From the ‘Cold War’ to the ‘Hot War’: Microbes change – Can We?

A 1997 public testimony by National Council for International Health (NCIH) regarding the prioritization of US foreign aid appropriations.

Make Love Go Viral!

1997 Congressional Testimony more relevant today.

April 24, 1997

Testimony by

Chuck Woolery, Issues Director

National Council for International Health

Submitted to

Congressman Sonny Callahan, Chairman of the

Foreign Operations Subcommittee of Appropriations

U.S. House of Representatives

From the ‘Cold War’ to the ‘Hot War’:  Microbes change – Can We?

 “No matter how selfish our motives, we can no longer be indifferent to the suffering of others. The microbe that felled one child in a distant country yesterday can reach yours today, and seed a global pandemic tomorrow.”   —Nobel Laureate Dr. Joshua Lederberg, 1996

Thank you for allowing the National Council for International Health (NCIH) to give public testimony regarding the prioritization of US foreign aid appropriations.  NCIH represents over 100 member organizations including the American Medical Association, the American Public Health Association, American Dental Association, the American College of Preventive Medicine, the American Nurses Association, the American Association of Critical Care Nurses, 6 Schools of Public Health and dozens of other international health and development organizations.  Most of these organizations and thousands of individual health professionals are in support of this Subcommittee re-examining its fundamental priorities in light of both human needs around the world and the growing threat to our nation’s security from new and re-emerging infectious diseases.

New threats to US Security:  For decades stopping the spread of Communism dictated most US foreign policy actions.   In the post Cold War era, a very strong case can be made for waging a serious ‘hot war’ against the spread of infectious diseases.  Overwhelming evidence already exists to support the launching of such an initiative as one of the primary directives of US foreign policy.

In some ways, infectious diseases pose a far greater threat to US security than any invading army.   We have the technological power to defend against armed aggressors.   We have few defenses against a growing number of new microbial threats.   We can easily detect the launch of an ICBM.  We didn’t detect the emergence of new strains of HIV/AIDS.  Even after we have identified a new virus, we may have nothing to stop it with.  Prevention, in the coming ‘Hot War’ may be our smartest and cheapest defense.    The old approach of ‘peace-through-strength’ must now be tempered with containment by prevention and compassion.   Given the potential for human devastation from the natural, accidental or intentional release of an infectious agent, we must reorient ourselves to achieving a broader security and lasting peace.

The best selling non-fiction book “The Hot Zone” awoke public interest with the details of an ‘air born’ strain of Ebola accidentally released at a research facility in Reston VA several years ago.  This particular Ebola strain only affected monkeys — this time.  It struck again at a facility last year in Alice, Texas.  Only a few months ago there was fire in a building at Fort Deitrick, the high security site in Maryland where our military houses some of the most lethal biological agents known to man.   A white supremacist was earlier arrested at his house with vials of Bubonic Plague not yet removed from the glove box of his car.  They were mail ordered from a federally supported lab in Rockville, Maryland.   A high school girl in California had part of her lung surgically removed because her strain of TB was not responding to our best antibiotics.  The incidence of children with whooping cough, a serious and sometimes fatal disease that’s preventable with a vaccination – has shot up 83% so far this year.  Tainted strawberries, a new strain of HIV/AIDS from Africa, a mysterious infection jumping the species barrier from fish to man off the shore of North Carolina – these are just a few examples of an increasing trend. Congressman Ganske returned from Peru last fall and was hospitalized for two weeks with a double infection of ‘post-viral encephalitis’ (inflammation of the brain) and an intestinal bacterium called campylobacter.  He still feels some of the effects.   A tuberculosis outbreak at Bancroft elementary school less than a mile from this Capital last week.  This week there was a measles outbreak in another part of town.  There is a trend here.

Laurie Garrett’s 750 page book “The Coming Plague” (recently made into a 4 hour documentary with the same name) details the many times in our past when humanity was both lucky in victory and not so lucky in defeat against microbial adversaries.   The best scientists, doctors, and experts from both the public and private sector and from nearly every branch of the USgovernment, in 4 separate reports over the last 6 years, say this is a dangerous trend.  The National Academy of Sciences Institute of Medicine, The Centers for Disease Control, the Department of Defense, The National Security Council and others has well documented these growing risks.

They have also made recommendations for action which can be classified into four basic areas; Surveillance, Response, Research and Prevention.   There has been little progress on any of these levels.

