old child survival the unfinished agenda to reduce global child mortality thank you for joining us for this very important hearing of the subcommittee on africa and global health on child survival the un finished a gender to reduce global child mortality you have with us a panel of experts which includes the distinguished former senate senate majority leader bill fris i will begin with an opening statement and will introduce each of the witnesses before each of the panels every day twenty seven thousand children on the age of five die mostly from venable disease and conditions actors such as malnutrition and save drinking water and inadequate access to vaccines contribute greatly to global child mortality we know we know how to prevent most of these deaths but we have not spent the resources necessary to do so as no surprise that most of these are children born into the developing were all those who are dying nor that half of these children are in africa in two thousand the united nations adopted a millennium development goals m d g's and called on member  states throughout the world to provide the necessary resources to reach key targets by two thousand and fifteen the fourth goal is to reduce child mortality by two thirds given the fact that malnutrition was by chronic hunger it causes the death of boredom five million children each year we cannot reach that goal without making strides in the first millennium development goal having extreme poverty and hunger this underscores the need for an integrated approach these millennium challenge goals united nations children's fund unicef recently released the state of the world's children two thousand and eight child survival which reports that annual decimo on children under five fell to nine point seven million a year first time that this number of fell under ten million cents we have been tracking the numbers from nineteen sixty the fact that nine point seven million children a dying each year of preventable diseases sends a clear message to all of us we absolutely must do more it's just that simple there is no excuse for children to be dying from preventable diseases these those figures represent human beings little children who deserve a shot at life just as children born here in the united states of america all little children are the same this is not to say that the work of countless individuals groups and governments are not making a difference on the contrary efforts are critical and have made serious inroads in reducing child mortality yet there are some countries such as sara lee own which has the highest child and maternal t morality rates mortality rates in the world one in every four children will not live to see their first birthday that's that's  unbelievable this means that we must increase our investments in lifesaving programmes if there is any good news to report on child so viable it is that according to the world health organization two thirds preventable as i mentioned before moreover they can be prevented with a very small investment and that's even better news today we are joined by congresswoman betty mccollum of minnesota and congressman chris shays of connecticut because of their leadership on child survival in may of two thousand and seven they introduced h r two to six six the united states commitment to global child survival act of two thousand and seven which i am a proud co sponsor which directs the presidents of develop a comprehensive strategy to reduce child mortality in established the inter force on child survival and maternal health in developing countries the bill also called the rises up to six six hundred million ending at one point six billion by two thousand and twelve to save lives of children around the world the significant commitment of the united states in reducing child mortality in the developing world contributes to a fifty percent reduction in the mortality of children under three hundred fifty to four hundred fifty million in f y o nine the budget administration has requested three hundred sixty nine point five million from child saliva maternal health programs some seventy seven million dollars less  then two thousand and eight levels which is not going in the right direction two weeks ago this committee voted for a bill which would provide fifty billion dollars in reauthorization for the president's emergency plan on aids relief pepfar and this once passed involve chambers will be a great victory for the president and for the congress and far will be remembered for years of calm as a cornerstone of president bush's africa legacy i mention that's him personally last week and we are hoping that we will be able to have the fifty billion real authorized it has created a tremendous amount of goodwill and of course have saved countless lives in africa i fully support and far and will continue to push for its approval at the same time we must take into account that according to the coalition for children and child survival more than ninety percent of child deaths are caused by preventable treatable diseases and conditions other than h i v an aids and malaria so as we ramp up pepfar we mus also increase funding for programs to address the basic health needs of children and pregnant mothers such as immunization nutrition assistance and treatment for diarrhea and other infections we can save children's lives we can prevent nearly ten million child deaths that will occur unnecessarily this year we must begin by providing six hundred million for child so violent and fly and increase our commitment each year as called for in the supportive in all of our issues mr smith from new jersey thanks very much mr chairman and i thank you very much for calling this important hearing on child survival and the related issue of maternal health stearman as we know reducing child and maternal mortality in providing quality health care and nutrition to ensure the wellbeing of both mother and baby has been one of my top legislative priorities throughout my tenure here in congress is early one nine hundred eighty five i sponsored the child survival legislation that led to providing fifty million dollars for what we then called the child survival fund members might recall that david stockman who was then the o m b director on the ronald reagan had zeroed out a new program that had begun just one year before sponsored by gus he had turned in tony hall at twenty five million dollars and when that happened we were able to not just say no way we doubled it and i offered the admin to make fifty million dollars it put a very heavy emphasis on oral  rehydration therapy breast feeding growth monitoring and of course on immunizations in one thousand nine hundred ninety legislation and proposed amendments that led to additional increased appropriations of two hundred and forty five million specifically for child survival activities and health plus ten percent for sub saharan africa with a special emphasis on maternal and child health in the one nine hundred ninety s chairman sonny callahan did yeoman's work and boosted the child survival fund even further and he  deserves an enormous amount of credit for his leadership as well saving the lives of children is an issue that unites and can even stop wars as we saw during the conflict in el salvador i'll never forget jim grant and meeting with and hundreds of thousands of kids some put it as high as two hundred thousand were vaccinated against the five leading killers of children i went down with jim grant for that vaccination day experienced it first hand went to several vaccination sites so how the church where many of the venues where the boy scouts and the whole mobilization of volunteers the only shots heard that day were those immunization shots going into the cans of the children and it was it was a remarkable day and it was followed up by several other days and then it was central america and so many kids were saved from these preventable diseases there is a universal recognition that children are our nation's most precious citizens most vulnerable most at risk citizens and they demand every protection and safeguard society can provide and is laid in state of the world's children unicef's cites several important reasons why investing in the health of children is important besides the primary and most obvious reason to want to spare every child and his or her family unnecessary pain and suffering there are societal considerations as well the child who lacks basic health care and adequate nutrients is less likely to survive to have a more disease have more disease and illness and be unable to develop thinking language emotional and social skills such a child is less likely to succeed in school and become a creative and productive member of his or her community but too many children lack not only what is necessary for them to thrive life but even what is necessary to survive in the first place although unicef report cites significant decreases in the numbers of neonatal and under five mortality rates between one thousand and two thousand the extremely high numbers of avoidable dowson still occurring give no reason to celebrate this outcome the latest evidence indicates that some four million babies die each year during the neonatal period and then half of these infants die within their first twenty four hours after birth the baby is about five hundred times more likely to die in the first day after birth during the first months when our address newborn death even further and to ensure the healthy development of the baby through adolescence and the long term health of the mother the baby and the mother must be provided adequate nutrition and health care from the earliest stages of life prior to birth birth is not the start of life it is an event that happens in the baby's existence and as part of a continuum from the moment of conception we need to recognize this biological fact in terms of policy funding and programming and treat both mother and unborn baby as two patients survival and wellbeing are mutually interdependent this would significantly increase the baby's chances of survival following birth and also reduce the risk of maternal