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THE U.S. CONTRIBUTION TO THE FIGHT

AGAINST MALARIA

HEARING AND MEETING

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

MAY 17, 2013

Serial No. 113–60

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

WITNESSES 

Rear Admiral Tim Ziemer, U.S. Global Malaria Coordinator, President’s Malaria Initiative ...................................................................................................... 7

Colonel Peter J. Weina, Ph.D., M.D., Deputy Commander, Walter Reed Army 

Institute of Research, U.S. Department of Defense .......................................... 20

BRIEFER 

The Honorable Mark Dybul, executive director, The Global Fund to Fight 

AIDS, Tuberculosis and Malaria ......................................................................... 42

LETTERS, STATEMENTS, ETC., SUBMITTED FOR THE HEARING 

Rear Admiral Tim Ziemer: Prepared statement ................................................... 10

Colonel Peter J. Weina, Ph.D., M.D.: Prepared statement .................................. 22

The Honorable Mark Dybul: Prepared statement ................................................. 46

APPENDIX 

Hearing notice .......................................................................................................... 70

Hearing minutes ...................................................................................................... 71

(1)

THE U.S. CONTRIBUTION TO THE FIGHT 

AGAINST MALARIA 

FRIDAY, MAY 17, 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 10 o’clock a.m., in 

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

Smith (chairman of the subcommittee) presiding. 

Mr. SMITH. The committee will come to order, and good morning 

to everyone, and thank you for being here this morning, especially 

at this hearing to examine the United States’ contribution to the 

global fight against malaria. 

Leadership matters. In 2005, President George W. Bush established the President’s Malaria Initiative, or PMI, and then targeted 

several African malaria endemic countries to receive over $1 billion 

to mitigate and, some day, eradicate this killer disease. The positive consequences of that bold and compassionate initiative now include over 1 million lives saved over the last decade. The program 

and its expansion and sustainability of the funding have been all 

important in that battle. 

Although we will hear statistics about malaria cited several 

times during the course of this hearing, the global impact of this 

disease is so severe that they are worth repeating, and I say that, 

even though we are making progress. 

The World Health Organization estimates that in 2010, there 

were 219 million malaria cases and 660,000 deaths. While still unconscionably high, and every life is absolutely precious and of extraordinary importance, the loss of life has declined from approximately 985,000 deaths in 2000. 

Not surprisingly, malaria has a particularly devastating impact 

on the most vulnerable. Nearly 86 percent of those who died are 

children under 5 years of age, living in sub-Saharan Africa. Dr. 

Mark Dybul, executive director of the Global Fund and George W. 

Bush’s extraordinarily effective Global AIDS coordinator, says that, 

in Africa alone, malaria takes a life of a child every minute. He 

also notes, as do our other panelists, that pregnant women are also 

disproportionately affected with the disease. 

WHO emphasizes in its 2012 World Malaria Report that malaria 

is strongly associated with poverty. Countries in which a larger 

percentage of the population lives in poverty also have a higher 

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mortality rate from malaria. Children living in poorer populations, 

and in rural areas, have the highest parasite prevalence rates. And 

it is also important to note, to the extent to which the prevalence 

of malaria is concentrated, 80 percent of malaria deaths occur in 

just 14 countries, and almost 80 percent of cases occur in 17 countries. 

Over 40 percent of malaria deaths occur in just two countries. 

The Democratic Republic of the Congo and Nigeria, and 40 percent 

of the malaria cases are in the Democratic Republic of the Congo, 

Nigeria, and in India. These high morbidity and mortality rates are 

not necessary. Malaria is both preventable and treatable. We will 

hear today from our distinguished witnesses who are leaders in the 

field about the cost-effective measures that are currently available 

and already having a profound impact or are in the development 

process. 

And the United States, despite the current financial constraint, 

is making a significant contribution to the global fight against malaria. In addition to our contribution to the Global Fund to Fight 

AIDS, Tuberculosis and Malaria, the United States provided $871 

million in anti-malaria assistance in Fiscal Year 2012 alone, and 

the request for Fiscal Year 2014 is $893 million. 

But these levels, even when combined with contributions from 

other donors, do fall short of the global need. So our question today 

will be, ‘‘What are the major challenges going forward and how can 

we best use our resources to meet those challenges to save the 

most lives and have the greatest impact in controlling, if not eradicating, this dreaded disease?’’

We will also be taking a close look at several immediate threats 

to global efforts to combat malaria. On April 23, this subcommittee 

held a hearing on ‘‘Meeting the Challenges of Drug-Resistant Diseases in Developing Countries.’’ In his testimony at our hearing, 

Dr. Thomas Friedman, director of the Centers for Disease Control 

and Prevention, warned that in recent years, malaria infections in 

parts of Southeast Asia have been showing resistance to 

artemisinin drugs. These drugs are the last remaining class of antimalarial drugs and form the basis of malaria treatment globally. 

If these resistant parasites manage to spread to sub-Saharan Africa, he stated that the results could be ‘‘devastating,’’ an assessment 

that will likely be repeated by our witnesses today. 

Insecticide-treated nets, bednets, which have an average useful 

life of 2 to 3 years are also an extremely important malaria prevention tool. According to WHO, 150 million nets are needed each and 

every year to provide protection to the vulnerable populations in 

sub-Saharan Africa. For the past 2 years, however, the supply has 

been considerably lower than this level, resulting in an estimated 

current shortfall of 77 million nets. The consequences, if not urgently addressed, could place entire populations, especially children, at risk of a dramatic malaria resurgence, and of course that 

means more death and more morbidity. 

We are fortunate again to have three distinguished experts who 

will provide us with valuable insights. These are truly leaders in 

this field. C–SPAN is here and we are grateful they are here. I 

would hope that Americans would sit up and take note of the extraordinary work you three individuals are doing. 

3

You know, people sometimes are very dismissive of foreign aid 

and initiatives that taxpayer funds are used for. This is one of the 

greatest success stories. It is not the only one, there are many, but 

this is one of the greatest success stories, but it is a work that remains unfinished. I thank our witnesses for being here and for 

being such leaders. 

I would like to now yield to Mr. Bera. 

Mr. BERA. Thank you, Chairman Smith, and thank you for holding today’s hearing and the series of hearings on global health, incredibly important topics, and I look at this from the perspective 

of being a doctor who has worked internationally, and the work 

that you guys are doing is incredibly important, and I look forward 

to hearing your testimony. 

You know, as has already been mentioned, there are over 219 

million cases of malaria worldwide. The Democratic Republic of the 

Congo, India, and Nigeria account for 40 percent of all malaria 

cases. Those cases account for over 600,000 deaths in 2010. Very 

preventable. So this is an incredibly important issue. 

Like so many other diseases, you know, with the right policy, 

with the right partnerships, we can save hundreds of thousands of 

lives. Unfortunately, far too often, these tools are not reaching 

those in need, and I am looking forward to hearing the testimony 

of best practices and how we get the therapies and the prevention 

and the nets out to those where we can make the biggest difference. 

You know, while malaria continues to take the lives of children 

and adults, you know, we also have seen the international community coming together and some great demonstrations of remarkable 

success. The Global Fund, the President’s Malaria Initiative, the 

Gates Foundation, the World Health Organization, just to name a 

few, have helped reduce unnecessary deaths in Africa by an estimated 33 percent in less than a decade. We can still do better. 

The fund has 779 active grants, 217 of which are for malaria. It has approved almost $7 billion or 27 percent of its funds in the 

fight against malaria. Since 2000, malaria mortality rates from 

fallen by more than 25 percent and 50 countries are on course to 

reduce malaria incidence by 75 percent by the end of 2015. These 

are efforts to be applauded. 

Again, I look forward to supporting and doing more. Chairman 

Smith has done an excellent job laying out the profound challenges 

that we face in fighting malaria. I would like to share with the 

committee just a couple of success stories over the course of testimony, and I certainly look forward to hearing the success stories 

and the best practices. 

In addition, you know, today we don’t have a vaccine that prevents someone from being infected with malaria, but I am here to 

say as a research scientist, as a physician, there is nothing that we 

can’t do in this country and in our academic community if we set 

our minds to it, and ultimately, that is where we need to go if we 

want to truly prevent disease and save lives. 

So thank you for being here, thank you for the testimony. You 

know, I look forward to hearing from each of you and, you know, 

again, Chairman Smith, thank you for calling this important hearing. 

4

Mr. SMITH. Thank you very much. I would like to now yield to 

Mr. Weber. 

Mr. WEBER. Thank you, Mr. Chairman. Very important topic. I 

appreciate the opportunity to be here and have this hearing. My 

dad, one of the last of the greatest generation, 88 years old, served 

in the Philippines, contracted malaria. To this day, he cannot give 

blood. He has the rarest blood type there is. Half a percent of 

America has AB negative, which is what I have, and now you know 

what is wrong with me. But just a great guy. I try to give blood 

as often as I can, and so it is very, very important, because that 

keeps those who contract the disease from giving blood. I think it 

is very vital, so I appreciate being here and looking forward to the 

testimony. Thank you. 

Mr. SMITH. Thank you very much, Mr. Weber. Just parenthetically, my father, too, served in World War II in New Guinea. He 

was a combat infantryman, and he got malaria, and my family was 

very well aware of the impact it had on him as well, so thank you. 

I would like to now yield to Mr. Cicilline. 

Mr. CICILLINE. Thank you, Chairman Smith, and thank you to 

you and Ranking Member Bass for holding today’s hearing on the 

role of the United States in the fight against malaria, and I want 

to thank my colleague and friend, Congressman Bera—Dr. Bera for 

his leadership on this issue and on issues of global health in general. This remains a serious worldwide public health emergency. 

The World Health Organization estimates that 219 million cases of 

malaria worldwide with 660,000 malaria deaths, so this is still an 

urgent, urgent issue. 

I want to begin by offering my gratitude to the witnesses not 

only for being here today and for your testimony, but for your incredible leadership in the work that you have led that is making 

a real difference all across the world as we combat this scourge of 

this disease. 

Our country, the United States, has a vested interest in addressing health conditions around the world in order to improve lives, 

to strengthen the economies of our trading partners, and to maintain our moral leadership position in the world. I think it is concerning to all of us that malaria remains a leading cause of death 

in many countries, especially when we have made such astonishing 

gains in health care here at home, and I hope that the United 

States will continue to support the funding of global health development as we transition to country ownership and eventually 

eradication of this disease and that we continue to value the work 

of the Global Fund to Fight AIDS, Tuberculosis and Malaria, the 

Gates Foundation, the President’s Malaria Initiative, and to just 

note that these are, as Chairman Smith said, great success stories 

of what our role around the world has been when we make the 

right kinds of investments, and these have been bipartisan efforts, 

and I know they will continue to be, and I thank the chairman 

again and yield back. 

Mr. SMITH. Thank you very much. I would like to yield to Mr. 

Meadows. 

Mr. MEADOWS. Thank you, Mr. Chairman, and thank you to each 

one of you for your service to our country. We appreciate it. We are 

here today to address a disease that has been a scourge on humanVerDate 0ct 09 2002 10:30 Sep 26, 2013 Jkt 000000 PO 00000 Frm 00008 Fmt 6633 Sfmt 6633 F:\WORK\_AGH\051713\80942 HFA PsN: SHIRL
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ity for almost our entire history. And as we have been fighting malaria for a very long time, it is encouraging to see how far we have 

come, but also what is left to be done, and so I look forward to your 

testimony today. 

We have seen malaria generally eradicated in the developed 

world and, but yet there is still a lot of work to do. As you know, 

some 80 percent of malaria deaths occur in just 14 countries, and 

as we see that, you know, 80 percent of the cases and 90 percent 

of the deaths occur in Africa, and we have learned over the past 

60 years that eradicating this disease is an ongoing challenge requiring multiple efforts working in concert and there is no magic 

bullet to do that. 

We heard testimony even in this very room in a hearing that the 

chairman conducted from the CDC offering some of the challenges 

that we face with different strains that are resistant to even the 

drugs that we have today, and so I am encouraged by Dr. Bera. We 

have teamed up on a number of bipartisan initiatives to try to 

work on finding some of those solutions, and so I look forward to 

hearing your testimony. 

I am proud of the role that the U.S. has played in this ongoing 

struggle. It has really been our leadership that has really worked 

very well, and I am mindful that that does not mean that we can 

advocate our duties to be good stewards of the taxpayers’ money either. And corruption cannot be tolerated in any manner. 

I have traveled a number of times to Africa, and when you start 

to see the lack of accountability in certain areas, it gives you great 

concern, and so part of the reason for holding this hearing is so 

that we remain vigilant in that we work against the bad actors 

that we have to deal with, but also that we encourage others and 

those that are suffering, certainly, that we come to their aid. 

This would include pressuring local governments and making 

sure that we have the encouragement there, not just from an oversight standpoint, but to make sure that what we do is that the 

American taxpayers’ dollars are invested wisely. When we do that, 

there is always a drawback. You know, when I go back home, there 

is a consistent call, ‘‘Why are we giving aid? We have people that 

are hungry and out of work here. Why are we doing that?’’ I would 

look for some of the testimony and really what it might do in terms 

of our men and women that serve in some of the things that we 

have in terms of challenges, not just from a global perspective, but 

as we bring that back home, and so I would look for each one of 

you to hopefully address that. 

