    [House Hearing, 118 Congress]
    [From the U.S. Government Publishing Office]

                   MEETING THE CHALLENGES OF GLOBAL BRAIN
                     HEALTH: DIAGNOSIS AND TREATMENT FOR
                     THE 21ST CENTURY
    =======================================================================

                                    HEARING

                                   BEFORE THE

                      SUBCOMMITTEE ON GLOBAL HEALTH, GLOBAL
                       HUMAN RIGHTS AND INTERNATIONAL ORGANIZA-
                       TIONS

                                     OF THE

                          COMMITTEE ON FOREIGN AFFAIRS
                         U.S. HOUSE OF REPRESENTATIVES

                        ONE HUNDRED EIGHTEENTH CONGRESS

                                 SECOND SESSION

                                   __________

                               November 20, 2024

                                   __________

                               Serial No. 118-136

                                   __________

            Printed for the use of the Committee on Foreign Affairs

    [GRAPHIC NOT AVAILABLE IN TIFF FORMAT]

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

                                   __________

                            U.S. GOVERNMENT PUBLISHING OFFICE
    63-407 PDF                     WASHINGTON : 2026
    =======================================================================

                          COMMITTEE ON FOREIGN AFFAIRS

                       MICHAEL T. McCAUL, Texas, Chairman

    CHRISTOPHER H. SMITH, New Jersey     GREGORY MEEKS, New York, Ranking
    JOE WILSON, South Carolina               Member
    SCOTT PERRY, Pennsylvania            BRAD SHERMAN, California
    DARRELL ISSA, California             GERALD E. CONNOLLY, Virginia
    ANN WAGNER, Missouri                 WILLIAM KEATING, Massachusetts
    BRIAN MAST, Florida                  AMI BERA, California
    TIM BURCHETT, Tennessee              JOAQUIN CASTRO, Texas
    MARK E. GREEN, Tennessee             DINA TITUS, Nevada
    ANDY BARR, Kentucky                  TED LIEU, California
    RONNY JACKSON, Texas                 SUSAN WILD, Pennsylvania
    YOUNG KIM, California                DEAN PHILLIPS, Minnesota
    MARIA ELVIRA SALAZAR, Florida        COLIN ALLRED, Texas
    BILL HUIZENGA, Michigan              ANDY KIM, New Jersey
    AUMUA AMATA COLEMAN RADEWAGEN,       SARA JACOBS, California
        American Samoa                   KATHY MANNING, North Carolina
    FRENCH HILL, Arkansas                SHEILA CHERFILUS-McCORMICK,
    WARREN DAVIDSON, Ohio                    Florida
    JIM BAIRD, Indiana                   GREG STANTON, Arizona
    MICHAEL WALTZ, Florida               MADELEINE DEAN, Pennsylvania
    THOMAS KEAN, JR., New Jersey         JARED MOSKOWITZ, Florida
    MICHAEL LAWLER, New York             JONATHAN JACKSON, Illinois
    CORY MILLS, Florida                  SYDNEY KAMLAGER-DOVE, California
    RICH McCORMICK, Georgia              JIM COSTA, California
    NATHANIEL MORAN, Texas               JASON CROW, Colorado
    JOHN JAMES, Michigan                 KWEISI MFUME, Maryland
    KEITH SELF, Texas                    BRAD SCHNEIDER, Illinois
    RYAN K. ZINKE, Montana
    JAMES C. MOYLAN, Guam

                    Brendan Shields, Majority Staff Director

                    Sophia Lafargue, Minority Staff Director
                                     ------

     SUBCOMMITTEE ON GLOBAL HEALTH, GLOBAL HUMAN RIGHTS AND INTERNATIONAL
                                 ORGANIZATIONS

                    CHRISTOPHER SMITH, New Jersey, Chairman
    MARIA SALAZAR, Florida               SUSAN WILD, Pennsylvania, Ranking
    AMATA RADEWAGEN, American Samoa          Member
    FRENCH HILL, Arkansas                AMI BERA, California
    RICH MCCORMICK, Georgia              SARA JACOBS, California
    JOHN JAMES, Michigan                 KATHY MANNING, North Carolina

                           C  O  N  T  E  N  T  S

                                  ----------

                                REPRESENTATIVES

                                                                       Page
    Opening Statement of Subcommittee Chairman Christopher H. Smith..     1
    Opening Statement of Representative Ami Bera.....................     4

                                   WITNESSES

    Statement of Gladys E. Maestre, M.D., Ph.D., Director,
      Alzheimer's Disease Resource Center for Minority Aging
      Research, University Of Texas..................................     6
      Prepared Statement.............................................     8
    Statement of Benjamin C. Warf, M.D., Chairman, Neurokids.........    17
      Prepared Statement.............................................    19
    Andy Shih, Ph.D., Chief Science Officer, Autism Speaks...........    23
      Prepared Statement.............................................    26
    Statement of Yashodhara Rana, Ph.D., Associate Director of
      Research, Eleanor Crook Foundation.............................    29
      Prepared Statement.............................................    31

                                    APPENDIX

    Hearing Notice...................................................    52
    Hearing Minutes..................................................    54
    Hearing Attendance...............................................    55

                            Materials for the Record

    Alzheimer's Assoc. and Alzheimer's Impact Movement Statement,
      submitted by Rep. Smith........................................    56
    Statement for the record, submitted by Rep. Susan Wild...........    62

                            Questions for the Record

    Questions submitted to Andy Shih by Rep. Smith...................    66
    Questions submitted to Benjamin C. Warf by Rep. Smith............    68
    Questions submitted to Gladys E. Maestre by Rep. Smith...........    73
    Questions submitted to Gladys E. Maestre by Rep. McCormick.......    78

    MEETING THE CHALLENGES OF GLOBAL BRAIN HEALTH: DIAGNOSIS AND TREATMENT
                              FOR THE 21ST CENTURY

                                  ----------

                          Wednesday, November 20, 2024

                      House of Representatives,
    Subcommittee on Global Health, Global Human Rights,
                       and International Organizations,
                                  Committee on Foreign Affairs,
                                                        Washington, DC.

        The subcommittee met, pursuant to notice, at 2:30 p.m., in
    room 2172, Rayburn House Office Building, Hon. Christopher H.
    Smith (chairman of the subcommittee) presiding.

