[Senate Hearing 110-443]
[From the U.S. Government Publishing Office]



                                                        S. Hrg. 110-443
 
                             GLOBAL HEALTH

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

                                HEARING

                                before a

                          SUBCOMMITTEE OF THE

            COMMITTEE ON APPROPRIATIONS UNITED STATES SENATE

                       ONE HUNDRED TENTH CONGRESS

                             FIRST SESSION

                               __________

                            SPECIAL HEARING

                      MAY 2, 2007--WASHINGTON, DC

                               __________

         Printed for the use of the Committee on Appropriations


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                      COMMITTEE ON APPROPRIATIONS

                ROBERT C. BYRD, West Virginia, Chairman
DANIEL K. INOUYE, Hawaii             THAD COCHRAN, Mississippi
PATRICK J. LEAHY, Vermont            TED STEVENS, Alaska
TOM HARKIN, Iowa                     ARLEN SPECTER, Pennsylvania
BARBARA A. MIKULSKI, Maryland        PETE V. DOMENICI, New Mexico
HERB KOHL, Wisconsin                 CHRISTOPHER S. BOND, Missouri
PATTY MURRAY, Washington             MITCH McCONNELL, Kentucky
BYRON L. DORGAN, North Dakota        RICHARD C. SHELBY, Alabama
DIANNE FEINSTEIN, California         JUDD GREGG, New Hampshire
RICHARD J. DURBIN, Illinois          ROBERT F. BENNETT, Utah
TIM JOHNSON, South Dakota            LARRY CRAIG, Idaho
MARY L. LANDRIEU, Louisiana          KAY BAILEY HUTCHISON, Texas
JACK REED, Rhode Island              SAM BROWNBACK, Kansas
FRANK R. LAUTENBERG, New Jersey      WAYNE ALLARD, Colorado
BEN NELSON, Nebraska                 LAMAR ALEXANDER, Tennessee
                    Charles Kieffer, Staff Director
                  Bruce Evans, Minority Staff Director
                                 ------                                

 Subcommittee on Departments of Labor, Health and Human Services, and 
                    Education, and Related Agencies

                       TOM HARKIN, Iowa, Chairman
DANIEL K. INOUYE, Hawaii             ARLEN SPECTER, Pennsylvania
HERB KOHL, Wisconsin                 THAD COCHRAN, Mississippi
PATTY MURRAY, Washington             JUDD GREGG, New Hampshire
MARY L. LANDRIEU, Louisiana          LARRY CRAIG, Idaho
RICHARD J. DURBIN, Illinois          KAY BAILEY HUTCHISON, Texas
JACK REED, Rhode Island              TED STEVENS, Alaska
FRANK R. LAUTENBERG, New Jersey      RICHARD C. SHELBY, Alabama
                           Professional Staff
                              Ellen Murray
                              Erik Fatemi
                              Mark Laisch
                            Adrienne Hallett
                             Lisa Bernhardt
                       Bettilou Taylor (Minority)
                    Sudip Shrikant Parikh (Minority)

                         Administrative Support
                              Teri Curtin
                         Jeff Kratz (Minority)

                            C O N T E N T S

                              ----------                              
                                                                   Page

Opening statement of Senator Tom Harkin..........................     1
    Prepared statement...........................................     2
Opening statement of Senator Arlen Specter.......................     3
Prepared statement of Senator Thad Cochran.......................     4
Statement of Hon. Michael O. Leavitt, Secretary, Department of 
  Health and Human Services......................................     4
    Prepared statement...........................................     6
Statement of Dr. Stephen Blount, Director, Office for Global 
  Health, Centers for Disease Control and Prevention, Department 
  of Health and Human Services...................................    22
    Prepared statement...........................................    24
Statement of Dr. Roger I. Glass, Director, Fogarty International 
  Center, National Institutes of Health, Department of Health and 
  Human Services.................................................    29
    Prepared statement...........................................    31
Questions submitted by Senator Daniel K. Inouye..................    38


                             GLOBAL HEALTH

                              ----------                              


                         WEDNESDAY, MAY 2, 2007

                           U.S. Senate,    
    Subcommittee on Labor, Health and Human
     Services, and Education, and Related Agencies,
                               Committee on Appropriations,
                                                    Washington, DC.
    The subcommittee met at 9:37 a.m., in room SD-124, Dirksen 
Senate Office Building, Hon. Tom Harkin (chairman) presiding.
    Present: Senators Harkin and Specter.


                opening statement of senator tom harkin


    Senator Harkin. The Subcommittee on Labor, Health and Human 
Services, Education and Related Agencies will come to order.
    The subcommittee this morning will hold a hearing on Global 
Health. We will have two panels. For the first panel, we have 
the Honorable Michael Leavitt, Secretary of the Department of 
Health and Human Services, and on Global Health, on the second 
panel, will be Dr. Stephen Blount for the Centers for Disease 
Control and Prevention and Dr. Glass from the Fogarty Center at 
NIH.
    Senator Inouye once said that the Defense Appropriations 
Subcommittee is the subcommittee that defends America. He said 
this subcommittee is the subcommittee that defines America. In 
no case is that clearer than global health.
    When this subcommittee funds programs to end child labor 
abroad, or fight diseases overseas or improve health conditions 
in developing countries, it shows the world the best side of 
America.
    Now, for the past few years, this subcommittee has taken 
the lead on different sources of funding that addresses some 
global health problems.
    For example, since 2005, we've appropriated over $6 billion 
to upgrade our Nation's public health system, deploy 
epidemiologists around the world, and develop a credible 
vaccine supply to check a possible pandemic of influenza.
    In the last 5 years, Senator Specter and I have worked to 
fund efforts to prevent SARS, bioterrorism and smallpox. This 
subcommittee also appropriates money every year to the Global 
Fund to Fight AIDS and TB and malaria. Of course, when we fight 
diseases abroad, we're protecting our own country, as well. 
After all, it only takes one person on a plane to bring a 
deadly disease from halfway across the world to within our own 
borders.
    I hasten to add that global health is about much more than 
protecting Americans from deadly diseases--it's about providing 
basic public health infrastructure for developing nations, 
training researchers, epidemiologists, to strengthen the health 
systems in those countries. It is about working collaboratively 
on studies that can benefit people all over the world.
    With that, I welcome the Secretary here. We have an 
excellent panel of witnesses to discuss other global health 
efforts with us this morning, and before I turn it over to 
Senator Specter, I just add parenthetically, that it seems that 
in many cases, we look at things very broadly here--well, 
obviously, we have to, we've got a lot of things on our plate.


                           PREPARED STATEMENT


    But, I'm wondering, if we shouldn't be a little bit more 
laser-like, and focused on certain things in certain countries 
that are near to us, and near to us in proximity, in terms of 
our neighbors to the South, where we could establish long-term 
types of health infrastructures, that not only help people have 
better lives, but also--as I said earlier--show them the better 
side of America.
    With that, I would yield to Senator Specter for an opening 
statement.
    [The statement follows:]

                Prepared Statement of Senator Tom Harkin

    The Subcommittee on Labor, Health and Human Services and Education 
will now come to order. I'd like to welcome everyone here this morning 
for a hearing on global health. We have a distinguished panel of 
witnesses from the Department of Health and Human Services, headed of 
course by Secretary Michael Leavitt. Secretary Leavitt, thank you for 
joining us.
    Senator Inouye once said that the Defense Subcommittee is the one 
that defends America, but it is this subcommittee that defines America. 
I believe that's true not only within our own country, but throughout 
the world. When this subcommittee funds programs to end child labor 
abroad, or fight diseases overseas, or improve health conditions in 
developing countries, it shows the world the best side of America.
    In no case is that clearer than global health. For the last few 
years, this subcommittee has taken the lead on funding to prevent and 
prepare for a possible pandemic influenza. Since 2005, we have 
appropriated over $6 billion to upgrade our Nation's public health 
system, deploy epidemiologists around the world, and develop a credible 
vaccine supply.
    But this subcommittee was engaged in global health long before H5N1 
flu came onto the scene. In the last 5 years, Senator Specter and I 
have worked to fund efforts to prepare against SARS (severe acute 
respiratory syndrome), bioterrorism and smallpox. This subcommittee 
also appropriates money every year to the Global Fund to Fight AIDS, 
TB, and Malaria.
    When we fight diseases abroad, we are, of course, protecting our 
own country as well. After all, it only takes one person on a plane to 
bring a deadly disease from halfway across the world to within our own 
borders.
    But global health is about much more than protecting Americans from 
deadly diseases. It's also about providing basic public health 
infrastructure for developing nations, and training researchers and 
epidemiologists to strengthen the health systems in those countries. 
And it is about working collaboratively on studies that can benefit 
people all over the world.
    I want to describe just one example of a great global partnership 
that this Subcommittee was very involved in: the U.S.-China 
Collaborative on folic acid.
    The idea was hatched by a Chinese scientist, Dr. Li Zhu, who was 
visiting CDC headquarters in 1987. At the time, research suggested that 
folic acid could help prevent birth defects such as spina bifida, but 
no large-scale studies had been conducted. For a variety of reasons, 
Dr. Li Zhu thought China would be a good place to test the theory.
    This subcommittee began funding the collaborative in 1992, and data 
collection ended in 1996. Thanks to this study, we now know that taking 
folic acid during pregnancy can reduce neural tube birth defects like 
spina bifida by up to 70 percent. As a result, the FDA ruled in 1996 
that breads, cereals, and other appropriate foods must be fortified 
with folic acid, and the incidence of spina bifida has dropped 
dramatically.
    That study formed the foundation of the U.S.-China partnership in 
health. Chinese officials were so impressed with the work of our CDC 
that they named their own public health department ``China CDC.'' That 
partnership is now expanding into avian flu surveillance, respiratory 
illness and occupational injury rates. It is a true success story.
    We have an excellent panel of witnesses to discuss other global 
health efforts with us this morning. But before I turn to them, I would 
yield to my ranking member, Senator Specter.

               OPENING STATEMENT OF SENATOR ARLEN SPECTER

    Senator Specter. Well, thank you, Mr. Chairman.
    Good morning, Secretary Leavitt. This subcommittee is a 
continuation of a partnership which Senator Harkin and I have 
had now for many years, we call it a seamless exchange of the 
gavel as party control has changed.
    But, this subcommittee has been dedicated to funding for 
very important health initiatives, evidenced by the leadership 
that this subcommittee has shown on NIH funding, raising it 
from $12 to $29 billion, which we have done on--focusing on the 
problems of the stem cell, embryonic stem cell research. The 
subcommittee has been very active on global health issues.
    We truly live in one world--one world politically, and one 
world as far as health issues are concerned.
    We have had a number of hearings on the Avian Flu problem, 
which threatens our health in the United States, if it 
originates across the globe. The subcommittee, and Senator 
Harkin's leadership, put a range of $7 billion to find ways to 
combat Avian Flu. While it is not on the front pages today, 
thankfully, we're still very much concerned about it.
    This subcommittee has moved into areas which, earlier, were 
unnoticed, really. Global disease detection, had no funding at 
all, and has been moved into the $34 million range by fiscal 
year 2007.
    We have funded the Global Immunization Campaigns to 
eradicate polio and measles. This subcommittee provided the 
funding for HIV/AIDS, TB and malaria, since its inception in 
the year 2002. A total of more than $1.2 billion has resulted 
from the initiatives taken by this subcommittee, which have 
been subscribed to by the full committee, the Senate, the 
Congress, and signed into law by the President. We're very 
mindful about the humanitarian aspect, as we help Third World 
countries in our efforts to eradicate disease around the world.
    So, this is a very important hearing we're undertaking 
today. It is part of our continuing efforts to put a focus on 
health care, and we admire the work that you've done, Secretary 
Leavitt, and your personal attention.
    I might note, parenthetically, that the Secretary paid me a 
visit recently on Part D Medicare, and nothing like having an 
activist Secretary of Health and Human Services, and we have a 
very good one.
    Thank you, Mr. Chairman.
    Senator Harkin. Thank you, Senator Specter.
    We will insert the prepared statement of Senator Cochran at 
this point in the record.
    [The statement follows:]

               Prepared Statement of Senator Thad Cochran

    Mr. Chairman, I appreciate the efforts of this committee to ensure 
that the Senate and the public are educated on the important issues 
surrounding global health. Health issues that cause minimal problems in 
developed countries are continuing to spread in poorer regions. 
Millions of people, many of them children, die each year from diseases 
that are preventable or treatable.
    Global health plays an important role in the protection of the 
United States. This role is increasingly significant as we are faced 
with the possible pandemics, such as avian flu. Malaria is also a great 
concern as it is estimated that 300 million cases are diagnosed each 
year worldwide and 100 million deaths occur from malaria annually. 
Promising research in malaria drug development is currently underway at 
the National Center for Natural Products Research at the University of 
Mississippi to address this growing concern. Research such as this, and 
the development of a global health care network, ensures that health 
issues are brought to the forefront, and strategies developed to deal 
with them.
    I am pleased representatives from the leading global health 
departments are present on the panel today. I look forward to your 
testimony.

    Senator Harkin. Well, we welcome our Secretary of Health 
and Human Services. Secretary Mike Leavitt was appointed 
Secretary in 2004. Prior to that he was head of the U.S. 
Environmental Protection Agency from 2003 to 2005, and served 
three terms as Governor of Utah, from 1992 to 2003, so a long 
and distinguished public service.
    Mr. Secretary, welcome. All statements will be made a part 
of the record in their entirety, please proceed.

STATEMENT OF HON. MICHAEL O. LEAVITT, SECRETARY, 
            DEPARTMENT OF HEALTH AND HUMAN SERVICES
    Secretary Leavitt. Thank you, Mr. Chairman, and Senator. 
I'll just summarize, and look forward to getting into a 
conversation with you.
    As you point out, our Department's mandate is to take care 
of the health of the American people, but our mission does not 
stop at the shoreline. We have a responsibility, and our health 
is very much intertwined with the health of others. A healthy 
world is a good thing for America, and I would like, today, to 
say I think health diplomacy is an integral tool in our foreign 
policy, as well.
    I must say that I was somewhat surprised, as the Secretary 
of Health and Human Services (HHS), by the degree to which HHS 
is involved, internationally. HHS plays a leadership role in a 
lot of multi-lateral organizations, almost every one of our 
Operating Divisions is currently involved in some way in an 
international role. I'll highlight, just briefly today, a 
couple of those, and then we can get into more detail on the 
ones that you have the most interest in talking about.
    I'd like to focus on five diseases, to which we have paid 
particular attention--HIV/AIDS, of course, which we've 
mentioned here, tuberculosis, malaria, polio and then also 
avian influenza. HHS is a participant in the President's 
Emergency Plan on HIV/AIDS that is broken into many different 
parts. CDC, for example, provides expert field presence and 
support for surveillance and lab support in the delivery of 
care. NIH is helping to strengthen evaluations of outcomes. FDA 
has reviewed and approved over 40 generic anti-retroviral drug 
formulations. So, you can see that our HIV/AIDS efforts are 
spread all across the Department.
    Malaria is an issue that the President has focused on. HHS 
has been partnering with USAID to implement his Malaria 
Initiative (PMI). This year, there will be an additional 30 
million people that will benefit from life-saving treatment and 
prevention, thanks to PMI.
    Through CDC, the Department works very closely with the WHO 
and a number of other organizations, including Rotary 
International on polio. We have never been closer to 
eradication of polio than we are right now.
    You mentioned pandemic influenza--last year, the President 
and the Congress mobilized the country to prepare for a 
pandemic influenza, and our efforts continue.
    In summary, let me just say that it is my view that health 
diplomacy ought to be a foundation theme in our American 
foreign policy. People understand health care, it is the 
universal language, it speaks to their heart. It endears our 
country to them in very important and profound ways.

                      CENTRAL AMERICA INITIATIVES

    I would like to just deal specifically with one initiative 
that I've been working on, and that is in Central America. Mr. 
Chairman, you mentioned some of our neighbors that are close 
by--you can fly to Central America faster than you can get to 
San Francisco or Seattle from where we are right now.
    There's a great deal of movement between Central America 
and the United States, and for many of those countries, as much 
as 20 to 25 percent of the entire country resides in the United 
States, and they're moving back and forth. For some of those 
nations, as much as 25 percent of the Gross Domestic Product of 
the Nation is in transfers back from workers in the United 
States--there's a very direct link. So, the disease link 
between these two regions is enormously important.
    It's also an important region to have stable governments 
and stable societies. The healthcare needs there are 
significant. I've begun to identify this in my visits with 
health ministers from that region, and it's become clear to me 
that the United States can play a very important role in 
Central America.
    For one initiative I'll speak of briefly, we have 
identified facilities in Panama, in the old Canal Zone working 
collaboratively, and as a convener with the Central American 
health ministers, we have developed a school, a training 
facility, for the short-term training of medical workers. I'm 
talking about basic medical work.
    I was in Central America recently, and going through 
various hospitals, it became evident that they have a lot of 
medical equipment that's been donated to them, but when it 
breaks, nobody knows how to fix it. So this school, for 
example, will have a training class for 6, 8, 10, 12 weeks, to 
train people from the region to fix medical equipment.
    I took people from our Commissioned Corps, who are involved 
in the Indian Health Service in Alaska. We have a unique method 
of training people from native villages how to do dental work, 
basic dental work.
    When we took them to Central America and showed them the 
kind of work that was being done in those most remote areas in 
Alaska, they could not get enough of it--they want to have 
people from their remote villages trained to do the same thing. 
Oral health is a profoundly important part of keeping healthy 
societies.
    In addition to that, of course, the President has recently 
initiated an area--my time is up, so I'll stop--but you can, 
well, this is an important thing to the President. He has--
we're taking the USNS Comfort to the region, we'll be going to 
12 countries. Having the banner of the United States involved 
in the delivery of health care is not only an important 
humanitarian gesture, it's also a very important foreign policy 
statement. We'll maintain the friendship that we have with that 
very important region that's so close.

                           PREPARED STATEMENT

    With that, Senator, I'll close, but as you can tell, this 
is a matter on which I have some passion, and I'm anxious to 
talk more about it.
    [The statement follows:]

           Prepared Statement of the Hon. Michael O. Leavitt

                              INTRODUCTION

    Good afternoon Mr. Chairman, Senator Specter, and members of the 
subcommittee.
    I am honored to be here today to talk with you about important 
challenges and opportunities in global health.
    For the past 6 years, this administration has worked hard to make 
our country--and our world--a healthier, safer and more compassionate 
place. We thank you,
    Mr. Chairman, and your colleagues for your solid financial support 
for our global efforts.
    I thank the Congress and the President for their vision and the 
American people for their generosity that always seeks to help others. 
I am proud to be part of our Nation's efforts to make for a healthier 
and more secure world.