The most recent report, “America’s Vital Interest in Global Health”, was announced in a March 17 press release issued by the National Academy of Sciences, Institute of Medicine.  It stated:

“The expansion of global trade has ushered in an era of unprecedented opportunity and risk.  As the number of goods, services, and people crossing national borders each day increases, so does the chance that they may spread infectious diseases…  In order to capitalize on the opportunities of this new era while protecting Americans, the United States must broaden its commitment to global health…  The United States now devotes a lower percentage of its gross domestic product (GDP) to global health than it has at any time since 1950… More than just a humanitarian concern, the report says, it is in America’s’  ‘enlightened self interest’ to more fully engage in global health.”  (Copies of the report are available from the Institute of Medicine’s Board on International Health;  202-334-2427)

All of the evidence overwhelmingly points to a future of certain catastrophe if we fail to adequately respond to this growing ‘real world’ threat.

With a focus on prevention, this Subcommittee can do more to protect the security of Americans than any other government agency, including the Department of Defense.   Secretary of State Madeline Albright recently said that foreign aid represents only 1% of our federal budget but it will determine 50% of our history.   In the context of infectious diseases, 50% could be an underestimate.   Given the severity of the situation, it is time to radically alter the US priorities regarding the appropriation of foreign aid dollars.

No debate:

While opposing sides debate other threats like chemical weapons, rogue missiles, global warming, NAFTA, or trade with China, there is no debate regarding the reality of this certain and most serious health risk.  The body count is just too high with the numbers climbing higher each year.  The numbers are already so high that they make death counts from all previous wars pale in comparison.   Well over 150,000 Americans now die each year from infectious diseases and that number is growing.  In fact, infectious diseases have risen from the 5th largest killer of Americans to the 3rd largest killer in just the last 12 years.  Over 60,000 Americans died last year from hospital acquired infections.  That’s almost 10 times the US annual casualty rate during the Vietnam War.  There were an additional 24,000 deaths from ‘unknown’ causes that same year but were attributed to a possible infection.   Infectious diseases now account for over 50% of all doctor visits in the US and the cost to our economy is well over $120 billion a year.

Globally, infectious diseases remain the single greatest killer taking the lives of over 50,000 people, mostly innocent children, every day.  They cause needless suffering and disability in far greater numbers.  Most of these deaths and disabilities are affordably preventable.

The most alarming fact is that while the growing threat is clearly documented, the response of this nation’s government has been minimal.  In some cases, this inaction could be labeled detestable.  The Clinton Administration itself, while well aware of the threat, has suggested a $30 million cut to ‘international health’ efforts while requesting a billion dollar increase in the overall foreign aid budget.  The increase is acceptable; however, the mere $60 million increase designated for Development Assistance and $30 million reduction in USAID child survival and health efforts is not!

While this subcommittee has been quite heroic in its protection of child survival and disease prevention efforts, it, too, has fallen short of the humanitarian and national security needs.  The opportunity for bold leadership still remains unfulfilled.   To twist a phrase, ‘for lack of vision, the people will perish’.

Warnings Unheeded:

Nearly two decades ago, Congress was given a clear warning by no less than a Presidential Commission after an exhaustive study of the issue of world hunger.  At the end of the Carter Administration, this prestigious group of experts concluded:

“In the final analysis, unless Americans — as citizens of an increasingly interdependent world — place far higher priority on overcoming world hunger, its effects will no longer remain remote or unfamiliar.  Nor can we wait until we reach the brink of the precipice; the major actions required do not lend themselves to crisis planning, patchwork management, or emergency financing… The hour is late.  Age-old forces of poverty, disease, inequity, and hunger continue to challenge the world.  Our humanity demands

that we act upon these challenges now…”

Presidential Commission on World Hunger, 1980.

Congress failed to act but the microbes were already in the process of fulfilling on the Commission’s prophecy.   Less than 2 years after the release of the Commission’s report, our nation began to feel the sting of the HIV/AIDS pandemic.   The lethal virus had been spreading through the human population for over a decade moving slowly from the Kinshasa Highway of Zaire to the main streets of the United States.  The fact is, if America had been more interested in the health and well being of poor people beyond our shores much earlier, we would have had at least a 10 year head start in slowing (or stopping) the spread of this rapidly mutating pathogen.   Our failure to detect early that single disease will cost the US hundreds of thousands of lives.  It is now also costing us an estimated $30 billion a year.   Some have called the AIDS epidemic an “act of God” as punishment for those who violate the “laws of God”.   A stronger case could be made that HIV/AIDS is God’s ‘wake-up call’ to humanity, gently telling us, “Take better care of one another or you will all suffer,”.  God’s next message could be ‘air-borne”.   Whatever belief system one might have, the reality is that microbes don’t care.   In the words of Nobel Laureate, Joshua Ledderberg, “They’re just looking for a piece of warm meat.”

