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FIGHTING MALARIA: PROGRESS AND CHALLENGES

HEARING

BEFORE THE

SUBCOMMITTEE ON AFRICA, GLOBAL HEALTH, 

AND HUMAN RIGHTS

OF THE

COMMITTEE ON FOREIGN AFFAIRS 

HOUSE OF REPRESENTATIVES

ONE HUNDRED TWELFTH CONGRESS

FIRST SESSION

DECEMBER 5, 2011

Serial No. 112–113

Printed for the use of the Committee on Foreign Affairs

(

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

(II)

COMMITTEE ON FOREIGN AFFAIRS 

ILEANA ROS-LEHTINEN, Florida, Chairman 

CHRISTOPHER H. SMITH, New Jersey 

DAN BURTON, Indiana 

ELTON GALLEGLY, California 

DANA ROHRABACHER, California 

DONALD A. MANZULLO, Illinois 

EDWARD R. ROYCE, California 

STEVE CHABOT, Ohio 

RON PAUL, Texas 

MIKE PENCE, Indiana 

JOE WILSON, South Carolina 

CONNIE MACK, Florida 

JEFF FORTENBERRY, Nebraska 

MICHAEL T. MCCAUL, Texas 

TED POE, Texas 

GUS M. BILIRAKIS, Florida 

JEAN SCHMIDT, Ohio 

BILL JOHNSON, Ohio 

DAVID RIVERA, Florida 

MIKE KELLY, Pennsylvania 

TIM GRIFFIN, Arkansas 

TOM MARINO, Pennsylvania 

JEFF DUNCAN, South Carolina 

ANN MARIE BUERKLE, New York 

RENEE ELLMERS, North Carolina 

ROBERT TURNER, New York 

HOWARD L. BERMAN, California 

GARY L. ACKERMAN, New York 

ENI F.H. FALEOMAVAEGA, American 

Samoa 

DONALD M. PAYNE, New Jersey 

BRAD SHERMAN, California 

ELIOT L. ENGEL, New York 

GREGORY W. MEEKS, New York 

RUSS CARNAHAN, Missouri 

ALBIO SIRES, New Jersey 

GERALD E. CONNOLLY, Virginia 

THEODORE E. DEUTCH, Florida 

DENNIS CARDOZA, California 

BEN CHANDLER, Kentucky 

BRIAN HIGGINS, New York 

ALLYSON SCHWARTZ, Pennsylvania 

CHRISTOPHER S. MURPHY, Connecticut 

FREDERICA WILSON, Florida 

KAREN BASS, California 

WILLIAM KEATING, Massachusetts 

DAVID CICILLINE, Rhode Island 

YLEEM D.S. POBLETE, Staff Director 

RICHARD J. KESSLER, Democratic Staff Director 

SUBCOMMITTEE ON AFRICA, GLOBAL HEALTH, AND HUMAN RIGHTS

CHRISTOPHER H. SMITH, New Jersey, Chairman 

JEFF FORTENBERRY, Nebraska 

TOM MARINO, Pennsylvania 

ANN MARIE BUERKLE, New York 

ROBERT TURNER, New York 

DONALD M. PAYNE, New Jersey 

KAREN BASS, California 

RUSS CARNAHAN, Missouri 

(III)

C O N T E N T S 

Page

WITNESSES 

The Honorable Mark Green, Senior Director, U.S. Global Leadership Coalition ........................................................................................................................ 6

Dennis Schmatz, Ph.D., President of the Board, Medicines for Malaria Venture North America, Inc. ..................................................................................... 12

Regina Rabinovich, M.D., Director, Infectious Diseases, Global Health Program, Bill & Melinda Gates Foundation ............................................................ 20

Mr. Roger Bate, Legatum Fellow in Global Prosperity, American Enterprise 

Institute ................................................................................................................ 26

David Bowen, Ph.D., Chief Executive Officer, Malaria No More ........................ 36

Richard W. Steketee, M.D., Science Director, Malaria Control Program, Program for Appropriate Technology in Health ...................................................... 49

LETTERS, STATEMENTS, ETC., SUBMITTED FOR THE HEARING 

The Honorable Mark Green: Prepared statement ................................................ 9

Dennis Schmatz, Ph.D.: Prepared statement ........................................................ 15

Regina Rabinovich, M.D.: Prepared statement ..................................................... 23

Mr. Roger Bate: Prepared statement ..................................................................... 29

David Bowen, Ph.D.: Prepared statement ............................................................. 39

Richard W. Steketee, M.D.: Prepared statement .................................................. 52

APPENDIX 

Hearing notice .......................................................................................................... 82

Hearing minutes ...................................................................................................... 83

The Honorable Jeff Fortenberry, a Representative in Congress from the State 

of Nebraska: Prepared statement ....................................................................... 84

Mr. Roger Bate: Material submitted for the record .............................................. 86

(1)

FIGHTING MALARIA: PROGRESS AND 

CHALLENGES 

MONDAY, DECEMBER 5, 2011

HOUSE OF REPRESENTATIVES, SUBCOMMITTEE ON AFRICA, GLOBAL HEALTH, AND HUMAN RIGHTS

COMMITTEE ON FOREIGN AFFAIRS, Washington, DC. 

The subcommittee met, pursuant to notice, at 3 p.m., in room 

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

(chairman of the subcommittee) presiding. 

Mr. SMITH. The subcommittee will come to order, and good afternoon to everyone. I want to thank you for joining us for this very 

important hearing on malaria, one of the most serious health 

issues facing the developing world and particularly Africa today. 

For the last century America has been a leader in the fight 

against malaria. While the United States and several other countries have been able to eliminate malaria, this deadly disease still 

persists and presents a serious challenge to other parts of our 

world. The World Health Organization estimates that 781,000 people died from malaria in 2009, and that 225 million people have 

suffered from infection. Malaria is the fifth leading cause of death 

from infectious disease worldwide. It inflicts a particularly severe 

toll on people of sub-Saharan Africa where 90 percent of the deaths 

caused by malaria occur. 

Moreover, approximately 85 percent of malaria deaths occur in 

children under the age of five. Every 45 seconds a mother and father in Africa lose their child to malaria. 

There is also a far-reaching impact on the wealth and the development of countries with endemic malaria. Africa may lose up to 

$12 billion in productivity due to malaria each year to the disease, 

while the disease in turn consumes about 40 percent of Africa’s 

public health expenditures. These numbers and statistics are staggering, but they have a greater impact when one has been to Africa 

and met the individuals who must live with this dreaded disease. 

Anyone who spends any meaningful time in Africa and mingles 

with the African people notices the prevalence of malaria. When 

you ask someone whether he or she has ever had malaria, they will 

likely respond not with a yes, but with how many times they have 

suffered from it. More astounding than the sad reality that malaria 

is killing or harming so many millions of people is the reality that 

malaria is preventable and treatable. The world has the tools to 

prevent and to treat malaria. No one in the 21st century should 

have to suffer from it, let alone die from it. 

2

When I last visited Uganda, I visited several homes including a 

home in the remote region of Bushenyi. The three-room dwelling 

of white-washed walls and dirt floors was particularly empty, and 

this made the insecticide-treated mosquito net over the floor mats 

all the more striking. These nets may seem like insignificant items 

when listed on paper, but they are noticeably visible in the modest 

homes of these families who rely on them for protection from this 

ravaging disease. 

What began in the United States as an effort to protect our 

troops abroad and citizens here at home has become for us a larger 

global health objective. In the last decade we have seen a renewed 

commitment by the United States, international organizations, and 

private foundations to eliminate all malaria deaths. The effort received a notable boost in 2007 when Bill and Melinda Gates renewed the challenge of worldwide malaria eradication. 

While much progress has been made in combating malaria, as we 

have seen from past eradication efforts, malaria can resurge when 

treatment becomes ineffective through drug resistance. While the 

global commitment remains to beat this disease, and to beat it as 

soon as possible, the stakes are too high to bet it all on doing so 

before the tools we have lose their impact. 

At today’s hearing the subcommittee will receive an update on 

the progress toward malaria elimination in the most endemic countries with a focus on the vitality and the effectiveness of the treatment component. The hearing will examine the future of antimalarial drugs, vaccine development, and challenges in ensuring 

an adequate supply of effective medicines. We also will hear about 

the continued availability, affordability, and safe distribution of 

quality antimalarial medicines. 

I look forward to hearing the testimony of our very distinguished 

panel, all of whom have made and are making an enormous difference in the lives of people who are being ravaged by this disease. 

With that, I would now like to yield to my friend and colleague 

Mr. Payne for any opening comments he may have. 

Mr. PAYNE. Thank you very much, Mr. Chairman, and let me 

commend you for calling this very important hearing on the international community’s progress toward eradicating malaria. I would 

also like to thank our distinguished panel who are here with us for 

agreeing to come to testify and to give us an update of the current 

state of the epidemic. 

I think you have heard the statistics just given by the chairman: 

225 million cases, 781,000 deaths in over 100 countries. It is an 

area that we wonder why it took so long for the world to really get 

serious about malaria. But of course, we know that because malaria impacted on areas where there was not considered to be a return on the investment, many pharmaceutical companies just did 

not spend time trying to come up with a cure or a prevention, because they figured if they did, who could pay for it? 

And so we have seen a sea change, though, in what is going on 

in the world today. We see many organizations now changing the 

manner in which they do, the fact that still though every 45 seconds malaria claims the life of an African child. The fact that even 

in our country many years ago when our Nation first began, ambassadors from foreign countries were paid hazardous pay to come 

3

to Washington, DC, as ambassadors because of the problem of malaria, but we dealt with malaria and we eliminated malaria. 

However, there are a number of unintended consequences with 

global warming going on, although people are saying it is not manmade, we still don’t have the science, et cetera. With the climates 

warming up again, we may see the fact that malaria will once 

again start to come into temperate zone countries because of the 

global warming, and the whole question of malaria could once 

again become an issue in the Western Hemisphere. 

The global fight against malaria is daunting, but it is winnable. 

This year I am pleased to welcome Congressman Fortenberry as 

my new co-chair of the Malaria Neglected Tropical Disease Caucus. 

We now have close to 60 Members in the House. Several years ago 

we were very excited when then-Congressman Boozman became cochair and we launched the Malaria Caucus with Ms. Laura Bush 

coming to the House on one of her very few appearances here. And 

we launched the Malaria Caucus with a great deal of bipartisan 

support, and he is still continuing to fight the good fight over in 

the Senate. 

The Senate Malaria Working Group led by Senator Coons and 

Senator Wicker, another former member of the House, is also enjoying bipartisan support. When we get bipartisan support we can 

conquer anything. I think we are doing that when we approach this 

question of malaria. In this time of difficult discussions on U.S. foreign assistance reform our malaria control and prevention commitments represents some of the strongest returns on investment for 

foreign assistance dollars. 

In the last few years through proven effective and low-cost intervention, the global community has been able to slash disease burdens and deaths in Africa and elsewhere in the world. Over the 

last decade, Zanzibar has managed to reduce both the number of 

confirmed malaria cases, as well as malaria deaths by 81 percent. 

Rwanda and Zambia have seen positive results through malaria 

control interventions as well, with Rwanda increasing the percentage of its population using net beds by 70 percent. Efforts to provide bed nets, indoor residential spraying treatment, and education 

are making a dramatic difference. 

As our global partners are working to address drug quality and 

control concerns, World Health Organization prequalifications of 

essential medicines has been shown to be an effective mechanism 

to reduce the abundance of substandard drugs on the market in 

countries that have a weak domestic regulatory authority. In response to the findings of substandard quality and antimalarials in 

Africa, WHO had suggested and assisted in implementing key recommendations to empower countries to improve regulations at the 

country level. All of the tremendous progress we have made in the 

fight against malaria will not be possible without the United 

States’ leadership and our global partnership. However, all of the 

groundwork that the United States and the international community has made in this fight currently is at risk. There are those in 

Congress who feel that the United States should cut back our already modest investment in life-saving global health programs. 

I strongly disagree. The U.S. has a moral responsibility to be a 

leader in the fight and suffering worldwide through the Global 

4

Fund Initiative, the President’s Malaria Initiative. And let me just 

mention we have so many great organizations—Roll Back Malaria, 

Medicines for Malaria Ventures, the Malaria Vaccine Initiative, the 

Abuja Declaration, the Global Fund to Fight AIDS, Tuberculosis 

and Malaria, The Global Fund, One World Health, the President’s 

Malaria Initiative, Malaria Control and Evaluation Partnership in 

Africa, the World Bank Booster Program for Malaria Control in Africa, Malaria No More, Malaria Vaccine Technology Roadmap of 

2006, the Global Malaria Action Plan, the Affordable Medicines Facility, and the African Leaders Malaria Alliance—all are working 

together in a coordinated effort. 

I have to commend Ray Chambers from my City of Newark who 

is the Special Envoy to the United Nations Secretary General for 

Malaria, and he and Peter Churnin are the ones who started Malaria No More; but Ray Chambers has done a fantastic job working 

on this, and of course, the Bill & Melinda Gates Foundation. Mr. 

Gates is involved in several of these organizations that I mentioned, and without him—I had the privilege to be at a meeting, 

it was like a fly on the wall, at the meeting with Mr. Gates and 

a number of people about 3 weeks ago, where they just talked 

about a war on malaria and the vision that there will be a vaccine 

created in our time in the future, in the near future. 

And so once again there is nothing that is passionate as this to 

me, and I commend the chairman for calling this important hearing. Thank you, I yield back. 

Mr. SMITH. Thank you very much. Mr. Turner. 

Mr. TURNER. Thank you, Mr. Chairman. I am interested in hearing what our distinguished and expert panel has to say. I yield 

back. 

