[House Hearing, 106 Congress]
[From the U.S. Government Printing Office]
INFECTIOUS DISEASES: A GROWING THREAT TO AMERICA'S HEALTH AND SECURITY
HOUSE OF REPRESENTATIVES
ONE HUNDRED SIXTH CONGRESS
JUNE 29, 2000
Serial No. 106-146
Printed for the use of the Committee on International Relations
Available via the World Wide Web: http://www.house.gov/
U.S. GOVERNMENT PRINTING OFFICE
67-067 WASHINGTON : 2000
COMMITTEE ON INTERNATIONAL RELATIONS
BENJAMIN A. GILMAN, New York, Chairman
WILLIAM F. GOODLING, Pennsylvania SAM GEJDENSON, Connecticut
JAMES A. LEACH, Iowa TOM LANTOS, California
HENRY J. HYDE, Illinois HOWARD L. BERMAN, California
DOUG BEREUTER, Nebraska GARY L. ACKERMAN, New York
CHRISTOPHER H. SMITH, New Jersey ENI F.H. FALEOMAVAEGA, American
DAN BURTON, Indiana Samoa
ELTON GALLEGLY, California MATTHEW G. MARTINEZ, California
ILEANA ROS-LEHTINEN, Florida DONALD M. PAYNE, New Jersey
CASS BALLENGER, North Carolina ROBERT MENENDEZ, New Jersey
DANA ROHRABACHER, California SHERROD BROWN, Ohio
DONALD A. MANZULLO, Illinois CYNTHIA A. McKINNEY, Georgia
EDWARD R. ROYCE, California ALCEE L. HASTINGS, Florida
PETER T. KING, New York PAT DANNER, Missouri
STEVE CHABOT, Ohio EARL F. HILLIARD, Alabama
MARSHALL ``MARK'' SANFORD, South BRAD SHERMAN, California
Carolina ROBERT WEXLER, Florida
MATT SALMON, Arizona STEVEN R. ROTHMAN, New Jersey
AMO HOUGHTON, New York JIM DAVIS, Florida
TOM CAMPBELL, California EARL POMEROY, North Dakota
JOHN M. McHUGH, New York WILLIAM D. DELAHUNT, Massachusetts
KEVIN BRADY, Texas GREGORY W. MEEKS, New York
RICHARD BURR, North Carolina BARBARA LEE, California
PAUL E. GILLMOR, Ohio JOSEPH CROWLEY, New York
GEORGE RADANOVICH, California JOSEPH M. HOEFFEL, Pennsylvania
JOHN COOKSEY, Louisiana
THOMAS G. TANCREDO, Colorado
Richard J. Garon, Chief of Staff
Kathleen Bertelsen Moazed, Democratic Chief of Staff
Adolfo Franco, Professional Staff Member
Nicolle A. Sestric, Staff Associate
C O N T E N T S
David Satcher, M.D., Ph.D., U.S. Surgeon General, Assistant
Secretary for Health, Department of Health and Human Services.. 11
David L. Heymann, M.D., Executive Director, Communicable
Diseases, World Health Organization (via video-conference)..... 25
David F. Gordon, Ph.D., National Intelligence Officer of
Economics and Global Issues, National Intelligence Council..... 35
The Honorable Benjamin A. Gilman, a Representative in Congress
from New York and Chairman, Committee on International
The Honorable Joseph Crowley, a Representative in Congress from
New York....................................................... 50
Dr. David Satcher................................................ 53
Dr. David L. Heymann............................................. 62
David F. Gordon.................................................. 101
Slides presented by Dr. Heymann.................................. 113
Article from Los Angeles Times, June 29, 2000 entitled ``In a
Shrinking World Disease Anywhere Means Disease Everywhere'', by
Representative Benjamin A. Gilman and Representative Sam
INFECTIOUS DISEASES: A GROWING THREAT TO AMERICA'S HEALTH AND SECURITY
THURSDAY, JUNE 29, 2000
House of Representatives,
Committee on International Relations,
The Committee met, pursuant to notice, at 10 a.m. in room
2172, Rayburn House Office Building, Hon. Benjamin A. Gilman
(Chairman of the Committee) presiding.
Chairman Gilman. The Committee will come to order.
During the summer and fall of last year, the West Nile
virus, previously unknown in the Western Hemisphere, reached
the New York metropolitan area. The outbreak of the West Nile
virus in New York claimed seven lives and resulted in 62 cases
of encephalitis. The introduction of this previously unknown
deadly virus to the United States vividly illustrates that
infectious diseases know no borders.
In addition, despite the valiant efforts of the health care
community in our Nation, the outbreak of this lethal virus also
demonstrates that we must do much more to handle the spread and
unforeseen introduction of new viruses in the United States. In
simple terms, the West Nile virus outbreak should serve as a
wake-up call for our Nation.
Just this past Sunday, a Rochester, New York, man died of
bacterial meningitis on a flight from Tel Aviv to New York. New
York health authorities are now concerned that other passengers
could have been infected with that disease. Clearly, infectious
diseases know no borders. The growing number of infectious
diseases and their strengths and mutations is both a domestic
and international problem of mounting concern, costing a
needless loss of life.
What is most regrettable is that most of the world's
deadliest diseases can be eradicated or treated inexpensively.
For example, every year our Nation spends over $300 million
immunizing our own citizens against polio, a disease that was
eliminated in this hemisphere in 1994. These immunizations are
necessary because polio has not been eradicated worldwide and
could be reintroduced in the United States at any time.
On June 12, the World Health Organization issued a report
citing under use of antibiotics in the developing world and
their overuse in the developed world as a major contributing
factor to the spread of infectious diseases. Because of the
improper use and overuse of antibiotics, viruses have developed
stronger strains that are increasingly able to overcome
Just a few years ago, a number of inexpensive antibiotics
proved effective at treating such diseases as tuberculosis.
Today the number of effective antibiotics in our arsenal has
dwindled because of overuse and, as noted by the World Health
Organization, as a consequence, slowly but surely, most
infectious diseases are becoming resistant to existing
What is clear to me is that infectious diseases today
threaten the hard won gains of the past 30 years in both health
care and life expectancy. Infectious diseases are now the
world's biggest killers of children and young adults and
account for more than 13 million deaths annually. In the
developing world, a staggering one in two deaths is
attributable to infectious diseases. The HIV/AIDS pandemic
alone has claimed 34 million victims and millions more will
lost their battle with the deadly disease.
An incredible statistic reveals the magnitude of this
crisis. Twenty percent of the population of South Africa is now
infected with HIV. Alarmingly, some routine vaccines cannot be
administered to HIV positive people without fatal consequences.
Therefore, in addition to the threat that AIDS singularly posts
worldwide, the eradication of other infectious diseases might
not be possible because vaccines for those diseases cannot be
administered to HIV infected victims.
Yesterday, the UNAIDS program and the United Nations
reported that the AIDS epidemic is already measurably eroding
economic development, educational opportunities, child survival
efforts, and in much of sub-Saharan Africa and the Central
African Republic. As many teachers die of AIDS as those who
retire each year.
Infectious diseases are not just a developing world
problem. Unless the spread of infectious diseases is checked
throughout the world, scourges such as tuberculosis will
reemerge with a vengeance in the industrialized world. In fact,
tuberculosis has already reappeared in Greece and Albania, and
polio cases have once again been reported in Southeastern
Europe. All of these countries had been free of those diseases
for many years.
As our witnesses who are with us today will attest to, the
spread of infectious diseases worldwide poses a threat to
millions of people, including the citizens of our own Nation.
So we thank our witnesses for joining us today and we look
forward to their testimony.
I will now call on our Ranking Minority Member, the
gentleman from Connecticut, Mr. Gejdenson.
Mr. Gejdenson. Thank you, Mr. Chairman. I think all of us
are stunned, frankly, by the issue that confronts us, not just
in the fact that the magnitude is so significant, but that 160
times more people die each year from infectious diseases than
in natural disasters. The natural disasters get our attention
because they seem so large at the moment, but, overall, these
infectious diseases are far more devastating.
The impact economically to the developing world is also
devastating. It takes about 20 years of education to create one
doctor. But if that doctor contracts AIDS and can only provide
services to his country for one-fifth or one-quarter of the
time that a doctor might do if he or she lived to their full
life expectancy, it means that the poorest countries in the
world often have to expend four and five times the amount of
money and effort in educating their doctors.
As you have pointed out, we have seen the West Nile virus
arriving in the United States, and apparently surviving the
first winter with birds being found still carrying the virus.
We are not going to be able to put a fence around the
country, and when we look at the challenge that we face here,
if this was a military invasion, if these were soldiers in
uniform coming in airplanes and boats, it would be easy to
galvanize public opinion and policy makers. These diseases do
arrive almost in the same way.
As you mentioned, on that 747 flight from Israel a disease
came to this country endangering hundreds of Americans and
individuals had to be contacted in seven different countries as
a result of that one individual.
The United States spends hundreds of millions of dollars to
deal with illnesses like polio, that if we were able to wipe
them out worldwide, could save us between a quarter and a third
of a billion dollars annually.
The cost of curing diseases that have become drug resistant
grows by 10 times or more. Think about diseases that were
virtually disappearing, like tuberculosis, where we virtually
had no new cases, it was dropping off the charts as an illness.
Now we are finding the cases of TB growing, and what is more
dangerous, these new resistant cases of TB, instead of costing
several thousands of dollars to treat, can cost tens of
thousands of dollars and more.
The good news is if we act and make the proper commitment
in resources, we will be able to deal with these issues, and
often be able to arrest them overseas before they come to the
The hard part is often to galvanize Americans for something
that is as hard to recognize as a slow moving disease is
abroad. But AIDS and TB are good examples of why it is not just
our humane instincts that we have to respond to, it is an
instinct for self-survival. When you look at what has happened
with AIDS in countries in Africa and elsewhere, when they reach
these kinds of numbers, they become the host for a number of
other infectious diseases.
So Americans who might have been sitting here thinking I am
not going to be using intravenous drugs, I am not going to be
involved in sexual activity that might expose me to AIDS, the
fact that AIDS is growing is not a danger to me or my family,
have been proven wrong. AIDS in the developing world provides a
direct threat to Americans. Those individuals are the host for
new and more virulent strains of TB and so many other
If we don't participate with our other human beings on this
planet to challenge, confront, and beat these diseases where
they exist, they will come here and they will ravage our own
populations. So both for humanitarian reasons and for self-
survival reasons, we need to act.
So I commend you, Mr. Chairman, for holding this hearing
today, and my colleagues, who I know are seriously committed to
putting forth the resources necessary to fight this challenge
as if it was an invading army.
Chairman Gilman. Mr. Burr.
Mr. Burr. Thank you, Mr. Chairman. Just this morning in the
AP story in London, it starts out earthquakes and other natural
disasters may have captured donations and headlines, but
preventable disease killed far more people, 13 million people
in 1999, according to a published report Wednesday by the
American Red Cross.
Mr. Chairman, I am here to thank you for holding this
hearing. By my count, this is the fifth hearing on world health
since I have been a Member of this Committee since 1998. All
have been important, but, Mr. Chairman, this one is
particularly so. It is focused on the threat posed to stability
of countries around the world and our own national security by
the spread of infectious disease. Broad advances in fighting
the spread of disease after World War II led to hopes that the
threats from disease was becoming more manageable.
As this January's national intelligence estimate points out
and our witnesses will testify today, those hopes may have been
misplaced. The optimism of the post-war era led to complacency
in many areas and overlooked the impact of increased trade,
travel and the emergence of resistant strains.
For the benefit of those that doubt the threat, I should be
very clear. While the situation in developing and former
communist countries is troubling, we must not overlook the fact
that the trend in infectious disease prevalence at home is up
as well. Annual deaths in our country from infectious diseases
have almost doubled since 1980, and many of these diseases
originated outside of the United States and are introduced by
businessmen, travelers, immigrants, and our own military
personnel who return home.
Infectious diseases do indeed pose a significant threat to
our Nation's interests, both at home and abroad, and will
continue to pose a threat in the years to come. The NIE paints
a grim picture, but I am hopeful our witnesses can provide us
with the ammunition in the form of ideas, proposals and
opinions needed to tackle some the problems we currently face.
Mr. Chairman, it is evident that our country must remain
vigilant and active in the fight against the spread of
infectious disease. The stakes are simply too high for us to
In conclusion, I would like to thank our witnesses. I would
like to make a special welcome to Dr. Satcher, and I would also
like to make a special welcome to Dr. Heymann, who is in fact a
graduate of Wake Forest University School of Medicine, we all
know the best ACC team in the conference, also my alma mater,
Mr. Chairman, and I welcome Dr. Heymann here today. I yield
Chairman Gilman. Thank you very much, Mr. Burr. Mr. Brown,
the gentleman from Ohio.
Mr. Brown. Thank you, Mr. Chairman. Mr. Burr, while Wake
Forest may be the best team in the ACC, I would like to welcome
Dr. Satcher, who went to Case Western, which is one of the best
medical schools in the country.
Last year TB killed more people than any year in world
history. It is the greatest infectious killer of adults
worldwide. It is the biggest killer of young women. It kills 2
million people per year, one person every 15 seconds. In 1999
there were 8 million new TB cases around the world, 95 percent
of them in developing countries.
The WHO estimates that one-third of the world's population
is infected with the bacteria that causes tuberculosis, 8
million people develop active TB each year, and 15 people
million people in the United States are infected. TB is the
biggest killer of people with HIV/AIDS. It accounts for one-
third of AIDS deaths worldwide and up to 40 percent of AIDS
deaths in Asia and in Africa. Eleven million people are
currently infected worldwide with TB and HIV.
The good news is that TB treatment is equally effective in
HIV positive and HIV negative people. So if we want to improve
the health of people with HIV, we must address tuberculosis. Up
to 50 million people worldwide may be infected with multi-drug
resistant tuberculosis. MDRTB has been identified on every
continent. It is particularly high in certain regions and
populations, such as Russian and Latvian prisons, where 5
percent of prisoners have active MDRTB. According to the WHO,
multi-drug resistant TB only threatens to return TB control to
the pre-antibiotic era where no cure for TB was available.
