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26–748 PDF 2006

S. Hrg. 109–614

BILATERAL MALARIA ASSISTANCE: PROGRESS AND

PROGNOSIS

HEARING

BEFORE THE

FEDERAL FINANCIAL MANAGEMENT, GOVERNMENT 

INFORMATION, AND INTERNATIONAL 

SECURITY SUBCOMMITTEE

OF THE

COMMITTEE ON 

HOMELAND SECURITY AND 

GOVERNMENTAL AFFAIRS 

UNITED STATES SENATE

ONE HUNDRED NINTH CONGRESS

SECOND SESSION

JANUARY 19, 2006

Printed for the use of the Committee on Homeland Security 

and Governmental Affairs

(

(II)

COMMITTEE ON HOMELAND SECURITY AND GOVERNMENTAL AFFAIRS 

SUSAN M. COLLINS, Maine, Chairman 

TED STEVENS, Alaska 

GEORGE V. VOINOVICH, Ohio 

NORM COLEMAN, Minnesota 

TOM COBURN, Oklahoma 

LINCOLN D. CHAFEE, Rhode Island 

ROBERT F. BENNETT, Utah 

PETE V. DOMENICI, New Mexico 

JOHN W. WARNER, Virginia 

JOSEPH I. LIEBERMAN, Connecticut 

CARL LEVIN, Michigan 

DANIEL K. AKAKA, Hawaii 

THOMAS R. CARPER, Delaware 

MARK DAYTON, Minnesota 

FRANK LAUTENBERG, New Jersey 

MARK PRYOR, Arkansas

MICHAEL D. BOPP, Staff Director and Chief Counsel 

JOYCE A. RECHTSCHAFFEN, Minority Staff Director and Chief Counsel 

TRINA DRIESSNACK TYRER, Chief Clerk 

FEDERAL FINANCIAL MANAGEMENT, GOVERNMENT INFORMATION, AND 

INTERNATIONAL SECURITY SUBCOMMITTEE 

TOM COBURN, Oklahoma, Chairman 

TED STEVENS, Alaska 

GEORGE V. VOINOVICH, Ohio 

LINCOLN D. CHAFEE, Rhode Island 

ROBERT F. BENNETT, Utah 

PETE V. DOMENICI, New Mexico 

JOHN W. WARNER, Virginia 

THOMAS CARPER, Delaware 

CARL LEVIN, Michigan 

DANIEL K. AKAKA, Hawaii 

MARK DAYTON, Minnesota 

FRANK LAUTENBERG, New Jersey

KATY FRENCH, Staff Director 

SHEILA MURPHY, Minority Staff Director 

JOHN KILVINGTON, Minority Deputy Staff Director 

LIZ SCRANTON, Chief Clerk 

(III)

C O N T E N T S 

Opening statements: Page 

Senator Coburn ................................................................................................. 1

Senator Carper ................................................................................................. 18

WITNESSES 

THURSDAY, JANUARY 19, 2006

Michael Miller, Deputy Assistant Administrator for Global Health, U.S. Agency for International Development ....................................................................... 7

Simon Kunene, Malaria Program Manager, Swaziland Ministry of Health ...... 24

Donald R. Roberts, Ph.D., Professor, Division of Tropical Public Health, Department of Preventive Medicine and Biometrics, Uniformed Services University of Health Sciences, Bethesda, Maryland ............................................... 26

Andy Arata, Vector Control Specialist ................................................................... 27

ALPHABETICAL LIST OF WITNESSES

Arata, Andy: 

Testimony .......................................................................................................... 27

Prepared statement .......................................................................................... 63

Kunene, Simon: 

Testimony .......................................................................................................... 24

Prepared statement .......................................................................................... 38

Miller, Michael: 

Testimony .......................................................................................................... 7

Prepared statement .......................................................................................... 35

Roberts, Donald R., Ph.D.: 

Testimony .......................................................................................................... 26

Prepared statement with an attachment ....................................................... 48

APPENDIX 

Two charts submitted by Senator Coburn entitled ‘‘USAID Malaria Spending 

for FY04’’ ............................................................................................................... 65

Article submitted by Mr. Roberts entitled ‘‘Overcoming Regulation Based 

on Innuendo and Litigation’’ ............................................................................... 67

Questions and responses for the Record from: 

Mr. Miller .......................................................................................................... 69

Mr. Roberts ....................................................................................................... 79

Roger Bate, Resident Fellow, American Enterprise Institute and Director, 

Africa Fighting Malaria, and Richard Tren, Director, Africa Fighting Malaria, prepared statement .................................................................................... 84

(1)

BILATERAL MALARIA ASSISTANCE: 

PROGRESS AND PROGNOSIS 

THURSDAY, JANUARY 19, 2006

U.S. SENATE, SUBCOMMITTEE ON FEDERAL FINANCIAL MANAGEMENT, GOVERNMENT INFORMATION, AND INTERNATIONAL SECURITY, OF THE COMMITTEE ON HOMELAND SECURITY

AND GOVERNMENTAL AFFAIRS, Washington, DC. 

The Subcommittee met, pursuant to notice, at 2:30 p.m., in room 

SD–342, Dirksen Senate Office Building, Hon. Tom Coburn, Chairman of the Subcommittee, presiding. 

Present: Senators Coburn and Carper. 

OPENING STATEMENT OF SENATOR COBURN 

Senator COBURN. The Subcommittee will come to order. 

I would like to thank our witnesses for taking the time to testify 

and the tremendous effort that some of them made to get here, the 

long distances they traveled. 

This is a follow-up hearing to a hearing we had some 6 months 

ago, and it is important for America to realize that malaria sickens 

somewhere around 500 million people a year. It kills nearly 2 million people every year. Of those, 85 percent of the victims reside 

in Sub-Saharan Africa. As we sit here for the next 2 hours, 240 

more children will die from malaria. The United States will spend 

$105 million to fight malaria this year, and the President has a 

new initiative where he has committed $1.2 billion over the next 

5 years to fight this dreaded disease. With plans to scale up spending so dramatically and in such a short period of time, it is all the 

more important that we get it right, that our program saves lives 

in a measurable way. 

After our hearing on this subject last year, U.S. Agency for International Development (USAID) went through its books and reported that less than 8 percent of the bilateral malaria budget 

went toward life-saving commodities such as $2 drugs that cure the 

disease, insecticides to kill the mosquitoes that carry the disease, 

and nets to keep the insects off people while they are sleeping. 

What is worse is that the majority of that 8 percent was spent to 

sell bed nets rather than to give them to the people who could not 

afford to buy them. 

When we brought some sunshine to the budget on this project, 

we discovered that the vast majority of the malaria money was 

going to advice-giving programs, administrative overhead, travel, 

and conferences. In other words, we spent most of our money tellVerDate 0ct 09 2002 11:29 Oct 17, 2006 Jkt 026748 PO 00000 Frm 00005 Fmt 6633 Sfmt 6633 C:\DOCS\26748.TXT SAFFAIRS PsN: PAT
2

ing people how to use the cheap and effective tools to fight malaria 

and very little money actually providing them those tools and very 

little money actually saving lives. 

Despite good intentions all around by those dedicated workers at 

USAID, our priorities have been out of whack. But things are 

changing, and I want to commend President Bush and those at 

USAID for recognizing the problem and announcing the major reforms over the past 6 months to change course. The President’s 

plan targets a few focus countries at a time for nationwide coverage 

with life-saving interventions, including insecticide spraying in 

homes and drug procurement. But even in countries not initially 

targeted, USAID recently announced an overhaul of its malaria 

programming so that by next year 50 percent of its budget in those 

areas will go towards purchasing commodities and 25 percent of its 

budget will be spent on spraying. This is ground-breaking movement, and I am encouraged to think how many children and pregnant women might be spared death from this preventable and curable disease. 

I want to congratulate the President for his leadership, and especially Assistant USAID Administrator Kent Hill and his deputy, 

Michael Miller, who is here today, for their courage and commitment in the face of the grueling task of implementing reforms at 

the programmatic level. It is very easy for Members of Congress to 

throw stones and criticize. It is quite another thing to actually turn 

a program around and change an international bureaucracy and 

move it in a different direction. We are having a follow-up hearing 

today because the sound policy and planning that have been 

achieved so far are only the beginning. So what I would like to do 

is get into some of the details of what we will be looking for over 

the coming months to carry out the new initiatives: 

Accountability. One of the first principles we aim for here is 

transparency. We have been assured that a website would be 

launched that tracks all the money and the progress made with 

that money toward measurable indicators. So far, the website is 

not up and is not running, but I will be interested to hear a firm 

date for that launch so that taxpayers and congressional overseers 

can perform our job of seeing where the U.S. dollars are actually 

carried out in action. 

Second, the President’s initiative sets an ambitious goal: 85 percent coverage in focus countries of vulnerable populations with lifesaving interventions, as appropriate. And it is that ‘‘as appropriate’’ 

that provides wiggle room, some of which is very legitimate. But 

we do not want to open loopholes that allow for those who are content with the status quo to rest on their laurels. So far I haven’t 

seen any of the technical guidelines or the criteria that govern 

when, where, and for whom certain interventions should and 

should not be used. It seems that these decisions are being made 

on an ad hoc basis for each country, which makes it difficult to 

compare the results across countries, to assess the scientific soundness of those decisions, and also for other donors and other countries who are looking to us for guidance about how to fight malaria 

in other countries and to imitate what we hope may be the most 

successful anti-malaria campaign since the world eradication effort 

last century. 

