa, and primarily sub-
Saharan Africa, and Southeast Asia and making significant 
    I think if you look at India and what has happened in India 
over the last few years, it is the most dramatic example of 
what we can achieve. There has been in India more than a 90-
percent reduction in cases of reported polio since 1988. We 
have really targeted in the last few years India. I was there 
in 1996, December 7, when we immunized 120 million children 
against polio.
    But I also gained on that occasion a new kind of respect 
for Rotary International. I was aware of all of their financial 
investment, but on that particular day, 57,000 Rotarians were 
in the streets throughout India getting children out to be 
immunized. The commitment of this organization throughout the 
world and the way it has coordinated its efforts has really 
been something to behold. It is a unique kind of public health 
partnership that we enjoy, and I commend Rotary International 
for their commitment and effective operations.
    It is going to be difficult to go the rest of the way. I 
was a long distance runner in college. I really was not that 
good, so you did not hear about me. [Laughter.]
    But I learned something, and that is, I learned that it 
does not matter how great your stride or how well you run the 
first one-half or the first two-thirds or three-fourths of the 
race. If you do not finish, you are a failure.
    And I believe we have come to the point now where the issue 
is, are we committed to finishing this race to eradicate polio? 
We know we can do it. We have demonstrated that we can do it, 
but I think we run the risk, if we are not careful, of slowing 
down and not finishing the race by the year 2000. So, I think 
it is really critical that we make the commitments, financial 
and otherwise, to finish this task.

                   struggles faced in southeast asia

    This chart demonstrates some of the struggles that we face 
in Southeast Asia and in Africa especially. Even though this is 
from Afghanistan, the fact of the matter is that some of the 
things we take for granted in terms of communication and 
transportation systems or the ability to preserve and move the 
vaccine from place to place, all those issues become very 
difficult, especially when you put on top of that often wars 
and conflicts of various kinds that make it very difficult for 
people to come together and implement national immunization 
    Those are some of the things we are facing now in terms of 
the logistics and the operations. We can overcome those 
barriers. We have demonstrated that and I think we will, 
working together, overcome them and complete the task of 
eradicating polio. The benefits are tremendous and certainly 
Dr. Foege who played such a critical role in the eradication of 
smallpox probably appreciates that better than anyone in terms 
of working very hard to accomplish the eradication of disease 
and then seeing the benefits of it play out over the years.
    As a leader in public health and all of the challenges that 
we are facing, I appreciate the fact that the effort to 
eradicate polio has really helped us to develop an 
infrastructure, a global infrastructure that we would not 
otherwise have in place. The importance of epidemiological and 
laboratory surveillance in terms of monitoring the progress of 
eradicating the disease and all of those systems that we have 
put in place in order to carry out this effort will benefit us 
tremendously, not only as we approach other diseases such as 
measles, but the whole challenge of global emerging infectious 
    I am meeting with our partners in eight nations throughout 
the world now in terms of trying to make sure that we have in 
place systems to deal with new and emerging infectious 
diseases. We are learning a lot from our experience in the 
eradication of polio. We have laboratories in place. We have 
trained people in place. We have systems in place that we would 
not have if it were not for this effort. So, the benefits are 
just tremendous.

                   effective vaccine against measles

    Well, I will just say a few words about measles because I 
am sure that is going to be discussed by my colleagues. As you 
pointed out, measles is still a very important disease, still 
responsible for the deaths of almost 1 million children a year 
in the world and almost 37 million cases of measles in the 
    We have a very effective vaccine. We know that we can 
eliminate this disease because in this country, for example, we 
have seen dramatic declines in measles over the last several 
years. In the past 5 years, we have averaged only about 400 
cases, and last year we had, I think, a total of 138 cases in 
this country. It looks like we are going to have fewer than 
that this year, my colleagues from CDC tell me.
    So, I think it is very clear that we can eliminate this 
disease, we can eradicate it, and I think on the horizon is the 
prospect of moving forward after we finish polio. If we do not 
finish the job with polio, I think the hope of being successful 
with measles and other diseases is not very great. So, we have 
got to finish polio, but I think after we have finished it, it 
looks like the prospects of eradicating measles are very real 
and that we should pursue that. We are already working very 
    Again, PAHO has been very successful in dealing with 
measles. To a great extent the reason we have had so few cases 
in this country is there have been so few cases in the Western 
Hemisphere. Now, last year we did have an outbreak in Brazil, 
and that demonstrated the importance of being diligent in terms 
of pursuing these diseases. But I think it is very clear that 
as we complete the task of polio, we can look to eradicating 
other diseases in the world and controlling emerging infectious 

                           prepared statement

    So, I am very pleased to be a part of this panel and very 
pleased to join you in reviewing our commitment to the 
eradication of polio and look forward to, even in your 
retirement from the Congress, working with you and Mrs. Bumpers 
as we continue to work toward a world that is free of polio and 
safe from other infectious diseases. Thank you.
    Senator Bumpers. Dr. Satcher, thank you very much for that 
wonderful, articulate, and enlightening statement.
    [The statement follows:]

