U.S. GOVERNMENT PRINTING OFFICE

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S. HRG. 105–883

GLOBAL ERADICATION OF POLIO

AND MEASLES

HEARING

BEFORE A

SUBCOMMITTEE OF THE

COMMITTEE ON APPROPRIATIONS

UNITED STATES SENATE

ONE HUNDRED FIFTH CONGRESS

SECOND SESSION

SPECIAL HEARING

Printed for the use of the Committee on Appropriations

(

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ISBN 0–16–058177–X
(II)

COMMITTEE ON APPROPRIATIONS

TED STEVENS, Alaska, Chairman

THAD COCHRAN, Mississippi

ARLEN SPECTER, Pennsylvania

PETE V. DOMENICI, New Mexico

CHRISTOPHER S. BOND, Missouri

SLADE GORTON, Washington

MITCH MCCONNELL, Kentucky

CONRAD BURNS, Montana

RICHARD C. SHELBY, Alabama

JUDD GREGG, New Hampshire

ROBERT F. BENNETT, Utah

BEN NIGHTHORSE CAMPBELL, Colorado

LARRY CRAIG, Idaho

LAUCH FAIRCLOTH, North Carolina

KAY BAILEY HUTCHISON, Texas

ROBERT C. BYRD, West Virginia

DANIEL K. INOUYE, Hawaii

ERNEST F. HOLLINGS, South Carolina

PATRICK J. LEAHY, Vermont

DALE BUMPERS, Arkansas

FRANK R. LAUTENBERG, New Jersey

TOM HARKIN, Iowa

BARBARA A. MIKULSKI, Maryland

HARRY REID, Nevada

HERB KOHL, Wisconsin

PATTY MURRAY, Washington

BYRON DORGAN, North Dakota

BARBARA BOXER, California

STEVEN J. CORTESE, Staff Director

LISA SUTHERLAND, Deputy Staff Director

JAMES H. ENGLISH, Minority Staff Director

SUBCOMMITTEE ON DEPARTMENTS OF LABOR, HEALTH AND HUMAN SERVICES, AND

EDUCATION, AND RELATED AGENCIES

ARLEN SPECTER, Pennsylvania, Chairman

THAD COCHRAN, Mississippi

SLADE GORTON, Washington

CHRISTOPHER S. BOND, Missouri

JUDD GREGG, New Hampshire

LAUCH FAIRCLOTH, North Carolina

LARRY E. CRAIG, Idaho

KAY BAILEY HUTCHISON, Texas

TED STEVENS, Alaska

(Ex officio)

TOM HARKIN, Iowa

ERNEST F. HOLLINGS, South Carolina

DANIEL K. INOUYE, Hawaii

DALE BUMPERS, Arkansas

HARRY REID, Nevada

HERB KOHL, Wisconsin

PATTY MURRAY, Washington

ROBERT C. BYRD, West Virginia

(Ex officio)

Majority Professional Staff

BETTILOU TAYLOR

MARY DIETRICH

Minority Professional Staff

MARSHA SIMON

Administrative Support

JIM SOURWINE and JENNIFER STIEFEL
(III)

C O N T E N TS

Page

Opening remarks of Senator Dale Bumpers .......................................................... 1

Eliminating polio throughout the world ................................................................ 1

International strategy ............................................................................................. 3

Statement of David Satcher, M.D., Ph.D., Assistant Secretary for Health

and Surgeon General, Public Health Service, Department of Health and

Human Services ................................................................................................... 3

Decrease in cases of poliomyelitis .......................................................................... 4

Struggles faced in Southeast Asia .......................................................................... 5

Effective vaccine against measles .......................................................................... 6

Prepared statement Dr. David Satcher ................................................................. 7

Statement of Erbahim M. Samba, M.D., regional director, Regional Office

for Africa, World Health Organization ............................................................... 13

World Health Organization ..................................................................................... 13

Winning the battle against polio ............................................................................ 14

Prepared statement of Dr. Erbahim M. Samba .................................................... 15

Human and natural resources to sustain everybody ............................................ 22

Statement of Herbert A. Pigman, chairman, polio eradication advocacy task

force, the Rotary Foundation, Rotary International ......................................... 22

Oral polio vaccine .................................................................................................... 23

Prepared statement of Herbert A. Pigman ............................................................ 24

Biographical sketch .......................................................................................... 29

Statement of Dr. Bill Foege, former Director, Centers for Disease Control ....... 30

Lessons from polio ................................................................................................... 31

Spreading of measles ............................................................................................... 32

Prepared statement of Dr. William Foege ............................................................. 33

When to stop manufacturing polio vaccine ............................................................ 36

Smallpox vaccine and stockpiling ........................................................................... 36

Two polio vaccines ................................................................................................... 37

Eradication programs .............................................................................................. 37

Civil strife ................................................................................................................. 37

HIV and AIDS .......................................................................................................... 38

Polio eradication ...................................................................................................... 38

Rotarians .................................................................................................................. 39

Eradicate measles .................................................................................................... 39
(1)

GLOBAL ERADICATION OF POLIO AND

MEASLES

FRIDAY, SEPTEMBER 23, 1998

U.S. SENATE, SUBCOMMITTEE ON LABOR, HEALTH AND HUMAN

SERVICES, AND EDUCATION, AND RELATED AGENCIES, COMMITTEE ON APPROPRIATIONS, Washington, DC.

The subcommittee met at 10:34 a.m., in room SD–124, Dirksen

Senate Office Building, Hon. Dale Bumpers, presiding.

DEPARTMENT OF HEALTH AND HUMAN SERVICES

PUBLIC HEALTH SERVICE

OFFICE OF THE SURGEON GENERAL

STATEMENT OF DAVID SATCHER, M.D., Ph.D., ASSISTANT SECRETARY

FOR HEALTH AND SURGEON GENERAL

OPENING REMARKS OF SENATOR BUMPERS

Senator BUMPERS. The committee will come to order.

First let me thank Chairman Specter for calling today’s hearing

to discuss the eradication of polio and measles throughout the

world. I know he shares my commitment to improve preventive

health care for children and to make investments necessary to ensure that all children have ready access to vaccines that protect

them from illness and death. Over the past several years, the

chairman’s mark has included significant funding increases for the

Centers for Disease Control to carry out its program to eradicate

polio and measles. Under his leadership and that of Senator Harkin, the entire subcommittee has supported these efforts in a bipartisan way and today we look forward to hearing some very good

news regarding how our investment in polio eradication is about to

pay off.

ELIMINATING POLIO THROUGHOUT THE WORLD

There are fewer than 800 days left before we reach the goal of

eliminating polio throughout the world by the end of the year 2000.

That victory will mark the second time in history we have been

able to eradicate an infectious disease. The first was the eradication of smallpox, a disease that claimed millions of lives through

the centuries. As recently as the 1950’s, smallpox was killing over

2 million people each year, despite the fact that an effective vaccine
2

for the disease had been in use since 1796. Smallpox eradication

began in 1967. The campaign required 11 years to complete and

cost nearly $300 million—$200 million from countries with endemic

smallpox and an additional $100 million from international donors.

The United States was the largest international contributor with a

total investment of $32 million, and that investment has repaid

itself many times over. Beyond the humanitarian benefits of eliminating this vicious killer, we have enjoyed tremendous economic

benefits. The United States alone has recouped the equivalent of its

entire investment every 26 days since the disease was eradicated.

The polio effort began in 1988 when the World Health Assembly

endorsed the program and set the year 2000 as the target date for

global eradication. Thus far, the campaign has been a very dramatic success story. Today, four out of every five of the world’s children receive polio vaccine. Over the past 10 years, polio cases have

been reduced by over 90 percent, and today more than 150 nations

report no polio. All countries in the western hemisphere have been

polio-free since 1991 and all countries in Europe and the western

Pacific region, including China, Vietnam, and Cambodia, have been

polio-free for 1 or more years.

In my view, the program’s achievements are the result of a model

public/private partnership. Rotary International began working on

immunization programs in the early 1980’s, and when the World

Health Assembly endorsed the polio eradication program in 1988,

Rotary became the primary private sector partner in the campaign.

We estimate that Rotary will have contributed $450 million by the

end of the year 2000, the largest private contribution to a public

health initiative in history.

In a combined effort with the health ministries in each country,

Rotary, UNICEF, World Health Organization, and CDC have mobilized thousands of volunteers to recruit, educate, transport, and

vaccinate children in a mass campaign strategy. The scope of the

program is enormous. In 1997 alone, more than 450 million children in 80 countries were vaccinated against polio through the use

of mass campaigns. And the partners have enjoyed unparalleled

success in densely populated areas where the risk of disease has

been high. During India’s first campaign in 1996, more than 87

million children were vaccinated by 100,000 volunteers over one 3-

day period.

The last frontier for the program is Africa, where the polio campaign faces formidable challenges. Efforts there have been hindered

by poverty, civil conflicts, and logistical problems in vaccine delivery. Even with these barriers, the program has enjoyed significant

success in many areas of the continent. National immunization

days have been conducted in over 35 African countries and put a

real dent in the number of polio cases.

Experts in the field, including one Betty Bumpers who participated in a mass campaign in West Africa earlier this year, have

all returned with the same message: We can win the war against

polio and Africa will put us over the top for the year 2000, but only

if we intensify our efforts in Africa over the next 2 years. This

means more funding from all the donors and more logistical support for programs that are conducted in countries racked by civil

conflict and supply shortages.
3

As was the case with smallpox, the rewards will far exceed the

costs. The United States alone will reap annual savings of over

$230 million, and worldwide savings will exceed $1.5 billion every

year. More importantly, we will have conquered a disease responsible for crippling millions of children in our history.

Finally, we have set the stage for our next campaign: the eradication of measles worldwide. Regional efforts to eliminate measles

have already begun, and an international effort is on the horizon.

Historically, measles has killed more children than any other infectious disease. Even today it is responsible for 1 out of every 10

deaths in children under age 5. I can remember when Dr. Satcher

was in my office 3 or 4 years ago and gave me that statistic. I was

absolutely staggered. Think of it: 1 out of every 10 deaths in children under age 5 caused by a preventable disease.

INTERNATIONAL STRATEGY

Many leaders in the public health field believe that we should

begin planning an international strategy over the next 2 years so

that resources can be easily shifted from the polio effort to a measles campaign once polio is eradicated.

We are privileged to have a very distinguished panel this morning to educate us on the polio and measles efforts. Dr. David

Satcher has been a leader in the polio effort during his tenure as

Director of CDC and more recently as Surgeon General. Dr. E.M.

Samba, whom I want to personally thank for his courtesy and hospitality to Betty, is with us this morning. He is head of the World

Health Organization in Africa and I am confident will be responsible for winning the final battle of the campaign when polio is

eradicated there over the next 2 years. Mr. Herb Pigman heads the

Rotary International polio program, and even though he is the only

nonphysician on the panel, has probably visited and participated in

more polio campaigns across the world than any doctor or nurse in

the entire public health care system. Dr. Bill Foege, former Director of the CDC and longtime advisor to the Congress and leader in

the international health community, brings us the wisdom of his

experience with smallpox, polio, and measles eradication.

Gentlemen, I welcome all of you and thank you very much for

taking your time to travel here, prepare your testimony, and enlighten the rest of us.

For lack of a better system, let me just suggest that we start on

the right with Dr. Foege.

SUMMARY STATEMENT OF DR. DAVID SATCHER

Dr. FOEGE. Thank you, Senator Bumpers.

Senator BUMPERS. Wait just a moment.

[Pause.]

Senator BUMPERS. I am sorry. Staff always prevails. [Laughter.]

Dr. Satcher, you are uno numero. [Laughter.]

Dr. SATCHER. Well, thank you very much. I certainly understand

the logic of starting from your right. [Laughter.]

I am delighted to be a part of this very outstanding panel. I am

David Satcher, Assistant Secretary for Health and Surgeon General of the United States.
4

Senator Bumpers, I just want to say, before I officially begin my testimony, how much it means to me to be here today and to be

a part of this panel. I want to thank you for your tireless and effective efforts in support of the health of the citizens of this country

and throughout the world. Your wisdom and foresight have helped

reach unprecedented achievements, especially in the area of immunization, and we are grateful. As Director of the CDC, I came to

respect your integrity, appreciate your commitment, and admire

your insights into issues surrounding immunizations. This will probably be my last opportunity to testify before you in Congress, and I will miss you greatly but I will always appreciate

the outstanding work that you have done as a Member of the Congress of the United States. Thank you.

Senator BUMPERS. Thank you, Dr. Satcher.

Dr. SATCHER. I will be brief because this is an outstanding panel, and I would just like to support some major points that you have

made: No. 1, about the rationale for polio eradication; two, the status of our efforts to eradicate this disease; and three, to talk about

the issue of measles eradication and where we are with that consideration and developments related to that.

Often when we talk about the rationale for eradicating polio, we

speak of it from the standpoint of the financial gains. And they are

significant in terms of being able to save on the costs of immunizations in this country and throughout the world. That is an important consideration, the fact that this was, in fact, a cost effective

effort. But I believe it is fair to say that the opportunity which we

have to prevent pain and suffering and unnecessary deaths in this

country and throughout the world should be our overriding consideration.

We are a Nation that invests over $1 trillion a year in our health

care system, and we are predicting that by the year 2007, we will

be spending over $2 trillion. We spend only about 1 percent of that

amount on population based prevention. Because of that, I think it

is critical to point out that there is no better investment that we

could make than to prevent this disease throughout the world and

the necessity for immunizing against it.

So, I think the rationale is really clear. We have the technical

ability to eradicate this disease. We have demonstrated that. We

eliminated this disease in the Western Hemisphere. We have not

had a case since 1991. As we speak, our colleagues from the Pan

American Health Organization are meeting down the street. They

played a great role in eliminating this disease from the Western

Hemisphere and demonstrating, in fact, that it can be eradicated

from the world.

In terms of the status of polio eradication, I would just like to

point to some very important charts, and that was the first one.

[Laughter.]

DECREASE IN CASES OF POLIOMYELITIS

The number of reported poliomyelitis cases by year worldwide.

Beginning in 1988 when the World Health Organization declared

its commitment to eradicate this disease, there has been an 85- to

90-percent decrease in the reported cases of poliomyelitis by year.

As you know, we do not report every case. We know that there are
5

many cases of polio that are not reported, but using an epidemiological model, we can estimate the number of cases from the number of cases that are reported.

So, this is a dramatic story of success in the efforts to eradicate polio in the world, and it reflects a great reduction in pain and suffering and deaths. Hundreds of thousands of children who would

have died from polio have been saved because of this effort. I think

that is the major message here. You are very familiar with these charts, as are members of the panel. In 1988, this disease was very common throughout the

world. The reports were very common. If you look at the color of

the charts, the red areas and the green areas especially, the increase in the number of countries reporting no cases of polio, when

you compare 1988 with 1997, and the fact that today we are struggling primarily in Africa, and primarily sub-Saharan Africa, and

Southeast Asia and making significant progress. I think if you look at India and what has happened in India over the last few years, it is the most dramatic example of what we can

achieve. There has been in India more than a 90-percent reduction

in cases of reported polio since 1988. We have really targeted in the

last few years India. I was there in 1996, December 7, when we immunized 120 million children against polio.

