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87–334PDF 2014

THE FIRST ONE THOUSAND DAYS: DEVELOPMENT

AID PROGRAMS TO BOLSTER HEALTH

AND NUTRITION

HEARING

BEFORE THE

SUBCOMMITTEE ON AFRICA, GLOBAL HEALTH, 

GLOBAL HUMAN RIGHTS, AND 

INTERNATIONAL ORGANIZATIONS

OF THE

COMMITTEE ON FOREIGN AFFAIRS 

HOUSE OF REPRESENTATIVES

ONE HUNDRED THIRTEENTH CONGRESS

SECOND SESSION

MARCH 25, 2014

Serial No. 113–195

Printed for the use of the Committee on Foreign Affairs

(

Available via the World Wide Web: http://www.foreignaffairs.house.gov/ or

http://www.gpo.gov/fdsys/

(II)

COMMITTEE ON FOREIGN AFFAIRS 

EDWARD R. ROYCE, California, Chairman 

CHRISTOPHER H. SMITH, New Jersey 

ILEANA ROS-LEHTINEN, Florida 

DANA ROHRABACHER, California 

STEVE CHABOT, Ohio 

JOE WILSON, South Carolina 

MICHAEL T. MCCAUL, Texas 

TED POE, Texas 

MATT SALMON, Arizona 

TOM MARINO, Pennsylvania 

JEFF DUNCAN, South Carolina 

ADAM KINZINGER, Illinois 

MO BROOKS, Alabama 

TOM COTTON, Arkansas 

PAUL COOK, California 

GEORGE HOLDING, North Carolina 

RANDY K. WEBER SR., Texas 

SCOTT PERRY, Pennsylvania 

STEVE STOCKMAN, Texas 

RON DESANTIS, Florida 

DOUG COLLINS, Georgia 

MARK MEADOWS, North Carolina 

TED S. YOHO, Florida 

LUKE MESSER, Indiana 

ELIOT L. ENGEL, New York 

ENI F.H. FALEOMAVAEGA, American 

Samoa 

BRAD SHERMAN, California 

GREGORY W. MEEKS, New York 

ALBIO SIRES, New Jersey 

GERALD E. CONNOLLY, Virginia 

THEODORE E. DEUTCH, Florida 

BRIAN HIGGINS, New York 

KAREN BASS, California 

WILLIAM KEATING, Massachusetts 

DAVID CICILLINE, Rhode Island 

ALAN GRAYSON, Florida 

JUAN VARGAS, California 

BRADLEY S. SCHNEIDER, Illinois 

JOSEPH P. KENNEDY III, Massachusetts 

AMI BERA, California 

ALAN S. LOWENTHAL, California 

GRACE MENG, New York 

LOIS FRANKEL, Florida 

TULSI GABBARD, Hawaii 

JOAQUIN CASTRO, Texas

AMY PORTER, Chief of Staff THOMAS SHEEHY, Staff Director

JASON STEINBAUM, Democratic Staff Director 

SUBCOMMITTEE ON AFRICA, GLOBAL HEALTH, GLOBAL HUMAN RIGHTS, AND

INTERNATIONAL ORGANIZATIONS

CHRISTOPHER H. SMITH, New Jersey, Chairman 

TOM MARINO, Pennsylvania 

RANDY K. WEBER SR., Texas 

STEVE STOCKMAN, Texas 

MARK MEADOWS, North Carolina 

KAREN BASS, California 

DAVID CICILLINE, Rhode Island 

AMI BERA, California 

(III)

C O N T E N T S 

Page

WITNESSES 

Ms. Tjada D’Oyen McKenna, Acting Assistant to the Administrator, Bureau 

for Food Security, U.S. Agency for International Development ....................... 6

Ms. Lisa Bos, senior policy advisor for health, education, and water, sanitation and hygiene, World Vision ........................................................................... 20

Henry Perry, M.D., Ph.D., senior associate, Health Systems Program, Department of International Health, Bloomberg School of Public Health, Johns 

Hopkins University .............................................................................................. 32

Ms. Carolyn Wetzel Chen, chief grant development officer, Food for the Hungry, Inc. ................................................................................................................. 41

Sophia Aguirre, Ph.D., chair, Integral Economic Development Management 

Program, Catholic University of America .......................................................... 50

Mehret Mandefro, M.D., adjunct professor of health policy, Milken Institute 

School of Public Health, The George Washington University .......................... 56

LETTERS, STATEMENTS, ETC., SUBMITTED FOR THE HEARING 

Ms. Tjada D’Oyen McKenna: Prepared statement ................................................ 9

Ms. Lisa Bos: Prepared statement ......................................................................... 23

Henry Perry, M.D., Ph.D.: Prepared statement .................................................... 35

Ms. Carolyn Wetzel Chen: Prepared statement .................................................... 44

Sophia Aguirre, Ph.D.: Prepared statement .......................................................... 52

Mehret Mandefro, M.D.: Prepared statement ....................................................... 58

APPENDIX 

Hearing notice .......................................................................................................... 76

Hearing minutes ...................................................................................................... 77

Written responses from Ms. Tjada D’Oyen McKenna to questions submitted 

for the record by the Honorable Christopher H. Smith, a Representative 

in Congress from the State of New Jersey, and chairman, Subcommittee 

on Africa, Global Health, Global Human Rights, and International Organizations ................................................................................................................... 78

Written response from Ms. Tjada D’Oyen McKenna to question submitted 

for the record by the Honorable Karen Bass, a Representative in Congress 

from the State of California ................................................................................ 83

Mehret Mandefro, M.D.: Revised and extended statement .................................. 84

Henry Perry, M.D., Ph.D.: Materials related to child nutrition .......................... 88

The Honorable Christopher H. Smith: 

Materials from The Lancet .................................................................................. 96

Statement for the record from the American Academy of Physicians ............. 104

Statement for the record from Bread for the World .......................................... 107

Statement for the record from Lions Clubs past president .............................. 109

(1)

THE FIRST ONE THOUSAND DAYS: 

DEVELOPMENT AID PROGRAMS TO BOLSTER 

HEALTH AND NUTRITION 

TUESDAY, MARCH 25, 2014

HOUSE OF REPRESENTATIVES,

SUBCOMMITTEE ON AFRICA, GLOBAL HEALTH,

GLOBAL HUMAN RIGHTS, AND INTERNATIONAL ORGANIZATIONS,

COMMITTEE ON FOREIGN AFFAIRS,

Washington, DC. 

The subcommittee met, pursuant to notice, at 3 o’clock p.m., in 

room 2172 Rayburn House Office Building, Hon. Christopher H. 

Smith (chairman of the subcommittee) presiding. 

Mr. SMITH. The subcommittee will come to order. Good afternoon. First of all, I want to apologize for the delayed opening or 

convening of this hearing. We did have a markup that was only put 

on yesterday and it included the Ukraine Support Act and two 

other bills. And the debate went late and then we had the votes 

that just completed. So we have no further votes, I believe, scheduled so we will not be interrupted. But again, I apologize to all of 

our witnesses and everyone who has taken the time to be here that 

we were late in beginning. 

We are here today to address the topic of ‘‘The First One Thousand Days: Development Aid Programs to Bolster Health and Nutrition.’’

There is perhaps no wiser investment that we could make in the 

human person than to concentrate on ensuring that sufficient nutrition and health assistance is given during the first 1,000 days 

of life; 1,000 days that begins with conception, continues throughout pregnancy, includes the milestone of birth and then finishes at 

roughly the second birthday of the child. 

Consider this: According to the United Nations Children’s Fund, 

6.6 million children died before reaching their fifth birthday in 

2012; an average of roughly 18,000 daily deaths among children 

under 5 years old. Among the factors contributing to such a grim 

tally are malnutrition, obstructed newborn breathing, pneumonia, 

and diarrheal disease. All these, and other causes, are ones which 

we are capable of addressing, if we apply resources and political 

will to the problem. 

Today’s hearing complements various hearings our subcommittee 

with jurisdiction over global health has held over the past several 

years. It was inspired in part by what I experienced at the U.N. 

2

Millennium Development Goals Summit in New York in September 

2010. 

There I had the privilege of participating in an extraordinary 

roundtable meeting of First Ladies of African nations that concluded with the signing of a declaration to end maternal and child 

malnutrition, with particular emphasis on ‘‘the first 1,000 days in 

the life of a child from the moment of conception.’’

The roundtable focused on that great killer of children, malnutrition. The roundtable concluded that undernutrition alone remains 

‘‘one of the world’s most serious, but least-addressed problems—

killing an estimated 3.5 million children annually.’’ In other words, 

food insecurity is a plague which ravages our future, ending the 

lives of little boys and little girls throughout the developing world 

well before their time. The roundtable also pointed out that 60 percent of the world’s chronically hungry are women. 

According to the Global Alliance for Improved Nutrition, or 

GAIN, cosponsor of the roundtable, and as a matter of fact, the 

folks that invited me to be there that day, malnutrition’s most devastating impact is actually in the womb, often causing death or significant mental and physical disability to the precious life of an unborn child. 

Children who do not receive adequate nutrition in utero are more 

likely to experience lifelong cognitive and physical deficiencies, 

such as stunting. UNICEF estimates that one in four children 

worldwide is stunted due to lack of adequate nutrition. 

Children who are chronically undernourished within the first 2 

years of their lives also often have impaired immune systems that 

are incapable of protecting them against life-threatening ailments, 

such as pneumonia and malaria. 

Adults who were stunted as children face increased risk of developing chronic diseases, such as diabetes, hypertension, and heart 

disease. Mothers who were malnourished as girls are 40 percent 

more likely to die during childbirth, experience debilitating complications like obstetric fistula, and deliver children who perish before reaching age 5. 

We must take a holistic, mother-and-child approach to the problem. By helping women throughout pregnancy receive adequate nutrition and supplemental micronutrients, such as iodine, Vitamin 

A, and folic acid, and ensuring that they are well-fed while nursing, 

both children and mothers thrive. 

In addition to addressing undernutrition, there are a number of 

other interventions that can make an impact. About 44 percent of 

all under-5 deaths occur within the first month of life, during the 

neonatal period. Among newborns, the greatest threats to survival 

are prematurity and failure to breathe at birth, known as birth asphyxia. Following the neonatal period through the first 5 years of 

life, child survival is imperiled primarily by pneumonia and diarrheal disease. 

The solutions are often readily at hand. Most neonatal deaths 

can be prevented at little to no expense with neonatal resuscitation, prompt administration of antibiotics, and nutrition supplementation. Inexpensive interventions like oral rehydration therapy, which cost 5 to 10 cents per dose, are also effective in curbing 

diarrheal disease. I would note parenthetically in the early 1980s 

3

I sponsored the amendment called the Child Survival amendment 

which provided $50 million for vaccinations, breastfeeding promotion, growth monitoring, and ORT (oral rehydration therapy). I 

will never forget Jim Grant, the famous director of UNICEF, who 

always had an oral rehydration packet of salts in his pocket and 

he was instrumental in promoting this child survival revolution in 

saying for a couple of cents per day we can save the life of a child. 

We must never pit the survival of the child against that of the 

mother, as both are complementary objectives. Curbing child mortality in the womb and at birth also goes hand-in-hand with reducing maternal mortality. 

Best practices to radically reduce maternal mortality can and 

must be life-affirming, protecting from harm both patients, the 

mother and the child in the womb. Of course, we have known for 

more than 60 years what actually saves women’s lives: Skilled 

birth attendants, treatment to stop hemorrhages, access to safe 

blood, emergency obstetric care, antibiotics, repair of fistulas, adequate nutrition, and pre- and post-natal care. 

Political will is absolutely essential to address this problem and 

to make sure it is adequately resourced. One thing that I hope this 

hearing will bring to light, that such interventions in the first 

1,000 days of life are not only morally imperative but also cost-effective as well. 

One group of Nobel laureate economic experts ranked efforts to 

address undernutrition as the single-most cost-effective investment 

in foreign aid. The economists concluded that each dollar spent on 

reducing undernutrition could yield a $30 benefit. 

One other thing I hope this hearing will highlight is the importance of faith-based organizations in fighting this battle, and to underscore the need for our aid programs to work with such organizations. We will hear from representatives from two such organizations, Food for the Hungry and World Vision, to discuss their insights. 

Faith-based organizations play an absolutely critical role in 

places such as Africa, which one can say is a faith based continent. 

Matthew 25 notes, one of my favorite Scriptures, ‘‘When I was hungry, you gave me food, when I was thirsty, you gave me drink, 

when I was naked, you clothed me,’’ inspires these and other great 

organizations such as Catholic Relief Services, just as it inspires 

the work of this subcommittee and so many Members of Congress. 

For example, in 2004, along with my colleague on the Foreign Affairs Committee, the former chair, Ileana Ros-Lehtinen, I sponsored an obstetric fistula resolution, which passed the House of 

Representatives, seeking to address one debilitating factor that 

wreaks havoc on the lives of mothers and their children. I would 

note that Kent Hill, when we got it past the House, we went over 

to USAID, Kent Hill, who is sick from a recent trip to Africa and 

cannot testify today, he and I had a meeting. I said, look, you have 

the authority already to initiate an obstetric fistula program. It has 

already passed the House, use this as a framework. He did and 

well over 20,000 women have had fistula repairs as a direct result 

of the USAID’s program which has been highly successful. 

The following year after I offered that bill, I was able to amend 

the Foreign Relations Authorization Act to fund 12 centers in the 

4

developing world to treat and prevent obstetric fistula, as well as 

to provide funding for skilled-birth attendants. Importantly, I was 

also able to remove restrictive language from the original bill that 

would have prohibited faith-based hospitals in the developing world 

from receiving funding. Again, I must stress, that it is these faithbased organizations that are doing yeoman’s work on the ground 

to address child and mother mortality, and they must be supported. 

