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94–180PDF 2015

THE CONTINUING THREAT OF NEGLECTED

TROPICAL DISEASES

HEARING

BEFORE THE

SUBCOMMITTEE ON AFRICA, GLOBAL HEALTH, 

GLOBAL HUMAN RIGHTS, AND 

INTERNATIONAL ORGANIZATIONS

OF THE

COMMITTEE ON FOREIGN AFFAIRS 

HOUSE OF REPRESENTATIVES

ONE HUNDRED FOURTEENTH CONGRESS

FIRST SESSION

APRIL 15, 2015

Serial No. 114–63

Printed for the use of the Committee on Foreign Affairs

(

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

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

(II)

COMMITTEE ON FOREIGN AFFAIRS 

EDWARD R. ROYCE, California, Chairman 

CHRISTOPHER H. SMITH, New Jersey 

ILEANA ROS-LEHTINEN, Florida 

DANA ROHRABACHER, California 

STEVE CHABOT, Ohio 

JOE WILSON, South Carolina 

MICHAEL T. MCCAUL, Texas 

TED POE, Texas 

MATT SALMON, Arizona 

DARRELL E. ISSA, California 

TOM MARINO, Pennsylvania 

JEFF DUNCAN, South Carolina 

MO BROOKS, Alabama 

PAUL COOK, California 

RANDY K. WEBER SR., Texas 

SCOTT PERRY, Pennsylvania 

RON DESANTIS, Florida 

MARK MEADOWS, North Carolina 

TED S. YOHO, Florida 

CURT CLAWSON, Florida 

SCOTT DESJARLAIS, Tennessee 

REID J. RIBBLE, Wisconsin 

DAVID A. TROTT, Michigan 

LEE M. ZELDIN, New York 

TOM EMMER, Minnesota 

ELIOT L. ENGEL, New York 

BRAD SHERMAN, California 

GREGORY W. MEEKS, New York 

ALBIO SIRES, New Jersey 

GERALD E. CONNOLLY, Virginia 

THEODORE E. DEUTCH, Florida 

BRIAN HIGGINS, New York 

KAREN BASS, California 

WILLIAM KEATING, Massachusetts 

DAVID CICILLINE, Rhode Island 

ALAN GRAYSON, Florida 

AMI BERA, California 

ALAN S. LOWENTHAL, California 

GRACE MENG, New York 

LOIS FRANKEL, Florida 

TULSI GABBARD, Hawaii 

JOAQUIN CASTRO, Texas 

ROBIN L. KELLY, Illinois 

BRENDAN F. BOYLE, Pennsylvania

AMY PORTER, Chief of Staff THOMAS SHEEHY, Staff Director

JASON STEINBAUM, Democratic Staff Director 

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

INTERNATIONAL ORGANIZATIONS

CHRISTOPHER H. SMITH, New Jersey, Chairman 

MARK MEADOWS, North Carolina 

CURT CLAWSON, Florida 

SCOTT DESJARLAIS, Tennessee 

TOM EMMER, Minnesota 

KAREN BASS, California 

DAVID CICILLINE, Rhode Island 

AMI BERA, California 

(III)

C O N T E N T S 

Page

WITNESSES 

Ariel Pablos-Me ́ndez, M.D., Assistant Administrator, Bureau for Global 

Health, U.S. Agency for International Development ........................................ 3

Peter J. Hotez, M.D., president, Sabin Vaccine Institute .................................... 21

Mr. Nicholas Kourgialis, vice president, Eye Health, Helen Keller International ................................................................................................................. 35

LETTERS, STATEMENTS, ETC., SUBMITTED FOR THE HEARING 

Ariel Pablos-Me ́ndez, M.D.: Prepared statement .................................................. 6

Peter J. Hotez, M.D.: Prepared statement ............................................................. 27

Mr. Nicholas Kourgialis: Prepared statement ....................................................... 37

APPENDIX 

Hearing notice .......................................................................................................... 54

Hearing minutes ...................................................................................................... 55

Written responses from USAID to questions submitted for the record by 

the Honorable Christopher H. Smith, a Representative in Congress from 

the State of New Jersey, and chairman, Subcommittee on Africa, Global 

Health, Global Human Rights, and International Organizations .................... 56

The Honorable Christopher H. Smith: Article by Dr. Peter Hotez ...................... 60

(1)

THE CONTINUING THREAT OF NEGLECTED 

TROPICAL DISEASES 

WEDNESDAY, APRIL 15, 2015

HOUSE OF REPRESENTATIVES,

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

COMMITTEE ON FOREIGN AFFAIRS,

Washington, DC. 

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

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

(chairman of the subcommittee) presiding. 

Mr. SMITH. Pursuant to notice the subcommittee meets for our 

hearing on neglected tropical diseases. 

Neglected tropical diseases, as I think many here know, or 

NTDs, are a group of 17 parasitic and bacterial diseases which 

blind, disable, disfigure, and sometimes kill sufferers among more 

than 1 billion of the world’s poorest people, trapping the most 

marginalized communities in a cycle of poverty and pain. 

The list ranges from Chagas to rabies to leprosy to dengue fever. 

However, there are others not on this list of 17 diseases that also 

receive far too little attention. These include diseases such as polio 

and small pox, which have been largely eliminated from the planet 

and often fatal—fortunately rare-NTDs such as kuru. 

Prior to last year, that list of rare diseases included Ebola. Even 

though not immediately fatal, these diseases can keep children 

from attending school and their parents from working, as well as 

resulting in excessive loss of blood by mothers during birth and a 

resultant low birth weight babies as well. 

These conditions constitute a significant hurdle to achieving economic growth and dilute the impact of foreign assistance programs. 

Last year, the world witnessed an Ebola disease pandemic that hit 

six African countries and spread to Spain, Scotland and the United 

States. 

Furthermore, in recent years such diseases as dengue fever and 

chikungunya have spread into the United States. These and other 

tropical diseases most often victimize the poor who live in tropical 

climates whether in Africa, Latin America, or parts of the United 

States. 

Even in the face of the worldwide challenges these tropical diseases pose, the administration has proposed cutting the budget in 

this area by 17 percent. Today’s hearing will examine the problem 

of neglected tropical diseases and U.S. current and potential efforts 

to address this problem. 

2

Eight NTDs account for almost all worldwide cases. Seven of 

them can be treated with low cost medication that could be dispensed by non-health workers irrespective of disease status. Nearly 

80 percent of all NTD cases are comprised of people carrying intestinal worms. 

On June 27th at our hearing in 2013, we learned the catastrophic nature of these preventable intestinal worm infections. So 

many of the problems we struggle with such as difficult births and 

malnourishment can be remedied without dealing with infections 

themselves. 

You know, I am a great fan and I know the administration, both 

Bush and now President Obama, have done much on the nutrition 

side. We have a bill that will codify and expand Feed the Future. 

It passed last year. It is going to be up on the docket we hope 

next week in the full committee. But we don’t want to feed the 

worms. We want to feed people. 

We want healthy children and mothers and families and to mitigate and eradicate these parasites. We can no longer look at photos 

of happy young children standing in muddy water without shoes 

and not think of the possibility that they are losing their future 

even as we see them enjoying a break from poverty in which they 

live because sometimes, of course, some of these diseases migrate 

through that means. 

Yet we must understand that these are not merely diseases affecting people in faraway lands. Current U.S. law favors research 

in those diseases threatening the American homeland but in today’s world diseases can cross borders as easily as those affected 

by them or the products imported into the United States. 

For example, Chagas is most prevalent in Latin America but it 

has been identified in patients in Texas, and cases of dengue have 

been recently reported in Florida. 

We cannot afford to assume that what may seem to be exotic diseases only happen to people in other countries, and I would note 

parenthetically, of course, even if that were true we have a moral 

obligation to aid and assist those who contract these diseases and 

to mitigate transmittal to the greatest extent possible. 

Ten years ago West Nile virus, another rare disease, was not 

seen in the U.S. or anywhere else outside the east African nation 

of Uganda. But in less than a decade it has spread across this 

country and much of the rest of the world. 

More than 10,000 people died of Ebola worldwide thus far. Although only one person died in this country due to that disease, we 

saw, clearly, how unprepared our medical services in the rest of the 

world were initially to deal with a rare disease that had previously 

been confined to isolated areas in central Africa. 

There are other rare diseases, not to mention the recognized 

NTDs, that cause havoc if they find their way to populated international transit areas such as Ebola did last year. 

Meanwhile, far too many people live lives of quiet suffering from 

diseases we must fight more effectively. That is why I have introduced today H.R. 1797, the End Neglected Tropical Disease Act. 

Among other provisions, H.R. 1797 calls on the U.S. Agency for 

International Development to modify its NTD programming with 

respect to rapid impact packaging treatments, school-based NTD 

3

programs which we know have been one of the most efficacious 

ways to date to deal with this, and new approaches to reach the 

goals of eliminating NTDs. 

The bill also sets forth measures to expand USAID programs including by establishment of research and development programs. 

One of the ideas that one of our distinguished panelists, Dr. 

Hotez, had suggested about a Centers of Excellence we include in 

the bill and I thank him again for that recommendation to combat 

what is happening here. 

I know, parenthetically, that in 1997 when we saw an alarming 

spike in the prevalence in autism I wrote a law and have now written three laws including the Combating Autism Act and most recently Autism Cares that builds on Centers of Excellence at CDC 

and NIH to really combat that pandemic. 

Although it is a developmental disease, a disability disease, the 

numbers are staggering worldwide as well as in the United 

States—one out of every 68. 

So Centers of Excellence, I think, or such a center in the Southern part of the U.S., as Dr. Peter Hotez has recommended, included 

in the bill I think would make a significant difference for our efforts here in the United States. 

In an effort to reach achievable and reachable goals to prevent 

and eliminate NTDs, the projected 70 percent cut in funding for 

such projects in the 2016 budget would pose a serious setback. 

I have appealed and we plan on doing a letter to the members 

of the Appropriations Committee because we had a similar proposal 

last year that they, thankfully, in a bipartisan way ensured that 

we got to the $100 million level, but hopefully we can go even beyond that as we move forward in Fiscal Year 2016. 

I would like to yield to any of my colleagues. 