Mr. SMITH. Thank you, Mr. Turner. 

Without objection, I ask that the full remarks of Vice Chairman 

Jeff Fortenberry be made a part of the record. I would note for the 

record that he co-chairs the Congressional Malaria and Neglected 

Tropical Diseases Caucus, as noted by Mr. Payne. But he also authored an amendment to the State Department authorization bill 

that reaffirms our commitment to end malaria deaths by 2015. He 

is unable to be here today and his full statement will be made a 

part of the record. 

I would like now to introduce our distinguished witnesses and 

again thank them for the Herculean efforts they have expended in 

trying to eradicate this vicious disease. Beginning first, welcoming 

back Ambassador Mark Green, former Member of the House, who 

served with great distinction here. Ambassador Green is a senior 

director of the U.S. Global Leadership Coalition and has had an extensive career in public office. He served as U.S. Ambassador to 

Tanzania from 2007 to 2009, where he worked closely with Tanzanian leaders to combat diseases such as malaria and HIV/AIDS. 

From 1999 to 2007 he served in the House of Representatives as 

a member of the International Relations Committee. He played a 

leading role in crafting the Millennium Challenge Act as well as 

other key legislation that addressed the global struggle to eradicate 

malaria. Ambassador Green has also served as managing director 

of the Malaria No More Policy Center right here in Washington, 

DC. 

5

We will then hear from Dr. Dennis Schmatz who is president of 

the U.S. Board of Medicines for Malaria Venture, and has over 30 

years of drug discovery experience. He was formerly the vice president of infectious disease research at Merck Research Laboratories. 

Dr. Schmatz has been involved with malaria research for his entire 

research career. He has served on and chaired a number of scientific advisory boards for the World Health Organization, including the tropical disease research program, and was founding member of the Medicines for Malaria Venture Expert Scientific Advisory 

Committee. He has a proven track record in managing large research teams across diverse therapeutic areas toward the successful delivery of novel medicines. 

We will then hear from Dr. Regina Rabinovich, who is currently 

the director of Global Health Infectious Diseases at the Bill & 

Melinda Gates Foundation, where she oversees the development 

and implementation of strategies for the prevention, treatment, 

and control of malaria. Dr. Rabinovich joined the Foundation in 

2003. She previously served in various positions at the U.S. National Institute of Allergy and Infectious Diseases, where she participated in Children’s Vaccine Initiative, and served as liaison to 

the National Vaccine Program Office. Dr. Rabinovich has also 

served as chief of the Clinical and Regulatory Affairs Branch of the 

Division of Microbiology and Infectious Diseases. 

Then we will hear from Dr. Roger Bate who is the Legatum Fellow in Global Prosperity at the American Enterprise Institute and 

a founding director of Africa Fighting Malaria. He researches international health policy with special interest in counterfeit medicines 

and malaria control. Dr. Bate has conducted extensive research in 

India and numerous African countries on the public health consequences of the counterfeit drug trade. He writes extensively on 

topics such as endemic diseases in developing countries as well as 

access and innovation in pharmaceuticals and international health 

agreements. He is author or editor of 14 books, 2 dozen peer-reviewed journal articles, and hundreds of newspaper articles. 

We will then hear from Dr. David Bowen who is currently the 

CEO of Malaria No More. Until November 2011, Dr. Bowen served 

as the deputy director for Global Health Policy and Advocacy at the 

Bill & Melinda Gates Foundation. In this role he had the responsibility for interactions between the Foundation and governments 

worldwide on global health. Dr. Bowen was previously staff director 

for health of the Senate Committee on Health, Education, Labor 

and Pensions. From 2000 to 2002, he held a joint appointment as 

a visiting fellow in the Department of Health Care Policy at Harvard Medical School. 

And finally, we will hear from Dr. Richard Steketee, who is the 

science director for the Malaria Control Program at PATH. He previously served as an active-duty member of the U.S Public Health 

Service and has served in a number of positions at the Centers for 

Disease Control and Prevention. These positions, including chief of 

the Malaria Epidemiology Section, branch chief of the Prevention 

Services Branch, and chief of CDC’s Malaria Branch. During his 

tenure with CDC, he lived in Malawi for 4 years working on malaria research. Dr. Steketee also provided expertise on malaria to 

a number of international consortia. 

6

Without objection, the fuller resumes of our very distinguished 

panel will be made a part of the record. 

I would like to now yield to my good friend and colleague, Ambassador Green, for such time as he may consume. 

STATEMENT OF THE HONORABLE MARK GREEN, SENIOR 

DIRECTOR, U.S. GLOBAL LEADERSHIP COALITION 

Ambassador GREEN. Thank you, Mr. Chairman and Ranking 

Member Payne and members of the subcommittee. I am truly honored to be appearing before this subcommittee and to have this 

chance to talk with you about an underpublicized success story, a 

great success story in American development policy. I also want to 

respectfully commend you for holding this hearing, because the 

final chapters in that story have yet to be written. As lawmakers 

such as yourselves, who obviously care deeply about Africa and the 

developing world, you are going to be the ones with pen in hand 

as we go forward in writing the final chapters. 

Very quickly, in terms of my own background, I myself suffered 

from malaria when I served as a teacher in Kenya in the mid1980s. One of my students died from malaria shortly before I came 

back. I have also had the honor of helping to craft malaria policy 

from my days as your colleague on this committee, to my days as 

Ambassador to Tanzania, which is one of the original President’s 

Malaria Initiative Focus countries. I have also had the privilege of 

advocating for malaria programs as a member of Malaria No More, 

and you will hear shortly from that organization’s distinguished 

new CEO, Dr. David Bowen. 

Since you will be hearing from experts like Dr. David Bowen who 

are far more conversant than I am on the numbers and research 

associated with this great success story, I will try to confine my remarks to what I believe is in many respects the most exciting development in this long battle, and that is leadership, leadership 

right here in the U.S. and, more importantly, exciting leadership 

in Africa itself. 

As you have laid out very well, Mr. Chairman, malaria has been 

with us for centuries and it has claimed millions of lives. And there 

have been times when the world has scored remarkable victories, 

truly important victories, eliminating the killer disease from places 

like the U.S. and Europe. There have been times when it seemed 

that victory was in sight in some of the world’s hardest-hit regions. 

Only to fall short. 

Members of the subcommittee, I honestly believe that this time 

the fight is different. These days the world is making real and sustainable progress. We have never been this close and we have 

never come this far in providing hope for generations of children 

and families all across the sub-Saharan Africa. Millions of lives 

have been saved and millions of lives can be saved in the years 

ahead. Most importantly, a new generation of strong African leaders is rising to take on the malaria challenge. While it is true that 

Africa cannot conquer malaria alone, it is just as true that the killer disease cannot be defeated unless Africans lead the way, and 

they are. 

At the 2009 United Nation’s General Assembly, 14 African heads 

of state in government came together to rededicate themselves to 

7

the goal of ending malaria deaths by 2015. They launched a new 

coalition called the Africa Leaders Malaria Alliance, or ALMA. Just 

2 years later, ALMA has grown to 41 heads of state and government, including membership by the African Union itself. It has become an invaluable forum for leaders to share ideas and best practices and to collaborate on common challenges. 

In just its first year of existence, ALMA tackled important issues 

like securing universal access to artemisinin-based combination 

therapies to prevent drug resistance, removing taxes and tariffs on 

essential antimalarial products, increasing local production of highquality, safe and effective antimalaria interventions, and the banning of monotherapies. That would not have been possible just 4, 

5, 6 years ago. 

As you will hear today, the world’s public health experts are 

armed with effective new tools and technologies. Just as with 

man’s struggle against killers like smallpox and polio, our scientists have labored long and hard in pursuit of a vaccine against 

malaria. While, as you will hear more today, researchers can now 

report historic progress. The first ever large-scale phase 3 trial of 

a malaria vaccine is underway right now in Africa. 

Some of the most exciting developments in our drive to end malaria deaths come not from new technology, but new uses of existing technology, and that to me is truly exciting. Take the example 

of the simple mobile phone, something that I think all of us here 

take for granted. Mobile phones are commonplace in sub-Saharan 

Africa. In fact, most experts tell you that is the great growth market. But now, thanks to innovative ingenious leaders in both the 

public and private sector in Africa, they have become not just simple mobile phones but amazing logistical and analytical tools to address global health challenges. Perhaps one of the best examples is 

the Malaria Early Epidemic Detection System, known as MEEDS, 

which is funded in part by the American people through USAID, 

the Centers for Disease Control, and PMI. 

The islands of Zanzibar, as you probably know, are part of Tanzania. They have almost eliminated malaria from their shores. To 

help them cross the finish line of totally breaking malaria’s death 

grip, the tool called MEEDS was created. Working with the Zanzibar Malaria Control Program, it was developed to detect the early 

stages of an epidemic within 2 weeks of onset. Every single Monday, health leaders from 53 different stations in Zanzibar use textmessaging technology to send into an automated server any positive tests that they have of malaria. If in fact there is a positive 

test or a tick up, if you will, they pounce on the epidemic with all 

of the interventions that we know about and work to erase it, to 

wipe it out. It is a partnership between pubic health leaders and 

Selcom Wireless. It is a remarkable example of taking an existing 

technology, bringing together the public sector, bringing together 

the private sector, and putting it to work. That is great leadership. 

Leadership in the fight is also coming from communities of faith. 

Nowhere in the world are faith networks more important or more 

influential than in Africa. Faith institutions, Christian and Muslim 

in particular, can reach towns and villages that are cut off all too 

often from limited infrastructure. And the message is that faith 

8

leaders express—well, let’s face it, they carry a lot more weight 

than any of us as politicians could ever hope to do. 

With one-fourth of the world’s malaria deaths occurring in Nigeria, a coalition of interfaith groups, international organizations, 

and Nigerian health officials are working hard to deliver interventions. 

The Sultan of Sukoto, the most powerful Islamic leader, who represents 70 million Muslims, and the Catholic Archbishop of Abuja, 

his counterpart among Christians, launched an effort to train 

300,000 imams, priests, pastors and ministers to carry the malaria 

prevention message to villages throughout the country. I don’t have 

to tell you how important this unity is, not only for public health 

reasons and in fighting malaria, but quite frankly for what it 

means for our national security interests. 

In 2002 world leaders created the Global Fund to Fight AIDS, 

Tuberculosis and Malaria. The Global Fund now funds nearly twothirds of the world’s malaria projects. Launched in 2005, the President’s Malaria Initiative has increased funding from $30 million to 

$618 million. These extraordinary investments have enabled a 

rapid scale-up of proven interventions such as insecticide-treated 

nets and rapid diagnostic tests. That is American leadership that 

works, and it is American leadership that shows the world what we 

stand for, and it shows the best that America has to offer. 

You have tough choices to make, obviously, in the months and 

years ahead, but what I can say to you is investments we make in 

malaria are working, their success is measurable, verifiable, and 

predictable. We know these tools work, we know how to conquer 

malaria, a disease that has killed so many millions. 

In the last 5 years deaths from malaria have fallen by over 20 

percent, and malaria cases have dropped by 50 percent in over 40 

countries worldwide, and that translates into millions of lives 

saved. There are always challenges and malaria is not exempt, but 

I continue to be impressed by the innovative efforts from the public 

sector and private sector. It is a remarkable success story. 

One last success story I wanted to point out to you that again 

shows the strength of leadership, public and private, and that is 

the challenge that Tanzania faced in trying to take care of its 

logistical challenge, how you actually get those interventions, those 

medical supplies, out to different parts of the country. 

The Global Fund helped the Government of Tanzania reach out 

to the private sector, and the result was a public-private partnership with an American organization that knows a thing or two 

about getting effective supply chains in place, an organization 

called Coca-Cola. Now Coca-Cola is providing technical expertise to 

individuals in Tanzania to develop stronger, more effective, and 

more extensive supply chains, better delivery to more places. That 

is a great success story that we can celebrate. 

So as we look to the future it is with a sense of great hope. We 

have come a long way in this fight. And those of us who were in 

the field 20 and 30 years ago, quite frankly if you would have told 

us then about the success that we would see, I am not sure that 

we would have believed you. This is a story of Republicans and 

Democrats coming together, this is a story of Americans working 

together with African leaders. This is a story of security experts, 

9

faith leaders, the world, truly coming together and it is a story to 

celebrate and to publicize because it is absolute proof that we can 

make a difference. Thank you, Mr. Chairman. 

[The prepared statement of Ambassador Green follows:]


71619a-1.eps
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Mr. SMITH. Thank you very much for your very encouraging testimony, but also the focus you put on leadership, and when that 

leadership is truly creative and determined, the huge benefits and 

consequences it actually yields. So thank you so very much. 

And personally, I want to thank you again for your personal 

leadership on this. You know how this place works, you know how 

the executive branch works, and you having lived in Africa both before and during your ambassadorship, you know what really works 

there. So your advice and counsel has been very, very helpful to the 

committee, to the Congress, and to the executive branch. Thank 

you. 

I would like to now yield such time as he may consume to Dr. 

Schmatz. Please proceed. 

STATEMENT OF DENNIS SCHMATZ, PH.D., PRESIDENT OF THE 

BOARD, MEDICINES FOR MALARIA VENTURE NORTH AMERICA, INC. 

Mr. SCHMATZ. Mr. Chairman, Congressman Payne, and members 

of the subcommittee, my name is Dennis Schmatz. I am president 

of Medicines for Malaria Venture’s U.S. Board, and I chair the 

MMV Expert Scientific Advisory Committee. Thank you for the opportunity to testify on the role that drug development plays in combating malaria in Africa and around the world. 