3

Let me outline some of the basics we are looking for: Insecticide 

spraying in homes virtually everywhere; the use of the cheapest 

and most effective insecticide, which almost always turns out to be 

DDT. The World Health Organization (WHO) and others have stigmatized DDT long enough, even as environmental groups now concede that the chemical should be used for malaria control. No 

human or wildlife harm has ever been demonstrated when DDT is 

used for spraying of homes. The unnecessary death toll caused by 

a bias against DDT needs to end right here and right now. I will 

be expecting USAID to reverse years of damage caused by an antiDDT message by enthusiastic and vocal support with dollars and 

words for spraying with DDT. 

Next, a bed net distribution strategy that can realistically reach 

85 percent coverage for vulnerable populations. Since almost every 

household contains a child under five or a woman of child-bearing 

age, that means you have to get at least one, maybe two or three 

bed nets into most houses in focus countries. That is going to involve a lot of free bed net distribution, and not a marketing campaign to sell nets. 

We will want to see artemisinin-based combination chemotherapy used where there is resistance to older drugs greater than 

10 percent. If we do not know what the resistance levels are in a 

given area, we should use artemisinin until we can establish what 

those resistant levels are. 

USAID can streamline the use of indoor insecticide spraying 

through lifting of regulatory barriers. Massive environmental impact assessments for public health initiatives were never the intent 

of Congress in the National Environmental Policy Act. I suggest 

that USAID carefully review these laws and regulations. Rather 

than trying to justify the onerous regulations as not as problematic 

as they seem, I would rather see the Acting Administrator of 

USAID exercise his authority to remove the barriers altogether. 

Finally, setting numerical goals for commodity allocations will 

further validate this Administration’s commitment to saving the 

lives of Africans. While a commitment was made for countries not 

targeted by the President’s initiative, I would like to see some targets set for the President’s focus countries as well. You see, what 

we saw and what we do does echo around the world. We are only 

one player vitally concerned with the welfare and health of those 

on the continent of Africa. But we are the biggest player when you 

count both our bilateral and multilateral contributions to malaria 

control. If our message and our money go out in a science-based, 

unapologetic, reformist way, the whole world will change with us. 

Given the death toll from this disease, nothing short of dramatic 

change by every donor and every host country’s malaria program 

is necessary. We are losing generations in the meantime. 

You will see on this other photograph a few of the children who 

died in one year at one school in Uganda from malaria. Tremendous potential wasted because we have not been effective in helping those that are dependent upon us. Every minute we take to get 

these programs up and running is precious time lost for millions 

of children just like them. 

[The prepared statement of Senator Coburn follows:]

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1The prepared statement of Mr. Miller appears in the Appendix on page 00. 

Senator COBURN. I know our witnesses today share my passion, 

and I am grateful for their time and their hard work to end the 

scourge of malaria on the world’s children and families. And I want 

to thank you for being here. 

Michael Miller has been with USAID in his present capacity 

since 2004. We welcome him back to the Subcommittee for the second time. He serves in various interagency capacities for USAID in 

the implementation of the President’s Emergency Plan for AIDS 

Relief, PEPFAR, and is directing the implementation of the President’s Malaria Initiative. 

Mr. Miller, you are welcome. Your testimony has been read. It 

will be introduced into the record as submitted, and you will be recognized for 5 minutes. And thank you again, personally, for being 

here. 

TESTIMONY OF MICHAEL MILLER,1 DEPUTY ASSISTANT ADMINISTRATOR FOR GLOBAL HEALTH, U.S. AGENCY FOR 

INTERNATIONAL DEVELOPMENT 

Mr. MILLER. Senator, it is my pleasure to be back, and we really 

appreciate your support and your interest in this. When we make 

big changes like that with any institution, it is never easy. And 

having the support of Congress is going to be essential as we go 

forward to maintaining those and building on those successes. 

Since this Subcommittee’s last hearing on the topic, the President has changed our global malaria strategy fundamentally in 

scope, size, and structure. Additionally, USAID has implemented 

necessary, complementary changes to its ongoing malaria programs. These changes, I believe, ensure greater effectiveness and 

accountability, provide critically needed global leadership, and will 

ultimately save more lives. 

The most important development is the President’s Malaria Initiative—or PMI, as we call it—which is a multi-agency program led 

by USAID. The PMI will reduce significantly the number of Africans who die from malaria and will challenge other donors to make 

similar commitments. President Bush’s commitment of an additional $1.2 billion over the next 5 years is unprecedented in the 

fight against malaria. Accordingly, the goals of PMI are ambitious: 

Reduce by 50 percent the number of deaths from malaria in target 

countries. The program will eventually include up to 15 countries 

and benefit 175 million Africans. 

The speed with which we have begun to implement the PMI is 

also unprecedented. In less than 6 months after the President’s announcement, USAID was already in the field implementing programs that differ considerably in scope and size and focus from 

their predecessors. Right now, the PMI is conducting an indoor residual spraying campaign in southern Angola to protect over 

500,000 people from epidemic malaria outbreaks. We recently distributed 130,000 long-lasting insecticide-treated nets in Zanzibar, 

which we will also follow up with indoor residual spraying. And in 

about a week, we will begin the distribution of 270,000 free longlasting insecticide-treated nets in war-ravaged northern Uganda, 

among many other activities. 

8

PMI is a very different way of doing business than past practice. 

The hallmarks of the PMI are first and foremost programming 

based on clearly defined numerical targets for outcomes. Second is 

transparency in how the money is being spent. Third is a robust 

and effective monitoring and evaluation plan to make sure that we 

are, in fact, reaching our goals. This approach provides assurances 

that taxpayers’ money is being spent effectively. 

PMI’s size and structure also provide opportunities to fight malaria in Africa in ways we could not just imagine a few years ago. 

In the past, USAID used the relatively small amount of funds to 

implement programs focused on issues such as policies to adopt 

artemisinin combination therapies over failing treatments, among 

other things. Much of that work is now done. With the PMI, we 

have the opportunity to design and implement many simultaneous, 

large-scale, comprehensive—meaning providing commodities as 

well—country-wide programs throughout Africa. 

But that opportunity also necessitated changes to the programs 

currently outside the PMI, as we call it, the non-PMI, the existing 

USAID malaria programs. These are the structural changes we announced in December. One of the most visible changes is the elimination of programs that were simply too small to be effective on a 

scale we require. That was set at $1.5 million for this year. It will 

go up to $2.5 million for next year. Second is a correction of the 

imbalance between technical assistance and commodities, which we 

spoke about at length. Third is the opportunity to push the dialogue and think about indoor residual spraying as a frontline tool 

for fighting malaria in Africa, and we believe it has been under utilized. 

The rapid scale-up of PMI means that next year more resources 

and more coverage of people will be inside the program than outside the program, since there is a very rapid graduation in. As a 

consequence, having two parallel but different programs side by 

side is as impractical as it is undesirable. Because PMI will expand 

rapidly, any real distinction between the two has to be temporary, 

and the programs that now fall outside the PMI have to start making critical adjustments now, including emphasis on life-saving 

commodities, reporting on planned activities and allocations, and 

programming more money. 

In the case of Indoor Residual House Spraying (IRHS), this year 

we will spend approximately $20 million on spraying, and I would 

note that is two times the entire amount of the global malaria programs in 1997 just on spraying alone this year, and about a 20-fold 

increase over fiscal year 2004. In at least three of the eight countries where USAID will support IRHS this year, DDT will be the 

primary insecticide. As some countries move into the matrix of PMI 

countries—in other words, they move off the list of outside PMI 

and into PMI—the specific numerical targets and the monitoring 

and evaluation regime will also apply to them as well. In short, the 

changes we instituted to the non-PMI are part and parcel of the 

creation of a single, large-scale, target-driven strategy to fight malaria in Africa and to demonstrate those results. 

What we have begun to do with PMI, as we have done with the 

President’s Emergency Plan for AIDS Relief, PEPFAR, is to judge 

and plan our programs based on outcomes, not simply on how 

9

much money we put in at the beginning. The difference is simple 

but profound in terms of how we plan and how we go about it. It 

demands a level of new programmatic transparency and documentation that in turn provides confidence in the effectiveness that 

allows the President to make the multi-year commitments and 

ramp up funding accordingly. Targets keep agencies, individuals, 

and entire governments focused. With accurate data, targets provide unambiguous measures of success or failure and allow informed judgments about whether the program is effective, whether 

it should continue to be funded or not, or that money should be 

moved elsewhere. Ultimately, that not only makes for good management and good governance, it is much more satisfying for those 

of us who are charged with implementing the programs. It also 

makes them more effective. In the case of the PMI, that means the 

opportunity for the United States to fill a global leadership role in 

the fight against malaria and to save millions of lives that might 

otherwise have been lost to a preventable and curable disease. 

Thank you. 

Senator COBURN. Thank you so much for coming. One of the 

things you alluded to was the transparency and accountability of 

this new program, and we have talked about having a way for the 

American public to track that. And this is not just with USAID. 

The American people ought to be able to see where all their money 

is going all the time, except in national security issues. And the 

idea of having that available to the American public, when do you 

perceive that will be available? 

Mr. MILLER. I will make a distinction between the fiscal year 

2004 data and the fiscal year 2005 data, because we have collected 

them at different times. The fiscal year 2004 data is complete. We 

have put what we call the aggregate or the composite spread sheet 

of expenditures up on the website yesterday or the day before. And 

then as we actually make the typed corrections, if you will, to the 

data sheets that we corrected by hand as we conferred with the 

field, did mathematical corrections and things like that, those will 

be posted subsequently. I think the last time I asked the staff was 

doing it. There were five up. 

