[Senate Hearing 109-139]
[From the U.S. Government Publishing Office]
S. Hrg. 109-139
EXAMINING USAID'S ANTI-MALARIA POLICIES
=======================================================================
HEARING
before the
FEDERAL FINANCIAL MANAGEMENT, GOVERNMENT INFORMATION, AND INTERNATIONAL
SECURITY
of the
COMMITTEE ON
HOMELAND SECURITY AND GOVERNMENTAL AFFAIRS
UNITED STATES SENATE
ONE HUNDRED NINTH CONGRESS
FIRST SESSION
__________
MAY 12, 2005
__________
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COMMITTEE ON HOMELAND SECURITY AND GOVERNMENTAL AFFAIRS
SUSAN M. COLLINS, Maine, Chairman
TED STEVENS, Alaska JOSEPH I. LIEBERMAN, Connecticut
GEORGE V. VOINOVICH, Ohio CARL LEVIN, Michigan
NORM COLEMAN, Minnesota DANIEL K. AKAKA, Hawaii
TOM COBURN, Oklahoma THOMAS R. CARPER, Delaware
LINCOLN D. CHAFEE, Rhode Island MARK DAYTON, Minnesota
ROBERT F. BENNETT, Utah FRANK LAUTENBERG, New Jersey
PETE V. DOMENICI, New Mexico MARK PRYOR, Arkansas
JOHN W. WARNER, Virginia
Michael D. Bopp, Staff Director and Chief Counsel
Joyce A. Rechtschaffen, Minority Staff Director and Counsel
Trina D. Tyrer, Chief Clerk
FEDERAL FINANCIAL MANAGEMENT, GOVERNMENT INFORMATION, AND INTERNATIONAL
SECURITY
TOM COBURN, Oklahoma, Chairman
TED STEVENS, Alaska THOMAS CARPER, Delaware
GEORGE V. VOINOVICH, Ohio CARL LEVIN, Michigan
LINCOLN D. CHAFEE, Rhode Island DANIEL AKAKA, Hawaii
ROBERT F. BENNETT, Utah MARK DAYTON, Minnesota
PETE V. DOMENICI, New Mexico FRANK LAUTENBERG, New Jersey
JOHN W. WARNER, Virginia
Katy French, Staff Director
Sean Davis, Legislative Assistant
Sheila Murphy, Minority Staff Director
John Kilvington, Minority Deputy Staff Director
Liz Scranton, Chief Clerk
C O N T E N T S
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Opening statements:
Page
Senator Coburn............................................... 1
Senator Carper............................................... 7
WITNESSES
Thursday, May 12, 2005
Hon. Sam Brownback, a U.S. Senator from the State of Kansas...... 3
Michael Miller, Deputy Assistant Administrator, Bureau of Global
Health, U.S. Agency for International Development.............. 8
Roger Bate, Ph.D., Resident Fellow, American Enterprise
Institute, and U.S. Director, Africa Fighting Malaria.......... 20
Amir Attaran, Associate Fellow, Royal Institute of International
Affairs, London, England, and Canada Research Chair, Institute
of Population Health and Faculty of Law, University of Ottawa,
Canada......................................................... 23
Carlos C. ``Kent'' Campbell, M.D., Program Director, Malaria
Control and Evaluation Program in Africa....................... 24
Alphabetical List of Witnesses
Attaran, Amir:
Testimony.................................................... 23
Prepared statement with attachments.......................... 97
Bate, Roger, Ph.D.:
Testimony.................................................... 20
Prepared statement........................................... 50
Brownback, Hon. Sam:
Testimony.................................................... 3
Prepared statement........................................... 39
Campbell, Carlos C. ``Kent'', M.D.:
Testimony.................................................... 24
Prepared statement........................................... 126
Miller, Michael:
Testimony.................................................... 8
Prepared statement........................................... 43
Appendix
Charts submitted by Senator Coburn:
``Malaria: Preventable, Curable, Controllable, The
Inexcusable Failure of Public Health''..................... 132
``Malaria Cases and Deaths--South Africa, 1971-2000''........ 133
``KwaZulu-Natal, South Africa: What can a little DDT and
Coartem do?''.............................................. 134
``Number of Houses Sprayed Compared to Number of Cases of
Malaria Above the Rate Expected if Spraying Had Continued'' 135
Additional copy submitted for the record from Senator Coburn..... 136
Responses to Questions for the Record submitted to Michael Miller
from Senator Coburn with attachments........................... 145
EXAMINING USAID'S ANTI-MALARIA POLICIES
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THURSDAY, MAY 12, 2005
U.S. Senate,
Subcommittee on Federal Financial Management,
Government Information, and International Security,
of the Committee on Homeland Security
and Governmental Affairs,
Washington, DC.
The Subcommittee met, pursuant to notice, at 10:37 a.m., in
room SD-562, Dirksen Senate Office Building, Hon. Tom Coburn,
Chairman of the Subcommittee, presiding.
Present: Senators Coburn and Carper.
OPENING STATEMENT OF SENATOR COBURN
Senator Coburn. The hearing will come to order. We do have
some intervening business in the Judiciary Committee so this
hearing may be interrupted for votes on judges coming out of
the Judiciary Committee.
Good afternoon. Today's hearing will examine the U.S.
Agency for International Development's efforts to control the
spread of malaria throughout Africa. When I learned that
funding for USAID's malaria program had increased from $14
million in 1998 to $90 million in 2005, I wasn't expecting to
find that the number of deaths due to malaria had, in fact,
increased by about 10 percent.
Not only hasn't the stated goal of reducing malaria by 50
percent been achieved, the actual number of deaths have
increased. How can this be? That is what we hope to learn
during the course of this hearing.
Recently, I have read reports on USAID's anti-malaria
program. An author of one such paper, Dr. Bate, is testifying
here today. In preparing for this hearing, I was struck by the
lack of accountability and transparency on the part of USAID in
providing a breakdown of how the agency allocates its malaria
budget. For instance, how much money does the agency actually
spend on interventions to prevent the further spread of the
disease? How much funding goes to contractors? And, more to the
point, why hasn't the agency provided this information when it
was precisely asked to do so?
I intend to ask the Government Accountability Office to
conduct an audit of USAID's malaria program because I believe
the citizens of this country have a right to know how their tax
dollars are being spent.
Malaria still claims a million victims annually, with over
90 percent of those deaths occurring in Africa. It is a
preventable, treatable disease. An even more daunting statistic
is that malaria kills a young African child every 30 seconds.
USAID can't be proud of this track record.
Representatives of USAID have testified in the past that
the agency supports the use of indoor residual spraying and
insecticide-treated nets to prevent new infections. However,
the fact is USAID has never been a strong proponent of these
methods and did not push for the use of indoor residual
spraying and insecticide-treated nets despite the fact that
such interventions have proven to be successful when they were
used by the agency in the 1950's and 1960's. Most recently,
such interventions were very successful in reducing malaria in
South Africa and Zambia.
Another disturbing issue is the resistance on the part of
USAID to stop using ineffective drugs to combat malaria. The
American Enterprise Institute's paper entitled: ``The Blind
Hydra,'' provides evidence from a project consultant to the
World Relief project, Dr. P. Ernst. Dr. Ernst related that
efforts to convince USAID and UNICEF to change the type of drug
included in its drug kits distributed to First Aid posts have
failed. He went on to say: ``Even today, children in Chokwe
receive ineffective medicine.'' That was in 2004. I believe
this to be completely unacceptable since the cost for a full
treatment, the smallest pack (young children) costs 90 cents
and the largest pack (adults) costs $2.40.
This Subcommittee notes that there are important questions
about the policy choices USAID has made. However, we are also
deeply concerned about the failure of the agency to provide
accurate information to the public about its activities. If the
Congress and the public do not know what is being spent and for
what purpose, how can results be assessed? With that in mind,
we will explore those issues with our witnesses.
In conclusion, I would like to call your attention to
several charts that are displayed in front of the dais.
The first chart,\1\ entitled ``Malaria: Preventable,
Curable, Controllable, The Inexcusable Failure of Public
Health.'' What this chart points out is that 2.5 billion people
in 90 countries around the world are at risk for malaria. That
is alarming, since we are talking about 40 percent of the
world's population.
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\1\ The chart entitled ``Malaria: Preventable, Curable,
Controllable, The Inexcusable Failure of Public Health,'' appears in
the Appendix on page 132.
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Malaria represents the most life-threatening infection in
the world, 500 million acute illnesses every year, 90 percent
of these are in sub-Saharan Africa. Malaria claims 3,000 people
every day, and up to 90 percent of these deaths occur in
pregnant women and children under the age of five. Malaria
accounts for as much as 40 percent of public health
expenditures, 30 to 50 percent of inpatient admissions, and up
to 50 percent of outpatient visits. Children that survive can
suffer brain damage, or experience cognitive learning deficits.
The next chart,\2\ ``Malaria Cases and Deaths--South
Africa, 1971-2000,'' shows the dramatic rise in the number of
deaths attributable to malaria when the government was
pressured into stopping its program of spraying with DDT. South
Africa had been successful in controlling malaria for years
with DDT. The chart shows the number of new cases and deaths
increased dramatically when DDT was no longer being used.
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\2\ The chart entitled ``Malaria Cases and Deaths--South Africa,
1971-2000,'' appears in the Appendix on page 133.
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The next chart,\1\ ``KwaZulu-Natal, South Africa: What can
a little DDT and Coartem do?'' This chart shows that when the
government reinstated the use of effective drug therapy with
Coartem (ACT drug) and the spraying of DDT, the number of cases
fell dramatically.
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\1\ The chart entitled ``KwaZulu-Natal, South Africa: What can a
little DDT and Coartem do?'' appears in the Appendix on page 134.
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The last chart,\2\ ``Number of Houses Sprayed Compared to
Number of Cases of Malaria Above the Rate Expected if Spraying
Had Continued'' (data from the countries of the Americas)
clearly illustrates that the resurgence of malaria is directly
linked to DDT spraying (bar graph--as the number of sprayed
houses decreased, the excess cases over the amount seen during
spraying exponentially increased).
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\2\ The chart entitled ``Number of Houses Sprayed Compared to
Number of Cases of Malaria Above the Rate Expected if Spraying Had
Continued,'' appears in the Appendix on page 135.
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We will hold for Senator Carper's opening statement and I
would like to recognize Senator Sam Brownback, who has a
special interest in this area and also in terms of reform. We
would like to ask our witnesses to limit their testimony to 5
minutes. Senator Brownback, it is a pleasure to have you before
our Subcommittee. It is my hope through your interest and your
initiative that some of these people in the future have a
greater opportunity to be treated and their lives saved and the
quality of their life improved. Senator Brownback.
TESTIMONY OF HON. SAM BROWNBACK,\3\ A U.S. SENATOR FROM THE
STATE OF KANSAS
Senator Brownback. Thank you, Dr. Coburn. I appreciate
that. I appreciate you holding the hearing on this topic. It is
one that is near and dear to my heart.
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\3\ The prepared statement of Senator Brownback appears in the
Appendix on page 39.
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I have traveled to some of these regions. And it is one of
those situations where you see somebody or a group suffering
and dying and you look at the numbers and you have got
basically, in some cases, 40- and 50-year-old technology that
is cheap that can solve this and you go, absolutely, why? ``Why
is this taking place? And this shouldn't happen.'' You went
through the numbers. This is a horrific situation and it is a
real shame that the world has allowed this to happen.
We used to have malaria in the United States and in
Southern Europe and we went aggressively about dealing with it
and malaria is not there today, although some cases now start
to come back in because of what is happening in other parts of
the world.
We have a cure for this. We don't even really need to spend
new money, just to take the money we are currently spending and
spend it in places that actually cure people and you are going
to save lives. So here is one case where we can save hundreds
of thousands, if not millions, of lives, not spend new money,
just spend the current money appropriately in the process. This
just makes all the sense in the world.
And then I ask myself, ``well, why isn't it happening?'' I
traveled to Uganda. I have been in the Sudan. I met with
officials from the U.N. I met with individuals from these
countries. And the best that really I have concluded is we are
spending most of our money on consultants and on meetings and
not on getting actual care taken out in the field.