In the United States treatment, normally about $2,000 per
person, skyrockets to as much as $250,000, as we found out in
the early nineties in New York City, $250,000 per patient to
treat MDRTB, and treatment may not even be successful.
The statistics on access to TB treatment worldwide are
pretty grim. Fewer than 1 in 5 of those with TB are receiving
directly observed treatment short-course, DOTS. Based on World
Bank estimates, DOTS treatment is one of the most cost-
effective health interventions available, costing as little as
$20 in developing countries to save a life. It can produce cure
rates, as we saw in a couple of states in India, up of up to 95
percent, even in the poorest areas.
An effective DOTS program can prevent the development of
MDRTB. A recent WTO study in India found in areas where
effective TB treatment was implemented, the TB rate fell by 85
The threat TB poses for Americans derives from the global
spread of tuberculosis. Foreign born people account for almost
half of TB cases in our country and from the emergence and
spread of strains of TB that are multi-drug resistant. MDRTB
kills more than half of those infected in the United States and
other wealthy nations. It is a virtual death sentence in the
As you know, the President recently visited India. Before
his trip we talked about TB in that nation. India has more TB
cases than any other country in the world. Their situation
illustrates the urgency of this issue. More than 1,000 people
every day die from tuberculosis in India. It has become a major
barrier to social and economic development, costing the Indian
economy at least $2 billion a year. TB attacks the poor and TB
causes poverty. 300,000 children are forced to leave school
each year because their parents have TB and more than 100,000
women with TB are rejected by their families due to social
stigma. India has undertaken an aggressive campaign, but they
need our help.
In order to control TB in the United States more
effectively, it is also necessary to assure the effectiveness
of TB control programs worldwide. TB experts estimate it will
cost an additional $1 billion a year to control this disease.
We have a very small window of opportunity during which
stopping TB would be very cost-effective. The cost of DOTS can
be as little, as I said earlier, as $20 in developing
countries. If we wait or go too slowly, so much drug resistant
TB will emerge that it will cost billions to control, with no
guarantee of success.
MDRTB is at least 100 times more expensive to cure than
non-drug resistant TB. I have introduced H.R. 4057, the Stop TB
Act Now, with Representative Morella in an effort to control
TB. The bill authorizes $100 million to USAID for tuberculosis
control in high incidence countries, mostly using DOTS, the
directly observed treatment short-course. It calls on USAID to
collaborate its efforts with the CDC, with the World Health
Organization and with the National Institutes of Health and
other organizations with specific knowledge of TB.
Gro Brundtland, the Director General of the World Health
Organization, has said that TB isn't a medical issue, it is a
political issue. Getting Americans engaged, as Mr. Gejdenson
said, in an international medical issue like TB, even when
addressing TB serves our own best interests, is still an uphill
battle. But we have an opportunity here as a Nation and as a
society, especially in the wealthy countries, to work with
developing countries to save millions of lives now and prevent
millions of deaths in the future.
Mr. Chairman, I thank you.
Chairman Gilman. Thank you, Mr. Brown. The gentlelady from
California, Ms. Lee.
Ms. Lee. Thank you, Mr. Chairman. I want to thank you and
our Ranking Member for today's hearing to discuss this very
important national security issue, which is the spread of
infectious disease around the world. I also want to welcome our
witnesses and look forward to their testimony.
Health is definitely a national security issue, but it is
also an international security issue that is worthy of our
close attention. Beyond today's hearing, however, we must
really begin to aggressively support a strategic investment in
foreign assistance above and beyond what we are currently
spending. In addition, this hearing today really does
underscore the importance of the direction of our country's
foreign policy, whether it be engagement or isolation. It also
highlights the need to provide foreign assistance to countries
that are in most dire need.
One issue which we all are talking about today and which we
all are working on very diligently is the HIV/AIDS crisis in
Africa. We are working on the World Bank AIDS Marshall Plan
Trust Fund Act, which was moved out of Congress about a month
ago, but we are working on this in a bipartisan fashion with
Chairman Leach of the Banking Committee and all of our Members
of International Relations, to really begin to craft a major
investment in the whole HIV/AIDS crisis in sub-Saharan Africa.
But $100 million a year is what we are currently working for 5
years. It is just a drop in the bucket to address this pandemic
in Africa. We have a long way to go.
In Africa right now you have heard the statistics.
Currently 70 percent of the AIDS deaths worldwide are in sub-
Saharan Africa. But as a result of that, the spread of AIDS in
Africa has increased economic instability, food and
agricultural destabilization and a severe drop in life
expectancy rates. Life expectancy has dropped in some countries
in Africa from 65 to 40 years of age. More than 13 million
children now have lost one or both parents to AIDS, and as of
the year 2010 it is projected that there will be 40 million
orphans in Africa as a result of the HIV/AIDS crisis and their
parents dying of this disease. That is the equivalent of every
child in America's public school system.
This health crisis has repercussions that are reverberating
far beyond the sick rooms and the hospitals where its victims
lie dying. It threatens to destabilize entire societies. So we
must do something before it is too late. Earlier this year the
President declared HIV/AIDS a national security issue. I think
it is an appropriate declaration. But now we must move
aggressively to come up with strategies to deal with this. It
is only when the United States commits itself to long-term
strategic investment do we have a fighting chance to address
the spread of HIV and AIDS as well as other infectious diseases
around the world. Diseases do not respect international
So I want to thank you, Mr. Chairman, again for holding
this hearing today, and thank the Committee for all of its hard
work and its commitment to really begin to invest in our
country's push to address infectious diseases.
Chairman Gilman. Thank you, Ms. Lee.
The gentleman from New Jersey, Mr. Payne.
Mr. Payne. Thank you very much, Mr. Chairman. Let me
commend you for calling this very important hearing today on
infectious diseases, a growing threat to America's health and
Let me also welcome the panelists, in particular our
Surgeon General, Dr. Satcher. Just yesterday I was watching you
talk about the new breakthrough in treatment for smoking, and I
hope that all the smokers heard that.
We certainly appreciate the outstanding work that you are
I also would like to commend my colleague, the gentlewoman
from the great State of California, for her initiative that she
has been taking in the question of dealing with HIV/AIDS in
Africa. Her Subcommittee, with Congresswoman Christensen, that
meets on a regular basis to talk about the whole problem of
HIV/AIDS in Africa, has really pushed forward the discussion
and the debate, and I certainly would like to commend her
publicly again for her diligence and the fine work that she has
done in that regard.
Let me say to the audience that I do feel that finally this
issue has come out of the Dark Ages and into the light in
Africa. Several hundred years ago in this country mental health
was considered something that should not be discussed, and
people would not acknowledge that there were people who
suffered from that problem, and as time went on here in the
United States we were able to finally deal with mental health
as a real health issue.
It seems the same taboo, not only in Africa, but here in
the United States, that no one wanted to talk about. It was
denial. There was some feeling even from the church that if you
followed the Bible you wouldn't get AIDS, and, therefore, if
you have it, it is because you deserve it. Those kinds of
illogical thinking. I am glad we finally are bringing this
subject out and we are talking about the virus, we are talking
about what should be done to attack it.
I think the breakthrough of Vice President Gore at the
United Nations in January, Africa Month, under the
recommendation of the U.N. Ambassador from the United States,
Ambassador Holbrooke, where Vice President Gore talked about
the fact that HIV virus and AIDS was a national security issue,
and for the first time in the United Nations Security Council
this issue was raised.
I think that these are positive signs, I think, that the
fact that this hearing is being held, that the Banking
Committee with Mr. Leach has joined in with Ms. Lee, that
others are talking about the fact that we need to have a
quantum leap in the education being brought to bear, but also
in the funding. I applaud the pharmaceutical companies several
months ago in Geneva announcing that they were going to reduce
the cost of some pharmaceuticals that are necessary for
treatment of the virus. We think it is a first step in the
right direction, but we need much more cooperation from the
pharmaceutical industries. We need much more appropriations
from the U.S. Congress.
So, with that, I would say that we look forward to your
testimony, and once again we appreciate the panel for being
Chairman Gilman. Thank you, Mr. Payne.
The gentleman from New York, Mr. Crowley.
Mr. Crowley. Thank you, Mr. Chairman. Thank you for calling
this important and timely hearing. As a fellow member from New
York, I believe you understand that New Yorkers are concerned
about the threat of global infectious diseases.
I want to welcome all the witnesses today, including Dr.
Satcher, Dr. Heymann, Dr. Gordon, and I see in the audience Dr.
Ostrov from the Center for Disease Control as well, someone I
had the opportunity and pleasure of working with most recently
on West Nile encephalitis. I would also like to thank Ranking
Member Gejdenson for his leadership on this critical issue as
As many of you know, in August 1999 my constituents were
shocked to learn that an outbreak of West Nile encephalitis had
surfaced for the first time in the Western Hemisphere in the
heart of my district in Queens and the Bronx. This outbreak was
a wake-up call for every American. It illustrates that the
global community has truly become the local community.
As demonstrated by West Nile encephalitis, HIV/AIDS and
tuberculosis, a disease respects no borders. An outbreak in
Africa, Europe, Asia, or South America can travel to United
States shores within days. No longer can diseases occurring in
far off lands be ignored. They pose a direct threat to the
national security of our great country and must be addressed by
the U.S. Government, this Congress and the international
community as a whole.
Diseases cannot be seized by Customs and they don't apply
at the U.S. embassy for a visa. The only way to halt them is to
target them at the source. But today we are losing that battle.
Thirteen million people die annually from infectious diseases,
most of which are preventable or curable. The 21st century
faces an estimated 33.5 million people around the world who are
infected with HIV/AIDS. The spread of AIDS can be prevented
with an urgent and necessary investment. We must stand at the
forefront of tackling this disease in order to secure the
health and prosperity of future generations.
In April of this year, I visited Africa with UNFPA to
examine family planning clinics and HIV/AIDS control efforts in
Malawi, a country where the life expectancy is no more than 36
years of age. In Malawi I witnessed the devastating effects of
HIV/AIDS firsthand. Everyone I met in Malawi suffered tragedy
due to the HIV/AIDS epidemic. In some instances, whole families
had been wiped out.
One gentleman told me that every time he had a position
open in his business, he had to hire three people, because he
knew that within a year, two would either be dead or caring for
a sick or dying family member with AIDS.
In sub-Saharan Africa, the AIDS epidemic is dramatically
changing the structure of society. Traditional extended
families are falling apart forcing children to leave school in
order to provide for their families. Poverty is skyrocketing,
and a vicious spiral of decline is setting in that further
destabilizes already volatile countries.
Because of this danger, the Clinton administration has
designated AIDS as a threat to our U.S. national security.
Additionally, the United Nations Security Council has held
joint meetings with relevant U.N. councils dealing with health
and social issues. I commend these efforts, but much more needs
to be done.
As many of you know, I have been joined by over 55 of my
House colleagues on legislation that I am sponsoring known as
the Global Health Act 2000, H.R. 3826. The Global Health Act
authorizes $1 billion in additional resources to improve
children's and women's health and nutrition, provide access to
voluntary family planning, and combat the spread of infectious
diseases, particularly HIV/AIDS. With the funding authorized in
the GHA, the United States would make a giant leap forward in
promoting access to health care for millions of people around
the world. In today's world, no nation is an island. We are all
in this together. Failing to make a commitment to global health
now will only cost us more in the long run.
Mr. Chairman, in August I will be holding a forum on the
interconnectedness of globalization and the spread of
infectious diseases. This event is cosponsored by the Global
Health Council and is called Infectious Diseases in Your Own
Mr. Chairman, given your interest in this topic as well as
the danger to New York and Connecticut, I would like to extend
an invitation to you and to Ranking Member Gejdenson to join me
for this event which will take place in the near future in New
Once again I would like to thank you and Ranking Member
Gejdenson for your work on this critical issue. I ask that my
full and complete written statement appear in the record.
[The prepared statement of Mr. Crowley appears in the
Chairman Gilman. Without objection. Thank you, Mr. Crowley.
We would welcome hearing more about your proposed meeting.
The gentleman from California, Mr. Sherman. Let me
interrupt a moment. We are joined today by way of video
conference by Dr. Heymann. Dr. Heymann is the Executive
Director of Communicable Diseases of the World Health
Organization. He is meeting with us from his offices in Geneva.
Welcome, Dr. Heymann.
Mr. Sherman. Thank you, Mr. Chairman. I want to commend you
for holding these hearings. There was a time when we thought of
disease as simply a personal matter, but a look at history
shows that disease is also something of great international and
historic significance. The Dark Ages were perhaps at their
darkest when the plague decimated Europe and really cost that
continent over a century of development, and today infectious
diseases around the world can pose a major threat to the
development, peace and security of our country and countries
around the world.
We have talked about AIDS in Africa. Not only does that
devastate that continent, but the more AIDS suffering people
there are in Africa, the more likelihood of a mutation
developing on that continent, producing another strain of AIDS
which our medicine may not be able to deal with.
We all, the health of every person on this planet, is
dependent upon the health of every other person on this planet,
and we in the United States should recognize that infectious
diseases are not always just something that comes from some
other continent and invades the United States.
The overuse of antibiotics in American agriculture may
create in cows and in chickens resistant strains of bacteria
where we in our practices could be creating the next plague
that will affect other continents.
I think historians in the future may wonder why in our
defense budget we spend so much defending ourselves from
missiles and so little defending ourselves from diseases.
Perhaps NIH is the next or the real Pentagon.
We have billions of people on this planet. The more people
we have, the more contact, the more international travel, the
more chance there is for diseases to develop and to move
quickly around the world; and the more we use drugs to combat
these diseases, the more likelihood there is of the development
of resistant disease strains.
Mr. Chairman, we have looked at many of the national
security threats that face America, our allies and the world in
hearings before this Committee, but this may be the biggest
Chairman Gilman. Thank you, Mr. Sherman.
We are now pleased to welcome the distinguished--I am
sorry, I have neglected one our Members, Dr. John Cooksey, the
gentleman from Louisiana.
