[House Hearing, 113 Congress]
[From the U.S. Government Publishing Office]



 
                  THE U.S. CONTRIBUTION TO THE FIGHT 
                            AGAINST MALARIA

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


                          HEARING AND MEETING

                               BEFORE THE

                 SUBCOMMITTEE ON AFRICA, GLOBAL HEALTH,

                        GLOBAL HUMAN RIGHTS, AND

                      INTERNATIONAL ORGANIZATIONS

                                 OF THE

                      COMMITTEE ON FOREIGN AFFAIRS

                        HOUSE OF REPRESENTATIVES

                    ONE HUNDRED THIRTEENTH CONGRESS

                             FIRST SESSION

                               __________

                              MAY 17, 2013

                               __________

                           Serial No. 113-60

                               __________

        Printed for the use of the Committee on Foreign Affairs


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                      COMMITTEE ON FOREIGN AFFAIRS

                 EDWARD R. ROYCE, California, Chairman
CHRISTOPHER H. SMITH, New Jersey     ELIOT L. ENGEL, New York
ILEANA ROS-LEHTINEN, Florida         ENI F.H. FALEOMAVAEGA, American 
DANA ROHRABACHER, California             Samoa
STEVE CHABOT, Ohio                   BRAD SHERMAN, California
JOE WILSON, South Carolina           GREGORY W. MEEKS, New York
MICHAEL T. McCAUL, Texas             ALBIO SIRES, New Jersey
TED POE, Texas                       GERALD E. CONNOLLY, Virginia
MATT SALMON, Arizona                 THEODORE E. DEUTCH, Florida
TOM MARINO, Pennsylvania             BRIAN HIGGINS, New York
JEFF DUNCAN, South Carolina          KAREN BASS, California
ADAM KINZINGER, Illinois             WILLIAM KEATING, Massachusetts
MO BROOKS, Alabama                   DAVID CICILLINE, Rhode Island
TOM COTTON, Arkansas                 ALAN GRAYSON, Florida
PAUL COOK, California                JUAN VARGAS, California
GEORGE HOLDING, North Carolina       BRADLEY S. SCHNEIDER, Illinois
RANDY K. WEBER SR., Texas            JOSEPH P. KENNEDY III, 
SCOTT PERRY, Pennsylvania                Massachusetts
STEVE STOCKMAN, Texas                AMI BERA, California
RON DeSANTIS, Florida                ALAN S. LOWENTHAL, California
TREY RADEL, Florida                  GRACE MENG, New York
DOUG COLLINS, Georgia                LOIS FRANKEL, Florida
MARK MEADOWS, North Carolina         TULSI GABBARD, Hawaii
TED S. YOHO, Florida                 JOAQUIN CASTRO, Texas
LUKE MESSER, Indiana

     Amy Porter, Chief of Staff      Thomas Sheehy, Staff Director

               Jason Steinbaum, Democratic Staff Director
                                 ------                                

    Subcommittee on Africa, Global Health, Global Human Rights, and 
                      International Organizations

               CHRISTOPHER H. SMITH, New Jersey, Chairman
TOM MARINO, Pennsylvania             KAREN BASS, California
RANDY K. WEBER SR., Texas            DAVID CICILLINE, Rhode Island
STEVE STOCKMAN, Texas                AMI BERA, California
MARK MEADOWS, North Carolina


                            C O N T E N T S

                              ----------                              
                                                                   Page

                               WITNESSES

Rear Admiral Tim Ziemer, U.S. Global Malaria Coordinator, 
  President's Malaria Initiative.................................     7
Colonel Peter J. Weina, Ph.D., M.D., Deputy Commander, Walter 
  Reed Army Institute of Research, U.S. Department of Defense....    20

                                BRIEFER

The Honorable Mark Dybul, executive director, The Global Fund to 
  Fight AIDS, Tuberculosis and Malaria...........................    42

          LETTERS, STATEMENTS, ETC., SUBMITTED FOR THE HEARING

Rear Admiral Tim Ziemer: Prepared statement......................    10
Colonel Peter J. Weina, Ph.D., M.D.: Prepared statement..........    22
The Honorable Mark Dybul: Prepared statement.....................    46

                                APPENDIX

Hearing notice...................................................    70
Hearing minutes..................................................    71


           THE U.S. CONTRIBUTION TO THE FIGHT AGAINST MALARIA

                              ----------                              


                          FRIDAY, MAY 17, 2013

                       House of Representatives,

                 Subcommittee on Africa, Global Health,

         Global Human Rights, and International Organizations,

                     Committee on Foreign Affairs,

                            Washington, DC.

    The subcommittee met, pursuant to notice, at 10 o'clock 
a.m., in room 2172, Rayburn House Office Building, Hon. 
Christopher H. Smith (chairman of the subcommittee) presiding.
    Mr. Smith. The committee will come to order, and good 
morning to everyone, and thank you for being here this morning, 
especially at this hearing to examine the United States' 
contribution to the global fight against malaria.
    Leadership matters. In 2005, President George W. Bush 
established the President's Malaria Initiative, or PMI, and 
then targeted several African malaria endemic countries to 
receive over $1 billion to mitigate and, some day, eradicate 
this killer disease. The positive consequences of that bold and 
compassionate initiative now include over 1 million lives saved 
over the last decade. The program and its expansion and 
sustainability of the funding have been all important in that 
battle.
    Although we will hear statistics about malaria cited 
several times during the course of this hearing, the global 
impact of this disease is so severe that they are worth 
repeating, and I say that, even though we are making progress.
    The World Health Organization estimates that in 2010, there 
were 219 million malaria cases and 660,000 deaths. While still 
unconscionably high, and every life is absolutely precious and 
of extraordinary importance, the loss of life has declined from 
approximately 985,000 deaths in 2000.
    Not surprisingly, malaria has a particularly devastating 
impact on the most vulnerable. Nearly 86 percent of those who 
died are children under 5 years of age, living in sub-Saharan 
Africa. Dr. Mark Dybul, executive director of the Global Fund 
and George W. Bush's extraordinarily effective Global AIDS 
coordinator, says that, in Africa alone, malaria takes a life 
of a child every minute. He also notes, as do our other 
panelists, that pregnant women are also disproportionately 
affected with the disease.
    WHO emphasizes in its 2012 World Malaria Report that 
malaria is strongly associated with poverty. Countries in which 
a larger percentage of the population lives in poverty also 
have a higher mortality rate from malaria. Children living in 
poorer populations, and in rural areas, have the highest 
parasite prevalence rates. And it is also important to note, to 
the extent to which the prevalence of malaria is concentrated, 
80 percent of malaria deaths occur in just 14 countries, and 
almost 80 percent of cases occur in 17 countries.
    Over 40 percent of malaria deaths occur in just two 
countries. The Democratic Republic of the Congo and Nigeria, 
and 40 percent of the malaria cases are in the Democratic 
Republic of the Congo, Nigeria, and in India. These high 
morbidity and mortality rates are not necessary. Malaria is 
both preventable and treatable. We will hear today from our 
distinguished witnesses who are leaders in the field about the 
cost-effective measures that are currently available and 
already having a profound impact or are in the development 
process.
    And the United States, despite the current financial 
constraint, is making a significant contribution to the global 
fight against malaria. In addition to our contribution to the 
Global Fund to Fight AIDS, Tuberculosis and Malaria, the United 
States provided $871 million in anti-malaria assistance in 
Fiscal Year 2012 alone, and the request for Fiscal Year 2014 is 
$893 million.
    But these levels, even when combined with contributions 
from other donors, do fall short of the global need. So our 
question today will be, ``What are the major challenges going 
forward and how can we best use our resources to meet those 
challenges to save the most lives and have the greatest impact 
in controlling, if not eradicating, this dreaded disease?''
    We will also be taking a close look at several immediate 
threats to global efforts to combat malaria. On April 23, this 
subcommittee held a hearing on ``Meeting the Challenges of 
Drug-Resistant Diseases in Developing Countries.'' In his 
testimony at our hearing, Dr. Thomas Friedman, director of the 
Centers for Disease Control and Prevention, warned that in 
recent years, malaria infections in parts of Southeast Asia 
have been showing resistance to artemisinin drugs. These drugs 
are the last remaining class of anti-malarial drugs and form 
the basis of malaria treatment globally. If these resistant 
parasites manage to spread to sub-Saharan Africa, he stated 
that the results could be ``devastating,'' an assessment that 
will likely be repeated by our witnesses today.
    Insecticide-treated nets, bednets, which have an average 
useful life of 2 to 3 years are also an extremely important 
malaria prevention tool. According to WHO, 150 million nets are 
needed each and every year to provide protection to the 
vulnerable populations in sub-Saharan Africa. For the past 2 
years, however, the supply has been considerably lower than 
this level, resulting in an estimated current shortfall of 77 
million nets. The consequences, if not urgently addressed, 
could place entire populations, especially children, at risk of 
a dramatic malaria resurgence, and of course that means more 
death and more morbidity.
    We are fortunate again to have three distinguished experts 
who will provide us with valuable insights. These are truly 
leaders in this field. C-SPAN is here and we are grateful they 
are here. I would hope that Americans would sit up and take 
note of the extraordinary work you three individuals are doing.
    You know, people sometimes are very dismissive of foreign 
aid and initiatives that taxpayer funds are used for. This is 
one of the greatest success stories. It is not the only one, 
there are many, but this is one of the greatest success 
stories, but it is a work that remains unfinished. I thank our 
witnesses for being here and for being such leaders.
    I would like to now yield to Mr. Bera.
    Mr. Bera. Thank you, Chairman Smith, and thank you for 
holding today's hearing and the series of hearings on global 
health, incredibly important topics, and I look at this from 
the perspective of being a doctor who has worked 
internationally, and the work that you guys are doing is 
incredibly important, and I look forward to hearing your 
testimony.
    You know, as has already been mentioned, there are over 219 
million cases of malaria worldwide. The Democratic Republic of 
the Congo, India, and Nigeria account for 40 percent of all 
malaria cases. Those cases account for over 600,000 deaths in 
2010. Very preventable. So this is an incredibly important 
issue.
    Like so many other diseases, you know, with the right 
policy, with the right partnerships, we can save hundreds of 
thousands of lives. Unfortunately, far too often, these tools 
are not reaching those in need, and I am looking forward to 
hearing the testimony of best practices and how we get the 
therapies and the prevention and the nets out to those where we 
can make the biggest difference.
    You know, while malaria continues to take the lives of 
children and adults, you know, we also have seen the 
international community coming together and some great 
demonstrations of remarkable success. The Global Fund, the 
President's Malaria Initiative, the Gates Foundation, the World 
Health Organization, just to name a few, have helped reduce 
unnecessary deaths in Africa by an estimated 33 percent in less 
than a decade. We can still do better.
    The fund has 779 active grants, 217 of which are for 
malaria. It has approved almost $7 billion or 27 percent of its 
funds in the fight against malaria. Since 2000, malaria 
mortality rates from fallen by more than 25 percent and 50 
countries are on course to reduce malaria incidence by 75 
percent by the end of 2015. These are efforts to be applauded.
    Again, I look forward to supporting and doing more. 
Chairman Smith has done an excellent job laying out the 
profound challenges that we face in fighting malaria. I would 
like to share with the committee just a couple of success 
stories over the course of testimony, and I certainly look 
forward to hearing the success stories and the best practices.
    In addition, you know, today we don't have a vaccine that 
prevents someone from being infected with malaria, but I am 
here to say as a research scientist, as a physician, there is 
nothing that we can't do in this country and in our academic 
community if we set our minds to it, and ultimately, that is 
where we need to go if we want to truly prevent disease and 
save lives.
    So thank you for being here, thank you for the testimony. 
You know, I look forward to hearing from each of you and, you 
know, again, Chairman Smith, thank you for calling this 
important hearing.
    Mr. Smith. Thank you very much. I would like to now yield 
to Mr. Weber.
    Mr. Weber. Thank you, Mr. Chairman. Very important topic. I 
appreciate the opportunity to be here and have this hearing. My 
dad, one of the last of the greatest generation, 88 years old, 
served in the Philippines, contracted malaria. To this day, he 
cannot give blood. He has the rarest blood type there is. Half 
a percent of America has AB negative, which is what I have, and 
now you know what is wrong with me. But just a great guy. I try 
to give blood as often as I can, and so it is very, very 
important, because that keeps those who contract the disease 
from giving blood. I think it is very vital, so I appreciate 
being here and looking forward to the testimony. Thank you.
    Mr. Smith. Thank you very much, Mr. Weber. Just 
parenthetically, my father, too, served in World War II in New 
Guinea. He was a combat infantryman, and he got malaria, and my 
family was very well aware of the impact it had on him as well, 
so thank you.
    I would like to now yield to Mr. Cicilline.
    Mr. Cicilline. Thank you, Chairman Smith, and thank you to 
you and Ranking Member Bass for holding today's hearing on the 
role of the United States in the fight against malaria, and I 
want to thank my colleague and friend, Congressman Bera--Dr. 
Bera for his leadership on this issue and on issues of global 
health in general. This remains a serious worldwide public 
health emergency. The World Health Organization estimates that 
219 million cases of malaria worldwide with 660,000 malaria 
deaths, so this is still an urgent, urgent issue.
    I want to begin by offering my gratitude to the witnesses 
not only for being here today and for your testimony, but for 
your incredible leadership in the work that you have led that 
is making a real difference all across the world as we combat 
this scourge of this disease.
    Our country, the United States, has a vested interest in 
addressing health conditions around the world in order to 
improve lives, to strengthen the economies of our trading 
partners, and to maintain our moral leadership position in the 
world. I think it is concerning to all of us that malaria 
remains a leading cause of death in many countries, especially 
when we have made such astonishing gains in health care here at 
home, and I hope that the United States will continue to 
support the funding of global health development as we 
transition to country ownership and eventually eradication of 
this disease and that we continue to value the work of the 
Global Fund to Fight AIDS, Tuberculosis and Malaria, the Gates 
Foundation, the President's Malaria Initiative, and to just 
note that these are, as Chairman Smith said, great success 
stories of what our role around the world has been when we make 
the right kinds of investments, and these have been bipartisan 
efforts, and I know they will continue to be, and I thank the 
chairman again and yield back.
    Mr. Smith. Thank you very much. I would like to yield to 
Mr. Meadows.
    Mr. Meadows. Thank you, Mr. Chairman, and thank you to each 
one of you for your service to our country. We appreciate it. 
We are here today to address a disease that has been a scourge 
on humanity for almost our entire history. And as we have been 
fighting malaria for a very long time, it is encouraging to see 
how far we have come, but also what is left to be done, and so 
I look forward to your testimony today.
    We have seen malaria generally eradicated in the developed 
world and, but yet there is still a lot of work to do. As you 
know, some 80 percent of malaria deaths occur in just 14 
countries, and as we see that, you know, 80 percent of the 
cases and 90 percent of the deaths occur in Africa, and we have 
learned over the past 60 years that eradicating this disease is 
an ongoing challenge requiring multiple efforts working in 
concert and there is no magic bullet to do that.
    We heard testimony even in this very room in a hearing that 
the chairman conducted from the CDC offering some of the 
challenges that we face with different strains that are 
resistant to even the drugs that we have today, and so I am 
encouraged by Dr. Bera. We have teamed up on a number of 
bipartisan initiatives to try to work on finding some of those 
solutions, and so I look forward to hearing your testimony.
    I am proud of the role that the U.S. has played in this 
ongoing struggle. It has really been our leadership that has 
really worked very well, and I am mindful that that does not 
mean that we can advocate our duties to be good stewards of the 
taxpayers' money either. And corruption cannot be tolerated in 
any manner.
    I have traveled a number of times to Africa, and when you 
start to see the lack of accountability in certain areas, it 
gives you great concern, and so part of the reason for holding 
this hearing is so that we remain vigilant in that we work 
against the bad actors that we have to deal with, but also that 
we encourage others and those that are suffering, certainly, 
that we come to their aid.
    This would include pressuring local governments and making 
sure that we have the encouragement there, not just from an 
oversight standpoint, but to make sure that what we do is that 
the American taxpayers' dollars are invested wisely. When we do 
that, there is always a drawback. You know, when I go back 
home, there is a consistent call, ``Why are we giving aid? We 
have people that are hungry and out of work here. Why are we 
doing that?'' I would look for some of the testimony and really 
what it might do in terms of our men and women that serve in 
some of the things that we have in terms of challenges, not 
just from a global perspective, but as we bring that back home, 
and so I would look for each one of you to hopefully address 
that.
    You know, Fiscal Year 2014, we look at both in USAID and 
the CDC have both requested increases in their funding as we 
see that, and what I would love to see from you is how I can 
make sure that we put forth and share with the voters back home 
that not only are we being wise stewards, but that we are being 
accountable and we are doing the very best that we can to make 
our money go as far as we can.
    The growth of public/private partnerships, the 
encouragement there, some of the work that we have already seen 
there, I applaud that. You know, in recent years, we have seen, 
you know, the President's Malaria Initiative, you know, working 
with the World Health Organization and other institutes using 
the Federal dollars to be leveraged in that private/public 
partnership in a real way.
    And so I just applaud you on the work you have done. I 
would love to hear and so we can share with those in these 
tight fiscal times how we are managing that properly and 
perhaps what we can do from an oversight standpoint to make 
sure that not only are we investing wisely but that those funds 
meet the real needs that are there.
    But I thank you, and with that I yield back, Mr. Chairman.
    Mr. Smith. Thank you very much, Mr. Meadows.
    Mr. Stockman.
    Mr. Stockman. In the course of building a Panama Canal, as 
you probably recall from your history, they had to address 
first the health problems there, and when I was over at the 
Democratic Republic of the Congo, DRC, I think they have 
assumed the circumstances, some of the health issues are 
holding back their productivity and their production and GDP, 
but I believe that even the great expense they have made, they 
still need help in that area.
    When I was over there, I noticed they were selling some of 
their mosquito nets, so I am looking forward to your testimony 
to find out if there is alternatives ways besides just mosquito 
netting, and I appreciate all the efforts that you have done 
and continue to do on behalf of the United States, and I think 
this sends a large signal to the rest of the world, the 
compassion of the Americans, and I yield back my time, 
chairman. Thank you.
    Mr. Smith. Thank you very much, Mr. Stockman.
    I would like to now introduce to the panel our two first 
witnesses. Rear Admiral Tim Ziemer was appointed in June 2006 
to lead the President's Malaria Initiative, a $1.2 billion, 5-
year initiative to control malaria in Africa, which was 
expanded through an authorization in the 2008 Lantos-Hyde Act.
    Admiral Ziemer was born in Iowa but raised in Asia, the son 
of missionary parents serving in Vietnam. After graduating from 
college, he joined the Navy, completed flight school and 
returned to Vietnam during the war. During his naval career, 
Admiral Ziemer commanded several squadrants and Naval stations 
in an air wing supporting the first Gulf War.
    Prior to his appointment at PMI, he served as executive 
director of World Relief, a humanitarian organization, and has 
had a distinguished stint as leader of the President's Malaria 
Initiative. Those of us on this committee are very well aware 
of the great contributions you have made and the leadership you 
have provided.
    We will then hear from Colonel Peter Weina, who is assigned 
to the Walter Reed Army Institute of Research, where he serves 
as deputy commander. He leads many medical initiatives in the 
Army and his work has been published extensively in journals 
and books.
    Colonel Weina is a recognized expert on numerous diseases. 
He was the lead behind the availability and licensure of a 
life-saving drug for the treatment of severe malaria throughout 
the United States and Canada from 2002 to 2009, an effort that 
was recognized by CDC's Silo Busters Collaborative Award of 
Excellence in 2008. Among his many other impressive awards, he 
is the recipient of the Bronze Star for service in Iraq during 
Operation Iraqi Freedom.
    I would like to yield to Admiral Ziemer.