You know, Fiscal Year 2014, we look at both in USAID and the 

CDC have both requested increases in their funding as we see that, 

and what I would love to see from you is how I can make sure that 

we put forth and share with the voters back home that not only 

are we being wise stewards, but that we are being accountable and 

we are doing the very best that we can to make our money go as 

far as we can. 

The growth of public/private partnerships, the encouragement 

there, some of the work that we have already seen there, I applaud 

that. You know, in recent years, we have seen, you know, the 

President’s Malaria Initiative, you know, working with the World 

6

Health Organization and other institutes using the Federal dollars 

to be leveraged in that private/public partnership in a real way. 

And so I just applaud you on the work you have done. I would 

love to hear and so we can share with those in these tight fiscal 

times how we are managing that properly and perhaps what we 

can do from an oversight standpoint to make sure that not only are 

we investing wisely but that those funds meet the real needs that 

are there. 

But I thank you, and with that I yield back, Mr. Chairman. 

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

Mr. Stockman. 

Mr. STOCKMAN. In the course of building a Panama Canal, as you 

probably recall from your history, they had to address first the 

health problems there, and when I was over at the Democratic Republic of the Congo, DRC, I think they have assumed the circumstances, some of the health issues are holding back their productivity and their production and GDP, but I believe that even the 

great expense they have made, they still need help in that area. 

When I was over there, I noticed they were selling some of their 

mosquito nets, so I am looking forward to your testimony to find 

out if there is alternatives ways besides just mosquito netting, and 

I appreciate all the efforts that you have done and continue to do 

on behalf of the United States, and I think this sends a large signal 

to the rest of the world, the compassion of the Americans, and I 

yield back my time, chairman. Thank you. 

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

I would like to now introduce to the panel our two first witnesses. Rear Admiral Tim Ziemer was appointed in June 2006 to 

lead the President’s Malaria Initiative, a $1.2 billion, 5-year initiative to control malaria in Africa, which was expanded through an 

authorization in the 2008 Lantos-Hyde Act. 

Admiral Ziemer was born in Iowa but raised in Asia, the son of 

missionary parents serving in Vietnam. After graduating from college, he joined the Navy, completed flight school and returned to 

Vietnam during the war. During his naval career, Admiral Ziemer 

commanded several squadrants and Naval stations in an air wing 

supporting the first Gulf War. 

Prior to his appointment at PMI, he served as executive director 

of World Relief, a humanitarian organization, and has had a distinguished stint as leader of the President’s Malaria Initiative. Those 

of us on this committee are very well aware of the great contributions you have made and the leadership you have provided. 

We will then hear from Colonel Peter Weina, who is assigned to 

the Walter Reed Army Institute of Research, where he serves as 

deputy commander. He leads many medical initiatives in the Army 

and his work has been published extensively in journals and books. 

Colonel Weina is a recognized expert on numerous diseases. He 

was the lead behind the availability and licensure of a life-saving 

drug for the treatment of severe malaria throughout the United 

States and Canada from 2002 to 2009, an effort that was recognized by CDC’s Silo Busters Collaborative Award of Excellence in 

2008. Among his many other impressive awards, he is the recipient 

of the Bronze Star for service in Iraq during Operation Iraqi Freedom. 

7

I would like to yield to Admiral Ziemer. 

STATEMENT OF REAR ADMIRAL TIM ZIEMER, U.S. GLOBAL 

MALARIA COORDINATOR, PRESIDENT’S MALARIA INITIATIVE 

Admiral ZIEMER. Chairman Smith, members of the committee, it 

is a pleasure to be back before you today. Before I begin my testimony, I would like to take a moment to acknowledge and express 

my appreciation for Congress’ ongoing and steadfast support for 

malaria control. The global fight is succeeding. Deaths have decreased by one-third with bipartisan support in Congress for both 

bilateral and multi-lateral efforts. Through the Malaria Initiative 

and the Global Fund, malaria is being rolled back. It is a triumph 

of partnership, all of us working together, the U.S. Government, 

our partners, host countries and the communities we are trying to 

serve. We simply would not be seeing the impact we are seeing 

today without your support and commitment. Thank you very 

much. 

The United States malaria program through the PMI continues 

to be a game changer. In the 7th year of the Initiative, the financial and technical contributions made by the United States Government are the major catalyst in the remarkable progress that has 

been achieved in many countries to reduce the devastating burden 

of malaria on child mortality. At the same time, with the U.S. Government support, countries are also strengthening their own capacity to fight this disease. 

PMI, at its very core, is an example of success and real impact 

that the United States Government can achieve through a solid 

interagency partnership. Through PMI, the core strength of both 

USAID and the Centers for Disease Control and indeed across the 

entire U.S. Government spectrum, Walter Reed, DOD and NIH, as 

well as the Peace Corps, it is a tremendous success story, yet it is 

still incomplete. 

I just returned from Uganda, and despite the recent progress, 

malaria remains the largest killer of children. In the midst of these 

tragic statistics, we have some good news. This year, with 21 million insecticide-treated bednets provided by the Global Fund, the 

U.S. Government, DFID, World Vision, and other partners, the 

Government of Uganda is poised to make real and substantial 

gains against malaria. 

Seeing children suffering from malaria, I am reminded of my 

childhood days in Vietnam. My parents, as was indicated in the 

opening statement, were missionaries there. I was fortunate to 

sleep under a bednet and yet I caught malaria. I was fortunate to 

have anti-malaria medicine to cure the disease. Every child in a 

malarious part of the world should be protected as I was. In the 

last 7 years, substantial reductions in mortality among children 

under 5 has dropped 16 to 50 percent in 12 of our original PMI 

countries. Although multiple factors may be influencing the decline 

in under 5 mortality rates, strong and growing evidence suggests 

that malaria prevention and treatment are playing a major role in 

these unprecedented reductions in mortality. 

PMI is participating in in-depth evaluations to ascertain the contribution of malaria control efforts to these reductions in mortality, 

with Tanzania being first country to complete this evaluation. 

8

63,000 lives have been saved over a 10-year period because of the 

scale-up of malaria interventions. 

In 2011, PMI commissioned an external evaluation team to review its performance. The evaluation affirmed that PMI’s planning, 

implementation, partnerships and funding have been key to the 

global efforts to combat malaria. The evaluation team made five 

policy and five technical recommendations that will guide programmatic improvements over the next years. PMI views these recommendations as relevant and useful for program improvement. 

We have come a very long way since the inception of the Global 

Fund in 2002 and the creation of PMI 3 years later when President 

Bush committed $1.2 billion for malaria control. 

The Initiative started with Tanzania, Uganda and Angola. Since 

then, 16 additional focus countries have been added with three 

non-focused countries. In addition to the bipartisan support of Congress, PMI benefited from the full support of President Bush and 

First Lady Laura Bush, and now the Obama administration. 

In 2010, President Obama launched his vision for how the 

United States would approach global development, which seized development assistance as a pillar for foreign policy, and is crucial to 

America’s national security and economic interests. 

In his 2013 State of the Union address, President Obama framed 

two goals, that the United States would join with our allies to 

eradicate extreme poverty in the next two decades, and saving the 

world’s children from preventable deaths. Malaria is a major cause 

of child mortality in Africa, and consequently, preventing and controlling malaria are a key focus of the U.S. Government foreign assistance program. PMI is playing a lead role in implementing the 

President’s vision. 

Partnership is the hallmark of how PMI does business. Partnership with host countries, other donors, the private sector, non-profits, and faith-based groups underpin our success. PMI has supported malaria activities through more than 200 non-profit organizations. Approximately one-third of those are faith-based. These 

groups often have strong and effective bases of operations in underserved rural areas where the burden of malaria is the greatest. 

The Global Fund and PMI’s commitment to effective coordination 

is maximizing our impact on the global malaria burden. Each program has its own unique strengths lending to the complementarity 

of the partnership and significant successes on the ground. Currently, all 19 PMI focused countries in Africa and the greater 

Mekong subregion receive substantial funding from the Global 

Fund. 

Because of the strength of our in-country technical staff, we support the effective implementation of Global Fund programs. While 

the risk of malaria is declining and more children are surviving, 

the gains are fragile and could be reversed without continued support. We recognize and appreciate the continued commitment of 

Congress and the American people to fighting malaria through PMI 

and the Global Fund in this time of budget austerity. The goal is 

to continue to shrink the malaria map and to ensure successes are 

not rolled back, even as the dual threats of artemisinin and drug 

resistance and insecticide resistance is growing. A strain of malaria, of the malaria parasite has appeared in parts of Southeast 

9

Asia with resistance to the most effective medicines to fight the 

parasite, and some fear that the parasite might ultimately become 

resistant to all drugs we currently have to treat malaria. 

The emergence of this resistant parasite to Africa would be devastating. We must also be diligent in identifying and monitoring 

mosquito resistance to insecticides so that our most effective prevention measures, insecticide-treated mosquito nets and indoor residual spraying aren’t undermined. If mosquitos become resistant 

to those insecticides, the efficacy of the interventions will be compromised. 

Tackling these new strategic challenges is a priority, and we are 

working with the private sector to develop new anti-malaria drugs 

as well as insecticide-based tools. At the same time, we must continue to expand our toolbox by developing a highly effective inexpensive vaccine that could result in hundreds of thousands of lives 

saved. 

So in closing, I would like to thank the U.S. Congress for its continued support and reiterate that together with our partners, we 

remain deeply committed to the global fight against malaria. 

Thank you, and I look forward to your questions. 

Mr. SMITH. Admiral Ziemer, thank you very much for your testimony and again for your leadership. 

[The prepared statement of Admiral Ziemer follows:]

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Mr. SMITH. We do have a vote, two votes on the floor, and I 

apologize for the inconvenience to our witnesses. We thought we 

would take a very brief recess, come back, and Colonel, then we 

will receive your testimony. We really do want to hear what you 

have to say. So the subcommittee stands in recess. 

[Recess.] 

Mr. SMITH. The subcommittee will resume its sitting, and Colonel Weina, if you could proceed with your testimony. 

STATEMENT OF COLONEL PETER J. WEINA, PH.D., M.D., DEPUTY COMMANDER, WALTER REED ARMY INSTITUTE OF RESEARCH, U.S. DEPARTMENT OF DEFENSE 

Colonel WEINA. Thank you, sir. Chairman Smith and distinguished members of the subcommittee, thank you for the opportunity to appear before you to discuss the Army’s medical research 

initiatives to improve soldier readiness and global health and highlight the incredible work of the military medical research community. 

I extend our appreciation to Congress for their support to military medicine faithfully given, which provides the resources we 

need to deliver leading edge health services and diligently continue 

innovative research. Malaria is a global agent scourge that has 

haunted mankind for much of our history, and yet it still impacts 

our lives in our society today. I know it has been said many times, 

but it bears repeating: Over 3.3 billion people remain at risk for 

the disease. Over 200 million cases of the disease appear every 

year along with over 650,000 deaths. 

Among the most vulnerable are the young children who account 

for over 85 percent of the malaria-related mortality globally. A preventable disease, malaria is a leading cause of death in children 

under 5 years old in sub-Saharan Africa. 

The U.S. military has also felt the threat of malaria as far back 

as 1775 when George Washington expended limited resources to 

purchase quinine for the treatment of malaria. Malaria has been 

diagnosed during the Civil War, World War II, Vietnam and even 

recently in Afghanistan. 

Historically, the incidents depends primarily on deployment location, but during the last 10 years, we have seen approximately 100 

cases every year, despite the resources we have to protect our 

troops. While the days of massive debilitating impact on malaria 

operations are behind us, we only have to look back to 2003 in 

order to appreciate the potential impact when a military peacekeeping operation in Liberia failed after only a few weeks due to 

80 cases of malaria in 225 Marines, 44 of those requiring medical 

evacuation. 

The destabilizing effects that diseases such as HIV/AIDS and 

malaria have on the critical infrastructure of developing nations is 

compelling evidence that global health is a means to global security. These diseases undermine the education and health systems, 

economic growth, micro-enterprises, policing and military capabilities, political legitimacy, family structures, and overall social cohesion. They undermine the stability of already weakened states and 

add to their vulnerability to extremists and terrorists who seek to 

corrupt or coerce. Our response, through medical engagement, 

21

needs to be comprehensive, fought at many levels, and on many 

fronts to provide for global stability and our own nation’s security. 

The Walter Reed Army Institute of Research has a trusted partnership in several countries that has been established for decades. 

Long-term relationships have been built with host countries as well 

as health organizations allowing both personnel and logistical support to establish larger work. 

We have been in partnership with the Royal Thai Army for over 

50 years, and with the Kenyan Medical Research Institute for over 

40 years. We have established robust relationships that have allowed the important work of military medicine’s research as well 

as the important work of PEPFAR and PMI. 

The U.S. military’s exceptional science, logistic and regulatory 

expertise allows for the testing of new products to the best standards of care for the local population as well as the delivery of critical life-saving HIV/AIDS and malaria interventions. 

Military medicine also serves as a partner in the critical platform 

of disease surveillance. Both the Army and Navy conduct oversees 

disease surveillance operations that not only keep a watchful eye 

on malaria patterns and malaria resistance throughout the world, 

but also survey for other infectious disease threats. These overseas 

operations are part of a complex ecosystem that provides not only 

surveillance, but also a platform for testing new products, medical 

engagement with many countries worldwide and outreach for the 

execution of PEPFAR and PMI missions and programs. 