           OPENING STATEMENT OF CHAIRMAN CHRISTOPHER H. SMITH

        Mr. Smith. Good afternoon. The subcommittee hearing of the
    Global Health, Global Human Rights, and International
    Organizations will come to order. And first let me apologize
    for the lateness. I was on the floor along with Kathy Manning
    with a couple of bills that she sponsored and one that I
    sponsored, so I do apologize and it just finished, so please
    accept my apologies. And thank you so very, very much for being
    here.
        Without objection, the chair is authorized to declare a
    recess at any point and all members will have 5 days to submit
    statements, extraneous material, and questions for the record,
    subject to the length limitations of the rules. I note the
    presence of a quorum and I now recognize myself for an opening
    statement.
        Today, we turn our attention to the vitally important issue
    of global brain health with the specific focus of Alzheimer's
    disease, autism spectrum disorders, and hydrocephalus. Global
    brain health is critically neglected. The United States is the
    leader in health assistance globally with foreign assistance
    that has saved millions of lives through programs that target
    malaria, HIV/AIDS, tuberculosis, and many, many other diseases
    and infectious diseases as well. But comparatively, brain
    health is overlooked and misunderstood.
        A major new study shows that more than three billion people
    worldwide live with a neurological condition. Neurological
    conditions are the leading cause of poor health and disability
    globally. I would note parenthetically that my wife deals with
    a very rare disease that is known as Marfan's disease. It has
    to do with brain encephalitis. She is doing very well
    overcoming it, but it is everywhere and it is not being, I
    don't think, adequately addressed on a global scale at least by
    our Government.
        As life expectancy grows and healthcare costs rise,
    policymakers must consider the looming health crisis of brain
    diseases and disorders, especially in low-and middle-income
    countries. I have introduced my bill, the Global Brain Health
    Bill in Congress after Congress after Congress and have not
    been able to get it passed, but I am absolutely determined that
    in the next Congress we will see it come to fruition.
        Take Alzheimer's disease. Alzheimer's is the most common
    form of dementia, usually affecting persons aged 60 and older.
    As we all know, it is degenerative, irreversible, and a
    terrible disease that progressively corrodes the brain's
    memory, thinking, and reasoning skills. Currently over 55
    million people worldwide live with a form of dementia and 60
    percent of those are in developing countries. With life
    expectancy on the rise, a tsunami of Alzheimer's cases is on
    the global horizon. In 2011, when I chaired the very first
    congressional hearing on the topic of the global crisis of
    Alzheimer's disease, projections estimated at 80 million people
    would get Alzheimer's or another form of dementia by 2050. In
    2015, the projection was revised to a whopping to 115 million.
        Today, Alzheimer's Disease International estimates 139
    million cases of dementia by 2050 and again, things are getting
    worse, not better. This increase will be felt more drastically
    in the low-and middle-income countries as populations grow
    rapidly and life expectancy, good news story, lengthen.
        One recent study found that dementia cases in Sub-Saharan
    African will grow by over 300 percent. Low-and middle-income
    countries will struggle to manage this health challenge due to
    a small and untrained health workforce and inadequate and
    inaccessible care.
        Little public awareness and health professional training on
    the signs and symptoms of Alzheimer's pose a challenge. A
    global study by Alzheimer's Disease International found that
    over two-thirds of people incorrectly think that Alzheimer's
    and other forms of dementia are just normal parts of aging. As
    the co-founder and co-chair of the congressional Alzheimer's
    Task Force, Ed Markey and I formed it back in the year 2000. We
    have maintained--I have maintained and we have maintained for
    over a decade that the administration of both parties must pay
    more careful attention to this mounting crisis. Yes, we have
    provided more money to NIH. There has been a quadrupling of
    funding for research and that is absolutely welcome, but more
    needs to be done, again, on the international level.
        I also co-chair the congressional Autism Caucus which I
    founded in 1999 and I authored the Autism Statistics
    Surveillance Research and Epidemiology Act, a bill to authorize
    grants and contracts for the collection, analysis, and
    reporting of data on autism and pervasive developmental
    disabilities and establish regional centers of excellence in
    autism and epidemiology. Passed as part of the Child Health Act
    in 2000, it was offered as an amendment by yours truly, this
    provided the basis for future iterations of autism legislation
    including the Autism Cares Act.
        Earlier this year, the House passed my bill, H.R. 7213, the
    Autism Cares Act of 2024 and I am happy to say after it was
    blocked in the Senate, that block seems to have been lifted and
    maybe as early as tonight they may unanimous consent the bill,
    both sides through the hotline procedure, have agreed to it, so
    it will become law. And it is a substantial, not only
    reiteration of current policy and reauthorization, but an
    expansion as well.
        About 1 in 100 children all around the world it is
    estimated have autism, a spectrum disorder marked by degrees of
    difficulty with social interaction and communication. While
    research and care for autism has improved in wealthier
    countries, such as the U.S. and including chronically how many,
    it is seriously neglected in much of the developing world. For
    many living in low-income countries, care is often
    inaccessible. I will never forget I had a mother was from Cote
    d'Ivoire at one of my hearings on global autism and she
    testified and said I couldn't get any help for my son until she
    moved and migrated to Ohio and then received a plethora of very
    good intervention and her son was performing and doing very
    well. There was autism in their family. They were off often
    socially isolated and stigmatized. Some communities attribute
    autism to witchcraft which is horrible.
        The United States can play a vital role in supporting
    developing countries and addressing autism spectrum disorders
    by raising awareness, developing culturally appropriate
    screening tools, and training parents, teachers, and healthcare
    professionals on interventions so as to improve the lives of
    individuals with autism.
        Last Congress, I also introduced the Global Autism Act
    which would establish a program within USAID. I hope to update
    that and reintroduce that in the next Congress and hopefully we
    will have some success there.
        Finally, our third very important topic of discussion will
    be on the issue of hydrocephalus. Hydrocephalus is a condition
    where fluid buildup in the brain leads to swelling of the head
    and serious brain damage that often ends in death.
    Hydrocephalus is a tragically common childhood condition. There
    are nearly half a million cases annually and perhaps many, many
    more. The most precious gifts in our society, our emphasis on
    children are the most vulnerable when it comes to hydrocephalus
    and yet this condition also affects our elderly.
        Once again, hydrocephalus plagues infants in the developing
    countries and again we have a man here today who, Dr. Benjamin
    Warf, who has been before our committee before, who developed
    an amazing procedure that has been applied in Uganda and
    throughout Africa that doesn't require a stent. It has
    revolutionized the effort. And I will never forget, we had a
    few of the doctors that he worked with, including indigenous
    Ugandans, who testified via remote as well as in person and
    they said when the moms got their kids back and the pain, as
    well, is mitigated and ended through this, the flow of tears
    was just almost unimaginable.
        So Dr. Warf, you have been a lifesaver. You all have been.
    But you have been a lifesaver when it comes to hydrocephalus
    and we thank you. I thank you. We all thank you for the great
    work you have done.
        I will introduce our very, very fine group of individuals
    in a moment, but I would like to yield to Dr. Bera for any
    comments you may have.

              OPENING STATEMENT OF REPRESENTATIVE AMI BERA

        Mr. Bera. Thank you, Mr. Chairman. And I know the Ranking
    Member, Ms. Wild, is tied up as Ranking Member in the Ethics
    Committee and will join us as soon as she can. She has got an
    opening statement.
        But again, thank you for holding this hearing on an
    incredibly important topic.
        I am going to focus mostly on Alzheimer's disease with
    regards to brain health. As the chairman pointed out, the
    number of people living with Alzheimer's disease and dementia
    is projected to triple from over 55 million people today to
    more than 152 million by 2050. The cost of Alzheimer's disease
    and dementia to the global economy is $1.3 trillion in 2019 and
    it will continue to grow exponentially in the coming years as
    demographic transitions lead to an aging global population.
        And while the U.S. Government has increased the domestic
    R&D budget on Alzheimer's at the NIH by tenfold over the last
    decade from $400 million to $4 billion, there is currently no
    funding for global Alzheimer's and dementia programs at the
    global level. So as a doctor, I have seen acutely and as an
    internist, I am acutely aware of how Alzheimer's disease and
    dementia affect not only the patient, but also the impact it
    has on the caregivers and the family and disproportionally in
    cases affect the female population.
        In our district, we have held nine annual brain health
    forums working with our local Alzheimer's association to
    provide our constituents with information and resources on the
    latest Alzheimer's research and what is available to them to
    assist caregivers and persons living with Alzheimer's or other
    dementias. That said, however, nearly all Alzheimer's research
    has been conducted on Caucasian populations of lesser European
    origin leaving out 90 percent of the world which has
    significantly limited progress.
        That is why today I introduced the bipartisan Global
    Alzheimer's Initiative Now, or the GAIN Act, alongside my co-
    leads, Representative Brian Fitzpatrick and Young Kim. The GAIN
    Act will authorize U.S. participation in and contributions to
    the Davos Alzheimer's Collaborative. The Davos Alzheimer's
    Collaborative, or DAC, was launched in 2021 as the first global
    alliance of governments, nonprofits, academia, and the private
    sector driving efforts to combat Alzheimer's disease. DAC aims
    to invest over $700 million over 6 years to link, scale, and
    build on existing efforts across every sector, and foster an
    innovative ecosystem to coordinate and accelerate the pace of
    innovation and Alzheimer's disease research and care and to
    improve brain health globally to achieve equitable and
    accessible healthcare.
        It is critical at this time that we leverage U.S. resources
    to most effectively combat the step saving disease for our
    constituents, their families and individuals impacted by
    Alzheimer's disease and dementia around the world. I look
    forward to hearing testimony and again, thank you for holding
    this hearing. I yield back.
        Mr. Smith. It is now my honor to introduce our very
    distinguished witnesses beginning with Dr. Gladys Maestre who
    is the Director of the Rio Grande Valley Alzheimer's Disease
    Resource Center for Minority Aging Research. She is a
    physician, scientist, who has devoted much of her professional
    life to Alzheimer's research in low-resource settings. Her
    research has explored cultural, educational, and genetic risks
    for Alzheimer's disease and cognitive decline, as well as
    cognitive function and health among minorities and ethnically
    diverse populations. Dr. Maestre was also the Co-Director of
    the South Texas Alzheimer's Disease Resource Center where she
    focuses on personalized medicine's approaches to improve
    prevention, treatment, and care for patients with Alzheimer's
    disease and related dementia.
        Dr. Benjamin Warf is the founding Chairman of NeuroKids, a
    nonprofit organization established in the year 2020 that exists
    to help children with hydrocephalus and spina bifida in low-
    resource countries. Dr. Warf is also a Professor of Neurology
    at Harvard Medical School and Director of Neonatal and
    Congenital Anomalies Neurosurgery at Boston Children's
    Hospital. He served as Chief Pediatric Neurosurgery and
    Director of Surgical Education at the University of Kentucky
    Medical Center in 2000 when he and his wife and six children
    moved to Uganda as a medical missionary with Cure International
    to be the founding medical director of a pediatric neurosurgery
    specialty hospital. While there, Dr. Warf developed and
    validated a new endoscopic neurosurgical procedure to treat
    infant hydrocephalus known as ETV/CPC and I will leave it to
    you to say what that stands for. He is also the first to
    identify neonatal infection as the most common cause of infant
    hydrocephalus in East Africa. And again, has been before this
    committee several times and has been amazing with the
    leadership he has provided.
        Dr. Andy Shih is the Chief Science Officer at Autism
    Speaks, an organization we work very closely with on the Autism
    Caucus and I want to thank him. Dr. Shih has led important
    advancements toward the organization's mission including the
    development of several large international research consortia
    that delivered high impact scientific outcomes for the
    community. He was essential to the 2008 passage of the World
    Autism Awareness Day Resolution at the U.N. and subsequently
    led to the development of the Global Autism Public Health
    Initiative that provides technical support to country
    governments to enhance autism awareness advocacy and services
    worldwide. His leadership at Autism Speaks supports ministries,
    governments, agencies, and leading non-government organizations
    in more than 70 countries to deliver better outcomes. And of
    course, we all remember when G20 adapted a very, very
    monumental and you played such a role in it, to have a change
    in direction to come up with something that will ameliorate
    autism by 2025. It was a very, very important pivot and it
    helped us, all of us in countries and governments around the
    world to focus additional resources saying we have a target
    date, let's try to achieve it.
        And then we have Dr. Yashodhara Rana, who serves as the
    Associate Director for Research at the Eleanor Crook
    Foundation. In this role, Dr. Rana oversees ECF's multi-million
    dollar portfolio of grants in maternal and child nutrition and
    provides thorough leadership both to the ECF team and its
    community of partners. She is currently a member of the Power
    of Nutrition Technical Advisory Group and serves as a member of
    the Editorial Board of Maternal and Child Nutrition Journal.
        Prior to ECF, Dr. Rana was Associate Director at the
    Results for Development overseeing a nutrition team's data and
    learning practices. There, Dr. Rana led DataDENT, a 5-year
    initiative aimed at strengthening the nutrition data value
    chain and informing the African Development Bank's nutrition
    strategy in costing and financial analyses.
        Thank you all for being here. The testimony you will
    provide will be incredibly useful going forward as well as
    starting today. Dr. Maestre.