HIV/AIDS was not the first disease in modern times to be brought into America and it will not be the last.  With over 27 million North Americans traveling to the less-developed nations each year and returning home virtually unscreened, it is guaranteed there will be more pandemics to come.  They could be new strains of HIV, Polio, or Tuberculosis, or an infectious disease we have never seen before.   In whatever form, they will come.

We could follow current policy and wait until each disease gets here before we respond.   We could even try endlessly to stop them from crossing our borders or entering via airports.  The cheapest and most effective alternative, however, remains a pre-emptive strike on their home turf, amid the conditions of poverty, hunger, illiteracy, squalor and chaos.   This subcommittee has jurisdiction over this key area of interdiction.

“…the emergence of the most harmful diseases can be countered not only for pathogens that are recognized as threats but also for those posing threats that are not yet recognized.  Providing pure water supplies, reducing attendant-borne transmission, reducing vector-borne transmission preferentially from ill people (e.g., by providing mosquito-proof houses) should guard against the emergence of virulent pathogens, whether the pathogens are unidentified or are highly virulent variants of identified human pathogens.”

Paul W. Ewald, Dept. of Biology, Amherst College. “Guarding Against the most Dangerous Emerging Pathogens:  Insights from Evolutionary Biology”, Emerging Infectious Diseases, CDC, Vol. 2, No. 4, Oct-Dec 1996.

Wide spread poverty and chaos, and the associated lack of basic health services, clean water, sanitation, nutrition, and education, are perhaps the greatest contributors to the vitality and virulence of pathogens.   These fertile microbial breeding grounds, combined with the modern air travel of over a million people a day across all national borders, creates a truly ‘global village’ where political, economic, or social boundaries become nothing more than a figment of the human imagination.   Microbes are indiscriminate predators of the human family.   Until we become as indiscriminate in caring for one another, we will continue to give advantage to their numbers and their virulence.

Funding our Nation’s Defense:

For almost 5 decades, we have spent hundreds of billions of dollars each year protecting our nation from the spread of communism.  The time has come to invest the cost equivalent of at least a single B-2 bomber in what may be the best security investment this nation has ever made — investing in the security of life, liberty (from fear of disease) and justice for all.

Would our nation’s military really notice one less B-2 bomber?  Yes, a few jobs might be lost, but how much could the US gain from the early global eradication of polio and measles and the significant global reduction of hunger, illiteracy, tuberculosis, HIV/AIDS, unwanted births, abortions, blindness, cholera, malaria, Hepatitis A, and dozens of other lethal and disabling diseases?    Imagine the increased US economic benefits from increased trade alone if half of the world’s people weren’t fatigued by some variety of pathogen every day of the week.

“There are risks and costs to a program of action.  But they are far less than the long-range risks and costs of comfortable inaction.”  – John F. Kennedy

Thousands of adventurous Americans return daily from their travels abroad, and increasingly they are returning from exotic and chaotic regions of the world.  Those that I know personally, often return with a sniffle or intestinal illness.   With the exception of AIDS, the US has been epidemiologically lucky.  But that luck is running out.   If a strain of the flu as lethal as the 1918 “Spanish flu” was present today, somewhere between 1 to 3 million Americans would die in matter of months.   These deaths would not be limited to the young and old.  Compare these numbers to the 400,000 American soldiers killed during our 4-year-long involvement in World War II; it would be the most horrific event in American history.   There is virtually nothing preventing the comeback of this virulent strain or some other pathogen with a similar or higher kill rate.   Surveillance, response, research and prevention efforts should now be a top national security priority.    This Subcommittee’s funding levels for development assistance are inadequate in this new context.  There has never been such a profound rationale for increasing US foreign aid.

If sufficient money is not added to the foreign aid appropriations budget to meet this need, this Subcommittee will have to make the tough decisions on where it will be found within the existing aid budget.  A shift of 20% of the current foreign aid appropriations could accomplish significant health and development objectives–objectives with which the Preamble of our Constitution aligns with:

“We the people of the United States in order to form a more perfect Union, establish justice, insure domestic tranquillity, provide for the common defense, promote the general welfare, and secure the blessings of liberty to ourselves and our posterity, do ordain and establish this Constitution for the United States of America.”

