U.S. GOVERNMENT PRINTING OFFICE

67–067 CC WASHINGTON : 2000

INFECTIOUS DISEASES: A GROWING THREAT TO

AMERICA’S HEALTH AND SECURITY

HEARING

BEFORE THE

COMMITTEE ON

INTERNATIONAL RELATIONS

HOUSE OF REPRESENTATIVES

ONE HUNDRED SIXTH CONGRESS

SECOND SESSION

JUNE 29, 2000

Serial No. 106–146

Printed for the use of the Committee on International Relations

(

Available via the World Wide Web: http://www.house.gov/international—relations

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COMMITTEE ON INTERNATIONAL RELATIONS

BENJAMIN A. GILMAN, New York, Chairman

WILLIAM F. GOODLING, Pennsylvania

JAMES A. LEACH, Iowa

HENRY J. HYDE, Illinois

DOUG BEREUTER, Nebraska

CHRISTOPHER H. SMITH, New Jersey

DAN BURTON, Indiana

ELTON GALLEGLY, California

ILEANA ROS-LEHTINEN, Florida

CASS BALLENGER, North Carolina

DANA ROHRABACHER, California

DONALD A. MANZULLO, Illinois

EDWARD R. ROYCE, California

PETER T. KING, New York

STEVE CHABOT, Ohio

MARSHALL ‘‘MARK’’ SANFORD, South

Carolina

MATT SALMON, Arizona

AMO HOUGHTON, New York

TOM CAMPBELL, California

JOHN M. MCHUGH, New York

KEVIN BRADY, Texas

RICHARD BURR, North Carolina

PAUL E. GILLMOR, Ohio

GEORGE RADANOVICH, California

JOHN COOKSEY, Louisiana

THOMAS G. TANCREDO, Colorado

SAM GEJDENSON, Connecticut

TOM LANTOS, California

HOWARD L. BERMAN, California

GARY L. ACKERMAN, New York

ENI F.H. FALEOMAVAEGA, American

Samoa

MATTHEW G. MARTINEZ, California

DONALD M. PAYNE, New Jersey

ROBERT MENENDEZ, New Jersey

SHERROD BROWN, Ohio

CYNTHIA A. MCKINNEY, Georgia

ALCEE L. HASTINGS, Florida

PAT DANNER, Missouri

EARL F. HILLIARD, Alabama

BRAD SHERMAN, California

ROBERT WEXLER, Florida

STEVEN R. ROTHMAN, New Jersey

JIM DAVIS, Florida

EARL POMEROY, North Dakota

WILLIAM D. DELAHUNT, Massachusetts

GREGORY W. MEEKS, New York

BARBARA LEE, California

JOSEPH CROWLEY, New York

JOSEPH M. HOEFFEL, Pennsylvania

RICHARD J. GARON, Chief of Staff

KATHLEEN BERTELSEN MOAZED, Democratic Chief of Staff

ADOLFO FRANCO, Professional Staff Member

NICOLLE A. SESTRIC, Staff Associate

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C O N T E N T S

WITNESSES

Page

David Satcher, M.D., Ph.D., U.S. Surgeon General, Assistant Secretary for

Health, Department of Health and Human Services ........................................ 11

David L. Heymann, M.D., Executive Director, Communicable Diseases, World

Health Organization (via video-conference) ....................................................... 25

David F. Gordon, Ph.D., National Intelligence Officer of Economics and Global

Issues, National Intelligence Council ................................................................. 35

APPENDIX

Prepared statements:

The Honorable Benjamin A. Gilman, a Representative in Congress from New

York and Chairman, Committee on International Relations ........................... 48

The Honorable Joseph Crowley, a Representative in Congress from New

York ....................................................................................................................... 50

Dr. David Satcher .................................................................................................... 53

Dr. David L. Heymann ............................................................................................ 62

David F. Gordon ....................................................................................................... 101

Additional material:

Slides presented by Dr. Heymann .......................................................................... 113

Article from Los Angeles Times, June 29, 2000 entitled ‘‘In a Shrinking

World Disease Anywhere Means Disease Everywhere’’, by Representative

Benjamin A. Gilman and Representative Sam Gejdenson ............................... 132

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INFECTIOUS DISEASES: A GROWING THREAT

TO AMERICA’S HEALTH AND SECURITY

THURSDAY, JUNE 29, 2000

HOUSE OF REPRESENTATIVES,

COMMITTEE ON INTERNATIONAL RELATIONS,

Washington, DC.

The Committee met, pursuant to notice, at 10 a.m. in room 2172,

Rayburn House Office Building, Hon. Benjamin A. Gilman (Chairman of the Committee) presiding.

Chairman GILMAN. The Committee will come to order.

During the summer and fall of last year, the West Nile virus,

previously unknown in the Western Hemisphere, reached the New

York metropolitan area. The outbreak of the West Nile virus in

New York claimed seven lives and resulted in 62 cases of encephalitis. The introduction of this previously unknown deadly virus to

the United States vividly illustrates that infectious diseases know

no borders.

In addition, despite the valiant efforts of the health care community in our Nation, the outbreak of this lethal virus also demonstrates that we must do much more to handle the spread and unforeseen introduction of new viruses in the United States. In simple terms, the West Nile virus outbreak should serve as a wakeup call for our Nation.

Just this past Sunday, a Rochester, New York, man died of bacterial meningitis on a flight from Tel Aviv to New York. New York

health authorities are now concerned that other passengers could

have been infected with that disease. Clearly, infectious diseases

know no borders. The growing number of infectious diseases and

their strengths and mutations is both a domestic and international

problem of mounting concern, costing a needless loss of life.

What is most regrettable is that most of the world’s deadliest diseases can be eradicated or treated inexpensively. For example,

every year our Nation spends over $300 million immunizing our

own citizens against polio, a disease that was eliminated in this

hemisphere in 1994. These immunizations are necessary because

polio has not been eradicated worldwide and could be reintroduced

in the United States at any time.

On June 12, the World Health Organization issued a report citing under use of antibiotics in the developing world and their overuse in the developed world as a major contributing factor to the

spread of infectious diseases. Because of the improper use and

overuse of antibiotics, viruses have developed stronger strains that

are increasingly able to overcome standard antibiotics.

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Just a few years ago, a number of inexpensive antibiotics proved

effective at treating such diseases as tuberculosis. Today the number of effective antibiotics in our arsenal has dwindled because of

overuse and, as noted by the World Health Organization, as a consequence, slowly but surely, most infectious diseases are becoming

resistant to existing medicines.

What is clear to me is that infectious diseases today threaten the

hard won gains of the past 30 years in both health care and life

expectancy. Infectious diseases are now the world’s biggest killers

of children and young adults and account for more than 13 million

deaths annually. In the developing world, a staggering one in two

deaths is attributable to infectious diseases. The HIV/AIDS pandemic alone has claimed 34 million victims and millions more will

lost their battle with the deadly disease.

An incredible statistic reveals the magnitude of this crisis. Twenty percent of the population of South Africa is now infected with

HIV. Alarmingly, some routine vaccines cannot be administered to

HIV positive people without fatal consequences. Therefore, in addition to the threat that AIDS singularly posts worldwide, the eradication of other infectious diseases might not be possible because

vaccines for those diseases cannot be administered to HIV infected

victims.

Yesterday, the UNAIDS program and the United Nations reported that the AIDS epidemic is already measurably eroding economic development, educational opportunities, child survival efforts, and in much of sub-Saharan Africa and the Central African

Republic. As many teachers die of AIDS as those who retire each

year.

Infectious diseases are not just a developing world problem. Unless the spread of infectious diseases is checked throughout the

world, scourges such as tuberculosis will reemerge with a vengeance in the industrialized world. In fact, tuberculosis has already

reappeared in Greece and Albania, and polio cases have once again

been reported in Southeastern Europe. All of these countries had

been free of those diseases for many years.

As our witnesses who are with us today will attest to, the spread

of infectious diseases worldwide poses a threat to millions of people, including the citizens of our own Nation.

So we thank our witnesses for joining us today and we look forward to their testimony.

I will now call on our Ranking Minority Member, the gentleman

from Connecticut, Mr. Gejdenson.

Mr. GEJDENSON. Thank you, Mr. Chairman. I think all of us are

stunned, frankly, by the issue that confronts us, not just in the fact

that the magnitude is so significant, but that 160 times more people die each year from infectious diseases than in natural disasters.

The natural disasters get our attention because they seem so large

at the moment, but, overall, these infectious diseases are far more

devastating.

The impact economically to the developing world is also devastating. It takes about 20 years of education to create one doctor.

But if that doctor contracts AIDS and can only provide services to

his country for one-fifth or one-quarter of the time that a doctor

might do if he or she lived to their full life expectancy, it means

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that the poorest countries in the world often have to expend four

and five times the amount of money and effort in educating their

doctors.

As you have pointed out, we have seen the West Nile virus arriving in the United States, and apparently surviving the first winter

with birds being found still carrying the virus.

We are not going to be able to put a fence around the country,

and when we look at the challenge that we face here, if this was

a military invasion, if these were soldiers in uniform coming in airplanes and boats, it would be easy to galvanize public opinion and

policy makers. These diseases do arrive almost in the same way.

As you mentioned, on that 747 flight from Israel a disease came

to this country endangering hundreds of Americans and individuals

had to be contacted in seven different countries as a result of that

one individual.

The United States spends hundreds of millions of dollars to deal

with illnesses like polio, that if we were able to wipe them out

worldwide, could save us between a quarter and a third of a billion

dollars annually.

The cost of curing diseases that have become drug resistant

grows by 10 times or more. Think about diseases that were virtually disappearing, like tuberculosis, where we virtually had no

new cases, it was dropping off the charts as an illness. Now we are

finding the cases of TB growing, and what is more dangerous, these

new resistant cases of TB, instead of costing several thousands of

dollars to treat, can cost tens of thousands of dollars and more.

The good news is if we act and make the proper commitment in

resources, we will be able to deal with these issues, and often be

able to arrest them overseas before they come to the United States.

The hard part is often to galvanize Americans for something that

is as hard to recognize as a slow moving disease is abroad. But

AIDS and TB are good examples of why it is not just our humane

instincts that we have to respond to, it is an instinct for self-survival. When you look at what has happened with AIDS in countries

in Africa and elsewhere, when they reach these kinds of numbers,

they become the host for a number of other infectious diseases.

So Americans who might have been sitting here thinking I am

not going to be using intravenous drugs, I am not going to be involved in sexual activity that might expose me to AIDS, the fact

that AIDS is growing is not a danger to me or my family, have

been proven wrong. AIDS in the developing world provides a direct

threat to Americans. Those individuals are the host for new and

more virulent strains of TB and so many other illnesses.

If we don’t participate with our other human beings on this planet to challenge, confront, and beat these diseases where they exist,

they will come here and they will ravage our own populations. So

both for humanitarian reasons and for self-survival reasons, we

need to act.

So I commend you, Mr. Chairman, for holding this hearing today,

and my colleagues, who I know are seriously committed to putting

forth the resources necessary to fight this challenge as if it was an

invading army.

Chairman GILMAN. Mr. Burr.

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Mr. BURR. Thank you, Mr. Chairman. Just this morning in the

AP story in London, it starts out earthquakes and other natural

disasters may have captured donations and headlines, but preventable disease killed far more people, 13 million people in 1999, according to a published report Wednesday by the American Red

Cross.

Mr. Chairman, I am here to thank you for holding this hearing.

By my count, this is the fifth hearing on world health since I have

been a Member of this Committee since 1998. All have been important, but, Mr. Chairman, this one is particularly so. It is focused

on the threat posed to stability of countries around the world and

our own national security by the spread of infectious disease. Broad

advances in fighting the spread of disease after World War II led

to hopes that the threats from disease was becoming more manageable.

As this January’s national intelligence estimate points out and

our witnesses will testify today, those hopes may have been misplaced. The optimism of the post-war era led to complacency in

many areas and overlooked the impact of increased trade, travel

and the emergence of resistant strains.

For the benefit of those that doubt the threat, I should be very

clear. While the situation in developing and former communist

countries is troubling, we must not overlook the fact that the trend

in infectious disease prevalence at home is up as well. Annual

deaths in our country from infectious diseases have almost doubled

since 1980, and many of these diseases originated outside of the

United States and are introduced by businessmen, travelers, immigrants, and our own military personnel who return home.

Infectious diseases do indeed pose a significant threat to our Nation’s interests, both at home and abroad, and will continue to pose

a threat in the years to come. The NIE paints a grim picture, but

I am hopeful our witnesses can provide us with the ammunition in

the form of ideas, proposals and opinions needed to tackle some the

problems we currently face.

Mr. Chairman, it is evident that our country must remain vigilant and active in the fight against the spread of infectious disease.

The stakes are simply too high for us to become indifferent.

In conclusion, I would like to thank our witnesses. I would like

to make a special welcome to Dr. Satcher, and I would also like to

make a special welcome to Dr. Heymann, who is in fact a graduate

of Wake Forest University School of Medicine, we all know the best

ACC team in the conference, also my alma mater, Mr. Chairman,

and I welcome Dr. Heymann here today. I yield back.

Chairman GILMAN. Thank you very much, Mr. Burr. Mr. Brown,

the gentleman from Ohio.

Mr. BROWN. Thank you, Mr. Chairman. Mr. Burr, while Wake

Forest may be the best team in the ACC, I would like to welcome

Dr. Satcher, who went to Case Western, which is one of the best

medical schools in the country.

Last year TB killed more people than any year in world history.

It is the greatest infectious killer of adults worldwide. It is the biggest killer of young women. It kills 2 million people per year, one

person every 15 seconds. In 1999 there were 8 million new TB

cases around the world, 95 percent of them in developing countries.

5

The WHO estimates that one-third of the world’s population is

infected with the bacteria that causes tuberculosis, 8 million people

develop active TB each year, and 15 people million people in the

United States are infected. TB is the biggest killer of people with

HIV/AIDS. It accounts for one-third of AIDS deaths worldwide and

up to 40 percent of AIDS deaths in Asia and in Africa. Eleven million people are currently infected worldwide with TB and HIV.

