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21–437 PDF 2005

S. Hrg. 109–139

EXAMINING USAID’S ANTI-MALARIA POLICIES

HEARING

BEFORE THE

FEDERAL FINANCIAL MANAGEMENT, GOVERNMENT 

INFORMATION, AND INTERNATIONAL SECURITY

OF THE

COMMITTEE ON 

HOMELAND SECURITY AND 

GOVERNMENTAL AFFAIRS 

UNITED STATES SENATE

ONE HUNDRED NINTH CONGRESS

FIRST SESSION

MAY 12, 2005

Printed for the use of the 

Committee on Homeland Security and Governmental Affairs

(

(II)

COMMITTEE ON HOMELAND SECURITY AND GOVERNMENTAL AFFAIRS 

SUSAN M. COLLINS, Maine, Chairman 

TED STEVENS, Alaska 

GEORGE V. VOINOVICH, Ohio 

NORM COLEMAN, Minnesota 

TOM COBURN, Oklahoma 

LINCOLN D. CHAFEE, Rhode Island 

ROBERT F. BENNETT, Utah 

PETE V. DOMENICI, New Mexico 

JOHN W. WARNER, Virginia 

JOSEPH I. LIEBERMAN, Connecticut 

CARL LEVIN, Michigan 

DANIEL K. AKAKA, Hawaii 

THOMAS R. CARPER, Delaware 

MARK DAYTON, Minnesota 

FRANK LAUTENBERG, New Jersey 

MARK PRYOR, Arkansas

MICHAEL D. BOPP, Staff Director and Chief Counsel 

JOYCE A. RECHTSCHAFFEN, Minority Staff Director and Counsel 

TRINA D. TYRER, Chief Clerk 

FEDERAL FINANCIAL MANAGEMENT, GOVERNMENT INFORMATION, AND 

INTERNATIONAL SECURITY 

TOM COBURN, Oklahoma, Chairman 

TED STEVENS, Alaska 

GEORGE V. VOINOVICH, Ohio 

LINCOLN D. CHAFEE, Rhode Island 

ROBERT F. BENNETT, Utah 

PETE V. DOMENICI, New Mexico 

JOHN W. WARNER, Virginia 

THOMAS CARPER, Delaware 

CARL LEVIN, Michigan 

DANIEL AKAKA, Hawaii 

MARK DAYTON, Minnesota 

FRANK LAUTENBERG, New Jersey

KATY FRENCH, Staff Director 

SEAN DAVIS, Legislative Assistant 

SHEILA MURPHY, Minority Staff Director 

JOHN KILVINGTON, Minority Deputy Staff Director 

LIZ SCRANTON, Chief Clerk 

(III)

C O N T E N T S 

Opening statements: Page 

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

Senator Carper ................................................................................................. 7

WITNESSES 

THURSDAY, MAY 12, 2005

Hon. Sam Brownback, a U.S. Senator from the State of Kansas ........................ 3

Michael Miller, Deputy Assistant Administrator, Bureau of Global Health, 

U.S. Agency for International Development ...................................................... 8

Roger Bate, Ph.D., Resident Fellow, American Enterprise Institute, and U.S. 

Director, Africa Fighting Malaria ....................................................................... 20

Amir Attaran, Associate Fellow, Royal Institute of International Affairs, London, England, and Canada Research Chair, Institute of Population Health 

and Faculty of Law, University of Ottawa, Canada .......................................... 23

Carlos C. ‘‘Kent’’ Campbell, M.D., Program Director, Malaria Control and 

Evaluation Program in Africa ............................................................................. 24

ALPHABETICAL LIST OF WITNESSES

Attaran, Amir: 

Testimony .......................................................................................................... 23

Prepared statement with attachments ........................................................... 97

Bate, Roger, Ph.D.: 

Testimony .......................................................................................................... 20

Prepared statement .......................................................................................... 50

Brownback, Hon. Sam: 

Testimony .......................................................................................................... 3

Prepared statement .......................................................................................... 39

Campbell, Carlos C. ‘‘Kent’’, M.D.: 

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

Prepared statement .......................................................................................... 126

Miller, Michael: 

Testimony .......................................................................................................... 8

Prepared statement .......................................................................................... 43

APPENDIX

Charts submitted by Senator Coburn: 

‘‘Malaria: Preventable, Curable, Controllable, The Inexcusable Failure 

of Public Health’’ ........................................................................................... 132

‘‘Malaria Cases and Deaths—South Africa, 1971–2000’’ ............................... 133

‘‘KwaZulu-Natal, South Africa: What can a little DDT and Coartem do?’’ .. 134

‘‘Number of Houses Sprayed Compared to Number of Cases of Malaria 

Above the Rate Expected if Spraying Had Continued’’ ............................. 135

Additional copy submitted for the record from Senator Coburn .......................... 136

Responses to Questions for the Record submitted to Michael Miller from 

Senator Coburn with attachments ...................................................................... 145

(1)

EXAMINING USAID’S ANTI-MALARIA POLICIES 

THURSDAY, MAY 12, 2005

U.S. SENATE, SUBCOMMITTEE ON FEDERAL FINANCIAL MANAGEMENT, GOVERNMENT INFORMATION, AND INTERNATIONAL SECURITY, 

OF THE COMMITTEE ON HOMELAND SECURITY

AND GOVERNMENTAL AFFAIRS, 

Washington, DC. 

The Subcommittee met, pursuant to notice, at 10:37 a.m., in 

room SD–562, Dirksen Senate Office Building, Hon. Tom Coburn, 

Chairman of the Subcommittee, presiding. 

Present: Senators Coburn and Carper. 

OPENING STATEMENT OF SENATOR COBURN 

Senator COBURN. The hearing will come to order. We do have 

some intervening business in the Judiciary Committee so this hearing may be interrupted for votes on judges coming out of the Judiciary Committee. 

Good afternoon. Today’s hearing will examine the U.S. Agency 

for International Development’s efforts to control the spread of malaria throughout Africa. When I learned that funding for USAID’s 

malaria program had increased from $14 million in 1998 to $90 

million in 2005, I wasn’t expecting to find that the number of 

deaths due to malaria had, in fact, increased by about 10 percent. 

Not only hasn’t the stated goal of reducing malaria by 50 percent 

been achieved, the actual number of deaths have increased. How 

can this be? That is what we hope to learn during the course of 

this hearing. 

Recently, I have read reports on USAID’s anti-malaria program. 

An author of one such paper, Dr. Bate, is testifying here today. In 

preparing for this hearing, I was struck by the lack of accountability and transparency on the part of USAID in providing a 

breakdown of how the agency allocates its malaria budget. For instance, how much money does the agency actually spend on interventions to prevent the further spread of the disease? How much 

funding goes to contractors? And, more to the point, why hasn’t the 

agency provided this information when it was precisely asked to do 

so? 

I intend to ask the Government Accountability Office to conduct 

an audit of USAID’s malaria program because I believe the citizens 

of this country have a right to know how their tax dollars are being 

spent. 

Malaria still claims a million victims annually, with over 90 percent of those deaths occurring in Africa. It is a preventable, treatVerDate 0ct 09 2002 11:52 Nov 21, 2005 Jkt 021437 PO 00000 Frm 00005 Fmt 6633 Sfmt 6633 C:\DOCS\21437.TXT SAFFAIRS PsN: PHOGAN
2

1The chart entitled ‘‘Malaria: Preventable, Curable, Controllable, The Inexcusable Failure of 

Public Health,’’ appears in the Appendix on page 132. 2The chart entitled ‘‘Malaria Cases and Deaths—South Africa, 1971–2000,’’ appears in the Appendix on page 133. 

able disease. An even more daunting statistic is that malaria kills 

a young African child every 30 seconds. USAID can’t be proud of 

this track record. 

Representatives of USAID have testified in the past that the 

agency supports the use of indoor residual spraying and insecticidetreated nets to prevent new infections. However, the fact is USAID 

has never been a strong proponent of these methods and did not 

push for the use of indoor residual spraying and insecticide-treated 

nets despite the fact that such interventions have proven to be successful when they were used by the agency in the 1950’s and 

1960’s. Most recently, such interventions were very successful in 

reducing malaria in South Africa and Zambia. 

Another disturbing issue is the resistance on the part of USAID 

to stop using ineffective drugs to combat malaria. The American 

Enterprise Institute’s paper entitled: ‘‘The Blind Hydra,’’ provides 

evidence from a project consultant to the World Relief project, Dr. 

P. Ernst. Dr. Ernst related that efforts to convince USAID and 

UNICEF to change the type of drug included in its drug kits distributed to First Aid posts have failed. He went on to say: ‘‘Even 

today, children in Chokwe receive ineffective medicine.’’ That was 

in 2004. I believe this to be completely unacceptable since the cost 

for a full treatment, the smallest pack (young children) costs 90 

cents and the largest pack (adults) costs $2.40. 

This Subcommittee notes that there are important questions 

about the policy choices USAID has made. However, we are also 

deeply concerned about the failure of the agency to provide accurate information to the public about its activities. If the Congress 

and the public do not know what is being spent and for what purpose, how can results be assessed? With that in mind, we will explore those issues with our witnesses. 

In conclusion, I would like to call your attention to several charts 

that are displayed in front of the dais. 

The first chart,1 entitled ‘‘Malaria: Preventable, Curable, Controllable, The Inexcusable Failure of Public Health.’’ What this chart 

points out is that 2.5 billion people in 90 countries around the 

world are at risk for malaria. That is alarming, since we are talking about 40 percent of the world’s population. 

Malaria represents the most life-threatening infection in the 

world, 500 million acute illnesses every year, 90 percent of these 

are in sub-Saharan Africa. Malaria claims 3,000 people every day, 

and up to 90 percent of these deaths occur in pregnant women and 

children under the age of five. Malaria accounts for as much as 40 

percent of public health expenditures, 30 to 50 percent of inpatient 

admissions, and up to 50 percent of outpatient visits. Children that 

survive can suffer brain damage, or experience cognitive learning 

deficits. 

The next chart,2 ‘‘Malaria Cases and Deaths—South Africa, 

1971–2000,’’ shows the dramatic rise in the number of deaths attributable to malaria when the government was pressured into 

stopping its program of spraying with DDT. South Africa had been 

3

1The chart entitled ‘‘KwaZulu-Natal, South Africa: What can a little DDT and Coartem do?’’ 

appears in the Appendix on page 134. 2The chart entitled ‘‘Number of Houses Sprayed Compared to Number of Cases of Malaria 

Above the Rate Expected if Spraying Had Continued,’’ appears in the Appendix on page 135. 3The prepared statement of Senator Brownback appears in the Appendix on page 39. 

successful in controlling malaria for years with DDT. The chart 

shows the number of new cases and deaths increased dramatically 

when DDT was no longer being used. 

The next chart,1 ‘‘KwaZulu-Natal, South Africa: What can a little 

DDT and Coartem do?’’ This chart shows that when the government reinstated the use of effective drug therapy with Coartem 

(ACT drug) and the spraying of DDT, the number of cases fell dramatically. 

The last chart,2 ‘‘Number of Houses Sprayed Compared to Number of Cases of Malaria Above the Rate Expected if Spraying Had 

Continued’’ (data from the countries of the Americas) clearly illustrates that the resurgence of malaria is directly linked to DDT 

spraying (bar graph—as the number of sprayed houses decreased, 

the excess cases over the amount seen during spraying exponentially increased). 

We will hold for Senator Carper’s opening statement and I would 

like to recognize Senator Sam Brownback, who has a special interest in this area and also in terms of reform. We would like to ask 

our witnesses to limit their testimony to 5 minutes. Senator 

Brownback, it is a pleasure to have you before our Subcommittee. 

It is my hope through your interest and your initiative that some 

of these people in the future have a greater opportunity to be treated and their lives saved and the quality of their life improved. Senator Brownback. 

TESTIMONY OF HON. SAM BROWNBACK,3 A U.S. SENATOR 

FROM THE STATE OF KANSAS 

Senator BROWNBACK. Thank you, Dr. Coburn. I appreciate that. 

I appreciate you holding the hearing on this topic. It is one that 

is near and dear to my heart. 

I have traveled to some of these regions. And it is one of those 

situations where you see somebody or a group suffering and dying 

and you look at the numbers and you have got basically, in some 

cases, 40- and 50-year-old technology that is cheap that can solve 

this and you go, absolutely, why? ‘‘Why is this taking place? And 

this shouldn’t happen.’’ You went through the numbers. This is a 

horrific situation and it is a real shame that the world has allowed 

this to happen. 

We used to have malaria in the United States and in Southern 

Europe and we went aggressively about dealing with it and malaria is not there today, although some cases now start to come 

back in because of what is happening in other parts of the world. 

