[Congressional Record Volume 145, Number 113 (Wednesday, August 4, 1999)]
[Senate]
[Pages S10238-S10241]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]

      By Mrs. BOXER (for herself, Mr. Smith of Oregon, and Mr. 
        Lautenberg):
  S. 1497. A bill to amend the Foreign Assistance Act of 1961 to take 
steps to control the growing international problem of tuberculosis; to 
the Committee on Foreign Relations.


             international tuberculosis control act of 1999

  Mrs. BOXER. Mr. President, today I am pleased to be joined by my 
colleague on the Foreign Relations Committee, Senator Smith of Oregon, 
and by Senator Lautenberg in introducing the International Tuberculosis 
Control Act.
  This bill speaks to the growing international problem of 
tuberculosis. That is a disease we thought we had eliminated--and in 
fact, in the Western World, we largely did with the development of 
antibiotics in the 1950s. But the disease is making a comeback. As the 
World Health Organization (WHO) notes on the back cover of its most 
recent report on TB, ``The tuberculosis epidemic is growing larger and 
more dangerous each year.''
  According to the WHO, last year, nearly 2 million people died of 
tuberculosis-related conditions. And--get this--the WHO estimates that 
one-third of the entire world's population is infected with TB.
  Like so many other diseases, it impacts women disproportionately. TB 
is the world's leading killer of women between the ages of 15 and 44. 
For women in the primes of their lives, more than twice as many die of 
tuberculosis than because of war. TB kills three times as many women 
aged 15-44 as HIV/AIDS, and three times as many as heart disease.
  And it is a leading cause of children becoming orphans.
  But this is not just a growing international problem. Because of its 
persistence abroad, it is having a tremendous impact here at home.
  TB is an airborne disease. You can get it when someone coughs or 
sneezes.

[[Page S10239]]

 And with the increased immigration and travel to the United States--as 
well as the homeless population, the rate of incarceration, and HIV/
AIDS--we are seeing it re-emerge in many of our communities. Nearly 40 
percent of the TB cases in the United States are attributable to 
foreign-born individuals.
  We have seen it in my state of California, where local public health 
officials never thought they would have to worry about TB again. But 
they are. In 1997, nearly 20,000 TB cases were reported to the Centers 
for Disease Control. And over 4000 of them--20 percent of all TB cases 
in the United States--were in California.
  The headline on the March 25 editorial in ``The Oakland Tribune'' 
said it best: ``We ignore TB at our peril.'' Public health officials 
acknowledge that the key to controlling TB at home is to control TB 
abroad.
  Fortunately, the experts know what to do--and it works. TB can be 
treated and cured. We have seen that in this country.
  But in many other countries where this disease persists, there are 
numerous barriers that are facing public health officials. For example, 
the process for screening, detecting, and treating tuberculosis is very 
lengthy and labor intensive. Also, there is a lack of trained personnel 
and medicine in those nations with a high incidence of TB.
  The United States Agency for International Development (USAID) and 
the World Health Organization have begun implementing a program to 
eliminate these barriers and to treat and control tuberculosis. So far, 
they have had some success. But the resources are, quite frankly, 
inadequate.
  And they may become even more inadequate in the near future. The WHO 
is currently developing a global action plan to combat tuberculosis. 
That plan should be finalized and ready for implementation early in the 
year 2001. But unless there is a greater global investment of 
resources, we may have an action plan that does not see much action.
  So the purpose of our bill is two-fold. First, we must raise 
awareness that TB is still a problem. I suspect that few Americans 
realize that the disease persists--not only in other countries, but 
also right here in the United States. And fewer still realize how 
easily it can be transmitted.
  Second, we must increase the resources available to fight this 
disease in foreign countries.
  This year, USAID will spend about $12 million on fighting 
tuberculosis abroad. Under the Foreign Operations Appropriations bill, 
as passed by the Senate, there should be enough funding for USAID to 
increase that to about $14 million next year.
  I wanted to increase that even more, and I offered an amendment to 
the Foreign Operations bill. My amendment, which was accepted, says 
that if more money overall is provided for foreign aid programs before 
the appropriations bill becomes law, a top priority should be to 
provide more money for the infectious disease control program, 
especially tuberculosis.
  But, Mr. President, I am not sure that will happen, and even if it 
does, I do not believe it will be enough. So our bill would authorize 
$60 million for fiscal year 2001--a five-fold increase over current 
funding levels--so that USAID can expand the work it has begun.
  Make no mistake, we cannot do this alone. That is why this 
legislation calls on USAID to coordinate its efforts with the WHO and 
other organizations and why the bill adopts detection- and cure-rate 
goals based on the goals established by WHO. This must be a global 
effort with contributions and participation from nations around the 
world. But it is also an opportunity for the United States to provide 
global leadership.
  Mr. President, this bill is supported by the American Lung 
Association, Results, the Global Health Council, and Princeton Project 
55, an organization formed specifically to fight the international TB 
problem. I ask unanimous consent that the statements of support from 
these groups be included in the Record.
  I am pleased to have their support, and I am pleased to have the 
cosponsorship of my colleagues from Oregon and New Jersey. I hope 
others will join us in this important bipartisan effort.
  Mr. President, I ask unanimous consent that additional material be 
printed in the Record.
  There being no objection, the material was ordered to be printed in 
the Record, as follows:
       Be it enacted by the Senate and House of Representatives of 
     the United States of America in Congress assembled,

