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98–949PDF 2016

THE GROWING THREAT OF CHOLERA AND OTHER

DISEASES IN THE MIDDLE EAST

HEARING

BEFORE THE

SUBCOMMITTEE ON AFRICA, GLOBAL HEALTH, 

GLOBAL HUMAN RIGHTS, AND 

INTERNATIONAL ORGANIZATIONS

OF THE

COMMITTEE ON FOREIGN AFFAIRS 

HOUSE OF REPRESENTATIVES

ONE HUNDRED FOURTEENTH CONGRESS

SECOND SESSION

MARCH 2, 2016

Serial No. 114–175

Printed for the use of the Committee on Foreign Affairs

(

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

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

(II)

COMMITTEE ON FOREIGN AFFAIRS 

EDWARD R. ROYCE, California, Chairman 

CHRISTOPHER H. SMITH, New Jersey 

ILEANA ROS-LEHTINEN, Florida 

DANA ROHRABACHER, California 

STEVE CHABOT, Ohio 

JOE WILSON, South Carolina 

MICHAEL T. MCCAUL, Texas 

TED POE, Texas 

MATT SALMON, Arizona 

DARRELL E. ISSA, California 

TOM MARINO, Pennsylvania 

JEFF DUNCAN, South Carolina 

MO BROOKS, Alabama 

PAUL COOK, California 

RANDY K. WEBER SR., Texas 

SCOTT PERRY, Pennsylvania 

RON DESANTIS, Florida 

MARK MEADOWS, North Carolina 

TED S. YOHO, Florida 

CURT CLAWSON, Florida 

SCOTT DESJARLAIS, Tennessee 

REID J. RIBBLE, Wisconsin 

DAVID A. TROTT, Michigan 

LEE M. ZELDIN, New York 

DANIEL DONOVAN, New York 

ELIOT L. ENGEL, New York 

BRAD SHERMAN, California 

GREGORY W. MEEKS, New York 

ALBIO SIRES, New Jersey 

GERALD E. CONNOLLY, Virginia 

THEODORE E. DEUTCH, Florida 

BRIAN HIGGINS, New York 

KAREN BASS, California 

WILLIAM KEATING, Massachusetts 

DAVID CICILLINE, Rhode Island 

ALAN GRAYSON, Florida 

AMI BERA, California 

ALAN S. LOWENTHAL, California 

GRACE MENG, New York 

LOIS FRANKEL, Florida 

TULSI GABBARD, Hawaii 

JOAQUIN CASTRO, Texas 

ROBIN L. KELLY, Illinois 

BRENDAN F. BOYLE, Pennsylvania

AMY PORTER, Chief of Staff THOMAS SHEEHY, Staff Director

JASON STEINBAUM, Democratic Staff Director 

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

INTERNATIONAL ORGANIZATIONS

CHRISTOPHER H. SMITH, New Jersey, Chairman 

MARK MEADOWS, North Carolina 

CURT CLAWSON, Florida 

SCOTT DESJARLAIS, Tennessee 

DANIEL DONOVAN, New York 

KAREN BASS, California 

DAVID CICILLINE, Rhode Island 

AMI BERA, California 

(III)

C O N T E N T S 

Page

WITNESSES 

Peter J. Hotez, M.D., president, Sabin Vaccine Institute .................................... 4

Issam I. Raad, M.D., president, Health Outreach to the Middle East ................ 14

J. Stephen Morrison, Ph.D., senior vice president, director of Global Health 

Policy Center, Center for Strategic and International Studies ........................ 26

LETTERS, STATEMENTS, ETC., SUBMITTED FOR THE HEARING 

Peter J. Hotez, M.D.: Prepared statement ............................................................. 8

Issam I. Raad, M.D.: Prepared statement ............................................................. 17

J. Stephen Morrison, Ph.D.: Prepared statement ................................................. 30

APPENDIX 

Hearing notice .......................................................................................................... 62

Hearing minutes ...................................................................................................... 63

(1)

THE GROWING THREAT OF CHOLERA AND 

OTHER DISEASES IN THE MIDDLE EAST 

WEDNESDAY, MARCH 2, 2016

HOUSE OF REPRESENTATIVES,

SUBCOMMITTEE ON AFRICA, GLOBAL HEALTH,

GLOBAL HUMAN RIGHTS, AND INTERNATIONAL ORGANIZATIONS,

COMMITTEE ON FOREIGN AFFAIRS,

Washington, DC. 

The subcommittee met, pursuant to notice, at 2:10 p.m., in room 

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

(chairman of the subcommittee) presiding. 

Mr. SMITH. The subcommittee will come to order, and good afternoon. 

During the last several years, conflicts in the Middle East have 

cost the lives of hundreds of thousands of people. It is estimated 

that as many as 470,000 people have been killed either directly or 

indirectly due to the fighting in Syria since 2011. During that same 

period more than 30,000 people have died in Iraq. In Yemen, more 

than 5,000 have died in a series of conflicts since 2009. 

As a result of the conflicts in these countries, as well as the influx of refugees from conflict zones into surrounding countries such 

as Turkey, Jordan, and Lebanon, many of those who die are the 

victims of disease. Almost 17 million people in the region are in 

need of humanitarian assistance, including roughly 4 million refugees who have fled their countries, and an additional 13 million 

IDPs. 

Dr. Peter Hotez, one of our distinguished witnesses today, points 

out that, and I quote,

We have already seen that polio and measles re-emerge, and 

we are now seeing a massive surge, more than 100,000 cases 

of a highly disfiguring parasitic disease known as leishmaniasis, which the locals call ‘‘Aleppo evil.’’ It is transmitted by 

sandflies that thrive in the uncollected garbage of Aleppo and 

other urban and suburban areas of Syria, Iraq, and Libya. The 

disease causes horrific ulcers that can appear on the face and 

disfigure people, especially girls and women and leave them 

with permanent scars that render them unmarriageable. There 

is a medicine that is administered by injection of an antimony 

containing compound into the lesion, but there is an access 

problem in the affected areas, and the bottom line is that we 

need a vaccine.

2

Today’s hearing will examine the scope of cholera and other diseases to determine what can and should be done to control it, assist 

those who have been afflicted, and mitigate the spread. The World 

Health Organization reported that the spread of the cholera epidemic that first began in Iraq in 2007, which crossed over into Iran 

and Syria, is considered the region’s greatest, although not only, 

health threat. These threats are worsened by the targeting of 

healthcare workers in Syria and by the Islamic State, which has 

no experience and little interest in providing social services. Thus, 

cholera and other diseases are untreated, often unreported, and 

pose a significant health threat in the region due to poor sanitation 

and overcrowding in areas such as refugee camps. 

Cholera is an acute diarrheal disease that can cause death within hours if left untreated. Roughly 80 percent of those who contract 

the disease do not develop symptoms, leaving some uncertainty 

about precisely about how many people contract the disease annually. Scientists estimate that between 1.4 and 4.3 million people 

contract it annually. 

Cholera bacteria are present in the feces of infected people for 1 

to 10 days after infection and can be spread to others if they ingest 

food or water that is contaminated with their fecal matter. The 

spread of cholera is mostly facilitated by inadequate water and 

sanitation management, and outbreaks are common in areas where 

basic infrastructure is unavailable, such as urban slums and camps 

for IDPs and for refugees. 

As devastating as this cholera epidemic has been and can be 

going forward, we must also remember the MERS epidemic of a 

few years ago. The Middle East Respiratory Syndrome is a respiratory illness and is caused by a virus which was first reported 

in 2012 in Saudi Arabia. It is different from other viruses that 

have been found in people before. MERS, like other viruses, is 

thought to be spread from an infected person’s respiratory secretions, such as through coughing. However, the precise ways the 

virus spreads are not currently well understood. 

The conflicts and political crises in the Middle East have brought 

anguished suffering and severe declines in health to people 

throughout the region. The most catastrophic case is by far Syria. 

More than a million people have experienced traumatic injuries, 

once-rare infectious diseases have returned, chronic diseases go untreated, and the health system has collapsed. 

In Yemen, Libya, Gaza, and Iraq as well, violence has limited access to healthcare and grievously harmed the population. According 

to Physicians for Human Rights, last summer at least 633 medical 

personnel have been killed, and more than 270 illegal attacks on 

202 separate medical facilities have taken place since March 2011 

in Syria. Of the attacks on medical facilities, at least 51, or 19 percent, were carried out with barrel bombs. Almost all of the assaults 

were inflicted by the regime of Assad. 

In the Middle East, threats against, as well as arrests and intimidation of health workers, extend beyond armed conflict to situations of political volatility, as is evident in Bahrain, Egypt, and 

Turkey. In most of these cases, doctors and nurses who treat victims of violence are, by the very act of providing treatment, deemed 

guilty of anti-government activity. In Bahrain, almost 100 doctors 

3

and nurses were arrested, and 48 originally charged with felonies 

for having offered medical care to wounded people in the wake of 

the 2011 Arab Spring uprising. 

Our panel today comprises health experts who will help us think 

through the health challenges and provide a roadmap with good 

concrete data and empirical information for us to consider as a subcommittee, which I can assure you will be used in helping us advocate for more assistance and more help to those who have been now 

affected. 

I would like to yield to Dr. Bera for any opening comments. 

Mr. BERA. Thank you, Chairman Smith, and thank you to the 

witnesses for taking time to be here today. 

As a physician and someone who has done public health and 

global health work, you think about the conditions in the Middle 

East as they are today in terms of diminishing infrastructure, refugees that are in crowded conditions, diminished sanitation, malnourished populations, and the environment is ripe for outbreaks 

of cholera, but also other infectious diseases. So I am very interested in getting a sense from our panel today of what measures we 

can take in terms of trying to alleviate and prevent some of these 

issues. 

Obviously vaccinations as appropriate, but even in a war zone 

that is very difficult because, as Chairman Smith has already indicated, to try to get healthcare workers in there, to try to get folks 

in there to help assess sanitation conditions, apply vaccinations 

where appropriate, and deliver rehydration salts or other therapies 

for those that are affected is very difficult to get that carry-in. I 

would be curious of your experience in other war zones and other 

conflict areas of the things we can try to do. While we may not be 

able to prevent some of these outbreaks, what can we do to mitigate and minimize some of these outbreaks, knowing that we may 

be stuck in a conflict zone not for months but maybe for a prolonged period? If we just look at Syria itself, much of the 

healthcare infrastructure is being devastated and will take quite 

some time to rebuild. 

