[Senate Hearing 113-]
[From the U.S. Government Publishing Office]


 
  STATE, FOREIGN OPERATIONS, AND RELATED PROGRAMS APPROPRIATIONS FOR 
                            FISCAL YEAR 2014 

                              ----------                              


                         TUESDAY, MAY 21, 2013

                                       U.S. Senate,
           Subcommittee of the Committee on Appropriations,
                                                    Washington, DC.
    The subcommittee met at 10:06 a.m., in room SD-192, Dirksen 
Senate Office Building, Hon. Patrick J. Leahy (chairman) 
presiding.
    Present: Senators Leahy and Landrieu.

      Review of U.S. Foreign Assistance for Children in Adversity

             OPENING STATEMENT OF SENATOR PATRICK J. LEAHY

    Senator Leahy. Thank you all for being here. I especially 
want to thank Senator Landrieu. It was her idea to hold this 
hearing.
    She is very subtle about it. She just came to me and said, 
Patrick, this is extraordinarily important, and we have to get 
it done, and let's find a date.
    So I agreed with her.
    I apologize, but with the immigration debate I'm going to 
have to leave soon. We're planning to stay at that markup until 
midnight, if necessary, with the idea of getting the bill 
finished this week before the Senate leaves for Memorial Day.
    I don't need to convince you that the fate of the world's 
children is the responsibility of everyone. Today, in the 21st 
century, it's appalling how many children are born into lives 
of misery.
    I've said so many times that for U.S. citizens this is a 
moral issue. We live in the wealthiest, most powerful Nation on 
Earth. Many of us do not have to worry about going hungry. We 
strive to ensure that our children and grandchildren have 
access to everything they need from education to food to 
medicine. We have a moral responsibility not to turn our backs 
on those who could not even imagine what our children and our 
grandchildren have.
    The United Nations Children's Fund (UNICEF) State of the 
World's Children 2013 report is due to be published later this 
month. Statistics show that in 2010, more than 8 million 
children died before the age of 5, mostly from preventable 
diseases or complications at birth, and about 20,000 children 
die needlessly every day.
    When I was looking at some of the notes that Tim Rieser and 
Nikole Manatt put together for me on this issue, it just brings 
tears to your eyes, because you recognize the pain you would 
feel if it were your own children or grandchildren.
    At any given time, nearly 2.5 million people are in forced 
labor situations as result of trafficking, and one-quarter to 
one-half of them are children. Even in the absence of 
trafficking, some 200 million children are forced to work to 
survive, and half of them are exposed to dangerous working 
conditions. I've read many articles in the paper about children 
who were basically sold into slavery.
    We've seen the photographs of child refugees, child 
soldiers, child prostitutes, children scavenging in garbage 
dumps, children laboring in garment factories, children 
starving, children abandoned or orphaned by war or disease, 
children fending for themselves in a dangerous, unforgiving 
world. How can we look at these images without it tearing our 
souls apart?
    As much as we wish it were otherwise, this subcommittee 
doesn't have the resources to eliminate these problems. In 
fact, the amount of funds we have for programs that directly or 
indirectly improve the lives of children in adversity is a 
pittance when you consider what the needs are.
    But there are things we're doing and, undoubtedly, there is 
more we can do to help developing countries care for and 
protect these children by, one, improving public health and 
education; two, enforcing laws against child labor, every one 
of us as a consumer can ask where our clothes come from; and 
three, improving the capacity of governments to find suitable 
homes for abandoned and orphaned children so they don't remain 
on the street or end up in an institution where they're 
vulnerable to abuse and neglect.
    We have witnesses here who can speak to this. Leading off 
the first panel is Ambassador Donald Steinberg, Deputy 
Administrator of the U.S. Agency for International Development 
(USAID). I've known Ambassador Steinberg for nearly 2 decades. 
He is as dedicated to improving the lives of the world's most 
vulnerable people as anyone I've met in Washington. And he has 
been in some areas of the world that are pretty grim.
    Dr. Neil Boothby is the USAID Special Advisor for Children 
in Adversity. He brings a wealth of experience to these issues.
    Dr. Susan Bissell is Chief of Child Protection at UNICEF, 
and has a long history of global leadership on children's 
issues.
    And Dr. Caroline Ryan is Deputy Coordinator for Technical 
Leadership at the State Department's Office of the U.S. Global 
AIDS Coordinator. She will speak to the role that her office is 
playing on behalf of children who are infected by HIV/AIDS. I 
have friends who have worked with this subcommittee for years 
on these issues, including Bill Gates, Bono, and many others.

                           PREPARED STATEMENT

    On the second panel are Dr. Philip Goldman, President of 
Maestral International; Jedd Medefind, President of the 
Christian Alliance for Orphans; and Dr. Charles Nelson, 
Professor of Pediatrics and Neuroscience at Harvard Medical 
School.
    [The statement follows:]
             Prepared Statement of Senator Patrick J. Leahy
    I want to thank Senator Landrieu, whose idea it was to hold this 
hearing, and I thank our witnesses for being here.
    The fate of the world's children is the responsibility of everyone. 
Today, in the 21st Century, it is appalling to consider how many 
children are born into lives of misery.
    UNICEF's 2013 State of the World's Children report is due later 
this month, but the statistics available today show that in 2010 more 
than 8 million children died before the age of five, mostly from 
preventable diseases or complications at birth. Some 20,000 children 
die needlessly every day.
    At any given time, nearly 2.5 million people are in forced labor as 
a result of trafficking, and from one quarter to one half of them are 
children. Even in the absence of trafficking, some 200 million children 
are forced to work to survive, half of them exposed to dangerous 
conditions.
    We have all seen the photographs of child refugees, child soldiers, 
child prostitutes, children scavenging in garbage dumps, children 
laboring in garment factories, children starving, children abandoned or 
orphaned by war or disease, children fending for themselves in a 
dangerous, unforgiving world. It is heartbreaking to see.
    As much as we wish it were otherwise, this subcommittee does not 
have the resources to eliminate these problems. In fact, the amount of 
funds we have for programs that directly or indirectly improve the 
lives of children in adversity is a pittance, measured against the 
amount of need.
    But there are things we are doing, and undoubtedly more we can do 
to help developing countries care for and protect these children, by:
  --improving public health and education;
  --enforcing laws against child labor; and
  --improving the capacity of governments to find suitable homes for 
        abandoned and orphaned children so they do not remain on the 
        street or end up in institutions where they are vulnerable to 
        abuse and neglect.
    Today's witnesses can speak to this.
  --Leading off the first panel is Ambassador Donald Steinberg, Deputy 
        Administrator of the U.S. Agency for International Development. 
        I have known Ambassador Steinberg for nearly two decades, and 
        he is as dedicated to improving the lives of the world's most 
        vulnerable people as anyone I have met in Washington.
  --Dr. Neil Boothby is USAID's Special Advisor for Children in 
        Adversity. He brings a wealth of experience to these issues.
  --Dr. Susan Bissell is Chief of Child Protection at UNICEF, which has 
        a long history of global leadership on children's issues.
  --Dr. Caroline Ryan, Deputy Coordinator for Technical Leadership at 
        the State Department's Office of the U.S. Global AIDS 
        Coordinator, will speak to the role that office is playing on 
        behalf of children who are affected by HIV/AIDS.
    For the second panel we will hear from:
  --Mr. Phillip Goldman, President of Maestral International;
  --Mr. Jedd Medefind [med EH fend], President of the Christian 
        Alliance for Orphans; and
  --Dr. Charles Nelson, Professor of Pediatrics and Neuroscience at 
        Harvard Medical School.
    Each of these witnesses has devoted their professional lives to the 
issues that we are here to discuss. Thank you all for coming.
    I want to apologize in advance that I cannot stay because I have to 
chair the Judiciary Committee which is continuing to mark up the 
immigration bill this morning.
    But I commend the Senator from Louisiana for her leadership on this 
issue, which is important to all of us.

    Senator Leahy. I'm going to ask Senator Landrieu if she can 
move over one seat to take the gavel.
    Senator Landrieu [presiding]. Before the Senator leaves, 
and I'm happy to do that, I just have to say how much I 
appreciate his leadership. He has been an extraordinary leader 
of this subcommittee for many years, not extraordinary but 
effective. His advocacy for children is really second to none. 
And I so appreciate him taking a few minutes in a very busy 
week on a major bill that he's leading, immigration reform, to 
give such opening remarks.
    Thank you, Senator Leahy.
    Senator Leahy. Thank you, Mary.
    Senator Landrieu. Again, let me thank the chairman and the 
ranking member, who I hope will be joining us, Senator Graham, 
and other members of the subcommittee may be able to stop in on 
a very busy morning to join us for this important hearing. I, 
again, thank him for his leadership.
    I also want to thank the chairwoman of the Appropriations 
Committee, Senator Barbara A. Mikulski, who I spoke to right 
before this hearing to let her know that we were conducting it. 
Of course, she gives us her full blessing and is very 
interested in the outcome of this hearing, and I think it will 
help instruct us as to how to build a better appropriations 
bill as we move forward.
    Last year, as you all know, the U.S. Government launched 
the first ever National Action Plan for Children in Adversity. 
The action plan, which took 18 months to develop, is the 
product of collaboration among 11 Federal agencies, really 
unprecedented, including USAID, Centers for Disease Control and 
Prevention (CDC), the Department of State, the Department of 
Health and Human Services, the Department of Homeland Security, 
among others, the broad coalition of stakeholders reflects the 
current best thinking on how to deliver assistance to the 
children that Senator Leahy was speaking so eloquently about.
    This document, for the first time, gives equal priority, 
and it's very exciting, to three main objectives. One, strong 
beginnings, keeping children alive and giving them a chance to 
thrive. I think Senator Leahy reported that 8 million children 
in the potential UNICEF report aren't going to live until the 
age of 5. Millions of other children will die before the age of 
12. Our plan says we must help keep children strong in the 
beginning.
    Second, very important, families first, ensuring that all 
children live and grow and thrive in a safe and permanent 
family. Which really, ultimately, when you think about it, the 
best and truly only form of real protection for children is a 
strong and nurturing and supportive family.
    I've often said, if you want to get rid of traffickers, 
then put every child in the arms of a powerful father and 
mother. The traffickers will never get them.
    Third, protecting each child from violence, abuse, and 
exploitation. I believe we can and should better target the 
investments through this subcommittee and other committees in 
maternal and child health toward ensuring that all children 
everywhere have a strong and connected beginning.
    Increasing our efforts to protect children from all forms 
of exploitation and abuse, and, perhaps most importantly, serve 
children in and through their biological families, if intact, 
and if not, find a family to minister to them.
    Even though the action plan has three equally important 
goals and pillars, the U.S. Government, in my view, and I think 
it's shared by many, does not seem to be currently organized 
and resourced to address these three goals equally.
    We have many people and significant resources, relatively 
speaking, in place to help children have strong beginnings, and 
we do have a great deal of work and resources to protect 
children from exploitation and abuse and anti-trafficking. And 
I believe the facts will show that our child protection work 
falls short, however, in recognizing the importance of 
children, their mental and physical need for family care.
    If we truly mean it when we say we want to reduce the 
number of children living without permanent families, we need 
to make some changes, I believe, in the way that we think and 
act, resource, and organize, not only as a Government, but to 
develop stronger partnerships with nonprofits and the faith-
based communities to accomplish these important goals.
    Dr. Neil Boothby, who is here today from the U.S. Agency 
for International Development (USAID), can speak to the action 
plan in more detail. I want to say how proud I am to have lent 
my efforts to this report, and I want to thank him for his 
leadership and the leadership of everyone at the table for this 
really breakthrough strategy.
    Today's second panel hosts a distinguish scientist, Dr. 
Charles Nelson of Harvard University, who will discuss the 
devastating impact of institutionalization on children. I'm 
particularly grateful for Dr. Nelson for joining us on such 
short notice to help make this critical point today. He can say 
more eloquently than I the importance of a nurturing family to 
a child's development.
    Millions of children are currently growing up in 
orphanages, on the streets, in refugee camps, asylums seekers, 
or stateless persons, uncounted, unrecognized, and unhelped. As 
a Government, we're not, in my view, currently investing 
sufficiently or with adequate focus in diplomacy or programs 
that work to preserve families, reunify families, or support 
development of domestic and international adoption programs in 
other countries when that might be the only option for millions 
of children.
    But there are organizations that work in the field of 
international child welfare and protection that have already 
recognized this fundamental principle and begun putting it into 
action.
    Many of you, no doubt, know the transformative work of 
Saddleback Church in California led by Kay and Rick Warren, or 
the dedication of organizations such as Holt International, 
Buckner International, Bethany Christian Services, the Gladney 
Center, and dozens of others who do transformative work helping 
children stay with their biological families or connect them 
quickly to a strong and willing and able relative, or domestic 
adoption, and if not, international adoption, to give them the 
safe harbor that every child deserves and needs.
    Today, we have testifying before this subcommittee a 
representative of the community of such organizations, the 
president of the Christian Alliance for Orphans, Jedd Medefind. 
There are many organizations and inspiring individuals that 
could come before this subcommittee. The room could not hold 
them all, so there will be people in the second panel giving 
voice to them.
    I'm also looking forward to hearing from Philip Goldman, 
who makes a very solid case for why putting families first is 
not only the right thing to do, but the smart thing to do. No 
investment promises a higher rate of return than a meaningful 
investment in strong families for every child.
    I believe we must embrace the full continuum of solutions 
and partners which offer permanent families with a sense of 
urgency to the millions and millions of unparented children in 
the world.
    Children cannot wait years and months without causing them 
harm in their emotional, spiritual, and physical development. 
We must carefully consider how we manage and deploy our limited 
resources as a Government to assist all children in adversity 
internationally.
    The testimony of our witnesses today will serve as a guide 
in this Congress to making the most meaningful and efficient 
foreign assistance investments for children in adversity that 
we can, and to help shape legislation being developed on this 
important issue.
    Thank you again for attending, and let's begin with our 
first panel. Deputy Administrator Steinberg, Dr. Ryan, Dr. 
Bissell--I'm very pleased that each have joined us today--and 
Dr. Boothby.
    We'll start with you, Mr. Steinberg.
STATEMENT OF HON. DONALD STEINBERG, DEPUTY 
            ADMINISTRATOR, UNITED STATES AGENCY FOR 
            INTERNATIONAL DEVELOPMENT
    Mr. Steinberg. Thank you, Madam Chairman. It's a great 
honor to testify here before this subcommittee on efforts to 
address the global challenge of children in adversity. And I 
did want to begin by saluting your tremendous leadership, as 
well as that of Senator Leahy, Senator Graham, and other 
members of the subcommittee.
    In his State of the Union Address 3 months ago, the 
President defined for us a new and inspirational global 
mission.
    He said that the United States will join with our allies 
around the world to eliminate extreme poverty in the next 2 
decades, including by giving our young and brightest minds new 
opportunities to serve by saving the world's children from 
preventable deaths and by realizing the promise of an AIDS-free 
generation.
    If we are to achieve this goal, we know we have to empower 
a new generation of global citizens with the skills they need 
to contribute fully to their societies. We need to ensure the 
children not only survive but thrive. And this is, indeed, as 
you've said, the goal of the President's Action Plan for 
Children in Adversity, a plan that has three principle 
objectives: building strong beginnings; putting families first; 
and protecting children from violence, exploitation, and 
neglect.
    Throughout my career, I've seen what young people can do, 
if they're properly empowered. All around this country, we have 
young people who are figuring out how to get arsenic out of 
drinking water, thus ensuring that children around the world 
aren't subjected to stunting, to poor cognitive development, 
and even deaths.
    They're developing solar-powered breathing machines that 
are already saving the lives of newborns with respiratory 
illnesses in Africa.
    They're creating cell-phone applications to inform 
consumers about how much trafficked labor was involved in 
manufacturing the goods that they buy.
    They're figuring out how to use the world's 6.5 billion 
cell phones as medical tools to diagnose malaria, tuberculosis, 
and other diseases.
    But, Madam Chairman, I've also seen what happens when we 
ignore this imperative. In my service in South Africa, I recall 
the thousands of so-called twilight children, kids separated 
from their families, wandering the streets of major cities by 
night, and sleeping in abandoned parking garages and empty lots 
by evening.
    I recall my service in Angola in the wake of 2 decades of 
civil war where literally millions of children sat in refugee 
camps, their eyes glazed, already having seen enough violence 
to last them a lifetime.
    Most recently, I recall my visits to children centers in 
Bangladesh and Guatemala, where up to one-half the children in 
those countries experience stunting, part of the 200 million 
children worldwide who have passed their 5th birthdays with 
serious cognitive and developmental delays.
    It's for this reason that we take so seriously the 
challenge of helping our young people survive and thrive. This 
is one of the reasons that we have created at USAID a Center on 
Excellence for Children in Adversity, bringing together world-
class experts like Dr. Neil Boothby who serves not only as the 
U.S. Government special advisor but as the special coordinator 
at USAID itself.
    My written testimony describes a number of the efforts 
we're putting together globally. In the area of new beginnings, 
they include our work to eliminate preventable child death by 
2035. When I began in the development arena some 3 decades ago, 
about 15 million children under the age of 5 died from common, 
preventable diseases. Today, that figure is 6.9 million, still 
a shocking number, but the lowest in my lifetime.
    To accelerate this progress, we are investing in high-
impact solutions to address the main causes of mortality, and 
we're supporting a strong enabling environment.
    Last year, we hosted, with Ethiopia, India, and UNICEF, the 
Child Survival Call to Action. And since that point, we've had 
172 countries and 400 civil society organizations sign a pledge 
to accelerate declines in child deaths. Each signature and the 
work it embodies represents a renewed commitment to give every 
child the best possible start in life.
    Madam Chairman, I strongly agree with you that we need to 
identify additional resources and put additional attention 
behind the second pillar, that of putting families first. We're 
pleased to be able to implement to Displaced Children and 
Orphans account, which assists programs to benefit children in 
vulnerable households and especially outside of family care in 
some 45 countries.
    These programs promote family-based alternatives to 
institutional care, something I care deeply about as the 
adoptive parent of two absolutely fabulous children. These 
programs also prevent family separation. They facilitate 
deinstitutionalization. They strengthen the capacity of 
families and communities and governments to care for children.
    We've succeeded under these programs in moving literally 
thousands of children from institutional or orphanage settings 
into appropriate and protective families.
    It's equally important that we protect the world's children 
from violence and abuse, especially in situations when social 
order breaks down or in situations of natural disaster.
    Last year, we promoted some two dozen humanitarian 
assistance programs to address child protection for vulnerable 
children. We also are supporting the minimum standards for 
child protection in humanitarian action. And we've put together 
new policies and programs to fight the phenomenon of child 
marriage, child soldiers, and child labor exploitation.
    These challenges are daunting for us, and we're not 
satisfied with the results we've achieved. Dr. Boothby will 
describe for you our efforts to restructure and reinforce our 
work to create coherent and visible homes for children in 
adversity, our efforts to build better cooperation among 
agencies, and our efforts to strengthen oversight to ensure 
effective implementation of the action plan.

                           PREPARED STATEMENT

    We must come together as a whole of society to bring strong 
beginnings, put families first, and protect our children from 
violence and abuse. The next generation of world citizens 
deserves nothing less.
    Thank you.
    [The statement follows:]
              Prepared Statement of Hon. Donald Steinberg
                              introduction
    Chairman Leahy and Ranking Member Graham, members of the 
subcommittee, thank you for having me here today. Let me first take a 
moment to express my appreciation for your ongoing and steadfast 
support for foreign assistance and in support of children throughout 
the world.
    In his State of the Union Address, President Barack Obama 
reaffirmed America's commitment to global development. In an inspiring 
challenge, he said:

        ``We also know that progress in the most impoverished parts of 
        our world enriches us all. In many places, people live on 
        little more than a dollar a day. So the United States will join 
        with our allies to eradicate such extreme poverty in the next 
        two decades: by connecting more people to the global economy 
        and empowering women; by giving our young and brightest minds 
        new opportunities to serve and helping communities to feed, 
        power, and educate themselves; by saving the world's children 
        from preventable deaths; and by realizing the promise of an 
        AIDS-free generation.''

    If we are to achieve this objective, we know that healthy mothers 
and children are the key.
    United States Agency for International Development (USAID) makes 
critical contributions to the U.S. Government's work to aid children in 
adversity. Our work to help children to first survive, then thrive, is 
an important piece of the efforts being coordinated under the recently 
released U.S. Government Action Plan for Children in Adversity. The 
action plan represents the work of more than seven different agencies 
across the government--and is one of finest examples of interagency 
collaboration and coordination in recent years.
    USAID's Global Health programs focus on ensuring child survival and 
basic health. USAID's foreign disaster assistance program works to 
protect the health and welfare of children in disaster situations, an 
especially acute form of adversity. USAID's Displaced Children and 
Orphans Fund program prevents family separation, promotes family-based 
alternatives to institutional care for children, and reduces other 
protection risks for children through strengthening the capacities of 
families, communities and governments to care for children.
    Together, our global health, humanitarian and disaster assistance 
programs, along with our broader development efforts, directly 
contribute to achieving the principal objectives of the Action Plan for 
Children in Adversity: building strong beginnings, putting families 
first, and protecting children from violence, exploitation, and 
neglect.
                           strong beginnings
    The effort to strengthen our support for children in adversity 
begins by ensuring that all children live to celebrate their 5th 
birthday.
    Nearly 30 years ago, USAID and United Nations International 
Children's Emergency Fund (UNICEF), with the support of the U.S. 
Congress, launched a ``child survival revolution'' aimed at reducing 
the number of deaths among young children in developing countries. Back 
then, every year, almost 15 million children younger than the age 5 
died from common preventable diseases. Without action, that number 
today would be about 17 million. Instead, by 2011 it had dropped to 6.9 
million--still a shocking figure, but arguably the lowest level in my 
lifetime.
    Almost a year ago in June, the Governments of the United States, 
Ethiopia and India, in close cooperation with UNICEF, held a Child 
Survival Call to Action in Washington D.C. World leaders embraced the 
strategic shifts necessary to speed up progress in reducing preventable 
child deaths, including: increasing efforts in the countries where most 
deaths occur; focusing on vulnerable populations; investing in high-
impact solutions to address the main causes of mortality; and 
supporting a strong enabling environment for women, including education 
and empowerment.
    Since the Call to Action event, 172 countries have signed the A 
Promise Renewed pledge to accelerate declines in child deaths, with a 
goal of all countries having fewer than 20 deaths per 1,000 live births 
by 2035. More than 400 civil society and faith-based organizations and 
more than 2,000 individuals also pledged support. Each signature 
represents a renewed commitment to give every child the best possible 
start in life.
    Healthy children need healthy mothers. Global health programs are 
working to combat the majority of these preventable maternal deaths. We 
help women have children when her body is healthiest for pregnancy. We 
provide pregnant mothers with quality antenatal care and nutrition and 
with cost-effective interventions that target the preventable 
complications of pregnancy and birth.
    USAID has contributed to better care for childbearing women by 
training midwives as primary healthcare providers and introducing a 
results-based financing scheme to increase coverage of assisted 
deliveries throughout countries such as Afghanistan, and we are seeing 
much success. This is one reason why the average life expectancy for 
women has increased by 15 years in Afghanistan over the past decade. 
Ten years ago, Afghanistan's maternal mortality was estimated to be 
among the highest in the world. Despite years of conflict and 
insecurity, today 60 percent of women receive prenatal care (compared 
to 16 percent in 2003), one-third of women deliver with a skilled birth 
attendant, and the level of maternal mortality is approaching other 
countries in the region.
    Roughly 40 percent of all child deaths occur in the first month of 
life. Up to two-thirds of these deaths can be prevented through 
existing effective interventions delivered during pregnancy, childbirth 
and in the first hours, days and week after birth. USAID is developing 
and testing simple, low-cost approaches to prevent death and treat 
severe illness in newborns in low-resource settings with limited access 
to quality facility-based care.
    USAID's newborn health programs provide training and improve 
policies for delivering high-impact interventions like immediate and 
exclusive breastfeeding, warmth, clean cord care, resuscitation, and 
antibiotics. In Bangladesh, Nepal, Rwanda, and Malawi, USAID supports 
successful community-based newborn health programs that are linked to 
strengthened health facilities.
    USAID invests in vaccine research directed at major killers of 
children and research to develop innovative vaccine delivery models. To 
help end preventable child deaths from pneumonia and diarrhea, USAID is 
supporting the introduction of pneumococcal and rotavirus vaccines, to 
children most in need.
    Thanks to support from USAID and partners, more than 100 million 
children receive a set of basic immunizations each year, and tens of 
millions more receive supplemental immunizations against polio, 
measles, and other killer diseases.
    In the early 2000s in Kenya, a partnership between USAID and the 
Kenyan Ministry of Health addressed the needs of each district and 
focused on systems issues. Our support helped to increase immunization 
coverage from 76 percent in 2005 to nearly 88 percent in 2011.
    Investments in nutrition are some of the most powerful and cost-
effective in global development. Good nutrition during the critical 
1,000-day window from pregnancy to a child's second birthday is crucial 
to developing a child's cognitive capacity and physical growth. In some 
countries half of all children are chronically undernourished or 
``stunted''. I recently traveled to Guatemala and to Bangladesh, where 
such stunting levels for children younger than the age of 5 are 48 and 
43 percent, respectively.
    Undernutrition is an underlying killer of more than 2.6 million 
children and more than 100,000 mothers every year. Sustained poor 
nutrition weakens immune systems, making children and adults more 
likely to die of diarrhea or pneumonia. Ensuring a child receives 
adequate nutrition during this window can yield dividends for a 
lifetime. A well-nourished child will perform better in school, more 
effectively fight off disease and earn more as an adult.
    In 2012, USAID reached more than 12 million children younger than 
the age of 5 through nutrition programs such as micronutrient 
supplementation and food fortification, anemia reduction, and the 
treatment of acute malnutrition.
    The financial and technical contributions of the President's 
Malaria Initiative (PMI) are the major catalyst in the remarkable 
progress that has been achieved over the last 7 years. Of the 12 PMI 
focus countries (Angola, Ethiopia, Ghana, Kenya, Madagascar, Malawi, 
Mozambique, Rwanda, Senegal, Tanzania, Uganda, and Zambia), where 
baseline and followup health surveys with data on childhood mortality 
have been conducted, all-cause mortality rates among children younger 
than the age of 5 have dropped by 16 percent (in Malawi) to 50 percent 
(in Rwanda).
    Early childhood health and development links health and survival 
with the young child's cognitive, social/emotional, language, and motor 
development. The mix of effective, proven health interventions and 
stable and supportive caregiving helps break cycles of poverty and 
inequality. Over the last year, USAID, together with UNICEF, the 
Centers for Disease Control and Prevention, and National Institutes of 
Health has been undertaking an evidence review process on effective 
social and behavior change interventions to achieve child survival and 
development. We are hosting an evidence summit next month to report the 
findings on how best to promote child survival and development through 
population-level behavior change. These findings will inform an 
evidence-to-action strategy.
                         putting families first
    USAID supports programs to identify children who are separated from 
their families in crisis situations and care for them while their 
families are traced and until children can be reunited with their 
caregivers. USAID supports efforts like these in Mali, Democratic 
Republic of the Congo, and other crises situations. In the aftermath of 
the devastating earthquake in Haiti, we implemented emergency family 
tracing programs to reunite children with their parents. And this past 
year in the Horn of Africa, when the worst drought in 60 years sent 
tens of thousands of families fleeing, we helped establish a single 
database that multiple partners across different refugee camps could 
use to identify and reunite separated and unaccompanied children.
    To preserve families, USAID sets up safe, child-friendly spaces in 
internally displaced person camps, where children can receive on-site 
food and water and join classes and activities, and changes community 
attitudes about the stigma of rape through door-to-door outreach.
    The impacts of illness, conflict, poverty, and lack of access to 
basic services seriously undermine families' abilities to care for 
their children. For some children the result is family separation and 
their living outside of family care, whether on the streets or in 
institutions or in exploitive labor situations away from the protective 
care of families. These children face increased risks of violence, 
abuse, exploitation and insufficient access to the emotional and 
developmental support they need.
    USAID's Displaced Children and Orphans Fund (DCOF) provides 
financial and technical assistance to programs benefiting children in 
vulnerable households and outside of family care, including children 
living on the streets and in residential care, in more than 45 
countries.
    DCOF programs prevent family separation, promote family-based 
alternatives to institutional care for children, facilitate de-
institutionalization, and reduce other protection risks for children 
through strengthening the capacities of families, communities and 
governments to care for children. DCOF supports innovative programs 
that promote household economic strengthening with caregiving support, 
including education on child protection risks and prevention 
strategies. DCOF leverages its resources through a learning agenda 
aimed at influencing and improving the state-of-the-art in programming 
for children in adversity who lack adequate family care.
    Last year, DCOF support resulted in more than 3,000 children 
directly moved from institutional or orphanage settings into family-
based care alternatives. To strengthen child protection systems DCOF 
worked to help governments and civil society partners develop and apply 
relevant national child protection legislation and policies, strengthen 
coordination among key actors, develop information systems to identify 
and monitor children at risk, build social service workforce 
capacities, strengthen community capacities to identify vulnerable 
children and increase their access to protective interventions. In 
fiscal year 2012 more than 550 social workers or government child 
welfare staff was formally trained and thousands of parents received 
coaching and mentoring. In Belarus alone, 1,208 foster/adoptive parents 
from 45 local communities were trained in parenting skills and 216 
children were placed within these families.
    For USAID, strengthening families is a top priority--whether that 
means providing cash transfers in times of hardship or linking families 
to support networks.
    Nyepue Bondo is a widow and a mother of five children in Bong 
Country, Liberia and a participant in the DCOF-funded ``Agriculture for 
Children's Empowerment'' project. Before joining the project, Nyepue 
grew vegetables on a small scale. With inadequate farming skills the 
results of her work did not yield sufficient vegetables for her to sell 
and adequately support her family. The project trained her how to do 
nursery preparation, planting in line, weeding on time and how to keep 
farm records. After 1 year in the project, Nyepue generated $371 from 
vegetable sales. Part of her income was used to pay for her children's 
school expenses and to start a small dry goods business.
    In Burundi, we've developed a 3-year randomized impact evaluation 
to explore how village savings and loans associations and family 
counseling could reduce poverty and nurture families. Results from the 
mid-term evaluation are in--and it is already clear that these combined 
interventions led to a 20-percent increase in the amount the household 
spends--a key indicator of welfare. And cases of harsh discipline-like 
hitting a child with a stick--fell by 64 percent.
                          protecting children
    A 2011 report on global funding for child protection in 
humanitarian crises found that in 2009 the U.S. Government was the 
single largest donor for humanitarian child protection programming.
    In fiscal year 2012, USAID funded 26 humanitarian assistance 
programs to address child protection for especially vulnerable children 
in 10 countries affected by disasters and conflicts. USAID invests in 
innovative technologies and capacity building initiatives to facilitate 
rapid, high-quality responses for separated children, and other highly 
vulnerable girls and boys in the wake of conflict and disaster.
    USAID works with children remaining within family care in crises to 
support them, their families, and their communities with holistic 
assistance. For example, to rapidly restart education in crisis-
affected communities by providing school supplies and repairs to school 
buildings. We support safe recreational activities for children--places 
where they can play with their peers and be watched over by trained, 
caring adults or older children.
    To ensure children's survival when faced with life-threatening 
crises, USAID also supports maternal and child healthcare, nutrition 
supplements for malnourished children, clean water, sanitation, hygiene 
materials, shelter, food, and blankets.
    USAID supports the roll-out of the newly developed Minimum 
Standards for Child Protection in Humanitarian Action. These standards 
provide guidance for all types of humanitarian interventions on how to 
ensure that children's unique needs are met, and that they are 
protected from harm, exploitation, and abuse.
    Across the world today, 5.5 million children are engaged in forced 
labor. Roughly 300,000 children serve as soldiers for rebel and 
government forces. And disturbingly large numbers of children--150 
million girls and 73 million boys--have experienced rape or other forms 
of sexual violence.
    USAID is harnessing the power of science and technology and the 
creativity of problem-solvers everywhere to end the enduring outrage of 
human trafficking and prevent and respond to atrocities--whether it is 
a new mobile app to help locate children and reunite them with their 
family in a crisis or a new monitoring tool that helps governments 
remain accountable to their citizens.
                               conclusion
    In closing, for USAID, support to children in adversity starts with 
making sure they are planned and spaced, their mothers well-nourished, 
and they grow and flourish in the womb. It continues with saving their 
lives at birth, along with that of their mothers. And it goes on, 
making sure they are fed, kept warm, and protected from vaccine-
preventable diseases through vaccines, rehydrated from diarrhea, kept 
safe from mosquitos, and given the right care at the right time when 
they are sick.
    Finally, our support preserves families and protects children in 
crisis situations and ultimately contributes to the economic growth and 
development needed to create a future with many positive possibilities.
    This is the vision our programs strive for.
    I appreciate the opportunity to testify today and look forward to 
your questions.