One scene I was in, in Northern Uganda, in the Gulu region,
children come in every night, these ``night commuters,'' they
are called. There will be 500, 1,000, even more kids that will
commute into a city, some of them walking five miles each way
just so they don't get abducted at night by the Lord's
Resistance Army. So their parents every night will send these
kids from 3 to 12 years of age into this area. It is an
incredible scene.
And they are not fed when they get there, but they are
within a fenced area, a tin roof, cement floor, and they are
cared for. But the walls aren't sprayed with DDT and mosquitoes
lurk in the area. So while they may be protected from the
Lord's Resistance Army, they are not from malaria. A simple
application would take place that is not going to harm the
environment, and save how many children from getting malaria?
And you look at this and go, ``why isn't this taking place?''
DDT has a bad name. It is associated with The Silent
Spring, Rachel Carson's book. It certainly was overused in
areas at prior times and did contribute to degradation in some
bird species. But we are not talking about widespread use of
DDT. We are talking about very targeted indoor spraying and
some very targeted pools around where people are. So this is
not the widespread aerial application that we have seen and
done in North America and Europe. We are talking about a very
targeted area. Yet the world community still seems to be very
hesitant and would rather not take this no-risk action, would
rather see the kids and mothers die. That is just a completely
unacceptable answer to me. It should be unacceptable to us as a
government.
So I have introduced S. 950, the Eliminate Neglected
Disease Act of 2005. It directs interventions, directs the
spending by our government to these effective means instead of
conferences and consultants. Let us use these funds for
applications in the field. We require accountability,
transparency, scientific and clinical integrity, coordination,
and priority setting.
It is a simple bill. It is sponsored by your colleague from
Oklahoma, and by Senator Landrieu, both of whom are Africa
hands, if I might say. Senator Inhofe has travelled to Africa
perhaps more than any other U.S. Senator. Senator Landrieu
heads a caucus on Uganda, has a deep heart for the region, and
I do, as well.
I just would say in conclusion, Mr. Chairman and Senator
Carper, that we will stand judged if we don't do something
effective here, when we have the money, we have the ability,
and then don't do something. This is wrong, what we are
currently doing, and we do need to change this. I think if we
really, even in this room, band together to do this, we will be
able to get this changed and we will save hundreds of thousands
of lives in the process, and probably not spend another dime.
Thank you.
Senator Coburn. I would like to recognize my friend,
Senator Carper, and if you have an opening statement, I would
be happy to have you give that now and then we will talk with
Senator Brownback.
Senator Carper. Rather than give my statement--I have just
a short statement I want to give, but can we just go back and
forth with the witness----
Senator Coburn. Sure.
Senator Carper [continuing]. And he can be on to his next
stop. Thanks. Good to see you, Sam.
Senator Brownback. Good to see you.
Senator Coburn. Senator, let me ask you some questions.
Some would say that by insisting that USAID money is spent on
certain types of intervention, your bill hamstrings countries'
malaria programs and tells governments what to do. How do you
respond to that claim?
Senator Brownback. The only government we tell to do
anything is the U.S. Government. We direct funds towards actual
treatment because, to date, when you have given broad
authority, it has gone more towards conferences and meetings
rather than actual application.
And in the countries that I have met with, what they
desperately want are actual treatments out in the field. They
want buildings sprayed with DDT, the inside of buildings. They
want bed nets that have DDT in it or other effective treatments
dispersed and distributed. That is what they want, as well.
So the only country we are directing what to do is the U.S.
Government. And number two, from the countries that--primarily
sub-Saharan Africa--that I have visited with, this is exactly
what they want to see take place that is not taking place
today.
Senator Coburn. How would you answer those who are
concerned about DDT and its effect on aviary species in terms
of how do you control the total limit and the exposure, even if
you are doing isolated exposure? Does it not, in fact, have
some impact?
Senator Brownback. I don't think there is any record
anywhere that says that it does. What we did in the United
States when this was a problem, particularly with the bald
eagle, which was the most known species, we had widespread
application of this in agricultural settings using aerial
application. Much of which then drifts into streams and rivers,
then ingested in amphibian life that is taken up by the eagles
and that is then where you see the egg shell much softer. My
background is in agriculture. I have worked with these issues.
I have regulated these things in the past in an agency I ran
when I was State Secretary of Agriculture in Kansas. So you had
an enormous build-up of this in a broad system where we had
used it for decades.
Here, you are talking about somebody going in with a hand
sprayer inside of a hut or a small building and spraying the
walls once every 6 months. The ability of this to flow into the
rivers and then build up in any quantity in the amphibian life
is minimal to anything and certainly not anywhere comparable to
what we did in the United States in the 1950's, and there is no
track record at all that this hurts avian species at all
anywhere.
Plus, you know, balance is back and forth. We can't find
any risk there, and we will save hundreds of thousands of
children in the process. That seems to me as absolutely worth
doing.
Senator Coburn. In your queries on this program, have you
been able to find out the number of people actually treated for
malaria?
Senator Brownback. I don't have that. By our programs
actually treated?
Senator Coburn. No, by your inquiry into what is going on
now. Anywhere, have you been able to find the data that would
say the number of people who have actually been treated with
medicines who have malaria, the number of facilities that have
been sprayed with indoor spraying, the number of actually
treated nets that have been given out? Anywhere, have you been
able to find those numbers?
Senator Brownback. No, I haven't. We did hold a hearing
last year in Foreign Relations on this topic and had several
experts in that gave broad estimates, but we don't--and that
was global, but we do not have U.S. funded numbers, and to my
knowledge, USAID has been unwilling to provide those or unable
to provide those to date.
Senator Coburn. Senator Carper.
Senator Carper. Again, welcome.
What do the folks at USAID say about what you are
suggesting? Sort of play the devil's advocate and explain what
their rationale is. Why do they agree or disagree with you?
Where do they agree? Where do they disagree?
Senator Brownback. I think you will have them up on the
witness stand, and I have met with the head of USAID. I have
met with individuals there. We have had them in to testify.
They generally don't disagree with the things that I am
saying, but there is difficulty. You do get push-back on the
use of DDT in any setting other than in bed nets and it is a
harder route to go. We do get some resistance, and instead of
pushing on through, it has been more, ``let us just keep going
pretty much the way we are going and we think we are going to
get there.''
My problem is, every day you don't get there, somebody else
dies, thousands die. And number two, we are not getting there.
The overall numbers show we are losing ground, not gaining
ground. I think this is an emergency, that you really should
move forward aggressively rather than timidly.
Senator Carper. Who are the other players other than us,
other than USAID? I guess World Bank is in it, but who are the
other major players that are involved in this? How do their
efforts complement ours or duplicate ours?
Senator Brownback. There are several players. The U.N. has
a program, and the Global Fund. We have bilateral efforts. And
then I believe the Europeans have some efforts, but I am not
that familiar with what they are doing.
Some of these are doing a good job of providing actual
spraying of the new level of drugs. The older level of drugs,
there has been a great resistance built up and a number of them
aren't effective.
So you have a mixed bag of other players, some doing a
pretty good job, the U.N. doing a horrible job, having set a
target of reduction of malaria in half by 2010 and the number
has actually gone up since they set that target.
Senator Carper. Is there an effort underway to coordinate
the efforts of these diverse parties to ensure that we are not
duplicating one another but we are complementing one another's
efforts?
Senator Brownback. There is communication. I don't know,
Senator Carper, if they have got a regularized system where,
``we are going to work in this country and you are going to
work in that country,'' but there is a clear communication. I
don't know otherwise the degree of how much it is hard-wired
within their system. That is a good question to ask and to have
in the implementation.
Senator Carper. I will probably ask it again, then. Thanks.
It is good to be with you. Thanks for being here.
Senator Brownback. Thanks.
Senator Coburn. Senator Brownback, thank you so much, first
of all, for your caring and your interest in this subject, but
thanks for coming to testify before us today. We will make sure
you get the results of this hearing.
Senator Brownback. And I would like to offer one of my
great staff members, Katy French, to help you out in this
process. She has been my lead person on this. She is excellent
and----
Senator Carper. What does Katy look like? [Laughter.]
Senator Brownback. She is going to be the Staff Director
here, I believe, in the next couple of days, and she is right
behind me, does a great job on these topics, excellent.
Senator Coburn. Thank you very much.
Senator Brownback. Thank you, Mr. Chairman.
Senator Coburn. Next, I would like to recognize Michael
Miller, Deputy Assistant Administrator, Bureau of Global
Health.
Senator Carper. Mr. Chairman, before you do that, you were
kind enough to ask me if I would like to give a statement----
Senator Coburn. Absolutely. Please do.
Senator Carper [continuing]. And now that Senator Brownback
has left, let me just mention a couple of things, if I could.
Senator Coburn. Absolutely.
OPENING STATEMENT OF SENATOR CARPER
Senator Carper. Thanks for holding the hearing and for the
staff pulling folks together to let us hear from them.
As you all know, this hearing today focuses on an important
issue. It is actually a life or death issue for a whole lot of
people. Despite years of work that aimed at dramatically
reducing malaria deaths, the toll this disease takes on
communities in some parts of the world, at least, appears to be
growing, as Senator Brownback has suggested.
With this in mind, we have a responsibility on the
Subcommittee, and I think in the Congress, to examine how
Federal agencies, especially USAID, have been spending our tax
dollars dedicated to this war on malaria, and there are
probably some steps that USAID can take that they are taking,
Mr. Chairman, to improve its financial management and
transparency. We just have to be careful, though, before
quickly drawing too many conclusions about how USAID is
addressing malaria and how it should address malaria in the
future. The work that the USAID does or doesn't do will have a
tremendous impact on the organizations it works with on the
ground and ultimately on with respect to the lives of millions
of people.
The Global Fund to fight AIDS, tuberculosis, and malaria is
currently spending hundreds of millions of dollars, I am told,
to purchase bed nets and anti-malaria drugs to be distributed
in the most vulnerable areas to prevent and treat malaria
outbreaks. U.S. taxpayers, I believe, are paying for about one-
third of that effort.
At the same time, the World Bank recently announced that
they are prepared to spend about $1 billion on a similar effort
on their own, and I suspect that the United States will be a
major contributor to that effort, too.
And we are going to hear today from some true experts on
malaria and other health issues in the developing world. I
certainly look forward to hearing their views on the
effectiveness of current U.S. and global efforts to fight
malaria. Most importantly, I would like to hear about how USAID
can best use its $80 million malaria budget to supplement the
extensive work and to complement the extensive work that is
being done by other organizations.
So again, I appreciate the opportunity to participate in
this hearing and look forward to hearing from our witnesses.
Thanks, Mr. Chairman.
Senator Coburn. Thank you, Senator Carper.
Mr. Miller, Deputy Assistant Administrator, Bureau of
Global Health, USAID, first of all, welcome.
Mr. Miller. Thank you.
Senator Coburn. We look forward to your testimony. Your
written testimony will be made a part of the record and I would
like for you to limit your oral comments, if you can, to 5
minutes. I would also say again we are close to a vote in the
Judiciary Committee, and if I might be able to be excused and
you take over for me so I can do that, I would appreciate that.
Senator Carper. You bet. Or I could vote in the Judiciary
Committee for you. [Laughter.]
Senator Coburn. I would like to do the vote.
Senator Carper. You send me where I can do the most good.
[Laughter.]
Senator Coburn. Mr. Miller, thank you.
TESTIMONY OF MICHAEL MILLER,\1\ DEPUTY ASSISTANT ADMINISTRATOR,
BUREAU OF GLOBAL HEALTH, U.S. AGENCY FOR INTERNATIONAL
DEVELOPMENT
Mr. Miller. Thank you, Senator Coburn and Senator Carper.
It is certainly a pleasure to be here and we thank you for the
opportunity to come up and testify.
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\1\ The prepared statement of Mr. Miller appears in the Appendix on
page 43.
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A couple of points that are not in my prepared statement
are I would just say that no institution and no program is
above examination and questioning and we do welcome that. I
think a deliberative process is certainly going to produce
better policy in the end than a process done in isolation.