So, again, I will keep my opening statement short and save time 

for questions, but look forward to hearing from the panel. Thank 

you. 

Mr. SMITH. Thank you, Dr. Bera. 

I would like to now welcome our distinguished panelists. And 

without objection, your full statements will be made a part of the 

record, but please proceed however you would like. Beginning first 

with Dr. Peter Hotez who is president of the Sabin Vaccine Institute, leads the Texas Children’s Hospital Center for Vaccine Development based at the Baylor College of Medicine. He is also founding dean of the National School of Tropical Medicine at Baylor. His 

academic research focuses on vaccine development for a wide range 

of neglected tropical diseases around the globe, as well as studies 

to increase awareness about the neglected tropical diseases in developing countries and in the United States. 

Dr. Hotez created the Sabin Vaccine Institute product development partnership and was instrumental in creating the Global Network for Neglected Tropical Diseases. In 2014, he was named by 

President Obama as one of four U.S. science envoys with a manVerDate 0ct 09 2002 09:58 Aug 03, 2016 Jkt 000000 PO 00000 Frm 00007 Fmt 6633 Sfmt 6633 F:\WORK\_AGH\030216\98949 SHIRL
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date to explore the development of vaccine centers of excellence in 

North Africa and the Middle East. 

I would note as well that our End Neglected Tropical Diseases 

Act, having had Dr. Hotez appear before this subcommittee on two 

previous occasions, has passed out of the Committee on Foreign Affairs and we greatly benefited from the insights, Dr. Hotez, that 

you provided as to what that legislation ought to look like. So 

thank you. 

We will then hear from Dr. Issam Raad Who is an infectious disease specialist and is a distinguished professor of medicine at the 

University of Texas at Houston. He is president of Health Outreach 

to the Middle East, or HOME, which is a Christian interdenominational organization that exists to bring physical, psychological, and 

spiritual healing to poor and suffering people in the Middle East 

in the name of Jesus Christ. HOME has established a program to 

train, build, and send thousands of Arab Christian physicians and 

healthcare professionals on how to share the love of God at the 

bedside. HOME supports three medical clinics, one charity hospital, a home care medical service, and mobile clinic that provides 

medical care for the people of Egypt. 

Then we will hear from Dr. Stephen Morrison who is a senior 

vice president at the Center for Strategic and International Studies 

and director of the Global Health Policy Center. Dr. Morrison 

writes widely, has directed several high level commissions, and is 

a frequent commentator on U.S. foreign policy, global health, Africa, and foreign assistance. He has served in the Clinton administration, as committee staff in the House, and taught for 12 years 

at Johns Hopkins School of Advanced International Studies. 

Dr. Hotez, the floor is yours. 

STATEMENT OF PETER J. HOTEZ, M.D., PRESIDENT, SABIN 

VACCINE INSTITUTE 

Dr. HOTEZ. Mr. Chairman, members of the subcommittee, Mr. 

Bera, thank you so much for giving me the opportunity to talk 

about a very ominous situation that is now happening in the Middle East. And now we are recognizing a spill-over into southern Europe. So this thing is already going beyond the Middle East and 

North Africa and that region. 

Before I do that I just thought you might like to hear a little 

good news based on the work of this committee and subcommittee. 

I am part of an enormous initiative known as the Global Burden 

of Disease Study that is funded by the Gates Foundation to evaluate what the impact has been of all these big-picture programs like 

PEPFAR and the President’s Malaria Initiative, and the USAID 

NTD program. And this is involving hundreds of scientists all 

across the world to evaluate the papers. The papers that come out 

look like something out of a certain physics laboratory, a massive 

numbers of authors and I will be happy to share that with you. 

But I want to just give you the punch line of what’s happened 

since the launch of all of these big programs. We have now seen 

a 30-percent reduction in the number of malaria cases and the 

number of malaria deaths. But you guys did that, so congratulations. 

5

We have turned the corner on HIV/AIDS, 19 million lives saved 

from HIV/AIDS, and for the first time turning the corner on the 

number of deaths. 

And then for neglected tropical diseases, you have reduced the 

number of cases of lymphatic filariasis, which is also known as elephantiasis, river blindness, and blinding trachoma, by almost 40 

percent, so to the point now where we can talk about eliminating 

these three diseases over the next decade. 

To date, over 500 million people have received treatments for neglected tropical diseases, totaling—I used to say 1 billion, I just got 

corrected yesterday by somebody from USAID—it is now 1.4 billion 

people. So these are incredibly effective programs. And now we 

have independent documentation to know how they are working. So 

congratulations and thank you for your leadership on that. 

Well, let’s get to the not-so-good news part of the story. The impacts of all these big picture programs has also, like peeling away 

the layers of an onion, revealed a new problem. And that, we have 

just completed on a large scale analysis in a series of papers to 

show that today most of the world’s neglected diseases are now occurring in wealthy countries, in G20 countries. So we have been ignoring the poor who live in wealthy countries, and now accounting 

for at least half the world’s worm infections, most of the dengue, 

the Chagas disease, most of the tuberculosis, most of the leishmaniasis, and quite a bit of the HIV/AIDS. 

The silver lining on that is because these are inherently wealthy 

countries it is not just a resource problem, it is a political will 

issue. So that we need to think about providing advocacy at the 

next G20 summits about how to get these global leaders to pay 

more attention to their own vulnerable populations. So an example 

would be China. Eastern China is incredibly wealthy. You go into 

western China, the Sichuan, Yunnan Province, you go back in time 

50 years. 

Or you look at Mexico, into southern Mexico, in northeastern 

Brazil where the Zika epidemic is. The Zika epidemic in northeastern Brazil is occurring in the same place where the epicenter 

of all the other neglected tropical diseases are. These poor, small 

states of Pernambuco and others where you are getting lymphatic 

filariasis and schistosomiasis as well. 

So paying attention to these pockets of intense poverty in G20 

countries is going to become an important new global health theme. 

Let’s talk about the Middle East and North Africa. I like to say 

that the reason why Ebola emerged out of West Africa is not because it was tropical, even though it is a neglected tropical disease, 

it was because those three countries, Guinea, Liberia, and Sierra 

Leone had undergone a decade of atrocities and, with it, the collapse, the collapse of its health system infrastructure. So we are 

now seeing the same thing happening in the ISIS-occupied areas 

of Syria, Iraq, Libya and now, to some extent, Lebanon as well. 

And the problem is it is very difficult to actually work in these 

countries to observe first-hand, so we have to rely on glimpses that 

we are getting of refugees spilling across the border into, into Turkey, Lebanon, Jordan, and Egypt. And that is where we are starting to see it. So you have mentioned leishmaniasis, Aleppo evil, 

that is transmitted by sandflies. Even in the best of times it was 

6

difficult for the Syrians to control this disease. And now, in the face 

of the collapse of the Syrian regime, what we are seeing are massive numbers of cases, more than 100,000 in the last year. People 

with horrific ulcers that disfigure the face, especially little girls 

who are then rendered unmarriageable later in life. 

There is a medicine that could be used to treat it. It requires an 

injection of the medicine in the lesion. Of course, the medicine is 

now unavailable. But also, with all the garbage now piling up, the 

sandflies are having a field day where they are proliferating incredibly, so they are able to bite people and transmit the disease. The 

disease is following the refugees, the sandflies are following the refugees into the border camps and the disease is continuing there. 

This is happening not only with leishmaniasis, although because 

it is so disfiguring it is one of the more dramatic examples, we are 

seeing the emergence of dengue or other arboviruses, scabies, malaria, tuberculosis, schistosomiasis, hepatitis A and B and, as you 

mentioned, the resurgence of measles and polio. 

The other thing that is happening in the Syria situation is not 

only humans are being trafficked but animals are as well. There 

is no border anymore, so with that, all of that trafficking with animals we are seeing a lot of zoonotic diseases, diseases transmitted 

from animals to humans, so an enormous amount of brucellosis. We 

are quite worried now about Middle Eastern Respiratory Syndrome, MERS coronavirus, going beyond the Arabian Peninsula. 

This is going to be we think an important problem that can cause 

an epidemic. 

We have additional issues that come up as well, which is that 

another big area of human migrations is the annual Hajj, the pilgrimage. It is believed that dengue fever actually got introduced in 

the Middle East through the Hajj. And because they have the mosquitoes there, then dengue got introduced. It spread across the Arabian Peninsula and the Middle East. I just came back from Saudi 

Arabia, and we were having discussions with the Ministry of 

Health there, that they are worried now about Zika coming in too 

for the same reasons. So there is every reason to believe that Zika 

is going to go in. 

These diseases are having a massive economic impact on the region. We have just completed an analysis looking at the neglected 

tropical diseases in the OIC countries, the Organization of Islamic 

Cooperation. And there is quite a bit of evidence that the OIC 

countries are disproportionately affected by the NTDs. And this is 

one of the major barriers to their economic development. 

Now were are seeing spillover into southern Europe. So something quite interesting is happening. For the first time in 70 years, 

malaria has reemerged in Greece. It had been eradicated, now it 

is back. We are seeing the appearance of dengue in Portugal after 

50 years. We are seeing West Nile Virus and chikungunya in Spain 

and Italy. We are seeing schistosomiasis, which is the ultimate neglected tropical disease of poverty, now on the island of Corsica. 

There is transmission of schistosomiasis in Corsica. 

So we are, we think that a lot of this is having to do with spillover from the Middle East. So we are now seeing the first evidence 

that it is not just being contained in the region. 

7

So let me end by just saying what I think you need to do about 

it. In my role as science envoy it is clear that there is no capacity 

for making vaccines for any of these diseases in the Middle East 

and North Africa. They are still entirely dependent on the multinational pharmaceutical companies, Glaxo, Merck, and Pfizer for 

making these vaccines. The problem is these diseases, for now anyway, are of regional importance, not global importance, and so the 

big pharmaceutical companies aren’t going into this. 

And we saw this before with Ebola, right? The technology to 

make the Ebola vaccine was actually first published in 2003, but 

the technology sat there for a decade because the big pharmaceutical companies weren’t interested in making an Ebola vaccine. 

It is because the business model is broken, it says we, an academic 

researcher, develops it, then waits to license it to a big pharmaceutical company, turns it around to a vaccine. And, of course, by 

the time Glaxo and Merck did this for Ebola, because BARDA put 

up $100 million at the 11th hour, 5 minutes to 12:00, they made 

the vaccine in record time. But by the time they did testing, Ebola 

was gone and 11,000 people perished. 

