SPEAKERS CONTENTS INSERTS
Page 1 TOP OF DOC
46–765 CC
1997
THE THREAT TO THE UNITED STATES FROM EMERGING INFECTIOUS DISEASES
HEARING
BEFORE THE
COMMITTEE ON
INTERNATIONAL RELATIONS
HOUSE OF REPRESENTATIVES
ONE HUNDRED FIFTH CONGRESS
FIRST SESSION
JULY 30, 1997
Printed for the use of the Committee on International Relations
COMMITTEE ON INTERNATIONAL RELATIONS
BENJAMIN A. GILMAN, New York, Chairman
WILLIAM GOODLING, Pennsylvania
JAMES A. LEACH, Iowa
HENRY J. HYDE, Illinois
Page 2 PREV PAGE TOP OF DOC
DOUG BEREUTER, Nebraska
CHRISTOPHER SMITH, New Jersey
DAN BURTON, Indiana
ELTON GALLEGLY, California
ILEANA ROS-LEHTINEN, Florida
CASS BALLENGER, North Carolina
DANA ROHRABACHER, California
DONALD A. MANZULLO, Illinois
EDWARD R. ROYCE, California
PETER T. KING, New York
JAY KIM, California
STEVEN J. CHABOT, Ohio
MARSHALL ''MARK'' SANFORD, South Carolina
MATT SALMON, Arizona
AMO HOUGHTON, New York
TOM CAMPBELL, California
JON FOX, Pennsylvania
JOHN McHUGH, New York
LINDSEY GRAHAM, South Carolina
ROY BLUNT, Missouri
JERRY MORAN, Kansas
KEVIN BRADY, Texas
LEE HAMILTON, Indiana
SAM GEJDENSON, Connecticut
TOM LANTOS, California
Page 3 PREV PAGE TOP OF DOC
HOWARD BERMAN, California
GARY ACKERMAN, New York
ENI F.H. FALEOMAVAEGA, American Samoa
MATTHEW G. MARTINEZ, California
DONALD M. PAYNE, New Jersey
ROBERT ANDREWS, New Jersey
ROBERT MENENDEZ, New Jersey
SHERROD BROWN, Ohio
CYNTHIA A. McKINNEY, Georgia
ALCEE L. HASTINGS, Florida
PAT DANNER, Missouri
EARL HILLIARD, Alabama
WALTER CAPPS, California
BRAD SHERMAN, California
ROBERT WEXLER, Florida
STEVE ROTHMAN, New Jersey
BOB CLEMENT, Tennessee
BILL LUTHER, Minnesota
JIM DAVIS, Florida
RICHARD J. GARON, Chief of Staff
MICHAEL H. VAN DUSEN, Democratic Chief of Staff
MARK KIRK, Counsel
PARKER H. BRENT, Staff Associate
C O N T E N T S
Page 4 PREV PAGE TOP OF DOC
WITNESSES
Major David Hernandez, Aeromedical Isolation Team, U.S. Army
Dr. David Heymann, Director, Division of Emerging and Other Communicable Diseases, World Health Organization
The Honorable Sally Shelton-Colby, Assistant Administrator, Bureau for Global Programs, Field Support and Research, U.S. Agency for International Development
APPENDIX
Prepared statement of Dr. David Heymann
Additional information provided by Dr. David Heymann
Prepared statement of Ambassador Sally Shelton-Colby
Additional information provided by Ambassador Shelton-Colby
Prepared statement of Congressman Robert Menendez
Testimony submitted for the record by the University of Medicine and Dentistry of New Jersey
Testimony submitted for the record by the University of Miami School of Medicine
Responses to questions submitted for the record from the World Health Organization
Responses to questions submitted for the record from the U.S. Agency for International Development
THE THREAT TO THE UNITED STATES FROM EMERGING INFECTIOUS DISEASES
WEDNESDAY, JULY 30, 1997
House of Representatives,
Page 5 PREV PAGE TOP OF DOC
Committee on International Relations,
Washington, DC.
The Committee met, pursuant to notice, at 10:36 a.m. in room 2172, Rayburn House Office Building, Hon. Benjamin A. Gilman, (chairman of the Committee) presiding.
Chairman GILMAN. The Committee will come to order. The purpose of today's hearing is to focus congressional attention on emerging and infectious diseases that threaten Americans here and abroad.
There is, however, another disease that threatens all civilized peoples and that is a disease of terrorism. As is well known by now, a pair of terrorist bombings in Jerusalem today in the vegetable market there have left more than a dozen people dead and scores wounded, approximately 150 to date. This terrorism has had but one objective, and that is to destroy what has been a very fragile peace process involving Israel and the Palestinians.
It is not enough for Yasser Arafat, as he has done, to express his personal sorrow for this tragic incident. He is going to have to do more to prevent these from happening. He must marshall the resources of the Palestinian authority to track down and punish those who plan, support and engage in terrorism, and there must be increased cooperation with the Israeli security forces. Mr. Arafat must also speak out publicly and strongly against all acts of terrorism in Arabic, as well as in English. Unless Mr. Arafat and his fellow Palestinian leaders make it crystal clear that terrorism against Israelis is not acceptable, then they risk losing all that they have struggled to gain through the peace process.
With regard to the issue at hand, smallpox was a deadly, infectious disease that has been eradicated through the application of medical science. Eradicating the deadly disease of terrorism requires the application of political will by the leaders of the Palestinian authorities. Our hearing today on infectious and emerging disease will begin with a briefing and demonstration by our U.S. Army and some of the equipment that our government has ready to respond to any outbreak of a deadly disease.
Page 6 PREV PAGE TOP OF DOC
We will then hear from Sally Shelton-Colby, Assistant Administrator of the Agency for International Development for Global Programs for Field Support and Research and Dr. David Heymann, Director of the Division of Emerging and Other Communicable Diseases of the World Health Organization (WHO). They will review the scope of the threat and what we can do about it.
This topic is very old and yet very new. In the 1340's, the Black Death killed one-third of all Europeans in what then looked like the end of the known world. In the 1620's, small pox and measles killed a major part of the American Indian population that had little resistance to what then were common European diseases. As late as 1918, thousands of Americans died in a worldwide influenza epidemic.