The good news is that TB treatment is equally effective in HIV

positive and HIV negative people. So if we want to improve the

health of people with HIV, we must address tuberculosis. Up to 50

million people worldwide may be infected with multi-drug resistant

tuberculosis. MDRTB has been identified on every continent. It is

particularly high in certain regions and populations, such as Russian and Latvian prisons, where 5 percent of prisoners have active

MDRTB. According to the WHO, multi-drug resistant TB only

threatens to return TB control to the pre-antibiotic era where no

cure for TB was available.

In the United States treatment, normally about $2,000 per per- son, skyrockets to as much as $250,000, as we found out in the

early nineties in New York City, $250,000 per patient to treat

MDRTB, and treatment may not even be successful.

The statistics on access to TB treatment worldwide are pretty

grim. Fewer than 1 in 5 of those with TB are receiving directly observed treatment short-course, DOTS. Based on World Bank estimates, DOTS treatment is one of the most cost-effective health

interventions available, costing as little as $20 in developing countries to save a life. It can produce cure rates, as we saw in a couple

of states in India, up of up to 95 percent, even in the poorest areas.

An effective DOTS program can prevent the development of

MDRTB. A recent WTO study in India found in areas where effective TB treatment was implemented, the TB rate fell by 85 percent.

The threat TB poses for Americans derives from the global

spread of tuberculosis. Foreign born people account for almost half

of TB cases in our country and from the emergence and spread of

strains of TB that are multi-drug resistant. MDRTB kills more

than half of those infected in the United States and other wealthy

nations. It is a virtual death sentence in the developing world.

As you know, the President recently visited India. Before his trip

we talked about TB in that nation. India has more TB cases than

any other country in the world. Their situation illustrates the urgency of this issue. More than 1,000 people every day die from tuberculosis in India. It has become a major barrier to social and economic development, costing the Indian economy at least $2 billion

a year. TB attacks the poor and TB causes poverty. 300,000 children are forced to leave school each year because their parents

have TB and more than 100,000 women with TB are rejected by

their families due to social stigma. India has undertaken an aggressive campaign, but they need our help.

In order to control TB in the United States more effectively, it

is also necessary to assure the effectiveness of TB control programs

worldwide. TB experts estimate it will cost an additional $1 billion

a year to control this disease. We have a very small window of opportunity during which stopping TB would be very cost-effective.

The cost of DOTS can be as little, as I said earlier, as $20 in develVerDate 11-MAY-2000 17:22 Nov 17, 2000 Jkt 000000 PO 00000 Frm 00009 Fmt 6633 Sfmt 6633 67067.TXT HINTREL1 PsN: HINTREL1
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oping countries. If we wait or go too slowly, so much drug resistant

TB will emerge that it will cost billions to control, with no guarantee of success.

MDRTB is at least 100 times more expensive to cure than nondrug resistant TB. I have introduced H.R. 4057, the Stop TB Act

Now, with Representative Morella in an effort to control TB. The

bill authorizes $100 million to USAID for tuberculosis control in

high incidence countries, mostly using DOTS, the directly observed

treatment short-course. It calls on USAID to collaborate its efforts

with the CDC, with the World Health Organization and with the

National Institutes of Health and other organizations with specific

knowledge of TB.

Gro Brundtland, the Director General of the World Health Organization, has said that TB isn’t a medical issue, it is a political

issue. Getting Americans engaged, as Mr. Gejdenson said, in an

international medical issue like TB, even when addressing TB

serves our own best interests, is still an uphill battle. But we have

an opportunity here as a Nation and as a society, especially in the

wealthy countries, to work with developing countries to save millions of lives now and prevent millions of deaths in the future.

Mr. Chairman, I thank you.

Chairman GILMAN. Thank you, Mr. Brown. The gentlelady from

California, Ms. Lee.

Ms. LEE. Thank you, Mr. Chairman. I want to thank you and our

Ranking Member for today’s hearing to discuss this very important

national security issue, which is the spread of infectious disease

around the world. I also want to welcome our witnesses and look

forward to their testimony.

Health is definitely a national security issue, but it is also an

international security issue that is worthy of our close attention.

Beyond today’s hearing, however, we must really begin to aggressively support a strategic investment in foreign assistance above

and beyond what we are currently spending. In addition, this hearing today really does underscore the importance of the direction of

our country’s foreign policy, whether it be engagement or isolation.

It also highlights the need to provide foreign assistance to countries that are in most dire need.

One issue which we all are talking about today and which we all

are working on very diligently is the HIV/AIDS crisis in Africa. We

are working on the World Bank AIDS Marshall Plan Trust Fund

Act, which was moved out of Congress about a month ago, but we

are working on this in a bipartisan fashion with Chairman Leach

of the Banking Committee and all of our Members of International

Relations, to really begin to craft a major investment in the whole

HIV/AIDS crisis in sub-Saharan Africa. But $100 million a year is

what we are currently working for 5 years. It is just a drop in the

bucket to address this pandemic in Africa. We have a long way to

go.

In Africa right now you have heard the statistics. Currently 70

percent of the AIDS deaths worldwide are in sub-Saharan Africa.

But as a result of that, the spread of AIDS in Africa has increased

economic instability, food and agricultural destabilization and a severe drop in life expectancy rates. Life expectancy has dropped in

some countries in Africa from 65 to 40 years of age. More than 13

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million children now have lost one or both parents to AIDS, and

as of the year 2010 it is projected that there will be 40 million orphans in Africa as a result of the HIV/AIDS crisis and their parents dying of this disease. That is the equivalent of every child in

America’s public school system.

This health crisis has repercussions that are reverberating far

beyond the sick rooms and the hospitals where its victims lie dying.

It threatens to destabilize entire societies. So we must do something before it is too late. Earlier this year the President declared

HIV/AIDS a national security issue. I think it is an appropriate

declaration. But now we must move aggressively to come up with

strategies to deal with this. It is only when the United States commits itself to long-term strategic investment do we have a fighting

chance to address the spread of HIV and AIDS as well as other infectious diseases around the world. Diseases do not respect international boundaries.

So I want to thank you, Mr. Chairman, again for holding this

hearing today, and thank the Committee for all of its hard work

and its commitment to really begin to invest in our country’s push

to address infectious diseases.

Chairman GILMAN. Thank you, Ms. Lee.

The gentleman from New Jersey, Mr. Payne.

Mr. PAYNE. Thank you very much, Mr. Chairman. Let me commend you for calling this very important hearing today on infectious diseases, a growing threat to America’s health and security.

Let me also welcome the panelists, in particular our Surgeon

General, Dr. Satcher. Just yesterday I was watching you talk about

the new breakthrough in treatment for smoking, and I hope that

all the smokers heard that.

We certainly appreciate the outstanding work that you are doing.

I also would like to commend my colleague, the gentlewoman

from the great State of California, for her initiative that she has

been taking in the question of dealing with HIV/AIDS in Africa.

Her Subcommittee, with Congresswoman Christensen, that meets

on a regular basis to talk about the whole problem of HIV/AIDS

in Africa, has really pushed forward the discussion and the debate,

and I certainly would like to commend her publicly again for her

diligence and the fine work that she has done in that regard.

Let me say to the audience that I do feel that finally this issue

has come out of the Dark Ages and into the light in Africa. Several

hundred years ago in this country mental health was considered

something that should not be discussed, and people would not acknowledge that there were people who suffered from that problem,

and as time went on here in the United States we were able to finally deal with mental health as a real health issue.

It seems the same taboo, not only in Africa, but here in the

United States, that no one wanted to talk about. It was denial.

There was some feeling even from the church that if you followed

the Bible you wouldn’t get AIDS, and, therefore, if you have it, it

is because you deserve it. Those kinds of illogical thinking. I am

glad we finally are bringing this subject out and we are talking

about the virus, we are talking about what should be done to attack it.

8

I think the breakthrough of Vice President Gore at the United

Nations in January, Africa Month, under the recommendation of

the U.N. Ambassador from the United States, Ambassador

Holbrooke, where Vice President Gore talked about the fact that

HIV virus and AIDS was a national security issue, and for the first

time in the United Nations Security Council this issue was raised.

I think that these are positive signs, I think, that the fact that

this hearing is being held, that the Banking Committee with Mr.

Leach has joined in with Ms. Lee, that others are talking about the

fact that we need to have a quantum leap in the education being

brought to bear, but also in the funding. I applaud the pharmaceutical companies several months ago in Geneva announcing that

they were going to reduce the cost of some pharmaceuticals that

are necessary for treatment of the virus. We think it is a first step

in the right direction, but we need much more cooperation from the

pharmaceutical industries. We need much more appropriations

from the U.S. Congress.

So, with that, I would say that we look forward to your testimony, and once again we appreciate the panel for being here.

Chairman GILMAN. Thank you, Mr. Payne.

The gentleman from New York, Mr. Crowley.

Mr. CROWLEY. Thank you, Mr. Chairman. Thank you for calling

this important and timely hearing. As a fellow member from New

York, I believe you understand that New Yorkers are concerned

about the threat of global infectious diseases.

I want to welcome all the witnesses today, including Dr. Satcher,

Dr. Heymann, Dr. Gordon, and I see in the audience Dr. Ostrov

from the Center for Disease Control as well, someone I had the opportunity and pleasure of working with most recently on West Nile

encephalitis. I would also like to thank Ranking Member Gejdenson for his leadership on this critical issue as well.

As many of you know, in August 1999 my constituents were

shocked to learn that an outbreak of West Nile encephalitis had

surfaced for the first time in the Western Hemisphere in the heart

of my district in Queens and the Bronx. This outbreak was a wakeup call for every American. It illustrates that the global community

has truly become the local community.

As demonstrated by West Nile encephalitis, HIV/AIDS and tuberculosis, a disease respects no borders. An outbreak in Africa, Europe, Asia, or South America can travel to United States shores

within days. No longer can diseases occurring in far off lands be

ignored. They pose a direct threat to the national security of our

great country and must be addressed by the U.S. Government, this

Congress and the international community as a whole.

Diseases cannot be seized by Customs and they don’t apply at

the U.S. embassy for a visa. The only way to halt them is to target

them at the source. But today we are losing that battle. Thirteen

million people die annually from infectious diseases, most of which

are preventable or curable. The 21st century faces an estimated

33.5 million people around the world who are infected with HIV/

AIDS. The spread of AIDS can be prevented with an urgent and

necessary investment. We must stand at the forefront of tackling

this disease in order to secure the health and prosperity of future

generations.

9

In April of this year, I visited Africa with UNFPA to examine

family planning clinics and HIV/AIDS control efforts in Malawi, a

country where the life expectancy is no more than 36 years of age.

In Malawi I witnessed the devastating effects of HIV/AIDS firsthand. Everyone I met in Malawi suffered tragedy due to the HIV/

AIDS epidemic. In some instances, whole families had been wiped

out.

One gentleman told me that every time he had a position open

in his business, he had to hire three people, because he knew that

within a year, two would either be dead or caring for a sick or

dying family member with AIDS.

In sub-Saharan Africa, the AIDS epidemic is dramatically changing the structure of society. Traditional extended families are falling apart forcing children to leave school in order to provide for

their families. Poverty is skyrocketing, and a vicious spiral of decline is setting in that further destabilizes already volatile countries.

Because of this danger, the Clinton administration has designated AIDS as a threat to our U.S. national security. Additionally, the United Nations Security Council has held joint meetings

with relevant U.N. councils dealing with health and social issues.

I commend these efforts, but much more needs to be done.

As many of you know, I have been joined by over 55 of my House

colleagues on legislation that I am sponsoring known as the Global

Health Act 2000, H.R. 3826. The Global Health Act authorizes $1

billion in additional resources to improve children’s and women’s

health and nutrition, provide access to voluntary family planning,

and combat the spread of infectious diseases, particularly HIV/

AIDS. With the funding authorized in the GHA, the United States

would make a giant leap forward in promoting access to health

care for millions of people around the world. In today’s world, no

nation is an island. We are all in this together. Failing to make a

commitment to global health now will only cost us more in the long

run.

Mr. Chairman, in August I will be holding a forum on the interconnectedness of globalization and the spread of infectious diseases. This event is cosponsored by the Global Health Council and

is called Infectious Diseases in Your Own Backyard.

Mr. Chairman, given your interest in this topic as well as the

danger to New York and Connecticut, I would like to extend an invitation to you and to Ranking Member Gejdenson to join me for

this event which will take place in the near future in New York

City.

Once again I would like to thank you and Ranking Member

Gejdenson for your work on this critical issue. I ask that my full

and complete written statement appear in the record.

[The prepared statement of Mr. Crowley appears in the appendix.]

Chairman GILMAN. Without objection. Thank you, Mr. Crowley.

We would welcome hearing more about your proposed meeting.

The gentleman from California, Mr. Sherman. Let me interrupt

a moment. We are joined today by way of video conference by Dr.

Heymann. Dr. Heymann is the Executive Director of CommuVerDate 11-MAY-2000 17:22 Nov 17, 2000 Jkt 000000 PO 00000 Frm 00013 Fmt 6633 Sfmt 6633 67067.TXT HINTREL1 PsN: HINTREL1
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nicable Diseases of the World Health Organization. He is meeting

with us from his offices in Geneva.

Welcome, Dr. Heymann.

Mr. Sherman.

Mr. SHERMAN. Thank you, Mr. Chairman. I want to commend

you for holding these hearings. There was a time when we thought

of disease as simply a personal matter, but a look at history shows

that disease is also something of great international and historic

significance. The Dark Ages were perhaps at their darkest when

the plague decimated Europe and really cost that continent over a

century of development, and today infectious diseases around the

world can pose a major threat to the development, peace and security of our country and countries around the world.

We have talked about AIDS in Africa. Not only does that devastate that continent, but the more AIDS suffering people there are

in Africa, the more likelihood of a mutation developing on that continent, producing another strain of AIDS which our medicine may

not be able to deal with.

We all, the health of every person on this planet, is dependent

upon the health of every other person on this planet, and we in the

United States should recognize that infectious diseases are not always just something that comes from some other continent and invades the United States.

The overuse of antibiotics in American agriculture may create in

cows and in chickens resistant strains of bacteria where we in our

practices could be creating the next plague that will affect other

continents.

I think historians in the future may wonder why in our defense

budget we spend so much defending ourselves from missiles and so

little defending ourselves from diseases. Perhaps NIH is the next

or the real Pentagon.

We have billions of people on this planet. The more people we

have, the more contact, the more international travel, the more

chance there is for diseases to develop and to move quickly around

the world; and the more we use drugs to combat these diseases, the

more likelihood there is of the development of resistant disease

strains.