                Prepared Statement of Dr. David Satcher

    Good morning. Mr. Chairman and members of the Subcommittee, I want 
to thank you for your invitation to testify at this important hearing 
on the eradication of polio and control or elimination of measles. I am 
Dr. David Satcher, Assistant Secretary for Health, Department of Health 
and Human Services (HHS) and Surgeon General of the United States.
    Mr. Chairman, like myself, some people in this room may remember 
the fearful time in the 1940's and 1950's when thousands of Americans 
were paralyzed by polio every year. Today, the Department is assisting 
the World Health Organization (WHO) in the worldwide effort to 
eradicate poliomyelitis by the year 2000. Ultimately, global polio 
eradication is the most cost-effective and permanent way to protect the 
United States from imported polio cases. No single country can be safe 
from polio until all countries are free of polio.
    Within HHS, the Centers for Disease Control and Prevention (CDC) 
has lead responsibility for global polio eradication and measles 
elimination programs. I would like to briefly address the following: 
The rationale for global polio and measles initiatives, progress toward 
global polio eradication, partnerships, and challenges, and the status 
of efforts to develop and implement a global measles elimination plan.
    rationale for global polio eradication and measles elimination 
    Diseases do not recognize national boundaries; therefore, 
international disease eradication and elimination activities are 
essential in protecting Americans from the threat of imported disease. 
Eradication is the permanent reduction to zero of the worldwide 
incidence of infection caused by a specific agent. Eradication creates 
an environment where intervention measures are no longer needed. 
Elimination is the reduction to zero of the incidence of infection in a 
defined geographic area.
    Although the United States has been free from indigenous polio 
since the early 1970's, polio cases resulting from imported polio virus 
occurred during the late 1970's, and such events remain a threat in the 
1990's, although, thankfully, a diminishing one. Virtually all measles 
cases in the United States are now directly or indirectly imported from 
other countries. By contrast, no American has suffered from smallpox 
since global eradication was reached in 1977.
    Successful eradication programs save significant amounts of money. 
The global eradication of smallpox in 1977, with support from the 
Department and the U.S. Agency for International Development (USAID), 
proved to be a remarkably good economic investment for public health. A 
total of $32 million was spent by the United States over a 10-year 
period in the global campaign to eradicate smallpox. The entire $32 
million has been recouped every 2\1/2\ months since 1971 when routine 
smallpox vaccination was discontinued in the United States by saving 
the costs of smallpox vaccine preparation and administration, medical 
care, quarantine and other direct and indirect costs. According to an 
April 1998 General Accounting Office (GAO) report, ``Infectious 
Diseases: Soundness of World Health Organization Estimates for 
Eradication or Elimination,'' the cumulative savings from smallpox 
eradication for the United States is $17 billion. The report also 
estimates the real rate of return on the smallpox investment for the 
United States to be 46 percent per year since smallpox was eradicated.
    Achievement of global polio eradication will offer benefits similar 
to those realized by smallpox eradication. More than $230 million will 
be saved annually in the United States alone when polio eradication is 
achieved and polio vaccination is stopped. Globally, more than $1.5 
billion will be saved annually.
    Disease eradication also dramatically reduces the global burden of 
disability and death resulting from disease. Smallpox eradication 
eliminated the suffering of an estimated 10- to 15-million people a 
year and saved the lives of 1.5 million people per year. The polio 
eradication initiative is eliminating the burden, disability and death 
related to polio. Since 1988, several million children worldwide who 
would have been paralyzed were not because of the dramatic reductions 
in polio virus transmission. More than 100,000 children who would have 
died from polio, were saved.
    Successful disease eradication initiatives also benefit the broader 
spectrum of public health.
    Disease surveillance systems established for eradication 
initiatives can be used for other important public health efforts. For 
example, polio surveillance systems in Latin America were helpful in 
determining the scope of cholera outbreaks in the early 1990's.
    Eradication initiatives provide models for appropriate and feasible 
laboratory networks. For example, the global polio laboratory network 
(87 virology labs) developed for polio eradication is a model for 
global infectious disease laboratory surveillance.
    Capacity-building required for successful eradication initiatives 
leads to improvements in public health planning, logistics, training, 
and communications. For example, the global polio eradication 
initiative has helped the expansion of computer capacity and 
development of health information systems in developing countries.
    Quite importantly, the success of polio eradication activities is 
increasing the enthusiasm for immunization and other public health 
programs by local and political officials.
                        global polio eradication
Basic strategies for polio eradication
    WHO has defined four basic strategies for polio eradication. They 
    (1) Achievement and maintenance of high routine immunization 
coverage levels among children with at least three doses of polio 
vaccine. When a high percentage of children are vaccinated, disease 
incidence is reduced and eradication becomes feasible.
    (2) Development of sensitive systems of epidemiologic and 
laboratory surveillance for suspected cases of poliomyelitis. 
Eradicating polio requires a system to detect, investigate and report 
every possible case of polio. Disease surveillance is a critical 
component of any disease eradication program. Two stool specimens are 
collected from every suspected polio case for testing in a virology 
laboratory for the presence of polio virus.
    (3) Implementation of National Immunization Days (NIDs)--mass 
immunization campaigns that aim to vaccinate every child in a country 
(generally children less than 5 years of age) in as short a time as 
possible, usually within one to a few days, to rapidly stop the spread 
of polio virus. Because not all children are reached by the routine 
immunization system and not all children are fully protected by the 
doses they have received, NIDs target all children less than 5 years of 
age, regardless of their prior immunization status. This strategy 
provides the additional advantage of boosting the intestinal immunity 
among previously protected children, providing a further barrier to the 
circulation of polio viruses in the community. Two doses of polio 
vaccine are administered to all children with an interval of 4- to 6-
weeks between doses. Because the oral polio vaccine does not require a 
needle and syringe to administer, volunteers with minimal training can 
serve as vaccinators during NID's, thus vastly increasing the number of 
vaccinators well beyond the existing staff of the country's ministry of 
health and facilitating completion of NIDs within a short period of 
    (4) Implementation of ``Mopping-Up'' Immunization Campaigns. These 
are localized campaigns conducted in the final stages of polio 
eradication in a country, which are targeted to high-risk areas where 
polio virus circulation still persists. In order to reach every child, 
polio vaccine is carried from house to house rather than having 
children come to a central immunization station. As with the NID's, two 
doses of polio vaccine are administered to all children less than five 
years of age, regardless of prior vaccination history, with an interval 
of 4- to 6-weeks between doses.
Progress toward achievement of global polio eradication
    Extraordinary progress continues toward achieving the goal of 
global polio eradication by the year 2000. Reported cases have declined 
by more than 85 percent since the initiative was launched in 1988. 
(Attachment I) A significant portion of the world has become polio-free 
since 1988. (Attachments II and III) All countries of the Americas have 
been polio-free since 1991, and virtually all countries in Europe and 
the Western Pacific Region (including China) have been polio-free for 1 
or more years.
    In addition to this progress, notable reductions in polio cases 
have occurred in other countries. For example, laboratory-confirmed 
polio in the European Region declined to less than 10 cases in 1997 
following three years of synchronized NIDs in 10 polio-endemic 
countries in the Region. Also, India has experienced the most dramatic 
declines in reported polio cases. In 1988, India documented a total of 
24,257 cases. The number of cases fell dramatically to a total of about 
2,300 cases in 1997, a decrease of more than 90 percent. In Indonesia, 
three years have passed since the last laboratory-confirmed cases of 
polio. Furthermore, the number of polio cases in Viet Nam has declined 
from 557 cases in 1992 to zero cases in the last 12 months.
    The polio eradication initiative has provided a tremendous example 
of global cooperation and action. More than 450 million children in 80 
countries worldwide were vaccinated against polio in National 
Immunization Days (NIDs) in 1997, which is approximately two-thirds of 
the world's children less than 5 years of age. NIDs in India in January 
1998 involved deployment of 2 million volunteers to vaccinate over 130 
million children in a single day. The polio-endemic countries of South 
Asia, including India, Bangladesh, Myanmar, Nepal and Indonesia, have 
conducted NID's for 2 or more years. In December 1997 and again in 
January 1998, six countries (Bangladesh, Bhutan, India, Myanmar, Nepal, 
and Thailand), in an unprecedented display of international 
coordination for health, conducted simultaneous NID's in which 165 
million children were vaccinated in each round. India's new National 
Polio Surveillance Project works with a national laboratory network and 
has greatly improved India's surveillance during the past 12 months. 
More than 100 persons have been hired whose main job is to find polio 
virus wherever it may be to guide further eradication efforts. Current 
efforts to eradicate polio involve continuing polio NIDs, improving 
polio surveillance, and strengthening routine immunization programs.
    The fight against polio is taking place in some of the most 
difficult locations, including those in the countries of Sudan, and 
Somalia. Despite the challenges of war, famine, extremes of weather, 
and a lack of roads or other infrastructure, polio immunization days 
were implemented in Southern Sudan from February through April of this 
year. New strategies to deliver the vaccine were developed including a 
unique process that uses vaccine temperature monitors to ensure the 
potency of polio vaccine in the absence of refrigerators. Small 
aircraft were rented to bring personnel, educational materials, and 
polio vaccine to the most remote areas.
    Only last month, polio immunization days were conducted in Southern 
Somalia. Somalia health workers and volunteers, under the leadership of 
experts from WHO, United Nations Children's Fund (UNICEF), and CDC, 
successfully vaccinated more than 1 million children, many of whom had 
not received any health services for more than 8 years.
Partnerships to eradicate polio by the year 2000
    Collaboration among Rotary International, WHO, UNICEF, USAID, the 
Task Force for Child Survival and Development, CDC, and the governments 
of Australia, Denmark, Japan, the United Kingdom, and other countries 
has been unique among public health initiatives for the unprecedented 
level of cooperation, the magnitude of private-sector contributions and 
the amount of funds raised. It is estimated that Rotary International 
will have contributed hundreds of millions of dollars by the end of the 
polio eradication initiative. Rotary International's contribution is 
the largest private contribution to a public health initiative in 
    A further example of the outstanding partnerships that are 
operating in this highly successful initiative is the joint effort 
required for NIDs in Afghanistan. Vaccine was transported by donkeys 
that carry loads of polio vaccine, packed to keep it cold, along 
mountainous terrain to remote vaccination stations. Under the direction 
of WHO, the vaccine was provided with CDC and Rotary International 
funds, procured and shipped to Afghanistan by UNICEF, prepared for 
distribution within the country using an action plan developed by WHO, 
UNICEF, and Afghanistan national staff of the Ministry of Health, and 
transported to its final destination within Afghanistan by Afghans 
using whatever local transportation was available. (Attachment IV)
Challenges for the final days of polio eradication
    Although polio eradication remains feasible by the year 2000, 
``business as usual'' will not get the job done. While all of the 
partner organizations involved in the effort are impressed with the 
tremendous progress which has been made, the program is at a critical 
stage with just over two years remaining before the end of the target 
year 2000 and much work remains to be done. It is critical to achieve 
eradication as close as possible to the target date, because: (1) the 
longer that it takes to complete the global effort, the longer that 
NIDs and other resource-intensive polio eradication activities will 
continue to be required in those countries which are already polio-
free; (2) there is potential for fatigue in eradication efforts in 
those areas that have already been successful, thereby jeopardizing the 
entire eradication initiative. The partner organizations participating 
in the eradication initiative are convinced that the established 
strategies, when fully implemented, will achieve eradication.
    While the vast majority of the costs of polio eradication is borne 
by the polio-endemic countries themselves, enhanced leadership and 
continued support from the major partner organizations and governments 
of the industrialized countries will be crucial at this critical phase 
for successful completion of the eradication program on schedule. About 
$170 million has been committed by partners in 1998.
    During the next 2 years, the global polio eradication activities 
will intensify to reach the needed peak of effort. However, global 
shortfalls will increase in the years 1999 and 2000 without greater 
commitment of resources on the part of the partner organizations and 
governments. WHO estimates that the 1999 global shortfall is $131 
million, and the year 2000 global shortfall is $116 million. These 
global shortfalls are due both to the lack of financial commitment by 
partners beyond a 1-year period, and a real shortfall of expected 
funds. Similar to the smallpox eradication campaign, the provision of 
adequate resources is important for finalizing efforts. Since the final 
stages of eradication efforts are often the most difficult and resource 
intensive, the year 2000 goals can only be met if adequate and timely 
partner commitments of the needed resources are made.
    Despite the extraordinary progress towards polio eradication, 
progress in Africa has not kept pace with progress in other regions. 
Rapid and complete implementation of the recommended polio eradication 
strategies is urgently needed. Completion of special initiatives in 
war-torn areas such as the Democratic Republic of Congo, Liberia, and 
Sierra Leone is essential to bringing the polio eradication program to 
a successful and timely conclusion. Additional funding from donor 
organizations and governments will also be required to support polio 
eradication activities in Africa.
    Recent events that have threatened eradication of polio by the year 
2000 include the tragic loss of life caused by the bombing of the U.S. 
Embassy in Nairobi, Kenya. NIDs in Kenya were postponed by one week 
nationwide and for one month in Nairobi. In subsequent developments, 
the CDC epidemiologist in Pakistan had to be evacuated last month. 
Necessary travel restrictions on U.S. Government employees traveling to 
some African countries will increase the difficulty of placing staff in 
long- and short-term positions there. Also, the eruption of civil war 
again in Democratic Republic of Congo suspended NIDs scheduled for 
August and September. It is important to remember, however, that 
smallpox eradication was achieved in Africa in 1977 despite similar 
    The legacy of polio eradication will not only be the prevention of 
millions of cases of paralysis, permanent disability, and deaths, but 
also a victory for global public health, with the demonstration that 
diverse groups throughout the world can work together toward a common 
goal. The successful conclusion of this initiative will have 
substantial implications for other public health initiatives, the 
strengthening of national health services and the credibility of 
national and international organizations. Stopping polio vaccination 
alone will save approximately $1.5 billion annually on a global basis 
in perpetuity. The polio eradication program will leave stronger 
immunization programs worldwide, improved capacity for disease 
surveillance, a functioning global laboratory network, and the momentum 
to tackle other major pubic health problems, including measles.
                 global measles control and elimination
Progress toward measles elimination
    Despite the availability of a highly effective vaccine, measles 
causes one million deaths annually and accounts for more child deaths 
than any other vaccine-preventable disease. (Attachment V) One out of 
every 10 deaths in children less than 5 years old is caused by measles, 
a preventable disease. Virtually all cases of measles in children in 
the United States are now the direct or indirect result of measles 
imported from Europe, Asia, or Africa.
    Global measles eradication would result in significant economic 
benefits for the United States. CDC estimates that more than $50 
million annually in measles vaccine costs alone would be saved in the 
United States following a successful measles elimination initiative and 
termination of measles immunization. Additional savings would accrue 
from the prevention of hospitalizations and medical costs if future 
measles epidemics in the United States were eliminated. For example, 
hospitalization and other medical costs exceeded $100 million during 
the measles resurgence in the United States during the period 1989-91.
    Although there is not yet consensus for a global measles 
eradication initiative, the Department fully supports regional measles 
elimination goals and accelerated measles control as a step toward a 
global initiative. If regional measles elimination goals continue to be 
successful, we hope that a global measles initiative will be launched 
as the polio eradication program comes to a successful conclusion.
    A tremendous amount of progress toward establishing a global 
measles initiative has already occurred. In 1994, the Pan American 
Sanitary Conference endorsed the goal of measles elimination in the 
Western Hemisphere by the year 2000. Implementation of an immunization 
strategy combining high routine coverage with at least one dose of 
measles vaccine and periodic mass campaigns vaccinating all children in 
target age groups regardless of prior receipt of measles vaccine, has 
led to a greater than 90-percent reduction of measles cases in the 
Western hemisphere from 1990 to 1997. (Attachment VI) For more than a 
year, measles transmission has been interrupted in Mexico, the 
Caribbean, all countries of Central America, and some in South America, 
including Colombia, Chile, and Peru. The importation of measles into 
the United States from countries in Latin America has virtually 
    In addition to the ongoing measles initiative in the Americas, 
other WHO regions are taking action. The Eastern Mediterranean Region 
of the WHO has established a regional measles elimination initiative. 
Countries in this region that have already conducted mass vaccination 
campaigns designed to interrupt measles transmission include: Oman, 
Kuwait, Jordan and Bahrain. Saudi Arabia, Syria, Tunisia, Qatar and the 
United Arab Emirates are planning similar activities in 1998-1999. In 
addition, the European Region of WHO is considering adopting a regional 
measles elimination initiative. England and Wales conducted a highly 
successful mass vaccination of school-aged children in 1994 which has 
resulted in elimination of indigenous measles. Romania experienced the 
largest measles outbreak in Europe in 1997 and is planning a mass 
vaccination campaign among school-aged children, starting in October 
1998. Other countries that have established national measles 
elimination initiatives include Australia, New Zealand, South Africa 
and several other southern African countries.
    The partnerships that will be required to accelerate measles 
control and achieve the eventual goal of measles eradication are being 
developed using the polio eradication model. Strong relationships are 
being developed among CDC, WHO, UNICEF, USAID, the International 
Federation of the Red Cross and Red Crescent Societies, and the 
American Red Cross.
    Many experts have concluded that global measles eradication is 
biologically feasible. However, the eradication of measles will be a 
more difficult challenge than either polio or smallpox eradication. The 
highly infectious nature of the measles virus and the complex 
logistical and operational requirements of conducting mass immunization 
campaigns using an injectable vaccine (rather than an orally 
administered vaccine as with polio), and ensuring safety of injections 
in developing countries, make this a unique challenge. Another major 
challenge will be harnessing the political will globally to move 
forward. This is particularly relevant for many developed countries in 
Western Europe and Asia that have not accepted measles as a serious 
health burden and thus have not made prevention of measles a high 
    Refinement of the technical strategies (e.g., vaccination, 
surveillance) for measles eradication may also be needed. Although we 
have achieved a tremendous amount of success with measles prevention 
and control, outbreaks still occur. In 1997, a measles outbreak in 
Brazil affected more than 20,000 individuals, primarily young adults. 
Investigations are ongoing to determine the reasons for the outbreak 
and what additional prevention strategies may be required for adults.
    Despite the importance of measles as a public health problem in the 
United States and worldwide, it is critical that the global public 
health community focus on finishing polio eradication before embarking 
on a more difficult and expensive measles eradication initiative. As we 
continue our efforts to eradicate polio by the year 2000, we are 
carefully considering how we can best achieve global measles 
eradication. The major challenges to measles eradication include: (1) 
developing the political and financial commitment within countries and 
regions, and at the global level to strive for measles eradication; (2) 
developing the technology and logistics to safely deliver measles 
vaccine in mass vaccination campaigns; (3) building consensus in the 
clinical and public health communities that the time is right for a 
measles eradication initiative; and (4) finalizing a timetable for 
measles eradication that is synchronized with polio eradication 
    The public health, financial and humanitarian benefits of 
eradication programs offer a compelling rationale for continued U.S. 
Government support of such initiatives. The smallpox eradication 
program and the ongoing polio eradication initiative best document that 
these potential benefits can be realized. However, for polio 
eradication it should again be stated that ``business as usual'' will 
not get the job done. Efforts must be extended to ensure success. While 
recognizing that appropriate caution is needed, the United States must 
also be willing to be ambitious and farsighted, even when some 
questions remain unanswered. Simply stated, the eradication of polio 
would be a remarkable gift to the children of the 21st Century.
                       NONDEPARTMENTAL WITNESSES

    Senator Bumpers. Dr. Samba, let me just say we are most 
honored to have you here. As I said, Betty talked more about 
you when she got home than she did about what she was doing 
over there. [Laughter.]
    She was immunizing children, but she did not know what she 
was doing. She was scared she was going to overdose some of 
them, and the doctors assured that was not possible.
    In any event, thank you very much for being with us. Please 
    Dr. Samba. Thank you very much, Senator Bumpers.
    For me this is an inspiration, again coming this morning. 
My colleagues behind me said, have you been here before? I 
said, yes, I have been here many times when I was director of 
the River Blindness Control Program. We used to come here to 
solicit your support, which we got. You were lead supporters 
and I am very pleased to tell you, sir, that we have won that 
battle. Nobody--nobody--risks being blind of that disease in 
west Africa today, thanks to you, thanks to your continued 
    Senator Bumpers. Dr. Samba, if I may interrupt you, this 
would be a very good time--and I know Dr. Foege will 
wholeheartedly agree. Jimmy Carter, the President of the United 
States, as you remember, from 1976 through 1980, deserves an 
awful lot of credit for the success of that program. I 
appreciate very much your mentioning it. Most people do not 
understand what river blindness is.
    Dr. Samba. That is right. Indeed, when I took over the 
regional office of the World Health Organization in 1995, we 
were looking for another challenge. Too many challenges in 
Africa, but a challenge that we can win. And we looked at the 
example of the United States and the Western Hemisphere, and we 
said the World Health Organization has declared that polio 
should and could be eradicated, but Africa was way behind.
    We took up the challenge. We appealed to our partners, 
Rotary, the United States, including CDC-Atlanta, and I went 
around to some donors. And it is amazing how many of them said, 
is the United States involved? And we said, yes. So, they 
joined in. The United Kingdom, Germany, and many others.

