[Senate Hearing 109-614]
[From the U.S. Government Publishing Office]



                                                        S. Hrg. 109-614
 
          BILATERAL MALARIA ASSISTANCE: PROGRESS AND PROGNOSIS

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

                                HEARING

                               before the

                FEDERAL FINANCIAL MANAGEMENT, GOVERNMENT
                     INFORMATION, AND INTERNATIONAL
                         SECURITY SUBCOMMITTEE

                                 of the

                              COMMITTEE ON
                         HOMELAND SECURITY AND
                          GOVERNMENTAL AFFAIRS
                          UNITED STATES SENATE


                       ONE HUNDRED NINTH CONGRESS

                             SECOND SESSION

                               __________

                            JANUARY 19, 2006

                               __________


       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 Chief Counsel
                  Trina Driessnack Tyrer, Chief Clerk


FEDERAL FINANCIAL MANAGEMENT, GOVERNMENT INFORMATION, AND INTERNATIONAL 
                         SECURITY SUBCOMMITTEE

                     TOM COBURN, Oklahoma, Chairman
TED STEVENS, Alaska                  THOMAS CARPER, Delaware
GEORGE V. VOINOVICH, Ohio            CARL LEVIN, Michigan
LINCOLN D. CHAFEE, Rhode Island      DANIEL K. 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
                 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...............................................    18

                               WITNESSES
                       Thursday, January 19, 2006

Michael Miller, Deputy Assistant Administrator for Global Health, 
  U.S. Agency for International Development......................     7
Simon Kunene, Malaria Program Manager, Swaziland Ministry of 
  Health.........................................................    24
Donald R. Roberts, Ph.D., Professor, Division of Tropical Public 
  Health, Department of Preventive Medicine and Biometrics, 
  Uniformed Services University of Health Sciences, Bethesda, 
  Maryland.......................................................    26
Andy Arata, Vector Control Specialist............................    27

                     Alphabetical List of Witnesses

Arata, Andy:
    Testimony....................................................    27
    Prepared statement...........................................    63
Kunene, Simon:
    Testimony....................................................    24
    Prepared statement...........................................    38
Miller, Michael:
    Testimony....................................................     7
    Prepared statement...........................................    35
Roberts, Donald R., Ph.D.:
    Testimony....................................................    26
    Prepared statement with an attachment........................    48

                                APPENDIX

Two charts submitted by Senator Coburn entitled ``USAID Malaria 
  Spending for FY04''............................................    65
Article submitted by Mr. Roberts entitled ``Overcoming Regulation 
  Based on Innuendo and Litigation''.............................    67
Questions and responses for the Record from:
    Mr. Miller...................................................    69
    Mr. Roberts..................................................    79
Roger Bate, Resident Fellow, American Enterprise Institute and 
  Director, Africa Fighting Malaria, and Richard Tren, Director, 
  Africa Fighting Malaria, prepared statement....................    84


          BILATERAL MALARIA ASSISTANCE: PROGRESS AND PROGNOSIS

                              ----------                              


                       THURSDAY, JANUARY 19, 2006

                                     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 2:30 p.m., in 
room SD-342, 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 Subcommittee will come to order.
    I would like to thank our witnesses for taking the time to 
testify and the tremendous effort that some of them made to get 
here, the long distances they traveled.
    This is a follow-up hearing to a hearing we had some 6 
months ago, and it is important for America to realize that 
malaria sickens somewhere around 500 million people a year. It 
kills nearly 2 million people every year. Of those, 85 percent 
of the victims reside in Sub-Saharan Africa. As we sit here for 
the next 2 hours, 240 more children will die from malaria. The 
United States will spend $105 million to fight malaria this 
year, and the President has a new initiative where he has 
committed $1.2 billion over the next 5 years to fight this 
dreaded disease. With plans to scale up spending so 
dramatically and in such a short period of time, it is all the 
more important that we get it right, that our program saves 
lives in a measurable way.
    After our hearing on this subject last year, U.S. Agency 
for International Development (USAID) went through its books 
and reported that less than 8 percent of the bilateral malaria 
budget went toward life-saving commodities such as $2 drugs 
that cure the disease, insecticides to kill the mosquitoes that 
carry the disease, and nets to keep the insects off people 
while they are sleeping. What is worse is that the majority of 
that 8 percent was spent to sell bed nets rather than to give 
them to the people who could not afford to buy them.
    When we brought some sunshine to the budget on this 
project, we discovered that the vast majority of the malaria 
money was going to advice-giving programs, administrative 
overhead, travel, and conferences. In other words, we spent 
most of our money telling people how to use the cheap and 
effective tools to fight malaria and very little money actually 
providing them those tools and very little money actually 
saving lives.
    Despite good intentions all around by those dedicated 
workers at USAID, our priorities have been out of whack. But 
things are changing, and I want to commend President Bush and 
those at USAID for recognizing the problem and announcing the 
major reforms over the past 6 months to change course. The 
President's plan targets a few focus countries at a time for 
nationwide coverage with life-saving interventions, including 
insecticide spraying in homes and drug procurement. But even in 
countries not initially targeted, USAID recently announced an 
overhaul of its malaria programming so that by next year 50 
percent of its budget in those areas will go towards purchasing 
commodities and 25 percent of its budget will be spent on 
spraying. This is ground-breaking movement, and I am encouraged 
to think how many children and pregnant women might be spared 
death from this preventable and curable disease.
    I want to congratulate the President for his leadership, 
and especially Assistant USAID Administrator Kent Hill and his 
deputy, Michael Miller, who is here today, for their courage 
and commitment in the face of the grueling task of implementing 
reforms at the programmatic level. It is very easy for Members 
of Congress to throw stones and criticize. It is quite another 
thing to actually turn a program around and change an 
international bureaucracy and move it in a different direction. 
We are having a follow-up hearing today because the sound 
policy and planning that have been achieved so far are only the 
beginning. So what I would like to do is get into some of the 
details of what we will be looking for over the coming months 
to carry out the new initiatives:
    Accountability. One of the first principles we aim for here 
is transparency. We have been assured that a website would be 
launched that tracks all the money and the progress made with 
that money toward measurable indicators. So far, the website is 
not up and is not running, but I will be interested to hear a 
firm date for that launch so that taxpayers and congressional 
overseers can perform our job of seeing where the U.S. dollars 
are actually carried out in action.
    Second, the President's initiative sets an ambitious goal: 
85 percent coverage in focus countries of vulnerable 
populations with life-saving interventions, as appropriate. And 
it is that ``as appropriate'' that provides wiggle room, some 
of which is very legitimate. But we do not want to open 
loopholes that allow for those who are content with the status 
quo to rest on their laurels. So far I haven't seen any of the 
technical guidelines or the criteria that govern when, where, 
and for whom certain interventions should and should not be 
used. It seems that these decisions are being made on an ad hoc 
basis for each country, which makes it difficult to compare the 
results across countries, to assess the scientific soundness of 
those decisions, and also for other donors and other countries 
who are looking to us for guidance about how to fight malaria 
in other countries and to imitate what we hope may be the most 
successful anti-malaria campaign since the world eradication 
effort last century.
    Let me outline some of the basics we are looking for: 
Insecticide spraying in homes virtually everywhere; the use of 
the cheapest and most effective insecticide, which almost 
always turns out to be DDT. The World Health Organization (WHO) 
and others have stigmatized DDT long enough, even as 
environmental groups now concede that the chemical should be 
used for malaria control. No human or wildlife harm has ever 
been demonstrated when DDT is used for spraying of homes. The 
unnecessary death toll caused by a bias against DDT needs to 
end right here and right now. I will be expecting USAID to 
reverse years of damage caused by an anti-DDT message by 
enthusiastic and vocal support with dollars and words for 
spraying with DDT.
    Next, a bed net distribution strategy that can 
realistically reach 85 percent coverage for vulnerable 
populations. Since almost every household contains a child 
under five or a woman of child-bearing age, that means you have 
to get at least one, maybe two or three bed nets into most 
houses in focus countries. That is going to involve a lot of 
free bed net distribution, and not a marketing campaign to sell 
nets.
    We will want to see artemisinin-based combination 
chemotherapy used where there is resistance to older drugs 
greater than 10 percent. If we do not know what the resistance 
levels are in a given area, we should use artemisinin until we 
can establish what those resistant levels are.
    USAID can streamline the use of indoor insecticide spraying 
through lifting of regulatory barriers. Massive environmental 
impact assessments for public health initiatives were never the 
intent of Congress in the National Environmental Policy Act. I 
suggest that USAID carefully review these laws and regulations. 
Rather than trying to justify the onerous regulations as not as 
problematic as they seem, I would rather see the Acting 
Administrator of USAID exercise his authority to remove the 
barriers altogether.
    Finally, setting numerical goals for commodity allocations 
will further validate this Administration's commitment to 
saving the lives of Africans. While a commitment was made for 
countries not targeted by the President's initiative, I would 
like to see some targets set for the President's focus 
countries as well. You see, what we saw and what we do does 
echo around the world. We are only one player vitally concerned 
with the welfare and health of those on the continent of 
Africa. But we are the biggest player when you count both our 
bilateral and multilateral contributions to malaria control. If 
our message and our money go out in a science-based, 
unapologetic, reformist way, the whole world will change with 
us.
    Given the death toll from this disease, nothing short of 
dramatic change by every donor and every host country's malaria 
program is necessary. We are losing generations in the 
meantime.
    You will see on this other photograph a few of the children 
who died in one year at one school in Uganda from malaria. 
Tremendous potential wasted because we have not been effective 
in helping those that are dependent upon us. Every minute we 
take to get these programs up and running is precious time lost 
for millions of children just like them.
    [The prepared statement of Senator Coburn follows:]

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    Senator Coburn. I know our witnesses today share my 
passion, and I am grateful for their time and their hard work 
to end the scourge of malaria on the world's children and 
families. And I want to thank you for being here.
    Michael Miller has been with USAID in his present capacity 
since 2004. We welcome him back to the Subcommittee for the 
second time. He serves in various interagency capacities for 
USAID in the implementation of the President's Emergency Plan 
for AIDS Relief, PEPFAR, and is directing the implementation of 
the President's Malaria Initiative.
    Mr. Miller, you are welcome. Your testimony has been read. 
It will be introduced into the record as submitted, and you 
will be recognized for 5 minutes. And thank you again, 
personally, for being here.

