SPEAKERS CONTENTS INSERTS
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50–550 CC
1998
ERADICATION AND ELIMINATION OF SIX INFECTIOUS DISEASES
HEARING
BEFORE THE
COMMITTEE ON
INTERNATIONAL RELATIONS
HOUSE OF REPRESENTATIVES
ONE HUNDRED FIFTH CONGRESS
SECOND SESSION
MAY 20, 1998
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
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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
KEVIN BRADY, Texas
RICHARD BURR, North Carolina
LEE HAMILTON, Indiana
SAM GEJDENSON, Connecticut
TOM LANTOS, California
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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
BRAD SHERMAN, California
ROBERT WEXLER, Florida
STEVE ROTHMAN, New Jersey
BOB CLEMENT, Tennessee
BILL LUTHER, Minnesota
JIM DAVIS, Florida
LOIS CAPPS, California
RICHARD J. GARON, Chief of Staff
MICHAEL H. VAN DUSEN, Democratic Chief of Staff
MARK KIRK, Counsel
CHARMAINE V. HOUSEMAN, Staff Associate
C O N T E N T S
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WITNESSES
Mr. Ben Nelson, Director, International Relations and Trade, National Security and International Affairs Division, U.S. General Accounting Office
Dr. Claire Broome, Acting Director, Centers for Disease Control
Dr. Nils Daulaire, Senior Health Advisor, Agency for International Development
Dr. David Heymann, Director, Division of Emerging and Other Communicable Diseases, Surveillance and Control, World Health Organization
Mr. Herbert Pigman, Former Secretary General, Rotary International
Dr. Brian Bagnall, Director of Project Management, SmithKline Beecham
APPENDIX
Prepared statements:
The Honorable Benjamin A. Gilman, a Representative in Congress from New York, and Chairman, Committee on International Relations
Mr. Ben Nelson
Dr. Claire Broome
Dr. Nils Daulaire
Dr. David Heymann
Mr. Herbert Pigman
Dr. Brian Bagnall
Additional material submitted for the record:
GAO Chart on Eradication/Elimination Targets of Infectious Diseases
Letter dated 5/20/98 from the Honorable Jimmy Carter
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World Health Organization Chart on Vaccine Development submitted by Dr. Heymann
World Health Organization Update on the Eradication of Leprosy and River Blindness
Letter dated 3/30/95 from the World Health Organization submitted by Congressman Christopher Smith
H.R. 1561, Section 3222 of the State Department Authorization Act for Fiscal Years 1996 and 1997, submitted by Congressman Christopher Smith
Additional testimony submitted for the record:
American Home Products Corporation, Wyeth-Lederle Vaccines and Pediatrics (WLVP) ''Contribution to Global Polio Eradication''
Letter dated 2/5/98 from WHO-AFRO Polio Laboratory Network
Arnauld E. Nicogossian, M.D., Associate Administrator and Chief Medical Officer, National Aeronautics and Space Administration
David Brandling-Bennett, M.D., Deputy Director, Pan American Health Organization
Questions:
Questions from The Honorable Richard Burr, answered by The Centers for Disease Control and Prevention
Questions from The Honorable Richard Burr, answered by WHO
Questions from The Honorable Richard Burr, answered by USAID
ERADICATION AND ELIMINATION OF SIX INFECTIOUS DISEASES
WEDNESDAY, MAY 20, 1998
House of Representatives,
Committee on International Relations,
Washington, DC.
The Subcommittee met, pursuant to notice, at 10:05 a.m., in room 2172, Rayburn House Office Building, Hon. Benjamin Gilman, (chairman of the Committee) presiding.
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Chairman GILMAN. [presiding] The Committee will come to order.
Members take their seats.
Today, we will be focusing on one of the most promising fields of international cooperation—the opportunity to wipe out seven infectious diseases that kill or hurt over 130,000,000 people. Some of these diseases are quite familiar to most of us—polio, measles, leprosy. Others are little less known, but kill and cause suffering just the same—Guinea worm, river blindness, elephantiasis, and Chagas' disease.
At a cost of just $32 million, the United States and our partners in the World Health Organization (WHO) were able to eradicate smallpox from our planet. And on December 31, 1999, American and Russian scientists will destroy the last living smallpox virus.
GAO estimates that we have saved $168 billion—$168 billion—in healthcare costs from this achievement, $17 billion alone in our own Nation. Over 30,000,000 people are alive today because smallpox is gone. Our investment in smallpox eradication repays our taxpayers every 26 days.
We're on the verge of better news regarding polio. Polio was once the scourge of our Nation, striking everyone up to and including President Roosevelt. Until polio is eradicated our Nation spends over $200 million per year for inoculations. Thanks to Rotary International, we're pleased we have Rotary's international president here, our WHO partners and especially our colleague, Sonny Callahan, the Chairman of the Appropriations Subcommittee on Foreign Operations, we're nearing our goal of eradicating polio, hopefully by the year 2002. Many of us are strong supporters of our polio effort. Most of the polio vaccine that has made this campaign possible is produced by American Home Products, right in my own congressional district.
The purpose of today's hearing is to focus attention on completing our polio effort, then moving on the next set of diseases that mankind can wipe off our planet.
One year ago, the WHO sent me an estimate that the seven key diseases that we're looking at today could be eradicated, could be eliminated by the year 2030, for a total of $7.5 billion, and that the annual cost would be some $214 million. If our Nation paid its customary 20 percent share, our Nation could lead this effort at a cost of about $40 million annually. I've asked the GAO to estimate how much the American taxpayer and the average American would save in healthcare costs if we were to start such crusade. The GAO responded that we could save at least $391 million annually—$391 million annually, savings. If we added the vaccines commonly mixed with the measles vaccine—mumps and rubella—the savings could top over a billion dollars annually. All of this could be done for a cost of $40 million each year.
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This is not an easy task. To build an effective eradication campaign, we're going to have to strengthen or even create a health infrastructure in many countries. As Dr. Heymann will note, much of this work has been done by doctors wearing combat helmets, because many of the diseases will make their last stands in war-torn areas like Sudan or Congo. There are some who do not wish to undertake this mission. Some officials fought the polio eradication initiative. To them, let us say, ''the mission of eradication is one that sparks the imagination.'' With that enthusiasm comes resources and funds.
Today, we'll take testimony of Rotary International, which made the largest private donation ever to international health. SmithKline's donation may top $1 billion. They've been joined by donations of Merck, American Home Products, and others. In sum, this crusade can be a win-win situation, mobilizing public and private donations to build the health infrastructure of this planet to better us all.
Before taking testimony from our witnesses, I'd like to welcome the newest Member of our Committee, Congressman Richard Burr, who represents the fifth district of North Carolina. Congressman Burr has handled some tough conflicts in his own district, such as whether Piedmont hickory barbecue or East Carolina vinegar barbecue is better.
[Laughter.]
Not to mention, the ACC basketball rivalries of Wake Forest, Duke, and North Carolina State. But compared to these issues, the problems between India and Pakistan should be easy for Congressman Burr.
On a more serious note, and quite coincidental to the subject of today's hearing, Mr. Burr's become quite an expert on healthcare issues as a Member of the Commerce Committee. Congressman Burr, we welcome you to our Committee. We look forward to your taking a leading role as we explore the international aspects of health, particularly in the hearing on the international AIDS epidemic that we expect to hold later this year.
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And with that, I'd like to recognize our Ranking Member of our Committee, Mr. Hamilton, for any opening statement.
Mr. HAMILTON. Well, thank you very much, Mr. Chairman.
I think you are to be commended for having the hearing. I might just say to our witnesses that the issue that will interest me throughout will be how limited U.S. resources can best be used to achieve the goals that we all want to achieve with respect to these infectious diseases.
You have assembled, Mr. Chairman, a very distinguished panel, and we look forward to their testimony.
I want to add a word of appreciation for the fact that we have Congressman Burr with us. He's a very distinguished Member of this body, and has already made significant contributions. I have no doubt at all that he will strengthen this Committee, and we're just delighted to have him with us.
Chairman GILMAN. Thank you, Mr. Hamilton.
Any other Members seeking recognition? If not, we'll proceed with our first witness.
Our first witness is Ben Nelson, the Director of International Relations and Trade Issue in the GAO's National Security and International Division. He has a distinguished record of service at GAO, where he started his career about the time I started in Congress, back in 1974. He has served in a variety of positions at GAO, ranging from the Office of Quality Assurance to Executive Assistant to the Assistant Comptroller General's Office. He has a master's degree from SAIS. He has completed work on international trade and competitive issues at both Georgetown and Berkeley. Today, the Committee is releasing GAO's report on the targets and costs of eradicating or eliminating seven major diseases by reviewing the soundness of WHO's estimates. I want to give special thanks to his assistants who are joining him—Lynne Holloway, Audrey Solis, Ann Baker, and Rus Kudnick—who helped to prepare this major study.
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Mr. Nelson, you may summarize your written statement. Your full statement will appear in the record, whichever you may deem appropriate. Mr. Nelson.
STATEMENT OF BEN NELSON, DIRECTOR, INTERNATIONAL RELATIONS AND TRADE, NATIONAL SECURITY AND INTERNATIONAL AFFAIRS DIVISION, U.S. GENERAL ACCOUNTING OFFICE
Mr. NELSON. Thank you, Mr. Chairman.
We're pleased to be here today to discuss the results of our review of WHO's estimates——
Chairman GILMAN. Could you? Mr. Nelson, let me interrupt. Would you put the mike a little closer to you?
Mr. NELSON. Certainly.
Chairman GILMAN. Thank you.
Mr. NELSON. I'll start over.
We're pleased to be here today to discuss the results of our review of WHO's estimates for eradicating or eliminating the following infectious diseases: dracunculiasis, polio, leprosy, measles, onchocerciasis or river blindness, Chagas' disease, and lymphatic filariasis. These diseases, as you stated in your opening statement, Mr. Chairman, exact an enormous cost of the developing world, killing almost 1.1 million people, and afflicting millions of others with serious disabilities and deformities. Measles alone kills 1 million children each year, the vast majority of them in the least developed countries.
In April 1997, WHO provided this Committee with estimated costs and target dates for eradicating or eliminating the seven diseases. Subsequently, WHO revised some of the costs and timeframes based on more recent information. We reviewed the estimates provided to us by WHO as of December 1997. WHO officials estimated that about $7.5 billion would be needed to eradicate or eliminate the targeted diseases.
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Today, we will discuss the soundness of WHO's cost and timeframe estimates; U.S. spending related to these diseases in Fiscal Year 1997 and any potential cost savings to the United States as a result of their eradication or elimination; other diseases that international health experts believe pose a risk to Americans and could be eventual candidates for eradication; and U.S. costs and savings from smallpox eradication and whether experts view smallpox eradication as a model for other diseases. We did not attempt to assess the cost effectiveness of these initiatives as compared to other options such as improving primary health care delivery systems.
Some background to put the issues into focus: eradication of infectious diseases involves reducing the worldwide incidence to zero, thereby obviating the need for further control measures. Elimination, on the other hand, involves reducing morbidity to a level no longer considered a major public health problem. Elimination still requires a basic level of control and surveillance.
Global disease eradication and elimination campaigns are initiated, primarily by WHO, to concentrate and mobilize resources from both affected and donor countries. WHO provides recommendations for disease eradication and elimination to its governing body, the World Health Assembly, based on two general criteria: scientific feasibility, and the level of political support by endemic and donor countries. Formal campaigns were initiated for dracunculiasis and leprosy in 1991, and for polio and lymphatic filariasis in 1988 and 1997, respectively. Regional or subregional campaigns are underway against measles, onchocerciasis, and Chagas' disease. Disease eradication and elimination efforts are normally implemented by the national governments of the affected countries. Developing countries typically receive assistance from bilateral and multilateral donors, non-governmental organizations, and the private sector.
I'd like to point out that developing costs and timeframes for these efforts is difficult due to challenges in gathering and verifying data from countries with minimal health infrastructure. Unpredictable and unstable country conditions, such as civil unrest, further complicates efforts to project how much these efforts will cost, and how much time is needed.
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WHO and other experts we contacted generally agree on the five factors necessary to estimate the cost of eradicating or eliminating a disease. The factors are: product costs; information on disease incidence, prevalence, and the size of the target populations; administrative and delivery costs; disease monitoring and surveillance costs; and, primarily for eradication, the costs of certifying that countries are free of the disease.
We focused our assessment on the accuracy and completeness of the underlying data for these five factors. WHO's estimates and our analysis did not include an assessment of opportunity costs or indirect costs that may be incurred as a result of eradication campaigns, such as the impact on routine health care services or the costs to individuals to seek vaccines or other treatment.
The soundness of WHO's cost and timeframe estimate vary by disease. Generally, the estimates were most sound for those diseases closest to meeting eradication or elimination goals, including Guinea worm, polio, and leprosy. Estimates for these three diseases were based on firm data about target populations and intervention costs from ongoing initiatives. For the other diseases, WHO's estimates are more speculative because underlying data are either incomplete or unavailable. WHO officials acknowledge this fact and said that the estimates are continually revised as data become available.
With respect to savings: The United States spent about $391 million in 1997 to combat these diseases. Three hundred million dollars of this amount was spent on polio and measles prevention and on leprosy treatment in the United States. Another $91 million went for overseas programs, primarily the polio eradication campaign. Savings to the United States from eradicating or eliminating these diseases would result primarily from not having to vaccinate U.S. children against polio and measles.
