    [House Hearing, 115 Congress]
    [From the U.S. Government Publishing Office]

                   COMBATING TUBERCULOSIS IN SOUTHERN AFRICA

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

                                    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 FIFTEENTH CONGRESS

                                 SECOND SESSION

                                   __________

                                 JULY 12, 2018

                                   __________

                               Serial No. 115-156

                                   __________

            Printed for the use of the Committee on Foreign Affairs

     [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

    Available: http://www.foreignaffairs.house.gov/, http://docs.house.gov,

                          or http://www.gpo.gov/fdsys/

                                    ______

                      U.S. GOVERNMENT PUBLISHING OFFICE

     30-710 PDF                WASHINGTON : 2018

                          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                       KAREN BASS, California
    DARRELL E. ISSA, California          WILLIAM R. KEATING, Massachusetts
    TOM MARINO, Pennsylvania             DAVID N. CICILLINE, Rhode Island
    MO BROOKS, Alabama                   AMI BERA, California
    PAUL COOK, California                LOIS FRANKEL, Florida
    SCOTT PERRY, Pennsylvania            TULSI GABBARD, Hawaii
    RON DeSANTIS, Florida                JOAQUIN CASTRO, Texas
    MARK MEADOWS, North Carolina         ROBIN L. KELLY, Illinois
    TED S. YOHO, Florida                 BRENDAN F. BOYLE, Pennsylvania
    ADAM KINZINGER, Illinois             DINA TITUS, Nevada
    LEE M. ZELDIN, New York              NORMA J. TORRES, California
    DANIEL M. DONOVAN, Jr., New York     BRADLEY SCOTT SCHNEIDER, Illinois
    F. JAMES SENSENBRENNER, Jr.,         THOMAS R. SUOZZI, New York
        Wisconsin                        ADRIANO ESPAILLAT, New York
    ANN WAGNER, Missouri                 TED LIEU, California
    BRIAN J. MAST, Florida
    FRANCIS ROONEY, Florida
    BRIAN K. FITZPATRICK, Pennsylvania
    THOMAS A. GARRETT, Jr., Virginia
    JOHN R. CURTIS, Utah

         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
    DANIEL M. DONOVAN, Jr., New York     AMI BERA, California
    F. JAMES SENSENBRENNER, Jr.,         JOAQUIN CASTRO, Texas
        Wisconsin                        THOMAS R. SUOZZI, New York
    THOMAS A. GARRETT, Jr., Virginia

                                C O N T E N T S

                                  ----------
                                                                       Page

                                   WITNESSES

    Rebecca Martin, Ph.D., Director, Center for Global Health, U.S.
      Centers for Disease Control and Prevention.....................     4
    The Honorable Deborah L. Birx, M.D., U.S. Global AIDS
      Coordinator, U.S. Special Representative for Global Health
      Diplomacy, U.S. Department of State............................    11
    Ms. Irene Koek, Senior Deputy Assistant Administrator, Global
      Health Bureau, U.S. Agency for International Development.......    20

              LETTERS, STATEMENTS, ETC., SUBMITTED FOR THE HEARING

    Rebecca Martin, Ph.D.: Prepared statement........................     6
    The Honorable Deborah L. Birx, M.D.: Prepared statement..........    13
    Ms. Irene Koek: Prepared statement...............................    22

                                    APPENDIX

    Hearing notice...................................................    44
    Hearing minutes..................................................    45
    The Honorable Christopher H. Smith, a Representative in Congress
      from the State of New Jersey, and chairman, Subcommittee on
      Africa, Global Health, Global Human Rights, and International
      Organizations:
      Statement of the Honorable Eliot L. Engel, a Representative in
        Congress from the State of New York..........................    46
      Statement of the American Thoracic Society.....................    48
    Written responses from the witnesses to questions submitted for
      the record by:
      The Honorable Eliot L. Engel, a Representative in Congress from
        the State of New York........................................    54
      The Honorable Ami Bera, a Representative in Congress from the
        State of California..........................................    60
      The Honorable Joaquin Castro, a Representative in Congress from
        the State of Texas...........................................    73

                   COMBATING TUBERCULOSIS IN SOUTHERN AFRICA

                                  ----------

                            THURSDAY, JULY 12, 2018

                           House of Representatives,

                     Subcommittee on Africa, Global Health,

             Global Human Rights, and International Organizations,

                         Committee on Foreign Affairs,

                                Washington, DC.