So the 2004 data is complete, and it is starting to be posted. The 

2005 data is going to take a little longer simply because when the 

fiscal year ended, we sent out the questionnaire, I believe, on October 31. So the missions received it presumably that day and were 

able to start collecting that data themselves and sending it out to 

their grantees for them to return data back to the mission. 

That will take a while because of a couple factors: Simply because they have not closed their books, they are still spending some 

2005 money. They have to rely on the grantees to send the information back, which, of course, you cannot always guarantee. Not 

much happens over Christmas in many of these countries, including here. 

Senator COBURN. Well, the point I am getting to is there is going 

to be created a continual expectation that there is going to be data 

collection and transparency, where the money is spent and the results of the money. 

Mr. MILLER. Absolutely. Our goal is to have by February 10 the 

complete 2005 data. If it is not accurate, we will not post it. We 

10

will continue to go back and make sure it is accurate. We do not 

want to rush it. But 2006 and beyond, it is built into the system, 

and that is the benefit that we do not have to do a retrospective. 

Senator COBURN. Under the President’s Malaria Initiative, the 

goal is 85 percent coverage of vulnerable populations as appropriate. How would you define ‘‘vulnerable populations’’? 

Mr. MILLER. Children under five, people living with HIV/AIDS in 

malarious areas, and pregnant women. 

Senator COBURN. OK. And what four interventions are essential 

to achieve malaria control? 

Mr. MILLER. Insecticide-treated nets and indoor residual spraying as prevention measures at the household level; treatment, 

ACTs, and treatment of expectant mothers with intermittent preventive treatment. That is four. 

Senator COBURN. When we go back to the goal of 85 percent coverage of vulnerable populations as appropriate, can you define to 

me what criteria you all are going to use for this ‘‘as appropriate’’? 

Mr. MILLER. There will be some cases where—it is rare, but in 

general you can say in most areas in tropical Africa, in the countries that we are focusing on this year and next year, everybody 

within those categories will be vulnerable; almost 100 percent in 

Angola I think you can say. There will be parts of—well, almost 

100 percent, but there are parts of Angola, in the highlands, where 

it may not be. There are parts of—people who live in the cities perhaps are not vulnerable. But, in general, I think you can say almost anybody who fits in those three categories of HIV/AIDS positive, children under five, or pregnant women is more than likely 

going to be in the vulnerable population. 

Senator COBURN. The ultimate goal is to fund adequately all four 

interventions. 

Mr. MILLER. Right. 

Senator COBURN. How are you going to make the decisions for 

priority, for which comes first? 

Mr. MILLER. Well, the idea is to do all simultaneously. We want 

those levels of coverage on all of them. The one distinction I will 

make is between nets and spraying. Whereas, at the home level, 

if you can achieve coverage of one of those two at 85 percent, we 

believe we will be meeting our targets. 

Now, there are cases where, in fact, in Zanzibar, we will do what 

we call the suspenders-and-belt approach, which is spraying and 

nets made available. And we will see what the effect of that is. 

What we do know is in the case of if you have proper and effective 

use of a net or the proper and effective use of IRHS, you can reduce 

the incidence of malaria for the protected person by 90 percent. 

Senator COBURN. But the difference is you can do IRHS once a 

year and have a variable use of net of not use of net, where somebody takes the net and goes fishing with it instead of using the net 

for prevention. So I guess I presume by your answer you all have 

scientific data to say that nets, if you get an 85-percent coverage, 

are just as effective as IRHS? 

Mr. MILLER. The way I would characterize it is we do know that 

nets are effective, we do know that IRHS is effective. What I don’t 

think we, the world, really have a sense of is exactly what the distribution should be, how much IRHS versus how much nets. 

11

Now, there are practical considerations as well, some areas 

where it would be conceivable that it simply just becomes cost-ineffective to do IRHS, which does have a logistical train along with 

it. You do have to have acceptance rates and stuff like that. But 

you are correct, there are clear advantages in some cases of IRHS 

over nets. And what we hope to find out is—take the issue of 

IRHS, which we believe has been underutilized, and start to push 

the issue to have people asking the question how much IRHS can 

we do, where is it cost-effective to really get the data on this, we 

have some data, and we know from places like South Africa, and 

I am sure in Swaziland, a place like that, that it can be very costeffective. But what we don’t know in these countries that are 

hyperendemic countries like Uganda, where 95 percent of the country has transmission almost all year round and they have not done 

spraying in decades. Where is it that we can cost-effectively do 

spraying before we start running out of money or where in the 

case—or if that is the case, where nets would be more appropriate. 

Additionally, we also have net distribution networks up and running. One of the tragedies, if you think of IRHS, is because it has 

been underutilized—and it is not just DDT. I think it is IRHS 

across the board. There is very little institutional capacity in these 

countries. For the case of Uganda, I had a very interesting conversation with the National Malaria Control Program and with the 

Vice President himself, who is also a physician like you. They are 

very inclined to use IRHS. They are leaning heavily towards DDT. 

But in this first year, they have chosen, under the PMI, in fact, to 

choose one district, Kabali District, do spraying in one district, and 

then see how—get their feet under them, essentially, start moving 

out to the other 14 districts that they have targeted, and then 

make a decision as to whether they think in that case they can rotate DDT in instead of synthetic pyrethroid. Their preference would 

be to use DDT simply because it is more effective in their case. 

Senator COBURN. It is also markedly less expensive. 

Mr. MILLER. It is a fourth of the cost, is what they told me. 

Senator COBURN. For the same amount of dollars, you get four 

times the amount of coverage. Once you have the infrastructure 

there. 

Mr. MILLER. Right. I don’t think the math would work out exactly, but, yes, you can presumably get much more coverage because the largest single cost in that program, speaking of Uganda 

specifically, if I remember right, it was the insecticides. So if you 

cut that by a fourth—now you do have additional transportation 

costs. DDT is bulkier, but you also have cost savings where DDT 

can have a longer residual effect——

Senator COBURN. It is twice as long. 

Mr. MILLER. Yes, and that is also the case in some other countries. We found that you could spray once a year with DDT or potentially——

Senator COBURN. Well, I think that is pretty well known. We are 

going to have some testimony today about that, and the fact is it 

is significantly less in cost, it lasts twice as long, and it is more 

effective. They are not equal in effectiveness. 

Mr. MILLER. Right. And there are cases where the building material, if it is a finished wall or a painted wall, you really have to 

12

make a judgment because there are adherence issues, residual 

issues, and streaking apparently is a problem when they wipe it off 

the wall. 

Senator COBURN. Is there still a plan in the new Malaria Initiative to subsidize nets rather than just giving them out? 

Mr. MILLER. The principle that USAID has established that economics should never be a barrier to net ownership, I think, is a 

sound principle. It is not the only—that in itself is not a net plan. 

It is a good principle, and we will stick to it. But my personal belief 

is at the levels of coverage we are looking at and the fact that so 

many people in malarious areas, particularly in rural areas, people 

who are destitute, who simply never will be able to afford a net 

under any circumstances, or people who possibly could but will 

have no exposure to a socially marketed message or very little contact with a formal marketplace, that those people—we cannot realistically expect that we can reach the kind of levels we want to by 

selling nets alone. And, yes, I think we will have to—we are prepared to, as the situation warrants, provide free nets, as we are in 

Uganda already, in large amounts. 

Senator COBURN. Other than infrastructure to do indoor residual 

spraying, the infrastructure limitations to be able to train people 

to do it, when is IRHS inappropriate in your view? I am hearing 

that bed nets equal IRHS, and from what I have read, I do not 

read that in the literature. 

Mr. MILLER. No. 

Senator COBURN. I am going to learn some of that today, but 

from what I have heard from you—and I have a little bit of concern—is that we are liable to not use the most effective, and the 

variable is if you have a bed net in your home and you don’t use 

it, you don’t have coverage. 

Mr. MILLER. You don’t have coverage, yes. 

Senator COBURN. If your home has been sprayed with DDT, you 

have coverage for a year. 

Mr. MILLER. Correct. 

Senator COBURN. There is a big difference. You take a variable 

out of the equation. 

Mr. MILLER. Yes, I agree that IRHS has many advantages in 

many situations. What we do not know—generally, IRHS has been 

underutilized. I think there is a big question mark about how much 

we can get—the cost-effectiveness, what kind of coverage levels—

with the money we have. I think that just requires doing a lot more 

of it. I think we have commissioned a study that will look at all 

the available data on cost-effectiveness, but I do not have confidence that alone will really give us the picture. I think we have 

to put more money against it and see what the data is, because 

there are a lot of questions about how effectively we can use it. And 

I think we can use it much more effectively, and that is sort of less 

of a question. But in the single home—I should clarify. What I 

meant is in a controlled situation, if you are using a net properly 

in a controlled situation, if you are in a home that has been 

sprayed properly, that individual, that vulnerable individual, can 

enjoy certain amounts of coverage. Now, I suspect that there are 

situations—and from past experience people say in urban areas, in 

peri-urban areas, there are these sort of diffuse, quasi-urban areas 

13

around the big cities in Africa, that spraying is much more advantageous. And that is what we are really aiming to find out, is put 

money behind that and see what really are the cost-effectiveness 

numbers that we can take to the bank and really plan against in 

future years. 