We have a cure for this. We don’t even really need to spend new 

money, just to take the money we are currently spending and 

spend it in places that actually cure people and you are going to 

save lives. So here is one case where we can save hundreds of thousands, if not millions, of lives, not spend new money, just spend the 

current money appropriately in the process. This just makes all the 

sense in the world. 

4

And then I ask myself, ‘‘well, why isn’t it happening?’’ I traveled 

to Uganda. I have been in the Sudan. I met with officials from the 

U.N. I met with individuals from these countries. And the best that 

really I have concluded is we are spending most of our money on 

consultants and on meetings and not on getting actual care taken 

out in the field. 

One scene I was in, in Northern Uganda, in the Gulu region, 

children come in every night, these ‘‘night commuters,’’ they are 

called. There will be 500, 1,000, even more kids that will commute 

into a city, some of them walking five miles each way just so they 

don’t get abducted at night by the Lord’s Resistance Army. So their 

parents every night will send these kids from 3 to 12 years of age 

into this area. It is an incredible scene. 

And they are not fed when they get there, but they are within 

a fenced area, a tin roof, cement floor, and they are cared for. But 

the walls aren’t sprayed with DDT and mosquitoes lurk in the 

area. So while they may be protected from the Lord’s Resistance 

Army, they are not from malaria. A simple application would take 

place that is not going to harm the environment, and save how 

many children from getting malaria? And you look at this and go, 

‘‘why isn’t this taking place?’’

DDT has a bad name. It is associated with The Silent Spring,

Rachel Carson’s book. It certainly was overused in areas at prior 

times and did contribute to degradation in some bird species. But 

we are not talking about widespread use of DDT. We are talking 

about very targeted indoor spraying and some very targeted pools 

around where people are. So this is not the widespread aerial application that we have seen and done in North America and Europe. We are talking about a very targeted area. Yet the world 

community still seems to be very hesitant and would rather not 

take this no-risk action, would rather see the kids and mothers die. 

That is just a completely unacceptable answer to me. It should be 

unacceptable to us as a government. 

So I have introduced S. 950, the Eliminate Neglected Disease Act 

of 2005. It directs interventions, directs the spending by our government to these effective means instead of conferences and consultants. Let us use these funds for applications in the field. We 

require accountability, transparency, scientific and clinical integrity, coordination, and priority setting. 

It is a simple bill. It is sponsored by your colleague from Oklahoma, and by Senator Landrieu, both of whom are Africa hands, 

if I might say. Senator Inhofe has travelled to Africa perhaps more 

than any other U.S. Senator. Senator Landrieu heads a caucus on 

Uganda, has a deep heart for the region, and I do, as well. 

I just would say in conclusion, Mr. Chairman and Senator Carper, that we will stand judged if we don’t do something effective 

here, when we have the money, we have the ability, and then don’t 

do something. This is wrong, what we are currently doing, and we 

do need to change this. I think if we really, even in this room, band 

together to do this, we will be able to get this changed and we will 

save hundreds of thousands of lives in the process, and probably 

not spend another dime. Thank you. 

Senator COBURN. I would like to recognize my friend, Senator 

Carper, and if you have an opening statement, I would be happy 

5

to have you give that now and then we will talk with Senator 

Brownback. 

Senator CARPER. Rather than give my statement—I have just a 

short statement I want to give, but can we just go back and forth 

with the witness——

Senator COBURN. Sure. 

Senator CARPER [continuing]. And he can be on to his next stop. 

Thanks. Good to see you, Sam. 

Senator BROWNBACK. Good to see you. 

Senator COBURN. Senator, let me ask you some questions. Some 

would say that by insisting that USAID money is spent on certain 

types of intervention, your bill hamstrings countries’ malaria programs and tells governments what to do. How do you respond to 

that claim? 

Senator BROWNBACK. The only government we tell to do anything 

is the U.S. Government. We direct funds towards actual treatment 

because, to date, when you have given broad authority, it has gone 

more towards conferences and meetings rather than actual application. 

And in the countries that I have met with, what they desperately 

want are actual treatments out in the field. They want buildings 

sprayed with DDT, the inside of buildings. They want bed nets that 

have DDT in it or other effective treatments dispersed and distributed. That is what they want, as well. 

So the only country we are directing what to do is the U.S. Government. And number two, from the countries that—primarily subSaharan Africa—that I have visited with, this is exactly what they 

want to see take place that is not taking place today. 

Senator COBURN. How would you answer those who are concerned about DDT and its effect on aviary species in terms of how 

do you control the total limit and the exposure, even if you are 

doing isolated exposure? Does it not, in fact, have some impact? 

Senator BROWNBACK. I don’t think there is any record anywhere 

that says that it does. What we did in the United States when this 

was a problem, particularly with the bald eagle, which was the 

most known species, we had widespread application of this in agricultural settings using aerial application. Much of which then drifts 

into streams and rivers, then ingested in amphibian life that is 

taken up by the eagles and that is then where you see the egg shell 

much softer. My background is in agriculture. I have worked with 

these issues. I have regulated these things in the past in an agency 

I ran when I was State Secretary of Agriculture in Kansas. So you 

had an enormous build-up of this in a broad system where we had 

used it for decades. 

Here, you are talking about somebody going in with a hand 

sprayer inside of a hut or a small building and spraying the walls 

once every 6 months. The ability of this to flow into the rivers and 

then build up in any quantity in the amphibian life is minimal to 

anything and certainly not anywhere comparable to what we did in 

the United States in the 1950’s, and there is no track record at all 

that this hurts avian species at all anywhere. 

Plus, you know, balance is back and forth. We can’t find any risk 

there, and we will save hundreds of thousands of children in the 

process. That seems to me as absolutely worth doing. 

6

Senator COBURN. In your queries on this program, have you been 

able to find out the number of people actually treated for malaria? 

Senator BROWNBACK. I don’t have that. By our programs actually 

treated? 

Senator COBURN. No, by your inquiry into what is going on now. 

Anywhere, have you been able to find the data that would say the 

number of people who have actually been treated with medicines 

who have malaria, the number of facilities that have been sprayed 

with indoor spraying, the number of actually treated nets that have 

been given out? Anywhere, have you been able to find those numbers? 

Senator BROWNBACK. No, I haven’t. We did hold a hearing last 

year in Foreign Relations on this topic and had several experts in 

that gave broad estimates, but we don’t—and that was global, but 

we do not have U.S. funded numbers, and to my knowledge, 

USAID has been unwilling to provide those or unable to provide 

those to date. 

Senator COBURN. Senator Carper. 

Senator CARPER. Again, welcome. 

What do the folks at USAID say about what you are suggesting? 

Sort of play the devil’s advocate and explain what their rationale 

is. Why do they agree or disagree with you? Where do they agree? 

Where do they disagree? 

Senator BROWNBACK. I think you will have them up on the witness stand, and I have met with the head of USAID. I have met 

with individuals there. We have had them in to testify. 

They generally don’t disagree with the things that I am saying, 

but there is difficulty. You do get push-back on the use of DDT in 

any setting other than in bed nets and it is a harder route to go. 

We do get some resistance, and instead of pushing on through, it 

has been more, ‘‘let us just keep going pretty much the way we are 

going and we think we are going to get there.’’

My problem is, every day you don’t get there, somebody else dies, 

thousands die. And number two, we are not getting there. The 

overall numbers show we are losing ground, not gaining ground. I 

think this is an emergency, that you really should move forward 

aggressively rather than timidly. 

Senator CARPER. Who are the other players other than us, other 

than USAID? I guess World Bank is in it, but who are the other 

major players that are involved in this? How do their efforts complement ours or duplicate ours? 

Senator BROWNBACK. There are several players. The U.N. has a 

program, and the Global Fund. We have bilateral efforts. And then 

I believe the Europeans have some efforts, but I am not that familiar with what they are doing. 

Some of these are doing a good job of providing actual spraying 

of the new level of drugs. The older level of drugs, there has been 

a great resistance built up and a number of them aren’t effective. 

So you have a mixed bag of other players, some doing a pretty 

good job, the U.N. doing a horrible job, having set a target of reduction of malaria in half by 2010 and the number has actually gone 

up since they set that target. 

7

Senator CARPER. Is there an effort underway to coordinate the efforts of these diverse parties to ensure that we are not duplicating 

one another but we are complementing one another’s efforts? 

Senator BROWNBACK. There is communication. I don’t know, Senator Carper, if they have got a regularized system where, ‘‘we are 

going to work in this country and you are going to work in that 

country,’’ but there is a clear communication. I don’t know otherwise the degree of how much it is hard-wired within their system. 

That is a good question to ask and to have in the implementation. 

Senator CARPER. I will probably ask it again, then. Thanks. It is 

good to be with you. Thanks for being here. 

Senator BROWNBACK. Thanks. 

Senator COBURN. Senator Brownback, thank you so much, first 

of all, for your caring and your interest in this subject, but thanks 

for coming to testify before us today. We will make sure you get 

the results of this hearing. 

Senator BROWNBACK. And I would like to offer one of my great 

staff members, Katy French, to help you out in this process. She 

has been my lead person on this. She is excellent and——

Senator CARPER. What does Katy look like? [Laughter.] 

Senator BROWNBACK. She is going to be the Staff Director here, 

I believe, in the next couple of days, and she is right behind me, 

does a great job on these topics, excellent. 

Senator COBURN. Thank you very much. 

Senator BROWNBACK. Thank you, Mr. Chairman. 

Senator COBURN. Next, I would like to recognize Michael Miller, 

Deputy Assistant Administrator, Bureau of Global Health. 

Senator CARPER. Mr. Chairman, before you do that, you were 

kind enough to ask me if I would like to give a statement——

Senator COBURN. Absolutely. Please do. 

Senator CARPER [continuing]. And now that Senator Brownback 

has left, let me just mention a couple of things, if I could. 

Senator COBURN. Absolutely. 

OPENING STATEMENT OF SENATOR CARPER 

Senator CARPER. Thanks for holding the hearing and for the staff 

pulling folks together to let us hear from them. 

As you all know, this hearing today focuses on an important 

issue. It is actually a life or death issue for a whole lot of people. 

Despite years of work that aimed at dramatically reducing malaria 

deaths, the toll this disease takes on communities in some parts of 

the world, at least, appears to be growing, as Senator Brownback 

has suggested. 

With this in mind, we have a responsibility on the Subcommittee, 

and I think in the Congress, to examine how Federal agencies, especially USAID, have been spending our tax dollars dedicated to 

this war on malaria, and there are probably some steps that 

USAID can take that they are taking, Mr. Chairman, to improve 

its financial management and transparency. We just have to be 

careful, though, before quickly drawing too many conclusions about 

how USAID is addressing malaria and how it should address malaria in the future. The work that the USAID does or doesn’t do 

will have a tremendous impact on the organizations it works with 

8

1The prepared statement of Mr. Miller appears in the Appendix on page 43. 

on the ground and ultimately on with respect to the lives of millions of people. 

The Global Fund to fight AIDS, tuberculosis, and malaria is currently spending hundreds of millions of dollars, I am told, to purchase bed nets and anti-malaria drugs to be distributed in the most 

vulnerable areas to prevent and treat malaria outbreaks. U.S. taxpayers, I believe, are paying for about one-third of that effort. 

At the same time, the World Bank recently announced that they are prepared to spend about $1 billion on a similar effort on their 

own, and I suspect that the United States will be a major contributor to that effort, too. 

And we are going to hear today from some true experts on malaria and other health issues in the developing world. I certainly 

look forward to hearing their views on the effectiveness of current 

U.S. and global efforts to fight malaria. Most importantly, I would 

like to hear about how USAID can best use its $80 million malaria 

budget to supplement the extensive work and to complement the 

extensive work that is being done by other organizations. 

So again, I appreciate the opportunity to participate in this hearing and look forward to hearing from our witnesses. Thanks, Mr. 

Chairman. 

Senator COBURN. Thank you, Senator Carper. 

Mr. Miller, Deputy Assistant Administrator, Bureau of Global 

Health, USAID, first of all, welcome. 

Mr. MILLER. Thank you. 

Senator COBURN. We look forward to your testimony. Your written testimony will be made a part of the record and I would like 

for you to limit your oral comments, if you can, to 5 minutes. I 

would also say again we are close to a vote in the Judiciary Committee, and if I might be able to be excused and you take over for 

me so I can do that, I would appreciate that. 

Senator CARPER. You bet. Or I could vote in the Judiciary Committee for you. [Laughter.] 

Senator COBURN. I would like to do the vote. 

Senator CARPER. You send me where I can do the most good. 

[Laughter.] 

Senator COBURN. Mr. Miller, thank you. 

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

FOR INTERNATIONAL DEVELOPMENT 

Mr. MILLER. Thank you, Senator Coburn and Senator Carper. It 

is certainly a pleasure to be here and we thank you for the opportunity to come up and testify. 