Since World War II when malaria disabled hundreds of thousands of our troops, the United States has been a key player in the 

development of malaria drugs. Those treatments originally deployed for our troops were used in the 1950s and 1960s to assist 

in the first global wave of malaria eradication. As those drugs became less and less effective due to growing resistance to the parasite, the U.S. again became involved with malaria drug development for our troops in Korea and Southeast Asia. 

Since then, the United States has continued its leadership role 

in malaria drug research, in part to protect our continued interests 

around the world and in part to care for the greater than 200 million people who contract the disease each year. When these people 

sicken, they are unable to earn wages, unable to care for their children, and countries lose billions of dollars in GDP per year. Over 

800,000 die each year, the most vulnerable being children under 5, 

and pregnant women in Africa. 

Continued investment in malaria drug research benefits both the 

U.S. and its allies, both troops and civilians, around the world. 

MMV receives funding from the U.S. Government from USAID and 

NIH, as well as from other foreign governments, including the 

United Kingdom, Switzerland, and Ireland. 

MMV is a private-public partnership based in Switzerland and 

registered as a 501(c)(3) in the U.S. Our mandate is to discover, develop, and deliver effective and affordable medicines to those who 

need them most. We need lead collaborations around the world to 

protect the most vulnerable, and to find new treatments that make 

management of malaria better, cheaper and easier, and to prevent 

transmission and relapse of malaria to finally help eradicate this 

disease. 

Protecting the most vulnerable, MMV can point to two recent 

successes. First, in 2009 we launched Coartem Dispersible in partVerDate 0ct 09 2002 14:04 Mar 06, 2012 Jkt 000000 PO 00000 Frm 00016 Fmt 6633 Sfmt 6633 F:\WORK\AGH\120511\71619 HFA PsN: SHIRL
13

nership with Novartis. Coartem D is a cherry-flavored pediatric formulation of the effective but bitter adult drug, Coartem. Before the 

development of this pediatric medicine, adult tablets were crushed 

and given to children, and dosing was approximate since children 

often spit or vomit it up, leading to suboptimal treatment. 

Since the launch of Coartem D, over 92 million doses have been 

distributed in 35 countries and it is rapidly becoming the preferred 

treatment for young children in Africa. 

MMV also partnered to manufacture and deliver injectable 

artesunate to treat severe malaria. Studies published in the UK 

journal, ‘‘The Lancet,’’ demonstrated that there were significantly 

fewer deaths using injectable artesunate versus the commonly used 

IV quinine. It is also much easier to administer than quinine and 

it has fewer side effects. Because of these other factors, Doctors 

Without Borders independently estimates that this drug could save 

some 195,000 lives each year. 

Since its launch in January, our partnership has been responsible for delivering over 1.1 million vials of this lifesaving drug, 

enough for 237,000 severely ill patients. However, there is still a 

number of unmet medical needs. Resistance to artemisinin, the primary compound in all the front-line drugs, appears to be developing along the Thai-Cambodian border, the same location where 

the last great wave of malaria resistance to chloroquine developed. 

The last time this happened, the world was caught empty-handed, with millions of people exposed to malaria and with no effective 

drug to cure their disease, our citizens among them. We simply 

cannot be caught empty-handed again. We must have new drugs 

at the ready to combat resistance when it develops. Those drugs 

simply are not there right now and should resistance emerge with 

no treatment to combat it, we will lose much of the successful work 

that has been accomplished to roll back malaria around the globe. 

Unfortunately, today’s drugs are imperfect, either because the 

full treatment takes too long to complete or the cost of treatment 

prohibitive for those who need it the most. To solve this dilemma, 

MMV is working on a single-dose cure that is not based on 

artemisinin, and it could dramatically change the way that malaria 

is treated throughout the world. 

Such a drug, known as OZ439, is now in phase 2 studies. OZ439 

originated from an MMV-sponsored partnership in Nebraska, also 

in collaboration with other partners around the world. If it lives up 

to its promise, OZ439 could be one of the most valuable gifts the 

United States has brought to the fight against malaria. In truth, 

though, because drug development is a complex scientific process 

and because there are often unexpected events during clinical development, neither MMV nor its partners can take the risk of depending on just one new molecule. Therefore, we are nurturing a 

portfolio of promising projects around the world, including several 

in the U.S., which can supply the next two generations of drugs to 

combat malaria. 

My distinguished colleagues on the panel will discuss the crucial 

places that preventions, such as nets and vaccines, vector control 

such as insecticides, and diagnostics play in fighting against malaria. These interventions and the continued development of new 

drugs against this parasite would be crucial in order to eradicate 

14

the disease. If there is anything the world learned in the last great 

foray into eradication is that overreliance on too few tools to fight 

this disease quickly led to defeat. 

The United States Congress and the executive branch to the 

President’s Malaria Initiative, USAID, NIH, CDC and the Walter 

Reed are all key players in this arena. A future without malaria 

is within reach, but only if we stay vigilant. Without a continuous 

supply of innovative medicines, defeating malaria will not be possible. 

Thank for the opportunity to testify. 

[The prepared statement of Mr. Schmatz follows:]

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Mr. SMITH. Thank you very much, Dr. Schmatz. Thank you for 

the encouraging news but also telling us about the ongoing challenges faced by all of us in finding the drugs that will truly mitigate and hopefully eradicate and treat this disease. 

I would note parenthetically that sitting right behind you is 

Mark Tavlarides. As Ambassador Green said earlier, he once 

served up here where Mark used to sit right here as chief of staff 

for the human rights subcommittee under Gus Yatron. He did a 

great job. He was Democrat staffer, worked very well with the minority. We became great friends over the years, and I want to 

thank him for his leadership in helping this hearing come into fruition. 

Dr. Rabinovich, you are next. 

STATEMENT OF REGINA RABINOVICH, M.D., DIRECTOR, INFECTIOUS DISEASES, GLOBAL HEALTH PROGRAM, BILL & 

MELINDA GATES FOUNDATION 

Dr. RABINOVICH. I want to thank you, Mr. Chairman, Mr. Payne, 

Mr. Turner, and other members of the subcommittee for taking the 

time to focus on malaria and for your commitment over the years 

to robust U.S. investment in global health and development. 

We have come a long way in malaria from just 10 years ago. 

Since 2000, more than 1 million African children have been saved 

from malaria. Approximately half of all countries with malaria 

have reduced malaria cases and deaths by 50 percent or more. This 

tremendous progress against malaria has been due to innovation 

and prevention and treatment, increased funding, and political will. 

New tools such as long-lasting insecticide-treated bed nets, and 

artemisinin-based and combination therapy, along with prevention 

during pregnancy, and indoor residual spraying, all of these have 

made this progress possible. 

The U.S. President’s Malaria Initiative, the Global Fund to Fight 

AIDS, TB and Malaria, and the World Bank are essential to the 

remarkable successes in malaria control. The Global Fund alone 

has distributed 190 million bed nets to protect families from malaria. 

I was trying to think about how big you would require a container to hold 190 million, to make that clear, but it is a tremendous effort and one that is worthy of note. 

The President’s Malaria Initiative provides lifesaving prevention 

and treatment to millions of people in Africa and Southeast Asia. 

However, even today, malaria has a disproportionate impact on the 

world’s poorest and most vulnerable individuals and still kills far 

too many children each year. Our children here in the U.S. do not 

have to suffer from malaria. No child anywhere should. 

Maintaining the gains achieved today in malaria control is essential, but it is not assured without the continued commitment of 

multiple partners, including the U.S. Government. Guided by the 

principle that all lives have equal value, the Bill & Melinda Gates 

Foundation works to help all people lead healthy and productive 

lives. Our Global Health Program seeks to ensure that lifesaving 

advances are developed and that they reach those who need the 

most. 

21

In malaria we focus our efforts on improving existing tools, on 

discovering new ones to reduce and prevent malaria transmission, 

and, in the long term, to eradicate malaria worldwide. 

Existing interventions have contributed to a 20-percent decline in 

mortality due to malaria. We must continue to improve access to 

intervention like long-lasting insecticide-treated bed nets, indoor 

residual spraying, and treatments that save lives. The impact of 

tools available right now is very real. However, the malaria parasite has a history of adapting to drugs and adapting to insecticides. 

Drug resistance to the most effective drug available, artemisininbased and combination therapy, is developing and has been recognized in Southeast Asia. 

Research and development is essential because the preventive 

tools available today that are so effective at controlling malaria are 

not sufficient to control malaria in the long term or for eradication, 

due in part to the development of the resistance. Today the world 

has the strongest research and development pipeline for malaria 

that has ever existed, and we must ensure that it stays this way. 

Significant credit goes to the National Institutes of Health, which 

is one of the primary funders of malaria research and development. 

When I left the National Institutes of Health to join the Malaria 

Vaccine Initiative, I was asked why I would bet my career in creating a malaria vaccine, something that did not exist and which 

had been troubling to many initiatives previously. At the time, I 

didn’t really have an answer based on impact. Most researchers 

were not convinced that the scientific path to a malaria vaccine 

was clear. And even if our work resulted in promising candidates, 

we did not know how we would finance or how we would deliver 

them. After all, at the time, which was about a decade ago, even 

the cheap and broadly available measles vaccine was not being 

used worldwide. 

In the last 10 years a lot has changed. We are much closer to 

having a malaria vaccine that works, through significant efforts by 

the PATH Malaria Vaccine Initiative and by many partners. It is 

possible a malaria vaccine will be available by 2015. We have seen 

interim results for the RTS,S malaria vaccine, which were announced in October and published in the ‘‘New England Journal of 

Medicine.’’ It showed that that vaccine, so far, prevents clinical malaria in 56 percent of the trial participants over a period of 1 year, 

and these are the first results. Those results are exciting. We now 

have proof it is possible to create a vaccine that is effective against 

malaria. 

The U.S. Government, through funding through the Department 

of Defense and USAID, has played an important role in development of this vaccine. 

Research is also underway on other vaccine candidates, including 

transmission-blocking vaccines which would prevent people infected 

with the malaria parasite from passing the disease on to mosquitoes, who would then infect other people, or, if vaccinated, not infect other people. In the effort for malaria eradication, these vaccines will ultimately be invaluable. However, significant work is 

still needed on the development of vaccines, and the U.S. Government will continue to play an important role in supporting these 

efforts. 

22

The Gates Foundation also invests in development of new drugs 

and methods to control mosquitoes. And there are today significant 

potential on both fronts. Medicines for Malaria Venture, as we 

heard from the previous speaker, is developing new drugs with entirely new classes of action, including a potential single-dose cure 

which would radically improve our ability to treat malaria in the 

field. 

The Innovative Vector Control Consortium and other partners 

are working on new insecticides for bed nets and entirely new 

methods to control mosquitoes that could look like the mosquito 

coils we use in our backyards or wall linings, with insecticides that 

are easier to use than bed nets. We must continue to support the 

development of new treatment and preventive measures to ensure 

that we stay a step ahead of the evolving parasite. 

We have reached an inflection point, a moment in which we either forge ahead and ensure permanent progress in the fight 

against malaria, or we slide back and run the risk of losing much 

of what we have already achieved. This is not the time to relax our 

guard. We cannot afford to accept partial success. To fight malaria 

we have to maintain momentum. We are either gaining ground or 

we are losing it. Resistance to drugs and insecticides is a very real 

threat. We have come too far to accept backsliding in the fight 

against malaria. 

In the face of today’s challenges, there is one primary reason that 

I am optimistic for the future of malaria, and that is the commitment and dedication of so many people here in the U.S. and around 

the world, from scientists and researchers, program managers in 

the field, political leaders, and partnerships faith-based organizations and nongovernmental organizations that have emerged to 

fight this disease. I am optimistic that we must face the current 

situation with urgency. Malaria fights back and recent gains could 

be lost. We need to be smarter, we need to act faster. We must continue to fund the President’s Malaria Initiative and the Global 

Fund. This funding saves the lives of children, women, and entire 

families. 

We also recognize funding is needed to develop new treatments 

and methods of prevention and to deliver more effective and affordable interventions. The Gates Foundation’s long-term objective is 

the eradication of malaria, but we can only achieve eradication if 

we act urgently and maintain attention and funding today. We are 

committed to fighting malaria for the long haul. Commitment and 

leadership by diverse partners, including the U.S. Government, African leaders, nongovernmental and faith-based organizations, and 

the private sector is critical. 

It has been an honor to appear before you today. I appreciate 

your time and I look forward to a productive conversation. 

Mr. SMITH. Thank you very much for your testimony and leadership. 

[The prepared statement of Dr. Rabinovich follows:]

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Mr. SMITH. We now turn to Dr. Bate. 

STATEMENT OF MR. ROGER BATE, LEGATUM FELLOW IN 

GLOBAL PROSPERITY, AMERICAN ENTERPRISE INSTITUTE 

Mr. BATE. Mr. Chairman, members of the committee, thank you 

very much for inviting me to testify on this extremely important 

topic. Just over 7 years ago, I testified before the committee on 

what was then a relatively weak effort against malaria. The United 

States Government and other donors were not funding all viable 

control measures. The most politically charged was the lack of the 

use of insecticide DDT, but, as important, was the lack of support 

for the best malaria drugs. 

Not long after that hearing, the reforms and funding began in 

earnest. The U.S. Government started implementing all interventions. The Global Fund ramped up spending on both preventative 

and treatment efforts, including the best drugs to fight malaria the 

artemisinin combination therapies (ACTs), which have already 

been mentioned. 

Progress was swift and impressive, particularly in locations targeted by the President’s Malaria Initiative, particularly the island 

the Zanzibar. And for those efforts and other efforts, the President’s Malaria Initiative in my estimation is deserving of continued, even increased, support. 