Mr. Cooksey. Thank you, Mr. Chairman. Since it has been a
number of years since I finished medical school, I will wait to
hear from the non-elected experts this morning and hear their
testimony. Thank you, Mr. Chairman.
Chairman Gilman. Thank you, Dr. Cooksey.
We now welcome the distinguished Dr. David Satcher, the
Surgeon General of our Nation, to testify before our Committee
Dr. Satcher is the 16th Surgeon General of the United
States. He has served in that position since early in 1998.
Previous to his appointment as Surgeon General, Dr. Satcher
served as Director of the Centers for Disease Control. Prior to
serving in government, Dr. Satcher was President of Meharry
Medical College in Nashville, Tennessee.
Welcome, Dr. Satcher. Please proceed. You may summarize
your testimony and place your full statement in the record if
you so desire.
STATEMENT OF DAVID SATCHER, M.D., U.S. SURGEON GENERAL,
ASSISTANT SECRETARY FOR HEALTH, U.S. DEPARTMENT OF HEALTH AND
Dr. Satcher. Thank you very much, Chairman Gilman.
Chairman Gilman. Would you please press the button in the
middle of your mike down on the base.
Dr. Satcher. Thank you very much, Chairman Gilman, and
Members of the Committee. I am very pleased to have this
opportunity to join you for this very important hearing and am
very pleased to appear with my colleagues, Dr. David Heymann
from the World Health Organization, and Dr. Gordon.
We are very concerned about the emergence and reemergence
of infectious diseases in this country. I should also say that,
as you pointed out, I am joined by colleagues from CDC, Dr.
Steven Ostrov; from FDA, Dr. Jesse Goodman; and from NIH, Dr.
John LaMontagne. We are all very concerned about infectious
diseases, and especially the reemergence and emergence of
We have come a long way in the last century. At the turn of
the century, in 1900, infectious diseases were by far the
leading causes of death in this country, and we have made
dramatic progress in the eradication of smallpox and now the
near eradication of polio. With the new antibiotics and
immunizations, we have made dramatic progress.
But as we all know, we also became complacent. In fact it
was in 1969 that a former Surgeon General appeared before
Congress and the concern was more about too much emphasis on
infectious diseases and the need to shift more emphasis to
chronic diseases. That was certainly true. But in some ways we
may have shifted too much, because by the mid-1970's, we were
seeing the emergence of many new infectious diseases.
Between 1980 and the end of this century, indeed death
rates from infectious diseases in this country increased
dramatically, and only a portion of that, maybe one-third or
one-fourth, due to HIV/AIDS. Other infectious diseases played a
So we are concerned. As we speak there are many examples.
Last year alone, two Boy Scouts acquired malaria while
attending a summer Camp in Suffolk County, New York. Last
August and September six people in the northeastern United
States and a Canadian visiting New York died from West Nile
encephalitis, a viral disease transmitted by mosquitoes. The
West Nile fever, which is carried by migratory birds, usually
from Asia, Africa, and Europe, had never before been reported
in the Western Hemisphere.
Also from July 1999 to January 2000, 56 people in south
Texas were recognized with Dengue Fever, and at least 17 of
those people acquired dengue fever in the United States.
The AIDS epidemic, of course, perhaps needs no further
discussion except to say that we are part of this global
community where this pandemic is probably the worst that we
have seen since the plague of the 14th century or the influenza
pandemic of 1918. You have discussed resistant tuberculosis,
and we have been very concerned about that in our work at CDC
and NIH, as well as FDA. Recently there was an interagency
report from these three agencies, a draft report on the
management of antimicrobial resistance.
While I want to put this in perspective, I think maybe the
best way to do that is to refer back to the Institute of
Medicine's report in 1992 in which it was pointed out that
there are six major factors involved in the emergence and
reemergence of infectious diseases. I think we need to look at
them as we think about the future.
One of those factors is changes in human demography and
behavior, including growth in population and density, sexual
activity, substance abuse, the way we use antibiotics and other
drugs, but also advances in technology and industry. The fact
that we have the technology, for example, to mass produce
foods, such as ground beef, which means that, as somebody
pointed out, one patty of hamburger may in fact include beef
from 100 different cows. Our technology, which is great, also
increases the risk of the spread of infectious diseases in many
Economic development and changes in land use patterns,
invasion of the rain forest, all of these things have been
factors. Ecological changes, certainly changes in temperature
and flooding contributed to the hantavirus outbreak in the
Southwest in 1993.
As you pointed out, increases in international travel and
commerce are major factors in the spread of infectious
diseases. Microbial adaptation and change, as Dr. Josh
Lederberg has said many times, we certainly underestimated the
intelligence of microorganisms and their ability to mutate and
to become resistant to our best drugs.
So the challenge is, of course, for us to change our
behavior that often gives advantages to these organisms, but
also to continue to produce new and effective drugs.
Finally, the Institute of Medicine pointed out the role of
the breakdown in the public health infrastructure. I think we
have to be really concerned that we have in fact not maintained
a strong public health infrastructure. Many of our State public
health laboratories are unable to make some really basic
infectious disease diagnosis. We made a lot of progress in the
last 4 to 5 years with the leadership of the CDC in
strengthening State public health laboratories, working with
States, and also the research taking place at NIH and other
places, but we still have some major public health challenges.
The other point I want to make relates to the report from
the Council on International Science, Engineering and
Technology, a Committee which I chaired in 1995 that involved
17 agencies of the government. The charge to that Committee was
to look at how we could strengthen our infrastructure to deal
with the emerging infectious diseases.
In December 1995, the Committee came out with a report
which said that both domestically and globally our
infrastructure was inadequate in terms of surveillance,
prevention, response to infectious diseases, and recommended a
major effort to strengthen this global infrastructure for
surveillance and response to emerging infections.
Many things have happened since that report. It led to a
Presidential Decision Directive. We now have an interagency
task force that is leading an effort in this country to work
with our colleagues, following the leadership of the World
Health Organization to really develop a global strategy for
surveillance and response to emerging infectious diseases. Dr.
Heymann certainly will discuss that, and he is playing a very
critical leadership role.
Let me say that the challenges continue. There are several
models which we have developed, which I will not discuss in
detail here except to say that we must continue to invest in
these global efforts, whether it relates to the HIV/AIDS
initiative, which you have discussed, which certainly requires
a global effort. We need to invest heavily. The LIFE program,
Leadership and Investment in Fighting an Epidemic, is a great
beginning, and we must continue that effort. The malaria
initiative, the Roll Back Malaria from WHO, is an initiative
that deserves all of our support globally, and we hopefully
will continue to support that. The Roll Back TB program, led by
WHO, is another one.
So these are some good models. The vaccine initiative, a
very strong public-private initiative, the Gates Foundation and
others are playing a major role. Many of the pharmaceutical
companies are making available drugs needed in other countries
at low or no cost. All of these initiatives are critical for us
to continue. Partnership, leadership, vigilance is what is
I thank you for the time and will be happy to respond to
[The prepared statement of Dr. Satcher appears in the
Chairman Gilman. Thank you, Dr. Satcher. I agree that
solutions, like problems, have to be global in space and scope.
I also agree that international cooperation is vitally
necessary to combat and eradicate infectious diseases. To that
end, what will our Nation be asking of our allies and our
partners at the next G-8 meeting to make certain that a
worldwide commitment is going to be made to provide the
resources necessary to combat AIDS?
Dr. Satcher. Mr. Chairman, we will certainly ask that we
all continue to support four major efforts: The Roll Back
Malaria program, the Stop TB Initiative. TB is responsible for
millions of deaths every year in the world, and none of us are
safe from it. The HIV/AIDS initiative with the focus on sub-
Saharan Africa and increasing in Southeast Asia; the vaccine
initiative, which I think is a really critical one. I think all
of the nations throughout the world must join in providing
resources to make sure that children are immunized all over the
world. I think the best way to combat our concern for global
emerging infection is to get children immunized against those
diseases for which we can immunize. It is also the best way, I
believe, to combat the growing antimicrobial resistance of
organisms. If children are immunized, then they are not going
to get the infections.
Certainly we don't have to worry about the use of
antibiotics, but we also have to continue to develop new
antibiotics. The Vaccine Initiative is certainly one we are
going to ask our global colleagues to support and follow the
leadership of the World Health Organization, which is very
Chairman Gilman. Thank you, Dr. Satcher. The recent
outbreak of the West Nile virus in the New York metropolitan
region served as a wake-up call for our Nation. The previously
unknown viruses can be introduced in our country without too
much difficulty but with deadly consequences. What more can we
do to prevent that kind of an introduction of virus into our
Dr. Satcher. I think, again, we have got to deal with it
from a global perspective. I think we have to make sure that we
are part of a global strategy of surveillance and response,
that if we detect these viruses early, even before they get to
our country, and we control them and contain them there, then
we significantly reduce the risk that they will get to this
In addition to that, we have to maintain a public health
infrastructure in this country that can prevent the spread of
viruses, whether they are carried by mosquitoes or in the role
of migratory birds, et cetera. We have to have a strong public
health infrastructure that detects as early as possible and
then a system that allows us to respond in such a way that we
stop these viruses in their tracks.
But it has got to be a global response. We have to have
laboratories all over the world capable of detecting new
Chairman Gilman. Dr. Satcher, do we have that kind of
response team in our own NIH offices?
Dr. Satcher. Yes and no. Let me make it very clear. This is
an interagency effort. NIH is primarily responsible for
research. CDC is responsible for the leadership of the public
health system in terms of coordinating the State level response
and even making sure that our laboratories at the State and
local levels are prepared. Those States and local levels look
to the CDC for support whenever there is an issue.
So we have a partnership here among CDC, FDA, and NIH that
has to be very strong.
Let me just say I think we have made tremendous progress in
developing a public health infrastructure in recent years and
strengthening State level laboratories. I think we still have a
long ways to go. We have to bring the best technology to bear
on this issue, which means very sophisticated communication
systems. The DNA fingerprinting, the Pulse Net systems, are
making a tremendous difference, but they have to be tied to
central systems at CDC and other places.
Chairman Gilman. Dr. Satcher, how best can our Nation play
a leadership role in strengthening our global disease
surveillance in response to any outbreak?
Dr. Satcher. I think we have to make available all our very
strong science and technology. I think we ought to be very
proud of the leadership that Dr. Heymann is playing and ought
to remember that. Not only did he graduate from Wake Forest,
but he started at CDC and was sent to WHO from CDC and recently
retired from CDC. He has done a tremendous job.
He represents the kind of quality in science we have in
this country. I think we have to provide our science and
technology as parts of a team and I think we have to make our
resources available, whether it is in dealing with the AIDS
epidemic in sub-Saharan Africa, I think we have to be able to
step up to the plate and do our part, as Vice President Gore
said at the United Nations and as Congresswoman Barbara Lee
just pointed out. We have to be committed to doing our part in
terms of resources, but also making sure we have the
partnership. Scientists must come together throughout the world
as scientists to fight this battle.
Chairman Gilman. Thank you, General Satcher.
Mr. Gejdenson. Thank you, Mr. Chairman.
I was just checking with staff, I was a little confused,
all these references to sports, and coming from the State and
my district which has the two best basketball teams in all of
college at every level, both the UCONN men's and women's, I was
confused by discussions of other schools without UCONN being
central to the discussion. But I have been informed by my staff
that there are other teams at these schools that do play
Let me just say that your role here is a very critical one.
You know, when the warnings on tobacco came out, I think it
electrified America and focused us on the challenge, and we are
now adding to that cigars beyond cigarettes.
In the national security arena, we have the issue of
terrorism, and we have gotten the United States and our global
partners to recognize the challenge from international
terrorism. Although when you look at the facts, what we
confront here, not to diminish any of the others, is far more
dangerous to America than terrorism, than tobacco, and I guess
I am asking you how you would assess it, is this the major
threat to the United States that it appears to be when we look
at these facts?
Dr. Satcher. Let's make sure we agree on the facts. I am
not sure I am ready to agree that what we are confronting is
more dangerous than tobacco. I won't dwell on that.
Mr. Gejdenson. Because of the magnitude. Not to diminish
tobacco, not to diminish terrorism--but obviously one terrorist
attack can kill a lot of people.
Dr. Satcher. I think this is a very serious problem
throughout the world, and I would in no way diminish the
significance of infectious diseases. Increasingly, the reason I
said what I said, increasingly throughout the world, including
developing countries, chronic illnesses are becoming leading
causes of death. Four million people died last year in the
world due to smoking. We estimate by 2025 it could be up to 10
million, with 70 percent occurring in developing countries. We
have to do all of these things at once, unfortunately.
Mr. Gejdenson. I wasn't trying to defend tobacco.
Dr. Satcher. I know you weren't. This is a very serious
problem and we have to get on top of them. The thing about
infectious diseases is, they spread from person to person,
either directly or through intermediaries like mosquitoes. That
is why we have to be more concerned about them, unlike if you
smoke, yourself, or are exposed to environmental tobacco. But
many people get infectious diseases because they are spread to
other places by other people. We do have to contain them, and
that is what this effort should be.
Mr. Gejdenson. One of the challenges that faces the
Congress and faces the American people worldwide is the issue
of intellectual property. Now, the drugs are developed here in
the United States, about 45 percent of them, made by American
pharmaceutical companies. They need to be profitable,
obviously. They need to know when they do the research they are
going to make the profits that attract the investors. We in
Congress have not given sufficient funding to have the
government do the research to create these new drugs. But there
is a terrible challenge that occurs here. As we have seen, the
drugs are so costly that many in Africa and many in this
country can't afford them. We have to deal with that issue.
Then it is complicated by oftentimes these illnesses at first
appear to be only affecting poor people, and it is very hard to
direct private sector funding to do research for illnesses that
don't affect people in the developed world. So we have seen for
years people dying of things like diarrhea, when we know the
cures and we have come up with really inexpensive cures, but it
took a very long time to get us to pay attention to that.
I guess my questions would be, one, without undermining the
present incredibly productive pharmaceutical industry in this
country, how do we make sure we get some of those drugs to
people, how do we direct resources to deal with illnesses that
don't affect us at first in the West, you know, with good
sanitation, with proper medical care available. We seem to
think of these as developing world challenges, and it is very
hard to attract private sector resources to deal with them.