The chart, at my left, provides a quick snapshot of the goals, the target dates, global costs, projected annual U.S. savings, and GAO's assessment of the soundness of the estimates for each of the seven diseases. Experts we contacted identified four of the diseases that pose serious health threats to the United States, and could be possible candidates for eradication: rubella, mumps, hepatitis B, and influenza type B, or HiB. WHO told us that, while it may be technically possible to eradicate these diseases with existing vaccines, the international community cannot support too many eradication initiatives at one time. Therefore, it is unlikely that other diseases will be considered for eradication before success is achieved with some of the diseases currently targeted.
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The United States saved almost $17 billion as a result of the eradication of smallpox in 1997. The savings were due to the cessation of vaccinations and related costs of surveillance and treatment. Experts generally agree that the primary lesson from smallpox is that a disease can actually be eradicated. The smallpox eradication effort also provided a valuable lesson in how to mobilize community, national, and international efforts. However, smallpox had unique characteristics that made it particularly vulnerable to eradication, and, therefore, has limitations as a model for current efforts. Smallpox was less infectious than polio or measles, is easily diagnosed, and multiple mass campaigns were unnecessary because a vaccine was effective with one dose.
Mr. Chairman, this concludes my opening statement.
I would be happy to take any questions you might have.
[The prepared statement of Mr. Nelson appears in the appendix.]
Chairman GILMAN. Thank you, Mr. Nelson.
In your report, Mr. Nelson, you largely confirm WHO's estimates that for $7.5 billion we could eradicate or eliminate these seven diseases. Seventy to eighty percent of the cost of the polio and smallpox efforts were paid by host governments. If these examples were used, what percentage do you think would be paid by the United States? Twenty percent or more or less?
Mr. NELSON. Mr. Chairman, clearly the major costs will be borne by the developing countries and the endemic countries but it varies by disease. I agree with you that the largest share would be paid by the endemic countries.
Chairman GILMAN. And no idea of what percentage?
Ms. SOLIS. Yes. The PAHO countries in Latin America funded about up to 80 percent; whereas, some of the poorer countries in Africa and elsewhere may be able to fund only 50 percent or less. We don't have a breakdown, though, by country.
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Chairman GILMAN. So the average would be, say, down to 50 percent?
Ms. SOLIS. Perhaps for the least developed countries. But the more advanced countries would be able to fund more.
Chairman GILMAN. When you received the estimate for eliminating lymphatic filariasis, it was before the huge donation of SmithKline Beecham. Mr. Nelson, since their donation haven't our cost estimates gone down?
Ms. SOLIS. No, the estimate that we received from WHO originally was $300 million. And as we note in the report, that amount included the costs of treating symptoms that were not related to the elimination or control efforts, so we subtracted those from the total.
The estimates at that time did not include drug costs, because it was expected that albendazole would be donated by SmithKline. It did include costs for another drug, DEC, and not for ivermectin, as well, because that's also donated by the Merck Company and can be used for lymphatic filariasis as well as onchocerciasis.
Chairman GILMAN. In your report, you estimated we could save $391 million a year from eradicating or eliminating these diseases. What made up those saving figures? Did you include the savings by the States? Did you include savings by private insurers and individuals? Could you tell us a little more about that?
Mr. NELSON. No, Mr. Chairman, those savings primarily relate to Federal expenditures on those diseases. They do not include costs by States or local governments.
Chairman GILMAN. So, therefore, the savings could be more, is that right?
Mr. NELSON. That's correct.
Chairman GILMAN. Why are the WHO estimates for measles costs so high and savings so low compared with those for polio?
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Mr. NELSON. That's because the measles campaign is just getting underway. There's more to be done, and a large percentage of the cost will be borne by the industrialized countries. And the costs there are higher than in the developing countries. The other reason is the administrative costs. The administrative costs saved with eliminating measles would not be substantial because the measles vaccine is given in conjunction with those for mumps and rubella.
Chairman GILMAN. Thank you. Mr. Luther.
Mr. LUTHER. Chair, I have no questions. Thank you.
Chairman GILMAN. Thank you, Mr. Luther. Mr. Smith.
Mr. SMITH. Thank you very much, Mr. Chairman.
Mr. Nelson, in its comments of USAID from Terrence Brown, the Assistant Administrator, he seems to take some issue with the whole idea of eradication and whether or not there is a consensus, and I wonder if any of our panelists might want to comment on this. They point out that there are technical, financial, and operational reservations about the feasibility of eradication in talking about measles.
It seems to me that when we're talking about a mobilization it's a matter of political will, financial willingness to come forward and provide the money. Many of us have been deeply concerned that money that has been earmarked for things like child survival gets diverted for things like family planning and population control. I say this having had some experience over my 18 years in Congress in trying to get more and more and more money into child survival. Back in 1984, Mr. Chairman, you will recall when President Reagan wanted to zero out the child survival account, I offered the amendment to double it, from $25 million to $50 million, and have been offering amendments ever since and encouraging colleagues—and you have been a leader on this as has Tony Hall, and others.
But it seems to me that when money is diverted in that way, you know, there's money for family planning, that's fine. But money that goes to child survival and to eradication efforts, it seems to me, ought to be clearly defined and should not be misspent. But in talking about this lack of consensus, how do you respond to that? It seems to me if we had the political will and were willing to put up sufficient resources, targeting these seven diseases ought to be a no-brainer. And could be, if the consensus breakers like abortion were taken out of the mix. But we're talking about this, so how do you respond to their response in your report?
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Mr. NELSON. Representative Smith, as you know, in most cases, particularly involving diseases in the developing world, the needs are typically greater than the resources available to meet them. And there's typically a dichotomy of views regarding the most effective or efficient approach to dealing with the problem. And that is the same issue with measles as well as with some of the other campaigns. Some experts argue that by launching the campaigns it detracts from regular immunization, regular health care. However, we did not encounter anyone who suggested or gave us evidence firmly that these diseases cannot be eradicated. What we noted in our report is that there will be challenges to eradication. And I do not remember meeting anyone who gave us evidence that the targeted diseases could not be eradicated. But several experts noted that there would be challenges to eradicating them, particularly measles, due to its unique prevalence patterns.
Would you like to add? Yes.
Ms. HOLLOWAY. If I could just amplify on that. I know that USAID will clarify their own comments here. But it wasn't a question of not being in favor of eradicating these horrible diseases or eliminating these horrible diseases, just the context in which it is done. The most questions were raised about measles, not in terms of whether it can be eradicated, but how long it would take, given the lack of infrastructure in some countries.
Mr. SMITH. Would you like to respond? Yes?
Ms. SOLIS. Several of these diseases are targeted only for elimination and not for eradication. They don't necessarily have a U.S. interest in terms of our public health interest. It's more of a humanitarian interest.
Mr. SMITH. I see my time is up. Thank you, Mr. Chairman.
Chairman GILMAN. Thank you, Mr. Smith. Mr. Hastings.
Mr. HASTINGS. Mr. Chairman, I have but one question, and I direct it to Mr. Nelson.
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Mr. Nelson, your report provides a good assessment of WHO strategy for the elimination and eradication of the seven infectious diseases that you've put on the chart. I would like to know what factors—or did your good offices take into consideration in the analysis of WHO strategy? And more importantly, in your opinion, is WHO a realistic one, given the fact that the cost and timeframe estimates vary for each disease?
Mr. NELSON. What we did at the GAO was to take the estimates provided by the WHO. The first step was to meet with other experts to discuss with them how the estimates should be developed. What are the factors that need to be considered? What are the various costs? We then examined the WHO estimates to determine the soundness of the underlying data for each of those factors, such as the data on the affected population, vaccine costs, and on prevalence. That was the basis of our assessment of their estimates. We did not come up with our own estimates but looked at the underlying support and their completeness and whether the information was available to fill in all the gaps that were needed to arrive at a good projection of the cost and timeframes, recognizing that in many cases this is very difficult, and that the WHO had to basically extrapolate from data that was available to fill in those gaps for some of the diseases.
Mr. HASTINGS. Well, do you believe the costs outlined in your report represent the full costs of eradication? I think that's something along the lines of what the Chairman had asked.
Mr. NELSON. I think that some of them were sounder than others. But the approach that they used to come up with the estimates—we don't have a problem with that approach. And the experts we met with generally agree that that is the approach that is appropriate for coming up with the direct costs.
The thing that is not included are the opportunity costs as well as the cost to individuals to avail themselves of the vaccines or to get the treatment. So, basically the numbers represent the direct costs.
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Mr. HASTINGS. Let me turn from that and ask any of the panelists, what are some of the diseases in the poorest countries which we could help eradicate with a little more assistance? Is there any data indicating how we might go about that or would this be better left for yet another panel?
Ms. HOLLOWAY. Well, the process for identifying a disease for global eradication is that WHO and public health experts from around the world talk about the relative possibilities. The World Health Assembly votes on the next diseases for eradication. At this point, the experts at WHO told us that they felt like they had enough in the pipeline, and they really needed to have some successes there before they moved on to other diseases. We do name a couple in our report as possibilities, but, at this point, nobody is seriously considering any other than measles, of course, for which a formal campaign has not yet been initiated.
Mr. HASTINGS. All right. Thank you, Mr. Chairman.
Chairman GILMAN. Thank you, Mr. Hastings. I'm pleased to recognize our distinguished Chairman of the House Foreign Operations Subcommittee, the gentleman from Alabama, Mr. Callahan. Without the diligent work of Sonny Callahan, there wouldn't have been any polio eradication congressional funding. We welcome Chairman Callahan before our Committee, and I'd like to invite him to make a statement. Mr. Callahan.
Mr. CALLAHAN. Well, thank you, Mr. Chairman. And thank you for allowing me to interrupt these people who are such experts on infectious diseases.
I always like to compliment people, even the Administration. I know that might sound strange to some of you Democrats to hear a Republican congratulating the Administration. But with respect to the child survival account, which was created by my Subcommittee with the assistance of Chairman Gilman; for 3 years, we had great difficulty in getting the Administration to even recognize its existence. They wouldn't even include it in the budget. This year, I congratulate them, they did include, for the first time, a line item for child survival. That's the good news.
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Now, the bad news. They advocated a cut.
The good news for people who are so deserving of this appropriation is that we're not going to facilitate the request of the Administration to cut child survival. As a matter of fact, it's our intention to even increase child survival by about an additional $50 million for 1999. So thanks to the Administration for first of all recognizing that there is a need and there is a necessity to line item child survival. And second, we would request for the year 2000, you come back with a sufficient amount of money to actually fund the total child survival account.
There's no need for me certainly to lecture this group or your Committee, Mr. Chairman, with respect to the good that comes from this program. In my State of Alabama, for example, the fight against Chagas' fever, which is endemic to Central America, is being led by the University of Alabama. Years ago, another breakthrough: against yellow fever in Panama. It was led by an Alabamian named Dr. Gorgas.
If you look at the programs that are underway throughout the world, for example, Rotary International and its goal of the eradication of polio. How could you not support a program such as that? And if you look at the proposed program by Kiwanis International addressing iodine deficiency. I think it's a very, very noble cause, moving our country in the right direction and creating a better life and a better environment, especially for children throughout the world.
So, Mr. Chairman, I come here today to congratulate your Committee and to tell you that, as you well know, the numbers that are going to be allocated to our Committee for the Fiscal Year 1999 are going to be very limited; that I would not be a bit surprised if the numbers weren't a minimum of a billion dollars less than what we had available for 1998. So, we're going to be very, very tight. But I intend to keep these cuts from affecting the fight against infectious diseases. And I expect to bring, as I said, to the House floor a measure that will provide $650 million for the child survival and disease program account. And I ask your Committee, Mr. Chairman, to support me in that effort.
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Chairman GILMAN. Well, thank you, Chairman Callahan. And thank you for that encouraging note. And we certainly will be supportive. We thank you for taking the time to come before our Committee today. And, again, we thank you for your diligent efforts in the past on these very important issues. Thank you, Sonny.
We'll now proceed with our—oh, before we do that, Mr. Burr.
Mr. BURR. I thank you, Mr. Chairman. And I think it's safe to say that this is not a question of whether we should or a question of if we do attempt to eradicate or eliminate, it's a question of how. And I want to get at the heart of your testimony, Mr. Nelson, if I may. Let me just read a portion to you and the results in brief: ''For the other diseases, WHO estimates are more speculative because data underlying the costs and timeframes are incomplete and unavailable.'' That sounds a little bit different than what you shared with Mr. Hastings. And my question is, how did you fill in data that was incomplete?
Mr. NELSON. Well, these campaigns involve multiple initiatives. In some cases, there are regional or subregional control efforts underway. Data can be collected regarding the prevalence, incidence, the costs, and so forth. And that data can then be used to come up with an estimate of the likely cost in that same scenario for a different disease. I believe that for the measles estimate, for example, WHO uses data developed from the polio eradication campaign, because of the similarity. That information is then extrapolated or adjusted to reflect the differences between polio and measles—the difference between the cost of giving an oral vaccine versus an injectable. But you do not really have a choice, because the information in some cases is simply not available or is difficult to obtain. In some cases, the estimates include eradicating or eliminating a disease in a country that is involved in civil unrest, where portions of the country may not be accessible, and where it is very difficult to come up with precise numbers on, for example, the affected population.
