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80–545PDF 2013

MEETING THE CHALLENGE OF DRUG–RESISTANT

DISEASES IN DEVELOPING COUNTRIES

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 THIRTEENTH CONGRESS

FIRST SESSION

APRIL 23, 2013

Serial No. 113–56

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 

TOM MARINO, Pennsylvania 

JEFF DUNCAN, South Carolina 

ADAM KINZINGER, Illinois 

MO BROOKS, Alabama 

TOM COTTON, Arkansas 

PAUL COOK, California 

GEORGE HOLDING, North Carolina 

RANDY K. WEBER SR., Texas 

SCOTT PERRY, Pennsylvania 

STEVE STOCKMAN, Texas 

RON DESANTIS, Florida 

TREY RADEL, Florida 

DOUG COLLINS, Georgia 

MARK MEADOWS, North Carolina 

TED S. YOHO, Florida 

LUKE MESSER, Indiana 

ELIOT L. ENGEL, New York 

ENI F.H. FALEOMAVAEGA, American 

Samoa 

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 

JUAN VARGAS, California 

BRADLEY S. SCHNEIDER, Illinois 

JOSEPH P. KENNEDY III, Massachusetts 

AMI BERA, California 

ALAN S. LOWENTHAL, California 

GRACE MENG, New York 

LOIS FRANKEL, Florida 

TULSI GABBARD, Hawaii 

JOAQUIN CASTRO, Texas

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 

TOM MARINO, Pennsylvania 

RANDY K. WEBER SR., Texas 

STEVE STOCKMAN, Texas 

MARK MEADOWS, North Carolina 

KAREN BASS, California 

DAVID CICILLINE, Rhode Island 

AMI BERA, California 

(III)

C O N T E N T S 

Page

WITNESS 

Tom Frieden, M.D., director, Centers for Disease Control and Prevention ........ 7

LETTERS, STATEMENTS, ETC., SUBMITTED FOR THE HEARING 

Tom Frieden, M.D.: Prepared statement ............................................................... 12

APPENDIX 

Hearing notice .......................................................................................................... 44

Hearing minutes ...................................................................................................... 45

The Honorable Eliot L. Engel, a Representative in Congress from the State 

of New York: Prepared statement ...................................................................... 46

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: Material 

submitted for the record ...................................................................................... 48

Tom Frieden, M.D.: Material submitted for the record ........................................ 53

(1)

MEETING THE CHALLENGE OF DRUG–RESISTANT DISEASES IN DEVELOPING COUNTRIES 

TUESDAY, APRIL 23, 2013

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 3:05 p.m., in room 

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

(chairman of the subcommittee) presiding. 

Mr. SMITH. The subcommittee will come to order. And welcome, 

Dr. Frieden. Good afternoon. Today’s hearing will examine a deadly 

phenomenon involving both natural and manmade elements: Diseases that are resistant to most or all available methods of treatment. While this is a growing problem of increasing concern 

throughout the world, the subcommittee will be focusing today on 

the impact of such diseases, known as superbugs, in developing 

countries and the challenge to preventing and treating these diseases in this part of the world. 

There is a family of germs that occur normally in everyone’s digestive system. They can cause infections when they get into the 

bladder, blood, or other areas where they don’t belong. That is the 

natural part of this growing problem. Gut flora are absolutely essential for health and an effectively functioning immune response, 

and the increasing use of things like probiotics is testimony to the 

fact that more and more people are understanding that. 

There are about 100 trillion microorganisms in our digestive systems, 10 times the number of cells in our bodies. Most of them help 

break down the foods that we eat, they help us with our immune 

systems. Those that are not helpful usually can be treated with existing medicines such as antibiotics. 

The manmade part is that antibiotics have been increasingly 

used to treat naturally occurring germs, but many of them have become resistant to such treatment. These so-called superbugs pose 

a threat because of overuse or misuse of antibiotics, but they also 

pose a threat because of what some call a drug discovery void in 

which there has been insufficient research and development of new 

medicines to treat emerging mutating infections. 

This situation recently has become much more serious. In the 

last 10 years, these drug-resistant diseases have been identified in 

patients in more than 200 hospitals in 42 States in this country. 

Over that period, there prevalence rate has increased from 1 perVerDate 0ct 09 2002 13:37 Sep 25, 2013 Jkt 000000 PO 00000 Frm 00005 Fmt 6633 Sfmt 6633 F:\WORK\_AGH\042313\80545 HFA PsN: SHIRL
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cent of patients to some 4 percent for those in short-term care, but 

for patients in long-term care facilities, the rate is as high as 18 

percent. 

Half of all patients who contract these diseases do not survive. 

MRSA, one of the better known of these superbugs, now kills as 

many as 19,000 Americans each year and a similar number in Europe. That is higher than the annual rate of deaths from HIV/

AIDS. 

Last year the World Health Organization identified strains of 

gonorrhea and tuberculosis that are currently completely untreatable, as well as a new wave of what might be called ‘‘super 

superbugs’’ with the mutation known as NDM–1. These frightening 

new strains were first seen in India, but they have now spread 

worldwide. The spread of the H7N9 birth flu in China is also causing considerable concern, with more than 100 confirmed cases and 

22 deaths reported thus far. According to the AFP, the WHO said 

yesterday that there was still no evidence that H7N9 was spreading in a sustained way between people in China. I know Dr. 

Frieden will speak to that because we are working with the Chinese on that issue. 

According to WHO, artemisinin, when used in combination with 

other drugs, is now considered the world’s best treatment against 

malaria, but malarial parasites resistant to the drug have emerged 

in western Cambodia, along the border in Thailand, as well in 

parts of Burma and in Vietnam. 

In the developed world, we pride ourselves on having top flight 

medical care widely available to patients. If we lose half of all patients who contract these drug-resistant diseases, what about patients in the developing world where statistics are often scarce and 

effective medical care can even be scarcer? 

Using accepted protocols for treating these diseases, their rate of 

infection can be curbed. In Israel, infection rates in all 27 of its 

hospitals fell by more than 70 percent in 1 year with a coordinated 

prevention program. By following accepted protocols for handling 

these diseases, the Colorado Department of Public Health and Environment and the Florida Department of Health both have 

stopped outbreaks of these drug-resistant diseases in recent years. 

But then again, what about hospitals in developing countries? 

For example, the brain drain has sent trained medical personnel 

in Africa in search of better working conditions and pay in the developed world. The lack of equipment and supplies that partly led 

to this brain drain would facilitate the rapid spread of drug-resistant diseases in these countries. What would be simple interventions, including removing temporary medical devices such as catheters or ventilators from patients as soon as possible, is less likely 

under current conditions in developing-world hospitals. 

Adding to this problem is the presence of expired and counterfeit 

drugs. Patients whose lives could be saved may not be because of 

inadequate medical care. Unfortunately, because so many countries 

do not maintain and report statistics on medical issues, we have 

little idea how serious the situation is today in many developing 

countries in Africa and elsewhere around the world. 

In our interconnected world, that means that infected people in 

the developing and developed countries pose a mutual threat. Last 

3

month a Nepalese man was detained at the Texas border while trying to make an illegal crossing from Mexico. Officials found that he 

was infected with an extensively drug-resistant strain of tuberculosis and had carried this potentially deadly airborne disease 

through some 13 countries over 3 months, from his home of Nepal 

through South Asia, Brazil, Mexico, and finally into the United 

States. Who can say how many people he infected during this long 

journey. 

Conversely, 6 years ago, an American infected with multidrug-resistant tuberculosis traveled from our country to France, Greece, 

and Italy, before returning through the Czech Republic and Canada. Upon his return to the United States, he became the first person subjected to a Centers for Disease Control and Prevention isolation order since 1963. 

Clearly, both developed and developing nations must work together to prevent and treat these diseases and find a way to implement the new strategies in an era of constrained budgets and loosening control of authority in far too many countries. However, the 

administration’s proposed budget for 2014 does call for a 19-percent 

cut in tuberculosis programming, and hopefully we might get some 

answers today and again on Thursday from Dr. Shah. 

Today’s witness, a very accomplished doctor, heads an agency 

that is charged with examining the elements of disease and helping 

to develop the strategies for addressing the threats they pose not 

just to Americans, but to all mankind. We look forward to hearing 

Dr. Frieden and exploring with him the means by which the U.S. 

Government is working with developing countries to counter global 

threats. 

I would like to yield to Ms. Bass. 

Ms. BASS. Thank you. And, Mr. Chairman, as always, I want to 

thank you for convening today’s hearing on drug-resistant diseases 

in developing countries. 

While we examine this very serious issue, I think it is worth noting that this is an issue with global dimensions that impacts all of 

us. While we sit in the halls of Congress, we are neither immune 

nor are we protected from what is a mere plane ride from this 

hearing room. 

Globalization has done much for allowing us to be more interconnected. The challenge before us today, however, is how do we 

understand and move to effectively address the smallest of things, 

microscopic organisms that have the ability to rapidly adapt and either avoid detection or resist efforts that would eliminate something that often has mortal consequences if left unaddressed. 

Dr. Frieden, I want to thank you for taking the time today to testify before the committee. I remember us talking about a very similar subject about a year ago, so I am very glad that you are here 

today. We all know that you have dedicated your life to addressing 

the great public health challenges of our day. You have been on the 

cutting edge of public health interventions and have undoubtedly 

saved millions of lives in the U.S. and around the world. For an 

extraordinary depth of work and experience, we owe you our 

thanks and look forward to your testimony. 

Without objection, I would like to submit for the record a written 

statement by Ranking Member Engel. He has been a staunch 

4

champion on a number of global health priorities and in particular 

the spread of tuberculosis, both multidrug-resistant and extensively 

drug-resistant TB. 