A couple of points that are not in my prepared statement are I 

would just say that no institution and no program is above examination and questioning and we do welcome that. I think a deliberative process is certainly going to produce better policy in the end 

than a process done in isolation. 

It is kind of hard to follow up Senator Brownback as a witness. 

I have big shoes to fill in that respect. I had the pleasure when I 

was a Senate staffer to work with him at the staff level on Sudan 

9

and other Africa issues and I certainly admire his dedication and 

commitment to it, and his involvement on the issue of malaria and 

how to best pursue and treat malaria is certainly welcome. 

My objective for this testimony is to describe the U.S.’s anti-malaria programs, to place them in a useful context for the Subcommittee, and describe where the world is, and not just the 

United States or USAID, but where the world is in terms of the 

fight. 

The starting point for any consideration of malaria programs is 

the fact that malaria is overwhelmingly, not exclusively, but overwhelmingly a killer of African children. In fact, malaria is the number one killer of African children, claiming the lives of at least one 

million each and every year. 

Between 80 and 90 percent of the deaths from malaria are in 

sub-Saharan Africa, and of those deaths, 80 to 90 percent, again, 

are children. The greatest tragedy, as you pointed out in your opening statement, sir, is that this death is largely preventable. The 

disease is curable. It is treatable. 

The interesting thing to note is that where in most of the world 

we have successfully controlled or even virtually eliminated malaria as a public health threat, in Africa, it has persisted. The disease actually has even gotten worse. The burden that Africa is carrying in terms of a true disease burden from malaria is greater 

than it was two decades ago. 

Why has malaria actually become more deadly in Africa when it 

has been effectively controlled or even eliminated in other regions? 

The answer is as significant as it is surprising. The effort to battle 

malaria in a comprehensive way and continent-wide is literally decades behind other regions. In the 1950’s and 1960’s in most other 

regions, including the Southern United States, a combination of insecticides and treatments was deployed with great effect. The results were positive and significant, but not in Africa. 

In 1955, a World Health Organization panel of technical experts 

met in, ironically, Kampala, Uganda, and decided to exclude tropical Africa from the global malaria eradication program. The reasons cited were because of the intense and efficient transmission of 

the disease and because of a lack of infrastructure necessary to undertake such an intensive spraying effort. In short, Africa was left 

out because it was judged to be too difficult. 

That decision essentially eliminated prevention from the antimalaria efforts and relied solely on treatment. Even until just the 

past few years, the backbone of anti-malaria efforts in Africa was 

limited to treatment of the disease once the symptoms appeared. 

In retrospect, that was a fateful and tragic decision and Africans 

are still paying the price. 

By the 1980’s and into the 1990’s, malaria infections in Africa 

began to soar. The reasons were treatment failure. Simply, the 

medicines that were deployed, Africa’s only defense, started to lose 

their effectiveness against the malaria. Populations became increasingly vulnerable. 

It wasn’t until the early 1990’s that an organized and dedicated 

effort to begin to introduce prevention measures on an appreciable 

scale in Africa, and funded largely by donors, did that begin. By 

10

the time, the need for new treatments also became too hard to ignore. 

By about 2000 or 2001, three new, highly efficacious prevention 

and treatment tools became available through American and other 

donor research. The first new tools, insecticide-treated nets, or 

ITNs, as a vehicle to get insecticide into people’s homes, and I 

think it is worth pointing out here that with respect to indoor residual spraying and the use of insecticide-treated nets, the goal is 

absolutely the same, getting insecticide into the dwelling and as 

close to people as you can when they are sleeping and when the 

mosquito is preying on them. 

The second is intermittent preventive treatment of pregnant 

women. That is a pretty simple procedure. It is usually two doses 

of anti-malarial drug before delivery and the protection it provides 

the child is tremendous, because a lot of times, if you can defend 

against malaria in the mother, you are going to defend the child, 

because the vulnerability of the child really begins before they are 

born. Malaria, it is a major contributor of low birthweight, and if 

a child is born underweight in Africa, you are essentially doomed. 

The third is artemisinin combination therapies, and that is the 

combination drugs that are derived from the ancient Chinese medicine artemisinin. They are extremely effective and they are, in fact, 

the only thing that on a continent-wide scale, even though other 

treatments can be effective in some areas, on a continent-wide 

scale and in the future is going to provide the only chance we have 

to really plug that treatment failure that has accounted for the 

most deaths in Africa. 

Are we at the point of success? How are we doing? Is what the 

United States doing worth pursuing, or should it be subject to 

change? I am just going to wrap up by giving four essential factors 

we need to consider. 

First, the effort to address malaria in a meaningful way, incorporating prevention and treatment across sub-Saharan Africa is 

new. It is shameful that it started so late. Also, sub-Saharan Africa 

is not like other regions. The lack of infrastructure and the intensity of the epidemic are far more acute than in any other region. 

The factors cited in the 1955 decision are still basically true. What 

has changed is that the political will now exists to try to overcome 

them. 

Second, the level of funding we are talking about for this overdue 

effort is only now coming online. Even in 2000 and 2001, the funds 

committed to fighting malaria by the United States and all other 

donors were a fraction of what it is now. The significant factors 

here are the increase in the U.S.’s bilateral funding, the advent of 

the Global Fund to fight AIDS, tuberculosis, and malaria, which 

brings significant funds online, particularly for commodities, and 

also, of course, the World Bank, which we know is on the verge of 

launching another anti-malaria program. 

Third, the number of infections and consequently the deadliness 

of the disease have increased considerably in recent decades due to 

the treatment failure. This situation is a classic race against adaptation by the pathogen. ACTs are the only effective treatment in 

much of Africa now. The donors, producers, and affected countries 

11

have not yet fulfilled the needs in terms of production or distribution. 

Finally, data are lacking. We believe we understand the effectiveness of individual elements of our strategy, but the potential for 

new or improved interventions and increasing funding holds for the 

battle against malaria. What we do not have is data on the trends 

and deaths from malaria at the country level, the continent level, 

and certainly at the global level. The fielding of new or improved 

prevention and treatment tools on an appreciable scale and with 

significant funding to back them up is simply too recent to reasonably judge the overall effectiveness on a large scale. 

The bottom line here is that for the first time, the tools, the political will, and the funding are in place in sufficient amounts, at sufficient levels to really have an effect. But any summary judgment 

of the progress or lack of progress is not supported by sufficient 

data at this time and is simply premature, in our view. 

We, in the Administration, are happy to have the discussion and 

debate about priorities and proportions. Ultimately, the goal of the 

United States is to save the most lives. I think there is a common 

and universal agenda here. Thank you. 

Senator COBURN. Mr. Miller, thank you very much. 

Do we know throughout sub-Saharan Africa how many people 

have been treated, how many people have been prophylaxed with 

the net, how many people have had their domiciles sprayed? Do we 

know these numbers? 

Mr. MILLER. Probably not with any precision. What we do know 

is—we can get number of treatments purchased. Now, tracing that 

treatment down to the individual and where that individual takes 

it and whether it is proven effective, we don’t know. 

Senator COBURN. What are the numbers of treatments purchased? 

Mr. MILLER. For example——

Senator COBURN. Effective treatments purchased? 

Mr. MILLER. Let us talk about ACTs. There are other treatments 

and some of them are still effective in some parts of Africa, but 

they simply will not be effective in the future. 

Number of ACTs purchased, I think the most significant number 

to cite is that the Global Fund has purchased. The United States 

is a 33 percent contributor to the Global Fund over the history 

probably even more, and they have purchased or have dedicated 

funding through grants to purchase up to 145 million doses of 

ACTs now. I am certain that will increase, certainly as ACT’s availability increases and the price drops and the ability to get it into 

markets and distributing, we are really at the beginning of that. 

Senator COBURN. How much is price a factor in terms of supplying medicines for treatment? 

Mr. MILLER. I think it is going to be a significant factor. 

Senator COBURN. What is the cost of treatment for a child? 

Mr. MILLER. For a child? For ACTs in a child, I think it is probably about $1.20 per treatment. 

Senator COBURN. OK. 

Mr. MILLER. It depends on where you are and how remote the 

person is. 

12

Senator COBURN. OK, so let us say $1.20 per child, and that is 

available? The medicine is available worldwide? 

Mr. MILLER. The medicine is available. I do not believe it is 

available to the extent that we need it. There is a shortfall in production capacity. In fact, USAID, one of the things we are doing 

is supporting the growing of Artemisia annua in Kenya and Tanzania. We believe that those crops will be able to produce effectively 40 million—the basis for 40 million new doses, and by the 

end of 2006, I think production will be up to the point where you 

actually can fill the need. I do not believe we are there yet, and 

as a consequence—yes. 

Senator COBURN. Let us take $2 a dose. What is the population 

of the continent of Africa? 

Mr. MILLER. Oh, goodness. I would just have to guess at about 

700 million. 

Senator COBURN. OK. At $2 a dose, that is $1.4 billion to treat 

everybody in Africa, and the Global Fund is going to spend what 

this year on treatment? 

Mr. MILLER. Well, if you take just the raw numbers, sure. In the 

past 2 years, it has been over $900 million for malaria programs, 

of which about 50 percent are going to be for commodities. 

Senator COBURN. So $450 million, which means we should have 

treated 225 million people. 

Mr. MILLER. We certainly hope to achieve that kind of coverage. 

I have to emphasize that this really is a fairly new venture. A lot 

of these ACTs, we are not even to the point yet where we can actually produce enough of them—we, globally, can actually produce 

enough of them to fulfill the need. Certainly the funding mechanisms and the programs in place, they are only now coming online. 

Our goal is simply to get as many people covered and save as many 

lives as possible, but we are reasonably new with levels of funding 

with the medicines that we are talking about and the types of programs and the ability to procure them. It is——

Senator COBURN. Of your budget, what percentage of the $80 

million is actually spent on treatment? 

Mr. MILLER. If we take commodities—I should first say that I 

think it is important to start not with an examination of USAID’s 

budget in isolation because, in fact, the United States and the 

Global Fund, of course, of which the United States is the largest 

contributor, and the World Bank, of which the United States is the 

single largest shareholder, do coordinate at the country level. There 

is, in fact, an agreement, if you will, the United States brings our 

strengths to the table, which are technical capacity, helping build 

the infrastructure necessary to get the commodities out to people. 

The Global Fund, on the other hand, does some of that, but they 

also spend about 50 percent of their budget—of their malaria 

grants, excuse me—about 50 percent of the malaria grants are 

dedicated to commodities. The goal there is to simply fill in behind 

what we can provide on a technical capacity. 

So having said that, the United States, if you break it down, it 

would probably be around 5 percent——

Senator COBURN. Five percent, $4 million? 

Mr. MILLER [continuing]. Of our bilateral budget. 

Senator COBURN. Four million dollars on treatment? 

13

Mr. MILLER. Yes. 

Senator COBURN. How much on prevention? 

Mr. MILLER. Prevention? 

Senator COBURN. Nets, spraying? 

Mr. MILLER. Prevention would be about 30 percent, treatment 

about 34 percent, but that is not purchase of commodities. 

Senator COBURN. OK. What is treatment besides purchase of 

commodities, in your viewpoint? 

Mr. MILLER. Logistical support for drugs. Simply getting the 

drug to an African capital is not going to do it. There is training, 

application of drugs. There are skills that people need to understand how to identify and prescribe the appropriate drugs. There 

are protocols, because, if, in fact, ACTs—ACTs are not the only 

drug effective in an area. For example, Fancidar is still effective in 

adults. You wouldn’t want to necessarily go to ACTs. They are ten 

times the price. So making a determination like that, that does 

take people and skills and time. 

Senator COBURN. But that is not hard to do, because if you have 

a drug-resistance problem in an area, you are going to know it and 

you are not about to start treating with a non-drug-resistant therapy if you have drug-resistant disease in an area. So that is one 

or two tests. Once you identify that, you know that. 

You have not collaborated with the Global Fund in the past. Is 

it not true that the MOA is brand new? 

Mr. MILLER. I am sorry, MOA? 

Senator COBURN. Yes. Is it not new? Is this not new? In other 

words, your collaboration with the Global Fund in the past, this is 

just beginning, is that right? 

Mr. MILLER. Right. The Global Fund is new. 

Senator COBURN. Well, the Global Fund has been around since 

I left Congress. It was started when I left, when President Bush 

came in and they set up this fund. 

Mr. MILLER. Right. 

Senator COBURN. So we are talking 2001 when this started, and 

2002 when it got going. 

Mr. MILLER. We are now seeing—just now, we are going 

through—as a Global Fund board member, we, the United States, 

are seeing consideration of the 2-year point of the first round of 

grants. So money was being—excuse me, votes were being taken by 

the board to dedicate funding to particular proposals 2 years ago. 