        The subcommittee met, pursuant to notice, at 3:00 p.m., in
    room 2255 Rayburn House Office Building, Hon. Christopher H.
    Smith (chairman of the subcommittee) presiding.
        Mr. Smith. The subcommittee will come to order, and good
    afternoon to everyone. Thank you for being here.
        Today's hearing will address the persistent and too often
    underestimated threat to global public health posed by
    tuberculosis. This brutal contagious disease killed 1.7 million
    people in 2016--the most recent data available--making it the
    deadliest infectious disease in the world, killing more than
    both HIV/AIDS and malaria combined.
        TB is devastating for many people globally but it impacts
    the people of Africa, especially southern Africa,
    disproportionately.
        In 2016, 44 percent of all TB deaths occurred in the Africa
    region, in spite of accounting for only 25 percent of all new
    TB cases. Africans die at a rate of 72 per 100,000 infected,
    compared with 35 per 100,000 in Southeast Asia and 13 per
    100,000 in the eastern Mediterranean region.
        Those infected with HIV/AIDS are particularly vulnerable to
    TB and nearly three-quarters of those co-infected with HIV and
    TB in 2016 lived in sub-Saharan Africa.
        Thankfully, most cases of TB are curable if patients are
    diagnosed and adhere to a proper treated regimen. However,
    millions of newly-infected people go undiagnosed and without
    treatment each year, and the global spread of multiple drug
    resistant, or MDR, or extensively drug resistant--XDR TB--which
    emerges when patients receive inappropriate or incomplete
    treatment, poses and even greater and more costly threat.
        In 2016, roughly, 490,000 people develop MDR TB. An
    additional 110 new cases were resistant to the most effective
    treatment. Not only is treating MDR and XDR TB a grueling
    process for the patient, it also costs far more to treat than
    the other manifestation of the disease.
        One study by the Stop TB Partnership estimated that drug-
    resistant TB could kill up to 2.5 million people annually and
    cost the global economy $16.7 trillion if left unchecked.
        The dangerous potential of a drug-resistant TB outbreak is
    evident in the South African mining sector where exposure to
    silica dust, crowded poor living conditions, and high HIV
    prevalence created an incubator for disease and heightened the
    risk of contracting TB.
        Further complicating the problem, approximately 40 percent
    of mine workers are migrants who frequently move across borders
    and don't receive consistent medical treatment from public
    health systems in the region that do not coordinate
    sufficiently.
        This further increases the risk of MDR and XDR TB
    infections.
        I am encouraged to see that U.S. funding for combating TB
    increased to $261 million in 2018, which is $20 million more
    than was allocated in 2017, and more than $82 million higher
    than the administration's request.
        This shows that my colleagues and I and all of us are
    taking this threat seriously and I think that is a positive
    step on our part.
        But we must not stop there or become complacent in any way.
    The World Health Organization anticipates a $7.4 billion budget
    shortfall for the global plan to end TB if the international
    community does not significantly increase funding.
        We must encourage our international partners to step up to
    this challenge and take the opportunity of the U.N. General
    Assembly high level meeting on ending TB this September to do
    so.
        But even more, we must explore more innovative and holistic
    approaches to eliminating this disease. We must work from a
    regional perspective and increase coordination among health
    systems.
        We must pay special attention to the mines in South Africa.
    We must redouble our efforts to diagnose and treat every person
    infected with TB and we must pull out all the stops when it
    comes to preventing MDR or XDR TB infections.
        We must also encourage the World Health Organization to
    stop being overly bureaucratic when it comes to battling TB.
    There are bottlenecks in the WHO approval process for new
    treatments and new diagnostic tests which need to be fixed.
        I am looking forward to hearing from our very distinguished
    panel, which I'll introduce shortly. I would like to welcome
    Tommy and Amanda Russo, distinguished guests who are here
    visiting, and their parents from Howell Township in my
    district.
        Thank you for coming, Tommy and Amanda, and I would like to
    yield to my good friend and colleague, the ranking member, Ms.
    Bass.
        Ms. Bass. Thank you, Mr. Chairman.
        I want to thank you for convening today's hearing on
    combating tuberculosis in southern Africa. We know this is an
    issue that is important to all of us with global dimensions
    that impact everyone.
        I want to thank our witnesses for taking the time to
    testify before this committee today. We know that you have
    dedicated your life to addressing the great public health
    challenges and we thank you.
        I also want to thank Ranking Member Engel, who might be
    here. He has consistently championed several health priorities
    and, in particular, the spread of tuberculosis, both multi-drug
    resistant and extensively drug resistant TB.
        In 2016, 25 percent of all new TB cases developed in Africa
    and 2.5 million people--44 percent of all TB deaths--occurred
    in the region. Meanwhile, we know that TB cases are both
    preventable and curable.
        But we are here today because the southern African region
    has the highest incidence of TB in the world. The association
    with HIV/AIDS and co-infection has made TB one of the leading
    killers of HIV/AIDS-positive people globally, and southern
    Africa has one of the highest burdens of TB and the highest
    burdens of HIV.
        Defeating TB requires expanding access to affordable
    treatment but also prevention of TB in the first place.
        I look forward to hearing on how the U.S. is supporting
    more effective treatment as well as prevention.
        Thank you.
        Mr. Smith. Thank you, Ranking Member.
        I now would like to introduce our distinguished panel,
    beginning first with Dr. Rebecca Martin, who is the director of
    the Center for Global Health at the U.S. Centers for Disease
    Control and Prevention, CDC.
        With over 18 years of experience working with immunization,
    HIV, and health system strengthening, Dr. Martin is a leading
    expert in the field of international health.
        She has worked extensively in Africa to measure and
    evaluate the HIV/AIDS epidemic and equip nations to respond
    effectively. As director of the Center for Global Health, Dr.
    Martin leads the CDC's global effort to protect and improve
    health globally through science, policy, partnership, and
    evidence-based health action. We are delighted that she is here
    today to provide her expert insights.
        Ambassador Deborah Birx, a medical doctor, is the
    coordinator for the United States Government Activities to
    Combat HIV/AIDS and U.S. Special Representative for Global
    Health Diplomacy.
        Over her 30-year career, she has focused on HIV immunology,
    vaccine research, and global health. Ambassador Birx oversees
    the implementation of the U.S. President's Emergency Plan for
    AIDS Relief, or PEPFAR, and all U.S. Government engagement with
    the Global Fund to fight AIDS, tuberculosis, and malaria.
        In her role as U.S. Special Representative for Global
    Health Diplomacy, she works to align the U.S. Government's
    diplomacy with foreign assistance programs and address global
    health challenges and move toward achieving goals, including
    eliminating AIDS, ending preventable child and maternal deaths,
    and combating infectious disease threats.
        We will then hear from Irene Koek, who is the senior deputy
    assistant administrator in USAID's Global Health Bureau.
    Previously, she was the senior infectious disease advisor for
    the Global Health Bureau and the Global Health Security Agenda
    led at USAID.
        From 2010 to 2014, she was director of the Health Office in
    USAID Indonesia, where she also served as the health attache
    and PEPFAR coordinator. During her 32-year career with USAID,
    Ms. Koek has also worked as a health advisor to the Policy and
    Program Coordination Bureau, and as chief of infectious disease
    division in the Global Health Bureau helped start the
    President's malaria initiative and served as chair of the Stop
    TB coordinating board.
        Ms. Koek, thank you for being here as well, and without
    objection, your full resumes will be made a part of the record.
        Dr. Martin, the floor is yours.

    STATEMENT OF REBECCA MARTIN, PH.D., DIRECTOR, CENTER FOR GLOBAL
        HEALTH, U.S. CENTERS FOR DISEASE CONTROL AND PREVENTION

        Ms. Martin. Thank you, Chairman Smith and Ranking Member
    Bass.
        My name is Dr. Rebecca Martin and I serve as the director
    for the Center for Global Health within the U.S. Centers for
    Disease Control and Prevention.
        I appreciate the opportunity to be here today to discuss
    the global health security threat of drug resistant
    tuberculosis and CDC's critical role in preventing and stopping
    it.
        It is a pleasure to join my friends and colleagues,
    Ambassador Birx and Deputy Assistant Administrator Koek.
        In 1973, my older sister was exposed to TB and infected and
    had to undergo 9 months of treatment, a practice still valid
    today in many countries, nearly 50 years later.
        In 1991, I worked in Haiti to set up a cutting-edge
    laboratory for TB with fluorescent microscopy, still in use
    nearly 30 years later in resource-constrained countries.
        HIV drives the TB epidemic in southern Africa with the co-
    infection rate of 60 percent. While we have benefitted from
    innovations to fight HIV, innovations for TB have not kept
    pace. We must fight these two diseases together.
        I want to emphasize three points about CDC's work in
    combatting TB. First, CDC leads the U.S. domestic TB program
    that supports states and large cities, and conducts clinical
    and epidemiologic and laboratory public health research.
        Our success in domestic elimination is dependent upon our
    work in global TB.
        Secondly, a disease threat anywhere is a disease threat
    everywhere, and there is no greater example than this than
    drug-resistant TB.
        Thirdly, to succeed in controlling TB, we need to develop
    new tools, scale up existing tools in prevention, and enhance
    political will.
        Today, tuberculosis, although preventable and treatable, is
    the world's leading infectious disease killer, taking the lives
    of nearly 1.7 million people each year.
        Over 25 percent of these deaths occurred in Africa in 2016
    with southern Africa as the epicenter. One-quarter of the
    world's population--nearly 2 billion--is infected with TB.
        Among those individuals who become ill with TB disease,
    approximately 4 million go undiagnosed and untreated. TB drug
    resistance first develops when patients receive incomplete or
    inadequate treatment.
        Drug-resistant TB can then spread from person to person,
    making the disease an even greater threat to global health
    security.
        Globally, in 2016, there were 600,000 new TB cases
    resistant to first line drugs and 80 percent of them were
    resistant to multiple drugs.
        Drug resistant infections are extremely costly to treat and
    manage, cause intense suffering, strain fragile health systems,
    and result in death at much higher rates than drug-susceptible
    TB, with only one in 10 being cured to date.
        A hundred and five countries, including the United States,
    have also reported cases of extensively drug-resistant TB, an
    even more severe form of the disease, which is at least 17
    times more expensive to treat than medication-responsive TB
    strains.
        I want to talk for a moment about the connection between
    CDC's global and domestic TB efforts. Over the past two
    decades, TB cases in the United States have decreased by 75
    percent, and U.S. now has one of the lowest cases in the world.
        Yet, there is still work to be done here and abroad. People
    born outside the U.S. make up 70 percent of the total TB cases
    in the U.S. Nearly all of these people arrived in the U.S. over
    10 years ago.
        To control TB and prevent drug resistance in the United
    States, we must work outside of our borders. For example, CDC
    works with our counterparts--ministries of health--in more than
    25 countries to combat TB, including those countries from which
    most U.S. TB cases originate.
        In South Africa, CDC has used molecular fingerprinting to
    determine that multi-drug-resistant TB cases were primarily due
    to person-to-person spread and not due to problems adhering to
    treatment regimens.
        Also, CDC is a co-lead in addressing TB-HIV co-infection in
    high burden countries through PEPFAR. Despite recent success,
    stopping TB will require that we scape up access to existing
    tools and redouble our efforts to develop the next generation
    of drugs and technologies to accelerate our impact.
        Importantly, expanding TB-preventive therapy, which is up
    to 90 percent effective in protecting people with latent TB
    infection from progressing to active disease could change the
    trajectory of the TB epidemic.
        In the coming years, continued U.S. leadership will be
    essential to eliminating TB domestically and in the
    international community mobilizes to address this threat.
        We have an opportunity to demonstrate our leadership at the
    upcoming United Nations General Assembly in September and we
    need champions like the Honorable Minister Motsoaledi, who
    could not be here with us today, and each of you.
        In closing, I'd like to leave you with a quote from Nelson
    Mandela, who said, ``It always seems impossible until it's
    done.''
        At CDC, we embrace the impossible.
        Thank you for the opportunity to appear before you today
    and I look forward to answering your questions.
        [The prepared statement of Ms. Martin follows:]

    [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

                      ----------

        Mr. Smith. Dr. Martin, thank you so very much.
        Dr. Birx.

