[Senate Hearing 109-139]
[From the U.S. Government Publishing Office]



                                                        S. Hrg. 109-139
 
                EXAMINING USAID'S ANTI-MALARIA POLICIES

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

                                HEARING

                               before the

FEDERAL FINANCIAL MANAGEMENT, GOVERNMENT INFORMATION, AND INTERNATIONAL 
                                SECURITY

                                 of the

                              COMMITTEE ON
               HOMELAND SECURITY AND GOVERNMENTAL AFFAIRS
                          UNITED STATES SENATE


                       ONE HUNDRED NINTH CONGRESS

                             FIRST SESSION

                               __________

                              MAY 12, 2005

                               __________

                       Printed for the use of the
        Committee on Homeland Security and Governmental Affairs


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        COMMITTEE ON HOMELAND SECURITY AND GOVERNMENTAL AFFAIRS

                   SUSAN M. COLLINS, Maine, Chairman
TED STEVENS, Alaska                  JOSEPH I. LIEBERMAN, Connecticut
GEORGE V. VOINOVICH, Ohio            CARL LEVIN, Michigan
NORM COLEMAN, Minnesota              DANIEL K. AKAKA, Hawaii
TOM COBURN, Oklahoma                 THOMAS R. CARPER, Delaware
LINCOLN D. CHAFEE, Rhode Island      MARK DAYTON, Minnesota
ROBERT F. BENNETT, Utah              FRANK LAUTENBERG, New Jersey
PETE V. DOMENICI, New Mexico         MARK PRYOR, Arkansas
JOHN W. WARNER, Virginia

           Michael D. Bopp, Staff Director and Chief Counsel
      Joyce A. Rechtschaffen, Minority Staff Director and Counsel
                      Trina D. Tyrer, Chief Clerk


FEDERAL FINANCIAL MANAGEMENT, GOVERNMENT INFORMATION, AND INTERNATIONAL 
                                SECURITY

                     TOM COBURN, Oklahoma, Chairman
TED STEVENS, Alaska                  THOMAS CARPER, Delaware
GEORGE V. VOINOVICH, Ohio            CARL LEVIN, Michigan
LINCOLN D. CHAFEE, Rhode Island      DANIEL AKAKA, Hawaii
ROBERT F. BENNETT, Utah              MARK DAYTON, Minnesota
PETE V. DOMENICI, New Mexico         FRANK LAUTENBERG, New Jersey
JOHN W. WARNER, Virginia

                      Katy French, Staff Director
                   Sean Davis, Legislative Assistant
                 Sheila Murphy, Minority Staff Director
            John Kilvington, Minority Deputy Staff Director
                       Liz Scranton, Chief Clerk



                            C O N T E N T S

                                 ------                                
Opening statements:
                                                                   Page
    Senator Coburn...............................................     1
    Senator Carper...............................................     7

                               WITNESSES
                         Thursday, May 12, 2005

Hon. Sam Brownback, a U.S. Senator from the State of Kansas......     3
Michael Miller, Deputy Assistant Administrator, Bureau of Global 
  Health, U.S. Agency for International Development..............     8
Roger Bate, Ph.D., Resident Fellow, American Enterprise 
  Institute, and U.S. Director, Africa Fighting Malaria..........    20
Amir Attaran, Associate Fellow, Royal Institute of International 
  Affairs, London, England, and Canada Research Chair, Institute 
  of Population Health and Faculty of Law, University of Ottawa, 
  Canada.........................................................    23
Carlos C. ``Kent'' Campbell, M.D., Program Director, Malaria 
  Control and Evaluation Program in Africa.......................    24

                     Alphabetical List of Witnesses

Attaran, Amir:
    Testimony....................................................    23
    Prepared statement with attachments..........................    97
Bate, Roger, Ph.D.:
    Testimony....................................................    20
    Prepared statement...........................................    50
Brownback, Hon. Sam:
    Testimony....................................................     3
    Prepared statement...........................................    39
Campbell, Carlos C. ``Kent'', M.D.:
    Testimony....................................................    24
    Prepared statement...........................................   126
Miller, Michael:
    Testimony....................................................     8
    Prepared statement...........................................    43

                                Appendix

Charts submitted by Senator Coburn:
    ``Malaria: Preventable, Curable, Controllable, The 
      Inexcusable Failure of Public Health''.....................   132
    ``Malaria Cases and Deaths--South Africa, 1971-2000''........   133
    ``KwaZulu-Natal, South Africa: What can a little DDT and 
      Coartem do?''..............................................   134
    ``Number of Houses Sprayed Compared to Number of Cases of 
      Malaria Above the Rate Expected if Spraying Had Continued''   135
Additional copy submitted for the record from Senator Coburn.....   136
Responses to Questions for the Record submitted to Michael Miller 
  from Senator Coburn with attachments...........................   145


                EXAMINING USAID'S ANTI-MALARIA POLICIES

                              ----------                              


                         THURSDAY, MAY 12, 2005

                                     U.S. Senate,  
            Subcommittee on Federal Financial Management,  
        Government Information, and International Security,
                            of the Committee on Homeland Security  
                                          and Governmental Affairs,
                                                    Washington, DC.
    The Subcommittee met, pursuant to notice, at 10:37 a.m., in 
room SD-562, Dirksen Senate Office Building, Hon. Tom Coburn, 
Chairman of the Subcommittee, presiding.
    Present: Senators Coburn and Carper.

              OPENING STATEMENT OF SENATOR COBURN

    Senator Coburn. The hearing will come to order. We do have 
some intervening business in the Judiciary Committee so this 
hearing may be interrupted for votes on judges coming out of 
the Judiciary Committee.
    Good afternoon. Today's hearing will examine the U.S. 
Agency for International Development's efforts to control the 
spread of malaria throughout Africa. When I learned that 
funding for USAID's malaria program had increased from $14 
million in 1998 to $90 million in 2005, I wasn't expecting to 
find that the number of deaths due to malaria had, in fact, 
increased by about 10 percent.
    Not only hasn't the stated goal of reducing malaria by 50 
percent been achieved, the actual number of deaths have 
increased. How can this be? That is what we hope to learn 
during the course of this hearing.
    Recently, I have read reports on USAID's anti-malaria 
program. An author of one such paper, Dr. Bate, is testifying 
here today. In preparing for this hearing, I was struck by the 
lack of accountability and transparency on the part of USAID in 
providing a breakdown of how the agency allocates its malaria 
budget. For instance, how much money does the agency actually 
spend on interventions to prevent the further spread of the 
disease? How much funding goes to contractors? And, more to the 
point, why hasn't the agency provided this information when it 
was precisely asked to do so?
    I intend to ask the Government Accountability Office to 
conduct an audit of USAID's malaria program because I believe 
the citizens of this country have a right to know how their tax 
dollars are being spent.
    Malaria still claims a million victims annually, with over 
90 percent of those deaths occurring in Africa. It is a 
preventable, treatable disease. An even more daunting statistic 
is that malaria kills a young African child every 30 seconds. 
USAID can't be proud of this track record.
    Representatives of USAID have testified in the past that 
the agency supports the use of indoor residual spraying and 
insecticide-treated nets to prevent new infections. However, 
the fact is USAID has never been a strong proponent of these 
methods and did not push for the use of indoor residual 
spraying and insecticide-treated nets despite the fact that 
such interventions have proven to be successful when they were 
used by the agency in the 1950's and 1960's. Most recently, 
such interventions were very successful in reducing malaria in 
South Africa and Zambia.
    Another disturbing issue is the resistance on the part of 
USAID to stop using ineffective drugs to combat malaria. The 
American Enterprise Institute's paper entitled: ``The Blind 
Hydra,'' provides evidence from a project consultant to the 
World Relief project, Dr. P. Ernst. Dr. Ernst related that 
efforts to convince USAID and UNICEF to change the type of drug 
included in its drug kits distributed to First Aid posts have 
failed. He went on to say: ``Even today, children in Chokwe 
receive ineffective medicine.'' That was in 2004. I believe 
this to be completely unacceptable since the cost for a full 
treatment, the smallest pack (young children) costs 90 cents 
and the largest pack (adults) costs $2.40.
    This Subcommittee notes that there are important questions 
about the policy choices USAID has made. However, we are also 
deeply concerned about the failure of the agency to provide 
accurate information to the public about its activities. If the 
Congress and the public do not know what is being spent and for 
what purpose, how can results be assessed? With that in mind, 
we will explore those issues with our witnesses.
    In conclusion, I would like to call your attention to 
several charts that are displayed in front of the dais.
    The first chart,\1\ entitled ``Malaria: Preventable, 
Curable, Controllable, The Inexcusable Failure of Public 
Health.'' What this chart points out is that 2.5 billion people 
in 90 countries around the world are at risk for malaria. That 
is alarming, since we are talking about 40 percent of the 
world's population.
---------------------------------------------------------------------------
    \1\ The chart entitled ``Malaria: Preventable, Curable, 
Controllable, The Inexcusable Failure of Public Health,'' appears in 
the Appendix on page 132.
---------------------------------------------------------------------------
    Malaria represents the most life-threatening infection in 
the world, 500 million acute illnesses every year, 90 percent 
of these are in sub-Saharan Africa. Malaria claims 3,000 people 
every day, and up to 90 percent of these deaths occur in 
pregnant women and children under the age of five. Malaria 
accounts for as much as 40 percent of public health 
expenditures, 30 to 50 percent of inpatient admissions, and up 
to 50 percent of outpatient visits. Children that survive can 
suffer brain damage, or experience cognitive learning deficits.
    The next chart,\2\ ``Malaria Cases and Deaths--South 
Africa, 1971-2000,'' shows the dramatic rise in the number of 
deaths attributable to malaria when the government was 
pressured into stopping its program of spraying with DDT. South 
Africa had been successful in controlling malaria for years 
with DDT. The chart shows the number of new cases and deaths 
increased dramatically when DDT was no longer being used.
---------------------------------------------------------------------------
    \2\ The chart entitled ``Malaria Cases and Deaths--South Africa, 
1971-2000,'' appears in the Appendix on page 133.
---------------------------------------------------------------------------
    The next chart,\1\ ``KwaZulu-Natal, South Africa: What can 
a little DDT and Coartem do?'' This chart shows that when the 
government reinstated the use of effective drug therapy with 
Coartem (ACT drug) and the spraying of DDT, the number of cases 
fell dramatically.
---------------------------------------------------------------------------
    \1\ The chart entitled ``KwaZulu-Natal, South Africa: What can a 
little DDT and Coartem do?'' appears in the Appendix on page 134.
---------------------------------------------------------------------------
    The last chart,\2\ ``Number of Houses Sprayed Compared to 
Number of Cases of Malaria Above the Rate Expected if Spraying 
Had Continued'' (data from the countries of the Americas) 
clearly illustrates that the resurgence of malaria is directly 
linked to DDT spraying (bar graph--as the number of sprayed 
houses decreased, the excess cases over the amount seen during 
spraying exponentially increased).
---------------------------------------------------------------------------
    \2\ The chart entitled ``Number of Houses Sprayed Compared to 
Number of Cases of Malaria Above the Rate Expected if Spraying Had 
Continued,'' appears in the Appendix on page 135.
---------------------------------------------------------------------------
    We will hold for Senator Carper's opening statement and I 
would like to recognize Senator Sam Brownback, who has a 
special interest in this area and also in terms of reform. We 
would like to ask our witnesses to limit their testimony to 5 
minutes. Senator Brownback, it is a pleasure to have you before 
our Subcommittee. It is my hope through your interest and your 
initiative that some of these people in the future have a 
greater opportunity to be treated and their lives saved and the 
quality of their life improved. Senator Brownback.