Senator COBURN. In November of this year, the South African 

Health Ministers, it was resolved that member states should support IRHS with insecticides. And, recently, Ugandan scientists 

urged their government to support IRHS with DDT. Is there some 

outside barrier to indoor residual spraying with DDT? 

Mr. MILLER. With DDT? Yes, I think there is. There is a lot of 

ignorance about DDT, as I think we have seen. People are afraid 

of it, and that is not just here. Again, I will go back to my Ugandan 

experience. I had a very fascinating conversation with Vice President Bukenya, who said they, for example, have started a net retreatment program in the area around where he is originally from, 

and they had very little uptake—uptake meaning people actually 

accepting the service for free. And they found out a rumor had gone 

around that the retreatment was with DDT, which, of course, first, 

is false, we don’t treat nets with DDT; and, second, it is false that 

it is harmful to humans in indoor residual spraying. 

So there is ignorance we have to fight and——

Senator COBURN. So do you all have a plan to address that in 

terms of remove the barriers to IRHS with DDT? 

Mr. MILLER. Absolutely. Well, the first part of the plan is simply 

do more of it. In fact, in the non-PMI programs, when we dedicated 

that 25 percent to IRHS, what we were able to do is go through 

and essentially cherrypick countries where we knew they had very 

robust IRHS plans and national malaria control plans, which is not 

true for every country, and where we had a reasonable number of 

them that would use DDT. 

Now, one of the main ones that does not in that roster of four—

five if you count Madagascar, and I will come back to that—Kenya 

does not. And they have the same problem that Uganda does, 

which is essentially if I—this is my own characterization. They feel 

like they are over the barrel in terms of exports, particularly to the 

EU, and they think it is a real concern, and I think it is, that the 

standard is very high that if there is any DDT detected in the cut 

flower industry, in the vegetable exports, freshwater fisheries, all 

of which are common to those countries and to Tanzania, then they 

face potentially a ban to exports to the EU. That would cripple 

their economies. In their minds, there would be no advantage. 

In Uganda, DDT is not illegal. But as I mentioned, they are essentially going to get themselves back into the IRHS program, understand what they want to do, make sure there is no seepage out 

in the agricultural community, make sure the security around 

sprays are adequate. In Kenya, they still have a ban. We have not 

had any dialogue with them as to whether they would lift that. I 

think they are going to have to make that decision on their own. 

But to answer your question, yes, there are. There are many considerations for them. 

Senator COBURN. I am going to turn this over to Senator Carper, 

but it is interesting when you look at the signs and you look at the 

death rate in Africa and you look at the effectiveness of DDT, and 

14

we are going to hold people hostage to not do the most effective, 

the most efficacious treatment and public health strategy because 

we are going to threaten them with poor science because we don’t 

understand the poor science. And I think there is an obligation on 

your part to bear the pressure to change that with the EU. When 

500,000 kids die a year because there is not IRHS and there is not 

artemisinin and there is not the medicines made available, and the 

IRHS isn’t there because somebody is afraid—not on the basis of 

scientific but on the basis of emotion—that it is going to have an 

impact on somebody, that is hijacking the world’s poorest people in 

the worst way. 

[The prepared statement of Senator Carper follows:]

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OPENING STATEMENT OF SENATOR CARPER 

Senator CARPER. Thank you, Mr. Chairman. Good to be with you 

again. And, Mr. Miller, thank you for joining us. 

I think you were before us back in May. Is that right? 

Mr. MILLER. I was. 

Senator CARPER. I thought so. If you would start with a little bit 

of a timeline for me, please, and take it from May when we had 

our hearing, and I think the President maybe offered his initiative 

in, I want to say, early summer, maybe June, can you walk me 

through the timeline from where we were back in May and sort of 

chronologically what is different today and when did that occur. 

Mr. MILLER. Yes, sir. I believe the hearing was May 12. By that 

time, we were already in very early planning stages with the White 

House in terms of what kind of program we could potentially propose to the President in the lead-up to the G–8. And a lot of the 

planning around the President’s Malaria Initiative really was from 

the G–8. As you know, last year at the Gleneagles Summit, the 

United Kingdom had as their theme, if you will, global health. And 

so one of the global health initiatives we had was a series of options on what we thought we could do in malaria. Ultimately, the 

President chose it because it could be—it is doable. Malaria is 

beatable. There is plenty of room for global leadership on this. And 

it is something we can do—with relatively reasonable amounts of 

money, we can have a huge impact. And that is why he chose it. 

He chose that leading up to the G–8, and by June 30, we had 

a completed proposal that he had approved, and he announced on 

June 30. We were up and running pretty fast. Certainly by December we had the spraying program started in Angola. We had net 

distribution started in Tanzania, and we will start the programs 

in—the jump-starts in Uganda as well. 

Also by December, we had our country teams make two trips to 

the region. The first was to make a needs assessment, and that is 

an assessment where a team, some of the malariologists that are 

with me here, went to Tanzania, Angola, and Uganda, and along 

with other donors, with the World Health Organization, and with 

the governments of those countries, the National Malaria Control 

Programs, made an assessment of who is doing what where and 

who is not doing what where and where we can start planning to 

put our resources against that. That was in August. The second 

would be a series of planning trips, both by country staff that is 

already there and our expertise here going out as needed, to pull 

together a country proposal, essentially. This is modeled, if you are 

familiar with PEPFAR COPs, the country plans that they submit 

every year, which show what they are going to do, with who, and 

where. We had a small version of that submitted to us. We had an 

interagency team that included Secretary Leavitt’s office, the Centers for Disease Control, DOD, State Department, Office of Management and Budget, the White House, the National Security 

Council, and us. 

We reviewed those and approved them in large part on December 

20. So just in that 6-month period or so, less than 6 months, we 

actually had approved programs, money behind them, and activities going on in the field. 

Senator CARPER. That is pretty fast. 

19

Mr. MILLER. Very fast, yes. And I should add——

Senator CARPER. Do you think it was largely instigated by our 

hearing, probably? [Laughter.] 

That is probably giving us more credit than we deserve. 

Mr. MILLER. It certainly did not hurt. 

Senator COBURN. Let me answer that. There are a lot of people 

that are interested in this. Senator Brownback has been working 

in this area for a long time. There are people in USAID that want 

to see it more—the people that work at USAID want to see success. 

And so highlighting it helps raise the pressure on it, but the leadership, both in USAID and at the President’s level, is responsible 

for this change, not us. And you did not hear my opening statement, but I said that. 

Mr. MILLER. But we do certainly appreciate your interest and 

support on that. 

I should also add that also in December Administrator Natsios 

signed a fairly comprehensive and fundamental restructuring of 

our programs, malaria programs within USAID that currently fall 

outside the President’s Malaria Initiative but are in the process of 

graduating in. So that was all within a 6-month period. We started 

the Presidential initiative, got it up and running, and independently made pretty fundamental reforms internally. 

I do have to give a tip of the hat to PEPFAR. The fact that we 

in the U.S. Government, we had exceptionally good leadership 

within PEPFAR from Ambassador Tobias, so we are very pleased 

to hear the news about him today—that is right, if the Senate confirms him, of course. And we also had the benefit of seeing where 

the barriers were, where things were easy, what kind of numbers 

we had to collect, what kind of data we needed in the end to prove 

that we were meeting our goals. And then the most basic point is 

that you have a program that is based on targets. You set a target 

that is realistic, you say how you are going to get there, and then 

you start programming against that with a program that can prove 

it is getting there. And that is the real innovation with PMI that 

PEPFAR really led the way on, and we have benefited tremendously. The people in the countries that have already gone through 

the process of making a country plan and that kind of planning 

and that kind of reporting was much easier for them and much 

easier for us. We have already been through that. So very much 

benefited from that. 

Senator CARPER. Just take a very short while on this one, and 

I know you spoke of this in your statement, but how are we doing? 

It has been 6 months since the President unveiled the initiative. 

Mr. MILLER. I think we are doing great. I am very satisfied——

Senator CARPER. How are we doing and how do you measure success? 

Mr. MILLER. We measure success in lives saved at the end of the 

day. The end of the day is actually at the end of 5 years, but we 

do have within that 5-year period ways to measure our progress. 

And it is very important. 

At the end of year two, or halfway in—first we establish baselines, what the coverage is in a country, what gaps we need to fill, 

what the mortality is from malaria, particularly in children under 

five. And halfway in, about the end of year two, we make an asVerDate 0ct 09 2002 11:29 Oct 17, 2006 Jkt 026748 PO 00000 Frm 00023 Fmt 6633 Sfmt 6633 C:\DOCS\26748.TXT SAFFAIRS PsN: PAT
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sessment of what our coverage rates are with preventions and with 

treatments. That data also provides for us what the deaths are 

within that sample area, what the under-five deaths are. And halfway through, we can go through and send people out to track down 

those deaths and do what we call a verbal autopsy. In other words, 

you take an expert that goes back to those homes where the child 

died and ask the mother a series of questions, because a child in 

Africa to have a fever, it can be any number of things. Half the 

time it is going to be malaria in these areas. But it could be meningitis, it could be any number of things, so they ask: Was the child 

vomiting? Did their neck hurt? Were they stiff? And they collect 

that data, they send it back to a panel of experts, who will do what 

they—that is part of the verbal autopsy, who make a pretty accurate determination of whether they think it was a malaria death 

or not. 

With that data, what we can—coverage data, is IRHS being implemented effectively? Is the insecticide being watered down, diverted, or are people missing, are people not understanding what 

we are doing? Are people using their nets for other things? Sometimes people leave nets in the bags. It is the only thing they own. 