     STATEMENT OF THE HONORABLE DEBORAH L. BIRX, M.D., U.S. GLOBAL
    AIDS COORDINATOR, U.S. SPECIAL REPRESENTATIVE FOR GLOBAL HEALTH
                  DIPLOMACY, U.S. DEPARTMENT OF STATE

        Dr. Birx. Thank you, Chairman Smith, Ranking Member Bass.
    Thank you for your continued incredible vision and support for
    PEPFAR and let me again thank your staff, who have been really
    instrumental in the work that we do every day, and to the rows
    behind me who are so extraordinarily dedicated for TB. There's
    a lot of people in the audience today who are very much
    committed to our response globally to TB/HIV.
        I am not going to repeat many of the numbers that were just
    presented. If we can have the first graphic--I think,
    hopefully, shows you the absolute ramp up of both TB and HIV
    concomitantly in southern Africa. And so picking this as a
    focus of southern Africa was really brilliant because it shows
    if we control the HIV pandemic, we return to those much lower
    and we control the TB pandemic in southern Africa.
        Our goal in PEPFAR has always been to provide the best
    care, and part of that best care now requires us to
    dramatically expand our TB activities, which we have done over
    the last 2 years.
        We've invested about $1.5 billion within PEPFAR on TB and
    TB/HIV but we are really focused on increasing and accelerating
    our impact.
        We've taken a three-prong approach. One is ensuring that
    all TB cases are tested for HIV and then those cases that are
    found to be dually infected start on HIV treatment immediately.
        We are also focused, number two, on preventing TB from
    developing in the first place in HIV positive clients and this
    is by treating them early before their immune system begins to
    deteriorate.
        Third, we are screening our HIV-infected clients for TB and
    ensuring that those who have active disease are treated
    immediately and those who don't have active disease are
    immediately put on TB-preventive therapy, which is a new
    addition to our program with a clear indicator.
        In our first focus area, and, you know, at PEPFAR we always
    try to be honest with ourselves, so in the first focus area of
    ensuring that every TB client is tested for HIV. We are at
    about a 95 percent success rate in our most recent data, and in
    getting those individuals on treatment we are at a 95 percent
    success rate.
        This makes sense because TB clients are often seen
    frequently, and so missing that opportunity of getting them on
    HIV drugs would be inexcusable.
        In the second area, which is really preventing
    deterioration of the immune system, we haven't done as well,
    and this is--really, we haven't been able to prevent the new
    cases of TB because countries have been delayed in often
    starting immediate treatment.
        But through sub-Saharan Africa, with the leadership of our
    Ambassadors in countries and the leaderships of ministers of
    health, many countries have gone to what we call test and
    start.
        So upon immediate diagnosis of HIV they started on TB--
    started on HIV therapy. Allowing them to thrive and not
    transmit the virus but also preventing opportunistic infection
    and, therefore, TB.
        If we can see the next graphic, I wanted to be honest also
    with who we are missing. The blue bars are men, the green bars
    are women, divided by age groups.
        These are the impact surveys that we have in the field.
    This is a summary of seven countries in sub-Saharan Africa
    clearly showing that we are missing men between age zero and 34
    and we are missing women between zero and 24.
        It makes sense because we implemented what we call B+, to
    ensure all women that are pregnant immediately have access to
    lifelong treatment about 4 years ago, and you can see that
    almost every woman over 25 has been diagnosed and is on
    treatment.
        It's really missing the healthy individuals. We know when
    people are infected with HIV they have a long prodrome of
    asymptomatic where their immune system is constantly under
    destruction.
        If we can find them early when they are perceived to be
    healthy, we can prevent the consequences of these opportunistic
    infections.
        So we are very much dedicated to finding these missing
    healthy children, missing healthy men, and missing healthy
    women, long before their immune system deteriorates.
        If we are able to do this, we've created a community of
    practice that not only is strengthening the health system for
    everyone but also provides the platform to find other
    communicable, noncommunicable, and future disease threats in
    the communities because the communities will see themselves
    within the health system and health-seeking behavior.
        Our third area of focus--the early diagnosis and treatment
    of TB in our HIV positive clients is also slowly improving.
        We are now up to about 76 percent of our clients are
    screened for TB when they come in to our PEPFAR HIV clinics and
    that has been a big change over the last 2 years.
        Where we are failing our clients is taking the ones that
    have been screened negative for active disease and getting them
    what we call preventive therapy.
        We were in the single digits and we are beginning to make
    progress quarter over quarter as we measure our progress in
    that indicator.
        We are beginning to see a real impact from our joint
    efforts of combatting HIV and TB together. The death rates
    have, remarkably, declined and in Botswana, Namibia, and a
    whole series of countries who had gone to earlier treatment
    there's been a dramatic decline in the number of TB cases.
        I really--if immediate therapy for anti-retro viral therapy
    is the cornerstone of PEPFAR, both the active TB case findings
    and the preventive therapy will be our capstone.
        And so although we are behind compared to our other areas
    of work, we are very much focused on these areas and we'd
    appreciate your attention to this critical issue for us.
        Thank you.
        [The prepared statement of Dr. Birx follows:]

    [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

                       ----------

        Mr. Smith. Dr. Birx, thank you very much.
        Ms. Koek.

         STATEMENT OF MS. IRENE KOEK, SENIOR DEPUTY ASSISTANT
         ADMINISTRATOR, GLOBAL HEALTH BUREAU, U.S. AGENCY FOR
                       INTERNATIONAL DEVELOPMENT