In this Congress I introduced legislation, H.R. 3525, the International Hydrocephalus Treatment and Training Act. Hydrocephalus, or ‘‘water on the brain,’’ is a disease which affects three 

to five out of every 1,000 newborns in developing countries, who 

are either born with it or acquire it due to neonatal infections in 

the first few months of life. For such children, it is often a death 

sentence and a very painful one at that. Doctors, even assuming 

there is even a doctor around, often do not know how to treat it. 

Moreover, if they do treat and use the traditional surgical procedure which requires the life-long use of a shunt, such shunts often 

become infected, leading to death a few years later. 

Our bill would train doctors in Africa in a new and proven technique which does not require a shunt. It was developed by Dr. Benjamin Warf of Harvard, a noted neurosurgeon. And it is effective 

in at least 2⁄3rds of the cases of infants with hydrocephalus. It is 

ideally suited to conditions in the developing world. The amount required to make a difference in the lives of these children and their 

parents is a paltry sum, an estimated $15 million over 3 years. I 

invite my colleagues to consider joining that legislation and I would 

ask, we have asked repeatedly that USAID look at doing it administratively. You don’t need to be told, you can just do it. 

Initiatives such as these are ones which should gather support 

across the political aisle. They are life affirming, and can save 

lives. And I would just note parenthetically, in Cure International’s 

effort in Uganda, in excess of 5,000 children who otherwise would 

have been dead and again, having suffered a very painful death, 

are alive. And we had one of the neurosurgeons testify before our 

committee from Africa, because part of the bill’s hope is to train 

neurosurgeons throughout Africa and to build out that capacity because there are many diseases of the brain that require that kind 

of expertise and there is an absolute dearth of such expertise in Africa and we want to change that. 

I would like to yield to my friend and colleague, Ms. Bass, for 

any opening comments. 

Ms. BASS. Thank you, Mr. Chair, for holding today’s hearing and 

also for yesterday’s meeting that we had with African Ambassadors. I thought it was very, very helpful. I also want to offer a 

word of thanks to today’s witnesses, including the Acting Administrator for USAID’s Bureau on Food Security and a wide range of 

academics, physicians, and non-governmental agency leaders focusing on maternal and public health, nutrition, and economic development. 

I look forward to hearing perspectives from these expert panelists as it relates to the roles of maternal health, nutrition, and food 

security in ensuring the health of mothers and children in the first 

1,000 days of life and beyond. 

5

As Chairman Smith has pointed out, the global scale of child 

mortality is staggering with 6.6 million children dying before their 

fifth birthday in 2012 alone. While efforts to address this challenge 

have produced significant progress over the past two decades, critical work remains to be done. This is particularly evident in subSaharan African nations where progress in the reduction of childhood deaths has shown the least progress. 

The good news is that sub-Saharan Africa’s progress in curbing 

childhood deaths related to infectious ailments are less prominent 

due to expanded immunization programs and increased success in 

the prevention of diarrhea and malaria. However, the issues of poverty, inadequate access to health care for expectant mothers and 

their children, and undernutrition continue to sustain high rates of 

childhood deaths continent-wide. This phenomena is particularly 

pronounced in Central and West Africa, the region which accounts 

for the majority of childhood deaths on the continent. Women in 

the Central and West African regions face the highest risk of maternal mortality and children in the regions are also impacted by 

the high prevalence of stunted growth. 

While serious challenges remain, I applaud international efforts 

to curb childhood mortality including the U.N. Millennium Development Goals related to improving maternal and child health. I 

also recognize the critical contributions of several of the United Nations’ largest collaborative efforts including the Scaling Up Nutrition Movement, the Zero Hunger Challenge, and the Integrated 

Global Action Plan for the Prevention of Pneumonia and Diarrhoea. 

As we prepare to hear from today’s witnesses, I hope we can 

learn critical lessons from their vast experiences and use them to 

increase support for the most effective measures of improving maternal and child health in the first 1,000 days of life. 

I would also hope that these lessons lead to the formulation of 

new ways to address the health concerns of mother and children 

specifically in the sub-Saharan African region where they are at 

greatest risk. As a former healthcare professional, I also know that 

there are several other contributing factors to maternal death, prematurity, and childhood death and one of the factors that I am 

very concerned about is child marriage, is girls having babies far 

too young, their bodies not being able to sustain a pregnancy or 

them having consequences like fistula. 

The other issue that contributes to maternal death is the inability of many African women and other women in developing countries to have access to birth control and so they cannot control the 

spacing between their pregnancies. If you have too many pregnancies, deliver too many babies too early before the body has completely matured, you are at risk of maternal death, as well as you 

are an increased incidence of prematurity and contributes to the 

death before 1,000 days. So all of these issues I would appreciate 

hearing about from our witnesses today. Thank you. 

Mr. SMITH. Thank you, Ms. Bass. I would like to now introduce 

our very distinguished first witness and thank her for being here 

and for her work and that is Tjada McKenna who is Deputy Coordinator for Development for Feed the Future, the U.S. Government’s global hunger and food security initiative, as well as the 

Acting Assistant to the Administrator in USAID’s Bureau for Food 

6

Security. Ms. McKenna coordinates implementation of Feed the Future across the U.S. Government, oversees its execution and reports on results, and leads engagement with external community 

to ensure that food security remains high on the development agenda. 

Ms. McKenna joined USAID in 2010. She previously held senior 

positions at the Bill & Melinda Gates Foundation, Monsanto, 

McKinsey & Company, and American Express as well as GE. 

Ms. McKenna, the floor is yours. 

STATEMENT OF MS. TJADA D’OYEN MCKENNA, ACTING ASSISTANT TO THE ADMINISTRATOR, BUREAU FOR FOOD SECURITY, U.S. AGENCY FOR INTERNATIONAL DEVELOPMENT 

Ms. MCKENNA. Thank you very much. Good afternoon. I am delighted to be here today to talk to you about USAID’s nutrition efforts. I first want to recognize you for your strong leadership in addressing global child and maternal nutrition. We also recognize the 

2013 congressional resolution put forward by Congresswoman 

Schultz and Congressman Diaz-Balart supporting U.S. Government 

global nutrition efforts. 

As you have heard, at least 165 million children worldwide are 

stunted. Stunting limits the potentials of individuals, communities, 

and economies to grow and thrive, costing low- and middle-income 

countries up to 8 percent of their economic growth potential. This 

is unacceptable. We have the tools and technologies to make a difference and we are sharpening our focus to ensure a well-coordinated approach to reach our goals of reducing extreme poverty and 

hunger. And we are doing so with a particular focus on the 1,000 

day window from pregnancy to a child’s second birthday, which is 

critical to ending preventable child and maternal deaths. 

Thanks in large part to new evidence that has deepened our understanding about the importance of nutrition in early life, nutrition has been the focus of recent and unprecedented global attention. Now is the time to continue this prioritization and to fuel the 

tremendous momentum of just the past few years. This momentum 

includes major developments such as the launch of a platform 

known as Scaling Up Nutrition or SUN. SUN is a partnership between the U.N., civil society, the private sector, donors and developing country governments to support country-led efforts to reduce 

undernutrition. Since its launch in 2010, 47 countries have joined 

and USAID is proud to serve as a donor convener providing focused 

support in six of those countries as well as leadership at the global 

level. 

In 2010, the U.S. Government and former Irish Foreign Minister 

Michea ́ Martin launched the 1,000 days partnership, a partnership 

of governments, civil society, and the private sector to promote targeted action and investment in nutrition. The 1,000 days partnership also supports SUN. 

Last June marked a banner moment for global nutrition. USAID 

was proud to join the Global Nutrition Summit in London in advance of the G8 where the U.S. Government announced an anticipated $1 billion for direct nutrition interventions and $9 billion 

worth of attributed nutrition sensitive investments from 2012 to 

2014. We also signed the Nutrition for Growth Compact which moVerDate 0ct 09 2002 09:54 Oct 02, 2014 Jkt 000000 PO 00000 Frm 00010 Fmt 6633 Sfmt 6633 F:\WORK\_AGH\032514\87334 SHIRL
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bilized nutrition funding commitments from G8 donors and civil society and reaffirmed our support of the World Health Assembly nutrition targets for reducing undernutrition by 2025 for women and 

children including a 40 percent reduction in stunting. 

USAID is taking a strong leadership role in these international 

efforts, both within the U.S. Government and at the global level. 

We are taking an evidence-based approach to inform and improve 

our programming including taking into account updated research 

analysis and recommended interventions and approaches featured 

in the landmark June 2013 Lancet series on maternal and child 

nutrition. 

USAID promotes nutrition through the Feed the Future and 

global health inter-agency initiatives, the Food for Peace development and emergency programs, and our humanitarian assistance 

efforts. Our goals are to reduce stunting by 20 percent in Feed the 

Future’s zones of influence and Food for Peace development programs and where possible, to maintain global acute malnutrition 

rates below 15 percent in times of crisis. 

Led by USAID, the Presidential Feed the Future initiative addresses nutrition at the goal level and reduces undernutrition and 

hunger by improving access to nutrition services, clean water, and 

support for agriculture value chain activities that include nutrientdense crops, and we are achieving impact. In 2013, Feed the Future, in collaboration with the Global Health Initiative reached 

more than 12.5 million children with nutrition interventions. 

Beyond Feed the Future, to help maintain global acute malnutrition rates below 15 percent in times of crisis and to support nutrition among the most vulnerable populations, especially during the 

first 1,000 days, USAID is seeking to reform how it delivers food 

aid. We preposition in-kind food aid stocks near food crises and 

now provide cash under certain circumstances to purchase local 

and regional food. 

By enacting the food aid reform requested in the 2015 budget to 

allow 20 percent of Title II food aid funding to be used for flexible 

emergency responses, USAID programs will be able to help about 

2 million more people in crises without additional resources. These 

reforms will allow USAID to expand the use of local and regional 

purchase and successful innovative approaches such as food vouchers which are often cheaper than in-kind food aid and also allow 

beneficiaries to select their own food in local markets. 

In addition, the Office of Food for Peace changed its approach to 

nutrition starting in 2006 to focus more on prevention of undernutrition during the 1,000 day window. USAID also continues to 

support research on various types of specialized foods and on updating and improving existing products based on evolving nutritional evidence. To further improve the integration and effectiveness of USAID nutrition programming across all of our efforts we 

are developing a multi-sector nutrition strategy that is near completion. 

The USAID nutrition strategy addresses the underlying causes of 

poor nutrition by promoting the scale-up of proven, cost effective 

nutrition interventions including both nutrition-specific and nutrition-sensitive activities and by linking nutrition investments in agriculture, food security, health, water, sanitation and hygiene, as 

8

well as more humanitarian and development contexts in a more integrated manner, the USAID nutrition strategy will enable us to 

address nutrition with more discipline than ever before. We will develop country nutrition targets that align with national plans, set 

country-specific targets and track and report on progress. 

The USAID strategy is also informing a coordinated U.S. Government nutrition plan which is also in development. This plan will, 

for the first time, bring together all of the U.S. Government agencies working in global nutrition to maximize impact through better 

coordination of U.S. Government global nutrition investments. 

There are continued efforts to coordinate and integrate multi-sectoral programs across USAID offices and bureaus and strengthen 

program quality using new findings. We are better addressing the 

complex underlying causes of stunting. We are also making meaningful contributions toward achieving the World Health Assembly 

2025 nutrition targets and reducing undernutrition during the first 

1,000 days worldwide. 

I would like to thank Congress again for your leadership on this 

issue. We look forward to working with you to continue progress toward a vision of a healthier, more prosperous world. Thank you. 

[The prepared statement of Ms. McKenna follows:]

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Mr. SMITH. Ms. McKenna, thank you very much for your testimony and for laying out and without objection your full statement 

will be made a part of the record and any other supplemental items 

you might want to include in the record. 

Could you give us an idea of when the strategy that you are developing, the comprehensive strategy might be available? Is it imminent? 

Ms. MCKENNA. Yes. We expect it very shortly. All along we have 

done a series of consultations with NGOs and other civil society 

groups. We have two more consultations to go. You are likely to see 

something in the May–June time frame. 

Mr. SMITH. The collaboration and the support for faith-based organizations, particularly in Africa, which is a continent of faith, 

yesterday at the closing with the Ambassadors, I mentioned the 

importance of that. And several of the Ambassadors came up to me 

afterwards and said you couldn’t have stated it more strongly and 

more accurately, that if you want to mitigate the healthcare crisis 

that is being experienced in Africa, you have got to include robustly 

faith-based organizations. 

How do you go about doing that, like with World Vision and 

some of the other groups? Could you perhaps provide us some insights? Is the trendline to do more of that or keep it the same or 

less? 

Ms. MCKENNA. Faith-based organizations such as Catholic Relief 

Services, World Vision, ADRA, are critical implementing partners 

for many of our efforts. We have long been working with them. And 

in fact, in the area such as family planning and mother-child 

health, they have been critical partners and critical to our success 

in working with that community. So we intend to continue the deep 

partnership and relationships that we have had with faith-based 

organizations to expand them where appropriate, where the programming warrants it, and to continue that open and strong dialogue. 

Mr. SMITH. About 1,400 kids die daily from diarrheal diseases. 

There was almost like a gee whiz factor in the beginning days of 

the child survival revolution, a simple mixture of salt and glucose 

could save a life. And I remember part of that mantra was that a 

child may get diarrheal disease five or six times during the course 

of the year, weakening them every time, sometimes to the point 

where they die. Are we making progress on that? I know we had 

a very effective program in Egypt, for example, and some other 

countries as well. Has the impetus been kept on that? 