                        HHS' MISSION AND MANDATE

    The U.S. Department of Health and Human Services (HHS) recognizes 
that our job does not end at the shoreline. This is true for a number 
of reasons. First, pathogens and other threats to human health have 
become as mobile as we are, and have, in some cases, become 
increasingly deadly through mutations and resistance to drugs: as more 
people move and diseases change, our own health is intertwined with 
that of people in other nations.
    Second, the health of other nations is important, and affects 
global productivity, stability, security, and good governance. It is 
clearly in our nation's interest to address global health concerns. 
This includes not only obvious threats, such as infectious diseases, 
but also health issues that do not pose such an immediate risk to the 
American people.
    But there is a third crucial role: to demonstrate the generosity 
and heart of the American people, a fact made clear in my travels, 
including recently to Central America. Health holds a special place as 
a foreign-policy tool. It is a universal and fundamental desire of all 
people, and is a common concern among almost every electorate in the 
world.
    We know that because health programs address these fundamental 
human interests, they also enjoy a level of acceptance and gratitude 
far beyond other types of assistance programs. Health programs are 
uniquely situated to be both an act of benevolence and a clear and 
powerful tool for advancing American diplomatic interests. Its 
importance as a diplomatic tool will only increase as we move forward 
to face the challenges and opportunities of the future.
    In short, a healthy world is good for America.

                       HOW HHS MEETS ITS MANDATE

    HHS works to fulfill its mandate to improve global health through 
direct assistance, technical and program support, training and 
capacity-building, and research. We partner with many other 
Departments, including the U.S. Departments of State, Defense, 
Agriculture, Homeland Security, and Commerce. We also collaborate 
closely with the U.S. Agency for International Development (USAID) and 
with the Environmental Protection Agency. We enjoy excellent bilateral 
partnerships with other Governments, multilateral organizations, non-
governmental and faith-based organizations, and with the private 
sector.
    Within HHS, Centers for Disease Control and Prevention (CDC) work 
to detect, verify, and quickly respond to infectious disease outbreaks 
around the globe, to address major causes of global morbidity and 
mortality, to build sustainable public-health systems and to control 
other health threats at their origin to prevent international spread. 
To maintain the safety of the American people, the Food and Drug 
Administration (FDA) regulates millions of products grown and 
manufactured abroad. The National Institutes of Health (NIH) address 
global health challenges through innovative, collaborative biomedical 
and behavioral research and training programs, and through basic 
clinical research to discover new medical interventions and evaluate 
their effectiveness. The Health Resources and Services Administration 
(HRSA) brings critical expertise in community health, the training of 
health-care workers, and ``twinning'' relationships that link U.S. 
institutions to our international work. The Substance Abuse and Mental 
Health Services Administration (SAMHSA) is providing advice on mental 
health and drug and alcohol rehabilitation to several strategic global 
programs.
    Over the last 6 years, we have doubled our international presence. 
We have almost 270 HHS staff--both civil servants and U.S. Public 
Health Service Commissioned Corps officers--in over 31 countries around 
the globe. These dedicated professionals work to improve the health of 
people throughout the world--through work on President Bush's Malaria 
Initiative, the President's Emergency Plan for AIDS Relief, the Global 
Polio Eradication Initiative, the Global Measles Partnership, and 
through work to encourage innovative, cooperative biomedical research. 
We also regularly send HHS staff to work as Health Attaches in U.S. 
Embassies and Missions abroad who represent the U.S. Government to 
host-country Ministries of Health and to international organizations, 
such as the World Health Organization.

                LOOKING TO THE FUTURE: HEALTH DIPLOMACY

    Last year, 15 U.S. Government Departments and Agencies, including 
HHS, cooperated on Project Horizon, an innovative, ground-breaking, 
long-term planning project that looked at the role of the U.S. 
Government in global affairs in the long-term future. The project was 
innovative because it examined, not just one possible or probable 
future, but at a range of possible futures. Through three workshops, 
U.S. Government senior executives, leaders from civil society, and 
private-sector executives considered how the world might look in 20 
years, and what the U.S. Government should be doing today to be 
prepared to operate in those future scenarios.
    Out of these high-level workshops came a set of ten capabilities 
that project participants recommended, across a wide range of possible 
futures, the U.S. Government develop to continue its global affairs 
leadership in the future. One of those was the capability to mobilize 
health resources across the Federal Government to advance U.S. global 
leadership. No matter what the future looks like, we will need hands-
on, high-visibility methods for engaging the world--to help prevent 
disease, to mitigate global health risks and to strengthen perceptions 
of the U.S. abroad.

                        GLOBAL HEALTH CHALLENGES

    Members of this committee know well the current landscape in 
international health.
    I would like to highlight for you five challenges we are working to 
address at HHS: HIV/AIDS, tuberculosis, malaria, polio, and pandemic 
influenza.
HIV/AIDS
    President Bush's Emergency Plan for AIDS Relief is the largest 
commitment ever by any nation for an international health initiative 
dedicated to a single disease--a five-year, $15 billion, comprehensive 
approach to combating the disease around the world. We are proud to 
work with USAID, the Peace Corps, and the Departments of State, 
Defense, Commerce, and Labor in this effort.
    Thanks to the commitment of President Bush, Congress and the 
American people, the U.S. Government is indeed the global leader in 
this fight. Based on estimates by the United Nations Joint Programme on 
HIV/AIDS, in 2005 our Government contributed more than all other 
Governments combined to HIV/AIDS control in foreign countries. That 
contribution has risen substantially in 2006 and 2007.
    With the overall U.S. contribution of approximately $4.6 billion 
for the Emergency Plan in the current fiscal year, and the President's 
unprecedented $5.4 billion request for fiscal year 2008, there can be 
no doubt the United States will continue to lead the world in 
responding to the AIDS crisis. The Emergency Plan has financed care for 
almost four and a half million people, including two million orphans 
and vulnerable children. We have supported counseling and testing for 
18.6 million-69 percent of whom are female.
    To meet our treatment goals, the Emergency Plan has supported 
treatment for over 822,000 individuals in 15 countries--61 percent of 
whom are women, and 9 percent of whom are children. We have also 
supported anti-retroviral treatment for HIV-positive women during more 
than 530,000 pregnancies, and experts estimate these treatments have 
averted more than 100,000 infant HIV infections.
    CDC provides expert field presence and support from headquarters 
for surveillance, laboratory support and the delivery of care to those 
infected or affected by AIDS. HRSA is also building on its management 
of the domestic HIV/AIDS efforts to provide training and quality-
improvement interventions in the Emergency Plan focus countries, and 
runs a Twinning Center to match volunteers and health-care institutions 
in the United States with counterparts in the focus countries to share 
expertise and best practices. NIH is helping to further strengthen 
evaluations of Emergency Plan outcomes, and linking its network of 
clinical trial sites to Emergency Plan care and treatment programs. 
SAMHSA is providing expert direction for programs in Viet Nam and 
Southern Africa to address the important intersection of HIV/AIDS and 
substance abuse, including alcohol.
    The FDA has reviewed and approved 44 generic anti-retroviral (ARV) 
drug formulations, including combination drug formulations and 
formulations appropriate for children. We estimate that when our host-
country colleagues in Africa, the Caribbean and Asia take full 
advantage of these generic ARVs, the Emergency Plan will realize a cost 
savings of $23 million. The safety and quality of these generic ARVs 
matches that of drugs marketed for HIV/AIDS in the United States. This 
process is also providing savings and greater choices for our HIV-
positive patients here at home as well: seven of these generic ARVs 
approved through this process are already on the market here in the 
United States. We expect more to appear in U.S. pharmacies in the years 
to come as other patents or exclusivities on the underlying branded 
drugs expire.
    In addition to our bilateral assistance to 15 focus countries and 
numerous additional countries for HIV/AIDS control and the integration 
of tuberculosis control activities into those HIV/AIDS interventions, 
we also contribute to the Global Fund to Fight AIDS, Tuberculosis and 
Malaria. Our contributions as a Government to the Global Fund 
constitute our principal multilateral contributions to the global 
efforts to control these diseases, and are a significant part of the 
President's Emergency Plan. The United States is a founding member of 
the Global Fund, was the Fund's first donor and remains its largest 
contributor, and continues to play a leadership role in ensuring the 
success of this important international effort. My predecessor, former 
Secretary Tommy Thompson served as the Chair of the Global Fund Board 
from 2003 to 2005. HHS is at the heart of our Government's relationship 
with the Global Fund: my Special Assistant for International Affairs, 
Dr. Bill Steiger, serves as the U.S. representative to the Global Fund 
Board. The U.S. Government's Global Fund activities extend to the 
country level. As U.S. Government personnel, many of them from HHS, 
they sit on 57 of the 97 Country Coordinating Mechanisms that submitted 
proposals to the Fund in 2006.
    The United States has given the Global Fund close to $1.9 billion, 
or 27 percent of total funding from all donors ($7.1 billion). As of 
April 19, 2007, the Global Fund had committed to funding a total of $7 
billion in 136 countries, and disbursed nearly $3.6 billion to grant 
recipients in 130 countries. Fifty-eight percent of proposals the Fund 
Board approved during the first six rounds of funding were dedicated to 
HIV/AIDS, 24 percent to malaria, and 17 percent to tuberculosis.
Tuberculosis
    The overlapping epidemics of tuberculosis and HIV require expanded 
screening and treatment for Tuberculosis (TB) among HIV/AIDS patients, 
and better screening and treatment for HIV/AIDS in TB patients. These 
complementary responses are a key part of treatment and care programs 
under the Emergency Plan as well. This year, the U.S. Global AIDS 
Coordinator allocated an additional $50 million for work on this dual 
threat, over and above the baseline work in this area already underway 
in the Emergency Plan. This plus-up will support enhanced case 
detection, laboratory capacity, infection-control activities, and 
clinical care.
    Our strategy to control TB and drug-resistant TB includes the 
following: expanding and strengthening TB-control programs; better 
integrating TB screening and treatment into HIV/AIDS programs, and HIV 
screening and treatment into TB programs; systematically improving 
laboratory networks, disease surveillance, and monitoring; developing 
reliable drug-supply mechanisms; enhancing the development and 
production of the next generation of anti-TB drugs; and, helping local 
partners in all countries in which we work to fully implement the World 
Health Organization's Stop TB Strategy.
    We must be especially vigilant about the alarming increase in drug-
resistant tuberculosis, including multi-drug-resistant (MDR-TB) and 
extensively drug-resistant TB (XDR-TB). XDR-TB is fatal in a 
significant percentage of those with this infection, including people 
whose immune systems HIV/AIDS has compromised. Experts are identifying 
XDR-TB in an increasing number of countries throughout Asia and Africa. 
In one documented outbreak of XDR-TB in South Africa among 53 
individuals, most of whom were co-infected with HIV, 52 died within 25 
days. CDC and NIH are working domestically and internationally to 
understand the extent of the XDR-TB situation, to build clinical and 
laboratory capacity to detect, control and treat this disease, and to 
address research needs to better understand the disease, its 
transmission, diagnosis, prevention and treatment. A Federal TB Task 
Force is examining activities across Federal agencies, including CDC, 
NIH, FDA, USAID, immigration services, health care institutions managed 
by the Federal bureau of Prisons health care systems, the Veterans 
Administration, the Indian Health Service, and others, and is preparing 
recommendations to address this threat. The National Security and 
Homeland Security Councils have also convened an interagency working 
group to put together an international strategy on MDR and XDR-TB.
Malaria
    Each year, over 1 million people die from malaria, and an estimated 
300 to 500 million become ill and debilitated. Of these deaths, 85 
percent or more occur in sub-Saharan Africa, the vast majority among 
children under 5 years of age. In many countries, malaria is the 
leading cause of mortality for both children and adults. Malaria has 
significant economic and social burdens: it accounts for more than 40 
percent of public-health expenditures in Africa, and causes an 
estimated annual loss of $12 billion from the continent's gross 
domestic product.
    In spite of these grim statistics, malaria is a preventable and 
treatable disease. In June 2005, President Bush issued a global call to 
action on malaria, and announced $1.2 billion in additional funding the 
U.S. Government will invest over 5 years to fight the disease in 15 
sub-Saharan African countries.
    The President's Malaria Initiative (PMI) represents a historic 5-
year expansion of the U.S. Government's efforts to fight malaria in the 
region most affected by the disease. The President set two ambitious 
goals for PMI focus countries: first, to reduce the estimated deaths 
from malaria by 50 percent by 2010; and second, to reach 85 percent of 
those most vulnerable to malaria--children under 5 years of age and 
pregnant women--with a package of four proven and highly-effective 
prevention and treatment measures. In each country, PMI works closely 
with national malaria-control programs to strengthen their efforts, 
complement ongoing activities, and meet the PMI targets of 85 percent 
coverage with proven interventions, including indoor spraying of homes 
with insecticides, the distribution of insecticide-treated mosquito 
nets, the use of lifesaving anti-malarial drugs, and expanding access 
to treatment to prevent malaria in pregnant women. PMI also works with 
civic leaders, non-governmental organizations, faith-based and service 
organizations, as well as corporations and foundations, in their 
commitments to defeat malaria as a public-health problem.
    I am proud HHS/CDC is partnering with USAID as the implementing 
agencies for the PMI, and that we are already seeing results in the 
early stages of the initiative. Aid from the American people has 
already reached about 6 million Africans in the first three focus 
countries. A U.S. Government spraying program in Zanzibar last August 
treated 200,000 households, which protected more than 1 million people 
from malaria. In camps throughout northern Uganda, a PMI-supported 
campaign distributed more than 200,000 nets, targeted at children under 
5 years old. In Tanzania, PMI has delivered 380,000 treatments of drug 
therapy. This year, an additional 30 million people should benefit from 
life-saving treatment and prevention measures as PMI expands to four 
additional countries. Complementing PMI's ongoing efforts, NIH 
continues to support clinical researchers in the quest to understand or 
intervene against malaria.
    The PMI has provided critical global leadership has rejuvenated 
interest and action on malaria prevention and treatment worldwide, and 
has saved children's lives in Africa.
Polio
    At the launch of the Global Polio Eradication Initiative (GPEI) in 
1988, polio was endemic in more than 125 countries, and paralyzed 
350,000 children each year. In 2006, polio paralyzed 1,985 people, and 
now there are only four endemic countries--Afghanistan, India, Nigeria, 
and Pakistan. We can attribute this tremendous progress to the 
commitments and monumental work of national, Provincial, and local 
Governments and communities worldwide to vaccinate all children against 
polio. The battle to wipe out polio truly is being fought on a 
grassroots, house-to-house level.
    HHS, through CDC, has been honored to work closely with the World 
Health Organization (WHO), the United Nations Children's Fund, and 
Rotary International as founding co-partners of the polio-eradication 
campaign. The U.S. Government is historically the largest financial 
donor to the effort, and has provided over $1.2 billion since 1988. 
U.S. Government contributions to polio eradication represent nearly 30 
percent of all global contributions. In addition, HHS/CDC continues to 
provide significant technical expertise and support to Governments and 
international organizations as we work to eradicate polio.
    We have never been closer to the goal of eradicating polio, but we 
also now face what might be the final and most difficult mile. We will 
continue to need your generous support and political commitment. Recent 
setbacks include the exportation of polio virus from endemic areas to 
regions and countries that had been polio-free. The populations polio 
affects in the four remaining endemic countries are among the poorest 
and most difficult for health workers to reach, whether through vaccine 
drives or communication campaigns. Conflict, poverty, inaccessibly, and 
religious and social tensions compound the difficulties. Nevertheless, 
we at HHS are convinced polio eradication is still possible.
Pandemic Influenza
    A little over a year ago, the President mobilized our Nation to 
prepare for an influenza pandemic. I traveled to almost every U.S. 
State and territory to hold planning summits. The appropriation this 
subcommittee made played a significant role as well. Every level of 
Government in the United States has developed plans and allocated 
resources, so that, today, we are better prepared than we were a year 
ago--but there is still much for us to do.
    There is also the danger that, as influenza slips from the 
headlines; people will believe the threat is no longer real. While the 
media buzz might have died down, the H5N1 strain of highly pathogenic 
avian influenza has not. As of April 11, 2007, the WHO has reported 28 
new cases of avian influenza in humans since the beginning of the year 
in six countries, and 14 of these people died.
    To date, 291 people have contracted the H5N1 strain around the 
world. Dozens of countries--across three continents--have seen H5N1 
claim poultry and wild birds. While we cannot be certain H5N1 will be 
the spark of the next pandemic, we can be sure pandemics happen. They 
have happened in the past, and they will happen in the future.
    That is why we continue to take this threat so seriously.
    At the national level, we have made significant investments in 
critical areas of research, including the development of vaccines, 
antiviral medications, and diagnostic tools. This research will benefit 
not only the citizens of the United States, but individuals throughout 
the world.
    In addition, NIH and CDC are supporting the development of new 
vaccines against H5N1 influenza and other virus strains. Our goal is to 
support and clinically test a library of live vaccine against all 
foreign influenza strains with pandemic potential, which could allow us 
to have a faster head start as any pandemic strain emerges.
    We are also working on adjuvants and other dose-optimizing 
strategies for vaccine administration that could enable the United 
States to immunize more people. In January 2007, HHS awarded contracts 
that totaled $132.5 million to three vaccine makers for the advanced 
development of H5N1 influenza vaccines that will use an adjuvant. We 
are developing rapid diagnostic tests that could shorten the testing 
time for H5 strains, from what has been in the past 2 or 3 days, to 
just a matter of 4 hours. In my judgment, that is still too slow, and 
we continue to work hard in that area, making substantial research 
investments targeting rapid diagnostics.
    We are also looking at mitigation strategies should a pandemic 
occur. Some recent pandemic modeling suggests there are partially 
effective interventions, such as school closings and social distancing, 
and we are working to use them in a layered manner that can be highly 
effective, we believe, in controlling influenza in a community. In 
February 2007, CDC released new guidance on community planning 
strategies that State and local community decision-makers, as well as 
individuals, need to consider based on the severity of an influenza 
pandemic. These strategies are important because the best protection 
against pandemic influenza--a vaccine--is not likely to be available in 
sufficient quantities for the entire population at the outset of a 
pandemic. Community strategies that delay or reduce the impact of a 
pandemic could help reduce the spread of disease until a vaccine that 
is well-matched to the virus is available.
    Internationally, we have also made significant contributions in 
preparing our world for an influenza pandemic.
    Partially through the appropriations this Committee made, the 
United States pledged $334 million last January to help nations prepare 
for, and respond to, outbreaks of avian influenza. You added to this 
total in the fiscal year 2007 Joint Resolution, which provided us at 
HHS with 24 million additional dollars for international work. This 
funding has made a significant difference in improving our preparedness 
and response, and I wish to thank you for your commitment to this 
important effort.
    With the funding you have given us, we at HHS have entered into 
cooperative agreements for influenza-control work in approximately 35 
countries, and have also awarded over $20 million to the WHO 
Secretariat and its Regional and Country Offices for influenza 
surveillance and capacity-building. We have stationed influenza experts 
in newly created positions overseas in the countries of greatest 
concern, like Indonesia, and at WHO Headquarters and Regional Offices 
around the world. For the first time, we will also have a liaison 
person focused on influenza inside the European Centers for Disease 
Control in Stockholm. In addition, around the world through CDC, we 
have established five Global Disease Detection and Response Centers to 
build regional capacity to respond to the emergence of pandemic 
influenza or any other infectious-disease threat.
    We have added value to the larger Departmental and U.S. Government 
activities by establishing and funding projects with the Institut 
Pasteur Network (in Viet Nam, Cambodia, Laos, Francophone North Africa 
and key Francophone West African countries at risk), the International 
Center for Diarrheal Disease Research in Bangladesh and the Gorgas 
Memorial Institute in Panama to make the collective global disease-
epidemiologic surveillance/laboratory diagnostic network more robust.
    The United States also supports efforts by the international 
community and multilateral organizations to meet the global need for an 
appropriate and efficacious influenza vaccine. The Office of the 
Assistant Secretary for Preparedness and Response (ASPR) in HHS 
provided $10 million last fiscal year to the WHO Secretariat to help 
developing countries produce safe and effective vaccine against 
influenza. The WHO Secretariat just announced the first five 
beneficiaries of this program on April 25 (Brazil, Mexico, Thailand, 
Viet Nam and Indonesia). We have also invested heavily in vaccine 
research, and in expanding our own production capacity.
    President Bush has made clear his commitment to a forward-leaning 
position on the development of antiviral stockpiles. In May 2006, the 
U.S. Government deployed treatment courses of Tamiflu to a secure 
location in Asia to aid an international rapid-response and containment 
effort if a potential pandemic breaks out overseas.
    As requested by the Homeland Security Council, HHS also leads an 
interagency effort to implement the International Health Regulations 
(IHRs) for the U.S. Government, linked across Federal Departments and 
agencies. The IHRs, an international legal instrument that comes into 
force in June 2007, will govern the roles and responsibilities of the 
WHO Secretariat and its Member States in identifying, responding to and 
sharing information about public-health emergencies of international 
concern (including a pandemic influenza).
    We have done significant work to prepare for the possibility of a 
pandemic influenza, but many challenges remain. Responding to a 
pandemic will require the cooperation of the entire global community, 
as no nation can go it alone. If a country is to protect its own 
people, it must work together with other nations to protect the people 
of the world.
    It is my belief we are better prepared for an influenza pandemic 
today than we were a year ago. And we are working to assure we are 
better prepared a year from now than we are today. Thank you for your 
continued interest and support. It will be crucial as we move forward.