Mr. BURR. Well, tell me this: Did GAO look at the historical trend on the estimates when the effort for polio was first started at what the estimate was for eradication and what we currently project the total costs of that projection to be? We've just looked at revisions from WHO that are very recent. Were the historical changes taken into account in your projections of verifying the data?
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Mr. NELSON. Estimates for all of the diseases almost always change as new information becomes available.
Mr. BURR. Let me say, Mr. Nelson. What I'm trying to do is to determine whether GAO actually took data and compiled it that they were supplied. And that's what we see in these numbers. Or whether you used some additional techniques to extrapolating numbers that you feel are as confident as GAO can be.
Mr. NELSON. With respect to the dollar savings in the report on polio, that represents GAO analysis using different analytic techniques to bring those dollars into current or future dollars to give you a better sense of the policy implications from eradicating the diseases.
But with respect to the seven diseases there, GAO did not come up with an independent estimate. Our charge was to determine whether WHO's estimates were sound.
Mr. BURR. Let me read you something out of your report: ''We did not develop independent estimates of the cost and timeframes for eradicating or eliminating these diseases, nor did we verify the accuracy of the data underlying the estimates.'' That tells me that you used what you were given. There's no verification on your part that the numbers are, in fact, correct numbers?
Mr. NELSON. That is correct. That is the limitation on our work, which is why we made that prominent in the report. I think it would not have been feasible or practical for us to verify all of the numbers. There's a reporting system whereby the countries report to WHO. And we did not go in-country to verify the numbers that had been forwarded to WHO regarding the incidence of diseases or any of the affected population in any of the countries.
Our approach was to look at WHO's methodology. Determine whether they had factored in the relevant items in their estimate, and then work with them to determine how much—how good, or how complete was the underlying data, not necessarily the accuracy of the count of the affected population in any particular country. That would not have been possible. What we tried to do was to see if the WHO had good data, say, on all of the countries where a disease is endemic and how recent that reporting was.
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Ms. HOLLOWAY. Yes, let me just add, it was not possible, because of the huge costs of going into countries, to verify the data—of having to go into the countries to see if what they were reporting was correct. As an alternative to that, we met with experts in CDC, at universities, Johns Hopkins in particular, and elsewhere who are very familiar with these diseases and who have visited these countries and been involved in the eradication or the elimination efforts. They provided their opinions about whether the cost estimates and incidence seem reasonable. So we did that kind of verification, but unfortunately it would be prohibitively expensive to actually go to the countries and verify the data they reported.
Mr. BURR. I thank you for clarifying that for me.
Ms. SOLIS. I was going to amplify that as well. WHO was candid about the limitations of its data. And some of these estimates will end up being costlier than what you see on the chart. For example, onchocerciasis. They have solid cost elements, sound data on what it takes to go in and start up a community-based program for treating onchocerciasis. However, because of some of the conditions in parts of Africa—Nigeria, the former Zaire, and others—they are still mapping the prevalence of the diseases, so some of the earlier estimates on which they based these costs will change once they have a better idea of the target population—the at-risk population that they have to treat. And these limitations are reflected in the report to the extent that the information was made available to us in the summary on each disease. Chagas' disease is another one in which some countries have not submitted data. But it should be pointed out with Chagas that the Andean countries are expected to fully fund their own efforts. That's the plan now. And the Central American countries are expected to fund half of their efforts.
Mr. BURR. I thank the Chairman, and yield back.
Chairman GILMAN. Thank you, Mr. Burr. If there are no other questions. Mr. Luther, any questions?
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I want to thank the panelists for your time and your excellent report. We thank you for making time available for your appearance here today.
We'll now move on to panel No. 2. Panel No. 2 we have Dr. Claire Broome, David Heymann, and Dr. Nils Daulaire. While the panelists are seating themselves, I'd like to note that in the Senate, Senator Leahy has called for significant increases in resources to combat infectious diseases, with a focus on strengthening the public health infrastructure and training in the developing nations to improve surveillance and response. I agree with those goals. Those goals can be advanced through targeted eradication programs, which, to succeed, depend on effective public health delivery systems. And we've just received a letter on the eradication crusade from our former President, Jimmy Carter. Without objection, we'll insert the entire letter in the record.
[The letter appears in the appendix.]
Chairman GILMAN. But I'd like to quote from a few paragraphs from President Carter's letter of May 20 where he says ''the world is at an historic crossroads due to the advancement of science and technology, the growth of the spirit of global community, and the unparalleled cooperation among multi-national organizations. The United States has a rare opportunity, humanitarian responsibility to assume a leadership role in controlling these diseases and, in some cases, wiping them forever from the face of the earth. Eradicating measles and polio will eliminate a direct threat to our population and hemisphere.
''And while the humanitarian and economic benefits to developing countries are immense, even the eradication of diseases such as the Guinea worm and eventually river blindness will benefit the United States. For example, an investment of $500 million over the next 7 years to complete the eradication of polio will eliminate the annual immunization costs of some $230 million annually in the United States. We're all aware of the enormous financial benefits to the United States in the eradication of smallpox. Every 26 days, we recover in cost savings the $30 million investment made in this undertaking.
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''The worldwide leader in that successful effort was the United States. And through the commitment of the Centers for Disease Control and USAID, 20 countries in west and central Africa became the first endemic region to eradicate smallpox.'' That's from President Jimmy Carter, a letter to our Committee dated May 20, 1998.
Chairman GILMAN. And now I'm pleased to welcome Dr. Broome, Dr. Nils Daulaire, and David Heymann. I'd like to introduce some of the heroes in the fight against infectious diseases. Our first witness is Dr. Claire Broome, Acting Director of the Centers for Disease Control. Dr. Broome has had a long history in the public health sector and is a specialist in the field of infectious diseases. She has won a variety of professional awards, including Infectious Disease Society Squibb Award for Excellence of Achievement in Infectious Diseases. She is a magna cum laude graduate of Harvard, where she also received her M.D.
Welcome, Dr. Broome, I know that you regularly appear before many of our Committees, but this is your first time with this Committee, and we hope your visit will begin a long and close partnership between our International Relations Committee and the CDC.
You may summarize your statement, or put your full statement in the record, whichever you prefer. Please proceed.
STATEMENT OF DR. CLAIRE BROOME, ACTING DIRECTOR, CENTERS FOR DISEASE CONTROL
Dr. BROOME. Thank you, Mr. Chairman, for that gracious introduction, and it is a real pleasure to be able to testify before your Committee on this important hearing on plans to eradicate or eliminate seven diseases. Accompanying me today are Dr. Walter Orenstein, head of CDC's National Immunization Program and one of the real heroes of the eradication effort, and Dr. James LeDuc, from the National Center for Infectious Diseases.
During my oral statement, I'd like to very briefly address some of the issues related to CDC and global disease eradication and elimination programs.
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CDC participates in global eradication and elimination programs because of the public health, economic, humanitarian, and other benefits. Eradication efforts protect Americans as well as protecting the world community. As we've heard, eradication is defined as the permanent reduction to zero in the incidence of infection so that intervention measures are no longer needed.
Elimination is the reduction to zero in a defined geographic area, but because the disease still exists in other areas intervention measures must continue.
As we've heard already, successful eradication programs save significant amounts of money. According to the GAO estimates the cumulative savings from smallpox eradication for the United States is $17 billion. The report also estimates the real rate of return for the United States for their investment is 46 percent per year, which I think anyone would agree is an outstanding rate of return.
However, we think at CDC it is critical to look at how eradication initiatives also benefit the broader spectrum of public health. These benefits include substantial improvements in health planning, training, and communications; development of disease surveillance systems—strengthening those that exist, creating those that are inadequate; the strengthening and creation of laboratory networks—these can be used for other important public health efforts. It's also important to note the increased enthusiasm and funding that eradication initiatives can bring for immunization and other public health programs by local political officials.
CDC believes that it is critical that diseases selected for eradication should be carefully identified and few in number. Eradication programs are major undertakings. We have to be very clear about the criteria that should be used before embarking on eradication initiatives. Factors we consider, we being the international public health community, include the biological feasibility of eradication; the burden of the disease—disability and death; the availability of effective and practical interventions; the cost effectiveness of eradication, compared to the current expenditures; and the operational and technical feasibility of implementing eradication strategies. Finally, the global capacity needs to be carefully considered.
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Let's take a look at what we believe will be a very successful eradication campaign to eradicate polio. It's very important to recognize the progress that has been made. Reported cases are down by 90 percent since the initiative was launched in 1988. All countries of the Americas have been free of polio since 1991, and many areas of the western Pacific and Europe have been polio free for one or more years. More than 400 million children have been vaccinated against polio in 1997. The multiple countries and organizations collaborating in the eradication initiative are unprecedented. I think it's particularly important to recognize Rotary International's contribution of $400 million and thousands of volunteers.
We also have to recognize that challenges still remain. Progress in Africa has not kept pace with the progress in other regions. And the completion of special initiatives in war-torn areas, such as Somalia and Sudan, will be essential to bringing the polio eradication program to a successful and timely conclusion.
Despite the challenges presented by Africa, CDC remains optimistic that polio will be eradicated by the target date of the end of the year 2000. In addition to this benefit, the legacy of the polio eradication program will be stronger immunization programs worldwide, improved capacity for disease surveillance, a functioning global laboratory network, and the momentum to tackle other major public health problems, including measles.
As you know, Mr. Chairman, measles causes 1 million deaths in the world annually—almost 10 percent of the deaths in children under 5. Almost all cases of measles in the United States are now due to imported cases so that measles control efforts will contribute both internationally and also domestically. We estimate that there be a $50 million annual savings in the United States alone, following a successful eradication initiative.
Obviously, the discussion around eradication of measles has considered a number of the issues I raised earlier. We clearly have an effective vaccine. We have the biological feasibility for eradication. But this undertaking will be much more complex than polio. We have to understand the infectiousness of the measles virus and the complex logistical and operational requirements for measles eradication, which make this a particular challenge.
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WHO is considering a global measles eradication initiative as a result of the global interest in ending the sickness and death caused by measles. CDC fully supports regional measles elimination goals and accelerated measles control as a step toward a global eradication initiative. If regional measles elimination programs continue to be successful, CDC hopes that a global measles initiative will be launched as the polio eradication program comes to a successful conclusion.
It's critical that the global public health community focus on finishing polio eradication before embarking on a more difficult and expensive measles eradication initiative.
Due to the time constraints, we have commented on the remaining diseases addressed in the GAO report in my written testimony, but I will not go into them in detail during my oral presentation. I do want to acknowledge the dramatic success with the Guinea worm eradication campaign, and the important role that President Jimmy Carter and the dedicated staff of the Carter Center have played in this success story.
Chairman GILMAN. Without objection, your full statement will be made part of the record.
Dr. BROOME. Thank you, Mr. Chairman.
Chairman GILMAN. Have you completed?
Dr. BROOME. If I could just make one concluding comment?
Chairman GILMAN. Yes.
Dr. BROOME. We feel the potential public health, financial, and humanitarian benefits of eradication programs offer a compelling rationale for U.S. Government support of such initiatives. The question is not either eradication or sustainable health development because we believe that eradication programs, properly carried out, can accomplish both. The health of our children and the world's children is too important to allow continuing paralysis or death from diseases which can be prevented forever.
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Thank you.
[The prepared statement of Dr. Broome appears in the appendix.]
Chairman GILMAN. Thank you, Dr. Broome.
Dr. Broome will be followed by Dr. Nils Daulaire, Senior Health Advisor, from the U.S. Agency for International Development. He's had an esteemed career, spanning the globe on each continent, except for Australia, in the field of public health. He's an expert in rural public health, speaks nine languages. We need you on our Committee to help translate. Prior to joining AID, Dr. Daulaire was the Director of the International Center for the Prevention and Treatment of Major Childhood Diseases. He has received his M.D. from Harvard, Masters in Public Health from John Hopkins.
Welcome, Dr. Daulaire. You may give your full statement or summarize, whichever you deem appropriate. We'll be pleased to make your full statement a part of the record.
STATEMENT OF DR. NILS DAULAIRE, AGENCY FOR INTERNATIONAL DEVELOPMENT
Dr. DAULAIRE. Thank you very much, Mr. Chairman. I have submitted my full statement for the record. I'll be giving a summary today.
Chairman GILMAN. Without objection, your full statement will be made part of the record.
Dr. DAULAIRE. Thank you.
Mr. Chairman, I would like to thank you and this Committee and the GAO for your very important contribution in bringing this critical issue to the attention of the American people. This report highlights an important new reality, which is that the world now has the tools and the know how to vastly improve the health of the 4 billion humans living in poverty in the developing world. Furthermore, the report also makes it 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. Again, this is a vitally important report, and I thank you very much for your leadership in bringing it about.
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In my verbal testimony, I'd like to highlight two major questions which I think have to be addressed that are raised in the report. And these two questions are the following: First, how important are these seven diseases in the context of global health? And second, what tradeoffs does the international community need to consider in deciding whether eradication of a particular disease warrants the investment? And we've heard a bit about that from GAO and from Dr. Broome already.