Ms. MCKENNA. Yes, as you mentioned very simple interventions 

have had real effect and impacts on decreasing infant mortality because of diarrheal diseases. USAID global child survival is something that is at the core of our global health initiatives. It is continuing to provide interventions to alleviate the impacts of diarrheal diseases as an integral part of that. 

Mr. SMITH. You know since the U.N. and especially I mentioned 

the roundtable, as a matter of fact, Lady Odinga was there among 

many other First Ladies. One of the emphases that we have all understood with that first 1,000 days from the moment of conception 

was the brain growth area, that if you don’t get that right, the ability of that child cognitively to reach his or her potential is greatly 

15

reduced. Are you finding a growing understanding of why this is 

so? Every dollar we spend in this area is a dollar that pays off in 

that child’s life as he or she become an adult, like few things that 

we could possibly do. 

Ms. MCKENNA. Yes, not only pays off, but the impact of a child’s 

growth of decreased brain development, the child never recovers 

those gains and never recovers. And those are losses to society permanently. The Scaling Up Nutrition movement is a multi-sectoral, 

multi-partner movement that countries themselves have to encourage. So we are proud to say that over 47 countries have signed up 

as SUN countries which means that they understand the importance of maternal and child nutrition and are committed to setting 

their own goals and targets and addressing it themselves with 

their own resources in partnership with local organizations, donors, 

and other partners. 

Mr. SMITH. How many countries do we have an arrangement 

with? I was actually in Guatemala the week when USAID signed 

an agreement and dedicated our resources to assisting them on the 

first 1,000 days. How many other countries do we have an arrangement with? 

Ms. MCKENNA. There are six countries where we are the lead 

donor partner in SUN, but we are active—we are part of the global 

convening for SUN. There are 19 Feed the Future focus countries. 

One of the top line goals in Feed the Future is a reduction in 

undernutrition and in all 19 of those countries you see focus on 

both nutrition-specific and nutrition-sensitive programming. On top 

of that, our Global Health Initiative focuses on there are an additional set of countries where we target our nutrition funding. But 

because these investments, as you have said, are so cost efficient 

and so impactful, we have really focused our funding on those 

countries where the burden is greatest because we want to bring 

these numbers down significantly. 

Mr. SMITH. Thank you. Dr. Perry from Johns Hopkins will testify 

later and in his written submission points out that there are an estimated three million stillbirths around the world each year; 99 

percent of which occur in low-income countries. He also points out 

there are 3.8 million live-born children who die each year before 

the age of 2 and three fourths of these deaths occur during the first 

month after birth. And then he bottom lines and says the tragedies 

of the great majority of these deaths can be readily prevented at 

low cost. 

Does that number comport with your understanding of what we 

are talking about in terms of the loss of life? Again, is there an understanding that with a little more oomph and effort a lot of these 

lives could be saved? 

Ms. MCKENNA. Yes, we would have to get back to you to confirm 

the exact numbers, but we agree. There is an understanding that 

very simple intervention such as immediate and exclusive 

breastfeeding from birth can have a big impact and prevent the 

loss of life during the early days. 

Mr. SMITH. During the war in El Salvador when the FMLN and 

the government were at great odds and it was war, Napoleon 

Duarte, then the President of El Salvador, negotiated a cease-fire, 

a Day of Tranquility, as they called it, to vaccinate the children 

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against the leading killers of children. And I traveled down myself 

with Jim Grant and others from UNICEF and one of the biggest 

takeaways and that was in the early ’80s, that I got from that was 

the importance of the pulpit, that if you want to drive people to 

low-cost and highly-efficacious interventions, you need more than 

just a community health center or a doctor or others, even if they 

go door to door, amplifying the message that you need to do this 

for yourself and your children. 

Do you find that USAID, again working with faith-based groups 

are able to effectively utilize that venue to get the message out? 

Because one of the things, again with vaccinations, was coming 

back for that second shot after the child developed a fever and they 

thought oh wait, this isn’t what I bargained for. No, that is part 

of what happens in a small percentage of those who get a vaccination. 

Ms. MCKENNA. Many of the solutions to these are simple behavior changes and as we know from our personal lives, behavior 

change is something that is very difficult to do. And so you have 

to go and work with organizations and people in institutions that 

people trust. And oftentimes, as you said, that does include their 

ministers and their church community. So working with them, 

bringing them into the coalition and training with them remains 

an integral part of what we do. 

Mr. SMITH. Let me just ask you and I know if you had your way 

personally, the number would be a blank check, but we all know 

whoever runs the White House, there is always OMB to deal with 

and I remember when I chaired Veterans, I was always at odds 

with OMB, not with the VA because VA wanted to do more in almost every instance. But there is a proposed 2015 cut of about 12 

percent and maybe we are misreading it, but in nutrition programs. I am wondering is it found somewhere else in the budget 

or is this just some reality that we have to deal with here and look 

to up it. 

I know in the ’80s, it was almost like a reflexive thing where 

OMB would cut UNICEF only to have Congress put back the 

money each and every year. But the 12 percent cut, are we missing 

something or do we need to make sure that we work with you and 

our colleagues on the Appropriations Committee to make sure that 

there is no diminution of those monies. 

Ms. MCKENNA. So even in a constrained budget environment, the 

President’s Fiscal Year 2014 budget request demonstrates a firm 

commitment to nutrition and ending preventable child deaths. We 

are using as efficiently as possible existing funding authority and 

are leveraging across USAID funding. Part of what we are doing 

with the nutrition strategy is prioritizing nutrition outcomes across 

multiple streams of funding, including Feed the Future, multiple 

streams to get better, more efficient outcomes from that funding. 

Mr. SMITH. Could you provide us, if you would, an analysis of 

what the cut would mean if it were to be implemented? And also, 

while you are doing that since you are being asked. I know OMB 

will probably react negatively to this, but what really is needed to 

do what has to be done, to really take this to the next level, to try 

to intervene so that those three million kids don’t die at stillbirth. 

There will always be stillbirths but it doesn’t have to be as high, 

17

as well as those who die in the first month and of course, how do 

we ratchet up this program? If you could provide us what we get 

for every extra dollar, it would make a huge difference. 

Ms. MCKENNA. Right. Yes. We can provide you that analysis. 

And I should also mention that a critical part of this is different 

parties really coming together to solve the solution. So our funding 

actively works to leverage the funding of other donors with resources that countries, lower- and middle-income countries themselves put into this problem, as well as looking for ways to engage 

the private sector and appropriate response. 

Mr. SMITH. I am all for partnership and leveraging, but if we had 

12 percent more or even higher than that, the leveraging could be 

that much more effective, I would think. So if they could provide 

any of that, it will help in the process as we do the 2015 budget. 

Ms. MCKENNA. We are happy to come back to the committee 

with that. Thank you. 

Mr. SMITH. Thank you. 

Ms. BASS. Thank you. I believe when you began to answer the 

chairman’s questions, you made reference to how you work with 

faith-based organizations for family planning. And I wanted to 

know if you could elaborate a little more on that? 

Ms. MCKENNA. Yes. So some critical things that we work on with 

faith-based organizations include some of the things that you alluded to in your remarks, actually. So birth spacing, delaying marriage, activities and behavior changes such as that to increase people’s abilities to plan their families, to have children at appropriate 

times to optimize nutrition for both the mother and the child and 

to prevent situations that are negative. For example, when adolescent girls become pregnant, they end up competing with their child 

for resources for their own growth spurts. Or when children are 

spaced too close together, a mother’s nutrition stores which are 

likely already depleted become even more and more depleted and 

so we work carefully with faith-based organizations on things like 

delayed marriage and child spacing to get optimal outcomes for 

mothers and children. 

Ms. BASS. How do they go about their work, both the faith-based, 

as well as the secular organizations? How do they go about their 

work in a village in regard to family planning? Do they distribute 

birth control? Is it education? What specifically do they do? 

Ms. MCKENNA. I think a lot of it is education, should be information about different behavior change, giving advice on different 

practices, things such as that. 

Ms. BASS. And on the governance issue wherein some countries 

it is in the constitution that a girl, because I won’t call a young 

lady, 8 years old, can get married. So I am wondering what is 

USAID doing in terms of educating different countries about raising the age in which females become sexually active? 

Ms. MCKENNA. All of our investments kind of depend on an enabling environment that supports the development work that we do. 

So in our work on maternal-child health, one of the key things that 

we work with other actors to provide to governments is information 

and advice on policy reforms and data on the impact of those policies, what they are on children now and what they could be and 

how others have structured policies to achieve better results. 

18

We also encourage our officers and our State Department and 

others to advocate on behalf of changes in those laws. But a lot of 

the policy support we do is providing data and evidence and helping provide the capacity to create alternative policies that will have 

better outcomes. 

Ms. BASS. So do we work with—you said primarily education, but 

I don’t recall if you answered me specifically on birth control. 

Ms. MCKENNA. I am sorry, I didn’t. I will have to get back to 

you. I am not—I don’t oversee directly our maternal-child health 

area. So I just don’t want to overstate anything. 

Ms. BASS. And I am sorry to say that some countries seem to be 

going backward whether you are talking about LGBT issues and 

legislation that has been put forward in that regard or whether you 

are talking about nations that just recently said that a man could 

have as many wives as he wanted and he didn’t even have to ask 

for permission. I can’t imagine being given permission, but anyway. 

So when we go about our education work I am just hoping that we 

attempt to educate on that level as well, especially on the question 

of spacing births. 

Ms. MCKENNA. Yes. 

Ms. BASS. I spent many years also working in a neonatal nursery, working with premature babies, working in the labor and delivery room and seeing women, you know, it was—almost never 

happens in the United States. It is extremely rare for there to be 

a death of a mother. And to travel to sub-Saharan Africa and to 

be in Nairobi and see billboards where they were trying to do public education around maternal death and knowing that one of the 

reasons why maternal death is so high is women who cannot control when they are pregnant. 

Ms. MCKENNA. I just got a note from our team. We actually do 

provide a variety of birth control options through our programming 

and I should mention another example of some of the training and 

education we do, the focus on exclusive breastfeeding for the first 

6 months helps to prevent low lactation, menorrhea, helps to prevent further pregnancy as well. 

Ms. BASS. In theory, in theory. 

Ms. MCKENNA. In theory. It is not foolproof. 

Ms. BASS. It is not. But we do provide birth control. 

Ms. MCKENNA. We do provide a variety. 

Ms. BASS. And are we prohibited by any age, especially considering the age of sexual activity can be very young? 

Ms. MCKENNA. Can be very young. 

Ms. BASS. Do we have any prohibitions on when birth control can 

be distributed? 

Ms. MCKENNA. Yes, so that is a good question. We will have to 

get back to you. I know our bias would be not to have limitations 

on that, but there may be some places——

Ms. BASS. I would like to know if you can get back to me specifically in those countries where we know that girls are conceiving at 

very young age and having difficulty like the ones that the chairman pointed out. 

Ms. MCKENNA. Yes. 

Ms. BASS. Thank you very much. 

Ms. MCKENNA. Thank you. 

19

Mr. SMITH. One concluding question. Could you give us, and it 

is probably better for the record the break out of how your funding 

goes to faith-based organizations in dollar terms as well as percentage of the program? 

Ms. MCKENNA. We will look to get that to you for the record. One 

of the things I should point out, one of the limitations we have had 

on pulling that data in the past is that there are cases where those 

organizations are the official grantees, but in many cases they are 

also subgrantees. 

Mr. SMITH. Have you captured that? Because I have asked that 

question repeatedly, why we don’t get the subgrantees as well. 

Ms. MCKENNA. We know them, but sometimes they are not categorized or coded appropriately as to—if they are faith based or 

not. So I know that has been a challenge that we have had in pulling it historically, but we will look to see what we can pull now. 

Mr. SMITH. Thank you. And some of the other members who 

would have been 11⁄2 hours ago had we not had the votes may have 

some questions that they want to submit for the record. 

Ms. MCKENNA. Okay. 

Mr. SMITH. I have a few extras, too. 

Ms. MCKENNA. We understand. We are happy to do that. Thank 

you very much. 

Mr. SMITH. Thank you very much, Ms. McKenna. 

I would like to now invite our second panel beginning first with 

Lisa Bos from World Vision, senior policy advisor for health, education, and water sanitation and hygiene at World Vision. In the 

Advocacy and Government Relations Department as such, she 

serves as the point person for World Vision’s advocacy and education efforts with Congress and the administration. In addition, to 

working to engage World Vision’s advocates on issues such as foreign assistance funding, maternal and child health, and water sanitation and hygiene, Ms. Bos spent nearly 9 years as legislative staff 

in the U.S. House of Representatives. 

We then will hear from Dr. Henry Perry who is a senior associate at Johns Hopkins Bloomberg School of Public Health. His primary research interest is in the impact of community-based primary healthcare programs on health improvement especially on 

maternal, neonatal, and child health. He has a broad interest in 

primary healthcare and community-oriented public health, community participation equity and empowerment. He is currently collaborating on operations research concerning community-based material, neonatal and child health in Guatemala, Kenya, and Sierra 

Leone. He has led formal child survival program evaluations in Afghanistan, Bangladesh, Cambodia, India, Tibet, China and he 

teaches on a broad variety of topics at Johns Hopkins. 

Then we will hear from Ms. Carolyn Wetzel Chen who has 14 

years of international public health and development program design implementation and donor relations experience. In her current 

role as chief grant development officer, she leads Food for the 

Hungry’s Global Service Center and 18 field offices in developing 

and executing a global strategy for raising resources from foundations, corporations, governments, and multi-lateral institutions. 

She has created systems, tools, and policies to guide multi-national 

and multi-sector teams to identify and pursue those grants for this 

20

important work. Her long-term professional specialty has been maternal and child health and nutrition programs design and implementation, social and behavioral change, and monitoring and evaluation. 

