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

      THE GROWING THREAT OF CHOLERA AND OTHER DISEASES IN THE MIDDLE EAST

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

                                    HEARING

                                   BEFORE THE

                     SUBCOMMITTEE ON AFRICA, GLOBAL HEALTH,
                            GLOBAL HUMAN RIGHTS, AND
                          INTERNATIONAL ORGANIZATIONS

                                     OF THE

                          COMMITTEE ON FOREIGN AFFAIRS
                            HOUSE OF REPRESENTATIVES

                        ONE HUNDRED FOURTEENTH CONGRESS

                                 SECOND SESSION

                                   __________

                                 MARCH 2, 2016

                                   __________

                               Serial No. 114-175

                                   __________

            Printed for the use of the Committee on Foreign Affairs

    [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

    Available via the World Wide Web: http://www.foreignaffairs.house.gov/
                                      or
                           http://www.gpo.gov/fdsys/
                                      ______

                             U.S. GOVERNMENT PUBLISHING OFFICE

    98-949PDF                     WASHINGTON : 2016
    -----------------------------------------------------------------------
      For sale by the Superintendent of Documents, U.S. Government Publishing
      Office Internet: bookstore.gpo.gov Phone: toll free (866) 512-1800;
             DC area (202) 512-1800 Fax: (202) 512-2104 Mail: Stop IDCC,
                              Washington, DC 20402-0001

                          COMMITTEE ON FOREIGN AFFAIRS

                     EDWARD R. ROYCE, California, Chairman
    CHRISTOPHER H. SMITH, New Jersey     ELIOT L. ENGEL, New York
    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
    SCOTT DesJARLAIS, Tennessee
    REID J. RIBBLE, Wisconsin
    DAVID A. TROTT, Michigan
    LEE M. ZELDIN, New York
    DANIEL DONOVAN, New York

         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
    DANIEL DONOVAN, New York

                                C O N T E N T S

                                  ----------
                                                                       Page

                                   WITNESSES

    Peter J. Hotez, M.D., president, Sabin Vaccine Institute.........     4
    Issam I. Raad, M.D., president, Health Outreach to the Middle
      East...........................................................    14
    J. Stephen Morrison, Ph.D., senior vice president, director of
      Global Health Policy Center, Center for Strategic and
      International Studies..........................................    26

              LETTERS, STATEMENTS, ETC., SUBMITTED FOR THE HEARING

    Peter J. Hotez, M.D.: Prepared statement.........................     8
    Issam I. Raad, M.D.: Prepared statement..........................    17
    J. Stephen Morrison, Ph.D.: Prepared statement...................    30

                                    APPENDIX

    Hearing notice...................................................    62
    Hearing minutes..................................................    63

      THE GROWING THREAT OF CHOLERA AND OTHER DISEASES IN THE MIDDLE EAST

                                  ----------

                            WEDNESDAY, MARCH 2, 2016

                           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 2:10 p.m., in
    room 2172 Rayburn House Office Building, Hon. Christopher H.
    Smith (chairman of the subcommittee) presiding.
        Mr. Smith. The subcommittee will come to order, and good
    afternoon.
        During the last several years, conflicts in the Middle East
    have cost the lives of hundreds of thousands of people. It is
    estimated that as many as 470,000 people have been killed
    either directly or indirectly due to the fighting in Syria
    since 2011. During that same period more than 30,000 people
    have died in Iraq. In Yemen, more than 5,000 have died in a
    series of conflicts since 2009.
        As a result of the conflicts in these countries, as well as
    the influx of refugees from conflict zones into surrounding
    countries such as Turkey, Jordan, and Lebanon, many of those
    who die are the victims of disease. Almost 17 million people in
    the region are in need of humanitarian assistance, including
    roughly 4 million refugees who have fled their countries, and
    an additional 13 million IDPs.
        Dr. Peter Hotez, one of our distinguished witnesses today,
    points out that, and I quote,

            We have already seen that polio and measles re-emerge,
            and we are now seeing a massive surge, more than
            100,000 cases of a highly disfiguring parasitic disease
            known as leishmaniasis, which the locals call ``Aleppo
            evil.'' It is transmitted by sandflies that thrive in
            the uncollected garbage of Aleppo and other urban and
            suburban areas of Syria, Iraq, and Libya. The disease
            causes horrific ulcers that can appear on the face and
            disfigure people, especially girls and women and leave
            them with permanent scars that render them
            unmarriageable. There is a medicine that is
            administered by injection of an antimony containing
            compound into the lesion, but there is an access
            problem in the affected areas, and the bottom line is
            that we need a vaccine.

        Today's hearing will examine the scope of cholera and other
    diseases to determine what can and should be done to control
    it, assist those who have been afflicted, and mitigate the
    spread. The World Health Organization reported that the spread
    of the cholera epidemic that first began in Iraq in 2007, which
    crossed over into Iran and Syria, is considered the region's
    greatest, although not only, health threat. These threats are
    worsened by the targeting of healthcare workers in Syria and by
    the Islamic State, which has no experience and little interest
    in providing social services. Thus, cholera and other diseases
    are untreated, often unreported, and pose a significant health
    threat in the region due to poor sanitation and overcrowding in
    areas such as refugee camps.
        Cholera is an acute diarrheal disease that can cause death
    within hours if left untreated. Roughly 80 percent of those who
    contract the disease do not develop symptoms, leaving some
    uncertainty about precisely about how many people contract the
    disease annually. Scientists estimate that between 1.4 and 4.3
    million people contract it annually.
        Cholera bacteria are present in the feces of infected
    people for 1 to 10 days after infection and can be spread to
    others if they ingest food or water that is contaminated with
    their fecal matter. The spread of cholera is mostly facilitated
    by inadequate water and sanitation management, and outbreaks
    are common in areas where basic infrastructure is unavailable,
    such as urban slums and camps for IDPs and for refugees.
        As devastating as this cholera epidemic has been and can be
    going forward, we must also remember the MERS epidemic of a few
    years ago. The Middle East Respiratory Syndrome is a
    respiratory illness and is caused by a virus which was first
    reported in 2012 in Saudi Arabia. It is different from other
    viruses that have been found in people before. MERS, like other
    viruses, is thought to be spread from an infected person's
    respiratory secretions, such as through coughing. However, the
    precise ways the virus spreads are not currently well
    understood.
        The conflicts and political crises in the Middle East have
    brought anguished suffering and severe declines in health to
    people throughout the region. The most catastrophic case is by
    far Syria. More than a million people have experienced
    traumatic injuries, once-rare infectious diseases have
    returned, chronic diseases go untreated, and the health system
    has collapsed.
        In Yemen, Libya, Gaza, and Iraq as well, violence has
    limited access to healthcare and grievously harmed the
    population. According to Physicians for Human Rights, last
    summer at least 633 medical personnel have been killed, and
    more than 270 illegal attacks on 202 separate medical
    facilities have taken place since March 2011 in Syria. Of the
    attacks on medical facilities, at least 51, or 19 percent, were
    carried out with barrel bombs. Almost all of the assaults were
    inflicted by the regime of Assad.
        In the Middle East, threats against, as well as arrests and
    intimidation of health workers, extend beyond armed conflict to
    situations of political volatility, as is evident in Bahrain,
    Egypt, and Turkey. In most of these cases, doctors and nurses
    who treat victims of violence are, by the very act of providing
    treatment, deemed guilty of anti-government activity. In
    Bahrain, almost 100 doctors and nurses were arrested, and 48
    originally charged with felonies for having offered medical
    care to wounded people in the wake of the 2011 Arab Spring
    uprising.
        Our panel today comprises health experts who will help us
    think through the health challenges and provide a roadmap with
    good concrete data and empirical information for us to consider
    as a subcommittee, which I can assure you will be used in
    helping us advocate for more assistance and more help to those
    who have been now affected.
        I would like to yield to Dr. Bera for any opening comments.
        Mr. Bera. Thank you, Chairman Smith, and thank you to the
    witnesses for taking time to be here today.
        As a physician and someone who has done public health and
    global health work, you think about the conditions in the
    Middle East as they are today in terms of diminishing
    infrastructure, refugees that are in crowded conditions,
    diminished sanitation, malnourished populations, and the
    environment is ripe for outbreaks of cholera, but also other
    infectious diseases. So I am very interested in getting a sense
    from our panel today of what measures we can take in terms of
    trying to alleviate and prevent some of these issues.
        Obviously vaccinations as appropriate, but even in a war
    zone that is very difficult because, as Chairman Smith has
    already indicated, to try to get healthcare workers in there,
    to try to get folks in there to help assess sanitation
    conditions, apply vaccinations where appropriate, and deliver
    rehydration salts or other therapies for those that are
    affected is very difficult to get that carry-in. I would be
    curious of your experience in other war zones and other
    conflict areas of the things we can try to do. While we may not
    be able to prevent some of these outbreaks, what can we do to
    mitigate and minimize some of these outbreaks, knowing that we
    may be stuck in a conflict zone not for months but maybe for a
    prolonged period? If we just look at Syria itself, much of the
    healthcare infrastructure is being devastated and will take
    quite some time to rebuild.
        So, again, I will keep my opening statement short and save
    time for questions, but look forward to hearing from the panel.
    Thank you.
        Mr. Smith. Thank you, Dr. Bera.
        I would like to now welcome our distinguished panelists.
    And without objection, your full statements will be made a part
    of the record, but please proceed however you would like.
    Beginning first with Dr. Peter Hotez who is president of the
    Sabin Vaccine Institute, leads the Texas Children's Hospital
    Center for Vaccine Development based at the Baylor College of
    Medicine. He is also founding dean of the National School of
    Tropical Medicine at Baylor. 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 developing
    countries and in the United States.
        Dr. Hotez created the Sabin Vaccine Institute product
    development partnership and was instrumental in creating the
    Global Network for Neglected Tropical Diseases. In 2014, he was
    named by President Obama 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.
        I would note as well that our End Neglected Tropical
    Diseases Act, having had Dr. Hotez appear before this
    subcommittee on two previous occasions, has passed out of the
    Committee on Foreign Affairs and we greatly benefited from the
    insights, Dr. Hotez, that you provided as to what that
    legislation ought to look like. So thank you.
        We will then hear from Dr. Issam Raad Who is an infectious
    disease specialist and is a distinguished professor of medicine
    at the University of Texas at Houston. He is president of
    Health Outreach to the Middle East, or HOME, which is a
    Christian interdenominational organization that exists to bring
    physical, psychological, and spiritual healing to poor and
    suffering people in the Middle East in the name of Jesus
    Christ. HOME has established a program to train, build, and
    send thousands of Arab Christian physicians and healthcare
    professionals on how to share the love of God at the bedside.
    HOME supports three medical clinics, one charity hospital, a
    home care medical service, and mobile clinic that provides
    medical care for the people of Egypt.
        Then we will hear from Dr. Stephen Morrison who is a senior
    vice president at the Center for Strategic and International
    Studies and director of the Global Health Policy Center. Dr.
    Morrison writes widely, has directed several high level
    commissions, and is a frequent commentator on U.S. foreign
    policy, global health, Africa, and foreign assistance. He has
    served in the Clinton administration, as committee staff in the
    House, and taught for 12 years at Johns Hopkins School of
    Advanced International Studies.
        Dr. Hotez, the floor is yours.