With the advent of antibiotics and other advanced drugs, the health of Americans has improved and become more secure, even complacent about infectious communicable diseases. Many of us remember President Ford's warning of the Swine flu epidemic that failed to materialize. However, if Americans feel secure from the threat of old fashioned epidemics, I believe some of that security is certainly misplaced. Let us take a look at some of the pertinent facts. Twenty years ago, drug-resistant malaria was found in Asia and it has now spread worldwide. Twenty years ago, the HIV virus was limited to Africa and to a few individuals in the West. Today, it has infected more than 10 million people worldwide, including two million of our own citizens. Twenty years ago, the highly lethal ebola virus was first found in the Sudan. Cases have been now been reported in Congo, in the Ivory Coast and even in the United States.
Drug-resistant pneumonia, cholera and plague have all spread to become international problems requiring international solutions. We in the Congress must wake up to this threat and we must bolster our efforts to combat it, because these diseases can be overcome if sufficient resources are properly marshalled.
In 1977, the world community banded together to eradicate the small pox virus from the face of our planet. I understand we may celebrate the final end of the last remaining lab small pox viruses on New Year's Eve, 1999. We have now dedicated our country to backing the international community's effort to wipe out polio within a 10-year period. We certainly support that effort.
Page 7 PREV PAGE TOP OF DOC
But, more is needed. Each year, thousands of people fall victim to endemic, debilitating diseases, such as River Blindness and the Guinea-Worm, particularly in undeveloped countries. The toll in human health and economic costs is incalculable and is a major impediment in the development of these countries.
At my request, the WHO has prepared an analysis of debilitating diseases that we now have the ability to eradicate, how long it would take and what the costs would be. According to WHO, we could eliminate debilitating diseases such as the Guinea-Worm in the year 2000, River Blindness by the year 2008 and Chagas Fever by the year 2010. While these diseases are not found anywhere here in our nation, neither were AIDS or Ebola virus.
With increased international trade and increased travel, the oceans are no longer barriers to disease for Americans here. Eliminating these and other eradicable diseases such as measles and leprosy would take approximately 30 years of a coordinated effort. The total cost to the world community over that period is estimated to be some $2 billion. The cost to the American taxpayer would be about $20 million a year.
We have a world without smallpox. Let's try to imagine a world without leprosy or measles, and we can do that. I know that some in USAID would like to focus resources on treating malaria and dysentery. We need to do that, but I suggest we can do even more. We are fully capable of eliminating whole classes of diseases from our planet. Our nation will save $250 million a year once polio is gone, to cite just one example. We will save much more once measles is gone, and we could go on and continue that long list.
Before we begin, I would like to call on our Ranking Minority Member, the gentleman from Indiana, Mr. Hamilton, for an opening statement.
Mr. HAMILTON. Thank you very much, Mr. Chairman. I want to commend you for having the hearing. I cannot remember when this Committee has focused on this particular topic of infectious diseases and I think it is a very appropriate topic for us. I thank you for providing the forum for it.
Page 8 PREV PAGE TOP OF DOC
I want to welcome, of course, our distinguished witnesses, especially Ambassador Shelton-Colby, who has served in a number of positions with distinction. We are delighted to have you here again, I might say, and the other witnesses, as well.
Let me just say that I appreciate very much the work that USAID and WHO are doing in combatting infectious disease around the world. You can be very proud of that, and I think all Americans can be proud of the fact that we are supporting your efforts.
I do not know an awful lot about your programs. I will learn more about them here, but I do understand you have had some successes in Thailand and Costa Rica, that you have a comprehensive approach to preventing these diseases, and I commend you for that effort and that strategy and all of the people that work with you in achieving those successes. So, we look forward to hearing from you. Thank you very much for coming.
Chairman GILMAN. Thank you, Mr. Hamilton. Do any of our other Members seek recognition at this point? If not, we will open our hearing. Before introducing our distinguished panel, we will have a short briefing on the kind of equipment available to our government to respond to the outbreak of an infectious disease both here at home and overseas.
I would like to welcome Major David Hernandez of the U.S. Army Medical Research Institute, headquarters located at Ft. Detrick, Maryland. Major Hernandez, welcome to our International Relations Committee. You may proceed. You may put your full statement into the record and summarize, or whichever you may deem appropriate. Major Hernandez.
STATEMENT OF MAJOR DAVID HERNANDEZ, AEROMEDICAL ISOLATION TEAM, U.S. ARMY
Major HERNANDEZ. Sir, this morning I have part of the Aeromedical Isolation Team from USAMRIID at Ft. Detrick. This team is designed to respond in a rapid mode to go anywhere in the world to bring back in high containment any patient that has been exposed to or infected with a highly contagious disease.
Page 9 PREV PAGE TOP OF DOC
Our mission is such that we have the only type of equipment in the country and I have brought several of those devices here to show you. To begin with, I have, I do not know if you can see it to the left over here, this little stretcher. It is a portable isolator. None of the devices are high tech. They are pretty simple.
One is a negative pressure device. Once we put the patient into the stretcher, we turn the machine on and it causes a negative pressure, so that if there is a compromise, none of the organisms will be exposed to the area. We seal it off, decontaminate it, and then we transfer the patient to the bigger model, which is an isolator. It is the same principle as the negative pressure device, that has all these little gloves that you can work on the patient. We can actually start treating the patient. We can intubate it and provide mechanical ventilation if we have to. We can draw blood, we can medicate, and we can stabilize the patient and bring them back to USAMRIID, where we can undergo and try to determine what was causing the high fever or deterioration of the patient.
We have two positive device suits that we wear. One is the famous blue suit that is hanging on the rack. That is a positive suit you hook up to oxygen. It blows up like the Pillsbury Doughboy suit, and it actually is a barrier. You can work with that inside our hot suite, which is a critical care unit, and provide total care to the patient. However, it is bulky, it is cumbersome to use and you cannot stay in it more than 4 hours. You really start dehydrating.
The plastic portable suits that we have here are called the racal suits. Those are the suits that we would deploy from the plane, go out and secure the patients. These funny looking pink suits are very effective. They do protect you. If you can turn around, they have battery packs that have filters on them, they have three filters. These filters are designed to filter out all harmful agents. They will filter out up to .3 microns, which is enough to remove all biological and viruses that are harmful. The same filters are designed for the isolator and the stretcher.
Page 10 PREV PAGE TOP OF DOC
They are not refrigerated. They just take the air from the outside and filter it, so we are not able to stay in them very long, for more than several hours in the heat. But, we can quickly decontaminate the patient, put them in the isolator and remove the equipment. That is all I have to say. Certainly, if you have some questions, I would be more than happy to answer them.