We will then hear from Dr. Sophia Aguirre, who is a professor 

of economics in the School of Business and Economics at the Catholic University of America. She is the director of economics program 

and academic chair of the Masters in Integral Economic Development. She specializes in international finance and integral economic development. She has researched and published in the areas 

of exchange rates and economic integration, as well as theories of 

population, resources, and family as it relates to development. She 

has testified in front of Congress on issues related to population, 

family, and health nationally and internationally. 

We will then hear from Dr. Mehret Mandefro of George Washington University, a primary care physician and public health researcher. She is founder and president of Truth Aid, a public 

health consultancy that specializes in community-based public 

health education efforts which addresses the social determinants of 

health using media in these efforts. She is also an adjunct professor of health policy at the Milken Institute of Public Health at 

George Washington University. Dr. Mandefro began her career as 

a physician as a public health practitioner working extensively on 

HIV-infected and affected communities in Botswana, South Africa, 

Ethiopia, and New York, and on issues of prevention and treatment. 

Ms. Bos, if you could begin. 

STATEMENT OF MS. LISA BOS, SENIOR POLICY ADVISOR FOR 

HEALTH, EDUCATION, AND WATER, SANITATION AND HYGIENE, WORLD VISION 

Ms. BOS. Thank you, Mr. Chairman, Ranking Member Bass. I 

appreciate this opportunity to testify before you today on the important issue of health and nutrition, particularly in the first 1,000 

days window. Kent Hill does send his apologies that he wasn’t able 

to be here today. I will do my best to fill his shoes. 

My name again is Lisa Bos and I am the senior policy advisor 

for health, education and WASH at World Vision US. World Vision 

is a Christian humanitarian organization working to improve the 

lives of children in nearly 100 countries. 

Good nutrition is an essential foundation for health and development, yet malnutrition continues to be the world’s most serious 

health problem and the single biggest contributor to child mortality. As one of the world’s largest private humanitarian organizations, World Vision recognizes that addressing malnutrition is essential to improving maternal and child health and so we have 

made it a top priority in our work. 

World Vision has several recommendations for what the U.S. 

Government can do, and where Congress should focus when exercising its oversight, budgeting, and appropriations responsibilities, 

to help contribute to the best outcomes for mothers and children. 

We base them on our 63 years of relief, development, and advocacy 

experience and expertise and the evidence of what is most effective 

and efficient. 

21

In summary, these recommendations are: 1) is to prioritize community-based initiatives. Our experience shows that ownership by 

the community and involvement of key community leaders, such as 

faith leaders, is critical to ensuring changes in behavior that lead 

to improvements in maternal and child health; 2) is to approach a 

child through the life-cycle, concentrating on the start of life at conception through the first 2 years, and concentrate interventions, 

like those to ensure adequate nutrition, on these initial 1,000 days; 

3) is to ensure that food is adequate both in volume and nutrition; 

4) is to include nutrition outcomes as an explicit objective of U.S. 

agricultural and other food security assistance programs. 

Another recommendation is to focus initiatives for mothers on 

their time of pregnancy, ensuring they are well nourished, able to 

provide sufficient nutrition for their children, and give birth to 

healthy children. 

Support and scale-up interventions that are proven to be effective, like breastfeeding, skilled birth attendants and frontline 

health workers, healthy timing and spacing of pregnancies, and 

consistent, safe access to clean water and sanitation. 

Focus breastfeeding programs on support for mothers immediately after and in the 24 hours following childbirth, ensuring a 

good start to that child’s life. 

Improve partnering with NGOs, especially faith-based NGOs, including by consulting with them earlier and more consistently, 

leveraging public and private funding, coordinating and collaborating between initiatives regardless of the funding source, and 

prioritizing initiatives aimed at improving governance at the local 

and national levels in the countries of partnership. Given the 

value-add of the rich community-based networks which FBOs possess, it makes sense to capitalize on these connections. 

The first 1,000 days is the time with the biggest risk of child 

mortality, as well as the period of most rapid physical and brain 

growth. Exposure to chronic malnutrition during this critical window can result in stunting which leads to impaired brain development, robbing a child of the ability to reach his or her full potential. There is strong evidence of the correlation between malnutrition and stunting, and long-term health and individual earning capacity. Therefore, it is critical that children receive good nutrition 

within this ‘‘window.’’ Interventions that prevent undernutrition 

during this time can be much more effective than those that target 

children who are already undernourished and prevention is at the 

core of all of World Vision’s work in health, nutrition, and food security. 

Breastfeeding is at the core of preventing undernutrition and 

malnutrition in children. There are challenges with breastfeeding 

programs, however, as critical factors come into play which impact 

a mother’s ability to breastfeed her child until the critical age of 

two. For example, if a mother becomes pregnant again, she may 

prematurely stop breastfeeding, often leading to significant malnutrition in that child. Programs like those that support the 

healthy timing and spacing of pregnancy are necessary to ensure 

the success of breastfeeding programs which is why multi-sectoral 

approaches that integrate nutrition specific interventions, direct 

interventions like breastfeeding, with nutrition sensitive intervenVerDate 0ct 09 2002 09:54 Oct 02, 2014 Jkt 000000 PO 00000 Frm 00025 Fmt 6633 Sfmt 6633 F:\WORK\_AGH\032514\87334 SHIRL
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tions, like birth spacing education and WASH programs, are critical. I would also encourage the U.S. Government to focus on 

health and nutrition in fragile states and in places with high rates 

of acute malnutrition. 

The financial cost to address acute malnutrition is high, usually 

because there is a lack of functioning infrastructure, trained staff 

and health services, and limited food ability. With an approach 

used by World Vision called Community-based Management of 

Acute Malnutrition or CMAM, malnourished children are found 

and treated early before complications occur and more costly in-patient treatment is required. However, despite the success of programs like CMAM, investments in better health infrastructure and 

investments to address chronic food insecurity in communities 

would help in the long term to reduce the need for more expensive 

interventions. CMAM funding is provided mainly through the Office of Foreign Disaster Assistance within USAID for emergencies. 

But we would recommend that USAID also expand funding for 

interventions like CMAM in development programs in countries 

with high levels of acute malnutrition, such as India, Nigeria, and 

Indonesia which currently have very low rates of CMAM coverage. 

The role of the faith community is also vital if we are going to 

reach the most rural and hard-to-reach communities. We have 

found that educating and mobilizing faith leaders to talk to their 

congregations and communities about what are sometimes viewed 

as taboo child and maternal health issues could be the most effective catalyst for change. The U.S. Government must continue to engage deeply with the faith community to ensure that programs recognize the convening power and reach of faith-based organizations 

in the developing world. 

It is hard to imagine a more humane or pragmatically valuable 

U.S. Government investment than to focus on women and children’s health, particularly nutrition in the first 1,000 days of life. 

Allow me to express my deep appreciation to the U.S. Congress 

who has consistently shown compassion and wisdom in addressing 

health concerns in the developing world and in fragile states. There 

is much more to do, but if we strengthen existing partnerships between USAID and the NGO community, we can have even more 

impact in the years ahead. Thank you for this opportunity to testify 

today and I look forward to any questions you may have. 

[The prepared statement of Ms. Bos follows:]

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Mr. SMITH. Ms. Bos, thank you very much for your leadership 

and please send our best to Kent Hill. Is he okay? I know he was 

very sick from his trip. 

Ms. BOS. He is. He is working on recovering at home. 

Mr. SMITH. Thank you. Dr. Perry. 

STATEMENT OF HENRY PERRY, M.D., PH.D., SENIOR ASSOCIATE, HEALTH SYSTEMS PROGRAM, DEPARTMENT OF 

INTERNATIONAL HEALTH, BLOOMBERG SCHOOL OF PUBLIC 

HEALTH, JOHNS HOPKINS UNIVERSITY 

Dr. PERRY. Thank you very much, Congressman Smith, Congressman Bass. It is a great privilege and honor for me to be here 

today. This is a subject that I am passionate about. I have spent 

35 years working with NGOs, working in community health and increasingly involved in the academic and research and evidence side 

of community-based programming to improve child health and particularly mothers and children during the first 1,000 days of life. 

I am going to restrict my verbal comments to a portion of what 

my written testimony conveys. You very well summarized a lot of 

the technical issues and the human magnitude of lives being lost 

from conditions that we know are readily preventable or treatable, 

given our current state of knowledge and know-how and programmatic strategies. I am very pleased that you have mentioned 

Jim Grant several times in your comments and one of the comments that Jim Grant made when he was the Executive Director 

of UNICEF that I think is very germane to my comments today is 

his phrase often repeated that ‘‘morality marches with capacity.’’ 

And even though we have made tremendous progress in reducing 

the number of deaths of mothers and children in the last 50 years, 

and I think it is one of the unheralded successes of our world and 

of the contribution of the United States toward that goal, the fact 

that 6.6 million children are still dying and 300,000 mothers are 

still dying, mostly from readily preventable treatable conditions is 

a point of great moral concern in the public health priority of 

course. 

What I want to focus on in my comments are the fact that we 

have these evidence-based interventions that we know work under 

ideal circumstances. The evidence, the scientific evidence is there 

that all of these things are highly effective and I have listed these 

in my testimony. You mentioned a number of them yourself, but 

interventions that are so supple in many respects, we find so hard 

to implement. Exclusive breastfeeding and hand washing are but 

two I think are the most important that obviously don’t involve 

health facilities. They don’t involve higher-level health staff to 

carry out. We still are needing the resources to apply the knowledge that we have to implement these interventions at scale in 

communities and countries with high mortality. 

So in the 75 countries with more than 98 percent of all maternal 

deaths and deaths of children under 5, the coverage of all of these 

interventions except for immunizations and Vitamin A is below 60 

percent and in some cases, for example, exclusive breastfeeding or 

antibiotic treatment of pneumonia, we have levels of coverage that 

are on the order of 25 or 30 percent. And so in my view, one of the 

most important things that we can do to save the lives of mothers 

33

and children in the first 1,000 days of life is to develop a better delivery system that reaches down to the household level that engages communities and uses community health workers to implement interventions that we know work and that we know that can 

be provided by these front line health workers. 

We know there is an enormous deficit of health manpower, of 

highly trained health manpower. The World Health Organization 

has estimated that by the year 2025, the global deficit will be about 

13 million, highly trained staff, and we know that from those of us 

like yourself, Congressman Smith, who have been in rural areas, 

facilities are very few and far between. And for the foreseeable future, these facilities will not be readily available to people. 

And so we need to develop a focus on a delivery system that is 

in the community that uses the community as capacity, its resources, adequately trains and supports them in order to deliver 

interventions that we know work. So we need the commitment to 

build a community-based delivery system for these interventions 

and it is also essential that we work with community empowerment approaches and women’s empowerment approaches to make 

use of these interventions as well. 

I had the recent privilege of evaluating a Food for the Hungry 

child survival project that focused on nutrition and prevention of 

diarrhea in Mozambique that reached a population of 1.1 million 

people. And Food for the Hungry has been a pioneer of a very exciting approach to community-based delivery which is the kind of 

thing that we need much of which is called care groups in which 

volunteer women are assigned responsibility for 10 to 12 households and they meet with 10 or 12 volunteers every 2 weeks to 

learn health education messages and deliver those to the households. This approach was applied by World Relief in a rural part 

of Mozambique, 1.1 million people, and it had a dramatic impact 

on reducing undernutrition within that population at a very low 

cost of only 55 cents per capita per year. No food was involved in 

terms of distribution of food. It was total health education, prevention of diarrhea which is an important predictor of malnutrition of 

course, so we need to apply a lot of our knowledge that we have 

at scale working with governments, using these very simple approaches that don’t rely on higher level health facilities, higher 

level health staff. We have enormous experience and knowledge in 

doing this. And in fact, the NGO community that I have worked 

with for the last 35 years particularly with the USAID Child Survival and Health Grants Program that I have been connected to for 

a long time which has been instrumental in developing these approaches and I think are vital for the success of ending preventable 

child deaths by the year 2035 which is one of the goals that the 

United States Government has signed on to with many other countries around the world and it represents an exciting opportunity for 

the next 20 years to see the progress that can be made with our 

current know-how and expanding of available programming at very 

low cost. 

So I would like to share my thoughts about what the United 

States Congress could do to end preventable deaths during the first 

1,000 days of life. The first point is that the United States Congress should at least maintain, but much more preferably, substanVerDate 0ct 09 2002 09:54 Oct 02, 2014 Jkt 000000 PO 00000 Frm 00037 Fmt 6633 Sfmt 6633 F:\WORK\_AGH\032514\87334 SHIRL
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tially expand its financial support for child survival programs in 

the 75 countries where 98 percent of maternal and child deaths 

occur. 

U.S. Congress should elevate U.S. Government support for community health workers by insisting on funding child survival and 

other global health programs that are carried out by community 

health workers in a way that builds long-term sustainability for 

community health worker programs that engage communities and 

civic society, not just government health programs. The NGO community, the faith-based community are an essential part of that. 

The U.S. Congress should call on the administration to draft a 

comprehensive health workforce strategy with the focus on community health workers and other frontline health workers to maximize the impact of U.S. Government investments in the global 

health workforce. 

And finally, the U.S. Congress should insist on strong funding for 

the USAID Child Survival and Health Grants Program which has 

been supporting U.S.-based NGOs, referred to as PVOs (private 

voluntary organizations), for three decades now and these organizations have been leaders of and champions of community-based programming for maternal and child health in low-income countries. 

This includes World Vision, Food for the Hungry, but many other 

NGOs, both faith-based and nonfaith-based. 