Vigilance in combating malaria is an enduring mission. The U.S. 

military is engaged in malaria research for several key reasons, to 

preserve the fighting strength of our men and women in uniform 

who go into harm’s way, to protect our Nation’s citizens who encounter these threats worldwide, and to positively impact the global health and stability of our allies. 

In closing, I am proud of the global impact that military medicine 

research has done throughout history and the continued diligence 

being done to combat one of the oldest infectious disease threats 

man has known. In partnership with the Department of Defense, 

my colleagues here today, our global partnerships and the Congress, we will be prepared for tomorrow’s challenges. Thank you for 

your time. 

Mr. SMITH. Colonel, thank you very much for your leadership 

and for your testimony today. 

[The prepared statement of Colonel Weina follows:]

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Mr. SMITH. Just to lead off the questioning, let me start off with 

a question to Admiral Ziemer. You mentioned about one-third of 

the NGOs that are getting assistance happen to be faith-based. 

One of the concerns that I have expressed from the very beginning, 

both with PEPFAR and malaria and every other U.S. foreign aid 

program, especially as it relates to Africa, has been the early exclusion of faith-based organizations, primarily because of ideological 

reasons, but there appears to be, and I think there has been good 

strong support for them. I actually wrote the conscience clause for 

the PEPFAR program because of that exclusion. 

If you could just elaborate a bit on how essential indigenous 

faith-based groups are being included. If we want to end the pandemic of HIV/AIDS, it seems to me, and TB, the problems associated there, and the malaria problem, we need to have as partners 

those faith-based groups. If you could touch on that. 

Admiral ZIEMER. Thanks for the questions. When PMI was 

launched, one of the first things we did was to look at the best 

practices of PEPFAR and model some of our programmatics after 

the PEPFAR model. So, to the extent there were clear guidances 

coming from here and from the administration, we looked at them 

and embraced them. But I can tell you from the beginning of PMI, 

we intentionally looked at a deliberate engagement of the NGOs in 

the field, specifically looked at the merits of the faith-based organizations because we acknowledged, and from personal experience, 

accepted the fact that they were there before we got there, and 

they will be there after we go. And when we start embracing capacity building and sustainability of programs, the local NGOs, specifically the faith based, are a huge component of building for the future. 

Mr. SMITH. I appreciate that. You know, the impact on childhood 

cognitive development, we know that obviously our goal is to eradicate malaria and to prevent deaths, but also to mitigate morbidity 

and other consequences like impact on cognitive development. Is 

the timeliness of the intervention key? I chair the Lyme Disease 

Caucus here in the House and have a bill pending that I hope will 

get brought up on establishing a blue ribbon commission on lyme 

disease, particularly chronic lyme. The longer the parasite grows 

inside an individual, the worse its deleterious effects. I am wondering, you know, the issue of how this mal-affects children as they 

become adolescents, adults and right on through the rest of their 

life. 

Admiral ZIEMER. You are asking a rather technical question, and 

I would defer that to some of our scientists and colleagues when 

it comes to the impact or the delayed impact of delayed parasite 

clearance from a system. I do know that we have a very rigorous 

prenatal program, so that when pregnant women go into the clinics, we are providing preventative treatment. So in terms of the 

health of the newborn child, it is being addressed through that prevention measure, but when a child presents with a fever, we are 

committed to appropriate diagnosis and then treatment. So at an 

early age, if the child presents and is diagnosed with a fever, we 

do everything we can to provide treatment. 

Mr. SMITH. In his testimony, Ambassador Dybul, the executive 

director of the Global Fund, points out that between 2004 and 2010 

29

the need, the coverage need, the level of need was essentially met, 

but only 92 million nets were delivered by manufacturers in 2011, 

largely due to funding constraints, and in 2012, only 66 million 

nets were produced. He points out that in February of this year, 

the Global Fund and WHO and other partners, I am sure that includes you and us, the United States, estimated that 77 million 

nets were needed to maintain coverage for communities that the 

Global Fund has previously protected. 

He also talks about the big push to replace insecticide-treated 

nets and its new, interim funding grant stream, along with fostering diagnostic and treatment needs, and bottom line, that between 2013 and 2015 there is a $3.5 billion gap. Now, I know the 

United States has been generous. It has been the leader. Is there 

more that we could be doing? I mean, can we, Congress, be partners in ensuring that that gap is closed? 

Admiral ZIEMER. The fact that we know what the gap is and we 

can have these numbers, represents information that we didn’t 

have 5 years ago. 

Mr. SMITH. Right. 

Admiral ZIEMER. So as we look at supporting the country’s requirements, we are able to refine the net requirements, and then 

collectively discuss at the funding level, the partner level, and at 

the national level how best to direct those resources. I think it is 

important to acknowledge that since 2008 and 2009, our partners, 

along with the United States, have distributed over 300 million 

bednets to sub-Saharan Africa, which represents coverage to close 

to 600 million people. I think the figure is 578 million. So we are 

making tremendous progress. 

As we look at those at risk, I think it is important to look at the 

full toolkit that we have. Four of the interventions that we use are 

focused on prevention. Bednets, of course, is one, along with indoor 

residual spraying. We are looking at country requirements, the 

most at risk population groups, and moving forward with the funding that we have. So, are there gaps? You bet. Are we dealing with 

them better? Yes. We just have to keep at it. 

Mr. SMITH. And if you could help us—I mean, we want to be advocates. I certainly personally want to make sure that all that can 

be done is done. I thought that again Ambassador Dybul makes an 

excellent point. Either progress is made or we lose momentum. The 

reality is invest now or pay forever, which is a very strong and I 

think a very declarative statement that we could make a difference, 

but funding is key, and obviously deploying those resources prudently is key. 

Colonel, if I could just ask you, your written testimony goes into 

some great length, thank you for your oral testimony as well. You 

point out that the Walter Reed Army Institute of Research, along 

with a pharmaceutical company, has developed what is currently 

the world’s leading malaria vaccine candidate. You point out that 

the product is currently in Phase III clinical trials in Africa, if you 

maybe would touch on where in Africa. Is it Kenya where we have 

the lab? And the medical research collaboration, and how close are 

we to, you know, actually developing a vaccine that is deployable? 

Colonel WEINA. Yes, Chairman Smith, the question of partnering 

with a drug company, we do partner all of the time with some sort 

30

of commercial entity to make sure that our products go forward. 

None of the products that we actually produced are things that are 

necessarily borne strictly by the United States to move forward. 

The question of where this work is being done, it is the Phase 

III trial is principally being done in Kenya right now where we 

have our laboratory. This work has moved forward significantly, 

but of course, the question of when are we going to have a vaccine 

is really tied up in some very significant details. 

First of all, the vaccine that we have right now is not a vaccine 

that absolutely protects an individual from getting malaria. The 

great thing about this vaccine, and this is why it is being pursued 

principally in Africa, is the fact that it reduces the mortality associated with the disease. This vaccine, just like a lot of other vaccines 

that we are having difficulties with, such as HIV, are things in 

which they don’t naturally occur in nature. We don’t have a situation like we have, for example, with chickenpox in which maybe 

somebody gets chickenpox and then they aren’t going to get chickenpox again. Those vaccines are the easy ones. Those are the ones 

that have already been developed. 

What we are trying to do is actually develop a vaccine for a condition that doesn’t occur in nature, so it is a lot tougher to do. 

What we have been able to mimic is the fact that children that 

have repeatedly gotten malaria are at lower risk of dying from malaria than individuals that may get it the first time. And this is a 

real success. It helps reduce the mortality, and it produces some information for us and possibly moving forward into a vaccine that 

does have significantly more efficacy and something that may actually prevent somebody from getting infected. 

Mr. SMITH. Let me ask you, Colonel, if I could. You point out that 

funding for malaria research and development in the military has 

been suffering since Vietnam. You talk about how you have worked 

very creatively, partnering with others, to try to lessen the impact 

of that diminished funding, and I think $10 million is what you 

have in use for research. 

You also point out that resistance is a fact of drug development 

in even the most cautious of drugs. Organisms we are fighting will 

always find a way to defeat our treatments, which is a very ominous statement and a very disconcerting statement. And we know 

in some four countries in Southeast Asia, Dr. Friedman was very 

emphatic on that when he appeared before our committee just a 

few weeks ago, there is concerns about drug resistance to 

artemisinin. Could you speak to that issue of drug resistance and 

also that budget for research? What would more money enable you 

to do, if it were to be available above the $10 million? 

Colonel WEINA. Yes, sir. The issue of resistance is something that 

we deal with not just with for malaria but for a lot of diseases. The 

malarial parasite is a very ingenious organism that is actually, I 

guess, just trying to survive, and we are constantly trying to beat 

it down. It has found a way of practically defeating every single 

drug that we have produced all the way back to something that we 

have been using like quinine for over 300 years. All of the new 

drugs that are out there, Mefloquine, Fansidar, all of these types 

of drugs, Malarone even, there is resistance. And our biggest tool 

31

in our arsenal right now are the artemisinins, artemisinin-based 

drugs. 

We are seeing an increase in the potential for resistance in 

Southeast Asia, particularly along the Thai-Cambodian border 

where we have seen a lot of resistance arise, and we are going to—

every single time we produce a new drug, these organisms are 

going to find a way around it, and that is why we need to have continued vigilance. That is why every single anti-malarial that has 

basically come out since World War II has had the involvement of 

the Walter Reed Army Institute of Research because of the fact 

that we have continually worked on it virtually our entire existence 

looking at a new drug. So every time we have a new one that is 

out there, we don’t stop and celebrate that we have the new one. 

We are actually looking for yet the next one that is out there, and 

we have a full pipeline of drugs that are being developed and looking for yet that next generation because we know we are going to 

have resistance, and there is no way of actually stopping that from 

moving forward. 

As far as the budget, I think everybody would just love to have 

more money. There are limited resources that are going to be available. I think what we would like to have more so than anything 

else is just to continue to get the money that we have been POM’d 

and that allows us to do the planning that is really necessary to 

move forward with our partnerships because our people are very 

entrepreneurial. And whatever investment that the U.S. taxpayer 

puts into developing these drugs, we are able to partner with private organizations, with academia, with other governmental organizations and really move the goal forward by bringing those types 

of partnerships together in this ecosystem that increases every single dollar three, four, five times and increase our budget to move 

things forward. 

Mr. SMITH. I think Americans should be concerned just because 

we are our brothers’ and sisters’ keeper, and that is what this program is built on, but there is the possibility, as you pointed out, 

of malaria being reintroduced into the United States. It is something I never read in the history books, and we talked about the 

Civil War. You point out, in the 1860s, the Civil War saw 50 percent of the Caucasian troops and a staggering 80 percent of the 

Black troops contracting malaria annually. That is extraordinary. 

And that is information that I think just underscores—we had it 

here. It is gone. Now we have to hope and pray and work hard to 

see that it will soon be eradicated in Africa and everywhere else 

that it is. 

Mr. Bera. 

Mr. BERA. Thank you, Chairman Smith. 

I think the American public, if you are out there watching, you 

can be very proud of what we have been able to accomplish and the 

reflection of our values as a Nation, you know the compassion, the 

humanitarian commitment to eradicating malaria; to the wonderful 

work that, Admiral Ziemer and Colonel Weina, you guys have been 

doing; and the fact that this is a real bipartisan effort. The President’s Malaria Initiative started under a Republican President and 

it has continued under a Democratic President. The leadership 

demonstrated on this committee and the commitment to compasVerDate 0ct 09 2002 10:30 Sep 26, 2013 Jkt 000000 PO 00000 Frm 00035 Fmt 6633 Sfmt 6633 F:\WORK\_AGH\051713\80942 HFA PsN: SHIRL
32

sionate and humanitarian need in eradicating some of the toughest 

diseases in the world, this is something that we can be proud of 

as an institution and as a country and Nation. 

I look at this from the perspective of being a doctor. And the first 

course of medicine is always to try to focus on prevention of disease. If you can prevent it, then you don’t have to treat it. And we 

are making strides. And when we think about prevention of malaria, we think about, obviously, nets and preventing the mosquito 

bites. We also look at the public health measures that we can do—

you know, pools of water, et cetera—and educating the population 

where malaria’s endemic. 

Chairman Smith touched on the cornerstone of prevention in 

fighting infectious disease, which is vaccination. And if our goal is 

eradication, we really do have to focus on finding a vaccine. 

Colonel, as you pointed out, malaria is a very smart challenge, 

and it is a smart parasite that has continually adapted. And yes, 

we are going to have to continue investing in the next generation 

of therapy. But until we can come up with an effective vaccine, it 

will be very difficult to eradicate. 

I think you talked about where we are on the vaccination side. 

And I would just reiterate our commitment and my commitment, 

as a physician and a Member of Congress, to continue to fight for 

that research funding until we do get that vaccine. 

You touched on the importance of partnership, and we do live in 

tight fiscal times. We do have a debt challenge here in this Nation, 

and we are forever grateful for individuals like Bill and Melinda 

Gates, who have stepped up philanthropically and have poured literally millions of dollars—billions of dollars into the fight to eradicate malaria. 