Chairman GILMAN. I am going to suggest to my colleagues that if you would like to personally examine the equipment for a few minutes before we go on with the hearing, I invite you to join us down here at the equipment.
[Recess.]
Chairman GILMAN. Gentlemen, the hearing will recommence and I thank the witnesses for being patient. I would now like to introduce Dr. David Heymann, Director of WHO's Division of Emerging and Other Communicable Diseases, Surveyance and Control. Dr. Heymann has authored 69 peer-reviewed scientific publications on hemorrhagic fevers, HIV/AIDS and other key topics to be covered today. I will also note that following the Cable News Network's ground-breaking series, The Coming Plague, which highlighted Dr. Heymann's work, he has become something of a high-profile spokesman in this field.
Dr. Heymann, we thank you for coming from Geneva to meet with us today. We want to welcome, also, Dr. Stephen Corber, Director of the Pan American Health Organization's Division of Disease Prevention and Control. The Pan American Health Organization's World Health Organization's regional office here in America is to combat the diseases we will talk about today. Welcome, Dr. Corber. Is Dr. Corber here? Will you come up to the table, also, Dr. Corber?
Gentlemen, you may proceed. You may put in your full statement, or summarize it, whichever you deem appropriate.
STATEMENT OF DR. DAVID HEYMANN, DIRECTOR, DIVISION OF EMERGING AND OTHER COMMUNICABLE DISEASES, WORLD HEALTH ORGANIZATION; ACCOMPANIED BY DR. STEPHEN CORBER, DIRECTOR, PAN AMERICAN HEALTH ORGANIZATION, DIVISION OF DISEASE PREVENTION AND CONTROL
Page 11 PREV PAGE TOP OF DOC
Dr. HEYMANN. Thank you, Mr. Chairman, Congressman Hamilton and Members of the Committee. WHO appreciates the opportunity to provide information to the Committee on the critical importance of strengthening international cooperation and participation in the surveillance, prevention and control of infectious diseases. WHO is the organization given the mandate by its 191 member countries to analyze the world situation of infectious diseases in great detail, to alert governments and others in a position to act, and to create a common approach and framework for the global response.
My verbal remarks will briefly describe the current infectious disease problem in the world, and the acceleration in the spread of these diseases, many of which were once considered under control. They will also outline the framework and activities which WHO has developed to encourage and facilitate international collaboration in surveillance, prevention and control of infectious diseases.
My written statement describes the problems in much more detail, and page 5 of that statement outlines four major areas which are top priority for the worldwide attention to control the threat of infectious diseases in every country. These are strong national infectious disease surveillance, prevention and control; global monitoring and alert systems electronically connected to WHO's data banks on infectious diseases; and international preparedness.
My written statement also describes the importance of engagement in these issues by every country, including the United States. As public health professionals, my colleagues at WHO and I are acutely aware that these brief statements can only begin to convey some of the most important challenges and opportunities the world community faces now in its ongoing battle against infectious diseases.
Many partners are involved in the global effort; countries, international organizations, business and industry, non-governmental organizations, scientific laboratories, research institutions, universities and the monitoring group of the Biological Warfare Convention. We at WHO would be pleased to work with any Member of the Committee who wishes more detailed information on any of these issues.
Page 12 PREV PAGE TOP OF DOC
I would like to now focus your attention to the first chart on your left. The 27 green dots on this map show a small portion of the infectious disease outbreaks which occurred throughout the world during 1996. These outbreaks have added to the already heavy burden of underlying infectious diseases, such as malaria, diarrheal diseases, tuberculosis, pneumonia and AIDS. Some of these diseases create ominous associations, such as TB and HIV, in which HIV makes people more susceptible to TB, thus fanning the tuberculosis epidemic.
Others suggest that infectious diseases can effectively jump the species barrier from animal to man, such as is the case of BSE or Mad Cow Disease in the United Kingdom. Over a half million cases of dengue, a viral disease carried by mosquitoes, have been reported from Latin America during the past 2 years. During 1996, a tourist to Latin America returned to Tennessee with yellow fever. Each year, close to 1,000 U.S. citizens who travel overseas and return to the United States return with malaria. In some instances, mosquitoes here in the United States have bitten these persons and have then gone on to bite other U.S. citizens who have never travelled internationally, thus giving them malaria as well.
This map shows the distribution of malaria in the United States 50 years ago. The States in green were countries where epidemic malaria occurred. They are mainly located in the Southeast, as you can see. Malaria was eliminated from the United States in the 1960's, but mosquitoes that can carry malaria, dengue and yellow fever, remain present in these States and others. These mosquitoes moved north to the great metropolitan areas in the summer. Strong surveillance and control of dengue, yellow fever and malaria in developing countries will lead to prevention and containment where these diseases occur, thus minimizing the possibility of their spread to the United States.
The rows of bars on this graph show that cholera has been on the increase throughout the world during the last 20 years. But, as shown by the row of turquoise bars in the back, the increase has mostly been in Latin America. Over 1.4 million cases of cholera have been reported from Latin America to WHO since 1991. This is only a fraction of all the cases which have actually occurred. Up to 10 percent of those who developed cholera died. Cholera costs countries in human suffering and death, patient care, lost economic output and trade sanctions. Peru lost $770 million in 1991 because of bans on its seafood exports after cholera entered that country.
Page 13 PREV PAGE TOP OF DOC
Cholera could have posed a real threat to the United States if unsuspecting authorities had not been alerted by information from WHO and if WHO, through the PAHO regional office here in Washington had not worked intensively with Latin American countries to stop its spread.
The next map shows one of WHO's global surveillance systems. It is WHO's collaborating centres' laboratory network for monitoring bacterial, viral and animal diseases worldwide. These are national laboratories of excellence, supported by the countries in which they are located and chosen by WHO for their geographic representativeness and areas of expertise.
The location of the laboratories in the network is shown in this map. The countries in pink have the most WHO collaborating centres while those with no color have none. Strong national laboratories that collaborate with WHO will ensure early detection of infectious diseases. Information from these laboratories is used nationally and provided directly to WHO for ensuring global alert so that when diseases of international importance occur, there may be an immediate international response to prevent their spread.
WHO is expanding this network to more developing countries where there are presently no collaborating laboratories, and is linking all laboratories electronically.