We still haven’t fixed that problem. The same now is coming out 

of the diseases in the Middle East. But one of the things that we 

are trying to do, and this will be a key component of the Center 

of Excellence, is at the Sabin Vaccine Institute which is based at 

Texas Children’s and Baylor College of Medicine, we are making 

the vaccines that people won’t make for these diseases in the Middle East. We are making a leishmaniasis vaccine, a schistosomiasis 

vaccine. And the nice thing about it is, because we are non-profit, 

we can teach others how to make vaccines. So we are teaching the 

Saudis now. We are working with the Tunisians, the Moroccans to 

build their own capacity. 

You can’t walk into Merck or Pfizer and say teach me how to 

make a vaccine, but we can do that. And so this is an active program going on now. We have a group of Saudi scientists coming to 

our laboratory to learn every aspect of the vaccine development 

cycle. They will bring it back to Saudi Arabia. And we hope that 

we can do this other times as well. 

And that is also important because we, as you can imagine, relations with Saudi Arabia have been strained over the last years, so 

being able to offer something like this to promote joint vaccine development is a really great example of what I call vaccine diplomacy. 

So thank you so much for having me speak. 

[The prepared statement of Dr. Hotez follows:]

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Mr. SMITH. Dr. Hotez, thank you, sir, very much for your leadership. 

Dr. Raad. 

STATEMENT OF ISSAM I. RAAD, M.D., PRESIDENT, HEALTH 

OUTREACH TO THE MIDDLE EAST 

Dr. RAAD. Thank you very much, Mr. Chairman and members of 

the subcommittee, Mr. Bera, and the staff director, Mr. Simpkins. 

It is a pleasure to be with you today. 

I would like to, again, emphasize what Dr. Hotez mentioned that 

the devastation resulting from the conflict in the Middle East creates the right environment for these alarming epidemics that have 

spread rapidly within the region. And there is concern that it could 

be a global spread. 

This has been also associated with the devastation, if you may, 

and the collapse of the local healthcare system in the area. And as 

you mentioned, Mr. Chairman, cholera is the, reported in 2015 in 

Iraq, is the tip of the iceberg, if you may. For example, the World 

Health Organization reports 5,000 confirmed cases between September to November 2015, with several deaths. But reports from 

our clinic in Baghdad, where we have clinics in Baghdad, we have 

in Kurdistan, we have even in the suburbs of Damascus, we have 

in Lebanon, Jordan and Egypt and in north Africa, but the reports 

from the clinics there that this is a vast underestimate. This is almost 2 to 5 percent of the cases actually contracted there, which 

we estimate at around 200,000 cases in 15 of the 18 governments 

in that part. 

The concern also with cholera is that cholera is unique among 

water-borne bacterial infectious disease and its potential for global 

pandemics. And now we are in the third, second and the third 

wave of the seventh pandemic with more antibiotic resistance and 

acquisition of newer, more intense cholera function associated with 

cholera. 

And also the concern is that some of these clusters or outbreaks 

occurred in Iraq in Najaf and Karbala, which are part of the holy, 

holy shrines in that country, with all the influx, with Shiite Muslims going to these religious pilgrimage areas. 

The other big concern is polio. And this has been mentioned. But 

polio was thought to be eradicated in Syria. But it emerged in 2014 

with more than 7,600 cases. And the big concern is that it occurred, 

the epicenter for the outbreak started in Deir ez-Zor which is the 

northeastern area, very close to Raqqa where the Islamic State is 

in control and where they have control in that district. And it is 

considered to be related to the fact, like the cholera, that the raw 

sewage is being pumped from these areas into, directly into the Euphrates River and the areas which provide the drinking and washing water to the other areas not under their control. 

So with cholera, polio represents a form of a spread of the disease related to the conflict, but possibly a bio-terrorism aspect 

where they are kind of basically moving the raw sewage. 

What is even more alarming is the fact that the strain of poliomyelitis in Syria has been linked to a wild type from Pakistan, particularly from a jihadist fighter who came from Pakistan to the 

15

area, highlighting the regional spread of this disease and the potential, again, for a global spread. 

Measles is another problem. I mentioned it in my written testimony. In Aleppo and then spilling over to Lebanon, for example, 

in 2013 the number of cases of measles among Syrian refugees increased to 1,760 from the baseline of 9 cases the year before. The 

same is true among the Syrian refugees in Jordan. 

Dr. Hotez mentioned about the leishmaniasis, which is also referred to as a flesh eating parasitic infection. Fifty-two thousand 

cases were reported in 2012 after a time when this was considered 

to be a contained, local infection more in northern Syria. 

MERS remains to be alive and well. You are well aware of the 

outbreak, large outbreak in the summer of 2015 in Riyadh in Saudi 

Arabia, as Dr. Hotez pointed. But also the recent outbreak in 2015 

in South Korea with transmission of the organisms, basically the 

index case traveling from the Arabian Peninsula, so again highlighting the spread of these diseases. 

I would like also to highlight in North Africa, although the hepatitis C epidemic in Egypt is not directly related to the conflict, but 

has been put under the rag for a long time. A recent study by D. 

Miller, with the Cornell Group, highlighted the fact that there is 

every year more than 500,000 new cases of hepatitis C, where almost 20 percent of the population, 15 to 20 percent of the population have this virus which has the potential in up to 85 percent 

of them to go into liver cirrhosis and hepatocellular carcinoma. So 

this is a major concern. 

The major concern in Egypt is that this is being propagated 

through the healthcare system, where almost 18 percent of the 

dental instruments have the hepatitis C RNA, 90 percent of patients on hemodialysis will end up with hepatitis C, and 70 percent 

of the blood transfusions that are being given are really not being 

checked for hepatitis C. 

So I think recently from a visit to Egypt I met with the head of 

the National Committee for Control of Viral Hepatitis C, and I 

have been in contact with the CDC basically, Dr. John Ward, who 

has been in contact with the CDC groups there. I met with the 

CDC and USAID. And there could be a lot of good effort that could 

be done in a concerted effort to contain and basically eliminate the 

spread of this virus. 

I also came from a trip from Mauritania. Ten days ago I was in 

Mauritania. I met with the President and the Minister of Health, 

as well as our Ambassador, Mr. Larry Andre, and talked about the 

hepatitis B epidemic there, where almost 15 percent of the population have this problem. And we can, Ambassador Andre has advised us to, and we have been in touch with the CDC, to really curtail that problem. 

I would finally like to highlight two major problems. One is 

multi-drug resistant TB, which is not much is being mentioned 

about, but we are detecting it from our groups who are working in 

Mafraq, in a rural hospital which is a TB sanatorium in northern 

Jordan, among Syrian refugees mainly. And this other problem is 

salmonella typhoid fever where an outbreak has been reported in 

the Yarmouk Camp in a suburb of Damascus, with resistant organisms. 

16

HOME has been serving as a group there. And most of us are 

from Middle Eastern origin. We have been working widely in all of 

these areas, particularly with mobile, a big network of mobile medical units and field clinics that we have established in various 

countries. We work closely with Samaritan’s Purse, World Vision, 

and the National Arab-American Medical Association. We work 

with the American College of Chest Physicians, and the AmericanLebanese Medical Association. 

But we believe that HOME and other groups, other NGOs working in the area, and this is what we would like to propose, should 

have work in a concerted effort, collaborative effort with governmental agencies such as USAID, CDC, and Peace Corps. 

And we ask that this subcommittee would, under you, Mr. Chairman, would call for a meeting for all relevant committee chairs, including the Health Subcommittee, with the experts, including Dr. 

Hotez and Dr. Morrison, and to set a plan and a policy for this joint 

effort for the Middle East. And have a model similar to what we 

have done with Ebola in west Africa where we have a concerted effort among the NGOs of Americans working there, as well as governmental agencies, to try to contain these, these infectious problems in the area. Because there is no doubt, like the Ebola, that 

they are going to spill over and we are going to reap the consequences. 

In addition, it could be part, and we are talking here to this esteemed subcommittee which is a subcommittee of the Committee 

on Foreign Affairs, this could be part of the medical diplomacy, if 

you may, initiative in combating terrorism in that area and its implications of this, of these infectious outbreaks. A lot could be done 

in this concerted effort in terms of refugee medicine training, in 

terms of early detection of these infectious diseases, working with 

the World Health Organization on community health and water decontamination, hygiene education, vaccination campaigns, and appropriate use of antimicrobial therapy, which is very important for 

TB and other, particularly training the local community physicians 

on how to appropriately use antimicrobial agents. 

Thank you very much. 

[The prepared statement of Dr. Raad follows:]

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Mr. SMITH. Dr. Raad, thank you very much for your testimony 

and specific, concrete proposals for follow-up. 

I would like to now recognize Dr. Morrison. 

STATEMENT OF J. STEPHEN MORRISON, PH.D., SENIOR VICE 

PRESIDENT, DIRECTOR OF GLOBAL HEALTH POLICY CENTER, CENTER FOR STRATEGIC AND INTERNATIONAL STUDIES 

Mr. MORRISON. Thank you very much, Representative Smith and 

Representative Bera. I appreciate your leadership on this and the 

opportunity to be here today. And a special thanks to Greg 

Simpkins, an old friend, for his leadership in pulling, pulling things 

together today. 

I worked on this subcommittee in 1987 and 1991 when Dante 

Fascell, Henry Hyde were the iconic leaders. I worked for Howard 

Wolpe, Dan Burton as the minority member of that subcommittee. 

And that subcommittee had enormous impact in those years. And 

I am very proud of that. That was the first job I had out of graduate school. And I believe very strongly in the power and impact 

that a subcommittee like this can have today. And thank you for 

your leadership and for putting a special focus on this subject. 

I am going to make five points. My first has to do with health 

security and where this crisis in Syria and the Middle East sits. 

We have had a lot of discussion around Ebola, a lot about, today 

about Zika, a lot about the global health security agenda. We 

haven’t situated this crisis too much that we are seeing in Syria 

in terms of health security. 

But I would argue that what we are seeing in Syria and the surrounding region is a very grave health security crisis that is gathering force. And it will become more evident. That health security 

crisis in Syria and the surrounding region is going to become more 

evident as infectious outbreaks proliferate and as other multiple 

health consequences become clearer due to the dissolution of the 

Syrian State, the deliberate targeting and destruction of health infrastructure, including killing of health workers, and the massive 

dislocation of vulnerable populations. 

We are going to see the indicators. Dr. Hotez, Dr. Raad both enumerated the evidence of this in terms of malnutrition, chronic disorders, maternal and newborn health, infectious diseases. And the 

scale is formidable. It has reached the point of really, for Syrians, 

we are talking about 12 million, over half of the population. 