                       World health organization

    And today, since we started in January 1995, of the 46 
African countries in the World Health Organization that did not 
have any polio eradication campaign, today 36 have had a 
national immunization day, even Angola where there has been 
civil war raging for years. We managed to convince the 
belligerents to lay down their arms and participate in the 
national immunization days against polio, and we succeeded in 
vaccinating over 90 percent of the targeted children.
    As you have heard, sir, as Dr. Satcher has heard, we can 
win but until we cross the finishing line--and in Africa the 
finishing line is very tough indeed. No roads, no boats. 
Sometimes we have to wear life jackets and wade our way through 
hazardous rivers, avoiding crocodiles to cross over to 
vaccinate all the children. But we know this is worth it 
because, as Dr. Satcher said, we have been able to put down in 
place mechanisms that can lead us to fight other battles in 
Africa. And there are so many.
    Recently Dr. Satcher, when he was Director of CDC, came to 
my office in Brazzaville and we crossed over the Congo River to 
Kinshasa to celebrate our defeat of ebola. I came here to this 
house to thank the United States Government and to inform my 
friends in the United States what we have done in protecting 
them from ebola because ebola killed 70 percent of Africans. I 
said, no disease will wipe out all Africans. Because we have 
lived with them, some of us have immunity, but here in the 
United States, you eat sterile food, your water is clean and 
potable, even your source in preparing them are sterilized. Any 
disease that can wipe out 70 percent of Africans will probably 
wipe out 100 percent of Americans. And from the area where 
ebola was in Kitwe to Kinshasa, a few hundred miles, and there 
are daily flights from Kinshasa to Paris, to Zurich, and 
between Zurich and the United States in a matter of hours.

                    Winning the battle against polio

    So, together we are convinced that we can win the battle 
against polio, and unless the last bastion of polio in Africa 
is eliminated, the whole world is at risk. So, we are here in 
this partnership, a noble partnership, led by the United States 
of America. This is why I am here today. I arrived a few days 
ago. I will be leaving tomorrow.
    We come to follow, to salute you. Mrs. Bumpers was in 
Africa a few months ago in my office, and she inspired us. I 
said to her, we are going to return the compliment. We are 
going to visit you and thank you and thank your husband, and 
through Mr. and Mrs. Bumpers, thank the population of the 
United States for helping us together eradicate polio, which is 
doable. We can win. We are convinced, but it is going to be 
very difficult. It is going to cost a bit more.
    After polio, already in southern Africa in some parts of 
Africa where polio has not been reported for the past 5 years, 
measles has come to replace polio in our eradication campaign. 
Similar principles, very slight modifications, dedicated, 
committed collaborators, sufficient resources, good will, and 
your support. We will win. We can win. We are going to win.

                           prepared statement

    The objective of my mission here today therefore is to 
thank you for the support you have always given Africa, for the 
support you continue to give. Senator Bumpers, Dr. Satcher said 
you are going to be missed. All the world will miss you. We 
hope and pray, when you retire from the Senate, you will be 
invigorated and you will have so much reserve energy, we invite 
you to Africa to collaborate with us to continue our battle 
against disease, suffering for the whole of humanity.
    Thank you, sir, for this privilege.
    [The statement follows:]

               Prepared Statement of Dr. Ebrahim M. Samba

 polio eradication and measles control/elimination initiatives in the 
                           who african region
    Mr. Chairman and distinguished Senators, the World Health 
Organization [WHO] and its Regional Office for Africa appreciate the 
opportunity to brief the Subcommittee on the initiatives to eradicate 
polio and to control measles in the African Region. This statement 
describes the progress and challenges to date, particularly in the 
areas of polio vaccination, surveillance for acute flaccid paralysis 
(AFP), and mobilization of funding, resources, and partnerships to 
support the Polio Eradication Initiative in the African Region.
                           polio eradication
Situation analysis
    Throughout the 1980's, 4,000 to 5,000 clinical cases of 
poliomyelitis were reported annually in the WHO African Region.\1\ 
Experience in the field showed that this figure reflected severe under-
reporting, representing perhaps only 10 percent of all cases that 
occurred in reality. The annual number of reported cases fell to 1,500 
to 2,000 during the first half of the 1990's, presumably as a result of 
the increasing impact of routine vaccination activities. This number 
represented almost one-half of all polio cases reported in the world. 
In 1997, only 883 clinical cases of polio were reported through the 
routine reporting systems in Member States in the African Region.
    \1\ The WHO African Region consists of forty-six WHO Member States: 
Algeria, Angola, Benin, Botswana, Burkina Faso, Burundi, Cameroon, Cape 
Verde, Central African Republic, Chad, Comoros, Congo, Cote d'Ivoire, 
Democratic Republic of the Congo, Equatorial Guinea, Eritrea, Ethiopia, 
Gabon, Gambia, Ghana, Guinea, Guinea-Bissau, Kenya, Lesotho, Liberia, 
Madagascar, Malawi, Mali, Mauritania, Mauritius, Mozambique, Namibia, 
Niger, Nigeria, Rwanda, Sao Tome and Principe, Senegal, Seychelles, 
Sierra Leone, South Africa, Swaziland, Togo, Uganda, United Republic of 
Tanzania, Zambia, and Zimbabwe.
    For programmatic purposes, the WHO African Region was divided into 
four epidemiological blocks--Central, Eastern, Southern and Western--to 
ensure that eradication activities could be tailored to the specific 
needs of groups of countries. In addition, a separate, fifth 
epidemiological block was formed by four large countries, each of which 
has suffered difficult circumstances in recent years: Angola, DR Congo, 
Ethiopia and Nigeria. These four countries represent major reservoirs 
of wild polioviruses in the African Region and are believed to spread 
polio to neighbouring countries.
    In order to achieve polio eradication, countries in the African 
Region have adopted and continue to implement four major strategies 
recommended by WHO: (1) achieving and sustaining high routine 
vaccination coverage with oral polio vaccine (OPV); (2) implementing 
mass vaccination campaigns, known as National Immunization Days (NIDs); 
(3) establishing effective surveillance of suspected polio cases (that 
is, surveillance of all cases of acute flaccid (floppy) paralysis 
(AFP)); and (4) carrying out mopping-up activities as indicated by 
surveillance data.
    Tremendous progress has been made to date in the Eastern and 
Southern African epidemiological blocks. Supplemental vaccination 
through National Immunization Days (NIDs) conducted in all countries of 
these two blocks appear to have had a significant impact on the 
circulation of ``wild'' polioviruses. NIDs aim to cover a high 
proportion of the under-5 child population of a given area with two 
doses of oral polio vaccine about a month apart. Despite increasingly 
sensitive surveillance based upon the clinical, epidemiological and 
virological investigation of AFP cases, wild polioviruses (that is, 
those which are not associated with the vaccine) have not been isolated 
in continental Southern Africa since 1995. A similar picture has 
emerged in Eastern Africa since 1997.
    Wild polioviruses continue to circulate in Central and Western 
Africa and the four large countries. The fact that polioviruses were 
detected after one or even two series of NIDs in some of these 
countries indicates that polio-free status will be more difficult to 
achieve in those areas.
Routine vaccination
    Routine vaccination coverage with three doses of oral polio vaccine 
(OPV3) among infants under 1 year of age reached 54 percent in the WHO 
African Region in 1997. This represented no increase as compared with 
the previous year. Coverage rates varied considerably by 
epidemiological block in 1997: 39 percent for Central Africa, 59 
percent for Eastern Africa, 74 percent for Southern Africa, 57 percent 
for Western Africa, and 45 percent for the four large countries in 
difficult circumstances. Factors which limit the achievement of high 
routine vaccination coverage in certain countries include poor access 
to health services, high drop-out rates, occasional shortages of 
vaccine and deficiencies in the refrigerated transport or cold chain 
system including fuel and power shortages and lack of transport.
    Although supplemental vaccination through NIDs is critical for the 
eradication of poliomyelitis, doses supplied through NIDs do not 
replace routine vaccination of infants with OPV. Therefore, the 
importance of educating and mobilizing communities to bring their 
infants to health facilities, outreach clinics and mobile units for 
routine vaccination has been strongly emphasized.
    It is widely recognized that routine vaccination benefits 
substantially from the implementation of NIDs. NIDs have increased 
political commitment and support for the whole Expanded Program on 
Immunization (EPI) from country-based and external partners. Additional 
resources become available which benefit EPI in general and may be used 
for strengthening planning and managerial capacities of health staff, 
and provision of additional equipment such as refrigerators and cold 
boxes. NIDs provide excellent opportunities for advocacy, social 
mobilization and increasing community awareness about target diseases 
and the benefits of immunization. Furthermore, it has been observed in 
many countries, for example Angola, that the success of NIDs increases 
the morale of health workers, especially where routine vaccination 
coverage was poor.
National immunization days
    The first series of National Immunization Days (NIDs), the biggest 
ever conducted in Africa, was implemented in 31 countries of the 
African Region in 1996 early 1997. Over 74 million children below five 
years of age were targeted. More than 55 million (74 percent) children 
received OPV in the first round and about 60 million (80 percent) in 
the second round of NIDs. The majority of countries achieved remarkable 
results in vaccinating their target population with OPV: 26 countries 
(84 percent of the 31 countries that participated) had 80 percent or 
greater coverage in at least one round and 20 (65 percent) achieved 80 
percent or greater coverage in both rounds.
    The second series of NIDs involved 36 countries between March 1997 
and March 1998. These were the first NIDs for seven countries: Burundi, 
Guinea, Guinea-Bissau, Madagascar, Mali, Niger and Senegal. Two 
supplemental OPV doses were received by 85 million children under age 
five. Immunization coverage was reported at 80 percent or greater for 
both NID rounds except in the Central African Republic (77 percent and 
82 percent), Equatorial Guinea (76 percent and 99 percent), Kenya (79 
percent and 82 percent), Lesotho (67 percent and 65 percent), 
Mozambique (65 percent and 75 percent), Nigeria (72 percent and 95 
percent), Rwanda (73 percent and 75 percent) and South Africa (81 
percent and 76 percent). It is hoped that the three countries which 
have yet to conduct nation-wide NIDs--DR Congo, Liberia and Sierra 
Leone--will do so in 1998. Those countries in West Africa where wild 
polioviruses have reappeared since the first series of NIDs will 
require four rounds of OPV (2 rounds of NIDs, 2 rounds of house-to-
house ``mopping-up'') if the goal is to be achieved by the year 2000.
    NIDs reached over 80 percent of children under five years of age in 
a number of countries where less than 50 percent of infants had 
previously received routine OPV3, such as Angola, Burkina Faso, 
Cameroon, Central African Republic, Chad, Mauritania and Niger.
    Particularly noteworthy is the success achieved in Angola. This 
country immunized 71 percent and 80 percent of its target population in 
the first and second rounds in 1996 and 83 percent and 90 percent in 
1997, respectively. This is especially remarkable since routine 
coverage in Angola was below 40 percent. NIDs resulted in increased 
collaboration between all national and international partners. 
Initiated by the Government, this important initiative has also 
involved UNITA, WHO, Rotary, UNICEF, UN Peacekeeping Forces and the 
private sector. It was the first time that the Government and UNITA 
worked together to improve health of their young compatriots. The 
challenge now is to extend EPI in general and NIDs in particular into 
those districts which remain inaccessible due to security problems.
    Furthermore, a number of countries have utilized the opportunity to 
include with OPV during NIDs the administration of other vaccines or 
health interventions, for example, measles vaccine and vitamin A 
supplementation. Although the inclusion of an injectable vaccine like 
measles vaccine adds technical and logistical complexity to the 
operation, the additional cost of including measles vaccine is less 
than that of a separate measles vaccination campaign.
    Although this support from external and country-based international 
agencies and NGOs was important, the remarkable success of NIDs was 
mainly achieved due to high-level political commitment, technical 
competence and experience of national health authorities and health 
staff, through the effective planning and coordination of activities. 
The implementation of NIDs demonstrated the tremendous potential of the 
health sector and communities to undertake joint activities, and 
effective coordination between governments, external and country-based 
partners. NIDs resulted in remarkable strengthening of inter-sectoral 
and inter-agency coordination and cooperation, and boosted the 
revitalization or formation of national EPI inter-agency coordination 
Disease surveillance
    The major task of countries implementing polio eradication 
activities is to prove that the circulation of wild polioviruses, whose 
presence in stool specimens of patients with AFP is considered 
definitive proof of confirmed polio, has been interrupted. This only 
can be done if all AFP cases are promptly detected, reported and 
investigated, and if adequate stool specimens are properly collected 
and shipped to a laboratory where they can be reliably cultured for 
    The WHO African Regional Polio Laboratory Network currently 
comprises three regional reference laboratories in Central African 
Republic, Ghana, and South Africa and ten national and inter-country 
laboratories. A further two national laboratories (Ethiopia and 
Maidugari/Nigeria) are in the process of being certified. National 
laboratories process stool specimens and identify serotypes from AFP 
cases, and regional reference laboratories confirm the identity of 
polioviruses isolated by national laboratories and determine whether 
the viruses are wild or vaccine-derived.
    In 1997, all but twelve countries of the African Region (Angola, 
Burundi, Congo Gabon, Equatorial Guinea, Eritrea, Liberia, Mali, 
Mauritania, Mozambique, Rwanda and Sierra Leone) submitted specimens to 
the regional polio network laboratories. All stool specimens collected 
from AFP cases in Eastern and Southern African countries in 1997 were 
laboratory negative for wild poliovirus.
    In 1997 and 1998, wild polioviruses were, however, isolated from 
specimens collected in DR Congo and a number of countries mainly 
situated in Central and Western Africa, including countries which had 
conducted NIDs (Angola, Benin, Burkina Faso, Central African Republic, 
Chad, Cote d'Ivoire, Ghana, Nigeria and Senegal). Partial genomic 
sequencing shows that many wild poliovirus isolates from countries 
surrounding the DR Congo originate in the DR Congo.
    The performance of AFP surveillance in many countries of the 
African Region, although it has markedly improved, still remains 
inadequate for the purposes of official certification of polio-free 
status. National surveillance systems need to be further strengthened 
to increase their reliability and effectiveness. One critical task is 
to sensitize medical professionals to the polio eradication initiative 
and its proven strategies, in order to help them understand the need to 
report and investigate AFP cases whose final diagnosis may eventually 
be other than poliomyelitis.
    The establishment of a system for AFP surveillance in Africa has 
laid the foundation for the development of integrated infectious 
disease surveillance throughout the continent. The provision of 
resources including staff, transport and communications tools will 
facilitate the inclusion of surveillance of other priority or epidemic 
diseases such as measles, cholera, dysentery, meningitis and 
haemorrhagic fevers.
    During 1996 and 1997, over US$65 million were provided by Rotary 
International, USAID, the U.S. Centers for Disease Control and 
Prevention (CDC), the Government of Japan, vaccine manufacturers and 
other partners for implementation of the two series of NIDs and disease 
surveillance in the African Region. The United States of America is 
playing a significant role in supporting the Polio Eradication 
Initiative in the African Region. In 1996-97, the U.S. Government not 
only disbursed US$34.5 million--that is, over half of all external 
funds for NIDs and surveillance of EPI target diseases--through USAID 
and CDC but also provided consultants to assist countries in planning 
and implementation of these activities. This important external 
financial support acted as a catalyst for national political and 
financial commitments, and stimulated preparations for NIDs, local fund 
raising, and resource mobilization in the majority of countries.
    The cost of NIDs was estimated from a study conducted in Southern 
Africa at approximately US$0.50 to 0.60 per child vaccinated with two 
OPV rounds. However, the actual NIDs cost may be slightly higher, since 
infrastructure, staff, funds and in-kind contributions were provided by 
national governments, country-based international agencies, 
nongovernmental organizations (NGOs) and other partners, including the 
private sector and local communities.
    Funding requirements for polio eradication activities in the WHO 
African Region during 1999-2001 are summarized in Annex 1.
Political commitment, advocacy and social mobilization
    In July 1996, African Heads of State and Government at the Thirty-
Second Ordinary Session of the OAU Summit in Yaounde, adopted a 
Declaration on Polio Eradication in Africa. This declaration urges all 
Member States to take immediate and concrete steps to urgently address 
the problem of poliomyelitis and give their full political support to 
polio eradication as a matter of top priority. The African leaders 
confirmed their strong determination to make Africa free of polio and 
committed themselves to fully support the implementation of the polio 
eradication strategies recommended by the World Health Organization. 
The Declaration states that adequate human, financial and material 
resources, both local and external, be mobilized to support polio 
eradication activities in Africa.
    The Yaounde Declaration on Polio Eradication in Africa was 
instrumental in obtaining the highest-level political commitment and 
support for the Polio Eradication Initiatives in the African Region.
    A ``Committee for a Polio-Free Africa'', chaired by President 
Nelson Mandela and with high-level representation from around the 
continent, was created to strengthen political advocacy and social 
mobilization for polio eradication, and met for the first time in South 
Africa in August 1996.
    A region-wide ``Kick Polio out of Africa'' campaign was launched in 
August 1996 in South Africa by President Mandela with participation of 
the Members of the ``Committee for a Polio-Free Africa'' (the First 
Ladies of Congo, Ghana and Nigeria, General Toumane Toure, former 
President of Mali, and senior officials representing Rotary 
International, WHO, OAU, UNICEF and USAID) at the first meeting of the 
    NIDs were especially successful in countries where this political 
commitment was attained. The role of Heads of State and Government and 
First Ladies was critical in ensuring that NIDs receive necessary 
attention and support, not only from external international and donor 
agencies and organizations but, most importantly, from various 
governmental sectors, as well as country-based agencies, non-
governmental organizations (NGOs) , the private sector and communities 
themselves. In many countries, Heads of State and Government 
demonstrated their support for NIDs by addressing the nation through 
the mass media and by participation in launching ceremonies. In a 
number of countries First Ladies served as patrons for the NIDs and 
other polio eradication activities.
    The three First Lady Members of the ``Committee for a Polio-Free 
Africa'' have remained very active in advocacy and social mobilization 
activities in preparation for NIDs in their respective countries. The 
First Lady of Mozambique was also particularly active in the promotion 
of NIDs in that country in 1998.
    The success of NIDs continues to be made possible by the very 
effective social mobilization campaigns carried out by each country, 
with support from the highest-levels political leaders and other 
opinion makers within countries, and advocacy from WHO and other 
partners. To consolidate and share this experience widely, an advisory 
group on social mobilization was established in the WHO African Region 
with the membership of all major partners. The campaign's soccer-linked 
theme in conjunction with its slogan and logo have now become widely 
accepted and powerful tools for advocacy. The advisory group has 
planned and implemented various regional activities such as the 
activities during the Cup of African Nations contest in 1998.
    The challenge is to maintain the interest and commitment for polio 
eradication and to extend it to all EPI activities to ensure that all 
partners play their part and contribute effectively to achieving this 
important goal.
    A strong and effective partnership has been created to support the 
Polio Eradication Initiative in the African Region with the leadership 
of the WHO Regional Office. The major partners are the African 
Governments, World Health Organization, Rotary International, UNICEF, 
USAID, Centers for Disease Control and Prevention in Atlanta (USA), 
Government of Japan, DFID (UK) and CIDA (Canada). The partners 
participate in annual technical conferences of the African Regional 
Task Force on Immunization, which are usually held in conjunction with 
donor meetings of the Regional EPI Inter-Agency Coordination Committee.
    Vaccine manufacturers also donated U.S. $600,000 worth of OPV for 
polio eradication activities in Africa in 1997.
    The Governments of Denmark, Finland, France, Germany and Ireland, 
Rotary Clubs, the National Peace Corps Association (USA), national Red 
Cross organizations, Swiss Development Corporation and private 
companies, such as SmithKline Beecham, Rhone Poulenc, Barclays Bank, 
Johnson & Johnson, Coca Cola and others, were involved in supporting 
polio eradication activities in individual countries.
                      measles control/elimination
    Since the introduction of measles vaccine in Africa, there has been 
an estimated 56 percent reduction in measles cases and an estimated 77 
percent reduction in measles deaths. However, the measles burden in 
Africa remains the highest of any of the six WHO Regions, with an 
estimated 9.2 million cases and 435,000 deaths in 1995. Studies have 
shown that measles case fatality rates of 6 percent and higher continue 
to occur.
    Most of the deaths attributable to measles in Africa occur as a 
result of various complications. It is estimated that approximately 5 
percent to 30 percent of measles cases will have severe measles disease 
and complications. The most common complication is bronchopneumonia, 
followed by dehydration from diarrhea and vomiting. Some of the measles 
cases also become malnourished. As much as half of all childhood 
corneal blindness may result from measles complications in vitamin A 
deficient children. Other complications include skin sepsis, purulent 
conjunctivitis, blindness and otitis media which lead to deafness in a 
small percent of children.
    Routine vaccination coverage with one dose of measles vaccine among 
infants under one year of age remains persistently the lowest of all 
the vaccines in the EPI. In 1997, 16 out of 46 countries in the WHO 
Africa Region, representing 21 percent of the regional population, 
failed to reach 50 percent routine vaccination coverage.
    In accordance with national variations in routine vaccination 
coverage, measles epidemiology and operational and financial 
feasibility, WHO has developed and, in some countries, begun to 
implement three sets of strategies designed specifically for three sets 
of countries, with the following primary objectives: to reduce measles 
mortality to accelerate measles control; or to eliminate measles 
    To achieve these objectives, a careful mix of activities will be 
implemented (see Table 1), including strengthening routine vaccination 
services, supplemental measles vaccination, social mobilization, 
surveillance and evaluation. The additional funds required to carry out 
supplemental vaccination are presented in Annex 2.