First, let me turn to the question of how important this is. I wonder if we could have the charts put up? All three of them? No, all three.
Polio, as you well know, has been a critical initiative in which USAID has been engaged since the 1980's, first in the Western Hemisphere, and then since 1996, under Representative Callahan's leadership, throughout the world in the eradication initiative, together with our friends from Rotary International.
What I would like to do right now is to highlight measles, which in terms of global health impact has to be considered the crown jewel of the diseases covered by this report. I'd like to introduce you to a young girl whom I met in the mountains of Nepal when I was working there as a physician in the 1980's. Her name was Laxmi, and I discussed her with the Senate Foreign Operations Subcommittee of the Appropriations Committee a few weeks ago in describing USAID's new initiative in infectious diseases and highlighting the fact that this young girl was suffering from antibiotic-resistant pneumonia.
Now, there are many happy stories in international health. This is not one of them. I met her in a remote village. She had been suffering from pneumonia for the past 10 days. She had been treated appropriately by her health workers with antibiotics, but despite this, her pneumonia was resistant, and a few hours after I met, in spite of our best efforts, she died. Now, in looking at this as a public health specialist, I tried to piece together why this happened. And I'd like to just run through briefly the background there.
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First of all, this young girl was one of seven children under the age of 10 in a very poor—her poverty is obvious from the picture—family. About 16 months after she was born, her younger brother was born. She was weaned too early and spent her entire childhood malnourished. But what was critical here, in addition to her malnutrition, was the fact that 2 months prior to my visit to her village, a measles epidemic had swept through the area. Measles infects absolutely everybody who has not either been immunized or has previously been infected with measles, and, along with dozens of other children in her village, Laxmi got measles, and then got the sad succession of after-effects that we see around the world, particularly among the poorest people—first diarrhea, a little bit better, then a cough, then that evolved into pneumonia, then ultimately the pneumonia that killed her.
Now it's clear that there are many things that contributed directly to her death, but it was equally clear that if she had been immunized against measles, she would not have entered this death spiral. It was the measles virus that pulled the trigger on this little girl, and it pulls the trigger on a million kids around the world every year. Every 30 seconds, as we sit here, another child will die of measles.
Now this is a particular issue among children who are poor and malnourished. When I was young, everybody got measles. We didn't worry about it. It was a common, routine disease of childhood. That's fine when you're well nourished and in good shape. When you're malnourished and have been subject to onslaughts from other diseases through your childhood, measles can kill one of twenty children that it strikes. That's like one child dying in every classroom in America, because it strikes every child who hasn't been immunized.
This highlights, on a human scale, I think a terribly important part of this report. As I've mentioned, we certainly put a great deal of stress as well on the polio eradication initiative. USAID, along with CDC and Rotary International and WHO, are very optimistic about its eradication in the year 2000. And we've also been very active with the Carter Center and others in the campaign to eradicate Guinea worm disease.
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What I'd like to do is to move to the second chart just to show you briefly the context of the diseases covered in this report.
You'll note the two slices of this pie chart that are pulled out to the side. Those represent measles which, as we've heard, account for a million deaths, and the other diseases in the report, which count for about another 100,000. Now, it's an important issue, but it's 1 million out of the 17 million infectious disease deaths around the world. And we have to look, as always, on the question of tradeoffs between programs aimed at the other 16 million deaths and the ones aimed at this. As Congressman Hamilton said, we have to make some decisions—hard decisions—on how best to use limited resources.
To make those decisions, I want to highlight three points. First is polio. As Dr. Broome has said, we have to finish polio, we're in the polio end game—right game. We expect over the next 3 to 5 years that it will be gone, and that we can then fruitfully turn our attention to new challenges.
Second, as I pointed out, the 16 million causes of death which are not eradicable, and the 600,000 women who die every year as a consequence of pregnancy and childbirth require ongoing routine health services. It's something we can't deal with right off the bat, and we're going to have to be able to help these countries to develop and maintain ongoing health programs and infrastructure.
And the third, the question of underlying conditions. Hunger, poverty, and social turmoil are the ultimate cause of disease and death in much of the developing world and a program which is balanced and appropriate has to address those as well. I would note, Mr. Chairman, that in this last Fiscal Year, AID's budget for health is now 48 percent of our entire budget for sustainable development. As a physician that makes me happy. But certainly in the context of balance we have to look at what we're doing about hunger, what we're doing about political and economic instability.
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Finally, on the third chart here I'd like to point out the issues relating to eradication, and this is not specific to a particular disease. It just gives you a sense of the cost per case eliminated as you move up the spectrum of disease coverage. Your costs go down as you cover a growing percentage of the population. In terms of measles right now in Africa, we're covering about 60 percent of the kids there.
Towards the end, though, that's when the costs start going up because you have to seek out the most difficult situations and cases, and that's where we have to start looking at the ultimate tradeoffs. Ultimately, what we have to do is to support the developing countries of the world in developing and running their own essential health programs on an ongoing basis.
Let me end with measles. Congressman Smith raised the question about whether there is support for measles eradication. There is a question, a technical question which we believe is close to being resolved, about whether measles can technically be eradicated. It looks likely, but it's not altogether certain. And there are questions, as Dr. Broome has raised, that we can resolve as we move forward in accelerated measles control. We are deeply committed to the prospect of accelerated measles control. We are committed to raising measles coverage in Africa, currently at 60 percent, all the way up to 90 percent by the year 2010. And we believe that that will provide the base for the ultimate elimination and eradication of this disease.
Thank you, Congressman.
[The prepared statement of Dr. Daulaire appears in the appendix.]
Chairman GILMAN. Thank you, Dr. Daulaire.
Our third panelist is Dr. David Heymann, the Director of the Division of Emerging and Other Communicable Diseases, Surveillance and Control, for WHO in Geneva. Dr. Heymann is our most recognized hero today for his work on the Ebola virus and other extremely lethal emerging diseases. Dr. Heymann is an expert in the field of tropical medicine, and in particular has worked in the area of childhood immunizable diseases and AIDS. Welcome back to our Committee, Dr. Heymann. And you may summarize your statement or read your full statement, or put your full statement in the record, whichever you deem advisable.
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STATEMENT OF DR. DAVID HEYMANN, DIRECTOR, DIVISION OF EMERGING AND OTHER COMMUNICABLE DISEASES, SURVEILLANCE AND CONTROL, WORLD HEALTH ORGANIZATION
Dr. HEYMANN. Thank you very much, Mr. Chairman and Members of the Committee. It's a pleasure to be back with you this year.
I have submitted my full written statement for the record.
Chairman GILMAN. Without objection, it will be made part of the record.
Dr. HEYMANN. Thank you very much, and I will give a brief summary. Before I speak, however, I would like to request your permission to show a 5-minute video on the diseases which are targeted for eradication and elimination.
Chairman GILMAN. Yes, please proceed.
Dr. HEYMANN. And if you agree, that will be narrated by Dr. David Brandling Bennett who is the Deputy Director of the Pan American Health Organization here in Washington.
Chairman GILMAN. Dr. Bennett. Welcome.
Dr. BENNETT. Thank you very much, Mr. Chairman and Members of the Committee. The Pan American Health Organization which serves as the regional office for the Americas in WHO is pleased to be able to participate with you today. And we thought it would be worthwhile for you to actually see the diseases that we're dealing with, and we'll look at the disease itself.
Here you see a person suffering from Guinea worm or dracunculiasis. You can see that a common practice is to try and extract the worm on a stick when it emerges. But that, of course—the appearance of the worm through the skin—can result in infection. The disease is acquired by contact with water where larvae have infected a water flea, a cyclops, and when the water with cyclops in it is ingested, when people drink it, they become infected. Now this can be prevented by treatment of the water or by filtration to take out the cyclops, as is shown here. And, of course, it's essential that to prevent this disease, we have safe water, and it serves as a measurement of how good our water supplies are.
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Polio is the next disease. Here you see a child suffering from polio in both legs. Another child here. This child is Luis Fermin Tenorio who is the last case of polio in the Americas, infected in August 1991. Commonly, polio is acquired by contact and by having the virus in infected water. And, of course, immunization is highly effective as a prevention—very simply given with the oral polio vaccine, which is widely used throughout the world. And, of course, we've had tremendous success in reducing the amount of disease burden worldwide.
Leprosy is a scourge I'm sure you're all familiar with, dating back beyond biblical times. Here you see the skin manifestations of leprosy. It commonly affects the extremities. As you can see, a woman writing having difficulty holding a chalk. This is a program to educate people from the disease to limit the adverse effects of the illness. The really significant advance has been multi-drug treatment for this disease, which now is effective in a very short time in removing the infection, but, of course, disability may persist.
Measles, as you've heard is a very common disease of childhood, commonly associated with pneumonia and neurological side effects. Deaths in even healthy populations is one per thousand cases—and much higher than that in malnourished populations. Commonly transmission occurs in school settings and day care centers. And we fortunately have a highly effective vaccine, which has been available since 1963, and is receiving more and more use. In the Americas region, we've reduced cases down to only 600 this year. Many countries are free of measles transmission—the United States is one of only five countries in the region with measles. So I think the feasibility of elimination and eventual eradication of this disease is demonstrated.
Onchocerciasis is a disease affecting 36 countries, six in the Americas. The most severe disease occurs in West Africa. The onchocerciasis control program has been going on since the 1970's. The disease causes blindness and skin effects. It is transmitted by a black fly. Here you see the Simulium damnosum, which is the vector in West Africa. The fly breeds in rivers, fast running waters, and the larvae of the fly can be eliminated with insecticides, but the most effective advance in controlling the disease and eventual eradication has been treatment with the drug ivermectin donated by Merck and Company.
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Chagas' disease is only encountered in the Americas. Here is the acute manifestation of the disease, Romano sign, usually resulting from a bite and the infection. The disease is transmitted by the reduviid bug, which comes out of the cracks in the walls of houses, bites people commonly when they're sleeping, and can be controlled by spraying insecticides very judiciously in houses to eliminate this bug. Also transmission can occur through the blood supply and hence the importance of screening blood supplies.
This is lymphatic filariasis, which results in a manifestation commonly known as elephantiasis—great swelling—transmitted by various forms of mosquitos. This is the Culex mosquito which can breed in contaminated or fresh water. And, of course, control has relied commonly on eliminating the vector, but now, thanks to donations by SmithKline Beecham, we will have available albendazolee, which, together with other drugs, can be highly effective in reducing or eliminating transmission and eventually eliminating this infection, which is so widespread.
Thank you very much, Mr. Chairman.
Chairman GILMAN. Thank you very much for your presentation. You may proceed, Dr. Heymann.
Dr. HEYMANN. Thank you very much.
As you can see from these diseases which are targeted for eradication and elimination, they're very disfiguring diseases which cause incapacity throughout a person's life. Persons who are infected suffer greatly. Great progress has already been made in eradication and elimination, as you've heard previously. And this has been due, in large part, because of the great contribution of the U.S.—USAID, CDC, NGO's in the United States, such as Rotary—chapters of Rotary International, and private industry such as Merck, Sharpe and Dohme, SmithKline Beecham and Wyeth Lederle.
Even so, Mr. Chairman, infectious diseases still remain responsible for 33 percent or 17.3 million of the 52 million deaths which occur in the world each year. We're getting some charts together which we will show you in a bit. These charts will show you that though mortality is occurring what does not show up on these graphs is the suffering and the disability in over 100 million people. And these infections—may I wait 1 minute while the charts come?
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Chairman GILMAN. While you're waiting, why don't you continue with some of your other testimony?
Dr. HEYMANN. OK. Well, thank you.
In addition to being responsible for a third of the infectious diseases, we're facing a problem where there's resistance to the antibiotics, which are usually used to treat them. In 1946, for examples, 2 years after the introduction of penicillin, 14 percent of staphylococcus aureus, a hospital infection was already resistant. By 1998, resistance exceeds 95 percent.
In addition to the resistance which develops, these organisms spread greatly internationally. And last year, I showed in this Committee a figure of the spread of multi-resistant streptococcus pneumoniae, which causes adult pneumonia.
Yes. OK. With your permission I will go back to the charts and just show you the infectious diseases which are the cause of one third of the mortality in the world—52 million deaths, 33 percent of them due to infectious diseases.
The underpinning of infectious disease control, antibiotics, are no longer as effective as they once were. If you would focus on the two red dates, 1946 and the 1980's to 1990's, you'll see that penicillin—very few years after it was introduced was already non-effective in treating many hospital infections of staphylococcus. Today, in the 1990's, 95 percent of hospital strains of staph are resistant to penicillin and so other antibiotics must be used. There's resistance also developing to our last antibiotic effective against staphylococcus.
There's also a great concern that these infectious diseases spread internationally. And here you can see the spread of a multi-drug-resistant pneumonia from Spain throughout the world within a period of 2 months.
The concerns because of the international spread of infectious diseases are shown in the next overhead. These concerns are different for the north and the south. In the developed countries of the north, the concerns are with international public health security, keeping these diseases out of countries where they've already been decreased to a very low level.
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The concerns for developing countries in the south are different. Their concerns are early detection and containment before these diseases can cause great suffering and death, and also because they many times interfere with tourism and travel. So, though we have many infectious diseases, the concerns are very useful. Both the north and the south can marry their concerns in one area and that is strong surveillance and control.
