[Senate Hearing 109-934] [From the U.S. Government Printing Office] S. Hrg. 109-934 A NEW INITIATIVE TO COMBAT CHILD HUNGER ======================================================================= HEARING BEFORE THE COMMITTEE ON FOREIGN RELATIONS UNITED STATES SENATE ONE HUNDRED NINTH CONGRESS SECOND SESSION __________ SEPTEMBER 26, 2006 __________ Printed for the use of the Committee on Foreign Relations Available via the World Wide Web: http://www.gpoaccess.gov/congress/ index.html U.S. GOVERNMENT PRINTING OFFICE 36-451 WASHINGTON : 2007 _____________________________________________________________________________ For Sale by the Superintendent of Documents, U.S. Government Printing Office Internet: bookstore.gpo.gov Phone: toll free (866) 512-1800; (202) 512�091800 Fax: (202) 512�092250 Mail: Stop SSOP, Washington, DC 20402�090001 COMMITTEE ON FOREIGN RELATIONS RICHARD G. LUGAR, Indiana, Chairman CHUCK HAGEL, Nebraska JOSEPH R. BIDEN, Jr., Delaware LINCOLN CHAFEE, Rhode Island PAUL S. SARBANES, Maryland GEORGE ALLEN, Virginia CHRISTOPHER J. DODD, Connecticut NORM COLEMAN, Minnesota JOHN F. KERRY, Massachusetts GEORGE V. VOINOVICH, Ohio RUSSELL D. FEINGOLD, Wisconsin LAMAR ALEXANDER, Tennessee BARBARA BOXER, California JOHN E. SUNUNU, New Hampshire BILL NELSON, Florida LISA MURKOWSKI, Alaska BARACK OBAMA, Illinois MEL MARTINEZ, Florida Kenneth A. Myers, Jr., Staff Director Antony J. Blinken, Democratic Staff Director (ii) ? C O N T E N T S ---------- Page Gerberding, Dr. Julie, Director, Centers for Disease Control and Prevention, Waashington, DC.................................... 11 Prepared Statement.......................................... 14 Kunder, James, Acting Deputy Administrator, U.S. Agency for International Development, Washington, DC...................... 3 Prepared statement........................................... 5 Lugar, Hon. Richard G., U.S. Senator from Indiana, opening statement...................................................... 1 Morris, James T., executive director, United Nations World Food Program, New York, NY.......................................... 24 Prepared statement........................................... 27 Veneman, Hon. Ann, executive director, United Nations Children's Fund, New York, NY............................................. 29 Prepared statement.......................................... 31 Ward, Hon. George, senior vice president for international programs, World Vision, Washington, DC......................... 20 Prepared statement........................................... 22 (iii) A NEW INITIATIVE TO COMBAT CHILD HUNGER ---------- TUESDAY, SEPTEMBER 26, 2006 U.S. Senate, Committee on Foreign Relations, Washington, DC. The committee met, pursuant to notice, at 9:00 a.m., in room SD-419, Dirksen Senate Office Building, Hon. Richard G. Lugar, (chairman of the committee) presiding. Present: Senators Lugar and Sarbanes. OPENING STATEMENT OF HON. RICHARD G. LUGAR, U.S. SENATOR FROM INDIANA The Chairman. This hearing of the Senate Foreign Relations Committee is called to order. This morning, the committee meets to examine the issue of global child hunger and malnutrition. In recent years, the committee has held hearings on global nutrition issues and the intersection of hunger and the HIV/AIDS crisis. These inquiries have underscored that societies and nations that experience high levels of hunger and malnutrition rarely function well. Consistent nutrition is an essential component of long-term economic growth and geopolitical stability. We have also reaffirmed that the most basic act of human charity is feeding a hungry person. It's my belief that the United States should extend such assistance wherever possible, both because we have a moral responsibility to do so and because our security and our prosperity depend upon what happens overseas. We're extremely fortunate to be one of the great food producers in human history. We're also fortunate that we have many creative and compassionate leaders, some of whom are with us today, who have applied their talents to addressing world hunger, often in the face of desperate circumstances. Tragically, many people around the world continue to face hunger and malnutrition. An estimated 850 million people go hungry. Most of them are among the world's poorest. For the estimated 1 billion people around the world living on less than $1 per day, obtaining adequate nutrition is a challenge under normal circumstances. When this population faces a crisis that intensifies food insecurity, such as the locusts that devastated crops in West Africa 2 years ago, the drought in Malawi last year, or the genocidal violence in Darfur, obtaining sufficient nutrition is nearly impossible. As we discovered in a 2004 hearing, the AIDS pandemic is decimating the agricultural sector in sub-Saharan Africa. As a result, the rate of malnutrition is actually increasing on the African continent. This is a sobering trend, given the science and technology at our disposal in the 21st century, and it must be reversed. Although famine and starvation are the most severe and visible forms of hunger, poor nutrition, which often goes unnoticed, can also be deadly. And often, malnutrition is caused not by scarce food supplies or by poor sanitation and disease. Even adequately fed people can become malnourished if their bodies are afflicted with diarrhea or parasites. In addition, gender inequities, the lack of nutritional education, and certain cultural practices have led to malnutrition in some regions of the world. Hunger and malnutrition are especially devastating to young children. An estimated 5 to 6 million children die each year from infections and disease caused by malnutrition. Nearly one- third of the children in the developing world are underweight or have had their growth stunted. Even before birth, malnutrition impacts a child's development. We know that the children of malnourished mothers often suffer irreversible physical and cognitive damage. Hunger and malnutrition also perpetuate poverty and undermine economic growth, development, and political stability in the developing world. Malnutrition often causes poor performance in school, which, in turn, leads to an overall loss in an individual's productivity. If the situation is common among a nation's youth, it becomes very difficult to make economic advances based on education. Nations understood the critical link between malnutrition and poverty when they pledged, in 2000--the year 2000--to meet the Millennium Development Goals, the first of which is to eradicate extreme poverty and hunger. Specifically, these goals call on the world community to halve, by 2015, the proportion of people who suffer from hunger. The primary measurement for this goal is the percentage of children younger than 5 who are underweight. Achieving the first goal goes hand-in-hand with the fourth Millennium Development Goal, which is to reduce by two-thirds the child mortality rate in the developing world. As chairman of this committee and a former member of the Agriculture Committee, I have advocated a nutrition program for the poor and for children in our country and abroad, and I'm hopeful that, as a result of our testimony today, we will better understand the causes of hunger and the malnutrition in children and the impact these conditions have on individual health and the advancement of developing societies. Most importantly, we hope to learn about new initiatives to address this problem. We're pleased to be joined today by a stellar panel of experts who are on the front lines of the fight against hunger. We welcome Mr. James Kunder, Acting Deputy Administrator for USAID; Dr. Julie Gerberding, Director of the Centers for Disease Control and Prevention; Mr. James T. Morris, executive director of the World Food Program; Ms. Ann Veneman, executive director of UNICEF; and Ambassador George Ward, World Vision's senior vice president for international programs. Each panelist will discuss his or her organization's efforts to combat child hunger and malnutrition, and comment on new initiatives to address this problem. We thank our witnesses for being with us today. We look forward to an important and hopefully enlightening discussion with each one of them. Let me mention that the statements that each of the witnesses has prepared will be placed in the record in full, so you need not ask for permission that that occurs. It will. And we will ask that you proceed--I will not have a rigorous time limit. Our desire is to hear from you and to have a full discussion of your testimony. I would suggest that, to the extent that your remarks are in the 10-minute area, plus or minus a bit, that that would be helpful. We expect that we'll be joined by other members of the committee, and we'll have a round of questions as they arrive and the testimony is complete. But we'll hear from all five witnesses, so that all five are heard completely, before we begin our questioning. And I will ask that the witnesses testify in the order that they are included in our agenda for the meeting. This is somewhat different from the order that I introduced you in my remarks, but let me just go through the order again. We will have Mr. Kunder, Dr. Gerberding, Ambassador--or, rather, President Ward, Mr. Morris, and then Secretary Veneman. So, I will ask you, first of all, to start off, Mr. Kunder. We welcome you back to the committee. And thank you for coming today, for your testimony. STATEMENT OF JAMES KUNDER, ACTING DEPUTY ADMINISTRATOR, U.S. AGENCY FOR INTERNATIONAL DEVELOPMENT, WASHINGTON, DC Mr. Kunder. Thank you, sir, and we very much appreciate the committee holding this important hearing. I appreciate your letting me go first. This is an extraordinarily distinguished panel, and I am, by far, the least distinguished member of it, so--I want to pay special tribute, as he leaves the presidency of the World Food Program, to Jim. He has been an extraordinary leader in the development community, and specifically on this issue of battling hunger around the world. I've had the opportunity to work with the superb organization he heads many times while I was Director of USAID's Office of Foreign Disaster Assistance. It is an extraordinary organization, and he is an extraordinary individual, and he has made signal contributions to the battle against hunger around the world. The amount of assistance that the U.S. Government focuses on food assistance and battling the problems that the chairman has just outlined is substantial. In terms of contributions to the World Food Program alone, the average contribution by the U.S. Government in the last several years has been just short of a billion dollars a year, so substantial U.S. Government resources are going to this area. And, of course, one of the critical issues is, as you pointed out, that there are many drivers of the staggering and sad statistics that you noted. I mean, not only is the assistance--direct food assistance and direct nutritional assistance--critical, but building institutions around the world and building government capacities to take care of the needs of their own citizens are equally important parts of the toolbox to battling child hunger in the world. USAID approaches this problem with a strategic plan that has four basic components to it, and I'll summarize those very briefly: The first strategic component is to raise agricultural production around the world, so there are substantial investments in improving agricultural productivity. I mentioned, during my statement to the committee just several weeks ago, that, for example, we understand the role of America's universities and agriculture extension services as important components, so we invest in creating similar institutions overseas. The second is what we call the question of access to food, and that has physical manifestations, in terms of infrastructure. But it also has to do with incomes, because, as all the witnesses know, and as the committee knows, many times there is adequate food in the society, but the poorest of the poor simply can't afford to access that food. And it has health aspects, because if children are wracked with diarrhea and other childhood diseases, the nutrients they are receiving aren't sustaining their bodies. So, the second area we focus on is access to food. The third area is response in emergencies. And, unfortunately, this is an area where an increasing share of U.S. food assistance overseas is going for the many emergencies we face around the world. That $970 million figure I mentioned, in terms of the U.S. Government support for the World Food Program--the proportion of that going to emergencies and the share of our Food for Peace Program that is going to using food for a long-term development component is, unfortunately, increasing. That is to say, there are more and more crises around the world that we're responding to. And, fourth, in terms of USAID's strategy, we do focus specifically on maternal and child nutrition interventions, specific programs to improve feeding programs and access to food by women and children around the world. The issues that WFP has raised, and that Jim has raised, in terms of the need for greater coordination, is, in our view, right on the money. There are a lot of resources going into the problems the chairman outlined, but what we need to do is focus, make sure we're getting maximum use of the taxpayers' dollars. Just to give you one example that the staff at USAID brought to my attention before this hearing, what we've done, effectively, around the world, as we've tried to bring this very successful polio eradication program to a conclusion, once you reach the isolated target audiences for polio eradication, we were doing vitamin A supplementation at the same time. The unfortunate result of our relative success around the world is, as the number of these polio immunization centers goes down, then we lose the ability to reach into these very isolated communities with vitamin A supplementation, as well. So, we've got to think very carefully about how we're getting the absolute maximum coordination in the field, so that these various interventions, brought to the field by all the organizations at this table, and many others, are achieving the maximum synergy among them. I'll stop there, Mr. Chairman. My testimony goes into great detail about the various programs that USAID is doing. But we very much support the ideas brought to the table by World Food Program, UNICEF, and many other organizations about the need to get better coordination in the field. We think this is a particularly complex issue, because the drivers of childhood malnutrition are so complicated. We invest, for example, in improving community service organizations and community-based organizations around the world. Now, at USAID, when we report to the Congress, such efforts can show up as democracy-and- governance interventions, and they may not show up as nutrition interventions or food or health interventions. But, of course, one of the ways we can most help achieve coordination and effective targeting is to build up the community-based organizations in Africa and Southern Asia and the other areas in which we work. So, this is an enormous coordination issue, as well as an enormous resource issue, and we look forward to working with the committee, with the organizations represented at the table, and the hundreds of other NGOs and international organizations involved in this fight, to improve the ability to tackle these problems. Thank you, sir. [The prepared statement of Mr. Kunder follows:] Prepared Statement of Hon. James Kunder, Acting Deputy Administrator, U.S. Agency for International Development, Washington, DC Mr. Chairman, thank you for the opportunity to join you again, this time to share with you an overview of USAID's strategy to combat hunger among children of the world. Here at the table with me are the true experts in that field, but I am glad to represent the experts at U.S. Agency for International Development (USAID) who partner with the experts in these great organizations around the world. Across the world some 10.8 million children under 5 years of age die every year. Most of these deaths are preventable and almost all occur in poor countries. I recognize the enormous impact of child hunger and malnutrition on future development and as an underlying cause of the deaths of these millions of children. For that reason, I welcome this opportunity to discuss what USAID is doing to reduce this awful and unnecessary blight on the world's future. According to U.N. estimates, currently, 296 million undernourished children live in the developing world. Other estimates are even higher. For many of these children, the damage from hunger and malnutrition can be life-long. Almost all nutritional deficiencies impair immune function and other host defenses leading to a cycle of longer lasting and more severe infections and ever-worsening nutritional status. Hunger leads to physical stunting, lowers intelligence, and increases susceptibility to diseases, dramatically increasing health care costs and severely limiting their full potential to contribute to nation building. USAID programs recognize that well-nourished children rarely die from diarrhea and common childhood infections, and maintaining good nutritional status is an integral part of improving child survival. USAID interventions are designed to decrease child and maternal mortality; reduce crippling healthcare costs; and boost intellectual and physical potential and national productivity. I would like to tell you what USAID is doing in five key areas of child hunger and nutrition: 1) Reducing micronutrient deficiencies; 2) food fortification; 3) expanding exclusive breastfeeding and appropriate infant feeding; 4) nutrition in emergencies; and 5) sanitation, hygiene and nutrition. 1. REDUCING MICRONUTRIENT DEFICIENCIES Vitamins and minerals--micronutrients--are essential components of good nutrition. Without micronutrients, bodies and minds are weakened and cannot resist many common diseases. For decades, USAID has been a leader in addressing micronutrient deficiencies, primarily through support of targeted supplementation and food fortification programs. USAID supports developing countries to ensure national distribution of vitamin A supplements to young children every 6 months and in the development and implementation of programs that fortify commonly consumed foods with combinations of vitamins and minerals missing or limited in the diet. USAID supported much of the initial research that identified the crucial links between micronutrients and child health and then helped developing countries deliver these essential nutrients to their children. USAID supports advocacy, policy development, health worker training and supervision, monitoring, logistics, and distribution support. Vitamin and mineral deficiencies contribute to extensive health problems and deaths throughout developing countries. Three of them-- vitamin A, iron, and iodine--have been shown to profoundly affect child survival, women's health, educational achievement, adult productivity, and overall resistance to illness. More recently, with evidence from new USAID-supported research showing the importance of zinc deficiency and increased morbidity and mortality during diarrhea episodes, USAID has included zinc in its programs. Women and children commonly make up the most vulnerable segment of societies with high rates of micronutrient deficiencies. Micronutrient deficiencies can result in serious health consequences including birth defects, maternal death, childhood mortality, blindness, anemia, and increased vulnerability to infections. Additionally nonhealth consequences include lower IQ, poor academic performance, and reduced work productivity. Vitamin A supplementation Vitamin A deficiency alone affects as many as 120 million children under 5, reducing their ability to survive common childhood illnesses and causing a million child deaths each year. These children suffer more severe and prolonged illnesses and are more likely to die from common infections such as measles and diarrhea than a well-nourished child. Approximately half a million children deficient in vitamin A become blind every year. Half die within a year of becoming blind. For more than 20 years, USAID has supported research into vitamin A. Vitamin A mobilizes the body's immune system and makes it stronger, and it heals submicroscopic cracks between cells in the body's armor-- the epidermis and intestine and lungs--which blocks invasion by outside organisms. USAID-funded research has demonstrated that vitamin A supplementation prevents child blindness and reduces child mortality by an average of 23 percent in deficient populations. USAID is also supporting groundbreaking scientific inquiry into the role of vitamin A in reducing maternal deaths. USAID-sponsored National Immunization Days (NIDs) for polio have provided many countries with the opportunity to supplement children with vitamin A at the same time, making this distribution mechanism one of the most successful in the world. But as progress toward eradication of polio is made, NIDs are being phased out in countries, and new solutions need to be developed for vitamin A supplementation programs. One of the solutions pioneered by USAID in the late 1990s was Child Health Weeks, which are now the primary method of distribution in 15 percent of countries and achieve 70 percent coverage on average.