But I also gained on that occasion a new kind of respect for Rotary International. I was aware of all of their financial investment,

but on that particular day, 57,000 Rotarians were in the streets

throughout India getting children out to be immunized. The commitment of this organization throughout the world and the way it

has coordinated its efforts has really been something to behold. It

is a unique kind of public health partnership that we enjoy, and

I commend Rotary International for their commitment and effective

operations.

It is going to be difficult to go the rest of the way. I was a long

distance runner in college. I really was not that good, so you did

not hear about me. [Laughter.]

But I learned something, and that is, I learned that it does not

matter how great your stride or how well you run the first one-half

or the first two-thirds or three-fourths of the race. If you do not finish, you are a failure.

And I believe we have come to the point now where the issue is,

are we committed to finishing this race to eradicate polio? We know

we can do it. We have demonstrated that we can do it, but I think

we run the risk, if we are not careful, of slowing down and not finishing the race by the year 2000. So, I think it is really critical that

we make the commitments, financial and otherwise, to finish this

task.

STRUGGLES FACED IN SOUTHEAST ASIA

This chart demonstrates some of the struggles that we face in

Southeast Asia and in Africa especially. Even though this is from

Afghanistan, the fact of the matter is that some of the things we

take for granted in terms of communication and transportation systems or the ability to preserve and move the vaccine from place to

place, all those issues become very difficult, especially when you

put on top of that often wars and conflicts of various kinds that
6

make it very difficult for people to come together and implement

national immunization days. Those are some of the things we are facing now in terms of the logistics and the operations. We can overcome those barriers. We

have demonstrated that and I think we will, working together,

overcome them and complete the task of eradicating polio. The benefits are tremendous and certainly Dr. Foege who played such a

critical role in the eradication of smallpox probably appreciates

that better than anyone in terms of working very hard to accomplish the eradication of disease and then seeing the benefits of it

play out over the years. As a leader in public health and all of the challenges that we are facing, I appreciate the fact that the effort to eradicate polio has

really helped us to develop an infrastructure, a global infrastructure that we would not otherwise have in place. The importance of

epidemiological and laboratory surveillance in terms of monitoring

the progress of eradicating the disease and all of those systems

that we have put in place in order to carry out this effort will benefit us tremendously, not only as we approach other diseases such

as measles, but the whole challenge of global emerging infectious

diseases.

I am meeting with our partners in eight nations throughout the

world now in terms of trying to make sure that we have in place

systems to deal with new and emerging infectious diseases. We are

learning a lot from our experience in the eradication of polio. We

have laboratories in place. We have trained people in place. We

have systems in place that we would not have if it were not for this

effort. So, the benefits are just tremendous.

EFFECTIVE VACCINE AGAINST MEASLES

Well, I will just say a few words about measles because I am

sure that is going to be discussed by my colleagues. As you pointed

out, measles is still a very important disease, still responsible for

the deaths of almost 1 million children a year in the world and almost 37 million cases of measles in the world.

We have a very effective vaccine. We know that we can eliminate

this disease because in this country, for example, we have seen

dramatic declines in measles over the last several years. In the

past 5 years, we have averaged only about 400 cases, and last year

we had, I think, a total of 138 cases in this country. It looks like

we are going to have fewer than that this year, my colleagues from

CDC tell me.

So, I think it is very clear that we can eliminate this disease, we

can eradicate it, and I think on the horizon is the prospect of moving forward after we finish polio. If we do not finish the job with

polio, I think the hope of being successful with measles and other

diseases is not very great. So, we have got to finish polio, but I

think after we have finished it, it looks like the prospects of eradicating measles are very real and that we should pursue that. We

are already working very hard.

Again, PAHO has been very successful in dealing with measles.

To a great extent the reason we have had so few cases in this country is there have been so few cases in the Western Hemisphere.

Now, last year we did have an outbreak in Brazil, and that dem7

onstrated the importance of being diligent in terms of pursuing

these diseases. But I think it is very clear that as we complete the

task of polio, we can look to eradicating other diseases in the world

and controlling emerging infectious diseases.

PREPARED STATEMENT

So, I am very pleased to be a part of this panel and very pleased

to join you in reviewing our commitment to the eradication of polio

and look forward to, even in your retirement from the Congress,

working with you and Mrs. Bumpers as we continue to work toward a world that is free of polio and safe from other infectious diseases. Thank you.

Senator BUMPERS. Dr. Satcher, thank you very much for that

wonderful, articulate, and enlightening statement.

[The statement follows:]

PREPARED STATEMENT OF DR. DAVID SATCHER

Good morning. Mr. Chairman and members of the Subcommittee, I want to thank

you for your invitation to testify at this important hearing on the eradication of

polio and control or elimination of measles. I am Dr. David Satcher, Assistant Secretary for Health, Department of Health and Human Services (HHS) and Surgeon

General of the United States.

Mr. Chairman, like myself, some people in this room may remember the fearful

time in the 1940’s and 1950’s when thousands of Americans were paralyzed by polio

every year. Today, the Department is assisting the World Health Organization

(WHO) in the worldwide effort to eradicate poliomyelitis by the year 2000. Ultimately, global polio eradication is the most cost-effective and permanent way to protect the United States from imported polio cases. No single country can be safe from

polio until all countries are free of polio.

Within HHS, the Centers for Disease Control and Prevention (CDC) has lead responsibility for global polio eradication and measles elimination programs. I would

like to briefly address the following: The rationale for global polio and measles initiatives, progress toward global polio eradication, partnerships, and challenges, and

the status of efforts to develop and implement a global measles elimination plan.

RATIONALE FOR GLOBAL POLIO ERADICATION AND MEASLES ELIMINATION INITIATIVES

Diseases do not recognize national boundaries; therefore, international disease

eradication and elimination activities are essential in protecting Americans from the

threat of imported disease. Eradication is the permanent reduction to zero of the

worldwide incidence of infection caused by a specific agent. Eradication creates an

environment where intervention measures are no longer needed. Elimination is the

reduction to zero of the incidence of infection in a defined geographic area.

Although the United States has been free from indigenous polio since the early

1970’s, polio cases resulting from imported polio virus occurred during the late

1970’s, and such events remain a threat in the 1990’s, although, thankfully, a diminishing one. Virtually all measles cases in the United States are now directly or

indirectly imported from other countries. By contrast, no American has suffered

from smallpox since global eradication was reached in 1977.

Successful eradication programs save significant amounts of money. The global

eradication of smallpox in 1977, with support from the Department and the U.S.

Agency for International Development (USAID), proved to be a remarkably good economic investment for public health. A total of $32 million was spent by the United

States over a 10-year period in the global campaign to eradicate smallpox. The entire $32 million has been recouped every 21⁄2 months since 1971 when routine smallpox vaccination was discontinued in the United States by saving the costs of smallpox vaccine preparation and administration, medical care, quarantine and other direct and indirect costs. According to an April 1998 General Accounting Office (GAO)

report, ‘‘Infectious Diseases: Soundness of World Health Organization Estimates for

Eradication or Elimination,’’ the cumulative savings from smallpox eradication for

the United States is $17 billion. The report also estimates the real rate of return

on the smallpox investment for the United States to be 46 percent per year since

smallpox was eradicated.
8

Achievement of global polio eradication will offer benefits similar to those realized

by smallpox eradication. More than $230 million will be saved annually in the

United States alone when polio eradication is achieved and polio vaccination is

stopped. Globally, more than $1.5 billion will be saved annually.

Disease eradication also dramatically reduces the global burden of disability and

death resulting from disease. Smallpox eradication eliminated the suffering of an estimated 10- to 15-million people a year and saved the lives of 1.5 million people per

year. The polio eradication initiative is eliminating the burden, disability and death

related to polio. Since 1988, several million children worldwide who would have

been paralyzed were not because of the dramatic reductions in polio virus transmission. More than 100,000 children who would have died from polio, were saved.

Successful disease eradication initiatives also benefit the broader spectrum of public health.

Disease surveillance systems established for eradication initiatives can be used for

other important public health efforts. For example, polio surveillance systems in

Latin America were helpful in determining the scope of cholera outbreaks in the

early 1990’s.

Eradication initiatives provide models for appropriate and feasible laboratory networks. For example, the global polio laboratory network (87 virology labs) developed

for polio eradication is a model for global infectious disease laboratory surveillance.

Capacity-building required for successful eradication initiatives leads to improvements in public health planning, logistics, training, and communications. For example, the global polio eradication initiative has helped the expansion of computer capacity and development of health information systems in developing countries.

Quite importantly, the success of polio eradication activities is increasing the enthusiasm for immunization and other public health programs by local and political

officials.

GLOBAL POLIO ERADICATION

Basic strategies for polio eradication

WHO has defined four basic strategies for polio eradication. They are:

(1) Achievement and maintenance of high routine immunization coverage levels

among children with at least three doses of polio vaccine. When a high percentage

of children are vaccinated, disease incidence is reduced and eradication becomes feasible.

(2) Development of sensitive systems of epidemiologic and laboratory surveillance

for suspected cases of poliomyelitis. Eradicating polio requires a system to detect,

investigate and report every possible case of polio. Disease surveillance is a critical

component of any disease eradication program. Two stool specimens are collected

from every suspected polio case for testing in a virology laboratory for the presence

of polio virus.

(3) Implementation of National Immunization Days (NIDs)—mass immunization

campaigns that aim to vaccinate every child in a country (generally children less

than 5 years of age) in as short a time as possible, usually within one to a few days,

to rapidly stop the spread of polio virus. Because not all children are reached by

the routine immunization system and not all children are fully protected by the

doses they have received, NIDs target all children less than 5 years of age, regardless of their prior immunization status. This strategy provides the additional advantage of boosting the intestinal immunity among previously protected children, providing a further barrier to the circulation of polio viruses in the community. Two

doses of polio vaccine are administered to all children with an interval of 4- to 6-

weeks between doses. Because the oral polio vaccine does not require a needle and

syringe to administer, volunteers with minimal training can serve as vaccinators

during NID’s, thus vastly increasing the number of vaccinators well beyond the existing staff of the country’s ministry of health and facilitating completion of NIDs

within a short period of time.

(4) Implementation of ‘‘Mopping-Up’’ Immunization Campaigns. These are localized campaigns conducted in the final stages of polio eradication in a country, which

are targeted to high-risk areas where polio virus circulation still persists. In order

to reach every child, polio vaccine is carried from house to house rather than having

children come to a central immunization station. As with the NID’s, two doses of

polio vaccine are administered to all children less than five years of age, regardless

of prior vaccination history, with an interval of 4- to 6-weeks between doses.

Progress toward achievement of global polio eradication

Extraordinary progress continues toward achieving the goal of global polio eradication by the year 2000. Reported cases have declined by more than 85 percent since
9

the initiative was launched in 1988. (Attachment I) A significant portion of the

world has become polio-free since 1988. (Attachments II and III) All countries of the

Americas have been polio-free since 1991, and virtually all countries in Europe and

the Western Pacific Region (including China) have been polio-free for 1 or more

years.

In addition to this progress, notable reductions in polio cases have occurred in

other countries. For example, laboratory-confirmed polio in the European Region declined to less than 10 cases in 1997 following three years of synchronized NIDs in

10 polio-endemic countries in the Region. Also, India has experienced the most dramatic declines in reported polio cases. In 1988, India documented a total of 24,257

cases. The number of cases fell dramatically to a total of about 2,300 cases in 1997,

a decrease of more than 90 percent. In Indonesia, three years have passed since the

last laboratory-confirmed cases of polio. Furthermore, the number of polio cases in

Viet Nam has declined from 557 cases in 1992 to zero cases in the last 12 months.

The polio eradication initiative has provided a tremendous example of global cooperation and action. More than 450 million children in 80 countries worldwide

were vaccinated against polio in National Immunization Days (NIDs) in 1997, which

is approximately two-thirds of the world’s children less than 5 years of age. NIDs

in India in January 1998 involved deployment of 2 million volunteers to vaccinate

over 130 million children in a single day. The polio-endemic countries of South Asia,

including India, Bangladesh, Myanmar, Nepal and Indonesia, have conducted NID’s

for 2 or more years. In December 1997 and again in January 1998, six countries

(Bangladesh, Bhutan, India, Myanmar, Nepal, and Thailand), in an unprecedented

display of international coordination for health, conducted simultaneous NID’s in

which 165 million children were vaccinated in each round. India’s new National

Polio Surveillance Project works with a national laboratory network and has greatly

improved India’s surveillance during the past 12 months. More than 100 persons

have been hired whose main job is to find polio virus wherever it may be to guide

further eradication efforts. Current efforts to eradicate polio involve continuing polio

NIDs, improving polio surveillance, and strengthening routine immunization programs.

The fight against polio is taking place in some of the most difficult locations, including those in the countries of Sudan, and Somalia. Despite the challenges of war,

famine, extremes of weather, and a lack of roads or other infrastructure, polio immunization days were implemented in Southern Sudan from February through April

of this year. New strategies to deliver the vaccine were developed including a unique

process that uses vaccine temperature monitors to ensure the potency of polio vaccine in the absence of refrigerators. Small aircraft were rented to bring personnel,

educational materials, and polio vaccine to the most remote areas.

Only last month, polio immunization days were conducted in Southern Somalia.

Somalia health workers and volunteers, under the leadership of experts from WHO,

United Nations Children’s Fund (UNICEF), and CDC, successfully vaccinated more

than 1 million children, many of whom had not received any health services for

more than 8 years.

Partnerships to eradicate polio by the year 2000

Collaboration among Rotary International, WHO, UNICEF, USAID, the Task

Force for Child Survival and Development, CDC, and the governments of Australia,

Denmark, Japan, the United Kingdom, and other countries has been unique among

public health initiatives for the unprecedented level of cooperation, the magnitude

of private-sector contributions and the amount of funds raised. It is estimated that

Rotary International will have contributed hundreds of millions of dollars by the

end of the polio eradication initiative. Rotary International’s contribution is the largest private contribution to a public health initiative in history.