I realize this, addressing this has a special set of challenges, particularly on the security side. This is an acutely dangerous and forbidding environment. Access by humanitarian health workers has 

become exceedingly limited. We are operating largely in the blind 

in terms of data and access and surveillance, and we need to admit 

that. But I think the situation is changing in some important ways. 

So that is point one. 

Point two is we ignored this problem for a while. The war started 

in Syria in 2011, in March. I would argue that for the first 3 years 

we were pretty numb, disengaged and paralyzed as a staggering 

and colossal human crisis unfolded in that period. The crisis was 

seen as too distant, too difficult, too dangerous and that perception 

only worsened as more and more armed radical Islamist groups 

27

gained prominence, even before ISIS entered in June 2014. And it 

became more difficult as MSF, as the International Committee of 

the Red Cross, as other NGOs were targeted, kidnapped, threatened and harmed grievously in that period. 

There was an assumption that the surrounding region, the borderlands, Turkey, Lebanon, and Jordan would absorb these populations and they would not move beyond that. That proved to be 

a very mistaken assumption. They took in 5 million but they quickly reached a certain saturation point, which I will say a bit about 

in a moment. In that first 3-year period the geopolitics around this 

crisis was particularly toxic: The stand-off between the United 

States and Western powers versus Russia, Assad, and Iran. The 

U.N. Security Council stepped forward and tried to address this 

but with a number of resolutions that were toothless and ineffectual, and did little, certainly in terms of Assad’s behavior, in terms 

of the egregious and flagrant violation of international law in this 

period. 

We, as a government, were preoccupied with the Iran nuclear negotiations and we were progressively seeking to lower our profile 

in this region. Options like safe zones, no-fly zones were explored 

but ultimately rejected as too risky and too difficult. We did intervene in the destruction of the chemical weapons stocks in Syria, together with the Russians. And that was relatively successful. But 

there was no humanitarian bounce that came off of that. 

Steadily, up until recently, the numbers, the funding levels for 

humanitarian operations into the U.N. were cut dramatically. And 

that, that resulted, of course, in a humanitarian regression and undermining the status of those populations that were reached in the 

border states. 

My third point is that the situation geopolitically has changed 

fundamentally. And we ought to, we ought to take account of that. 

And I will explain what I mean. 

I think that the geopolitical change has in fact pushed health 

and health security to the forefront of the stage, and it has created 

some very early opportunities potentially. The tipping point came, 

of course, as Turkey, Lebanon, and Jordan reached their saturation 

point, as the monies coming in on humanitarian operations were 

reducing, and as the Syrian populations both in those settings and 

inside Syria made a dramatic calculation in 2015 to embark 

straight off for Europe. So the numbers of Syrians moving went 

from 100,000 in 2014 to 1⁄2 million in 2015, accounting for roughly 

half of the population. 

And those flows are continuing today. We are expecting fully 1 

million more migrants this year into Europe, if not more, with a 

heavy share of those coming out of Syria. That, of course, has become a destabilizing factor. Just look at what’s happening in Europe. Look at what’s happening in Austria and the Balkan states 

where there is a, basically, they are freezing up the free flow of 

populations, refugee populations. Greece is becoming a black box, 

a holding operation. The politics are broken of the EU. And it is 

becoming an utterly untenable and destabilizing situation. 

The geopolitical situation changed in two other very important 

respects: ISIS entered the region in June 2014, displaced 3.2 million people, took under its control roughly 8 to 10 million, and 

28

then, of course, you had the Russians enter in September of last 

year and begin the aerial campaigns from Syrian bases, which 

drove, up to now have driven 300,000 to 400,000 people up to the 

Turkish borders and systematically targeted hospitals, clinics and 

other facilities. 

So why is it now possible to think a little differently about the 

health crisis in Syria and the surrounding region? The process, the 

context has changed. The U.S. is now working with others in aggressively trying to achieve a cessation of hostilities and expand 

humanitarian access to the besieged and those difficult to reach inside Syria. And that is about 4.5 million people. Right now the aim 

this week is to reach 150,000 in besieged cities and to continue on 

that trajectory to reach 1.7 million by the end of March. 

We don’t know if that is possible. It is supposed to be done under 

joint U.S.-Russian oversight. We know this is a very perilous undertaking, but if it is successful it will create new windows for restoring capacities, including basic services and immunizations. 

We are pressing at this same time to accelerate negotiations over 

national transition in Syria and expand support dramatically to the 

front line states, Turkey, Lebanon, and Jordan. February 4th was 

the astonishing summit in London which took in pledges of $11 billion, $6 billion in 2016 alone, $1 billion from the United States. 

These are unprecedented levels. And it is a stark reminder of just 

how geopolitically important this crisis has become, that you could 

have something like this happen. 

Money is not the barrier. The barrier now is becoming access, vision, political leadership and capacity. 

My fifth and final point is that there is more that the U.S. can 

do. The U.S. has been very generous on the humanitarian front. 

We have invested over $4.5 billion into the humanitarian response 

to this crisis since 2011. We are carrying 50 percent of the freight. 

But there is more that we can do. And let me just say a few specific 

things. 

We need to get U.S. public health experts closer to the problem 

on a long-term and continuous basis. Right now in the cholera outbreak we were channeling volunteers, we were channeling temporary employees into UNICEF and WHO. We should continue 

that. We should step that up. But in order to be really effective in 

this next period we need a hub within the region, perhaps in Jordan, a continuous presence charged with coordination, quick response, and building relationships across the region. 

This is an essential step to enlarge the U.S. region influence and 

to be better positioned to get smart about what is going on inside 

Syria, and to build the relations with the front line states, and address the security, the health security threats we are talking about. 

There is much more that we can do to support Turkey, Lebanon, 

and Jordan. They have serious health security needs but there is 

access and opportunity to do that. We have not framed this in 

terms of the global health security agenda. I am arguing that we 

should think about that. We should think about planting this within that vision. That is a way to get assessments going. That is a 

way to leverage the G7. That is a way to offer an international 

framework around this. It has not been applied typically to situaVerDate 0ct 09 2002 09:58 Aug 03, 2016 Jkt 000000 PO 00000 Frm 00032 Fmt 6633 Sfmt 6633 F:\WORK\_AGH\030216\98949 SHIRL
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tions as dangerous and complicated as this, but there is no reason 

why it could not be. 

Lastly, the U.S. is not in a hegemonic position to drive events. 

We are in a position to be very influential. But we are not going 

to be the hegemon as this health security crisis grows. 

Russia has established itself as a major driver. It has been a 

major contributor to chaos, dislocation and suffering. It has 

weaponized refugees. But it appears that there are some changes 

going on and we are going to have to move forward aggressively 

to rebuild capacities with the Russians, the Saudis, the Turks, the 

Iranians. We are going to have to rely very much upon our friends 

at the International Committee of the Red Cross, MSF, Doctors 

Without Borders, Syrian Red Crescents, courageous groups like the 

Syrian-American Medical Society which has done remarkable work. 

So thank you very much, Mr. Chairman, for your patience. 

[The prepared statement of Mr. Morrison follows:]

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Mr. SMITH. Dr. Morrison, thank you for your insights, your leadership all these years. And I am sure you miss being here on this 

side of the dais. 

I do have a couple questions and I will probably come up with 

a few more that we might submit in writing. But to begin with, Dr. 

Hotez, how many vaccines do you have under study at the Sabin 

Institute? 

Dr. HOTEZ. Thank you for that question. We have half a dozen, 

six vaccines now. So for hookworms, schistosomiasis, leishmaniasis, 

Chagas disease, SARS, and MERS. 

Mr. SMITH. And are any of those ready for deployment? 

Dr. HOTEZ. Well, right now they are in various stages of product 

and clinical testing. So we have two vaccines in clinical trials in Africa and in Brazil for hookworm and schistosomiasis. The SARS 

vaccine is about to be manufactured. The other ones are at an earlier stage. 

One of the big problems that we face, of course, is funding. So 

there is not a real push mechanism of funds that go to product development partnerships. These non-profits fall through the cracks. 

They use industry practices, but because they are not registered as 

small businesses or businesses, we don’t benefit from the SBIR 

mechanism for instance. And whereas the Dutch Government, the 

German Government has now specifically started funding PDPs 

specifically, and the Japanese as well, it is not really done in the 

United States. So it is a gap that could be addressed through the 

Center of Excellence concept, the neglected disease legislation, or 

we need more mechanisms like that. 

Mr. SMITH. Now, with leishmaniasis you mentioned that there is 

a need for a vaccine? 

Dr. HOTEZ. Absolutely. 

And there is proof of concept that it is quite possible. Because 

what the locals do is quite interesting. They will scrape the lesions 

of somebody who has leishmaniasis and inject it into the buttocks 

of their kids to prevent them from getting, prevent them from getting a disfiguring scar on the face. It actually was discovered by 

the ancients. It predates vaccination. It’s called leishmanization. 

But it shows you that you can make a vaccine. 

Now, we can do better than doing that. So and you can do it by 

genetic engineering, making a recombinant vaccine. And we have 

done it now in the laboratory. Now it is a matter of getting the support for scaling it up. 

Mr. SMITH. What would it take to scale it up? I mean what kind 

of money are we talking about? 

Dr. HOTEZ. Well, we are looking at around $5 million to really 

move it into clinical trials. 

And that is the incredible thing about this, it is, you know, it is 

not billions, it is not hundreds of millions, it is not even tens of millions, it is 10 to the 6th dollars, not 10 to the 7th or 10 to the 8th 

or 10 to the 9th. So the funding needs are so modest, and yet it 

is just not there. 

Mr. SMITH. One of the reasons why I have introduced the End 

Neglected Tropical Diseases Act is because it really does take a 

modest amount of money to have a spectacular impact. 

44

I would note parenthetically that for the second year in a row the 

administration’s budget has looked to cut the neglected tropical disease budget. And, thankfully, in a bipartisan way we have been 

able to get the appropriations at least at level funding at $100 million. But it was a 20-percent cut now 3 years in a row, that too, 

which is very disconcerting from my point of view in terms of 

prioritization. 

Dr. HOTEZ. And especially since the U.S. Government is getting 

so much bang for its buck. Through that, through that $100 million 

a year you are eliminating three diseases. I mean where else in the 

U.S. Government can you get that kind of impact? 

Mr. SMITH. Exactly. 

