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21–964 PDF 2005

S. HRG. 108–848

NEGLECTED DISEASES IN EAST ASIA: ARE PUBLIC

HEALTH PROGRAMS WORKING?

HEARING

BEFORE THE

SUBCOMMITTEE ON EAST ASIAN

AND PACIFIC AFFAIRS

OF THE

COMMITTEE ON FOREIGN RELATIONS

UNITED STATES SENATE

ONE HUNDRED EIGHTH CONGRESS

SECOND SESSION

OCTOBER 6, 2004

Printed for the use of the Committee on Foreign Relations

(

Available via the World Wide Web: http://www.access.gpo.gov/congress/senate

COMMITTEE ON FOREIGN RELATIONS

RICHARD G. LUGAR, Indiana, Chairman

CHUCK HAGEL, Nebraska

LINCOLN CHAFEE, Rhode Island

GEORGE ALLEN, Virginia

NORM COLEMAN, Minnesota

GEORGE V. VOINOVICH, Ohio

LAMAR ALEXANDER, Tennessee

JOHN E. SUNUNU, New Hampshire

LISA MURKOWSKI, Alaska

MEL MARTINEZ, Florida

JOSEPH R. BIDEN, Jr., Delaware

PAUL S. SARBANES, Maryland

CHRISTOPHER J. DODD, Connecticut

JOHN F. KERRY, Massachusetts

RUSSELL D. FEINGOLD, Wisconsin

BARBARA BOXER, California

BILL NELSON, Florida

BARACK OBAMA, Illinois

KENNETH A. MYERS, JR., Staff Director

ANTONY J. BLINKEN, Democratic Staff Director

SUBCOMMITTEE ON EAST ASIAN

AND PACIFIC AFFAIRS

LISA MURKOWSKI, Alaska, Chairman

LAMAR ALEXANDER, Tennessee

CHUCK HAGEL, Nebraska

LINCOLN CHAFEE, Rhode Island

GEORGE ALLEN, Virginia

JOHN F. KERRY, Massachusetts

JOSEPH R. BIDEN, Jr., Delaware

RUSSELL D. FEINGOLD, Wisconsin

BARACK OBAMA, Illinois

(II)

CONTENTS

Page

Hon. Sam Brownback, U.S. Senator from Kansas, opening statement ............... 1

Dr. Robert Desowitz, Adjunct Professor of Epidemiology, School of Public

Health, University of North Carolina, Chapel Hill, NC ................................... 32

Prepared statement .......................................................................................... 34

Dr. Anne Peterson, Assistant Administrator for Global Health, U.S. Agency

for International Development, Washington, DC .............................................. 4

Prepared statement .......................................................................................... 8

Dr. Donald Roberts, Professor, Department of Preventive Medicine and Biometrics, Uniformed Services, University of Health Sciences, Bethesda, MD . 23

Prepared statement .......................................................................................... 25

(III)

(1)

NEGLECTED DISEASES IN EAST ASIA: ARE

PUBLIC HEALTH PROGRAMS WORKING?

WEDNESDAY, OCTOBER 6, 2004

U.S. SENATE, SUBCOMMITTEE ON EAST ASIAN AND PACIFIC AFFAIRS, COMMITTEE ON FOREIGN RELATIONS, Washington, DC.

The subcommittee met at 2:36 p.m., in room SD–419, Dirksen

Senate Office Building, Hon. Sam Brownback, chairman of the subcommittee, presiding.

Present: Senator Brownback.

OPENING STATEMENT OF HON. SAM BROWNBACK, U.S.

SENATOR FROM KANSAS

Senator BROWNBACK. We’ll call the hearing to order.

Thank you all for joining us today. Appreciate your being here.

The purpose of the hearing is to discuss ongoing efforts to control

malaria and what the U.S. Government is doing, what the international community is doing, and what is taking place.

I am delighted to have Dr. Peterson here with us, and we will

also have some testimony from other witnesses as well. Also, I

want to note your personal service in the region, in Africa, as a

physician and the work that you have done previously, and that is

quite noteworthy and highly appreciated.

I was saying to Dr. Peterson before we started the hearing, this

has really attracted my attention from the standpoint of the number of deaths and morbidity that has been going on due to malaria.

This is something that we can deal with and I do not think we

have dealt with effectively.

I want to go through a few charts that we have.

The burden of malaria: This disease is a huge killer and much

more common than anything else that is out there. As I understand, it is the leading killer of children in Africa and third leading

in the world.

If we compare what has taken place globally, we have got some

charts to show some of what happened during the global eradication campaign years. When we used a very aggressive application

of pesticide—in this case DDT—we had some very promising historical trends regarding what was taking place in treatment and

dealing with the disease of malaria. This is a chart that shows

global rates, and I do not think, Dr. Peterson, you can probably see

the years very well, but this is 1900 here and it goes to 1990. We

can see that when we really got aggressive on dealing with this

and using all the tools available, particularly in this case, pesVerDate 11-MAY-2000 13:47 Jun 27, 2005 Jkt 000000 PO 00000 Frm 00005 Fmt 6633 Sfmt 6633 96224.SEN SFORELA1 PsN: SFORELA1
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ticides, DDT, global rates went down aggressively. But they are

spiking back up. The red line here, which is Africa, is spiking up

aggressively, which to me is an area of great concern—that we see

that rate jumping back up, where it has not shown a similar spike

in other countries in Asia, Central and South American countries.

Here we see rates in some Asian countries. I have a chart up

next that focuses on the same sort of thing. It shows much the

same issue. These are Asian countries: Bhutan, Burma, Sri Lanka,

India. We have got a rate here in 1965 to 1969 where there was

aggressive spraying taking place, a multifaceted approach, very low

infection rates, and then when that lost favor, the rates go up very

high in these selective countries.

In South American countries, we show some of the same things.

I have a comparison chart of 1960 to 1995. Here are the 1960’s

charts of malaria rates in South America. You can see the continent was really doing very well on infections on a per capita

basis. By 1995, spraying is out of vogue, out of favor, and the rates

go up dramatically in South America. This then puts, obviously,

people there at much greater potential for their own harm, but also

infection possibilities back into the United States.

The next chart. Resurgence is directly linked to DDT spraying or

the lack thereof. As the number of sprayed households in South

America increases, the excess cases over the amount seen during

spraying exponentially increases. And this is just one of those inverse relationships where the numbers of cases were going down,

but then when you stopped spraying, and the cases took off.

Even when DDT was being phased out internationally for agricultural use, Secretary Powell emphasized the dire humanitarian

need for DDT to control malaria. We all know the difficulties of

DDT and that the removing of it in this country is one of the things

that brought the bald eagle back after numbers of eagles were

down due to widespread agricultural spraying. But what we are

talking about here is much more targeted spraying, household

spraying, not the broad agricultural spraying that was used with

DDT, that brought the weakening of the eggshell around the eagles’ eggs that caused so much trouble here in this country.

But what we are talking about is a targeted spraying, to what

the Secretary is referring, in recognition of the dire humanitarian

need for DDT to fight malaria in Africa, an exception will be made

for those purposes and should be. I think this is one of those cases

where you have got a clear need and we have a targeted basis to

be able to use it, and we can save a lot of lives.

But the WHO and other donors ignored this call. Some Asian

countries and South Africa were able to keep spraying with DDT

without those donor funds. They did it without donor funds, and

we can see from South Africa’s experience that Secretary Powell

was absolutely right. Here we can see the South African model,

what went wrong when they stopped DDT and the wrong medicine.

Cases skyrocket. They said, we have got to stop. They went the

other way. Cases of malaria go down.

South Africa had been controlling its malaria for years with

DDT. Environmental activists pressured the government the following year to stop these measures, prioritizing hypothetically

unproven environmental concerns over the many lives of tiny chilVerDate 11-MAY-2000 13:47 Jun 27, 2005 Jkt 000000 PO 00000 Frm 00006 Fmt 6633 Sfmt 6633 96224.SEN SFORELA1 PsN: SFORELA1
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dren and moms. And we can see then what happens in that situation.

Again, I want to emphasize we are not talking about the agricultural use, widespread use of DDT. This is household spraying, very

narrow, very targeted.

So the government reinstated DDT spraying, the effective drug

therapy of the ACT drug, and its cases fell again. It is a tried and

true approach to conquering malaria.

The donor community, which launched the Roll Back Malaria

program, did not support these measures, the DDT and ACT drug

measures. And since the Roll Back Malaria promise to reduce the

malaria burden by half, the trend has actually gone in the other

direction, and we have seen that take place now.

We have another chart. And we will provide all these to you as

handouts, but I wanted to get them out and for those that were in

attendance.

We can actually see the Roll Back Malaria campaign coming in

and actually numbers have gone up. The Roll Back Malaria has

failed. Millions of deaths have resulted each year since the Roll

Back Malaria made its promise. Not only has the donor community

failed to incorporate the proven DDT intervention, but they have

refused to support effective treatments. In fact, today UNICEF is

handing out pills that do not work to Sudanese refugees in Darfur.

We all know the situation in Darfur. But to give them the medicines that do not work, I think, to me, is a double tragedy.

The USAID record is one, I am afraid, that is not that good.

Many words have been said that we need to do things, but effective

interventions have been few and the dollars have been, I do not believe, effectively targeted. You can see that AID has put forward

statements that it wants to step its efforts up, but they have not

included funding real interventions in suffering countries. It refuses to fund drug purchases that actually will work, is requiring

Africans to buy the bednets, and is not supporting the use of DDT.

I do want to note a good story on this, though. The Global Fund

is an exception to some of the trends we have seen of the public

sector entities, like USAID and the Roll Back campaign. The Global Fund, after public pressure earlier this year, reversed its drug

policy and it does support some DDT targeted spraying and is moving in the right direction.

I put this all forward because I look at this and I just think we

are putting some money forward, we are putting some effort forward, but if we do not get the policy right on it, we are going to

keep getting people dying of this and having morbidity as a result

of malaria, which is something that we can handle in today’s day

and age. We are seeing the impact in Africa. It does not need to

take place.

I do realize it will take some difficult political decisions because

there is going to be a fair pushback from some activists that do not

want anything to do with DDT and do not want these drugs used.

Yet, if that is the effective way and we can get these trend lines

going back in the right direction, I would urge us to do that with

U.S. Government funds. I think you will find a lot of support here

if the Government gets on programs that do work and we do get

4

these deaths and morbidity by malaria moving in the right direction.

We will have two panels today. We do have a series of votes this

afternoon. I am hopeful we are going to be able to get all of this

together and into the record. Dr. Anne Peterson is the Assistant

Administrator for Global Health, U.S. Agency for International Development. That will be the first panel presentation. Then we have

two expert witnesses that will be presenting afterwards.

I did have a staff member just come back from a conference in

Africa, meeting with a number of recipient countries who were begging her that they be allowed—and they are getting funding from

us and from other international groups—for that funding to go toward intervention strategies, use of pesticides and the application

of pesticides, use of effective drug regimes, and not be used for

technicians, conferences, experts. They want help actually putting

the medicine in the hands of people, buying the medicines, and

using the pesticides directly. They want intervention strategies, not

technicians. They were really pleading with her and through her,

with me, that they be helped on these effective strategies.

So, Dr. Peterson, I know you bring a lot of personal experience

and knowledge to these issues and to Africa, and I hope that this

is one where we can work closely to get on a policy track that

starts reducing these cases of malaria instead of the continued

growth.

Thank you for joining us today. I will take your full testimony

into the record. You can summarize. You can present it, whatever

you would like to do. But delighted to have you here.

STATEMENT OF DR. ANNE PETERSON, ASSISTANT ADMINISTRATOR FOR GLOBAL HEALTH, U.S. AGENCY FOR INTERNATIONAL DEVELOPMENT, WASHINGTON, DC

Dr. PETERSON. Thank you, Senator. I really appreciate your convening this important hearing. I get to talk very often about HIV/

AIDS and not so often about malaria, and as I think you pointed

out very nicely, this is an area that is out of control. It is growing

and it needs the attention of Congress. So I am very pleased that

you have convened this hearing and invited me.

You talked about the impact of malaria on the families, on

women and children. I would add that we have a newly identified

population that is at risk. Those who are HIV-positive are at much

higher risk of dying of malaria because of their compromised immune system. As we are looking at the growth of malaria, we have

a new and large vulnerable population that is getting larger by the

minute. So coinfection is a big issue.

I appreciate your understanding of the issues and you have

raised a number of very deep concerns that I hope I will begin to

address, as I give my opening statement and in answering some of

the specific questions for you.

We do know that most of the people who are affected are women

and children. And the U.S. Government has been a leading force

in the worldwide battle against malaria. Just this year we had $80

million for malaria. This is a four-fold increase over the past 4

years. This is the kind of scale-up that is necessary to begin to curb

the kinds of trends that you have just shown to reach national

5

level impact instead of small-scale projects. We are moving toward

better policies and visibly stronger programs. You talked about getting drugs into the hands of people, but also meeting that need

based on strong policies. That is part of the leadership that the

U.S. Government has been doing in the past years.

Seven countries, specifically in Asia, receive support for malaria

with a major focus on limiting the emergence and spread of drugresistant forms of malaria in the Mekong subregion of Southeast

Asia, including Afghanistan, Cambodia, India, Indonesia, Philippines, Nepal, and Thailand.

We provide support to national malaria programs in 20 countries

in sub-Saharan Africa where the burden of deaths is the highest.

The international experts have identified a policy of three priority interventions that together reduce the deaths of illness from

malaria. There is not a single bullet. Because of the complex nature

of malaria, its transmission, and the people at risk, you need a

comprehensive package.

The first component of the package is prompt and effective treatment with an antimalarial drug within 24 hours of the onset of

fever.

The second component is prevention of malaria through the use

of insecticide-treated bednets for young women and children.

And the third component is provision of intermittent preventive

treatment for pregnant women as part of their antenatal services.

Other parts of an integrated program, depending on the epidemiology and the mosquito characteristics, are indoor residual spraying and the use of insecticides and environmental cleanup.

We know that a comprehensive approach that includes prevention, an effective and prompt treatment, and research for better

tools is the most effective strategy for saving lives. We have seen

this in Asia with the recent emergence and spread of multidrugresistant malaria. There has been a threat to reverse the gains

that we have seen in malaria. We have been very concerned about

this increase and invested significant resources into documenting

the speed and the scope of the developing antimalarial drug resistance and the burgeoning deaths due to malaria.

Because of the cross-border nature of the drug-resistant malaria

problem, surveillance and disease control capacity are needed in

Southeast Asia. We have been supporting a coordinated approach

since 1999, together with the World Health Organization, to monitor drug resistance. The U.S. Centers for Disease Control and Prevention have been a very close colleague in our efforts to do the

surveillance. As a result of the drug resistance data, USAID, the

other donors, and the national governments themselves can bring

forward the appropriate policies and, in fact, have updated a number of the East Asian countries’ malaria treatment policies. So

again, the right policy is what is needed. You need to have the

right data to make that happen.

The malaria programs in many of the Mekong Delta region now

use combination therapy which includes the new artemisinin-based

drugs. USAID has played a major role to change national malaria

policy to ACT in three of the six countries in the Mekong region.

We know from many infectious diseases that simultaneous use of

multiple drugs instead of a single drug regimen slows the developVerDate 11-MAY-2000 13:47 Jun 27, 2005 Jkt 000000 PO 00000 Frm 00009 Fmt 6633 Sfmt 6633 96224.SEN SFORELA1 PsN: SFORELA1
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ment of resistance. In fact, a fair amount of the change in trends

of malaria that you showed is due to increasing resistance and the

fact that we had single drug regimen in the past.

The World Health Organization and Roll Back Malaria, including

USAID, now recommend that all countries experiencing resistance

should move from a first-line single therapy to combination therapy, ideally including artemisinin drugs. In fact, USAID is working

in a number of countries to grow more of the plant from which

artemisinin is derived in order to increase the supply of the

artemisinin drugs.