The Southern African Development Community is targeting malaria elimination in eight countries, starting with Botswana, Namibia, South Africa, and Swaziland. With enough political will, 

elimination is a real possibility relatively soon. So overall there is 

good news. I would echo every comment that has been made by 

every speaker so far. And I stress it is good news, because I intend 

on spending the bulk of my time discussing some of the significant 

challenges that I see that remain. And those discussions are going 

to revolve around problems related to drug resistance. There are 

others I could mention; mission creep in certain agencies, and procurement problems which is increasing mortality in certain occasions. We may get to those in questions. 

But as has already been mentioned, the artemisinin combination 

therapies are the best treatment available. Resistance is being noticed on the Thai-Cambodian-Burmese borders, and resistance is 

likely to increase. 

I am going to cover a few reasons as to why I see that to be the 

case. The first is fake and substandard antimalaria medications are 

a significant, and probably a growing, problem. It is uncertain how 

many poor-quality antimalarials there are on the market in Africa, 

but it is certainly not a negligible amount. Many of these inferiorquality products are not illegal in the countries in question. 

Of the sampling that my research team and colleagues around 

the world have done, we found that roughly about half the drugs 

that failed quality control contain artemisinin, so they are directly 

contributing to resistance. There is also an increasing proliferation 

of brands, legitimate and otherwise, in many countries in the 

world. Nigeria has already been mentioned. Nigeria and Kenya 

have over 200 different brands of artemisinin therapy on sale. 

Working with the American Enterprise Institute, you would not 

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kets, but this is not a controlled market. There is a considerable 

free-for-all in these markets and its quality control is bad because 

the medical regulation authorities in those countries have limited 

capacity. 

There is a significant positive note that the U.S. Government is 

supporting via the U.S. Agency for International Development—the 

very excellent program on quality medicines at U.S. Pharmacopeia, 

which is combating fake and substandard drugs, and helping developing-country medical regulatory authorities to identify unregistered illegal medicines and whether they cause problems. Most will 

on the market. 

Again, from different research that colleagues of mine have undertaken, unregistered medicines on the whole fail quality control 

tests five times more often than registered medicines. So simply 

getting the medical regulatory authorities to control what is on the 

market for antimalarials, I think, is important. The U.S. Pharmacopeia program, to the tune of $35 million, is in my opinion deserving of continued and increased support. 

The second major problem related to increasing resistance has already been mentioned. That is the sale of monotherapies. Coordinated action and attempts for the last 6 years to remove these from 

the markets, in Africa in particular, have had some success. But 

there are still some companies, a few companies in China, Vietnam, and to a lesser extent India, that are still producing them. 

This is a major contributor to resistance. 

In order to combat those monotherapy sales and replace them 

with ACTs, a team at the Institute for Medicine suggested subsidizing ACTs in the private sector, where most people buy their 

drugs. In the poorer regions, probably around 70 percent of drugs 

are bought privately. 

The Affordable Medicine Facility for Malaria is currently being 

piloted by the Global Fund in eight countries. This is an interesting 

idea. It may have a significant impact where it works well, but 

from my assessment of it, this is a project that has run ahead of 

itself. It is not achieving its aim. Even though we are in the first 

year and the first pilot phase, we are already beginning to see significant problems. For instance, the AMFm is exacerbating existing 

problems with diagnosis. This is not unique by any means to the 

AMFm, but it is increasing the number of people being treated 

with malaria drugs who do not have malaria. 

Secondly, there are ordering practices going on. We have already 

heard Zanzibar has almost eliminated the disease, yet 243,000 ACT 

treatments were authorized by the Global Fund for Zanzibar, and 

70 percent of all of the orders for AMFm are for adult treatment. 

Malaria is primarily a childhood disease. 

So there are significant problems that we are noticing out there. 

The subsidy is supposed to massively reduce the price of these 

drugs. Looking in 37 pharmacies in Nigeria and Ghana, my research team found that the drugs were two to five times higher in 

price than had been expected. Yes, they are lowering the price of 

ACTs, which is good. They are driving out some of the 

monotherapies. But the impact is still very worrying. Perhaps most 

worrying of all is that four pilot countries—Kenya, Nigeria, Ghana, 

Tanzania—account now for 80 percent of the annual global ACT 

28

production capacity if all of those orders are fulfilled. That is a 

major problem. 

The United States Government so far has boycotted the AMFm, 

and I think for good reason. And you might wonder why I am mentioning the AMFm if the U.S. Government isn’t funding it. Well, I 

think the U.S. Government procurement program of malaria treatments are going to be seriously curtailed. I already know that there 

will be serious problems in procuring medicines over the next 6 

months. 

All in all, the AMFm is disrupting distribution systems and causing medicine procurement to operate on a first come/first served 

basis, creating huge problems. The Global Fund already doesn’t 

have enough funding to fund its round 11, and it is probably short 

of funding for the AMFm. In my opinion, it should probably be 

stopped now before it completes the initial phase. I like experiments, I like to try and find out when things work. This is an innovative idea. If it continues through the first phase, we might learn 

enormously interesting information. In my opinion, the U.S. Government should work harder to end the AMFm, or at least limit its 

scope, before even greater damage is done to distribution systems, 

and it has a harmful effect on drug resistance. 

I could go on on other potential challenges, but I will end there, 

thank you. 

Mr. SMITH. Dr. Bate, thank you very, very much. 

[The prepared statement of Mr. Bate follows:]

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Mr. SMITH. Dr. Bowen, please proceed as you would like. 

STATEMENT OF DAVID BOWEN, PH.D., CHIEF EXECUTIVE 

OFFICER, MALARIA NO MORE 

Mr. BOWEN. Chairman Smith, Ranking Member Payne, Mr. 

Turner, and members of the subcommittee, thank you for the opportunity to testify on the great strides we have made and are 

making toward eliminating malaria as a public health threat. 

Members of this committee on both sides of the aisle have been 

great champions in the fight against malaria and your support has 

helped save countless lives. 

I would like to echo Ambassador Green’s comment that this is an 

under-publicized and under-appreciated success story against a disease literally as old as humanity itself. 

I am David Bowen, the CEO of Malaria No More, an advocacy 

organization which was established 5 years ago, at the White 

House Summit on Malaria. Thank you, Ambassador Green, for that 

very generous introduction. Yours are very, very big shoes to fill. 

Malaria No More works to raise awareness and build support for 

the fight against malaria among policymakers, the public, businesses, and we have helped provide 2.7 million lifesaving mosquito 

nets. Thanks to a global partnership of government, the private 

sector, faith-based organizations, and community leaders across the 

world, there have been remarkable advances in the fight against 

malaria. Global malaria deaths have fallen by over 20 percent, and 

in less than 5 years malaria cases have been halved in over 40 

countries, and childhood deaths from malaria fell by over 200,000. 

Yet the fact remains, the unacceptable fact remains that malaria 

still kills a child every 45 seconds. 

To address this major health threat, the President’s Malaria Initiative was launched in 2005 by President George W. Bush, with 

strong bipartisan support from Congress, and has been continued 

and expanded under President Obama. Since its founding, PMI has 

distributed over 30 million insecticide-treated mosquito nets, provided over 67 million lifesaving antimalarial treatments, and protected more than 27 million people as a result of indoor residual 

spraying. 

The successes of PMI have been many, and a fuller list of examples is provided in my written testimony. But here I will mention 

just two. In Senegal, PMI documented a 40 percent reduction in 

child deaths between 2005 and 2010; and in Tanzania, child deaths 

fell by 28 percent in the same period. 

The success of PMI is inextricably linked to the efforts of the 

Global Fund. In his annual report the leader of PMI, Admiral 

Ziemer, stated, ‘‘Coordinating PMI investments with local initiatives financed by the Global Fund is critical to the success of both 

the Global Fund and PMI.’’

Under the leadership of George W. Bush and with bipartisan 

support in Congress, the U.S. pledged the founding donation to the 

Global Fund in 2001, and the U.S. continues to be its largest single 

donor. By law, the U.S. does not contribute more than 33 percent 

of the total funding, thereby leveraging $2 from other donors for 

every $1 invested by the U.S. taxpayer. The Global Fund provides 

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mately 200 million bed nets and treated 230 million cases of malaria. 

Through PMI and its contributions to the Global Fund, the U.S. 

is helping win the battle against malaria today. And U.S. support 

is just as indispensable to the effort to develop new ways of fighting malaria in the days to come. A remarkable innovation in this 

fight, as you have heard and you will hear further, is the RTS,S 

vaccine which has proven that additional protection against malaria is possible. 

Since the days of Walter Reed himself, the U.S. has been a leader in malaria research. And this proud tradition has been carried 

on with distinction by the Walter Reed Army Institute of Research 

which worked with GlaxoSmithKline and PATH to develop this impressive new vaccine. Sustained support for malaria R&D is crucial 

in developing new ways to prevent and treat malaria, as well as 

in combating the threat of drug and insecticide resistance. 

The remarkable progress made in recent years is critically dependent on robust funding. We are making major progress toward 

the day in which the world can say that malaria, like smallpox, is 

a disease of the past. This dream cannot be realized unless U.S. bilateral and multilateral funding remains strong. Through an investment of less than 1 percent of our budget, the U.S. saves and 

improves millions of lives, helps build robust current and future 

trading partners around the world, and contributes to our national 

security. 

Just this week AFRICOM published a statement indicating that 

malaria remains a direct threat to the health of U.S. personnel in 

that command. More indirectly, but just as crucially, widespread 

disease can contribute to the destabilization of a society, leading to 

failed states. According to the National Intelligence Strategy published under President Bush in 2005, ‘‘Failed states are a refuge 

and breeding ground of extremism.’’

Investing in global health is critical to advancing our economic 

interests and building jobs at home. History has shown us that today’s aid recipients often become tomorrow’s consumers of American goods. 

Eleven of the 15 largest importers of American goods and services are former recipients of U.S. foreign aid, including South 

Korea, Taiwan and Brazil. 

A recent African Development Bank report states that Africa’s 

income is expected to triple in the next 50 years. African countries 

as potential markets for American products can only be successful 

if their consumers are healthy and productive. 

The road to eliminating malaria deaths will not be easy. A fundamental requirement is the proper use of taxpayer funds. We must 

and will work against misuse of funds in any form and must also 

employ every feasible mechanism to guard against counterfeit or 

substandard medication. 

Malaria No More is dedicated to achieving measurable results. 

That is why we have partnered with the African Leaders Malaria 

Alliance, ALMA, through which African nations are holding themselves accountable by scoring their progress on country led efforts 

and sharing best practices. 

38

You have already heard from Ambassador Green about the leadership ALMA has shown in the fight against malaria. I just want 

to highlight one thing, which is the scorecard that ALMA has produced, ranking each country on their progress against definable 

measures. 

These kinds of scorecards provide clear public evidence about 

who is doing well and who needs to improve. We are optimistic that 

with robust support from the U.S. Government, we can continue 

the remarkable momentum of the last 5 years and bring forward 

the day which no child dies of this preventable disease. As a result 

of U.S. leadership, more children than ever before are surviving to 

see their fifth birthday and spending more time in school, giving 

them hope for a brighter tomorrow. More parents are able to spend 

time working to improve the lives of their children, their families 

and their communities. Thank you for the opportunity to testify, 

and I would be happy to take any questions. 

[The prepared statement of Mr. Bowen follows:]

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Mr. SMITH. Dr. Bowen, thank you very, very much. 

Now our final witness. I do thank for your leadership as well, so 

please proceed. 

STATEMENT OF RICHARD W. STEKETEE, M.D., SCIENCE DIRECTOR, MALARIA CONTROL PROGRAM, PROGRAM FOR APPROPRIATE TECHNOLOGY IN HEALTH 

Dr. STEKETEE. Thank you very much, Chairman Smith and 

Ranking Member Payne and Mr. Turner and other members of the 

subcommittee. 

It is a real pleasure to be here and I appreciate following a number of strong reports from each of my colleagues here at the table. 

Let me highlight a couple of things. One is that this progress has 

also shown us the incredible speed of change and innovation as we 

have gone forward, and it has been done through a remarkable 

partnership both within this country and across many nations. The 

second issue that I will come to, though, is that this progress is 

fragile and we need to pay attention because while there is speed 

in change and progress, holding that and going forward with it is 

and will be the true test for all of us. 

So just a little history: 1,000 years ago, we had just a name for 

this. Malaria comes from mal air or bad air, and that is what we 

thought caused it. It was just over 100 years ago that we actually 

identified the parasite and recognized that humans transmit them 

to mosquitoes and those mosquitoes transmit them to other humans. It was just over 50 years ago that we embarked upon a malaria eradication program globally. With actually huge success—

and you may hear different stories about that—but included in that 

was the United States eliminated malaria. And I was 19 years old 

when it certified its malaria eradication in the United States with 

the World Health Organization. 

Since that time, we actually had a hiatus after that global malaria eradication program. The scientists didn’t stop working, but 

there were essentially no resources. And in addition to that, the 

global malaria eradication program had never really gone to Africa. 

It had left out the hardest place in the world. 

At the end of the 1990s, particularly with the attention from 

leadership in Africa, we ended up with new leadership amongst the 

U.N. agencies and then that followed with resources. So this last 

decade, the first 5 years was essentially countries coming together 

and getting better plans, and we have that documented actually 

quite nicely. 

But the subsequent 5 years mark when the money came, the 

Global Fund was developed, the U.S. President’s Malaria Initiative 

and the World Bank Booster Program all came together and funding went from about $100 million a year of external assistance to 

malaria in 2000 to $1.6 billion in 2009 and 2010. Unfortunately, 

$1.6 billion is actually still relatively small, but it has made an 

enormous difference in what has occurred. 