                HEALTH DIPLOMACY TODAY: CENTRAL AMERICA

    I spoke in my introductory comments about Project Horizon and 
health diplomacy in the future. Under the President's leadership, I 
have already begun to implement the kind of health-diplomacy capability 
Project Horizon identified as a critical need.
    As you know, in March 2007, President Bush shared with the people 
of the Americas his commitment to advancing social justice in the 
Western Hemisphere. That commitment includes helping democracies in the 
region to build Governments that are fair, effective, and free from 
corruption; to maintain economies that make it possible for people to 
provide for their families; and to meet basic needs for education, 
housing, and health care.
    My part in this effort is helping to improve the region's health 
care, especially in rural or areas that lack sufficient health-care 
personnel, in ways that are complementary to what other Federal 
Departments and agencies are already doing. The U.S. Government invests 
millions of dollars each year in health programs in Latin America; 
since 2001, the United States has spent almost $1 billion on health 
programs in the region.
    Our new effort at HHS will focus on three main objectives:
  --Increasing direct patient care provided by U.S. Government 
        personnel;
  --Improving the training of local health workers; and
  --Forging partnerships of public and private groups to provide more 
        and better health care.
    Toward the first objective, people from my Department and the U.S. 
Department of Defense will work with our Central American partners to 
provide health care to those most in need. The President is sending the 
USNS Comfort--a Navy medical ship--to Latin America and the Caribbean. 
The Comfort will make port calls in 12 countries. Between June and 
September of this year, its doctors, nurses, and technicians expect to 
treat 85,000 patients--and conduct up to 1,500 surgeries.
    Dental care among the poor is an area of special concern. So, this 
summer, dentists and dental hygienists from the U.S. Public Health 
Service Commissioned Corps will join military dentists from the U.S. 
Southern Command on humanitarian missions to the region. They will 
perform basic treatments like filling cavities, treating infections and 
pulling teeth. They will apply sealants to children's teeth to protect 
them from cavities for many years to come. They will also offer 
preventive education on oral health and hygiene to children and their 
parents.
    Our second objective is improving training of local health workers 
in the region. To do that, my Department is working with the 
Governments of Central America to start a Regional Training Center in 
Panama. This training center will train a range of health-care 
workers--community health workers, physicians assistants, nurses 
assistants, technicians, and dental hygienists, among other 
disciplines--according to the particular needs in each country, because 
needs vary significantly across the region.
    To make the school a success, we are working together as partners 
with our Central American hosts:
  --To forge agreements between our countries and the school to supply 
        and fund its students;
  --To develop a governing structure and curricula for the school; and
  --To engage universities, professional associations, and non-
        government health workers to build school faculty, resources, 
        distance-learning capabilities, and other needs.
    Our third objective is working more closely with American non-
governmental health-care providers in the region. By partnering with 
these providers, we can have a greater impact on health care delivery 
in the region.
    Now, let me tell you about our recent activities in Central 
America.
    In June 2006, I visited Panama to build the groundwork for the 
training facility, in the former Canal Zone, which I hope Panamanian 
Minister of Health Alleyne and I can inaugurate in June 2007. In 
September 2006, I discussed the idea of a training partnership with 
Health Ministers from Central America at the annual Directing Council 
of the Pan American Health Organization in Washington. In January 2007, 
I discussed the partnership with Central American Heads of State while 
in Nicaragua for President Ortega's inauguration. In March 2007, I 
visited Guatemala, Honduras, El Salvador, Costa Rica, and Nicaragua to 
discuss this initiative with heads of state, ministers of health, 
medical and dental professionals, and grass-roots health-care 
providers.
    We formalized our planning by signing Letters of Intent between HHS 
and each Central American Minister of Health to establish the Regional 
Training Center. The first training module at the training center took 
place in April 2007, and went very well. Fifty health-care workers from 
six Central American countries received training on pandemic-flu 
preparedness and response. At every step, we have worked with local 
health-care providers, who are the real experts in the needs of their 
countries and their communities.

                               CONCLUSION

    No matter what the future looks like, the U.S. Government will have 
to be engaged in a serious and direct way in global health. On my trip 
to Central America, I not only experienced the very real needs of the 
present; I glimpsed the future of that kind of cooperation. Given the 
many challenges we face--HIV/AIDS, tuberculosis, malaria, polio, 
pandemic influenza--I can tell you that we need today, and will 
increasingly need tomorrow, to strategically wield all the global 
health assets we have as a Government. HHS counts it a privilege to be 
one partner in the larger fight for a healthier, safer, more 
compassionate world.

    Senator Harkin. Mr. Secretary, thank you very much and for 
your leadership in this area.
    I think you're on to something, in terms of, re-focusing, 
perhaps? Thinking about how we set up structures in these 
countries, and how we address ourselves to do that.
    We have a lot of wonderful doctors in this country that 
periodically travel to another country, and provide healthcare. 
They go down for 2 weeks or something like that, and dentists 
will fix some teeth, and reconstructive surgeons do this, and 
heart surgeons do that. This is all good stuff, but, it's 
episodic, and I'm not certain that it gets to the long-term 
real healthcare needs of people.
    It seems that many of the problems that confront our 
neighbors in underdeveloped countries, poorer countries--they 
are chronic type illnesses that need to be addressed. This can 
only be done with long-term investments in infrastructures, 
public health infrastructures, like community health centers.
    As I said earlier, we always seem to target certain areas. 
We target AIDS, we target malaria, we target pandemic flu, and 
TB, and no one would argue that that isn't all well and good, 
but I just wonder if it wouldn't be better to shift a little 
bit.
    For example, if mothers are dying in childbirth, and 
children are dying before they turn 5, then that's a basic 
public health problem.
    I understand that a woman living in sub-Saharan Africa--I'm 
not talking about Central America here--has a 1 in 16 chance of 
dying in pregnancy or childbirth. That compares to a 1 in 2,800 
risk in developed countries. I don't know what it is in Central 
America, Latin America, South America--I don't know that, 
probably higher than 1 in 2,800.
    Again, it's not so much a question--I'm just trying to draw 
you out to get your thinking on this, on--what should we be 
doing to address some of these underlying problems to help 
build up long-term type structures? Structures in which we 
interact with people for a longer period of time to become 
knowledgable. I don't mean institutions--just set structures?

            TRAINING HEALTH PROFESSIONALS IN CENTRAL AMERICA

    Secretary Leavitt. Mr. Chairman, I referenced a trip I 
recently completed in Central America. I visited five Central 
American countries, and I met with the medical communities in 
each of these areas, and had this conversation.
    Without hesitation, or exception, each of them raised the 
issue that you have, and that is that mothers are dying, 
particularly in rural, remote areas, where there is no health 
care. They said, ``If you could help us train midwives, you 
could save lives.'' Not only would you save lives, you would 
create an educational foundation where people would have 
employment. It would also create a base, when you want to 
provide services, you could build on it.
    So, one of the things, in Central America, for example, 
that we're looking at developing is a short-term course in 
training mid-wives. All of the health ministers in that area 
have committed, and the presidents--by the way--I met with each 
of the presidents, and this is a high enough priority that they 
have--each of them--entered into a letter of intent to send 
students.
    So, we'll take students from six different Central American 
countries, they will come to Panama, they'll be trained for a 
period of 12 to 15 weeks, whatever it takes to learn a 
particular skill, then they will go back to their village or 
remote area, and continue to interact with this training school 
for continuing education, and continued contact with the United 
States.
    Now, this is a school that, in fact, will be run 
collaboratively by the region--the United States has obviously 
been a major player in convening it, but that's just one area.
    Another area is in lab technicians--sometimes they have 
labs, but they have no one to run them. Learning to manage 
blood banks--many of them said, ``If you could just give us 
people that could learn to run blood banks.'' Others said, ``We 
need basic public health schools, we wouldn't know a case of 
avian influenza if we saw one.''
    The whole area of dental training--you've traveled in these 
areas, you've seen the oral health challenges that are there--
when they learn of our capacity to train technicians from their 
village to basic dental procedures, they could not have been 
more hungry to have that kind of training.
    We're talking about a few million dollars a year, to be 
able to have a facility where people from that entire region 
can come, be trained, go back, have a job, make contributions--
not only to their community and health, but also economically.
    Senator Harkin. How soon could we do something--how long 
would it take to do something? I mean----
    Secretary Leavitt. We started the project in Central 
America in November, and we held the first class this month. We 
had about 50, I think, students from around the region, it was 
a small class. But, we anticipate that--this does not require a 
lot of bricks and mortar, at least in Central America----
    Senator Harkin. Do you have facilities available?
    Secretary Leavitt. We had a facility, in the old Canal Zone 
that we were able to use.
    Senator Harkin. Yeah.
    Secretary Leavitt. But----
    Senator Harkin. Yeah.
    Secretary Leavitt. You know, we don't have to build up a 
lot of bricks and mortar here. We can move rapidly. I think 
it's a model. I'm going to South America to meet with our 
Ambassador to Brazil for this same reason. He believes--and the 
Brazilian Government believes--that there are regions of South 
America where this would be applicable.
    We've had some conversation about using this model in sub-
Saharan Africa, again, to train midwives and others. So, we're 
creating lasting skills that we leave in the region and are 
about lasting contact that we have with a provider.
    Senator Harkin. I shouldn't--the Brazil thing would be 
where they would be helpful, financially, and that type of 
thing.
    Secretary Leavitt. Oh yes, we're looking to partner with 
them in other parts of Latin America.
    Senator Harkin. Yeah, I mean, yeah, partner with----
    Secretary Leavitt. Not just in Brazil, but in other areas--
--
    Senator Harkin [continuing]. Partnering with them in other 
areas, I understand that. That'd be good.
    Well, I--if there's something you'd like us to look at on 
this Subcommittee that we would be helpful to move this another 
step further in the next round, I--just speaking for myself, 
I'd like to take a look at it----
    Secretary Leavitt. Thank you.
    Senator Harkin [continuing]. We'd like to be helpful.
    Secretary Leavitt. We'll have to give a detailed plan.

                     SHORTAGE OF HEALTHCARE WORKERS

    Senator Harkin. One last, just one last question and I'll 
turn it over to Senator Specter.
    Now, you mentioned, a lot of these Central American 
countries, especially, let's face it--a lot of them are here, 
and they're working here, and they're sending money home. But 
there's another problem that I've come across--I don't know how 
big it is, but it's there.
    Because we have a shortage of certain kinds of healthcare 
workers in this country, there's sort of a brain drain, there's 
sort of a drain, if they get trained in those countries to be 
healthcare workers, they can make more money coming here. So 
they come here. I have, myself, come across some people from 
other countries who are here, and they're very valuable 
healthcare workers. So, how do we reduce that?
    Secretary Leavitt. Well, we dealt with that directly, with 
the heads of state and the health ministers, and our commitment 
has been, ``Look, we're not training people to bring into the 
United States. We're training people to meet needs in rural 
Honduras, or rural Nicaragua, or rural Guatemala,'' and that 
issue continues, it will continue, but right now they have 
nothing. We can provide them with substantial improvement in 
that health base by doing this.
    Senator Harkin. That's a--that drain of healthcare workers 
out of some of those--I don't know, again, I have no idea how 
big it is, it's a significant, it's there, I just don't know 
how big it is, and----
    Secretary Leavitt. We're not training people in these 
centers to be Registered Nurses, or physicians.
    Senator Harkin. Right. Right, I understand that.
    Secretary Leavitt. We're training them in basic medical 
skills, and they're mostly community health workers.
    Senator Harkin. That's what you're, that's what's really 
important right there. I think, anyway.
    Thank you, Mr. Secretary.
    Senator Specter.

                            AVIAN INFLUENZA

    Senator Specter. Thank you, Mr. Chairman.
    Secretary Leavitt, as noted in my brief opening statement, 
a great deal of money has been appropriated for pandemic flu, a 
concern that there might be a great worldwide academic, which 
is, wrecks such havoc, so many deaths back in 1918, and 
periodically.
    I know from your written testimony that 291 people have 
contracted Avian Influenza around the world with 28 new cases 
reported in humans since the beginning of the year. We had 
authorized some $7.1 billion, and $5.6 billion has been 
appropriated, and contracts have been let. What is your 
evaluation today of the potential threat of a worldwide 
epidemic? Is it off the table? Is it still possible? How likely 
is it to occur?
    Secretary Leavitt. The most important response is a 
reminder to all of us that pandemics happen. They have happened 
throughout human history, and there's no reason to believe that 
the 21st Century will be any different. The H5N1 virus 
continues to spread across the world, it continues to mutate, 
it continues to follow a pattern, it's very troubling.
    Senator Specter. So, you think it will happen, it's just a 
question of when?
    Secretary Leavitt. A pandemic will surely happen, whether 
it's the H5N1 virus that causes it, we do not know, but there 
is a certainty about the existence of pandemics that dates back 
throughout human history.
    Senator Specter. Have we done enough, are we doing enough 
to guard against that eventuality?
    Secretary Leavitt. We are dramatically better prepared 
today than we were a year ago, but we need to be dramatically 
better prepared a year from now than we are today. It's a 
continuum of preparation. The generous appropriation of the 
Congress has allowed us to pursue preparation in five very 
important areas, one of which is monitoring around the world.
    The training center I've spoken of is just a very small 
nugget that shows that progress. We're now training people 
throughout the world, and equipping them with laboratories and 
the skills to recognize when H5N1 virus occurs we can get an 
early jump on, hopefully, containing it should it mutate into 
the position that could cause a pandemic. That's happening in 
almost every region of the world.
    The second area is, of course, monitoring here at home. 
We're developing monitoring systems, and that's part of a broad 
State and local preparedness. The Congress has generously 
allocated funds in a way that we're able to provide pandemic 
training, and now a lot of exercising is going on. We developed 
plans, we're now exercising those plans in virtually every 
State--well, in every State in the country, and virtually every 
community.
    We're not at the point I wish we were in that area, but 
we're substantially better than we were a year ago.
    Another area is in the area of vaccines. We have let 
contracts--we're well over $1 billion now--to developers----

                                VACCINES

    Senator Specter. Have you monitored the progress from 
those--are making toward the development of the vaccines?
    Secretary Leavitt. Yes, we are, and I'm able to report 
substantial progress, particularly in the area of adjuvant 
technologies, and the development of a cell-based vaccine. As 
you may be aware, we've actually seen vaccines now that have 
been approved by FDA for use, but we're not at the point where 
we could crank up production and produce 300 million courses of 
a vaccine in the period that we desire to be able.
    So, we still have some work, but we're making substantial 
progress. We've made stockpiles of anti-virals, and other 
disposable medical equipment.
    Senator Specter. Mr. Secretary, I want to move onto a 
couple of other areas----
    Secretary Leavitt. Okay.
    Senator Specter [continuing]. And there is limited time, 
but you've already given an encouraging response. I want to 
compliment what your Department has done, and what the Centers 
for Disease Control has done with Dr. Julie Gerberding. When 
the issue was on the front pages many months ago, Americans 
were alerted, and I think it is important at a hearing like 
this, that the alert be maintained.
    Firsthand, I can tell you how concerned my wife was, and we 
have laid provisions for an extended period of time if you have 
to be confined to your homes, which is one of the consequences 
if there should be a pandemic. We couldn't go to movies, you 
might not even be able to leave your house safely, so the 
provisions have to be set in, which is a complicated matter--
foodstuffs, water, medicines to tide you over, so that anyone 
watching this hearing on C-Span later, these are warnings which 
ought to be heeded. Dr. Gerberding testified about the website 
which CDC has, with practical suggestions as to what might be 
accomplished.