USAID and its partners have helped increase global vitamin A coverage in children 6-59 months from 50 percent in 1999 to 68 percent in 2004. In 2004 alone UNICEF estimates that 500,000 children were saved. USAID is currently working on vitamin A supplementation in 17 key countries where this is a major health problem. Anemia prevention Anemia affects about 2 billion people across the globe. Half of all cases of anemia are due to iron deficiency. Iron deficiency anemia often goes unreported because there are no outward symptoms to report. The anemia prevention package promoted by USAID programs includes deworming, malaria prevention and treatment, and iron supplementation activities. Overall, about 24 percent of maternal and 22 percent of perinatal mortality in developing countries is attributable to iron deficiency anemia. Even modest reductions in the severity of anemia can reduce deaths. USAID's strategic approach is focused on two key areas. First, USAID conducts research on the safe delivery of iron to women and children, including those in malaria endemic areas. Second, USAID is expanding Anemia Intervention Packages to tackle the main causes of anemia, namely inadequate intake/poor absorption (food fortification, iron supplementation), malaria (intermittent preventive therapy, bed- nets, indoor residual spraying), and intestinal parasite (deworming). In order to reduce the anemia that increases the risk of a mother dying in childbirth, as well as the likelihood that the baby will be born prematurely or with low birth weight, USAID has worked to raise the profile of anemia control for women and children on country national health agendas, and USAID is helping governments develop programs to address the multidimensional problem with an integrated approach. Since 1995, USAID has supported anemia programs in more than 25 countries, including: Nicaragua, where coverage with prenatal iron rose from 70 percent to 88 percent, and the prevalence of anemia in pregnant women fell by one-third from 2000-2003. In the same time period, coverage of children, ages 6-59 months, with iron supplements improved from 37 percent to 62 percent, and anemia fell from 29 percent to 23 percent. India, where the prevalence of anemia fell by 25 percent among participants in a USAID program to increase intake of iron folic acid supplements (IFA) and control infections with malaria and parasitic worms in pregnant women. Service delivery was improved by using Anganwadi Centers as distribution sites for IFA for both pregnant women and adolescents; and, using the twice-annual ``catch-up'' rounds to distribute IFA to pregnant women. Iodine In 1990, about 1.6 billion people, or 30 percent of the world's population, lived at risk of iodine deficiency disorder (IDD); some 750 million people suffered from goiter, mainly because of chronically low iodine intake. An estimated 43 million were affected by some degree of brain damage as a result of inadequate iodine intake before or during infancy and early childhood--largely the consequence of living in mountainous or flood-plain regions where erosion has caused the local soil and crops to contain too little iodine for healthy thyroid function. Since 1999, USAID has funded over $22 million for universal salt iodization (USI) and elimination of iodine deficiency disorders in 43 countries through a partnership with UNICEF and Kiwanis. This has resulted in a dramatic increase in the consumption of iodized salt. Today, thanks to these efforts, 82 million newborns are now being protected from learning disabilities caused by iodine deficiency disorders. Overall consumption of iodized salt has increased in poor countries from 20 percent of households in 1990 to over 70 percent today. Successes include: In sub-Saharan Africa, the regional average for households using salt containing 15ppm or more of iodine is 64 percent. Two notable countries are Uganda and Kenya, where USAID has invested US $589,000 and $250,000, respectively, since 1999. As a result, over 90 percent of households in both countries consume adequately iodized salt. In Asia, USAID has invested heavily in Bangladesh and Indonesia. Both countries have obtained household coverage rates that are significantly higher than the regional average coverage of 49 percent-70 percent and 73 percent, respectively. Zinc Zinc supplementation, a simple and inexpensive intervention, not only decreases the duration and severity of diarrheal disease, but also reduces the risk of occurrence of diarrhea among children under 5. In the last 6 years, USAID has sponsored research on zinc in both the prevention and treatment of major illnesses like acute respiratory infections, diarrheal diseases, malaria, and low birthweight. Diarrhea remains a leading cause of child deaths worldwide. Every year more than 1.5 million children under the age of 5 die as a result of acute diarrhea despite the availability of effective low-cost therapies to manage diarrhea cases. Clinical and field studies have consistently shown that when children with diarrhea receive 20 mg of elemental zinc for 10-14 days in conjunction with oral rehydration solution, the duration of the episode shortens by 24 percent, severity is reduced (24 percent less admission to hospital), and there is a preventive effect for future episodes. Overall, diarrhea incidence rates decrease 15 percent, and there is a 42 percent reduction in treatment failure or death. USAID has been a major contributor to the research leading to these findings. In 2004, WHO and UNICEF issued a joint statement recommending the use of zinc during diarrhea as an adjunct treatment to oral rehydration therapy (ORT). USAID is disseminating and implementing these recommendations to decrease the burden of disease related to diarrhea, and improve the immunity of children by focusing on ensuring the availability of low- cost, quality zinc products for international procurement by working with the private sector internationally and in country. By 2007, USAID will be supporting the introduction and expansion of this program in 15 countries. In order to achieve this, USAID is working with partners to ensure that policy is translating into standard treatment guidelines and training materials for health workers. Partnering with pharmaceutical companies is facilitating the production of zinc dispersible tablets, and leveraging their marketing and distribution divisions to accelerate the distribution of zinc to public and private sector health facilities. NGOs and social marketing groups subsidize the treatment for those with limitations to pay. 2. FOOD FORTIFICATION Food fortification is perhaps the most generally applicable approach to micronutrient deficiencies. Beginning in the 1940s, the industrialized world has broadly embraced fortification, fortifying flour, salt, milk, and butter and margarine with a range of nutrients. Food fortification in now being introduced into the developing countries as large-scale food processing has become available. More than 2 billion people worldwide lack sufficient quantities of zinc, vitamin A, iron, and iodine, which are now being added to processed foods such as rice and sugar under USAID-supported programs. USAID is improving the micronutrient content of basic foods by expanding research, development, and dissemination of biofortified crops--enhanced vitamin A, iron, and zinc maize; enhanced iron and zinc beans; and vitamin A enhanced sweet potato--and through supplementation. Food fortification is a proven way for public and private sectors to join in ending nutrition deficiencies for a sustainable solution. USAID has been working to fortify foods for three decades and continues to accelerate and expand food fortification programs as one of the most effective, long-term strategies to reduce micronutrient malnutrition. USAID and the Centers for Disease Control and Prevention (CDC) are working together to improve monitoring and evaluations systems to ensure public health impact. Through the Global Alliance for Improved Nutrition (GAIN), USAID is directly supporting 22 programs in 19 countries around the world that fortify staple foods and condiments with iron, iodine, vitamin A, and other micronutrients. When at scale, these programs are expected to reach over 486 million people with fortified foods such as corn meal, wheat flour, and soy sauce. USAID and the Bill and Melinda Gates Foundation joined forces to create GAIN and this successful collaboration continues in order to identify new partners for this alliance. GAIN is an excellent example of the public and private sectors working together for global change, cited by Ending Child Hunger and Undernutrition Initiative. GAIN will serve as a catalyst to mobilize the efforts, expertise, and resources of the public and corporate sectors, toward the shared vision of reducing micronutrient malnutrition. Commercial sector companies in both developing and developed countries are critical partners in the success of GAIN. Since 1993, 30 countries have implemented food fortification programs with USAID support, either through a centrally funded program, bilaterals, or our partnership with GAIN. With USAID funding, these 30 countries have fortified more than 10 kinds of food, determined by food consumption patterns in each country (for example, fish sauce in Vietnam and cottonseed oil in Burkina Faso), with 6 different fortificants (iron, folic acid, B vitamins, vitamin A, zinc, iodine). In the 1970s, all Central American countries suffered from high levels of vitamin A deficiency. With USAID assistance over the past three decades, El Salvador, Guatemala, Honduras, and Nicaragua all developed sustainable sugar fortification programs. Today, vitamin A deficiency is virtually nonexistent in these four countries. Since 1997, Zambia has fortified maize meal and sugar with vitamin A with USAID assistance. In a series of surveys, the prevalence of vitamin A deficiency in children decreased from 65.7 percent in 1997 to 54.1 percent in 2003. And fortification is cost-effective. Every $1 spent on vitamin A fortification returns $7 in increased wages and decreased disability. A dollar spent on iodized salt returns $28; iron fortification, $84. 3. EXPANDING EXCLUSIVE BREASTFEEDING AND APPROPRIATE INFANT FEEDING More than two-thirds of malnutrition-related infant and child deaths are associated with a failure to grow in children under 5 years of age. Within this time period, the sharpest increase in malnutrition occurs between 6 and 24 months of age, the time when children grow most rapidly. This situation is made worse by the fact that less than a third of infants in most countries are exclusively breastfed during the first 6 months of life. In addition, early cessation of breastfeeding and the introduction of nutritionally inadequate complementary foods is a common occurrence. This compounds the danger for infants who are at highest risk of mortality because of their exposure to disease and limited access to health services. Mothers and babies form an inseparable biological and social unit. The health and nutrition of one group cannot be divorced from the health and nutrition of the other. A well-nourished mother gives birth to a healthy baby with sufficient nutrient stores to grow and develop. To continue the child's well-being, the mother needs to have her nutritional needs satisfied so that she can produce high nutritional quality breast milk and actively take part in the care of her child. A sick or malnourished woman is in danger of succumbing to illness and to being unable to accomplish all the tasks of childbirth and child rearing. USAID programs recognize the importance of women's nutrition both to themselves, their children, and families and include them in programs. USAID also supports efforts to identify and support safer infant feeding strategies in communities affected by HIV. Optimal infant feeding is a key component of prevention of mother to child transmission (PMTCT), as well as a critical intervention to ensure overall child survival. USAID supports programs to counsel all mothers about the risks of mother to child transmission and the need to know their HIV status. USAID's new Infant and Young Child Feeding (IYCF) program will develop innovative interventions that build on 1) proven positive impact, 2) effective behavior change and communication to target populations, and 3) improve household food quality through small- and large-scale fortification. Ensuring optimal nutrition involves various interventions coordinated at key points in the healthcare setting and community. USAID has developed the universally recognized and adopted Essential Nutrition Actions (ENAs) consisting of proven, high impact, feasible program interventions which, implemented at the community level, have a significant impact on nutritional status and child survival. The Ending Child Hunger and Undernutrition Initiative recognizes the importance of these ``essential packages.'' These include: Exclusive breastfeeding up to 6 months; Appropriate infant and young child feeding through 23 months; Optimal nutritional care of sick children; Prevention of vitamin A deficiency; Prevention of anemia; Prevention of iodine deficiency; and Optimal nutrition for women. P.L. 480, Title II food assistance programs and community-based maternal and child health and nutrition activities implemented by USAID's child survival and health grants recipients are especially effective ways to increase the impact of these life-saving interventions. For example, between 40 and 50 percent of Title II nonemergency resources support multiyear community-based maternal and child health and nutrition programs that distribute food, much of it micronutrient fortified, and monetize to fund the implementation of proven interventions to improve child survival and nutrition. These include promotion of exclusive breastfeeding and appropriate complementary feeding, prevention and treatment of preventable childhood diseases, including diarrhea, increased micronutrient consumption, and improvements in antenatal care. Title II MCHN programs also create linkages between health and nutrition activities and Title II-funded activities in the agriculture sector so that improvements in agricultural productivity and income translate into better nutrition for households, mothers, and children. USAID has been at the forefront of efforts to increase the focus on and coverage of children in the 6-23 month age group, and to take a preventative rather than curative approach to undernutrition. Title II food-assisted development programs are encouraged to provide universal coverage of all children under 2 rather than focusing only on those who are currently malnourished. Recent USAID-funded research in Haiti, led by the International Food Policy Research Institute, found that this kind of food-assisted preventative program achieved significantly greater impacts on child malnutrition--stunting and underweight--than recuperative programs do. In addition to food aid resources from USAID's Food for Peace program, USDA administers the McGovern-Dole International Food for Education (FFE) and Child Nutrition Program. The key objectives of the FFE program are to reduce hunger and improve literacy and primary education, especially for girls. By providing school meals, teacher training, and related support, FFE projects help boost school enrollment and academic performance. The FFE program also provides nutrition programs for pregnant women, nursing mothers, infants, and preschool youngsters, to sustain and improve the health and learning capacity of children before they enter school. In fiscal 2005, the FFE program made approximately $91 million available to provide 118,000 tons of food to 3.4 million children in 15 developing countries in Africa, Asia, Latin America, and Eastern Europe. 4. NUTRITION IN EMERGENCIES Children in emergency and conflict situations are especially vulnerable to hunger. USAID supports activities for the nutritional rehabilitation of malnourished children in these situations. A new program direction, pioneered by USAID, Community Therapeutic Care (CTC) in Malawi and Ethiopia, has shown greater impact in rehabilitation than traditional Therapeutic Feeding Centers in emergency situations. CTC is a community-based approach of care for managing large numbers of severely malnourished children and adults at home, using outreach teams to promote community participation and behavioral change. CTC aims to build community capacity to manage and to better respond to repeated cycles of relief and recovery. Providing appropriate Ready-to-Use-Therapeutic Food (RUTF) like ``Plumpynut,'' which is similar to F-100 Therapeutic Milk, is central to the home- based care of the severely malnourished. USAID is focused on establishing international guidelines on the use of CTC and ensuring their adoption through training, monitoring, and evaluation across implementing agencies. Current programs are exploring the possibilities for local production of RUTF in formulations appropriate to the population. Manufacturers of Plumpynut are enthusiastic partners with USAID in devising ways to transfer the technology involved in the preparation of rehabilitation foods. 5. SANITATION, HYGIENE, AND NUTRITION Extensive research has established the important link between diarrhea, intestinal parasites, and poor nutritional status of children under 5. To reduce nutrition losses (macro- and micronutrients) and maximize the impact of nutrition interventions, the incidence of diarrhea and intestinal parasites needs to be reduced through hygiene improvement. Hygiene improvement focuses on the behaviors that are the key determinants of diarrhea risk, especially drinking safe water, sanitary disposal of feces, and washing hands with good technique at appropriate times. Each of these practices typically results in a 30-40 percent reduction in diarrhea prevalence. Solid evidence indicates that improvements in sanitation alone or in sanitation and water supply together are associated with significant increases in children's nutritional status. Data from eight countries showed sanitation improvements were associated with a reduction in height deficit, relative to the reference standard, ranging from 22 percent and 53 percent for urban children and from 4 percent to 37 percent for rural children. CONCLUSION USAID supports the objectives of the Ending Child Hunger and Undernutrition Initiative (ECHUI). The face of child hunger is too stark and the needs are too great. Forging a strong alliance of collaborators from among national governments, international agencies, the private sector, and other sectors of civil society has been an important part of the way USAID nutrition programs have worked in the past and will continue to work in the future. The five nutrition areas I have described today: 1) Reducing micronutrient deficiencies; 2) food fortification; 3) expanding exclusive breastfeeding and appropriate infant feeding; 4) nutrition in emergencies; and 5) sanitation, hygiene, and nutrition, all are stronger because of the partnerships they bring to the table. And partnerships will be important for the challenges these areas will meet in the future. Vitamin A supplementation programs have significantly increased coverage rates since they were appended to NIDS. The winding down of NIDS programs presents a challenge in terms of sustainability of vitamin A supplementation coverage, and new partners and platforms will need to be identified. Since most children in poor countries suffer from more than a single nutrient deficiency, the ability for nutrition programs to deliver multiple nutrients at the limited points of contact is an imperative. USAID, together with partners, is researching the optimal combination of vitamins and minerals for women of reproductive age and children. Supplementation and nutritional rehabilitation programs are only a short-term answer to chronic malnutrition. USAID will increase its efforts to work with other agencies and host country counterparts to improve the food and nutrition policy, strategy, and program development in assisted countries in order to improve equity and improved health benefits. Despite considerable progress in iodizing salt and preventing IDD, large differences exist in the consumption of adequate iodized salt among regions of the developing world. In 33 countries, less than half of households consume adequately iodized salt, and 37 million newborns in the developing world are born every year unprotected from iodine deficiency and its lifelong consequences. Progress in ensuring universal salt iodization needs to be accelerated. Finally, food fortification presents a cost-effective, sustainable alternative that shares the cost with some very important partners-- consumers and the private sector. USAID has been combating child hunger for a long time. We will continue to do so, in step with our existing partners, and welcoming our new partners and initiatives. The millions of children who die, before they reach the age of 5, of hunger-related causes, and the hundreds of millions of undernourished children who will bear the damage from hunger and malnutrition for the rest of their lives deserve nothing less. Thank you. The Chairman. Thank you very much, Mr. Kunder. Dr. Gerberding. STATEMENT OF DR. JULIE GERBERDING, DIRECTOR, CENTERS FOR DISEASE CONTROL AND PREVENTION, WASHINGTON, DC Dr. Gerberding. Good morning, Mr. Chairman. It's really a pleasure to be here on this important topic. I don't think, in all of the hearings that I've appeared in, in front of Congress, that I've ever been at one that's more important, and I don't think I've ever read testimony that's been more filled with the kind of humanitarian work that we really can accomplish around the world. I just wish we could do more of it. I'm going to start by just reminding all of us of some of the facts that have motivated our presence here today. In the next 24 hours around the world, 1,200 children will die of measles, 1,600 children will die from diarrhea caused by rotavirus, about 3,500 people will die of malaria, 5,400 from TB, and 8,200 from AIDS, and almost all of these people will disproportionately be children. What's tragic about that is not just the lives of these young people being lost, but these lives represent preventable deaths, they represent infectious diseases, and they represent, really, the ultimate vicious cycle of poverty, lack of safe water, poor nutrition, preventable infectious diseases, and death. And that circle is spiraling, as we speak, in many corners of the world. What's remarkable is that we are doing so much, and we can do more about it. I asked today to present to you the perspective of the CDC, but I wanted to make very clear that we don't do anything by ourselves; we work in solid partnership with many of the organizations here at the table and many of the people around the world. Our global role is not one that's very familiar to many people. First and foremost, we do have the job of health protection internationally, and that's something that some people are familiar with because of pandemic planning and SARS, and we do have a very important role to play in protecting people at home and abroad from those emerging infectious- disease threats. But we also do have a very important role in promoting health around the world. Much of what we're talking about today falls into that category. But I agree with my colleague that perhaps the most important role that we play is the role of health diplomacy. When we roll up our sleeves as scientists, and take our science to the streets in the farthest corner of the world, we are putting a best-possible face on America. And that is something that, I think, all of us feel in our hearts, as organizations, it's a value that we exemplify, and we want to do our part to make sure that people around the world value and respect and appreciate what our democracy and what our citizens are really willing to do to help make the world better for everyone. I'd like to just spend a brief minute or two talking about some of the specifics of the programs that we've accomplished, and also acknowledging the tremendous reliance that we have on not just our domestic partnerships, but our international partnerships, as we succeed. So, I'm not going to mention each other organization. I just want you to be aware of some of the activities that are making the biggest difference. Let me start with this group of people here in the photograph. This is a CDC scientist who's in the streets of Afghanistan, in Kabul, and he is responsible for a program that's part of something called IMMPaCt, or the International Micronutrient Malnutrition Prevention and Control Program. This is a set of programs that we conduct with our partners that really help, first of all, survey the problem of undernutrition, and, second, design very targeted programs to solve problems. In Afghanistan, there was a particular problem of lack of iodine in the food supply and the diseases of thyroid and other conditions that go along with that. So, through an iodine fortification program, we've been able to measure that in Kabul there now is a restoration of iodine levels, and that the program has really contributed to better nutrition in that community. We're working, in Kenya, in Tajikistan, for door-to-door food distribution. You know, in countries that have problems with HIV infection, mothers are told not to breastfeed their babies if they're HIV-positive, because that's a way of transmitting the virus to the baby after birth; even if they've taken antivirals during birth, they can still transmit, after birth, if they're breastfeeding. But that mom is in a very difficult situation, because often she does not have clean water, and so, she doesn't have the materials she needs to make safe baby formula or baby food. So, either her choice is: Risk passing the virus via breastfeeding or risk exposing her child to deadly diarrheal diseases, which have an equal, if not greater, short-term fatality rate. So, we are working in these countries to improve the distribution of commercially available infant formula, but also our safe water system, which is a very inexpensive intervention to try to bring safe water into people's homes through water vessels that either contain materials that help precipitate out the impurities or chlorine bleach to help keep the water clean. Ambassador Tobias, from the--when he was with the President's program for AIDS, the PEPFAR program--and I, visited a hut in the remote area of Uganda, and we asked the gentleman in the hut, ``What do you think about this program to deliver you antiviral drugs?'' And he said, ``Oh, I feel great. I'm getting much better.'' And we said, ``Well, when did you start to feel better?'' And he said, ``Well, first they brought me a clean water vessel, and they brought antibiotics to treat my diarrhea, and not only did my diarrhea get better, but all of my children's diarrhea got better, and, the first time, they started gaining weight, and we could really see that the nutrition in our household improved.'' That antibiotic, incidentally, also helped with the malaria that he was harboring, and, between that and the bed net, he and his family have much lower risk of developing malaria, which is the complicating factor of HIV in many of these communities. Then the patient got treated for his tuberculosis, which was contributing to his malnutrition, and the children were also screened and treated. Finally, after all of that, he got started on antiretroviral therapy for his HIV infection. So, through a series of very inexpensive