A further example of the outstanding partnerships that are operating in this highly successful initiative is the joint effort required for NIDs in Afghanistan. Vaccine

was transported by donkeys that carry loads of polio vaccine, packed to keep it cold,

along mountainous terrain to remote vaccination stations. Under the direction of

WHO, the vaccine was provided with CDC and Rotary International funds, procured

and shipped to Afghanistan by UNICEF, prepared for distribution within the country using an action plan developed by WHO, UNICEF, and Afghanistan national

staff of the Ministry of Health, and transported to its final destination within Afghanistan by Afghans using whatever local transportation was available. (Attachment IV)

Challenges for the final days of polio eradication

Although polio eradication remains feasible by the year 2000, ‘‘business as usual’’

will not get the job done. While all of the partner organizations involved in the ef10

fort are impressed with the tremendous progress which has been made, the program

is at a critical stage with just over two years remaining before the end of the target

year 2000 and much work remains to be done. It is critical to achieve eradication

as close as possible to the target date, because: (1) the longer that it takes to complete the global effort, the longer that NIDs and other resource-intensive polio eradication activities will continue to be required in those countries which are already

polio-free; (2) there is potential for fatigue in eradication efforts in those areas that

have already been successful, thereby jeopardizing the entire eradication initiative.

The partner organizations participating in the eradication initiative are convinced

that the established strategies, when fully implemented, will achieve eradication. While the vast majority of the costs of polio eradication is borne by the polio-endemic countries themselves, enhanced leadership and continued support from the

major partner organizations and governments of the industrialized countries will be

crucial at this critical phase for successful completion of the eradication program on

schedule. About $170 million has been committed by partners in 1998.

During the next 2 years, the global polio eradication activities will intensify to

reach the needed peak of effort. However, global shortfalls will increase in the years

1999 and 2000 without greater commitment of resources on the part of the partner

organizations and governments. WHO estimates that the 1999 global shortfall is

$131 million, and the year 2000 global shortfall is $116 million. These global shortfalls are due both to the lack of financial commitment by partners beyond a 1-year

period, and a real shortfall of expected funds. Similar to the smallpox eradication

campaign, the provision of adequate resources is important for finalizing efforts.

Since the final stages of eradication efforts are often the most difficult and resource

intensive, the year 2000 goals can only be met if adequate and timely partner commitments of the needed resources are made.

Despite the extraordinary progress towards polio eradication, progress in Africa

has not kept pace with progress in other regions. Rapid and complete implementation of the recommended polio eradication strategies is urgently needed. Completion

of special initiatives in war-torn areas such as the Democratic Republic of Congo,

Liberia, and Sierra Leone is essential to bringing the polio eradication program to

a successful and timely conclusion. Additional funding from donor organizations and

governments will also be required to support polio eradication activities in Africa.

Recent events that have threatened eradication of polio by the year 2000 include

the tragic loss of life caused by the bombing of the U.S. Embassy in Nairobi, Kenya.

NIDs in Kenya were postponed by one week nationwide and for one month in

Nairobi. In subsequent developments, the CDC epidemiologist in Pakistan had to be

evacuated last month. Necessary travel restrictions on U.S. Government employees

traveling to some African countries will increase the difficulty of placing staff in

long- and short-term positions there. Also, the eruption of civil war again in Democratic Republic of Congo suspended NIDs scheduled for August and September. It

is important to remember, however, that smallpox eradication was achieved in Africa in 1977 despite similar impediments.

The legacy of polio eradication will not only be the prevention of millions of cases

of paralysis, permanent disability, and deaths, but also a victory for global public

health, with the demonstration that diverse groups throughout the world can work

together toward a common goal. The successful conclusion of this initiative will have

substantial implications for other public health initiatives, the strengthening of national health services and the credibility of national and international organizations.

Stopping polio vaccination alone will save approximately $1.5 billion annually on a

global basis in perpetuity. The polio eradication program will leave stronger immunization programs worldwide, improved capacity for disease surveillance, a functioning global laboratory network, and the momentum to tackle other major pubic

health problems, including measles.

GLOBAL MEASLES CONTROL AND ELIMINATION

Progress toward measles elimination

Despite the availability of a highly effective vaccine, measles causes one million

deaths annually and accounts for more child deaths than any other vaccine-preventable disease. (Attachment V) One out of every 10 deaths in children less than 5

years old is caused by measles, a preventable disease. Virtually all cases of measles

in children in the United States are now the direct or indirect result of measles imported from Europe, Asia, or Africa.

Global measles eradication would result in significant economic benefits for the

United States. CDC estimates that more than $50 million annually in measles vaccine costs alone would be saved in the United States following a successful measles

elimination initiative and termination of measles immunization. Additional savings
11

would accrue from the prevention of hospitalizations and medical costs if future

measles epidemics in the United States were eliminated. For example, hospitalization and other medical costs exceeded $100 million during the measles resurgence

in the United States during the period 1989–91.

Although there is not yet consensus for a global measles eradication initiative, the

Department fully supports regional measles elimination goals and accelerated measles control as a step toward a global initiative. If regional measles elimination goals

continue to be successful, we hope that a global measles initiative will be launched

as the polio eradication program comes to a successful conclusion.

A tremendous amount of progress toward establishing a global measles initiative

has already occurred. In 1994, the Pan American Sanitary Conference endorsed the

goal of measles elimination in the Western Hemisphere by the year 2000. Implementation of an immunization strategy combining high routine coverage with at

least one dose of measles vaccine and periodic mass campaigns vaccinating all children in target age groups regardless of prior receipt of measles vaccine, has led to

a greater than 90-percent reduction of measles cases in the Western hemisphere

from 1990 to 1997. (Attachment VI) For more than a year, measles transmission has

been interrupted in Mexico, the Caribbean, all countries of Central America, and

some in South America, including Colombia, Chile, and Peru. The importation of

measles into the United States from countries in Latin America has virtually disappeared.

In addition to the ongoing measles initiative in the Americas, other WHO regions

are taking action. The Eastern Mediterranean Region of the WHO has established

a regional measles elimination initiative. Countries in this region that have already

conducted mass vaccination campaigns designed to interrupt measles transmission

include: Oman, Kuwait, Jordan and Bahrain. Saudi Arabia, Syria, Tunisia, Qatar

and the United Arab Emirates are planning similar activities in 1998–1999. In addition, the European Region of WHO is considering adopting a regional measles elimination initiative. England and Wales conducted a highly successful mass vaccination

of school-aged children in 1994 which has resulted in elimination of indigenous measles. Romania experienced the largest measles outbreak in Europe in 1997 and is

planning a mass vaccination campaign among school-aged children, starting in October 1998. Other countries that have established national measles elimination initiatives include Australia, New Zealand, South Africa and several other southern African countries.

Partnerships

The partnerships that will be required to accelerate measles control and achieve

the eventual goal of measles eradication are being developed using the polio eradication model. Strong relationships are being developed among CDC, WHO,

UNICEF, USAID, the International Federation of the Red Cross and Red Crescent

Societies, and the American Red Cross.

Challenges

Many experts have concluded that global measles eradication is biologically feasible. However, the eradication of measles will be a more difficult challenge than

either polio or smallpox eradication. The highly infectious nature of the measles

virus and the complex logistical and operational requirements of conducting mass

immunization campaigns using an injectable vaccine (rather than an orally administered vaccine as with polio), and ensuring safety of injections in developing countries, make this a unique challenge. Another major challenge will be harnessing the

political will globally to move forward. This is particularly relevant for many developed countries in Western Europe and Asia that have not accepted measles as a serious health burden and thus have not made prevention of measles a high priority.

Refinement of the technical strategies (e.g., vaccination, surveillance) for measles

eradication may also be needed. Although we have achieved a tremendous amount

of success with measles prevention and control, outbreaks still occur. In 1997, a

measles outbreak in Brazil affected more than 20,000 individuals, primarily young

adults. Investigations are ongoing to determine the reasons for the outbreak and

what additional prevention strategies may be required for adults.

Despite the importance of measles as a public health problem in the United States

and worldwide, it is critical that the global public health community focus on finishing polio eradication before embarking on a more difficult and expensive measles

eradication initiative. As we continue our efforts to eradicate polio by the year 2000,

we are carefully considering how we can best achieve global measles eradication.

The major challenges to measles eradication include: (1) developing the political and

financial commitment within countries and regions, and at the global level to strive

for measles eradication; (2) developing the technology and logistics to safely deliver
12

measles vaccine in mass vaccination campaigns; (3) building consensus in the clinical and public health communities that the time is right for a measles eradication

initiative; and (4) finalizing a timetable for measles eradication that is synchronized

with polio eradication activities.

CONCLUSION

The public health, financial and humanitarian benefits of eradication programs

offer a compelling rationale for continued U.S. Government support of such initiatives. The smallpox eradication program and the ongoing polio eradication initiative

best document that these potential benefits can be realized. However, for polio

eradication it should again be stated that ‘‘business as usual’’ will not get the job

done. Efforts must be extended to ensure success. While recognizing that appropriate caution is needed, the United States must also be willing to be ambitious and

farsighted, even when some questions remain unanswered. Simply stated, the eradication of polio would be a remarkable gift to the children of the 21st Century.
(13)

NONDEPARTMENTAL WITNESSES

STATEMENT OF EBRAHIM M. SAMBA, M.D., REGIONAL DIRECTOR, REGIONAL OFFICE FOR AFRICA, WORLD HEALTH ORGANIZATION

Senator BUMPERS. Dr. Samba, let me just say we are most hon- ored to have you here. As I said, Betty talked more about you when

she got home than she did about what she was doing over there.

[Laughter.] She was immunizing children, but she did not know what she was doing. She was scared she was going to overdose some of them,

and the doctors assured that was not possible.

In any event, thank you very much for being with us. Please pro- ceed.

Dr. SAMBA. Thank you very much, Senator Bumpers. For me this is an inspiration, again coming this morning. My col- leagues behind me said, have you been here before? I said, yes, I

have been here many times when I was director of the River Blindness Control Program. We used to come here to solicit your support, which we got. You were lead supporters and I am very

pleased to tell you, sir, that we have won that battle. Nobody—nobody—risks being blind of that disease in west Africa today, thanks

to you, thanks to your continued support.

Senator BUMPERS. Dr. Samba, if I may interrupt you, this would be a very good time—and I know Dr. Foege will wholeheartedly

agree. Jimmy Carter, the President of the United States, as you remember, from 1976 through 1980, deserves an awful lot of credit

for the success of that program. I appreciate very much your mentioning it. Most people do not understand what river blindness is.

Dr. SAMBA. That is right. Indeed, when I took over the regional office of the World Health Organization in 1995, we were looking

for another challenge. Too many challenges in Africa, but a challenge that we can win. And we looked at the example of the United

States and the Western Hemisphere, and we said the World Health

Organization has declared that polio should and could be eradicated, but Africa was way behind.

We took up the challenge. We appealed to our partners, Rotary,

the United States, including CDC-Atlanta, and I went around to

some donors. And it is amazing how many of them said, is the

United States involved? And we said, yes. So, they joined in. The

United Kingdom, Germany, and many others.

WORLD HEALTH ORGANIZATION

And today, since we started in January 1995, of the 46 African

countries in the World Health Organization that did not have any

polio eradication campaign, today 36 have had a national immunization day, even Angola where there has been civil war raging for

years. We managed to convince the belligerents to lay down their

arms and participate in the national immunization days against
14

polio, and we succeeded in vaccinating over 90 percent of the targeted children.

As you have heard, sir, as Dr. Satcher has heard, we can win but

until we cross the finishing line—and in Africa the finishing line

is very tough indeed. No roads, no boats. Sometimes we have to

wear life jackets and wade our way through hazardous rivers,

avoiding crocodiles to cross over to vaccinate all the children. But

we know this is worth it because, as Dr. Satcher said, we have

been able to put down in place mechanisms that can lead us to

fight other battles in Africa. And there are so many.

Recently Dr. Satcher, when he was Director of CDC, came to my

office in Brazzaville and we crossed over the Congo River to

Kinshasa to celebrate our defeat of ebola. I came here to this house

to thank the United States Government and to inform my friends

in the United States what we have done in protecting them from

ebola because ebola killed 70 percent of Africans. I said, no disease

will wipe out all Africans. Because we have lived with them, some

of us have immunity, but here in the United States, you eat sterile

food, your water is clean and potable, even your source in preparing them are sterilized. Any disease that can wipe out 70 percent

of Africans will probably wipe out 100 percent of Americans. And

from the area where ebola was in Kitwe to Kinshasa, a few hundred miles, and there are daily flights from Kinshasa to Paris, to

Zurich, and between Zurich and the United States in a matter of

hours.

WINNING THE BATTLE AGAINST POLIO

So, together we are convinced that we can win the battle against

polio, and unless the last bastion of polio in Africa is eliminated,

the whole world is at risk. So, we are here in this partnership, a

noble partnership, led by the United States of America. This is why

I am here today. I arrived a few days ago. I will be leaving tomorrow.

We come to follow, to salute you. Mrs. Bumpers was in Africa a

few months ago in my office, and she inspired us. I said to her, we

are going to return the compliment. We are going to visit you and

thank you and thank your husband, and through Mr. and Mrs.

Bumpers, thank the population of the United States for helping us

together eradicate polio, which is doable. We can win. We are convinced, but it is going to be very difficult. It is going to cost a bit

more.

After polio, already in southern Africa in some parts of Africa

where polio has not been reported for the past 5 years, measles has

come to replace polio in our eradication campaign. Similar principles, very slight modifications, dedicated, committed collaborators, sufficient resources, good will, and your support. We will

win. We can win. We are going to win.

PREPARED STATEMENT

The objective of my mission here today therefore is to thank you

for the support you have always given Africa, for the support you

continue to give. Senator Bumpers, Dr. Satcher said you are going

to be missed. All the world will miss you. We hope and pray, when
15

1The WHO African Region consists of forty-six WHO Member States: Algeria, Angola, Benin,

Botswana, Burkina Faso, Burundi, Cameroon, Cape Verde, Central African Republic, Chad,

Comoros, Congo, Cote d’Ivoire, Democratic Republic of the Congo, Equatorial Guinea, Eritrea,

Ethiopia, Gabon, Gambia, Ghana, Guinea, Guinea-Bissau, Kenya, Lesotho, Liberia, Madagascar,

Malawi, Mali, Mauritania, Mauritius, Mozambique, Namibia, Niger, Nigeria, Rwanda, Sao Tome

and Principe, Senegal, Seychelles, Sierra Leone, South Africa, Swaziland, Togo, Uganda, United

Republic of Tanzania, Zambia, and Zimbabwe.

you retire from the Senate, you will be invigorated and you will

have so much reserve energy, we invite you to Africa to collaborate

with us to continue our battle against disease, suffering for the

whole of humanity.

Thank you, sir, for this privilege.

[The statement follows:]

PREPARED STATEMENT OF DR. EBRAHIM M. SAMBA

POLIO ERADICATION AND MEASLES CONTROL/ELIMINATION INITIATIVES IN THE WHO

AFRICAN REGION

Mr. Chairman and distinguished Senators, the World Health Organization [WHO]

and its Regional Office for Africa appreciate the opportunity to brief the Subcommittee on the initiatives to eradicate polio and to control measles in the African Region.

This statement describes the progress and challenges to date, particularly in the

areas of polio vaccination, surveillance for acute flaccid paralysis (AFP), and mobilization of funding, resources, and partnerships to support the Polio Eradication Initiative in the African Region.