Some aid constituencies will not be happy with such a shift; but they can make their case to the American people if their needs are indeed more urgent or important than this.

In addition to National security interests…

There are several other superb reasons why we, the US, should be paying our fair share in achieving measurable progress in health and humanitarian goals before the turn of this millennium.  Doing so is the right thing to do, we said we would do it, and the American people want it done.

Philosophical/ethical/religious Interests:  Only those who value money more than human life would argue that funding the most basic of human needs is a poor choice of priorities.

Political Credibility Interests:   In 1990, President Bush attended the UN World Summit for Children.  At the conclusion of that summit his Administration pledged that the US was willing to, “make available the resources,”  to meet a set of measurable, affordable and achievable goals for the year 2000.  Other global summits and US Administrations aligned on these goals as well. We urge Congress to help keep the US commitments made by both the Republican and Democratic Administrations in the first half of this decade. The 27 specific goals agreed to at the 1990 World Summit for Children include:

  1.  A one-third reduction in 1990 under-five death rates (or to 70 per 1,000 live births, whichever is less).
  2.  A halving of 1990 maternal mortality rates.
  3.  A halving of 1990 rates of malnutrition among the world’s under-fives (to include the elimination of micronutrient deficiencies, support for breastfeeding by all maternity units, and a reduction in the incidence of low birth weight to less than 10 %).
  4. The achievement of the 90 % immunization among under-ones, the eradication of polio, the elimination of neonatal tetanus, a 90% reduction in measles cases, and a 95% reduction in measles deaths.
  5. A halving of child deaths caused by diarrhoeal diseases.
  6. A one-third reduction in child deaths from acute respiratory infections.
  7. Basic education for all children and completion of primary education by at least 80 % girls as well as boys.
  8. Safe water and sanitation for all communities.
  9. Acceptance by all countries of the Convention on the Rights of the child, including improved protection for children in especially difficult circumstances.
  10. Universal access to high-quality family planning information and services in order to prevent pregnancies that are too early, too closely spaced, too late or too many.

Political interests:

This subcommittee could continue the leadership it started when it created the Child Survival and Disease account by significantly increasing the funding for child survival, disease prevention and the other development efforts that are needed to sustain the lives of children and the health of the world’s population.  We believe with a high degree of confidence that this could be done without any political liability.  In fact, it is not hard to imagine the political liabilities of not continuing such leadership.

We all know the reputation of past politicians who appeased Hitler’s spread across Europe.  And we are all aware of the stigma attached to those who stood idly by as millions of innocent lives were lost in Hitler’s concentration camps.   Future generations may judge today’s policy makers and this generation with similar distaste regarding our failure to stop the spread of infectious diseases and our lack of response to the massive loss of innocent life when so much could have been done at so little cost.   Toward the end of the movie Schindler’s List, the gutsy and wealthy businessman /hero is left crying and grasping a piece of jewelry with the realization that he literally could have bought the survival of a few more innocent Jews with the measly trappings of his lavish lifestyle.  He made the cold calculation of how many lives he could have saved with his gold ring.

The choices this subcommittee and ultimately this Congress must make are not much different.   Antibiotics costing less than two dollars per child could greatly reduce the acute respiratory infections now taking about 3 million lives a year.    A six cent measles vaccine per child, could be saving another 1.5 million.  A two cent dose of Vitamin A or iodized salt could save the lives and proper development of millions more.   The questions we should ask ourselves include:  What programs are merely for political gain?   Which programs mean the difference between life and death?  How will each of us feel at the end of this millennium?  Will we know we did our best, or, when we look back on history, will we be left with the same haunting feeling as Schindler?   I think there is a powerful message here for us all as we approach the year 2000.

Popular Interests:

While polls indicate American’s want foreign aid cut, everyone on this subcommittee is aware that the same polls indicate the majority of Americans really don’t know how little we actually spend on foreign aid.  Most Americans feel we should be spending at least 5% of our budget on aid, which would actually be a 4-fold increase.   Other polls indicate that the most popular role for US aid is in addressing unmet human needs.    The dislike of foreign aid by the majority of Americans may stem from the fact that US aid fails to meet this popular criteria.