It is the only thing that has been produced that is new, and they 

would rather keep it than use it because they don’t have the education. So we make sure people understand how they have to do 

this on their own. We can make corrective adjustments then, and 

also at the end of the year three, we can also go back and do another assessment of what the coverage issues are, whether IRHS, 

nets, and the treatments are doing what we say we need. 

So we have several chances within that time to make corrective 

actions, so that plus the surveillance data, which will take a little 

more time to explain, we have a pretty good sense of where we are. 

So by the end of year five, at the end of the day, I think we can 

say with a pretty high level of confidence if we are meeting those 

targets or not, or even at the end of year two, if we need to take 

corrective actions that soon. 

Senator CARPER. All right. Thanks very much. 

Mr. MILLER. You are welcome. 

Senator CARPER. Thanks, Mr. Chairman. 

Senator COBURN. I have three real quick additional questions. 

You related to our staff that the programmatic environmental assessment should be completed in March, and you still feel comfortable with that? The programmatic environmental assessment? 

Mr. MILLER. Right, we do, yes, and that is probably worth explaining real quickly. That is, in the environmental assessment period for leading up to spraying, what we have decided to do is try 

to make life a little easier on these country plans and take and do 

one large assessment, the types of assessments that we need across 

the board, a toxicity, chances of leakage—we use international 

standards—potential harm to fisheries, things like that. So the 

country plans can go and have a greatly reduced assessment burden. 

Senator COBURN. Right. 

Mr. MILLER. So, yes, we are still sticking by that. 

Senator COBURN. And I understand there is underway a search 

for a malaria czar, somebody to take charge of this. As a country, 

21

we are going to have three times the investment on an average. We 

are going to go to about $350 million a year in terms of malaria. 

I am wondering, what are the characteristics for the person that 

you are going to fill that? I sit and look as a physician at the failed 

strategies in Africa, and I am wondering if we ought to be choosing 

an infectious disease expert that was not associated with a failed 

strategy. 

Mr. MILLER. Right. 

Senator COBURN. I would just put that out as a comment. If we 

go from back inside of the failed strategies, I think we lose confidence, first. I can tell you I will lose confidence. Second, is new 

ideas, fresh ideas, and new invigoration will be helpful. So I am interested in that. 

Then, finally, my final question is one of the other big problems 

that we are facing in Africa is tuberculosis. And can you relate to 

me—and I know this hearing is not on that, but are there plans 

ongoing in USAID to expand our help on that dreaded disease? 

Mr. MILLER. I will start backwards, on the TB. I can’t tell you 

off the bat what our projections are on TB. But I agree that, when 

we were planning PEPFAR—I was actually in a different position 

at that time—and also here on the Hill, people identified—we used 

to call them ‘‘the big three’’ in Africa. They are very commonly associated with each other. If someone has HIV, there is a good 

chance you are going to die of TB or malaria. So it is very reasonable to say that as we are dealing with AIDS and malaria, we 

would also benefits from taking a look at TB. I am not offering any 

criticisms right off the bat, but I do want to recognize that, yes, it 

makes sense. 

Now, on the coordinator, I agree with you. We are not looking to 

enforce or reinforce the status quo. We are looking to change the 

way Americans view our role in fighting malaria worldwide, the 

way the world views our role. So we have to have a leader. Someone with public health expertise I think would be helpful, but as 

we have seen with many leaders in public health, it is not necessary. I do not come from a public health background. My boss 

does not. Ambassador Tobias does not. So it is not required. If you 

surround yourself with real professionals—and we do—it is really 

qualities of leadership, someone who understands opportunity, 

someone who can push the issues for IRHS, for example, someone 

who can do that not just here within USAID or within an interagency but also globally. 

That search is ongoing. There are some candidates, but presumably we have our own leadership change coming up, and it will 

have to be at least connected to that. 

So I would have liked to have had one by now. That is not for 

lack of trying. And certainly by next year, when we ramp up to 

$135 million within the PMI and go up to presumably—potentially 

up to $200 million overall, it is an incredible amount of responsibility. We have to staff up some more internally. We will want 

somebody that has leadership and has the experience, and our job 

now, I think we see it as we get a program up and running that 

we can hand over to that person, that there is minimal distractions, minimal corrective action that will have to be taken. 

22

Senator COBURN. All right. Thank you. I am going to have about 

four or five other questions that I will submit to you in writing, if 

you would get those back to us in a couple of weeks. 

Mr. MILLER. I would be happy to, yes. 

Senator COBURN. I would appreciate it 

Senator Carper, do you have additional questions? 

Senator CARPER. Just one, if I could. 

In your opinion, what role should malaria experts and African 

governments be playing in defining where house spraying should 

be used? But before you answer, let me give you sort of a second 

part. Do you have any concerns that legislating that a percentage 

of U.S. funding be for spraying, taking out of the equation both African governments who may better understand logistics in their 

particular part of the world, and experts who may best understand 

which sprays or which nets or other tools may work best? 

Mr. MILLER. I think in any circumstances, answering generically, 

we want to have experts as closely associated with the planning as 

possible. I think the best way to go about it is to start with the 

idea that we believe spraying has been underutilized in Africa. Personally, I believe everything has been underutilized in Africa. That 

is part of the problem. 

In the 1950s, when a panel of experts, a WHO panel of experts, 

and the donors decided that Africa was simply too difficult to undertake the eradication—and eradication was the aim then—to undertake the eradication programs in Africa, as we did on many 

other continents, we were literally decades behind. And what we 

found is in these countries, as the Ugandans told us very clearly, 

there is very little expertise on indoor residual spraying. Some people remember it. Some people are very enthusiastic about it. A lot 

of people don’t know about it. And the expertise within the National Malaria Control Programs varies quite a bit. And I think the 

attitudes toward indoor residual spraying varies quite a bit. 

One thing that we have observed internally is that the National 

Malaria Control Programs’ posture toward indoor residual spraying 

very often reflects the prevailing opinions of outside experts who 

are hired as consultants to help write them. So it’s going to be a 

real grab bag of opinions. Predominantly, the opinion is that IRHS 

does not have a role. We don’t agree with that. Most Africans don’t 

agree with that. It is not universal. 

In the case of Tanzania, for example—Zanzibar, rather, it was 

USAID staff that said, Why don’t we try an indoor residual spraying campaign here as well? They said that is a good idea. In Uganda they have a very clearly defined plan where they have planned 

over long periods what to do, and we come in behind that without 

much questioning. It can be expanded or it can be limited, depending on it. But I think it is fair to say that the level of expertise 

on IRHS worldwide, particularly in Africa, is pretty spotty, and we 

need to support that. We need to support more interventions across 

the board, not just IRHS but more interventions, more attention on 

malaria from all donors. 

Senator CARPER. All right. Thank you very much. And thank you 

for the report. 

Mr. MILLER. Thank you. 

23

Senator COBURN. I would just note that there is great scientific 

data that proved the effectiveness of IRHS in terms of controlling 

malaria. 

Mr. MILLER. I agree. 

Senator COBURN. Reductions by 50 percent in the death rate 

among those where it has been utilized properly. And that is what 

we are talking about. We are talking about saving those kids’ 

brothers’ and sisters’ lives. And it is effective. And it is not about 

mandating the percentage. It is about having more than 8 percent 

of the budget go to actually making an impact in the disease. 

Mr. MILLER. Right. 

Senator COBURN. That is what it is about. Mr. Miller, thank you 

very much. 

Mr. MILLER. My pleasure, sir. 

Senator COBURN. We will submit some questions. Thank you for 

coming before us, and congratulations on a job well done. 

Mr. MILLER. Thank you very much. Thank you, Senator. 

Senator COBURN. I would like to thank our next panel. We have 

three witnesses. I want to personally express my appreciation for 

you coming. We have Simon Kunene, Malaria Program Manager, 

Swaziland Ministry of Health. Mr. Kunene has directed Swaziland’s National Malaria Program since 1993. He is the Chairperson 

of the Southern African Development Community Subcommittee on 

Malaria. He also serves as a consultant to the World Health Organization on vector control and indoor residual spraying for malaria 

control. I appreciate very much the distance that he has traveled 

to come to be with us. I know what that long ride is like, and to 

share the lessons that you have learned from being involved with 

this in the field. 

Next is Dr. Don Roberts, Professor at the Uniformed Services 

University of the Health Sciences. Since 1986 Dr. Roberts has been 

a professor at the Division on Tropical Public Health. He has authored over 100 peer review publications. Much of his research is 

focused on malaria control methods, specifically on indoor residual 

spraying. I appreciate the scientific expertise he will share with the 

Subcommittee. 

Next is Dr. Andy Arata, Vector Control Specialist. Dr. Arata 

serves as a consultant to USAID and the World Bank projects involving vector-borne disease and their control. He has previously 

held a post as professor in the Department of International Health 

and Development at the Tulane School of Public Health and Tropical Medicine. He has served as the Deputy Project Director of the 

Environmental Health Project funded by USAID, and has over 30 

years of experience consulting, managing, teaching, and researching in the field of tropical diseases and vector control. I look forward to hearing about lessons learned from his extensive career. 

I want to welcome you all. Your full testimony will be made a 

part of the record, and you will be recognized. We would like for 

you to limit to 5 minutes. If you go over, we are OK. We do not 

have any votes that we are going to have to worry about today. 

Mr. Kunene. 

24

1The prepared statement of Mr. Kunene appears in the Appendix on page 00. 