So I think it is fair to say that it is fairly new. And once a grant 

is made, that doesn’t necessarily give you an indication how soon 

the money is going to be out there——

Senator COBURN. What percentage of the amount of grants that 

you give are consumed—in other words, the expenditure from that 

grant is consumed in other than prevention and treatment? 

Mr. MILLER. I can’t say. On a grant-by-grant basis, it is going to 

be different, and——

Senator COBURN. No, as a total. What do you think? 

Mr. MILLER. As a total for treatment? 

Senator COBURN. No. What percentage of the grant money that 

you give out of this $80 million—here is the grant money we are 

giving to implement . . . 

14

First of all, the doctors in Africa that I have met—I have been 

there twice—could teach every doctor here about diagnosing malaria. I have seen two cases in 20 years in Oklahoma of malaria. 

So they know how to diagnose it. The question is, what is the resistance factor of the area that you are in? So they actually could 

train us. 

But in terms of your grants that are given, what percentage are 

actually for treatment or prevention? Of the amount of money 

through this budget, how much goes to prevention——

Mr. MILLER. I see. Grants are typically not given for something 

as narrow as treatment. In fact, typically, grants are not made for 

something as narrow as malaria. They usually fall within a larger 

maternal and child health grant. In other words, it can be to help 

support ante-natal clinics and it is at the ante-natal clinic where 

you can actually get to the mother while she is pregnant and either 

provide preventative therapies, provide a net, provide some education. The grants typically go for something a little more broader 

than that. Is that your question? 

Senator COBURN. Well, I am just trying to find out, because we 

have other parts of USAID that have grant money for that, as well. 

What you are saying is some of the grant money goes to areas of 

responsibility in other areas of USAID as supplement that? Is that 

what you are telling me? 

Mr. MILLER. I am not sure I characterize it that way. Would say 

that grants typically will be for something in child and maternal 

health that is broader than just malaria or malaria treatment. 

Senator COBURN. Well, I am way over my time. I will come back 

to you. I have to go for a vote in Judiciary. Senator Carper, if you 

would be so kind to handle the hearing, and I will be right back. 

Senator CARPER [presiding.] Thanks, Mr. Chairman. 

Mr. Miller, welcome. Thanks for being here and thanks for your 

stewardship. 

I want to go back to a couple of earlier things that you said in 

your testimony, just ask you to clarify them for me. You spoke earlier of the success in much of the rest of the world in eradicating 

malaria but a lack of success in Africa. In fact, if anything, it is 

getting worse. Why, again, do you think we have been successful 

in the rest of the world and not in Africa and what lessons can we 

derive from our success in the rest of the world to make sure we 

are applying those lessons appropriately in Africa? 

Mr. MILLER. I think the first thing to note is that we are starting 

pretty late in Africa, at least on an appreciable scale. What we did 

in the United States, what was undertaken in Southeast Asia, Central America, and South America in the 1950’s and 1960’s was very 

effective. Africa is just now coming online. 

That is what I was trying to get to in my statement, which is 

the types of—the level of funding we are talking about, the degree 

to which we can introduce interventions into the areas that need 

it is relatively new. We are really just talking about since 2000 on 

an appreciable scale. 

What we can learn from other regions that can be applied to Africa, you have to be careful. Africa is different for a number of reasons. It is not just that it was started late, which is a factor. You 

15

also have new interventions that were not available then, ACTs, insecticide-treated nets, for example. 

But also, Africa, the intensity of the epidemic in Africa is far beyond, at least continent-wide, is far beyond what it is or was in any 

other area. You have some areas of Africa that are what we call 

hyperendemic. In other words, you have transmission of malaria 7 

to 12 months out of the year. There is literally no seasonal break 

and there is no escaping at night mosquitoes, either during the season where they are not breeding or just by changing localities. 

The second thing to consider about hyperendemic areas is in 

some cases, 85 percent of the people living there are going to be 

infected with the plasmodia that causes malaria, 85 percent. That 

is a huge reservoir for transfer. Those people will probably not necessarily show symptoms. They have acquired immunity. Once you 

pass about 5 years of age, if you contacted malaria when you were 

a child and you lived through it, the chances are you probably will 

not die from it. So people actually acquire immunity over time. But 

just because they have that acquired immunity doesn’t mean they 

won’t get sick, and it certainly doesn’t mean that they cannot be 

infected from one person to another. They effectively are a reservoir for the mosquito and it is very difficult to do that. 

Finally, I would point out that in a lot of Africa, the infrastructure is acutely lacking, let us say. People live rural lives. I know 

in Ethiopia, for example, which is not typically a hyperendemic 

area, but just for illustration, 70 percent of the population lives 3 

hours’ walk from a road, not even from a paved road, not from a 

facility, but from a road. It just gives you an illustration, even in 

a very densely populated country like Ethiopia, that people live 

rural and sometimes very isolated lives in Africa. So it is very difficult. 

That is not true in all of Africa. Certainly the South Africa example that was raised demonstrates that there is some applicability 

to the continent, depending on where it is, depending on the infrastructure and the effectiveness of services in that area. But it is 

going to be a harder nut to crack, frankly. 

Senator CARPER. Thank you. Could we talk a little bit about the 

resistance of drugs, or the resistance, rather, of mosquitoes and the 

disease to drugs that we have, the failure of those drugs to be able 

to protect people today——

Mr. MILLER. Yes. 

Senator CARPER [continuing]. And new medicines that are available that are being introduced. 

Mr. MILLER. Right. The treatment failure, if you will, really is 

the cause of the increase in malaria infections in Africa in the 

1980’s and 1990’s. Simply people had no protection. 

ACTs are really the great hope of the future. I don’t think there 

is any debating that. They are very effective——

Senator CARPER. Why do they call them ACTs? 

Mr. MILLER. Well, they are in combination. The ‘‘C’’ is for combination. Artemisinin is a natural extract from what we call 

wormwood. It is an ancient therapy. It is very effective. The extract 

itself has—I don’t think there is a question of shelf life there. But 

once they are put in combination to make them more effective, to 

16

make the body absorb them better, whatever the combination does, 

you get about 18 months’ shelf life. So it is a huge challenge. 

Plus, as I mentioned answering Senator Coburn earlier, they are 

relatively new. The combinations are relatively new. I believe there 

are two companies that hold patents for ACTs now. Production is 

not to a level to meet worldwide need and, hence, USAID’s support 

for actually growing of Artemisia annua to help meet that shortfall. 

Senator CARPER. Would you talk a little bit about—you have already discussed this some and we have mentioned it in our statements, but talk with us, please, about how, on a relative scale, the 

magnitude of USAID’s efforts in these areas with respect to other 

efforts in these areas. 

Mr. MILLER. Sure. Bilaterally, we are by far the largest donor. 

We are at about $80 million a year. If you break down the Global 

Fund by year, you are going to get about $400-and-some-million 

per year, over $900 million total over the past 2 years. Of course, 

the United States, as you mentioned earlier, is the single largest 

contributor to the Global Fund, so a lot of that can be ascribed to 

us, the same with the World Bank. 

There are other donors on a bilateral level. The U.K., I think the 

Nordic countries also have bilateral programs. All said and done, 

I think we put the total global anti-malaria funding at about $600 

million a year. 

Senator CARPER. So overall, $600 million. About $80 million is 

directly through your budget? 

Mr. MILLER. Bilateral USAID, yes. 

Senator CARPER. And then additional monies that we may put 

into the World Bank or the Global Fund——

Mr. MILLER. That is correct. 

Senator CARPER [continuing]. Above and beyond that. Share with 

us again your thoughts on how USAID’s efforts are complementary, 

or might be duplicative of other efforts. How do they complement 

or support each other? 

Mr. MILLER. Thank you. I think the best way to imagine it is 

that, as I mentioned before, USAID does focus where we have our 

strengths, providing skills, providing infrastructure, if you will—I 

am not talking about buildings here, but providing infrastructure. 

We have presence in almost every country we are talking about. 

We can deploy skilled people for training, for running programs, 

providing grants. We have many other bilateral programs of which 

anti-malaria efforts can be effectively incorporated into, which is 

really one of the fundamental pieces of our strategy. 

As I said before, it is really not—you are really not going to get 

an accurate picture if you just take USAID’s budget and proportions of the spending per sector in isolation because they really are 

planned even down at the country level along with the other donors, multilateral institutions. 

I think with respect to the question of priorities and spending on 

commodities and how the United States, bilaterally, we look to the 

multilateral agencies, of which we are a part, to really do the bulk 

of the commodities purchase, the United States and USAID in malaria programs or any other programs has never really emphasized 

commodity purchases outside emergency situations, and that is 

true here. 

17

But the best way to think of that and put it in perspective is to 

think of an army being judged simply by the amount of bullets you 

have on hand. It is really not a fair judgment and you simply can’t 

judge a single army if they are operating in coalition with each 

other. You really have to take a snapshot of the entire picture globally, especially if it is coordinated at the level we coordinate in 

countries. 

Senator CARPER. My last question would be, someone described 

for me, they used an analogy. They said USAID’s efforts are in 

part, if you will use the analogy of a toolbox, with tools in the toolbox to address a particular challenge. They said USAID’s efforts 

are, in part, to put tools in the toolbox, but also to help those to 

whom the toolboxes are distributed, countries, to be able to better 

use the tools that USAID puts in the box, but also the tools that 

other entities put in the box to fight malaria. Is that a fair analogy? 

Mr. MILLER. It is. Simply, we play to our strengths and we play 

in coordination with other teams, with other members of the team, 

yes. It is a fair characterization. 

Senator CARPER. And how do we measure success with the approach you are talking? 

Mr. MILLER. Ultimately, success is going to have to be measured 

in lives saved. That is a difficult question, number of lives saved, 

for a couple of reasons, if you would let me go into it. Identifying 

the number of deaths from malaria in rural Africa is going to be 

very hard. Survey-wise, every 5 years, we, USAID, sponsors what 

is called a demographic health survey. It is a comprehensive health 

survey of the entire country. It is the gold standard of health surveys for development global assistance. They are retrospective. 

What happens is if someone who is conducting the survey goes 

out to an affected area and asks the mother, did you have a child 

that died in the past 5 years? What did they die from? What were 

the symptoms they were displaying? And from that, you simply 

have to deduce what this child—if they have a fever, which is what 

you are typically going to see, it could be pneumonia, it could be 

malaria, it could be a combination of things. It is hard to do with 

precision, to say what that person died from. We think we know. 

We think we have a level of confidence where we can say malaria 

infection rates and deaths are at about this level per year. That is 

probably not in dispute. But identifying on a scale of how many 

people are actually dying of malaria is very difficult. 

The second thing I would note is one thing we found troubling 

is the statistic often quoted is that malaria deaths are increasing 

in Africa in recent years. We have heard that quoted. Actually, we 

do not use that statistic. We have actually tried—I have asked my 

staff to identify where did that originate, what is the data behind 

it, and does anybody else use that? We don’t use that statistic. I 

am not here saying it is true or it is false, but the data set behind 

something that broad is simply we don’t have it. We have to question whether that is reliable data to hang your hat on. 

Senator CARPER. Thanks very much. 

Mr. MILLER. You are welcome. 

Senator COBURN [presiding]. Just another little round here if we 

can, for a minute. First of all, WHO says malaria is increasing. 

18

Lancet articles say malaria is increasing. They are surveying the 

same way they did 10 years ago and the number of deaths of children is skyrocketing, and it isn’t pneumonia that is causing them 

to die, it is malaria. That is not something that is hard to know 

because you are using the same study method to collect the data 

10 years ago as you are today in terms of looking at deaths. So 

there is no question. 

The other question I have for you: USAID doesn’t normally provide treatment unless there is an emergency. The fact is, that with 

3,000 children a day dying in Africa, I think that is an emergency. 

There was a malaria program by USAID before there was ever a 

Global Fund, true? 

Mr. MILLER. That is correct. 

Senator COBURN. And it was operating all this time that we are 

seeing this large increase. So the fact is we have been ineffective 

through USAID in abating this increase with the money that we 

have spent. Now, maybe again, your first testimony, the problem 

is too big. Maybe the resources aren’t enough. I don’t know that answer. That is one of the things that we want to try to help find out. 

But what we do know is the numbers aren’t lying, and I would 

like to ask you just a couple other questions. In your testimony, 

you gave us that insecticide-treated bed nets are the key to saving 

children’s lives, and you write that ‘‘ITN coverage increased, for example, from zero to 21 percent in Ghana.’’ But you omitted saying 

that 21 percent is the proportion of rural homes in Ghana using 

an untreated bed net. There is a big difference in terms of that prevention. So you are using a number that is on untreated as part 

of your statistics for treated. My question is, actually aren’t only 

5 percent of Ghana’s homes covered with insecticide-treated bed 

nets, not 21 percent, as you state in your testimony? 

Mr. MILLER. Sir, it is an important question and I would like to 

answer it truthfully and best I can with a level of precision. I honestly cannot say right now whether what you just said is correct. 