Okay. We will now welcome our first witness, the Honorable 

Ariel Pablos-Mendez, who is the Assistant Administrator for Global 

Health at USAID, a position he assumed in August 2011. 

Dr. Pablos-Mendez joined USAID’s leadership team with a vision 

to shape the Bureau for Global Health programmatic efforts to accomplish scalable, sustainable, and measurable impact in the lives 

of people in developing countries. 

Prior to joining USAID, he worked on global health strategies 

and a transformation of health systems in Africa and Asia. He also 

served as director of knowledge management at the World Health 

Organization. 

Dr. Pablos-Mendez is a board certified internist and until recently he was practicing as a professor of clinical medicine and epidemiology at Columbia University. 

Doctor, welcome back. 

We appreciate your previous testimonies before this subcommittee, always insightful and expert, and I thank you for being 

here. I yield. 

STATEMENT OF ARIEL PABLOS–ME ́ NDEZ, M.D., ASSISTANT ADMINISTRATOR, BUREAU FOR GLOBAL HEALTH, U.S. AGENCY 

FOR INTERNATIONAL DEVELOPMENT 

Dr. PABLOS-MENDEZ. Thank you, Chairman Smith, and thank 

you to all the members of this subcommittee for highlighting this 

4

important issue and I really appreciate the opportunity to discuss 

the U.S. Agency for International Development program to combat 

neglected tropical diseases. 

You explained very well the realm of this space of diseases and 

the spectrum and the populations that it affects. 

While Ebola is not technically classified as an NTD by USAID 

and the World Health Organization, the high profile outbreak of 

Ebola in west Africa in the past year has highlighted the risk of 

paying insufficient attention to diseases which typically occur in resource-limited settings. 

And I take the opportunity to thank you, Chairman Smith, for 

the leadership role you played back in August when we were in recess and nonetheless it was just the right timing for mobilizing 

American people in the response against Ebola. 

USAID is focused on its overall mission of partnering to end extreme poverty and promote resilient democratic societies while advancing our security and prosperity and our NTD program is making great progress toward ending diseases of extreme poverty. 

Our global health programs include typical priorities—ending 

preventable child-maternal deaths and, again, I recognize the 

championing in this subcommittee for this cause, creating an 

AIDS-free generation working with PEPFAR, and protecting communities against infectious diseases under which our NTD program 

operates. 

Still, even though we have made great progress, there are more 

than 1 billion people globally who suffer from NTDs and this 

disproportionally impacts poor and rural populations who often 

lack access to safe water, sanitation, essential services, and medicines. 

NTDs take a very heavy human toll by creating sickness, disability, blindness, and severe disfigurement, contributing to childhood malnutrition and leading to an appreciable loss of productivity lifelong. 

That is why I am very proud of the achievements in USAID’s integrated NTDs program which began less than 10 year ago with a 

lot of support from the Congress and has accelerated success in 

what is really a historical scale. 

With support from the Congress, the program has made solid advance in addressing the seven diseases we represent, approximately 80 percent of the global burden of NTDs and can be addressed through highly cost effective community and school-based 

distribution of preventive chemotherapy generally once or twice a 

year in these populations. 

The integration of these programs has been the hallmark of the 

program in USAID and is now a global standard. With a budget 

of $100 million in the year 2014, USAID’s program distributes 240 

million treatments to 115 million people in 31 countries. 

To date, the cumulative figure is over 1.2 billion treatments have 

been provided. In the year 2011, when I joined the U.S. Government, 7.7 million no longer required treatment for lymphatic filariasis in USAID-supported countries. 

Last year, that increased from 7.7 to 92 million. By 2018, the 

number is predicted to jump to over 250 million. That is, half of 

the totality of the problem in the world will be managed. 

5

In Latin America, onchocerciasis is close to elimination with 

transmission mainly remaining in the hard to reach border area 

between Venezuela and Brazil. It is a great success story in this 

continent. 

I would like to highlight a few factors that have contributed to 

the success of the USAID’s program and the global progress to date 

in addition to the support of the American people. 

First, the success of USAID’s NTD program would not have been 

possible without the partnership with the pharmaceutical sector. In 

2014, USAID-supported countries benefited from over $2 billion in 

donated drugs. To date, nearly $9 billion have been generously donated by 

Merck & Company, GSK, Pfizer, Johnson & Johnson, Merck 

Serono. We estimate that for every tax dollar spent by USAID, 

more than $26 in drugs are being donated for the countries we are 

supporting with USAID funding making critical investments in 

countries’ systems to distribute the drugs and monitor progress. 

Second, USAID partnership and coordination with the United 

Kingdom has allowed for a collective reach to almost 50 countries 

and the provision of 340 million treatments last year alone. 

This has allowed for expansion in high burden countries including Ethiopia and Nigeria, which are very large, and ancillary global 

efforts to put trachoma elimination on track by defining the burden 

in countries throughout Africa and in Asia. 

Third, USAID builds upon the existing infrastructure of national 

disease control and elimination programs to ensure sustainability. 

USAID and our partners coordinate with ministries to ensure that 

U.S. resources complement investment from other stakeholders and 

leverage local funding working with national NTD plans, and a lot 

of the work, of course, is based on the research, the science, and 

the advocates that have allowed us to come this far in the fight 

against NTDs. 

Thanks to congressional support, progress made to date and 

available tools and partnerships, the elimination of these diseases 

of extreme poverty as a public health scourge is being—is really 

within our grasp. USAID is committed to working with countries 

and our global partners to reach the remaining 800 million people 

who still need treatment. 

In order to ensure sustainability, we must maintain investments 

in research and development and monitoring and evaluation. For 

example, our partnerships with the Drugs for Neglected Diseases 

initiative just established last year and with a Coalition for Research on Neglected Tropical Diseases make important contributions toward new and much needed technologies to make it simpler 

initially to reach more people and to begin to consider additional 

diseases that today are very expensive to treat. 

Part of USAID’s commitment to all innovation that many of you 

have seen recently the work that our Center for Innovations has 

been doing on behalf of Ebola with new innovative personal protection equipment. I really just have to thank you for the leadership. 

I think that progress has been impressive. We all need to work 

in maintaining support for these programs and we believe that 

with your support we will continue to do so. 

Thank you very much. 

6

[The prepared statement of Dr. Pablos-Mendez follows:]


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Mr. SMITH. Dr. Pablos-Mendez, thank you so much for your leadership and, you know, the materials, again, that you sent over to 

our office yesterday were very informative and encouraging and it 

is a great record and I want to thank you for your personal leadership. 

I would like to yield to the vice chairman of the committee, Mr. 

Meadows. 

Mr. MEADOWS. Thank you, Mr. Chairman, and for those of you 

that are here I think I would be remiss if I didn’t say this. There 

are a number of times when the chairman has held hearings and 

there are not the cameras, there are not the reporters, because the 

actual thing that we are addressing is not necessarily newsworthy 

to the people on Main Street. 

And yet the heart of this chairman has been not only diligent but 

tenacious and unyielding in his desire to be a voice for so many 

that have no voice. So I want to say thank you to the chairman for 

his work each and every day that is unrelenting. 

Thank you, Doctor, for your work and your willingness to team 

up. It does come at a cost sometimes for some of us when you look 

at foreign aid and you look at helping other countries when there 

are so many needs here in the United States, and so it is imperative that you are efficient and focused with your money because it 

is every dollar that counts. 

And so I know that a lot of USAID money in terms of this particular topic accounts for about 35 percent of the treatment is what 

I understand from what I have read. Who else is partnering with 

us or with you to address this particular medical concern? 

Dr. PABLOS-MENDEZ. Thank you, Representative Meadows. 

Thanks for those kind words. I also want to recognize the chairman. 

I did so in person earlier because you are right, you are also giving us your time and your political capital to support something to 

help the poorest people in the world and there is usually not a political pay for that. 

It is just because it is the right thing and in particular in these 

diseases, and although some of them can sometimes spread and hit 

us, there is a security rationale. It is truly because it is the right 

thing and the American people support that. 

You are right and I think that the partnership that we have had, 

particularly with the British Government, has been very important 

and it has been growing and it is allowing us to reach now 50 countries as opposed to the 30 countries that we were supporting directly. 

DFID has committed $195 million UK pounds in the last period 

of 4 years or so and that is a very significant commitment. The Bill 

and Melinda Gates Foundation has stepped up to the plate as a big 

champion following that London partnership and declarations and 

so on and they have committed $363 million over 5 years. 

They are particularly supporting research and innovation and 

that is a very important part of the overall global effort against 

these diseases. 

So you are right, we are just about 40 percent of the total. But 

as I said before, it is the companies’ historical willingness to work 

with the government in a public-private partnership to donate 

11

these life-saving interventions and many of them from the beginning committed to do it for as long as it takes. 

So we do have great partners and we also see many of the countries are now growing economically. So we are working to make 

sure those governments begin to invest more if the global investment is about $250 million outside the donations. 

Now, the countries where the diseases are endemic are contributing maybe $100 million or $120 million a year. We expect this 

equation to evolve in the next 5 to 10 years for countries to begin 

to spend more, particularly those countries are already in the middle income category like Brazil or Nigeria, and we are working to 

mobilize those resources because that will be necessary to sustain 

the success of these programs. 

Mr. MEADOWS. Right. One other area, and you mentioned Ebola, 

and the good success story that we are hearing today on the ground 

from many of those areas that were affected, one of the concerns 

I have is that this particular problem was one we knew about before it became the epidemic in the region that it was. 

Samaritan’s Purse had been there, as we know now, because of 

the highlighted newsreels that had been there. They had been 

there on the ground. 

What vehicle is there, Doctor, that we can use with either 

USAID and primarily I guess it would USAID to bring that to the 

attention before it becomes a billion-dollar problem when it is a 

million-dollar problem? 

Because what I feel like we did in this particular case is, whether it be bureaucratic, whether it be Congress or anything else, we 

looked the other way until it became such a big problem that it 

scared people in Texas and in New York and in Atlanta or wherever it may be and then we responded with big money when a few 

dollars wisely spent earlier on would have corrected the problem. 

That may be simplistic. I am not a doctor. That is my take of it. 

What can we do to work closer with that so that it doesn’t become 

a huge problem that the taxpayers have to bail out? 

Dr. PABLOS-MENDEZ. Well, thank you very much. It is a very important point and it was the subject of that hearing that we had 

here last August. 