Tuberculosis is on the increase throughout the world, in both developing and industrialized countries. The multicolored bars on this graph show that TB has steadily increased from 1990 to 1995 and is projected to continue its increase to the year 2000, despite control activities which are already underway. Last year, there were 53,000 deaths a week from tuberculosis throughout the world, mainly in adults in the reproductive years of life. The antibiotics used to treat tuberculosis are becoming less effective, because tuberculosis bacteria are developing resistance. WHO evaluates TB therapies and works with countries to establish effective tuberculosis control programs.
International travel spreads infectious diseases. It also spreads micro-organisms that have developed resistance to antibiotics. Strains of the bacteria that cause common pneumonia, a major adult killer in the United States, resist both old and new antibiotics. This map shows that during a period of weeks in the early 1990's, a strain of pneumonia-causing bacteria which was resistant to all commonly used antibiotics spread from Spain throughout the world. Man, like a mosquito, has become a vector of infectious disease. Antibiotic resistance and infectious diseases spread rapidly. Death rates increase when antibiotics no longer work effectively, and costs for treating patients increase.
Page 14 PREV PAGE TOP OF DOC
WHO works with developing countries to ensure that antibiotic resistance is tracked, that prescribing practices are correct, and that resistant organisms are contained at their source.
This next map shows the location of the laboratories participating in the WHO system for monitoring drug-resistant tuberculosis. Countries in green are fully participating, while those in yellow are planned for participation. The countries in white are not yet enrolled in the system. Highly specialized antibiotics, such as those used to treat tuberculosis, must be monitored worldwide so that when resistance develops, the organisms can be contained before they spread. Knowing that resistant strains are present permits selection of combinations of antibiotics which will compensate for resistance and cure tuberculosis infections.
The next chart shows the new WHO network of laboratories for monitoring resistance to the more commonly used antibiotics, used to treat a wide range of infections from pneumonia and gonorrhea to ear, intestinal and kidney infections. They include such common antibiotics as penicillin and tetracycline. Information from the network is used nationally as WHO helps countries develop effective treatment policies for common infections, thus preventing the spread of resistant organisms.
Earlier this year, eight developing countries in Asia and Africa, shown in purple on this map, were brought into the network with support from Japan, the U.S. Pharmaceutical Research and Manufacturers Association, the United Kingdom and CDC. Presently, laboratories in the countries in yellow are being brought into the network. The network must be rapidly expanded to other developing countries in Africa and Latin America, to both human and veterinary laboratories, and linked electronically to industrialized country networks, so that we are aware of the true picture of antibiotic resistance.
One solution, as the Chairman has indicated, to the infectious disease problem and the problem of anti-microbial resistance is eradication. Getting rid of a disease means getting rid of the organism which causes it and therefore, any resistance that might develop to that organism. Smallpox, as the Chairman said, was eradicated in 1977 and the United States saves its investment in the global smallpox eradication program every 30 days. We anticipate that with the continued support from the United States, polio will be the next infectious disease to be eradicated. This map shows the steady decrease in polio during the 8 years since the WHO global program was begun.
Page 15 PREV PAGE TOP OF DOC
But, most infectious diseases are not candidates for eradication and for the majority of these infectious diseases, we must concentrate on strong prevention and control systems where these diseases are occurring, in order to prevent suffering, death and international spread.
New vaccines to prevent many of these diseases are essential, as are new antibiotics for their treatment. Influenza is one of the many infectious diseases which cannot be eradicated. It is caused by a virus which is continually changing, making the vaccine used one year ineffective the next. Each year in the United States, between 10,000 and 40,000 senior citizens die from influenza, and influenza costs the United States $17 billion annually in direct medical costs and lost productivity.
This map shows the WHO network for surveillance on influenza worldwide. The countries in red support their own laboratories, which then provide information about the influenza virus strains to WHO. The countries in yellow and orange are directly supported by WHO, so that they can also participate in global surveillance. The countries in white presently do not have laboratories to monitor influenza.
WHO is expanding the network in southern China, where new influenza viruses frequently jump the gap between animals and humans and cause epidemics such as that which killed at least 20 million people in 1918. Information on virus strains obtained from all these laboratories in the WHO influenza network is provided to the pharmaceutical industry every month of February, for the production of reformulated vaccines, which prevent influenza in the very young and aging populations the following year.
This map shows the rapidity with which AIDS, a disease which has recently emerged in humans, has increased in Africa during the past 17 years. In 1980, less than 1 percent of the African population was infected with the AIDS virus, shown in light yellow on the map at the left. By 1994, this percentage had increased to well over 10 percent in many of these same countries, shown in pink.
Page 16 PREV PAGE TOP OF DOC
If global surveillance and control systems, such as WHO is establishing, had been in place and functioning during the 1970's, the magnitude of the AIDS problem would probably not be so severe today.
I would like to call your attention, Mr. Chairman, to the first chart again, to remind you that infectious diseases occur throughout the world. They know no boundaries. They are becoming resistant to antibiotics which were once the mainstay of their treatment and are spread far and wide by international travel. They are increasing because of weakened public health infrastructure, and are linked to behavior, deforestation, climate change and social upheaval. They divert resources from other endemic diseases, such as tuberculosis, pneumonia and AIDS. It is in the interest of the world community to strengthen WHO's program to strengthen national and international capacity to detect and control infectious diseases, to ensure their containment at the source, and to expand WHO's global surveillance, alert and response networks and its electronic information systems.
U.S. support could make the decisive difference in how rapidly and how well the job can be done. Thank you, Mr. Chairman.
[The prepared statement of Dr. Heymann appears in the appendix.]
Chairman GILMAN. Thank you, Dr. Heymann. We will next hear from Ambassador Sally Shelton-Colby, Assistant Administrator for Global Programs at the U.S. Agency for International Development. Ambassador Shelton-Colby is responsible for USAID's work on health, including our current efforts to stamp out polio. Madam Ambassador, you are always welcome here at our Committee. It is good to see you back here, no matter what distinguished post you currently hold while serving your nation.
You may proceed with your full statement or you may summarize it, whichever you see fit. Please proceed.
STATEMENT OF SALLY SHELTON-COLBY, ASSISTANT ADMINISTRATOR FOR GLOBAL PROGRAMS, U.S. AGENCY FOR INTERNATIONAL DEVELOPMENT
Page 17 PREV PAGE TOP OF DOC
Ms. SHELTON-COLBY. Thank you very much, Mr. Chairman and it is very nice to be back here and see you, again, and Congressman Hamilton, as well. I would like to submit my written statement for the record and if you would allow me to synthesize it.