  TESTIMONY OF HON. SAM BROWNBACK,\3\ A U.S. SENATOR FROM THE 
                        STATE OF KANSAS

    Senator Brownback. Thank you, Dr. Coburn. I appreciate 
that. I appreciate you holding the hearing on this topic. It is 
one that is near and dear to my heart.
---------------------------------------------------------------------------
    \3\ The prepared statement of Senator Brownback appears in the 
Appendix on page 39.
---------------------------------------------------------------------------
    I have traveled to some of these regions. And it is one of 
those situations where you see somebody or a group suffering 
and dying and you look at the numbers and you have got 
basically, in some cases, 40- and 50-year-old technology that 
is cheap that can solve this and you go, absolutely, why? ``Why 
is this taking place? And this shouldn't happen.'' You went 
through the numbers. This is a horrific situation and it is a 
real shame that the world has allowed this to happen.
    We used to have malaria in the United States and in 
Southern Europe and we went aggressively about dealing with it 
and malaria is not there today, although some cases now start 
to come back in because of what is happening in other parts of 
the world.
    We have a cure for this. We don't even really need to spend 
new money, just to take the money we are currently spending and 
spend it in places that actually cure people and you are going 
to save lives. So here is one case where we can save hundreds 
of thousands, if not millions, of lives, not spend new money, 
just spend the current money appropriately in the process. This 
just makes all the sense in the world.
    And then I ask myself, ``well, why isn't it happening?'' I 
traveled to Uganda. I have been in the Sudan. I met with 
officials from the U.N. I met with individuals from these 
countries. And the best that really I have concluded is we are 
spending most of our money on consultants and on meetings and 
not on getting actual care taken out in the field.
    One scene I was in, in Northern Uganda, in the Gulu region, 
children come in every night, these ``night commuters,'' they 
are called. There will be 500, 1,000, even more kids that will 
commute into a city, some of them walking five miles each way 
just so they don't get abducted at night by the Lord's 
Resistance Army. So their parents every night will send these 
kids from 3 to 12 years of age into this area. It is an 
incredible scene.
    And they are not fed when they get there, but they are 
within a fenced area, a tin roof, cement floor, and they are 
cared for. But the walls aren't sprayed with DDT and mosquitoes 
lurk in the area. So while they may be protected from the 
Lord's Resistance Army, they are not from malaria. A simple 
application would take place that is not going to harm the 
environment, and save how many children from getting malaria? 
And you look at this and go, ``why isn't this taking place?''
    DDT has a bad name. It is associated with The Silent 
Spring, Rachel Carson's book. It certainly was overused in 
areas at prior times and did contribute to degradation in some 
bird species. But we are not talking about widespread use of 
DDT. We are talking about very targeted indoor spraying and 
some very targeted pools around where people are. So this is 
not the widespread aerial application that we have seen and 
done in North America and Europe. We are talking about a very 
targeted area. Yet the world community still seems to be very 
hesitant and would rather not take this no-risk action, would 
rather see the kids and mothers die. That is just a completely 
unacceptable answer to me. It should be unacceptable to us as a 
government.
    So I have introduced S. 950, the Eliminate Neglected 
Disease Act of 2005. It directs interventions, directs the 
spending by our government to these effective means instead of 
conferences and consultants. Let us use these funds for 
applications in the field. We require accountability, 
transparency, scientific and clinical integrity, coordination, 
and priority setting.
    It is a simple bill. It is sponsored by your colleague from 
Oklahoma, and by Senator Landrieu, both of whom are Africa 
hands, if I might say. Senator Inhofe has travelled to Africa 
perhaps more than any other U.S. Senator. Senator Landrieu 
heads a caucus on Uganda, has a deep heart for the region, and 
I do, as well.
    I just would say in conclusion, Mr. Chairman and Senator 
Carper, that we will stand judged if we don't do something 
effective here, when we have the money, we have the ability, 
and then don't do something. This is wrong, what we are 
currently doing, and we do need to change this. I think if we 
really, even in this room, band together to do this, we will be 
able to get this changed and we will save hundreds of thousands 
of lives in the process, and probably not spend another dime. 
Thank you.
    Senator Coburn. I would like to recognize my friend, 
Senator Carper, and if you have an opening statement, I would 
be happy to have you give that now and then we will talk with 
Senator Brownback.
    Senator Carper. Rather than give my statement--I have just 
a short statement I want to give, but can we just go back and 
forth with the witness----
    Senator Coburn. Sure.
    Senator Carper [continuing]. And he can be on to his next 
stop. Thanks. Good to see you, Sam.
    Senator Brownback. Good to see you.
    Senator Coburn. Senator, let me ask you some questions. 
Some would say that by insisting that USAID money is spent on 
certain types of intervention, your bill hamstrings countries' 
malaria programs and tells governments what to do. How do you 
respond to that claim?
    Senator Brownback. The only government we tell to do 
anything is the U.S. Government. We direct funds towards actual 
treatment because, to date, when you have given broad 
authority, it has gone more towards conferences and meetings 
rather than actual application.
    And in the countries that I have met with, what they 
desperately want are actual treatments out in the field. They 
want buildings sprayed with DDT, the inside of buildings. They 
want bed nets that have DDT in it or other effective treatments 
dispersed and distributed. That is what they want, as well.
    So the only country we are directing what to do is the U.S. 
Government. And number two, from the countries that--primarily 
sub-Saharan Africa--that I have visited with, this is exactly 
what they want to see take place that is not taking place 
today.
    Senator Coburn. How would you answer those who are 
concerned about DDT and its effect on aviary species in terms 
of how do you control the total limit and the exposure, even if 
you are doing isolated exposure? Does it not, in fact, have 
some impact?
    Senator Brownback. I don't think there is any record 
anywhere that says that it does. What we did in the United 
States when this was a problem, particularly with the bald 
eagle, which was the most known species, we had widespread 
application of this in agricultural settings using aerial 
application. Much of which then drifts into streams and rivers, 
then ingested in amphibian life that is taken up by the eagles 
and that is then where you see the egg shell much softer. My 
background is in agriculture. I have worked with these issues. 
I have regulated these things in the past in an agency I ran 
when I was State Secretary of Agriculture in Kansas. So you had 
an enormous build-up of this in a broad system where we had 
used it for decades.
    Here, you are talking about somebody going in with a hand 
sprayer inside of a hut or a small building and spraying the 
walls once every 6 months. The ability of this to flow into the 
rivers and then build up in any quantity in the amphibian life 
is minimal to anything and certainly not anywhere comparable to 
what we did in the United States in the 1950's, and there is no 
track record at all that this hurts avian species at all 
anywhere.
    Plus, you know, balance is back and forth. We can't find 
any risk there, and we will save hundreds of thousands of 
children in the process. That seems to me as absolutely worth 
doing.
    Senator Coburn. In your queries on this program, have you 
been able to find out the number of people actually treated for 
malaria?
    Senator Brownback. I don't have that. By our programs 
actually treated?
    Senator Coburn. No, by your inquiry into what is going on 
now. Anywhere, have you been able to find the data that would 
say the number of people who have actually been treated with 
medicines who have malaria, the number of facilities that have 
been sprayed with indoor spraying, the number of actually 
treated nets that have been given out? Anywhere, have you been 
able to find those numbers?
    Senator Brownback. No, I haven't. We did hold a hearing 
last year in Foreign Relations on this topic and had several 
experts in that gave broad estimates, but we don't--and that 
was global, but we do not have U.S. funded numbers, and to my 
knowledge, USAID has been unwilling to provide those or unable 
to provide those to date.
    Senator Coburn. Senator Carper.
    Senator Carper. Again, welcome.
    What do the folks at USAID say about what you are 
suggesting? Sort of play the devil's advocate and explain what 
their rationale is. Why do they agree or disagree with you? 
Where do they agree? Where do they disagree?
    Senator Brownback. I think you will have them up on the 
witness stand, and I have met with the head of USAID. I have 
met with individuals there. We have had them in to testify.
    They generally don't disagree with the things that I am 
saying, but there is difficulty. You do get push-back on the 
use of DDT in any setting other than in bed nets and it is a 
harder route to go. We do get some resistance, and instead of 
pushing on through, it has been more, ``let us just keep going 
pretty much the way we are going and we think we are going to 
get there.''
    My problem is, every day you don't get there, somebody else 
dies, thousands die. And number two, we are not getting there. 
The overall numbers show we are losing ground, not gaining 
ground. I think this is an emergency, that you really should 
move forward aggressively rather than timidly.
    Senator Carper. Who are the other players other than us, 
other than USAID? I guess World Bank is in it, but who are the 
other major players that are involved in this? How do their 
efforts complement ours or duplicate ours?
    Senator Brownback. There are several players. The U.N. has 
a program, and the Global Fund. We have bilateral efforts. And 
then I believe the Europeans have some efforts, but I am not 
that familiar with what they are doing.
    Some of these are doing a good job of providing actual 
spraying of the new level of drugs. The older level of drugs, 
there has been a great resistance built up and a number of them 
aren't effective.
    So you have a mixed bag of other players, some doing a 
pretty good job, the U.N. doing a horrible job, having set a 
target of reduction of malaria in half by 2010 and the number 
has actually gone up since they set that target.
    Senator Carper. Is there an effort underway to coordinate 
the efforts of these diverse parties to ensure that we are not 
duplicating one another but we are complementing one another's 
efforts?
    Senator Brownback. There is communication. I don't know, 
Senator Carper, if they have got a regularized system where, 
``we are going to work in this country and you are going to 
work in that country,'' but there is a clear communication. I 
don't know otherwise the degree of how much it is hard-wired 
within their system. That is a good question to ask and to have 
in the implementation.
    Senator Carper. I will probably ask it again, then. Thanks. 
It is good to be with you. Thanks for being here.
    Senator Brownback. Thanks.
    Senator Coburn. Senator Brownback, thank you so much, first 
of all, for your caring and your interest in this subject, but 
thanks for coming to testify before us today. We will make sure 
you get the results of this hearing.
    Senator Brownback. And I would like to offer one of my 
great staff members, Katy French, to help you out in this 
process. She has been my lead person on this. She is excellent 
and----
    Senator Carper. What does Katy look like? [Laughter.]
    Senator Brownback. She is going to be the Staff Director 
here, I believe, in the next couple of days, and she is right 
behind me, does a great job on these topics, excellent.
    Senator Coburn. Thank you very much.
    Senator Brownback. Thank you, Mr. Chairman.
    Senator Coburn. Next, I would like to recognize Michael 
Miller, Deputy Assistant Administrator, Bureau of Global 
Health.
    Senator Carper. Mr. Chairman, before you do that, you were 
kind enough to ask me if I would like to give a statement----
    Senator Coburn. Absolutely. Please do.
    Senator Carper [continuing]. And now that Senator Brownback 
has left, let me just mention a couple of things, if I could.
    Senator Coburn. Absolutely.

              OPENING STATEMENT OF SENATOR CARPER

    Senator Carper. Thanks for holding the hearing and for the 
staff pulling folks together to let us hear from them.
    As you all know, this hearing today focuses on an important 
issue. It is actually a life or death issue for a whole lot of 
people. Despite years of work that aimed at dramatically 
reducing malaria deaths, the toll this disease takes on 
communities in some parts of the world, at least, appears to be 
growing, as Senator Brownback has suggested.
    With this in mind, we have a responsibility on the 
Subcommittee, and I think in the Congress, to examine how 
Federal agencies, especially USAID, have been spending our tax 
dollars dedicated to this war on malaria, and there are 
probably some steps that USAID can take that they are taking, 
Mr. Chairman, to improve its financial management and 
transparency. We just have to be careful, though, before 
quickly drawing too many conclusions about how USAID is 
addressing malaria and how it should address malaria in the 
future. The work that the USAID does or doesn't do will have a 
tremendous impact on the organizations it works with on the 
ground and ultimately on with respect to the lives of millions 
of people.
    The Global Fund to fight AIDS, tuberculosis, and malaria is 
currently spending hundreds of millions of dollars, I am told, 
to purchase bed nets and anti-malaria drugs to be distributed 
in the most vulnerable areas to prevent and treat malaria 
outbreaks. U.S. taxpayers, I believe, are paying for about one-
third of that effort.
    At the same time, the World Bank recently announced that 
they are prepared to spend about $1 billion on a similar effort 
on their own, and I suspect that the United States will be a 
major contributor to that effort, too.
    And we are going to hear today from some true experts on 
malaria and other health issues in the developing world. I 
certainly look forward to hearing their views on the 
effectiveness of current U.S. and global efforts to fight 
malaria. Most importantly, I would like to hear about how USAID 
can best use its $80 million malaria budget to supplement the 
extensive work and to complement the extensive work that is 
being done by other organizations.
    So again, I appreciate the opportunity to participate in 
this hearing and look forward to hearing from our witnesses. 
Thanks, Mr. Chairman.
    Senator Coburn. Thank you, Senator Carper.
    Mr. Miller, Deputy Assistant Administrator, Bureau of 
Global Health, USAID, first of all, welcome.
    Mr. Miller. Thank you.
    Senator Coburn. We look forward to your testimony. Your 
written testimony will be made a part of the record and I would 
like for you to limit your oral comments, if you can, to 5 
minutes. I would also say again we are close to a vote in the 
Judiciary Committee, and if I might be able to be excused and 
you take over for me so I can do that, I would appreciate that.
    Senator Carper. You bet. Or I could vote in the Judiciary 
Committee for you. [Laughter.]
    Senator Coburn. I would like to do the vote.
    Senator Carper. You send me where I can do the most good. 
[Laughter.]
    Senator Coburn. Mr. Miller, thank you.