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

    Mr. Miller. Senator, it is my pleasure to be back, and we 
really appreciate your support and your interest in this. When 
we make big changes like that with any institution, it is never 
easy. And having the support of Congress is going to be 
essential as we go forward to maintaining those and building on 
those successes.
---------------------------------------------------------------------------
    \1\ The prepared statement of Mr. Miller appears in the Appendix on 
page 00.
---------------------------------------------------------------------------
    Since this Subcommittee's last hearing on the topic, the 
President has changed our global malaria strategy fundamentally 
in scope, size, and structure. Additionally, USAID has 
implemented necessary, complementary changes to its ongoing 
malaria programs. These changes, I believe, ensure greater 
effectiveness and accountability, provide critically needed 
global leadership, and will ultimately save more lives.
    The most important development is the President's Malaria 
Initiative--or PMI, as we call it--which is a multi-agency 
program led by USAID. The PMI will reduce significantly the 
number of Africans who die from malaria and will challenge 
other donors to make similar commitments. President Bush's 
commitment of an additional $1.2 billion over the next 5 years 
is unprecedented in the fight against malaria. Accordingly, the 
goals of PMI are ambitious: Reduce by 50 percent the number of 
deaths from malaria in target countries. The program will 
eventually include up to 15 countries and benefit 175 million 
Africans.
    The speed with which we have begun to implement the PMI is 
also unprecedented. In less than 6 months after the President's 
announcement, USAID was already in the field implementing 
programs that differ considerably in scope and size and focus 
from their predecessors. Right now, the PMI is conducting an 
indoor residual spraying campaign in southern Angola to protect 
over 500,000 people from epidemic malaria outbreaks. We 
recently distributed 130,000 long-lasting insecticide-treated 
nets in Zanzibar, which we will also follow up with indoor 
residual spraying. And in about a week, we will begin the 
distribution of 270,000 free long-lasting insecticide-treated 
nets in war-ravaged northern Uganda, among many other 
activities.
    PMI is a very different way of doing business than past 
practice. The hallmarks of the PMI are first and foremost 
programming based on clearly defined numerical targets for 
outcomes. Second is transparency in how the money is being 
spent. Third is a robust and effective monitoring and 
evaluation plan to make sure that we are, in fact, reaching our 
goals. This approach provides assurances that taxpayers' money 
is being spent effectively.
    PMI's size and structure also provide opportunities to 
fight malaria in Africa in ways we could not just imagine a few 
years ago. In the past, USAID used the relatively small amount 
of funds to implement programs focused on issues such as 
policies to adopt artemisinin combination therapies over 
failing treatments, among other things. Much of that work is 
now done. With the PMI, we have the opportunity to design and 
implement many simultaneous, large-scale, comprehensive--
meaning providing commodities as well--country-wide programs 
throughout Africa.
    But that opportunity also necessitated changes to the 
programs currently outside the PMI, as we call it, the non-PMI, 
the existing USAID malaria programs. These are the structural 
changes we announced in December. One of the most visible 
changes is the elimination of programs that were simply too 
small to be effective on a scale we require. That was set at 
$1.5 million for this year. It will go up to $2.5 million for 
next year. Second is a correction of the imbalance between 
technical assistance and commodities, which we spoke about at 
length. Third is the opportunity to push the dialogue and think 
about indoor residual spraying as a frontline tool for fighting 
malaria in Africa, and we believe it has been under utilized.
    The rapid scale-up of PMI means that next year more 
resources and more coverage of people will be inside the 
program than outside the program, since there is a very rapid 
graduation in. As a consequence, having two parallel but 
different programs side by side is as impractical as it is 
undesirable. Because PMI will expand rapidly, any real 
distinction between the two has to be temporary, and the 
programs that now fall outside the PMI have to start making 
critical adjustments now, including emphasis on life-saving 
commodities, reporting on planned activities and allocations, 
and programming more money.
    In the case of Indoor Residual House Spraying (IRHS), this 
year we will spend approximately $20 million on spraying, and I 
would note that is two times the entire amount of the global 
malaria programs in 1997 just on spraying alone this year, and 
about a 20-fold increase over fiscal year 2004. In at least 
three of the eight countries where USAID will support IRHS this 
year, DDT will be the primary insecticide. As some countries 
move into the matrix of PMI countries--in other words, they 
move off the list of outside PMI and into PMI--the specific 
numerical targets and the monitoring and evaluation regime will 
also apply to them as well. In short, the changes we instituted 
to the non-PMI are part and parcel of the creation of a single, 
large-scale, target-driven strategy to fight malaria in Africa 
and to demonstrate those results.
    What we have begun to do with PMI, as we have done with the 
President's Emergency Plan for AIDS Relief, PEPFAR, is to judge 
and plan our programs based on outcomes, not simply on how much 
money we put in at the beginning. The difference is simple but 
profound in terms of how we plan and how we go about it. It 
demands a level of new programmatic transparency and 
documentation that in turn provides confidence in the 
effectiveness that allows the President to make the multi-year 
commitments and ramp up funding accordingly. Targets keep 
agencies, individuals, and entire governments focused. With 
accurate data, targets provide unambiguous measures of success 
or failure and allow informed judgments about whether the 
program is effective, whether it should continue to be funded 
or not, or that money should be moved elsewhere. Ultimately, 
that not only makes for good management and good governance, it 
is much more satisfying for those of us who are charged with 
implementing the programs. It also makes them more effective. 
In the case of the PMI, that means the opportunity for the 
United States to fill a global leadership role in the fight 
against malaria and to save millions of lives that might 
otherwise have been lost to a preventable and curable disease.
    Thank you.
    Senator Coburn. Thank you so much for coming. One of the 
things you alluded to was the transparency and accountability 
of this new program, and we have talked about having a way for 
the American public to track that. And this is not just with 
USAID. The American people ought to be able to see where all 
their money is going all the time, except in national security 
issues. And the idea of having that available to the American 
public, when do you perceive that will be available?
    Mr. Miller. I will make a distinction between the fiscal 
year 2004 data and the fiscal year 2005 data, because we have 
collected them at different times. The fiscal year 2004 data is 
complete. We have put what we call the aggregate or the 
composite spread sheet of expenditures up on the website 
yesterday or the day before. And then as we actually make the 
typed corrections, if you will, to the data sheets that we 
corrected by hand as we conferred with the field, did 
mathematical corrections and things like that, those will be 
posted subsequently. I think the last time I asked the staff 
was doing it. There were five up.
    So the 2004 data is complete, and it is starting to be 
posted. The 2005 data is going to take a little longer simply 
because when the fiscal year ended, we sent out the 
questionnaire, I believe, on October 31. So the missions 
received it presumably that day and were able to start 
collecting that data themselves and sending it out to their 
grantees for them to return data back to the mission.
    That will take a while because of a couple factors: Simply 
because they have not closed their books, they are still 
spending some 2005 money. They have to rely on the grantees to 
send the information back, which, of course, you cannot always 
guarantee. Not much happens over Christmas in many of these 
countries, including here.
    Senator Coburn. Well, the point I am getting to is there is 
going to be created a continual expectation that there is going 
to be data collection and transparency, where the money is 
spent and the results of the money.
    Mr. Miller. Absolutely. Our goal is to have by February 10 
the complete 2005 data. If it is not accurate, we will not post 
it. We will continue to go back and make sure it is accurate. 
We do not want to rush it. But 2006 and beyond, it is built 
into the system, and that is the benefit that we do not have to 
do a retrospective.
    Senator Coburn. Under the President's Malaria Initiative, 
the goal is 85 percent coverage of vulnerable populations as 
appropriate. How would you define ``vulnerable populations''?
    Mr. Miller. Children under five, people living with HIV/
AIDS in malarious areas, and pregnant women.
    Senator Coburn. OK. And what four interventions are 
essential to achieve malaria control?
    Mr. Miller. Insecticide-treated nets and indoor residual 
spraying as prevention measures at the household level; 
treatment, ACTs, and treatment of expectant mothers with 
intermittent preventive treatment. That is four.
    Senator Coburn. When we go back to the goal of 85 percent 
coverage of vulnerable populations as appropriate, can you 
define to me what criteria you all are going to use for this 
``as appropriate''?
    Mr. Miller. There will be some cases where--it is rare, but 
in general you can say in most areas in tropical Africa, in the 
countries that we are focusing on this year and next year, 
everybody within those categories will be vulnerable; almost 
100 percent in Angola I think you can say. There will be parts 
of--well, almost 100 percent, but there are parts of Angola, in 
the highlands, where it may not be. There are parts of--people 
who live in the cities perhaps are not vulnerable. But, in 
general, I think you can say almost anybody who fits in those 
three categories of HIV/AIDS positive, children under five, or 
pregnant women is more than likely going to be in the 
vulnerable population.
    Senator Coburn. The ultimate goal is to fund adequately all 
four interventions.
    Mr. Miller. Right.
    Senator Coburn. How are you going to make the decisions for 
priority, for which comes first?
    Mr. Miller. Well, the idea is to do all simultaneously. We 
want those levels of coverage on all of them. The one 
distinction I will make is between nets and spraying. Whereas, 
at the home level, if you can achieve coverage of one of those 
two at 85 percent, we believe we will be meeting our targets.
    Now, there are cases where, in fact, in Zanzibar, we will 
do what we call the suspenders-and-belt approach, which is 
spraying and nets made available. And we will see what the 