   Epidemiological characteristics           Geographic areas                    Proposed strategies
Low routine coverage (<50 percent),    West Africa and Central       Reduction of measles deaths:
 presumed high number of deaths (Case   Africa, Angola, DR Congo,       Achieve higher routine coverage with
 Fatality Rate >4 percent).             Ethiopia, Nigeria.               measles vaccine;
                                                                        Reduce measles deaths through measles
                                                                         campaigns in urban, densely populated
                                                                         rural areas and other high-risk areas
                                                                         (target age group: children below 5
                                                                         years of age);
                                                                        Conduct periodic measles campaigns in
                                                                         high risk areas with 2-3 year
                                                                        Collect aggregated surveillance data.
Medium routine coverage (50-75         East Africa, Algeria,         Accelerated measles control:
 percent), presumed low-medium number   Madagascar, Mauritania,         Achieve higher routine coverage with
 of deaths (Case Fatality Rate 0.5-4    Mozambique.                      measles vaccine;
 percent).                                                              Further reduce measles cases and deaths
                                                                         through campaigns in high-risk areas
                                                                         (target age group: children below 5 yrs
                                                                         of age);
                                                                        Conduct periodic measles campaigns in
                                                                         high risk areas (frequency of campaigns
                                                                         and target age group to be determined
                                                                         by surveillance data);
                                                                        Establish sentinel collection of case-
                                                                         based data.
High routine coverage (>75 percent),   Southern Africa.............  Measles elimination:
 presumed low number of deaths (Case                                    Increase and sustain routine coverage
 Fatality Rate <0.5 percent).                                            with measles vaccine to above 90
                                                                        Conduct ``catch-up'' measles campaigns
                                                                         among children below 15 years of age;
                                                                        Conduct periodic ``follow-up''
                                                                         campaigns; and
                                                                        Case-based surveillance including
                                                                         laboratory investigation of cases.

    Less than 1,000 days remain to achieve the goal of polio 
eradication by the end of the year 2000, as established by the Member 
States of the World Health Organization in 1988, and endorsed by the 
World Summit for Children in 1990.
    In view of current trends, it appears that the polio eradication 
goal is achievable in Africa. Marked progress is reported from Eastern 
Africa, and there is justifiable confidence that Southern Africa is 
close to being confirmed as polio-free. However, despite the remarkable 
progress achieved, there is an urgent need to improve surveillance in 
order to document the progress achieved to date. To accomplish the goal 
by the target date, implementation of polio eradication strategies must 
be accelerated, in particular, by establishing effective disease 
surveillance systems. Financial and political support from all partners 
for polio eradication in the African Region is particularly important 
right now, in light of the success to date and the remaining challenges 
to reaching the regional and global goals of polio eradication.
    The eradication of poliomyelitis will not only prevent our children 
from becoming crippled for life and reduce human suffering caused by 
this terrible disease in Africa. It will also save an estimated US $1.5 
billion per year worldwide, currently spent on immunization, 
surveillance and rehabilitation of patients. After eradication, these 
resources could be reprogrammed to address other emerging health 
problems in Africa.
    Measles remains significant among the major causes of childhood 
morbidity and mortality in Africa. The lessons learned from the Polio 
Eradication Initiative in the African Region will serve as critical 
experience for the next vaccine-preventable disease control step. 
Measles control and elimination in the African Region will require 
further coordination of efforts and resources from all partners.

                                                 [U.S. dollars]
                           Budget line                                 1999            2000            2001
OPV for NID's...................................................      20,817,000      17,107,000       6,946,000
NID's operational costs.........................................      40,878,000      36,165,000      13,764,000
Mopping-up activities...........................................      19,875,000      19,875,000      19,875,000
Disease surveillance............................................       8,395,000       8,582,000       8,960,000
Laboratory activities...........................................         810,000         664,000         739,000
Certification activities........................................         102,000         140,000         175,000
Personnel (including duty travel and support)...................       9,067,000       8,880,000       9,324,000
Regional office/inter-country activities........................         650,000         683,000         716,000
      Subtotal..................................................     100,594,000      92,096,000      60,499,000
PSC.............................................................       6,608,000       6,010,000       3,166,000
      Total.....................................................     107,202,000      98,106,000      63,665,000
      Grand total: U.S. dollars.................................     268,973,000  ..............  ..............

                                                 [U.S. dollars]
            Budget line                 1999         2000         2001         2002         2003        Total
Costs of vaccine and injection        1,674,993    6,209,330    5,511,090    8,763,394    8,063,125   30,221,932
 equipment for supplemental
Operational costs of supplemental     1,486,680    5,511,240    4,891,500    7,778,160    7,156,620   26,824,200
Costs of injection safety and           495,560    1,837,080    1,630,500    2,592,720    2,385,540    8,941,400
      Subtotal: Supplemental          3,657,233    13,557,65   12,033,090   19,134,274   17,605,285   65,987,532
PSC................................     475,440    1,762,495    1,564,302    2,487,456    2,288,687    8,578,380
      Total........................   4,132,673   15,320,145   13,597,392   21,621,730   19,893,972   74,565,912
\1\ Supplemental immunization.

