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