Now this next overhead is just to remind you that eradication and elimination are different. In eradication, there will be no remaining infected humans, and there is no non-human reservoir to keep the organism until it could reinfect a human. In elimination, there may be remaining humans in some parts of the world or there may be a non-human reservoir, which means that disease is always considered a public health problem which must be continuously regarded.
The next overhead shows you that in the targeted seven diseases for eradication and elimination, there won't be much decrease in mortality. The percentage of mortality that will be decreased is from 33 percent to 31 percent of all deaths. There is undue suffering which would be decreased and eliminated, but the actual death will not be as great as we would hope. But it's important to complete the unfinished business of eradication and elimination because these programs set up three very important activities which are necessary to control all infectious diseases. And these are disease surveillance and detection of diseases, health prevention and care delivery systems, and research and development for new drugs and vaccines.
Now let me show you how this will work. How this is working, in fact. In the polio eradication program, as Dr. Broome said earlier, there's a network of laboratories that's been set up throughout the world to verify that polio has been eradicated eventually. These laboratories have the capacity to identify polio virus in the stool of children infected with the virus. Now these laboratories are presently being enlarged in their scope to deal with other viral diseases, such as yellow fever, such as Ebola, and the hemorrhagic fevers, and such as HIV and AIDS. So this network, though it's being developed specifically for polio, is being enlarged as a global network of alert for many, many other infectious diseases.
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The same is true in the polio eradication effort for the cold chain, a system which ensures the potency and the safety of vaccines during their distribution to the point of use. Vaccines come out of the factory in cold storage, and they must remain in cold storage until they get to the village and the community where they're distributed.
The system which is being set up for polio eradication is useful for all of their vaccines, as are the education programs which are going on when vaccinations are given so that families can be better aware of infectious diseases.
The next to the last overhead shows you the vaccines that have been licensed since 1900. What you can see, in summary, is that there have been very many vaccines, 12 developed between 1990 and 1950, and thereafter between 8 and 4 a year. We're still missing the vaccines that we need for diseases such as tuberculosis, HIV-AIDS, the diarrheal diseases that kill so many children. And that means that research and development, the third element which is being strengthened in eradication and elimination programs must also continue for the other infectious diseases.
Now, why is eradication and elimination important? It's important because of the partnerships in public health which are developed. And that's clear from this. WHO, serving as a facilitator, can mobilize many different groups around a project, ranging from non-governmental organizations to private industry, to government and government agencies, foundations, and other international organizations. Second, the global infectious disease picture, which is much bigger than just eradicable diseases will benefit from these types of partnerships which are focused on infectious diseases.
And finally, the indispensable framework for dealing with these eradicable diseases and diseases which can be eliminated will be useful in strengthening other infectious disease control and prevention to finally decrease the mortality from infectious diseases.
Thank you very much, Mr. Chairman.
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[The prepared statement of Dr. Heymann appears in the appendix.]
Chairman GILMAN. Thank you, Dr. Heymann.
We appreciate the testimony of our three panelists. Dr. Broome, you noted that by eradicating polio, our Nation could save some $230 million a year and the international community would save about $1.5 billion a year. Where would those international savings come from? And would developing countries stand to save the most?
Dr. BROOME. The savings include the fact that countries no longer would have to purchase and deliver polio vaccine so that a very substantial part of the savings are because of the lack of need to purchase polio vaccine.
There are also savings in developing countries which no longer need to treat polio cases and also the major disability. As you saw in the video, polio victims have a life-long disability, which causes substantial costs, particularly in developing countries.
Chairman GILMAN. And CDC is not just a U.S. resource. You're the first experts any foreign government calls on to respond to an outbreak. Do those governments and other agencies help cover any of your costs? And are there any cost sharing and partnerships that help you in your campaigns.
Dr. BROOME. Well, we do consider that our mission, together with our partners in WHO and USAID is global. As was mentioned earlier, although CDC, thanks to support from the Congress, has provided substantial portions of the external resources, over 50 percent of the costs of polio eradication are being borne by the countries themselves. In Latin America, approximately 80 percent of the costs were borne by the Latin American countries. In addition, the crucial partnerships with the private sector, with Rotary International, and also other governments have really stepped up. And Japan, Britain, Denmark have been major contributors to eradication, as it became clear that this was a feasible goal.
Chairman GILMAN. Thank you. And Dr. Daulaire, I understand from the Appropriations Committee staff that USAID was reluctant to get involved in the effort to eradicate polio. Now USAID touts its historic partnership with Rotary, WHO, and others in that effort. Given that early reluctance, and the push that Mr. Callahan gave you, should we in the Congress give you another push to eradicate these diseases?
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Dr. DAULAIRE. I can say without equivocation, Mr. Chairman, that I was never reluctant, and I've been there throughout this Administration. We have been engaged from the 1980's, from long before this period, in the eradication campaign in Latin America. We continued through the early 1990's, before the major push in 1996 to support and promote polio activities throughout the world. The issue to which the Appropriations Committee is referring comes more as a question of earmarks and balancing and where money would have to be pulled away from. I believe the Committee was extremely successful. Instead of having money pulled away from other activities in providing additional resources, that it was possible to do both—the health systems development that we've done over many years, and contribute directly to polio eradication. So we have been extremely enthusiastic partners, albeit this issue of the tradeoffs was one that caused concern early on.
Chairman GILMAN. Well, it's good to hear that you're going to be enthusiastically supportive.
Dr. Heymann, if we're to eradicate disease, we have to build an international health infrastructure to monitor outbreaks and to coordinate the response to those outbreaks. How easy will it be to convert and to expand the infrastructure we've created to conquer smallpox and polio to fight other diseases? Are we going to be able to utilize those networks?
Dr. HEYMANN. Thank you, Mr. Chairman. Fortunately, these eradication and elimination programs are setting up strong networks because they're endowed with funding because of the mobilization of many different partners behind them. What WHO is doing is making sure that the laboratory networks which are set up and the disease reporting networks throughout the world which are set up will be increased in their capacity to deal with many different diseases other than those eradicated and eliminated so that they will serve as an excellent alert and monitoring system worldwide.
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Chairman GILMAN. Dr. Heymann, some in the Administration say that we shouldn't waste funding on curing the last, say, 3,500 cases of polio, and instead we should be working on the more numerous cases of, say, malaria, HIV. What do you say to that?
Dr. HEYMANN. It's clear that the last cases in any eradication or elimination program are the most expensive because they're the ones that have not had access to health services, so it costs a lot of money to get to them. Certainly, the cost benefit of getting to those populations with some type of infrastructure for other infectious diseases is great. So, therefore, I would say that getting those last cases is very important not only because it will make cost savings for the entire world, because of the elimination and eradication of those diseases, but also because it will set up an infrastructure which can be used to attack other diseases.
Chairman GILMAN. Thank you. Thank you very much. Mr. Payne.
Mr. PAYNE. Thank you very much. I certainly feel that this issue is very, very important. I'm sorry that I've been in and out a bit. I was actually at the White House before I got here, where we were trying to drum up support and had over a thousand young people to try to get an anti-tobacco bill going. Because, as you know, every day, 2,000 new young people start smoking, and I'm very anti-tobacco, and I'm sorry to be late. But it was for a good cause. And I would also like to say that there are people that certainly should be commended, as you mentioned, Rotary's Polio Eradication Program. I had the opportunity to be with them just a week or two ago when they were here on Capitol Hill. I think that's an outstanding program. And also the Guinea worm project that President Carter—I think that DuPont making a certain kind of a strain to keep the larvae out of the water—I think that that shows that with some support from industry and cooperation from the health industry providers, we could really make great strides forward—and also President Carter leading that work on getting the worm—and then the river blindness with Merck in New Jersey working at trying to develop the one pill.
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I have a question and then I'll make another statement. Why do you feel that, for example, tuberculosis is also another disease which seems to need a stronger kind of a—the old method isn't working—are the pharmaceutical companies putting in enough work on trying to come up with new vaccines or new products that can overcome the resistance that the new diseases have?
Dr. BROOME. I think the question that you raise is an important one, and it shows the complexity of what we all have to deal with. We have to continue to treat disease as it occurs with our current tools, but we also have to be looking to the future by investing in research. CDC and other groups will actually be sponsoring a meeting in August to look specifically at the question of enhanced development of vaccines to prevent tuberculosis. This is an important issue for global public health. It's also important for the United States, because, of course, many of our tuberculosis cases occur in the foreign born. So, again, global control of infectious diseases has benefits internationally and also domestically. It also highlights the major importance of research in any of these areas, from the basic questions such as vaccine development to applied questions such as effectiveness of regional measles elimination efforts. I think we have to recognize PAHO's leadership in measles elimination in the Americas and the important lessons that we will learn from that about the feasibility of global eradication.
Mr. PAYNE. It seems, and I don't know how the pharmaceutical industry works, but there is a need to find a vaccine or a medication that may do something to finally eliminate some area in a Third World country where the ability to buy and pay for it probably is very limited. The use may only be in a developing country. Is there any thing to prove or to suggest that the pharmaceutical companies perhaps make those less of a priority? I know they're in business to make money, and I will conclude with that. But do you feel that there is less excitement about trying to come up with cures of medication that could eradicate something that is not going to have a very high value economically, but is going to improve the quality of life tremendously or do you think there should be tax incentives in order to prod the companies into taking on some of these issues of the less-desired, less-glamorous pharmaceutical products?
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Dr. HEYMANN. Thank you, Congressman. With your permission, I'd like to show you an overhead which just lays out some of the issues that you've discussed. This will show you that the road to the development of a new drug or vaccine is very difficult for pharmaceutical industries, especially for products for developing countries.
[The chart appears in the appendix.]
First of all, the disease distribution is such that the market for many of these products is only in developing countries, as you've said. In addition, many times there's a long interval from development of a product to licensing which decreases the time of that patent and, therefore, it's very difficult to regain the investment from a developing country market where it takes a long period of time to regain, rather than a short period of time.
So, products that are developed for developing countries can't regain, with any guarantee, the investment which has been put in by pharmaceutical companies.
There are also many other problems. The limited duration of a patent to 20 years doesn't permit full recovery of money in developing countries, as I said, and, finally, the market in developing countries is many times a soft-currency market which cannot reimburse industry for its development.
So, unfortunately, industry, which rightfully has to regain its investment in a very short period of time, cannot do that for a developing country product.
Dr. BROOME. This is a problem that has been recognized by the international community; there are a number of approaches that have been considered.
First of all, there have been creative financing initiatives such as the PAHO, funding for vaccine self-sufficiency in the Americas.
In addition to that, we think it is very important to be sure there's adequate research support in the public sector, for development of products which may not have substantial commercial markets in the developed world. This needs to include partnerships between the public sector and the private sector because manufacturing capacity is needed.
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The Children's Vaccine Initiative has been particularly interested in these issues for vaccine development, and has proposed some innovative approaches, but it is a very daunting problem. It is one for which some substantial seed resources could be very important for making some of these initiatives work.
Mr. PAYNE. OK. Let me just conclude by saying I would hope that we could do something with the malaria, I know they are trying to work that as a tremendous killer. I know that the WHO recently had a meeting this last week where the question of the availability of pharmaceutical products in Third World countries was an issue, of course I certainly supported strongly the position of the pharmaceutical companies which are very heavy in New Jersey, that we think the integrity of patents must be kept and, as a matter of fact, the information I did intervene to ask the South African people to take another look and perhaps this is not the time to do this and let's look at how we can have a better distribution of health care because I do feel that integrity of intellectual properties is very important and that it has to be preserved in my opinion and being from New Jersey I'm very concerned about pharmaceutical industry and I do compliment—when I had a drive for some pharmaceutical for Somalia, we had tremendous—we raised close to $3 million worth, street value for specific products to go to Somalia, donated by the pharmaceutical companies.
But let me just say this, that unless the pharmaceutical companies take another look at what products they decide to look at, I think we have to take a look at the global situation and, if they don't, you're going to find the same thing that happened at WHO this week coming up again and, finally, when we talk about profits, I don't know if you saw the Star-Ledger a month ago that just simply dealt with pharmaceuticals in New Jersey, and we're all for profits, but these 12 or 15 men's salary for last year was $15 million and one poor chap only made $8 million, that was the bracket of salaries of CEO's of pharmaceutical corporations.
Everybody has a right to earn their keep. When I hear them talking about we can't do a particular kind of vaccine because we can't afford it, when J&J pays $15.3 million, when Upjohn pays $8.2, and Warner-Lambert pays $12.3, this is per year, and Pfizer pays $11 million and Merck pays $10 million and Eli Lily pays $8 million and Sherring-Plough has two people both making $9.5 million and Abbot Labs is $10.1 and American Home Products—and I didn't make it up, it was in the paper, I guess they want everyone to know it, so I'm just making it very crystal clear. Since you're advertising yourselves, then let's advertise it all the way in that we're going to have to have some integrity in the quality of life of people around this world, or we're all going to be in jeopardy because those germs get on a plane, or on a boat, or on a ship, or in a product, and with NAFTA and fast track and the other authority the President wants, you're simply not going to be able to run away from contagious diseases and if you were doing poorly, that would be one thing. But this does not make sense where we talk about the fact that we can't afford to go into this kind of thing, and I know the thing we do 100 products, we end up with 50, we end up with 5, we only get 3—I know the whole story, I know it; and, believe it or not, whether it sounds that way or not, I'm very supportive of the pharmaceutical industry because it provides employment for people in my state and I represent New Jersey.