To either one of you, I would love to hear what you think are 

best practices in partnership, the role of the philanthropic and 

NGO community in helping us eradicate malaria or at least hold 

it down and continue to make progress. And then the role in terms 

of capacity building in Africa, India, you know, countries that are 

affected by malaria. So whoever wants to take that question. 

Admiral ZIEMER. Thanks for that question. 

Let me just address a couple of points. The USAID has been investing in vaccine research for over 40 years. So it is a high priority, and we will continue to focus in on that for the reasons you 

have stated. On the prevention side, I am pleased to say, of the 

four interventions that we used, WHO approved, three are prevention. And then we are scaling up case management, diagnosis, and 

then proper treatment. So as we continue to work with the countries, our focus is truly on the prevention side. 

Our partnership in this austere time is actually very critical. And 

I am really pleased to report that we are seeing significant 

progress made at every level. On the partnership advocacy piece, 

the work with the U.N. Special Envoy, Malaria No More, the U.N. 

Foundation, Nothing But Nets, the celebrities, as well as the athletes are informing the American public about this disease. And 

there has been a wonderful response collectively, as American citizens, to do something about that. So that is on the advocacy side. 

On the technical side, the fact that the Gates Foundation is totally invested on the high tech end and the governments and the 

33

multilaterals are invested on the country side, we have a global 

malaria vision and plan to bring those two together. And so, again, 

over the last 4 years, we have something that we never have had 

before, and that is a vision, a strategy and places for countries, donors, research folks to plug in to move us toward control, elimination and eradication. 

One of the most important partners we have is the private sector. And we can showcase and give you more details. But let me 

just give you three examples: In Western Ghana, we are partnering 

with Ashanti gold through IRS. They are also funded by the Global 

Fund, the national government, as well as the U.S. Government in 

looking at best practices and scaling up IRS. 

In Zambia, we are working with the copper mine companies to 

do the same thing. So let me just stop there. Oh, ExxonMobil is 

working with us in Angola and their contributions directly into the 

program have been $4.5 million just for nets and the scale-up of 

events. So we can give you multiple examples of how we are seeing 

the partnership not only on the advocacy side but in the planning 

and visioning as well as in the implementation side. I hope that is 

helpful. 

Mr. BERA. Very helpful. 

Colonel WEINA. Yes. 

Dr. Bera, the idea of partnerships is absolutely critical when it 

comes to combating any disease and especially something that is as 

broad and as widespread as malaria is. 

I describe it as an ecosystem. And when one part of an ecosystem 

suffers, then the entire part of the system suffers. But there is also 

strength in that ecosystem so that when one part suffers, the other 

parts can help them out. The partnerships are critical and the 

partnerships come at many different levels. There are the publicprivate partnerships. But there are also our partnerships with the 

overseas laboratories in which we have in Thailand and in Kenya, 

Egypt, and Peru. Some of them have been in existence for over 50 

years. These partnerships are not just to provide us a platform for 

surveillance and for testing new products, but it is also a way of 

capacity building so that we can also pass on what we have learned 

and also learn from our partners. In most of these overseas laboratories, a majority of the people that are working there are local nationals. And there really is a trust relationship that is built up. 

Some of the people having been associated with that partnership 

for over 50 years. And there are strengths and weaknesses that 

each of the partners bring. And the more we talk to each other, the 

more we interact with each other, the more we learn where we can 

make a real difference. I know that we execute quite a bit of PMI 

funds. We execute quite a bit of PEPFAR funds at some of our 

overseas laboratories. And it is not just the laboratories. Those laboratories actually are a jump-off point for work in other countries 

as well. And it is not just a logistic aspect like that, but it is also 

a scientific aspect. We have learned a tremendous amount from the 

work that is being done with the HIV vaccine as well as the HIV 

vaccine finding, learning a tremendous amount from the work that 

is being done with malaria. So there are scientific interactions and 

partnerships that are done across diseases as well as all of the logistic work that I have just talked about. 

34

Mr. BERA. It sounds like this is a remarkable partnership, public-private advocacy. Is there anything that this institution, that we 

can do here as men and women in Congress to help continue to facilitate this partnership? Or is there anything—obviously the law 

of unintended consequences sometimes hinders partnership. Is 

there anything that you would want us to do outside of increasing 

research funding? 

Admiral ZIEMER. The fact that you are calling for an update and 

having this hearing to support this U.S. Government foreign assistance program is evident to our global partners and the countries 

that we are working with. There isn’t an opportunity that goes by 

where I don’t pay tribute to the leadership, the bipartisan support 

of this Congress. It is critical. We need to political leadership and 

we need the funding. Everybody understands the constraints that 

we are currently under. 

So our pledge is that the funding that is appropriated to this program and our other health programs we are going to do everything 

we can to be transparent, accountable, and deliver impact that will 

convince the American people that their tax dollars are being wisely invested. When we show results, it is really kind of a no-brainer. 

They are going to say, I wish more money was going into programs 

like this. I hear it all the time. 

Mr. BERA. Great. Thank you. We will bring some of that commonsense approach here to Congress as well. 

Mr. SMITH. Thank you very much. 

The vice chairman. Mr. Weber. 

Mr. WEBER. Well thank you, Mr. Chairman. 

A couple of questions for you: Of course you guys started with 

the valiant men and women overseas. What is the incidence of 

cases of malaria in our own armed forces? Is that up, down? Can 

you give me kind of a breakdown? 

Colonel WEINA. Well, sir, we still suffer from malaria even 

though we have these interventions, principally because we do 

have troops that are going to be operating in areas in which they 

may not have expected to run into malaria. So they may not be on 

prophylaxis or it may be in the fog of war, if you will, in which they 

don’t have opportunities to protect themselves with the bednets. 

We have done interventions though that may help drive the numbers down. As I said in my testimony, we have maybe 100 cases 

per year, yet that are still bothering us in the military. And we 

would sure like that to be down as close to zero as possible. 

So some of the things that we could do are to intervene where 

we don’t necessarily have to have the soldier involvement in it. A 

vaccine would be absolutely wonderful. But, in the meantime, we 

have situations in which, for example, the Army and the Marines 

now all of our battle dress uniforms are permethrin-treated from 

the factory. And that is a true improvement because now the individuals don’t have to think about an intervention themselves. It is 

already there. Those types of efforts are going to help drive them 

down. It sure would be nice to have zero cases and not have to 

worry about malaria intervening like it did in 2003 in Liberia. But 

that is something we need to continually plan for and think about 

in the back of our minds. 

35

Mr. WEBER. Well, thank you for that, Colonel. I wasn’t here during the testimony. It turns out I don’t walk as fast as the chairman 

does. So I apologize if this is redundant. 

Malaria was pretty much eliminated in India, as I understand it, 

but now it is starting to come back. Speak to that if you would. 

Why is that? 

Colonel WEINA. Yes. In India, in the 1960s, it was virtually eliminated from the entire subcontinent. Today they have actually increased the number of cases potentially up to 200,000 deaths per 

year. And it is fairly widespread. I have recently, over the last 

number of years, traveled in India to about 20 different cities. And 

from the rain forest all the way to the deserts, you can see patients 

lined up with malaria, and it is having a true impact. 

The reasons for that are pretty much the same reasons that we 

should remain vigilant and do remain vigilant here in the United 

States. We have a susceptible population. We have the vector 

present—the mosquito that can carry malaria—present throughout 

the United States just like they did in India. And all it takes is the 

reintroduction of the infection into the population and into the mosquito population without an adequate response. We have been very 

fortunate that the CDC keeps a very, very close eye on this and 

has prevented any small outbreaks from becoming big ones like it 

has in India. But we remain vulnerable as long as there is malaria 

anywhere in the world. Certainly all it takes is somebody getting 

on a plane and 8, 10 hours later to be at one of our borders and 

potentially bring the disease back home. 

Mr. WEBER. Okay. Thank you, Mr. Chairman. 

I yield back. 

Mr. SMITH. Thank you very much. Mr. Meadows. 

Mr. MEADOWS. Thank you, Mr. Chairman. 

And thank you both. 

Admiral, thank you so much for being so candid with regards to 

your fiscal oversight and understanding the demands of where we 

are today. But also knowing that as a wise steward of that money, 

I take you at your word but also see it in your passion in your eyes 

that you are willing to invest that wisely. And I just want to say 

thank you, not on behalf of Congress but on behalf of the American 

people for doing that. 

I want to go on a little bit further and let’s talk about the dangers to our men and women in service. 

Colonel, if you could speak to that because really, when it gets 

down to funding, most people are only concerned about providing 

funding if it affects them. And that is a sad commentary, but that 

is the truth, the truth of the matter. 

So what I would like for you to do is help the folks back home 

understand, one, why do we need to be investing these dollars? 

What are the dangers to family members that may be serving overseas? And perhaps talk a little bit about the reintroduction into 

some of these areas that we felt like were malaria-free, but now we 

are seeing that it has come back. Because, as you say, we are in 

a global, transient world now. So one disease in Vietnam showing 

up in America is just a few hours away. So if you could comment 

on that, please, Colonel. 

36

Colonel WEINA. Yes, sir. So the threat to our military, to our men 

and women that are serving in the uniform of our country is very 

much dependent upon where they happen to be doing it, where 

they happen to be serving at the time. If they are in an area, say 

in Iraq, we found that there was very little malaria, if any at all. 

And we really didn’t have much of a problem with malaria there. 

Certainly we do have a problem with it though in places like Afghanistan and in other areas in which we may be providing peacekeeping missions, for example, in Africa, in which there is a tremendous amount of transmission. As I have said, the disease, the 

parasite is very smart. No matter what we produce, no matter 

what we come up with, be it an insecticide or a drug, it is going 

to figure out a way to work around this and actually——

Mr. MEADOWS. So what you are saying is it mutates and changes 

enough where it can go against the technology that we have. 

Colonel WEINA. Yes, sir. So we need to continually take a look 

at this. The reason it is important though and the reason we talk 

about global health is because—one reason is that as we work on 

these solutions for our soldiers, it has got a much broader impact 

and it has got a much broader unintended consequence of being 

able to help other individuals that have malaria. But on the other 

hand, if we reduce the amount of malaria and other infectious disease threats worldwide, our soldiers serving in these areas are 

going to be at reduced risk as well and also the issue of making 

sure that we invest in decreasing the destabilizing effects of these 

particular diseases so that maybe we don’t have to have soldiers 

there in the first place because they are not unstable areas because 

of the fact that their health is better. 

Mr. MEADOWS. And so what you are saying is, part of the unrest 

is not just economic. It is health-generated, is that right? 

Colonel WEINA. Well, health has an impact on the economy. If 

you are sick with malaria, you can’t work. If you can’t work, you 

can’t provide for your family. And there is this vicious cycle that 

happens. While we may not think about health as the very first 

thing in an unstable country, health certainly has some impact in 

the background. We just have to trace back to where that is. If you 

are able to work, I think most people want to work no matter 

where they are in the world. 

Mr. MEADOWS. Right. Let’s go back to this partnership that has 

been alluded to with both the pharmaceutical companies, with 

CDC, with NIH. Who takes the lead? How do we make sure that 

we are charging—you know in our military we have rank. So we 

know who we follow. In these partnerships, it becomes much more 

problematic to see who is taking the lead and who is making decisions. What are some of the successes there? And perhaps if you 

care to comment, what are some of the barriers to that? 

Admiral ZIEMER. Speaking from the PMI perspective, I appreciate the question a lot. But if you go back to the Lantos-Hyde bill, 

you will see that there were specific authorities and responsibilities 

given to how the program was to be established and run and managed and report back to you. 

Mr. MEADOWS. And are we following that? 

Admiral ZIEMER. Yes, sir, we are. And I would venture to say 

that that is one of the key reasons for the successes and the 

37

progress that we are making. There are clear lines of authority and 

responsibility. And it also encourages and enables us to have an effective interagency, collaborative, functioning program. So I would 

commend a review of that simple governance concept as we ask the 

question about partnership. 

Mr. MEADOWS. So you are saying it is a success? 

Admiral ZIEMER. In my view yes, sir. 

Mr. MEADOWS. So we need to repeat it throughout all other areas 

of Congress is what you are saying? 

Admiral ZIEMER. I would say it is a good reference depending on 

what outcome is desired. 

But on the global level, it is much more difficult. And there are 

collaborative bodies at WHO, partnerships, Stop TB, the Roll Back 

Malaria Partnership. At the Roll Back Malaria Partnership—which 

is meeting right now and I am skipping it because I am here—the 

Gates Foundation, the U.N. Foundation, Malaria No More, multiple private sectors, the pharmaceuticals are there, the countries, 

the endemic countries, Asia, Latin America, and Africa are there 

along with the major funders, the Global Fund, the UK, and the 

U.S. Government. We are looking at the global challenge, looking 

at the plan, and having discussions about how we work together 

on a global partnership to move toward control, elimination, and 

one day eradication. So there are different mechanisms depending 

on where we are to enhance and to develop these partnerships. 

I would like to say that over the 6 years that I have been in this 

job, that program, those mechanisms have continued to mature and 

become more professional. And I spend my time by going to them 

because I think it is worth it, and we are able to influence and provide technical as well as programmatic leadership to achieve common ends. 

Mr. MEADOWS. And you would agree with that, Colonel? 

Colonel WEINA. I would. From the standpoint of being in the 

military, of course, we do what we are told. I would like to think 

we are very good at doing what we are told and making the best 

with what we have. So the partnerships have been very good. 