effect of that is. What we do know is in the case of if you 
have proper and effective use of a net or the proper and 
effective use of IRHS, you can reduce the incidence of malaria 
for the protected person by 90 percent.
    Senator Coburn. But the difference is you can do IRHS once 
a year and have a variable use of net of not use of net, where 
somebody takes the net and goes fishing with it instead of 
using the net for prevention. So I guess I presume by your 
answer you all have scientific data to say that nets, if you 
get an 85-percent coverage, are just as effective as IRHS?
    Mr. Miller. The way I would characterize it is we do know 
that nets are effective, we do know that IRHS is effective. 
What I don't think we, the world, really have a sense of is 
exactly what the distribution should be, how much IRHS versus 
how much nets.
    Now, there are practical considerations as well, some areas 
where it would be conceivable that it simply just becomes cost-
ineffective to do IRHS, which does have a logistical train 
along with it. You do have to have acceptance rates and stuff 
like that. But you are correct, there are clear advantages in 
some cases of IRHS over nets. And what we hope to find out is--
take the issue of IRHS, which we believe has been 
underutilized, and start to push the issue to have people 
asking the question how much IRHS can we do, where is it cost-
effective to really get the data on this, we have some data, 
and we know from places like South Africa, and I am sure in 
Swaziland, a place like that, that it can be very cost-
effective. But what we don't know in these countries that are 
hyperendemic countries like Uganda, where 95 percent of the 
country has transmission almost all year round and they have 
not done spraying in decades. Where is it that we can cost-
effectively do spraying before we start running out of money or 
where in the case--or if that is the case, where nets would be 
more appropriate.
    Additionally, we also have net distribution networks up and 
running. One of the tragedies, if you think of IRHS, is because 
it has been underutilized--and it is not just DDT. I think it 
is IRHS across the board. There is very little institutional 
capacity in these countries. For the case of Uganda, I had a 
very interesting conversation with the National Malaria Control 
Program and with the Vice President himself, who is also a 
physician like you. They are very inclined to use IRHS. They 
are leaning heavily towards DDT. But in this first year, they 
have chosen, under the PMI, in fact, to choose one district, 
Kabali District, do spraying in one district, and then see 
how--get their feet under them, essentially, start moving out 
to the other 14 districts that they have targeted, and then 
make a decision as to whether they think in that case they can 
rotate DDT in instead of synthetic pyrethroid. Their preference 
would be to use DDT simply because it is more effective in 
their case.
    Senator Coburn. It is also markedly less expensive.
    Mr. Miller. It is a fourth of the cost, is what they told 
me.
    Senator Coburn. For the same amount of dollars, you get 
four times the amount of coverage. Once you have the 
infrastructure there.
    Mr. Miller. Right. I don't think the math would work out 
exactly, but, yes, you can presumably get much more coverage 
because the largest single cost in that program, speaking of 
Uganda specifically, if I remember right, it was the 
insecticides. So if you cut that by a fourth--now you do have 
additional transportation costs. DDT is bulkier, but you also 
have cost savings where DDT can have a longer residual effect--
--
    Senator Coburn. It is twice as long.
    Mr. Miller. Yes, and that is also the case in some other 
countries. We found that you could spray once a year with DDT 
or potentially----
    Senator Coburn. Well, I think that is pretty well known. We 
are going to have some testimony today about that, and the fact 
is it is significantly less in cost, it lasts twice as long, 
and it is more effective. They are not equal in effectiveness.
    Mr. Miller. Right. And there are cases where the building 
material, if it is a finished wall or a painted wall, you 
really have to make a judgment because there are adherence 
issues, residual issues, and streaking apparently is a problem 
when they wipe it off the wall.
    Senator Coburn. Is there still a plan in the new Malaria 
Initiative to subsidize nets rather than just giving them out?
    Mr. Miller. The principle that USAID has established that 
economics should never be a barrier to net ownership, I think, 
is a sound principle. It is not the only--that in itself is not 
a net plan. It is a good principle, and we will stick to it. 
But my personal belief is at the levels of coverage we are 
looking at and the fact that so many people in malarious areas, 
particularly in rural areas, people who are destitute, who 
simply never will be able to afford a net under any 
circumstances, or people who possibly could but will have no 
exposure to a socially marketed message or very little contact 
with a formal marketplace, that those people--we cannot 
realistically expect that we can reach the kind of levels we 
want to by selling nets alone. And, yes, I think we will have 
to--we are prepared to, as the situation warrants, provide free 
nets, as we are in Uganda already, in large amounts.
    Senator Coburn. Other than infrastructure to do indoor 
residual spraying, the infrastructure limitations to be able to 
train people to do it, when is IRHS inappropriate in your view? 
I am hearing that bed nets equal IRHS, and from what I have 
read, I do not read that in the literature.
    Mr. Miller. No.
    Senator Coburn. I am going to learn some of that today, but 
from what I have heard from you--and I have a little bit of 
concern--is that we are liable to not use the most effective, 
and the variable is if you have a bed net in your home and you 
don't use it, you don't have coverage.
    Mr. Miller. You don't have coverage, yes.
    Senator Coburn. If your home has been sprayed with DDT, you 
have coverage for a year.
    Mr. Miller. Correct.
    Senator Coburn. There is a big difference. You take a 
variable out of the equation.
    Mr. Miller. Yes, I agree that IRHS has many advantages in 
many situations. What we do not know--generally, IRHS has been 
underutilized. I think there is a big question mark about how 
much we can get--the cost-effectiveness, what kind of coverage 
levels--with the money we have. I think that just requires 
doing a lot more of it. I think we have commissioned a study 
that will look at all the available data on cost-effectiveness, 
but I do not have confidence that alone will really give us the 
picture. I think we have to put more money against it and see 
what the data is, because there are a lot of questions about 
how effectively we can use it. And I think we can use it much 
more effectively, and that is sort of less of a question. But 
in the single home--I should clarify. What I meant is in a 
controlled situation, if you are using a net properly in a 
controlled situation, if you are in a home that has been 
sprayed properly, that individual, that vulnerable individual, 
can enjoy certain amounts of coverage. Now, I suspect that 
there are situations--and from past experience people say in 
urban areas, in peri-urban areas, there are these sort of 
diffuse, quasi-urban areas around the big cities in Africa, 
that spraying is much more advantageous. And that is what we 
are really aiming to find out, is put money behind that and see 
what really are the cost-effectiveness numbers that we can take 
to the bank and really plan against in future years.
    Senator Coburn. In November of this year, the South African 
Health Ministers, it was resolved that member states should 
support IRHS with insecticides. And, recently, Ugandan 
scientists urged their government to support IRHS with DDT. Is 
there some outside barrier to indoor residual spraying with 
DDT?
    Mr. Miller. With DDT? Yes, I think there is. There is a lot 
of ignorance about DDT, as I think we have seen. People are 
afraid of it, and that is not just here. Again, I will go back 
to my Ugandan experience. I had a very fascinating conversation 
with Vice President Bukenya, who said they, for example, have 
started a net retreatment program in the area around where he 
is originally from, and they had very little uptake--uptake 
meaning people actually accepting the service for free. And 
they found out a rumor had gone around that the retreatment was 
with DDT, which, of course, first, is false, we don't treat 
nets with DDT; and, second, it is false that it is harmful to 
humans in indoor residual spraying.
    So there is ignorance we have to fight and----
    Senator Coburn. So do you all have a plan to address that 
in terms of remove the barriers to IRHS with DDT?
    Mr. Miller. Absolutely. Well, the first part of the plan is 
simply do more of it. In fact, in the non-PMI programs, when we 
dedicated that 25 percent to IRHS, what we were able to do is 
go through and essentially cherrypick countries where we knew 
they had very robust IRHS plans and national malaria control 
plans, which is not true for every country, and where we had a 
reasonable number of them that would use DDT.
    Now, one of the main ones that does not in that roster of 
four--five if you count Madagascar, and I will come back to 
that--Kenya does not. And they have the same problem that 
Uganda does, which is essentially if I--this is my own 
characterization. They feel like they are over the barrel in 
terms of exports, particularly to the EU, and they think it is 
a real concern, and I think it is, that the standard is very 
high that if there is any DDT detected in the cut flower 
industry, in the vegetable exports, freshwater fisheries, all 
of which are common to those countries and to Tanzania, then 
they face potentially a ban to exports to the EU. That would 
cripple their economies. In their minds, there would be no 
advantage.
    In Uganda, DDT is not illegal. But as I mentioned, they are 
essentially going to get themselves back into the IRHS program, 
understand what they want to do, make sure there is no seepage 
out in the agricultural community, make sure the security 
around sprays are adequate. In Kenya, they still have a ban. We 
have not had any dialogue with them as to whether they would 
lift that. I think they are going to have to make that decision 
on their own.
    But to answer your question, yes, there are. There are many 
considerations for them.
    Senator Coburn. I am going to turn this over to Senator 
Carper, but it is interesting when you look at the signs and 
you look at the death rate in Africa and you look at the 
effectiveness of DDT, and we are going to hold people hostage 
to not do the most effective, the most efficacious treatment 
and public health strategy because we are going to threaten 
them with poor science because we don't understand the poor 
science. And I think there is an obligation on your part to 
bear the pressure to change that with the EU. When 500,000 kids 
die a year because there is not IRHS and there is not 
artemisinin and there is not the medicines made available, and 
the IRHS isn't there because somebody is afraid--not on the 
basis of scientific but on the basis of emotion--that it is 
going to have an impact on somebody, that is hijacking the 
world's poorest people in the worst way.
    [The prepared statement of Senator Carper follows:]