TESTIMONY OF MICHAEL MILLER,\1\ DEPUTY ASSISTANT ADMINISTRATOR, 
    BUREAU OF GLOBAL HEALTH, U.S. AGENCY FOR INTERNATIONAL 
                          DEVELOPMENT

    Mr. Miller. Thank you, Senator Coburn and Senator Carper. 
It is certainly a pleasure to be here and we thank you for the 
opportunity to come up and testify.
---------------------------------------------------------------------------
    \1\ The prepared statement of Mr. Miller appears in the Appendix on 
page 43.
---------------------------------------------------------------------------
    A couple of points that are not in my prepared statement 
are I would just say that no institution and no program is 
above examination and questioning and we do welcome that. I 
think a deliberative process is certainly going to produce 
better policy in the end than a process done in isolation.
    It is kind of hard to follow up Senator Brownback as a 
witness. I have big shoes to fill in that respect. I had the 
pleasure when I was a Senate staffer to work with him at the 
staff level on Sudan and other Africa issues and I certainly 
admire his dedication and commitment to it, and his involvement 
on the issue of malaria and how to best pursue and treat 
malaria is certainly welcome.
    My objective for this testimony is to describe the U.S.'s 
anti-malaria programs, to place them in a useful context for 
the Subcommittee, and describe where the world is, and not just 
the United States or USAID, but where the world is in terms of 
the fight.
    The starting point for any consideration of malaria 
programs is the fact that malaria is overwhelmingly, not 
exclusively, but overwhelmingly a killer of African children. 
In fact, malaria is the number one killer of African children, 
claiming the lives of at least one million each and every year.
    Between 80 and 90 percent of the deaths from malaria are in 
sub-Saharan Africa, and of those deaths, 80 to 90 percent, 
again, are children. The greatest tragedy, as you pointed out 
in your opening statement, sir, is that this death is largely 
preventable. The disease is curable. It is treatable.
    The interesting thing to note is that where in most of the 
world we have successfully controlled or even virtually 
eliminated malaria as a public health threat, in Africa, it has 
persisted. The disease actually has even gotten worse. The 
burden that Africa is carrying in terms of a true disease 
burden from malaria is greater than it was two decades ago.
    Why has malaria actually become more deadly in Africa when 
it has been effectively controlled or even eliminated in other 
regions? The answer is as significant as it is surprising. The 
effort to battle malaria in a comprehensive way and continent-
wide is literally decades behind other regions. In the 1950's 
and 1960's in most other regions, including the Southern United 
States, a combination of insecticides and treatments was 
deployed with great effect. The results were positive and 
significant, but not in Africa.
    In 1955, a World Health Organization panel of technical 
experts met in, ironically, Kampala, Uganda, and decided to 
exclude tropical Africa from the global malaria eradication 
program. The reasons cited were because of the intense and 
efficient transmission of the disease and because of a lack of 
infrastructure necessary to undertake such an intensive 
spraying effort. In short, Africa was left out because it was 
judged to be too difficult.
    That decision essentially eliminated prevention from the 
anti-malaria efforts and relied solely on treatment. Even until 
just the past few years, the backbone of anti-malaria efforts 
in Africa was limited to treatment of the disease once the 
symptoms appeared. In retrospect, that was a fateful and tragic 
decision and Africans are still paying the price.
    By the 1980's and into the 1990's, malaria infections in 
Africa began to soar. The reasons were treatment failure. 
Simply, the medicines that were deployed, Africa's only 
defense, started to lose their effectiveness against the 
malaria. Populations became increasingly vulnerable.
    It wasn't until the early 1990's that an organized and 
dedicated effort to begin to introduce prevention measures on 
an appreciable scale in Africa, and funded largely by donors, 
did that begin. By the time, the need for new treatments also 
became too hard to ignore.
    By about 2000 or 2001, three new, highly efficacious 
prevention and treatment tools became available through 
American and other donor research. The first new tools, 
insecticide-treated nets, or ITNs, as a vehicle to get 
insecticide into people's homes, and I think it is worth 
pointing out here that with respect to indoor residual spraying 
and the use of insecticide-treated nets, the goal is absolutely 
the same, getting insecticide into the dwelling and as close to 
people as you can when they are sleeping and when the mosquito 
is preying on them.
    The second is intermittent preventive treatment of pregnant 
women. That is a pretty simple procedure. It is usually two 
doses of anti-malarial drug before delivery and the protection 
it provides the child is tremendous, because a lot of times, if 
you can defend against malaria in the mother, you are going to 
defend the child, because the vulnerability of the child really 
begins before they are born. Malaria, it is a major contributor 
of low birthweight, and if a child is born underweight in 
Africa, you are essentially doomed.
    The third is artemisinin combination therapies, and that is 
the combination drugs that are derived from the ancient Chinese 
medicine artemisinin. They are extremely effective and they 
are, in fact, the only thing that on a continent-wide scale, 
even though other treatments can be effective in some areas, on 
a continent-wide scale and in the future is going to provide 
the only chance we have to really plug that treatment failure 
that has accounted for the most deaths in Africa.
    Are we at the point of success? How are we doing? Is what 
the United States doing worth pursuing, or should it be subject 
to change? I am just going to wrap up by giving four essential 
factors we need to consider.
    First, the effort to address malaria in a meaningful way, 
incorporating prevention and treatment across sub-Saharan 
Africa is new. It is shameful that it started so late. Also, 
sub-Saharan Africa is not like other regions. The lack of 
infrastructure and the intensity of the epidemic are far more 
acute than in any other region. The factors cited in the 1955 
decision are still basically true. What has changed is that the 
political will now exists to try to overcome them.
    Second, the level of funding we are talking about for this 
overdue effort is only now coming online. Even in 2000 and 
2001, the funds committed to fighting malaria by the United 
States and all other donors were a fraction of what it is now. 
The significant factors here are the increase in the U.S.'s 
bilateral funding, the advent of the Global Fund to fight AIDS, 
tuberculosis, and malaria, which brings significant funds 
online, particularly for commodities, and also, of course, the 
World Bank, which we know is on the verge of launching another 
anti-malaria program.
    Third, the number of infections and consequently the 
deadliness of the disease have increased considerably in recent 
decades due to the treatment failure. This situation is a 
classic race against adaptation by the pathogen. ACTs are the 
only effective treatment in much of Africa now. The donors, 
producers, and affected countries have not yet fulfilled the 
needs in terms of production or distribution.
    Finally, data are lacking. We believe we understand the 
effectiveness of individual elements of our strategy, but the 
potential for new or improved interventions and increasing 
funding holds for the battle against malaria. What we do not 
have is data on the trends and deaths from malaria at the 
country level, the continent level, and certainly at the global 
level. The fielding of new or improved prevention and treatment 
tools on an appreciable scale and with significant funding to 
back them up is simply too recent to reasonably judge the 
overall effectiveness on a large scale.
    The bottom line here is that for the first time, the tools, 
the political will, and the funding are in place in sufficient 
amounts, at sufficient levels to really have an effect. But any 
summary judgment of the progress or lack of progress is not 
supported by sufficient data at this time and is simply 
premature, in our view.
    We, in the Administration, are happy to have the discussion 
and debate about priorities and proportions. Ultimately, the 
goal of the United States is to save the most lives. I think 
there is a common and universal agenda here. Thank you.
    Senator Coburn. Mr. Miller, thank you very much.
    Do we know throughout sub-Saharan Africa how many people 
have been treated, how many people have been prophylaxed with 
the net, how many people have had their domiciles sprayed? Do 
we know these numbers?
    Mr. Miller. Probably not with any precision. What we do 
know is--we can get number of treatments purchased. Now, 
tracing that treatment down to the individual and where that 
individual takes it and whether it is proven effective, we 
don't know.
    Senator Coburn. What are the numbers of treatments 
purchased?
    Mr. Miller. For example----
    Senator Coburn. Effective treatments purchased?
    Mr. Miller. Let us talk about ACTs. There are other 
treatments and some of them are still effective in some parts 
of Africa, but they simply will not be effective in the future.
    Number of ACTs purchased, I think the most significant 
number to cite is that the Global Fund has purchased. The 
United States is a 33 percent contributor to the Global Fund 
over the history probably even more, and they have purchased or 
have dedicated funding through grants to purchase up to 145 
million doses of ACTs now. I am certain that will increase, 
certainly as ACT's availability increases and the price drops 
and the ability to get it into markets and distributing, we are 
really at the beginning of that.
    Senator Coburn. How much is price a factor in terms of 
supplying medicines for treatment?
    Mr. Miller. I think it is going to be a significant factor.
    Senator Coburn. What is the cost of treatment for a child?
    Mr. Miller. For a child? For ACTs in a child, I think it is 
probably about $1.20 per treatment.
    Senator Coburn. OK.
    Mr. Miller. It depends on where you are and how remote the 
person is.
    Senator Coburn. OK, so let us say $1.20 per child, and that 
is available? The medicine is available worldwide?
    Mr. Miller. The medicine is available. I do not believe it 
is available to the extent that we need it. There is a 
shortfall in production capacity. In fact, USAID, one of the 
things we are doing is supporting the growing of Artemisia 
annua in Kenya and Tanzania. We believe that those crops will 
be able to produce effectively 40 million--the basis for 40 
million new doses, and by the end of 2006, I think production 
will be up to the point where you actually can fill the need. I 
do not believe we are there yet, and as a consequence--yes.
    Senator Coburn. Let us take $2 a dose. What is the 
population of the continent of Africa?
    Mr. Miller. Oh, goodness. I would just have to guess at 
about 700 million.
    Senator Coburn. OK. At $2 a dose, that is $1.4 billion to 
treat everybody in Africa, and the Global Fund is going to 
spend what this year on treatment?
    Mr. Miller. Well, if you take just the raw numbers, sure. 
In the past 2 years, it has been over $900 million for malaria 
programs, of which about 50 percent are going to be for 
commodities.
    Senator Coburn. So $450 million, which means we should have 
treated 225 million people.
    Mr. Miller. We certainly hope to achieve that kind of 
coverage. I have to emphasize that this really is a fairly new 
venture. A lot of these ACTs, we are not even to the point yet 
where we can actually produce enough of them--we, globally, can 
actually produce enough of them to fulfill the need. Certainly 
the funding mechanisms and the programs in place, they are only 
now coming online. Our goal is simply to get as many people 
covered and save as many lives as possible, but we are 
reasonably new with levels of funding with the medicines that 
we are talking about and the types of programs and the ability 
to procure them. It is----
    Senator Coburn. Of your budget, what percentage of the $80 
million is actually spent on treatment?
    Mr. Miller. If we take commodities--I should first say that 
I think it is important to start not with an examination of 
USAID's budget in isolation because, in fact, the United States 
and the Global Fund, of course, of which the United States is 
the largest contributor, and the World Bank, of which the 
United States is the single largest shareholder, do coordinate 
at the country level. There is, in fact, an agreement, if you 
will, the United States brings our strengths to the table, 
which are technical capacity, helping build the infrastructure 
necessary to get the commodities out to people.
    The Global Fund, on the other hand, does some of that, but 
they also spend about 50 percent of their budget--of their 
malaria grants, excuse me--about 50 percent of the malaria 
grants are dedicated to commodities. The goal there is to 
simply fill in behind what we can provide on a technical 
capacity.
    So having said that, the United States, if you break it 
down, it would probably be around 5 percent----
    Senator Coburn. Five percent, $4 million?
    Mr. Miller [continuing]. Of our bilateral budget.
    Senator Coburn. Four million dollars on treatment?
    Mr. Miller. Yes.
    Senator Coburn. How much on prevention?
    Mr. Miller. Prevention?
    Senator Coburn. Nets, spraying?
    Mr. Miller. Prevention would be about 30 percent, treatment 
about 34 percent, but that is not purchase of commodities.
    Senator Coburn. OK. What is treatment besides purchase of 
commodities, in your viewpoint?
    Mr. Miller. Logistical support for drugs. Simply getting 
the drug to an African capital is not going to do it. There is 
training, application of drugs. There are skills that people 
need to understand how to identify and prescribe the 
appropriate drugs. There are protocols, because, if, in fact, 
ACTs--ACTs are not the only drug effective in an area. For 
example, Fancidar is still effective in adults. You wouldn't 
want to necessarily go to ACTs. They are ten times the price. 
So making a determination like that, that does take people and 
skills and time.
    Senator Coburn. But that is not hard to do, because if you 
have a drug-resistance problem in an area, you are going to 
know it and you are not about to start treating with a non-
drug-resistant therapy if you have drug-resistant disease in an 
area. So that is one or two tests. Once you identify that, you 
know that.
    You have not collaborated with the Global Fund in the past. 
Is it not true that the MOA is brand new?
    Mr. Miller. I am sorry, MOA?
    Senator Coburn. Yes. Is it not new? Is this not new? In 
other words, your collaboration with the Global Fund in the 
past, this is just beginning, is that right?
    Mr. Miller. Right. The Global Fund is new.
    Senator Coburn. Well, the Global Fund has been around since 
I left Congress. It was started when I left, when President 
Bush came in and they set up this fund.
    Mr. Miller. Right.
    Senator Coburn. So we are talking 2001 when this started, 
and 2002 when it got going.
    Mr. Miller. We are now seeing--just now, we are going 
through--as a Global Fund board member, we, the United States, 
are seeing consideration of the 2-year point of the first round 
of grants. So money was being--excuse me, votes were being 
taken by the board to dedicate funding to particular proposals 
2 years ago. So I think it is fair to say that it is fairly 
new. And once a grant is made, that doesn't necessarily give 
you an indication how soon the money is going to be out there--
--
    Senator Coburn. What percentage of the amount of grants 
that you give are consumed--in other words, the expenditure 
from that grant is consumed in other than prevention and 
treatment?
    Mr. Miller. I can't say. On a grant-by-grant basis, it is 
going to be different, and----
    Senator Coburn. No, as a total. What do you think?
    Mr. Miller. As a total for treatment?
    Senator Coburn. No. What percentage of the grant money that 
you give out of this $80 million--here is the grant money we 
are giving to implement . . .
    First of all, the doctors in Africa that I have met--I have 
been there twice--could teach every doctor here about 
diagnosing malaria. I have seen two cases in 20 years in 
Oklahoma of malaria. So they know how to diagnose it. The 
question is, what is the resistance factor of the area that you 
are in? So they actually could train us.
    But in terms of your grants that are given, what percentage 
are actually for treatment or prevention? Of the amount of 
money through this budget, how much goes to prevention----
    Mr. Miller. I see. Grants are typically not given for 
something as narrow as treatment. In fact, typically, grants 
are not made for something as narrow as malaria. They usually 
fall within a larger maternal and child health grant. In other 
words, it can be to help support ante-natal clinics and it is 
at the ante-natal clinic where you can actually get to the 
mother while she is pregnant and either provide preventative 
therapies, provide a net, provide some education. The grants 
typically go for something a little more broader than that. Is 
that your question?
    Senator Coburn. Well, I am just trying to find out, because 
we have other parts of USAID that have grant money for that, as 
well. What you are saying is some of the grant money goes to 
areas of responsibility in other areas of USAID as supplement 
that? Is that what you are telling me?
    Mr. Miller. I am not sure I characterize it that way. Would 
say that grants typically will be for something in child and 
maternal health that is broader than just malaria or malaria 
treatment.
    Senator Coburn. Well, I am way over my time. I will come 
back to you. I have to go for a vote in Judiciary. Senator 
Carper, if you would be so kind to handle the hearing, and I 
will be right back.
    Senator Carper [presiding.] Thanks, Mr. Chairman.
    Mr. Miller, welcome. Thanks for being here and thanks for 
your stewardship.