     SECTION 1. SHORT TITLE.

       This Act may be cited as the ``International Tuberculosis 
     Control Act of 1999''.

      SEC. 2. FINDINGS.

       Congress makes the following findings:
       (1) Since the development of antibiotics in the 1950s, 
     tuberculosis has been largely controlled in the United States 
     and the Western World.
       (2) Due to societal factors, including growing urban decay, 
     inadequate health care systems, persistent poverty, 
     overcrowding, and malnutrition, as well as medical factors, 
     including the HIV/AIDS epidemic and the emergence of multi-
     drug resistant strains of tuberculosis, tuberculosis has 
     again become a leading and growing cause of adult deaths in 
     the developing world.
       (3) According to the World Health Organization--
       (A) in 1998, about 1,860,000 people worldwide died of 
     tuberculosis-related illnesses;
       (B) one-third of the world's total population is infected 
     with tuberculosis; and
       (C) tuberculosis is the world's leading killer of women 
     between 15 and 44 years old and is a leading cause of 
     children becoming orphans.
       (4) Because of the ease of transmission of tuberculosis, 
     its international persistence and growth pose a direct public 
     health threat to those nations that had previously largely 
     controlled the disease. This is complicated in the United 
     States by the growth of the homeless population, the rate of 
     incarceration, international travel, immigration, and HIV/
     AIDS.
       (5) With nearly 40 percent of the tuberculosis cases in the 
     United States attributable to foreign-born persons, 
     tuberculosis will never be controlled in the United States 
     until it is controlled abroad.
       (6) The means exist to control tuberculosis through 
     screening, diagnosis, treatment, patient compliance, 
     monitoring, and ongoing review of outcomes.
       (7) Efforts to control tuberculosis are complicated by 
     several barriers, including--
       (A) the labor intensive and lengthy process involved in 
     screening, detecting, and treating the disease;
       (B) a lack of funding, trained personnel, and medicine in 
     virtually every nation with a high rate of the disease;
       (C) the unique circumstances in each country, which 
     requires the development and implementation of country-
     specific programs; and
       (D) the risk of having a bad tuberculosis program, which is 
     worse than having no tuberculosis program because it would 
     significantly increase the risk of the development of more 
     widespread drug-resistant strains of the disease.
       (8) Eliminating the barriers to the international control 
     of tuberculosis through a well-structured, comprehensive, and 
     coordinated worldwide effort would be a significant step in 
     dealing with the increasing public health problem posed by 
     the disease.

