This is an archived USAID document retained on this web site as a matter of public record.
Testimony of Ambassador Sally Shelton-Colby, Assistant Administrator for Global Programs
Before the House International Relations Committee
Washington, D.C., July 30, 1997
U.S. Agency for International Development
Thank you Chairman Gilman and other members of the Committee. I am
pleased to appear today, and welcome the opportunity to discuss the U.S. Agency for
International Development's (USAID's) role in addressing infectious diseases in the
developing world. The threat posed by infectious diseases to the security and well-being of the global community is well documented. In today's highly interconnected
world, no disease is more than a day away from our own shores. National borders are
irrelevant to microbes. To effectively deal with infectious diseases, and the
conditions that engender them, we must go to their source. In a great number of
cases, that source is the developing world.
A UNICEF report on global sanitation released last week starkly underscored
what a fertile breeding ground for infectious disease the developing world has become.
According to the United Nations, nearly three billion people, more than half the
world's population, do not have access to even a minimally sanitary toilet. As the
author of the study noted, "When you have a medieval level of sanitation, you have a
medieval level of disease."
Acute outbreaks of exotic viral diseases such as ebola and threats of plague
have dominated the headlines. While dangerous new disease strains make for great
movies and books, we should not overlook that fact that today's true killers are often
all too familiar. Deaths from high-visibility diseases like ebola have numbered in the
hundreds. In contrast, every year 17 million people die around the world as a result
of more routine infectious diseases such as malaria and tuberculosis and dehydration
from diarrhea. Other diseases that are major killers can be prevented by simple
vaccines. Combatting the major diseases that still haunt so many in the developing
world is our greatest challenge.
More than 3 million lives are saved every year through USAID immunization
and related programs, according to the World Health Organization. Similarly, it was
U.S. leadership, working in partnership with organizations such as UNICEF and the
World Health Organization -- that made possible the formal eradication of polio in the
Western Hemisphere three years ago. In 1996, USAID launched an expanded
immunization program to eradicate polio from Asia and Africa, and we are confident
that both polio and the guinea worm can be globally eradicated early in the next
century. Moreover, USAID has assisted in developing and strengthening over 100
national diarrheal disease control programs, which has resulted in three-quarters of
the world's population now having access to oral rehydration therapy. This saves the
lives of 1 million children annually. Oral rehydration therapy, developed through
USAID programs in Bangladesh, is credited with saving tens of millions of lives
around the globe.
USAID has, and will continue to, contribute directly to control efforts for rare
and high-visibility outbreaks of infectious diseases. However, as our record of
success indicates, large-scale threats to public well-being are at the core of our health
programs around the world. Let me stress that fighting infectious diseases is already a
considerable part of the agency's budget. In fiscal year 1996, USAID devoted
approximately $320 million dollars to the prevention, control and treatment of
infectious diseases -- the largest bilateral contribution to combatting infectious disease
in the world. However, we do not consider a dollar comparison with other donors the
most appropriate yardstick of U.S efforts. It is our hope that the Congress will fully
support the Administration's budget request for foreign operations and resist the
temptation to earmark funds. We share Congress' belief that it is in America's best
interest to do more to address infectious diseases, but we do not seek to do so at the
expense of other foreign policy and development priorities.
USAID's approach to infectious disease consists of four interrelated elements.
First, we are working to change the social and economic conditions -- such as
poverty, lack of sanitation, rapid population growth and environmental degradation --
that allow infectious diseases to flourish. Second, we are working to improve health
systems so developing countries themselves can better control infectious diseases. Third, we are carrying out specific targeted programs to address priority diseases.
Lastly, we are continuing to enhance our capability to respond to emergency disease
situations.
Addressing the Social and Economic Conditions that Foster Disease
The Institute of Medicine's ground breaking 1992 report on emerging infectious
diseases stressed the role of factors such as the breakdown of public health systems,
microbial adaptation, economic development, land use and human behavior in the
spread of infectious diseases. USAID plays an important part in efforts directed at
addressing these underlying causes of the spread of disease. A number of agency
programs -- although not part of the immediate health portfolio -- have a major
impact on public health and disease prevention.
Our efforts in family planning are helping to stem the rapid population growth
that is leading to overcrowded mega-slums, the true breeding grounds that allow
diseases to reach a critical mass. Our work in economic development, agriculture and
food security are helping developing nations improve nutrition, and thereby strengthen
resistance to the spread of diseases. Through the agency's water and sanitation
programs, we are striving to provide clean drinking water that reduces the
transmission of deadly pathogens. By enhancing sustainable agricultural practices and
encouraging sound natural resource management, we are working to reduce the
growth of vectors and disease organisms.
Collectively, these efforts represent a true long-term prevention strategy. The
fact that all of these efforts also produce important economic and social benefits for
developing nations only make them more valuable as an integrated approach to
development.