It is kind of hard to follow up Senator Brownback as a
witness. I have big shoes to fill in that respect. I had the
pleasure when I was a Senate staffer to work with him at the
staff level on Sudan and other Africa issues and I certainly
admire his dedication and commitment to it, and his involvement
on the issue of malaria and how to best pursue and treat
malaria is certainly welcome.
My objective for this testimony is to describe the U.S.'s
anti-malaria programs, to place them in a useful context for
the Subcommittee, and describe where the world is, and not just
the United States or USAID, but where the world is in terms of
the fight.
The starting point for any consideration of malaria
programs is the fact that malaria is overwhelmingly, not
exclusively, but overwhelmingly a killer of African children.
In fact, malaria is the number one killer of African children,
claiming the lives of at least one million each and every year.
Between 80 and 90 percent of the deaths from malaria are in
sub-Saharan Africa, and of those deaths, 80 to 90 percent,
again, are children. The greatest tragedy, as you pointed out
in your opening statement, sir, is that this death is largely
preventable. The disease is curable. It is treatable.
The interesting thing to note is that where in most of the
world we have successfully controlled or even virtually
eliminated malaria as a public health threat, in Africa, it has
persisted. The disease actually has even gotten worse. The
burden that Africa is carrying in terms of a true disease
burden from malaria is greater than it was two decades ago.
Why has malaria actually become more deadly in Africa when
it has been effectively controlled or even eliminated in other
regions? The answer is as significant as it is surprising. The
effort to battle malaria in a comprehensive way and continent-
wide is literally decades behind other regions. In the 1950's
and 1960's in most other regions, including the Southern United
States, a combination of insecticides and treatments was
deployed with great effect. The results were positive and
significant, but not in Africa.
In 1955, a World Health Organization panel of technical
experts met in, ironically, Kampala, Uganda, and decided to
exclude tropical Africa from the global malaria eradication
program. The reasons cited were because of the intense and
efficient transmission of the disease and because of a lack of
infrastructure necessary to undertake such an intensive
spraying effort. In short, Africa was left out because it was
judged to be too difficult.
That decision essentially eliminated prevention from the
anti-malaria efforts and relied solely on treatment. Even until
just the past few years, the backbone of anti-malaria efforts
in Africa was limited to treatment of the disease once the
symptoms appeared. In retrospect, that was a fateful and tragic
decision and Africans are still paying the price.
By the 1980's and into the 1990's, malaria infections in
Africa began to soar. The reasons were treatment failure.
Simply, the medicines that were deployed, Africa's only
defense, started to lose their effectiveness against the
malaria. Populations became increasingly vulnerable.
It wasn't until the early 1990's that an organized and
dedicated effort to begin to introduce prevention measures on
an appreciable scale in Africa, and funded largely by donors,
did that begin. By the time, the need for new treatments also
became too hard to ignore.
By about 2000 or 2001, three new, highly efficacious
prevention and treatment tools became available through
American and other donor research. The first new tools,
insecticide-treated nets, or ITNs, as a vehicle to get
insecticide into people's homes, and I think it is worth
pointing out here that with respect to indoor residual spraying
and the use of insecticide-treated nets, the goal is absolutely
the same, getting insecticide into the dwelling and as close to
people as you can when they are sleeping and when the mosquito
is preying on them.
The second is intermittent preventive treatment of pregnant
women. That is a pretty simple procedure. It is usually two
doses of anti-malarial drug before delivery and the protection
it provides the child is tremendous, because a lot of times, if
you can defend against malaria in the mother, you are going to
defend the child, because the vulnerability of the child really
begins before they are born. Malaria, it is a major contributor
of low birthweight, and if a child is born underweight in
Africa, you are essentially doomed.
The third is artemisinin combination therapies, and that is
the combination drugs that are derived from the ancient Chinese
medicine artemisinin. They are extremely effective and they
are, in fact, the only thing that on a continent-wide scale,
even though other treatments can be effective in some areas, on
a continent-wide scale and in the future is going to provide
the only chance we have to really plug that treatment failure
that has accounted for the most deaths in Africa.
Are we at the point of success? How are we doing? Is what
the United States doing worth pursuing, or should it be subject
to change? I am just going to wrap up by giving four essential
factors we need to consider.
First, the effort to address malaria in a meaningful way,
incorporating prevention and treatment across sub-Saharan
Africa is new. It is shameful that it started so late. Also,
sub-Saharan Africa is not like other regions. The lack of
infrastructure and the intensity of the epidemic are far more
acute than in any other region. The factors cited in the 1955
decision are still basically true. What has changed is that the
political will now exists to try to overcome them.
Second, the level of funding we are talking about for this
overdue effort is only now coming online. Even in 2000 and
2001, the funds committed to fighting malaria by the United
States and all other donors were a fraction of what it is now.
The significant factors here are the increase in the U.S.'s
bilateral funding, the advent of the Global Fund to fight AIDS,
tuberculosis, and malaria, which brings significant funds
online, particularly for commodities, and also, of course, the
World Bank, which we know is on the verge of launching another
anti-malaria program.
Third, the number of infections and consequently the
deadliness of the disease have increased considerably in recent
decades due to the treatment failure. This situation is a
classic race against adaptation by the pathogen. ACTs are the
only effective treatment in much of Africa now. The donors,
producers, and affected countries have not yet fulfilled the
needs in terms of production or distribution.
Finally, data are lacking. We believe we understand the
effectiveness of individual elements of our strategy, but the
potential for new or improved interventions and increasing
funding holds for the battle against malaria. What we do not
have is data on the trends and deaths from malaria at the
country level, the continent level, and certainly at the global
level. The fielding of new or improved prevention and treatment
tools on an appreciable scale and with significant funding to
back them up is simply too recent to reasonably judge the
overall effectiveness on a large scale.
The bottom line here is that for the first time, the tools,
the political will, and the funding are in place in sufficient
amounts, at sufficient levels to really have an effect. But any
summary judgment of the progress or lack of progress is not
supported by sufficient data at this time and is simply
premature, in our view.
We, in the Administration, are happy to have the discussion
and debate about priorities and proportions. Ultimately, the
goal of the United States is to save the most lives. I think
there is a common and universal agenda here. Thank you.
Senator Coburn. Mr. Miller, thank you very much.
Do we know throughout sub-Saharan Africa how many people
have been treated, how many people have been prophylaxed with
the net, how many people have had their domiciles sprayed? Do
we know these numbers?
Mr. Miller. Probably not with any precision. What we do
know is--we can get number of treatments purchased. Now,
tracing that treatment down to the individual and where that
individual takes it and whether it is proven effective, we
don't know.
Senator Coburn. What are the numbers of treatments
purchased?
Mr. Miller. For example----
Senator Coburn. Effective treatments purchased?
Mr. Miller. Let us talk about ACTs. There are other
treatments and some of them are still effective in some parts
of Africa, but they simply will not be effective in the future.
Number of ACTs purchased, I think the most significant
number to cite is that the Global Fund has purchased. The
United States is a 33 percent contributor to the Global Fund
over the history probably even more, and they have purchased or
have dedicated funding through grants to purchase up to 145
million doses of ACTs now. I am certain that will increase,
certainly as ACT's availability increases and the price drops
and the ability to get it into markets and distributing, we are
really at the beginning of that.
Senator Coburn. How much is price a factor in terms of
supplying medicines for treatment?
Mr. Miller. I think it is going to be a significant factor.
Senator Coburn. What is the cost of treatment for a child?
Mr. Miller. For a child? For ACTs in a child, I think it is
probably about $1.20 per treatment.
Senator Coburn. OK.
Mr. Miller. It depends on where you are and how remote the
person is.
Senator Coburn. OK, so let us say $1.20 per child, and that
is available? The medicine is available worldwide?
Mr. Miller. The medicine is available. I do not believe it
is available to the extent that we need it. There is a
shortfall in production capacity. In fact, USAID, one of the
things we are doing is supporting the growing of Artemisia
annua in Kenya and Tanzania. We believe that those crops will
be able to produce effectively 40 million--the basis for 40
million new doses, and by the end of 2006, I think production
will be up to the point where you actually can fill the need. I
do not believe we are there yet, and as a consequence--yes.
Senator Coburn. Let us take $2 a dose. What is the
population of the continent of Africa?
Mr. Miller. Oh, goodness. I would just have to guess at
about 700 million.
Senator Coburn. OK. At $2 a dose, that is $1.4 billion to
treat everybody in Africa, and the Global Fund is going to
spend what this year on treatment?
Mr. Miller. Well, if you take just the raw numbers, sure.
In the past 2 years, it has been over $900 million for malaria
programs, of which about 50 percent are going to be for
commodities.
Senator Coburn. So $450 million, which means we should have
treated 225 million people.
Mr. Miller. We certainly hope to achieve that kind of
coverage. I have to emphasize that this really is a fairly new
venture. A lot of these ACTs, we are not even to the point yet
where we can actually produce enough of them--we, globally, can
actually produce enough of them to fulfill the need. Certainly
the funding mechanisms and the programs in place, they are only
now coming online. Our goal is simply to get as many people
covered and save as many lives as possible, but we are
reasonably new with levels of funding with the medicines that
we are talking about and the types of programs and the ability
to procure them. It is----
Senator Coburn. Of your budget, what percentage of the $80
million is actually spent on treatment?
Mr. Miller. If we take commodities--I should first say that
I think it is important to start not with an examination of
USAID's budget in isolation because, in fact, the United States
and the Global Fund, of course, of which the United States is
the largest contributor, and the World Bank, of which the
United States is the single largest shareholder, do coordinate
at the country level. There is, in fact, an agreement, if you
will, the United States brings our strengths to the table,
which are technical capacity, helping build the infrastructure
necessary to get the commodities out to people.
The Global Fund, on the other hand, does some of that, but
they also spend about 50 percent of their budget--of their
malaria grants, excuse me--about 50 percent of the malaria
grants are dedicated to commodities. The goal there is to
simply fill in behind what we can provide on a technical
capacity.
So having said that, the United States, if you break it
down, it would probably be around 5 percent----
Senator Coburn. Five percent, $4 million?
Mr. Miller [continuing]. Of our bilateral budget.
Senator Coburn. Four million dollars on treatment?
Mr. Miller. Yes.
Senator Coburn. How much on prevention?
Mr. Miller. Prevention?
Senator Coburn. Nets, spraying?
Mr. Miller. Prevention would be about 30 percent, treatment
about 34 percent, but that is not purchase of commodities.
Senator Coburn. OK. What is treatment besides purchase of
commodities, in your viewpoint?
Mr. Miller. Logistical support for drugs. Simply getting
the drug to an African capital is not going to do it. There is
training, application of drugs. There are skills that people
need to understand how to identify and prescribe the
appropriate drugs. There are protocols, because, if, in fact,
ACTs--ACTs are not the only drug effective in an area. For
example, Fancidar is still effective in adults. You wouldn't
want to necessarily go to ACTs. They are ten times the price.
So making a determination like that, that does take people and
skills and time.
Senator Coburn. But that is not hard to do, because if you
have a drug-resistance problem in an area, you are going to
know it and you are not about to start treating with a non-
drug-resistant therapy if you have drug-resistant disease in an
area. So that is one or two tests. Once you identify that, you
know that.
You have not collaborated with the Global Fund in the past.
Is it not true that the MOA is brand new?
Mr. Miller. I am sorry, MOA?
Senator Coburn. Yes. Is it not new? Is this not new? In
other words, your collaboration with the Global Fund in the
past, this is just beginning, is that right?
Mr. Miller. Right. The Global Fund is new.
Senator Coburn. Well, the Global Fund has been around since
I left Congress. It was started when I left, when President
Bush came in and they set up this fund.
Mr. Miller. Right.
Senator Coburn. So we are talking 2001 when this started,
and 2002 when it got going.
Mr. Miller. We are now seeing--just now, we are going
through--as a Global Fund board member, we, the United States,
are seeing consideration of the 2-year point of the first round
of grants. So money was being--excuse me, votes were being
taken by the board to dedicate funding to particular proposals
2 years ago. So I think it is fair to say that it is fairly
new. And once a grant is made, that doesn't necessarily give
you an indication how soon the money is going to be out there--
--
Senator Coburn. What percentage of the amount of grants
that you give are consumed--in other words, the expenditure
from that grant is consumed in other than prevention and
treatment?