        Ms. Koek. Thank you very much, Chairman Smith, Ranking
    Member Bass. Thank you very much for your leadership and
    support for the work the U.S. Government does to advance global
    health and your commitment to fight tuberculosis.
        I am very honored to be here today with my U.S. Government
    colleagues to discuss our collective efforts against this
    deadly disease.
        TB has long been an important issue for me. As chief of the
    infectious diseases division I helped start USAID's program 20
    years ago and watched it grow the first part of its existence.
        Thanks to the support of Congress, the U.S. Government is
    the single largest donor to TB programs globally. Collectively,
    we share a vision of a world free from TB.
        The collaboration and complementary efforts of USG
    departments and agencies is reflected in our implementation of
    U.S. Government global TB strategy and the MDR national action
    plan.
        USAID leads USG global TB efforts through our support for
    high-quality diagnosis, treatment, prevention, and care
    services for millions of people who are at risk or suffer from
    MTB and MDR TB.
        We focus in 22 high-burden countries including five in
    southern Africa. We also support an additional 32 countries
    through targeted technical assistance primarily in support of
    Global Fund TB grants.
        Our efforts are designed to accelerate and optimize
    implementation of country-owned and led national TB programs.
    In order to achieve the greatest impact on the TB epidemic, we
    focus on the areas with the greatest burden of disease and on
    ensuring that the innovations with the highest potential are
    rapidly identified and widely implemented. We focus in
    countries with the highest burden of TB, of drug-resistant TB,
    and HIV-associated TB.
        We use data to target our interventions to benefit the
    majority of those suffering from TB. TB predominantly affects
    the poorest and most vulnerable with approximately 95 percent
    of TB deaths occurring in low and middle income countries.
        Each day, more than 4,600 individuals die from this curable
    disease. The majority of the TB burden is in Asia. Almost 60
    percent of all TB cases are found in India, Indonesia, China,
    Pakistan, and the Philippines.
        Although while HIV-associated TB only accounts for one-
    tenth of the world's TB cases, it has a disproportionate impact
    in Africa, which is home to 75 percent of the global TB-HIV
    cases.
        The investments on TB have paid off. Since 2000, our
    support in USAID priority countries contributed to a 40 percent
    decrease in TB-related mortality and a 27 percent decrease in
    TB prevalence.
        In the last 2 years, USAID has helped provide high-quality
    TB treatment for 6 million TB patients including 150,000 MDR TB
    patients. USAID investments over the past 20 years have
    dramatically improved global and national TB surveillance
    systems, which have enabled better targeting of interventions
    at the global and country level, and improved data for decision
    making.
        At the country level, USAID works with national TB programs
    and local partners to scale up and accelerate implementation of
    new tools and approaches, focusing on four pillars.
        The first is person-centered care. TB care has evolved to
    embrace a human rights approach that is focused on meeting the
    individual needs of each person so they are able to access
    timely quality diagnosis, care, and treatment regardless of
    where they seek services.
        Typically, this is through primary health care in community
    settings. USAID increasingly works with faith-based and
    community organizations to provide the support needed, improved
    treatment outcomes, and combat the stigma so often borne by TB
    patients, particularly among women and children.
        Secondly, access to early diagnosis and initiation of
    quality treatment is one of the best ways to prevent the
    transmission of active TB disease as well as the development of
    MDR TB.
        We leverage American innovation in industry to scale up new
    tools for better diagnosis and treatment. With Johnson &
    Johnson, for example, we've introduced bedaquiline, a new TB
    option for people with drug resistance in more than 70
    countries for 25,000 people often providing the only treatment
    option.
        USAID is also partnering with diagnostic companies such as
    Cepheid and Becton Dickinson to expand access to rapid TB and
    drug-resistant testing.
        The third pillar is preventing the development of active TB
    disease. USAID works to prevent both the transmission of TB
    from one person to another and the progression from latent TB
    infection to active TB disease.
        The combination of TB preventive therapy and anti-
    retroviral therapy reduced the risk of developing active TB
    disease and people living with HIV by up to 90 percent.
        As Ambassador Birx has already noted, scaling up TB-
    preventive therapy among people with HIV is critical and
    requires a strengthened and more focused approach.
        Fourth is accelerating research and innovation. USAID's
    research portfolio has been a key component of our TB program
    since its inception. In close cooperation with USG partners,
    USAID has supported several late-stage research cities that
    have led to major policy changes, including a standardized
    fixed dose combination TB regimen and a shortened MDR TB
    treatment regimen.
        The U.N. High Level Meeting on TB later this year will
    provide a much-needed opportunity to bring global attention to
    a disease that, despite its horrific impact is all too often
    ignored or unseen.
        It is critical that we continue to maximize investments and
    leverage additional resources to bring self-reliant sustainable
    TB responses within countries.
        We stand at a pivotal juncture, but with your steadfast
    support, we can help the world take the right path. With
    increased political commitment, we can and will end TB.
        Thank you again for your support. I look forward to your
    questions.
        [The prepared statement of Ms. Koek follows:]