    I want to go back to a couple of earlier things that you 
said in your testimony, just ask you to clarify them for me. 
You spoke earlier of the success in much of the rest of the 
world in eradicating malaria but a lack of success in Africa. 
In fact, if anything, it is getting worse. Why, again, do you 
think we have been successful in the rest of the world and not 
in Africa and what lessons can we derive from our success in 
the rest of the world to make sure we are applying those 
lessons appropriately in Africa?
    Mr. Miller. I think the first thing to note is that we are 
starting pretty late in Africa, at least on an appreciable 
scale. What we did in the United States, what was undertaken in 
Southeast Asia, Central America, and South America in the 
1950's and 1960's was very effective. Africa is just now coming 
online.
    That is what I was trying to get to in my statement, which 
is the types of--the level of funding we are talking about, the 
degree to which we can introduce interventions into the areas 
that need it is relatively new. We are really just talking 
about since 2000 on an appreciable scale.
    What we can learn from other regions that can be applied to 
Africa, you have to be careful. Africa is different for a 
number of reasons. It is not just that it was started late, 
which is a factor. You also have new interventions that were 
not available then, ACTs, insecticide-treated nets, for 
example.
    But also, Africa, the intensity of the epidemic in Africa 
is far beyond, at least continent-wide, is far beyond what it 
is or was in any other area. You have some areas of Africa that 
are what we call hyperendemic. In other words, you have 
transmission of malaria 7 to 12 months out of the year. There 
is literally no seasonal break and there is no escaping at 
night mosquitoes, either during the season where they are not 
breeding or just by changing localities.
    The second thing to consider about hyperendemic areas is in 
some cases, 85 percent of the people living there are going to 
be infected with the plasmodia that causes malaria, 85 percent. 
That is a huge reservoir for transfer. Those people will 
probably not necessarily show symptoms. They have acquired 
immunity. Once you pass about 5 years of age, if you contacted 
malaria when you were a child and you lived through it, the 
chances are you probably will not die from it. So people 
actually acquire immunity over time. But just because they have 
that acquired immunity doesn't mean they won't get sick, and it 
certainly doesn't mean that they cannot be infected from one 
person to another. They effectively are a reservoir for the 
mosquito and it is very difficult to do that.
    Finally, I would point out that in a lot of Africa, the 
infrastructure is acutely lacking, let us say. People live 
rural lives. I know in Ethiopia, for example, which is not 
typically a hyperendemic area, but just for illustration, 70 
percent of the population lives 3 hours' walk from a road, not 
even from a paved road, not from a facility, but from a road. 
It just gives you an illustration, even in a very densely 
populated country like Ethiopia, that people live rural and 
sometimes very isolated lives in Africa. So it is very 
difficult.
    That is not true in all of Africa. Certainly the South 
Africa example that was raised demonstrates that there is some 
applicability to the continent, depending on where it is, 
depending on the infrastructure and the effectiveness of 
services in that area. But it is going to be a harder nut to 
crack, frankly.
    Senator Carper. Thank you. Could we talk a little bit about 
the resistance of drugs, or the resistance, rather, of 
mosquitoes and the disease to drugs that we have, the failure 
of those drugs to be able to protect people today----
    Mr. Miller. Yes.
    Senator Carper [continuing]. And new medicines that are 
available that are being introduced.
    Mr. Miller. Right. The treatment failure, if you will, 
really is the cause of the increase in malaria infections in 
Africa in the 1980's and 1990's. Simply people had no 
protection.
    ACTs are really the great hope of the future. I don't think 
there is any debating that. They are very effective----
    Senator Carper. Why do they call them ACTs?
    Mr. Miller. Well, they are in combination. The ``C'' is for 
combination. Artemisinin is a natural extract from what we call 
wormwood. It is an ancient therapy. It is very effective. The 
extract itself has--I don't think there is a question of shelf 
life there. But once they are put in combination to make them 
more effective, to make the body absorb them better, whatever 
the combination does, you get about 18 months' shelf life. So 
it is a huge challenge.
    Plus, as I mentioned answering Senator Coburn earlier, they 
are relatively new. The combinations are relatively new. I 
believe there are two companies that hold patents for ACTs now. 
Production is not to a level to meet worldwide need and, hence, 
USAID's support for actually growing of Artemisia annua to help 
meet that shortfall.
    Senator Carper. Would you talk a little bit about--you have 
already discussed this some and we have mentioned it in our 
statements, but talk with us, please, about how, on a relative 
scale, the magnitude of USAID's efforts in these areas with 
respect to other efforts in these areas.
    Mr. Miller. Sure. Bilaterally, we are by far the largest 
donor. We are at about $80 million a year. If you break down 
the Global Fund by year, you are going to get about $400-and-
some-million per year, over $900 million total over the past 2 
years. Of course, the United States, as you mentioned earlier, 
is the single largest contributor to the Global Fund, so a lot 
of that can be ascribed to us, the same with the World Bank.
    There are other donors on a bilateral level. The U.K., I 
think the Nordic countries also have bilateral programs. All 
said and done, I think we put the total global anti-malaria 
funding at about $600 million a year.
    Senator Carper. So overall, $600 million. About $80 million 
is directly through your budget?
    Mr. Miller. Bilateral USAID, yes.
    Senator Carper. And then additional monies that we may put 
into the World Bank or the Global Fund----
    Mr. Miller. That is correct.
    Senator Carper [continuing]. Above and beyond that. Share 
with us again your thoughts on how USAID's efforts are 
complementary, or might be duplicative of other efforts. How do 
they complement or support each other?
    Mr. Miller. Thank you. I think the best way to imagine it 
is that, as I mentioned before, USAID does focus where we have 
our strengths, providing skills, providing infrastructure, if 
you will--I am not talking about buildings here, but providing 
infrastructure. We have presence in almost every country we are 
talking about. We can deploy skilled people for training, for 
running programs, providing grants. We have many other 
bilateral programs of which anti-malaria efforts can be 
effectively incorporated into, which is really one of the 
fundamental pieces of our strategy.
    As I said before, it is really not--you are really not 
going to get an accurate picture if you just take USAID's 
budget and proportions of the spending per sector in isolation 
because they really are planned even down at the country level 
along with the other donors, multilateral institutions.
    I think with respect to the question of priorities and 
spending on commodities and how the United States, bilaterally, 
we look to the multilateral agencies, of which we are a part, 
to really do the bulk of the commodities purchase, the United 
States and USAID in malaria programs or any other programs has 
never really emphasized commodity purchases outside emergency 
situations, and that is true here.
    But the best way to think of that and put it in perspective 
is to think of an army being judged simply by the amount of 
bullets you have on hand. It is really not a fair judgment and 
you simply can't judge a single army if they are operating in 
coalition with each other. You really have to take a snapshot 
of the entire picture globally, especially if it is coordinated 
at the level we coordinate in countries.
    Senator Carper. My last question would be, someone 
described for me, they used an analogy. They said USAID's 
efforts are in part, if you will use the analogy of a toolbox, 
with tools in the toolbox to address a particular challenge. 
They said USAID's efforts are, in part, to put tools in the 
toolbox, but also to help those to whom the toolboxes are 
distributed, countries, to be able to better use the tools that 
USAID puts in the box, but also the tools that other entities 
put in the box to fight malaria. Is that a fair analogy?
    Mr. Miller. It is. Simply, we play to our strengths and we 
play in coordination with other teams, with other members of 
the team, yes. It is a fair characterization.
    Senator Carper. And how do we measure success with the 
approach you are talking?
    Mr. Miller. Ultimately, success is going to have to be 
measured in lives saved. That is a difficult question, number 
of lives saved, for a couple of reasons, if you would let me go 
into it. Identifying the number of deaths from malaria in rural 
Africa is going to be very hard. Survey-wise, every 5 years, 
we, USAID, sponsors what is called a demographic health survey. 
It is a comprehensive health survey of the entire country. It 
is the gold standard of health surveys for development global 
assistance. They are retrospective.
    What happens is if someone who is conducting the survey 
goes out to an affected area and asks the mother, did you have 
a child that died in the past 5 years? What did they die from? 
What were the symptoms they were displaying? And from that, you 
simply have to deduce what this child--if they have a fever, 
which is what you are typically going to see, it could be 
pneumonia, it could be malaria, it could be a combination of 
things. It is hard to do with precision, to say what that 
person died from. We think we know. We think we have a level of 
confidence where we can say malaria infection rates and deaths 
are at about this level per year. That is probably not in 
dispute. But identifying on a scale of how many people are 
actually dying of malaria is very difficult.
    The second thing I would note is one thing we found 
troubling is the statistic often quoted is that malaria deaths 
are increasing in Africa in recent years. We have heard that 
quoted. Actually, we do not use that statistic. We have 
actually tried--I have asked my staff to identify where did 
that originate, what is the data behind it, and does anybody 
else use that? We don't use that statistic. I am not here 
saying it is true or it is false, but the data set behind 
something that broad is simply we don't have it. We have to 
question whether that is reliable data to hang your hat on.
    Senator Carper. Thanks very much.
    Mr. Miller. You are welcome.
    Senator Coburn [presiding]. Just another little round here 
if we can, for a minute. First of all, WHO says malaria is 
increasing. Lancet articles say malaria is increasing. They are 
surveying the same way they did 10 years ago and the number of 
deaths of children is skyrocketing, and it isn't pneumonia that 
is causing them to die, it is malaria. That is not something 
that is hard to know because you are using the same study 
method to collect the data 10 years ago as you are today in 
terms of looking at deaths. So there is no question.
    The other question I have for you: USAID doesn't normally 
provide treatment unless there is an emergency. The fact is, 
that with 3,000 children a day dying in Africa, I think that is 
an emergency. There was a malaria program by USAID before there 
was ever a Global Fund, true?
    Mr. Miller. That is correct.
    Senator Coburn. And it was operating all this time that we 
are seeing this large increase. So the fact is we have been 
ineffective through USAID in abating this increase with the 
money that we have spent. Now, maybe again, your first 
testimony, the problem is too big. Maybe the resources aren't 
enough. I don't know that answer. That is one of the things 
that we want to try to help find out.
    But what we do know is the numbers aren't lying, and I 
would like to ask you just a couple other questions. In your 
testimony, you gave us that insecticide-treated bed nets are 
the key to saving children's lives, and you write that ``ITN 
coverage increased, for example, from zero to 21 percent in 
Ghana.'' But you omitted saying that 21 percent is the 
proportion of rural homes in Ghana using an untreated bed net. 
There is a big difference in terms of that prevention. So you 
are using a number that is on untreated as part of your 
statistics for treated. My question is, actually aren't only 5 
percent of Ghana's homes covered with insecticide-treated bed 
nets, not 21 percent, as you state in your testimony?
    Mr. Miller. Sir, it is an important question and I would 
like to answer it truthfully and best I can with a level of 
precision. I honestly cannot say right now whether what you 
just said is correct.
    Senator Coburn. This actually comes--your department is a 
coauthor on the World Malaria Report that was published only 
last week that made that very statement. So either what you are 
saying in that report is right or what you are saying in your 
testimony is right, and they can't both be right.
    You can catch the frustration in my voice. It is not 
directed to you personally, and please don't take that.
    Mr. Miller. I understand.
    Senator Coburn. When I know that 3,000 kids a day are dying 
and we are spending $80 million a year, which could save 40 
million of them if the money was put there in terms of 
insecticide-treated bed nets and medicines, that, to me, is 
just incomprehensible, that we can say we have got to have all 
these other programs when, in fact, we could take 20 people and 
make tremendous delivery of goods tomorrow to those kids in 
those villages.
    And so the statistics you quote are important, but they 
also have to be accurate, and I will be happy to let you answer 
that in writing for our Subcommittee.
    Mr. Miller. Thank you. We will, sir.
    Senator Coburn. Do you have any other questions?
    Senator Carper. Just one more. USAID and, I believe, other 
Western donor organizations have been criticized for being 
reluctant or maybe even unwilling to fund the indoor spraying 
of insecticides in communities that are plagued by malaria. Is 
there any official USAID policy that you know about that 
prevents the agency from funding spraying projects where that 
is appropriate?
    Mr. Miller. Thank you, Senator. I maybe should have 
emphasized this more emphatically in my opening statement. The 
shared goal of prevention is to get insecticide into the home. 
That can either be through indoor residual spraying or it can 
be through insecticide-treated nets. We are open to debate 
about which is most cost effective in what areas. That is part 
of what we do with $80 million, is determine what is most cost 
effective.
    We do emphasize insecticide-treated nets over indoor 
residual spraying. We do not have a prohibition on the use of 
insecticides in the homes, spraying of insecticides nor of DDT 
in particular, even though DDT is, in fact, just one 
insecticide we are talking about. There are 12 approved 
insecticides for indoor residual spraying. IRS is very 
effective. IRS has proven effective in South Africa, in areas 
where you have the infrastructure and the services to make the 
coverage. IRS is not the vehicle for insecticide of choice in 
all of Africa.
    So no, sir, there is no prohibition on DDT or indoor 
residual spraying.
    Senator Carper. Thank you.
    Senator Coburn. Let me follow up with that, because I think 
it is important. First of all, DDT is the most effective 
insecticide. It is also the cheapest insecticide. There is no 
question about that. Administrator Natsios told Senator 
Brownback that you will not use DDT. That is a quote from him.
    I also have a quote from Zambian health officials that said 
USAID staff have repeatedly refused to fund DDT spraying and 
told them that they should not adopt effective drugs as part of 
the anti-malaria strategy. Can you explain this? Why would they 
say that?
    Mr. Miller. I cannot explain what someone in Zambia said. I 
will tell you, we do not support or peddle ineffective drugs, 
and we do, in fact, when, at a country level, it is determined 
that indoor residual spraying would be the most effective to 
save the most lives, we will support it----
    Senator Coburn. Is that true in Zambia?
    Mr. Miller. We will support that. In fact, Zambia is one of 
the places we do support indoor residual spraying, yes.
    Senator Coburn. Well, here is the Malaria Program Control 
Director for Zambia, and that is who gave us this information, 
and will you follow up with her and clarify that USAID supports 
ACT treatment and in Zambia--DDT spraying--and let this 
Subcommittee know the outcome of that conversation?
    Mr. Miller. We will.
    Senator Coburn. And that is Naawa, and I will try to 
pronounce this name, it is S-i-p-i-l-a-n-y-a-m-b-e, the Malaria 
Control Program Director for Zambia.
    I also would like to ask you to maintain your seat, if you 
would, because I would like to have you on the panel with our 
other guests, and I also will, without objection from Senator 
Carper, would like to submit written questions for you to 
answer and give back to the Subcommittee. Rather than take your 
time up with it today, I have about 20 specific questions that 
I would like to get answers to----
    Mr. Miller. Absolutely.\1\
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    \1\ The questions and responses from Mr. Miller appears in the 
Appendix on page 136.
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    Senator Coburn [continuing]. And I would like that on a 
timely basis, if we can have that.
    Mr. Miller. We will do our best, sir.
    Senator Coburn. Thank you.
    Next, I would like to recognize Dr. Roger Bate, Resident 
Fellow, American Enterprise Institute, Director, Africa 
Fighting Malaria, U.S. and South Africa; and also Dr. Amir 
Attaran, Ph.D., Associate Professor and Canada Research Chair 
in Law, Population Health and Global Development Policy, 
University of Ottawa; and also recognize Dr. Carlos C. ``Kent'' 
Campbell, M.D., Program Director, Malaria Control and 
Evaluation Program in Africa.
    We will start with Dr. Bate, if you would.