mortality and morbidity child survival revolution in my opinion must recognize embrace protect and tangibly assist unborn children from all threats including disease trauma and abortion abortion is the antithesis of child survival and is violence against unborn children more children die from abortion whether it be legal or illegal than from any other cause dismembering an unborn child with sharp knives pulverizing a child with powerful suction machines or devices chemically poisoning of a bee with any number of toxic chemicals is child abuse matter how many euphemisms are employed to sanitize this child violence  any consistent definition of child survival must include the vulnerable child i am placed to know that unicef recognizes that unborn children require care and nurturing stating that quote significant improvement in the early period will depend on essential interventions for mother and babies before during and immediately after birth into the latest estimates for two thousand to two thousand and six at present in the developing world one quarter of pregnant women do not receive even a single visit from a skilled personnel doctor nurse or midwife and only fifty nine percent of births take place with the assistance of a skilled attendance and just over half take place in a health facility and yet for the unborn child it cannot be received and yet care for the unborn child cannot be restricted to medical consultations as important as they are for example and its child survival series the lancet identified fetal malnutrition and low maternal body mass index as likely factors in neonatal mortality rates and fetal growth retardation just as under nutrition is the underlying cause of a substantial percentage of all child deaths so the mother's  ritional status as a direct bearing on the unborn child's development and ability to survive and develop normally following birth the lancet stated that in all countries all countries need sound logical information to prioritize plan and implement public health interventions it added that neonatal deaths have only recently been identified as a global priority and concluded there was an urgent need for further research in this area i would strongly suggest that such epidemiology will information and research must be extended to the development needs of the unborn child addressed in conjunction with the needs of the mother in order to determine how prenatal care can be expanded and improved upon the care for both mother and baby prior to birth united nations convention on the rights of the child in its preamble recognizes and i quote the child by reason of his physical and mental immaturity needs special safeguards in care including appropriate legal protection before as well as after birth the global child survival bills have been introduced in the house and senate must provide significantly greater protection and have greater impact if they are expressly include this right in relation to health care legislation already references the lancet and its finding that maternal health is an important determinant in neonatal survival of maternal death increasing the death rate for newborns to as high as one hundred percent  countries the purposes of the legislation should be expanded to include assistance i'm going to reduce mortality and improve the health of newborns children and mothers but that of unborn children as well the child survival revolution isn't factors such as malnutrition and safe drinking water and adequate access to vaccines contribute greatly to cobol char all mortality chairman we know how to prevent most of these tests and so we need to spin the necessary resources to do just that we need to coordinate aggressive accountable systems to address this global tragedy global child survival act of two thousand and seven is about legislation which strengthens the united states government's role in saving the lives of children and mothers in four countries this act will continue as a us leadership in developing an integrated strategy for supporting the improvement and coordinating activities directed towards achieving child and maternal  health goals the us government naturally needs to be cautious with its development policy because it is entrusted with the wise stewardship of taxpayers dollars however if we were able to find new creative strategies to save children import countries we need to be import countries we need to sometimes be tolerant what policies and systems can  put in place to encourage our foreign policy professionals particularly our development professionals to innovate this chairman this hearing is essentially important because we're going to hear  the people on the ground responsible so we need to be able to measure the results of our development so that we can ensure that all the calls are met and lived to say so thank you so much thank you very much  cold sponsors of the legislation mr shays from connecticut chairman could you to purr to the sponsor chief sponsor and also i think a member of the committee well we will you know we were doing democrat republican issue and so it's an honor to have mr shays as a co author chairman payne i want to thank you once again for inviting me to join the subcommittee on africa for this important hearing and for all the great work you do it's wonderful to be here with all  today's hearings about children about newborns intense toddlers it's about whole opportunity arbil it is a caring nation how moms and dads in the world's poorest countries keep their children alive united states have been a global leader in child survival for decades and i commend usa id for its remarkable record investments and basic interventions like antibiotics are already hydration solution and initiations micronutrients basic nutrition health education maternal health have resulted in millions of children being alive today many of us here today are parents and we know every one of our children is precious for parents in liberia afghanistan haiti or yemen their child's life is just as precious to them as well and they're in need of our health because many of their children are dying i'm very proud to be the sponsor of a charge twenty two sixty six the united states commitment to the global child survival act chairman payne thank you for being an original co sponsor i think the other co sponsors here today shays and watson and other subcommittee members jackson lee wellesley and miller and i would respectfully ask the other members of the subcommittee to seriously look at cause spon us legislation the call of a charge twenty two sixty six is not complicated it increases the u s investment child survival and directs the presidential palace a comprehensive strategy to reduce mortality and put the health of newborn children and mothers in developing countries h r twenty two sixty six if it becomes law will save hundreds of thousands of newborn infants and toddlers it will save their lives because they will not die from preventable diseases and diseases that are easily treatable congress's commitment to invest in pepfar and the president's malaria and tb initiatives is making a significant global health impact on killer diseases but we must have balance we must have a balanced approach to global health balance in my opinion is not minimizing or neglecting our investments in the lives of children and their mothers and poor countries because they are not dying of aids hiv aids hiv and aids and they are not is hiv positive last year around the world two point five million children died of aids diarrhea long killed almost two million children last year is about six cents to treat and cure a child with diarrhea in total ten million children under the age of five died last year as many of them as two thirds was deaf that were totally preventable eighty percent of us has global health investment is for age hiv aids disinvestments important but it does not reflect the global disease burden or the metallic the rates import countries for example let me dr twelve million south nigerian children under the age of five will report it yet in two thousand and nine proposed united states in its proposals will send twelve times more the resources  every four years if this congress invests in child survival parents will watch their children grow and they will know that the us is a caring partner in their child's development if we do not allow th child survival budget to be cut in half as has been proposed in two thousand and nine then we can be assured more children without needlessly turman pain thank you for your commitment to all children around the world and especially to the children on the african continent i look forward to working closely with you in the foreign affairs committee on the markup of a charge twenty two sixty six the senate foreign relations committee has marked up the companion legislation so we have a real opportunity to move this legislation forward and put it on president bush's staff in the year two thousand and eight it is shameful that millions of children are dying needlessly let us all work together here in congress and with moms and dads around the world to make sure that those lives are saved thank you again mr participate in this hearing this legislation is why one of the main reasons why i wanted to serve in congress it's so sensible it's so logical and it will mean so much to so many a s a former peace corps volunteer i can speak to the benefit of a program that cares about children that spends a minimal amount of dollars to save literally hundreds and hundreds of thousands of lives if not millions and i am just grateful that you're moving forward with this legislation you all have talked about this it is takes i'll just align myself with the comments made i hope that this legislation will not be viewed as an issue dealing with abortion or not there's nothing in this legislation that would be promoting abortion and so i hope that that is not the issue what i hope is the issue is that we can spend six cents to save a life dying of diarrhea or pneumonia or malaria or measles and that we would have the good sense to do that i want to particularly thank the one campaign