[House Hearing, 114 Congress]
[From the U.S. Government Publishing Office]

                         TROPICAL DISEASES



                               BEFORE THE

                        GLOBAL HUMAN RIGHTS, AND

                                 OF THE

                      COMMITTEE ON FOREIGN AFFAIRS
                        HOUSE OF REPRESENTATIVES


                             FIRST SESSION


                             APRIL 15, 2015


                           Serial No. 114-63


        Printed for the use of the Committee on Foreign Affairs

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                      COMMITTEE ON FOREIGN AFFAIRS

                 EDWARD R. ROYCE, California, Chairman
ILEANA ROS-LEHTINEN, Florida         BRAD SHERMAN, California
DANA ROHRABACHER, California         GREGORY W. MEEKS, New York
STEVE CHABOT, Ohio                   ALBIO SIRES, New Jersey
JOE WILSON, South Carolina           GERALD E. CONNOLLY, Virginia
MICHAEL T. McCAUL, Texas             THEODORE E. DEUTCH, Florida
TED POE, Texas                       BRIAN HIGGINS, New York
MATT SALMON, Arizona                 KAREN BASS, California
DARRELL E. ISSA, California          WILLIAM KEATING, Massachusetts
TOM MARINO, Pennsylvania             DAVID CICILLINE, Rhode Island
JEFF DUNCAN, South Carolina          ALAN GRAYSON, Florida
MO BROOKS, Alabama                   AMI BERA, California
PAUL COOK, California                ALAN S. LOWENTHAL, California
RANDY K. WEBER SR., Texas            GRACE MENG, New York
SCOTT PERRY, Pennsylvania            LOIS FRANKEL, Florida
RON DeSANTIS, Florida                TULSI GABBARD, Hawaii
MARK MEADOWS, North Carolina         JOAQUIN CASTRO, Texas
TED S. YOHO, Florida                 ROBIN L. KELLY, Illinois
CURT CLAWSON, Florida                BRENDAN F. BOYLE, Pennsylvania
REID J. RIBBLE, Wisconsin
DAVID A. TROTT, Michigan
TOM EMMER, Minnesota

     Amy Porter, Chief of Staff      Thomas Sheehy, Staff Director

               Jason Steinbaum, Democratic Staff Director

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

               CHRISTOPHER H. SMITH, New Jersey, Chairman
MARK MEADOWS, North Carolina         KAREN BASS, California
CURT CLAWSON, Florida                DAVID CICILLINE, Rhode Island
SCOTT DesJARLAIS, Tennessee          AMI BERA, California
TOM EMMER, Minnesota
                            C O N T E N T S



Ariel Pablos-Mendez, M.D., Assistant Administrator, Bureau for 
  Global Health, U.S. Agency for International Development.......     3
Peter J. Hotez, M.D., president, Sabin Vaccine Institute.........    21
Mr. Nicholas Kourgialis, vice president, Eye Health, Helen Keller 
  International..................................................    35


Ariel Pablos-Mendez, M.D.: Prepared statement....................     6
Peter J. Hotez, M.D.: Prepared statement.........................    27
Mr. Nicholas Kourgialis: Prepared statement......................    37


Hearing notice...................................................    54
Hearing minutes..................................................    55
Written responses from USAID to questions submitted for the 
  record by the Honorable Christopher H. Smith, a Representative 
  in Congress from the State of New Jersey, and chairman, 
  Subcommittee on Africa, Global Health, Global Human Rights, and 
  International Organizations....................................    56
The Honorable Christopher H. Smith: Article by Dr. Peter Hotez...    60



                       WEDNESDAY, APRIL 15, 2015

                       House of Representatives,

                 Subcommittee on Africa, Global Health,

         Global Human Rights, and International Organizations,

                     Committee on Foreign Affairs,

                            Washington, DC.

    The subcommittee met, pursuant to notice, at 2:30 p.m., in 
room 2172 Rayburn House Office Building, Hon. Christopher H. 
Smith (chairman of the subcommittee) presiding.
    Mr. Smith. Pursuant to notice the subcommittee meets for 
our hearing on neglected tropical diseases.
    Neglected tropical diseases, as I think many here know, or 
NTDs, are a group of 17 parasitic and bacterial diseases which 
blind, disable, disfigure, and sometimes kill sufferers among 
more than 1 billion of the world's poorest people, trapping the 
most marginalized communities in a cycle of poverty and pain.
    The list ranges from Chagas to rabies to leprosy to dengue 
fever. However, there are others not on this list of 17 
diseases that also receive far too little attention. These 
include diseases such as polio and small pox, which have been 
largely eliminated from the planet and often fatal--fortunately 
rare-NTDs such as kuru.
    Prior to last year, that list of rare diseases included 
Ebola. Even though not immediately fatal, these diseases can 
keep children from attending school and their parents from 
working, as well as resulting in excessive loss of blood by 
mothers during birth and a resultant low birth weight babies as 
    These conditions constitute a significant hurdle to 
achieving economic growth and dilute the impact of foreign 
assistance programs. Last year, the world witnessed an Ebola 
disease pandemic that hit six African countries and spread to 
Spain, Scotland and the United States.
    Furthermore, in recent years such diseases as dengue fever 
and chikungunya have spread into the United States. These and 
other tropical diseases most often victimize the poor who live 
in tropical climates whether in Africa, Latin America, or parts 
of the United States.
    Even in the face of the worldwide challenges these tropical 
diseases pose, the administration has proposed cutting the 
budget in this area by 17 percent. Today's hearing will examine 
the problem of neglected tropical diseases and U.S. current and 
potential efforts to address this problem.
    Eight NTDs account for almost all worldwide cases. Seven of 
them can be treated with low cost medication that could be 
dispensed by non-health workers irrespective of disease status. 
Nearly 80 percent of all NTD cases are comprised of people 
carrying intestinal worms.
    On June 27th at our hearing in 2013, we learned the 
catastrophic nature of these preventable intestinal worm 
infections. So many of the problems we struggle with such as 
difficult births and malnourishment can be remedied without 
dealing with infections themselves.
    You know, I am a great fan and I know the administration, 
both Bush and now President Obama, have done much on the 
nutrition side. We have a bill that will codify and expand Feed 
the Future.
    It passed last year. It is going to be up on the docket we 
hope next week in the full committee. But we don't want to feed 
the worms. We want to feed people.
    We want healthy children and mothers and families and to 
mitigate and eradicate these parasites. We can no longer look 
at photos of happy young children standing in muddy water 
without shoes and not think of the possibility that they are 
losing their future even as we see them enjoying a break from 
poverty in which they live because sometimes, of course, some 
of these diseases migrate through that means.
    Yet we must understand that these are not merely diseases 
affecting people in faraway lands. Current U.S. law favors 
research in those diseases threatening the American homeland 
but in today's world diseases can cross borders as easily as 
those affected by them or the products imported into the United 
    For example, Chagas is most prevalent in Latin America but 
it has been identified in patients in Texas, and cases of 
dengue have been recently reported in Florida.
    We cannot afford to assume that what may seem to be exotic 
diseases only happen to people in other countries, and I would 
note parenthetically, of course, even if that were true we have 
a moral obligation to aid and assist those who contract these 
diseases and to mitigate transmittal to the greatest extent 
    Ten years ago West Nile virus, another rare disease, was 
not seen in the U.S. or anywhere else outside the east African 
nation of Uganda. But in less than a decade it has spread 
across this country and much of the rest of the world.
    More than 10,000 people died of Ebola worldwide thus far. 
Although only one person died in this country due to that 
disease, we saw, clearly, how unprepared our medical services 
in the rest of the world were initially to deal with a rare 
disease that had previously been confined to isolated areas in 
central Africa.
    There are other rare diseases, not to mention the 
recognized NTDs, that cause havoc if they find their way to 
populated international transit areas such as Ebola did last 
    Meanwhile, far too many people live lives of quiet 
suffering from diseases we must fight more effectively. That is 
why I have introduced today H.R. 1797, the End Neglected 
Tropical Disease Act.
    Among other provisions, H.R. 1797 calls on the U.S. Agency 
for International Development to modify its NTD programming 
with respect to rapid impact packaging treatments, school-based 
NTD programs which we know have been one of the most 
efficacious ways to date to deal with this, and new approaches 
to reach the goals of eliminating NTDs.
    The bill also sets forth measures to expand USAID programs 
including by establishment of research and development 
    One of the ideas that one of our distinguished panelists, 
Dr. Hotez, had suggested about a Centers of Excellence we 
include in the bill and I thank him again for that 
recommendation to combat what is happening here.
    I know, parenthetically, that in 1997 when we saw an 
alarming spike in the prevalence in autism I wrote a law and 
have now written three laws including the Combating Autism Act 
and most recently Autism Cares that builds on Centers of 
Excellence at CDC and NIH to really combat that pandemic.
    Although it is a developmental disease, a disability 
disease, the numbers are staggering worldwide as well as in the 
United States--one out of every 68.
    So Centers of Excellence, I think, or such a center in the 
Southern part of the U.S., as Dr. Peter Hotez has recommended, 
included in the bill I think would make a significant 
difference for our efforts here in the United States.
    In an effort to reach achievable and reachable goals to 
prevent and eliminate NTDs, the projected 70 percent cut in 
funding for such projects in the 2016 budget would pose a 
serious setback.
    I have appealed and we plan on doing a letter to the 
members of the Appropriations Committee because we had a 
similar proposal last year that they, thankfully, in a 
bipartisan way ensured that we got to the $100 million level, 
but hopefully we can go even beyond that as we move forward in 
Fiscal Year 2016.
    I would like to yield to any of my colleagues.
    Okay. We will now welcome our first witness, the Honorable 
Ariel Pablos-Mendez, who is the Assistant Administrator for 
Global Health at USAID, a position he assumed in August 2011.
    Dr. Pablos-Mendez joined USAID's leadership team with a 
vision to shape the Bureau for Global Health programmatic 
efforts to accomplish scalable, sustainable, and measurable 
impact in the lives of people in developing countries.
    Prior to joining USAID, he worked on global health 
strategies and a transformation of health systems in Africa and 
Asia. He also served as director of knowledge management at the 
World Health Organization.
    Dr. Pablos-Mendez is a board certified internist and until 
recently he was practicing as a professor of clinical medicine 
and epidemiology at Columbia University.
    Doctor, welcome back.
    We appreciate your previous testimonies before this 
subcommittee, always insightful and expert, and I thank you for 
being here. I yield.