Mr. Chairman, we have looked at many of the national security

threats that face America, our allies and the world in hearings before this Committee, but this may be the biggest threat.

Thank you.

Chairman GILMAN. Thank you, Mr. Sherman.

We are now pleased to welcome the distinguished—I am sorry,

I have neglected one our Members, Dr. John Cooksey, the gentleman from Louisiana.

Mr. COOKSEY. Thank you, Mr. Chairman. Since it has been a

number of years since I finished medical school, I will wait to hear

from the non-elected experts this morning and hear their testimony. Thank you, Mr. Chairman.

Chairman GILMAN. Thank you, Dr. Cooksey.

We now welcome the distinguished Dr. David Satcher, the Surgeon General of our Nation, to testify before our Committee this

morning.

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Dr. Satcher is the 16th Surgeon General of the United States. He

has served in that position since early in 1998. Previous to his appointment as Surgeon General, Dr. Satcher served as Director of

the Centers for Disease Control. Prior to serving in government,

Dr. Satcher was President of Meharry Medical College in Nashville, Tennessee.

Welcome, Dr. Satcher. Please proceed. You may summarize your

testimony and place your full statement in the record if you so desire.

STATEMENT OF DAVID SATCHER, M.D., U.S. SURGEON GENERAL, ASSISTANT SECRETARY FOR HEALTH, U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

Dr. SATCHER. Thank you very much, Chairman Gilman.

Chairman GILMAN. Would you please press the button in the

middle of your mike down on the base.

Dr. SATCHER. Thank you very much, Chairman Gilman, and

Members of the Committee. I am very pleased to have this opportunity to join you for this very important hearing and am very

pleased to appear with my colleagues, Dr. David Heymann from

the World Health Organization, and Dr. Gordon.

We are very concerned about the emergence and reemergence of

infectious diseases in this country. I should also say that, as you

pointed out, I am joined by colleagues from CDC, Dr. Steven

Ostrov; from FDA, Dr. Jesse Goodman; and from NIH, Dr. John

LaMontagne. We are all very concerned about infectious diseases,

and especially the reemergence and emergence of infectious diseases.

We have come a long way in the last century. At the turn of the

century, in 1900, infectious diseases were by far the leading causes

of death in this country, and we have made dramatic progress in

the eradication of smallpox and now the near eradication of polio.

With the new antibiotics and immunizations, we have made dramatic progress.

But as we all know, we also became complacent. In fact it was

in 1969 that a former Surgeon General appeared before Congress

and the concern was more about too much emphasis on infectious

diseases and the need to shift more emphasis to chronic diseases.

That was certainly true. But in some ways we may have shifted too

much, because by the mid-1970’s, we were seeing the emergence of

many new infectious diseases.

Between 1980 and the end of this century, indeed death rates

from infectious diseases in this country increased dramatically, and

only a portion of that, maybe one-third or one-fourth, due to HIV/

AIDS. Other infectious diseases played a major role.

So we are concerned. As we speak there are many examples.

Last year alone, two Boy Scouts acquired malaria while attending

a summer Camp in Suffolk County, New York. Last August and

September six people in the northeastern United States and a Canadian visiting New York died from West Nile encephalitis, a viral

disease transmitted by mosquitoes. The West Nile fever, which is

carried by migratory birds, usually from Asia, Africa, and Europe,

had never before been reported in the Western Hemisphere.

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Also from July 1999 to January 2000, 56 people in south Texas

were recognized with Dengue Fever, and at least 17 of those people

acquired dengue fever in the United States.

The AIDS epidemic, of course, perhaps needs no further discussion except to say that we are part of this global community where

this pandemic is probably the worst that we have seen since the

plague of the 14th century or the influenza pandemic of 1918. You

have discussed resistant tuberculosis, and we have been very concerned about that in our work at CDC and NIH, as well as FDA.

Recently there was an interagency report from these three agencies, a draft report on the management of antimicrobial resistance.

While I want to put this in perspective, I think maybe the best

way to do that is to refer back to the Institute of Medicine’s report

in 1992 in which it was pointed out that there are six major factors

involved in the emergence and reemergence of infectious diseases.

I think we need to look at them as we think about the future.

One of those factors is changes in human demography and behavior, including growth in population and density, sexual activity,

substance abuse, the way we use antibiotics and other drugs, but

also advances in technology and industry. The fact that we have

the technology, for example, to mass produce foods, such as ground

beef, which means that, as somebody pointed out, one patty of

hamburger may in fact include beef from 100 different cows. Our

technology, which is great, also increases the risk of the spread of

infectious diseases in many ways.

Economic development and changes in land use patterns, invasion of the rain forest, all of these things have been factors. Ecological changes, certainly changes in temperature and flooding contributed to the hantavirus outbreak in the Southwest in 1993.

As you pointed out, increases in international travel and commerce are major factors in the spread of infectious diseases. Microbial adaptation and change, as Dr. Josh Lederberg has said many

times, we certainly underestimated the intelligence of microorganisms and their ability to mutate and to become resistant to our

best drugs.

So the challenge is, of course, for us to change our behavior that

often gives advantages to these organisms, but also to continue to

produce new and effective drugs.

Finally, the Institute of Medicine pointed out the role of the

breakdown in the public health infrastructure. I think we have to

be really concerned that we have in fact not maintained a strong

public health infrastructure. Many of our State public health laboratories are unable to make some really basic infectious disease

diagnosis. We made a lot of progress in the last 4 to 5 years with

the leadership of the CDC in strengthening State public health laboratories, working with States, and also the research taking place

at NIH and other places, but we still have some major public

health challenges.

The other point I want to make relates to the report from the

Council on International Science, Engineering and Technology, a

Committee which I chaired in 1995 that involved 17 agencies of the

government. The charge to that Committee was to look at how we

could strengthen our infrastructure to deal with the emerging infectious diseases.

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In December 1995, the Committee came out with a report which

said that both domestically and globally our infrastructure was inadequate in terms of surveillance, prevention, response to infectious diseases, and recommended a major effort to strengthen this

global infrastructure for surveillance and response to emerging infections.

Many things have happened since that report. It led to a Presidential Decision Directive. We now have an interagency task force

that is leading an effort in this country to work with our colleagues, following the leadership of the World Health Organization

to really develop a global strategy for surveillance and response to

emerging infectious diseases. Dr. Heymann certainly will discuss

that, and he is playing a very critical leadership role.

Let me say that the challenges continue. There are several models which we have developed, which I will not discuss in detail here

except to say that we must continue to invest in these global efforts, whether it relates to the HIV/AIDS initiative, which you have

discussed, which certainly requires a global effort. We need to invest heavily. The LIFE program, Leadership and Investment in

Fighting an Epidemic, is a great beginning, and we must continue

that effort. The malaria initiative, the Roll Back Malaria from

WHO, is an initiative that deserves all of our support globally, and

we hopefully will continue to support that. The Roll Back TB program, led by WHO, is another one.

So these are some good models. The vaccine initiative, a very

strong public-private initiative, the Gates Foundation and others

are playing a major role. Many of the pharmaceutical companies

are making available drugs needed in other countries at low or no

cost. All of these initiatives are critical for us to continue. Partnership, leadership, vigilance is what is needed.

I thank you for the time and will be happy to respond to any

questions.

[The prepared statement of Dr. Satcher appears in the appendix.]

Chairman GILMAN. Thank you, Dr. Satcher. I agree that solutions, like problems, have to be global in space and scope. I also

agree that international cooperation is vitally necessary to combat

and eradicate infectious diseases. To that end, what will our Nation

be asking of our allies and our partners at the next G–8 meeting

to make certain that a worldwide commitment is going to be made

to provide the resources necessary to combat AIDS?

Dr. SATCHER. Mr. Chairman, we will certainly ask that we all

continue to support four major efforts: The Roll Back Malaria program, the Stop TB Initiative. TB is responsible for millions of

deaths every year in the world, and none of us are safe from it. The

HIV/AIDS initiative with the focus on sub-Saharan Africa and increasing in Southeast Asia; the vaccine initiative, which I think is

a really critical one. I think all of the nations throughout the world

must join in providing resources to make sure that children are immunized all over the world. I think the best way to combat our concern for global emerging infection is to get children immunized

against those diseases for which we can immunize. It is also the

best way, I believe, to combat the growing antimicrobial resistance

of organisms. If children are immunized, then they are not going

to get the infections.

14

Certainly we don’t have to worry about the use of antibiotics, but

we also have to continue to develop new antibiotics. The Vaccine

Initiative is certainly one we are going to ask our global colleagues

to support and follow the leadership of the World Health Organization, which is very strong.

Chairman GILMAN. Thank you, Dr. Satcher. The recent outbreak

of the West Nile virus in the New York metropolitan region served

as a wake-up call for our Nation. The previously unknown viruses

can be introduced in our country without too much difficulty but

with deadly consequences. What more can we do to prevent that

kind of an introduction of virus into our own Nation?

Dr. SATCHER. I think, again, we have got to deal with it from a

global perspective. I think we have to make sure that we are part

of a global strategy of surveillance and response, that if we detect

these viruses early, even before they get to our country, and we

control them and contain them there, then we significantly reduce

the risk that they will get to this country.

In addition to that, we have to maintain a public health infrastructure in this country that can prevent the spread of viruses,

whether they are carried by mosquitoes or in the role of migratory

birds, et cetera. We have to have a strong public health infrastructure that detects as early as possible and then a system that allows

us to respond in such a way that we stop these viruses in their

tracks.

But it has got to be a global response. We have to have laboratories all over the world capable of detecting new infections.

Chairman GILMAN. Dr. Satcher, do we have that kind of response

team in our own NIH offices?

Dr. SATCHER. Yes and no. Let me make it very clear. This is an

interagency effort. NIH is primarily responsible for research. CDC

is responsible for the leadership of the public health system in

terms of coordinating the State level response and even making

sure that our laboratories at the State and local levels are prepared. Those States and local levels look to the CDC for support

whenever there is an issue.

So we have a partnership here among CDC, FDA, and NIH that

has to be very strong.

Let me just say I think we have made tremendous progress in

developing a public health infrastructure in recent years and

strengthening State level laboratories. I think we still have a long

ways to go. We have to bring the best technology to bear on this

issue, which means very sophisticated communication systems. The

DNA fingerprinting, the Pulse Net systems, are making a tremendous difference, but they have to be tied to central systems at CDC

and other places.

Chairman GILMAN. Dr. Satcher, how best can our Nation play a

leadership role in strengthening our global disease surveillance in

response to any outbreak?

Dr. SATCHER. I think we have to make available all our very

strong science and technology. I think we ought to be very proud

of the leadership that Dr. Heymann is playing and ought to remember that. Not only did he graduate from Wake Forest, but he

started at CDC and was sent to WHO from CDC and recently retired from CDC. He has done a tremendous job.

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He represents the kind of quality in science we have in this country. I think we have to provide our science and technology as parts

of a team and I think we have to make our resources available,

whether it is in dealing with the AIDS epidemic in sub-Saharan Africa, I think we have to be able to step up to the plate and do our

part, as Vice President Gore said at the United Nations and as

Congresswoman Barbara Lee just pointed out. We have to be committed to doing our part in terms of resources, but also making

sure we have the partnership. Scientists must come together

throughout the world as scientists to fight this battle.

Chairman GILMAN. Thank you, General Satcher.

Mr. Gejdenson.

Mr. GEJDENSON. Thank you, Mr. Chairman.

I was just checking with staff, I was a little confused, all these

references to sports, and coming from the State and my district

which has the two best basketball teams in all of college at every

level, both the UCONN men’s and women’s, I was confused by discussions of other schools without UCONN being central to the discussion. But I have been informed by my staff that there are other

teams at these schools that do play basketball.

Let me just say that your role here is a very critical one. You

know, when the warnings on tobacco came out, I think it electrified

America and focused us on the challenge, and we are now adding

to that cigars beyond cigarettes.

In the national security arena, we have the issue of terrorism,

and we have gotten the United States and our global partners to

recognize the challenge from international terrorism. Although

when you look at the facts, what we confront here, not to diminish

any of the others, is far more dangerous to America than terrorism,

than tobacco, and I guess I am asking you how you would assess

it, is this the major threat to the United States that it appears to

be when we look at these facts?

Dr. SATCHER. Let’s make sure we agree on the facts. I am not

sure I am ready to agree that what we are confronting is more dangerous than tobacco. I won’t dwell on that.

Mr. GEJDENSON. Because of the magnitude. Not to diminish tobacco, not to diminish terrorism—but obviously one terrorist attack

can kill a lot of people.

Dr. SATCHER. I think this is a very serious problem throughout

the world, and I would in no way diminish the significance of infectious diseases. Increasingly, the reason I said what I said, increasingly throughout the world, including developing countries, chronic

illnesses are becoming leading causes of death. Four million people

died last year in the world due to smoking. We estimate by 2025

it could be up to 10 million, with 70 percent occurring in developing

countries. We have to do all of these things at once, unfortunately.

Mr. GEJDENSON. I wasn’t trying to defend tobacco.

Dr. SATCHER. I know you weren’t. This is a very serious problem

and we have to get on top of them. The thing about infectious diseases is, they spread from person to person, either directly or

through intermediaries like mosquitoes. That is why we have to be

more concerned about them, unlike if you smoke, yourself, or are

exposed to environmental tobacco. But many people get infectious

diseases because they are spread to other places by other people.

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We do have to contain them, and that is what this effort should

be.

Mr. GEJDENSON. One of the challenges that faces the Congress

and faces the American people worldwide is the issue of intellectual

property. Now, the drugs are developed here in the United States,

about 45 percent of them, made by American pharmaceutical companies. They need to be profitable, obviously. They need to know

when they do the research they are going to make the profits that

attract the investors. We in Congress have not given sufficient

funding to have the government do the research to create these

new drugs. But there is a terrible challenge that occurs here. As

we have seen, the drugs are so costly that many in Africa and

many in this country can’t afford them. We have to deal with that

issue. Then it is complicated by oftentimes these illnesses at first

appear to be only affecting poor people, and it is very hard to direct

private sector funding to do research for illnesses that don’t affect

people in the developed world. So we have seen for years people

dying of things like diarrhea, when we know the cures and we have

come up with really inexpensive cures, but it took a very long time

to get us to pay attention to that.