interventions, we set the stage so that the treatment for the HIV that we were delivering had a chance of being successful. You cannot treat HIV in adults and children if they're undernourished. And that, I think, is a very important component of all the work we're doing. It's that story about how problems come together to affect people. But solutions can also come together, and I'm very pleased to tell you--I think there's a picture on the next graphic--of a situation where we have a child who was suffering from very profound undernutrition, a starving child, and then, through a series of interventions that are reflected here in the table among our partnerships, this child was able to enjoy not only food replenishment, but replenishment with the hidden nutrients that often go unnoticed--vitamin A, folate, iron, minerals, things that without fortification of the food supply--it doesn't matter how many calories you put in a child, they're not going to be well nourished, because they don't have the trace minerals to have those nutrients do some good. Another example of bundling occurs in the context of malaria--excuse me--in the context of measles. Measles is a very important focus of CDC's work and partnership internationally, and over the last few years, because of the programs in Africa, we've been able to cut in half the number of children dying from measles. So, the good news is a 50 percent reduction, the bad news is there are still more than 450,000 deaths caused by measles every year. But our program now is bundling not only the measles vaccine, but an inexpensive bed net; a worm pill, which is another reason for anemia and undernutrition around the world with the neglected tropical diseases; vitamin A shots, so that the measles vaccine will work and the child will have less risk from many other infectious diseases; and sometimes a hug so that that child knows that somewhere some people in the world really care about their growth and their opportunity to become adults and contribute to the development of their country. The last thing I wanted to mention is more sobering, even, than these issues related to overt malnutrition, undernutrition in hidden hunger. That relates to the complex role that we all play in areas like Sudan, where there are very complicated humanitarian situations. CDC, in conjunction with the United Nations programs there, is called upon to do the nutritional surveys. And I recall a day not too long ago at CDC when a team of CDC scientists were heading to Sudan to do the kind of nutritional survey in an environment where their security was under threat, and the amount of preparation they needed in terms of their own personal protection, and the amount of preparation needed in terms of their situation there, was very sobering to me, personally. And I wasn't sure that it was right for people to go and put their lives on the line in this way. But when I learned about the problem, and I learned about the value of this, I realized that it was part of our job to step up to the plate and do this. And we thank our partners for doing everything they do to assure our security when we're in these regions. But the mission was to go into that area and to determine, of all the people there who were hungry and undernourished, which were the people that weren't so far gone that a food supplement could save their lives. So, we were going in to help determine where to target the food resources that we had so that they would do the most good. And, of course, what that means is that some people are so hungry that even refeeding is too late. So, I think we feel very passionate about our international work in this regard, and we appreciate so much your attention and the attention of this committee in allowing us to display for more people the importance of the work, but also the successes that we've had. Thank you. [The prepared statement of Dr. Gerberding follows:] Prepared Statement of Dr. Julie Gerberding, Director, Centers for Disease Control and Prevention, Washington, DC Good morning, Mr. Chairman and members of the committee. I am pleased to be here today to discuss the work of the Centers for Disease Control and Prevention (CDC) in combating child hunger and malnutrition in developing countries and our collaborations with other U.S. agencies, multilateral and bilateral health organizations, and private partners. Since its inception, CDC has been active in applying its technical skills to global health priorities of the United States, from the pivotal role the agency played in the campaign to eradicate smallpox, to CDC's current global portfolio, which includes science-based activities throughout the world. CDC has initiatives to directly address nutritional status of children through its micronutrient malnutrition program, safe water and humanitarian response activities, and infectious disease activities that impact nutritional status. CDC also plays a lead role in global disease detection and pandemic influenza preparedness efforts. CDC has strengthened its commitment to global health by recently establishing Health Protection Goals specifically focused on helping people around the world live healthier, safer, and longer lives through global health promotion, health protection, and health diplomacy. In particular, through our health diplomacy activities we work to engender trust, maintain high ethical standards, and engage the community; strengthen the public health workforce and leadership both within CDC and around the world; and meet country needs through our humanitarian responses to national disasters and efforts to address ``core'' public health issues--including improved availability and access to safe water and adequate food and nutrition, the focus of my testimony today. STATISTICS ON NUTRITIONAL CONTRIBUTORS TO CHILD DEATHS AND ILLNESS The nutritional and infectious disease contributors to child deaths and illness are well-documented. Each year, undernutrition contributes to the deaths of about 5.6 million children younger than 5 in the developing world, according to UNICEF. Another 146 million children younger than in 5 are underweight and at increased risk of early death, illness, disability, and underachievement (UNICEF, 2006). UNICEF reports that in the least developed countries, 42 percent of children are stunted and 36 percent are underweight. A vitamin A deficient child faces a 23 percent greater risk of dying from ailments such as respiratory illnesses, diarrhea, and malaria. Lack of sufficient folic acid intake among women of childbearing age contributes to an estimated 200,000 babies born with crippling birth defects throughout the world. Iron deficiency, one of the top 10 causes of global disease burden (World Bank), contributes to about 60,000 deaths among women in pregnancy and childbirth, and robs 40 percent to 60 percent of the developing world's children of their intellectual development (UNICEF/MI). Effective and inexpensive interventions such as food fortification, supplementation, and dietary improvements have eliminated most micronutrient malnutrition in developed countries and could result in similar public health improvements in developing countries. CDC, in partnership with other global public health leaders, is putting into practice these interventions. CDC INTERVENTIONS TO IMPROVE NUTRITIONAL STATUS International Micronutrient Malnutrition Prevention and Control Program (IMMPaCt) In 2000, CDC established the IMMPaCt Program to support the global effort to eliminate vitamin and mineral deficiencies, or hidden hunger. Through the IMMPaCt program, CDC provides funding and/or technical assistance directly to countries through cooperative and interagency agreements with UNICEF, the World Health Organization (WHO), the U.S. Agency of International Development (USAID), the Global Alliance for Improved Nutrition (GAIN), and the Micronutrient Initiative (MI). With these partners, CDC has assisted countries in assessing the burden of hidden hunger through national surveys and surveillance systems that allow countries to monitor the coverage and impact of their food fortification and micronutrient supplementation programs. In addition, computer and Web-based training tools and regional and national training workshops developed by CDC have strengthened the capacity of countries to assess the burden of malnutrition, track the effectiveness of interventions strategies through surveillance systems, and plan social marketing and health communication strategies to promote the consumption of vitamin- and mineral-fortified foods. In 2002, in collaboration with the WHO Eastern Mediterranean Regional Office (EMRO), CDC provided funding support and consultation toward a national micronutrient survey to generate baseline data on iron status of adult women and preschool children in order to monitor the impact of the recently initiated national flour fortification program in Jordan. CDC also worked with the Ministry of Health (MOH) and UNICEF- Afghanistan on establishing salt iodization activities, including building several iodized salt-producing plants. In 2004, CDC subsequently helped the MOH and UNICEF-Afghanistan to plan and implement the first national nutrition survey which provided estimates of nutritional deficiency among children, women, and men in Afghanistan, and showed that iodine status of the Kabul population is already substantially better since an iodized salt production factory started operating in 2003. Through its International Micronutrient Reference Laboratory, CDC has collaborated with global partners to establish and support a global network of resource laboratories around the world to help improve and monitor the quality of national micronutrient testing. IMMPACT MULTISECTORAL PARTNERSHIPS TO SUPPORT IMPROVED NUTRITION Fortification of flour and food with vitamins and minerals To help improve nutrition worldwide, the CDC IMMPaCt Program helped launch the Flour Fortification Initiative (FFI) in 2002. The Initiative was formalized in 2005. The FFI Leaders Group, a network of government and international agencies, wheat and flour industries, academia, and consumer and civic organizations, was established to promote flour fortification. FFI supports fortification of flour with essential vitamins and minerals, especially folic acid and iron, as one important way to help improve the nutritional status of populations, especially women and children, around the world. To more directly improve dietary vitamin and mineral intakes of infants and young children, CDC recently implemented a cooperative agreement with UNICEF CEE/CIS to begin a multisectoral initiative to mobilize and engage the food industries, as well as the governments and public health sectors in countries of Eastern Europe and Central Asia, to strengthen breastfeeding promotion programs and to fortify all commercially produced complementary food (foods added to a child's diet during transition from breast milk) for infants older than 6 months of age. Experience in the United States and Canada suggests that the impact of such a partnership between the public sector and food industry in that region of the world is likely to be enormous. In many Asian and African countries, commercially produced infant foods are either not commonly used or readily accessible through markets in remote areas. Through the IMMPaCt program, CDC is actively planning pilot interventions in Kenya and Tajikistan to assess the feasibility of alternative approaches to sustainable distribution, through small local markets and house-to-house sales, of easy-to-use, ``in-home'' fortificants to enrich baby foods. These efforts will require public-private-civic sector partnerships to be nurtured and strengthened over time. CDC INFECTIOUS DISEASE INTERVENTIONS THAT IMPACT NUTRITIONAL STATUS Global immunization Over recent decades, the experience of national immunization programs demonstrates that immunization is one of the ``best buys'' in public health. Rapid implementation and use of the traditional vaccines against childhood killer diseases has been the single most important contributor to the reduction of child mortality in developing countries. Prevention of vaccine preventable diseases (VPDs) has the potential to positively impact malnutrition. Pertussis infection (whooping cough) is associated with coughing followed by vomiting that can last several months. This has been shown to result in poor growth and lower than normal weight for age, along with the potential to result in malnutrition. Several studies suggest that children vaccinated against measles may have improved nutritional status compared with unvaccinated children. Fewer deaths due to diarrhea and malnutrition have also been reported in children vaccinated against measles. Infections, including those preventable by immunization, have been shown to lower the body's immune defenses leading to more infections, lowered nutritional intake, and eventual malnutrition. For example, measles infections are associated with lowered levels of vitamin A, which increases susceptibility to diarrhea and pneumonia. These infections result in poor appetite, lowered food intake, and the potential for malnutrition. Studies from one African country demonstrated a decrease in the number of malnutrition cases that was temporally related to a mass measles vaccination campaign that improved control of measles. In collaboration with WHO, UNICEF, and other agencies, CDC's Global Immunization Division has been involved in international activities to improve immunization coverage rates for all vaccine preventable diseases. Global routine measles coverage increased from 71 percent in 1999 to 76 percent in 2004. Overall, global measles-related deaths decreased 48 percent from 1999 to 2004, i.e., from 871,000 people to 454,000. CDC is also a founding member of the Measles Partnership, which from 2001 to 2005 supported 40 African countries in conducting mass measles vaccination campaigns. An estimated 213 million African children were vaccinated, averting 1.2 million measles-related deaths. The Partnership is also supporting measles vaccination in WHO's Eastern Mediterranean and Southeast Asia region, where 60 million children are to be vaccinated in 2006. These activities have the potential to impact on malnutrition by greatly reducing the risk of developing measles infection. In addition to providing measles vaccine during Partnership- supported campaigns, vitamin A, antihelminthic (deworming) medication, and bed nets (to prevent malaria infection) were also distributed together in a number of countries. These integrated or ``bundled'' interventions are more efficient and effective. From 2001 to 2005, more than 43 million children received doses of vitamin A, more than 13 million received deworming medication, and 1.5 million received insecticide-treated bed nets to prevent malaria. Plans in WHO's AFRO region for 2006 include vaccinating 64 million children and providing 10 million children with deworming medication, 20 million with vitamin A, and 5 million with antimalarial bed nets. Integrated delivery of child survival interventions are also planned in countries in other regions as well, including Indonesia. INTESTINAL HELMINTHES (WORMS) More than 2 billion children globally are infected by intestinal helminthes, with 155,000 deaths reported annually. The burden of diseases caused by intestinal helminthes infection (39 million disability associated life years (DALYs) is higher than that caused by measles (34 million DALYs) or malaria (36 million DALYs). Intestinal helminthes infection affects the nutritional status of children through intestinal bleeding, malabsorption, competition for nutrients, loss of appetite, and diarrhea. All of these effects are reversible after treatment. Another benefit of treatment is better digestion of the sometimes limited food available. Drugs for deworming treatment are highly effective, widely available, inexpensive, easy to administer during school or general population drug campaigns, and without serious side effects. One caveat is that treatment must be repeated every 6-12 months because of reinfection. CDC has provided technical support to programs addressing neglected tropical diseases (NTD), such as intestinal helminthes, in more than 10 countries. NTD programs provide significant public health value at low cost, less than $1 per person per year and represent excellent examples of public-private partnerships through the generous donations of drugs by Merck, Glaxo-Smith-Kline, Pfizer, and Johnson & Johnson. Safe water In settings with poor access to safe water and hygiene, children can become trapped in a vicious cycle of diarrheal illness and malnutrition. Diarrheal infections kill nearly 2 million children less than 5 years of age annually and can cause substantial short- and long- term morbidity among survivors. Children with diarrhea frequently lose their appetites and can't absorb food, which can lead to nutritional deficiencies. Similarly, malnourished children are also at higher risk for diarrheal diseases. Poor weight and height gains have been reported among children with heavy diarrheal burdens early in life. Where drinking water and hygiene practices are unsafe, improving child nutrition may not be as simple as providing food aid. Additionally, foods prepared with unsafe water or contaminated hands may expose children to diarrheal pathogens, causing additional illness and further compromising child nutrition. This problem was highlighted during an early 2006 diarrhea outbreak in Botswana--investigated by CDC and partners, including the Ministry of Health, U.S. Office of Foreign Disaster Assistance (OFDA), Peace Corps, UNICEF, and Doctors Without Borders--that killed more than 530 children. HIV-infected mothers in Botswana are provided free infant formula during their children's first year of life in an effort to prevent mother-to-child transmission of HIV, but water used to prepare the formula is not always safe to drink. In this outbreak, diarrhea and acute malnutrition were more common among children who were not breastfed. The lesson learned is that food aid is likely to be most effective when combined with additional interventions, such as safe water. The Safe Water System (SWS) consists of water treatment with dilute, locally produced sodium hypochlorite solution, safe water storage, and behavior change techniques. The solution is typically marketed through commercial channels at an affordable price and is promoted locally by project partners. Through partnerships with dozens of public, private, and nongovernmental organization (NGO) partners, the SWS has been implemented in 23 countries. Approximately 3 million persons per month benefit from the program. In Kenya, a partnership including CDC, USAID, WHO, Rotary International, Population Services International, CARE, Emory University, the Millennium Water Alliance, the Ministry of Health, the Ministry of Education, and several private companies, is promoting and distributing SWS products through the private sector, women's groups, primary schools, clinics, hospitals, and religious organizations. In Kenya, Uganda, and Nigeria, SWS products and handwashing supplies are distributed to HIV-infected people to help prevent opportunistic infections, improve their nutritional status, and protect the health of other vulnerable family members. In Afghanistan, hygiene kits, including SWS products and soap, are provided free to pregnant mothers as an incentive to attend antenatal clinics and to help them develop good hygienic habits before the birth of their children. CDC has also collaborated with Procter & Gamble (P&G) Company to develop and field test PuR, a water treatment product that clarifies and disinfects water. PuR has been used in internally displaced populations in Ethiopia to prevent illness and improve nutritional status. CDC is also currently conducting a clinical trial of a new water treatment product produced by Occidental Chemicals in collaboration with Medentech, Inc. CDC has collaborated with P&G on handwashing research, including a recent study in China that documented a decrease in primary school absenteeism in children in a handwashing promotion program. CDC is also part of the Public Private Partnership for Handwashing that is coordinated by the World Bank. Safe water also contributes to preventing Guinea worm disease (GWD), a parasitic disease that affects resource-poor communities in remote parts of Africa that lack safe drinking water. Infection is painful and debilitating, with serious negative economic and social consequences, such as loss of agricultural production and reduced school attendance. GWD is targeted for eradication, and since the mid- 1980s the incidence of the disease has declined from more than 3 million cases per year to less than 12,000 in 2005. Transmission has been stopped in 11 of 20 countries. CDC collaborates with many partners in the global GWD eradication efforts, including the Global 2000 program of the Carter Center, UNICEF, and WHO. Eradication efforts include simple interventions and CDC has been instrumental in demonstrating that cloth filters and pipe filters can protect users from GW-contaminated drinking water, identifying barriers to early case identification and containment, and assessing the effectiveness of health education and messages to inform villagers about GWD. CDC plans to continue to assist ministries of health and other partners with monitoring and evaluation activities, provide technical assistance concerning surveillance, case detection and containment, and to work with WHO and the Carter Center to reduce cases in the two remaining most highly endemic countries of Ghana and Sudan to fully eradicate this disease. IMPACT OF MALARIA INTERVENTION ON CHILD NUTRITION CDC also contributes to improved child nutrition through its malaria prevention and control program. It is generally accepted that poor nutrition may lead to increased susceptibility to infectious diseases such as malaria along with immune and metabolic system dysfunction that can then further impair nutritional status. Study findings include these: 1) Over time, infections such as malaria may impair growth in young children; 2) Anemia is a common result of both nutritional deficiency and malaria and in areas of intense malaria transmission, where children experience repeated and chronic malaria infection, this nutritional/malarial anemia is likely to resemble iron deficiency anemia and may require iron therapy along with antimalarial treatment; 3) Persistent malaria may induce iron deficiency through one or more mechanisms, including decreased iron absorption, enhanced iron loss during an acute malarial episode, or making iron unavailable in the body for red blood cell production; 4) Malaria-associated low birth weight is a risk factor for increased neonatal and infant mortality; and 5) Prevention of malaria and associated anemia through control strategies such as insecticide-treated nets (ITNs) may help to improve infant growth and weight gain. CDC is actively involved in malaria research that may impact on overall nutritional status of children. For example, CDC has measured the impact of specific treatments and assessed the optimal frequency of iron supplementation to address the anemia associated with malaria. In other work, CDC has documented the beneficial positive impact of insecticide-treated nets (ITNs) on anemia and growth in infants; assessed the impact of ITNs on growth, nutritional status, and body composition of primary school children; and is conducting an ongoing study of IPT with different antimalarial regimens plus iron supplementation in infancy to assess impact on malaria, anemia, and growth. In addition, the synergy and heightened health benefit of deworming and malaria interventions such as bed nets helps address the combined anemia caused by malaria and intestinal worms (especially hookworm). President's Malaria Initiative activities CDC is working to control malaria and its deleterious effects on child survival, morbidity, and nutritional status through participation in the President's Malaria Initiative (PMI), an intergovernmental initiative led by USAID, as well as HHS/CDC, HHS/National Institutes of Health (NIH), the U.S. Department of State, the U.S. Department of Defense, and the White House. When PMI was launched in the summer of 2005, President Bush pledged to increase funding of malaria prevention and treatment in sub-Saharan Africa by more than $1.2 billion over 5 years. The goal of the President's Malaria Initiative is