for what it is doing and i was up in new hampshire during the elections and there was one somewhere in that audience and there certainly was in the john mccain events that i went to and you helped educate a lot of people about this legislation so i want to thank  grassroots effort i want to thank u s coalition for child survival and i want to particularly thank save the children that is in our district the fourth district rather than the district i am grateful to represent it's an amazing organization care mercy corps catholic with the service i r i and so many others there there are literally literally hundreds of non government organizations that frankly are accomplishing a lot more than we in congress are accomplishing and i just say i'm for this effort so for me this is a real special privilege to be able to listen to our witnesses and thank the former majority leader for his effort to bring attention to this issue and all our panelists thank you have as our witness dr kent hill dr ken hill was sworn in on november the second as the two thousand and five as assistant and minister a tip for the bureau for global health s agency for international development the hill had served as acting it minister assistant administrator from january twenty one two thousand and five until his confirmation by the  october seventh usa id is the government agency that administers economic and humanitarian assistance around the world from november two thousand and one to october two thousand and five mr hill served as assistant administrator for the bureau for europe in your asia and usa id as assistant administrator for the bureau for global health still is responsible for a year old that in fiscal year old six managed or called managed health programs all over the world with funding of more than one point eight billion dollars estimated to be over two billion in fiscal year two thousand and seven the  influenza other infectious diseases such as the burglar malaria maternal and child health family planning environmental health and nutrition thank you for your service and your commitment and we look forward to hearing your testimony thank you chairman payne congressman smith other distinguished members of the committee i want to thank you very much for convening this important hearing and let me just and thank you from usa id all of the members of the congress who've been so gracious and supporting of our work including our work in child survival maternal health programs and we came here to witness to you but i believe i could to play a leadership role in an international child survival effort that has yielded some of the greatest improvements in global health ever seen and this would not have been possible apart from your health now let me put this in perspective because the revolution really began in the early one nine hundred eighty s when usaid and unicef launched the child survival revolution with the support of congress and at that point an estimated fifteen million children in the developing world were dying every single year and had there been no action in the early one nine hundred eighty s the number of deaths today we estimate would be about seventeen million a year and of course with a larger population that's part of the answer instead as you yourself  results of the global survival efforts by the united states and by there's throughout the world by two thousand and six the estimated number of child deaths in the world is not seventeen million but it's fallen below ten million to nine point seven million something about the way this revolution has unfolded has worked and worked very well and i don't want to dwell there very long but it's particularly tragic about the remaining deaths is that most are preventable two thirds are preventable every year three point million newborns fail to survive even the first month of life each year half a million mothers lose their lives in the process of giving birth millions more suffer complications that produce lifelong disability because the survival and health of young children especially newborn starts with the health of their mothers and the care of those mothers received during pregnancy and childbirth usaid integrates our programming to the fullest extent possible and approach which increases the affordability and sustainability of our global efforts to tackle those important public health challenges most of our missions for example already support integrated maternal and child health and family planning and malaria programs all together this helps to build broad based health systems yet there is an urgent unmet need to improve the survival and wellbeing of mothers newborns and children usas continuing role in this effort focus on three key elements to address this unmet need first we support research to develop i am packed low cost interventions such as ways to manage the birth weight babies and to prevent and treat life threatening infections of newborn second support programs that deliver lights a life saving high impact cost effective intervention such as immunizations vitamin a treatment of child illness and essential newborn keir and third we help countries build the essential elements of health systems and human capacity they will need to sustain progress and i don't want to just talk in generalities i want to be very specific about what we do and why it makes a difference to start with bolivia as a government implemented a national health insurance system that covered maternity services usa trained health care providers in obstetric care and promoted culturally appropriate birth practices and quality twenty four hour a day care of women and the results are as follows from  thousand and four maternal mortality dropped by forty five percent in bolivia or take the example of ethiopia here we are supporting the government and extending access to basic maternal and child health care through scaling up a program that links female community health volunteers with the health system to bring vitamin a immunization and the treatment of child illness to villages that in the past had no health care at all result this program now reaches more than half the population of the paul nepal has recorded decline in under five mortality of forty one percent since one thousand nine hundred eighty let's take a look at af taliban fell in two thousand and one afghanistan registered some of the most arithmetic else statistics in the world they are one and every four children in afghanistan and scan died before their first earth day and one in six of every mother giving birth died in that childbirth usa and its partners started immediately with measles immunizations and then set up in place abroad grand provided a basic package of health services to mothers and children in rural afghanistan i've visited those places i've seen places we were there to open a health care clinic an afghan militia were killed trying to protect a health clinic we had just opened because they didn't want to see the success of the program the program also paid attention to rebuilding key elements of the health system including management drug supply and training as a result of this sense then under harsh and insecure conditions skilled attendance at birth and afghanistan has tripled and under five mortality has been reduced by twenty six percent saving the lives of eighty thousand children per year we are waiting for the results now and what it means that we've tripled the  attendance at birth of skilled attendance but we believe it's going to show a similar decline in maternal mortality written testimony by the way has other examples and those of you who really care about this i think you'll find them there including ones in indonesia these countries demonstrate that it is possible to make a real make real progress despite continuing property instability and even conflict as shown in the display chart this progress also  occurring more broadly and usaid is says that countries in the world and i want to mention these charts and i'm sorry you can't see them but you've got the charts in the materials that you were given but the audience doesn't have them this one here which shows the percent declines and under five five percent in cambodia going down through allow in the fall and then the nisha and it varies between fifty percent and twenty percent averaging about thirty three percent between the years one thousand nine hundred two thousand and six that is a decline countries that are on that chart show that thirty three percent decline i'm going to insert something here before i talk about this chart i want to put this in perspective for us we talk about things coming down but we don't often make the comparison we ought to make between what it's like to be lucky enough to live in the industrialized world and what it's not so lucky to be living someplace else in the developing world let's start with maternal mortality maternal mortality ratio if you're lucky enough to be in the developed regions of the world of every hundred thousand live births nine mothers will die in the united states it would be eleven mothers would die out of a hundred thousand births the average  under five mortality rate what's it like if you live in the united states it would be out of every thousand die before their fifth birthday or in most industrialized countries an average of six what is it in the rest of the world well over ten times that big seventy nine out of every one thousand die in the developing countries that's what these charts are talking about if you look at this chart you can see that the lines are going down and it shows you that maternal mortality in those  countries is going down steadily over a period of years we find it more difficult to bring the lines down here we need to do more more focused work to get that done but in those ten countries even there and of those usaid assisted countries had a decline of thirty two percent this progress is the result of usaid working hand in hand with many partners and mine with commitment and leadership by countries themselves much much much manes to be done  norway and we're seeing increased attention to reaching the