We predict that there will be a need for almost 300 million treatments annually by 2008, and the majority of those drugs are likely

to be needed in Africa. Therefore, it is very important to expand

the production of the artemisinin.

We have also been working with global partners to increase the

pharmaceutical producers to gauge their interest and willingness to

scale up production. We have been working with financial institutions like the World Bank and the Global Fund to see if they are

willing to mobilize sufficient support for financing of ACTs, and we

have worked with the technical agencies to prepare countries for effective application of those resources.

We have been working with 11 of the East Asian countries that

have received the Global Fund awards for malaria to make sure

that the policies and the technical assistance that they need are in

place to retrain the physicians, the health care providers, and the

providers of the drug itself to be ready to move to the new drug

regimens.

Just last week in Nairobi at a Global Fund programming meeting, USAID and HHS provided technical support to 25 recipient

countries, including Pakistan and Indonesia, to pave the way for

ACT introduction, including addressing drug management, policy

reform, and appropriate use.

But we need to remember that even if we get ACTs out to all

of the countries and if everyone uses them properly, malaria

parasites can still grow in patients if we have poor drug quality or

wrong formulations. Unlike in developed countries, poor quality

medicines, either produced intentionally as counterfeits or accidentally because of poor quality control, are readily available on the

open market and often are visually indistinguishable from the genuine product. USAID has been very involved in looking at the drug

quality issue especially for malaria drug products. In one study in

East Asia, 38 percent of artesunate samples from drug shops in

Burma, Cambodia, Laos, Thailand, and Vietnam contained insufficient or no active ingredient. Other studies have detected other

poor quality antimalarials, including chloroquine, mefloquine, and

quinine.

Besides contributing to the drug resistance, which will exacerbate the trends in malaria, poor drug quality is equally dangerous

for the individual patient. In 1999, at least 30 people in Cambodia

died after taking SP, an older and less effective antimalarial drug,

which was sold to them as artesunate. Poor quality drugs sometimes also contain toxic products that can be lethal.

USAID is strengthening national drug regulatory authorities.

The aim is to improve the manufacturing of pharmaceuticals

7

through good manufacturing practices, including drug quality control in national programs. Across the Mekong Delta region, USAID

provides support for 37 sentinel surveillance sites for monitoring

drug resistance. These sites, the national malaria control programs,

and drug regulatory authorities will be linked to create a regional

warning system for poor quality drugs found in the market. USAID

is also working to build similar sentinel surveillance systems in Afghanistan, Bangladesh, Nepal, and India.

Prevention, though, is still the key and use of insecticide at the

household level is the mainstay of prevention. There are two main

ways to administer insecticide treatment at the household level:

Through indoor residual spraying, as you talked about, which was

the centerpiece of the eradication campaign of the fifties and sixties, or through the more recent advent of insecticide-treated nets,

ITNs. For those individuals at risk for malaria, ITNs are still the

most practical and effective means for protecting the largest percentage of populations, and consistent use of ITNs has been shown

to decrease severe malaria by 45 percent, reduce premature births

by 42 percent, and cut all-cause mortality by 17 to 63 percent. In

Cambodia, where malaria was a major problem among rural populations, with strong USAID support, a twin strategy of deploying

ITNs and effective treatment reduced malaria incidence by more

than 70 percent.

USAID does provide free nets and promotes targeting for heavily

subsidized ITNs to the most vulnerable populations, pregnant

women and children under 5, and the poorest populations. Nets can

be deployed now in desperately poor countries where malaria-related deaths are highest and can be put into the hands of parents

who want to protect their children instead on relying on government systems that, as you pointed out, in the past have not taken

care of their populations.

The other way to bring insecticide into play in preventing malaria is through IRS, indoor residual spraying. Contrary to popular

belief, USAID does support the use of DDT in its malaria control

programs. We are fully supportive of careful use of DDT through

indoor spraying of the interior walls. It has a potential role in malaria prevention in some countries in certain circumstances, but a

global one-size-fits-all strategy that requires the use of DDT might

be counterproductive.

Last December, I visited Ethiopia as they were responding to an

unprecedented wave of malaria deaths. USAID was supporting

Save the Children in the provision of both nets and indoor residual

spraying. In the Cambodia example I just mentioned, they chose

and were successful at turning around a malaria upsurge using

bednets plus ACTs.

As we consider the plight of those who face these deadly diseases, we must act rapidly with the most effective methods of treatment and prevention. We must and are responding to this challenge, but I must emphasize that there is no silver bullet, no single

intervention that is the answer to malaria. We must support a

comprehensive approach that includes prevention, effective treatment, and research for better tools.

The session was to talk a little bit about TB, and I will just say

that TB, like malaria, is on the upsurge. It has some of the same

8

problems of old drugs and too little attention for the scope of the

epidemic.

Similarly, when we look at the child survival strategies overall,

malaria is one of the major killers and we have great opportunities

to do more in these areas of international health than we have

been doing. USAID is spending a lot of time trying to prioritize

where the scarce resources that we have can make the most difference for women and children. If we only have the resources before us, what are the biggest priorities? Where can we make the

most difference with the interventions that we have, which are the

most cost effective, and which will save the most lives? Public

health is always about balancing competing goods, and in malaria,

both in treatment and prevention, we have competing interventions, we have competing goods, and it is a balance for each country, for each place, and for each circumstance. It really needs a

comprehensive strategy.

Thank you.

[The prepared statement of Dr. Peterson follows:]

PREPARED STATEMENT OF DR. ANNE PETERSON, ASSISTANT ADMINISTRATOR FOR

GLOBAL HEALTH, U.S. AGENCY FOR INTERNATIONAL DEVELOPMENT, WASHINGTON,

DC

Thank you, for convening this important hearing and for inviting me to testify on

a very deadly disease, malaria.

Malaria affects the health and wealth of nations and individuals alike around the

world. It is not only a disease of poverty but also a disease that causes poverty and

is a major constraint to economic development.

As a public health physician who has worked internationally and domestically for

more than 20 years, I am very pleased at the growing interest and response to the

challenge malaria poses. The international community has mobilized funding and

action recently to develop and implement sustainable actions against malaria. I will

address the burden and suffering caused by malaria with a special focus on East

Asia and outline what USAID is doing to save lives now and in the future.

Malaria

Worldwide, it is estimated that malaria kills more than one million people each

year, making it the world’s third deadliest infectious disease, after AIDS and tuberculosis. But malaria—spread by mosquitoes—is the most common of the three diseases, with more than 500 million persons experiencing acute malaria illness annually, compared with 5.3 million for AIDS and 8.8 million for TB. Each year there

are about 3.6 million confirmed malaria cases and 6,000 malaria deaths in Asia and

the Near East. However, there are probably many more unreported cases and

deaths given that malaria occurs mostly in rural areas where health services and

surveillance are weak. Malaria also accounts for a loss of approximately $12 billion

a year in gross domestic product in Africa alone.

Eighty-five percent of malaria deaths occur in Africa, while about eleven percent

of the deaths occur in Asia and the Near East. In Africa, malaria’s greatest impact

is felt by very young children and pregnant women because of their reduced immunity to the malaria parasite. As many as a quarter of childhood deaths in endemic

areas of Africa are attributable to malaria. But infection of African women during

pregnancy also takes a huge toll, both on the health of the mother as well as on

the development of her unborn child. Placental infection in Africa is a significant

contributor to low birthweight and subsequent neonatal death. In areas of unstable

or epidemic malaria such as Asia, all persons are also at risk of serious illness and

death. The drain on the physical and financial resources of households and communities of the disease, as well as the often ineffective attempts to respond to it, is

well documented.

Scope of USAID Role in Battling Malaria

The United States is and has been a leading force worldwide in the battle against

malaria. USAID has directed and supported critical research that forms the backbone of some of the most effective interventions, including insecticide-treated mosquito nets (ITNs), rapid diagnostics, and drugs. It is also studying ways to identify

9

and deal with increasing drug resistance. Our technical and financial resources are

being brought to bear around the world and leveraged to increase global commitments to reduce illness and death. This year USAID committed over $80 million for

malaria programs—a nearly four-fold increase since 1998 when USAID’s Infectious

Disease Initiative was launched. These new and expanded resources have allowed

for a significant scaling-up of malaria activities to have national level impact and

have led to increased coverage with interventions, better policies and visibly stronger programs. Many countries in Asia are also receiving support for malaria from the

Global Fund to Fight AIDS, TB, and Malaria. I will say more about the Global Fund

later.

Seven countries in Asia receive USAID support for malaria, with a major focus

on limiting the emergence and spread of drug-resistant forms of malaria in the

Mekong subregion of Southeast Asia. These include Afghanistan, Cambodia, India,

Indonesia, Philippines, Nepal and Thailand. Activities supported are determined by

local priorities, resource availability, and complementary activities by other donors

and multinational institutions.

The international efforts to fight malaria are largely coordinated by a global partnership that includes leaders from across Asia, local health institutions, the World

Health Organization (WHO), UNICEF, World Bank, UNDP, multilateral agencies,

the Department of Health and Human Services (HHS), specifically the Centers for

Disease Control and Prevention (CDC), international, national and local NGOs, and

the private sector. USAID is a key partner in the Roll Back Malaria Partnership.

Integrated Flexible Program Approach Saves Most Lives

International experts have identified three priority interventions to reduce deaths

and illness from malaria, each of which is backed by solid evidence of their effectiveness. These three interventions are consistent with USAID’s priority areas for investment in malaria. They are:

1. Provision of prompt and effective treatment with an antimalarial drug

within 24 hours of onset of fever;

2. Prevention of malaria primarily through the use of insecticide-treated mosquito nets (ITNs) by young children, pregnant women, and other high-risk populations; and

3. Provision of intermittent preventive treatment (IPT) for pregnant women

as a part of the standard antenatal services—proper use of which can reduce

overall child deaths by up to 30 percent and significantly reduce sickness in

children and pregnant women [this one is not really a focus in Asia since little

has been documented on malaria in pregnancy].

Other parts of an integrated program—based on appropriate epidemiology and

mosquito characteristics—are:

a. Indoor Residual Spraying and use of insecticides, and

b. Environmental Clean-up to remove mosquito breeding sites.

The three interventions to reduce deaths and illness from malaria are internationally agreed upon and can be adapted to the local context depending on the needs

and priorities.

Improving Treatment With Effective Drugs

Historically, national malaria control programs have relied primarily on

monotherapy with drugs, such as chloroquine, amodiaquine, or sulfadoxinepyrimethamine SP (Fansidar). These are the first-line treatment for Plasmodium

falciparum infections, which are responsible for the vast majority of deaths due to

malaria. However, many of these drugs are no longer useful in Southeast Asia as

well in other parts of the world including Africa because of widespread drug resistance among P. falciparum parasites. Malaria programs in many of the Mekong

countries now use a combination therapy which includes one of the newer

artemisinin-based drugs. In Cambodia, Indonesia, and Thailand, USAID has been

supporting efforts to improve rapid diagnosis and treatment of malaria, particularly

in poor, underserved populations or where the disease is reemerging. Although prohibited from providing assistance to Burma, USAID is providing support to nongovernmental organizations (NGOs) in western Thailand to address malaria and

other priority infectious diseases among Burmese migrants.

USAID Instrumental in Tracking Spread of Resistance—Documenting Need for Better Drugs

Like many infectious diseases such as TB, gonorrhea, and pneumonia, resistance

to antimalarial drugs can develop and spread in areas where these medicines are

not used properly or where their quality is poor. In Southeast Asia, strains of P.

10

falciparum have developed resistance over the past 20 years to multiple antimalarial agents and very few drugs remain effective.

Because of the cross-border nature of the drug-resistant malaria problem and the

need for improved surveillance and disease-control capacity in Southeast Asia,

USAID has been supporting since 1999 a coordinated, regional approach led by the

World Health Organization to monitor drug-resistant malaria in East Asia and,

more recently, in South Asia and limit its spread. The U.S. Centers for Disease Control and Prevention have also been involved in these efforts. As a result of drugresistance data collected with the assistance of USAID and other donors and partners, malaria treatment policies have recently been updated in a number of East

Asian countries including Cambodia and Thailand.

At the country level, USAID is working with national malaria programs to: Improve the diagnosis of P. falciparum; providing effective combination therapies to

vulnerable populations; expanding the use of insecticide-impregnated mosquito nets

to limit transmission of malaria and the need for antimalarial drugs; and monitoring drug resistance, drug-use practices, and drug quality.

Drug Resistant Strains Present Additional Challenges

East Asia and the Pacific include Burma, Cambodia, China, East Timor, Indonesia, Laos, Mongolia, Philippines, Thailand and Vietnam. Populations at risk for

severe disease and death in East Asia include children, pregnant women, people

routinely in contact with forested areas where malaria-transmitting mosquitoes live,

and rural and mobile populations with limited access to health services. While improved access to prompt diagnosis and effective treatment has contributed to a decrease in the number of malaria deaths here over the past decades, the recent emergence and spread of multi-drug-resistant (MDR) malaria threatens to reverse these

gains as treatments become more complicated and costly.

USAID has been instrumental in documenting the extent of the drug-resistance

problem as well as studying the factors—such as poor drug use and poor drug quality—that are contributing to the emergence and spread or resistance. This information is critical for focusing interventions on priority areas in order to preserve the

effectiveness of current antimalarial drugs that are safe and affordable. Only a limited number of alternative drugs are available if the current therapies fail and there

is little economic incentive for new drug discovery and development, given its high

cost and the fact that malaria predominantly affects the world’s poorest nations.

Newer drugs are also likely to be significantly more expensive which can limit people’s access to them, especially in poor, rural communities. If steps are not taken

immediately to address the root causes of drug resistance, these drug combinations

will also lose their effectiveness in the near future.

Identifying Factors Contributing to Drug Resistance

There are two main factors that are driving the emergence of drug-resistant malaria in East Asia and elsewhere. They are: poor use of antimalarial drugs; and use

of poor-quality antimalarial drugs. Both result in under-dosing which can allow malaria parasites to survive and adapt while exposed to sub-lethal amounts of the

medicines. On the issue of poor drug use, health care providers and drug sellers can

contribute to the problem in several ways, including: prescribing/dispensing the

wrong drug when a patient has malaria; and prescribing/dispensing the proper drug,

but in an incorrect dosage. Patients can assist the development of drug resistance

by failing to complete the full drug course when they are ill. This may occur because

they only had enough money to buy a partial treatment or because they stopped

treatment once they started feeling better. Self diagnosis and medication can also

lead to the wrong drug being used and/or the wrong dose. This occurs frequently

as people go to traditional healers and drug sellers first before visiting trained

health providers, especially if the official sources are not always stocked with the

first-line therapy. Since prescriptions are rarely required for obtaining antimalarial

drugs in the private and informal sector, patients have easy access to medicines.

This may be especially common in international border areas where patients are

poor and they may be avoiding the public health care system because they are in

the country illegally or they do not speak the local language.

USAID has been instrumental in documenting the extent of the drug-resistance

problem in the Mekong region, as well as studying the factors—such as poor drug

use and poor drug quality—that are contributing to the emergence and spread or

resistance. This three pronged approach in the Mekong is unique in allowing decision-makers to more broadly understand factors that affect community behaviors

and to monitor their impact on drug resistance. Documentation of changes in drug

resistance, quality and use will enhance the ability of countries to evaluate their national malaria drug policy and to introduce changes from a more informed perspecVerDate 11-MAY-2000 13:47 Jun 27, 2005 Jkt 000000 PO 00000 Frm 00014 Fmt 6633 Sfmt 6621 96224.SEN SFORELA1 PsN: SFORELA1
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tive. This information is critical for focusing interventions on priority areas in order

to preserve the effectiveness of current antimalarial drugs that are safe and affordable. A recent study of antimalarial drug use in western Cambodia revealed that

only 11 percent of people who had malaria were using the recommended first-line

therapy of artesunate+mefloquine, despite efforts by health officials to make the

drug combination widely available through both the public and private sector. Moreover, 41 percent of people receiving treatment for malaria did not take the full

course of the medicine. And 50 percent of people were self-prescribing with medications obtained in the private market.