                              GLOBAL FUND

    There are a number of other faces, and obviously we can't 
cover everything, but I note on the Global Fund for HIV/AIDS, 
TB and malaria, about $300 million was appropriated in fiscal 
year 2002, went up to $724 million in fiscal year 2007, but the 
budget request has only $300 million for next year. I'd like 
you to submit in writing why it has gone down, and what your 
evaluation of the resources is?
    [The information follows:]

    In May 2001, President Bush made the founding pledge of $200 
million to the Global Fund, and has consistently requested $200-$300 
million each year for the fund since. These contributions complement 
the rapid bilateral scale-up of the U.S. Government's bilateral HIV/
AIDS and malaria programs.
    In January 2003, the President framed future commitments to the 
Global Fund under his new, 5-year Emergency Plan for AIDS Relief 
(Emergency Plan). Of the $15 billion he pledged for the Emergency Plan, 
he pledged $1 billion to the Global Fund. Taking into account the $300 
million in the President's fiscal year 2008 budget request, the U.S. 
Government will have provided approximately $3 billion to the Fund by 
2008, far more than the amount the President pledged for 2004-2008. In 
addition to being the Fund's largest contributor, responsible for 
almost 30 percent of all the Fund's resources, the U.S. Government 
provides over 50 percent of all resources for global HIV/AIDS through 
bilateral programs, research, and contributions to multilateral 
organizations. We are eager to see other donors, particularly those 
without strong bilateral programs, come forward with significantly 
increased funding directed to the Global Fund. The Fund's greatest 
challenge is to raise more money from other donors, including new 
donors, not increase the share the United States contributes.
    To date, over six rounds of funding the Global Fund Board, on which 
the U.S. Government holds a seat, has been able to award grants for all 
proposals the Fund's independent Technical Review Panel has recommended 
for approval, including its most recent funding round in November 2006. 
The Fund has a surplus of resources beyond those necessary to meet all 
of its commitments to its current grantees.

                              AFGHANISTAN

    Senator Specter. I note that in Afghanistan, that some $6 
million was allocated to improve maternal and child healthcare, 
which has been started over the last 4 years, and I'd like in 
writing what has happened on that program?
    [The information follows:]

    The Afghanistan Health Initiative aims to improve maternal and 
child health, and reduce maternal and child mortality in that country. 
The U.S. Department of Health and Human Services (HHS) believes these 
strategic objectives are achievable through the provision of training 
to upgrade the knowledge and clinical skills of physicians and other 
health care professionals and the leadership and management skills of 
hospital administrators. The primary focus of these efforts is ensuring 
that the attending physicians, residents, midwives and nurse-midwives 
and other staff at Rabia Balkhi Women's Hospital (RBH) in Kabul, the 
largest maternal hospital in Afghanistan, possess the core knowledge 
and skills required to provide quality maternal and neo-natal health 
care for mothers and their babies. Before HHS involvement at RBH three 
to four mothers died per day. Now only two to four mothers die per 
month, with no maternal deaths in some months. There have been similar 
results in neo-natal mortality rates.
    From 2004 to 2006, Congress approved a total of $16.811 million to 
the Afghanistan Health Initiative. HHS dedicated the largest portion of 
these appropriated dollars to support the activities of the Maternal 
and Child Health program at RBH, which the Afghanistan Ministry of 
Public Health authorized in accordance with the Ministry's policies, 
procedures and directives. These funds went to three recipients: the 
HHS/Centers for Disease Control and Prevention (CDC), and two non-
governmental organizations (NGOs), International Medical Corps (IMC) 
and CURE International. In combination, these recipients have been the 
cornerstones of the Afghanistan Health Initiative. Two other HHS 
Operating Divisions--the Health Resources and Services Administration 
(HRSA) and the Indian Health Service--have participated in capacity-
building efforts at RBH.
    Through professional training and technical assistance, HHS seeks 
to bolster the administrative and management capacity of RBH officers 
and foster an environment conducive to learning, skill refinement and 
the overall provision of quality maternal and infant health care. At 
RBH, the largest and busiest maternal hospital in the country (with 
13,000-15,000 births each year), managerial and clinical capacities 
have proven integral in establishing a sustainable health-delivery 
system, as well as improving infection-control procedures, developing 
medical records for patients, collecting vital statistics related to 
improving health (including morbidity and mortality), and conducting 
disease surveillance.
    HHS adapted a basic U.S. training program for residents in 
obstetrics and gynecology, for use in Afghanistan. Components of the 
medical residency program are modeled on the system used in the United 
States approved by the Accreditation Council for Graduate Medical 
Education (ACGME). HHS has taken care to clarify, however, our use of 
an adaptation of a curriculum endorsed by ACGME does not mean the 
training program has ``imposed'' unrealistic or inappropriate standards 
to the Afghan setting, nor set the expectation that the instruction at 
RBH would actually qualify for ACGME accreditation. Rather, our intent 
has always been to create a residency program that approximated those 
seen in neighboring countries. In 2006, the program's efforts resulted 
in the development of a new 4-year residency program approved by the 
Afghanistan Ministry of Public Health Expert Group in Obstetrics and 
Gynecology. In 2007 and 2008, HHS will also be investing in 
strengthening the vertical referral system among clinics and hospitals 
in Kabul, which will help pregnant women receive appropriate care at 
every level in the health system, and relieve pressure on RBH.
    HHS has focused additional efforts on patient education and has 
developed and helped distribute the Afghan Family Health Book (AFHB), 
an electronic, interactive tool that uses sound and pictures to deliver 
health-education messages in Dari and Pashto, Afghanistan's two main 
languages, to people who cannot read. The Afghan Ministry of Public 
Health (MOPH), has distributed the books in 30 of the country's 34 
Provinces. To extend the benefits of this program, HHS recently teamed 
with the U.S. Department of State and a non-government organization to 
develop a series of serialized, local-language radio shows based on the 
AFHB. These radio shows are scheduled for broadcast this summer.
    In response to requests from Afghan Minister of Public Health, 
Mohammed Fatemi, to Secretary Leavitt, in 2007 and 2008 HHS will also 
be allocating resources to activities in Afghanistan in the fields of 
mental health and the quality and safety of food and drugs. We are 
working with the Ministry of Public Health and other partners to 
determine the specifics of these elements of our program, which will 
tie back into our goals of improving the health of women and children.
    Finally, HHS has agreed to assign two U.S. Public Health Service 
(PHS) Commissioned Corps Officers to the staff of the Coalition Forces 
Command Surgeon in Kabul, to work on integrating the health-care system 
for uniformed Afghan military and police personnel with civilian health 
institutions, the U.S. Department of Defense (DOD) is reimbursing HHS 
for the cost of these billets. With Afghan Health Initiative funding, 
HHS will also be assigning two HHS/PHS officers to Provincial 
Reconstruction Teams in Afghanistan in 2007, to better link our program 
with broader reconstruction efforts in the health sector.

                        LATIN AMERICA INITIATIVE

    Senator Specter. It is something that is good to do, we are 
fighting the Taliban in Afghanistan, and to have a showing of 
our concern for child and maternal care has to be a good 
foreign policy initiative, which you have mentioned.
    In Latin America initiative, there was $1.5 million, I'd 
like to get the specifics on what you can accomplish there.
    Since Senator Harkin and I have a running dialogue about 
our seniority, Senator Harkin was selected in 1984, and I, 4 
years earlier. Now, as we're moving up the seniority chain, 
we're waiting for the day when--instead of being chairman and 
ranking on this subcommittee, we'll be chairman and ranking on 
the full Appropriations Committee. I have a preference as to 
who should be the chairman there, and Senator Harkin has a 
preference, too, but----
    I couldn't pick anybody better for second place.
    Or, perhaps, for first place, to be the chairman. But, I 
mention this in terms of what he and I have talked about, 
should we get there, to have an overall evaluation as to how we 
divide the $2.9 trillion--staggering sum of money. But, we 
start off with $500 billion on defense, except when we add 
another $100 billion as we are now--and we start off with $34 
billion on homeland security, and what's left over comes to 
Health and Human Services. When you have only $6 million to 
allocate to Afghanistan child and maternal care, and back to 
the 2002 level on Global HIV/AIDS, we know what you're 
struggling with.
    So that, we look forward to a time when there might be a 
top to bottom reevaluation as to how we allocate these funds. 
But, if you could give us some insights on those particular 
items, we would be appreciative.
    Secretary Leavitt. Indeed, we will.
    Senator Specter. Thank you, Secretary Leavitt.
    Thank you, Mr. Chairman.
    Senator Harkin. Well, Mr. Secretary, I don't have any 
further, Senator Specter asked all the questions I wanted to, 
but, just on that Latin America thing, if there's more 
information that you want to give us, and we'll look at that 
budget item, we'll be glad to do so.
    Secretary Leavitt. Good, thank you.
    [The information follows:]

    Thank you for your interest in this important initiative. Under the 
President's Initiative to Advance the Cause of Social Justice, my 
Department is proposing to channel technical and financial resources 
from the U.S. Government and the private-sector to improve health care 
to people in Central America. I outlined three objectives of the 
proposal: (1) to improve the training of Latin American healthcare 
workers in their home region; (2) to train U.S. Government medical 
personnel through deployment to Central American countries as part of 
U.S. Military medical and humanitarian missions to provide oral health 
care for poor populations in the region; and (3) maximize the quality 
and quantity of health care delivery through closer coordination with 
U.S. non-governmental organizations (NGOs) that are operating in the 
region. On my recent trip to Central American, I signed Letters of 
Intent between our Government and the Governments of the Republics of 
Costa Rica, El Salvador, Guatemala, Honduras, Nicaragua, and Panama, to 
enhance and expand bilateral cooperative efforts in health and the 
medical sciences, and to confront common threats to health security. 
The signatory Governments, through their Ministries of Health, 
expressed their intent to collaborate to establish a multi-country 
Regional Health Care Training Center in Panama, City.
    The Regional Training Center (RTC) will support the development of 
a coordinated health approach in the region, with the intent of 
strengthening the capacity of Central American's health-care 
institutions for preventive and public health approaches. Students from 
the six countries will enhance their skills and abilities to provide 
basic care to poor populations, and to be prepared for specific 
situations related to infectious disease, including respiratory 
conditions and potential emerging threats like pandemic influenza. At 
the completion of the training, students will return to their homes to 
apply the skills to improve the health care provided in their own 
communities.
    The first course for students from the region ended on April 30, 
2007, focused specifically on pandemic influenza preparedness and 
response. In the first year, a cadre of faculty from each of the 
Central American countries, as well as from HHS and universities in the 
United States, including academics and professionals in practice with 
expertise and high recognition in the field, will train 150 students 
from across the region. The Regional Training Center is very popular 
among the Ministries of Health and among the professional dental and 
medical societies in the region, yet significant aspects of the Center 
are still under development or negotiation (the governance, long-term 
sustainable financial support, the makeup of the student body and 
faculty, and physical facilities, among other aspects), even as the 
classes are underway. Future training would include, for example, 
classes for the development of community health workers, technicians, 
dental hygienists, paramedics and skilled birth attendants and 
midwifes; and courses would address subjects like pandemic preparedness 
and response, and emergency neo-natal and obstetric care.
    Second, U.S. Government personnel will be trained to provide high-
quality oral health care, particularly preventive dental care, by 
deploying them on humanitarian missions in Central America. HHS will 
work with the U.S. Department of Defense (DOD) and our Central American 
partners to provide health care to those most in need. The President 
has ordered the USNS Comfort to Latin America and the Caribbean to make 
port calls in 12 countries, to treat 85,000 patients and conduct up to 
1,500 surgeries. HHS Commissioned Corps health officers, primarily 
dentists, will join those missions. They will also join military 
dentists from the United States DOD.
    Southern Command (USSOUTHCOM) on medical readiness and training 
missions to the region, which are mutually beneficial, as they will 
represent an opportunity for the U.S. Government personnel to hone 
their skills in providing culturally competent care here at home, and 
also provide to the local population badly needed medical and dental 
interventions.
    The total training costs for fiscal year 2007 are estimated at 
$3,229,000. $2.5 million comes through a cooperative agreement between 
HHS and the Gorgas Memorial Institute in Panama. We also expect an in-
kind contribution for the Government of Panama. HHS Operating Divisions 
will cover the rest with existing resources.
    For fiscal year 2008, the President has requested a total of $1.5 
million for the health care portion of his new Latin American Health 
Initiative. Included in the President's fiscal year 2008 budget request 
of $1.5 million for the health care portion of his new Latin American 
Health Initiative are the following costs (please see the chart for 
complete fiscal year 2008 budget detail):
  --Training of Central American health-care workers in Panama: 
        $315,000. A total of 240 health-care workers will be trained 
        from six countries (40 health-care workers per country).
  --Deployment of HHS USPHS Commissioned Corps Officers training to 
        provide oral health care: $309,744. There are 12, one-month 
        USSOUTHCOM missions scheduled to Central America. HHS will 
        provide several officers on each rotation.
  --Supplies for HHS USPHS Commissioned Corps: $375,256. This cost 
        covers sealants, other types of oral health care, and 
        educational materials for 8,640 children.
  --$500,000 to supplement the training component of this initiative 
        through coordinated health campaigns, to provide care, and 
        faculty participation at the Regional Training Center, and to 
        create an evaluation plan for the initiative.
    We are also thankful for the opportunity to provide further 
information on the Latin American Health Initiative and what more we 
hope to accomplish. During my visit to Central America in March 2006, 
the Governments and civic and professional organizations demonstrated 
an eagerness to engage with the United States that surpassed my 
expectations, and a number of significant opportunities for greatly 
enhancing the effectives of the program became evident. The United 
States has a remarkable opportunity to connect directly to the people 
of Central America and engender the friendship and goodwill that is so 
clearly in our national interest. HHS is eager to take full advantage 
of the potential that a more robust health-diplomacy effort could 
provide for the United States' interests in the region. There are three 
key opportunities to strengthen the initiative immediately: increase 
the number of U.S. Government faculty at the Regional Training Center; 
expand the curricula into many areas beyond the first session focus on 
pandemic preparedness and response; launch a more robust plan for 
public-private partnerships and collaboration.
    HHS would like to place a U.S. Government employee as the Deputy 
Executive Director of the Regional Trading Center, which would thus 
ensure American involvement but Central American ownership. A broader 
and more dynamic role for private and non-governmental health 
organizations would also be an excellent opportunity to enhance the 
effectiveness of the effort overall, both in direct support of the 
Regional Training Center, but also in the direct provision of health 
care. Expansion of the Regional Training Center's curriculum and U.S. 
faculty are within the parameters of the HHS existing business plan, 
but is likely to require more resources beyond the relatively modest 
first year of funding. Additionally, HHS could greatly enhance the 
reach and effectiveness of its health diplomacy if it had clearer, more 
specific legal authority to support with appropriated funds health-
diplomacy objectives and opportunities in limited and defined areas 
this initiative and HHS' overseas activities in general can provide.
    Perhaps the greatest opportunity to increase the effectiveness of 
the initiative would be a greater role for U.S. health-care 
professionals to interact with and treat Central American patients at 
the community level. Both as a part of the USNS Comfort and in the 
DOD's readiness and training missions, U.S. Government health 
professionals will have limited opportunities to provide oral health-
care to populations with which they interact. However, as we have seen 
in many cases worldwide, an American provider's healing presence and 
interaction with host-county residents is a powerful tool in health 
diplomacy, and we will continue to explore more opportunities for this 
kind of high-touch medical care. Also, the value to the professional 
development of skills and experience for our own personnel gained 
through overseas readiness and training exercises is exceptional, as 
the U.S. military has demonstrated for decades.
    Finally, because this would be an innovative and pioneering effort 
in health diplomacy, demonstrating its effectiveness and measuring its 
outcomes would be even more important than in other settings. My 
expectation is that this initiative in Central America will provide a 
test bed for new ideas and a chance to demonstrate proof-of-principle 
in health diplomacy and the training of community health professionals 
for under severed populations. HHS would create a Department-wide 
Technical Advisory Group to provide oversight to the project and ensure 
it is following public-health and evidence-based best practices.

    Senator Harkin. Thank you for your leadership in that area.
    Now, we call for our second panel, and that's Dr. Stephen 
Blount, Director of the Office for Global Health with CDCP, Dr. 
Roger Glass, Director of the Fogarty Center at NIH.
    We'll start first with Dr. Blount. Stephen Blount became 
the first Director of the Office for Global Health in 1997. In 
1993 to 1997, he was assigned to the World Health Organization, 
as Director of the Caribbean Epidemiology Center in Trinidad.
    Dr. Blount received his M.D. from Tufts, and his M.Ph. in 
1980 from the University of Michigan. Dr. Blount, welcome to 
the committee, your statement will be made part of the record 
in its entirety, and please proceed, and then we'll turn to Dr. 
Glass.

STATEMENT OF DR. STEPHEN BLOUNT, DIRECTOR, OFFICE FOR 
            GLOBAL HEALTH, CENTERS FOR DISEASE CONTROL 
            AND PREVENTION, DEPARTMENT OF HEALTH AND 
            HUMAN SERVICES
    Dr. Blount. Good morning, Mr. Chairman. Thank you very 
much, to you and other members of the subcommittee.
    I do serve as Director of the Coordinating Office for 
Global Health at the Centers for Disease Control and 
Prevention, where I've worked for the last 19 years, with the 
most recent 15 years in the area of Global Health.
    I'm honored to talk with you today about the important 
contributions that CDC is making to improve the world's health.
    Secretary Leavitt has already highlighted a number of 
Global Health programs in which CDC is a partner, and my 
written statement provides further information about our Global 
Health activities.
    CDC currently has a total of approximately 1,400 employees 
in 46 countries, including our own U.S. Government employees, 
and hundreds of locally employed staff working with our 
international partners and host countries. It's the 
extraordinary commitment of our workforce that enables us to 
effectively carry out our mission in some of the most difficult 
countries in the world.
    In general, the core work of CDC country offices includes: 
disease surveillance, program development and implementation, 
research, systems and capacity development, and emergency 
preparedness and response.