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        Mr. Smith. Thank you, Ms. Koek. Thank you very much.
        Thank you all for your testimonies and, again, most
    importantly, for your extraordinary leadership.
        Let me just ask you, now, one of those reasons why drug
    resistance in all diseases including TB has increased across
    many diseases--infectious diseases--is the misuse of
    antibiotics, not completing the regimen as prescribed.
        How are the physicians and the dispensers, the health care
    professionals--has the education of those individuals and
    especially those who are affected then been as robust as it
    could be to mitigate that problem?
        Ms. Martin. Thank you for the question. I will start off
    and happy to hand over. But, definitely, with the work that we
    have been doing in training health care providers, also working
    through the clinical trials consortium, which engages other
    countries as well, the opportunity to create centers of
    excellence for training is very critical.
        CDC's efforts as well in combatting anti-microbial
    resistance has taken on these efforts and been ensuring that we
    are working toward the efforts of addressing, as you have
    mentioned, both the leadership and the use of anti-microbial
    resistant agents but also the importance of making sure that
    people complete treatment.
        And this is something within TB that we have been working
    on to ensure looking at how to improve regimens for treatment
    so that they can be shorter courses and also less harmful side
    effects so that people will finish and less drug resistance
    will form.
        Mr. Smith. Yes.
        Ms. Koek. If I could just add to what Dr. Martin just
    talked about.
        One of the areas that's been a real focus for our programs
    is reaching all clinicians and throughout the system. I mean,
    very often what we see at a number of countries is people will
    go to their regular doctor--their private provider, for
    example--who may or may not be trained on tuberculosis or
    recognize it right away. So they may just prescribe some
    antibiotics or a piece of it.
        So it's been really important and a real focus to try to
    reach all providers, whether they be in the public sector or
    the private sector and try to make sure that particularly
    private sector providers--and we see this often in a number of
    countries--may not at the outset provide the right treatment
    but to make sure they really understand what the appropriate
    treatment regimen is and do the diagnosis before they begin
    treatment.
        And that's been a really important area of support for us
    and something we really need to continue to get the word out
    and make sure all providers are part of the network and are
    connected to the public system so you can get the reporting up
    through the--through the systems.
        Mr. Smith. You know, the High Level Meeting that's slated
    for September 26th at the United Nations--which could be a true
    pivot point for all governments, including our own, to have a
    more cohesive plan--could you perhaps fill us in on where we
    are in terms of--obviously, they will show up--the delegates--
    on September 26th with a plan largely intact.
        How well along are you in those preparations? What does it
    look like? I don't think this is the Manhattan Project where
    we've got secrets that can't be conveyed. Could you give us a
    good insight as to where we are right now?
        Ms. Koek. Let me start and ask my colleagues to add on.
        So there's been much, much discussion around what really do
    we need to get out of the High Level Meeting and this--
    actually, this meeting is the culmination of years and years of
    effort to really get it on the agenda, and we really owe a big
    thanks to Minister Motsoaledi, who's been a tremendous
    champion, to make this happen.
        So what we are really hoping is will come out of this is a
    very high level goal of getting--targeting 40 million people on
    treatment by 2022. So 40 by 2022 is the very high level ask.
        But part of that, and this is one of the things that is
    being pushed through the development of the communique is about
    making sure there's an accountability framework.
        So in order to reach that goal, what every country really
    needs to do and using the kind of data that we've been talking
    about, that there is an accountability for every country about
    what they need to do to reach those patients who are not yet
    diagnosed and put on treatment and supported throughout
    treatment.
        We are also really pushing for an independent body to
    monitor that, much like has been done for polio and done so
    successfully to really make sure that there is--that not only
    is there accountability but there's a oversight about
    accountability.
        And then also working with faith-based and civil society
    groups, making sure they're part and parcel of the commitment
    and the instruction and also private sector as well.
        Mr. Smith. Has the outreach to faith-based groups been as
    robust as it should be?
        Ms. Koek. I think it's underway, and this is where the Stop
    TB partnership has been playing a really important role of
    reaching civil society and trying to reach the outreach.
        I think that we can do a lot more and that would be a
    really high priority over the coming months to make sure the
    faith-based community is absolutely----
        Mr. Smith. I raise that--you know, in my early career in
    the 1980s--early in the '80s--I authored the Child Survival
    Amendment, which put $50 million into immunizations, and went
    to Central America several times including to El Salvador when
    they had Days of Tranquility and the FMLN and the Duarte
    government ceased all fighting so kids could be immunized
    against polio, diphtheria, pertussis, and the like.
        And it was the church that made that happen. They
    admonished mothers, families, to bring their children for the
    immunization. Many of the vaccination sites were church sites.
        I know USAID and Mark Green get it. I know all of you get
    it, how important it is to have a partner that has such a low
    cost overhead that can get volunteers.
        We've done it with HIV/AIDS for years with PEPFAR. But I
    just hope in this mobilization there's a full inclusion of
    faith-based entities.
        Ms. Koek. No, I couldn't agree with you more, sir. The
    faith-based community is a tremendously important voice on
    this, and as you have described, they've been so involved.
    Members of that community have been so involved in health
    issues but certainly TB as well, and I think can be an
    extraordinarily powerful force at the U.N. High Level Mission
    and it's part of our engagement.
        And, as you noted, Administrator Green is very, very
    committed to this and we have regular conversations with that
    community and continue to make sure that TB is on their agenda
    as well.
        Mr. Smith. Let me ask you--first of all, I want to thank
    Dr. Birx for holding that meeting that we had in New York with
    Dr. Aaron Motsoaledi. We had hoped that he would be here and he
    had to cancel due to other pressing issues.
        But that meeting was extraordinary, so I want to thank Dr.
    Birx for putting that meeting together.
        Let me ask you--for many of our pharmaceutical companies,
    developing drugs to combat or to, hopefully, cure TB, is a high
    bar because the rate of return is just not there for them and I
    am wondering if there are incentives--any recommendation you
    can make to try to get even further buy-in on the R&D side with
    our pharmaceuticals who do amazing work.
        Like on neglected tropical diseases, I mean, they have been
    leaders and have provided enormous amount of research with very
    little or no return because it's the right thing to do, and I
    am wondering on the TB issue if you could speak to that.
        Dr. Birx. I will just open on this one because I think one
    of the--the important part we have from the program side is as
    new drugs--and we saw the new CDC recommendation in the MMWR
    for a 1-month short course on treatment--our job is that as we
    have these new drugs new regimens available is to get them into
    program, because nothing is more encouraging to the
    pharmaceutical industry to take their hard-earned research and
    clinical trials and translate that into client care and I think
    that's part of--that's part of our job to really ensure not
    only that there's incentives but that the drugs get utilized
    quickly when they're shown to be effective.
        This new preventive therapy going to 1 month will be--it's
    a huge breakthrough for clients. That's a game changer when
    they know they only have to take a medicine for 30 days.
        We do have supposed to remind people curative drugs
    available today for each of these different entities, we would
    love that in HIV if we had a curative drug.
        So I think for us not to do everything to utilize them
    effectively is really a tragedy. So I think we want to be
    really committed to translating new drugs into action
    immediately.
        Ms. Koek. Just to add to that, I think the--you know, we--
    in the last couple of years there finally has been a new drug
    that has come out for TB--bedaquiline and some other--for the
    first time in over 40 years.
        And so the investments in research that have happened over
    the last 10 or 15 years are finally paying off after long, long
    neglect. There are a few more, I think, in the research
    pipeline and we've been really fortunate for bedaquiline.
    Johnson & Johnson, which has been behind this, is really
    committed to making sure that it's available.
        We have a memorandum of understanding with J&J to do
    donation of bedaquiline as it goes through the final stages of
    research. It's already been approved actually by WHO even ahead
    of being approved by the FDA, which is quite a groundbreaking
    effort, if you will.
        So as we go through the donation program and they move to
    market in the final stages, it will be available and it really
    has made a huge difference on the treatment of MDR TB.
        But there are more drugs needed in the pipeline and we need
    to continue the research pipeline. I know that NIH and it looks
    like the TB Alliance for Drug Development are after it and it's
    a hugely important part of what we do in TB overall.
        Mr. Smith. Yes, Dr. Martin.
        Ms. Martin. If I could just add to this. I think as well
    the work that is being done, especially in finding the missing
    cases so the active case finding, also makes and closes the gap
    by 40 percent of those who don't complete treatment, and this
    will also make the market more viable once you see the ability
    to be able to use the drugs and to close the gap for ensuring
    people are treated.
        Mr. Smith. Ranking Member Bass.
        Ms. Bass. I want to thank the three of you again for
    testifying today but way more important than that, for your
    dedication and your work.
        Unfortunately, I am doing double duty in two hearings and
    will have to run out. But I did want to ask just a few quick
    questions.