It would be remiss for me not to acknowledge that in my hometown of Los Angeles there has been a recent outbreak of TB, and 

I understand it is close to 5,000 people that have been diagnosed, 

and there is a concern that there is not a sufficient supply of drug 

treatment to address this outbreak. Dr. Frieden, perhaps in your 

remarks you can update us all on the situation, how the CDC is 

working with local officials. I am sure Los Angeles is not the only 

city that is dealing with this. 

But I will note that in the U.S. alone there are over 10,000 cases 

of TB infection annually. In a country like India, four times our 

population size, there are approximately 2.3 million cases each 

year and close to 1⁄2 million people can die from it. The Wall Street 

Journal reports that India has the largest number of people infected with drug-resistant strains. 

In 2010, the Center for Global Development wrote a paper entitled ‘‘The Race Against Drug Resistance,’’ and in that paper the authors address the health and economic consequences of global drug 

resistance, the drivers of drug resistance, and the current global response to the problem. They concluded with four recommendations 

that I would like to read for the committee’s consideration but also 

to get your feedback on. Recommendation one, improve surveillance 

by collecting and sharing resistance information across network of 

laboratories. Two, secure the drug supply chain to ensure quality 

products and practices. Three, strengthen national drug regulatory 

authorities in developing countries. And four, catalyze research and 

innovation to speed the development of resistance-fighting technologies. 

The challenge before us is multifaceted and will require a comprehensive approach. Understanding the drivers of drug resistance 

and addressing them is critical, including strengthening health systems to include well trained and equitably distributed health workers who can properly administer treatments, eliminating substandard and counterfeit drugs. And I would in particular like if 

you could comment about the role that counterfeit drugs might 

play in this. 

We need to have well-structured surveillance and reporting systems that are in track to monitor outbreaks and infections and a 

strong focus on research development. I would add that public and 

private sectors must also play their part to ensure financial resources and regulatory standards are in place for the challenges of 

today. In Africa, for example, you don’t have to look very far to find 

stories that report on totally drug-resistant TB or emerging concerns of increased drug-resistant strains of HIV and malaria. These 

are troubling trends as our Nation continues to fund programs that 

we hope will end these crisis in our lifetime. We have heard President Obama and former Secretary of State Clinton speak of an 

AIDS-free generation, while at the same time you read a BBC article with the headline, ‘‘Drug-Resistant HIV on Increase in Sub-Saharan Africa.’’

The World Health Organization reports that India, China, the 

Russian Federation, and South Africa are home to almost 60 perVerDate 0ct 09 2002 13:37 Sep 25, 2013 Jkt 000000 PO 00000 Frm 00008 Fmt 6633 Sfmt 6633 F:\WORK\_AGH\042313\80545 HFA PsN: SHIRL
5

cent of the world’s cases of multidrug-resistant TB. I would love to 

know your opinion, number one, if you agree with that or if you 

have a sense of why that is when we consider that, combined, India 

and China are home to over one-third of the global population of 

2.6 billion people. 

This problem won’t go away on its own and we continue to see 

people becoming infected with any number of diseases, and as our 

world continues to become smaller as a result of globalization we 

will continue to be confronted with the challenges of how to adequately deal with drug resistance that may or may not be on our 

doorstep today, but might be tomorrow. 

Thank you very much. I yield my time. 

Mr. SMITH. Thank you, Ms. Bass. 

Mr. Meadows. 

Mr. MEADOWS. Thank you, Mr. Chairman. 

This is a timely hearing on an important issue. And, Dr. Frieden, 

I appreciate your willingness to be here as well and I look forward 

to your testimony. 

Obviously drug-resistant diseases are a serious problem everywhere. You know, our own healthcare providers are struggling to 

stay on top of this issue on a daily basis, and, you know, I firmly 

believe that to address this problem we must first determine the 

scale of the problem, and, you know, we need to make sure and ensure that we have the data necessary both here and in the developing world to properly define the problem. 

These drug-resistant diseases, you know, they don’t recognize a 

political boundary. You know, in a globalized world that we live in 

a threat anywhere is a threat here, and so, therefore, we are bound 

to work on this problem wherever it presents itself and that obviously creates challenges, as you know. We know that developing 

countries may struggle with sanitary practices, the use of nonprescribed antibiotics, limited access to care, you know, and so on. And 

so I look forward to hearing how we can address those challenges 

and improve our knowledge of these severe threats. 

And with that, Mr. Chairman, I yield back. 

Mr. SMITH. Dr. Bera. 

Mr. BERA. Chairman Smith, thank you. And again thank you for 

calling this hearing. It is extremely timely. And today I will be a 

doctor as opposed to a Congressman because that is really how I 

look at this issue, from the perspective of being a doctor. You know, 

as the former chief medical officer for Sacramento County we dealt 

with issues of drug-resistant tuberculosis, but 5 or 6 years ago we 

had second and third line medications that we could use judiciously 

and still deal with these cases when we are called into consultation 

in the hospital. 

What keeps me awake at night and what I worry about is the 

emergence of extremely drug-resistant cases of tuberculosis that we 

are starting to see pop up in Africa and other nations around the 

globe, and that is of critical concern not only to those countries 

abroad in Africa, but clearly to our hospitals and our patients here 

domestically. It is a real issue and it is one that we have to take 

very seriously. 

You know, I have seen it firsthand, having travelled to South Africa a few years ago with a group of doctors to evaluate how they 

6

were caring for the HIV epidemic there. You are seeing the devastating effects of these cases and the limited resources in the arsenal. 

The other thing that keeps me awake at night, and I saw it firsthand this past weekend when I was back home and rounding with 

a group of doctors at Mercy San Juan Hospital, seeing what was 

happening there. If I am not mistaken, the nurse administrator 

who was rounding with us suggested that close to 50 percent of the 

patients that they are admitting now have a history of MRSA, or 

methicillin-resistant staph aureus. So there is a real concern of the 

efficacy of antibiotics that we are using and starting to run out of 

those tools in our arsenal as physicians. 

That leads me to another body of literature that really is emerging. As we incent our pharmaceutical companies to come up with 

the fourth generation of antibiotics, we really have to extend the 

life of these medications. And I have been a doctor for over 20 

years and for years we could use penicillin and so forth. But now, 

as we get into our first, second, third generation of cephalosporins 

and antibiotics, the lifespan of these drugs are increasingly shorter 

and shorter. And part of that is the ease of access of antibiotics in 

third world countries, the ability to just buy them over the counter, 

and there is no guarantee that they are being used in an appropriate manner. 

So we have to work with industry to make sure, as we come up 

with the next generation of antibiotics, we are very judicious in 

how they are used, not only here domestically, but also abroad in 

other countries. And I would be interested in hearing your testimony on all of these issues, what we can do proactively here in 

Congress, as well as our medical community, to address that next 

generation of tuberculosis resistant, but then also how we work 

with industry as we develop the fourth generation of antibiotics 

and make sure we can extend the lives of these medications. 

And with that, Mr. Chairman, again, thank you for this hearing, 

and I yield back. 

Mr. SMITH. Thank you, Dr. Bera. 

Mr. Weber. 

Mr. WEBER. I will yield back. 

Mr. SMITH. Okay. Thank you. Thank you. 

I would like now to extend a very special welcome to Dr. Frieden. 

Tom Frieden, medical doctor, M.P.H., who has been the Director of 

the Centers for Disease Control and Prevention since June 2009, 

has controlled both infectious and chronic diseases in this country 

and globally. From 1992 to 1996, he led New York City’s program 

that controlled tuberculosis and reduced multidrug-resistant cases 

by 80 percent. Dr. Frieden then worked in India for 5 years, helping to build a tuberculosis control program that has saved nearly 

3 million lives. 

As commissioner of the New York City Health Department from 

2002 to 2009, Dr. Frieden led programs that reduced illness and 

death and increased life expectancy substantially, including programs that reduced adult and teen smoking dramatically and 

eliminated artificial transfats from restaurants, and the department eliminated racial/ethnic disparities in colon cancer screening 

7

and began the country’s largest community-based electronic health 

records project. 

As CDC Director, Dr. Frieden has intensified CDC’s 24/7 work to 

save lives and protect people, including through more effective response to outbreaks and other health threats at the local, State, 

Federal, and global levels. New programs have prevented infections 

from food and healthcare, helped Americans quit smoking, reduce 

childhood obesity, and save lives of teens and others from car 

crashes, and extended lifesaving treatment and disease prevention 

in more than 50 countries. 

A graduate of Columbia University’s College of Physicians and 

Surgeons and School of Public Health, Dr. Frieden completed infectious disease training at Yale University and CDC’s Epidemic Intelligence Service. The recipient of numerous awards and honors, 

Dr. Frieden speaks Spanish and has published more than 200 scientific articles, and we welcome him back. 

And the floor is yours, Doctor. 

STATEMENT OF TOM FRIEDEN, M.D., DIRECTOR, CENTERS 

FOR DISEASE CONTROL AND PREVENTION 

Dr. FRIEDEN. Thank you so very much, Chairman Smith, Ranging Member Bass, and the other members of the committee, both 

for your support for global health issues and for this opportunity 

to speak with you today about such important threats that we face 

and the important work that the CDC does in this country and 

around the world to protect Americans 24/7. 

CDC’s work is critical to addressing antimicrobial resistance and 

other global threats. What I would like to do here is briefly outline 

what the problem is, what we are doing about it, and what more 

needs to be done in three broad sections. Obviously, any one of 

those three could take a lot of time, so I will just give you some 

of the highlights. And I would really agree with all of what was 

said in the introductory comments from the chair, the ranking 

member, and the panel. This is a critical problem for us. If there 

is one basic concept, it is that we are inevitably interconnected as 

a world, and whether we like it or not, whether drugs are used correctly all over the world affects what happens to people in our communities. 

I think we are facing essentially a perfect storm of vulnerability. 

There are four trends that are combining to make us in some ways 

at greater risk than we have ever been in the past. The first is the 

emergence and spread of new microbes, things like SARS and 

H7N9 influenza, which I can speak about later if you would like. 