I guess my questions would be, one, without undermining the

present incredibly productive pharmaceutical industry in this country, how do we make sure we get some of those drugs to people,

how do we direct resources to deal with illnesses that don’t affect

us at first in the West, you know, with good sanitation, with proper

medical care available. We seem to think of these as developing

world challenges, and it is very hard to attract private sector resources to deal with them.

Dr. SATCHER. Well, these are very critical questions and very difficult. I think the only way that we can deal with the appropriate

distribution of drugs throughout the world to protect all of us in

this global village, and realizing we are in this village, is that there

has to be, I think, a public-private partnership with a commitment

to getting drugs to people who need them most.

But we also need a commitment for public health infrastructure.

It is one thing to talk about making drugs available. It is another

thing to make sure the public health infrastructure is there to appropriately prevent and educate and diagnose early infectious diseases.

I think President Clinton’s recent action in terms of making

drugs available to people in Africa was very critical, and it recognizes a global crisis. When you have a global crisis, you have to respond in kind. I also believe, however, that we should not underestimate the role that our pharmaceutical companies have played

in developing new drugs. Working with the NIH, in many cases

building on research at NIH and CDC and other places, our pharmaceutical companies have really done an outstanding job of producing drugs. They have to have an incentive.

At the same time, all together we have to have a public-private

partnership that says we have got to recognize that we are part of

a global community, a global village, and we have to protect all the

people in that village from infectious diseases if we are going to

protect the health of the American people. I think that is the attitude that we have to have, and we have to continue to come up

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with new strategies. We are, as I speak. I will commend not just

the pharmaceutical companies, but foundations, like the Gates

Foundation, the Turner Foundation, Robert Wood Johnson, Kaiser,

and others that I can name, who are really stepping up to the plate

and playing a leadership role in this. The Rockefeller Foundation

has been involved in vaccine development. That is what it is going

to take.

Mr. GEJDENSON. I thank you. Obviously it will take a lot more

discussion than we have time for here, but the issue of the infrastructure, I think the thing that shook me the most in a sense was

in many of these countries, if we could get the drugs to the capital

city, we still couldn’t get them, we still couldn’t administer them

to the people that need them.

Dr. SATCHER. At the last meeting of the World Health Assembly

which I attended, there was a lot of discussion among the African

countries about the real challenge of using drugs, if available, in

terms of the fact it is so difficult in many cases to make the diagnosis and keep people in systems of care. So our commitment has

to be to systems of care, a part of which is making drugs available.

Mr. GEJDENSON. Thank you.

Chairman GILMAN. Thank you.

Mr. Burr.

Mr. BURR. Thank you, Mr. Chairman. I think Mr. Gejdenson hit

on the real key in his last statement, and that is the infrastructure

is vital. There is no single shot solution, is there, Dr. Satcher?

Dr. SATCHER. No. I think it has to be a public-private solution,

and it has to be global in nature.

Mr. BURR. In this country, 2 years ago I think it was, we passed

legislation which was the biggest children’s health initiative, I

think, it was called S–CHIP. We made the resources available, and

I am not sure what the percentage were of States who have successfully identified and provided coverage for every child in their

State that was available for this program. But it is a very low percentage of States who have actually met the challenge of having

the resources and finding in fact—identifying the kids to be covered. So we have our own challenges here, even with the resources,

to make sure that those most at risk get the services.

I want to go to the heart of the infrastructure. We learned with

the Polio-Plus program that even when governments around the

world commit to it, that sometimes it took a private organization

to go in, and in this case of Rotary, and to implement the program

in a way that could assure us of its effectiveness.

What effect, if any, does what we do here have on overcoming the

infrastructure deficiencies that exist in some of these countries?

Dr. SATCHER. I think it has a tremendous effect. I had the opportunity as Director of CDC to work very closely with Rotary International in the polio eradication program. I agree with you, it is

one of the best models I have ever seen, and I think it is largely

responsible for the progress we have made.

I think we can support the development of public health infrastructures globally. We have our own problems. I would just remind you the report from the World Health Organization last week

ranked us number 37 in terms of health system efficiency. So that

means that even though we spend more and more per capita, the

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efficiency of our health system leaves a lot to be desired. That is

why we have got so much trouble on the one hand of implementing

CHIP, because as you pointed out, it is probably the most significant advancement in many years in terms of our health system.

We are having a lot of trouble implementing it and getting children enrolled throughout the country. I believe, as you know, we

need a universal system of health care, and we ought to move rapidly to that so we can put some of these challenges behind us. So

we can help other countries by providing support for public health

infrastructures. Again, WHO is providing leadership in terms of

that. They just came out with a very important report on health

systems and we ought to follow their lead.

Mr. BURR. We are as susceptible as our weakest link in a health

care delivery system, and I don’t quite hold the optimism that you

do that we can have the perfect system that has no flaws. For that

reason, we can’t continue to, I think, try everything, and I think

that is in fact what you have suggested we have to do as it relates

to infectious disease globally, we have to do D, all of the above.

Let me ask you specifically as it relates to the HIV/AIDS as a

national security threat. I happen to believe that in fact it is. Were

you a participant in that process where the President designated

HIV/AIDS as that threat?

Dr. SATCHER. Yes, I accompanied Vice President Gore to the

United Nations on January 10th where we made our presentation

and supported Ambassador Holbrooke and moved toward a declaration of this as a security issue. As you know, this was the first time

the Security Council of the U.N. had ever discussed a health issue

at the Security Council level.

Mr. BURR. Why limit it to one? You have listed—one disease,

HIV/AIDS.

Dr. SATCHER. That is a very good question. I think it is a start,

and I think the magnitude of the AIDS pandemic, especially in subSaharan Africa, where 24.5 million people have been infected, more

than 2 million deaths last year, in places like Zambia we are expecting life expectancy to drop from around 60 to 30-something,

and in Zimbabwe from 60 to 40. We haven’t seen anything like this

in recent years. As I said before, I don’t know if we have seen a

pandemic of this level ever. Certainly we haven’t seen an epidemic

since the plague and the pandemic of 1918.

So I do think it stands out and in the magnitude of its impact,

especially in sub-Saharan Africa. The same thing could happen in

Southeast Asia in a few years if the right measures are not taken.

So I think AIDS stands out in the terms of the magnitude of its

impacts.

Mr. BURR. I appreciate that answer. I think sometimes our exclusion of others in fact leads us to be complacent on those other diseases and efforts.

One last question as it relates to New York and specifically the

outbreak of West Nile.

Could you tell us based upon the infrastructure that we had set

up and the process that was in place, and I would think that New

York would be one of the better response areas because of the interest there——

Dr. SATCHER. Yes.

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Mr. BURR. How did our identification take place and our reaction

happen based upon what we had planned if in fact anything like

this happened?

Dr. SATCHER. I think it is a mixed picture. I mostly agree with

the GAO report. I think there is a lot to be pleased with in terms

of the detection, the early detection and communication among

members of the Public Health Service, the State, and local, but

there were also some major weaknesses in the quality of that response that can be corrected in the future.

So we have a lot to be proud of in terms of the early detection.

St. Louis encephalitis, as you know, is very similar in many ways

to West Nile fever. That was the first diagnosis. In fact, the response would be about the same in either indication. But I think

in terms of what kind of infrastructure does it take to prevent and

make sure that that infrastructure is available in communities

throughout this country, I still think we have a ways to go.

Mr. BURR. I thank you, Dr. Satcher, and I yield back, Mr. Chairman.

Chairman GILMAN. Thank you, Mr. Burr.

Ms. Lee.

Ms. LEE. Thank you, Mr. Chairman. Dr. Satcher, I believe, and

thank you very much for your very clear testimony, and I believe

that the Vice President and our U.N. Ambassador and yourself

were absolutely correct in sounding the clarion call with regard to

the HIV/AIDS crisis in terms of it being a national security threat.

It is important that the American people hear you. Now we are beginning to see an understanding as a result of the public awareness

that is being raised around the pandemic with regard to HIV/AIDS,

and it is important for us in Congress to hear that from the American people.

What is it that you think Congress can do to really move this

issue forward so that we can make sure that the resources by the

United States are there for combating infectious diseases?

Dr. SATCHER. I think Congress can make sure that our response

is consistent with the magnitude of the problem. I don’t think it

has been yet. I think, as former Congressman Dellums and you and

others have pointed out, this is an indication for a major assault

on a very dangerous pandemic. Again, I could say more about the

security threat, I am sure Dr. Gordon is probably going to talk

more about things like that, but when you think about what has

happened in sub-Saharan Africa in terms of the impacts on a family, the social systems, the education, the fact that much of the

progress made in development over many years is being undermined by this epidemic in sub-Saharan Africa, then it is very clear

it is a very real security threat to the world as a whole.

So I believe that Congress should make available the needed resources, and certainly UNAIDS has done a great job of outlining

what is needed, with the leadership of Peter Piot. I agree with Dr.

Piot in terms of his projection of the need for sub-Saharan Africa.

We ought to contribute our share of that.

Ms. LEE. Let me ask you also in terms of the emergence of infectious diseases here in this country that we really haven’t seen either before in a long time, such as diphtheria and malaria, the two

Boy Scouts which got malaria as a result of a mosquito bite in New

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York, is it possible that some of these diseases such as malaria

could become a problem here in this country now, or are these very

isolated instances and we know how to contain it at that level?

Dr. SATCHER. I think it is possible. I think it is going to require

a continuing investment in our public health infrastructure to

make sure that it doesn’t happen. Dengue fever, would you have

thought 5 years ago that we would have 56 cases of dengue fever

in Texas, and 17 of them would have been infected within Texas,

not people who migrated into Texas? We would have doubted that.

So our failure to participate in a global system, the extent to

which we failed, I shouldn’t say our failure, because I think in

many ways we have provided leadership for developing a global

system, but we need to continue to do that, and we also need to

continue to invest domestically in strengthening our State and local

public health infrastructures. I think that is what is going to prevent this happening.

Ms. LEE. Do you think the public will is here to do that in America?

Dr. SATCHER. I am not sure the public knowledge is there, and

that is why this hearing is so important. I think, first of all, the

public needs to know the nature of this threat, the fact that this

is in fact a global threat and that we are not secure as long as

these infectious diseases are moving throughout the world.

So I think the public will probably follow, hopefully, with adequate public education.

Ms. LEE. Thank you.

Mr. BURR [presiding]. The Chair would recognize Dr. Cooksey for

purposes of questions.

Mr. COOKSEY. Thank you, Mr. Satcher, Dr. Satcher. It is great

to have a physician here. You have very good testimony. It is refreshing to hear from someone other than politicians.

I am going to ask some questions that I——

Dr. SATCHER. Coming from a physician, I am delighted to hear

that, a physician-politician.

Mr. COOKSEY. I don’t have near the depth of knowledge. You obviously have a great depth of knowledge. Your testimony was very

clear and it is very good to have that testimony. There is a little

bit, if in fact there is a lot of demagoguery in this body. The other

day we had a group of politicians that was going to correct the

price of gasoline. I had to leave the meeting, I was afraid I was

going to get sick listening to it.

Anyway, question, first, what percentage of the cases of infectious diseases are in sub-Saharan Africa, approximately?

Dr. SATCHER. Between 70 and 80 percent, and certainly I think

83 percent as of December last year were in sub-Saharan Africa.

Mr. COOKSEY. Worldwide you mean?

Dr. SATCHER. Worldwide. We estimate there are probably about

36 million people living today who have been infected, somewhere

between 35 and 36 million, and certainly more than 25 million of

them are in sub-Saharan Africa. But more than 80 percent of the

deaths are occurring in sub-Saharan Africa.

Mr. COOKSEY. What percentage of the world population lives in

sub-Saharan Africa, where over 80 percent of the deaths of infectious diseases are?

21

Dr. SATCHER. It is very small.

Mr. COOKSEY. Is my number 10 percent correct, approximately

correct?

Dr. SATCHER. It may even be higher.

Mr. GEJDENSON. I think it is about 400 million. We have a population of about 6 billion. So it is even less than that.

Dr. SATCHER. It is less than 10 percent.

Mr. COOKSEY. So it is a high percentage.

Next question, what medications that are out there to either cure

or prevent—incidentally, I took my yellow fever shot yesterday for

the first time since 1986, and got a hepatitis shot as well. But what

percentage of these medications or specifically what medications for

these infectious diseases have been developed in Canada or in Mexico or Europe or Asia or Africa? We had a lot of discussion yesterday on the drug bill for Medicare patients, and I heard a lot of comments by some self-appointed experts. I really consider you a real

scholar, so I would like to know from you.

Dr. SATCHER. This scholar is going to have to get back to you,

because clearly the United States is the leader in the development

of these drugs that we are discussing. Research at NIH of course

has been really critical to that, the role of FDA working with industries. FDA regulates the development of drugs by industry and

bringing them to market. So I think clearly we are the leaders in

that regard. But I won’t say what percentage are developed in

other places.

Mr. COOKSEY. I don’t know that answer either.

Mr. GEJDENSON. If the gentleman will yield, I think it is 45 percent of all new drugs are developed in the United States.

Dr. SATCHER. We are talking specifically about the AIDS drugs.

I think it is probably higher.

Mr. COOKSEY. The protease inhibitors, were any of those developed in Europe or Mexico or Africa or Canada?

Dr. SATCHER. Some of the companies are multinational. That is

a very good point. We have been talking about global. Some of

these companies are now global. We all agree most of them have

been developed in the United States, but we also know some of the

pharmaceutical companies are not just limited to the United States

any more.

Mr. COOKSEY. My concern, and again this should not involve us

as physicians, but the economists and the experts here, is that the

United States is indeed developing most of these great medications

that cure infectious diseases and a lot of other diseases, chronic

diseases too, and yet these countries that have socialized health

care, like Canada, like Mexico, like Europe, have price controls on

their medications, so there is no profit there, and there is no profit

made, there is not enough made for them to ever develop, or maybe

they just aren’t smart enough to develop them in Canada or Mexico

or whatever. But I can’t think of anything that has been developed.

Pasteur, Dr. Pasteur and his wife were instrumental 100 years ago.

Who developed smallpox, the British surgeon? Someone here

should know that.

Dr. SATCHER. Edward Jenner actually developed the first cow

pox used in the vaccine.