Senator COBURN. This actually comes—your department is a coauthor on the World Malaria Report that was published only last 

week that made that very statement. So either what you are saying 

in that report is right or what you are saying in your testimony is 

right, and they can’t both be right. 

You can catch the frustration in my voice. It is not directed to 

you personally, and please don’t take that. 

Mr. MILLER. I understand. 

Senator COBURN. When I know that 3,000 kids a day are dying 

and we are spending $80 million a year, which could save 40 million of them if the money was put there in terms of insecticidetreated bed nets and medicines, that, to me, is just incomprehensible, that we can say we have got to have all these other programs 

when, in fact, we could take 20 people and make tremendous delivery of goods tomorrow to those kids in those villages. 

And so the statistics you quote are important, but they also have 

to be accurate, and I will be happy to let you answer that in writing for our Subcommittee. 

Mr. MILLER. Thank you. We will, sir. 

Senator COBURN. Do you have any other questions? 

19

Senator CARPER. Just one more. USAID and, I believe, other 

Western donor organizations have been criticized for being reluctant or maybe even unwilling to fund the indoor spraying of insecticides in communities that are plagued by malaria. Is there any 

official USAID policy that you know about that prevents the agency 

from funding spraying projects where that is appropriate? 

Mr. MILLER. Thank you, Senator. I maybe should have emphasized this more emphatically in my opening statement. The shared 

goal of prevention is to get insecticide into the home. That can either be through indoor residual spraying or it can be through insecticide-treated nets. We are open to debate about which is most cost 

effective in what areas. That is part of what we do with $80 million, is determine what is most cost effective. 

We do emphasize insecticide-treated nets over indoor residual 

spraying. We do not have a prohibition on the use of insecticides 

in the homes, spraying of insecticides nor of DDT in particular, 

even though DDT is, in fact, just one insecticide we are talking 

about. There are 12 approved insecticides for indoor residual spraying. IRS is very effective. IRS has proven effective in South Africa, 

in areas where you have the infrastructure and the services to 

make the coverage. IRS is not the vehicle for insecticide of choice 

in all of Africa. 

So no, sir, there is no prohibition on DDT or indoor residual 

spraying. 

Senator CARPER. Thank you. 

Senator COBURN. Let me follow up with that, because I think it 

is important. First of all, DDT is the most effective insecticide. It 

is also the cheapest insecticide. There is no question about that. 

Administrator Natsios told Senator Brownback that you will not 

use DDT. That is a quote from him. 

I also have a quote from Zambian health officials that said 

USAID staff have repeatedly refused to fund DDT spraying and 

told them that they should not adopt effective drugs as part of the 

anti-malaria strategy. Can you explain this? Why would they say 

that? 

Mr. MILLER. I cannot explain what someone in Zambia said. I 

will tell you, we do not support or peddle ineffective drugs, and we 

do, in fact, when, at a country level, it is determined that indoor 

residual spraying would be the most effective to save the most 

lives, we will support it——

Senator COBURN. Is that true in Zambia? 

Mr. MILLER. We will support that. In fact, Zambia is one of the 

places we do support indoor residual spraying, yes. 

Senator COBURN. Well, here is the Malaria Program Control Director for Zambia, and that is who gave us this information, and 

will you follow up with her and clarify that USAID supports ACT 

treatment and in Zambia—DDT spraying—and let this Subcommittee know the outcome of that conversation? 

Mr. MILLER. We will. 

Senator COBURN. And that is Naawa, and I will try to pronounce 

this name, it is S-i-p-i-l-a-n-y-a-m-b-e, the Malaria Control Program 

Director for Zambia. 

I also would like to ask you to maintain your seat, if you would, 

because I would like to have you on the panel with our other 

20

1The questions and responses from Mr. Miller appears in the Appendix on page 136. 

2The prepared statement of Mr. Bate appears in the Appendix on page 50. 

guests, and I also will, without objection from Senator Carper, 

would like to submit written questions for you to answer and give 

back to the Subcommittee. Rather than take your time up with it 

today, I have about 20 specific questions that I would like to get 

answers to——

Mr. MILLER. Absolutely.1

Senator COBURN [continuing]. And I would like that on a timely 

basis, if we can have that. 

Mr. MILLER. We will do our best, sir. 

Senator COBURN. Thank you. 

Next, I would like to recognize Dr. Roger Bate, Resident Fellow, 

American Enterprise Institute, Director, Africa Fighting Malaria, 

U.S. and South Africa; and also Dr. Amir Attaran, Ph.D., Associate 

Professor and Canada Research Chair in Law, Population Health 

and Global Development Policy, University of Ottawa; and also recognize Dr. Carlos C. ‘‘Kent’’ Campbell, M.D., Program Director, Malaria Control and Evaluation Program in Africa. 

We will start with Dr. Bate, if you would. 

TESTIMONY OF ROGER BATE, PH.D.,2 RESIDENT FELLOW, 

AMERICAN ENTERPRISE INSTITUTE, AND U.S. DIRECTOR, 

AFRICA FIGHTING MALARIA 

Mr. BATE. Senator Coburn and Senator Carper, thank you very 

much for inviting me to testify today on behalf of Africa Fighting 

Malaria and the American Enterprise Institute. 

Ninety years ago, a million Americans suffered from malaria and 

a Congressional committee held hearings to discuss policy options 

to eradicate it. This was achieved by the 1950’s through the judicious use of window screens and DDT and, of course, increased 

wealth. 

Today, malaria, as we have already heard, is a significant risk 

for perhaps two billion people, suppressing hope and economies 

alike, notably in Africa, but also, I should stress, given what has 

been said before, it is increasing in parts of Latin America and 

Asia, as well. I do not think it has been conquered around the 

world. And unfortunately, I think we are losing the war to combat 

malaria. 

But there are bright spots. Southern African countries are enacting comprehensive malaria control programs which are grounded in 

the idea that success requires every tool that science has provided, 

much like the United States did to rid itself from malaria 50 years 

ago. Government and private entities in South Africa and Zambia, 

for example, are using a combination of low-level controlled indoor 

insecticide use, both DDT and other chemicals, bed nets for key 

staff, and prompt treatment of malaria cases to keep malaria incidence low, and the results are startling, 70 to 90 percent reductions 

in disease within a couple of years and even better reductions in 

mortality in some locations. 

Unfortunately, the U.S. Government has not been directly involved with the two most successful strategies, indoor residual 

spraying and effective drugs, except perhaps in marginal ways at 

21

best. I say perhaps because it is hard to know exactly what the $4 

million USAID allocation in Zambia supports. 

USAID releases data as reluctantly as if it were a national security outfit. We have to surmise a lot of information, unfortunately. 

We fought to get from FOIA requests, from interviews with people 

in the field, from pressure from friends within Congress to try to 

get as much information as possible, and there is an ongoing Government Accountability Office inquiry into USAID’s malaria programs and I welcome its outcome. We need the information. 

Despite the obvious benefits of comprehensive malaria control 

programs, by its own admission, as we have just heard, USAID 

typically does not purchase drugs or insecticides except in emergency situations. Yet USAID continues to say it supports comprehensive programs. This is a fiction. 

Our estimation of the 2004 budget, and it is basically confirmed 

here today, is that less than 10 percent, perhaps as low as 5 percent of the budget is spent on actual commodities that save lives. 

The vast majority of the rest is spent in support and technical assistance. This is not comprehensive. It is, in fact, highly selective 

in favor of Western staff. It is likely that well over half the budget 

goes on salaries, staffing costs, and travel, perhaps even a lot in 

the United States. 

From the information that is published, it appears that USAID 

coordinates randomly, perhaps occasionally in a more coordinated 

fashion, with other entities, and in many instances, technical assistance, which we have already heard today is its kind of backbone, its greatest skill, is provided where no commodities are, in 

fact, available. 

But even if coordination were well managed, USAID rarely measure outcomes, and I am talking about the key outcome in particular here, reductions in morbidity and mortality. So we wouldn’t 

know whether its programs are working very well anyway. 

And by the way, given it has been mentioned today on several 

occasions, in my opinion, bed net distribution is not a good measure 

of outcome. And in many respects, in the written testimony from 

Mr. Miller, it is the main performance criteria given. It is not a 

good measure from personal experience, also, from looking at the 

data, because we are not always certain how many people regularly 

sleep under a bed net. 

Imagine an August night in Washington, D.C., and your air conditioner is broken and you are trying to sleep under a stifling net. 

Bed net use data is extremely important to collect. I have spent 

many nights in the field where I have been incapable of sleeping 

under a net. It was just simply too hot. I wouldn’t have had any 

sleep. I was offered some prophylactic drugs, as well, a belt and 

braces policy. Therefore, I could afford to take the risk. For everyone else living in Africa, that is not the case. 

While we can quibble about the best interventions, and I am delighted to hear that there is greater interest in indoor residual 

spraying, there is no doubt in my mind that USAID fails badly in 

the transparency and accountability stakes, and that is the point 

that I think is most important to make today. USAID does not consistently measure anything useful. It does not measure real outcomes. It has not updated its Yellow Book since 2001, so we don’t 

22

know what USAID’s contracts are for, with whom they are made, 

and for how much. 

Of the few reports USAID does file, many are self-serving. That 

is not just according to me, that is from a Government Accountability Office inquiry in 2002 and its own internal review last year. 

And since it doesn’t collect, as I have already mentioned, useful 

data, it is incapable of effectively evaluating its performance. 

Since Anne Peterson, then Assistant Administrator for Global 

Health, first testified to a Congressional subcommittee about 

USAID’s malaria program in September of last year, not a single 

program report, evaluation, or other document concerning the 

agency’s malaria activities has been submitted to the agency’s publicly available database. In that 8-month period, I notice some welcome rhetorical changes in favor of ACTs and spraying and saying 

the support of indoor residual spraying, but I have seen no change 

in action on the ground. 

When I testified alongside Dr. Peterson last September, I suggested that if accountability and transparency were not delivered 

quickly, U.S. funding for their program should perhaps be reallocated to agencies that have a better chance of improving health. As 

we have heard today, too many children’s lives from this disease 

are at stake for failure to continue. 

I conclude the same way today, 8 months later, and with stronger emphasis. I think that USAID must rapidly increase its transparency. I would encourage it to follow the lesson from the Global 

Fund and establish a website, or even on its own website, which 

would hold all technical information for USAID. That would include contracts, grants, and corporate agreements, budgets, and 

implementation plans. Until it does that, and I think it should be 

given a time limit to do that, I think it should seriously consider 

its budget being reallocated elsewhere. 

Thank you, Mr. Chairman. 

Senator COBURN. Thank you, Dr. Bate. 

We have a vote on. What we will do is recess the Subcommittee 

for the period of that vote and then we will return. I would ask 

your indulgence. 

[Recess.] 

Senator COBURN. The Subcommittee will come back to order. 

Mr. Miller, it is my understanding that we did not advise you appropriately of what we would be requesting of you in terms of time 

commitment, and if you feel necessary to keep those commitments 

with other people, the Subcommittee will understand. 

However, it is my understanding you are working on a transparent website so that people can look at USAID in this area in 

terms of your funding details, is that true, and when will that be 

available? 

Mr. MILLER. Sorry, I had to consult with my staff. I am not 

aware of something exactly as you describe. I don’t have any objection to it, and it is certainly something we will consider. 

Senator COBURN. Well, what I would like to hear is, yes, we will 

do that and here is when we will have it done. People should be 

able to address USAID programs via a website to see what is happening and where. What I would like for you to give, first of all, 

23

1The prepared statement of Mr. Attaran with attachments appears in the Appendix on page 

97. 

commit to do that, and second, give us some sort of time frame 

from your staff when that will be available. 

Mr. MILLER. Sir, I could commit that we will do our best. In 

terms of a time frame, let us talk with your staff about what types 

of data and the depth of data we are talking about and come up 

with a reasonable time frame, mutually agreeable time frame, is 

that all right? 

Senator COBURN. That is fine. 

Mr. MILLER. Good. Happy to do it. Sir, I can stay, by the way. 

Senator COBURN. OK. Next, we will recognize Dr. Attaran. Dr. 

Attaran, if you would, please. 

TESTIMONY OF AMIR ATTARAN,1 ASSOCIATE FELLOW, ROYAL 

INSTITUTE OF INTERNATIONAL AFFAIRS, LONDON, ENGLAND, AND CANADA RESEARCH CHAIR, INSTITUTE OF POPULATION HEALTH AND FACULTY OF LAW, UNIVERSITY OF OTTAWA, CANADA 

Mr. ATTARAN. Thank you, Mr. Chairman, Doctor. My deepest 

thanks for your interest to discuss malaria today and USAID’s response, which I view as inadequate. 