                     STATEMENT OF GLADYS E. MAESTRE

        Dr. Maestre. Chairman Smith, Ranking Member Wild, and I am
    pretty sure she is going to look at this, Dr. Bera,
    distinguished members of this committee, it is an honor to
    testify before you today. To harness the promise of science to
    mitigate the suffering of the millions experiencing Alzheimer's
    dementia across the globe, we need to advance scientific
    knowledge, but also design the infrastructure and resources
    required to make this promise a reality.
        A comprehensive, cohesive global agenda will allow our
    Nation to leverage the momentum that the national plan to
    address Alzheimer's Disease Act, known as NAPA, and the
    Alzheimers Accountability and Investment Act have facilitated.
    This bill was recently reauthorized with unanimous support in
    Congress. We are grateful to you, Chairman Smith, and all
    Members of the Congress who have championed and continue to
    support this bill, and Dr. Bera, for that initiative.
        As a result of these investments, seminal advances were
    made in diagnosing and treating Alzheimer's disease. For
    example, we now know that Alzheimer's begins 20 years or
    earlier before memory loss or other symptoms develop. And in an
    unprecedented move, the FDA approved two treatments that can
    modify some changes in the brain of Alzheimer's dementia
    patients.
        We are moving toward incorporating biomarker detection for
    Alzheimer's disease into routine preventive health care. Even
    though many aspects still needs to be clarified, we can now
    detect brain changes in vivo by measuring cerebrospinal fluid
    and plasma molecules. We refer to these molecules as biomarkers
    and they may function similarly to prostrate specific antigens,
    PSAs, where elevated levels from further assessments to rule
    out disease.
        Our global brain health agenda needs to be cohesive and
    should take advantage of the momentum and consider the
    following facts. First, Africa, the most genetically diverse
    continent, offers a vast, yet under utilized resource for
    studying how genetic and environmental factors contribute to
    chronic and infectious diseases. While the African diaspora in
    the U.S. is growing, it represents a fraction of the genetic
    diversity found on the continent.
        Second, the risk factors affecting every brain disease vary
    across ethnic groups due to genetic and cultural differences.
    However, most studies focus on European populations, limiting
    their applicability to other groups. For instance, ApoE, the
    most common genetic risk factor for Alzheimer's in Europeans,
    has minimal impact on African Americans or Hispanics.
        Third, without the knowledge of disease etiology in the
    ancestral source populations, our ability to fully address the
    needs of African Americans who are also experiencing a rising
    life expectancy remains limited.
        China and the U.S. compete for a strategic influence in
    Africa and Latin America, includes U.S. investment in health
    research and infrastructure offers a strategic, cost effective
    way to counter China's advance and rebuild trust in the global
    south. One example of this that we have done in Latin America
    is the Maracaibo Aging Study in Venezuela. Despite efforts to
    move from programs, projects, to a cohesive strategy, brain
    health, especially Alzheimer's, still lacks a clear, global
    agenda.
        I urge you to consider a global strategy to advance
    Alzheimer's research that benefits all people in America and it
    strengthens the U.S. position in African and all lower-income
    regions. This approach may leverage NIH funded programs that
    combine research training with community engagement such as the
    Resource Centers for Minority Aging Research, the RCMAR, and
    the Alzheimer's Disease Research Centers, ADRCs, and the
    Diversity Centers for Genomic Research.
        Partnership with Alzheimer's Associations and other patient
    advocacy groups, as well as professional societies like the
    Gerontological Society of America are instrumental in
    implementing a concerted agenda.
        Finally, we must develop a pipeline of experts in both
    brain health and foreign affairs. With over 250 North American
    universities offering global health education, we have the
    means to do that.
        Thank you very much for the opportunity to testify today. I
    look forward to answering any questions you may have.
        [The prepared statement of Dr. Maestre follows:]
        [GRAPHIC NOT AVAILABLE IN TIFF FORMAT]

        Mr. Smith. Thank you very much, Doctor, and your very, very
    lengthy and scholarly testimony will be made a part of the
    record and any other extraneous material you want to include in
    the record. Dr. Warf.