Chairman GILMAN. Without objection.
Ms. SHELTON-COLBY. I will briefly describe USAID's role in addressing infectious disease in the developing world. We are all aware of the threat to our national security and the well being of the global community and as Dr. Heymann indicated, no disease is more than a day away from our own shores. National boundaries are irrelevant to microbes. So, to effectively deal with infectious disease, we must go to their source, and the source, in many cases, is the developing world.
I would like to call attention to a very interesting UNICEF report that was published 2 weeks ago, which starkly underscored what a fertile breeding ground for infectious disease the developing world has become. According to this report, nearly three billion people, that is to say slightly more than half the world's population, do not have access to even a minimally sanitary toilet. As the author of the study noted, when you have a medieval level of sanitation, you have a medieval level of disease.
Now, acute outbreaks of exotic diseases such as Ebola, such as the plague, have dominated our headlines in recent years. These make for great movies and books, but one should not overlook the fact that today's true killers are more well known and more routine, if you will. Deaths from high visibility disease like Ebola have numbered in the hundreds. In contrast, every year, 17 million people die from malaria and tuberculosis and dehydration from diarrhea and other infectious diseases.
Other diseases can be prevented by simple vaccines, so combatting these major killers is USAID's most important challenge. As you know, Mr. Chairman, USAID has been involved for almost three decades in international health programs. We work along with WHO, PAHO and other international health organizations to conduct immunization programs around the world, which we estimate save approximately three million lives a year.
Page 18 PREV PAGE TOP OF DOC
Dr. Heymann made mention of the international polio eradication campaign which we are conducting in conjunction with Rotary, WHO and UNICEF. We have eradicated polio from the Western Hemisphere, and we expect that we will be able to eradicate it from the rest of the world by the year 2000. In addition, we are developing and strengthening over 100 national diarrheal disease control systems around the world, so that today, three-quarters of the world's population now have access to oral rehydration therapy. We estimate that this saves the lives of one million children annually.
USAID has put a high priority on fighting infectious disease. Last year, we spent approximately $320 million for prevention, control and treatment of infectious disease. This is the largest bilateral contribution to combatting infectious disease in the world. For this fiscal year, we expect to spend approximately the same level as we would for next fiscal year. We hope very much that we will be able to avoid an earmark for infectious disease, which again is a priority of ours, but we would hope, unless the foreign assistance budget were to expand, not to have to take scarce resources from other development priority areas.
Our approach to infectious disease, Mr. Chairman, consists of four inter-related elements. First we work to change the social and economic conditions within which infectious diseases breed: poverty, lack of sanitation, rapid population growth and environmental degradation.
Second, we work to improve health systems, which Dr. Heymann also addressed, so the developing countries can themselves take more effective control of infectious diseases.
Third, we are working to focus on specific targeted programs to address priority diseases, and last, we are continuing to increase our capacity to respond to emergencies such as Ebola. I will elaborate just very, very briefly in the interest of time on each of these. Addressing the social and economic conditions that foster disease has been recognized by a number of international health organizations, including the Institute of Medicine, as one of the most important ways of controlling infectious disease.
Page 19 PREV PAGE TOP OF DOC
Such factors as the breakdown of public health systems, microbial adaptation, economic development, land use and human behavior are very important elements in the spread of infectious disease, and many of our programs across USAID deal with these issues, above and beyond the work being done in our immediate health portfolio. Our efforts in family planning are well known to this Committee, as is our work in economic development, agriculture and food security, our agency's water and sanitation programs, sustainable agricultural practices, natural resource management programs, all contribute to the management of infectious disease and the containment of infectious disease.
In the second area, improving public health systems, which Dr. Heymann also mentioned, we are working very hard to improve the capacity of developing countries' health systems to help developing countries take this burden on more effectively themselves, so that we may wind down our foreign assistance programs in these countries.
Developing countries must develop the capability of managing, running and supporting their own health systems if they are to control infectious diseases. To help in this, we have trained hundreds of thousands of health care professionals from developing countries over the next 30 years. We are working with developing countries to reform health systems policies, and to help develop self-supporting finance mechanisms, so that when USAID programs come to an end, as Congressman Hamilton had indicated, in countries like Thailand and Costa Rica, those governments will be able to take on infectious disease management themselves.
A third area where we work is targeting priority disease. Of the 17 million annual deaths from infectious disease, Mr. Chairman, the majority are among children. Infectious diseases continue to be the single largest killer of children around the globe. We have worked closely with the Congress in recent years with regard to our child survival program, which is very heavily aimed at infectious disease, specifically with regard to control of diarrheal disease, including cholera and dysentery, that cause more than three million annual deaths and hundreds of millions of infections, prevention and control of pneumonia, which is responsible for four million deaths annually. Immunizations against the major vaccine preventable diseases of childhood, such as measles, tetanus, diphtheria and polio. Malaria has already been discussed. Malaria is responsible for two million deaths annually, 90 percent of which are among children, and many others.
Page 20 PREV PAGE TOP OF DOC
Mr. Chairman, there is one area which I think has gotten inadequate attention and which I would like to flag briefly this morning. That is the impact of HIV/AIDS on children. I think that when we have looked at HIV/AIDS, we have tended to think of it as an adult disease, but it is impacting children more and more. The statistics are just stunning.
About 550,000 new HIV infections in children occur every year. That translates to 1,450 new perinatal infections every day, Mr. Chairman. Essentially, all of these children are going to die by their fifth birthday. You know, I think the world should be very proud of the declines in infant mortality and early childhood mortality in recent years. Yet, because of HIV/AIDS, we are seeing tragic increases in infant mortality in some parts of the world, especially in Eastern Africa. In Kenya, in Zambia, in Zimbabwe, in Tanzania and Uganda, infant mortality and early childhood mortality would be much lower if it were not for HIV/AIDS.
Let me give you a couple of really terrifying estimates, Mr. Chairman. This year, we are estimating that childhood mortality rates in Kenya will be 95 per thousand. Without HIV/AIDS, they would have been 68 per thousand. By the year 2010, AIDS will result in a doubling of the childhood mortality rate in Kenya and Zambia. I think we need to focus much more on the HIV/AIDS component of infant and early childhood mortality than we have.