millennium development goals first filed survival and maternal health and trees like india are substantially increasing their own investments in maternal and child he these new developments and resources provide an important opportunity for the united states to help reach more children through leveraging non usaid resources and co investments by usaid we have a recognized leadership role in the global child survival a maternal health ever usaid is unique among international partners in child survival maternal health let me tell you why we have the technical expertise to support groundbreaking research and to guide development of solid evidence based program we have the missions on the ground that can adapt this evidence to each country situation and coordinate our support with other donors and with other governments strategies and we have the strength of our partnership with n g o s with faith based and others civil society with the private sector both the international and the country levels and now with the support of congress we have additional resources to apply these strengths i am pleased to share with you how we intend to maximize the use of any funds that can be appropriated after they are authorized we plan to focus the major share of these resource in approximately thirty u s assistant countries that represent the percent of the maternal and child deaths worldwide interventions are relevant each country will strengthen the health systems and human capacity to link the water and sanitation investments to and chill improve children's self complement u s g donor another house host country resources and in difficult settings most conflicts settings like liberia for the democratic republic of congo or southern sudan will extend basic services as quickly as possible while rebuilding the foundations of the health system so what is actually going to me what have you made the comment we have to be accountable what's the goal and are we going to be able to reach it one hundred thirteen believe we can aim to achieve at least an average twenty five per cent reduction in maternal and under mortality in those thirty priority countries as well as a average fifteen percent reduction of child malnutrition and at least ten of those countries that the same time you recognise the critical human resource constraints on in progress or its progress in many countries therefore as part of the plan we are making a commitment to increase by at least one hundred thousand the number of trained equipped and supervise community health workers and maternal and child health share your commitment to make a difference and i want to end with some words that i learned long ago when i was in college i remember reading the works of albert can move and although albert can move is often depressing writer and i knowledge that i think i was quite depressed in college myself but one of the phrases that he used that i've never forgotten i used in a speech is there is sense in it to paraphrase albert to move here he said perhaps we can do nothing about living in a world where the children suffer we can lessen the number do you very much thank you very much for that very comprehensive testimony i understand you have to leave i  wonder if you have how soon would you have known i can take a few questions i'm headed to lansing to give a speech but well let me just ask one quick question and then we'll see if we can get each person i've got a  question on the there and this year there's been a request in the budget for three hundred sixty nine point five million seventy seven million or less than two thousand and eight we've fluctuated between three fifty and four fifty throughout the years and i just wonder if you have any rationale why the president requested a decrease in the funding of these programs it's important question and i went through in two ways when i think the most delicate and difficult process for all the bureaucrats who are responsible for trying to make something happen is what happens with o m b and the administration and eventually with congress about how you divide up whatever pot of money you think you dare ask for any given year and there are a lot of competing priorities and there are some major concerns about  priorities overall in the budget and even priorities within the health budget personally i wish the number could have been higher i suppose most of my colleagues and other who represent other programs would say the same thing and were never  completely satisfied with the ask i would point out one thing that is often missed in the discussions if you look just at the accounts within the child survival health that has to do child a maternal health your right to point out that he goes down but it would be a mistake to believe that the only parts of the budget that affect a child and maternal health are in that account since about a million die every year of malaria and the president's goal in the president's malaria initiative is to have eighty five percent coverage and then have a fifty percent mortality reduction success and the huge ramp up of the president's malaria initiative when i came to work at the global health bureau we were going to spend thirty five million dollars that first two on the president's malaria initiative has up to over three hundred million this year that we couldn't touch most of those deaths now we have the opportunity to make a big difference is child in maternal health working on congress in a bipartisan way became so exercised to try to do the most they could why they've increased the amount from thirty to fifty billion in the present draft is because they are so afraid of what will happen if the  expands dramatically the impact in terms of children in terms of orphans in terms of the deaths of children and mothers the vulnerability of mothers all sorts of things if there is their immune system is is impacted that means that if pepfar succeeds the impact on children and mothers will be dramatic don't just look at the number that has to do with child maternal health was in the budget  by lots of other things as well recently on his trip to africa the president announced a new initiative a three hundred fifty million dollars collected and drop these is over five years this will have a huge impact on children and mothers are a whole village in africa where everybody is blind the burden on society the suffering of children all of these things are impacted so i would be less than honest if i didn't tell you i'd like to see that account higher than it is and i hope that the authorisation dreams of this legislation will be filled in subsequent years and whether i mean government or out of government i will support that i hope the appropriations can go up significantly because this is one area we're talking about low hanging fruit always concerned that there would be falloff after a heightened focus and secondly very important and i referenced this in my opening comments the unborn child as patients you know low birth weight babies did not get that way while there traversing the birth canal obviously that all happened prenatally more needs to be done and we need to get rid of this myth that somehow an unborn child is not human and alive sound has shattered that myth hopefully forever  so what can we do should we be doing definition wise to include so that no child is left behind including the unborn child and child survival programs i think you're very right to point out that all of the global experts in health say what happens in terms of the health of both the mother in the child is what happens in the nine months before the child is born and there's just no question about it if there wasn't agreement on that we wouldn't be doing all the programs we do that have to do with  cetera so the empirical evidence is we understand that something's going on in the moon that is tremendously important and if it doesn't develop right it's going to cause a lot of suffering later on so your point that to draw a red line between birth and the three months before or even before that i think is on is on target in terms of of the logic of that we do our best in antenatal care to deal and help the mothers and the children to be and so i think you're right we that's part of what we're trying to do in terms of child's survival and maternal health is to make sure that all goes well from the time of conception right up to birth laughter you know i have never been told that i could say one thing or another on that so i'm going to take the liberty of saying this is an author as i piece of legislation which is i understand it says this is the kind of ceiling we think the need is this great and to the extent congress is an administration is can find the money to do it it makes all the sense in the world and i'm going to cut you off right there i think the answer is yes thank you child for death actually in ethiopia whereas in jordan it's thirty five hundred dollars in other words ethiopia where three hundred eighty nine thousand children die under five administration asked for a point one million but in jordan where four thousand under five there's a fourteen million so you have to have a disproportionate how is that criteria figured out well there are factors involved in dispersing development funds that are not entirely lady just to help that's certainly been the case from the very beginning and it does turn out sometimes that large sums of money have gone to countries that have been more developed in one sense seem to be less and then to some countries it was a very large population and sometimes that is because we wanted to have to encourage a strategic relationship with the country and we've done it through some of our development programs we've done this with israel we've done it with egypt we've done it with jordan we've done it with other countries in the world will probably continue to do it the good news about the topic we're dealing with today is such a wide bipartisan consensus in places like nigeria or ethiopia or the big countries bangladesh when the most densely populated in the world i don't know people who are willing to stand up and say if we couldn't