    Dr. Pablos-Mendez. Thank you, Chairman Smith, and thank you 
to all the members of this subcommittee for highlighting this 
important issue and I really appreciate the opportunity to 
discuss the U.S. Agency for International Development program 
to combat neglected tropical diseases.
    You explained very well the realm of this space of diseases 
and the spectrum and the populations that it affects.
    While Ebola is not technically classified as an NTD by 
USAID and the World Health Organization, the high profile 
outbreak of Ebola in west Africa in the past year has 
highlighted the risk of paying insufficient attention to 
diseases which typically occur in resource-limited settings.
    And I take the opportunity to thank you, Chairman Smith, 
for the leadership role you played back in August when we were 
in recess and nonetheless it was just the right timing for 
mobilizing American people in the response against Ebola.
    USAID is focused on its overall mission of partnering to 
end extreme poverty and promote resilient democratic societies 
while advancing our security and prosperity and our NTD program 
is making great progress toward ending diseases of extreme 
    Our global health programs include typical priorities--
ending preventable child-maternal deaths and, again, I 
recognize the championing in this subcommittee for this cause, 
creating an AIDS-free generation working with PEPFAR, and 
protecting communities against infectious diseases under which 
our NTD program operates.
    Still, even though we have made great progress, there are 
more than 1 billion people globally who suffer from NTDs and 
this disproportionally impacts poor and rural populations who 
often lack access to safe water, sanitation, essential 
services, and medicines.
    NTDs take a very heavy human toll by creating sickness, 
disability, blindness, and severe disfigurement, contributing 
to childhood malnutrition and leading to an appreciable loss of 
productivity lifelong.
    That is why I am very proud of the achievements in USAID's 
integrated NTDs program which began less than 10 year ago with 
a lot of support from the Congress and has accelerated success 
in what is really a historical scale.
    With support from the Congress, the program has made solid 
advance in addressing the seven diseases we represent, 
approximately 80 percent of the global burden of NTDs and can 
be addressed through highly cost effective community and 
school-based distribution of preventive chemotherapy generally 
once or twice a year in these populations.
    The integration of these programs has been the hallmark of 
the program in USAID and is now a global standard. With a 
budget of $100 million in the year 2014, USAID's program 
distributes 240 million treatments to 115 million people in 31 
    To date, the cumulative figure is over 1.2 billion 
treatments have been provided. In the year 2011, when I joined 
the U.S. Government, 7.7 million no longer required treatment 
for lymphatic filariasis in USAID-supported countries.
    Last year, that increased from 7.7 to 92 million. By 2018, 
the number is predicted to jump to over 250 million. That is, 
half of the totality of the problem in the world will be 
    In Latin America, onchocerciasis is close to elimination 
with transmission mainly remaining in the hard to reach border 
area between Venezuela and Brazil. It is a great success story 
in this continent.
    I would like to highlight a few factors that have 
contributed to the success of the USAID's program and the 
global progress to date in addition to the support of the 
American people.
    First, the success of USAID's NTD program would not have 
been possible without the partnership with the pharmaceutical 
sector. In 2014, USAID-supported countries benefited from over 
$2 billion in donated drugs.
    To date, nearly $9 billion have been generously donated by 
Merck & Company, GSK, Pfizer, Johnson & Johnson, Merck Serono. 
We estimate that for every tax dollar spent by USAID, more than 
$26 in drugs are being donated for the countries we are 
supporting with USAID funding making critical investments in 
countries' systems to distribute the drugs and monitor 
    Second, USAID partnership and coordination with the United 
Kingdom has allowed for a collective reach to almost 50 
countries and the provision of 340 million treatments last year 
    This has allowed for expansion in high burden countries 
including Ethiopia and Nigeria, which are very large, and 
ancillary global efforts to put trachoma elimination on track 
by defining the burden in countries throughout Africa and in 
    Third, USAID builds upon the existing infrastructure of 
national disease control and elimination programs to ensure 
sustainability. USAID and our partners coordinate with 
ministries to ensure that U.S. resources complement investment 
from other stakeholders and leverage local funding working with 
national NTD plans, and a lot of the work, of course, is based 
on the research, the science, and the advocates that have 
allowed us to come this far in the fight against NTDs.
    Thanks to congressional support, progress made to date and 
available tools and partnerships, the elimination of these 
diseases of extreme poverty as a public health scourge is 
being--is really within our grasp. USAID is committed to 
working with countries and our global partners to reach the 
remaining 800 million people who still need treatment.
    In order to ensure sustainability, we must maintain 
investments in research and development and monitoring and 
evaluation. For example, our partnerships with the Drugs for 
Neglected Diseases initiative just established last year and 
with a Coalition for Research on Neglected Tropical Diseases 
make important contributions toward new and much needed 
technologies to make it simpler initially to reach more people 
and to begin to consider additional diseases that today are 
very expensive to treat.
    Part of USAID's commitment to all innovation that many of 
you have seen recently the work that our Center for Innovations 
has been doing on behalf of Ebola with new innovative personal 
protection equipment. I really just have to thank you for the 
    I think that progress has been impressive. We all need to 
work in maintaining support for these programs and we believe 
that with your support we will continue to do so.
    Thank you very much.
    [The prepared statement of Dr. Pablos-Mendez follows:]