Well over half of the US Congress was not in office in 1990 when the Bush Administration committed this nation to, ‘making available the resources,’ to meet the year 2000 goals.   Not keeping our nation’s promises is one thing; not keeping promises when they were made to the world’s children is quite another.  Especially when failing to meet those promises means millions of children will die or be permanently disabled.   I guarantee you the vast majority of Americans are against such a tragedy.

It is rather awkward to imagine starting the new millennium with hunger still significantly effecting nearly one out of every five people on this wealthy and abundant planet.   It is hard to imagine that 350 of the world’s billionaires control more of the world’s resources than the poorest billion people.  It is even harder to imagine that Americans spent over $450 billion dollars last year on gambling but would be upset with this Congress if it made a $2 billion investment to eradicate the worst aspects of wide spread disease, hunger and poverty.

Personal Interests:

Wealth, power and technology are no fortress against the world’s ills.  To microbes, people are all created equal — at about 98.6 degrees Fahrenheit.  President Roosevelt was crippled by polio.  Less than four months ago Congressman Tajeda (D-TX) lost his life to a virulent case of pneumonia which took advantage of his immune system weakened by cancer treatment.  Congressman Ganske’s episodes with  ‘post-viral encephalitis’ and campylobacter demonstrate no one is really safe.

Economic interests:

Minor global expenditures yield enormous domestic savings.   The US investment of just $32 million dollars in the global eradication of Small Pox 20 years ago has already saved the USover $3 billion! [a GAO Report in 1997 updated this figure to over $17 Billion.]  And, we continue to save approximately $300 million a year in today’s dollars.

This year, protecting US children against polio will cost Americans $231 million, plus an additional $14.3 million for a second vaccine to prevent “7 to 8” Americans from getting polio as a rare reaction to the first vaccine.   None of these expenditures will be necessary when polio is eradicated.  The US share of that global eradication effort is only a minute fraction of our current domestic costs.   Targeted cuts to Child Survival efforts by the Clinton Administration, however, are unlikely to accelerate the eradication effort.  Each year of delay will cost the US hundreds of millions more.   Measles and Tuberculosis (TB) are other examples where small international health investments will bring great domestic savings.   Eradication of measles will save Americans over $250 million a year while reduction of TB could be saving us up to $500 million annually.  Deficient TB treatment practices anywhere in the world can cause the TB bacteria to become multi-drug resistant.  Strains then imported into the US will cost as much as $250,000 per patient to cure.  In the developing world TB can be prevented for well under $100 per patient.  Treatment of TB in the US now costs hundreds of millions of dollars per year while our international efforts at TB control are virtually non -existent.

There is a second US economic benefit that will be realized by improving world health.  Healthy people contribute more to a healthy economy.  People in poor health anywhere cause economic implications for both the rich and the poor in the form of lost work or reduced productivity.   With less income, people buy less.   In a global economy poverty anywhere translates into fewer US jobs as a direct result of lost foreign purchasing power or US companies moved to cheaper labor markets.    With less income people may also go without healthcare.  Undiagnosed conditions would be more likely to emerge putting other people at risk.  Good health reduces health care costs and health education promotes the usage of annual physical, dental and eye exams.  Preventative campaigns which promote healthy lifestyles reduce the chances of illness.  This saves both consumer and public money which can then be spent on other things.

“The total economic loss to India due to the plague epidemic in 1994 was in the order of $1.7 billion.  Over 45,000 travelers to India canceled their travel plans, leading to a 20-60% decrease in hotel occupancy rates.  While Air India lost $66,000 per day, Indian Airlines lost $1 million every week. There was a 50% decrease in ships docking at the port of Mumbai. The country lost $460 million in exports, of which $23 million was in diamond exports alone.”

THE HINDU ON-LINE, “WHO sounds alert on new diseases” April 7, 1997

By Our Special Correspondent, NEW DELHI, April 6.

For economic reasons alone, global disease prevention efforts should remain a top priority.  There will be no enduring economic prosperity for our country without economic growth in the Third World. There will not be security and peace for our citizens without stability and peace in developing countries.

George P. Shultz

Military interests:

US troops are regularly exposed to harsh conditions and foreign populations.   Protecting them from accidental or intentional infections is a major emphasis of US defense strategy.  Few people realize that 75% of all US military hospitalizations during World War II, the Korean War and the Vietnam War were a result of infectious diseases.