    Senator Landrieu. Thank you so much, Dr. Steinberg.
    Dr. Ryan.
STATEMENT OF DR. CAROLINE RYAN, M.D., DEPUTY 
            COORDINATOR FOR TECHNICAL LEADERSHIP, 
            OFFICE OF THE U.S. GLOBAL AIDS COORDINATOR, 
            DEPARTMENT OF STATE
    Dr. Ryan. Chairman Leahy, Ranking Member Graham, Senator 
Landrieu, I thank you for the opportunity to appear before you 
to discuss the U.S. President's Emergency Plan for AIDS Relief 
and to highlight our essential work to support orphans and 
vulnerable children.
    On behalf of the entire PEPFAR family, we are profoundly 
grateful to Congress for its sustained investment in and 
support of our programs.
    In 2013, PEPFAR will celebrate 10 years of success. None of 
this would've been possible without the vision and leadership 
of President Bush, President Obama, and the bipartisan support 
of Congress.
    A decade ago, AIDS was wiping out an entire generation in 
Africa. Today, because of the efforts coordinated by Ambassador 
Eric Goosby at the Department of State and those of its many 
partners, we have brought the world to a new era, a time when 
new AIDS infections, HIV infections are on the decline, and 
AIDS deaths are also on decline. And an AIDS-free generation is 
both U.S. policy and a goal within our reach.
    As of October 2012, PEPFAR directly supported more than 5 
million people on antiretroviral treatment. That is a threefold 
increase in only 4 years. This means that more parents with HIV 
are staying alive. That's averting 1.6 million children from 
becoming orphans in 2012 alone.
    PEPFAR also supports ARV treatment to prevent mother-to-
child transmission to more than 750,000 pregnant women living 
with HIV, and directly supports 15 million people with care and 
support, which includes nearly 5 million OVCs.
    PEPFAR already supports and plays a critical role to 
contribute to the objectives of the recently released U.S. 
Government's Action Plan for Children in Adversity.
    Our 2012 OVC guidelines outline our strategic goals: one, 
strengthen families as primary caregivers of children; two, 
support the capacity of communities to create protective and 
caring environments; three, build capacity of social service 
systems to protect the most vulnerable; and four, integrate OVC 
programs into the broader PEPFAR platform and response.
    The impact of HIV and AIDS on children is absolutely 
devastating. It's estimated that there are 16 million children 
that have lost one or both of their parents due to AIDS, and 90 
percent of those live in to sub-Saharan Africa.
    Children can quickly move from being affected by HIV to 
becoming infected with HIV, and an estimated 3.4 million 
children under the age of 15 are now living with HIV.
    PEPFAR's comprehensive, integrated, evidence-based approach 
has had a transformative effect. While it's well-known that 
PEPFAR dedicates 10 percent of its country funding to orphan 
and vulnerable children programs, our OVC interventions gain 
from their integration across the broader PEPFAR platform.
    And family strengthening is a major priority for PEPFAR 
programs. We support family unity both with keeping families 
and caregivers healthy and alive to care for their children, 
and also through household economic strengthening. We also 
support parenting skills training, educational support, and 
early childhood interventions, such as preschools.
    For example, in Rwanda, the PEPFAR global community 
supports stability and resilience in the most vulnerable of 
families, those affected by HIV and AIDS and with OVCs. Since 
2009, this program has served over 62,000 households delivering 
a holistic package of services that are designed to build 
household resilience, including economic strengthening, food 
and security, nutrition, and formal educational assistance.
    PEPFAR also strengthens community and system responses to 
combat gender-based violence against children, including 
improved legislation and enforcement of child protection.
    Addressing all of these needs requires a strong child 
welfare system that facilitates access to services across 
sectors, including social protection through child grants, 
deinstitutionalization, foster care, local adoption procedures, 
and resources.
    PEPFAR has strengthened the capacity of partner countries 
to improve the leadership and governance of social service 
ministries, civil society organizations, faith-based 
organizations, and communities that support children.
    In South Africa, we have been supporting the Department of 
Social Welfare to hire 10,000 new children and youth care 
workers by 2017. These workers will protect children from 
exploitation and abuse, ensuring children remain in school, and 
referring for children for HIV testing. Thirty-six thousand 
children were referred for HIV testing in 2012 alone.
    Thank you again for the opportunity to testify before you, 
to share what PEPFAR is doing across the globe to bring 
children out of adversity and to create an AIDS-free 
generation.
    Congress's 10 years of bipartisan support and investment in 
PEPFAR's work has profoundly improved the lives of so many 
children and their families. This has only been possible 
because of PEPFAR's integrated approach, which strengthens 
access to medical care, support services at the family, 
community, and country level.

                           PREPARED STATEMENT

    While significant challenges remain, there is no doubt that 
millions of men, women, and children have a brighter, 
healthier, and more productive future thank to PEPFAR. This is 
truly a smart investment in our future.
    Thank you.
    [The statement follows:]
             Prepared Statement of Dr. Caroline Ryan, M.D.
    Chairman Leahy, Ranking Member Graham, Senator Landrieu and 
distinguished members of the subcommittee, thank you for the 
opportunity to appear before you to discuss the President's Emergency 
Plan for AIDS Relief (PEPFAR) and to highlight the lifesaving work we 
do each day, including our essential work to support orphans and 
vulnerable children.
                          pepfar introduction
    Let me begin by stating that on behalf of the entire PEPFAR family, 
we are profoundly grateful to Congress for its sustained investment in 
and support of our program. At the end of this month, PEPFAR will 
celebrate 10 years of success. None of this would have been possible 
without the vision and leadership of President Bush, President Obama, 
and the bipartisan support of Congress. A decade ago AIDS was wiping 
out an entire generation in Africa, stalling economic development, and 
leaving countries in poverty. Today, PEPFAR's efforts and those of its 
many partners have brought the world to a new era--a time when new HIV 
infections and AIDS-related deaths are on a steep decline and creating 
an AIDS-free generation is both U.S. policy and a goal within our 
reach.
    Through the resources appropriated to PEPFAR, as of September 30, 
2012, PEPFAR was directly supporting more than 5.1 million people on 
antiretroviral treatment--a three-fold increase in only 4 years. 
Moreover, in 2012 alone, PEPFAR provided antiretroviral drugs to 
prevent mother-to-child transmission of HIV to more than 750,000 
pregnant women living with HIV, which allowed approximately 230,000 
infants to be born without HIV; enabled more than 46.5 million people 
to receive testing and counseling, and directly supported nearly 15 
million people with care and support, including nearly 5 million 
orphans and vulnerable children (OVC).
    PEPFAR's efforts already play a critical role in contributing to 
many of the coordinated objectives of the recently released U.S. 
Government Action Plan for Children in Adversity, a Government-wide 
plan for vulnerable children.
                         children and hiv/aids
    While significant progress has been made through PEPFAR, our work 
is far from done. A central mission from the start of PEPFAR has been 
addressing the diverse, complex and critical needs of orphans and 
vulnerable children affected by the AIDS epidemic, and so we appreciate 
the opportunity to discuss the progress made and the challenges that 
remain in caring for this very special population. It is important to 
note that PEPFAR has a disease-specific mandate, serving many 
populations including orphans and vulnerable children. PEPFAR's role 
concerning OVCs is to mitigate the effect of the HIV epidemic on this 
population.
    The impact of HIV and AIDS on children is devastating. To date, an 
estimated 16 million children have lost one or both parents due to 
AIDS, 90 percent of whom live in sub-Saharan Africa. In addition, an 
estimated 3.4 million children under the age of 15 are living with HIV, 
and millions more children are made vulnerable due to chronically ill 
parents or the social and economic effects of living in communities 
with high HIV prevalence. These numbers clearly demonstrate how 
vulnerable children are to the social, emotional, economic, and 
environmental effects that HIV and AIDS has on families, communities, 
and countries.
    Experience shows us that children can quickly move from being 
affected by HIV to becoming infected with HIV, particularly if they 
lack the necessary services and support to address their complex needs. 
In addition, even when children are not living with HIV, social and 
economic conditions can impede their ability to lead healthy, 
productive lives.
                pepfar's impact on children in adversity
    PEPFAR's programs are first and foremost guided by evidence-based 
interventions that work. As the Institute of Medicine recently reported 
as part of its congressionally mandated evaluation of PEPFAR, ``With 
its explicit focus on orphans and vulnerable children, PEPFAR has 
elevated attention to and investment in meeting the needs of this 
population through programs and services that are informed by 
evidence.'' Building on nearly a decade of lessons learned, and 
rigorous evaluation of our programs, PEPFAR released new Guidance for 
Orphans and Vulnerable Children in 2012, which outlines sound 
interventions for children in adversity and specifically for children 
affected by HIV/AIDS. This guidance not only benefits our U.S. 
Government efforts but is a significant resource for vulnerable 
children's programming across the globe. Additionally, on World AIDS 
Day last year, PEPFAR released a blueprint that outlines a global path 
toward creating an AIDS-free generation, including key interventions 
necessary to aid children in adversity.
           pepfar's orphans and vulnerable children programs
    PEPFAR's comprehensive, integrated, results driven approach has had 
a transformative effect on vulnerable children. While it is well known 
that PEPFAR dedicates 10 percent of its country funding directly to 
Orphans and Vulnerable Children programs, the truth is that our cross-
cutting investments across our portfolio benefit children and families. 
PEPFAR`s interventions for vulnerable children gain from their 
integration across the broader PEPFAR platform and specifically support 
achieving an AIDS-free generation as well as general child well-being. 
In turn, the integrated goals of other portions of the HIV/AIDS 
response gain from the interventions to support child vulnerability.
    Broadly speaking PEPFAR has enabled access to healthcare where 
previously little or none existed and strengthened the capacity of 
partner country health systems to address a range of issues. Through 
PEPFAR, we have ensured that more parents with HIV/AIDS are staying 
alive, thus averting 1.6 million children from becoming orphans in 2012 
alone, expanding access to pediatric treatment, and ensuring that fewer 
children are being infected with HIV/AIDS through successful prevention 
of mother-to-child transmission (PMTCT).
    In addition to these meaningful contributions to the well-being of 
children, PEPFAR's 10 percent OVC set-aside strategically and 
comprehensively addresses the diverse support services that complement 
the entire PEPFAR portfolio, including family-strengthening education 
initiatives that keep children in school, and building the capacity of 
social service systems for children. These programs protect children 
from HIV/AIDS and other risks to their development and well-being, and 
work directly with families, communities, national social service 
systems, and governments to strengthen national capacity for OVC 
service delivery, as well as HIV treatment and prevention services.
                          family strengthening
    Family strengthening is a major priority of the PEPFAR program, and 
we have integrated large-scale programming that supports and keeps 
children in families whenever possible. Over the past decade, PEPFAR 
has worked hand-in-hand with partner countries to provide the physical, 
emotional, and social support that strengthens families and 
communities, and mitigates negative outcomes for children. PEPFAR is 
able to support family unity both through its work on keeping families 
and caregivers healthy and alive to care for their children, and also 
through extensive and evidence-based household economic strengthening 
interventions such as village savings and loans associations which have 
positive effects on the well-being of families and the children in 
their care. These programs prevent the separation of children from 
families due to the heavy economic burden placed by HIV.
    Globally, PEPFAR OVC programs have supported 9,000 Village Savings 
and Loans Associations in 15 countries. As a result of these efforts, 
approximately 720,000 children affected by AIDS are living in families 
with improved economic stability. And these groups are not only self-
sustaining after a few years, they are also self-generating, and do not 
require ongoing support from PEPFAR or any government to continue and 
even to expand their membership.
    PEPFAR programs also strengthen families to keep children within 
them, through parenting skills training, educational support and early 
childhood interventions that promote strong attachment and stimulation 
for the youngest children. Throughout the world PEPFAR-supported 
programs have created pre-school classrooms and home and community-
based programs for thousands of children.
                         systems strengthening
    PEPFAR programs also recognize that some children are already 
living outside of care and that all families made vulnerable by AIDS 
need support. Important progress toward better meeting the needs of 
vulnerable children are underway in many countries, including social 
protection through child grants, deinstitutionalization, and foster 
care. Within this, PEPFAR strengthens system and community responses to 
combat gender-based violence (GBV) against children, including efforts 
to improve legislation and enforcement for child protection. Addressing 
these needs requires strong child welfare systems that facilitate 
access to services across sectors.
    Therefore, in recent years, PEPFAR has focused its efforts not only 
on community-based responses for children but also on child welfare 
systems strengthening. In fact, PEPFAR has been a leader in 
spearheading such efforts globally. The needs of OVC and their families 
are complex, including health services, economic security, legal 
rights, education, child protection, and emotional support. When 
systems are strong and working then all of the services required for 
children in and outside of family care are typically in place.
    To strengthen social welfare systems, PEPFAR has prioritized 
strategies in 16 countries to improve the leadership and governance of 
social service ministries, civil society organizations, and communities 
that support children. This strengthening includes facilitating 
strategic planning and child protection responses, as well as 
supporting and training government and community leaders, and assisting 
in the development of policies, including OVC quality standards and 
local adoption procedures and resources.
    With PEPFAR support, 17 countries in sub-Saharan Africa have 
formulated national plans of action for vulnerable children. Through 
its implementing partners, PEPFAR also works with ministries and non-
governmental organizations (NGOs) to increase the number of social 
workers and expand their capacity in partner countries. In Uganda, for 
example, PEPFAR support has led to the training and accreditation of 
1,100 Community Development Officers and probation officers in child 
protection, who, in turn, provide services to 66,000 children.
    And in South Africa, with PEPFAR support, the Department of Social 
Welfare will hire 10,000 new child and youth care workers by 2017. 
These workers play a vital role in strengthening families to protect 
children from exploitation and abuse, ensuring children remain in 
school, and referring children for pediatric testing--36,000 of them in 
2012 alone.
                                closing
    Thank you again for the opportunity to testify before you to share 
the significant work that PEPFAR is doing across the globe to bring 
children out of adversity, and to create an AIDS-free generation. 
Congress' 10 years of robust and bipartisan investment in PEPFAR's work 
has profoundly improved the lives of so many children and their 
families. This has only been possible because of PEPFAR's integrated 
approach and the multifaceted nature of the interventions it supports, 
which strengthen access to medical care and support services at the 
family, community and country level. While significant challenges 
remain, there is no doubt that millions of men, women and children have 
a brighter, healthier, more productive future thanks to PEPFAR. This is 
truly a smart investment in our future.

    Senator Landrieu. Thank you very much.
    Dr. Bissell.
STATEMENT OF DR. SUSAN BISSELL, ASSOCIATE DIRECTOR AND 
            PROGRAMMES CHIEF CHILD PROTECTION, UNITED 
            NATIONS CHILDREN'S FUND
    [Note: In accordance with the rules governing the appearance of 
United Nations employees before parliamentary bodies, Susan Bissell of 
the United Nations Children's Fund (UNICEF) comes before the U.S. 
Senate Appropriations Committee's Subcommittee on State, Foreign 
Operations, and Related Programs as a UNICEF representative in her 
capacity as an official of the United Nations and as part of her 
official duties. She provides an informal, unsworn, oral briefing to 
the subcommittee on the topic of ``children in adversity'' and UNICEF's 
programming responses to that issue. UNICEF has agreed voluntarily to 
provide this briefing and she is pleased to offer a written copy of her 
remarks to the subcommittee to be included in the record of 
proceedings. Dr. Bissell is available to provide clarifications and 
additional comments related to her briefing and will be available to 
provide those either orally or at a later time in writing, subject to 
complying with her duties as an official of the United Nations. Nothing 
relating to the provision of this informal briefing shall be considered 
as a waiver, express or implied, of any of the privileges and 
immunities of the United Nations.]

    Dr. Bissell. Good morning, Senator Landrieu. Thank you very 
much for inviting UNICEF to brief you here on the role that we 
play globally in the protection of children.
    And if I may, before I get into the full remarks, I wanted 
to express particular thanks to the leadership of Senator Leahy 
on a particular area that this subcommittee has worked on, 
which is protecting children from the effects of landmines and 
explosive remnants of war, particularly relevant in our 
contemporary child protection work.
    We have ample examples of UNICEF and American Government 
collaboration in child protection, including in gender-based 
violence prevention, a pioneering public-private partnership 
we're involved right now with USAID, PEPFAR, and the CDC, where 
we are working on the prevention of violence against children 
and, in particular, sexual violence and girls.
    We also work together with the Displaced Children and 
Orphans Fund strengthening child protection systems and 
strengthening families to enable them to stay together. And we 
also have our collective efforts with the U.S. Government on 
the prevention of female genital mutilation and cutting, as 
well as child marriage, which Don has already mentioned.
    Madam Chairman, a key principle in our child protection 
work is universality, and, accordingly, we focus on children 
everywhere. We also realize that children do thrive best in 
loving and supporting families. An important principle in our 
work includes protecting all children in early, middle, and 
late childhood. We engage with specialists in early childhood 
education at primary and secondary education, health, and, 
importantly, with experts in adolescence and youth as well as 
gender.
    Prevention is the critical feature of all of our work. To 
wit, we do not want the 1 billion children living in countries 
affected by conflict to be its victims. And we're active in 
these countries that are affected by our armed conflict, 
preventing the recruitment of children as soldiers and 
integrating them into schools and communities, as well 
attempting to return them to their families.
    We're on the ground where children are displaced across 
borders and within countries, including where there are natural 
disasters.
    And we're slowly winning the fight together with partners 
against child labor, but the recent tragedies in Bangladesh and 
Cambodia are a stark reminder that not enough is being done. 
Preventing trafficking also preoccupies us and many of our 
partners.
    Madam Chairman, 220 million children younger than the age 
of 5 don't even have a birth certificate right now. A birth 
certificate is a basic form of protection of children. It also 
allows them access to health care, to education, and prevents 
them from being recruited, married early, recruited into labor.
    Technology, innovation, and political will are helping us 
to make sure that children are documented. Caste, class, faith, 
and ethnicity simply don't matter in this regard.
    We're using technology also for family tracing and 
reunification after floods and earthquakes.
    With an emphasis on prevention, we also know that we need 
to respond to those who experience violence, abuse, 
exploitation, and neglect. We have a child protection strategy 
that lays out some fundamental approaches, and there are two 
sort of pillars in that approach. The first is strengthening 
parts of what we call a child protection system.
    You've referred to that already in your comments, Caroline.
    Social Welfare, justice, labor, planning ministries 
together with health and education coming together to create an 
allied system that prevents violence, abuse, and exploitation, 
and social workers--a social worker workforce, such as we see a 
health workforce, is integral to the success of that system.
    But we know that even where we have strong child protection 
systems in place, there are aspects of social change and social 
norms that prevent, if we can put it that way, the protection 
of children. And to address social change and harmful social 
practices such child marriage and female genital mutilation and 
cutting, we engage with local leaders, the faith-based 
community, and others to whom the families and communities look 
for wisdom and guidance. Social change requires deep and 
sustained cooperation at local levels.
    Finally, our child protection efforts rely on good data. In 
times of conflict and, in particular, in countries and parties 
that are listed by the Security Council for having grave 
violations against children, of which there are 14 at present, 
we're a key party to what's called the monitoring and reporting 
mechanism wherein we are creating databases of the killing and 
maiming of children, sexual violence against children, 
recruitment and use by rebel groups, as well as armed forces.

                           PREPARED STATEMENT

    Madam Chairman, what can be more important than the 
protection of our children? We protect them to enable them to 
develop, to grow, to become active and productive citizens in 
safe families, safe communities, and societies. All of this 
protection comes at a cost. But to coin the phrase of some 
contemporary thinkers, the cost of inaction is simply too high.
    Thank you for inviting UNICEF to be here and for including 
our views in this very important hearing.
    [The statement follows:]
                Prepared Statement of Dr. Susan Bissell
    Mr. Chairman, Senator Landrieu, and members of the State, Foreign 
Operations, and Related Programs Subcommittee: It is a pleasure to 
appear before you today to brief you on the role that the United 
Nations Children's Fund (UNICEF) plays in the protection and care of 
children. Our efforts are guided by a Child Protection Strategy that 
was approved by our executive board in May 2008. We work on the 
protection of children, their well-being and development in all 
contexts, including in armed conflict and natural disaster. Our child 
protection teams are currently present in roughly 170 countries, 
spanning seven regions. We enjoy strong collaboration with and the 
support of the U.S. Government. One of our most important and 
successful interventions and partnership with the U.S. Government has 
been as a result of this subcommittee, and your leadership in 
protecting children and their families from landmines and other 
explosive remnants of war for decades. You have been working with 
UNICEF and many partners to provide mine risk education and to 
eradicate these lethal hazards once and for all.
    U.S. Government engagement has also been critical to gender-based 
violence prevention through programing at the field and global levels. 
This includes participating in the revision of the minimum standards 
for addressing gender-based violence in humanitarian contexts. It also 
includes supporting innovative approaches to addressing sexual violence 
prevention in conflict settings. Child protection in humanitarian 
settings has historically been an area of high-priority U.S. Government 
leadership.
    Another area of collaboration is a pioneering public/private 
partnership to address violence against children, with a focus on the 
prevention of sexual violence against girls, called Together for Girls. 
The U.S. Government has provided financing for the Together for Girls 
Secretariat, in addition to support provided via the Centers for 
Disease Control and Prevention. The President's Emergency Plan for AIDS 
Relief (PEPFAR), though the United States Agency for International 
Development (USAID), has also provided resources for survey work and 
implementation. The partnership has made important progress from a 
technical perspective with the joint development of a survey 
methodology or instrument that can be used at the global level and 
contributes to improved national data, the ability to compare data 
across countries and regions, and the consequent use of data to prevent 
and respond to violence against children.
    UNICEF is also grateful for the support provided from the Displaced 
Children and Orphan's Fund (DCOF) to strengthen child protection 
systems. Since 2009, DCOF funding supported activities in Liberia, 
Guatemala, Cambodia and Rwanda. In all countries, the work focused on 
developing a range of services to strengthen families to enable them to 
stay together.
    Finally, I would be remiss in not mentioning that the U.S. 
Government has been an active supporter of UNICEF efforts to address 
female genital mutilation and cutting (FGM/C) and child marriage. This 
work together has largely been in the form of national and global 
advocacy as well as financial support to some of UNICEF's key partners 
on the ground, in the global South.
    Mr. Chairman, a key principle in our child protection work is 
universality, and accordingly we focus on the protection of children 
everywhere, irrespective of the income status of the country in 
question. Our work in high-income countries relies on the important 
work of the national committee family, such as in the case of the U.S. 
Fund for UNICEF here in the United States.
    Realizing that children grow and thrive best in loving and 
supportive families, an important principle of our work includes 
protecting all children across the life course; that is, in early, 
middle, and late childhood. Additionally, we work inter-sectorally, 
including with specialists in early childhood education, in education, 
health, and importantly with experts in adolescents and youth, as well 
as in gender.
    The 2008 Child Protection Strategy necessitates that we privilege 
the prevention of violence, abuse, exploitation, and neglect. Indeed--
addressing violence is a growing imperative for us all. We do not want 
the 1 billion children living in countries affected by conflict to be 
its victims. It is for this reason that you will see UNICEF active in 
such countries, preventing the recruitment of children as soldiers, 
trying to integrate them in schools and communities or returning them 
to families. UNICEF is also active and on the ground where children are 
displaced across borders or within countries. Family preservation and 
reunification are critical to these efforts.
    Likewise, we want to reduce the numbers of children working in the 
worst possible conditions, in hazardous conditions in factories and 
diamond and coal mines. There are 115 million such children today. This 
is a lower number than we saw 10 years ago as we see the responses to 
our collaboration, but it is still unacceptably high. Add to that the 
approximately 220 million children under the age of 5 who do not have a 
birth certificate, and you quickly get a sense of our challenges to 
prevent recruitment of all types, including into marriage as a child. 
Thankfully, with the use of technology and thinking innovatively, we 
are striving to have every child, everywhere, documented.
    Eleven percent of women worldwide today, between the ages of 20 and 
24, report being married before the age of 15. All of these numbers--
including those children subjected to sexual violence--are staggering 
and I append them to this statement for your closer review.
    With that emphasis on prevention, we also know that we need to 
respond to those who experience the impact of violence, abuse, 
exploitation, and neglect. Our Child Protection Strategy lays out some 
fundamental approaches to that. First, we emphasize the strengthening 
of child protection systems, and allied systems--those that make the 
interventions and approaches of core protection actors more effective. 
This means working with ministries of social welfare, justice, labor 
and planning, together with health and education ministries. We here 
all know well that there is a dearth of social workers globally, and we 
also know that a strong social welfare workforce can make the 
difference between a family finding ways to cope in times of stress, 
and child abandonment. At the same time, where social workers are 
active alongside medical professionals trained in the counseling of 
parents with newborn children with disabilities, that child is less 
likely to be placed in an institution. Add to that a widespread system 
of social protection--support to families in the form of cash, free 
health care, and access to education--and we have a very good recipe 
for the protection of children and the preservation of family and 
community.
    The second fundamental approach of our strategy targets and 
supports processes of social change. In particular, in the face of 
child marriage, FGM/C and other social practices and violations of the 
rights of children, we work on social norms. This means we engage with 
local leaders, the faith-based community and others to whom families 
and communities look for wisdom and guidance. Changing social norms 
requires deep and sustained cooperation at the local level. Legal norms 
and processes of social change in terms of law reform are also 
important. This is an area where there has been considerable success. 
However, we know from more than two decades of child protection work 
that law reform is a necessary but not a sufficient condition for the 
lives of children and families to change, and to improve.
    Finally, our child protection efforts rely on good data. In times 
of the conflict, and in particular in countries and parties ``listed'' 
by the Security Council for committing grave violations against 
children, UNICEF is a key party to the establishment of the Monitoring 
and Reporting Mechanism. Based on that data, we are able to prepare 
action plans to prevent and respond to children's lived experiences, 
not to hypothetical understanding, anecdotes, or assumptions. Household 
data is critical to our work, however we know that the most 
marginalized and least protected children are out of households, on the 
streets, in institutions and otherwise ``hidden''. Any work that the 
international community can do to fill this gap is both urgent and 
important.
    Mr. Chairman, what can be more important than the protection of our 
children? We protect them to enable them to develop, to grow, and to 
become active and productive citizens of safe families, communities, 
and societies.
    Naturally, we strive to protect them in very early childhood from 
the neglect and associate toxic stress that has life-long consequences. 
In middle childhood, protection actors work hard to make sure children 
are safe in schools, not laboring, and are far from the reach of 
traffickers and exploiters.
    Thankfully, as global education data demonstrates, more children 
are protected from labor and are in schools than ever before. Late 
childhood years carry with them great resilience and promise, however 
concomitant vulnerability lends itself to gang violence, the afore-
mentioned child marriage, and even recruitment into armed groups.
    All of this protection comes at a cost, but to coin the phrase some 
contemporary thinkers, ``the cost of inaction'' is simply too high.
    Thank you for inviting UNICEF to be here, and for including our 
views in this important hearing.