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But I think there has to be a serious look. I don't know who's going to do the looking, but let me just tell you that I'm just a single little Member from New Jersey. If I can see this, I'm sure people that are in more important positions than I am can also see it.
Chairman GILMAN. The gentleman's time has expired. Mr. Smith.
Mr. SMITH. Thank you, Mr. Chairman. Mr. Chairman, just let me add my voice to yours and express some concern with the Administration. Sonny Callahan, our distinguished chairman of the House Foreign Operations Appropriations Committee, also, while being grateful that the Administration has now asked for a child survival line item, not only was in opposition but very vigorous opposition since coming into office to make sure that that didn't happen.
I would remind my colleagues, and, Mr. Chairman, you remember it so well when we marked up H.R. 1561, I had done some preliminary research and I contacted WHO, Special Program for Research and Training in Tropical Diseases, talked with—and had an extensive briefing by—Tor Godal, who is the director for special programs, and asked him where's the gap, how much do we have to come up with to make the difference?
He came up with a very detailed analysis and suggested that an approximate $14.7 million per year would be needed over the next several years and that number would then drop down to $4.5 million beginning in the year 2006. So I drafted an amendment and the chairman was totally supportive, offered it to the Committee for markup, to provide $15 million, $15 million each year for the U.N. Development Program, WHO's Special Program for Research and Training in tropical diseases.
We also put $25 million each year for vitamin A deficiency, and had a very high child survival mark and the Administration opposed this completely. We had a vigorous floor debate in this Committee. Thankfully we won, we won on the floor, and then the appropriators asked that we make it ''may'' rather than ''shall'' so it was soft earmark, but nevertheless clear guidance that this money needs to be spent in that way.
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Mr. Callahan did point out, Dr. Daulaire, as you know, that there is money requested for child survival, but it has been a back-breaking prioritization battle that we've had on this Committee. My concern about child survival goes back to day one, in 1981, when I first came here and people were talking about it. But it was cemented when I went with Jim Grant to one of those mass vaccination days, a ''day of tranquility'', in El Salvador in 1984 when thousands of kids were vaccinated against some of the leading killers of children. And then they had one for all of Central America. I mean UNICEF and WHO have done marvelous work in this with very few resources. I want all those concerned to know that we're concerned when we see money diverted from child survival to population.
Let the population fight be fought on its merits, up or down. People like myself are concerned about the promotion of abortion. We have to believe, I believe strongly that's violence against children and absolutely antithetical to any view of child survival when you're pumping poisons and dismembering children by way of abortion; that's not child survival, that's child destruction.
But the consensus should be for these different programs. Dr. Daulaire, I would be—and so would Mr. Gilman and others—we'd be pushing so hard for more developmental assistance if we had any assurance the money would not be diverted in other ways. And I know many of my conservative colleagues feel likewise that we're concerned about money not being used for these kinds of programs.
You oppose this over and over again and even Brian Atwood, when he came and testified here, lamenting the cuts in development assistance, right away locked onto child survival so I used his very words when I argued to put the earmark in and the Administration opposed us.
It was like talking out of both sides of your mouth.
My hope is, and it may not happen, that the President will sign the bill that will be sent down sometime in the near future to him. If he doesn't it will be a consensus breaker ad nauseam. We will fight. We will try to earmark money for things like this; we may win, we may lose, we'll probably be opposed. All Administrations oppose earmarks, I know, Reagan, Bush, and now the Clinton Administration. But hopefully we can move to the next order and that would be to really build as we go into the year 2000 and beyond to get more money for these things. I ask, Brian, and perhaps you would want to comment on this, Mr. Atwood, what Glaxo's great thought that they would come forward with AZT to help those women who are carrying children but have AIDS or are HIV positive. WHO has done some great work on that to find that you can cut the number of children to whom it is transmitted. And he said he would get back to us. You might want to respond for us whether or not that is something for which you might earmark or use the money.
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Chairman GILMAN. The gentleman's time has expired. We have 5 minutes to get to the floor. I'm going to put the Committee in recess. Mr. Burr will be coming back to chair the remainder of the meeting. Please bear with us. The meeting stands in recess.
[Recess.]
Mr. BURR. [presiding] The Chair would like to reconvene the last panel, if all the panelists are here. Great, everybody's back. We apologize for the inconvenience. We'd like to keep this going as best we can and I believe I can get my questions in before the next beep for another vote.
Dr. Broome, congratulations on acting director. Let me ask you, would we have been as successful with polio had Rotary not gotten involved?
Dr. BROOME. I think that Rotary has been an essential part of the success of the polio eradication initiative. I think people tend to focus on the dramatic amount of money contributed—over $400 million—but equally important has been the commitment of members of Rotary and International Rotary to provide thousands of volunteers, and to develop the political commitment in countries around the world.
Mr. BURR. I don't want to speak for the representative from Rotary, but I can remember well when the program was kicked off and one of the driving forces behind it was that Rotary was able to bypass the politics of countries outside of the United States of America which raises some real questions about what is the single most important thing. Is it money? Or is it the structure and how we go about the elimination or eradication?
Dr. BROOME. I don't think its an either/or question. We've tried to learn from the lessons of smallpox eradication and, clearly, the resources are important. We also have to have the infrastructure, the country capacity either in place or supplemented by the eradication effort. We need to have the technical ability, and where needed, the research activities to know what's going to be the most effective way to proceed. We definitely need the management capacity and the political will both at an international level and at a local level.
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Dr. DAULAIRE. Yes, let me just add to that, Congressman. I would totally agree with Dr. Broome. It's an either/or—it's like trying to get from here to New York; do you want a car or do you want gas for your car.
If we don't have funds or if the world community doesn't have funds to support these activities, then all the organization and structure in the world isn't going to take it anywhere. On the other hand, throwing money at problems has never done us much good either; so our effort has been in our international development programs and working in cooperation with both WHO and CDC to build up these structures, to have people on the ground. American doctors aren't going to do this, it's going to be the health workers in the countries themselves, trained, adequately supplied, well motivated, with management structures that help them to move forward and then putting in the money really makes a big difference.
Let me just go back to Rotary though. Rotary has been absolutely critical in the polio effort. I think there's no question but that we would not be looking at polio eradication in the year 2000 but for the leadership, the energy, and the resources brought to this by Rotary and we have enormously enjoyed our interaction with them.
Mr. BURR. You clearly know the obstacles and you referenced the smallpox experience. And, Dr. Heymann, you look at things truly from a global standpoint. Let's assume that the pot is unlimited—can we overcome the structural vacancies that exist out there whether they are political in nature, whether they are health vacancies in nature in certain countries? Can we choose elimination of certain diseases given the voids that we have? How do we bypass those? How do we overcome them?
Dr. HEYMANN. Congressman, I believe you've already given one of the answers in talking about the importance of the nongovernmental organizations, such as Rotary. Just let me follow up on Rotary. On a recent day in India, 134 million children under 5 were vaccinated against polio. To mobilize all the people to do the work, there were 150,000 Rotarians who participated side-by-side among the 2 million health workers and volunteers who ran the campaign to vaccinate children.
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Mr. BURR. Is there a similar plan as it relates to measles, written that incorporates the private sector to support this effort?
Dr. HEYMANN. Yes, in fact, there's a movement within WHO, as you know we will have a new Director-General in 2 months. The new Director-General has already spoken about the importance of nongovernmental organizations and how she will ensure that nongovernmental organizations have an even more important role in issues pertaining to all types of diseases including infectious diseases.
This is very important to bypass many of the political problems which do exist.
Dr. DAULAIRE. Congressman, let me also answer your question. I think your question goes right to the heart of development. Clearly there are countries in which we work—USAID, CDC—where the infrastructure is there. There are trained people, they have the facilities to get things out, and we can finish the job, you name the job, ''Job X,'' in a relatively short period of time because they've got those fundamental structures. But in the poorest countries, which are really the focus of USAID's development programs, we have a lot of building still to do. Africa is much better off today in spite of its poor economics than it was 40 years ago because it has a set of trained and educated people who've come up through a schooling system, through universities, and so forth, and who are now in positions of leadership. That wasn't true in the 1960's. So Africa is in better shape but many of those countries still have a long way to go to get those basic infrastructures in place.
Mr. BURR. Tell me, if you will, do we have a handle on the increased AIDS reported cases in Africa? Is that trending down, is it leveling off, or is it still—?
Dr. DAULAIRE. It is, it continues to trend up. It is not trending up as steeply as it was but——
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Mr. BURR. Are we using some of this knowledge to try to address that one specific disease in Africa?
Dr. DAULAIRE. Absolutely. It's a huge part of our program.
Mr. BURR. For the sake of time, let me shift gears because I can't have Dr. Broome here and since both of our other panelists alluded to this. I'm curious about the most recent outbreaks of antibiotics resistance. Is there a specific region? Is there a geographical region? Is there a specific disease that we have seen very resistant to antibiotics?
Dr. DAULAIRE. I can start on that. We're really seeing it across the spectrum. The nature of organisms, bacteria and parasites, is that they evolve in response to their environment. We have put a lot of antibiotics into the environment and where antibiotics are inappropriately used, we facilitate the conditions for these bugs to evolve into resistant forms. Now there are some that are more frightening than others. Tuberculosis is key among them. We're seeing a substantial increase in multidrug-resistant tuberculosis and TB was a deadly killer in the Americas and in Europe before the 1930's and 1940's when we started developing some good drugs for dealing with it. We may be losing those tools; it's coming from all over the world, Congressman, wherever there are drugs—which is everywhere—and we're in a borderless world as far as these bugs are concerned.
Dr. BROOME. We think one of the most important activities is to be able to track what is happening with antimicrobial resistance among these childhood killers, such as pneumonia, that Dr. Daulaire referred to. So, we've been working actively with WHO to set up a network of laboratories that can track antimicrobial resistance and, then, help to develop appropriate control programs.
Mr. BURR. I would agree with you that tracking is a necessity; is there anybody that would disagree that right now we lack the treatment for many of the resistant strains and that—I know you want to say something but let me ask you from a standpoint of this country and CDC, how concerned are you? I mean, certainly, we have a very finite number of antibiotic NDA's at FDA.
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Dr. BROOME. Yes. We are very concerned. This is a top priority and target for our emerging infectious diseases initiative. Switching gears to the domestic side, there are major organisms such as the Staphylococcus, which are killers in our hospitals, where we are starting to see some strains which are resistant to all available antimicrobials.
Mr. BURR. In fact, we see the treatment for most staph infections today, the strongest medication that a physician can find intravenously because they don't know whether this might be a resistant strain which really makes the problem that much worse because of the use of the strongest antibiotic in the strongest way that we possibly can.
Dr. Heymann, I think you wanted to say something before——
Dr. HEYMANN. I would only add that antibiotic use is a very complex problem because it's not only in the human sector, although humans use the most antibiotics; antibiotics are used in treatment of animals, they are used as additives to animal feed, and they are also used in agriculture. In the United States, for example, last year, over 300,000 pounds of antibiotics were spread on fruit trees in order to prevent a blight. So antibiotics are coming from many, many different sectors and it's very important that all these sectors together decide on the most rational use so that we don't continue to select out resistant strains.
Mr. BURR. Have we seen the creation of animal-resistant strains?
Dr. HEYMANN. We have. We've not only seen animal-resistant strains, but we've seen resistance in strains from animals which are passed on to humans and resistance therefore transfers to humans.
Mr. BURR. In this country as well, Dr. Broome?
Dr. BROOME. That's correct.
Mr. BURR. Let me go to, I think, a slide you had with the number 17 million annual deaths, I think from infectious diseases.
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Dr. DAULAIRE. That's right.
Mr. BURR. Let me ask you to comment on what the trends are. I think we had 2 million from measles, we had 1.5 million from AIDS. I'm curious. If we were to look at that chart 10 years from now, what would be the most significant change that you would project would happen and, I might even get staff to put that chart back up if we could. The pie chart of 17 million annual deaths.
[Chart.]
Dr. DAULAIRE. Let me comment first of all on what the trend has been. That trend is down from what that same chart would have been 10 years ago in terms of absolute numbers. For instance, because of the success of measles immunization, the number of measles deaths has dropped from over 3 million to a million; still unacceptably large, but it's dropping.
The toll of diarrheal deaths used to be about 4 million deaths a year. It's now down to 2.5 million, largely thanks to diarrheal disease control programs and oral rehydration therapy. Pneumonia is now the leading killer of children. We have over the past decade, again in close coordination with WHO, developed effective interventions against pneumonia at the community level. That number is dropping as well.
Malaria——
Mr. BURR. That number has dropped how significantly?
Dr. DAULAIRE. Probably not—not by a large amount at this point, we're sort of at the early point of the drop in curve; we've just got the infrastructures in place to do that. Malaria has been resurgent in Africa; there are more deaths today than there would have been 10 years ago and that's why a big part of our new infectious disease initiative at USAID is focused on malaria.
Mr. BURR. Is there a lesson that we should note from that as it relates to our structure——
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Dr. DAULAIRE. Absolutely. You take your eye off the ball at your own risk. The world community was very close to having malaria totally contained in the 1950's and 1960's. Relatively few cases in relatively isolated areas. The world community moved on to other more immediately pressing things and that certainly is an issue.