                               INFLUENZA

    Today, the United States and the rest of the world face a 
real and urgent threat--the deadly H5N1 Influenza virus that 
Secretary Leavitt just commented on. CDC is playing a critical 
role in supporting the efforts of 20 priority countries to 
develop national preparedness plans.
    In 2006, through our Global Disease Detection efforts, we 
helped countries respond to, and assess, in less than 48 hours, 
the public health risk of 28 cases of human H5N1 reported to 
the World Health Organization. We also helped to train more 
than 230 participants from 32 countries in influenza rapid 
response.
    Still, we recognize--just as the conversation before 
focused on--that we have to build capacity to respond to all 
potential, natural or intentional, health threats.

                        GLOBAL DISEASE DETECTION

    A significant resource for addressing these threats is 
CDC's Global Disease Detection Program. In collaboration with 
host countries at WHO, we are establishing response centers 
across the globe to strengthen global capacity for responding 
to these threats. This past year, we collectively responded to 
more than 144 disease outbreaks, including Avian Influenza, 
hemorrhagic fevers, meningitis, cholera, and unexplained sudden 
death.
    Other urgent realities that we're committed to addressing 
include endemic infections, such as measles and malaria--also 
discussed earlier--chronic diseases, injury and core public 
health issues such as safe water, and, as you mentioned, 
maternal and infant health.
    For example, CDC has been a core partner in the Global 
Measles initiative. Earlier this year, the initiative's 
partners confirmed that measles deaths have fallen by 60 
percent worldwide--a major public health success, and a story 
that we haven't told widely enough. This achievement exceeded 
the United Nations goal of cutting measles deaths in half by 
2005, and is due largely to an unprecedented decline of 75 
percent of measles deaths in the Africa region.

                               SAFE WATER

    Another area where we're continuing to have a significant 
health impact is access to safe water, sanitation, and hygiene. 
More than 1 billion people worldwide have no safe water, and 
more than 2 billion lack access to adequate sanitation, 
resulting in--what we estimate to be--3 million deaths that 
are, essentially, unnecessary.
    Unsafe water is the source of not only potentially deadly 
enteric diseases, but it also results in chronic debilitating 
conditions that do not cause dealth but cause individuals to 
live much less rich lives because of this. To achieve 
reductions in this enormous burden caused by these diseases in 
poor countries, CDC is developing sustainable approaches to 
providing safe water.
    For example, with our international partners, we've 
developed a new and low-cost technology called the Safe Water 
System, that has reduced diarrheal deaths in some locations by 
50 percent.

                         PUBLIC HEALTH RESEARCH

    We continue to engage in critical collaborations with 
global partners on applied public health research--by applied, 
Dr. Glass is going to talk about basic research, I believe--our 
work is in translating the results of NIH and other research 
into public health interventions on the ground that save lives. 
These leverage our unique capacities and opportunities for 
mutual benefit for the United States and our host countries.
    Our collaborative study in China, for example, in the use 
of folic acid to prevent birth defects resulted in a 
significant decrease in birth defects in high-risk areas, and 
provide ongoing safety data to support the U.S. policy of 
fortifying cereal grain products with folic acid.
    I just returned from China last week, and met with CDC 
staff, who are engaged in rapidly scaling up our presence in 
that country, which is critically important in executing our 
own foreign policy.
    Additional CDC research efforts support the implementation 
of PEPFAR, the President's Emergency Plan for AIDS Relief. 
These research efforts focus on novel approaches for HIV and 
other diseases. We also, of course, support the President's 
Malaria Initiative.
    Let me move quickly, in concern about the time.
    So, let me turn from some of the successes that we've 
contributed to, to very quickly, three of the challenges.

                           FUTURE CHALLENGES

    First, we need to continue to engage our external partners 
in the development of a strategic vision for Global Health 
Action. We continue to work very closely with WHO in this area, 
and other multilateral partners.
    Second, recent global successes with integrated campaigns 
that bundle interventions--such as malaria, measles, Vitamin A 
supplementation--have made enormous progress in Africa.
    Finally, the Global Health community must build a 
foundation for a collaborative response to the growing problem 
of chronic diseases.
    You mentioned earlier, Senator, and I'll conclude with 
this, about the concern for building the public health capacity 
in developing countries. Here in our own hemisphere, and 
abroad, our focus is on training public health physicians, 
laboratory specialists, and managers in public health programs.
    As Secretary Leavitt indicated, we're helping to build the 
capacity in countries to deal with their own problems. We're 
hoping that they will remain in their countries--one of the 
major benefits of these training programs is that in time, not 
only do they build immediate skills to address problems, but 
the graduates of the programs to which we contribute, have 
become leaders in public health in their countries. That builds 
friendship, it builds communication, it builds capacity in 
these countries, and a strong regard for our own country.

                           PREPARED STATEMENT

    So, we want to thank you and the other members of the 
committee for their support. The world looks to the United 
States for public health leadership and guidance, and it's 
imperative that we fulfill our health diplomacy goals, with our 
expertise, our partnerships, and our spirit of innovation, I'm 
confident that CDC can help America to help the world. Thank 
you.
    [The statement follows:]

                Prepared Statement of Dr. Stephen Blount

                              INTRODUCTION

    Good afternoon Mr. Chairman, Senator Specter, and members of the 
subcommittee. My name is Stephen Blount. I serve as the Director of the 
Centers for Disease Control and Prevention's (CDC) Coordinating Office 
for Global Health. I am honored to be here today to talk with you about 
the important contributions that CDC is making to improve the world's 
health.
    The scope and nature of the agency's global health efforts have 
expanded over the years, but the constant is that CDC is on the 
frontlines of international disease eradication and health promotion. 
The most recent addition to our global mandate is the ambitious goal of 
protecting the United States and world population from emerging global 
threats.

                   CDC'S COMMITMENT TO GLOBAL HEALTH

    In fiscal year 2007, CDC has devoted approximately $334 million to 
global health efforts, in addition to the approximately $815 million it 
has received thus far in transfers from the Department of State, Office 
of the Global AIDS Coordinator, as part of the President's Emergency 
Plan for AIDS Relief (PEPFAR). We strongly believe that program and 
scientific staff should be embedded in the countries they serve. As of 
May 2007, the CDC has 166 staff working on assignments in 46 countries 
around the world. Besides these assigned staff, the agency employs 
approximately 1,200 local staff in host countries to support these 
programs and has approximately 40 staff detailed to work with our 
international partners. It is this commitment of funding, staff, and 
resources that has produced effective, efficient, and high quality 
global health results at CDC. Today, I will share with you some of our 
greatest accomplishments.

            CDC'S STRATEGY TO ADDRESS GLOBAL HEALTH CONCERNS

    CDC is committed to working with partners, both domestic and 
international, to achieve our goal of Healthy People in a Healthy 
World. Through the leadership of the Coordinating Office for Global 
Health (COGH), CDC is developing the first-ever agency-wide strategy to 
improve global health. This strategy includes health promotion, health 
protection, and health diplomacy.
    Our health promotion activities help prevent the major causes of 
global illness and death through the implementation of proven 
interventions. Our commitment to health protection focuses on our 
collaborations within a transnational network of countries and other 
organizations that are dedicated to protecting the health of Americans 
and the global community from emerging threats. Finally, our health 
diplomacy efforts reflect our commitment to provide humanitarian 
leadership by sharing tools that enable other countries to identify and 
act on their own health priorities.
    CDC also understands that our global health work cannot be 
accomplished without strong global partnerships. Today, approximately 
30 of CDC's programs serve as World Health Organization (WHO) 
Collaborating Centers. In this role, CDC efforts help to protect the 
world's health by strengthening laboratory and epidemiological capacity 
and improving control and prevention strategies for selected diseases. 
CDC also works with a variety of sectors including government, private, 
and non-profits organizations. We partner with Ministries of Health, 
the Pan American Health Organization, USAID, CARE, the Carter Center, 
and UNICEF, just to name a few.

              CDC GLOBAL HEALTH SUCCESS: HEALTH PROMOTION

    A key CDC strength is our work in global health promotion 
activities. I will highlight a few outstanding examples.
Global HIV/AIDS, Tuberculosis, and Hepatitis
    CDC's Global AIDS Program (GAP) is a proud partner in the 
President's Emergency Plan for AIDS Relief (PEPFAR). Secretary Leavitt 
has already shared with you some of its major program components and 
achievements. Through PEPFAR CDC is also engaged in developing next-
generation solutions to the HIV/AIDS problem.
    CDC is working to deploy known strategies to address Global HIV/
AIDS in support of PEPFAR through new biomedical interventions. For 
example, we are conducting clinical trials on the safety and 
effectiveness of carageenan, a vaginal gel microbicide in Thailand, and 
on the safety and effectiveness of daily use of the antiretroviral 
agent tenofovir in the United States, Thailand, and Botswana. As part 
of the Partnership for AIDS Vaccine Evaluation, CDC is developing new 
animal models for the evaluation of vaccine candidates. CDC's current 
research priorities include microbicides, pre-exposure prophylaxis 
(PrEP), HIV vaccine development, and emerging retroviruses.
    Tuberculosis (TB) remains a major cause of illness and deaths 
globally, and is closely tied to our HIV/AIDS program activities 
because of high rates of co-infection. Nearly 9 million people develop 
TB each year, and 2 million die from the disease. CDC is actively 
engaged in addressing the emerging global concern arising out of 
reports of extensively drug-resistant tuberculosis (XDR TB). XDR TB has 
been reported in all regions of the world that have looked for drug 
resistance to second-line medications. The keys to preventing the 
development and spread of XDR TB are to ensure that patients are 
treated until cured with medications that are effective and by 
implementing appropriate infection control practices in medical care 
settings. CDC is working closely with the other parts of HHS, the 
Department of State, USAID, WHO and other international partners to 
address XDR TB.
    Perinatal transmission of hepatitis B also remains an international 
concern. The good news, however, is that through support for WHO and 
work with the Global AIDS Vaccine Initiative (GAVI) Alliance and other 
partners, CDC has contributed to the substantial progress in control of 
global hepatitis B. To date, 158 of 192 WHO member states have 
introduced hepatitis B vaccine into routine infant immunization 
programs.
Malaria and other Neglected Tropical Diseases
    Malaria is responsible for 300 to 500 million clinical episodes and 
1 million deaths each year, mostly in young children in sub-Saharan 
Africa. Recently malaria control efforts have been expanded by the 
President's Malaria Initiative (PMI). CDC is an active technical 
partner in PMI, and science conducted by CDC and our partners underpins 
the proven strategies being used in PMI: indoor residual spraying, 
insecticide-treated bednets, anti-malarial drugs and prevention in 
pregnancy. CDC's contributions to the fight against malaria generally--
and to PMI specifically--capitalize on the agency's strengths in 
translation of data into policy and program, monitoring and evaluation, 
and applied research and the advancement of science that can quickly be 
translated into effective prevention and control strategies. CDC also 
supports ongoing activities to address the malaria burden in Asia and 
the Americas.
    Beyond the burden of malaria, as much as one sixth of the world's 
population is affected by one or more of a group of maladies 
collectively known as neglected tropical diseases. These diseases are 
responsible for tremendous illness and death worldwide and pose direct 
threats to the health of the American public. Yet efforts to reduce or 
eliminate these diseases have historically received little attention 
and few resources. CDC is actively working with a broad range of 
partners, including the pharmaceutical industry, to bring much-needed 
treatments and preventive interventions to those in greatest need.
Global immunizations
    Global immunizations is another major global health program at CDC, 
and Secretary Leavitt provided significant details about achievements 
to date in polio eradication. The Urgent Stakeholder Consultation on 
Polio Eradication at the World Health Organization in Geneva in 
February 2007 reconfirmed that polio eradication remains both 
technically and operationally feasible. New, targeted strategies in 
each of the four remaining endemic countries, together with monovalent 
oral polio vaccine--which has proven to be up to 3 times as effective 
as the traditional vaccine--provide powerful tools to help achieve 
polio eradication. As a key member of the Global Polio Eradication 
Initiative, CDC is actively involved in providing technical support and 
advocacy to reach this worthwhile goal.
    Another major effort in immunization where we are seeing dramatic 
strides is measles control and elimination. Although entirely 
preventable with a vaccine that costs less than $1 per child in the 
developing world, measles ranks among the top 10 killers of young 
children around the world--taking the lives of 345,000 in 2005. 
Reflecting one of the greatest successes in global public health in 
recent years, in January 2007, Measles Initiative partners announced 
that measles deaths had fallen by 60 percent between 1999 and 2005, 
from 873,000 to 345,000, surpassing a United Nations goal of cutting 
measles deaths by half during that period. CDC is a founding member of 
the Measles Initiative, which has provided funding and technical 
assistance to developing countries to fight this scourge. This 
achievement has led to the setting of a bold new global goal: to cut 
measles deaths by 90 percent by 2010. Protecting children against 
measles globally also protects American children from measles because 
of the risk of importation of the disease.
    In other immunization-related activities, CDC is expanding 
surveillance for rotovirus and pneumococcus and is helping to introduce 
vaccines for those diseases in countries where they are needed most. 
These new vaccines will help prevent diarrhea and pneumonia, two of the 
biggest killers of children in developing countries.
Non-communicable diseases
    As I mentioned earlier, chronic diseases contribute substantially 
to global illness and deaths, and CDC is increasing its involvement in 
this area by addressing major risk factors such as inadequate or poor 
nutrition, tobacco use, and physical inactivity. CDC has several 
programs involved in chronic disease prevention and treatment work. One 
program is the International Micronutrient Malnutrition Prevention and 
Control Program (IMMPaCt). This program assesses the state of 
micronutrient malnutrition in a community and works to eliminate it 
through evaluation and expansion of effective interventions, assistance 
and guidance in communication and advocacy, and strengthening of global 
micronutrient laboratory capacity.
    CDC has worked with WHO to develop and implement the Global Youth 
Tobacco Survey (GYTS) to track tobacco use among youth throughout the 
world using a common methodology and core questionnaire. This survey 
has been vitally important in providing evidence to demonstrate the 
effectiveness of youth tobacco prevention activities worldwide. Late 
last year the CDC Foundation received a grant from the Bloomberg 
Foundation to establish systematic surveys to monitor global tobacco 
use among adults. The grant is part of a $125 million initiative by 
Bloomberg to create a partnership devoted to reducing dependence on 
tobacco around the world.
Injury, violence, and safety
    Car crashes kill 1.2 billion people a year worldwide and currently 
rank as the 11th leading cause of death, accounting for 2 percent of 
all deaths globally. Another 20 to 50 million people per year are 
injured or disabled as a result of car crashes. CDC collaborates with 
WHO to develop the World Report on Road Traffic Injury Prevention and 
to provide technical assistance to develop and implement hospital-based 
injury surveillance systems in Central and South America. We also 
supported WHO in the publication of the WHO multi-country study on 
domestic violence against women, contributing to worldwide efforts to 
prevent intimate partner violence and sexual violence. In addition, CDC 
funded the creation of a curriculum to train first responders on the 
nature of blast injuries and proper triage criteria and collaborated 
with WHO on guidelines for essential trauma care.
    Health and safety in the occupational setting is also a concern for 
CDC, particularly related to Americans who work overseas. CDC has been 
a WHO Collaborating Center in Occupational Health since 1976 and 
currently serves as Chair of the Global Network of 64 Centers. CDC 
contributes to the reduction of occupational diseases, injuries, and 
fatalities among workers employed globally by cultivating international 
partnerships and sharing pertinent information.
Maternal, infant and child health
    While chronic diseases are a threat to both the developed and 
developing world, the vast majority of maternal, fetal, and neo-natal 
deaths occur in the developing world. It is estimated that worldwide, 
more than half a million maternal deaths occur annually, and 4 million 
late fetal deaths and 4 million neo-natal deaths occur each year.
    With respect to HIV/AIDS, the prevention of mother-to-child 
transmission of HIV/AIDS (PMTCT) is a main focus and strong component 
of PEPFAR. In addition to the PMTCT activities that CDC undertakes as 
part of PEPFAR, we also conduct research that helps influence global 
policy change. For example, CDC research conducted in Thailand reduced 
rates of maternal to child transmission through effective treatment of 
mothers infected with HIV. This led to a policy change in Thailand that 
eventually became the world's standard.
    Another example of how CDC research activities have influenced 
policy decisions is our critical collaboration with global partners to 
advance research focused on the prevention of birth defects and 
developmental disabilities and the identification of strategies to 
improve the health and quality of life individuals affected by these 
conditions. CDC's country-specific efforts also leverage unique 
research capacities and opportunities found globally. For example, 
China recently had the highest known rate of neural tube defects in the 
world--5 per 1,000 infants. Following a collaborative study conducted 
jointly by CDC and China, these birth defects were reduced by up to 85 
percent in high risk areas of China and by 40 percent in areas with 
prevalence similar to the United States. Our research in China has 
provided important information about strategies to prevent such 
defects, and underpins the continuation of flour fortification in the 
United States by addressing safety concerns and providing evidence for 
other countries considering fortification.