The United States has been a global leader in support for innovation and community-based child survival programming. It should 

continue in this role. The current levels of funding for maternal 

and child health programs both to USAID and to UNICEF need to 

be expanded, not cut. To not fully support these efforts and to cut 

funding for these programs that represent a moral failure on the 

part of our Government and it would not support the wishes of the 

great majority of American citizens who repeatedly have expressed 

their support for U.S. Government funding for saving the lives of 

mothers and children. 

Fully engaging the U.S. PVO community by providing major financial support to it for this effort will increase the quality of child 

survival programming around the world, promote innovation, expand community engagement and community-based services and 

accelerate the reduction and readily preventable deaths during the 

first 1,000 days of life. Thank you. 

[The prepared statement of Dr. Perry follows:]

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Mr. SMITH. Thank you so very much for your testimony and your 

very specific recommendations to us. 

Ms. Wetzel Chen. 

STATEMENT OF MS. CAROLYN WETZEL CHEN, CHIEF GRANT 

DEVELOPMENT OFFICER, FOOD FOR THE HUNGRY, INC. 

Ms. WETZEL CHEN. Let me begin by thanking Chairman Smith 

and Ranking Member Bass for holding this important hearing. 

Eight years ago when I was working in Mozambique and visiting 

a household, I noticed a severely malnourished child. The family 

explained that they were not sure if the child would live or die and 

they were reticent to invest resources and time into the well-being 

because it seemed unlikely he would live. I remember the grandmother saying to me, ‘‘In what world do children not die?’’ And as 

that statement hit home to me ‘‘in what world do children not die?’’ 

I thought, in my world. I was born in Clovis, California and if a 

child died, it was a tragedy. It was an anomaly. And here a grandmother was telling me this was normality for her. 

I consider it a great privilege to speak to you today representing 

faith-based organizations because we have at hand the knowledge 

and the means to make poor child nutrition and child death not 

normal in communities like the one I visited in Mozambique. 

I am speaking on behalf of Food for the Hungry, a global poverty 

solutions partner that helps the world’s most vulnerable children 

and communities thrive. We are proud to often work ourselves out 

of a job as communities we have partnered with exchange povertyproducing mindsets and behaviors for healthy perspectives and actions. 

Faith-based organizations are a critical component of the first 

1,000 day effort. In 2011, 78 of the largest U.S. faith-based international development organizations invested more than $5 billion 

in funds from private sources to meet the needs of those living in 

poverty. Faith communities are called to care for children regardless of national boundary or religious identification. Responding to 

the neediest, not just the nearest, is an important component of 

many faiths. 

Research has found that stunting in the first years of life result 

in cognitive impairment that reduces an individual’s ability to 

learn, resulting in reduced lifetime earning potential. Those who 

experience poor nutrition in the first 1,000 days of life have a higher risk of life-long physical and mental disability which is likely to 

impact their cognitive ability, school performance, and early potential. 

If you have ever been on the Dell Web site or maybe it was an 

Apple, and you have looked at buying a computer and you said do 

I want this much RAM? How fast do I want my processing system 

to be? Well, I hate to compare buying a computer to what we are 

discussing here, but I couldn’t help but think about that in that 

you are deciding at that moment what your future is going to be 

for the next 3, 5 or how many years you are going to use that computer. How am I going to build this system? Well, the same thing 

is happening with children in the womb, in the 1,000 days we are 

investing in their future. And if we don’t do it well, it is going to 

be a lifetime of suffering. 

42

Now if there was a low-risk investment opportunity that delivered a 10-to-1 benefit to cost ratio, most people would take it. I certainly would, especially in this environment. Whatever sacrifices it 

might take in the present moment, if we knew that we could invest 

$100 today and receive $1,000 in a specified period of time, it 

would be a very popular investment. A conservative medium value 

of benefit to cost ratio for investment to reduce stunting in selected 

high burdened countries is 18 to 1. For every $1 invested to reduce 

stunting, an $18 return is estimated considering increased productivity, savings of resources, and increased earnings in the job market. This is an excellent return on investment and compares favorably with other investments for which public funds compete. 

Food for the Hungry trains teams of community volunteers to deliver behavior-change communication about key nutrition, hygiene 

and disease-prevention practices. The strategy of behavior change 

that we use is called the care group model. My colleague, Dr. 

Perry, mentioned this. It has reduced infant and child mortality 

rates dramatically. A final evaluation of Food for the Hungry’s 

USAID funded child survival project in rural Mozambique, a 

project that I helped to start up and oversee, saved an estimated 

6,316 lives of children less than 5 years of age. More than 6,000 

children could have died now live. Malnutrition in that same 

project in children under 2 years of age decreased by 34 percent in 

project areas. 

Many international development projects mobilize paid employees, but Food for the Hungry mobilizes entire communities to contribute to the first 1,000 day window. In the above-mentioned Mozambique child survival project, FH found that 80 percent or 1.8 

million hours of project work was carried out by community volunteers and 97 percent of the work was done by community-level staff 

and volunteers. The care group model FH promotes blankets the 

community with life-saving messages and behavior change support. 

In one care group project, a survey was done 20 months and again 

4 years after the project ended. So think about this, in this community all government funding has now departed. It is just the community carrying on. Those surveys found that the mothers continued practicing key health behaviors. 

In addition to behavior sustainability, care group volunteers also 

were found to be continuing their work with local leaders, taking 

initiatives to replace positions if a volunteer was not able to continue. 

FH is committed to sharing with governments, NGOs, and other 

stakeholders effective ways of improving nutrition in the 1,000 

days window. We host a care group Web site. We share at international forums and we have created a care group implementation 

manual to help other organizations implement care groups effectively. We believe in this model. We believe in its ability to save 

children’s lives and we want others to be using it. 

Care groups have been so widely recognized for their effectiveness in reducing malnutrition that they are now used by 24 NGOs 

in at least 20 countries. The Center for High Impact Philanthropy 

at the University of Pennsylvania has endorsed Food for the 

Hungry’s care group model as a high impact, low cost solution to 

child malnutrition and illness. 

43

Considering the body of evidence supporting an investment in 

the first 1,000 days of life, what can the United States Government 

do to further success? Number one, we would suggest to encourage 

local governments to increasingly promote nutrition as a cross-cutting and whole of government initiative. 

Number two, as my colleague at World Vision mentioned, support local community delivery platforms for nutrition education and 

promotion. Increasingly include livelihood programs as an integral 

component of women’s empowerment and as a strategic approach 

to reducing the underlying determinants of poverty. Ensure that 

WASH strategies, frameworks, and resources are increasingly integrated into U.S. and government nutrition programs. Increase 

awareness that strategic nutrition investments can contribute to 

human capital formation and can thereby drive economic growth. 

It is not simply a health program. It is an economic impact. 

Food for the Hungry runs a food security project funded by the 

U.S. Government and Ethiopia. In this project, we have a subpartner named ORDA. They are a local organization and they have 

been increasing in their capacity to run such a program. 

My last recommendation is to recognize that as we aim to increase local ownership of such strategies, the international NGO 

community offers a key role in helping local agencies build and 

scale their own capacity. Thank you. 

[The prepared statement of Ms. Wetzel Chen follows:]

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Mr. SMITH. Thank you very much for your testimony and again 

in your written, more elaborate testimony you just lay out so many 

good recommendations for this subcommittee to consider. And it 

must be very gratifying when you talk about Mozambique, about 

the 6,000 children who might otherwise not be here. I mean all of 

you must have that sense of what you have done has had a profound impact. So again, I thank you. 

I would like to now ask Dr. Aguirre, if you could. 

STATEMENT OF SOPHIA AGUIRRE, PH.D., CHAIR, INTEGRAL 

ECONOMIC DEVELOPMENT MANAGEMENT PROGRAM, 

CATHOLIC UNIVERSITY OF AMERICA 

Ms. AGUIRRE. Thank you, Mr. Chair, Chairman Smith, for your 

invitation to participate in this hearing. I submitted in my written 

reports all the necessary references to literature evidence for what 

I am going to say and some of my previous colleagues in this panel 

have also raised some of the issues that are relevant to this discussion, so I am going to limit myself to some specific comments, 

among the comments I have already submitted in writing. 

The first 1,000 days of a person’s life is really established in the 

literature and that is why it is important because it affects the normal development of that individual for the rest of their lives. But 

I want to focus on something that Ms. Chen already mentioned and 

that is that this has an economic consequence. When we shortchange a child before their income because they don’t have enough 

to eat, then the rest of his life or her life as well as the whole community is hampered. It really means depriving the child, the family, the community, the society and their country of a human and 

social capital potential that they could have contributed and that 

it has a high cost when it comes in terms of GDP as well as the 

cost of attending that person who is handicapped and could have 

been prevented from being there. 

Undernourishment in an infant or in an expectant mother causes 

low birth weight and poor cognitive development as was mentioned 

before. That also means lower productivity and hampers development in the long run. These illnesses are not easily treated as we 

know once they occur. In many cases they cannot be solved any 

longer and the cost of attending these needs are very high. So in 

addition to the lost human capital and social capital that we acquire on the top of that, these burdens can be added to the financial side of these countries and these communities. And it can be 

solved, as already mentioned, with very low cost interventions. 

Ensuring household food access, good health and hygiene conditions, as well as good care and health practices for infants and 

pregnant mothers, is to ensure that future generations will have 

the opportunity to contribute toward building the human and social 

capital necessary for sustainable development. We know that sustainable development is more than economic processes. That involves many other processes that are necessary, social, political, 

economic. And therefore, the contribution of each individual to this 

social and human capital is very important. 

That if these needs are first met in the family, typically for children and therefore healthy families are key to providing stability 

during the earliest stage of life. Successful nutritional programs, 

51

such as CONIN in Argentina, ASEPUENTE and APIB cooperatives 

in Guatemala to mention just a few of some of the ones that I have 

evaluated in terms of their nutrition success, focus on prevention 

of hunger and/or undernourishment by taking a holistic approach. 

All these programs have in common that their focus of action goes 

beyond immediate provision of nutrients for those in need. And I 

want to emphasize it is not enough to provide food. Rather, the success relies on the integral approach, these programs seek to 

strengthen family life and engage communities so to address the 

obstacles encountered to achieve lasting nutritional and healthy solutions. We need to provide the means for lasting solutions. They 

seek to improve the overall living conditions by helping those under 

nutritional stress develop initiatives that will provide access to food 

and/or household appliances at accessible prices; they foster households and community agency by teaching responsibility and providing seed funds for home gardens and personal initiatives; they 

train beneficiaries in household management, hygiene, nutrition, 

saving schemes, and local government agency. All these are means 

that provide long-term solutions and sustained provision of food. 

They facilitate training and education so head of households can 

find jobs. 

Mr. Chairman and honorable members of the committee, and especially I want to acknowledge Congressman Bass, the U.S. Government foreign assistance programs which target the very young 

cannot be considered one more effort among the many initiatives 

in which the U.S. is engaged. It is a priority and it is a long term 

investment. We know that the best way to invest is in prevention, 

right? And we don’t have to pay for the consequences. These programs have lasting effects on the lives and opportunities of disadvantaged populations; and they prevent essential human and social capital losses wherever malnourishment prevails. Because of 

the lasting impacts infant malnutrition brings, identifying strategies that go beyond the mere provision of food to families but take 

an integral and holistic approach and places the family at the center of these solutions, is to work toward making sustainable development possible. Thank you again for inviting me to testify today. 

[The prepared statement of Ms. Aguirre follows:]

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Mr. SMITH. Thank you very much, Doctor, for your testimony and 

without objection since you had additional comments they will be 

made a part of the record as well as everybody else’s full statement. 

I would like to now welcome our final witness, Dr. Mandefro. 

STATEMENT OF MEHRET MANDEFRO, M.D., ADJUNCT PROFESSOR OF HEALTH POLICY, MILKEN INSTITUTE SCHOOL 

OF PUBLIC HEALTH, THE GEORGE WASHINGTON UNIVERSITY 

Dr. MANDEFRO. I am delighted to be providing remarks today 

and I want to commend both you, Chairman Smith, and Ranking 

Member Bass for shining a light on a very important topic, child 

survival and maternal health. 

The public health components of our foreign assistance programs 

are the most leveraged commitments we can make to advance the 

well being of communities around the world. And we know from 

scientific data and practical experience that the underlying social 

conditions provide the foundation for realizing the physical, mental, 

and social well being of all, especially children. As we think about 

the importance of the first 1,000 days in a child’s life, beginning 

in pregnancy, we know that the launch conditions, in my field we 

call these social determinants, materially impact child survival and 

maternal health. 

Dr. Perry Klass recently wrote in the New York Times about poverty as a childhood disease. I could not agree more. My own work 

has brought me to clinics in Addis Ababa, Ethiopia and in the 

South Bronx. I have personally seen the effects of poverty in a 

child’s life and the ways in which it affects the entire family unit. 

The connection between the toxic levels of stress that poverty can 

cause and its debilitating effects in early childhood development is 

well studied in the scientific literature. We have seen the damaging 

effects that stress hormones can cause on brain and cognitive development. To name just one specific example, exposure to excessive levels of cortisol can permanently change the brain architecture in a developing child. The science is unequivocal on this point. 

Early childhood experiences of stress have a profound effect on the 

long-term health outcomes of children into the adult years. So now 

that we know more we must do more. With more than 200 million 

children under 5 years of age that are not achieving their full development potential, we cannot afford to leave the discussion of improving the health of children to what they eat alone. We must also 

address the environments they are born into with clarity, courage, 

and accountable outcomes. These are the primary factors that ultimately determine health in their lives and their mothers. 