                               Appendix 1

                ``Violence Against Children'' Statistics
Domestic Violence
  --Each year, between 133 million and 275 million children witness 
        episodes of violent behavior between their parents.\1\
  --Three in four children are disciplined by their parents in a 
        violent manner.\2\
Sexual Violence \3\
  --Approximately 20 percent of women and between 5 to 10 percent of 
        men report being sexually abused as a child.\4\
  --According to the World Health Organization (WHO), approximately 150 
        million girls and 73 million boys under age 18 experienced 
        sexual violence and exploitation in 2002, the most recent year 
        for which comprehensive data are available.\5\
  --In a number of countries with available data, large proportions of 
        adolescent girls aged 15-19 report having experienced sexual 
        violence, defined as forced sexual intercourse or the 
        performance of sexual acts against their will.\6\
  --The National Violence Against Children Surveys showed that among 
        women aged 18-24 years; nearly 38 percent in Swaziland,\7\ 27 
        percent in Tanzania \8\ and 32 percent in Zimbabwe \9\ reported 
        experiencing any sexual violence before the age of 18. About 1 
        in 9 men in Tanzania and 1 in 10 men in Zimbabwe experienced 
        the same.
---------------------------------------------------------------------------
    \1\ Estimates based on: UN Population Division Data for Global 
Population under 18 Years for 2000; Domestic Violence Studies from 1987 
to 2005; analysis conducted by the Secretariat of the United Nations 
Secretary-General's Study on Violence against Children (2006).
    \2\ Sources: UNICEF global databases, including data from the most 
recently available MICS, DHS, other nationally representative household 
surveys, 2005-2011. This estimate is based on data for 49 countries 
representing around one third of the world population of children.
    \3\ The data presented here are based on different definitions of 
sexual violence used in the various studies. Therefore, the data are 
not a comparison of prevalence across countries/regions but rather 
demonstrates that sexual violence is a pervasive global problem.
    \4\ WHO Child Maltreatment Fact Sheet, August 2010.
    \5\ UNICEF Progress for Children Report Card on Adolescents, April 
2012.
    \6\ UNICEF PFC Report Card on Adolescents, April 2012.
    \7\ UNICEF Swaziland and CDC. 2007. National Survey on Violence 
Against Children in Swaziland. Atlanta: CDC.
    \8\ UNICEF Tanzania, CDC, and Muhimbili University of Health and 
Allied Sciences. 2011. Violence Against Children in Tanzania: Findings 
from a National Survey 2009. Dar es Salaam, Tanzania. *Prevalence data 
may differ from the report due to additional analysis focusing on 18-24 
year olds.
    \9\ Zimbabwe National Statistics Agency (ZIMSTAT). 2012. National 
Baseline Survey on Life Experiences of Adolescents in Zimbabwe 2011: 
Preliminary Report.
---------------------------------------------------------------------------
  --A multi-country survey reveals that the prevalence of forced first 
        sex among adolescent girls younger than 15 years ranges between 
        11 percent and 48 percent globally.\10\
  --In a study conducted in six Central American cities, 3 to 10 
        percent of men aged 19-30 reported experiencing sexual abuse as 
        a child. Most men reported this abuse taking place when they 
        were between 4 and 9 years of age.\11\
  --Recent data from the U.S. show that 1 in 5 women has been raped--
        about 40 percent of those occurring before age 18.\12\
Armed Violence
  --An estimated 526,000 people die violently every year from, but only 
        55,000 of them lose their lives in conflict or as a result of 
        terrorism.\13\
  --In the 53 countries for the WHO European region, 15,000 young 
        people lose their lives each year to interpersonal or gang 
        violence, the third-leading cause of death among people aged 
        10-29 years old.\14\
  --For each young person killed, 20-40 more sustain injuries requiring 
        hospital treatment.\15\
Bullying
  --In numerous countries, large percentages of students aged 13-15; 
        boys in particular, report having been involved in physical 
        attacks or bullying within the last month. Bullying, whether 
        physical or emotional, typically takes place at school and 
        affects many adolescents.\16\
Child Marriage
  --Globally, almost 400 million women aged 20-49 (or 41 percent of the 
        total population of women of this age) were married or entered 
        into union while they were children (i.e., at less than 18 
        years old). Although the proportion of child brides has 
        generally decreased over the last 30 years, in some regions 
        child marriage is still common, even among the youngest 
        generations, and particularly in poor rural areas.\17\
  --Around 1 in 3 (or 70 million) of young women aged 20-24, worldwide, 
        were married as children, and around 11 percent (or 23 million) 
        entered into marriage or union before they reached 15 years of 
        age.\18\
---------------------------------------------------------------------------
    \10\ World Health Organization (WHO). 2005. WHO multi-country study 
on women's health and domestic violence against women. Geneva: WHO.
    \11\ Contreras J, et al. 2011. Sexual Violence in Latin America and 
the Caribbean: A Desk review. Pretoria: Sexual Violence Research 
Initiative.
    \12\ Black M, et al. 2011. The National Intimate Partner and Sexual 
Violence Survey: 2010 Summary Report. Atlanta: National Center for 
Injury Prevention and Control, CDC.
    \13\ Global Burden of Armed Violence: Lethal Encounter (2011). 
Geneva Declaration Secretariat. Published by Cambridge University 
Press.
    \14\ UNICEF PFC Report Card on Adolescents, April 2012.
    \15\ WHO Youth Violence Fact Sheet, 2011.
    \16\ UNICEF PFC Report Card on Adolescents, April 2012.
    \17\ UNICEF global databases, including data from the most recently 
available MICS, DHS, other nationally representative household surveys, 
2002-2011. This estimate is based on data for 105 countries 
representing 90 percent of the world population of women aged 20-49. 
The estimate was calculated using the 2011 figures for the number of 
women aged 20-49 years and prevalence of child marriage for the period 
2002-2011. This estimate does not include China and its population 
since data on child marriage is not available in UNICEF databases for 
this country.
    \18\ Idem.
---------------------------------------------------------------------------
Female Genital Mutilation/Cutting
  --More than 120 million girls and women have been cut in 29 countries 
        in Africa and the Middle East where FGM/C is concentrated, and 
        as many as 30 million young girls are at risk of being cut 
        before they reach their 15th birthday.\19\
Birth Registration
  --Only half of children under 5 years of age have had their birth 
        registered in the developing world.\20\
Sexual Exploitation & Recruitment & Hazardous Child Labor
  --Around the world millions of children, predominantly girls, are 
        exploited in prostitution and pornography, and thousands of 
        boys and girls are recruited into government armed forces and 
        rebel groups, placing them at heightened risk of physical, 
        psychological, and emotional violence (UNICEF).
  --An estimated 215 million children are involved in child labor, of 
        which 115 million are in hazardous work.\21\
---------------------------------------------------------------------------
    \19\ Sources: UNICEF global databases including data from the most 
recently available MICS, DHS, and other nationally representative 
household surveys (1997-2012) for the 29 countries where FGM/C is 
concentrated.
    \20\ Sources: UNICEF global databases, including data from the most 
recently available MICS, DHS, other nationally representative household 
surveys and vital registration systems, 2005-2011. This estimate is 
based on data for 113 countries representing around 90 percent of the 
world population of children under-5. This estimate does not include 
China and its population since data on birth registration is not 
available in UNICEF databases for this country.
    \21\ Children in Hazardous Work. What we know. What we need to do. 
International Labour Organization (ILO). 2011

    Senator Landrieu. Thank you very much.
    Dr. Boothby.
STATEMENT OF DR. NEIL BOOTHBY, PH.D., SPECIAL ADVISOR 
            AND THE SENIOR COORDINATOR FOR THE UNITED 
            STATES AGENCY FOR INTERNATIONAL DEVELOPMENT 
            ADMINISTRATOR ON CHILDREN IN ADVERSITY
    Dr. Boothby. Thank you, Senator Landrieu, for your 
leadership and, more importantly, for your heart.
    You've already outlined, essentially, what the U.S. Action 
Plan on Children in Adversity is. It's the first ever whole-of-
government strategic guidance for the U.S. Government 
international assistance for children.
    It's a requirement of Public Law 109-95. Seven U.S. 
agencies and departments have endorsed the action plan, which 
was cleared by OMB and launched at the White House on December 
19, 2012.
    The goal is simple: to achieve a world in which all 
children grow up within protective family care free from 
deprivation, exploitation, and danger. And as you've already 
noted, it has three core objectives.
    One we're referring to as strong beginnings. Now, most of 
us are familiar with the 6.9 million preventable deaths and the 
incredible effort that is underway to reduce that number. What 
we may not be as well aware of is 200 million children will 
fail to reach their full potential, their full developmental 
potential.
    And the reason we have to ensure that child development 
stays on a healthy track is because we know much more now than 
we did before about the consequences of it being off track. 
Adverse early experiences including unstable care giving, 
deprivation of love or stimulation or nutrition, and stresses 
associated with neglect and maltreatment greatly increase the 
likelihood of poor health outcomes across the entire life 
course.
    The evidence is compelling to expand the child survival 
agenda to encompass child development as well. We have science 
that now tells us this is imperative and our programs need to 
catch up with that science.
    The family care first objective is extremely important. We 
are wired neurologically, if not otherwise, into relationships. 
It's actually in our DNA. And we have seen babies in Goma, for 
example, in the aftermath of the genocide in Rwanda the summer 
of 1994. I was working there with a special envoy and watched 
babies die by the tens per day sitting on cots like loaves of 
bread with IVs in their veins being fed, being taken care of 
from a health and nutrition standpoint, and they were dying 
because they did not have that human interaction or contact. 
It's called failure to thrive.
    And we know from the Bucharest study, which Dr. Nelson has 
played an important part of, short of dying, children growing 
up in institutions can have IQs as low as 64 when the control 
group outside were up to 103. And if you don't get them out of 
that situation within the first 24 months, they never recover 
that intellectual capacity.
    So there's an urgent need to focus more firmly on this 
particular objective.
    And in my role as special advisor in Public Law 109-95, I 
will say, unequivocally, that this is a gap area to what is 
otherwise a very generous and robust response to these sets of 
issues.
    Protecting children from violence, exploitation, abuse is 
the third sort of pathway out of adversity. These three 
pathways focus on brain health and body health, making sure 
kids stay in families, and protecting them from violence--the 
three minimal investments in pathways out of adversity. This is 
what science would tell us.
    Between 133 million and 275 million children are estimated 
to witness domestic violence annually. One-hundred-fifty-
million girls and 73 million boys under the age of 18 
experience forced sexual intercourse or other forms of sexual 
violence in 1 year. And the percentage that is happening in 
schools is obscene, and it needs to be addressed.
    What I'd like to do is spend my last 50 seconds here 
talking about implementation. We have agreed in the action plan 
to focus on focus countries or priority countries. We're 
meeting weekly now to determine what those countries are.
    I'm going to use Rwanda as an example, illustrative only. 
If we were to look at approximately $21 million that's being 
spent in Rwanda by the United States Government in health and 
nutrition, and added a bit to that, we could transform that 
health platform into----
    Senator Landrieu. Take your time. I want you to explain 
this.
    Dr. Boothby. Okay.
    We could transform this already robust child survival, 
maternal health, reproductive health, nutrition platform into a 
strong beginnings initiative that would reduce by 40 percent 
developmental delays in 4 years. A modest investment.
    We are already funding, the Government of Rwanda is 
committed to deinstitutionalization, to getting kids out of 
orphanages into families. USAID is providing $3.2 million 
toward that effort. It requires a bit more. With a bit more, we 
could reduce, over 4 years, the percentage of children living 
outside of family care by 75 percent.
    The third area--let me just augment the second area.
    PEPFAR is a leader in the area of preventing family 
separation, and Caroline has made reference to this. It is a 
game-changer. It is a mega-force out here that occupies the 
space in a way that no other government agency or other 
government does, and I want to just make that really clear. 
They focus on prevention, for the most part.
    The part that's missing, really, is the 
deinstitutionalization, and the resource base there is not 
adequate.
    Protecting children from violence is an imperative. Just to 
mention a couple of agencies, CDC is going to be engaged in 
Rwanda with the Government to look at surveillance, to actually 
create a system where we can measure results. And our friends 
at the Department of Labor, DOL, are engaged in an initiative 
in Rwanda that will eliminate, and I love that word, eliminate 
exploit of child labor, eliminate children in the tea sector 
industry within 4 years.

                           PREPARED STATEMENT

    When we work together, when we combine, when we look at 
synergies and working together, we can accomplish a lot more 
than we're currently doing separately.
    Thank you.
    [The statement follows:]
             Prepared Statement of Dr. Neil Boothby, Ph.D.
    Thank you Chairman Leahy, Ranking Member Graham and members of the 
Senate Appropriations Subcommittee on State, Foreign Operations, and 
Related Programs, for the opportunity to speak with you today about the 
U.S. Government Action Plan on Children in Adversity. Thank you for 
your continued support for our efforts to make a difference in the 
lives of millions of children.
                                overview
    The U.S. Government Action Plan on Children in Adversity is the 
first-ever whole-of-government strategic guidance for U.S. Government 
international assistance for children. It is a requirement of Public 
Law 109-95. Seven U.S. Government agencies and departments have 
endorsed the Action Plan, which was cleared by the Office of Management 
and Budget (OMB) and launched at the White House on December 19, 2012.
    The Plan is grounded in evidence that shows a promising future 
belongs to those nations that invest wisely in their children, while 
failure to do so undermines social and economic progress. Child 
development is a cornerstone for all development, and it is central to 
U.S. development and diplomatic efforts. The Plan seeks to integrate 
internationally recognized, evidence-based good practices into all of 
its international assistance initiatives for the best interests of the 
child.
                                  goal
    The goal of the U.S. Government Action Plan on Children in 
Adversity is to achieve a world in which all children grow up within 
protective family care and free from deprivation, exploitation, and 
danger.
                          principal objectives
    The Plan is focused on coordinating programs throughout the U.S. 
Government to achieve three primary objectives. The first objective is 
to build strong beginnings. The U.S. Government will help ensure that 
children younger than the age 5 not only survive, but also thrive by 
supporting comprehensive programs that promote sound development of 
children through the integration of health, nutrition, and family 
support.
    The second objective is to put family care first. U.S. Government 
assistance will support and enable families to care for their children, 
prevent unnecessary family-child separation, and promote appropriate, 
protective and permanent family care.
    The third objective is to protect children. The U.S. Government 
will facilitate the efforts of national governments and partners to 
prevent, respond to, and protect children from violence, exploitation, 
abuse, and neglect.
                         supporting objectives
    In addition, the Plan highlights the importance of three supporting 
objectives and across the U.S. Government we are working to execute 
these objectives. The first supporting objective is to strengthen child 
welfare and protection systems. The U.S. Government will support 
partners to build and strengthen holistic and integrated models to 
promote the best interests of the child.
    The second supporting objective is to promote evidence-based 
policies and programs. The U.S. Government devotes resources to 
building and maintaining a strong evidence base on which future 
activities to reach and assist the most vulnerable children can be 
effectively planned and implemented. This evidence base will assist in 
the cost-effective utilization of program funds as well as the 
monitoring and evaluation of program effectiveness and long-term impact 
on children.
    The third and final supporting objective of the Plan is to 
integrate this Plan within U.S. Government departments and agencies. 
The U.S. Government will institutionalize and integrate the components 
of this Plan as reflected in its diplomatic, development, and 
humanitarian efforts overseas.
                          legislative mandate
    An interagency strategy is a requirement of Public Law 109-95: The 
Assistance for Orphans and Other Vulnerable Children in Developing 
Countries Act of 2005, which was signed into law to promote a 
comprehensive, coordinated, and effective response on the part of the 
U.S. Government to the world's most vulnerable children. In accordance 
with the legislative mandate, an interagency coordination strategy was 
developed in 2006. However, interagency partners agreed that the 
strategy required revision given the number of U.S. Government offices, 
departments and agencies involved in international assistance to 
vulnerable children that were not included in the 2006 strategy, the 
2006 strategy lacked clarity with regard to overarching guiding 
principles, goals, objectives and outcome indicators.
                               leadership
    The U.S. Agency for International Development (USAID) is the 
coordinating agency under Public Law 109-95 and the administrative home 
of the U.S. Government Special Advisor on Children in Adversity, a 
position mandated by Public Law 109-95 (see roles and responsibilities 
below). To better coordinate its efforts, USAID has recently 
established a Center of Excellence on Children in Adversity to bring 
together USAID's technical experts--abroad and in Washington--who are 
leading our response to the world's most vulnerable children.
    the architecture of u.s. government international assistance to 
                                children
    U.S. international assistance to children is substantial and 
channeled through more than 30 offices in seven U.S. Government 
departments and agencies--the Departments of Agriculture, Defense, 
Health and Human Services, Labor, and State; the U.S. Agency for 
International Development, and Peace Corps--in more than 100 countries.
    U.S. Government efforts to assist vulnerable girls and boys in low- 
and middle-income countries have focused on single vulnerability 
cohorts and categories--for example, children affected by HIV/AIDS, in 
emergencies, or in the worst forms of child labor, including those who 
have been trafficked. Although such efforts have produced substantial 
benefits, this diffused approach has sometimes resulted in a fragmented 
response.
    Before the U.S. Government Action Plan on Children in Adversity was 
released in December 2012, there had been no overarching policy or 
guidance for U.S. international assistance for children. Coordinated, 
multifaceted action can help ensure that children in adversity benefit 
fully from policies and services. With its significant investments in 
international development, the technical expertise and research 
capabilities embedded within key agencies, and diplomatic outreach, the 
U.S. Government is well positioned to lead and mobilize around a 
sensible and strategic global agenda for children in adversity.
                             the challenge
    The United States' sustained commitment through investments and 
partnerships has resulted in important initiatives that have increased 
the impact of foreign assistance in many key areas, including 
impressive gains in child survival. The Action Plan on Children in 
Adversity signals a strong commitment to providing the integrated 
assistance required to ensure that children not only survive, but 
thrive.
    While the Action Plan on Children in Adversity applies to U.S. 
Government assistance globally, it also identifies a more targeted 
starting point for coordination of these efforts: to achieve three core 
outcomes in at least six focus countries over a span of 5 years. In 
these countries, through U.S. Government collaboration with other 
government, international, private, faith-based, and academic partners, 
the Plan calls for significant reductions in the number of children not 
meeting age-appropriate growth and developmental milestones, children 
living outside of family, and children who experience violence or 
exploitation.
                            focus countries
    The vision for focus countries is proof of concept: ensuring that 
U.S. Government assistance is coordinated and effective at the country 
level by focusing on the Action Plan's three core outcomes over a span 
of 5 years. In essence, focus countries are ``laboratories'' to see if 
we can achieve, scale up, and sustain greater results for children 
through a defined (3 outcomes) and comprehensive (whole-of-government) 
approach. A focus on outcomes, measurement and results reporting are 
Action Plan and Public Law 109-95 requirements.
    Designation will be based on consultations with the Congress, U.S. 
departments and agencies, partner donor governments, and other 
stakeholders. To promote country ownership and ensure meaningful 
engagement in the additional and intensive effort required for 
transformational positive change in children's lives, host country 
governments will fully be part of discussions, planning, and 
negotiations from the outset.
                          implementation plans
    In accordance with the Action Plan agency--and Department-specific 
implementation plans are due within 180 days of the Plan's launch (June 
20, 2013). These plans specify how each U.S. Government entity that 
signed onto the Plan will work to achieve its objectives. The 
consolidated plans will be included as a web-based appendix in the 
annual report to Congress on Public Law 109-95, also due at the end of 
June.
                     measurement and accountability
    In accordance with the legislative requirements set forth in Public 
Law 109-95: Section 3(e)(2), the Special Advisor will coordinate U.S. 
Government assistance to vulnerable children, establish priorities that 
promote the delivery of assistance to the most vulnerable populations, 
and measure the effectiveness of this assistance by administering a 
whole-of-government monitoring and evaluation system.
    ``The monitoring and evaluation system shall--
  --(A) establish performance goals for the assistance and expresses 
        such goals in an objective and quantifiable form, to the extent 
        feasible;
  --(B) establish performance indicators to be used in measuring or 
        assessing the achievement of the performance goals described in 
        subparagraph (A); and
  --(C) provide a basis for recommendations for adjustments to the 
        assistance to enhance the impact of assistance.''
                               conclusion
    I am excited about the potential for gains in assisting children in 
adversity and humbled by the challenges we face. I look forward to 
continued partnership with my colleagues throughout the U.S. 
Government, and with the subcommittee and Congress more generally, to 
harness our U.S. foreign assistance investments to meet the worthy aims 
of the Action Plan.

                     U.S. ACTION PLAN FOR CHILDREN

    Senator Landrieu. Thank you so much, Dr. Boothby.
    I'm going to have a line of questioning, because I think 
this is some of the most important testimony this subcommittee 
will receive is the game-changing possibilities of getting 
other U.S. agencies involved in meeting the objectives, so 
beautifully stated by other members that testified, but really 
impossible to do without a more unified and comprehensive and 
coordinated approach. So thank you very much.
    Let me start with Administrator Steinberg. On December 19, 
2012, the U.S. Action Plan for Children was launched at the 
White House, as you know. This effort represents the first time 
which appropriate and permanent family care has been explicitly 
set forth as a core objective of U.S. foreign assistance 
policy.
    Objective one of the plan calls for strong beginnings. I 
was pleased to see the maternal and child health account in 
this committee grow from $680 million, 12 percent up from 2012. 
However, action plans two and three, which call for family for 
every child, with a particular focus on getting children out of 
institutions and into families and protection for children--and 
again, to underscore, the best protection any child could have 
is not a government, not an army, not the navy, not the air 
force, but in the loving arms of a supportive and nurturing 
family.
    What are we going to do or how can the action plan present 
a coordinated approach of key accounts used for the 
collaboration for the second and third? The vulnerable children 
account fell from $13 million, 26 percent below fiscal year 
2000.
    And so, how are we going to meet objectives two and three 
with $13 million? And, if there is more, please testify to 
where it is in the USAID budget, what additional divisions and 
what other funds are specifically responsible for focusing on 
objectives two and three.
    Mr. Steinberg. Madam Chairman, indeed the $13 million that 
Congress has appropriated to us for the DCOF program is an 
important element in addressing objectives two and three. But 
it's only a tip of the iceberg.
    We have to expand our assistance under our global health 
initiatives. We effectively use, at USAID, much of the funding 
that Dr. Ryan was referring to. We implement a wide variety of 
funds under that initiative. We have also made resources 
available to objective two and three in support of Dr. 
Boothby's efforts from the administrator's initiative fund, 
which is a special fund that he has available to address----
    Senator Landrieu. And how much is that fund?
    Mr. Steinberg. That fund is $5 million, and we are in the 
process of trying to determine exactly how much of that funding 
for next year we will provide in this space. And the 
information you're providing in this hearing is going to be 
very useful for that.
    In addition, however, we have a very important element in 
terms of mainstreaming and integration of these principles into 
our broader programming. And so as we look at our program for 
Feed the Future and for climate change and democracy and 
governance, we have done trainings for our staffs. I've 
participated in a half dozen of those trainings, where we 
highlight the need for family orientation, we highlight the 
need to prevent violence against children, and we ensure that 
there is indeed mainstreaming in that area.
    The third area that we're working in is partnerships. And 
Dr. Boothby can describe these much more carefully, but we are 
working with nongovernmental organizations, we're working with 
foundations, with private businesses and with other donors to 
create international partnerships that can dramatically expand 
the funding that's available.
    We realize in the U.S. Government that no agency has a 
monopoly on financial resources or ground truth or good ideas 
or moral authority.
    And I'd like to leave it to Dr. Boothby, who has been the 
key in putting those partnerships together, to describe those.
    Senator Landrieu. Okay, I will call on him in a minute, but 
let me understand clearly for the record a couple of things.
    In your view, is it true that the Action Plan for Children 
in Adversity is the first time the U.S. Government has set 
forth a whole-of-government, outcome-focused strategy to help 
better align our foreign assistance resources for vulnerable 
children in the world? Would you say yes or no?
    Mr. Steinberg. Yes.
    Senator Landrieu. If so, could you state again, as 
succinctly and clearly, how USAID is positioned to lead and 
oversee the level of interagency cooperation that is now 
necessary under this plan? And what resources do you have to do 
that?
    Mr. Steinberg. Well, the first thing that we did was to set 
up Dr. Boothby and the office as a full-fledged center, so he 
now has a Center of Excellence. We have staffed that with a 
wide variety of individuals. We have identified within each of 
our other bureaus individuals to work with him to ensure that 
the multitude of USAID programs are indeed dedicated to the 
initiatives that he has identified.
    By June 20, we have committed to put together the plan to 
implement for USAID the programs that we've been discussing, 
including the identification of six target countries. I, 
myself, have traveled around the world and talked with mission 
directors to encourage them to be the sponsors of this program 
in their countries.
    I would be the first to acknowledge that we have a long way 
to go. The program has only been in place for about a year, 
building on the great work that Gary Newton had previously done 
as the coordinator. But this, indeed, is the first time we've 
brought together the whole variety of U.S. Government programs.
    We did, in our report to you, 109-95, identify the 
literally 1,500 projects that are being conducted by the U.S. 
Government and, in particular, by PEPFAR and USAID in support 
of the objectives you've identified.
    Senator Landrieu. And that's exciting to have 1,500 
projects that we've identified, but to have $5 million to 
coordinate them is, I think, the gap that Dr. Boothby and 
others are concerned about.
    Let me ask you this question, Dr. Boothby, to follow up on 
what Administrator Steinberg said, and I want to commend you 
all for a close working relationship and really appreciate the 
team effort that you all are making here.
    As you are aware, because you run this, the Public Law 109-
95 passed in 2005. It required USAID specifically to establish 
a special advisor on orphans and vulnerable children, develop 
an interagency strategy for more comprehensive, coordinated, 
and effective response on behalf of U.S. Government to the 
world's most vulnerable children, thinking about AIDS orphans 
actually.
    Is it correct that the Action Plan for Children in 
Adversity grew out of a shared desire to improve upon the 2006 
coordination strategy, which focused almost exclusively on 
programming for children affected by HIV, which did not include 
input from critical departments, which lacked some clarity with 
regard to goals, objective, and outcome indicators?
    Would you say that that's a fairly correct description of 
the first law and the need to upgrade it? Or what would your 
views of that be?
    Dr. Boothby. Thank you. I think it is fair to say that 
since 2005, the world has evolved and the U.S. Government's 
response for these issues have evolved, and there are more 
actors and more parts in play.
    I think it is fair to say that the original strategy was 
very HIV/AIDS-centric and really encouraged, if I understand 
the history correctly, by our HIV/AIDS colleagues to expand out 
to include other issues.
    And so the U.S. action plan is an effort to put together a 
framework and to focus on three core objectives and to begin 
doing these three objectives in five or six priority countries 
over the course of 4 or 5 years. By focusing and moving 
towards--the concept we're trying to prove is by doing this in 
countries and combining resources and colocating resources that 
the mandate, the law, Public Law 109-95, will actually be 
realized at the country level.
    Senator Landrieu. Thank you.
    Dr. Steinberg, let me ask you this, and then I'm going to 
move on to some other questions to other panelists. You've 
identified the resources, which are very slim. I think you said 
$5 million. Do you need additional authorities in order to 
accomplish what Dr. Boothby is saying? Or is it really just a 
matter of resources and organization? How would you clarify or 
testify to this?
    Mr. Steinberg. I would say it's primarily a question of 
resources. I think with the leadership that Dr. Boothby is 
providing, with the strong support of Administrator Shah, with, 
frankly, my own personal engagement in trying to achieve these 
objectives, I think that will is there. I think the 
intellectual brainpower is there. I think you and other 
Senators have provided us, along with House Members, the 
attention that we need.
    But indeed, I think this is a question. We're in a period 
of constrained resources, and we have some tough decisions to 
make.

                            AID FOR ORPHANS

    Senator Landrieu. Okay, let me ask Dr. Ryan, in 2012, 10 
percent orphans and vulnerable children set-aside in PEPFAR 
totaled of $330 million. As you know, PEPFAR, as Dr. Boothby 
said and we all recognize, is the largest single investment 
made for health in the world. And we're very, very proud of 
what we've done there. But some of us had thought that setting 
aside 10 percent focused on orphans and vulnerable children of 
$330 million might be a good start to help focus the need for 
single and double orphans to find families, if the original 
family wasn't able to be kept alive.
    What percentage of the 10 percent set-aside today is used 
to fund programs that are not health-related, that provide 
assistance specifically to orphans and children that find 
themselves without a family having perished from the disease?
    Dr. Ryan. Thank you, Senator, for your question. It's a 
very important one, and I look forward to perhaps giving you 
more detail.
    But the majority of the programs that are under that 10 
percent are not health-related, because the guidance to our 
countries is that any care for pediatric care, any drugs, would 
not come out of that budget code. So it really is for social 
service support. We see it as the community level support.
    It also is for things such as deinstitutionalization, like 
in PEPFAR where the government asked us to train social workers 
so they could process placement and permanency, and also 
support community service organization, FBOs, to identify 
adopting families and provide family follow-up.
    We've been very careful about making sure that that did not 
become a pediatric AIDS resource, especially in the limited 
environment we all are in. And we fought very hard to keep 
that. It really is, in our program, a very strong part of our 
continuum of care and supports the community response.
    Senator Landrieu. Okay, I think it would be very helpful to 
this subcommittee to have some real detail about the $330 
million that's been approximately that amount in the budget 
over the last several years, about how many new families, both 
domestic and international, were found for double orphans; what 
the most likely outcome is for single orphans, et cetera, et 
cetera; in some specificity, because I think this subcommittee 
and I are having a little difficult time sorting through some 
of that data, because this could be a resource solution here. 
$330 million is a lot more than $5 million.
    And while your program is specifically focused on children 
affected by AIDS, as Dr. Boothby said before, and I've heard 
him, and I've said it, I mean, this disease produces orphans at 
a greater rate than almost anything in the world.
    And so while it's not the only subset of orphans, it's a 
big subset. It's probably the largest subset of orphans, 
perhaps. It's going to be interesting to get this data.
    But if you could submit that to the subcommittee, and I'm 
glad to know that you recognize it as not just another health 
account but as a specific response for those children orphaned 
by AIDS or likely to be orphaned by AIDS to try to find them a 
permanent family.
    Dr. Ryan. I'd be happy to submit that.