              CDC GLOBAL HEALTH SUCCESS: HEALTH PROTECTION

    Currently, the United States and the rest of the world are facing a 
very real threat posed by the highly pathogenic H5N1 avian influenza 
virus. Our experience with SARS showed us how a highly infectious 
disease in a remote region of the world can spread in a matter of days 
and weeks. Thanks to the rapid and constant movement of people and 
commodities, pathogens can hitch rides on airplanes and boats and slip 
across national borders unnoticed. The key to interrupting these 
pathogenic journeys is early detection as close to the source as 
possible.
    An estimated 60 percent of all known human infectious diseases and 
approximately 75 percent of all recently recognized emerging infectious 
diseases affecting humans are of animal origin. We witnessed sobering 
evidence of the health impact of the human-animal interface during our 
rapid multidisciplinary response to the large epidemic of potentially 
fatal Rift Valley fever virus earlier this year in east Africa. 
Additional disease surveillance tools, laboratory capacity, and CDC 
expertise deployed abroad can rapidly improve our ability to recognize 
and intervene to contain emerging threats--including a possible avian 
influenza pandemic--before they become significant problems within U.S. 
borders.
    To prepare for a pandemic of influenza, key issues we need to 
address are appropriate training and exercising of rapid response teams 
to identify, investigate, and contain local outbreaks. We also need to 
be able to trust that we have the most accurate and reliable 
information about influenza viruses and novel human influenza cases--
through strong and established surveillance systems, laboratory 
capacity, and communication channels so we can respond effectively.
    One of the most significant USG contributions to our preparedness 
for an influenza pandemic is the CDC's Global Disease Detection (GDD) 
Program. This program improves our ability to recognize infectious 
disease outbreaks faster and then better control and perhaps contain 
them. In collaboration with host countries and the World Health 
Organization, CDC is establishing GDD Centers across the globe that are 
already strengthening global capacity to detect and respond to 
infectious disease outbreaks. The GDD Centers build upon proven, 
effective interventions and approaches including the International 
Emerging Infections Program and the Field Epidemiology and Laboratory 
Training Program. Having CDC staff on the ground was invaluable in 
providing initial response support for the December 2004 Tsunami, 
particularly in Thailand, and is a mainstay of global response to the 
current avian influenza outbreaks. During the past year, CDC's GDD 
staff helped countries respond--in less than 48 hours--to all 28 human 
cases of H5N1 influenza reported to WHO. The GDD Centers have 
collectively responded to more than 144 outbreaks of avian influenza, 
hemorrhagic fever, meningitis, cholera and unexplained sudden death. 
CDC also helped train more than 230 participants from 32 countries in 
influenza pandemic response, contributing to the development of more 
than 1,000 local Rapid Response Teams that are prepared act in the case 
of a pandemic.
    Naturally emerging infections like influenza or hemorrhagic fever 
are not the only disease threats we face. Through its administration of 
and leadership in the World Health Organization's Global Salm-Surv 
network, CDC is helping to greatly increase the laboratory surveillance 
and diagnostic capacity of more than 100 countries worldwide to 
monitor, detect and respond to foodborne and other infectious enteric 
diseases, as well as potential bioterrorist threat agents, such as 
anthrax.

              CDC GLOBAL HEALTH SUCCESS: HEALTH DIPLOMACY

    CDC recognizes the importance of the leveraged investments we make 
in sustainable health systems that can help develop the people, tools 
and systems needed to carry out essential public health functions above 
and beyond what CDC can do alone.
Sustainable health systems
    A key component of such sustainable capacity is the development of 
a trained and skilled workforce. CDC has made significant contributions 
to the global health workforce through the Field Epidemiology Training 
Programs (FETPs), developed in response to country requests for 
programs like the U.S. Epidemic Intelligence Service (EIS). Trainees 
provide epidemiologic services, including surveillance system 
assessments and outbreak investigations, to the Ministry of Health 
during their training.
    Since 1980, CDC has provided a resident advisor to 28 programs 
covering 36 countries. Of these, 19 no longer need support from a full-
time resident advisor and 19 are still producing graduates. Of the more 
than 1,200 epidemiologists who have graduated from these programs, many 
are in influential decision-making positions in their respective 
countries' Ministries of Health.
Safe water, sanitation and hygiene
    A key area in which we have the potential to have a significant 
impact is through provision of safe water and sanitation systems. More 
than a billion people worldwide have no access to safe water and more 
than 2 billion lack access to adequate sanitation, resulting in an 
estimated 3 million deaths each year, mostly among children younger 
than 5 years. Unsafe water is the source not only of potentially deadly 
enteric diseases such as cholera, E. coli O157:H7, and shigella, but 
also greatly debilitating illnesses such as Guinea worm, 
schistosomiasis, and trachoma. Targeted improvements in water, 
sanitation, and hygiene in developing countries could save millions of 
lives each year, adding an expected 15 years to the average life 
expectancy, and providing powerful health and economic developmental 
benefits. To achieve reductions in this enormous disease burden in 
resource-poor nations, CDC is developing, evaluating and promoting the 
use of simple and sustainable approaches to providing safer, cleaner 
water. For example, with our international partners, we have developed 
a low-cost technology--The Safe Water System--that has reduced 
diarrheal disease in some locations by 50 percent.

                NEXT STEPS FOR CDC'S GLOBAL HEALTH WORK

    Today I have shared with you the framework and strategies 
supporting our global health portfolio, as well as substantial evidence 
of the scope and magnitude of CDC's efforts. While we celebrate our 
successes in global health, we must also look forward to next steps and 
future challenges.
    First, CDC needs to continue to engage our external partners in the 
development of our strategic vision for global health action. CDC is 
committed to sustaining and improving our collaborations with WHO and 
other multilateral partners, and to continuing to foster strong 
bilateral relationships with Ministries of Health in our host 
countries. As never before, we are also working more closely with other 
federal partners such as the Departments of State, Defense, and 
Agriculture, and the U.S. Agency for International Development. CDC is 
also expanding existing collaborations and seeking out and working to 
engage with new partners.
    Second, recent global experience with integrated campaigns focusing 
on immunization, malaria prevention and vitamin supplementation shows 
us that CDC needs to seek more ways to promote integration across 
global programs. Some examples of the kind of success we can have in 
this arena are the simple addition of bednet distribution to prevent 
malaria within HIV/AIDS prevention and treatment activities, or within 
polio/measles immunization campaigns, and the integration of 
information about simple techniques to ensure safe water into the 
PEPFAR basic care package. Research supporting other integrated 
interventions must be conducted, and when proven, implemented in the 
field.
    Third, CDC and the entire global health community must begin to 
build a foundation for a collaborative response to the increasing 
burden of non-communicable diseases in the developing world. Left 
unchecked, chronic diseases like heart disease, diabetes, high blood 
pressure, and preventable cancers are poised to be an ever larger 
proportion of global disease burden.
    I thank the Chair, the Committee, and Congress for this opportunity 
to discuss our global health work and for your support for global 
health. The world looks to the United States for public health 
leadership and guidance and it is imperative that we fulfill our 
responsibility as a world leader in this arena. Furthermore, our 
Nation's commitment to global health provides a unique opportunity for 
humanitarian leadership, which CDC is implementing through its priority 
on Global Health Diplomacy. With our resources, our partners, and our 
innovative spirit, I am confident that CDC can help America help the 
world.

    Senator Harkin. Thank you, Dr. Blount.
    Now, we'll turn to Dr. Roger Glass, who was named Director 
of the Fogarty International Center in 2006. He's a graduate of 
Harvard, studied at the University of Buenos Aires, and 
received his M.D. and M.Ph. from Harvard in 1972, and a 
Doctorate from the University of Goteborg, Sweden, in 1984. I 
understand he's gone back and forth between CDC and NIH 
throughout his career.
    So, welcome, again, to the committee, Dr. Glass, and please 
proceed.

STATEMENT OF DR. ROGER I. GLASS, DIRECTOR, FOGARTY 
            INTERNATIONAL CENTER, NATIONAL INSTITUTES 
            OF HEALTH, DEPARTMENT OF HEALTH AND HUMAN 
            SERVICES
    Dr. Glass. Senator Harkin, thank you very much for having 
us here today, and letting me speak about the agenda of the 
Fogarty International Center in Global Health. The NIH 
currently invests about $700 million in research overseas, much 
of this is in the developed world. About 25 percent is in the 
developing world. The Fogarty International Center is the only 
Center at NIH on the campus that deals directly with problems 
of international health, global health, and all of our funding 
goes to the developing world.
    Let me just paint a landscape of how we see global health 
in the future. A long life, and a healthy life, is what every 
human on Earth expects and what is the ultimate goal of medical 
research. When we look at the panorama of the world, we see, in 
Africa, that life expectancy has declined precipitously over 
the last decade, due to the triple epidemic of HIV, TB and 
malaria.
    At the same time, in much of the rest of the developing 
world, we see life expectancy--in China, for instance--going up 
to 71 years. So, they are not only burdened with the acute 
infections and childhood diseases, but also within the chronic 
diseases that affect us all--cardiovascular disease, cancer, 
mental illness, obesity, diabetes, and the like.
    So, as we think about global health and the 21st century, 
we really need to broaden our perspective from the acute 
infectious diseases in Africa, to some of these chronic 
problems in the developing world.
    Well, let me tell you a little bit about how Fogarty--the 
Fogarty Center--addresses these issues of global health. The 
Fogarty Center has, as its mission, the promotion of training 
and research in global health--training and research overseas. 
We fund U.S. universities who train foreign scientists and 
develop long-term collaborative efforts, longstanding 
collaborations between scientists, mentors and students, and 
institutions. We're really extending the arms of the research 
activities of American universities.
    Let me give you an example--I was in South Africa recently 
at the beside of a 25-year-old man with extremely drug-
resistant TB. He was dying, and we had no drugs that would 
possibly save him. Diseases have no borders--he's only a flight 
away from the United States, and if we have this patient in our 
own setting, how would we treat him? Fogarty has trained, and 
through our collaborations, trainees in South Africa, who are 
skilled in doing the trials that are needed to develop the 
drugs and the strategies right there where the disease is 
common. So, when these diseases come to the United States, 
we'll have some idea of how to treat them.
    Another example in chronic diseases is a grantee we have 
from Nigeria, working in Chicago on breast cancer. We thought 
that in the African-American community, African-American women, 
when they have breast cancer, have the disease which is much 
more aggressive, and much less responsive to treatment.
    We thought that this might be due to access to care, but 
this oncologist, a woman from Nigeria, has identified that the 
genes of breast cancer in African-Americans and in Nigerians 
are different than the genes that determine the cause of cancer 
in Caucasians. That determines why the disease is more 
fulminate, more aggressive and why it's less responsive to 
treatment. Another example where studying the disease and the 
genetics overseas can really determine the appropriateness of 
treatment for American women.
    Now, Dr. Zerhouni commented in his testimony in this 
committee that global health will be one of the exciting new 
frontiers in biomedical research in the 21st century. Programs 
at the Fogarty Center extend the U.S. leadership in biomedical 
research overseas. We are taking science to where the problems 
are. We engage the best and the brightest, at home and abroad, 
in cutting-edge research. These investments have the unstated 
value of humanitarianism and diplomacy that was mentioned here 
already, and they underscore America's caring face to the 
world.

                           PREPARED STATEMENT

    But they also fuel novel discovery, novel vaccines, novel 
treatments, and novel approaches--we can learn a lot from our 
studies overseas. They advance the competitiveness of 
biomedical enterprise in the United States, and really, the 
future of America's leadership in global health will be 
determined by how effectively we can grow these investigators 
overseas, and build partnerships with American universities and 
institutions.
    The Fogarty Center is really working to advance this 
critical mission for the American public.
    [The statement follows:]

                Prepared Statement of Dr. Roger I. Glass

    Mr. Chairman and members of the committee, I am pleased to present 
the fiscal year 2008 President's Budget for the Fogarty International 
Center (FIC). The fiscal year 2008 budget includes $66,594,000, which 
reflects an increase of $240,000 over the fiscal year 2007 Continuing 
Resolution level of $66,354,000 comparable for transfers proposed in 
the President's request.
    Fogarty plays a uniquely critical role in promoting better health 
around the globe, an increasingly significant priority for the U.S. 
Government. To address complex global health challenges, scientists 
worldwide must be able to work together, and robust research capacity 
must exist in locations where priority diseases are most prevalent, and 
be true for both communicable and non-communicable diseases. For 
example, the use of chemotherapy for cancer, the genes of Huntington's 
Disease, and hazards of methyl mercury poisoning and widespread 
radiation all resulted from the study of populations abroad where these 
conditions are highly prevalent. Fogarty rises to this challenge with 
its innovative research training programs that build the knowledge and 
skills of developing country scientists to perform health research in 
their countries and collaborate with U.S. scientists as full and 
effective partners. To advance global health research and research 
training domestically, Fogarty is also investing in the next generation 
of U.S. scientific leaders in global health research. Finally, Fogarty 
identifies crucial gaps in global health research and supports 
international research collaborations, which helps U.S. scientists 
maintain their competitive lead.

                 STRENGTHENING RESEARCH CAPACITY ABROAD

    Infectious diseases continue to exact an enormous toll on millions 
of people in developing countries. HIV/AIDS, TB and malaria constitute 
a triple threat in many developing countries and collectively kill over 
6 million people each year, according to the Global Fund to Fight AIDS, 
Tuberculosis and Malaria (Global Fund).
    In the past 20 years, Fogarty programs have trained thousands of 
scientists in developing countries. Strong local research capacity is 
essential to ensuring the success of the President's Emergency Plan for 
AIDS Relief (PEPFAR), the Global Fund, and the President's Malaria 
Initiative (PMI). Fogarty's AIDS International Training and Research 
Program (AITRP) responds to the demand for in-country research capacity 
to effectively deal with the expanding HIV/AIDS epidemic. For example, 
Zambia, one of PEPFAR's focus countries, has received a significant 
amount of recent attention due to its early success in scale-up of 
antiretroviral therapy for its HIV/AIDS-infected population. This 
success is, in part, a result of the AITRP, which has allowed the 
University of Alabama to provide long-term degree training to 22 
Zambian research scientists, all of whom have returned home and are 
working as researchers, educators, or program leaders in PEPFAR 
programs and other institutions such as the Centers for Disease Control 
and Prevention, UNICEF, and the World Health Organization (WHO).
    Fogarty's International Clinical, Operational, and Health Services 
Research Training Award for AIDS and TB (ICOHRTA-AIDS/TB) is a newer 
effort that strengthens the ability of foreign scientists and their 
institutions to conduct clinical, operational, and health services 
research with U.S. scientists in the context of HIV/AIDS and TB. These 
investments help countries to identify effective interventions specific 
to local needs and better implement interventions and scale-up of 
treatment and care through the local health care system. For example, 
Haiti's ICOHRTA-AIDS/TB research training program is designed 
specifically to provide training for monitoring and evaluation for the 
scale-up of HIV prevention and care services supported by PEPFAR and 
the Global Fund. To support the implementation of the PMI, to provide 
sustainable scientific capacity to address the challenges of malaria 
control, and to rapidly move malaria research results into practice, 
FIC is duplicating the ICOHRTA-AIDS/TB model into a similar effort for 
malaria for PMI countries.
    New TB technologies research is of particular importance given the 
emergence of extensively drug resistant TB, unresponsive to first- and 
second-line drugs, and which could pose a serious threat globally. 
Supported by a Fogarty Global Infectious Disease research grant to the 
University of Cape Town in South Africa, clinical research team members 
are training in collaboration with The George Washington University to 
conduct trials of new drugs and vaccines, including TB vaccines.
    New vaccines and drugs for these diseases can have a major impact 
on health worldwide, but the clinical research and must be conducted 
ethically, in a culturally sensitive manner, and in accordance with all 
relevant laws and regulations to enable scientists to gain the trust of 
the public and research participants. This can be particularly 
challenging when research is conducted in resource-poor and culturally 
diverse settings. Fogarty's International Bioethics and Career 
Development Award program addresses this challenge by supporting the 
advanced training of developing country professionals who can assume 
the roles and responsibilities of ethicists involved in ethical review 
of clinical trial design and clinical research in their countries. Many 
trainees have gone on to become leaders in research ethics and hold key 
posts in government, in-country academic research institutions or 
multilateral organizations such as the WHO, and are now helping to 
train the next generation of experts.

             FUTURE U.S. LEADERS IN GLOBAL HEALTH RESEARCH

    There is a burgeoning interest in global health in U.S. 
universities across the country, and Fogarty is providing the 
leadership to sustain and capitalize on this energy. By investing in 
these junior scientists, FIC accomplishes two central objectives: 
attracting new research talent to global health research and advancing 
the career paths of exceptional junior U.S. scientists.
    Fogarty's International Clinical Research Scholars Program (ICRSP) 
responds to the acute need for future clinical investigators who can 
translate basic research advances into clinical care in a global 
context. This next generation of clinical researchers will require 
hands-on experience in conducting clinical trials and clinical research 
in countries where the disease burdens are highest, typically in poorer 
countries. The ICRSP provides highly motivated U.S. graduate students 
in the health sciences with the opportunity to experience one year of 
mentored clinical research training at distinguished research 
institutions in developing countries. Since its inception, the program 
has supported 70 U.S. scholars. This program is being expanded to 
provide resources and opportunities during residency or fellowships to 
launch physician scientists on a career path that focuses on health 
problems and scientific challenges abroad. Through the International 
Research Scientist Development Award (IRSDA), Fogarty provides research 
support to U.S. postdoctoral scientists in the formative stages of 
their careers to solidify their commitment to global health research. 
Each IRSDA grantee works closely with an established developing country 
scientist and a U.S. mentor involved in collaborative research and 
training at both the developed and developing country institutions. 
These awards forge long-term partnerships between senior developing 
country researchers and outstanding U.S. junior scientists, who are the 
potential future leaders in global health research.

                  INTERNATIONAL COLLABORATIVE RESEARCH

    Fogarty also provides leadership by identifying critical gaps in 
research that must be addressed to confront current and future global 
health challenges. For example, according to the WHO, there are more 
than 450 million people with mental, neurological or behavioral 
problems throughout the world at any given time. Brain disorders are 
the leading contributor to years lived with a disability in all regions 
of the world, with the exception of sub-Saharan Africa. The economic 
and social costs of these disorders are staggering. Despite the 
enormous burden of disease, brain disorders have been largely absent 
from the global health research agenda. In response, Fogarty, in 
partnership with other NIH Institutes, Centers and Offices (ICs), 
supports a program on Brain Disorders in the Developing World: Research 
Across the Lifespan. This program funds collaborative research projects 
between developed and developing country scientists on brain disorders 
throughout life, relevant to low- and middle income nations. Examples 
of research topics supported by this program include: neurocognitive 
consequences of HIV/AIDS in India, cerebral malaria neurological 
disorders, zinc nutrition and brain development, and gene-environment 
interactions in cognition. New insights generated from this program can 
lead to better treatment and delivery of services for mental illness 
both at home and abroad.

                            THE WAY FORWARD

    Fogarty is now developing a Strategic Plan that will guide our 
priorities from fiscal year 2007 through fiscal year 2011. Several 
themes have emerged after consulting with a wide range of stakeholders 
within and outside the NIH. For example, in anticipating and addressing 
changing trends in the global burden of disease and evolving research 
needs, Fogarty will explore new ways to confront the rising burden of 
non-communicable disease in developing countries. In addition, given 
the number of preventable deaths and extent of preventable illness 
around the world due to a failure to implement evidence-based 
interventions, Fogarty plans to provide leadership in ``implementation 
science.'' Implementation science is the study of methods to promote 
the integration of research findings and other evidence-based practices 
into routine practice, which leads to better quality and effectiveness 
of health services and care. Fogarty will also strengthen its efforts 
to build sustainable health research capacity in low- and middle-income 
countries, and expand its investments in U.S. scientists that are 
committed to global health research. Fogarty has historically 
considered the needs of other NIH ICs in the development of its 
programs, and has collaborated with almost every IC over the past 5 
years. We will continue to do this as we plan for the future.
    Never before has global health been a larger priority for the U.S. 
Government, U.S. academic research institutions or philanthropic 
organizations. Public and private sectors have found new and productive 
ways to work together, and all sectors have invested significant 
resources to promote better health globally. Strengthening research 
capacity abroad through its research training programs, Fogarty helps 
to maximize the benefits of these investments in the long-term. 
Fogarty's investments in junior global health researchers also help to 
ensure that a critical mass of U.S. scientists will be able to lead the 
world in building a healthier future for everyone and expand the 
influence of American preeminence in biomedical research to the areas 
of greatest need.