TESTIMONY OF SIMON KUNENE,1 MALARIA PROGRAM MANAGER, SWAZILAND MINISTRY OF HEALTH, AND CHAIRMAN 

OF THE SOUTHERN AFRICAN DEVELOPMENT COMMUNITY 

SUBCOMMITTEE ON MALARIA 

Mr. KUNENE. Thank you, Mr. Chairman. Thank you very much 

for inviting me to give this testimony today, and I hope this hearing will lead to a better understanding of what Swaziland is doing 

or has done in malaria control, and how the U.S. Government can 

better assist other African countries, including Swaziland, to save 

lives. 

As my written testimony explains, Swaziland’s main intervention 

in malaria control is indoor residual house spraying, and this method of control has been highly effective for many years, and was first 

introduced shortly after the end of the Second World War. 

As a result of the successes and a reduced pattern of malaria, 

funding for malaria control was reduced significantly in the 1980s. 

Indoor residual house spraying coverage declined, and malaria 

cases and deaths increased. 

In 1986 and 1987, the government of Swaziland, along with some 

partners, which included the World Health Organization, the South 

African Trade Mission and USAID, reinvigorated malaria control. 

This relaunched program was, and is still, mainly based on indoor 

residual house spraying and provision of effective drugs. And recently we have introduced insecticide treated nets in our program. 

We now have a very wide coverage, Mr. Chairman, of IRHS, and 

with more than 90 percent in targeted areas is now coverage 

achieved. We use DDT and synthetic pyrethroids, which continue 

to be highly efficacious and cost effective. 

An innovation of our program is to use geographical positioning 

system, GPS, to enhance planning, monitoring and evaluation of 

our malaria control activities. The introduction of GPS in our program ensures that limited resources are put to the best possible 

use. With support from the Global Fund we recently introduced 

ITNs, targeting pregnant women and children under five years of 

age. 

To ensure that we achieve the appropriate targets, these nets are 

distributed to the high risk groups free of charge. We strongly believe that IRHS and ITNs complement each other. In other words, 

ITNs are not a replacement for IRHS and vice versa. 

Malaria case management remains very critical if we are to reduce malaria morbidity and mortality. This requires that health 

personnel are properly trained in the management of the disease, 

and there should be a consistent supply of drugs. The Kingdom of 

Swaziland, over the years, ensured that all anti-malarial drugs are 

available at health facilities, and the distribution and administration of these drugs remains the responsibility of health professionals. 

The consistent implementation of IRHS and the limitation of 

antimalarial drugs to health professionals have probably contributed to the slow development and spread of chloroquine resistance 

in the country. It is against this background that the chloroquine 

remains the drug of choice. However, the country has taken a deciVerDate 0ct 09 2002 11:29 Oct 17, 2006 Jkt 026748 PO 00000 Frm 00028 Fmt 6633 Sfmt 6633 C:\DOCS\26748.TXT SAFFAIRS PsN: PAT
25

sion to introduce ACT in the country, not because of resistance, but 

because of the added advantages of ACTs. 

Malaria is very unstable in Swaziland and epidemics are very 

common in the years of favorable conditions for transmission. It is, 

therefore, crucial that we have a very sound disease surveillance 

system in place to pick up any abnormal situations. 

Our decisions on malaria control are based on scientific evidence. 

Therefore, we monitor drug and insecticide resistance, and we work 

with international institutions in this regard. 

The effective implementation of the above has ensured that the 

pattern of disease is maintained at acceptable levels. For example, 

clinical malaria cases have been reduced from 45,000 in 2000 to 

over 5,000 in 2004. Malaria admissions have fallen from about 

1,800 in 2001 to fewer than 200 in 2004. There were less than 10 

malaria deaths in 2005. We now have a situation where a single 

malaria death becomes a news item. 

The Kingdom of Swaziland works closely with other partners in 

the Southern African Development Community. An important factor in our success has been the inter-country collaboration with 

South Africa and Mozambique in Lubombo Spatial Development 

Initiative. This is an initiative that has been highly successful and 

is based on IRHS, effective drugs, good disease surveillance and capacity building. These interventions have resulted in significant reduction in the pattern of the disease in the three countries. 

The inter-country collaboration shows what can be achieved 

when the right interventions are chosen, and when good operational research supports decisionmaking. 

We would like to see a situation where a far greater proportion 

of U.S. Government support for malaria control goals on commodities. That will have an immediate impact on malaria cases and 

deaths. We would also like the U.S. Government to promote policies that will provide essential commodities, such as ITNs, free of 

charge to the vulnerable groups. I would also like to see the U.S. 

Government taking a more active role in positively promoting this 

intervention, which has been degraded over the years. We also 

need a clear position on the use of DDT, whether or not U.S. funds 

can be used to purchase this insecticide. We also would like to appreciate U.S. support in the research, development of alternatives 

to DDT. 

Finally, Mr. Chairman, we strongly believe that U.S. Government supported malaria initiative should fit with country’s own 

strategic framework instead of being imposed on them for sustainability. 

Thank you for the opportunity to give evidence today, and for 

your interest and leadership on this issue. I thank you. 

Senator COBURN. Thank you very much. Dr. Roberts. 

26

1The prepared statement of Mr. Roberts appears in the Appendix on page 00. 

TESTIMONY OF DONALD R. ROBERTS, Ph.D.,1 PROFESSOR, DIVISION OF TROPICAL PUBLIC HEALTH, DEPARTMENT OF 

PREVENTIVE MEDICINE AND BIOMETRICS, UNIFORMED 

SERVICES UNIVERSITY OF THE HEALTH SCIENCES, BETHESDA, MARYLAND 

Mr. ROBERTS. Thank you, Chairman Coburn, for the opportunity 

to present my views on malaria and DDT this afternoon. As a government employee, I am required to state that my comment should 

not be construed as reflecting the opinions of my university, the 

Department of Defense, or the U.S. Government. 

In preparing my comments I was reminded of a statement often 

used in discussions of controversial issues, namely, that each of us 

is entitled to our own interpretations, opinions, and ideologies, but 

we are not entitled to our own facts. Certain basic facts about DDT 

and malaria control might help focus our thoughts and discussions. 

DDT is sprayed on the inner walls of houses to control malaria, 

and this is referred to as indoor residual house spraying, or IRHS. 

When sprayed on walls, DDT acts primarily as a spatial repellent. 

This spatial repellent action stops mosquitoes from entering houses 

and transmitting malaria while people sleep. DDT is moderately 

toxic to mosquitoes, but toxicity is not its primary mode of action. 

Our research shows that mosquito resistance to DDT toxic actions 

does not neutralize DDT’s spatial repellent action. Thus, DDT is effective in the control of malaria even when the mosquitoes are resistant to its toxicity. 

Some people argue against house spray programs and the use of 

DDT solely on the basis that poor or less developed countries do 

not have the infrastructure or people trained to administer such 

programs. 

To the contrary, many malaria endemic countries started malaria 

control program operations on their own initiative in the 1940s. 

Those pioneering programs were quick-starts, and the managers 

learned valuable lessons as the programs progressed, and the programs progressed quickly. It seems reasonable to me that if poor 

countries created such programs 60 years ago, governments can do 

the same thing today. 

Another argument against indoor spraying is expense, that it’s 

OK for urban areas, but that indoor spraying is just too expensive 

for rural areas. Well, malaria is a rural disease. The truly significant value of DDT in the 1940s was that it offered, for the very 

first time, an affordable method of protecting rural households from 

malaria. In fact, any claim that indoor spraying is ineffective or 

cannot be used in rural areas because of cost, is simply not consistent with the historical experience. 

There has been a lot of discussion about DDT’s usefulness in 

areas where mosquito vectors show variable levels of resistance. I 

have already explained that DDT does not function by killing mosquitoes, so DDT resistance does not impair its mode of action, that 

of spatial repellency. 

Regardless, let us assume there is evidence that DDT resistance 

is a problem. The best way to evaluate the problem is to spray 

DDT and monitor its effect on malaria cases. I suppose we could 

27

1The prepared statement of Mr. Arata appears in the Appendix on page 00. 

call this a trial and error method. If DDT does not control disease, 

then use another chemical. If it controls disease, then it works, regardless of any finding of resistance. 

I propose a similar method to address claims that DDT is not effective under some epidemiological conditions. This trial and error 

method is consistent with advice of one of the world’s most famous 

malariologist. In a presentation before the Royal Society of Tropical 

Medicine and Hygiene in 1949, Dr. Arnoldo Gabaldon admonished 

the audience that DDT’s effectiveness should be judged on reducing 

malaria cases, not on reducing mosquitoes. 

Additionally, this trial and error method is in line with funding 

objectives of the President’s Malaria Initiative, that is, disease control, not mosquito control. 

I will end my testimony with a historical perspective on leadership for USAID’s new malaria program. Before DDT house spraying began, almost 2 billion lived in malaria endemic areas and 

were at risk of malaria. Even before the global malaria eradication 

became functional in 1959, DDT house spraying freed roughly a 

third of a billion people from endemic malaria. By 1969, only 9 

years later, DDT house spraying had freed another two-thirds of a 

billion people from endemic malaria, almost one billion people living without the daily threat of endemic malaria. 

Now, let’s look at the Roll Back Malaria Initiative, which began 

in May 1998 and is now in its eighth year. I cannot figure out what 

the initiative has accomplished, and numbers of malaria cases have 

actually increased during the last 8 years. Eight years is a precious 

long time for those who are at constant risk of disease and death 

from malaria. 