   STATEMENT OF REAR ADMIRAL TIM ZIEMER, U.S. GLOBAL MALARIA 
          COORDINATOR, PRESIDENT'S MALARIA INITIATIVE

    Admiral Ziemer. Chairman Smith, members of the committee, 
it is a pleasure to be back before you today. Before I begin my 
testimony, I would like to take a moment to acknowledge and 
express my appreciation for Congress' ongoing and steadfast 
support for malaria control. The global fight is succeeding. 
Deaths have decreased by one-third with bipartisan support in 
Congress for both bilateral and multi-lateral efforts. Through 
the Malaria Initiative and the Global Fund, malaria is being 
rolled back. It is a triumph of partnership, all of us working 
together, the U.S. Government, our partners, host countries and 
the communities we are trying to serve. We simply would not be 
seeing the impact we are seeing today without your support and 
commitment. Thank you very much.
    The United States malaria program through the PMI continues 
to be a game changer. In the 7th year of the Initiative, the 
financial and technical contributions made by the United States 
Government are the major catalyst in the remarkable progress 
that has been achieved in many countries to reduce the 
devastating burden of malaria on child mortality. At the same 
time, with the U.S. Government support, countries are also 
strengthening their own capacity to fight this disease.
    PMI, at its very core, is an example of success and real 
impact that the United States Government can achieve through a 
solid interagency partnership. Through PMI, the core strength 
of both USAID and the Centers for Disease Control and indeed 
across the entire U.S. Government spectrum, Walter Reed, DOD 
and NIH, as well as the Peace Corps, it is a tremendous success 
story, yet it is still incomplete.
    I just returned from Uganda, and despite the recent 
progress, malaria remains the largest killer of children. In 
the midst of these tragic statistics, we have some good news. 
This year, with 21 million insecticide-treated bednets provided 
by the Global Fund, the U.S. Government, DFID, World Vision, 
and other partners, the Government of Uganda is poised to make 
real and substantial gains against malaria.
    Seeing children suffering from malaria, I am reminded of my 
childhood days in Vietnam. My parents, as was indicated in the 
opening statement, were missionaries there. I was fortunate to 
sleep under a bednet and yet I caught malaria. I was fortunate 
to have anti-malaria medicine to cure the disease. Every child 
in a malarious part of the world should be protected as I was. 
In the last 7 years, substantial reductions in mortality among 
children under 5 has dropped 16 to 50 percent in 12 of our 
original PMI countries. Although multiple factors may be 
influencing the decline in under 5 mortality rates, strong and 
growing evidence suggests that malaria prevention and treatment 
are playing a major role in these unprecedented reductions in 
mortality.
    PMI is participating in in-depth evaluations to ascertain 
the contribution of malaria control efforts to these reductions 
in mortality, with Tanzania being first country to complete 
this evaluation. 63,000 lives have been saved over a 10-year 
period because of the scale-up of malaria interventions.
    In 2011, PMI commissioned an external evaluation team to 
review its performance. The evaluation affirmed that PMI's 
planning, implementation, partnerships and funding have been 
key to the global efforts to combat malaria. The evaluation 
team made five policy and five technical recommendations that 
will guide programmatic improvements over the next years. PMI 
views these recommendations as relevant and useful for program 
improvement. We have come a very long way since the inception 
of the Global Fund in 2002 and the creation of PMI 3 years 
later when President Bush committed $1.2 billion for malaria 
control.
    The Initiative started with Tanzania, Uganda and Angola. 
Since then, 16 additional focus countries have been added with 
three non-focused countries. In addition to the bipartisan 
support of Congress, PMI benefited from the full support of 
President Bush and First Lady Laura Bush, and now the Obama 
administration.
    In 2010, President Obama launched his vision for how the 
United States would approach global development, which seized 
development assistance as a pillar for foreign policy, and is 
crucial to America's national security and economic interests.
    In his 2013 State of the Union address, President Obama 
framed two goals, that the United States would join with our 
allies to eradicate extreme poverty in the next two decades, 
and saving the world's children from preventable deaths. 
Malaria is a major cause of child mortality in Africa, and 
consequently, preventing and controlling malaria are a key 
focus of the U.S. Government foreign assistance program. PMI is 
playing a lead role in implementing the President's vision.
    Partnership is the hallmark of how PMI does business. 
Partnership with host countries, other donors, the private 
sector, non-profits, and faith-based groups underpin our 
success. PMI has supported malaria activities through more than 
200 non-profit organizations. Approximately one-third of those 
are faith-based. These groups often have strong and effective 
bases of operations in underserved rural areas where the burden 
of malaria is the greatest.
    The Global Fund and PMI's commitment to effective 
coordination is maximizing our impact on the global malaria 
burden. Each program has its own unique strengths lending to 
the complementarity of the partnership and significant 
successes on the ground. Currently, all 19 PMI focused 
countries in Africa and the greater Mekong subregion receive 
substantial funding from the Global Fund.
    Because of the strength of our in-country technical staff, 
we support the effective implementation of Global Fund 
programs. While the risk of malaria is declining and more 
children are surviving, the gains are fragile and could be 
reversed without continued support. We recognize and appreciate 
the continued commitment of Congress and the American people to 
fighting malaria through PMI and the Global Fund in this time 
of budget austerity. The goal is to continue to shrink the 
malaria map and to ensure successes are not rolled back, even 
as the dual threats of artemisinin and drug resistance and 
insecticide resistance is growing. A strain of malaria, of the 
malaria parasite has appeared in parts of Southeast Asia with 
resistance to the most effective medicines to fight the 
parasite, and some fear that the parasite might ultimately 
become resistant to all drugs we currently have to treat 
malaria.
    The emergence of this resistant parasite to Africa would be 
devastating. We must also be diligent in identifying and 
monitoring mosquito resistance to insecticides so that our most 
effective prevention measures, insecticide-treated mosquito 
nets and indoor residual spraying aren't undermined. If 
mosquitos become resistant to those insecticides, the efficacy 
of the interventions will be compromised.
    Tackling these new strategic challenges is a priority, and 
we are working with the private sector to develop new anti-
malaria drugs as well as insecticide-based tools. At the same 
time, we must continue to expand our toolbox by developing a 
highly effective inexpensive vaccine that could result in 
hundreds of thousands of lives saved.
    So in closing, I would like to thank the U.S. Congress for 
its continued support and reiterate that together with our 
partners, we remain deeply committed to the global fight 
against malaria. Thank you, and I look forward to your 
questions.
    Mr. Smith. Admiral Ziemer, thank you very much for your 
testimony and again for your leadership.
    [The prepared statement of Admiral Ziemer follows:]
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
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    Mr. Smith. We do have a vote, two votes on the floor, and I 
apologize for the inconvenience to our witnesses. We thought we 
would take a very brief recess, come back, and Colonel, then we 
will receive your testimony. We really do want to hear what you 
have to say. So the subcommittee stands in recess.
    [Recess.]
    Mr. Smith. The subcommittee will resume its sitting, and 
Colonel Weina, if you could proceed with your testimony.