find more money to do this we should we have a moral obligation and i would argue that it's in our pragmatic best interest to expand our work in those areas i know that there's a lot of work that needs to be done but i notice that in number of programs for example the water for the poor program which is supposed to go to the places that need water programs the most we find the same thing that jordan and iraq and other other seem like there's some other ration out it's going into i mean if we have to fund programs over there maybe we need to put it in the sense the partment but if you have a program like water for the poor or you think that the countries  that need like knives year directly out of water chad they're not even in the program but it's afghanistan it's iraq it's it's jordan and so they need it too but we were really short changing those places that need it the greatest i'm going to miss the vote so i'm for sale and i have to leave and i know you have to go i might have missed the vote already i might as well just stay but but anyway we  w there's a second vote maybe i'll make that one that but the meeting stands and adjourned for recess until we come back in about ten minutes hopefully the honorable william frist will be our first witness on this panel now and to do so each of the panelists and then we will start with senator frist currently serves as a visiting professor of international economic policy at princeton university's woodrow wilson school of public and international affairs where he teaches graduate and undergraduate courses in health related care  economics and policy senator frist represented tennessee in the u s senate from one thousand nine hundred five until his retirement in two thousand and seven serving as majority leader from two thousand and eight he rose to the majority leader just eight years after his election having served less time in the congress then anyone ever to hold the leadership position on that level sen frist who strongly advocates executive level involvement in charitable and community causes currently serves on numerous prestigious boards among them our africana center for strategic and international studies the holocaust museum committee on conscious the clinton global initiative is global health working group save the children u s global leadership campaign advisory committee we have traveled as the associate vice president for health at save the children usa in that capacity is responsible for managing a diverse portfolio of maternal newborn child and adolescent health activities and oversees the delivery of technical support and assistance to over forty countries worldwide david began his career as a peace corps volunteer in india in the mid sixt r currently chairs the steering committee of the u s coalition for child so vital and is a member of the international health section counsel of the american public health association is a graduate of a graduate degree in health from the university of michigan and i think you join your former peace corps volunteer well if you go if you go by the hair line dr and the media finance longtime public health physician whose career has spanned the globe from teaching doctors enroll african villages to the decision tables of washington d c for almost six years in sub saharan africa kenya and zimbabwe she focused her expertise community development public health training and aids prevention dr peterson consulted for the centers for disease control and prevention and the world health organization in haiti and brazil and served for three years as the health commissioner for the state of virginia prior to joining world  vision petersen was assistant administrator for the buell of global health at usa id she led us governments into national health policies and represent that the u s on board such as the global fund to fight tuberculosis to fight aids rather tuberculosis malaria j v i stopped tb and the child survival partnership currently she is director of the center for global health within world vision's new drat currently serves as the ing of the future generations graduate school and applied community change and conservation in this capacity guides the development of practical instructional programs and curricul creates training programs that meets the needs of multiple communities overseas student practicum and teaches and mentors research design and methods is had over twenty years of international public health and management experience and leadership born in cameroon west africa has worked for the past ten years in the united states and worked as planned international senior child survival and health programs specialist in this capacity he has provided technical management training in the form of program designed management implementation monitoring and evaluation in the technical areas of child survival maternal and child health reproductive health h i mean a tuberculosis and tropical disease control in over thirty developing countries not the wily dr robert wiley was educated poland in and london england and qualified in medicine at london university in nine hundred sixty three his residency training was in london and at the university of toronto as first hand experience and west africa beginning in one thousand nine hundred one prompted him to initiate the formation of them outside care international in one nine hundred ninety five this non governmental organization is interdisciplinary and it made up of initiatives of service training research and advocacy based on the ethic that all mothers and babies matter not to while he has developed new approaches to the delivery of maternal health care and nigeria and g presently involved in developing similar projects and sierra leone rwanda and canyon dr weil he was asked to conduct a maternal needs assessment of refugees in albania during the kosovo crisis and east timor following withdrawal of occupying forces there thank you all for being here and we'll start with senator frist thank you mr chairman mr smith since we've been here today about two thousand children have died over the last hour or so and i think the remarkable thing about that and really goes right to the heart of why we're here today is  about fifteen hundred of those kids who an hour ago were alive could be alive today by taking actions that we in some way celebrate today because we all know it's the right thing to do but it's also really going to take action to do that very different than when i was doing heart transplant answered treating people individuals one on one for cancer to do it is cheap cheap inexpensive is proven it's been previously demonstrated and the techniques in the tools are readily available you can't really say that about any other real piece of legislation that we've had to deal with as a colleague when i was a quality old or really probably before you as legislators today miss some remarkable things putting those two facts together speaking from the heart i spent twenty years in medicine healing or doing my best to heal one on one and going back to that individual li that that all of this comes back to and then came to washington it's been twelve years the united states senate and ultimately as leader of that body and then left and the fact that i'm here today really from my public public slash private a vent demonstrates to you that based on my observations of twenty years of healing directly one on one and then twelve years and united states senate trying to do it all of you are really all about today and that is healing smack at this hearing back at this legislation back on this particular issue and i think in the first in the first doctor he'll not really mention today there's nothing else it's quite like this and that's really my observation that's why i'm here i appreciate mr chairman and all of you the invitation to be here and just share my my quick my quick thoughts i do come before you today as chairman of the survive to five campaign as a product of initiative with save the children who've just like we've traveled to africa together that i've had the opportunity to travel to africa to bangladesh looking very directly through the eyes of someone as a physician as apollo so you make what can be done and i concluded that through this legislation that is bipartisan pull together that we can have a huge impact in reversing this course of  humanity as oneness of humanity the goal of ours survive to five is basically what it says and that is to increase the survival where we know that we have now about ten million deaths about twenty seven thousand children die every day increase that survival and doing that through these cheap inexpensive proven and demonstrated tools statistics clearly show that if you get through that first day where you have two million deaths every year and you get through that first month and you get through that milestone you're five years of age then the odds of really blossoming into a productive live a happy life of filling life the drain that we all invasion all of us who have children for our own children becomes a reality number one when when children die needlessly when we know we have these affective therapies that are cheap and inexpensive unproven and easily available it is clearly a moral imperative it is the right thing to do as individuals as communities as states and indeed as a nation and this is been a really gotten principle for our country throughout the great history the great history that we've all seen really an experiment  in democracy and it is it is this impulse that springs from our conscience and it's one that represents the highest ideals of what being a person is all about clearly what that american flag represents what being an american is all about secondly scaling up our child programs the survival programs and leading other nations to follow with what we do practically but also what we represent with with with this voice also serves our national security interest and and i mention that's not the reason for doing it but as chairman payne said i had the opportunity as majority leader of the united states senator of going just about every year somewhere in the