It is the case that as you know there have been many, many 

Ebola outbreaks, particularly in central Africa. Each of them was 

successfully controlled and actually they were getting smaller and 

smaller because we learned in those geographical areas to respond 

quickly and control those outbreaks. 

Although the virus was not new we have evidence that has been 

around west Africa for several years, it was the first time that the 

virus was recognized in west Africa. 

Mr. MEADOWS. Okay. 

Dr. PABLOS-MENDEZ. So those populations were not familiar with 

Ebola. In the cities their immune system may not have been familiar with the virus and the fact that it reached cities transformed 

this into something that was different than before even though the 

virus itself was similar to the virus that we know. 

And the epidemic that began in December 2013 indeed was 

spreading through the spring, but by the end of May when I was 

at the World Health Assembly in WHO in Geneva there was a 

12

sense that the numbers were coming down. And so in fact it was 

not even a major subject. 

But we now know that even though we were paying attention 

and we were monitoring things, the virus reached in cities and 

spread in the ways that we saw in July and in August where I 

called it the summer of panic and because it was truly a scary 

time. 

Now what to do? Because you are right, we have been successful 

with the response and the support of the Congress has been magnificent. 

As someone who worked in global health and who was also talking to many others around the world in Africa and in other partners, the respect of that leadership and commitment has been quite 

palpable and important because it has been the right thing and it 

has worked in a quite dramatic way. 

We are not out of the woods but it is pretty good. What to do? 

So we do have this neglected tropical diseases program that is focusing on all diseases of the poor for which simple treatments are 

the best way to prevent their damage on populations. 

But we have a separate program, USAID’s emerging pandemic 

stress programs, that, again, has been supported by the Congress 

as well, and the purpose of that program is to work precisely at the 

interface between humans and ecology and animals where all of 

these viruses are happening all the time. 

I have to say that we hear about those viruses that breakout but 

there are many others, I am talking about hundreds—hundreds 

that we are detecting——

Mr. MEADOWS. Right. 

Dr. PABLOS-MENDEZ [continuing]. And not happening. But as we 

know, it is not enough. In—we have——

Mr. MEADOWS. It is kind of like our job. We only hear about it 

when we don’t do it right. 

Dr. PABLOS-MENDEZ. Something like that. 

Mr. MEADOWS. Yes. 

Dr. PABLOS-MENDEZ. And in this case, the global community has 

recognized that preparedness of pandemics has been an area that 

has been under invested. In addition to some reform efforts from 

the World Health Organization to really call for help earlier and 

support the countries quicker, there had been a lot of discussion on 

the fact that the economic impact of these outbreaks will just grow 

because of the interconnectedness of society, and how we respond 

to that, clearly, we do not have yet in the world the right platforms. 

The U.S. Government is now leading, as you know, with the 

Global Health Security Agenda——

Mr. MEADOWS. Right. 

Dr. PABLOS-MENDEZ [continuing]. A process to reinvigorate the 

capacity of countries that are most vulnerable and creating with 

WHO, the World Bank, and others the mechanisms to respond in 

the human resources sense, in the financial sense, and also in the 

technology sense because we always come to try to do a vaccine 

when we are in the middle of the outbreak. 

So we need to develop systems that will be there because now 

we know that these things do happen every 5 or 10 years. 

13

Mr. MEADOWS. Very good. Well, that ends my questions. I am 

going to close with one personal request that comes way out of left 

field. 

There is a hospital in Pakistan that is known as the American 

Hospital that is falling in somewhat of disrepair. If USAID could 

look at how we could partner with them on that particular facility 

from a health—global health standpoint, if you would personally 

look into that for me I would greatly appreciate it. 

I think it would go a long ways in the region. I yield back. Thank 

you, Mr. Chairman. 

Mr. SMITH. Thank you very much. 

Mr. MEADOWS. I apologize. I have to leave. But we are monitoring it from my office. 

Dr. PABLOS-MENDEZ. Thank you very much. 

Mr. SMITH. Mr. Meadows, thank you very much and, again, for 

your leadership especially. Mr. Clawson? 

Mr. CLAWSON. Thank you for coming. Thank you, Mr. Chairman, 

and full respect to those that work at USAID, and I have seen their 

work on a personal level in poor countries around the world and 

admire the sacrifice these folks make. That is my starting point. 

I represent south Florida, southwest Florida. It is a great place. 

But when I think about the Caribbean I think about dengue fever 

and the chikungunya, and I think about my own population—large 

retiree base—and I have the impression that in the Caribbean and 

in South America lots of folks get dengue fever in particular and 

now more and more chikungunya when they are young and able to 

overcome. 

I can’t imagine having break bone fever at age 70. Can you? And 

so I am always worried about this epidemic that most Americans 

don’t even know about. 

I am worried about it invading my district and having a meaningful impact. Am I right about being worried about what I am 

worried—I mean, I am worried that, you know, you get a few mosquitoes going north on a year that we have a lot of rain and you 

have got a mixture for a really bad outcome. Do I view that correctly or am I being alarmist? 

Dr. PABLOS-MENDEZ. No, I think you are correct. Dengue is a disease that can kill you although it rarely does so. Most of the time 

it is like a severe flu. 

Mr. CLAWSON. But it would kill an 80-year-old? 

Dr. PABLOS-MENDEZ. It could kill children and pregnant women, 

so vulnerable populations are the most at risk around the world. 

So it is a real threat. And you are also correct that dengue has 

been growing. Dengue is transmitted by mosquitoes that thrive in 

cities, unlike the malaria mosquitoes of the more rural areas. 

Mr. CLAWSON. Yes. 

Dr. PABLOS-MENDEZ. And because we are having this urban development in many places——

Mr. CLAWSON. It is an urban indoor mosquito? 

Dr. PABLOS-MENDEZ. Correct. 

Mr. CLAWSON. It is—so it is the inverse of malaria, if I understand it. 

Dr. PABLOS-MENDEZ. That is correct. 

Mr. CLAWSON. All right. 

14

Dr. PABLOS-MENDEZ. And so because there has been so much 

urban growth in the tropical world, we are seeing now dengue really at unprecedented levels—Brazil, we hear in the news every day. 

So dengue is up and it also exists in Africa. We used to think it 

was all malaria. 

Mr. CLAWSON. So do you agree we are vulnerable in Florida or—

I mean, would we be vulnerable by this combination of a bad mosquito year and a bad rain year? 

You know, if we had as much rain in my district as they get in 

some of the Caribbean Islands and get the wrong mosquitos, either 

chikungunya or dengue fever——

Dr. PABLOS-MENDEZ. Right. 

Mr. CLAWSON [continuing]. Do we have a problem? 

Dr. PABLOS-MENDEZ. Well, two things. One is that because you 

need to have reservoirs of water that stays there unattended, you 

have things that in poor settings are common—tires with water 

near the houses—that are less prevalent in the United States. 

But that is important because we have better development. We 

are less at risk. In addition, even though you could get dengue and 

certainly you can get dengue in south Florida, the severity of the 

disease in better nourished populations and the ability to get medical care, which is general at this point, is also pretty good. 

But I would say to you that there is a risk, of course, that dengue 

can spread. It had been growing. But I don’t imagine something 

like Ebola spreading in the country as a risk in the mindset that 

we had in the fall. There is a different epidemiology, a different behavior in terms of the geography. 

Now, for southern Florida being in the Caribbean it is certainly 

possible. There is no treatment, as you know, for dengue but there 

has been a lot of progress on the development of vaccines. 

Because it is a large problem in the world and because it afflicts 

now many middle income countries, companies have been working 

with academia in developing vaccines for dengue. 

Mr. CLAWSON. I have read that there is a dengue vaccine under 

development in Singapore but I have not read anything about 

chikungunya. Am I right about that? 

Dr. PABLOS-MENDEZ. I am not following the vaccines for 

chikungunya but we will be happy to report back on chikungunya 

vaccines. 

Mr. CLAWSON. All right. 

[The information referred to follows:]

WRITTEN RESPONSE RECEIVED FROM ARIEL PABLOS-ME ́ NDEZ, M.D. TO QUESTION

ASKED DURING THE HEARING BY THE HONORABLE CURT CLAWSON


94180f.eps
15

Dr. PABLOS-MENDEZ. Dengue is a much bigger problem and the 

research attention—we have a lot of work that has been done in 

dengue. An effort that we have been particularly focused on is in 

making sure that the pediatric versions of the vaccines are developed soon because those are the people who die. It is usually kids. 

I mean, elderly could, but it is usually kids that are accounting for 

the deaths. 

Mr. CLAWSON. Okay. Can I have a couple more minutes? Let me 

follow up on that and I appreciate your patience here. So I am not 

trying to pretend to be a doctor at all. It is just a topic that is important to me. 

So monsoon season is in October in India. There are four or five 

different strains of dengue. Someone gets on the plane and flies to 

Florida. 

He has been bit 2 or—you know, 2 or 3 days later, typically 6 

or 7 days after being bit by the wrong mosquito you get a fever, 

right? And then he brings that—patient zero, so to speak, brings 

a different strain where we already have another strain, which increases the degree of danger. Am I right about that? 

Dr. PABLOS-MENDEZ. Well, very interesting. You are right about 

some of the science there. Two things—first of all, because you 

don’t transmit dengue person to person——

Mr. CLAWSON. But a mosquito can bite the sick person and transmit it? 

Dr. PABLOS-MENDEZ. That is correct. So you would have to have 

been also in such conditions which make what you are saying possible. Unlikely, but possible. And you are right about the different 

types of the virus. 

There used to be four. Now we have five, and immunity to one 

may protect you against that and may cross react with immunity 

against the other virus which has been one of the technical difficulties in vaccine development. 

But they have been overcome and we are developing now that 

technology in the end. In addition to development, making sure you 

don’t have pots and tires with water in your backyard or in your 

house, the development of vaccines probably holds the best promise 

for dengue, which is a real and growing problem in the world. 

Mr. CLAWSON. I mean, I understand my bright researchers in our 

office say that there could be up to 500 million cases a year. I think 

I read in the New York Times a year or two ago that it maybe 10 

percent of the population. 

So it is a big number, which is why it worries me so much in 

south Florida. So let me ask—you know, I am taking more than my 

share of time here. 