TB, as well, has been increasing largely because of its concurrence with HIV and AIDS and, of course, AIDS has been spreading rapidly around the world.
What I would expect to see, Congressman, in 10 years, and much of our infectious disease initiative is focused on these major killers, what we are projecting is a 10 percent decrease in all non-HIV/AIDS deaths. We still don't have a very good handle on HIV and AIDS; our prevention programs are starting to pay off, but it's really work in the trenches, and since I see Congressman Smith is back, I will answer his question about AIDS and mother-to-child transmission because it's been the topic of a very intense technical review inside USAID and in collaboration with our partner agencies.
We are, in fact, engaged right now in finding field sites where these programs can be put in place to look at how—you know, it's one thing to get a scientific discovery as was published, I think, in February or March, that you could reduce mother-to-child transmission of AIDS by treating mothers with AZT. That accounts for about 10 percent of AIDS infections around the world, at this point, and we're looking at how to apply that effectively in developing country situations. So, yes, we are most definitely following up on that.
Mr. BURR. We understand the difficulty that you'll deal with because I think we have difficulty here as it relates to that policy, though we know there are a tremendous amount of newborns that could be positively affected by that policy.
What on that list, and I apologize, I was distracted; what on that list, do we expect 10 years from now to grow?
Dr. DAULAIRE. To grow? HIV and AIDS? The epidemic is just really starting to hit in Asia now, and, in fact, last year, I think, for the first time there were more new infections in Asia than there were in Africa.
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Mr. BURR. Is that centrally located in any one area——
Dr. DAULAIRE. Its epicenter is in a couple of areas. It's in Southeast Asia, the Thailand-Cambodia-Vietnam nexus, and probably the most important new nexus is in India where it's spreading very rapidly.
Mr. BURR. Dr. Broome, we're at a point in this country where we've had a leveling off?
Dr. BROOME. Well, we have been very fortunate to be able to afford the latest antiretroviral therapy and this has caused, for the first time, an impressive decrease in deaths due to AIDS and new cases of AIDS. However, when we look at the figures on new HIV infections, those are not going down. Even in some of the risk groups which have been most open to prevention messages, we see a constant rate of new HIV infections. So, I think it's premature to think that we have solved the HIV infection crisis in this country. And in some subgroups, such as African-Americans, the rates of HIV infection are increasing.
Mr. BURR. Let me ask you, off the subject, real quick just a hypothetical. If in this country we supplied the current cocktail drug to potentially every AIDS patient, do you believe that our health care cost in total for AIDS would go up or go down?
Dr. BROOME. I will get you the detailed calculations of that, because we do try to look at the cost effectiveness of these new therapies. They are, of course, changing very rapidly, but we are making major efforts to provide the best antiretroviral therapy available to all people who need it in this country. It is definitely a financial challenge for the United States.
[The information below was supplied following the hearing.]
This is an important and complex question for which the scientific data is yet very preliminary. There are many factors that must be taken into account in exploring this issue, including:
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1. The efficacy and response rate of specific combinations of highly active antiretroviral therapy and the durability of clinical benefit, as observed for both antiretroviral naive persons and those who have previously received antiretroviral therapies;
2. Clinical issues such as the optimal time to begin antiretroviral therapies and the ability to tolerate side effects and sustain adherence to difficult regimens; and
3. The changing costs for HIV/AIDS care, including cost-shifting from inpatient to outpatient sectors concurrent with increasing pharmacy costs.
As we gain experience in defining the population(s) that will benefit maximally from contribution therapy, we are also learning to better define those populations that do not have total suppression of viral replication but for whom new therapies have altered the natural history of HIV disease with a slower decline in immune function. These altered patterns of disease progression will likely result in new constellations of related disease processes, such as the incidence of opportunistic infections, malignancies, and effects on specific organ systens in the body. The impact of these changes, yet to be defined, on utilization and cost considerations may be considerable in light of the rising prevalence and prolonged intervals prior to an AIDS diagnosis and death.
Because of the complexity of these issues and limited experience with new combination antiretroviral therapies, we do not have sufficient data to provide a definitive answer to this question at this time.
Mr. BURR. Certainly at the state level, programs like ADAP are not sufficient to fill the needs of every patient which leads, in all likelihood to extended hospital stays in any given year which is, we all know, a very expensive process.
Dr. BROOME. We would love to get you the actual figures.
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Mr. BURR. I would have to have that number if I could. Dr. Heymann, do you have anything you wanted to——
Dr. HEYMANN. I would just add on what Dr. Daulaire has said to tell you that we don't know yet what HIV/AIDS has in store but we do know in East Africa, for example, if you look at 1980 on the savings that were made in child survival by immunization programs and control of diarrheal diseases, they have now been negated by the impact of AIDS. So that we are now where we were in 1980 as far as child survival, it has now continued its downward trend.
Dr. DAULAIRE. And let me just add one final thing to your question about the dynamics of illness and disease in the developing world. What we expect to see over the next 10 to 20 years in the developing world is three diseases will be increasing in the developing world. The first of those is HIV and AIDS and the question here is how effective our prevention programs can be in slowing that and eventually reversing the increase.
The second one is TB, which is growing in direct association with HIV and AIDS because a third of the human population is already infected with the TB bacillus and the breakdown in immunity that comes with HIV and AIDS lets the disease rekindle and that's why we are seeing so much more of it.
And, then, the third one is smoking-related illness and death. In the developing world today, about a million people a year die as a direct consequence of tobacco. The projections are that by the year 2015, that will rise to about 7 million people a year. So those three are the three big killers of the next generation.
Mr. BURR. I have abused my time, is there any other Member that has questions of this panel?
I'm sorry. The gentleman, Mr. Smith.
Mr. SMITH. Thank you very much, Mr. Chairman. Dr. Heymann if you could, and this might be something you might want to do for the record, update our information in terms of what would be needed on the tropical disease front, the shortfall if you will. And very often—again, we get this from Republican and Democratic administrations, they always want more participation from other countries. But as we've seen, not just in the context of eradicating diseases, but also regarding money that was not forthcoming to deal with the tribunals in Rwanda and Bosnia, as my Subcommittee oversees many of those things. I tried to increase the amount of money because of lost evidence. I was told we need more burden sharing. Well, I mean people who have committed crimes against humanity have got off scot free because of a lack of evidence and a lack of financial commitment.
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If you could make that available to us it would be very helpful, so it's updated and we have a copy of this letter, which is outdated obviously, March 30, 1995.
[The letter appears in the appendix.]
I also would like to ask, with Dr. Bruntland now as head of WHO, there are some concerns that some of us have that WHO may take a new course or may veer, perhaps just a few degrees, which I think would be unfortunate, into areas that, again, are consensus breakers.
I was very much chagrined and I was joined by many people in the House and in the Senate and I think worldwide, including parliamentarians in Australia and elsewhere, that WHO was involved with RU–46 which we consider baby pesticide, kills babies, prevents them from having an environment that is hospitable to their continuance, usually around the seventh week.
I heard Dr. Bruntland at the Cairo population conference. I heard her speak. She gave a strongly pro-abortion statement, she's entitled to her opinion, but now she heads an organization with considerable assets, commanding considerable deference by the world's governments to provide sufficient resources.
I know in our own CDC, and I remember reading this 20 years ago, Dr. Willard Cates of the Abortion Surveillance, wrote a paper, ''Pregnancy, the Second-Most Sexually Transmitted Disease.'' Absolutely appalling; pregnancy is not a disease. It is a naturally occurring state—and when we get those kinds of mindsets, it raises questions about, you know, in what direction, in this case, is WHO heading?
I know that a pregnancy vaccine is something that is very much opposed by the women's groups. Again treating an unborn child or, in this case, before the child comes into being, as a disease to be prevented. Something on the order of keeping leprosy out, or keeping—you know, controlling measles or diphtheria or tetanus and it creates a very hostile environment for children, and I know, I see some people rolling their eyes, they don't like to hear this, but for some of us—birth is an event that happens to every one of us. It's not the beginning of life and we need to look at unborn children, newborn children, 5-year-olds, right until natural death, with respect, with a capital ''R.''
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So, I would just ask you, again, to get back to us, unless you have it at hand how we can be of greater assistance on the tropical disease front and on all these fronts, obviously, but on this one especially, and perhaps, you might want to comment on Dr. Bruntland and where she might take the organization.
Dr. HEYMANN. Thank you, Congressman. We will certainly get back to you with the estimates on tropical diseases. As far as Dr. Brundtland, Dr. Brundtland will take office on the 21st of July. I can only tell you that in her speeches which she has given to the World Health Assembly last week and to our executive board this week, she's identified primary health care as one of her major areas, and in that it is roll back malaria and the other area that she's picked out as a priority is smoking, especially the glamorization of smoking to youth.
So these have been her two major announcements to date. She has mentioned nothing about reproductive health as far as any detailed plans in that area.
Mr. SMITH. OK, we will, all of us, I think, will be watching very carefully, because again, as I've said to my good friend, Dr. Nils Daulaire, this is a consensus breaker for many of us when we could have a natural, and I think synergistic relationship and could be putting much more money into the development assistance account. I would fight for it and I think others could be successful. I can't say we will be. But unfortunately those kinds of issues lead to dissension—Dr. Daulaire, maybe you might want to comment on the earlier question about the AZT, on hepatitis C, and some of those other diseases that are out there, that are a high threat.
What would be the eighth disease, and the ninth disease, and the tenth? You mentioned, I think, smoking, was something that was not covered——
Dr. DAULAIRE. The report is specific to the diseases that are thought to be eradicable or amenable to elimination, and there are many diseases that are clearly a very high priority that are on that chart right there. Pneumonia is not eradicable or eliminatable. There are bacteria that cause pneumonia rampant in the environment. Some of them may be amenable to vaccination, some of them are not likely to be and we'll always have pneumonia with us; diarrhea similarly; but there are some—virus, for instance, one of the major causes of early childhood diarrhea, there's not a vaccine, so that may be a target. What we have to look at in each of these circumstances is whether there are other reservoirs for the organism than man, because that makes it very, very difficult to eradicate.
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If it's only man who gets it, like polio, like smallpox, like measles, then, if you have programs aimed at people, you can get to every case of the disease in principal, but many of these things go beyond that.
TB, for instance, we don't see any prospects in the foreseeable future of eradicating even though it is a huge and growing problem in the world because we don't have a good preventive vaccine for it, and the same is true about malaria, so I don't think there is anything at present that can be added to that list of seven because scientifically we haven't come up with things that technically could be eliminated or eradicated, but clearly, as I showed here, again, those are a very small portion of the world's burden of disease and the major focus of our programs clearly have to be on the remaining 94 percent of illness and death in the developing world.
Mr. SMITH. I see my time is up and I do thank you for yours.
Mr. BURR. The gentleman's time has expired. The Chair would recognize the gentleman from New Jersey for one question.
Mr. PAYNE. Just a question in regard to the Guinea worm. It was indicated at WHO or CDC about the fact that 75 percent, approximately, of the cases are in southern Sudan in the area where there is crisis. I wonder if you've been, Dr. Heymann, in touch with say, the UNHCR or some of the other humanitarian agencies associated with the United Nations, to see whether the Abashir Government in Khartoum would allow a humanitarian—we know up to now they have not been—you know food has been used as a weapon and that crisis has been going on for decades almost. Has there been any effort to attempt to have U.N. agencies make an appeal in the regions where this is so devastating?
Dr. HEYMANN. We have several means of working with the people in the area where there is civil strife in southern Sudan. We're working very closely with UNICEF in polio eradication efforts, and those efforts we've expanded the surveillance, the detection of diseases of polio, to include Guinea worm. So that's one way in which we're working in that area.
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In another area, we're working with Global 2000 which periodically provides us with people who will go into the area and work on the eradication and elimination activities with WHO and with this NGO, so, yes, there is intensive activity.
In addition we have a group called Emergency and Humanitarian Action at WHO which is looking at the overall health problems in the area and trying to mobilize resources through constant interactions with international development agencies and with donor groups.
Mr. PAYNE. Thank you. Thank you, Mr. Chairman.
Mr. BURR. [presiding] The gentleman's time has expired. The Chair would like to thank this group of witnesses for being here today and certainly for their knowledge that they've been able to share with this Committee.
At this time I would adjourn this panel and call up the third panel, Dr. Brian Bagnall, director of project management at SmithKline Beecham, and Mr. Herbert Pigman, past secretary general of Rotary International.
The Chair would ask unanimous consent to enter into the record the March 30, 1995 letter from the WHO tropical disease program and section 3222 of H.R. 1561, the State Department authorization bill for Fiscal Years 1996 and 1997. Without objection, so ordered.
[The information referred to appears in the appendix.]
Mr. BURR. The Chair would recognize Mr. Pigman.
STATEMENT OF HERBERT PIGMAN, PAST SECRETARY GENERAL, ROTARY INTERNATIONAL AND CHAIRMAN, TASK FORCE ON INTERNATIONAL ADVOCACY, THE ROTARY FOUNDATION, ROTARY INTERNATIONAL
Mr. PIGMAN. Thank you, Congressman Burr. I'd like to supplement the written testimony with a few remarks about the subject of public-private partnerships and the effort to combat infectious diseases, and offer a viewpoint from a voluntary association.