POLIO ERADICATION

Situation analysis

Throughout the 1980’s, 4,000 to 5,000 clinical cases of poliomyelitis were reported

annually in the WHO African Region.1 Experience in the field showed that this figure reflected severe under-reporting, representing perhaps only 10 percent of all

cases that occurred in reality. The annual number of reported cases fell to 1,500 to

2,000 during the first half of the 1990’s, presumably as a result of the increasing

impact of routine vaccination activities. This number represented almost one-half of

all polio cases reported in the world. In 1997, only 883 clinical cases of polio were

reported through the routine reporting systems in Member States in the African Region.

For programmatic purposes, the WHO African Region was divided into four epidemiological blocks—Central, Eastern, Southern and Western—to ensure that eradication activities could be tailored to the specific needs of groups of countries. In addition, a separate, fifth epidemiological block was formed by four large countries,

each of which has suffered difficult circumstances in recent years: Angola, DR

Congo, Ethiopia and Nigeria. These four countries represent major reservoirs of wild

polioviruses in the African Region and are believed to spread polio to neighbouring

countries.

In order to achieve polio eradication, countries in the African Region have adopted

and continue to implement four major strategies recommended by WHO: (1) achieving and sustaining high routine vaccination coverage with oral polio vaccine (OPV);

(2) implementing mass vaccination campaigns, known as National Immunization

Days (NIDs); (3) establishing effective surveillance of suspected polio cases (that is,

surveillance of all cases of acute flaccid (floppy) paralysis (AFP)); and (4) carrying

out mopping-up activities as indicated by surveillance data.

Tremendous progress has been made to date in the Eastern and Southern African

epidemiological blocks. Supplemental vaccination through National Immunization

Days (NIDs) conducted in all countries of these two blocks appear to have had a

significant impact on the circulation of ‘‘wild’’ polioviruses. NIDs aim to cover a high

proportion of the under-5 child population of a given area with two doses of oral

polio vaccine about a month apart. Despite increasingly sensitive surveillance based

upon the clinical, epidemiological and virological investigation of AFP cases, wild

polioviruses (that is, those which are not associated with the vaccine) have not been

isolated in continental Southern Africa since 1995. A similar picture has emerged

in Eastern Africa since 1997.

Wild polioviruses continue to circulate in Central and Western Africa and the four

large countries. The fact that polioviruses were detected after one or even two series
16

of NIDs in some of these countries indicates that polio-free status will be more difficult to achieve in those areas.

Routine vaccination

Routine vaccination coverage with three doses of oral polio vaccine (OPV3) among

infants under 1 year of age reached 54 percent in the WHO African Region in 1997.

This represented no increase as compared with the previous year. Coverage rates

varied considerably by epidemiological block in 1997: 39 percent for Central Africa,

59 percent for Eastern Africa, 74 percent for Southern Africa, 57 percent for Western Africa, and 45 percent for the four large countries in difficult circumstances.

Factors which limit the achievement of high routine vaccination coverage in certain

countries include poor access to health services, high drop-out rates, occasional

shortages of vaccine and deficiencies in the refrigerated transport or cold chain system including fuel and power shortages and lack of transport.

Although supplemental vaccination through NIDs is critical for the eradication of

poliomyelitis, doses supplied through NIDs do not replace routine vaccination of infants with OPV. Therefore, the importance of educating and mobilizing communities

to bring their infants to health facilities, outreach clinics and mobile units for routine vaccination has been strongly emphasized.

It is widely recognized that routine vaccination benefits substantially from the implementation of NIDs. NIDs have increased political commitment and support for

the whole Expanded Program on Immunization (EPI) from country-based and external partners. Additional resources become available which benefit EPI in general

and may be used for strengthening planning and managerial capacities of health

staff, and provision of additional equipment such as refrigerators and cold boxes.

NIDs provide excellent opportunities for advocacy, social mobilization and increasing

community awareness about target diseases and the benefits of immunization. Furthermore, it has been observed in many countries, for example Angola, that the success of NIDs increases the morale of health workers, especially where routine vaccination coverage was poor.

National immunization days

The first series of National Immunization Days (NIDs), the biggest ever conducted

in Africa, was implemented in 31 countries of the African Region in 1996 early 1997.

Over 74 million children below five years of age were targeted. More than 55 million

(74 percent) children received OPV in the first round and about 60 million (80 percent) in the second round of NIDs. The majority of countries achieved remarkable

results in vaccinating their target population with OPV: 26 countries (84 percent of

the 31 countries that participated) had 80 percent or greater coverage in at least

one round and 20 (65 percent) achieved 80 percent or greater coverage in both

rounds.

The second series of NIDs involved 36 countries between March 1997 and March

1998. These were the first NIDs for seven countries: Burundi, Guinea, GuineaBissau, Madagascar, Mali, Niger and Senegal. Two supplemental OPV doses were

received by 85 million children under age five. Immunization coverage was reported

at 80 percent or greater for both NID rounds except in the Central African Republic

(77 percent and 82 percent), Equatorial Guinea (76 percent and 99 percent), Kenya

(79 percent and 82 percent), Lesotho (67 percent and 65 percent), Mozambique (65

percent and 75 percent), Nigeria (72 percent and 95 percent), Rwanda (73 percent

and 75 percent) and South Africa (81 percent and 76 percent). It is hoped that the

three countries which have yet to conduct nation-wide NIDs—DR Congo, Liberia

and Sierra Leone—will do so in 1998. Those countries in West Africa where wild

polioviruses have reappeared since the first series of NIDs will require four rounds

of OPV (2 rounds of NIDs, 2 rounds of house-to-house ‘‘mopping-up’’) if the goal is

to be achieved by the year 2000.

NIDs reached over 80 percent of children under five years of age in a number of

countries where less than 50 percent of infants had previously received routine

OPV3, such as Angola, Burkina Faso, Cameroon, Central African Republic, Chad,

Mauritania and Niger.

Particularly noteworthy is the success achieved in Angola. This country immunized 71 percent and 80 percent of its target population in the first and second

rounds in 1996 and 83 percent and 90 percent in 1997, respectively. This is especially remarkable since routine coverage in Angola was below 40 percent. NIDs resulted in increased collaboration between all national and international partners.

Initiated by the Government, this important initiative has also involved UNITA,

WHO, Rotary, UNICEF, UN Peacekeeping Forces and the private sector. It was the

first time that the Government and UNITA worked together to improve health of
17

their young compatriots. The challenge now is to extend EPI in general and NIDs

in particular into those districts which remain inaccessible due to security problems.

Furthermore, a number of countries have utilized the opportunity to include with

OPV during NIDs the administration of other vaccines or health interventions, for

example, measles vaccine and vitamin A supplementation. Although the inclusion

of an injectable vaccine like measles vaccine adds technical and logistical complexity

to the operation, the additional cost of including measles vaccine is less than that

of a separate measles vaccination campaign.

Although this support from external and country-based international agencies and

NGOs was important, the remarkable success of NIDs was mainly achieved due to

high-level political commitment, technical competence and experience of national

health authorities and health staff, through the effective planning and coordination

of activities. The implementation of NIDs demonstrated the tremendous potential of

the health sector and communities to undertake joint activities, and effective coordination between governments, external and country-based partners. NIDs resulted in

remarkable strengthening of inter-sectoral and inter-agency coordination and cooperation, and boosted the revitalization or formation of national EPI inter-agency

coordination committees.

Disease surveillance

The major task of countries implementing polio eradication activities is to prove

that the circulation of wild polioviruses, whose presence in stool specimens of patients with AFP is considered definitive proof of confirmed polio, has been interrupted. This only can be done if all AFP cases are promptly detected, reported and

investigated, and if adequate stool specimens are properly collected and shipped to

a laboratory where they can be reliably cultured for poliovirus.

The WHO African Regional Polio Laboratory Network currently comprises three

regional reference laboratories in Central African Republic, Ghana, and South Africa and ten national and inter-country laboratories. A further two national laboratories (Ethiopia and Maidugari/Nigeria) are in the process of being certified. National laboratories process stool specimens and identify serotypes from AFP cases,

and regional reference laboratories confirm the identity of polioviruses isolated by

national laboratories and determine whether the viruses are wild or vaccine-derived.

In 1997, all but twelve countries of the African Region (Angola, Burundi, Congo

Gabon, Equatorial Guinea, Eritrea, Liberia, Mali, Mauritania, Mozambique, Rwanda and Sierra Leone) submitted specimens to the regional polio network laboratories. All stool specimens collected from AFP cases in Eastern and Southern African countries in 1997 were laboratory negative for wild poliovirus.

In 1997 and 1998, wild polioviruses were, however, isolated from specimens collected in DR Congo and a number of countries mainly situated in Central and Western Africa, including countries which had conducted NIDs (Angola, Benin, Burkina

Faso, Central African Republic, Chad, Cote d’Ivoire, Ghana, Nigeria and Senegal).

Partial genomic sequencing shows that many wild poliovirus isolates from countries

surrounding the DR Congo originate in the DR Congo.

The performance of AFP surveillance in many countries of the African Region, although it has markedly improved, still remains inadequate for the purposes of official certification of polio-free status. National surveillance systems need to be further strengthened to increase their reliability and effectiveness. One critical task is

to sensitize medical professionals to the polio eradication initiative and its proven

strategies, in order to help them understand the need to report and investigate AFP

cases whose final diagnosis may eventually be other than poliomyelitis.

The establishment of a system for AFP surveillance in Africa has laid the foundation for the development of integrated infectious disease surveillance throughout the

continent. The provision of resources including staff, transport and communications

tools will facilitate the inclusion of surveillance of other priority or epidemic diseases such as measles, cholera, dysentery, meningitis and haemorrhagic fevers.

Funding

During 1996 and 1997, over US$65 million were provided by Rotary International,

USAID, the U.S. Centers for Disease Control and Prevention (CDC), the Government of Japan, vaccine manufacturers and other partners for implementation of the

two series of NIDs and disease surveillance in the African Region. The United

States of America is playing a significant role in supporting the Polio Eradication

Initiative in the African Region. In 1996–97, the U.S. Government not only disbursed US$34.5 million—that is, over half of all external funds for NIDs and surveillance of EPI target diseases—through USAID and CDC but also provided consultants to assist countries in planning and implementation of these activities. This

important external financial support acted as a catalyst for national political and
18

financial commitments, and stimulated preparations for NIDs, local fund raising,

and resource mobilization in the majority of countries.

The cost of NIDs was estimated from a study conducted in Southern Africa at approximately US$0.50 to 0.60 per child vaccinated with two OPV rounds. However,

the actual NIDs cost may be slightly higher, since infrastructure, staff, funds and

in-kind contributions were provided by national governments, country-based international agencies, nongovernmental organizations (NGOs) and other partners, including the private sector and local communities.

Funding requirements for polio eradication activities in the WHO African Region

during 1999–2001 are summarized in Annex 1.

Political commitment, advocacy and social mobilization

In July 1996, African Heads of State and Government at the Thirty-Second Ordinary Session of the OAU Summit in Yaounde, adopted a Declaration on Polio Eradication in Africa. This declaration urges all Member States to take immediate and

concrete steps to urgently address the problem of poliomyelitis and give their full

political support to polio eradication as a matter of top priority. The African leaders

confirmed their strong determination to make Africa free of polio and committed

themselves to fully support the implementation of the polio eradication strategies

recommended by the World Health Organization. The Declaration states that adequate human, financial and material resources, both local and external, be mobilized to support polio eradication activities in Africa.

The Yaounde Declaration on Polio Eradication in Africa was instrumental in obtaining the highest-level political commitment and support for the Polio Eradication

Initiatives in the African Region.

A ‘‘Committee for a Polio-Free Africa’’, chaired by President Nelson Mandela and

with high-level representation from around the continent, was created to strengthen

political advocacy and social mobilization for polio eradication, and met for the first

time in South Africa in August 1996.

A region-wide ‘‘Kick Polio out of Africa’’ campaign was launched in August 1996

in South Africa by President Mandela with participation of the Members of the

‘‘Committee for a Polio-Free Africa’’ (the First Ladies of Congo, Ghana and Nigeria,

General Toumane ́ Toure ́, former President of Mali, and senior officials representing

Rotary International, WHO, OAU, UNICEF and USAID) at the first meeting of the

Committee.

NIDs were especially successful in countries where this political commitment was

attained. The role of Heads of State and Government and First Ladies was critical

in ensuring that NIDs receive necessary attention and support, not only from external international and donor agencies and organizations but, most importantly, from

various governmental sectors, as well as country-based agencies, non-governmental

organizations (NGOs) , the private sector and communities themselves. In many

countries, Heads of State and Government demonstrated their support for NIDs by

addressing the nation through the mass media and by participation in launching

ceremonies. In a number of countries First Ladies served as patrons for the NIDs

and other polio eradication activities.

The three First Lady Members of the ‘‘Committee for a Polio-Free Africa’’ have

remained very active in advocacy and social mobilization activities in preparation

for NIDs in their respective countries. The First Lady of Mozambique was also particularly active in the promotion of NIDs in that country in 1998.

The success of NIDs continues to be made possible by the very effective social mobilization campaigns carried out by each country, with support from the highest-levels political leaders and other opinion makers within countries, and advocacy from

WHO and other partners. To consolidate and share this experience widely, an advisory group on social mobilization was established in the WHO African Region with

the membership of all major partners. The campaign’s soccer-linked theme in conjunction with its slogan and logo have now become widely accepted and powerful

tools for advocacy. The advisory group has planned and implemented various regional activities such as the activities during the Cup of African Nations contest in

1998.

The challenge is to maintain the interest and commitment for polio eradication

and to extend it to all EPI activities to ensure that all partners play their part and

contribute effectively to achieving this important goal.

Partnership

A strong and effective partnership has been created to support the Polio Eradication Initiative in the African Region with the leadership of the WHO Regional Office. The major partners are the African Governments, World Health Organization,

Rotary International, UNICEF, USAID, Centers for Disease Control and Prevention
19

in Atlanta (USA), Government of Japan, DFID (UK) and CIDA (Canada). The partners participate in annual technical conferences of the African Regional Task Force

on Immunization, which are usually held in conjunction with donor meetings of the

Regional EPI Inter-Agency Coordination Committee.

Vaccine manufacturers also donated U.S. $600,000 worth of OPV for polio eradication activities in Africa in 1997.

The Governments of Denmark, Finland, France, Germany and Ireland, Rotary

Clubs, the National Peace Corps Association (USA), national Red Cross organizations, Swiss Development Corporation and private companies, such as SmithKline

Beecham, Rhoˆne Poulenc, Barclays Bank, Johnson & Johnson, Coca Cola and others, were involved in supporting polio eradication activities in individual countries.