USAID is working with 500 private voluntary and non-governmental organizations around the world and we are very proud of what we are accomplishing. We can discuss that more, perhaps, during the question and answer period, if you are interested. We are also working to develop new technologies. Now, since I knew that my co-testifiers, witnesses, would have props, I brought some, as well, Mr. Chairman.
Chairman GILMAN. Ambassador Shelton-Colby, both Mr. Hamilton and I are going to have to go to a conference committee with the Senate in a few minutes, and I am just wondering if you could quickly summarize, so we might be able to have an opportunity to question before we leave.
Page 21 PREV PAGE TOP OF DOC
Ms. SHELTON-COLBY. Yes, I will, Mr. Chairman. I would like to show you the SoloSHOT, which is manufactured in the United States. This is a one-time-only injection. I think you may have seen this before. This is a vaccine vial monitor, which will save over $10 million a year by allowing us to identify when vaccines are no longer effective.
There are four areas, very quickly, Mr. Chairman, where we believe more work needs to be done. One area is in the area of anti-microbial resistance. As Dr. Heymann pointed out, we are having difficulty treating more and more diseases because, as in the case of flu, new variants are developing.
Tuberculosis, I think, is the area that we want to concentrate on much more in the future, because of the rapid spreading of the disease. Malaria is another disease priority and disease monitoring and surveillance would be a fourth priority for USAID in coming years. Thank you, Mr. Chairman.
[The prepared statement of Ms. Shelton-Colby appears in the appendix.]
Chairman GILMAN. Thank you, Madam Ambassador, and I want to thank Dr. Heymann and Major Hernandez for your very comprehensive testimony.
Dr. Heymann, WHO produced an estimate showing the years when a number of these diseases can be eradicated; polio, leprosy, the Guinea-Worm, measles, River Blindness, Chagas and elephantitis. The total cost you estimate to the world community would be about $2 billion over the 30 year period, and total cost to our nation would be about $500 million over 30 years, or about $20 million a year.
Are those goals realistic? Can we really accomplish all of that with that estimate in that period of time?
Dr. HEYMANN. Certainly the eradicable diseases, of which there are not many, merit the attention which they are being given. Getting rid of these diseases will eliminate them from the face of the earth.
Page 22 PREV PAGE TOP OF DOC
The estimates that WHO has made have taken into account all of the necessary activities, including the research necessary to better fight against these diseases and the actual interventions necessary to control them. We estimate that the figures which you have given are accurate figures and that they will accomplish the goal of eradication or elimination of these diseases. Thank you.
Chairman GILMAN. Thank you, Dr. Heymann.
Ambassador Shelton-Colby, in your statement, you urged us to focus on the killers of 17 million people a year, malaria, TB, diarrhea, rather than the killers of hundreds, including the diseases mentioned by WHO that we could wipe off the planet. I understand the argument.
But, given USAID's commitment to eradicating polio, have you already decided to eradicate some diseases yourself?
Ms. SHELTON-COLBY. Mr. Chairman, USAID in conjunction with WHO, UNICEF and other international health bodies are looking at this very issue of what other diseases might be eradicable.
I think there are some questions that need to be asked with regard to all of them. Is eradication technically doable? That is to say, is there a vaccine or an effective drug? Second, do the benefits from eradication outweigh the costs? Another question, is the disease a major health burden and killer of people? I think another important question is, do countries targeted for eradication have the capability, both human and financial, to meet the infrastructure requirements that are essential to an effective eradication campaign?
So, these are the questions that we need to ask before we reach decisions.
Chairman GILMAN. Thank you.
Mr. Hamilton.
Mr. HAMILTON. Thank you, Mr. Chairman. Major Hernandez, you are with the Army and all of this equipment is Army equipment. This may not be a fair question to you, but can you give me some idea of the scope of resources the Army puts into this communicable disease effort and the so-called isolation effort? Do you have any idea about that?
Page 23 PREV PAGE TOP OF DOC
Major HERNANDEZ. A small portion of it goes toward this isolation. Most of our emphasis is on research and developing vaccines to prevent or counter biological threats. I do not know if that answers your question or not, sir.
Mr. HAMILTON. Well, maybe we can find that out from another source.
Ambassador Shelton-Colby, I was interested in the sentence when you have a medieval level of sanitation, you have a medieval level of disease. With regard to these communicable diseases you are talking about, would this be the most important thing you could do in terms of prevention, to get adequate sanitation? In other words, are most of these diseases related to bad sanitation in one way or the other?
Ms. SHELTON-COLBY. Mr. Chairman, I would hesitate to say that sewage and sanitation is the most important element. It is certainly one of the most important elements and a major focus of ours.
Mr. HAMILTON. [presiding] Other elements of prevention are?
Ms. SHELTON-COLBY. Would be basic health systems, immunization campaigns, the development of vaccines. Nutrition also is an area that we are going to be spending more and more focus on. We believe, for example, that Vitamin A has enormous potential for improving child mortality rates.
Mr. HAMILTON. Your budget is $320 million?
Ms. SHELTON-COLBY. That is approximate, yes, sir.
Mr. HAMILTON. What is the trend line on that over a period of years?
Ms. SHELTON-COLBY. The trend line has come down slightly because of declines in our overall budget, but our trendlines for health have declined far less sharply than our trendlines in certain other areas such as economic growth.
Page 24 PREV PAGE TOP OF DOC
Mr. HAMILTON. So, the maximum amount that we have spent would have been what?
Ms. SHELTON-COLBY. I cannot tell you the figure, Mr. Chairman, but I will certainly be happy to get back to you on that.
Mr. HAMILTON. Is it $400 million or $500 million?
Ms. SHELTON-COLBY. Again, it depends on how you define health. Let me go back and look at, say, the high point of USAID's budget a few years back and I will get back to you with that figure.
We do expect to maintain this trend line, assuming no further reductions in our overall funding level. If we were to get an overall increase in our foreign assistance budget, we would presumably increase our funding for this area, as well.
Mr. HAMILTON. Suppose we doubled your budget? What would happen?
Ms. SHELTON-COLBY. Well, I am a bit reluctant to contemplate such a wonderful scenario, since it seems somewhat unrealistic.
Mr. HAMILTON. I am not promising it, I am just asking.
Ms. SHELTON-COLBY. Oh, I understand. Hope does spring eternal.
Mr. HAMILTON. I am just trying to get some idea. You operate, I guess, like everybody else, with limited resources. You would like to have more resources, and I am just trying to get dramatic statistics. Three million lives saved through immunization, you say in your statement. Seventeen million people die around the world because they do not have access to proper care. They are killed by malaria or tuberculosis or dehydration. All of these things are treatable. If we double the budget, what would happen?