Dr. Satcher. Well, these are very critical questions and
very difficult. I think the only way that we can deal with the
appropriate distribution of drugs throughout the world to
protect all of us in this global village, and realizing we are
in this village, is that there has to be, I think, a public-
private partnership with a commitment to getting drugs to
people who need them most.
But we also need a commitment for public health
infrastructure. It is one thing to talk about making drugs
available. It is another thing to make sure the public health
infrastructure is there to appropriately prevent and educate
and diagnose early infectious diseases.
I think President Clinton's recent action in terms of
making drugs available to people in Africa was very critical,
and it recognizes a global crisis. When you have a global
crisis, you have to respond in kind. I also believe, however,
that we should not underestimate the role that our
pharmaceutical companies have played in developing new drugs.
Working with the NIH, in many cases building on research at NIH
and CDC and other places, our pharmaceutical companies have
really done an outstanding job of producing drugs. They have to
have an incentive.
At the same time, all together we have to have a public-
private partnership that says we have got to recognize that we
are part of a global community, a global village, and we have
to protect all the people in that village from infectious
diseases if we are going to protect the health of the American
people. I think that is the attitude that we have to have, and
we have to continue to come up with new strategies. We are, as
I speak. I will commend not just the pharmaceutical companies,
but foundations, like the Gates Foundation, the Turner
Foundation, Robert Wood Johnson, Kaiser, and others that I can
name, who are really stepping up to the plate and playing a
leadership role in this. The Rockefeller Foundation has been
involved in vaccine development. That is what it is going to
Mr. Gejdenson. I thank you. Obviously it will take a lot
more discussion than we have time for here, but the issue of
the infrastructure, I think the thing that shook me the most in
a sense was in many of these countries, if we could get the
drugs to the capital city, we still couldn't get them, we still
couldn't administer them to the people that need them.
Dr. Satcher. At the last meeting of the World Health
Assembly which I attended, there was a lot of discussion among
the African countries about the real challenge of using drugs,
if available, in terms of the fact it is so difficult in many
cases to make the diagnosis and keep people in systems of care.
So our commitment has to be to systems of care, a part of which
is making drugs available.
Mr. Gejdenson. Thank you.
Chairman Gilman. Thank you.
Mr. Burr. Thank you, Mr. Chairman. I think Mr. Gejdenson
hit on the real key in his last statement, and that is the
infrastructure is vital. There is no single shot solution, is
there, Dr. Satcher?
Dr. Satcher. No. I think it has to be a public-private
solution, and it has to be global in nature.
Mr. Burr. In this country, 2 years ago I think it was, we
passed legislation which was the biggest children's health
initiative, I think, it was called S-CHIP. We made the
resources available, and I am not sure what the percentage were
of States who have successfully identified and provided
coverage for every child in their State that was available for
this program. But it is a very low percentage of States who
have actually met the challenge of having the resources and
finding in fact--identifying the kids to be covered. So we have
our own challenges here, even with the resources, to make sure
that those most at risk get the services.
I want to go to the heart of the infrastructure. We learned
with the Polio-Plus program that even when governments around
the world commit to it, that sometimes it took a private
organization to go in, and in this case of Rotary, and to
implement the program in a way that could assure us of its
What effect, if any, does what we do here have on
overcoming the infrastructure deficiencies that exist in some
of these countries?
Dr. Satcher. I think it has a tremendous effect. I had the
opportunity as Director of CDC to work very closely with Rotary
International in the polio eradication program. I agree with
you, it is one of the best models I have ever seen, and I think
it is largely responsible for the progress we have made.
I think we can support the development of public health
infrastructures globally. We have our own problems. I would
just remind you the report from the World Health Organization
last week ranked us number 37 in terms of health system
efficiency. So that means that even though we spend more and
more per capita, the efficiency of our health system leaves a
lot to be desired. That is why we have got so much trouble on
the one hand of implementing CHIP, because as you pointed out,
it is probably the most significant advancement in many years
in terms of our health system.
We are having a lot of trouble implementing it and getting
children enrolled throughout the country. I believe, as you
know, we need a universal system of health care, and we ought
to move rapidly to that so we can put some of these challenges
behind us. So we can help other countries by providing support
for public health infrastructures. Again, WHO is providing
leadership in terms of that. They just came out with a very
important report on health systems and we ought to follow their
Mr. Burr. We are as susceptible as our weakest link in a
health care delivery system, and I don't quite hold the
optimism that you do that we can have the perfect system that
has no flaws. For that reason, we can't continue to, I think,
try everything, and I think that is in fact what you have
suggested we have to do as it relates to infectious disease
globally, we have to do D, all of the above.
Let me ask you specifically as it relates to the HIV/AIDS
as a national security threat. I happen to believe that in fact
it is. Were you a participant in that process where the
President designated HIV/AIDS as that threat?
Dr. Satcher. Yes, I accompanied Vice President Gore to the
United Nations on January 10th where we made our presentation
and supported Ambassador Holbrooke and moved toward a
declaration of this as a security issue. As you know, this was
the first time the Security Council of the U.N. had ever
discussed a health issue at the Security Council level.
Mr. Burr. Why limit it to one? You have listed--one
Dr. Satcher. That is a very good question. I think it is a
start, and I think the magnitude of the AIDS pandemic,
especially in sub-Saharan Africa, where 24.5 million people
have been infected, more than 2 million deaths last year, in
places like Zambia we are expecting life expectancy to drop
from around 60 to 30-something, and in Zimbabwe from 60 to 40.
We haven't seen anything like this in recent years. As I said
before, I don't know if we have seen a pandemic of this level
ever. Certainly we haven't seen an epidemic since the plague
and the pandemic of 1918.
So I do think it stands out and in the magnitude of its
impact, especially in sub-Saharan Africa. The same thing could
happen in Southeast Asia in a few years if the right measures
are not taken. So I think AIDS stands out in the terms of the
magnitude of its impacts.
Mr. Burr. I appreciate that answer. I think sometimes our
exclusion of others in fact leads us to be complacent on those
other diseases and efforts.
One last question as it relates to New York and
specifically the outbreak of West Nile.
Could you tell us based upon the infrastructure that we had
set up and the process that was in place, and I would think
that New York would be one of the better response areas because
of the interest there----
Dr. Satcher. Yes.
Mr. Burr. How did our identification take place and our
reaction happen based upon what we had planned if in fact
anything like this happened?
Dr. Satcher. I think it is a mixed picture. I mostly agree
with the GAO report. I think there is a lot to be pleased with
in terms of the detection, the early detection and
communication among members of the Public Health Service, the
State, and local, but there were also some major weaknesses in
the quality of that response that can be corrected in the
So we have a lot to be proud of in terms of the early
detection. St. Louis encephalitis, as you know, is very similar
in many ways to West Nile fever. That was the first diagnosis.
In fact, the response would be about the same in either
indication. But I think in terms of what kind of infrastructure
does it take to prevent and make sure that that infrastructure
is available in communities throughout this country, I still
think we have a ways to go.
Mr. Burr. I thank you, Dr. Satcher, and I yield back, Mr.
Chairman Gilman. Thank you, Mr. Burr.
Ms. Lee. Thank you, Mr. Chairman. Dr. Satcher, I believe,
and thank you very much for your very clear testimony, and I
believe that the Vice President and our U.N. Ambassador and
yourself were absolutely correct in sounding the clarion call
with regard to the HIV/AIDS crisis in terms of it being a
national security threat. It is important that the American
people hear you. Now we are beginning to see an understanding
as a result of the public awareness that is being raised around
the pandemic with regard to HIV/AIDS, and it is important for
us in Congress to hear that from the American people.
What is it that you think Congress can do to really move
this issue forward so that we can make sure that the resources
by the United States are there for combating infectious
Dr. Satcher. I think Congress can make sure that our
response is consistent with the magnitude of the problem. I
don't think it has been yet. I think, as former Congressman
Dellums and you and others have pointed out, this is an
indication for a major assault on a very dangerous pandemic.
Again, I could say more about the security threat, I am sure
Dr. Gordon is probably going to talk more about things like
that, but when you think about what has happened in sub-Saharan
Africa in terms of the impacts on a family, the social systems,
the education, the fact that much of the progress made in
development over many years is being undermined by this
epidemic in sub-Saharan Africa, then it is very clear it is a
very real security threat to the world as a whole.
So I believe that Congress should make available the needed
resources, and certainly UNAIDS has done a great job of
outlining what is needed, with the leadership of Peter Piot. I
agree with Dr. Piot in terms of his projection of the need for
sub-Saharan Africa. We ought to contribute our share of that.
Ms. Lee. Let me ask you also in terms of the emergence of
infectious diseases here in this country that we really haven't
seen either before in a long time, such as diphtheria and
malaria, the two Boy Scouts which got malaria as a result of a
mosquito bite in New York, is it possible that some of these
diseases such as malaria could become a problem here in this
country now, or are these very isolated instances and we know
how to contain it at that level?
Dr. Satcher. I think it is possible. I think it is going to
require a continuing investment in our public health
infrastructure to make sure that it doesn't happen. Dengue
fever, would you have thought 5 years ago that we would have 56
cases of dengue fever in Texas, and 17 of them would have been
infected within Texas, not people who migrated into Texas? We
would have doubted that.
So our failure to participate in a global system, the
extent to which we failed, I shouldn't say our failure, because
I think in many ways we have provided leadership for developing
a global system, but we need to continue to do that, and we
also need to continue to invest domestically in strengthening
our State and local public health infrastructures. I think that
is what is going to prevent this happening.
Ms. Lee. Do you think the public will is here to do that in
Dr. Satcher. I am not sure the public knowledge is there,
and that is why this hearing is so important. I think, first of
all, the public needs to know the nature of this threat, the
fact that this is in fact a global threat and that we are not
secure as long as these infectious diseases are moving
throughout the world.
So I think the public will probably follow, hopefully, with
adequate public education.
Ms. Lee. Thank you.
Mr. Burr [presiding]. The Chair would recognize Dr. Cooksey
for purposes of questions.
Mr. Cooksey. Thank you, Mr. Satcher, Dr. Satcher. It is
great to have a physician here. You have very good testimony.
It is refreshing to hear from someone other than politicians.
I am going to ask some questions that I----
Dr. Satcher. Coming from a physician, I am delighted to
hear that, a physician-politician.
Mr. Cooksey. I don't have near the depth of knowledge. You
obviously have a great depth of knowledge. Your testimony was
very clear and it is very good to have that testimony. There is
a little bit, if in fact there is a lot of demagoguery in this
body. The other day we had a group of politicians that was
going to correct the price of gasoline. I had to leave the
meeting, I was afraid I was going to get sick listening to it.
Anyway, question, first, what percentage of the cases of
infectious diseases are in sub-Saharan Africa, approximately?
Dr. Satcher. Between 70 and 80 percent, and certainly I
think 83 percent as of December last year were in sub-Saharan
Mr. Cooksey. Worldwide you mean?
Dr. Satcher. Worldwide. We estimate there are probably
about 36 million people living today who have been infected,
somewhere between 35 and 36 million, and certainly more than 25
million of them are in sub-Saharan Africa. But more than 80
percent of the deaths are occurring in sub-Saharan Africa.
Mr. Cooksey. What percentage of the world population lives
in sub-Saharan Africa, where over 80 percent of the deaths of
infectious diseases are?
Dr. Satcher. It is very small.
Mr. Cooksey. Is my number 10 percent correct, approximately
Dr. Satcher. It may even be higher.
Mr. Gejdenson. I think it is about 400 million. We have a
population of about 6 billion. So it is even less than that.
Dr. Satcher. It is less than 10 percent.
Mr. Cooksey. So it is a high percentage.
Next question, what medications that are out there to
either cure or prevent--incidentally, I took my yellow fever
shot yesterday for the first time since 1986, and got a
hepatitis shot as well. But what percentage of these
medications or specifically what medications for these
infectious diseases have been developed in Canada or in Mexico
or Europe or Asia or Africa? We had a lot of discussion
yesterday on the drug bill for Medicare patients, and I heard a
lot of comments by some self-appointed experts. I really
consider you a real scholar, so I would like to know from you.
Dr. Satcher. This scholar is going to have to get back to
you, because clearly the United States is the leader in the
development of these drugs that we are discussing. Research at
NIH of course has been really critical to that, the role of FDA
working with industries. FDA regulates the development of drugs
by industry and bringing them to market. So I think clearly we
are the leaders in that regard. But I won't say what percentage
are developed in other places.
Mr. Cooksey. I don't know that answer either.
Mr. Gejdenson. If the gentleman will yield, I think it is
45 percent of all new drugs are developed in the United States.
Dr. Satcher. We are talking specifically about the AIDS
drugs. I think it is probably higher.
Mr. Cooksey. The protease inhibitors, were any of those
developed in Europe or Mexico or Africa or Canada?
Dr. Satcher. Some of the companies are multinational. That
is a very good point. We have been talking about global. Some
of these companies are now global. We all agree most of them
have been developed in the United States, but we also know some
of the pharmaceutical companies are not just limited to the
United States any more.
Mr. Cooksey. My concern, and again this should not involve
us as physicians, but the economists and the experts here, is
that the United States is indeed developing most of these great
medications that cure infectious diseases and a lot of other
diseases, chronic diseases too, and yet these countries that
have socialized health care, like Canada, like Mexico, like
Europe, have price controls on their medications, so there is
no profit there, and there is no profit made, there is not
enough made for them to ever develop, or maybe they just aren't
smart enough to develop them in Canada or Mexico or whatever.
But I can't think of anything that has been developed. Pasteur,
Dr. Pasteur and his wife were instrumental 100 years ago. Who
developed smallpox, the British surgeon? Someone here should
Dr. Satcher. Edward Jenner actually developed the first cow
pox used in the vaccine.
Mr. Cooksey. At times I feel some consideration should be
given to telling these countries that if they are going to put
price controls on our medications in their countries, they
basically are forcing the American people to pay for research
and development of all these medications worldwide, and it is
unfortunate. Would you agree with that or disagree with that?