     SEC. 3. ASSISTANCE FOR TUBERCULOSIS PREVENTION, TREATMENT, 
                   CONTROL, AND ELIMINATION.

       Section 104(c) of the Foreign Assistance Act of 1961 (22 
     U.S.C. 2151b(c)) is amended by adding at the end the 
     following:
       ``(4)(A) Congress recognizes the growing international 
     problem of tuberculosis and the impact its continued 
     existence has on those nations that had previously largely 
     controlled the disease. Congress further recognizes that the 
     means exist to control and treat tuberculosis, and that it is 
     therefore a major objective of the foreign assistance program 
     to control the disease. To this end, Congress expects the 
     agency primarily responsible for administering this part--
       ``(i) to coordinate with the World Health Organization, the 
     Centers for Disease Control, the National Institutes of 
     Health, and other organizations toward the development and 
     implementation of a comprehensive tuberculosis control 
     program; and
       ``(ii) to set as a goal the detection of at least 70 
     percent of the cases of infectious tuberculosis, and the cure 
     of at least 85 percent of the cases detected, in those 
     countries in which the agency has established development 
     programs, by December 31, 2010.
       ``(B) There are authorized to be appropriated to the 
     President, $60,000,000 for fiscal year 2001 to be used to 
     carry out this paragraph. Funds appropriated under this 
     subparagraph are authorized to remain available until 
     expended.''.
                                  ____



                                    American Thoracic Society,

                                                   August 4, 1999.
     Hon. Barbara Boxer,
     U.S. Senate, Washington, DC.
       Dear Senator Boxer: On behalf of the American Lung 
     Association and its medical section, the American Thoracic 
     Society, I want to express our strong support for your 
     legislation, the International Tuberculosis Control Act 1999. 
     This bill will provide needed resources to combat the threat 
     that tuberculosis poses the world and to the United States.
       The American Lung Association was founded in 1904 as the 
     National Association for the Study of Prevention of 
     Tuberculosis.

[[Page S10240]]

     While the American Lung Associations and its medical section, 
     the American Thoracic Society has made steady progress over 
     the past 90 years, much has changed in the area of U.S. 
     tuberculosis control. The two biggest changes have been the 
     development of multi-drug resistant tuberculosis and the 
     growth of foreign-born cases of TB in the U.S.
       Multi-drug resistant tuberculosis (MDR-TB) is a form of 
     tuberculosis that is resistant to two or more of the primary 
     drugs used to treat TB. A strain of MDR-TB develops when a 
     case of a drug susceptible TB is improperly treated. MDR-TB 
     is more expensive to treat and more likely to kill. MDR-TB is 
     on the rise, both in the U.S., and throughout the world. 
     Unless we quickly develop and implement an effective global 
     response to TB, deadly strains of MDR-TB will continue to 
     spread.
       Tuberculosis will kill almost two million people this year. 
     Eight million people will become sick with the disease. Today 
     nearly 40% of TB cases in the U.S. are in foreign-born 
     individuals. We can't stop TB from entering the country. But 
     through our continued support of global TB programs we can 
     reduce the impact of the disease around the world and at 
     home.
       The U.S. Agency for International Development has taken 
     initial steps towards coordinating an international response 
     to the global TB epidemic. Your legislation will provide the 
     U.S. Agency for International Development the resources 
     needed to plan and implement a cooperative global TB control 
     strategy. With direction from Congress and your leadership we 
     are confident that U.S. can lead the way to controlling TB 
     globally.
           Sincerely,
                                                     Fran DuMelle,
     Deputy Managing Director.
                                  ____