I believe by now you are quite familiar with what malaria is. You 

know that it is killing a million kids and pregnant women a year, 

mainly in Africa, that it is pauperizing entire families and nations 

when it isn’t killing them, that it is a threat—perhaps this is a new 

piece of information—to the American military. It did hospitalize a 

quarter of our troops in Liberia only a couple of years ago. And 

that prospects for a vaccine are a decade or longer in the future 

and have been that way for about the last 30 years. The vaccine 

is always 10 years away. 

We also seem to have, I think, in this Subcommittee a certain 

amount of agreement on what the interventions are to prevent or 

to treat. There are basically three of them, insecticides, bed nets, 

and medicines. Everyone agrees on that. But what I see little 

agreement on is how USAID should spend their money in respect 

to those three. So let me sketch out these differences of views, such 

as they are. 

My view is that Africans are very different from Americans. They 

are poor. They live on $2 a day, the vast majority of them. They 

are very poor. So when there is foreign aid money voted by the 

American government to spend, we should be spending it on the 

poor Africans. That is my hypothesis. 

USAID fundamentally disagrees with that point of view. As you 

question them, you will find they spend most of their air money on 

Americans—American consultants, American experts, and very 

highly-paid American nonprofit organizations. It rarely is true that 

USAID is spending its money actually buying and supplying the 

weapons of combat—the medicines, the insecticides, the nets—that 

actually get to the patient and have an effect on malaria. 

Instead of preference for these cozy deals with consultants, 

which, to steal a phrase from President Eisenhower, resembles to 

24

1The prepared statement of Dr. Campbell appears in the Appendix on page 126. 

me a ‘‘Foreign Aid Industrial Complex,’’ really—USAID should 

make the provision of supplies and commodities. 

Now, let me look at a few examples of that, and perhaps we can 

dive deeper into these in questions. USAID does tell the public that 

it ‘‘strongly supports ACT,’’ but it also says that it typically doesn’t 

buy commodities. For example, no malaria pills whatsoever, or very 

few in number. 

If that is support, what would opposition look like? The medicines aren’t being bought, and aren’t being given to the patients. 

Compare that to when we do food aid as the United States: We actually provide the food. We provide the commodity. When we do 

malaria aid, we don’t provide the commodities. That is wrong. 

So where does that USAID malaria money go if it is actually not 

going to the commodities? Well, for the most part, it is going to 

contractors, and the contracts are big and they are not terribly 

transparent. For example, USAID has a $65 million contract with 

an organization known as Net Mark. Net Mark sells, not gives, bed 

nets to the poorest people on earth in Africa. That is its mission. 

The $65 million is spent predominantly on marketing and not on 

actual, ‘‘Here, have a net for free’’ provision. 

Net Mark is overseen by a contractor known as the Academy for 

Educational Development. It bills itself as a nonprofit, but last 

year, its CEO paid himself in excess of $400,000 in salary and benefits. That is more than President Bush collects. 

Getting details beyond generalities such as these, further details, 

is next to impossible because USAID has not updated its contracts 

database to the public since 2001; basically Clinton-era contracts 

all what is available. USAID is not terribly cooperative in inquiries 

about its contracts, and it admits that contracts ‘‘are not reported 

or collected centrally in Washington.’’

Really, there is a lack of information about all sorts of contractual aspects of the USAID program. It was asked, Mr. Chairman, 

earlier, how many nets is USAID providing? And there was no answer to that question. Nobody knows. 

So as I said, it is such that poor Africans aren’t getting the commodities from USAID. They are not getting the basic tools. But unfortunately, a large network, this Foreign Aid Industrial Complex, 

of contracts is living on generous salaries and we don’t really know 

how well they are accomplishing their work. That information is 

not available. How many pills or nets. It is not available. 

I thank you for your patience and wish to be of service to you 

in getting to the bottom of this. Thank you, sir. 

Senator COBURN. Dr. Campbell. 

TESTIMONY OF CARLOS C. ‘‘KENT’’ CAMPBELL, M.D.,1 PROGRAM DIRECTOR, MALARIA CONTROL AND EVALUATION 

PROGRAM IN AFRICA 

Dr. CAMPBELL. Thank you, Mr. Chairman, Dr. Chairman. It is a 

pleasure to be with you today. I have a written testimony that I 

would like to offer to be set into the record——

Senator COBURN. Without objection, it will be so done. 

25

Dr. CAMPBELL [continuing]. And I would just like to make a few 

comments. 

First is my role here today, both in terms of how I was invited 

and how I would like to be perceived. I am not here representing 

any institution nor to defend any institution. I am here and was 

invited to be here today to be a resource to this Subcommittee in 

this process in terms of I spent 30-some-odd years working exclusively in malaria and almost exclusively in Africa, beginning working in clinics in Western Kenya before HIV came in, continuing 

working in leadership positions with the Centers for Disease Control, with UNICEF, WHO, and now having the opportunity to work 

on what I think many of us believe to be the single big focus that 

we need in Africa right now, and that is rapid, well-demonstrated, 

well-documented progress to bringing malaria control to the capability of African nations to be able to manage that as a program 

activity. 

I share with you, and I would reflect back 20-some-odd years ago 

when I first had my opportunity for Congressional testimony, working for the Centers for Disease Control and Prevention, it was virtually impossible to get an audience to speak about malaria. In 

fact, I had to spend most of my time convincing people there still 

was malaria in the world, and how wonderful it is to see the intensity of interest, the impatience, the desire on the part of the U.S. 

Congress to get it better, and I applaud you for leading in that direction, and Senator Brownback and others in this process. I think 

that is something that all of us on this panel share, though I will 

speak just for myself. 

I think the second thing that I would like to say is that the malaria problem in Africa can be measured in terms of people, it can 

be measured in terms of suffering, it can be measured in terms of 

money. It can be measured in many ways. It absolutely needs to 

be measured and measured much better than we are doing at this 

point, and there is progress occurring on those fronts. 

I think one of the things which many people find so tedious and 

many people see as potentially a waste of time and effort, but I 

would like to make just two key points which I have tried to elaborate in what I have written. There is a lot of money coming in to 

support malaria right now and the window of opportunity to make 

certain that is used well and documented well is probably much 

shorter than many of us want to believe. That money will go elsewhere if malaria does not produce, and malaria does not produce 

and document impact, not just in terms of where we went and who 

we were, but who got sick and who didn’t die. 

We all understand that it is hard, but it is vital and it will occur 

and it must occur, and we need your help in terms of pushing that 

forward. 

I think the second thing that is the difficult part of this is that 

as more money is coming into many African countries right now, 

and this is what I spend my life doing, is that the capacity of national governments to receive and allocate that money to turn that 

program into—turn that money into saved lives is a huge challenge, is that these very systems, and we can talk about infrastructure, we can talk about capacity, all of these potentially murky topVerDate 0ct 09 2002 11:52 Nov 21, 2005 Jkt 021437 PO 00000 Frm 00029 Fmt 6633 Sfmt 6633 C:\DOCS\21437.TXT SAFFAIRS PsN: PHOGAN
26

ics are vitally important. They are not more important than commodities. 

But the challenge that we run into in many countries in Africa 

right now, and this is a big problem that the Global Fund is currently facing, is the capacity to do things that we take for granted—procurement, distribution—a number of these other things are 

vital issues that we as the leadership position which the U.S. Government can bring to these issues, we need to make sure that we 

have a balanced armamentarium as we move forward. 

We must make certain, and we need more money for commodities. But to take current monies and push them toward the commodities and to take away the enormous, almost unique capacity 

which the U.S. agencies have in their academic institutions and 

other Federal institutions that know how to support governments 

to do these things is vitally important. Call that technical assistance, and yes, there are many egregious examples of technical assistance running amok. But there also are as many or more examples of where technical assistance has been well thought out, has 

supported the capacity of national governments to move forward in 

malaria and other issues. 

And we need to make certain that the U.S. Government, which 

in many respects—or the United States, which in many respects 

has unique capacities to support those areas, can do that and do 

it better than we are doing it now. So I ask you to not move everything to commodities, but keep a balanced view. 

The last thing I would want to say is that we must all keep in 

mind is that malaria in Africa will be controlled by Africa and not 

by us, and so the capacity of national governments to understand 

and to adapt systems right now which are stressed in many respects by the enormous and much greater infusion of HIV–AIDS 

money and resources coming in, these systems really have an enormously difficult time in terms of how they absorb these monies and 

move them forward, and that is not as simple as diagnosing and 

treating malaria. That is much more complicated, and it may be 

the Achilles heel of this whole process. 

The U.S. Government can do a better job. The U.S. Government 

is not doing as bad a job as perhaps some people would like to believe. Single agencies have good pieces and bad pieces and pieces 

that all can be improved, and I think that at this point in time, 

as we look forward to legislation to suggest how we move forward, 

I would encourage us to make certain that we understand what is 

working well, and then off of that basis figure out how to make it 

better. Thank you very much. 

Senator COBURN. Dr. Campbell, your points are well taken. The 

point is, when you can’t find out what is being spent where and 

there are no measured outcomes on the basis of what the goals are. 

There is no way you can evaluate that. So there is no way you can 

make an assessment. That is what this hearing is all about. 

What are the goals? How do you measure the goals? Where is the 

money being spent? How is it being spent? Are the contractors efficient? Are they doing what they are supposed to be doing? Is the 

money being spent inappropriately in terms of the domestic side of 

the issue? 

27

When 50 percent of the money of this budget is spent in the 

country, and we don’t know that for sure because I can’t find out. 

I am going to find out, I will tell you that. I am going to find out 

where every penny that goes with this malaria program is spent, 

no matter what. So we are going to know, and we are not going 

to just know on malaria. We are going to know on every area. That 

is what this Subcommittee is going to be about the next 6 years 

if I am still the Chairman of this Subcommittee and we are going 

to have accountability. 

And it is not to say that those people, Mr. Miller and his staff, 

don’t care, aren’t trying as hard as they can. The fact is, the only 

way you can be evaluated, it has a measurable outcome. And our 

outcome is based on lives saved and disease prevented. That is the 

outcome that we have got to be looking at. 

Whether it is implementation, delivering the product, not just 

commodity product, but whether you are implementing it, if you 

haven’t implemented that properly, you are not going to save the 

lives. So it is not just one or the other. It is measuring the outcome, 

how many lives are saved, and is it an emergency? 

To me, there are not 3,000 children who die in the Southwest in 

this country every year from disease. So this is an important thing, 

and what we are asking is transparency on where the money, responsiveness to those people who also care so they can see where 

the money goes—so that they might be able to contribute a great 

idea, and the ability for Congress to look at where the money is 

spent to know whether or not we ought to put more money. How 

do we know we shouldn’t be putting $200 million a year into the 

malaria program? We don’t know that. 

So the fact is, if there is resistance on the part of any agency in 

this government to cough up the numbers of where they are spending the money, that automatically sets an assumption that either 

there is something to hide or they are incompetent. There are only 

two answers. I don’t believe they are incompetent. They may not 

know, and that is just as bad, because if they don’t know where the 

money is going or what the purpose is for the money, then we are 

not doing our jobs in terms of oversight or looking at how we spend 

the money. 

The hearts and intent of the people at USAID are good. There 

is no question about that. The goal is, how do we spend the money 

effectively. We are going to run a true $650 billion deficit this year. 

That is the real number, and I will be happy to go through that 

with anybody that wants to dispute that. But that is how much 

money we are going to borrow for the future, the kids that are here 

today that aren’t getting malaria that are going to pay back. Any 

dollar that we don’t spend well in saving a life from malaria, our 

grandchildren are going to pay back about $10 to pay for that because we are borrowing the money to do it. So it is implicit on us 

to be great about where we go. 

Dr. CAMPBELL. Sir, I just would say, I couldn’t agree with you 

more that, in fact, that level of attention to how well we do our job, 

all of us do our job, and that accountability and data are vital, I 

think all of us would support wholeheartedly. And how we do that 

and how we get to the end of that inquiry and make certain that 

28

those 3,000 children benefit from that inquiry is something that all 

of us would like to help you do well. 

Senator COBURN. Thank you. Let us start with Dr. Bate, and I 

presume Senator Carper is coming back. Can you give me an example of what you meant when you said USAID is not transparent. 

I believe that to be true, but give this Subcommittee an example 

of that. 

Mr. BATE. Well, first, the Yellow Book, not updating its contract 

information, that makes it very difficult to know. I mean, that is 

a prime example of lack of transparency. 

Senator COBURN. Can you think of a good reason why somebody 

wouldn’t update that? 

Mr. BATE. Again, I refer to your remarks, which is incompetence 

or something to hide. I doubt it is incompetence. Perhaps they don’t 

want people to know how the money is being spent. 