The second is globalization of travel, where people just a plane 

ride away can bring new organisms and resistant organisms from 

one part of the world to another, and also globalization of our food 

and medical supply. We are increasingly interconnected. 

The third and the main topic of this hearing is the inexorable 

rise of drug resistance. We now face an increasing rate of resistance in many different types of organisms. To mention just three, 

we have tuberculosis strains—and tuberculosis is an area that I 

worked in for many years—that are resistant to virtually all antibiotics. We have strains of Gram-negative organisms, a group, a 

problem referred to as CRE, or carbapenem-resistant 

8

enterobacteriaceae, basically very dangerous bacteria that are now 

resistant to most or even all antibiotics and are spreading in our 

country. And third, malaria. We are now beginning to see resistance to the last best drug we have treated on an outpatient basis, 

the artemisinin drugs and that class of drugs. 

There are about 12 million Americans a year who go visit 

malarious areas, areas where they are at risk for getting malaria. 

If these resistant strains spread, the risk to people in this country 

will be substantial, in addition to the number of deaths and the 

amount of suffering and economic hardship that that will cause 

around the world. 

The fourth risk is the potential of people, either intentionally or 

unintentionally, to create dangerous organisms and then to release 

those into the environment, either intentionally or unintentionally. 

Unfortunately, that has become easier as we have had technological advances. 

Poor quality treatment, whether of tuberculosis or of pneumonia 

in the hospital, anywhere in the world, in Asia or Africa, can and 

in fact has become a nightmare in communities in the U.S. Today 

in many communities, most likely each of the communities that you 

represent in this country, there is someone in a nursing home or 

a hospital who is fighting for their life against an infection that 

doctors have limited or no tools to treat. And as we saw, for example, in Colorado, where there was an outbreak recently, the indexed 

patient had just come from Asia and undoubtedly had brought that 

organism with them through no fault of the individual and unavoidably. 

Given the four big challenges that we face, I think there are two 

broad areas that give me a great deal of hope for being able to 

tackle them in the future. One is, frankly, political and one is technological. On the political side, I think we have more commitment 

to addressing this in more countries than we have ever had before. 

The SARS outbreak cost the world more that $30 billion. H7N9 

Avian influenza in less than a month has cost China more than $2 

billion. So I think countries get that, in addition to the human suffering, there are strong economic incentives to address health 

threats more effectively. 

In addition, we have global commitments through things like the 

International Health Regulations which require countries of the 

world to find, report, and stop disease threats, and we are getting 

reporting from an increasing number of countries. We are nowhere 

near where we need to be, but we have the political framework to 

provide the support and assistance so that the world can be safer 

because each of the countries around us is safer and each of the 

countries in the world is safer. 

And also, in terms of the commitment, we have success stories, 

and I will go into some of them, but we have seen that when we 

work with China or Thailand or Brazil or many, many other countries and help them see what needs to be done, they invest their 

own resources, their own substantial talent, their own capacities in 

doing that, so that we end up with a true partnership to reduce 

health risks both for their country and for the whole world. 

The second broad reason for optimism is the advances in both 

laboratory work and informatics. They are breathtaking. We are 

9

able to do things in the laboratory now that we could not have even 

dreamed of even just a few years ago. When I started at the CDC 

as an Epidemic Intelligence Service officer, we were just beginning 

to do genetic sequencing of tiny parts of the genome and to use 

that to figure out how tuberculosis and other organisms were 

spreading and to stop them sooner. It took a large room, months 

of work, a lot of very difficult comparison by hand sometimes of different patterns. Now much more information can be obtained in 

just 3 or 4 hours. 

In the President’s budget for fiscal 2014, there is an initiative 

called Advanced Molecular Detection. This initiative would allow 

us to go to this next generation of tools, find outbreaks that we are 

missing now, find them sooner, stop them more effectively, and figure out how they are spreading so we can prevent more of them. 

This is our single highest priority for the 2014 budget at CDC. And 

in addition, there are really exciting bioinformatics developments 

where we can look at huge amounts of data and begin to make 

sense of it. So I think we have real reasons for optimism. 

In terms of what CDC is doing today, Ambassador Carson, the 

recently retired former Ambassador to Africa, said to me CDC is 

the 911 for the world, and we are happy to play that role, but we 

are even happier that we are now teaching countries to do that for 

themselves. And we are doing that in critical ways and with important platforms, and I want to thank the chairman, ranking member, and all members of the committee for your steadfast support 

for the PEPFAR program over the years. PEPFAR is really changing the world. There are more than 5.3 million people alive today 

who would be dead or dying otherwise. Last year alone a quarter 

of a million babies were born without HIV because of PEPFAR. 

And in order to do what we have done with PEPFAR, with the 

leadership of the State Department and the Global AIDS coordinator, in order to have those results, we have also used PEPFAR 

as a platform. We have come in under budget and ahead of schedule, but we have also used PEPFAR as a platform to strengthen 

laboratories for HIV and for other conditions, to strengthen diagnosis, to strengthen maternal and child health. And what we have 

seen with that, for example, is strengthening through PEPFAR, 

and also through the Global Disease Detection Program, which is 

a CDC program that is a platform to find and stop outbreaks. We 

have seen strengthening of laboratories, which are crucial, of epidemiologists or disease detectives who are essential to finding and 

stopping problems and of prevention measures. 

And just to mention a few of them, through the laboratory work, 

we now have created an African Society for Laboratory Medicine. 

Hundreds and soon thousands of laboratories throughout Africa 

will be certified so doctors and patients can rely on accurate results. Do they have an infection or not? Is it resistant or not? Is 

treatment working or not? Right now, without good laboratories, 

you can’t answer those questions in far too much of the world. 

We are also expanding influenza surveillance throughout Asia 

and Africa so that we can get a better handle on where it is emerging, how it is happening. We know that a risk anywhere can be a 

risk everywhere, and though we have worked with 50 countries on 

influenza surveillance, we were taken off-guard by H1N1 which 

10

emerged in Mexico. We have expected new influenza strains to 

emerge in China and Southeast Asia, as H7 is now, but H1 took 

us by surprise. And that emphasizes a key point, which is that a 

blind spot anywhere is a risk to all of us. But our laboratory work 

at CDC has strengthened work throughout the world so that there 

is much more accurate diagnosis. 

I will give you one example of this that CDC is doing with Uganda right now. Our CDC lab in Fort Collins, Colorado, came up with 

a new way to diagnose plague. Plague is often fatal, but with a 

simple $1 dipstick test, we are determining whether patients have 

plague. 

CDC is working with local traditional healers. We are working 

with the medical care system, and CDC is also working to see what 

treatment is best for plague. As a result, in just the past few 

months, we have diagnosed people who would likely have died otherwise and treated them before they have spread plague to others, 

and we are transferring this technology to Uganda so that they 

don’t need for us to do it in the future, as we have done with Ebola 

as an example. We have taught them how to control it, how to diagnose it, so instead of the large outbreaks that we saw a decade 

ago, we are seeing isolated cases or smaller outbreaks now. 

The second key area is epidemiology, disease detectives, and this 

is so crucial to what we do, figuring out where disease is spreading, 

what the threats are, how to stop them, and whether our efforts 

are working. Our flagship program in epidemiology at the CDC is 

the Epidemic Intelligence Service. What we have done with more 

than 30 countries is help them start similar programs, called Field 

Epidemiology Training Programs. In the next year or 2, we will 

graduate the 3,000th disease detective. It is a 2-year, intensively 

mentored program. Eighty percent of the graduates stay in their 

home country, often in leadership positions, finding and stopping 

health threats. We also do epidemiologic investigations, and we 

start on average one of these a day in this country and on average, 

with our partners, one a day around the world to identify and stop 

a new threat. 

And third is prevention, and we do this in important ways, including vaccination. After all, if you vaccinate and prevent an infection from happening, it won’t be resistant, and we are seeing that 

with, for example, pneumococcal infections now, with vaccination 

resistances less of a concern in that one organism. 

And of course we are closer than ever to the finish line in polio 

eradication, and the work of Rotary International and so many 

partners with CDC as the spearheading partner for this country 

has brought us to this point from 1988, when there were more than 

350,000 children affected by polio in that year alone, to last year, 

when there were 222, the lowest number ever in the history of humanity as far as we know. We are also active in quarantine, identifying passengers who are ill and helping to reduce risks of people 

who come here from other countries. 

That is some of what we at CDC are doing. In terms of what 

more is needed, I have to say, frankly, that we are not keeping 

pace with the threats. Microbes evolve and emerge rapidly, and we 

need to keep pace with that evolution. What we are faced with is 

a need to accelerate progress in three specific areas. 

11

The first is detection. We need to fund and implement the Advanced Molecular Detection program. I brought for you a remarkable thing. This is a chip. It is one company. It fits very easily to 

carry. There are about five different companies that make something like this. But this chip in less than 4 hours can sequence the 

entire genome of not just one, but many different microbes, and 

with advanced supercomputing, we can then take—there are actually more than 10 million individual wells on this chip. We can 

take the fragments of DNA, and with a supercomputer put them 

back together like a jigsaw puzzle with tens of thousands of pieces 

to figure out where the connections are, whether it is resistant, 

how it is spreading, and whether it is becoming more virulent. We 

are using this technology now to track H7N9, and this is the kind 

of thing that we need to invest in more to make an even bigger difference going forward. We have too many blind spots. 

Second, we need to improve our ability to respond to infectious 

disease and other threats. At CDC, we have an Emergency Operations Center, and if any of you are ever passing through Atlanta, 

please come by and spend an hour or 2 with us to see what we do 

there. We track what is happening around the world. We have an 

information system. We have a communication system. We respond 

rapidly. Ideally every country in the world should have some system like that. They will be safer and we will be safer. 

And third, we need to increase our ability to prevent, through 

better vaccines, through antibiotic stewardship, through better supply chain control in terms of antibiotics. 