   STATEMENT OF COLONEL PETER J. WEINA, PH.D., M.D., DEPUTY 
    COMMANDER, WALTER REED ARMY INSTITUTE OF RESEARCH, U.S. 
                     DEPARTMENT OF DEFENSE

    Colonel Weina. Thank you, sir. Chairman Smith and 
distinguished members of the subcommittee, thank you for the 
opportunity to appear before you to discuss the Army's medical 
research initiatives to improve soldier readiness and global 
health and highlight the incredible work of the military 
medical research community.
    I extend our appreciation to Congress for their support to 
military medicine faithfully given, which provides the 
resources we need to deliver leading edge health services and 
diligently continue innovative research. Malaria is a global 
agent scourge that has haunted mankind for much of our history, 
and yet it still impacts our lives in our society today. I know 
it has been said many times, but it bears repeating: Over 3.3 
billion people remain at risk for the disease. Over 200 million 
cases of the disease appear every year along with over 650,000 
deaths.
    Among the most vulnerable are the young children who 
account for over 85 percent of the malaria-related mortality 
globally. A preventable disease, malaria is a leading cause of 
death in children under 5 years old in sub-Saharan Africa.
    The U.S. military has also felt the threat of malaria as 
far back as 1775 when George Washington expended limited 
resources to purchase quinine for the treatment of malaria. 
Malaria has been diagnosed during the Civil War, World War II, 
Vietnam and even recently in Afghanistan.
    Historically, the incidents depends primarily on deployment 
location, but during the last 10 years, we have seen 
approximately 100 cases every year, despite the resources we 
have to protect our troops. While the days of massive 
debilitating impact on malaria operations are behind us, we 
only have to look back to 2003 in order to appreciate the 
potential impact when a military peacekeeping operation in 
Liberia failed after only a few weeks due to 80 cases of 
malaria in 225 Marines, 44 of those requiring medical 
evacuation.
    The destabilizing effects that diseases such as HIV/AIDS 
and malaria have on the critical infrastructure of developing 
nations is compelling evidence that global health is a means to 
global security. These diseases undermine the education and 
health systems, economic growth, micro-enterprises, policing 
and military capabilities, political legitimacy, family 
structures, and overall social cohesion. They undermine the 
stability of already weakened states and add to their 
vulnerability to extremists and terrorists who seek to corrupt 
or coerce. Our response, through medical engagement, needs to 
be comprehensive, fought at many levels, and on many fronts to 
provide for global stability and our own nation's security.
    The Walter Reed Army Institute of Research has a trusted 
partnership in several countries that has been established for 
decades. Long-term relationships have been built with host 
countries as well as health organizations allowing both 
personnel and logistical support to establish larger work.
    We have been in partnership with the Royal Thai Army for 
over 50 years, and with the Kenyan Medical Research Institute 
for over 40 years. We have established robust relationships 
that have allowed the important work of military medicine's 
research as well as the important work of PEPFAR and PMI.
    The U.S. military's exceptional science, logistic and 
regulatory expertise allows for the testing of new products to 
the best standards of care for the local population as well as 
the delivery of critical life-saving HIV/AIDS and malaria 
interventions.
    Military medicine also serves as a partner in the critical 
platform of disease surveillance. Both the Army and Navy 
conduct oversees disease surveillance operations that not only 
keep a watchful eye on malaria patterns and malaria resistance 
throughout the world, but also survey for other infectious 
disease threats. These overseas operations are part of a 
complex ecosystem that provides not only surveillance, but also 
a platform for testing new products, medical engagement with 
many countries worldwide and outreach for the execution of 
PEPFAR and PMI missions and programs.
    Vigilance in combating malaria is an enduring mission. The 
U.S. military is engaged in malaria research for several key 
reasons, to preserve the fighting strength of our men and women 
in uniform who go into harm's way, to protect our Nation's 
citizens who encounter these threats worldwide, and to 
positively impact the global health and stability of our 
allies.
    In closing, I am proud of the global impact that military 
medicine research has done throughout history and the continued 
diligence being done to combat one of the oldest infectious 
disease threats man has known. In partnership with the 
Department of Defense, my colleagues here today, our global 
partnerships and the Congress, we will be prepared for 
tomorrow's challenges. Thank you for your time.
    Mr. Smith. Colonel, thank you very much for your leadership 
and for your testimony today.
    [The prepared statement of Colonel Weina follows:]
    
    
    
    
    
    
    
    
    
    
    