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    [GRAPHIC] [TIFF OMITTED] T6748.006
    
              OPENING STATEMENT OF SENATOR CARPER

    Senator Carper. Thank you, Mr. Chairman. Good to be with 
you again. And, Mr. Miller, thank you for joining us.
    I think you were before us back in May. Is that right?
    Mr. Miller. I was.
    Senator Carper. I thought so. If you would start with a 
little bit of a timeline for me, please, and take it from May 
when we had our hearing, and I think the President maybe 
offered his initiative in, I want to say, early summer, maybe 
June, can you walk me through the timeline from where we were 
back in May and sort of chronologically what is different today 
and when did that occur.
    Mr. Miller. Yes, sir. I believe the hearing was May 12. By 
that time, we were already in very early planning stages with 
the White House in terms of what kind of program we could 
potentially propose to the President in the lead-up to the G-8. 
And a lot of the planning around the President's Malaria 
Initiative really was from the G-8. As you know, last year at 
the Gleneagles Summit, the United Kingdom had as their theme, 
if you will, global health. And so one of the global health 
initiatives we had was a series of options on what we thought 
we could do in malaria. Ultimately, the President chose it 
because it could be--it is doable. Malaria is beatable. There 
is plenty of room for global leadership on this. And it is 
something we can do--with relatively reasonable amounts of 
money, we can have a huge impact. And that is why he chose it.
    He chose that leading up to the G-8, and by June 30, we had 
a completed proposal that he had approved, and he announced on 
June 30. We were up and running pretty fast. Certainly by 
December we had the spraying program started in Angola. We had 
net distribution started in Tanzania, and we will start the 
programs in--the jump-starts in Uganda as well.
    Also by December, we had our country teams make two trips 
to the region. The first was to make a needs assessment, and 
that is an assessment where a team, some of the malariologists 
that are with me here, went to Tanzania, Angola, and Uganda, 
and along with other donors, with the World Health 
Organization, and with the governments of those countries, the 
National Malaria Control Programs, made an assessment of who is 
doing what where and who is not doing what where and where we 
can start planning to put our resources against that. That was 
in August. The second would be a series of planning trips, both 
by country staff that is already there and our expertise here 
going out as needed, to pull together a country proposal, 
essentially. This is modeled, if you are familiar with PEPFAR 
COPs, the country plans that they submit every year, which show 
what they are going to do, with who, and where. We had a small 
version of that submitted to us. We had an interagency team 
that included Secretary Leavitt's office, the Centers for 
Disease Control, DOD, State Department, Office of Management 
and Budget, the White House, the National Security Council, and 
us.
    We reviewed those and approved them in large part on 
December 20. So just in that 6-month period or so, less than 6 
months, we actually had approved programs, money behind them, 
and activities going on in the field.
    Senator Carper. That is pretty fast.
    Mr. Miller. Very fast, yes. And I should add----
    Senator Carper. Do you think it was largely instigated by 
our hearing, probably? [Laughter.]
    That is probably giving us more credit than we deserve.
    Mr. Miller. It certainly did not hurt.
    Senator Coburn. Let me answer that. There are a lot of 
people that are interested in this. Senator Brownback has been 
working in this area for a long time. There are people in USAID 
that want to see it more--the people that work at USAID want to 
see success. And so highlighting it helps raise the pressure on 
it, but the leadership, both in USAID and at the President's 
level, is responsible for this change, not us. And you did not 
hear my opening statement, but I said that.
    Mr. Miller. But we do certainly appreciate your interest 
and support on that.
    I should also add that also in December Administrator 
Natsios signed a fairly comprehensive and fundamental 
restructuring of our programs, malaria programs within USAID 
that currently fall outside the President's Malaria Initiative 
but are in the process of graduating in. So that was all within 
a 6-month period. We started the Presidential initiative, got 
it up and running, and independently made pretty fundamental 
reforms internally.
    I do have to give a tip of the hat to PEPFAR. The fact that 
we in the U.S. Government, we had exceptionally good leadership 
within PEPFAR from Ambassador Tobias, so we are very pleased to 
hear the news about him today--that is right, if the Senate 
confirms him, of course. And we also had the benefit of seeing 
where the barriers were, where things were easy, what kind of 
numbers we had to collect, what kind of data we needed in the 
end to prove that we were meeting our goals. And then the most 
basic point is that you have a program that is based on 
targets. You set a target that is realistic, you say how you 
are going to get there, and then you start programming against 
that with a program that can prove it is getting there. And 
that is the real innovation with PMI that PEPFAR really led the 
way on, and we have benefited tremendously. The people in the 
countries that have already gone through the process of making 
a country plan and that kind of planning and that kind of 
reporting was much easier for them and much easier for us. We 
have already been through that. So very much benefited from 
that.
    Senator Carper. Just take a very short while on this one, 
and I know you spoke of this in your statement, but how are we 
doing? It has been 6 months since the President unveiled the 
initiative.
    Mr. Miller. I think we are doing great. I am very 
satisfied----
    Senator Carper. How are we doing and how do you measure 
success?
    Mr. Miller. We measure success in lives saved at the end of 
the day. The end of the day is actually at the end of 5 years, 
but we do have within that 5-year period ways to measure our 
progress. And it is very important.
    At the end of year two, or halfway in--first we establish 
baselines, what the coverage is in a country, what gaps we need 
to fill, what the mortality is from malaria, particularly in 
children under five. And halfway in, about the end of year two, 
we make an assessment of what our coverage rates are with 
preventions and with treatments. That data also provides for us 
what the deaths are within that sample area, what the under-
five deaths are. And halfway through, we can go through and 
send people out to track down those deaths and do what we call 
a verbal autopsy. In other words, you take an expert that goes 
back to those homes where the child died and ask the mother a 
series of questions, because a child in Africa to have a fever, 
it can be any number of things. Half the time it is going to be 
malaria in these areas. But it could be meningitis, it could be 
any number of things, so they ask: Was the child vomiting? Did 
their neck hurt? Were they stiff? And they collect that data, 
they send it back to a panel of experts, who will do what 
they--that is part of the verbal autopsy, who make a pretty 
accurate determination of whether they think it was a malaria 
death or not.
    With that data, what we can--coverage data, is IRHS being 
implemented effectively? Is the insecticide being watered down, 
diverted, or are people missing, are people not understanding 
what we are doing? Are people using their nets for other 
things? Sometimes people leave nets in the bags. It is the only 
thing they own. It is the only thing that has been produced 
that is new, and they would rather keep it than use it because 
they don't have the education. So we make sure people 
understand how they have to do this on their own. We can make 
corrective adjustments then, and also at the end of the year 
three, we can also go back and do another assessment of what 
the coverage issues are, whether IRHS, nets, and the treatments 
are doing what we say we need.
    So we have several chances within that time to make 
corrective actions, so that plus the surveillance data, which 
will take a little more time to explain, we have a pretty good 
sense of where we are. So by the end of year five, at the end 
of the day, I think we can say with a pretty high level of 
confidence if we are meeting those targets or not, or even at 
the end of year two, if we need to take corrective actions that 
soon.
    Senator Carper. All right. Thanks very much.
    Mr. Miller. You are welcome.
    Senator Carper. Thanks, Mr. Chairman.
    Senator Coburn. I have three real quick additional 
questions. You related to our staff that the programmatic 
environmental assessment should be completed in March, and you 
still feel comfortable with that? The programmatic 
environmental assessment?
    Mr. Miller. Right, we do, yes, and that is probably worth 
explaining real quickly. That is, in the environmental 
assessment period for leading up to spraying, what we have 
decided to do is try to make life a little easier on these 
country plans and take and do one large assessment, the types 
of assessments that we need across the board, a toxicity, 
chances of leakage--we use international standards--potential 
harm to fisheries, things like that. So the country plans can 