22

Mr. COOKSEY. At times I feel some consideration should be given

to telling these countries that if they are going to put price controls

on our medications in their countries, they basically are forcing the

American people to pay for research and development of all these

medications worldwide, and it is unfortunate. Would you agree

with that or disagree with that?

Dr. SATCHER. I am going to disagree in part. I want to make it

very clear I think some very quality research is being done in many

other countries, and I believe the other day when we had the conference on the human genome project, one of the reasons we had

the hookup with England, of course, I believe about 30 percent of

the people working on that project have been in Great Britain and

supported by the Welcome Trust Fund.

So Canada, there is some outstanding work going on in Canada,

some of the recently developed Level 4 laboratories there. So there

are some places in the world other than the United States in which

really high quality work is going on. The Pasteur Institute is recognized as one of them. It is still a very quality institute.

Mr. COOKSEY. I agree there is important work being done in

these countries, but they all have offices and market their products

here. They make their profits there and not in the U.K. Thanks

you very much. Your testimony has been excellent. I wish we could

have you here testifying in front of this Committee every time we

have a meeting. It would improve the level of the discussion.

Dr. SATCHER. Thank you very much, Mr. Congressman.

Mr. BURR. The Chair recognizes the gentleman from New Jersey,

Mr. Payne, for questions.

Mr. PAYNE. Thank you very much. I have seen a number of the

researchers at many of the pharmaceutical companies in New Jersey, and in a lot of instances many of the researchers are not

Americans as a matter of fact. They just happen to be here working, just to knock the myth that only Americans can discover

things.

Let me just ask a question quickly. The world AIDS organization

in Geneva is relatively newly created. What participation does CDC

have in it and how do you think they are moving along in their activities?

Dr. SATCHER. UNAIDS is a multi-agency organization that includes WHO, World Bank, UNICEF and several others under the

leadership of Dr. Peter Piot.

I think it is moving well. It is a very difficult task they have, and

Dr. Heymann is probably going to say more about that, he knows

more about it. But we have had a very good working relationship

with UNAIDS. We have a lot to do. We know that. But we have

a lot of confidence in the leadership of UNAIDS and WHO generally.

By the way, I think the new Director General of WHO, Dr.

Brundtland, who we supported, is doing a tremendous job in reorganizing. So I think we are optimistic, but it is a very difficult road

ahead.

Mr. PAYNE. Before the AIDS pandemic came about, malaria has

always been a big killer in sub-Saharan Africa and Africa in general and Third World countries, but there seemed to have been

very little research and move to try to eradicate malaria. Do you

23

think that the fact that the people that get malaria were in areas

where they were impoverished, primarily that there was a lack of

an incentive because of the marketplace?

Dr. SATCHER. The issue of eradication of a disease is a difficult

one, and I am not sure that I could do it justice here, but let me

just say the decision to embark upon the eradication of diseases is

based on several factors. When we decided that it was possible, feasible, to eradicate smallpox, it was because of systems that had

been developed in many places throughout the world and it was

very clear what had to be done, and that some very innovative

leadership was needed. I think the same thing is true for polio.

Polio affects people all over the world, and it affects people in developing countries disproportionately.

Our attitude in this country in terms of supporting a commitment to eradicating a disease has been if it is feasible to do in the

near future working with our colleagues globally, that we should

join that effort.

I think there are a lot of issues related to malaria at this point

in time in terms of the appropriateness of embarking upon an

eradication program. We talk about elimination and eradication.

We have eliminated polio in the Western Hemisphere. We haven’t

had a case now since 1991, the last case in Peru, and not one in

this country since 1979. There are a lot of issues here related to

malaria, in terms of whether we are ready to embark upon a campaign for eradication. Guinea Worm Disease, which does not even

occur in this country—we are all committed to eradicating. We are

very close.

So I don’t think we have made commitments just because of what

happens, whether it happens in this country or in poor countries,

because when we have seen the opportunity to eradicate a disease,

an infectious disease, for the most part we have historically joined

that effort.

Mr. PAYNE. Thank you. I have another two quick questions, and

then I will end. One, since we see that malaria is carried by mosquitoes and Lyme disease by ticks, and currently AIDS virus is not

transported by mosquitoes, is there any research going on that

would determine—of course if indeed mosquitoes could transmit

AIDS, then we are in a very serious situation everywhere.

What is the current medical research on that?

Dr. SATCHER. I think there has been research at CDC and perhaps other places too. I think the present position is that there is

no evidence that the AIDS virus can be transmitted by mosquitoes.

So it is transmitted human to human through sexual intercourse

and certainly increasingly IV drug sharing of dirty needles. Those

are the major ways, of course, and still mother-to-child is a big factor in sub-Saharan Africa, by the way.

Mr. PAYNE. My second question, and then my last half a statement, the fact that you have mentioned on yesterday about the

business of smoking and you also mentioned in your testimony

about the impact of smoking and deaths related to that, my concern is that U.S. tobacco companies now are pushing in Third

World countries tobacco and smoking, making it glamorous. Is the

World Health Organization starting any kind of campaigns to try

to educate Third World people about the dangers of smoking?

24

Dr. SATCHER. Most definitely. That is one of the priorities of

WHO, and, again, Dr. Heymann can say more about it. But the

leadership of WHO, Dr. Brundtland, has made stopping the spread

of tobacco a major part of the WHO. There is a global conference

in August that I will participate in Chicago, I believe there is one

in China in November that I will join. But we are also moving toward trying to get some kind of world treaty dealing with tobacco

that will affect globally this problem and protect people globally. It

is not going to be easy and obviously Congress here will play a

major role in it.

Mr. PAYNE. Thank you. Let me just conclude by saying that although these statistics on HIV/AIDS are just extraordinary, I do

think that finally there is a recognition and that the whole question that it does not exist in many countries now, they are stepping

up to the plate. Even in Zimbabwe, President Mugabe and others

are saying we have a problem and have to deal with it. So I am

optimistic, because I recall my first meetings with President

Museveni in Uganda about 10 years ago, he didn’t want to discuss

it at all, it wasn’t a problem, people shouldn’t be bothering with it.

Then with the conversion that came along 3 or 4 years later, and

then with the aggressive education program that Uganda went out

with song and dance and everybody getting involved, we have seen

the leveling off and probably the decrease in new cases of infection.

So I am optimistic that with this attention being brought, the article in the Washington Post on yesterday, the world focusing on

what you are doing, that perhaps the awakening of leaders to protect, particularly in sub-Saharan Africa, to say we really have a

problem and we need some help, the education part may come

about, and I think we may see a leveling off and perhaps then the

decrease.

Dr. SATCHER. I hope you are right. I think there is some basis

for optimism. Uganda, Senegal and others have demonstrated that

it can be done. So we do have some models. We work very closely

with Uganda over the last 10 to 15 years. But this is a very serious

pandemic. Nobody should for a minute underestimate the potential

of this pandemic. We have got to get very serious globally about

stopping it now.

Mr. PAYNE. Thank you.

Mr. BURR. The gentleman’s time has expired. Do any other Members seek time?

Dr. Satcher, we once again thank you for not only your willingness to come and testify in front of this Committee, but also your

willingness to share with us just how big the challenge is for us,

not only internationally, but domestically, and that we can’t fall

asleep and that there is no single solution. This requires the coordination of many efforts, including that public-private partnership.

For that we are grateful for your message today.

Dr. SATCHER. Thank you, Mr. Chairman.

Mr. BURR. You are welcome. The Committee is now joined via

video conferencing, by Dr. David Heymann, Executive Director,

Communicable Diseases, for the World Health Organization. Dr.

Heymann has held this post for a number of years and has served

at the World Health Organization since 1989. Prior to joining the

World Health Organization, Dr. Heymann spent 13 years working

25

as a medical researcher in sub-Saharan Africa. Therefore, Dr.

Heymann actually is acquainted with the challenges of infectious

disease in the developing world.

We welcome you, Dr. Heymann, your testimony today from the

Headquarters of the World Health Organization in Geneva, Switzerland. It is also good to have another Demon Deacon here in this

hearing.

Dr. Heymann, we now recognize you for the purposes of any

opening statement you would like to make.

STATEMENT OF DAVID L. HEYMANN, M.D., EXECUTIVE DIRECTOR, COMMUNICABLE DISEASES, WORLD HEALTH ORGANIZATION (via video-conference)

Dr. HEYMANN. Thank you, Mr. Chairman.

Congressman Gejdenson and Members, as many of you have indicated, infectious diseases are the world’s biggest killer of young

people in developing countries. In fact, they represent 13 million

deaths each year, one of every two deaths in developing countries.

You can see on the right of this pie diagram those diseases: AIDS,

malaria, TB, diarrhea, measles and acute respiratory diseases or

pneumonia. As Dr. Satcher has indicated, sub-Saharan Africa is

where the majority of the AIDS deaths occur. The remaining infectious diseases and their deaths are spread throughout the world,

so that in Southeast Asia, based on sheer population, one-third of

all the infectious diseases deaths are occurring.

These are diseases of the poor in both industrialized and developing countries, and they also interfere with economic growth,

globalization and international security.

Infectious diseases impede our development efforts. They keep

children away from school and they keep adults from working for

a living. This graph shows that adults infected with malaria are incapacitated and unable to work for an average of 2 days in a country such as Nigeria, and an average of 6 days in Sudan. Malaria

in children prevents their mothers from working in the fields because they must tend to a sick child, and this often occurs during

the rainy season when they should be planting or harvesting.

[Text of the overhead review graphs mentioned appears in the

appendix.]

Infectious diseases are one of the major reasons why poor people

remain poor.

On the next overhead, as shown in this center box, a recent

study from Harvard has indicated that Africa’s GDP would be up

to $100 billion greater this year if malaria had been controlled.

This extra $100 billion would be nearly five times greater than all

development aid provided to Africa last year.

Other infections, such as cholera and plague, also cost countries

money, often because of trade barriers and decreased tourism. Periodic food recalls because of infection can cost millions of dollars, as

in the case of mad cow disease in the U.K., or the recall of hamburger and fruits that has often occurred in the United States.

The global spread of diseases occurs quickly. As shown in this

map, international travel has increased from 27 percent in Europe

to 44 percent in Africa. In 1 year’s time, drug resistant TB has

26

been imported to Germany and Denmark and there has been an increase of 50 percent in resistant tuberculosis in these countries.

Disease, as has been said by many of the Members and by Dr.

Satcher, does not respect national boundaries. In 1991 in Peru, a

ship carrying contaminated water from Asia in its ballast tanks

sparked off a cholera epidemic that spread throughout South America and was responsible for 11,000 deaths. Recently, as we have

heard, mosquitoes imported to the United States in water that had

collected in tires spread infection to the unsuspecting.

CDC is one of WHO’s major partners in the global surveillance

and response activities and infectious disease control activities

worldwide that are greatly supported by the United States, and we

thank the U.S. Congress for assuring that this support continues

to occur.

The security threat of AIDS and other infectious diseases is

great. As you can see on this graph, since 1945, infectious disease

has killed approximately 150 million people, while war has killed

23 million, mainly military and some civilians. Yet the investment

for public defense in 1995 was only U.S. $15 million for infectious

diseases, as compared to $864 billion for military defense.

Immunization campaigns have eradicated smallpox, are on the

verge of eradicating polio, and are rapidly decreasing deaths caused

by measles. Vaccines have greatly reduced illness and death during

the last 30 years, and today deaths occurring from infectious diseases are occurring in those diseases which have no vaccines such

as tuberculosis, malaria and HIV. Fortunately, other low cost treatments and preventive measures are available for fighting these diseases.

We are the first generation ever to have the means of protecting

the world from infectious diseases. Today we possess the knowledge

and the drugs, vaccines and commodities, to prevent or cure the

high mortality infections, tuberculosis, malaria, HIV, diarrhea diseases, pneumonia and measles. These tools have become available

because of successful research in the United States and other countries and the development of research-based pharmaceutical companies, who have, as shown in its second column on this table, developed many, many different tools. They have given us such tools

as the ingredients for DOTS therapy for TB, which is shown in the

third column, and other treatment strategies which have been developed with support from international organizations and also

with heavy support from USAID.

These medicines and preventive tools are inexpensive and they

are cost-effective. The cheapest of these can be bought for less than

5 cents and even the most expensive for tuberculosis costs no more

than $20 for a full course of treatment. As shown in the last column of this table, these strategies are highly effective in curing infection and in preventing death.

Examples of the effectiveness of these strategies is shown in

these two graphs. Malaria deaths are no longer common in Vietnam because of advances in the use of anti-malarial drugs and insecticide-treated bed nets. Oral rehydration therapy developed by

USAID has dramatically reduced death from diarrhea in Mexico.

TB deaths have decreased sevenfold in parts of India through the

effective use of antibiotics, and increased condom use and health

27

education have enabled Thailand and Uganda to reduce the spread

of HIV.

If we fail to make wider and wiser use of these medicines, they

will likely slip through our grasp because the microbes are becoming resistant to their effect. We are in a race against time to bring

down levels of infectious diseases worldwide before these diseases

wear the drugs down first or before new diseases arrive and collaborate to render our interventions today ineffective.

This map shows a small sample of the infectious diseases that

have emerged or reemerged during the past 4 years. They occur

worldwide and regularly they travel with those infected. During

this month alone, we could add eight more diseases to this map.

In 1980, AIDS was just identified and would have appeared on the

map. This was the same year that smallpox was declared eradicated. If smallpox had not been eradicated, the world might still

have its 2 million deaths each year. Immunization with the smallpox vaccine is now known to be fatal for people whose immune system is impaired by HIV. Just a few years delay in eradicating

smallpox might have made it impossible to eradicate because of the

arrival of HIV.

We took advantage of a window of opportunity without knowing

it. Had smallpox not been eradicated, it would be among the top

6 infectious killers in the world today.

Antimicrobial resistance is eroding the strength of medicines,

eventually leaving them ineffective. Antimicrobial resistance is a

natural biological phenomenon amplified many fold from overuse of

medicines in developed countries and paradoxically from under use

of medicines in developing countries.

As seen in this figure on the left, penicillin was introduced in

1942, and already 14 percent of hospital staph infections had developed resistance by 1946. Today penicillin is virtually ineffective

against staphylococcus, as are the second line drugs which replaced

penicillin.