Are the right percentage of the resources that you all spoke 

about earlier being spent on this problem in general and this problem’s prevention aspects in the United States within your organization? 

Dr. PABLOS-MENDEZ. The investments in dengue and dengue vaccine, of course, are bigger than those that we have at USAID. 

USAID’s NTD program is currently focused on those simplest to 

treat and prevent diseases, the most cost effective of those interventions. We do not have a program devoted to dengue. 

16

But I do hear you because the epidemiologists are asking us to 

consider doing that and we should certainly consider how we could 

add resources to do more on dengue. I would say that in addition 

to the strategies of prevention that I spoke of before, making sure 

that we get to a vaccine is the most important thing and supporting that is something that we should consider. 

USAID invests close to $200 million in reasearch and development. Almost half of that is in the HIV space because that is where 

we get most of the resources. But we cover many of the other 

things as well based on burden of disease. 

In the case of the dengue vaccine, we have now candidate vaccines that are close. It seems to us that although we may not need 

to put more money in developing the vaccines themself making 

sure that the pediatric formulations and making sure that those 

vaccines will be available in the future will be a very good and 

timely investment for us and we are going to be following closely 

with that. 

That will happen. Until then, we only have these general measures I spoke of before and health systems strengthening too, to 

treat people because if you are untreated with severe dengue you 

may have 5 or 10 percent may have severe outcomes. With good 

treatment it is less than 1 percent. 

Mr. CLAWSON. So with good treatment less than 1 percent are 

going to be hemorrhagic is basically what you are saying? 

Dr. PABLOS-MENDEZ. Less than 1 percent of people with dengue 

will get severe disease. 

Mr. CLAWSON. And so when this bill comes up or when we look 

at this even the appropriations process—look, I am a Republican, 

right, so we have a thing about debt and taking from future generations. 

On the other hand, I also have a thing about poverty killing people and there is a lot of different ways that poverty kills people, 

right. 

Well, this is one of them and all the world’s needy aren’t suddenly going to be middle class and therefore we are going to be 

fighting these infectious diseases. Tell me if you think I am wrong. 

So it seems like the shortcut is the vaccine, which is a quick way 

to save a lot of lives, and then it also puts insulation on my state. 

I am glad to hear you say there is not enough tires with water sitting in them. 

But, you know, we have all seen what happens in Santo Domingo 

and Hyderabad, for that matter. And so I would like, you know, a 

little vaccine in order to insulate my state from a southern invasion 

of the wrong mosquito would be a good idea for my developed state 

as well as the poor folk living across the world. Am I saying that 

the right way? I mean, you are——

Dr. PABLOS-MENDEZ. I am happy to hear you because you are 

right that more attention is needed, that even though we are focusing on those things that are the simplest for the poorest because 

then we can get the most bang in terms of life saving and preventing problems, that this is a problem that requires not only the 

U.S. Government but many more and then, of course, efforts, as I 

said before. 

17

But I believe that we should explore how we could do more and 

with your support we could certainly look into that. I would say 

that——

Mr. CLAWSON. But are we more—we are more cost effective with 

a vaccine——

Dr. PABLOS-MENDEZ. Correct. 

Mr. CLAWSON [continuing]. Than we are everybody in a poverty 

level existence digging a well, having shoes so they don’t get worms 

and clean water and a clean septic. 

That is—we all—we want all of that but that is a longer term, 

more expensive thing than giving somebody a vaccine. Am I right? 

You know, are you following? 

Dr. PABLOS-MENDEZ. You are right, and vaccines have been one 

of the best things that we have done in public health in the last 

century and we are happy, as you know, with the Global Alliance 

for Vaccines and Immunizations recent replenishment. 

The whole global community came together to put together $7.5 

billion in vaccines because they are so important, and the U.S. 

Government has committed $1 billion to that. And vaccines are a 

great investment and, indeed, GAVI is open to look at how they 

can work in either support of the polio, as the polio eradication 

evolves. Ebola vaccines—there was one available. Once dengue vaccine will become available that also could be considered. We have 

a platform that we contribute to on vaccines that could pick this 

up. 

But I think there are limitations to keep us thinking beyond any 

narrow particular programs and we do so, then choose where our 

dollars can have the most impact, and what you are saying is very 

important for us. 

It is very important for the NIH. It is important for the CDC and 

globally with many of the other partners. So I will say to you that 

I will have this in mind, and the point you make about—we started 

with a humanitarian point as to why we do these things and you 

are making a very good point on the economics of this. 

There has been a recent commission on investing in health. You 

should know because this is not a bad investment. It is actually 

one of the best investments that can be made today and I am not 

talking as an advocate. This is what the Commission on Investing 

in Health said; they looked at the payoff of investing in health, particularly in these types of things which are very cost effective. 

You have a 10- to 25-fold leverage in terms of the economics of 

those countries. And you know at USAID we used to invest in Mexico, Brazil, South Korea when they needed help. Now they are our 

partners. 

Actually, ten of the 15 largest trading partners used to be a recipient of USAID assistance. Now they are our partners. So it is 

in our interest also to help, as you have pointed out, because in the 

end it is good for America in more than just do the right thing or 

being safe. It is also a good investment. 

Mr. CLAWSON. Well, as we go through the appropriations process, 

you know, anything I can do to help. I like free market solutions 

but there are gaps when it is poor people that can’t pay for things 

and so this makes your role important, as far I can tell, in the 

breach and therefore I am supportive. 

18

But I want to understand that it is, as you were discussing here, 

that it is money well spent and that others are paying their fair 

share, and then if that is the case we are all the same and we need 

to do what we can for everybody. 

So thank you for what you are doing. 

Dr. PABLOS-MENDEZ. Thank you. 

Mr. SMITH. Mr. Clawson, thank you for your incisive questions 

and very compassionate comments. 

Mr. CLAWSON. Sorry to take so much time. 

Mr. SMITH. No, it was very well done. I thank you so very much. 

I just have a few questions. We have been advised that we may 

have a series of votes that will go on for about an hour. So I will 

collapse all of my questions into one. 

Mr. CLAWSON. I am sorry, Chris. 

Mr. SMITH. No, no. I just got the word. First of all, on the gaps 

issue, Mr. Clawson, I think, brings a very good point up about 

gaps. 

In his testimony, Dr. Hotez says that it is estimated that the annual global funding gap is over $220 million per year. He has recommended that—I think at a minimum that we put an additional 

$25 million on last year’s number to bring it to $125 million. 

Again, let the record note that we are all concerned that the administration’s request suggested a $13.5 million decrease and my 

hope is that that will not have any traction and that we look to 

actually increase because of the work that it is doing. 

And I think, as you point out in your own testimony, Doc, you 

know, that for every $1, $26 donated comes from the private sector, 

from the pharmaceuticals and the like. 

That is leveraging the likes of which I have not seen and every 

dollar we put in we are getting back a huge impact on people’s 

lives. 

So if I could just ask all of our witnesses that follow will talk 

about public-private partnership being extraordinarily good. 

The gap issue, $220 million—if you had additional dollars like 

$125 million how would you use it? Dr. Hotez makes a point about 

the horrific NTD outbreaks coming out of ISIS-occupied Syria and 

Iraq and possibly Libya and Yemen and in his testimony—and he 

has done this before—he talks about this being one of the consequences of war, very often under appreciated. 

If you could speak to that. The integration with PEPFAR—our 

new bill has language and, again, I learned that having read his 

book—Dr. Hotez’s book and his testimony last year that there is, 

again, an under appreciation of how—what NTDs—the role they 

play in making women especially more susceptible to HIV/AIDS 

and in his testimony he put it this way:

‘‘I am concerned that NTDs are still not a component of largescale programs to combat HIV/AIDS such as PEPFAR and the 

Global Fund despite evidence that 20 million to 150 million 

girls and women in Africa suffer from female genital 

shistosomiasis, which increases susceptibility to HIV/AIDS and 

represents a major co-factor in Africa’s AIDS epidemic.’’

Your view on that. 

19

It seems to me that integration has to take place yesterday. The 

post-2015 goals, I have read them. I have read the targets. I am 

concerned that there doesn’t seem to be the underscoring. 

Our bill does that. It calls for those goals in effect since the year 

2000, particularly goals three, ensuring healthy lives and, one, ending poverty in all its forms everywhere. 

There needs to be, I think, a hyper sense of the disproportionately negative role that NTDs play and if you could—maybe not 

today but certainly soon—give your and the administration’s view 

in supporting H.R. 1797, our new bipartisan bill that I just introduced today, the End Neglected Tropical Diseases Act, which incorporates so much of this, and hopefully will help take us to an even 

better level on this. 

Dr. PABLOS-MENDEZ. Well, thank you very much, Congressman. 

Thank you very much. 

Well, as you know, in terms of the overall budget we are making 

many critical investments across the spectrum of global health programs and you have been a champion of many of those, especially 

maternal and child health. 

And as we have discussed, now half the kids who are dying are 

dying in the first month of life. Because of the success of the older 

kids it is now the babies who are dying or who are accounting for 

the greater proportion, and we are increasing our support for the 

newborns as one of the best ways to decrease total mortality. 

But that calls for very difficult choices for us and since we are 

operating on a flat-line environment for budgets those choices are 

very difficult. 

But I have to say that I fully support the funding level requested 

but, most importantly, I feel confident that the level of funds that 

will be available in Fiscal Year 2016 will allow us to continue the 

remarkable progress on NTDs and will also continue to save the 

lives of mothers and children. 

If we had an additional $25 million, as you suggest, well, that 

would allow us to treat 30 million more people and, clearly, get 

sooner to the place in which we can get closer to elimination and 

control of many of these diseases. PEPFAR——

Mr. SMITH. Thank you for that——

Dr. PABLOS-MENDEZ. Yes. 

Mr. SMITH [continuing]. That analysis. Perhaps elaborate that a 

little more so the rationale and the justification as we lobby our 

friends on the Appropriations Committee. 

Because we will be doing a letter from our subcommittee and it 

will be, I am sure, bipartisan, it would be great if we could break 

that with as much exactness as possible——

Dr. PABLOS-MENDEZ. That is right. So——

Mr. SMITH [continuing]. And what good we can add. 

Dr. PABLOS-MENDEZ [continuing]. Our teams will ready to expand in seven countries in Africa with—and we will send more details as needed. 