So I will be happy to get into specific issues that you have raised. 

I don’t want to take too much time with my introductory statement. But I do want to conclude with one simple thought, which 

is that a safer United States and a safer world is within reach if 

we invest in it, if we work with partners, if we take advantage of 

the unique opportunities that both the commitment of countries 

around the world has and this very exciting technology that we 

have to bring to bear on longstanding threats to our health. Thank 

you so much for your interest. 

Mr. SMITH. Thank you so very much, Doctor. 

[The prepared statement of Dr. Frieden follows:]

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Mr. SMITH. And without objection, your full written statement 

will be made a part of the record, as well as that of Ranking Member Eliot Engel. 

Let me just ask you a couple of opening questions. Artemisinins, 

the power of these very important drugs to help cure people with 

malaria, may be thrown a huge curveball in, as I said earlier, in 

Cambodia, Burma, and particularly along the Thai border. And my 

question is, you know, there are 104 malaria-endemic countries. 

Obviously, and you know it, because you have been a part of this, 

we went from a $100 million in the year 2000 to $1.8 billion worldwide in 2012, certainly below what the target was if we wanted to 

really look to eradicate this horrible disease. 

But how concerned are you and CDC about this problem? I know 

WHO talks about containment and trying to ensure that this does 

not spread to other places, particularly Africa, where it would be 

even more catastrophic. If you could spend some time on that, I 

would appreciate it. 

Dr. FRIEDEN. Thank you. Thank you very much. And thank for 

your support for the President’s Malaria Initiative. I have seen, as 

you have, this program in action in Africa and elsewhere and it is 

breathtaking. I have gone into communities that previously had extensive amounts of malaria. CDC has documented that in some of 

these communities, one out of every four medical visits of children 

was for malaria. One out of every two units of blood used for transfusion was for malaria. And in communities where they have implemented good control measures, we have seen essentially zero 

cases of malaria with good control and zero deaths. So we know 

that tremendous progress is possible. 

We are quite concerned about artemisinin resistance. We have 

seen areas, as you say, in Cambodia and elsewhere where as many 

as 30 percent of patients have evidence that their particular strain 

of malaria is responding much less well to the artemisinins. This 

is our last hope for good malaria control. We have to preserve this 

drug. 

I think you can think of drug resistance and prevention of drug 

resistance as something that we owe the world, we owe our children, that these antibiotics that we have been bequeathed by people who worked so hard to come up with them are preserved and 

can be used to protect lives for many years going forward. 

What we think is possible is, first, to understand better what has 

happened and, second, to contain as well as possible, through a 

comprehensive approach to vector control, that is stopping the mosquito, treating effectively, diagnosing and treating well. And I 

think overall with malaria, we are quite reassured by the overall 

amount of progress that is happening. 

The challenge with malaria is the challenge of persistence. We 

have seen big progress with malaria before, we let off our guard, 

and it came roaring back. That is exactly what we have to avoid. 

We have to intensify our work in Southeast Asia to understand and 

contain artemisinin resistance. At the same time we have to scale 

up the core malaria control interventions in Asia and Africa, especially so that we can reduce the number of deaths and the burden 

of illness. 

25

There is still a lot we know that we are not doing and we need 

to scale up that net use and high quality diagnosis and treatment. 

There is still certain things that we don’t know that we need to understand better about the malaria parasite, about the best tools to 

control it. 

Mr. SMITH. And isn’t it true that about half of those who should 

have bed nets have it, but we are running into the problem of the 

bed nets now losing their efficacy to keep the mosquitos out? So we 

need a replacement effort as well. 

Dr. FRIEDEN. CDC scientists have looked at this carefully. The 

life of a bed net is not an easy one. They get embers put on them 

from the stove, they are worn out. And so having the first set of 

nets out was great and knocked down child mortality enormously. 

We have documented at CDC overall reductions, not malaria specific, but overall reductions in child deaths of 25 percent just from 

the malaria control program. But exactly as you say, Mr. Chairman, the nets now need to be replaced, and that requires resources. 

Mr. SMITH. You know, in terms of drugs that are actually in the 

pipeline, you know, we know that newer orders of new types of 

antibiotics are few and in between. On tuberculosis, without objection, we are including testimony from Dr. Adrian Thomas from 

Johnson & Johnson. And he points out that Janssen is bringing 

forward a new medicine specifically indicated to treat a drug-resistant form of tuberculosis. It is called Sirturo. It seems to have gone 

to the next stage, although it is not used yet. 

My question on that drug specifically and other drugs that are 

or not in the pipeline, particularly as it relates to malaria and 

multiresistant tuberculosis. 

Dr. FRIEDEN. I think a key concept is that the development of 

new antimicrobials, new antibiotics is a necessary but not a sufficient condition. Now, for those two conditions particularly, we are 

very encouraged. It is the first new anti-tuberculosis drugs in decades. We think at this point it should be reserved for people for 

whom other drugs are not available. The CDC has convened national experts to look at what is the optimal way of using this new 

drug. We will need to have some clinical trials and the FDA moved 

very quickly to approve it so that patients could get it and their 

lives could be saved. There are some other drugs for tuberculosis 

that are in the pipeline that are somewhat encouraging, but what 

we know is, unless we improve our treatment system, we will lose 

those drugs as well. 

In terms of malaria, the situation is perhaps a little less encouraging because virtually everything in the pipeline is either an 

artemisinin-related product, a synthetic artemisinin, or something 

that has the same resistance mechanisms as the artemisinins appear to have. So if we lose the artemisinins, we may lose the new 

drugs before we even get them. 

I think this comes back to one of the core concepts of antimicrobial resistance. Resistance develops because of poor quality 

programs. It is very straightforward. If you have a good quality 

program, you will not get lots of drug resistance. And in tuberculosis, which I worked in for many years, one of the core concepts 

is that a poor quality program can create multidrug resistance faster than a good program can treat it, no matter how many resources 

26

you have. And it is critically important to stop resistance from 

emerging and then to stop it from spreading. 

We documented in New York City in the early 1990s that as 

many as half of all of the multidrug-resistant tuberculosis patients 

had actually caught it in the hospital. So hospitals can become an 

amplification point for drug resistance. That is why in our work in 

this country and our recommendations to other countries we have 

advocated a program called Detect and Protect. Detect and Protect. 

It is a simple concept: Find the patients that have the resistant organisms, protect them from harm with it, and protect other patients from getting it from them. And one of the things that we are 

encouraged by is the amount of progress in things like methicillinresistant staph aureus where since 2005 we have documented a 

more than 50 percent reduction in the serious infections with that 

highly resistant organism. 

This is not a problem for which we have no solution. We know 

what to do. It is a question of doing it. We also need some new 

knowledge, but what we can do now is a much better job at reducing the risk of detecting it, so we find the patients who have it and 

are protecting others from them and protecting them from the organism. 

Mr. SMITH. Dr. Frieden, you made a very strong appeal to Congress to include in its budget what is in the Fiscal Year 2014 President’s budget for the Advanced Molecular Detection initiative. As 

you point out, it combines two powerful technologies, molecular sequencing and bioinformatics. Could you perhaps elaborate on exactly how that works, and if you could also—and then I yield to my 

colleagues for their questions—speak to the area of labs, which you 

made reference to. How much connectivity is there with CDC and 

those labs? Are they at a basic level? 

When I travel, I always ask about the labs myself. As a matter 

of fact, we had hearing in the last Congress with CURE International and the magnificent work they are doing with the infection-based hydrocephalic condition. And they have cured over 5,000 

children in Uganda alone with a simple intervention that does not 

require any stents, it doesn’t require, you know, the kind of followup that we often would need here. But it is infection based, they 

believe, and I watched one of the operations myself. The lab you 

mentioned in Uganda, I am not sure if that lends itself to the kind 

of detection that they need to do on this, but the labs. Where are 

they? Particularly in Africa, but elsewhere in the world, how do we 

grow those labs, as well as their sophistication and their 

connectivity to you? 

Dr. FRIEDEN. Thank you very much. The Advanced Molecular 

Detection initiative would give our top-quality disease detectives 

the cutting-edge tools to find problems and stop them sooner. We 

have terrific scientists at CDC. We have a mandate within this 

country and abroad to detect and stop problems. But our hands are 

in some ways tied because we can’t look into the microbe’s genome 

in the way that technology actually allows us to today. 

To give you just one example of that. With H7N9 influenza, 

which we can talk about more a bit later, we are very concerned 

to see will it develop the capacity to spread easily from person to 

27

person. So far we are confident it hasn’t. If it does, it has major 

implications for all of us and for every country. 

We think we could learn more if we could go into clinical specimens and sequence the entire genetic material in those specimens. 

What happens when you grow an organism is that one particular 

strain grows very well and you can analyze that in a laboratory, 

but that is not exactly what is happening in the patient’s body. 

What is happening in the patient’s body is that there are many different—an assortment of different sub-strains or what are sometimes called quasi-species of that organism, and by sequencing 

from there you can figure out what is going to happen. You can 

skate to where the puck is going, not where the puck is. 

AMD (advanced molecular detection) would allow us to do that, 

not just for influenza but for other organisms as well. It is a critical 

tool in helping us not only avoid problems, but prevent them in the 

future. 

The laboratories, we are very encouraged by the progress around 

the world. I think there are two broad areas where we are going 

to see more progress. The one is what are called point-of-care tests, 

things that a doctor or nurse or other health worker can do at the 

patient’s bedside or at the patient’s hut side. Things that use a dipstick, as we are using in Uganda with plague now. So these are 

great technologies because they take not much time, they are highly accurate. It is how we are diagnosing HIV and malaria now in 

the field. 

The other are the high-tech things where we can go in and look 

at a specimen, and there are now technologies which can look at 

two dozen different organisms to say in this one specimen of blood 

or sputum, which of these organisms are present. We have already 

use this on an experimental basis, for example, to look at an outbreak that we couldn’t figure out what was causing it, and to our 

surprise it was a yellow fever outbreak, and because of that, we 

were able to do control measures. So there is the ability to bring 

these new technologies to bear on laboratories throughout the 

world. 

