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



 
                THE FIRST ONE THOUSAND DAYS: DEVELOPMENT
                     AID PROGRAMS TO BOLSTER HEALTH
                             AND NUTRITION

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

                                HEARING

                               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

                             SECOND SESSION

                               __________

                             MARCH 25, 2014

                               __________

                           Serial No. 113-195

                               __________

        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--resigned 1/27/  GRACE MENG, New York
    14 deg.                          LOIS FRANKEL, Florida
DOUG COLLINS, Georgia                TULSI GABBARD, Hawaii
MARK MEADOWS, North Carolina         JOAQUIN CASTRO, Texas
TED S. YOHO, Florida
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

Ms. Tjada D'Oyen McKenna, Acting Assistant to the Administrator, 
  Bureau for Food Security, U.S. Agency for International 
  Development....................................................     6
Ms. Lisa Bos, senior policy advisor for health, education, and 
  water, sanitation and hygiene, World Vision....................    20
Henry Perry, M.D., Ph.D., senior associate, Health Systems 
  Program, Department of International Health, Bloomberg School 
  of Public Health, Johns Hopkins University.....................    32
Ms. Carolyn Wetzel Chen, chief grant development officer, Food 
  for the Hungry, Inc............................................    41
Sophia Aguirre, Ph.D., chair, Integral Economic Development 
  Management Program, Catholic University of America.............    50
Mehret Mandefro, M.D., adjunct professor of health policy, Milken 
  Institute School of Public Health, The George Washington 
  University.....................................................    56

          LETTERS, STATEMENTS, ETC., SUBMITTED FOR THE HEARING

Ms. Tjada D'Oyen McKenna: Prepared statement.....................     9
Ms. Lisa Bos: Prepared statement.................................    23
Henry Perry, M.D., Ph.D.: Prepared statement.....................    35
Ms. Carolyn Wetzel Chen: Prepared statement......................    44
Sophia Aguirre, Ph.D.: Prepared statement........................    52
Mehret Mandefro, M.D.: Prepared statement........................    58

                                APPENDIX

Hearing notice...................................................    76
Hearing minutes..................................................    77
Written responses from Ms. Tjada D'Oyen McKenna to questions 
  submitted for the record by the Honorable Christopher H. Smith, 
  a Representative in Congress from the State of New Jersey, and 
  chairman, Subcommittee on Africa, Global Health, Global Human 
  Rights, and International Organizations........................    78
Written response from Ms. Tjada D'Oyen McKenna to question 
  submitted for the record by the Honorable Karen Bass, a 
  Representative in Congress from the State of California........    83
Mehret Mandefro, M.D.: Revised and extended statement............    84
Henry Perry, M.D., Ph.D.: Materials related to child nutrition...    88
The Honorable Christopher H. Smith:
  Materials from The Lancet......................................    96
  Statement for the record from the American Academy of 
    Physicians...................................................   104
  Statement for the record from Bread for the World..............   107
  Statement for the record from Lions Clubs past president.......   109


                      THE FIRST ONE THOUSAND DAYS:
                  DEVELOPMENT AID PROGRAMS TO BOLSTER
                          HEALTH AND NUTRITION

                              ----------                              


                        TUESDAY, MARCH 25, 2014

                       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 3 o'clock 
p.m., in room 2172 Rayburn House Office Building, Hon. 
Christopher H. Smith (chairman of the subcommittee) presiding.
    Mr. Smith. The subcommittee will come to order. Good 
afternoon. First of all, I want to apologize for the delayed 
opening or convening of this hearing. We did have a markup that 
was only put on yesterday and it included the Ukraine Support 
Act and two other bills. And the debate went late and then we 
had the votes that just completed. So we have no further votes, 
I believe, scheduled so we will not be interrupted. But again, 
I apologize to all of our witnesses and everyone who has taken 
the time to be here that we were late in beginning.
    We are here today to address the topic of ``The First One 
Thousand Days: Development Aid Programs to Bolster Health and 
Nutrition.''
    There is perhaps no wiser investment that we could make in 
the human person than to concentrate on ensuring that 
sufficient nutrition and health assistance is given during the 
first 1,000 days of life; 1,000 days that begins with 
conception, continues throughout pregnancy, includes the 
milestone of birth and then finishes at roughly the second 
birthday of the child.
    Consider this: According to the United Nations Children's 
Fund, 6.6 million children died before reaching their fifth 
birthday in 2012; an average of roughly 18,000 daily deaths 
among children under 5 years old. Among the factors 
contributing to such a grim tally are malnutrition, obstructed 
newborn breathing, pneumonia, and diarrheal disease. All these, 
and other causes, are ones which we are capable of addressing, 
if we apply resources and political will to the problem.
    Today's hearing complements various hearings our 
subcommittee with jurisdiction over global health has held over 
the past several years. It was inspired in part by what I 
experienced at the U.N. Millennium Development Goals Summit in 
New York in September 2010.
    There I had the privilege of participating in an 
extraordinary roundtable meeting of First Ladies of African 
nations that concluded with the signing of a declaration to end 
maternal and child malnutrition, with particular emphasis on 
``the first 1,000 days in the life of a child from the moment 
of conception.''
    The roundtable focused on that great killer of children, 
malnutrition. The roundtable concluded that undernutrition 
alone remains ``one of the world's most serious, but least-
addressed problems--killing an estimated 3.5 million children 
annually.'' In other words, food insecurity is a plague which 
ravages our future, ending the lives of little boys and little 
girls throughout the developing world well before their time. 
The roundtable also pointed out that 60 percent of the world's 
chronically hungry are women.
    According to the Global Alliance for Improved Nutrition, or 
GAIN, cosponsor of the roundtable, and as a matter of fact, the 
folks that invited me to be there that day, malnutrition's most 
devastating impact is actually in the womb, often causing death 
or significant mental and physical disability to the precious 
life of an unborn child.
    Children who do not receive adequate nutrition in utero are 
more likely to experience lifelong cognitive and physical 
deficiencies, such as stunting. UNICEF estimates that one in 
four children worldwide is stunted due to lack of adequate 
nutrition.
    Children who are chronically undernourished within the 
first 2 years of their lives also often have impaired immune 
systems that are incapable of protecting them against life-
threatening ailments, such as pneumonia and malaria.
    Adults who were stunted as children face increased risk of 
developing chronic diseases, such as diabetes, hypertension, 
and heart disease. Mothers who were malnourished as girls are 
40 percent more likely to die during childbirth, experience 
debilitating complications like obstetric fistula, and deliver 
children who perish before reaching age 5.
    We must take a holistic, mother-and-child approach to the 
problem. By helping women throughout pregnancy receive adequate 
nutrition and supplemental micronutrients, such as iodine, 
Vitamin A, and folic acid, and ensuring that they are well-fed 
while nursing, both children and mothers thrive.
    In addition to addressing undernutrition, there are a 
number of other interventions that can make an impact. About 44 
percent of all under-5 deaths occur within the first month of 
life, during the neonatal period. Among newborns, the greatest 
threats to survival are prematurity and failure to breathe at 
birth, known as birth asphyxia. Following the neonatal period 
through the first 5 years of life, child survival is imperiled 
primarily by pneumonia and diarrheal disease.
    The solutions are often readily at hand. Most neonatal 
deaths can be prevented at little to no expense with neonatal 
resuscitation, prompt administration of antibiotics, and 
nutrition supplementation. Inexpensive interventions like oral 
rehydration therapy, which cost 5 to 10 cents per dose, are 
also effective in curbing diarrheal disease. I would note 
parenthetically in the early 1980s I sponsored the amendment 
called the Child Survival amendment which provided $50 million 
for vaccinations, breastfeeding promotion, growth monitoring, 
and ORT (oral rehydration therapy). I will never forget Jim 
Grant, the famous director of UNICEF, who always had an oral 
rehydration packet of salts in his pocket and he was 
instrumental in promoting this child survival revolution in 
saying for a couple of cents per day we can save the life of a 
child.
    We must never pit the survival of the child against that of 
the mother, as both are complementary objectives. Curbing child 
mortality in the womb and at birth also goes hand-in-hand with 
reducing maternal mortality.
    Best practices to radically reduce maternal mortality can 
and must be life-affirming, protecting from harm both patients, 
the mother and the child in the womb. Of course, we have known 
for more than 60 years what actually saves women's lives: 
Skilled birth attendants, treatment to stop hemorrhages, access 
to safe blood, emergency obstetric care, antibiotics, repair of 
fistulas, adequate nutrition, and pre- and post-natal care.
    Political will is absolutely essential to address this 
problem and to make sure it is adequately resourced. One thing 
that I hope this hearing will bring to light, that such 
interventions in the first 1,000 days of life are not only 
morally imperative but also cost-effective as well.
    One group of Nobel laureate economic experts ranked efforts 
to address undernutrition as the single-most cost-effective 
investment in foreign aid. The economists concluded that each 
dollar spent on reducing undernutrition could yield a $30 
benefit.
    One other thing I hope this hearing will highlight is the 
importance of faith-based organizations in fighting this 
battle, and to underscore the need for our aid programs to work 
with such organizations. We will hear from representatives from 
two such organizations, Food for the Hungry and World Vision, 
to discuss their insights.
    Faith-based organizations play an absolutely critical role 
in places such as Africa, which one can say is a faith based 
continent. Matthew 25 notes, one of my favorite Scriptures, 
``When I was hungry, you gave me food, when I was thirsty, you 
gave me drink, when I was naked, you clothed me,'' inspires 
these and other great organizations such as Catholic Relief 
Services, just as it inspires the work of this subcommittee and 
so many Members of Congress.
    For example, in 2004, along with my colleague on the 
Foreign Affairs Committee, the former chair, Ileana Ros-
Lehtinen, I sponsored an obstetric fistula resolution, which 
passed the House of Representatives, seeking to address one 
debilitating factor that wreaks havoc on the lives of mothers 
and their children. I would note that Kent Hill, when we got it 
past the House, we went over to USAID, Kent Hill, who is sick 
from a recent trip to Africa and cannot testify today, he and I 
had a meeting. I said, look, you have the authority already to 
initiate an obstetric fistula program. It has already passed 
the House, use this as a framework. He did and well over 20,000 
women have had fistula repairs as a direct result of the 
USAID's program which has been highly successful.
    The following year after I offered that bill, I was able to 
amend the Foreign Relations Authorization Act to fund 12 
centers in the developing world to treat and prevent obstetric 
fistula, as well as to provide funding for skilled-birth 
attendants. Importantly, I was also able to remove restrictive 
language from the original bill that would have prohibited 
faith-based hospitals in the developing world from receiving 
funding. Again, I must stress, that it is these faith-based 
organizations that are doing yeoman's work on the ground to 
address child and mother mortality, and they must be supported.
    In this Congress I introduced legislation, H.R. 3525, the 
International Hydrocephalus Treatment and Training Act. 
Hydrocephalus, or ``water on the brain,'' is a disease which 
affects three to five out of every 1,000 newborns in developing 
countries, who are either born with it or acquire it due to 
neonatal infections in the first few months of life. For such 
children, it is often a death sentence and a very painful one 
at that. Doctors, even assuming there is even a doctor around, 
often do not know how to treat it. Moreover, if they do treat 
and use the traditional surgical procedure which requires the 
life-long use of a shunt, such shunts often become infected, 
leading to death a few years later.
    Our bill would train doctors in Africa in a new and proven 
technique which does not require a shunt. It was developed by 
Dr. Benjamin Warf of Harvard, a noted neurosurgeon. And it is 
effective in at least \2/3\rds of the cases of infants with 
hydrocephalus. It is ideally suited to conditions in the 
developing world. The amount required to make a difference in 
the lives of these children and their parents is a paltry sum, 
an estimated $15 million over 3 years. I invite my colleagues 
to consider joining that legislation and I would ask, we have 
asked repeatedly that USAID look at doing it administratively. 
You don't need to be told, you can just do it.
    Initiatives such as these are ones which should gather 
support across the political aisle. They are life affirming, 
and can save lives. And I would just note parenthetically, in 
Cure International's effort in Uganda, in excess of 5,000 
children who otherwise would have been dead and again, having 
suffered a very painful death, are alive. And we had one of the 
neurosurgeons testify before our committee from Africa, because 
part of the bill's hope is to train neurosurgeons throughout 
Africa and to build out that capacity because there are many 
diseases of the brain that require that kind of expertise and 
there is an absolute dearth of such expertise in Africa and we 
want to change that.
    I would like to yield to my friend and colleague, Ms. Bass, 
for any opening comments.
    Ms. Bass. Thank you, Mr. Chair, for holding today's hearing 
and also for yesterday's meeting that we had with African 
Ambassadors. I thought it was very, very helpful. I also want 
to offer a word of thanks to today's witnesses, including the 
Acting Administrator for USAID's Bureau on Food Security and a 
wide range of academics, physicians, and non-governmental 
agency leaders focusing on maternal and public health, 
nutrition, and economic development.
    I look forward to hearing perspectives from these expert 
panelists as it relates to the roles of maternal health, 
nutrition, and food security in ensuring the health of mothers 
and children in the first 1,000 days of life and beyond.
    As Chairman Smith has pointed out, the global scale of 
child mortality is staggering with 6.6 million children dying 
before their fifth birthday in 2012 alone. While efforts to 
address this challenge have produced significant progress over 
the past two decades, critical work remains to be done. This is 
particularly evident in sub-Saharan African nations where 
progress in the reduction of childhood deaths has shown the 
least progress.
    The good news is that sub-Saharan Africa's progress in 
curbing childhood deaths related to infectious ailments are 
less prominent due to expanded immunization programs and 
increased success in the prevention of diarrhea and malaria. 
However, the issues of poverty, inadequate access to health 
care for expectant mothers and their children, and 
undernutrition continue to sustain high rates of childhood 
deaths continent-wide. This phenomena is particularly 
pronounced in Central and West Africa, the region which 
accounts for the majority of childhood deaths on the continent. 
Women in the Central and West African regions face the highest 
risk of maternal mortality and children in the regions are also 
impacted by the high prevalence of stunted growth.
    While serious challenges remain, I applaud international 
efforts to curb childhood mortality including the U.N. 
Millennium Development Goals related to improving maternal and 
child health. I also recognize the critical contributions of 
several of the United Nations' largest collaborative efforts 
including the Scaling Up Nutrition Movement, the Zero Hunger 
Challenge, and the Integrated Global Action Plan for the 
Prevention of Pneumonia and Diarrhoea.
    As we prepare to hear from today's witnesses, I hope we can 
learn critical lessons from their vast experiences and use them 
to increase support for the most effective measures of 
improving maternal and child health in the first 1,000 days of 
life.
    I would also hope that these lessons lead to the 
formulation of new ways to address the health concerns of 
mother and children specifically in the sub-Saharan African 
region where they are at greatest risk. As a former healthcare 
professional, I also know that there are several other 
contributing factors to maternal death, prematurity, and 
childhood death and one of the factors that I am very concerned 
about is child marriage, is girls having babies far too young, 
their bodies not being able to sustain a pregnancy or them 
having consequences like fistula.
    The other issue that contributes to maternal death is the 
inability of many African women and other women in developing 
countries to have access to birth control and so they cannot 
control the spacing between their pregnancies. If you have too 
many pregnancies, deliver too many babies too early before the 
body has completely matured, you are at risk of maternal death, 
as well as you are an increased incidence of prematurity and 
contributes to the death before 1,000 days. So all of these 
issues I would appreciate hearing about from our witnesses 
today. Thank you.
    Mr. Smith. Thank you, Ms. Bass. I would like to now 
introduce our very distinguished first witness and thank her 
for being here and for her work and that is Tjada McKenna who 
is Deputy Coordinator for Development for Feed the Future, the 
U.S. Government's global hunger and food security initiative, 
as well as the Acting Assistant to the Administrator in USAID's 
Bureau for Food Security. Ms. McKenna coordinates 
implementation of Feed the Future across the U.S. Government, 
oversees its execution and reports on results, and leads 
engagement with external community to ensure that food security 
remains high on the development agenda.
    Ms. McKenna joined USAID in 2010. She previously held 
senior positions at the Bill & Melinda Gates Foundation, 
Monsanto, McKinsey & Company, and American Express as well as 
GE.
    Ms. McKenna, the floor is yours.