            Human and natural resources to sustain everybody

    Senator Bumpers. Thank you very much, Dr. Samba, and thank 
you very much for your kind words. It was a very powerful, 
wonderful statement. I regret that 99 other Senators could not 
have heard your testimony this morning. [Laughter.]
    You know, there is not anything wrong with this country. 
Indeed, there is not anything wrong with the world. We have the 
assets and we have the human and natural resources to sustain 
everybody in relative prosperity, but we simply miscue our 
priorities and squander so much on misspent priorities. And you 
have set that out with a great deal of specificity and very 
    Again, I thank you very much for being with us.
    Dr. Satcher. Senator Bumpers.
    Senator Bumpers. Yes.
    Dr. Satcher. Please allow me to apologize for having to 
leave. As I said, the Pan American Health Organization is 
meeting, and I have just been paged and told that we are 
getting ready for a very important vote.
    Senator Bumpers. That is quite all right.
    Dr. Satcher. I am part of the U.S. delegation.
    I am delighted to have been able to be here and to testify 
in front of you once again about this very important issue and 
to join my outstanding colleagues here. I am sure they can 
answer any questions that you have. Thank you.
    Senator Bumpers. Well, most of them were directed to you, 
so we will see. [Laughter.]
    Senator Bumpers. Mr. Pigman, once again welcome. Thank you 
in advance for the magnificent job Rotary International has 
done in bringing us really to this happy state. Please proceed.
    Mr. Pigman. Thank you, Senator Bumpers. Rotary 
International would like to thank your subcommittee for 
conducting this hearing. It comes at a critical time in the 
fight against polio. The virus may indeed be on the threshold 
of extinction, but that final threshold is a formidable one, 
and without the needed resources directed on a timely basis, we 
could fail to reach the target in the year 2000.
    I would like the privilege of joining my colleagues here in 
commending you, Senator Bumpers. Throughout your distinguished 
career, you have carried the torch for immunization both here 
and abroad, and speaking on behalf of the 450,000 members of 
Rotary in this country, we could wish for no greater advocate 
of the rights of the children for a healthy start in life. We 
thank you.
    Polio eradication is one of the great public health 
stories, and since that resolution by WHO 10 years ago, a 
global partnership has developed and it includes the private 
sector. The private sector has joined with health ministries 
and their workers in polio endemic countries, and as you have 
seen, the reported incidence of this disease has declined by 90 
percent and now 160 nations are polio-free. Some 4 million 
cases of polio have been prevented in this period, and victory 
holds the promise of $1.5 billion in savings and $230 million 
in this country alone.
    Support for polio eradication by the private sector is 
unprecedented, and I think it is instructive to question why 
this has developed and furthermore what lessons are there for 
the future of such collaboration.
    The polio initiative presents an attractive case to the 
private sector. It is a time-limited goal. It is an achievable 
goal. We have an effective vaccine. We have a proven strategy, 
the promise of future savings and future benefits in the fight 
against other infectious diseases. Health workers in countries 
all over the world soon awakened to the potential of their new 
ally, the private sector, and they identified roles which play 
to the strengths and the interests of the private sector. All 
these I believe are positive factors in the decisions by the 
private sector to get on board on polio eradication, and it has 
been a fruitful marriage.

                           Oral polio vaccine

    Three pharmaceutical firms have donated 100 million doses 
of oral polio vaccine. Another has contributed $1 million to 
support polio virology labs in Africa. Corporations are lending 
advertising know-how to convey the message of immunization. In 
support of national immunization days, they have deployed 
private helicopters, jets, vehicles. They have printed posters, 
provided faxes and fuel, megaphones, and meals, all with the 
aim that the war on polio in their particular country shall not 
fail for the want of a horseshoe nail.
    Rotary, as a service club organization, has helped to tap 
this private sector potential because we ourselves are the 
private sector. We comprise business and professional leaders 
in 159 countries and our 1.2 million members try to lead by 
example. Since the PolioPlus Program began in 1985, Rotary has 
committed $313 million for vaccine, social mobilization, and 
laboratory support in 119 nations. We support a core of 
experts, some of whom are here today, who are leading the polio 
fight at WHO headquarters in Geneva and in regional offices. 
Very recently $5 million has been contributed by cooperating 
clubs to fund polio laboratories in a dozen countries. We will 
invest, as you have said, Senator Bumpers, at least $425 
million in polio by the year 2005 when we celebrate Rotary's 
100th anniversary in a polio-free world.
    This financial support was welcome. It is needed, but of 
even greater value are the millions of hours invested by 
Rotarians and friends and others in volunteer service. They 
constitute an army of workers on the front lines, and in 
stretching out a hand of help to health workers, they help them 
stretch their nation's health dollars. Some 150,000 Rotarians 
and their friends have turned out for each of India's national 
immunization days, and in many countries, members of Rotary 
chair the national and regional interagency coordinating 
committees which help health ministries to plan and execute 
    Rotary also is advocating the benefits of polio eradication 
to the leaders of donor governments, some 30 other governments. 
This effort has helped to produce more than $500 million in 
polio specific grants in the last 5 years, and I am very proud 
to say as a citizen of this country that the United States has 
contributed 40 percent of this total, or $201 million, toward 
polio eradication overseas.
    We wish to commend your subcommittee for the recommended 
increase of $20 million for polio needs in Africa. These funds 
are vitally needed not only for fiscal year 1999, but also for 
the year 2000.
    The task of delivering oral polio vaccine to children faces 
enormous problems in many parts of Africa, as Dr. Samba has 
testified. Civil conflict, poor roads, uncertain communication, 
unpaid health workers, shortages of transportation and 
refrigeration, and a weak but rapidly improving surveillance 
    The good news is that national immunization days against 
polio in Africa have achieved remarkable results despite these 
obstacles. The health workers of these countries need these 
additional resources. Furthermore, they merit the encouragement 
which such special help will bring them. New funds will buy 
needed vaccine, fuel, training, extend surveillance capacity. 
But, moreover, they will trigger new private support. Rotary 
has committed $92 million to the program needs of 47 African 
nations, and that continent continues to have our highest 
    In closing, Senator Bumpers, I would like to emphasize that 
private sector collaboration in the war on polio, for which I 
have provided a few examples, has implications which transcend 
the victory over a single infectious disease. The private 
sector has responded to an appeal by leaders of the public 
health community. They have asked for help in winning a war 
that can be won, a war that can eliminate forever a terrible 

                           prepared statement

    Now we are allied in a mutual testing ground. The goal is 
in sight, and all partners, governments of polio endemic 
nations, donor governments, and the private sector, must stay 
the course and keep the resources flowing. Victory over polio 
will prove to have many lasting benefits, but I believe one of 
the most important benefits may well be that the value of 
childhood immunization will engrave itself on the corporate 
social conscience and nurture the realization that in the long 
run healthy kids are the future of a healthy global economy.
    Thank you for this opportunity to testify, Senator.
    Senator Bumpers. Thank you very much, Mr. Pigman.
    [The statement follows:]