MEASLES CONTROL/ELIMINATION

Since the introduction of measles vaccine in Africa, there has been an estimated

56 percent reduction in measles cases and an estimated 77 percent reduction in

measles deaths. However, the measles burden in Africa remains the highest of any

of the six WHO Regions, with an estimated 9.2 million cases and 435,000 deaths

in 1995. Studies have shown that measles case fatality rates of 6 percent and higher

continue to occur.

Most of the deaths attributable to measles in Africa occur as a result of various

complications. It is estimated that approximately 5 percent to 30 percent of measles

cases will have severe measles disease and complications. The most common complication is bronchopneumonia, followed by dehydration from diarrhea and vomiting.

Some of the measles cases also become malnourished. As much as half of all childhood corneal blindness may result from measles complications in vitamin A deficient

children. Other complications include skin sepsis, purulent conjunctivitis, blindness

and otitis media which lead to deafness in a small percent of children.

Routine vaccination coverage with one dose of measles vaccine among infants

under one year of age remains persistently the lowest of all the vaccines in the EPI.

In 1997, 16 out of 46 countries in the WHO Africa Region, representing 21 percent

of the regional population, failed to reach 50 percent routine vaccination coverage.

In accordance with national variations in routine vaccination coverage, measles

epidemiology and operational and financial feasibility, WHO has developed and, in

some countries, begun to implement three sets of strategies designed specifically for

three sets of countries, with the following primary objectives: to reduce measles mortality to accelerate measles control; or to eliminate measles transmission.

To achieve these objectives, a careful mix of activities will be implemented (see

Table 1), including strengthening routine vaccination services, supplemental measles vaccination, social mobilization, surveillance and evaluation. The additional

funds required to carry out supplemental vaccination are presented in Annex 2.
20

TABLE 1.—PROPOSED MEASLES CONTROL/ELIMINATION STRATEGIES IN THE WHO AFRICAN REGION

Epidemiological characteristics Geographic areas Proposed strategies

Low routine coverage (<50 percent), presumed high

number of deaths (Case Fatality Rate >4 percent).

West Africa and Central Africa, Angola, DR Congo,

Ethiopia, Nigeria.

Reduction of measles deaths:

Achieve higher routine coverage with measles vaccine;Reduce measles deaths through measles campaigns in urban, densely populated rural

areas and other high-risk areas (target age group: children below 5 years of age);

Conduct periodic measles campaigns in high risk areas with 2–3 year intervals;Collect aggregated surveillance data.

Medium routine coverage (50–75 percent), presumed

low-medium number of deaths (Case Fatality Rate0.5–4 percent).

East Africa, Algeria, Madagascar, Mauritania, Mozambique. Accelerated measles control: Achieve higher routine coverage with measles vaccine;

Further reduce measles cases and deaths through campaigns in high-risk areas (target

age group: children below 5 yrs of age);

Conduct periodic measles campaigns in high risk areas (frequency of campaigns and target age group to be determined by surveillance data);Establish sentinel collection of case-based data.

High routine coverage (>75 percent), presumed low

number of deaths (Case Fatality Rate <0.5 percent).

Southern Africa ............................................................... Measles elimination:

Increase and sustain routine coverage with measles vaccine to above 90 percent;Conduct ‘‘catch-up’’ measles campaigns among children below 15 years of age;Conduct periodic ‘‘follow-up’’ campaigns; andCase-based surveillance including laboratory investigation of cases.
21

CONCLUSIONS

Less than 1,000 days remain to achieve the goal of polio eradication by the end

of the year 2000, as established by the Member States of the World Health Organization in 1988, and endorsed by the World Summit for Children in 1990.

In view of current trends, it appears that the polio eradication goal is achievable

in Africa. Marked progress is reported from Eastern Africa, and there is justifiable

confidence that Southern Africa is close to being confirmed as polio-free. However,

despite the remarkable progress achieved, there is an urgent need to improve surveillance in order to document the progress achieved to date. To accomplish the goal

by the target date, implementation of polio eradication strategies must be accelerated, in particular, by establishing effective disease surveillance systems. Financial

and political support from all partners for polio eradication in the African Region

is particularly important right now, in light of the success to date and the remaining challenges to reaching the regional and global goals of polio eradication.

The eradication of poliomyelitis will not only prevent our children from becoming

crippled for life and reduce human suffering caused by this terrible disease in Africa. It will also save an estimated US $1.5 billion per year worldwide, currently

spent on immunization, surveillance and rehabilitation of patients. After eradication, these resources could be reprogrammed to address other emerging health

problems in Africa.

Measles remains significant among the major causes of childhood morbidity and

mortality in Africa. The lessons learned from the Polio Eradication Initiative in the

African Region will serve as critical experience for the next vaccine-preventable disease control step. Measles control and elimination in the African Region will require

further coordination of efforts and resources from all partners.

ANNEX 1.—FUNDS NEEDED FOR POLIO ERADICATION ACTIVITIES IN THE AFRICAN REGION

[U.S. dollars]

Budget line 1999 2000 2001

OPV for NID’s ..................................................................... 20,817,000 17,107,000 6,946,000

NID’s operational costs ...................................................... 40,878,000 36,165,000 13,764,000

Mopping-up activities ........................................................ 19,875,000 19,875,000 19,875,000

Disease surveillance .......................................................... 8,395,000 8,582,000 8,960,000

Laboratory activities ........................................................... 810,000 664,000 739,000

Certification activities ........................................................ 102,000 140,000 175,000

Personnel (including duty travel and support) ................. 9,067,000 8,880,000 9,324,000

Regional office/inter-country activities .............................. 650,000 683,000 716,000

Subtotal ................................................................ 100,594,000 92,096,000 60,499,000

PSC ..................................................................................... 6,608,000 6,010,000 3,166,000

Total ...................................................................... 107,202,000 98,106,000 63,665,000

Grand total: U.S. dollars ...................................... 268,973,000 ........................ ........................

ANNEX 2.—FUNDS NEEDED FOR MEASLES CONTROL/ELIMINATION ACTIVITIES IN THE AFRICAN

REGION 1

[U.S. dollars]

Budget line 1999 2000 2001 2002 2003 Total

Costs of vaccine and injection equipment for

supplemental immunization .......................... 1,674,993 6,209,330 5,511,090 8,763,394 8,063,125 30,221,932

Operational costs of supplemental immunization ................................................................ 1,486,680 5,511,240 4,891,500 7,778,160 7,156,620 26,824,200

Costs of injection safety and evaluation/surveillance ........................................................ 495,560 1,837,080 1,630,500 2,592,720 2,385,540 8,941,400

Subtotal: Supplemental immunization 3,657,233 13,557,65 12,033,090 19,134,274 17,605,285 65,987,532
22

ANNEX 2.—FUNDS NEEDED FOR MEASLES CONTROL/ELIMINATION ACTIVITIES IN THE AFRICAN

REGION 1—Continued

[U.S. dollars]

Budget line 1999 2000 2001 2002 2003 Total

PSC .................................................................... 475,440 1,762,495 1,564,302 2,487,456 2,288,687 8,578,380

Total ..................................................... 4,132,673 15,320,145 13,597,392 21,621,730 19,893,972 74,565,912

1 Supplemental immunization.

HUMAN AND NATURAL RESOURCES TO SUSTAIN EVERYBODY

Senator BUMPERS. Thank you very much, Dr. Samba, and thank you very much for your kind words. It was a very powerful, wonderful statement. I regret that 99 other Senators could not have

heard your testimony this morning. [Laughter.] You know, there is not anything wrong with this country. Indeed, there is not anything wrong with the world. We have the assets

and we have the human and natural resources to sustain everybody in relative prosperity, but we simply miscue our priorities and

squander so much on misspent priorities. And you have set that

out with a great deal of specificity and very graphically. Again, I thank you very much for being with us.

Dr. SATCHER. Senator Bumpers.

Senator BUMPERS. Yes.

Dr. SATCHER. Please allow me to apologize for having to leave. As I said, the Pan American Health Organization is meeting, and

I have just been paged and told that we are getting ready for a

very important vote.

Senator BUMPERS. That is quite all right.

Dr. SATCHER. I am part of the U.S. delegation. I am delighted to have been able to be here and to testify in front of you once again about this very important issue and to join my

outstanding colleagues here. I am sure they can answer any questions that you have. Thank you.

Senator BUMPERS. Well, most of them were directed to you, so we will see. [Laughter.]

STATEMENT OF HERBERT A. PIGMAN, CHAIRMAN, POLIO ERADICATION ADVOCACY TASK FORCE, THE ROTARY FOUNDATION,

ROTARY INTERNATIONAL

Senator BUMPERS. Mr. Pigman, once again welcome. Thank you in advance for the magnificent job Rotary International has done

in bringing us really to this happy state. Please proceed.

Mr. PIGMAN. Thank you, Senator Bumpers. Rotary International would like to thank your subcommittee for conducting this hearing.

It comes at a critical time in the fight against polio. The virus may

indeed be on the threshold of extinction, but that final threshold

is a formidable one, and without the needed resources directed on

a timely basis, we could fail to reach the target in the year 2000. I would like the privilege of joining my colleagues here in commending you, Senator Bumpers. Throughout your distinguished career, you have carried the torch for immunization both here and

abroad, and speaking on behalf of the 450,000 members of Rotary

in this country, we could wish for no greater advocate of the rights

of the children for a healthy start in life. We thank you.
23

Polio eradication is one of the great public health stories, and since that resolution by WHO 10 years ago, a global partnership

has developed and it includes the private sector. The private sector

has joined with health ministries and their workers in polio endemic countries, and as you have seen, the reported incidence of

this disease has declined by 90 percent and now 160 nations are

polio-free. Some 4 million cases of polio have been prevented in this

period, and victory holds the promise of $1.5 billion in savings and

$230 million in this country alone. Support for polio eradication by the private sector is unprece- dented, and I think it is instructive to question why this has developed and furthermore what lessons are there for the future of such

collaboration.

The polio initiative presents an attractive case to the private sector. It is a time-limited goal. It is an achievable goal. We have an

effective vaccine. We have a proven strategy, the promise of future

savings and future benefits in the fight against other infectious diseases. Health workers in countries all over the world soon awakened to the potential of their new ally, the private sector, and they

identified roles which play to the strengths and the interests of the

private sector. All these I believe are positive factors in the decisions by the private sector to get on board on polio eradication, and

it has been a fruitful marriage.

ORAL POLIO VACCINE

Three pharmaceutical firms have donated 100 million doses of

oral polio vaccine. Another has contributed $1 million to support

polio virology labs in Africa. Corporations are lending advertising

know-how to convey the message of immunization. In support of

national immunization days, they have deployed private helicopters, jets, vehicles. They have printed posters, provided faxes

and fuel, megaphones, and meals, all with the aim that the war on

polio in their particular country shall not fail for the want of a

horseshoe nail.

Rotary, as a service club organization, has helped to tap this private sector potential because we ourselves are the private sector.

We comprise business and professional leaders in 159 countries

and our 1.2 million members try to lead by example. Since the

PolioPlus Program began in 1985, Rotary has committed $313 million for vaccine, social mobilization, and laboratory support in 119

nations. We support a core of experts, some of whom are here

today, who are leading the polio fight at WHO headquarters in Geneva and in regional offices. Very recently $5 million has been contributed by cooperating clubs to fund polio laboratories in a dozen

countries. We will invest, as you have said, Senator Bumpers, at

least $425 million in polio by the year 2005 when we celebrate Rotary’s 100th anniversary in a polio-free world.

This financial support was welcome. It is needed, but of even

greater value are the millions of hours invested by Rotarians and

friends and others in volunteer service. They constitute an army of

workers on the front lines, and in stretching out a hand of help to

health workers, they help them stretch their nation’s health dollars. Some 150,000 Rotarians and their friends have turned out for

each of India’s national immunization days, and in many countries,
24

members of Rotary chair the national and regional interagency coordinating committees which help health ministries to plan and

execute strategies.

Rotary also is advocating the benefits of polio eradication to the

leaders of donor governments, some 30 other governments. This effort has helped to produce more than $500 million in polio specific

grants in the last 5 years, and I am very proud to say as a citizen

of this country that the United States has contributed 40 percent

of this total, or $201 million, toward polio eradication overseas.

We wish to commend your subcommittee for the recommended

increase of $20 million for polio needs in Africa. These funds are

vitally needed not only for fiscal year 1999, but also for the year

2000.

The task of delivering oral polio vaccine to children faces enormous problems in many parts of Africa, as Dr. Samba has testified.

Civil conflict, poor roads, uncertain communication, unpaid health

workers, shortages of transportation and refrigeration, and a weak

but rapidly improving surveillance system.

The good news is that national immunization days against polio

in Africa have achieved remarkable results despite these obstacles.

The health workers of these countries need these additional resources. Furthermore, they merit the encouragement which such

special help will bring them. New funds will buy needed vaccine,

fuel, training, extend surveillance capacity. But, moreover, they

will trigger new private support. Rotary has committed $92 million

to the program needs of 47 African nations, and that continent continues to have our highest priority.

In closing, Senator Bumpers, I would like to emphasize that private sector collaboration in the war on polio, for which I have provided a few examples, has implications which transcend the victory

over a single infectious disease. The private sector has responded

to an appeal by leaders of the public health community. They have

asked for help in winning a war that can be won, a war that can

eliminate forever a terrible disease.

PREPARED STATEMENT

Now we are allied in a mutual testing ground. The goal is in

sight, and all partners, governments of polio endemic nations,

donor governments, and the private sector, must stay the course

and keep the resources flowing. Victory over polio will prove to

have many lasting benefits, but I believe one of the most important

benefits may well be that the value of childhood immunization will

engrave itself on the corporate social conscience and nurture the

realization that in the long run healthy kids are the future of a

healthy global economy.

Thank you for this opportunity to testify, Senator.

Senator BUMPERS. Thank you very much, Mr. Pigman.

[The statement follows:]

PREPARED STATEMENT OF HERBERT A. PIGMAN

Mr. Chairman, members of the subcommittee, Rotary International thanks you for

the opportunity to participate in this hearing as a representative of the non-governmental, private sector community, a sector which has emerged as a key partner in

the global effort to raise immunization levels among the children of this world.
25

We particularly wish to commend Senator Bumpers for his leadership in immunization, both here in the United States and in the international arena. Early in his

distinguished career he recognized the value of investing in immunization. He has

worked assiduously toward this end, with the great support and participation of

Mrs. Bumpers. Newborns around the world could wish for no greater advocates of

their right to a healthy start in life.

I will address in particular one theme of this hearing: the importance of public

and private sector collaborative efforts in achieving the world-wide eradication of

polio, and its implications for measles eradication and other public health goals. The

global program to eradicate poliomyelitis provides an outstanding example of how

a public/private partnership can be forged and sustained, producing dramatic results.

The international team which is attacking this dreaded, crippling disease includes

among its public sector the World Health Organization, UNICEF, the U.S. Centers

for Disease Control and Prevention, the U.S. Agency for International Development

and counterpart agencies in other donor nations, and the health ministries and

workers in the countries where the battle against polio continues. Chief among the

private sector is Rotary International, the service club organization of over 1.2 million business and professional leaders in 29,000 communities in 159 countries.