I think sometimes the information that is presented can be misleading. Mr. Miller, the testimony he gave on April 26, so 21⁄2

weeks ago, discussed a contract or a grant to Technoserve, which 

he described as an East African agricultural concern in his testimony. It may well have operations in East Africa, but its headquarters is 49 Bay Street, Norwalk, Connecticut, and it received $8 

million from USAID in 2003. I don’t know what it got in 2004. 

That is not to say they are not doing a good job, but that was 

not a competitive tender. We have no idea whether other organizations, perhaps in Southern Africa, where there is great competence 

in farming, could have helped in growing that at a lower cost. Perhaps it was done in an emergency setting to increase the production of what is an extremely important crop. I don’t know that. But 

I do know that—you asked for an example. I think that is one. I 

am not saying it was willfully done to mislead, but it is misleading 

to say that a moderate-sized U.S. contractor is an East African agricultural concern. 

Senator COBURN. Let me ask you, if you were in charge of $80 

million for a malaria budget for Africa, where would you be spending the money? 

Mr. BATE. In terms of the——

Senator COBURN. And I am going to ask you to answer that in 

a short period of time. I know that is a terrible question, but——

Mr. BATE. The short answer is I would be buying a lot more commodities than USAID is buying. The idea that they coordinate with 

other agencies and other forms on the ground may be true. We 

don’t know because of transparency, lack thereof. But the examples 

I have seen, there are instances where they are providing technical 

assistance and the commodities are not available. 

Second, I think that, to use the analogy that Mr. Miller gave, 

which I think is a good one, it would be to a certain extent like 

trying to fight the Iraq war, relying on the Royal Air Force for air 

cover. Now, the Royal Air Force is a marvelous organization and 

as a Brit, I am very proud of it, but it doesn’t have the power that 

the U.S. Air Force does and I think we need U.S. purchases of commodities. 

So is the budget allocation, I am not 100 percent certain what 

it should be, but I would say certainly 50 percent or more on commodities. 

29

The technical assistance they can provide, I am sure, in many instances is very good. We simply do not know. 

Senator COBURN. Dr. Attaran, you are an immunologist and you 

are the author of a very famous paper in the Lancet which revolutionized how USAID and others think about malaria treatment. 

Why is ACT better clinically, and whether the Coartem deal is a 

good deal for Africans and Americans and whether USAID has 

treated the pharmaceutical manufacturer of that appropriately. 

Mr. ATTARAN. Thank you for the question, Mr. Chairman. 

Coartem is an example of a class of medicines known as 

artemisinin combination therapies, which we have been calling 

ACT. There are four approved ACTs and they are all good and they 

are all far superior to previous medicines, mainly for two reasons. 

One, they achieve high cure rates. Chloroquine, which is an older 

medicine, as of about 2 years ago was failing to treat the patient 

successfully 79 percent of the time in Ethiopia. Seventy-nine percent of the time, you had drug resistance and, consequently, treatment failure. You don’t get any treatment failure with ACTs. If it 

is the right ACT for that setting, you get cured. It works all the 

time. 

Senator COBURN. And there is no potential for resistance development? 

Mr. ATTARAN. Well, artemisinin is a herbal remedy from Chinese 

medicine, and they have been using it for 2,000 years and we 

haven’t found resistance yet. Maybe the 2,001st year is going to be 

really bad——

Senator COBURN. Do we understand the mechanism of action? 

What does it do to the trophozoite? 

Mr. ATTARAN. There are heated controversies about that. The 

leading theory is that it actually creates free radicals that destroy 

some of the internal contents of the parasite, but that is not settled 

conclusively right now. What we do know is that it does achieve 

these much better treatment rates than older medicines. 

And it wasn’t long ago, I would say only about a year and a half, 

2 years ago, that we had USAID and UNICEF vigorously supporting the use of chloroquine in Ethiopia. There is a brilliant New 

York Times story about that, where USAID is quoted as saying 

that artemisinin in combination therapies, ‘‘aren’t ready for prime 

time,’’ which was scientifically, I think, an indefensible point of 

view. 

That said, since ACT is better, how do we get enough of it, at 

what price? The prices that were told to you earlier are fairly accurate. Coartem, to take that as an example, because it is the number one listed product by WHO—it is the one that they put at the 

top of their priority list, and it is approved by them—sells for between 90 cents for a pediatric treatment to $2.40 for an adult treatment. It is sold under an agreement with WHO entered into by 

Novartis for absolutely no profit on Novartis’s part. 

You don’t have to take my word for that. WHO did engage 

Deloitte and Touche to audit Novartis and, in fact, Deloitte and 

Touche returned and said that Novartis was making about an 80-

cent loss. So they are in the red, actually, on the adult treatments. 

That was at a time before we saw a sudden spike in raw material 

30

prices. It could even be more of a loss now, but I don’t know and 

you would have to ask Novartis. 

So WHO is satisfied that is a good deal. Global Fund is satisfied 

that is a good deal. What I am aware of is that when Novartis has 

made outreach to USAID, it has not been perfectly reciprocated, 

but that is, again, not the topic in which I can engage very deeply 

and I would encourage you to be in touch with Novartis and 

USAID. 

Senator COBURN. When I was in Congress in the late 1990’s, the 

idea of a Global Fund kind of synergized around myself and some 

other people, and I know many in this room were involved in that. 

Should Congress just strip away the USAID money and send it to 

the Global Fund? 

Mr. ATTARAN. I think what is true is that the Global Fund has 

made very helpful and important and, I would say, impactful 

strides, measured as how many patients are going to get treatment 

and live, since last year when I published my highly critical article 

in the Lancet about them. That is a fantastic development and they 

deserve to be commended for this. 

There are two options here for you, sir. One is to either try and 

reform USAID, and I think that the Brownback-Landrieu-Inhofe 

bill is a fantastic way of going about that, and then USAID perhaps could be effective on malaria in a way that it currently is not. 

The alternative is to simply give the money to the Global Fund. 

Both agencies are obviously capable of doing a good job, and so 

what it turns on at the end of the day is whether you, sir, and your 

colleagues believe it is important to have an independent U.S. ability to execute in malaria and possibly the other diseases about 

which the Global Fund is concerned. 

Senator COBURN. Senator Carper. 

Senator CARPER. Thank you, Mr. Chairman. 

I want to start off with Mr. Miller. Take 2 minutes if you want 

to rebut anything or respond to anything that has been said, just 

mostly the compliments that have been thrown your way. [Laughter.] 

Mr. MILLER. Thank you, sir. I think I wouldn’t know where to 

start. There is a lot out there. A lot of it has to do——

Senator CARPER. Just a couple of priorities. Don’t do it all, just 

a couple of top priorities. 

Mr. MILLER. Sure. I would start by emphasizing that there is 

agreement, and I am glad to hear Mr. Bate and Dr. Attaran mention that. There is a shared goal here of eliminating malaria. In 

fact, there is actually agreement on the effectiveness of interventions that IRS, ITNs, and ACTs have, this is what the United 

States and multilateral agencies, we are a part of, should and will 

support. 

The debate is really about the proportions and the priorities they 

are in, and we are happy to have that debate, and Senator Coburn 

emphasized that greater transparency and accountability are called 

for. As I said in the beginning of my opening statement, no agency 

is beyond criticism and we certainly do welcome that dialogue and, 

of course, we will do the best we can. Again, our goal is to save 

the most lives possible and whatever we can do, if it can be demVerDate 0ct 09 2002 11:52 Nov 21, 2005 Jkt 021437 PO 00000 Frm 00034 Fmt 6633 Sfmt 6633 C:\DOCS\21437.TXT SAFFAIRS PsN: PHOGAN
31

onstrated that we are doing it wrong, we should do it a different 

way. I think President Bush would expect us to do that. 

Senator CARPER. I say, everything I do, I can do better, and my 

suspicion is that is true about most of us and even agencies, as 

well. 

To our other witnesses who joined us on the second panel, I 

apologize for missing the presentations of all of you but one. I want 

to start maybe with a question or two for Dr. Campbell, if I may. 

We have heard some—and I approach these issues as a lay person, so this is a great opportunity for me to learn and to be educated and I think that is the purpose of these hearings anyway, so 

it is serving, at least with respect to this member, it is serving its 

purpose. 

Dr. Campbell, there has been some discussion here today on the 

value of indoor spraying of insecticides and how effective that is 

and there seems to be agreement that can be pretty effective. Are 

there any parts of Africa where it is maybe not as appropriate to 

use sprayed insecticides on the inside of dwellings? 

Dr. CAMPBELL. The answer is that as best we understand, and 

I think we understand this quite well, that indoor residual spraying with a range of insecticides can be highly effective in virtually 

anyplace in Africa except under some remote situations where the 

quality of housing surfaces is such that the insecticide doesn’t adhere or vaporize from the surface as well. 

But the fact of the matter is that its ability to kill mosquitoes 

after they bite and rest on it is essentially uniform in Africa. That 

is not the limiting factor. The limiting factor really has to do with 

the manpower, infrastructure that is required to deliver it and a 

variety of issues of that sort. 

So I think that the debate, as we see it at this point, is not—

I do not find the IRS debate as being the central most important 

issue in terms of moving forward on malaria control at this point. 

And second, I am committed, as are many of our colleagues, in not 

letting the controversies around DDT and IRS get in our way of 

moving forward. It has a role. National governments are dealing 

with it right now to understand the appropriate role. Largely, as 

WHO says, it is in more compact, urban areas, but there is good 

experience of using it in other areas, also. 

Senator CARPER. Thank you. Did you say anything in your testimony about how one role of the USAID is to help countries in Africa to develop the capacity to better utilize—I talked about tools and 

toolboxes. It seems to me part of USAID’s role is to put tools in the 

toolbox to combat malaria. But another part of their role is to help 

ensure that the rest of the tools that are placed in the toolbox by 

others are then better utilized, more effectively utilized by nations 

and so forth to combat the disease. 

If you could just give us your thoughts, and maybe you already 

have and I missed it, on the effectiveness of USAID in coordinating 

this capacity building, folks within national governments and other 

folks that are putting tools in the toolbox, like the Global Fund and 

maybe the World Fund, World Ban. 

Dr. CAMPBELL. In fact, I think one of the things that I would say 

is that I would probably defer those kind of observations and others. That is not an area in which I have a vast amount of experiVerDate 0ct 09 2002 11:52 Nov 21, 2005 Jkt 021437 PO 00000 Frm 00035 Fmt 6633 Sfmt 6633 C:\DOCS\21437.TXT SAFFAIRS PsN: PHOGAN
32

ence and I don’t think I am the best person to comment on that. 

I have worked with many organizations, but I would refer that to 

Mr. Miller and others, and you have got other experts——

Senator CARPER. Good. Let me just ask the same question of others. I already discussed this a little bit with Mr. Miller, so I am 

going to ask if you will hold off. Would you pronounce your last 

name for me, Doctor? 

Mr. ATTARAN. Attaran. 

Senator CARPER. Attaran, OK. And is your last name Bate? 

Mr. BATE. No ‘‘s’’. 

Senator CARPER. No ‘‘s’’. Where did you get that name? 

Mr. BATE. Well, it is a long tradition of singular British men who 

do not have an ‘‘s’’ on the end of their name. 

Senator CARPER. That is remarkable. [Laughter.] 

Do you all have any thoughts on the question I just directed to 

Dr. Campbell? He has done something that few of us here do, and 

that is just admit we don’t know and move on. We usually go 

ahead and answer the question anyway. 

Mr. BATE. There is no doubt that coordination is a vital role that 

with good assistance the USAID can help with. There is, unfortunately, a paucity of data out there as to how that technical assistance works, and in some of the examples we had cited in my written testimony, there are some problems to the extent that technical 

assistance is provided where the commodities are not available. 

So there is no doubt coordination can be improved, even if 

USAID does have great technical assistance, and because of the 

lack of transparency and accountability in reporting, we simply 

don’t know. 

Senator CARPER. All right. Dr. Attaran. 

Mr. ATTARAN. Thank you, Senator. There is a fine line between 

technical assistance and meddling or backseat driving. Technical 

assistance is a good thing. One wants to make sure that the money 

that is given is being used in a proper way, that the people are 

using scientifically up-to-date strategies to control malaria. All of 

that is certainly true. 

But when we end up with a program such as USAID’s, where, 

for instance, ‘‘treatment’’ really is about giving a lot of advice on 

how countries should do treatment and yet no medicines or very 

few are purchased, we are backseat driving at that stage. We are 

telling other people how they should spend their money on medicines that are the ones we, as Americans, want them to use, and 

that is not helpful. 

In fact, that is—in my experience in Africa, I have had formal 

experiences and I have also hitchhiked across Africa for months at 

a time——

Senator CARPER. Is it hard to get a ride there? 

Mr. ATTARAN. There was a 4-day stop on the Equator which I am 

not proud of, sir. 

Senator CARPER. That is a long time to wait. 