Mr. MEADOWS. Do I have time for just two more questions, Mr. 

Chairman? 

Mr. SMITH. Yes, sir. 

Mr. MEADOWS. I wanted to follow up with that then. 

From a legislative standpoint, you outlined some of the things 

that were good. And I am not asking you—unless you had something on the forefront of your mind, to speak to this. But I would 

love to see if there is anything legislatively—tweaks, reporting, accountability—that we could provide to, you know, follow under the 

chairman’s leadership to address by Congress. Is there anything 

that comes to mind? And if not, if you could have your staff work 

on that and report back to the committee. 

Admiral ZIEMER. Sir, I think that is a great question. I would 

like to come back to you with the specifics, depending on what you 

would find helpful as you look forward to fulfilling your responsibilities. But I think it is worth time to continue looking at that. And 

we will get back to you, sir. 

Mr. MEADOWS. And then my last question. It really gets back—

I think we are in clinical trials, in the third clinical trials in terms 

38

of a vaccine. And having seen that, that is a hopeful sign if we are 

getting to stage three clinical trials. My question is, how do we look 

at the severity? Because I think you mentioned in your testimony 

the severity of those. They are 5 months to 17 months old. How do 

we measure quantifiably the success of that? I mean it is very difficult when we have children to figure out, you know, if pain is on 

a scale of 1 to 10 because they won’t rate it out. How are we doing 

that? 

Colonel WEINA. One of the ways of assessing severity when it 

comes to malaria is actually pretty simple because severe malaria 

is a disease—although we have very uniform and very stringent 

criteria that we need to follow, I think it is real simple. If you can’t 

take water, if you can’t swallow things, if you can’t take a pill to 

treat the malaria and you need an IV treatment, that is pretty severe malaria. And the outcome measure is unfortunately very easy 

to measure, and that is death because once they start down that 

circle of having severe malaria, it takes some extraordinary measures——

Mr. MEADOWS. So primarily through dehydration or——

Colonel WEINA. There are a number of different mechanisms. 

Sometimes through pulmonary malaria, sometimes through cerebral malaria, there are a variety of different ways. But typically 

with children, it is because of anemia. 

Mr. MEADOWS. I thank the chair’s indulgence. I would also ask 

if you could for the record address if there are any 

nanotechnologies that we are using in terms of clothing, netting, 

and so forth that might be out there or at least hopes in terms of 

future research, in terms of nanotechnology. 

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

Mr. SMITH. I thank the gentleman. 

Mr. Stockman. 

Mr. STOCKMAN. Thank you. 

I don’t know who could answer this question. But I think I was 

watching Frontline or one of those shows. And they talked about 

the Chinese counterfeiting malaria medication and how that impacts and creates resistance to malaria. And that is kind of a big 

elephant in the room. As we are spending millions, in some cases 

hundreds of millions of dollars developing a new drug, they are out 

there emulating and making fake copies of it. And as you take the 

pill and you stop taking it, of course, that is how the resistance 

builds. I guess I am asking, have you guys addressed that issue on 

how to stop the counterfeit? 

Admiral ZIEMER. Sir, it is a global issue. It has a lot of visibility 

and attention. I know it is a priority for the State Department 

right now. It is a matter that we are very concerned about because 

people that are sick with malaria taking counterfeit, fake, or unsafe drugs are going to continue to get sick and die. So it is not 

only a health issue, but it does beat resistance, and it really is a 

concern to us in terms of how it manifests itself in the resistance 

of the parasite. 

But on the criminal side, it is a high priority, and we are working with our governments and criminal agencies to take appropriate action. But we have got to stay at it at multiple levels, diploVerDate 0ct 09 2002 10:30 Sep 26, 2013 Jkt 000000 PO 00000 Frm 00042 Fmt 6633 Sfmt 6633 F:\WORK\_AGH\051713\80942 HFA PsN: SHIRL
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matic, technical, and at the country level, where these drugs are 

being regulated, are not regulated, purchased, and distributed. 

Colonel WEINA. There are actually two issues with that particular question, sir. One of them has to do with actually counterfeit ones in which they are trying to sell them for other manufactured ones so that they look the same. Typically they don’t just put 

sugar pills in. Typically what they do is they add just enough of 

the drug there, so if somebody were to test it, they would detect 

a level of drug. 

Mr. STOCKMAN. That is even worse, too. 

Colonel WEINA. And that is even worse because what it does is 

it feeds into providing a low level exposure of that drug to the 

parasite so it kind of helps them learn how to become resistant. So 

that is a problem. But there is also a problem of poor quality drugs. 

And one of the hallmarks and one of the reasons why people love 

the U.S. medical machine, if you will, is because of the fact that 

we have good quality products that are available, manufactured 

under good manufacturing practices and tested under good clinical 

practices. And quite often, we compete with other countries that 

may produce a drug under different standards. They can sell it for 

a cheaper amount and, therefore, it becomes used. So quite often 

what happens is that we need to make sure that we look at, for 

example, the technical ways and the legislative ways and the diplomatic ways of making sure that we are using not just good quality 

drugs and that everybody is kind of following the same standards 

when it comes to that but also trying to make sure that we ferret 

out and get rid of these counterfeit drugs. 

Mr. STOCKMAN. The implication in the program was is that there 

is a staggering amount of fake drugs out there. Do you have any 

way of quantifying how much is fake and how much—I mean do 

you guys ever sample it? Because they showed a package and you 

couldn’t tell the difference. It was stunning. And it looked like an 

American-produced product. But they are implying that there was 

a lot of it out there. Is that quantifiable? Do you guys trace that? 

Colonel WEINA. We aren’t ourselves particularly following that. 

But there are a number of different organizations that take this on 

and really do a wonderful job of finding out exactly how much is 

out there. It is worthwhile for them because instead of the $60 that 

they could reap for it, it may only cost them pennies to make it. 

So they get quite a bit of profit as opposed to ours. 

Mr. STOCKMAN. Do you know who those folks are so we can have 

them before our committee? I feel like what we are doing is we are 

competing against ourselves. We are throwing millions of dollars, 

which is what we want to do because we want to save lives, but 

at the same time if somebody is in the boat drilling holes, it would 

be nice to stop that person from drilling holes. So if you have some 

experts and if you could get with the chairman and let us know, 

I would love to hear their testimony on exactly how big this problem is because if we constantly are competing against ourselves 

trying to produce new stuff, and then they emulate it and then, 

like you said, the organ gets a little bit of it and adjusts again, 

then we will be in a never-ending—we are chasing our tail. But do 

you know the individuals that would have that information? 

40

Colonel WEINA. I don’t have that information right in front of me 

at this moment. But I do know that there are several—again, several organizations that are following that quite closely and there 

are congresses that meet, international congresses because this is 

an international problem. It is not just here in the United States. 

And they follow this very closely. They try and track down where 

these are. But finding the actual individuals or the actual country 

that is producing it has proven quite illusive. 

Admiral ZIEMER. We do have some information. But I think what 

I would like to do is go back, look at our files and then get back 

to you specifically to make sure we can answer the questions that 

you have and share what we have. Okay. 

Mr. STOCKMAN. I am trying to remember. I think the show was 

‘‘Malaria.’’ It was really fascinating. I can’t remember. 

The other question I have, if I may, we eliminated malaria here 

and a lot of us see the film clips of it, how we eliminate it. And 

no one ever wants to talk about it. But it was very effective. It was 

how it was eliminated in India and a lot of places around the 

world. 

And now with atomizing our DDT, you cannot have the impact 

on the environment that we had in the 1950s. And I remember you 

see the film clips of kids just covered with DDT. My brother was 

one of them, and he turned out, I think, fairly normal. He might 

disagree politically at times. But he is okay. And then I see the sacrifice. I know we have to trade off a balance. 

But your heart goes out to these young kids who don’t have the 

same protection we had. And I don’t know if there is really a tradeoff where we should maybe—because of technology now—reintroduce that product because it could save—some estimates—millions 

of lives. And I would like to see it reintroduced under the controlled situations where we can make the molecules much smaller 

through atomizing the product. 

Admiral ZIEMER. Sir, there are 12 approved insecticides on the 

WHO-approved list. DDT is on the list. And we were using DDT 

in three of our programs. We switched off of DDT because there 

was a resistance developing by the mosquitoes. So we alternate it 

to pyrethroid or another effective insecticide. So the issue of DDT 

is front and center, but I think what we need to do is continue to 

focus in on effective, safe insecticides that are approved and then 

look at the best application based on resistance, protocol, and the 

data that we have. 

Mr. STOCKMAN. I also noticed they are taking—and indulge me 

a little bit, and I will yield back the time. But aren’t they taking 

mosquitoes and injecting them so they don’t bear other mosquitoes? 

I guess birth control for mosquitoes, which is kind of amazing. RU–

486 for mosquitoes. 

Colonel WEINA. We do have a number of very innovative strategies that are being developed by our entomologists that look at 

doing things besides insecticides, because we do know that, just 

like the parasite is going to be able to develop resistance to our 

drugs, the insects develop resistance to our pesticides and eventually will overcome the ones that we have available to them. So we 

need to be thinking, as it has been said, outside the box and to 

41

other strategies, which include sterilized mosquitoes that are able 

to decrease the burden of the vectors that are present. 

Mr. STOCKMAN. And lastly, my father used to do this. He was a 

zoologist, and what he used—I don’t know if you can do this—he 

used vegetable oil on still ponds. As the larvae comes up to get air 

and then gets vegetable oil. Is that something that you can use 

widely? 

Admiral ZIEMER. Larvaciding is an option. 

Mr. STOCKMAN. You are being diplomatic. 

Admiral ZIEMER. Yes, sir. But it is an important one because 

where we work, the application of larvaciding by WHO guidelines 

isn’t the most costly, effective program. 

Mr. STOCKMAN. I know they did it in Panama, too, right? 

Admiral ZIEMER. Yes, sir. So there are certain parameters that 

WHO says ought to be used if larvaciding is considered an option. 

In the countries where we are working, we are not even looking at 

it because of the places and the conditions would not make it a 

cost-effective intervention for prevention purposes. 

Mr. STOCKMAN. Well, thank you for your candor and your time. 

You guys have been great. Thank you so much. 

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

Not to make light, but when Mr. Stockman was talking about the 

foggers, I grew up in Iselin, New Jersey. My friends and I, when 

we were 8, without our parents’ knowledge or consent, used to follow the foggers on our bikes. We were covered with the stuff. 

Mr. MEADOWS. Me, too, Mr. Chairman. That is our problem. 

Mr. SMITH. That is when I decided to run for Congress. 

Thank you so much for your great witness today, your testimony, 

and above all, your leadership. It is so greatly appreciated. 

Admiral ZIEMER. Thank you. 

Mr. SMITH. Pursuant to the rules of the committee, we will now 

have to end the formal part of the hearing and go officially to a 

briefing. It is part of the rules of the House and the committee, I 

should say, to receive testimony from Ambassador Mark Dybul. 

[Whereupon, at 11:54 p.m., the subcommittee was moved to a 

briefing.] 

Mr. SMITH. I will welcome the Ambassador to the witness table. 

Ambassador Mark Dybul—and it is a very high honor to welcome 

him here today—is the executive director of the Global Fund to 

Fight HIV/AIDS, Tuberculosis and Malaria. As an immunologist, as 

an administrator, as a teacher and as a leader, Ambassador Dybul 

has worked for more than 25 years to help prevent and treat infectious diseases. 

Ambassador Dybul has written extensively in scientific and public policy literature. He is a founding architect and a driving force 

in the formation of the President’s Emergency Plan for AIDS Relief, or PEPFAR. I know—and I say this firsthand because I was 

very involved with that legislation—it was Congressman Henry 

Hyde, who was the prime sponsor. It was a bipartisan bill. But Ambassador Dybul was absolutely critical in crafting that text, the 

language, the all important law and its reauthorization in 2008. So 

I want to thank him for that leadership. 

He was formally appointed as U.S. Global AIDS Coordinator, 

with the rank of Ambassador from 2006 to 2009. Before joining the 

42

Global Fund, he was codirector of the O’Neill Institute For Global 

Health Law program at Georgetown University, where he was also 

a distinguished scholar. 

Welcome, Ambassador Dybul. 

STATEMENT OF THE HONORABLE MARK DYBUL, EXECUTIVE 

DIRECTOR, THE GLOBAL FUND TO FIGHT AIDS, TUBERCULOSIS AND MALARIA 

Ambassador DYBUL. Thank you, Mr. Chairman. 

It is a great privilege to be back before this committee in a different role. Other members of the committee, thank you for your 

dedication and for being here. This committee, as I know firsthand, 

has had such long, strong bipartisan support for serving those in 

need. 

And Mr. Chairman, thank you for your leadership going back so 

long in this fight. And I know now you have new friends and colleagues that will help support this effort with you. 

You have heard a lot of the data and information. So if it is acceptable, I would like to enter my testimony for the record and 

highlight a couple of key points, including in response to some of 

the issues that have been raised. This is a very difficult financial 

time. We are very conscious of that. And coming before this body 

or any body, actually, around the world to ask for increased resources for foreign investment, we understand, is difficult to ask. 