That is a more than tenfold increase in the funding and that has 

been followed by essentially a tenfold reduction in the incidence of 

infection and that has led to the saving of essentially 1.1 million 

child lives in sub-Saharan Africa in the last decade, almost all of 

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patient visits for malaria have been reduced by 50 percent in at 

least 10 African countries and essentially almost all of the countries outside of Africa. 

That burden of all of those health visits actually saves money. 

The number of blood transfusions has markedly reduced; and to 

walk into a ward that used to be full of children getting blood 

transfusions and today seeing that work with one or two patients, 

sometimes empty, is the remarkable progress that has occurred. 

The countries show their ability to deliver this, and that is part of 

the partnership that has gone forward. 

So we have had many interventions out there, and we have always had concerns about whether or not this could go forward with 

actual country leadership and countries demonstrating that they 

could do the work. And as Dr. Rabinovich mentioned, the concept 

of 190 million bed nets into homes is a remarkable logistics effort. 

It is not perfect. There is still much work to be done, but that is 

truly remarkable. 

Another issue in this is the fact that this money has gone widely, 

and it has come from wide places. So U.S. leadership in this and 

particularly the President’s Malaria Initiative and the combined 

contribution also to the Global Fund have allowed us to do the 

right thing as Americans and the right thing to influence global donors because it is through the Global Fund that we have additional 

leverage to encourage other donors to come forward. And that has 

proven to be remarkable. 

In addition to that, the Global Fund has reached out and essentially supported programs in, I believe, 82 countries for the malaria 

control and that is 82 out of the 100 nations that have malaria. 

With all due respect to the 18 that didn’t get resources, they are 

the ones that are almost ready to eliminate. 

So, in addition to saving more than 1 million child lives in this 

last decade, we also have eliminated malaria transmission in four 

countries and certified that under WHO leadership. We have set 

goals between now and 2015 to eliminate in 10 additional countries, all of which is thought to be entirely doable as long as resources are available. 

Another aspect to be aware of is that some companies have invested in this, and we have actually been able to document that. 

Sugar industries in these countries, some mining companies, both 

for copper or for precious metals. Where the company provided prevention to their workforce and the families of their workforce, and 

then realized that the decreased number of health visits and the 

improved productivity of their workers meant that they got a return for every dollar invested. They essentially made back an additional dollar in lower costs and improved productivity. And that is 

a pretty good return on investment. So there has been a huge 

amount of work and investment by many people. 

The financing nations, ours included, the many agencies, the scientists and the countries themselves, where we have a little bit of 

trouble counting the money that individual countries have put into 

malaria control. That is a hard number to come up with because 

they pay the salaries of all their health workers. They support the 

facilities that they work in. And it is through that and the logistics 

systems that are supported by external funding and the commodVerDate 0ct 09 2002 14:04 Mar 06, 2012 Jkt 000000 PO 00000 Frm 00054 Fmt 6633 Sfmt 6633 F:\WORK\AGH\120511\71619 HFA PsN: SHIRL
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ities that are supported that actually allow them to deliver really 

important services. 

This demonstrated and remarkable success is just as fragile as 

it has been innovative and fun. What we do today is actually categorically different than what we did just one decade ago. We 

didn’t use insecticide-treated nets in hardly any homes. While we 

knew about indoor residual spraying, we weren’t doing it. We didn’t 

actually have ACTs to provide as the best drug. And we didn’t have 

a good rapid diagnostic test which we have today. We actually have 

many of them today that we can take out into communities and 

know where malaria is. And as was mentioned earlier, we have cell 

phones that allow people to send text messages and either alert us 

of outbreaks or tell us about cases and their needs for the supplies 

that are so important. But that progress is incredibly fragile and 

while the speed of change is remarkable, if we let our guard down 

and stop the resource flow, the speed of reversion will be, I am 

afraid, in our face. So, as has been mentioned, this has been 

through bipartisan leadership in our country. It has actually been 

bipartisan leadership across the globe or multipartisan leadership 

across the globe it has been an incredible health success. 

And let me just highlight the Roll Back Malaria Partnership produced and launched just 21⁄2 months ago this document on a decade of partnership and results in malaria control. And I refer the 

committee to this should there be additional questions about the 

extent and the numbers related to the success. We do this as people and the number of us have actually come down from the American Society of Tropical Medicine and Hygiene annual meeting 

being held in Philadelphia. That is actually a remarkable meeting. 

Many of the people there are malaria experts, certainly not all of 

them. A number of them work in other—particularly the neglected 

tropical diseases. But they provide huge leadership and have for a 

generation now and will continue to do so for subsequent generations. 

That leadership on the science side has finally turned to incredible success on the program side. And that is what makes me proud 

as a scientist, as somebody who cares about malaria and as an 

American citizen about our country’s investment in this because I 

don’t think there is any better. Thank you very much. 

[The prepared statement of Dr. Skeketee follows:]

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Mr. SMITH. Thank you very much, Doctor. 

Let me begin with the questions. And again, I want to thank all 

of you. 

Your full testimonies, without objection, will be made a part of 

the record, and they are very much filled with recommendations 

and good data that this subcommittee, and all interested parties 

here in Congress, ought to become very well acquainted with. 

Let me begin with Ambassador Green, if I could. You spoke of 

leadership, the importance of it, and others who might want to step 

in and speak to this as well, please do. How much U.S. funding is 

needed in the immediate term, this fiscal year, and going out into 

the near term, to ensure that there is no speed of reversion that 

I think we have to be very concerned about. We are in combat, as 

Dr. Rabinovich said, with the danger that this terrible parasite, as 

you put it, malaria, fights back and recent gains could be lost. I 

thought that was very telling and obviously very true. 

So if you could start with that. And secondly, Ambassador Green, 

you talked about the malaria early epidemic detection system. You 

talked about how MEEDs has been created and how well it worked. 

And I am wondering if this best practice is being replicated—and 

if anyone else would like to touch on it? Anywhere else, it seems 

to me when you prove something and prove it well, it ought to be 

rolled out as quickly as possible. 

Then you also spoke about the importance of faith-based collaboration, and I, too, believe that with the HIV/AIDS pandemic, without full cooperation with the faith-based community, particularly in 

Africa, where it represents 70 percent of all health care that is delivered via a health care institution or clinic. To bypass that would 

mean that fewer people get antiretrovirals, in the case of 

HIV/AIDS, as well as testing and all the other important things. 

You highlighted how the Catholics and the Muslims are working so 

well together to train 300,000 imams, priests, pastors and ministers to carry out the malaria prevention message to villages 

throughout Nigeria. 

If you could maybe elaborate on that a bit, because it seems to 

me that is not only an important health care initiative but also 

mitigates some of the unnecessary and deleterious animosity between Muslims and Christians in Nigeria, where there has been a 

flare up, as we know, in recent months and years. 

Ambassador GREEN. Well, thank you, Mr. Chairman. 

I will attempt to partially duck the first two questions you asked, 

particularly with respect to funding. What I would rather do is 

defer to my colleagues. And Dr. Bowen can talk to you a bit about 

the state of funding and the funding request. What I can say is 

that what separates the malaria challenge and our approach to it 

from some of the other challenges and choices that, respectfully, 

you face and you face here in Congress is, again, we know precisely 

what to do; that this is a question of our willingness to invest the 

necessary resources. Again, technologies are fairly proven. It is a 

financial challenge and a challenge in our commitment and leadership. 

A name that has come up a couple of times in the testimony that 

I would commend to you is Rear Admiral Tim Ziemer, the head of 

the President’s Malaria Initiative, who I believe is an outstanding 

63

leader in not just global health, but also in logistics. And what he 

can tell you is, take a look at the map of Africa and tell you in 

those countries in which PMI is operating, precisely what we—we 

being the world community—will get for the investment of resources. In other words, you can boil down to the bed nets that can 

be purchased, the rounds of indoor residual spraying that can be 

purchased, precisely what we will be able to get with resources invested. 

He can also tell you geographically, and one of the things that 

I think is remarkable about his leadership is when he takes a look 

at that map, he is able to tell you precisely what we need to be 

able to go into certain countries and add them to the list of those 

nations that will see a reduction in malaria of 50 percent or more. 

And the same is true with respect to your second question. 

MEEDs was a project that was developed and piloted in cooperation between the President’s Malaria Initiative, the country director, Dr. McElroy, working in Tanzania with public health leaders 

in Tanzania and Zanzibar, in particular. And it was launched just 

a couple of years ago but, again, has already shown remarkable 

progress. One thing you can count on from Admiral Ziemer is that 

he will, in fact, take and use those best practices and spread them 

wherever we can. 

One of the things that maybe—one of the reasons it was pioneered in Zanzibar—is because we had seen such progress down to 

the point of below 1 percent infection rate. And the question was, 

what does success look like? You know, when is it that we can say 

we have crossed the goal line. MEEDs is an effort to do just that. 

MEEDs is an effort to take the remarkable efforts that have been 

made, lock them in and to take those final steps to stamp out 

whatever, God willing, minor infection outbreaks that we see. 

With respect to the faith-based story, Nigeria in particular, but 

in other parts of Africa, it really is remarkable, just as you pointed 

to. It is remarkable for two reasons, or its advantages are really 

twofold. In terms of being able to deliver a product, I was always 

amazed as Ambassador when organizations from the West would 

come to me and talk about reaching out to other parts of the country and having no concept whatsoever about the logistical challenges that that presents. These are remote areas that are oftentimes completely cut off in terms of modern media access, in terms 

of the traditional infrastructure that, you know, we have become 

accustomed to. Faith leaders, of course, are well established in 

every corner of the land. So when you are able to enlist the armies 

of compassion that come from our faith leaders, you have a builtin distribution network that can move product very quickly. 

But the other part to it, that I really want to focus on, is faith 

leaders are able to pierce through the lack of education and knowledge that in some ways is the most daunting challenge that you 

face in some countries. When I taught school in Kenya, my students were absolutely convinced you got malaria from rain. And 

you could see how they would jump to that conclusion, and that 

would be relatively harmless, except if it comes from rain, why 

would you sleep under a bed net? So enlisting respected faith leaders, whose voice and opinion is held in high regard and trusted and 

listened to, they are able to pierce through that. 

64

I faced a similar situation last year when I went to Liberia, and 

part of the reason for that was with Malaria No More, where we 

did a focus group and asked young mothers why they didn’t sleep 

under a bed net. And a lady said to me that she couldn’t sleep 

under a bed net because at night when her spirit left her body and 

went out into the village, that if she slept under a bed net, it might 

not be able to come back. An American recovering politician can 

say over and over again, that is not what happens, and that of 

course is to no avail. But when the local faith leader comes and 

says, this is why we need to do this, that is the voice that makes 

a difference. 

The Nigeria story is the most remarkable in terms of numbers, 

and it really is a model to hold up as a success. And I think we 

all owe a debt of gratitude to the Center For Interfaith Action 

Against Global Poverty, another Gates funded institution, which 

has spearheaded this from our perspective. But the best news is it 

is not just confined to Nigeria. The story is in many other parts of 

the continent as well. 

Mr. BOWEN. If I might just pick up on two points from Ambassador Green. First, very briefly, on the faith-based organizations. 

I, until quite recently, worked for the Gates Foundation. And one 

of my most memorable experiences there was traveling to northwest Nigeria and working with the sultan and the amirs. And I 

had the privilege of being able to address a meeting called by the 

amir of Gwandu in a room that felt like it was about 120 degrees, 

where the entire leadership from northwestern Nigeria was there. 

And when the amir said, you know, please cooperate with the polio 

vaccination campaign, that message went from the amir, to the district’s head, to the village heads. It is an extraordinary reach. Just 

on the funding. 

We certainly strongly support the President’s request of $691 

million for PMI and $1.3 billion for the Global Fund. And the math 

here is grim, but inescapable. For every $50 million cut under the 

2011 levels, that means a million fewer bed nets distributed and 

2.5 million fewer combination therapies. 

Mr. BATE. I would concur with my panelists that the funding request from the PMI should indeed be met as best as possible. I 

think we also need to think tangentially about funding efforts that 

will improve malaria treatment. 

And so I will refer to the remarks I made before about USAID’s 

funding of the U.S. Pharmacopeia project on quality medicines, an 

extremely important role in building up. They have the competence 

to help the medical regulator authorities in these countries that is 

very important to control for quality of drugs. 

Where I may part company is on the funding of the Global Fund. 

I think the Global Fund is a fantastic organization, but recently, 

the high level independent review panel recommended that the 

Global Fund—and I quote—‘‘mandate the outsourcing of drug storage and delivery as the norm, except where the fund certifies a 

local institution according to international standards.’’ At the Global Fund’s 24th board meeting, it merely decided to give consideration to this recommendation rather than begin its implementation. 

65

In certain parts of Africa, where my colleagues and myself to a 

certain extent, have looked at the private sector ACTs markets. In 

one study we published in the peer-reviewed literature, 28 percent 

of the drugs on sale, the ACTs on sale in the private sector, were 

stolen and diverted from the public sector. That is because of poor 

management. 

Now, I think that the U.S. should be pressuring the Global Fund 

as far as it can to not only look into the recommendations of that 

high-level panel but actually enact them or perhaps potentially restrict the funding from the U.S. Government. 

Mr. SMITH. Dr. Schmatz, you identified, as did other panelists, 

the growing threat of resistance to artemisinin as a key challenge 

to controlling malaria. 

Dr. Bate, you talked about monotherapies, and that 6 years ago 

the WHO demanded that manufacturers stop making and selling 

artemisinin monotherapies. And you point out that producers in 

China, India, and Vietnam in particular, ignored WHO policies and 

demands and continue manufacturing these drugs. 