In concluding my comments, I want to say that I hope the person 

selected to lead USAID’s malaria program will not be wed to the 

Roll Back Malaria approaches to malaria control. 

Thank you. 

Senator COBURN. Thank you, Dr. Roberts. Dr. Arata. 

TESTIMONY OF ANDY ARATA,1 VECTOR CONTROL SPECIALIST 

Mr. ARATA. Thank you, Chairman Coburn and Members of the 

Subcommittee on Federal Financial Management, Government Information and International Security, for the opportunity to speak 

before you today and to present my perspective on malaria control 

and progress in malaria control programs. 

As you mentioned in your statement, I have spent over 35 years 

working in malaria and vector-borne disease control, working for a 

number of international organizations in over 30 different countries. 

I began my WHO career at the actual peak of the Malaria Eradication program in the 1960s, and worked for WHO on new control 

methods, particularly biological control in the 1970s, and I have 

served as a consultant evaluating malaria control programs in Africa, Latin America and Asia, for USAID, WHO, and the World 

Bank. 

I am really quite pleased to see that U.S. foreign aid in malaria 

control is reconsidering the use of indoor residual spraying and 

28

DDT. For a number of years I have felt that the almost sole approach to vector control through the employment of insecticide 

treated nets, the ITNs, was very shortsighted, producing positive, 

but limited, results. 

In general, I and many field-oriented colleagues have proposed 

integrated control measures, employing more than one approach to 

vector control, depending upon the ecology of the vectors in each 

specific area. This approach is employed not only for malaria control but for the control of other vector-borne diseases such as dengue, yellow fever, West Nile, as well as nuisance insects. Integrated 

control is also used extensively in agriculture, and we have a lot 

to learn from that. For malaria vectors, integrated control may include larval control by chemical or biological insecticides, elimination of breeding sites, especially man-made, in irrigation ditches, 

ponds, rice paddies, etc., housing improvements, ITNs, depending 

on the characteristics in vector ecology in a given area. 

Malaria is a very variable disease. There are four different parasitic species and numerous anopheline vectors—40-50 vectors more 

or less, and a range of transmission intensities from endemic to 

stable to unstable, to variable biting patterns in terms of where 

and when the mosquitoes prefer to bite, resistance potential for 

both the parasites to anti-malarial drugs and the vectors to insecticides. We also have both forest and urban transmission patterns. 

In other words, measures that work in Southern Africa may not 

necessarily work in the Congo. The variety of circumstances facing 

the control program manager in the field is huge. On top of these 

factors, there are other complexities; differences in housing construction material, whether wood, mud, etc. These will modify the 

efficacy of any insecticide, so depending on only a single compound 

or a single method of application is, in my opinion, a recipe for failure. 

My career in malaria control has spanned from the eradication 

era through the reemergence of IRHS as a major control measure. 

To my mind, the overriding lesson of the malaria eradication period, has been that there was no ‘‘magic bullet.’’ Local variations 

mattered, and a flexible approach, what I have called ‘‘integrated 

control’’ was the most effective. In many instance malaria programs 

of the past were problematic and what we might refer to as cookiecutter. They tried the same thing in country after country without 

any variation or consideration of local problems. 

Sole reliance on IRHS with DDT did not work well, and we now 

have more tools available to us than we did earlier. The bed nets 

and the newer drugs for malaria treatment offer new opportunities 

for effective control measures using integrated approaches tailored 

to local circumstances and vector-specific variables. Integrated control also implies the development of infrastructure and management practices, as well as community participation, and even appropriate diagnosis and treatment. 

I hope that those charged with the development of new malaria 

control programs will see their way to employ DDT as they would 

any other insecticide, to be tested and evaluated for efficacy, for 

safety and cost in each situation. I think DDT has a role to play 

in malaria vector control, and if it is used particularly as a component in integrated control systems. Thank you, sir. 

29

Senator COBURN. Thank you, Dr. Arata. 

Mr. Kunene, you have an integrated program, do you not? You 

have impregnated nets and indoor residual spraying. We saw from 

the data you presented to the Subcommittee this marked reduction 

in infection, marked reduction in hospitalization and marked reduction in deaths. Is that correct? 

Mr. KUNENE. Yes. 

Senator COBURN. When Dr. Arata talks about an integrated, 

would you describe the system in your country as an integrated 

system? 

Mr. KUNENE. Yes. I think we fully support an integrated approach. As I mentioned in my presentation, we use IRHS, then we 

use ITNs. ITNs are targeting pregnant women, which are considered a vulnerable group, and children under five. So if we were to 

use ITNs and ignore IRHS, we probably would be covering about 

20 percent of the total population at risk because pregnant women 

plus children under five, I think they contribute about 20 percent. 

So you will have about 80 percent of the population not covered or 

not protected. 

So with the IRHS we are able to cover the 80 percent, which is 

not covered by the ITN program. So integrated, we fully support. 

Senator COBURN. And it is true, the same program you are using 

has been used in South Africa as well. Where you have countries 

today, where we are not doing anything, we are not seeing anything done, does it makes sense to apply what is being done until 

we figure out an integrated strategy? Nobody is wanting to use a 

cookie-cutter approach, we understand that, but we also understand that a lot of the buildings in your country have disparate different materials that are part of it, and there is no question they 

absorb at a different rate, it lasts varying lengths of times in terms 

of the application of indoor residual spraying with DDT. But the 

fact is it acts as an irritant and repellent in very small quantities. 

Is that true? 

Mr. KUNENE. Yes. 

Senator COBURN. So what is working somewhere now is better 

than nothing happening where people are dying by the thousands. 

Mr. KUNENE. I think there is attempts—as the Chairman has 

mentioned, we are treating it as a solution, that these two interventions will never replace each other. They complement each 

other. And as the region, South Africa, I strongly believe that is 

what even our minister has decided, and DDT remains the insecticide of choice, not only for South Africa, Botswana and Namibia. 

Zambia has just relaunched IRHS, and they have seen significant 

results in terms of reduction of malaria mortality and morbidity. 

We are now moving towards maybe Malawi, Tanzania, the whole 

sort of region, I think will move towards IRHS, IRHS as method, 

that the choice of insecticide, we leave that to the countries. They 

can do their own recommendations. What would be affordable to 

us, and what would be more effective, but IRHS as the method. 

Senator COBURN. Thank you. 

Dr. Roberts, Dr. Arata asserted that DDT should be tested like 

other insecticides and evaluated. Do you have any comment on 

that? 

30

Mr. ROBERTS. I do believe that there is a role for pilot testing in 

areas where there are no recent test data for the effectiveness of 

DDT in an indoor residual spray program. So it seems to me that 

would be an intelligent way to proceed, doing pilot testing. 

On the other hand, it is somewhat difficult to reconcile a slow approach in a setting where just literally thousands of people are 

dying. So it seems to me that this is one of those situations where 

outsiders should step back and let the countries make those decisions, how do they want to proceed, and then support them in any 

way possible, whether it is DDT or another insecticide. 

Senator COBURN. Mr. Kunene, you testified that DDT has been 

your primary insecticide, is that correct? 

Mr. KUNENE. Yes. 

Senator COBURN. And how many years since your program 

began? That is 6, 7 years ago; is that correct? 

Mr. KUNENE. It was introduced in 1946. 

Senator COBURN. I understand that, but the reuse of it really 

started, your numbers started coming down starting in 2000, correct? 

Mr. KUNENE. Yes. 

Senator COBURN. Have you all seen adverse health impacts from 

the use of DDT in your country? 

Mr. KUNENE. As I mentioned, we are working in collaboration 

with the Swaziland Environmental Authority, which is a government wing, and they are the ones monitoring our responsible use 

of the product. And over the years they have not indicated that 

there are any adverse health effects as a result of the use of DDT 

in the country. 

Senator COBURN. Dr. Roberts, do you know of any publication of 

scientific data, peer-reviewed, that shows adverse health effects 

from indoor residual spraying of DDT? 

Mr. ROBERTS. I do not. Could I amplify? 

Senator COBURN. Sure. 

Mr. ROBERTS. I do not know of a published peer-reviewed article 

that shows that there is an adverse human health effect from indoor residual spraying with DDT. But I would like to add to that 

that I have actually been told by, for example, the head of the NIH 

in Mexico, that they have looked at that extensively because of the 

very considerable environmental pressures that were applied in 

Mexico to stop the use of DDT in malaria control. His comment to 

me—this was March of last year—was that they have found nothing. 

Senator COBURN. Dr. Arata, are you familiar with any peer-reviewed scientific data that would suggest that? 

Mr. ARATA. No, I am not. We do know, of course, from an environmental standpoint, there are risks to be taken, but even there, 

the vast majority of the problems are associated with excessive use 

in agriculture, forestry, and the like. In general, public health use 

of insecticides in most of the countries that I am familiar with, developing countries, usually amounts to only about 10 percent of 

what is used in agriculture, and used within the houses in IRHS. 

It is really unlikely that it would cause any environmental damage. 

31

Senator COBURN. So you would agree with the program. There is 

not any peer-reviewed literature out there on DDT when used in 

indoor residual spraying offers any threat to the environment? 

Mr. ARATA. Not that I know of. 

Senator COBURN. There is not any. We have looked at it. 

Mr. ARATA. There is none. 

Senator COBURN. There is no search that would show that. 