Even if everyone in East Asia uses antimalarial drugs properly, malaria parasites

can still be exposed to sub-lethal doses of antimalarial medicines if poor quality

drug formulations are used to treat the disease. Unlike in developed countries, poorquality medicines—either produced intentionally as counterfeits or accidentally because of poor quality control—are readily available on the open market and often

visually indistinguishable from the genuine products. In one study in East Asia, 38

percent of ‘‘artesunate’’ samples from drug shops in Burma, Cambodia, Laos, Thailand, and Vietnam contained insufficient or no active ingredient. Other studies have

detected other poor-quality antimalarial drugs, including chloroquine, mefloquine

and quinine. Besides contributing to drug resistance, poor drug quality has real

health implications for the individual patient. In 1999, at least 30 people in Cambodia died after taking SP (an older, less effective antimalarial drug) which was sold

to them as artesunate. Poor-quality drugs can also contain toxic products which can

be lethal if ingested.

Ensuring Drug Quality and Appropriate Drug Use

USAID is strengthening national drug regulatory authorities. The aim is to improve the manufacturing of pharmaceuticals through good manufacturing practices,

including drug quality control in national malaria programs. At 17 sentinel surveillance sites in six countries in Southeast Asia and Africa, the United States Pharmacopeia Program (USP DQI) has trained staff of national malaria programs to collect

and test drugs for quality, using low technology screening methods. Sentinel surveillance sites, national malarial control programs and drug regulatory authorities will

be linked to create regional warning systems for poor quality drugs found in the

market. USP DQI has also provided technical assistance in good manufacturing

practices to selected producers of malaria drugs in Cambodia, Laos, and Vietnam.

At the same time, USAID is also working with the Management Sciences for Health

(MSH) Rational Pharmaceutical Management (RPM) Plus program to identify

household and provider drug management and use problems, and to strengthen the

capacity of local health officials and partners in East Asia to utilize this information

to improve access to high-quality antimalarial drugs in the public and private sectors and to ensure their appropriate use. RPM Plus is also working with WHO and

other partners to develop and implement a standardized methodology for monitoring

the extent of ACT introduction as first line therapy in several Mekong countries.

Mainstreaming Rapid Diagnostics

New community-based approaches to diagnostics, including rapid diagnostics

tests, can help overcome insufficient laboratory capacity or resources so that disease

surveillance information can be rapidly used for action. USAID is working to develop diagnostics tests for both P. falciparum and P. vivax infections and assisting

in mainstreaming their use around the world. In Southeast Asia, artemisinin-based

combination therapies (ACTs) are routinely deployed with rapid diagnostic test kits

so that these newer and more-costly therapies are used only when needed. USAID

has also been supporting the development of quality assurance system to allow

countries in East Asia to verify that their rapid tests are not degrading over time

under normal field conditions.

Combination Therapy Recommended by WHO, Roll Back Malaria and USAID

We know from many infectious diseases that simultaneous use of multiple drugs

instead of a single regimen slows development of resistance. The World Health Organization (WHO) and the Roll Back Malaria partnership (including USAID as one

of the partners) now recommend that all countries experiencing resistance to their

current first-line, single-drug therapy should change to a combination therapy,

ideally including an artemisinin drug. The rationale for using combination therapy

for malaria is similar to that for the treatment of tuberculosis, cancer, and HIV infections. When used alone, antimalarial drugs are more likely to select resistant

parasites. The addition of a rapidly-acting and highly effective second drug, such as

artemisinin or one of its derivatives, greatly reduces the probability of selecting

parasites that are resistant to both drugs. This should prolong their useful therapeutic lifetimes. The WHO and Roll Back Malaria (RBM) recommend several ACT

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options: artemether/lumefantrine (Coartem) or artesunate plus either amodiaquine,

sulfadoxine-pyrimethamine, or mefloquine. USAID has supported the development

and critical research for ACTs.

Over the past year the RBM partnership has developed a comprehensive ‘‘roadmap’’ on how best to ensure access to and effective use of ACTs. The roadmap highlights major milestones and potential barriers towards achieving full access to and

appropriate use of ACTs—and more importantly, establishes a framework for

prioritizing the actions of the RBM partnership.

USAID and our global partners have worked with endemic countries over the past

several months to assess their treatment needs. We are working with pharmaceutical producers to gauge their interest, willingness, and ability to scale-up production of ACT as well as with financial institutions to determine their ability to

mobilize sufficient support for the financing of ACTs. We are also seeking help from

development and technical support agencies to ensure in-country support for effective application of these resources.

We have identified four potential ‘‘bottlenecks’’ or barriers that hinder access to

and effective use of ACTs:

• The capacity of agricultural producers to increase their yields of the plant

Artemisia annua, the source of artemisinin;

• The number and capacity of pharmaceutical industry to produce high quality

ACTs;

• The availability of resources to finance their procurement; and

• The availability of training and capacity to build support in country for widespread and appropriate use.

The identification of these potential bottlenecks in turn has led to an agreement

within the RBM partnership of the key actions needed for their resolution.

Enhancing Production Quality and Capacity

Ensuring high quality and low cost ACTs requires an adequate pool of qualified

ACT producers. Currently, there is only one pharmaceutical company which has

been ‘‘prequalified’’ by WHO as a manufacturer of quality ACTs. USAID in 2004 and

2005 will continue to work with WHO to maximize the number of ‘‘prequalified’’

companies. USAID’s support will target both upgrading the production capacity of

pharmaceutical companies to meet WHO’s standards for prequalification and will

assist the WHO in expediting the evaluation process. USAID and its partners in

Roll Back Malaria are currently working with legitimate local producers in Asia to

assist them in incorporating Good Manufacturing Practices into their drug production facilities. This will help reduce the number of poor-quality antimalarial drugs

available on the market, improve cure rates, and slow the emergence of drug resistance.

Financing ACTs

USAID and RBM partnership is taking a two-pronged strategy: (1) To identify financing over the next 18–24 months for country procurement of ACTs; and (2) to

address the longer-term financing of ACTs. To meet the long-term demand, USAID

has commissioned the Institute of Medicine to convene an expert panel to study options for funding ACTs from 2007 and beyond. This study has just been released

and provides a clear and practical ‘‘roadmap’’ for the long-term financing of ACTs.

While recent public discussions of malaria treatment have largely focused on

which drugs to use, the real challenge to providing effective treatment is in the

‘‘nuts and bolts’’ of delivering these drugs to those in need: Enabling policies must

be in place; logistic and management capabilities need to be upgraded; health workers need to be appropriately trained and supported; and communities and households need to be knowledgeable and cognizant of appropriate services. USAID is

working with partners in the public and private sector in all of these areas to ensure that effective, affordable, and safe antimalarial drugs get to the patients who

need them.

With these and other similar challenges in mind, USAID is bringing the full

weight of its technical and programmatic resources in support of those countries

that have made changes in their policies to ACTs to ensure that they have adequate

support in procurement and management of ACTs, training of health workers in diagnosis and use of ACTs for treatment of malaria, and mobilizing communities and

households. USAID is also presently working with 25 Global Fund recipient countries—11 in East Asia have received GFATM awards for malaria—in preparing detailed plans for the introduction of ACT over the next year.

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Prevention of Malaria

For those individuals at risk from malaria, insecticide treated nets (ITNs) are the

most practical and effective means for protecting the largest percentage of populations. Consistent use of an ITN has been shown to decrease severe malaria by 45

percent, reduce premature births by 42 percent and cut all-cause child mortality by

17–63 percent. In most settings, ITNs are unquestionably the most effective way

that families can protect themselves from malaria.

Free Nets to Those Most in Need

USAID promotes targeting free or heavily subsidized ITNs to the most vulnerable

(pregnant women and children under five years) and poorest populations—thus ensuring economics is not a barrier to net ownership. For example, USAID support

in Indonesia helped the Ministry of Health to respond to malaria outbreaks and distribute 95,000 long-lasting insecticide treated bednets which provided protection for

approximately 500,000 people in high-risk malaria areas of Central Java, and in

Bali, Aceh and Lombok.

New technologies now provide long-lasting nets and treatments that remove the

necessity for retreatment. These technical developments, the product of committed

commercial sector engagement with Roll Back Malaria partners, render ITNs even

more affordable, more easily used, and more effective. ITNs also have an additional

advantage. Studies show some protection of children who live nearby a net, as opposed to IRS where there is no added protection.

DDT

Contrary to popular belief, USAID does support use of DDT in its malaria control

programs. We are supportive of careful use of DDT for malaria control through the

spraying of interior house walls—Indoor Residual Spraying, or (IRS). DDT is only

used for malaria control through this spraying method. The spraying of pesticides

which may include DDT does have a potential role in malaria prevention in some

countries under certain circumstances. A number of other insecticides can also be

used for IRS, and are in many countries when those alternative insecticides are

safer and equally effective. IRS, when efficiently conducted in appropriate settings,

is considered to be as efficacious as ITNs in controlling malaria.

From a purely technical point of view in terms of effective methods of addressing

malaria, USAID and others have not seen IRS as the highest priority component

of malaria programs for many reasons. In many cases, indoor residual spraying of

DDT, or any other insecticide, is not practical, cost-effective and is very difficult to

maintain. IRS requires major infrastructure, including a high level of organization,

geographic coverage, application personnel and financial resources, regardless of

what insecticide is used. To be effective, IRS needs 80 percent community compliance. It is also more expensive in rural or peri-urban than in urban areas.

In most countries in Africa where USAID provides support to malaria control programs, it has been judged more cost-effective and appropriate to put U.S. government funds into other malaria control activities than IRS. However, in countries in

which circumstances support the use of IRS (including DDT) USAID has funded and

supported such malaria control programs.

USAID regulations (22 CFR 216) require an assessment of potential environmental impacts of supporting either the procurement or use of pesticides in any

USAID assisted project, but if the evidence assembled in preparing such an environmental review indicates that DDT is the only effective alternative and it could be

used safely (such as in interior wall spraying undertaken with WHO application

protocols), then that option would be considered. The U.S government is signatory

to the Stockholm Convention on Persistent Organic Pollutants (the POPs treaty),

which specifically allows an exemption for countries to use DDT for public health

use in vector control programs, as long as WHO guidelines are followed and until

a safer and equally effective alternative is found.

The United States voted in favor of this exemption. For example, this exemption

was used to spray DDT and other insecticides in South Africa when certain mosquitoes developed resistance to the major alternative class of insecticides, the synthetic

pyrethroids. Such situations are relatively rare, however, and demonstrate the value

of the provisions of the POPs Treaty, which restrict and document use of DDT, but

provide for its use when appropriate.

Prevention of Malaria in Pregnancy

While preventing malaria in pregnancy is not a major focus of work in Asia, it

is in Africa. Each year, more than 30 million African women become pregnant in

malaria-endemic areas and are at risk for Plasmodium falciparum malaria infection

during pregnancy. Most women live in areas with relatively stable malaria transVerDate 11-MAY-2000 13:47 Jun 27, 2005 Jkt 000000 PO 00000 Frm 00017 Fmt 6633 Sfmt 6621 96224.SEN SFORELA1 PsN: SFORELA1
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mission, where the major impact of infection during pregnancy is related to anemia

in the mother and the presence of parasites in the placenta. The resulting impairment of fetal nutrition contributing to low birth weight (LBW) is a leading cause

of poor infant survival and development in Africa. HIV infection diminishes even

more a pregnant woman’s ability to control P. falciparum infections. The prevalence

and intensity of malaria infection during pregnancy is higher in women who are

HIV-infected. Women with HIV infection are more likely to have symptomatic infections and to have an increased risk for malaria-associated adverse birth outcomes.

WHO has recommended intermittent preventive treatment (IPT) using the antimalarial drug, sulfadoxine-pyrimethamine (SP), as the preferred approach to reduce

the adverse consequences of malaria during pregnancy in areas with stable transmission. Since more than 70 percent of pregnant women in Africa attend antenatal

clinics, IPT provides a highly effective base for programmes through use of safe and

effective antimalarial drugs in treatment doses which can be linked to antenatal

clinic visits. The potential of IPT to attain high levels of program coverage and its

benefit in reducing maternal anemia and LBW makes it a preferred strategy in subSaharan Africa. In HIV-negative pregnant women, two doses of IPT provide adequate protection, but a minimum of three doses appears to be necessary in HIV

positive women. Outside of areas with stable transmission in Africa and in other

regions of the world, while malaria in pregnancy is a risk for both the mother and

fetus, there is no evidence that IPT is worthwhile.

USAID played a key role in supporting the original studies in Africa that documented the efficacy of IPT in preventing the impact of malaria on both HIV positive

and HIV negative pregnant women and their offspring. Many countries have already changed their malaria in pregnancy policies. Currently, through a coalition

of partners, USAID is assisting ministries of health in about 10 African countries

to implement IPT and distribute ITNs as part of a package of health interventions

at the antenatal clinic level. Over the last year this technical assistance has contributed significantly to revision of outdated policies in Senegal, Ghana, Rwanda, and

Zambia and to increased implementation of revised policies in DRC, Tanzania, and

Kenya. Among women attending antenatal services in Tanzania, delivery of intermittent preventive therapy has increased from below 30 percent to over 60 percent.

Expanding Global Network

Multilaterals, bilaterals . . . no one agency can do it all. Roll Back Malaria partners—leaders from across Asia, health institutions, WHO, UNICEF, World Bank, bilateral agencies, international, national and local NGOs, and the private sector are

engaged in the fight against malaria. One ‘‘home-grown’’ partnership in East Asia

is the Asian Collaborative Training Network for Malaria which focuses on training

and information sharing. This organization was created by countries to deal with

common issues related to malaria control. Both USAID and HHS have participated

in the development of training strategies and curriculum development.

Global Fund

Through the Global Fund to Fight AIDS, Tuberculosis, and Malaria, USAID, HHS

and international partners have come together to combine financial, technical, management, and other expertise to reduce the public health impact of malaria. Over

the past three years, the U.S. government has contributed $623 million to the Global Fund, and has appropriated for a FY 2004 contribution of up to $547 million this

year. USAID and HHS are presently working with 25 Global Fund recipient countries—11 in East Asia have received GFATM awards for malaria—some proposals

specifically focus on drug resistant malaria and include efforts to address drug quality and drug management.

We have some of the best malaria experts in the world who have been requested

to be on technical review panels for the Global Fund for malaria and USAID provides in-country technical assistance to assist in the development of Global Fund

proposals. Strategically, there is a rapidly evolving partnership between the Global

Fund and USAID’s malaria program. With USAID providing critical technical ‘‘know

how’’ and the Global Fund providing the resources for the procurement of key commodities for the prevention and control of malaria there is a growing optimism that

malaria endemic countries can soon begin turning the tide against malaria.

Partnerships

These actors are playing unique roles—roles only they can perform due to their

expertise, positions and responsibilities.

Research institutions and pharmaceutical companies can develop improved treatments and interventions to help protect us against malaria and its impacts. USAID

works closely with the HHS, which, with USAID support, provides technical assistance to the World Health Organization and ministries of health in a variety of areas

15

related to malaria diagnosis and treatment, prevention of malaria in pregnancy, use

of insecticide-treated mosquito nets (ITNs), indoor residual spraying (IRS), and monitoring and evaluation of malaria programs. USAID also provides funding to NIH

for work on a malaria vaccine.

Community- and faith-based organizations and other NGOs extend deeply into

many of the most rural areas, reaching societies and cultures to ensure health care

services and malaria treatments and interventions get to hard-to-reach populations.

National governments have especially important roles to play with specific, attainable steps to reducing the impacts of malaria—steps that only they can take. The

international donor community, in partnership with developing country partners,

can ensure that technical and financial resources are allocated where they will be

most effective.

USAID is committed to working with these important partners to turn the tide

against malaria and other infectious diseases.