STATEMENT OF MS. TJADA D'OYEN MCKENNA, ACTING ASSISTANT TO THE 
   ADMINISTRATOR, BUREAU FOR FOOD SECURITY, U.S. AGENCY FOR 
                   INTERNATIONAL DEVELOPMENT

    Ms. McKenna. Thank you very much. Good afternoon. I am 
delighted to be here today to talk to you about USAID's 
nutrition efforts. I first want to recognize you for your 
strong leadership in addressing global child and maternal 
nutrition. We also recognize the 2013 congressional resolution 
put forward by Congresswoman Schultz and Congressman Diaz-
Balart supporting U.S. Government global nutrition efforts.
    As you have heard, at least 165 million children worldwide 
are stunted. Stunting limits the potentials of individuals, 
communities, and economies to grow and thrive, costing low- and 
middle-income countries up to 8 percent of their economic 
growth potential. This is unacceptable. We have the tools and 
technologies to make a difference and we are sharpening our 
focus to ensure a well-coordinated approach to reach our goals 
of reducing extreme poverty and hunger. And we are doing so 
with a particular focus on the 1,000 day window from pregnancy 
to a child's second birthday, which is critical to ending 
preventable child and maternal deaths.
    Thanks in large part to new evidence that has deepened our 
understanding about the importance of nutrition in early life, 
nutrition has been the focus of recent and unprecedented global 
attention. Now is the time to continue this prioritization and 
to fuel the tremendous momentum of just the past few years. 
This momentum includes major developments such as the launch of 
a platform known as Scaling Up Nutrition or SUN. SUN is a 
partnership between the U.N., civil society, the private 
sector, donors and developing country governments to support 
country-led efforts to reduce undernutrition. Since its launch 
in 2010, 47 countries have joined and USAID is proud to serve 
as a donor convener providing focused support in six of those 
countries as well as leadership at the global level.
    In 2010, the U.S. Government and former Irish Foreign 
Minister Michea Martin launched the 1,000 days partnership, a 
partnership of governments, civil society, and the private 
sector to promote targeted action and investment in nutrition. 
The 1,000 days partnership also supports SUN.
    Last June marked a banner moment for global nutrition. 
USAID was proud to join the Global Nutrition Summit in London 
in advance of the G8 where the U.S. Government announced an 
anticipated $1 billion for direct nutrition interventions and 
$9 billion worth of attributed nutrition sensitive investments 
from 2012 to 2014. We also signed the Nutrition for Growth 
Compact which mobilized nutrition funding commitments from G8 
donors and civil society and reaffirmed our support of the 
World Health Assembly nutrition targets for reducing 
undernutrition by 2025 for women and children including a 40 
percent reduction in stunting.
    USAID is taking a strong leadership role in these 
international efforts, both within the U.S. Government and at 
the global level. We are taking an evidence-based approach to 
inform and improve our programming including taking into 
account updated research analysis and recommended interventions 
and approaches featured in the landmark June 2013 Lancet series 
on maternal and child nutrition.
    USAID promotes nutrition through the Feed the Future and 
global health inter-agency initiatives, the Food for Peace 
development and emergency programs, and our humanitarian 
assistance efforts. Our goals are to reduce stunting by 20 
percent in Feed the Future's zones of influence and Food for 
Peace development programs and where possible, to maintain 
global acute malnutrition rates below 15 percent in times of 
crisis.
    Led by USAID, the Presidential Feed the Future initiative 
addresses nutrition at the goal level and reduces 
undernutrition and hunger by improving access to nutrition 
services, clean water, and support for agriculture value chain 
activities that include nutrient-dense crops, and we are 
achieving impact. In 2013, Feed the Future, in collaboration 
with the Global Health Initiative reached more than 12.5 
million children with nutrition interventions.
    Beyond Feed the Future, to help maintain global acute 
malnutrition rates below 15 percent in times of crisis and to 
support nutrition among the most vulnerable populations, 
especially during the first 1,000 days, USAID is seeking to 
reform how it delivers food aid. We preposition in-kind food 
aid stocks near food crises and now provide cash under certain 
circumstances to purchase local and regional food.
    By enacting the food aid reform requested in the 2015 
budget to allow 20 percent of Title II food aid funding to be 
used for flexible emergency responses, USAID programs will be 
able to help about 2 million more people in crises without 
additional resources. These reforms will allow USAID to expand 
the use of local and regional purchase and successful 
innovative approaches such as food vouchers which are often 
cheaper than in-kind food aid and also allow beneficiaries to 
select their own food in local markets.
    In addition, the Office of Food for Peace changed its 
approach to nutrition starting in 2006 to focus more on 
prevention of undernutrition during the 1,000 day window. USAID 
also continues to support research on various types of 
specialized foods and on updating and improving existing 
products based on evolving nutritional evidence. To further 
improve the integration and effectiveness of USAID nutrition 
programming across all of our efforts we are developing a 
multi-sector nutrition strategy that is near completion.
    The USAID nutrition strategy addresses the underlying 
causes of poor nutrition by promoting the scale-up of proven, 
cost effective nutrition interventions including both 
nutrition-specific and nutrition-sensitive activities and by 
linking nutrition investments in agriculture, food security, 
health, water, sanitation and hygiene, as well as more 
humanitarian and development contexts in a more integrated 
manner, the USAID nutrition strategy will enable us to address 
nutrition with more discipline than ever before. We will 
develop country nutrition targets that align with national 
plans, set country-specific targets and track and report on 
progress.
    The USAID strategy is also informing a coordinated U.S. 
Government nutrition plan which is also in development. This 
plan will, for the first time, bring together all of the U.S. 
Government agencies working in global nutrition to maximize 
impact through better coordination of U.S. Government global 
nutrition investments.
    There are continued efforts to coordinate and integrate 
multi-sectoral programs across USAID offices and bureaus and 
strengthen program quality using new findings. We are better 
addressing the complex underlying causes of stunting. We are 
also making meaningful contributions toward achieving the World 
Health Assembly 2025 nutrition targets and reducing 
undernutrition during the first 1,000 days worldwide.
    I would like to thank Congress again for your leadership on 
this issue. We look forward to working with you to continue 
progress toward a vision of a healthier, more prosperous world. 
Thank you.
    [The prepared statement of Ms. McKenna follows:]

    
    
    
    
    
    
    
    
    
    