    Mr. Smith. Dr. Pablos-Mendez, thank you so much for your 
leadership and, you know, the materials, again, that you sent 
over to our office yesterday were very informative and 
encouraging and it is a great record and I want to thank you 
for your personal leadership.
    I would like to yield to the vice chairman of the 
committee, Mr. Meadows.
    Mr. Meadows. Thank you, Mr. Chairman, and for those of you 
that are here I think I would be remiss if I didn't say this. 
There are a number of times when the chairman has held hearings 
and there are not the cameras, there are not the reporters, 
because the actual thing that we are addressing is not 
necessarily newsworthy to the people on Main Street.
    And yet the heart of this chairman has been not only 
diligent but tenacious and unyielding in his desire to be a 
voice for so many that have no voice. So I want to say thank 
you to the chairman for his work each and every day that is 
    Thank you, Doctor, for your work and your willingness to 
team up. It does come at a cost sometimes for some of us when 
you look at foreign aid and you look at helping other countries 
when there are so many needs here in the United States, and so 
it is imperative that you are efficient and focused with your 
money because it is every dollar that counts.
    And so I know that a lot of USAID money in terms of this 
particular topic accounts for about 35 percent of the treatment 
is what I understand from what I have read. Who else is 
partnering with us or with you to address this particular 
medical concern?
    Dr. Pablos-Mendez. Thank you, Representative Meadows. 
Thanks for those kind words. I also want to recognize the 
    I did so in person earlier because you are right, you are 
also giving us your time and your political capital to support 
something to help the poorest people in the world and there is 
usually not a political pay for that.
    It is just because it is the right thing and in particular 
in these diseases, and although some of them can sometimes 
spread and hit us, there is a security rationale. It is truly 
because it is the right thing and the American people support 
    You are right and I think that the partnership that we have 
had, particularly with the British Government, has been very 
important and it has been growing and it is allowing us to 
reach now 50 countries as opposed to the 30 countries that we 
were supporting directly.
    DFID has committed $195 million UK pounds in the last 
period of 4 years or so and that is a very significant 
commitment. The Bill and Melinda Gates Foundation has stepped 
up to the plate as a big champion following that London 
partnership and declarations and so on and they have committed 
$363 million over 5 years.
    They are particularly supporting research and innovation 
and that is a very important part of the overall global effort 
against these diseases.
    So you are right, we are just about 40 percent of the 
total. But as I said before, it is the companies' historical 
willingness to work with the government in a public-private 
partnership to donate these life-saving interventions and many 
of them from the beginning committed to do it for as long as it 
    So we do have great partners and we also see many of the 
countries are now growing economically. So we are working to 
make sure those governments begin to invest more if the global 
investment is about $250 million outside the donations.
    Now, the countries where the diseases are endemic are 
contributing maybe $100 million or $120 million a year. We 
expect this equation to evolve in the next 5 to 10 years for 
countries to begin to spend more, particularly those countries 
are already in the middle income category like Brazil or 
Nigeria, and we are working to mobilize those resources because 
that will be necessary to sustain the success of these 
    Mr. Meadows. Right. One other area, and you mentioned 
Ebola, and the good success story that we are hearing today on 
the ground from many of those areas that were affected, one of 
the concerns I have is that this particular problem was one we 
knew about before it became the epidemic in the region that it 
    Samaritan's Purse had been there, as we know now, because 
of the highlighted newsreels that had been there. They had been 
there on the ground.
    What vehicle is there, Doctor, that we can use with either 
USAID and primarily I guess it would USAID to bring that to the 
attention before it becomes a billion-dollar problem when it is 
a million-dollar problem?
    Because what I feel like we did in this particular case is, 
whether it be bureaucratic, whether it be Congress or anything 
else, we looked the other way until it became such a big 
problem that it scared people in Texas and in New York and in 
Atlanta or wherever it may be and then we responded with big 
money when a few dollars wisely spent earlier on would have 
corrected the problem.
    That may be simplistic. I am not a doctor. That is my take 
of it. What can we do to work closer with that so that it 
doesn't become a huge problem that the taxpayers have to bail 
    Dr. Pablos-Mendez. Well, thank you very much. It is a very 
important point and it was the subject of that hearing that we 
had here last August.
    It is the case that as you know there have been many, many 
Ebola outbreaks, particularly in central Africa. Each of them 
was successfully controlled and actually they were getting 
smaller and smaller because we learned in those geographical 
areas to respond quickly and control those outbreaks.
    Although the virus was not new we have evidence that has 
been around west Africa for several years, it was the first 
time that the virus was recognized in west Africa.
    Mr. Meadows. Okay.
    Dr. Pablos-Mendez. So those populations were not familiar 
with Ebola. In the cities their immune system may not have been 
familiar with the virus and the fact that it reached cities 
transformed this into something that was different than before 
even though the virus itself was similar to the virus that we 
    And the epidemic that began in December 2013 indeed was 
spreading through the spring, but by the end of May when I was 
at the World Health Assembly in WHO in Geneva there was a sense 
that the numbers were coming down. And so in fact it was not 
even a major subject.
    But we now know that even though we were paying attention 
and we were monitoring things, the virus reached in cities and 
spread in the ways that we saw in July and in August where I 
called it the summer of panic and because it was truly a scary 
    Now what to do? Because you are right, we have been 
successful with the response and the support of the Congress 
has been magnificent.
    As someone who worked in global health and who was also 
talking to many others around the world in Africa and in other 
partners, the respect of that leadership and commitment has 
been quite palpable and important because it has been the right 
thing and it has worked in a quite dramatic way.
    We are not out of the woods but it is pretty good. What to 
do? So we do have this neglected tropical diseases program that 
is focusing on all diseases of the poor for which simple 
treatments are the best way to prevent their damage on 
    But we have a separate program, USAID's emerging pandemic 
stress programs, that, again, has been supported by the 
Congress as well, and the purpose of that program is to work 
precisely at the interface between humans and ecology and 
animals where all of these viruses are happening all the time.
    I have to say that we hear about those viruses that 
breakout but there are many others, I am talking about 
hundreds--hundreds that we are detecting----
    Mr. Meadows. Right.
    Dr. Pablos-Mendez [continuing]. And not happening. But as 
we know, it is not enough. In--we have----
    Mr. Meadows. It is kind of like our job. We only hear about 
it when we don't do it right.
    Dr. Pablos-Mendez. Something like that.
    Mr. Meadows. Yes.
    Dr. Pablos-Mendez. And in this case, the global community 
has recognized that preparedness of pandemics has been an area 
that has been under invested. In addition to some reform 
efforts from the World Health Organization to really call for 
help earlier and support the countries quicker, there had been 
a lot of discussion on the fact that the economic impact of 
these outbreaks will just grow because of the 
interconnectedness of society, and how we respond to that, 
clearly, we do not have yet in the world the right platforms.
    The U.S. Government is now leading, as you know, with the 
Global Health Security Agenda----
    Mr. Meadows. Right.
    Dr. Pablos-Mendez [continuing]. A process to reinvigorate 
the capacity of countries that are most vulnerable and creating 
with WHO, the World Bank, and others the mechanisms to respond 
in the human resources sense, in the financial sense, and also 
in the technology sense because we always come to try to do a 
vaccine when we are in the middle of the outbreak.
    So we need to develop systems that will be there because 
now we know that these things do happen every 5 or 10 years.
    Mr. Meadows. Very good. Well, that ends my questions. I am 
going to close with one personal request that comes way out of 
left field.
    There is a hospital in Pakistan that is known as the 
American Hospital that is falling in somewhat of disrepair. If 
USAID could look at how we could partner with them on that 
particular facility from a health--global health standpoint, if 
you would personally look into that for me I would greatly 
appreciate it.
    I think it would go a long ways in the region. I yield 
back. Thank you, Mr. Chairman.
    Mr. Smith. Thank you very much.
    Mr. Meadows. I apologize. I have to leave. But we are 
monitoring it from my office.
    Dr. Pablos-Mendez. Thank you very much.
    Mr. Smith. Mr. Meadows, thank you very much and, again, for 
your leadership especially. Mr. Clawson?
    Mr. Clawson. Thank you for coming. Thank you, Mr. Chairman, 
and full respect to those that work at USAID, and I have seen 
their work on a personal level in poor countries around the 
world and admire the sacrifice these folks make. That is my 
starting point.
    I represent south Florida, southwest Florida. It is a great 
place. But when I think about the Caribbean I think about 
dengue fever and the chikungunya, and I think about my own 
population--large retiree base--and I have the impression that 
in the Caribbean and in South America lots of folks get dengue 
fever in particular and now more and more chikungunya when they 
are young and able to overcome.
    I can't imagine having break bone fever at age 70. Can you? 
And so I am always worried about this epidemic that most 
Americans don't even know about.
    I am worried about it invading my district and having a 
meaningful impact. Am I right about being worried about what I 
am worried--I mean, I am worried that, you know, you get a few 
mosquitoes going north on a year that we have a lot of rain and 
you have got a mixture for a really bad outcome. Do I view that 
correctly or am I being alarmist?
    Dr. Pablos-Mendez. No, I think you are correct. Dengue is a 
disease that can kill you although it rarely does so. Most of 
the time it is like a severe flu.
    Mr. Clawson. But it would kill an 80-year-old?
    Dr. Pablos-Mendez. It could kill children and pregnant 
women, so vulnerable populations are the most at risk around 
the world. So it is a real threat. And you are also correct 
that dengue has been growing. Dengue is transmitted by 
mosquitoes that thrive in cities, unlike the malaria mosquitoes 
of the more rural areas.
    Mr. Clawson. Yes.
    Dr. Pablos-Mendez. And because we are having this urban 
development in many places----
    Mr. Clawson. It is an urban indoor mosquito?
    Dr. Pablos-Mendez. Correct.
    Mr. Clawson. It is--so it is the inverse of malaria, if I 
understand it.
    Dr. Pablos-Mendez. That is correct.
    Mr. Clawson. All right.
    Dr. Pablos-Mendez. And so because there has been so much 
urban growth in the tropical world, we are seeing now dengue 
really at unprecedented levels--Brazil, we hear in the news 
every day. So dengue is up and it also exists in Africa. We 
used to think it was all malaria.
    Mr. Clawson. So do you agree we are vulnerable in Florida 
or--I mean, would we be vulnerable by this combination of a bad 
mosquito year and a bad rain year?
    You know, if we had as much rain in my district as they get 
in some of the Caribbean Islands and get the wrong mosquitos, 
either chikungunya or dengue fever----
    Dr. Pablos-Mendez. Right.
    Mr. Clawson [continuing]. Do we have a problem?
    Dr. Pablos-Mendez. Well, two things. One is that because 
you need to have reservoirs of water that stays there 
unattended, you have things that in poor settings are common--
tires with water near the houses--that are less prevalent in 
the United States.
    But that is important because we have better development. 
We are less at risk. In addition, even though you could get 
dengue and certainly you can get dengue in south Florida, the 
severity of the disease in better nourished populations and the 
ability to get medical care, which is general at this point, is 
also pretty good.
    But I would say to you that there is a risk, of course, 
that dengue can spread. It had been growing. But I don't 
imagine something like Ebola spreading in the country as a risk 
in the mindset that we had in the fall. There is a different 
epidemiology, a different behavior in terms of the geography.
    Now, for southern Florida being in the Caribbean it is 
certainly possible. There is no treatment, as you know, for 
dengue but there has been a lot of progress on the development 
of vaccines.
    Because it is a large problem in the world and because it 
afflicts now many middle income countries, companies have been 
working with academia in developing vaccines for dengue.
    Mr. Clawson. I have read that there is a dengue vaccine 
under development in Singapore but I have not read anything 
about chikungunya. Am I right about that?
    Dr. Pablos-Mendez. I am not following the vaccines for 
chikungunya but we will be happy to report back on chikungunya 
    Mr. Clawson. All right.
    [The information referred to follows:]
 Written Response Received from Ariel Pablos-Mendez, M.D. to Question 
         Asked During the Hearing by the Honorable Curt Clawson