And with so many new partners, the coordination of our efforts becomes even

more critical. This is as true among the U.S. government agencies as it is among

our international partners, including the new Global Fund. Coordination efforts

must occur at two levels: At headquarters and in the countries we are assisting.

Research

USAID has also targeted the creation of a vaccine for malaria. A vaccine candidate against malaria is currently being tested in Kenya and Mali where the disease disables or kills hundreds of thousands of people each year.

After initial safety trials in the United States, clinical trials jointly supported by

the Gates Foundation, the Malaria Vaccine Initiative began last year in Kenya with

a safety study on some 50 adults.

The tests showed that the vaccine was safe in adults in Kenya, so this year testing was extended to about 50 children aged 1 to 4 years. The National Institute of

Allergy and Infectious Diseases (NIAID), a component of the National Institutes of

Health (NIH), is now working with USAID in testing the vaccine on some 40 adults

in Mali to obtain safety data in a different epidemiological setting.

While ACTs are now effective, we know that won’t last. Research on new and better drugs is absolutely critical and another important part of USAID’s strategy. We

are supporting Medicines for Malaria Venture (MMV) and WHO in new drug development.

Tuberculosis (TB) Background

Tuberculosis (TB) is an ancient disease. While a cure has been available for over

fifty years, TB still kills more than two million people every year. Each day, nearly

25,000 people develop active TB and 5,000 die from their disease. Approximately

one-third of the world’s population or two billion people are infected with TB. According to the 2004 WHO Global Report on TB, in 2002 there were an estimated

8.8 million new cases of TB, of which 3.9 million were sputum smear positive (sputum smear positive TB cases affect the lungs, are the most infectious and therefore

the most responsible for transmission of the disease (SS+) or ‘‘infectious’’ TB). In

2002, the global incidence rate (per capita) of TB was growing at a rate of 1.1 percent per year, and the number of cases was growing at 2.4 percent. Asia leads the

world in terms of burden of TB—of the 22 high burden countries in the world today

(accounting for 80 percent of the world TB cases), 11 are in Asia, including 4 out

of the top 5, (India, China, Indonesia, and Bangladesh).

The global resurgence of TB has been fueled by increasing HIV/AIDS prevalence,

inadequate public health systems, and emerging resistance to anti-TB drugs. Persistent poverty, crowded living conditions, and delayed diagnosis and treatment contribute to transmission of the disease.

TB threatens the poorest and most marginalized groups, disrupts the social fabric

of society, and slows or undermines gains in economic development. An overwhelming 98 percent of the two million annual TB deaths—and 95 percent of the

new TB cases each year—occur in developing countries. On average, TB causes

three to four months of lost work time and lost earnings of 20–30 percent of household income. For families of persons who die from the disease, the impact of TB is

even greater as about 15 years of income is lost due to premature death. In developing countries, the impact of TB on the family is even more important as TB generally afflicts the most economically active segment of the population between the

ages of 15 and 54.

Treating TB Through the Directly Observed Treatment, Short-Course (DOTS)

Much progress has been made since The Stop TB Partnership (of which USAID

is a member) was launched in 1998. The Amsterdam Ministerial Conference on Tuberculosis and Sustainable Development held in March 2000 established global tarVerDate 11-MAY-2000 13:47 Jun 27, 2005 Jkt 000000 PO 00000 Frm 00019 Fmt 6633 Sfmt 6621 96224.SEN SFORELA1 PsN: SFORELA1
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gets of 70 percent TB case detection and 85 percent treatment success rates in SS+

pulmonary TB cases to be achieved by the year 2005 in the 22 High Burden Countries (HBCs). These countries together account for 80 percent of the world’s estimated cases, and served to catalyze governments and donors to address TB.

The Stop TB partners and countries have endorsed The Directly Observed Treatment, Short-Course strategy as the most effective strategy available for the treatment and control of TB. The DOTS Strategy has five components: Political commitment; passive case detection among patients seeking care at health facilities and diagnosis using sputum smear microscopy; standardized short-course treatment with

direct observation of therapy at least in the initial phase; assurance of an uninterrupted supply of high quality drugs.

The number of countries implementing DOTS increased from 112 in 1998 to 180

in 2002 and one high burden country (Peru) reduced TB incidence sufficiently to

graduate from the list of 22 HBCs. The Partnership has grown to include over 200

donors, nongovernmental organizations (NGOs) and other institutions, which demonstrates the strong global commitment to combat TB and to collaboration in that

effort.

However, recent analysis of global TB trends and progress in DOTS implementation indicates that without an acceleration of DOTS expansion and program

strengthening, these global targets will not be achieved for many years to come. Reported global DOTS coverage of 69 percent masks the reality that many people,

even in areas where DOTS is reportedly available, lack true access to DOTS. While

the overall treatment success in DOTS areas is 82 percent (2001 cohort) about 31

percent of the world’s population resides in non-DOTS areas where treatment success averages just 40 percent.

USAID’s Response

USAID currently supports programs to expand and strengthen DOTS in 34 countries worldwide, including eight in Asia—Afghanistan, Bangladesh, Cambodia,

Egypt, India, Indonesia, Pakistan and the Philippines. Illustrative activities supported in these countries include training of health personnel, strengthening of laboratory services and provision of laboratory equipment, development of guidelines

and training materials, and technical assistance to strengthen program planning,

monitoring, evaluation, and supervision.

For example, in India, USAID has been a major supporter of the very successful

national TB program—where DOTS coverage reached 71 percent of the population

by the end of September 2003—774 million people. The death rate among TB patients nationally has dropped to less than 5 percent. In Indonesia, which is another

of USAID’s major TB programs, USAID has provided critical support to the expansion of DOTS in two major provinces, and provided the technical support for the national TB program’s implementation of a Global Fund grant for TB. In the Philippines, USAID is not only providing critical support to the national public sector

TB program, contributing to a 10-percent increase in coverage but has pioneered an

innovative private sector program. This program is designed to ensure that private

sector services follow appropriate regimens and are coordinated with the public sector. This is critically important in a place like the Philippines, where people with

TB symptoms are more likely to seek treatment from private providers than from

the public sector.

USAID’s Technical Leadership

In addition to our direct support for improving TB treatment programs at the

country level, USAID also provides assistance to support DOTS programs worldwide

through several global mechanisms and partners such as the STOP TB Partnership

and the Global TB Drug Facility (GDF). USAID is actively involved in the STOP

TB Partnership—the Agency is a member of the Partnership coordinating board and

USAID technical personnel are members of all STOP TB technical working groups.

The Agency provides funding and technical support to the GDF, and we are the

second largest donor to the GDF. Since it was launched in 2001, the GDF has raised

and committed $39 million for grants for anti-TB drugs. Through the GDF and

USAID’s technical assistance programs countries and NGOs also receive technical

assistance and training to strengthen the management of anti-TB drugs. They can

also purchase anti-TB drugs through the GDF direct procurement mechanism, and

therefore take advantage of the highly competitive pricing and good quality products

that are available through the GDF.

In this respect, the GDF is a perfect partner to the GFATM. Using funding provided by Global Fund grants for TB, countries and organizations can purchase TB

drugs through the GDF direct procurement service.

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Battling Multi-Drug Resistance

USAID is also working to address the problem of multi-drug resistant TB (MDR

TB). We support country surveys to measure the magnitude of TB drug resistance

as part of the on-going WHO/IUATLD Global Project on Anti-TB Drug Resistance

Surveillance. To date, USAID has supported surveys in 15 countries or sites (including 3 provinces in China), with studies in 16 more countries ongoing or planned (including Indonesia and India). We also support an effective response to MDR TB by

funding DOTS Plus for MDR TB pilot projects in a number of countries and settings, focusing on countries with the most serious MDR TB problem such as Russia

(Orel and Ivanovo oblasts), and the Baltics (Latvia, Estonia, and Lithuania), and

Kazakhstan. We provide funding to support the work of the STOP TB Green Light

Committee (GLC). The GLC provides technical assistance and monitoring of DOTS

Plus for MDR TB pilot projects. So far, the GLC has approved DOTS Plus pilot

projects in 11 countries and another 14 applications are under review. DOTS plus

projects that are approved by the GLC are eligible to purchase second-line anti-TB

drugs at lower prices than on the open market. Finally, we support a network of

supra-national reference laboratories that provide the necessary quality control for

anti-TB drug susceptibility testing, and we are supporting training and operations

research in hospital infection control to help reduce the risk of transmission of MDR

TB in clinic or hospital settings.

USAID and Global Fund Support

USAID missions work closely with the Global Fund to Fight AIDS, TB and Malaria (GFATM) by leveraging mission funded programs with the substantial funding

provided by the GFATM. USAID missions participate in the Country Coordinating

Mechanisms, assist with grant proposal writing, and help countries prepare implementation and monitoring and evaluation plans for these grants. Through USAID

technical partners such as the TBCTA and others, USAID missions provide support

for technical assistance, capacity building and monitoring and evaluation to help the

grant-recipient countries to effectively implement and manage GFATM grant-funded

programs and activities. A total of $422 million has been awarded to 21 countries

in the ANE region for TB control.

Investing in Disease Detection and Control

Drug-resistant malaria and tuberculosis are just two examples of the many public

health problems that exist in East Asia. However, the basic approaches just mentioned—including capacity building, partnerships, developing new tools—also apply

to other infectious diseases as well. As you know, East Asia has been in the spotlight over the past few years with outbreaks of new diseases including SARS and

bird flu. While their mortality has been relatively low compared to diseases such

as HIV/AIDS, TB, and malaria, these new diseases have had a major economic impact on trade, tourism, and foreign investment. First-response organizations such as

the World Health Organization and the U.S. HHS have been providing key support

to track these epidemics and identify ways to limit their spread and impact. In addition, USAID’s Office of Foreign Disaster Assistance has provided emergency assistance to affected countries. As part of longer-term development efforts, USAID is also

working to strengthen human and institutional capacity in disease surveillance and

response so that new diseases can be rapidly detected and stopped before they

spread widely.

Next Steps

There is much to do. If we are to meet our goal of halving malaria by 2010, and

of achieving global program targets for TB, all of us, our esteemed partners from

Asian governments, health institutions and our global partners must act together

through the opportunity offered by the Global Fund and through the Roll Back Malaria and Stop TB partnerships at all levels, most importantly in countries, to deliver the tools we have in hand, to develop new tools, and to fulfill the promise of

coordinated and concerted support to countries.

Senator BROWNBACK. Thank you, Dr. Peterson. I will go through

a series of questions, if I can, with you.

Could you put that chart back up that showed the number of

deaths by malaria just over a period of time? Did you get a chance

to look at that or was it up too fast for you? Do those track with

your trend lines? They may not be with the exact numbers, but do

they track with your trend lines? Are we seeing a big increase in

malaria infections and deaths in Africa?

18

Dr. PETERSON. I think those do track. In fact, in accordance with

the worldwide eradication initiative, we truly hoped in the fifties

and sixties that we would be able to eradicate malaria. We made

huge progress, as you show, but the single intervention using one

modality did not work. We were not able to completely eradicate

malaria, and if you do not eradicate it completely, as we are seeing

with polio right now, then it can begin to surge up again. So we

could, and should, expect that if we do not continue to work at a

communicable disease, we will see it come back.

And what has happened is not just whether there has been

spraying with DDT or not or whether it could have been completely

eradicated. We were not successful in the fifties and sixties using

only the insecticide.

Senator BROWNBACK. But you really drove that thing down.

Dr. PETERSON. We did.

Senator BROWNBACK. And let us get the South African chart up

there. You tell me where the analysis is wrong on this. South Africa said, OK, I will agree with you, we will stop using DDT, we will

go with your drug regime. Their deaths and incidence of malaria

skyrocketed. They said, OK, we are backing away from this stuff

and we are going to go back to what we know worked, which is,

we are going to use DDT. We are going to use a particular set of

drugs. A dramatic fall, a dramatic fall. It looks like to me we have

tried this a couple of times. We pretty well do know what the silver

set of bullets are. I mean, there are a couple of them here. They

have got to be used in tandem, and used in tandem, you can drive

those numbers down hard and fast. It just seems like we are not

using the set strategy that we know will work.

Dr. PETERSON. What you will see in South Africa is that they use

two strategies. They used DDT and an effective drug treatment.

And that is really what we are talking about, that you need to use

more than one strategy. The reason we were not successful in the

fifties and sixties is we had a single intervention. What we realize

now is that when we do treatment, we need, whenever we can, to

use more than one drug at a time to stop drug resistance. In fact,

that is where a lot of the upsurge has happened, because we have

had developing drug resistance over the last 20 to 30 years.

The issue is not: DDT or not DDT. It is: What is the most effective way to use insecticide to reach the greatest number of people?

It can be DDT or it can be another insecticide, and it can be

through spraying or it can be through bednets. They both have

their place, and there are different reaches with the different modalities. The important thing is to be able to use the prevention

strategies, the right one for the right place, and the treatment

strategies and bring them both forward together in an integrated

package.

Senator BROWNBACK. OK. Then why are we not doing that?

Dr. PETERSON. We are.

Senator BROWNBACK. Why are these numbers doing this on these

other cases in Africa then? If we are doing it right, why are these

numbers going up?

Dr. PETERSON. South Africa is a country with a small amount of

malaria, mainly in circumscribed areas. It has a lot of funding

itself, and it is using an integrated package. And it has done very

19

nicely with a good push of resources and an integrated package to

take care of a small epidemic.

Other parts of Africa don’t have the infrastructure to do national

level indoor spraying, like South Africa has done, and they have

much larger burdens of malaria in much more impoverished countries. So you are talking about a much greater scope of work in a

country that has less capacity.

So we are doing the right things and we are making a difference.

We have seen in places where we have changed the drug treatment

policy, where we are doing programs for treatment of pregnant

women, that we can bring down the death rates and the impact on

children. We do not have the resources to do programming in all

of the countries at national scale. This is where you will begin to

see a change as USAID funding has gone up in the last 4 years.

That is a very short period of time.

Senator BROWNBACK. Well, it takes a year on this. You saw that

South African program.

Dr. PETERSON. Yes.

Senator BROWNBACK. Let me ask you this very directly on it. You

have got $80 million, is what you have said, in your budget. Does

any of that go for indoor spraying of DDT?

Dr. PETERSON. Yes. We are supporting indoor spraying in five or

six countries.

Senator BROWNBACK. Do you know how many dollars you are

putting into that? And are you providing the money to buy the

DDT? What are you providing?

Dr. PETERSON. Usually, we have been providing the training and

the assistance for the programs to go forward. You have to train

the people. You have got to provide the logistics systems and put

it together with the rest of the program.

Senator BROWNBACK. Is that what you are funding then?

Dr. PETERSON. Yes.

Senator BROWNBACK. So you are not buying DDT.

Dr. PETERSON. To my understanding, we are not buying the

DDT, but we generally work in partnership with the countries and

with our local partners. So the Save the Children Program that I

mentioned in Ethiopia was being funded by USAID, but we did not

actually buy the DDT ourselves. But it did include indoor residual

spraying with DDT. It has included bednets to 50,000 women and

children.

Senator BROWNBACK. Zambian health officials reported to my

staff that they have repeatedly asked USAID for DDT funding for

spraying and repeatedly been refused in that effort.

I do not want this to be a gotcha hearing. What I want to do is

work with you. I look at these numbers and they make me cry because this does not need to be this way. In the world today, if we

were able to drive those numbers like that in the fifties and sixties,

we know how to do this. I want to make sure if we move forward

on this—and I think we will, and we have tried to get some additional funding in this appropriation bill for malaria. It would be

nearly double what you have now—that we are not scared of DDT.

I understand the problem. I come from a farm background. I am

used to using pesticides. I understand both the good and the problem with it.

20

The bednets I can see some usefulness, but also you cannot be

under that net all night long. If you have got to get up and get

around to get something or go to the bathroom, you are out from

under the net. Mosquitoes are still around. I think it can work and

be helpful.