        You know, you mentioned, Dr. Birx, about diagnosing and
    treating people right away and I was just curious how is TB
    diagnosed in Africa? I mean, I certainly know how--I worked in
    the medical field for many years.
        We do a skin test or an x-ray. But that also takes time to
    get the results back. So you can't just see a patient and then
    give treatment. So how is it diagnosed?
        Dr. Birx. So we are very fortunate in collaborating both
    with the TB program and the HIV program to rapidly get gene
    experts in the field so that we can rapidly diagnosis.
        Now, this gene expert machine is molecular in basis and can
    be used for HPV. It can be used for new zoonotic events. So it
    is a technology that's now available throughout sub-Saharan
    Africa.
        We spent the last year mapping where every single gene
    expert machine is, and interestingly, we found that we have
    more gene expert machines than we need.
        So the good news is that the equipment is not the limiting
    factor. It's utilizing it effectively. So if we want to test
    every TB client we have enough gene expert machines available
    in the country and I think that's really reassuring to
    everybody.
        Until we map them, you know, everybody wasn't communicating
    but we've had this great collaboration between the TB program
    and the HIV program because we were each buying them, and now
    when we put them together we see that there's a capacity there
    to test everyone and provide that rapid diagnosis and get
    people on treatment immediately. And as you said, that is the
    key----
        Ms. Bass. Right.
        Dr. Birx [continuing]. To the health and welfare of our
    clients in the long run and also the key to creating
    nontransmissability at the household level, and to the health
    care providers, which we have to remember--and thank you for
    bring that up--it's really not only important that we train the
    health care provider on how to diagnose TB but also how they
    can protect themselves with infection control.
        Ms. Bass. You were also mentioning a percentage of patients
    that are diagnosed with TB and you test them immediately for
    HIV. What's the percent?
        Dr. Birx. Ninety-five. We are up to 95 percent of the TB
    cases are tested for HIV.
        Ms. Bass. No. What's the percent of HIV--that are HIV
    positive?
        Dr. Birx. It changes by country. In South Africa, some
    places it's--so that graphic where I showed you where we are
    missing men, it's higher the more people you're missing early
    in the early stages.
        So as we find ways to find men and well children early, the
    TB cases should plummet. So a TB case and that percentage--
    having a high percentage of HIV and the TB is a reference point
    for us not doing as well as we should----
        Ms. Bass. I see.
        Dr. Birx [continuing]. Because that shouldn't happen. So we
    want that to be zero. But right now, it's everywhere from 5
    percent to probably 60 percent.
        Ms. Bass. Wow.
        Dr. Birx. But that's our failure on the HIV side to not
    getting people on HIV treatment early so that there's no dual
    infection.
        Ms. Bass. And you mentioned--thank you. Thank you.
        And, Dr. Martin, you were mentioning other countries. You
    said that there are several countries where people come into
    the United States and TB is spread.
        I am used to seeing in Los Angeles a lot of our TB cases
    were in the homeless population. It didn't impact--it wasn't
    from people coming in the country but what are those countries
    that you were referring to?
        Ms. Martin. Thank you, and just to note too, while they may
    not be U.S. born, it's not that it's they're first arriving
    with TB. It's more that we are seeing that after a year or 50
    percent after 10 years may move on to active TB disease.
        Ms. Bass. I see.
        Ms. Martin. And those countries that we are seeing them are
    India, Vietnam, China, Philippines--I am missing one--Mexico.
        Ms. Bass. Oh, the countries that Dr. Koek was mentioning. I
    see.
        Ms. Martin. And we are seeing, as Irene Koek mentioned,
    it's with the middle income countries where they're seeing
    these as well. It's not just low income countries but middle
    income countries that need to be able to stop and detect
    diseases where they are occurring--the TB--and stop it before
    it comes and be able to spread or create drug resistance.
        Thank you.
        Ms. Bass. I see. Dr. Koek, did you want to respond to that
    as well?
        Ms. Koek. Yes, just to add on to that, because I think the
    burden is indeed in a number of those countries and in addition
    to a very high burden in southern Africa, particularly where
    the co-infection issue is, as Dr. Birx talked about, but there
    is a big burden in other countries in Africa, which is less
    driven by HIV, and then as we talked about earlier, also in
    Asia where you do have the largest number--countries with the
    largest numbers and they are these lower middle income
    countries.
        And so our work in those countries is really catalytic
    because the resources to pay for the TB programs or pay for the
    health systems is really coming from the countries but our work
    is catalytic to make sure that--to get the right treatment,
    make sure the right treatment and diagnosis is happening.
        Mr. Smith. Mr. Garrett.
        Mr. Garrett. So, obviously, a little late getting to the
    table here. But on the subject matter of tuberculosis, I pulled
    up the Chemonics site. I want to thank you all and your staff.
        I believe that Dr. Birx, you were present on the Chemonics
    hearing and we got a wonderfully detailed series of responses
    from you all, which I would like to pretend happens all the
    time that we ask for them, but it doesn't, and I am grateful
    for that.
        And as soon as I got it, I sat down and looked up Chemonics
    to see if they were doing TB work in sub-Saharan Africa, which
    they're not. So that abates a potential line of questioning.
        But, you know, I guess what I am most interested in is the
    cost-benefit analysis as it relates to fostering desirable
    outcomes for global stability, minimum basis global human
    opportunity as within the scope of this committee and how
    addressing something that was largely eradicated, largely, in
    the United States three generations ago--my father's mother had
    tuberculosis that she contracted as a nurse during the Great
    Depression--what the cost benefit analysis is for us getting
    involved in this realm now.
        What's the good that we are--and this is in no way, shape,
    or form a skeptical question but just an opportunity to tell
    the story that we are able to do and at what cost and are we
    having success--and, again, I apologize for my tardiness--bang-
    for-the-buck wise.
        Again, PEPFAR is a success story as it relates to HIV in
    Africa, et cetera. We talked about that in a previous hearing.
        What are we doing in this realm that we need to know about,
    that we need to trumpet? When I go tell my constituents of why
    foreign aid dollars matter, why U.S. global health involvement
    matters?
        Dr. Birx. I just want to thank you for your line of
    questioning during the Chemonics group to really talking about
    efficiencies and effectiveness in programming because that is a
    very critical component to our work at all times.
        And I think the work that we described within the
    tuberculosis field is--we've done analysis not only cost
    savings for the United States but cost savings to the health
    programs in every one of these countries so they can invest
    dollars in their new and burgeoning issues that are going to
    come up.
        We know that there's this youth bulge, and so if we have
    co-infection of TB or HIV--we had a slide up before you came in
    about the undiagnosed HIV cases are all in healthy people now
    and those healthy people are all under 35, and 60 percent of
    sub-Saharan Africa will be under 20 by 2020.
        So we see that confluence of those two pieces that by
    preventing the next cycle of either HIV or TB the cost savings
    not only to us but to the health system in general for sub-
    Saharan Africa so that they can invest more and more dollars
    into their new and burgeoning, we hope, growing age expectancy
    into the 60s in the NCDs.
        Ms. Martin. Could I add to that question.
        Thank you very much, Congressman. I wanted to just add for
    our analysis we've done. For every $1 invested there's $43
    return on the investment for investing in reduction of
    mortality for TB.
        In addition, we do see multi drug-resistant in TB as one of
    the largest global health security threats in national security
    to countries both economically and in terms of trade. So I just
    wanted to mention that. Thank you.
        Mr. Garrett. Yes, ma'am.
        Ms. Koek. If I could just add one----
        Mr. Garrett. I knew you were ready.
        Ms. Koek. I hate to beat this horse to death, but just one
    more piece. The other thing about TB is a part of the global
    efforts and the global assistance that the U.S. does provide is
    more--our resources are relatively small to what countries are
    putting into their own TB programs.
        So our pieces of money, they are really catalytic and it
    really is that 80 percent of the costs are borne by countries--
    --
        Mr. Garrett. And you're--you're literally getting buy-in
    and, again, I am a fiscal hawk who leans toward shrinking
    government but I am a big advocate for foreign aid where it's
    done properly.
        And so what I want to see, and I think we are seeing here--
    and PEPFAR, again, is the great example--is the good will that
    we can export by virtue of, for lack of a better expression,
    giving a darn that manifests itself, and there are a lot of
    things that need to happen. That 60 percent of sub-Saharan
    Africa under the age of 20 by 2020 is scary in and of itself.
        Having said that, with increased education, for example,
    you see decreased birth rates. Right now, the United States
    can't, with $21 trillion in debt, shoulder this entire burden.
        But somebody's got to lead. The Chinese foreign aid model
    is give money to the oligarchs and the dictators and ours is to
    help people.
        But we need to brand it so it's clear I am asking--there's
    a question mark coming--that these are the efforts of the
    United States--that this leadership, this seed money, this 20
    percent that begets the 80 percent, is--essentially got a red,
    white, and blue USAID--not literally--label on it.
        Ms. Koek. Yes, it is, and there's a lot of recognition for
    the work we do at country level through the TB programs, in
    addition, that's complementary to the work through PEPFAR
    because it really is recognized that this is coming from the
    American people and the engagement from the U.S. Government.
        Mr. Garrett. I would commend that to continue and that you
    guys are not the enemy. We are on the same team here.
        Ms. Koek. Yes.
        Mr. Garrett. That's so important. I think you stem
    radicalization and there's certainly a lot of messaging, some
    of it within this country. Have you gone all this time without