                        PRIORITIES WITHIN PEPFAR

    Senator Landrieu. It's very, very good to know.
    So how much would you say is focused on finding permanent 
family care for children? Would you say that $330 or a big 
percentage or half? Or what would you say?
    Dr. Ryan. I would prefer to give you a more detailed 
answer, so we will submit that to you.
    Senator Landrieu. Okay, that would be great.
    Let me ask again here, over the past decade, PEPFAR has 
worked hand-in-hand with partner countries to provide the 
physical, emotional, and social support that strengthens 
families and communities, and mitigate negative outcomes for 
children, including robust efforts to prevent mother-to-child 
transmission of HIV, and expand access to pediatric HIV 
treatment.
    To what extent do you see programs funded by the 10 percent 
set-aside being aligned with the goals of two and three? I 
think this is a repeat of a question, but basically, can we 
take away from this hearing that the $330 is really focused on 
goals two and three of the Children in Adversity plan?
    Dr. Ryan. I would say that there is putting families first 
and protecting children against violence, since we have been 
supporting the majority of violence against children programs, 
and then working with partner countries to get a plan at the 
country level for response.
    We do support the strong beginnings to an early childhood 
development, and we have programs in Zimbabwe, Kenya, Malawi, 
and South Africa that have led to the establishment of 
thousands of new pre-school classes for young children. And 
what we're trying to do is also integrate attachment and 
stimulation into PMTCT and pediatric programs. So it's a very 
good venue.
    But I do agree that that is an emerging part of the 
program, so there probably is more investment in objectives two 
and three. But as I said, we can provide additional detail to 
the record.

                      EFFECTS ON CHILD DEVELOPMENT

    Senator Landrieu. And, Dr. Boothby, we'll have more 
testimony on the second panel, which we're going to move to in 
just a minute, but why don't you just mention sort of the, and 
reinstate again, the latest findings about attachment, that 
it's attachment to one or two particular adults, not attachment 
to multiple adults, and the difference between that, as we're 
trying to build some of these programs? I mean, what is the 
difference, in your mind, between a child's attachment to one 
caring adult or 20 caring adults?
    Dr. Boothby. Well, again, I think that Dr. Nelson will 
probably speak to this, so I'll be brief. But essentially, the 
last trimester of pregnancy and the first couple years of life, 
first 24 months, is a critical time in terms of cognitive 
development, brain development. And we think about nature and 
nurture, it's both. It's a combination.
    As children's brains are growing, the experiences that they 
receive or the experiences that they're deprived of become part 
of their DNA. It actually gets in. It's what the epigenetic 
signature is, in a sense.
    And if you don't get that stuff early, and I think this is 
what the Bucharest study shows us, it wasn't that the orphanage 
couldn't feed children. It wasn't that they weren't getting 
healthcare. It's they were getting inadequate social 
stimulation.
    And the only constellation of human relationships that 
we've found in the world that does this on a regular basis is 
the family. And it can be extended; it can be nuclear. But at 
heart, whether it's an aunt, an uncle, a grandmother, a mother, 
a father, having that person in a child's life, that when she 
cries, she's held; when her diapers or the equivalent thereof 
are wet, she's changed; when she's hungry, she's fed; that 
becomes part of who we are. And we are wired for human 
connections.
    It's an area that we need to pay much more attention to.

                         UNICEF CHILD PROGRAMS

    Senator Landrieu. Thank you.
    Dr. Bissell, let me ask, UNICEF is recognized as a world 
leader in ensuring the survival and development of every child. 
Last year, our Government, the U.S. Government, contributed 
about $132 million in direct support to UNICEF, as well as 
millions of other dollars for country-specific grants. Can you 
tell me what portion of the money that we send from this 
subcommittee to UNICEF was dedicated to programs specifically 
promoting permanent family care for children? Any idea?
    Dr. Bissell. UNICEF's child protection work, broadly, 
receives 10 percent of UNICEF's overall funding, so that 
allocation that you described goes into what are called regular 
resources, which then get dispersed through all----
    Senator Landrieu. But child protection work is much broader 
than children and families, right?
    Dr. Bissell. Right.
    Senator Landrieu. So it would be less than 10 percent?
    Dr. Bissell. Absolutely, less than 10 percent.
    Senator Landrieu. What portion of the 10 percent do you 
think it would be dedicated to finding permanent families for 
children?
    Dr. Bissell. I wouldn't have that data.
    Senator Landrieu. Okay, if you could try to get us that 
data, I think it would be important. Do you know what portion 
of UNICEF funding is dedicated to preventing abandonment?
    Dr. Bissell. The way the budgets are determined, it would 
be under a broad category of child protection programming, 
which is, as you probably know, the budgets are done on a 
country-by-country basis, so it would be possible to aggregate 
the programs that are specifically dedicated to the system-
strengthening work and aspects of interaction with families.
    Senator Landrieu. So you're testifying, which is a little 
concerning to me and I think would be concerning to other 
members, but it is what it is, and I appreciate you being so 
clear, that there is really no way to track how much money of 
UNICEF's budget is either going to preventing abandonment, 
going to reunification of family care, or going to find 
domestic adoptive families or kinship adoption or intercountry 
adoption?
    Dr. Bissell. Well, first, I'm not testifying. I'm briefing, 
just for the record.
    And I am saying that it is possible to disaggregate our 
budgets to determine which parts of our child protection 
program, for instance, are addressing child soldiers or 
humanitarian, and those that are addressing child protection 
system strengthening, which would speak to your point.
    Senator Landrieu. Well, I'm going to ask for UNICEF to 
provide some detail to this subcommittee, because I think it's 
important for the subcommittee to look at it through the lens 
of how UNICEF's budget is either supporting or currently 
organized to support this Children in Adversity plan based on 
the three goals.
    [The information follows:]

    The following are estimates of approximate expenditures in calendar 
year 2012 in the following three principal objectives areas of the U.S. 
Action Plan:
  --Build strong beginnings: helping children under five survive and 
        thrive;
  --Put family care first: supporting and enabling families to care for 
        their children, prevent unnecessary separation, and promote 
        appropriate, protective, and permanent family care; and
  --Protect children: work with national governments and partners to 
        prevent, respond to, and protect children from violence, 
        exploitation, abuse, and neglect.
                       1. build strong beginnings
    More than half of UNICEF's program funding in 2012 supported Young 
Child Survival and Development programs, totaling $1.57 billion. These 
programs focus on sectors critical to the health and well-being of 
young children and their mothers, including improving child nutrition, 
improving child and maternal health through increased coverage of 
integrated packages of services, and increasing access to and 
sustainable use of improved water sources and sanitation facilities. 
This amount includes funding for humanitarian crises to help ensure 
that every child is covered with life-saving interventions.
    In addition, UNICEF has increased its support for family care 
practices and early childhood development (ECD) in recent years, to 
help children develop appropriately and be ready to succeed in school. 
In 2012, UNICEF provided $55 million for ECD policy and programming 
activities.
    Finally, UNICEF's work to build strong beginnings for children 
includes children threatened by HIV. UNICEF spent $52.5 million to 
prevent mother-to-child transmission of HIV, to help ensure treatment 
for children with AIDS, and to help build government capacity to assist 
children orphaned or made vulnerable by HIV/AIDS.
    Examples of UNICEF's work to ``build strong beginnings'' include:
  --Malnutrition contributes to nearly half of all child deaths; it can 
        cause stunting that affects a child's physical and cognitive 
        development. In 2012, UNICEF procured 29,000 tons of 
        therapeutic foods to treat 2.1 million severely malnourished 
        children, and 271 million sachets of micronutrient powder to 
        boost children's diets, that reached 12 million young children 
        in more than 30 countries.
  --Immunizations are critical to child survival and well-being. For 
        more than 50 years, UNICEF has been a world leader in 
        immunizations. In 2012, UNICEF supplied 1.9 billion vaccine 
        doses for 96 countries, and procured half a billion 
        immunization syringes. UNICEF is responsible for procuring 
        vaccines for the GAVI Alliance; and also buys all vaccines and 
        related items for global campaigns not covered by GAVI, 
        including polio eradication, elimination of neonatal and 
        maternal tetanus, and measles control. In addition, UNICEF 
        works in-country to ensure that vaccines safely reach even the 
        poorest children and communities.
  --UNICEF provided research and guidance to inform the PEPFAR strategy 
        for orphans and vulnerable children, launched in 2012. This 
        strategy places strong emphasis on strengthening child 
        protection systems for children affected by HIV and AIDS, to 
        keep HIV-affected children in family-based care, protect 
        orphans and vulnerable children from abuse and neglect, and 
        ensure that children affected by AIDS can access basic 
        services.
  --Malaria is still a major killer of children under 5 years old. 
        UNICEF is one of the largest buyers of mosquito nets in the 
        world, delivering 18.5 million bed-nets to 39 countries in 
        2012; as well as 18.1 million malaria rapid diagnostic test 
        kits.
  --Maternal and neonatal tetanus (MNT) is still endemic in 28 
        countries, and kills a baby every nine minutes. MNT is easily 
        preventable by immunizing women against tetanus, which also 
        protects newborn babies; and with hygienic birth practices and 
        cord care. UNICEF is partnering with Kiwanis International to 
        eliminate maternal and neonatal tetanus by immunizing 100 
        million women and their future babies.
                        2. put family care first
    UNICEF believes that a family is the best place to raise a child, 
and works with governments to build and strengthen systems to support 
families, promote parental care, prevent separation of families, and 
end institutionalization of children. UNICEF further believes that 
children's well-being begins at home. The practices of a caregiver are 
intimately connected to the relationship between children and the 
adults in their lives, and are crucial to children's survival and well-
being. Within its basic education and gender equality portfolio, UNICEF 
provided $55 million for early childhood development activities, 
including programs to help parents provide structured play and other 
stimulation activities at home, with resources through radio programs, 
access to training in designated centers, and access to appropriate 
equipment and materials.
    In relation to family separation, UNICEF's work is informed by the 
Guidelines for the Alternative Care of Children,\1\ adopted by the UN 
General Assembly in 2009, which stipulate that a child should only be 
separated from their family if necessary, and then a placement should 
be found that best addresses the individual child's needs and best 
interests. Kinship care, foster care, other forms of family-based or 
family-like care, and inter-country adoption are among the range of 
appropriate, stable care options. UNICEF does not play a role in the 
placement of children in foster or adoptive families. Rather, its work 
and funding address overall systems and issues affecting children in 
adverse circumstances, such as orphans or children otherwise separated 
from their families (e.g. in emergencies, or due to poverty or abuse), 
in order to address policy, legislative, service delivery and budget 
issues and social norms that can lead to the unnecessary separation of 
children from their families. In extreme circumstances, UNICEF 
negotiates directly with armed forces to rescue child soldiers and help 
them return to their families and communities, and supports family 
reunification services after disasters for unaccompanied children.
---------------------------------------------------------------------------
    \1\ http://www.unicef.org/protection/alternative_care_Guidelines-
English.pdf
---------------------------------------------------------------------------
    In 2012, UNICEF spent nearly $208 million on its work to improve 
child protection systems. In addition, UNICEF spent $60 million on 
promoting policy and advocacy engagement with governments, focused on 
strengthening budgets, policies, and social protection systems to 
protect children and families.
    Helping governments build appropriate policies and systems to 
support families requires a solid understanding of the challenges and 
disparities that families face. UNICEF is a global leader in developing 
new approaches to analyze child poverty and deprivation, focused on 
identifying the most vulnerable communities and populations, including 
children with disabilities. In 2012, UNICEF invested $65 million in 
such research and policy analysis.
    Examples of UNICEF's work to support families include:
  --In 2012, UNICEF's support to protection programs resulted in the 
        reintegration of 5,300 children associated with armed forces or 
        groups into their families and communities; and the 
        reunification of nearly 20,000 unaccompanied and separated 
        children with their family members.
  --UNICEF supported the continuing development of child protection 
        systems in more than 122 countries during 2012, including 
        supporting 82 countries to improve their birth registration 
        rates, 51 countries to improve their alternative care systems, 
        53 on addressing trafficking and migration issues, and 94 on 
        strengthening justice for children.
  --UNICEF has supported the development of a Rapid Family Tracing and 
        Reunification application. It serves as a versatile open-source 
        mobile phone application and data storage system that expedites 
        the collection, sorting and sharing of information about 
        unaccompanied and separated children in emergency situations.
  --In 2011, UNICEF launched a regional campaign in Central and Eastern 
        Europe and the Commonwealth of Independent States (CEE/CIS) to 
        end the placement of children under age 3 in institutions, with 
        positive responses from many countries in the region.
  --UNICEF worked in 113 countries on various aspects relating to 
        alternative care, with 51 countries focusing specific efforts 
        to strengthen social protection and community-based services 
        provision. We are seeing results: in Azerbaijan, the 
        residential care population was reduced from 21,000 to 8,336 
        children over 5 years; in Albania, the Government is expanding 
        a successful pilot foster care program that includes financial 
        allowances to foster parents. In addition, UNICEF supported 35 
        countries in aligning their alternative care standards to the 
        Guidelines for the Alternative Care of Children, including 
        Bangladesh, Belize, Croatia, Haiti, Iran, Kenya, Kosovo, 
        Mexico, Papua New Guinea, Rwanda, Senegal, Serbia, South Sudan, 
        and Togo.
                          3. protect children
    For UNICEF, protecting children from violence, exploitation, and 
abuse is a strategic priority, a development necessity, and a moral 
duty. In 2012, UNICEF spent $331 million overall on programs for child 
protection, including in humanitarian crises.
    Keenly aware of the lifelong impact that the lack of protection can 
have on a child, UNICEF focuses its child protection efforts on four 
key areas:
  --strengthening systems to better protect all children from violence, 
        exploitation, and abuse;
  --promoting the social conventions, norms, and values that keep 
        children from harm;
  --protecting children from the immediate and long-term impact of 
        armed conflict and humanitarian crises; and
  --improving country-level monitoring, research, evaluation, and use 
        of child protection data.
    UNICEF is the sole UN agency with the full breadth of child 
protection within its mandate, and this is the organization's 
comparative advantage as it plays convening and advocacy roles, 
bringing technical expertise and applying research and innovative 
approaches to deliver results for children worldwide. UNICEF also has 
unique access to governments who, under the Convention of the Rights of 
the Child, hold the ultimate responsibility for supporting families and 
ensuring the well-being of the children in their country. Working with 
many partners, UNICEF focuses on strengthening systems and promoting 
beliefs and practices that protect children in all contexts, and on 
replicating ``what works'' through robust evidence.
    The focus on equity and on child protection has galvanized UNICEF 
at all levels to better generate representative data on child 
protection issues, which, compared to other sectors, remains difficult 
due to the hidden and sensitive nature of many violations. Data 
collection on the scale and extent of violations against children in 
situations of armed conflict also presents complex challenges. Current 
global household surveys, such as Multiple Indicator Cluster Surveys 
and Demographic and Health Surveys, do not account for children living 
outside of households--those in institutions, in detention centers, 
trafficking victims, engaged in the worst forms of child labor, or 
living on the street.
    UNICEF is a global leader in developing safe, appropriate ways to 
collect data, working with governments and partners to strengthen data 
collection systems. For example, UNICEF works in partnership with the 
University of California-San Diego, the University of Pennsylvania, and 
the Centers for Disease Control and Prevention to strengthen data 
collection on violence against children and changes in social norms. 
UNICEF also works with partners to enable humanitarian actors to more 
securely collect, store and analyze reports of gender-based violence, 
and facilitate the safe and ethical sharing of this data with other 
local actors.
    Conflicts and emergencies are especially difficult for children. 
They can cause displacement, breakdown of family and social structures, 
erosion of traditional value systems, and violence, all of which 
seriously degrade the protective environment for children. UNICEF is 
the global leader on child protection in emergencies; in 2012, UNICEF 
responded to the protection needs of children in emergencies in at 
least 46 countries affected by armed conflict and natural disasters, 
including situations in the Syrian Arab Republic and the Sahel region 
that required intensive efforts to develop sub-regional and cross-
border responses for integrated programming.
    Key results for child protection in 2012 include:
  --The capacity of UNICEF partners to address issues of child 
        protection was greatly strengthened in over 98 countries, 
        including the provision of social welfare services, alternative 
        care, and psychosocial support.
  --With UNICEF support, in 82 programming countries birth registration 
        is now free and universal, in line with international 
        standards. More than 29.5 million births were registered in 
        these countries, thus helping to ensure the social and legal 
        rights of the newborns.
  --An additional 1,775 communities declared their abandonment of 
        female genital mutilation and cutting, bringing the number of 
        communities that have abandoned the practice to approximately 
        10,000 since the start of the UNICEF program with other 
        partners.
  --More than 1.4 million children in emergencies in 42 countries had 
        access to protective community spaces, learning spaces, and 
        psychosocial support services.
  --Over 5,300 children associated with armed forces or groups in nine 
        countries were released and reintegrated into their families 
        and communities.
  --Globally, UNICEF is involved in a groundbreaking public-private 
        partnership that collects evidence on the prevalence and 
        pervasiveness of violence against children, with a particular 
        focus on sexual violence. Countries are using the findings to 
        develop programs and approaches to address the underlying 
        drivers of sexual violence against children and support 
        survivors. So far, ``National Violence Against Children 
        Surveys'' have been completed in Kenya, Swaziland, Tanzania, 
        and Zimbabwe; and are in process in Cambodia, Haiti, Indonesia, 
        Malawi, Nigeria, and the Philippines.
    These examples underscore how UNICEF's global child survival, child 
development, and child protection efforts reflect major objectives that 
are being advanced by the Children in Adversity Action Plan.

    Senator Landrieu. So to look at your budget under a new 
light, which is how much is helping kids survive and thrive in 
the early years, how much of the UNICEF budget is going to find 
permanent families for kids, how much of the UNICEF budget is 
primarily for protection.
    And it might be a good exercise for UNICEF to be able to go 
through the budget and provide some detail on that.
    One of the most critical needs facing the world's 
vulnerable children is the lack of surveillance and baseline 
data. I think you testified to this. Would you say that, of all 
the groups and organizations in the world, and I think UNICEF 
has the most money to spend of any child adversity group in the 
world, is that true? UNICEF has the most money? Is your 
budget--what is it, $5 billion?
    Dr. Bissell. Our budget is little less than $4 billion 
annually, all privately raised, but I haven't actually seen 
data that compares us to other organizations.
    Senator Landrieu. Does anybody at the table know of any 
organization larger?
    Do you, Dr. Ryan? Do you, Dr. Steinberg? Do you, Dr. 
Boothby?
    Okay, I think that UNICEF is the largest. If I'm wrong, 
then somebody can correct me.
    So given that you're the largest group in the world focused 
on children, and you're producing the state of the world's 
children report and other sources of data, what advice would 
you give to the U.S. Government as it attempts to build a 
system to measure the effectiveness of programming for children 
in adversity? That's question number one.

                         UNICEF DATA-GATHERING

    And two, do you believe that UNICEF's data-gathering 
approach through household surveys adequately captures the full 
spectrum of children in adversity? If so, why? And if not, why 
not?
    Dr. Bissell. I think your second question speaks well to 
the first, and it's not a surprise. The whole area of measuring 
out-of-household populations, I think, has been--well, the 
evidence would suggest has been grossly overlooked.
    So we've invested, as an international community, in DHS, 
demographic and health surveys, and in multiple indicator 
cluster surveys, which look at households. And those are a good 
way of tracking what happens in households.
    And your second question, if you're going to track the 
National Action Plan on Children in Adversity, and as Dr. 
Boothby has already indicated, a priority area of data 
collection on out-of-household populations is precisely the way 
to go, and something we've also been advocating for.
    Senator Landrieu. Okay, you are sharing information before 
this subcommittee that indicates, I just want to get this 
straight, that currently, UNICEF, which we believe is the 
largest group in the world focused on children's health and 
well-being, is not counting children out of households; yes or 
no?
    Dr. Bissell. Well, we are but there's no comparable method 
to DHS and MICS for out-of-household populations. There are 
many approaches in many different countries for determining--
for example, we're currently surveying around the world the 
number of children in institutions. There's actually no global 
number on that. Governments need to put systems in place to 
collect that kind of information. We're supporting that.
    But there is no universal, systematic approach to 
collecting data on children out of households.
    Senator Landrieu. Okay, so out of households would mean 
children in orphanages or institutions or group homes, 
children's homes, licensed, unlicensed. It would also mean 
children in refugee camps?
    Dr. Bissell. In refugee camps, on the streets.
    Senator Landrieu. It would also mean children on the 
streets.
    Dr. Bissell. In brothels, yes.
    Senator Landrieu. In brothels, in drug trafficking, in the 
sex trade, all the above. We don't have a real accurate count.
    So how do we actually know how many double orphans there 
are in the world, if we're not counting accurately?
    Dr. Bissell. Well, the double orphan issue, I mean, our 
information on household--the information that is used for 
determining that is actually quite--I would let Caroline 
comment--but there's actually a systematic method of data 
collection, in terms of children affected by HIV and AIDS.
    But I think we know that we have--the single and double 
orphan definition gets us into a lot trouble.

                            TYPES OF ORPHANS

    Senator Landrieu. Let's describe what those definitions are 
real quickly before we move to the second panel, because I 
think it's important. What is a double orphan? What is the 
definition of a double orphan?
    Dr. Bissell. A child who has neither father nor mother.
    Senator Landrieu. Okay, and what is a single orphan?
    Dr. Bissell. A child who has lost one parent.
    Senator Landrieu. Is there a word for a child that has lost 
either one or both parents but that is currently unparented 
because the one parent they have is not willing to parent?
    Dr. Bissell. No.
    Senator Landrieu. Do you know a title for that? Okay, so we 
don't we have a definition of unparented, really? We just have 
double orphans; we have single orphans. But we don't really 
even count kids that have a single parent, but a parent that is 
either unwilling or unable, like if a parent was a paraplegic 
and couldn't, or if a parent was in jail for the next 30 years 
and couldn't, or a parent that was missing, alive but missing. 
We don't have good counts of that.
    Dr. Bissell. No.
    Senator Landrieu. Caroline, do you want to add anything, 
Dr. Ryan, to this discussion?
    Dr. Ryan. Just to say that, often, what we see is, if a 
child, even if it is a double orphan, it is sometimes cared 
for, or often cared for, by an extended family. So it's brought 
into a family unit. So we often find our support going to 
households where there are orphan, but the household is 
supported. It may be a grandmother or an aunt, especially in 
sub-Saharan Africa.
    So I wouldn't say that it's necessary the same thing as a 
child that has been abandoned to the streets.
    But those are the households that we're supporting. Because 
of the extra burden, usually an economic burden, you try to 
keep those extended family households still viable.
    Senator Landrieu. Do we have any actual data of how many 
single or double orphans who are unparented have been placed 
with family members? And do we have any information about how 
those children are thriving in those extended families?
    Dr. Ryan. We could probably get that information, if we 
were to go to the country level and look at what the household 
programs are doing. They probably keep track of who are in 
those households and what kind of support.
    Senator Landrieu. Would you do something, would you just 
pick one country, the best country that you think is doing that 
work, and submit some data to this subcommittee within the next 
30 days about their reports on children who are unparented, who 
have been taken in in a guardianship or an adoption by the 
extended family, and what their reports are regarding the 
status of that child?
    Dr. Ryan. We'd be happy to do that.
    Senator Landrieu. And the programs that support that?
    Dr. Ryan. Okay.
    Senator Landrieu. Okay, the record will be open for other 
members as well for other questions to be submitted to the 
record.
    Let me just ask each of you to give a 30-second wrap-up, 
something that you want to say that you didn't say that you 
think is important, starting with you, Mr. Steinberg.
    Mr. Steinberg. Well, just addressing your last question, 
that is one of the purposes for identifying six countries over 
the next 5 years for intensive activity. And we have a variety 
of metrics we're applying to decide what those countries are, 
including how best to impact the most amount of children, how 
to make sure that the government is cooperative in that effort, 
how to build civil society. And we hope to have to you within 
the next month the list of those countries and the 
implementation plans that we're putting together.
    Senator Landrieu. Thank you very much.
    Mr. Steinberg. Thank you for your leadership.
    Senator Landrieu. Dr. Ryan.
    Dr. Ryan. Thank you very much. I just wanted to say that 
we're fully supportive of the Action Plan for Children in 
Adversity and feel that coordinating with the plan will be very 
helpful. And we think that we have a very good platform already 
in which to base the coordination on. And we see it as a 
coordination program to support our implementation of programs.
    Senator Landrieu. Thank you.
    Dr. Bissell.
    Dr. Bissell. Thanks again for the opportunity to be here. I 
think any effort that brings more resources to the table 
through the U.S. Government will be very welcome, and we look 
forward to collaborating in the counties in question that we're 
working in.
    And finally, I think it's very important that all of us, in 
the particular roles and agencies that were playing, that we 
leverage the resources of national governments in those 
countries as well. We're increasingly seeing that this 
protection work is playing out in low- and middle-income 
countries where, in fact, there are domestic resources. So the 
power of the U.S. Government to help us bring those national 
resources to the table would be welcome. Thank you.
    Senator Landrieu. Yes, particularly encouraging countries 
to have--everybody has different views, but to take as value 
the fact that children should be in families and not in 
institutions and not in make-believe families or in group 
homes, but real families, if possible, their relatives, 
hopefully, but if not, someone in the community or somebody in 
the world that can care for them.
    Dr. Boothby.
    Dr. Boothby. Thank you very much. Public Law 109-95 states 
that the President of the United States ``shall establish a 
monitoring and evaluation system to measure the effectiveness 
of United States assistance to orphans and other vulnerable 
children.'' CDC is taking the lead on surveillance of violence. 
We are in the process of stepping up around surveillance on 
children outside of family care and are developing methods and 
approaches, and actually doing that with UNICEF.
    Where the rubber hits the road will be in these six 
countries. And I think it will be here that the surveillance 
will get into existence. It is here that the proof of concept 
of Public Law 109-95 will either succeed or fail. And we think 
it will succeed tremendously, because we have such great 
cooperation from PEPFAR, CDC, DOL, and other actors. Thank you.
    Senator Landrieu. Thank you very much. You all are excused. 
I appreciate it. Thank you.
    And we'll get the second panel up. And if you all could 
stay and listen to the second panel, as we requested earlier, 
if your time permits, I think that would be very appropriate.
    Okay, we have three gentlemen on our second panel, and I 
really appreciate their tremendous advocacy in this area and 
their knowledge.
    First, Dr. Charles Nelson is a professor of pediatric and 
neuroscience and a professor of psychology at Harvard Medical 
School and holds the Richard David Scott Chair in Pediatric 
Developmental Medicine Research at Boston Children's Hospital. 
Dr. Nelson also holds faculty appointments in the Harvard 
School of Public Health, Harvard Graduate School of Education, 
and sits on the steering committee for the Center on the 
Developing Child and the Interfaculty Initiative on Mind, 
Brain, and Behavior.
    We could not have a more distinguished expert in the area 
of child development, and we're truly honored, Dr. Nelson, that 
you have appeared before our panel today.
    Philip Goldman is the president of Maestral International, 
a consulting firm that is working to strengthen child 
protection systems around the world. In 1992 to 2005, Mr. 
Goldman was a member of the World Bank human development 
operations team in Europe and Central Asia, supervising a 
significant portfolio of social protection, education, and 
health operations, supporting poverty reduction and providing 
related project funding.
    From 2005 to 2008, Mr. Goldman was senior vice president of 
Encore One, LCC, a private equity firm in Minneapolis, 
Minnesota, and has done an enormous amount of work both 
privately and publicly in this field.
    And finally, Jedd Medefind--and, Jedd, thank you for short 
notice and rearranging your schedule to come.
    He serves as president of the Christian Alliance for 
Orphans, an alliance that unites more than 145 organizations 
that collectively serve millions of orphans and vulnerable 
children both in the United States and around the world. The 
program of the Christian Alliance for Orphan member 
organizations vary widely from foster care groups mentoring, to 
adoption, family preservation, in-country orphan care 
worldwide. They are churches, individuals, I understand, and 
nonprofit organizations that are members of your growing and 
very dynamic organization.
    Prior to this role, Jedd served in the White House, leading 
the Office of Faith-Based and Community Initiatives. In this 
post, he oversaw reform efforts across the Government to make 
community and faith-based groups essential partners in all 
Federal efforts to aid the needy, from prisoner re-entry to 
global HIV and AIDS.
    So thank you, Jedd.
    And let's begin, if we could, with you, Dr. Nelson, and why 
the subject is so important and why you're here today to 
testify.
STATEMENT OF DR. CHARLES A. NELSON III, PH.D., 
            PROFESSOR OF PEDIATRICS AND NEUROSCIENCE AT 
            HARVARD MEDICAL SCHOOL
ACCOMPANIED BY RICHARD DAVID SCOTT, CHAIR IN PEDIATRIC DEVELOPMENTAL 
            MEDICINE RESEARCH AT BOSTON CHILDREN'S HOSPITAL

    Dr. Nelson. Good morning. Thank you, Senator Landrieu, for 
the honor of being invited to talk with this group about the 
science of early child and brain development and what it has to 
say about children growing up in adversity.
    The basic principles of neuroscience in child development 
tell us that what happens early in life can have a profound 
impact in what happens later in life, even decades later, both 
psychologically and biologically.
    For example, a child exposed to so-called toxic stress, 
which might include things like serious abuse and neglect, 
living in object poverty, exposure to violence, or exposure to 
a parent suffering from serious----
    Senator Landrieu. Doctor, pull the mike a little bit closer 
to you. There you go. Thank you.
    Dr. Nelson [continuing]. serious or untreated mental health 
problems, raises the risk of that child growing up with 
psychological problems themselves.
    In addition, important aspects of biological development 
can also be compromised. For example, if they're exposed to 
chronic stress or they experience a severe lack of social or 
emotional stimulation, the parts of the brain that can help 
regulate our response to stress or regulating our emotions can 
be compromised.
    Advances in neuroscience tell us that although early brain 
development benefits from good experiences, it can also be 
disadvantaged by bad ones. Further, if these bad experiences 
occurred during what neurosciences refer to as a sensitive 
period, there's the risk that a child's subsequent development 
may be the derailed.
    And the longer these bad experiences continue, the more 
difficult it will be to redirect development back towards 
normal--not impossible, just more difficult and more costly.
    So the simple reason for this is that, as the brain 
continues to develop over the first years of life, its 
architecture becomes less flexible, making it more difficult to 
adapt and change.
    Let me illustrate these issues with one example with 
children experiencing profound early adversity, children reared 
in institutional care. UNICEF estimates that there may be as 
many as 8 million children worldwide living in institutions, 
although, as we heard moments ago, that figure is very squishy.
    Some children wind up in institutions because their parents 
die, such as occurs in war-torn regions or because of HIV 
infection. Others are simply abandoned by their parents for a 
variety of social, cultural, and economic reasons. Some of the 
more common examples include poverty, a baby with a birth 
defect, and parents who leave their children behind to move to 
another town, another city, or, increasingly, another country 
to find work.
    Countless studies have demonstrated that children who are 
brought up in institutions instead of family suffer from a 
variety of developmental problems.
    For example, if you can look at this slide here, children 
who grew up in institutions have IQs that typically are in the 
70s, sometimes lower. They also showed dramatic reductions in 
their brain's electrical activity. So if you look here, the 
more red in this image, the more brain activity. Children who 
grow up in an institution show dramatically less brain activity 
than children who do not grow up in an institution.
    But importantly, as you can see here, a lot of these 
developmental problems can be remediated if institutions are 
replaced by families.
    So, this is the IQ of children raised in families and this 
is the IQ of children placed in families after institutional 
care, but before the age of 2 years. Similarly, if this is the 
brain activity of children who grow up in institutions, notice 
it's identical to the brain activity who started in an 
institution but moved to a family before the age of 2.
    Being abandoned to an institution is but one example of 
children living in adversity. Other examples include children 
who experience food insecurity, those experiencing violence in 
the home or the neighborhood, children growing up with an HIV-
infected parent, and children growing up in regions where armed 
conflict is prevalent, which currently affects approximately 1 
billion children worldwide. All those experiences can 
substantially compromise development.
    Why is exposure to early adversity bad for the brain and 
bad for the child? The brief answer is that the developing 
brain craves experience. If it lacks experience, as occurs, for 
example, with neglect, the brain, to use a metaphor, has no one 
talking to it. And it's thus left to its own devices to wire 
itself, which it invariably does incorrectly.
    On the other hand, if it's exposed to overtly adverse 
experiences, such as violence that occurs with armed conflict, 
the brain is constructed in such a way as to lead to a variety 
of poor outcomes. For example, children exposed to war suffer 
from high rates of traumatic stress reactions, depression, 
anxiety, and high-risk behaviors.
    Importantly, the sequelae of these adversities, these early 
adverse experiences, can carry forward to the next generation. 
After all, the ability of these children to parent their own 
children is surely compromised.
    In summary, we must all be mindful of the environment in 
which children are reared, because the capacity for change is 
greater earlier in life when the brain is still developing 
rapidly than it is after the basic architecture or the brain 
has been established.
    The best way to ensure healthy brain development is to see 
to it that children are protected against exposure to early 
adversity. If that's not possible, then we must do our best to 
remove them from these environments as early in life as 
possible, so as to take advantage of the brain's ability to 
adapt in early childhood.
    If I can leave you with one message then, it is that it is 
the intersection of the severity, the duration, and the timing 
of the adversity that largely accounts for how children will 
grow and develop.