Of course poverty is the primary target of our foreign assistance 

programs. So what, you may ask, does framing poverty as a childhood disease bring to the conversation of child survival and maternal health? First, it changes where we begin the conversation by 

highlighting the fact that feeding a child’s mind is as important as 

feeding a child’s body. Children need nurturing environments to 

thrive that take into account their emotional and cognitive development; the psychosocial development is often left off the table in disVerDate 0ct 09 2002 09:54 Oct 02, 2014 Jkt 000000 PO 00000 Frm 00060 Fmt 6633 Sfmt 6633 F:\WORK\_AGH\032514\87334 SHIRL
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cussions about global child survival. This is harder to do when poverty is the differential. 

Second, given that we know that child survival begins with maternal health, framing poverty as a childhood disease also calls into 

question the conditions under which pregnant mothers live and 

give birth. In other words, because we pay insufficient attention to 

the prenatal and postpartum environment, we miss a huge opportunity to improve the lives of the very people we could help the 

most. 

It turns out poverty is also a health hazard for adults. Early 

childhood experiences of stress have a profound effect on the longterm health outcomes of adults. According to one study, there is a 

240 percent increase in hepatitis, a 250 percent increase in sexually transmitted diseases, a 260 percent increase in chronic obstructive pulmonary disease, and a 460 percent increase in depression. Those statistics are humbling. 

The connection between these outcomes is thought to be mediated by social, emotional, and cognitive impairment as well as the 

adoption of harmful health risk behaviors later in life. These harmful effects also affect pregnancy outcomes by increasing the likelihood of fetal death in pregnant women. In one study, researchers 

found a direct correlation, up to 80 percent increased risk of fetal 

death in pregnant women with the highest amount of exposures of 

toxic stress while they were children. So these statistics compel us 

to rethink our approach to child survival and women’s health by 

recognizing that physical health begins with mental health. Considering the psychological health of children also affords the opportunity to consider a host of related issue that affect the mental 

well-being of kids, namely child marriage as you recognized in your 

opening comments. 

Child marriage robs the chance for a child to be a child and the 

statistics are also disturbing. Over the next 10 years we are talking 

about 180 million girls that will be married before the age of 18 

and often under violent conditions. We know this has direct health 

effects on both child survival issues, but also maternal mortality as 

adolescent girls are the group most at risk to experience negative 

pregnancy outcomes. 

So in closing, I submit that as the 2015 deadline approaches for 

the Millennium Development Goals, perhaps the most impactful 

improvement we can make to improve the health of women and 

children around the world is including mental health in our post2015 objectives and our discussions of child survival. Thank you for 

the opportunity. 

[The prepared statement of Dr. Mandefro follows:]

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Mr. SMITH. Thank you very much, Doctor, for your testimony and 

your recommendations as well. A question for everyone and then 

I will ask some to each of you and then I will yield to my colleague, 

Ms. Bass. As I asked of USAID earlier, Ms. McKenna, there is a 

12.2 percent cut in the line item for nutrition in the official presentation from the administration from $115 million to $101 million. 

There has also been a cut of 19 percent in tuberculosis, from $236 

million to $191 million. There is a discouraging trendline in some 

of these recommendations for the budget. Even vulnerable children 

is cut by 34 percent from $22 million to $14.5. And I am wondering 

again, thankfully budgets are dynamic processes and this isn’t the 

bottom line. Hopefully, it will ratchet up from this. But what would 

that kind of cut do to the work, especially sometimes other countries and partners take their cue from us? If we deemphasize something, will they in a corresponding way do the same, especially 

when as you spoke earlier about the ratios, 18-to-1 and some of 

those other very, very unbelievable ratios in terms of investments 

made and consequences gleaned. 

Also, if you could, constructively speaking criticism is good. I am 

sure and Ms. Bass, we get it all the time, given the nature of our 

jobs. And frankly sometimes when it is well meaning and properly 

focused, it really does cause recalibrations and changes in behavior 

in Congress, as it should. Sometimes, it is just negative. Anything 

positively and negatively you can suggest with regards to USAID, 

here is your chance, if you could. I am sure you convey privately, 

but I do think they are grownups. It is good for them to hear what 

is working, what is not, and any suggestions that you might have. 

You, Dr. Perry, had a number of them and one of them was to 

draft a comprehensive health workforce strategy. I thought we 

tried to do that in PEPFAR. There was a very significant capacitybuilding component to that legislation, particularly the first bill 

that was signed. But it would appear we haven’t done it well 

enough so maybe you want to elaborate on that. And you also say 

the U.S. Congress should elevate U.S. Government support for 

community health workers by insisting on funding child survival 

carried out by community health workers. Don’t we do that? Is that 

something we need to revisit. And you can elaborate on that either 

in written form or even now on exactly how we might do that. 

Ms. Bos, again, from a faith-based perspective, do you find that 

World Vision is discriminated against at all or are you fully accepted as partners in this very worthwhile endeavor? 

Ms. Wetzel, again, if you could speak to that as well and utilize 

existing religious networks. Do you find that the go-to group that 

is already in-country building on their capacity and their roots, if 

you will, particularly from the sustainability point of view. Once 

the money dries up or goes elsewhere, it is always nice to know the 

work continues. 

Dr. Perry again, you obviously are well published and I have to 

get that article that was mentioned earlier that you wrote or the 

op-ed, but the Lancet, I will never forget this, back in 2008 and I 

read it, talked about and focused on undernutrition and that if you 

didn’t get it right in those first 2,000 days or so what happens to 

that child is largely irreversible. You might want to talk about that 

and whether or not—there was a great deal of buzz and positive 

61

reaction to those early articles. Has that literature continued? Are 

we still writing about it? Not we, but people who are experts in the 

field to drive this train and do even more to elaborate on it if you 

would. 

Dr. Aguirre, if you could speak about Guatemala and maybe 

elaborate a bit on that. You have done a lot of work there. It would 

be nice to get your insights into how that has worked since USAID 

did provide significant funding there. 

Dr. Mandefro, the toxic stress, you did elaborate a bit on it and 

I am wondering when you stated that one study, research has 

found a direct correlation between risk of fetal death and the 

amount of exposure to toxic stress that pregnant women had experienced when they were children. If you could maybe cite that 

study and maybe elaborate on that. Those are just some opening 

questions and I will yield to my colleague. 

Yes, Ms. Bos. 

Ms. BOS. Thank you, Mr. Chairman. Regarding the FY15 budget, 

certainly as implementing partners of USAID, we work with them 

to try to do more with less where we can and be as efficient and 

effective as possible. Of course, we do always support robust funding of foreign assistance programs for the nutrition line item specifically because those interventions are so cross-cutting and so cost 

effective. We would certainly support strong funding in that area. 

The community request for nutrition for FY15 is I believe $200 million. So there is a significant gap there and we appreciate Congress 

in the past having given strong support to the maternal and child 

health and global health programs at USAID. 

As far as recommendations for USAID or our faith-based experience with USAID as a partner, we certainly feel like they value 

their partnership with us as we do our partnership with them. I 

would say that some of the movement at USAID has been more toward localization of aid. Often that means a definition of a local 

partner being an entity based in the country where USAID is putting in a program. Often that excludes international NGOs, even 

though we have local staff, we have local partners with churches, 

other NGOs, other organizations, it does exclude us from some of 

those programs if localization is a key component of that. So that 

is something——

Mr. SMITH. On that point, do you find or you have concerns that 

especially since you are so well audited and oversighted both internally as well as externally, that those protections might not exist 

for an indigenous NGO that might have people who are friends of 

the health minister or others that—where corruption might become 

a problem? 

Ms. BOS. That is certainly something that could happen. I mean 

certainly we have sound oversight both within our organization and 

externally to make sure that we are financially responsible. But 

really at the end of the day if the goal is to build up local capacity, 

faith-based organizations are so well suited to do that because we 

already work from a bottom up perspective with the local communities. I mean that is how you build the capacity with those local 

communities and then you create the sustainability, the behavior 

change that lasts generation after generation. 

62

Dr. PERRY. Thank you very much for your questions, Congressman Smith. I would like to start out with your question about what 

I think USAID could do better to strengthen its support for child 

survival programming. As I mentioned in my testimony, I have 

been connected with the child survival and health grants program 

for over 25 years now and it was an outgrowth of your original legislation back in the ’80s that Congress earmarked for the child survival program. It was an effort to provide funding directly to U.S.-

based PVOs to work in partnership with local PVOs in developing 

countries to address to child survival funding. It was a centrally 

funded program that has always been very small. The amount of 

money that has been given out by this program has never exceeded 

$20 million and it has been going downhill for the last 25 years. 

And I find that to be an extraordinary observation, given the fact 

that universally within USAID and outside of USAID, this is seen 

as one of USAID’s very best programs for many reasons which I 

won’t elaborate on right now, but it does involve World Vision, 

Food for the Hungry, many other faith-based NGOs, PVOs, and 

non-faith-based organizations. But it provides an opportunity for 

the Government to support the NGO efforts that originate in the 

United States to strengthen what they can do. But in my experience for more than three decades now, the creativity and innovation and deep passion and commitment that exists within the NGO 

community in the United States for child survival is extraordinary. 

I think what USAID has done in developing this program has 

been excellent. They have developed a tremendous rapport, as you 

just mentioned, with the PVO community. But at this particular 

moment in time, it is the understanding of the NGO, PVO community that this whole program may be shelved. It hasn’t been funded 

for 2 years now. And I find this extraordinary given the success, 

the demonstrated success of this program and what it has meant 

in terms of developing the kinds of approaches and programs that 

we feel are so important to move this agenda forward in nutrition 

and other aspects of child survival. 

So I would like to make a passionate plea that the committee 

give special attention to ensuring in child survival funding that 

there is a serious effort made to engage the U.S. NGO, PVO community going forward and to greatly accelerate the amount of funding that has been made available to this program. I have asked 

over the years many times why this program has continually been 

cut back and one of the answers that has been consistently given 

is exactly what Ms. Bos said a second ago and that is that funding 

has been decentralized to the country level so there is no money 

available at the central level to fund these kinds of programs. And 

this kind of funding is vital to engage the U.S. NGO community 

because frequently the NGO U.S.-based NGO community within 

the country level doesn’t have quite the same opportunity of operations that it does have by functioning as it has through the U.S. 

child survival and health grants program for the last 25 years. So 

I hope I have made my point. 

Mr. SMITH. If you could, again, how much has actually been 

spent? Not any for the last 2 years from that spigot? 

Dr. PERRY. There have been no grants awarded by the United 

States Child Survival and Health Grants Program for the last 2 

63

years and there are none scheduled at the present time. Previously, 

the amount of funding was on the order of $20 million and the 

project that I discussed—that I evaluated with Food for the Hungry 

was funded through this mechanism. And I think it is a terribly 

important one for many reasons. 

Mr. SMITH. And what would be an ideal amount in your view? 

Dr. PERRY. $200 million, minimum. 

Mr. SMITH. Okay. Your thoughts comport with Niels Daulaire 

who used to be very active over at USAID during——

Dr. PERRY. Yes. 

Mr. SMITH. I know he has been concerned. None of us want to 

see any lessening of the commitment to the HIV/AIDS, malaria, 

and tuberculosis efforts. We also don’t want to see a crowding out 

of other worthwhile programs robbing those in order to get to a 

critical mass and PEPFAR certainly has been successful beyond 

our dreams in many, many ways. 

Dr. PERRY. It takes money to be successful. 

Mr. SMITH. But that shouldn’t mean that these other very important—so if you could give further thought, all of you, on—we will 

fight to try to get this—that is why we are having the hearing. It 

is about that first 1,000 days. And it seems to me when you talk 

about the development goals, which will be the post-2015 goals, 

when they will come up with a whole new set, the laggard has been 

child mortality. 

As one of you said, and I have to remember which, we should celebrate, as you put it, the success that has been made, but there is 

so much that we have not done as a world or as a country to try 

to mitigate the problem of child mortality that is right within our 

grasp. 

Dr. PERRY. Right. 

Mr. SMITH. So $200 million, whatever you think, we need a sustainable and a very accurate number to fight for it and I know that 

Members of Congress are very open to—and I know that because 

I talk with them about these issues all the time to making sure we 

get it right. So that is why this hearing is being held, frankly. 

Dr. PERRY. I will be happy to address your other question, but 

I think I have taken more time than I should. 

Mr. SMITH. We will get to everyone, if you don’t mind? 

Dr. PERRY. I mean you had some other questions about ——

Mr. SMITH. The Lancet study. 

Dr. PERRY. About our support for community health worker programs and our comprehensive health workforce strategy and also 

the issue about what is the current status of knowledge about 

undernutrition. So let me just very briefly make a comment about 

those. 

There have been programs supported by USAID that involve 

community health workers, but we now need—we are at a new 

stage where we need to professionalize our community health 

worker workforce which has not happened before. There are going 

to be more and more interventions that can be provided at the community level, but we need to learn how to integrate these together 

in an effective system that can be sustained over time and that can 

be effective and that is what we have not been funding so far. So 

64

we are going to continue to need to build a system and it is an integral part of a health system strengthening approach. 

In my experience, health system strengthening is being recognized more and more as an important area for our involvement, but 

too often health system strengthening has been limited to services 

that take place at facilities without giving full recognition to the 

critical role of communities and community-based delivery in terms 

of improving population health. And it is not recognized by ministries of health still. It is an area that needs a lot of work and support. 

My only comment about undernutrition is that there was a recent series in the Lancet that was published only a few months ago 

that updated the 2008 Lancet series that you mentioned that was 

led by Dr. Robert Black at Johns Hopkins. Their conclusion is that 

54 percent of child mortality can be attributed to undernutrition 

and in the 2008 version I think they were saying something like 

38 percent or something like that. So I mean the science has continued to stress the importance of undernutrition as a fundamental 

part of reducing mortality, improving child survival in the first 

1,000 days of life. 