Mr. Miller. I can't say. On a grant-by-grant basis, it is
going to be different, and----
Senator Coburn. No, as a total. What do you think?
Mr. Miller. As a total for treatment?
Senator Coburn. No. What percentage of the grant money that
you give out of this $80 million--here is the grant money we
are giving to implement . . .
First of all, the doctors in Africa that I have met--I have
been there twice--could teach every doctor here about
diagnosing malaria. I have seen two cases in 20 years in
Oklahoma of malaria. So they know how to diagnose it. The
question is, what is the resistance factor of the area that you
are in? So they actually could train us.
But in terms of your grants that are given, what percentage
are actually for treatment or prevention? Of the amount of
money through this budget, how much goes to prevention----
Mr. Miller. I see. Grants are typically not given for
something as narrow as treatment. In fact, typically, grants
are not made for something as narrow as malaria. They usually
fall within a larger maternal and child health grant. In other
words, it can be to help support ante-natal clinics and it is
at the ante-natal clinic where you can actually get to the
mother while she is pregnant and either provide preventative
therapies, provide a net, provide some education. The grants
typically go for something a little more broader than that. Is
that your question?
Senator Coburn. Well, I am just trying to find out, because
we have other parts of USAID that have grant money for that, as
well. What you are saying is some of the grant money goes to
areas of responsibility in other areas of USAID as supplement
that? Is that what you are telling me?
Mr. Miller. I am not sure I characterize it that way. Would
say that grants typically will be for something in child and
maternal health that is broader than just malaria or malaria
treatment.
Senator Coburn. Well, I am way over my time. I will come
back to you. I have to go for a vote in Judiciary. Senator
Carper, if you would be so kind to handle the hearing, and I
will be right back.
Senator Carper [presiding.] Thanks, Mr. Chairman.
Mr. Miller, welcome. Thanks for being here and thanks for
your stewardship.
I want to go back to a couple of earlier things that you
said in your testimony, just ask you to clarify them for me.
You spoke earlier of the success in much of the rest of the
world in eradicating malaria but a lack of success in Africa.
In fact, if anything, it is getting worse. Why, again, do you
think we have been successful in the rest of the world and not
in Africa and what lessons can we derive from our success in
the rest of the world to make sure we are applying those
lessons appropriately in Africa?
Mr. Miller. I think the first thing to note is that we are
starting pretty late in Africa, at least on an appreciable
scale. What we did in the United States, what was undertaken in
Southeast Asia, Central America, and South America in the
1950's and 1960's was very effective. Africa is just now coming
online.
That is what I was trying to get to in my statement, which
is the types of--the level of funding we are talking about, the
degree to which we can introduce interventions into the areas
that need it is relatively new. We are really just talking
about since 2000 on an appreciable scale.
What we can learn from other regions that can be applied to
Africa, you have to be careful. Africa is different for a
number of reasons. It is not just that it was started late,
which is a factor. You also have new interventions that were
not available then, ACTs, insecticide-treated nets, for
example.
But also, Africa, the intensity of the epidemic in Africa
is far beyond, at least continent-wide, is far beyond what it
is or was in any other area. You have some areas of Africa that
are what we call hyperendemic. In other words, you have
transmission of malaria 7 to 12 months out of the year. There
is literally no seasonal break and there is no escaping at
night mosquitoes, either during the season where they are not
breeding or just by changing localities.
The second thing to consider about hyperendemic areas is in
some cases, 85 percent of the people living there are going to
be infected with the plasmodia that causes malaria, 85 percent.
That is a huge reservoir for transfer. Those people will
probably not necessarily show symptoms. They have acquired
immunity. Once you pass about 5 years of age, if you contacted
malaria when you were a child and you lived through it, the
chances are you probably will not die from it. So people
actually acquire immunity over time. But just because they have
that acquired immunity doesn't mean they won't get sick, and it
certainly doesn't mean that they cannot be infected from one
person to another. They effectively are a reservoir for the
mosquito and it is very difficult to do that.
Finally, I would point out that in a lot of Africa, the
infrastructure is acutely lacking, let us say. People live
rural lives. I know in Ethiopia, for example, which is not
typically a hyperendemic area, but just for illustration, 70
percent of the population lives 3 hours' walk from a road, not
even from a paved road, not from a facility, but from a road.
It just gives you an illustration, even in a very densely
populated country like Ethiopia, that people live rural and
sometimes very isolated lives in Africa. So it is very
difficult.
That is not true in all of Africa. Certainly the South
Africa example that was raised demonstrates that there is some
applicability to the continent, depending on where it is,
depending on the infrastructure and the effectiveness of
services in that area. But it is going to be a harder nut to
crack, frankly.
Senator Carper. Thank you. Could we talk a little bit about
the resistance of drugs, or the resistance, rather, of
mosquitoes and the disease to drugs that we have, the failure
of those drugs to be able to protect people today----
Mr. Miller. Yes.
Senator Carper [continuing]. And new medicines that are
available that are being introduced.
Mr. Miller. Right. The treatment failure, if you will,
really is the cause of the increase in malaria infections in
Africa in the 1980's and 1990's. Simply people had no
protection.
ACTs are really the great hope of the future. I don't think
there is any debating that. They are very effective----
Senator Carper. Why do they call them ACTs?
Mr. Miller. Well, they are in combination. The ``C'' is for
combination. Artemisinin is a natural extract from what we call
wormwood. It is an ancient therapy. It is very effective. The
extract itself has--I don't think there is a question of shelf
life there. But once they are put in combination to make them
more effective, to make the body absorb them better, whatever
the combination does, you get about 18 months' shelf life. So
it is a huge challenge.
Plus, as I mentioned answering Senator Coburn earlier, they
are relatively new. The combinations are relatively new. I
believe there are two companies that hold patents for ACTs now.
Production is not to a level to meet worldwide need and, hence,
USAID's support for actually growing of Artemisia annua to help
meet that shortfall.
Senator Carper. Would you talk a little bit about--you have
already discussed this some and we have mentioned it in our
statements, but talk with us, please, about how, on a relative
scale, the magnitude of USAID's efforts in these areas with
respect to other efforts in these areas.
Mr. Miller. Sure. Bilaterally, we are by far the largest
donor. We are at about $80 million a year. If you break down
the Global Fund by year, you are going to get about $400-and-
some-million per year, over $900 million total over the past 2
years. Of course, the United States, as you mentioned earlier,
is the single largest contributor to the Global Fund, so a lot
of that can be ascribed to us, the same with the World Bank.
There are other donors on a bilateral level. The U.K., I
think the Nordic countries also have bilateral programs. All
said and done, I think we put the total global anti-malaria
funding at about $600 million a year.
Senator Carper. So overall, $600 million. About $80 million
is directly through your budget?
Mr. Miller. Bilateral USAID, yes.
Senator Carper. And then additional monies that we may put
into the World Bank or the Global Fund----
Mr. Miller. That is correct.
Senator Carper [continuing]. Above and beyond that. Share
with us again your thoughts on how USAID's efforts are
complementary, or might be duplicative of other efforts. How do
they complement or support each other?
Mr. Miller. Thank you. I think the best way to imagine it
is that, as I mentioned before, USAID does focus where we have
our strengths, providing skills, providing infrastructure, if
you will--I am not talking about buildings here, but providing
infrastructure. We have presence in almost every country we are
talking about. We can deploy skilled people for training, for
running programs, providing grants. We have many other
bilateral programs of which anti-malaria efforts can be
effectively incorporated into, which is really one of the
fundamental pieces of our strategy.
As I said before, it is really not--you are really not
going to get an accurate picture if you just take USAID's
budget and proportions of the spending per sector in isolation
because they really are planned even down at the country level
along with the other donors, multilateral institutions.
I think with respect to the question of priorities and
spending on commodities and how the United States, bilaterally,
we look to the multilateral agencies, of which we are a part,
to really do the bulk of the commodities purchase, the United
States and USAID in malaria programs or any other programs has
never really emphasized commodity purchases outside emergency
situations, and that is true here.
But the best way to think of that and put it in perspective
is to think of an army being judged simply by the amount of
bullets you have on hand. It is really not a fair judgment and
you simply can't judge a single army if they are operating in
coalition with each other. You really have to take a snapshot
of the entire picture globally, especially if it is coordinated
at the level we coordinate in countries.
Senator Carper. My last question would be, someone
described for me, they used an analogy. They said USAID's
efforts are in part, if you will use the analogy of a toolbox,
with tools in the toolbox to address a particular challenge.
They said USAID's efforts are, in part, to put tools in the
toolbox, but also to help those to whom the toolboxes are
distributed, countries, to be able to better use the tools that
USAID puts in the box, but also the tools that other entities
put in the box to fight malaria. Is that a fair analogy?
Mr. Miller. It is. Simply, we play to our strengths and we
play in coordination with other teams, with other members of
the team, yes. It is a fair characterization.
Senator Carper. And how do we measure success with the
approach you are talking?
Mr. Miller. Ultimately, success is going to have to be
measured in lives saved. That is a difficult question, number
of lives saved, for a couple of reasons, if you would let me go
into it. Identifying the number of deaths from malaria in rural
Africa is going to be very hard. Survey-wise, every 5 years,
we, USAID, sponsors what is called a demographic health survey.
It is a comprehensive health survey of the entire country. It
is the gold standard of health surveys for development global
assistance. They are retrospective.
What happens is if someone who is conducting the survey
goes out to an affected area and asks the mother, did you have
a child that died in the past 5 years? What did they die from?
What were the symptoms they were displaying? And from that, you
simply have to deduce what this child--if they have a fever,
which is what you are typically going to see, it could be
pneumonia, it could be malaria, it could be a combination of
things. It is hard to do with precision, to say what that
person died from. We think we know. We think we have a level of
confidence where we can say malaria infection rates and deaths
are at about this level per year. That is probably not in
dispute. But identifying on a scale of how many people are
actually dying of malaria is very difficult.
The second thing I would note is one thing we found
troubling is the statistic often quoted is that malaria deaths
are increasing in Africa in recent years. We have heard that
quoted. Actually, we do not use that statistic. We have
actually tried--I have asked my staff to identify where did
that originate, what is the data behind it, and does anybody
else use that? We don't use that statistic. I am not here
saying it is true or it is false, but the data set behind
something that broad is simply we don't have it. We have to
question whether that is reliable data to hang your hat on.
Senator Carper. Thanks very much.
Mr. Miller. You are welcome.
Senator Coburn [presiding]. Just another little round here
if we can, for a minute. First of all, WHO says malaria is
increasing. Lancet articles say malaria is increasing. They are
surveying the same way they did 10 years ago and the number of
deaths of children is skyrocketing, and it isn't pneumonia that
is causing them to die, it is malaria. That is not something
that is hard to know because you are using the same study
method to collect the data 10 years ago as you are today in
terms of looking at deaths. So there is no question.
The other question I have for you: USAID doesn't normally
provide treatment unless there is an emergency. The fact is,
that with 3,000 children a day dying in Africa, I think that is
an emergency. There was a malaria program by USAID before there
was ever a Global Fund, true?
Mr. Miller. That is correct.
Senator Coburn. And it was operating all this time that we
are seeing this large increase. So the fact is we have been
ineffective through USAID in abating this increase with the
money that we have spent. Now, maybe again, your first
testimony, the problem is too big. Maybe the resources aren't
enough. I don't know that answer. That is one of the things
that we want to try to help find out.
But what we do know is the numbers aren't lying, and I
would like to ask you just a couple other questions. In your
testimony, you gave us that insecticide-treated bed nets are
the key to saving children's lives, and you write that ``ITN
coverage increased, for example, from zero to 21 percent in
Ghana.'' But you omitted saying that 21 percent is the
proportion of rural homes in Ghana using an untreated bed net.
There is a big difference in terms of that prevention. So you
are using a number that is on untreated as part of your
statistics for treated. My question is, actually aren't only 5
percent of Ghana's homes covered with insecticide-treated bed
nets, not 21 percent, as you state in your testimony?