    Dr. Pablos-Mendez. Dengue is a much bigger problem and the 
research attention--we have a lot of work that has been done in 
dengue. An effort that we have been particularly focused on is 
in making sure that the pediatric versions of the vaccines are 
developed soon because those are the people who die. It is 
usually kids. I mean, elderly could, but it is usually kids 
that are accounting for the deaths.
    Mr. Clawson. Okay. Can I have a couple more minutes? Let me 
follow up on that and I appreciate your patience here. So I am 
not trying to pretend to be a doctor at all. It is just a topic 
that is important to me.
    So monsoon season is in October in India. There are four or 
five different strains of dengue. Someone gets on the plane and 
flies to Florida.
    He has been bit 2 or--you know, 2 or 3 days later, 
typically 6 or 7 days after being bit by the wrong mosquito you 
get a fever, right? And then he brings that--patient zero, so 
to speak, brings a different strain where we already have 
another strain, which increases the degree of danger. Am I 
right about that?
    Dr. Pablos-Mendez. Well, very interesting. You are right 
about some of the science there. Two things--first of all, 
because you don't transmit dengue person to person----
    Mr. Clawson. But a mosquito can bite the sick person and 
transmit it?
    Dr. Pablos-Mendez. That is correct. So you would have to 
have been also in such conditions which make what you are 
saying possible. Unlikely, but possible. And you are right 
about the different types of the virus.
    There used to be four. Now we have five, and immunity to 
one may protect you against that and may cross react with 
immunity against the other virus which has been one of the 
technical difficulties in vaccine development.
    But they have been overcome and we are developing now that 
technology in the end. In addition to development, making sure 
you don't have pots and tires with water in your backyard or in 
your house, the development of vaccines probably holds the best 
promise for dengue, which is a real and growing problem in the 
    Mr. Clawson. I mean, I understand my bright researchers in 
our office say that there could be up to 500 million cases a 
year. I think I read in the New York Times a year or two ago 
that it maybe 10 percent of the population.
    So it is a big number, which is why it worries me so much 
in south Florida. So let me ask--you know, I am taking more 
than my share of time here.
    Are the right percentage of the resources that you all 
spoke about earlier being spent on this problem in general and 
this problem's prevention aspects in the United States within 
your organization?
    Dr. Pablos-Mendez. The investments in dengue and dengue 
vaccine, of course, are bigger than those that we have at 
    USAID's NTD program is currently focused on those simplest 
to treat and prevent diseases, the most cost effective of those 
interventions. We do not have a program devoted to dengue.
    But I do hear you because the epidemiologists are asking us 
to consider doing that and we should certainly consider how we 
could add resources to do more on dengue. I would say that in 
addition to the strategies of prevention that I spoke of 
before, making sure that we get to a vaccine is the most 
important thing and supporting that is something that we should 
    USAID invests close to $200 million in reasearch and 
development. Almost half of that is in the HIV space because 
that is where we get most of the resources. But we cover many 
of the other things as well based on burden of disease.
    In the case of the dengue vaccine, we have now candidate 
vaccines that are close. It seems to us that although we may 
not need to put more money in developing the vaccines themself 
making sure that the pediatric formulations and making sure 
that those vaccines will be available in the future will be a 
very good and timely investment for us and we are going to be 
following closely with that.
    That will happen. Until then, we only have these general 
measures I spoke of before and health systems strengthening 
too, to treat people because if you are untreated with severe 
dengue you may have 5 or 10 percent may have severe outcomes. 
With good treatment it is less than 1 percent.
    Mr. Clawson. So with good treatment less than 1 percent are 
going to be hemorrhagic is basically what you are saying?
    Dr. Pablos-Mendez. Less than 1 percent of people with 
dengue will get severe disease.
    Mr. Clawson. And so when this bill comes up or when we look 
at this even the appropriations process--look, I am a 
Republican, right, so we have a thing about debt and taking 
from future generations.
    On the other hand, I also have a thing about poverty 
killing people and there is a lot of different ways that 
poverty kills people, right.
    Well, this is one of them and all the world's needy aren't 
suddenly going to be middle class and therefore we are going to 
be fighting these infectious diseases. Tell me if you think I 
am wrong.
    So it seems like the shortcut is the vaccine, which is a 
quick way to save a lot of lives, and then it also puts 
insulation on my state. I am glad to hear you say there is not 
enough tires with water sitting in them.
    But, you know, we have all seen what happens in Santo 
Domingo and Hyderabad, for that matter. And so I would like, 
you know, a little vaccine in order to insulate my state from a 
southern invasion of the wrong mosquito would be a good idea 
for my developed state as well as the poor folk living across 
the world. Am I saying that the right way? I mean, you are----
    Dr. Pablos-Mendez. I am happy to hear you because you are 
right that more attention is needed, that even though we are 
focusing on those things that are the simplest for the poorest 
because then we can get the most bang in terms of life saving 
and preventing problems, that this is a problem that requires 
not only the U.S. Government but many more and then, of course, 
efforts, as I said before.
    But I believe that we should explore how we could do more 
and with your support we could certainly look into that. I 
would say that----
    Mr. Clawson. But are we more--we are more cost effective 
with a vaccine----
    Dr. Pablos-Mendez. Correct.
    Mr. Clawson [continuing]. Than we are everybody in a 
poverty level existence digging a well, having shoes so they 
don't get worms and clean water and a clean septic.
    That is--we all--we want all of that but that is a longer 
term, more expensive thing than giving somebody a vaccine. Am I 
right? You know, are you following?
    Dr. Pablos-Mendez. You are right, and vaccines have been 
one of the best things that we have done in public health in 
the last century and we are happy, as you know, with the Global 
Alliance for Vaccines and Immunizations recent replenishment.
    The whole global community came together to put together 
$7.5 billion in vaccines because they are so important, and the 
U.S. Government has committed $1 billion to that. And vaccines 
are a great investment and, indeed, GAVI is open to look at how 
they can work in either support of the polio, as the polio 
eradication evolves. Ebola vaccines--there was one available. 
Once dengue vaccine will become available that also could be 
considered. We have a platform that we contribute to on 
vaccines that could pick this up.
    But I think there are limitations to keep us thinking 
beyond any narrow particular programs and we do so, then choose 
where our dollars can have the most impact, and what you are 
saying is very important for us.
    It is very important for the NIH. It is important for the 
CDC and globally with many of the other partners. So I will say 
to you that I will have this in mind, and the point you make 
about--we started with a humanitarian point as to why we do 
these things and you are making a very good point on the 
economics of this.
    There has been a recent commission on investing in health. 
You should know because this is not a bad investment. It is 
actually one of the best investments that can be made today and 
I am not talking as an advocate. This is what the Commission on 
Investing in Health said; they looked at the payoff of 
investing in health, particularly in these types of things 
which are very cost effective.
    You have a 10- to 25-fold leverage in terms of the 
economics of those countries. And you know at USAID we used to 
invest in Mexico, Brazil, South Korea when they needed help. 
Now they are our partners.
    Actually, ten of the 15 largest trading partners used to be 
a recipient of USAID assistance. Now they are our partners. So 
it is in our interest also to help, as you have pointed out, 
because in the end it is good for America in more than just do 
the right thing or being safe. It is also a good investment.
    Mr. Clawson. Well, as we go through the appropriations 
process, you know, anything I can do to help. I like free 
market solutions but there are gaps when it is poor people that 
can't pay for things and so this makes your role important, as 
far I can tell, in the breach and therefore I am supportive.
    But I want to understand that it is, as you were discussing 
here, that it is money well spent and that others are paying 
their fair share, and then if that is the case we are all the 
same and we need to do what we can for everybody.
    So thank you for what you are doing.
    Dr. Pablos-Mendez. Thank you.
    Mr. Smith. Mr. Clawson, thank you for your incisive 
questions and very compassionate comments.
    Mr. Clawson. Sorry to take so much time.
    Mr. Smith. No, it was very well done. I thank you so very 
    I just have a few questions. We have been advised that we 
may have a series of votes that will go on for about an hour. 
So I will collapse all of my questions into one.
    Mr. Clawson. I am sorry, Chris.
    Mr. Smith. No, no. I just got the word. First of all, on 
the gaps issue, Mr. Clawson, I think, brings a very good point 
up about gaps.
    In his testimony, Dr. Hotez says that it is estimated that 
the annual global funding gap is over $220 million per year. He 
has recommended that--I think at a minimum that we put an 
additional $25 million on last year's number to bring it to 
$125 million.
    Again, let the record note that we are all concerned that 
the administration's request suggested a $13.5 million decrease 
and my hope is that that will not have any traction and that we 
look to actually increase because of the work that it is doing.
    And I think, as you point out in your own testimony, Doc, 
you know, that for every $1, $26 donated comes from the private 
sector, from the pharmaceuticals and the like.
    That is leveraging the likes of which I have not seen and 
every dollar we put in we are getting back a huge impact on 
people's lives.
    So if I could just ask all of our witnesses that follow 
will talk about public-private partnership being 
extraordinarily good.
    The gap issue, $220 million--if you had additional dollars 
like $125 million how would you use it? Dr. Hotez makes a point 
about the horrific NTD outbreaks coming out of ISIS-occupied 
Syria and Iraq and possibly Libya and Yemen and in his 
testimony--and he has done this before--he talks about this 
being one of the consequences of war, very often under 
    If you could speak to that. The integration with PEPFAR--
our new bill has language and, again, I learned that having 
read his book--Dr. Hotez's book and his testimony last year 
that there is, again, an under appreciation of how--what NTDs--
the role they play in making women especially more susceptible 
to HIV/AIDS and in his testimony he put it this way:

        ``I am concerned that NTDs are still not a component of 
        large-scale programs to combat HIV/AIDS such as PEPFAR 
        and the Global Fund despite evidence that 20 million to 
        150 million girls and women in Africa suffer from 
        female genital shistosomiasis, which increases 
        susceptibility to HIV/AIDS and represents a major co-
        factor in Africa's AIDS epidemic.''