Let me just ask you, Dr. Raad, on MERS-CoV. You talk about 

how it is spreading, 36 percent mortality rate. You know, I am always, we are all I think thinking, you know, after World War I the 

misnamed Spanish flu, obviously the incubator for that had to have 

been the degradation caused by World War I. Is this one of those 

possible diseases, illnesses that could spread and become a pandemic? We know it is local and it is causing a huge amount of sickness and death. But looking at all of these diseases, including that 

one, what are your thoughts on that? 

Dr. RAAD. Yeah, the South Korean outbreak is the best example 

of the global spread of MERS. And seeing MERS cases not only in 

the region but beyond, beyond the region. So, and it is a 

coronavirus. It is, as you well know, SARS is a coronavirus and had 

a global spread. So there is always that concern that it could have 

a global spread. 

Again, the good work of my colleague Dr. Hotez as far as vaccination would be very important, because at this point all that we 

provide for MERS is supportive care. And this is why we have the 

high mortality rate associated with it. But also early diagnosis and 

to be on the alert. 

And I think MERS is part of the bigger picture of the Middle 

East. The Middle East needs special attention for as far as infectious diseases. And this can be done. And it could be done as part 

of this concerted effort but also could be part of a, as I am talking 

here to your subcommittee which is part of the Committee of Foreign Affairs, part of the medical diplomacy to reach that area. Because the uniqueness of the United States is that we are not just 

providing a activity on the ground like the Russians are doing, and 

as Dr. Morrison has mentioned, in terms of a force, but providing 

also a solution to some of the devastating problems, including these 

epidemics and solution for refugees. 

So I think there needs to be a concerted effort with special attention that the NGOs, governmental agencies, groups working, like 

my two colleagues here, to reach out to the region. 

Mr. SMITH. And I do thank you for your idea of bringing other 

relevant chairmen and subcommittee chairman together. I think 

that is an excellent idea that we will look to follow up. 

Dr. RAAD. Thank you. 

Mr. SMITH. Let me ask you with regard to the bioterrorism you 

spoke about, the chlorinization has discontinued. 

Dr. RAAD. Yes. 

45

Mr. SMITH. Is that one of the casualties of war or why would, 

why did that happen? 

Dr. RAAD. Well, it is one of the casualties of war. The whole 

healthcare system, if you may, and the sanitary system has collapsed. Syria, as you well know, the basic, basic needs basically of 

the people are non-existent. And I would dare say from reports of 

our colleagues in Baghdad, the same is true, is happening within 

Iraq. Baghdad is in chaos. 

And I have some of the slides that I sent where people are going 

to wells that are already contaminated to provide drinking and 

sanitary water. 

Mr. SMITH. Dr. Morrison, you note that 1⁄2 million children under 

5 in Syria have not been vaccinated in more than 2 years. Is there 

a danger of unrestrained polio? Is that imminent in your view? 

Mr. MORRISON. There is a risk. There is a continuous risk of further outbreaks of polio. There were 35 cases of polio in 2013. There 

was one case in early in January 2014. There were concerted efforts undertaken by a consortium of groups under the Global Polio 

Eradication Initiative that have resulted in 12 campaigns, 12 immunization campaigns that have been undertaken. And that is a 

remarkable achievement given the gravity of the situation and the 

dangers involved and the intensification of the war itself. 

The fact that polio has been contained through those efforts, 

however, doesn’t leave me completely confident that we are not 

going to see more outbreaks, more cases as this conflict continues. 

And I think there has to be, and there is, pretty concerted vigilance 

across the region. 

No state within the region wants to see the reintroduction of 

polio into its borders. When that first case happened in 2013, there 

had not been a case of polio in Syria in 14 years before that. And 

this was a country that had managed its campaigns very competently, very effectively across a range of immunizations. And but 

that is broken now. And we know the hazards. 

So I would say a need for high, continued high vigilance. But 

also, you know, an awareness of the achievements we have seen in 

the last period in reacting to those 2013 outbreaks. 

Mr. SMITH. Dr. Hotez, you mentioned that the Hajj has had an 

impact on the spread of dengue and you raise concerns about the 

Zika virus potentially being spread that way. Do the clerics, do the 

leaders of Saudi Arabia understand the potential pitfalls, is there 

a plan of action that could be used to mitigate that? 

Dr. HOTEZ. Yes. Yes, to the first part. But I think they are mystified about where to go from there in terms of restricting. Because 

one of the problems that you have with Zika is that many times 

you are without any symptoms at all. So you are going to have people coming in carrying the virus in their bloodstream without 

showing any manifestations. So it is not like we could check them 

at the Jeddah airport and say don’t come into the country. 

So this is going to be a real problem. We are going to see this. 

And the Hajj I think is occurring late in the summer or early fall 

this year, and that is going to be a huge issue. 

Mr. SMITH. I mentioned earlier the targeting of so many medical 

personnel. Well, now that there is a cessation of hostilities—of 

course it doesn’t apply to ISIS or to al-Nusra—but my question 

46

would be are the medical doctors, the healthcare workers streaming in during this lull in hostilities, knowing that there are grave 

risks to them and that these hostilities could recommence at any 

moment? 

Dr. RAAD. All of this has escalated to a tremendous number of 

healthcare workers, particularly physicians, immigrating and leaving the country with the exodus, and left basically. So the best policy is to work with the local people. And as long as we are working 

with groups that are neutral, non-discriminatory, and doing the 

work on the ground, and to strengthen. 

And I think there is something similar to the healthcare, originally the health strengthening bill that was there for Africa, something similar should be done for the Middle East and to work with 

local groups on the ground in order to retain them. Because the 

healthcare workers are like anyone else basically in the midst of 

a catastrophe, and particularly when they are targeted. 

We had difficulty having a mobile medical unit in Syria because 

it would be either shelled or basically and the people would be 

killed. And then the mobile medical unit would be taken over to be 

used to kind of transport weapons and so on. So I think the most 

important thing is to work within the system collectively and try 

to strengthen the healthcare system. 

Mr. MORRISON. I don’t think you are going to see a sudden return. Well over half of the 30,000 doctors that were in Syria prior 

to the advent of the war on March 11th are gone. And they are not 

coming back. And you have had over 800 healthcare workers murdered in this period. You have had the deliberate targeting your infrastructure. Fully half of your infrastructure is either destroyed or 

just non-functional at this moment in time. 

So I think what’s like—and the security threats remain very 

grave and very fluid. So I think what you are going to see is a step 

by step incremental reintroduction of personnel with heavy security 

guarantees around this. The U.N. convoys that have been going in 

in this last few days, into the five or six besieged cities, some in 

the government territory, some in opposition control, these are trying to get to those 15 sites where you have got 450,000 people who 

have been cut off for months and months and month, those are 

being done with very heavy preparation, very heavy concerns 

around security. 

I might add one other thing. You have Deir ez-Zor, you have the 

city out in the east that is besieged by ISIS where you have got 

200,000 people. There the airlifts are being attempted to reach that 

population. They are having serious problems with those. And, of 

course, airlifts are terribly expensive and not particularly effective 

oftentimes. But that is another measure of how desperate that population is. 

But to get Syrians back in and to get international health personnel to go back in you are going to have to lay a pathway down 

in which their security is going to be guaranteed and protected. 

This is a much bigger challenge even than trying to get the hundreds of health workers who were needed to go into the three Ebola 

states in 2014 who were terribly worried about evacuation should 

they become infected or at risk, or if they perhaps infect. 

47

So we face big challenges. There are a lot of very courageous people in civil groups and that have stayed behind in ad hoc facilities 

who are doing cross-border operations, who are working from the 

side of Damascus. The Red Crescent has lost hundreds of people in 

this period. There are many courageous people who have stayed to 

try and keep the lights on. And they deserve a great deal of credit. 

Dr. HOTEZ. I agree with all these points. I would like to make 

the additional point that Ebola was relatively easy to contain because it was contained in a relatively isolated area of West Africa. 

Look where the Middle East is, it is at the crossroads of Asia, 

Europe, and Africa. We are already seeing the expansion into 

southern Europe. Dubai is one of the busiest airports. We are going 

to be seeing widespread dissemination across into Pakistan and 

India, and then into sub-Saharan Africa. 

So in terms of priorities in the global health security agenda, I 

think the Middle East has to be one of the most important because 

you are going to see this continuous seeding of three continents 

with infectious diseases. And we are already seeing the beginnings 

of that. 

Mr. BERA. Thank you, Chairman. You have laid out a number of 

challenges that we obviously face. And if we were to start to look 

at these as separate challenges, but interrelated challenges, and 

one challenge is in the refugee camps, whether you are looking at 

Jordan, Lebanon, or Turkey, and how we approach those challenges where safety may be less of the risk, but the conditions 

under which people are living clearly is a risk and an incubator of 

sorts where, if you do have an outbreak things could travel fast. 

So I would segregate that and think about how we address some 

of that challenge. 

Looking internally in Syria or occupied areas within Iraq, safety 

becomes an issue. The infrastructure, Dr. Morrison, you pointed 

out some of the infrastructure that has been decimated certainly 

becomes an issue. And how you get healthcare personnel in there 

may not be as feasible, but how you work with the individuals that 

are still there and the infrastructure there may be a different challenge in how you address that. 

And then we have been talking a little bit about MERS and so 

forth. And, again in, folks that may be traveling to the Hajj and 

then traveling back to their home countries, how you work, whether it is MERS or dengue or Zika virus, how we work with the infrastructure in Saudi Arabia and a country like that. So folks that are 

coming there maybe perhaps getting exposed and then returning to 

all parts of the world how we work. 

And that is I would think about it in three separate ways where 

you may have slightly different solutions. And maybe, Dr. Morrison, if you want to start? 

Mr. MORRISON. Thank you, Dr. Bera. I think those are great 

points. A few, a few thoughts on that. 

One is to keep in mind the demographic transformations going 

on within the region. Syria before the war was 23 million people. 

Syria today is roughly 17 million, and continuing to empty. I do not 

believe, given how devastated this country is, and how you have 

seen the dissolution of sovereign power, unitary sovereign power, 

I do not expect you are going to see many of those who have fled 

48

coming back any time soon, and that there has been a shift of 

thinking today toward those populations in Turkey, Lebanon, and 

Jordan working toward enabling those countries to be able to provide employment opportunities, education, housing, health services, 

and the like to those populations as well as their own citizens, and 

restabilize those societies and make it in their interests to take 

that step. 

And you have got trade deals, you have got the EU stepping forward, this London conference I spoke to. That is a big shift of 

thinking and a very important one. 