And we are getting complaints that we are not supporting the effective drug strategy, but rather we are supporting cheaper drug

strategies on this. If we could, what is your breakdown of how the $80 million is

being spent? Can you put it in categories for me or do you have

that available to you now?

[The information requested was submitted and has been made

part of the committee’s permanent record.]

Dr. PETERSON. I do not have that available. I can get it for you.

I will say that it includes research in new malaria drugs, research

on vaccines, the surveillance, the assistance in policy change, and

we have been actively moving countries to the new drugs. It includes this partnership with the agricultural sector to grow more

of the new drug so that the supply will be available as we scale

up the programs. It includes the training of people to use new

medicines, to know that they should be integrating it into their

pregnancy programs, and to begin to put malaria programs into

our HIV/AIDS programs. Those are the kinds of things that we are

doing, including moving whole countries from a policy of one drug

to the more effective combination drugs.

As we look at the insecticide, we are not afraid of using the DDT.

But it is very clear that there are places where it works better. If

you are in an urban setting or a peri-urban setting where people

are close together, it is much easier to go from house to house to

house and do the spraying. But in the far rural reaches of any

State in the United States or any country that we are talking

about where people are spread out, then teams going from house

to house, having to revisit houses because people are not home,

takes more time, more money, and more teams to reach them. That

is why having both modalities is so important. When you use the

bednets, they can go out through normal commercial sector routes

like Coca Cola, like flour and sugar go out, and it is available to

the families where they can reach them. If we are relying on government sector infrastructure, it will work better in places where

people live close together in areas where malaria is upsurging,

where you go in for a short-term need.

What we really need to do is have the flexibility to address the

epidemic, as it is changing, and deal with each country’s needs,

which will be different. South Africa is very different than Zambia,

than Uganda, or than Cambodia. And we need to bring all of the

modalities, not limit ourselves to just one.

Senator BROWNBACK. Are you considering in your current funding that you have, purchasing DDT or direct purchases of DDT by

your recipients to distribute it? Are you considering that in your

expenditures right now?

Dr. PETERSON. We certainly can consider it. We also are a major

funder of the Global Fund, and I sit on the Global Fund board. The

moneys are going for malaria in all of these different countries,

which as you pointed out, are purchasing DDT. They are also the

21

major purchasers of the drugs themselves. That is U.S. dollars

leveraging other donors to buy commodities and drugs. And so our

bilateral programs really serve a unique purpose. When I meet

with other donors, often U.S. Government—our bilateral programs

are the only ones still providing technical assistance on policies, on

how to make things happen, on how to get drugs from one place

to another.

Senator BROWNBACK. So you are not considering it. You could,

but you are not currently considering purchasing DDT by USAID

funds.

Dr. PETERSON. We could consider it. I think the role that the

U.S. Government is playing in our bilateral foreign aid programs

is a special role. When we go and help countries get to the right

policies or do the technical assistance——

Senator BROWNBACK. I understand that point. I am really trying

to get to a narrow point here and then to understand why it is that

you are not, when you acknowledge this is an effective strategy. It

is a good strategy. It is part of the strategy, but we are not funding

it. I want the other funds to do that and we are just going to provide technical assistance or bednets. If that is the deal, OK, that

is the deal. I do not agree with it, but I just want to really try to

understand why, when this is such an effective part of the strategy,

we are not funding it.

Dr. PETERSON. Because, I think we have another mechanism that

the United States is participating in, through the Global Fund and

our other partnerships, that is set and ready to buy large amounts

of commodities. What is unique about our bilateral programs that

the other donors are not doing, is the assistance to make those programs work. The Global Fund is a financing institution and it is

buying the commodities. Forty-five percent of what they are buying

is commodities, including malaria treatments and DDT. They are

having trouble making it work without our assistance.

Senator BROWNBACK. I understand that point and I appreciate it.

I want you to know we are receiving complaints about that; that

these countries do not want the sort of things that we are funding;

that I am getting. We can provide you names. Here are people who

are saying, ‘‘look, I do not need another conference. I do not need

another technician. I do not need another contractor. I need these

drugs and this spray.’’ They are willing to do it on their own in

their distribution systems and the way they will go at it.

Obviously, we were able to figure out in the past how you could

get some of this stuff distributed, at least the sprays and some of

the drugs, where we drove this thing down so hard, so fast, in the

fifties and sixties where your distribution problems would have

been infinitely more difficult than those now in more remote areas.

I will look more at here, why we are just providing technical assistance in these areas rather than these items. I will look at it,

and then maybe we need to respond here by saying, OK, then we

need to fund the other programs rather than this one because that

is where we actually get the delivery of the goods that the countries are asking for to actually drive the numbers down. And we

can do that. We can go that route.

Dr. PETERSON. We have not heard these complaints from the

countries. We would be very pleased to hear any specifics that you

22

have. We try and always be responsive to the country’s needs, their

decisions, and the route that they would want to go.

I often get ministers of health or ministries saying, please, would

you just give the government the money or just buy us this. And

when I say, well, does that mean you do not want this group providing this technical assistance to help you with your policies, they

say, oh, no, no, we do want that and you are the only one still providing it for us. So I am happy to respond to specific country issues,

but I often find that when they have to have a choice between what

we are currently providing and something else, what they really

want is both.

Senator BROWNBACK. I would like, if you would, for you to provide to the committee your breakdown of how you are spending the

current allocation of funds.

I appreciated your hitting on tuberculosis. At another time, I

would like to catch you more on other disease issues in developing

countries and get from you your list of top five, top ten. I think we

are hitting pretty hard the HIV/AIDS issue and are starting to be

effective, and we are putting in billions on that. We have really

stepped up. The administration, the President, has pushed this. It

has been a great initiative. So they are really hitting strong.

My focus is to say, OK, what is the next level of issues that are

there that we have not effectively addressed and we have not put

near the focus on and let us start looking at that series of items.

So we would like it if you could provide, when you get back, your

top five or ten. Here are the ones that I am most concerned about

and they do not gather as many headlines.

Do you have on the top of your head on what you focus on your

top three or four that you believe, OK, these are the ones, if you

would give me resources, that I would focus on?

Dr. PETERSON. AIDS, TB, and malaria are sort of the ones that

have captured most of the attention, and we have touched on malaria and a little bit on TB today. But I think the equivalent area

like malaria and TB, where we were making some great progress

and have not done so well in the past, probably because we are focused on these other three diseases, is the child survival package

of interventions. We still have 11 million children who die every

year, and we could prevent probably two-thirds of them. We could

prevent almost 7 million deaths. Malaria is one of the big killers

within that group, but it is also diarrhea, pneumonia, malnutrition,

and the vaccine-preventable diseases. Those are all things that we

are working on but we are not making progress anymore. They are

cheap. We know what works and we just need to do them at scale.

So child survival is an area to balance with AIDS, TB, and malaria

priorities. We talk a lot about HIV/AIDS, but in fact, it is the children who are orphaned by AIDS who are now dying of malnutrition

and pneumonia and malaria because they are the most impoverished with the least access to the services. So that is my number

one area of concern.

And within each country, it is a little different spectrum of what

their needs are for that country. Cambodia is different than Ethiopia, two of the top countries for child survival problems. But that

would be my other one, packaging the priority interventions by

country needs.

23

Senator BROWNBACK. Well, thank you very much. If you have a

chance, I would appreciate it—and I do not know if you can—if you

would stick around to hear, at least, the presentation of the next

two presenters. I think they are pretty thoughtful on this. Hopefully then, we will all be able to work together toward what we can

see as effective strategy. I do appreciate both your public and private service because you have done this before in a private setting,

and I appreciate that and I appreciate your doing it in a public setting.

Dr. PETERSON. Thank you very much.

Senator BROWNBACK. Thank you.

The second panel will be Dr. Donald Roberts and Dr. Robert

Desowitz. Dr. Roberts is a professor of tropical health at the Uniformed Services University for the Health Sciences. He has conducted extensive international research on malaria. He currently

operates an NIH-funded research program focusing on developing

chemicals to replace DDT for preventing the spread of malaria.

Dr. Robert Desowitz is a renowned researcher, lecturer, and professor. He has published numerous books and articles, including

‘‘The Malaria Capers: Tales of Parasites and People.’’ Dr. Desowitz

has held faculty positions at universities around the world, including Singapore and Nigeria. He is currently professor emeritus of

tropical medicines and medical microbiology at the University of

Hawaii, and an adjunct professor of epidemiology at the University

of North Carolina at Chapel Hill.

I am delighted, gentlemen, that both of you could be here to join

us today with your expertise and background. I appreciate your

testimony. Your written statement will be included in the record.

If you would like to summarize, that would be fine. So, whatever

route you would like to take. Dr. Roberts, let us start with you.

STATEMENT OF DR. DONALD ROBERTS, PROFESSOR, DEPARTMENT OF PREVENTIVE MEDICINE AND BIOMETRICS, UNIFORMED SERVICES, UNIVERSITY OF HEALTH SCIENCES, BETHESDA, MD

Dr. ROBERTS. Thank you, Chairman Brownback, for the opportunity to present my views on malaria control today.

Asia does not present us with the worst of malaria control problems, but this does not mean that there are no problems of malaria

control in Asia. As you will see in my written testimony, conditions

in many Asian countries are far worse today than they were decades ago when a systematic approach to indoor spraying of insecticides was used to combat malaria. The return of malaria to the

country of South Korea is symbolic of the reversals that have occurred in the global strategy to control malaria. However, the malaria problem in South Korea is more than symbolic. There were

115,000 cases in North Korea in 2001, and malaria now poses a

risk to our military.

The malaria control community around the world is presently

locked into several different debates on best practices for dealing

with a continuing and, in some areas, a worsening problem of a

very preventable disease, which is the topic of today’s meeting, and

that is malaria. One part of the debate is whether to use insecticide-treated nets as the only preventive measure or to use nets and

24

indoor spraying of small quantities of insecticide on house walls.

Real differences exist between these methods. Nets protect only

those under the nets, whereas indoor spraying protects all within

the household 7/24. The option of using one or the other is an important debate. If the decision is to go with nets alone, then public

funds will continue to be used to pressure countries to abandon

their uses of indoor spraying.

In a larger context, I am surprised that we have this debate at

all. There is no scientific basis for stopping or preventing indoor

spraying. On the contrary, replacing indoor spraying with nets defies a fundamental lesson of preventive medicine. Clearly delineated within the annals of occupational preventive medicine is the

fundamental truth that the least desirable preventive measure for

reducing environmental risk is reliance on personal protective

measures. We have certainly learned this lesson over and over

again in the military. This principle is expressed in the form of patients failing to take a full course of drugs, failure of troops to properly wear uniforms to prevent insect bites, or failure to properly

apply topical repellents, or failure to use their bednets.

It is also a fundamental truth that proper use of nets requires

user compliance. The user must be educated on the proper use and

must then be highly disciplined in proper use night after night. Additionally, the user must be conscientious and follow a routine of

repairing those nets and retreating those nets with insecticides. If

we could be certain that there would be full and proper user compliance, we would still need to determine whether the practice

would truly deliver a meaningful level of disease prevention. Let

me present one single study to illustrate why we should worry

about that specific issue.

A bednet study was conducted in the small and highly malarious

Phan Tien village in southern Vietnam from 1995 to 1999. Case

treatment and net use was supervised and monitored. Malaria was

reduced but rose again in the last year. The investigators stated

that after malaria was reduced, the population lost interest in the

intervention. Basically after 5 years of costly effort, malaria in the

last year had declined only 2 percent from numbers of cases in the

beginning year. While this is not the best that we can expect, it

certainly indicates that in the long term disease prevention can be

very low indeed.

To repeat, the fundamental lessons of occupational preventive

medicine is that use of personal protective measures is the least desirable of methods for reducing environmental risk. The flip side of

this principle is that the most desirable method for reducing environmental risk is to engineer risk out of the human environment.

The use of indoor spraying is absolutely consistent with that fundamental principle of preventive medicine, and let me explain why.

Most cases of malaria are acquired inside houses. Mosquitoes

that aggressively enter and bite indoors transmit the infections. Indoor residual spraying can act to prevent mosquitoes from entering

houses in the first place. If they still enter, then chemical contact

indoors can cause the mosquitoes to exit without biting. If they remain indoors, the chemical can, with longer contact, kill the mosquitoes. In other words, the chemical applied to house walls exerts

25

multiple and sequential actions to prevent indoor transmission of

malaria and other diseases.

These relationships explain why indoor spraying has been so

wonderfully effective in combating malaria and other diseases. I

want to emphasize that lack of effectiveness is not the reason that

the World Health Organization and bilateral and multilateral donors have pressed countries to stop spraying programs. To the contrary, indoor spraying has been and continues to be the most highly effective preventive measure yet discovered for preventing malaria.

WHO, USAID, and others argue that spraying should not be

used because it requires a strong and well-developed public health

infrastructure. I would respond to that assessment by saying that

spraying was used to reduce or eliminate malaria in many countries of the world long before WHO defined the organizational

structures needed for indoor spraying programs. The countries accomplished these great achievements on their own. I can think of

two remarkable examples. One is Guyana and another is Taiwan.

Guyana began experimenting with indoor spraying in 1946. In that

year, the country instituted a national program of spraying and reduced their malaria problems by 99 percent in 3 years, and they

used no therapeutic drugs. Malaria treatments were not part of

that program. Taiwan began a national program in 1952 and had

reduced numbers of cases from 1.2 million cases to 676 in 1956. In

comparison, during the last 20 years, treated nets have been pilot

tested in many, many countries. There is not one result from those

studies that can compare with the performance of indoor spraying

of DDT in Guyana or Taiwan.

The statement was made earlier that countries have failed to

protect their populations, and for that, they need to have training

and encouragement to do so. The fact is that many of these countries have been pressured to stop those programs, and your graph

shows the results of the pressures to change those programs.

To sum up my oral testimony, during the last 24 years, many developing countries have been pressed to stop programs of indoor

spraying due to an environmental ideology that strives for an environmental utopia, an environment free of manmade chemicals. This

ideology is strong and pervasive. It prioritizes scientifically unfounded risk of environmental harm over the basic health needs of

the world’s poorest and most vulnerable people. Countries need the

freedom to return to the use of indoor spraying if they so desire.

Today, due to pressure from WHO and bilateral and multilateral

donors, developing countries really do not have that freedom.

Thank you.

[The prepared statement of Dr. Roberts follows:]

PREPARED STATEMENT BY DONALD R. ROBERTS, PH.D., PROFESSOR, DIVISION OF

TROPICAL PUBLIC HEALTH, DEPARTMENT OF PREVENTIVE MEDICINE AND BIO- METRICS, UNIFORMED SERVICES, UNIVERSITY OF THE HEALTH SCIENCES, BETHESDA,

MD

Thank you Chairman Brownback and members of the Subcommittee on East

Asian and Pacific Affairs for the opportunity to present my views on malaria control.

Asia does not present us with the worst of malaria control problems; but this does

not mean that there are no problems of malaria control in Asia. Conditions in many

Asian countries are far worse today than they were decades ago when insecticides

26

1ProMed Notice ‘‘Malaria Reemerges-Korea,’’ http://www.tmd.ac.jp/med/mzoo/ProMed/

971118.html. Also: Ree, HI. Unstable vivax malaria in Korea. Korean J Parasitology 38(3):119–

138. 2Malaria profile DPR Korea, http://w3.whosea.org/malaria/profile-dprk.htm.

3 Attaran and Maharaj. Ethical debate: doctoring malaria, badly: the global campaign to ban

DDT.BMJ. 2000 Dec 2; 321 (7273):1403–5. 4Seventeenth Report, WHO Expert Committee on Malaria. WHO Tech. Rep. Ser. No. 640

(1979). 5 H. Gilles, D. Warrell, Bruce-Chwatts’ essential malariology. Edward Arnold, Boston (1993).

6 Implementation of the global malaria control strategy. WHO Tech. Rep. Ser. 1993, no. 839

(1993). 7http://www.rbm.who.int/amd2003/amr2003/chl.htm.