                      STATEMENT OF BENJAMIN C. WARF

        Dr. Warf. Thank you, Mr. Chairman and Dr. Bera and other
    members that will be listening. Thank you for this invitation.
    It is an honor as always. And thank you, Mr. Chairman, in
    particular, for your commitment and support over the last many
    years now. It is very valuable and very much appreciated.
        Hydrocephalus is a common childhood condition that can be
    devastating or even fatal. The good news is that it is
    treatable. The bad news is that children in much of the world
    either get sub-optimal treatment or no treatment at all. The
    normal brain contains fluid-filled spaces called ventricles
    that communicate with the fluid space outside the brain.
    Anything that disrupts this circulation can cause a fluid
    called CSF, or cerebral spinal fluid, to accumulate within the
    ventricles which then enlarge under pressure. That is
    hydrocephalus. There are many causes of hydrocephalus. Some
    cases are congenital. And others are secondary to another
    condition.
        In resource-poor countries, the two most common causes are
    neonatal infection and neural tube defects, commonly referred
    to as spina bifida. Together, these account for about two
    thirds of all causes of hydrocephalus in the developing world.
    Thus, a great deal of hydrocephalus could be prevented by
    reducing the incidents of newborn infections and spina bifida.
    Hydrocephalus is the most common condition treated by pediatric
    neurosurgeons, with close to one half million new cases per
    year. But it is tragically most common among those children who
    have the least access to treatment. The incidence of congenital
    hydrocephalus is highest in Africa and Latin America and it is
    lowest in the United States and Canada.
        When you include cases related to neonatal infection and
    neural tube defects, the annual case volume in resource-poor
    countries is more than 20 times that for high-income countries.
    Three quarters of the world's case volume of childhood
    hydrocephalus can be found in Latin America, Africa, and
    Southeast Asia.
        Infant hydrocephalus, whatever its cause, results in
    expansion of the brain's ventricles which stretch and compress
    the surrounding brain tissue causing mechanical injury and
    decreased blood flow. The head enlarges dramatically and the
    child suffers from progressive symptoms and about half will die
    without treatment within 2 years. Survivors typically have
    severe neurocognitive disabilities and spasticity and
    blindness. Untreated hydrocephalus is also costly. The
    estimated annual economic burden of untreated infant
    hydrocephalus in Sub-Saharan Africa is between 1.4 and 56
    billion U.S. dollars per year using the value of a statistical
    life method. The estimated benefit-to-cost ratio for treatment
    is more than seven to one which is more than some of the other
    interventions that are more commonly performed.
        The standard and most widely practiced treatment for infant
    hydrocephalus is to implant a tube called a shunt, that allows
    CSF to escape from the brain's ventricles to the abdominal
    cavity, but 60 percent of shunts will have failed at least once
    within in the first 4 years and the risk of failure which can
    be life threatening never ends. A minimally invasive endoscopic
    brain operation caused ETV/CPC which stands for endoscopic
    third ventriculostomy and choroid plexus cauterization, which
    is why we call it ETV/CPC, can permanently treat infant
    hydrocephalus without the need for a shunt in around two out of
    three infants and has been shown at least as effective and safe
    as shunts and with a far lower risk of infection. But unlike
    shunts that can fail repeatedly over a lifetime, virtually no
    ETV/CPC treatment failures will occur after the first 6 months.
        It is notable that this procedure was originally developed
    and validated in Uganda with the support of funding from both
    USAID and NIH. Its subsequent adoption by major pediatric
    centers here in the U.S. demonstrates how Federal funding of
    projects abroad can benefit U.S. citizens.
        Countries with the highest volume of hydrocephalus have the
    fewest neurosurgeons with around 330 pediatric neurosurgeons
    caring for a population of 1.2 billion children in low-resource
    countries where shunt dependence is more dangerous. Children
    with shunt failure and no access to emergency surgery often
    die. Therefore, training and equipping these neurosurgeons to
    perform this procedure will substantially reduce the number of
    shunts placed and save lives while also reducing the number of
    repeated shunt operations on an overburdened neurosurgical
    workforce.
        NeuroKids is a nonprofit organization that uniquely focuses
    on training and equipping these neurosurgeons to perform ETV/
    CPC using a combination of onsite training in their home
    institution and subsequent remote mentoring that employs
    virtual presence technology during surgery. We prioritize
    partnerships with neurosurgeons in high volume referral centers
    and subsequently leverage their training by adding them to our
    growing international team of neurosurgical mentors.
        NeuroKids currently works with partner sites in 13
    countries of Latin America, Africa, the Middle East, and
    Southeast Asia.
        In conclusion, more funding is needed to accelerate the
    elimination of untreated pediatric hydrocephalus and to
    minimize life threatening shunt dependence in low-resource
    countries, thus savings the lives of countless children. As
    well, public health strategies that reduce neonatal infection
    and neural tube defects would substantially reduce the number
    of children throughout the world who are affected by this
    condition.
        Thank you again for the opportunity of being here.
        [The prepared statement of Dr. Warf follows:]
        [GRAPHIC NOT AVAILABLE IN TIFF FORMAT]

        Mr. Smith. Thank you, Dr. Warf. Thank you so very much for
    your leadership and being here. Dr. Shih.

                         STATEMENT OF ANDY SHIH

        Mr. Shih. Thank you, Chairman Smith, Ranking Member Wild,
    and distinguished--all distinguished member of the subcommittee
    for inviting me to testify and for holding this important
    hearing.
        I am Dr. Andy Shih, Chief Science Officer at Autism Speaks,
    a national and not-for-profit organization dedicated to
    creating an inclusive word for people with autism through their
    life-span. We do this through advocacy, services, supports,
    research and innovation, and advances in care.
        In addition to the work we engage in domestically, Autism
    Speaks has been committed for many years to developing and
    implementing strategies and programs that positively impact the
    lives of people with autism, other developmental disability
    around the world. The primary vehicle for this has been our
    Global Autism Public Health Initiative, also known as GAPH.
    GAPH is a community participatory research and advocacy
    programs where, in addition to facilitating high-impact science
    to inform program and policy development, we serve as technical
    advisors to governments and NGO's committed to enhancing
    support for our community. We help source expertise, support
    community-based knowledge co-production, and facilitate
    dissemination and implementation of sustainable solutions.
        What we've learned from our many years of work in this
    space and throughout our Autism Leadership Network, a
    distinguished group of leading international autism advocates
    that Autism Speaks has supported for over a decade, is that
    there are some absolutely incredible individuals and
    organizations working in countries across the globe to raise
    awareness of autism and increase service--access to services.
    These are truly some of the most remarkable caring people you
    will ever meet, who often work with extremely limited resources
    in difficult political climates. What we've also learned is
    that while these advocates have made a significant impact, have
    only scratched the surface in terms of building the awareness
    and acceptance of autism and infrastructure for services that
    needed around the globe to meet the needs of autistic people.
        Much of the work has engaged internationally involve--
    involving working directly with community organizations. Last
    year we had the opportunity to collaborate with the World
    Health Organization and UNICEF on a first-of-its-kind report,
    the Global Report on Children with Developmental Disability.
    This report provides a comprehensive perspective on the
    prevalence and characteristic of children with developmental
    disability globally and serve as a call to action for all
    nations.
        Like to focus on a few of the findings and recommendation
    from this report. I think they are helpful for informing our
    conversation today. First, the report note that there are an
    estimated 317 million children and adolescents worldwide that
    have health condition that contribute to developmental
    disabilities and 95 percent have no access to appropriate care
    at all. Children and adolescents with developmental disability
    are at increased risk of mental health conditions and premature
    death due to illnesses such as obesity, diabetes, heart and
    respiratory diseases. Their needs are largely neglected and
    they continue to experience stigmatization, prejudice,
    institutionalization and barriers to participation, as well as
    social, economic, educational, and other forms exclusion and
    barriers in access health care along with poorer quality of
    care when compare with their peers. This result in widespread
    inequities in terms of health outcomes, and tragically,
    premature mortality for many people with developmental
    disabilities.
        Despite the depth of these challenges, this report provide
    hopes and a path forward. The overarching objective of this
    report is to take action for change. Children with
    developmental disability and their families have long been
    neglected to the margins, and that has to change. That has to
    change now. This report maps out 10 action area to accelerate
    change in policies and care system for children and young
    people with developmental disabilities. I encourage all member
    of the subcommittee to read through them.
        One key takeaway from the report is that improving health
    outcome for those children must involve a holistic approach. To
    truly make progress institutional barriers to care must be
    addressed and the same time more personalized approaches must
    be utilized to address each child's individual needs.
        To accomplish this one approach known as the stepped-care
    model is being increasingly recognized as an efficient and
    effective way to build tier system of care for children with
    developmental disabilities. This approach involve making
    available care options of varying levels of intensity linked
    through defined care systems.
        Recently Autism Speak implemented the stepped-care approach
    by supporting UNICEF pilot that focus on early identification
    and intervention for children with developmental delays in
    three countries: Bulgaria, Peru, and Uganda, as part of Care
    for Child Development Initiative. The work being done in these
    countries is already having a substantial impact, and the
    Global Report on Children with Developmental Disabilities will
    continue to serve as a rallying point as well as a road map to
    make progress around the world.
        Last, while millions of people with developmental
    disability around the world still struggle to access
    appropriate care--health care, like to acknowledge the progress
    that has been made in the development of tools to improve
    autism diagnosis. Autism Speaks support the development of two
    freely available tools: the Open Source Screening and
    Diagnostic tool, which is called OSSDx, for autism spectrum
    disorder, and the Nigerian Autism Screening Questionnaire. The
    ability to reliably screen and diagnose autism is critical in
    determining the most appropriate level of care for autistic
    children. High-quality screening tools like these are necessary
    to address the challenge and improving diagnosis and
    intervention.
        Chairman Smith, throughout your career you have been an
    incredible champion for autistic people, not just here in the
    United States, but around the world. If passed, the Global
    Autism Act that you have previously proposed would be a
    tremendous step in the right direction in helping to address
    the--some of the challenges I've mentioned today. I am grateful
    to you for inviting me to testify at this particular hearing
    where we're focused on neglected aspect of public health.
    People with autism and other developmental disability around
    the world have tragically been neglected for many years across
    the very system--across every system of care. As I said
    earlier, the time for change is now. I look forward to working
    with you and all members of subcommittee to making that change.
    Thank you again. I look forward to your questions.
        [The prepared statement of Mr. Shih follows:]
        [GRAPHIC NOT AVAILABLE IN TIFF FORMAT]

        Mr. Smith. Mr. Shih, thank you so very much and thank you
    for the great work Autism--I mean, geez, I just--for the great
    work that you have done at Autism Speaks. It is just
    incredible. Matter of fact, in 2005, when the Autism bill was
    going to die because of House inaction, it was Autism Speaks
    that saved it. And so I will never forget that. So deeply
    appreciate it.
        Mr. Shih. Thank you, Chairman Smith.
        Mr. Smith. Let me now turn to Dr. Rana for your comments.