      STATEMENT OF PETER J. HOTEZ, M.D., PRESIDENT, SABIN VACCINE
                               INSTITUTE

        Dr. Hotez. Mr. Chairman, members of the subcommittee, Mr.
    Bera, thank you so much for giving me the opportunity to talk
    about a very ominous situation that is now happening in the
    Middle East. And now we are recognizing a spill-over into
    southern Europe. So this thing is already going beyond the
    Middle East and North Africa and that region.
        Before I do that I just thought you might like to hear a
    little good news based on the work of this committee and
    subcommittee. I am part of an enormous initiative known as the
    Global Burden of Disease Study that is funded by the Gates
    Foundation to evaluate what the impact has been of all these
    big-picture programs like PEPFAR and the President's Malaria
    Initiative, and the USAID NTD program. And this is involving
    hundreds of scientists all across the world to evaluate the
    papers. The papers that come out look like something out of a
    certain physics laboratory, a massive numbers of authors and I
    will be happy to share that with you.
        But I want to just give you the punch line of what's
    happened since the launch of all of these big programs. We have
    now seen a 30-percent reduction in the number of malaria cases
    and the number of malaria deaths. But you guys did that, so
    congratulations.
        We have turned the corner on HIV/AIDS, 19 million lives
    saved from HIV/AIDS, and for the first time turning the corner
    on the number of deaths.
        And then for neglected tropical diseases, you have reduced
    the number of cases of lymphatic filariasis, which is also
    known as elephantiasis, river blindness, and blinding trachoma,
    by almost 40 percent, so to the point now where we can talk
    about eliminating these three diseases over the next decade.
        To date, over 500 million people have received treatments
    for neglected tropical diseases, totaling--I used to say 1
    billion, I just got corrected yesterday by somebody from
    USAID--it is now 1.4 billion people. So these are incredibly
    effective programs. And now we have independent documentation
    to know how they are working. So congratulations and thank you
    for your leadership on that.
        Well, let's get to the not-so-good news part of the story.
    The impacts of all these big picture programs has also, like
    peeling away the layers of an onion, revealed a new problem.
    And that, we have just completed on a large scale analysis in a
    series of papers to show that today most of the world's
    neglected diseases are now occurring in wealthy countries, in
    G20 countries. So we have been ignoring the poor who live in
    wealthy countries, and now accounting for at least half the
    world's worm infections, most of the dengue, the Chagas
    disease, most of the tuberculosis, most of the leishmaniasis,
    and quite a bit of the HIV/AIDS.
        The silver lining on that is because these are inherently
    wealthy countries it is not just a resource problem, it is a
    political will issue. So that we need to think about providing
    advocacy at the next G20 summits about how to get these global
    leaders to pay more attention to their own vulnerable
    populations. So an example would be China. Eastern China is
    incredibly wealthy. You go into western China, the Sichuan,
    Yunnan Province, you go back in time 50 years.
        Or you look at Mexico, into southern Mexico, in
    northeastern Brazil where the Zika epidemic is. The Zika
    epidemic in northeastern Brazil is occurring in the same place
    where the epicenter of all the other neglected tropical
    diseases are. These poor, small states of Pernambuco and others
    where you are getting lymphatic filariasis and schistosomiasis
    as well.
        So paying attention to these pockets of intense poverty in
    G20 countries is going to become an important new global health
    theme.
        Let's talk about the Middle East and North Africa. I like
    to say that the reason why Ebola emerged out of West Africa is
    not because it was tropical, even though it is a neglected
    tropical disease, it was because those three countries, Guinea,
    Liberia, and Sierra Leone had undergone a decade of atrocities
    and, with it, the collapse, the collapse of its health system
    infrastructure. So we are now seeing the same thing happening
    in the ISIS-occupied areas of Syria, Iraq, Libya and now, to
    some extent, Lebanon as well.
        And the problem is it is very difficult to actually work in
    these countries to observe first-hand, so we have to rely on
    glimpses that we are getting of refugees spilling across the
    border into, into Turkey, Lebanon, Jordan, and Egypt. And that
    is where we are starting to see it. So you have mentioned
    leishmaniasis, Aleppo evil, that is transmitted by sandflies.
    Even in the best of times it was difficult for the Syrians to
    control this disease. And now, in the face of the collapse of
    the Syrian regime, what we are seeing are massive numbers of
    cases, more than 100,000 in the last year. People with horrific
    ulcers that disfigure the face, especially little girls who are
    then rendered unmarriageable later in life.
        There is a medicine that could be used to treat it. It
    requires an injection of the medicine in the lesion. Of course,
    the medicine is now unavailable. But also, with all the garbage
    now piling up, the sandflies are having a field day where they
    are proliferating incredibly, so they are able to bite people
    and transmit the disease. The disease is following the
    refugees, the sandflies are following the refugees into the
    border camps and the disease is continuing there.
        This is happening not only with leishmaniasis, although
    because it is so disfiguring it is one of the more dramatic
    examples, we are seeing the emergence of dengue or other
    arboviruses, scabies, malaria, tuberculosis, schistosomiasis,
    hepatitis A and B and, as you mentioned, the resurgence of
    measles and polio.
        The other thing that is happening in the Syria situation is
    not only humans are being trafficked but animals are as well.
    There is no border anymore, so with that, all of that
    trafficking with animals we are seeing a lot of zoonotic
    diseases, diseases transmitted from animals to humans, so an
    enormous amount of brucellosis. We are quite worried now about
    Middle Eastern Respiratory Syndrome, MERS coronavirus, going
    beyond the Arabian Peninsula. This is going to be we think an
    important problem that can cause an epidemic.
        We have additional issues that come up as well, which is
    that another big area of human migrations is the annual Hajj,
    the pilgrimage. It is believed that dengue fever actually got
    introduced in the Middle East through the Hajj. And because
    they have the mosquitoes there, then dengue got introduced. It
    spread across the Arabian Peninsula and the Middle East. I just
    came back from Saudi Arabia, and we were having discussions
    with the Ministry of Health there, that they are worried now
    about Zika coming in too for the same reasons. So there is
    every reason to believe that Zika is going to go in.
        These diseases are having a massive economic impact on the
    region. We have just completed an analysis looking at the
    neglected tropical diseases in the OIC countries, the
    Organization of Islamic Cooperation. And there is quite a bit
    of evidence that the OIC countries are disproportionately
    affected by the NTDs. And this is one of the major barriers to
    their economic development.
        Now were are seeing spillover into southern Europe. So
    something quite interesting is happening. For the first time in
    70 years, malaria has reemerged in Greece. It had been
    eradicated, now it is back. We are seeing the appearance of
    dengue in Portugal after 50 years. We are seeing West Nile
    Virus and chikungunya in Spain and Italy. We are seeing
    schistosomiasis, which is the ultimate neglected tropical
    disease of poverty, now on the island of Corsica. There is
    transmission of schistosomiasis in Corsica.
        So we are, we think that a lot of this is having to do with
    spillover from the Middle East. So we are now seeing the first
    evidence that it is not just being contained in the region.
        So let me end by just saying what I think you need to do
    about it. In my role as science envoy it is clear that there is
    no capacity for making vaccines for any of these diseases in
    the Middle East and North Africa. They are still entirely
    dependent on the multinational pharmaceutical companies, Glaxo,
    Merck, and Pfizer for making these vaccines. The problem is
    these diseases, for now anyway, are of regional importance, not
    global importance, and so the big pharmaceutical companies
    aren't going into this.
        And we saw this before with Ebola, right? The technology to
    make the Ebola vaccine was actually first published in 2003,
    but the technology sat there for a decade because the big
    pharmaceutical companies weren't interested in making an Ebola
    vaccine. It is because the business model is broken, it says
    we, an academic researcher, develops it, then waits to license
    it to a big pharmaceutical company, turns it around to a
    vaccine. And, of course, by the time Glaxo and Merck did this
    for Ebola, because BARDA put up $100 million at the 11th hour,
    5 minutes to 12:00, they made the vaccine in record time. But
    by the time they did testing, Ebola was gone and 11,000 people
    perished.
        We still haven't fixed that problem. The same now is coming
    out of the diseases in the Middle East. But one of the things
    that we are trying to do, and this will be a key component of
    the Center of Excellence, is at the Sabin Vaccine Institute
    which is based at Texas Children's and Baylor College of
    Medicine, we are making the vaccines that people won't make for
    these diseases in the Middle East. We are making a
    leishmaniasis vaccine, a schistosomiasis vaccine. And the nice
    thing about it is, because we are non-profit, we can teach
    others how to make vaccines. So we are teaching the Saudis now.
    We are working with the Tunisians, the Moroccans to build their
    own capacity.
        You can't walk into Merck or Pfizer and say teach me how to
    make a vaccine, but we can do that. And so this is an active
    program going on now. We have a group of Saudi scientists
    coming to our laboratory to learn every aspect of the vaccine
    development cycle. They will bring it back to Saudi Arabia. And
    we hope that we can do this other times as well.
        And that is also important because we, as you can imagine,
    relations with Saudi Arabia have been strained over the last
    years, so being able to offer something like this to promote
    joint vaccine development is a really great example of what I
    call vaccine diplomacy.
        So thank you so much for having me speak.
        [The prepared statement of Dr. Hotez follows:]

     [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
                                  ----------

        Mr. Smith. Dr. Hotez, thank you, sir, very much for your
    leadership.
        Dr. Raad.