So one of the things I wanted to establish for this hearing is, we 

do not want to use DDT because it is cheap and because it works 

if it harms the environment and truly will make things worse; we 

want to use DDT is because it is very effective in certain areas at 

controlling the disease. And we have to get over the hump of the 

environmental bias against it because of the lack of understanding 

of the confined use of this and the diluted quantities that are used 

compared to what our experience was in this country. 

When I was a young boy, they used to come down the streets 

spraying. The fogs would be out and they would be spraying it. As 

a young boy I can remember the massive use of it, and the massive 

use of it in terms of agriculture for cotton, things like that. 

Mr. Kunene, would you comment on the importance, what would 

it mean in the continent of Africa if America would aggressively 

support indoor residual spraying? 

Mr. KUNENE. Mr. Chairman, I think we would see a significant 

reduction of mortality and morbidity as a relate of malaria in the 

country. Just IRHS as a principal. If you add the DDT, I think that 

will even make it even more successful, Mr. Chairman. 

Senator COBURN. From your perspective, is there something that 

our USAID folks can do as they roll out this new program, looking 

at it from Africa, what can they do to be quicker, more efficacious, 

more effective, and attain greater results other than what you’ve 

heard here today? If you were to sit down and had a chance to give 

them advice, what advice would you give them? 

Mr. KUNENE. I do not know what the approach is now—I strongly believe that for when you put money, you must be able to evaluate whether you are making success or not. Baseline surveys I 

think are critical. We do not just come and spray, then start evaluating later. Let us determine the situation now from an etymological perspective. What species or vector species are available, 

and what is the parasite prevalence for now, the hospital data? 

Then will come in with the interventions. 

But when it comes to IRHS implementation, as my colleagues 

say, that initial cost will be on the high side considering the equipment, considering the recruitment of personnel, and we must invest 

on personnel. People must be properly trained. I think in Africa we 

have the expertise now. And since we are using some of the insecticides which are very sensitive like DDT, the responsible use remains very critical, so that is why the training of personnel is critical. 

Ensuring that you establish a very good database. You should 

know where to spray. We have moved a step forward because we 

are now on GPS. We are plotting all homesteads or all houses that 

are sprayed, but that is a very good planning, monitoring and evaluation tool. 

32

Insecticides, equipment and human resource, that is where most 

of the money will come. So I am happy when—I was happy when 

I looked at the fact that USAID or the U.S. Government is considering increasing the cake for IRHS. That is welcome. Thank you. 

Senator COBURN. Thank you. 

Dr. Roberts, in your testimony you talked about what history has 

taught us what happened in the 1940s and 1950s and the effective 

use. And your proposition was, let us do it and see what happens 

with the trial and error approach. One of the things I have heard, 

as I followed this issue for a couple of years, is integrated control 

sometimes is a code word for everything except IRHS. We will do 

everything, but we are not going to do indoor residual spraying. 

When you hear the words ‘‘integrated program,’’ what comes to 

mind? 

Mr. ROBERTS. Unfortunately, that is what comes to mind, that it 

is a code word for let us do anything but IRHS. And there are some 

examples out there that vividly illustrate that. There is a program 

going on in Central America. The Global Environment Facility 

funds, I think it is a $7 million project. There is no question, if you 

read through the document for the GEF project in Central America, 

there is no question that the design and the goal of that project is 

to eliminate the use of insecticides in malaria control. 

And there have been statements even in WHO literature, and 

the WHO staff, in exchange of communications with me, that show 

very clearly that the goal is with integrated vector management, 

IVM, is that the goal is to reduce the use of insecticides for disease 

control. 

Furthermore, there is a World Health Assembly resolution that 

specifically calls on the countries to reduce their reliance on the 

use of insecticides for disease control. 

My own personal opinion is that it is an awful resolution, and 

I do not understand how it was ever adopted by the World Health 

Assembly. That is the ultimate governing body for the World 

Health Organization, a decisionmaking body, so the World Health 

Organization is functioning under a resolution that calls on countries to reduce reliance on the use of insecticides. 

Senator COBURN. I would like all of you to answer this, given 

your extensive experience. If we had a program as outlined—it 

looks like we are going to—which is really going to be a balanced 

program to use for interventions to impact this, and it would end 

up being dominated by impregnated nets and IRHS and then treatment, would the rest of the world follow? What do you think? 

Mr. ROBERTS. I will comment. I think so. I gave a presentation 

before the Ministry of Health in Thailand in November, and I was 

talking about the need for the use of DDT. This is not a specific 

answer to your question, but in general I think it is, and an individual from the political section of the Ministry of Health stood up 

and said that the world is not going to make any move at all to 

restarting the use of DDT in these critical programs unless the 

United States shows leadership. I take it from that, is that it will 

make a difference if we can show change and flexibility. 

Senator COBURN. I think Dr. Kunene testified to the fact that 

you have to have—we are not talking about indiscriminate use of 

DDT, we are talking about trained use and utilization of DDT in 

33

terms of indoor residual spraying. I believe you also testified earlier that we saw tremendous results from the use of DDT in the 

rural areas in terms of IRHS in the 1940s, 1950s and 1960s. Dr. 

Arata, would you want to comment? 

Mr. ARATA. Regarding the role and the position of WHO, I do not 

speak for WHO, but I might mention a couple of things. The resolution reducing the amount of insecticide usage has to be taken into 

context. For one thing, programs like the onchocerciasis control 

program (OCP), used a large amount of insecticides, which was replaced by ivermectin as a drug, so therefore, they no longer needed 

the same amounts of insecticides. The same thing is happening 

with control of other filarial diseases, with diethylcarbamazine 

being used for treatment in urban areas, for example, rather than 

vector control, so no need to specify which vector-home diseases 

that may also use insecticides are we talking about. 

Integrated programs do not come as code words to me, nor to 

most of the people that I work with. Integrated vector control just 

means using more than one type of vector control measure. Then 

you can have integrated malaria control, which integrates vector 

control and the diagnosis and treatment. And then you can have 

integrated health programs where through sentinel sites and 

through clinics, one treats a multitude or a number of different 

problems. 

So really, integration is, for me at least, not a code word for not 

using something, but rather a very positive thing, and is really copied after some of the integrated control measures in agriculture, 

which are very advanced in terms of economic analysis and economic modeling, which is a level we have not reached in public 

health at the present time. 

As far as whether other countries will follow us, I think that 

there is a very good chance that they will, but I think the only way 

they will do that is if we give them an opportunity to get involved 

fairly early in the game, rather than sending them a program of 

saying, ‘‘This is what we are going to do now. Come and join us.’’ 

So I think if we ask for some cooperation and collaboration in some 

of the planning, at least opinions, then I think we will have the 

leadership role that we would like. So thank you. 

Senator COBURN. Dr. Roberts, one last question. What happens 

when we replace IRHS with drugs only? What is the natural history of that? We do not see resistance for parasites to ivermectin 

yet, but it does not mean we will not, correct? 

Mr. ROBERTS. Right. We could look back at our uses, for example, 

chloroquinized salt. That has been tried in more than one location 

in the world. The one that I am most familiar with was in Surinam 

and Guyana and Brazil. The result was almost immediate resistance to chloroquine, and in that case it was falciparum malaria, 

which is the more deadly form. 

When you start suppressing the use of insecticides in malaria 

control, the truth is, we really only have one major option for preventing malaria transmission, and that is the use of insecticides, 

and breaking man/vector contact inside of house. And when you 

eliminate that as an option, really the government will have only 

one option or alternative, and that will be to go with mass drug 

distribution, what I refer to as chemoprophylaxis, and that is preVerDate 0ct 09 2002 11:29 Oct 17, 2006 Jkt 026748 PO 00000 Frm 00037 Fmt 6633 Sfmt 6633 C:\DOCS\26748.TXT SAFFAIRS PsN: PAT
34

cisely what has happened in Central America with this GEF 

project. 

Senator COBURN. Then you have the propensity to develop resistance. 

Mr. ROBERTS. Exactly. 

Senator COBURN. Could I also comment? In many ways I agree 

with Andy about integrated vector management. The problem that 

we have with the concept of integrated vector management is that 

it has, in fact, been used in the wrong way. The concept is valid. 

The concept is good, but it has been used to eliminate the use of 

insecticides. 

Senator COBURN. That has been the goal, rather than to eliminate disease? 

Mr. ROBERTS. Right. 

Senator COBURN. I want to thank each of you. There will be several questions that will be directed to you. If you would be so kind 

as to respond to those, we will not take more time in the hearing. 

Our goal is to not see a picture like that, where it is not there. And 

if there is anything, $2 for ACT treatment, $2 to cure somebody of 

a disease, to spray a room for a buck, fully absorbed cost, we do 

not have any reason not to be successful. I will assure you that we 

will follow up. I am very pleased with USAID’s response. 

Just so they will know, and the others, we had 21 Subcommittee 

hearings on ineffective spending of the Federal Government’s 

money last year. We are going to have over 40 this year in terms 

of the follow up, and the whole goal is not to be critical, but to 

make sure that when we intend to help somebody, that we really 

help them, and that we get the most value for every dollar that the 

American taxpayer pays, because in the long run what it does, it 

makes a difference in those people’s lives. You can see those young 

children, we did not make a difference. We did not impact. If 98 

percent of what we spend ends up impacting somebody, then we 

are the better for it and so are they. 

I thank you for coming, appreciate it very much. Mr. Kunene, 

again, the long trip here, thank you for the testimony of what you 

are doing in your country, and we congratulate you on your success. Thank you. 

The hearing is adjourned. 

[Whereupon, at 4:07 p.m., the Subcommittee was adjourned.] 

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