                              ----------                              

    Mr. Smith. Ms. McKenna, thank you very much for your 
testimony and for laying out and without objection your full 
statement will be made a part of the record and any other 
supplemental items you might want to include in the record.
    Could you give us an idea of when the strategy that you are 
developing, the comprehensive strategy might be available? Is 
it imminent?
    Ms. McKenna. Yes. We expect it very shortly. All along we 
have done a series of consultations with NGOs and other civil 
society groups. We have two more consultations to go. You are 
likely to see something in the May-June time frame.
    Mr. Smith. The collaboration and the support for faith-
based organizations, particularly in Africa, which is a 
continent of faith, yesterday at the closing with the 
Ambassadors, I mentioned the importance of that. And several of 
the Ambassadors came up to me afterwards and said you couldn't 
have stated it more strongly and more accurately, that if you 
want to mitigate the healthcare crisis that is being 
experienced in Africa, you have got to include robustly faith-
based organizations.
    How do you go about doing that, like with World Vision and 
some of the other groups? Could you perhaps provide us some 
insights? Is the trendline to do more of that or keep it the 
same or less?
    Ms. McKenna. Faith-based organizations such as Catholic 
Relief Services, World Vision, ADRA, are critical implementing 
partners for many of our efforts. We have long been working 
with them. And in fact, in the area such as family planning and 
mother-child health, they have been critical partners and 
critical to our success in working with that community. So we 
intend to continue the deep partnership and relationships that 
we have had with faith-based organizations to expand them where 
appropriate, where the programming warrants it, and to continue 
that open and strong dialogue.
    Mr. Smith. About 1,400 kids die daily from diarrheal 
diseases. There was almost like a gee whiz factor in the 
beginning days of the child survival revolution, a simple 
mixture of salt and glucose could save a life. And I remember 
part of that mantra was that a child may get diarrheal disease 
five or six times during the course of the year, weakening them 
every time, sometimes to the point where they die. Are we 
making progress on that? I know we had a very effective program 
in Egypt, for example, and some other countries as well. Has 
the impetus been kept on that?
    Ms. McKenna. Yes, as you mentioned very simple 
interventions have had real effect and impacts on decreasing 
infant mortality because of diarrheal diseases. USAID global 
child survival is something that is at the core of our global 
health initiatives. It is continuing to provide interventions 
to alleviate the impacts of diarrheal diseases as an integral 
part of that.
    Mr. Smith. You know since the U.N. and especially I 
mentioned the roundtable, as a matter of fact, Lady Odinga was 
there among many other First Ladies. One of the emphases that 
we have all understood with that first 1,000 days from the 
moment of conception was the brain growth area, that if you 
don't get that right, the ability of that child cognitively to 
reach his or her potential is greatly reduced. Are you finding 
a growing understanding of why this is so? Every dollar we 
spend in this area is a dollar that pays off in that child's 
life as he or she become an adult, like few things that we 
could possibly do.
    Ms. McKenna. Yes, not only pays off, but the impact of a 
child's growth of decreased brain development, the child never 
recovers those gains and never recovers. And those are losses 
to society permanently. The Scaling Up Nutrition movement is a 
multi-sectoral, multi-partner movement that countries 
themselves have to encourage. So we are proud to say that over 
47 countries have signed up as SUN countries which means that 
they understand the importance of maternal and child nutrition 
and are committed to setting their own goals and targets and 
addressing it themselves with their own resources in 
partnership with local organizations, donors, and other 
partners.
    Mr. Smith. How many countries do we have an arrangement 
with? I was actually in Guatemala the week when USAID signed an 
agreement and dedicated our resources to assisting them on the 
first 1,000 days. How many other countries do we have an 
arrangement with?
    Ms. McKenna. There are six countries where we are the lead 
donor partner in SUN, but we are active--we are part of the 
global convening for SUN. There are 19 Feed the Future focus 
countries. One of the top line goals in Feed the Future is a 
reduction in undernutrition and in all 19 of those countries 
you see focus on both nutrition-specific and nutrition-
sensitive programming. On top of that, our Global Health 
Initiative focuses on there are an additional set of countries 
where we target our nutrition funding. But because these 
investments, as you have said, are so cost efficient and so 
impactful, we have really focused our funding on those 
countries where the burden is greatest because we want to bring 
these numbers down significantly.
    Mr. Smith. Thank you. Dr. Perry from Johns Hopkins will 
testify later and in his written submission points out that 
there are an estimated three million stillbirths around the 
world each year; 99 percent of which occur in low-income 
countries. He also points out there are 3.8 million live-born 
children who die each year before the age of 2 and three 
fourths of these deaths occur during the first month after 
birth. And then he bottom lines and says the tragedies of the 
great majority of these deaths can be readily prevented at low 
cost.
    Does that number comport with your understanding of what we 
are talking about in terms of the loss of life? Again, is there 
an understanding that with a little more oomph and effort a lot 
of these lives could be saved?
    Ms. McKenna. Yes, we would have to get back to you to 
confirm the exact numbers, but we agree. There is an 
understanding that very simple intervention such as immediate 
and exclusive breastfeeding from birth can have a big impact 
and prevent the loss of life during the early days.
    Mr. Smith. During the war in El Salvador when the FMLN and 
the government were at great odds and it was war, Napoleon 
Duarte, then the President of El Salvador, negotiated a cease-
fire, a Day of Tranquility, as they called it, to vaccinate the 
children against the leading killers of children. And I 
traveled down myself with Jim Grant and others from UNICEF and 
one of the biggest takeaways and that was in the early '80s, 
that I got from that was the importance of the pulpit, that if 
you want to drive people to low-cost and highly-efficacious 
interventions, you need more than just a community health 
center or a doctor or others, even if they go door to door, 
amplifying the message that you need to do this for yourself 
and your children.
    Do you find that USAID, again working with faith-based 
groups are able to effectively utilize that venue to get the 
message out? Because one of the things, again with 
vaccinations, was coming back for that second shot after the 
child developed a fever and they thought oh wait, this isn't 
what I bargained for. No, that is part of what happens in a 
small percentage of those who get a vaccination.
    Ms. McKenna. Many of the solutions to these are simple 
behavior changes and as we know from our personal lives, 
behavior change is something that is very difficult to do. And 
so you have to go and work with organizations and people in 
institutions that people trust. And oftentimes, as you said, 
that does include their ministers and their church community. 
So working with them, bringing them into the coalition and 
training with them remains an integral part of what we do.
    Mr. Smith. Let me just ask you and I know if you had your 
way personally, the number would be a blank check, but we all 
know whoever runs the White House, there is always OMB to deal 
with and I remember when I chaired Veterans, I was always at 
odds with OMB, not with the VA because VA wanted to do more in 
almost every instance. But there is a proposed 2015 cut of 
about 12 percent and maybe we are misreading it, but in 
nutrition programs. I am wondering is it found somewhere else 
in the budget or is this just some reality that we have to deal 
with here and look to up it.
    I know in the '80s, it was almost like a reflexive thing 
where OMB would cut UNICEF only to have Congress put back the 
money each and every year. But the 12 percent cut, are we 
missing something or do we need to make sure that we work with 
you and our colleagues on the Appropriations Committee to make 
sure that there is no diminution of those monies.
    Ms. McKenna. So even in a constrained budget environment, 
the President's Fiscal Year 2014 budget request demonstrates a 
firm commitment to nutrition and ending preventable child 
deaths. We are using as efficiently as possible existing 
funding authority and are leveraging across USAID funding. Part 
of what we are doing with the nutrition strategy is 
prioritizing nutrition outcomes across multiple streams of 
funding, including Feed the Future, multiple streams to get 
better, more efficient outcomes from that funding.
    Mr. Smith. Could you provide us, if you would, an analysis 
of what the cut would mean if it were to be implemented? And 
also, while you are doing that since you are being asked. I 
know OMB will probably react negatively to this, but what 
really is needed to do what has to be done, to really take this 
to the next level, to try to intervene so that those three 
million kids don't die at stillbirth. There will always be 
stillbirths but it doesn't have to be as high, as well as those 
who die in the first month and of course, how do we ratchet up 
this program? If you could provide us what we get for every 
extra dollar, it would make a huge difference.
    Ms. McKenna. Right. Yes. We can provide you that analysis. 
And I should also mention that a critical part of this is 
different parties really coming together to solve the solution. 
So our funding actively works to leverage the funding of other 
donors with resources that countries, lower- and middle-income 
countries themselves put into this problem, as well as looking 
for ways to engage the private sector and appropriate response.
    Mr. Smith. I am all for partnership and leveraging, but if 
we had 12 percent more or even higher than that, the leveraging 
could be that much more effective, I would think. So if they 
could provide any of that, it will help in the process as we do 
the 2015 budget.
    Ms. McKenna. We are happy to come back to the committee 
with that. Thank you.
    Mr. Smith. Thank you.
    Ms. Bass. Thank you. I believe when you began to answer the 
chairman's questions, you made reference to how you work with 
faith-based organizations for family planning. And I wanted to 
know if you could elaborate a little more on that?
    Ms. McKenna. Yes. So some critical things that we work on 
with faith-based organizations include some of the things that 
you alluded to in your remarks, actually. So birth spacing, 
delaying marriage, activities and behavior changes such as that 
to increase people's abilities to plan their families, to have 
children at appropriate times to optimize nutrition for both 
the mother and the child and to prevent situations that are 
negative. For example, when adolescent girls become pregnant, 
they end up competing with their child for resources for their 
own growth spurts. Or when children are spaced too close 
together, a mother's nutrition stores which are likely already 
depleted become even more and more depleted and so we work 
carefully with faith-based organizations on things like delayed 
marriage and child spacing to get optimal outcomes for mothers 
and children.
    Ms. Bass. How do they go about their work, both the faith-
based, as well as the secular organizations? How do they go 
about their work in a village in regard to family planning? Do 
they distribute birth control? Is it education? What 
specifically do they do?
    Ms. McKenna. I think a lot of it is education, should be 
information about different behavior change, giving advice on 
different practices, things such as that.
    Ms. Bass. And on the governance issue wherein some 
countries it is in the constitution that a girl, because I 
won't call a young lady, 8 years old, can get married. So I am 
wondering what is USAID doing in terms of educating different 
countries about raising the age in which females become 
sexually active?
    Ms. McKenna. All of our investments kind of depend on an 
enabling environment that supports the development work that we 
do. So in our work on maternal-child health, one of the key 
things that we work with other actors to provide to governments 
is information and advice on policy reforms and data on the 
impact of those policies, what they are on children now and 
what they could be and how others have structured policies to 
achieve better results.
    We also encourage our officers and our State Department and 
others to advocate on behalf of changes in those laws. But a 
lot of the policy support we do is providing data and evidence 
and helping provide the capacity to create alternative policies 
that will have better outcomes.
    Ms. Bass. So do we work with--you said primarily education, 
but I don't recall if you answered me specifically on birth 
control.
    Ms. McKenna. I am sorry, I didn't. I will have to get back 
to you. I am not--I don't oversee directly our maternal-child 
health area. So I just don't want to overstate anything.
    Ms. Bass. And I am sorry to say that some countries seem to 
be going backward whether you are talking about LGBT issues and 
legislation that has been put forward in that regard or whether 
you are talking about nations that just recently said that a 
man could have as many wives as he wanted and he didn't even 
have to ask for permission. I can't imagine being given 
permission, but anyway. So when we go about our education work 
I am just hoping that we attempt to educate on that level as 
well, especially on the question of spacing births.
    Ms. McKenna. Yes.
    Ms. Bass. I spent many years also working in a neonatal 
nursery, working with premature babies, working in the labor 
and delivery room and seeing women, you know, it was--almost 
never happens in the United States. It is extremely rare for 
there to be a death of a mother. And to travel to sub-Saharan 
Africa and to be in Nairobi and see billboards where they were 
trying to do public education around maternal death and knowing 
that one of the reasons why maternal death is so high is women 
who cannot control when they are pregnant.
    Ms. McKenna. I just got a note from our team. We actually 
do provide a variety of birth control options through our 
programming and I should mention another example of some of the 
training and education we do, the focus on exclusive 
breastfeeding for the first 6 months helps to prevent low 
lactation, menorrhea, helps to prevent further pregnancy as 
well.
    Ms. Bass. In theory, in theory.
    Ms. McKenna. In theory. It is not foolproof.
    Ms. Bass. It is not. But we do provide birth control.
    Ms. McKenna. We do provide a variety.
    Ms. Bass. And are we prohibited by any age, especially 
considering the age of sexual activity can be very young?
    Ms. McKenna. Can be very young.
    Ms. Bass. Do we have any prohibitions on when birth control 
can be distributed?
    Ms. McKenna. Yes, so that is a good question. We will have 
to get back to you. I know our bias would be not to have 
limitations on that, but there may be some places----
    Ms. Bass. I would like to know if you can get back to me 
specifically in those countries where we know that girls are 
conceiving at very young age and having difficulty like the 
ones that the chairman pointed out.
    Ms. McKenna. Yes.
    Ms. Bass. Thank you very much.
    Ms. McKenna. Thank you.
    Mr. Smith. One concluding question. Could you give us, and 
it is probably better for the record the break out of how your 
funding goes to faith-based organizations in dollar terms as 
well as percentage of the program?
    Ms. McKenna. We will look to get that to you for the 
record. One of the things I should point out, one of the 
limitations we have had on pulling that data in the past is 
that there are cases where those organizations are the official 
grantees, but in many cases they are also subgrantees.
    Mr. Smith. Have you captured that? Because I have asked 
that question repeatedly, why we don't get the subgrantees as 
well.
    Ms. McKenna. We know them, but sometimes they are not 
categorized or coded appropriately as to--if they are faith 
based or not. So I know that has been a challenge that we have 
had in pulling it historically, but we will look to see what we 
can pull now.
    Mr. Smith. Thank you. And some of the other members who 
would have been 1\1/2\ hours ago had we not had the votes may 
have some questions that they want to submit for the record.
    Ms. McKenna. Okay.
    Mr. Smith. I have a few extras, too.
    Ms. McKenna. We understand. We are happy to do that. Thank 
you very much.
    Mr. Smith. Thank you very much, Ms. McKenna.
    I would like to now invite our second panel beginning first 
with Lisa Bos from World Vision, senior policy advisor for 
health, education, and water sanitation and hygiene at World 
Vision. In the Advocacy and Government Relations Department as 
such, she serves as the point person for World Vision's 
advocacy and education efforts with Congress and the 
administration. In addition, to working to engage World 
Vision's advocates on issues such as foreign assistance 
funding, maternal and child health, and water sanitation and 
hygiene, Ms. Bos spent nearly 9 years as legislative staff in 
the U.S. House of Representatives.
    We then will hear from Dr. Henry Perry who is a senior 
associate at Johns Hopkins Bloomberg School of Public Health. 
His primary research interest is in the impact of community-
based primary healthcare programs on health improvement 
especially on maternal, neonatal, and child health. He has a 
broad interest in primary healthcare and community-oriented 
public health, community participation equity and empowerment. 
He is currently collaborating on operations research concerning 
community-based material, neonatal and child health in 
Guatemala, Kenya, and Sierra Leone. He has led formal child 
survival program evaluations in Afghanistan, Bangladesh, 
Cambodia, India, Tibet, China and he teaches on a broad variety 
of topics at Johns Hopkins.
    Then we will hear from Ms. Carolyn Wetzel Chen who has 14 
years of international public health and development program 
design implementation and donor relations experience. In her 
current role as chief grant development officer, she leads Food 
for the Hungry's Global Service Center and 18 field offices in 
developing and executing a global strategy for raising 
resources from foundations, corporations, governments, and 
multi-lateral institutions. She has created systems, tools, and 
policies to guide multi-national and multi-sector teams to 
identify and pursue those grants for this important work. Her 
long-term professional specialty has been maternal and child 
health and nutrition programs design and implementation, social 
and behavioral change, and monitoring and evaluation.
    We will then hear from Dr. Sophia Aguirre, who is a 
professor of economics in the School of Business and Economics 
at the Catholic University of America. She is the director of 
economics program and academic chair of the Masters in Integral 
Economic Development. She specializes in international finance 
and integral economic development. She has researched and 
published in the areas of exchange rates and economic 
integration, as well as theories of population, resources, and 
family as it relates to development. She has testified in front 
of Congress on issues related to population, family, and health 
nationally and internationally.
    We will then hear from Dr. Mehret Mandefro of George 
Washington University, a primary care physician and public 
health researcher. She is founder and president of Truth Aid, a 
public health consultancy that specializes in community-based 
public health education efforts which addresses the social 
determinants of health using media in these efforts. She is 
also an adjunct professor of health policy at the Milken 
Institute of Public Health at George Washington University. Dr. 
Mandefro began her career as a physician as a public health 
practitioner working extensively on HIV-infected and affected 
communities in Botswana, South Africa, Ethiopia, and New York, 
and on issues of prevention and treatment.
    Ms. Bos, if you could begin.