The graph on the left of this next overhead shows how rapidly

resistance to salmonella, a bacterium that commonly taints food

products, has developed resistance in Germany. The graph on the

right shows how rapidly malaria has developed resistance to all

drugs used in its treatment. Likewise, Streptomycin was once the

most effective drug we had in treating tuberculosis. Today it is virtually useless in Europe. In the United States, a variety of medicines used to treat patients in hospitals, such as Vancomycin, are

less effective, leading to thousands of deaths each year.

Drug resistance threatens to put simple medical treatments out

of the reach of poor people, even out of the reach of those who are

wealthy. We heard about tuberculosis in the United States. The

emergence of multi-drug resistant bacteria means that infections in

the United States which once cost $2,000 to completely cure must

now be replaced with treatments that cost well over $200,000, and

there are no known TB medicines to cure a recently detected strain

of TB in New York.

Since 1970, no new classes of antibacterial drugs have been

placed on the market to combat infectious diseases in humans. On

the average research and development of anti-infective drugs takes

10 to 20 years, as shown in this table. Currently there are no new

28

antibiotics or vaccines ready to emerge from the research and development pipeline. This is why it is urgent that we make wider

and wider use of the effective medicines and tools we now have, before resistance makes them ineffective.

We may only have the next decade or two in which to make optimal use of these medicines before our window of opportunity to

fight these infectious diseases closes. We must remember, as many

of the Members have said, today’s world of globalization causes a

resistant organism anywhere to be a problem for us all.

At the same time, infectious diseases are no longer seen exclusively as a health issue. They concern finance ministers and the

IMF as they discuss modalities for debt relief. They concern the

U.N. Security Council as it discusses HIV/AIDS in Africa, and they

concern 22 ministers of health and finance in the Netherlands who

recently conducted a summit on tuberculosis. They concern leaders

of G–8 countries meeting this July 21 to 23 in Okinawa, as we

have heard, and we understand that the G–8 countries will consider calling for a powerful health initiative as a contribution to reducing world poverty.

Mr. Chairman, Committee Members, it is time to go to scale with

the knowledge we have about controlling major diseases of poverty

as a means of ensuring international public health security for us

all.

The next overhead shows us what is required. A massive effort

is required to reduce the infectious diseases of poverty. This massive effort must broaden our thinking from vaccines as a means of

preventing mortality and alleviating poverty to also emphasize

drugs and other commodities such as bed nets and condoms. We

must aim such a massive effort against the high mortality causes

of poverty, those 6 diseases which we have talked about, and unsafe pregnancy.

At the same time, we must implement this massive effort

through weakened health systems, but we must also count on nongovernmental organizations and communities and other proven

means to get the goods to the patients.

With a massive effort, deaths and disability caused by the high

burden diseases in low income countries could be reduced by as

much as 50 percent, as shown in the next overhead. This could be

before the year 2010. Then we could also have security from these

infectious diseases worldwide.

Two futures are equally conceivable as we enter the 21st century.

Infectious diseases can continue to burden human development,

while diseases emerge and drug resistance reverses the scientific

progress of the past century and threatens human security; or we

can make a massive effort to provide the medical advances of recent decades to all people, dramatically cutting the impact of infectious diseases and preventing health, economic and security problems tomorrow.

Thank you, Mr. Chairman.

[The prepared statement of Dr. Heymann appears in the appendix.]

Chairman GILMAN. Thank you, Dr. Heymann, for your informative statement on the situation on infectious diseases worldwide.

We appreciate your cooperation in testifying from your headVerDate 11-MAY-2000 17:22 Nov 17, 2000 Jkt 000000 PO 00000 Frm 00032 Fmt 6633 Sfmt 6633 67067.TXT HINTREL1 PsN: HINTREL1
29

quarters in Geneva. We have a few questions, if you would be

pleased to entertain them.

Dr. Heymann, I understand the World Health Organization has

launched this massive effort to take advantage of our narrow window of opportunity to eradicate these deadly infectious diseases.

Can you please explain what is different about this effort and how

the international community can better coordinate its efforts to

combat and defeat these infectious diseases?

Dr. HEYMANN. This effort is occurring because we are seeing a

decrease in the effectiveness of those tools which we already have

available, of the antibiotics used to treat these infections and the

various other interventions. Therefore, what is new is we have a

very short window of opportunity in which to use these tools which

U.S. industry has provided to the world.

We need to use them rapidly. We need to get them more widely

used throughout the world.

Chairman GILMAN. Dr. Heymann, I would be interested in knowing whether the recently announced efforts by the World Health

Organization to focus on the principal killer diseases, AIDS, tuberculosis, and malaria, will distract in any way from our efforts to

build the health infrastructure of the developing nations?

Dr. HEYMANN. We think that by concentrating an effort on these

infectious diseases and by getting the drugs and the goods that are

necessary to weakened health systems, we can strengthen this by

depending on nongovernmental organizations, community structures and others to help the governments themselves spread these

goods throughout the country.

Chairman GILMAN. Dr. Heymann, when the leaders of the G–8

countries meet next month to discuss, among other things, the

threat of infectious diseases, how will the World Health Organization focus international attention on the need to build the overall

health care capabilities of the developing world?

Dr. HEYMANN. The World Health Organization has started two

major initiatives: The Stop TB Initiative and the Roll Back Malaria

Initiative. As we heard earlier, the UNAIDS program is coordinating a massive effort against AIDS.

By working together with these three initiatives, and our partners who are from both the public and the private sector, including

industry, including groups who are working on these diseases in

developing countries, we anticipate that this massive effort that

will be called for by the G–8 will be successful.

Chairman GILMAN. Thank you, Doctor. I will now recognize the

gentleman from Connecticut, Mr. Gejdenson.

Mr. GEJDENSON. Thank you, Doctor. It was a pleasure meeting

with you at breakfast, I guess a week or two ago. The more we look

at this, the things you have laid out for us, obviously are critical

issues.

I guess several areas, one is we really need to get direction on

the kinds of assistance we need to provide or guidance to develop

the infrastructure, because it seems clear that is one place that is

really lacking in a lot of the particularly sub-Saharan Africa countries, but elsewhere in the world, where even if you have the medicine, the needles and everything, you can’t get the job done.

30

The second is getting the G–7 to direct some resources to the illnesses of the poor, something Mr. Payne was pointing out. We tend

to put all of our resources or most of our resources where it affects

developed nations, and that is a short-term obvious response, but

long-term it does endanger us, and it is just good humanitarian

policy to find cures for those illnesses that affect the developing

world.

I guess the last thing is, when we looked at this 747 flight coming in from Israel with one man with, I guess, meningitis, I mean,

how concerned should we be about bioterrorism in the sense that,

here is an easy way to spread disease very rapidly, and are we in

the developed world prepared to respond to this challenge?

Senator Schumer, our former colleague now in the Senate, argued that the basic infrastructure systems that we have, even in

major metropolitan areas like New York City, would very rapidly

be overcome.

Dr. HEYMANN. Thank you. Regarding infrastructure, I think any

of us who have been in developing countries know that we can get

a Coca-Cola, a cold Coca-Cola anywhere, or a cold beer anywhere.

We can also get drugs and bed nets and condoms anywhere. But

it takes a massive effort, not just of governments in those countries, but of the private sector, of nongovernmental organizations,

of everyone working together to get these goods out. We are convinced these goods can be made available, as are Coca-Colas, beer

and cigarettes.

Regarding the 747 and the case of meningitis, this was one of

many cases of meningitis this year that have circulated around the

world. After the Haj in the Mecca this year, there were over 500

pilgrims that returned to their countries in North America, Asia

and Latin America and in Africa, with bacterial meningitis. Many

of these people died and spread this disease elsewhere.

Now, this was not bioterrorism, but bioterrorism will appear the

same way. It will be an epidemic of disease occurring somewhere,

and therefore we are working closely with CDC and with our other

partners throughout the world to develop a network which will

help us identify any infectious disease when it occurs and respond

to that infectious disease on a global basis.

So we are very concerned about not only naturally occurring infectious diseases, but about diseases which 1 day might be caused

intentionally.

Mr. GEJDENSON. Thank you.

Mr. BURR [presiding]. The gentleman’s time has expired. The

Chair will recognize himself.

Once again, welcome, Dr. Heymann. You have been asked and

you have addressed the issue of the infrastructure challenges that

we have that vary greatly from country to country. Let me ask you

to address the cultural hurdles that exist throughout the world,

given the fact that we can get drugs, we can get condoms, we can

get prevention there. What cultural hurdles exist that would make

us optimistic that we can overcome them and meet this challenge?

Dr. HEYMANN. The cultural hurdles are many. In the early days

of HIV infection, countries throughout the world refused to admit

that they had this disease because they felt it was stigmatizing.

The same occurs with diseases such as Ebola. People don’t want to

31

admit this disease occurs in their country because they fear that

they will be blamed if it spreads out of their country, or they fear

they are being blamed for the disease. So culturally, countries are

not willing to accept these diseases.

Only by working with them, through activities such as CDC will

soon have in the Life initiative project, which is working throughout Africa on HIV/AIDS, and this project will also be supplemented

by USAID activities, can we begin to change cultural norms and

cultural behavior.

Taxes are also a very important reason why goods don’t get into

countries. We have just completed working with Uganda and having them decrease, actually eliminate, all their import taxes on bed

nets and anti-malaria drugs for treating malaria, so that these will

not be an obstacle to infection treatment.

So what you are seeing is, working together as a global community we can change cultural habits so that countries do accept recommendations to drop taxes or to admit that they have infectious

diseases.

Mr. BURR. Dr. Heymann, in your estimation, can we ever hope

to actually control infectious disease, or is the best we can do to

have a better understanding of what our risk is and where that

risk may be coming from?

Dr. HEYMANN. We must control infectious diseases where they

are occurring, and presently they are occurring among the poorest

of the poor. Our hope is that we can decrease mortality, decrease

deaths from these infectious diseases enough so that people do survive, do produce economically, and pull themselves also out of poverty. We can’t push people out of poverty, we can help them pull

themselves out of poverty. If we can do that, and we can change

the balance of people who are out of poverty to those who are in

poverty, there is a good chance that we can continue the momentum to get rid of infectious diseases, at least as major public health

problems. But they will still be with us, and there will still be the

chance of new infections jumping the barrier from animals to humans and causing major epidemics in humans, as did HIV 20 years

ago.

Mr. BURR. Thank you, Dr. Heymann. Once again I appreciate

your patience during this hearing, but I am sure it was much easier than the flight over would be.

The Chair recognizes the gentleman from New Jersey.

Mr. PAYNE. Thank you very much. It is according to what time

it is over there. Let me ask about the World Health Organization.

In your Report 2000, you refer to a new paradigm to combat infectious diseases. We have had great success in the past with the

eradication of smallpox and other diseases such as polio. Would you

please explain what is new about the new efforts to combat microbial resistance to infectious diseases and whether the program

sponsored by the United States needs to be altered in light of the

new threats?

Dr. HEYMANN. What has happened, and this has been through

major support from industrialized countries, including the United

States, is that we have been able to get vaccines to the populations

that needed them and we have decreased deaths occurring from

32

vaccine preventable diseases. Now what remains is the diseases for

which there are no vaccines.

We must continue our efforts to develop new vaccines, and we

must intensify this effort, because a vaccine is the only way to prevent an infection and to prevent the complications of an infection,

and also to prevent the effects of drug resistance.

What we see today is that we have the drugs to treat these major

infections, but we are losing them because of resistance. The organisms we use to treat them are rapidly becoming resistant to these

drugs.

As a result, we need to get the drugs available rapidly while

there is still time. We need to get them to all people with infections

so we can decrease infections while the majority of these infections

are still not resistant, and get them to a level at which they will

not interfere with economic development or spread to other countries.

Mr. PAYNE. Thank you very much. It is sometimes suggested

that we have an overuse of antibiotics in the United States and

other industrialized countries. In terms of educational efforts, what

should we be doing here to discourage overuse and what can we do

to prevent the misuse in developing countries? Are there any ongoing programs that you are addressing this problem with?

Dr. HEYMANN. Education is the answer to overcoming antimicrobial resistance. Health workers, physicians, must not over

prescribe, and, at the same time the public should not demand

antibiotics, which many times happens. We have all gone to a doctor and requested an antibiotic when we didn’t know we really

needed one, and because the doctor wanted to make us happy, he

or she provided an antibiotic, and, if not, we went to another doctor

who did.

Education of the public decreases demand for antibiotics. This

has been shown in Canada, just next door, where they decreased

antibiotic use by over 4 percent through an education campaign of

the general public indicating that the public should not demand

antibiotics.

In developing countries, the issue is different. It is under use

which causes resistance. There we have to make sure that the

drugs are available in sufficient quantities so that there is no

under use, so that infections are properly treated.

Mr. PAYNE. Finally, I have heard you talk about the private sector. How are you there at the World Health Organization involving

the private sector to meet some of these challenges?

Dr. HEYMANN. The original program with private segment input

was with Merck & Company from the United States, which provided all the drugs necessary to eliminate river blindness in subSaharan Africa. Since then there have been many, many more programs. SmithKline Beecham from the United States has provided

the drug that is necessary to get rid of elephantiasis throughout

the world, and, in partnership with Merck, which is providing

Ivermectin, another drug also useful in this disease, we will eliminate this disease from the world.

At the same time, the Novartis Company has given all the drugs

necessary to get rid of leprosy. Pfizer has given drugs to eliminate

trachoma as a public health problem. So companies have joined

33

with WHO in providing the goods necessary. When this occurs,

other partners come in very rapidly, from the private sector, from

the nongovernmental organizations and from governments such as

the United States

So what we are seeing is the private sector is catalyzing the possibility of eradicating and eliminating many infectious diseases, but

this is a short-term solution. We need also to have industry at the

same time producing the new vaccines and the new drugs that are

necessary for the future.

Mr. PAYNE. Thank you very much. I am very aware of the Merck

project, since it is in New Jersey, and I visited them while they

were working on the river blindness, and Du Pont providing some

of the nylon to be used in the process, and, of course, former President Carter taking this on as a main issue. So we do know that

that cooperation between private and public is very important.

Thank you very much for your testimony.

Chairman GILMAN [presiding]. Thank you, Mr. Payne. Mr.

Meeks.