    
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    Mr. Smith. Just to lead off the questioning, let me start 
off with a question to Admiral Ziemer. You mentioned about one-
third of the NGOs that are getting assistance happen to be 
faith-based. One of the concerns that I have expressed from the 
very beginning, both with PEPFAR and malaria and every other 
U.S. foreign aid program, especially as it relates to Africa, 
has been the early exclusion of faith-based organizations, 
primarily because of ideological reasons, but there appears to 
be, and I think there has been good strong support for them. I 
actually wrote the conscience clause for the PEPFAR program 
because of that exclusion.
    If you could just elaborate a bit on how essential 
indigenous faith-based groups are being included. If we want to 
end the pandemic of HIV/AIDS, it seems to me, and TB, the 
problems associated there, and the malaria problem, we need to 
have as partners those faith-based groups. If you could touch 
on that.
    Admiral Ziemer. Thanks for the questions. When PMI was 
launched, one of the first things we did was to look at the 
best practices of PEPFAR and model some of our programmatics 
after the PEPFAR model. So, to the extent there were clear 
guidances coming from here and from the administration, we 
looked at them and embraced them. But I can tell you from the 
beginning of PMI, we intentionally looked at a deliberate 
engagement of the NGOs in the field, specifically looked at the 
merits of the faith-based organizations because we 
acknowledged, and from personal experience, accepted the fact 
that they were there before we got there, and they will be 
there after we go. And when we start embracing capacity 
building and sustainability of programs, the local NGOs, 
specifically the faith based, are a huge component of building 
for the future.
    Mr. Smith. I appreciate that. You know, the impact on 
childhood cognitive development, we know that obviously our 
goal is to eradicate malaria and to prevent deaths, but also to 
mitigate morbidity and other consequences like impact on 
cognitive development. Is the timeliness of the intervention 
key? I chair the Lyme Disease Caucus here in the House and have 
a bill pending that I hope will get brought up on establishing 
a blue ribbon commission on lyme disease, particularly chronic 
lyme. The longer the parasite grows inside an individual, the 
worse its deleterious effects. I am wondering, you know, the 
issue of how this mal-affects children as they become 
adolescents, adults and right on through the rest of their 
life.
    Admiral Ziemer. You are asking a rather technical question, 
and I would defer that to some of our scientists and colleagues 
when it comes to the impact or the delayed impact of delayed 
parasite clearance from a system. I do know that we have a very 
rigorous prenatal program, so that when pregnant women go into 
the clinics, we are providing preventative treatment. So in 
terms of the health of the newborn child, it is being addressed 
through that prevention measure, but when a child presents with 
a fever, we are committed to appropriate diagnosis and then 
treatment. So at an early age, if the child presents and is 
diagnosed with a fever, we do everything we can to provide 
treatment.
    Mr. Smith. In his testimony, Ambassador Dybul, the 
executive director of the Global Fund, points out that between 
2004 and 2010 the need, the coverage need, the level of need 
was essentially met, but only 92 million nets were delivered by 
manufacturers in 2011, largely due to funding constraints, and 
in 2012, only 66 million nets were produced. He points out that 
in February of this year, the Global Fund and WHO and other 
partners, I am sure that includes you and us, the United 
States, estimated that 77 million nets were needed to maintain 
coverage for communities that the Global Fund has previously 
protected.
    He also talks about the big push to replace insecticide-
treated nets and its new, interim funding grant stream, along 
with fostering diagnostic and treatment needs, and bottom line, 
that between 2013 and 2015 there is a $3.5 billion gap. Now, I 
know the United States has been generous. It has been the 
leader. Is there more that we could be doing? I mean, can we, 
Congress, be partners in ensuring that that gap is closed?
    Admiral Ziemer. The fact that we know what the gap is and 
we can have these numbers, represents information that we 
didn't have 5 years ago.
    Mr. Smith. Right.
    Admiral Ziemer. So as we look at supporting the country's 
requirements, we are able to refine the net requirements, and 
then collectively discuss at the funding level, the partner 
level, and at the national level how best to direct those 
resources. I think it is important to acknowledge that since 
2008 and 2009, our partners, along with the United States, have 
distributed over 300 million bednets to sub-Saharan Africa, 
which represents coverage to close to 600 million people. I 
think the figure is 578 million. So we are making tremendous 
progress.
    As we look at those at risk, I think it is important to 
look at the full toolkit that we have. Four of the 
interventions that we use are focused on prevention. Bednets, 
of course, is one, along with indoor residual spraying. We are 
looking at country requirements, the most at risk population 
groups, and moving forward with the funding that we have. So, 
are there gaps? You bet. Are we dealing with them better? Yes. 
We just have to keep at it.
    Mr. Smith. And if you could help us--I mean, we want to be 
advocates. I certainly personally want to make sure that all 
that can be done is done. I thought that again Ambassador Dybul 
makes an excellent point. Either progress is made or we lose 
momentum. The reality is invest now or pay forever, which is a 
very strong and I think a very declarative statement that we 
could make a difference, but funding is key, and obviously 
deploying those resources prudently is key.
    Colonel, if I could just ask you, your written testimony 
goes into some great length, thank you for your oral testimony 
as well. You point out that the Walter Reed Army Institute of 
Research, along with a pharmaceutical company, has developed 
what is currently the world's leading malaria vaccine 
candidate. You point out that the product is currently in Phase 
III clinical trials in Africa, if you maybe would touch on 
where in Africa. Is it Kenya where we have the lab? And the 
medical research collaboration, and how close are we to, you 
know, actually developing a vaccine that is deployable?
    Colonel Weina. Yes, Chairman Smith, the question of 
partnering with a drug company, we do partner all of the time 
with some sort of commercial entity to make sure that our 
products go forward. None of the products that we actually 
produced are things that are necessarily borne strictly by the 
United States to move forward.
    The question of where this work is being done, it is the 
Phase III trial is principally being done in Kenya right now 
where we have our laboratory. This work has moved forward 
significantly, but of course, the question of when are we going 
to have a vaccine is really tied up in some very significant 
details.
    First of all, the vaccine that we have right now is not a 
vaccine that absolutely protects an individual from getting 
malaria. The great thing about this vaccine, and this is why it 
is being pursued principally in Africa, is the fact that it 
reduces the mortality associated with the disease. This 
vaccine, just like a lot of other vaccines that we are having 
difficulties with, such as HIV, are things in which they don't 
naturally occur in nature. We don't have a situation like we 
have, for example, with chickenpox in which maybe somebody gets 
chickenpox and then they aren't going to get chickenpox again. 
Those vaccines are the easy ones. Those are the ones that have 
already been developed.
    What we are trying to do is actually develop a vaccine for 
a condition that doesn't occur in nature, so it is a lot 
tougher to do. What we have been able to mimic is the fact that 
children that have repeatedly gotten malaria are at lower risk 
of dying from malaria than individuals that may get it the 
first time. And this is a real success. It helps reduce the 
mortality, and it produces some information for us and possibly 
moving forward into a vaccine that does have significantly more 
efficacy and something that may actually prevent somebody from 
getting infected.
    Mr. Smith. Let me ask you, Colonel, if I could. You point 
out that funding for malaria research and development in the 
military has been suffering since Vietnam. You talk about how 
you have worked very creatively, partnering with others, to try 
to lessen the impact of that diminished funding, and I think 
$10 million is what you have in use for research.
    You also point out that resistance is a fact of drug 
development in even the most cautious of drugs. Organisms we 
are fighting will always find a way to defeat our treatments, 
which is a very ominous statement and a very disconcerting 
statement. And we know in some four countries in Southeast 
Asia, Dr. Friedman was very emphatic on that when he appeared 
before our committee just a few weeks ago, there is concerns 
about drug resistance to artemisinin. Could you speak to that 
issue of drug resistance and also that budget for research? 
What would more money enable you to do, if it were to be 
available above the $10 million?
    Colonel Weina. Yes, sir. The issue of resistance is 
something that we deal with not just with for malaria but for a 
lot of diseases. The malarial parasite is a very ingenious 
organism that is actually, I guess, just trying to survive, and 
we are constantly trying to beat it down. It has found a way of 
practically defeating every single drug that we have produced 
all the way back to something that we have been using like 
quinine for over 300 years. All of the new drugs that are out 
there, Mefloquine, Fansidar, all of these types of drugs, 
Malarone even, there is resistance. And our biggest tool in our 
arsenal right now are the artemisinins, artemisinin-based 
drugs.
    We are seeing an increase in the potential for resistance 
in Southeast Asia, particularly along the Thai-Cambodian border 
where we have seen a lot of resistance arise, and we are going 
to--every single time we produce a new drug, these organisms 
are going to find a way around it, and that is why we need to 
have continued vigilance. That is why every single anti-
malarial that has basically come out since World War II has had 
the involvement of the Walter Reed Army Institute of Research 
because of the fact that we have continually worked on it 
virtually our entire existence looking at a new drug. So every 
time we have a new one that is out there, we don't stop and 
celebrate that we have the new one. We are actually looking for 
yet the next one that is out there, and we have a full pipeline 
of drugs that are being developed and looking for yet that next 
generation because we know we are going to have resistance, and 
there is no way of actually stopping that from moving forward.
    As far as the budget, I think everybody would just love to 
have more money. There are limited resources that are going to 
be available. I think what we would like to have more so than 
anything else is just to continue to get the money that we have 
been POM'd and that allows us to do the planning that is really 
necessary to move forward with our partnerships because our 
people are very entrepreneurial. And whatever investment that 
the U.S. taxpayer puts into developing these drugs, we are able 
to partner with private organizations, with academia, with 
other governmental organizations and really move the goal 
forward by bringing those types of partnerships together in 
this ecosystem that increases every single dollar three, four, 
five times and increase our budget to move things forward.
    Mr. Smith. I think Americans should be concerned just 
because we are our brothers' and sisters' keeper, and that is 
what this program is built on, but there is the possibility, as 
you pointed out, of malaria being reintroduced into the United 
States. It is something I never read in the history books, and 
we talked about the Civil War. You point out, in the 1860s, the 
Civil War saw 50 percent of the Caucasian troops and a 
staggering 80 percent of the Black troops contracting malaria 
annually. That is extraordinary. And that is information that I 
think just underscores--we had it here. It is gone. Now we have 
to hope and pray and work hard to see that it will soon be 
eradicated in Africa and everywhere else that it is.
    Mr. Bera.
    Mr. Bera. Thank you, Chairman Smith.
    I think the American public, if you are out there watching, 
you can be very proud of what we have been able to accomplish 
and the reflection of our values as a Nation, you know the 
compassion, the humanitarian commitment to eradicating malaria; 
to the wonderful work that, Admiral Ziemer and Colonel Weina, 
you guys have been doing; and the fact that this is a real 
bipartisan effort. The President's Malaria Initiative started 
under a Republican President and it has continued under a 
Democratic President. The leadership demonstrated on this 
committee and the commitment to compassionate and humanitarian 
need in eradicating some of the toughest diseases in the world, 
this is something that we can be proud of as an institution and 
as a country and Nation.
    I look at this from the perspective of being a doctor. And 
the first course of medicine is always to try to focus on 
prevention of disease. If you can prevent it, then you don't 
have to treat it. And we are making strides. And when we think 
about prevention of malaria, we think about, obviously, nets 
and preventing the mosquito bites. We also look at the public 
health measures that we can do--you know, pools of water, et 
cetera--and educating the population where malaria's endemic.
    Chairman Smith touched on the cornerstone of prevention in 
fighting infectious disease, which is vaccination. And if our 
goal is eradication, we really do have to focus on finding a 
vaccine.
    Colonel, as you pointed out, malaria is a very smart 
challenge, and it is a smart parasite that has continually 
adapted. And yes, we are going to have to continue investing in 
the next generation of therapy. But until we can come up with 
an effective vaccine, it will be very difficult to eradicate.
    I think you talked about where we are on the vaccination 
side. And I would just reiterate our commitment and my 
commitment, as a physician and a Member of Congress, to 
continue to fight for that research funding until we do get 
that vaccine.
    You touched on the importance of partnership, and we do 
live in tight fiscal times. We do have a debt challenge here in 
this Nation, and we are forever grateful for individuals like 
Bill and Melinda Gates, who have stepped up philanthropically 
and have poured literally millions of dollars--billions of 
dollars into the fight to eradicate malaria.
    To either one of you, I would love to hear what you think 
are best practices in partnership, the role of the 
philanthropic and NGO community in helping us eradicate malaria 
or at least hold it down and continue to make progress. And 
then the role in terms of capacity building in Africa, India, 
you know, countries that are affected by malaria. So whoever 
wants to take that question.
    Admiral Ziemer. Thanks for that question.
    Let me just address a couple of points. The USAID has been 
investing in vaccine research for over 40 years. So it is a 
high priority, and we will continue to focus in on that for the 
reasons you have stated. On the prevention side, I am pleased 
to say, of the four interventions that we used, WHO approved, 
three are prevention. And then we are scaling up case 
management, diagnosis, and then proper treatment. So as we 
continue to work with the countries, our focus is truly on the 
prevention side.
    Our partnership in this austere time is actually very 
critical. And I am really pleased to report that we are seeing 
significant progress made at every level. On the partnership 
advocacy piece, the work with the U.N. Special Envoy, Malaria 
No More, the U.N. Foundation, Nothing But Nets, the 
celebrities, as well as the athletes are informing the American 
public about this disease. And there has been a wonderful 
response collectively, as American citizens, to do something 
about that. So that is on the advocacy side.
    On the technical side, the fact that the Gates Foundation 
is totally invested on the high tech end and the governments 
and the multilaterals are invested on the country side, we have 
a global malaria vision and plan to bring those two together. 
And so, again, over the last 4 years, we have something that we 
never have had before, and that is a vision, a strategy and 
places for countries, donors, research folks to plug in to move 
us toward control, elimination and eradication.
    One of the most important partners we have is the private 
sector. And we can showcase and give you more details. But let 
me just give you three examples: In Western Ghana, we are 
partnering with Ashanti gold through IRS. They are also funded 
by the Global Fund, the national government, as well as the 
U.S. Government in looking at best practices and scaling up 
IRS.
    In Zambia, we are working with the copper mine companies to 
do the same thing. So let me just stop there. Oh, ExxonMobil is 
working with us in Angola and their contributions directly into 
the program have been $4.5 million just for nets and the scale-
up of events. So we can give you multiple examples of how we 
are seeing the partnership not only on the advocacy side but in 
the planning and visioning as well as in the implementation 
side. I hope that is helpful.
    Mr. Bera. Very helpful.
    Colonel Weina. Yes.
    Dr. Bera, the idea of partnerships is absolutely critical 
when it comes to combating any disease and especially something 
that is as broad and as widespread as malaria is.
    I describe it as an ecosystem. And when one part of an 
ecosystem suffers, then the entire part of the system suffers. 
But there is also strength in that ecosystem so that when one 
part suffers, the other parts can help them out. The 
partnerships are critical and the partnerships come at many 
different levels. There are the public-private partnerships. 
But there are also our partnerships with the overseas 
laboratories in which we have in Thailand and in Kenya, Egypt, 
and Peru. Some of them have been in existence for over 50 
years. These partnerships are not just to provide us a platform 
for surveillance and for testing new products, but it is also a 
way of capacity building so that we can also pass on what we 
have learned and also learn from our partners. In most of these 
overseas laboratories, a majority of the people that are 
working there are local nationals. And there really is a trust 
relationship that is built up. Some of the people having been 
associated with that partnership for over 50 years. And there 
are strengths and weaknesses that each of the partners bring. 
And the more we talk to each other, the more we interact with 
each other, the more we learn where we can make a real 
difference. I know that we execute quite a bit of PMI funds. We 
execute quite a bit of PEPFAR funds at some of our overseas 
laboratories. And it is not just the laboratories. Those 
laboratories actually are a jump-off point for work in other 
countries as well. And it is not just a logistic aspect like 
that, but it is also a scientific aspect. We have learned a 
tremendous amount from the work that is being done with the HIV 
vaccine as well as the HIV vaccine finding, learning a 
tremendous amount from the work that is being done with 
malaria. So there are scientific interactions and partnerships 
that are done across diseases as well as all of the logistic 
work that I have just talked about.
    Mr. Bera. It sounds like this is a remarkable partnership, 
public-private advocacy. Is there anything that this 
institution, that we can do here as men and women in Congress 
to help continue to facilitate this partnership? Or is there 
anything--obviously the law of unintended consequences 
sometimes hinders partnership. Is there anything that you would 
want us to do outside of increasing research funding?
    Admiral Ziemer. The fact that you are calling for an update 
and having this hearing to support this U.S. Government foreign 
assistance program is evident to our global partners and the 
countries that we are working with. There isn't an opportunity 
that goes by where I don't pay tribute to the leadership, the 
bipartisan support of this Congress. It is critical. We need to 
political leadership and we need the funding. Everybody 
understands the constraints that we are currently under.
    So our pledge is that the funding that is appropriated to 
this program and our other health programs we are going to do 
everything we can to be transparent, accountable, and deliver 
impact that will convince the American people that their tax 
dollars are being wisely invested. When we show results, it is 
really kind of a no-brainer. They are going to say, I wish more 
money was going into programs like this. I hear it all the 
time.
    Mr. Bera. Great. Thank you. We will bring some of that 
commonsense approach here to Congress as well.
    Mr. Smith. Thank you very much.
    The vice chairman. Mr. Weber.
    Mr. Weber. Well thank you, Mr. Chairman.
    A couple of questions for you: Of course you guys started 
with the valiant men and women overseas. What is the incidence 
of cases of malaria in our own armed forces? Is that up, down? 
Can you give me kind of a breakdown?
    Colonel Weina. Well, sir, we still suffer from malaria even 
though we have these interventions, principally because we do 
have troops that are going to be operating in areas in which 
they may not have expected to run into malaria. So they may not 
be on prophylaxis or it may be in the fog of war, if you will, 
in which they don't have opportunities to protect themselves 
with the bednets. We have done interventions though that may 
help drive the numbers down. As I said in my testimony, we have 
maybe 100 cases per year, yet that are still bothering us in 
the military. And we would sure like that to be down as close 
to zero as possible.
    So some of the things that we could do are to intervene 
where we don't necessarily have to have the soldier involvement 
in it. A vaccine would be absolutely wonderful. But, in the 
meantime, we have situations in which, for example, the Army 
and the Marines now all of our battle dress uniforms are 
permethrin-treated from the factory. And that is a true 
improvement because now the individuals don't have to think 
about an intervention themselves. It is already there. Those 