On PEPFAR, because it is an important part of the program, 

clearly, PEPFAR is an incredible platform. It has helped especially 

in recent years to support the systems that can then help deal with 

other new problems. 

20

Some of the diseases are parasitic, which are not amenable to or 

targeted by the cost-effective programs that we have today—are expensive to treat, and I would like to say that their research and 

development efforts will be very important and if we have more resources we could someday also offer support for those diseases. 

In terms of collaboration—we see also great opportunity and we 

leverage opportunity of working with our water, sanitation and 

health programs (WASH) because as we heard before many of 

these issues have to do with water that is a vector or water reservoirs. 

So WASH programs are important. Our collaboration with malaria, some of this is to minimize mosquitoes and so the bed nets 

are helpful in lymphatic filariasis as much as they are helpful in 

malaria. 

And in terms of the post-2015, I think you are making a good 

point. Maybe in part it is because the post-2015 agenda for the 

world is looking at a grand convergence in gains by 2030. 

But in this case, we have to look at 2020 to eliminate many of 

these diseases. So we are almost ahead of the schedule in which 

the larger agendas are. But it is a good point that we should continue to maintain this ability and important——

Mr. SMITH. Well, and again, it is in goal three, target three but 

it is one line and it seems to be—maybe the indicators will expand 

and give it the weight that I think it just needs to get—it is not 

just one on a list of things. 

Dr. PABLOS-MENDEZ. We will convey this to our negotiators. 

Thank you. 

Mr. SMITH. I appreciate that. Thank you. Thank you very much. 

Just because of time, I do have other questions. I will submit them 

for the record. But I thank you so much, Doctor. 

I would now like to welcome—look forward to working with you 

and please get back to us on supporting the End Neglected Tropical 

Diseases Act, any changes you think might be necessary to improve 

it, we are wide open for that and I think this is something that 

would get the whole Congress——

Dr. PABLOS-MENDEZ. Thank you. 

Mr. SMITH [continuing]. Further on board on this important 

issue. 

Dr. PABLOS-MENDEZ. Technical staff is happy to continue to do 

so. 

Mr. SMITH. Thank you. 

I would like to now invite our second panel, and I am only rushing because of the pending votes, beginning with Dr. Peter Hotez, 

who is president of the Sabin Vaccine Institute and leads the Texas 

Children’s Hospital for Vaccine Development based at the Baylor 

College of Medicine. 

He is also the founding dean of the National School of Tropical 

Medicine at Baylor College of Medicine. His academic research focuses on vaccine development for a wide range of neglected tropical 

diseases around the globe as well as studies to increase awareness 

about the neglected tropical diseases in the U.S. as well as other 

countries. 

He created the Sabin Vaccine Institute Product Development 

Partnership and was instrumental in creating the Global Network 

21

for Neglected Tropical Diseases. In 2014, President Obama named 

him as one of four U.S. science envoys with a mandate to explore 

the development of vaccine Centers of Excellence in North Africa 

and the Middle East and, again, he has also recommended such a 

thing, a Center of Excellence, for the United States. 

We will then hear from Mr. Nicholas Kourgialis, who is the vice 

president for eye health at Helen Keller International where he 

provides programmatic direction and oversight for its eye health 

and neglected tropical disease programs worldwide. 

Mr. Kourgialis joined Helen Keller in December 2003 and brings 

more than 13 years of related experience to his work at HKI, having spent his career specializing in public and global health interventions, addressing the needs of disadvantaged children. 

Helen Keller International’s integrated program includes several 

NTDs and they are actively supporting a number of programs 

across 14 countries in Africa and deworming in school children in 

the Asia Pacific and he is also, I am happy to say, from my state. 

Dr. Hotez? 

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

VACCINE INSTITUTE 

Dr. HOTEZ. Good afternoon, and thank you, Chairman Smith, for 

inviting me and to members of the subcommittee, Congressman 

Clawson. I ask that my full written statement be added to the 

record. 

Mr. SMITH. Without objection, so ordered. 

Dr. HOTEZ. Thank you. My name is Peter Hotez. I am a physician scientist. As you pointed out, I am dean of the National School 

of Tropical Medicine and also president of Baylor College of Medicine, president of the Sabin Vaccine Institute where we make vaccines for neglected tropical diseases. 

We make the vaccines that the drug companies can’t make or 

won’t make including vaccines for diseases that are affecting or will 

soon affect Congressman Clawson’s district. 

I would like to point out that I am the recent author of a paper 

called ‘‘The Gulf Coast: A New American Underbelly of Tropical 

Diseases and Poverty.’’ And so that is very relevant, I think, to this 

committee. 

Mr. SMITH. Without objection, I would like to add that to the 

record because there is a very keen interest. So without objection, 

if we could get a copy we will——

Dr. HOTEZ. Sure. We recently estimated that there are 12 million 

Americans living with one or more neglected tropical diseases, 

mostly affecting those in the Gulf Coast. I am on one end of the 

Gulf Coast. I am in Houston on the Texas side of the Gulf Coast. 

We are the bookends, Congressman. 

Mr. CLAWSON. That is all right. I mean, you know, we got the 

better district but that is—it is all right. You are still on the Gulf. 

At least you didn’t say ocean. 

Dr. HOTEZ. And so—and then I would like to talk a little bit 

about my role as U.S. science envoy and some great concerns that 

we have for the next shoe that is going to fall after Ebola, which 

is going to be the Middle East and North Africa. 

22

It won’t be Ebola but I will tell you about that. So let me just 

briefly summarize the situation globally and then tell you about my 

concerns of what is happening in the Middle East and then fine 

tune it to disease and poverty here in the Gulf Coast and the 

United States. 

Working with the Institute for Health Metrics in Seattle, we 

have just determined that practically every single person living in 

extreme poverty is affected by one or more neglected tropical diseases—these chronic and debilitating conditions. 

The numbers we have just come up with are extraordinary—819 

million people with ascariasis infection, 440 million with 

hookworm, 390 million with dengue, schistosomiasis 252 million, 

river blindness 30 million, Chagas disease 7 to 10 million—every 

single person living in poverty. 

And the point is these diseases both occur in the setting of poverty and they cause poverty. We are about to publish at the end 

of next week a worm index for human development where you can 

actually show that there is this very inverse correlation between 

human development index and the level of neglected tropical disease burden and think this also applies to the United States as 

well, which I will point out. 

Now, although Ebola virus infection is the best known neglected 

tropical disease, it remains one of the rarest. We have recently 

done an estimate of the three Ebola-affected countries in west Africa—Guinea, Liberia, and Sierra Leone—and while there are 20,000 

cases of Ebola there, or what was 0.1 percent of the population, a 

third of the population is infected with either hookworm infection, 

schistosomiasis, or both. 

So these are probably the major severe and incapacitating 

sequelae of the west African countries, and as I pointed out these 

diseases are not restricted to the poorest countries of Africa because poverty is the overriding determinant and can be found even 

among the extreme poor living in wealthy countries such as in the 

United States. 

There are an estimated 20 million people who live in extreme 

poverty in the U.S. and now new numbers coming out of the University of Michigan Center for Poverty find that there are 1.65 million families in the U.S. that live on less than $2 a day. 

So we could take that same benchmark for global poverty and 

apply it to the U.S. Now, throughout the month of October 2014 

I appeared regularly on MSNBC or Fox News. Imagine appearing 

in the same day on MSNBC and Fox News. That was interesting. 

And but the question I would get almost every time is Doctor, 

aren’t you worried about Ebola virus coming to the United States 

and my answer was almost always no, and here is why—here is 

what we know—it is a difficult disease to transmit and only occurs 

in the setting of post-conflict when there is massive breakdown in 

public health infrastructure but we do have 12 million Americans 

living in extreme poverty, mostly in the Southern U.S., mostly on 

the Gulf Coast who are affected by at least one neglected tropical 

disease including Chagas disease, toxocariasis, and cysticercosis. 

We have dengue in Houston. We have dengue in the west coast 

of Florida and chikungunya will surely follow. I predicted last summer but probably this coming summer. 

23

What was interesting about that the anchors, whether from 

MSNBC or Fox, always responded the same way, which was, 

‘‘Thank you, Doctor. We are out of time.’’

So the neglected tropical diseases continue to represent our nation’s most glaring and ignored health disparity issues. Let me 

briefly summarize, if I may, what is working globally and what’s 

not for the neglected tropical diseases. 

First, a very important achievement has been the scale up of 

mass treatment packages of donated drugs, which we first proposed 

in partnership at the World Health Organization in 2005. 

Today, this approach is in operation in more than two dozen lessdeveloped countries which is leading to the elimination of two key 

neglected tropical diseases of major global importance, lymphatic 

filariasis and trachoma. 

And I would like to thank Dr. Ariel Pablos-Mendez for his leadership on this issue and we are really thrilled with the fact that 

under his leadership and with the Administrator that over the past 

8 years they have improved the lives of over 460 million people and 

delivered more than 1 billion neglected tropical disease treatments. 

This successful public-private partnership with leading pharmaceutical companies has exceeded expectations in its ability to deliver treatments for the seven most common neglected tropical diseases which make up a bulk of the global NTD burden and leverage more than $6.7 billion worth of donated medicines in 25 target 

countries including Bangladesh, Indonesia, Nigeria, and Sierra 

Leone. 

In addition, tremendous global progress has been made in tackling neglected tropical diseases since the announcement of the London Declaration on NTDs in 2012, partnerships which includes the 

United Kingdom and the Gates Foundation, 13 pharmaceutical 

companies and, of course, the U.S. Government. 

In 2013, more than 1.35 billion treatments were supplied by 

pharmaceutical partners alone and by the end of 2014 more than 

70 endemic countries had developed multi-year integrated NTD 

control plans, narrowly a 50-percent increase. 

Despite the progress, as you pointed out, the funding gap remains. It is estimated that the global annual funding gap is over 

$220 million a year. 

That is why we are disappointed to see the President’s proposed 

budget request for USAID’s NTD program for Fiscal Year 2016 at 

$86.5 million, which is actually a $13.5 million decrease from Fiscal Year 2015 enacted level of $100 million and urge Congress to 

increase funding for NTDs from $100 million to $125 million. 