And, Dr. Bowen, you also talk about drug quality in your testimony, and you note, I think, some progress being made. But what 

about those countries that continue? It seems to me that China, 

which increasingly is garnering the market on the manufacture of 

drugs of all types, you know, this could be a serious detrimental 

effect of trying to use the ACTs, as you talked about in your testimony? Why are the WHO policies being ignored and resisted by 

these manufacturing countries? 

Mr. BATE. The extremely good manufacturers in China and India 

and perhaps in Vietnam—I know them less well—are brilliant at 

getting their products into the market. And that is one of the reasons why there are so many different brands and so many good 

antimalarials out there. And that needs to be stressed. And I probably should have stressed that before. 

The problem that you identified correctly is that they are not adhering—some of the manufacturers are not adhering to that. The 

only immediate thing I can think of doing is to in every sense limit 

donor support for any manufacturer that is selling a monotherapy, 

even if it is also selling an ACT. So do not fund the ACTs from 

those manufacturers that still are in breach of the guidelines. That 

is the only short-run thing I can think of doing. 

Mr. SCHMATZ. One aspect of that that I think does work is that 

for the Global Fund and other donor organizations, in many cases, 

countries cannot buy drugs that are not pre-qualified by WHO. And 

so I think that is a really important standard to set and to stick 

with. I mean, not that you can totally enforce that everywhere. But 

the funding that is used from these donor organizations, if it can’t 

be used for those other products, it won’t be. And at least they will 

focus you toward the ones that are quality drugs. 

Our mandate in everything we do is to focus on quality drugs 

that are approved by rigorous regulatory agencies, like the FDA or 

the DMA, and all the things we are bringing forward in the future 

and make sure those quality standards are met and that again 

those drugs would be pre-qualified by the World Health Organization to be the ones that could be bought with those funds. It is 

66

much more difficult, of course, in country to deal with drugs coming from other sources. 

Mr. BOWEN. And I would add just one comment which is that the 

ultimate response to resistance is really two-prong. One prong is to 

implement the safeguards that were identified against the use of 

counterfeit and substandard medications, but this is ultimately an 

arms race with the disease itself. And you can slow the pace of that 

through adequate controls, and we certainly should. But the other 

prong of the response is robust research and development so there 

is a constant stream of new approaches and new treatments. 

Ambassador GREEN. Mr. Chairman, just a couple of quick additional thoughts. 

You have put it the right way with respect to monotherapies, and 

that is focusing on the producers. Some might be tempted to ask, 

why can’t we ban these in-country? Of course, the difficulty is if 

you are a poor family in Tanzania and you have access to a 

monotherapy of artemisinin, which you are told will, in fact, address malaria for you, although in the future, it may lead to resistance, but it is much less expensive; it is very difficult to expect that 

family not to take the less expensive drug because, of course, in so 

many cases, they have profound challenges of poverty. So you are 

focusing on this issue in the right way. 

Secondly, I would hearken back to ALMA, the African Leaders 

Malaria Alliance, and really the banding together of heads of state 

from all across Africa has been a remarkable development and I 

think offers great hope in this area. Dr. Bowen put up the scorecard. 

I have been very impressed with how strongly they have tried to 

share best practices and quite frankly hold themselves and their 

colleagues accountable for those standards. So, again, I think the 

emerging African leadership does offer some real hope in this area. 

Mr. SMITH. Dr. Steketee, in your testimony you raise so many 

questions. You all do. Time does permit—we will submit a number 

of written questions for all of you. But, Dr. Steketee, you, in your 

Message No. 3, talk about prevention in pregnancy and you point 

out that coverage of women with intermittent preventive treatment 

for pregnant women has been slower and not as well supported as 

might have been possible. Efforts in this area need to be redoubled 

to protect susceptible women and their newborns. We all know that 

malaria contributes to 8–14 percent of low birth weight in malaria 

endemic countries. Obviously, that decreases significantly the 

child’s chances of survival. And I am wondering what your recommendations would be there. Is that something that from a policy 

point of view has not been emphasized? 

Dr. STEKETEE. Thank you very much for that question. I actually 

spent much of my science career looking at malaria and pregnancy 

and its prevention. It is interesting. This is actually a relatively 

easy and low-hanging fruit, and where people have paid attention 

to it, the programs have done quite well. That is, we have gotten 

both the insecticide-treated nets and the intermittent preventive 

treatment to those pregnant women. 

It is typically administered through existing antenatal clinics, 

and antenatal clinics actually are some of the best attended health 

facilities by the target population. So the women come, and one of 

67

the challenges has been that it has been just a little off the radar. 

It hasn’t been quite as important as the insecticide-treated nets or 

indoor residual spraying. And everybody, of course, needs drugs to 

treat the acute infection. And it is relatively inexpensive because 

it is two doses, maybe three doses in the course of a pregnancy of 

sulfadoxine/pyrimethamine, which is one of our least expensive 

drugs out there. And we are looking for new drugs as well. 

But in the scheme of things, having said that, this was actually 

raised at the Gates Malaria Forum last month. And it was highlighted, and there is a process underway as we speak about looking 

at some of those policy issues and some of the performance issues 

in solving them, and experience says that they are relatively easily 

solved. It is just a bit more attention that needs to be paid. 

Mr. SMITH. Dr. Rabinovich. 

Dr. RABINOVICH. Yes, actually, tomorrow morning at 7 o’clock 

o’clock in the morning, in Philadelphia, a meeting of the partners 

will occur because I think this one fell off the radar due to lack of 

attention. The drug is cheap. This is really doable. Prenatal care 

is happening. It should be delivered, and the resources exist because of the Global Fund and PMI funding in country. So we just 

need to make sure we pay attention, work with the leaders and 

hold ourselves accountable. And tomorrow morning we are on our 

way. 

Mr. SMITH. Thank you. 

Mr. SCHMATZ. I just want to comment on the resistance question 

that you asked earlier, and that is I think one of the big problems 

we have with the current resistance we are starting to see in the 

ACTs now is the drugs that are—the combinations in those, those 

fixed-dose combination drugs, all of those components at one time 

were used as monotherapy well before the time when people decided—actually it was HIV that kind of led into the understanding 

that putting two different drugs and two different mechanisms together, you can delay resistance against both of them and extend 

the life of both of those drugs. 

We unfortunately didn’t have that luxury in the malaria world 

because the ones we had available to do these combinations with 

had already been used quite frequently before that for many years 

as monotherapy, leading to resistance of both of them in the parasite population. So when you put them together, there is still that 

potential for that. The goal now going forward is the new drugs we 

develop need to be made as fixed-dosed combination immediately 

and never be sold and available as single entities. That would definitely extend the life of any of those new drugs that we develop 

going forward. 

Mr. SMITH. Dr. Rabinovich, you mentioned that we are much 

closer to having a malaria vaccine that works through significant 

efforts by the Malaria Vaccine Initiative and many partners. You 

said it is possible that the malaria vaccine will be available by 

2015. Now is that possible or probable? And how far are we in 

terms of—and, Dr. Bate, you talked about this and all of you did 

really—the whole resistance problem? At what point does our current ACT treatment, or whatever the best treatment is, become obsolete? We are in a race with time. How much of a race are we in? 

68

And finally, to Dr. Rabinovich, if I could, you said the Gates 

Foundation also invests in the development of new drugs and 

methods to control mosquitoes. The BBC in August—and I am sure 

you all saw it—did an article about a spermless mosquito holding 

the promise to stop malaria. And, of course, it talked about developing 10,000 mosquito embryos with tiny fragments of RNA designed to turn off the gene that is essential for normal sperm development in mosquitoes. Is this something that is promising? Do we 

give much weight to this as a way of controlling the very population of mosquitoes? 

Dr. RABINOVICH. Thank you for those questions. Let me take 

them one at a time. The first question you asked is about a vaccine. 

And the results that were published in October are the preliminary 

results, just the 1-year result of the RTS,S vaccine, which has been 

tested in—at 11 sites, 7 countries in Africa. That trial is ongoing. 

And I think for full transparency, the first year results were presented. But really we need the full results, not only from the toddlers but from the babies that were just recruited. And we are 

going to have those results able to look at in 2014. Now, it needs 

to be evidenced-based. If it works and it protects children for a 

number of years, we want to make sure there is no rebound. It is 

something that the advisory committees, the WHO and the countries will consider for use. 

But it is not a perfect vaccine. The evidence so far is that it is 

about 50, 55 percent efficacious at preventing malaria and preventing clinical illness from malaria. So we are going to have figure 

out how that compares and how it adds to bed nets and to the 

other measures that are available when those data are available. 

So the story still is still to be told, but it is the first time that we 

have really shown in a large enough population is that you can 

have an impact with a vaccine. 

The second question you asked was about resistance. And the 

place where resistance has been shown has not been in Africa. We 

are all scared to death that it will actually move over to Africa. 

Historically, resistance for reasons that are not totally clear to us 

I think have begun in Vietnam, Thailand, Cambodia and Asia and 

then migrated over to India and then hopped right over into Africa. 

It was recognized by planned studies looking for resistance. These 

have to be small piloted studies to evaluate how well the drugs are 

working, recognized along the Thai-Cambodia border. And the partners of bilaterals have gotten together to actually work to decrease 

the amount of malaria there, ideally eliminate it, because of fear 

it would move onward, and that really is a global crisis if it did. 

We would lose ACTs. 

We are very excited about the portfolio that sits at MMV. You 

call it OS. I call it ‘‘Oz’’ because it would really be a wonderful 

thing to have. But they are not available yet, and so we really have 

to pay attention to resist intense ACTs today. The third thing you 

asked was about mosquitoes. And I think it is important to consider innovation, not only in new drugs and vaccines but also in 

ways to control mosquitoes, because we know that bed nets right 

now—bed nets and indoor residual spraying are at the core of our 

impact in Africa today. And there are several approaches. 

69

The one that you refer to is they have genetically modified the 

mosquito so that it cannot be reproduced. That is one idea that is 

being tested. 

Another is to have ways of having a Wolbachia, which is actually 

an infection within the mosquito that requires to attack it through 

Wolbachia-based approaches. There may be other innovative approaches, not just insecticides that would ultimately help us in the 

fight of decreasing the risk of getting bit by an infected mosquito. 

And all I can say is we need to look at their safety. We need to 

make sure that they work and then evaluate them to see which one 

gets introduced. And there will be concerns in the global stage 

about genetically modified organisms, and I think that is why I am 

saying that the data needs to drive their full evaluation for inclusion in the global program. 

Thank you. 

Mr. SMITH. Yes, Dr. Bate. 

Mr. BATE. Just one point on the research agenda. Although this 

is a hearing primarily about treatment, I think it is somewhat worrying that only about 4 percent of the global malaria budget is 

spent on areas of insecticide research. And regardless of whether 

it is indoor residual spraying or bed nets, we are going to need better insecticides, and with the exception of the Gates Foundation, 

which funds the IVCC, there is very little effort in that area. 

It is probably more contentious and people don’t like insecticides. 

But I think that is going to be an area in the short run that needs 

to be ramped up because until we have—this is not to downplay 

the vaccine. I think it would be fabulous. Until we have a much 

more effective vaccine, then I think we are going to continue to 

need insecticides and new ones at that. 

Mr. SMITH. Just one last question before yielding to my friend, 

Mr. Payne. With regards to vector control, which Dr. Steketee also 

spoke about in his testimony, are malaria-bearing mosquitoes 

spreading, despite all of our efforts? Obviously, bed nets protect individuals during the most fearful times, at night, during sleep, 

when children and adults could get bit. But are the mosquitoes 

that bear and carry malaria spreading in their borders? I chair the 

Lyme Disease Caucus here in the United States Congress, and we 

know that the Lyme disease-bearing tick, particularly the deer tick, 

just every year expands, and, unfortunately, mal-affects people 

with disease. Should Americans be concerned that malaria has 

come to our shores, for example, from countries that are in Africa 

and other endemic areas? 

Dr. STEKETEE. Thank you very much for that question. You also 

raise the issue of borders and which becomes an interesting thing. 

This is—and I just highlight this because I think one of the potential progresses here and particularly with ALMA, the idea of African leaders actually banding together for leadership purposes and 

allowing them to cross their own borders with the right ideas. So 

I just put that aside as really a critical issue. 

Most mosquitoes actually would like to move as little as possible. 

It is a pretty tough life out there for them. It is a fragile little 

woman mosquito, because those are the ones we care about. She 

would like to go and find a very close body of water to lay her eggs 

in and then return to the house where she came from. So she has 

70

very little incentive to go across borders. So, for the most part, the 

mosquito itself will not be the big transmitter going across the borders. 

It is actually us people that move the parasite and make us concerned about that. 

Having said that, we think of populations of mosquitoes. And if 

you have a very good intervention, which we do with insecticidetreated nets and indoor residual spraying, that intervention has 

been shown to essentially kill all of that population that have the 

particular behavior of feeding indoors and on those people sleeping 

at night and essentially kills all of those. Now there may be in the 

midsts of that population a few that didn’t read the textbook, and 

they go out, and they bite somebody outside, and they get their 

blood meal and they are able to continue, and they stay outside of 

that immediately targeted area of insecticide. So we end up with 

actually an evolving population because of how good our intervention is. We have left remaining those few that don’t have that behavior, and they start to look like we have created the wrong thing, 

that is we now have allowed them to survive, but we have killed 

all the others. Mind you, those are the ones that are a little less 

likely to bite indoors, and they are a little less likely to transmit 

ongoing. So they actually become a weaker and weaker transmission for the malaria. We may need to go after those. 