Over the past 13 years, this global team—unprecedented in the history of public

health—has applied innovative strategies to reduce the reported cases of polio by

90 percent. The polio virus is on the threshold of extinction, and we are surrounding

it in its final stronghold: sub-Saharan Africa. If adequate financial resources continue to flow to this program, there is great optimism that we will see the last case

of polio by the end of the target year 2000. This virus, which once crippled or killed

some 600,000 people annually, mostly children, will join the smallpox virus as the

second to be eradicated from the planet. In addition to immeasurable human benefits, the world will save at least $1.5 billion every year in the cost of vaccine and

its administration, when polio immunization is no longer needed. There will be lasting benefits in the form of a stronger infrastructure for the delivery of vaccines

against other infectious diseases.

The strategy, the successes, and the challenges remaining to the global polio

eradication campaign have all been reviewed by my distinguished colleagues who

are testifying today. I would like to take this opportunity to point out that Rotary

holds these men in great esteem, for their vision of a world without polio. Dr.

Satcher, Dr. Foege and Dr. Samba are all recipients of Rotary’s Polio Eradication

Champion award, for their leadership in the international partnership which is

making the ‘‘Target 2000’’ dream a reality.

On behalf of Rotary International and the 400,000 American Rotarians, I would

also like to express our deep gratitude to this Subcommittee for its staunch support

of the CDC’s international polio eradication efforts over the past several years. In

particular, I would like to thank the Subcommittee for the recommended increase

of $20 million for fiscal year 1999. The CDC has accomplished so much with the

funds you have allocated them to date. This additional appropriation will help make

it possible to eliminate polio in Africa by the end of the year 2000. As may be seen

in the appendix to this document, the United States’ generosity has fueled the rapid

progress. US appropriations in the last three fiscal years total $201 million, or 40

percent of the major polio-specific grants of all donor nations. These monies have

been deployed most effectively by the CDC and USAID, which are spearheading

America’s fight against polio. Few investments are as risk-free or can guarantee

such an immense return. Rotary greatly appreciates your personal leadership and

continued support of the CDC’s program and ‘‘Target 2000.’’

THE POLIO ERADICATION STRATEGY WORKS

Polio, like smallpox before it, can be eradicated because humans are the only host

for the virus. At the 1988 World Health Assembly, the nations of the world resolved

to see the last case of polio by the end of the year 2000, with certification of eradication by the year 2005. This is possible because we have a proven strategy. In

1994, the entire Western Hemisphere was certified free of polio. Every country

which can effectively implement WHO’s polio eradication strategy can expect to be

polio-free within three to four years. We must make certain that every country is

able to do this, because if we fail in any one country, we fail world-wide.

Although polio-free since 1979, the United States currently spends at least $230

million annually to protect its newborns against the threat of importation of the

polio virus. This threat is real. In 1996, for example, a polio outbreak in Albania,

caused by an imported virus, killed and crippled dozens of people and spread to

neighboring Greece and Yugoslavia. Once polio is eradicated and immunization
26

against it can be ceased, America will save this amount every year. Eradicating the

disease in the 50 countries where it remains clearly benefits the American people.

ROTARY’S ROLE IN THE GLOBAL PARTNERSHIP

Thanks in large measure to United States support, the international effort to

eradicate polio has made tremendous progress during the past year: 160 countries

now polio-free; polio apparently gone from the Western Pacific, and virtually eliminated in Europe; solid improvements in polio surveillance and the global laboratory

network; National Immunization Days (NIDs) conducted or scheduled in all polioendemic African nations. Rotary is proud to have played a role in these many successes. Rotary’s contribution to the international effort is fourfold: funding, volunteerism, laboratory and surveillance support, and advocacy for polio eradication.

Funding.—When the PolioPlus Program began in 1985, Rotary initially intended

to raise $120 million to provide oral polio vaccine (OPV) for all the newborns in the

developing world for a period of five years. Rotarians responded with $247 million,

more than double the original fund-raising goal. Since then, Rotary has committed

additional resources, and by the year 2005, when we expect to celebrate the certification of polio’s eradication, Rotary International will have expended over $425 million on the effort—the largest private contribution to a public health initiative ever.

Of this, $313 million has already been allocated for polio vaccine, operational costs,

laboratory surveillance, cold chain, training and social mobilization in 119 countries,

including $92 million to date for 47 African nations. Over the past year, realizing

the increased role which external donors need to play in order to ensure that polio

eradication is not jeopardized due to lack of resources, The Rotary Foundation has

allocated an additional $40 million to its PolioPlus Fund. But Rotary’s contribution

goes beyond the financial.

Volunteerism.—Around the world, Rotarians and their friends and families have

contributed millions of hours to polio immunization and eradication efforts in their

nations and communities. Rotarians are active at all levels of the campaign—international, regional, national and local. They work together with their national ministries of health, UNICEF and WHO, and with health providers at the grass-roots

level. They help to plan and implement the National Immunization Days, to publicize the campaigns, to transport vaccine, to staff immunization posts, and to help

track children who may have missed the immunization. In Angola, for instance, Rotarians helped negotiate a cease-fire in order to immunize children, and led a campaign to solicit corporate jets, helicopters and vehicles to move vaccine through Angola’s land-mine infested countryside. The Government has been so impressed by

Rotary’s ability to negotiate with the factions and build consensus that the President of Angola has approached Angolan Rotarians to solicit Rotary’s assistance in

convening a national peace conference. In India, 70,000 Rotarians and the 100,000

additional volunteers they were able to mobilize were critical to the success of the

NIDs, during which 130 million children were immunized on one day—the largest

single public health event in history.

Laboratory and surveillance support.—Rotary is committed to strengthening the

network of international, regional and national laboratories which is necessary to

investigate suspected polio cases. We have made grants to fund laboratory equipment, personnel, and training of virologists, and through our PolioPlus Partners

program have enabled Rotarians in polio-free countries to make direct, specific contributions to the global eradication of polio, by adopting laboratory and social mobilization projects in polio-endemic countries. Rotary districts in America, Canada and

Japan have funded polio laboratories in Coˆte d’Ivoire, Kenya, Madagascar, Nigeria,

Senegal, Zambia, and 6 other African nations, in some cases providing all the equipment and materials necessary to get the lab functioning. In addition, Rotarians in

polio-endemic countries are involved in surveillance for suspected polio cases at the

local level, actively looking for any child with the tell-tale signs of paralysis and

fever and informing the appropriate health authorities. In the 1980’s, Rotarians

worked with the Brazilian Pediatrics Association to educate 12,000 Brazilian pediatricians about the need to report suspected polio cases. During the last stages of the

eradication campaign in the Americas, Rotarians in several countries even offered

substantial rewards to citizens reporting confirmed polio cases.

Advocacy.—For the past 3 years, The Rotary Foundation’s Polio Eradication Advocacy Task Force has coordinated Rotarian efforts to inform both governments and

the private sector about the benefits to all nations of global polio eradication, and

the urgent need for all to increase their commitment to the Target 2000 goal. Advocacy also means building the political will to eradicate polio in those countries of

the world in which it still exists. Many of you may be familiar with our efforts here

in the USA—we have testified before your Subcommittee and others, and held
27

events to celebrate progress in the polio eradication campaign and United States

leadership of the international partnership. But you may not be aware that Rotarians are engaged in similar activities in over 25 other nations around the world.

Australia, Belgium, Canada, Denmark, Germany, Japan and the United Kingdom

are among those countries which have followed the United States’ lead in increasing

their commitment to Target 2000. In these and other countries, Rotarians have been

taking the message to parliamentarians, foreign aid agencies, and heads of state.

Over the past three years, Rotarians have played a role, sometimes greater, sometimes lesser, in decisions by their governments to commit some $500 million in new

funds for international polio eradication. We hope to maintain this momentum until

polio is eradicated, and also step up efforts to solicit the support of international

corporations and other private sector sources.

The examples I have cited above are just a few of the reasons why United Nations

Secretary General Kofi Annan has called Rotary’s PolioPlus Program ‘‘A shining example of the achievements made possible by cooperation between the United Nations and non-governmental organizations.’’

PRIVATE SECTOR SUPPORT FOR POLIO ERADICATION

The Polio Eradication Initiative has been strongly supported by the private sector,

most notably at local levels. Corporate involvement has often resulted from efforts

by Rotarians to engage private sector partners for the highly visible and popular

National Immunization Days. A few examples are provided below:

Financial contributions.—Lederle Laboratories donated US$1 million over a 3-

year period to support the development of the Polio Laboratory Network in Africa.

During the polio eradication initiative in Latin America, a fast-food chain donated

a fixed amount of the proceeds from each item sold in their restaurants in several

countries.

Vaccine.—The largest corporate contribution for polio eradication to date has been

the donation by Chiron, Pasteur-Merieux, and SmithKline Beecham of 100 million

doses of oral polio vaccine to WHO, over a 3-year period. These three companies the

principal suppliers of OPV to UNICEF. The vaccine is valued at US$8 million and

is targeted to African countries, where the need is greatest. Connaught Laboratories

also donated 1 million doses of OPV through Rotary in 1996.

Advertising and social mobilization.—Within the private sector, particularly corporations, there are considerable resources and expertise for ‘‘communications.’’ A

number of corporations and media organizations have supported polio eradication by

providing advertising to inform and motivate parents regarding NIDs. Local and national firms have paid for print and electronic media announcements on NIDs. They

have also paid for more traditional forms of advertising and social mobilization, including posters, banners and mobile megaphone announcements. One striking example of this approach was the free television advertising provided by a major

household products company in Turkey. During the weeks leading up to the NIDs,

the last 10 seconds of each of their television commercials was an NID announcement. This advertising was provided without cost to the Ministry of Health.

Transportation.—Transportation of vaccine, vaccinators and laboratory specimens

is another area where local private sector support has been substantial. Soft drink

companies have transported vaccine from central storage facilities to villages where

it was used in NIDs. In some cases this was accomplished during regular deliveries

and with minimal cost to the company. Local companies and individuals have also

contributed the use of vehicles for the short period of time needed to transport

vaccinators and vaccine to the immunization clinics. In one country an oil company

donated gasoline for vehicles for an NID. Finally, in the Philippines, an express-delivery company donated the service of delivering laboratory specimens from provincial health centers to the central laboratory in Manila.

Facilitating NID’s immunization clinics.—Corporate sponsors have assisted with

NIDs immunization clinics in many countries. For example, several major food companies in the Philippines offered their restaurants as immunization posts during

NIDs, while companies in Egypt donated food for the immunization teams. Companies have also donated balloons, candy and other small items to be given to children

as a reward for being immunized. T-shirts, aprons, pins, baseball caps and other

items bearing NIDs logos have been donated by corporate sponsors to increase the

visibility of the NIDs and serve as a reward for health workers.

Other approaches to the private sector.—In addition to the successful examples of

private/public sector collaboration for polio eradication outlined above, Rotary and

WHO have made approaches to a number of other corporations at both the national

and international levels. These include approaches to a major soft drink manufacturer, a large mining concern, an oil company, an automobile manufacturer and a
28

computer manufacturer, asking them to consider donations of money and/or materials.

AFRICA: THE KEY TO GLOBAL SUCCESS

The task of delivering oral polio vaccine to children faces enormous problems on

the African continent. These include civil conflict, poor roads, uncertain communication, shortages of transportation, unreliable refrigeration facilities, lack of sufficiently trained personnel to plan and manage National Immunization Days, and a

weak system of surveillance.

Despite these obstacles, however, the countries of Africa have made remarkable

strides in polio immunization. These countries need and merit special assistance in

their fight against polio. Thus Rotary International strongly endorses the recommendation of this Subcommittee in providing an additional $20 million for Africa’s needs in fiscal year 1999, supplementing the planned deployment of $47.2 million by the CDC. Furthermore, Rotary International hopes that such an amount can

be included in the President’s budget for fiscal year 2000.

The additional $20 million would go to three areas of need: $6 million for oral

polio vaccine for NIDs, $5 million for NID operational support in difficult countries,

and $9 million for developing the surveillance systems which are critical to the

eradication strategy. These areas of expenditure all provide additional opportunities

for private sector support on national and local levels. Increased funding for the

polio campaign is critical for eradication of the virus by the year 2000.

THE LEGACY OF POLIO ERADICATION

The global Polio Eradication Initiative learned much from the successful campaign to eradicate smallpox, and in turn the polio eradication effort is teaching the

public health experts important lessons which will help other disease control and

elimination programs. Firstly, increased political and financial support for childhood

immunization has many documented long-term benefits. Polio eradication is helping

countries to develop public health and disease surveillance systems useful in the

control of other vaccine-preventable infectious diseases. Already, much of Latin

America is free of measles, due in part to improvements in the public health infrastructure implemented during the war on polio. As a result of this success, measles

has been targeted for elimination in the Americas by the year 2000, and it is anticipated that measles can be eradicated world-wide. The disease surveillance system—

the network of laboratories, computers and trained personnel built up during the

Polio Eradication Initiative—is now being used to track measles, Chagas, neonatal

tetanus, and other viral diseases.

The campaign to eliminate polio from communities has led to increased public

awareness of the benefits of immunization, creating a ‘‘culture of immunization’’ and

resulting in increased usage of primary health care and higher immunization rates

for other vaccines. It has identified and eliminated barriers to immunization. It has

improved public health communications and taught nations important lessons about

vaccine storage and distribution, and the logistics of organizing nation-wide health

programs. Lastly, the unprecedented cooperation between the public and private

sectors serves as a model for other public health initiatives. In this regard, Rotary

applauds two service club organizations: Kiwanis International for its work with

UNICEF to eliminate Iodine Deficiency Disorders (IDD) worldwide, and Lions Clubs

International which is working with WHO’s Blindness Prevention Programme to

eliminate onchocerciasis (river blindness) and other causes of blindness.

Humankind is on the threshold of victory against polio, and we must not miss this

window of opportunity. Poliomyelitis will be the second major disease in history to

be eradicated, but not the last. The world celebrated the eradication of smallpox in

1979, and no child anywhere in the world will ever suffer from smallpox again. The

annual global savings of nearly $1 billion per year in smallpox immunization and

control costs far exceed the approximately $300 million that was spent over ten

years to eradicate the disease. The United States was a major force behind the successful eradication of the smallpox virus, and has recouped its entire investment in

smallpox eradication every 21⁄2 months since 1971. Even greater benefits will result

from the eradication of polio, and after that, measles and other infectious diseases

which kill and maim millions of children every year.

Polio eradication is an excellent example of truly cost-effective foreign assistance.

It is estimated that the world will ‘‘break even’’ on its investment in polio eradication—saving the more than $1.5 billion now spent annually on routine polio vaccination—only 2 years after the virus has been vanquished and immunization

against it can be ceased. The financial and humanitarian benefits of polio eradi29

cation, which will accrue forever, will be a gift to the children of the twenty-first

century.