                      STATEMENT OF YASHODHARA RANA

        Ms. Rana. Chairman Smith, Ranking Member Wild,
    Representative Manning, thank you for the opportunity to
    discuss the critical role of combating malnutrition and
    promoting global brain health. Thank you to Chairman Smith and
    Ranking Member Wild for your leadership in the fight against
    child malnutrition.
        I serve as the Associate Director of Research at the
    Eleanor Crook Foundation, or ECF, a U.S.-based philanthropy
    solely focused on ending malnutrition. I manage a multi-million
    dollar portfolio of grants that is focused on child and
    maternal nutrition.
        Today I will summarize my written statement in three key
    points: First, malnutrition is harming the brain health of
    children worldwide. Second, the crisis of malnutrition is
    detrimental not only to children and their families, but entire
    nations and economies. And third, malnutrition is a solvable
    crisis. We have cost-effective solutions ready to be scaled
    today.
        To my first point, malnutrition is a leading cause of child
    death and children who survive face stunted growth and
    cognitive impairment. As we all know, brain development begins
    during pregnancy. By the 4th week a fetus has 10,000 brain
    cells and by the 24th week this number expands to 10 billion.
    In fact, by age three a brain--a child's brain is about 80
    percent the size of an adult's brain.
        The importance of proper nutrition during these early years
    cannot be overstated. Malnourished mothers are more likely to
    give birth to children who are too small or born too soon and
    these vulnerable babies are likely to have worse
    neurodevelopment and cognitive outcomes and also are at a
    serious risk of illness, and even death.
        This brings me to my second point, the harmful effects of
    malnutrition on brain health extend beyond individuals to
    entire nations and economies. As President Adesina of the
    African Development Bank frequently says, the greatest
    contributor to economic growth is not physical infrastructure;
    it's brain power, what he calls as gray matter infrastructure.
    Individuals who face childhood hunger earn 10 percent less over
    their life times and are 33 percent less likely to escape
    poverty. The economic cost is huge. Malnutrition is estimated
    to result in an annual productivity loss of up to $3 trillion.
        But for all these dire statistics there is hope, which
    brings me to my third point. Proven cost-effective solutions to
    malnutrition exist and are ready to be scaled up. Take the
    solution of prenatal multivitamins for pregnant women that you
    can see here, which we call as MMS. This complete prenatal
    vitamin is considered as one of the best buys in global health.
    It not only protects the health of the mother, but it also
    prevents kids from being born too early or born too small. And
    we have studies showing that babies born too small have lower
    IQs than their counterparts.
        On a personal note, when I had my two pregnancies here in
    the United States I took a prenatal multiple-vitamin just like
    MMS because I knew I wanted my children to have the best start
    in life and I could access these supplements. But in low and
    middle-income countries where the prevalence of malnutrition is
    much higher, pregnant women only get two nutrients: iron and
    folic acid.
        Another cost-effective solution is breastfeeding. Breast
    milk is nature's superfood that protects--and that protects
    children's brain health. And it also protects the health of
    mothers and babies, yet only 41 percent of kids worldwide are
    exclusively breastfed. When breastfeeding moms are supported
    they're twice as likely to continue to breastfeeding their
    children.
        Finally, despite global efforts to improve children's diet,
    there are still families that are still not able to meet the
    nutritional needs of infants. A food-based supplement here that
    I'm showing designed--is designed specifically for vulnerable
    children and it's called SQ-LNS. It's proven to save lives.
    It's proven to prevent malnutrition. And it contains the
    recommended intake of micronutrients as well as protein.
        I want to end my remarks by talking about the impact of
    U.S. leadership. The U.S. has historically been the largest
    donor in the fight against malnutrition. My birth country of
    Nepal offers a notable example of the benefits of this
    leadership.
        In 1995 Nepal had the highest stunting rate in the world.
    Seven out of ten children had delayed growth. But over the past
    20 years, with strong government leadership, policies, and
    donor support, specifically USAID's Nutrition Program,
    Suaahara, Nepal has reduced stunting by half. And thanks to
    U.S. Government leadership we've seen a historic surge in
    treatment for children with severe acute malnutrition. In 2023,
    an estimated 1.2 million children's lives were saved because of
    this treatment.
        This success highlights the critical role of bipartisan
    congressional support, but UNICEF recently reported that one in
    four children today is living in severe food poverty. That
    means 181 million children do not have the equal opportunity to
    grow, develop, and learn. That means 181 million minds are at
    risk of being wasted. It is not easy to comprehend a number so
    huge, but I urge you to remember that every one of that
    callosal figure stands for a child, a child who deserves to
    have ambitions and who, with the right nutrition and care, can
    grow and prosper. We know that progress is possible, and now we
    must stand--we must stay the course.
        Thank you and I look forward to your questions.
        [The prepared statement of Ms. Rana follows:]
        [GRAPHIC NOT AVAILABLE IN TIFF FORMAT]