                           PREPARED STATEMENT

    In closing, permit me to thank you for your leadership and 
to stand ready to offer the help of the scientific community in 
any way that I can.
    [The statement follows:]
  Prepared Statement of Dr. Charles A. Nelson III, Ph.D. and Richard 
                              David Scott
    Good morning. Thank you for the honor of being invited to talk with 
you about what the science of early child and brain development has to 
say about children growing up in adversity.
    The basic principles of neuroscience and child development tell us 
that what happens early in life can have a profound impact on what 
happens later in life, even decades later, both psychologically and 
biologically. For example, a child exposed to so-called ``toxic 
stress'', which might include things like serious abuse or neglect, 
living in abject poverty, exposure to violence, or exposure to a parent 
suffering from serious and untreated mental health problems, raises the 
risk of that child growing up with psychological problems themselves; 
in addition, important aspects of biological development may also be 
compromised--for example, if they are exposed to chronic stress, or 
experience severe social or emotional deprivation, the parts of the 
brain that help regulate our response to stress and in regulating our 
emotions may be compromised.
    Advances in neuroscience tell us that although early brain 
development benefits from good experiences, it can also be 
disadvantaged by exposure to bad ones. Further, if these bad 
experiences occur during what neuroscientists refer to as a sensitive 
period, there is the risk that a child's subsequent development may be 
derailed. And, the longer these bad experiences continue, the more 
difficult it will be to redirect development back toward normal. Not 
impossible, just more difficult . . . and more costly. The simple 
reason for this is that as the brain continues to develop over the 
first years of life, its architecture becomes less flexible, making it 
more difficult to adapt and change.
    Let me illustrate these issues with one example of children 
experiencing profound early adversity--children reared in institutional 
care. The United Nations International Children's Emergency Fund 
(UNICEF) estimates that there may be as many as 8 million children 
living in institutions. Some children wind up in institutions because 
their parents die, such as occurs in war-torn regions or because of HIV 
infection. Others are simply abandoned by their parents for a variety 
of social, cultural, and economic reasons--some of the more common 
examples include poverty, a baby with a birth defect, and parents who 
leave behind their children to move to another town or city or 
increasingly common, another country, so that the parent can find work. 
Countless studies have demonstrated that children who are brought up in 
institutions instead of families suffer from a variety of developmental 
problems; for example, as you can see in the poster, such children have 
IQs in the 60s and 70s (instead of 100, which is average), and show 
dramatic reductions in their brain activity--and they also have smaller 
brains.
    Importantly, as can also be seen in this poster, many of these 
developmental problems can be remedied if children are removed from 
institutional care and placed in good families . . . with the rule of 
thumb being the earlier the better. Thus, children removed from 
institutional care before their second birthday have IQs that are 15-20 
points higher than children placed after their second birthday; 
similarly, earlier placed children show normative amounts of brain 
activity instead of marked reductions.
    Being abandoned to an institution is but one example of children 
living in adversity. Other examples include children who experience 
food insecurity; those experiencing violence in the home or 
neighborhood; children growing up with an HIV infected parent; and 
children growing up in regions where armed conflict is prevalent (which 
affects approximately 1 billion children worldwide). All of these 
experiences can substantially compromise development.
Why is exposure to early adversity bad for the brain and for the child?
    The brief answer is that the developing brain craves experience. If 
it lacks experience, as occurs with neglect, the brain--to use a 
metaphor--has no one talking to it, and is thus left to its own devices 
to wire itself, which it invariably does incorrectly. On the other 
hand, if it is exposed to overtly adverse experiences, such as the 
violence that occurs with armed conflict, the brain is constructed in 
such a way as to lead to a variety of poor outcomes. For example, 
children exposed to war suffer from high rates of traumatic stress 
reactions, depression, anxiety and high-risk behaviors. Importantly, 
the sequelea of these adverse early experiences can carry forward to 
the next generation--after all, the ability of these children to parent 
their own children is surely compromised.
    In summary, we must all be mindful of the environment in which 
children are reared. Because capacity for change is greater early in 
life, when the brain is still developing rapidly, rather than after its 
basic architecture has been established, the best way to ensure healthy 
brain development is to see to it that children are protected against 
exposure to early adversity. If that is not possible, then we must do 
our best to remove them from these environments as early in life as 
possible so as to take advantage of the brain's ability to adapt in 
early childhood. If I can leave you with one message, then, it is that 
it is the interaction of the severity, the duration and the timing of 
the adversity that largely accounts for how children will grow and 
develop.
    In closing, permit me to thank you for your leadership and to stand 
ready to offer the help of the scientific community in any way that I 
can.

    Senator Landrieu. Thank you so very much.
    Mr. Medefind.
STATEMENT OF JEDD MEDEFIND, PRESIDENT, CHRISTIAN 
            ALLIANCE FOR ORPHANS
    Mr. Medefind. Madam Chair, as you've already noted, the 
Christian Alliance for Orphans--thank you, it took a Harvard 
professor to turn it on. Thank you.
    As you've noted, the Christian Alliance for Orphans unites 
more than 145 respected organizations, which collectively serve 
millions of orphans and vulnerable children around the world. 
Most of these organizations do not seek government grants, but 
all affirm that government has a vital role to play in the 
protection and survival of vulnerable children.
    And as we have already heard this morning, studies 
consistently show that children that grow up outside of 
parental care consistently face the worst ravages of poverty, 
disease, sexual predators, and human trafficking. These 
children also offer opportune recruits for child soldiers, gang 
members, and other harmful engagements.
    So it is both compassion and self-interest that calls us to 
address this need wisely and effectively.
    But here is the fundamental challenge. Through government, 
we can effectively deliver many things on a large scale--food, 
medicine, shelter, education, and more. And these elements are 
absolutely critical to enabling children to survive. But while 
necessary, they are not sufficient to enable unparented 
children to thrive.
    Why is this? Because the deepest need of every child is for 
things that cannot be mass-produced, things like affection, 
nurture, and permanent relationship.
    As other witnesses here describe well, science now 
recognizes that these things are not simply fluff elements from 
childhood. They're utterly essential to brain development, to 
physical and emotional health, and to essentially every other 
thing that proves necessary to grow a baby into a whole and 
productive adult.
    We see this vividly even in the United States. Children 
that grow up in foster care without being adopted struggle for 
the rest of their lives. By their mid-20s, less than half are 
employed, and 80 percent of the men have been arrested at least 
once.
    It's believed that between one-half and three-quarters of 
domestic human trafficking victims have come out of the foster 
care system.
    These statistics are tragic. And yet, we must also remember 
that children growing up without families in other parts of the 
world often face an even more difficult route with far less 
access to private opportunities, public support, and justice 
systems.
    Seeing all of this reveals a vexing reality. This is a 
mass-scale need that defies mass-scale solutions. We can 
deliver many things en masse, but nurture, affection, and 
attachment are not among them.
    So how can government cultivate solutions that it cannot 
create on its own? It can be done.
    The State of Colorado offers a great example here. Over the 
past several years, it has embraced a wide range of 
partnerships with faith-based organizations, houses of worship, 
and nonreligious organizations to find welcoming families for 
waiting children in foster care.
    Colorado's Government has worked to be effective at what it 
can do best, child protection and survival, while partnering to 
offer children the essential things that government cannot 
provide on its own.
    As a result, since 2008, the number of children in foster 
care waiting for permanent families has been steadily reduced 
from nearly 800 to less than 300 today. Similar efforts are 
proving effective in many regions across the United States as 
well.
    This same basic approach is working around the world as 
well. We see it in China where regional governments partnering 
with the organization Care for Children have moved 250,000 
children from orphanages into local families. We see it in 
Ethiopia, where organizations like Bethany Christian Services, 
Buckner International, Kidmia, and many others are helping keep 
struggling families together and placing orphans into local 
foster care and adoptive families; and in Rwanda, where the 
government is working with an array of NGOs and a wide network 
of Rwandan churches, cultivated by Saddleback Church, to shift 
children from orphanages into families.
    Three primary principles are at the root of successes like 
these.
    First, priority. Doing the best for unparented children 
requires that our policies and investments clearly prioritize 
family as the goal for children that lack it. The U.S. Action 
Plan for Children in Adversity takes a very significant step in 
this direction.
    Second, preservation. The best way to guarantee a family 
for a vulnerable child is to ensure that she does not lose her 
family in the first place or is reunited with her family if 
separated.
    And third, placement. When preservation or reunification 
isn't possible, a child deserves a permanent family as soon as 
is feasible, locally if possible, and via international 
adoption if not.

                           PREPARED STATEMENT

    If our desire is that global investments will enable 
children who lack families to truly thrive, these three Ps are 
essential: priority upon family, preservation of struggling 
families, and swift placement into permanent families for 
children who need them.
    [The statement follows:]
                  Prepared Statement of Jedd Medefind
    Esteemed Senators and Senate Staff: It represents America at her 
best that our leaders desire not only to aid vulnerable children, but 
to continually improve our approach to doing so.
    Thank you for this opportunity to address you toward that end.
    My name is Jedd Medefind. I have the privilege of serving as 
President of the Christian Alliance for Orphans.
    This Alliance unites more than 145 respected organizations. 
Collectively, they serve millions of orphans and vulnerable children, 
both across the U.S. and worldwide. Their emphases range from foster 
care, residential care and adoption, to efforts to help keep struggling 
families together.
    Through the Alliance, these organizations work together to both 
inspire and equip individuals, families, and churches to care for 
vulnerable children effectively.
    The majority of these organizations do not seek government grants. 
But all recognize that government has a vital role to play in the 
protection and survival of vulnerable children.
    Among the most vulnerable of all groups worldwide are children 
growing up outside of parental care.
    Currently available statistics are notoriously incomplete, and 
sometimes misleading, in diagnosing the scope and nature of the need.
    UNICEF estimates that 17.8 million children worldwide have lost 
both parents. Many of these children live with caring relatives. Many 
others do not. In addition, it is believed that tens of millions of 
additional children live on the streets, in orphanages, and other 
settings devoid of consistent, nurturing parental care.
    Studies consistently show that children who lack the protection and 
nurture that parents uniquely provide typically lag far behind their 
peers in virtually every respect. They are highly susceptible to the 
worst ravages of poverty, disease, sexual predators, and human 
trafficking. They also offer opportune recruits as child soldiers, gang 
members and potential terrorists.\1\
---------------------------------------------------------------------------
    \1\ For a sampling of research on the impact of lack of parental 
care on the intellectual, physical and emotional development of 
children, see:
    -- Bakermans-Kranenburg, M.J. Steele, H., Zeanah, C. H., 
Muhamedrahimov, R. J., Vorria, P., Dobrova-Krol, N. A., Steele, M., van 
IJzendoorn, M. H., Juffer, F., & Gunnar, M. R. (2011). Attachment and 
emotional development in institutional care: Characteristics and catch-
up. The neurobiological toll of early human deprivation. In R. B. 
McCall, M. H. van IJzendoorn, F. Juffer, C. J. Groark, and V. K. Groza 
(Eds.), Children without permanent parents: Research, practice, and 
policy. Monographs of the Society for Research in Child Development, 
76(4), pp. 62-91. Abstract available at: http://
onlinelibrary.wiley.com/doi/10.1111/mono.2011.76.issue-4/issuetoc
    -- Bucharest Early Intervention Project (2009) Caring for Orphaned, 
Abandoned and Maltreated Children. Available at: http://
www.bettercarenetwork.org/BCN/
details.asp?id=12323&themeID=1003&topicID=1023
    -- Carter, R (2005). Family Matters: A study of institutional 
childcare in Central and Eastern Europe and the Former Soviet Union. 
London: EveryChild. Available at: http://p-ced.com/reference/
Family_Matters_summary.pdf
    -- Dobrova-Krol, N. A., Van IJzendoorn, M. H., Bakermans-
Kranenburg, M.J., Juffer, F., & Cyr, C.. (2008). Physical growth delays 
and stress dysregulation in stunted and non-stunted Ukrainian 
institution-reared children. Infant Behavior and Development, 31, pp. 
539-553. Abstract available at: www.sciencedirect.com/science/article/
pii/S0163638308000404
    -- EveryChild (2011). Scaling Down: Reducing, Reshaping and 
Improving Residential Care around the World. Available at: http://
www.bettercarenetwork.org/BCN/
details.asp?id=24928&themeID=1003&topicID=1023
    -- Johnson, D. E., & Gunnar, M. R. (2011). Growth failure in 
institutionalized children. The neurobiological toll of early human 
deprivation. In R. B. McCall, M. H. van IJzendoorn, F. Juffer, C. J. 
Groark, and V. K. Groza (Eds.), Children without permanent parents: 
Research, practice, and policy. Monographs of the Society for Research 
in Child Development, 76(4), pp. 92-126. Abstract available at: http://
onlinelibrary.wiley.com/doi/10.1111/mono.2011.76.issue-4/issuetoc
    -- McCall, R., Van Ijzendoorn, M., Juffer, F., Groark, C., & Groza, 
K. (2011). Children without permanent parents: Research, practice and 
policy. Monographs of the Society for Research in Child Development, 
76(4). Abstract available at: http://onlinelibrary.wiley.com/doi/
10.1111/mono.2011.76.issue-4/issuetoc
    -- National Scientific Council on the Developing Child. (2012). The 
Science of Neglect: The Persistent Absence of Responsive Care Disrupts 
the Developing Brain: Working Paper 12. Available at: http://
www.developingchild.harvard.edu
    -- Nelson, C. A., Fox, N.A., and Zeanah, C.H. (2013). Anguish of 
the Abandoned Children. Scientific American. Available at: http://
www.adoptionpolicy.org/sad0413Nels3pRV.pdf
    -- Nelson, C. A., Bos, K., Gunnar, M. R., & Sonuga-Barke, E. S. 
(2011). The neurobiological toll of early human deprivation. In R. B. 
McCall, M. H. van IJzendoorn, F. Juffer, C. J. Groark, and V. K. Groza 
(Eds.), Children without permanent parents: Research, practice, and 
policy. Monographs of the Society for Research in Child Development, 
76(4), pp. 201-237. Abstract available at: http://
onlinelibrary.wiley.com/doi/10.1111/mono.2011.76.issue-4/issuetoc
    -- Nelson, C. A., Zeanah, C. H., Fox, N. A., Marshall, P. J., 
Smyke, A. T., & Guthrie, D. (2007). Cognitive recovery in socially 
deprived young children: The Bucharest early intervention project. 
Science, 318(5858), pp. 1937-1940. Available at: 
www.bucharestearlyinterventionproject.org/
Nelson_et_al_combined_2007_.pdf
    -- Van IJzendoorn, M. H., Luijk, M., & Juffer, F. (2008). IQ of 
children growing up in children's homes: A meta-analysis on IQ delays 
in orphanages. Merrill-Palmer Quarterly-Journal of Developmental 
Psychology, 54, pp. 341-366. Abstract available at: http://
digitalcommons.wayne.edu/mpq/vol54/iss3/
---------------------------------------------------------------------------
    We see this vividly even in the U.S. Children that grow up in 
foster care without being adopted often struggle for the rest of their 
lives. By their mid-20s, less than half are employed. Nearly 70 percent 
of the women must rely upon food stamps compared to 7 percent of women 
overall. Among the men, 80 percent have been arrested, versus 17 
percent overall.\2\ Experts report that between 55 and 75 percent of 
domestic human trafficking victims came out of the foster system.\3\
---------------------------------------------------------------------------
    \2\ See Courtney, Mark, et al. ``Midwest Evaluation of the Adult 
Functioning of Former Foster Youth.'' Available at http://
www.chapinhall.org/research/report/midwest-evaluation-adult-
functioning-former-foster-youth.
    \3\ See http://www.tampabay.com/news/publicsafety/crime/fbi-agent-
leads-task-force-targeting-pimps-in-child-prostitution/1125800; http://
www.misssey.org/csec.html; and http://www.nytimes.com/2007/04/24/
nyregion/24child.html?_r=3&oref=slogin&.
---------------------------------------------------------------------------
    These statistics are tragic. Yet we must remember that children 
without parents in other parts of the world often face an even harder 
road--with far, far less access to private opportunities, public 
supports, and justice systems.
    Little wonder that studies worldwide so often connect literal or 
effective orphan status with homelessness, suicide, depression, 
unemployment, violence, crime and all manner of other social ills.
    In short, children that grow up without parents are continually 
threatened as they grow. And those that survive often become a threat 
to others as well.
    So it is both compassion and self-interest that call governments 
and individuals to address this need wisely, passionately, and 
effectively.
    But here is the fundamental challenge.
    Governments and large NGOs can deliver many vital things on a large 
scale: food, medicine, shelter, and more.
    And these elements are vital to enabling children to survive. But 
we must also affirm that things are necessary but not sufficient to 
ensuring that children who lack parents can thrive.
    Why? Because the deepest need of every child is for things that 
cannot be mass produced--things like affection, attachment, identity, 
and belonging.
    And, as other witnesses here describe well, modern science now 
recognizes that these are not simply ``fluff'' elements of childhood. 
They are utterly essential to brain development, to physical and 
emotional health . . . and to virtually every other factor that grows a 
baby into a whole and productive adult.
    Grasping this is vital if we are to address the deepest needs of 
children who lack parental care.
    And yet, it leaves us with a daunting but inescapable conclusion: 
This mass scale dilemma defies mass scale solutions.
    We can marshal and deliver many things en masse . . . but nurture, 
affection and attachment are not among them.
    This is why we must look beyond the capabilities of government 
alone if we are to truly help children that lack parental care to 
thrive.
    This is not easy. All of us, regardless of our profession, tend to 
unconsciously limit ourselves to solutions that can be readily achieved 
with the tools we possess.
    So it is only natural that government efforts would focus heavily, 
or even exclusively, on child protection and survival. This is what 
government and large NGOs can do--and often do so well.
    But . . . what government cannot create on its own is families 
willing to welcome and care for children. It is much easier to buy 
food, medicine or shelter than to buy nurture and love.
    So it makes sense that the need for permanent, caring families for 
children would often slip off the radar of government-led efforts.
    But how can government cultivate solutions that it cannot create on 
its own?
    Colorado offers a great example here. The State now partners 
actively with faith-motivated groups, houses of worship and non-
religious civic organizations to find welcoming families for children 
in need of a home.
    Colorado's government has worked to be effective at what it can 
do--child protection and survival--while partnering to offer children 
those truly essential things government cannot provide on its own.
    They have found large numbers of families motivated by their faith 
to welcome in children, including many of the hardest to place kids. 
They have also discovered that faith communities often provide vital 
support for families amidst the challenges that come with loving 
wounded children. Not surprisingly, the level of commitment and care 
provided by these faith communities often is much higher than families 
that foster primarily because of the payments they receive. Businesses, 
civic groups, and other non-governmental actors have also played vital 
roles in these efforts.
    The result? Over the past several years, the number of children in 
Colorado waiting in foster care for permanent families has been 
steadily reduced--from over 800 to under 300 today.
    Similar efforts are proving effective in many other states across 
the U.S., from New Jersey to Texas to Illinois to California.
    This same basic approach is working around the world as well:
  --In China, where regional governments have partnered with the 
        organization ``Care for Children'' to move 250,000 children 
        from orphanages into caring families.
  --In Ethiopia, where organizations like Bethany Christian Services, 
        Buckner International, and Kidmia are working to help keep 
        struggling families intact and to place double orphans into 
        local foster and adoptive families.
  --In Rwanda, where Saddleback Church and other faith-based groups are 
        working with the government and NGOs to shift children from 
        orphanages into foster and adoptive homes.
  --In Costa Rica, where a group called Casa Viva has grown a network 
        of churches that now welcomes children for both temporary and 
        permanent family-based care.
    Three primary principles are at the root of each of these 
successes:
  --First, Priority.--We must clearly prioritize family as the ultimate 
        goal for children that currently lack it. By naming ``Family 
        Care'' as one of its three foundational objectives, the U.S. 
        Action Plan on Children in Adversity helps point our global 
        investments decisively in this direction.
  --Second, Preservation.--The very best way to guarantee a family for 
        a vulnerable child is to ensure she doesn't lose her family in 
        the first place. On one level, virtually all effective foreign 
        aid--from community development to health projects and micro-
        finance--do contribute to family preservation. But efforts 
        targeting the most vulnerable families on the verge of 
        disintegration are still vital.
  --And Third, Partnership.--To provide what unparented children most 
        need, we must actively partner with community organizations--
        both faith-based and secular--that offer what government cannot 
        provide on its own--most importantly, caring homes and also 
        communities of wrap-around support.
    To these three principles, we can add three important caveats:
  --First, although healthy families provide affection and nurture that 
        ``systems'' can never match, families can sometimes be the 
        source of neglect, abuse or worse. Effective child protection 
        systems are always necessary as a check against abusive homes.
  --Second, commitment to family-based care should always be 
        complementary . . . not competitive to an equally firm 
        commitment to child protection and survival efforts. We need 
        not become partisans of either families or broad-based anti-
        poverty efforts. We can and should champion both.
  --And finally, even as we affirm permanent family as the ideal, we 
        need not become ideologically rigid. Anyone who dares to engage 
        the world at its most broken will sometimes be forced to make 
        peace with imperfect solutions. We can simultaneously work 
        towards the ideal of family . . . while also affirming the 
        value of residential care in cases where family care is not 
        currently a feasible option.
    In all of this, we can continually affirm and seek to build a broad 
continuum of response to the needs of highly-vulnerable children.
    This continuum always starts with efforts to preserve families 
threatened with disintegration and to re-unify families that have been 
needlessly severed. When it's clearly not possible for a child to 
remain safely with his first family, a loving second family is promptly 
sought--with relatives or caring neighbors in-country if possible, and 
via international adoption when local options for permanent family 
aren't available. When finding a permanent new family is not an option, 
other home-based options become the priority, including foster care. 
Finally, when no home-based options are feasible, well-run residential 
care facilities provide an important alternative far preferable to an 
abusive home or life on the streets.
    Esteemed Senators and Senate staff, I believe that every American 
desires to see children not only survive, but to thrive. I know this is 
your desire also.
    If this is indeed our shared commitment as Americans, it must be 
embodied through our global child welfare investments with the three 
``Ps.'' Priority upon family. Preservation of struggling families. And 
Partnerships that find and support families for children who need them.