to reduce malaria deaths by half in each target country after 3 years of full implementation. The initiative helps national governments deliver proven, effective interventions--insecticide-treated bednets (ITNs), indoor residual spraying, prompt and effective treatment with artemisinin-based combination therapies (ACTs), and intermittent preventive treatment for pregnant women--to a majority (85 percent of people at greatest risk--pregnant women and children less than 5 years old). Work is ongoing in Angola, Tanzania, and Uganda. In 2007, PMI will target four additional African countries: Malawi, Mozambique, Rwanda, and Senegal. In 2008, eight more countries will be added. The initiative will eventually be implemented in 15 African countries most affected by malaria. HIV/AIDS HIV/AIDS and malnutrition are both highly prevalent in many parts of the world, especially in sub-Saharan Africa. There are well- established links between HIV/AIDS and poor nutrition and food insecurity. HIV, which causes weight loss and wasting, specifically affects nutritional status by increasing energy requirements, reducing food intake, and adversely affecting nutrient absorption and metabolism. PEPFAR recognizes that nutrition is important for people living with HIV/AIDS (including pregnant women) and HIV-exposed children. Within PEPFAR, CDC is helping to support efforts to provide appropriate nutritional support and to create links with broader nutrition programs. Infants born to HIV-positive mothers (``HIV-exposed children'' including both infected and uninfected children) are at a substantially higher risk of low birth weight, early malnutrition, and mortality in the first 2 years of life than children born to mothers without HIV. The risks are greatest for infants of mothers with more advanced disease (Kuhn et al., 2005). These HIV-exposed infants are the major focus of the prevention of mother-to-child HIV transmission (PMTCT) and orphans and other vulnerable children (OVC) programs. Successful outcomes for these children depend on early detection, strong counseling, antiretroviral (ARV) provision, safe infant feeding and follow-up and support system for the infant/mother pairs. Growth, nutritional status and survival of HIV-infected children are also improved by prophylactic cotrimoxazole, ARV therapy, and prevention and treatment of opportunistic infections, while improved dietary intake improves weight gain, growth, and recovery from opportunistic infections and decreases risk of mortality. PMTCT programs target both the HIV-positive pregnant women (and mothers) and their infants and young children with these interventions. The prevention of mother-to-child HIV transmission programs encourage and support safe infant feeding. In settings where breastfeeding is common and prolonged, transmission through breast milk may account for up to half of the HIV infections in infants and young children. The overall risk of mother-to-child HIV transmission (MTCT) in nonbreastfeeding populations is 15-25 percent (without interventions to reduce transmission) and in breastfeeding populations 20-45 percent. To reduce the risk of HIV transmission, HIV-positive mothers are advised to avoid breastfeeding and use replacement feeding when it is acceptable, feasible, affordable, sustainable, and safe to do so. Otherwise, exclusive breastfeeding for the first months of life is recommended, followed by early breastfeeding cessation when conditions for safe replacement feeding can be met. Available ARV prophylaxis interventions can substantially reduce MTCT during pregnancy, labor, and delivery but, so far, significant reduction of postnatal mother-to- child HIV transmission has been less successful. Safe infant feeding is still a major challenge. In resource-limited settings, where large numbers of HIV-infected women and their infants benefit from PMTCT programs, safe feeding of infants without breast milk is difficult. Many women have inadequate access to clean water, infant formula, and other safe, nutritionally complete products for infants. Many mothers and health providers are unaware of the food requirements of infants who do not receive breast milk, because children in these countries have historically been breastfed for up to 2 years. Because of these issues, some infants born to HIV-infected mothers receive inadequate nutrition as a result of efforts to prevent HIV. Several research projects are currently underway to assess the impact of HIV prevention programs on child survival overall and to determine the best way to feed infants of HIV-positive women in resource-limited settings. CDC RESPONDS TO COMPLEX HUMANITARIAN EMERGENCIES Through its International Emergency and Refugee Health program, CDC works to document the nutritional status and needs of children in complex humanitarian emergencies, food crises, and famines, and uses the results to target the most vulnerable populations and improve relief efforts. Recent surveys have been conducted in Darfur, Sudan, Niger, Chad, and tsunami affected areas of Indonesia. In addition, CDC provides technical assistance to U.N. agencies and OFDA in response to nutritional crises, such as the food crisis in Ethiopia in 2003, to assess the magnitude of the problem and prioritize intervention strategies and the Southern Africa crisis in 2003 where CDC assisted UNICEF in reviewing all survey data from the region. CDC supports innovative research to enhance field practice with the goal of reducing morbidity and mortality. Examples include investigating feasible interventions and programs to reduce micronutrient malnutrition in food aid dependent populations and the evaluation of new approaches to the treatment of severe malnutrition. In addition, CDC has helped develop guidelines, manuals, and tools for measuring nutritional status for both WFP and UNICEF. CDC has conducted many trainings on improved practices for field level and country level staff to strengthen overall capacity and enhance the competency of international agencies. CDC activities in Darfur are illustrative. Beginning in 2004, CDC and partners conducted a series of nutrition surveys to determine the extent of acute malnutrition among children living in conflict-affected areas of Darfur. The most recent survey, completed on September 21, 2006, covered the entire 3.8 million persons currently affected by the crisis. These surveys have assisted the United Nations in monitoring the coverage and impact of their interventions over time, as well as providing valuable data for planning humanitarian assistance for 2004 through 2007. Another example is CDC's response to the food crisis in the West African country of Niger. In 2005, an estimated 2.5 million people were potentially at risk due to food insecurity. CDC conducted a series of eight regional nutrition surveys in collaboration with UNICEF during the crisis to document the extent and severity of the problem. The results of the survey were used to improve the general food distributions in the areas with the highest levels of malnutrition and leverage funding from donor agencies. CDC's involvement in fighting malnutrition in complex humanitarian emergencies has a broad impact on the health of vulnerable children. The surveys and assessments conducted by CDC have raised awareness to the magnitude and severity of nutritional emergencies in crisis- affected populations around the world and helped focus limited resources on the most vulnerable. CDC is committed to continuing to work with U.N. agencies and NGOs to implement best nutritional practices in emergency settings and to document the burden of malnutrition in emergency settings. CDC supports international collaboration to improve training for U.N., international, and local aid staff. With our partners, we are working to strengthen the capacity of agencies and staff in order to effectively and efficiently implement nutrition programs. CONCLUSION CDC's unique contributions to addressing child hunger and malnutrition around the world are through the scientific and technical expertise we bring to partnerships for vitamin supplementation, food fortification, and data collection activities of the IMMPaCt and related programs, and the proven and effective interventions that prevent and control the infectious diseases that lead to malnutrition and are the major causes of deaths and illness in children in developing countries. CDC also responds to the nutrition and health needs of vulnerable populations who are affected by conflict, natural disasters, and famine. Collaboration with other Federal agencies is key to developing strong multilateral, bilateral, and private partnerships around the world. CDC is committed to continuing to address these ``core'' public health issues--including improved availability and access to safe water and adequate food and nutrition. Thank you for the opportunity to testify. I would be happy to answer any questions you may have. The Chairman. Well, thank you very much, Dr. Gerberding. Mr. Ward, would you please proceed. STATEMENT OF HON. GEORGE WARD, SENIOR VICE PRESIDENT FOR INTERNATIONAL PROGRAMS, WORLD VISION, WASHINGTON, DC Ambassador Ward. Mr. Chairman, thank you for holding this important hearing on child hunger. As the senior vice president for international programs at World Vision, it's a privilege to be here with such a distinguished panel. World Vision is a Christian relief and development organization dedicated to helping children and their communities worldwide reach their full potential by tackling the causes of poverty. We operate in nearly 100 countries. More than 3 million donors and supporters, from every congressional district, partner with us in fighting global poverty. I'm also, today, representing the Alliance for Food Aid, which is comprised of 15 private voluntary organizations and co-ops that conduct international food programs. Mr. Chairman, it's a great tragedy that there are 400 million hungry children in the world today. About one-third of these children are under age 5 and underweight. Poor nutrition during critical growth phases results in poor cognitive and physical development. It's all the more tragic that the world has the know-how to solve this problem, and yet has not done so. The solution does not require any new inventions, but it does require focused attention. Child hunger can be solved one child, one household, and one community at a time by empowering caregivers with the necessary tools and resources. One of the strengths that private voluntary organizations like World Vision bring to the fight against child hunger is that we are community-based. World Vision makes long-term 15- year commitments to communities through our area development programs. These programs integrate funding from public and private sectors to produce targeted interventions in five main areas: Clean water, food/nutrition, education, health, and job creation. ``Integrated'' and ``long-term programming'' are the watchwords for success. Charities also provide an opportunity for private donors to make a real, tangible difference in children's lives. For example, in 2005 nearly 2.6 million children worldwide benefited from World Vision child sponsorship programs, with 812,000 of these children supported by American donors. USAID, through P.L. 480, Title II, funds many maternal health and nutrition programs aimed at reducing childhood malnutrition. Infants and young children in their first few years of life require special foods with adequate nutrition density, consistency, and texture. This is why a number of Title II programs include wheat-soy or corn-soy blends that are fortified with vitamins and minerals. World Vision operates such programs in Haiti, Indonesia, Mozambique, Rwanda, Uganda, and Zambia. We note with concern that because of reduced funding for development food aid programs, the level and coverage of Title II maternal child health and nutrition programs are being cut. The Alliance for Food Aid urges the continued and expanded use of Title II food aid for these tested and successful programs. UNICEF and the World Food Program have done an excellent job in working together to create the new global initiative for Ending Child Hunger and Undernutrition. This is a collaborative public/private partnership that seeks resources to achieve results. World Vision supports this initiative, which recognizes that good nutrition and health go hand-in-hand. Each year, 5-6 million children die each year from infections that would not have killed them if they had proper nutrition. Over 50 percent of all deaths of young children due to infectious diseases, such as malaria, pneumonia, diarrhea, and measles, have malnutrition as an underlying cause. Mr. Chairman, I know you and other members of this committee have been strong supporters of both international and domestic child hunger programs. All of these programs are important, and we thank you for your leadership. On the international front, only people who are healthy and educated can achieve peace and security. The journey to this goal begins with proper child nutrition. We need congressional leadership and support to ensure that these critical international programs are funded and expanded. Mr. Chairman, there are many difficult problems in this world today that we do not know how to solve. Child hunger is not one of them. It is my hope and prayer that, by working together, we can rededicate ourselves to providing tangible help many children need. This concludes my testimony, Mr. Chairman. I'll be happy to answer any of your questions. [The prepared statement of Ambassador Ward follows:] Prepared Statement of Hon. George Ward, Senior Vice President for International Programs, World Vision, Washington, DC Mr. Chairman, thank you for holding this critical hearing on child hunger and malnutrition. It is a privilege to be here with such a distinguished panel. My name is George Ward and I am the senior vice- president for international programs at World Vision. World Vision is a Christian relief and development organization dedicated to helping children and their communities worldwide reach their full potential by tackling the causes of poverty. We operate in nearly 100 counties with 23,000 employees. World Vision has over 3 million private donors and supporters from every congressional district within the United States who partner with us in fighting global poverty. I am also representing the Alliance for Food Aid, which is comprised of 15 private voluntary organizations and co-ops that conduct international food aid programs.\1\ The Adventist Development and Relief Agency currently chairs the Alliance for Food Aid, and the Alliance's executive director is Ellen Levinson. --------------------------------------------------------------------------- \1\ Members of the Alliance for Food Aid include: Adventist Development and Relief Agency International, ACDI/VOCA, Africare, American Red Cross, Counterpart International, Food for the Hungry International, Joint Aid Management, International Orthodox Christian Charities, International Relief and Development, Land O'Lakes, OIC International, Partnership for Development, Project Concern, United Methodist Committee on Relief, and World Vision. --------------------------------------------------------------------------- PVO CONTRIBUTIONS Mr. Chairman, it is a great tragedy that there are 400 million hungry children in the world today. About one-third of these children are under the age of 5 and underweight. Poor nutrition during critical growth phases results in poor physical and cognitive development. It is all the more tragic that the world has the know-how to solve the problem of child hunger and malnutrition and yet has not done so. The solution does not require any new invention, but it does require focused attention. Child hunger can be solved one child, one household, and one community at a time. This solution requires empowering children's caregivers with the necessary tools and resources. Clearly, there is much work to be done. One of the strengths that private voluntary organizations like World Vision bring to the fight against child hunger is that we are community based. World Vision makes long-term, 15-year commitments to communities through our ``Area Development Programs.'' These programs integrate funding from public and private sectors to produce targeted interventions in five main areas: Clean water, food/nutrition, education, health, and job creation. Immunization, health screening and care, education, and adequate nutrition are critical for ensuring the health and growth of young children. Delivery of these services depends on the development of the community as a whole. Private voluntary organizations therefore use a combination of child services and community capacity-building techniques to support the health and nutrition of the child. Integrated and long-term programming are the watchwords for success. Charities also provide an opportunity for private donors to make a real tangible difference in children's lives. For example, in 2005, nearly 2.6 million children benefited from World Vision child sponsorship programs, with 812,000 of these children supported by U.S. donors. USAID FOOD AID PROGRAMS Through P.L. 480, Title II, United States Agency for International Development funds many Maternal Child Health and Nutrition programs aimed at reducing childhood malnutrition by providing food aid for children. Programs include supplemental food; monitoring the weight, height, and health of the children; immunization, oral rehydration, and other health interventions; clean water; and training mothers about proper sanitation, nutrition, and managing health problems, such as the commonly found respiratory and diarrheal diseases. Infants and young children in their first 2 years of life require special foods of adequate nutrient density, consistency, and texture. In resource-constrained populations, children are at high risk of suffering from micronutrient and protein deficiencies. This is why a number of Title II Maternal Child Health programs include wheat-soy blend or corn-soy blend that are fortified with vitamins and minerals, including vitamin A, iron, and zinc. World Vision operates such programs in Haiti, Indonesia, Mozambique, Rwanda, Uganda, and Zambia. Maternal Child Health and Nutrition programs have been a great success. Positive results are evidenced by reduced stunting and improved weight and height among children. While children's health and nutrition are improved, the broader community also benefits from the educational and capacity-building components of the program. We note with concern that because of reduced funding for developmental food aid programs, the level and coverage of Title II Maternal Child Health and Nutrition programs are shrinking. We urge the committee to support continued and expanded use of Title II food aid for these tested and successful programs. ENDING CHILD HUNGER AND UNDERNUTRITION INITIATIVE UNICEF and the World Food Program have done an excellent job in working together to create the new global initiative for ``Ending Child Hunger and Undernutrition.'' This is a collaborative public-private partnership that seeks resources to achieve results. World Vision supports it. The initiative also provides a tangible focus for governments and private institutions to rally around to ensure the first Millennium Development Goal of reducing hunger by 50 percent is reached by 2015. This initiative recognizes that good nutrition and health go hand- in-hand. Many medical interventions for children can be successful only with adequate nutrition. For example, 5-6 million children die each year from infections that would not have killed them if they had proper nutrition. Over 50 percent of all deaths of young children due to infectious diseases--such as malaria, pneumonia, diarrhea, and measles--have malnutrition as an underlying cause. The ``essential package'' developed by this initiative will drastically improve the nutrition and health of children. It includes: Health and nutrition education; supplemental food; micronutrients; household water treatment; hand-washing with soap; and deworming. U.S. GOVERNMENT POLICY Mr. Chairman, I know you and other members of this committee have been strong supporters of both international and domestic child hunger programs. While not under the jurisdiction of this committee, I think it is critical to note the importance of the National School Lunch, and Women, Infants, and Children supplemental feeding programs in fighting child hunger in the United States. On the international front, only people who are healthy and educated can achieve peace and security. The journey to this goal begins with proper child nutrition. We therefore thank you for your continued support of the hunger-focused international food aid programs like P.L. 480 and McGovern-Dole Food for Education program. These initiatives are making a life-saving difference to millions of people around the world. However, the emergency demands on the P.L. 480 Title II resources have increasingly left little room for development programs such as Maternal-Child Health and Nutrition. We need congressional leadership and support to ensure that these critical programs are funded and expanded. Mr. Chairman, there are many difficult problems in this world today that we do not know how to solve. Child hunger is not one of them. It is my hope and prayer that by working together, we can rededicate ourselves to providing the tangible help many children need. This concludes my testimony, Mr. Chairman. I would be happy to answer any of the committee's questions. The Chairman. Well, thank you very much, Mr. Ward. As I introduce the next speaker, Mr. Jim Morris, of the World Food Program, I would just simply add, as many of you know, that we have been good friends and workers together for 40 years, and I appreciate, especially, his being here this morning as he concludes a remarkable tenure with the World Food Program. His travels have been described in previous hearings of our committee, and I know that he will be equally forceful today. It's a very great pleasure and honor to have my friend Jim Morris. And would you please proceed. STATEMENT OF JAMES T. MORRIS, EXECUTIVE DIRECTOR, UNITED NATIONS WORLD FOOD PROGRAM, NEW YORK, NY Mr. Morris. Thank you, Mr. Chairman. I appreciate your comments. And there would be no way I could express my appreciation for you. Your opening statement reflected characteristic insight and concern and commitment and passion for great humanitarian issues around the world. And we're grateful for that. If I might just open by saying that the international humanitarian community is deeply, profoundly grateful to the United States of America for the extraordinary generosity and concern for people at risk around the world. The United States helps us with enormous amounts of cash, brainpower, technical capacity, and does it in a nice way, in a caring way. And I worked for a man by the name of Eli Lilly for a number of years, and he always said, ``If you're going to do something nice for someone, do it in a nice way.'' And the United States extends its concern and generosity in the nicest way possible. Our partnership with USAID, with the Department of Agriculture, the Department of State, the Department of Labor is extraordinary. The historic contribution of our country through Food for Peace, feeding more than 6 billion people around the world, 135 countries over 50 years, the contribution of the Peace Corps, the remarkable contribution, really, that Julie mentioned, of PEPFAR, and the role of the land-grant college system in the United States in educating much of the agricultural leadership around the world, is extraordinary. And I'm grateful for that. The past 5 years have been a life-changing, life-affirming experience for me. I've spent as much time as humanly possible in the field. And I come from a fairly comfortable existence in the United States. And I must say, the faces of children around the world who are hungry and at risk, and are suffering, and their mothers--often, their mothers, maybe age 25, look like they're 75. The burden is extraordinary. The unfairness of life for so many children who find themselves in these difficult circumstances, not of their own making, to visit a child in a hospice, and to have the nurse say, ``This child is infected with HIV,'' and, ``Give the little girl a hug, because she won't be here next week,'' or to visit a little girl in Zimbabwe--small little girl, but she's 15 years of age, and her mom and dad