 STATEMENT OF MS. LISA BOS, SENIOR POLICY ADVISOR FOR HEALTH, 
   EDUCATION, AND WATER, SANITATION AND HYGIENE, WORLD VISION

    Ms. Bos. Thank you, Mr. Chairman, Ranking Member Bass. I 
appreciate this opportunity to testify before you today on the 
important issue of health and nutrition, particularly in the 
first 1,000 days window. Kent Hill does send his apologies that 
he wasn't able to be here today. I will do my best to fill his 
shoes.
    My name again is Lisa Bos and I am the senior policy 
advisor for health, education and WASH at World Vision US. 
World Vision is a Christian humanitarian organization working 
to improve the lives of children in nearly 100 countries.
    Good nutrition is an essential foundation for health and 
development, yet malnutrition continues to be the world's most 
serious health problem and the single biggest contributor to 
child mortality. As one of the world's largest private 
humanitarian organizations, World Vision recognizes that 
addressing malnutrition is essential to improving maternal and 
child health and so we have made it a top priority in our work.
    World Vision has several recommendations for what the U.S. 
Government can do, and where Congress should focus when 
exercising its oversight, budgeting, and appropriations 
responsibilities, to help contribute to the best outcomes for 
mothers and children. We base them on our 63 years of relief, 
development, and advocacy experience and expertise and the 
evidence of what is most effective and efficient.
    In summary, these recommendations are: 1) is to prioritize 
community-based initiatives. Our experience shows that 
ownership by the community and involvement of key community 
leaders, such as faith leaders, is critical to ensuring changes 
in behavior that lead to improvements in maternal and child 
health; 2) is to approach a child through the life-cycle, 
concentrating on the start of life at conception through the 
first 2 years, and concentrate interventions, like those to 
ensure adequate nutrition, on these initial 1,000 days; 3) is 
to ensure that food is adequate both in volume and nutrition; 
4) is to include nutrition outcomes as an explicit objective of 
U.S. agricultural and other food security assistance programs.
    Another recommendation is to focus initiatives for mothers 
on their time of pregnancy, ensuring they are well nourished, 
able to provide sufficient nutrition for their children, and 
give birth to healthy children.
    Support and scale-up interventions that are proven to be 
effective, like breastfeeding, skilled birth attendants and 
frontline health workers, healthy timing and spacing of 
pregnancies, and consistent, safe access to clean water and 
sanitation.
    Focus breastfeeding programs on support for mothers 
immediately after and in the 24 hours following childbirth, 
ensuring a good start to that child's life.
    Improve partnering with NGOs, especially faith-based NGOs, 
including by consulting with them earlier and more 
consistently, leveraging public and private funding, 
coordinating and collaborating between initiatives regardless 
of the funding source, and prioritizing initiatives aimed at 
improving governance at the local and national levels in the 
countries of partnership. Given the value-add of the rich 
community-based networks which FBOs possess, it makes sense to 
capitalize on these connections.
    The first 1,000 days is the time with the biggest risk of 
child mortality, as well as the period of most rapid physical 
and brain growth. Exposure to chronic malnutrition during this 
critical window can result in stunting which leads to impaired 
brain development, robbing a child of the ability to reach his 
or her full potential. There is strong evidence of the 
correlation between malnutrition and stunting, and long-term 
health and individual earning capacity. Therefore, it is 
critical that children receive good nutrition within this 
``window.'' Interventions that prevent undernutrition during 
this time can be much more effective than those that target 
children who are already undernourished and prevention is at 
the core of all of World Vision's work in health, nutrition, 
and food security.
    Breastfeeding is at the core of preventing undernutrition 
and malnutrition in children. There are challenges with 
breastfeeding programs, however, as critical factors come into 
play which impact a mother's ability to breastfeed her child 
until the critical age of two. For example, if a mother becomes 
pregnant again, she may prematurely stop breastfeeding, often 
leading to significant malnutrition in that child. Programs 
like those that support the healthy timing and spacing of 
pregnancy are necessary to ensure the success of breastfeeding 
programs which is why multi-sectoral approaches that integrate 
nutrition specific interventions, direct interventions like 
breastfeeding, with nutrition sensitive interventions, like 
birth spacing education and WASH programs, are critical. I 
would also encourage the U.S. Government to focus on health and 
nutrition in fragile states and in places with high rates of 
acute malnutrition.
    The financial cost to address acute malnutrition is high, 
usually because there is a lack of functioning infrastructure, 
trained staff and health services, and limited food ability. 
With an approach used by World Vision called Community-based 
Management of Acute Malnutrition or CMAM, malnourished children 
are found and treated early before complications occur and more 
costly in-patient treatment is required. However, despite the 
success of programs like CMAM, investments in better health 
infrastructure and investments to address chronic food 
insecurity in communities would help in the long term to reduce 
the need for more expensive interventions. CMAM funding is 
provided mainly through the Office of Foreign Disaster 
Assistance within USAID for emergencies. But we would recommend 
that USAID also expand funding for interventions like CMAM in 
development programs in countries with high levels of acute 
malnutrition, such as India, Nigeria, and Indonesia which 
currently have very low rates of CMAM coverage.
    The role of the faith community is also vital if we are 
going to reach the most rural and hard-to-reach communities. We 
have found that educating and mobilizing faith leaders to talk 
to their congregations and communities about what are sometimes 
viewed as taboo child and maternal health issues could be the 
most effective catalyst for change. The U.S. Government must 
continue to engage deeply with the faith community to ensure 
that programs recognize the convening power and reach of faith-
based organizations in the developing world.
    It is hard to imagine a more humane or pragmatically 
valuable U.S. Government investment than to focus on women and 
children's health, particularly nutrition in the first 1,000 
days of life. Allow me to express my deep appreciation to the 
U.S. Congress who has consistently shown compassion and wisdom 
in addressing health concerns in the developing world and in 
fragile states. There is much more to do, but if we strengthen 
existing partnerships between USAID and the NGO community, we 
can have even more impact in the years ahead. Thank you for 
this opportunity to testify today and I look forward to any 
questions you may have.
    [The prepared statement of Ms. Bos follows:]

    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
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    Mr. Smith. Ms. Bos, thank you very much for your leadership 
and please send our best to Kent Hill. Is he okay? I know he 
was very sick from his trip.
    Ms. Bos. He is. He is working on recovering at home.
    Mr. Smith. Thank you. Dr. Perry.

STATEMENT OF HENRY PERRY, M.D., PH.D., SENIOR ASSOCIATE, HEALTH 
SYSTEMS PROGRAM, DEPARTMENT OF INTERNATIONAL HEALTH, BLOOMBERG 
       SCHOOL OF PUBLIC HEALTH, JOHNS HOPKINS UNIVERSITY

    Dr. Perry. Thank you very much, Congressman Smith, 
Congressman Bass. It is a great privilege and honor for me to 
be here today. This is a subject that I am passionate about. I 
have spent 35 years working with NGOs, working in community 
health and increasingly involved in the academic and research 
and evidence side of community-based programming to improve 
child health and particularly mothers and children during the 
first 1,000 days of life.
    I am going to restrict my verbal comments to a portion of 
what my written testimony conveys. You very well summarized a 
lot of the technical issues and the human magnitude of lives 
being lost from conditions that we know are readily preventable 
or treatable, given our current state of knowledge and know-how 
and programmatic strategies. I am very pleased that you have 
mentioned Jim Grant several times in your comments and one of 
the comments that Jim Grant made when he was the Executive 
Director of UNICEF that I think is very germane to my comments 
today is his phrase often repeated that ``morality marches with 
capacity.'' And even though we have made tremendous progress in 
reducing the number of deaths of mothers and children in the 
last 50 years, and I think it is one of the unheralded 
successes of our world and of the contribution of the United 
States toward that goal, the fact that 6.6 million children are 
still dying and 300,000 mothers are still dying, mostly from 
readily preventable treatable conditions is a point of great 
moral concern in the public health priority of course.
    What I want to focus on in my comments are the fact that we 
have these evidence-based interventions that we know work under 
ideal circumstances. The evidence, the scientific evidence is 
there that all of these things are highly effective and I have 
listed these in my testimony. You mentioned a number of them 
yourself, but interventions that are so supple in many 
respects, we find so hard to implement. Exclusive breastfeeding 
and hand washing are but two I think are the most important 
that obviously don't involve health facilities. They don't 
involve higher-level health staff to carry out. We still are 
needing the resources to apply the knowledge that we have to 
implement these interventions at scale in communities and 
countries with high mortality.
    So in the 75 countries with more than 98 percent of all 
maternal deaths and deaths of children under 5, the coverage of 
all of these interventions except for immunizations and Vitamin 
A is below 60 percent and in some cases, for example, exclusive 
breastfeeding or antibiotic treatment of pneumonia, we have 
levels of coverage that are on the order of 25 or 30 percent. 
And so in my view, one of the most important things that we can 
do to save the lives of mothers and children in the first 1,000 
days of life is to develop a better delivery system that 
reaches down to the household level that engages communities 
and uses community health workers to implement interventions 
that we know work and that we know that can be provided by 
these front line health workers.
    We know there is an enormous deficit of health manpower, of 
highly trained health manpower. The World Health Organization 
has estimated that by the year 2025, the global deficit will be 
about 13 million, highly trained staff, and we know that from 
those of us like yourself, Congressman Smith, who have been in 
rural areas, facilities are very few and far between. And for 
the foreseeable future, these facilities will not be readily 
available to people.
    And so we need to develop a focus on a delivery system that 
is in the community that uses the community as capacity, its 
resources, adequately trains and supports them in order to 
deliver interventions that we know work. So we need the 
commitment to build a community-based delivery system for these 
interventions and it is also essential that we work with 
community empowerment approaches and women's empowerment 
approaches to make use of these interventions as well.
    I had the recent privilege of evaluating a Food for the 
Hungry child survival project that focused on nutrition and 
prevention of diarrhea in Mozambique that reached a population 
of 1.1 million people. And Food for the Hungry has been a 
pioneer of a very exciting approach to community-based delivery 
which is the kind of thing that we need much of which is called 
care groups in which volunteer women are assigned 
responsibility for 10 to 12 households and they meet with 10 or 
12 volunteers every 2 weeks to learn health education messages 
and deliver those to the households. This approach was applied 
by World Relief in a rural part of Mozambique, 1.1 million 
people, and it had a dramatic impact on reducing undernutrition 
within that population at a very low cost of only 55 cents per 
capita per year. No food was involved in terms of distribution 
of food. It was total health education, prevention of diarrhea 
which is an important predictor of malnutrition of course, so 
we need to apply a lot of our knowledge that we have at scale 
working with governments, using these very simple approaches 
that don't rely on higher level health facilities, higher level 
health staff. We have enormous experience and knowledge in 
doing this. And in fact, the NGO community that I have worked 
with for the last 35 years particularly with the USAID Child 
Survival and Health Grants Program that I have been connected 
to for a long time which has been instrumental in developing 
these approaches and I think are vital for the success of 
ending preventable child deaths by the year 2035 which is one 
of the goals that the United States Government has signed on to 
with many other countries around the world and it represents an 
exciting opportunity for the next 20 years to see the progress 
that can be made with our current know-how and expanding of 
available programming at very low cost.
    So I would like to share my thoughts about what the United 
States Congress could do to end preventable deaths during the 
first 1,000 days of life. The first point is that the United 
States Congress should at least maintain, but much more 
preferably, substantially expand its financial support for 
child survival programs in the 75 countries where 98 percent of 
maternal and child deaths occur.
    U.S. Congress should elevate U.S. Government support for 
community health workers by insisting on funding child survival 
and other global health programs that are carried out by 
community health workers in a way that builds long-term 
sustainability for community health worker programs that engage 
communities and civic society, not just government health 
programs. The NGO community, the faith-based community are an 
essential part of that.
    The U.S. Congress should call on the administration to 
draft a comprehensive health workforce strategy with the focus 
on community health workers and other frontline health workers 
to maximize the impact of U.S. Government investments in the 
global health workforce.
    And finally, the U.S. Congress should insist on strong 
funding for the USAID Child Survival and Health Grants Program 
which has been supporting U.S.-based NGOs, referred to as PVOs 
(private voluntary organizations), for three decades now and 
these organizations have been leaders of and champions of 
community-based programming for maternal and child health in 
low-income countries. This includes World Vision, Food for the 
Hungry, but many other NGOs, both faith-based and nonfaith-
based.
    The United States has been a global leader in support for 
innovation and community-based child survival programming. It 
should continue in this role. The current levels of funding for 
maternal and child health programs both to USAID and to UNICEF 
need to be expanded, not cut. To not fully support these 
efforts and to cut funding for these programs that represent a 
moral failure on the part of our Government and it would not 
support the wishes of the great majority of American citizens 
who repeatedly have expressed their support for U.S. Government 
funding for saving the lives of mothers and children.
    Fully engaging the U.S. PVO community by providing major 
financial support to it for this effort will increase the 
quality of child survival programming around the world, promote 
innovation, expand community engagement and community-based 
services and accelerate the reduction and readily preventable 
deaths during the first 1,000 days of life. Thank you.
    [The prepared statement of Dr. Perry follows:]

    
    
    
    
    
    
    
    
    
    
    
    
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    Mr. Smith. Thank you so very much for your testimony and 
your very specific recommendations to us.
    Ms. Wetzel Chen.

 STATEMENT OF MS. CAROLYN WETZEL CHEN, CHIEF GRANT DEVELOPMENT 
               OFFICER, FOOD FOR THE HUNGRY, INC.