And as insecticide resistance evolves in a population, it evolves 

because we are using just one, and we are learning to do and discussing, and it is going on again as we speak, there is a—WHO has 

produced a draft document for controlling insecticide resistance, 

which includes the idea of rotating, which is a lot like using combination therapy for drugs, but of rotating insecticides so that we 

are not allowing a population of resistant mosquitoes to evolve. 

So I think there is actually a lot of work being done on that. And 

as long as we don’t lose sight, and I will highlight the idea that 

research ongoing on insecticide is actually critical in the midst of 

this. We do need that. 

Mr. SMITH. Thank you. 

Dr. Bowen, did you want to comment? 

Mr. BOWEN. Just one very brief comment. A lot of the previous 

comments have focused on sort of the high-tech methods for mosquito control, and those are all very, very important but there is 

a lot of low-tech work that can be done. For example, we are working with an organization in Senegal with a French acronym of 

PECADOM, which trains people to be community leaders and just 

do very simple things to stop mosquitoes from breeding; making 

sure that there aren’t tires lying around that can serve as pools of 

standing water and that sort of thing. So it really is a partnership 

of both the very high tech, the transgenic mosquitoes, with the very 

low tech of just making sure there aren’t tires lying around in the 

village. 

Mr. SMITH. Mr. Payne. 

Mr. PAYNE. Thank you very much. 

It is a very in-depth discussion. 

According to WHO—and anyone can answer—insecticide-treated 

nets that were distributed between 2007 and 2008 need to be replaced. What steps does your organization take to ensure that the 

71

nets will be replaced as needed? And in your opinion, what steps 

should the donor community take to ensure that the nets are replaced? And also if you could even, preceding that question, there 

was always some question about the treated nets, and there was, 

I think, initial opposition in some countries. Could you tell me how 

that has been overcome? I suppose it has been. But do you still find 

some resistance to that? And secondly, how do you keep a count of 

the replacement needs for the nets after several years of use? 

Dr. STEKETEE. Let me take that question on. We have actually 

worked with a number of countries now in that process, and this 

is where the country logistic systems have really dramatically 

changed in the last few years. I would say that from 2005 to 2007, 

we had a hard time understanding exactly where the nets were 

needed, where they were, where they weren’t and how to understand when to replace them. 

We have now gotten to the point where almost village by village 

in many countries, they have a roster of nets in households, which 

ones are short of nets, which ones are—ways of measuring—picking up on who lost a net, maybe it burned last night under the 

stove for the kitchen; maybe it is just now torn too much and registering its loss. So the systems are categorically better. For example, we have been working in Zambia a lot. Zambia has district-bydistrict, regularly-updated numbers as to how many nets they have 

in stock, how many nets are in households, how many they anticipate needing to replace in the coming year and what the resources 

are. 

I will just highlight one challenge in the midst of that, and that 

is, unfortunately, the ups and downs of funding that determine 

that tranche of insecticide-treated nets comes to the country. If the 

country doesn’t have the money to procure, they hold off. And because this is so seasonally tied in many places, if you miss one season, you allow your entire population to just be inadequately protected for that season. 

So one of the challenges for the countries has been to take that 

information and to try to match it with some consistent funding so 

that they have supplies when they need them. 

Mr. PAYNE. Thank you very much. 

So the question, just listening to your answer, really has a lot to 

do with the manner in which the individual countries have worked 

on their health systems, delivery systems and—how have your—

any of your organizations worked with the basic things that you 

mentioned, keeping inventory, making sure that people know that 

a program is going to start? Are there any programs—I am sure 

you do have that—that go into communities to build that kind of 

very basic infrastructure up? 

Mr. BOWEN. One of the areas that we are working in is—again, 

innovation doesn’t just happen in the lab. We are trying to find innovative ways to communicate with communities, and having cell 

phone technology and other kind of mass media to let people know 

about the need to use bed nets properly is another way to just 

make sure that families are using the bed nets every night and are 

using them adequately. And I am sure others can comment on 

some other things that are being done to build up the health systems. 

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But also, I think your question highlights the fact that ongoing 

funding really is needed because it is not adequate simply to buy 

one tranche of bed nets, as you pointed out. There is an ongoing 

need to replace as they get worn and as the long-lasting insecticide 

ultimately wears out. 

Ambassador GREEN. I think, first off, the most important thing 

to remember is that no program, no plan will be successful if it 

isn’t a partnership between donors and leaders in-country. 

I mean, I think a basic rule is you can’t want it more than they 

do. In other words, these programs have to be built around in-country, innovative leadership that is committed, top to bottom, to getting this done. And when I do take a look at those countries where 

the success has taken place, those are the countries. 

In Tanzania, when President Kikwete talks publicly about sleeping under a bed net himself, when he takes to the stage at concerts 

with malaria messages, when that kind of leadership is shown and 

when clear signals are sent throughout the ministry of health and 

leadership all over the country, where faith leaders are enlisted, 

that is where success takes place. 

Also, in terms of our response to malaria interventions, I think 

a very innovative program that really hasn’t gotten enough attention is the involvement of the Peace Corps. Peace Corps volunteers—in some ways, this was pioneered in Senegal, and Malaria 

No More played a huge role in that. Peace Corps volunteers have 

been very effective in using the typical volunteer’s ingenuity and 

sense of can-do in malaria messaging, in working with leaders, in 

keeping track on the logistics front. So it is partnerships across 

borders and across oceans, and it is partnerships across cultural 

sectors inside the country that is making the difference. 

Mr. PAYNE. There is the debate I think in the millennium development goals on the question of control versus elimination. And 

when we get into, you know, limited funding, especially now that 

we understand that the Global Health Fund, a number in Spain 

and Italy, some are going to be unable to reach their goals because 

of their financial situation. We have the two to one—and by us actually reducing our appropriations proposal, we restrict how much 

the others can give. How do you see this—us being able to kind of 

get through with the combination of the European problem and the 

possibility for the Global Fund in particular of the cut in funding? 

Dr. RABINOVICH. I think there are a number of things that can 

be done and are being done. The first is to look for efficiencies in 

countries, and the Global Fund has prioritized this and they call 

it value for money. But it is actually looking for the most efficient 

way to use the dollars and to make sure that you are getting the 

impact that you want. The second is—and I think was announced 

at the Global Fund board a couple of weeks ago, which is to focus 

on the most fragile countries so that lower-middle-income countries 

are no longer—or fewer of them are receiving funding; Brazil offered not to receive funding, China will not receive funding—allowing them to focus on the poorest countries that actually don’t have 

a lot of alternative ways of funding the sustainability of bed nets 

and of treatment. I think those things go part of the way toward 

dealing with the temporary gap in any single country to give. But 

I think we have to look at the bigger picture, given the impact not 

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only on malaria, but HIV and TB, that this is a priority program 

that has really been recognized for its effectiveness and for its impact and to figure out how to sustain it for the longer term. And 

I think that must be a priority. 

Mr. PAYNE. Yes. 

Mr. BATE. Looking whether it is nets or spraying or treatment, 

it is a bit like removing garage; it is only sustainable if it is paid 

for. And the real question is how it is paid for. And whilst I actually do concur with nearly every remark that has been made in answer to these questions, I do think there are some African countries that are in a parlous state and really not that able to contribute as much. But some of the countries have significant wealth 

and have significant corruption problems. Maybe we have an opportunity here—I am thinking of Nigeria and Angola with their 

considerable oil wealth—to step up a little more than is currently 

the situation. 

That is not to deny that there aren’t major problems and that the 

aid community should not do what it can. But given strained conditions, these may be opportunities to press harder for the nations 

most affected to step up a little more themselves. 

Mr. PAYNE. Yes, Dr. Bowen. 

Mr. BOWEN. Just to pick up briefly on that. There clearly is a 

great need for financial transparency. That is why one of the things 

that ALMA is doing, the measures are not just about public health 

measures. They are things like financial transparency, removal of 

tariffs on antimalarial goods and preventive bed nets and products 

such as that. So I couldn’t be more supportive of Ambassador 

Green’s comments about the leadership of President Kikwete, and 

we are delighted that Ellen Johnson Sirleaf is coming in as the 

leader of ALMA. 

And I would also agree with Dr. Rabinovich’s comments, that it 

is important to get the most—to squeeze the most valuable for 

money out of every dollar, euro, yen that goes into the Global 

Fund. But ultimately, of course, the United States is the indispensable nation in this. If the United States isn’t there, the effort 

there will be significantly imperiled. 

Ambassador GREEN. If I can, just a couple of thoughts I think are 

important to put on the record. Remember, this challenge is unlike 

some of the other development challenges that we are taking on. 

Half measures don’t work. This is not a situation where you can 

extend out, you know, filling the jar with pebbles over more years. 

There really is a premium on the mobilization of resources. You either do it, or you don’t do it. But sort of crawling along slowly, you 

won’t get the return on investment. 

One of the remarkable things about the malaria challenge is, 

again, we know what to do. And in Zanzibar and other parts of the 

world, there is clear evidence of that. And one of the things that 

we have learned is an integrated mobilization of resources is what 

makes the difference. And so one of the things I admire about what 

PMI is doing is when they take a look at those countries, they can 

go into, they don’t simply take their resources and divide it up by 

50. They instead look and say, okay, here is leadership; here is a 

definable challenge. You know, we look at the math. We can do 

this. Let’s do it. 

74

And what that means in some cases is there are terribly impoverished countries where there are huge problems that we would 

like to go into and try to make a difference, but we are resource 

constrained. There are other countries that we look at and perhaps 

they aren’t as poor, but we look and we say, okay, we can do this, 

you know, we can defeat this here. And as you take a look at the 

overall challenge, those are the choices you have to make. But it 

is important that we understand you have got to mobilize, you have 

got to mobilize fully, you can’t simply extend this out and go on the 

cheap. If you do, sadly, we won’t get there. We won’t be able to fill 

the promise. 

Mr. PAYNE. With the new ALMA project that you mentioned—

and I was very impressed with just looking at the schematic 

there—how long have they been putting out that report that complicated—I mean, that thorough? 

Mr. BOWEN. This is the initial scorecard, but the plan is to keep 

it going and to use this as a touchstone for responsibility for accountability in the fight. 

Mr. PAYNE. I think that measures like that—NEPAD was supposed to be a move in that direction, and it has kind of had some 

stumbling blocks. But I think that once nations are held accountable, that they are compared to others—I think what Mo Ibrahim 

is doing with his whole question of rating, you know, heads of state 

I think is really putting the spotlight on, and I do believe that we 

will get to the point where, you know, 15, 10 years ago, people 

didn’t even discuss corruption and these things that had been going 

on, you know, for decades. 

And of course, we also have to work more on the European countries. As many of you may know, the corruption has not been illegal in most of those countries, and as a matter of fact, I think it 

was in Germany, you could make it a tax deductible item; you just 

had to declare it. But it was not—it was not considered criminal. 

It was considered the cost of doing business. So if we can work 

more on the corrupters, you know, it is a two-way street, it doesn’t 

condone those who take corruption, but I think that those who are 

offering it and like I said, I travelled in Africa for decades and decades, and it seemed like a practice that was just a part of a business portfolio for a number of the European countries. So I think 

that it is a two-way fight. We have got to continue to work in exposing it, having reporting, have things that are verifiable, having 

things that are out in the public so that people can be judged on 

what they do or do not do. 

Just lastly, how rife as a problem is the sale of counterfeited or 

adulterated or poor quality drugs? Do we have any fix on that? Is 

there anyone who is really monitoring that? Do we really know 

how bad it is. 

Mr. BATE. Yes. The short answer is, no, we don’t have a good 

handle on the size of the problem. A lot of the data that has been 

collected is not easily comparable. There is no doubt that there is 

a significant both substandard and falsified drug problem, products 

which are either intentionally there to mislead people or, more likely I think in the poorest countries in Africa, drugs which have been 

made legally but are just not up to the standards. And also, in adVerDate 0ct 09 2002 14:04 Mar 06, 2012 Jkt 000000 PO 00000 Frm 00078 Fmt 6633 Sfmt 6633 F:\WORK\AGH\120511\71619 HFA PsN: SHIRL
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dition to that, you have a problem with storage, transportation, 

which leads to degradation of products. 

So it depends how you define it as to the numbers you get, but 

most of the studies that have been published which do any level 

of comparison from one location to another, follow reasonably tight 

protocols, you are seeing at least 10 percent of the products failing 

in quality control. And in some markets for some drugs and 

antimalarials, it is considerably higher than that, but we don’t 

really have a good handle on the exact numbers. 

Mr. PAYNE. Yes, Doctor. 

Dr. RABINOVICH. If I could give you an example from the diagnostic field, we funded the Foundation For Innovative New 

Diagnostics to work with WHO to evaluate how good were the 

diagnostics. And of the first more than 100 diagnostics, only about 

a third were working the way that they should. 

Now that information was fed back to the Global Fund and PMI 

and other funders so that they focused on the use of good 

diagnostics which then becomes the basis for credible diagnosis at 

the field level which is necessary for adequate and appropriate use 

of drugs. But it is these quality systems, not only for—I mean, the 

same thing can be said for vector control tools. Do they really have 

an insecticide that will really least 3 or 4 or whatever the advertised number of years? These regulatory systems and validation 

systems are really important to the ongoing credibility of the program and really needs to be part of what is maintained. 