    STATEMENT OF ISSAM I. RAAD, M.D., PRESIDENT, HEALTH OUTREACH TO
                            THE MIDDLE EAST

        Dr. Raad. Thank you very much, Mr. Chairman and members of
    the subcommittee, Mr. Bera, and the staff director, Mr.
    Simpkins. It is a pleasure to be with you today.
        I would like to, again, emphasize what Dr. Hotez mentioned
    that the devastation resulting from the conflict in the Middle
    East creates the right environment for these alarming epidemics
    that have spread rapidly within the region. And there is
    concern that it could be a global spread.
        This has been also associated with the devastation, if you
    may, and the collapse of the local healthcare system in the
    area. And as you mentioned, Mr. Chairman, cholera is the,
    reported in 2015 in Iraq, is the tip of the iceberg, if you
    may. For example, the World Health Organization reports 5,000
    confirmed cases between September to November 2015, with
    several deaths. But reports from our clinic in Baghdad, where
    we have clinics in Baghdad, we have in Kurdistan, we have even
    in the suburbs of Damascus, we have in Lebanon, Jordan and
    Egypt and in north Africa, but the reports from the clinics
    there that this is a vast underestimate. This is almost 2 to 5
    percent of the cases actually contracted there, which we
    estimate at around 200,000 cases in 15 of the 18 governments in
    that part.
        The concern also with cholera is that cholera is unique
    among water-borne bacterial infectious disease and its
    potential for global pandemics. And now we are in the third,
    second and the third wave of the seventh pandemic with more
    antibiotic resistance and acquisition of newer, more intense
    cholera function associated with cholera.
        And also the concern is that some of these clusters or
    outbreaks occurred in Iraq in Najaf and Karbala, which are part
    of the holy, holy shrines in that country, with all the influx,
    with Shiite Muslims going to these religious pilgrimage areas.
        The other big concern is polio. And this has been
    mentioned. But polio was thought to be eradicated in Syria. But
    it emerged in 2014 with more than 7,600 cases. And the big
    concern is that it occurred, the epicenter for the outbreak
    started in Deir ez-Zor which is the northeastern area, very
    close to Raqqa where the Islamic State is in control and where
    they have control in that district. And it is considered to be
    related to the fact, like the cholera, that the raw sewage is
    being pumped from these areas into, directly into the Euphrates
    River and the areas which provide the drinking and washing
    water to the other areas not under their control.
        So with cholera, polio represents a form of a spread of the
    disease related to the conflict, but possibly a bio-terrorism
    aspect where they are kind of basically moving the raw sewage.
        What is even more alarming is the fact that the strain of
    poliomyelitis in Syria has been linked to a wild type from
    Pakistan, particularly from a jihadist fighter who came from
    Pakistan to the area, highlighting the regional spread of this
    disease and the potential, again, for a global spread.
        Measles is another problem. I mentioned it in my written
    testimony. In Aleppo and then spilling over to Lebanon, for
    example, in 2013 the number of cases of measles among Syrian
    refugees increased to 1,760 from the baseline of 9 cases the
    year before. The same is true among the Syrian refugees in
    Jordan.
        Dr. Hotez mentioned about the leishmaniasis, which is also
    referred to as a flesh eating parasitic infection. Fifty-two
    thousand cases were reported in 2012 after a time when this was
    considered to be a contained, local infection more in northern
    Syria.
        MERS remains to be alive and well. You are well aware of
    the outbreak, large outbreak in the summer of 2015 in Riyadh in
    Saudi Arabia, as Dr. Hotez pointed. But also the recent
    outbreak in 2015 in South Korea with transmission of the
    organisms, basically the index case traveling from the Arabian
    Peninsula, so again highlighting the spread of these diseases.
        I would like also to highlight in North Africa, although
    the hepatitis C epidemic in Egypt is not directly related to
    the conflict, but has been put under the rag for a long time. A
    recent study by D. Miller, with the Cornell Group, highlighted
    the fact that there is every year more than 500,000 new cases
    of hepatitis C, where almost 20 percent of the population, 15
    to 20 percent of the population have this virus which has the
    potential in up to 85 percent of them to go into liver
    cirrhosis and hepatocellular carcinoma. So this is a major
    concern.
        The major concern in Egypt is that this is being propagated
    through the healthcare system, where almost 18 percent of the
    dental instruments have the hepatitis C RNA, 90 percent of
    patients on hemodialysis will end up with hepatitis C, and 70
    percent of the blood transfusions that are being given are
    really not being checked for hepatitis C.
        So I think recently from a visit to Egypt I met with the
    head of the National Committee for Control of Viral Hepatitis
    C, and I have been in contact with the CDC basically, Dr. John
    Ward, who has been in contact with the CDC groups there. I met
    with the CDC and USAID. And there could be a lot of good effort
    that could be done in a concerted effort to contain and
    basically eliminate the spread of this virus.
        I also came from a trip from Mauritania. Ten days ago I was
    in Mauritania. I met with the President and the Minister of
    Health, as well as our Ambassador, Mr. Larry Andre, and talked
    about the hepatitis B epidemic there, where almost 15 percent
    of the population have this problem. And we can, Ambassador
    Andre has advised us to, and we have been in touch with the
    CDC, to really curtail that problem.
        I would finally like to highlight two major problems. One
    is multi-drug resistant TB, which is not much is being
    mentioned about, but we are detecting it from our groups who
    are working in Mafraq, in a rural hospital which is a TB
    sanatorium in northern Jordan, among Syrian refugees mainly.
    And this other problem is salmonella typhoid fever where an
    outbreak has been reported in the Yarmouk Camp in a suburb of
    Damascus, with resistant organisms.
        HOME has been serving as a group there. And most of us are
    from Middle Eastern origin. We have been working widely in all
    of these areas, particularly with mobile, a big network of
    mobile medical units and field clinics that we have established
    in various countries. We work closely with Samaritan's Purse,
    World Vision, and the National Arab-American Medical
    Association. We work with the American College of Chest
    Physicians, and the American-Lebanese Medical Association.
        But we believe that HOME and other groups, other NGOs
    working in the area, and this is what we would like to propose,
    should have work in a concerted effort, collaborative effort
    with governmental agencies such as USAID, CDC, and Peace Corps.
        And we ask that this subcommittee would, under you, Mr.
    Chairman, would call for a meeting for all relevant committee
    chairs, including the Health Subcommittee, with the experts,
    including Dr. Hotez and Dr. Morrison, and to set a plan and a
    policy for this joint effort for the Middle East. And have a
    model similar to what we have done with Ebola in west Africa
    where we have a concerted effort among the NGOs of Americans
    working there, as well as governmental agencies, to try to
    contain these, these infectious problems in the area. Because
    there is no doubt, like the Ebola, that they are going to spill
    over and we are going to reap the consequences.
        In addition, it could be part, and we are talking here to
    this esteemed subcommittee which is a subcommittee of the
    Committee on Foreign Affairs, this could be part of the medical
    diplomacy, if you may, initiative in combating terrorism in
    that area and its implications of this, of these infectious
    outbreaks. A lot could be done in this concerted effort in
    terms of refugee medicine training, in terms of early detection
    of these infectious diseases, working with the World Health
    Organization on community health and water decontamination,
    hygiene education, vaccination campaigns, and appropriate use
    of antimicrobial therapy, which is very important for TB and
    other, particularly training the local community physicians on
    how to appropriately use antimicrobial agents.
        Thank you very much.
        [The prepared statement of Dr. Raad follows:]

     [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
                                  ----------

        Mr. Smith. Dr. Raad, thank you very much for your testimony
    and specific, concrete proposals for follow-up.
        I would like to now recognize Dr. Morrison.

    STATEMENT OF J. STEPHEN MORRISON, PH.D., SENIOR VICE PRESIDENT,
     DIRECTOR OF GLOBAL HEALTH POLICY CENTER, CENTER FOR STRATEGIC
                       AND INTERNATIONAL STUDIES