 TESTIMONY OF ROGER BATE, PH.D.,\2\ RESIDENT FELLOW, AMERICAN 
   ENTERPRISE INSTITUTE, AND U.S. DIRECTOR, AFRICA FIGHTING 
                            MALARIA

    Mr. Bate. Senator Coburn and Senator Carper, thank you very 
much for inviting me to testify today on behalf of Africa 
Fighting Malaria and the American Enterprise Institute.
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    \2\ The prepared statement of Mr. Bate appears in the Appendix on 
page 50.
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    Ninety years ago, a million Americans suffered from malaria 
and a Congressional committee held hearings to discuss policy 
options to eradicate it. This was achieved by the 1950's 
through the judicious use of window screens and DDT and, of 
course, increased wealth.
    Today, malaria, as we have already heard, is a significant 
risk for perhaps two billion people, suppressing hope and 
economies alike, notably in Africa, but also, I should stress, 
given what has been said before, it is increasing in parts of 
Latin America and Asia, as well. I do not think it has been 
conquered around the world. And unfortunately, I think we are 
losing the war to combat malaria.
    But there are bright spots. Southern African countries are 
enacting comprehensive malaria control programs which are 
grounded in the idea that success requires every tool that 
science has provided, much like the United States did to rid 
itself from malaria 50 years ago. Government and private 
entities in South Africa and Zambia, for example, are using a 
combination of low-level controlled indoor insecticide use, 
both DDT and other chemicals, bed nets for key staff, and 
prompt treatment of malaria cases to keep malaria incidence 
low, and the results are startling, 70 to 90 percent reductions 
in disease within a couple of years and even better reductions 
in mortality in some locations.
    Unfortunately, the U.S. Government has not been directly 
involved with the two most successful strategies, indoor 
residual spraying and effective drugs, except perhaps in 
marginal ways at best. I say perhaps because it is hard to know 
exactly what the $4 million USAID allocation in Zambia 
supports.
    USAID releases data as reluctantly as if it were a national 
security outfit. We have to surmise a lot of information, 
unfortunately. We fought to get from FOIA requests, from 
interviews with people in the field, from pressure from friends 
within Congress to try to get as much information as possible, 
and there is an ongoing Government Accountability Office 
inquiry into USAID's malaria programs and I welcome its 
outcome. We need the information.
    Despite the obvious benefits of comprehensive malaria 
control programs, by its own admission, as we have just heard, 
USAID typically does not purchase drugs or insecticides except 
in emergency situations. Yet USAID continues to say it supports 
comprehensive programs. This is a fiction.
    Our estimation of the 2004 budget, and it is basically 
confirmed here today, is that less than 10 percent, perhaps as 
low as 5 percent of the budget is spent on actual commodities 
that save lives. The vast majority of the rest is spent in 
support and technical assistance. This is not comprehensive. It 
is, in fact, highly selective in favor of Western staff. It is 
likely that well over half the budget goes on salaries, 
staffing costs, and travel, perhaps even a lot in the United 
States.
    From the information that is published, it appears that 
USAID coordinates randomly, perhaps occasionally in a more 
coordinated fashion, with other entities, and in many 
instances, technical assistance, which we have already heard 
today is its kind of backbone, its greatest skill, is provided 
where no commodities are, in fact, available.
    But even if coordination were well managed, USAID rarely 
measure outcomes, and I am talking about the key outcome in 
particular here, reductions in morbidity and mortality. So we 
wouldn't know whether its programs are working very well 
anyway.
    And by the way, given it has been mentioned today on 
several occasions, in my opinion, bed net distribution is not a 
good measure of outcome. And in many respects, in the written 
testimony from Mr. Miller, it is the main performance criteria 
given. It is not a good measure from personal experience, also, 
from looking at the data, because we are not always certain how 
many people regularly sleep under a bed net.
    Imagine an August night in Washington, D.C., and your air 
conditioner is broken and you are trying to sleep under a 
stifling net. Bed net use data is extremely important to 
collect. I have spent many nights in the field where I have 
been incapable of sleeping under a net. It was just simply too 
hot. I wouldn't have had any sleep. I was offered some 
prophylactic drugs, as well, a belt and braces policy. 
Therefore, I could afford to take the risk. For everyone else 
living in Africa, that is not the case.
    While we can quibble about the best interventions, and I am 
delighted to hear that there is greater interest in indoor 
residual spraying, there is no doubt in my mind that USAID 
fails badly in the transparency and accountability stakes, and 
that is the point that I think is most important to make today. 
USAID does not consistently measure anything useful. It does 
not measure real outcomes. It has not updated its Yellow Book 
since 2001, so we don't know what USAID's contracts are for, 
with whom they are made, and for how much.
    Of the few reports USAID does file, many are self-serving. 
That is not just according to me, that is from a Government 
Accountability Office inquiry in 2002 and its own internal 
review last year. And since it doesn't collect, as I have 
already mentioned, useful data, it is incapable of effectively 
evaluating its performance.
    Since Anne Peterson, then Assistant Administrator for 
Global Health, first testified to a Congressional subcommittee 
about USAID's malaria program in September of last year, not a 
single program report, evaluation, or other document concerning 
the agency's malaria activities has been submitted to the 
agency's publicly available database. In that 8-month period, I 
notice some welcome rhetorical changes in favor of ACTs and 
spraying and saying the support of indoor residual spraying, 
but I have seen no change in action on the ground.
    When I testified alongside Dr. Peterson last September, I 
suggested that if accountability and transparency were not 
delivered quickly, U.S. funding for their program should 
perhaps be reallocated to agencies that have a better chance of 
improving health. As we have heard today, too many children's 
lives from this disease are at stake for failure to continue.
    I conclude the same way today, 8 months later, and with 
stronger emphasis. I think that USAID must rapidly increase its 
transparency. I would encourage it to follow the lesson from 
the Global Fund and establish a website, or even on its own 
website, which would hold all technical information for USAID. 
That would include contracts, grants, and corporate agreements, 
budgets, and implementation plans. Until it does that, and I 
think it should be given a time limit to do that, I think it 
should seriously consider its budget being reallocated 
elsewhere.
    Thank you, Mr. Chairman.
    Senator Coburn. Thank you, Dr. Bate.
    We have a vote on. What we will do is recess the 
Subcommittee for the period of that vote and then we will 
return. I would ask your indulgence.
    [Recess.]
    Senator Coburn. The Subcommittee will come back to order.
    Mr. Miller, it is my understanding that we did not advise 
you appropriately of what we would be requesting of you in 
terms of time commitment, and if you feel necessary to keep 
those commitments with other people, the Subcommittee will 
understand.
    However, it is my understanding you are working on a 
transparent website so that people can look at USAID in this 
area in terms of your funding details, is that true, and when 
will that be available?
    Mr. Miller. Sorry, I had to consult with my staff. I am not 
aware of something exactly as you describe. I don't have any 
objection to it, and it is certainly something we will 
consider.
    Senator Coburn. Well, what I would like to hear is, yes, we 
will do that and here is when we will have it done. People 
should be able to address USAID programs via a website to see 
what is happening and where. What I would like for you to give, 
first of all, commit to do that, and second, give us some sort 
of time frame from your staff when that will be available.
    Mr. Miller. Sir, I could commit that we will do our best. 
In terms of a time frame, let us talk with your staff about 
what types of data and the depth of data we are talking about 
and come up with a reasonable time frame, mutually agreeable 
time frame, is that all right?
    Senator Coburn. That is fine.
    Mr. Miller. Good. Happy to do it. Sir, I can stay, by the 
way.
    Senator Coburn. OK. Next, we will recognize Dr. Attaran. 
Dr. Attaran, if you would, please.