This additional $25 million will allow USAID to further maximize the benefits of increased drug donations received from pharmaceutical companies, conduct impact assessment surveys to measure progress and increase the impact of this successful public-private partnership. 

The subcommittee should also consider the inclusion of additional NTD control and elimination measures within other USAID 

programs which are among broader U.S. Government and foreign 

assistant programming. This would include water, sanitation, and 

hygiene programs as well as food security or nutrition initiatives. 

24

I am also concerned that NTDs are still not a component of 

large-scale programs to combat HIV/AIDS such as PEPFAR and 

the Global Fund, despite the evidence of tens of millions of girls 

and women suffer from female genital schistosomiasis and which 

increases their susceptibility to HIV/AIDS. 

And parallel with these global public health measures there is an 

urgent need to support research and development for new drugs, 

diagnostics, and vaccines for NTDs. As the head of the nonprofit 

Sabin Product Development Partnership, we have developed two 

critically important neglected tropical diseases—one for hookworm 

infection, the other for schistosomiasis—which are now undergoing 

clinical testing in Brazil, Gabon, and the United States. 

We also have new vaccines for Chagas disease, leishmaniasis, 

and other neglected tropical diseases in earlier stage of development. Greater U.S. investment in NTD related research and development are needed to support the introduction of these new technologies as a means to ensure the achievement of goals for control 

and elimination. 

I would like to say that people who live in poverty deserve more 

than access to essential medicines. They also deserve access to innovation. 

Previously, I proposed setting aside 1 to 2 percent of the U.S. 

commitment to global health for the development of new drugs, 

diagnostics and vaccines which would pump $100 million to $200 

million new dollars into the system for NTD product development. 

Yet, it is very important to point out that these research and development efforts must not come at the expense of accelerating the 

success of the NTD program at the USAID. We need to keep that 

program intact, otherwise, if you take it away—the research and 

development dollars—it would undercut the positive gains that resulted to date and put hundreds of millions of people at risk. 

Now, we also need new vaccines for other countermeasures in 

preparation for new catastrophic NTD outbreaks such as the one 

that hit west Africa in 2014, and what I would like to say is the 

fact that we saw this catastrophic outbreak in west Africa last year 

and into 2015 was not because Guinea, Sierra Leone, Liberia are 

tropical. 

It was because they emerged out of conflict and post-conflict settings, and when I had the time to point it out on television I would 

say Ebola’s version 3.0 of a trend that we have seen for the last 

three or four decades, which is that you have a catastrophic conflict 

and then something terrible happens. It happened in Angola, the 

Democratic Republic of the Congo, in the 1970s, breakdown in infrastructure. 

Half a million people died of African sleeping sickness after that 

conflict. So 20 times more than Ebola. It went unrecorded because 

there were no journalists there. Version 2.0 was in southern Sudan 

in the 1980s and 1990s with the conflict there. A hundred thousand 

people died of kala-azar—leishmaniasis transmitted by sand flies—

Ebola’s version 3.0. 

So and the problem is the world reacts too slowly. So what happens is nobody is stockpiling vaccines to get ready for these diseases and when the crisis hits it is too late. 

25

So what we saw now is even though the technology to make the 

Ebola vaccine was around for a decade, we sat around waiting for 

big pharma to pick it up and then it only happened after the 11th 

hour and only now are these vaccines going into clinical trials 

when there are no more cases around to really see if even the vaccines work. 

So we need a new model and what I am particularly concerned 

about in my role as U.S. science envoy—and I would like to point 

out that the views in herein are my own and do not reflect those 

of the White House or the State Department—is that version 4.0, 

given the strong link between conflict and contagion, is going to be 

in ISIS-occupied zones of the Middle East, Iraq, Syria, Libya, and 

Yemen. 

We don’t have the World Health Organization working there because it is too dangerous. We are only getting glimpses of it from 

refugees spilling across the border into Jordan and Lebanon, into 

Turkey and to Egypt. 

But what are we seeing? The resurgence of measles, the resurgence of polio, a horrific neglected tropical disease that the locals 

call Aleppo evil. It is a disfiguring disease of the face that particularly affects little girls and renders then unmarriageable. 

The other name is cutaneous leishmaniasis, more than 100,000 

new cases, and I am quite worried about the Middle Eastern Respiratory Syndrome virus. And the problem is big pharma will take 

on problems which have global importance but not regional importance. 

Right now, there is no capacity to make vaccines or minimal capacity to make vaccines in the Middle East and North Africa. The 

Iranians do it on a good day, maybe a little bit of Israel Defense 

Forces, but that is about it. 

So in my role as U.S. science envoy, I am trying to take the 

model of what we are doing for making vaccines in Houston in the 

nonprofit sector and reproducing that somewhere in a stable country in the Middle East and North Africa, one that has some underlying infrastructure for doing so, and I am happy to address that 

in more detail. 

Finally, let me end by revisiting the NTDs in the United States. 

Twelve million Americans live with at least one neglected tropical 

diseases and most people have never heard of them. They include 

toxocariasis, a larval worm infection linked to deficits in cognitive 

development that affect almost one in five African-Americans living 

in poverty. 

In a paper I wrote in JAMA Psychiatry, I asked whether 

toxocariasis could be partly responsible for the achievement gap 

noted among socioeconomically disadvantaged students. At our National School of Tropical Medicine in Houston, we are finding 

unique modes of transmission of diseases like toxocariasis as well 

as Chagas disease, a parasitic disease that causes debilitating and 

life-threatening heart defects among the poor and among hunters 

and campers in our state. 

A key point is that many if not most of these neglected tropical 

diseases are not being imported through immigration, because that 

is usually the first response people have. Instead, we are finding 

26

transmission among the poor, especially in the American South, especially in the Gulf Coast. 

Throughout the Gulf Coast we have got two major species of 

mosquitoes, each capable of transmitting dengue, each capable of 

transmitting chikungunya. 

So we need more comprehensive surveillance and to develop improved point of care diagnostics. One of the problems is physicians 

aren’t trained to even recognize these diseases. When we had our 

outbreak in Houston we found that none of the cases were picked 

up by physicians because they are not trained in these diseases. 

The other problem is we don’t have point of care diagnostics. So, 

you know, when you go to your doctor you get a blood test and you 

see the little boxes checked off with your blood chemistries. There 

is no box for chikungunya. 

There is no box for dengue. There is no box for toxocariasis or 

Chagas disease. We have got to change that. We also need a new 

generation of drugs and vaccines. 

So that is the whole point behind this Center of Excellence idea 

and the legislation that you just introduced and I am so grateful, 

again, for your tenacity, Chairman Smith, in making this happen. 

So we just learned about the H.R. 1797. I assume it has similarities to what was H.R. 4847 and we are so grateful for this committee taking on this important issue which is devastating populations living in poverty and conflict everywhere, and I appreciate 

the opportunity the subcommittee has given me to speak on this 

issue. 

Thank you. 

[The prepared statement of Dr. Hotez follows:]

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Mr. SMITH. Dr. Hotez, thank you so very much. And again, many 

of the ideas that you recommended at our last hearing found a 

home in our legislation. 

So I thank you for that guidance that you provided to the committee and to the legislation. 

Mr. Kourgialis, please proceed. 

STATEMENT OF MR. NICHOLAS KOURGIALIS, VICE 

PRESIDENT, EYE HEALTH, HELEN KELLER INTERNATIONAL 

Mr. KOURGIALIS. Mr. Chairman, thank you for the opportunity to 

testify regarding the importance of continued funding for the U.S. 

Government’s neglected tropical disease program and to highlight 

the enormous impact that it is having on the health and welfare 

of individuals living in the world’s poorest communities. 

I also want to thank you for your continued commitment to improving the lives of millions by helping to eliminate or control the 

seven most prevalent NTDs targeted by the U.S. Government. 

Collectively, these parasitic and bacterial diseases blind, disfigure, and disable millions of people in the world’s poorest communities and limit their ability to lead healthy and productive lives. 

According to the World Health Organization, NTDs infect more 

than 1 billion people, a sixth of the world’s population including an 

estimated 800 million children who, as a result, suffer from malnutrition, decreased school enrollment and diminished physical and 

intellectual development. 

Eliminating NTDs can allow millions to climb out of poverty by 

increasing access to education and improving their ability to work. 

Since its inception, the U.S. Government’s NTD program has supported the delivery of more than 1 billion treatments to approximately 470 million people in 25 countries. 

The impressive reach and impact of the program would not be 

possible without the remarkable public-private partnership with 

the pharmaceutical sector. We commend the U.S. Congress and 

USAID for their global leadership on this issue. 

Co-founded in 1915 by the deaf-blind crusader, Helen Keller, 

Helen Keller International offers programs in 21 countries in Africa and Asia as well as the United States. The prevention and treatment of NTDs is a key organizational priority and one of our most 

important and far-reaching programs. 

HKI has been the recipient of integrated NTD program funding 

from USAID in Burkina Faso, Cameroon, Guinea, Mali, Niger, and 

Sierra Leone. Despite their many challenges, all six countries supported by HKI have made significant progress toward global NTD 

control and elimination targets. 

In 2015, HKI will lead a new 5-year project aimed at managing 

morbidity and preventing disability related to trachoma and lymphatic filariasis. 

HKI’s approach and strength has been to partner with government ministries to provide technical assistance and support to national disease control teams and to build capacity within countries 

with the goal of scaling up and creating sustainable systems of 

care. 

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ments to commit the necessary human and financial resources 

needed to achieve control or elimination of the targeted diseases. 

Trachoma offers a valuable example of what can be achieved 

through global cooperation. It also highlights the critical importance of continued funding for NTD program implementation activities. 

Trachoma is the leading cause of infectious blindness in the 

world. This bacterial infection is transmitted by flies and through 

physical contact with eye and nose discharge of infected people, 

particularly young children who are often the principal reservoir of 

infection. 

Repeated cycles of infection and inflammation can result in scarring of the inside of the eyelid, causing it to turn inward so the eyelashes scratch the cornea, ultimately causing blindness through a 

very painful condition called trichiasis. 

To combat trachoma, HKI supports the distribution of antibiotics, 

increased face washing, and the use of latrines to reduce disease 

transmission. Surgery is also provided for those suffering from trichiasis. 