Mr. Miller. Sir, it is an important question and I would
like to answer it truthfully and best I can with a level of
precision. I honestly cannot say right now whether what you
just said is correct.
Senator Coburn. This actually comes--your department is a
coauthor on the World Malaria Report that was published only
last week that made that very statement. So either what you are
saying in that report is right or what you are saying in your
testimony is right, and they can't both be right.
You can catch the frustration in my voice. It is not
directed to you personally, and please don't take that.
Mr. Miller. I understand.
Senator Coburn. When I know that 3,000 kids a day are dying
and we are spending $80 million a year, which could save 40
million of them if the money was put there in terms of
insecticide-treated bed nets and medicines, that, to me, is
just incomprehensible, that we can say we have got to have all
these other programs when, in fact, we could take 20 people and
make tremendous delivery of goods tomorrow to those kids in
those villages.
And so the statistics you quote are important, but they
also have to be accurate, and I will be happy to let you answer
that in writing for our Subcommittee.
Mr. Miller. Thank you. We will, sir.
Senator Coburn. Do you have any other questions?
Senator Carper. Just one more. USAID and, I believe, other
Western donor organizations have been criticized for being
reluctant or maybe even unwilling to fund the indoor spraying
of insecticides in communities that are plagued by malaria. Is
there any official USAID policy that you know about that
prevents the agency from funding spraying projects where that
is appropriate?
Mr. Miller. Thank you, Senator. I maybe should have
emphasized this more emphatically in my opening statement. The
shared goal of prevention is to get insecticide into the home.
That can either be through indoor residual spraying or it can
be through insecticide-treated nets. We are open to debate
about which is most cost effective in what areas. That is part
of what we do with $80 million, is determine what is most cost
effective.
We do emphasize insecticide-treated nets over indoor
residual spraying. We do not have a prohibition on the use of
insecticides in the homes, spraying of insecticides nor of DDT
in particular, even though DDT is, in fact, just one
insecticide we are talking about. There are 12 approved
insecticides for indoor residual spraying. IRS is very
effective. IRS has proven effective in South Africa, in areas
where you have the infrastructure and the services to make the
coverage. IRS is not the vehicle for insecticide of choice in
all of Africa.
So no, sir, there is no prohibition on DDT or indoor
residual spraying.
Senator Carper. Thank you.
Senator Coburn. Let me follow up with that, because I think
it is important. First of all, DDT is the most effective
insecticide. It is also the cheapest insecticide. There is no
question about that. Administrator Natsios told Senator
Brownback that you will not use DDT. That is a quote from him.
I also have a quote from Zambian health officials that said
USAID staff have repeatedly refused to fund DDT spraying and
told them that they should not adopt effective drugs as part of
the anti-malaria strategy. Can you explain this? Why would they
say that?
Mr. Miller. I cannot explain what someone in Zambia said. I
will tell you, we do not support or peddle ineffective drugs,
and we do, in fact, when, at a country level, it is determined
that indoor residual spraying would be the most effective to
save the most lives, we will support it----
Senator Coburn. Is that true in Zambia?
Mr. Miller. We will support that. In fact, Zambia is one of
the places we do support indoor residual spraying, yes.
Senator Coburn. Well, here is the Malaria Program Control
Director for Zambia, and that is who gave us this information,
and will you follow up with her and clarify that USAID supports
ACT treatment and in Zambia--DDT spraying--and let this
Subcommittee know the outcome of that conversation?
Mr. Miller. We will.
Senator Coburn. And that is Naawa, and I will try to
pronounce this name, it is S-i-p-i-l-a-n-y-a-m-b-e, the Malaria
Control Program Director for Zambia.
I also would like to ask you to maintain your seat, if you
would, because I would like to have you on the panel with our
other guests, and I also will, without objection from Senator
Carper, would like to submit written questions for you to
answer and give back to the Subcommittee. Rather than take your
time up with it today, I have about 20 specific questions that
I would like to get answers to----
Mr. Miller. Absolutely.\1\
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\1\ The questions and responses from Mr. Miller appears in the
Appendix on page 136.
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Senator Coburn [continuing]. And I would like that on a
timely basis, if we can have that.
Mr. Miller. We will do our best, sir.
Senator Coburn. Thank you.
Next, I would like to recognize Dr. Roger Bate, Resident
Fellow, American Enterprise Institute, Director, Africa
Fighting Malaria, U.S. and South Africa; and also Dr. Amir
Attaran, Ph.D., Associate Professor and Canada Research Chair
in Law, Population Health and Global Development Policy,
University of Ottawa; and also recognize Dr. Carlos C. ``Kent''
Campbell, M.D., Program Director, Malaria Control and
Evaluation Program in Africa.
We will start with Dr. Bate, if you would.
TESTIMONY OF ROGER BATE, PH.D.,\2\ RESIDENT FELLOW, AMERICAN
ENTERPRISE INSTITUTE, AND U.S. DIRECTOR, AFRICA FIGHTING
MALARIA
Mr. Bate. Senator Coburn and Senator Carper, thank you very
much for inviting me to testify today on behalf of Africa
Fighting Malaria and the American Enterprise Institute.
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\2\ The prepared statement of Mr. Bate appears in the Appendix on
page 50.
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Ninety years ago, a million Americans suffered from malaria
and a Congressional committee held hearings to discuss policy
options to eradicate it. This was achieved by the 1950's
through the judicious use of window screens and DDT and, of
course, increased wealth.
Today, malaria, as we have already heard, is a significant
risk for perhaps two billion people, suppressing hope and
economies alike, notably in Africa, but also, I should stress,
given what has been said before, it is increasing in parts of
Latin America and Asia, as well. I do not think it has been
conquered around the world. And unfortunately, I think we are
losing the war to combat malaria.
But there are bright spots. Southern African countries are
enacting comprehensive malaria control programs which are
grounded in the idea that success requires every tool that
science has provided, much like the United States did to rid
itself from malaria 50 years ago. Government and private
entities in South Africa and Zambia, for example, are using a
combination of low-level controlled indoor insecticide use,
both DDT and other chemicals, bed nets for key staff, and
prompt treatment of malaria cases to keep malaria incidence
low, and the results are startling, 70 to 90 percent reductions
in disease within a couple of years and even better reductions
in mortality in some locations.
Unfortunately, the U.S. Government has not been directly
involved with the two most successful strategies, indoor
residual spraying and effective drugs, except perhaps in
marginal ways at best. I say perhaps because it is hard to know
exactly what the $4 million USAID allocation in Zambia
supports.
USAID releases data as reluctantly as if it were a national
security outfit. We have to surmise a lot of information,
unfortunately. We fought to get from FOIA requests, from
interviews with people in the field, from pressure from friends
within Congress to try to get as much information as possible,
and there is an ongoing Government Accountability Office
inquiry into USAID's malaria programs and I welcome its
outcome. We need the information.
Despite the obvious benefits of comprehensive malaria
control programs, by its own admission, as we have just heard,
USAID typically does not purchase drugs or insecticides except
in emergency situations. Yet USAID continues to say it supports
comprehensive programs. This is a fiction.
Our estimation of the 2004 budget, and it is basically
confirmed here today, is that less than 10 percent, perhaps as
low as 5 percent of the budget is spent on actual commodities
that save lives. The vast majority of the rest is spent in
support and technical assistance. This is not comprehensive. It
is, in fact, highly selective in favor of Western staff. It is
likely that well over half the budget goes on salaries,
staffing costs, and travel, perhaps even a lot in the United
States.
From the information that is published, it appears that
USAID coordinates randomly, perhaps occasionally in a more
coordinated fashion, with other entities, and in many
instances, technical assistance, which we have already heard
today is its kind of backbone, its greatest skill, is provided
where no commodities are, in fact, available.
But even if coordination were well managed, USAID rarely
measure outcomes, and I am talking about the key outcome in
particular here, reductions in morbidity and mortality. So we
wouldn't know whether its programs are working very well
anyway.
And by the way, given it has been mentioned today on
several occasions, in my opinion, bed net distribution is not a
good measure of outcome. And in many respects, in the written
testimony from Mr. Miller, it is the main performance criteria
given. It is not a good measure from personal experience, also,
from looking at the data, because we are not always certain how
many people regularly sleep under a bed net.
Imagine an August night in Washington, D.C., and your air
conditioner is broken and you are trying to sleep under a
stifling net. Bed net use data is extremely important to
collect. I have spent many nights in the field where I have
been incapable of sleeping under a net. It was just simply too
hot. I wouldn't have had any sleep. I was offered some
prophylactic drugs, as well, a belt and braces policy.
Therefore, I could afford to take the risk. For everyone else
living in Africa, that is not the case.
While we can quibble about the best interventions, and I am
delighted to hear that there is greater interest in indoor
residual spraying, there is no doubt in my mind that USAID
fails badly in the transparency and accountability stakes, and
that is the point that I think is most important to make today.
USAID does not consistently measure anything useful. It does
not measure real outcomes. It has not updated its Yellow Book
since 2001, so we don't know what USAID's contracts are for,
with whom they are made, and for how much.
Of the few reports USAID does file, many are self-serving.
That is not just according to me, that is from a Government
Accountability Office inquiry in 2002 and its own internal
review last year. And since it doesn't collect, as I have
already mentioned, useful data, it is incapable of effectively
evaluating its performance.
Since Anne Peterson, then Assistant Administrator for
Global Health, first testified to a Congressional subcommittee
about USAID's malaria program in September of last year, not a
single program report, evaluation, or other document concerning
the agency's malaria activities has been submitted to the
agency's publicly available database. In that 8-month period, I
notice some welcome rhetorical changes in favor of ACTs and
spraying and saying the support of indoor residual spraying,
but I have seen no change in action on the ground.
When I testified alongside Dr. Peterson last September, I
suggested that if accountability and transparency were not
delivered quickly, U.S. funding for their program should
perhaps be reallocated to agencies that have a better chance of
improving health. As we have heard today, too many children's
lives from this disease are at stake for failure to continue.
I conclude the same way today, 8 months later, and with
stronger emphasis. I think that USAID must rapidly increase its
transparency. I would encourage it to follow the lesson from
the Global Fund and establish a website, or even on its own
website, which would hold all technical information for USAID.
That would include contracts, grants, and corporate agreements,
budgets, and implementation plans. Until it does that, and I
think it should be given a time limit to do that, I think it
should seriously consider its budget being reallocated
elsewhere.
Thank you, Mr. Chairman.
Senator Coburn. Thank you, Dr. Bate.
We have a vote on. What we will do is recess the
Subcommittee for the period of that vote and then we will
return. I would ask your indulgence.
[Recess.]
Senator Coburn. The Subcommittee will come back to order.
Mr. Miller, it is my understanding that we did not advise
you appropriately of what we would be requesting of you in
terms of time commitment, and if you feel necessary to keep
those commitments with other people, the Subcommittee will
understand.
However, it is my understanding you are working on a
transparent website so that people can look at USAID in this
area in terms of your funding details, is that true, and when
will that be available?
Mr. Miller. Sorry, I had to consult with my staff. I am not
aware of something exactly as you describe. I don't have any
objection to it, and it is certainly something we will
consider.
Senator Coburn. Well, what I would like to hear is, yes, we
will do that and here is when we will have it done. People
should be able to address USAID programs via a website to see
what is happening and where. What I would like for you to give,
first of all, commit to do that, and second, give us some sort
of time frame from your staff when that will be available.
Mr. Miller. Sir, I could commit that we will do our best.
In terms of a time frame, let us talk with your staff about
what types of data and the depth of data we are talking about
and come up with a reasonable time frame, mutually agreeable
time frame, is that all right?
Senator Coburn. That is fine.
Mr. Miller. Good. Happy to do it. Sir, I can stay, by the
way.
Senator Coburn. OK. Next, we will recognize Dr. Attaran.
Dr. Attaran, if you would, please.
TESTIMONY OF AMIR ATTARAN,\1\ ASSOCIATE FELLOW, ROYAL INSTITUTE
OF INTERNATIONAL AFFAIRS, LONDON, ENGLAND, AND CANADA RESEARCH
CHAIR, INSTITUTE OF POPULATION HEALTH AND FACULTY OF LAW,
UNIVERSITY OF OTTAWA, CANADA
Mr. Attaran. Thank you, Mr. Chairman, Doctor. My deepest
thanks for your interest to discuss malaria today and USAID's
response, which I view as inadequate.