go and have a greatly reduced assessment burden.
    Senator Coburn. Right.
    Mr. Miller. So, yes, we are still sticking by that.
    Senator Coburn. And I understand there is underway a search 
for a malaria czar, somebody to take charge of this. As a 
country, we are going to have three times the investment on an 
average. We are going to go to about $350 million a year in 
terms of malaria.
    I am wondering, what are the characteristics for the person 
that you are going to fill that? I sit and look as a physician 
at the failed strategies in Africa, and I am wondering if we 
ought to be choosing an infectious disease expert that was not 
associated with a failed strategy.
    Mr. Miller. Right.
    Senator Coburn. I would just put that out as a comment. If 
we go from back inside of the failed strategies, I think we 
lose confidence, first. I can tell you I will lose confidence. 
Second, is new ideas, fresh ideas, and new invigoration will be 
helpful. So I am interested in that.
    Then, finally, my final question is one of the other big 
problems that we are facing in Africa is tuberculosis. And can 
you relate to me--and I know this hearing is not on that, but 
are there plans ongoing in USAID to expand our help on that 
dreaded disease?
    Mr. Miller. I will start backwards, on the TB. I can't tell 
you off the bat what our projections are on TB. But I agree 
that, when we were planning PEPFAR--I was actually in a 
different position at that time--and also here on the Hill, 
people identified--we used to call them ``the big three'' in 
Africa. They are very commonly associated with each other. If 
someone has HIV, there is a good chance you are going to die of 
TB or malaria. So it is very reasonable to say that as we are 
dealing with AIDS and malaria, we would also benefits from 
taking a look at TB. I am not offering any criticisms right off 
the bat, but I do want to recognize that, yes, it makes sense.
    Now, on the coordinator, I agree with you. We are not 
looking to enforce or reinforce the status quo. We are looking 
to change the way Americans view our role in fighting malaria 
worldwide, the way the world views our role. So we have to have 
a leader. Someone with public health expertise I think would be 
helpful, but as we have seen with many leaders in public 
health, it is not necessary. I do not come from a public health 
background. My boss does not. Ambassador Tobias does not. So it 
is not required. If you surround yourself with real 
professionals--and we do--it is really qualities of leadership, 
someone who understands opportunity, someone who can push the 
issues for IRHS, for example, someone who can do that not just 
here within USAID or within an interagency but also globally.
    That search is ongoing. There are some candidates, but 
presumably we have our own leadership change coming up, and it 
will have to be at least connected to that.
    So I would have liked to have had one by now. That is not 
for lack of trying. And certainly by next year, when we ramp up 
to $135 million within the PMI and go up to presumably--
potentially up to $200 million overall, it is an incredible 
amount of responsibility. We have to staff up some more 
internally. We will want somebody that has leadership and has 
the experience, and our job now, I think we see it as we get a 
program up and running that we can hand over to that person, 
that there is minimal distractions, minimal corrective action 
that will have to be taken.
    Senator Coburn. All right. Thank you. I am going to have 
about four or five other questions that I will submit to you in 
writing, if you would get those back to us in a couple of 
weeks.
    Mr. Miller. I would be happy to, yes.
    Senator Coburn. I would appreciate it
    Senator Carper, do you have additional questions?
    Senator Carper. Just one, if I could.
    In your opinion, what role should malaria experts and 
African governments be playing in defining where house spraying 
should be used? But before you answer, let me give you sort of 
a second part. Do you have any concerns that legislating that a 
percentage of U.S. funding be for spraying, taking out of the 
equation both African governments who may better understand 
logistics in their particular part of the world, and experts 
who may best understand which sprays or which nets or other 
tools may work best?
    Mr. Miller. I think in any circumstances, answering 
generically, we want to have experts as closely associated with 
the planning as possible. I think the best way to go about it 
is to start with the idea that we believe spraying has been 
underutilized in Africa. Personally, I believe everything has 
been underutilized in Africa. That is part of the problem.
    In the 1950s, when a panel of experts, a WHO panel of 
experts, and the donors decided that Africa was simply too 
difficult to undertake the eradication--and eradication was the 
aim then--to undertake the eradication programs in Africa, as 
we did on many other continents, we were literally decades 
behind. And what we found is in these countries, as the 
Ugandans told us very clearly, there is very little expertise 
on indoor residual spraying. Some people remember it. Some 
people are very enthusiastic about it. A lot of people don't 
know about it. And the expertise within the National Malaria 
Control Programs varies quite a bit. And I think the attitudes 
toward indoor residual spraying varies quite a bit.
    One thing that we have observed internally is that the 
National Malaria Control Programs' posture toward indoor 
residual spraying very often reflects the prevailing opinions 
of outside experts who are hired as consultants to help write 
them. So it's going to be a real grab bag of opinions. 
Predominantly, the opinion is that IRHS does not have a role. 
We don't agree with that. Most Africans don't agree with that. 
It is not universal.
    In the case of Tanzania, for example--Zanzibar, rather, it 
was USAID staff that said, Why don't we try an indoor residual 
spraying campaign here as well? They said that is a good idea. 
In Uganda they have a very clearly defined plan where they have 
planned over long periods what to do, and we come in behind 
that without much questioning. It can be expanded or it can be 
limited, depending on it. But I think it is fair to say that 
the level of expertise on IRHS worldwide, particularly in 
Africa, is pretty spotty, and we need to support that. We need 
to support more interventions across the board, not just IRHS 
but more interventions, more attention on malaria from all 
donors.
    Senator Carper. All right. Thank you very much. And thank 
you for the report.
    Mr. Miller. Thank you.
    Senator Coburn. I would just note that there is great 
scientific data that proved the effectiveness of IRHS in terms 
of controlling malaria.
    Mr. Miller. I agree.
    Senator Coburn. Reductions by 50 percent in the death rate 
among those where it has been utilized properly. And that is 
what we are talking about. We are talking about saving those 
kids' brothers' and sisters' lives. And it is effective. And it 
is not about mandating the percentage. It is about having more 
than 8 percent of the budget go to actually making an impact in 
the disease.
    Mr. Miller. Right.
    Senator Coburn. That is what it is about. Mr. Miller, thank 
you very much.
    Mr. Miller. My pleasure, sir.
    Senator Coburn. We will submit some questions. Thank you 
for coming before us, and congratulations on a job well done.
    Mr. Miller. Thank you very much. Thank you, Senator.
    Senator Coburn. I would like to thank our next panel. We 
have three witnesses. I want to personally express my 
appreciation for you coming. We have Simon Kunene, Malaria 
Program Manager, Swaziland Ministry of Health. Mr. Kunene has 
directed Swaziland's National Malaria Program since 1993. He is 
the Chairperson of the Southern African Development Community 
Subcommittee on Malaria. He also serves as a consultant to the 
World Health Organization on vector control and indoor residual 
spraying for malaria control. I appreciate very much the 
distance that he has traveled to come to be with us. I know 
what that long ride is like, and to share the lessons that you 
have learned from being involved with this in the field.
    Next is Dr. Don Roberts, Professor at the Uniformed 
Services University of the Health Sciences. Since 1986 Dr. 
Roberts has been a professor at the Division on Tropical Public 
Health. He has authored over 100 peer review publications. Much 
of his research is focused on malaria control methods, 
specifically on indoor residual spraying. I appreciate the 
scientific expertise he will share with the Subcommittee.
    Next is Dr. Andy Arata, Vector Control Specialist. Dr. 
Arata serves as a consultant to USAID and the World Bank 
projects involving vector-borne disease and their control. He 
has previously held a post as professor in the Department of 
International Health and Development at the Tulane School of 
Public Health and Tropical Medicine. He has served as the 
Deputy Project Director of the Environmental Health Project 
funded by USAID, and has over 30 years of experience 
consulting, managing, teaching, and researching in the field of 
tropical diseases and vector control. I look forward to hearing 
about lessons learned from his extensive career.
    I want to welcome you all. Your full testimony will be made 
a part of the record, and you will be recognized. We would like 
for you to limit to 5 minutes. If you go over, we are OK. We do 
not have any votes that we are going to have to worry about 
today.
    Mr. Kunene.