types of efforts are going to help drive them down. It sure 
would be nice to have zero cases and not have to worry about 
malaria intervening like it did in 2003 in Liberia. But that is 
something we need to continually plan for and think about in 
the back of our minds.
    Mr. Weber. Well, thank you for that, Colonel. I wasn't here 
during the testimony. It turns out I don't walk as fast as the 
chairman does. So I apologize if this is redundant.
    Malaria was pretty much eliminated in India, as I 
understand it, but now it is starting to come back. Speak to 
that if you would. Why is that?
    Colonel Weina. Yes. In India, in the 1960s, it was 
virtually eliminated from the entire subcontinent. Today they 
have actually increased the number of cases potentially up to 
200,000 deaths per year. And it is fairly widespread. I have 
recently, over the last number of years, traveled in India to 
about 20 different cities. And from the rain forest all the way 
to the deserts, you can see patients lined up with malaria, and 
it is having a true impact.
    The reasons for that are pretty much the same reasons that 
we should remain vigilant and do remain vigilant here in the 
United States. We have a susceptible population. We have the 
vector present--the mosquito that can carry malaria--present 
throughout the United States just like they did in India. And 
all it takes is the reintroduction of the infection into the 
population and into the mosquito population without an adequate 
response. We have been very fortunate that the CDC keeps a 
very, very close eye on this and has prevented any small 
outbreaks from becoming big ones like it has in India. But we 
remain vulnerable as long as there is malaria anywhere in the 
world. Certainly all it takes is somebody getting on a plane 
and 8, 10 hours later to be at one of our borders and 
potentially bring the disease back home.
    Mr. Weber. Okay. Thank you, Mr. Chairman.
    I yield back.
    Mr. Smith. Thank you very much. Mr. Meadows.
    Mr. Meadows. Thank you, Mr. Chairman.
    And thank you both.
    Admiral, thank you so much for being so candid with regards 
to your fiscal oversight and understanding the demands of where 
we are today. But also knowing that as a wise steward of that 
money, I take you at your word but also see it in your passion 
in your eyes that you are willing to invest that wisely. And I 
just want to say thank you, not on behalf of Congress but on 
behalf of the American people for doing that.
    I want to go on a little bit further and let's talk about 
the dangers to our men and women in service.
    Colonel, if you could speak to that because really, when it 
gets down to funding, most people are only concerned about 
providing funding if it affects them. And that is a sad 
commentary, but that is the truth, the truth of the matter.
    So what I would like for you to do is help the folks back 
home understand, one, why do we need to be investing these 
dollars? What are the dangers to family members that may be 
serving overseas? And perhaps talk a little bit about the 
reintroduction into some of these areas that we felt like were 
malaria-free, but now we are seeing that it has come back. 
Because, as you say, we are in a global, transient world now. 
So one disease in Vietnam showing up in America is just a few 
hours away. So if you could comment on that, please, Colonel.
    Colonel Weina. Yes, sir. So the threat to our military, to 
our men and women that are serving in the uniform of our 
country is very much dependent upon where they happen to be 
doing it, where they happen to be serving at the time. If they 
are in an area, say in Iraq, we found that there was very 
little malaria, if any at all. And we really didn't have much 
of a problem with malaria there. Certainly we do have a problem 
with it though in places like Afghanistan and in other areas in 
which we may be providing peacekeeping missions, for example, 
in Africa, in which there is a tremendous amount of 
transmission. As I have said, the disease, the parasite is very 
smart. No matter what we produce, no matter what we come up 
with, be it an insecticide or a drug, it is going to figure out 
a way to work around this and actually----
    Mr. Meadows. So what you are saying is it mutates and 
changes enough where it can go against the technology that we 
have.
    Colonel Weina. Yes, sir. So we need to continually take a 
look at this. The reason it is important though and the reason 
we talk about global health is because--one reason is that as 
we work on these solutions for our soldiers, it has got a much 
broader impact and it has got a much broader unintended 
consequence of being able to help other individuals that have 
malaria. But on the other hand, if we reduce the amount of 
malaria and other infectious disease threats worldwide, our 
soldiers serving in these areas are going to be at reduced risk 
as well and also the issue of making sure that we invest in 
decreasing the destabilizing effects of these particular 
diseases so that maybe we don't have to have soldiers there in 
the first place because they are not unstable areas because of 
the fact that their health is better.
    Mr. Meadows. And so what you are saying is, part of the 
unrest is not just economic. It is health-generated, is that 
right?
    Colonel Weina. Well, health has an impact on the economy. 
If you are sick with malaria, you can't work. If you can't 
work, you can't provide for your family. And there is this 
vicious cycle that happens. While we may not think about health 
as the very first thing in an unstable country, health 
certainly has some impact in the background. We just have to 
trace back to where that is. If you are able to work, I think 
most people want to work no matter where they are in the world.
    Mr. Meadows. Right. Let's go back to this partnership that 
has been alluded to with both the pharmaceutical companies, 
with CDC, with NIH. Who takes the lead? How do we make sure 
that we are charging--you know in our military we have rank. So 
we know who we follow. In these partnerships, it becomes much 
more problematic to see who is taking the lead and who is 
making decisions. What are some of the successes there? And 
perhaps if you care to comment, what are some of the barriers 
to that?
    Admiral Ziemer. Speaking from the PMI perspective, I 
appreciate the question a lot. But if you go back to the 
Lantos-Hyde bill, you will see that there were specific 
authorities and responsibilities given to how the program was 
to be established and run and managed and report back to you.
    Mr. Meadows. And are we following that?
    Admiral Ziemer. Yes, sir, we are. And I would venture to 
say that that is one of the key reasons for the successes and 
the progress that we are making. There are clear lines of 
authority and responsibility. And it also encourages and 
enables us to have an effective interagency, collaborative, 
functioning program. So I would commend a review of that simple 
governance concept as we ask the question about partnership.
    Mr. Meadows. So you are saying it is a success?
    Admiral Ziemer. In my view yes, sir.
    Mr. Meadows. So we need to repeat it throughout all other 
areas of Congress is what you are saying?
    Admiral Ziemer. I would say it is a good reference 
depending on what outcome is desired.
    But on the global level, it is much more difficult. And 
there are collaborative bodies at WHO, partnerships, Stop TB, 
the Roll Back Malaria Partnership. At the Roll Back Malaria 
Partnership--which is meeting right now and I am skipping it 
because I am here--the Gates Foundation, the U.N. Foundation, 
Malaria No More, multiple private sectors, the pharmaceuticals 
are there, the countries, the endemic countries, Asia, Latin 
America, and Africa are there along with the major funders, the 
Global Fund, the UK, and the U.S. Government. We are looking at 
the global challenge, looking at the plan, and having 
discussions about how we work together on a global partnership 
to move toward control, elimination, and one day eradication. 
So there are different mechanisms depending on where we are to 
enhance and to develop these partnerships.
    I would like to say that over the 6 years that I have been 
in this job, that program, those mechanisms have continued to 
mature and become more professional. And I spend my time by 
going to them because I think it is worth it, and we are able 
to influence and provide technical as well as programmatic 
leadership to achieve common ends.
    Mr. Meadows. And you would agree with that, Colonel?
    Colonel Weina. I would. From the standpoint of being in the 
military, of course, we do what we are told. I would like to 
think we are very good at doing what we are told and making the 
best with what we have. So the partnerships have been very 
good.
    Mr. Meadows. Do I have time for just two more questions, 
Mr. Chairman?
    Mr. Smith. Yes, sir.
    Mr. Meadows. I wanted to follow up with that then.
    From a legislative standpoint, you outlined some of the 
things that were good. And I am not asking you--unless you had 
something on the forefront of your mind, to speak to this. But 
I would love to see if there is anything legislatively--tweaks, 
reporting, accountability--that we could provide to, you know, 
follow under the chairman's leadership to address by Congress. 
Is there anything that comes to mind? And if not, if you could 
have your staff work on that and report back to the committee.
    Admiral Ziemer. Sir, I think that is a great question. I 
would like to come back to you with the specifics, depending on 
what you would find helpful as you look forward to fulfilling 
your responsibilities. But I think it is worth time to continue 
looking at that. And we will get back to you, sir.
    Mr. Meadows. And then my last question. It really gets 
back--I think we are in clinical trials, in the third clinical 
trials in terms of a vaccine. And having seen that, that is a 
hopeful sign if we are getting to stage three clinical trials. 
My question is, how do we look at the severity? Because I think 
you mentioned in your testimony the severity of those. They are 
5 months to 17 months old. How do we measure quantifiably the 
success of that? I mean it is very difficult when we have 
children to figure out, you know, if pain is on a scale of 1 to 
10 because they won't rate it out. How are we doing that?
    Colonel Weina. One of the ways of assessing severity when 
it comes to malaria is actually pretty simple because severe 
malaria is a disease--although we have very uniform and very 
stringent criteria that we need to follow, I think it is real 
simple. If you can't take water, if you can't swallow things, 
if you can't take a pill to treat the malaria and you need an 
IV treatment, that is pretty severe malaria. And the outcome 
measure is unfortunately very easy to measure, and that is 
death because once they start down that circle of having severe 
malaria, it takes some extraordinary measures----
    Mr. Meadows. So primarily through dehydration or----
    Colonel Weina. There are a number of different mechanisms. 
Sometimes through pulmonary malaria, sometimes through cerebral 
malaria, there are a variety of different ways. But typically 
with children, it is because of anemia.
    Mr. Meadows. I thank the chair's indulgence. I would also 
ask if you could for the record address if there are any 
nanotechnologies that we are using in terms of clothing, 
netting, and so forth that might be out there or at least hopes 
in terms of future research, in terms of nanotechnology.
    And with that, I yield back, Mr. Chairman. Thank you.
    Mr. Smith. I thank the gentleman.
    Mr. Stockman.
    Mr. Stockman. Thank you.
    I don't know who could answer this question. But I think I 
was watching Frontline or one of those shows. And they talked 
about the Chinese counterfeiting malaria medication and how 
that impacts and creates resistance to malaria. And that is 
kind of a big elephant in the room. As we are spending 
millions, in some cases hundreds of millions of dollars 
developing a new drug, they are out there emulating and making 
fake copies of it. And as you take the pill and you stop taking 
it, of course, that is how the resistance builds. I guess I am 
asking, have you guys addressed that issue on how to stop the 
counterfeit?
    Admiral Ziemer. Sir, it is a global issue. It has a lot of 
visibility and attention. I know it is a priority for the State 
Department right now. It is a matter that we are very concerned 
about because people that are sick with malaria taking 
counterfeit, fake, or unsafe drugs are going to continue to get 
sick and die. So it is not only a health issue, but it does 
beat resistance, and it really is a concern to us in terms of 
how it manifests itself in the resistance of the parasite.
    But on the criminal side, it is a high priority, and we are 
working with our governments and criminal agencies to take 
appropriate action. But we have got to stay at it at multiple 
levels, diplomatic, technical, and at the country level, where 
these drugs are being regulated, are not regulated, purchased, 
and distributed.
    Colonel Weina. There are actually two issues with that 
particular question, sir. One of them has to do with actually 
counterfeit ones in which they are trying to sell them for 
other manufactured ones so that they look the same. Typically 
they don't just put sugar pills in. Typically what they do is 
they add just enough of the drug there, so if somebody were to 
test it, they would detect a level of drug.
    Mr. Stockman. That is even worse, too.
    Colonel Weina. And that is even worse because what it does 
is it feeds into providing a low level exposure of that drug to 
the parasite so it kind of helps them learn how to become 
resistant. So that is a problem. But there is also a problem of 
poor quality drugs. And one of the hallmarks and one of the 
reasons why people love the U.S. medical machine, if you will, 
is because of the fact that we have good quality products that 
are available, manufactured under good manufacturing practices 
and tested under good clinical practices. And quite often, we 
compete with other countries that may produce a drug under 
different standards. They can sell it for a cheaper amount and, 
therefore, it becomes used. So quite often what happens is that 
we need to make sure that we look at, for example, the 
technical ways and the legislative ways and the diplomatic ways 
of making sure that we are using not just good quality drugs 
and that everybody is kind of following the same standards when 
it comes to that but also trying to make sure that we ferret 
out and get rid of these counterfeit drugs.
    Mr. Stockman. The implication in the program was is that 
there is a staggering amount of fake drugs out there. Do you 
have any way of quantifying how much is fake and how much--I 
mean do you guys ever sample it? Because they showed a package 
and you couldn't tell the difference. It was stunning. And it 
looked like an American-produced product. But they are implying 
that there was a lot of it out there. Is that quantifiable? Do 
you guys trace that?
    Colonel Weina. We aren't ourselves particularly following 
that. But there are a number of different organizations that 
take this on and really do a wonderful job of finding out 
exactly how much is out there. It is worthwhile for them 
because instead of the $60 that they could reap for it, it may 
only cost them pennies to make it. So they get quite a bit of 
profit as opposed to ours.
    Mr. Stockman. Do you know who those folks are so we can 
have them before our committee? I feel like what we are doing 
is we are competing against ourselves. We are throwing millions 
of dollars, which is what we want to do because we want to save 
lives, but at the same time if somebody is in the boat drilling 
holes, it would be nice to stop that person from drilling 
holes. So if you have some experts and if you could get with 
the chairman and let us know, I would love to hear their 
testimony on exactly how big this problem is because if we 
constantly are competing against ourselves trying to produce 
new stuff, and then they emulate it and then, like you said, 
the organ gets a little bit of it and adjusts again, then we 
will be in a never-ending--we are chasing our tail. But do you 
know the individuals that would have that information?
    Colonel Weina. I don't have that information right in front 
of me at this moment. But I do know that there are several--
again, several organizations that are following that quite 
closely and there are congresses that meet, international 
congresses because this is an international problem. It is not 
just here in the United States. And they follow this very 
closely. They try and track down where these are. But finding 
the actual individuals or the actual country that is producing 
it has proven quite illusive.
    Admiral Ziemer. We do have some information. But I think 
what I would like to do is go back, look at our files and then 
get back to you specifically to make sure we can answer the 
questions that you have and share what we have. Okay.
    Mr. Stockman. I am trying to remember. I think the show was 
``Malaria.'' It was really fascinating. I can't remember.
    The other question I have, if I may, we eliminated malaria 
here and a lot of us see the film clips of it, how we eliminate 
it. And no one ever wants to talk about it. But it was very 
effective. It was how it was eliminated in India and a lot of 
places around the world.
    And now with atomizing our DDT, you cannot have the impact 
on the environment that we had in the 1950s. And I remember you 
see the film clips of kids just covered with DDT. My brother 
was one of them, and he turned out, I think, fairly normal. He 
might disagree politically at times. But he is okay. And then I 
see the sacrifice. I know we have to trade off a balance.
    But your heart goes out to these young kids who don't have 
the same protection we had. And I don't know if there is really 
a trade-off where we should maybe--because of technology now--
reintroduce that product because it could save--some 
estimates--millions of lives. And I would like to see it 
reintroduced under the controlled situations where we can make 
the molecules much smaller through atomizing the product.
    Admiral Ziemer. Sir, there are 12 approved insecticides on 
the WHO-approved list. DDT is on the list. And we were using 
DDT in three of our programs. We switched off of DDT because 
there was a resistance developing by the mosquitoes. So we 
alternate it to pyrethroid or another effective insecticide. So 
the issue of DDT is front and center, but I think what we need 
to do is continue to focus in on effective, safe insecticides 
that are approved and then look at the best application based 
on resistance, protocol, and the data that we have.
    Mr. Stockman. I also noticed they are taking--and indulge 
me a little bit, and I will yield back the time. But aren't 
they taking mosquitoes and injecting them so they don't bear 
other mosquitoes? I guess birth control for mosquitoes, which 
is kind of amazing. RU-486 for mosquitoes.
    Colonel Weina. We do have a number of very innovative 
strategies that are being developed by our entomologists that 
look at doing things besides insecticides, because we do know 
that, just like the parasite is going to be able to develop 
resistance to our drugs, the insects develop resistance to our 
pesticides and eventually will overcome the ones that we have 
available to them. So we need to be thinking, as it has been 
said, outside the box and to other strategies, which include 
sterilized mosquitoes that are able to decrease the burden of 
the vectors that are present.
    Mr. Stockman. And lastly, my father used to do this. He was 
a zoologist, and what he used--I don't know if you can do 
this--he used vegetable oil on still ponds. As the larvae comes 
up to get air and then gets vegetable oil. Is that something 
that you can use widely?
    Admiral Ziemer. Larvaciding is an option.
    Mr. Stockman. You are being diplomatic.
    Admiral Ziemer. Yes, sir. But it is an important one 
because where we work, the application of larvaciding by WHO 
guidelines isn't the most costly, effective program.
    Mr. Stockman. I know they did it in Panama, too, right?
    Admiral Ziemer. Yes, sir. So there are certain parameters 
that WHO says ought to be used if larvaciding is considered an 
option. In the countries where we are working, we are not even 
looking at it because of the places and the conditions would 
not make it a cost-effective intervention for prevention 
purposes.
    Mr. Stockman. Well, thank you for your candor and your 
time. You guys have been great. Thank you so much.
    Mr. Smith. Thank you very much, Mr. Stockman.
    Not to make light, but when Mr. Stockman was talking about 
the foggers, I grew up in Iselin, New Jersey. My friends and I, 
when we were 8, without our parents' knowledge or consent, used 
to follow the foggers on our bikes. We were covered with the 
stuff.
    Mr. Meadows. Me, too, Mr. Chairman. That is our problem.
    Mr. Smith. That is when I decided to run for Congress.
    Thank you so much for your great witness today, your 
testimony, and above all, your leadership. It is so greatly 
appreciated.
    Admiral Ziemer. Thank you.
    Mr. Smith. Pursuant to the rules of the committee, we will 
now have to end the formal part of the hearing and go 
officially to a briefing. It is part of the rules of the House 
and the committee, I should say, to receive testimony from 
Ambassador Mark Dybul.
    [Whereupon, at 11:54 p.m., the subcommittee was moved to a 
briefing.]
    Mr. Smith. I will welcome the Ambassador to the witness 
table. Ambassador Mark Dybul--and it is a very high honor to 
welcome him here today--is the executive director of the Global 
Fund to Fight HIV/AIDS, Tuberculosis and Malaria. As an 
immunologist, as an administrator, as a teacher and as a 
leader, Ambassador Dybul has worked for more than 25 years to 
help prevent and treat infectious diseases.
    Ambassador Dybul has written extensively in scientific and 
public policy literature. He is a founding architect and a 
driving force in the formation of the President's Emergency 
Plan for AIDS Relief, or PEPFAR. I know--and I say this 
firsthand because I was very involved with that legislation--it 
was Congressman Henry Hyde, who was the prime sponsor. It was a 
bipartisan bill. But Ambassador Dybul was absolutely critical 
in crafting that text, the language, the all important law and 
its reauthorization in 2008. So I want to thank him for that 
leadership.
    He was formally appointed as U.S. Global AIDS Coordinator, 
with the rank of Ambassador from 2006 to 2009. Before joining 
the Global Fund, he was codirector of the O'Neill Institute For 
Global Health Law program at Georgetown University, where he 
was also a distinguished scholar.
    Welcome, Ambassador Dybul.