                Prepared Statement of Herbert A. Pigman

    Mr. Chairman, members of the subcommittee, Rotary International 
thanks you for the opportunity to participate in this hearing as a 
representative of the non-governmental, private sector community, a 
sector which has emerged as a key partner in the global effort to raise 
immunization levels among the children of this world.
    We particularly wish to commend Senator Bumpers for his leadership 
in immunization, both here in the United States and in the 
international arena. Early in his distinguished career he recognized 
the value of investing in immunization. He has worked assiduously 
toward this end, with the great support and participation of Mrs. 
Bumpers. Newborns around the world could wish for no greater advocates 
of their right to a healthy start in life.
    I will address in particular one theme of this hearing: the 
importance of public and private sector collaborative efforts in 
achieving the world-wide eradication of polio, and its implications for 
measles eradication and other public health goals. The global program 
to eradicate poliomyelitis provides an outstanding example of how a 
public/private partnership can be forged and sustained, producing 
dramatic results.
    The international team which is attacking this dreaded, crippling 
disease includes among its public sector the World Health Organization, 
UNICEF, the U.S. Centers for Disease Control and Prevention, the U.S. 
Agency for International Development and counterpart agencies in other 
donor nations, and the health ministries and workers in the countries 
where the battle against polio continues. Chief among the private 
sector is Rotary International, the service club organization of over 
1.2 million business and professional leaders in 29,000 communities in 
159 countries.
    Over the past 13 years, this global team--unprecedented in the 
history of public health--has applied innovative strategies to reduce 
the reported cases of polio by 90 percent. The polio virus is on the 
threshold of extinction, and we are surrounding it in its final 
stronghold: sub-Saharan Africa. If adequate financial resources 
continue to flow to this program, there is great optimism that we will 
see the last case of polio by the end of the target year 2000. This 
virus, which once crippled or killed some 600,000 people annually, 
mostly children, will join the smallpox virus as the second to be 
eradicated from the planet. In addition to immeasurable human benefits, 
the world will save at least $1.5 billion every year in the cost of 
vaccine and its administration, when polio immunization is no longer 
needed. There will be lasting benefits in the form of a stronger 
infrastructure for the delivery of vaccines against other infectious 
    The strategy, the successes, and the challenges remaining to the 
global polio eradication campaign have all been reviewed by my 
distinguished colleagues who are testifying today. I would like to take 
this opportunity to point out that Rotary holds these men in great 
esteem, for their vision of a world without polio. Dr. Satcher, Dr. 
Foege and Dr. Samba are all recipients of Rotary's Polio Eradication 
Champion award, for their leadership in the international partnership 
which is making the ``Target 2000'' dream a reality.
    On behalf of Rotary International and the 400,000 American 
Rotarians, I would also like to express our deep gratitude to this 
Subcommittee for its staunch support of the CDC's international polio 
eradication efforts over the past several years. In particular, I would 
like to thank the Subcommittee for the recommended increase of $20 
million for fiscal year 1999. The CDC has accomplished so much with the 
funds you have allocated them to date. This additional appropriation 
will help make it possible to eliminate polio in Africa by the end of 
the year 2000. As may be seen in the appendix to this document, the 
United States' generosity has fueled the rapid progress. US 
appropriations in the last three fiscal years total $201 million, or 40 
percent of the major polio-specific grants of all donor nations. These 
monies have been deployed most effectively by the CDC and USAID, which 
are spearheading America's fight against polio. Few investments are as 
risk-free or can guarantee such an immense return. Rotary greatly 
appreciates your personal leadership and continued support of the CDC's 
program and ``Target 2000.''
                  the polio eradication strategy works
    Polio, like smallpox before it, can be eradicated because humans 
are the only host for the virus. At the 1988 World Health Assembly, the 
nations of the world resolved to see the last case of polio by the end 
of the year 2000, with certification of eradication by the year 2005. 
This is possible because we have a proven strategy. In 1994, the entire 
Western Hemisphere was certified free of polio. Every country which can 
effectively implement WHO's polio eradication strategy can expect to be 
polio-free within three to four years. We must make certain that every 
country is able to do this, because if we fail in any one country, we 
fail world-wide.
    Although polio-free since 1979, the United States currently spends 
at least $230 million annually to protect its newborns against the 
threat of importation of the polio virus. This threat is real. In 1996, 
for example, a polio outbreak in Albania, caused by an imported virus, 
killed and crippled dozens of people and spread to neighboring Greece 
and Yugoslavia. Once polio is eradicated and immunization against it 
can be ceased, America will save this amount every year. Eradicating 
the disease in the 50 countries where it remains clearly benefits the 
American people.
                rotary's role in the global partnership
    Thanks in large measure to United States support, the international 
effort to eradicate polio has made tremendous progress during the past 
year: 160 countries now polio-free; polio apparently gone from the 
Western Pacific, and virtually eliminated in Europe; solid improvements 
in polio surveillance and the global laboratory network; National 
Immunization Days (NIDs) conducted or scheduled in all polio-endemic 
African nations. Rotary is proud to have played a role in these many 
successes. Rotary's contribution to the international effort is 
fourfold: funding, volunteerism, laboratory and surveillance support, 
and advocacy for polio eradication.
    Funding.--When the PolioPlus Program began in 1985, Rotary 
initially intended to raise $120 million to provide oral polio vaccine 
(OPV) for all the newborns in the developing world for a period of five 
years. Rotarians responded with $247 million, more than double the 
original fund-raising goal. Since then, Rotary has committed additional 
resources, and by the year 2005, when we expect to celebrate the 
certification of polio's eradication, Rotary International will have 
expended over $425 million on the effort--the largest private 
contribution to a public health initiative ever. Of this, $313 million 
has already been allocated for polio vaccine, operational costs, 
laboratory surveillance, cold chain, training and social mobilization 
in 119 countries, including $92 million to date for 47 African nations. 
Over the past year, realizing the increased role which external donors 
need to play in order to ensure that polio eradication is not 
jeopardized due to lack of resources, The Rotary Foundation has 
allocated an additional $40 million to its PolioPlus Fund. But Rotary's 
contribution goes beyond the financial.
    Volunteerism.--Around the world, Rotarians and their friends and 
families have contributed millions of hours to polio immunization and 
eradication efforts in their nations and communities. Rotarians are 
active at all levels of the campaign--international, regional, national 
and local. They work together with their national ministries of health, 
UNICEF and WHO, and with health providers at the grass-roots level. 
They help to plan and implement the National Immunization Days, to 
publicize the campaigns, to transport vaccine, to staff immunization 
posts, and to help track children who may have missed the immunization. 
In Angola, for instance, Rotarians helped negotiate a cease-fire in 
order to immunize children, and led a campaign to solicit corporate 
jets, helicopters and vehicles to move vaccine through Angola's land-
mine infested countryside. The Government has been so impressed by 
Rotary's ability to negotiate with the factions and build consensus 
that the President of Angola has approached Angolan Rotarians to 
solicit Rotary's assistance in convening a national peace conference. 
In India, 70,000 Rotarians and the 100,000 additional volunteers they 
were able to mobilize were critical to the success of the NIDs, during 
which 130 million children were immunized on one day--the largest 
single public health event in history.
    Laboratory and surveillance support.--Rotary is committed to 
strengthening the network of international, regional and national 
laboratories which is necessary to investigate suspected polio cases. 
We have made grants to fund laboratory equipment, personnel, and 
training of virologists, and through our PolioPlus Partners program 
have enabled Rotarians in polio-free countries to make direct, specific 
contributions to the global eradication of polio, by adopting 
laboratory and social mobilization projects in polio-endemic countries. 
Rotary districts in America, Canada and Japan have funded polio 
laboratories in Cote d'Ivoire, Kenya, Madagascar, Nigeria, Senegal, 
Zambia, and 6 other African nations, in some cases providing all the 
equipment and materials necessary to get the lab functioning. In 
addition, Rotarians in polio-endemic countries are involved in 
surveillance for suspected polio cases at the local level, actively 
looking for any child with the tell-tale signs of paralysis and fever 
and informing the appropriate health authorities. In the 1980's, 
Rotarians worked with the Brazilian Pediatrics Association to educate 
12,000 Brazilian pediatricians about the need to report suspected polio 
cases. During the last stages of the eradication campaign in the 
Americas, Rotarians in several countries even offered substantial 
rewards to citizens reporting confirmed polio cases.
    Advocacy.--For the past 3 years, The Rotary Foundation's Polio 
Eradication Advocacy Task Force has coordinated Rotarian efforts to 
inform both governments and the private sector about the benefits to 
all nations of global polio eradication, and the urgent need for all to 
increase their commitment to the Target 2000 goal. Advocacy also means 
building the political will to eradicate polio in those countries of 
the world in which it still exists. Many of you may be familiar with 
our efforts here in the USA--we have testified before your Subcommittee 
and others, and held events to celebrate progress in the polio 
eradication campaign and United States leadership of the international 
partnership. But you may not be aware that Rotarians are engaged in 
similar activities in over 25 other nations around the world. 
Australia, Belgium, Canada, Denmark, Germany, Japan and the United 
Kingdom are among those countries which have followed the United 
States' lead in increasing their commitment to Target 2000. In these 
and other countries, Rotarians have been taking the message to 
parliamentarians, foreign aid agencies, and heads of state. Over the 
past three years, Rotarians have played a role, sometimes greater, 
sometimes lesser, in decisions by their governments to commit some $500 
million in new funds for international polio eradication. We hope to 
maintain this momentum until polio is eradicated, and also step up 
efforts to solicit the support of international corporations and other 
private sector sources.
    The examples I have cited above are just a few of the reasons why 
United Nations Secretary General Kofi Annan has called Rotary's 
PolioPlus Program ``A shining example of the achievements made possible 
by cooperation between the United Nations and non-governmental 
              private sector support for polio eradication
    The Polio Eradication Initiative has been strongly supported by the 
private sector, most notably at local levels. Corporate involvement has 
often resulted from efforts by Rotarians to engage private sector 
partners for the highly visible and popular National Immunization Days. 
A few examples are provided below:
    Financial contributions.--Lederle Laboratories donated US$1 million 
over a 3-year period to support the development of the Polio Laboratory 
Network in Africa. During the polio eradication initiative in Latin 
America, a fast-food chain donated a fixed amount of the proceeds from 
each item sold in their restaurants in several countries.
    Vaccine.--The largest corporate contribution for polio eradication 
to date has been the donation by Chiron, Pasteur-Merieux, and 
SmithKline Beecham of 100 million doses of oral polio vaccine to WHO, 
over a 3-year period. These three companies the principal suppliers of 
OPV to UNICEF. The vaccine is valued at US$8 million and is targeted to 
African countries, where the need is greatest. Connaught Laboratories 
also donated 1 million doses of OPV through Rotary in 1996.
    Advertising and social mobilization.--Within the private sector, 
particularly corporations, there are considerable resources and 
expertise for ``communications.'' A number of corporations and media 
organizations have supported polio eradication by providing advertising 
to inform and motivate parents regarding NIDs. Local and national firms 
have paid for print and electronic media announcements on NIDs. They 
have also paid for more traditional forms of advertising and social 
mobilization, including posters, banners and mobile megaphone 
announcements. One striking example of this approach was the free 
television advertising provided by a major household products company 
in Turkey. During the weeks leading up to the NIDs, the last 10 seconds 
of each of their television commercials was an NID announcement. This 
advertising was provided without cost to the Ministry of Health.
    Transportation.--Transportation of vaccine, vaccinators and 
laboratory specimens is another area where local private sector support 
has been substantial. Soft drink companies have transported vaccine 
from central storage facilities to villages where it was used in NIDs. 
In some cases this was accomplished during regular deliveries and with 
minimal cost to the company. Local companies and individuals have also 
contributed the use of vehicles for the short period of time needed to 
transport vaccinators and vaccine to the immunization clinics. In one 
country an oil company donated gasoline for vehicles for an NID. 
Finally, in the Philippines, an express-delivery company donated the 
service of delivering laboratory specimens from provincial health 
centers to the central laboratory in Manila.
    Facilitating NID's immunization clinics.--Corporate sponsors have 
assisted with NIDs immunization clinics in many countries. For example, 
several major food companies in the Philippines offered their 
restaurants as immunization posts during NIDs, while companies in Egypt 
donated food for the immunization teams. Companies have also donated 
balloons, candy and other small items to be given to children as a 
reward for being immunized. T-shirts, aprons, pins, baseball caps and 
other items bearing NIDs logos have been donated by corporate sponsors 
to increase the visibility of the NIDs and serve as a reward for health 
    Other approaches to the private sector.--In addition to the 
successful examples of private/public sector collaboration for polio 
eradication outlined above, Rotary and WHO have made approaches to a 
number of other corporations at both the national and international 
levels. These include approaches to a major soft drink manufacturer, a 
large mining concern, an oil company, an automobile manufacturer and a 
computer manufacturer, asking them to consider donations of money and/
or materials.
                   africa: the key to global success
    The task of delivering oral polio vaccine to children faces 
enormous problems on the African continent. These include civil 
conflict, poor roads, uncertain communication, shortages of 
transportation, unreliable refrigeration facilities, lack of 
sufficiently trained personnel to plan and manage National Immunization 
Days, and a weak system of surveillance.
    Despite these obstacles, however, the countries of Africa have made 
remarkable strides in polio immunization. These countries need and 
merit special assistance in their fight against polio. Thus Rotary 
International strongly endorses the recommendation of this Subcommittee 
in providing an additional $20 million for Africa's needs in fiscal 
year 1999, supplementing the planned deployment of $47.2 million by the 
CDC. Furthermore, Rotary International hopes that such an amount can be 
included in the President's budget for fiscal year 2000.
    The additional $20 million would go to three areas of need: $6 
million for oral polio vaccine for NIDs, $5 million for NID operational 
support in difficult countries, and $9 million for developing the 
surveillance systems which are critical to the eradication strategy. 
These areas of expenditure all provide additional opportunities for 
private sector support on national and local levels. Increased funding 
for the polio campaign is critical for eradication of the virus by the 
year 2000.
                    the legacy of polio eradication
    The global Polio Eradication Initiative learned much from the 
successful campaign to eradicate smallpox, and in turn the polio 
eradication effort is teaching the public health experts important 
lessons which will help other disease control and elimination programs. 
Firstly, increased political and financial support for childhood 
immunization has many documented long-term benefits. Polio eradication 
is helping countries to develop public health and disease surveillance 
systems useful in the control of other vaccine-preventable infectious 
diseases. Already, much of Latin America is free of measles, due in 
part to improvements in the public health infrastructure implemented 
during the war on polio. As a result of this success, measles has been 
targeted for elimination in the Americas by the year 2000, and it is 
anticipated that measles can be eradicated world-wide. The disease 
surveillance system--the network of laboratories, computers and trained 
personnel built up during the Polio Eradication Initiative--is now 
being used to track measles, Chagas, neonatal tetanus, and other viral 
    The campaign to eliminate polio from communities has led to 
increased public awareness of the benefits of immunization, creating a 
``culture of immunization'' and resulting in increased usage of primary 
health care and higher immunization rates for other vaccines. It has 
identified and eliminated barriers to immunization. It has improved 
public health communications and taught nations important lessons about 
vaccine storage and distribution, and the logistics of organizing 
nation-wide health programs. Lastly, the unprecedented cooperation 
between the public and private sectors serves as a model for other 
public health initiatives. In this regard, Rotary applauds two service 
club organizations: Kiwanis International for its work with UNICEF to 
eliminate Iodine Deficiency Disorders (IDD) worldwide, and Lions Clubs 
International which is working with WHO's Blindness Prevention 
Programme to eliminate onchocerciasis (river blindness) and other 
causes of blindness.
    Humankind is on the threshold of victory against polio, and we must 
not miss this window of opportunity. Poliomyelitis will be the second 
major disease in history to be eradicated, but not the last. The world 
celebrated the eradication of smallpox in 1979, and no child anywhere 
in the world will ever suffer from smallpox again. The annual global 
savings of nearly $1 billion per year in smallpox immunization and 
control costs far exceed the approximately $300 million that was spent 
over ten years to eradicate the disease. The United States was a major 
force behind the successful eradication of the smallpox virus, and has 
recouped its entire investment in smallpox eradication every 2\1/2\ 
months since 1971. Even greater benefits will result from the 
eradication of polio, and after that, measles and other infectious 
diseases which kill and maim millions of children every year.
    Polio eradication is an excellent example of truly cost-effective 
foreign assistance. It is estimated that the world will ``break even'' 
on its investment in polio eradication--saving the more than $1.5 
billion now spent annually on routine polio vaccination--only 2 years 
after the virus has been vanquished and immunization against it can be 
ceased. The financial and humanitarian benefits of polio eradication, 
which will accrue forever, will be a gift to the children of the 
twenty-first century.
    Thank you for this opportunity to testify.

                                         MAJOR POLIO-SPECIFIC GRANTS \1\
                                                [In U.S. dollars]
                                                                 Fiscal year--
                                               ------------------------------------------------       Total
                                                     1996            1997          1998 \2\
Australia.....................................         210,000         948,000  ..............         1,158,000
Belgium.......................................       5,100,000  ..............  ..............         5,100,000
Canada........................................       1,400,000  ..............      40,740,000        42,140,000
Denmark.......................................      40,000,000       6,000,000  ..............        46,000,000
European Union................................         704,000         400,000  ..............         1,104,000
Finland.......................................         330,000  ..............  ..............           330,000
Germany.......................................  ..............         451,000      24,000,000        24,451,000
Italy.........................................         750,000  ..............  ..............           750,000
Japan.........................................      22,430,000      25,720,000      10,228,000        58,378,000
Korea.........................................  ..............  ..............         900,000           900,000
Netherlands...................................  ..............         248,000  ..............           248,000
Norway........................................       2,120,000         700,000  ..............         2,820,000
Sweden........................................         481,000         400,000  ..............           881,000
Switzerland...................................         177,000       1,300,000  ..............         1,477,000
United Kingdom................................      78,600,000       1,550,000      31,160,000       111,310,000
USA...........................................      47,200,000      72,200,000      81,200,000       200,600,000
Vaccine manufacturers \3\.....................       9,000,000  ..............  ..............         9,000,000
      Total...................................     208,502,000     109,917,000  \2\ 188,228,00       506,647,000
\1\ Grants in excess of US$100,000 intended primarily for polio eradication activities. These may be direct
  bilateral grants to polio-endemic nations, or multi-lateral grants through international organizations such as
  WHO or UNICEF. Some are for multiple years.
\2\ As of August 1998.
\3\ Donation from three European and one American vaccine manufacturer: 100 million doses of Oral Polio Vaccine
  plus US$1 million.

Note: In addition to these polio-specific grants, many countries are supporting the WHO Expanded Programme on
  Immunization, which combats several infectious diseases, among them polio.


                Biographical Sketch of Herbert A. Pigman

     general secretary of rotary international, 1979-86 and 1993-95
    Herb Pigman served as General Secretary of Rotary International and 
of The Rotary Foundation of Rotary International from 1979 to 1986 and 
again from 1993 to 1995. As Rotary International's managing officer, he 
supervised the Rotary International staff located at Rotary's World 
Headquarters in Evanston, IL, USA, and service centers in eight other 
    He began his 35-year career with Rotary International in 1956 as an 
editor of The Rotarian magazine. As Under Secretary from 1964 to 1975 
he was responsible for Rotary's program development, publications, and 
international meetings. From 1976 to 1978 he was executive assistant to 
the president. In 1979 he was elected General Secretary, serving until 
his retirement in 1986 after 30 years' service.
    In 1986-89, he directed the Rotary International Immunization Task 
Force for the PolioPlus Program. The Task Force helped to launch 
Rotary's child immunization operations in 90 countries of Asia, the 
Pacific, Latin America, and Africa. He was Rotary's liaison with 
UNICEF, the World Health Organization, and with national health 
ministers. More than 1 billion children in developing countries have 
been immunized against polio with Rotary's help, an effort recognized 
by the World Health Organization in the awarding of its Gold Medal.
    He currently serves as chairman of the Polio Eradication Advocacy 
Task Force, which encourages governments to commit financial resources 
needed to eradicate polio by the year 2000. He is also a member of The 
Rotary Foundation Permanent Fund Leadership Team.
    He is a graduate and former trustee of Franklin College of Indiana, 
from which he holds a degree in journalism and an honorary doctorate in 
the humanities. He is a member of the Indiana Academy. He and his wife, 
Betty, who have five children, live in rural Warren County, IN, where 
he pursues farming and newspaper publishing. Herb is a past president 
of the Rotary Club of Evanston, Illinois. He is a member and past 
president of the Rotary Club of Boswell, IN, USA.