are gone, because of HIV, and suddenly she finds herself mother and father, protector, caregiver for five or six brothers and sisters, she's never had a childhood, she never will, and she's completely compromised and completely unprepared for what she faces. If these issues, circumstances, affected a few children, it would be sad, but these circumstances affect hundreds of millions of children around the world. You know, more than half the children under 5 years of age in Guatemala are chronically malnourished. And if you go into the indigenous populations, the numbers approach 70 or 80 percent. You go to North Korea, and you see extraordinarily different standards between children in South Korea and North Korea, all related to nutrition. And, in my judgment, the life of a child in Washington, DC, in London or Indianapolis, the life of the child in Malawi or Honduras or Bangladesh, the value of the child's life is the same. And when the child is compromised, circumstances not of their own making, the rest of the world must step in and help to provide the physical requirements of the child. But, as Julie said, you know, a child needs the arm of a caring adult. And that is so important. WFP and UNICEF have been working now for a couple of years with our partners in the NGO community, with national governments, with others in the U.N. to see if we could build a movement, a partnership in the world that would say it's no longer acceptable for children in the world in 2006 to be hungry, it's unacceptable, it's sad, it's sinful, it's reprehensible. And, as we've all said, it's a solvable problem. We know how to do this. We know what it costs. We know what the approaches are that will be effective. And we know how to build the partnerships to get it done. This is an effort that requires champions, political leadership, resources, and commitment. And when the world understands the seriousness of the issue and the solutions that are available to address the issues, the world wants to respond. If there's one thing that heads of state and heads of government all around the world agree on, it's that women and children should not be at risk, should not be vulnerable, should not starve. Eighteen thousand children will die today of hunger, one every 5 seconds, all day long. Four hundred million hungry children in the world, 146 million of them under the age of 5 years. We are talking about a short-term approach to saving lives. Clearly, the longer-term situation that Jim talked about, requiring agricultural investment and more capacity to produce food around the world, is really important. But there is a sense of urgency to look at this in the short term, because so many children's lives are at risk. And, as you said in your opening statement, this is about more than food; it's about health, it's about sanitation, it's about water, it's about all sorts of things. We know, when we make an investment in nutrition, it reduces poverty, it improves educational outcomes, it produces productivity, either by the individual life or by the country. Our commitment is to find a way to double the rate of reduction of underweight children under the age of 5 years from about 1.7 percent to something approaching 2.6 percent. We know how to approach these issues in a predictable way, a preventable way, and a way that is affordable. China, Chile, Thailand are tremendous examples where thoughtful approaches to these issues have produced extraordinary results. And I must say, Mr. Chairman, when you visit with people in Japan or Germany, they talk about the role the United States played in their country after World War II, in terms of providing food for children, the impact that had on bringing their educational systems alive. You know, I've talked to political leaders, ministers, members of parliament in both countries, and their emotional appreciation and resonance with what our country did to feed their children after the war, they would say that this made as much difference in the success, the prosperity of those places, than anything that ever happened. Our approach is to find a way to locate where the most vulnerable children are. It's interesting that the 400 million vulnerable children essentially live in 100 million households. Three-fourths of the hungry children in the world are in 10 countries. Half the underweight children in Africa live in just 10 percent of the administrative districts. The opportunity to approach this in a fairly narrow geographic situation, where the concentration of children at risk is located, makes the opportunity to address this easier. To work with national governments--as Jim pointed out, is important, as is working with community-based institutions. There are remarkable people in every country of the world that spend their life focused on the well-being of children. Just as we have community-based organizations in our cities, coaches and YMCAs and Girl Scouts, these same kinds of people exist around the world, and they simply need help. We need to work with national governments, to work with community-based institutions, and then to provide the essential package of services that, first, deal with health, hygiene, nutrition education. Julie also mentioned this issue of micronutrients, parasite reduction, the importance of sanitation in the household, and safe water. Handwashing with soap makes all the difference in the world. So, a fairly specific geographic approach with the provision of an essential package of services. We believe that the cost of addressing this is about $80 per annum per household--if you're looking at 100 million households in the world over time, an annual cost of about $8 billion. And our research would tell you that we have the infrastructure in place to address about a billion dollars of opportunity immediately. To find a way to build a movement that includes NGOs, donor governments, host governments, the business community, we have a partnership with a remarkable company, TNT, in the Netherlands, 170,000 employees. Every one of their employees has committed to feed a school child, and the company has agreed to match it. We have a remarkable partnership with Citigroup, in the U.S.--the same kind of commitment to humanitarian issues. Service clubs can also make a difference. What Rotary has done in the last 25 years, working with CDC and with UNICEF and many more, to virtually provide the leadership to eradicate polio in the world, they've immunized almost 2 billion children in the world over the last 25 years. It is extraordinary the leadership that Rotary has provided for this issue, and the success that's been made possible. I'm optimistic that Rotary now, with Kiwanis and others, may be willing to focus on the issue of eliminating child hunger. The same goes for the faith-based organizations, youth- serving organizations. I spent last week, one day, down at Auburn University, and Auburn is spearheading an effort to engage not only the American Land Grant University System, but also colleges, across the United States in the issue of eliminating child hunger. They gave me a check to feed 600 kids for a year. I gave the commencement address at Georgetown College in Kentucky last year. They gave a check to feed 1,400 children for a full year. Somehow, there's an opportunity for everyone to be engaged in this issue, for everyone to do just a little more. So little goes so far in the issues that we are trying to address. So, Mr. Chairman, that gives me the opportunity to talk about the magnitude of the issue, the importance of the issue. You know, I prefer that people look at this from a humanitarian point of view, but--the economic perspective, the political perspective, are also quite important--but, the fact of the matter is, if millions of people are at risk around the world, especially children, we're all at risk. And, you know, we're all diminished if anyone's diminished. And it simply is not acceptable today for so many children to perish every day, to have their lives compromised from the very beginning, when the resources and the technology and the willpower and the goodwill are available to make a difference. And so, my hope is that, over time, this extraordinary movement, worldwide, will come together and find a way for everyone to participate. And, at the end of the day, you know, none of us ever feel as good about ourselves as when we're doing something for someone else, especially a child, and that opportunity is before us. Thank you. [The prepared statement of Mr. Morris follows:] Prepared Statement of James T. Morris, Executive Director, United Nations World Food Program, New York, NY Good morning Mr. Chairman, distinguished representatives, ladies and gentlemen. Thank you Mr. Chairman. Few experiences have changed my life more than holding an acutely malnourished child in my arms, as I did on a recent visit to Kenya. To hold in my arms a 1-year-old girl who weighs little more than an average newborn in the United States unleashes a tide of emotions. One can't help but feel grief for this child's pain; shame that this should be allowed to happen in the 21st century; anger that this child will not be the last to suffer this fate. In fact, 18,000 children will not make it through today. Their tiny bodies will succumb to months and years of not getting the nutrition they needed to survive. Millions more will have their growth stunted forever, their minds dulled by malnutrition, and their futures limited to a life of poverty and ignorance. The OECD reports that international aid was higher in 2005 than in any year in history. Industrialized countries gave US $107 billion in foreign aid. Despite last year's record levels, funding for global child health efforts have not increased significantly in the past 10 years and investments in agricultural research have declined. CHALLENGE Often we think about these sectors as if they are unconnected. But while resources may flow through different channels, they serve the same people, the same communities, and the same children. We must do more to ensure that our investments in the agriculture, health, and education arenas are working together on the same outcomes. With a depressing regularity, we see the same communities that are hit by drought struggling with poverty, child malnutrition, and HIV/ AIDS. In pockets--sometimes large, sometimes small--there are children who have been battling hunger their whole lives. Hunger and related diseases cause between 5 and 6 million deaths per year. The damage caused by malnutrition is not just death--it affects just about every stage and aspect of life. The vast majority of the children who will die today from hunger and related causes won't perish in a high-profile emergency. They'll pass, unnoticed by anyone other than their families and neighbors, in squalid slums or in remote dusty villages. We are simply not doing enough for these children. In many cases, we are not even reaching them, much less giving them a foothold on the bottom rung of the ladder of development. The evidence is clear: Investment in nutrition reduces poverty, increases educational outcomes, and boosts productivity throughout the life cycle and across generations. RESPONSE That's why WFP and UNICEF are working more closely than ever with the widest possible group of partners to fight hunger. Our goal is nothing less than to end child hunger and severe undernutrition within a generation. For a start, we are working to achieve the hunger target of the first Millennium Development Goal (target 2). We will focus on supporting country efforts to double the current annual reduction rates of underweight children under 5. The causes of child hunger are predictable, preventable, and can be addressed through affordable means. Combined with improved research and technology, this once idealistic notion of ending child hunger is now operationally feasible. EVIDENCE To be sure, there are long and short routes to improving nutrition. Higher incomes and better food security improve nutrition in the long- term. But malnutrition is not simply the result of food insecurity. Many children in food-secure environments are underweight or stunted because of infant feeding and care practices, poor access to health services, or poor sanitation. We have concrete historical examples of what strategies have worked in places like post-war Europe and Japan, and in developing countries like Chile, Thailand, and China, where hunger among children has been dramatically reduced. For example, improving the nutrition of pregnant women directly contributes to child health. Good nutritional status also slows the onset of AIDS in HIV-positive individuals. It increases malaria survival rates and lowers the risk of diet-related chronic disease. The highly concentrated nature of undernourished children in countries makes it possible to target and support national and community efforts. There are roughly 400 million hungry children in the world today--with an estimated 146 million of them under the age of 5. These children live in approximately 100 million households. In Africa, over half of the underweight children live in just 10 percent of the administrative districts. We are proposing a set of urgent actions to address the needs of children at most immediate risk of death or lifelong disability from hunger: First, that we locate the most seriously undernourished children and the communities in which they live; Second, that we identify and support local organizations to reach them with essential interventions; and Third, that we leverage complementary interventions, such as childhood immunization, education, and food security efforts, to the same underserved areas. A significant part of our effort will be promoting an ``essential package'' of health and nutrition interventions that can impact the immediate causes of hunger. It includes the basic health, hygiene, and nutrition practices we use daily, together with a set of life-saving commodities--micronutrients, household water treatment, hand-washing with soap, parasite control measures, and situation-specific household food security interventions. The annual household cost of these lifesaving interventions is roughly USD $80. In many cases we have seen that even the poorest households are prepared to reallocate their own sparse resources when these key commodities are available for purchase. In other cases, some component of community, national, or international assistance will be required. Over time, the total cost--with an increasing share provided by national governments--to assist 100 million families to protect their children from hunger and undernutrition is estimated at roughly $8 billion dollars per year. Of this amount, it is estimated that approximately $1 billion dollars of new international resources could be effectively programmed immediately. This investment can change lives--even generations. And the costs of action are but a tiny fraction of what we will shoulder by doing business as usual. PARTNERSHIPS SECTION An effort of this magnitude can only be undertaken by a strong partnership with solid partners. It will require the continued engagement of the United States Centers for Disease Control and their unique capacities to strengthen the surveillance systems and technical networks required to find and more effectively target and evaluate antihunger interventions. It will require continued leadership from the United States Agency for International Development and the further engagement of its technical contractors, uniquely placed to support the adaptation of technical strategies to scale in a wide range of settings. This effort will require expanded partnerships and strengthened technical capacities among the larger international NGOs, the community-based support networks, and the families in the most affected areas. It will require increased leadership and partnership with the private sector, following the stellar examples of those companies that have already joined this effort: Contributing their know-how in marketing, logistics, and health communications--and their R and D capacities developing new ways to deliver micronutrients, fortify food, and make household water safe to drink. In the long-term, it will require the success of agriculture and education efforts like the ``Education for All Initiative'' and the new partnership between the Rockefeller and Gates Foundation to launch a green revolution in Africa and dramatically improve soil fertility and increase the productivity of small farms. No one organization or sector can do it all. Together we can provide a framework that clearly identifies the opportunities, eliminates some of the obstacles, and clears some of the smoke and mirrors of who does what. I can appreciate this might appear to some to be a daunting task, but no more daunting than the task of polio eradication must have appeared 25 years ago. The partnership that formed then and has grown and succeeded throughout the world has now very nearly reached its goal. It is a living reminder to us of what happens to so-called ``impossible feats'' when confronted with the steady and focused efforts of committed individuals and institutions. The choice that societies and communities have before them is whether to act now to end child hunger and undernutrition in this generation, or to wait for improvements in income and education to have an eventual--long-term impact on child growth. Because children are only children in the short-term, this initiative is focused on their immediate needs. Growing minds and bodies require daily nourishment, healthy care practices, and sanitary living conditions. We know what needs to be done if we are to meet the Millennium Development Goals and provide the basic necessities not only for a life of dignity and health, but also to make an economy work. Mr. Chairman, distinguished committee members, thank you for the opportunity to address you today on this most important issue. The Chairman. Well, thank you very much, Mr. Morris. And now, it's a real privilege to have Ann Veneman at this table. In a part of my legislative life, I was chairman of the Agriculture Committee for over 6 years and Ann Veneman was the distinguished Secretary of Agriculture who brought such leadership not only to our farm programs, our nutrition programs, and our conservation programs in rural America. It's wonderful that you are now serving the United Nations Children's Fund. We're delighted to have you, today, Ann. Would you please proceed. STATEMENT OF HON. ANN VENEMAN, EXECUTIVE DIRECTOR, UNITED NATIONS CHILDREN'S FUND, NEW YORK, NY Ms. Veneman. Thank you so much, Mr. Chairman. And it is my privilege and opportunity to be before you, once again, in the United States Senate. It is also my privilege to be here with such a distinguished panel. And I particularly want to add my words of appreciation for my friend, Jim Morris. He--as you know, I've worked with him both at USDA and now in my current position, and I can tell you he is an extraordinary person who is doing extraordinary work, and deserves a great deal of credit for all he's doing to help the world's most needy. As you indicated, Mr. Chairman, nutrition is a very important part of what the U.S. Department of Agriculture does. It is about 50 percent, or more, of the USDA budget. One of the programs that we have always found to be most effective is the Program of Women, Infants, and Children, a program that really focuses on the nutrition of pregnant and lactating mothers and children under 2 years old. And that has been one of the more effective programs. And if you look at the kinds of issues we're talking about today, indeed these issues are the very same that we are addressing in our own country with the WIC program. So, as others have stated, nutrition profoundly affects the life of children at every stage of development, from conception, basically, through early childhood years. And proper nutrition will determine whether or not a child will be healthy, whether or not they will learn, whether or not they will develop properly, whether or not they'll reach their ultimate full potential. This spring, UNICEF released a report called--one of our series of reports called Progress for Children. This one focused on nutrition and particularly looked at how the world was doing in reaching Millennium Development Goal number 1 on addressing hunger. One of the measures of that success of--in implementing that Millennium Development Goal--is how many children under 5 years of age were--are underweight. And I must say that the conclusions of that report are disturbing. It is estimated that more than a quarter of the world's children under 5 years old are seriously underweight. As Jim Morris pointed out, that's about 156 million children in a--in developing countries--27 percent in developing countries fall into that category. Global rates have fallen only 5 percentage points since 1990. So, we estimate that, at our current pace, the world will not meet the promise of the Millennium Development Goals to cut the rate in half--to cut the rate of under-5's underweight in half--by 2015. It is estimated that persistent undernutrition is a contributing cause in more than 5 million under-5 deaths every year. But underweight children are really only part of the story, and I think we've heard a lot of--about this today. While many children may be eating enough to fend off hunger, many are missing essential vitamins and minerals. Something as simple as the lack of iodine can lower average IQ in iodine-deficient children by up to 13 points. Vitamin A deficiency can make a child significantly more likely to die from common childhood diseases, like measles. And every year, iron deficiency means that tens of thousands of pregnant women will not live to see their babies born. If you look at the findings of this report, you see that, in India alone, 7.8 million babies are born underweight every year, and 47 percent of the under-5 population in India is underweight--48 percent of the under-5's are underweight in Nepal; 48 percent are underweight in Bangladesh. Now, when you compare this to the United States, the number is 2 percent. In sub-Saharan Africa, if you look at it as a whole, there is--there are 28 percent of the children, on average, who are underweight. In South Africa, one of the more developed sub- Saharan African countries, the number is 12 percent under-5's underweight. In Ethiopia, nearly half of the children, or 47 percent, are underweight. Millions of children in sub-Saharan Africa live in an almost constant state of emergency, fueled by war, by famine, and other crises. HIV/AIDS, as we've talked about, is putting an additional strain on communities that are already struggling to produce and to find food. And HIV/AIDS is leaving children alone and vulnerable. With so much at stake, we are long overdue for a new approach. So, we believe that the End Child Hunger and Undernutrition Initiative will help provide focus and resources to address this issue of childhood hunger around the world. Food aid alone is not enough. Reversing the current trends requires a holistic approach, as many have talked about today, including agricultural productivity, addressing all that helps to keep children healthy and developing properly, including healthy mothers during pregnancy, good nutrition and vitamins, breastfeeding, better education, effective disease control, policies that safeguard food access, access to clean water, and sanitation. It has to be an integrated approach. And we must do more to focus on children age 2 and under, where the majority of the under-5 deaths occur. If a child falls behind in this critical stage of under-age-2, he or she may never catch up. In addressing the underlying causes of malnutrition, there are simple, practical things that we can do to make a difference. The global campaign to iodize salt, for example, is bringing iodine to almost 70 percent of all households, and protecting 82 million newborns per year against iodine deficiency. The UNICEF-supported Accelerated Child Survival and Development Program in West Africa has shown results-- preliminary results of a reduction of child mortality by 20 percent in some of the areas where we've implemented it. And this is by delivering a simple integrated package of both nutrients and healthcare to families in community-based settings. We have seen clear signs that point the way forward, and evidence of the strategies that do work, and that do produce results and make a difference. While the goals of this initiative are ambitious, they are not impossible, and they show a future where children can and will have equal opportunity to fulfill their unique potential. Thank you very much, Mr. Chairman. [The prepared statement of Ms. Veneman follows:] Prepared Statement of Hon. Ann Veneman, Executive Director, United Nations Children's Fund, New York, NY Mr. Chairman, members of the committee, thank you for this opportunity to discuss the ``End Child Hunger and Undernutrition Initiative,'' and the importance of nutrition to children. It is a special pleasure to appear with my U.N. colleague, Jim Morris, of the World Food Program, who will be ending his tenure next year. He has been a valued partner and friend for several years, and so committed to the work of the World Food Program. He has a record of boundless energy, compassion, and creativity. When I last appeared before a Senate committee, it was in my capacity as the U.S. Secretary of Agriculture. Nutrition programs accounted for some 60 percent of the USDA budget. At UNICEF, I continue to pursue effective, strategic approaches to the health of mothers, babies, and children, which was a hallmark of USDA's WIC, or Women, Infants, and Children Program. Nutrition profoundly affects life at every stage of development, starting before a child is even born. It helps determine how healthy a child will be, how fast she will grow, how easily she will resist diseases, how well she will learn at school, and whether her own children will reach their full potential. It is critical that we understand the vital importance of nutrition and how serious undernutrition is around the world. One underweight and undernourished child is an individual tragedy. But multiplied by tens of millions, undernutrition becomes a global threat to societies and to economies. ``Underweight'' is the indicator that is used for undernutrition because it is one of the most visible and easily measured attributes, and because it correlates strongly with disease and premature death. A few months ago, UNICEF released its ``Progress for Children'' report, revealing where the world stands on the first Millennium Development Goal, which seeks to cut in half by the year 2015 the global proportion of underweight children. The conclusions of that report, which I would offer for the complete record of this hearing, are disturbing. Undernutrition is a global epidemic. In a time of plenty, it is estimated that more than one-quarter of the world's children under the age of 5 are seriously underweight. In developing countries, about 146 million children, or 27 percent, fall into that category. Global rates have fallen only 5 percentage points since 1990. At our current pace, we will not meet the promise of the Millennium Development Goals to cut the rate in half by the year 2015. [Editor's note.