Dr. Satcher. I am going to disagree in part. I want to make
it very clear I think some very quality research is being done
in many other countries, and I believe the other day when we
had the conference on the human genome project, one of the
reasons we had the hookup with England, of course, I believe
about 30 percent of the people working on that project have
been in Great Britain and supported by the Welcome Trust Fund.
So Canada, there is some outstanding work going on in
Canada, some of the recently developed Level 4 laboratories
there. So there are some places in the world other than the
United States in which really high quality work is going on.
The Pasteur Institute is recognized as one of them. It is still
a very quality institute.
Mr. Cooksey. I agree there is important work being done in
these countries, but they all have offices and market their
products here. They make their profits there and not in the
U.K. Thanks you very much. Your testimony has been excellent. I
wish we could have you here testifying in front of this
Committee every time we have a meeting. It would improve the
level of the discussion.
Dr. Satcher. Thank you very much, Mr. Congressman.
Mr. Burr. The Chair recognizes the gentleman from New
Jersey, Mr. Payne, for questions.
Mr. Payne. Thank you very much. I have seen a number of the
researchers at many of the pharmaceutical companies in New
Jersey, and in a lot of instances many of the researchers are
not Americans as a matter of fact. They just happen to be here
working, just to knock the myth that only Americans can
Let me just ask a question quickly. The world AIDS
organization in Geneva is relatively newly created. What
participation does CDC have in it and how do you think they are
moving along in their activities?
Dr. Satcher. UNAIDS is a multi-agency organization that
includes WHO, World Bank, UNICEF and several others under the
leadership of Dr. Peter Piot.
I think it is moving well. It is a very difficult task they
have, and Dr. Heymann is probably going to say more about that,
he knows more about it. But we have had a very good working
relationship with UNAIDS. We have a lot to do. We know that.
But we have a lot of confidence in the leadership of UNAIDS and
By the way, I think the new Director General of WHO, Dr.
Brundtland, who we supported, is doing a tremendous job in
reorganizing. So I think we are optimistic, but it is a very
difficult road ahead.
Mr. Payne. Before the AIDS pandemic came about, malaria has
always been a big killer in sub-Saharan Africa and Africa in
general and Third World countries, but there seemed to have
been very little research and move to try to eradicate malaria.
Do you think that the fact that the people that get malaria
were in areas where they were impoverished, primarily that
there was a lack of an incentive because of the marketplace?
Dr. Satcher. The issue of eradication of a disease is a
difficult one, and I am not sure that I could do it justice
here, but let me just say the decision to embark upon the
eradication of diseases is based on several factors. When we
decided that it was possible, feasible, to eradicate smallpox,
it was because of systems that had been developed in many
places throughout the world and it was very clear what had to
be done, and that some very innovative leadership was needed. I
think the same thing is true for polio. Polio affects people
all over the world, and it affects people in developing
Our attitude in this country in terms of supporting a
commitment to eradicating a disease has been if it is feasible
to do in the near future working with our colleagues globally,
that we should join that effort.
I think there are a lot of issues related to malaria at
this point in time in terms of the appropriateness of embarking
upon an eradication program. We talk about elimination and
eradication. We have eliminated polio in the Western
Hemisphere. We haven't had a case now since 1991, the last case
in Peru, and not one in this country since 1979. There are a
lot of issues here related to malaria, in terms of whether we
are ready to embark upon a campaign for eradication. Guinea
Worm Disease, which does not even occur in this country--we are
all committed to eradicating. We are very close.
So I don't think we have made commitments just because of
what happens, whether it happens in this country or in poor
countries, because when we have seen the opportunity to
eradicate a disease, an infectious disease, for the most part
we have historically joined that effort.
Mr. Payne. Thank you. I have another two quick questions,
and then I will end. One, since we see that malaria is carried
by mosquitoes and Lyme disease by ticks, and currently AIDS
virus is not transported by mosquitoes, is there any research
going on that would determine--of course if indeed mosquitoes
could transmit AIDS, then we are in a very serious situation
What is the current medical research on that?
Dr. Satcher. I think there has been research at CDC and
perhaps other places too. I think the present position is that
there is no evidence that the AIDS virus can be transmitted by
mosquitoes. So it is transmitted human to human through sexual
intercourse and certainly increasingly IV drug sharing of dirty
needles. Those are the major ways, of course, and still mother-
to-child is a big factor in sub-Saharan Africa, by the way.
Mr. Payne. My second question, and then my last half a
statement, the fact that you have mentioned on yesterday about
the business of smoking and you also mentioned in your
testimony about the impact of smoking and deaths related to
that, my concern is that U.S. tobacco companies now are pushing
in Third World countries tobacco and smoking, making it
glamorous. Is the World Health Organization starting any kind
of campaigns to try to educate Third World people about the
dangers of smoking?
Dr. Satcher. Most definitely. That is one of the priorities
of WHO, and, again, Dr. Heymann can say more about it. But the
leadership of WHO, Dr. Brundtland, has made stopping the spread
of tobacco a major part of the WHO. There is a global
conference in August that I will participate in Chicago, I
believe there is one in China in November that I will join. But
we are also moving toward trying to get some kind of world
treaty dealing with tobacco that will affect globally this
problem and protect people globally. It is not going to be easy
and obviously Congress here will play a major role in it.
Mr. Payne. Thank you. Let me just conclude by saying that
although these statistics on HIV/AIDS are just extraordinary, I
do think that finally there is a recognition and that the whole
question that it does not exist in many countries now, they are
stepping up to the plate. Even in Zimbabwe, President Mugabe
and others are saying we have a problem and have to deal with
it. So I am optimistic, because I recall my first meetings with
President Museveni in Uganda about 10 years ago, he didn't want
to discuss it at all, it wasn't a problem, people shouldn't be
bothering with it. Then with the conversion that came along 3
or 4 years later, and then with the aggressive education
program that Uganda went out with song and dance and everybody
getting involved, we have seen the leveling off and probably
the decrease in new cases of infection.
So I am optimistic that with this attention being brought,
the article in the Washington Post on yesterday, the world
focusing on what you are doing, that perhaps the awakening of
leaders to protect, particularly in sub-Saharan Africa, to say
we really have a problem and we need some help, the education
part may come about, and I think we may see a leveling off and
perhaps then the decrease.
Dr. Satcher. I hope you are right. I think there is some
basis for optimism. Uganda, Senegal and others have
demonstrated that it can be done. So we do have some models. We
work very closely with Uganda over the last 10 to 15 years. But
this is a very serious pandemic. Nobody should for a minute
underestimate the potential of this pandemic. We have got to
get very serious globally about stopping it now.
Mr. Payne. Thank you.
Mr. Burr. The gentleman's time has expired. Do any other
Members seek time?
Dr. Satcher, we once again thank you for not only your
willingness to come and testify in front of this Committee, but
also your willingness to share with us just how big the
challenge is for us, not only internationally, but
domestically, and that we can't fall asleep and that there is
no single solution. This requires the coordination of many
efforts, including that public-private partnership. For that we
are grateful for your message today.
Dr. Satcher. Thank you, Mr. Chairman.
Mr. Burr. You are welcome. The Committee is now joined via
video conferencing, by Dr. David Heymann, Executive Director,
Communicable Diseases, for the World Health Organization. Dr.
Heymann has held this post for a number of years and has served
at the World Health Organization since 1989. Prior to joining
the World Health Organization, Dr. Heymann spent 13 years
working as a medical researcher in sub-Saharan Africa.
Therefore, Dr. Heymann actually is acquainted with the
challenges of infectious disease in the developing world.
We welcome you, Dr. Heymann, your testimony today from the
Headquarters of the World Health Organization in Geneva,
Switzerland. It is also good to have another Demon Deacon here
in this hearing.
Dr. Heymann, we now recognize you for the purposes of any
opening statement you would like to make.
STATEMENT OF DAVID L. HEYMANN, M.D., EXECUTIVE DIRECTOR,
COMMUNICABLE DISEASES, WORLD HEALTH ORGANIZATION (via video-
Dr. Heymann. Thank you, Mr. Chairman.
Congressman Gejdenson and Members, as many of you have
indicated, infectious diseases are the world's biggest killer
of young people in developing countries. In fact, they
represent 13 million deaths each year, one of every two deaths
in developing countries. You can see on the right of this pie
diagram those diseases: AIDS, malaria, TB, diarrhea, measles
and acute respiratory diseases or pneumonia. As Dr. Satcher has
indicated, sub-Saharan Africa is where the majority of the AIDS
deaths occur. The remaining infectious diseases and their
deaths are spread throughout the world, so that in Southeast
Asia, based on sheer population, one-third of all the
infectious diseases deaths are occurring.
These are diseases of the poor in both industrialized and
developing countries, and they also interfere with economic
growth, globalization and international security.
Infectious diseases impede our development efforts. They
keep children away from school and they keep adults from
working for a living. This graph shows that adults infected
with malaria are incapacitated and unable to work for an
average of 2 days in a country such as Nigeria, and an average
of 6 days in Sudan. Malaria in children prevents their mothers
from working in the fields because they must tend to a sick
child, and this often occurs during the rainy season when they
should be planting or harvesting.
[Text of the overhead review graphs mentioned appears in
Infectious diseases are one of the major reasons why poor
people remain poor.
On the next overhead, as shown in this center box, a recent
study from Harvard has indicated that Africa's GDP would be up
to $100 billion greater this year if malaria had been
controlled. This extra $100 billion would be nearly five times
greater than all development aid provided to Africa last year.
Other infections, such as cholera and plague, also cost
countries money, often because of trade barriers and decreased
tourism. Periodic food recalls because of infection can cost
millions of dollars, as in the case of mad cow disease in the
U.K., or the recall of hamburger and fruits that has often
occurred in the United States.
The global spread of diseases occurs quickly. As shown in
this map, international travel has increased from 27 percent in
Europe to 44 percent in Africa. In 1 year's time, drug
resistant TB has been imported to Germany and Denmark and there
has been an increase of 50 percent in resistant tuberculosis in
Disease, as has been said by many of the Members and by Dr.
Satcher, does not respect national boundaries. In 1991 in Peru,
a ship carrying contaminated water from Asia in its ballast
tanks sparked off a cholera epidemic that spread throughout
South America and was responsible for 11,000 deaths. Recently,
as we have heard, mosquitoes imported to the United States in
water that had collected in tires spread infection to the
CDC is one of WHO's major partners in the global
surveillance and response activities and infectious disease
control activities worldwide that are greatly supported by the
United States, and we thank the U.S. Congress for assuring that
this support continues to occur.
The security threat of AIDS and other infectious diseases
is great. As you can see on this graph, since 1945, infectious
disease has killed approximately 150 million people, while war
has killed 23 million, mainly military and some civilians. Yet
the investment for public defense in 1995 was only U.S. $15
million for infectious diseases, as compared to $864 billion
for military defense.
Immunization campaigns have eradicated smallpox, are on the
verge of eradicating polio, and are rapidly decreasing deaths
caused by measles. Vaccines have greatly reduced illness and
death during the last 30 years, and today deaths occurring from
infectious diseases are occurring in those diseases which have
no vaccines such as tuberculosis, malaria and HIV. Fortunately,
other low cost treatments and preventive measures are available
for fighting these diseases.
We are the first generation ever to have the means of
protecting the world from infectious diseases. Today we possess
the knowledge and the drugs, vaccines and commodities, to
prevent or cure the high mortality infections, tuberculosis,
malaria, HIV, diarrhea diseases, pneumonia and measles. These
tools have become available because of successful research in
the United States and other countries and the development of
research-based pharmaceutical companies, who have, as shown in
its second column on this table, developed many, many different
tools. They have given us such tools as the ingredients for
DOTS therapy for TB, which is shown in the third column, and
other treatment strategies which have been developed with
support from international organizations and also with heavy
support from USAID.
These medicines and preventive tools are inexpensive and
they are cost-effective. The cheapest of these can be bought
for less than 5 cents and even the most expensive for
tuberculosis costs no more than $20 for a full course of
treatment. As shown in the last column of this table, these
strategies are highly effective in curing infection and in
Examples of the effectiveness of these strategies is shown
in these two graphs. Malaria deaths are no longer common in
Vietnam because of advances in the use of anti-malarial drugs
and insecticide-treated bed nets. Oral rehydration therapy
developed by USAID has dramatically reduced death from diarrhea
in Mexico. TB deaths have decreased sevenfold in parts of India
through the effective use of antibiotics, and increased condom
use and health education have enabled Thailand and Uganda to
reduce the spread of HIV.
If we fail to make wider and wiser use of these medicines,
they will likely slip through our grasp because the microbes
are becoming resistant to their effect. We are in a race
against time to bring down levels of infectious diseases
worldwide before these diseases wear the drugs down first or
before new diseases arrive and collaborate to render our
interventions today ineffective.
This map shows a small sample of the infectious diseases
that have emerged or reemerged during the past 4 years. They
occur worldwide and regularly they travel with those infected.
During this month alone, we could add eight more diseases to
this map. In 1980, AIDS was just identified and would have
appeared on the map. This was the same year that smallpox was
declared eradicated. If smallpox had not been eradicated, the
world might still have its 2 million deaths each year.
Immunization with the smallpox vaccine is now known to be fatal
for people whose immune system is impaired by HIV. Just a few
years delay in eradicating smallpox might have made it
impossible to eradicate because of the arrival of HIV.
We took advantage of a window of opportunity without
knowing it. Had smallpox not been eradicated, it would be among
the top 6 infectious killers in the world today.
Antimicrobial resistance is eroding the strength of
medicines, eventually leaving them ineffective. Antimicrobial
resistance is a natural biological phenomenon amplified many
fold from overuse of medicines in developed countries and
paradoxically from under use of medicines in developing
As seen in this figure on the left, penicillin was
introduced in 1942, and already 14 percent of hospital staph
infections had developed resistance by 1946. Today penicillin
is virtually ineffective against staphylococcus, as are the
second line drugs which replaced penicillin.