    Ms. Wetzel Chen. Let me begin by thanking Chairman Smith 
and Ranking Member Bass for holding this important hearing. 
Eight years ago when I was working in Mozambique and visiting a 
household, I noticed a severely malnourished child. The family 
explained that they were not sure if the child would live or 
die and they were reticent to invest resources and time into 
the well-being because it seemed unlikely he would live. I 
remember the grandmother saying to me, ``In what world do 
children not die?'' And as that statement hit home to me ``in 
what world do children not die?'' I thought, in my world. I was 
born in Clovis, California and if a child died, it was a 
tragedy. It was an anomaly. And here a grandmother was telling 
me this was normality for her.
    I consider it a great privilege to speak to you today 
representing faith-based organizations because we have at hand 
the knowledge and the means to make poor child nutrition and 
child death not normal in communities like the one I visited in 
Mozambique.
    I am speaking on behalf of Food for the Hungry, a global 
poverty solutions partner that helps the world's most 
vulnerable children and communities thrive. We are proud to 
often work ourselves out of a job as communities we have 
partnered with exchange poverty-producing mindsets and 
behaviors for healthy perspectives and actions.
    Faith-based organizations are a critical component of the 
first 1,000 day effort. In 2011, 78 of the largest U.S. faith-
based international development organizations invested more 
than $5 billion in funds from private sources to meet the needs 
of those living in poverty. Faith communities are called to 
care for children regardless of national boundary or religious 
identification. Responding to the neediest, not just the 
nearest, is an important component of many faiths.
    Research has found that stunting in the first years of life 
result in cognitive impairment that reduces an individual's 
ability to learn, resulting in reduced lifetime earning 
potential. Those who experience poor nutrition in the first 
1,000 days of life have a higher risk of life-long physical and 
mental disability which is likely to impact their cognitive 
ability, school performance, and early potential.
    If you have ever been on the Dell Web site or maybe it was 
an Apple, and you have looked at buying a computer and you said 
do I want this much RAM? How fast do I want my processing 
system to be? Well, I hate to compare buying a computer to what 
we are discussing here, but I couldn't help but think about 
that in that you are deciding at that moment what your future 
is going to be for the next 3, 5 or how many years you are 
going to use that computer. How am I going to build this 
system? Well, the same thing is happening with children in the 
womb, in the 1,000 days we are investing in their future. And 
if we don't do it well, it is going to be a lifetime of 
suffering.
    Now if there was a low-risk investment opportunity that 
delivered a 10-to-1 benefit to cost ratio, most people would 
take it. I certainly would, especially in this environment. 
Whatever sacrifices it might take in the present moment, if we 
knew that we could invest $100 today and receive $1,000 in a 
specified period of time, it would be a very popular 
investment. A conservative medium value of benefit to cost 
ratio for investment to reduce stunting in selected high 
burdened countries is 18 to 1. For every $1 invested to reduce 
stunting, an $18 return is estimated considering increased 
productivity, savings of resources, and increased earnings in 
the job market. This is an excellent return on investment and 
compares favorably with other investments for which public 
funds compete.
    Food for the Hungry trains teams of community volunteers to 
deliver behavior-change communication about key nutrition, 
hygiene and disease-prevention practices. The strategy of 
behavior change that we use is called the care group model. My 
colleague, Dr. Perry, mentioned this. It has reduced infant and 
child mortality rates dramatically. A final evaluation of Food 
for the Hungry's USAID funded child survival project in rural 
Mozambique, a project that I helped to start up and oversee, 
saved an estimated 6,316 lives of children less than 5 years of 
age. More than 6,000 children could have died now live. 
Malnutrition in that same project in children under 2 years of 
age decreased by 34 percent in project areas.
    Many international development projects mobilize paid 
employees, but Food for the Hungry mobilizes entire communities 
to contribute to the first 1,000 day window. In the above-
mentioned Mozambique child survival project, FH found that 80 
percent or 1.8 million hours of project work was carried out by 
community volunteers and 97 percent of the work was done by 
community-level staff and volunteers. The care group model FH 
promotes blankets the community with life-saving messages and 
behavior change support. In one care group project, a survey 
was done 20 months and again 4 years after the project ended. 
So think about this, in this community all government funding 
has now departed. It is just the community carrying on. Those 
surveys found that the mothers continued practicing key health 
behaviors.
    In addition to behavior sustainability, care group 
volunteers also were found to be continuing their work with 
local leaders, taking initiatives to replace positions if a 
volunteer was not able to continue.
    FH is committed to sharing with governments, NGOs, and 
other stakeholders effective ways of improving nutrition in the 
1,000 days window. We host a care group Web site. We share at 
international forums and we have created a care group 
implementation manual to help other organizations implement 
care groups effectively. We believe in this model. We believe 
in its ability to save children's lives and we want others to 
be using it.
    Care groups have been so widely recognized for their 
effectiveness in reducing malnutrition that they are now used 
by 24 NGOs in at least 20 countries. The Center for High Impact 
Philanthropy at the University of Pennsylvania has endorsed 
Food for the Hungry's care group model as a high impact, low 
cost solution to child malnutrition and illness.
    Considering the body of evidence supporting an investment 
in the first 1,000 days of life, what can the United States 
Government do to further success? Number one, we would suggest 
to encourage local governments to increasingly promote 
nutrition as a cross-cutting and whole of government 
initiative.
    Number two, as my colleague at World Vision mentioned, 
support local community delivery platforms for nutrition 
education and promotion. Increasingly include livelihood 
programs as an integral component of women's empowerment and as 
a strategic approach to reducing the underlying determinants of 
poverty. Ensure that WASH strategies, frameworks, and resources 
are increasingly integrated into U.S. and government nutrition 
programs. Increase awareness that strategic nutrition 
investments can contribute to human capital formation and can 
thereby drive economic growth. It is not simply a health 
program. It is an economic impact.
    Food for the Hungry runs a food security project funded by 
the U.S. Government and Ethiopia. In this project, we have a 
subpartner named ORDA. They are a local organization and they 
have been increasing in their capacity to run such a program.
    My last recommendation is to recognize that as we aim to 
increase local ownership of such strategies, the international 
NGO community offers a key role in helping local agencies build 
and scale their own capacity. Thank you.
    [The prepared statement of Ms. Wetzel Chen follows:]

    
    
    
    
    
    
    
    
    
    
    
    
                              ----------                              

    Mr. Smith. Thank you very much for your testimony and again 
in your written, more elaborate testimony you just lay out so 
many good recommendations for this subcommittee to consider. 
And it must be very gratifying when you talk about Mozambique, 
about the 6,000 children who might otherwise not be here. I 
mean all of you must have that sense of what you have done has 
had a profound impact. So again, I thank you.
    I would like to now ask Dr. Aguirre, if you could.

 STATEMENT OF SOPHIA AGUIRRE, PH.D., CHAIR, INTEGRAL ECONOMIC 
 DEVELOPMENT MANAGEMENT PROGRAM, CATHOLIC UNIVERSITY OF AMERICA

    Ms. Aguirre. Thank you, Mr. Chair, Chairman Smith, for your 
invitation to participate in this hearing. I submitted in my 
written reports all the necessary references to literature 
evidence for what I am going to say and some of my previous 
colleagues in this panel have also raised some of the issues 
that are relevant to this discussion, so I am going to limit 
myself to some specific comments, among the comments I have 
already submitted in writing.
    The first 1,000 days of a person's life is really 
established in the literature and that is why it is important 
because it affects the normal development of that individual 
for the rest of their lives. But I want to focus on something 
that Ms. Chen already mentioned and that is that this has an 
economic consequence. When we shortchange a child before their 
income because they don't have enough to eat, then the rest of 
his life or her life as well as the whole community is 
hampered. It really means depriving the child, the family, the 
community, the society and their country of a human and social 
capital potential that they could have contributed and that it 
has a high cost when it comes in terms of GDP as well as the 
cost of attending that person who is handicapped and could have 
been prevented from being there.
    Undernourishment in an infant or in an expectant mother 
causes low birth weight and poor cognitive development as was 
mentioned before. That also means lower productivity and 
hampers development in the long run. These illnesses are not 
easily treated as we know once they occur. In many cases they 
cannot be solved any longer and the cost of attending these 
needs are very high. So in addition to the lost human capital 
and social capital that we acquire on the top of that, these 
burdens can be added to the financial side of these countries 
and these communities. And it can be solved, as already 
mentioned, with very low cost interventions.
    Ensuring household food access, good health and hygiene 
conditions, as well as good care and health practices for 
infants and pregnant mothers, is to ensure that future 
generations will have the opportunity to contribute toward 
building the human and social capital necessary for sustainable 
development. We know that sustainable development is more than 
economic processes. That involves many other processes that are 
necessary, social, political, economic. And therefore, the 
contribution of each individual to this social and human 
capital is very important.
    That if these needs are first met in the family, typically 
for children and therefore healthy families are key to 
providing stability during the earliest stage of life. 
Successful nutritional programs, such as CONIN in Argentina, 
ASEPUENTE and APIB cooperatives in Guatemala to mention just a 
few of some of the ones that I have evaluated in terms of their 
nutrition success, focus on prevention of hunger and/or 
undernourishment by taking a holistic approach. All these 
programs have in common that their focus of action goes beyond 
immediate provision of nutrients for those in need. And I want 
to emphasize it is not enough to provide food. Rather, the 
success relies on the integral approach, these programs seek to 
strengthen family life and engage communities so to address the 
obstacles encountered to achieve lasting nutritional and 
healthy solutions. We need to provide the means for lasting 
solutions. They seek to improve the overall living conditions 
by helping those under nutritional stress develop initiatives 
that will provide access to food and/or household appliances at 
accessible prices; they foster households and community agency 
by teaching responsibility and providing seed funds for home 
gardens and personal initiatives; they train beneficiaries in 
household management, hygiene, nutrition, saving schemes, and 
local government agency. All these are means that provide long-
term solutions and sustained provision of food. They facilitate 
training and education so head of households can find jobs.
    Mr. Chairman and honorable members of the committee, and 
especially I want to acknowledge Congressman Bass, the U.S. 
Government foreign assistance programs which target the very 
young cannot be considered one more effort among the many 
initiatives in which the U.S. is engaged. It is a priority and 
it is a long term investment. We know that the best way to 
invest is in prevention, right? And we don't have to pay for 
the consequences. These programs have lasting effects on the 
lives and opportunities of disadvantaged populations; and they 
prevent essential human and social capital losses wherever 
malnourishment prevails. Because of the lasting impacts infant 
malnutrition brings, identifying strategies that go beyond the 
mere provision of food to families but take an integral and 
holistic approach and places the family at the center of these 
solutions, is to work toward making sustainable development 
possible. Thank you again for inviting me to testify today.
    [The prepared statement of Ms. Aguirre follows:]

    
    
    
    
    
    
    
    
                              ----------                              

    Mr. Smith. Thank you very much, Doctor, for your testimony 
and without objection since you had additional comments they 
will be made a part of the record as well as everybody else's 
full statement.
    I would like to now welcome our final witness, Dr. 
Mandefro.

STATEMENT OF MEHRET MANDEFRO, M.D., ADJUNCT PROFESSOR OF HEALTH 
 POLICY, MILKEN INSTITUTE SCHOOL OF PUBLIC HEALTH, THE GEORGE 
                     WASHINGTON UNIVERSITY

    Dr. Mandefro. I am delighted to be providing remarks today 
and I want to commend both you, Chairman Smith, and Ranking 
Member Bass for shining a light on a very important topic, 
child survival and maternal health.
    The public health components of our foreign assistance 
programs are the most leveraged commitments we can make to 
advance the well being of communities around the world. And we 
know from scientific data and practical experience that the 
underlying social conditions provide the foundation for 
realizing the physical, mental, and social well being of all, 
especially children. As we think about the importance of the 
first 1,000 days in a child's life, beginning in pregnancy, we 
know that the launch conditions, in my field we call these 
social determinants, materially impact child survival and 
maternal health.
    Dr. Perry Klass recently wrote in the New York Times about 
poverty as a childhood disease. I could not agree more. My own 
work has brought me to clinics in Addis Ababa, Ethiopia and in 
the South Bronx. I have personally seen the effects of poverty 
in a child's life and the ways in which it affects the entire 
family unit. The connection between the toxic levels of stress 
that poverty can cause and its debilitating effects in early 
childhood development is well studied in the scientific 
literature. We have seen the damaging effects that stress 
hormones can cause on brain and cognitive development. To name 
just one specific example, exposure to excessive levels of 
cortisol can permanently change the brain architecture in a 
developing child. The science is unequivocal on this point. 
Early childhood experiences of stress have a profound effect on 
the long-term health outcomes of children into the adult years. 
So now that we know more we must do more. With more than 200 
million children under 5 years of age that are not achieving 
their full development potential, we cannot afford to leave the 
discussion of improving the health of children to what they eat 
alone. We must also address the environments they are born into 
with clarity, courage, and accountable outcomes. These are the 
primary factors that ultimately determine health in their lives 
and their mothers.
    Of course poverty is the primary target of our foreign 
assistance programs. So what, you may ask, does framing poverty 
as a childhood disease bring to the conversation of child 
survival and maternal health? First, it changes where we begin 
the conversation by highlighting the fact that feeding a 
child's mind is as important as feeding a child's body. 
Children need nurturing environments to thrive that take into 
account their emotional and cognitive development; the 
psychosocial development is often left off the table in 
discussions about global child survival. This is harder to do 
when poverty is the differential.
    Second, given that we know that child survival begins with 
maternal health, framing poverty as a childhood disease also 
calls into question the conditions under which pregnant mothers 
live and give birth. In other words, because we pay 
insufficient attention to the prenatal and postpartum 
environment, we miss a huge opportunity to improve the lives of 
the very people we could help the most.
    It turns out poverty is also a health hazard for adults. 
Early childhood experiences of stress have a profound effect on 
the long-term health outcomes of adults. According to one 
study, there is a 240 percent increase in hepatitis, a 250 
percent increase in sexually transmitted diseases, a 260 
percent increase in chronic obstructive pulmonary disease, and 
a 460 percent increase in depression. Those statistics are 
humbling.
    The connection between these outcomes is thought to be 
mediated by social, emotional, and cognitive impairment as well 
as the adoption of harmful health risk behaviors later in life. 
These harmful effects also affect pregnancy outcomes by 
increasing the likelihood of fetal death in pregnant women. In 
one study, researchers found a direct correlation, up to 80 
percent increased risk of fetal death in pregnant women with 
the highest amount of exposures of toxic stress while they were 
children. So these statistics compel us to rethink our approach 
to child survival and women's health by recognizing that 
physical health begins with mental health. Considering the 
psychological health of children also affords the opportunity 
to consider a host of related issue that affect the mental 
well-being of kids, namely child marriage as you recognized in 
your opening comments.
    Child marriage robs the chance for a child to be a child 
and the statistics are also disturbing. Over the next 10 years 
we are talking about 180 million girls that will be married 
before the age of 18 and often under violent conditions. We 
know this has direct health effects on both child survival 
issues, but also maternal mortality as adolescent girls are the 
group most at risk to experience negative pregnancy outcomes.
    So in closing, I submit that as the 2015 deadline 
approaches for the Millennium Development Goals, perhaps the 
most impactful improvement we can make to improve the health of 
women and children around the world is including mental health 
in our post-2015 objectives and our discussions of child 
survival. Thank you for the opportunity.
    [The prepared statement of Dr. Mandefro follows:]