    Senator Landrieu. Thank you very, very much, Mr. Medefind.
    Mr. Goldman.
STATEMENT OF PHILIP GOLDMAN, PRESIDENT, MAESTRAL 
            INTERNATIONAL
    Mr. Goldman. Good morning, Madam Chair, and thank you for 
the opportunity to testify before you and the subcommittee 
today, and more importantly, for your leadership and dedication 
in raising the issues before the subcommittee and helping us 
all to seek ways to address them.
    I'm going to take a little bit of a different twist on the 
information and data that's been presented to the subcommittee 
this morning, and suggest that there are three good reasons for 
devoting U.S. resources for the Government Action Plan for 
Children in Adversity.
    First, we will increase the investment yields from our 
foreign assistance. Second, this will result in greater fiscal 
efficiency. And finally, the United States can make a major 
impact by promoting this agenda globally.
    Now let's discuss what we mean by increased yields. As 
you've heard, children's neurodevelopment is compromised by 
neglect, poor nutrition, lack of stimulation, and violence.
    Now, if a child falls behind by the age of primary school 
age, the effects are life-long and contribute to long-term 
poverty. For example, it's been estimated that poor children 
who are stunted will earn 30 percent less as adults than their 
peers.
    Throughout childhood, those who experience violence and 
neglect are typically poorer, less educated, less healthy, and 
face higher HIV risk. Yet we know that only the smallest 
fraction of government attention and expenditure is aimed at 
addressing these risks. Investments in poverty reduction will 
be secured and enhanced when children are protected and 
developmentally prepared.
    And we can't ignore the numbers that we've heard today. 
More than one out of three children below the age of 5 are 
living below their development potential--one out of three. Of 
the 400 million children in sub-Saharan Africa, one in eight 
have gone through the profound experience of parental loss. And 
that's probably an underestimate.
    Studies in Africa are showing that one in three girls are 
subject to sexual violence, close to 7 in 10 to physical abuse. 
These and other issues contribute to, and they also result 
from, long-term poverty, and they must be addressed head on.
    My second point concerns fiscal efficiency. It is less 
expensive and more effective to work with children and 
families, especially from infancy and with an emphasis on 
preventing problems before they arise. Orphanages do illustrate 
this issue quite well. While just one category of children at 
risk, millions of children live in some form of residential 
care even though many still have at least one living parent. 
The results for many of these children are devastating and 
well-documented.
    You asked about attachment earlier in this subcommittee 
hearing. While quality of care varies, one study found that 
there can be up to 30 children and sometimes 50 in a single 
ward. Children might be exposed to between 60 and 100 different 
caregivers by the age of 2. Consider that national zoo has one 
staff for every eight vertebrates in its collection, at least 
in 2004.
    In contrast, studies show family-based care is a fraction 
of the cost of residential care and a small percentage of the 
costs of the services that families need. It is also more 
effective. Children in family care typically do better in 
executive functioning, attachment, and overall psychiatric and 
behavioral health.
    My final point is that the United States can make a major 
difference by promoting this agenda on the global stage. 
There's a robust dialogue on the targets that will succeed, the 
Millennium Development Goals in 2015. Our position on this 
should be firm. Today's children are tomorrow's hope. The 
United States should promote clear targets that focus on three 
things--on children's development potential, on living in 
families, and on freedom from violence.
    Governments will maximize their long-term returns from 
investments by avoiding single-issue projects and working to 
transform the entire system. This means addressing their 
policies, government capacities, community practices, services, 
surveillance systems, and resources. And protective systems 
should support basic services that include--many have been 
discussed this morning--household strengthening, justice and 
police systems, violence programs in schools, positive 
parenting programs, and access to reintegration, fostering, 
kinship, and local and intercountry adoption services, all 
sorts of family placements that are reliable, effective, and 
working in the best interest of the child.
    We need to open effective pathways for children.
    Now, we heard the case of Rwanda earlier today from Dr. 
Boothby. From the numbers that I've seen--now, remember that he 
was stating that the estimates are that we'd achieve reductions 
in cognitive delays by 40 percent. We reduced the number of 
those bereft of family care by 75 percent, and those 
experiencing violence by 50 percent.
    Now, that has been estimated at about $12 million per year 
for Rwanda. That's less than 1 percent of the total overseas 
development assistance delivered to the country in 2011. So 
these are marginal resources. And they don't have to be borne 
by the United States alone. They can be borne in partnership.
    Tying it all together, Madam Chairman, targeting children 
in adversity will improve the efficiency and effectiveness of 
our foreign aid programs with minimal costs. The U.S. 
Government Action Plan on Children in Adversity represents a 
paradigm shift in how we can engage on growth and poverty 
reduction. And I strongly encourage you to support it. In fact, 
we're perhaps decades behind.
    Thank you, Madam Chairman, and, of course, we look forward 
to your questions.
    [The statement follows:]
                  Prepared Statement of Philip Goldman
    Good morning, Mr. Chairman, Ranking Member Graham and subcommittee 
members. My name is Philip Goldman, and I am the President of Maestral 
International, an operation working to strengthen child protection 
systems in countries around the world. Prior to founding Maestral, I 
spent many years at the World Bank developing and managing lending 
programs to strengthen human capital and development, and I have served 
on the boards of numerous other organizations working here at home and 
abroad to improve the lives of children.
    I come before the Committee today to argue for an important 
paradigm shift in how we might direct our foreign assistance efforts. 
The United States has three good reasons for focusing our attention on 
(i) developing children's full potential from when they are born, (ii) 
ensuring those children are cared for in families, and (iii) protecting 
them from violence, abuse and neglect:
  --First, the yields from our foreign assistance programming will 
        increase, because we are confident from the available evidence 
        that if children thrive, nations will thrive.
  --My second point is that we will achieve greater fiscal efficiency 
        in our foreign aid expenditures if we incorporate a focus on 
        children in adversity.
  --And finally, at a time of tight resource constraints, the United 
        States can still make a significant impact by promoting this 
        agenda globally, and through marginal shifts in existing 
        country programming.
    In 2010, 25 high income countries allocated approximately $129 
billion to official development assistance efforts.\1\ Much of this 
assistance seeks to promote pro-poor policies and better health and 
education outcomes, and the achievements on child survival and school 
enrollments in recent years have been impressive. However, the 
potential returns from these investments are being compromised because 
we are missing a critical dimension of the reality of children's 
experiences in lower income economies.
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    \1\ See http://www.oecd.org/dac/stats/
50yearsofofficialdevelopmentassistance.htm.
---------------------------------------------------------------------------
    There is increasing evidence across multiple country contexts that 
absence of parental care, violence and abuse have profound and complex 
effects on the cognitive, social, and emotional development of the 
child. This is particularly true in the earliest years. Research shows 
that children's cognitive and noncognitive skills are heavily 
influenced by their family environments, and the gaps in those skills 
manifest themselves by ages 4 to 6,\2\ just before many begin primary 
school. One conservative estimate suggests that more than 1 out of 3 
children below the age of 5 and living in low income countries are 
below their cognitive development potential.\3\ Exposure to one or more 
adverse experiences in childhood has been repeatedly shown to have life 
cycle impacts on the ability to learn, health outcomes and utilization 
of services, levels of income later in life, and the likelihood of 
social problems.\4\ Since the prevalence of these adverse experiences 
is so large in lower income countries, our aid efforts are too often 
seeking to build a house on a very unstable foundation.
---------------------------------------------------------------------------
    \2\ Heckman, J. (2006). Skill formation and the economics of 
investing in disadvantaged children. Science, 312.
    \3\ Grantham-McGregor, S., Cheung, Y., Cueto, S., Glewwe, P., 
Richter, L L., Strupp, B., & The International Child Development 
Steering Group. (2007). Developmental potential in the first 5 years 
for children in developing countries. Lancet, 369(9555), 60-70.
    \4\ Walker, S. P., Wachs, T. D., Gardner, J., Lozoff, B., 
Wasserman, G. A., Pollitt, E., . . . the International Child 
Development Steering Committee Group. (2007). Child development: Risk 
factors for adverse outcomes in developing countries. Lancet, 369, 145-
157.; Holt, S., Buckley, H., & Whelan, S. (2008). The impact of 
exposure to domestic violence and young people: A review of the 
literature. Child Abuse and Neglect, 32(8), 797-810.; Frederick, J., & 
Goddard, C. (2007). Exploring the relationship between poverty, 
childhood adversity and child abuse from the perspective of adulthood. 
Child Abuse Review, 16(5), 323-341.; Glaser, D. (2000). Child abuse and 
neglect and the brain: A review. Journal of Child Psychology and 
Psychiatry, 41(1), 97-116.
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    What do we mean by high prevalence? There are over 400 million 
children under the age of 18 in sub-Saharan Africa, almost half of the 
total population. In 2011, UNICEF calculated that 53.6 million of them 
were missing one or both parents due to death from all causes, with 8.5 
million missing both parents. Those estimates are low as they do not 
include 10 of the poorest countries in the region such as Niger and 
Somalia.\5\ Put in another way, roughly 1 out of every 8 children in 
sub-Saharan Africa have gone through the profound experience of 
parental loss. Parental loss, while only one vulnerability children 
face, leads to lower household income and higher ratios between 
dependents and earners, exerts pressures on extended families and can 
lead to more child-headed households, and is significantly associated 
with diminished school performance by age,\6\ among many other issues.
---------------------------------------------------------------------------
    \5\ See http://www.childinfo.org/hiv_aids_orphanestimates.php.
    \6\ Bicego, G., Rutstein, S., & Johnson, K. (2003). Dimensions of 
the emerging orphan crisis in sub-Saharan Africa. Social Science and 
Medicine, 56(6), 1235-1247.
---------------------------------------------------------------------------
    We know that some of these children, along with some who still have 
both living parents, end up in some form of residential care. We have 
no confidence on how many. The common global estimate is from 2 million 
to 8 million,\7\ a fourfold range that only serves to emphasize the 
extent of our ignorance. At the higher end, that is equivalent to 
roughly 20 children for every man, woman, and child from my home city 
of Minneapolis. We can say that for those of us who travel abroad 
frequently, orphanages are ubiquitous and easy to find. Any taxi driver 
will know where to take you if asked.
---------------------------------------------------------------------------
    \7\ See http://www.google.com/
url?sa=t&rct=j&q=&esrc=s&frm=1&source=web&cd=2&cad=rja&
ved=0CDYQFjAB&url=http%3A%2F%2Fwww.christianalliancefororphans.org%2Fwp-
content%2
Fuploads%2FChristian-Alliance-for-Orphans-_On-Understanding-Orphan-
Statistics_.pdf&ei=
LkWRUZyKH4X5ygHZwIHQAg&usg=AFQjCNHdQdPBYc5BUy-Dyp0IjBvKV2F1HA&sig2=yl55
_GJSfTkGWDanT-OJPw&bvm=bv.46340616.d.aWc.
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    On a personal note, I can't say that I had a true passion for 
working to alleviate poverty until I first saw the condition of 
children in institutional care. While the quality of institutional care 
varies widely, ``mere poverty'' would be a blessing for many of these 
children. By virtue of their separation from family and society, they 
are, in a sense, completely stripped of their economic and social 
assets and are at the highest level of vulnerability. In many, the 
neural development of the youngest infants is severely compromised by a 
dearth of interaction and stimulation during the day, other than 
perhaps the occasional scheduled visit by an often untrained caregiver. 
Limited data from some institutions shows that there can be up to 30, 
and sometimes 50, infants and young children in a single ward, and that 
children might be exposed to from 60 to 100 different caregivers by age 
two.\8\ While clearly an inappropriate comparison, consider that the 
National Zoo has about one staff member for every 8 vertebrates in its 
collection.\9\
---------------------------------------------------------------------------
    \8\ McCall, R., & Groark, C. (forthcoming). Research on 
institutionalized children: Principles for international child welfare 
practitioners and policy makers.
    \9\ National Research Council of the National Academies. (2004). 
Animal care and management at the National Zoo: Interim report. 
Washington, D.C.: The National Academies Press.
---------------------------------------------------------------------------
    Very generally speaking, studies suggest a child loses 1 month of 
development for every 3 in an institution as a result of the poor 
quality of care, which includes caregiver-child interactions that are 
largely deficient.\10\ One meta-analysis of 75 studies found that 
children in institutions have on average IQ scores that are 20 points 
below their peers in foster care.\11\ The difficult conditions for many 
of these children is only compounded in later years, particularly in 
the very worst facilities where older children might be confined to 
cribs during the day, subjected to physical and/or sexual abuse by 
staff, outsiders or other children, or endure untended medical or 
health needs that can sometimes be severe or life threatening. These 
children experience a profound separation from not only their families 
and communities, but their nation and world. Few are fit to enter that 
world when they become 18: in Russia, a study found that 1 in 3 
orphanage leavers become homeless and 1 in 10 commits suicide.\12\
---------------------------------------------------------------------------
    \10\ Williamson, J., & Greenberg, A. (2010). Families, not 
orphanages. Better Care Network.
    \11\ Cited in ibid.
    \12\ Tobis, D. (2000). Moving from residential institutions to 
community-based social services in Central and Eastern Europe and the 
Former Soviet Union (Washington, D.C.: The World Bank).
---------------------------------------------------------------------------
    In many ways, these children represent the most extreme dimensions 
of life outside of family care. But their circumstances speak to the 
much more difficult environment that many children live in. Recent 
violence surveys from Swaziland, Tanzania, and Kenya find that 1 in 3 
girls is subject to sexual violence before the age of 18, and up to 7 
in 10 experience physical abuse in the latter 2 countries.\13\ The 
Positive Outcomes for Orphans study, which draws in part from data from 
Ethiopia, Kenya and Tanzania, found that 84 percent of abandoned 
children experience physical or sexual abuse.\14\ Roughly 1 in 3 girls 
in lower income countries are married or in union by age 18, and this 
figure approaches 9 out of 10 girls in some countries.\15\ Large 
numbers of children live in child headed households or are on the 
streets, many are engaged in hazardous or forced labor, are victims of 
trafficking, are internally displaced or are refugees, are girls 
subject to genital mutilation or cutting, are engaged in child labor, 
lack birth registration, or are children associated with armed forces. 
Worse, many children experience more than one of these adversities, for 
example, they can be subjected simultaneously or sequentially to both 
sexual and physical violence.
---------------------------------------------------------------------------
    \13\ United Nations Children's Fund and the U.S. Center for Disease 
Control and Prevention. (2010). Violence against children in Kenya: 
Findings from a 2010 national survey.; Reza, A., Breiding, M., Blanton, 
C., Mercy, J. A., Dahlberg, L. L., Anderson, M., & Bamrah, S. (2007). 
Violence children in Swaziland: Findings from a national survey on 
violence against children in Swaziland May 15-June 16, 2007.; United 
Nations Children's Fund, U.S. Centers for Disease Control and 
Prevention, & Muhimbili University of Health and Allied Sciences. 
(2011). Violence against children in Tanzania.
    \14\ Whetten, K., Ostermann, J., Whetten, R. A., Pence, B. W., 
O'Donnell, K., Messer, L. C., . . . Positive Outcomes for Orphans 
Research Team. (2009). A comparison of the wellbeing of orphans and 
abandoned children ages 6-12 in institutional and community-based care 
settings in 5 less wealthy nations. PLoS One, 4(12), 8169.; Kagotho, 
N., & Ssewamala, F. M. (2012). Correlates of depression among 
caregivers of children affected by HIV/AIDS in Uganda: Findings from 
the Suubi-Maka family study. AIDS Care, 24, 1226-1232. doi: 10.1080/
09540121.2012.658754.
    \15\ A United States Government interagency approach to assisting 
the world's most vulnerable children: Fifth annual report to Congress 
on public law 109-95, The Assistance for Orphans and Other Vulnerable 
Children in Developing Countries Act of 2005.
---------------------------------------------------------------------------
    There is one key takeaway here. These are not isolated children 
suffering rights violations at the margins. Rather, these adversities 
represent major dimensions of children's life experiences in poor 
countries, and in many cases affect a large majority of children. 
Further, we know that these experiences have a direct relationship to 
poverty. Data suggest significant correlative relationships between 
child violence, exploitation, abandonment, and neglect and lower socio-
economic status, less education, and poorer health outcomes. For 
example, a recent review of social and child protection linkages in 
West Africa identifies a strong relationship between poverty and 
increased child vulnerability to trafficking, exploitative labor, 
heightened domestic violence and abuse, domestic labor, and early 
marriage.\16\ Research in Eastern and Southern Africa is suggesting 
comparable conclusions.\17\
---------------------------------------------------------------------------
    \16\ Jones, N. (2009). Promoting synergies between child protection 
and social protection: West and Central Africa. Dakar, Senegal: 
Overseas Development Institute/UNICEF West and Central Africa Regional 
Office.
    \17\ Collings, S. (2012). Child sexual abuse experiences mediate 
the effects of poverty and posttraumatic stress disorder. Social 
Behavior and Personality, 40(6), 983-984.; Simister, J. (2009). The 
importance of being earners: Why women in South Africa need well-paying 
jobs. Development Southern Africa, 26(5), 478-481.; Burns, J., & 
Esterhuizen, T. (2008). Poverty, inequality and the treated incidence 
of first-episode psychosis: An ecological study from South Africa. 
Social Psychiatry & Pediatric Epidemiology, 43(4), 331-335.; Uthman, 
O., Lamoko, S., & Moradi, T. (2010). Sex disparities in attitudes 
towards intimate partner violence against women in Sub-Saharan Africa: 
A socio-ecological analysis. BMC Public health, 10(1), 223-230.
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    There is increasing evidence highlighting the linkages between 
lifetime health and adverse experiences. Recent research shows a 
demonstrated relationship between lifetime traumatic history and 
sexually-acquired HIV infection in Tanzania,\18\ and the Global School-
based Student Health Survey in five African countries shows an 
association between physical and sexual violence and suicidal ideation, 
substance abuse, and risky sexual behaviors.\19\ Children born HIV-
positive are negatively impacted in their cognitive development and 
emotional adjustment, and children exposed to HIV in utero but born 
HIV-negative are more susceptible to violence, abuse, and neglect.\20\ 
Adolescents in South Africa affected by AIDS orphan-hood and sickness 
are three times more likely to experience physical and emotional 
abuse.\21\ A recent South African study suggested nearly one in seven 
cases of young women acquiring HIV could have been prevented if the 
women had not been subjected to intimate partner violence.\22\
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    \18\ Pence, B., Shirey, K., Whetten, K., Agala, B., Itemba, D., 
Adams, J., . . . Shao, J. (2012). Prevalence of psychological trauma 
and association with current health and functioning in a sample of HIV-
infected and HIV-uninfected Tanzanian adults. PLoS One, 7(5).
    \19\ Brown, D., Riley, L., Butchart, A., Meddings, D., Kann, L., & 
Harvey, A. (2009). Exposure to physical and sexual violence and adverse 
health behaviors in African children: Results from the Global School-
based Student Health Survey. Bulletin of the World Health Organization, 
87(6), 447-455.
    \20\ Sherr, L. (2011). Distinct disadvantage: A review of children 
under 8 and the HIV/AIDS epidemic.
    \21\ Cluver, L., Orkin, M., Boyes, M., Gardner, F., & Meinck, F. 
(2011). Transactional sex amongst AIDS-orphaned and AIDS-affected 
adolescents predicted by abuse and extreme poverty. Journal of Acquired 
Immune Deficiency Syndromes, 58(3), 336-343.
    \22\ Jewkes, R., Dunkle, K., Nduna, M., & Shai, N. (2010). Intimate 
partner violence, relationship power equity, and incidence of HIV 
infection in young women in South Africa: A cohort study. Lancet, 
376(9734), 41-48.
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    There are many connections that need to be made. We need a much 
more comprehensive picture and understanding of the environments 
children live in and the challenges they face, with efforts aimed at 
reducing toxic stressors from birth, and increasing resilience to 
stress from birth if children are to function fully in the economic and 
social development of their countries. For one example, nations cannot 
hope to achieve their desired educational targets simply by increasing 
teacher-student ratios or changing the curricula being taught in 
schools. Too many children are starting school well below their 
potential, and they continue that schooling facing risks to their 
safety and well-being as they get older. Improving school readiness and 
reducing risks of adverse experiences can have profound effects.
    The second issue concerns fiscal efficiency and economic returns. 
To achieve either, we need to start with the family, and assuming good 
pre-natal health, begin with the child from infancy. Put simply, it is 
cheaper and more cost effective to work with children and families.
    Let's start with the costs of different programs. A pioneering 
study in South Africa compared six different forms of care, and found 
that home-based care was about 12 percent of the cost of statutory 
residential care, and that adoption and foster care were about 16 
percent of the cost of statutory residential care.\23\ A World Bank 
study in Romania found that professional foster care is from 33 to 45 
percent the cost of institutional care, and adoption and foster care 
costs from 7 to 9 percent of institutional care.\24\ In Eritrea, the 
cost of tracing and reintegrating an orphan was from 5 to 7 percent of 
the cost of orphanage care in one study.\25\ In Botswana, psycho-social 
support programs were assessed at 13 percent of the cost of shelter 
care.\26\ A macro analysis of what it would cost to deliver a complete 
and comprehensive package of health, nutrition, education, and other 
services to orphans and vulnerable children found that community 
support programs would represent only 1 to 5 percent of the total 
required, depending on the category and level of need.\27\ In Rwanda, a 
package to deliver significant results to children in adversity was 
costed at just more than $1 per capita. Russia's Government has 
calculated roughly $5,000 in savings from each child abandonment that 
has been prevented.\28\
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    \23\ Desmond, C., & Gow, J. (2001). The most cost effectiveness of 
six models of care for orphans and vulnerable children in South Africa. 
Pretoria, South Africa: UNICEF.
    \24\ Tobis, D. (2000). Moving from residential institutions to 
community-based services in Eastern-Europe and the former Soviet Union. 
The World Bank.
    \25\ Santa-Ana-Tellez, Y., DeMaria, L., & Galarraga, O. (2011). 
Cost interventions for AIDS orphans and vulnerable children. Tropical 
Medicine and International Health, 16, 1417-1426.
    \26\ Formson, C., & Forsythe, S. (2010). A costing analysis of 
selected orphans and vulnerable children (OVC) programs in Botswana. 
Washington, D.C.: Futures Group, Health Policy Initiative, Task Order 
1.
    \27\ Stover, J., Bollinger, L., Walker, N., & Monasch, R. (2007). 
Resource needs to support orphans and vulnerable children in sub-
Saharan Africa. Health Policy and Planning, 22, 21-27.
    \28\ A United States Government interagency approach to assisting 
the world's most vulnerable children: Fifth annual report to Congress 
on public law 109-95, The Assistance for Orphans and Other Vulnerable 
Children in Developing Countries Act of 2005.
---------------------------------------------------------------------------
    Not only is family care less expensive than many alternatives, it 
is more effective. A proverb in Ghana states that ``the orphan does not 
rejoice after a heavy breakfast.'' For most children, families are the 
source of love, nurturing, and support from birth. An infant will be 
picked up and held constantly throughout the day by her mother, 
regardless of whether that mother is rich or poor. In stark contrast, 
studies of children who have been placed from an institution into 
family care show those children arrive in their new homes with poor 
executive functioning and language development, attachment problems, 
psychiatric issues, and behavior problems.\29\ Research from the 
Bucharest Early Intervention Project shows dramatic developmental gains 
for children who were placed from institutions into foster care, with 
the youngest children experiencing greater improvements, again 
demonstrating the need to start from the earliest years of life.\30\
---------------------------------------------------------------------------
    \29\ Johnson, D. E., & Gunnar, M. R. (2011). Growth failure in 
institutionalized children. In R. B. McCall, M. H. van IJzendoorn, F. 
Juffer, C. J. Groark, and V. K. Groza (Eds.). Children without 
permanent parents: Research, practice, and policy. 92-126.; Hawk, B., & 
McCall, R. B. (2011). Specific extreme behaviors of post-
institutionalized Russian adoptees. Development Psychology, 47(3), 732-
738.; Bos, Z., Zeanah, C. H., Fox, N. A., Drury, S. S., McLaughlin, K. 
A., & Nelson, C. A. (2011). Psychiatric outcomes in young children with 
a history of institutionalization. Harvard Review of Psychiatry, 19(1), 
15-24.; Merz, E. C., & McCall, R. B. (2011). Parent ratings of 
executive functioning in children adopted from psychosocially depriving 
institutions. Journal of Psychology and Psychiatry, 52(5), 537-546.
    \30\ Cited in Williamson & Greenberg.
---------------------------------------------------------------------------
    Sadly, we have few robust studies outlining the returns from 
investment from early childhood interventions in lower income 
countries, and this should clearly be made a larger part of the global 
research agenda. One influential study reviewing data and research from 
a large strata of countries finds that being developmentally unprepared 
for entering school is associated with a more than 20 percent loss in 
income later in life, in essence, contributing to poverty in future 
generations.\31\ We can perhaps, with many caveats, extrapolate from 
our own national experience to examine how profound the effects might 
be. In 2012, the direct costs of child abuse and neglect in the United 
States were estimated in one study at $30.3 billion.\32\ Many studies 
in our 50 States show significant economic returns from early childhood 
development programs, as well as programs targeting at risk youth, both 
of which mitigate that neglect. For example, Rob Grunewald and Art 
Rolnick calculated a 16 percent internal rate of return from the 
Michigan Perry Preschool Project, which included early childhood 
interventions and extensive home visits.\33\ A review of the Washington 
State child welfare system found that focusing on expanding effective 
evidence-based programs would yield long term net benefits of between 
$317 million and $493 million, with net taxpayer benefits of estimated 
at between $6 million to $62 million.\34\
---------------------------------------------------------------------------
    \31\ Grantham-McGregor, S., Cheung, Y., Cueto, S., Glewwe, P., 
Richter, L L., Strupp, B., & The International Child Development 
Steering Group. (2007). Developmental potential in the first 5 years 
for children in developing countries. Lancet, 369(9555), 60-70.
    \32\ Gelles, R. J., & Perlman, S. (2012). Estimated annual cost of 
child abuse and neglect. Chicago, IL: Prevent Child Abuse America.
    \33\ http://www.minneapolisfed.org/publications_papers/
pub_display.cfm?id=3832.
    \34\ Lee, S., Aos, Steve, & Miller, M. (2008). Evidence-based 
programs to prevent children from entering and remaining in the child 
welfare system: benefits and costs for Washington. Olympia: Washington 
State Institute for Public Policy. Document No. 08-07-3901.
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    In short, governments and private donors should avoid spending 
scarce resources to develop and support programs that are more 
expensive and less effective than family and community alternatives. 
This is increasingly recognized, and there has been a significant 
global push to move away from inefficient residential care models 
toward family strengthening and other programs. For example, Rwanda is 
undertaking to place all of its institutionalized children (except 
those with disabilities) with families by end-2013, and many other 
countries are taking less aggressive measures to develop appropriate 
alternatives to institutional care.
    My final point is that the United States is uniquely positioned to 
support efforts in this area, and without a major change in programming 
or expenditure. Much can be accomplished simply by changing the way 
that we articulate our positions on global and national priorities, by 
leveraging the global momentum on this agenda and reorienting or 
redirecting some of our existing programs, and by encouraging countries 
to ``stand on their own two feet'' and to establish sustainable systems 
of care and protection that are not dependent on external aid and 
support.
    Let's begin with the current robust global dialogue on establishing 
the successors to the Millennium Development Goals, which set targets 
for 2015. Much of this current dialogue centers on reaching agreement 
on new future targets for sustainable development in lower income 
economies. We should be very clear in our position with respect to the 
post-2015 agenda: preventing poverty in future generations requires us 
to work with today's youngest generations. Today's children are 
tomorrow's hope. The United States can make a tremendous impact simply 
by promoting new targets that focus on ensuring that children begin 
life meeting their development potential, living in families, and free 
from violence. What can be more sustainable than helping a current 
young generation succeed over the next decades?
    At the country level, our dialogue should focus on developing and 
strengthening systems of care and protection for children. We often 
talk about strengthening health systems to prevent and respond to 
disease . . . it is time to use the same language when we speak of 
developing child protection systems that prevent and respond to child 
violence, abandonment, abuse, exploitation, and neglect. The systems 
approach was initially articulated by UNICEF in its 2008 Child 
Protection Policy, and has since been embraced by numerous influential 
non-governmental organizations (NGOs), bilaterals, and private donors. 
A Joint Statement by many of these organizations on child protection 
systems strengthening in sub-Saharan Africa has been drafted and is 
expected to be endorsed shortly. Many countries around the world have 
launched or completed mapping and assessments of their child protection 
systems to give them a baseline picture of what their current systems 
look like and what priorities need to be addressed.
    Working systemically is ultimately about countries and communities 
taking ownership of this agenda, and seeing it as being in their own 
self-interest. It means working on national policies, coordinating the 
work of key national actors (such as ministries of justice, social 
affairs, health, and education) in fulfilling their protective 
mandates, strengthening the social service workforce, improving 
surveillance systems and data collection, improving the access and 
quality of protective services, supporting protective social norms and 
community practices and addressing those that are harmful, and 
including the care and protection of children in the national budget 
dialogue.
    These are areas where change is possible. In Guatemala, USAID 
funded a survey in 2008 that, for the first time, provided specific 
data on children residing in orphanages in the country. Once these 
children were made visible, local courts and social workers were much 
better positioned to follow up on these children's cases, some of which 
had not been reviewed in many years. With support from the GHR 
Foundation and a partner organization, more than 1,000 children were 
reintegrated with their families, and the model is being taken forward 
in large cities such as Guatemala City and Quetzeltenango. In Tanzania, 
the U.S. Centers for Disease Control and UNICEF supported a Violence 
Against Children study in 2009 that revealed the large prevalence of 
violence in the country--as a result, a multi-sector task force was 
established and a national 3-year action plan has been developed that 
will be launched next month. This is occurring in parallel with a major 
strengthening and expansion of the country's child protection 
committees at the district level. In Romania, programs that were 
supported by USAID and others helped lead to a 46 percent decrease in 
institutionalized children between 2000 and 2006.\35\ USAID's Safe 
Schools Initiative is showing impressive results on reducing violence 
in schools in Ghana and Malawi, and is being rolled out in the 
Democratic Republic of the Congo, the Dominican Republic, Senegal, 
Tajikistan and Yemen.\36\
---------------------------------------------------------------------------
    \35\ Cited in Williamson & Greenberg.
    \36\ United States action plan on children in adversity: A 
framework for international assistance: 2012-2017.
---------------------------------------------------------------------------
    While this represents a long-term agenda, we will know that nations 
are on track when we see more children living within appropriate, 
permanent, and protective family care, and fewer separated from 
families and/or placed in institutions. This means access to 
reintegration, fostering and kinship, local and inter-country adoption 
services along with mentoring/transition services that are reliable, 
effective, and working in the best interests of the child. We will be 
further convinced of progress when we see children reaching age 
appropriate growth and development milestones and showing secure 
attachment to primary caregivers. These objectives can only be 
achieved, and will also contribute to, an agenda that focuses on 
reducing violence, exploitation, abuse, and neglect of children. These 
three areas are beautifully articulated in the United States Government 
Action Plan on Children in Adversity.\37\ By incorporating them in our 
international assistance dialogue and programs, we will begin to see 
the paradigm shift that I spoke of earlier in these comments.
---------------------------------------------------------------------------
    \37\ Ibid.
---------------------------------------------------------------------------
    In summary, Mr. Chairman and members of the subcommittee, there are 
three reasons why our foreign assistance programs should focus on 
children in adversity. First, this will improve the effectiveness of 
our expenditures, leading to long-term growth and poverty reduction 
over future generations. Second, it will improve the efficiency of our 
programming, encouraging cost-effective approaches that are owned and 
resourced by our national partners. And third, this United States is 
uniquely positioned to provide the necessary support, and to ensure 
that these issues are placed on the global and national agendas.
    Thank you, Mr. Chairman, Ranking Member Graham and subcommittee 
members, for the opportunity to appear before you today. I stand ready 
to answer any questions you might have.

    Senator Landrieu. Thank you.