                                    Princeton Project 55 Inc.,

                                      Tuberculosis Initiative,

                                   Washington, DC, August 3, 1999.
     Senator Barbara Boxer,
     Hart Senate Office Building,
     Washington, DC.
       Dear Senator Boxer, The Princeton Project 55 Tuberculosis 
     Initiative (TBI) would like to express its support for your 
     sponsorship of the ``International Tuberculosis Control Act 
     of 1999,'' aimed at increasing funding for international TB 
     control. At a time when funding for tuberculosis is severely 
     inadequate, it is important that additional monies be 
     allocated to fight the world's second leading infectious 
     disease killer.
       The TBI commends your leadership in calling attention to 
     the TB threat and your work to increase funding for the 
     international fight against tuberculosis. In order to control 
     TB within the United States, it is crucial that we control TB 
     internationally.
       As you know, although TB is an easily preventable and 100% 
     curable disease, over one third of the world's population is 
     infected with TB and many international TB control programs 
     are poorly managed and underfunded. It has been proven that 
     TB treatment is cost-effective and saves both money and 
     lives. Yet only 16% of TB patients receive the recommended 
     Directly Observed Therapy (DOTS) regimen. The risk of multi-
     drug resistant TB, a strain of TB that is often incurable, 
     has become more widespread as a result of the poorly 
     organized TB control programs.
       Your bill's proposed $60 million for U.S. Agency for 
     International Development (USAID) to support tuberculosis 
     control would expand funding to develop country-specific 
     plans for TB control programs for nations with the highest 
     prevalence of TB. Many of these nations face major barriers 
     to effective TB control programs, including lack of funds, 
     trained personnel, and drug supply. The $60 million would 
     also increase support to develop an integrated global 
     tuberculosis control program in coordination with Centers for 
     Disease Control (CDC), National Institutes of Health (NIH), 
     World Health Organization (WHO), and private voluntary 
     organizations.
       The Princeton Project 55 Tuberculosis Initiative has worked 
     tirelessly with you and other health organizations to 
     increase awareness of the need for increased international 
     tuberculosis funding. Your bill aims to control TB 
     internationally now, before the problem is uncontrollable. 
     The bill also brings needed attention to an often forgotten 
     disease.
       The TBI congratulates your efforts to fight TB and looks 
     forward to working with you in the future, to ensure the 
     passage of your TB bill in the coming legislative session.
           Sincerely,
                                                   Gordon Douglas,
                                                  Project Manager.
                                                      Ralph Nader,
     Steering Committee.
                                  ____



                                        Global Health Council,

                                                   August 4, 1999.
     Senator Barbara Boxer,
     112 Hart Office Building,
     Washington, DC
       Dear Senator Boxer. On behalf of the Global Health Council, 
     a private, not-for-profit membership organization consisting 
     of over 2000 individual and organizational members world-
     wide, I would like to thank you for your support and 
     leadership on the issue of tuberculosis control. Your bill, 
     the ``International Tuberculosis Control Act of 1999,'' is an 
     important step in the prevention of and fight against 
     tuberculosis.
       I would especially like to commend you on your recognition 
     of the increase of tuberculosis internationally and the 
     problem of the development of multiple drug resistant strains 
     of the disease. World wide, more people die of tuberculosis 
     than at any other time in our history--between two to three 
     million deaths per year. Projections indicate that left 
     unchecked, the death toll for this disease could reach as 
     high as 30 million in the next decade.
       The problem of Multiple Drug Resistant Tuberculosis--100 
     times more expensive to treat--is emerging in communities 
     around the world. Inappropriate treatment regimens, self-
     medication, the proliferation of inferior drugs, and 
     interruptions in patient treatment all give TB the 
     opportunity to become resistant to one or more drugs over 
     times, making the disease more expensive and difficult to 
     cure.
       As we move towards a global economy--economic trade policy, 
     improved transportation and tourism, voluntary and forced 
     migration have collectively changed the pattern and spread of 
     infectious diseases. Last year, more than 19,000 people came 
     down with this disease in the U.S.--more than 4,000 in 
     California.
       A 1998 General Accounting report highlights the new 
     reality: the world now has tools and the know-how to vastly 
     improve the health of the four billion humans living in 
     poverty in the developing world. It also makes clear that 
     there are enormous benefits to the American people, both in 
     terms of health and of economics that will come from 
     improving the health of others.
       Your legislation is another step towards achieving this new 
     reality. It sets achievable goals that will work to control 
     the threat of tuberculosis in our nation and in our world. 
     Thank you again for your commitment to this cause. we look 
     forward to working with you to assure global health for all.
           Sincerely,
                                           Nils Daulaire, MD, MPH,
     President & CEO
                                  ____



     RESULTS hails Senator Boxer's Efforts to Control TB's Spread: 
  Tuberculosis is on the rise around the world--killing as many as 2 
                       million people each year.