On the access internal to within Syria itself, I think we need to 

come at it from multiple directions. The WHO, UNICEF have 

shown extraordinary courage in their operations, though they will 

remain central in trying to use their legitimacy and their record 

and their access to move forward. But there is going to be more 

and more cross-border work. That has been validated and endorsed 

unanimously in the U.N. Security Council resolutions. And those 

corridors can be opened up as well. 

Thank you. 

Mr. BERA. Dr. Raad. 

Dr. RAAD. Mr. Bera, I think you bring a very, very insightful 

thought into this because this is a very complicated problem with 

multiple dimensions and sort of moving variables. And you pointed 

to the fact there needs to be a strategy for the refugees and the 

displaced from, you know, the displaced in these countries like Jordan, Lebanon, and Turkey, versus something else respective to the 

areas that are inside the war zone, if you may, Syria proper, Iraq. 

There are certain areas where we cannot get to like where under 

the control of the Islamic State. So this is a red area where we cannot get to. 

And then there needs to be a contemplation or part of the policy 

of the Hajj and the flux and the movement that has taken place 

and how to handle this. So I think this is why we need a team that 

would be looking into all of this. Because now a lot of groups are 

working from the U.S., and sometimes the right hand is not knowing what the left hand is doing. 

And there is excellent effort, Dr. Morrison has pointed out, and 

great ideas that Dr. Hotez has brought into the picture, but we 

need to integrate this into one common strategy where in these different areas how do we act and how do it? 

This is why the thought in some of these areas we have to rely 

on some of the either the local people or more Arab-Americans that 

are willing to work there, Dr. Morrison mentioned SAMS, the Syrian-American Medical Society. We are Arab-American at our work. 

From various backgrounds and faith value as long as they remain 

neutral and within representing they are a medical-diplomatic 

Peace Corps, if you may, of this country that are moving into this 

area. But it should be part of a bigger picture of the general policy 

that is being devised by your subcommittee and other relevant 

committees. 

Mr. BERA. Dr. Hotez. 

Dr. HOTEZ. I would just mention also the other actor in this 

could be the Russians, doing some cooperative medical diplomacy 

activities with Russia. There is precedent for that. Many people 

49

don’t realize that the oral polio vaccine most of us took as kids was 

developed jointly between the U.S. and Soviets. At the height of the 

Cold War right after the Sputnik launch the two countries put 

aside their ideologies and made the polio vaccine. And they cooperated to make the dry vaccs for smallpox eradication. So there is 

precedent for that and it would be an interesting opportunity to investigate. 

Mr. BERA. Great. Thanks, Dr. Hotez. 

Dr. Morrison, how are medical personnel, and actually any of the 

witnesses, you know, medical personnel that are not attached to, 

you know, that are going into this war zone, how are they perceived by whether it is the Assad regime, whether it is from the 

rebel fighters outside of the Islamic State, are they perceived as 

neutral players coming in for humanitarian need, are they are 

under constant threat as well? 

Mr. MORRISON. In the chairman’s opening statement he referenced the study by the Physicians for Human Rights. That group, 

as well as the International Committee of the Red Cross and Doctors Without Borders, MSF, have carefully documented and tracked 

what has happened in Syria, which is harrowing, which is the deliberate targeting of health personnel and infrastructure. The most 

egregious violence coming from the Assad government, and most 

recently from the Russians. But not limited to that. 

And you have the introduction of radical Islamist dimensions 

into this as well, where it becomes actions taken against Westerners who are seen as carrying a hostile agenda, and they just 

happen to be operating in the health sector. 

So the respective neutrality of these operations has eroded. And 

the degree to which the providers themselves have had their access, their access to populations and their abilities to function have 

narrowed significantly. They don’t have the benefit that in other 

conflicts where you have had a legitimacy and a respect and level 

of protection, where even in a highly-conflicted setting you could 

migrate across lines. Instead you are seen as partisan, as party to 

one side or another, giving active support. And, in fact, serving 

those who are wounded who are combatants as simply implicating 

you, so leaving you open to being attached because it is just part 

of a broader combat operation. 

Mr. BERA. So shifting gears, Dr. Hotez, you talked about what 

it would take for vaccine development. And let’s take leishmaniasis. If we were to be able to appropriate the funds to do the research and come up with, you know, some of these cures or viable 

vaccinations, in your assessment, kind of looking at American 

pharmaceutical companies or global pharmaceutical companies, because you will now have to commercialize some of this, is there a 

market for commercialization or would it, you know, in many ways 

would we have to continue to appropriate those funds or through 

the WHO or other organizations? 

Dr. HOTEZ. Thanks for that question. I think once the product is 

developed there is a commercial market and there is a commercialization plan. It is modest. It is, you know, it is a fraction of 

what some of the other vaccines are that Merck and 

GlaxoSmithKline makes. And even the vaccines are less than a lot 

50

of the small molecular drugs that we all take. So it is a very modest market but it’s not zero, and it should be sustainable. 

Mr. BERA. Okay, great. I will pass——

Mr. MORRISON. May I just add one point,——

Mr. BERA. Yeah, please. 

Mr. MORRISON [continuing]. Dr. Bera. In this last year there 

have been four major studies of what happened in Ebola undertaken by the Stocking panel, the Harvard-London School Panel, the 

National Academies of Medicine, the U.N. Secretary-General’s 

High-Level Panel. All four of those panels, to varying degrees, identified the research and development dimension as this critical gap, 

one where there needs to be a mobilization of resources and a higher level of effort in order to create some kinds of platforms that 

would prioritize those dangerous and neglected diseases for which 

there is no market, and be able to get the early development accelerated through new initiatives. 

And at the Davos, at the World Economic Forum earlier this 

year, a number of players came together to try and build on that 

momentum coming out of Ebola and those four studies and move 

it to the next stage. And that is led by the Norwegians, the 

Wellcome Trust, Gates Foundation, the British Government, and 

others. And that is, that is moving along. 

And I am hopeful—Peter probably knows more about exactly 

what might be in store on this—but it is still in, it is still getting 

worked out. But at some point later in the year I think Ebola convinced us of the need for a higher level of action to correct for this 

and to put us on a different pathway. 

Mr. BERA. And before I yield back let me thank the chairman for 

his leadership in making sure we do not forget about some of these 

neglected diseases that pop up and making sure that we continue 

to focus in on this. 

If we use the Ebola example, we are not that far off from developing a vaccine and developing—is that a correct statement that 

with a concerted effort we could come up with? 

Dr. HOTEZ. Specifically for Ebola now and after there was a big 

investment by the U.S. Government to get it launched, yeah, I 

think we are pretty close. 

Mr. BERA. So we are pretty close. 

If we were to now look back in hindsight and think about how 

much we spent cumulatively globally to maintain, contain and 

treat this last outbreak I am going to guess it is not an insignificant amount of dollars that went into that. Is that? 

Dr. HOTEZ. Well, and I am sure Steve knows those numbers 

probably better than anyone, but the economic impact of Ebola was 

certainly in the billions of dollars. I am sure there is a specific 

number attached to that. 

You can imagine what the economic impact of Zika is going to 

be——

Mr. BERA. Right. 

Dr. HOTEZ [continuing]. On the Caribbean economy, for instance. 

And we are going to see this again now with the diseases coming 

out of the Middle East. It is already in southern Europe. What is 

going to be the impact now of having malaria in Greece? 

51

So there is no question that these innovations will pay for themselves hundreds of times over. 

Mr. BERA. Dr. Morrison, do you have an idea what that number 

is? 

Mr. MORRISON. In terms of the economic costs for west Africa of 

Ebola? 

Mr. BERA. Yeah. 

Mr. MORRISON. The World Bank has tracked that cost fairly carefully and also offered projections. In the first phase of 2014–15 it 

was somewhere in the order of $3 billion to $4 billion, if I recall, 

which may not sound that much, but when you are talking about 

economics of this scale, these three countries have a total population of 22 million people. They are among the poorest countries 

in the world. That is a pretty serious setback. 

And just to add to this, OECD just 2 days ago came in with estimates of what is going to happen in Brazil. And we are looking at 

a 4-percent drop of GDP in Brazil this year. Now, before Zika hit 

they were having trouble. But this can be, this can have profound 

impacts in an economy as big as Brazil’s. 

Mr. BERA. It is fair to say we will have another Ebola outbreak, 

whether it is this year, whether it is 2 years from now. So it is a 

drop in the bucket to not stop now but actually continue and finish 

it and come up with that vaccine and that therapy? 

Dr. HOTEZ. Yeah. As we pointed out getting to launch of a leishmaniasis vaccine or a MERS coronavirus vaccine it is a few million, 

and the economic impacts in the billions. So anybody would tell 

you, any economist would tell you, it is a great investment. It is 

just a matter of getting those initial funds. 

Mr. BERA. Well, let’s go ahead and do that then, so we don’t have 

to, you know, lose those billions on the back end. Thank you. 

And I will yield back, Mr. Chairman. 

Mr. SMITH. Before moving to Mr. Clawson, I appreciate you being 

here, the two questions: One, as we all know, incentives make the 

world go around. You point out, Dr. Hotez, that there are no commercial incentives to develop new tools. And you do point out in 

your testimony, unlike the EU and governments of Japan and several European countries, the United States Government does not 

specifically fund initiatives that support product development partnerships, or PDPs. 

And you mention that there are 16 to 20 PDPs globally. I wonder 

if you could tell us how many are in the United States? 

And what do these other countries do? Are there tax incentives? 

Are they grants? You know, are there a number of best practices 

that we ought to just look to apply to our own situation here in the 

United States, again learning from the EU on this one, and Japan? 

Mr. MORRISON. So thanks. So of the 16 to 20 PDPs, they are 

equally shared between Europe and the United States. So about 

half in the United States, half in Europe. But the way that things 

are working on the European side is they are being mobilized 

through their Ministry of Foreign Affairs. So the Dutch Government has launched a fund for product development partnerships, so 

has the German Government just released one. The Japanese Government has just released one. 

52

And they, the way they operate is through what are called RFAs, 

Requests for Applications. And they are really lifelines for us because the Gates Foundation has dramatically decreased funding for 

PDPs. So Gates Foundation funding for product development partnerships is about half of what it was back in 2008. So some of them 

are really struggling now for survival. And we are going to lose all 

of that innovation expertise. So it is great that the European governments have done this. 