The African Society of Laboratory Medicine, which PEPFAR 

helped to start, has made really progress by leaps and bounds. In 

fact, the Ethiopian Government has given them, the African Union 

has given them free space. Countries all over Africa are doing more 

with that. In Africa they are being very willing to do regionalization so that not every country needs to create everything. It is not 

efficient. They can work regionally very effectively. Our polio labs, 

our measles labs, our influenza labs, our foodborne labs are a global network where all of us are safer if every country can do a better 

job finding and tracking it. 

Mr. SMITH. Before I yield to Ms. Bass, is there an inventory of 

all of those labs that could be made a part of the record and give 

us a better sense of—and also would be a place that when we do 

travel, we will visit. 

Dr. FRIEDEN. We will certainly get you what we have in terms 

of an inventory. I will also mention that Congress requested that 

CDC do summaries of CDC’s laboratory work last year and this 

year, so we have two reports on laboratory work that CDC does in 

28

this country and around the world, and we would be delighted to 

share those as well, as the global laboratory network information. 

Mr. SMITH. Thank you so much. 

Ms. Bass. 

Ms. BASS. Thank you. 

Once again, thank you for your testimony. And I do look forward 

to, I was saying to the chairman, I would love to go to Atlanta and 

to see the CDC. So I hope to do that in the future. 

You know, I wanted to ask you to address two areas, and one is, 

especially, you know, you said that internationally you thought 

there were good news on the political framework, so a couple of 

international issues I would like for you to address as to how countries are dealing with the unregulated sale of antibiotics, I mean, 

you know, you can get them over the counter in a lot of different 

countries, and how you are relating to countries and trying to get 

them to stop that practice. 

The other thing is on counterfeit drugs and how prevalent do you 

think that is. You know, I have heard it is only anecdotal, though, 

but I have certainly heard that there is a lot of countries, countries 

in Africa and also many other countries around the world that are 

buying medications that they think are legitimate and they are not. 

Dr. FRIEDEN. Both of those problems are big problems, and I 

don’t think we have great news in terms of what is happening 

today to address them, but we do have a pretty clear pathway to 

get there. 

On the unregulated sale of antibiotics, fundamentally this is a 

question of strengthening governmental public sector capacity to do 

core things that we take for granted in this country. We take for 

granted in this country that you can’t go to the local pharmacy and 

pick up the latest antibiotic because you think maybe you need it. 

There is control over the use of antibiotics. 

I think many countries are not in that world yet, and one of the 

things that we do at CDC and the FDA does as well is to work with 

partner governments, both the public sector and the private sector, 

to strengthen their capacity to do those core governmental capacities that they need to have and it will protect them and us. As an 

example, the Government of India has recently passed rules outlawing an inaccurate test for tuberculosis that was being used very 

widely in India and very misleadingly. So people were being told 

they didn’t have TB when they did and that they did have TB 

when they didn’t. They have also ruled that you can’t get TB over 

the market. 

Well, it is wonderful that they have taken those steps to have 

those rules so that people would need a prescription and you would 

have an accurate test. The next step is get them implemented effectively, and that is something that with any country we are willing 

to partner to help them get it right because that helps them and 

it helps us. 

In terms——

Ms. BASS. Could I ask you a little bit, just one question about 

that? How about Mexico? You know, living in Los Angeles, I am 

just 2 hours from the border and a lot of times people do go across 

the border to get antibiotics and bring them back. We also had a 

problem in Los Angeles, frankly, with people selling them over the 

29

counter at swap meets and different places. What is our relationship with Mexico? 

Dr. FRIEDEN. We have a longstanding relationship with Mexico. 

We have, at CDC, binational programs, especially for some of the 

border areas. Mexico has a very robust public health system. In 

terms of antibiotic availability, I would have to find out and get 

back to you. 

Ms. BASS. Okay. 

Dr. FRIEDEN. In terms of counterfeit drugs, I don’t think we have 

a good sense of the scope of the problem. We know it is a risk. We 

are very concerned about counterfeit artemisinins which we have 

seen and we are very concerned about the continued sale of 

monotherapy with artemisinin. One of the great ways to protect 

antibiotics is to the give them in pairs or groups of three or four. 

This makes a huge difference because it reduces the risk that if 

you develop resistance it will spread. This is one of the key lessons 

from tuberculosis and from HIV, that by using multiple drugs together you can cure patients more effectively and prevent the 

emergence of drug resistance. 

So the sale of monotherapy artemisinin alone is just a terrible 

thing. It should never happen. And one of the things that we need 

to do more of is work with WHO, work with other international organizations, work with individual countries on reducing both counterfeit and irrational drug formulations on the market. 

Ms. BASS. So then do you think the counterfeiting of drugs is not 

that big of a problem? I mean, it is talked about huge, and I don’t 

know if it is playing that big of a role in drug resistance. 

Dr. FRIEDEN. I think what I was trying to say is I don’t think 

we know how big of a problem it is. 

Ms. BASS. Oh, okay. 

Dr. FRIEDEN. We know that there are many problems of which 

that is one, and the FDA has some new technologies that they are 

looking at which may help countries to identify counterfeit drugs 

more easily. A lot of this involves strengthening national regulatory 

authorities in other countries. That may sound like something, why 

would we want to do that? But we want to do that because we don’t 

want people anywhere getting drugs that they shouldn’t be getting 

or drugs that are ineffective when their resistance will soon be just 

a plane ride away from us in the U.S. We have already seen this 

happen with patients from Asia coming here and creating outbreaks of disease. 

The answer to this isn’t to try to say we are going to keep all 

microbes out. We are a globalized world, whether it is in our food 

supply, whether it is in our medications, whether it is in the travelers from the U.S. who go abroad and come back or people who 

come here, and in the case of tuberculosis, may have been here for 

decades and then develop an infection or an active infection with 

tuberculosis. 

Ms. BASS. Thank you. 

Mr. SMITH. Mr. Weber? 

Mr. WEBER. Wow, where do I start? 

I think you might have answered it, Doctor. You held up the 

chip, and you said the chip was instrumental, I think, in the detection of H7N9? And then you mentioned it had, oh, I don’t know 

30

how many pieces of information on it. Would you go back through 

that again, please? 

Dr. FRIEDEN. Sure. And if you would like, I will also talk some 

about H7N9 at some point. 

Mr. WEBER. Okay. 

Dr. FRIEDEN. But this chip allows you to take either a culture 

that you have in a laboratory or a patient’s specimen, blood or 

urine, and then to isolate the DNA and put it in these wells and 

then, through testing, figure out what DNA is in it, so what organism it is, whether the DNA encodes for resistance genes, whether, 

when we learn more, whether it is related to other organisms. So 

two people may have the same species infection, but they may be 

totally unrelated or they may have gotten it one from the other. 

That kind of information can come from this kind of technology, 

but we need to learn more about it, we need to invest in it, we need 

to study the genome of many of the organisms that are causing 

human illness. 

Mr. WEBER. Does that give us the ability to look at that DNA 

and say some strings of DNA are more resistant to drugs than others? 

Dr. FRIEDEN. Yes, it would allow you to say which of the strains 

are more dangerous. I should give the caveat that this is only effective if it is done along with a lot of our traditional tools of laboratory work and what we call shoe-leather epidemiology, going out, 

asking people questions, figuring out who is sick, figuring out who 

is resistant, and who had contact where with who. 

Mr. WEBER. Okay. So this gives the ability to predict, for lack of 

a better term, I think the phrase you used was to skate not to 

where the puck is, but is going to be. 

Dr. FRIEDEN. That is what we hope it will do. 

Mr. WEBER. Yeah. Wayne Gretzky he said over here. 

Dr. FRIEDEN. That is right. 

Mr. WEBER. Okay. I didn’t know he was a doctor. 

So what does that look like? I mean, are you anticipating strains 

evolving? What do you mean by that? 

Dr. FRIEDEN. So we could see within an individual patient with 

influenza, in our current way of doing it, we can only see one dominant strain. With the new technology, we would actually see many 

strains that are in their body and making them sick. 

Some of those strains may be drug-resistant. Some of them, in 

the case of H7, may have picked up the ability to spread person 

to person. We don’t know that yet. That is something we will be 

tracking very, very closely as H7 progresses and as we learn more 

about it. 

Mr. WEBER. And then you do what? You skate to where the medicine that he or she needs? 

Dr. FRIEDEN. We might, for example, use a different drug to treat 

that patient. We might change the way we create the vaccine so 

that the parts of the vaccine that are active are active against a 

different strain of the virus or a different type of the virus. So it 

would help us to both find it and stop it and prevent it. 

Mr. WEBER. So when you do that, when you have this data—and 

I forget how many pieces you said was on there, hundreds of millions, I am sure—are you able to get that into a database that says, 

31

okay, we can share this and we know—at some point, somebody 

named the H7N9. And so at what point do you determine that a 

particular strain is wide and it gets a name? Who determines that, 

and when does that happen? 

Dr. FRIEDEN. So, for influenza, we have really a wonderful global 

partnership. We work with more than 50 countries, we work with 

the World Health Organization. And after the SARS epidemic in 

China, the Chinese got very interested in improving their system. 

So we have worked very closely with them to set up systems to 

track influenza, to help them develop their laboratory abilities to 

be able to detect it and to do the genetic sequence of influenza. 

And, in fact, we helped them become a World Health Organization collaborating center on influenza. And that is important, because, as a collaborating center, they are required to post on the 

Internet the entire gene sequence of every new influenza organism 

that they sequence, and they are happy to do so. 

So, within days of receiving the first sample, the China CDC, 

which is the collaborating center there, had sequenced the genome 

in ways that we had helped them to do and then posted that on 

the Internet. We brought that sequence down and used the sequence to create a test to see if someone has this organism. 