                       COORDINATION WITH PARTNERS

    Senator Harkin. Dr. Glass, thank you very much. Both of 
you, I appreciate your testimony and your leadership.
    Dr. Blount, in listening to you and sort of skimming 
through your testimony--I'm wondering if--tell me about 
coordination. I made a mark here on your testimony about, ``CDC 
needs to continue to engage our external partners, development 
of our strategic vision,'' et cetera, collaborations with WHO, 
Department of State, Agriculture, you mentioned AID.
    That's what I'm wondering, I'm wondering--what's the 
coordination between CDCP and AID? How about the Peace Corps, 
and Peace Corps workers in other countries? How much 
coordination is going on there to address some of these 
underlying problems of chronic--you mentioned we've got a 
shift, in the 21st century, shift into chronic, progressing to 
chronic illnesses--a lot of those have to do with 
infrastructure, public health and basic things like clean 
water, and waste disposal and basic sanitation systems, so you 
know, that's what you do--that's what CDCP is supposed to be 
doing, that's what AID does, some of it, and Peace Corps 
workers--so how much coordination do you do with these other 
people?
    Dr. Blount. Actually, Senator, thank you for that question. 
We spend a huge amount of time, in the case of PEPFAR, in the 
case of the President's Malaria Initiative, what's called the 
One U.S. Government Response. We coordinate our efforts in 
terms of the different roles and responsibilities we have--as 
you mentioned, USAID is a development agency. They're helping 
to build long-term capacity in the countries in which we work. 
As a technical agency, we have a major role in working with 
them, to help build that public health infrastructure.
    The Assistant Administrator of USAID, Kent Hill, and the 
head of the President's Malaria Initiative were in Atlanta just 
this past Friday, spending the day with Dr. Gerberding and our 
leaders to strengthen our collaboration. We've worked for many 
years with USAID and are finding ways to work even more closely 
with them.
    We also work, because of the nature of our mission, very 
closely with the State Department, helping in every one of the 
46 countries in which we work develop mission performance plans 
that indicate the funding that we have available, the staff, 
how they work closely as part of the Ambassador's mission 
there.
    You mentioned WHO. We're the largest contributor--our 
country is--to WHO, in it's headquarters and regional offices. 
We have more than 30 staff assigned to various WHO offices. We 
also, and you also quickly asked the point about chronic 
diseases and sanitation. We are shifting some of our emphasis 
to those chronic problems that Roger spoke about, doing it 
closely with USAID, and other U.S. Government partners.

              MICRONUTRIENT MALNUTRITION AND FORTIFICATION

    Senator Harkin. One thing you also mentioned in your 
testimony, you didn't mention verbally, but there's a private 
group that I'm aware of, I just lost the name right now, that 
is involved in providing multi--at least one multivitamin to 
kids in underdeveloped countries on an, you know, every day 
basis. You mentioned that here--vitamin supplementation.
    Now, a lot of times these kids just don't get the basic 
vitamins and minerals. So, you know, one good multivitamin and 
mineral supplement every day would be something I would think 
we could do at very low cost. So, is CDC involved in this? Are 
you doing something about trying to extend vitamin 
supplementation?
    Dr. Blount. Well, we are. I mentioned, just briefly, the 
supplementation of cereal grains with folic acid, and the 
impact that that's made in China, that's part of a broader 
effort looking at micro-nutrient malnutrition.
    I also quickly mentioned our work with WHO, USAID and 
others to add a single vitamin--Vitamin A--that improves the 
quality of sight. We help provide that at the same time that we 
do vaccinations for measles, and provide bed nets to prevent 
malaria, so we----
    Senator Harkin. Vitamin A has to do with a certain kind of 
blindness, if I'm not mistaken, right? The lack of Vitamin A.
    Dr. Blount. Yes.
    Senator Harkin. I saw a figure, and once again, I don't 
have it in front of me right now, but for this--a small cost of 
providing Vitamin A--what that would mean in terms of saving 
kids from going blind in these other countries--a very small 
cost. So, how come we're not doing more of that?
    Dr. Blount. Well, we are trying to do more, trying to find 
ways--just to your point, what are the most cost-effective 
interventions that can save lives, that can improve 
productivity, and that, as the Secretary said, leave a lasting 
legacy of improved health, that redounds to the benefit of our 
country--we're looking at different ways every day to do that.
    Senator Harkin. Well, again, it just seems to me the CDC 
has got a unique role to play in this. You're doing it, but you 
know, new times call for new approaches. I'd like to know how 
we shift from the acute illnesses, and focusing on those, to 
the more chronic illnesses, and how we get to the underlying 
causes of those. That's what my thing's about. If kids are 
malnourished and stuff, I mean, again, food obviously, but you 
know, a simple multivitamin and mineral every day would be a 
pretty darn good thing to give to a kid in an underdeveloped 
country, at very small cost.
    Dr. Blount. You're absolutely correct--USAID is working on 
that. We're working closely with them, again, trying to find 
the cheapest, most efficient way to provide this to the largest 
number of children. That, as part of building the 
infrastructure that must be available in order to deliver 
this--that's one of the major challenges in a number of 
countries, the trained healthcare providers--to meet with that 
mother, and take advantage of that one opportunity per year 
when she may bring a child to a healthcare center.
    Senator Harkin. Well, I'll tell you what, you build some 
incentives into a program for a healthcare worker in an 
underdeveloped country to keep people healthy--you build in 
those incentives--you'll get them to do it. But, you've got to 
have the incentives in there. Incentives means money. Paying 
people to provide those healthcare options--not just treating 
someone who is sick, but keeping people healthy, in terms of 
nutrition, that type of thing. There are ways of doing that, 
incentivizing it. We've really got to look at ways, better 
ways, of spending taxpayers' dollars, in terms of addressing 
long-term chronic problems in other countries.
    Again, we just--we go after the acute illnesses, but we've 
got to get upstream. We're just treating things downstream, and 
we've got to get upstream a little ways to take care of these 
before they break out.
    Again, I also want to ask you one other question: How close 
are we to eradicating polio from the face of the Earth? A few 
years ago, I thought we were down to one or two countries, I 
was told it was, maybe, by now we would have eradicated it. But 
now we seem to have fallen back a little bit. What's happening 
here?
    Dr. Blount. Two quick responses, Senator. To your first 
point, about moving upstream--the P in our name is for 
Prevention. We are the Nation's Prevention Agency; that is the 
substantial focus of our work.

                     TOBACCO PREVENTION AND CONTROL

    Let me mention the need to upgrade and modify our 
approaches--I didn't mention tobacco in the interest of time, 
but in fact, prevention of smoking among children across the 
world is a major effort of our Office on Smoking and Health----
    Senator Harkin. Good for you.
    Dr. Blount. Recently Mayor Bloomberg, through his private 
foundation, has pledged more than $200 million to improving the 
capacity of high-burden, low-income countries to confront the 
issues of tobacco. Through our partner, the CDC Foundation, we 
are working with those countries to conduct surveys of adult 
tobacco use that complement the surveys that we've helped to 
do, looking at tobacco use in children in 150 countries over 
the last few years. So, we are working closely with the 
Bloomberg Foundation on this very important preventable risk 
factor.

                           POLIO ERADICATION

    Let me come to your question about polio. You're right, 
sir, and Secretary Leavitt mentioned it--we are close, but 
we're not there yet. We are down to four countries--India, 
Afghanistan, Pakistan, and Nigeria, are the only countries in 
which polio is now endemic. In 1988, there were 350,000 cases 
of paralytic polio diagnosed every year--that's about 1,000 a 
day. This past year, 2006, we were down to 2,000 cases--from 
350,000 cases 19 years ago--that's enormous progress.
    As we've seen with smallpox eradication, it's those last 
few cases, the last few countries where the challenge has been 
so great.
    A last point, here, a point about the challenge of working 
in those four countries--almost every case we've found, working 
with WHO involves the Muslim community--that's the case in 
Nigeria, the Northern part of Nigeria, and is the case in 
India, Pakistan, and Afghanistan. So, we are working closely--
in fact, Dr. Gerberding was at a meeting yesterday with the 
countries that surround those four endemic countries--urging 
the leaders of those countries at greatest risk for importation 
of cases from the endemic countries, to ban together, to 
provide more resources to deal with this issue. We're close, 
Senator, but we're not there yet. Each administration, each 
Congress, has continued to provide support. We're doing 
everything that we can. We remain optimistic, but we don't 
minimize the challenges of the next few years--we will make it.
    Senator Harkin. I appreciate that. I hope we don't let up 
on it.
    Dr. Glass, on the Fogarty Center--again, tell me why is it 
important for us, the United States, to invest in research 
capacity of other nations? Why shouldn't we just be investing 
in research capacity here?
    Dr. Glass. That's a good question, Senator Harkin.
    The science and the discoveries that we make in medical 
research are global. As we develop new technologies, new 
techniques, we're really extending the reach of American 
science to all of these people who have been trained in the 
United States, who are linked to our universities. They're 
taking science to the periphery, to the real frontiers--the 
exciting frontiers.
    Just, for example, in Iowa, you have problems with 
pesticides. It's a big problem we fund through one of our 
environmental health grants, collaborations with some of the 
countries of Eastern Europe, so that where pesticide exposures 
are still a major problem, we can do research and understand 
how to address these problems together, and understand the 
cause of disease.
    Genetics--a new frontier. The United States is a melting 
pot of genes--we've all brought our genes from around the 
world. If we want to decipher the important causes of disease, 
we almost have to go back to those communities where these 
genetic diseases are common. This is now a technology that's 
available to us. We're discovering the genes of deafness--well, 
we have deafness in the United States that's genetic, but we 
can find it in studies that we're funding in the Palestinians 
and Pakistanis.
    We can look at other genetic links to diabetes, an 
incredibly important problem in the United States--15 percent 
of our health budget goes to diabetes. Now, we can look at 
genetic links of diabetes, and get at the roots of this disease 
in other populations.
    We're really extending the science we can do to the 
frontiers to the world, where these diseases are more common, 
where we can try new treatments--like I mentioned for extremely 
drug-resistant TB--there's a lot that we will discover by doing 
these studies overseas.
    Senator Harkin. Dr. Glass, I understand you've spent some 
time in Haiti?
    Dr. Glass. In Haiti.
    Senator Harkin. Tell me what the Fogarty Center is doing in 
Haiti?
    Dr. Glass. One of our first programs through our AIDS 
Program was to support Jean Pape, a young researcher from 
Cornell, who went back to Haiti--from Haiti originally--who 
developed an HIV program in Haiti. He started out with 
diarrheal diseases, and trained field workers around the 
country when HIV epidemic became identified, he was the first 
investigator--young investigator--to demonstrate the importance 
of HIV and describe it outside the United States. It's clearly 
now a global disease problem, and he was the first to identify 
it.
    He went on to demonstrate that you could control HIV in 
Haiti by controlling the blood supply, the private blood supply 
was contaminated in 50 percent of the cases in women, which 
came from the blood supply. He could stop that source 
immediately, and change the blood supply.
    Most recently, we wonder--what can you learn from Haiti 
about treatment? He's been able to demonstrate in treatment 
programs that he can actually get survivals and compliance with 
therapy as good as the United States, and he's just recently 
done the same for children.
    The impact of this has been enormous. He's got 30 treatment 
centers around the country, he's done basic research, and the 
incidence of HIV in Haiti has dropped from about 6 percent, a 
decade ago, to 2 percent today. Two-thirds decrease, because of 
this effort. A nice collaboration between Cornell, where he's a 
professor, and his group in Haiti, where he's trained 
researchers, and field workers.
    So, it's the best of international collaboration--we've 
learned from this experience, and we've delivered care, and 
he's an outreach of American research in Haiti.
    Senator Harkin. So, what was your involvement--I don't 
understand--what was the Fogarty involvement?
    Dr. Glass. Fogarty, we----
    Senator Harkin. Jean Pape, was that his name?
    Dr. Glass. Jean Pape, we gave Jean Pape his first grant, 
and we've supported his grants throughout this process. In the 
course of this, he's gotten other funding, he's trained up as a 
researcher, he's been able to attract other funding--from 
PEPFAR, for instance--he has a team in place that's been 
developed. We've invested in people, and without Jean Pape, and 
without that little circle of researchers, we would never be 
able to accomplish the tasks at hand. We have these small seed 
grants that are incredibly effective at building people and 
nurturing these relations with American Universities.

                          ACTIVITIES IN HAITI

    Senator Harkin. Dr. Blount, what are you doing in Haiti? 
What's CDC doing in Haiti?
    Dr. Blount. CDC has two major programs in Haiti, Roger 
mentioned the HIV effort. It is one--Haiti is one of the focus 
countries of the PEPFAR initiative. We have staff there, 
working with the Ministry of Health, with non-governmental 
organizations, with other multilateral agencies, with faith-
based U.S. organizations, working in Haiti on prevention and on 
treatment of HIV. Preventing mother to child transmission, 
providing antiretrovirals to people ill, and also materials and 
other efforts to prevent the disease.
    Second effort that we're working on, Senator, involves what 
are called, ``neglected tropical diseases.'' Particularly in 
the case of Haiti, a disease called alariasis, you may have 
heard it called elephantiasis, where you've seen the very 
large, enlarged limbs of men and women--this is a disease of 
poverty--we know that Haiti is the poorest country in this 
hemisphere.
    So, in trying to prevent--and to treat--this condition, 
we've been working with the University of Notre Dame, and other 
universities on research, on treatment, and particularly on 
prevention of this terrible condition. It's debilitating, it 
leads to social isolation, people are unable to work--but there 
are treatments, there are effective interventions to prevent 
the disease, among people, again, who have no choice. We're 
working very closely with the Government and others in Haiti, 
both in prevention of elephantiasis and HIV.

                     ADDITIONAL COMMITTEE QUESTIONS

    Senator Harkin. Good. Okay, I think that about concludes 
our--well, unless there's nothing else, I thank you both very 
much for your leadership and for your work in these areas.
    [The following questions were not asked at the hearing, but 
were submitted to the Department for response subsequent to the 
hearing:]