Your view on that.
    It seems to me that integration has to take place 
yesterday. The post-2015 goals, I have read them. I have read 
the targets. I am concerned that there doesn't seem to be the 
    Our bill does that. It calls for those goals in effect 
since the year 2000, particularly goals three, ensuring healthy 
lives and, one, ending poverty in all its forms everywhere.
    There needs to be, I think, a hyper sense of the 
disproportionately negative role that NTDs play and if you 
could--maybe not today but certainly soon--give your and the 
administration's view in supporting H.R. 1797, our new 
bipartisan bill that I just introduced today, the End Neglected 
Tropical Diseases Act, which incorporates so much of this, and 
hopefully will help take us to an even better level on this.
    Dr. Pablos-Mendez. Well, thank you very much, Congressman. 
Thank you very much.
    Well, as you know, in terms of the overall budget we are 
making many critical investments across the spectrum of global 
health programs and you have been a champion of many of those, 
especially maternal and child health.
    And as we have discussed, now half the kids who are dying 
are dying in the first month of life. Because of the success of 
the older kids it is now the babies who are dying or who are 
accounting for the greater proportion, and we are increasing 
our support for the newborns as one of the best ways to 
decrease total mortality.
    But that calls for very difficult choices for us and since 
we are operating on a flat-line environment for budgets those 
choices are very difficult.
    But I have to say that I fully support the funding level 
requested but, most importantly, I feel confident that the 
level of funds that will be available in Fiscal Year 2016 will 
allow us to continue the remarkable progress on NTDs and will 
also continue to save the lives of mothers and children.
    If we had an additional $25 million, as you suggest, well, 
that would allow us to treat 30 million more people and, 
clearly, get sooner to the place in which we can get closer to 
elimination and control of many of these diseases. PEPFAR----
    Mr. Smith. Thank you for that----
    Dr. Pablos-Mendez. Yes.
    Mr. Smith [continuing]. That analysis. Perhaps elaborate 
that a little more so the rationale and the justification as we 
lobby our friends on the Appropriations Committee.
    Because we will be doing a letter from our subcommittee and 
it will be, I am sure, bipartisan, it would be great if we 
could break that with as much exactness as possible----
    Dr. Pablos-Mendez. That is right. So----
    Mr. Smith [continuing]. And what good we can add.
    Dr. Pablos-Mendez [continuing]. Our teams will ready to 
expand in seven countries in Africa with--and we will send more 
details as needed.
    On PEPFAR, because it is an important part of the program, 
clearly, PEPFAR is an incredible platform. It has helped 
especially in recent years to support the systems that can then 
help deal with other new problems.
    Some of the diseases are parasitic, which are not amenable 
to or targeted by the cost-effective programs that we have 
today--are expensive to treat, and I would like to say that 
their research and development efforts will be very important 
and if we have more resources we could someday also offer 
support for those diseases.
    In terms of collaboration--we see also great opportunity 
and we leverage opportunity of working with our water, 
sanitation and health programs (WASH) because as we heard 
before many of these issues have to do with water that is a 
vector or water reservoirs.
    So WASH programs are important. Our collaboration with 
malaria, some of this is to minimize mosquitoes and so the bed 
nets are helpful in lymphatic filariasis as much as they are 
helpful in malaria.
    And in terms of the post-2015, I think you are making a 
good point. Maybe in part it is because the post-2015 agenda 
for the world is looking at a grand convergence in gains by 
    But in this case, we have to look at 2020 to eliminate many 
of these diseases. So we are almost ahead of the schedule in 
which the larger agendas are. But it is a good point that we 
should continue to maintain this ability and important----
    Mr. Smith. Well, and again, it is in goal three, target 
three but it is one line and it seems to be--maybe the 
indicators will expand and give it the weight that I think it 
just needs to get--it is not just one on a list of things.
    Dr. Pablos-Mendez. We will convey this to our negotiators. 
Thank you.
    Mr. Smith. I appreciate that. Thank you. Thank you very 
much. Just because of time, I do have other questions. I will 
submit them for the record. But I thank you so much, Doctor.
    I would now like to welcome--look forward to working with 
you and please get back to us on supporting the End Neglected 
Tropical Diseases Act, any changes you think might be necessary 
to improve it, we are wide open for that and I think this is 
something that would get the whole Congress----
    Dr. Pablos-Mendez. Thank you.
    Mr. Smith [continuing]. Further on board on this important 
    Dr. Pablos-Mendez. Technical staff is happy to continue to 
do so.
    Mr. Smith. Thank you.
    I would like to now invite our second panel, and I am only 
rushing because of the pending votes, beginning with Dr. Peter 
Hotez, who is president of the Sabin Vaccine Institute and 
leads the Texas Children's Hospital for Vaccine Development 
based at the Baylor College of Medicine.
    He is also the founding dean of the National School of 
Tropical Medicine at Baylor College of Medicine. His academic 
research focuses on vaccine development for a wide range of 
neglected tropical diseases around the globe as well as studies 
to increase awareness about the neglected tropical diseases in 
the U.S. as well as other countries.
    He created the Sabin Vaccine Institute Product Development 
Partnership and was instrumental in creating the Global Network 
for Neglected Tropical Diseases. In 2014, President Obama named 
him as one of four U.S. science envoys with a mandate to 
explore the development of vaccine Centers of Excellence in 
North Africa and the Middle East and, again, he has also 
recommended such a thing, a Center of Excellence, for the 
United States.
    We will then hear from Mr. Nicholas Kourgialis, who is the 
vice president for eye health at Helen Keller International 
where he provides programmatic direction and oversight for its 
eye health and neglected tropical disease programs worldwide.
    Mr. Kourgialis joined Helen Keller in December 2003 and 
brings more than 13 years of related experience to his work at 
HKI, having spent his career specializing in public and global 
health interventions, addressing the needs of disadvantaged 
    Helen Keller International's integrated program includes 
several NTDs and they are actively supporting a number of 
programs across 14 countries in Africa and deworming in school 
children in the Asia Pacific and he is also, I am happy to say, 
from my state.
    Dr. Hotez?


    Dr. Hotez. Good afternoon, and thank you, Chairman Smith, 
for inviting me and to members of the subcommittee, Congressman 
Clawson. I ask that my full written statement be added to the 
    Mr. Smith. Without objection, so ordered.
    Dr. Hotez. Thank you. My name is Peter Hotez. I am a 
physician scientist. As you pointed out, I am dean of the 
National School of Tropical Medicine and also president of 
Baylor College of Medicine, president of the Sabin Vaccine 
Institute where we make vaccines for neglected tropical 
    We make the vaccines that the drug companies can't make or 
won't make including vaccines for diseases that are affecting 
or will soon affect Congressman Clawson's district.
    I would like to point out that I am the recent author of a 
paper called ``The Gulf Coast: A New American Underbelly of 
Tropical Diseases and Poverty.'' And so that is very relevant, 
I think, to this committee.
    Mr. Smith. Without objection, I would like to add that to 
the record because there is a very keen interest. So without 
objection, if we could get a copy we will----
    Dr. Hotez. Sure. We recently estimated that there are 12 
million Americans living with one or more neglected tropical 
diseases, mostly affecting those in the Gulf Coast. I am on one 
end of the Gulf Coast. I am in Houston on the Texas side of the 
Gulf Coast. We are the bookends, Congressman.
    Mr. Clawson. That is all right. I mean, you know, we got 
the better district but that is--it is all right. You are still 
on the Gulf. At least you didn't say ocean.
    Dr. Hotez. And so--and then I would like to talk a little 
bit about my role as U.S. science envoy and some great concerns 
that we have for the next shoe that is going to fall after 
Ebola, which is going to be the Middle East and North Africa.
    It won't be Ebola but I will tell you about that. So let me 
just briefly summarize the situation globally and then tell you 
about my concerns of what is happening in the Middle East and 
then fine tune it to disease and poverty here in the Gulf Coast 
and the United States.
    Working with the Institute for Health Metrics in Seattle, 
we have just determined that practically every single person 
living in extreme poverty is affected by one or more neglected 
tropical diseases--these chronic and debilitating conditions.
    The numbers we have just come up with are extraordinary--
819 million people with ascariasis infection, 440 million with 
hookworm, 390 million with dengue, schistosomiasis 252 million, 
river blindness 30 million, Chagas disease 7 to 10 million--
every single person living in poverty.
    And the point is these diseases both occur in the setting 
of poverty and they cause poverty. We are about to publish at 
the end of next week a worm index for human development where 
you can actually show that there is this very inverse 
correlation between human development index and the level of 
neglected tropical disease burden and think this also applies 
to the United States as well, which I will point out.
    Now, although Ebola virus infection is the best known 
neglected tropical disease, it remains one of the rarest. We 
have recently done an estimate of the three Ebola-affected 
countries in west Africa--Guinea, Liberia, and Sierra Leone--
and while there are 20,000 cases of Ebola there, or what was 
0.1 percent of the population, a third of the population is 
infected with either hookworm infection, schistosomiasis, or 
    So these are probably the major severe and incapacitating 
sequelae of the west African countries, and as I pointed out 
these diseases are not restricted to the poorest countries of 
Africa because poverty is the overriding determinant and can be 
found even among the extreme poor living in wealthy countries 
such as in the United States.
    There are an estimated 20 million people who live in 
extreme poverty in the U.S. and now new numbers coming out of 
the University of Michigan Center for Poverty find that there 
are 1.65 million families in the U.S. that live on less than $2 
a day.
    So we could take that same benchmark for global poverty and 
apply it to the U.S. Now, throughout the month of October 2014 
I appeared regularly on MSNBC or Fox News. Imagine appearing in 
the same day on MSNBC and Fox News. That was interesting.
    And but the question I would get almost every time is 
Doctor, aren't you worried about Ebola virus coming to the 
United States and my answer was almost always no, and here is 