Several HKI-supported countries have made notable progress in 

reaching specific disease control targets. For example, Burkina 

Faso is on track to stop mass drug administration for trachoma by 

the end of 2016. 

Similarly, in Mali, despite the challenges posed by recent political instability and violence, more than 90 percent of districts that 

require trachoma treatment have been able to stop drug administration. 

The U.S. Government’s support of country-level implementation 

activities is essential to achieving the WHO goal of goal of eliminating trachoma as a public health problem by 2020. 

Mr. Chairman, in order to sustain the accomplishments of the 

current NTD program I hope that the Congress will restore funding 

in Fiscal Year 2016 to at least the $100 million level provided in 

Fiscal Year 2015. 

I also urge that the focus of the seven targeted diseases be continued. Enormous progress has been achieved over the past 8 years 

in combating these diseases. A decrease in USAID funding at this 

critical time would significantly undermine the ability of national 

NTD programs to continue their activities and to reach their control and elimination targets. 

I am optimistic that funding levels for NTDs will be restored so 

I will conclude with the words of Helen Keller—‘‘Optimism is the 

faith that leads to achievement. Nothing can be done without hope 

and confidence.’’

Thank you, Mr. Chairman. 

[The prepared statement of Mr. Kourgialis follows:]

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Mr. SMITH. Thank you so very much for your leadership, for 

those insights as well, and so many lives that have benefitted because of your work. 

Just a few questions, if I could, beginning with Dr. Hotez and 

perhaps both of you might want to address this. In your testimony 

you said it is estimated that the annual global funding gap is over 

$220 million per year. 

In the 1980s, I was on this committee and I remember I contacted WHO and asked them what it would take to make the 

meaningful difference in neglected tropical diseases, and I think we 

just called it tropical diseases then, and I got back a time line, 

numbers and I worked every year to try to get those numbers as 

close as possible both on the authorizing and the appropriation 

side. 

We never actually got there but it was far less than this, I can 

tell you, and I am just wondering if you could for the committee 

and for us, all of us here, break that out either here or by way of 

a written submission. 

You suggested $125 million, Dr. Hotez, as, I guess, our additional. You know, we are always constrained by the doable versus 

what really would make all the difference in the world. 

Whatever you could do to provide, I asked Dr. Pablos-Mendez 

earlier. He said 30 million people would be positively impacted and 

said he would get back. The more detailed the better in terms of 

making our case to the leadership and to the appropriators on this 

because it seems to me, again, the sustainable development goals—

post-2015 their goal is to eliminate it by 2030. 

Talk of 2020 is always in the mix. For the person dying or suffering from this they want it now, as we all know. So if you could 

speak to that, if you would. Yes? 

Dr. HOTEZ. Thank you, and I appreciate that question. I guess 

just to give it some perspective let us remember the budget of 

PEPFAR is around the order of $8 billion a year so we are talking 

about $25 million. 

Remember what you get for that $25 million. This package we 

helped design is 50 cents a person per year. It is probably the single most cost effective public health control measure out there. 

I mean, where else are you going to treat 50 million people for 

$25 million? Maybe it won’t get quite to 50 but those are the numbers we are talking about. 

And so, when we—the neglected tropical disease people are always grateful for any crumbs that anyone can throw at us and so 

we think $25 million is a very modest amount but look what you 

get for it. So USAID is currently operating in more than two dozen 

countries. 

We have the opportunity to take on a whole additional country 

with that, just to give you a perspective on what that money can 

do. 

Mr. SMITH. I thank you for that. 

Mr. Kourgialis, would you want to speak to that? 

Mr. KOURGIALIS. Certainly, the needs for services far exceed the 

available resources. So any additional resources that can be 

brought to bear would be very valuable. 

45

Mr. SMITH. You spoke, Mr. Kourgialis, very, I think, eloquently 

about the importance of pushing ownership. I am sure, Dr. Hotez, 

you believe the same thing, as does USAID. 

How receptive have you found the ministries of health and political leaders to say we do want to take this over and more of our 

resources are going to be devoted to ending neglected tropical diseases? 

Mr. KOURGIALIS. I can only speak to the countries in which we 

work. But, certainly, we couldn’t do our work without the support 

of the ministries. They are a critical player in all this and we must 

have their cooperation and support in order to conduct any activities at this scale. 

We are functioning at a national scale. We face enormous challenges in reaching people at the end of the road, these are the poorest of the poor. Without the ministries’ support that wouldn’t be 

possible. 

So it is critical and in most of the countries the support is. They 

certainly see the effect that these diseases have on their populations. They want to address that. 

The support is there on the part of the global community at this 

point on a very broad scale. So I think they are taking advantage 

of that opportunity, accomplishing it as much as they can with the 

resources that are available. 

Dr. HOTEZ. Yes, I would agree with that and just to say that because the packages of medicines are so low cost—50 cents a person 

per year—a Minister of Health and a Minister of Finance for a 

country can look at that and say yes, we can do this—we can help 

with this. 

So, for instance, Burkina Faso, when I last looked was paying for 

69 percent of its NTD bill. So and as opposed to something like 

PEPFAR where you are talking about hundreds of dollars a person 

to put a person on anti-retro viral drugs for a year, this is 50 cents. 

So it is not so daunting for a lot of these disease-endemic countries to help take this on and assume a lot of ownership. 

Mr. SMITH. Can I ask you, Dr. Hotez, how receptive has USAID 

and the PEPFAR program leaders, especially the czar, been to your 

recommendation that it be integrated—the neglected tropical diseases component—to the PEPFAR fight? 

Dr. HOTEZ. Well, I have not approached PEPFAR recently. The 

last time I approached PEPFAR Ambassador Goosby was still in 

charge and, you know, in principle they thought it was a great idea 

but there was—there was just too much inertia to make it happen. 

So I haven’t had the opportunity to meet with the new Global 

AIDS Coordinator to discuss it. You know, we have had this conversation with Mark Dybul, head of the Global Fund, and there 

was some initial push back. 

But then we understood that Mark Dybul was visiting the schistosomiasis people at WHO. So maybe we are getting some movement. 

Mr. SMITH. I was there when you had that phone call. 

Dr. HOTEZ. Yes. 

Mr. SMITH. Your very persuasive case. As you know, we did include in the bill that kind of direction to integrate into work in a 

partnership. So thank you. 

46

You mentioned NTD vaccines for hookworm and for schistosomiasis there at the clinical testing level in Brazil, Gabon, and 

United States. How soon before something might be available? 

Dr. HOTEZ. So we are in the phase one testing now for safety and 

immunogenicity and now we are going to be moving to look at the 

efficacy. 

So I am hoping within 5 years we will be able to be well advanced on the way, and the idea behind it is the package of medicines has been great for eliminating lymphatic filariasis and trachoma. 

The problem was that for hookworm and schistosomiasis they 

keep coming back. So they knock down the bioburden, there tends 

to be reinfection and that is the idea behind the vaccine. Thank 

you for that question. 

Mr. SMITH. Quick, the issue that you have raised repeatedly 

about the consequences of war and you did it in your testimony and 

I did ask our previous witness about that, could you elaborate on 

that? 

I mean, you just came back from a visit some weeks ago to the 

Middle East. 

Dr. HOTEZ. Yes. I don’t have to tell this committee the situation 

in the Middle East is dire with an ever expanding territory now 

over four countries—Syria, Iraq, Libya, and Yemen—and the first 

thing that happens, of course, is all public health control measures 

pretty much stop. 

All access to medicine stops, and my point in my testimony was 

that when we have seen this before where, again, calling them 

tropical diseases it is a bit of a misnomer. 

They are diseases of poverty and disease of poverty in conflict. 

So you bring in those social forces of poverty conflict and with it 

comes human migrations, trafficking of animals, which transmit 

zoonotic diseases, deforestation. 

All of these create the perfect storm to allow a catastrophic neglected tropical disease. That is why Ebola arose in west Africa, 

and from my point of view in my role as dean of National School 

of Tropical Medicine all those same forces are in place now in ISISoccupied zones and therefore we need to be ready. 

Mr. SMITH. Before going to Mr. Clawson, just let me conclude by 

quoting from your testimony, I don’t know if you said this orally 

but it bears repeating if you did. 

Dr. Hotez, you said, ‘‘NTDs continue to represent our nation’s 

most glaring and ignored health disparity issue’’ and I think they 

are called neglected tropical diseases for a reason. The ‘‘neglected’’ 

has to fall out of that phrase. 

Mr. Clawson? 

Mr. CLAWSON. Well, I am thinking about everything you are saying. Most of the time you are saying it and I am tapping my foot 

but once in a while I am not understanding exactly. 

So since none of my colleagues showed up I guess I get to ask 

you some more questions and I appreciate you all’s patience. I believe in a strong military because it creates leverage. 

But I wish our country was more judicious in where we send 

bombs because it feels like bad wars create bad outcomes, one of 

which I hear you saying is not just the bombs killing people but 

47

far more people probably die from the secondary unintended impacts of refugee camps whether they are in Kurdistan, or on the 

Thai-Cambodian border 30 years ago. 

Am I hearing you right on that? Is that right? 

Dr. HOTEZ. That is correct. I call it the link conflict and contagion and but it is conflict in the areas where we have had a lot 

of intense poverty for years as well. Those two forces combined are 

synergistic to create this. 

Mr. CLAWSON. So it is odd to me, really, that therefore that given 

that the Ebola thing also rose out of conflict, which wasn’t nearly 

as bad as some other countries in central Africa, right, that when 

we speak about ISIS and our own propensity to go to war that we 

don’t talk enough about this outcome. Am I right about that? 

Dr. HOTEZ. That is right. It is not a sexy topic and it just doesn’t 

get a lot of time either in the news media or elsewhere. 

But it is—and it is something that not a lot of people appreciate 

that there is this link between conflict and disease. And so it is 

something we need to create better awareness of because remember, we are not talking small numbers. 

Five hundred thousand people died of sleeping sickness as a consequence of the wars in Angola and the Democratic Republic of the 

Congo, and that is a lowball estimate. 

Mr. CLAWSON. I don’t think you are going to venture to predict 

how many people could die in the Middle East because of disease 

as a result of war? I am not trying to get——

Dr. HOTEZ. Right. Right. 

Mr. CLAWSON [continuing]. Make you get wet here but I am—

what is your worst case scenario? 