The problem is that so much of our aid is focused on curative 

health systems and not driven down to the community with behavior change communication, hand washing, exclusive breastfeeding, 

very simple low-cost things. These have not been given the kind of 

attention that other sort of medically-oriented interventions have 

gotten in the past and it takes a change of mindset that we are 

still struggling to bring about in the donor community. 

Mr. SMITH. Without objection, the most recent Lancet studies 

that you have mentioned by R.A. Black will be made a part of the 

record and I thank you for reminding of us that. 

Dr. PERRY. Yes. 

Mr. SMITH. It is very important. Dr. Wetzel Chen? 

Ms. WETZEL CHEN. Thank you. First responding to your question 

about recommendations for the U.S. Government, for one thing I 

would say we have really appreciated USAID’s focus on improving 

their monitoring and evaluation. So for many years we were doing 

programs, there wasn’t a heavy focus or guidance put on how to do 

baseline surveys, how to do followup. So it was unclear what was 

really working. So that support and initiative by the Government 

is very helpful. 

Secondly, we have appreciated multi-sector and multi-year funding from the U.S. Government. One of the programs that Food for 

the Hungry has been able to rely on over many years has been the 

food security programs. So those cover nutrition, but they also include agriculture livelihoods and they provide an excellent base for 

us really to make changes in the community. They are typically 5-

year programs and that is what is so key. When we are funded for 

1 year or 3 years, it is very difficult to see behavior change happening and make an impact, so that long-term funding makes a 

world of difference. 

Another thing that we always face as a challenge is 

contextualizing our programs. So there is usually a push when once 

we are funded to start implementing right away and see impact. 

But what we need to do is step back and say what are the specific 

65

barriers that are preventing what has worked maybe in other 

places from working here. So allowing a lead time where we can 

do investigative work would be very helpful. DFID recently started 

doing programming slightly different where they would fund, they 

would select an organization or a consortia and then they would 

say, okay, you have 6 months to do studies and develop your full 

proposal. That seemed like a great way to really allow us to make 

impact through the programs. 

Thirdly, I would like to recommend or to comment on the restraints that we have seen in terms of local NGOs. So as Ms. Bos 

shared, as an international NGO, we have seen that our funding 

is becoming more competitive. It is difficult. We don’t feel that we 

are being discriminated against in any way as a faith-based organization. We can come to the table, compete for funding just like any 

other international NGO. But as Ms. Bos was sharing, 97 percent 

of our staff worldwide are nationals of the country where they 

work, but we are unable to access more and more of the funding 

that is made available because we are not considered a local NGO. 

And there is a lot of strength and capacity that comes from having global service centers that support our field operations. We find 

that with the funding that we are able to win, we are using more 

and more resources to build the programmatic capacity of local organizations versus the technical impact of the program. 

Fourthly, I would like to say we have appreciated the U.S. Government’s focus on capacity-building grants and initiatives. For example, the CORE group. This is a group of maternal and child 

health technical implementers, NGOs. They come together twice a 

year. They have working groups. Some focus on nutrition. That has 

been a great place for the sharing of technical innovations, of best 

practices that TOPS Initiative by the U.S. Government. In years 

past, there was the institutional capacity building grant. Those are 

great ways to get out what works to NGOs that are implementing 

that. 

Your question was about community health workers. Well, as I 

combine that with recommendations for the Government, I would 

say there has been a focus lately on innovation and while I applaud 

that focus, it often means that what we have seen to work is harder and harder to get funding for. A lot of it isn’t rocket science. 

Breastfeeding, ORS, it works. And it is simple, but it is not happening at the level that we want to see it happening. So balancing 

that focus on innovation with funding what really works is important. And that relates to the community health worker question. 

That is funded. We have seen that going on, but it is not scaled 

up. 

In so many countries where Food for the Hungry enters, there 

may be a community health worker initiative, but you may have 

one person trying to reach thousands of households. And what we 

have seen work in our care group approach is that we take one 

community volunteer. That person reaches somewhere between 10 

and 12 neighbors. So it is peer-to-peer education. And social and 

behavior change research has shown that that is what really creates the changes at the household level, that we need not just a 

community health worker system, but one that has research has 

66

proven is effective in creating behavior change. That is my comment. Thank you. 

Mr. SMITH. Dr. Aguirre. 

Ms. AGUIRRE. Yes. I will focus particularly on Guatemala which 

is what you have requested from me. I want to say when you look 

at the funding allocation in the case of USAID and what Guatemala—more than 30 percent goes to democracy and governance, 

something that is not surprising given the conditions of Guatemala 

at this point in time. We know it is a very conflicting and high 

crime country at this point in time. 

And so having worked specifically in red zones, areas of high 

crime in this country, we see the consequences for the malnutrition, etcetera that we are dealing with this today because of crime, 

because of the lack of security, etcetera, broken families, widows. 

I have researched areas where the average structure is a widow because the husband has been killed in entire areas, in departments 

in the country. That is the framework that is not a misallocation 

of funds when you think in terms of long-term growth in a country 

and the consequences of high cost of lack of democracy and governance has on security in a country. 

That being said though, I would say that I find it difficult to justify the high level of funding that in Guatemala is placed today on 

family planning, disproportionately given the needs of the country. 

We are talking about almost as much as allocation for democracy 

and governance when people are dying of malnutrition or lack of 

access to clean water or basic education. 

So if I have one comment I have to make is about the allocation 

of funding from an economic point of view I would call inefficient 

as it does not meet the requirements of long-term growth for that 

country. 

Together with that though, I was thinking of other areas where 

I have seen very interesting work done and USAID had been part 

of it is the public/private initiatives that have been taking place in 

Guatemala. I have been working there for several years and what 

I have seen specifically since 2007 has been a significant growth of 

public/private initiatives where you see USAID has played a good 

role in some aspects, for example, in the area of education of agriculture, of HIV. So there are areas that are very good. However, 

I wish I would see much more engagement on the part of USAID 

for the purpose of erasing malnutrition where you have very good 

community-based private initiative programs, long-term investments in communities in very needy communities, for example, as 

in the north of Guatemala, where we have very high-level malnutrition and hunger. There are very good initiatives taking place 

there. There are long-term investments as my colleagues have 

mentioned before. Those are the ones who are really finding longterm solutions. They take 3, 4 years investment in the different 

communities; USAID having not really a partner in those efforts. 

It will serve them well to do so. 

Also, the lead time. I think this is also a very important issue. 

When you look at some of the investments of USAID, I will surrender they lack an institutional acknowledgment or reality of 

what are the values that this country wants to hold, what are the 

cultural backgrounds that take place in that country and that 

67

sometimes the programs promoted by USAID, not only misplace 

the authority I should say. For example, by ignoring tyrants when 

we are talking about minors, but also by the type of programs 

that—our educational programs that they propose, especially in the 

area of sex education and family planning and I want to go to this 

because I have found it in my own data and that is that access to 

family planning, contraceptives, sex education, among some of 

these in this red area, red zone areas as they call, high crime 

areas, none of this has been helpful for early pregnancies for example. In fact, it has increased early pregnancies and it has misplaced 

the emphasis. 

Unfortunately in Guatemala you have a lot of child abuse. The 

data is across the country. I can say it now because there is research everywhere. And it is an area that systematically we ignore. 

Interesting enough, right? Where we have—we offer all type of 

methodologies for contraception. We ignore the fact that we have 

child abuse and the consequence of that, lasting consequences for 

that in children. 

So there are some areas where I think USAID has done a fantastic job and there are some areas where I am greatly concerned 

because I really think it is a misuse of funds, especially when we 

are talking about cutting budgets. It might be worth it to take a 

serious revision and especially looking at the goals that they have 

proposed from here to 2016 as per their report. Thank you. 

Dr. MANDEFRO. So at this point I feel like I am just echoing my 

colleagues which I will do, happily. First of all, I could not agree 

with you more in terms of the child abuse statistics. They are really disheartening and one thing that continues to amaze me in my 

work is wherever I got across cultures, across race, across economic 

divides the numbers are startling and it is about one in three. And 

if we are looking at specifically at sexual abuse, actually it is one 

in three before the age of 18. And when you have a population risk 

factor that is that big, we can’t afford to ignore it, so I guess my 

first comment would be is really getting USAID to do more in the 

sphere of mental health. And I think as a whole in global public 

health, we have a long way to go. And I say this to you as an internist, as a primary care physician, not even as a mental health specialist because I have seen it. 

I truly believe that physical health begins with mental health. 

And I think a correlate point to that is that you know to the point 

you raised about behavior change programs, behavior change is 

about psychological health and well being. We know that even from 

the scientific literature in this country. Forty percent of our premature deaths are due to behaviors. And it is a very tough issue 

which is why it requires investment and I think why Congress can 

kind of place some restrictions about at least a certain percentage 

of the global public health assistance program being really directly 

at behavior change and more importantly addressing these large 

issues of abuse. 

The second point to the community health workers point I 

couldn’t agree more about the need to professionalize and I just 

wanted to name two projects in particular. In Ethiopia, there has 

actually been a lot of headway with the Ethiopian health extension 

workers program and a lot of their materials can serve as an exemVerDate 0ct 09 2002 09:54 Oct 02, 2014 Jkt 000000 PO 00000 Frm 00071 Fmt 6633 Sfmt 6633 F:\WORK\_AGH\032514\87334 SHIRL
68

plary model of how you professionalize in addition to the brave and 

pioneering work of partners in health. And Haiti and Rwanda are 

truly exemplary programs of how you can do this community 

health worker approach and take it to scale and get some really 

lasting affects. 

And then to your point, Chairman Smith, the study that I cited 

and I think I might not have actually included the reference in my 

original written comments comes out of the literature in child 

abuse actually in this country. It is the 2004 Journal of Pediatrics 

study by Susan Hillis, et al., there are a lot of authors, but it is 

actually the original authors who came up with the adverse childhood experiences study. It is a retrospective cohort study, so they 

looked back on these experiences of 9,159 women over the age of 

18 who attended a primary care clinic in San Diego. What they 

looked at was adverse childhood experiences as scored from one to 

eight and these are really a list of things like physical abuse, emotional abuse, sexual abuse, experiences of violence, household dysfunctions, all kinds of measures. And when they stratified this, the 

highest group which had an experience of 5 to 8 abuse adverse experiences had an increased risk of 80 percent in fetal death. So 

fetal death was actually one of the outcomes they looked at and I 

can give you the specifics for that reference. 

Mr. SMITH. Thank you very much, for all of you. Ms. Bass. 

Ms. BASS. Thank you very much. Dr. Perry, I was looking at your 

testimony and on page two, you list interventions that you thought 

would be the most appropriate. And I was just wondering what you 

thought in terms of how our funding is going now. I don’t know 

where we might emphasize, but it seems like a lot of these we don’t 

address. 

Dr. PERRY. We don’t. 

Ms. BASS. Oral rehydration, I am sure we do, but of our funding, 

where do you think the emphasis is lacking now, given your list of 

interventions? 

Dr. PERRY. Well, I think one basic fundamental idea in all of this 

is that nutrition has not been given the level of funding that it 

should have. And I think there is a wide consensus of that and 

that, in fact, one of the highlights, I think, of The Lancet series, 

The Lancet Maternal and Child Nutrition series, both in 2008 and 

2013 is that we do need stronger funding for nutrition programs. 

And so that is an important part of this. 

One area that is particularly important that I wanted to mention 

that responds to your question, but I also was looking for a chance 

to bring it up anyway since you said you had been a nurse in neonatal care unit. 

Ms. BASS. Yes. 

Dr. PERRY. Home based neonatal care is one of the exciting new 

interventions that has been developed scientifically, is now being 

applied on a broader scale. It is very simple. It uses community 

health workers to give education messages to mothers during pregnancy, have somebody who is trained to be there at the time of delivery, and then to have visitation every day for the first few days 

after birth and then periodically after that. Promoting good nutrition is one of the fundamental parts of it, exclusive breastfeeding, 

looking for signs of infection that could be treated with antibiotics 

69

early on, proper care of the umbilical cord. This is unbelievable, but 

studies that are led by Hopkins and other groups now show that 

just simply applying chlorhexidine to the umbilical cord at the time 

of birth today in the world we live in can reduce neonatal mortality 

rates by 25 percent. 

Ms. BASS. Do people use traditional methods? Is there some——

Dr. PERRY. There is still all kinds of unclean practices that take 

place in this world that we live in today. Why haven’t we done a 

better job of this? I mean it is really astounding. We are not talking about money. This is pennies involved for this. So I think that 

home based neonatal care is a very important area that we need 

to put more money into. We know that as under-5 mortality continues to decline, the proportion of deaths that are occurring in the 

neonatal period will be increasing over time, so putting more and 

more emphasis on preventing neonatal deaths and stillbirths which 

basically requires good prenatal care and also good quality basic 

medical care during the time of delivery by somebody who can be 

a community level worker, but who has some basic training in the 

management of clean delivery and recognition of complications. All 

of these areas are going to need more funding. 

We have done fairly well with oral rehydration. Zinc has come 

in now as an additional component for treating diarrhea. The coverage of zinc for cases of diarrhea is very low, so we have got to 

bring that up. Community case management of pneumonia with 

antibiotics, using community health workers, that has been known 

for a long time that that can reduce mortality from pneumonia by 

a third or more, but it is still a very low coverage level of this intervention. We have done very well with immunizations and Vitamin 

A. Those coverage levels are 80 percent or higher, but it is these 

other ones that are very low that we really need to focus on and 

we need to work on doing these in an integrated way. 

You can’t have a community level worker doing one thing and 

then having a different community level worker doing another 

thing. It doesn’t work like that at the community level. It may 

work that way at the higher levels of government, but when you 

get down to the village level, we have got to learn how to apply 

these things in an integrated, coordinated way that is effective. 