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As has been reported, the number of cases of polio has dropped by 90 percent since the WHO resolution of 1988. I believe that that WHO resolution was adopted because of three major developments. One was the steady progress of the expanded program on immunization which had begun in 1972, in which nations were working to raise the level of immunization of newborns against six major infectious diseases, among them polio.
The second development was the dramatic results of the special strategy against polio adopted in the 1980's in the Americas, which is routine immunization supplemented by national days of immunization, along with surveillance and mop-up efforts.
But the third development was the clear evidence that the private sector was willing and able to make important contributions to help carry out this polio eradication strategy. So, we now speak of a public-private partnership which has been alluded to as unprecedented in the field of public health.
In this particular partnership, WHO gives technical leadership and training, UNICEF provides vaccine and program expertise. The CDC deploys epidemiologists and virologists and lends support to a global lab network. Donor nation agencies, of which USAID is a leader with its polio eradication initiative, support operations which at the same time help to build sustainable infrastructure. And Rotary, with its 1.2 million members in 159 countries, has unleashed an army of volunteers who staff immunization posts, inform parents, and bring private sector resources and ingenuity to the logistical problems of vaccine distribution.
In addition to committing more than $400 million in private funds, we also serve as an advocate. In the past 3 years donor governments have responded with polio-targeted grants of more than $475 million, $200 million of which have been provided, I'm proud to say, by the United States. And, of course, the final and most important element in the partnership are the health workers in the countries where the disease is being attacked.
I think the important question is, Can similar partnerships be forged in a battle to eliminate or eradicate other diseases? I believe it is possible; however, intensified technical efforts by themselves are not going to bring about the acceleration and expansion needed. Ultimate success will depend on sustained global partnerships.
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It will require, on the part of public health leaders at all levels—global, national, district—to market their causes. They will need to identify for each potential private sector partner a role which is within the capacity of that partner, whether the contribution be that of financial aid, technical resources, voluntary power, or combinations thereof.
Different diseases are going to require different sets of resources. For example, it was alluded to, the fact that there were 2 million volunteers involved in the India NID's. Volunteers were able to administer much of the polio vaccine. The administration of measles vaccine, on the other hand, is by injection and can only be done by those medically qualified.
Technical considerations aside, however, it is clear there are many tasks in which the private sector can assist; namely community awareness, case reporting, transportation, social mobilization and advocacy, all of which serve to stretch the public health dollars and bolster results and morale.
Thank you for the opportunity to make these comments.
[The prepared statement of Mr. Pigman appears in the appendix.]
Mr. BURR. I thank the gentleman. The gentleman's time has expired.
The Chair would recognize Dr. Bagnall.
STATEMENT OF BRIAN BAGNALL, DIRECTOR OF PROJECT MANAGEMENT, CORPORATE AFFAIRS, SMITHKLINE BEECHAM
Mr. BAGNALL. Thank you, Mr. Chairman. I'm director of the Lymphatic Filariasis Program for SmithKline Beecham, and I'd like to point out that our company does have a very active tropical diseases research program, including malaria vaccine research, which we've been working on for some time. And I'm happy to represent the private sector here today.
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What is lymphatic filariasis? It's a difficult word to pronounce, and it's one of the world's forgotten diseases. I'd like, with your permission, Mr. Chairman, to show a 2-minute video tape.
[Video.]
Mr. Chairman, thank you for allowing us to show that videotape. That was President Carter speaking at a recent meeting of our company. We are also supporting the Carter Center in their work against lymphatic filariasis and some other tropical diseases.
SmithKline Beecham announced an agreement last January with WHO, through its Division of Control of Tropical Diseases. The director, Dr. Behbehani is sitting behind me here, and we're working very closely with him to collaborate on a global program to eliminate this disease.
The disease that you saw in the video is now entirely preventable, and we are committed to doing whatever is necessary to eliminate this disease. The tools and the strategies for diagnosing and treating this disease, as was said in the video, have only recently been elucidated.
The target that we have set with WHO is the year 2020. You'll notice from the chart this morning from the GAO report, that it listed the year 2030 and that the elimination was very speculative. We'd like to update that today and say that the target of elimination can be brought forward by 10 years, to 2020. And we think that the outlook is now very hopeful rather than very speculative.
The aim is to treat the people in at-risk areas with two drugs once a year for 4 to 6 years, and one of the drugs will be albendazolee, which we will donate free of charge. We're planning to produce about 5 billion tablets of this over the 15- or 20-year period to donate to 75 target countries. In addition we'll be providing financial support, advice, and education and training help.
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We're currently in the organizing and planning phase of this program. We hope to begin shipping the first drugs toward the end of the year to the ministries of health of the countries which have submitted elimination plans.
The treatment program that I've described, which has been devised by WHO with the scientific and tropical medicine community, has a very special mission and that is to break the transmission of lymphatic filariasis. It's a truly preventive public health program aimed particularly at children and young adults who are infected with this parasite, but who have not yet developed the long-term effects.
Those individuals with long-term effects and disabilities will benefit from another WHO program aimed at hygiene of the skin and wound programs, so they're really two separate programs. This program is to break transmission of the disease.
I've said that SmithKline Beecham will do whatever it takes to rid the world of this dreadful disease, but we cannot do it alone, even with WHO and even with the likes of the World Bank helping us. Therefore, we're actively seeking to build a coalition of partners for lymphatic filariasis elimination from public, private, and non-profit sectors which make up the worldwide community of public health resources.
We also recognize the generous contribution of Merck & Company over the past 10 years with the Mectizan Donation Program for river blindness control, which is another filarial parasite disease. We are keeping in close touch with Merck, and we're hoping to work together in the future as part of a growing private sector coalition.
Mr. Chairman, over the past few months we've been encouraged by messages of support that we've received, including a number of messages from your colleagues in the House and Senate, and we want to hear from anybody, and WHO wants to hear from anybody, who's willing to join the fight against this terrible disease.
We applaud you and the Committee for holding this hearing because it will send a clear call for action to both the public and the private sectors, and I hope that you will be able to encourage the U.S. Government to directly support the efforts to stamp out lymphatic filariasis, which was for so many years regarded as a hopeless disease.
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And finally, I'd just like to say that our collaboration with WHO allows us as a company to directly improve the health of at least one-fifth of the world's population. This program will spearhead our health care focus to global communities in the new millennium beyond just lymphatic filariasis.
Thank you, Mr. Chairman.
[The prepared statement of Mr. Bagnall appears in the appendix.]
Mr. BURR. Thank you, Dr. Bagnall. Your time has expired, and on behalf of Chairman Gilman and the rest of the Members of this Committee, let me thank both of you—SmithKline Beecham and Rotary International—for the contribution to two diseases that you have devoted not only the financial resources, but in many cases the volunteers, both from Rotary and from the 54,000 SmithKline Beecham employees.
Let me ask you, Mr. Pigman, how tough was this for Rotary International?—the Chair would recognize himself for 5 minutes; I apologize. How tough was this for a public-private partnership with world health organizations?
Mr. PIGMAN. Well, Rotary had no experience in public health, and when we offered help we were greeted cautiously, but kindly, by the global partners. They found a place at the table for us, identified tasks for us, and pretty soon this partnership grew into a very solid relationship. I think that that will be a process that will have to be followed by other private sector partners as they seek a role in combatting infectious diseases.
Mr. BURR. Well, I can remember vividly the day my district Governor came to my Rotary club and announced what the Rotary commitment was going to be, and most Members thought that polio was gone, or at least as we know it in this country.
Let me ask, as a private sector entity, was this easy to communicate worldwide to your membership why this type of focused effort needed to take place?
Mr. PIGMAN. Well, in the developed countries, of course, polio had all but disappeared, and it took an education campaign to inform these people that it was a tremendous problem worldwide to attack this problem and educate our own membership. We trained 3,700 volunteers to carry the message worldwide. We went for $120 million, and the Rotarians responded with double that. Raising the money wasn't hard at all, but telling Rotarians how they could actually do hands-on help took a little more effort. But thanks to WHO, UNICEF, and National Health Ministries, tasks were found and a relationship developed very well.
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Mr. BURR. Is the structure in place, not only for us to meet the eradication goal of Rotary for polio, but is the structure in place, as Rotary has seen it, for us to eliminate or eradicate these other targeted diseases?
Mr. PIGMAN. Well, Rotary is very much focused on polio. We call our program Polio Plus because we know there are going to be residual benefits that will transfer to other areas. I would hope that Rotary's interest in public health, and polio particularly, would not atrophy after the polio virus is conquered.
Mr. BURR. What is next for Rotary?
Mr. PIGMAN. That is yet to be decided.
Mr. BURR. Well, again, we thank you for the commitment that Rotary has made to polio and to its eradication, and I'm still hopeful that the year 2000 or 2002 is a realistic goal for us to expect.
Dr. Bagnall, you said that you had moved forward the goal from 2030, which I think was a WHO goal, to 2020 for eradication. Am I correct?
Mr. BAGNALL. Yes; that's due to the new science. The previous figures from WHO were based on estimates using diethylcar-bamazine (DEC), an old anti-filarial drug, which will still play a role. That figure was based on distributing that via cooking salt. What's become possible with the 10-year advancement is the use of albendazolee and either ivermectin or DEC together—the combination therapy. So it's the new science and the new data that have been able to bring that date forward by 10 years.
Mr. BURR. Now, I will not be shy. I will tell you I don't have a clue as to why that shortened it 10 years. Could you, in layman's terms, tell me what the combination of the two has done to shorten the goal by 10 years?
Mr. BAGNALL. It's just much more effective. In some ways this disease is like AIDS. Using these cocktail combinations of drugs is just more effective and much more powerful, and that's what the data shows.
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Mr. BURR. So, can I conclude from that where, under the prior treatment it took multiple dosages, that this takes less and therefore the timeframe—I see a lot of heads shaking, so——
Mr. BAGNALL. It's still an annual program, but by using two drugs together you get much enhanced efficacy, so that's the new data. There's been a lot of scientific progress in the last couple of years.
Mr. BURR. Well, let me ask, was albendazolee, or this indication for it, is this a supplemental indication for that drug?
Mr. BAGNALL. No. Albendazole has been used in human therapy for more than 15 years as a de-worming drug for the treatment of intestinal worms. It's still one of the most common drugs used in the world. It just so happens that when you use it together with recognized anti-filarial drugs like DEC or ivermectin, you get this enhanced synergistic effect. The scientific community is not exactly sure why this occurs, but it's a very definite result.
Mr. BURR. Well, we thank you for the company's commitment to eradicate this disease.
The Chair would at this time recognize the gentleman from New Jersey.
Mr. PAYNE. Thank you very much. Let me also commend SmithKline Beecham for having a goal and to really hear that the goalposts are not being moved further away, but moved closer to the ball. Today, it's very positive to see goals being met before time, and I certainly would like to commend you for the good corporate citizenship that you've shown in this fight and in other areas, but for this lymphatic filariasis.
I think that if somehow pharmaceutical corporations could somehow come together, or WHO convene, and maybe each could take a target of a non-profitable problem, that if that particular pharmaceutical organization took on the responsibility with private and public and civic groups they could take 15 of the areas that are not attractive to pharmaceuticals and maybe they'd each simply target that area with support from governments, with support from groups like Rotary. Maybe that would be an approach to try to eliminate some of these diseases, and I will probably be in touch with the WHO to talk about ways—and our CDC and NIH and others—to see how we could have a common approach to some of these issues.
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I think they can be solved. I think they can be eradicated if everyone does their share, and I certainly would like to. I've talked to a gentleman, Mr. Wheat, who is with your firm, on a number of occasions, and I've been very pleased at some of the progress. And as I indicated before, Merck Corporation, with the river blindness, and others are doing the job. I simply think, though, that corporations can do more. They should do more. There's no reason for them not to be doing more.
And I would like to also commend the Rotary. I had the opportunity to be at their international meeting here a week or two ago, and I have your little time—your hourglass—on my desk. You know, they have an hourglass to be used to eliminate polio, and I keep turning it over and watching the time when I don't have a red light like that.
But we hope that the goal of eradicating polio—I was very pleased—I don't know if you know Michael Diamond, who is with Rotary International and came to visit with us. The last time I saw him was in Bangladesh in the early 1980's when he was working for the World YMCA with children.
So, I think that the way that you've brought the Rotarians together—and I wish I had known this a month ago. I spoke before the Newark Rotary club and I was unaware that you had this drive going, but I would have mentioned it there, or they should have told me. But I would just like to commend both of you for just moving in the right direction, so far as I'm concerned, and I wish you continued success in your goals.
Thank you.
Mr. BAGNALL. Thank you.
Mr. BURR. The gentleman's time has expired.
The Chair would again like to thank Mr. Pigman and Dr. Bagnall for the commitment of not only Rotary, but SmithKline Beecham, to all of our panelists today for their knowledge and input into something that this Committee really wants to work hand-in-hand to see that eradication and elimination is successful over some specific timeframe. Certainly the information we've been given today is going to be extremely helpful to work hand-in-hand on that process.
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At this time, this hearing is adjourned.
[Whereupon, at 12:50 p.m., the Committee adjourned subject to the call of the Chair.]
A P P E N D I X
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