The graph on the left of this next overhead shows how
rapidly resistance to salmonella, a bacterium that commonly
taints food products, has developed resistance in Germany. The
graph on the right shows how rapidly malaria has developed
resistance to all drugs used in its treatment. Likewise,
Streptomycin was once the most effective drug we had in
treating tuberculosis. Today it is virtually useless in Europe.
In the United States, a variety of medicines used to treat
patients in hospitals, such as Vancomycin, are less effective,
leading to thousands of deaths each year.
Drug resistance threatens to put simple medical treatments
out of the reach of poor people, even out of the reach of those
who are wealthy. We heard about tuberculosis in the United
States. The emergence of multi-drug resistant bacteria means
that infections in the United States which once cost $2,000 to
completely cure must now be replaced with treatments that cost
well over $200,000, and there are no known TB medicines to cure
a recently detected strain of TB in New York.
Since 1970, no new classes of antibacterial drugs have been
placed on the market to combat infectious diseases in humans.
On the average research and development of anti-infective drugs
takes 10 to 20 years, as shown in this table. Currently there
are no new antibiotics or vaccines ready to emerge from the
research and development pipeline. This is why it is urgent
that we make wider and wider use of the effective medicines and
tools we now have, before resistance makes them ineffective.
We may only have the next decade or two in which to make
optimal use of these medicines before our window of opportunity
to fight these infectious diseases closes. We must remember, as
many of the Members have said, today's world of globalization
causes a resistant organism anywhere to be a problem for us
At the same time, infectious diseases are no longer seen
exclusively as a health issue. They concern finance ministers
and the IMF as they discuss modalities for debt relief. They
concern the U.N. Security Council as it discusses HIV/AIDS in
Africa, and they concern 22 ministers of health and finance in
the Netherlands who recently conducted a summit on
tuberculosis. They concern leaders of G-8 countries meeting
this July 21 to 23 in Okinawa, as we have heard, and we
understand that the G-8 countries will consider calling for a
powerful health initiative as a contribution to reducing world
Mr. Chairman, Committee Members, it is time to go to scale
with the knowledge we have about controlling major diseases of
poverty as a means of ensuring international public health
security for us all.
The next overhead shows us what is required. A massive
effort is required to reduce the infectious diseases of
poverty. This massive effort must broaden our thinking from
vaccines as a means of preventing mortality and alleviating
poverty to also emphasize drugs and other commodities such as
bed nets and condoms. We must aim such a massive effort against
the high mortality causes of poverty, those 6 diseases which we
have talked about, and unsafe pregnancy.
At the same time, we must implement this massive effort
through weakened health systems, but we must also count on
nongovernmental organizations and communities and other proven
means to get the goods to the patients.
With a massive effort, deaths and disability caused by the
high burden diseases in low income countries could be reduced
by as much as 50 percent, as shown in the next overhead. This
could be before the year 2010. Then we could also have security
from these infectious diseases worldwide.
Two futures are equally conceivable as we enter the 21st
century. Infectious diseases can continue to burden human
development, while diseases emerge and drug resistance reverses
the scientific progress of the past century and threatens human
security; or we can make a massive effort to provide the
medical advances of recent decades to all people, dramatically
cutting the impact of infectious diseases and preventing
health, economic and security problems tomorrow.
Thank you, Mr. Chairman.
[The prepared statement of Dr. Heymann appears in the
Chairman Gilman. Thank you, Dr. Heymann, for your
informative statement on the situation on infectious diseases
worldwide. We appreciate your cooperation in testifying from
your headquarters in Geneva. We have a few questions, if you
would be pleased to entertain them.
Dr. Heymann, I understand the World Health Organization has
launched this massive effort to take advantage of our narrow
window of opportunity to eradicate these deadly infectious
diseases. Can you please explain what is different about this
effort and how the international community can better
coordinate its efforts to combat and defeat these infectious
Dr. Heymann. This effort is occurring because we are seeing
a decrease in the effectiveness of those tools which we already
have available, of the antibiotics used to treat these
infections and the various other interventions. Therefore, what
is new is we have a very short window of opportunity in which
to use these tools which U.S. industry has provided to the
We need to use them rapidly. We need to get them more
widely used throughout the world.
Chairman Gilman. Dr. Heymann, I would be interested in
knowing whether the recently announced efforts by the World
Health Organization to focus on the principal killer diseases,
AIDS, tuberculosis, and malaria, will distract in any way from
our efforts to build the health infrastructure of the
Dr. Heymann. We think that by concentrating an effort on
these infectious diseases and by getting the drugs and the
goods that are necessary to weakened health systems, we can
strengthen this by depending on nongovernmental organizations,
community structures and others to help the governments
themselves spread these goods throughout the country.
Chairman Gilman. Dr. Heymann, when the leaders of the G-8
countries meet next month to discuss, among other things, the
threat of infectious diseases, how will the World Health
Organization focus international attention on the need to build
the overall health care capabilities of the developing world?
Dr. Heymann. The World Health Organization has started two
major initiatives: The Stop TB Initiative and the Roll Back
Malaria Initiative. As we heard earlier, the UNAIDS program is
coordinating a massive effort against AIDS.
By working together with these three initiatives, and our
partners who are from both the public and the private sector,
including industry, including groups who are working on these
diseases in developing countries, we anticipate that this
massive effort that will be called for by the G-8 will be
Chairman Gilman. Thank you, Doctor. I will now recognize
the gentleman from Connecticut, Mr. Gejdenson.
Mr. Gejdenson. Thank you, Doctor. It was a pleasure meeting
with you at breakfast, I guess a week or two ago. The more we
look at this, the things you have laid out for us, obviously
are critical issues.
I guess several areas, one is we really need to get
direction on the kinds of assistance we need to provide or
guidance to develop the infrastructure, because it seems clear
that is one place that is really lacking in a lot of the
particularly sub-Saharan Africa countries, but elsewhere in the
world, where even if you have the medicine, the needles and
everything, you can't get the job done.
The second is getting the G-7 to direct some resources to
the illnesses of the poor, something Mr. Payne was pointing
out. We tend to put all of our resources or most of our
resources where it affects developed nations, and that is a
short-term obvious response, but long-term it does endanger us,
and it is just good humanitarian policy to find cures for those
illnesses that affect the developing world.
I guess the last thing is, when we looked at this 747
flight coming in from Israel with one man with, I guess,
meningitis, I mean, how concerned should we be about
bioterrorism in the sense that, here is an easy way to spread
disease very rapidly, and are we in the developed world
prepared to respond to this challenge?
Senator Schumer, our former colleague now in the Senate,
argued that the basic infrastructure systems that we have, even
in major metropolitan areas like New York City, would very
rapidly be overcome.
Dr. Heymann. Thank you. Regarding infrastructure, I think
any of us who have been in developing countries know that we
can get a Coca-Cola, a cold Coca-Cola anywhere, or a cold beer
anywhere. We can also get drugs and bed nets and condoms
anywhere. But it takes a massive effort, not just of
governments in those countries, but of the private sector, of
nongovernmental organizations, of everyone working together to
get these goods out. We are convinced these goods can be made
available, as are Coca-Colas, beer and cigarettes.
Regarding the 747 and the case of meningitis, this was one
of many cases of meningitis this year that have circulated
around the world. After the Haj in the Mecca this year, there
were over 500 pilgrims that returned to their countries in
North America, Asia and Latin America and in Africa, with
bacterial meningitis. Many of these people died and spread this
Now, this was not bioterrorism, but bioterrorism will
appear the same way. It will be an epidemic of disease
occurring somewhere, and therefore we are working closely with
CDC and with our other partners throughout the world to develop
a network which will help us identify any infectious disease
when it occurs and respond to that infectious disease on a
So we are very concerned about not only naturally occurring
infectious diseases, but about diseases which 1 day might be
Mr. Gejdenson. Thank you.
Mr. Burr [presiding]. The gentleman's time has expired. The
Chair will recognize himself.
Once again, welcome, Dr. Heymann. You have been asked and
you have addressed the issue of the infrastructure challenges
that we have that vary greatly from country to country. Let me
ask you to address the cultural hurdles that exist throughout
the world, given the fact that we can get drugs, we can get
condoms, we can get prevention there. What cultural hurdles
exist that would make us optimistic that we can overcome them
and meet this challenge?
Dr. Heymann. The cultural hurdles are many. In the early
days of HIV infection, countries throughout the world refused
to admit that they had this disease because they felt it was
stigmatizing. The same occurs with diseases such as Ebola.
People don't want to admit this disease occurs in their country
because they fear that they will be blamed if it spreads out of
their country, or they fear they are being blamed for the
disease. So culturally, countries are not willing to accept
Only by working with them, through activities such as CDC
will soon have in the Life initiative project, which is working
throughout Africa on HIV/AIDS, and this project will also be
supplemented by USAID activities, can we begin to change
cultural norms and cultural behavior.
Taxes are also a very important reason why goods don't get
into countries. We have just completed working with Uganda and
having them decrease, actually eliminate, all their import
taxes on bed nets and anti-malaria drugs for treating malaria,
so that these will not be an obstacle to infection treatment.
So what you are seeing is, working together as a global
community we can change cultural habits so that countries do
accept recommendations to drop taxes or to admit that they have
Mr. Burr. Dr. Heymann, in your estimation, can we ever hope
to actually control infectious disease, or is the best we can
do to have a better understanding of what our risk is and where
that risk may be coming from?
Dr. Heymann. We must control infectious diseases where they
are occurring, and presently they are occurring among the
poorest of the poor. Our hope is that we can decrease
mortality, decrease deaths from these infectious diseases
enough so that people do survive, do produce economically, and
pull themselves also out of poverty. We can't push people out
of poverty, we can help them pull themselves out of poverty. If
we can do that, and we can change the balance of people who are
out of poverty to those who are in poverty, there is a good
chance that we can continue the momentum to get rid of
infectious diseases, at least as major public health problems.
But they will still be with us, and there will still be the
chance of new infections jumping the barrier from animals to
humans and causing major epidemics in humans, as did HIV 20
Mr. Burr. Thank you, Dr. Heymann. Once again I appreciate
your patience during this hearing, but I am sure it was much
easier than the flight over would be.
The Chair recognizes the gentleman from New Jersey.
Mr. Payne. Thank you very much. It is according to what
time it is over there. Let me ask about the World Health
Organization. In your Report 2000, you refer to a new paradigm
to combat infectious diseases. We have had great success in the
past with the eradication of smallpox and other diseases such
as polio. Would you please explain what is new about the new
efforts to combat microbial resistance to infectious diseases
and whether the program sponsored by the United States needs to
be altered in light of the new threats?
Dr. Heymann. What has happened, and this has been through
major support from industrialized countries, including the
United States, is that we have been able to get vaccines to the
populations that needed them and we have decreased deaths
occurring from vaccine preventable diseases. Now what remains
is the diseases for which there are no vaccines.
We must continue our efforts to develop new vaccines, and
we must intensify this effort, because a vaccine is the only
way to prevent an infection and to prevent the complications of
an infection, and also to prevent the effects of drug
What we see today is that we have the drugs to treat these
major infections, but we are losing them because of resistance.
The organisms we use to treat them are rapidly becoming
resistant to these drugs.
As a result, we need to get the drugs available rapidly
while there is still time. We need to get them to all people
with infections so we can decrease infections while the
majority of these infections are still not resistant, and get
them to a level at which they will not interfere with economic
development or spread to other countries.
Mr. Payne. Thank you very much. It is sometimes suggested
that we have an overuse of antibiotics in the United States and
other industrialized countries. In terms of educational
efforts, what should we be doing here to discourage overuse and
what can we do to prevent the misuse in developing countries?
Are there any ongoing programs that you are addressing this
Dr. Heymann. Education is the answer to overcoming
antimicrobial resistance. Health workers, physicians, must not
over prescribe, and, at the same time the public should not
demand antibiotics, which many times happens. We have all gone
to a doctor and requested an antibiotic when we didn't know we
really needed one, and because the doctor wanted to make us
happy, he or she provided an antibiotic, and, if not, we went
to another doctor who did.
Education of the public decreases demand for antibiotics.
This has been shown in Canada, just next door, where they
decreased antibiotic use by over 4 percent through an education
campaign of the general public indicating that the public
should not demand antibiotics.
In developing countries, the issue is different. It is
under use which causes resistance. There we have to make sure
that the drugs are available in sufficient quantities so that
there is no under use, so that infections are properly treated.
Mr. Payne. Finally, I have heard you talk about the private
sector. How are you there at the World Health Organization
involving the private sector to meet some of these challenges?
Dr. Heymann. The original program with private segment
input was with Merck & Company from the United States, which
provided all the drugs necessary to eliminate river blindness
in sub-Saharan Africa. Since then there have been many, many
more programs. SmithKline Beecham from the United States has
provided the drug that is necessary to get rid of elephantiasis
throughout the world, and, in partnership with Merck, which is
providing Ivermectin, another drug also useful in this disease,
we will eliminate this disease from the world.
At the same time, the Novartis Company has given all the
drugs necessary to get rid of leprosy. Pfizer has given drugs
to eliminate trachoma as a public health problem. So companies
have joined with WHO in providing the goods necessary. When
this occurs, other partners come in very rapidly, from the
private sector, from the nongovernmental organizations and from
governments such as the United States
So what we are seeing is the private sector is catalyzing
the possibility of eradicating and eliminating many infectious
diseases, but this is a short-term solution. We need also to
have industry at the same time producing the new vaccines and
the new drugs that are necessary for the future.
Mr. Payne. Thank you very much. I am very aware of the
Merck project, since it is in New Jersey, and I visited them
while they were working on the river blindness, and Du Pont
providing some of the nylon to be used in the process, and, of
course, former President Carter taking this on as a main issue.
So we do know that that cooperation between private and public
is very important.
Thank you very much for your testimony.
Chairman Gilman [presiding]. Thank you, Mr. Payne. Mr.
Mr. Meeks. Thank you, Mr. Chairman. Doctor, thank you. Your
testimony has been very informative.