TESTIMONY OF AMIR ATTARAN,\1\ ASSOCIATE FELLOW, ROYAL INSTITUTE 
OF INTERNATIONAL AFFAIRS, LONDON, ENGLAND, AND CANADA RESEARCH 
   CHAIR, INSTITUTE OF POPULATION HEALTH AND FACULTY OF LAW, 
                  UNIVERSITY OF OTTAWA, CANADA

    Mr. Attaran. Thank you, Mr. Chairman, Doctor. My deepest 
thanks for your interest to discuss malaria today and USAID's 
response, which I view as inadequate.
---------------------------------------------------------------------------
    \1\ The prepared statement of Mr. Attaran with attachments appears 
in the Appendix on page 97.
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    I believe by now you are quite familiar with what malaria 
is. You know that it is killing a million kids and pregnant 
women a year, mainly in Africa, that it is pauperizing entire 
families and nations when it isn't killing them, that it is a 
threat--perhaps this is a new piece of information--to the 
American military. It did hospitalize a quarter of our troops 
in Liberia only a couple of years ago. And that prospects for a 
vaccine are a decade or longer in the future and have been that 
way for about the last 30 years. The vaccine is always 10 years 
away.
    We also seem to have, I think, in this Subcommittee a 
certain amount of agreement on what the interventions are to 
prevent or to treat. There are basically three of them, 
insecticides, bed nets, and medicines. Everyone agrees on that. 
But what I see little agreement on is how USAID should spend 
their money in respect to those three. So let me sketch out 
these differences of views, such as they are.
    My view is that Africans are very different from Americans. 
They are poor. They live on $2 a day, the vast majority of 
them. They are very poor. So when there is foreign aid money 
voted by the American government to spend, we should be 
spending it on the poor Africans. That is my hypothesis.
    USAID fundamentally disagrees with that point of view. As 
you question them, you will find they spend most of their air 
money on Americans--American consultants, American experts, and 
very highly-paid American nonprofit organizations. It rarely is 
true that USAID is spending its money actually buying and 
supplying the weapons of combat--the medicines, the 
insecticides, the nets--that actually get to the patient and 
have an effect on malaria.
    Instead of preference for these cozy deals with 
consultants, which, to steal a phrase from President 
Eisenhower, resembles to me a ``Foreign Aid Industrial 
Complex,'' really--USAID should make the provision of supplies 
and commodities.
    Now, let me look at a few examples of that, and perhaps we 
can dive deeper into these in questions. USAID does tell the 
public that it ``strongly supports ACT,'' but it also says that 
it typically doesn't buy commodities. For example, no malaria 
pills whatsoever, or very few in number.
    If that is support, what would opposition look like? The 
medicines aren't being bought, and aren't being given to the 
patients. Compare that to when we do food aid as the United 
States: We actually provide the food. We provide the commodity. 
When we do malaria aid, we don't provide the commodities. That 
is wrong.
    So where does that USAID malaria money go if it is actually 
not going to the commodities? Well, for the most part, it is 
going to contractors, and the contracts are big and they are 
not terribly transparent. For example, USAID has a $65 million 
contract with an organization known as Net Mark. Net Mark 
sells, not gives, bed nets to the poorest people on earth in 
Africa. That is its mission. The $65 million is spent 
predominantly on marketing and not on actual, ``Here, have a 
net for free'' provision.
    Net Mark is overseen by a contractor known as the Academy 
for Educational Development. It bills itself as a nonprofit, 
but last year, its CEO paid himself in excess of $400,000 in 
salary and benefits. That is more than President Bush collects.
    Getting details beyond generalities such as these, further 
details, is next to impossible because USAID has not updated 
its contracts database to the public since 2001; basically 
Clinton-era contracts all what is available. USAID is not 
terribly cooperative in inquiries about its contracts, and it 
admits that contracts ``are not reported or collected centrally 
in Washington.''
    Really, there is a lack of information about all sorts of 
contractual aspects of the USAID program. It was asked, Mr. 
Chairman, earlier, how many nets is USAID providing? And there 
was no answer to that question. Nobody knows.
    So as I said, it is such that poor Africans aren't getting 
the commodities from USAID. They are not getting the basic 
tools. But unfortunately, a large network, this Foreign Aid 
Industrial Complex, of contracts is living on generous salaries 
and we don't really know how well they are accomplishing their 
work. That information is not available. How many pills or 
nets. It is not available.
    I thank you for your patience and wish to be of service to 
you in getting to the bottom of this. Thank you, sir.
    Senator Coburn. Dr. Campbell.

  TESTIMONY OF CARLOS C. ``KENT'' CAMPBELL, M.D.,\1\ PROGRAM 
   DIRECTOR, MALARIA CONTROL AND EVALUATION PROGRAM IN AFRICA