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\1\ The prepared statement of Mr. Attaran with attachments appears
in the Appendix on page 97.
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I believe by now you are quite familiar with what malaria
is. You know that it is killing a million kids and pregnant
women a year, mainly in Africa, that it is pauperizing entire
families and nations when it isn't killing them, that it is a
threat--perhaps this is a new piece of information--to the
American military. It did hospitalize a quarter of our troops
in Liberia only a couple of years ago. And that prospects for a
vaccine are a decade or longer in the future and have been that
way for about the last 30 years. The vaccine is always 10 years
away.
We also seem to have, I think, in this Subcommittee a
certain amount of agreement on what the interventions are to
prevent or to treat. There are basically three of them,
insecticides, bed nets, and medicines. Everyone agrees on that.
But what I see little agreement on is how USAID should spend
their money in respect to those three. So let me sketch out
these differences of views, such as they are.
My view is that Africans are very different from Americans.
They are poor. They live on $2 a day, the vast majority of
them. They are very poor. So when there is foreign aid money
voted by the American government to spend, we should be
spending it on the poor Africans. That is my hypothesis.
USAID fundamentally disagrees with that point of view. As
you question them, you will find they spend most of their air
money on Americans--American consultants, American experts, and
very highly-paid American nonprofit organizations. It rarely is
true that USAID is spending its money actually buying and
supplying the weapons of combat--the medicines, the
insecticides, the nets--that actually get to the patient and
have an effect on malaria.
Instead of preference for these cozy deals with
consultants, which, to steal a phrase from President
Eisenhower, resembles to me a ``Foreign Aid Industrial
Complex,'' really--USAID should make the provision of supplies
and commodities.
Now, let me look at a few examples of that, and perhaps we
can dive deeper into these in questions. USAID does tell the
public that it ``strongly supports ACT,'' but it also says that
it typically doesn't buy commodities. For example, no malaria
pills whatsoever, or very few in number.
If that is support, what would opposition look like? The
medicines aren't being bought, and aren't being given to the
patients. Compare that to when we do food aid as the United
States: We actually provide the food. We provide the commodity.
When we do malaria aid, we don't provide the commodities. That
is wrong.
So where does that USAID malaria money go if it is actually
not going to the commodities? Well, for the most part, it is
going to contractors, and the contracts are big and they are
not terribly transparent. For example, USAID has a $65 million
contract with an organization known as Net Mark. Net Mark
sells, not gives, bed nets to the poorest people on earth in
Africa. That is its mission. The $65 million is spent
predominantly on marketing and not on actual, ``Here, have a
net for free'' provision.
Net Mark is overseen by a contractor known as the Academy
for Educational Development. It bills itself as a nonprofit,
but last year, its CEO paid himself in excess of $400,000 in
salary and benefits. That is more than President Bush collects.
Getting details beyond generalities such as these, further
details, is next to impossible because USAID has not updated
its contracts database to the public since 2001; basically
Clinton-era contracts all what is available. USAID is not
terribly cooperative in inquiries about its contracts, and it
admits that contracts ``are not reported or collected centrally
in Washington.''
Really, there is a lack of information about all sorts of
contractual aspects of the USAID program. It was asked, Mr.
Chairman, earlier, how many nets is USAID providing? And there
was no answer to that question. Nobody knows.
So as I said, it is such that poor Africans aren't getting
the commodities from USAID. They are not getting the basic
tools. But unfortunately, a large network, this Foreign Aid
Industrial Complex, of contracts is living on generous salaries
and we don't really know how well they are accomplishing their
work. That information is not available. How many pills or
nets. It is not available.
I thank you for your patience and wish to be of service to
you in getting to the bottom of this. Thank you, sir.
Senator Coburn. Dr. Campbell.
TESTIMONY OF CARLOS C. ``KENT'' CAMPBELL, M.D.,\1\ PROGRAM
DIRECTOR, MALARIA CONTROL AND EVALUATION PROGRAM IN AFRICA
Dr. Campbell. Thank you, Mr. Chairman, Dr. Chairman. It is
a pleasure to be with you today. I have a written testimony
that I would like to offer to be set into the record----
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\1\ The prepared statement of Dr. Campbell appears in the Appendix
on page 126.
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Senator Coburn. Without objection, it will be so done.
Dr. Campbell [continuing]. And I would just like to make a
few comments.
First is my role here today, both in terms of how I was
invited and how I would like to be perceived. I am not here
representing any institution nor to defend any institution. I
am here and was invited to be here today to be a resource to
this Subcommittee in this process in terms of I spent 30-some-
odd years working exclusively in malaria and almost exclusively
in Africa, beginning working in clinics in Western Kenya before
HIV came in, continuing working in leadership positions with
the Centers for Disease Control, with UNICEF, WHO, and now
having the opportunity to work on what I think many of us
believe to be the single big focus that we need in Africa right
now, and that is rapid, well-demonstrated, well-documented
progress to bringing malaria control to the capability of
African nations to be able to manage that as a program
activity.
I share with you, and I would reflect back 20-some-odd
years ago when I first had my opportunity for Congressional
testimony, working for the Centers for Disease Control and
Prevention, it was virtually impossible to get an audience to
speak about malaria. In fact, I had to spend most of my time
convincing people there still was malaria in the world, and how
wonderful it is to see the intensity of interest, the
impatience, the desire on the part of the U.S. Congress to get
it better, and I applaud you for leading in that direction, and
Senator Brownback and others in this process. I think that is
something that all of us on this panel share, though I will
speak just for myself.
I think the second thing that I would like to say is that
the malaria problem in Africa can be measured in terms of
people, it can be measured in terms of suffering, it can be
measured in terms of money. It can be measured in many ways. It
absolutely needs to be measured and measured much better than
we are doing at this point, and there is progress occurring on
those fronts.
I think one of the things which many people find so tedious
and many people see as potentially a waste of time and effort,
but I would like to make just two key points which I have tried
to elaborate in what I have written. There is a lot of money
coming in to support malaria right now and the window of
opportunity to make certain that is used well and documented
well is probably much shorter than many of us want to believe.
That money will go elsewhere if malaria does not produce, and
malaria does not produce and document impact, not just in terms
of where we went and who we were, but who got sick and who
didn't die.
We all understand that it is hard, but it is vital and it
will occur and it must occur, and we need your help in terms of
pushing that forward.
I think the second thing that is the difficult part of this
is that as more money is coming into many African countries
right now, and this is what I spend my life doing, is that the
capacity of national governments to receive and allocate that
money to turn that program into--turn that money into saved
lives is a huge challenge, is that these very systems, and we
can talk about infrastructure, we can talk about capacity, all
of these potentially murky topics are vitally important. They
are not more important than commodities.
But the challenge that we run into in many countries in
Africa right now, and this is a big problem that the Global
Fund is currently facing, is the capacity to do things that we
take for granted--procurement, distribution--a number of these
other things are vital issues that we as the leadership
position which the U.S. Government can bring to these issues,
we need to make sure that we have a balanced armamentarium as
we move forward.
We must make certain, and we need more money for
commodities. But to take current monies and push them toward
the commodities and to take away the enormous, almost unique
capacity which the U.S. agencies have in their academic
institutions and other Federal institutions that know how to
support governments to do these things is vitally important.
Call that technical assistance, and yes, there are many
egregious examples of technical assistance running amok. But
there also are as many or more examples of where technical
assistance has been well thought out, has supported the
capacity of national governments to move forward in malaria and
other issues.
And we need to make certain that the U.S. Government, which
in many respects--or the United States, which in many respects
has unique capacities to support those areas, can do that and
do it better than we are doing it now. So I ask you to not move
everything to commodities, but keep a balanced view.
The last thing I would want to say is that we must all keep
in mind is that malaria in Africa will be controlled by Africa
and not by us, and so the capacity of national governments to
understand and to adapt systems right now which are stressed in
many respects by the enormous and much greater infusion of HIV-
AIDS money and resources coming in, these systems really have
an enormously difficult time in terms of how they absorb these
monies and move them forward, and that is not as simple as
diagnosing and treating malaria. That is much more complicated,
and it may be the Achilles heel of this whole process.
The U.S. Government can do a better job. The U.S.
Government is not doing as bad a job as perhaps some people
would like to believe. Single agencies have good pieces and bad
pieces and pieces that all can be improved, and I think that at
this point in time, as we look forward to legislation to
suggest how we move forward, I would encourage us to make
certain that we understand what is working well, and then off
of that basis figure out how to make it better. Thank you very
much.
Senator Coburn. Dr. Campbell, your points are well taken.
The point is, when you can't find out what is being spent where
and there are no measured outcomes on the basis of what the
goals are. There is no way you can evaluate that. So there is
no way you can make an assessment. That is what this hearing is
all about.
What are the goals? How do you measure the goals? Where is
the money being spent? How is it being spent? Are the
contractors efficient? Are they doing what they are supposed to
be doing? Is the money being spent inappropriately in terms of
the domestic side of the issue?
When 50 percent of the money of this budget is spent in the
country, and we don't know that for sure because I can't find
out. I am going to find out, I will tell you that. I am going
to find out where every penny that goes with this malaria
program is spent, no matter what. So we are going to know, and
we are not going to just know on malaria. We are going to know
on every area. That is what this Subcommittee is going to be
about the next 6 years if I am still the Chairman of this
Subcommittee and we are going to have accountability.
And it is not to say that those people, Mr. Miller and his
staff, don't care, aren't trying as hard as they can. The fact
is, the only way you can be evaluated, it has a measurable
outcome. And our outcome is based on lives saved and disease
prevented. That is the outcome that we have got to be looking
at.
Whether it is implementation, delivering the product, not
just commodity product, but whether you are implementing it, if
you haven't implemented that properly, you are not going to
save the lives. So it is not just one or the other. It is
measuring the outcome, how many lives are saved, and is it an
emergency?
To me, there are not 3,000 children who die in the
Southwest in this country every year from disease. So this is
an important thing, and what we are asking is transparency on
where the money, responsiveness to those people who also care
so they can see where the money goes--so that they might be
able to contribute a great idea, and the ability for Congress
to look at where the money is spent to know whether or not we
ought to put more money. How do we know we shouldn't be putting
$200 million a year into the malaria program? We don't know
that.
So the fact is, if there is resistance on the part of any
agency in this government to cough up the numbers of where they
are spending the money, that automatically sets an assumption
that either there is something to hide or they are incompetent.
There are only two answers. I don't believe they are
incompetent. They may not know, and that is just as bad,
because if they don't know where the money is going or what the
purpose is for the money, then we are not doing our jobs in
terms of oversight or looking at how we spend the money.
The hearts and intent of the people at USAID are good.
There is no question about that. The goal is, how do we spend
the money effectively. We are going to run a true $650 billion
deficit this year. That is the real number, and I will be happy
to go through that with anybody that wants to dispute that. But
that is how much money we are going to borrow for the future,
the kids that are here today that aren't getting malaria that
are going to pay back. Any dollar that we don't spend well in
saving a life from malaria, our grandchildren are going to pay
back about $10 to pay for that because we are borrowing the
money to do it. So it is implicit on us to be great about where
we go.
Dr. Campbell. Sir, I just would say, I couldn't agree with
you more that, in fact, that level of attention to how well we
do our job, all of us do our job, and that accountability and
data are vital, I think all of us would support wholeheartedly.
And how we do that and how we get to the end of that inquiry
and make certain that those 3,000 children benefit from that
inquiry is something that all of us would like to help you do
well.
Senator Coburn. Thank you. Let us start with Dr. Bate, and
I presume Senator Carper is coming back. Can you give me an
example of what you meant when you said USAID is not
transparent. I believe that to be true, but give this
Subcommittee an example of that.
Mr. Bate. Well, first, the Yellow Book, not updating its
contract information, that makes it very difficult to know. I
mean, that is a prime example of lack of transparency.
Senator Coburn. Can you think of a good reason why somebody
wouldn't update that?