STATEMENT OF THE HONORABLE MARK DYBUL, EXECUTIVE DIRECTOR, THE 
      GLOBAL FUND TO FIGHT AIDS, TUBERCULOSIS AND MALARIA

    Ambassador Dybul. Thank you, Mr. Chairman.
    It is a great privilege to be back before this committee in 
a different role. Other members of the committee, thank you for 
your dedication and for being here. This committee, as I know 
firsthand, has had such long, strong bipartisan support for 
serving those in need.
    And Mr. Chairman, thank you for your leadership going back 
so long in this fight. And I know now you have new friends and 
colleagues that will help support this effort with you.
    You have heard a lot of the data and information. So if it 
is acceptable, I would like to enter my testimony for the 
record and highlight a couple of key points, including in 
response to some of the issues that have been raised. This is a 
very difficult financial time. We are very conscious of that. 
And coming before this body or any body, actually, around the 
world to ask for increased resources for foreign investment, we 
understand, is difficult to ask. And I think it is important to 
understand why we are doing this now. It is easy to say in 
these difficult financial times, we can wait 3 or 4 years, 5 
years, until we have better economic times and better budgets. 
The reality is that because of the massive investment of the 
last 10 years and because of advances in science and our 
understanding of the diseases, we are at a critical tipping 
point in the history of malaria and HIV and tuberculosis. We 
now have the science and implementation understanding to 
actually end these diseases and public health threats and to 
put us in a position to ultimately eliminate them.
    We have never had this moment in history before. Malaria 
has been with us as long as history has been recorded, as long 
as we know. We are the generation. You are the leaders that can 
actually put us on the course to end this disease as a public 
health threat. And that is why it is so important to act today. 
And I will expand a little bit on that.
    The scientific advances, you have heard about: The new 
long-lasting insecticide treated nets, new indoor residual 
sprays, new treatments, much more effective combination 
treatments and eventually a vaccine, which I will come back to. 
One thing we have not talked about is the success of the 
interventions to date leading to a new understanding in 
epidemiology of the disease. We have had so much success over 
the last 10 years, which you have heard about, that high-
transmission areas are becoming much more confined. A good 
example is South Africa and Swaziland. They now have malaria 
only on their borders with Mozambique. Not too long ago, they 
had malaria throughout their countries. We see this over and 
over and over again. Because of the success of the 
interventions, we now have areas that are being more and more 
contained with high transmission, which allows us to target our 
interventions much more effectively. We are also understanding 
that high levels of the parasite in the body are very limited 
in geographic scope. So we are now focusing our efforts on 
those areas.
    All of this has been made possible because of the 
experience of the last 10 years, because of the investments 
that have been made. We are now in a position to actually get 
for you a full return on that investment by completely 
controlling and ultimately eliminating malaria. If we succeed 
in what I just described, a partially effective vaccine would 
be enough in all likelihood. And that means some of the things 
the colonel talked about could be, in our lifetime, available. 
If we control the infection to such low rates, to such 
inefficient transmission, then you don't need an overly 
powerful vaccine. And that is the opportunity before us. But we 
are at a tipping point. And tipping points can go in two 
directions. You can continue on the course you are on or you 
can tip backwards. And you have already talked about some of 
that tipping backwards that has occurred. We have extraordinary 
data for how quickly--especially in malaria--you can tip 
backwards from success.
    Zambia is an excellent example. It achieved fantastic 
coverage of interventions, significant declines in their 
infection rates. But because of funding issues were unable to 
replace nets and immediately saw an uptick in new infections. 
We have seen the same thing in Rwanda and other places. And 
while you have talked a little bit about what happens when the 
malaria comes back, one thing that is important to emphasize is 
if you have protected a child for a few years and then they no 
longer have protection, it is almost worse than never having 
protected the child because they were never exposed to malaria. 
They have no immunity to malaria. So if they then become 
infected, their malaria will be far worse and, as the colonel 
described, can lead to the meningeal, pulmonary, and other 
fatal forms of malaria because they were protected and became 
unprotected.
    And that is why the data the chairman mentioned on the 
inability to just replace nets is so striking and such an 
important moral issue for us. And that is why the Global Fund 
dedicated $450 million this year to reduce that gap from 77 
million to 24 million bednets. But we still have some gap. And 
that is just to maintain, not to achieve the vision we talked 
about, to drive toward complete control.
    The bottom line of this is this is not a bottomless pit. 
This is not what we would have done for the last thousands of 
years in the fight against malaria. We are actually on the 
tipping point where today we can say we can completely control 
and ultimately end malaria in the world. But it is going to 
take resources.
    And in that regard, we are very grateful to Congress for 
the 2013 budget. We know how difficult that was to maintain the 
financing for the Global Fund that allowed us to replace all of 
those bednets that otherwise we could not have replaced. We are 
very hopeful that the 2014 budget can meet the President's 
request, which is similar to the 2013 budget. In fact, it is 
the same. And one thing I believe is important for you all to 
know is that your contributions to the Global Fund are 
leveraged two to one from other donors because you can never 
give more than 33 percent. And we use that to leverage two to 
one. So every $1 you give gets us $3 in the fight against 
malaria.
    As has been mentioned, the Global Fund has committed about 
a third of its $23 billion portfolio to malaria. We work very 
closely with the President's Malaria Initiative. We support the 
same comprehensive approach. And more recently, we reorganized 
our structures so that we are focused on the high-impact, high-
disease-burdened countries in a much more aggressive way, the 
countries that you all have mentioned where most of the malaria 
resides.
    Partnership has come up a fair amount, and I would like to 
just say a few words about the close working relationship with 
PMI and others. One of the areas we are working aggressively--
and to ensure that when you go to the taxpayers, you can tell 
them the money is being used well--is to increase efficiencies. 
Last week, the Global Fund hosted with PMI and UNICEF a new 
round of negotiations on the price of bednets to drive the 
prices of the nets down by using our collective buying power. 
It is the first time that has been done, that we worked 
together to use that collective buying power to drive those 
prices down.
    A second example is to partner with the private sector and 
the U.S. Government through USAID. Yesterday, we announced a 
new innovative process that will allow us to more rapidly 
utilize the resources that you make available us to and to 
leverage the private sector's capability of guaranteeing 
resources to do that.
    A third example and one that has come up is our work with 
PMI and other global partners in the Mekong Valley to address 
drug-resistant malaria. The Global Fund has committed $100 
million to a regional partner there and has partnered with PMI 
and the technical expertise of the U.S. Government and other 
partners to ensure that our global investments are not 
threatened by the resistance that is developing there.
    A fourth example is to partner with national malarial 
control programs to move toward that use of the science, use of 
the epidemiology to make sure the resources you commit are most 
effective and dedicated where the highest risk of transmission 
is. A final example I will give you relates to counterfeit 
drugs. Mr. Stockman, you asked who is working on this. Actually 
the Food and Drug Administration is working very aggressively 
on this. And there are several other international partners, 
including the private sector, that are developing new 
technology so that we can identify counterfeit products in a 
very rapid way through international consortia. And the Global 
Fund is actively involved this those efforts, which is 
something that a multilateral can do. It is more difficult for 
bilaterals to engage in.
    I also want to point out that we are not just relying on 
you and your taxpayers for what we are talking about. Africa, 
itself, is stepping up in dramatically new and exciting ways, 
as is India and parts of Southeast Asia. The African Leaders 
Malaria Alliance brings together the heads of State of Africa 
at that level to focus on malaria. And in part, as a result of 
that, last year alone and annually, $625 million came from 
countries themselves to fight malaria. So they are partnering 
with you with their own resources as well as their commitment. 
A good example is Zambia, which in the last 2 years has almost 
tripled the resources they commit to malaria. The private 
sector is also in the game heavily, in part with the 
commodities they provide, in part because of the delivery 
systems, but also with money. Chevron has provided the Global 
Fund about $55 million. Product (RED) is a partnership of CEOs 
and companies in the United States that provided the goal of 
funding over $200 million. The Bill & Melinda Gates Foundation 
has provided significant resources, and we are also targeting 
other high-net-worth individuals. So we are not looking to you 
all alone. We are developing financing partnerships that will 
relieve the burden on the American taxpayer in an exciting way. 
One of the reasons heads of state and the private sector are so 
involved is because of something that was touched on but not 
probed enough perhaps. And that is the impact of malaria on 
productivity. Nigeria alone estimates that they lose over $3 
billion a year in lost productivity because of malaria. 
Globally, the estimates range as high as $40 billion. And most 
people think those are significantly underestimated. And that 
is why the private sector has gotten engaged, because Chevron, 
for example, in Nigeria, was losing so much time in their 
offices and in their production facilities because of malaria. 
So it was good business to intervene. That is good for the 
United States to have a rapidly growing economy in Africa to be 
a buyer of our goods and services.
    So the opportunity before us is huge. The partnership that 
is responding is huge. But the most important opportunity is, 
in fact, for the first time, which we could not have told you 2 
years ago, we are on the cusp of completely controlling this 
infection and ultimately eliminating it.
    As it has been mentioned, we had malaria in this country. 
Eight United States Presidents have suffered from malaria, 
including Teddy Roosevelt and John F. Kennedy. John F. Kennedy 
of course was after 1951 when we eliminated it, but he served 
in Vietnam and came back with malaria. And as we talked about, 
that is a threat that is growing for us.
    CDC in fact was created initially largely to respond to 
malaria and is still deeply involved. We have now eliminated it 
in the United States, but there is a risk it could come back. 
And we have the opportunity--if we invest wisely, if we use 
taxpayer dollars well, if we continue this partnership--to 
achieve something that has not been possible for thousands of 
years and is possible today: To completely control this 
infection, ultimately to have more scientific advancements and 
to move toward elimination. And if we don't do that, the cost 
in millions of lives is extraordinary. But more, the billions 
upon billions upon billions of dollars that you will continue 
to have to dedicate would not be necessary if we act today, if 
we act now. So we can leave for the first time a generation 
free of malaria that has not happened since recorded time in 
history. What an opportunity. What an opportunity. If we 
maintain our resolve, if we work together, if we capitalize on 
new scientific advancements, collectively we can accomplish one 
of the greatest feats in history, to defeat a plague that has 
been with us for thousands of years. Now is the time to act. 
Now is the time to invest so that we don't pay forever. Thank 
you very much for your attention. I look forward to answering 
your questions.
    [The prepared statement of Ambassador Dybul follows:]