We have already had about two dozen people in this country 

coming back from China with severe illness who we have tested in 

our laboratories. None of them have had this. We don’t think any 

have had it yet, of the ones that are still pending. But, in addition, 

we have already begun through what is called reverse engineering 

to make a vaccine against H7 based on this information from the 

Internet. 

That is all great, but there is actually a next generation of genetic work that can be even more powerful and allow us to see in 

advance—we only saw this once it had made a bunch of people 

sick. It has now made over 100 people sick in China——

Mr. WEBER. Well, and that is my question. How do know over 

here in this country? How do you get that word out? At what point 

do you know that these people—do they have a common theme? 

They have been overseas, I guess. 

Dr. FRIEDEN. So for the H7N9, if I can just address that for a 

moment, influenza is, of all of the infectious diseases, the one that 

can kill the most people. During the 1918 pandemic, more than 50 

million people around the world died. The death rate among people 

who got the virus in 1918 was around 1.7 percent. 

Now, in an average flu year in the U.S., average seasonal flu 

year, about 20 percent of people, 60 million Americans, get the flu. 

So if a virus could be that severe and infect that many people, it 

would be of enormous risk. 

Mr. WEBER. Knock out 6,000 people, basically, if you went—and 

more than that at 1.7 percent of 60 million. 

Dr. FRIEDEN. So that is why flu we take so very seriously and 

we track it all around the world. In fact, the Southern Hemisphere 

tends to get flu before we do, and we use the pattern there to decide which strains of flu to put into the virus for the coming year, 

and they use for the next year what happens here. So it is really 

a global collaboration on influenza. 

32

H7N9 is a new scenario. We have never seen anything quite like 

this before in China. And there are aspects of it that are reassuring, there are aspects that are not reassuring, and there are 

things that we are specifically doing. 

I will tell you the most reassuring thing about the bird flu in 

China now, the H7, is that it is not spreading from one person to 

another efficiently. And we are quite confident in that. The Chinese 

Government has checked more than 2,000 contacts of people with 

flu, and they have found only a very small handful of secondary 

cases, whereas with a usual flu we might expect to see as many 

as 20 or 30 percent of those people sick. So we are not seeing 

spread. And we are seeing most of the cases had contact with 

birds—ducks, pigeons, quail, or chickens. 

So what is reassuring is we are not seeing person-to-person 

spread. We are also seeing very good collaboration with the Chinese authorities. In fact, the head of our flu program is there now 

on a World Health Organization delegation and getting great collaboration. The Chinese Government has asked us to send them 

three of our top experts in flu to work with them for weeks and 

months to come so that they can do everything possible to get 

ahead of it. And for 10 years we have been increasing our preparedness for threats and working better across the U.S. Government. That is the good news. 

The not-so-reassuring news is that this particular strain of bird 

flu, H7, is severe. So, of the 100 people or so who have gotten it, 

about 20 have died, and many of the remaining are quite sick. We 

also don’t see birds getting sick from it. Now, you might say that 

is a good thing, but it is not, because with H5N1, another bird flu 

that we have been tracking for 10 years, with H5, the birds get sick 

and the country culls the flock and it stops spreading. Here the 

birds aren’t sick, so you can’t cull the flock. You don’t have that 

marker. 

And H5, the other bird flu, spread all over the world in years. 

So it started in Asia and soon was all over the Middle East and 

Africa. And for H5, it took about 18 months between the time the 

first case came and we had 100 cases. H1 was recognized on April 

1st of this year, and we already have 100 cases. 

So there are things that we are very concerned about in what the 

genome looks like, and creating a vaccine is particularly challenging for these types of virus. But our plan for addressing the flu 

basically uses four pillars that the Department of Health and 

Human Services coordinates. The first is tracking so we know what 

is happening. The second is mitigation, figuring out how we can reduce damage if it comes by treating people and helping them survive flu, by good care in hospitals. Third is vaccine development. 

Vaccine development in influenza takes at least 6 months, and for 

H7 it is likely to require probably two doses and maybe an adjuvant because the human body doesn’t respond well to this. And 

communication. We are very up front. We have a fundamental rule: 

Tell them what you know when you know it; tell them what you 

don’t know and how you are trying to find out. And that is our approach to this. 

The bottom line with H7 is that, currently, it is not spreading 

person to person. If it does not gain that capacity, it will not cause 

33

a pandemic. But I cannot predict if it will and, if it does, if it is 

going to be tomorrow or in 10 years. 

Mr. WEBER. Sure. 

Let me ask one final question, if I may, Mr. Chairman. 

In your remarks, you said there were four trends, and your 

fourth trend was the potential for folks to intentionally or unintentionally create dangerous organisms and release them, which got 

my attention, because in all this talk about, you know, biological 

warfare, for example, with all of these databases up on the Web 

you talked about, where they identify a strain, they are supposed 

to post it as a member of the WHO, do you guys, for national security reasons, work with the branch of government that would track 

something like that? 

And I don’t know if you can really go into it. How do you identify 

that strain, if you will? And how do you know who is working on 

it? 

Dr. FRIEDEN. So within this country, within the United States, 

CDC operates something that looks at what are called select 

agents, things that could be used for terrorist purposes or could be 

dangerous if they got out of the laboratory. There are currently 

about 354 laboratories in this country that work with one or another toxin or select agent. 

We are generally not a regulatory agency, unless you want to import or work with plague or something like it in your laboratory, 

in which case we will do the regulation. And for each of these laboratories, we do on-site visits and we oversee them. And we ensure 

that both the workers there don’t get infected, because if they got 

infected, they could bring it outside and they could be very sick, 

and we do everything possible to minimize the risk of spread. 

Mr. WEBER. Well, I am not too concerned about the laboratories 

that are here. I was concerned about your example or, for example, 

other foreign countries posted their stuff online. If they find something that is so bad that there is really hardly a cure for it, what 

would keep them from just sending it over to our country? That is 

really my question. 

Dr. FRIEDEN. Yep. The risk of biological warfare is real. 

Mr. WEBER. Do you all track that? 

Dr. FRIEDEN. We do. And we also retain under our jurisdiction 

the strategic national stockpile. It is countermeasures for a natural 

or manmade disaster that we can deploy to anywhere in the U.S. 

within 12 hours. 

Mr. WEBER. So if you see a country that is hostile to America—

of course, they probably aren’t going to post that on the Web. That 

is the catch-22. If they come up with something like that, there is 

no good way for us to have a preventative vaccine in place without 

foreknowledge. 

Dr. FRIEDEN. Well, we look at all the potential risks. So we have 

scientists at CDC who are essentially the world’s experts in just 

about all of the threats that could be faced. 

We know, for example, that smallpox is something that we have 

been very concerned about someone reintroducing in the world. 

CDC, working with World Health Organization, eradicated smallpox from the world, but we have been concerned that someone 

might bring it back as a terrorist agent. We have in the stockpile 

34

enough vaccine to vaccinate the country. So we have essentially 

taken that risk off the table. 

Mr. WEBER. Okay. 

Dr. FRIEDEN. Not all risks are that amenable to our intervention, 

but we both track and think of how to prepare. 

And I would mention that the advanced molecular detection allows us to do very specific fingerprinting of strains which would 

help us in identifying the source of it. So that it is something that 

has additional benefits, as well. 

Mr. WEBER. Okay. Thank you. 

Thank you, Mr. Chairman. I yield back. 

Mr. SMITH. Thank you very much, Mr. Weber. 

Mr. Bera? 

Mr. BERA. Thank you, Mr. Chairman. 

And my apologies, Dr. Frieden, if you have been asked this question. But in my opening statement, I talked a little bit about how 

we come up with the next generation of antibiotics and certainly 

extend the life of those antibiotics. 

Part of the challenge that we face is, as our domestic pharmaceutical companies and global pharmaceutical companies look at 

making those investments and the amount of research that goes 

into developing that next generation and then the return on that 

investment, many of these companies are making those cost-benefit 

analyses and realizing, you know, the costs of prohibitive. So, clearly, the Federal Government has a role in making sure we are providing adequate resources and funding, creating that partnership 

between industry and academia to do this research and develop the 

next generation. 

But the critical question here is, as we are making those investments, we certainly want to extend the life of these therapeutics. 

And we are seeing—I was reading my home medical journal, the 

Annals of Internal Medicine, in this latest issue, and they were 

touching on the increasing incidents of CRE and the impact that 

is having and potentially will have in the future. 

What are some thoughts that you might have as we come up 

with this next generation to both protect and extend the life of 

these discoveries here domestically? But then also, we talk about 

the ease of obtaining antibiotics overseas in third world countries. 

What are some creative things that we can do here in Congress, 

working with industry, to, again, extend the life? 

Dr. FRIEDEN. I think everything you say is a critical issue. We 

need to figure out how to preserve the antibiotics we have now and 

ensure that, as new antibiotics come on line, which we anticipate 

and hope they will, we don’t lose them as quickly as we have lost 

some of the current ones. 

The amount of antibiotic usage in the U.S. is actually astonishing. CDC just published data on this within the past week, I believe. There are more than a quarter of a billion, ‘‘B,’’ quarter of 

a billion courses of antibiotics prescribed in this country each year, 

about 8 courses of antibiotics for every 10 people in the country. 

And in some parts of the country, it is 12 for every 10 people. 

So I think we really have to work on antibiotic stewardship, 

making sure that when people need antibiotics, they get them, and 

when they don’t need them, they don’t get them. And CDC has 

35

sponsored some antibiotic stewardship programs which have been 

shown to save money for facilities. They require an investment; you 

have to have staff doing them. But they pay off. And this is something that is really quite important. 

In terms of the pipeline of how to get new antibiotics, the NIH 

is critical in that regard, and the FDA as well. It is figuring out 

ways to help companies bring products to the market sooner and 

at lower cost so that we can address this gap, because we don’t 

have a lot of great antibiotics in the pipeline. 