    
    
    
    
                              ----------                              

    Mr. Smith. Thank you very much, Doctor, for your testimony 
and your recommendations as well. A question for everyone and 
then I will ask some to each of you and then I will yield to my 
colleague, Ms. Bass. As I asked of USAID earlier, Ms. McKenna, 
there is a 12.2 percent cut in the line item for nutrition in 
the official presentation from the administration from $115 
million to $101 million. There has also been a cut of 19 
percent in tuberculosis, from $236 million to $191 million. 
There is a discouraging trendline in some of these 
recommendations for the budget. Even vulnerable children is cut 
by 34 percent from $22 million to $14.5. And I am wondering 
again, thankfully budgets are dynamic processes and this isn't 
the bottom line. Hopefully, it will ratchet up from this. But 
what would that kind of cut do to the work, especially 
sometimes other countries and partners take their cue from us? 
If we deemphasize something, will they in a corresponding way 
do the same, especially when as you spoke earlier about the 
ratios, 18-to-1 and some of those other very, very unbelievable 
ratios in terms of investments made and consequences gleaned.
    Also, if you could, constructively speaking criticism is 
good. I am sure and Ms. Bass, we get it all the time, given the 
nature of our jobs. And frankly sometimes when it is well 
meaning and properly focused, it really does cause 
recalibrations and changes in behavior in Congress, as it 
should. Sometimes, it is just negative. Anything positively and 
negatively you can suggest with regards to USAID, here is your 
chance, if you could. I am sure you convey privately, but I do 
think they are grownups. It is good for them to hear what is 
working, what is not, and any suggestions that you might have.
    You, Dr. Perry, had a number of them and one of them was to 
draft a comprehensive health workforce strategy. I thought we 
tried to do that in PEPFAR. There was a very significant 
capacity-building component to that legislation, particularly 
the first bill that was signed. But it would appear we haven't 
done it well enough so maybe you want to elaborate on that. And 
you also say the U.S. Congress should elevate U.S. Government 
support for community health workers by insisting on funding 
child survival carried out by community health workers. Don't 
we do that? Is that something we need to revisit. And you can 
elaborate on that either in written form or even now on exactly 
how we might do that.
    Ms. Bos, again, from a faith-based perspective, do you find 
that World Vision is discriminated against at all or are you 
fully accepted as partners in this very worthwhile endeavor?
    Ms. Wetzel, again, if you could speak to that as well and 
utilize existing religious networks. Do you find that the go-to 
group that is already in-country building on their capacity and 
their roots, if you will, particularly from the sustainability 
point of view. Once the money dries up or goes elsewhere, it is 
always nice to know the work continues.
    Dr. Perry again, you obviously are well published and I 
have to get that article that was mentioned earlier that you 
wrote or the op-ed, but the Lancet, I will never forget this, 
back in 2008 and I read it, talked about and focused on 
undernutrition and that if you didn't get it right in those 
first 2,000 days or so what happens to that child is largely 
irreversible. You might want to talk about that and whether or 
not--there was a great deal of buzz and positive reaction to 
those early articles. Has that literature continued? Are we 
still writing about it? Not we, but people who are experts in 
the field to drive this train and do even more to elaborate on 
it if you would.
    Dr. Aguirre, if you could speak about Guatemala and maybe 
elaborate a bit on that. You have done a lot of work there. It 
would be nice to get your insights into how that has worked 
since USAID did provide significant funding there.
    Dr. Mandefro, the toxic stress, you did elaborate a bit on 
it and I am wondering when you stated that one study, research 
has found a direct correlation between risk of fetal death and 
the amount of exposure to toxic stress that pregnant women had 
experienced when they were children. If you could maybe cite 
that study and maybe elaborate on that. Those are just some 
opening questions and I will yield to my colleague.
    Yes, Ms. Bos.
    Ms. Bos. Thank you, Mr. Chairman. Regarding the FY15 
budget, certainly as implementing partners of USAID, we work 
with them to try to do more with less where we can and be as 
efficient and effective as possible. Of course, we do always 
support robust funding of foreign assistance programs for the 
nutrition line item specifically because those interventions 
are so cross-cutting and so cost effective. We would certainly 
support strong funding in that area. The community request for 
nutrition for FY15 is I believe $200 million. So there is a 
significant gap there and we appreciate Congress in the past 
having given strong support to the maternal and child health 
and global health programs at USAID.
    As far as recommendations for USAID or our faith-based 
experience with USAID as a partner, we certainly feel like they 
value their partnership with us as we do our partnership with 
them. I would say that some of the movement at USAID has been 
more toward localization of aid. Often that means a definition 
of a local partner being an entity based in the country where 
USAID is putting in a program. Often that excludes 
international NGOs, even though we have local staff, we have 
local partners with churches, other NGOs, other organizations, 
it does exclude us from some of those programs if localization 
is a key component of that. So that is something----
    Mr. Smith. On that point, do you find or you have concerns 
that especially since you are so well audited and oversighted 
both internally as well as externally, that those protections 
might not exist for an indigenous NGO that might have people 
who are friends of the health minister or others that--where 
corruption might become a problem?
    Ms. Bos. That is certainly something that could happen. I 
mean certainly we have sound oversight both within our 
organization and externally to make sure that we are 
financially responsible. But really at the end of the day if 
the goal is to build up local capacity, faith-based 
organizations are so well suited to do that because we already 
work from a bottom up perspective with the local communities. I 
mean that is how you build the capacity with those local 
communities and then you create the sustainability, the 
behavior change that lasts generation after generation.
    Dr. Perry. Thank you very much for your questions, 
Congressman Smith. I would like to start out with your question 
about what I think USAID could do better to strengthen its 
support for child survival programming. As I mentioned in my 
testimony, I have been connected with the child survival and 
health grants program for over 25 years now and it was an 
outgrowth of your original legislation back in the '80s that 
Congress earmarked for the child survival program. It was an 
effort to provide funding directly to U.S.-based PVOs to work 
in partnership with local PVOs in developing countries to 
address to child survival funding. It was a centrally funded 
program that has always been very small. The amount of money 
that has been given out by this program has never exceeded $20 
million and it has been going downhill for the last 25 years. 
And I find that to be an extraordinary observation, given the 
fact that universally within USAID and outside of USAID, this 
is seen as one of USAID's very best programs for many reasons 
which I won't elaborate on right now, but it does involve World 
Vision, Food for the Hungry, many other faith-based NGOs, PVOs, 
and non-faith-based organizations. But it provides an 
opportunity for the Government to support the NGO efforts that 
originate in the United States to strengthen what they can do. 
But in my experience for more than three decades now, the 
creativity and innovation and deep passion and commitment that 
exists within the NGO community in the United States for child 
survival is extraordinary.
    I think what USAID has done in developing this program has 
been excellent. They have developed a tremendous rapport, as 
you just mentioned, with the PVO community. But at this 
particular moment in time, it is the understanding of the NGO, 
PVO community that this whole program may be shelved. It hasn't 
been funded for 2 years now. And I find this extraordinary 
given the success, the demonstrated success of this program and 
what it has meant in terms of developing the kinds of 
approaches and programs that we feel are so important to move 
this agenda forward in nutrition and other aspects of child 
survival.
    So I would like to make a passionate plea that the 
committee give special attention to ensuring in child survival 
funding that there is a serious effort made to engage the U.S. 
NGO, PVO community going forward and to greatly accelerate the 
amount of funding that has been made available to this program. 
I have asked over the years many times why this program has 
continually been cut back and one of the answers that has been 
consistently given is exactly what Ms. Bos said a second ago 
and that is that funding has been decentralized to the country 
level so there is no money available at the central level to 
fund these kinds of programs. And this kind of funding is vital 
to engage the U.S. NGO community because frequently the NGO 
U.S.-based NGO community within the country level doesn't have 
quite the same opportunity of operations that it does have by 
functioning as it has through the U.S. child survival and 
health grants program for the last 25 years. So I hope I have 
made my point.
    Mr. Smith. If you could, again, how much has actually been 
spent? Not any for the last 2 years from that spigot?
    Dr. Perry. There have been no grants awarded by the United 
States Child Survival and Health Grants Program for the last 2 
years and there are none scheduled at the present time. 
Previously, the amount of funding was on the order of $20 
million and the project that I discussed--that I evaluated with 
Food for the Hungry was funded through this mechanism. And I 
think it is a terribly important one for many reasons.
    Mr. Smith. And what would be an ideal amount in your view?
    Dr. Perry. $200 million, minimum.
    Mr. Smith. Okay. Your thoughts comport with Niels Daulaire 
who used to be very active over at USAID during----
    Dr. Perry. Yes.
    Mr. Smith. I know he has been concerned. None of us want to 
see any lessening of the commitment to the HIV/AIDS, malaria, 
and tuberculosis efforts. We also don't want to see a crowding 
out of other worthwhile programs robbing those in order to get 
to a critical mass and PEPFAR certainly has been successful 
beyond our dreams in many, many ways.
    Dr. Perry. It takes money to be successful.
    Mr. Smith. But that shouldn't mean that these other very 
important--so if you could give further thought, all of you, 
on--we will fight to try to get this--that is why we are having 
the hearing. It is about that first 1,000 days. And it seems to 
me when you talk about the development goals, which will be the 
post-2015 goals, when they will come up with a whole new set, 
the laggard has been child mortality.
    As one of you said, and I have to remember which, we should 
celebrate, as you put it, the success that has been made, but 
there is so much that we have not done as a world or as a 
country to try to mitigate the problem of child mortality that 
is right within our grasp.
    Dr. Perry. Right.
    Mr. Smith. So $200 million, whatever you think, we need a 
sustainable and a very accurate number to fight for it and I 
know that Members of Congress are very open to--and I know that 
because I talk with them about these issues all the time to 
making sure we get it right. So that is why this hearing is 
being held, frankly.
    Dr. Perry. I will be happy to address your other question, 
but I think I have taken more time than I should.
    Mr. Smith. We will get to everyone, if you don't mind?
    Dr. Perry. I mean you had some other questions about
    ----
    Mr. Smith. The Lancet study.
    Dr. Perry. About our support for community health worker 
programs and our comprehensive health workforce strategy and 
also the issue about what is the current status of knowledge 
about undernutrition. So let me just very briefly make a 
comment about those.
    There have been programs supported by USAID that involve 
community health workers, but we now need--we are at a new 
stage where we need to professionalize our community health 
worker workforce which has not happened before. There are going 
to be more and more interventions that can be provided at the 
community level, but we need to learn how to integrate these 
together in an effective system that can be sustained over time 
and that can be effective and that is what we have not been 
funding so far. So we are going to continue to need to build a 
system and it is an integral part of a health system 
strengthening approach.
    In my experience, health system strengthening is being 
recognized more and more as an important area for our 
involvement, but too often health system strengthening has been 
limited to services that take place at facilities without 
giving full recognition to the critical role of communities and 
community-based delivery in terms of improving population 
health. And it is not recognized by ministries of health still. 
It is an area that needs a lot of work and support.
    My only comment about undernutrition is that there was a 
recent series in the Lancet that was published only a few 
months ago that updated the 2008 Lancet series that you 
mentioned that was led by Dr. Robert Black at Johns Hopkins. 
Their conclusion is that 54 percent of child mortality can be 
attributed to undernutrition and in the 2008 version I think 
they were saying something like 38 percent or something like 
that. So I mean the science has continued to stress the 
importance of undernutrition as a fundamental part of reducing 
mortality, improving child survival in the first 1,000 days of 
life.
    The problem is that so much of our aid is focused on 
curative health systems and not driven down to the community 
with behavior change communication, hand washing, exclusive 
breastfeeding, very simple low-cost things. These have not been 
given the kind of attention that other sort of medically-
oriented interventions have gotten in the past and it takes a 
change of mindset that we are still struggling to bring about 
in the donor community.
    Mr. Smith. Without objection, the most recent Lancet 
studies that you have mentioned by R.A. Black will be made a 
part of the record and I thank you for reminding of us that.
    Dr. Perry. Yes.
    Mr. Smith. It is very important. Dr. Wetzel Chen?
    Ms. Wetzel Chen. Thank you. First responding to your 
question about recommendations for the U.S. Government, for one 
thing I would say we have really appreciated USAID's focus on 
improving their monitoring and evaluation. So for many years we 
were doing programs, there wasn't a heavy focus or guidance put 
on how to do baseline surveys, how to do followup. So it was 
unclear what was really working. So that support and initiative 
by the Government is very helpful.
    Secondly, we have appreciated multi-sector and multi-year 
funding from the U.S. Government. One of the programs that Food 
for the Hungry has been able to rely on over many years has 
been the food security programs. So those cover nutrition, but 
they also include agriculture livelihoods and they provide an 
excellent base for us really to make changes in the community. 
They are typically 5-year programs and that is what is so key. 
When we are funded for 1 year or 3 years, it is very difficult 
to see behavior change happening and make an impact, so that 
long-term funding makes a world of difference.