Thank you for this opportunity to testify.

MAJOR POLIO-SPECIFIC GRANTS 1

[In U.S. dollars]

Fiscal year—

Total

1996 1997 1998 2

Australia ............................................ 210,000 948,000 ........................ 1,158,000

Belgium .............................................. 5,100,000 ........................ ........................ 5,100,000

Canada .............................................. 1,400,000 ........................ 40,740,000 42,140,000

Denmark ............................................. 40,000,000 6,000,000 ........................ 46,000,000

European Union ................................. 704,000 400,000 ........................ 1,104,000

Finland ............................................... 330,000 ........................ ........................ 330,000

Germany ............................................. ........................ 451,000 24,000,000 24,451,000

Italy .................................................... 750,000 ........................ ........................ 750,000

Japan ................................................. 22,430,000 25,720,000 10,228,000 58,378,000

Korea .................................................. ........................ ........................ 900,000 900,000

Netherlands ........................................ ........................ 248,000 ........................ 248,000

Norway ............................................... 2,120,000 700,000 ........................ 2,820,000

Sweden ............................................... 481,000 400,000 ........................ 881,000

Switzerland ........................................ 177,000 1,300,000 ........................ 1,477,000

United Kingdom ................................. 78,600,000 1,550,000 31,160,000 111,310,000

USA .................................................... 47,200,000 72,200,000 81,200,000 200,600,000

Vaccine manufacturers 3 ................... 9,000,000 ........................ ........................ 9,000,000

Total ..................................... 208,502,000 109,917,000 2 188,228,000 506,647,000

1 Grants in excess of US$100,000 intended primarily for polio eradication activities. These may be direct bilateral

grants to polio-endemic nations, or multi-lateral grants through international organizations such as WHO or UNICEF. Some

are for multiple years. 2 As of August 1998.

3 Donation from three European and one American vaccine manufacturer: 100 million doses of Oral Polio Vaccine plus

US$1 million.

Note: In addition to these polio-specific grants, many countries are supporting the WHO Expanded Programme on Immunization, which combats several infectious diseases, among them polio.

BIOGRAPHICAL SKETCH OF HERBERT A. PIGMAN

GENERAL SECRETARY OF ROTARY INTERNATIONAL, 1979–86 AND 1993–95

Herb Pigman served as General Secretary of Rotary International and of The Rotary Foundation of Rotary International from 1979 to 1986 and again from 1993 to

1995. As Rotary International’s managing officer, he supervised the Rotary International staff located at Rotary’s World Headquarters in Evanston, IL, USA, and

service centers in eight other countries.

He began his 35-year career with Rotary International in 1956 as an editor of The

Rotarian magazine. As Under Secretary from 1964 to 1975 he was responsible for

Rotary’s program development, publications, and international meetings. From 1976

to 1978 he was executive assistant to the president. In 1979 he was elected General

Secretary, serving until his retirement in 1986 after 30 years’ service.

In 1986–89, he directed the Rotary International Immunization Task Force for the

PolioPlus Program. The Task Force helped to launch Rotary’s child immunization

operations in 90 countries of Asia, the Pacific, Latin America, and Africa. He was

Rotary’s liaison with UNICEF, the World Health Organization, and with national

health ministers. More than 1 billion children in developing countries have been immunized against polio with Rotary’s help, an effort recognized by the World Health

Organization in the awarding of its Gold Medal.

He currently serves as chairman of the Polio Eradication Advocacy Task Force,

which encourages governments to commit financial resources needed to eradicate

polio by the year 2000. He is also a member of The Rotary Foundation Permanent

Fund Leadership Team.
30

He is a graduate and former trustee of Franklin College of Indiana, from which

he holds a degree in journalism and an honorary doctorate in the humanities. He

is a member of the Indiana Academy. He and his wife, Betty, who have five children, live in rural Warren County, IN, where he pursues farming and newspaper

publishing. Herb is a past president of the Rotary Club of Evanston, Illinois. He is

a member and past president of the Rotary Club of Boswell, IN, USA.

ROTARY—A SERVICE ORGANIZATION

Senator BUMPERS. It was only a few years ago I discovered Rotary’s role in this whole thing. One day I was going home for the

weekend, and Betty said, what is your schedule? And among other

things, there was a Rotary Club speech on the agenda, and she

said, do not forget to thank them. I said, thank them for what?

[Laughter.]

And that is when I first discovered Rotary as a service organization in the very highest meaning of the word. Your work on polio

is probably not well known in the country, but it is no less meaningful because of that. I want to again express my personal gratitude to all Rotarians, all 450,000 of them, for their commitment to

this, and I hope they will stay committed as we move from polio

to measles.

STATEMENT OF DR. BILL FOEGE, FORMER DIRECTOR, CENTERS FOR

DISEASE CONTROL

Senator BUMPERS. Dr. Foege, a close friend of mine and Betty,

for many, many years. Dr. Foege, we are most honored that you

could be with us this morning and please proceed.

Dr. FOEGE. Thank you, Senator Bumpers.

Unlike a marathon, we will not know the day we cross the line

with polio. We will only know afterwards. For example, it was October 1977, a family entered a hospital in Somalia with two small

children. They both had smallpox. They asked directions to the infectious disease ward, and a cook at the hospital said, instead of

giving directions, I will take you there. In the few minutes that it

took him to take that family to the infectious disease ward, he got

smallpox from one of those children. We did not know that day that

that was the last time smallpox would be transmitted from one

person to the next. He recovered. No one got smallpox from him.

That broke the chain. It went right back to the very first human

case. So, we did not know that day. We will not know until sometime later the day we have crossed the line on polio.

Senator BUMPERS. Where was that, Dr. Foege?

Dr. FOEGE. In Somalia.

So, it was not only the first disease eradicated that day, but it

is the first time a body of medical knowledge actually benefits everyone in the world and everyone who will ever be born in the future. There are lots of lessons from smallpox. I want to mention

four of them.

One is the value of tenacity. You mentioned that the first smallpox vaccination was in 1796, and you can understand why people

150 or 160 years later would come to the conclusion smallpox could

not be terminated. Yet, a new look was taken, a global approach

was taken. People shared the value of smallpox eradication, and

hard work led to, 11 years later, smallpox eradication. So, it is

worth always taking new looks.
31

No. 2, the value of partnership and the possibility of partnerships even during the cold war. We forget it was the Soviets who

first suggested smallpox eradication, and we found, during the cold

war because we had a health objective, we learned how to work together and it had value beyond smallpox.

No. 3, the most refreshing lesson, I believe, was the discovery

that some things have to be done only once in the entire history

of the world. Smallpox vaccine had to be developed only once. The

eradication of the disease does not have to be repeated. It is almost

an afterthought to find out it was such a good financial investment.

And No. 4, the value of U.S. leadership. USAID provided the

early smallpox eradication resources, and CDC actually provided

300 people to WHO over those 11 years. We get a return on that

investment in this country by having global and domestic health

people who really have a totally different view.

One strange outcome was the feeling by many people that such

a success could not be repeated, that this was unique. So, while

some things need be done only once, some lessons apparently have

to be relearned.

Some people in this room will recall that April day in 1955 when

a press conference at the University of Michigan announced that

the Salk vaccine actually protected children against polio. It is almost impossible to recreate the feeling of that day, but the next

day around the United States, simultaneously and spontaneously,

there were signs in store windows that said, thank you, Dr. Salk.

Well, as you know, we struggled with the best mechanisms, but

we finally got it right, and 25 years after the vaccine was introduced, we had the last outbreak in this country. But we did not

automatically go the next step and commit to global eradication. It

took a catalyst, and as we have heard repeatedly this morning,

that catalyst was Rotary International. It was not just the resources that we have heard about of millions of hours of work or

millions of dollars. It was their role as a collective conscience. Gandhi once said that his interpretation of the Golden Rule is that he

should not be able to enjoy something denied to others, and Rotary

reminded us that we cannot enjoy having our children and grandchildren free of polio unless we give all parents that same joy.

I will never forget the day when Dr. Maseto, director of the Pan

American Health Organization, called a group of people together to

look at the science behind polio, and at the end of the day, the scientific evidence was so compelling that he went out on a limb by

himself, the first person in WHO to say we will eradicate polio.

And he announced that it would be eliminated from the Americas,

and as we have heard, by 1991 it was.

LESSONS FROM POLIO

So, what are some of the lessons from polio?

No. 1, the scientific case is clear. The objective is realistic, as we

have heard, but we still have not fully grasped the size of the effort

which will be required in Africa. In smallpox eradication, our first

success was in west and central Africa. It was a CDC/USAID effort

and we demonstrated what could be done with people who were realistic but very motivated. The same can be done for polio in Africa,
32

but it will require more support I believe than people have thought

heretofore.

The key lesson is that we do not save money by just getting by.

You asked where the last case of smallpox was. It was in Somalia.

The smallpox eradication program put great effort into Ethiopia,

but not quite enough. Elimination from Ethiopia took one month

longer than it should have, and in that last month smallpox was

transmitted to Somalia and it took us 2 years of hard effort to get

it out of Somalia. That is my fear with polio. If it takes 1 month,

6 months, 1 year too long than we will have reimportations into

Brazil or India or Burma.

We are at a crucial phase where a labor intensive effort is required in Africa. The structure, as we have heard today, has rapidly been put into place in that continent, and the next step, and

the last major step, should be to flood them with help before anything can go wrong. If that is to be done, it will be done because

the United States decides to do it, giving even more support to

CDC to, in turn, give to UNICEF and WHO and others. We can

assure this country that that is a direct investment in American

children for all time.

A few closing words on measles. It is because of you and your

wife that we even raise the idea of measles eradication. Your efforts on immunization in Arkansas were shared with President and

Mrs. Carter at a dinner at the White House in 1977. The next day

I had a phone call from Joe Califano and he said, we are going to

have an immunization initiative in this country.

Within a year, the results were so good we started asking the

question could we actually interrupt measles transmission in the

United States, and I can tell you many public health people told

me do not take that objective. You will only ruin the credibility of

CDC.

SPREADING OF MEASLES

We did take that as an objective and we had weekly reviews. One

problem after another was uncovered. Military recruits going to

basic training would spread measles around the country as they

went home on furlough. That was solved by immunizing all military recruits, whatever their past history was. Then day care centers, colleges, one problem after another, until we got down to the

last barrier, and that turned out to be importation of measles from

other countries. We were having on average two importations a

week at that time. As Dr. Satcher mentioned, PAHO has now done

such a good job, that we have very few importations from this

hemisphere, but we can clearly say we have interrupted transmission of measles in this country and all of our cases are due to

importation.

So, we have discovered that we are interrelated. It takes more

than a village to raise a child. It takes the entire world, and if we

are to protect American children, it will be by getting rid of measles in the rest of the world.

What are the lessons we have learned from this? Scientifically

measles eradication can be done, and we have shown that by getting rid of it in this country.
33

It will require tremendous effort. We should continue to build the

infrastructure for measles immunization, and we should improve

the tools. We should develop vaccines that are heat resistant so we

do not need the cold chain. We should develop stealth vaccines that

actually get by the maternal antibody so you can give measles immunization in the first 9 months of life. And we should make measles vaccine a tugboat to pull the entire immunization program to

greatness. We should some day make global measles eradication a

legacy of the Arkansas immunization program. Our best argument

for measles eradication will be made by finishing polio with all the

speed we can generate.

Permit me to end on a personal note. I no longer work for the

Government. I am nearing the end of my professional career and,

therefore, I feel free to say what I want. [Laughter.]

Senator BUMPERS. Sort of like not running again. [Laughter.]

Dr. FOEGE. At a time of great criticism of Government, Government employees, and politicians, I can identify few instances of social justice by groups other than Government. No church group, no

service club, no organization represents all of us except Government. Our immunization successes in this country have resulted

from Government at its best by a desire to protect every child individually and society collectively. It is the result of politics at its

best. And likewise, the U.S. support of smallpox eradication, polio

eradication, child health, child immunization for the rest of the

world, it is enlightened self-interest, yes, but it also expresses our

understanding as Americans of a responsibility to the world and to

the future. As with the Marshall plan and the Point Four Program,

it is the U.S. Government at its best.

PREPARED STATEMENT

For years of giving us Government at its best and on behalf of

tens of millions and hundreds of millions of people who are never

invited to a hearing like this, I thank both you and Mrs. Bumpers.

Thank you.

[The statement follows:]

PREPARED STATEMENT OF WILLIAM FOEGE M.D., M.P.H

INTRODUCTION

It is not possible to grasp the pace of health improvements in our lifetime. When

my parents were born, 15 percent of children in this country died before their first

birthday. Now the figure is less than 1 percent. Given his life expectancy at birth,

my father was destined to die in 1953. 20th Century medicine and science have

given him both quantity and quality of life, and at age 93 he enjoys a full life.

Likewise, global health gains stagger our imagination. The World Bank has reported that health has improved more in the past 40 years than in the previous

4,000. Global life expectancy has approached 65 and infant mortality rates for the

world have been cut in half in the past 35 years. But the gains cannot be mentioned

without also noting the increasing gaps between the haves and the have-nots, the

rich and the poor. Disease eradication efforts help to close that gap, providing the

same benefits for everyone.

SMALLPOX

On an October day in 1977, a family arrived at a hospital in Somalia with two

small children. They both had smallpox. Asking for directions to the infectious disease ward, they were escorted by a hospital employee. In that brief period, the employee contracted smallpox. But, no one acquired smallpox from him, thus breaking
34

the chain of smallpox transmission that went back to the very first human case

hundreds of years before. Not only was that the first disease eliminated from the

world, it was also the first time that a body of medical knowledge benefited everyone living and everyone who would be born in the future. It was truly social justice

in the medical field.

Many lessons come from the smallpox eradication experience. I will mention only

four.

1. The value of tenacity.—Senator Bumpers mentioned that the first smallpox vaccination was given in 1796. It is understandable that after 150 or 160 years people

would conclude the disease could not be eliminated. But after a new analysis, global

agreement was reached, a shared goal was defined and the hard work of 11 years

led to eradication.

2. The value of partnerships.—It was possible, even in the Cold War, to develop

effective partnerships with the Soviet Union. [Indeed, we forget that it was the Soviets who originally suggested smallpox eradication as a global goal.] The program

gave us practice in working together and this led to benefits beyond smallpox eradication.

3. But the most refreshing lesson for me was the demonstration that some things

need to be done only once in the history of the world. Smallpox vaccine did not need

to be developed a second time. The eradication of smallpox did not have to be repeated. It is almost an afterthought to find what a good financial investment it was.

4. The value of U.S. leadership. USAID provided the early resources and the Centers for Disease Control and Prevention provided over 300 people to the World

Health Organization for the eradication effort. The U.S. got a return on that investment with global and domestic health workers that had a different perspective and

great skills.