       Washington, D.C.--Senator Boxer (D-CA), along with Senator 
     Smith (R-OR) and Senator Lautenberg (D-NJ) introduced 
     legislation today which would control the growing problem of 
     tuberculosis internationally. The bill calls for the 
     investment of $60 million next year to jump-start 
     tuberculosis control programs in some of the countries of the 
     world with the highest TB rates.
       Senator Barbara Boxer, a leading health advocate in 
     Congress, is also a member of the Foreign Relations 
     Committee. Her bill sets out to address the fact that despite 
     the existence of an extremely cost-effective TB treatment 
     (according to the World Bank, an investment of between $20-
     $100 can save a life), only 16 percent of those with active 
     TB, actually have access to it.
       The fact that millions of victims are not being treated for 
     TB, combined with its highly infectious nature, has resulted 
     in two million people dying every year from this disease. TB 
     kills more women than any cause of maternal mortality and is 
     the biggest killer of people with AIDS. In addition, with the 
     rise in global travel and with forty percent of TB cases here 
     in the United States attributable to foreign born persons, 
     tuberculosis will never be eliminated in this country until 
     it is controlled worldwide. Multi drug resistant TB, the 
     result of poor treatment programs, threaten to render this 
     disease incurable unless we act now.
       RESULTS Executive Director, Lynn McMullen, praised Boxer 
     for her leadership. ``Thanks to the efforts of Senator Boxer 
     and her colleagues, TB will not be allowed to spread 
     unchecked around the world. Her commitment to controlling 
     this plague will mean millions of lives saved.''
       RESULTS is a citizens grassroots advocacy organization 
     which works to end hunger and the worst aspects of poverty.

  Mr. SMITH of Oregon. Mr. President, I am pleased to join my colleague 
Senator Boxer in introducing this legislation to help control a deadly 
and easily communicable disease--tuberculosis (TB). I, like many of 
you, thought we had this scourge under control since the development of 
antibiotics more than 40 years ago.
  However, TB is a real problem here and abroad. It is a disease that 
knows no borders--because of the ease of transmission of TB, its growth 
abroad poses a real public health threat to nations like the United 
States that had previously controlled TB.
  Our bill will authorize $60 million in FY 2001 to help control this 
deadly disease. This bill calls for a coordinated effort to wipe out 
this disease and sets goals for the detection and cure.
  The statistics surrounding tuberculosis are terrifying. TB kills 
almost 2 million people abroad every year. The rate of infection abroad 
is increasing each year and TB is transmitted as easily as the common 
cold. Every second someone is infected with TB. Further, TB is the 
leading killer of women, more than any single cause of maternal

[[Page S10241]]