Ms. SHELTON-COLBY. If we were to get a doubling of the entire USAID budget——
Page 25 PREV PAGE TOP OF DOC
Mr. HAMILTON. The $320 million, not the entire budget.
Ms. SHELTON-COLBY. Oh, I see. I am sorry. I misunderstood.
Mr. HAMILTON. Do not run wild with me here.
[Laughter.]
Ms. SHELTON-COLBY. If we were to get a doubling of the health budget, my concern would be what would happen to the overall USAID budget, Mr. Chairman, because certain parts of USAID's budget, including health and child survival, have been relatively protected during recent years, as compared with other parts of our budget, such as our economic growth budget, the democracy portion of our budget.
If we were to double our budget for infectious disease without increase in the overall size, it would mean that that money would have to come from other valuable programs, and we believe, as you know, in an integrated approach to development.
Mr. HAMILTON. If we doubled it, would you save six million lives instead of three million lives?
Ms. SHELTON-COLBY. It would depend on——
Mr. HAMILTON. In the immunization program?
Ms. SHELTON-COLBY. It would depend on how we were to spend the money.
Mr. HAMILTON. Sure.
Ms. SHELTON-COLBY. We could certainly save more lives, but as for doubling, I could not tell you right now.
Mr. HAMILTON. You have the potential to save an awful lot more lives, if you get higher resources?
Ms. SHELTON-COLBY. That is absolutely correct.
Mr. HAMILTON. Now, does USAID contribute, is that the way we do it, USAID contributes to the WHO?
Page 26 PREV PAGE TOP OF DOC
Ms. SHELTON-COLBY. We do, and we work very closely.
Mr. HAMILTON. How much do we give to the WHO each year?
Ms. SHELTON-COLBY. I do not know if you know the figure. The State Department funds part of WHO and we fund part of WHO. This year we are contributing $18 million to the U.N. program on AIDS. We provide several million dollars for a number of WHO's specialized programs, such as in tropical disease. I can get back to you with a precise number.
Mr. HAMILTON. Dr. Heymann, how much of your budget comes from the United States?
Dr. HEYMANN. WHO budget is an assessed budget and one-quarter of the WHO regular budget is paid by the United States or is assessed to the United States. The programs that we are working with depend on mobilization of extra budgetary funds as well. These funds come from various groups, including development agencies such as USAID.
The budget which we are talking about that has accomplished or will accomplish the activities in global surveillance and in strengthening national disease surveillance and control programs is probably around $30 million for the biennium, showing what I showed on these slides. That goes over many different programs within WHO.
Mr. HAMILTON. WHO has had a lot of administrative problems recently, have they not?
Dr. HEYMANN. That is correct.
Mr. HAMILTON. Are they getting straightened out?
Dr. HEYMANN. We will be having a new Director-General as of next year, and we hope that the problems which have been causing difficulties will be resolved, either with the reform process, which is going on now, or with the arrival of a new Director-General.
Mr. HAMILTON. Well, you know, I think all of us want to support your work. We recognize that an awful lot of good work is done, not just by USAID, but WHO, as well. But, and I know this is not your responsibility, but I have heard very disturbing reports about the administrative problems of the WHO. I hope very much they are getting corrected.
Page 27 PREV PAGE TOP OF DOC
It may be you might have some of your people give a report to me and to Chairman Gilman about what is being done.
Dr. HEYMANN. Yes. I actually have here a one-page handout which talks about the WHO reform process and, to summarize it, the overall reform effort in WHO has been directed at putting in place processes, procedures, structures and programs that will enhance priority setting, transparency, accountability, efficiency and cost containment.
Mr. HAMILTON. Well, that sounds good and I am all for it. But let me tell you, when you go to try to find out how much one of these specialized agencies spends and all the rest of it, it is a formidable task. I have tried it and have not succeeded at it. There are very few things that you could do that would be more important from the standpoint of the long-range effectiveness of the WHO than to straighten out those problems and to bring real accountability and transparency into your budget system, and personnel system, as well.
I am very pleased to hear that report. I will follow up to see what has been done and we wish you well in your reform efforts. Thank you very much, Mr. Chairman.
Mr. CAMPBELL. [presiding] Thank you, Mr. Hamilton.
The gentleman from New York, Mr. McHugh.
Mr. MCHUGH. Thank you, Mr. Chairman. Let me start off by associating myself with the remarks of the gentleman from Indiana. Obviously, these are difficult budgetary times and anything that a very worthy and necessary organization such as yours can do to help itself would be, I would think, very, very important.
Madam Ambassador, I had the opportunity to look through your full statement, and I found it very enlightening and very interesting. But, I would like to go to page 6, where you make the comment, ''The Committee should not be in a hurry to rob Peter to pay Paul.''
I had listened very carefully, as well, to your spoken testimony with respect to earmarks. I was wondering if you would care to expand a little bit upon some of the specific circumstances that cause you to use that statement, ''should not be in a hurry to rob Peter to pay Paul?''
Page 28 PREV PAGE TOP OF DOC
Ms. SHELTON-COLBY. Congressman, the USAID's budget has been highly earmarked in the last several years. At the same time our overall budget, as I am sure you know very well, has declined quite sharply. So, as a result, as I was indicating to Congressman Hamilton, a number of areas in which we work, economic growth, specifically, have been sharply decreased. So, if you want to increase one sector of activity without increasing the overall budget, that money has to come from somewhere else.
We believe in an integrated approach to development, as I indicated earlier in my remarks. One of the most effective ways of dealing with infectious disease, and I think this is a consensus within the international health community, is not only health programs, specifically, but also eradication of poverty, improvements in agriculture and natural resource management, improvements in sanitation, etc.
So, we do not believe that focusing on one specific area of development, however important that is, is sustainable without a broader approach. So, we would simply like to avoid any possible further earmarking that might come out of the obvious interest and very welcome interest on the part of this Committee.
Mr. MCHUGH. Can I assume that your concern is one of a philosophical nature against earmarks, rather than anything specific, or would you like to comment upon any of the specific earmarks that you are dealing with?
Ms. SHELTON-COLBY. It is a philosophical concern with earmarks, as I am sure you hear from most, if not all, Administration witnesses.