And I think it is important to understand why we are doing this 

now. It is easy to say in these difficult financial times, we can wait 

3 or 4 years, 5 years, until we have better economic times and better budgets. The reality is that because of the massive investment 

of the last 10 years and because of advances in science and our understanding of the diseases, we are at a critical tipping point in the 

history of malaria and HIV and tuberculosis. We now have the 

science and implementation understanding to actually end these 

diseases and public health threats and to put us in a position to 

ultimately eliminate them. 

We have never had this moment in history before. Malaria has 

been with us as long as history has been recorded, as long as we 

know. We are the generation. You are the leaders that can actually 

put us on the course to end this disease as a public health threat. 

And that is why it is so important to act today. And I will expand 

a little bit on that. 

The scientific advances, you have heard about: The new longlasting insecticide treated nets, new indoor residual sprays, new 

treatments, much more effective combination treatments and eventually a vaccine, which I will come back to. One thing we have not 

talked about is the success of the interventions to date leading to 

a new understanding in epidemiology of the disease. We have had 

so much success over the last 10 years, which you have heard 

about, that high-transmission areas are becoming much more confined. A good example is South Africa and Swaziland. They now 

have malaria only on their borders with Mozambique. Not too long 

ago, they had malaria throughout their countries. We see this over 

and over and over again. Because of the success of the interventions, we now have areas that are being more and more contained 

with high transmission, which allows us to target our interventions 

43

much more effectively. We are also understanding that high levels 

of the parasite in the body are very limited in geographic scope. So 

we are now focusing our efforts on those areas. 

All of this has been made possible because of the experience of 

the last 10 years, because of the investments that have been made. 

We are now in a position to actually get for you a full return on 

that investment by completely controlling and ultimately eliminating malaria. If we succeed in what I just described, a partially 

effective vaccine would be enough in all likelihood. And that means 

some of the things the colonel talked about could be, in our lifetime, available. If we control the infection to such low rates, to 

such inefficient transmission, then you don’t need an overly powerful vaccine. And that is the opportunity before us. But we are at 

a tipping point. And tipping points can go in two directions. You 

can continue on the course you are on or you can tip backwards. 

And you have already talked about some of that tipping backwards 

that has occurred. We have extraordinary data for how quickly—

especially in malaria—you can tip backwards from success. 

Zambia is an excellent example. It achieved fantastic coverage of 

interventions, significant declines in their infection rates. But because of funding issues were unable to replace nets and immediately saw an uptick in new infections. We have seen the same 

thing in Rwanda and other places. And while you have talked a little bit about what happens when the malaria comes back, one 

thing that is important to emphasize is if you have protected a 

child for a few years and then they no longer have protection, it 

is almost worse than never having protected the child because they 

were never exposed to malaria. They have no immunity to malaria. 

So if they then become infected, their malaria will be far worse 

and, as the colonel described, can lead to the meningeal, pulmonary, and other fatal forms of malaria because they were protected and became unprotected. 

And that is why the data the chairman mentioned on the inability to just replace nets is so striking and such an important moral 

issue for us. And that is why the Global Fund dedicated $450 million this year to reduce that gap from 77 million to 24 million 

bednets. But we still have some gap. And that is just to maintain, 

not to achieve the vision we talked about, to drive toward complete 

control. 

The bottom line of this is this is not a bottomless pit. This is not 

what we would have done for the last thousands of years in the 

fight against malaria. We are actually on the tipping point where 

today we can say we can completely control and ultimately end malaria in the world. But it is going to take resources. 

And in that regard, we are very grateful to Congress for the 2013 

budget. We know how difficult that was to maintain the financing 

for the Global Fund that allowed us to replace all of those bednets 

that otherwise we could not have replaced. We are very hopeful 

that the 2014 budget can meet the President’s request, which is 

similar to the 2013 budget. In fact, it is the same. And one thing 

I believe is important for you all to know is that your contributions 

to the Global Fund are leveraged two to one from other donors because you can never give more than 33 percent. And we use that 

44

to leverage two to one. So every $1 you give gets us $3 in the fight 

against malaria. 

As has been mentioned, the Global Fund has committed about a 

third of its $23 billion portfolio to malaria. We work very closely 

with the President’s Malaria Initiative. We support the same comprehensive approach. And more recently, we reorganized our structures so that we are focused on the high-impact, high-disease-burdened countries in a much more aggressive way, the countries that 

you all have mentioned where most of the malaria resides. 

Partnership has come up a fair amount, and I would like to just 

say a few words about the close working relationship with PMI and 

others. One of the areas we are working aggressively—and to ensure that when you go to the taxpayers, you can tell them the 

money is being used well—is to increase efficiencies. Last week, the 

Global Fund hosted with PMI and UNICEF a new round of negotiations on the price of bednets to drive the prices of the nets down 

by using our collective buying power. It is the first time that has 

been done, that we worked together to use that collective buying 

power to drive those prices down. 

A second example is to partner with the private sector and the 

U.S. Government through USAID. Yesterday, we announced a new 

innovative process that will allow us to more rapidly utilize the resources that you make available us to and to leverage the private 

sector’s capability of guaranteeing resources to do that. 

A third example and one that has come up is our work with PMI 

and other global partners in the Mekong Valley to address drugresistant malaria. The Global Fund has committed $100 million to 

a regional partner there and has partnered with PMI and the technical expertise of the U.S. Government and other partners to ensure that our global investments are not threatened by the resistance that is developing there. 

A fourth example is to partner with national malarial control 

programs to move toward that use of the science, use of the epidemiology to make sure the resources you commit are most effective 

and dedicated where the highest risk of transmission is. A final example I will give you relates to counterfeit drugs. Mr. Stockman, 

you asked who is working on this. Actually the Food and Drug Administration is working very aggressively on this. And there are 

several other international partners, including the private sector, 

that are developing new technology so that we can identify counterfeit products in a very rapid way through international consortia. 

And the Global Fund is actively involved this those efforts, which 

is something that a multilateral can do. It is more difficult for 

bilaterals to engage in. 

I also want to point out that we are not just relying on you and 

your taxpayers for what we are talking about. Africa, itself, is stepping up in dramatically new and exciting ways, as is India and 

parts of Southeast Asia. The African Leaders Malaria Alliance 

brings together the heads of State of Africa at that level to focus 

on malaria. And in part, as a result of that, last year alone and 

annually, $625 million came from countries themselves to fight malaria. So they are partnering with you with their own resources as 

well as their commitment. A good example is Zambia, which in the 

last 2 years has almost tripled the resources they commit to maVerDate 0ct 09 2002 10:30 Sep 26, 2013 Jkt 000000 PO 00000 Frm 00048 Fmt 6633 Sfmt 6633 F:\WORK\_AGH\051713\80942 HFA PsN: SHIRL
45

laria. The private sector is also in the game heavily, in part with 

the commodities they provide, in part because of the delivery systems, but also with money. Chevron has provided the Global Fund 

about $55 million. Product (RED) is a partnership of CEOs and 

companies in the United States that provided the goal of funding 

over $200 million. The Bill & Melinda Gates Foundation has provided significant resources, and we are also targeting other highnet-worth individuals. So we are not looking to you all alone. We 

are developing financing partnerships that will relieve the burden 

on the American taxpayer in an exciting way. One of the reasons 

heads of state and the private sector are so involved is because of 

something that was touched on but not probed enough perhaps. 

And that is the impact of malaria on productivity. Nigeria alone estimates that they lose over $3 billion a year in lost productivity because of malaria. Globally, the estimates range as high as $40 billion. And most people think those are significantly underestimated. 

And that is why the private sector has gotten engaged, because 

Chevron, for example, in Nigeria, was losing so much time in their 

offices and in their production facilities because of malaria. So it 

was good business to intervene. That is good for the United States 

to have a rapidly growing economy in Africa to be a buyer of our 

goods and services. 

So the opportunity before us is huge. The partnership that is responding is huge. But the most important opportunity is, in fact, 

for the first time, which we could not have told you 2 years ago, 

we are on the cusp of completely controlling this infection and ultimately eliminating it. 

As it has been mentioned, we had malaria in this country. Eight 

United States Presidents have suffered from malaria, including 

Teddy Roosevelt and John F. Kennedy. John F. Kennedy of course 

was after 1951 when we eliminated it, but he served in Vietnam 

and came back with malaria. And as we talked about, that is a 

threat that is growing for us. 

CDC in fact was created initially largely to respond to malaria 

and is still deeply involved. We have now eliminated it in the 

United States, but there is a risk it could come back. And we have 

the opportunity—if we invest wisely, if we use taxpayer dollars 

well, if we continue this partnership—to achieve something that 

has not been possible for thousands of years and is possible today: 

To completely control this infection, ultimately to have more scientific advancements and to move toward elimination. And if we 

don’t do that, the cost in millions of lives is extraordinary. But 

more, the billions upon billions upon billions of dollars that you 

will continue to have to dedicate would not be necessary if we act 

today, if we act now. So we can leave for the first time a generation 

free of malaria that has not happened since recorded time in history. What an opportunity. What an opportunity. If we maintain 

our resolve, if we work together, if we capitalize on new scientific 

advancements, collectively we can accomplish one of the greatest 

feats in history, to defeat a plague that has been with us for thousands of years. Now is the time to act. Now is the time to invest 

so that we don’t pay forever. Thank you very much for your attention. I look forward to answering your questions. 

[The prepared statement of Ambassador Dybul follows:]

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

and for your leadership. 

Your testimony is quite extensive. And I do hope that all members of the subcommittee, and the full committee as well, will read 

it, because you really lay out even more than what you have just 

done very well in your oral presentation. 

You point out that we can all agree that no child should die for lack of a $1 insecticide-treated net—and I think that very low cost 

is under-appreciated. People don’t realize how cheap it really is: A 

$1 rapid diagnostic test kit and $7 drug treatment regimen if, of 

course, the child is sick with malaria. 

You talk in your testimony about the $3.5 billion gap. And I am 

wondering, in addition to the United States, and I frankly think we 

should do more, and I know maintaining current levels with the 

crisis in the budget that we face is job one, but certainly if we could 

go above that, obviously that is all value-added? What other countries are really stepping up to the plate? And, as you pointed out 

in your testimony, some of the affected countries, like Zambia, are 

doing more, which is greatly appreciated because they have resources, and they are prioritizing those resources. But what other 

countries typically in Europe and elsewhere are really stepping up 

to the plate? 

Ambassador DYBUL. Thank you, Mr. Chairman. 

And I think it is a really good question because it really does emphasize that the U.S. is not going it alone. The U.S. leadership has 

been out in front since the beginning of this fight on malaria. But 

it has not had to go it alone. So the Global Fund, as I mentioned, 

is a multilateral institution. We are not part of the United Nations. 

Actually, we are an independent multilateral. And we were created 

that way so we would have more flexibility. And through that 

mechanism, we have a board, which has the major contributors and 

countries represented on it. The United States is, by far, the largest single contributor to the Global Fund. But as I mentioned, you 

can never give more than 33 percent. And that leverage is two to 

one from others. Other countries that are large contributors: 

France is the second largest contributor to the Global Fund; the 

United Kingdom is the third. The United Kingdom also has a large 

bilateral program with a big emphasis on malaria. So they also 

have bilateral efforts in addition to their contributions to the Global Fund. Japan, Germany, Sweden—pretty much all of the Nordic 

countries have participated to very high degrees. We even have 

countries like Russia contributing to the Global Fund. India provides a contribution. Thailand provides a contribution. So it really 

is a way to have a shared responsibility, a global response to these 

epidemics. 

But importantly, as you pointed out, African countries themselves—South Africa not only receives grants from us, they actually 

provide a gift to the Global Fund. Zambia is considering such a gift. 

Namibia provides a gift to the Global Fund. So, at the same time 

they are moving to fund their own domestic programs, they are trying to contribute to the broader effort globally. So it really is a 

shared responsibility. 

I would also like to mention again the private sector contributions, which are critically important: The Gates Foundation, ChevVerDate 0ct 09 2002 10:30 Sep 26, 2013 Jkt 000000 PO 00000 Frm 00061 Fmt 6633 Sfmt 6633 F:\WORK\_AGH\051713\80942 HFA PsN: SHIRL
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ron, Product (RED). You are in there as a leader. But you don’t 

have to go it alone. And we work very hard to ensure that your 

money is matched two-to-one. 

Mr. SMITH. Let me just ask, on the insecticide-treated bednets, 

you have suggested that 77 million nets are needed just to get back 

where we were—especially because some of the nets wear out after 

a 2- or 3-year useful life. 

The WHO says that to have complete coverage, we need 150 million such nets. Where are we in terms of actually getting to those 

numbers? And secondly, had President Bush not created the President’s Malaria Initiative, or the PMI, where would we have been? 

Ambassador DYBUL. So in terms of what is needed to get to that 

complete control we talk about, that is where the $3.4 billion gap 

comes from. If we are really going to contain the epidemic, if we 

are really going to get to that full control so that we can with a 

partially effective vaccine eliminate malaria, or at least eliminate 

it as a public health threat, we have the knowledge today, that is 

what that $3.4 billion would do. The 150 million nets a year is really to maintain. And we are not at universal coverage yet. We have 

a little bit to go. And we also need indoor residual spraying. We 

also need to treat people who do get malaria which actually contributes as a preventive tool as well because you reduce the 

parasitemia. And that is where the $3.4 billion would fill in and 

allow us to contain. 