    talking about Russian meddling?
        I am trying to identify us as something that I hope we are
    not. We need to be clear on what we are and this is a good way
    to do it. And, again, when I get with my fiscal sort of budget
    hawk crowd, I need to be able to say here's why this matters--
    that we are quantifying lives saved not just in sub-Saharan
    Africa but around the world by virtue of creating outcomes
    wherein there's hope, right, I would argue, and Chris has
    probably heard me do this 100 times, that a young person who
    wants to go to med school usually doesn't strap on a bomb vest.
        But when there's no hope, the 14-year-old will pick up the
    AK-47 for a meal. So thank you, and please continue to make
    sure that folks know not that we are, you know, hegemonic and
    all-knowing, because arrogance precedes resentment, right, but
    that we give a darn.
        So thank you.
        Ms. Martin. If I could add on that, too. I think the other
    value is the lessons that we've learned here in the U.S., being
    one of the lowest cases--countries in the world--the lessons
    we've learned in how to deal with latent TB infection and how
    we've been able to test and how to be able to identify.
        These are practices and opportunities we can share with
    other countries as well our experiences that can then be
    tailored, and this is something as well that gives us an
    opportunity to share this information. Thank you.
        Mr. Garrett. Thanks for what you do.
        Thank you, Mr. Chairman.
        Mr. Smith. Thank you.
        Dr. Martin, you had said in an article that you published
    on World Tuberculosis Day that every dollar spent on TB results
    in a $43 economic benefit to society. And, of course, if you're
    disease- or parasite-free--that's incalculable and we all want
    to be healthy.
        But in the actual dollars and cents world, we often have to
    make an argument as to why spending that next dollar or dollars
    is justifiable and that kind of analysis is helpful in prying
    loose those additional dollars.
        So if you could speak to that calculation, if you would.
    Secondly, let me ask, if I could, you know, more than half of
    the funds--roughly, $16 billion--for the global plan to
    eliminate TB by 2035 are anticipated to be raised by affected
    countries, and I am wondering if you could speak to--you know,
    are we talking about greater burden sharing and those countries
    picking up more of a piece?
        If they don't, obviously, there has to be a safety net so
    that sick people don't continue to be sick. So if you could
    speak to that.
        What countries are doing the best? I mean, we know some of
    the countries are doing the worst. We look at North Korea where
    the President just visited just recently.
        I remember being in South Korea many years ago meeting with
    a priest who actually had access to Pyongyang to treat and help
    tuberculosis patients including those who were suffering from
    drug resistance. Our Government was supportive--not to overtly
    because--but it was like an open secret that they're there just
    to help the people, and I am wondering, a country like North
    Korea where the health care grid is invisible.
        It doesn't get much worse, and the prioritization given by
    Kim is probably nonexistent. But, you know, as this drug
    resistance breaks out, obviously there are pockets. Speak to
    the worst countries of the world, if you would, as well as this
    idea of the burden sharing to meet the goals by 2035.
        Let me also ask you, if I could, what would you like to see
    included in new TB legislation? Where are the gaps, what
    haven't we met before?
        You do so much and do it so extraordinarily well by
    administrative action when there are gaps. But there probably
    are some authorities and statutory changes that you would find
    to be helpful.
        What needs to be updated in the national action for
    combatting MDR TB of 2015? Again, that would be a similar issue
    of what we can do--and what you're doing that we need to catch
    up on--if you would.
        And, again, I did ask before--maybe you can elaborate a
    little further, if you would, for the upcoming U.N. meeting,
    what does it look like? What will the plan, in your view--if
    you can share that with us--look like or is it still in a stage
    where it's not ready for publication?
        Ms. Martin. Maybe you answer this.
        Okay. I will start with the first question. On that, as
    we've said, in terms of doing the analysis of looking, that for
    every $1 that's invested in reducing mortality due to TB we do
    find a $43 savings.
        Now, this--in looking at return on investments for other
    infectious diseases, this is very comparable, but actually one
    of the higher ones in terms of being able to invest.
        And I think as Irene Koek has mentioned, we do see that
    countries are shouldering most of the burden and the cost of
    this--of 80 percent of the cost for TB are paid for by the
    countries that have the disease burden as well and that this
    will continue.
        To your point then about what's going to be needed and
    looking at to shoulder this, going forward, and what are we
    expecting countries to do, I think one of the biggest things
    that's important, and it leads into the U.N. General Assembly,
    is the political will--creating that political will and having
    that--those champions to be able to make sure that this is
    taken on as a serious issue and brought forward.
        We've seen this in some countries and you asked for some
    good examples. Looking at India--one country where we work--
    we've been working at looking at how to improve air control and
    air quality in some of the facilities.
        The model that was seen did lead to good success for
    infection prevention and control and the states has now been
    expanded to an additional seven states in India. But the
    government is picking this up and doing it themselves.
        So as we see good practices and the governments being able
    to take them on and to scale them up, our funds are seen--our
    activities are catalytic in moving forward a lot of these
    efforts.
        In thinking about what are some of the--what post-UNGA
    looks like and thinking about this, I think Irene Koek has
    mentioned very well the need for an accountability framework,
    and this is to look at progress being made globally but also
    the resources that are being tracked and being followed.
        The mention of an independent monitoring board such as
    exists for polio eradication is one example of moving this
    effort forward. But it would have to make sure that there is
    some accountability and I think U.S. leadership in this is
    critical and appreciate you keeping this on the agenda to move
    these efforts forward, and thank you for your work in that.
        The other big piece, I think, as we've mentioned, is
    engaging the civil society, the faith-based organizations, and
    really looking at well, how U.S. commitment can be leveraged by
    other countries to get them more engaged as well as to step up
    and ensure that we continue our resources globally for the
    efforts that are needed.
        I will stop there for now. Thank you.
        Ms. Koek. Just building on some of your questions, on the
    $16 billion I don't have the global plan in front of me and
    we'd be happy to share that. But exactly as Dr. Martin said, 80
    percent of it does come from countries.
        Now, a significant share from the administrative health
    budget, if you will, but there's also a concern that a fair bit
    of that also comes from out-of-pocket expenditures, and since
    TB really does affect the poorest of the poor, we want to make
    sure that they're not being driven into complete poverty by TB.
        So looking at those details at a country level is really,
    really important. But I would be happy to share what we have on
    that, as we go forward.
        Mr. Garrett. Yes, if you don't mind. You have really given
    me a great segue. So we know that TB affects the poorest of the
    poor and we know that we try to tie our aid to the economic
    achievement in a country because it's more reasonable to demand
    that, say, South Africa chip in than maybe one of their
    neighbors to the north who might not have the opportunity
    toward economic prosperity that, say, the mining has
    perpetually sort of brought to South Africa.
        But all fruit aren't apples and so in South Africa, for
    example, in the Rand buildup around Pretoria you have got sort
    of a transient population based on economic opportunity that
    exists within the mining employment community and therefore a
    heightened risk of transmission and then travelling outward.
        How do you make sure we are not doing a one-size-fits-all
    and saying well, South Africa has achieved this level of
    economic achievement, therefore, they need to carry this
    burden, when perhaps we might be more effective in addressing
    the spread if we target sort of the hotbeds of transmission,
    right, which exists there.
        And then, secondarily and tangentially, I've been--the
    health minister in South Africa has kind of taken a role here.
    If you can sort of tie that in in your response. I was going to
    say Aaron's last name but then I would say it wrong and----
    [laughter]--we learned it by reading.
        Ms. Koek. Thank you, because that actually leads into an
    answer to one of Chairman Smith's other questions because----
        Mr. Garrett. Teamwork.
        Ms. Koek [continuing]. South Africa is a really good
    example both of a success story and given the strong leadership
    we've seen from Mr. Motsoaledi in the government and even
    courteous I've had practice, sir, on it--[laughter]--and
    they've worked--the government and the minister of health has
    worked really closely with the mining industry to make sure
    that because it is--mines are a hotbed of TB, right, and miners
    do go back to their homes where--which might be much poorer--so
    making sure they're--the miners are tested and started on
    treatment and the treatment is followed as they go home so
    they're not taking TB back to their communities. So we have a
    very, very strong program on that partnership with the mining
    industry.
        Our work in South Africa is, you know, minuscule compared
    to--in terms of dollar amount. You know, it builds on the work
    that Ambassador Birx is doing through PEPFAR around TB--that it
    really is that kind of partnership Ambassador Birx talks about
    before--that it is meant to catalyze what the Government of
    South Africa is doing.
        And exactly as you say, that work in South Africa is much
    more catalytic and much smaller relative to what we might need
    to do in a much more poorer country. We are trying to work also
    with the global fund grants in those countries to make sure
    they're----
        Mr. Garrett. And one of the problems of government
    inherently, in my experience--and I think you guys do a bang-up
    job here--but is that we do create a one-size-fits-all paradigm
    wherein sometimes we let things fall out.
        So that's to be commended you have identified really the