    TESTIMONY OF SIMON KUNENE,\1\ MALARIA PROGRAM MANAGER, 
  SWAZILAND MINISTRY OF HEALTH, AND CHAIRMAN OF THE SOUTHERN 
     AFRICAN DEVELOPMENT COMMUNITY SUBCOMMITTEE ON MALARIA

    Mr. Kunene. Thank you, Mr. Chairman. Thank you very much 
for inviting me to give this testimony today, and I hope this 
hearing will lead to a better understanding of what Swaziland 
is doing or has done in malaria control, and how the U.S. 
Government can better assist other African countries, including 
Swaziland, to save lives.
---------------------------------------------------------------------------
    \1\ The prepared statement of Mr. Kunene appears in the Appendix on 
page 00.
---------------------------------------------------------------------------
    As my written testimony explains, Swaziland's main 
intervention in malaria control is indoor residual house 
spraying, and this method of control has been highly effective 
for many years, and was first introduced shortly after the end 
of the Second World War.
    As a result of the successes and a reduced pattern of 
malaria, funding for malaria control was reduced significantly 
in the 1980s. Indoor residual house spraying coverage declined, 
and malaria cases and deaths increased.
    In 1986 and 1987, the government of Swaziland, along with 
some partners, which included the World Health Organization, 
the South African Trade Mission and USAID, reinvigorated 
malaria control. This relaunched program was, and is still, 
mainly based on indoor residual house spraying and provision of 
effective drugs. And recently we have introduced insecticide 
treated nets in our program.
    We now have a very wide coverage, Mr. Chairman, of IRHS, 
and with more than 90 percent in targeted areas is now coverage 
achieved. We use DDT and synthetic pyrethroids, which continue 
to be highly efficacious and cost effective.
    An innovation of our program is to use geographical 
positioning system, GPS, to enhance planning, monitoring and 
evaluation of our malaria control activities. The introduction 
of GPS in our program ensures that limited resources are put to 
the best possible use. With support from the Global Fund we 
recently introduced ITNs, targeting pregnant women and children 
under five years of age.
    To ensure that we achieve the appropriate targets, these 
nets are distributed to the high risk groups free of charge. We 
strongly believe that IRHS and ITNs complement each other. In 
other words, ITNs are not a replacement for IRHS and vice 
versa.
    Malaria case management remains very critical if we are to 
reduce malaria morbidity and mortality. This requires that 
health personnel are properly trained in the management of the 
disease, and there should be a consistent supply of drugs. The 
Kingdom of Swaziland, over the years, ensured that all anti-
malarial drugs are available at health facilities, and the 
distribution and administration of these drugs remains the 
responsibility of health professionals.
    The consistent implementation of IRHS and the limitation of 
antimalarial drugs to health professionals have probably 
contributed to the slow development and spread of chloroquine 
resistance in the country. It is against this background that 
the chloroquine remains the drug of choice. However, the 
country has taken a decision to introduce ACT in the country, 
not because of resistance, but because of the added advantages 
of ACTs.
    Malaria is very unstable in Swaziland and epidemics are 
very common in the years of favorable conditions for 
transmission. It is, therefore, crucial that we have a very 
sound disease surveillance system in place to pick up any 
abnormal situations.
    Our decisions on malaria control are based on scientific 
evidence. Therefore, we monitor drug and insecticide 
resistance, and we work with international institutions in this 
regard.
    The effective implementation of the above has ensured that 
the pattern of disease is maintained at acceptable levels. For 
example, clinical malaria cases have been reduced from 45,000 
in 2000 to over 5,000 in 2004. Malaria admissions have fallen 
from about 1,800 in 2001 to fewer than 200 in 2004. There were 
less than 10 malaria deaths in 2005. We now have a situation 
where a single malaria death becomes a news item.
    The Kingdom of Swaziland works closely with other partners 
in the Southern African Development Community. An important 
factor in our success has been the inter-country collaboration 
with South Africa and Mozambique in Lubombo Spatial Development 
Initiative. This is an initiative that has been highly 
successful and is based on IRHS, effective drugs, good disease 
surveillance and capacity building. These interventions have 
resulted in significant reduction in the pattern of the disease 
in the three countries.
    The inter-country collaboration shows what can be achieved 
when the right interventions are chosen, and when good 
operational research supports decisionmaking.
    We would like to see a situation where a far greater 
proportion of U.S. Government support for malaria control goals 
on commodities. That will have an immediate impact on malaria 
cases and deaths. We would also like the U.S. Government to 
promote policies that will provide essential commodities, such 
as ITNs, free of charge to the vulnerable groups. I would also 
like to see the U.S. Government taking a more active role in 
positively promoting this intervention, which has been degraded 
over the years. We also need a clear position on the use of 
DDT, whether or not U.S. funds can be used to purchase this 
insecticide. We also would like to appreciate U.S. support in 
the research, development of alternatives to DDT.
    Finally, Mr. Chairman, we strongly believe that U.S. 
Government supported malaria initiative should fit with 
country's own strategic framework instead of being imposed on 
them for sustainability.
    Thank you for the opportunity to give evidence today, and 
for your interest and leadership on this issue. I thank you.
    Senator Coburn. Thank you very much. Dr. Roberts.

 TESTIMONY OF DONALD R. ROBERTS, Ph.D.,\1\ PROFESSOR, DIVISION 
 OF TROPICAL PUBLIC HEALTH, DEPARTMENT OF PREVENTIVE MEDICINE 
  AND BIOMETRICS, UNIFORMED SERVICES UNIVERSITY OF THE HEALTH 
                  SCIENCES, BETHESDA, MARYLAND

    Mr. Roberts. Thank you, Chairman Coburn, for the 
opportunity to present my views on malaria and DDT this 
afternoon. As a government employee, I am required to state 
that my comment should not be construed as reflecting the 
opinions of my university, the Department of Defense, or the 
U.S. Government.
---------------------------------------------------------------------------
    \1\ The prepared statement of Mr. Roberts appears in the Appendix 
on page 00.
---------------------------------------------------------------------------
    In preparing my comments I was reminded of a statement 
often used in discussions of controversial issues, namely, that 
each of us is entitled to our own interpretations, opinions, 
and ideologies, but we are not entitled to our own facts. 
Certain basic facts about DDT and malaria control might help 
focus our thoughts and discussions.
    DDT is sprayed on the inner walls of houses to control 
malaria, and this is referred to as indoor residual house 
spraying, or IRHS. When sprayed on walls, DDT acts primarily as 
a spatial repellent. This spatial repellent action stops 
mosquitoes from entering houses and transmitting malaria while 
people sleep. DDT is moderately toxic to mosquitoes, but 
toxicity is not its primary mode of action. Our research shows 
that mosquito resistance to DDT toxic actions does not 
neutralize DDT's spatial repellent action. Thus, DDT is 
effective in the control of malaria even when the mosquitoes 
are resistant to its toxicity.
    Some people argue against house spray programs and the use 
of DDT solely on the basis that poor or less developed 
countries do not have the infrastructure or people trained to 
administer such programs.
    To the contrary, many malaria endemic countries started 
malaria control program operations on their own initiative in 
the 1940s. Those pioneering programs were quick-starts, and the 
managers learned valuable lessons as the programs progressed, 
and the programs progressed quickly. It seems reasonable to me 
that if poor countries created such programs 60 years ago, 
governments can do the same thing today.
    Another argument against indoor spraying is expense, that 
it's OK for urban areas, but that indoor spraying is just too 
expensive for rural areas. Well, malaria is a rural disease. 
The truly significant value of DDT in the 1940s was that it 
offered, for the very first time, an affordable method of 
protecting rural households from malaria. In fact, any claim 
that indoor spraying is ineffective or cannot be used in rural 
areas because of cost, is simply not consistent with the 
historical experience.
    There has been a lot of discussion about DDT's usefulness 
in areas where mosquito vectors show variable levels of 
resistance. I have already explained that DDT does not function 
by killing mosquitoes, so DDT resistance does not impair its 
mode of action, that of spatial repellency.
    Regardless, let us assume there is evidence that DDT 
resistance is a problem. The best way to evaluate the problem 
is to spray DDT and monitor its effect on malaria cases. I 
suppose we could call this a trial and error method. If DDT 
does not control disease, then use another chemical. If it 
controls disease, then it works, regardless of any finding of 
resistance.
    I propose a similar method to address claims that DDT is 
not effective under some epidemiological conditions. This trial 
and error method is consistent with advice of one of the 
world's most famous malariologist. In a presentation before the 
Royal Society of Tropical Medicine and Hygiene in 1949, Dr. 
Arnoldo Gabaldon admonished the audience that DDT's 
effectiveness should be judged on reducing malaria cases, not 
on reducing mosquitoes.
    Additionally, this trial and error method is in line with 
funding objectives of the President's Malaria Initiative, that 
is, disease control, not mosquito control.
    I will end my testimony with a historical perspective on 
leadership for USAID's new malaria program. Before DDT house 
spraying began, almost 2 billion lived in malaria endemic areas 
and were at risk of malaria. Even before the global malaria 
eradication became functional in 1959, DDT house spraying freed 
roughly a third of a billion people from endemic malaria. By 
1969, only 9 years later, DDT house spraying had freed another 
two-thirds of a billion people from endemic malaria, almost one 
billion people living without the daily threat of endemic 
malaria.
    Now, let's look at the Roll Back Malaria Initiative, which 
began in May 1998 and is now in its eighth year. I cannot 
figure out what the initiative has accomplished, and numbers of 
malaria cases have actually increased during the last 8 years. 
Eight years is a precious long time for those who are at 
constant risk of disease and death from malaria.
    In concluding my comments, I want to say that I hope the 
person selected to lead USAID's malaria program will not be wed 
to the Roll Back Malaria approaches to malaria control.
    Thank you.
    Senator Coburn. Thank you, Dr. Roberts. Dr. Arata.