Again, I know that sounds like a lot of money, and it is a lot of 

money. But the opportunity cost not to invest today is to actually 

lose the return on investment of what you have invested for the 

last 10 years because, again, we are at that tipping point. And we 

can either continue to work to get to complete control or we can 

slide back down, in effect losing some of the return on investment—obviously not all of it since we have saved millions of lives. 

President Bush’s leadership was extraordinarily important. The 

President’s Malaria Initiative has had a significant impact and 

really with the Global Fund and the UK’s program are the major 

external funders, along with increasing domestic contribution, in 

the fight against malaria. But again, everyone is getting in the 

game, but it takes leadership to cause that effort. 

Prime Minister Blair was actually a tremendous leader and 

worked closely with President Bush at Gleneagles, and the UK will 

be hosting the follow-on to the Gleneagles G–8 Summit this year. 

And we are hopeful that they will recognize the importance of this 

partnership through the G–8, going back to that Gleneagles, when 

President Bush and Prime Minister Blair were in office, that has 

led to where we are today with success in malaria. 

Mr. SMITH. Thank you. I do have other questions, but in the interest of time, I yield to my good friend and colleague Mr. Weber. 

Mr. WEBER. Thank you, Mr. Chairman. 

Mr. Dybul you said that Swaziland had almost eliminated malaria, only had it in some areas on their border with Mozambique, 

I think. How did they do that? 

Ambassador DYBUL. And South Africa is the same. And they did 

it through a strong national program with external financing and 

all the partners working together with a common objective to get 

to complete control. And so with long-acting insecticide-treated 

59

bednets, with available treatment, with the correct treatment, the 

effective treatment, they were able to push it out so that it is really—because of the border, mosquitoes don’t much follow geographic 

borders. They go wherever they want to go. So it is a very important issue because we are seeing this happen in country after country, where they are actually managing the infection in their own 

countries, but it is the bordering regions. So we are shifting to an 

approach that looks like a cross-border transmission and cross-border control so that we can do that. 

But it really was through what we have been talking about, and 

you have been talking about all day, using the science, using the 

advancements in interventions, getting the ground game so that 

you get the coverage rates, using faith- and community-based organizations and make sure people are sleeping under the nets and 

that people are accessing services and having a national strategy 

and a national approach. 

It is not just these two countries. Right now, Tanzania has had 

a 50 percent reduction. They have had 90 percent coverage of their 

bednets. They have had a 50 percent reduction in mortality and 

case detection and almost a 45 percent reduction in all caused child 

mortality because malaria contributed so much. So many countries 

are pursuing this effort. And what we know now is if we act in this 

coherent way, if we use all the interventions smartly, we can actually get to complete control. 

Mr. WEBER. Let me ask you, are you able to quantify, when you 

look at that country, are you able to say the program cost X, they 

poured X amount of resources into it and their incidents went 

down, is that quantifiable? 

Ambassador DYBUL. It is. It is. In fact, we have those data for 

you. We have the total dollar amount and we have the total impact. 

What we are doing now is actually combining all the spigots of 

funding. So what we have done in the past is look at what the 

Global Fund invested, look at what PMI invested, look what the 

country invested. What we are now doing is taking a country look 

and saying what should that cost be to actually achieve those results? And again, working with the U.S. Government to get the 

cost of the nets down, getting cost of the supply down, so I think 

what you are getting at is exactly right. We now have the knowledge of how much it should cost and to drive the cost down even 

further. 

Mr. WEBER. All right. And then final question, Mr. Chairman, 

my colleague Mr. Stockman, had asked the previous panel could 

they give us the names of witnesses who knew who was doing the 

counterfeiting, and let me just say, tongue in cheek, we don’t necessarily need those names. We need the names and the addresses 

of the counterfeiters so we can send Igor and Bruno over there with 

a No. 34 baseball bat and break their kneecaps. 

Are there such a thing as sanctions? Or when you identify a 

country that has that kind of counterfeiting going on, is there a 

database that says this country has been participating, and is there 

such a thing as—how do you sanction them? 

Ambassador DYBUL. It is rarely a country. It is usually people 

working within a country, and often——

60

Mr. WEBER. But if you were able to get with that government 

and say you-all need to shut this down. 

Ambassador DYBUL. Which is exactly where it is going. And 

INTERPOL is actually actively involved in global counterfeiting 

with the FDA and others exactly for that purpose, so that people 

can begin to identify where people have refuge to do counterfeit activities, to track them with new technology, and then work collectively as an international community to shut them down. 

Mr. WEBER. And so INTERPOL takes the information. There is 

a particular provider of medicine that is sending counterfeit drugs 

in and they can track that back and are keeping a database who 

not to buy from, for example. 

Ambassador DYBUL. It is being developed. These programs are 

being developed because everyone has gotten so much attention for 

it. To Mr. Stockman’s question, I think if you brought FDA in, they 

could give you a very full picture because they are very aggressively and actively involved in all of these conversations, and using 

these new handheld technologies where we can identify counterfeit 

and trace it back. 

Mr. WEBER. Okay. Thank you, Mr. Chairman. 

Mr. SMITH. Thank you. 

Mr. Meadows. 

Mr. MEADOWS. Thank you, Mr. Chairman, and thank you for 

your testimony and briefing, and I wanted to follow up a little bit 

in terms of, you know, you mentioned the Global Fund and I think 

you implemented a series of reforms, you know, due in part to a 

response from Congress. And as you have implemented those reforms, how would you say those have progressed since, you know, 

your leadership and what is still left to be done? 

Ambassador DYBUL. Thank you for the question, because I think 

it is very important and really is a testament, in my mind, and the 

reason I was so interested in going into the Global Fund it that it 

is a true learning organization. It really looks at itself constantly 

to say how can we improve, how can we do better and let’s change, 

and as we all know, that is not a typical approach in organizations. 

Mr. MEADOWS. Right. 

Ambassador DYBUL. And that is one of the most exciting things 

about it. So the reforms are really an evolution from looking to see 

where we are today, what the landscape looks like and how do we 

implement more effectively with higher impact. So some of the key 

things that have been done, and again, the board—the U.S. being 

an important member of the board and the U.S. Congress pushing, 

really—the board itself pushed for these reforms, and how rare is 

that that you have a governing body pushing for this type of 

change? Because often we think change means you made a mistake. Sometimes change is good because you are learning. 

One of a few things we learned was that we didn’t have the 

right—we don’t have as much focus on high-impact grant management as we needed to and so we shifted so that now 75 percent of 

our staff is dedicated as a financing facility, which is what we are, 

to grant management, because that is our core business. And we 

are identifying what our core competencies are and partnering 

more with other organizations, which is what we were created to 

do for technical and other purposes. 

61

Mr. MEADOWS. And so if you are looking at that grant management, what matrix do we use in terms of, one, the awarding of the 

grant, and then I guess the second part of that is the effectiveness 

once the grant has been given, what is the matrix, the area? 

Ambassador DYBUL. So the matrix for how grants are given are 

based on disease burden, because that is where the impact is going 

to be. Co-investment is a key part of our—how we make——

Mr. MEADOWS. So the better co-investment, the more likely they 

are to get to the grant? 

Ambassador DYBUL. And also a requirement for co-investment is 

based on economic situation. So even if you have a high disease 

burden but have a good economy, you need to be giving more, and 

we work on that in a formalized way as part of the grant-making 

identification. 

Mr. MEADOWS. And there are no other political agendas or sidebars that evaluate it. 

Ambassador DYBUL. No. Well, the other is ability to implement 

in terms of rapidity. We don’t want to dedicate money and put it 

in a country when they don’t have the capacity to move it. And 

then we have a risk management tool that is new, which looks at 

not only risks of misuse of funds so that we can ensure that—and 

go after any misuse of funds—but also risk in non-implementation, 

which gets to capacity a little bit, and what are those risk implementations. Is it the supply chain? Is it human resources? Is it the 

inability to reach certain parts of a country for various reasons? 

And then we dedicate our resources to alleviating those risks. So 

it is a very complex matrix across those areas, but it is leading to 

a much more impactful approach. 

Mr. MEADOWS. So you are saying this is really more of a new 

funding model than you have had in the past; is that correct? 

Ambassador DYBUL. In fact, we call it a new funding model. 

Mr. MEADOWS. All right. So, and thus my question. And so as we 

look at this new funding model, what can we do in terms of the 

planning stages and the implementation stages, similar question 

that I asked the Admiral, what can we do from a legislative standpoint, knowing that we are only part of the pie, to help facilitate 

that and help encourage that to make sure that American taxpayers are getting what they pay for. 

Ambassador DYBUL. Well, I am probably a little biased since, as 

the chairman pointed out, I actually was involved in the writing of 

the legislation, but I think it is pretty good. 

Mr. MEADOWS. What tweaks would you make to your own writing; how about that? 

Ambassador DYBUL. I actually believe currently that the language you have is very useful to us, and it actually helped the 

Fund, along with other people on the board, move toward this new 

exciting approach. 

What we are really focused on is the partnership piece, and that 

is in the legislation that we should be focused on using the resources from the U.S. taxpayer from whatever source they come in 

the most effective way to have the greatest impact and partner and 

leverage. And that leveraging piece is something we have not always done well, none of us, and that is what is so exciting about 

this new funding model—we actually bring all the partners toVerDate 0ct 09 2002 10:30 Sep 26, 2013 Jkt 000000 PO 00000 Frm 00065 Fmt 6633 Sfmt 6633 F:\WORK\_AGH\051713\80942 HFA PsN: SHIRL
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gether to look at the epidemiology, look at the science, to ensure 

that the investments going in aren’t duplicative. 

Mr. MEADOWS. Right. 

Ambassador DYBUL. Aren’t ineffective and are going to the right 

outcome. And then, importantly, to the other part of your question, 

we evaluate it on a quarterly basis: How is the progress against the 

targets? And we can track it in a programmatic way so that we can 

adjust and reprogram as needed as we are identifying new realities 

on the ground. Grant management is not writing a grant. You start 

grant management when you write a grant. You then work to ensure that the money is used well. We also only disburse funds as 

the countries need them. We don’t give them a pot of money and 

then 5 years later come back and see what they did. 

Mr. MEADOWS. What a novel concept. Well, and so let me go 

back. You mentioned ‘‘tipping point’’ in your testimony here today. 

You mentioned ‘‘tipping point’’ four different times, and so as, as 

we see that, you say we are at a tipping point, we are at a tipping 

point and we can go forwards or backwards. And yet what you also 

said is that we are at a position where we can eradicate malaria. 

What is the timeframe, and what is the greatest barrier to—and 

I know that we are talking about science here. We are talking 

about—but probability, the probability of eradicating malaria within what period of time? 

Ambassador DYBUL. There are different models, and I have to 

say a lot of this is mathematical modeling to predict——

Mr. MEADOWS. Sure. 

Ambassador DYBUL [continuing]. When we intervene how we will 

do. The model so far over the last 10 years have held up pretty 

well, and really, eradication will require a vaccine in all likelihood. 

What we can do is eliminate it as a public health threat and completely control malaria. And what we have seen in the last 5 years, 

I think, makes us much more hopeful that the timeline could be 

even more compressed. But we are actually, and the World Health 

Organization reports on this, about 20 countries have eliminated 

malaria in the last 10 years—so you go from endemic or epidemic, 

to control, to elimination, and then ultimately eradication. 

And if you look at the trajectory and the curves, we were seeing 

a 20-year horizon, 30-year horizon, but we are bending those curves 

down, including in countries, because of the success of the last 10 

years. We are working on that precise type of modeling based on 

the new data to try to give us a better sense of that. But the 

wildcard in that, and this is why I emphasize it a little, what we 

are learning more and more is you can actually push the epidemic 

into corners, and that then means you throw everything you can 

at those corners to have the biggest impact to get everything down 

to low level. And if you can do that, then a relatively efficient vaccine should be enough. If you allow a couple of pockets somewhere, 

you are going to need a really highly effective vaccine, so a lot of 

it is going to depend on that variability. 

The one thing we do know is that if we don’t get down to complete control, near elimination, we will be continuing to fight this 

fight forever, and that is the tipping point, and that is the change 

that we have seen. Up until the last 2 years, we would have just 

had to keep doing the same thing and the same thing and the same 

63

thing until we have a vaccine or until all countries had enough economic growth that they didn’t have some of the issues around pooling of water and other things. But now we are seeing the opportunity to push, push the timeline forward strongly. 

The reverse of that is if we don’t stick in this game, we know 

what is going to happen. And malaria, more than any other disease, we know it will come back, and then we won’t have the 

science or the tools to bring it back down, and a partially effective 

vaccine won’t do it, and then we are going to have to just keep putting in more and more and more money rather than investing now, 

and that is the issue of the tipping point. 

Again, I—you know, under most circumstances, I wouldn’t—I 

have been around governments a long time, I have been around 

budgets a long time. I wouldn’t come to you with a straight face 

to say we need more money today, given the current economic environment, except for this unique moment in history. It is a shame 

it is coming at a time of tough budgets, but it really is. We have 

never had in the thousands and thousands of years that we have 

had malaria. 

Mr. MEADOWS. Well, I must admit, it was very unique testimony 

and thus why I followed up with a question, but with that, being 

sensitive to the other members, I want to yield back to the chairman at this point. 