In terms of preserving antibiotics, I talked briefly before about 

the new antibiotic for tuberculosis, which we are trying to do just 

that with, saying, let’s just reserve this for the patients for whom 

there are no other options while we figure out the best mechanism 

for it. 

As you know as a doctor, Dr. Bera, if you use antibiotics correctly, you won’t get drug resistance. A lot of the things that we 

need to do are fairly simple and straightforward: Getting 

healthcare workers to wash their hands, removing urinary catheters and intravenous lines very promptly and only using them 

when essential, getting patients off ventilators as rapidly as possible, reducing healthcare-associated infection. 

And CDC’s healthcare-associated infection program does that in 

this country. Other countries, particularly low- and middle-income 

countries, are not doing much in that area. And that is an area we 

would like to expand work on, but we are unable to for lack of resources. 

Mr. BERA. You have touched on a couple areas. I am astonished 

at the number of courses of antibiotics. I realized there was a lot 

being prescribed; I didn’t realize it was that high. 

Are there best practices that we can make sure physicians 

around the country are utilizing that have been shown to be effective? So for years we have been talking about appropriate antibiotic 

prescriptions and prescribing habits. Are there best practices that 

you have seen and effective models? 

Dr. FRIEDEN. Yes, we have seen antibiotic stewardship models 

that really make a difference. We have a program at CDC called 

Get Smart About Antibiotics. And we think it is important to involve both the clinicians and the community. Because the clinicians 

will say to us, you know, the patient came in and they demanded 

antibiotics, and they said if I don’t give them to them, they are 

going to go to the guy down the street. 

Mr. BERA. Right. 

Dr. FRIEDEN. So I think it is important to get more awareness 

that antibiotics—no medicine is without risk. So things should absolutely be taken when they are needed but not be taken when 

they are not needed. And I think that is the essence of the best 

practice. 

We have often seen that getting nondoctors involved in the system—pharmacists, nurses, allied health workers—can be very important. 

And the other thing that has been very effective is to track the 

prescribing trends of different doctors, not as a way of criticizing 

someone, but providing feedback, and if there are outliers, proVerDate 0ct 09 2002 13:37 Sep 25, 2013 Jkt 000000 PO 00000 Frm 00039 Fmt 6633 Sfmt 6633 F:\WORK\_AGH\042313\80545 HFA PsN: SHIRL
36

viding them that information and education so that they can do a 

better job. 

When I worked in tuberculosis control, we were able to standardize treatment for tuberculosis across an entire city, an entire 

country, using outreach workers to reach out to doctors, private 

doctors, in case the prescription wasn’t appropriate or rational, and 

just provide them with education and information so we could improve the quality of care. 

Mr. BERA. Great. 

You know, just one last question. My colleague, Mr. Weber, 

touched on the threat of biological agents and so forth and the imminent threat here locally, or domestically. You know, in the full 

committee, we have certainly had a few hearings on Syria, a country that increasingly looks like it is going to fall and a country that 

we know possesses some of these biological agents. 

You know, as we prepare ourselves for, you know, all threats and 

so forth, is there anything that you would like to see from this body 

in terms of helping the CDC make sure that we are fully prepared 

for——

Dr. FRIEDEN. Well, at CDC we work 24/7 protecting Americans 

from threats, whether they are natural or manmade, whether they 

are infectious or environmental, whether they are from this country 

or abroad. 

What we do, frankly, is dependent on the resources we are provided. So when we have fewer resources, that means the resources 

that we provide to State and local entities to detect and respond 

to problems are less, that means the resources we have to work 

globally are less. 

Sequestration has had broad and serious impacts on CDC’s ability to detect and respond to a wide variety of problems. We understand that we are in fiscally constrained times. We have done a lot 

to be more efficient, to make sure that as much of our money that 

we are entrusted goes out for direct program services. But we are 

concerned that our ability to respond is really at the breaking point 

in some of our programs. 

Mr. BERA. Right. Thank you. 

Mr. SMITH. Thank you. 

Mr. Meadows? 

Mr. MEADOWS. Thank you, Mr. Chairman. 

And thank you for your illuminating testimony. 

And one of the areas that I want to broach is, Dr. Bera and I 

actually have had a lead letter together where we had Dr. Collins 

come in with NIH, National Institutes of Health. And he was sharing some of the groundbreaking, exciting research that they have 

been doing, particularly in influenza. 

And so what kind of correlation or partnership has there been 

with that group? And what can be learned from that partnership? 

Because as he was sharing, you know, right now we treat, and 

he described it, it is kind of like a mushroom. And, you know, every 

year you get a flu shot, and, you know, it is a different strain, and 

we are coming up with that, and that there is a hope that one day 

we will be able to, in the not-too-distant future, just have one shot 

for that stem that, from a DNA perspective, helps us address that. 

And so are you working with them, and in what ways? 

37

Dr. FRIEDEN. We work very closely with NIH, with FDA, with 

other parts of HHS. In fact, in the H7N9 response, we are having 

twice-weekly coordination calls to make sure we are perfectly 

aligned. 

What we are finding—really, what NIH is working on we really 

hope will work out. 

Mr. MEADOWS. Right. 

Dr. FRIEDEN. They are doing the basic research to try to come 

up with a universal, long-lasting flu vaccine. 

Mr. MEADOWS. Right. 

Dr. FRIEDEN. This would be phenomenal. Right now, our flu vaccine works okay. It doesn’t work as well as most of our vaccines. 

You have to take it every year. Sometimes we have a mismatch, 

and it doesn’t——

Mr. MEADOWS. Right. 

Dr. FRIEDEN [continuing]. Meet the strains. If you look at something like H7, it doesn’t work particularly well. You have to give 

two doses and maybe an adjuvant. 

Mr. MEADOWS. Right. 

Dr. FRIEDEN. So we have real challenges, and we ardently hope 

that they will succeed. 

But our job really is to take what is existing knowledge and turn 

it into practice. That is the CDC space——

Mr. MEADOWS. Okay. 

Dr. FRIEDEN [continuing]. Take what we know how to do and get 

it happening as broadly as possible to protect as many people as 

possible. 

And we are able through our laboratory, for example, to accelerate and improve some of the current vaccine development techniques. We are able through our laboratory to cut a month off vaccine production time through a new technology that we have developed. 

So it really is a partnership across the system. 

Mr. MEADOWS. All right. So you mentioned the FDA. And, obviously, there is this, where you are analyzing and seeing the issue 

and identifying the problem, so to speak. And then we have to figure out a way, how do we deal with the problem. And so there are 

a number of components there. One would be the FDA; the other 

would be pharmaceutical companies. 

What are the barriers that you face right now with either sharing that information or speeding up the process? You know, if you 

are identifying the issue, how do we make sure that as quickly as 

possible that we see the enemy and that we know how to fight it, 

with drugs or whatever? What are the barriers that you are seeing 

there? 

Dr. FRIEDEN. I think within the Federal system, we are very 

well-aligned. I honestly might not have said that a few years ago, 

but that——

Mr. MEADOWS. So that is part of the government that is working 

well, is what you are saying? 

Dr. FRIEDEN. Yeah. 

Mr. MEADOWS. Okay. 

38

Dr. FRIEDEN. Just to take food safety as an example, we have 

weekly reviews with both USDA and FDA on every potential cluster and investigate those that make sense. 

On influenza development, we are really very tightly aligned between FDA, USDA, NIH, and ourselves. So, for example, if we go 

forward to make vaccine for H7, even trial vaccine——

Mr. MEADOWS. Right. 

Dr. FRIEDEN [continuing]. It would be part of HHS that contracts 

for that, it would be NIH that does the clinical trials, it would be 

FDA that licenses it. So I think that is going well. 

There are at least two areas where we face real challenges. One 

of them is, as I have mentioned, our limitation in being able to do 

some of the advanced molecular work that would open doors and 

make things visible that are currently invisible to us. 

Mr. MEADOWS. Right. 

Dr. FRIEDEN. The second are sometimes some of the incentives. 

The private sector is a crucial partner in this work, but for some 

of the work they don’t have the incentive to do what might do the 

most good, either because a product wouldn’t pay or because the 

market isn’t necessarily there. If we don’t have an H7 pandemic, 

there will be no market for the vaccine. So there are areas where 

the government needs to step in because there is no natural incentive for it. 

New antibiotics are an area where we are trying to get the incentives right, because it does cost so much money to develop a new 

antibiotic. How do we make sure that, if they do get one to market, 

it is preserved and they can get a return on their substantial investment to bring it to market? 

So I think those are two of the issues that we are looking at 

more. 

Mr. MEADOWS. All right. And so let’s look at that prioritization, 

because I think you have come up and you have said, okay, you 

know, we have fiscal constraints, we have, you know, a priority on 

where we are in terms of our investment on these. 

How would you look at those areas and prioritize them? I mean, 

I have a number of friends that have worked for the CDC. I mean, 

they come up to the mountains of North Carolina to get away, and 

so I get to see them on a regular basis. And all of them are very 

dedicated, capable individuals. 

I still at times, though, see the CDC, what I believe, may have 

mission creep in terms of getting into areas that tangentially 

maybe have to do with disease. For example, I mean, I was real 

surprised to see some of the advertising done by the CDC with regards to gun control. You know, there was an issue there that came 

up, and I was just blown away that there would even be anything 

there. 

And so, how can you—or who is the best person to prioritize 

those things for us? 

Dr. FRIEDEN. Well, first, I am not aware of any advertising CDC 

has done on gun violence. So if there is any example of that, I 

would like to see it. 

Mr. MEADOWS. I will get you a copy of it. 

39

Dr. FRIEDEN. I think the bottom line for us is a return on investment, return on investment both in terms of health and in terms 

of dollars. 