    Another thing that we always face as a challenge is 
contextualizing our programs. So there is usually a push when 
once we are funded to start implementing right away and see 
impact. But what we need to do is step back and say what are 
the specific barriers that are preventing what has worked maybe 
in other places from working here. So allowing a lead time 
where we can do investigative work would be very helpful. DFID 
recently started doing programming slightly different where 
they would fund, they would select an organization or a 
consortia and then they would say, okay, you have 6 months to 
do studies and develop your full proposal. That seemed like a 
great way to really allow us to make impact through the 
programs.
    Thirdly, I would like to recommend or to comment on the 
restraints that we have seen in terms of local NGOs. So as Ms. 
Bos shared, as an international NGO, we have seen that our 
funding is becoming more competitive. It is difficult. We don't 
feel that we are being discriminated against in any way as a 
faith-based organization. We can come to the table, compete for 
funding just like any other international NGO. But as Ms. Bos 
was sharing, 97 percent of our staff worldwide are nationals of 
the country where they work, but we are unable to access more 
and more of the funding that is made available because we are 
not considered a local NGO.
    And there is a lot of strength and capacity that comes from 
having global service centers that support our field 
operations. We find that with the funding that we are able to 
win, we are using more and more resources to build the 
programmatic capacity of local organizations versus the 
technical impact of the program.
    Fourthly, I would like to say we have appreciated the U.S. 
Government's focus on capacity-building grants and initiatives. 
For example, the CORE group. This is a group of maternal and 
child health technical implementers, NGOs. They come together 
twice a year. They have working groups. Some focus on 
nutrition. That has been a great place for the sharing of 
technical innovations, of best practices that TOPS Initiative 
by the U.S. Government. In years past, there was the 
institutional capacity building grant. Those are great ways to 
get out what works to NGOs that are implementing that.
    Your question was about community health workers. Well, as 
I combine that with recommendations for the Government, I would 
say there has been a focus lately on innovation and while I 
applaud that focus, it often means that what we have seen to 
work is harder and harder to get funding for. A lot of it isn't 
rocket science. Breastfeeding, ORS, it works. And it is simple, 
but it is not happening at the level that we want to see it 
happening. So balancing that focus on innovation with funding 
what really works is important. And that relates to the 
community health worker question. That is funded. We have seen 
that going on, but it is not scaled up.
    In so many countries where Food for the Hungry enters, 
there may be a community health worker initiative, but you may 
have one person trying to reach thousands of households. And 
what we have seen work in our care group approach is that we 
take one community volunteer. That person reaches somewhere 
between 10 and 12 neighbors. So it is peer-to-peer education. 
And social and behavior change research has shown that that is 
what really creates the changes at the household level, that we 
need not just a community health worker system, but one that 
has research has proven is effective in creating behavior 
change. That is my comment. Thank you.
    Mr. Smith. Dr. Aguirre.
    Ms. Aguirre. Yes. I will focus particularly on Guatemala 
which is what you have requested from me. I want to say when 
you look at the funding allocation in the case of USAID and 
what Guatemala--more than 30 percent goes to democracy and 
governance, something that is not surprising given the 
conditions of Guatemala at this point in time. We know it is a 
very conflicting and high crime country at this point in time.
    And so having worked specifically in red zones, areas of 
high crime in this country, we see the consequences for the 
malnutrition, etcetera that we are dealing with this today 
because of crime, because of the lack of security, etcetera, 
broken families, widows. I have researched areas where the 
average structure is a widow because the husband has been 
killed in entire areas, in departments in the country. That is 
the framework that is not a misallocation of funds when you 
think in terms of long-term growth in a country and the 
consequences of high cost of lack of democracy and governance 
has on security in a country.
    That being said though, I would say that I find it 
difficult to justify the high level of funding that in 
Guatemala is placed today on family planning, 
disproportionately given the needs of the country. We are 
talking about almost as much as allocation for democracy and 
governance when people are dying of malnutrition or lack of 
access to clean water or basic education.
    So if I have one comment I have to make is about the 
allocation of funding from an economic point of view I would 
call inefficient as it does not meet the requirements of long-
term growth for that country.
    Together with that though, I was thinking of other areas 
where I have seen very interesting work done and USAID had been 
part of it is the public/private initiatives that have been 
taking place in Guatemala. I have been working there for 
several years and what I have seen specifically since 2007 has 
been a significant growth of public/private initiatives where 
you see USAID has played a good role in some aspects, for 
example, in the area of education of agriculture, of HIV. So 
there are areas that are very good. However, I wish I would see 
much more engagement on the part of USAID for the purpose of 
erasing malnutrition where you have very good community-based 
private initiative programs, long-term investments in 
communities in very needy communities, for example, as in the 
north of Guatemala, where we have very high-level malnutrition 
and hunger. There are very good initiatives taking place there. 
There are long-term investments as my colleagues have mentioned 
before. Those are the ones who are really finding long-term 
solutions. They take 3, 4 years investment in the different 
communities; USAID having not really a partner in those 
efforts. It will serve them well to do so.
    Also, the lead time. I think this is also a very important 
issue. When you look at some of the investments of USAID, I 
will surrender they lack an institutional acknowledgment or 
reality of what are the values that this country wants to hold, 
what are the cultural backgrounds that take place in that 
country and that sometimes the programs promoted by USAID, not 
only misplace the authority I should say. For example, by 
ignoring tyrants when we are talking about minors, but also by 
the type of programs that--our educational programs that they 
propose, especially in the area of sex education and family 
planning and I want to go to this because I have found it in my 
own data and that is that access to family planning, 
contraceptives, sex education, among some of these in this red 
area, red zone areas as they call, high crime areas, none of 
this has been helpful for early pregnancies for example. In 
fact, it has increased early pregnancies and it has misplaced 
the emphasis.
    Unfortunately in Guatemala you have a lot of child abuse. 
The data is across the country. I can say it now because there 
is research everywhere. And it is an area that systematically 
we ignore. Interesting enough, right? Where we have--we offer 
all type of methodologies for contraception. We ignore the fact 
that we have child abuse and the consequence of that, lasting 
consequences for that in children.
    So there are some areas where I think USAID has done a 
fantastic job and there are some areas where I am greatly 
concerned because I really think it is a misuse of funds, 
especially when we are talking about cutting budgets. It might 
be worth it to take a serious revision and especially looking 
at the goals that they have proposed from here to 2016 as per 
their report. Thank you.
    Dr. Mandefro. So at this point I feel like I am just 
echoing my colleagues which I will do, happily. First of all, I 
could not agree with you more in terms of the child abuse 
statistics. They are really disheartening and one thing that 
continues to amaze me in my work is wherever I got across 
cultures, across race, across economic divides the numbers are 
startling and it is about one in three. And if we are looking 
at specifically at sexual abuse, actually it is one in three 
before the age of 18. And when you have a population risk 
factor that is that big, we can't afford to ignore it, so I 
guess my first comment would be is really getting USAID to do 
more in the sphere of mental health. And I think as a whole in 
global public health, we have a long way to go. And I say this 
to you as an internist, as a primary care physician, not even 
as a mental health specialist because I have seen it.
    I truly believe that physical health begins with mental 
health. And I think a correlate point to that is that you know 
to the point you raised about behavior change programs, 
behavior change is about psychological health and well being. 
We know that even from the scientific literature in this 
country. Forty percent of our premature deaths are due to 
behaviors. And it is a very tough issue which is why it 
requires investment and I think why Congress can kind of place 
some restrictions about at least a certain percentage of the 
global public health assistance program being really directly 
at behavior change and more importantly addressing these large 
issues of abuse.
    The second point to the community health workers point I 
couldn't agree more about the need to professionalize and I 
just wanted to name two projects in particular. In Ethiopia, 
there has actually been a lot of headway with the Ethiopian 
health extension workers program and a lot of their materials 
can serve as an exemplary model of how you professionalize in 
addition to the brave and pioneering work of partners in 
health. And Haiti and Rwanda are truly exemplary programs of 
how you can do this community health worker approach and take 
it to scale and get some really lasting affects.
    And then to your point, Chairman Smith, the study that I 
cited and I think I might not have actually included the 
reference in my original written comments comes out of the 
literature in child abuse actually in this country. It is the 
2004 Journal of Pediatrics study by Susan Hillis, et al., there 
are a lot of authors, but it is actually the original authors 
who came up with the adverse childhood experiences study. It is 
a retrospective cohort study, so they looked back on these 
experiences of 9,159 women over the age of 18 who attended a 
primary care clinic in San Diego. What they looked at was 
adverse childhood experiences as scored from one to eight and 
these are really a list of things like physical abuse, 
emotional abuse, sexual abuse, experiences of violence, 
household dysfunctions, all kinds of measures. And when they 
stratified this, the highest group which had an experience of 5 
to 8 abuse adverse experiences had an increased risk of 80 
percent in fetal death. So fetal death was actually one of the 
outcomes they looked at and I can give you the specifics for 
that reference.
    Mr. Smith. Thank you very much, for all of you. Ms. Bass.
    Ms. Bass. Thank you very much. Dr. Perry, I was looking at 
your testimony and on page two, you list interventions that you 
thought would be the most appropriate. And I was just wondering 
what you thought in terms of how our funding is going now. I 
don't know where we might emphasize, but it seems like a lot of 
these we don't address.
    Dr. Perry. We don't.
    Ms. Bass. Oral rehydration, I am sure we do, but of our 
funding, where do you think the emphasis is lacking now, given 
your list of interventions?
    Dr. Perry. Well, I think one basic fundamental idea in all 
of this is that nutrition has not been given the level of 
funding that it should have. And I think there is a wide 
consensus of that and that, in fact, one of the highlights, I 
think, of The Lancet series, The Lancet Maternal and Child 
Nutrition series, both in 2008 and 2013 is that we do need 
stronger funding for nutrition programs. And so that is an 
important part of this.
    One area that is particularly important that I wanted to 
mention that responds to your question, but I also was looking 
for a chance to bring it up anyway since you said you had been 
a nurse in neonatal care unit.
    Ms. Bass. Yes.
    Dr. Perry. Home based neonatal care is one of the exciting 
new interventions that has been developed scientifically, is 
now being applied on a broader scale. It is very simple. It 
uses community health workers to give education messages to 
mothers during pregnancy, have somebody who is trained to be 
there at the time of delivery, and then to have visitation 
every day for the first few days after birth and then 
periodically after that. Promoting good nutrition is one of the 
fundamental parts of it, exclusive breastfeeding, looking for 
signs of infection that could be treated with antibiotics early 
on, proper care of the umbilical cord. This is unbelievable, 
but studies that are led by Hopkins and other groups now show 
that just simply applying chlorhexidine to the umbilical cord 
at the time of birth today in the world we live in can reduce 
neonatal mortality rates by 25 percent.
    Ms. Bass. Do people use traditional methods? Is there 
some----
    Dr. Perry. There is still all kinds of unclean practices 
that take place in this world that we live in today. Why 
haven't we done a better job of this? I mean it is really 
astounding. We are not talking about money. This is pennies 
involved for this. So I think that home based neonatal care is 
a very important area that we need to put more money into. We 
know that as under-5 mortality continues to decline, the 
proportion of deaths that are occurring in the neonatal period 
will be increasing over time, so putting more and more emphasis 
on preventing neonatal deaths and stillbirths which basically 
requires good prenatal care and also good quality basic medical 
care during the time of delivery by somebody who can be a 
community level worker, but who has some basic training in the 
management of clean delivery and recognition of complications. 
All of these areas are going to need more funding.
    We have done fairly well with oral rehydration. Zinc has 
come in now as an additional component for treating diarrhea. 
The coverage of zinc for cases of diarrhea is very low, so we 
have got to bring that up. Community case management of 
pneumonia with antibiotics, using community health workers, 
that has been known for a long time that that can reduce 
mortality from pneumonia by a third or more, but it is still a 
very low coverage level of this intervention. We have done very 
well with immunizations and Vitamin A. Those coverage levels 
are 80 percent or higher, but it is these other ones that are 
very low that we really need to focus on and we need to work on 
doing these in an integrated way.
    You can't have a community level worker doing one thing and 
then having a different community level worker doing another 
thing. It doesn't work like that at the community level. It may 
work that way at the higher levels of government, but when you 
get down to the village level, we have got to learn how to 
apply these things in an integrated, coordinated way that is 
effective. And we are still learning and struggling with that.
    Ms. Bass. Thank you. Dr. Aguirre, I was interested in what 
you were saying about family planning in the red zone and child 
abuse. And maybe you could connect that more for me. And when 
you are referring to child abuse, actually both of you and I 
was wondering what you were talking about, what type of abuse, 
you know. Here, for example, the main reason why children are 