    Dr. Campbell. Thank you, Mr. Chairman, Dr. Chairman. It is 
a pleasure to be with you today. I have a written testimony 
that I would like to offer to be set into the record----
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    \1\ The prepared statement of Dr. Campbell appears in the Appendix 
on page 126.
---------------------------------------------------------------------------
    Senator Coburn. Without objection, it will be so done.
    Dr. Campbell [continuing]. And I would just like to make a 
few comments.
    First is my role here today, both in terms of how I was 
invited and how I would like to be perceived. I am not here 
representing any institution nor to defend any institution. I 
am here and was invited to be here today to be a resource to 
this Subcommittee in this process in terms of I spent 30-some-
odd years working exclusively in malaria and almost exclusively 
in Africa, beginning working in clinics in Western Kenya before 
HIV came in, continuing working in leadership positions with 
the Centers for Disease Control, with UNICEF, WHO, and now 
having the opportunity to work on what I think many of us 
believe to be the single big focus that we need in Africa right 
now, and that is rapid, well-demonstrated, well-documented 
progress to bringing malaria control to the capability of 
African nations to be able to manage that as a program 
activity.
    I share with you, and I would reflect back 20-some-odd 
years ago when I first had my opportunity for Congressional 
testimony, working for the Centers for Disease Control and 
Prevention, it was virtually impossible to get an audience to 
speak about malaria. In fact, I had to spend most of my time 
convincing people there still was malaria in the world, and how 
wonderful it is to see the intensity of interest, the 
impatience, the desire on the part of the U.S. Congress to get 
it better, and I applaud you for leading in that direction, and 
Senator Brownback and others in this process. I think that is 
something that all of us on this panel share, though I will 
speak just for myself.
    I think the second thing that I would like to say is that 
the malaria problem in Africa can be measured in terms of 
people, it can be measured in terms of suffering, it can be 
measured in terms of money. It can be measured in many ways. It 
absolutely needs to be measured and measured much better than 
we are doing at this point, and there is progress occurring on 
those fronts.
    I think one of the things which many people find so tedious 
and many people see as potentially a waste of time and effort, 
but I would like to make just two key points which I have tried 
to elaborate in what I have written. There is a lot of money 
coming in to support malaria right now and the window of 
opportunity to make certain that is used well and documented 
well is probably much shorter than many of us want to believe. 
That money will go elsewhere if malaria does not produce, and 
malaria does not produce and document impact, not just in terms 
of where we went and who we were, but who got sick and who 
didn't die.
    We all understand that it is hard, but it is vital and it 
will occur and it must occur, and we need your help in terms of 
pushing that forward.
    I think the second thing that is the difficult part of this 
is that as more money is coming into many African countries 
right now, and this is what I spend my life doing, is that the 
capacity of national governments to receive and allocate that 
money to turn that program into--turn that money into saved 
lives is a huge challenge, is that these very systems, and we 
can talk about infrastructure, we can talk about capacity, all 
of these potentially murky topics are vitally important. They 
are not more important than commodities.
    But the challenge that we run into in many countries in 
Africa right now, and this is a big problem that the Global 
Fund is currently facing, is the capacity to do things that we 
take for granted--procurement, distribution--a number of these 
other things are vital issues that we as the leadership 
position which the U.S. Government can bring to these issues, 
we need to make sure that we have a balanced armamentarium as 
we move forward.
    We must make certain, and we need more money for 
commodities. But to take current monies and push them toward 
the commodities and to take away the enormous, almost unique 
capacity which the U.S. agencies have in their academic 
institutions and other Federal institutions that know how to 
support governments to do these things is vitally important. 
Call that technical assistance, and yes, there are many 
egregious examples of technical assistance running amok. But 
there also are as many or more examples of where technical 
assistance has been well thought out, has supported the 
capacity of national governments to move forward in malaria and 
other issues.
    And we need to make certain that the U.S. Government, which 
in many respects--or the United States, which in many respects 
has unique capacities to support those areas, can do that and 
do it better than we are doing it now. So I ask you to not move 
everything to commodities, but keep a balanced view.
    The last thing I would want to say is that we must all keep 
in mind is that malaria in Africa will be controlled by Africa 
and not by us, and so the capacity of national governments to 
understand and to adapt systems right now which are stressed in 
many respects by the enormous and much greater infusion of HIV-
AIDS money and resources coming in, these systems really have 
an enormously difficult time in terms of how they absorb these 
monies and move them forward, and that is not as simple as 
diagnosing and treating malaria. That is much more complicated, 
and it may be the Achilles heel of this whole process.
    The U.S. Government can do a better job. The U.S. 
Government is not doing as bad a job as perhaps some people 
would like to believe. Single agencies have good pieces and bad 
pieces and pieces that all can be improved, and I think that at 
this point in time, as we look forward to legislation to 
suggest how we move forward, I would encourage us to make 
certain that we understand what is working well, and then off 
of that basis figure out how to make it better. Thank you very 
much.
    Senator Coburn. Dr. Campbell, your points are well taken. 
The point is, when you can't find out what is being spent where 
and there are no measured outcomes on the basis of what the 
goals are. There is no way you can evaluate that. So there is 
no way you can make an assessment. That is what this hearing is 
all about.
    What are the goals? How do you measure the goals? Where is 
the money being spent? How is it being spent? Are the 
contractors efficient? Are they doing what they are supposed to 
be doing? Is the money being spent inappropriately in terms of 
the domestic side of the issue?
    When 50 percent of the money of this budget is spent in the 
country, and we don't know that for sure because I can't find 
out. I am going to find out, I will tell you that. I am going 
to find out where every penny that goes with this malaria 
program is spent, no matter what. So we are going to know, and 
we are not going to just know on malaria. We are going to know 
on every area. That is what this Subcommittee is going to be 
about the next 6 years if I am still the Chairman of this 
Subcommittee and we are going to have accountability.
    And it is not to say that those people, Mr. Miller and his 
staff, don't care, aren't trying as hard as they can. The fact 
is, the only way you can be evaluated, it has a measurable 
outcome. And our outcome is based on lives saved and disease 
prevented. That is the outcome that we have got to be looking 
at.
    Whether it is implementation, delivering the product, not 
just commodity product, but whether you are implementing it, if 
you haven't implemented that properly, you are not going to 
save the lives. So it is not just one or the other. It is 
measuring the outcome, how many lives are saved, and is it an 
emergency?
    To me, there are not 3,000 children who die in the 
Southwest in this country every year from disease. So this is 
an important thing, and what we are asking is transparency on 
where the money, responsiveness to those people who also care 
so they can see where the money goes--so that they might be 
able to contribute a great idea, and the ability for Congress 
to look at where the money is spent to know whether or not we 
ought to put more money. How do we know we shouldn't be putting 
$200 million a year into the malaria program? We don't know 
that.
    So the fact is, if there is resistance on the part of any 
agency in this government to cough up the numbers of where they 
are spending the money, that automatically sets an assumption 
that either there is something to hide or they are incompetent. 
There are only two answers. I don't believe they are 
incompetent. They may not know, and that is just as bad, 
because if they don't know where the money is going or what the 
purpose is for the money, then we are not doing our jobs in 
terms of oversight or looking at how we spend the money.
    The hearts and intent of the people at USAID are good. 
There is no question about that. The goal is, how do we spend 
the money effectively. We are going to run a true $650 billion 
deficit this year. That is the real number, and I will be happy 
to go through that with anybody that wants to dispute that. But 
that is how much money we are going to borrow for the future, 
the kids that are here today that aren't getting malaria that 
are going to pay back. Any dollar that we don't spend well in 
saving a life from malaria, our grandchildren are going to pay 
back about $10 to pay for that because we are borrowing the 
money to do it. So it is implicit on us to be great about where 
we go.
    Dr. Campbell. Sir, I just would say, I couldn't agree with 
you more that, in fact, that level of attention to how well we 
do our job, all of us do our job, and that accountability and 
data are vital, I think all of us would support wholeheartedly. 
And how we do that and how we get to the end of that inquiry 
and make certain that those 3,000 children benefit from that 
inquiry is something that all of us would like to help you do 
well.
    Senator Coburn. Thank you. Let us start with Dr. Bate, and 
I presume Senator Carper is coming back. Can you give me an 
example of what you meant when you said USAID is not 
transparent. I believe that to be true, but give this 
Subcommittee an example of that.
    Mr. Bate. Well, first, the Yellow Book, not updating its 
contract information, that makes it very difficult to know. I 
mean, that is a prime example of lack of transparency.
    Senator Coburn. Can you think of a good reason why somebody 
wouldn't update that?
    Mr. Bate. Again, I refer to your remarks, which is 
incompetence or something to hide. I doubt it is incompetence. 
Perhaps they don't want people to know how the money is being 
spent.
    I think sometimes the information that is presented can be 
misleading. Mr. Miller, the testimony he gave on April 26, so 
2\1/2\ weeks ago, discussed a contract or a grant to 
Technoserve, which he described as an East African agricultural 
concern in his testimony. It may well have operations in East 
Africa, but its headquarters is 49 Bay Street, Norwalk, 
Connecticut, and it received $8 million from USAID in 2003. I 
don't know what it got in 2004.
    That is not to say they are not doing a good job, but that 
was not a competitive tender. We have no idea whether other 
organizations, perhaps in Southern Africa, where there is great 
competence in farming, could have helped in growing that at a 
lower cost. Perhaps it was done in an emergency setting to 
increase the production of what is an extremely important crop. 
I don't know that. But I do know that--you asked for an 
example. I think that is one. I am not saying it was willfully 
done to mislead, but it is misleading to say that a moderate-
sized U.S. contractor is an East African agricultural concern.
    Senator Coburn. Let me ask you, if you were in charge of 
$80 million for a malaria budget for Africa, where would you be 
spending the money?
    Mr. Bate. In terms of the----
    Senator Coburn. And I am going to ask you to answer that in 
a short period of time. I know that is a terrible question, 
but----
    Mr. Bate. The short answer is I would be buying a lot more 
commodities than USAID is buying. The idea that they coordinate 
with other agencies and other forms on the ground may be true. 
We don't know because of transparency, lack thereof. But the 
examples I have seen, there are instances where they are 
providing technical assistance and the commodities are not 
available.
    Second, I think that, to use the analogy that Mr. Miller 
gave, which I think is a good one, it would be to a certain 
extent like trying to fight the Iraq war, relying on the Royal 
Air Force for air cover. Now, the Royal Air Force is a 
marvelous organization and as a Brit, I am very proud of it, 
but it doesn't have the power that the U.S. Air Force does and 
I think we need U.S. purchases of commodities.
    So is the budget allocation, I am not 100 percent certain 
what it should be, but I would say certainly 50 percent or more 
on commodities.
    The technical assistance they can provide, I am sure, in 
many instances is very good. We simply do not know.
    Senator Coburn. Dr. Attaran, you are an immunologist and 
you are the author of a very famous paper in the Lancet which 
revolutionized how USAID and others think about malaria 
treatment. Why is ACT better clinically, and whether the 
Coartem deal is a good deal for Africans and Americans and 
whether USAID has treated the pharmaceutical manufacturer of 
that appropriately.
    Mr. Attaran. Thank you for the question, Mr. Chairman. 
Coartem is an example of a class of medicines known as 
artemisinin combination therapies, which we have been calling 
ACT. There are four approved ACTs and they are all good and 
they are all far superior to previous medicines, mainly for two 
reasons.
    One, they achieve high cure rates. Chloroquine, which is an 
older medicine, as of about 2 years ago was failing to treat 
the patient successfully 79 percent of the time in Ethiopia. 
Seventy-nine percent of the time, you had drug resistance and, 
consequently, treatment failure. You don't get any treatment 
failure with ACTs. If it is the right ACT for that setting, you 
get cured. It works all the time.
    Senator Coburn. And there is no potential for resistance 
development?
    Mr. Attaran. Well, artemisinin is a herbal remedy from 
Chinese medicine, and they have been using it for 2,000 years 
and we haven't found resistance yet. Maybe the 2,001st year is 
going to be really bad----
    Senator Coburn. Do we understand the mechanism of action? 
What does it do to the trophozoite?
    Mr. Attaran. There are heated controversies about that. The 
leading theory is that it actually creates free radicals that 
destroy some of the internal contents of the parasite, but that 
is not settled conclusively right now. What we do know is that 
it does achieve these much better treatment rates than older 
medicines.
    And it wasn't long ago, I would say only about a year and a 
half, 2 years ago, that we had USAID and UNICEF vigorously 
supporting the use of chloroquine in Ethiopia. There is a 
brilliant New York Times story about that, where USAID is 
quoted as saying that artemisinin in combination therapies, 
``aren't ready for prime time,'' which was scientifically, I 
think, an indefensible point of view.
    That said, since ACT is better, how do we get enough of it, 
at what price? The prices that were told to you earlier are 
fairly accurate. Coartem, to take that as an example, because 
it is the number one listed product by WHO--it is the one that 
they put at the top of their priority list, and it is approved 
by them--sells for between 90 cents for a pediatric treatment 
to $2.40 for an adult treatment. It is sold under an agreement 
with WHO entered into by Novartis for absolutely no profit on 
Novartis's part.
    You don't have to take my word for that. WHO did engage 
Deloitte and Touche to audit Novartis and, in fact, Deloitte 
and Touche returned and said that Novartis was making about an 
80-cent loss. So they are in the red, actually, on the adult 
treatments. That was at a time before we saw a sudden spike in 
raw material prices. It could even be more of a loss now, but I 
don't know and you would have to ask Novartis.
    So WHO is satisfied that is a good deal. Global Fund is 
satisfied that is a good deal. What I am aware of is that when 
Novartis has made outreach to USAID, it has not been perfectly 
reciprocated, but that is, again, not the topic in which I can 
engage very deeply and I would encourage you to be in touch 
with Novartis and USAID.
    Senator Coburn. When I was in Congress in the late 1990's, 
the idea of a Global Fund kind of synergized around myself and 
some other people, and I know many in this room were involved 
in that. Should Congress just strip away the USAID money and 
send it to the Global Fund?
    Mr. Attaran. I think what is true is that the Global Fund 
has made very helpful and important and, I would say, impactful 
strides, measured as how many patients are going to get 
treatment and live, since last year when I published my highly 
critical article in the Lancet about them. That is a fantastic 
development and they deserve to be commended for this.
    There are two options here for you, sir. One is to either 
try and reform USAID, and I think that the Brownback-Landrieu-
Inhofe bill is a fantastic way of going about that, and then 
USAID perhaps could be effective on malaria in a way that it 
currently is not.
    The alternative is to simply give the money to the Global 
Fund. Both agencies are obviously capable of doing a good job, 
and so what it turns on at the end of the day is whether you, 
sir, and your colleagues believe it is important to have an 
independent U.S. ability to execute in malaria and possibly the 
other diseases about which the Global Fund is concerned.
    Senator Coburn. Senator Carper.
    Senator Carper. Thank you, Mr. Chairman.
    I want to start off with Mr. Miller. Take 2 minutes if you 
want to rebut anything or respond to anything that has been 
said, just mostly the compliments that have been thrown your 
way. [Laughter.]
    Mr. Miller. Thank you, sir. I think I wouldn't know where 
to start. There is a lot out there. A lot of it has to do----
    Senator Carper. Just a couple of priorities. Don't do it 
all, just a couple of top priorities.
    Mr. Miller. Sure. I would start by emphasizing that there 
is agreement, and I am glad to hear Mr. Bate and Dr. Attaran 
mention that. There is a shared goal here of eliminating 
malaria. In fact, there is actually agreement on the 
effectiveness of interventions that IRS, ITNs, and ACTs have, 
this is what the United States and multilateral agencies, we 
are a part of, should and will support.
    The debate is really about the proportions and the 
priorities they are in, and we are happy to have that debate, 
and Senator Coburn emphasized that greater transparency and 
accountability are called for. As I said in the beginning of my 
opening statement, no agency is beyond criticism and we 
certainly do welcome that dialogue and, of course, we will do 
the best we can. Again, our goal is to save the most lives 
possible and whatever we can do, if it can be demonstrated that 
we are doing it wrong, we should do it a different way. I think 
President Bush would expect us to do that.
    Senator Carper. I say, everything I do, I can do better, 
and my suspicion is that is true about most of us and even 
agencies, as well.
    To our other witnesses who joined us on the second panel, I 
apologize for missing the presentations of all of you but one. 
I want to start maybe with a question or two for Dr. Campbell, 
if I may.
    We have heard some--and I approach these issues as a lay 
person, so this is a great opportunity for me to learn and to 
be educated and I think that is the purpose of these hearings 
anyway, so it is serving, at least with respect to this member, 
it is serving its purpose.
    Dr. Campbell, there has been some discussion here today on 
the value of indoor spraying of insecticides and how effective 
that is and there seems to be agreement that can be pretty 
effective. Are there any parts of Africa where it is maybe not 