So with influenza as an example, we are looking at what will be 

the return on investment from a better vaccine. Now, we hope we 

will come up with a universal vaccine. It might or might not happen. But we know that if we can increase——

Mr. MEADOWS. Right. 

Dr. FRIEDEN [continuing]. The use of existing tools, we can tamp 

down the impact of influenza. 

For many of the vaccines, we know that if we got to higher vaccination rates, we would have less disease in the future. In fact, 

vaccines are a great example of that. For every $1 we spend on vaccines, we get $3 back in healthcare savings and $10 back in societal savings. 

So I think, for me, the key concept is the return on investment. 

It is not something we do because it makes us feel good or we 

think——

Mr. MEADOWS. Oh, no, no. And I realize that. And I guess my 

question becomes, how do we share the issue of how concerning 

these issues are without creating panic and yet, at the same time—

because, you know, funding becomes—you know, you only go to the 

doctor when you know you are sick. And a lot of these issues are 

here, that are out there, that, quite frankly, the average person on 

Main Street has no idea that the threat exists. 

So how do we share that information where we build, you know, 

public consensus and yet, at the same time, not create a fear, you 

know, where everybody is running around on Main Street with 

masks on their face? 

Dr. FRIEDEN. So, right now, for H7 as an example, there is nothing for people to do differently. As a family member, as a parent, 

there is nothing that I am advising my family to do differently. 

Mr. MEADOWS. Because of the contagious nature that you talked 

about earlier. 

Dr. FRIEDEN. That is right. 

Mr. MEADOWS. Okay. 

Dr. FRIEDEN. For 10 years, we have told people, if you visit 

China, don’t go to live markets. That was to protect you against 

SARS and avian influenza and other things. And that remains our 

advice, and that is——

Mr. MEADOWS. Sure. 

Dr. FRIEDEN [continuing]. Essentially the only thing different. 

For us at CDC, it is different. We have activated our emergency 

operations center. We are tracking it 24/7. We are sending teams 

out to look at it. We are working with State and local governments. 

We are working with neighboring countries. So there is a lot that 

we are doing. 

I think the issue of building consensus is a challenging one, and 

it really gets to the heart of this hearing, I think, which is, how 

do we ensure that there is a widespread recognition that in terms 

of global health threats we are inevitably interconnected, that a 

risk anywhere is a risk everywhere, that a blind spot anywhere 

puts us all at risk? And that is something that I think all of us 

can think together on, how to convey that most effectively. 

40

Mr. MEADOWS. So you think the Federal answer—and this is my 

last question, Mr. Chairman—you think the Federal answer to that 

would be to prioritize those, identify those areas, as we did with 

smallpox when there was a potential risk with smallpox after 9/11, 

and identify those areas that may not have a pharmaceutical payback, so to speak, and say that is where the Federal Government 

needs to get involved, and on the others leave it to the private sector? 

Dr. FRIEDEN. Yes, in general. I would say that it is not an either/

or. There are very important public-private partnerships where, 

say, take the example of the cell-based flu manufacturing capacity 

that the public sector invested in but Novartis also invested in. 

Mr. MEADOWS. Right. 

Dr. FRIEDEN. So I think there are partnerships possible there. 

In terms of the gaps, we have talked about the advanced molecular detection. We have also talked about the global health security 

and the need to have that network around the world, because if 

any country is weak, we are all at higher risk. And, ultimately, 

things like vaccines can take diseases off the table but require 

more investment or, where we have the vaccine, investment to get 

it into people. 

Mr. MEADOWS. Okay. 

I thank you, Mr. Chairman, and I yield back. 

Mr. SMITH. Thank you very much. 

Dr. Frieden, you have been very generous with your time. If I 

could just ask you a couple of final questions, and perhaps any 

other colleagues who would like to ask a final question as well. 

You mentioned drug-resistant gonorrhea. If you perhaps could 

speak to how prevalent that is, that we saw strains, ‘‘we’’ being the 

government, detected in Asia, and now it has been observed around 

the world, including the United States. 

On MRSA, is that something that is multiplying globally, and at 

what rate, perhaps? 

I, on one trip to Korea, met with a number of people, but one of 

them was a priest who was doing work in Pyongyang to help multiresistant TB and XDR TB-affected patients, who are unbelievably 

sick, and yet he was allowed in. In that case, Kim Jong Il welcomed him because he was doing such a great humanitarian initiative. 

When you have a country like North Korea, or perhaps Iran or 

Eritrea, or some other country where human rights abusers are in 

power, like China and even Vietnam, they welcome, thankfully, the 

collaboration to try to mitigate and stop disease spread, but in a 

country like North Korea, that is not happening. Do you have any 

recommendations on what could be done, you know, to build that 

bridge? Because, obviously, I am sure CDC would love to be there 

helping to eradicate something like—or help people with drug-resistant tuberculosis. 

Let me also just ask you briefly if you can comment on the, 

maybe you might not want to, but the $236 million in last year’s 

budget for Fiscal Year 2012 will be cut by $45 million in the President’s budget for TB to $191 million. I mean, yes, these are hard 

times, but it seems to me that that money, minimally straight-lining it, if not increasing it, is—every dollar well-spent. 

41

And, finally, back in the early 1980s, during the child survival 

revolution, Jim Grant and all the others at UNICEF, and of course 

our Government was pushing hard for it, David Stockman came 

along as OMB Director and zeroed out in its second year the child 

survival emphasis on vaccines or rehydration therapy and the like. 

I offered the amendment to double it, to double down and say not 

only should we not end that money, we need to increase it. 

And I travelled to El Salvador and many other places when vaccination days were called. And pertussis, diptheria, and other killers of children, kids were vaccinated against it. Now, this is obviously several decades later, and I am wondering, are we hitting all 

the diseases? Are any of those diseases, like pertussis or diptheria, 

morphing into something that becomes drug-resistant? 

We thought we were on our way to eradication and universal immunization, but obviously they keep rearing their ugly heads. I 

mean, we need to redouble our efforts on the child survival effort 

as well. 

If you could speak to that. 

Dr. FRIEDEN. Thank you so much. 

On drug-resistant gonorrhea, we have seen an increasing proportion of strains in this country and around the world that are resistant to cephalosporins. So, earlier, just a few months ago, we issued 

new treatment guidelines to use two drugs for patients, not one, 

because, again, using two will reduce that emergence. 

We know that it is a problem globally and we will have to address it globally. There is a lot of global transmission. And what 

we have seen is the need to have that kind of action. We have 

worked very actively with the World Health Organization to track 

it. 

In terms of MRSA, I think there is very limited evidence or 

knowledge about where it is globally. So that is one of the things 

that we would like to work with other countries on to further develop. But we do know that in this country we have been able to 

substantially reduce invasive MRSA through some commonsense, 

low-cost ways of reducing infections in hospitals. 

I agree with you completely that health is often a great way to 

foster collaboration. I mean, look at the partnership, steadfast partnership, over the past 10 years with China on influenza and other 

infectious diseases, regardless of what else may be happening. Or 

if you look at smallpox eradication, that was done when the Soviet 

Union still existed. There was a partnership between the CDC, the 

U.S., and the Soviet Union for smallpox eradication. 

So health can be a safe space. And the days of tranquility that 

you mentioned of James Grant and UNICEF were a very inspiring 

example of that, where people actually stopped the war to vaccinate kids. 

I can’t comment on the budget on TB. I believe that is the 

USAID budget that you are referring to. 

In terms of the child survival revolution and what is happening 

now, vaccinations remain one of the great accomplishments of all 

time in humanity. Take measles alone. There are about 10 million 

children who would be dead who are alive today because of measles 

vaccinations. Low cost, it is highly effective. 

42

We know that there are limits to vaccines. For example, our pertussis vaccine doesn’t work as well as we would like. Many countries are not using the vaccines that we know work. So rubella vaccines have to be used at a high rate or you actually can do more 

harm than good. So the vaccine work is very important. 

One thing that has been very encouraging is GAVI, the Global 

Alliance for Vaccines and Immunizations, which is funding and creating an incentive for companies to sell at a reasonable price vaccines around the world. And the vaccine manufacturers have been 

wonderful partners in this. The result of that is that new vaccines 

against rotavirus, something that CDC helped develop; against 

pneumococcal disease, which killed lots of kids last year; and 

against haemophilus are being introduced around the world. 

We still have much further to go to make sure that every child 

in the world can have the potential of receiving those vaccines. And 

there are some new vaccines that we are hoping to see developed 

in the coming years. But right now we have kind of a full plate getting these scaled up. 

We have worked in Haiti, for example, to help that country implement new vaccination programs at a higher rates for three of 

leading killers that they were never vaccinating against before 

post-earthquake, so rotavirus, pneumococcal, and haemophilus. 

Major killers, at least probably 10,000 deaths per year per pathogen. And those are getting introduced last year, this year, and next 

year in Haiti. 

So I think it is a great example of how much can be accomplished in global health. And I really thank the committee, the 

chairman for how much you have done in this area. 

At CDC, we also have searing memories of the zeroing out of the 

child survival revolution, because we were expanding vaccination. 

And lot of children could have had a fuller, longer life if that program hadn’t been stopped. 

Mr. SMITH. Doctor, is there anything you would like to say in 

conclusion? 

Dr. FRIEDEN. Only to thank you again for your attention to these 

issues and to emphasize that, despite all the problems, despite all 

the threats, despite all of the risks, I remain fundamentally optimistic. We have commitment and we have tools, we have great people, we have will in this country and around the world. There is 

a broad consensus in this country and around the world of what 

needs to be done. And I am confident that we will make even more 

progress in the future. 

Mr. SMITH. Thank you so very much for your great testimony 

but, more importantly, your leadership. It is making a huge difference and deeply appreciated by this committee. Thank you. 

Dr. FRIEDEN. Thank you very much. 

Mr. SMITH. The hearing is adjourned. 

[Whereupon, at 4:44 p.m., the subcommittee was adjourned.] 

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