-- The report mentioned was not reproducible in this hearing but will be maintained in the committee's permanent record.] It is estimated that persistent undernutrition is a contributing cause in more than 5 million under-5 child deaths every year. But underweight children are just part of the story. While millions of children are eating enough to fend off hunger, many are missing the critical vitamins and minerals they need. Something as simple as a lack of iodine in diets can lower the average IQ in iodine-deficient children by up to 13 points. Vitamin A deficiency can make a child significantly more likely to die from a common childhood disease like measles. And every year, iron deficiency means tens of thousands of pregnant women will not live to see their babies born. According to ``Progress for Children,'' only two out of seven developing-country regions are making sufficient progress to meet the Millennium Development Goal target. But there are bright spots in every region, and there is particularly good news in China. The country with the highest population on Earth already met the Millennium Development Goal target regarding underweight children more than 10 years ahead of schedule. The proportion of underweight children in China dropped from 19 percent in 1990 to 8 percent in 2002, thanks in part to a strong government commitment to make nutrition a priority. This dramatic progress shows we can make swift advances in a very short time if we take a comprehensive approach to a child's needs. The worst crisis is in South Asia, where almost one in two children under age 5 is underweight, or 46 percent. In India alone, 7.8 million babies are born underweight every year. That equates to the combined population of the State of Virginia and the District of Columbia. Sub-Saharan Africa, as a whole, has been largely stagnating, with 28 percent of its children under 5 years old underweight. In South Africa, 12 percent of the children under 5 are underweight. In Niger, the rate is 40 percent; and in Ethiopia, nearly half of all children under 5, 47 percent, are underweight. Millions of young children in sub-Saharan Africa live in an almost constant state of emergency, fueled by war, famine, and other crises. HIV/AIDS is putting additional strain on communities that are already struggling to find adequate food, and leaving children alone and vulnerable. Examples from other individual countries show the rate of undernutrition is 48 percent in Nepal and Bangladesh, 47 percent in India, and 46 percent in Yemen and Timor-Leste. In Guatemala, the rate is 23 percent, the highest in Latin America and the Caribbean. In Albania, 14 percent of children under 5 are underweight, the highest rate in Central and Eastern Europe and the Commonwealth of Independent States. Compare that to only about 2 percent in the United States. We cannot blame this global epidemic on food shortages alone. These numbers reflect broken health and education systems in countries, poor governance and corruption, and a widespread failure to provide basic services, such as clean water and sanitation. With 2.6 billion people living without a simple toilet, diarrhea has become one of the world's leading causes of child deaths and malnutrition. We also know the importance of educating girls, and keeping mothers healthy, especially in the developing world. Millions of women and girls come into pregnancy too young and too often. Far too many are malnourished themselves, and very few spend their teenage years in school. This impairs their ability to bear, raise, and care for healthy children. At least 20 million babies are born underweight every year in developing countries, which puts them at a higher risk of an early death. With so much at stake, we are long overdue for a different approach. We believe the ``End Child Hunger and Undernutrition'' initiative will provide focus and resources to address childhood hunger. Food aid alone is not enough. Reversing the current trends requires a holistic approach to what keeps children healthy and developing properly. This includes healthy mothers during pregnancy, breastfeeding, better education, effective disease control, and policies that safeguard food access, even in times of crisis. There must be a special focus on protecting children under age 2. If a child falls behind during this critical development stage, he or she might never catch up. In addressing the underlying causes of malnutrition, there are simple, practical things we can do that make a critical difference. The global campaign to iodize salt, for example, is bringing iodine to almost 70 percent of all households and protecting 82 million newborns per year against deficiency. The UNICEF-supported Accelerated Child Survival and Development program in West Africa has managed to reduce child deaths by an estimated 20 percent in some areas by delivering a simple, integrated package of nutrients and health care to families in community-based settings. It is time to believe in, and invest in, the scaling up of programs that yield results for children. We have seen clear signs that point the way forward and evidence that our strategies work. While our goals are ambitious, they are not impossible, and they show a future where children have an equal opportunity to fulfill their unique potential. Thank you, Mr. Chairman. The Chairman. Well, thank you very much, Secretary Veneman. Let me begin the questions by noting that in your testimony each of you has mentioned the importance of partnerships in fighting hunger and malnutrition. The World Food Program and UNICEF are partnering in their new initiative. Mr. Kunder gave a few examples of partnerships in his written testimony, such as the USAID/UNICEF/Kiwanis partnership to address iodine deficiency and partnering with pharmaceutical companies to develop zinc tablets. But, as I listen, each of you has mentioned how some of your efforts intertwine. Can each of you give some idea of who's in charge here? Now, that's not meant to be provocative. Obviously, there are U.S. Government agencies, there are faith-based initiatives, service clubs, and the United Nations. But as Mr. Morris said, if you were to seek out 10 top countries that have a majority of the problems, or 10 particular sectors, even in Africa--if there was a so-called business plan for all of this--and maybe there is--perhaps there would be some greater confidence that the goals are going to be met, and that United States investments, whether they are public or private, are on target, as opposed to solving one problem, only to run into another. Dr. Gerberding was skillful in pointing out that in a progression of four or five different programs, you lead to the possible treatment for HIV/AIDS, which would not be successful without the intervening steps in front of that. And that shows a degree of sophistication which is very, very important to describe. But I'm just hoping for some reflections as to where the business plan is, who's in charge, or if anybody ought to be, and how we come to grips with the overall organization of the effort. Now, let me ask you, Secretary Veneman, because you have presented a report that attempts to go into the Millennium Goal No. 1 and the graph of child nutrition around the world in which the red countries are those that are either not changing or falling back, and the blue countries at least are on track to reach this first target. Insufficient data is the case for some situations such as all of the Korean Peninsula or Libya or Argentina or some countries in sub-Saharan Africa. So, we really don't know, I suppose, at this point. But at least there is an attempt being made here, graphically, to portray, with this goal, how we're doing, collectively. Would you address that question, first of all, as to the overall ``who's in charge''? Ms. Veneman. Well, Mr. Chairman, I think it's a very appropriate question, because I think that as I've come into this world of development, and development agencies, one of the things, I think, that we have to be addressing is, how do we work closely together on issues related to poverty alleviation, hunger, healthcare, and the whole range of issues that impact people in the developing world. And so, it's critical that we work in partnerships. And I think one of the ways that we collectively address these issues is by having common goals, as this nutrition initiative indicates--the Millennium Development Goals, for example, are common goals--and that we collectively measure results, collect data in a uniform way, so that we can measure the progress that we're making. One of the things that we hope to address with this initiative is, it was begun as a partnership between WFP and UNICEF, partly beginning--as I came into this job, Jim Morris and I started talking about this partnership--we've tried to make it as broad as possible. The World Bank's been very involved. A number of NGOs have been very involved. WHO's been very involved. So, it attempts to bring all of the parties together in a cohesive way to address the issue, particularly of child hunger, but recognizing how important hunger is to so many other things--children's health, to education--you can't learn if you don't have enough to eat--and also to bring in the NGOs. I began, in August, chairing a committee on nutrition, which is all of the agencies of the U.N. that deal with nutrition, as well as NGOs and governments, and many universities, and that committee, also, is a major part of this End Child Hunger Initiative. So, we are trying, really, to address the very issue that you're bringing up, and that is, how do we bring all of the various parties that are involved together around common goals and trying to achieve common results in areas which are most in need? The Chairman. Now, at UNICEF--and you've mentioned the partnership with Jim Morris and the World Food Program--you're dealing as officials of the United Nations, so presumably you have the attention of all of the countries that are members of the United Nations. By definition, at least, that's the group that you represent. The NGOs, I gather, could be international organizations also, in some cases. The World Bank certainly has many of the same constituents. But is this how you come to grips with all of the governments or humanitarian resources of the world? At least through the United Nations setup there, you have some reporting situation. Ms. Veneman. Well, I think that is a very important question, as well, because--you know, particularly as the U.N. has addressed this high-level panel on coherence, one of the things we see is the importance of also--particularly donor governments working in a cohesive manner within its own agencies and with other governments and with the U.N. agencies and with NGOs. So, I do think that we all have to work very closely together to address the kinds of issues that we're talking about. And what we hope to do with an initiative like this is to rally all of the various parties around common goals and trying to achieve common results. And I think that's one of the best ways we can work to achieve the kind of results we want to see and to help children. The Chairman. Mr. Morris, do you have a comment on this question? Mr. Morris. Sure. Essentially, there's no one in charge. Hopefully, we'll all be focused on those who need our help, and that common mindset will draw us together. But, really, the leadership needs to come from the country where the problems are being addressed. The Government of Malawi needs to own the responsibility and provide the leadership to draw us together. They need to have one plan, one coordinating mechanism, one system for monitoring and evaluation that we all buy into. UNAIDS has really done a good job on what they call the ``three in one'' theory of one plan, one mechanism, one evaluation system to look at the HIV/AIDS issue country by country. And, ultimately, the responsibility for addressing what we're talking about is a country responsibility. And our job is to be there to be helpful. Now, there are very difficult issues of capacity and resources, technical competency, that the rest of the world will have to provide. But the only chance for this to be sustained, and, really, to work, is if the country where the work's being done is in charge. The Chairman. Now, I know, from personal conversation, that you have visited North Korea and Zimbabwe, to take two cases. And clearly a number of children, or maybe others, were fed through the efforts of the World Food Program, but, on the other hand, on some occasions, for instance, the Government of North Korea has taken the position that, ``We don't need you this year.'' In an imperfect world, there is no real answer to this, but the fact is that a number of people are starving because they have governments that do not have a very good plan or, in fact, are not particularly receptive, during certain years, to this kind of aid. And I gather that the World Food Program has, in a humanitarian way, persisted to insist that there are still hungry people there, despite the politics, and that you would like to help, or you would like to insinuate help, in those situations. Mr. Morris. Of the 191 members of the United Nations, you couldn't have picked two better examples to discuss. [Laughter.] Mr. Morris. North Korea and Zimbabwe are both very difficult places. We provided food, this past year, for more than 5 million people in Zimbabwe. The last 5 or 6 years, we've been providing food for a third of the population of North Korea, with good support, by the way, from the United States. Our job there is to save lives. And we've had to find a way to do our work so that we can get food distributed to those who need it. Now, the Zimbabwe situation is very interesting. We've made it clear to the Zimbabwe Government that we're there to help. We're there, not in a political role, but a humanitarian role, and our job is to get food to people who are most at risk, absent any other consideration. We have 24 NGO partners at the high point in Zimbabwe, World Vision being one of the best, that enable us to distribute food to more than 5 million people, and to do all the distribution through private mechanisms. I suspect that Zimbabwe does not have a plan to address the kinds of issues that we are focused on. And I'm very concerned about Zimbabwe. They have more than a million orphans because mom and/or dad has died of HIV/AIDS. The predicament is extraordinary. In North Korea, you know, our job has been simply to get food to millions of people who need it. Before we were there, people were dying in that country. And with UNICEF, we've found a way to turn the situation around, to reduce dramatically the percentage of chronically and acutely malnourished children, to reduce the percentage of children underweight. We've not made much progress with the issue of anemia with women. It's been steady. North Korea came to us last year, all of us, and said, ``We're no longer in an emergency situation. We don't need you to do emergency work. We want you to begin to do development work.'' And our plan for North Korea this year is to provide food for 1.9 million people, mostly in the northeast, away from Pyongyang, where things are the most difficult. They've recently had floods, and we've gone in to feed another 55,000 people during the crisis. But these are two places that need to be more thoughtful about addressing the issues that we're all concerned about. I agree with you. The Chairman. Mr. Ward, mention has been made of World Vision in Mr. Morris's comments. Do you have an overall comment about these issues? Ambassador Ward. Yes, Mr. Chairman, I do. I think, first of all, on the question--I'd just like, very briefly, to return to the question of who's in charge. And I think that needs to be answered in two ways. First, who's in charge really needs to be the families in need, because unless the families--they know best their needs, and they also are the ones who are going to have to implement solutions. So, we need to--we need to find solutions that they can adapt to and that they can implement. And that's World Vision's way, is-- throughout the world, to work very, very closely, not just with national governments, but also with community-based organizations, at the grassroots level, to find solutions that people can actually use and to find the kind of prioritized interventions that Dr. Gerberding was talking about, so that we can get in there and help people. But I also think that we need--we need the international partnerships. We need the partnerships that are really blossoming now between international organizations, national governments, and international NGOs in this field of food and nutrition, and also in health. And we have, as unifying principles, the Millennium Development Goals, which are very clear, and which provide, perhaps for the first time in this business, very clear targets. So, we are working together, not--in Zimbabwe, for example--not just with World Food Program, but also benefiting from grants from USAID and feeding--we have a very active food program in Zimbabwe, and we're able to continue, because we're connected to the communities. It's--that's also true--for example, I was, earlier this year, in Afghanistan, where we work in a difficult situation, a situation where travel is difficult, security is a challenge, but we're connected to the community, and we find that very, very important in our work. The Chairman. Dr. Gerberding, do you have a comment on this question? Dr. Gerberding. Thank you. I've been thinking a lot about it, because this question about who's in charge comes up in a lot of settings--terrorism, hurricane preparedness, and so forth. And I feel very fortunate to work in a department led by a secretary, Secretary Leavitt, who sees the world as a network. And I really agree with him. And I think what we're talking about here is a very complicated network of organizations and individuals, from government and nongovernment sectors who are all working on the same problem. But there is no one in charge of the network, and I very much agree that ultimately the decisionmaker has to be the Minister of Health or the leader of the affected countries. But I think what we're learning to do in these very complicated times is to understand better what makes a networked effect successful. And it really is having a very clear goal and a very clear set of strategies so that, wherever you are in the network, you understand the goal and the strategies, you agree to the measures, but then you can identify, ``Okay, if that's what we want to accomplish, what's my part? What can my organization do? What can I bring to bear? And how can I measure our own contribution to the overall goal?'' And I think that's fundamentally what we're learning to do. UNICEF and the U.N. is an amazingly important convening force to get us all around the table to decide and contribute to the goals and the strategies, but once those are established, then the network is, in a sense, self-governing, because we know what we're supposed to be doing, and we work really hard to be an effective contributor to that effort. So, it's a different way of thinking. It's also a different kind of leadership, because it isn't that ``I'm the boss'' sort of leadership, it's ``What is my collaborative role here, and how can I influence and bring other people to point in the same direction?'' The Chairman. Mr. Kunder. Mr. Kunder. Mr. Chairman, I'm very glad you asked us for our reflections rather than the answer. [Laughter.] Mr. Kunder. As you know, we've just had the committee lead us in a lot of discussions on how we can coordinate even better, even within the U.S. Government. And this larger question of how we communicate to the international communities, interventions, is critical. I would agree with Ann Veneman that part of this is the framework of the Millennium Development Goals, because we do have an overall framework. And I would very much agree with Jim Morris that we--however we look at this--have to keep the local, the country leadership, out in front. Because if we all come in from outside and have a great coordination plan, but if there's no buy-in at the country level, it's not going to be sustained. And I found myself agreeing with Dr. Gerberding, as well, that part of this is a systems approach. And one of the things we tried to point out in my testimony, is that, for example, in USAID's work to try to do more with food fortification, part of the problem is to pull apart these complex issues, like child survival, and then really target the objectives on the component problems, because while we're dealing with global initiatives, global problems, and global organizations, I've found that, certainly, there's an inverse relationship between the complexity of the problem and the amount of mobilization of resources and public support you can get around them. That's why, as Jim was saying, one of the successes of the polio immunization campaign is, in polio, you're targeting it. And what we're trying to do is, by focusing on initiatives like micronutrients or food fortification, the more you can target it, the better we can get the focused coordination. One last element that I think we haven't touched on--or maybe Jim touched on just briefly--that is absolutely critical, is we've got to get the private for-profit corporations involved. And, I mean, not just something bold, like the recent Gates-Rockefeller initiative on food production, but something like food fortification. This is a critical way of spreading the costs among producers and consumers, not just the taxpayers here or in Malawi. And in the private sector, I think we're just scratching the surface on the enormous resources that we can bring to bear on