     TESTIMONY OF ANDY ARATA,\1\ VECTOR CONTROL SPECIALIST

    Mr. Arata. Thank you, Chairman Coburn and Members of the 
Subcommittee on Federal Financial Management, Government 
Information and International Security, for the opportunity to 
speak before you today and to present my perspective on malaria 
control and progress in malaria control programs.
---------------------------------------------------------------------------
    \1\ The prepared statement of Mr. Arata appears in the Appendix on 
page 00.
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    As you mentioned in your statement, I have spent over 35 
years working in malaria and vector-borne disease control, 
working for a number of international organizations in over 30 
different countries.
    I began my WHO career at the actual peak of the Malaria 
Eradication program in the 1960s, and worked for WHO on new 
control methods, particularly biological control in the 1970s, 
and I have served as a consultant evaluating malaria control 
programs in Africa, Latin America and Asia, for USAID, WHO, and 
the World Bank.
    I am really quite pleased to see that U.S. foreign aid in 
malaria control is reconsidering the use of indoor residual 
spraying and DDT. For a number of years I have felt that the 
almost sole approach to vector control through the employment 
of insecticide treated nets, the ITNs, was very shortsighted, 
producing positive, but limited, results.
    In general, I and many field-oriented colleagues have 
proposed integrated control measures, employing more than one 
approach to vector control, depending upon the ecology of the 
vectors in each specific area. This approach is employed not 
only for malaria control but for the control of other vector-
borne diseases such as dengue, yellow fever, West Nile, as well 
as nuisance insects. Integrated control is also used 
extensively in agriculture, and we have a lot to learn from 
that. For malaria vectors, integrated control may include 
larval control by chemical or biological insecticides, 
elimination of breeding sites, especially man-made, in 
irrigation ditches, ponds, rice paddies, etc., housing 
improvements, ITNs, depending on the characteristics in vector 
ecology in a given area.
    Malaria is a very variable disease. There are four 
different parasitic species and numerous anopheline vectors--
40-50 vectors more or less, and a range of transmission 
intensities from endemic to stable to unstable, to variable 
biting patterns in terms of where and when the mosquitoes 
prefer to bite, resistance potential for both the parasites to 
anti-malarial drugs and the vectors to insecticides. We also 
have both forest and urban transmission patterns. In other 
words, measures that work in Southern Africa may not 
necessarily work in the Congo. The variety of circumstances 
facing the control program manager in the field is huge. On top 
of these factors, there are other complexities; differences in 
housing construction material, whether wood, mud, etc. These 
will modify the efficacy of any insecticide, so depending on 
only a single compound or a single method of application is, in 
my opinion, a recipe for failure.
    My career in malaria control has spanned from the 
eradication era through the reemergence of IRHS as a major 
control measure. To my mind, the overriding lesson of the 
malaria eradication period, has been that there was no ``magic 
bullet.'' Local variations mattered, and a flexible approach, 
what I have called ``integrated control'' was the most 
effective. In many instance malaria programs of the past were 
problematic and what we might refer to as cookie-cutter. They 
tried the same thing in country after country without any 
variation or consideration of local problems.
    Sole reliance on IRHS with DDT did not work well, and we 
now have more tools available to us than we did earlier. The 
bed nets and the newer drugs for malaria treatment offer new 
opportunities for effective control measures using integrated 
approaches tailored to local circumstances and vector-specific 
variables. Integrated control also implies the development of 
infrastructure and management practices, as well as community 
participation, and even appropriate diagnosis and treatment.
    I hope that those charged with the development of new 
malaria control programs will see their way to employ DDT as 
they would any other insecticide, to be tested and evaluated 
for efficacy, for safety and cost in each situation. I think 
DDT has a role to play in malaria vector control, and if it is 
used particularly as a component in integrated control systems. 
Thank you, sir.
    Senator Coburn. Thank you, Dr. Arata.
    Mr. Kunene, you have an integrated program, do you not? You 
have impregnated nets and indoor residual spraying. We saw from 
the data you presented to the Subcommittee this marked 
reduction in infection, marked reduction in hospitalization and 
marked reduction in deaths. Is that correct?
    Mr. Kunene. Yes.
    Senator Coburn. When Dr. Arata talks about an integrated, 
would you describe the system in your country as an integrated 
system?
    Mr. Kunene. Yes. I think we fully support an integrated 
approach. As I mentioned in my presentation, we use IRHS, then 
we use ITNs. ITNs are targeting pregnant women, which are 
considered a vulnerable group, and children under five. So if 
we were to use ITNs and ignore IRHS, we probably would be 
covering about 20 percent of the total population at risk 
because pregnant women plus children under five, I think they 
contribute about 20 percent. So you will have about 80 percent 
of the population not covered or not protected.
    So with the IRHS we are able to cover the 80 percent, which 
is not covered by the ITN program. So integrated, we fully 
support.
    Senator Coburn. And it is true, the same program you are 
using has been used in South Africa as well. Where you have 
countries today, where we are not doing anything, we are not 
seeing anything done, does it makes sense to apply what is 
being done until we figure out an integrated strategy? Nobody 
is wanting to use a cookie-cutter approach, we understand that, 
but we also understand that a lot of the buildings in your 
country have disparate different materials that are part of it, 
and there is no question they absorb at a different rate, it 
lasts varying lengths of times in terms of the application of 
indoor residual spraying with DDT. But the fact is it acts as 
an irritant and repellent in very small quantities. Is that 
true?
    Mr. Kunene. Yes.
    Senator Coburn. So what is working somewhere now is better 
than nothing happening where people are dying by the thousands.
    Mr. Kunene. I think there is attempts--as the Chairman has 
mentioned, we are treating it as a solution, that these two 
interventions will never replace each other. They complement 
each other. And as the region, South Africa, I strongly believe 
that is what even our minister has decided, and DDT remains the 
insecticide of choice, not only for South Africa, Botswana and 
Namibia. Zambia has just relaunched IRHS, and they have seen 
significant results in terms of reduction of malaria mortality 
and morbidity.
    We are now moving towards maybe Malawi, Tanzania, the whole 
sort of region, I think will move towards IRHS, IRHS as method, 
that the choice of insecticide, we leave that to the countries. 
They can do their own recommendations. What would be affordable 
to us, and what would be more effective, but IRHS as the 
method.
    Senator Coburn. Thank you.
    Dr. Roberts, Dr. Arata asserted that DDT should be tested 
like other insecticides and evaluated. Do you have any comment 
on that?
    Mr. Roberts. I do believe that there is a role for pilot 
testing in areas where there are no recent test data for the 
effectiveness of DDT in an indoor residual spray program. So it 
seems to me that would be an intelligent way to proceed, doing 
pilot testing.
    On the other hand, it is somewhat difficult to reconcile a 
slow approach in a setting where just literally thousands of 
people are dying. So it seems to me that this is one of those 
situations where outsiders should step back and let the 
countries make those decisions, how do they want to proceed, 
and then support them in any way possible, whether it is DDT or 
another insecticide.
    Senator Coburn. Mr. Kunene, you testified that DDT has been 
your primary insecticide, is that correct?
    Mr. Kunene. Yes.
    Senator Coburn. And how many years since your program 
began? That is 6, 7 years ago; is that correct?
    Mr. Kunene. It was introduced in 1946.
    Senator Coburn. I understand that, but the reuse of it 
really started, your numbers started coming down starting in 
2000, correct?
    Mr. Kunene. Yes.
    Senator Coburn. Have you all seen adverse health impacts 
from the use of DDT in your country?
    Mr. Kunene. As I mentioned, we are working in collaboration 
with the Swaziland Environmental Authority, which is a 
government wing, and they are the ones monitoring our 
responsible use of the product. And over the years they have 
not indicated that there are any adverse health effects as a 
result of the use of DDT in the country.
    Senator Coburn. Dr. Roberts, do you know of any publication 
of scientific data, peer-reviewed, that shows adverse health 
effects from indoor residual spraying of DDT?
    Mr. Roberts. I do not. Could I amplify?
    Senator Coburn. Sure.
    Mr. Roberts. I do not know of a published peer-reviewed 
article that shows that there is an adverse human health effect 
from indoor residual spraying with DDT. But I would like to add 
to that that I have actually been told by, for example, the 
head of the NIH in Mexico, that they have looked at that 
extensively because of the very considerable environmental 
pressures that were applied in Mexico to stop the use of DDT in 
malaria control. His comment to me--this was March of last 
year--was that they have found nothing.
    Senator Coburn. Dr. Arata, are you familiar with any peer-
reviewed scientific data that would suggest that?
    Mr. Arata. No, I am not. We do know, of course, from an 
environmental standpoint, there are risks to be taken, but even 
there, the vast majority of the problems are associated with 
excessive use in agriculture, forestry, and the like. In 
general, public health use of insecticides in most of the 
countries that I am familiar with, developing countries, 
usually amounts to only about 10 percent of what is used in 
agriculture, and used within the houses in IRHS. It is really 
unlikely that it would cause any environmental damage.
    Senator Coburn. So you would agree with the program. There 
is not any peer-reviewed literature out there on DDT when used 
in indoor residual spraying offers any threat to the 
environment?
    Mr. Arata. Not that I know of.
    Senator Coburn. There is not any. We have looked at it.
    Mr. Arata. There is none.
    Senator Coburn. There is no search that would show that.
    So one of the things I wanted to establish for this hearing 
is, we do not want to use DDT because it is cheap and because 
it works if it harms the environment and truly will make things 
worse; we want to use DDT is because it is very effective in 
certain areas at controlling the disease. And we have to get 
over the hump of the environmental bias against it because of 