developing world in very quietly working on the ground doing medical procedures treating young children older people and i've seen the trust that is engendered by that mere presence in the war torn zone whether is in southern sudan in northern uganda if you're of working in your view your healing and your delivering lie in helping facilitate life there's a trust it's built up that all of a sudden fighting stops built on that trust and i call it a currency for peace you could call it any number of things but it is what we have as an opportunity both before us in addition to that moral imperative the despair that comes when people die very early in the maternal deaths or in that first day of life or that first months in the first five years it breeds despair and now their despair we know that is that the potential for terrorism and come put that out there because others probably won't talk about but i do think it's important just based on my own experience not eleven commission concluded when people lose hope when societies break down which countries fragment the breeding grounds for terrorism or created diplomacy undermines that ideological support of terror by shining a light of trust chart today where there's been huge progress with a twenty five to thirty percent improvement in child mortality i had the opportunity to work side by side with other community health workers and with some of the doctors doing the very simple things that we know make such a profound impact met with the ministry of health their food offered country's profound thanks to the united states of america for assisting in reducing child mortality a true success story as we saw many success as we work side by side n g o s working with our government and most importantly with the local communities to help deliver both this care that established this prevention a recent pew global attitudes survey shows that bangladeshis have one of the most and i remove views of the united states in the entire muslim world and this support is due largely to the assistance we've provided bangladesh since its independence relatively tiny relatively modest investment that continues to pay huge dividends by submitting a link with this moderate muslim nation and building a bomb between its citizens and americans as someone who has served in congress and wrestled with the whole broad range of policy issues that that you are  every day and all these global health issues same daunting but as americans who are generous people we're a compassionate people and now is the time that we can demonstrate that in ways that we absolutely know we know will work i think it is a credit to as we heard a little bit earlier to this administration to this congress and the american people that the u s has made huge efforts and tackling a chevy aids and malaria and tuberculosis and i like all of you have participated aggressively in that regard and appreciate the contributions of this committee in that regard yet as much as we've done we still have ten million kids twenty seven twenty eight thousand a day dying two thousand dying since we started this hearing all of which underscores that yes the commitment that we've made thus far with pepfar and with the initiatives that were non existent five six seven years ago we still have tough tough battles ahead of us what's claiming these young lives there are two charts that we deaths are due to we see pneumonia we see diarrhea we see the other newborn complications that are related to sub optimal pretty metal care care during pregnancy delivery care and postnatal care we see that malnutrition is an underlying condition contributing to more than one third of these deaths what is interesting and i think that's what he's important at least as a policy maker people will say well you're committing so much to pepfar you're committing so much to  and so much similar in all the things we've been fighting for you how can you justify this is competitive in many ways well i think these charts show part of that if you look at the cause of death in there you see that malaria was about eight percent of these two thousand deaths over the last hour and hiv aids caused three percent of the deaths we need to focus and continue to focus and and they have done that in this in this very hearing room i guess a couple of weeks ago look at where the other eighty eight percent of people are dying i mentioned that things are simple they're an expensive they're readily available and i think of things just like the little vitamin a they had literally just one of these little capsule you just cut it open or put a needle and then you know square in the mouth twice a year in certain areas can reduce mortality by twenty percent if you if you little and all of us know in buying the days this just happens to be what they use in terms of oral rehydration physiologic standpoint whether it's infection or whether it's dirty water out there died the hydrating diarrhea causes cardiovascular collapse in the heart just simply doesn't meet anymore and this is lifesaving again for fifteen cents can be life saving for a child today antibiotics you know dad didn't have any bodies when he was practicing medicine one hundred forty five we got him we take him for granted today but antibiotics which can cost again less than a dollar becomes life saving these interventions you can go on down the list immunizations which again we talked about the sustainability is so important for sixteen seventeen dollars clearly life saving and so it really becomes a matter of stepping up leading to the world and making sure the distribution of these inexpensive little little little tools that we have in our tool box are our applied little things like a big cat up all over the united states of america to make those the simple things the u s commitment to global child survival act which has been introduced by representatives of mccollum and she's with us today and over on the senate side chris dodd and gordon smith will advance this cause we've talked about it being bipartisan legislation strongly supported survey last fall by the u s coalition for child survival show that ninety three percent of all americans believe saving the seven thousand children who die every day should be our or your but our responsibility is a government responsibility we mentioned the one campaign earlier in the tremendous leadership of the one campaign and really other grassroots organizations more than two point four million americans seeking to raise awareness of extreme poverty and global disease so there's one campaign that's symbolized by the band that i have on that you'll see all of the presidential candidates wearing a wearing at some time i look at these letters before me and this stack of obviously is just a sampling of them but over two hundred and letters just like these have been sent by one members two hundred thousand to you you may not have seen them all but they're in your offices and and without one of the top three bullet points that they bring up to us because we are leaders on the malaria and tuberculosis their leaders know that they've got to respond so the m pact of us once again leading in this field where we know we can have an impact politically is important other countries are standing up we have countries such as norway who have undertaken major initiatives to reduce child mortality japanese government has also placed global health on july's g eight summit agenda which is a tremendous forum for addressing these issues both for the united states and for our g eight partners to play just that time in all out effort to accelerate the reduction of child mortality and to boost investment that will be required in order to distribute  make sure that these very simple tools are disseminated appropriately bolstering our action to save these ten million children is the moral thing to do under america's humanitarian ideals and this the smart thing for our nation long term security interest i look forward personally to working with all of you and to working with all of the hundreds of thousands of your abilities you across america in promoting our nation's leadership in fighting to save millions of young year of highly preventable causes largely unnoticed both here and abroad we are committed to educating and advocating for increased attention to this issue and specifically dedicated to mobilizing u s and global leadership and resources to save these lives our membership is diverse and made up of more than forty organizations it includes representatives of academic other technical institutions student  groups based and other non governmental organizations electively our members represent literally hundreds of years of experience working in developing countries delivering lifesaving maternal newborn and child health service i also like to say that our members represent grassroots american constituents who actually care deeply about this issue and how do we know they care and very interesting experience on the part of save the children when we literally at save the children had a vacated entire wing of our headquarters to receive the scab the heartfelt notes that were attached asking the president and our policy makers to do more to save newborn line so what did we learn first we programs work and i'll just reiterate a couple of points made dr hill had there been no change in under five mortality since  hundred seventeen million children would be dying instead that number is less than ten million per annum and i have to repeat sunday pollock's parents because based purely for decades of personal experience nearly twenty of which were spent living in asia and africa i've had a chance to see these programs firsthand and during the nine hundred ninety s early one nine hundred ninety s i lived and worked in a call when this program in fact expanded rapidly at that development goals for of a two thirds reduction and under five mortality what it is since one thousand nine hundred five mortality has declined by nearly fifty per cent by focusing on  package of proven low cost interventions delivered through local health facilities but even more importantly extends