Improving Public Health Systems
Our efforts to improve public health systems are consistent with the agency's
overall approach to development. In every case, we seek to develop the capacity and systems that will allow developing nations to effectively manage their problems
without the need for foreign assistance. Countries must be able to manage, run and
support their own health systems if they are to control infectious diseases. A great
deal of USAID's assistance in health over the past several decades has focused on
training health professionals in developing countries so that they can carry out health
instruction, supervision, logistics, information systems, communications, and
budgetary management effectively.
Training has been carried out in conjunction with efforts to reform health
system policies and encourage self-supporting financing mechanisms and collaboration
between public and private health care providers. In addition, USAID has actively
supported reform of national pharmaceutical policies, regulations and training to
ensure the appropriate use of anti-microbials and other drugs. The development of
new low-cost technologies and the use of information and communications
technologies to enhance health programs and health education efforts will supplement
programs in all of these areas.
Ultimately, we want to leave successful and workable health systems in place
when USAID assistance has come to an end, as we have done in countries as diverse
as Thailand and Costa Rica. These systems serve as the true first line of defense
against infectious diseases that are international in scope.
Targeting Priority Diseases.
USAID's health programs target specific infectious diseases which are the
principal contributors to death and illness around the world. Of the 17 million annual
infectious disease deaths, the majority are among children. Infectious diseases continue
to be the largest killer of children around the globe. USAID's child survival program
is a major element of our efforts directed at infectious diseases. Some of our most
important programs include:
* Control of diarrheal diseases, including cholera and dysentery, that cause more
than 3 million annual deaths and hundreds of millions of infections.
* Prevention and control of pneumonia which is responsible for more than 4
million deaths annually.
* Immunizations against the major vaccine-preventable diseases of childhood,
such as measles, tetanus, diphtheria, and polio.
* Prevention, control and treatment of malaria, the scourge responsible for over 2
million deaths, more than 90 percent of which are among children.
* Efforts to assure appropriate and full courses of antimicrobial treatment to
minimize the likelihood of antibiotic resistance.
* Targeted research in testing new vaccines, technologies and treatments against
the major childhood killers.
In addition to our child survival efforts, the other major targeted component of
our current infectious disease efforts is directed at the prevention and control of
today's most threatening and costly newly emerged infectious disease: HIV/AIDS.
For the past decade, USAID has played a leading role in developing the tools needed
to combat this epidemic, and in helping countries to apply these tools. USAID is
working with more than 500 private voluntary and nongovernmental organizations to
implement HIV prevention programs, and we have reached more than 15 million
people with comprehensive HIV prevention education.
USAID has also worked to harness new technologies which will improve the
delivery of vaccines. Two good examples of our work in harnessing new technologies
to this end can be found in the SoloShot and Vaccine Vial Monitors. Partnerships
between USAID and America's private sector accelerated the development of these
products. These products are now creating both American jobs and helping combat
infectious disease. SoloSHOT--the first successful auto-destruct syringe needle,
prevents infections associated with the reuse of soiled syringes and needles-- is now
distributed globally by UNICEF. Vaccine Vial Monitors, in the process of being
introduced within the context of the polio eradication effort, are expected to reduce vaccine wastage resulting in savings of over $10 million per year.
Responding to Emergencies
As I noted earlier, USAID was a major contributor to the emergency response
to the Ebola outbreak in Zaire and played a smaller role in the plague panic in India.
We have played a similar role over the years in numerous emergencies around the
world. However, we strongly believe that responding to emergencies should be a last
recourse, not our first; and we worry that fundamental prevention and control efforts
may inadvertently be undermined by a diversion of resources to whatever has most
recently appeared on CNN.
As I have described, USAID's efforts in addressing infectious diseases over the
span of several decades have been considerable. We are doing all we can within the
limits of our resources. It is important to remember that increased support for
combatting diseases will come directly out of other vitally important agency programs
or other foreign policy priorities. As I detailed at the beginning of this testimony,
programs as diverse as economic reform and family planning all have important
ramifications for infectious diseases. The Committee should not be in a hurry to rob
Peter to pay Paul. This is not to say that there are not still areas for potentially
expanding infectious disease related activities, including: slowing the emergence and
spread of antimicrobial resistance, testing and improving options for controlling
tuberculosis, expanding the control of malaria and strengthening disease surveillance
and monitoring.
Anti-microbial Resistance
America continues to be at considerable risk from the emergence of drug
resistant microbes which cause infectious diseases such as pneumonia, dysentery,
malaria and tuberculosis. Resistance makes the control of these diseases more
complex, difficult and expensive -- constituting a serious threat to progress made in
developing country health programs. USAID's investments in addressing the problems
of resistance have been instrumental in expanding our understanding of the factors which promote resistance and have guided important policy decisions at both global
and national levels.
Two areas of continuing need are: slowing the emergence of resistance and
improving the detection and response to resistance. It is a well documented fact that as
drug use increases, so does resistance. Therefore, the first line of defense against
slowing the emergence of resistance is to decrease drug usage through the rational use
of drugs and through the prevention of disease by methods such as vaccines.