Mr. MCHUGH. True, very true. Your comments about the death rates in Africa, with respect to HIV/AIDS, is frightening. I would particularly become concerned when, from my very small knowledge base, I understand the cost implications of treating AIDS patients. Certainly here in the United States, we spend an enormous amount of money on a per patient basis, probably not as much as perhaps we could and some would argue that we should.
Page 29 PREV PAGE TOP OF DOC
But, on a relative basis, it is far more than these countries can spend. They spend pennies, dollars a day, perhaps. What kind of future are we looking at if that kind of circumstance goes unaddressed, and what can we possibly do?
Ms. SHELTON-COLBY. You are absolutely right, Congressman, to highlight the cost of treatment. Our AIDS prevention program is aimed heavily at education with regard to behavior change programs, and supplying condoms. We are not really investing in the development of a vaccine. NIH is really doing most of that, but we are working in other areas to prevent sexually transmitted infections, because there is a clear link between STI's and HIV.
We do very little in the area of treatment, precisely because of the cost. Yet, you have identified an issue, it is a kind of equity issue, that the international health community is very focused on and is thinking a great deal about. Until recently, I was the chairman of the board of U.N. AIDS, and this is an issue that we are dealing with, because the developing world, as you say, does not have the resources to spend on treatment. We barely have the resources in this country to spend on treatment.
The other element here is that the disease, the treatment regime that is saving lives in this country, is beyond the reach of some individuals in this country. So, this equity issue is one that we are struggling with, but I do not expect USAID to be allocating more resources, appreciably greater resources to treatment in the future. We think we need to stay focused on prevention, rather than treatment. That would absorb our entire USAID budget.
Mr. CAMPBELL. Thank you, Mr. McHugh.
Mr. Hastings from Florida is gone. Mr. Payne from New Jersey.
Mr. HASTINGS. I am going to pass.
Mr. CAMPBELL. Oh, I am sorry, you are present and you are passing. Very well.
The gentleman from New Jersey. We have a vote, so we perhaps have 5 minutes and we can discuss what we will do thereafter.
Page 30 PREV PAGE TOP OF DOC
Mr. PAYNE. OK, let me first of all thank you for this very important testimony and I would like to commend the Chairman, in his absence, for calling this very important hearing.
First of all, I would like to mention that in my district, the UMDNJ, the University of Medicine and Dentistry of New Jersey has set up a Center for Public Health, an International Center for Public Health which is working precisely on some of these contagious diseases and so forth, and is striving to have, in conjunction, I guess, with CDC and NIH, sort of an international hookup to monitor the various diseases.
Of course, they have two major areas that they are looking at. One is the question of antibiotic resistance, and second, the research of tuberculosis. I think in this country we found that there has been an increase in tuberculosis in the last 7 years by about, from 1985 to 1992, anyway, of about 20 percent. Of course, we know that tuberculosis is certainly a preventable disease, so that is very alarming, and the resistant strain of tuberculosis, much of it is found in urban areas where health care is limited and many times inaccessible.
I think that as we are looking to strengthen the WHO around the world, I think that we also need to concentrate more on the increase in infectious diseases here in the United States.
Let me just ask, very quickly, the support, I would just like to get a quick picture of financial support from other countries as opposed to the United States. Are other countries giving more now as we are declining, or what is the overall picture, really, in a quick nutshell?
Ms. SHELTON-COLBY. Of donor support for programs to combat infectious disease?
Mr. PAYNE. Yes, right.
Ms. SHELTON-COLBY. It is quite strong. Other donors are cutting back their foreign assistance budgets, overall, Congressman, as a result of budgetary pressures. Japan has recently announced a cut of 10 percent. The British have cut back, the Canadians are cutting back. Two or three countries have actually increased, some of the Scandinavian countries.
Page 31 PREV PAGE TOP OF DOC
Overall, however, even within those reductions, support for international health programs, specifically infectious diseases, is holding more or less steady.
Mr. PAYNE. Just the last quick one, because maybe we can wrap it up before we go vote, Dr. Heymann, you mention the environment and you mention the fact that degradation of the environment, deforestation and so forth is becoming a problem.
Do you see a continued degradation in the environment? Particularly, now, they are talking about the whole question of the ozone and just deforestation increasing, therefore, creating more problems for these diseases to go around?
Dr. HEYMANN. Certainly today in the world, we are seeing environmental problems which are difficult to handle. We are seeing rapid expansion of urban areas in many developing countries, and sanitation and water cannot keep up. So, water-borne diseases and diarrheal diseases are increasingly transmitted.
We are also seeing at the same time that the demand on resources of the world depletes forests and other things, and those animals that live in the forest and get their food in the forest no longer have a forest where they can search for food. So they come closer to man to steal man's food, and in so doing, they carry new diseases to man. Then man gets these diseases, has no immune response to these diseases and himself dies, because the medical community does not understand how to treat these diseases.
So, we are seeing phenomenon which are very difficult to combat. It certainly will take a worldwide effort, the joint activity of development groups, of governments themselves and of international agencies to ensure that the environmental degradation of the world is stopped and turned around.
Mr. PAYNE. Thank you.
Mr. Chairman, I appreciate that and would like to put into the record the testimony from the UMDNJ and would like for it to be a part of the record as it relates to this subject.
Page 32 PREV PAGE TOP OF DOC
Mr. CAMPBELL. Without objection, that will be the order.
Thank you, Mr. Payne.
[The information referred to appears in the appendix.]
Mr. PAYNE. Thank you.
Mr. CAMPBELL. I want to thank my colleague from Florida. I understand you are going to kindly yield back. I will yield back on my side our time, so we are equal in yielding back.
I want to thank the witnesses, Dr. Heymann, Ambassador Shelton-Colby and Major Hernandez for your attendance here today. I have unanimous consent request if my colleagues would indulge me, unanimous consent requested that the statement of Mr. Menendez be included in the record, and that in addition, the statement of the University of Miami School of Medicine and the Center for Public Health at the University Hyde Science Park, Newark, New Jersey, be submitted into the record, as well.
[The information referred to appears in the appendix.]
Mr. CAMPBELL. That will be the order without objection. Thank you and because of the pendency of a vote, we will cut off a little bit sooner. That does not reflect a lack of interest or lack of appreciation for your kindness in being here.
Thank you. The Committee stands adjourned.
[Whereupon, at 11:45 a.m., the Committee was adjourned.]
A P P E N D I X
Insert "The Official Committee record contains additional material here."