through community health workers and especially through a national  percent of children under five routinely receive vitamin a supplementation and children who previously had little or no access to treatment for pneumonia are seen and treated in or near their homes deliver a package of critical services for mothers newborns and children so it's not just about just about mothers it really is about mothers newborns and children and we need to extend these services beyond health centers to households and communities not succeed if we do not reach those households in communities where most of these tests occur in villages and homes are often far from any health facility lastly we need to focus more attention on newborns nearly forty percent of children under five occur in that first month of life and in india where i began my career as a peace recently it was thought there was really little that could be done about this from what we've learned working with local non governmental institutions in india save the children and our partners is  of newborn care delivered by community health workers and prevent as many as half of these deaths so clearly we know these programs work and more lives million more each year can be saved but as others have said business as usual will not save these we must do much more thanks to chairman payne and other co sponsors of the united states commitment to  global child survival act we have an unprecedented opportunity to provide the leadership and resources needed to make this happen the recognition that this is truly a partnership involving governments civil poised to deliver these lifesaving services to those most in need their donors has been mentioned canada norway the united kingdom are stepping up to the plate as our multilateral donors and especially in working to expand these programs that will take all of us working together to make this happen authorizes increasing funding to support the expansion of has an exemplary commitment to effective child and maternal health programs much more can be done there's no need for the ten million deaths that you've been hearing about this morning but i'd like to add that hundreds of millions of your children and mothers suffer on a regular and repeated basis and so we're talking about it's not just the death of women and children it is also the disease and women it harms that is caused by the exposure to disease united states can provide leadership to keep global promises to face the compassion of the american people and strengthens us relationships with other countries and most importantly does impact the lives of women and children like to highlight for critical areas first we could have far more impact by increasing our support to prevention activities and at the household and community level in rural villages in africa and pediatric boards i've seen the ongoing harm of malnutrition measles diarrhea and seen children dying needlessly until we suspect what i'm saying prevented we do not address the underlying causes that put children at risk and hospitals and clinics valving doorsteps implementing the proven cost effective interventions at the community level we can actually reduce occurrence of those diseases and deaths and promote a healthy environment where children can grow and lage their full potential that it's a whole health system include civil society and the community  itself community level focus isn't just to get improved outcomes empowers parents as congresswoman poem was talking about just put into the parents the power to keep their children healthy that's seligman the parents know what to do it also helps avoid missed opportunities across sectors and the synergy of working with food security and cultural and micro enterprise when we take those community perspectives and interventions and purposely link it with the public sector whether it's government or other faith based organizations or un agencies only then do we have a little health care system that addresses environment around the child all the way to the clinical care needed when they get sick third if we truly want to change the millennium development goals we need to focus attention on the forgotten children that senator first talked about those hardest to reach that are in the slums and the valleys elected tribes already divorced and we know that for every intervention and for every disease that before us there were those who are richer and that the gaps are getting wider between countries and within countries they have less access to preventive services and less access to care when the for access to care how can a child not only survive but thrive in such circumstances often the governments in these cases may not be able or want to care for those children and yet fake community based organization account for as much as thirty to seventy percent of all of health care and here in africa there are important components of health care delivery throughout the world networks are far reaching and lamentations those work and providing a crucial between government and civil society based and community based organizations to attribute to more sustainable solutions and help reduce dependence on foreign aid twenty five years ago i worked with a small mission organization and with a church in kenya doing community based health program thanks in part to a small usa i ran to twenty five thousand dollars i recently returned to church was not only continuing but had expanded the work with the rioting of funding sources and that new generations of children were still being cared for twenty years later that sustainable development americans do care about children other than the continued growth of child based organizations given that there are inexpensive prison solutions that partners ready to take action in the places most in need a reduction by two thirds of the child and mortality and turning around the maternal mortality problem these are important it was was the training of community has workers expanding these and mortality ratio was one thousand seven hundred hundred thousand live births illustrates the enormity of the situation some two hundred million women are pregnant worldwide each year most mothers live in villages without agony from obstructed labor and another after days in labor with a ruptured uterus and she was young and consequently her pelvis was too small others would arrive unconscious due to pregnancy induced hypertension ended but also the lives of their babies and then the aftermath the chances of survival of their younger children decreases dramatically resulting in the disintegration of their families sadly these deaths represent don't need the tip of the iceberg some cultural practices for example you see the cuts of female circumcision the result is because of damage to the bladder and rectum these mothers become incontinent of urine and feces consequently they are complete out health care has been discussed by the international community for years most recently as the millennium development goal number five to improve maternal mortality and morbidity by seventy five percent committed by the un and the be met for two hundred seventy five years that is twenty two eighty two and not twenty fifteen as intended the reasons are poverty lack of compassion lack of political and professional wills a conspiracy of silence and the lack of imagination the consensus of the obstruction called me on duty as mothers need to sensual prenatal care skilled attendance at all deliveries and specialist care for life threatening complications billions of dollars have been spent on so called reproductive health programs and more is demanded and a small fraction is focused on providing the services that ensures mothers and their babies survive pregnancy in my experience mothers in africa or  have babies as they know they are the future of their families communities and countries mothers in developing countries do not expect to die have to suffer both injuries and those who die obviously have no voice only hours to plead their causes for adequate care which mothers have access to in the united states of america and canada which is second to none but which is frankly frequently taken for granted not of care international was percent of the beds and we work with our local colleagues in addition to providing much of the health care in rural areas and african countries these faith based hospitals have for many years enjoyed the confidence and trust of mothers and their families  approach has been to put into practice the old obstetrical adage that live healthy mothers produce live healthy babies as a consequence and c r has developed a model of comprehensive rule of maternal health care based on local causes of mortality and the circumstances under  found usually in hospitals close to the mother it provides at a small thirty but mission hospital for prenatal care with the treatment for common medical conditions for example malaria h i v severe namely a with and specialist management of life threatening obstetrical complications example since an infection blood transfusion the hospital is linked by radio to an emergency transport which can go to the mother was life threatening complications with the equipment needed to and labors may run into complications so the radio and transport system is able to make these emergency needs this model was developed in nigeria in the early ninety's and is still functioning an out and done a ninety seven compared with the cost of hospitals and other countries funding proposals from some projects in sierra leone rwanda and kenya to government agencies have however been termed as any mother in the twenty first century should die having no baby or sustain the birth injury is an international disgrace this tragedy will only be sold one mother at a time when appropriate obstetrical care to which she has a fundamental you know we talked about the pepfar program before and i wonder if any of you could comment on how you feel that  there could be better coordination with pepfar if we can get a fund that the level that we're going to have that we're requesting to be appropriated how much of an