We know from more than three decades of experience that the rational use of
drugs is enhanced by strong disease control programs reflecting strict clinical
guidelines for drug treatment. We know that successful application of these programs
and policies are dependent upon multiple factors such as compliance by care-givers,
the behavior of drug providers, education and training curricula and quality assurance
at all levels of service delivery. The ultimate weapon against anti-microbial resistance
is prevention, and vaccines are potentially the most cost effective tools in our arsenal.
Therefore,USAID will continue to support the development of new and better vaccines
and more effective vaccination delivery technologies and systems. In partnership with
the World Health Organization, the National Institutes for Health, vaccine
manufacturers and others, USAID has supported the development and testing of
vaccines for diarrhea, meningitis, pneumonia and malaria, especially for use in young
children, where the majority of mortality occurs.
Controlling Tuberculosis
Tuberculosis, after years of decline, is again emerging as a leading infectious
scourge of mankind. Our principal efforts, outside childhood BCG immunization
which provides modest protection against new tuberculosis infection, have been in
support of programs aimed at developing a rational approach to managing tuberculosis
among people with HIV infection. Since the chance of rekindling an active case of
tuberculosis rises by a factor of ten as a result of the immuno-suppression that comes
with HIV, we believe this is a critical area for action.
The World Health Organization has recommended that wide-scale tuberculosis
control efforts not be initiated in the absence of confirmable and strong program
management and oversight. Tuberculosis experts have recognized that treatment and
control of tuberculosis is among the most labor-intensive of health interventions with
current protocol requiring direct health provider contact with each tuberculosis patient
several times a week during the entire eight months of short course therapy. The
principal risk of a widespread poorly run program is the high likelihood of the
development of multi-drug resistance, which transforms tuberculosis into an
untreatable deadly disease.
It has been our experience that health service delivery systems in developing
countries are generally not well prepared to attack tuberculosis systematically and on
the scale which is required. Consequently, the question of how existing technologies
can be effectively applied needs to be determined. It is clear that the resource needs
of a truly global effort to address tuberculosis are enormous, in all likelihood dwarfing
current resources for AIDS control efforts. This is unquestionably the biggest unmet
need among infectious diseases today.
Combatting Malaria
Although malaria is a global problem, Africa currently accounts for 85 percent
of the world's total malaria clinical cases, and 90 percent of the malaria deaths, which
occur principally among infants and children. Consequently, additional efforts in
malaria will concentrate on, but not be limited to, Africa. Over the last decade,
lessons learned from USAID-supported field programs have significantly increased the
understanding of malaria impact and control. For example, we have helped African
governments adopt new malaria treatment policies in response to the rising death toll
caused by the spread of drug resistant strains of the malaria parasite throughout the
region. Where these policies have been adopted, malaria-related mortality has fallen
by more than 20 percent. It is clear that substantial reduction in malaria-related deaths
and cases of severe illness can be achieved by properly applying technologies
currently available.
To meet the challenge of malaria in Sub-Saharan Africa and elsewhere, it
would be necessary to target malaria for special attention, with particular focus on
expanding the application of proven interventions, malaria vaccine development and
the development of new technologies for prevention and control of malaria.
Disease Monitoring and Surveillance
The ability to detect disease is an essential component of establishing a line of
defense. This is particularly true if prevention and control activities or available
intervention options are insufficient. Improving disease monitoring and surveillance
internationally requires at least four areas of effort. First, the national capacity of
developing countries needs to be strengthened so that countries can better perform
their own disease surveillance and monitoring functions. USAID brings extensive
experience in institution-building within the health sector to this important task and
also plans to use linkages with other U.S. institutions to strengthen disease
surveillance and epidemiological training within developing countries.
Secondly, international, particularly regional, capacity in disease surveillance
needs strengthening, including looking at new collaborative approaches for
strengthening disease surveillance activities in the developing world. The third area of
need is the expansion of the capacity to rapidly respond to emergency disease
outbreaks. USAID has performed this function in the past in situations of natural or
social disasters and when potentially important outbreaks occur in developing
countries, such as was the case with the African ebola outbreak in 1995. Lastly, we
need to have available simple and cost-effective methodologies to detect drug
resistance in least developed countries.
Is the international community doing enough to address infectious diseases
around the world? Of course not -- the needs are many times greater than the
resources we have available to apply to them. Yet USAID devotes a greater
proportion of our Development Assistance funds than ever before to health and
nutrition, and we do not think it would be wise to further cut back our efforts in
agriculture, combatting poverty and hunger, basic education, environmental protection -- all, as I have mentioned, key factors in helping to prevent the spread of infectious
diseases.
We continue our efforts to meet this challenge, recognizing the greater need
before us, and working to make the most efficient use of the resources the Congress
has made available to us to improve both human health and the human condition in the
countries of the developing world. In giving priority to prevention, and in helping
countries to develop their own capacities to control infectious diseases, we believe that
USAID is acting in a manner consistent with promoting both development and the
long-term interests of the American people. Thank you.
This is an archived USAID document retained on this web site as a matter of public record.
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Last Updated on: July 18, 2001
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