        Mr. Morrison. Thank you very much, Representative Smith and
    Representative Bera. I appreciate your leadership on this and
    the opportunity to be here today. And a special thanks to Greg
    Simpkins, an old friend, for his leadership in pulling, pulling
    things together today.
        I worked on this subcommittee in 1987 and 1991 when Dante
    Fascell, Henry Hyde were the iconic leaders. I worked for
    Howard Wolpe, Dan Burton as the minority member of that
    subcommittee. And that subcommittee had enormous impact in
    those years. And I am very proud of that. That was the first
    job I had out of graduate school. And I believe very strongly
    in the power and impact that a subcommittee like this can have
    today. And thank you for your leadership and for putting a
    special focus on this subject.
        I am going to make five points. My first has to do with
    health security and where this crisis in Syria and the Middle
    East sits. We have had a lot of discussion around Ebola, a lot
    about, today about Zika, a lot about the global health security
    agenda. We haven't situated this crisis too much that we are
    seeing in Syria in terms of health security.
        But I would argue that what we are seeing in Syria and the
    surrounding region is a very grave health security crisis that
    is gathering force. And it will become more evident. That
    health security crisis in Syria and the surrounding region is
    going to become more evident as infectious outbreaks
    proliferate and as other multiple health consequences become
    clearer due to the dissolution of the Syrian State, the
    deliberate targeting and destruction of health infrastructure,
    including killing of health workers, and the massive
    dislocation of vulnerable populations.
        We are going to see the indicators. Dr. Hotez, Dr. Raad
    both enumerated the evidence of this in terms of malnutrition,
    chronic disorders, maternal and newborn health, infectious
    diseases. And the scale is formidable. It has reached the point
    of really, for Syrians, we are talking about 12 million, over
    half of the population.
        I realize this, addressing this has a special set of
    challenges, particularly on the security side. This is an
    acutely dangerous and forbidding environment. Access by
    humanitarian health workers has become exceedingly limited. We
    are operating largely in the blind in terms of data and access
    and surveillance, and we need to admit that. But I think the
    situation is changing in some important ways. So that is point
    one.
        Point two is we ignored this problem for a while. The war
    started in Syria in 2011, in March. I would argue that for the
    first 3 years we were pretty numb, disengaged and paralyzed as
    a staggering and colossal human crisis unfolded in that period.
    The crisis was seen as too distant, too difficult, too
    dangerous and that perception only worsened as more and more
    armed radical Islamist groups gained prominence, even before
    ISIS entered in June 2014. And it became more difficult as MSF,
    as the International Committee of the Red Cross, as other NGOs
    were targeted, kidnapped, threatened and harmed grievously in
    that period.
        There was an assumption that the surrounding region, the
    borderlands, Turkey, Lebanon, and Jordan would absorb these
    populations and they would not move beyond that. That proved to
    be a very mistaken assumption. They took in 5 million but they
    quickly reached a certain saturation point, which I will say a
    bit about in a moment. In that first 3-year period the
    geopolitics around this crisis was particularly toxic: The
    stand-off between the United States and Western powers versus
    Russia, Assad, and Iran. The U.N. Security Council stepped
    forward and tried to address this but with a number of
    resolutions that were toothless and ineffectual, and did
    little, certainly in terms of Assad's behavior, in terms of the
    egregious and flagrant violation of international law in this
    period.
        We, as a government, were preoccupied with the Iran nuclear
    negotiations and we were progressively seeking to lower our
    profile in this region. Options like safe zones, no-fly zones
    were explored but ultimately rejected as too risky and too
    difficult. We did intervene in the destruction of the chemical
    weapons stocks in Syria, together with the Russians. And that
    was relatively successful. But there was no humanitarian bounce
    that came off of that.
        Steadily, up until recently, the numbers, the funding
    levels for humanitarian operations into the U.N. were cut
    dramatically. And that, that resulted, of course, in a
    humanitarian regression and undermining the status of those
    populations that were reached in the border states.
        My third point is that the situation geopolitically has
    changed fundamentally. And we ought to, we ought to take
    account of that. And I will explain what I mean.
        I think that the geopolitical change has in fact pushed
    health and health security to the forefront of the stage, and
    it has created some very early opportunities potentially. The
    tipping point came, of course, as Turkey, Lebanon, and Jordan
    reached their saturation point, as the monies coming in on
    humanitarian operations were reducing, and as the Syrian
    populations both in those settings and inside Syria made a
    dramatic calculation in 2015 to embark straight off for Europe.
    So the numbers of Syrians moving went from 100,000 in 2014 to
    \1/2\ million in 2015, accounting for roughly half of the
    population.
        And those flows are continuing today. We are expecting
    fully 1 million more migrants this year into Europe, if not
    more, with a heavy share of those coming out of Syria. That, of
    course, has become a destabilizing factor. Just look at what's
    happening in Europe. Look at what's happening in Austria and
    the Balkan states where there is a, basically, they are
    freezing up the free flow of populations, refugee populations.
    Greece is becoming a black box, a holding operation. The
    politics are broken of the EU. And it is becoming an utterly
    untenable and destabilizing situation.
        The geopolitical situation changed in two other very
    important respects: ISIS entered the region in June 2014,
    displaced 3.2 million people, took under its control roughly 8
    to 10 million, and then, of course, you had the Russians enter
    in September of last year and begin the aerial campaigns from
    Syrian bases, which drove, up to now have driven 300,000 to
    400,000 people up to the Turkish borders and systematically
    targeted hospitals, clinics and other facilities.
        So why is it now possible to think a little differently
    about the health crisis in Syria and the surrounding region?
    The process, the context has changed. The U.S. is now working
    with others in aggressively trying to achieve a cessation of
    hostilities and expand humanitarian access to the besieged and
    those difficult to reach inside Syria. And that is about 4.5
    million people. Right now the aim this week is to reach 150,000
    in besieged cities and to continue on that trajectory to reach
    1.7 million by the end of March.
        We don't know if that is possible. It is supposed to be
    done under joint U.S.-Russian oversight. We know this is a very
    perilous undertaking, but if it is successful it will create
    new windows for restoring capacities, including basic services
    and immunizations.
        We are pressing at this same time to accelerate
    negotiations over national transition in Syria and expand
    support dramatically to the front line states, Turkey, Lebanon,
    and Jordan. February 4th was the astonishing summit in London
    which took in pledges of $11 billion, $6 billion in 2016 alone,
    $1 billion from the United States. These are unprecedented
    levels. And it is a stark reminder of just how geopolitically
    important this crisis has become, that you could have something
    like this happen.
        Money is not the barrier. The barrier now is becoming
    access, vision, political leadership and capacity.
        My fifth and final point is that there is more that the
    U.S. can do. The U.S. has been very generous on the
    humanitarian front. We have invested over $4.5 billion into the
    humanitarian response to this crisis since 2011. We are
    carrying 50 percent of the freight. But there is more that we
    can do. And let me just say a few specific things.
        We need to get U.S. public health experts closer to the
    problem on a long-term and continuous basis. Right now in the
    cholera outbreak we were channeling volunteers, we were
    channeling temporary employees into UNICEF and WHO. We should
    continue that. We should step that up. But in order to be
    really effective in this next period we need a hub within the
    region, perhaps in Jordan, a continuous presence charged with
    coordination, quick response, and building relationships across
    the region.
        This is an essential step to enlarge the U.S. region
    influence and to be better positioned to get smart about what
    is going on inside Syria, and to build the relations with the
    front line states, and address the security, the health
    security threats we are talking about.
        There is much more that we can do to support Turkey,
    Lebanon, and Jordan. They have serious health security needs
    but there is access and opportunity to do that. We have not
    framed this in terms of the global health security agenda. I am
    arguing that we should think about that. We should think about
    planting this within that vision. That is a way to get
    assessments going. That is a way to leverage the G7. That is a
    way to offer an international framework around this. It has not
    been applied typically to situations as dangerous and
    complicated as this, but there is no reason why it could not
    be.
        Lastly, the U.S. is not in a hegemonic position to drive
    events. We are in a position to be very influential. But we are
    not going to be the hegemon as this health security crisis
    grows.
        Russia has established itself as a major driver. It has
    been a major contributor to chaos, dislocation and suffering.
    It has weaponized refugees. But it appears that there are some
    changes going on and we are going to have to move forward
    aggressively to rebuild capacities with the Russians, the
    Saudis, the Turks, the Iranians. We are going to have to rely
    very much upon our friends at the International Committee of
    the Red Cross, MSF, Doctors Without Borders, Syrian Red
    Crescents, courageous groups like the Syrian-American Medical
    Society which has done remarkable work.
        So thank you very much, Mr. Chairman, for your patience.
        [The prepared statement of Mr. Morrison follows:]