impact could that have on the areas that that you are are interested in this child survival and i'd be happy to answer that question it's something that i struggled with a lot when i was at and part of the reason that i'm doing what i'm doing now is because i really felt like we had  survival one of the lessons we're learning in africa not just as pepfar goes forward but the global fund and other large amounts of money for focused singulair on a tb and malaria is that the resources and she has to addressing those very needy causes and i've worked in a since one thousand nine hundred two with my first aids patients in the year in one nine hundred eighty two i saw my second one in new york long island that same year so i've been back and forth what we're seeing is that the people and resources are shifting and in fact if you look at unicef report on a which is one of the exemplary countries for having dealt with hiv aids look at the under five mortality rate and it has doubled since nine hundred ninety eight we don't want to address hiv at the expense of children and what one could do is link your pepfar and aids funding and make sure that you focus resources on that need full area that the health resources that complement it and keep it intact health system  changing grow with the increases in aids in that way you won't have these hydraulic shifting the people and the resources away from one area to another yes i think one of the concerns i always have been dealing with international funding agencies is that they have funding comes to compartmentalize and they're not adaptable so i would be a soviet sees a very important part of prenatal immunization for children is very important to them but immunization of mothers is very important against that best and the problem is in the democratic way of doing things that's the way things are really only fun for this particular type of program we only from  i guess there really should be a call for a more holistic or comprehensive approach somehow to be able to integrate  the needs i mean what can the u s do now to ensure that maternal and child health programs and interventions are being linked and integrated and where do you think that pepfar needs to perhaps focus a bit more on that or do you think that the countries themselves many of them not having strong health departments i think one of ministries in countries to strengthen them which is certainly needed with the influx so i guess we might try to solicit suggestions from from you  funds could be better integrated yes i mean it seems to me that one of the opportunities is to more clearly single purpose but it is in fact to improve the lives and the survival of mothers newborns and children i think that can be done without diluting the impact in fact i think it's entity but it really is survival quality of life product to getting them up to this sort of age of five at least in the end in this community we know that that milestone people have that opportunity and i think that's important this integration the  bill that we referred to today of course talks about the importance of the strategic planning bringing people together in an integrated way the second point i'd like to make because the most common thing i hear we're spending so much money on a chevy aids malaria and tuberculosis and yes some of and if you do that you look for the problem is those ten worst countries where it's most challenging that only one of those is talking about that far it means that we need to refocus raise the visibility in an integrated way and doctor but a man who was able to bring disparate factions together time and time again for a very good outcome legislatively and policy wise and just a totally decent man so i'm going to see you again and you gave me a crash course on what a horrific preventable certainly a curable in terms of reconstruction surgery and then the attendant psychological counseling that goes along with someone who has been and when we did get it out of the senate we went right to dr can hill who was here earlier and he did almost dollar for dollar exactly what the house legislation would have done but it all came from dr weil and since then i've had visited fistula hospitals and repair centers all over africa including the famous one adice was greatly moved by the work that was done there and most recently a few weeks ago was in goma where women were getting fistula repairs as a result of sexual violence  your work honestly has been groundbreaking for africa and has spawned so much wonderful outcomes for women who otherwise have lost their lives have given their lives back i know we're going to break in a minute but i do have a africa and the fact that the lack of it greatly contributed to hemorrhaging of women during childbirth who then die because of it and joe rip suggested that upwards of forty to forty five percent  misuse of a horrific tragedy of maternal mortality she said what we want and you just said it is essential obstetrical services trained birth attendants midwives if there is an obstructed delivery to know exactly what to do and to and let me say parents ethically when abortion was being considered in the united states and i know there are a lot of strong advocates for child survival here and i believe in child survival for all the children there is not this artificial line of demarcation that says then lauren slater and betty friedan and founded that organization he ran the largest abortion clinic in new york did so i was testified all over the country he made up the number ten thousand women in america are dying from illegal abortions every year fred astaire and that got amplified by the media and by members of congress and senators and the number according to c d c was thirty nine thirty nine too many we want to zero and certainly  antibiotics down the number precipitously in sixty seventies and eighties but it was not ten thousand the same kind of exaggeration hyperbole and the lancet article makes a very good point about it w h o makes a point about it we don't have hard numbers but again if there's one it's one too many large exaggerated numbers don't help either but this idea of essential obstetrical services dr wiley that's what africa is calling for why would they want to buy into this and i consider it a hijacking of the legitimate concerns we all have for ending the maternal mortality tragedy of africa and everywhere i'm sitting next to to somebody who knows things better than i do this is his home we're talking about i think the most important thing you should do but we don't governments international organizations funding agencies all the ones you've mentioned is to listen to the people that we are talking of imposing something on is to ask them what they want us the mother what she wants you know what i've heard it said and i'm certain many times you know we haven't got much hope here but we do hope he's hoping that the children and almost it seems you want to take those away as well abortion pills this is an insult and i don't know how people would take it that people can impose these kind of values on us oh maybe they have seen the way we treat our own babies in canada or the thank you for that well i'll just very quickly just comment i think i appreciate the comments made and clearly the focus of legislation or policy comes forward that is very clear i have to say from my experience and most recently in bangladesh was save the children what we witnessed him so that in terms of the postnatal care in terms of vitamin a ministration vaccine work in the field back in dhaka prenatal care and respect for visits that are instrumental part of the program the respect for the mother the education that  on and then the during birth has been the focus of what i've observed i don't want to have to fear quite the fear of a hijacking of the agenda i guess just based on my experience working with the sort of groups that are represent listening to people and mothers in particular is that many of them either can't or don't get to those facilities and so moving those services that could help save lives closer to communities does have some of the critical as dr wile y was referring to the mcallen thank you i think all the witnesses for their testimony just a brief comment dr aleo had the opportunity to travel with care in peru where they were identifying high risk pregnancies to usa id and doing a lot of the interventions that you're talking about and i think there's much work to be done and so thank you for for your efforts and speaking up for women who needlessly suffer  during delivery because we know the child needs a mom in order to be successful i would just ask all of you if you if you if you would comment i mean i know a couple of you support the bill but just at a time when we're seeing this account i'm on the appropriations committee limited to the child survival account being cut and the concerns that we have about bringing result i think it was very easy to take this and did eventually approach but did he meet that we're sitting on now sure that if we listen more to those motives if we really go down there and try to be stronger coming in and imposing their western way for the practice of medicine the way that we practice in the country is is doomed to failure and it does come back to the sort of empowerment on the ground initiatives coming from from within and supporting those and supporting them with the inexpensive technologies that we know do work today and apply and if we marry those together we end up being successful and that is indeed the way infrastructure must develop overall it's not going to be just an investment in a single drug or a single treatment or a single virus it's going to require that broader investment incorporating assimilating interest from within and helping with education in a very simple technologies we have today let me thank all the pal and fortunately we our time is expired on the vote also and i know you have a one thirty press conference so we will normally come back and ask for another round but we won't but let me thank you again and i should add as consent that written statement submitted by the