                   INSTITUTIONAL CARE AND FOSTER CARE

    Let me start with you, Dr. Nelson. The work that you and 
your colleagues have done has really inspired a much needed 
global conversation, and I really appreciate your leadership on 
the importance of moving away from institutions as a form of 
care for children, which has really been the world's answer to 
unparented children for the last two centuries since the first 
orphanages were created, I mean, in the modern world that we 
know of, I think, probably out of England two centuries ago or 
150 years or so ago. And it's really a conversation that the 
world has not had, now it's having, you know, what are the 
ramifications of institutionalization, et cetera, et cetera?
    So my first question is, what advice would you give to 
governments that are still using, which the United States is 
not, as you know, but that is still using institutional care as 
a place for their orphans and unparented children? What advice 
would you give them? What is the sense of urgency they should 
have?
    And number two, and most importantly, the alternative that 
many governments are seeing to institutions is long-term foster 
care. Could you take a minute to describe, from your 
perspective, what helpful structures of foster care and what 
harmful structures of foster care--and I'm trying to get to the 
question, which is, is foster care always better than 
institutional care? And if so, why? And if not, why not?
    Dr. Nelson. So let me begin with the first question. I 
think that the first advice I'd give to governments would be 
that the more we try to improve institutional care, the longer 
we're going to prolong institutional care and send the message 
to governments that it's okay to raise kids in institutions. 
And what we need to do is change that mindset and essentially 
say that there's psychological harm to the kids, but there's 
also economic harm to the society.
    So a kid coming out of an institution with an IQ of 60 with 
bad attention deficit disorder and no ability to form 
relationships is very unlikely to become an active and a 
contributing member to society and to the economic framework of 
that society. So they're hurting themselves on the economic 
front, leaving aside just the ethics of the harm done to kids. 
So that's the first message I think I would give to 
governments.
    In terms of your second question, I think that we know, as 
a rule, kids do better in families than they do in 
institutions. The middle ground is foster care. We all know the 
hazards of bad foster care. And there are two things that I 
think we define as bad foster care. One is multiple foster care 
placements. But the bigger one is when foster care parents 
don't make a psychological investment in the kids.
    So if we think of good foster care, we start to think of 
features like a good investment in the kid, loving parents. 
They're really looking after the kid. They raise the kids as 
their own. Pretty soon, you're describing a family.
    So what we want to strive for is getting kids into 
permanent families. If foster care is the intermediary step 
before kids are placed in a permanent family, it needs to be 
short term and it needs to be handpicked, high-quality foster 
care, like we set up in Bucharest.
    But the average garden variety foster care in this country 
needs some work, I'm afraid to say.
    Senator Landrieu. Thank you so much.
    Jedd, would you like to add anything to that harmful foster 
care description, and what you've seen in your experience?
    Mr. Medefind. I definitely would. And I would first add one 
caveat, that while we can set family as the ideal and 
relentlessly pursue it, we do know that anyone who dares to get 
close to the world at its most broken sometimes will be dealing 
with broken systems and imperfect solutions, and we can affirm 
that while also relentlessly pursuing that goal of family.
    And the reason we do is because we see that even with good 
foster systems, systems that are at least well-funded like in 
the United States, the outcomes are far less than ideal. The 
statistics I mentioned earlier, by their mid-20s, children in 
the United States who grew up in foster care without being 
adopted, less than half were employed. Of the women, 70 percent 
must rely upon food stamps versus 17 percent overall. And of 
the men, 80 percent have been arrested by their mid-20s.
    And if that is in a very well-funded foster system in the 
United States compared to what we would expect in many parts of 
the world, we need to say that family needs to be ideal that 
we'll always aim for.
    Senator Landrieu. And we're spending approximately, I 
think, $8 billion in our foster care system in United States 
alone. Does anybody in the audience know that? Sorry, $25 
billion. I was off by quite a bit.
    We're spending $25 billion in a foster care system in the 
United States that, unfortunately, in my view, we sometimes 
hold up as a model to other countries. And in our own model, 
which they could never, in developing countries, even meet in 
terms of the funding--$25 billion is a lot of money anywhere in 
the world--our outcomes are still very, very poor.
    So it's not a model that I ever hold up as I travel around 
the world, because as Dr. Nelson said, there is a description 
of good foster care that's helpful and supportive and according 
to science. And then there is the U.S. foster care system that 
has long ago left the model that Dr. Nelson described, which is 
very sad and very unfortunate.

                   IMPROVING CHILD PROTECTION SYSTEMS

    Let me ask, if I could, to Mr. Goldman, a considerable part 
of the work that you do is based on helping foreign governments 
assess strengths and weaknesses in their child protection 
system. Can you talk about any one or two countries that you've 
worked in and kind of describe for the subcommittee how that 
process goes on? And are governments willing and open to share 
with you, in your experience, what their strengths and 
weaknesses are, and share with you the help they need, and et 
cetera, et cetera?
    Mr. Goldman. I would like to preface that, and I think it's 
a very interesting question, with my decades of work just in 
human development, and I feel like we're speaking a new 
language with many of these governments.
    Twenty or 30 years ago, and in the intervening years, it 
was about health. It was about education. It was, in a sense, 
two-dimensional. Very important issues, obviously, in building 
human capital.
    But because poverty surveys and all sorts of surveys are 
not yielding information in this area that was clear to 
governments or their partners, they were just neglected.
    So it has felt since about 2008, 2009, that a lot of this 
has just been about going into countries, whether it's Kenya or 
Tanzania or Vietnam or anywhere, and just talking about, why is 
protection important? Why are families important? Why is 
freedom from violence important?
    We know that health and education systems don't address 
these issues directly. They contribute to an environment that 
can support children, but it's not their mandate, necessarily, 
to protect children.
    Justice systems, even there we've had a big gap in our 
understanding of what needs to be done.
    So in recent years, I think there's been an effort to look 
systematically, map and assess child protection systems in many 
countries, in Asia, in sub-Saharan Africa, that's led to an 
entry point to talk about abuse, neglect, abandonment, 
exploitation of children, and to think a little more 
comprehensively about the policies and the government systems 
and the community role and all of that.
    Senator Landrieu. Is there any country that you 
particularly worked in or had some experience that would serve 
maybe as, real quickly, just an example of some government that 
is making some advance?
    Mr. Goldman. Yes. I won't repeat Rwanda. Why don't I add 
Tanzania.
    Tanzania, because of the results of the violence against 
children surveys, has really mobilized and developed a national 
action plan, which will be rolled out next month. They have 
developed child protection committees throughout the country, 
and they're replicating those. Those include both formal 
officials as well as local stakeholders.
    Senator Landrieu. And who conducted that survey or who led 
it and who funded it?
    Mr. Goldman. That was supported by UNICEF and the CDC. I 
believe there was a university also involved. I'm not entirely 
sure.
    And it was a multiyear, very thorough study that has 
yielded remarkable data that the government has then taken and 
acted on because it was made visible to them and the partners 
were also----
    Senator Landrieu. And would you say that the data of that 
study were shocking to the government and mobilized them to 
action?
    Mr. Goldman. I think so, yes.
    Senator Landrieu. Okay.
    Mr. Medefind, do you want to add anything to your 
testimony, which was outstanding as usual, but go ahead.
    Mr. Medefind. Thank you. You know, I think one important 
thing would be, we would never want to create a false dichotomy 
between the goal of families for children that are outside of 
parental care and broader anti-poverty efforts, child survival 
efforts. I see those two as very much complementary, not 
competitive, and we can champion both at the same time.
    But I think we can also realize that government will always 
have a natural gravity toward these child protection and 
survival efforts with good reason, because those are the things 
that government naturally can do more effectively. And when all 
of us come after a big issue, a big, difficult, complex 
problem, we tend to draw from those tools which are in our 
toolbox.
    And so government will draw from those things that it can 
produce on a mass scale, the medicine and food and shelter and 
education. Those are great things. But we can also say, for 
unparented children to thrive, we know they need more than 
that.
    And so government will need to kind of go beyond its 
natural proclivity, beyond itself, to form those key 
partnerships with faith communities, with nonprofit 
organizations, and community civic organizations, to be able to 
provide the things that government can't provide, especially 
the nurture, attachment, affection that only families can give 
kids.

                FUNCTION OF INTERNATIONAL ORGANIZATIONS

    Senator Landrieu. And I know you've given some thought to 
what some of the major international organizations outside of 
the direct arm of our Government which is USAID, but 
organizations that are both government and private-funded like 
UNICEF or like Save the Children, or like--what would be 
another? I guess UNICEF and Save the Children are the two 
largest.
    What role could those organizations play, in your mind, 
that might be a little bit more effective in connecting kids to 
families?
    Mr. Medefind. Well, I think, number one would be, they can 
continue to do the great work they're doing in child survival 
and protection. Those are, I think, their natural strong suits. 
They operate on a large scale and can do those things on a 
grand scale, and that's a tremendously complementary effort to 
the goal of children and families.
    To preserve families and ensure that they don't 
disintegrate is really central in this whole vision. At the 
same time, I think that they can take steps to work more with 
those local organizations, faith-based groups, network of 
churches, and other houses of worship, smaller community 
organizations, to ensure that they're recruiting families that 
have the right motivation to take children in, whether this is 
in the high-quality foster care that Dr. Nelson was talking 
about or permanent families, ideally. That should always be the 
ideal of permanent attachment of loving caregivers.
    So those are, I think, the two things that we can always 
hold in tension, that continued commitment to child survival 
and protection, and yet pressing beyond that toward the goal of 
permanent families for children, whenever that's possible.

                          INTERCOUNTY ADOPTION

    Senator Landrieu. And why, in your view, is intercountry 
adoption an important option to leave? I know that our focus is 
to try to place every child within a family in their own 
country, but is that always possible? And if, not why is 
intercountry adoption an important option for many of these 
children?
    Mr. Medefind. Well, the goal of the Christian Alliance for 
Orphans is that, ultimately, the local community would be the 
primary answer for the orphans of that community, the children 
that are truly unparented.
    But we know now, living in a broken world, that that is not 
always possible. And as Dr. Nelson mentioned, for children, 
it's not a matter of years, it's a matter of months and 
sometimes even days that their development can be severely 
impacted, if they're growing up outside of parental care.
    And so at least within the world we live in now, we need to 
be committed to both placing children locally whenever that is 
possible, but if it's not, children need families wherever 
those families may be found. And sometimes, the only route to 
that is through international adoption.
    Senator Landrieu. Dr. Nelson, do you want to add anything 
before we wrap up?
    Dr. Nelson. Just one thing, if I might. I think, by now, 
the notion that what happens early can impact child development 
has worked its way into the fabric of our thinking. But what we 
forget sometimes is that these experiences work their way into 
the biology of the organism, which can affect the child for his 
or her lifetime.
    And one example of that is, at the end of the Second World 
War in Holland, there was a brief famine. The women who were 
pregnant during that famine, the offspring have been studied 
for the last 70 years. These individuals are still impacted by 
that very brief period of food deprivation that occurred when 
they were fetuses. They had poor attentional control, for 
example.
    So I think as we talk about these early life events, we 
have to keep in mind that it's not just that what happens to a 
1-year-old will influence them when they're 5. It may influence 
them when they're 50. So that's something we should keep in 
mind.
    Senator Landrieu. Thank you, Dr. Nelson. I really 
appreciate you and your colleague trying to help this 
subcommittee and other committees have a sense of urgency about 
this, that 3 months or 6 months in the life of the child, a lot 
of damage can occur. And the sooner we are able to mobilize our 
eyes, our intellect, to try to identify as early in a child's 
life the likelihood that they will have a parent to parent 
them, and if not, a relative that will and is able, and if not, 
finding a family for that child, not only is it better off that 
child is going to be, the stronger the community will be, the 
stronger that government will be, the stronger the world will 
be.
    And I just feel like we're making progress, but I think 
this hearing has done a lot to help, and I really appreciate 
you all being available.

                     ADDITIONAL COMMITTEE QUESTIONS

    Let me just state one more time, as we call this meeting to 
a close, that there are additional questions that can be asked 
of panel one or two. Questions can be submitted through our 
subcommittee. We will submit them in writing to the panelists 
until 5 p.m. on Friday. And then any additional testimony that 
you all have can be given until 5 p.m. on Friday.
    So any comments or questions from any organizations 
listening in, any individual citizens that have a view about 
this subject, we do want to hear from you, because I think this 
is an important priority for the subcommittee.
    [The following questions were not asked at the hearing, but 
were submitted to the Department for response subsequent to the 
hearing:]
              Questions Submitted to Hon. Donald Steinberg
             Questions Submitted by Senator Lindsey Graham
    Question. Public Law 109-95 mandates that USAID assume the role of 
``lead agency'' in all efforts related to the development and 
implementation of the Action Plan for Children in Adversity.
  --Can you please describe what resources and/or authorities are 
        necessary for USAID to continue to be most effective in this 
        role in the future?
  --To what extent have other implementing agencies been responsive to 
        your call for better coordination and focus?
    Answer. As the ``lead agency'' for the U.S. Government Action Plan 
on Children in Adversity (Action Plan), USAID has recently established 
a Center of Excellence on Children in Adversity in the Bureau for 
Global Health. The Center brings together USAID's technical experts--at 
the Missions and in Washington--who are leading our response to the 
world's most vulnerable children. Dr. Neil Boothby, the U.S. Government 
Special Advisor and Senior Coordinator to the USAID Administrator on 
Children in Adversity, directs the Center. We are in the process of 
assessing the alignment of current resources and programs, which 
operate under various offices in response to separate legislative 
mandates, in order to help support the successful implementation of the 
Action Plan and the work of the Center. As with any activity in today's 
Federal budget environment, however, the objectives of the Action Plan 
are in competition with many other priorities for scarce resources.
    Our U.S. Government interagency partners have been very responsive 
to our call for better coordination and focus. Representatives from 30 
offices within seven departments and agencies worked together to draft 
the Action Plan, which received prompt interagency and OMB clearance 
last year. These same offices have developed agency- and department-
specific implementation plans in response to the Action Plan. These are 
forward-looking plans, specifying how each U.S. Government entity that 
committed to the Action Plan will work to achieve its objectives. The 
consolidated interagency implementation plans reflect how interagency 
partners are using existing resources to meet the Action Plan's 
objectives.
    Question.
  --What is the fiscal year 2012 estimate for programs across the U.S. 
        Government that address the needs of children in adversity, and 
        who is responsible for tracking such expenditures?
  --Regarding the President's fiscal year 2014 budget request, what 
        funding level within the 150 account is anticipated for 
        programs for children in adversity?
  --Are these funds double counted? For example, is funding for basic 
        education in Rwanda counted toward that activity and children 
        in adversity?
  --What is the total funding level for children in adversity across 
        all Government programs in the President's fiscal year 2014 
        request?
    Answer. In previous years, annual reports to Congress on Public Law 
109-95 included a breakdown of U.S. Government assistance to highly 
vulnerable children, as collected through an interagency data call 
facilitated by the Public Law 109-95 secretariat. Because the criteria 
for inclusion were extremely broad, the reliability of the information 
was limited and, therefore, the exercise was discontinued. However, in 
fiscal year 2010, 30 offices within seven U.S. Government agencies and 
departments spent approximately $2.66 billion for more than 1,700 
projects in over 100 countries targeting ``highly vulnerable 
children.''
    In response to the U.S. Government Action Plan on Children in 
Adversity (Action Plan), a new system is currently under development to 
reflect the levels of funding that support objectives and outcomes 
specified in the Action Plan. A collaborative interagency process is 
underway to create a system to capture simple descriptive information 
on projects that contribute to the Action Plan, and whether they are 
designed to measure one or more of its outcomes. The inclusion criteria 
for projects--projects that ``count''--will be predefined and focused. 
A global profile of interagency progress, including funding levels, 
made toward achieving whole-of-government coordination in relation to 
the Action Plan, will be made within 1 year of the release of the 
Action Plan and on an annual basis for the Action Plan's five-year 
timeframe.
    In the meantime, in accordance with the Action Plan and in line 
with the legislative requirements set forth in Public Law 109-95, 
agency- and department-specific implementation plans are due within 180 
days of the plan's launch. These are forward-looking plans, specifying 
how each U.S. Government entity that committed to the Action Plan will 
work to achieve its objectives. The consolidated interagency 
implementation plans, which will be posted online in July 2013, reflect 
how interagency partners are using existing resources to meet the 
Action Plan's objectives. Some activities, like USAID's Displaced 
Children and Orphans Fund (DCOF), are able to clearly state funding 
levels that contribute to the Action Plan's objectives. Other offices 
within U.S. Government agencies and departments are as yet unable to 
specify how much of their existing portfolio will be used to support 
the Action Plan's objectives.
    Public Law 109-95 provides no new resources to support the 
objectives of the Action Plan. To better meet the demands of the core 
objectives, USAID is assessing the alignment of existing programs to 
meet the Action Plan's objectives, as well as support for the rollout 
of activities in priority countries. Likewise, U.S. Government agencies 
and departments that are participating in the Action Plan have agreed 
to use existing resources to achieve its objectives. Funding levels for 
implementation of the Action Plan's objectives in priority countries 
are being determined.
                                 ______
                                 
           Questions Submitted by Senator Frank R. Lautenberg
    Question. I have long supported efforts to promote the protection 
and development of children around the globe, and I am pleased that the 
National Action Plan (NAP) on Children in Adversity recognizes the 
importance of developing a comprehensive approach to preventing and 
responding to the needs of children facing danger, deprivation, and 
exploitation. The NAP on Children in Adversity includes numerous 
actions that implementing agencies will take to achieve the six 
objectives, and it is my hope that these actions will lead to improved 
coordination and efficiency among the agencies working towards these 
efforts.
  --How will these implementing agencies coordinate to ensure that they 
        are not undertaking duplicative actions?
  --How will the implementing agencies work to reduce overlap in 
        implementation actions with other strategic documents such as 
        the NAP on Women, Peace, and Security?
  --How will each implementing agency share its planned programs and 
        budget with each other to achieve the outcomes highlighted for 
        each objective?
  --How will the six priority countries be selected for the starting 
        point of these efforts?
    Answer. An interagency working group has been meeting on a 
quarterly basis since 2006, convened and chaired by the Special 
Advisor, a position mandated by Public Law 109-95. This is the primary 
vehicle for interagency coordination, and the mechanism through which 
the U.S. Government Action Plan on Children in Adversity (Action Plan) 
was developed.
    In accordance with the Action Plan and in line with the legislative 
requirements set forth in Public Law 109-95, agency- and department-
specific implementation plans are due within 180 days of the Action 
Plan's launch. These are forward-looking plans, specifying how each 
U.S. Government entity that committed to the Action Plan will work to 
achieve its objectives. The consolidated interagency implementation 
plans reflect how interagency partners are using existing resources to 
meet the Action Plan's objectives. These are ``living documents'' and 
may be amended to reflect developments and changes in U.S. Government 
programming over time. The implementation plans will be posted online 
in July 2013. The implementation plans--which include information 
pertaining to activities, country focus, outcomes, and budgets--will be 
used to analyze the overall U.S. Government international assistance 
portfolio for children in adversity, including possible areas of 
duplication and gaps. This facilitates coordination among programs that 
support the Action Plan, as well as other strategic policy documents, 
including the NAP on Women, Peace, and Security. At this point, we are 
less concerned about duplication and more so about gaps.
    While the Action Plan applies to U.S. Government assistance 
globally, it also identifies a more targeted starting point for these 
efforts: to achieve three core outcomes in at least six focus countries 
over a span of 5 years. In these countries--through U.S. Government 
collaboration with other government, international, private, faith-
based and academic partners--the Action Plan calls for significant 
reductions in the number of:
  --Children not meeting age-appropriate growth and developmental 
        milestones;
  --Children living outside of family care; and
  --Children who experience violence or exploitation.
    Advances toward these core outcomes necessarily require the 
selection of countries in which collective assistance across 
vulnerability categories can be harnessed at scale. Designation is 
being based on consultations with Congress, U.S. departments and 
agencies, partner donor governments, and other stakeholders. To promote 
country ownership and ensure meaningful engagement in the additional 
and intensive effort required for transformational positive change in 
children's lives, host country governments will be full participants in 
discussions, planning, and negotiations from the outset.
    The vision for priority countries is proof of concept: ensuring 
that U.S. Government assistance is comprehensive, coordinated and 
effective at the country level by focusing on the Action Plan's three 
core outcomes over a span of 5 years. In essence, focus countries are 
``laboratories'' for achieving, scaling up and sustaining greater 
results for children through a defined and comprehensive approach. A 
focus on outcomes, measurement and results reporting are Action Plan 
and Public Law 109-95 requirements.
    Question. While I am very supportive of this new ``whole of 
government'' approach to improving the lives of vulnerable children, I 
am concerned that the NAP does not include any mention of the need for 
increased funding to be committed towards these efforts.
  --How will the administration's fiscal year 2014 budget help 
        implementing agencies listed in the National Action Plan meet 
        the demands placed on them to achieve the core objectives?
  --What impact could sequestration have on our efforts to meet these 
        objectives?
    Answer. Public Law 109-95 provided no new funding to support the 
objectives of the U.S. Government Action Plan on Children in Adversity 
(Action Plan). To better meet the demands of the core objectives, USAID 
is assessing the alignment of existing programs to meet the Action 
Plan's objectives, as well as support for the rollout of activities in 
priority countries. Likewise, U.S. Government agencies and departments 
that have agreed to the Action Plan will use existing resources to 
achieve its objectives.
    In accordance with the Action Plan and in line with the legislative 
requirements set forth in Public Law 109-95, agency- and department-
specific implementation plans are due within 180 days of the Action 
Plan's launch. These are forward-looking plans, specifying how each 
U.S. Government entity that committed to the Action Plan will work to 
achieve its objectives. The consolidated interagency implementation 
plans reflect how interagency partners are using existing resources to 
meet the Action Plan's objectives. An analysis of the implementation 
plans has illuminated gap areas, including inadequate resources to 
achieve objective 2 (Family Care First) in priority countries. USAID is 
committed to addressing these issues and is providing an increased 
focus on the implementation plans, including the achievement of Family 
Care First. Sequestration, along with other possible future cuts to the 
USAID budget, will make it very difficult to achieve the development 
and humanitarian assistance objectives laid out for USAID. As with any 
activity in today's Federal budget environment, the objectives of the 
Action Plan are in competition with many other priorities for scarce 
resources.
    Question. Over the past 3 years, I have written to the 
administration several times concerning my interest in ensuring that 
U.S. aid to Haiti is spent as efficiently and effectively as possible. 
In particular, I have expressed concern about the speed and 
accountability of aid distribution, as well as progress made on the 
prevention of gender-based violence and the protection of children.
  --Three years after the earthquake in Haiti, what progress has USAID 
        seen in its efforts to strengthen child protection systems, 
        build the Haitian public education system, and improve child 
        healthcare services? What challenges has USAID faced that have 
        hindered progress on these efforts?
  --How will the actions in this National Action Plan work to better 
        coordinate and streamline U.S. aid to Haiti on these specific 
        efforts?
    Answer. Over 46 percent of the population in Haiti is under 18 
years old, meaning the protection of the rights of children and youth 
is fundamental to the population's well-being as a whole and to its 
prospects for economic development. To strengthen the protection of 
vulnerable groups, USAID is supporting efforts by the Government of 
Haiti (GOH), non-governmental organizations (NGOs), and community 
organizations to prevent abuses and address victims' needs. The U.S. 
Government's (USG) cross-cutting sector programming highlights efforts 
that have been undertaken to better coordinate USG assistance on 
gender-based violence (GBV) and child protection issues. Although Haiti 
was not selected as a priority country to pilot the USG Action Plan on 
Children in Adversity, the plan has provided a framework for organizing 
and focusing USG investments around key objectives, specifically (1) 
building strong beginnings through support for early reading removing 
education barriers and health initiatives for pregnant women and young 
children, (2) putting families first through U.S. President's Emergency 
Plan for AIDS Relief (PEPFAR) funded initiatives to mitigate the impact 
of HIV and AIDS on vulnerable families and prevent unnecessary family 
separation, and (3) protecting children against violence through cross-
sectoral protection activities supporting children, youth and women.
    Lack of access to quality education remains a key obstacle to 
Haiti's social and economic development. Surveys indicate that 
approximately 35 percent of Haitian youth are illiterate and that the 
average Haitian child spends less than 4 years in school. Approximately 
75 percent of teachers lack adequate training. After the 2010 
earthquake that destroyed or damaged many schools, the GOH made free 
and universal education a key priority. In 2011, the GOH's Ministry of 
National Education and Vocational Training (MENFP) began the rollout of 
an operational plan to get 1.5 million students in school by 2016, 
improve curricula, train teachers, and set standards for schools.
    USAID is committed to helping the GOH improve basic education. 
USAID's education program, Tout Timoun Ap Li (ToTAL), is helping to 
build the reading skills of children in first through third grades in 
the three USG development corridors in the Northern, St. Marc, and 
Port-au-Prince areas. Over the course of 2 years, ToTAL will provide 
more than 28,000 children with innovative reading curricula that meet 
international standards for best practice literacy instruction. ToTAL 
is also developing and implementing innovative teacher training and 
community literacy activities. This initiative will eventually reach 
more than one million children nationwide as other partners extend the 
use of the program's curricula and training methods beyond the three 
development corridors. USAID is also providing technical assistance to 
build the capacity of the Ministry of National Education to foster 
public-private partnerships and assist in the licensing and 
accreditation of schools. Since January 2013, USAID has trained 800 
principals and teachers through ToTAL on how to implement the new 
curricula for Haitian Creole and French. Additionally, USAID has 
distributed 30,000 reading books and workbooks, 800 teacher guides, and 
400 posters at 200 primary schools in the St. Marc and Northern 
Corridors.
    In addition to the ToTAL program, USAID plans to assess the size 
and scope of educational barriers for vulnerable children including 
child laborers, out-of-school youth and children with disabilities. The 
findings will assist the Ministry of Education in developing strategies 
for addressing the educational needs of the most vulnerable children. 
In addition, for the past decade, through PEPFAR funded activities for 
children affected by HIV and AIDS, over 37,000 of the country's most 
vulnerable children have been directly supported to attend elementary 
school and cover the costs of their school fees through livelihoods 
support. Globally, the relationship between school attendance and 
protection, particularly among girls, is positive.
    USG programming has also been making gains in the health sector in 
regards to child services. Prior to the earthquake, the USG was 
providing access to a basic package of health services, including 
maternal and child health services, for approximately 50 percent of the 
population. Following the earthquake, the USG continued this support 
and moved quickly to address new health concerns. While major 
challenges remain in the health sector, a newly released nationwide 
health survey of Haiti shows positive trends in key health-care 
indicators, in particular, those of children.
    The latest Demographic and Health Survey, conducted by the Haitian 
Ministry of Public Health and Population with donor support in 2012, 
compares favorably with the last survey, conducted in 2006. Of note 
were improved indicators for child vaccination and malnutrition, as 
well as infant and child mortality. Childhood vaccinations increased 
from 53 percent in 2006 to 62.5 percent in 2012. The survey showed that 
22 percent of children under 5 suffer from chronic malnutrition, a 
decrease from 29 percent in 2006. The survey also revealed a decrease 
in acute malnutrition from 10 percent in 2006 to 5 percent in 2012 and 
a decrease in percentage of children underweight from 18 percent to 11 
percent. Childhood mortality has decreased over the last 15 years. 
Survey results show that infant mortality has decreased from 79 to 59 
deaths for 1,000 live births. In addition, mortality for children under 
5 has also decreased from 112 deaths to 88 deaths per 1,000 live 
births.
    Since 2009, through the Community Health and AIDS Mitigation 
Project (CHAMP), implemented by FHI 360, USAID has supported a 
nationwide effort to extend health and HIV and AIDS services to 
vulnerable communities, families, and specifically children orphaned 
and made vulnerable for HIV and AIDS (OVC). The comprehensive care 
provided under this project includes education, livelihoods, and 
psychosocial support and facilitates access to health, nutrition and 
protection services. USAID's Management Sciences for Health/Sante pour 
le Developpement et la Stabilite d'Haiti (MSH/SDSH) project supports 
government managed health facilities and increases access among 
vulnerable children to critical pediatric and general clinical care 
services beyond pediatric AIDS. The MSH/SDSH project also provides 
psychosocial support and legal assistance referrals to victims of 
gender-based violence (GBV) and child victims of emotional, physical 
and sexual violence within 31 sites located in nine geographical 
departments. USAID is preparing to award a new OVC care project to 
replace CHAMP. The project will continue direct support for OVC as well 
as scale up economic strengthening activities to better enable families 
to care for vulnerable children in the long term. The OVC Projects 
operate in collaboration with and under the supervision of the Ministry 
of Social Affairs and Work (MAST), Institute of Social Welfare and 
Research (IBESR), and the Ministry of Health.
    Children and youth in Haiti have become increasingly vulnerable to 
human rights abuses, including GBV, trafficking, sexual exploitation, 
child labor, domestic violence, and recruitment into crime or violence. 
USAID's programs aim to protect at-risk children and youth or victims 
of human rights abuses. In 2012, USAID signed a five-year cooperative 
agreement with Care International for the Protecting the Rights of 
Children, Women, and Youth project. This cross-sectoral protection 
mechanism, funded by USAID's Democracy and Governance program and 
PEPFAR, aims to improve the safety and security of women, children and 
youth by decreasing the incidence of human rights abuses and expanding 
access to services and care. While the project will work at the 
national level to strengthen the legislative framework, it will also 
work at the community level to establish and strengthen referral 
networks and service delivery involving hospitals, churches, schools, 
police stations, and other community institutions in the USG 
development corridors, and in the border areas as well as the Southwest 
region, which is considered a source for child domestic servitude.
    Additionally, USAID, in coordination with other USG agencies, is 
mobilizing two programs to work with the Ministry of Justice, the 
Institute of Social Welfare and Research and the School of Magistrates. 
These programs aim to train judicial actors, local elected and other 
community leaders on child protection laws recently released by the 
Haitian Child Protection institution, IBESR. Furthermore, upon IBESR's 
request and in line with USG Action Plan on Children in Adversity 
objectives, USAID will provide technical support to the GOH to 
elaborate a National Child Protection Strategy. To help strengthen the 
Child Protection System, USAID is supporting IBESR as an entity working 
under the Ministry of Social Affairs to set up national case management 
procedures for child protection vulnerabilities.
    The USG is also supporting large scale and rigorous research in 
order to better understand violence against children in Haiti. 
Currently, USAID, in conjunction with the Centers for Disease Control 
(CDC), is collaborating closely with a government led multi-sectoral 
taskforce to develop a response plan addressing the findings of the 
2012 PEPFAR funded national Violence Against Children Survey (VACS).
    In addition to the above actions, USAID/Haiti recently hired a 
Child Protection Advisor to work with the USAID/Haiti Mission and other 
USG agencies to advise, integrate and coordinate child protection 
activities, and has set up USG Interagency Child Protection Working 
Group. Also, in 2012, the U.S. Embassy in Haiti created a multi-agency 
Disabilities Task Force which is addressing the mission's role in 
programming for people with disabilities, with children as a primary 
focus. This initiative will promote access to Embassy services and 
programs and a more inclusive workplace for Haitians with disabilities.
                                 ______
                                 