And we are still learning and struggling with that. 

Ms. BASS. Thank you. Dr. Aguirre, I was interested in what you 

were saying about family planning in the red zone and child abuse. 

And maybe you could connect that more for me. And when you are 

referring to child abuse, actually both of you and I was wondering 

what you were talking about, what type of abuse, you know. Here, 

for example, the main reason why children are removed from home 

is actually neglect as opposed to physical abuse, but you both referred to child abuse, so I was wondering—how we were defining 

it. 

Ms. AGUIRRE. Thank you very much, Congressman Bass. Two 

things I wanted to say. What I found systematically in the studies 

I have done and specifically in red zones, but to some——

Ms. BASS. Red zones are the high crime areas? 

Ms. AGUIRRE. High crime areas. High crimes areas that unfortunately there are more than we would like to see in Guatemala. 

What you find is in schools, so we are talking about high schools 

70

or grade schools where access to contraceptives is widespread or 

the type of education promoted and often connected to USAID, this 

is why I brought this issue are present. Typically, you find a higher 

level of sexual activity among the young and sometimes beginning 

in fifth grade. This is what I find in the data. And actually, this 

is consistent with other findings in other countries, too. This is not 

only a Guatemala surprise. 

Ms. BASS. So is this related to—because there are people in this 

country that believe if you do sex education or if you provide access 

to contraceptives that that makes kids more sexually active. 

Ms. AGUIRRE. I will say I find consistent data to that position. 

However, let me say that I have recommended in some places the 

introductions of sex education. The question is what of sex education we are engaging. For example, I have experiments where I 

have present parents and children in this area of abuse precisely 

to show that we need to address this address since the schools are 

being ignored. And this is a very serious issue. And when I refer 

to sexual abuse it is not only child abuse, not only verbal abuse, 

we are talking about sexual abuse. 

Ms. BASS. Okay. 

Ms. AGUIRRE. Ninety-nine percent of the time it is not immediate 

family members, but it might be extended family or others, often 

members of a gang. There are plenty of them. Gang members. 

So this is the type of data that I find. So what I am saying is 

this is not—what I am trying to say here is this is not about not 

having a sex education program if there is a need for one. I think 

it is the approach. What I find in the data on the studies that I 

have undertaken, that is problematic. 

Ms. BASS. And I would ask you what was the approach? You 

know, for instance, we went through a number of years here before 

my time where we promoted abstinence which wasn’t very successful. But so what was the approach that you felt that led to sexual 

abuse? 

Ms. AGUIRRE. So what I found is two things here. I said more 

pregnancy and sexual activity, one subject. That is what I said. 

And another subject, the issue, the fact that we find sexual abuse 

and it is not being addressed. 

Ms. BASS. Okay. 

Ms. AGUIRRE. So we are putting funding on safe sex type of programs, read safe sex as ‘‘do sex, but just be protected’’ as opposed 

to perhaps delayed sexual activity. You are in fifth grade, right? 

Ms. BASS. Right. 

Ms. AGUIRRE. Delay sexual activity and instead of focusing for 

example on more healthy and comprehensive sex education where 

you show respect and in addition to that, you address the issue of 

sexual abuse. That is what I was trying to say. 

Ms. BASS. So you are separating them. I see. I got that. And then 

just on the side note if the chairman doesn’t mind, I was in Guatemala, I believe it was the beginning of last year with Senator 

Landrieu looking at the issue of orphans in Guatemala and I am 

just curious if you have any information about that. What I understand happened is that the Guatemalans cut off adoption in the 

United States for some real reasons because there was a lot of corruption going on. 

71

Ms. AGUIRRE. You are absolutely right, yes. 

Ms. BASS. But when Guatemala did that, it left about 300 kids 

in limbo because they had already been in the process. And so you 

happen, I am sorry, this is not really our subject, but anyway, I 

thought I would——

Ms. AGUIRRE. Well, I will be happy to address this issue because 

I have worked closely with people who have been very connected 

with the change of the law as well as with orphans. 

Ms. BASS. Oh, good. 

Ms. AGUIRRE. So I have to say I don’t know if I will call it left 

in limbo. If there is a system, a large system in Guatemala where 

extended family will take those children, same pattern that often 

you will find, for example, in sub-Saharan Africa. 

Ms. BASS. And here. 

Ms. AGUIRRE. And here. We were talking about developing countries, so I am sorry. But also there has been a real concern, as you 

said because of the abuses that have been taking place in the process of adoptions, so they are working toward stabilizing that situation and there have been quite a lot of initiatives actually, especially at the local government levels, for example, in Guatemala 

City, they have an incredible, very interesting project on taking the 

kids from the streets and working with them. So I think that they 

are addressing the issue of orphans. It is not that they are being 

neglected. 

Ms. BASS. Right, I mean I went to an orphanage and I saw the 

kids there, but the ones I was referring to in limbo were ones that 

were actually in the process of being adopted. 

Ms. AGUIRRE. Oh, I am sorry. I misunderstood you. 

Ms. BASS. And U.S. parents here who were in the process of 

adopting them and then the government shut it down. So I didn’t 

know if that ban had been lifted. 

Ms. AGUIRRE. To the best of my knowledge, it has not been. 

Ms. BASS. Okay, thank you. 

Ms. AGUIRRE. I cannot——

Ms. BASS. I am sorry. I appreciate that. I am sorry to put you 

on the spot here. 

Dr. Mandefro, I wanted to ask you a couple of questions, too. Dr. 

Perry recommended exclusive breastfeeding which I certainly understand and would support, but I was just wondering when you 

find the women who are undernourished, how does that work actually, you know what I mean? Does that wind up compromising the 

woman’s health or does her body protect her by not really producing? 

Dr. MANDEFRO. I mean it is a problem, right? This is why child 

health must begin with maternal health. The moms definitely need 

their own nourishment in order for that to work. In some cases, 

they can still provide exclusive breast milk. Everyone’s responses 

are slightly different, but it is a problem for sure. 

I also wanted to just address the abuse question before that you 

had asked. When I said one in three, I was specifically talking 

about sexual abuse, but actually the scientific literature as it relates to adverse childhood experiences, breaks out all of these into 

four different abuses, physical, sexual, emotional, and neglect. So 

it actually gives you a score for each. So it is all of those abuses. 

72

Ms. BASS. And so what do you think that we are doing to really 

address in various countries the issue of girls getting married too 

early, child marriage? Is there anything that we are doing to support efforts, educational efforts against that? 

Dr. MANDEFRO. This is a very tough issue. Actually, the Council 

on Foreign Relations had a report that came out not even 7 months 

ago on how child marriage is a U.S. foreign policy issue now. So 

this issue is actually getting some traction in the domestic policy 

scene as well. I think child marriages also have been very effectively framed by development community as being connected to at 

least five of the MDGs, you know, affecting all of those outcomes. 

But we are ultimately talking about cultural change which is very 

difficult to do from the outside. I think it requires innovative methods of doing community-based outreach. There are programs. 

I actually sit on the board of an organization, a reproductive 

health organization called Engender Health and they have been 

doing a lot of interesting things around gender norms in South Africa. They have a program call Men as Partners because I think 

where you have to start with an issue like child marriage is obviously engaging the men in a conversation and in particular, young 

men. So some of the most pioneering work, I think, in this area has 

been actually these community-based efforts that take on this challenge of talking to the men directly in these communities. And I 

think Men as Partners is a great program to look at. Yes, there are 

other programs like that. 

Ms. BASS. Thank you. Thank you very much. Thank you, Mr. 

Chair. 

Mr. SMITH. Thank you very much. Just one final question. I 

chaired a hearing better part of a year ago, about a year ago. We 

heard from Dr. Peter Hotez from Baylor who is an expert in the 

area of neglected tropical diseases. And I have since read his book 

and the question arises about in talking about the global health 

programs, in regard to the submission from the administration, we 

have already talked about the cut of 12.2 percent from $115 million 

to $102 million. The cut in the vulnerable children line was a 34 

percent cut. But there is also a cut for neglected tropical diseases 

from $100 million to $86.5 million, a 13.5 percent cut or proposed 

cut. 

I am wondering one of the biggest takeaways from reading the 

book and from hearing from our witnesses including Dr. Hotez 

from Baylor, that there were some 2 billion people who have neglected tropical diseases, that it actually worsens the vulnerability 

of a woman, especially for HIV/AIDS, which was something that 

even though I have been at many PEPFAR meetings, worked on 

the legislation, was not aware of it until that hearing. 

But also the fact that so many children, their immune systems 

get compromised and in the context of nutrition, we want to feed 

the children, not feed the worms. And I am wondering what your 

thoughts might be on this. We are working on some legislation 

right now which will probably be a multi-month, even multi-year 

project because it is hard to get bills passed, I know, because most 

of my bills take 3 years before they become law. But this whole 

idea of neglected tropical diseases, the first 1,000 days, obviously, 

the mother is weakened, less likely if she has one of these terrible 

73

diseases to effectively provide breast milk for her child, plus she is 

sick. What are your thoughts about the correlation between NTDs 

and nutrition and again, hopefully, we don’t feed the worms? Anyone want to touch on that? 

Ms. BOS. I can chime in on that, Chairman. I think that reemphasizes the need for a multi-sectoral approach to maternal and 

child health. If you are getting worms from unsafe water, you 

know, it obviously is then tying into all of the health outcomes both 

for the mother and the child. So too often I think the U.S. Government has been guilty of this and I think sometimes us as NGOs 

have also been guilty of taking a very vertical approach and seeing 

things in silos. And we have really learned lessons from that that 

you cannot address just one issue at one point in time because they 

are so interconnected. 

And to build on something that Dr. Perry said as well, how do 

you get those integrated multi-sectoral interventions? The message 

is out through community health workers. There are ways that we 

are growing our knowledge of how to do that and part of that is 

using a lifecycle approach. So there are certain things that need to 

happen at 30 days of a child’s life or at 6 months or at 2 years, 

whether it be vaccinations or teaching the mother how to prepare 

complementary foods for her child properly. All of those messages 

can be delivered at a certain point in time in a congruent way 

where the mothers really understand at the household level what 

they need to be doing. So that is just another piece, I think, of how 

all of this comes together. But again, getting away from some of 

the vertical structures that we have had. And that is where some 

of these strategies come into play as well, both a nutrition strategy, 

USAID has a water strategy. Hopefully, we can get a health worker strategy. Because different agencies are doing some of these different vertical pieces, having those intergovernmental, interagency 

strategies really would be very helpful into making sure every 

piece is working together the way it should. 

Dr. PERRY. You asked a very complicated question that is a 

source of debate in the global health academic community and 

practitioner community, so I am not going to try to resolve all of 

that in 30 seconds. But just a comment or two. One is that there 

is a very exciting and successful program for neglected tropical diseases called CDI, Community Directed Interventions. And it has 

been supported, I don’t know to what degree the United States 

Government directly has supported this, but it has been part of the 

WHO tropical disease research program and it has been going on 

a long time. But the reason I mention this is because it involves 

community empowerment, community-based delivery systems that 

started out as a very integrated, vertical, sort of top-down program 

that reached down to the community in the ways that we are arguing for, I think all of us here. But they are now starting to use this 

approach to bring in other child survival interventions in an integrated fashion. So I would encourage you to look into that and 

think about how we can build on these kinds of programs. We need 

all these programs and unfortunately, in the global health community, funding is so limited we end up fighting with each other to 

get a little bigger piece of the pie. We need a bigger pie. 

74

I would encourage you to look for ways in which the implementation of neglected tropical diseases at the community level that 

reach down to the household, which they have to do to be effective, 

can link as well into some of the nutrition and child survival interventions that we are talking about. I think there is a lot of published literature on this, a lot of evaluations of CDI and there is 

some exciting opportunities there, particularly in Africa. 

Ms. AGUIRRE. I was going to second Dr. Perry. That is what I 

was going to bring up, too. 

Mr. SMITH. Thank you very much to all of you. Thank you for 

your leadership, your patience. I again apologize for that long 

delay. 

And your information I can assure you will be widely disseminated among my colleagues and it will help me and others know 

what we need to do next step. I am very grateful and I know Ms. 

Bass is as well for your participation today. 

This hearing has generated a great deal of interest among other 

civil society organizations and some of whom have provided unsolicited submissions for the record and without objection, I will ask 

that these documents be entered into the record from the American 

Academy of Pediatrics, a statement by its president, James M. 

Perrin, M.D.; from Bread for the World, a statement by its president, Rev. David Beckman. And from Lions Club International, a 

statement by its immediate past international president, Wayne A. 

Madden. Without objection, it is so ordered. 

Members have 5 legislative days to submit additional questions 

or material for the record and again I thank you so very, very 

much. The hearing is adjourned. 

[Whereupon, at 5:36 p.m., the committee was adjourned.] 

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A P P E N D I X 

MATERIAL SUBMITTED FOR THE RECORD

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MATERIAL SUBMITTED FOR THE RECORD BY HENRY PERRY, M.D., PH.D., SENIOR ASSOCIATE, HEALTH SYSTEMS PROGRAM, DEPARTMENT OF INTERNATIONAL HEALTH, 

BLOOMBERG SCHOOL OF PUBLIC HEALTH, JOHNS HOPKINS UNIVERSITY


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MATERIAL SUBMITTED FOR THE RECORD BY THE HONORABLE CHRISTOPHER H. SMITH, 

A REPRESENTATIVE IN CONGRESS FROM THE STATE OF NEW JERSEY, AND CHAIRMAN, 

SUBCOMMITTEE ON AFRICA, GLOBAL HEALTH, GLOBAL HUMAN RIGHTS, AND INTERNATIONAL ORGANIZATIONS


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