     [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

                                     ----------

        Mr. Smith. Dr. Morrison, thank you for your insights, your
    leadership all these years. And I am sure you miss being here
    on this side of the dais.
        I do have a couple questions and I will probably come up
    with a few more that we might submit in writing. But to begin
    with, Dr. Hotez, how many vaccines do you have under study at
    the Sabin Institute?
        Dr. Hotez. Thank you for that question. We have half a
    dozen, six vaccines now. So for hookworms, schistosomiasis,
    leishmaniasis, Chagas disease, SARS, and MERS.
        Mr. Smith. And are any of those ready for deployment?
        Dr. Hotez. Well, right now they are in various stages of
    product and clinical testing. So we have two vaccines in
    clinical trials in Africa and in Brazil for hookworm and
    schistosomiasis. The SARS vaccine is about to be manufactured.
    The other ones are at an earlier stage.
        One of the big problems that we face, of course, is
    funding. So there is not a real push mechanism of funds that go
    to product development partnerships. These non-profits fall
    through the cracks. They use industry practices, but because
    they are not registered as small businesses or businesses, we
    don't benefit from the SBIR mechanism for instance. And whereas
    the Dutch Government, the German Government has now
    specifically started funding PDPs specifically, and the
    Japanese as well, it is not really done in the United States.
    So it is a gap that could be addressed through the Center of
    Excellence concept, the neglected disease legislation, or we
    need more mechanisms like that.
        Mr. Smith. Now, with leishmaniasis you mentioned that there
    is a need for a vaccine?
        Dr. Hotez. Absolutely.
        And there is proof of concept that it is quite possible.
    Because what the locals do is quite interesting. They will
    scrape the lesions of somebody who has leishmaniasis and inject
    it into the buttocks of their kids to prevent them from
    getting, prevent them from getting a disfiguring scar on the
    face. It actually was discovered by the ancients. It predates
    vaccination. It's called leishmanization. But it shows you that
    you can make a vaccine.
        Now, we can do better than doing that. So and you can do it
    by genetic engineering, making a recombinant vaccine. And we
    have done it now in the laboratory. Now it is a matter of
    getting the support for scaling it up.
        Mr. Smith. What would it take to scale it up? I mean what
    kind of money are we talking about?
        Dr. Hotez. Well, we are looking at around $5 million to
    really move it into clinical trials.
        And that is the incredible thing about this, it is, you
    know, it is not billions, it is not hundreds of millions, it is
    not even tens of millions, it is 10 to the 6th dollars, not 10
    to the 7th or 10 to the 8th or 10 to the 9th. So the funding
    needs are so modest, and yet it is just not there.
        Mr. Smith. One of the reasons why I have introduced the End
    Neglected Tropical Diseases Act is because it really does take
    a modest amount of money to have a spectacular impact.
        I would note parenthetically that for the second year in a
    row the administration's budget has looked to cut the neglected
    tropical disease budget. And, thankfully, in a bipartisan way
    we have been able to get the appropriations at least at level
    funding at $100 million. But it was a 20-percent cut now 3
    years in a row, that too, which is very disconcerting from my
    point of view in terms of prioritization.
        Dr. Hotez. And especially since the U.S. Government is
    getting so much bang for its buck. Through that, through that
    $100 million a year you are eliminating three diseases. I mean
    where else in the U.S. Government can you get that kind of
    impact?
        Mr. Smith. Exactly.
        Let me just ask you, Dr. Raad, on MERS-CoV. You talk about
    how it is spreading, 36 percent mortality rate. You know, I am
    always, we are all I think thinking, you know, after World War
    I the misnamed Spanish flu, obviously the incubator for that
    had to have been the degradation caused by World War I. Is this
    one of those possible diseases, illnesses that could spread and
    become a pandemic? We know it is local and it is causing a huge
    amount of sickness and death. But looking at all of these
    diseases, including that one, what are your thoughts on that?
        Dr. Raad. Yeah, the South Korean outbreak is the best
    example of the global spread of MERS. And seeing MERS cases not
    only in the region but beyond, beyond the region. So, and it is
    a coronavirus. It is, as you well know, SARS is a coronavirus
    and had a global spread. So there is always that concern that
    it could have a global spread.
        Again, the good work of my colleague Dr. Hotez as far as
    vaccination would be very important, because at this point all
    that we provide for MERS is supportive care. And this is why we
    have the high mortality rate associated with it. But also early
    diagnosis and to be on the alert.
        And I think MERS is part of the bigger picture of the
    Middle East. The Middle East needs special attention for as far
    as infectious diseases. And this can be done. And it could be
    done as part of this concerted effort but also could be part of
    a, as I am talking here to your subcommittee which is part of
    the Committee of Foreign Affairs, part of the medical diplomacy
    to reach that area. Because the uniqueness of the United States
    is that we are not just providing a activity on the ground like
    the Russians are doing, and as Dr. Morrison has mentioned, in
    terms of a force, but providing also a solution to some of the
    devastating problems, including these epidemics and solution
    for refugees.
        So I think there needs to be a concerted effort with
    special attention that the NGOs, governmental agencies, groups
    working, like my two colleagues here, to reach out to the
    region.
        Mr. Smith. And I do thank you for your idea of bringing
    other relevant chairmen and subcommittee chairman together. I
    think that is an excellent idea that we will look to follow up.
        Dr. Raad. Thank you.
        Mr. Smith. Let me ask you with regard to the bioterrorism
    you spoke about, the chlorinization has discontinued.
        Dr. Raad. Yes.
        Mr. Smith. Is that one of the casualties of war or why
    would, why did that happen?
        Dr. Raad. Well, it is one of the casualties of war. The
    whole healthcare system, if you may, and the sanitary system
    has collapsed. Syria, as you well know, the basic, basic needs
    basically of the people are non-existent. And I would dare say
    from reports of our colleagues in Baghdad, the same is true, is
    happening within Iraq. Baghdad is in chaos.
        And I have some of the slides that I sent where people are
    going to wells that are already contaminated to provide
    drinking and sanitary water.
        Mr. Smith. Dr. Morrison, you note that \1/2\ million
    children under 5 in Syria have not been vaccinated in more than
    2 years. Is there a danger of unrestrained polio? Is that
    imminent in your view?
        Mr. Morrison. There is a risk. There is a continuous risk
    of further outbreaks of polio. There were 35 cases of polio in
    2013. There was one case in early in January 2014. There were
    concerted efforts undertaken by a consortium of groups under
    the Global Polio Eradication Initiative that have resulted in
    12 campaigns, 12 immunization campaigns that have been
    undertaken. And that is a remarkable achievement given the
    gravity of the situation and the dangers involved and the
    intensification of the war itself.
        The fact that polio has been contained through those
    efforts, however, doesn't leave me completely confident that we
    are not going to see more outbreaks, more cases as this
    conflict continues. And I think there has to be, and there is,
    pretty concerted vigilance across the region.
        No state within the region wants to see the reintroduction
    of polio into its borders. When that first case happened in
    2013, there had not been a case of polio in Syria in 14 years
    before that. And this was a country that had managed its
    campaigns very competently, very effectively across a range of
    immunizations. And but that is broken now. And we know the
    hazards.
        So I would say a need for high, continued high vigilance.
    But also, you know, an awareness of the achievements we have
    seen in the last period in reacting to those 2013 outbreaks.
        Mr. Smith. Dr. Hotez, you mentioned that the Hajj has had
    an impact on the spread of dengue and you raise concerns about
    the Zika virus potentially being spread that way. Do the
    clerics, do the leaders of Saudi Arabia understand the
    potential pitfalls, is there a plan of action that could be
    used to mitigate that?
        Dr. Hotez. Yes. Yes, to the first part. But I think they
    are mystified about where to go from there in terms of
    restricting. Because one of the problems that you have with
    Zika is that many times you are without any symptoms at all. So
    you are going to have people coming in carrying the virus in
    their bloodstream without showing any manifestations. So it is
    not like we could check them at the Jeddah airport and say
    don't come into the country.
        So this is going to be a real problem. We are going to see
    this. And the Hajj I think is occurring late in the summer or
    early fall this year, and that is going to be a huge issue.
        Mr. Smith. I mentioned earlier the targeting of so many
    medical personnel. Well, now that there is a cessation of
    hostilities--of course it doesn't apply to ISIS or to al-
    Nusra--but my question would be are the medical doctors, the
    healthcare workers streaming in during this lull in
    hostilities, knowing that there are grave risks to them and
    that these hostilities could recommence at any moment?
        Dr. Raad. All of this has escalated to a tremendous number
    of healthcare workers, particularly physicians, immigrating and
    leaving the country with the exodus, and left basically. So the
    best policy is to work with the local people. And as long as we
    are working with groups that are neutral, non-discriminatory,
    and doing the work on the ground, and to strengthen.
        And I think there is something similar to the healthcare,
    originally the health strengthening bill that was there for
    Africa, something similar should be done for the Middle East
    and to work with local groups on the ground in order to retain
    them. Because the healthcare workers are like anyone else
    basically in the midst of a catastrophe, and particularly when
    they are targeted.
        We had difficulty having a mobile medical unit in Syria
    because it would be either shelled or basically and the people
    would be killed. And then the mobile medical unit would be
    taken over to be used to kind of transport weapons and so on.
    So I think the most important thing is to work within the
    system collectively and try to strengthen the healthcare
    system.
        Mr. Morrison. I don't think you are going to see a sudden
    return. Well over half of the 30,000 doctors that were in Syria
    prior to the advent of the war on March 11th are gone. And they
    are not coming back. And you have had over 800 healthcare
    workers murdered in this period. You have had the deliberate
    targeting your infrastructure. Fully half of your
    infrastructure is either destroyed or just non-functional at
    this moment in time.
        So I think what's like--and the security threats remain
    very grave and very fluid. So I think what you are going to see
    is a step by step incremental reintroduction of personnel with
    heavy security guarantees around this. The U.N. convoys that
    have been going in in this last few days, into the five or six
    besieged cities, some in the government territory, some in
    opposition control, these are trying to get to those 15 sites
    where you have got 450,000 people who have been cut off for
    months and months and month, those are being done with very
    heavy preparation, very heavy concerns around security.
        I might add one other thing. You have Deir ez-Zor, you have
    the city out in the east that is besieged by ISIS where you
    have got 200,000 people. There the airlifts are being attempted
    to reach that population. They are having serious problems with
    those. And, of course, airlifts are terribly expensive and not
    particularly effective oftentimes. But that is another measure
    of how desperate that population is.
        But to get Syrians back in and to get international health
    personnel to go back in you are going to have to lay a pathway
    down in which their security is going to be guaranteed and
    protected. This is a much bigger challenge even than trying to
    get the hundreds of health workers who were needed to go into
    the three Ebola states in 2014 who were terribly worried about
    evacuation should they become infected or at risk, or if they
    perhaps infect.
        So we face big challenges. There are a lot of very
    courageous people in civil groups and that have stayed behind
    in ad hoc facilities who are doing cross-border operations, who