Mr. Bate. Again, I refer to your remarks, which is
incompetence or something to hide. I doubt it is incompetence.
Perhaps they don't want people to know how the money is being
spent.
I think sometimes the information that is presented can be
misleading. Mr. Miller, the testimony he gave on April 26, so
2\1/2\ weeks ago, discussed a contract or a grant to
Technoserve, which he described as an East African agricultural
concern in his testimony. It may well have operations in East
Africa, but its headquarters is 49 Bay Street, Norwalk,
Connecticut, and it received $8 million from USAID in 2003. I
don't know what it got in 2004.
That is not to say they are not doing a good job, but that
was not a competitive tender. We have no idea whether other
organizations, perhaps in Southern Africa, where there is great
competence in farming, could have helped in growing that at a
lower cost. Perhaps it was done in an emergency setting to
increase the production of what is an extremely important crop.
I don't know that. But I do know that--you asked for an
example. I think that is one. I am not saying it was willfully
done to mislead, but it is misleading to say that a moderate-
sized U.S. contractor is an East African agricultural concern.
Senator Coburn. Let me ask you, if you were in charge of
$80 million for a malaria budget for Africa, where would you be
spending the money?
Mr. Bate. In terms of the----
Senator Coburn. And I am going to ask you to answer that in
a short period of time. I know that is a terrible question,
but----
Mr. Bate. The short answer is I would be buying a lot more
commodities than USAID is buying. The idea that they coordinate
with other agencies and other forms on the ground may be true.
We don't know because of transparency, lack thereof. But the
examples I have seen, there are instances where they are
providing technical assistance and the commodities are not
available.
Second, I think that, to use the analogy that Mr. Miller
gave, which I think is a good one, it would be to a certain
extent like trying to fight the Iraq war, relying on the Royal
Air Force for air cover. Now, the Royal Air Force is a
marvelous organization and as a Brit, I am very proud of it,
but it doesn't have the power that the U.S. Air Force does and
I think we need U.S. purchases of commodities.
So is the budget allocation, I am not 100 percent certain
what it should be, but I would say certainly 50 percent or more
on commodities.
The technical assistance they can provide, I am sure, in
many instances is very good. We simply do not know.
Senator Coburn. Dr. Attaran, you are an immunologist and
you are the author of a very famous paper in the Lancet which
revolutionized how USAID and others think about malaria
treatment. Why is ACT better clinically, and whether the
Coartem deal is a good deal for Africans and Americans and
whether USAID has treated the pharmaceutical manufacturer of
that appropriately.
Mr. Attaran. Thank you for the question, Mr. Chairman.
Coartem is an example of a class of medicines known as
artemisinin combination therapies, which we have been calling
ACT. There are four approved ACTs and they are all good and
they are all far superior to previous medicines, mainly for two
reasons.
One, they achieve high cure rates. Chloroquine, which is an
older medicine, as of about 2 years ago was failing to treat
the patient successfully 79 percent of the time in Ethiopia.
Seventy-nine percent of the time, you had drug resistance and,
consequently, treatment failure. You don't get any treatment
failure with ACTs. If it is the right ACT for that setting, you
get cured. It works all the time.
Senator Coburn. And there is no potential for resistance
development?
Mr. Attaran. Well, artemisinin is a herbal remedy from
Chinese medicine, and they have been using it for 2,000 years
and we haven't found resistance yet. Maybe the 2,001st year is
going to be really bad----
Senator Coburn. Do we understand the mechanism of action?
What does it do to the trophozoite?
Mr. Attaran. There are heated controversies about that. The
leading theory is that it actually creates free radicals that
destroy some of the internal contents of the parasite, but that
is not settled conclusively right now. What we do know is that
it does achieve these much better treatment rates than older
medicines.
And it wasn't long ago, I would say only about a year and a
half, 2 years ago, that we had USAID and UNICEF vigorously
supporting the use of chloroquine in Ethiopia. There is a
brilliant New York Times story about that, where USAID is
quoted as saying that artemisinin in combination therapies,
``aren't ready for prime time,'' which was scientifically, I
think, an indefensible point of view.
That said, since ACT is better, how do we get enough of it,
at what price? The prices that were told to you earlier are
fairly accurate. Coartem, to take that as an example, because
it is the number one listed product by WHO--it is the one that
they put at the top of their priority list, and it is approved
by them--sells for between 90 cents for a pediatric treatment
to $2.40 for an adult treatment. It is sold under an agreement
with WHO entered into by Novartis for absolutely no profit on
Novartis's part.
You don't have to take my word for that. WHO did engage
Deloitte and Touche to audit Novartis and, in fact, Deloitte
and Touche returned and said that Novartis was making about an
80-cent loss. So they are in the red, actually, on the adult
treatments. That was at a time before we saw a sudden spike in
raw material prices. It could even be more of a loss now, but I
don't know and you would have to ask Novartis.
So WHO is satisfied that is a good deal. Global Fund is
satisfied that is a good deal. What I am aware of is that when
Novartis has made outreach to USAID, it has not been perfectly
reciprocated, but that is, again, not the topic in which I can
engage very deeply and I would encourage you to be in touch
with Novartis and USAID.
Senator Coburn. When I was in Congress in the late 1990's,
the idea of a Global Fund kind of synergized around myself and
some other people, and I know many in this room were involved
in that. Should Congress just strip away the USAID money and
send it to the Global Fund?
Mr. Attaran. I think what is true is that the Global Fund
has made very helpful and important and, I would say, impactful
strides, measured as how many patients are going to get
treatment and live, since last year when I published my highly
critical article in the Lancet about them. That is a fantastic
development and they deserve to be commended for this.
There are two options here for you, sir. One is to either
try and reform USAID, and I think that the Brownback-Landrieu-
Inhofe bill is a fantastic way of going about that, and then
USAID perhaps could be effective on malaria in a way that it
currently is not.
The alternative is to simply give the money to the Global
Fund. Both agencies are obviously capable of doing a good job,
and so what it turns on at the end of the day is whether you,
sir, and your colleagues believe it is important to have an
independent U.S. ability to execute in malaria and possibly the
other diseases about which the Global Fund is concerned.
Senator Coburn. Senator Carper.
Senator Carper. Thank you, Mr. Chairman.
I want to start off with Mr. Miller. Take 2 minutes if you
want to rebut anything or respond to anything that has been
said, just mostly the compliments that have been thrown your
way. [Laughter.]
Mr. Miller. Thank you, sir. I think I wouldn't know where
to start. There is a lot out there. A lot of it has to do----
Senator Carper. Just a couple of priorities. Don't do it
all, just a couple of top priorities.
Mr. Miller. Sure. I would start by emphasizing that there
is agreement, and I am glad to hear Mr. Bate and Dr. Attaran
mention that. There is a shared goal here of eliminating
malaria. In fact, there is actually agreement on the
effectiveness of interventions that IRS, ITNs, and ACTs have,
this is what the United States and multilateral agencies, we
are a part of, should and will support.
The debate is really about the proportions and the
priorities they are in, and we are happy to have that debate,
and Senator Coburn emphasized that greater transparency and
accountability are called for. As I said in the beginning of my
opening statement, no agency is beyond criticism and we
certainly do welcome that dialogue and, of course, we will do
the best we can. Again, our goal is to save the most lives
possible and whatever we can do, if it can be demonstrated that
we are doing it wrong, we should do it a different way. I think
President Bush would expect us to do that.
Senator Carper. I say, everything I do, I can do better,
and my suspicion is that is true about most of us and even
agencies, as well.
To our other witnesses who joined us on the second panel, I
apologize for missing the presentations of all of you but one.
I want to start maybe with a question or two for Dr. Campbell,
if I may.
We have heard some--and I approach these issues as a lay
person, so this is a great opportunity for me to learn and to
be educated and I think that is the purpose of these hearings
anyway, so it is serving, at least with respect to this member,
it is serving its purpose.
Dr. Campbell, there has been some discussion here today on
the value of indoor spraying of insecticides and how effective
that is and there seems to be agreement that can be pretty
effective. Are there any parts of Africa where it is maybe not
as appropriate to use sprayed insecticides on the inside of
dwellings?
Dr. Campbell. The answer is that as best we understand, and
I think we understand this quite well, that indoor residual
spraying with a range of insecticides can be highly effective
in virtually anyplace in Africa except under some remote
situations where the quality of housing surfaces is such that
the insecticide doesn't adhere or vaporize from the surface as
well.
But the fact of the matter is that its ability to kill
mosquitoes after they bite and rest on it is essentially
uniform in Africa. That is not the limiting factor. The
limiting factor really has to do with the manpower,
infrastructure that is required to deliver it and a variety of
issues of that sort.
So I think that the debate, as we see it at this point, is
not--I do not find the IRS debate as being the central most
important issue in terms of moving forward on malaria control
at this point. And second, I am committed, as are many of our
colleagues, in not letting the controversies around DDT and IRS
get in our way of moving forward. It has a role. National
governments are dealing with it right now to understand the
appropriate role. Largely, as WHO says, it is in more compact,
urban areas, but there is good experience of using it in other
areas, also.
Senator Carper. Thank you. Did you say anything in your
testimony about how one role of the USAID is to help countries
in Africa to develop the capacity to better utilize--I talked
about tools and toolboxes. It seems to me part of USAID's role
is to put tools in the toolbox to combat malaria. But another
part of their role is to help ensure that the rest of the tools
that are placed in the toolbox by others are then better
utilized, more effectively utilized by nations and so forth to
combat the disease.
If you could just give us your thoughts, and maybe you
already have and I missed it, on the effectiveness of USAID in
coordinating this capacity building, folks within national
governments and other folks that are putting tools in the
toolbox, like the Global Fund and maybe the World Fund, World
Ban.
Dr. Campbell. In fact, I think one of the things that I
would say is that I would probably defer those kind of
observations and others. That is not an area in which I have a
vast amount of experience and I don't think I am the best
person to comment on that. I have worked with many
organizations, but I would refer that to Mr. Miller and others,
and you have got other experts----
Senator Carper. Good. Let me just ask the same question of
others. I already discussed this a little bit with Mr. Miller,
so I am going to ask if you will hold off. Would you pronounce
your last name for me, Doctor?
Mr. Attaran. Attaran.
Senator Carper. Attaran, OK. And is your last name Bate?
Mr. Bate. No ``s''.
Senator Carper. No ``s''. Where did you get that name?
Mr. Bate. Well, it is a long tradition of singular British
men who do not have an ``s'' on the end of their name.
Senator Carper. That is remarkable. [Laughter.]
Do you all have any thoughts on the question I just
directed to Dr. Campbell? He has done something that few of us
here do, and that is just admit we don't know and move on. We
usually go ahead and answer the question anyway.
Mr. Bate. There is no doubt that coordination is a vital
role that with good assistance the USAID can help with. There
is, unfortunately, a paucity of data out there as to how that
technical assistance works, and in some of the examples we had
cited in my written testimony, there are some problems to the
extent that technical assistance is provided where the
commodities are not available.
So there is no doubt coordination can be improved, even if
USAID does have great technical assistance, and because of the
lack of transparency and accountability in reporting, we simply
don't know.
Senator Carper. All right. Dr. Attaran.
Mr. Attaran. Thank you, Senator. There is a fine line
between technical assistance and meddling or backseat driving.
Technical assistance is a good thing. One wants to make sure
that the money that is given is being used in a proper way,
that the people are using scientifically up-to-date strategies
to control malaria. All of that is certainly true.
But when we end up with a program such as USAID's, where,
for instance, ``treatment'' really is about giving a lot of
advice on how countries should do treatment and yet no
medicines or very few are purchased, we are backseat driving at
that stage. We are telling other people how they should spend
their money on medicines that are the ones we, as Americans,
want them to use, and that is not helpful.
In fact, that is--in my experience in Africa, I have had
formal experiences and I have also hitchhiked across Africa for
months at a time----
Senator Carper. Is it hard to get a ride there?
Mr. Attaran. There was a 4-day stop on the Equator which I
am not proud of, sir.
Senator Carper. That is a long time to wait.