Let me ask a question in that in developing nations, they
have a whole host of problems and issues, and the statistics
you utilized to show this, talking about the economic impact of
infectious diseases in developing nations, is astounding. But
one of the things that I think happens, and I ask you do you
agree, that a large part of the problem is the willingness of
developing countries to acknowledge that they in fact have
these kinds of health problems and as a result the economic
So my question to you is how does the World Health
Organization work with governments to help them understand that
they have that problem so they can address their health care
Dr. Heymann. It is true that governments many times want to
close their eyes to problems and commitment to health is very
low in most developing countries.
The way that the World Health Organization works to
increase the importance of this is through global meetings or
summits. For example, we worked with the president of Nigeria
in April of this year in which we had a summit of African heads
of State who discussed malaria, who committed by signing a
declaration to work to eliminate malaria as a public health
problem in Africa.
They signed an agreement that they would commit resources
and the WHO and other partners agreed that they would provide
The same thing happened in tuberculosis. The government of
Netherlands hosted a tuberculosis summit where ministers of
health and ministers of finance from the 22 tuberculosis
burdened countries, those countries with the most tuberculosis,
met. Secretary Shalala was present at this meeting in the
Netherlands in March.
At this meeting, ministers of health and finance both
signed a declaration on the willingness of these countries to
commit funds to the elimination of tuberculosis while the
window of opportunity is still open.
Mr. Meeks. We talked and I know that a significant amount
of resources, although the resources that are going toward
health care in the chart that you showed was a drastic
difference, $15 billion for research in dealing with vaccines,
et cetera, as opposed to 400 and some odd billion we invest in
defense, but a significant amount of those resources have been
made available to develop vaccines for a whole host of
infectious diseases. I understand the importance of them. But
what are the specific health care tools that the World Health
Organization considers of vital importance to immediately
combat diseases that can be prevented or treated, such as
tuberculosis, malaria and the measles?
Dr. Heymann. The tools that we have today are a vaccine for
measles. This must be expanded, because measles kills many
children. It still kills about 1 million children in the world.
So we need to get this vaccine out. It is available, we need to
get it out.
For tuberculosis, we have antibiotics. For diarrheal
diseases, which kill the majority of children in developing
countries, we have oral rehydration therapy, which was
developed with support from USAID. We now need to get these
goods out to the people, through a massive effort, making use
of any delivery system we can.
Mr. Meeks. I am listening and you are telling me that we
have these vaccines that are readily available, we need to get
them out. What can we in the United States, what can we do to
help get them out, because as indicated throughout the
testimony, this may be happening or occurring in the developing
nations now, but tomorrow someone can take a plane ride and
they are here in the United States of America. So it is in our
national defense to get these vaccines out. What in addition to
what we are doing can we in the United States and the G-7
nations do to get them out and distribute them in a more timely
Dr. Heymann. The United States, as you already said, is
doing a lot. But what we need to think now is in much greater
terms. We know that the G-7 this year will be promoting a fight
against the diseases of poverty. What we need to do is think
not in millions, but in billions of dollars.
We estimate that by an investment of $15 billion in getting
the goods available, the drugs and the bed nets and the condoms
available to countries, to NGO's, that we could halve
infectious disease mortality from the major infectious diseases
in the next 10 years.
That takes much bigger thinking than we have done before.
It takes dependence on many, many types of distribution systems
in countries. But we feel it can be done, and we are very
pleased that the G-7 is taking this up as an issue in the
meetings coming up in Japan.
Mr. Meeks. Thank you.
Chairman Gilman. Thank you, Mr. Meeks.
Any other questions? Mr. Burr?
Mr. Burr. No.
Chairman Gilman. Mr. Payne, any additional questions?
Mr. Payne. No, Mr. Chairman.
Chairman Gilman. If not, Dr. Heymann, we thank you very
much for taking your time to be with us by way of video
conferring. We thank you for your recent visit to Washington.
We hope we will see you again soon. Keep up your good work.
Dr. Heymann. Thank you, Mr. Chairman.
Chairman Gilman. We will now proceed with our next witness,
Dr. David Gordon, National Intelligence Officer of the National
The Committee is pleased to welcome the testimony of Dr.
David Gordon of the Economics and Global Issues Section of the
National Intelligence Council. Prior to joining the NIC, Dr.
Gordon was U.S. Policy Program Director of the Overseas
Development Council, and in early 1990's, Dr. Gordon served as
a professional staff member of the House International
Welcome back, Dr. Gordon.
STATEMENT OF DAVID F. GORDON, PH.D., NATIONAL INTELLIGENCE
OFFICER OF ECONOMICS AND GLOBAL ISSUES, NATIONAL INTELLIGENCE
Mr. Gordon. Thank you very much, Mr. Chairman.
Chairman Gilman. Please proceed. You may put your full
statement in the record and summarize, whichever you deem
Mr. Gordon. Thank you very much, Mr. Chairman. I want to
thank you and the Distinguished Members of the Committee for
providing me the opportunity to participate in this very
It certainly is an honor for me to share the podium with
Dr. Satcher and Dr. Heymann, both of whom I greatly respect and
admire. My testimony this morning will be drawn from a
declassified national intelligence estimate recently produced
under my direction entitled ``The Global Infectious Disease
Threat and Its Implications for the United States''.
As you know, Mr. Chairman, NIE's are prepared for the
President and other senior policy makers on issues that have
strategic implications for the United States, and they
represent the most authoritative assessments of the
Intelligence Community because they reflect the coordinated
judgments of the senior officers of all of the relevant
The Infectious Disease Estimate represents an important
initiative on the part of the Intelligence Community to
consider the broad national security implications of a
nontraditional but highly lethal threat. My remarks today will
focus on the social, economic, political and security
implications of the infectious disease threat. We have heard a
lot about the science and the epidemiology from our
distinguished panelists this morning.
The Estimate's most significant judgment is that new and
reemerging diseases will pose a rising and in the worst case a
catastrophic global health threat that will complicate U.S. and
global security over the next 20 years. These diseases will
endanger U.S. citizens at home and abroad, threaten U.S. Armed
Forces deployed overseas, and exacerbate social and political
instability in key countries and regions where the United
States has significant interests.
In national security terms, the global infectious disease
threat manifests itself in a number of ways. First is the link
between infectious diseases and the increasing possibility of a
biological warfare or biological terrorism attack against the
United States or U.S. equities overseas as hostile states and
terrorist groups exploit the ease of global travel and
communications in pursuit of their goals.
Today, at least a dozen states are pursuing offensive BW
programs, as are a growing number of terrorist organizations.
The West Nile virus scare in the New York-Connecticut area last
year indicates the confusion and fear that even the possibility
of a BW attack can sow, and it highlights the importance of
effective collaboration among public health authorities, law
enforcement agencies, and the Intelligence Community in
monitoring global BW threats.
Second is the direct risk posed to U.S. health by the
importation of infectious diseases which, as we have all
discussed this morning, do not respect national borders.
The next major infectious disease threat to the United
States may be like AIDS, a previously unrecognized pathogen, or
it may be a new strain of influenza developing in Asia. Flu now
kills some 30,000 Americans annually. Epidemiologists generally
agree it is not a question of whether, but when the next killer
flu pandemic will occur.
Or it may be, as several people emphasized this morning,
drug resistant TB, which we thought we had under control but is
now being brought back into the United States by travelers and
The third national security dimension is the potential
impact on the military, both U.S. troops abroad and on the
readiness of foreign militaries and their ability to engage in
international peacekeeping operations. U.S. military personnel
deployed in support of peacekeeping and humanitarian operations
in developing and former communist countries will be of highest
Fourth, the worst infectious diseases, TB, malaria, and
especially AIDS, are slowing economic development in and
undermining the social structures of countries and regions of
specific interest to the United States. As the most recent
UNAIDS report that was highlighted in the media yesterday
underscores, this will challenge democratic development and
transitions and possibly contribute to humanitarian emergencies
and to military conflicts to which the United States may be
expected to respond.
Fifth, in the economic realm, infectious disease-related
embargoes and restrictions on travel and immigration will be a
source of friction among and with key U.S. trading partners and
other states and the issue of intellectual property rights with
respect to new and existing drugs promises to become a major
source of controversy between developed and developing
The outlook for infectious diseases shows extreme
geographic variation, both between and within regions.
Developing and former communist countries will continue to
experience the greatest impact, but developed countries will
also be affected. Although global health care capacity has
improved substantially in recent decades, the gap between rich
and poor countries and the availability and quality of health
care is widening and the revolution in medical technology may
reinforce this trend.
Almost all research and development funds allocated by rich
country governments and the pharmaceutical industries are
focused on advancing therapies and drugs relevant to rich
country maladies. In general, our study highlights a very close
linkage between persistent poverty, malnutrition, poor levels
of health care, and social and political insecurity on the one
hand, and high levels of infectious diseases prevalence on the
Let me speak to the social, economic and political impacts.
The persistent infectious disease burden is likely to aggravate
and may even provoke social fragmentation, economic decay and
political polarization in the hardest hit countries in the
developing and former communist worlds. At least some of the
hardest hit countries, initially in sub-Saharan Africa and
later in other regions, face a demographic catastrophe as AIDS
and associated diseases reduces human life span dramatically
and kills up to one-quarter or more of their populations over
the next 15 years, including up to one-half of their youth.
Last year, 10 times as many people in sub-Saharan Africa
died of AIDS than died of civil conflicts.
Life expectancy is likely to be reduced by 30 years in
Botswana and Zimbabwe, 20 years in South Africa, 13 years in
Honduras, 8 years in Brazil, and 3 years in Thailand.
AIDS, particularly in Africa, has hit very hard the
professional classes of teachers, civil servants, engineers and
skilled workers who have formed the social backbone of recent
advances in both political and economic liberalization. The
degradation of nuclear and extended families from all across
the social structure will produce severe social and economic
dislocations with likely political consequences as well.
With as many as a third of the children under 15 years of
age in the hardest hit countries, some 42 million by 2010,
expected to comprise a lost orphan generation, these countries
will be at risk of further economic decay, increased crime and
political instability as these young people become radicalized
or are exploited by various political groups for their own
The economic impact of infectious diseases is already
significant and is likely to grow. They will take an even
higher toll on productivity, profitability and foreign
investment, again especially in those most affected countries.
World Bank President James Wolfensohn has recently declared
AIDS to be the single greatest threat to economic development
in sub-Saharan Africa, and a growing number of studies suggest
that AIDS and malaria will reduce GDP growth in Africa by 20
percent over the next decade.
The impact of infectious diseases at the sector and firm
level is already substantial and growing, and will be reflected
in higher GDP loss as well, particularly in the more advanced
developing countries with specialized work force needs, such as
Several firms have undertaken surveys recently of the costs
of AIDS on profitability and productivity, and these tell a
story that has the potential of having a truly devastating
impact as costs escalate and the investment climate
Infectious diseases also will add substantially to national
health bills, setting the stage for cruel budgetary dilemmas
and conflicts. For instance, treating one AIDS patient even
modestly in sub-Saharan Africa costs as much as educating 10
primary school students for a year. In Zimbabwe, already half
the meager health budget is spent on treating AIDS, while in
Kenya AIDS treatment costs will rise to 50 percent of health
spending over the next several years.
Few countries will be able to afford the high cost of
multi-drug treatments for AIDS, ensuring that this disease will
continue to be highly prevalent.
The political impact of infectious diseases will be
indirect and it will be direct to assess with any precision,
but it is our view that the infectious disease burden threatens
to add to political instability and slow democratic development
in social security in Africa, parts of Asia, and the former
Soviet Union, and may become a growing source of political
tensions in and among some developed countries as well.
The severe economic impact of AIDS and other diseases and
the infiltration of these diseases into ruling political and
military elites is likely to intensify the struggle for
political power to control scarce resources. Mounting
infectious diseases cause deaths among the officer corps and
may also continues contribute to deprivation, insecurity and
political machinations that incline some to launch coups and
contrecoups aimed as often as not at plundering state coffers.
The human losses from infectious diseases is already hampering
the development of civil society and will increase the pressure
on democratic transitions in sub-Saharan Africa and the former
A CIA-sponsored study on the causes of instability suggests
that infant mortality, highly correlated with infectious
diseases, is a powerful predictor of political instability,
especially in those states that have started along a democratic
path but have not yet fully consolidated a transition to
Infectious diseases also will affect international security
and peacekeeping efforts as militaries and military recruitment
pools experience increased deaths and disabilities. The
greatest impact will be among hard to replace officers, NCO's
and enlisted soldiers with specialized skills among militaries
with advanced weapons and weapons platforms of all kinds.
HIV/AIDS prevalence in the militaries of heavily infected
countries is considerably higher, often twice as high as the
rates among civilian populations, owing to risky lifestyles and
deployments away from home. Militaries in several former Soviet
Union states are increasingly experiencing the impact of
negative health developments within their countries and one in
three Russian draftees is currently rejected for health reasons
as compared to only one in 20 back in 1985.
While it is difficult to make a direct connection between
high rates of HIV/AIDS prevalence and other infectious diseases
on overall military performance and readiness, it is likely,
given a large number of officers and other key personnel are
dying or becoming disabled, that combat readiness and
capability of such military forces is bound to deteriorate.
Over the longer term, the consequences of the continuing
spread of deadly diseases such as HIV/AIDS on the more
modernized militaries in the former Soviet Union and possibly
China, India and some other states in Africa, may be
increasingly severe and have an impact similar to what we are
seeing in sub-Saharan Africa.
The negative impact of high infectious disease prevalence
on national militaries will be felt in international and
regional peacekeeping operations as well, limiting their
effective necessary and making them vectors for further spread
of diseases among coalition peacekeepers and local populations.
Healthy peacekeeping forces will remain at risk of being
infected by disease carrying forces and local populations as
well as by high risk behavior and inadequate medical care.
Chairman Gilman, thank you very much for your attention. I
will be happy to answer any questions that you or other Members
of the Committee have.
[The prepared statement of Dr. Gordon appears in the
Chairman Gilman. Thank you, Dr. Gordon. We thank you for
your review of this problem. How capable is U.S. Intelligence
Community in the field of bioterrorism? To your knowledge, has
our Intelligence Community been successful in thwarting any
bioterrorist attacks in the form of infectious diseases?