8G. Yamey. British Medical Journal: Roll Back Malaria: a failing global health campaign.

8 May 2004: http://www.accessmed-msf.org/prod/publications.asp?scntid=13520041552454

&contenttype=PARA&. 9D. Roberts, et al., DDT, global strategies, and a malaria control crisis in South America.

Emerg. Inf. Dis. 3:297 (1997). Also: Roberts, Manguin, Mouchet. 2000. DDT house spraying and

re-emerging malaria. Lancet 356:330–332. 10Data presented in graphs were extracted from WHO reports: WHO, malaria profile:

http://w3.whosea.org/malaria/pdf/ino.pdf.

were sprayed on house walls to combat malaria. The return of malaria to the countries of North Korea and South Korea is symbolic of the reversals that have occurred.1 However the malaria problem in South Korea is much more than symbolic,

115,000 cases of malaria occurred in North Korea in 2001,2 and malaria along the

demilitarized zone now poses a risk to U.S. military personnel.

Today, the malaria control community around the world is locked into several different debates on best practices for dealing with continuing and, in some areas,

worsening malaria problems.3 One part of the debate is efficacy of different preventive measures, and this debate narrows to the issue of whether to use insecticide

treated nets as the only preventive measure or whether to open the field to both

the use of insecticide treated nets and indoor spraying of small quantities of insecticide on house walls. This is an important debate, because if the decision is to go

with the former approach, then aid agencies will continue to use public funds to

press countries to abandon their uses of indoor spraying to control malaria.

To gain a historical perspective, if we were to look from our 2004 vantage point

back over the history of global strategies to control malaria, we would see a period

of failure followed by a period of great success followed by a period of failure.

The first period covers the years before the mid-1940s. In this era, public health

officials tried many methods of malaria control. Most of these methods failed, and

malaria remained largely unabated. The second period, the era of intensive household spraying programs, came after the mid-1940s. Health officials sprayed small

quantities of DDT on the interior walls of a house, a process known as indoor residual spraying (IRS). To contrast the small quantity on walls with agricultural usage,

the amount used on just ten acres of cotton during a growing season would be sufficient for spraying enough houses to protect 4,500 people. Additionally, agricultural

use puts the chemical directly into the environment and the food chain. When used

in malaria control, the chemical is put only on house walls.

House spraying controlled malaria and even eradicated it in some regions. The period of spraying and its intensive control of malaria lasted for about 33 years, ending in 1979. In 1979, the World Health Organization strategy for malaria control

changed to de-emphasize indoor spraying.4 In 1985 WHO further distanced itself

from indoor spraying in a World Health Assembly resolution (38.24) that directed

countries to decentralize malaria control programs.5 Those changes in global strategies brought most effective spraying programs to an end. Instead of spraying, WHO

and donors like USAID place an emphasis on case treatment, community participation, and integrated vector management.6 This modem strategy for malaria control

has failed.7 Since the startup of the ‘‘Roll Back Malaria’’ initiative in 1985, malaria

rates have actually increased.8

In contrast to the results of WHO’s current malaria control strategy, results with

indoor spraying, and especially spraying with DDT, were spectacular. Almost without exception, when DDT was sprayed on interior house walls, it rapidly brought

malaria rates down or completely eradicated the disease.

Just as the use of DDT in house spraying brought spectacular reductions in malaria, declining use of house spraying brought spectacular increases in malaria.9

Data from countries of the Americas clearly document changes in malaria rates that

coincide with changes in house spraying rates (Figure 1). Data 10 from Asian countries show similar relationships. Figures 2–5 contrast malaria rates in recent years

with the years when DDT was used. The data represent annual parasite indexes

(a population-based index of malaria prevalence) during the period from 1995–99

27

11Data extracted from: PAHO reports ‘‘Status of Malaria In the Americas.’’ Calculations of

numbers of cases derived by standardizing slide positive rates per 1000 population according

to a standardized annual blood examination rate. Standardized rate was calculated as average

for each country during period of 1965 to 1979. Adjustments were made for differences in size

of population across 5 countries. 12Malaria rate by country: http://www.overpopulation.com/faq/health/infectiousldiseases/malaria/asia.html. 13Data presented in graphs were extracted from WHO reports: WHO, malaria profile:

http://w3.whosea.org/malaria/pdf/ino.pdf.

compared with identical data from 1965–69. Differences in rates for the two performance periods are stunning.

Today, out of 30 countries in Asia, Bhutan, Myanmar, and Sri Lanka are the

three most malarious.12 In Bhutan, the malaria burden has grown 17.5-fold since

the period when DDT was sprayed on house walls. For the countries of Myanmar,

Sri Lanka, and India, malaria rates have grown 6.7-, 6.4-, and 807-fold, respectively.

28

14Data presented in graphs were extracted from WHO reports: WHO, malaria profile:

http://w3.whosea.org/malaria/pdf/ino.pdf. 15WHO WPRO. 2000. A Story to be Shared: The Successful Fight Against Malaria in Vietnam. l5pp. 16Malaria rate by country: http://www.overpopulation.com/faq/health/infectiousldiseases/malaria/asia.html.

WHO, however, touts one Asian country as a success story of its modem malaria

control strategy, Vietnam. A WHO report 15 entitled ‘‘A Story to Be Shared: The

Successful Fight Against Malaria in Vietnam’’ recounts the story of this success. The

report describes Vietnam’s transition from a program based on indoor spraying

using DDT to a program of spraying with Icon (a pyrethroid) and treated nets, as

well as changes in strategies of case detection and case treatment. If this is the success story that is the basis for USAID’s and WHO’s current strategies for malaria

control, they need to re-evaluate the lessons this story teaches.

The story begins in 1991, when over a million cases of malaria occurred in Vietnam, and ends in 1999, when the number of cases of malaria dropped to under

400,000. The report’s overview states that the government completely changed the

malaria control strategy in 1991 away from use of DDT, implying that this was a

voluntary change. In fact, I visited Vietnam’s control program in the early 1990s.

Government officials told me that they wanted to use DDT, because it still worked

well in Vietnam, but Vietnam had long ago used most of its DDT stocks. The government had been trying to get DDT for several years. However international agencies and foreign donors refused to help the government make those purchases. Vietnam didn’t choose to switch to another insecticide. It had no choice but to switch.

I have heard this same story of international agencies and donors like USAID blocking use of DDT in country after country, in both Asia and the Americas.

Despite its unwilling switch, Vietnam did have significant reductions in malaria

between 1991–1999, brought about by the use of indoor spraying, effective case

treatment, and the use of treated nets. When indoor spraying is used, malaria cases

drop immediately, which is fortunate as the use of nets grew slowly in Vietnam. The

costs of the program however skyrocketed. In 1991, malaria control cost

US$540,000. From then to 1999, the malaria program cost US$28 million (about

US$3.5 million per year), and it didn’t yield as large a decline in malaria cases as

control programs had in the past. In earlier years when the country carried out

DDT spraying, malaria declined by a factor of 20-fold (2000%) in the north and 4-

fold in the south. In 1999, Vietnam reported 350,000 cases, representing a 2.9-fold

decline from number of cases in 1991. In areas where malaria is brought under control, treated nets are the primary preventive measure. House spraying remains the

primary means of control in remote areas, areas of persistent malaria, and in outbreak areas. Although Vietnam has enjoyed some success, the 350,000 cases in 1999

represents a lot of malaria, making Vietnam the fourth most malarious country in

Asia.16

WHO and others seem to overlook the fact that effectiveness of the Vietnam system seems dependent on the authoritarian rule of a socialist system and its extenVerDate 11-MAY-2000 13:47 Jun 27, 2005 Jkt 000000 PO 00000 Frm 00032 Fmt 6633 Sfmt 6621 96224.SEN SFORELA1 PsN: SFORELA1
29

17World Health Assembly adopted resolution 38.24 in 1985 calling on countries to decentralize

their malaria control programs by moving malaria control into primary health care systems. 18WHO, malaria profile: http://w3.whosea.org/malaria/pdf/ino.pdf. 19G. Yamey. British Medical Journal: Roll Back Malaria: a failing global health campaign.

8 May 2004: http://www.accessmed-msf.org/prod/publications.asp?scntid=13520041552454

&contenttype=PARA&. 20Description of DDT use in Madagascar described on the Malaria Foundation International

website: http://www.malaria.org/DDTEconomist14lXIIl00.html. 21Sharp, et al. (2002), ‘‘Malaria control by residual insecticide spraying in Chingola and

Chililabombwe, Copperbelt Province, Zambia’’ Tropical Medicine and International Health, 7, no.

9:732–36.

sive network of rural communes. The report states that once a year re-treatment

of nets is not adequate and nets must be retreated every 6 months, which requires

an extensive network of trained malaria control workers. Additionally, Vietnam

workers declared in ‘‘final words of wisdom’’ that control requires a strong national

program, one with a dedicated team, a high level of support and a fair amount of

vertically controlled components. Ironically, WHO has worked diligently to eliminate

the vertical components of malaria control programs, going so far as to direct countries to eliminate those infrastructures,17 which Vietnam thinks were so critical to

its success.

It is in fact quite peculiar that WHO and aid agencies such as USAID tout Vietnam’s control effort as such a success story. The program bucks WHO policy in that

house spraying remained a key part of control and the community participation,

which WHO considers such a triumph, was not the result of the spontaneous embrace of the people, but rather directed by a strong centralized, authoritarian government.

Vietnam however is not the only country in Asia to control malaria. Thailand, a

nearby country with similar vectors, environments, and malaria problems, has not

embraced treated nets and community participation to the extent as has Vietnam.

Indoor spraying remains, as it has for decades, the mainstay of Thailand’s preventive measures. In 1999, out of the 30 Asian countries, Thailand was the 11th most

malarious country in Asia; Vietnam was the 4th. Yet even though Thailand has

similar conditions and far lower malaria rates 18 than Vietnam and has consistently

maintained those lower rates for decades (see Figure 6, malaria rates for the comparison periods of 1995–99 and 1965–69), WHO and other aid agencies consider

Vietnam the success story in Asia, not Thailand.

Since the shift in malaria control policies that began in 1979 occurred, malaria

has increased greatly in countries outside Africa (see Figures 1–5). In Africa, which

had been excluded from the malaria eradication campaign of the l950s and 60s,

there is almost no evidence that malaria rates are changing for the better as a result of implementing the WHO program of case treatment, community participation,

integrated vector management, and treated nets, but not indoor spraying.19 On the

other hand, countries in Africa that have gone against WHO doctrine and used indoor spraying, such as Madagascar 20 and Zambia,21 have seen large declines in malaria rates.

30

22 Ranking of countries by malaria mortality: http://www.overpopulation.com/faq/health/infectiousldiseases/malaria/asia.html. 23 Rom, WN. Editor. Environmental and Occupational Medicine, Third Edition. LippincottRaven Publishers, Philadelphia, PA:1753–1755. Also: Olishifaki, JB, Editor-in-Chief. Fundamental of Industrial Hygiene, Second Edition. National Safety Council. Section on Fundamental

Concepts, pages 35–39. 24 Hung, LQ, et al., Control of malaria: a successful experience from Vietnam. Bulletin of the

World Health Organization 2002;80:660–666. 25 Rom, WN. Editor. Environmental and Occupational Medicine, Third Edition. LippincottRaven Publishers, Philadelphia, PA:1753–1755. Also: Olishifaki, JB, Editor-in-Chief. FundaOne fascinating aspect of attempts to implement WHO’s current strategy for malaria control is that countries of Africa are the focal point of these efforts. This is

doubtless due to Africa having the worst malaria problems in the world.22 These

countries were excluded from global eradication efforts and so have had limited experience successfully controlling their malaria problems. In this regard African nations are unlike many countries in the Americas and Asia that enjoyed high levels

of success during the eradication era. Curiously countries that have had more experience with successful malaria control are less likely to adopt the use of treated

nets. The Pan American Health Organization, for example, won’t recommend them

for malaria control in the Americas. Although donors provide generous funds for net

use, nets are only now gaining a foothold in control programs outside Africa. As this

occurs, the countries of Africa, frustrated by their continuing high malaria rates, are

expressing interest in using indoor spraying.

As I stated at the beginning of this testimony, a large part of the debate about

best practices for preventing malaria is whether to use insecticide treated nets as

the only preventive measure or whether to open the field to both the use of insecticide treated nets and the indoor spraying of small quantities of insecticide on house

walls. Frankly, I am surprised that we are having this debate at all. There is no

scientific basis for stopping or preventing indoor spraying of insecticides. On the

contrary, replacing spraying with nets defies a fundamental lesson of preventive

medicine.

Clearly delineated within the annals of occupational preventive medicine is the

fundamental truth that the least desirable preventive measure for reducing environmental risk is reliance on personal protective measures.23 We have certainly learned

this lesson over and over again in the military. This principle is expressed in the

form of patients failing to take a full course of drugs, failure of troops to wear uniforms properly to prevent insects from biting, or failure to properly apply topical

repellents, or failure to use their bednets.

It is a fundamental fact that proper use of nets requires user compliance. The

user must be educated into proper use and must then be highly disciplined in proper use, night after night after night. Additionally, the user must be conscientious

and follow a routine of repairing nets and retreating nets with insecticides. Another

fundamental aspect of personal protective measure is that the measure may not

lower overall environmental risk. For example, placing infants or pregnant women

under treated nets may do little to lower risk for others in the household. For these

reasons, even if we were certain of full user compliance, we would still need to be

certain the practice would truly deliver a meaningful level of disease prevention.

This is an important question, and I will present one single study to illustrate why

we should worry about that specific issue opposed to blanket acceptance of treated

nets as the only approach to malaria prevention.

A bednet study was conducted in the small and highly malarious Phan Tien village in southern Vietnam from 1995 to 1999.24 Case treatment and treated net use

was closely supervised and tightly monitored. Malaria was reduced, but, as stated

by the investigators, ‘‘The number of passive cases [cases coming to the clinic for

diagnosis and treatment] had dropped steadily from year to year (despite an increase in population), but rose again in 1999.’’ The investigators also stated ‘‘After

1997, when malaria incidence had started to decline, the population became less interested in participating.’’ This is a very telling statement that confirms the weakness of methods that require sustained user compliance. My summary of this study

is that at the beginning in 1995 there were 104 cases of falciparum malaria, in the

last year of the study, in 1999, there were 102 cases. So, after five years of costly

effort, there had been a 2 percent drop in falciparum malaria, a difference of 104

cases versus 102.

To iterate, the fundamental lessons of occupational preventive medicine is that

use of personal protective measures is the least desirable of methods for reducing

environmental risk. The flip side of this principle is that the most desirable method

for reducing environmental risk is to engineer risk out of the human environment.25

31

mental of Industrial Hygiene, Second Edition. National Safety Council. Section on Fundamental

Concepts, pages 35–39. 26 Roberts, DR, et al., 2000. A probability model of vector behavior: Effects of DDT repellency,

irritancy and toxicity in malaria control. J. Vector Ecol. 25(l):48–61. 27Giglioli, G. 1951. Eradication of Anopheles darlingi from the inhabited areas of British Guiana by DDT residual spraying. J. National Mal. Soc. 10:142–161. 28Department of Health, Republic of China, Malaria eradication in Taiwan (Department of

Health, Republic of China), p. 183.

The use of indoor spraying is absolutely consistent with that fundamental principle

of preventive medicine. Let me explain why.

Most cases of malaria are acquired inside houses. Mosquitoes that aggressively

enter and bite indoors transmit the infections. Indoor residual spraying can act to

prevent mosquitoes from entering houses in the first place. If they still enter, then

chemical contact indoors may stimulate mosquitoes to exit without biting, or if they

remain indoors, the chemical can, with longer contact, kill the mosquitoes. In other

words, the chemical applied to house walls exerts multiple and sequential actions

to prevent indoor transmission of malaria and other diseases.26

These relationships explain why indoor spraying has been so wonderfully effective

in combating malaria and other diseases. I want to emphasize that lack of effectiveness is not the reason that WHO and bilateral and multilateral donors have pressed

countries to stop indoor spraying. To the contrary, indoor spraying has been and

continues to be the most highly effective measure yet discovered for malaria prevention. WHO, USAID and others argue that indoor spraying should not be used because it requires a strong and well-developed public health infrastructure. This is

a contrived argument that ignores the lessons from the history of malaria control.