mortality. This has an enormous impact on families and the very social 
fabric of a society. TB is the leading cause of death among HIV-
positive individuals. It accounts for almost one-third of AIDS deaths 
worldwide.
  Many TB cases are easily treatable by a six-month antibiotic regimen. 
Tragically, this regimen is only used in 15% of TB cases worldwide. An 
untreated person with active TB will infect 10-15 people per year. TB 
control programs are underfunded and poorly organized in many 
countries. Since millions of people travel between the U.S. and other 
nations daily, we must develop stable country-specific programs that 
will control this disease.
  I believe that our bill is a good strong step towards ending TB here 
and abroad and I look forward to working with my colleague from 
California on this legislation. I ask all my colleagues in the Senate 
to support his important legislation.
  Mr. LAUTENBERG. Mr. President, I rise as a proud cosponsor of 
legislation the Senator from California, Senator Boxer, is introducing 
today, the ``International Tuberculosis Act of 1999.'' This bill seeks 
to control the growing international problem of tuberculosis.
  Mr. President, we cannot stand idly by while tuberculosis kills more 
people worldwide than AIDS and malaria combined, and yet still receives 
substantially less attention and aid dollars.
  Although the introduction of antibiotics in the 1950's led to the 
near eradication of tuberculosis, it still plagues many nations 
throughout the world. In 1993 the World Health Organization declared 
tuberculosis to be a public health emergency, with an estimated 1,700 
million people, or nearly one third of the world's population, infected 
with the tubercle bacillus. The World Health Organization estimates 
that eight million people get TB every year, and an estimated 3 million 
die from the disease annually.
  Mr. President, the registered number of new cases of TB worldwide 
roughly correlates with economic conditions: the highest incidences are 
seen in those countries of Africa, Asia, and Latin America with the 
lowest gross national products. We must now face the realization that 
without much needed aid, most of the countries with a high burden of TB 
will not be able to reach the targets for TB control established by the 
World Health Assembly for the year 2000. In human terms, this means 
that each year millions of lives could be lost due to a preventable and 
curable disease.
  Thankfully, Mr. President, efforts to combat this terrible disease 
have been largely successful inside U.S. borders. In my own State of 
New Jersey, the number of people with active tuberculosis has declined 
each year for the past six years. But the problem still persists. Each 
year over 25,000 people in the United States contract TB. The treat of 
infection here in America still looms large for anyone who travels 
abroad or comes into contact with those who have recently traveled 
outside the United States. This disease does not discriminate: People 
of all ages, all nationalities and all incomes can get tuberculosis.
  An airborne disease that can be spread through a simple cough, TB can 
be carried around the world in a matter of hours on a transcontinental 
flight. Nearly 40 percent of TB cases in the U.S. are attributable to 
foreign-born persons. Until TB is eradicated worldwide, no person--no 
American--will ever be safe from its affliction.
  Only small steps have been taken to eradicate TB outside the United 
States. Medical experts estimate that over $1 billion is necessary to 
control TB. This money will allow scientists and doctors to take the 
necessary steps to wipe out this disease, much like the world community 
has already done with malaria and small pox. The longer we wait, the 
larger the TB population will be. This translates into higher costs to 
eradicate this debilitating disease. International organizations note 
that for every dollar spent on prevention, a nation saves between three 
and four dollars in treatment.
  Mr. President, TB control efforts have received approximately $12 
million a year for the last two fiscal years under USAID's Infectious 
Disease Initiative to create a TB Global Action Plan. However, this is 
not enough; an increase in funding is critical if tuberculosis is to be 
vanquished. The U.S. must do its part.
  An increase in funding to $60 million for TB would help expedite 
global action, and give aid officials the necessary resources to 
develop and implement country specific plans for control programs for 
nations with a high prevalence of TB. Once a plan is implemented, it is 
necessary to formulate a systematic program to avoid increases of drug 
resistant strains of TB.
  A plan, coordinated with the World Health Organization, the Centers 
for Disease Control, the National Institutes of Health and other 
organizations, will expand and provide a framework for enhanced 
direction and coordination of worldwide tuberculosis research 
activities, translate research results into efficient and effective TB 
control practices which are applicable to all environments, and engage 
society and government control programs more quickly and widely.
  The American Lung Association, American Thoracic Society and 
International Union Against Tuberculosis and Lung Disease and other 
renowed organizations support an increase in funding for TB prevention.
  Mr. President, a global TB prevention effort makes sense. The 
benefits outweigh the costs. Given the importance of a global plan to 
eradicate TB, and its potential in saving lives, I urge the Senate to 
approve this bill.
  Mr. President, tuberculosis is a global problem. We will never 
control TB in this country until we control it worldwide, since 
infectious diseases do not stop at the border. I commend the Senator 
from California for introducing this important and timely legislation 
to address tuberculosis effectively now. I hope and believe this bill 
will gain the support of the full Senate.
  I yield the floor.

                          ____________________