What I have said is, the U.S. Government doesn’t have an easy 

mechanism for funding PDPs right now. They do fund one specific 

one, IAVI, which is the International AIDS Vaccine Initiative, 

they’re a very specific appropriation that goes through USAID. It 

is a pass-through. But beyond that, they don’t really. 

Even if you mobilized 1 or 2 percent of funds for global health 

for PDPs, that would release $100 million to $200 million into the 

system. That would do it right then and there. 

Mr. SMITH. Why has Gates pulled out or at least diminished 

their portion? 

Dr. HOTEZ. This, I don’t know. This current regime is very focused more on supporting directly industry it seems. And so they 

are taking some different routes. And but we will see how long that 

lasts for. 

Mr. SMITH. And one last——

Dr. HOTEZ. They are still, they are still funding us, you know, 

fairly well. 

Mr. SMITH. Yes. 

Dr. HOTEZ. But not as much as they used to. 

But as I said, you know, we know for some of these vaccines, you 

know, $5 million here, $6 million here, $3 million here makes a 

huge difference. We are doing our whole Chagas vaccine project on 

$4 million. We were able to get a schistosomiasis vaccine through, 

from discovery through clinical trials, all the way for $2 million. 

And that was done in part because NIAID rescued us and they 

paid for the clinical trials separately, and they paid for the toxicology tests. 

Mr. SMITH. When might something for leishmaniasis be available? 

Dr. HOTEZ. Well, we could go into manufacturing pretty soon. 

But we don’t have the funds right now. So we could probably go 

into manufacturing by next year or if not earlier. But——

Mr. SMITH. Could we get all the details on that——

Dr. HOTEZ. Sure. 

Mr. SMITH [continuing]. From you? 

Dr. HOTEZ. Yeah, absolutely. 

Mr. SMITH. Appreciate that. 

And one last question on the G20 question. If we, as a subcommittee, put together a letter, which I think would be a great 

idea, I would appreciate if all three of you would provide us insight 

as to what you think ought to be in that letter. 

Dr. HOTEZ. Absolutely. 

Mr. SMITH. Thank you. 

Dr. HOTEZ. You are welcome. 

Mr. SMITH. Yes, Dr. Raad. 

53

Dr. RAAD. Mr. Chairman, I think the issue of vaccines is extremely important. But from my interaction in the area there is a 

tremendous respectability to the healthcare, the U.S. healthcare 

system. And I think we can do a lot with whatever we have as we 

are developing new vaccines. 

For example, the polio is, there is an available vaccine, but how 

to implement it there? The issue of water sanitation, the refugee 

medicine kind of training, the early detection of these diseases. I 

think we have the best healthcare system in the world and they 

look up to us. 

And, again, to improve relationships maybe beyond governments 

with the people, and the people if they would see us as a country 

trying to reach out in a way to provide them better health and opportunity to kind of deal with the catastrophic situation, I think a 

lot can be done. Appropriate use of antimicrobials and training programs for the people who are doing relief, and so forth. 

Mr. SMITH. I saw in your list you mentioned training other 

healthcare personnel for refugee situations. What does that take: 

A weekend, longer? 

Dr. RAAD. It might take a week or 2 weeks on refugee medicine 

and how to deal with different situations. There is tremendous 

need for such initiatives. And on the ground they are effective. And 

they are——

Mr. SMITH. Who are the trainers for the camps? 

Dr. RAAD [continuing]. They are cost effective. You can send 

trainers to train them in areas that are safe like Jordan or possibly 

Lebanon, or maybe other places. But you can—they are very cost 

effective. I mean the whole thing is not a——

Mr. SMITH. Is USAID doing that now? 

Dr. RAAD. I am not sure. I would like to investigate by being in 

touch with them. But this is something that could be emphasized. 

Mr. SMITH. Mr. Clawson. 

Mr. CLAWSON. Sorry I came late, I had another meeting. We are 

often double-booked up here. So appreciate you all hanging around 

long enough to hear my questions. I may very well be repetitive 

since I haven’t heard what has already been asked. So if that is 

the case, I apologize. 

When I think about mosquito-based illnesses I have kind of this 

sequence in my mind that starts with, at least with daytime diseases, mosquito-based diseases, that starts with dengue fever, dengue fever times four strains, then chikungunya, now Zika. And 

each one of those rides the same Trojan horse, the same tiger mosquito. And that there will, therefore, be another Zika or another 

chikungunya. That the movie we have been seeing the last 10 

years or so will continue, and the next one could be even worse 

than Zika and could be, you know, a real disaster. That is how I 

think of it in my mind. 

And so although I like getting rid of stored water or pooling 

water, I like making sure people have air conditioning so they kill 

the larva under the bed, like all those things, it still seems to me 

that until we get something that takes out the tiger, the Aedes 

mosquito, that we are going to see this movie again and again and 

again. And so I don’t know if that is a genetic fix for this mosquito 

54

or if right now it just seems like we are going after the results as 

opposed to the base carrier of these types of diseases. 

Do you all see it the same way I do? And if that is the case, that 

is my theory would say the only long-term solution, at least for this 

strain, is to get on that mosquito. You all agree with what I am 

saying? 

Dr. HOTEZ. Well, I guess I could start. This morning I testified 

to Energy and Commerce; they were holding hearings about Zika. 

I work on the Gulf Coast of Texas and I focused on the fact that 

the Gulf Coast of the U.S., Texas, Louisiana, Mississippi, Alabama, 

and Florida have something very unique. We have not the Asian 

tiger mosquito, which we have that as well, but the real bad actor 

is Aedes aegypti, which is the one that is transmitting Zika——

Mr. CLAWSON. Right. 

Dr. HOTEZ [continuing]. Throughout South America and now into 

the Caribbean. 

The other factor that the Gulf Coast, our states have is poverty. 

And that is not often appreciated as a risk factor. But the reason 

why Zika is wiping out Pernambuco State in Brazil, and now it is 

going to decimate Haiti, is because women who live in poverty have 

no access, live in houses without window screens or holes in the 

window screens, and the environmental degradation around them 

breeds the Aedes aegypti mosquito. 

So I am very worried about the Gulf Coast of the United States 

more than many others. 

And the consequence of that is we need to do something about 

the mosquito. We are not going to have a Zika vaccine in time for 

this epidemic. And so we have been pushing very hard for a program——

Mr. CLAWSON. And just to interrupt. And we are not going to get 

rid of all pooling water in the lower socioeconomic neighborhoods 

that don’t have air conditioning either. We need to work on all of 

that. 

Dr. HOTEZ. Yeah. 

Mr. CLAWSON. I am in southwest Florida. I am on the Gulf too. 

Dr. HOTEZ. Yeah. 

Mr. CLAWSON. So I am really worried about my more humble 

neighborhoods and their ability to fight back if the virus, if this 

mosquito comes north. And I am not sure why it is not there now. 

But it doesn’t seem to be. 

Dr. HOTEZ. It will. I will come north. And so I am quite worried 

we are going to start seeing Zika on the Gulf Coast, including your 

district, starting this spring and summer. 

And so the approach needs to be, one, we know we can go pretty 

far with old-fashioned methods using existing insecticides and getting rid of the garbage, getting rid of the discarded tires on the side 

of the road and doing what you can with water. There are some 

new technologies out there. Whether or not they are going to be 

available, whether they can be shown to be scalable in time for this 

epidemic is unclear. 

Mr. CLAWSON. Are we close on this mosquito? And I got you that 

we need to get rid of tires and other pooling water and have more 

air conditioning and more screen doors. We hear it. But until we 

take out this particular mosquito, not only in our country but parVerDate 0ct 09 2002 09:58 Aug 03, 2016 Jkt 000000 PO 00000 Frm 00058 Fmt 6633 Sfmt 6633 F:\WORK\_AGH\030216\98949 SHIRL
55

ticularly, you go to the Caribbean and you go to Haiti or the Dominican Republic or Curacao, no one has air conditioning. And 

when it rains, there is water everywhere. 

Dr. HOTEZ. That is right. 

Mr. CLAWSON. Dr. Morrison, what were you going to say? 

Mr. MORRISON. I support what Peter has to say which is that 

control of mosquitos is really hard, and it is expensive and it is tedious. And the old methods are still the ones that we are going to 

rely on in this period. And I worry enormously about what is going 

to happen in the areas where Aedes aegypti is endemic in the 

United States. And as it gets warmer those areas are going to become enlarged. 

There are technological fixes that people are exploring: There is 

radiation, there is introduction of bacteria, and there is genetic engineering. Those are the three methods that are actively being explored. I think they are going to get much higher attention in this 

next period, but there are no quick fixes here. 

Mr. CLAWSON. I dropped a bill that would give a 10-percent tax 

credit, like the investment tax credit from years ago, to any company that is working on what you just said. Because I am with you, 

we are, we have got to treat pooling water, but we have also got 

to get at this mosquito. And that is not the typical screen methods 

at night that we would use for a malaria mosquito, right? This is 

a daytime,——

Mr. MORRISON. Right. 

Mr. CLAWSON [continuing]. Indoor, hot zone kind of——

Mr. MORRISON. Right. 

Mr. CLAWSON [continuing]. Critter, right? 

Mr. MORRISON. Right. 

Mr. CLAWSON. Let me ask one other thing and maybe——

Dr. HOTEZ. I would say one other,——

Mr. CLAWSON. Yes. 

Dr. HOTEZ [continuing]. One of the other issues, problems that 

we are seeing in the U.S. is mosquito control is very much done at 

the local level, at the county or city level, and there is a lot of inconsistency in terms of how well that is carried out from county to 

county. 

Mr. CLAWSON. I agree. I agree. 

Dr. HOTEZ. So there is going to be a, I think there is going to 

be some need for Federal Government intervention with these harmonized technologies and coming up with a more consistent——

Mr. CLAWSON. Or standardize what the treatment ought to be, 

even if it is implemented locally. I think my districts are pretty 

good. My counties are pretty good. But lots of times when I travel 

I see people spraying at night. And I say that is going to kill the 

wrong mosquito. 

Dr. HOTEZ. Right. 

Mr. CLAWSON. And so we think we see spraying at nighttime 

that might be a good thing. As far as I can tell from this bug, that 

doesn’t do anything. 

One more question real quick about the Middle East. I mean it 

seems to me that you have distrust of governments, distrust of outsiders in the Middle East in general. Can’t get doctors in. Bad 

water, bad sanitation. It is just an invitation for mosquito-based inVerDate 0ct 09 2002 09:58 Aug 03, 2016 Jkt 000000 PO 00000 Frm 00059 Fmt 6633 Sfmt 6633 F:\WORK\_AGH\030216\98949 SHIRL
56

fectious diseases, and all infectious diseases. And I don’t even know 

where to start in that environment. 