Mr. SMITH. Thank you, Mr. Meadows. 

Mr. Stockman. 

Mr. STOCKMAN. Mr. Meadows, you can keep going. Those are 

great questions. I enjoyed them. And following up on his line of 

comments and statements, you mention in your testimony, Mr. Ambassador, Zambia and Rwanda are reinfected. Can you tell me, in 

your mind, because you have been working with this for so long, 

what is the rationale behind that? What happened? 

Ambassador DYBUL. So in both, neither country had eliminated, 

but they had significant control, very close to complete control in 

many areas. And that was because, like in Swaziland, they had national bednet campaigns, they had excellent care and treatment 

programs, they had an excellent program and a strategy that they 

implemented. But then they had some funding shortfalls and they 

weren’t able to replace them, some nets, or couldn’t complete some 

campaign. 

Mr. STOCKMAN. Can I interrupt for a second? Was it the NGOs 

that had the shortfalls or the government? 

Ambassador DYBUL. Both. So both NGOs and the government 

are involved. Basically it is one pot of money that gets divided out. 

Most bednets are distributed through national campaigns that are 

organized by the government because it is the only way you can do 

a national program, but implemented often through NGOs, especially the sleep-under-the-net campaigns. One important thing is 

you can’t just distribute the nets. You make sure people know how 

to use them. 

Mr. STOCKMAN. I was going to say, because don’t they sell them 

or resell them or so? 

Ambassador DYBUL. You know, sometimes that happens. With 

the national campaigns, that is rare because there is no reason to, 

64

because your neighbor has one, too, but in the past, that actually 

did happen. 

Mr. STOCKMAN. I saw them using it for everything. 

Ambassador DYBUL. Yeah. And actually there was a big education campaign. I mean, in the early going, people were afraid to 

use them, didn’t know how to use them. Actually in one case, I 

went into a home and I asked them where their bednet was because it wasn’t hanging, and they pulled it out from under the bed 

in the plastic packets because they thought it was so beautiful and 

still in the plastic package. So you need to go in and teach people 

and encourage them, and that is where the communities are so important and the faith and faith-based communities and the community-based organizations. 

In Nigeria, the Muslim community and the Christian community 

are working together to ensure that everyone in their congregation 

sleeps under their nets. It is part of their Sunday sermons. They 

do it all the time, and so that is really important. The funding 

shortfall was actually from external resources, but the governments 

couldn’t make up and so they couldn’t meet their deadlines to ensure that nets were replaced or campaigns were completed, and 

then we saw the increase. But then we all came back in, we moved 

heaven and earth to get the nets in and they came right back 

down. 

So it tells you how rapidly with this disease, if you lose just a 

little bit, you lose a lot, but if you stay contained and you stay suppressed, then you start pushing to where you just have these little 

pockets of high rates of infection. 

Mr. STOCKMAN. Why do you think in Vietnam they are drug resistant? What is the rationale behind that? 

Ambassador DYBUL. So it is more than Vietnam. It is actually 

the whole Mekong Valley, so Myanmar, Vietnam, Thailand and 

really in that that nexus, again, because the mosquitoes and the 

resistance doesn’t respect borders. 

The resistance develops either because, as you pointed out, people get partially effective drugs, or they stop and start and don’t 

take enough. And one of the key issues which has been raised is 

that, you know, if you are out in a village and you are in malaria 

season and your kid gets a fever, you are not going to walk the 2 

days or the day—and the clinic may not even be open. You are 

going to go to a kiosk and you are going to pay for an anti-malarial 

drug, and the Global Fund actually has been engaged in a program 

to reduce the cost of the effective products in those kiosks. So what 

people do, they buy the cheapest product, which often is quinine or 

quinine-based products in an area that has quinine resistance or 

quinolone resistance and it just expands. Or they buy, rather than 

a combination artemisinin product, they buy a single artemisinin 

product, and we know it has to be in combination. 

And so this single use of single artemisinin products rather than 

in combination develops resistance to the artemisinin, and so we 

are trying to get people in the private sector where people go to 

those kiosks so that when they go, they will still buy the cheapest 

drug, but it will be the effective drug. And then sometimes they 

just don’t complete the course. 

65

What we are working on internationally is bringing all partners 

together to really intensively address this resistance problem in 

this area so that it doesn’t spread, threatening all our investments 

everywhere else, but there are multiple reasons. And we are 

hypothesizing because we weren’t there as it developed, but we 

have a pretty good sense of how it developed and what is necessary 

to contain it. 

Mr. STOCKMAN. Thank you. I know we are getting ready to vote, 

so I yield back the balance of what time we don’t have. 

Mr. SMITH. Thank you. Thank you, Mr. Stockman. Just a few 

final questions and maybe my colleagues might have a question or 

two before we go to votes over on the House floor. 

In 2000 I authored legislation that became known as the Combating Autism Act. It took 3 years to get the bill passed, and one 

of the cores of that piece of legislation—as a matter of fact, I did 

the reauthorization in 2011 as well—was surveillance. At the time, 

we thought that the prevalence of autism in the U.S. was 3 out of 

10,000, at least that was what we thought in the early 1980s, and 

CDC was spending $287,000, a drop in the bucket, per year, 

straight line for 5 years. We had essentially no real program on 

surveillance, and our legislation created centers of excellence; all of 

a sudden, now we know the number, at least on the spectrum, is 

1 out of every 50. I held a hearing recently on what I call the global 

developmental disability pandemic autism. Sixty-seven million is 

one estimate worldwide, but we don’t have reliable statistics, and 

reliable statistics are what drives, I think, good policy. 

In the World Malaria Report for 2012, WHO suggests that in the 

41 countries around the world that account for 85 percent of malaria cases, it is not possible to make a reliable assessment of malaria trends due to incompleteness or inconsistency of reporting 

over time. WHO concludes that surveillance systems seem to be the 

weakest where malaria’s burden is the greatest and states that 

there is an urgent need to improve surveillance in those settings. 

I wonder if you might speak to that issue of surveillance, again, to 

drive the prioritization, the money, and of course, the deployment 

of resources. 

Ambassador DYBUL. It is an extraordinarily important question 

because if we are really going to invest smartly and if we are really 

going to get toward this elimination, we need to know with very 

solid data how to invest and where to invest, and that requires surveillance, and that is part of what we are doing in the new funding 

model, and I think we are doing as a global community. Really, you 

know, 10 years ago, you could do anything and have a huge impact 

because there was just so much out there, and that is one of the 

reasons larvicides don’t work in these communities. There is just 

too much malaria, and it is not going to do enough. 

Now we have to be a lot smarter because of the impact, and that 

means better surveillance. So we are working with countries so 

that by the time they come in with a concept note, as the partnership, we will have invested in getting that data and those—that 

surveillance data so that we will know how to invest in the most 

impactful way. It is going to be a process to get there, but I do have 

to say, too, compared to where we were 10 years ago in these countries with surveillance to today, because of their work, because of 

66

our investment, because of our partnership, it is night and day. 

And you have seen it, sir, I know, Mr. Chairman, I know many of 

the members have been and seen the radical transformation that 

has occurred that the American people have partnered with people 

in Africa to do. And part of it is in surveillance, but we are getting 

there in a way that was inconceivable 10 years ago, which is why 

I am much more optimistic than the models, because none of the 

models were able to predict that we would be today where we are 

today. And that is really because of the leadership of countries like 

the United States, but fundamentally because of the energy in people in Africa who are now looking to the United States and countries that have supported them in these diseases in a much different way and a much more positive way. And as we continue to 

work with them to support them, to identify their pockets with surveillance and improve their systems more broadly, that just expands and expands. 

Mr. SMITH. Thank you. 

On April 23, Dr. Thomas Frieden testified before our subcommittee. The title of our hearing was, ‘‘Meeting the Challenge of 

Drug-Resistant Diseases in Developing Countries.’’ I know the 

Global Fund deals with PEPFAR, HIV/AIDS, as well as with tuberculosis. He did focus on MDR and XDR tuberculosis and all the 

challenges that are being faced going forward, but he did spend 

some time talking about artemisinin-resistant malaria and pointed 

out, and I would just quote in pertinent part his testimony:

‘‘Since 2008, malaria infections in parts of Southeast Asia 

have been shown to be resistant to artemisinin drugs. This is 

the last remaining class of antimalarial drugs and forms the 

basis of malaria treatment around the world. If these resistant 

parasites were to spread to sub-Saharan Africa (which has occurred with other forms of drug resistant malaria), the results 

could be devastating.’’

Could you speak to that? 

Ambassador DYBUL. First, I would completely agree with Tom’s 

assessment, and we have actually talked about this. 

I would point out that there actually is a new—several new 

classes that are being created through remarkably brilliant publicprivate partnerships, the Gates Foundation is heavily involved, 

medicines for malaria and vaccines is involved, so we will have new 

classes of drugs, but we can’t keep doing that, right, so we need 

to stamp out the resistance and that is why we are investing $100 

million in that region to jump on it right away working with partners. It is estimated that it will cost about $400 million and we are 

basically leveraging and we are looking for people in that region 

who are interested in those countries to step up financially as well, 

and then coordinate across the countries because it is a cross-country effort. It is a regional effort because we have three countries 

that have the resistance. So, we are jumping on it immediately because of the threat. 

MDR–TB is another big problem, and Global Fund is the largest 

funder of MDR–TB—external funder of MDR–TB—programs in the 

world, so we are very active there, but that is another committee 

hearing. 

67

Mr. SMITH. Let me just ask, Ambassador Dybul, early on, and I 

have raised this repeatedly with Global Fund, I am not the only 

one, it had excluded, or largely excluded faith-based groups. I know 

that there is a renewed effort to try to be inclusive, if you might 

want to speak to that. Also, the challenges you face, the Global 

Fund’s Web site indicates that malaria is the greatest cause of illness and death in the Democratic Republic of the Congo and that 

there are at least 10 million cases of malaria per year. Yet some 

of their programs get unacceptable ratings; of course, the challenges in the DRC are huge, namely the war. I have been to Goma 

myself. I know how the terrorism is, and the sexual violence is almost without precedent anywhere in the world, but if you could 

speak to that as well. Then I will go to my colleagues because we 

do have a vote. 

Ambassador DYBUL. So on Congo, it is a difficult place, no question about it, but you can actually get things done even in difficult 

environments. And you know, Sudan actually has universal coverage of bednets, so it is possible, and we are intensively focused 

on Congo right now, and it is by working with more than the government. That is how you get the job done, by working with partners, including faith-based organizations, which is a segue into 

your other question. 

We recognize that you cannot succeed, and then particularly 

when you are talking about getting to the last mile, getting to the 

people and making sure they stay in services and use their bednets 

and use the right anti-malarial drugs, that the communities and 

the faith communities are critically important to that. 

We have changed the way we operate in a number of ways. We 

do have quite a number of faith-based implementers, Catholic Relief Services, World Vision. We also work with the faith community 

to raise additional resources. The large Lutheran group and Methodist group are actually trying to raise $40 million around malaria 

control right now with us. But it also about implementation and 

engagement, and so in our new funding model, we actually have 

shifted the process around, and it was always intended that faithbased communities be part of our country coordinating mechanisms, but it didn’t always work well, and through our new mechanisms, we are actually working on that more and more, and actually welcoming people into our dialogue that leads to a country 

plan from all walks of life. And we are actually working with faith 

communities here in the United States to identify in these countries who should be at the table, who needs to be engaged in the 

conversation. 

Now, that doesn’t mean we have to fund them, but they need to 

be part of the conversation and part of the national planning because they do so much on their own. Even if we don’t funnel money 

to them, they need to be part of the national plan and the national 

approach to ensure that we combat and actually ultimately eliminate malaria. 

Mr. MEADOWS. So what you are saying—let me just follow up on 

that. So what you are saying is with these faith-based groups, 

there is no, in your matrix, when we were talking about funding 

matrix, there is no disqualifier in terms of providing funding for 

that? 

68

Ambassador DYBUL. Absolutely not. 

Mr. MEADOWS. Okay. And as we know in Africa, it is either faith 

or it is tribal or cultural, and so you are reaching out to all those 

different groups and the leaders of those groups to make sure we 

hit these pockets? 

Ambassador DYBUL. We are, and our new funding model actually 

is designed to ensure that we do in a much more aggressive and 

effective way. 

Mr. MEADOWS. All right. Well, I yield back. I thank you, Mr. 

Chairman. Thank you for your testimony. 

Mr. SMITH. Thank you. Anybody else like to make any final comments? Ambassador Dybul, would you like to make any final comment? 

Ambassador DYBUL. I would just like to thank the committee 

again and thank you, Mr. Chairman, for your many years of leadership and look forward to continuing to work with all of you. 

Mr. SMITH. Well, frankly, we want to thank you for your extraordinary lifelong leadership. You have made an extraordinary difference, and I know it because the passage of PEPFAR was in no 

way a done deal. Its reauthorization, in which it was greatly expanded, there were lessons learned, and again, you were critical in 

the drafting of that legislation. So you have made an impact and 

saved lives. That really deserves a great deal of praise, so thank 

you for being here, thank you for the work that you do. This hearing, or briefing part of the hearing, is adjourned. 

[Whereupon, at 12:42 p.m., the subcommittee was adjourned.] 

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