                Questions Submitted to Dr. Susan Bissell
           Questions Submitted by Senator Frank R. Lautenberg
    Question. I have strongly advocated for a robust U.S. commitment to 
reducing and preventing sexual and gender-based violence, and I am 
pleased that the United Nations Children's Fund (UNICEF) has joined 
with U.S. agencies and private partners to establish the Together for 
Girls initiative. Our enormous efforts towards and investments in the 
promotion of gender equality and women's empowerment cannot be achieved 
if women and girls continue to be targeted for violence and trafficking 
around the globe.
  --What progress has the Together for Girls partnership made in the 
        development of surveys on violence against children, 
        particularly violence targeting girls, and support for programs 
        in countries aimed at combating sexual violence? Why are strong 
        U.S. investments in this partnership critical to furthering 
        these efforts?
    Answer. Together for Girls is an innovative partnership formed to 
address violence against children, with a particular focus on sexual 
violence and girls. The initiative brings together five UN agencies, 
led by UNICEF; the U.S. Government (through the President's Emergency 
Plan for AIDS Relief (PEPFAR) and its implementing U.S. Government 
agencies, as well as the Centers for Disease Control (CDC) Division of 
Violence Prevention and the U.S. Department of State Office of Global 
Women's Issues); and private sector partners. The objectives of the 
partnership are tightly aligned with those of UNICEF, as well as the 
U.S. Government National Strategy for Children in Adversity.
    Together for Girls focuses on three pillars: (1) conducting and 
supporting national surveys on the magnitude, nature and impact of 
violence against children; (2) supporting coordinated programme actions 
in response to the data; and (3) leading global advocacy and public 
awareness efforts to draw attention to the problem and promote 
evidence-based solutions. In addition, developing and strengthening the 
capacity of individuals and institutions at country level is an 
important crosscutting element of the partnership. Working with 
governments and civil society throughout the world, the Together for 
Girls model builds on existing programmes and platforms wherever 
possible, to integrate the issue of violence against children into 
social welfare, health, education, and justice programmes. This 
integration and coordination aspect is an important output of the 
partnership, improving efficiencies and linking efforts around the 
common goal to eliminate violence against children.
    The Together for Girls partnership has made remarkable progress 
since its launch in 2009. A key component is the development and 
application of a Violence Against Children Survey (VACS), providing 
ground-breaking national household survey data on the dimensions of the 
problem in low-income countries and using the data generated to 
mobilize a national level response. The VACS is a nationwide household 
survey that interviews 13-24-year-old males and females on their 
experiences of emotional, physical and sexual violence. The survey 
process is led by a national steering committee or Multi-Sector Task 
Force (MSTF), led by a relevant government ministry. While specifics 
vary between countries, usually under the direction of the partner 
government, the UNICEF in-country office coordinates work on the ground 
including contracting with a local research institution for field 
interviews and data collection. CDC provides technical assistance and 
quality assurance to carry out the survey, data collection and 
analysis.
    To date, the results from the VACS in four African countries--
Swaziland, Tanzania, Zimbabwe and Kenya--are changing the global 
landscape in terms of what we know about the abuse of children, 
especially sexual violence. Across the survey countries, 28 percent to 
38 percent of females reported an unwanted sexual experience before the 
age of 18.\1\ For males, the range is from 9 percent to almost 18 
percent.\2\ Between one in two and one in four females reported her 
first sexual experience was ``unwilling''.\3\ Only around 50 percent of 
girls ever disclosed the experience, only a very few ever seek 
services, and fewer still receive them. These numbers are even worse 
for boys where the stigma is even greater. The data also consistently 
confirms findings from similar surveys in the United States and Europe, 
which found that these childhood experiences have serious immediate and 
long-term impacts, including poor school performance and drop-out, high 
risk behaviors associated with HIV/AIDS, early pregnancy (and the 
associated poor maternal outcomes), depression and suicide.
---------------------------------------------------------------------------
    \1\ Findings are from four different reports: See Reference 13 
(Kenya 2012, Zimbabwe 2012, Tanzania 2011, Swaziland 2007).
    \2\ Findings are from three different reports: Kenya 2012, Zimbabwe 
2012, Tanzania 2011.
    \3\ See Reference 34.
---------------------------------------------------------------------------
    These data have mobilized policy makers to develop and implement 
coordinated national responses to strengthen child protection systems 
and incorporate violence prevention and response measures into key 
sectors, such as health, social welfare, justice and education. This 
multi-sectoral approach not only serves as a vehicle to coordinate 
across government, but also brings in civil society and children 
themselves and is enhancing donor and partner coordination. In 
addition, as word spreads on the VACS, the data and the evidence based 
multi-sectorial responses, the demand for national violence against 
children surveys is increasing and is providing a strong case for a 
multi-sector systems approach that engages communities. Haiti, 
Cambodia, Indonesia and Malawi are currently in the process of 
completing surveys, an additional 10 countries are actively planning 
for a VACS and many more have expressed interest and would like to move 
forward.
    Examples of how the VACS data has mobilized strong action in 
countries, is impressive.
  --Swaziland has passed Child Welfare Bill and Domestic Violence and 
        Sexual Offenses Bill, introduced child friendly courts, trained 
        police and is now introducing One Stop Centers for post-rape 
        care.
  --The Government of Tanzania developed a costed national action plan 
        that engages multiple ministries and civil society to address 
        the findings. They have completed the first year of 
        implementation and have just launched the medium term plan for 
        the next 3 years. The plan directly addresses work and capacity 
        building across social welfare, health, education, and justice, 
        working at the village, ward, district, and regional levels. 
        The first child protection teams have been established in eight 
        districts and district level managers are now budgeting for 
        child protection. Special Women and Children's desks are being 
        established in every region and One Stop Centers for 
        comprehensive post rape care are being established. A child-
        abuse hot line is now operational in five districts and 
        community awareness campaigns are being planned to raise 
        awareness and promote prevention. In addition, there is a 
        strong focus on teaching children about their rights.
  --Both the Government of Kenya and the Government of Zimbabwe have 
        released comprehensive multi-national action plans in the last 
        6 months and are beginning implementation.
  --All programs have strong elements that try to reach children and 
        make them aware of their risks and their rights and in 
        particular to develop the protective assets of girls.
    In addition, through the Together for Girls partnership, in 
collaboration with PEPFAR and USAID, new guidelines have been developed 
for clinicians on post-rape care for children.
    The Together for Girls partnership has been able to bring data, 
action, and results to the issue of violence against children and is 
uncovering a problem of a magnitude that is hard to imagine. CDC 
currently estimates that one billion children experience child abuse, 
including child sexual abuse, with significant long-term negative 
consequences. The problem is large and requires coordinated, multi-
sectoral action, and the Together for Girls partnership provides a 
forum to ensure that close collaboration on the ground and globally. It 
also brings together communities working on issues of gender-based 
violence, child protection, and violence prevention efforts, using a 
life-cycle approach to the issue. Important efficiencies are gained by 
using a model that builds on existing programs wherever possible, thus 
reducing duplication and enhancing the utilization of scarce resources.
    The U.S. Government's investments in surveys, response plans, and 
support for the Secretariat have been and will continue to be 
indispensible. There has been a large demand for the surveys and 
participation in the Together for Girls initiative because government 
leaders and practitioners have come to recognize the value of obtaining 
nationally representative data on violence, and the powerful catalytic 
impact these surveys can have to mobilize national action. The U.S. 
Government has played a critical role, including key and timely staff 
and financial support to carry out the surveys and follow-up action. 
The national plans have also provided an outstanding vehicle to 
coordinate donor investments and sustainable responses--again an area 
where U.S. Government funding is essential.
    Moving forward, the partnership will not only focus on improving 
data and awareness around violence against children but also make an 
important contribution to the evidence on programs that work to address 
violence--in both prevention and response. Effective programs that have 
been piloted will be brought to scale, and community mobilization 
efforts will be supported for long-term and sustainable change. Robust 
and consistent funding is required to sustain this important and 
successful initiative.
    Question. For more than 5 years, I have been calling on the 
Government of Guatemala to implement a transparent and predictable 
process that will allow the hundreds of pending American adoptions to 
be resolved both fairly and expeditiously. I have applauded the 
Guatemalan Government's efforts to reform its inter-country adoption 
system and share the goal of ensuring that children in Guatemala and 
their birth parents are protected from exploitation. However, I am 
concerned that more than 100 U.S. transition adoption cases are still 
pending, including several of my constituents' cases. I understand 
UNICEF has worked closely over the years with the International 
Commission against Impunity in Guatemala evaluating the adoption system 
there. My office met with you in 2010 to discuss these cases and 
appealed for UNICEF's involvement in resolving them.
  --Does UNICEF believe the 112 outstanding U.S. transition adoption 
        cases in Guatemala should be resolved? If so, what is the 
        agency currently doing to support the resolution of these 
        cases?
    Answer. UNICEF expects all outstanding transition adoption cases in 
Guatemala to be resolved, in an ethical and transparent way, as quickly 
as possible. The Guatemalan Government is now working on a timeline 
agreed across the relevant Guatemalan authorities for resolving the 
remaining cases. Over the last few years, UNICEF has provided 
considerable support to the relevant authorities, to support the 
resolution of transition cases.
    Question. According to the U.N. Population Fund, more than 140 
million girls will become child brides between 2011 and 2020. I know 
UNICEF agrees that this is a severe violation of human rights and 
damages the health, security, and well-being of children. In March 
2013, I strongly supported passage of the ``Violence Against Women 
Act,'' which requires the U.S. Secretary of State to develop a plan to 
prevent child marriage.
  --How will UNICEF coordinate with the State Department and USAID to 
        support the U.S. Government's efforts to prevent child 
        marriages and integrate these prevention activities across 
        development programs?
    Answer. Over the past few years and especially in the last year, 
UNICEF has been working in collaboration with the U.S. Government and 
other governments, as well as with leaders in civil society including 
the Girls Not Brides Partnership, both to make evident the magnitude 
and consequences of child marriage and to strengthen the capacity of 
communities and governments to bring an end to the practice.
    UNICEF played a key role in 2012 in the organization of the 1st 
International Day of the Girl Child, which was devoted to child 
marriage. The commemoration brought the issue of child marriage much 
higher on the international agenda and created new opportunities for 
joint advocacy and policy initiatives with the U.S. Government.
    A central one, which is fully coherent and supportive of the 
``Violence Against Women Act,'' is the joint pursuit of the inclusion 
in the future sustainable development goals of an objective on 
empowering girls and women and achieving gender equality, with 
indicators to measure progress with respect to preventing and 
eliminating all forms of violence against girls and women and ending 
child marriage, as proposed in The Report of the High-Level Panel of 
Eminent Persons on the Post-2015 Development Agenda.\4\
---------------------------------------------------------------------------
    \4\ See http://www.post2015hlp.org/wp-content/uploads/2013/05/UN-
Report.pdf.
---------------------------------------------------------------------------
    In program countries where child marriage is still practiced, 
UNICEF and USAID can strengthen their existing partnership in 
supporting comprehensive programs and policy actions in support of 
government efforts to end child marriage, and to work directly with 
communities to convince them to give up this harmful practice.
    Niger has the highest rate of child marriage in the world: one in 
three girls is married before age 15, even though child marriage is 
against the law. UNICEF supports an outreach program that reaches more 
than 100 villages in Niger to help educate traditional and religious 
leaders about the dangers to girls, and to change community norms. For 
example, last year 12-year-old Zahara's father Sami had decided that 
she was going to be married. When word reached the local chief, he 
informed the village court. The father and his daughter were told by 
the court that child marriage would violate the girl's rights and 
compromise her health, development, and future. After hearing this from 
the village authorities, the father agreed to cancel the marriage.
    Question. The U.S. National Action Plan on Children in Adversity 
identifies the critical need for the establishments of survey tools and 
metrics to determine the number of children in adversity worldwide and 
evaluate the effectiveness of programs committed towards helping them. 
UNICEF is already supporting efforts to gather this data through its 
role in the development of the State of the World's Children Report, 
the Together for Girls partnership, and other sources of data 
collection.
  --Through UNICEF's experience, what advice would you give to our 
        Government as we attempt to build systems to measure the 
        effectiveness of programming for children in adversity?
    Answer. UNICEF's guidance comprises the following:
  --Working with key stakeholders at all levels (including governments 
        and civil society organizations) to establish monitoring and 
        evaluation (M&E) frameworks based on evidence of what works in 
        producing changes that are beneficial to children.
  --When establishing M&E frameworks, work with key stakeholders to 
        identify ways of using findings from monitoring (both 
        quantitative and qualitative data) to inform program 
        refinement--even correction--as needed to ensure that the 
        results for children and families adhere to the principle of 
        ``do no harm'', are appropriate, timely, resource-effective, 
        and of high quality.
  --Working with key stakeholders to build or strengthen routine 
        monitoring, management, accountability, and data collection 
        systems.
  --Underpinning these efforts is the importance of ensuring adequate 
        and timely resources for capacity building in planning and M&E 
        at all stages of programming, from planning and development of 
        conceptual frameworks, to implementation, monitoring, 
        evaluation, and analysis.
                                 ______
                                 
             Questions Submitted to Dr. Neil Boothby, Ph.D.
             Questions Submitted by Senator Lindsey Graham
    Question. If one of the three principal objectives of the Action 
Plan for Children in Adversity is to ``protect children from violence, 
exploitation, abuse and neglect,'' what action is being taken to 
protect children in unfolding crises such as Syria?
    Answer. As the conflict in Syria has evolved and continues to grow 
in scale and complexity, the risks children face increase as well. U.S. 
assistance efforts support the objectives outlined in the U.S. 
Government Action Plan on Children in Adversity, including objective 
three to protect children from violence, exploitation, abuse, and 
neglect. As an integral part of the humanitarian response to the crisis 
in Syria, the U.S. Government is supporting multi-sectoral projects in 
which protection mainstreaming addresses the specific needs of 
children. U.S. Government-funded projects aim to promote a protective 
environment for children through school and community-based 
organizations.
    Working through international and non-governmental organizations 
with networks inside Syria, local organizations, and international 
organizations, USAID has provided approximately $325 million in 
humanitarian assistance for the Syria crisis despite constantly 
changing security conditions. The U.S. Department of State has provided 
over $488 million to assist Syrian refugees and other conflict-affected 
populations in the region. This humanitarian assistance includes 
emergency food aid, medical care, relief supplies, safe drinking water 
and improved sanitation, which help alleviate strains on families, 
strengthening the protective environment for children. This assistance 
also includes psychosocial activities and targeted protection 
activities for vulnerable populations, especially children.
    Delivering humanitarian assistance in the Syrian context is 
extremely challenging, but the U.S. Government is working with partners 
in Syria to mitigate risks for harm, exploitation, and abuse of 
children through all possible means. For example, USAID partners 
distributing relief commodities are ensuring that children's unique 
needs are addressed in hygiene supplies, and partners establishing 
water and sanitation facilities are ensuring that those facilities are 
safe and accessible for children, including children with disabilities. 
Because many schools are closed and continuing violence affects 
children's ability to travel to school, the United Nations Relief and 
Works Agency for Palestine Refugees in the Near East (UNRWA) is 
providing students opportunities to continue their education. Newly 
developed ``self-learning materials'' give children the opportunity to 
make up for lessons lost due to the violence. Educational materials, 
including study guides are made available online through an UNRWA 
account and accessible to students wherever they may be. UNRWA is also 
developing video learning materials to address children's learning 
needs inside Syria.
    Additionally, the U.S. Government is investing in programs that 
provide services and support for survivors of violence, including 
appropriate medical care, recreational and learning activities for 
girls and boys, case management and referral services for highly 
vulnerable children, and broad-reaching basic psychosocial support to 
as many affected persons as possible. One partner in Syria continues to 
reach children residing in internally displaced person (IDP) camps with 
psychosocial support through child-friendly spaces. In mid-May, more 
than 3,000 children in Atmeh IDP camp near the Syria--Turkey border 
benefited from organized activities in six spaces. Schools can create a 
safe environment for psychological and emotional healing. In Lebanon, 
the U.S. is funding UNICEF and its partners to provide over 7,500 
children and adolescents who were unable to enroll in Lebanese schools 
with informal education services; and over 8,400 with psychosocial 
support as part of their education program. In addition, learning 
support programs and accelerated learning programs are underway, to 
reduce the risk of children dropping out of schools and at preparing 
out of school children to reintegrate in the coming school year.
    U.S.-funded programs will continue to promote the protection and 
psychosocial wellbeing of children through safe learning and child-
friendly play spaces. Ongoing efforts will continue to promote 
protection through formal/informal education opportunities, drawing on 
the existing school systems and structures where possible. Efforts are 
also underway to reach out to organizations with the expertise to 
respond to the needs of the affected child population.
    Question. Coordinating the work of seven different departments and 
30 different offices around a single action plan is a daunting task. In 
the coming months, implementing agencies are expected to report back on 
their efforts to implement the Plan. Please describe what challenges 
might already be identified that could stand in the way of the Action 
Plan for Children in Adversity being fully effective.
    Answer. In accordance with the U.S. Government Action Plan on 
Children in Adversity (Action Plan) and in line with the legislative 
requirements set forth in Public Law 109-95, agency- and department-
specific implementation plans are due within 180 days of the plan's 
launch. These are forward-looking plans, specifying how each U.S. 
Government entity that committed to the Action Plan will work to 
achieve its objectives. The consolidated interagency implementation 
plans, which will be posted online in July 2013, reflect how 
interagency partners are using existing resources to meet the Action 
Plan's objectives. An analysis of the implementation plans has 
illuminated gap areas, including inadequate resources to achieve 
objective 2 (Family Care First) in priority countries. However, as with 
any activity in today's Federal budget environment, the objectives of 
the Action Plan are in competition with many other priorities for 
scarce resources.
    We are in the process of assessing the alignment of current 
resources and programs, which operate under various offices in response 
to separate legislative mandates, in order to help support the 
successful implementation of the Action Plan.
                                 ______
                                 
           Questions Submitted by Senator Frank R. Lautenberg
    Question. Ensuring coordination among all of the implementing 
agencies in this National Action Plan will be one of the central 
components of its success. I was supportive of the establishment of 
your position to facilitate improved coordination among the numerous 
offices in U.S. Government departments and agencies that work on child 
protection and welfare issues.
  --What role do you expect to play in coordinating implementation of 
        actions established in the National Action Plan and ensuring 
        efforts and programs are not duplicated?
  --Will you be the final decision maker as to whether or not a program 
        moves forward to meet the objectives established in the 
        National Action Plan, or will it be left up to the individual 
        agencies?
    Answer. The role of the Special Advisor is defined by Public Law 
109-95 (see below). The Special Advisor's responsibilities include 
coordinating, convening, and advising; the position, however, currently 
has no direct oversight or decisionmaking authority over resources or 
programs, which operate under various offices in response to separate 
legislative mandates.
          ``(2) Duties.--The duties of the Special Advisor for 
        Assistance to Orphans and Vulnerable Children shall include the 
        following:
                  ``(A) Coordinate assistance to orphans and other 
                vulnerable children among the various offices, bureaus, 
                and field missions within the United States Agency for 
                International Development.
                  ``(B) Advise the various offices, bureaus, and field 
                missions within the United States Agency for 
                International Development to ensure that programs 
                approved for assistance under this section are 
                consistent with best practices, meet the requirements 
                of this Act, and conform to the strategy outlined in 
                section 4 of the Assistance for Orphans and Other 
                Vulnerable Children in Developing Countries Act of 
                2005.
                  ``(C) Advise the various offices, bureaus, and field 
                missions within the United States Agency for 
                International Development in developing any component 
                of their annual plan, as it relates to assistance for 
                orphans or other vulnerable children in developing 
                countries, to ensure that each program, project, or 
                activity relating to such assistance is consistent with 
                best practices, meets the requirements of this Act, and 
                conforms to the strategy outlined in section 4 of the 
                Assistance for Orphans and Other Vulnerable Children in 
                Developing Countries Act of 2005.
                  ``(D) Coordinate all United States assistance to 
                orphans and other vulnerable children among United 
                States departments and agencies, including the 
                provision of assistance relating to HIV/AIDS authorized 
                under the United States Leadership Against HIV/AIDS, 
                Tuberculosis, and Malaria Act of 2003 (Public Law 108-
                25), and the amendments made by such Act (including 
                section 102 of such Act, and the amendments made by 
                such section, relating to the coordination of HIV/AIDS 
                programs).
                  ``(E) Establish priorities that promote the delivery 
                of assistance to the most vulnerable populations of 
                orphans and children, particularly in those countries 
                with a high rate of HIV infection among women.
                  ``(F) Disseminate a collection of best practices to 
                field missions of the United States Agency for 
                International Development to guide the development and 
                implementation of programs to assist orphans and 
                vulnerable children.
                  ``(G) Administer the monitoring and evaluation system 
                established in subsection (d).
                  ``(H) Prepare the annual report required by section 5 
                of the Assistance for Orphans and Other Vulnerable 
                Children in Developing Countries Act of 2005.''
    Question. Under the National Action Plan, implementation plans are 
required to be developed during the 180 days after the December release 
date.
  --Given that this deadline is quickly approaching, have you 
        identified any challenges that may hinder the actions 
        identified in the Plan from being implemented?
    Answer. In accordance with the U.S. Government Action Plan on 
Children in Adversity (Action Plan) and in line with the legislative 
requirements set forth in Public Law 109-95, agency- and department-
specific implementation plans are due within 180 days of the plan's 
launch. These are forward-looking plans, specifying how each U.S. 
Government entity that committed to the Action Plan will work to 
achieve its objectives. The consolidated interagency implementation 
plans, which will be posted online in July 2013, reflect how 
interagency partners are using existing resources to meet the Action 
Plan's objectives. An analysis of the implementation plans has 
illuminated gap areas, including inadequate resources to achieve 
objective 2 (Family Care First) in priority countries. However, as with 
any activity in today's Federal budget environment, the objectives of 
the Action Plan are in competition with many other priorities for 
scarce resources.
    We are in the process of assessing the alignment of current 
resources and programs, which operate under various offices in response 
to separate legislative mandates, in order to help support the 
successful implementation of the Action Plan.
    Question. I have commended President Obama and his administration 
for working to ensure that the advancement of women and girls is 
integrated into all aspects of U.S. foreign policy. I was extremely 
pleased that USAID released a newly updated policy on Gender Equality 
and Female Empowerment last year that integrates gender equality and 
female empowerment across all of USAID's policies and programs.
  --How will gender equality and female empowerment be integrated into 
        all aspects of the objectives and actions established in this 
        National Action Plan?
    Answer. The United States Government Action Plan on Children in 
Adversity recognizes that adversity is a significant concern for both 
boys and girls, although the experiences may differ. As such, the 
objectives of this plan facilitate and complement many of the 
priorities articulated in other U.S. Government strategic documents, 
including the United States Strategy to Prevent and Respond to Gender-
Based Violence Globally, the National Action Plan on Women, Peace and 
Security, and the USAID Counter-Trafficking in Persons Policy--all of 
which emphasize attention to the need of boys and girls, both as 
beneficiaries and as critical agents of change.
    In that vein, USAID works to ensure that the Agency's commitment to 
promoting gender equality and women's empowerment is reflected in all 
that we do to provide assistance to vulnerable boys and girls. Under 
the United States Government Action Plan on Children in Adversity, our 
commitment will focus on addressing the needs of boys and girls, and 
promoting women and girls as agents of change throughout our research, 
program design, implementation, monitoring and evaluation efforts.
    Specifically, the Plan commits USAID to:
  --mainstream and integrate protective and responsive Gender-Based 
        Violence (GBV) activities into sector work;
  --promote equitable access to educational opportunities in safe and 
        appropriate learning environments;
  --ensure that men and boys are actively engaged as allies in 
        interventions to prevent violence against and exploitation and 
        abuse of boys and girls; and
  --elevate the voices of women and girls as leaders and agents of 
        change in programming and policies to prevent and respond to 
        violence and exploitation and abuse of boys and girls.
                                 ______
                                 
                  Questions Submitted to Jedd Medefind
             Questions Submitted by Senator Lindsey Graham
    Question. Your organization works with faith-based organizations 
from all over the world with a shared interest in the three core 
objectives of the Action Plan for Children in Adversity. What 
opportunities do you see for the public, private, and faith-based 
communities to work in tandem toward this common goal?
    Answer. Thank you for this question, Senator Graham. When it comes 
to caring for children in adversity, these three sectors--public, 
private, and nonprofit (including both faith-based and secular)--each 
offer unique and truly complementary strengths. [See ``The Permanency 
Center Model'' concept below for a specific proposal on a particularly 
promising opportunity for public-private-FBO/CBO partnership.]
    The three sectors achieve maximum impact for good when each 
operates primarily from within its core competencies. Effective 
partnerships enable this to happen, freeing each actor to use its 
primary strengths while also releasing to others the roles for which 
they would be better suited. This is perhaps nowhere more true than in 
seeking to resolve the deep, complex needs of children who lack 
parental care.
    The public sector tends to be at its best when focused on child 
protection and survival. Non-governmental organizations (NGOs) also 
play a vital role in large-scale child survival efforts and in longer-
term community development as well. Meanwhile, it is often the local 
faith-based and other community organizations that best marshal the 
``relational'' elements that children need to truly thrive--committed 
mentors, foster families, adoptive parents and also empathetic support 
for these care-givers. Finally, the for-profit sector provides an 
indispensible third leg to this stool. Businesses offer the only means 
by which the positive impact of government- and NGO-led initiatives can 
be sustained for the long-term via jobs, commerce and needed goods and 
services.
    Many of the partnership examples I mentioned in the hearing are 
successful precisely because they draw upon the distinctive, 
complementary strengths of each of these sectors. This is seen vividly 
in the State of Colorado's success in reducing the number of children 
waiting for families in foster care, as well as in the child welfare 
partnerships I mentioned that are now active in Rwanda, Costa Rica, 
China, and Ethiopia.
    It's important to emphasize that government funding is often 
unnecessary, and sometimes unhelpful, in such partnerships. When driven 
primarily by government monies, partnerships rarely outlast their 
funding. Thus, ideal partnerships--even if seeded by government funds--
tap the deeper motivations of each sector: the profit motive of the 
business sector, the philanthropic and faith motivations of the 
nonprofit sector, and the constituent-serving and problem-solving 
motivation of government.
    Even without government funds, well-led collaborative efforts can 
designate clear roles and priorities for each partner, enabling them to 
focus on the things they do best. This enables deeper, more lasting 
impact from each sector's contribution.
    That said, strategic investments by government can indeed catalyze 
such partnerships. Government grants, vouchers and/or other financial 
incentives can help enlist and coordinate the contributions of the 
other two sectors.
    One especially significant opportunity for this kind of strategic 
investment today pertains to Objective Two of the Action Plan--the goal 
of prioritizing permanent family for children who lack it.
    No factor is more critical to the long-term thriving of children 
than consistent, nurturing parental care. Yet without robust 
partnership with the other sectors, government simply cannot provide 
this. Its child welfare efforts thus must often be limited to a 
narrower focus on child protection and survival. This is 
understandable, and even appropriate, given the distinct strengths and 
weaknesses of government. But it results in an under-emphasis on the 
goal of permanent family for unparented children.
    This gap represents both a critical oversight in U.S. foreign 
investment and yet also a tremendous opportunity. Objective Two of the 
Action Plan provides a clear mandate to address this gap. Meanwhile, 
the nature of the needs of children reminds us that government cannot 
accomplish this goal alone. Effective partnership is not just helpful 
but essential.
    Toward this end, new or re-programmed U.S. funds can be used to 
seed pilot projects that build and test strong public-private-nonprofit 
partnerships centered on the priority of family for children who lack 
it.
    Specifically, I believe it would be tremendously valuable to fund 
pilot projects testing various expressions of a ``Permanency Center'' 
model in in (1) Some or all of the six priority countries designated by 
the Action Plan; and (2) A modest number of additional countries with 
strong interest in family-based solutions.
    The Permanency Center Model. Although the structure of any 
Permanency Center would vary by country, the primary mandate would be 
the same: to create an independent authority capable of making timely 
best-interest determinations for children who lack parental care.
    Permanency Center staff would seek to identify the best achievable 
outcome for each child. They would aim always for a result for each 
child that is as close as attainable to the ideal of permanent, 
nurturing family.
    To the fullest extent possible, the Permanency Center's authority 
would be independent of influences that could skew best-interest 
determinations away from the ideal, whether political pressures, quid-
pro-quo funding, or other pressures.
    While sensitive to the uniqueness of each child and the local 
solutions available, the Permanency Center would operate with a clear 
continuum of prioritization. This continuum would always begin with 
family preservation and reunification, then kinship care and adoption 
(local if at all possible, international when necessary), followed by 
less permanent solutions as needed: foster care, small group homes, and 
larger residential facilities.
    While relentlessly seeking the ideal outcome of permanent family 
for every child, this paradigm is also capable of affirming the many 
other options that are sometimes necessary as a far preferable 
alternative to life on the streets or in an abusive home.
    Given its mandate, the Permanency Center would become an effective 
hub for the efforts of the government, nonprofit, and business sectors 
to serve children in adversity.
    For instance, when it is determined that a widow on the verge of 
relinquishing her child could be aided to continue raising that child, 
the widow could be connected to NGO micro-finance projects, the 
sponsorship programs of faith-based organizations, government social 
services and/or jobs offered by local employers. Likewise, when it is 
clear that no safe, permanent home can be found with relatives, options 
for finding a new family via adoption could be swiftly initiated 
through the Permanency Center--locally whenever possible, 
internationally when not.
    Over time, this model will not only enable more efficient use of 
existing services, but will also highlight significant gaps in the 
continuum of options for children. For example, if it becomes clear 
there are few local families willing to adopt or foster, then 
government and NGOs may choose to invest in campaigns to recruit such 
families. If it appears that many impoverished parents are 
relinquishing children for reasons of poverty alone, expanded 
microfinance programs may become a greater priority.
    Ultimately, the Permanency Center model and the collaborative 
paradigm it represents offer a tremendous opportunity for the public, 
private and faith-based communities to work in tandem for the goal of 
permanent, caring family for children who currently lack it. I can 
think of very little more likely to prove worthy of our investment.

                          SUBCOMMITTEE RECESS

    Senator Landrieu. Again, I thank Senator Leahy and Senator 
Graham. Senator Graham could not be here, but he has expressed 
personally to me his interest. Senator Blunt as well has 
expressed a great interest. And, of course, Senator Barbara A. 
Mikulski, who chairs the Appropriations Committee, is anxiously 
waiting our report from our subcommittee.
    So thank you very much. The hearing is concluded.
    [Whereupon, at 11:52 a.m., Tuesday, May 21, the 
subcommittee was recessed, to reconvene subject to the call of 
the Chair.]
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