One of the most dangerous activities for US troops outside of waging war is trying to stop a war or quell civil unrest.  Given the escalating cost and risk of peace keeping, prevention of war and the breakdown of nation states are receiving increased attention.  A recent CIA report studied the breakdown of nation states in order to predict and possibly prevent future hot spots.    After looking at hundreds of variables, the CIA identified the infant mortality rate as the number one indicator for predicting the breakdown of a nation state.  While it is obvious that child survival programs alone are insufficient to keep nations from imploding, the value of reducing child deaths should not be underestimated as a critical factor in keeping populations more docile.

Those who believe the cost of ‘peace keeping’ is too high have not fully examined the human and economic costs of chaos.   Exposing US troops to chaos anywhere does expose them to higher rates of infectious disease as well as other dangers.  However, not sending US troops to quell conflicts could result in even greater chaos and increased advantage to our microbial adversaries in a host of other ways.  For example:  Wars always increase the spread of disease.  Refugees which are created by war are usually the most affected by loss of health infrastructure.  They are also most likely to migrate to areas of safety, taking whatever health problems they have acquired with them.

The intentional use of biological infectious agents by our human adversaries is perhaps the most frightening future prospect.   There is really no way to defend against such an attack if an agitated force is committed to delivering pathogens to US citizens.   While the threat of retaliation by a powerful US military force might prevent some adversaries from using biological weapons, the same US military force of unconfrontable power will force other aggressors into covert actions to achieve their objectives. The smaller the force, the more likely it could immunize its members against the infectious agent and then deliver that agent, undetected, to its target population.    The bottom line is that the US should be very hesitant in making enemies of anyone except the microbes.   It is not possible to overstate our vulnerability to the use of biological weapons.   Even trying to defend against biologicals may carry serious health side effects as now possibly manifested by the Gulf War Syndrome.   Adequately supporting the four basic recommendations of the CISET report would help neutralize the effects of an intentional biological attack. Just as important, this Subcommittee should not overlook the degree to which US leadership in helping the world meet the most basic of human needs globally will reduce the likely hood of future conflicts and aggression.

History has taught us that wars produce hunger,  but we are less aware that mass poverty can lead to war or end in chaos.  While hunger rules, peace cannot prevail.

–Willie Brandt, Chairperson of the Brandt Commission.  1981

Standing by in a land of great abundance while millions are dying each year from malnutrition and infection does not build good will or stability.  Almost any American child is uncomfortable with this injustice.

Justice is the great interest of man on earth.  Wherever her temple stands, there is a foundation for social security, general happiness and the improvement and progress of our race.  (Inscribed above the entrance to the US Dept. of Justice, Washington DC.)

The Basic Needs of Woman and Children:

While great progress has been made in saving and protecting the lives of children, it appears progress is waning.  The US response to the conditions that continue to kill 35,000 children each day must not.  The majority of these deaths are still caused by easily and affordably preventable malnutrition and infection.  Funding for traditional Child Survival and micronutrient efforts should be increased and a portion of that increase given to not-for-profit organizations doing direct services to those most in need.   More emphasis should also be put on getting resources where they are most needed.   The two regions of the world where child deaths are still highest receive the least amounts of US aid – Africa and Asia.    Vaccines, ORT, antibiotics and Vitamin A are essential but not enough to sustain child survival and development.  Other health and development programs are also essential.

Maternal survival and health, which are vital in and of themselves and also vital for child survival, are not currently a fiscal priority of our international aid package.  Tuberculosis alone kills over 1.5 million women each year.  Little of US aid is spent addressing this rapidly mutating killer. There is food distribution, but where does it go?  There is micronutrient work, but the worldwide blight of anemia and the resulting intellectual dullness and lack of energy for work continues on a massive scale.   There is essential obstetric care, but due to fiscal constraints, it is limited to small pockets of intervention.  As many as 580,000 women will die this year as a result of complications in pregnancy or child birth.

Increased funding for the promotion of breastfeeding alone may be as productive in saving lives as ORT, immunization or antibiotics and may prevent as many births as family planning programs. It is estimated that breastfeeding ALONE has THE POTENTIAL TO SAVE 1-2 MILLION MORE children each year.

In general, about 55% of child mortality is attributed to poor nutrition.  These nutritional deficiencies cannot be filled by micronutrients alone.  There must be at least a 10 fold increase in breastfeeding support programming and a 20 fold increase in micronutrient and non-micronutrient programs targeted specifically to the needs of women and children if we wish to make the desired strides in addressing maternal and infant mortality.