Mr. Gordon. The Intelligence Community is increasing its
focus on biological warfare and has an increasing capability to
monitor the efforts of both hostile regimes and other groups.
That said, that said, we are concerned both about the
groups we know about and the groups that we don't know about.
While the risk of biological warfare is still a small one in
percentage terms, the impact is potentially very, very, very
great. We are working very hard, both with people in the public
health communities, with people in the law enforcement
communities, both nationally and internationally, to increase
our capability to monitor the efforts of those who would do us
Chairman Gilman. Dr. Gordon, you noted in your testimony
despite your collaboration with the World Health Organization
progress has been slow to be able to strengthen your
surveillance programs. In your opinion, what additional
specific measures should be undertaken to enhance the
surveillance of infectious diseases? Also, are there any
additional early warning systems that should be developed to
enhance our capabilities to detect any bioterrorist threats to
Mr. Gordon. I think that the answer lies in enhancing
international collaboration, enhancing the U.S. role, already a
very strong leadership role in international efforts on
surveillance, working with the world health organizations.
We have been quite impressed by the improvements made in
the world health organizations by Dr. Heymann and his
colleagues that currently undertake a highly sophisticated
epidemiological intelligence operation to ensure that new
pathogens, as soon as they are noticed, can be quickly
identified and linked up into broader intelligence and law
enforcement operations to judge whether or not they pose a
political threat as well as a health threat.
I think that a good deal of diplomacy will be needed, both
at the bilateral and multilateral level, to increase
collaboration, particularly by developing country governments
with these efforts internationally.
Chairman Gilman. Dr. Gordon, one last question. In addition
to the danger posed to American Armed Service personnel who
serve overseas, is there an increased danger to the American
public of diseases unwittingly brought to our shores by
soldiers returning from overseas duty? Does the military have
adequate measures in place to both safeguard the health of
military personnel and to prevent their becoming unwitting
carriers of infectious diseases?
Mr. Gordon. The military is constantly monitoring these
issues. In fact, within the Intelligence Community, our main
component that works on these issues is in Armed Forces
intelligence. We at this point are satisfied that we do have
the capabilities to ensure that returning U.S. military
personnel will be effectively screened so as to ensure that an
infectious disease that might have been acquired while
overseas, either in a normal deployment or in a peacekeeping
operation, does not get transmitted to the United States.
These, however, are not foolproof and depend upon the
existence of a robust overall surveillance program
Chairman Gilman. Thank you, Dr. Gordon.
Mr. Payne. Thank you very much for your very clear paper
and your comments. I was also concerned about what steps the
military, and maybe the question wasn't asked, what steps are
we taking with our military as they are overseas? I know we
don't have--we have virtually no U.S. peacekeepers in sub-
Saharan Africa, but we do have them in Eastern Europe and Asia
where I am sure, the disease is not as prevalent, but it is
What do we do when they are in the regions outside of the
country to ensure that their health and safety is provided for?
Mr. Gordon. There are basically three elements to the
efforts of U.S. military to ensure the health of U.S. forces
First, are that U.S. forces have as comprehensive and up-
to-date immunization package as exists in the world. We work
very, very hard to ensure that happens, and, again, that is
partially facilitated by the international collaboration that I
have been talking about.
Second, is education, to ensure that our soldiers know what
the risks are and know how to protect themselves against those
risks and are constantly being reeducated about those issues.
Third, is monitoring, and there is a very aggressive
program of monitoring the status, the health status, of U.S.
forces deployed overseas.
Mr. Payne. Thank you. Perhaps you could explain a little
bit to us about the general overview of the contingency plans
that exist should the worst case scenario develop with regard
to the spread of infectious diseases in developing countries.
Specifically, what measures would the United States have to
undertake in the event that the spread of infectious diseases
were to be unchecked as set forth in part of your statement?
Mr. Gordon. Mr. Payne, I think that our main efforts have
gone into working to ensure that the worst case scenario is not
going to take place, so part of the whole aim of international
efforts here at both surveillance and response to infectious
diseases is to try to minimize the likelihood of the worst case
scenarios coming into play.
That being said, we are already in sub-Saharan Africa and
in several of the sub-Saharan African countries, in a situation
that is, if not a worst case, close to a worst case scenario,
and we are trying to work collaboratively both with those
governments, with the international community, institutions
like the World Health Organization, the international financial
institutions, particularly the World Bank, to ensure that there
is as effective as possible a response to these issues.
There is no grand plan for a worst case scenario developing
which would occur over a longer term. Certainly if we see
ourselves moving into that scenario, I think planning for those
contingencies would take on a more prominent role.
Mr. Payne. Thank you. In your opinion though, is there an
effective coordination between the military intelligence and
science and health communities in addressing the infectious
disease threat? Do you all kind of stay in touch with each
Mr. Gordon. We are certainly pleased by the increasing
degree of collaboration on biological terrorism and biological
warfare. There is increasingly close collaboration between the
Department of Defense, the Centers for Disease Control and the
Intelligence Community in monitoring and working together to
plan contingencies to address these issues. I think that is one
of the large advances that we have made in recent years.
Mr. Payne. Just finally, do you feel that Congress is
providing enough assistance to deal with these infectious
diseases, for security and surveillance programs and all the
rest? I know it is a real concern, and our goal is to provide
assistance overseas as needed, but also to safeguard the health
of American people. What is your feeling on that question?
Mr. Gordon. Congress has been responsive to the requests
for support from the Intelligence Community, and I believe that
as we stand now, we are in an adequate situation. I think as
several of the other speakers mentioned, in the larger view of
the infectious disease threat, I think that the international
community as a whole is just beginning to come to grips with
the resource mobilization that will be needed.
Mr. Payne. Finally, it has been mentioned that it has been
declared that this whole question of infectious disease is a
national security issue or threat. Do you concur with that
Mr. Gordon. Yes, I think that as several speakers today
have highlighted, both among the Members and the panelists,
that taken together, I think the range of effects that the
rising global infectious disease trends provides to the United
States raises some very, very serious national security
I would not want to get into an academic exercise of trying
to define precisely whether and when something becomes a
national security issue or a national security threat, nor
would I suggest that all health issues are national security
issues. I think many, if not most health issues, are not
national security issues, they are public health issues.
But in general for the reasons I laid out in my testimony,
we see a whole series of national security concerns attached to
the infectious disease threat, which in sum I do believe raise
it to a national security interest of the United States.
Mr. Payne. Thank you very much.
Mr. Burr [presiding]. I thank the gentleman from New
Jersey. The Chair would recognize himself. Welcome, Dr. Gordon.
You and I have had an opportunity to spend some time together
to talk in depth, so I will be very brief today.
Let me followup on Mr. Payne's comments as it relates to
the cooperation, collaboration, between intelligence, the
science community, the health community.
I sensed just a little bit of hesitancy in the answer from
the standpoint of the way the question was posed, so let me try
to restate it and hopefully solicit an answer that covers
everybody in that loop.
From the standpoint of the military, the Intelligence
Community, the science community, the health community, is
there the level of cooperation between all of those that makes
you feel confident that we are on top of this challenge of
infectious disease and its threat?
Mr. Gordon. I believe, as I said earlier, that we are still
at a place where we have work to do, both as a national
government and internationally as a global community, in
effectively addressing the global infectious disease threat.
I do believe that as a government we have taken very
significant steps to enhance collaboration among the scientific
community, the national security establishment, and the
Intelligence Community, particularly on issues relating to the
biological weapons threat per se.
We also now have an interagency working group at the White
House level on AIDS that is working to bring together all of
the various elements in government who have a stake in the AIDS
I think the fact of the matter is that as both of our
previous speakers emphasized, that coming to grips with the
global infectious disease threat is not something that is going
to happen overnight, and that there is still a need to mobilize
support, both publicly and privately, so that a sufficiently
robust effort is made that will enable us to turn the corner on
Mr. Burr. You are, and I think it is safe to say the
Congress is, aware of the challenges that exists between
agencies to communicate, and when we bring health and the
science community into it, it is naturally a challenge. But in
fact that level of communication has to exist if in fact we
want to be ahead of a problem that we can't stick our finger
out today and say ``this is it,'' because it is a range of
scenarios that could pop up is the problem.
I trust that you, from the standpoint of the intelligence
agencies, like I would the health community who was here
earlier, will share with us when you think that there is help
that is needed from this body to make sure that that
cooperation and collaboration, not only to address an existing
problem, but to anticipate where our greatest needs might be in
the future and when we can help.
Let me ask one question, and that deals with HIV as the
only designation from the infectious disease as a national
security threat. I personally agree with that designation. I am
not sure that I would limit it to one infectious disease, and I
would ask you from the standpoint of the Intelligence
Community, was that your recommendation as well, or would you
include additional infectious diseases at the same level that
you would AIDS/HIV?
Mr. Gordon. We have done a lot of work on the issue of HIV/
AIDS, on the impact of HIV/AIDS on militaries. Certainly the
work that was undertaken on this issue by the Intelligence
Community was a major input into this designation.
In our study of infectious diseases and their implications
for the United States, we did take a broader look at the global
infectious disease environment, and I do think that while I
agree with you that while HIV/AIDS in and of itself is a
security issue globally and to the United States, there is a
I don't believe that there is necessarily a tradeoff
between dealing with HIV/AIDS on the one hand as a security
threat and dealing larger--with infectious diseases more
generally as a security threat, but I do think it is something
we have to pay attention to, that HIV/AIDS is not the only
disease out there.
Mr. Burr. Is there a reason that the national security
threat was not infectious disease versus one specific
Mr. Gordon. We were asked by the State Department, the
Secretary of State, to look at infectious diseases more
generally when this paper was tasked to us.
Mr. Payne. Would the gentleman yield? I listened to the
question regarding--and there is no question about the fact
that malaria really is a real killer and tuberculosis is
increasing. But when I read that Washington Post article on
yesterday, I mean, we have got a lot of diseases, and we have
bad diseases and tough diseases and diseases that have been
around, but we have never had a disease that has reduced the
life expectancy by one-third in 3 or 4 years. I mean, this is
magnitude that the Black Plague in Europe didn't even
experience. The life expectancies of 20 years and 25 years in
some countries at this point, I mean, I concur that there are a
number of serious problems that we have around, even more being
discovered in food products.
We once thought if you just ate chicken, you were fine,
leave the pork alone. Then you find, there was salmonella or
whatever comes up, and beef was always definitely OK, but now
you find you got to be careful, we can't leave the beef out
when you do your backyard cooking. So we are discovering a lot
more in food products, shellfish, you got to watch that, you
know. I am on carrots right now.
But there has been nothing that I can remember, reading
history or at the present, that is anywhere near, in my
opinion, as devastating as this pandemic. I think this AIDS and
HIV virus is really standing in a class all by itself, is the
way I see it. But that is not to--you know----
Mr. Burr. The gentleman's point is a very important one,
and one I would agree with. My question stems more from the
fact that we do know the means of transmission for AIDS, we do
see and can follow its progress from sub-Saharan Africa to
Asia, and we have a history which gives us a good gauge for
what the threat is to the new areas that HIV/AIDS is emerging
But from a standpoint of the other infectious diseases that
we might not yet know the scope of transmission, that we might
be faced with resistant strains without the tools to treat it
today, in fact there is a bigger question mark and an unknown
as it relates to its impact 10 years down the road, and I raise
the issue more to make sure we are not focused on one area of
the water balloon while there is a squeeze somewhere else and a
bulge that is in fact created. I think it goes hand in hand
with my original question to Dr. Gordon.
Mr. Gordon. Congressman, I think you are absolutely right,
that the issue of global surveillance and having the ability to
monitor infectious disease outbreaks and understand the
epidemiology and likely epidemiology of those outbreaks is
So I think that it is not a question of focusing on HIV/
AIDS, but not focusing on other particular diseases, but
especially not losing track of the ability of the international
community to build a very, very robust surveillance system.
Mr. Burr. My hope is that not only the communications
within our branches of not only government, the health
community and the science community, are in fact strong, but
that the world health organizations can compel other countries
to bring their similar communities together to make sure that
the review of this threat worldwide is one that we all take
seriously and all share the information.
Mr. Payne. If the gentleman would yield, I am in concert
with the fact that we are looking at drug resistant strains of
tuberculosis and so forth. As a matter of fact, when
tuberculosis reappeared, there was no streptomycin around,
because no one had it around because there was no tuberculosis
around, so they had to run around to find some streptomycin,
and they found a little place in France that still had some
So we do have to really remain focused.
But, for example, are we doing anything, Dr. Gordon, say
with the problem of the tough strains of tuberculosis in the
Russian prison system, where I understand that infection is
almost at epidemic proportions and the strains are tough?
Mr. Gordon. Yes, it is. The issue of drug resistant
tuberculosis, particularly in Russia and some of the other
areas of the former Soviet Union, is one of the major
infectious disease issues as we see it evolving over the next
several years. It is something that a great deal of attention
is being paid to.
Again, none of these issues, and I want to emphasize what
Dr. Heymann and Dr. Satcher said, none of these issues is
amenable to an easy or quick resolution. Even on AIDS, on which
we know the elements of a strategy that works, combining
political leadership, education and destigmatization of the
disease, and partnerships between the private sector and
nongovernmental organizations and both local governments and
the international community, we know a strategy that works. But
that doesn't mean that you can easily turn the problem around.
The issue of TB and drug resistant TB, I think it is going
to be one of the very large challenges we face over the next
Mr. Burr. I thank the gentleman from New Jersey. I also
thank you, Dr. Gordon, for your patience and willingness to
compile the report that you did, and to share with this
Committee in a number of fashions the findings of your
The unfortunate conclusion of this hearing is that we will
continue to meet on this issue well into the future, and my
hopes are today that we are able to narrow the threats down and
to talk about successes, not only here at home, but abroad in
some of the many countries we have talked about.
At this time this hearing is adjourned.
[Whereupon, at 2:50 p.m., the Committee was adjourned to
reconvene subject to the call of the Chair.]
A P P E N D I X
June 29, 2000