By the way, I am not sure it is American. I mean I think it in 

Southeast Asia and Africa there are a lot of people that looked at 

other refugee crises and had to set up sanitation real quick in previous wars. I am not sure it even has to be America. But I see that 

big, wide problem. And unless resources, even if it is regional, unless we can come in, it is going to be hard to solve it. Am I right 

on that, Doctor? 

Dr. RAAD. I fully agree with you. I think it is, as we mentioned 

earlier,——

Mr. CLAWSON. Sorry I missed it. 

Dr. RAAD [continuing]. It is a complicated problem, it is multifaceted, and it is not one size fits all. I mean we need to kind of 

handle it in different areas in different ways. 

For example, there needs to be a policy for how you deal with 

the refugees and the problems related to that? How do you deal 

within the areas which are the combat zone or may be difficult to 

enter to? There has been one other issue is the issue of the Hajj 

and where you have the aggregation of people, whether it is in 

Saudi Arabia, or possibly Iraq and some other places, and so forth. 

Water sanitation and the implication of what is happening now of 

the sewage being directed into the water supply for these areas 

from the areas where the Islamic State is. 

So it is a complicated problem but I think it needs to be dealt 

with systemically, in a multi-faceted manner creatively. I think 

there needs to be some creativity because in some areas. But I believe that what you are saying is very true, but the response should 

be insightful, should be practical, and should be creative. And I 

think a lot will be done. 

The other factor is one has to account for the fact that the problem is escalating and it has so many variables that are moving targets occurring that this is why there needs to be a special attention 

through a concerted effort. And maybe a joint project between 

NGOs——

Mr. CLAWSON. In some conflicts more people die of illnesses than 

they do from gunshots or bombs. 

Dr. RAAD. That is very true. 

Mr. CLAWSON. What about in this case? 

Dr. RAAD. Which is true. For example, I gave some figures. An 

area which is not really in the major conflict, Egypt, where the conflict is mainly in Sinai, but people are dying, there are more casualties from hepatitis C in Egypt over the last 5 years than there 

are from the war in Syria. 

Mr. CLAWSON. Yeah. 

Dr. RAAD. Actually, you know, 1⁄4 million in Syria killed during 

the war. There certainly in all these outbreaks have resulted in a 

lot of people killed because of these infectious outbreaks because of 

the Syrian-Iraqi conflict, if you may. So I fully agree with you. 

Mr. CLAWSON. Dr. Morrison. 

Mr. MORRISON. There has been various efforts made in this current, these current wars and in the past to try and estimate mortality from various sources. And the data remains weak oftentimes. 

But there seems to be across multiple cases a pattern where a subVerDate 0ct 09 2002 09:58 Aug 03, 2016 Jkt 000000 PO 00000 Frm 00060 Fmt 6633 Sfmt 6633 F:\WORK\_AGH\030216\98949 SHIRL
57

stantial, a substantial portion of mortality comes through the decay 

of your health system. 

Mr. CLAWSON. Okay, so let me interrupt. Can I have 1 more 

minute on it? 

What do we spend on bombs and guns and killing versus what 

do we spend on preventing disease? 

Mr. MORRISON. That is a big question. 

Mr. CLAWSON. I know you have got a, I know you thought of this 

now. Come on now. I know you all thought of this, right? We spend 

a lot more on bombs. 

Dr. RAAD. I think that, yeah. 

Mr. CLAWSON. I’m just asking. 

Dr. RAAD. I think this is the whole point that we, we together 

were trying to bring, that a lot could be done if we appropriately 

use these resources in a targeted manner. And that would reflect 

a certain view in the region, particularly among the people. It is 

people to people of how they view the United States of America. 

That we are not involved in the conflicts through the only really 

kind of the war sort of policy that we have, which is legit and certainly we are fighting terrorists. But there is another side initiative 

of this great country where we are reaching, where we are the kind 

of hosts of groups like Doctors Without Borders and so forth, that 

we are making initiatives on the ground and we are having people 

move on the ground. 

And this, this had a tremendous impact in west Africa with the 

Ebola virus, and could have a tremendous impact on the people 

and, ultimately, the governments in the area. If we have a good 

policy that will deal with this crisis and we come as the people are 

trying to solve a major catastrophic problem——

Mr. CLAWSON. You would agree in the case, I mean I have a close 

friend who is a physician that went to Africa to fight the Ebola outbreak, as an example, university professor, physician, et cetera. A 

lot of Americans, Americans are great that way, right? If there is 

a problem around the world, we are always one of the few that 

swashbuckle and get on over there to help out, right? 

Dr. RAAD. Yes. 

Mr. CLAWSON. But it is a lot harder in war zones. And it is a 

lot of our dollars that are going in there to, right, to defend and 

make war. So maybe in those zones we ought to think how can we 

also offset part of that with medical——

Dr. RAAD. That is true. 

Mr. CLAWSON [continuing]. And sanitation. 

Mr. MORRISON. Congressman, we were talking earlier about the 

response to the human crisis that has grown out of the Syria war 

and has spilled into the region and now spilled into Europe. The 

United States’ engagement on that side has amounted to $4.4 billion since the Syrian war started in March of 2011. 

The military side of the equation has been largely, within that 

region we have been scaling down our military engagement, but 

only recently scaling up with the coalition campaign against ISIS. 

Right? That is the central investment that we are making within 

that region on a military ground. So I mean you——

58

Mr. CLAWSON. The President’s original ask was $5 billion or $6 

billion, something like that, correct? To train Syrian insurgents, as 

I recall. 

Mr. MORRISON. I don’t remember the exact number that was 

made in terms of the training. 

Can I come back to one point that you raised about the Zika response, just to get back to that? 

Mr. CLAWSON. Sure. 

Mr. MORRISON. Because I want to, before we run out of time I 

wanted to make one important point. 

Mr. CLAWSON. You know, the chairman over here might have a 

different view on that. But go ahead. Are you all right here, boss? 

Mr. SMITH. Yes. 

Mr. CLAWSON. Alright. 

Mr. MORRISON. You know, it is going to be very important in this 

period that the CDC be able to bring forward additional capacities 

and resources to states and communities that are attempting to address these threats through a variety of different measures of sanitation, water, screening, air conditioning. But and the current, the 

current $1.9 billion request, emergency request that is up here for 

consideration includes I think it is almost $900 million to meet that 

need. 

Mr. CLAWSON. Seems low. 

Mr. MORRISON. And——

Mr. CLAWSON. If I wanted to do an economic impact of an outbreak in south Florida, I could probably get to that number just in 

Florida pretty quick. Am I right? You all agree with that? So it 

seems low, $1.9 billion just seems low. Just a cursory view of it, 

seems low. 

Dr. HOTEZ. Well, I think you have to remember the consequences. If we start seeing clusters of microcephaly cases appear 

on the Gulf Coast by the end of this year, it is going to be spoken 

about in the same context as Hurricane Katrina or the BP oil spill. 

Mr. CLAWSON. Seems low. 

Dr. HOTEZ. So, yes. 

Mr. CLAWSON. But the human cost would be hard to describe, 

right? 

Mr. MORRISON. When you look at the costs I think it is important 

to keep in mind, we are not talking about a crisis of Zika and of 

the mosquitos, we are talking about a crisis of microcephaly. 

Mr. CLAWSON. No, I understand that. I got you. 

Mr. MORRISON. And the population that is most vulnerable is the 

pregnant women or women who are to become pregnant. 

Mr. CLAWSON. Right. In poor neighborhoods. 

Mr. MORRISON. In poor neighborhoods in particular. 

Mr. CLAWSON. Where there is no air conditioning. 

Mr. MORRISON. And so, so we need to, we need to keep our eye 

on the ball in terms of what the most vulnerable population in 

need is. 

Mr. CLAWSON. And what was the basis for the $1.9 billion? What 

is the——

Mr. MORRISON. Well, that has been detailed in the request. It 

breaks it into its different component parts. 

Mr. CLAWSON. Right. 

59

Mr. MORRISON. They were making an estimate of the requirements in this first phase to get moving. And I think the urgency 

around this is what Peter is referring to, which is we do not know 

if we are going to see 8, 9, 10 months out or beyond, if we are going 

to see a proliferation of microcephaly. 

Mr. CLAWSON. But you all would agree, and again let me, you all 

agree with me, even if it is not—remember where I started—even 

if it is not Zika, it is going to be something riding the back of this 

particular mosquito. So whatever money that we spend, even if 

Zika is not an outbreak, we might be very likely preventing a future outbreak in whatever we do to attack Zika now. Even if Zika 

isn’t our worst case scenario, there will be another one on this, on 

the Tiger mosquito that is going to get us. 

Mr. MORRISON. No, this Aedes aegypti mosquito that is endemic 

in these coastal areas, 23 million people live in those areas, this 

same mosquito carries dengue. 

Mr. CLAWSON. And chikungunya. 

Mr. MORRISON. And you have had outbreaks that have been 

brought under control. 

Mr. CLAWSON. That is my point. 

Mr. MORRISON. I mean there was an outbreak in Key West of 

dengue in 2009–2010 that was brought under control. So it stands 

to reason that many of the same measures that have protected 

Americans against dengue and chikungunya—correct me, Peter, if 

I am wrong—are, should be applicable in this instance with lots of 

modifications around the, around the threat module. 

Mr. CLAWSON. Right. Which is why I would like more than $1.9 

billion. It just seems like cheap money for future lives and problems. 

And with that I will—and I really like the CDC, by the way. 

With that I yield back. 

Mr. MORRISON. Thank you very much. 

Mr. CLAWSON. Thanks for the time. Appreciate you all—sorry I 

came in late—appreciate you all’s input here. 

Dr. RAAD. Thank you. 

Mr. SMITH. Thanks, Mr. Clawson. And thank you. 

Anything you would like to say before we conclude the hearing? 

Mr. MORRISON. Just thank you. 

Mr. SMITH. Oh, I mean anything on the subjects. 

Dr. HOTEZ. Well, thank you for raising this issue because this 

has been beow everybody’s radar screen, and yet it is so important. 

Mr. SMITH. Thank you for the insights and counsel. And we do 

have a lot of things to do in follow-up. 

The hearing is adjourned. 

Mr. CLAWSON. Thank you, Mr. Chairman. Really good job. 

[Whereupon, at 3:50 p.m., the subcommittee was adjourned.] 

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