HIV/AIDS is increasingly taking the lives of women and children and dramatically affecting the lives of even those who are not even infected.  Clean water, sanitation and antibiotics are of great benefit in reducing the complications of opportunistic infections, and microenterprise credit efforts can reduce the number of females trading sex for money.  Basic education is as important to reducing HIV/AIDS in the Third World as the availability of condoms.   A comprehensive approach to all infectious agents will be the most effective, and few approaches will be as effective as the training of basic health providers (nurses, nurse midwives, primary care doctors).  Investments in training people to safely deliver immunizations and antibiotics, quality family planning services and family health information, would be some of the most effective money we could spend.   The strengthening of the public health sector in areas such as education, nutrition, and child survival prevents the diffusion of infections and, thus, averts potential costs of treatment.  Adequately supplied health clinics staffed by adequately trained health workers affordably accessible to all the world’s people would provide us with our first line of defense and our  ‘first alert’ system to protecting us from any new or re-emerging diseases.

Funding Levels:

Too small a portion of US foreign aid is directed at improving health conditions where they are most lacking.    To make matters worse, development programs have received deeper and more disproportionate cuts than any other sector in the foreign aid budget.  This subcommittee has done much to restore funding to international health programs but these programs are still about $200 million short of what they were in FY’95 and are still far short of meeting the year 2000 goals.

We support the President’s request for a $1.4 billion increase in the foreign aid budget.  We strongly disagree, however, with how and where this money will be spent.  In the President’s FY’98 budget for USAID, funds for population, health and nutrition have been targeted for a reduction of approximately $25-30 million dollars.  The USAID Budget office has told us that this cut will come from Health and Child Survival programs, and most of the  “$20-25 million” from “Child Survival”.   This is unacceptable.  While other categories in the USAID budget, such as agriculture and environment or aid to the former Soviet states, certainly deserve increases, these increases should not come at the expense of health and child survival programs.  We strongly urge any budget increase to be applied in a fair and proportional manner.

More US aid is needed to address global poverty.   According to Church World Service/Lutheran World Relief, “Only 34% of bilateral assistance (including development assistance, ESF, military assistance, NIS/SEED, international narcotics control, and debt restructuring) requested for FY98 is designated for low-income countries (GNP per capita $695 and below in 1993).  Two thirds of that aid goes to Egypt ($2.1 billion), leaving just over $1 billion (of the total $9.2 billion) for the more than forty low-income aid recipient countries.  Israel, with a per capita income of $13,920, receives three times the amount allocated to these poor countries.”

While it is obvious for political reasons why only two nations receive over $5 billion in US aid, from all the reasons listed above, it is indefensible that development efforts focused on the poorest half of the world would receive so little.  As the senior Members of this subcommittee know, the central mission of USAID is to alleviate poverty.  For the newer Members of this Subcommittee, I would like to point out that the Foreign Assistance Act of 1961 states that USAID’s principal purpose is “to help the poor majority in developing countries,” with the goal of “increasing their incomes and access to public services which will enable them to satisfy their basic needs…”.     We believe that the USAID budget should reflect this.    We urge this subcommittee to continue its leadership in supporting the “Child Survival and Disease Account,” and believe the US should be spending at least $800 million in FY’98 on these specific efforts without reducing aid to other vital development programs.

Debt Relief:   Debt Relief to countries like Uganda will assist political leaders to better meet the health and education needs of their own people.

Multilateral Programs:   NCIH supports $1.035 billion for the International Development Association (IDA) of the World Bank to cover both FY’98 contributions and past arrears.   We are also hopeful you will press the World Bank to promote popular participation in its operations, especially by consulting local communities prior to approving loans.  NCIH will work with Bread for the World and others in direct advocacy through Congress at both the World Bank and the US Treasury to achieve the participation goal.

There is really only one reason not to increase funding for international health and development efforts:   the immediate economic gains of not spending the money now.    This logic roughly falls into the same category as not changing the oil in your car or buying new tires to ‘save’ money.   The reality is, we can pay a little now, or we will pay a lot more down the road.   Prevention pays for itself.   In the case of development assistance and disease prevention it will be saving lives as well as dollars.  As my Junior High daughter would say,  This is a “no-brainer”.

“Public health is purchasable.

Within natural limitations, any community can determine its own death rate.”

Herman M. Biggs, MD, Msc, LLD (1859-1923).


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