Mr. MEEKS. Thank you, Mr. Chairman. Doctor, thank you. Your

testimony has been very informative.

Let me ask a question in that in developing nations, they have

a whole host of problems and issues, and the statistics you utilized

to show this, talking about the economic impact of infectious diseases in developing nations, is astounding. But one of the things

that I think happens, and I ask you do you agree, that a large part

of the problem is the willingness of developing countries to acknowledge that they in fact have these kinds of health problems

and as a result the economic problems.

So my question to you is how does the World Health Organization work with governments to help them understand that they

have that problem so they can address their health care needs?

Dr. HEYMANN. It is true that governments many times want to

close their eyes to problems and commitment to health is very low

in most developing countries.

The way that the World Health Organization works to increase

the importance of this is through global meetings or summits. For

example, we worked with the president of Nigeria in April of this

year in which we had a summit of African heads of State who discussed malaria, who committed by signing a declaration to work to

eliminate malaria as a public health problem in Africa.

They signed an agreement that they would commit resources and

the WHO and other partners agreed that they would provide additional resources.

The same thing happened in tuberculosis. The government of

Netherlands hosted a tuberculosis summit where ministers of

health and ministers of finance from the 22 tuberculosis burdened

countries, those countries with the most tuberculosis, met. Secretary Shalala was present at this meeting in the Netherlands in

March.

At this meeting, ministers of health and finance both signed a

declaration on the willingness of these countries to commit funds

to the elimination of tuberculosis while the window of opportunity

is still open.

34

Mr. MEEKS. We talked and I know that a significant amount of

resources, although the resources that are going toward health care

in the chart that you showed was a drastic difference, $15 billion

for research in dealing with vaccines, et cetera, as opposed to 400

and some odd billion we invest in defense, but a significant amount

of those resources have been made available to develop vaccines for

a whole host of infectious diseases. I understand the importance of

them. But what are the specific health care tools that the World

Health Organization considers of vital importance to immediately

combat diseases that can be prevented or treated, such as tuberculosis, malaria and the measles?

Dr. HEYMANN. The tools that we have today are a vaccine for

measles. This must be expanded, because measles kills many children. It still kills about 1 million children in the world. So we need

to get this vaccine out. It is available, we need to get it out.

For tuberculosis, we have antibiotics. For diarrheal diseases,

which kill the majority of children in developing countries, we have

oral rehydration therapy, which was developed with support from

USAID. We now need to get these goods out to the people, through

a massive effort, making use of any delivery system we can.

Mr. MEEKS. I am listening and you are telling me that we have

these vaccines that are readily available, we need to get them out.

What can we in the United States, what can we do to help get

them out, because as indicated throughout the testimony, this may

be happening or occurring in the developing nations now, but tomorrow someone can take a plane ride and they are here in the

United States of America. So it is in our national defense to get

these vaccines out. What in addition to what we are doing can we

in the United States and the G–7 nations do to get them out and

distribute them in a more timely fashion?

Dr. HEYMANN. The United States, as you already said, is doing

a lot. But what we need to think now is in much greater terms.

We know that the G–7 this year will be promoting a fight against

the diseases of poverty. What we need to do is think not in millions, but in billions of dollars.

We estimate that by an investment of $15 billion in getting the

goods available, the drugs and the bed nets and the condoms available to countries, to NGO’s, that we could halve infectious disease

mortality from the major infectious diseases in the next 10 years.

That takes much bigger thinking than we have done before. It

takes dependence on many, many types of distribution systems in

countries. But we feel it can be done, and we are very pleased that

the G–7 is taking this up as an issue in the meetings coming up

in Japan.

Mr. MEEKS. Thank you.

Chairman GILMAN. Thank you, Mr. Meeks.

Any other questions? Mr. Burr?

Mr. BURR. No.

Chairman GILMAN. Mr. Payne, any additional questions?

Mr. PAYNE. No, Mr. Chairman.

Chairman GILMAN. If not, Dr. Heymann, we thank you very

much for taking your time to be with us by way of video conferring.

We thank you for your recent visit to Washington. We hope we will

see you again soon. Keep up your good work.

35

Dr. HEYMANN. Thank you, Mr. Chairman.

Chairman GILMAN. We will now proceed with our next witness,

Dr. David Gordon, National Intelligence Officer of the National Intelligence Council.

The Committee is pleased to welcome the testimony of Dr. David

Gordon of the Economics and Global Issues Section of the National

Intelligence Council. Prior to joining the NIC, Dr. Gordon was U.S.

Policy Program Director of the Overseas Development Council, and

in early 1990’s, Dr. Gordon served as a professional staff member

of the House International Relations Committee.

Welcome back, Dr. Gordon.

STATEMENT OF DAVID F. GORDON, PH.D., NATIONAL INTELLIGENCE OFFICER OF ECONOMICS AND GLOBAL ISSUES, NATIONAL INTELLIGENCE COUNCIL

Mr. GORDON. Thank you very much, Mr. Chairman.

Chairman GILMAN. Please proceed. You may put your full statement in the record and summarize, whichever you deem appropriate.

Mr. GORDON. Thank you very much, Mr. Chairman. I want to

thank you and the Distinguished Members of the Committee for

providing me the opportunity to participate in this very important

hearing.

It certainly is an honor for me to share the podium with Dr.

Satcher and Dr. Heymann, both of whom I greatly respect and admire. My testimony this morning will be drawn from a declassified

national intelligence estimate recently produced under my direction

entitled ‘‘The Global Infectious Disease Threat and Its Implications

for the United States’’.

As you know, Mr. Chairman, NIE’s are prepared for the President and other senior policy makers on issues that have strategic

implications for the United States, and they represent the most authoritative assessments of the Intelligence Community because

they reflect the coordinated judgments of the senior officers of all

of the relevant agencies.

The Infectious Disease Estimate represents an important initiative on the part of the Intelligence Community to consider the

broad national security implications of a nontraditional but highly

lethal threat. My remarks today will focus on the social, economic,

political and security implications of the infectious disease threat.

We have heard a lot about the science and the epidemiology from

our distinguished panelists this morning.

The Estimate’s most significant judgment is that new and reemerging diseases will pose a rising and in the worst case a catastrophic global health threat that will complicate U.S. and global

security over the next 20 years. These diseases will endanger U.S.

citizens at home and abroad, threaten U.S. Armed Forces deployed

overseas, and exacerbate social and political instability in key countries and regions where the United States has significant interests.

In national security terms, the global infectious disease threat

manifests itself in a number of ways. First is the link between infectious diseases and the increasing possibility of a biological warfare or biological terrorism attack against the United States or U.S.

36

equities overseas as hostile states and terrorist groups exploit the

ease of global travel and communications in pursuit of their goals.

Today, at least a dozen states are pursuing offensive BW programs, as are a growing number of terrorist organizations. The

West Nile virus scare in the New York-Connecticut area last year

indicates the confusion and fear that even the possibility of a BW

attack can sow, and it highlights the importance of effective collaboration among public health authorities, law enforcement agencies, and the Intelligence Community in monitoring global BW

threats.

Second is the direct risk posed to U.S. health by the importation

of infectious diseases which, as we have all discussed this morning,

do not respect national borders.

The next major infectious disease threat to the United States

may be like AIDS, a previously unrecognized pathogen, or it may

be a new strain of influenza developing in Asia. Flu now kills some

30,000 Americans annually. Epidemiologists generally agree it is

not a question of whether, but when the next killer flu pandemic

will occur.

Or it may be, as several people emphasized this morning, drug

resistant TB, which we thought we had under control but is now

being brought back into the United States by travelers and immigrants.

The third national security dimension is the potential impact on

the military, both U.S. troops abroad and on the readiness of foreign militaries and their ability to engage in international peacekeeping operations. U.S. military personnel deployed in support of

peacekeeping and humanitarian operations in developing and

former communist countries will be of highest risk.

Fourth, the worst infectious diseases, TB, malaria, and especially

AIDS, are slowing economic development in and undermining the

social structures of countries and regions of specific interest to the

United States. As the most recent UNAIDS report that was highlighted in the media yesterday underscores, this will challenge

democratic development and transitions and possibly contribute to

humanitarian emergencies and to military conflicts to which the

United States may be expected to respond.

Fifth, in the economic realm, infectious disease-related embargoes and restrictions on travel and immigration will be a source of

friction among and with key U.S. trading partners and other states

and the issue of intellectual property rights with respect to new

and existing drugs promises to become a major source of controversy between developed and developing countries.

The outlook for infectious diseases shows extreme geographic

variation, both between and within regions. Developing and former

communist countries will continue to experience the greatest impact, but developed countries will also be affected. Although global

health care capacity has improved substantially in recent decades,

the gap between rich and poor countries and the availability and

quality of health care is widening and the revolution in medical

technology may reinforce this trend.

Almost all research and development funds allocated by rich

country governments and the pharmaceutical industries are focused on advancing therapies and drugs relevant to rich country

37

maladies. In general, our study highlights a very close linkage between persistent poverty, malnutrition, poor levels of health care,

and social and political insecurity on the one hand, and high levels

of infectious diseases prevalence on the other.

Let me speak to the social, economic and political impacts. The

persistent infectious disease burden is likely to aggravate and may

even provoke social fragmentation, economic decay and political polarization in the hardest hit countries in the developing and former

communist worlds. At least some of the hardest hit countries, initially in sub-Saharan Africa and later in other regions, face a demographic catastrophe as AIDS and associated diseases reduces

human life span dramatically and kills up to one-quarter or more

of their populations over the next 15 years, including up to one-half

of their youth.

Last year, 10 times as many people in sub-Saharan Africa died

of AIDS than died of civil conflicts.

Life expectancy is likely to be reduced by 30 years in Botswana

and Zimbabwe, 20 years in South Africa, 13 years in Honduras, 8

years in Brazil, and 3 years in Thailand.

AIDS, particularly in Africa, has hit very hard the professional

classes of teachers, civil servants, engineers and skilled workers

who have formed the social backbone of recent advances in both political and economic liberalization. The degradation of nuclear and

extended families from all across the social structure will produce

severe social and economic dislocations with likely political consequences as well.

With as many as a third of the children under 15 years of age

in the hardest hit countries, some 42 million by 2010, expected to

comprise a lost orphan generation, these countries will be at risk

of further economic decay, increased crime and political instability

as these young people become radicalized or are exploited by various political groups for their own ends.

The economic impact of infectious diseases is already significant

and is likely to grow. They will take an even higher toll on productivity, profitability and foreign investment, again especially in

those most affected countries. World Bank President James

Wolfensohn has recently declared AIDS to be the single greatest

threat to economic development in sub-Saharan Africa, and a growing number of studies suggest that AIDS and malaria will reduce

GDP growth in Africa by 20 percent over the next decade.

The impact of infectious diseases at the sector and firm level is

already substantial and growing, and will be reflected in higher

GDP loss as well, particularly in the more advanced developing

countries with specialized work force needs, such as South Africa.

Several firms have undertaken surveys recently of the costs of

AIDS on profitability and productivity, and these tell a story that

has the potential of having a truly devastating impact as costs escalate and the investment climate deteriorates.

Infectious diseases also will add substantially to national health

bills, setting the stage for cruel budgetary dilemmas and conflicts.

For instance, treating one AIDS patient even modestly in sub-Saharan Africa costs as much as educating 10 primary school students for a year. In Zimbabwe, already half the meager health

budget is spent on treating AIDS, while in Kenya AIDS treatment

38

costs will rise to 50 percent of health spending over the next several years.

Few countries will be able to afford the high cost of multi-drug

treatments for AIDS, ensuring that this disease will continue to be

highly prevalent.

The political impact of infectious diseases will be indirect and it

will be direct to assess with any precision, but it is our view that

the infectious disease burden threatens to add to political instability and slow democratic development in social security in Africa,

parts of Asia, and the former Soviet Union, and may become a

growing source of political tensions in and among some developed

countries as well.

The severe economic impact of AIDS and other diseases and the

infiltration of these diseases into ruling political and military elites

is likely to intensify the struggle for political power to control

scarce resources. Mounting infectious diseases cause deaths among

the officer corps and may also continues contribute to deprivation,

insecurity and political machinations that incline some to launch

coups and contrecoups aimed as often as not at plundering state

coffers. The human losses from infectious diseases is already hampering the development of civil society and will increase the pressure on democratic transitions in sub-Saharan Africa and the

former Soviet Union.

A CIA-sponsored study on the causes of instability suggests that

infant mortality, highly correlated with infectious diseases, is a

powerful predictor of political instability, especially in those states

that have started along a democratic path but have not yet fully

consolidated a transition to democracy.

Infectious diseases also will affect international security and

peacekeeping efforts as militaries and military recruitment pools

experience increased deaths and disabilities. The greatest impact

will be among hard to replace officers, NCO’s and enlisted soldiers

with specialized skills among militaries with advanced weapons

and weapons platforms of all kinds.

HIV/AIDS prevalence in the militaries of heavily infected countries is considerably higher, often twice as high as the rates among

civilian populations, owing to risky lifestyles and deployments

away from home. Militaries in several former Soviet Union states

are increasingly experiencing the impact of negative health developments within their countries and one in three Russian draftees

is currently rejected for health reasons as compared to only one in

20 back in 1985.

While it is difficult to make a direct connection between high

rates of HIV/AIDS prevalence and other infectious diseases on

overall military performance and readiness, it is likely, given a

large number of officers and other key personnel are dying or becoming disabled, that combat readiness and capability of such military forces is bound to deteriorate.

Over the longer term, the consequences of the continuing spread

of deadly diseases such as HIV/AIDS on the more modernized militaries in the former Soviet Union and possibly China, India and

some other states in Africa, may be increasingly severe and have

an impact similar to what we are seeing in sub-Saharan Africa.

39

The negative impact of high infectious disease prevalence on national militaries will be felt in international and regional peacekeeping operations as well, limiting their effective necessary and

making them vectors for further spread of diseases among coalition

peacekeepers and local populations.

Healthy peacekeeping forces will remain at risk of being infected

by disease carrying forces and local populations as well as by high

risk behavior and inadequate medical care.

Chairman Gilman, thank you very much for your attention. I will

be happy to answer any questions that you or other Members of

the Committee have.

[The prepared statement of Dr. Gordon appears in the appendix.]