the lack of understanding of the confined use of this and the 
diluted quantities that are used compared to what our 
experience was in this country.
    When I was a young boy, they used to come down the streets 
spraying. The fogs would be out and they would be spraying it. 
As a young boy I can remember the massive use of it, and the 
massive use of it in terms of agriculture for cotton, things 
like that.
    Mr. Kunene, would you comment on the importance, what would 
it mean in the continent of Africa if America would 
aggressively support indoor residual spraying?
    Mr. Kunene. Mr. Chairman, I think we would see a 
significant reduction of mortality and morbidity as a relate of 
malaria in the country. Just IRHS as a principal. If you add 
the DDT, I think that will even make it even more successful, 
Mr. Chairman.
    Senator Coburn. From your perspective, is there something 
that our USAID folks can do as they roll out this new program, 
looking at it from Africa, what can they do to be quicker, more 
efficacious, more effective, and attain greater results other 
than what you've heard here today? If you were to sit down and 
had a chance to give them advice, what advice would you give 
them?
    Mr. Kunene. I do not know what the approach is now--I 
strongly believe that for when you put money, you must be able 
to evaluate whether you are making success or not. Baseline 
surveys I think are critical. We do not just come and spray, 
then start evaluating later. Let us determine the situation now 
from an etymological perspective. What species or vector 
species are available, and what is the parasite prevalence for 
now, the hospital data? Then will come in with the 
interventions.
    But when it comes to IRHS implementation, as my colleagues 
say, that initial cost will be on the high side considering the 
equipment, considering the recruitment of personnel, and we 
must invest on personnel. People must be properly trained. I 
think in Africa we have the expertise now. And since we are 
using some of the insecticides which are very sensitive like 
DDT, the responsible use remains very critical, so that is why 
the training of personnel is critical.
    Ensuring that you establish a very good database. You 
should know where to spray. We have moved a step forward 
because we are now on GPS. We are plotting all homesteads or 
all houses that are sprayed, but that is a very good planning, 
monitoring and evaluation tool.
    Insecticides, equipment and human resource, that is where 
most of the money will come. So I am happy when--I was happy 
when I looked at the fact that USAID or the U.S. Government is 
considering increasing the cake for IRHS. That is welcome. 
Thank you.
    Senator Coburn. Thank you.
    Dr. Roberts, in your testimony you talked about what 
history has taught us what happened in the 1940s and 1950s and 
the effective use. And your proposition was, let us do it and 
see what happens with the trial and error approach. One of the 
things I have heard, as I followed this issue for a couple of 
years, is integrated control sometimes is a code word for 
everything except IRHS. We will do everything, but we are not 
going to do indoor residual spraying. When you hear the words 
``integrated program,'' what comes to mind?
    Mr. Roberts. Unfortunately, that is what comes to mind, 
that it is a code word for let us do anything but IRHS. And 
there are some examples out there that vividly illustrate that. 
There is a program going on in Central America. The Global 
Environment Facility funds, I think it is a $7 million project. 
There is no question, if you read through the document for the 
GEF project in Central America, there is no question that the 
design and the goal of that project is to eliminate the use of 
insecticides in malaria control.
    And there have been statements even in WHO literature, and 
the WHO staff, in exchange of communications with me, that show 
very clearly that the goal is with integrated vector 
management, IVM, is that the goal is to reduce the use of 
insecticides for disease control.
    Furthermore, there is a World Health Assembly resolution 
that specifically calls on the countries to reduce their 
reliance on the use of insecticides for disease control.
    My own personal opinion is that it is an awful resolution, 
and I do not understand how it was ever adopted by the World 
Health Assembly. That is the ultimate governing body for the 
World Health Organization, a decisionmaking body, so the World 
Health Organization is functioning under a resolution that 
calls on countries to reduce reliance on the use of 
insecticides.
    Senator Coburn. I would like all of you to answer this, 
given your extensive experience. If we had a program as 
outlined--it looks like we are going to--which is really going 
to be a balanced program to use for interventions to impact 
this, and it would end up being dominated by impregnated nets 
and IRHS and then treatment, would the rest of the world 
follow? What do you think?
    Mr. Roberts. I will comment. I think so. I gave a 
presentation before the Ministry of Health in Thailand in 
November, and I was talking about the need for the use of DDT. 
This is not a specific answer to your question, but in general 
I think it is, and an individual from the political section of 
the Ministry of Health stood up and said that the world is not 
going to make any move at all to restarting the use of DDT in 
these critical programs unless the United States shows 
leadership. I take it from that, is that it will make a 
difference if we can show change and flexibility.
    Senator Coburn. I think Dr. Kunene testified to the fact 
that you have to have--we are not talking about indiscriminate 
use of DDT, we are talking about trained use and utilization of 
DDT in terms of indoor residual spraying. I believe you also 
testified earlier that we saw tremendous results from the use 
of DDT in the rural areas in terms of IRHS in the 1940s, 1950s 
and 1960s. Dr. Arata, would you want to comment?
    Mr. Arata. Regarding the role and the position of WHO, I do 
not speak for WHO, but I might mention a couple of things. The 
resolution reducing the amount of insecticide usage has to be 
taken into context. For one thing, programs like the 
onchocerciasis control program (OCP), used a large amount of 
insecticides, which was replaced by ivermectin as a drug, so 
therefore, they no longer needed the same amounts of 
insecticides. The same thing is happening with control of other 
filarial diseases, with diethylcarbamazine being used for 
treatment in urban areas, for example, rather than vector 
control, so no need to specify which vector-home diseases that 
may also use insecticides are we talking about.
    Integrated programs do not come as code words to me, nor to 
most of the people that I work with. Integrated vector control 
just means using more than one type of vector control measure. 
Then you can have integrated malaria control, which integrates 
vector control and the diagnosis and treatment. And then you 
can have integrated health programs where through sentinel 
sites and through clinics, one treats a multitude or a number 
of different problems.
    So really, integration is, for me at least, not a code word 
for not using something, but rather a very positive thing, and 
is really copied after some of the integrated control measures 
in agriculture, which are very advanced in terms of economic 
analysis and economic modeling, which is a level we have not 
reached in public health at the present time.
    As far as whether other countries will follow us, I think 
that there is a very good chance that they will, but I think 
the only way they will do that is if we give them an 
opportunity to get involved fairly early in the game, rather 
than sending them a program of saying, ``This is what we are 
going to do now. Come and join us.'' So I think if we ask for 
some cooperation and collaboration in some of the planning, at 
least opinions, then I think we will have the leadership role 
that we would like. So thank you.
    Senator Coburn. Dr. Roberts, one last question. What 
happens when we replace IRHS with drugs only? What is the 
natural history of that? We do not see resistance for parasites 
to ivermectin yet, but it does not mean we will not, correct?
    Mr. Roberts. Right. We could look back at our uses, for 
example, chloroquinized salt. That has been tried in more than 
one location in the world. The one that I am most familiar with 
was in Surinam and Guyana and Brazil. The result was almost 
immediate resistance to chloroquine, and in that case it was 
falciparum malaria, which is the more deadly form.
    When you start suppressing the use of insecticides in 
malaria control, the truth is, we really only have one major 
option for preventing malaria transmission, and that is the use 
of insecticides, and breaking man/vector contact inside of 
house. And when you eliminate that as an option, really the 
government will have only one option or alternative, and that 
will be to go with mass drug distribution, what I refer to as 
chemoprophylaxis, and that is precisely what has happened in 
Central America with this GEF project.
    Senator Coburn. Then you have the propensity to develop 
resistance.
    Mr. Roberts. Exactly.
    Senator Coburn. Could I also comment? In many ways I agree 
with Andy about integrated vector management. The problem that 
we have with the concept of integrated vector management is 
that it has, in fact, been used in the wrong way. The concept 
is valid. The concept is good, but it has been used to 
eliminate the use of insecticides.
    Senator Coburn. That has been the goal, rather than to 
eliminate disease?
    Mr. Roberts. Right.
    Senator Coburn. I want to thank each of you. There will be 
several questions that will be directed to you. If you would be 
so kind as to respond to those, we will not take more time in 
the hearing. Our goal is to not see a picture like that, where 
it is not there. And if there is anything, $2 for ACT 
treatment, $2 to cure somebody of a disease, to spray a room 
for a buck, fully absorbed cost, we do not have any reason not 
to be successful. I will assure you that we will follow up. I 
am very pleased with USAID's response.
    Just so they will know, and the others, we had 21 
Subcommittee hearings on ineffective spending of the Federal 
Government's money last year. We are going to have over 40 this 
year in terms of the follow up, and the whole goal is not to be 
critical, but to make sure that when we intend to help 
somebody, that we really help them, and that we get the most 
value for every dollar that the American taxpayer pays, because 
in the long run what it does, it makes a difference in those 
people's lives. You can see those young children, we did not 
make a difference. We did not impact. If 98 percent of what we 
spend ends up impacting somebody, then we are the better for it 
and so are they.
    I thank you for coming, appreciate it very much. Mr. 
Kunene, again, the long trip here, thank you for the testimony 
of what you are doing in your country, and we congratulate you 
on your success. Thank you.
    The hearing is adjourned.
    [Whereupon, at 4:07 p.m., the Subcommittee was adjourned.]


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