                     Rotary--a service organization

    Senator Bumpers. It was only a few years ago I discovered 
Rotary's role in this whole thing. One day I was going home for 
the weekend, and Betty said, what is your schedule? And among 
other things, there was a Rotary Club speech on the agenda, and 
she said, do not forget to thank them. I said, thank them for 
what? [Laughter.]
    And that is when I first discovered Rotary as a service 
organization in the very highest meaning of the word. Your work 
on polio is probably not well known in the country, but it is 
no less meaningful because of that. I want to again express my 
personal gratitude to all Rotarians, all 450,000 of them, for 
their commitment to this, and I hope they will stay committed 
as we move from polio to measles.
    Senator Bumpers. Dr. Foege, a close friend of mine and 
Betty, for many, many years. Dr. Foege, we are most honored 
that you could be with us this morning and please proceed.
    Dr. Foege. Thank you, Senator Bumpers.
    Unlike a marathon, we will not know the day we cross the 
line with polio. We will only know afterwards. For example, it 
was October 1977, a family entered a hospital in Somalia with 
two small children. They both had smallpox. They asked 
directions to the infectious disease ward, and a cook at the 
hospital said, instead of giving directions, I will take you 
there. In the few minutes that it took him to take that family 
to the infectious disease ward, he got smallpox from one of 
those children. We did not know that day that that was the last 
time smallpox would be transmitted from one person to the next. 
He recovered. No one got smallpox from him. That broke the 
chain. It went right back to the very first human case. So, we 
did not know that day. We will not know until sometime later 
the day we have crossed the line on polio.
    Senator Bumpers. Where was that, Dr. Foege?
    Dr. Foege. In Somalia.
    So, it was not only the first disease eradicated that day, 
but it is the first time a body of medical knowledge actually 
benefits everyone in the world and everyone who will ever be 
born in the future. There are lots of lessons from smallpox. I 
want to mention four of them.
    One is the value of tenacity. You mentioned that the first 
smallpox vaccination was in 1796, and you can understand why 
people 150 or 160 years later would come to the conclusion 
smallpox could not be terminated. Yet, a new look was taken, a 
global approach was taken. People shared the value of smallpox 
eradication, and hard work led to, 11 years later, smallpox 
eradication. So, it is worth always taking new looks.
    No. 2, the value of partnership and the possibility of 
partnerships even during the cold war. We forget it was the 
Soviets who first suggested smallpox eradication, and we found, 
during the cold war because we had a health objective, we 
learned how to work together and it had value beyond smallpox.
    No. 3, the most refreshing lesson, I believe, was the 
discovery that some things have to be done only once in the 
entire history of the world. Smallpox vaccine had to be 
developed only once. The eradication of the disease does not 
have to be repeated. It is almost an afterthought to find out 
it was such a good financial investment.
    And No. 4, the value of U.S. leadership. USAID provided the 
early smallpox eradication resources, and CDC actually provided 
300 people to WHO over those 11 years. We get a return on that 
investment in this country by having global and domestic health 
people who really have a totally different view.
    One strange outcome was the feeling by many people that 
such a success could not be repeated, that this was unique. So, 
while some things need be done only once, some lessons 
apparently have to be relearned.
    Some people in this room will recall that April day in 1955 
when a press conference at the University of Michigan announced 
that the Salk vaccine actually protected children against 
polio. It is almost impossible to recreate the feeling of that 
day, but the next day around the United States, simultaneously 
and spontaneously, there were signs in store windows that said, 
thank you, Dr. Salk.
    Well, as you know, we struggled with the best mechanisms, 
but we finally got it right, and 25 years after the vaccine was 
introduced, we had the last outbreak in this country. But we 
did not automatically go the next step and commit to global 
eradication. It took a catalyst, and as we have heard 
repeatedly this morning, that catalyst was Rotary 
International. It was not just the resources that we have heard 
about of millions of hours of work or millions of dollars. It 
was their role as a collective conscience. Gandhi once said 
that his interpretation of the Golden Rule is that he should 
not be able to enjoy something denied to others, and Rotary 
reminded us that we cannot enjoy having our children and 
grandchildren free of polio unless we give all parents that 
same joy.
    I will never forget the day when Dr. Maseto, director of 
the Pan American Health Organization, called a group of people 
together to look at the science behind polio, and at the end of 
the day, the scientific evidence was so compelling that he went 
out on a limb by himself, the first person in WHO to say we 
will eradicate polio. And he announced that it would be 
eliminated from the Americas, and as we have heard, by 1991 it 

                           Lessons from polio

    So, what are some of the lessons from polio?
    No. 1, the scientific case is clear. The objective is 
realistic, as we have heard, but we still have not fully 
grasped the size of the effort which will be required in 
Africa. In smallpox eradication, our first success was in west 
and central Africa. It was a CDC/USAID effort and we 
demonstrated what could be done with people who were realistic 
but very motivated. The same can be done for polio in Africa, 
but it will require more support I believe than people have 
thought heretofore.
    The key lesson is that we do not save money by just getting 
by. You asked where the last case of smallpox was. It was in 
Somalia. The smallpox eradication program put great effort into 
Ethiopia, but not quite enough. Elimination from Ethiopia took 
one month longer than it should have, and in that last month 
smallpox was transmitted to Somalia and it took us 2 years of 
hard effort to get it out of Somalia. That is my fear with 
polio. If it takes 1 month, 6 months, 1 year too long than we 
will have reimportations into Brazil or India or Burma.
    We are at a crucial phase where a labor intensive effort is 
required in Africa. The structure, as we have heard today, has 
rapidly been put into place in that continent, and the next 
step, and the last major step, should be to flood them with 
help before anything can go wrong. If that is to be done, it 
will be done because the United States decides to do it, giving 
even more support to CDC to, in turn, give to UNICEF and WHO 
and others. We can assure this country that that is a direct 
investment in American children for all time.
    A few closing words on measles. It is because of you and 
your wife that we even raise the idea of measles eradication. 
Your efforts on immunization in Arkansas were shared with 
President and Mrs. Carter at a dinner at the White House in 
1977. The next day I had a phone call from Joe Califano and he 
said, we are going to have an immunization initiative in this 
    Within a year, the results were so good we started asking 
the question could we actually interrupt measles transmission 
in the United States, and I can tell you many public health 
people told me do not take that objective. You will only ruin 
the credibility of CDC.

                          Spreading of measles

    We did take that as an objective and we had weekly reviews. 
One problem after another was uncovered. Military recruits 
going to basic training would spread measles around the country 
as they went home on furlough. That was solved by immunizing 
all military recruits, whatever their past history was. Then 
day care centers, colleges, one problem after another, until we 
got down to the last barrier, and that turned out to be 
importation of measles from other countries. We were having on 
average two importations a week at that time. As Dr. Satcher 
mentioned, PAHO has now done such a good job, that we have very 
few importations from this hemisphere, but we can clearly say 
we have interrupted transmission of measles in this country and 
all of our cases are due to importation.
    So, we have discovered that we are interrelated. It takes 
more than a village to raise a child. It takes the entire 
world, and if we are to protect American children, it will be 
by getting rid of measles in the rest of the world.
    What are the lessons we have learned from this? 
Scientifically measles eradication can be done, and we have 
shown that by getting rid of it in this country.
    It will require tremendous effort. We should continue to 
build the infrastructure for measles immunization, and we 
should improve the tools. We should develop vaccines that are 
heat resistant so we do not need the cold chain. We should 
develop stealth vaccines that actually get by the maternal 
antibody so you can give measles immunization in the first 9 
months of life. And we should make measles vaccine a tugboat to 
pull the entire immunization program to greatness. We should 
some day make global measles eradication a legacy of the 
Arkansas immunization program. Our best argument for measles 
eradication will be made by finishing polio with all the speed 
we can generate.
    Permit me to end on a personal note. I no longer work for 
the Government. I am nearing the end of my professional career 
and, therefore, I feel free to say what I want. [Laughter.]
    Senator Bumpers. Sort of like not running again. 
    Dr. Foege. At a time of great criticism of Government, 
Government employees, and politicians, I can identify few 
instances of social justice by groups other than Government. No 
church group, no service club, no organization represents all 
of us except Government. Our immunization successes in this 
country have resulted from Government at its best by a desire 
to protect every child individually and society collectively. 
It is the result of politics at its best. And likewise, the 
U.S. support of smallpox eradication, polio eradication, child 
health, child immunization for the rest of the world, it is 
enlightened self-interest, yes, but it also expresses our 
understanding as Americans of a responsibility to the world and 
to the future. As with the Marshall plan and the Point Four 
Program, it is the U.S. Government at its best.

                           prepared statement

    For years of giving us Government at its best and on behalf 
of tens of millions and hundreds of millions of people who are 
never invited to a hearing like this, I thank both you and Mrs. 
Bumpers. Thank you.
    [The statement follows:]
            Prepared Statement of William Foege M.D., M.P.H
    It is not possible to grasp the pace of health improvements in our 
lifetime. When my parents were born, 15 percent of children in this 
country died before their first birthday. Now the figure is less than 1 
percent. Given his life expectancy at birth, my father was destined to 
die in 1953. 20th Century medicine and science have given him both 
quantity and quality of life, and at age 93 he enjoys a full life.
    Likewise, global health gains stagger our imagination. The World 
Bank has reported that health has improved more in the past 40 years 
than in the previous 4,000. Global life expectancy has approached 65 
and infant mortality rates for the world have been cut in half in the 
past 35 years. But the gains cannot be mentioned without also noting 
the increasing gaps between the haves and the have-nots, the rich and 
the poor. Disease eradication efforts help to close that gap, providing 
the same benefits for everyone.
    On an October day in 1977, a family arrived at a hospital in 
Somalia with two small children. They both had smallpox. Asking for 
directions to the infectious disease ward, they were escorted by a 
hospital employee. In that brief period, the employee contracted 
smallpox. But, no one acquired smallpox from him, thus breaking the 
chain of smallpox transmission that went back to the very first human 
case hundreds of years before. Not only was that the first disease 
eliminated from the world, it was also the first time that a body of 
medical knowledge benefited everyone living and everyone who would be 
born in the future. It was truly social justice in the medical field.
    Many lessons come from the smallpox eradication experience. I will 
mention only four.
    1. The value of tenacity.--Senator Bumpers mentioned that the first 
smallpox vaccination was given in 1796. It is understandable that after 
150 or 160 years people would conclude the disease could not be 
eliminated. But after a new analysis, global agreement was reached, a 
shared goal was defined and the hard work of 11 years led to 
    2. The value of partnerships.--It was possible, even in the Cold 
War, to develop effective partnerships with the Soviet Union. [Indeed, 
we forget that it was the Soviets who originally suggested smallpox 
eradication as a global goal.] The program gave us practice in working 
together and this led to benefits beyond smallpox eradication.
    3. But the most refreshing lesson for me was the demonstration that 
some things need to be done only once in the history of the world. 
Smallpox vaccine did not need to be developed a second time. The 
eradication of smallpox did not have to be repeated. It is almost an 
afterthought to find what a good financial investment it was.
    4. The value of U.S. leadership. USAID provided the early resources 
and the Centers for Disease Control and Prevention provided over 300 
people to the World Health Organization for the eradication effort. The 
U.S. got a return on that investment with global and domestic health 
workers that had a different perspective and great skills.
    One disconcerting outcome was the feeling by many that such a 
success could not be repeated, that it was unique.
    So, while some things need be done only once, some lessons 
apparently have to be relearned.
    Some here will remember that April day in 1955, when a press 
conference at the University of Michigan caused absolute euphoria with 
the announcement that the vaccine developed by Jonas Salk protected 
children from polio. There was a spontaneous reaction with signs 
appearing in store windows the next morning saying, ``Thank you, Dr. 
    We struggled in this country for the best mechanisms, but we 
finally got it right. Our last outbreak occurred 25 years after the 
vaccine was introduced.
    But we did not automatically go the next step and commit to global 
eradication. It took a catalyst and that catalyst was Rotary 
International. It was not just their resources of millions of hours in 
the field and millions of dollars that was important. It was also their 
role as a collective conscience.
    Gandhi once said that his interpretation of the Golden Rule is that 
he shouldn't be able to enjoy something denied to others. Rotary 
reminded us that we cannot enjoy having our children and grandchildren 
free of polio unless we give all parents that joy.
    I will never forget the day when Dr. Macedo, director of the Pan 
American Health Organization, called together a group to review the 
science of polio control. On hearing the scientific evidence, he 
immediately went out on a limb, ahead of his colleagues, to announce 
that polio would be eliminated from the Americas. And it was done by 
    What then are the lessons we take to from our polio eradication to 
this date?
    1. The scientific case is clear as larger and larger geographic 
areas are freed of the disease.
    2. The objective is still realistic.
    3. But, we still haven't grasped the size of the effort required in 
Africa. In smallpox eradication, our first success was in West and 
Central Africa. It was a CDC/USAID effort that demonstrated what could 
be done with realistic and well-motivated people. The same can be done 
for polio in Africa, but it will require more support for the next two 
years than we have given, or even imagined to date.
    4. The key lesson is that we don't save money by just getting by. 
In smallpox eradication we put great effort into the program in 
Ethiopia but not quite enough. Elimination of smallpox took one month 
too long. In the last month of smallpox in Ethiopia, the disease was 
transmitted to Somalia, and it took an additional 2 years to rid 
Somalia of the disease.
    That is my fear with polio. If it takes one month, 6 months, 1 year 
too long we may get re-importation into Brazil, India, or Burma.
    We are now in a crucial phase, where a labor-intensive effort is 
required in Africa. The structure has rapidly been put into place and 
the next step (and the last major step), should be to flood them with 
help before anything can go wrong.
    If this is to be done, it will require the support of the United 
States giving even more support to CDC to, in turn, provide assistance 
to WHO, UNICEF and others.
    We can assure Congress that it is a direct investment in American 
children for all time.
    A few closing words on measles. It is because of you, Senator 
Bumpers, and your wife, that we even raise the idea of measles 
    Your efforts on immunization in Arkansas were shared with President 
and Mrs. Carter at a dinner in the White House in 1977. The next day I 
received a call from the Secretary of HHS, Joseph Califano, to inform 
me that we were going to have an immunization initiative.
    Within a year the results were so good that we began asking 
ourselves if measles transmission could be interrupted in this country. 
Many public health people advised against it saying it was not possible 
and would serve only to impair the credibility of CDC. But we chose 
that objective and began to have weekly reviews of progress. We found 
one problem after another, from military recruits spreading the 
disease, to problems in day care centers, colleges, sports events, etc. 
But we solved each problem as it arose until the ultimate barrier 
presented itself--importations from other countries.
    We were experiencing two importations of measles in the average 
week. Once again we were faced with the fact that everything in the 
world is interrelated. If we want to protect American children from 
measles we have to protect all children in the world from measles.
    It doesn't just take a village to raise a child, it now takes the 
entire world to raise a child. PAHO launched a very effective program 
and importations from this hemisphere have been dramatically reduced.
    We have now interrupted measles transmission in this country. All 
cases now are due to importations.
    What are the lessons?
    1. We have demonstrated the science. Measles eradication is 
    2. It will require tremendous effort.
    3. We should continue to build the infrastructure for measles 
immunization. All children in the world need to be immunized.
    4. But we should also improve the tools. We should strive for 
vaccines that are heat stable in order to minimize the costly and 
difficult cold chain. We should seek ``stealth'' vaccines that evade 
maternal antibody, allowing immunization in the first 9 months of life.
    5. We should make measles vaccine a tugboat to pull the entire 
immunization program to even greater heights. All of the new vaccine 
possibilities require an ever stronger immunization structure.
    6. We should make global measles eradication the legacy of the 
Arkansas immunization program.
    7. Our best argument for measles eradication will be made by 
eradicating polio with all of the speed we can generate.
    Finally, permit me to end on a personal note. I no longer work for 
the government; I'm near the end of my professional career; therefore, 
I am free to say what I want.
    At a time of great criticism of government, government employees 
and politicians, I can identify few instances of social justice by 
groups other than government. No church group, no service club, no 
other organization represents all of us. Only government does that.
    Our immunization successes in this country have resulted from 
government at its best by a desire to protect every child individually 
and society collectively. It is the product of politics at its best.
    Likewise, the U.S. support of smallpox eradication, polio 
eradication, child health, and child immunization for the rest of the 
world, while we know it is enlightened self interest, it also expresses 
our understanding, as Americans, of a responsibility to the world and 
to the future.
    As with the Marshall Plan, and the Point Four Program, it is the 
U.S. Government at its very best.
    For the years of giving us government at its best, and on behalf of 
ten's and hundred's of millions who are never invited to a Senate 
hearing, I thank you and Mrs. Bumpers.
    Thank you.