    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
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    Mr. Smith. Dr. Dybul, thank you very much for your 
testimony and for your leadership.
    Your testimony is quite extensive. And I do hope that all 
members of the subcommittee, and the full committee as well, 
will read it, because you really lay out even more than what 
you have just done very well in your oral presentation.
    You point out that we can all agree that no child should 
die for lack of a $1 insecticide-treated net--and I think that 
very low cost is under-appreciated. People don't realize how 
cheap it really is: A $1 rapid diagnostic test kit and $7 drug 
treatment regimen if, of course, the child is sick with 
malaria.
    You talk in your testimony about the $3.5 billion gap. And 
I am wondering, in addition to the United States, and I frankly 
think we should do more, and I know maintaining current levels 
with the crisis in the budget that we face is job one, but 
certainly if we could go above that, obviously that is all 
value-added? What other countries are really stepping up to the 
plate? And, as you pointed out in your testimony, some of the 
affected countries, like Zambia, are doing more, which is 
greatly appreciated because they have resources, and they are 
prioritizing those resources. But what other countries 
typically in Europe and elsewhere are really stepping up to the 
plate?
    Ambassador Dybul. Thank you, Mr. Chairman.
    And I think it is a really good question because it really 
does emphasize that the U.S. is not going it alone. The U.S. 
leadership has been out in front since the beginning of this 
fight on malaria. But it has not had to go it alone. So the 
Global Fund, as I mentioned, is a multilateral institution. We 
are not part of the United Nations. Actually, we are an 
independent multilateral. And we were created that way so we 
would have more flexibility. And through that mechanism, we 
have a board, which has the major contributors and countries 
represented on it. The United States is, by far, the largest 
single contributor to the Global Fund. But as I mentioned, you 
can never give more than 33 percent. And that leverage is two 
to one from others. Other countries that are large 
contributors: France is the second largest contributor to the 
Global Fund; the United Kingdom is the third. The United 
Kingdom also has a large bilateral program with a big emphasis 
on malaria. So they also have bilateral efforts in addition to 
their contributions to the Global Fund. Japan, Germany, 
Sweden--pretty much all of the Nordic countries have 
participated to very high degrees. We even have countries like 
Russia contributing to the Global Fund. India provides a 
contribution. Thailand provides a contribution. So it really is 
a way to have a shared responsibility, a global response to 
these epidemics.
    But importantly, as you pointed out, African countries 
themselves--South Africa not only receives grants from us, they 
actually provide a gift to the Global Fund. Zambia is 
considering such a gift. Namibia provides a gift to the Global 
Fund. So, at the same time they are moving to fund their own 
domestic programs, they are trying to contribute to the broader 
effort globally. So it really is a shared responsibility.
    I would also like to mention again the private sector 
contributions, which are critically important: The Gates 
Foundation, Chevron, Product (RED). You are in there as a 
leader. But you don't have to go it alone. And we work very 
hard to ensure that your money is matched two-to-one.
    Mr. Smith. Let me just ask, on the insecticide-treated 
bednets, you have suggested that 77 million nets are needed 
just to get back where we were--especially because some of the 
nets wear out after a 2- or 3-year useful life.
    The WHO says that to have complete coverage, we need 150 
million such nets. Where are we in terms of actually getting to 
those numbers? And secondly, had President Bush not created the 
President's Malaria Initiative, or the PMI, where would we have 
been?
    Ambassador Dybul. So in terms of what is needed to get to 
that complete control we talk about, that is where the $3.4 
billion gap comes from. If we are really going to contain the 
epidemic, if we are really going to get to that full control so 
that we can with a partially effective vaccine eliminate 
malaria, or at least eliminate it as a public health threat, we 
have the knowledge today, that is what that $3.4 billion would 
do. The 150 million nets a year is really to maintain. And we 
are not at universal coverage yet. We have a little bit to go. 
And we also need indoor residual spraying. We also need to 
treat people who do get malaria which actually contributes as a 
preventive tool as well because you reduce the parasitemia. And 
that is where the $3.4 billion would fill in and allow us to 
contain.
    Again, I know that sounds like a lot of money, and it is a 
lot of money. But the opportunity cost not to invest today is 
to actually lose the return on investment of what you have 
invested for the last 10 years because, again, we are at that 
tipping point. And we can either continue to work to get to 
complete control or we can slide back down, in effect losing 
some of the return on investment--obviously not all of it since 
we have saved millions of lives.
    President Bush's leadership was extraordinarily important. 
The President's Malaria Initiative has had a significant impact 
and really with the Global Fund and the UK's program are the 
major external funders, along with increasing domestic 
contribution, in the fight against malaria. But again, everyone 
is getting in the game, but it takes leadership to cause that 
effort.
    Prime Minister Blair was actually a tremendous leader and 
worked closely with President Bush at Gleneagles, and the UK 
will be hosting the follow-on to the Gleneagles G-8 Summit this 
year. And we are hopeful that they will recognize the 
importance of this partnership through the G-8, going back to 
that Gleneagles, when President Bush and Prime Minister Blair 
were in office, that has led to where we are today with success 
in malaria.
    Mr. Smith. Thank you. I do have other questions, but in the 
interest of time, I yield to my good friend and colleague Mr. 
Weber.
    Mr. Weber. Thank you, Mr. Chairman.
    Mr. Dybul you said that Swaziland had almost eliminated 
malaria, only had it in some areas on their border with 
Mozambique, I think. How did they do that?
    Ambassador Dybul. And South Africa is the same. And they 
did it through a strong national program with external 
financing and all the partners working together with a common 
objective to get to complete control. And so with long-acting 
insecticide-treated bednets, with available treatment, with the 
correct treatment, the effective treatment, they were able to 
push it out so that it is really--because of the border, 
mosquitoes don't much follow geographic borders. They go 
wherever they want to go. So it is a very important issue 
because we are seeing this happen in country after country, 
where they are actually managing the infection in their own 
countries, but it is the bordering regions. So we are shifting 
to an approach that looks like a cross-border transmission and 
cross-border control so that we can do that.
    But it really was through what we have been talking about, 
and you have been talking about all day, using the science, 
using the advancements in interventions, getting the ground 
game so that you get the coverage rates, using faith- and 
community-based organizations and make sure people are sleeping 
under the nets and that people are accessing services and 
having a national strategy and a national approach.
    It is not just these two countries. Right now, Tanzania has 
had a 50 percent reduction. They have had 90 percent coverage 
of their bednets. They have had a 50 percent reduction in 
mortality and case detection and almost a 45 percent reduction 
in all caused child mortality because malaria contributed so 
much. So many countries are pursuing this effort. And what we 
know now is if we act in this coherent way, if we use all the 
interventions smartly, we can actually get to complete control.
    Mr. Weber. Let me ask you, are you able to quantify, when 
you look at that country, are you able to say the program cost 
X, they poured X amount of resources into it and their 
incidents went down, is that quantifiable?
    Ambassador Dybul. It is. It is. In fact, we have those data 
for you. We have the total dollar amount and we have the total 
impact. What we are doing now is actually combining all the 
spigots of funding. So what we have done in the past is look at 
what the Global Fund invested, look at what PMI invested, look 
what the country invested. What we are now doing is taking a 
country look and saying what should that cost be to actually 
achieve those results? And again, working with the U.S. 
Government to get the cost of the nets down, getting cost of 
the supply down, so I think what you are getting at is exactly 
right. We now have the knowledge of how much it should cost and 
to drive the cost down even further.
    Mr. Weber. All right. And then final question, Mr. 
Chairman, my colleague Mr. Stockman, had asked the previous 
panel could they give us the names of witnesses who knew who 
was doing the counterfeiting, and let me just say, tongue in 
cheek, we don't necessarily need those names. We need the names 
and the addresses of the counterfeiters so we can send Igor and 
Bruno over there with a No. 34 baseball bat and break their 
kneecaps.
    Are there such a thing as sanctions? Or when you identify a 
country that has that kind of counterfeiting going on, is there 
a database that says this country has been participating, and 
is there such a thing as--how do you sanction them?
    Ambassador Dybul. It is rarely a country. It is usually 
people working within a country, and often----
    Mr. Weber. But if you were able to get with that government 
and say you-all need to shut this down.
    Ambassador Dybul. Which is exactly where it is going. And 
INTERPOL is actually actively involved in global counterfeiting 
with the FDA and others exactly for that purpose, so that 
people can begin to identify where people have refuge to do 
counterfeit activities, to track them with new technology, and 
then work collectively as an international community to shut 
them down.
    Mr. Weber. And so INTERPOL takes the information. There is 
a particular provider of medicine that is sending counterfeit 
drugs in and they can track that back and are keeping a 
database who not to buy from, for example.
    Ambassador Dybul. It is being developed. These programs are 
being developed because everyone has gotten so much attention 
for it. To Mr. Stockman's question, I think if you brought FDA 
in, they could give you a very full picture because they are 
very aggressively and actively involved in all of these 
conversations, and using these new handheld technologies where 
we can identify counterfeit and trace it back.
    Mr. Weber. Okay. Thank you, Mr. Chairman.
    Mr. Smith. Thank you.
    Mr. Meadows.
    Mr. Meadows. Thank you, Mr. Chairman, and thank you for 
your testimony and briefing, and I wanted to follow up a little 
bit in terms of, you know, you mentioned the Global Fund and I 
think you implemented a series of reforms, you know, due in 
part to a response from Congress. And as you have implemented 
those reforms, how would you say those have progressed since, 
you know, your leadership and what is still left to be done?
    Ambassador Dybul. Thank you for the question, because I 
think it is very important and really is a testament, in my 
mind, and the reason I was so interested in going into the 
Global Fund it that it is a true learning organization. It 
really looks at itself constantly to say how can we improve, 
how can we do better and let's change, and as we all know, that 
is not a typical approach in organizations.
    Mr. Meadows. Right.
    Ambassador Dybul. And that is one of the most exciting 
things about it. So the reforms are really an evolution from 
looking to see where we are today, what the landscape looks 
like and how do we implement more effectively with higher 
impact. So some of the key things that have been done, and 
again, the board--the U.S. being an important member of the 
board and the U.S. Congress pushing, really--the board itself 
pushed for these reforms, and how rare is that that you have a 
governing body pushing for this type of change? Because often 
we think change means you made a mistake. Sometimes change is 
good because you are learning.
    One of a few things we learned was that we didn't have the 
right--we don't have as much focus on high-impact grant 
management as we needed to and so we shifted so that now 75 
percent of our staff is dedicated as a financing facility, 
which is what we are, to grant management, because that is our 
core business. And we are identifying what our core 
competencies are and partnering more with other organizations, 
which is what we were created to do for technical and other 
purposes.
    Mr. Meadows. And so if you are looking at that grant 
management, what matrix do we use in terms of, one, the 
awarding of the grant, and then I guess the second part of that 
is the effectiveness once the grant has been given, what is the 
matrix, the area?
    Ambassador Dybul. So the matrix for how grants are given 
are based on disease burden, because that is where the impact 
is going to be. Co-investment is a key part of our--how we 
make----
    Mr. Meadows. So the better co-investment, the more likely 
they are to get to the grant?
    Ambassador Dybul. And also a requirement for co-investment 
is based on economic situation. So even if you have a high 
disease burden but have a good economy, you need to be giving 
more, and we work on that in a formalized way as part of the 
grant-making identification.
    Mr. Meadows. And there are no other political agendas or 
sidebars that evaluate it.
    Ambassador Dybul. No. Well, the other is ability to 
implement in terms of rapidity. We don't want to dedicate money 
and put it in a country when they don't have the capacity to 
move it. And then we have a risk management tool that is new, 
which looks at not only risks of misuse of funds so that we can 
ensure that--and go after any misuse of funds--but also risk in 
non-implementation, which gets to capacity a little bit, and 
what are those risk implementations. Is it the supply chain? Is 
it human resources? Is it the inability to reach certain parts 
of a country for various reasons? And then we dedicate our 
resources to alleviating those risks. So it is a very complex 
matrix across those areas, but it is leading to a much more 
impactful approach.
    Mr. Meadows. So you are saying this is really more of a new 
funding model than you have had in the past; is that correct?
    Ambassador Dybul. In fact, we call it a new funding model.
    Mr. Meadows. All right. So, and thus my question. And so as 
we look at this new funding model, what can we do in terms of 
the planning stages and the implementation stages, similar 
question that I asked the Admiral, what can we do from a 
legislative standpoint, knowing that we are only part of the 
pie, to help facilitate that and help encourage that to make 
sure that American taxpayers are getting what they pay for.
    Ambassador Dybul. Well, I am probably a little biased 
since, as the chairman pointed out, I actually was involved in 
the writing of the legislation, but I think it is pretty good.
    Mr. Meadows. What tweaks would you make to your own 
writing; how about that?
    Ambassador Dybul. I actually believe currently that the 
language you have is very useful to us, and it actually helped 
the Fund, along with other people on the board, move toward 
this new exciting approach.
    What we are really focused on is the partnership piece, and 
that is in the legislation that we should be focused on using 
the resources from the U.S. taxpayer from whatever source they 
come in the most effective way to have the greatest impact and 
partner and leverage. And that leveraging piece is something we 
have not always done well, none of us, and that is what is so 
exciting about this new funding model--we actually bring all 
the partners together to look at the epidemiology, look at the 
science, to ensure that the investments going in aren't 
duplicative.
    Mr. Meadows. Right.
    Ambassador Dybul. Aren't ineffective and are going to the 
right outcome. And then, importantly, to the other part of your 
question, we evaluate it on a quarterly basis: How is the 
progress against the targets? And we can track it in a 
programmatic way so that we can adjust and reprogram as needed 
as we are identifying new realities on the ground. Grant 
management is not writing a grant. You start grant management 
when you write a grant. You then work to ensure that the money 
is used well. We also only disburse funds as the countries need 
them. We don't give them a pot of money and then 5 years later 
come back and see what they did.
    Mr. Meadows. What a novel concept. Well, and so let me go 
back. You mentioned ``tipping point'' in your testimony here 
today. You mentioned ``tipping point'' four different times, 
and so as, as we see that, you say we are at a tipping point, 
we are at a tipping point and we can go forwards or backwards. 
And yet what you also said is that we are at a position where 
we can eradicate malaria. What is the timeframe, and what is 
the greatest barrier to--and I know that we are talking about 
science here. We are talking about--but probability, the 
probability of eradicating malaria within what period of time?
    Ambassador Dybul. There are different models, and I have to 
say a lot of this is mathematical modeling to predict----
    Mr. Meadows. Sure.
    Ambassador Dybul [continuing]. When we intervene how we 
will do. The model so far over the last 10 years have held up 
pretty well, and really, eradication will require a vaccine in 
all likelihood. What we can do is eliminate it as a public 
health threat and completely control malaria. And what we have 
seen in the last 5 years, I think, makes us much more hopeful 
that the timeline could be even more compressed. But we are 
actually, and the World Health Organization reports on this, 
about 20 countries have eliminated malaria in the last 10 
years--so you go from endemic or epidemic, to control, to 
elimination, and then ultimately eradication.
    And if you look at the trajectory and the curves, we were 
seeing a 20-year horizon, 30-year horizon, but we are bending 
those curves down, including in countries, because of the 
success of the last 10 years. We are working on that precise 
type of modeling based on the new data to try to give us a 
better sense of that. But the wildcard in that, and this is why 
I emphasize it a little, what we are learning more and more is 
you can actually push the epidemic into corners, and that then 
means you throw everything you can at those corners to have the 
biggest impact to get everything down to low level. And if you 
can do that, then a relatively efficient vaccine should be 
enough. If you allow a couple of pockets somewhere, you are 
going to need a really highly effective vaccine, so a lot of it 
is going to depend on that variability.
    The one thing we do know is that if we don't get down to 
complete control, near elimination, we will be continuing to 
fight this fight forever, and that is the tipping point, and 
that is the change that we have seen. Up until the last 2 
years, we would have just had to keep doing the same thing and 
the same thing and the same thing until we have a vaccine or 
until all countries had enough economic growth that they didn't 
have some of the issues around pooling of water and other 
things. But now we are seeing the opportunity to push, push the 
timeline forward strongly.
    The reverse of that is if we don't stick in this game, we 
know what is going to happen. And malaria, more than any other 
disease, we know it will come back, and then we won't have the 
science or the tools to bring it back down, and a partially 
effective vaccine won't do it, and then we are going to have to 
just keep putting in more and more and more money rather than 
investing now, and that is the issue of the tipping point.
    Again, I--you know, under most circumstances, I wouldn't--I 
have been around governments a long time, I have been around 
budgets a long time. I wouldn't come to you with a straight 
face to say we need more money today, given the current 
economic environment, except for this unique moment in history. 
It is a shame it is coming at a time of tough budgets, but it 
really is. We have never had in the thousands and thousands of 
years that we have had malaria.
    Mr. Meadows. Well, I must admit, it was very unique 
testimony and thus why I followed up with a question, but with 
that, being sensitive to the other members, I want to yield 
back to the chairman at this point.
    Mr. Smith. Thank you, Mr. Meadows.
    Mr. Stockman.
    Mr. Stockman. Mr. Meadows, you can keep going. Those are 
great questions. I enjoyed them. And following up on his line 
of comments and statements, you mention in your testimony, Mr. 
Ambassador, Zambia and Rwanda are reinfected. Can you tell me, 
in your mind, because you have been working with this for so 
long, what is the rationale behind that? What happened?
    Ambassador Dybul. So in both, neither country had 
eliminated, but they had significant control, very close to 
complete control in many areas. And that was because, like in 
Swaziland, they had national bednet campaigns, they had 
excellent care and treatment programs, they had an excellent 
program and a strategy that they implemented. But then they had 
some funding shortfalls and they weren't able to replace them, 
some nets, or couldn't complete some campaign.
    Mr. Stockman. Can I interrupt for a second? Was it the NGOs 
that had the shortfalls or the government?
    Ambassador Dybul. Both. So both NGOs and the government are 
involved. Basically it is one pot of money that gets divided 
out. Most bednets are distributed through national campaigns 
that are organized by the government because it is the only way 
you can do a national program, but implemented often through 
NGOs, especially the sleep-under-the-net campaigns. One 
important thing is you can't just distribute the nets. You make 
sure people know how to use them.
    Mr. Stockman. I was going to say, because don't they sell 
them or resell them or so?
    Ambassador Dybul. You know, sometimes that happens. With 
the national campaigns, that is rare because there is no reason 
to, because your neighbor has one, too, but in the past, that 
actually did happen.
    Mr. Stockman. I saw them using it for everything.
    Ambassador Dybul. Yeah. And actually there was a big 
education campaign. I mean, in the early going, people were 
afraid to use them, didn't know how to use them. Actually in 
one case, I went into a home and I asked them where their 
bednet was because it wasn't hanging, and they pulled it out 
from under the bed in the plastic packets because they thought 
it was so beautiful and still in the plastic package. So you 
need to go in and teach people and encourage them, and that is 
where the communities are so important and the faith and faith-
based communities and the community-based organizations.
    In Nigeria, the Muslim community and the Christian 
community are working together to ensure that everyone in their 
congregation sleeps under their nets. It is part of their 
Sunday sermons. They do it all the time, and so that is really 
important. The funding shortfall was actually from external 
resources, but the governments couldn't make up and so they 
couldn't meet their deadlines to ensure that nets were replaced 
or campaigns were completed, and then we saw the increase. But 
then we all came back in, we moved heaven and earth to get the 
nets in and they came right back down.
    So it tells you how rapidly with this disease, if you lose 
just a little bit, you lose a lot, but if you stay contained 
and you stay suppressed, then you start pushing to where you 
just have these little pockets of high rates of infection.
    Mr. Stockman. Why do you think in Vietnam they are drug 
resistant? What is the rationale behind that?
    Ambassador Dybul. So it is more than Vietnam. It is 
actually the whole Mekong Valley, so Myanmar, Vietnam, Thailand 
and really in that that nexus, again, because the mosquitoes 
and the resistance doesn't respect borders.
    The resistance develops either because, as you pointed out, 
people get partially effective drugs, or they stop and start 
and don't take enough. And one of the key issues which has been 
raised is that, you know, if you are out in a village and you 
are in malaria season and your kid gets a fever, you are not 
going to walk the 2 days or the day--and the clinic may not 
even be open. You are going to go to a kiosk and you are going 
to pay for an anti-malarial drug, and the Global Fund actually 
has been engaged in a program to reduce the cost of the 
effective products in those kiosks. So what people do, they buy 
the cheapest product, which often is quinine or quinine-based 
products in an area that has quinine resistance or quinolone 
resistance and it just expands. Or they buy, rather than a 
combination artemisinin product, they buy a single artemisinin 
product, and we know it has to be in combination.
    And so this single use of single artemisinin products 
rather than in combination develops resistance to the 
artemisinin, and so we are trying to get people in the private 
sector where people go to those kiosks so that when they go, 
they will still buy the cheapest drug, but it will be the 
effective drug. And then sometimes they just don't complete the 
course.
    What we are working on internationally is bringing all 
partners together to really intensively address this resistance 
problem in this area so that it doesn't spread, threatening all 
our investments everywhere else, but there are multiple 
reasons. And we are hypothesizing because we weren't there as 
it developed, but we have a pretty good sense of how it 
developed and what is necessary to contain it.
    Mr. Stockman. Thank you. I know we are getting ready to 
vote, so I yield back the balance of what time we don't have.
    Mr. Smith. Thank you. Thank you, Mr. Stockman. Just a few 
final questions and maybe my colleagues might have a question 
or two before we go to votes over on the House floor.
    In 2000 I authored legislation that became known as the 
Combating Autism Act. It took 3 years to get the bill passed, 
and one of the cores of that piece of legislation--as a matter 
of fact, I did the reauthorization in 2011 as well--was 
surveillance. At the time, we thought that the prevalence of 
autism in the U.S. was 3 out of 10,000, at least that was what 
we thought in the early 1980s, and CDC was spending $287,000, a 
drop in the bucket, per year, straight line for 5 years. We had 
essentially no real program on surveillance, and our 
legislation created centers of excellence; all of a sudden, now 
we know the number, at least on the spectrum, is 1 out of every 
50. I held a hearing recently on what I call the global 
developmental disability pandemic autism. Sixty-seven million 
is one estimate worldwide, but we don't have reliable 
statistics, and reliable statistics are what drives, I think, 
good policy.
    In the World Malaria Report for 2012, WHO suggests that in 
the 41 countries around the world that account for 85 percent 
of malaria cases, it is not possible to make a reliable 
assessment of malaria trends due to incompleteness or 
inconsistency of reporting over time. WHO concludes that 
surveillance systems seem to be the weakest where malaria's 
burden is the greatest and states that there is an urgent need 
to improve surveillance in those settings. I wonder if you 
might speak to that issue of surveillance, again, to drive the 
prioritization, the money, and of course, the deployment of 
resources.
    Ambassador Dybul. It is an extraordinarily important 
question because if we are really going to invest smartly and 
if we are really going to get toward this elimination, we need 
to know with very solid data how to invest and where to invest, 
and that requires surveillance, and that is part of what we are 
doing in the new funding model, and I think we are doing as a 
global community. Really, you know, 10 years ago, you could do 
anything and have a huge impact because there was just so much 
out there, and that is one of the reasons larvicides don't work 
in these communities. There is just too much malaria, and it is 
not going to do enough.
    Now we have to be a lot smarter because of the impact, and 
that means better surveillance. So we are working with 
countries so that by the time they come in with a concept note, 
as the partnership, we will have invested in getting that data 
and those--that surveillance data so that we will know how to 
invest in the most impactful way. It is going to be a process 
to get there, but I do have to say, too, compared to where we 
were 10 years ago in these countries with surveillance to 
today, because of their work, because of our investment, 
because of our partnership, it is night and day. And you have 
seen it, sir, I know, Mr. Chairman, I know many of the members 
have been and seen the radical transformation that has occurred 
that the American people have partnered with people in Africa 
to do. And part of it is in surveillance, but we are getting 
there in a way that was inconceivable 10 years ago, which is 
why I am much more optimistic than the models, because none of 
the models were able to predict that we would be today where we 
are today. And that is really because of the leadership of 
countries like the United States, but fundamentally because of 
the energy in people in Africa who are now looking to the 
United States and countries that have supported them in these 
diseases in a much different way and a much more positive way. 
And as we continue to work with them to support them, to 
identify their pockets with surveillance and improve their 
systems more broadly, that just expands and expands.
    Mr. Smith. Thank you.
    On April 23, Dr. Thomas Frieden testified before our 
subcommittee. The title of our hearing was, ``Meeting the 
Challenge of Drug-Resistant Diseases in Developing Countries.'' 
I know the Global Fund deals with PEPFAR, HIV/AIDS, as well as 
with tuberculosis. He did focus on MDR and XDR tuberculosis and 
all the challenges that are being faced going forward, but he 
did spend some time talking about artemisinin-resistant malaria 
and pointed out, and I would just quote in pertinent part his 
testimony:

          ``Since 2008, malaria infections in parts of 
        Southeast Asia have been shown to be resistant to 
        artemisinin drugs. This is the last remaining class of 
        antimalarial drugs and forms the basis of malaria 
        treatment around the world. If these resistant 
        parasites were to spread to sub-Saharan Africa (which 
        has occurred with other forms of drug resistant 
        malaria), the results could be devastating.''

Could you speak to that?
    Ambassador Dybul. First, I would completely agree with 
Tom's assessment, and we have actually talked about this.
    I would point out that there actually is a new--several new 
classes that are being created through remarkably brilliant 
public-private partnerships, the Gates Foundation is heavily 
involved, medicines for malaria and vaccines is involved, so we 
will have new classes of drugs, but we can't keep doing that, 
right, so we need to stamp out the resistance and that is why 
we are investing $100 million in that region to jump on it 
right away working with partners. It is estimated that it will 
cost about $400 million and we are basically leveraging and we 
are looking for people in that region who are interested in 
those countries to step up financially as well, and then 
coordinate across the countries because it is a cross-country 
effort. It is a regional effort because we have three countries 
that have the resistance. So, we are jumping on it immediately 
because of the threat.
    MDR-TB is another big problem, and Global Fund is the 
largest funder of MDR-TB--external funder of MDR-TB--programs 
in the world, so we are very active there, but that is another 
committee hearing.
    Mr. Smith. Let me just ask, Ambassador Dybul, early on, and 
I have raised this repeatedly with Global Fund, I am not the 
only one, it had excluded, or largely excluded faith-based 
groups. I know that there is a renewed effort to try to be 
inclusive, if you might want to speak to that. Also, the 
challenges you face, the Global Fund's Web site indicates that 
malaria is the greatest cause of illness and death in the 
Democratic Republic of the Congo and that there are at least 10 
million cases of malaria per year. Yet some of their programs 
get unacceptable ratings; of course, the challenges in the DRC 
are huge, namely the war. I have been to Goma myself. I know 
how the terrorism is, and the sexual violence is almost without 
precedent anywhere in the world, but if you could speak to that 
as well. Then I will go to my colleagues because we do have a 
vote.
    Ambassador Dybul. So on Congo, it is a difficult place, no 
question about it, but you can actually get things done even in 
difficult environments. And you know, Sudan actually has 
universal coverage of bednets, so it is possible, and we are 
intensively focused on Congo right now, and it is by working 
with more than the government. That is how you get the job 
done, by working with partners, including faith-based 
organizations, which is a segue into your other question.
    We recognize that you cannot succeed, and then particularly 
when you are talking about getting to the last mile, getting to 
the people and making sure they stay in services and use their 
bednets and use the right anti-malarial drugs, that the 
communities and the faith communities are critically important 
to that.
    We have changed the way we operate in a number of ways. We 
do have quite a number of faith-based implementers, Catholic 
Relief Services, World Vision. We also work with the faith 
community to raise additional resources. The large Lutheran 
group and Methodist group are actually trying to raise $40 
million around malaria control right now with us. But it also 
about implementation and engagement, and so in our new funding 
model, we actually have shifted the process around, and it was 
always intended that faith-based communities be part of our 
country coordinating mechanisms, but it didn't always work 
well, and through our new mechanisms, we are actually working 
on that more and more, and actually welcoming people into our 
dialogue that leads to a country plan from all walks of life. 
And we are actually working with faith communities here in the 
United States to identify in these countries who should be at 
the table, who needs to be engaged in the conversation.
    Now, that doesn't mean we have to fund them, but they need 
to be part of the conversation and part of the national 
planning because they do so much on their own. Even if we don't 
funnel money to them, they need to be part of the national plan 
and the national approach to ensure that we combat and actually 
ultimately eliminate malaria.
    Mr. Meadows. So what you are saying--let me just follow up 
on that. So what you are saying is with these faith-based 
groups, there is no, in your matrix, when we were talking about 
funding matrix, there is no disqualifier in terms of providing 
funding for that?
    Ambassador Dybul. Absolutely not.
    Mr. Meadows. Okay. And as we know in Africa, it is either 
faith or it is tribal or cultural, and so you are reaching out 
to all those different groups and the leaders of those groups 
to make sure we hit these pockets?
    Ambassador Dybul. We are, and our new funding model 
actually is designed to ensure that we do in a much more 
aggressive and effective way.
    Mr. Meadows. All right. Well, I yield back. I thank you, 
Mr. Chairman. Thank you for your testimony.
    Mr. Smith. Thank you. Anybody else like to make any final 
comments? Ambassador Dybul, would you like to make any final 
comment?
    Ambassador Dybul. I would just like to thank the committee 
again and thank you, Mr. Chairman, for your many years of 
leadership and look forward to continuing to work with all of 
you.
    Mr. Smith. Well, frankly, we want to thank you for your 
extraordinary lifelong leadership. You have made an 
extraordinary difference, and I know it because the passage of 
PEPFAR was in no way a done deal. Its reauthorization, in which 
it was greatly expanded, there were lessons learned, and again, 
you were critical in the drafting of that legislation. So you 
have made an impact and saved lives. That really deserves a 
great deal of praise, so thank you for being here, thank you 
for the work that you do. This hearing, or briefing part of the 
hearing, is adjourned.
    [Whereupon, at 12:42 p.m., the subcommittee was adjourned.]
                                     

                                     

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