            Questions Submitted by Senator Daniel K. Inouye

    Question. Hawaii has the potential to be at the center of a major 
outbreak of infectious diseases or other public health threats due to 
in large part to the widespread international travel industry, as well 
its interface with the relatively low level of public health reporting 
in the poorer countries of Asia. Recently, the Centers for Disease 
Control (CDC) announced that it is establishing a forward base in 
Hawaii in order to strengthen its disease detection and response 
systems for the entire Asia-Pacific region. I appreciate the 
recognition by the Centers for Disease Control (CDC) of the unique 
contributions of Hawaii as a leader in response to potential regional 
epidemics. Dr. Blount, what is your vision of the role this Hawaiian 
CDC office will play in the global efforts of disease surveillance?
    Answer. The Pacific is a critically important location for the 
Centers for Disease Control and Prevention (CDC) and for the Department 
of Health and Human Services (HHS). The aspects of free association and 
the increasing ease and convenience of travel among the peoples in the 
Pacific and Asian countries may present avenues for spreading 
communicable diseases. In the past 10 years, the world has experienced 
several global, five public health emergencies caused by epidemic 
pathogens (H5N1, Nipah encephalitis, and Severe Acute Respiratory 
Syndrome or SARS) that, if detected early and responded to quickly, 
might have been contained at their point of origin. All of these 
outbreaks originated in the Asian-Pacific region, where future 
infectious disease epidemics with global potential, could also 
originate. This underscores the necessity of strengthening disease 
detection systems and response in the Pacific Basin, to protect the 
United States from infectious disease such as highly pathogenic avian 
influenza (H5N1).
    The plan for establishing a permanent presence in the Pacific is to 
have an HHS/CDC Senior Management Official placed in Hawaii, with an 
area of operations to include Hawaii, the four U.S. Territories, and 
two Freely Associated States (American Samoa, Guam, the Commonwealth of 
the Northern Mariana Islands, the Federated States of Micronesia, the 
Republic of the Marshall Islands, and the Republic of Palau). These 
Territories and States all receive domestic grants from HHS/CDC and a 
number of other HHS Operating Divisions. Additionally, the placement of 
a Senior Medical Epidemiologist in Hawaii would provide support to and 
build on HHS/CDC's growing pandemic influenza program, to include 
supporting disease surveillance systems, disease detection, and 
laboratory capacity in the region.
    While HHS/CDC's presence for the Pacific would be based in 
Honolulu, HI, it would form part of a broad-based public health network 
focused on U.S. Pacific interests. We have already formed a working 
group with senior staff members from the Hawaii State Department of 
Health; the U.S. Department of Defense--including the Pacific Command 
(PACOM), Tripler--U.S. Army Medical Center, and the Joint Task Force 
for Homeland Defense (JTFHD); the Pacific Islands Health Officer 
Association (PIHOA--which represents the Health Directors from the U.S. 
Territories and Freely Associated States); and the University of 
Hawaii--Asian-Pacific Institute for Tropical Medicine and Infectious 
Diseases.
    Question. In 2001, Hawaii experienced its first dengue fever 
outbreak since the mid-1940s, on the island of Maui. A report on this 
outbreak was done by the Hawaii State Department of Health, and 
published in the CDC's Emerging Infectious Diseases journal, that 
suspected the Maui outbreak resulted from travelers that visited 
Tahiti. Before this outbreak Dengue fever cases were the result of 
``imported'' infections, and this report found that the Aedes 
albopictus mosquito species, prevalent in Hawaii and found in 24 States 
in the contiguous United States, could be in addition to the Aedes 
aegypti mosquito. Realizing that such an incident requires an 
interagency response could you elaborate on how your Center fits into 
this picture?
    Answer. The response to an outbreak of an exotic, vector-borne 
disease, such as has occurred with dengue, malaria, and West Nile 
viruses, or could occur with the continued risk of chikungunya or Rift 
Valley Fever from imported cases because of the presence of competent 
vectors in the United States, requires close interagency coordination. 
In a situation such as described above, the Centers for Disease Control 
and Prevention (CDC) within the U.S. Department of Health and Human 
Services (HHS) assists State health departments with outbreak response 
and the diagnosis of specimens, including genetic sequencing to 
determine the origin of the pathogen. HHS/CDC also offers expert 
support to States in identifying the vectors and helping to organize 
vector control, as well as providing epidemiology assistance. Often 
other Government agencies will also participate as part of the response 
team, depending on the nature of the threat and the needs of the 
affected States. The response can involve immigration and quarantine 
issues, and if the pathogen is one harbored in animals, the U.S. 
Department of Agriculture's Animal and Plant Health Inspection Service 
(APHIS) and the U.S. Department of the Interior's Fish and Wildlife 
Service could be involved.
    Question. I would also like you to comment further on the CDC's 
global health initiatives that pertain to the Asia-Pacific region 
outside of the realm of influenza or SARS? Given Hawaii's unique 
geographic location, the State's Department of Health has in place a 
plan should sick passengers be heading to Hawaii from parts of Asia. In 
what capacity is your Center's monitoring network being developed, or 
augmented? In addition, I would also like you to comment on work being 
done on ``neglected tropical diseases'' outside of HIV/AIDS, malaria, 
and TB.
    Answer. Disease Detection.--The Global Disease Detection (GDD) 
program of the Centers for Disease Control and Prevention (CDC) within 
the U.S. Department of Health and Human Services (HHS) aims to protect 
the health of Americans and the global community by developing and 
strengthening the capacity to rapidly detect and respond to emerging 
infectious diseases and bioterrorist threats. The central focus of the 
program is the establishment and expansion of the GDD Centers, which 
are HHS/CDC-funded international centers of excellence in the detection 
and control of emerging infectious diseases.
    HHS/CDC currently operates five GDD Centers--including a mature 
center in Thailand and a developing center in China. Other Centers are 
located in Kenya, Guatemala, and Egypt. These Centers monitor a broad 
range of infectious diseases within the host country and the region, 
and conduct activities that enhance the capacity of Government 
Institutions (such as the Ministry of Health) to detect and respond to 
such diseases. For example, in 2006, the Thailand Center expanded an 
ongoing pneumonia surveillance system by adding advanced microbiology 
diagnostic capacity. Within 10 months of implementation, the Center had 
begun to describe the bacterial causes of pneumococcal disease at a 
rate more than six-fold higher than the previous 3 years combined. This 
new capacity produces reliable information to identify appropriate 
public health interventions, including the potential use of 
pneumococcal vaccines.
    In addition, the GDD Operations Center (located in HHS/CDC's 
Emergency Operations Center in Atlanta) is HHS/CDC's central analytical 
clearinghouse for information gathering, monitoring, and responding to 
international outbreaks. HHS/CDC collects information about outbreaks 
worldwide, from many different sources (including WHO, the U.S. 
Department of State, the U.S. Department of Defense, and others) and 
analyzes it by using the expertise of scientists across the Department. 
HHS/CDC is then able to determine the threat posed by a given event and 
initiate appropriate response actions.
    HHS/CDC also has assets located in a number of other Asian 
countries. In 2006, the Department placed in Asia staff dedicated to 
pandemic influenza preparedness and training, including in the People's 
Republic of China, Viet Nam, Cambodia, Laos, Thailand, Indonesia, and 
at two Regional Offices of the World Health Organization (WHO), in 
Manila and New Delhi. Through the President's Emergency Plan for AIDS 
Relief, HHS/CDC also has staff posted to U.S. Embassies in India, 
Cambodia, Thailand, Viet Nam, and the People's Republic of China. The 
Department has Health Attaches assigned to the U.S. Embassies in 
Beijing, Hanoi, and New Delhi, who work on a wide range of health 
issues, and help to coordinate the work of HHS/CDC and the HHS National 
Institutes of Health. Finally, HHS/CDC has an expert on loan to the 
International Center for Diarrheal Disease Research (ICDDR-B) in 
Bangladesh, which has an extensive disease surveillance and research 
network.
    HHS/CDC and other parts of the Department also fund several 
regional institutions (including ICDDR-B, the Institute Pasteur 
International Network in Southeast Asia, and the Regional Emerging 
Disease Investigation Center in Singapore) for work on influenza and 
other disease priorities.
    Neglected Tropical Diseases.--Estimates are that 1 to 3 billion 
people worldwide are at-risk for one or more of a group of maladies 
collectively known as neglected tropical diseases (NTDs). These 
diseases are responsible for tremendous illness and death worldwide, 
and pose direct threats to the health of the American public. Yet 
efforts to reduce or eliminate these diseases have historically 
received little attention and few resources. For five of these NTDs--
lymphatic filariasis (elephantiasis), onchocerciasis (river blindness), 
schistosomiasis, soil transmitted helminths (Ascaris, Trichuris, 
hookworm), and trachoma--disease control or elimination is possible 
through a strategy of mass drug administration, with annual or semi-
annual doses of safe and effective oral medicines; and for one, Guinea 
worm, simple filtration through cloth filters or the use of insecticide 
applied to drinking water. HHS/CDC is actively working with a broad 
range of partners to bring much-needed treatments and preventive 
interventions to those in greatest need, and is also working on 
critical continued monitoring and evaluation of NTDs to maximize the 
impact of the most effective control strategies.
    HHS/CDC offer technical support and expertise in monitoring and 
evaluation to partners that are developing or operating NTD programs, 
and conducts our own operational research that helps to define best 
practices for NTD programs. Since programs to target individual NTDs 
began in the 1990's, HHS/CDC has:
  --Initiated in partnership with WHO, eradication program for Guinea 
        worm;
  --Tested intervention methods (filters, Abate) against Guinea worm;
  --Developed improved surveillance and containment strategies for 
        cases of Guinea worm;
  --Developed molecular assay to confirm/distinguish human Guinea worm;
  --Conducted research that provided the foundation for the global 
        strategy to eliminate lymphatic filariasis;
  --Developed monitoring and evaluation guidelines for the World Health 
        Organization (WHO);
  --Monitored and evaluated the safety and effectiveness of combination 
        drug therapy in mass-treatment interventions;
  --Developed collaborations with partners on a project to design, 
        implement, monitor, and evaluate integrated programs to 
        eliminate co-endemic NTDs;
  --Provided technical assistance in the monitoring and evaluation of 
        NTDs in more than 10 countries (including mapping, coverage 
        surveys, and the assessment of social mobilization); and
  --Evaluated new serologic tools and epidemiologic approaches to 
        conduct surveillance for onchocerciasis, lymphatic filariasis, 
        and schistosomiasis.
    Financing from the Bill and Melinda Gates Foundation and donations 
of drugs from pharmaceutical manufacturers have jump-started NTD 
programs. Additional partners include Ministries of Health, the World 
Health Organization, the Pan American Health Organization, schools of 
public health and other academic institutions, non-governmental 
organizations and pharmaceutical companies.
    Question. In your testimony, you discuss the power of health 
diplomacy to not only prevent disease and mitigate global health risks, 
but to strengthen perceptions of the United States abroad. In the 
National Security Strategy, President Bush charges the United States to 
``promote development programs that achieve measurable results--
rewarding reforms, encouraging transparency, and improving people's 
lives.'' Secretary Leavitt, would you discuss how you will measure the 
effectiveness of global health programs with respect to health 
diplomacy. Does the HHS have any plans to reinstate its previous 
practice of positioning Public Health Commissioned Corps into other 
U.S. Government Agencies?
    Answer. The U.S. Government invests millions of dollars each year 
in health programs in countries throughout the world. Since 2001, the 
United States has spent almost $1 billion on health programs in Latin 
America alone. While this financial commitment is important, money 
alone can only do so much. The health diplomacy initiatives in which 
HHS participates seek to add the human element to our health care 
assistance. With other Federal departments and the non-governmental 
organizations, HHS is becoming more directly involved in seeing that 
the people of foreign countries get the health care they need. This 
effort has focused on three main objectives:
    Increasing direct patient care provided by U.S. personnel; working 
closer with American charities to provide more, and better, health 
care; and improving the training of local health workers.
    Regarding the first objective, HHS and the U.S. military are 
becoming more directly involved in the delivery of medical, dental and 
public health services in various countries throughout the world.
    For example, through participation this summer on joint missions 
aboard Navy ships such as the USNS Comfort and the USS Peleliu, U.S. 
Public Health Service Commissioned Officers from HHS (and other Federal 
Departments) have been delivering care and providing public health 
services to indigenous populations in numerous countries. The outcome 
of these missions can be measured in many ways. The number and types of 
clinical encounters can be tallied. The public health assessments and 
interventions can be recorded. The collective impact of these clinical 
and professional services has already been profound, and recognized as 
such by both the political, medical and professional leadership within 
the countries visited by the ships. But perhaps more importantly, the 
generosity of the United States and the compassion of its people have 
been recognized by the people who have been the recipients of the 
health care and public health services provided. Surveys done following 
the visit of such hospital ships have consistently shown a dramatic 
improvement in attitudes toward America and the American people.
    Our second objective is working closer with American health-care 
providers in the region. Often this involves coordinating care with 
non-governmental organizations which are based in the United States 
and/or have significant numbers of health professionals in the 
countries where we are also investing resources. By coordinating 
health-care delivery, we can do a better job of making the most of 
available resources, in both the private and public sectors. The 
results of these collaborative efforts can be measured by U.S. 
Government personnel on the ground as well as by our non-governmental 
partners.
    Our third objective is to improve the training of health workers. 
The need for better training of health workers has been a consistent 
message we have heard from health ministers throughout the world. In 
addition to the highly professional physicians, dentists, and nurses 
that many of these countries already have, they need more trained sub-
physicians, sub-nurses, medical and dental technicians, and community 
health workers. By investing some of its resources toward this end, HHS 
is partnering with some countries to help them develop more of these 
health professionals. Hopefully, the outcome will be a strengthened 
health care system within those countries--a system that can better 
address its health care needs before those needs reach our borders.
    One example of this collaboration is the Regional Training 
Institute recently opened in Panama. The center opened its doors for 
the first time in April at the City of Knowledge in Panama City. Fifty 
students from all six partner countries attended. The faculty included 
regional experts as well as experts from American universities and HHS. 
The curriculum for the first training module focused on a challenge 
every country in the world faces: pandemic influenza.
    Initial results of this training were very encouraging. Pre- and 
post-course knowledge tests demonstrated a high level of learning among 
the students. Student feedback after the course indicated that the 
training was highly beneficial to them.
    The solution to our shared challenges is shared expertise. By 
working together, we can improve the health of the people of various 
regions of the world, build a common defense against disease, and bring 
all of our countries closer.
    There is no need to re-instate the practice of assigning 
Commissioned Officers to other Departments; we have not stopped and 
continue to provide such support today.
    The Commissioned Corps of the U.S. Public Health Service supports 
the public health activities and missions of several U.S. Government 
Agencies by detailing approximately one-third of its officers or over 
1,900 officers outside the Department of Health and Human Services. The 
Corps has a statutory commitment to provide health care services and 
health providers in support of the Federal Bureau of Prisons (641 
officers), U.S. Environmental Protection Agency (77 officers) and the 
U.S. Coast Guard (172 officers). Other Departments where Corps officers 
are detailed include: Department of State (7 officers); Department of 
Homeland Security (250 officers); Department of Interior (31 officers); 
U.S. Department of Agriculture (21 officers); Department of Justice, 
U.S. Marshals Service (22 officers); and Tribal Health Programs (over 
1,000 officers). The Corps will soon enter into an agreement to support 
the Department of Defense by assigning Corps officers to military 
treatment facilities providing mental health care and critical care to 
the men and women of our armed services and to their families.
    Question. In your testimony, you describe how the Navy supported 
humanitarian missions to provide healthcare in the Caribbean and in 
Central and South America, and most recently deployed the USS Mercy on 
a PACOM mission. However, most humanitarian missions require an 
interagency approach. In 1998, I established the Center for Excellence 
in Disaster Management and Humanitarian Assistance in Hawaii, to study 
civil-military operations in response to international disaster 
management, humanitarian assistance and interagency coordination. 
Secretary Leavitt, can you describe the interagency coordination you 
expect to be involved in public health diplomacy through HIV/AIDS 
mitigation, pandemic outbreak preparedness and disease research and 
public health education such as the Center for Excellence in Disaster 
Management and Humanitarian Assistance at U.S Pacific Command, Armed 
Forces Research Institute for Medical Sciences (AFRIMS) in Bangkok, or 
the Naval Medical Research Unit in Djakarta?
    Answer. Much of our current and future work in public-health 
diplomacy would not be possible without close interagency coordination, 
especially with the U.S. Agency for International Development (USAID), 
and the U.S. Departments of Defense (DOD) and Agriculture (USDA). As an 
example, the Department has experts assigned to the DOD Navel Advanced 
Medical Research Units (NAMRU) in Lima, Peru and Cairo, Egypt, and 
funds disease-surveillance, research, laboratory and training 
activities at those two facilities and its sister lab in Jakarta, 
Indonesia. Commissioned Corps officers from the HHS Public Health 
Service are serving on billets with DOD in Afghanistan to assist in the 
reconstruction of the health-care infrastructure of that country, both 
on the staff of the Command Surgeon of the combined Security Transition 
Command and on Provincial Reconstruction Teams. Also, HHS officers 
served with distinction this summer on the humanitarian missions of the 
USNS Comfort and the USS Pelilieu in Latin America and the Caribbean 
and the Pacific, respectively, and the Department is negotiating 
arrangements to deploy with DOD medical and dental missions in Central 
America in fiscal year 2008. Finally, jointly funded projects and 
personnel arrangements with USAID are also a common feature of our 
international programming.
    I should also note that for several years the Office of Global 
Health Affairs in my Department had a Commissioned Corps officer 
assigned on a detail to the Center for Excellence in Disaster 
Management and Humanitarian Assistance in Hawaii, an association that 
was productive.
    Question. Could you please comment on the Fogarty International 
Center's research initiatives in the ``neglected tropical disease'' 
area, and those that pertain to waterborne diseases, as well as other 
vector borne diseases, some of which can also be found in the United 
States and U.S. Territories which have more tropical and sub-tropical 
climates?
    Answer. The Fogarty International Center (FIC), within the National 
Institutes of Health (NIH) of the U.S. Department of Health and Human 
Services (HHS), funds several research and research-training efforts 
focused on neglected tropical diseases, as well as water-borne and 
vector-borne infectious diseases.
    Examples include the following:
    (1) The Ecology and Infectious Diseases (EID) Research Program, in 
which innovative, multidisciplinary research projects define factors 
that drive transmission of infections in the United States and 
globally, and create predictive models for the spread of these 
diseases.
    (2) The Global Infectious Disease (GID) Research Training Program 
funds collaborations between United States and developing-country 
institutions to build research capacity and expertise in malaria, 
tuberculosis, and many of the high prevalence, more neglected 
infections that cause significant disability and mortality world-wide. 
Some of these activities include the following:
    (A) Leptospirosis.--Leptospirosis is a zoonotic bacterial disease 
often carried by animals that contaminate standing water contacted by 
people who are living in poor peri-urban or rural agricultural areas. 
Untreated, this illness can result in kidney damage, meningitis, liver 
failure, and respiratory distress. Recent outbreaks of leptospirosis in 
the United States have occurred in Illinois and Florida (1998), while 
leptospirosis is endemic to Hawaii and many developing countries, where 
millions of cases occur, and fatality rates range as high as 20-25 
percent. One long-term GID research program through Cornell University, 
together with Brazilian scientists, sequenced the organism's genome, 
developed a patented leptospirosis diagnostic test, and is currently 
testing an experimental vaccine.
    (B) Dengue Fever.--Dengue fever is a viral disease transmitted by 
Aedes mosquitoes in most tropical areas of the world. Each year, tens 
of millions of cases of dengue fever occur, and, depending on the year, 
up to hundreds of thousands of cases of dengue hemorrhagic fever. 
Locally acquired cases of dengue fever occurred in southern Texas in 
1980, and were associated with epidemic dengue in adjacent States in 
Mexico. The most recent cases occurred in 2005. A limited outbreak of 
dengue fever occurred in Hawaii in 2001, associated with epidemic 
dengue in the South Pacific. HHS/NIH/Fogarty supports two dengue 
research-training programs--one in Peru and another in Mexico.
    (C) Cholera.--Cholera is an acute, diarrheal illness caused by 
infection of the intestine with the bacterium Vibrio cholerae, 
primarily by ingesting contaminated water or food. In January 1991, 
epidemic cholera appeared in Peru, and quickly spread to several 
countries via contaminated food carried on a flight from Argentina to 
Los Angeles. In 2005, 131,943 cases from 52 countries were reported to 
the World Health Organization, with nearly 95 percent of the cases from 
Africa. Current vaccines confer brief and incomplete immunity. HHS/NIH/
Fogarty currently funds a research training program grant at the 
Massachusetts General Hospital to train Bangladeshi scientists at the 
International Diarrheal Disease Research Center (IDDRC), as well as to 
conduct research on cholera vaccine candidates at this same center.
    (D) Hantavirus.--Humans contract hantavirus pulmonary syndrome when 
they come into contact with infected rodents. The disease was first 
recognized in the Four Corners area of the United States in 1993 
(Arizona, New Mexico, Colorado and Utah). It has since been identified 
in 30 U.S. States, including most of the western half of the country. 
Thirty-five percent of all reported cases have resulted in death. 
American Indians account for about 19 percent of cases, and Hispanics 
account for 14 percent of the cases. Outbreaks occurred in Argentina in 
1996, in Chile in 1997, and in Panama in 1999. HHS/NIH/Fogarty funds 
training and research grants related to hantavirus transmission in 
Paraguay, Brazil and Chile.
    (3) HHS/NIH/Fogarty has provided funding at levels of approximately 
$5 million for work on neglected diseases in fiscal year 2006 and 
expects a similar funding level in fiscal year 2007.

                         CONCLUSION OF HEARING

    Senator Harkin. Thanks for being here this morning. That 
concludes our hearing.
    [Whereupon, at 10:40 a.m., Wednesday, May 2, the hearing 
was concluded, and the subcommittee was recessed, to reconvene 
subject to the call of the Chair.]

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