House spraying was used to dramatically reduce malaria in many countries of the

world long before WHO defined the organizational structures for malaria eradication

by use of indoor spraying. The countries accomplished those great achievements

largely on their own accord. I can think of two remarkable examples, one is Guyana

and another is Taiwan. Guyana began experimenting with indoor spraying in 1946.

The country quickly instituted a national program of indoor spraying and reduced

malaria by 99 percent within 3 years.27 Taiwan began a national program in 1952

and had reduced numbers of cases from 1.2 million per year to just 676 in 1956.28

These accomplishments predated the beginning of malaria eradication. In comparison, during the last 20 years treated nets have been pilot tested in many countries.

There is not one result that is even remotely comparable with the performance of

indoor spraying in Guyana or Taiwan.

The infrastructure argument against indoor spraying also ignores the fact that

WHO, bilateral, and multilateral agencies have implemented policies and strategies

under a 1985 WHA resolution that have effectively eliminated infrastructures they

claim are needed for indoor spraying. So it is extremely disingenuous to say a method cannot be used because infrastructure does not exist, when those who oppose

using the method are directly responsible for eliminating the needed infrastructures

in the first place.

What I have described in the preceding text and figures is a struggle between

public health science and an environmental ideology. It is an ideology that strives

for an environmental utopia, an environment free of man-made chemicals. The ideology is strong, pervasive and extremely destructive. It prioritizes a scientifically unfounded risk of environmental harm over the basic health needs of the world’s poorest and most vulnerable people. As the driving force behind the modern policies for

malaria control, it ignores the time honored practice of malaria control to use all

available measures to curb the disease, and replaces it instead with partial control

measures adopted because they are apparently more palatable to those living in developed countries. Our national and international bureaucracies put this ideology

over the needs of poor people in developing countries. I, along with many others in

the malaria control community, do not agree with this ideology. This ideology has

created a colossal public health and humanitarian disaster. In particular, we object

to the use of public funds to pressure developing countries to comply with policies

and strategies that increase the risk of disease and death. It is an irrefutable fact

that for over two decades WHO, bilateral and multilateral donors, and other international agencies have been pressing countries to abandon indoor spray programs.

The world has already paid an enormous price in lost life, lost economic vitality, and

lost human welfare as a result of those practices. It is time to stop this flagrant

use of public funds to force compliance with a scientifically fraudulent and immoral

ideology.

32

Senator BROWNBACK. Thank you, Dr. Roberts. I look forward to

questioning.

Dr. Desowitz, thank you for being here and your years of service.

In reading your resume and background, that is quite impressive.

STATEMENT OF DR. ROBERT DESOWITZ, ADJUNCT PROFESSOR OF EPIDEMIOLOGY, SCHOOL OF PUBLIC HEALTH,

UNIVERSITY OF NORTH CAROLINA, CHAPEL HILL, NC

Dr. DESOWITZ. Thank you, Senator Brownback. Welcome to our

magic circle of malariologists. [Laughter.]

I think everything I wanted to say has already been said, but I

will begin with the conventional malariological plea that there is

a carnage every year of 2 million to 3 million children and pregnant women. This is usually followed by ‘‘send more money.’’

I would depart from that in expressing my feeling that for the

last 50 years, no child, no pregnant woman, no transmigrant need

have died of malaria. We disparage the pharmaceutical industry for

not being attentive to Third World needs, but in actual fact we

have had therapeutic drugs that could cure each and every

malarious person, again for the last 50 years, or if you want to look

in the longer perspective, practically for the last 400 years, with

quinine always being the bulwark.

Today, there is present a number of therapies that act quickly,

they act effectively, and they will act against multidrug-resistant

strains of falciparum, the killer malaria. Foremost of those drugs

is Coartem. This is a modern drug that is 2,000 years old, as you

know. It is an extract of Artemisia annua, the sweet wormwood;

China, I think first used for hemorrhoids 2,000 years ago, but it

seems to be better for malaria. [Laughter.]

It is produced extensively in China.

A late-night thought occurred to me that—I think it was in part

of the debate the other night where they were talking about Afghanistan and opium poppy growing—Artemisia would be a marvelous replacement crop for that.

Senator BROWNBACK. There is a good idea.

Dr. DESOWITZ. Actually there is only one drug that is being used

now, and this is a drug put together by Novartis. It is called

Coartem and it is a combination of artemisinin, which acts very

quickly but has a very short half-life, and a drug called

lumefantrine, which is terrific. It sort of mops up the rest of the

parasites. Coartem, as far as I know, is the only one of the combined artemisinin therapeutics that is commercially available and

standardized. It is produced by Novartis.

Now, Novartis is selling Coartem. If you go to your friendly

Swiss drugstore, it is $52. You might get it at your friendly Swiss

Wal-Mart, if there is such a thing, for maybe $30.

At a consultative meeting that I attended last year—I think it

was last year—Novartis was trying to introduce Coartem into Africa. They said we have enough of the drug—in fact, they gave us

these things, ballpoint pens and a little thing as they sell it. It is

a beautiful packaging for the whole therapy. They said, yes, we sell

it for $50, but we will give it to Africa for our manufacturing costs,

which was 90 cents which, to a naive person like myself, was a

33

rather startling insight into the pharmaceutical industry. Where

that is going I am not sure.

In June of this year, I had the privilege and delight to be faculty

at American Fogarty-sponsored, along with the Gates Foundation,

workshop in Tanzania on malaria pregnancy. We had 21 young Africans, a third women, Ph.D.s, physicians, terrific kids, who gave

great hope for Africa, along with one of the great African men himself, Dr. Mutabingwa, as faculty. They have found and declared

that Coartem is the only thing that works. We had been trying to

peddle artemisinin plus amodiaquine, which was sort of a

chloroquine. It has not worked. They are going completely to

Coartem now. West Africans are a little more uncertain about this,

but they are coming around to it as well.

The question is: Can we get Coartem to the Africans? Can we get

Coartem and we diminish the malaria problem in Southeast Asia,

but it is growing and it is terrible. Areas on the Burma—thank

you, Ms. French, for telling me it is still Burma because I never

know how to spell Myanmar—on the Burmese-Thai border. In

Cambodia it is a tremendous problem. They have had outbreaks,

pitiful outbreaks even in India again. Asia is feeling a real brunt

again of malaria. We do not know what is happening in the fertile

crescent called Iraq, but that used to be a terribly malarious area.

Whether USAID directly can buy a drug that is not approved by

FDA I do not know. Whether other arrangements—Novartis have

no desire whatsoever to license this in the United States, but it is

approved by the European Union, their equivalent of FDA.

So, for the moment, with falciparum malaria, I think we have to

go with Coartem. At $1, people object. They say it is too expensive.

It is inconceivable to me that we would allow a child to die for

what would cost us a bottle of aspirin at a discount store.

There are other drugs, malarone, mefloquine, which is losing its

effectiveness, but we do have backup drugs.

Nobody has to die. I put to you, I think we have the money. Everybody decries that there is not enough funds. You put it all together and there is enough funding to save every child if we can

get the drugs to them.

Let me depart from that a bit and let me speak to DDT. The passions are running very, very high once again and always excited

since St. Rachel wrote her book. It has produced some of the most

violent discourse I have ever heard. I will tell you a story about

Alan Ginsburg, which is in the book, going down University King

Street when he had a very drunken evening with us actually saying, I am the bald eagle, when I was trying to describe the effect

of DDT on him.

But it is coming back. We have just had a very productive meeting last month, Don? July. Time passes. From the National Academy of Sciences on DDT, which they now tell me that there is not

going to be any report forthcoming because NAS is beginning to

feel the heat.

I have always been a great advocate of DDT. It is a unique drug.

It is the best thing since sliced bread. It is terrific. There is nothing

like it. My concern is that in our fervor to reintroduce it, we may

overstate the case.

34

Don, who is a card-carrying entomologist, knows more than I do

about it. But I was taught that there are about 50 or 60 anopheline

vectors of malaria and each one of them has characteristics that

are genetically ingrained and they carry their genetic behavior out

like a 2-year-old kid. Some of them will fly indoors, some will bite

indoors, some will bite outdoors. They will have different feeding

preferences.

In the fifties and sixties, when they were formulating the great global eradication of malaria, which we put $800 million into in

1960 dollars, which was neither global nor eradicating, we had

great intelligence at that point. We knew where to use DDT, how

to spray it, and where to spray it. And DDT, as we have seen, particularly used with Coartem—Coartem I might mention also kills

the stage of the malaria parasite which is transmitted through the

mosquitoes. So there is a synergistic effect, and that is why it was

so effective. And it is a unique drug.

But what we are lacking today—again, if I might say sort of a

rye joke of age, but the only thing the global eradication scheme

eradicated was the malariologists. The malaria did fine. And I do

not think we have the intelligence today to be able to pinpoint exactly where and how we must use DDT. I think somehow we must

gain this even if it means—sorry—taking the money from vaccine

researchers.

In this last month or so or 2 months, I have been surprised and

rather amazed by the, again, various strong feelings on the USAID

program. Again, I suggested in my report that what I think is

needed for the general intelligence of where we are going to go and

what we are going to do, is an independent body of people, completely independent, to try to sort out what they are doing, how

they are doing, and what the malaria situation is today. Some of

those people are still around. We could still do it and they are still

independent.

[The prepared statement of Dr. Desowitz follows:]

PREPARED STATEMENT OF ROBERT DESOWITZ, PHD., D.SC., EMERITUS PROFESSOR OF

TROPICAL MEDICINE AND MEDICAL MICROBIOLOGY, UNIVERSITY OF HAWAII; ADJUNCT PROFESSOR OF EPIDEMIOLOGY, UNIVERSITY OF NORTH CAROLINA, CHAPEL

HILL, NC

The manner in which an industrialized nation comes to the assistance of the tropical third world’s health problems is a faithful representation of its economic and

diplomatic policies. It is also a reflection of its moral and ethical values. In turn,

malaria has traditionally been the ‘‘epidemiological metaphor’’ to analyze and assess

donor health programs and strategies. But malaria, especially in its most lethal

guise caused by Plasmodium falciparum is more than a metaphor. It is estimated

to kill between 2 and 3 million each year; young children and pregnant women

being its chief victims. It is a major cause in hyperendemic regions of spontaneous

abortion and low birth weight babies. Billions of tropical and subtropical peoples are

at risk, hundreds of millions are infected. Even in its non-lethal form, caused by

Plasmodium vivax, it is responsible for untold sickness with the debilities of anemia

and recurrent fevers. Populations burdened with malaria suffer from the lethargy

and cognitive defects that inhibit economic, technological and cultural progress.

Our country has had a long, and continuing interest in malaria. First, because

of our epidemiologic history in which from about 1542 to 1942 we have been a ‘‘tropical’’ country with entrenched ‘‘tropical diseases.’’ Malaria, which in my 1995 Gorgas

Memorial Lecture at the National Institutes of Health I characterized as being ‘‘as

American as the heart attack,’’ was entrenched in a vast zone between Florida and

New York. Second, malaria has been a major factor in the prosecution of our tropical wars with, for example, as many troops in Vietnam being disabled from combat

by malaria as by the wounds of war. The military has responded since the 1940s

35

through their medical research establishments at home and abroad which continue

to be highly productive. The Army, at Walter Reed Army Institute of Research with

its satellite laboratories in endemic sites such as Thailand, Kenya, and Malaysia.

The Navy at its Medical Research Center in Bethesda and satellite units in Egypt

and Indonesia. I would particularly note the military’s contributions to medical entomology and discoveries of new antimalarial therapies.

In the civilian research arena the National Institutes of Health’s Malaria and

Parasitic Diseases Laboratories are internationally renowned for their basic research on the malaria parasites. There has also been a long and large body of federally funded research coming from universities and institutions. The Center for Diseases Control have continuing activities in malaria, their great strength being epidemiological and operational studies in endemic settings. There have also been American organizations to promote the public understanding of malaria and facilitate

interchange of ideas and knowledge between malaria researchers throughout the

world. The Malaria Foundation International, based in Atlanta with its founder Dr.

Mary Galinski of Emory University at the helm is the most notable organization

and has the great potential ability to be a non-biased, non-government instrument

to organize working parties for strategy sessions. More recently the Bill Gates Foundation is funding malaria projects with a generosity reminiscent of the Rockefeller

Sanitary Commission and Foundation of the early 20th century.

Our government has also had a long history of contributing to international malaria endeavors. There is the $800 million, in 1960–1970 dollars, we gave to the

World Health Organization for their Global Eradication of Malaria program—that

was neither global nor eradicating. The international malaria activities of our own

Agency for International Development is now, quite properly, under scrutiny by this

and other congressional committees. It is estimated that the USAID annual budget

for malaria is $85 million. In addition, since 1972 when USAID embarked on their

malaria vaccine project I estimate a further $250 million has been spent. The

project has produced 5 convictions for criminal felonies but no vaccine.

It is the inherent nature of the scientific establishment to complain that there is

never enough money to make the progress they envision to bestow the benefits of

research on suffering humanity. Malariologists, basic ‘‘molecular’’ laboratory-based

researchers and applied ‘‘field hands’’ alike are given to much hand wringing and

in supplicating for more funding invariably citing the 2–3 million annual malaria

death rate. From my now comfortable position of retirement—free at last from grant

writing, I would offer the, no doubt challengeable, opinion that the total monies,

from American and international sources are adequate to bring the malaria carnage

to an end. That malaria is an eminently treatable disease and no child, born and

unborn, no pregnant woman, no non-immune adult transmigrant need suffer or die

of malaria.

1. Prevention, let alone eradication, is problematic. There are the means to reduce

transmission, notably DDT and insecticide-treated bednets which I will speak to

later. Priority should be to furnish and deploy appropriate, effective antimalarial

chemotherapy in the endemic areas of South/SE Asia (as well as in Africa and other

regions such as Melanesia).

The cheap, former sheet-anchor of antimalarial therapy and prophylaxis,

chloroquine, is now virtually useless, because of parasite multi-drug-resistant

strains of Plasmodium falciparum and to a growing extent against Plasmodium

vivax. Furnishing of chloroquine by donor agencies is useless—and dangerous.

Childhood mortality can rise as much as eleven-fold when it is not replaced. Until

recently the Global Fund on the advice of the WHO representatives in Africa (and

elsewhere?) were still buying chloroquine to distribute to the health services of subSaharan nations. The overall and nation-specific antimalarial drug policy(s), if any,

of USAID must be scrutinized by unaffiliated experts as expeditiously as possible.

The antimalarial of choice is the artemisinin combined therapeutic (ACT) Coartem

(artemisinin+lumefantrine) which rapidly resolves parasitemia and fever in severe,

multi-drug-resistant falciparum malaria. It also has the unique property of acting

against the gametocytes (the stages responsible for transmission through the

Anopheles mosquitoes) and thus has a useful transmission-lowering action, especially when used in conjunction with DDT spraying. Most sub-Saharan African nations have now designated Coartem as the antimalarial of national policy and its

purchase is being funded by the Global Fund and other donor agencies. Coartem is

also being used, to an increasing degree, in SE Asia, especially in the hyperendemic

areas of the Thai-Myanmar border, Cambodia, Vietnam and Laos. It is essential

that USAID adhere to and support these national policies for Coartem’s use in the

36

1 Coartem is the only ACT formulation that is produced commercially. It is an approved drug

in Europe but Novartis has no intention of seeking FDA approval in the United States (can

USAID directly or indirectly purchase a FDA unapproved drug for overseas distribution?). The

Coartem treatment pack of 24 tablets sells for $30 to $50 in Europe; however at the 2003 consultative meeting, which I attended, called by Novartis, the company declared that as a responsible global industrial citizen they would sell it to Africa at their manufacturing cost—$1.

treatment of falciparum malaria.1 Recent work by Dr. Francois Nosten and his colleagues on treating pregnant women in the unstable situation on the Thai-Burma

border indicates that Coartem is safe when used to treat malaria of pregnancy.