    are working from the side of Damascus. The Red Crescent has
    lost hundreds of people in this period. There are many
    courageous people who have stayed to try and keep the lights
    on. And they deserve a great deal of credit.
        Dr. Hotez. I agree with all these points. I would like to
    make the additional point that Ebola was relatively easy to
    contain because it was contained in a relatively isolated area
    of West Africa.
        Look where the Middle East is, it is at the crossroads of
    Asia, Europe, and Africa. We are already seeing the expansion
    into southern Europe. Dubai is one of the busiest airports. We
    are going to be seeing widespread dissemination across into
    Pakistan and India, and then into sub-Saharan Africa.
        So in terms of priorities in the global health security
    agenda, I think the Middle East has to be one of the most
    important because you are going to see this continuous seeding
    of three continents with infectious diseases. And we are
    already seeing the beginnings of that.
        Mr. Bera. Thank you, Chairman. You have laid out a number
    of challenges that we obviously face. And if we were to start
    to look at these as separate challenges, but interrelated
    challenges, and one challenge is in the refugee camps, whether
    you are looking at Jordan, Lebanon, or Turkey, and how we
    approach those challenges where safety may be less of the risk,
    but the conditions under which people are living clearly is a
    risk and an incubator of sorts where, if you do have an
    outbreak things could travel fast. So I would segregate that
    and think about how we address some of that challenge.
        Looking internally in Syria or occupied areas within Iraq,
    safety becomes an issue. The infrastructure, Dr. Morrison, you
    pointed out some of the infrastructure that has been decimated
    certainly becomes an issue. And how you get healthcare
    personnel in there may not be as feasible, but how you work
    with the individuals that are still there and the
    infrastructure there may be a different challenge in how you
    address that.
        And then we have been talking a little bit about MERS and
    so forth. And, again in, folks that may be traveling to the
    Hajj and then traveling back to their home countries, how you
    work, whether it is MERS or dengue or Zika virus, how we work
    with the infrastructure in Saudi Arabia and a country like
    that. So folks that are coming there maybe perhaps getting
    exposed and then returning to all parts of the world how we
    work.
        And that is I would think about it in three separate ways
    where you may have slightly different solutions. And maybe, Dr.
    Morrison, if you want to start?
        Mr. Morrison. Thank you, Dr. Bera. I think those are great
    points. A few, a few thoughts on that.
        One is to keep in mind the demographic transformations
    going on within the region. Syria before the war was 23 million
    people. Syria today is roughly 17 million, and continuing to
    empty. I do not believe, given how devastated this country is,
    and how you have seen the dissolution of sovereign power,
    unitary sovereign power, I do not expect you are going to see
    many of those who have fled coming back any time soon, and that
    there has been a shift of thinking today toward those
    populations in Turkey, Lebanon, and Jordan working toward
    enabling those countries to be able to provide employment
    opportunities, education, housing, health services, and the
    like to those populations as well as their own citizens, and
    restabilize those societies and make it in their interests to
    take that step.
        And you have got trade deals, you have got the EU stepping
    forward, this London conference I spoke to. That is a big shift
    of thinking and a very important one.
        On the access internal to within Syria itself, I think we
    need to come at it from multiple directions. The WHO, UNICEF
    have shown extraordinary courage in their operations, though
    they will remain central in trying to use their legitimacy and
    their record and their access to move forward. But there is
    going to be more and more cross-border work. That has been
    validated and endorsed unanimously in the U.N. Security Council
    resolutions. And those corridors can be opened up as well.
        Thank you.
        Mr. Bera. Dr. Raad.
        Dr. Raad. Mr. Bera, I think you bring a very, very
    insightful thought into this because this is a very complicated
    problem with multiple dimensions and sort of moving variables.
    And you pointed to the fact there needs to be a strategy for
    the refugees and the displaced from, you know, the displaced in
    these countries like Jordan, Lebanon, and Turkey, versus
    something else respective to the areas that are inside the war
    zone, if you may, Syria proper, Iraq. There are certain areas
    where we cannot get to like where under the control of the
    Islamic State. So this is a red area where we cannot get to.
        And then there needs to be a contemplation or part of the
    policy of the Hajj and the flux and the movement that has taken
    place and how to handle this. So I think this is why we need a
    team that would be looking into all of this. Because now a lot
    of groups are working from the U.S., and sometimes the right
    hand is not knowing what the left hand is doing.
        And there is excellent effort, Dr. Morrison has pointed
    out, and great ideas that Dr. Hotez has brought into the
    picture, but we need to integrate this into one common strategy
    where in these different areas how do we act and how do it?
        This is why the thought in some of these areas we have to
    rely on some of the either the local people or more Arab-
    Americans that are willing to work there, Dr. Morrison
    mentioned SAMS, the Syrian-American Medical Society. We are
    Arab-American at our work. From various backgrounds and faith
    value as long as they remain neutral and within representing
    they are a medical-diplomatic Peace Corps, if you may, of this
    country that are moving into this area. But it should be part
    of a bigger picture of the general policy that is being devised
    by your subcommittee and other relevant committees.
        Mr. Bera. Dr. Hotez.
        Dr. Hotez. I would just mention also the other actor in
    this could be the Russians, doing some cooperative medical
    diplomacy activities with Russia. There is precedent for that.
    Many people don't realize that the oral polio vaccine most of
    us took as kids was developed jointly between the U.S. and
    Soviets. At the height of the Cold War right after the Sputnik
    launch the two countries put aside their ideologies and made
    the polio vaccine. And they cooperated to make the dry vaccs
    for smallpox eradication. So there is precedent for that and it
    would be an interesting opportunity to investigate.
        Mr. Bera. Great. Thanks, Dr. Hotez.
        Dr. Morrison, how are medical personnel, and actually any
    of the witnesses, you know, medical personnel that are not
    attached to, you know, that are going into this war zone, how
    are they perceived by whether it is the Assad regime, whether
    it is from the rebel fighters outside of the Islamic State, are
    they perceived as neutral players coming in for humanitarian
    need, are they are under constant threat as well?
        Mr. Morrison. In the chairman's opening statement he
    referenced the study by the Physicians for Human Rights. That
    group, as well as the International Committee of the Red Cross
    and Doctors Without Borders, MSF, have carefully documented and
    tracked what has happened in Syria, which is harrowing, which
    is the deliberate targeting of health personnel and
    infrastructure. The most egregious violence coming from the
    Assad government, and most recently from the Russians. But not
    limited to that.
        And you have the introduction of radical Islamist
    dimensions into this as well, where it becomes actions taken
    against Westerners who are seen as carrying a hostile agenda,
    and they just happen to be operating in the health sector.
        So the respective neutrality of these operations has
    eroded. And the degree to which the providers themselves have
    had their access, their access to populations and their
    abilities to function have narrowed significantly. They don't
    have the benefit that in other conflicts where you have had a
    legitimacy and a respect and level of protection, where even in
    a highly-conflicted setting you could migrate across lines.
    Instead you are seen as partisan, as party to one side or
    another, giving active support. And, in fact, serving those who
    are wounded who are combatants as simply implicating you, so
    leaving you open to being attached because it is just part of a
    broader combat operation.
        Mr. Bera. So shifting gears, Dr. Hotez, you talked about
    what it would take for vaccine development. And let's take
    leishmaniasis. If we were to be able to appropriate the funds
    to do the research and come up with, you know, some of these
    cures or viable vaccinations, in your assessment, kind of
    looking at American pharmaceutical companies or global
    pharmaceutical companies, because you will now have to
    commercialize some of this, is there a market for
    commercialization or would it, you know, in many ways would we
    have to continue to appropriate those funds or through the WHO
    or other organizations?
        Dr. Hotez. Thanks for that question. I think once the
    product is developed there is a commercial market and there is
    a commercialization plan. It is modest. It is, you know, it is
    a fraction of what some of the other vaccines are that Merck
    and GlaxoSmithKline makes. And even the vaccines are less than
    a lot of the small molecular drugs that we all take. So it is a
    very modest market but it's not zero, and it should be
    sustainable.
        Mr. Bera. Okay, great. I will pass----
        Mr. Morrison. May I just add one point,----
        Mr. Bera. Yeah, please.
        Mr. Morrison [continuing]. Dr. Bera. In this last year
    there have been four major studies of what happened in Ebola
    undertaken by the Stocking panel, the Harvard-London School
    Panel, the National Academies of Medicine, the U.N. Secretary-
    General's High-Level Panel. All four of those panels, to
    varying degrees, identified the research and development
    dimension as this critical gap, one where there needs to be a
    mobilization of resources and a higher level of effort in order
    to create some kinds of platforms that would prioritize those
    dangerous and neglected diseases for which there is no market,
    and be able to get the early development accelerated through
    new initiatives.
        And at the Davos, at the World Economic Forum earlier this
    year, a number of players came together to try and build on
    that momentum coming out of Ebola and those four studies and
    move it to the next stage. And that is led by the Norwegians,
    the Wellcome Trust, Gates Foundation, the British Government,
    and others. And that is, that is moving along.
        And I am hopeful--Peter probably knows more about exactly
    what might be in store on this--but it is still in, it is still
    getting worked out. But at some point later in the year I think
    Ebola convinced us of the need for a higher level of action to
    correct for this and to put us on a different pathway.
        Mr. Bera. And before I yield back let me thank the chairman
    for his leadership in making sure we do not forget about some
    of these neglected diseases that pop up and making sure that we
    continue to focus in on this.
        If we use the Ebola example, we are not that far off from
    developing a vaccine and developing--is that a correct
    statement that with a concerted effort we could come up with?
        Dr. Hotez. Specifically for Ebola now and after there was a
    big investment by the U.S. Government to get it launched, yeah,
    I think we are pretty close.
        Mr. Bera. So we are pretty close.
        If we were to now look back in hindsight and think about
    how much we spent cumulatively globally to maintain, contain
    and treat this last outbreak I am going to guess it is not an
    insignificant amount of dollars that went into that. Is that?
        Dr. Hotez. Well, and I am sure Steve knows those numbers
    probably better than anyone, but the economic impact of Ebola
    was certainly in the billions of dollars. I am sure there is a
    specific number attached to that.
        You can imagine what the economic impact of Zika is going
    to be----
        Mr. Bera. Right.
        Dr. Hotez [continuing]. On the Caribbean economy, for
    instance. And we are going to see this again now with the
    diseases coming out of the Middle East. It is already in
    southern Europe. What is going to be the impact now of having
    malaria in Greece?
        So there is no question that these innovations will pay for
    themselves hundreds of times over.
        Mr. Bera. Dr. Morrison, do you have an idea what that
    number is?
        Mr. Morrison. In terms of the economic costs for west
    Africa of Ebola?
        Mr. Bera. Yeah.
        Mr. Morrison. The World Bank has tracked that cost fairly
    carefully and also offered projections. In the first phase of
    2014-15 it was somewhere in the order of $3 billion to $4
    billion, if I recall, which may not sound that much, but when