Mr. Attaran. It really was. But in my formal and informal
experiences both, I have found that there is a certain amount
of resentment engendered by, if I can paraphrase it, that we
are telling people to do a certain something and we are not
helping them do it. You are coming in and you are meddling. I
have heard that said in all sorts of African contexts.
Senator Carper. Thanks. Mr. Miller, just a quick comment if
you have, just briefly in response to this again. I know you
talked about it a little bit already. Is there anything else
you want to add?
Mr. Miller. Yes, sir. I would say we are not meddling.
Certainly we don't design our programs from Washington to be
impressed upon anybody. These are designed almost always with
the cooperation of the host government or with NGOs or with
other interested or affected people, and that is always the
goal.
Senator Carper. All right. Thanks. Dr. Attaran, do you have
something else?
Mr. Attaran. If I could just add an analogy that I think
might be of assistance to you, Senator, USAID does food aid and
in the food aid context, bags of grain and buckets of oil, the
actual commodities are delivered and people are grateful for
that around the world.
Imagine we did food aid by actually recommending to people
what their diet should be in a starvation situation, but we
didn't provide them the grain and we didn't provide them the
oil. ``You really ought to eat some rice today,'' but they
don't have any. ``You really ought to have a bit of oil,'' but
we don't give them any.
That is the analogy that illustrates how our technical
assistance without the provision of commodities becomes
misunderstood and our good intentions are misunderstood, which
is to me quite a sad reality and, I think, one that we can fix.
Senator Carper. All right. Thanks. One last question, Dr.
Campbell, if I could. Let me just ask what your views are on
the recommendations, I think made by Mr. Bate and I think his
coauthor, that USAID should maybe concentrate its anti-malaria
efforts in a smaller number or the most needy countries.
Dr. Campbell. In terms of the--there are several
recommendations out there right now and to the extent to which
my view would apply to USAID is for others to interpret.
I think that we are in a situation in Africa right now
where there is clearly progress in terms of one of the
important ways of understanding and that is coverage in terms
of the proportion of individuals who were sleeping last night
under an insecticide-treated net, for example. There are some
great examples of enormous progress.
Malawi just completed a national survey and the average was
38 percent of children under five sleeping under a bed net.
That is not 60 percent, but 3 years ago, it was under 5
percent, and those are truly insecticide-treated nets. Those
are not just nets. Yes, that is one country, but there are
several other countries that are making dramatic progress.
I think one of the things that we have is that we have a
lack of confidence on the part of ourselves and, quite
honestly, there is a great deal of skepticism on the part of
national leaders who are the ones who are going to ultimately
decide the priority that malaria gets within their ministries
of health that malaria can be programmed to impact.
You share this concern, too, and so I think that one of the
challenges we have at this point is that making slow progress,
incremental progress across all of Africa, is important. But
unless we have some dramatic examples of progress in the short
haul, and I am talking in 3 to 5 years, our concern is, is that
the edge on malaria as a doable, feasible entity is going to
wane and we will have lost an enormous opportunity.
So the answer is, I think that we need a balance of
investment across many countries, but we also need more
attention to intensive multi-donor, not just single country,
efforts in a few countries that actually can provide an example
to other countries to say, wow, this is possible, because we do
not have examples of success in Africa at this point in time,
and until we begin to accumulate those very rapidly, I think
that the confidence issue is going to become an increasing
impediment.
So the answer is, yes, I think that we need some intensive
investment with the Global Fund and with several other
bilaterals to come together in a few countries and say, this
needs to be done really well and documented to the n-th degree
so that people can see it, understand it, and have confidence
in it.
Senator Carper. Thank you. Dr. Bate, a last word?
Mr. Bate. If I just may, I think there are examples of
success in Africa and those examples are where people actually
measure outcomes and they use interventions. I mentioned South
Africa, and Zambia has already been mentioned. Northern Zambia
is a great example of a rapid reduction of morbidity from
malaria of 70 or 80 percent.
Senator Brownback said something which I think is very
good, and I can say this as an outsider. The American people
are the most generous on earth. If they are shown that malaria
treatment, prevention will work, I am sure more money will be
made available, and that is something we all want. And I think
that if the only examples you have are provided by national
governments in South Africa's case, or the private sector, that
is a very--I think that is an indictment on the fact that no
data has been collected. We need to collect data and we need to
have that data presented transparently, and then I think the
American people will spend even more money to malaria.
Senator Carper. All right. Our thanks to all of you.
Senator Coburn. I just want to follow up with a couple of
questions. Mr. Miller, do you know and do you have at your
fingertips where the money is spent for the malaria program
with USAID?
Mr. Miller. At my fingertips, no, sir.
Senator Coburn. Do you know it? I mean, is it available to
you?
Mr. Miller. It will be--yes, it is available to me.
Senator Coburn. So it is not that the information isn't
available. So my question is, since it is available to you, why
isn't it available to us?
Mr. Miller. It is the form in which the information is
available, I think is important to remember. I would point out
that most of what we do, most of what USAID funds in terms of
anti-malaria programs--this is true of all health and
development programs--is done through grants. We call them
cooperative agreements, but they are, in fact, grants. They are
not through contracts, so you are not going to get a contract-
like response.
Senator Coburn. I don't need to have that. I just want to
know where the grants are, who gets them, what time they got
them, what are the requirements of the grants, what is the
performance evaluation of the grants. How do you measure
whether somebody as a grantee did what you asked them to do? In
other words, that is the data that I want to see, and it is not
just USAID. I want to see that in the entire Federal
Government. The American people deserve to see that and know
that, and if that is available, I want this Subcommittee to
have it.
Mr. Miller. Sure. That type of accountability is stuff we
do collect with every grantee. They have to go through audits.
They have to have a performance appraisal----
Senator Coburn. Then I would assume you would make that
available to the Subcommittee.
Mr. Miller. We will make everything we can, sir.
Senator Coburn. I just have one other question. Dr.
Attaran, would you comment on the World Bank situation now and
what is going on in terms of the malaria?
Mr. Attaran. Yes, Mr. Chairman. The World Bank has, only a
couple weeks ago, published a new malaria plan--it is not
implemented, it isn't yet funded by their board--which has as
its bottom line that they will commit between $500 million and
$1 billion towards malaria. They very carefully are cagey about
that. They say $500 million to $1 billion, together with their
partners, and nowhere do they say what the World Bank's
contribution will be. It is always, together with our partners.
So we really don't know what they are committing.
But what I can tell you is that history is not on the side
of children with malaria, because in 2000, the World Bank did
promise to provide $300 to $500 million of its own money for
malaria in Africa which initially it said it did, and then
following an investigation that I conducted and published in
the journal Nature, which you may be aware of, the World Bank
admitted that, in fact, they had only spent $100 to $150
million, not the $300 to $500 million that they said. And
similarly to USAID, the World Bank declined to explain how they
spent it. So we don't even know where that $100 to $150 million
has gone.
It is curious that this is a bank that doesn't know how
much it has got in its accounts: ``Maybe we spent $100 million,
maybe we spent $150 million on malaria. We are really not sure
and we please don't want any more questions on the situation.''
I am, of course, being summary in my assessment of the
situation, but I think that is, frankly, accurate, and the
editors at Nature agreed with that.
Senator Coburn. All right. I think our testimony is true
that--and let me just, Mr. Miller, give you a chance. You do
have a contract for $65 million for nets?
Mr. Miller. I believe that is a grant, or a cooperative
agreement.
Senator Coburn. You have a grant.
Mr. Miller. A cooperative agreement, yes, sir.
Senator Coburn. Sixty-five million, and that is over how
many years?
Mr. Miller. Net Mark, is that per year, or is it 5 years?
It is an 8-year grant.
Senator Coburn. An 8-year grant.
Mr. Miller. Cooperative agreement.
Senator Coburn. And those grants are not--those nets are
not given away, they are sold, is that correct?
Mr. Miller. It can be both.
Senator Coburn. Do we know what percentage of that money--
--
Mr. Miller. We can determine that. The way we determine----
Senator Coburn. You don't know that?
Mr. Miller. No, sir, not on the spot.
Senator Coburn. Does somebody here know that?
Mr. Miller. I think we can determine that. Do we know the
percentage?
Mr. Carroll. Ten percent, 15 percent are given away. The
rest are sold. They're sold, I might add--prices that these
nets are being sold for represent 50 percent reduced prices
from what they were in the market 3 years ago. So this is
moving nets through the commercial sector into retail shops and
making them available at very low prices, along with nets going
into antenatal clinics and making those available for free.
Senator Coburn. Here's the difference. What do the nets
cost? What's the true cost of the net? If you're going to spend
$65 million buying nets, I'll bet you they're the biggest net
buyer on this side of the ocean. And if we're going to buy the
nets there shouldn't be any profit in them. The nets ought to
go to people at what they cost. Is that what they're doing,
they're going at cost? The Africans are buying the nets at cost
and that's around $4?
Mr. Carroll. Three dollars, fifty cents, $4.
Senator Coburn. That's the cost that's paid to the
manufacturer for the net and that's the cost that they're sold
at?
Mr. Miller. But I don't think nets always go at cost.
Senator Coburn. Why not?
Mr. Miller. Some are free.
Senator Coburn. Other than the free ones, why would the
nets not go for what they cost?
Mr. Carroll. Senator, this is a program--again, this is an
exercise where we are working in concert with other donors,
UNICEF, for instance, World Health Organization, where we are
looking at the full range of opportunities to get nets not just
tomorrow or today, but in a sustained way to make sure that
every kid and every pregnant woman has access to this
lifesaving measure.
Our role in this case has been multifold. We have been
working with textile industry across Africa to increase their
ability to produce the nets so that we are creating more
opportunities for nets to be flowing into African homes.
Senator Coburn. That's a great point, but here's my point.
Is somebody making profit off the nets?
Mr. Carroll. If there's a profit being made, it's a local
retailer, it's an African retailer bringing food home to their
family. This is building a local capacity to solve a local
problem.
Senator Coburn. So somebody is going to spend----
Mr. Carroll. Part of our role, our other role, which is
equally important, is working in the communities to make sure
that there are affordable nets free to those who cannot afford
them. So we're working both sides of this. We can share with
you data now that is coming in from Senegal and Ghana, for
instance, that shows when we take an approach that involves
both making--strengthening local retail shops in villages to be
able to sell these nets at these prices along with targeted
subsidies and free nets, we're looking at the poorest of the
poor households and the wealthiest households, all vulnerable
to malaria, but all getting equal access and equal use of these
nets in their homes. So we're getting very equitable
distribution against a disease that is rampant in those
countries.
Senator Coburn. I want to see the data. Since you seem to
have a measurement on that, let's look at it.
Mr. Carroll. We have that measurement and in fact that has
been shared with panel members here.
Senator Coburn. One of the things that we will do--first of
all, thank you all for spending the time to come. Thank you,
Mr. Miller, for adjusting your schedule for us. I promise if we
have you here again we will make sure you are well advised in
advance in terms of your time requirement.
You will hear from the Subcommittee specific questions we
would like for you to answer. We'd like those answered on a
timely basis. This is the first hearing on this. I'm not
through with this. We're going to talk to the Global Fund.
We're going to find out what's happening. We're going to make
sure--I'm very pleased that Mr. Miller is going to avail the
Subcommittee of where the money is spent and how. I'm very
pleased that we're going to have a transparent ability to get
that over the Web. We'll talk about how fast that can be done.
I would hope that would be a priority because with the
information comes less criticism, not more. Part of the
criticism of the malaria program today is because the
information isn't available. So the assumption is that it's not
being done right when in fact it may be done right.
So I want to thank each of you. You will have a follow-up
letter from us. If we have not heard back from you--in other
words, we're not going to have a hearing and expect something
to come back, just like most hearings in Congress and then you
never hear anything about it. You're going to hear back again
from us. We're going to get the questions answered. And then if
we don't have the questions answered, we'll be back here
talking about it again.
Thank you all very much for being here. I thank you for
your work, each of you, and the staff at USAID. I know you're
committed to the same thing that everybody else in the room is,
and that's eradication of malaria in Africa. Thank you very
much.
The hearing is adjourned.
[Whereupon, at 12:45 p.m., the Subcommittee was adjourned.]
A P P E N D I X
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