Chairman GILMAN. Thank you, Dr. Gordon. We thank you for

your review of this problem. How capable is U.S. Intelligence Community in the field of bioterrorism? To your knowledge, has our Intelligence Community been successful in thwarting any bioterrorist

attacks in the form of infectious diseases?

Mr. GORDON. The Intelligence Community is increasing its focus

on biological warfare and has an increasing capability to monitor

the efforts of both hostile regimes and other groups.

That said, that said, we are concerned both about the groups we

know about and the groups that we don’t know about. While the

risk of biological warfare is still a small one in percentage terms,

the impact is potentially very, very, very great. We are working

very hard, both with people in the public health communities, with

people in the law enforcement communities, both nationally and

internationally, to increase our capability to monitor the efforts of

those who would do us harm.

Chairman GILMAN. Dr. Gordon, you noted in your testimony despite your collaboration with the World Health Organization

progress has been slow to be able to strengthen your surveillance

programs. In your opinion, what additional specific measures

should be undertaken to enhance the surveillance of infectious diseases? Also, are there any additional early warning systems that

should be developed to enhance our capabilities to detect any bioterrorist threats to our country?

Mr. GORDON. I think that the answer lies in enhancing international collaboration, enhancing the U.S. role, already a very

strong leadership role in international efforts on surveillance,

working with the world health organizations.

We have been quite impressed by the improvements made in the

world health organizations by Dr. Heymann and his colleagues that

currently undertake a highly sophisticated epidemiological intelligence operation to ensure that new pathogens, as soon as they are

noticed, can be quickly identified and linked up into broader intelligence and law enforcement operations to judge whether or not

they pose a political threat as well as a health threat.

I think that a good deal of diplomacy will be needed, both at the

bilateral and multilateral level, to increase collaboration, particularly by developing country governments with these efforts internationally.

Chairman GILMAN. Dr. Gordon, one last question. In addition to

the danger posed to American Armed Service personnel who serve

overseas, is there an increased danger to the American public of

40

diseases unwittingly brought to our shores by soldiers returning

from overseas duty? Does the military have adequate measures in

place to both safeguard the health of military personnel and to prevent their becoming unwitting carriers of infectious diseases?

Mr. GORDON. The military is constantly monitoring these issues.

In fact, within the Intelligence Community, our main component

that works on these issues is in Armed Forces intelligence. We at

this point are satisfied that we do have the capabilities to ensure

that returning U.S. military personnel will be effectively screened

so as to ensure that an infectious disease that might have been acquired while overseas, either in a normal deployment or in a peacekeeping operation, does not get transmitted to the United States.

These, however, are not foolproof and depend upon the existence

of a robust overall surveillance program internationally.

Chairman GILMAN. Thank you, Dr. Gordon.

Mr. Payne.

Mr. PAYNE. Thank you very much for your very clear paper and

your comments. I was also concerned about what steps the military, and maybe the question wasn’t asked, what steps are we taking with our military as they are overseas? I know we don’t have—

we have virtually no U.S. peacekeepers in sub-Saharan Africa, but

we do have them in Eastern Europe and Asia where I am sure, the

disease is not as prevalent, but it is there.

What do we do when they are in the regions outside of the country to ensure that their health and safety is provided for?

Mr. GORDON. There are basically three elements to the efforts of

U.S. military to ensure the health of U.S. forces overseas.

First, are that U.S. forces have as comprehensive and up-to-date

immunization package as exists in the world. We work very, very

hard to ensure that happens, and, again, that is partially facilitated by the international collaboration that I have been talking

about.

Second, is education, to ensure that our soldiers know what the

risks are and know how to protect themselves against those risks

and are constantly being reeducated about those issues.

Third, is monitoring, and there is a very aggressive program of

monitoring the status, the health status, of U.S. forces deployed

overseas.

Mr. PAYNE. Thank you. Perhaps you could explain a little bit to

us about the general overview of the contingency plans that exist

should the worst case scenario develop with regard to the spread

of infectious diseases in developing countries. Specifically, what

measures would the United States have to undertake in the event

that the spread of infectious diseases were to be unchecked as set

forth in part of your statement?

Mr. GORDON. Mr. Payne, I think that our main efforts have gone

into working to ensure that the worst case scenario is not going to

take place, so part of the whole aim of international efforts here

at both surveillance and response to infectious diseases is to try to

minimize the likelihood of the worst case scenarios coming into

play.

That being said, we are already in sub-Saharan Africa and in

several of the sub-Saharan African countries, in a situation that is,

if not a worst case, close to a worst case scenario, and we are trying

41

to work collaboratively both with those governments, with the

international community, institutions like the World Health Organization, the international financial institutions, particularly the

World Bank, to ensure that there is as effective as possible a response to these issues.

There is no grand plan for a worst case scenario developing

which would occur over a longer term. Certainly if we see ourselves

moving into that scenario, I think planning for those contingencies

would take on a more prominent role.

Mr. PAYNE. Thank you. In your opinion though, is there an effective coordination between the military intelligence and science and

health communities in addressing the infectious disease threat? Do

you all kind of stay in touch with each other?

Mr. GORDON. We are certainly pleased by the increasing degree

of collaboration on biological terrorism and biological warfare.

There is increasingly close collaboration between the Department

of Defense, the Centers for Disease Control and the Intelligence

Community in monitoring and working together to plan contingencies to address these issues. I think that is one of the large advances that we have made in recent years.

Mr. PAYNE. Just finally, do you feel that Congress is providing

enough assistance to deal with these infectious diseases, for security and surveillance programs and all the rest? I know it is a real

concern, and our goal is to provide assistance overseas as needed,

but also to safeguard the health of American people. What is your

feeling on that question?

Mr. GORDON. Congress has been responsive to the requests for

support from the Intelligence Community, and I believe that as we

stand now, we are in an adequate situation. I think as several of

the other speakers mentioned, in the larger view of the infectious

disease threat, I think that the international community as a whole

is just beginning to come to grips with the resource mobilization

that will be needed.

Mr. PAYNE. Finally, it has been mentioned that it has been declared that this whole question of infectious disease is a national

security issue or threat. Do you concur with that finding?

Mr. GORDON. Yes, I think that as several speakers today have

highlighted, both among the Members and the panelists, that

taken together, I think the range of effects that the rising global

infectious disease trends provides to the United States raises some

very, very serious national security implications.

I would not want to get into an academic exercise of trying to define precisely whether and when something becomes a national security issue or a national security threat, nor would I suggest that

all health issues are national security issues. I think many, if not

most health issues, are not national security issues, they are public

health issues.

But in general for the reasons I laid out in my testimony, we see

a whole series of national security concerns attached to the infectious disease threat, which in sum I do believe raise it to a national

security interest of the United States.

Mr. PAYNE. Thank you very much.

Mr. BURR [presiding]. I thank the gentleman from New Jersey.

The Chair would recognize himself. Welcome, Dr. Gordon. You and

42

I have had an opportunity to spend some time together to talk in

depth, so I will be very brief today.

Let me followup on Mr. Payne’s comments as it relates to the cooperation, collaboration, between intelligence, the science community, the health community.

I sensed just a little bit of hesitancy in the answer from the

standpoint of the way the question was posed, so let me try to restate it and hopefully solicit an answer that covers everybody in

that loop.

From the standpoint of the military, the Intelligence Community,

the science community, the health community, is there the level of

cooperation between all of those that makes you feel confident that

we are on top of this challenge of infectious disease and its threat?

Mr. GORDON. I believe, as I said earlier, that we are still at a

place where we have work to do, both as a national government

and internationally as a global community, in effectively addressing the global infectious disease threat.

I do believe that as a government we have taken very significant

steps to enhance collaboration among the scientific community, the

national security establishment, and the Intelligence Community,

particularly on issues relating to the biological weapons threat per

se.

We also now have an interagency working group at the White

House level on AIDS that is working to bring together all of the

various elements in government who have a stake in the AIDS

issue.

I think the fact of the matter is that as both of our previous

speakers emphasized, that coming to grips with the global infectious disease threat is not something that is going to happen overnight, and that there is still a need to mobilize support, both publicly and privately, so that a sufficiently robust effort is made that

will enable us to turn the corner on this issue.

Mr. BURR. You are, and I think it is safe to say the Congress is,

aware of the challenges that exists between agencies to communicate, and when we bring health and the science community into

it, it is naturally a challenge. But in fact that level of communication has to exist if in fact we want to be ahead of a problem that

we can’t stick our finger out today and say ‘‘this is it,’’ because it

is a range of scenarios that could pop up is the problem.

I trust that you, from the standpoint of the intelligence agencies,

like I would the health community who was here earlier, will share

with us when you think that there is help that is needed from this

body to make sure that that cooperation and collaboration, not only

to address an existing problem, but to anticipate where our greatest needs might be in the future and when we can help.

Let me ask one question, and that deals with HIV as the only

designation from the infectious disease as a national security

threat. I personally agree with that designation. I am not sure that

I would limit it to one infectious disease, and I would ask you from

the standpoint of the Intelligence Community, was that your recommendation as well, or would you include additional infectious

diseases at the same level that you would AIDS/HIV?

Mr. GORDON. We have done a lot of work on the issue of HIV/

AIDS, on the impact of HIV/AIDS on militaries. Certainly the work

43

that was undertaken on this issue by the Intelligence Community

was a major input into this designation.

In our study of infectious diseases and their implications for the

United States, we did take a broader look at the global infectious

disease environment, and I do think that while I agree with you

that while HIV/AIDS in and of itself is a security issue globally and

to the United States, there is a larger context.

I don’t believe that there is necessarily a tradeoff between dealing with HIV/AIDS on the one hand as a security threat and dealing larger—with infectious diseases more generally as a security

threat, but I do think it is something we have to pay attention to,

that HIV/AIDS is not the only disease out there.

Mr. BURR. Is there a reason that the national security threat was

not infectious disease versus one specific infectious disease?

Mr. GORDON. We were asked by the State Department, the Secretary of State, to look at infectious diseases more generally when

this paper was tasked to us.

Mr. PAYNE. Would the gentleman yield? I listened to the question

regarding—and there is no question about the fact that malaria

really is a real killer and tuberculosis is increasing. But when I

read that Washington Post article on yesterday, I mean, we have

got a lot of diseases, and we have bad diseases and tough diseases

and diseases that have been around, but we have never had a disease that has reduced the life expectancy by one-third in 3 or 4

years. I mean, this is magnitude that the Black Plague in Europe

didn’t even experience. The life expectancies of 20 years and 25

years in some countries at this point, I mean, I concur that there

are a number of serious problems that we have around, even more

being discovered in food products.

We once thought if you just ate chicken, you were fine, leave the

pork alone. Then you find, there was salmonella or whatever comes

up, and beef was always definitely OK, but now you find you got

to be careful, we can’t leave the beef out when you do your backyard cooking. So we are discovering a lot more in food products,

shellfish, you got to watch that, you know. I am on carrots right

now.

But there has been nothing that I can remember, reading history

or at the present, that is anywhere near, in my opinion, as devastating as this pandemic. I think this AIDS and HIV virus is really standing in a class all by itself, is the way I see it. But that is

not to—you know——

Mr. BURR. The gentleman’s point is a very important one, and

one I would agree with. My question stems more from the fact that

we do know the means of transmission for AIDS, we do see and can

follow its progress from sub-Saharan Africa to Asia, and we have

a history which gives us a good gauge for what the threat is to the

new areas that HIV/AIDS is emerging in.

But from a standpoint of the other infectious diseases that we

might not yet know the scope of transmission, that we might be

faced with resistant strains without the tools to treat it today, in

fact there is a bigger question mark and an unknown as it relates

to its impact 10 years down the road, and I raise the issue more

to make sure we are not focused on one area of the water balloon

while there is a squeeze somewhere else and a bulge that is in fact

44

created. I think it goes hand in hand with my original question to

Dr. Gordon.

Mr. GORDON. Congressman, I think you are absolutely right, that

the issue of global surveillance and having the ability to monitor

infectious disease outbreaks and understand the epidemiology and

likely epidemiology of those outbreaks is crucially important.

So I think that it is not a question of focusing on HIV/AIDS, but

not focusing on other particular diseases, but especially not losing

track of the ability of the international community to build a very,

very robust surveillance system.

Mr. BURR. My hope is that not only the communications within

our branches of not only government, the health community and

the science community, are in fact strong, but that the world

health organizations can compel other countries to bring their similar communities together to make sure that the review of this

threat worldwide is one that we all take seriously and all share the

information.

Mr. PAYNE. If the gentleman would yield, I am in concert with

the fact that we are looking at drug resistant strains of tuberculosis and so forth. As a matter of fact, when tuberculosis reappeared, there was no streptomycin around, because no one had

it around because there was no tuberculosis around, so they had

to run around to find some streptomycin, and they found a little

place in France that still had some around.

So we do have to really remain focused.

But, for example, are we doing anything, Dr. Gordon, say with

the problem of the tough strains of tuberculosis in the Russian

prison system, where I understand that infection is almost at epidemic proportions and the strains are tough?

Mr. GORDON. Yes, it is. The issue of drug resistant tuberculosis,

particularly in Russia and some of the other areas of the former

Soviet Union, is one of the major infectious disease issues as we see

it evolving over the next several years. It is something that a great

deal of attention is being paid to.

Again, none of these issues, and I want to emphasize what Dr.

Heymann and Dr. Satcher said, none of these issues is amenable

to an easy or quick resolution. Even on AIDS, on which we know

the elements of a strategy that works, combining political leadership, education and destigmatization of the disease, and partnerships between the private sector and nongovernmental organizations and both local governments and the international community,

we know a strategy that works. But that doesn’t mean that you can

easily turn the problem around.

The issue of TB and drug resistant TB, I think it is going to be

one of the very large challenges we face over the next several

years.

Mr. BURR. I thank the gentleman from New Jersey. I also thank

you, Dr. Gordon, for your patience and willingness to compile the

report that you did, and to share with this Committee in a number

of fashions the findings of your investigation.

The unfortunate conclusion of this hearing is that we will continue to meet on this issue well into the future, and my hopes are

today that we are able to narrow the threats down and to talk

45

about successes, not only here at home, but abroad in some of the

many countries we have talked about.

At this time this hearing is adjourned.

[Whereupon, at 2:50 p.m., the Committee was adjourned to reconvene subject to the call of the Chair.]

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A P P E N D I X

JUNE 29, 2000

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