    you are talking about economics of this scale, these three
    countries have a total population of 22 million people. They
    are among the poorest countries in the world. That is a pretty
    serious setback.
        And just to add to this, OECD just 2 days ago came in with
    estimates of what is going to happen in Brazil. And we are
    looking at a 4-percent drop of GDP in Brazil this year. Now,
    before Zika hit they were having trouble. But this can be, this
    can have profound impacts in an economy as big as Brazil's.
        Mr. Bera. It is fair to say we will have another Ebola
    outbreak, whether it is this year, whether it is 2 years from
    now. So it is a drop in the bucket to not stop now but actually
    continue and finish it and come up with that vaccine and that
    therapy?
        Dr. Hotez. Yeah. As we pointed out getting to launch of a
    leishmaniasis vaccine or a MERS coronavirus vaccine it is a few
    million, and the economic impacts in the billions. So anybody
    would tell you, any economist would tell you, it is a great
    investment. It is just a matter of getting those initial funds.
        Mr. Bera. Well, let's go ahead and do that then, so we
    don't have to, you know, lose those billions on the back end.
    Thank you.
        And I will yield back, Mr. Chairman.
        Mr. Smith. Before moving to Mr. Clawson, I appreciate you
    being here, the two questions: One, as we all know, incentives
    make the world go around. You point out, Dr. Hotez, that there
    are no commercial incentives to develop new tools. And you do
    point out in your testimony, unlike the EU and governments of
    Japan and several European countries, the United States
    Government does not specifically fund initiatives that support
    product development partnerships, or PDPs.
        And you mention that there are 16 to 20 PDPs globally. I
    wonder if you could tell us how many are in the United States?
        And what do these other countries do? Are there tax
    incentives? Are they grants? You know, are there a number of
    best practices that we ought to just look to apply to our own
    situation here in the United States, again learning from the EU
    on this one, and Japan?
        Mr. Morrison. So thanks. So of the 16 to 20 PDPs, they are
    equally shared between Europe and the United States. So about
    half in the United States, half in Europe. But the way that
    things are working on the European side is they are being
    mobilized through their Ministry of Foreign Affairs. So the
    Dutch Government has launched a fund for product development
    partnerships, so has the German Government just released one.
    The Japanese Government has just released one.
        And they, the way they operate is through what are called
    RFAs, Requests for Applications. And they are really lifelines
    for us because the Gates Foundation has dramatically decreased
    funding for PDPs. So Gates Foundation funding for product
    development partnerships is about half of what it was back in
    2008. So some of them are really struggling now for survival.
    And we are going to lose all of that innovation expertise. So
    it is great that the European governments have done this.
        What I have said is, the U.S. Government doesn't have an
    easy mechanism for funding PDPs right now. They do fund one
    specific one, IAVI, which is the International AIDS Vaccine
    Initiative, they're a very specific appropriation that goes
    through USAID. It is a pass-through. But beyond that, they
    don't really.
        Even if you mobilized 1 or 2 percent of funds for global
    health for PDPs, that would release $100 million to $200
    million into the system. That would do it right then and there.
        Mr. Smith. Why has Gates pulled out or at least diminished
    their portion?
        Dr. Hotez. This, I don't know. This current regime is very
    focused more on supporting directly industry it seems. And so
    they are taking some different routes. And but we will see how
    long that lasts for.
        Mr. Smith. And one last----
        Dr. Hotez. They are still, they are still funding us, you
    know, fairly well.
        Mr. Smith. Yes.
        Dr. Hotez. But not as much as they used to.
        But as I said, you know, we know for some of these
    vaccines, you know, $5 million here, $6 million here, $3
    million here makes a huge difference. We are doing our whole
    Chagas vaccine project on $4 million. We were able to get a
    schistosomiasis vaccine through, from discovery through
    clinical trials, all the way for $2 million. And that was done
    in part because NIAID rescued us and they paid for the clinical
    trials separately, and they paid for the toxicology tests.
        Mr. Smith. When might something for leishmaniasis be
    available?
        Dr. Hotez. Well, we could go into manufacturing pretty
    soon. But we don't have the funds right now. So we could
    probably go into manufacturing by next year or if not earlier.
    But----
        Mr. Smith. Could we get all the details on that----
        Dr. Hotez. Sure.
        Mr. Smith [continuing]. From you?
        Dr. Hotez. Yeah, absolutely.
        Mr. Smith. Appreciate that.
        And one last question on the G20 question. If we, as a
    subcommittee, put together a letter, which I think would be a
    great idea, I would appreciate if all three of you would
    provide us insight as to what you think ought to be in that
    letter.
        Dr. Hotez. Absolutely.
        Mr. Smith. Thank you.
        Dr. Hotez. You are welcome.
        Mr. Smith. Yes, Dr. Raad.
        Dr. Raad. Mr. Chairman, I think the issue of vaccines is
    extremely important. But from my interaction in the area there
    is a tremendous respectability to the healthcare, the U.S.
    healthcare system. And I think we can do a lot with whatever we
    have as we are developing new vaccines.
        For example, the polio is, there is an available vaccine,
    but how to implement it there? The issue of water sanitation,
    the refugee medicine kind of training, the early detection of
    these diseases. I think we have the best healthcare system in
    the world and they look up to us.
        And, again, to improve relationships maybe beyond
    governments with the people, and the people if they would see
    us as a country trying to reach out in a way to provide them
    better health and opportunity to kind of deal with the
    catastrophic situation, I think a lot can be done. Appropriate
    use of antimicrobials and training programs for the people who
    are doing relief, and so forth.
        Mr. Smith. I saw in your list you mentioned training other
    healthcare personnel for refugee situations. What does that
    take: A weekend, longer?
        Dr. Raad. It might take a week or 2 weeks on refugee
    medicine and how to deal with different situations. There is
    tremendous need for such initiatives. And on the ground they
    are effective. And they are----
        Mr. Smith. Who are the trainers for the camps?
        Dr. Raad [continuing]. They are cost effective. You can
    send trainers to train them in areas that are safe like Jordan
    or possibly Lebanon, or maybe other places. But you can--they
    are very cost effective. I mean the whole thing is not a----
        Mr. Smith. Is USAID doing that now?
        Dr. Raad. I am not sure. I would like to investigate by
    being in touch with them. But this is something that could be
    emphasized.
        Mr. Smith. Mr. Clawson.
        Mr. Clawson. Sorry I came late, I had another meeting. We
    are often double-booked up here. So appreciate you all hanging
    around long enough to hear my questions. I may very well be
    repetitive since I haven't heard what has already been asked.
    So if that is the case, I apologize.
        When I think about mosquito-based illnesses I have kind of
    this sequence in my mind that starts with, at least with
    daytime diseases, mosquito-based diseases, that starts with
    dengue fever, dengue fever times four strains, then
    chikungunya, now Zika. And each one of those rides the same
    Trojan horse, the same tiger mosquito. And that there will,
    therefore, be another Zika or another chikungunya. That the
    movie we have been seeing the last 10 years or so will
    continue, and the next one could be even worse than Zika and
    could be, you know, a real disaster. That is how I think of it
    in my mind.
        And so although I like getting rid of stored water or
    pooling water, I like making sure people have air conditioning
    so they kill the larva under the bed, like all those things, it
    still seems to me that until we get something that takes out
    the tiger, the Aedes mosquito, that we are going to see this
    movie again and again and again. And so I don't know if that is
    a genetic fix for this mosquito or if right now it just seems
    like we are going after the results as opposed to the base
    carrier of these types of diseases.
        Do you all see it the same way I do? And if that is the
    case, that is my theory would say the only long-term solution,
    at least for this strain, is to get on that mosquito. You all
    agree with what I am saying?
        Dr. Hotez. Well, I guess I could start. This morning I
    testified to Energy and Commerce; they were holding hearings
    about Zika. I work on the Gulf Coast of Texas and I focused on
    the fact that the Gulf Coast of the U.S., Texas, Louisiana,
    Mississippi, Alabama, and Florida have something very unique.
    We have not the Asian tiger mosquito, which we have that as
    well, but the real bad actor is Aedes aegypti, which is the one
    that is transmitting Zika----
        Mr. Clawson. Right.
        Dr. Hotez [continuing]. Throughout South America and now
    into the Caribbean.
        The other factor that the Gulf Coast, our states have is
    poverty. And that is not often appreciated as a risk factor.
    But the reason why Zika is wiping out Pernambuco State in
    Brazil, and now it is going to decimate Haiti, is because women
    who live in poverty have no access, live in houses without
    window screens or holes in the window screens, and the
    environmental degradation around them breeds the Aedes aegypti
    mosquito.
        So I am very worried about the Gulf Coast of the United
    States more than many others.
        And the consequence of that is we need to do something
    about the mosquito. We are not going to have a Zika vaccine in
    time for this epidemic. And so we have been pushing very hard
    for a program----
        Mr. Clawson. And just to interrupt. And we are not going to
    get rid of all pooling water in the lower socioeconomic
    neighborhoods that don't have air conditioning either. We need
    to work on all of that.
        Dr. Hotez. Yeah.
        Mr. Clawson. I am in southwest Florida. I am on the Gulf
    too.
        Dr. Hotez. Yeah.
        Mr. Clawson. So I am really worried about my more humble
    neighborhoods and their ability to fight back if the virus, if
    this mosquito comes north. And I am not sure why it is not
    there now. But it doesn't seem to be.
        Dr. Hotez. It will. I will come north. And so I am quite
    worried we are going to start seeing Zika on the Gulf Coast,
    including your district, starting this spring and summer.
        And so the approach needs to be, one, we know we can go
    pretty far with old-fashioned methods using existing
    insecticides and getting rid of the garbage, getting rid of the
    discarded tires on the side of the road and doing what you can
    with water. There are some new technologies out there. Whether
    or not they are going to be available, whether they can be
    shown to be scalable in time for this epidemic is unclear.
        Mr. Clawson. Are we close on this mosquito? And I got you
    that we need to get rid of tires and other pooling water and
    have more air conditioning and more screen doors. We hear it.
    But until we take out this particular mosquito, not only in our
    country but particularly, you go to the Caribbean and you go to
    Haiti or the Dominican Republic or Curacao, no one has air
    conditioning. And when it rains, there is water everywhere.
        Dr. Hotez. That is right.
        Mr. Clawson. Dr. Morrison, what were you going to say?
        Mr. Morrison. I support what Peter has to say which is that
    control of mosquitos is really hard, and it is expensive and it
    is tedious. And the old methods are still the ones that we are
    going to rely on in this period. And I worry enormously about
    what is going to happen in the areas where Aedes aegypti is
    endemic in the United States. And as it gets warmer those areas
    are going to become enlarged.
        There are technological fixes that people are exploring:
    There is radiation, there is introduction of bacteria, and
    there is genetic engineering. Those are the three methods that
    are actively being explored. I think they are going to get much
    higher attention in this next period, but there are no quick
    fixes here.
        Mr. Clawson. I dropped a bill that would give a 10-percent
    tax credit, like the investment tax credit from years ago, to
    any company that is working on what you just said. Because I am
    with you, we are, we have got to treat pooling water, but we
    have also got to get at this mosquito. And that is not the
    typical screen methods at night that we would use for a malaria
    mosquito, right? This is a daytime,----
        Mr. Morrison. Right.
        Mr. Clawson [continuing]. Indoor, hot zone kind of----
        Mr. Morrison. Right.