as appropriate to use sprayed insecticides on the inside of 
dwellings?
    Dr. Campbell. The answer is that as best we understand, and 
I think we understand this quite well, that indoor residual 
spraying with a range of insecticides can be highly effective 
in virtually anyplace in Africa except under some remote 
situations where the quality of housing surfaces is such that 
the insecticide doesn't adhere or vaporize from the surface as 
well.
    But the fact of the matter is that its ability to kill 
mosquitoes after they bite and rest on it is essentially 
uniform in Africa. That is not the limiting factor. The 
limiting factor really has to do with the manpower, 
infrastructure that is required to deliver it and a variety of 
issues of that sort.
    So I think that the debate, as we see it at this point, is 
not--I do not find the IRS debate as being the central most 
important issue in terms of moving forward on malaria control 
at this point. And second, I am committed, as are many of our 
colleagues, in not letting the controversies around DDT and IRS 
get in our way of moving forward. It has a role. National 
governments are dealing with it right now to understand the 
appropriate role. Largely, as WHO says, it is in more compact, 
urban areas, but there is good experience of using it in other 
areas, also.
    Senator Carper. Thank you. Did you say anything in your 
testimony about how one role of the USAID is to help countries 
in Africa to develop the capacity to better utilize--I talked 
about tools and toolboxes. It seems to me part of USAID's role 
is to put tools in the toolbox to combat malaria. But another 
part of their role is to help ensure that the rest of the tools 
that are placed in the toolbox by others are then better 
utilized, more effectively utilized by nations and so forth to 
combat the disease.
    If you could just give us your thoughts, and maybe you 
already have and I missed it, on the effectiveness of USAID in 
coordinating this capacity building, folks within national 
governments and other folks that are putting tools in the 
toolbox, like the Global Fund and maybe the World Fund, World 
Ban.
    Dr. Campbell. In fact, I think one of the things that I 
would say is that I would probably defer those kind of 
observations and others. That is not an area in which I have a 
vast amount of experience and I don't think I am the best 
person to comment on that. I have worked with many 
organizations, but I would refer that to Mr. Miller and others, 
and you have got other experts----
    Senator Carper. Good. Let me just ask the same question of 
others. I already discussed this a little bit with Mr. Miller, 
so I am going to ask if you will hold off. Would you pronounce 
your last name for me, Doctor?
    Mr. Attaran. Attaran.
    Senator Carper. Attaran, OK. And is your last name Bate?
    Mr. Bate. No ``s''.
    Senator Carper. No ``s''. Where did you get that name?
    Mr. Bate. Well, it is a long tradition of singular British 
men who do not have an ``s'' on the end of their name.
    Senator Carper. That is remarkable. [Laughter.]
    Do you all have any thoughts on the question I just 
directed to Dr. Campbell? He has done something that few of us 
here do, and that is just admit we don't know and move on. We 
usually go ahead and answer the question anyway.
    Mr. Bate. There is no doubt that coordination is a vital 
role that with good assistance the USAID can help with. There 
is, unfortunately, a paucity of data out there as to how that 
technical assistance works, and in some of the examples we had 
cited in my written testimony, there are some problems to the 
extent that technical assistance is provided where the 
commodities are not available.
    So there is no doubt coordination can be improved, even if 
USAID does have great technical assistance, and because of the 
lack of transparency and accountability in reporting, we simply 
don't know.
    Senator Carper. All right. Dr. Attaran.
    Mr. Attaran. Thank you, Senator. There is a fine line 
between technical assistance and meddling or backseat driving. 
Technical assistance is a good thing. One wants to make sure 
that the money that is given is being used in a proper way, 
that the people are using scientifically up-to-date strategies 
to control malaria. All of that is certainly true.
    But when we end up with a program such as USAID's, where, 
for instance, ``treatment'' really is about giving a lot of 
advice on how countries should do treatment and yet no 
medicines or very few are purchased, we are backseat driving at 
that stage. We are telling other people how they should spend 
their money on medicines that are the ones we, as Americans, 
want them to use, and that is not helpful.
    In fact, that is--in my experience in Africa, I have had 
formal experiences and I have also hitchhiked across Africa for 
months at a time----
    Senator Carper. Is it hard to get a ride there?
    Mr. Attaran. There was a 4-day stop on the Equator which I 
am not proud of, sir.
    Senator Carper. That is a long time to wait.
    Mr. Attaran. It really was. But in my formal and informal 
experiences both, I have found that there is a certain amount 
of resentment engendered by, if I can paraphrase it, that we 
are telling people to do a certain something and we are not 
helping them do it. You are coming in and you are meddling. I 
have heard that said in all sorts of African contexts.
    Senator Carper. Thanks. Mr. Miller, just a quick comment if 
you have, just briefly in response to this again. I know you 
talked about it a little bit already. Is there anything else 
you want to add?
    Mr. Miller. Yes, sir. I would say we are not meddling. 
Certainly we don't design our programs from Washington to be 
impressed upon anybody. These are designed almost always with 
the cooperation of the host government or with NGOs or with 
other interested or affected people, and that is always the 
goal.
    Senator Carper. All right. Thanks. Dr. Attaran, do you have 
something else?
    Mr. Attaran. If I could just add an analogy that I think 
might be of assistance to you, Senator, USAID does food aid and 
in the food aid context, bags of grain and buckets of oil, the 
actual commodities are delivered and people are grateful for 
that around the world.
    Imagine we did food aid by actually recommending to people 
what their diet should be in a starvation situation, but we 
didn't provide them the grain and we didn't provide them the 
oil. ``You really ought to eat some rice today,'' but they 
don't have any. ``You really ought to have a bit of oil,'' but 
we don't give them any.
    That is the analogy that illustrates how our technical 
assistance without the provision of commodities becomes 
misunderstood and our good intentions are misunderstood, which 
is to me quite a sad reality and, I think, one that we can fix.
    Senator Carper. All right. Thanks. One last question, Dr. 
Campbell, if I could. Let me just ask what your views are on 
the recommendations, I think made by Mr. Bate and I think his 
coauthor, that USAID should maybe concentrate its anti-malaria 
efforts in a smaller number or the most needy countries.
    Dr. Campbell. In terms of the--there are several 
recommendations out there right now and to the extent to which 
my view would apply to USAID is for others to interpret.
    I think that we are in a situation in Africa right now 
where there is clearly progress in terms of one of the 
important ways of understanding and that is coverage in terms 
of the proportion of individuals who were sleeping last night 
under an insecticide-treated net, for example. There are some 
great examples of enormous progress.
    Malawi just completed a national survey and the average was 
38 percent of children under five sleeping under a bed net. 
That is not 60 percent, but 3 years ago, it was under 5 
percent, and those are truly insecticide-treated nets. Those 
are not just nets. Yes, that is one country, but there are 
several other countries that are making dramatic progress.
    I think one of the things that we have is that we have a 
lack of confidence on the part of ourselves and, quite 
honestly, there is a great deal of skepticism on the part of 
national leaders who are the ones who are going to ultimately 
decide the priority that malaria gets within their ministries 
of health that malaria can be programmed to impact.
    You share this concern, too, and so I think that one of the 
challenges we have at this point is that making slow progress, 
incremental progress across all of Africa, is important. But 
unless we have some dramatic examples of progress in the short 
haul, and I am talking in 3 to 5 years, our concern is, is that 
the edge on malaria as a doable, feasible entity is going to 
wane and we will have lost an enormous opportunity.
    So the answer is, I think that we need a balance of 
investment across many countries, but we also need more 
attention to intensive multi-donor, not just single country, 
efforts in a few countries that actually can provide an example 
to other countries to say, wow, this is possible, because we do 
not have examples of success in Africa at this point in time, 
and until we begin to accumulate those very rapidly, I think 
that the confidence issue is going to become an increasing 
impediment.
    So the answer is, yes, I think that we need some intensive 
investment with the Global Fund and with several other 
bilaterals to come together in a few countries and say, this 
needs to be done really well and documented to the n-th degree 
so that people can see it, understand it, and have confidence 
in it.
    Senator Carper. Thank you. Dr. Bate, a last word?
    Mr. Bate. If I just may, I think there are examples of 
success in Africa and those examples are where people actually 
measure outcomes and they use interventions. I mentioned South 
Africa, and Zambia has already been mentioned. Northern Zambia 
is a great example of a rapid reduction of morbidity from 
malaria of 70 or 80 percent.
    Senator Brownback said something which I think is very 
good, and I can say this as an outsider. The American people 
are the most generous on earth. If they are shown that malaria 
treatment, prevention will work, I am sure more money will be 
made available, and that is something we all want. And I think 
that if the only examples you have are provided by national 
governments in South Africa's case, or the private sector, that 
is a very--I think that is an indictment on the fact that no 
data has been collected. We need to collect data and we need to 
have that data presented transparently, and then I think the 
American people will spend even more money to malaria.
    Senator Carper. All right. Our thanks to all of you.
    Senator Coburn. I just want to follow up with a couple of 
questions. Mr. Miller, do you know and do you have at your 
fingertips where the money is spent for the malaria program 
with USAID?
    Mr. Miller. At my fingertips, no, sir.
    Senator Coburn. Do you know it? I mean, is it available to 
you?
    Mr. Miller. It will be--yes, it is available to me.
    Senator Coburn. So it is not that the information isn't 
available. So my question is, since it is available to you, why 
isn't it available to us?
    Mr. Miller. It is the form in which the information is 
available, I think is important to remember. I would point out 
that most of what we do, most of what USAID funds in terms of 
anti-malaria programs--this is true of all health and 
development programs--is done through grants. We call them 
cooperative agreements, but they are, in fact, grants. They are 
not through contracts, so you are not going to get a contract-
like response.
    Senator Coburn. I don't need to have that. I just want to 
know where the grants are, who gets them, what time they got 
them, what are the requirements of the grants, what is the 
performance evaluation of the grants. How do you measure 
whether somebody as a grantee did what you asked them to do? In 
other words, that is the data that I want to see, and it is not 
just USAID. I want to see that in the entire Federal 
Government. The American people deserve to see that and know 
that, and if that is available, I want this Subcommittee to 
have it.
    Mr. Miller. Sure. That type of accountability is stuff we 
do collect with every grantee. They have to go through audits. 
They have to have a performance appraisal----
    Senator Coburn. Then I would assume you would make that 
available to the Subcommittee.
    Mr. Miller. We will make everything we can, sir.
    Senator Coburn. I just have one other question. Dr. 
Attaran, would you comment on the World Bank situation now and 
what is going on in terms of the malaria?
    Mr. Attaran. Yes, Mr. Chairman. The World Bank has, only a 
couple weeks ago, published a new malaria plan--it is not 
implemented, it isn't yet funded by their board--which has as 
its bottom line that they will commit between $500 million and 
$1 billion towards malaria. They very carefully are cagey about 
that. They say $500 million to $1 billion, together with their 
partners, and nowhere do they say what the World Bank's 
contribution will be. It is always, together with our partners. 
So we really don't know what they are committing.
    But what I can tell you is that history is not on the side 
of children with malaria, because in 2000, the World Bank did 
promise to provide $300 to $500 million of its own money for 
malaria in Africa which initially it said it did, and then 
following an investigation that I conducted and published in 
the journal Nature, which you may be aware of, the World Bank 
admitted that, in fact, they had only spent $100 to $150 
million, not the $300 to $500 million that they said. And 
similarly to USAID, the World Bank declined to explain how they 
spent it. So we don't even know where that $100 to $150 million 
has gone.
    It is curious that this is a bank that doesn't know how 
much it has got in its accounts: ``Maybe we spent $100 million, 
maybe we spent $150 million on malaria. We are really not sure 
and we please don't want any more questions on the situation.'' 
I am, of course, being summary in my assessment of the 
situation, but I think that is, frankly, accurate, and the 
editors at Nature agreed with that.
    Senator Coburn. All right. I think our testimony is true 
that--and let me just, Mr. Miller, give you a chance. You do 
have a contract for $65 million for nets?
    Mr. Miller. I believe that is a grant, or a cooperative 
agreement.
    Senator Coburn. You have a grant.
    Mr. Miller. A cooperative agreement, yes, sir.
    Senator Coburn. Sixty-five million, and that is over how 
many years?
    Mr. Miller. Net Mark, is that per year, or is it 5 years? 
It is an 8-year grant.
    Senator Coburn. An 8-year grant.
    Mr. Miller. Cooperative agreement.
    Senator Coburn. And those grants are not--those nets are 
not given away, they are sold, is that correct?
    Mr. Miller. It can be both.
    Senator Coburn. Do we know what percentage of that money--
--
    Mr. Miller. We can determine that. The way we determine----
    Senator Coburn. You don't know that?
    Mr. Miller. No, sir, not on the spot.
    Senator Coburn. Does somebody here know that?
    Mr. Miller. I think we can determine that. Do we know the 
percentage?
    Mr. Carroll. Ten percent, 15 percent are given away. The 
rest are sold. They're sold, I might add--prices that these 
nets are being sold for represent 50 percent reduced prices 
from what they were in the market 3 years ago. So this is 
moving nets through the commercial sector into retail shops and 
making them available at very low prices, along with nets going 
into antenatal clinics and making those available for free.
    Senator Coburn. Here's the difference. What do the nets 
cost? What's the true cost of the net? If you're going to spend 
$65 million buying nets, I'll bet you they're the biggest net 
buyer on this side of the ocean. And if we're going to buy the 
nets there shouldn't be any profit in them. The nets ought to 
go to people at what they cost. Is that what they're doing, 
they're going at cost? The Africans are buying the nets at cost 
and that's around $4?
    Mr. Carroll. Three dollars, fifty cents, $4.
    Senator Coburn. That's the cost that's paid to the 
manufacturer for the net and that's the cost that they're sold 
at?
    Mr. Miller. But I don't think nets always go at cost.
    Senator Coburn. Why not?
    Mr. Miller. Some are free.
    Senator Coburn. Other than the free ones, why would the 
nets not go for what they cost?
    Mr. Carroll. Senator, this is a program--again, this is an 
exercise where we are working in concert with other donors, 
UNICEF, for instance, World Health Organization, where we are 
looking at the full range of opportunities to get nets not just 
tomorrow or today, but in a sustained way to make sure that 
every kid and every pregnant woman has access to this 
lifesaving measure.
    Our role in this case has been multifold. We have been 
working with textile industry across Africa to increase their 
ability to produce the nets so that we are creating more 
opportunities for nets to be flowing into African homes.
    Senator Coburn. That's a great point, but here's my point. 
Is somebody making profit off the nets?
    Mr. Carroll. If there's a profit being made, it's a local 
retailer, it's an African retailer bringing food home to their 
family. This is building a local capacity to solve a local 
problem.
    Senator Coburn. So somebody is going to spend----
    Mr. Carroll. Part of our role, our other role, which is 
equally important, is working in the communities to make sure 
that there are affordable nets free to those who cannot afford 
them. So we're working both sides of this. We can share with 
you data now that is coming in from Senegal and Ghana, for 
instance, that shows when we take an approach that involves 
both making--strengthening local retail shops in villages to be 
able to sell these nets at these prices along with targeted 
subsidies and free nets, we're looking at the poorest of the 
poor households and the wealthiest households, all vulnerable 
to malaria, but all getting equal access and equal use of these 
nets in their homes. So we're getting very equitable 
distribution against a disease that is rampant in those 
countries.
    Senator Coburn. I want to see the data. Since you seem to 
have a measurement on that, let's look at it.
    Mr. Carroll. We have that measurement and in fact that has 
been shared with panel members here.
    Senator Coburn. One of the things that we will do--first of 
all, thank you all for spending the time to come. Thank you, 
Mr. Miller, for adjusting your schedule for us. I promise if we 
have you here again we will make sure you are well advised in 
advance in terms of your time requirement.
    You will hear from the Subcommittee specific questions we 
would like for you to answer. We'd like those answered on a 
timely basis. This is the first hearing on this. I'm not 
through with this. We're going to talk to the Global Fund. 
We're going to find out what's happening. We're going to make 
sure--I'm very pleased that Mr. Miller is going to avail the 
Subcommittee of where the money is spent and how. I'm very 
pleased that we're going to have a transparent ability to get 
that over the Web. We'll talk about how fast that can be done. 
I would hope that would be a priority because with the 
information comes less criticism, not more. Part of the 
criticism of the malaria program today is because the 
information isn't available. So the assumption is that it's not 
being done right when in fact it may be done right.
    So I want to thank each of you. You will have a follow-up 
letter from us. If we have not heard back from you--in other 
words, we're not going to have a hearing and expect something 
to come back, just like most hearings in Congress and then you 
never hear anything about it. You're going to hear back again 
from us. We're going to get the questions answered. And then if 
we don't have the questions answered, we'll be back here 
talking about it again.
    Thank you all very much for being here. I thank you for 
your work, each of you, and the staff at USAID. I know you're 
committed to the same thing that everybody else in the room is, 
and that's eradication of malaria in Africa. Thank you very 
much.
    The hearing is adjourned.
    [Whereupon, at 12:45 p.m., the Subcommittee was adjourned.]


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