        Mr. Smith. Thank you so very much, Dr. Rana, for your
    testimony and leadership.
        Just a few opening questions: First of all, your
    testimoneys are--just answer many of the questions that all of
    us might have had, so that is deeply appreciated.
        With regards to the 2013 G8 Summit that was held of course
    for--trying to find a disease-modifying or a cure for
    Alzheimer's, I wonder if you could speak to how well or poorly
    we are doing on that time line. NAPA did help us, and that was
    a total bipartisan effort, to have a strategy to quadruple the
    amount of money that is going toward--most of it to NIH in the
    area of Alzheimer's research, but if you could speak to--as
    2025 rolls around--and of course the SDGs also speaks to health
    in a variety of ways, including in the dementia realm. If you
    could speak to that.
        Second, I would say and ask Dr. Warf, when you testified in
    the past, not only have you pioneered and helped save countless
    lives with your intervention, the non-stunt intervention, you
    had spoken of the effort to train Ugandans and Africans at Cure
    International and other initiatives to be the neurologists, to
    be the surgeons, to be the brain health experts. And I am
    wondering if you could update us on how well that might be
    doing, whether or not it needs a major push.
        And any estimate on how many--I mean, I remember you showed
    us pictures of kids in Uganda who--before and after, after
    their--unfortunately the fact that their brains had so swelled
    up and the after pictures with their parents with smiles from
    ear to ear because they had been cured. If you could speak to
    that.
        And again, further elaborate briefly if you would on the
    issue of the infection-based, because we had a lot of people--I
    chair the Spina Bifida Caucus as well here in the House and it
    is completely different. We know interventions in utero can
    help mitigate the impact of spina bifida, but you pointed out;
    and you had experts to verify, this was infections-based.
    Because I went and spoke, as I do every time--Samantha Power,
    Mark Green, all the USAID administrators are all wonderful
    people. They always say, well, we are dealing with infectious
    diseases. They do not want to cross that line into global brain
    health.
        That is why my bill has failed at the launching pad every
    year. It is not going to fail this coming year, and your
    testimoneys and your help will help make that happen. I mean,
    why aren't we doing this? And so many people are so mal-
    affected by it. Yes, HHS does some good work, but it is mostly
    in the realm of diplomacy, health diplomacy, not funding
    projects, NGO's and the like to take all of the global brain
    health initiatives on.
        With Regards to autism, just a brief little story: I was in
    Abuja and then went over to Lagos in the year 2000. It was on a
    combating human trafficking trip. And I spoke to about 500
    people and a man came up and he says what are you doing about
    autism here? Nothing. So I went and had lunch with him,
    breakfast as you would say, and we had a great meeting. And I
    know you guys do a great work internationally and I thank you
    for that. But again, we need to make sure that our government
    is doing more, which is why this initiative I think just has to
    be--and I do think we can succeed.
        And, Dr. Rana, if I could with you, I am a great believe in
    the first 1,000 days from conception to the second birthday.
    Food nutrition for the mom so that both mother and baby are as
    healthy as humanly possible. And we do know that folic acid--
    and this has come out of the research pursuant to the Autism
    Cares work and the--that folic acid can, if taken very early in
    the pregnancy or by a woman of reproductive age as she becomes
    pregnant--it greatly reduces autism. Greatly reduces it. And so
    the more of that initiative: ours and the U.N.'s and others,
    can be shared with everybody, the better.
        But first 1,000 days. I remember I was in Guatemala the day
    they announced their cooperation with a first 1,000 days
    initiative, because they have a stunting problem, as does
    Nigeria and so many other places. And it works. Mother's
    healthier. Baby's healthier. I mean, it is the most crucial
    time health-wise in any of our lives and it seems to me that we
    need to be doing more.
        We have the Global Food Security Act. I was the House
    sponsor. Got it passed twice. Went over to the Senate. It came
    back as a Senate bill. Who cares. It is a good bill. But are we
    doing enough when it comes to global food security? If you
    could speak to that.
        And you did mention folic acid, but--and thank you for
    bringing some of the other things that are so important. But if
    you could also--your presence here, your testimoneys, it will
    be the gist of a brand new, all-out effort to get the Global
    Brain Health Initiative enacted into law and to get as much by
    executive branch policy as possible, but also by statute. So I
    do ask you, if you could, speak to those issues as--and
    anything else you think we need to touch on.
        Gladys?
        Dr. Maestre. Thank you, Chairman Smith, for your question
    and your insights. So you asked me about the treatment and
    advances and how close are we to cure. And I have to elaborate
    a little bit on this. We didn't know the situation was so
    complex for the brain as the brain ages. So we thought we were
    going to have a patient with memory loss and dementia and that
    we were going to be able to treat it just like that.
        But we learned that it takes 20 years or more to get to the
    point of memory loss and other cognitive changes. So it takes
    20 years. So we are now looking forward to therapeutics that
    will begin early enough to really stop the progression to the
    disease. That's our hope.
        With the current medications which have been approved by
    FDA, they are--they do work taking out of the brain one of the
    proteins that deposit--that is deposited in the brain, that
    accumulates in the brain of people with dementia, which is the
    beta-amyloid. So they do work. They are monoclonal antibodies.
    They get to the amyloid and they clean it. So if--but if there
    is too much amyloid already, then there are going to be already
    other changes in the brain like neuron death, deposition of
    other things. So it's not enough to cause a clinical
    improvement. Not too much. It delays few months, but not--it's
    not a cure. Are we closer? Yes. Are we there? No.
        So we are hoping that we are going to develop similar
    techniques and that we are going to develop strategies for
    different elements in the brain of people already with dementia
    enough to at least stop the progression and maybe reverse. But
    what we are really hoping is to--once that we have the
    capability now to detect earlier before the symptoms appear
    that we are going to be able to develop therapeutics to stop
    right there, preventing the onset of the disease.
        Dr. Warf. My turn. So I'll try to address each of the--each
    of your categories of questions.
        So first of all, you asked about, Mr. Chairman, the
    progress in training surgeons. And so the last time that I was
    here in this place was in 2011. And at the time we had a
    training program onsite in the hospital that we started in
    Uganda where we brought neurosurgeons from other countries,
    developing countries to train them there in this technique for
    a period of time and then sent them back home. All right?
        And using--through that program we actually trained
    neurosurgeons in about 30 different countries.
        There were challenges though with that and one of those was
    that we were taking sometimes the only neurosurgeon in the--in
    that region and taking them away from their practice for two or
    3 months for training. They were being trained in an
    environment that was unlike the one they were going back to and
    treating a different population of children, and sometimes
    there were obstacles to implementing their training when they
    got home.
        The pandemic sort of made us appreciate the role of remote
    presence teaching and technology. And around that time we
    founded NeuroKids, which has a different paradigm of training.
    In this way we identified partner neurosurgeons in needy
    places, high-volume centers that are seeing a lot of
    hydrocephalus. And we have a Zoom-based pre-site visit
    protocol. We do then a site visit and do hands-on
    interoperative training.
        And then after the trainer goes back, what we're able to do
    is continue to mentor that surgeon through remote presence
    technology. For instance, I can sit at my desk in Boston and in
    real time with the screen, the video endoscope screen on my
    computer I can talk to the surgeon, take them through what
    they're doing. I can telestrate on the screen. They can see
    that. And so we can virtually be there in the operating room
    with them. And that continues their training over a few months
    thereafter.
        In the last couple of years we've been able to train in a
    number of sites in different countries, not just in Sub-Saharan
    Africa, but also South America, Southeast Asia. And by the end
    of this year we will have close to 20 different sites.
        And the strengths--one of the strengths of this program is
    that we aim to train trainers. And so the person that we train,
    once they're competent, we support their mentoring and training
    of other surgeons in the region. So that's--that helps us to
    scale this kind of work.
        In regard to the folate question, I won't speak a lot on
    that, but simply to say that because spina bifida/neural tube
    defects is a major cause of hydrocephalus, preventing that is
    very important. And if--when there is adequate folate
    supplementation or fortification of the grain supply, that has
    the potential to reduce the incidence of spina bifida in a
    country by about two--down to two-thirds of what it is. So it
    can make a significant impact on that condition.
        And then finally in regard to the infectious origins of
    hydrocephalus, the pathogen causing that is largely unknown in
    most places in the world. Over the course of about the past 10
    years and quite a bit of NIH funding we finally were able to
    identify, with the appropriate experts--not me--but we were
    able to, with leadership of Steve Schiff in particular,
    identify a new human pathogen that was actually causing the
    post-infectious hydrocephalus in Eastern Uganda to a bacteria
    called Paenibacillus. And that hadn't been known to be a
    pathogen in humans.
        And so the next stage will be learning how to better treat
    and prevent that particular infection, but we have no illusions
    that that's what's causing these infections elsewhere. And so
    what's needed is similar research programs to identify what's
    causing the infections in the neonates in other parts of the
    world.
        And then finally, one of the important interventions is a
    simple public health intervention around perinatal care. In
    Uganda, for instance, most of the children were born at home in
    the village without professional help. They're in an
    environment where they're constantly exposed to mud and animal
    dung. One of the practices was to place animal dung on the cut
    umbilical stump to staunch the bleeding after the baby was
    born.
        And so there are a lot of sort of simple things that could
    be done, but on a big scale in terms of advancing basic public
    health measures to prevent neonatal infection, which in low-
    income countries neonatal infections are very, very common. We
    don't have that kind of burden here in the U.S. That's really a
    condition of poverty.
        Here in the U.S. one of the most common causes of