addressing this problem of hunger. Thank you, sir. The Chairman. Yes, Jim. Mr. Morris. Mr. Chairman, just one comment. Not answering your question about who's in charge, but--I believe the leadership of the United States of America is absolutely critical in making progress on the humanitarian agenda. For the United States to tell the world how important it is to address the Millennium Development Goals of reducing hunger and poverty for children, infant mortality, maternal health, HIV/AIDS, universal primary education, gender equity, and--the leadership of the United States on these issues bringing the world together to talk about these issues, and for the world to know how strongly our country cares about these issues. And, in fact, the United States has earned, and deserves, the opportunity to do that, shows great leadership on HIV/AIDS. Eighty percent of the research money for AIDS comes from National Institutes of Health, and PEPFAR has made the most remarkable step forward on HIV in the last 20 years. The McGovern-Dole school feeding program and of course Food for Peace, both demonstrate sustained unprecedented humanitarian commitment. And the world really, I believe, cries out for leadership from our country on these issues. The Chairman. Well, I agree. And let me just add as a footnote, without extending this particular question, but yesterday it was a privilege to visit with the President's new envoy to Sudan, Andrew Natsios, who is well known to all of you. He had many comments to make about that intervention and this potential for success. But one of the elements of this is a very practical one, that from certain tribes in the south who have been very badly disadvantaged in the turmoil, about 2 million livestock have been taken. Now, in short, this is not only a question of people shooting at each other, but, in a very, very severe systemic way, the livelihoods of all of those tribes, without their livestock and without their land, is very grim. They could have some existence in refugee camps for periods of time, at the sufferance either of the government or of the rest of the world that might be able to inject some food and nutrition, some hope, into that situation. But we are faced--as a Nation, or as a world, as the case may be, if there is to be some equilibrium and some future for all of Sudan-- with the replacement of about 2 million animals, in addition to land-equity situations and emergency feeding. And this is often the case, as Secretary Veneman has testified before, with agricultural situations. They are enormous, in terms of simply the productive facilities, the abilities of people to continue on a normal livelihood; in this case, it is very much akin to food. Let me ask this, because there have been, as some of you have touched upon, some recent remarkable initiatives with regard to fighting hunger. And specific mention has been made of the Gates and Rockefeller Foundations, and, in fact, a joint initiative of the two, for an agricultural Green Revolution in Africa, through programs that among other things, increase crop production and improve irrigation. In general, there's been testimony that the private sector in our country, corporate America, and others, ought to do more. What I find to be especially exciting in the past 12 months is the extraordinary outreach of private foundations, people who have extraordinary wealth that have decided to devote it to very important humanitarian causes. Now, what I would like to gain from you is some sense of how these initiatives, some of which are in the area of agricultural research and long-term or intermediate steps, as opposed to emergency ones or systemic feeding of people, fit. If there was more philanthropy, to what extent does it begin to fill the gap with regard to the financial resources and, in some cases, the organization of these efforts? Does anybody have a comment on that issue? Yes, Ann. Ms. Veneman. Well, I will be happy to attempt to address some of this. I think you bring up a very important point, and that is the new focus, particularly brought about by the Gates and Rockefeller Foundation, on the need to really address the root of the problem, the root of hunger, in terms of food production. In 2003, I held a Science and Technology Conference in Agriculture, ministerial conference that brought together over a hundred countries, and almost 120 people at ministerial level. The main speaker, or one of the most impressive speakers, was Norman Borlaug, who, as you know, started the Green Revolution that was so successful in India. And he basically challenged, particularly the African ministers that were there, if we don't begin to address these issues in a systemic way and take advantage of new technologies, whether it's new seed varieties, utilizing fertilizers. One of the things that came out of that conference was the need for both water quantity and quality to produce food. But I think that there are so many opportunities to apply basic technologies, as well as better work with extension systems. As I've traveled throughout Africa, one of the things I've seen--you see extension stations, but they don't seem to be having the kind of work and impact that they once had. The other thing that came out of this conference we had in 2003 was, one of the--one of the findings was that the foundations, like the Ford Foundation and the Rockefeller Foundation, weren't engaged in food production and agriculture, like they once were. And so, as this Gates-Rockefeller initiative comes forward, I think it's a very important new development to recognize how important it is, particularly for Africa, to have the kind of thing, a Green Revolution, to address the issue of food production, because I think whether it's--you know, in some places, we see overpopulations of cattle, because cattle are the measure of wealth; they don't put their money in the bank, they--you measure your wealth by how many head of cattle you have. In other places, like you indicated, the Sudan, where they've lost their only, really, source of wealth by losing all of their cattle, so the agriculture end and, sort of, economic development of wealth generation becomes very intertwined with the issue of proper nutrition and hunger. I think it's extraordinary what Gates is doing, what Warren Buffet is doing, what others are now doing. And it's not just private foundations. It's, how do we address corporate social responsibilities? How do we better engage universities to work together? How do we build capacity in universities in developing countries to help address some of these issues? And I think all of these are critical as we move forward. The Chairman. Yes, Mr. Ward. Ambassador Ward. Mr. Chairman, I think that the initiatives that we've seen in recent months by the Gates Foundation, the Rockefeller Foundation, and other foundations, are very, very important, especially because they are focusing on using technology to find new techniques and new ways of solving the problems that we all face. What will be important as we move into the future is to find ways of disseminating that technology in a sustainable fashion, and I think that's where governments and international organizations and NGOs can play a large role. The--for example, the Millennium Villages Project, which is run out of an institute at Columbia University, is a project which is attempting to bring in new agricultural technologies to villages in various areas in Africa. We're partnering with them in a way--to try to see if their scope for socializing these techniques into our community development projects, our area development programs throughout Africa, so as to give them roots within the community and make them sustainable, so they'll go forward on their own. The Chairman. Ms. Gerberding. Dr. Gerberding. Just thinking a little bit more generic, you know, we are thrilled with what's happening with Gates and Buffet, from a CDC perspective. But, to me, it reflects on two out of the three most important things we need to do to solve these problems. And you've mentioned innovation. And I think the ability of the private sector to innovate probably exceeds even that of some of our government research enterprises, in that what this allows innovators to do is to take some risks. And it's very difficult to take risks with government dollars, but it is possible to take risks and stretch your brain and get out of the box with these private-sector enterprises, because that's what they expect us to do, and they understand why that's important. So, the innovation is definitely a part of this. But, also, it's the scaling. And if you want to scale up a problem solution that you have in one area, you have proof of principle, and you want to make it more widely available, there are not too many options. One is, you can get more investors. Another is, you can get more money per investor. And third is that you can get more value for the money that you have. And I think these large-scale investments, whether it's the U.S. Government through PEPFAR or the Gates-Buffett enterprise, the Global Fund, some of the private-sector opportunities that are coming to the--into play now, really allow us to scale in one those three ways, in very exciting ways. I don't think any of us have ever really been more excited that there is a much more tangible possibility of solving some of these huge problems now with this scaling opportunity that we have. But the third thing--innovation scale--the third thing really is the issue of sustainability. And that, I think, we have some ideas about what is the requirement for sustainability. But I personally believe we need much more work in this area, and I would really look forward to learning from my colleagues on how we can support a more sustainable uptake of these opportunities that are in front of us now. The Chairman. To underline your point, before this committee we've had testimony with the Gates Foundation and their fight against HIV/AIDS, that some type of inoculation for prevention is possible, and even suggesting, maybe, within a 10-year period of time. And just to underline your point--this is not exactly relevant to nutrition, but it is, in various ways, as we've seen the intersection of this--but this type of intensive research, with the risktaking that's involved, all of the paths that don't work out, combinations that don't register, perhaps could only be done by private initiative, private foundations. So, the intersection, now, of these large sums of money and this leadership is probably a very, very important development. Let me ask you for your comment, Mr. Kunder, and then I'll recognize my colleague Senator Sarbanes. Mr. Kunder. Just very briefly, sir. I--first of all--have just two comments. One is, there are still some very basic research agenda items that--have to be completed, and we're still looking at what's the optimal combination for food fortification. And some of this is basic social marketing research. I've included some examples in my testimony of the kinds of things we're using for fortification around the world. It could be fish sauce in Vietnam, because that's what we've found is the most culturally appropriate way to get these micronutrients into the diet. And there are still tens of millions of children who don't have properly iodized salt around the world. So, there's some low-hanging fruit that still has to be done. So, my comment is, as we rush to the future, we've still got some basic problems to solve, and those require funding, and they require some not-very-glamorous solutions, but they're critical to improving children's nutrition. Thank you, sir. The Chairman. Excellent point. I'd like to recognize, now, Senator Paul Sarbanes, the distinguished member of our committee from Maryland. And would you please proceed, Paul, with your statements or questions or comments on this. Senator Sarbanes. Well, maybe I'll fuse the two together Mr. Chairman. The Chairman. Excellent. Senator Sarbanes. First of all, I want to commend Senator Lugar for holding this hearing. I think it's an extremely important hearing. And I want to underscore something he said in his opening statement, and I'd just quote him, very quickly, here, ``Although famine and starvation are the most severe and visible forms of hunger, poor nutrition, which often goes unnoticed, can also be deadly.'' And he goes on to develop the point about the critical link between malnutrition and poverty, how it really handicaps young people as they try to move ahead, in so many ways. So, I think it's an extremely important point, and it underscores the breadth of this problem. I'd like to ask the panel this question. Regrettably, the budget submitted by the President in fiscal 2007 reduced funding for a number of programs that involve child survival and health. The Child Survival and Health account itself was substantially reduced. Development assistance was reduced. International disaster and famine assistance were reduced. There was a massive increase requested for the Millennium Challenge Corporation. Now, I support the Millennium Challenge Account, but I think there is a disproportionate amount of resources being provided to it. And, of course, the MCC has a large pipeline, because they haven't been able to move the funds. At the time that that program was sold to the Congress, it was asserted that support for the MCA would not come at the expense of established development programs, including those designed to combat child hunger around the world. Now, regrettably, that's not been the case, and I am interested in hearing, from the panel, how severely you feel these existing programs have been impacted by the diminishing of resources available to carry the programs forward. Mr. Kunder, why don't we let you come last, since---- [Laughter.] Senator Sarbanes. In the---- Mr. Kunder. Sir, as you well know, I'm here both as a administration witness and as a USAID witness, so you've put me right on the cusp of---- Senator Sarbanes. All right, in the spirit---- Mr. Kunder [continuing]. This critical issue. Senator Sarbanes [continuing]. Or rebuttal--no, I'll start over here with Mr. Ward and come across the panel. [Laughter.] Mr. Kunder. Sir, I'm more than glad to take a crack---- Senator Sarbanes. Yes. Mr. Kunder [continuing]. At it. Senator Sarbanes. All right. All right. Mr. Ward. Ambassador Ward. Yes, thank you very much, Senator. I think we need to look at this question in the context of the overall move by the administration to reform foreign assistance, and to reorganize foreign assistance. Oh, and the-- I think, NGOs, in general, applaud the administration's intention to rationalize some of the processes around foreign assistance, but we look at the process with a bit of trepidation, because, as we look at the priorities set forth in the foreign--various foreign--in the foreign assistance program, we would feel more comfortable if some basic humanitarian needs were given a bit higher priority than they seem to be, although we've had assurances that humanitarian needs will not be neglected, and we appreciate the increases that we've had in the past. However, in the current budget, for example, food aid is-- the proposal for food aid is, we believe, far short of what the requirements for food in the coming months will be, and we believe that the Title II appropriation should be around $2 billion, which would provide for both relief and development needs under Title II. And yet, the administration has not requested that amount, given the--I suppose, the fiscal constraints. But we would like to see the amount for food aid programs increased so that we could address some of the childhood nutrition programs that we've talked about today. Senator Sarbanes. Yes. Ms. Veneman. Ms. Veneman. Thank you, Senator Sarbanes. I haven't studied the budget in detail, so I don't feel confident to comment on the specifics. I would say that UNICEF is very grateful for the tremendous support of the U.S. Government for the work that it does in education, in health, in nutrition interventions, which are--have absolutely been critical. And the United States is UNICEF's biggest donor. But I would comment, just for a moment, on the MCC, because I recently, in--at the end of July, was in Ghana, just before the MCC agreement was signed between the State Department and the president of Ghana. And one of the things I asked, in some detail, in meeting with the officials in Ghana was, what kinds of programs will the MCC fund? Will they be consistent with, you know, support for things like education, improving healthcare systems, particularly for children, and so forth? And I was very pleased that the kinds of things that the MCC was investing in, the kinds of programs they were negotiating with governments, are very consistent with the kinds of things we are collectively working on to try to address, to improve the lives of people who are living in poverty, and particularly children. So, again, I think that we need to look at all of the kinds of assistance, as a whole, to see whether or not the goals are being achieved. Senator Sarbanes. Mr. Morris. Mr. Morris, I might note that you wrote a very moving column in the Washington Post, back in the spring, and you started off that column, and I quote you, ``The U.N. World Food Program recently had to make a terrible decision, one that would give even King Solomon pause: either to halve''--cut in half, halve--``food aid rations for almost 3 million people in Darfur--one of the world's worst humanitarian emergencies--or halve the number of recipients.'' And it helps to underscore this problem, I think, that Chairman Lugar outlined in this opening statement. But how do you see this situation? Mr. Morris. That particular decision in Darfur was a decision to go from allocating 2,100 calories per day per person to 1,100 calories per day per person, because we had to be confident that we had at least 1,100 calories per person through the long rainy season. At that time, the United States was providing 85 percent of what we had to work with in Darfur. The United States is overwhelmingly our most generous partner in Darfur and the rest of Sudan. In August, we fed 2.6 million people in Darfur. We couldn't get to another 400,000 because of the violence in Darfur, but continued to support another 230,000 refugees across the border, in Chad. This is, of course, a situation that cries out for a political solution. These were people that were leading good lives, by their own standards. They want to go home, but they're afraid to go home. I've spent a lot of time in Darfur, and I've never seen people so frightened. But we were able--after we had that intense period of advocacy, to get back to a point where we were providing people about 1,850 calories a day, 85 percent of what they needed. But we're about to face that same predicament again over the next 90 days. Sir, as it relates to your basic question, I just have these thoughts. The McGovern-Dole School Feeding Program, one of the great things that the United States Congress has done, is an extraordinary example of people on both sides of the aisle working together with their focus on people who were at risk. It started off with a $300 million annual appropriation. It's now down to something in the neighborhood of $100 million. There is no more powerful investment this country could make in seeing that children are fed and go to school. The long-term benefit of that short-term investment is enormous. And the School Feeding Program is incredibly important. Earlier, we were talking about Norman Borlaug. I would remind you that Norman Borlaug is a graduate of the University of Minnesota, the United States Land Grant College system. This remarkable man had this opportunity to change the world because of his experience at the University of Minnesota. There is nothing much more important than a continuing, sustained, growing investment in bringing the best young minds in our own country to become competent in agricultural technology and research, and we have to find a way to continue to bring the emerging agricultural leadership from around the world to study at our universities in our country. I was in Auburn this week. I'm close to Purdue. The contributions American higher education and the land-grant system can make are remarkable. Now, there was a profound change in the world, the last 25 years--by and large, weather-driven. If you look at the report the World Bank produced for its spring meeting that talked about the change in natural disasters in the world, it said that in 2005 there were 400 natural disasters, compared to 100 in 1975; 2.6 billion people affected by natural disasters during the 10 years preceding 2005, compared to 1.6 billion during the 10 years preceding that. The World Food Program used to be 80 percent development/prevention/mitigation/moderating program. Today we are 80-85 percent engaged in responding to natural disasters. And so, this limited pot of money that is available has been heavily skewed to saving lives in an immediate set of circumstances, as opposed to investing in programs around the world that, long term, once again, have a huge payoff. We have a lot of experience working in Ethiopia, where a very small investment of a few tons of food changes a community. And still we are trying to respond to the tsunami and to the Pakistan earthquake as well as the terrible loss of livestock in Sudan, which Senator Lugar mentioned. Well, the same thing has happened in northeast Kenya. You know, the pastoral way of life in northeast Kenya has been obliterated. If you go there, you just see the landscape replete with animal carcasses. We used to spend 12 percent of overseas development assistance on investment in basic agricultural infrastructure. Today, it's 4 percent. Now, the United States, Canada, and the United Kingdom are beginning to turn that around, but there is no substitute, either on a macro or a micro basis, for investment in basic agricultural infrastructure. So, I would say that the United States is very good to us, overwhelmingly good. But the magnitude of the issues that we are faced with--juxtapose the natural-disaster issue, with the conflict in the world. For instance, we fed 735,000 people in Lebanon in the last 6 weeks. Then you add the HIV/AIDS issue on top and you can see--the world is facing unusual challenges. Senator Sarbanes. Dr. Gerberding. Dr. Gerberding. I wish I had studied the big picture of the Federal budget for this before I got here, but I didn't, so I can't give you a direct answer to your question. What I can tell you, from the CDC perspective, is that we have not had a cut in the dollars that we have available for our contribution to these activities. But we do agree completely with this concern about the balance between the new urgent threats that we are responsible for and the long-term urgent realities of the problems that we need to handle. And because of the times that we're operating in, and because of the terrorism issues and the pandemic concerns and the natural disasters, we have seen an unbalancing of our investment much more in the direction of urgent threats. And I think all of us need to step back and say, what are we going to do about the urgent realities? We can't continue to pull on the same pie, when we've got new challenges that are confronting us. The other point I would like to make, from a CDC perspective, is that we have, I think, learned something remarkable in the context of the PEPFAR program, and that is that when you invest, you get results. And that program is succeeding in achieving its results, because it had clear goals and strategy, but also because we scaled the investment to the scope of the problem we were attempting to consider. And I think, unlike, maybe, in past eras, when there was always a question mark, ``Well, what is this money really doing?'' or, ``Are we really having an impact?'' we have now, I think, developed irrefutable evidence that when you properly invest, you get the true results, on a macro scale that you're looking for. And I feel very proud of CDC's contribution to that, but I also feel like I can look you in the eye and say, if you invest here, we can deliver what you expect, and it will be a good value for the American taxpayers, to consider these kinds of longer-term investments. Senator Sarbanes. Mr. Kunder, let me just sharpen the question a little bit for you. I'm concerned that the international NGOs that have been working in this field are geared up to function at a certain level. They bring a lot of expertise, a