Coartem is relatively expensive but the day of the 10 cents chloroquine treatment

is over—gone! finished!—and I believe no American would deny a child to his or her

life for what would be the cost a bottle of aspirin.

2. DDT has once again returned to become once again a contentious issue as an

anti-malarial strategy. A product of World War II research (in Switzerland) it remains the unique insecticide by virtue of its long residual (up to 6 months) activity,

its safety for humans, and its dirt-cheapness.

There is now a coterie of American scientists and science journalists who are vigorously advocating—demanding—that DDT be returned to the antimalarial armamentarium. Indeed, countries such as Ethiopia and South Africa have effectively deployed DDT to combat recent malaria epidemics. Several months ago the National

Academy of Sciences/Institute of Medicine convened a meeting to reconsider the introduction of DDT. A report of the meeting has not been forthcoming and may never

be forthcoming as the NAS feels the heat from the ‘‘Silent Springers.’’ At that meeting I voiced my belief that DDT is incomparably useful—where it is useful. And I

voiced my concern that the new combative passion for DDT may unrealistically

overstate the case. An axiom of malaria control is that each of the 50, or so, Anopheles species that are malaria vectors has genetically determined characteristics (biting preferences, breeding-water preferences, post-feeding behaviors, insecticide

resistence) that make it a target or non-target for attack by DDT. A wry ‘‘in’’ joke

amongst the surviving ‘‘field hands’’ malariologists is that the only thing the WHO

global malaria eradication program eradicated was the malariologists. A real problem, as I see it, is that we do not have the contemporary epidemiological/entomological intelligence from this absent/diminished expertise to formulate region-specific

logical strategies for malaria control.

3. Insecticide treated nets (ITNs) are a favorite antimalarial strategy of donors.

They are easy to buy, easy to distribute (for free). Pilot studies have resulted in a

30 percent reduction in malaria-caused mortality. Other pilot studies have shown

little or no effect and a few studies, mortality has actually risen. Going against convention I would give ITNs lower priority for funding if it competes with

chemotherapeutic needs.

4. Again, contrary to fashionable molecular frontier malariology I offer my opinion

that the much heralded malaria vaccine is a goal, an illusion, that has not been realized and may never be realized in combating the disease at a population level.

Research on the vaccine has been pursued for over 70 years with increasing intensification of the effort during the past 30 years. Hundreds of millions of dollars, the

energies and resources of some of our best scientific minds have been, and are, devoted to vaccine research. It would be appropriate to now reexamine the overall malaria vaccine programs and determine whether some of those resources, intellectual

and financial, should be redirected to applied malariology.

Some recommendations for the committee’s consideration:

1. We urgently need an independent American panel of experienced malaria experts who can speak with authority to authority (this committee?).

2. The panel should have a relatively long term working life, probably over several

years and be funded for their various investigatory and administrative needs. There

was such an assemblage in the early 1970s, the Effect of Herbicides in Vietnam

Committee (in which I headed the epidemiological investigations) under the administration of the National Academies of Sciences and funded by Congress that worked

very well. The malaria panel could similarly be organized by, and work under NAS,

possibly in collaboration with the Malaria Foundation.

3. The panel should critically examine American malaria programs and American

programs that interface with international programs such as the WHO Roll Back

Malaria. This is especially true in respect of USAID’s malaria, funding, policies and

activities. The panel would therefore need authority to speak with USAID personnel

within the United States and at their overseas postings, and have access to their

records (much in the manner that the herbicide committee had in respect to military

personnel and their spraying records).

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4. The current lack of good malaria-entomological intelligence should be addressed

by the panel and have the funding to act on this. The appropriate experts of the

panel (and the experts they would need to co-opt) should be able to obtain countryby-country inventory on vectors, their behaviors, and suitability for attack by DDT

as well as the suitability of ITN distribution.

5. USAID should carefully consider, if not be obliged to follow, the expert panel’s

finding and decisions—especially in respect of chemotherapeutic and DDT deployments. There should be a reevaluation of United States obligations and interactions

with international bodies, notably the WHO, on the basis of the panel’s findings.

6. The guiding principle of America’s malaria activities should be to save lives as

expeditiously as possible—to drug malaria into submission, to end the carnage of

the young and pregnant in the malaria regions.

Senator BROWNBACK. Dr. Desowitz, let me make sure I understand this point. You are talking about, I guess, a global malaria

survey. Am I understanding you correctly?

Dr. DESOWITZ. Yes.

Senator BROWNBACK. Of both cases and vectors.

Dr. DESOWITZ. Cases and vectors. We must know where the cases

are, what they are responding to, what the vectors are, and as we

knew in the fifties, what their behavior is. Are they still DDT-resistant? It may be foolish to spray in some areas. I do not know.

I do not think anybody else does now. We did 50 years ago, but we

do not now.

Senator BROWNBACK. Why did we know it 50 years ago and we

do not know it now?

Dr. DESOWITZ. We went at this like gangbusters, sir. In 1955

when they were beginning the global eradication scheme, there

were extremely well-trained entomologists and malariologists. The

whole idea, then, was to carefully evaluate all the vectors and to

carefully evaluate the epidemiology. They did not always act on

that knowledge because it became very politicized, but it was there.

If we had that knowledge today, I think we would be in a much

better position and we would not have to be arguing with each

other as well.

Senator BROWNBACK. Dr. Roberts, what do you think of the survey? Do you believe we need that today?

Dr. ROBERTS. I do believe we need more medical intelligence on

a variety of issues in this regard. I think, for example, we do not

have a really good handle on how bednets, for example, actually

work and how the different insecticides in these bednets actually

work. But if we had a good handle on that and we had good intelligence on vectors and vector behaviors and vector susceptibilities

to insecticides in various regions, it would certainly be beneficial.

However, I do believe we have the tools.

I would also like to emphasize that we are not really talking

about going back to the silver bullet days of just DDT. The struggle

is not that. The struggle is to be able to use it at all. I think if we

could use all of the tools that we have available today, they will

work in one configuration or another in practically any place in the

world. That is just my opinion.

Senator BROWNBACK. Dr. Desowitz, you made a very bold statement that there is no child, no woman, no person in this world that

should have died of malaria over the past—did you say 50 years?

Dr. DESOWITZ. Yes.

Senator BROWNBACK. That must make you terribly frustrated to

see these numbers go up then. I mean, if you are saying that 50

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years ago nobody should have died—we are in 2004 and you still

have a million annual deaths from malaria.

Dr. DESOWITZ. Yes. The simple fact is that each and every case

of malaria, if you got to it in time or you had proper medical administration, is and was treatable. If you did not get the drugs, if

you faked the drugs, if you sold the drugs, if you purloined the

drugs, or if you did not have the administrative infrastructure to

get the drugs to the people, that is another thing again. But the

drugs were there. Malaria was always treatable.

Senator BROWNBACK. Dr. Roberts, I have received reports from

individuals, not just on DDT, saying that the U.S. Government is

pushing some ineffective drugs. Not that they are counterfeit or

poorly made drugs, but they are just ineffective drug regimes that

we are supporting. Have you heard that? Is there any accuracy to

these reports?

Dr. ROBERTS. I have heard that. I think there is some documentation for that. I believe there was an article published in the

Lancet not too long ago that would document that that indeed is

occurring. But to be honest with you, sir, I am not an expert in the

area of drugs for malaria control.

Senator BROWNBACK. Dr. Desowitz, have you heard this charge?

Dr. DESOWITZ. I have correspondence from many parts of the

world on this. And I do not know. I do not know whether it is true

or not true.

Senator BROWNBACK. Are there ineffective drug regimes out

there that are being pushed by governmental entities?

Dr. DESOWITZ. Up until a year ago, they were still pushing

chloroquine. It was a kind of a chloroquine addiction. They were

killing people with this. Who was buying it? Certainly WHO was

pushing it. The Fansidar kind of combination was being used and

it again was useless in many places. But the Global Fund, as I understand it, was buying it.

Now, I think, they have seen the justice in it and they are going

to the artemisinin combinations. Whether they are going to the

only effective one I do not know, and I do not know whether

Novartis will be selling it to Asian governments with the same concessionary price. I do not know.

Senator BROWNBACK. Dr. Peterson, you have been very kind to

stay through this, and I appreciate that. May I invite you back up

to the table? Is there any response you would care to give to these

two expert witnesses? I would like to give you that chance so that

we have your response to some of the input from these experts, as

we try to formulate the right answers and the sort of policy issues

to put forward.

Dr. PETERSON. Thank you very much, Senator. I appreciate the

chance to respond.

First, let me say, I think they are both correct that during the

eradication effort of the fifties and sixties, the thing that died was

the malaria expertise. We do not have the entomologists and the

malariologists that we used to have when there was such a huge

push, when it was really the single, big public health endeavor that

was happening at that time.

We have been tracking the drug resistance in doing the surveillance for where drugs are working and where they are not working.

39

That is a lot of what you will see, when we do the breakdown, that

we have been spending our money to be able to track how fast it

is moving, where, and which are the priority countries to try and

get the artemisinin drugs into.

We have good entomologists and good malaria folks at CDC, but

there are few. I have worked in that branch at CDC, but there is

not a lot there. I did a little consultation, and my understanding

is that we probably do not have the world mapped out to the extent

that we did in the fifties or sixties as far as the mosquito vectors,

which ones are still transmitting malaria of all of the different

kinds, which ones are still resistant to DDT, and which ones are

not resistant. So there are some holes that could be fixed and some

expertise that we need to have.

On the drugs, we are moving to the combination therapy, and together with the surveillance work, we have been pushing very hard

for moving countries. We have actively helped specific countries, as

they have shown that they have got significant resistance, to be

some of the first ones to move to the combination therapy.

I am not sure if Coartem, the Novartis product, is the only effective one. That is probably something we need to look at. We are

sure that we need to be working and bringing countries to combination therapies and that one of the combinations should probably be the artemisinin.

It is wonderful that Novartis is willing to provide for Africa, but

it always better if you have multiple providers. Right now, China

is the only place that is growing the artemisinin, and Novartis is

really the sole provider of the Coartem.

What we would like to do is to broaden that. I do not know if

it has been tried in Afghanistan. I have seen and been in the poppy

fields myself, and we would love to see them growing something

different, I promise.

We have been working in Tanzania and in Ethiopia so that Africa can begin to grow the drug that is needed for its own malaria.

That would bring income to Africa and then they would have the

solution to their malaria problem in their own countries. So that

is part of what we have been trying to move forward so that there

will be an adequate supply of the drug as we expand the capability

of responding with the combination therapies.

Senator BROWNBACK. Dr. Peterson, what about Dr. Roberts’ comment about the Vietnamese study on bednets? When you were presenting—or was it you or Dr. Desowitz—the 5-year study that

showed that at the end of the 5 years you did not have any significant difference in malaria infections. In my experience I have run

a little agency that supervised insecticides in the State of Kansas.

I had entomologists working in the agency. Just the idea that you

are going to be surrounded by mosquitoes and if you stay under the

bednets, you will be all right, and if you get out you are not, seems

like a really crazy strategy to me. What if, in the middle of the

night, you have to do something. You are not going to take the

bednet with you and in that system you would subject yourself to

exposure to the mosquitoes. This does not seem to me that this system works over a period of time. Yet, it is where we are putting,

it appears, most of our effort.

40

Dr. PETERSON. We are putting a fair amount of effort there. We

do have studies that show that they do work. In fact, with the malaria bednets, you do not even have to get as high a community

coverage as you do for indoor residual spraying. If you do community spraying with the indoor residual spraying, in order to get collateral benefit, you have to cover 80 percent of the homes in that

community. With bednets, if you have them in a community—and

we have got studies that have shown this—you not only protect the

person who is under the bednet, you begin to protect others in the

household who are——

Senator BROWNBACK. How?

Dr. PETERSON. Because it does kill the mosquitoes that land on

the net. It is some of the same kind of things that he talked about

for indoor residual spraying, but you have to get a higher coverage

in the community with the indoor residual spraying.

The doctor talked about the——

Senator BROWNBACK. Dr. Roberts, respond to that, would you

please?

Dr. ROBERTS. Actually, I do not agree with that assessment at

all. It really comes down to some very basic relationships. If a

house is sprayed, the residents of that house are protected. If an

individual is inside of a bednet, that individual inside the bednet

is protected. For the bednets, we use pyrethroids. For indoor residual spraying, we have in the past, at least, used DDT. DDT is the

most potent spatial repellent we have yet tested.

The pyrethroids exert no spatial repellent action. They are powerful contact irritants and they are potent toxins, but they exert no

spatial repellency action at all. And that separates them from DDT.

If you sprayed a house wall with the pyrethroid, the mosquitoes

will enter. We know that. We have tested it in the field. We have

tested it in the laboratory. When the mosquitoes enter the house,

they will bite. The pyrethroid is a powerful locomotor stimulant,

and so in some cases, it could even increase the biting because they

are agitated. They are highly agitated. With DDT, they will not

enter the house.

So there are major, major differences between modes of action of

these chemicals. And, of course, as you commented on, there are

differences in the way they are being used.

Senator BROWNBACK. Plus, it just seemed to me that instead of

having individual protection, you try to expand your sphere so that

people within the sphere are protected—that seems to make a lot

of sense to me.

Dr. PETERSON. I agree it does make sense, and in fact, that is

part of what we have seen with the bednets. They are a protection

also for people who are not covered by the bednets. We can get the

studies for you.

[The information requested was submitted and has been made

part of the committee’s permanent record.]

In outbreak situations, there have been a number of times when

we have provided both strategies in a household, both the spraying

of the walls and the bednets around the individual person, and that

combination is very effective.

Senator BROWNBACK. And that is great. Let us keep going that

way.

41

Dr. PETERSON. I think that is my major point, that we have two

modalities that provide protection. We need to try and use both.

Senator BROWNBACK. That is my major point. I see you funding

one, but not the other.

Dr. PETERSON. We are both providing bednets and trying to build

the capacity of the local systems themselves to produce and to distribute the bednets.

Senator BROWNBACK. OK, not spraying or using DDT.

Dr. PETERSON. We are equivalently encouraging the systems to

provide the DDT as well.

Senator BROWNBACK. I do not understand the hesitancy to use

DDT other than the really strong philosophy and difficulty you

might encounter from some people on the use of DDT. I understand

that, I understand that completely. But I do not understand why

there would be any hesitancy to using or supplying DDT other

than, I understand, a strong pushback from the environmental

community or others that do not like DDT. I do not like it at all.

I have seen that war and I understand that philosophical position

and I respect it, but as somebody who is trying to pay for treatments, I do not understand why you would not be using DDT.

Dr. PETERSON. We have no opposition, and in fact, through the

Global Fund and other moneys, we are supporting it and we are

supporting programs that have incorporated it.

I think, again, there are rural areas where it is going to be harder to reach, and the doctor talked about the compliance, the staying

under the bednet. We have equivalent situations with people willing to have their homes sprayed with insecticides, but not liking

the color that it changes it and repainting it. We have compliance

issues in all of these areas, and therefore, we need to have both

available in the places where it is most appropriate.

Senator BROWNBACK. I agree with that.

Thank you. Thank you, gentlemen, for being here, for your years

of work and expertise and effort. I look forward to the day when

that number starts going way down. Maybe we do not get to zero

soon, but we really start to drive those numbers down hard and

fast. I do think it is within our capacity to do it. Thank you all for

being here.

The hearing is adjourned.

[Whereupon, at 4:05 p.m., the subcommittee was adjourned.]