[House Hearing, 106 Congress]
[From the U.S. Government Printing Office]




                               BEFORE THE

                              COMMITTEE ON
                        INTERNATIONAL RELATIONS
                        HOUSE OF REPRESENTATIVES

                       ONE HUNDRED SIXTH CONGRESS

                             SECOND SESSION


                             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/



67-067                     WASHINGTON : 2000


                 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
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
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
    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
                    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


Prepared statements:

The Honorable Benjamin A. Gilman, a Representative in Congress 
  from New York and Chairman, Committee on International 
  Relations......................................................    48
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

Additional material:

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 
  Gejdenson......................................................   132



                        THURSDAY, JUNE 29, 2000

                          House of Representatives,
                      Committee on International Relations,
                                                    Washington, DC.
    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 
standard antibiotics.
    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 
United States.
    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 
become indifferent.
    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 
developing world.
    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 
York City.
    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.
    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 
    Thank you.
    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 
this morning.
    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.

                         HUMAN SERVICES

    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 
infectious diseases.
    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 
major role.
    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 
any questions.
    [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 
own Nation?
    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.
    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.
    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 
disease, HIV/AIDS.
    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.
    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 
know that.
    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 
discover things.
    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 
WHO generally.
    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 
countries disproportionately.
    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.


    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 
the appendix.]
    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 
these countries.
    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 
preventing death.
    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 
developing nations?
    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 
disease elsewhere.
    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 
global basis.
    So we are very concerned about not only naturally occurring 
infectious diseases, but about diseases which 1 day might be 
caused intentionally.
    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 
these diseases.
    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 
infectious diseases.
    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 
years ago.
    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 
problem with?
    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 
additional resources.
    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 
Intelligence Council.
    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 
Relations Committee.
    Welcome back, Dr. Gordon.


    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 
important hearing.
    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 
South Africa.
    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 
Soviet Union.
    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 
our country?
    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.
    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 
this issue.
    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 
larger context.
    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 
infectious disease?
    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 
crucially important.
    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 
several years.
    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