removed from home is actually neglect as opposed to physical 
abuse, but you both referred to child abuse, so I was 
wondering--how we were defining it.
    Ms. Aguirre. Thank you very much, Congressman Bass. Two 
things I wanted to say. What I found systematically in the 
studies I have done and specifically in red zones, but to 
some----
    Ms. Bass. Red zones are the high crime areas?
    Ms. Aguirre. High crime areas. High crimes areas that 
unfortunately there are more than we would like to see in 
Guatemala. What you find is in schools, so we are talking about 
high schools or grade schools where access to contraceptives is 
widespread or the type of education promoted and often 
connected to USAID, this is why I brought this issue are 
present. Typically, you find a higher level of sexual activity 
among the young and sometimes beginning in fifth grade. This is 
what I find in the data. And actually, this is consistent with 
other findings in other countries, too. This is not only a 
Guatemala surprise.
    Ms. Bass. So is this related to--because there are people 
in this country that believe if you do sex education or if you 
provide access to contraceptives that that makes kids more 
sexually active.
    Ms. Aguirre. I will say I find consistent data to that 
position. However, let me say that I have recommended in some 
places the introductions of sex education. The question is what 
of sex education we are engaging. For example, I have 
experiments where I have present parents and children in this 
area of abuse precisely to show that we need to address this 
address since the schools are being ignored. And this is a very 
serious issue. And when I refer to sexual abuse it is not only 
child abuse, not only verbal abuse, we are talking about sexual 
abuse.
    Ms. Bass. Okay.
    Ms. Aguirre. Ninety-nine percent of the time it is not 
immediate family members, but it might be extended family or 
others, often members of a gang. There are plenty of them. Gang 
members.
    So this is the type of data that I find. So what I am 
saying is this is not--what I am trying to say here is this is 
not about not having a sex education program if there is a need 
for one. I think it is the approach. What I find in the data on 
the studies that I have undertaken, that is problematic.
    Ms. Bass. And I would ask you what was the approach? You 
know, for instance, we went through a number of years here 
before my time where we promoted abstinence which wasn't very 
successful. But so what was the approach that you felt that led 
to sexual abuse?
    Ms. Aguirre. So what I found is two things here. I said 
more pregnancy and sexual activity, one subject. That is what I 
said. And another subject, the issue, the fact that we find 
sexual abuse and it is not being addressed.
    Ms. Bass. Okay.
    Ms. Aguirre. So we are putting funding on safe sex type of 
programs, read safe sex as ``do sex, but just be protected'' as 
opposed to perhaps delayed sexual activity. You are in fifth 
grade, right?
    Ms. Bass. Right.
    Ms. Aguirre. Delay sexual activity and instead of focusing 
for example on more healthy and comprehensive sex education 
where you show respect and in addition to that, you address the 
issue of sexual abuse. That is what I was trying to say.
    Ms. Bass. So you are separating them. I see. I got that. 
And then just on the side note if the chairman doesn't mind, I 
was in Guatemala, I believe it was the beginning of last year 
with Senator Landrieu looking at the issue of orphans in 
Guatemala and I am just curious if you have any information 
about that. What I understand happened is that the Guatemalans 
cut off adoption in the United States for some real reasons 
because there was a lot of corruption going on.
    Ms. Aguirre. You are absolutely right, yes.
    Ms. Bass. But when Guatemala did that, it left about 300 
kids in limbo because they had already been in the process. And 
so you happen, I am sorry, this is not really our subject, but 
anyway, I thought I would----
    Ms. Aguirre. Well, I will be happy to address this issue 
because I have worked closely with people who have been very 
connected with the change of the law as well as with orphans.
    Ms. Bass. Oh, good.
    Ms. Aguirre. So I have to say I don't know if I will call 
it left in limbo. If there is a system, a large system in 
Guatemala where extended family will take those children, same 
pattern that often you will find, for example, in sub-Saharan 
Africa.
    Ms. Bass. And here.
    Ms. Aguirre. And here. We were talking about developing 
countries, so I am sorry. But also there has been a real 
concern, as you said because of the abuses that have been 
taking place in the process of adoptions, so they are working 
toward stabilizing that situation and there have been quite a 
lot of initiatives actually, especially at the local government 
levels, for example, in Guatemala City, they have an 
incredible, very interesting project on taking the kids from 
the streets and working with them. So I think that they are 
addressing the issue of orphans. It is not that they are being 
neglected.
    Ms. Bass. Right, I mean I went to an orphanage and I saw 
the kids there, but the ones I was referring to in limbo were 
ones that were actually in the process of being adopted.
    Ms. Aguirre. Oh, I am sorry. I misunderstood you.
    Ms. Bass. And U.S. parents here who were in the process of 
adopting them and then the government shut it down. So I didn't 
know if that ban had been lifted.
    Ms. Aguirre. To the best of my knowledge, it has not been.
    Ms. Bass. Okay, thank you.
    Ms. Aguirre. I cannot----
    Ms. Bass. I am sorry. I appreciate that. I am sorry to put 
you on the spot here.
    Dr. Mandefro, I wanted to ask you a couple of questions, 
too. Dr. Perry recommended exclusive breastfeeding which I 
certainly understand and would support, but I was just 
wondering when you find the women who are undernourished, how 
does that work actually, you know what I mean? Does that wind 
up compromising the woman's health or does her body protect her 
by not really producing?
    Dr. Mandefro. I mean it is a problem, right? This is why 
child health must begin with maternal health. The moms 
definitely need their own nourishment in order for that to 
work. In some cases, they can still provide exclusive breast 
milk. Everyone's responses are slightly different, but it is a 
problem for sure.
    I also wanted to just address the abuse question before 
that you had asked. When I said one in three, I was 
specifically talking about sexual abuse, but actually the 
scientific literature as it relates to adverse childhood 
experiences, breaks out all of these into four different 
abuses, physical, sexual, emotional, and neglect. So it 
actually gives you a score for each. So it is all of those 
abuses.
    Ms. Bass. And so what do you think that we are doing to 
really address in various countries the issue of girls getting 
married too early, child marriage? Is there anything that we 
are doing to support efforts, educational efforts against that?
    Dr. Mandefro. This is a very tough issue. Actually, the 
Council on Foreign Relations had a report that came out not 
even 7 months ago on how child marriage is a U.S. foreign 
policy issue now. So this issue is actually getting some 
traction in the domestic policy scene as well. I think child 
marriages also have been very effectively framed by development 
community as being connected to at least five of the MDGs, you 
know, affecting all of those outcomes. But we are ultimately 
talking about cultural change which is very difficult to do 
from the outside. I think it requires innovative methods of 
doing community-based outreach. There are programs.
    I actually sit on the board of an organization, a 
reproductive health organization called Engender Health and 
they have been doing a lot of interesting things around gender 
norms in South Africa. They have a program call Men as Partners 
because I think where you have to start with an issue like 
child marriage is obviously engaging the men in a conversation 
and in particular, young men. So some of the most pioneering 
work, I think, in this area has been actually these community-
based efforts that take on this challenge of talking to the men 
directly in these communities. And I think Men as Partners is a 
great program to look at. Yes, there are other programs like 
that.
    Ms. Bass. Thank you. Thank you very much. Thank you, Mr. 
Chair.
    Mr. Smith. Thank you very much. Just one final question. I 
chaired a hearing better part of a year ago, about a year ago. 
We heard from Dr. Peter Hotez from Baylor who is an expert in 
the area of neglected tropical diseases. And I have since read 
his book and the question arises about in talking about the 
global health programs, in regard to the submission from the 
administration, we have already talked about the cut of 12.2 
percent from $115 million to $102 million. The cut in the 
vulnerable children line was a 34 percent cut. But there is 
also a cut for neglected tropical diseases from $100 million to 
$86.5 million, a 13.5 percent cut or proposed cut.
    I am wondering one of the biggest takeaways from reading 
the book and from hearing from our witnesses including Dr. 
Hotez from Baylor, that there were some 2 billion people who 
have neglected tropical diseases, that it actually worsens the 
vulnerability of a woman, especially for HIV/AIDS, which was 
something that even though I have been at many PEPFAR meetings, 
worked on the legislation, was not aware of it until that 
hearing.
    But also the fact that so many children, their immune 
systems get compromised and in the context of nutrition, we 
want to feed the children, not feed the worms. And I am 
wondering what your thoughts might be on this. We are working 
on some legislation right now which will probably be a multi-
month, even multi-year project because it is hard to get bills 
passed, I know, because most of my bills take 3 years before 
they become law. But this whole idea of neglected tropical 
diseases, the first 1,000 days, obviously, the mother is 
weakened, less likely if she has one of these terrible diseases 
to effectively provide breast milk for her child, plus she is 
sick. What are your thoughts about the correlation between NTDs 
and nutrition and again, hopefully, we don't feed the worms? 
Anyone want to touch on that?
    Ms. Bos. I can chime in on that, Chairman. I think that 
reemphasizes the need for a multi-sectoral approach to maternal 
and child health. If you are getting worms from unsafe water, 
you know, it obviously is then tying into all of the health 
outcomes both for the mother and the child. So too often I 
think the U.S. Government has been guilty of this and I think 
sometimes us as NGOs have also been guilty of taking a very 
vertical approach and seeing things in silos. And we have 
really learned lessons from that that you cannot address just 
one issue at one point in time because they are so 
interconnected.
    And to build on something that Dr. Perry said as well, how 
do you get those integrated multi-sectoral interventions? The 
message is out through community health workers. There are ways 
that we are growing our knowledge of how to do that and part of 
that is using a lifecycle approach. So there are certain things 
that need to happen at 30 days of a child's life or at 6 months 
or at 2 years, whether it be vaccinations or teaching the 
mother how to prepare complementary foods for her child 
properly. All of those messages can be delivered at a certain 
point in time in a congruent way where the mothers really 
understand at the household level what they need to be doing. 
So that is just another piece, I think, of how all of this 
comes together. But again, getting away from some of the 
vertical structures that we have had. And that is where some of 
these strategies come into play as well, both a nutrition 
strategy, USAID has a water strategy. Hopefully, we can get a 
health worker strategy. Because different agencies are doing 
some of these different vertical pieces, having those 
intergovernmental, interagency strategies really would be very 
helpful into making sure every piece is working together the 
way it should.
    Dr. Perry. You asked a very complicated question that is a 
source of debate in the global health academic community and 
practitioner community, so I am not going to try to resolve all 
of that in 30 seconds. But just a comment or two. One is that 
there is a very exciting and successful program for neglected 
tropical diseases called CDI, Community Directed Interventions. 
And it has been supported, I don't know to what degree the 
United States Government directly has supported this, but it 
has been part of the WHO tropical disease research program and 
it has been going on a long time. But the reason I mention this 
is because it involves community empowerment, community-based 
delivery systems that started out as a very integrated, 
vertical, sort of top-down program that reached down to the 
community in the ways that we are arguing for, I think all of 
us here. But they are now starting to use this approach to 
bring in other child survival interventions in an integrated 
fashion. So I would encourage you to look into that and think 
about how we can build on these kinds of programs. We need all 
these programs and unfortunately, in the global health 
community, funding is so limited we end up fighting with each 
other to get a little bigger piece of the pie. We need a bigger 
pie.
    I would encourage you to look for ways in which the 
implementation of neglected tropical diseases at the community 
level that reach down to the household, which they have to do 
to be effective, can link as well into some of the nutrition 
and child survival interventions that we are talking about. I 
think there is a lot of published literature on this, a lot of 
evaluations of CDI and there is some exciting opportunities 
there, particularly in Africa.
    Ms. Aguirre. I was going to second Dr. Perry. That is what 
I was going to bring up, too.
    Mr. Smith. Thank you very much to all of you. Thank you for 
your leadership, your patience. I again apologize for that long 
delay.
    And your information I can assure you will be widely 
disseminated among my colleagues and it will help me and others 
know what we need to do next step. I am very grateful and I 
know Ms. Bass is as well for your participation today.
    This hearing has generated a great deal of interest among 
other civil society organizations and some of whom have 
provided unsolicited submissions for the record and without 
objection, I will ask that these documents be entered into the 
record from the American Academy of Pediatrics, a statement by 
its president, James M. Perrin, M.D.; from Bread for the World, 
a statement by its president, Rev. David Beckman. And from 
Lions Club International, a statement by its immediate past 
international president, Wayne A. Madden. Without objection, it 
is so ordered.
    Members have 5 legislative days to submit additional 
questions or material for the record and again I thank you so 
very, very much. The hearing is adjourned.
    [Whereupon, at 5:36 p.m., the committee was adjourned.]
                                     

                                     

                            A P P E N D I X

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         Material Submitted for the RecordNotice deg.



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 Material submitted for the record by Henry Perry, M.D., Ph.D., senior 
associate, Health Systems Program, Department of International Health, 
      Bloomberg School of Public Health, Johns Hopkins University

















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   Material submitted for the record by the Honorable Christopher H. 
 Smith, a Representative in Congress from the State of New Jersey, and 
 chairman, Subcommittee on Africa, Global Health, Global Human Rights, 
                    and International Organizations

















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