One disconcerting outcome was the feeling by many that such a success could not

be repeated, that it was unique.

POLIO

So, while some things need be done only once, some lessons apparently have to

be relearned.

Some here will remember that April day in 1955, when a press conference at the

University of Michigan caused absolute euphoria with the announcement that the

vaccine developed by Jonas Salk protected children from polio. There was a spontaneous reaction with signs appearing in store windows the next morning saying,

‘‘Thank you, Dr. Salk!’’

We struggled in this country for the best mechanisms, but we finally got it right.

Our last outbreak occurred 25 years after the vaccine was introduced.

But we did not automatically go the next step and commit to global eradication.

It took a catalyst and that catalyst was Rotary International. It was not just their

resources of millions of hours in the field and millions of dollars that was important.

It was also their role as a collective conscience.

Gandhi once said that his interpretation of the Golden Rule is that he shouldn’t

be able to enjoy something denied to others. Rotary reminded us that we cannot

enjoy having our children and grandchildren free of polio unless we give all parents

that joy.

I will never forget the day when Dr. Macedo, director of the Pan American Health

Organization, called together a group to review the science of polio control. On hearing the scientific evidence, he immediately went out on a limb, ahead of his colleagues, to announce that polio would be eliminated from the Americas. And it was

done by 1991.

What then are the lessons we take to from our polio eradication to this date?

1. The scientific case is clear as larger and larger geographic areas are freed of

the disease.

2. The objective is still realistic.

3. But, we still haven’t grasped the size of the effort required in Africa. In smallpox eradication, our first success was in West and Central Africa. It was a CDC/

USAID effort that demonstrated what could be done with realistic and well-motivated people. The same can be done for polio in Africa, but it will require more support for the next two years than we have given, or even imagined to date.

4. The key lesson is that we don’t save money by just getting by. In smallpox

eradication we put great effort into the program in Ethiopia but not quite enough.

Elimination of smallpox took one month too long. In the last month of smallpox in

Ethiopia, the disease was transmitted to Somalia, and it took an additional 2 years

to rid Somalia of the disease.
35

That is my fear with polio. If it takes one month, 6 months, 1 year too long we

may get re-importation into Brazil, India, or Burma.

We are now in a crucial phase, where a labor-intensive effort is required in Africa.

The structure has rapidly been put into place and the next step (and the last major

step), should be to flood them with help before anything can go wrong.

If this is to be done, it will require the support of the United States giving even

more support to CDC to, in turn, provide assistance to WHO, UNICEF and others.

We can assure Congress that it is a direct investment in American children for

all time.

MEASLES

A few closing words on measles. It is because of you, Senator Bumpers, and your

wife, that we even raise the idea of measles eradication.

Your efforts on immunization in Arkansas were shared with President and Mrs.

Carter at a dinner in the White House in 1977. The next day I received a call from

the Secretary of HHS, Joseph Califano, to inform me that we were going to have

an immunization initiative.

Within a year the results were so good that we began asking ourselves if measles

transmission could be interrupted in this country. Many public health people advised against it saying it was not possible and would serve only to impair the credibility of CDC. But we chose that objective and began to have weekly reviews of

progress. We found one problem after another, from military recruits spreading the

disease, to problems in day care centers, colleges, sports events, etc. But we solved

each problem as it arose until the ultimate barrier presented itself—importations

from other countries.

We were experiencing two importations of measles in the average week. Once

again we were faced with the fact that everything in the world is interrelated. If

we want to protect American children from measles we have to protect all children

in the world from measles.

It doesn’t just take a village to raise a child, it now takes the entire world to raise

a child. PAHO launched a very effective program and importations from this hemisphere have been dramatically reduced.

We have now interrupted measles transmission in this country. All cases now are

due to importations.

What are the lessons?

1. We have demonstrated the science. Measles eradication is possible.

2. It will require tremendous effort.

3. We should continue to build the infrastructure for measles immunization. All

children in the world need to be immunized.

4. But we should also improve the tools. We should strive for vaccines that are

heat stable in order to minimize the costly and difficult cold chain. We should seek

‘‘stealth’’ vaccines that evade maternal antibody, allowing immunization in the first

9 months of life.

5. We should make measles vaccine a tugboat to pull the entire immunization program to even greater heights. All of the new vaccine possibilities require an ever

stronger immunization structure.

6. We should make global measles eradication the legacy of the Arkansas immunization program.

7. Our best argument for measles eradication will be made by eradicating polio

with all of the speed we can generate.

Finally, permit me to end on a personal note. I no longer work for the government; I’m near the end of my professional career; therefore, I am free to say what

I want.

At a time of great criticism of government, government employees and politicians,

I can identify few instances of social justice by groups other than government. No

church group, no service club, no other organization represents all of us. Only government does that.

Our immunization successes in this country have resulted from government at its

best by a desire to protect every child individually and society collectively. It is the

product of politics at its best.

Likewise, the U.S. support of smallpox eradication, polio eradication, child health,

and child immunization for the rest of the world, while we know it is enlightened

self interest, it also expresses our understanding, as Americans, of a responsibility

to the world and to the future.

As with the Marshall Plan, and the Point Four Program, it is the U.S. Government at its very best.
36

For the years of giving us government at its best, and on behalf of ten’s and hundred’s of millions who are never invited to a Senate hearing, I thank you and Mrs.

Bumpers.

Thank you.

WHEN TO STOP MANUFACTURING POLIO VACCINE

Senator BUMPERS. Dr. Foege, that statement can only be described as beautiful, powerful, clear, representing the highest and

best values of citizens of this country. I cannot tell you how impressed I am with it and how, once again, I wish not just my colleagues in the Senate but every citizen in America could hear that.

This is such an unbelievable success story, and at the same time

we have to recognize that the success just simply points out how

far we have to go and you have done that in your statement.

Let me ask you three or four questions, Dr. Foege. No. 1, how

soon after the last case of polio can we safely quit manufacturing

polio vaccine?

SMALLPOX VACCINE AND STOCKPILING

Dr. FOEGE. It is a difficult question to answer because as with

smallpox, we are now reasking the question 20 years later. Should

we be making smallpox vaccine and stockpiling it in case something goes wrong?

With polio eradication, it will take us some time, some years actually, of close surveillance and monitoring every suspected case,

every case of flaccid paralysis, to make sure that there is no virus

actually circulating in the population. Then we have to make the

decision do we stockpile vaccine even if we do not use it. But we

are talking about a period of years, not a period of decades.

Senator BUMPERS. How long has it been since the last case of

smallpox was reported?

Dr. FOEGE. It has been over 20 years since the last case.

Senator BUMPERS. When did we discontinue manufacturing

smallpox vaccine? I assume we have discontinued it.

Dr. FOEGE. We have. We actually stopped giving smallpox vaccine in this country before it was eradicated from the world. That

is how confident we were that eradication was going to take place

and that we could respond to an emergency.

Polio is more of a stealth virus that it can get into the population

without us knowing. So, we cannot do that with polio. We have to

continue right up until the last case and then longer.

But we did stop making smallpox vaccine. We could do it again

without any problems if we had to.

Senator BUMPERS. Oh, you could.

Dr. FOEGE. We could make it again. We do not have to have

smallpox virus to make the vaccine because the vaccine is actually

made from a vaccinia virus or a cowpox virus.

Senator BUMPERS. At the time we chose vaccine for international,

worldwide eradication, was that the only vaccine we had that was

practical for such a big undertaking or did we do it for another reason?
37

TWO POLIO VACCINES

Dr. FOEGE. We, of course, had two polio vaccines and still do: the

inactivated polio vaccine that Jonas Salk developed which is injected, and the oral vaccine that Dr. Sabin developed which is

taken by mouth. The decision was made to use the oral vaccine because it was easier to use and because it provides an immunity in

the intestine of the person that is not always achieved with the inactivated vaccine. So, it was considered to be the better vaccine to

use on a global basis.

In this country we now talk about using the inactivated vaccine

at the end of the campaign, but these decisions have not been totally made as yet.

Senator BUMPERS. Is it feasible or desirable to do more than one

global eradication at the same time?

Dr. FOEGE. We, of course, are doing two global eradication programs right now, one for guinea worm and one for polio, and we

are talking at the same time about doing one for measles.

I think what happened after smallpox is we lost a certain momentum because people were so convinced this was unique, they

did not automatically ask, OK, how do we use what we have done

to continue on something else?

ERADICATION PROGRAMS

I think it is probably useful to think in terms of always doing one

or two actual eradication programs and one or two programs where

you are building up to it. I would hope that measles eradication

will be so feasible that it will be almost seamless to go from polio

eradication to measles. So, yes, we can do two at the same time.

Senator BUMPERS. Where is guinea worm indigenous to, what

part of the planet?

Dr. FOEGE. Guinea worm used to be in areas south of the Sahara

in Africa and in Pakistan and in India. It has been reduced by over

95 percent in just the last 8 or 9 years. Now we are finding the

problems that we fear with polio; that is, in Sudan we are having

difficulties with guinea worm because of the political problems. You

do not know what will happen with social and political problems.

It is another reason to do this as fast as we can.

Senator BUMPERS. Is the kind of civil conflict in some African nations—maybe, Dr. Samba, I should address this question to you.

We have quite a few civil disturbances in Africa, in various parts

of Africa. What, if any, impact—I know it is going to have some,

but how difficult is it going to be to continue with this schedule we

are on to try to eliminate polio, say, by the year 2000? I know, first

of all, it increases our cost because transportation is often interrupted and so on, but just comment generally on that subject, if

you would.

CIVIL STRIFE

Dr. SAMBA. It is feasible because the civil strife does not continue

indefinitely. Like in Sierra Leone now we are starting the polio

eradication, in Liberia, in Niger. Even in Congo, we got the stocks

ready and within a week of starting, the civil strife erupted, so we

had to suspend. When the electricity was stopped, we bought port38

able generators to preserve the vaccines and so on. And in December we will restart again. In Angola, it was during the civil strife

that we managed to have over 90 percent vaccinations. We have

been able to convince the warring partners that health is in the interest of all concerned, and even during civil strife, we have been

able to carry on. It is very difficult but it can be done.

HIV AND AIDS

Senator BUMPERS. Let me ask you a second question. Some critics say that HIV and AIDS are much more critical to these nations

and this money could be better spent on trying to control and even

to treat HIV and AIDS. What is your thought on that?

Dr. SAMBA. My impression, for what it is worth, I said earlier,

as a result of partnership, governments inside Africa, governments

outside Africa, the United States taking the lead, civil society—in

the case of river blindness, Merck, Sharp, & Dome, a private enterprise—we have been able to win. With polio we are on the way of

winning. Smallpox we have won.

We are convinced that with the partnership, the dedication, the

commitment, increasing resources and knowledge, that with AIDS

we will win. We are already starting on an initiative in Africa to

complement the United States system on AIDS. For the moment it

is a big problem. It is increasing, but AIDS is relatively new. We

knew about it in the 1980’s. It is much more recent than polio and

smallpox and river blindness.

Senator BUMPERS. Are other nations in Africa trying to assist

with what a lot of people in this country consider rather epidemic

proportions of HIV and AIDS? Is the United States involved in it,

and if so, to what extent? Let me rephrase the other question. Are

other, for example, European nations, Japan, wealthier nations, involved in trying to help with HIV/AIDS problems in Africa?

Dr. SAMBA. Yes; indeed. The United States is involved. Japan is

involved. Britain, all western countries, all Asia, in fact, are involved because the whole world is realizing more than ever that

with any epidemic anywhere in the world with the type of mobility

of human beings, no other country is safe. So, it is in the interest

of all concerned that the last bastion of these diseases are attacked.

They are all involved, sir.

Senator BUMPERS. It is what we call enlightened self-interest on

an international basis.

Dr. SAMBA. Exactly.

Senator BUMPERS. Mr. Pigman, do you think we would be able

to count on the Rotary Club, once we eradicate polio, to continue

with their assistance, say, in measles?

POLIO ERADICATION

Mr. PIGMAN. That question is often asked, Senator Bumpers, and

I would respond by saying that when we named our program back

in 1985, we could have named it ‘‘polio eradication’’ or we could

have named it ‘‘kick polio off the planet,’’ but we named it

PolioPlus, the ‘‘plus’’ implying that our focus on polio is aimed at

raising the immunization levels against all infectious diseases.
39

Now, we have an army currently deployed against polio. Polio

eradication is going to be their focus until the job is done, but I

would hope that we would not have disarmament.

Senator BUMPERS. Well, I hope not too. I hope to be a private citizen then, but I will do my best to weigh in with such Rotarians

as I have any influence with to make sure that they continue their

efforts.

Mr. PIGMAN. Thank you.

ROTARIANS

Senator BUMPERS. I find, incidentally, that Rotarians take great

personal satisfaction in what they have been able to accomplish,

and they are very proud of themselves. As I say, a lot of service

organizations are not service organizations at all, but the Rotarians

have shown that they really are truly a service organization.

Mr. PIGMAN. Well, Senator, in defense of sister organizations, we

are very happy to see that such large service organizations such as

Kiwanis has tackled iodine disease deficiency and Lions, vitamin A

deficiency, et cetera. So, let us hope that the partnership will only

grow in the future.

Senator BUMPERS. Dr. Foege, will there be any significant

change, up or down, in the cost of eliminating measles compared

to the cost of eliminating polio?

ERADICATE MEASLES

Dr. FOEGE. Measles is going to be a tougher disease to eliminate,

and my belief is that it will probably be somewhat greater cost

than polio. It is a very difficult disease to contain. It spreads rapidly and it is going to take a massive effort to eradicate measles,

but it is doable.

Senator BUMPERS. You do not think there is any question but

that measles ought to be the next effort I take it.

Dr. FOEGE. That is right. The figures that you gave, the single

most lethal agent in the world just a few years ago. It is such a

problem in Africa that I think we should do this, and I think that

we are getting experience now in how to improve our infrastructure. So, there is no question in my mind that we should do this,

but that polio should be eradicated as a step toward measles.

Senator BUMPERS. I have a couple of technical questions that I

probably will submit in writing to you, Dr. Foege, just for my own

enlightenment and the members of the subcommittee, about the

possible shortfall of funds to make sure we finish this.

CONCLUSION OF HEARING

Well, let me just again thank you all very much for what I know

is a great effort to get here to be here for this. I have been here

24 years, and I can tell you—and this is not to flatter you—this has

been one of the most enlightening, gratifying hearings I have ever

attended in my life. All of you spoke so extremely well. Whether

they read it or not, it will be shared with all the members of the

full committee, not just the subcommittee. So, we will submit two

or three questions in writing, but again thank you all very much

for coming.
40

The subcommittee will stand in recess subject to the call of the

Chair.

[Whereupon, at 11:39 a.m., Wednesday, September 23, the hearing was concluded, and the subcommittee was recessed, to reconvene subject to the call of the Chair.]

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