why--here is what we know--it is a difficult disease to 
transmit and only occurs in the setting of post-conflict when 
there is massive breakdown in public health infrastructure but 
we do have 12 million Americans living in extreme poverty, 
mostly in the Southern U.S., mostly on the Gulf Coast who are 
affected by at least one neglected tropical disease including 
Chagas disease, toxocariasis, and cysticercosis.
    We have dengue in Houston. We have dengue in the west coast 
of Florida and chikungunya will surely follow. I predicted last 
summer but probably this coming summer.
    What was interesting about that the anchors, whether from 
MSNBC or Fox, always responded the same way, which was, ``Thank 
you, Doctor. We are out of time.''
    So the neglected tropical diseases continue to represent 
our nation's most glaring and ignored health disparity issues. 
Let me briefly summarize, if I may, what is working globally 
and what's not for the neglected tropical diseases.
    First, a very important achievement has been the scale up 
of mass treatment packages of donated drugs, which we first 
proposed in partnership at the World Health Organization in 
    Today, this approach is in operation in more than two dozen 
less-developed countries which is leading to the elimination of 
two key neglected tropical diseases of major global importance, 
lymphatic filariasis and trachoma.
    And I would like to thank Dr. Ariel Pablos-Mendez for his 
leadership on this issue and we are really thrilled with the 
fact that under his leadership and with the Administrator that 
over the past 8 years they have improved the lives of over 460 
million people and delivered more than 1 billion neglected 
tropical disease treatments.
    This successful public-private partnership with leading 
pharmaceutical companies has exceeded expectations in its 
ability to deliver treatments for the seven most common 
neglected tropical diseases which make up a bulk of the global 
NTD burden and leverage more than $6.7 billion worth of donated 
medicines in 25 target countries including Bangladesh, 
Indonesia, Nigeria, and Sierra Leone.
    In addition, tremendous global progress has been made in 
tackling neglected tropical diseases since the announcement of 
the London Declaration on NTDs in 2012, partnerships which 
includes the United Kingdom and the Gates Foundation, 13 
pharmaceutical companies and, of course, the U.S. Government.
    In 2013, more than 1.35 billion treatments were supplied by 
pharmaceutical partners alone and by the end of 2014 more than 
70 endemic countries had developed multi-year integrated NTD 
control plans, narrowly a 50-percent increase.
    Despite the progress, as you pointed out, the funding gap 
remains. It is estimated that the global annual funding gap is 
over $220 million a year.
    That is why we are disappointed to see the President's 
proposed budget request for USAID's NTD program for Fiscal Year 
2016 at $86.5 million, which is actually a $13.5 million 
decrease from Fiscal Year 2015 enacted level of $100 million 
and urge Congress to increase funding for NTDs from $100 
million to $125 million.
    This additional $25 million will allow USAID to further 
maximize the benefits of increased drug donations received from 
pharmaceutical companies, conduct impact assessment surveys to 
measure progress and increase the impact of this successful 
public-private partnership.
    The subcommittee should also consider the inclusion of 
additional NTD control and elimination measures within other 
USAID programs which are among broader U.S. Government and 
foreign assistant programming. This would include water, 
sanitation, and hygiene programs as well as food security or 
nutrition initiatives.
    I am also concerned that NTDs are still not a component of 
large-scale programs to combat HIV/AIDS such as PEPFAR and the 
Global Fund, despite the evidence of tens of millions of girls 
and women suffer from female genital schistosomiasis and which 
increases their susceptibility to HIV/AIDS.
    And parallel with these global public health measures there 
is an urgent need to support research and development for new 
drugs, diagnostics, and vaccines for NTDs. As the head of the 
nonprofit Sabin Product Development Partnership, we have 
developed two critically important neglected tropical 
diseases--one for hookworm infection, the other for 
schistosomiasis--which are now undergoing clinical testing in 
Brazil, Gabon, and the United States.
    We also have new vaccines for Chagas disease, 
leishmaniasis, and other neglected tropical diseases in earlier 
stage of development. Greater U.S. investment in NTD related 
research and development are needed to support the introduction 
of these new technologies as a means to ensure the achievement 
of goals for control and elimination.
    I would like to say that people who live in poverty deserve 
more than access to essential medicines. They also deserve 
access to innovation.
    Previously, I proposed setting aside 1 to 2 percent of the 
U.S. commitment to global health for the development of new 
drugs, diagnostics and vaccines which would pump $100 million 
to $200 million new dollars into the system for NTD product 
    Yet, it is very important to point out that these research 
and development efforts must not come at the expense of 
accelerating the success of the NTD program at the USAID. We 
need to keep that program intact, otherwise, if you take it 
away--the research and development dollars--it would undercut 
the positive gains that resulted to date and put hundreds of 
millions of people at risk.
    Now, we also need new vaccines for other countermeasures in 
preparation for new catastrophic NTD outbreaks such as the one 
that hit west Africa in 2014, and what I would like to say is 
the fact that we saw this catastrophic outbreak in west Africa 
last year and into 2015 was not because Guinea, Sierra Leone, 
Liberia are tropical.
    It was because they emerged out of conflict and post-
conflict settings, and when I had the time to point it out on 
television I would say Ebola's version 3.0 of a trend that we 
have seen for the last three or four decades, which is that you 
have a catastrophic conflict and then something terrible 
happens. It happened in Angola, the Democratic Republic of the 
Congo, in the 1970s, breakdown in infrastructure.
    Half a million people died of African sleeping sickness 
after that conflict. So 20 times more than Ebola. It went 
unrecorded because there were no journalists there. Version 2.0 
was in southern Sudan in the 1980s and 1990s with the conflict 
there. A hundred thousand people died of kala-azar--
leishmaniasis transmitted by sand flies--Ebola's version 3.0.
    So and the problem is the world reacts too slowly. So what 
happens is nobody is stockpiling vaccines to get ready for 
these diseases and when the crisis hits it is too late.
    So what we saw now is even though the technology to make 
the Ebola vaccine was around for a decade, we sat around 
waiting for big pharma to pick it up and then it only happened 
after the 11th hour and only now are these vaccines going into 
clinical trials when there are no more cases around to really 
see if even the vaccines work.
    So we need a new model and what I am particularly concerned 
about in my role as U.S. science envoy--and I would like to 
point out that the views in herein are my own and do not 
reflect those of the White House or the State Department--is 
that version 4.0, given the strong link between conflict and 
contagion, is going to be in ISIS-occupied zones of the Middle 
East, Iraq, Syria, Libya, and Yemen.
    We don't have the World Health Organization working there 
because it is too dangerous. We are only getting glimpses of it 
from refugees spilling across the border into Jordan and 
Lebanon, into Turkey and to Egypt.
    But what are we seeing? The resurgence of measles, the 
resurgence of polio, a horrific neglected tropical disease that 
the locals call Aleppo evil. It is a disfiguring disease of the 
face that particularly affects little girls and renders then 
    The other name is cutaneous leishmaniasis, more than 
100,000 new cases, and I am quite worried about the Middle 
Eastern Respiratory Syndrome virus. And the problem is big 
pharma will take on problems which have global importance but 
not regional importance.
    Right now, there is no capacity to make vaccines or minimal 
capacity to make vaccines in the Middle East and North Africa. 
The Iranians do it on a good day, maybe a little bit of Israel 
Defense Forces, but that is about it.
    So in my role as U.S. science envoy, I am trying to take 
the model of what we are doing for making vaccines in Houston 
in the nonprofit sector and reproducing that somewhere in a 
stable country in the Middle East and North Africa, one that 
has some underlying infrastructure for doing so, and I am happy 
to address that in more detail.
    Finally, let me end by revisiting the NTDs in the United 
States. Twelve million Americans live with at least one 
neglected tropical diseases and most people have never heard of 
them. They include toxocariasis, a larval worm infection linked 
to deficits in cognitive development that affect almost one in 
five African-Americans living in poverty.
    In a paper I wrote in JAMA Psychiatry, I asked whether 
toxocariasis could be partly responsible for the achievement 
gap noted among socioeconomically disadvantaged students. At 
our National School of Tropical Medicine in Houston, we are 
finding unique modes of transmission of diseases like 
toxocariasis as well as Chagas disease, a parasitic disease 
that causes debilitating and life-threatening heart defects 
among the poor and among hunters and campers in our state.
    A key point is that many if not most of these neglected 
tropical diseases are not being imported through immigration, 
because that is usually the first response people have. 
Instead, we are finding transmission among the poor, especially 
in the American South, especially in the Gulf Coast.
    Throughout the Gulf Coast we have got two major species of 
mosquitoes, each capable of transmitting dengue, each capable 
of transmitting chikungunya.
    So we need more comprehensive surveillance and to develop 
improved point of care diagnostics. One of the problems is 
physicians aren't trained to even recognize these diseases. 
When we had our outbreak in Houston we found that none of the 
cases were picked up by physicians because they are not trained 
in these diseases.
    The other problem is we don't have point of care 
diagnostics. So, you know, when you go to your doctor you get a 
blood test and you see the little boxes checked off with your 
blood chemistries. There is no box for chikungunya.
    There is no box for dengue. There is no box for 
toxocariasis or Chagas disease. We have got to change that. We 
also need a new generation of drugs and vaccines.
    So that is the whole point behind this Center of Excellence 
idea and the legislation that you just introduced and I am so 
grateful, again, for your tenacity, Chairman Smith, in making 
this happen.
    So we just learned about the H.R. 1797. I assume it has 
similarities to what was H.R. 4847 and we are so grateful for 
this committee taking on this important issue which is 
devastating populations living in poverty and conflict 
everywhere, and I appreciate the opportunity the subcommittee 
has given me to speak on this issue.
    Thank you.
    [The prepared statement of Dr. Hotez follows:]