    hydrocephalus, if not the most common, is hemorrhage in the
    brain in prematurely born babies that are preserved and
    supported in our NICUs. That's a condition, post-hemorrhagic
    hydrocephalus of prematurity, which is really a condition of
    prosperity you might say. We don't see that in the developing
    world because those children, those prematurely born babies
    don't survive.
        Yes, so I think hopefully that covers some of your
    questions. Thank you.
        Mr. Smith. Mr, Shih?
        Mr. Shih. Thank you, Chairman Smith. I just wanted sum up
    some reflection here. I think one the last previous time that I
    testify in front of the committee may be almost 10 years ago
    now. I remember that time we focus on conversation around
    awareness and inclusion of our community.
        Part of the reason we did that is because there were no
    tools, right, and programs and policy that could really
    facilitate the inclusion of our community in society and system
    of care.
        But now that we have. I mention in my testimony about this
    diagnostic screening tool that we develop, like Nigerian autism
    screening tool and the OS--open-source diagnostic tool that we
    develop Sub-Saharan Africa, as well as the Care giver Skill
    Training Program, Early Intervention Program develop at WHO.
    They're now available globally. So is no longer a question of
    what to do, but how quickly can we do it, right? We have the
    tools now. We have the resources to make things--to make a
    change happen. So it's become a implementation problem. And
    that's why with U.S. leadership I think we can greatly
    accelerate the implementation process and bring a better
    tomorrow to all of our community around the world. Thank you,
    Chairman Smith.
        Ms. Rana. Thank you for the question, Chairman Smith. I
    just wanted to start by appreciating both the chair and ranking
    member for passing the Global Malnutrition Prevention and
    Treatment Act and for really codifying the approach of focusing
    on evidence-based cost-effective interventions.
        in my testimony I mentioned U.S. leadership in scaling
    treatment for severe malnutrition, which you all might now more
    commonly as Plumpy'nut, or RUTF. Because of bipartisan support
    from Congress and USAID, RUTF was accessed by nearly 9.3
    million children, saving 1.2 million lives in 2023.
        And I'm sharing this success story as a proof that when we
    focus on high-impact cost-effective solutions and become razor-
    focused impact is possible.
        And this is what we're to do with these improved prenatal
    supplements. They also contain folic acid. But the case is we
    have a solution but we still need to figure out how deliver it.
    And the challenges can be multiple. Women not taking--women not
    coming to antenatal care on time; so the folic acid is not
    taken in the early stages of pregnancy, it's not going to work
    the magic that we need to. Women could be coming to antenatal
    care, but not be able to afford or access these prenatal
    supplements. They might not be getting counseled on the
    importance of these supplements and there could also be
    misconception or other adherence-related issues.
        So we have a solution, but there is still a lot of work to
    be done in order to deliver it to get to impact. For this
    reason our foundation along with three other philanthropies has
    developed a road map for how we can reach women in the 45 high-
    burden countries with these improved prenatal supplements.
        So over the next 6 years with an investment of 1.1 million
    we aim to reach nearly 260 million women with these improved
    prenatal supplements which has the potential to save nearly
    600,000 lives and prevent 5 million vulnerable births. And
    these births are at risk for also having impaired brain health.
    Thank you.
        Mr. Smith. Thank you.
        Ms. Manning?
        Ms. Manning. Thank you.
        Thank you to my good friend, Chairman Chris Smith and also
    to my friend--my good friend Susan Wild, who is in another
    meeting right now. It has been a real honor to work with you on
    this subcommittee. Let me just say how much I will miss this
    work in the future.
        To our witnesses, thank you so much for your testimony
    today. You have given us wonderful examples of what can be done
    to help prevent or treat devastating brain and health issues
    with the right tools, training, and resources from the U.S.
        So, Dr. Warf, I want to ask you a question first. The
    President-elect plans to establish a Department of Government
    Efficiency to cut government spending. Do you believe that cuts
    to medical research should be on the table and would reducing
    funding to entities like NIH, CDC, CMS, HHS hurt efforts to
    find the kinds of tools you have described or cures for
    diseases--cures or treatments I should say for diseases like
    Alzheimer's?
        Dr. Warf. Well, thank you for that question. I of course
    think that reducing support for the entities that you describe
    would be harmful to the health of children in most of the
    world. I also think; and this is partly in reference to what my
    colleague to the right of me here pointed out, in my opinion,
    for what's worth, when the U.S. invests in helping other people
    in other countries, we show our best side. And I think few
    things could be more valuable to diplomacy, not that I know
    anything about that. But that's my humble opinion as I think--I
    think we need to show our best, which is caring about the rest
    of the world and being willing to invest and help them, because
    it--in a sense, if we want to look at it from a selfish way,
    that does come back to help us as well.
        Ms. Manning. Thank you for that.
        Dr. Maestre, would you like to comment on that as well?
        Dr. Maestre. Sure. Thank you very much, Representative
    Manning, for coming here today and for these thoughtful
    questions.
        I like efficiency. I like to do things better. So I can
    only be hopeful that the advantages of research and aid will
    come up. So I don't think that it's--I hope, right, that the
    funding will only keep increasing and being redirected to the
    needs and where we have a chance to be more impactful.
    Alzheimer's disease without doubt we are at a moment where we
    need to take advantage of where we are and what we can do at
    the global level.
        Ms. Manning. So in 2023, the NIH announced $3 million in
    funding for Alzheimer's research, a collaboration between the
    U.S. and countries in Africa. Can you share just a little bit
    about what the impact of funding for programs like that can do?
        Dr. Maestre. The main success is that we have access to
    resources that we don't have in our Nation, and that's at
    least--to mention one of them is DNA, the diversity, the
    genetic and genomic diversity that we don't have. So and this
    implies that we have access to cures, to targets that we don't
    have now. And that--it's the leadership that we need in the
    world. We need to have access to resources in ways that we can
    use them right away. Because we have the technology, we have
    the infrastructure, and we have the desire.
        I also want to mention that we have, I think, a secret
    weapon which is not a secret, which is the African American
    scientists. I think they are very eager to work even more with
    African scientists and the African communities. So I think that
    we have a lot of pieces to really accelerate the discoveries
    that we need to bring back home, but also to make stronger
    partnerships in Africa and in other low and middle-income
    countries. Thank you.
        Mr. Manning. Dr. Shih, the President-elect's nominee to be
    the Secretary of Health and Human Services, Robert F. Kennedy,
    Jr., said in a 2023 Fox News interview the following: He said,
    I do believe that autism does come from vaccines. As a doctor
    do you agree with him?
        Mr. Shih. Thank you for that question, Representative
    Manning. So there have been numerous studies that have been
    done, both in the U.S. and around the world to look at the
    causal link between autism and vaccine, and today there has
    been no established evidence that link the two, vaccination
    with autism. So it is a settled scientific question.
        Ms. Manning. I am sorry. Can you say that Again, please?
        Mr. Shih. It's a settled scientific question for the
    research community.
        Ms. Manning. That vaccines do not cause autism?
        Mr. Shih. That's correct.
        Ms. Manning. Are you at all concerned about the potential
    head of HHS who might hold these views?
        Mr. Shih. We have worked successfully with both parties
    over the years to advance the interests of our community, the
    well-being of our community, and we strongly believe that we'll
    be able to continue to.
        Ms. Manning. I have heard some discussion about the fact
    that people believe that autism is on the rise. You described I
    think in your testimony some of the tools' better ability to
    diagnose autism. So do you believe autism on the rise or is
    there--are we better able to diagnose autism which gives higher
    numbers?
        Mr. Shih. So certainly we're diagnosing autism more than
    ever before in history. And certainly part of the reason that
    we're able to do that has been the improvement in knowledge,
    right, and awareness, efficacy of clinicians, and so on, the
    tools that we have to assist in these processes. But I think
    there's still uncertainties. We know that autism is the result
    of genetic environmental factors interaction. We have some
    understanding of the genetic factors that are at play. We're
    beginning to understand what environmental factors are at play.
    So I think over time we'll have a better understanding on what
    are all the factor that are really contributing to this
    condition.
        Ms. Manning. And when you say over time, will it just occur
    or would investment in more research be helpful?
        Mr. Shih. Absolutely investment in more research.
        Ms. Manning. Thank you. Individuals with autism are far
    more likely than their peers to suffer from social isolation,
    exclusion, mental health conditions such as depression and
    anxiety. How can we help first of all reduce the stigmas around
    autism, but second try to address some of those issues?
        Mr. Shih. Yes, that's a excellent question. So I think
    first of all awareness, right? And not only about awareness of
    autism, but really advocating for acceptance and understanding
    of autism I think is crucial to make progress in the particular
    area.
        And I think the second thing is to really try to create
    accommodations for autistic people and their loved ones on our
    community so they can be actively intentionally included in
    family life and in social life and so on and so forth.
        Ms. Manning. And gainfully employed?
        Mr. Shih. Absolutely. That is so crucial, right? Because
    with--by addressing all these social determinants that can lead
    to better health we can actually improve the well-being and
    outcome of our community overall.
        Ms. Manning. Wonderful. I have a question from my colleague
    who won't be able to make it here. Dr. Shih, in your written
    testimony you highlighted your collaboration with the World
    Health Organization and UNICEF to help publish the first Global
    Report on Children with Developmental Disabilities. How
    important are multilateral institutions including the WHO and
    UNICEF in supporting global autism and health research
    initiatives?
        Mr. Shih. I think it's very important because obviously as
    an organization we're limited in our reach and ability to
    influence programs and policy, but by collaborating with
    multinational organization like WHO UNICEF it allows us to