Mr. PAYNE. Well, let me thank you very much. We will certainly 

continue to focus on this issue. Actually, Thursday of this week we 

are going to be cohosting an event with PATH and Roll Back Malaria, where the whole question of RTS,S, the discussion about malaria vaccination that continues on and was really at the 15th anniversary celebration of IABI, where Mr. Gates and some of his folks 

were about a month ago—where the whole question, as you may 

you recall, dealing with the vaccine, I think that is the goal that 

we really need to continue to move forward on, and then we won’t 

have the debate, the question that I almost asked about, you know, 

should we spend money on trying to prevent, or should we put it 

on research? We get a vaccine, and we don’t have to worry about 

it. So, once again, let me thank you all, and I yield back to the 

chairman. 

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

Just a few follow-up questions and final questions if I could. 

Dr. Schmatz, could you discuss more the single-dose cure for malaria that was in your testimony that is in development? How long 

are the clinical trial phases? 

Mr. SCHMATZ. Currently in phase 2A, getting prepared to do bigger trials now. And the projection is that if everything goes smooth, 

which in our discovery that is not always the case, but we are very 

hopeful here from what we are seeing, that that product could be 

potentially available around 2016, going through all the steps along 

the way in the regulatory process and pulling all the stops out as 

well to get there. 

Mr. SMITH. Let me ask Dr. Steketee, you in your testimony point 

out that four countries over the past 4 years—United Arab Emirates, Morocco, Turkmenistan, and Armenia—certified by WHO as 

76

having eliminated malaria, are the first countries to achieve this 

distinction in 20 years. Are there other nations that may be getting 

close to that distinction? Are any of those nations in sub-Saharan 

Africa? And if anyone would like to talk about this, which countries 

in Africa—and I know Dr. Bowen, you did raise up a very detailed 

chart, which I will read very carefully later, as I am sure others 

will—but which countries are doing the best across the whole broad 

range of strategies to combat malaria and who are the laggards? 

Dr. Steketee? 

Dr. STEKETEE. Well, thanks very much. Because this issue of 

eliminating malaria is obviously where many, many nations have 

put that in their current plans, that is what they are wanting to 

do. In the discussions that led to the updated Roll Back Malaria 

goals for 10 countries to eliminate in the coming 5 years, they actually did that because there are nine countries that are in the WHO 

European region—this is not only Western Europe. This is a set of 

relatively small countries that have almost no malaria, but they 

have little pockets of it. And those are slated within the next 5 

years to hopefully eliminate malaria. Armenia was actually part of 

that group and just declared elimination 2 months ago. So, yes, 

there are a number of countries in that stage. 

In terms of other places, you ask specifically about Africa, as Ambassador Green has mentioned, a small part of Tanzania, that is 

the islands off the coast, are actually not very far away. And this 

is the case of making a decision, do you go for it, and when do you 

go for it? In that sort of sub-national setting, but because they are 

islands, clearing islands tends to be both easier and something that 

you can continue to sustain. 

Now among the other places in sub-Saharan Africa, first of all, 

South Africa still has transmission, but in focal areas along its 

boarders with Zimbabwe and Swaziland and Mozambique. And 

that is a lot because, not the mosquitoes moving across the border, 

but people move across those borders. And they are in particular 

trying to pay attention to whether or not they can eliminate it. And 

this is actually a pretty important discussion because that southern 

cone of Africa—Botswana, Namibia, Zimbabwe—once it gets beyond its political strife, has an incredibly strong health system, or 

did, and it has been hampered in the recent years, particularly 

from the political strife, but that could turn around. And if that 

does, you could have Namibia, Botswana, Zimbabwe, South Africa, 

and Swaziland actually quite close to eliminating malaria. 

Just north of that, I mentioned we had worked a fair amount in 

Zambia. There are parts of Zambia where you can now count cases 

in districts on hands and maybe hands and toes, and that is new. 

And that is why I am talking about the speed of change here and 

the innovation has gotten us thinking and gotten countries talking 

about what it takes to do elimination. 

The other places in sub-Saharan Africa are in West Africa. Particularly Senegal and Gambia have recently shown remarkable 

progress. Northern Senegal has districts where over the past year 

they have had trouble finding any malaria. So this elimination happens in these countries step by step, district by district, but both 

Senegal and Gambia are now meeting and talking about how they 

can work both across their boards and jointly against the parasite. 

77

And lastly, I will mention, outside of Africa, in the Americas, we 

have—the Americas have made incredible progress. And if you look 

country by country, particularly in Central America, but also in 

South America, they are not very far away. We are talking about 

a few deaths left. Just as an aside, Mexico is a huge place for U.S., 

you know, visitors to go on holiday. And we used to identify that 

we would recommend from the U.S. that our citizens take prophylaxis when they go to Mexico, and that was actually the largest 

number of use of prophylaxis for the citizens of our country. And 

that malaria in Mexico is almost gone. 

So the progress and the possibilities out there are really exciting, 

and they take attention, but that group of South American countries, they formed a coalition to try to do this, and they are close. 

And whether it is just moral support and applause from the sidelines or ways of figuring out how to emphasize that would be 

hugely helpful. 

Lastly, out in, again, back to the island issue in the Western Pacific, there are a number of islands that are working toward elimination. So while we haven’t called those countries out for the next 

5 years, it is—this is what is in abeyance here, that is if the global 

community backs off of malaria as a priority, then you can imagine 

that these places will say, hmm, not sure where the help is coming 

from and maybe we have to go do something different now. 

Mr. SMITH. Thank you very much for that very extensive answer. 

We have talked a lot today about the importance and efficaciousness of insecticide-treated bed nets, indoor residual spraying and 

intermittent preventive treatment for pregnant women, three of the 

best tools that we have for prevention. 

And I am reminded, Dr. Steketee, that you mentioned earlier 

that the treated bed nets actually help kill the mosquitoes, which 

I think is a very important point to underscore. It reminds me in 

the whole fight against the pandemic of HIV/AIDS that 

antiretrovirals, ARVs, actually have capability of reducing the viral 

load, which becomes a way of defeating that terrible virus. Here we 

are defeating the actual parasite and the carrier of parasite. 

But let me ask anyone who would like to answer this, how and 

by whom are decisions made regarding what prevention strategies 

to promote in any particular region or country or even a specific 

area within that country? Who makes those decisions right now? 

Is it the Health Department? Is it the collaboration of the partners, 

or what? 

Dr. RABINOVICH. I think any of us could answer. There is a global process, and WHO is entrusted with technical assessment of the 

data and making policy recommendations for the countries. But 

then there are regional WHO offices. And the responsibility really 

sits with the country to figure out how it is and what it is going 

to implement. 

And there are differences. Malaria is not a single disease. It demonstrates and has different patterns of transmission and different 

things that must be emphasized in different places. Trying to segment that into a pattern that would be easier to attack is something WHO is doing. 

But it really is a partnership between the many partners, including WHO, the Roll Back Malaria Partnership, which brings everyVerDate 0ct 09 2002 14:04 Mar 06, 2012 Jkt 000000 PO 00000 Frm 00081 Fmt 6633 Sfmt 6633 F:\WORK\AGH\120511\71619 HFA PsN: SHIRL
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one to the table, and most important of all is the countries, because 

that is where the key decisions, not only at the national level but 

down to the district level, must be made. I don’t know if anyone 

has anything to add. It is a little complicated, but it works. 

Dr. STEKETEE. I will just add this as an example where the U.S. 

President’s Malaria Initiative sits with the country, country by 

country where they work and look at their plans and then look to 

see how they can help support the implementation of those plans. 

And it has been that set of years actually where there was very little money where people spent a lot of time figuring what the strategy should be that got us a solid set of national programs that 

could speak to this is our strategy. 

And then those evolve over time as we get new information. And 

so, for example, if we got a new vaccine or if we got a new drug 

that was a single-dose therapy with high cure rates, those would 

be rapidly discussed at WHO. And they would be rapidly discussed 

with the regional offices and then country by country. And experience has shown that we now have enough people with enough 

knowledge at country level that the uptake of that information is 

both thoughtful and relatively expeditious.

Mr. SCHMATZ. If I could add to that, the immediate approach and 

reaction to dealing with malaria is procurement, optimizing the 

current interventions you have, and in-country activities, and all of 

those are critical and have made a huge impact already. The long 

gain is clearly going to come from R&D. And when you look at the 

actual investment that is made in R&D, it is a long sustained expensive process. But I would argue, and I think most of the people 

in the room would agree with me, without that, the end game—you 

won’t win the end game. So while the immediate interventions are 

critical, you are saving lives today with the tools you have now; you 

won’t win that long game without sustained effort to really support 

the R&D that is out there. That is a very small component of the 

investment that is made today on the actual R&D part. 

Mr. SMITH. I just want to note for the record, and mention was 

made of the $691 million request for Fiscal Year 2012. But in 2004, 

it was $89 million; 2005, $99.9 million up to $111 million; in 2007, 

$256 million; $358 million in 2008; $391 million in 2009; and it 

went up rather significantly in 2010 to $594 million. So the glide 

slope is a build out that needs to be sustained, and I think all of 

you have made your cases extremely persuasively, backed by your 

knowledge and your expertise, and very, very important information. 

I have a final question, and Mr. Payne may have a final question 

as well. 

Ambassador Green, again getting back to your original point 

about leadership and the importance of it, you did talk about how 

Coca-Cola is partnering with the Global Fund on a technical assistance project with regards to supply chains. I would note parenthetically that I travel often to Africa and elsewhere often to 

places that are way out of the way. All of you do even more so, I 

am sure. I am always amazed because once I am jet lagged by day 

2, I drink a Coca-Cola for breakfast, and there is always one available at the hotel wherever I may be. So their supply chain is second to none. Could you elaborate on how well that is working and 

79

whether or not that expertise will be shared as a best practice for 

others? 

Ambassador GREEN. Yes, it is quite extraordinary, you can get a 

Coca-Cola just about anywhere in the world and certainly all over 

Africa. The early returns are good. But I want to build on that, and 

it is not just Coca-Cola. I want to point out another remarkable 

project that is current currently run by Barbara Bush, President 

George W. Bush’s daughter, in which she came up with the idea, 

gee, we have lots of business expertise here in the U.S. and we 

have lots of young business executives who are dedicated to changing the world, so we have got expertise, we have got challenges, 

what do we do? And the Global Health Fellows, which is the name 

of her organization, matches up young business executives with development opportunities overseas. 

On Zanzibar, a young executive from The Gap spent a year helping the ministry of health in Zanzibar doing supply chain management on meds and was able to put his expertise and experience to 

work in remarkable ways. So have you Coca-Cola, which is doing 

things on a grand scale, and you have young entrepreneurs, business executives, doing it on a microscale. And the combination of 

those is truly uplifting. Because at the end of the day, it is going 

to be leadership. It is going to be that can-do sense that I think 

we are all very proud of, and that will make all the difference. 

Thank you. 

Mr. SMITH. Thank you. 

Mr. Payne. 

Mr. PAYNE. Just that I really appreciate the fine work that all 

of you do. 

I agree that it is the will of the individual country and the community. About 3 or 4 years ago, I went to Rwanda, where they 

were starting this big initiative, maybe 2 years ago, and they started in the churches and in the community centers. And they had 

someone discussing it every week that this event was going to 

start. I happened to be there when we were out in a village where 

they were starting. Everyone had to take their furniture out of the 

house. They had to put their curtains up. I put on a suit. They 

thought I was a guy that had the job, but they were worried because they knew a local guy was supposed to do the job, so they 

thought I came and bumped him out or something. But I put on 

my suit, and we did the spraying around the house, and it was just 

like a community event. Everybody was involved. They knew what 

was going on. They were alerted. They knew when they had to 

have things out. They knew how long it had to be, have the kids 

out while the spraying went on. They put the nets up, and so I 

think it is very important how we work on the very local communities. 

One other issue that shows how I think it is catching on, I was 

in Djibouti at a military installation and there was a border dispute with the other country—I won’t mention because they deny 

there was a border dispute. But there were 21 prisoners of war 

from the opposite country. And I wanted to meet them to see how 

they were being treated, and they were all being treated okay, well 

and so forth, and we had a conversation with them. But the thing 

that was most impressive is when I went into their housing facility, 

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lo and behold, they had bed nets. And that really said something, 

that they, in Djibouti, the government felt it was important enough 

to have bed nets around prisoners of war. You know, then, they 

thought this was an important issue. Same way in Rwanda where 

we have seen—I have talked to Ray Chambers. As I mentioned he 

is from Newark, New Jersey, and he talks about going to some of 

those pediatric wards and infant—in Rwanda where they used to 

be packed with kids, and now they have virtually no one there, 

which shows that in certain parts, it is really working. 

So what you are doing is fantastic and I commend the chairman 

for having this very important hearing, and we will keep pushing 

for elimination with the vaccine. Thank you very much. 

Mr. SMITH. Would any of you like to make a final comment? You 

have been very gracious with your time. This couldn’t come at a 

more timely period during consideration of the 2012 budget, so 

thank you for that. 

Yes, Dr. Rabinovich. 

Dr. RABINOVICH. On behalf of this group, I would like to thank 

you for holding this session. We are but a fraction of the partners 

that are involved in this. And as I think about the Rotarians in 

Zambia, the Methodists as principal; recipient of the Global Fund 

Award, Exxon Mobil talking about malaria at the Olympics, Nothing But Nets bringing in every sport that has a net of any kind into 

the fight. Under the partnership model, this has really been already an incredible decade, but there is really so much more that 

needs to be done over the next decade. When I visited the Gambia 

10 years ago, there were three children to a bed for a disease that 

has almost disappeared from the Gambia 10 years later. This is 

possible. This is possible, but it really takes that kind of partnership, commitment, and steadfast attention to make it happen. 

Thank you. 

Mr. SMITH. On that final very wise note, the hearing is adjourned. 

[Whereupon, at 5:23 p.m., the subcommittee was adjourned.] 

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