        Mr. Clawson [continuing]. Critter, right?
        Mr. Morrison. Right.
        Mr. Clawson. Let me ask one other thing and maybe----
        Dr. Hotez. I would say one other,----
        Mr. Clawson. Yes.
        Dr. Hotez [continuing]. One of the other issues, problems
    that we are seeing in the U.S. is mosquito control is very much
    done at the local level, at the county or city level, and there
    is a lot of inconsistency in terms of how well that is carried
    out from county to county.
        Mr. Clawson. I agree. I agree.
        Dr. Hotez. So there is going to be a, I think there is
    going to be some need for Federal Government intervention with
    these harmonized technologies and coming up with a more
    consistent----
        Mr. Clawson. Or standardize what the treatment ought to be,
    even if it is implemented locally. I think my districts are
    pretty good. My counties are pretty good. But lots of times
    when I travel I see people spraying at night. And I say that is
    going to kill the wrong mosquito.
        Dr. Hotez. Right.
        Mr. Clawson. And so we think we see spraying at nighttime
    that might be a good thing. As far as I can tell from this bug,
    that doesn't do anything.
        One more question real quick about the Middle East. I mean
    it seems to me that you have distrust of governments, distrust
    of outsiders in the Middle East in general. Can't get doctors
    in. Bad water, bad sanitation. It is just an invitation for
    mosquito-based infectious diseases, and all infectious
    diseases. And I don't even know where to start in that
    environment.
        By the way, I am not sure it is American. I mean I think it
    in Southeast Asia and Africa there are a lot of people that
    looked at other refugee crises and had to set up sanitation
    real quick in previous wars. I am not sure it even has to be
    America. But I see that big, wide problem. And unless
    resources, even if it is regional, unless we can come in, it is
    going to be hard to solve it. Am I right on that, Doctor?
        Dr. Raad. I fully agree with you. I think it is, as we
    mentioned earlier,----
        Mr. Clawson. Sorry I missed it.
        Dr. Raad [continuing]. It is a complicated problem, it is
    multi-faceted, and it is not one size fits all. I mean we need
    to kind of handle it in different areas in different ways.
        For example, there needs to be a policy for how you deal
    with the refugees and the problems related to that? How do you
    deal within the areas which are the combat zone or may be
    difficult to enter to? There has been one other issue is the
    issue of the Hajj and where you have the aggregation of people,
    whether it is in Saudi Arabia, or possibly Iraq and some other
    places, and so forth. Water sanitation and the implication of
    what is happening now of the sewage being directed into the
    water supply for these areas from the areas where the Islamic
    State is.
        So it is a complicated problem but I think it needs to be
    dealt with systemically, in a multi-faceted manner creatively.
    I think there needs to be some creativity because in some
    areas. But I believe that what you are saying is very true, but
    the response should be insightful, should be practical, and
    should be creative. And I think a lot will be done.
        The other factor is one has to account for the fact that
    the problem is escalating and it has so many variables that are
    moving targets occurring that this is why there needs to be a
    special attention through a concerted effort. And maybe a joint
    project between NGOs----
        Mr. Clawson. In some conflicts more people die of illnesses
    than they do from gunshots or bombs.
        Dr. Raad. That is very true.
        Mr. Clawson. What about in this case?
        Dr. Raad. Which is true. For example, I gave some figures.
    An area which is not really in the major conflict, Egypt, where
    the conflict is mainly in Sinai, but people are dying, there
    are more casualties from hepatitis C in Egypt over the last 5
    years than there are from the war in Syria.
        Mr. Clawson. Yeah.
        Dr. Raad. Actually, you know, \1/4\ million in Syria killed
    during the war. There certainly in all these outbreaks have
    resulted in a lot of people killed because of these infectious
    outbreaks because of the Syrian-Iraqi conflict, if you may. So
    I fully agree with you.
        Mr. Clawson. Dr. Morrison.
        Mr. Morrison. There has been various efforts made in this
    current, these current wars and in the past to try and estimate
    mortality from various sources. And the data remains weak
    oftentimes. But there seems to be across multiple cases a
    pattern where a substantial, a substantial portion of mortality
    comes through the decay of your health system.
        Mr. Clawson. Okay, so let me interrupt. Can I have 1 more
    minute on it?
        What do we spend on bombs and guns and killing versus what
    do we spend on preventing disease?
        Mr. Morrison. That is a big question.
        Mr. Clawson. I know you have got a, I know you thought of
    this now. Come on now. I know you all thought of this, right?
    We spend a lot more on bombs.
        Dr. Raad. I think that, yeah.
        Mr. Clawson. I'm just asking.
        Dr. Raad. I think this is the whole point that we, we
    together were trying to bring, that a lot could be done if we
    appropriately use these resources in a targeted manner. And
    that would reflect a certain view in the region, particularly
    among the people. It is people to people of how they view the
    United States of America. That we are not involved in the
    conflicts through the only really kind of the war sort of
    policy that we have, which is legit and certainly we are
    fighting terrorists. But there is another side initiative of
    this great country where we are reaching, where we are the kind
    of hosts of groups like Doctors Without Borders and so forth,
    that we are making initiatives on the ground and we are having
    people move on the ground.
        And this, this had a tremendous impact in west Africa with
    the Ebola virus, and could have a tremendous impact on the
    people and, ultimately, the governments in the area. If we have
    a good policy that will deal with this crisis and we come as
    the people are trying to solve a major catastrophic problem----
        Mr. Clawson. You would agree in the case, I mean I have a
    close friend who is a physician that went to Africa to fight
    the Ebola outbreak, as an example, university professor,
    physician, et cetera. A lot of Americans, Americans are great
    that way, right? If there is a problem around the world, we are
    always one of the few that swashbuckle and get on over there to
    help out, right?
        Dr. Raad. Yes.
        Mr. Clawson. But it is a lot harder in war zones. And it is
    a lot of our dollars that are going in there to, right, to
    defend and make war. So maybe in those zones we ought to think
    how can we also offset part of that with medical----
        Dr. Raad. That is true.
        Mr. Clawson [continuing]. And sanitation.
        Mr. Morrison. Congressman, we were talking earlier about
    the response to the human crisis that has grown out of the
    Syria war and has spilled into the region and now spilled into
    Europe. The United States' engagement on that side has amounted
    to $4.4 billion since the Syrian war started in March of 2011.
        The military side of the equation has been largely, within
    that region we have been scaling down our military engagement,
    but only recently scaling up with the coalition campaign
    against ISIS. Right? That is the central investment that we are
    making within that region on a military ground. So I mean you--
    --
        Mr. Clawson. The President's original ask was $5 billion or
    $6 billion, something like that, correct? To train Syrian
    insurgents, as I recall.
        Mr. Morrison. I don't remember the exact number that was
    made in terms of the training.
        Can I come back to one point that you raised about the Zika
    response, just to get back to that?
        Mr. Clawson. Sure.
        Mr. Morrison. Because I want to, before we run out of time
    I wanted to make one important point.
        Mr. Clawson. You know, the chairman over here might have a
    different view on that. But go ahead. Are you all right here,
    boss?
        Mr. Smith. Yes.
        Mr. Clawson. Alright.
        Mr. Morrison. You know, it is going to be very important in
    this period that the CDC be able to bring forward additional
    capacities and resources to states and communities that are
    attempting to address these threats through a variety of
    different measures of sanitation, water, screening, air
    conditioning. But and the current, the current $1.9 billion
    request, emergency request that is up here for consideration
    includes I think it is almost $900 million to meet that need.
        Mr. Clawson. Seems low.
        Mr. Morrison. And----
        Mr. Clawson. If I wanted to do an economic impact of an
    outbreak in south Florida, I could probably get to that number
    just in Florida pretty quick. Am I right? You all agree with
    that? So it seems low, $1.9 billion just seems low. Just a
    cursory view of it, seems low.
        Dr. Hotez. Well, I think you have to remember the
    consequences. If we start seeing clusters of microcephaly cases
    appear on the Gulf Coast by the end of this year, it is going
    to be spoken about in the same context as Hurricane Katrina or
    the BP oil spill.
        Mr. Clawson. Seems low.
        Dr. Hotez. So, yes.
        Mr. Clawson. But the human cost would be hard to describe,
    right?
        Mr. Morrison. When you look at the costs I think it is
    important to keep in mind, we are not talking about a crisis of
    Zika and of the mosquitos, we are talking about a crisis of
    microcephaly.
        Mr. Clawson. No, I understand that. I got you.
        Mr. Morrison. And the population that is most vulnerable is
    the pregnant women or women who are to become pregnant.
        Mr. Clawson. Right. In poor neighborhoods.
        Mr. Morrison. In poor neighborhoods in particular.
        Mr. Clawson. Where there is no air conditioning.
        Mr. Morrison. And so, so we need to, we need to keep our
    eye on the ball in terms of what the most vulnerable population
    in need is.
        Mr. Clawson. And what was the basis for the $1.9 billion?
    What is the----
        Mr. Morrison. Well, that has been detailed in the request.
    It breaks it into its different component parts.
        Mr. Clawson. Right.
        Mr. Morrison. They were making an estimate of the
    requirements in this first phase to get moving. And I think the
    urgency around this is what Peter is referring to, which is we
    do not know if we are going to see 8, 9, 10 months out or
    beyond, if we are going to see a proliferation of microcephaly.
        Mr. Clawson. But you all would agree, and again let me, you
    all agree with me, even if it is not--remember where I
    started--even if it is not Zika, it is going to be something
    riding the back of this particular mosquito. So whatever money
    that we spend, even if Zika is not an outbreak, we might be
    very likely preventing a future outbreak in whatever we do to
    attack Zika now. Even if Zika isn't our worst case scenario,
    there will be another one on this, on the Tiger mosquito that
    is going to get us.
        Mr. Morrison. No, this Aedes aegypti mosquito that is
    endemic in these coastal areas, 23 million people live in those
    areas, this same mosquito carries dengue.
        Mr. Clawson. And chikungunya.
        Mr. Morrison. And you have had outbreaks that have been
    brought under control.
        Mr. Clawson. That is my point.
        Mr. Morrison. I mean there was an outbreak in Key West of
    dengue in 2009-2010 that was brought under control. So it
    stands to reason that many of the same measures that have
    protected Americans against dengue and chikungunya--correct me,
    Peter, if I am wrong--are, should be applicable in this
    instance with lots of modifications around the, around the
    threat module.
        Mr. Clawson. Right. Which is why I would like more than
    $1.9 billion. It just seems like cheap money for future lives
    and problems.
        And with that I will--and I really like the CDC, by the
    way. With that I yield back.
        Mr. Morrison. Thank you very much.
        Mr. Clawson. Thanks for the time. Appreciate you all--sorry
    I came in late--appreciate you all's input here.
        Dr. Raad. Thank you.
        Mr. Smith. Thanks, Mr. Clawson. And thank you.
        Anything you would like to say before we conclude the
    hearing?
        Mr. Morrison. Just thank you.
        Mr. Smith. Oh, I mean anything on the subjects.
        Dr. Hotez. Well, thank you for raising this issue because
    this has been beow everybody's radar screen, and yet it is so
    important.
        Mr. Smith. Thank you for the insights and counsel. And we
    do have a lot of things to do in follow-up.
        The hearing is adjourned.
        Mr. Clawson. Thank you, Mr. Chairman. Really good job.
        [Whereupon, at 3:50 p.m., the subcommittee was adjourned.]

                                A P P E N D I X

                                  ----------

                       Material Submitted for the Record

    [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

                                     [all]