Mr. ATTARAN. It really was. But in my formal and informal experiences both, I have found that there is a certain amount of resentment engendered by, if I can paraphrase it, that we are telling people to do a certain something and we are not helping them do it. 

33

You are coming in and you are meddling. I have heard that said 

in all sorts of African contexts. 

Senator CARPER. Thanks. Mr. Miller, just a quick comment if you 

have, just briefly in response to this again. I know you talked about 

it a little bit already. Is there anything else you want to add? 

Mr. MILLER. Yes, sir. I would say we are not meddling. Certainly 

we don’t design our programs from Washington to be impressed 

upon anybody. These are designed almost always with the cooperation of the host government or with NGOs or with other interested 

or affected people, and that is always the goal. 

Senator CARPER. All right. Thanks. Dr. Attaran, do you have 

something else? 

Mr. ATTARAN. If I could just add an analogy that I think might 

be of assistance to you, Senator, USAID does food aid and in the 

food aid context, bags of grain and buckets of oil, the actual commodities are delivered and people are grateful for that around the 

world. 

Imagine we did food aid by actually recommending to people 

what their diet should be in a starvation situation, but we didn’t 

provide them the grain and we didn’t provide them the oil. ‘‘You 

really ought to eat some rice today,’’ but they don’t have any. ‘‘You 

really ought to have a bit of oil,’’ but we don’t give them any. 

That is the analogy that illustrates how our technical assistance 

without the provision of commodities becomes misunderstood and 

our good intentions are misunderstood, which is to me quite a sad 

reality and, I think, one that we can fix. 

Senator CARPER. All right. Thanks. One last question, Dr. Campbell, if I could. Let me just ask what your views are on the recommendations, I think made by Mr. Bate and I think his coauthor, 

that USAID should maybe concentrate its anti-malaria efforts in a 

smaller number or the most needy countries. 

Dr. CAMPBELL. In terms of the—there are several recommendations out there right now and to the extent to which my view would 

apply to USAID is for others to interpret. 

I think that we are in a situation in Africa right now where there 

is clearly progress in terms of one of the important ways of understanding and that is coverage in terms of the proportion of individuals who were sleeping last night under an insecticide-treated net, 

for example. There are some great examples of enormous progress. 

Malawi just completed a national survey and the average was 38 

percent of children under five sleeping under a bed net. That is not 

60 percent, but 3 years ago, it was under 5 percent, and those are 

truly insecticide-treated nets. Those are not just nets. Yes, that is 

one country, but there are several other countries that are making 

dramatic progress. 

I think one of the things that we have is that we have a lack 

of confidence on the part of ourselves and, quite honestly, there is 

a great deal of skepticism on the part of national leaders who are 

the ones who are going to ultimately decide the priority that malaria gets within their ministries of health that malaria can be programmed to impact. 

You share this concern, too, and so I think that one of the challenges we have at this point is that making slow progress, incremental progress across all of Africa, is important. But unless we 

34

have some dramatic examples of progress in the short haul, and I 

am talking in 3 to 5 years, our concern is, is that the edge on malaria as a doable, feasible entity is going to wane and we will have 

lost an enormous opportunity. 

So the answer is, I think that we need a balance of investment 

across many countries, but we also need more attention to intensive multi-donor, not just single country, efforts in a few countries 

that actually can provide an example to other countries to say, 

wow, this is possible, because we do not have examples of success 

in Africa at this point in time, and until we begin to accumulate 

those very rapidly, I think that the confidence issue is going to become an increasing impediment. 

So the answer is, yes, I think that we need some intensive investment with the Global Fund and with several other bilaterals to 

come together in a few countries and say, this needs to be done 

really well and documented to the n-th degree so that people can 

see it, understand it, and have confidence in it. 

Senator CARPER. Thank you. Dr. Bate, a last word? 

Mr. BATE. If I just may, I think there are examples of success 

in Africa and those examples are where people actually measure 

outcomes and they use interventions. I mentioned South Africa, 

and Zambia has already been mentioned. Northern Zambia is a 

great example of a rapid reduction of morbidity from malaria of 70 

or 80 percent. 

Senator Brownback said something which I think is very good, 

and I can say this as an outsider. The American people are the 

most generous on earth. If they are shown that malaria treatment, 

prevention will work, I am sure more money will be made available, and that is something we all want. And I think that if the 

only examples you have are provided by national governments in 

South Africa’s case, or the private sector, that is a very—I think 

that is an indictment on the fact that no data has been collected. 

We need to collect data and we need to have that data presented 

transparently, and then I think the American people will spend 

even more money to malaria. 

Senator CARPER. All right. Our thanks to all of you. 

Senator COBURN. I just want to follow up with a couple of questions. Mr. Miller, do you know and do you have at your fingertips 

where the money is spent for the malaria program with USAID? 

Mr. MILLER. At my fingertips, no, sir. 

Senator COBURN. Do you know it? I mean, is it available to you? 

Mr. MILLER. It will be—yes, it is available to me. 

Senator COBURN. So it is not that the information isn’t available. 

So my question is, since it is available to you, why isn’t it available 

to us? 

Mr. MILLER. It is the form in which the information is available, 

I think is important to remember. I would point out that most of 

what we do, most of what USAID funds in terms of anti-malaria 

programs—this is true of all health and development programs—

is done through grants. We call them cooperative agreements, but 

they are, in fact, grants. They are not through contracts, so you are 

not going to get a contract-like response. 

Senator COBURN. I don’t need to have that. I just want to know 

where the grants are, who gets them, what time they got them, 

35

what are the requirements of the grants, what is the performance 

evaluation of the grants. How do you measure whether somebody 

as a grantee did what you asked them to do? In other words, that 

is the data that I want to see, and it is not just USAID. I want 

to see that in the entire Federal Government. The American people 

deserve to see that and know that, and if that is available, I want 

this Subcommittee to have it. 

Mr. MILLER. Sure. That type of accountability is stuff we do collect with every grantee. They have to go through audits. They have 

to have a performance appraisal——

Senator COBURN. Then I would assume you would make that 

available to the Subcommittee. 

Mr. MILLER. We will make everything we can, sir. 

Senator COBURN. I just have one other question. Dr. Attaran, 

would you comment on the World Bank situation now and what is 

going on in terms of the malaria? 

Mr. ATTARAN. Yes, Mr. Chairman. The World Bank has, only a 

couple weeks ago, published a new malaria plan—it is not implemented, it isn’t yet funded by their board—which has as its bottom 

line that they will commit between $500 million and $1 billion towards malaria. They very carefully are cagey about that. They say 

$500 million to $1 billion, together with their partners, and nowhere do they say what the World Bank’s contribution will be. It 

is always, together with our partners. So we really don’t know 

what they are committing. 

But what I can tell you is that history is not on the side of children with malaria, because in 2000, the World Bank did promise 

to provide $300 to $500 million of its own money for malaria in Africa which initially it said it did, and then following an investigation that I conducted and published in the journal Nature, which 

you may be aware of, the World Bank admitted that, in fact, they 

had only spent $100 to $150 million, not the $300 to $500 million 

that they said. And similarly to USAID, the World Bank declined 

to explain how they spent it. So we don’t even know where that 

$100 to $150 million has gone. 

It is curious that this is a bank that doesn’t know how much it 

has got in its accounts: ‘‘Maybe we spent $100 million, maybe we 

spent $150 million on malaria. We are really not sure and we 

please don’t want any more questions on the situation.’’ I am, of 

course, being summary in my assessment of the situation, but I 

think that is, frankly, accurate, and the editors at Nature agreed 

with that. 

Senator COBURN. All right. I think our testimony is true that—

and let me just, Mr. Miller, give you a chance. You do have a contract for $65 million for nets? 

Mr. MILLER. I believe that is a grant, or a cooperative agreement. 

Senator COBURN. You have a grant. 

Mr. MILLER. A cooperative agreement, yes, sir. 

Senator COBURN. Sixty-five million, and that is over how many 

years? 

Mr. MILLER. Net Mark, is that per year, or is it 5 years? It is 

an 8-year grant. 

Senator COBURN. An 8-year grant. 

Mr. MILLER. Cooperative agreement. 

36

Senator COBURN. And those grants are not—those nets are not 

given away, they are sold, is that correct? 

Mr. MILLER. It can be both. 

Senator COBURN. Do we know what percentage of that 

money——

Mr. MILLER. We can determine that. The way we determine——

Senator COBURN. You don’t know that? 

Mr. MILLER. No, sir, not on the spot. 

Senator COBURN. Does somebody here know that? 

Mr. MILLER. I think we can determine that. Do we know the percentage? 

Mr. CARROLL. Ten percent, 15 percent are given away. The rest 

are sold. They’re sold, I might add—prices that these nets are 

being sold for represent 50 percent reduced prices from what they 

were in the market 3 years ago. So this is moving nets through the 

commercial sector into retail shops and making them available at 

very low prices, along with nets going into antenatal clinics and 

making those available for free. 

Senator COBURN. Here’s the difference. What do the nets cost? 

What’s the true cost of the net? If you’re going to spend $65 million 

buying nets, I’ll bet you they’re the biggest net buyer on this side 

of the ocean. And if we’re going to buy the nets there shouldn’t be 

any profit in them. The nets ought to go to people at what they 

cost. Is that what they’re doing, they’re going at cost? The Africans 

are buying the nets at cost and that’s around $4? 

Mr. CARROLL. Three dollars, fifty cents, $4. 

Senator COBURN. That’s the cost that’s paid to the manufacturer 

for the net and that’s the cost that they’re sold at? 

Mr. MILLER. But I don’t think nets always go at cost. 

Senator COBURN. Why not? 

Mr. MILLER. Some are free. 

Senator COBURN. Other than the free ones, why would the nets 

not go for what they cost? 

Mr. CARROLL. Senator, this is a program—again, this is an exercise where we are working in concert with other donors, UNICEF, 

for instance, World Health Organization, where we are looking at 

the full range of opportunities to get nets not just tomorrow or 

today, but in a sustained way to make sure that every kid and 

every pregnant woman has access to this lifesaving measure. 

Our role in this case has been multifold. We have been working 

with textile industry across Africa to increase their ability to 

produce the nets so that we are creating more opportunities for 

nets to be flowing into African homes. 

Senator COBURN. That’s a great point, but here’s my point. Is 

somebody making profit off the nets? 

Mr. CARROLL. If there’s a profit being made, it’s a local retailer, 

it’s an African retailer bringing food home to their family. This is 

building a local capacity to solve a local problem. 

Senator COBURN. So somebody is going to spend——

Mr. CARROLL. Part of our role, our other role, which is equally 

important, is working in the communities to make sure that there 

are affordable nets free to those who cannot afford them. So we’re 

working both sides of this. We can share with you data now that 

is coming in from Senegal and Ghana, for instance, that shows 

37

when we take an approach that involves both making—strengthening local retail shops in villages to be able to sell these nets at 

these prices along with targeted subsidies and free nets, we’re looking at the poorest of the poor households and the wealthiest households, all vulnerable to malaria, but all getting equal access and 

equal use of these nets in their homes. So we’re getting very equitable distribution against a disease that is rampant in those countries. 

Senator COBURN. I want to see the data. Since you seem to have 

a measurement on that, let’s look at it. 

Mr. CARROLL. We have that measurement and in fact that has 

been shared with panel members here. 

Senator COBURN. One of the things that we will do—first of all, 

thank you all for spending the time to come. Thank you, Mr. Miller, for adjusting your schedule for us. I promise if we have you 

here again we will make sure you are well advised in advance in 

terms of your time requirement. 

You will hear from the Subcommittee specific questions we would 

like for you to answer. We’d like those answered on a timely basis. 

This is the first hearing on this. I’m not through with this. We’re 

going to talk to the Global Fund. We’re going to find out what’s 

happening. We’re going to make sure—I’m very pleased that Mr. 

Miller is going to avail the Subcommittee of where the money is 

spent and how. I’m very pleased that we’re going to have a transparent ability to get that over the Web. We’ll talk about how fast 

that can be done. I would hope that would be a priority because 

with the information comes less criticism, not more. Part of the 

criticism of the malaria program today is because the information 

isn’t available. So the assumption is that it’s not being done right 

when in fact it may be done right. 

So I want to thank each of you. You will have a follow-up letter 

from us. If we have not heard back from you—in other words, we’re 

not going to have a hearing and expect something to come back, 

just like most hearings in Congress and then you never hear anything about it. You’re going to hear back again from us. We’re 

going to get the questions answered. And then if we don’t have the 

questions answered, we’ll be back here talking about it again. 

Thank you all very much for being here. I thank you for your 

work, each of you, and the staff at USAID. I know you’re committed to the same thing that everybody else in the room is, and 

that’s eradication of malaria in Africa. Thank you very much. 

The hearing is adjourned. 

[Whereupon, at 12:45 p.m., the Subcommittee was adjourned.] 

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