Dr. HOTEZ. Well, it is a two-step process because the first step 

is you have to accurately predict what the diseases are going to be 

and so some of them are not even lethal diseases, like cutaneous 

leishmaniasis is disfiguring, it is ruining people’s lives but it is not 

killing. 

But something like—I am worried about MERS—the Middle 

Eastern Respiratory Syndrome corona virus—that we know it is a 

high rate of mortality. 

You add it to the mix of conflict and animal trafficking and the 

numbers could go very high. And so the point is we need to be 

flexible in being ready to make vaccines for these diseases. 

Mr. CLAWSON. Could I have another minute, Chairman? Is that 

all right? Okay. Thank you for your patience. 

Mr. SMITH. Sure. 

Mr. CLAWSON. So let us change gears a little bit. That is all new 

learning for me so it is on the shelf and I plan to think about it 

in my duties in Foreign Affairs Committee as well as Homeland Security. 

Dr. HOTEZ. Great. Thank you for that. 

Mr. CLAWSON. Well, I am pretty new around here so I wouldn’t 

overrate that. So somebody gets off a plane. He has got 

chikungunya or dengue fever. The emergency room goes through 

their checklist. 

They think about malaria because they know he came from a 

tropical country. They think about influenza. They probably don’t 

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ic, even though the person has got a high fever and is coming from 

one of those infected countries. Am I right or wrong about that? 

Dr. HOTEZ. Well, we can actually prove you are right because we 

did this exercise. Kristy Murray, who is a faculty member in our 

National School of Tropical Medicine, found that dengue, when she 

did this through retrospective records, emerged in Houston, which 

has got a pretty good medical center, which I am from, one of the 

best health care facilities in the world, dengue emerged in 2003 

with an epidemic, again, from people who never left Houston—people who have been living there the whole time, and it occurred 

again in 2004 and 2005. Not a single case was diagnosed by a physician. 

Mr. CLAWSON. So then the conclusions that I am drawing from 

everything I have heard so far today are——

Dr. HOTEZ. Which, by the way, is the reason why we have now 

created a unique certificate program—a diploma in tropical medicine, an 8-week concentrated course that we are now giving to physicians, medical students, residents to actually teach them how to 

recognize these diseases. 

Mr. CLAWSON. And what percentage of doctors in the Gulf Coast 

states that you have talked about earlier have had that course? 

Dr. HOTEZ. Well, we have probably graduated about six classes 

with maybe 20 physicians each. So it is a small number—a very 

small number. 

Mr. CLAWSON. So right now on vaccines, mosquito nets and not 

letting the water pool up and our diagnosis is about 20 doctors that 

know enough to have an idea what they are seeing. I don’t want 

to overstate the negative but tell me if I am——

Dr. HOTEZ. No, I think you are reading between the lines of my 

testimony which is that it is not clear to me that we have adequate 

public health preparedness for neglected tropical diseases affecting 

the Southern part of the United States. 

We need to step it up and part of the problem is we are not 

even—we are doing almost nothing in regard to active surveillance 

of many of these diseases. Dengue may actually be an exception because there is a dengue branch of the Centers for Disease Control 

based in Puerto Rico. 

But, certainly, for the other diseases, I mean, again, they mimic 

other conditions. So Chagas disease mimics heart disease or 

toxocariasis——

Mr. CLAWSON. Nonspecific symptoms? 

Dr. HOTEZ. Right. So unless you are actively looking for it and 

going into the affected communities, you are going to miss it. 

Mr. CLAWSON. I got it. I guess I would then draw the conclusions 

that as—to the chairman’s point, as we see the funding for appropriations, given that I am from a Gulf state I am going to be interested in how much prevention and how much diagnosis is going to 

be a part of the program. 

Dr. HOTEZ. Yes. I mean, the key, from my perspective, is we have 

to figure out how to walk and chew gum at the same time because 

USAID has now launched this mass treatment program, which in 

my estimate is one of the most effective and most cost effective 

public health control programs out there globally. 

49

But and so we need to keep that going, even increase it. But at 

the same time we have got to pay attention to our neglected populations here in the Southern part of the United States. 

Mr. CLAWSON. And then I guess my final point is a little bit from 

left field, as Mr. Meadows might have said. At some point, our employers have got to understand this, too. 

I mean, if I was operating a resort in southern Florida I would 

want to know a little bit about dengue fever. Am I missing something or would you agree with that? 

Dr. HOTEZ. Yes. We will certainly know it if we see chikungunya 

hit the Southern part of the United States. Dengue is a febrile illness. 

It could mimic other diseases even though it is called break bone 

fever. Chikungunya can cause excruciating joint symptoms and 

that is going to be a show stopper if and when it hits over the summer. 

Mr. CLAWSON. Well, then my main message is we need to win. 

Dr. HOTEZ. We sure do. 

Mr. CLAWSON. Okay. Anything I can do to help you all let me 

know. 

Dr. HOTEZ. Thank you. I do appreciate it. 

Mr. CLAWSON. Thanks for your patience with all of these questions. 

Dr. HOTEZ. Great questions. Thank you. 

Mr. SMITH. So thank you very much. I will just conclude with a 

couple of final questions. The surgeries that sometimes are required how often do they occur? When medicines are not up to the 

task? 

Mr. KOURGIALIS. Trichiasis surgery—can you clarify your question? In terms of how frequently they——

Mr. SMITH. Yes, do they get—do individuals get the surgeries? I 

think—did you have the 4 million number? 

Mr. KOURGIALIS. Okay. There is a considerable trichiasis backlog 

though it is being addressed now. Certainly, the recent USAID 

grant will help to address that in a significant way in many of the 

countries where we work. 

Certainly, there is a broader commitment on the part of the global community to address morbidity management. A lot of resources 

have been invested in preventative chemotherapy and distribution 

of drugs. 

But dealing with the later consequences of diseases, both for lymphatic filariasis and for trichiasis, there haven’t been the comparable investments made in the past. But they are being made 

now and a lot of progress is being made as we speak. 

But, certainly, it is going to take some time to address that backlog. It has been a longstanding commitment of Helen Keller International to address this need and it is something that the global 

community has committed to do, too. 

In order to achieve the elimination criteria that WHO has set, 

these issues have to be addressed: Hydrocele, lymphedema management, and trichiasis. So that is why this investment is being 

pushed in order to achieve these elimination targets. 

50

Mr. SMITH. Thank you. Finally, in his statement, Dr. PablosMendez mentioned that there are 800 million people who still need 

treatment. 

Does that comport with your estimations as well? And it seems 

when we are talking about this, it is almost like money that falls 

off the table in terms of magnitude versus what we could be doing. A $25-million increase from the current levels at a time when a 

cut was recommended is not all that much money when you have 

such an overwhelming pool of people not getting the help they 

need. 

Dr. HOTEZ. So that is based on WHO. I believe that number is 

based on WHO estimates. They just came out with new numbers 

this month which says that 1.7 billion people require treatment for 

neglected tropical diseases on our planet, which is somewhere between a little more than the number of people that live on no 

money in the world, that live less than the World Bank poverty figure of a $1.25 a day. We got a few people living on less than $2 a day who also have 

that problem. Of that I think it was 1.7 billion there are about 717 

million people who have received access to essential medicine. 

It is pretty good and a pretty amazing program. But that still 

leaves a gap and, of course, the United States cannot be expected 

to do all of this. 

We need the United Kingdom, of course, to continue their commitments. Also, some of the disease-endemic countries can do more 

than they are doing. 

So our global network for neglected tropical diseases, which is 

headed by Neeraj Mistry, is going into some of the wealthier 

emerging economies to say, you have got to step up also and do better at treating your own NTDs. 

So he is leading efforts in India for this purpose, in Nigeria for 

this purpose. These guys should be able to support their own NTDs 

and I think that is going to be a big step forward as well. 

And then Neeraj, which Michelle Brooks, who is with me here 

today, is also working on the German Government to start stepping 

up. We need to have some of the other European countries step up 

as well. 

So the whole point is the United States should not be going alone 

on this. Other countries need to weigh in as well. 

Mr. SMITH. Section 202 of our new bill would require a report on 

neglected tropical diseases in the U.S. To your knowledge, has that 

been done before? 

And secondly, the Centers of Excellence idea, the establishment 

of such a center—how much do you think that would cost? You 

know, do you have any kind of ballpark estimate of what such a 

center would require in terms of appropriation? 

And when you spoke earlier about when we get a blood test—

that box and having to check the box—do you perceive that that 

is something that might emanate out of these centers—that the 

unmet need would be or the lack of surveillance on an individual 

basis would manifest and they would say, this is what we need to 

do now? 

Dr. HOTEZ. It does, Congressman, and we are looking at what we 

are doing here in Houston as a model for what needs to be done. 

51

So we are focusing on developing new diagnostics and new vaccines. 

I think the key point of having a Center of Excellence is not only 

on the surveillance component but you want to see tangible 

deliverables. We need products for this and they are going to have 

to come out of the public’s—of the nonprofit sector jointly with 

pharma. 

But we can’t count on pharma alone to do this. In terms of level 

of funding, it depends on the extent of the deliverables. I think it is unrealistic to expect anything more than $3 million or $4 million a year at most and probably less than that. 

Mr. SMITH. Mr. Clawson, anything before we conclude? 

Anything you would like to add before we conclude the hearing, 

either of you? 

Mr. KOURGIALIS. Thank you. 

Dr. HOTEZ. No, again, thank you for this opportunity. 

Mr. SMITH. Oh, thank you. One of the things we do with this 

committee is that we do take information and it is all about what 

is actionable, and we will follow up and use what you have provided as effectively as we can. 

So I thank you for your leadership but also for sharing your valuable time with the subcommittee to make your very, very valid 

points and to give guidance on these issues. 

Dr. HOTEZ. Congressman, thank you for your leadership and 

yours, Congressman Clawson, as well. Thank you. 

Mr. SMITH. Thank you. 

The hearing is adjourned. 

[Whereupon, at 4:06 p.m., the committee was adjourned.] 

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MATERIAL SUBMITTED FOR THE RECORD BY THE HONORABLE CHRISTOPHER H. SMITH, 

A REPRESENTATIVE IN CONGRESS FROM THE STATE OF NEW JERSEY, AND CHAIRMAN, 

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


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Æ


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