lot of committed and trained manpower and womanpower. They raise some money privately to increase the amount of resources that are available. If U.S. Government support for their programs is reduced, then they're placed in a very difficult position. They have this capacity that's been built up. They have an available infrastructure. And then, they're not making full use of it, which seems to be, if nothing else, wasteful. I mean, there's an opportunity there that is, sort of, being lost, where you can get a benefit at a relatively small marginal or additional cost. And that's my perception of one of the consequences of these reductions in the budgeted amounts that are reflected in the submission by the administration. So, I'd like you to, in addition to the broader point, address that point, as well, if you would. Mr. Kunder. Yes, sir. I'm going to try to answer your question very directly and very specifically, because it's an excellent question. In my honest perspective of what's happening right now--back to this question of, sort of, Millennium Challenge Account and traditional accounts--in his new role as director of foreign assistance, what Ambassador Tobias is trying to do is take a look at what the U.S. Government is doing, in total, in any given country, trying to apply the same kind of methodology that was developed in the PEPFAR program over to the broader foreign assistance program, demanding detailed country operational plans from each of our mission directors, and, in fact, from the ambassador in the country, trying to get a better look at all of the funding streams, the refugee funding stream, the democracy and human rights funding stream, the USAID funding stream and the PEPFAR funding stream. Now, some of these are not under his direct control, like the Millennium Challenge Account, because it's a different statutory basis, but---- Senator Sarbanes. Now, the Millennium Challenge Account requires a country--I don't quarrel with this objective-- requires a country to do a number of things---- Mr. Kunder. Yes, sir. Senator Sarbanes [continuing]. Including having in place a government that is proceeding according to bona fide and accepted---- Mr. Kunder. Yes, sir. Senator Sarbanes [continuing]. Standards, correct? Mr. Kunder. Yes, sir. Senator Sarbanes. All right. Now, what do you do about hungry children in a country that doesn't have such a government, and, therefore, is completely outside of any possibility of qualifying for the Millennium Challenge Account? If you're shifting all your resources to the Millennium Challenge Account, you set out these criteria--I don't quarrel with the criteria; it's just where we put the resources, and to what extent. What happens to hungry children in countries that couldn't begin to qualify for the Millennium Challenge Account? Perhaps they have a dictatorial, autocratic government. Some of these programs have been able to work in those countries in order to address, specifically, the problem of hungry children. Mr. Kunder. Yes, sir. Senator Sarbanes. Now, what happens to hungry children in those countries? Mr. Kunder. The only thing I want to point out, sir, is that this new system is attempting to take a look at whether we're spending all the U.S. resources wisely to meet our total priorities, including humanitarian priorities, and including investing in people. And my honest perspective is that the jury is still out, in terms of how this new process is going to work--that Ambassador Tobias, my boss, is leading--in terms of how we're going to allocate total U.S. Government resources. Many of my USAID colleagues are concerned, going into the process, that investing in people would come out on the short end of the stick, quite bluntly. And what I've seen of the process, so far, is that it has not gone in that direction at all. And, of course, I'm talking about the entire list of U.S. foreign-assistance recipients, which far exceeds the number of Millennium Challenge countries around the world. So, what we're going to have to do, I think, the Congress and those of us in the administration will now take a look at the totality of the resource allocation--Millennium Challenge Account and this new system being put in place by Ambassador Tobias--and see if it does align with the priorities. In my view, what I've seen so far, it looks like it is. I take your point that if we're taking some resources off the top for Millennium Challenge Corporation, then that has to be put into the scale, as well. But, as Ann Veneman just said, from what we've seen so far, there does appear to be investment of those funds into this broader issue of investing in people, as well. But the jury is still out, because we haven't gone through a full cycle of this new paradigm. Senator Sarbanes. We've had, and continue to have, established programs to deal with some of these problems, that seem to have worked fairly well. And my perception now is that the resources devoted to those programs is being reduced. That's what the budget reflects. Now, the amount being committed to the Millennium Challenge Account has been significantly raised. At the time the account was argued to the Congress, we were told that it wasn't going to result in diversion of resources. These were going to be new resources, an initiative of further commitment. Now, the amount of money being given to the Millennium Challenge Account is quite high. The amount they've been able to expend is much lower. There's a big reserve there. Now, they say to you, ``Well, we're going to spend the funds. We need this reserve, we're moving ahead,'' and so forth and so on. They keep projecting times when they will have caught up on the reserve, and so forth. But that keeps getting extended out, that projection. All I'm suggesting to you is that you shift some of that money back to these existing programs. Let these NGOs go about their business. Now, we've managed, in the Congress, to get funding for UNICEF back up, every time; but the budget comes in with cuts to UNICEF. We've made some adjustments for some of these other programs, but we haven't succeeded in doing it entirely. And, of course, the administration's budget request always has an initial momentum. So, I'm simply suggesting to you that you take a harder look at this and see if we can't get these programs back up to their previous level so they can move ahead. From what I hear, it's tremendously dispiriting to the NGOs, and other groups that work off of these contributions, to confront this situation. You can examine new approaches all you want, but at least let's keep these other approaches working. I mean, this is a real problem. You have a current crisis. And as has been pointed out by the chairman in his statement and people at the table, you're building a future crisis, too, by falling short. Mr. Kunder. Yes, sir. Well, message received. I mean, as Jim was just saying, part of the issue here is that our budget at USAID reflects the problem that he was mentioning at World Food Program: To some extent, money that we had been putting into nutrition programs and development programs, because of the large number of crises in the world, has been diverted into immediate response. But, long term, we certainly understand the value added of the NGO community, and none of this is intended to disadvantage the NGO community or fail to leverage what they bring to the table. Senator Sarbanes. Well, Mr. Chairman, I, regrettably, have another hearing. This is a tremendously important subject, though, and I, again, commend you for raising it, as well as for the way you have pursued it over a sustained period of time. This has been very important leadership. Before I leave, I want to say, I understand, Mr. Morris, that, shortly, you're going to be retiring as executive director of the U.N.'s World Food Program. I understand the chairman has already made some comments about that, but I think I would be remiss if I did not add my own thanks for the contributions you've made. You've really done a valiant job over the years, and we're very grateful to you. And there are a lot of children around the world who are grateful to you. Thank you very much, Mr. Chairman. The Chairman. Thank you very much, Senator Sarbanes. We really appreciate your coming today. Mention has been made, during the responses to Senator Sarbanes, of the McGovern-Dole program. Obviously, you would all be in favor of it. I would ask if you have any further advice about the situation. Mr. Morris has outlined the diminishing amounts of money coming from our Government, and obviously there are many reasons why this may be so. I just wanted to ask if anyone else on the panel has a comment on the McGovern-Dole program. Yes, Mr. Ward. Ambassador Ward. Well, Mr. Chairman, I would just cite an example in which this tremendously important program is helping in ways that actually go far beyond just the provision of food and nutrition. In Afghanistan, girls had been--were denied, under the Taliban, access to education. And one of the major goals of the coalition in Afghanistan, and of NGOs that are working there, is to increase the access of girls to formal education, and to also help women who were teachers in the past to find their way back into the teaching profession. And it's been through a program funded by McGovern-Dole that we've been able to benefit young girls in grades one through three by keeping them in school and also sending them home with food rations that benefit them and their families. This has materially reduced problems, such as diarrhea and constant vomiting, that are endemic in rural Afghanistan, and has really created a new sort of environment in which there can be a culture of learning for girls, as well as boys. So, this is an incredibly important program, and we certainly support it and are grateful for the assistance, for our ability to access it. The Chairman. Just let me indicate that, as Senator Sarbanes' questions indicated, we've had debate within the committee. The Millennium Challenge budget comes before our committee, and we've been supportive of that effort. Now, sometimes the argument has been made that this subtracts from various other categorical grant programs. And, as Mr. Kunder has said, there is an attempt on the part of the State Department to rationalize, with Ambassador Tobias now, all the programs. It was a bold initiative, in my judgment, by Secretary Rice. The jury is still out on how all this works, what finally occurs. And Mr. Kunder is a large part of trying to make certain it does work well. But this is certainly a debatable area, as to how allocations go. And when we get over to the Agriculture Committee and the budget there, we have a whole new set of arguments, a potential new farm bill next year. Many groups have pointed out this offers a remarkable opportunity, in terms of nutrition in this country, as well as abroad, which, indeed, it does. So, these are important issues to be before the Senate, and the Congress as a whole, as well as the administration, because, essentially, eventually people negotiate and try to work out, really, what the resources are that are going to occur, and in what form. And that's the reason we've initiated that question as a part of this panel. Let me just ask, maybe as a final summary question--we've raised the issues of the first Millennium Development Goal. And Secretary Veneman and UNICEF provided this report, Progress for Children, a report card on nutrition, as of--and this is number 4--as of May 2006. All of you, I'm certain, have seen the report. Maybe there are other reports that offer indicators of progress. Who's in charge? How do we organize this? How do we know what is occurring? And at least this report does have maps and statistics, and so forth. Let me just ask, first of all, for reaction that any of you might have to the report. And, second, are there other reports, or is there other data, that ought to be made a part of this record so that at least at this benchmark time, as we have oversight of this area, we're aware of that and can include that in this record? Secretary Veneman, let me ask you, first of all, to comment on the report you have thoughtfully produced and distributed to all of us. Ms. Veneman. Mr. Chairman, I appreciate this question, because I think--as I said earlier, I think that being able to access data, the best available data, to determine where the gaps are in reaching agreed goals is absolutely critical to putting resources in the right places. UNICEF began this process awhile back to take--we do two of these Progress for Children reports each year. The Chairman. I see. Ms. Veneman. And we began a process awhile back of taking each Millennium Development Goal that applies to children--we like to say ``Children are at the heart of the Millennium Development Goals''--and to address each of those issues separately and to measure the progress that we know has been made, or not made. On Thursday, I will be releasing the next in the series. It will be on Millennium Development Goal 7 and the target, particularly, on water and sanitation. The Chairman. Is that what the area is, on 7? Ms. Veneman. Right. The Chairman. Water and sanitation. Ms. Veneman. Well, it's on environment. The Chairman. I see. Ms. Veneman. Millennium Development Goal 7 covers the environment, generally, but water and sanitation, and reducing the number--I mean, the percentage of people without clean water and sanitation, is the--one of the key targets there. It will show that the world has made considerable progress in addressing the issue of clean water. Sanitation is much further behind. But, in fact, all of these issues, as you know, really intersect with each other. I mean, as we've talked about today, clean water and sanitation are critical to whether or not a child actually can maintain accurate--or adequate nutrition, because if they have diarrheal diseases, obviously they're going to suffer from malnutrition, as well. And so, we are looking--we, just last week, held a big symposium on MDG4, child survival. And, again, the progress is very uneven, but we are seeing some promising programs that do, with an integrated, you know, nutrition-and-healthcare approach, begin to reduce those absolute percentages in so many of the areas. I think one of the most difficult has been maternal mortality, very difficult to both measure and to get good results. Education, I think the--we've done a report on education, showing that the world is making tremendous progress in universal primary education, which is the measure of the education goal, although it is lacking somewhat in the overall gender-equity goal, and, particularly, there are still less girls than boys in school, and that is something we have to address worldwide. So, I think as you look at the whole range, it is important to look at the progress and see what kind of actions we need to take in the next 9 years, before the deadline of 2015, to make these a reality. I think if we all have a sense of urgency, we can do it. The Chairman. Mr. Morris. Mr. Morris. I would call your attention to this remarkable document that UNICEF produces each year, the State of the World's Children. In terms of an analysis, as well as a factual report on annual progress, this is the bible in the world. I would also call your attention to our publication this year, Hunger and Learning, which is one of the undergirding documents of the Ending Child Hunger Initiative. [Editor's note.--The publication mentioned were not reproducible in this hearing but will be maintained in the committee's permanent record.] Reform of U.S. overseas development assistance is really important, and I would hope that one of the longer term measurements, on how the reform works is a measurement of the outcome of improving child nutrition around the world. This is at the base of all the Millennium Development Goals--hunger and nutrition--you can't make progress on any of them if people are starving and poorly nourished. And my final comment, sir, would be, as we talk about sustainability. I don't believe there is any better approach to people being able to sustain themselves, than to be healthy, to be well nourished, to be educated, and to be productive. That gives them the capacity to take care of themselves, to sustain their families, and ultimately their communities. We have a huge debate about sustainability, but, I don't know how you fill the bucket up, other than a drop at a time or addressing the issues a child at a time. And the fact of the matter is, parents around the world are the same as they are in Indiana. They care about their kids. And when they learn that washing hands with soap works, they'll buy the soap. And communities, when they learn that children are fed at school they will build new schools and their parents will volunteer, just like they do in our hometown. And this is not only the essence of community-building, but also the essence of sustainability. Thank you. The Chairman. Yes, Mr. Ward. Ambassador Ward. Mr. Chairman, I would just like to comment on the importance of having really good data about outcomes in our programs. And that is not an area in which, in the past, either governments or NGOs have excelled. We know how much money we've put in. We have, in the past, not always known what's come out. And we've realized this at World Vision, and, some years ago, we formulated a series of transformational development indicators that are very concrete. We're looking now at how those transformational development indicators and the Millennium Challenge Goals can really come together. And we're using them in our programs to provide--and we survey each of our programs every 3 years--to provide measurable data. So, over time, we'll be able to present to our--to the growing group of Americans who are concerned about these issues, through vehicles, such as the ONE Campaign that unites NGOs and private industry and so many others in advocacy for the poor, will be able to present hard data that will hopefully be compelling and provide a consensus for moving forward on these issues. The Chairman. Dr. Gerberding. Dr. Gerberding. Just a quick observation. I couldn't agree more with the importance of data and science and evidence being, ultimately, the driver of all this, but I think we've used data for a long time to try to draw attention to the problems. I started out with some data about the number of children who die from various conditions every day around the world. But I think it's now time to use that data to deliver the solutions and to let people know that it isn't just about the problem. We know what to do. We have the solutions, and it's a good investment in their resources to help us move those solutions out into broader and broader communities. Success sells. And I think we need to put as much emphasis on what does work as we do on what are the problems remaining to be solved. The Chairman. Mr. Kunder. Mr. Kunder. Sir, we make available an annual report to the Congress on the Child Survival and Health Account. I think this gets at some of the questions of Senator Sarbanes--that is an overview of how we are spending the money that the Congress has entrusted to us in this area. Also, in preparation for this hearing, one of the documents I read was something called Infant and Young Child Feeding. It's what USAID calls a ``program and technical report.'' We'd be glad to make that available to the committee, as well, for possible incorporation in the record. [Editor's note.--The information mentioned was not reproducible in this hearing but will be maintained in the committee's permanent record.] Mr. Kunder. But it's a primer on some of the critical issues that we've been discussing today. The Chairman. That would be very helpful. Let me just offer, anecdotally, that one of the great points of emphasis of our committee has been governmental corruption, or corruption of delivery systems. We've taken a look at the inter-development bank businesses and the World Bank and elsewhere. And the World Bank meeting has just been seized with this problem in which there was quite an international conversation about the rigor that the World Bank and its bureaucracy ought to have with this. But it was a healthy conversation, I think, with a good outcome. For other purposes, we went to study weapons of mass destruction in Albania, 2 years ago. I found one of the great preoccupations of the Albanian Government was the Millennium Challenge program. Albania had not been on the list of countries being considered. And one reason was the pervasive corruption in almost all elements of that government with a closed society that had opened up but had all sort of problems. But the fact was, the Albanians, seeing this program, wanted to know, ``How do we get in line? What do we need to do?'' And they appreciated that in order to do that, they would have to clear up the pervasive corruption in their government. We could hardly have asked for more than governments that were not even involved in our programs to be seeking to be a part of that situation. I returned this year, and they've made a lot of headway. They are on a provisional list, sort of a watchlist of people taking a look, now, very carefully. But there was no data from Albania. The data from Albania now is just beginning to come in. And, as you've all pointed out, there are gaps in the reports that we have looked at in which data are just not available. This always leads us to believe, here on this committee, as we examine international organizations, even reputable banks and so forth, that without there being this kind of oversight, this determination, on the part not just of our country, but the world, to monitor the delivery of the services--Does the bridge get built? Does the road ever happen?--quite apart from whether the food is delivered. Now, each of you have these problems in the organizations that you head, or that you supervise. And they're not easy. And the farther out you get into various difficult areas of the world, the more that's going to be a problem. And, in some cases, maybe you have to make compromises, that in order to feed starving people, whether you're fastidious to a fault, that somebody actually puts it in that place, to that person, it sort of breaks down. But I raise this point, because I think it is important that there are world standards that I believe are improving for both data--reporting--and at least the perception of corruption, if not the rooting out of it. And our committee reports on this corruption did not really make great waves in this country. But I would just say, abroad, this really created some waves as the free press, or not so free press in some places, began to pick up on this. And just making Mr. Morris's point again, or Ms. Veneman's, often the country itself has to take some responsibility for the plan, as well as for the execution. And to the extent that there is a more visible free press or NGOs really are pervasive, in terms of their outlook, the quality of that delivery and what actually happens to real people in this life is likely to improve, we think. So, all of these things are interrelated, and we've taken advantage, maybe, of a conference or a hearing today on world hunger to try to make that point about these intersections, both governmentally, as well as even in the cultures, various governments. Let me ask, before we conclude the hearing, if anyone has a final comment that you would like to make that would be a part of our record today. Yes, Mr. Kunder. Mr. Kunder. If the committee would just indulge me for one minute, sir. All of us lead organizations, have really courageous and highly skilled technical people in the field, and I just would like to note, for the record, that two of our staff were killed in Nepal during the helicopter crash in the last couple of days--Margaret Alexander, one of our senior Foreign Service officers, and Dr. Bijnan Acharya, who was one of our Foreign Service nationals from Nepal, one of those folks who works for the U.S. Government and their own people around the world very skillfully and courageously. And all of us lead organizations where a lot of people have folks at risk all the time, certainly in Darfur right now, just appreciate the opportunity to mention this in front of the committee. The Chairman. Well, I thank you for doing so, and for that recognition. Well, we appreciate the witnesses very much, your original testimony, and your forthcoming responses to our questions. The hearing is adjourned. [Whereupon, at 11:15 a.m., the hearing was adjourned.]