    problem and--because, yeah, I mean, on an economic achievement
    scale and by virtue of natural resources that are really, in
    certain areas, unparalleled, but and--so yes.
        Ms. Koek. Just on that----
        Mr. Garrett. Avoiding the ``this is the way we do it so
    this is the way we should do it'' thing, which I think you're
    doing.
        Ms. Koek. On that point because it's really an important
    one, and one-size-fits-all really doesn't work for something
    like TB as it does for anything else.
        So we work really closely with our counterparts at country
    for--they'll have a strategy for how to deal with TB--where are
    the--where is the burden the greatest--where are the patients
    most--where do we need to do the most work. So working within
    that----
        Mr. Garrett. Now if we could just get you guys----
        Ms. Koek [continuing]. Country level strategy is what
    happens, and it really does vary from one country to another.
        Mr. Garrett. We just need to get you guys to work on K-12
    out here in the states.
        Dr. Birx. Just quickly, because I think it ties some of
    your pieces together and you talk about what things should look
    like.
        I mean, what we've learned in PEPFAR is this political will
    and transcending that political and to really focusing domestic
    and global resources where the need is the greatest. And I
    think you point out a really critical issue.
        Oftentimes, in opposition areas, in informal settlements,
    there is not that same attention to the most vulnerable who are
    at higher risk for HIV and TB, and we need to link our
    catalytic funds to these kind of policy changes and investments
    that are linked to where the need is the greatest and I think
    holding countries accountable to investing in this
    accountability framework needs to be linking where diseases are
    and where investments are because we often see that those
    aren't always in complete alignment and I think that's really
    important.
        And I think when you talked about education of the health
    care workers and that importance, the piece of this within the
    FBOs that I think we haven't paid enough attention to in the
    last decade is the alignment with the churches and engagement
    with the churches.
        We have to get education back into the churches around
    these core diseases. They can be critical and identify the most
    vulnerable in the community that aren't getting adequate access
    to either health care or the resources that they need and I
    think the FBOs have been tremendous but we need to engage
    directly the pastors in the churches in a real way.
        Mr. Smith. Before I yield to Mr. Castro, on that point--on
    one trip to Nigeria that I made during the previous
    administration, we had about $500 million health care budget.
    So I asked how much of that in Nigeria, like much of Africa if
    not all of sub-Saharan Africa is being allocated toward faith-
    based entities.
        I had just left Jos, where churches have been firebombed
    and Archbishop Kaigama had a HIV/AIDS or a PEPFAR program
    pulled from him, which was absolutely inexplicable for
    orphans--100 orphans--and all of a sudden there's no more
    money.
        I never got an answer, ever. But I asked how much of that
    money--the $500 million--has been broken out for faith-based
    work in Nigeria, and it was about 7 percent, 8 percent. Just
    that has to change and is changing, like I know.
        I would like to yield to Mr. Castro.
        Mr. Castro. Thanks. Thank you for your testimony and thank
    you for being here and for all the work that you're doing in
    Africa and, I am sure, in different parts of the world.
        I am told by my grandmother--I was told back then that her
    mother died of tuberculosis in Mexico around 1922--early 1920,
    and I notice that there has been about a 26 percent cut in the
    President's budget request in 2018 from 2017.
        And so let me ask you what would be the impact--the human
    impact of the work that you do and how many more people
    wouldn't get served if that in fact ends up being the cut that
    we sustain?
        Ms. Koek. Thank you, sir, and I really do want to
    appreciate and thank the strong support we've received from
    Congress for the TB program. So I think you're aware the budget
    request did reflect an overall constrained budget environment.
        However, the resources that were in that even reduced
    request would be targeted to the highest priority countries for
    us where the biggest burden is.
        So I can't quite do the calculation on how many people
    would not do services, but given that our work really is
    catalytic, meant to be for--at country level, we would really
    try to prioritize among those high burden countries and try to
    really make sure that the resources went as far as they could.
        Mr. Castro. But you agree that less people will get served?
        Ms. Koek. I would imagine so. It would have to be a
    calculation. We'd have to.
        Mr. Castro. Sure. Yes, I guess I can submit for the record
    an analysis, I mean, if there's 400,000 people each year in
    Africa that die from tuberculosis. So I will submit a question
    for the record on the human impact of the 26 percent cut if it
    in fact goes through.
        Let me ask you, the chairman sent out a memo that has the
    rankings of the top 10 causes of death worldwide and but do you
    know with respect to Africa where TB ranks? This is a worldwide
    ranking, but do you know where it ranks in terms of Africa?
        Dr. Birx. Right now, it's the primary infectious disease
    cause of death because of the high HIV-driving component to
    that. So we believe, as we control the HIV pandemic, we will
    control the TB pandemic in sub-Saharan Africa in those
    countries where it's being dual driven.
        Ms. Martin. I was just going to add as well, I think the
    other piece that we see is that the increased drug resistance
    occurring as well and also the importance of as we see it being
    one of the leading causes that as well is if people are not
    treated and if people don't finish treatment, the opportunity
    for drug resistance to grow and to increase and the impact of
    that as well increases in terms of being able to treat them and
    the cost to treat them as well.
        Mr. Castro. All right. Thank you.
        I yield back.
        Mr. Smith. Thank you, Mr. Castro.
        Let me just ask one final question. You know, there is an
    enhanced vulnerability of women who are pregnant to TB and, you
    know, from my point of view, I believe that there are two
    patients when the woman is pregnant--both the unborn child and
    the mother--and everything humanly possible should be done to
    enhance their health.
        That's why this committee and I and my staff are so
    absolutely committed to the first 1,000 days from conception to
    the second birthday so the children and the women--the
    mothers--are as healthy as humanly possible.
        And I am wondering, is there any special protocol necessary
    to ensure that the woman's health is protected and strengthened
    if she were to get TB while she's pregnant?
        And, of course, what are the vulnerabilities to the baby in
    terms of transfer of the disease?
        Dr. Birx. I will start. I am glad you picked up on that
    because we've also noticed that within HIV. There's a unique
    high rate of susceptibility--it was just published in an
    abstract at CROI just a few months ago--of women in their last
    tri semester and in those first 6 months after delivery, and we
    are trying to really understand that.
        And so this increased intensity of oversight and screening
    both for TB and HIV will be absolutely critical because,
    obviously, it's much more important to the pregnant woman to
    prevent the disease from ever occurring because the drugs, as
    all drugs, have toxicity across the board and, certainly, MDR
    drugs have particularly toxicity.
        So it's more about making sure that women remain healthy be
    ensuring they come into the pregnancy healthy and their immune
    system is intact so that you can prevent the occurrence of
    reactivation of TB.
        Mr. Smith. Thank you. Okay.
        Anything further any of you would like to say? And, again,
    your recommendations on legislation would be very well
    appreciated.
        Yes, Dr. Martin.
        Ms. Martin. Thank you.
        I just wanted to respond to Congressman Garrett's question
    too about not one-size-fits-all and how do you identify those
    areas, and I think this is the importance of surveillance and
    the importance of being able to hone in and know what's
    happening, having those data to be able to use in real time to
    know where those hot spots are--to know what we can then do to
    focus as opposed to blanketing everywhere how you can really
    hone in, and that requires that we have and that countries have
    those data available and the importance of surveillance to be
    able to detect and the laboratory work to be able to know the
    confirmation.
        Thank you.
        Mr. Smith. I just--oh, yes, Ms. Koek.
        Ms. Koek. I would just say one thing on legislation. I
    think the most important thing from legislation would be it's
    the signal it sends of the importance of something like TB, and
    just as this hearing has been a really important signal about
    why this is such an issue that requires the attention.
        So we very much appreciate your time on that.
        Mr. Smith. Thank you.
        Your testimonies and the information as well as the
    questions and those that we'll submit we do share with the
    appropriators who are always looking for insights, so we will
    expand this to other Members of Congress so that they know just
    how important this is.
        But, again, thank you for your leadership. I would just
    conclude by saying that sustainable political will coupled with
    compassion and competent leadership is the reason, I believe,
    why the HIV/AIDS pandemic, which Henry Hyde, the author of that
    legislation--it was George Bush and Henry Hyde and all of us
    behind them, but they were the leaders--I remember Henry Hyde
    telling all of us in a Republican caucus that he did it
    frequently from the chair that this is the equivalent of
    bubonic plague--that unless very, very aggressive actions are
    taken, this will get--it's already awful--it will get far
    worse.
        And he was a driver like no other, as Bush was right there,
    of course, leading, and it shows that where there's a political
    will, where that compassion exists and you have competent
    leadership like you, it makes all the difference in the world.
        So thank you. You have friends here on the Hill. It's
    bipartisan, and we'll do everything we can to support you,
    following your lead.
        The hearing is adjourned.
        [Whereupon, at 4:08 p.m., the committee was adjourned.]

                                A P P E N D I X

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             Material Submitted for the Record

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

    [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

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

    [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]