    expand our reach and further disseminate sustainable solution
    to community in need.
        Ms. Manning. Thank you.
        Dr. Rana, Thank you for holding up some of those very small
    packages of items that can have just a huge impact on the
    health of children and the nutrition for families. Can you tell
    us what aspects of U.S. global nutrition assistance programs
    have proven the most effective, and also which have proven the
    least effective?
        Ms. Rana. Thank you, Representative Manning, for your
    question. The ones that have proven most effective in my
    perspective had been the ones that have focused on cost-
    effective solutions. having a razor-focus on really upping the
    coverage of these interventions that we know works. It's a
    tragedy that we have these solutions but we haven't still
    figured out how to scale them at high coverage so that every
    woman everywhere and babies are able to access them.
        On what has not worked is a question I'd like to followup
    with a written response because I haven't seen the entire
    portfolio of programs and it wouldn't be right for me right now
    make a comment beyond that.
        Ms. Manning. Thank you. I think that would be helpful
    because we do talk about wanting to make sure that we are
    putting our efforts in the right place. And I agree we want to
    be efficient and effective. So sometimes it is important not to
    just know what does work, but what is not working, what we
    should stop doing so that we can devote our resources to the
    things that are working.
        And I had another question here. Dr. Rana, how can global
    health partnerships help feed children with neurodevelopmental
    needs in malnutrition-prone regions? How can we be partnering?
    We had a bill on the floor that we were discussing earlier
    today about the war in Sudan and how 14 million people have
    been impacted by that war, either relocated or put in
    devastating circumstances where they are at risk of
    malnutrition. How can we be partnering to address some of the
    nutritional needs that are going to be--that are affecting
    people in such difficult circumstances?
        Ms. Rana. Thank you again for that thoughtful question,
    Representative Manning, especially as there are multiple
    crisises worldwide that are happening simultaneously. And the
    people who bear the biggest brunt are pregnant women and young
    children, what you, Chairman Smith, called precious to our
    society.
        We have again these cost-effective solutions. If you look
    at the packet of ready-to-use therapeutic food, it is
    specifically for kids who are severely malnourished. Given
    their condition, taking a normal meal is not going to be easy
    for them and so this provides them with the required nutrition
    for their treatment.
        SQ-LNS, that I talked about, is also from a prevention
    angle of how do we get kids early on before they get too
    wasted? And similarly for pregnant women we are talking about
    solutions like prenatal vitamins that are more holistic. But
    also in some cases when women are very undernourished we are
    looking at supplements for lactating and pregnant women also.
    So there are solutions that are feasible, that are possible.
        But then the challenge again is financing. How do we
    finance given the scale at which these crisises are happening
    and how do we reach these populations, which some of the U.N.
    agencies like UNICEF and WFP--they have baskets of food and
    services for both pregnant and vulnerable populations.
        Ms. Manning. Thank you. Well, let me just thank you all for
    the really important work you do. Thank you for being here
    today. My sister specializes in treating Alzheimer's patients
    at the UVA Medical School, so I am well aware of how
    devastating Alzheimer's can be for patients and families, how
    desperate they are for treatments that work either to arrest or
    prevent the disease from developing.
        So I hope we continue to invest in the research and the
    great organizations and great researchers who can provide
    solutions and treatments for all of the diseases that we have
    been talking about today and that we continue to share our
    knowledges and our resources with the areas of the world that
    are most prone to having these problems where our small amount
    of help can provide an enormous benefit.
        And not only do we help them, but, Dr. Warf, as you
    suggested, it also helps us in our standing in a world where
    there is great power competition right now and it is a good
    effective way for us to build friends and alliances. So thank
    you.
        With that, I yield back.
        Mr. Smith. Thank you very much.
        If I could just recognized Scott Badesch, who is now on my
    staff. Ten years as president of Autism Society and has been
    very helpful and as we write this new bill with all of the
    groups.
        And, Stewart, great to see you again as always. We miss you
    already.
        He just retired in September. Did a wonderful job in the
    Autism CARES legislation.
        And I want to thank you especially for that.
        But as we go forward, this is going to be an all-out push
    and I think we can succeed. I mean, your testimoneys, but your
    work, your life work is so important. You have saved so many
    lives and can enhance the lives of so many others. They have
    improved the quality of life. It is just extraordinary. So
    thank you for that.
        I do have just one brief question to Dr. Shih about the--I
    remember when thimerosal was all the rage. Of course that has
    been out of our immunizations for quite some time. And some
    people still cling to that, but it is not there anymore, so how
    can you be suffering from that and contributing to autism?
        And one of my first amendments I offered here as a new
    second-term Member of Congress was to provide $50 million for
    the Child Survival Fund. It passed; it became law. And it was
    for one of the pillars of the Child Survival Fund was
    immunizations. And I actually traveled to El Salvador, and many
    Central American countries and African countries later, but for
    Days of Tranquility, when the FMLN were fighting against
    Duarte's government and they would stop all fighting to
    immunize the children against diphtheria, polio, pertussis, the
    leading killers of children. So I do believe there is an
    absolute important role to be played.
        But there is an argument made; and I would appreciate your
    thoughts on this, that if too many vaccinations are given at
    once that that could have a negative impact, maybe contributing
    to autism, but could have a negative impact on that child
    because of the absorption capacity of a very young child. If
    you get five immunizations at once, what does that do? So
    spreading them out might be a wise and prudent course of action
    for mothers. Just wondering what your thoughts are on that. Get
    the vaccination, but spread it out?
        Mr. Shih. Right. Whether or not it's vaccination, just
    spread it out. So this has been an issue in the community, as
    you know, for a couple of decades now. Certainly there's no
    evidence that suggests that having receiving multiple doses of
    vaccines a day isleads to autism or associative autism.
        My understanding is that the developing child are able to
    tolerate this kind of vaccine schedule, right? And we have seen
    through history this is not a new program that's introduced.
    It's been around for decades and we certainly have not seen the
    evidence that this kind of vaccine schedule actually lead to
    significant harm for children's health.
        Mr. Smith. I appreciate that.
        Let me just conclude. My hope is that your testimoneys, the
    work you have done builds on a renewed call to action to the
    incoming administration to really take on global brain health.
    And we will do it by way of legislation. I do think we can get
    it passed this time. I have already spoken to some of the
    leadership including the Speaker about this. This is an idea
    whose time has come to quote, or paraphrase Victor Hugo. And
    you have been doing it. You all have been doing it. And we just
    need to do even more to make sure that USAID and not just HHS
    through diplomacy is embracing this achievable goal. So I want
    to thank you so much.
        Anything else you wanted to add now or by way of written
    submissions? Please, yes, Gladys?
        Dr. Maestre. Thank you very much, Chair Smith. I wanted to
    reaffirm some of the comments you made. I have been devoted all
    my life to international work, not only because I come from
    Venezuela and that Imy work has been in Africa and Latin
    America, but because now I work at the University of Texas, Rio
    Grande Valley, which is located in Brownsville, Texas. This is
    10 minutes from the Rio Grande, from the river and 40 minutes
    from SpaceX.
        Many of my patients and participants, when I talk to them,
    they mention the adversity of human trafficking in their lives.
    At least I would say that 20 to 25 percent of the women that I
    see as Alzheimer patients have been subjected to this type of
    abuse. And I wanted to lay that out because I think that the
    social determinants of health that we are experiencing in the
    border are many--in many ways related to what's happening in
    low and middle-income countries, the lack of access and the new
    opportunities that we have now to bring together issues which
    you have led for many, many years. And now we can envision a
    global health strategy with these diseases and these
    strategies, but also too that will benefit not only low and
    middle-income countries, but low-resource settings like the Rio
    Grande Valley in South Texas.
        Mr. Smith. Thank you for that. Are you suggesting trauma-
    induced Alzheimer's?
        Dr. Maestre. We----
        Mr. Smith. Is it because of beatings or because of sexual
    assault?
        Dr. Maestre. We believe that adversity of that level
        Mr. Smith. Right.
        Dr. Maestre [continuing]. Is increased vulnerability of the
    brain to confront aging and to develop a healthy life.
        Mr. Smith. Thank you for that. That bears us really
    focusing on that.
        Just for the record, I am the author of the Frederick
    Douglass Trafficking Victims Prevention Act. Passed the House
    in February; still pending in the Senate. It is probably going
    to die in the dustbin called the U.S. Senate. It just kills me
    that it is just sitting there. And I have been calling. I have
    been asking. And it looks like it is going to die in the next 3
    weeks. We are going to reintroduce it, start it all over again.
    And the original TVPA, which I wrote in the year 2000, took 3
    years to get enacted. And we didn't know until the very end
    whether or not it would be pocket vetoed or approved by the
    Clinton administration. Clinton did sign it. Thank God for
    that.
        But I mean it is like why isn't this a no-brainer and just
    do it? But that is an area that we need to look into. I have
    never heard that before, so I thank you.
        So thank you so much. And we look forward to all of your
    input on what the bill should further look like. And maybe you
    might consider a collaborative letter from your organizations
    to Trump. We could highlight it as well. I will do one from
    Members of Congress. And I am sure I could get bipartisan
    signatures for it because we want to make sure there is no
    diminution of what we are focusing on. We don't want to see
    money stop going to Alzheimer's research, or autism, or all
    these other important initiatives. But I think we need to go
    big. And I thank you so very, very much.
        Hearing is adjourned.
        [Whereupon, at 3:53 p.m, the subcommittee was adjourned.]

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