    Mr. Smith. Dr. Hotez, thank you so very much. And again, 
many of the ideas that you recommended at our last hearing 
found a home in our legislation.
    So I thank you for that guidance that you provided to the 
committee and to the legislation.
    Mr. Kourgialis, please proceed.


    Mr. Kourgialis. Mr. Chairman, thank you for the opportunity 
to testify regarding the importance of continued funding for 
the U.S. Government's neglected tropical disease program and to 
highlight the enormous impact that it is having on the health 
and welfare of individuals living in the world's poorest 
    I also want to thank you for your continued commitment to 
improving the lives of millions by helping to eliminate or 
control the seven most prevalent NTDs targeted by the U.S. 
    Collectively, these parasitic and bacterial diseases blind, 
disfigure, and disable millions of people in the world's 
poorest communities and limit their ability to lead healthy and 
productive lives.
    According to the World Health Organization, NTDs infect 
more than 1 billion people, a sixth of the world's population 
including an estimated 800 million children who, as a result, 
suffer from malnutrition, decreased school enrollment and 
diminished physical and intellectual development.
    Eliminating NTDs can allow millions to climb out of poverty 
by increasing access to education and improving their ability 
to work. Since its inception, the U.S. Government's NTD program 
has supported the delivery of more than 1 billion treatments to 
approximately 470 million people in 25 countries.
    The impressive reach and impact of the program would not be 
possible without the remarkable public-private partnership with 
the pharmaceutical sector. We commend the U.S. Congress and 
USAID for their global leadership on this issue.
    Co-founded in 1915 by the deaf-blind crusader, Helen 
Keller, Helen Keller International offers programs in 21 
countries in Africa and Asia as well as the United States. The 
prevention and treatment of NTDs is a key organizational 
priority and one of our most important and far-reaching 
    HKI has been the recipient of integrated NTD program 
funding from USAID in Burkina Faso, Cameroon, Guinea, Mali, 
Niger, and Sierra Leone. Despite their many challenges, all six 
countries supported by HKI have made significant progress 
toward global NTD control and elimination targets.
    In 2015, HKI will lead a new 5-year project aimed at 
managing morbidity and preventing disability related to 
trachoma and lymphatic filariasis.
    HKI's approach and strength has been to partner with 
government ministries to provide technical assistance and 
support to national disease control teams and to build capacity 
within countries with the goal of scaling up and creating 
sustainable systems of care.
    Our ultimate goal is for ministries of health and education 
to assume clear ownership over these programs and for national 
governments to commit the necessary human and financial 
resources needed to achieve control or elimination of the 
targeted diseases.
    Trachoma offers a valuable example of what can be achieved 
through global cooperation. It also highlights the critical 
importance of continued funding for NTD program implementation 
    Trachoma is the leading cause of infectious blindness in 
the world. This bacterial infection is transmitted by flies and 
through physical contact with eye and nose discharge of 
infected people, particularly young children who are often the 
principal reservoir of infection.
    Repeated cycles of infection and inflammation can result in 
scarring of the inside of the eyelid, causing it to turn inward 
so the eyelashes scratch the cornea, ultimately causing 
blindness through a very painful condition called trichiasis.
    To combat trachoma, HKI supports the distribution of 
antibiotics, increased face washing, and the use of latrines to 
reduce disease transmission. Surgery is also provided for those 
suffering from trichiasis.
    Several HKI-supported countries have made notable progress 
in reaching specific disease control targets. For example, 
Burkina Faso is on track to stop mass drug administration for 
trachoma by the end of 2016.
    Similarly, in Mali, despite the challenges posed by recent 
political instability and violence, more than 90 percent of 
districts that require trachoma treatment have been able to 
stop drug administration.
    The U.S. Government's support of country-level 
implementation activities is essential to achieving the WHO 
goal of goal of eliminating trachoma as a public health problem 
by 2020.
    Mr. Chairman, in order to sustain the accomplishments of 
the current NTD program I hope that the Congress will restore 
funding in Fiscal Year 2016 to at least the $100 million level 
provided in Fiscal Year 2015.
    I also urge that the focus of the seven targeted diseases 
be continued. Enormous progress has been achieved over the past 
8 years in combating these diseases. A decrease in USAID 
funding at this critical time would significantly undermine the 
ability of national NTD programs to continue their activities 
and to reach their control and elimination targets.
    I am optimistic that funding levels for NTDs will be 
restored so I will conclude with the words of Helen Keller--
``Optimism is the faith that leads to achievement. Nothing can 
be done without hope and confidence.''
    Thank you, Mr. Chairman.
    [The prepared statement of Mr. Kourgialis follows:]