                when to stop manufacturing polio vaccine

    Senator Bumpers. Dr. Foege, that statement can only be 
described as beautiful, powerful, clear, representing the 
highest and best values of citizens of this country. I cannot 
tell you how impressed I am with it and how, once again, I wish 
not just my colleagues in the Senate but every citizen in 
America could hear that.
    This is such an unbelievable success story, and at the same 
time we have to recognize that the success just simply points 
out how far we have to go and you have done that in your 
    Let me ask you three or four questions, Dr. Foege. No. 1, 
how soon after the last case of polio can we safely quit 
manufacturing polio vaccine?

                    smallpox vaccine and stockpiling

    Dr. Foege. It is a difficult question to answer because as 
with smallpox, we are now reasking the question 20 years later. 
Should we be making smallpox vaccine and stockpiling it in case 
something goes wrong?
    With polio eradication, it will take us some time, some 
years actually, of close surveillance and monitoring every 
suspected case, every case of flaccid paralysis, to make sure 
that there is no virus actually circulating in the population. 
Then we have to make the decision do we stockpile vaccine even 
if we do not use it. But we are talking about a period of 
years, not a period of decades.
    Senator Bumpers. How long has it been since the last case 
of smallpox was reported?
    Dr. Foege. It has been over 20 years since the last case.
    Senator Bumpers. When did we discontinue manufacturing 
smallpox vaccine? I assume we have discontinued it.
    Dr. Foege. We have. We actually stopped giving smallpox 
vaccine in this country before it was eradicated from the 
world. That is how confident we were that eradication was going 
to take place and that we could respond to an emergency.
    Polio is more of a stealth virus that it can get into the 
population without us knowing. So, we cannot do that with 
polio. We have to continue right up until the last case and 
then longer.
    But we did stop making smallpox vaccine. We could do it 
again without any problems if we had to.
    Senator Bumpers. Oh, you could.
    Dr. Foege. We could make it again. We do not have to have 
smallpox virus to make the vaccine because the vaccine is 
actually made from a vaccinia virus or a cowpox virus.
    Senator Bumpers. At the time we chose vaccine for 
international, worldwide eradication, was that the only vaccine 
we had that was practical for such a big undertaking or did we 
do it for another reason?

                           two polio vaccines

    Dr. Foege. We, of course, had two polio vaccines and still 
do: the inactivated polio vaccine that Jonas Salk developed 
which is injected, and the oral vaccine that Dr. Sabin 
developed which is taken by mouth. The decision was made to use 
the oral vaccine because it was easier to use and because it 
provides an immunity in the intestine of the person that is not 
always achieved with the inactivated vaccine. So, it was 
considered to be the better vaccine to use on a global basis.
    In this country we now talk about using the inactivated 
vaccine at the end of the campaign, but these decisions have 
not been totally made as yet.
    Senator Bumpers. Is it feasible or desirable to do more 
than one global eradication at the same time?
    Dr. Foege. We, of course, are doing two global eradication 
programs right now, one for guinea worm and one for polio, and 
we are talking at the same time about doing one for measles.
    I think what happened after smallpox is we lost a certain 
momentum because people were so convinced this was unique, they 
did not automatically ask, OK, how do we use what we have done 
to continue on something else?

                          eradication programs

    I think it is probably useful to think in terms of always 
doing one or two actual eradication programs and one or two 
programs where you are building up to it. I would hope that 
measles eradication will be so feasible that it will be almost 
seamless to go from polio eradication to measles. So, yes, we 
can do two at the same time.
    Senator Bumpers. Where is guinea worm indigenous to, what 
part of the planet?
    Dr. Foege. Guinea worm used to be in areas south of the 
Sahara in Africa and in Pakistan and in India. It has been 
reduced by over 95 percent in just the last 8 or 9 years. Now 
we are finding the problems that we fear with polio; that is, 
in Sudan we are having difficulties with guinea worm because of 
the political problems. You do not know what will happen with 
social and political problems. It is another reason to do this 
as fast as we can.
    Senator Bumpers. Is the kind of civil conflict in some 
African nations--maybe, Dr. Samba, I should address this 
question to you. We have quite a few civil disturbances in 
Africa, in various parts of Africa. What, if any, impact--I 
know it is going to have some, but how difficult is it going to 
be to continue with this schedule we are on to try to eliminate 
polio, say, by the year 2000? I know, first of all, it 
increases our cost because transportation is often interrupted 
and so on, but just comment generally on that subject, if you 

                              civil strife

    Dr. Samba. It is feasible because the civil strife does not 
continue indefinitely. Like in Sierra Leone now we are starting 
the polio eradication, in Liberia, in Niger. Even in Congo, we 
got the stocks ready and within a week of starting, the civil 
strife erupted, so we had to suspend. When the electricity was 
stopped, we bought portable generators to preserve the vaccines 
and so on. And in December we will restart again. In Angola, it 
was during the civil strife that we managed to have over 90 
percent vaccinations. We have been able to convince the warring 
partners that health is in the interest of all concerned, and 
even during civil strife, we have been able to carry on. It is 
very difficult but it can be done.

                              HIV and AIDS

    Senator Bumpers. Let me ask you a second question. Some 
critics say that HIV and AIDS are much more critical to these 
nations and this money could be better spent on trying to 
control and even to treat HIV and AIDS. What is your thought on 
    Dr. Samba. My impression, for what it is worth, I said 
earlier, as a result of partnership, governments inside Africa, 
governments outside Africa, the United States taking the lead, 
civil society--in the case of river blindness, Merck, Sharp, & 
Dome, a private enterprise--we have been able to win. With 
polio we are on the way of winning. Smallpox we have won.
    We are convinced that with the partnership, the dedication, 
the commitment, increasing resources and knowledge, that with 
AIDS we will win. We are already starting on an initiative in 
Africa to complement the United States system on AIDS. For the 
moment it is a big problem. It is increasing, but AIDS is 
relatively new. We knew about it in the 1980's. It is much more 
recent than polio and smallpox and river blindness.
    Senator Bumpers. Are other nations in Africa trying to 
assist with what a lot of people in this country consider 
rather epidemic proportions of HIV and AIDS? Is the United 
States involved in it, and if so, to what extent? Let me 
rephrase the other question. Are other, for example, European 
nations, Japan, wealthier nations, involved in trying to help 
with HIV/AIDS problems in Africa?
    Dr. Samba. Yes; indeed. The United States is involved. 
Japan is involved. Britain, all western countries, all Asia, in 
fact, are involved because the whole world is realizing more 
than ever that with any epidemic anywhere in the world with the 
type of mobility of human beings, no other country is safe. So, 
it is in the interest of all concerned that the last bastion of 
these diseases are attacked. They are all involved, sir.
    Senator Bumpers. It is what we call enlightened self-
interest on an international basis.
    Dr. Samba. Exactly.
    Senator Bumpers. Mr. Pigman, do you think we would be able 
to count on the Rotary Club, once we eradicate polio, to 
continue with their assistance, say, in measles?

                           polio eradication

    Mr. Pigman. That question is often asked, Senator Bumpers, 
and I would respond by saying that when we named our program 
back in 1985, we could have named it ``polio eradication'' or 
we could have named it ``kick polio off the planet,'' but we 
named it PolioPlus, the ``plus'' implying that our focus on 
polio is aimed at raising the immunization levels against all 
infectious diseases.
    Now, we have an army currently deployed against polio. 
Polio eradication is going to be their focus until the job is 
done, but I would hope that we would not have disarmament.
    Senator Bumpers. Well, I hope not too. I hope to be a 
private citizen then, but I will do my best to weigh in with 
such Rotarians as I have any influence with to make sure that 
they continue their efforts.
    Mr. Pigman. Thank you.


    Senator Bumpers. I find, incidentally, that Rotarians take 
great personal satisfaction in what they have been able to 
accomplish, and they are very proud of themselves. As I say, a 
lot of service organizations are not service organizations at 
all, but the Rotarians have shown that they really are truly a 
service organization.
    Mr. Pigman. Well, Senator, in defense of sister 
organizations, we are very happy to see that such large service 
organizations such as Kiwanis has tackled iodine disease 
deficiency and Lions, vitamin A deficiency, et cetera. So, let 
us hope that the partnership will only grow in the future.
    Senator Bumpers. Dr. Foege, will there be any significant 
change, up or down, in the cost of eliminating measles compared 
to the cost of eliminating polio?

                           Eradicate measles

    Dr. Foege. Measles is going to be a tougher disease to 
eliminate, and my belief is that it will probably be somewhat 
greater cost than polio. It is a very difficult disease to 
contain. It spreads rapidly and it is going to take a massive 
effort to eradicate measles, but it is doable.
    Senator Bumpers. You do not think there is any question but 
that measles ought to be the next effort I take it.
    Dr. Foege. That is right. The figures that you gave, the 
single most lethal agent in the world just a few years ago. It 
is such a problem in Africa that I think we should do this, and 
I think that we are getting experience now in how to improve 
our infrastructure. So, there is no question in my mind that we 
should do this, but that polio should be eradicated as a step 
toward measles.
    Senator Bumpers. I have a couple of technical questions 
that I probably will submit in writing to you, Dr. Foege, just 
for my own enlightenment and the members of the subcommittee, 
about the possible shortfall of funds to make sure we finish 

                         conclusion of hearing

    Well, let me just again thank you all very much for what I 
know is a great effort to get here to be here for this. I have 
been here 24 years, and I can tell you--and this is not to 
flatter you--this has been one of the most enlightening, 
gratifying hearings I have ever attended in my life. All of you 
spoke so extremely well. Whether they read it or not, it will 
be shared with all the members of the full committee, not just 
the subcommittee. So, we will submit two or three questions in 
writing, but again thank you all very much for coming.
    The subcommittee will stand in recess subject to the call 
of the Chair.
    [Whereupon, at 11:39 a.m., Wednesday, September 23, the 
hearing was concluded, and the subcommittee was recessed, to 
reconvene subject to the call of the Chair.]