    Mr. Smith. Thank you so very much for your leadership, for 
those insights as well, and so many lives that have benefitted 
because of your work.
    Just a few questions, if I could, beginning with Dr. Hotez 
and perhaps both of you might want to address this. In your 
testimony you said it is estimated that the annual global 
funding gap is over $220 million per year.
    In the 1980s, I was on this committee and I remember I 
contacted WHO and asked them what it would take to make the 
meaningful difference in neglected tropical diseases, and I 
think we just called it tropical diseases then, and I got back 
a time line, numbers and I worked every year to try to get 
those numbers as close as possible both on the authorizing and 
the appropriation side.
    We never actually got there but it was far less than this, 
I can tell you, and I am just wondering if you could for the 
committee and for us, all of us here, break that out either 
here or by way of a written submission.
    You suggested $125 million, Dr. Hotez, as, I guess, our 
additional. You know, we are always constrained by the doable 
versus what really would make all the difference in the world.
    Whatever you could do to provide, I asked Dr. Pablos-Mendez 
earlier. He said 30 million people would be positively impacted 
and said he would get back. The more detailed the better in 
terms of making our case to the leadership and to the 
appropriators on this because it seems to me, again, the 
sustainable development goals--post-2015 their goal is to 
eliminate it by 2030.
    Talk of 2020 is always in the mix. For the person dying or 
suffering from this they want it now, as we all know. So if you 
could speak to that, if you would. Yes?
    Dr. Hotez. Thank you, and I appreciate that question. I 
guess just to give it some perspective let us remember the 
budget of PEPFAR is around the order of $8 billion a year so we 
are talking about $25 million.
    Remember what you get for that $25 million. This package we 
helped design is 50 cents a person per year. It is probably the 
single most cost effective public health control measure out 
    I mean, where else are you going to treat 50 million people 
for $25 million? Maybe it won't get quite to 50 but those are 
the numbers we are talking about.
    And so, when we--the neglected tropical disease people are 
always grateful for any crumbs that anyone can throw at us and 
so we think $25 million is a very modest amount but look what 
you get for it. So USAID is currently operating in more than 
two dozen countries.
    We have the opportunity to take on a whole additional 
country with that, just to give you a perspective on what that 
money can do.
    Mr. Smith. I thank you for that.
    Mr. Kourgialis, would you want to speak to that?
    Mr. Kourgialis. Certainly, the needs for services far 
exceed the available resources. So any additional resources 
that can be brought to bear would be very valuable.
    Mr. Smith. You spoke, Mr. Kourgialis, very, I think, 
eloquently about the importance of pushing ownership. I am 
sure, Dr. Hotez, you believe the same thing, as does USAID.
    How receptive have you found the ministries of health and 
political leaders to say we do want to take this over and more 
of our resources are going to be devoted to ending neglected 
tropical diseases?
    Mr. Kourgialis. I can only speak to the countries in which 
we work. But, certainly, we couldn't do our work without the 
support of the ministries. They are a critical player in all 
this and we must have their cooperation and support in order to 
conduct any activities at this scale.
    We are functioning at a national scale. We face enormous 
challenges in reaching people at the end of the road, these are 
the poorest of the poor. Without the ministries' support that 
wouldn't be possible.
    So it is critical and in most of the countries the support 
is. They certainly see the effect that these diseases have on 
their populations. They want to address that.
    The support is there on the part of the global community at 
this point on a very broad scale. So I think they are taking 
advantage of that opportunity, accomplishing it as much as they 
can with the resources that are available.
    Dr. Hotez. Yes, I would agree with that and just to say 
that because the packages of medicines are so low cost--50 
cents a person per year--a Minister of Health and a Minister of 
Finance for a country can look at that and say yes, we can do 
this--we can help with this.
    So, for instance, Burkina Faso, when I last looked was 
paying for 69 percent of its NTD bill. So and as opposed to 
something like PEPFAR where you are talking about hundreds of 
dollars a person to put a person on anti-retro viral drugs for 
a year, this is 50 cents.
    So it is not so daunting for a lot of these disease-endemic 
countries to help take this on and assume a lot of ownership.
    Mr. Smith. Can I ask you, Dr. Hotez, how receptive has 
USAID and the PEPFAR program leaders, especially the czar, been 
to your recommendation that it be integrated--the neglected 
tropical diseases component--to the PEPFAR fight?
    Dr. Hotez. Well, I have not approached PEPFAR recently. The 
last time I approached PEPFAR Ambassador Goosby was still in 
charge and, you know, in principle they thought it was a great 
idea but there was--there was just too much inertia to make it 
    So I haven't had the opportunity to meet with the new 
Global AIDS Coordinator to discuss it. You know, we have had 
this conversation with Mark Dybul, head of the Global Fund, and 
there was some initial push back.
    But then we understood that Mark Dybul was visiting the 
schistosomiasis people at WHO. So maybe we are getting some 
    Mr. Smith. I was there when you had that phone call.
    Dr. Hotez. Yes.
    Mr. Smith. Your very persuasive case. As you know, we did 
include in the bill that kind of direction to integrate into 
work in a partnership. So thank you.
    You mentioned NTD vaccines for hookworm and for 
schistosomiasis there at the clinical testing level in Brazil, 
Gabon, and United States. How soon before something might be 
    Dr. Hotez. So we are in the phase one testing now for 
safety and immunogenicity and now we are going to be moving to 
look at the efficacy.
    So I am hoping within 5 years we will be able to be well 
advanced on the way, and the idea behind it is the package of 
medicines has been great for eliminating lymphatic filariasis 
and trachoma.
    The problem was that for hookworm and schistosomiasis they 
keep coming back. So they knock down the bioburden, there tends 
to be reinfection and that is the idea behind the vaccine. 
Thank you for that question.
    Mr. Smith. Quick, the issue that you have raised repeatedly 
about the consequences of war and you did it in your testimony 
and I did ask our previous witness about that, could you 
elaborate on that?
    I mean, you just came back from a visit some weeks ago to 
the Middle East.
    Dr. Hotez. Yes. I don't have to tell this committee the 
situation in the Middle East is dire with an ever expanding 
territory now over four countries--Syria, Iraq, Libya, and 
Yemen--and the first thing that happens, of course, is all 
public health control measures pretty much stop.
    All access to medicine stops, and my point in my testimony 
was that when we have seen this before where, again, calling 
them tropical diseases it is a bit of a misnomer.
    They are diseases of poverty and disease of poverty in 
conflict. So you bring in those social forces of poverty 
conflict and with it comes human migrations, trafficking of 
animals, which transmit zoonotic diseases, deforestation.
    All of these create the perfect storm to allow a 
catastrophic neglected tropical disease. That is why Ebola 
arose in west Africa, and from my point of view in my role as 
dean of National School of Tropical Medicine all those same 
forces are in place now in ISIS-occupied zones and therefore we 
need to be ready.
    Mr. Smith. Before going to Mr. Clawson, just let me 
conclude by quoting from your testimony, I don't know if you 
said this orally but it bears repeating if you did.
    Dr. Hotez, you said, ``NTDs continue to represent our 
nation's most glaring and ignored health disparity issue'' and 
I think they are called neglected tropical diseases for a 
reason. The ``neglected'' has to fall out of that phrase.
    Mr. Clawson?
    Mr. Clawson. Well, I am thinking about everything you are 
saying. Most of the time you are saying it and I am tapping my 
foot but once in a while I am not understanding exactly.
    So since none of my colleagues showed up I guess I get to 
ask you some more questions and I appreciate you all's 
patience. I believe in a strong military because it creates 
    But I wish our country was more judicious in where we send 
bombs because it feels like bad wars create bad outcomes, one 
of which I hear you saying is not just the bombs killing people 
but far more people probably die from the secondary unintended 
impacts of refugee camps whether they are in Kurdistan, or on 
the Thai-Cambodian border 30 years ago.
    Am I hearing you right on that? Is that right?
    Dr. Hotez. That is correct. I call it the link conflict and 
contagion and but it is conflict in the areas where we have had 
a lot of intense poverty for years as well. Those two forces 
combined are synergistic to create this.
    Mr. Clawson. So it is odd to me, really, that therefore 
that given that the Ebola thing also rose out of conflict, 
which wasn't nearly as bad as some other countries in central 
Africa, right, that when we speak about ISIS and our own 
propensity to go to war that we don't talk enough about this 
outcome. Am I right about that?
    Dr. Hotez. That is right. It is not a sexy topic and it 
just doesn't get a lot of time either in the news media or 
    But it is--and it is something that not a lot of people 
appreciate that there is this link between conflict and 
disease. And so it is something we need to create better 
awareness of because remember, we are not talking small 
    Five hundred thousand people died of sleeping sickness as a 
consequence of the wars in Angola and the Democratic Republic 
of the Congo, and that is a lowball estimate.
    Mr. Clawson. I don't think you are going to venture to 
predict how many people could die in the Middle East because of 
disease as a result of war? I am not trying to get----
    Dr. Hotez. Right. Right.
    Mr. Clawson [continuing]. Make you get wet here but I am--
what is your worst case scenario?
    Dr. Hotez. Well, it is a two-step process because the first 
step is you have to accurately predict what the diseases are 
going to be and so some of them are not even lethal diseases, 
like cutaneous leishmaniasis is disfiguring, it is ruining 
people's lives but it is not killing.
    But something like--I am worried about MERS--the Middle 
Eastern Respiratory Syndrome corona virus--that we know it is a 
high rate of mortality.
    You add it to the mix of conflict and animal trafficking 
and the numbers could go very high. And so the point is we need 
to be flexible in being ready to make vaccines for these 
    Mr. Clawson. Could I have another minute, Chairman? Is that 
all right? Okay. Thank you for your patience.
    Mr. Smith. Sure.
    Mr. Clawson. So let us change gears a little bit. That is 
all new learning for me so it is on the shelf and I plan to 
think about it in my duties in Foreign Affairs Committee as 
well as Homeland Security.
    Dr. Hotez. Great. Thank you for that.
    Mr. Clawson. Well, I am pretty new around here so I 
wouldn't overrate that. So somebody gets off a plane. He has 
got chikungunya or dengue fever. The emergency room goes 
through their checklist.
    They think about malaria because they know he came from a 
tropical country. They think about influenza. They probably 
don't think about dengue fever or chikungunya, even in a very 
good clinic, even though the person has got a high fever and is 
coming from one of those infected countries. Am I right or 
wrong about that?
    Dr. Hotez. Well, we can actually prove you are right 
because we did this exercise. Kristy Murray, who is a faculty 
member in our National School of Tropical Medicine, found that 
dengue, when she did this through retrospective records, 
emerged in Houston, which has got a pretty good medical center, 
which I am from, one of the best health care facilities in the 
world, dengue emerged in 2003 with an epidemic, again, from 
people who never left Houston--people who have been living 
there the whole time, and it occurred again in 2004 and 2005. 
Not a single case was diagnosed by a physician.
    Mr. Clawson. So then the conclusions that I am drawing from 
everything I have heard so far today are----
    Dr. Hotez. Which, by the way, is the reason why we have now 
created a unique certificate program--a diploma in tropical 
medicine, an 8-week concentrated course that we are now giving 
to physicians, medical students, residents to actually teach 
them how to recognize these diseases.
    Mr. Clawson. And what percentage of doctors in the Gulf 
Coast states that you have talked about earlier have had that 
    Dr. Hotez. Well, we have probably graduated about six 
classes with maybe 20 physicians each. So it is a small 
number--a very small number.
    Mr. Clawson. So right now on vaccines, mosquito nets and 
not letting the water pool up and our diagnosis is about 20 
doctors that know enough to have an idea what they are seeing. 
I don't want to overstate the negative but tell me if I am----
    Dr. Hotez. No, I think you are reading between the lines of 
my testimony which is that it is not clear to me that we have 
adequate public health preparedness for neglected tropical 
diseases affecting the Southern part of the United States.
    We need to step it up and part of the problem is we are not 
even--we are doing almost nothing in regard to active 
surveillance of many of these diseases. Dengue may actually be 
an exception because there is a dengue branch of the Centers 
for Disease Control based in Puerto Rico.
    But, certainly, for the other diseases, I mean, again, they 
mimic other conditions. So Chagas disease mimics heart disease 
or toxocariasis----
    Mr. Clawson. Nonspecific symptoms?
    Dr. Hotez. Right. So unless you are actively looking for it 
and going into the affected communities, you are going to miss 
    Mr. Clawson. I got it. I guess I would then draw the 
conclusions that as--to the chairman's point, as we see the 
funding for appropriations, given that I am from a Gulf state I 
am going to be interested in how much prevention and how much 
diagnosis is going to be a part of the program.
    Dr. Hotez. Yes. I mean, the key, from my perspective, is we 
have to figure out how to walk and chew gum at the same time 
because USAID has now launched this mass treatment program, 
which in my estimate is one of the most effective and most cost 
effective public health control programs out there globally.
    But and so we need to keep that going, even increase it. 
But at the same time we have got to pay attention to our 
neglected populations here in the Southern part of the United 
    Mr. Clawson. And then I guess my final point is a little 
bit from left field, as Mr. Meadows might have said. At some 
point, our employers have got to understand this, too.
    I mean, if I was operating a resort in southern Florida I 
would want to know a little bit about dengue fever. Am I 
missing something or would you agree with that?
    Dr. Hotez. Yes. We will certainly know it if we see 
chikungunya hit the Southern part of the United States. Dengue 
is a febrile illness.
    It could mimic other diseases even though it is called 
break bone fever. Chikungunya can cause excruciating joint 
symptoms and that is going to be a show stopper if and when it 
hits over the summer.
    Mr. Clawson. Well, then my main message is we need to win.
    Dr. Hotez. We sure do.
    Mr. Clawson. Okay. Anything I can do to help you all let me 
    Dr. Hotez. Thank you. I do appreciate it.
    Mr. Clawson. Thanks for your patience with all of these 
    Dr. Hotez. Great questions. Thank you.
    Mr. Smith. So thank you very much. I will just conclude 
with a couple of final questions. The surgeries that sometimes 
are required how often do they occur? When medicines are not up 
to the task?
    Mr. Kourgialis. Trichiasis surgery--can you clarify your 
question? In terms of how frequently they----
    Mr. Smith. Yes, do they get--do individuals get the 
surgeries? I think--did you have the 4 million number?
    Mr. Kourgialis. Okay. There is a considerable trichiasis 
backlog though it is being addressed now. Certainly, the recent 
USAID grant will help to address that in a significant way in 
many of the countries where we work.
    Certainly, there is a broader commitment on the part of the 
global community to address morbidity management. A lot of 
resources have been invested in preventative chemotherapy and 
distribution of drugs.
    But dealing with the later consequences of diseases, both 
for lymphatic filariasis and for trichiasis, there haven't been 
the comparable investments made in the past. But they are being 
made now and a lot of progress is being made as we speak.
    But, certainly, it is going to take some time to address 
that backlog. It has been a longstanding commitment of Helen 
Keller International to address this need and it is something 
that the global community has committed to do, too.
    In order to achieve the elimination criteria that WHO has 
set, these issues have to be addressed: Hydrocele, lymphedema 
management, and trichiasis. So that is why this investment is 
being pushed in order to achieve these elimination targets.
    Mr. Smith. Thank you. Finally, in his statement, Dr. 
Pablos-Mendez mentioned that there are 800 million people who 
still need treatment.
    Does that comport with your estimations as well? And it 
seems when we are talking about this, it is almost like money 
that falls off the table in terms of magnitude versus what we 
could be doing.
    A $25-million increase from the current levels at a time 
when a cut was recommended is not all that much money when you 
have such an overwhelming pool of people not getting the help 
they need.
    Dr. Hotez. So that is based on WHO. I believe that number 
is based on WHO estimates. They just came out with new numbers 
this month which says that 1.7 billion people require treatment 
for neglected tropical diseases on our planet, which is 
somewhere between a little more than the number of people that 
live on no money in the world, that live less than the World 
Bank poverty figure of a $1.25 a day.
    We got a few people living on less than $2 a day who also 
have that problem. Of that I think it was 1.7 billion there are 
about 717 million people who have received access to essential 
    It is pretty good and a pretty amazing program. But that 
still leaves a gap and, of course, the United States cannot be 
expected to do all of this.
    We need the United Kingdom, of course, to continue their 
commitments. Also, some of the disease-endemic countries can do 
more than they are doing.
    So our global network for neglected tropical diseases, 
which is headed by Neeraj Mistry, is going into some of the 
wealthier emerging economies to say, you have got to step up 
also and do better at treating your own NTDs.
    So he is leading efforts in India for this purpose, in 
Nigeria for this purpose. These guys should be able to support 
their own NTDs and I think that is going to be a big step 
forward as well.
    And then Neeraj, which Michelle Brooks, who is with me here 
today, is also working on the German Government to start 
stepping up. We need to have some of the other European 
countries step up as well.
    So the whole point is the United States should not be going 
alone on this. Other countries need to weigh in as well.
    Mr. Smith. Section 202 of our new bill would require a 
report on neglected tropical diseases in the U.S. To your 
knowledge, has that been done before?
    And secondly, the Centers of Excellence idea, the 
establishment of such a center--how much do you think that 
would cost? You know, do you have any kind of ballpark estimate 
of what such a center would require in terms of appropriation?
    And when you spoke earlier about when we get a blood test--
that box and having to check the box--do you perceive that that 
is something that might emanate out of these centers--that the 
unmet need would be or the lack of surveillance on an 
individual basis would manifest and they would say, this is 
what we need to do now?
    Dr. Hotez. It does, Congressman, and we are looking at what 
we are doing here in Houston as a model for what needs to be 
done. So we are focusing on developing new diagnostics and new 
    I think the key point of having a Center of Excellence is 
not only on the surveillance component but you want to see 
tangible deliverables. We need products for this and they are 
going to have to come out of the public's--of the nonprofit 
sector jointly with pharma.
    But we can't count on pharma alone to do this. In terms of 
level of funding, it depends on the extent of the deliverables.
    I think it is unrealistic to expect anything more than $3 
million or $4 million a year at most and probably less than 
    Mr. Smith. Mr. Clawson, anything before we conclude?
    Anything you would like to add before we conclude the 
hearing, either of you?
    Mr. Kourgialis. Thank you.
    Dr. Hotez. No, again, thank you for this opportunity.
    Mr. Smith. Oh, thank you. One of the things we do with this 
committee is that we do take information and it is all about 
what is actionable, and we will follow up and use what you have 
provided as effectively as we can.
    So I thank you for your leadership but also for sharing 
your valuable time with the subcommittee to make your very, 
very valid points and to give guidance on these issues.
    Dr. Hotez. Congressman, thank you for your leadership and 
yours, Congressman Clawson, as well. Thank you.
    Mr. Smith. Thank you.
    The hearing is adjourned.
    [Whereupon, at 4:06 p.m., the committee was adjourned.]


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