Health in Developing Countries: The U.S. Response
Order Code RL30793
CRS Report for Congress
Received through the CRS Web
Health in Developing Countries:
The U.S. Response
Updated February 27, 2001
Lois B. McHugh
Analyst in International Relations
Foreign Affairs, Defense, and Trade Division
Congressional Research Service ˜ The Library of Congress
Health in Developing Countries: The U.S. Response
Summary
P.L. 106-429, the Foreign Operations, Export Financing, and Related Programs
appropriates $963 million for Child Survival and Disease program activities. Of this
amount, Congress directed $295 million for child survival and maternal health, $300
million for HIV/AIDS, $125 million for other infectious diseases, and $30 million for
vulnerable children. The sum also includes $110 million for UNICEF and $103
million for education. The law directs USAID to allocate up to $50 million for
GAVI, an international vaccine initiative, and up to $30 million for an international
AIDS Initiative and fund.
Health assistance spending has increased overall in recent years, but only in
some areas of the account. Both the Administration and Congress have devoted
growing amounts to programs to control HIV/AIDS and some infectious diseases, but
funding for other health programs has stayed the same or declined. An October 1999
GAO report stated that USAID funding for childhood vaccination programs, for
example, fell from about $53 million in the early 1990s to $47 million in FY98 and to
an estimated $33 million in FY2000. USAID has been concerned in recent years that
funding for such basics of health development programs as disease surveillance and
building health infrastructure has also fallen. Growing alarm at the spread of new
infectious diseases and the resurgence of many others due to the spread of antibiotic
resistant strains has put pressure on traditional health assistance programs. How to
address this situation with limited funds is the debate within Congress, the
Administration and among health professionals around the world.
Contents
Background . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
USAID Health Program Allocations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Vaccination Against Childhood Diseases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Contributions to UNICEF . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
Infectious Diseases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Tuberculosis (TB) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Malaria . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Pneumonia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Diarrheal Diseases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Measles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Hepatitis B and C . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
HIV/AIDS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Congressional Action . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Issues for the 107th Congress . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
List of Figures
Figure 1. Leading Infectious Killers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
List of Tables
Table 1. USAID Health Spending from All Accounts . . . . . . . . . . . . . . . . . . . . . 3
Table 2. Selected USAID Child Survival and Health Account Expenditures . . . . 4
Table 3. Infectious Disease Initiative Appropriations . . . . . . . . . . . . . . . . . . . . . 8
Table 4. USAID Funding for HIV/AIDS from All Accounts . . . . . . . . . . . . . . 11
Health in Developing Countries:
the U.S. Response
Background
P.L. 106-429, the FY2001 Foreign Operations Appropriation provides $963
million for the Child Survival and Disease Programs of the U.S. Agency for
International Development (USAID).1 Of this amount, $103 million is for educational
programs rather than health programs and $110 million for the regular U.S.
contribution to UNICEF, leaving $750 million for bilateral health programs. The
legislation earmarks $300 million for HIV/AIDS and $125 million for other infectious
diseases. Overall, $295 million is dedicated to child survival and maternal health
programs and an additional $30 million for vulnerable children (which includes
HIV/AIDS orphans).
In addition to the funds of the Child Survival and Disease Account, USAID
allocates money to health programs from its regional and other programs. Other
sources of health assistance funds, both in USAID and in other agencies, are also
available. Population programs, which are in a separate USAID account, have been
funded at about $400 million per year in recent years.2 Other funds used for
international health are in the annual budgets of the Department of Health and Human
Services, in the appropriation for the Center for Disease Control and Prevention
(CDC) and the National Institute of Health. The CDC focuses on epidemiology and
disease surveillance abroad as part of its role of preventing and controlling disease
outbreaks. CDC is also the historic leader of U.S. worldwide vaccination efforts,
working closely with USAID. The CDC estimate for international activities for
FY2000 is $158 million. The Fogarty International Center of NIH is also involved in
health programs. Its FY2001 budget is $50.5 million. The Department of Defense
budget supports research, prevention, and response to disease outbreaks as part of its
broader operations. U.S. contributions to the World Health Organization are
appropriated in the Department of State Appropriation. But for purposes of this
paper, health assistance is the funding identified by USAID.
Health has become an increasingly significant part of the world’s political agenda
as donors have become aware that health problems hinder development and limit
trade. Moreover, diseases in one country can and have led to health problems in other
countries. The current U.S. concern about West Nile Virus is just the latest example
1 P.L. 106-429 enacts by reference H.R. 5526 and this paper will refer to the provisions of
H.R. 5526 as P.L. 106-429.
2 For information on U.S. population programs, see CRS Issue Brief IB96026, Population
Assistance and Family Planning Programs: Issues for Congress. Updated regularly.
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of a disease entering the United States from another continent. World Health
Organization (WHO) Director General Gro Brundtlund noted in her opening speech
to the delegates of the World Health Assembly in May 2000 that health has become
a regular part of the agenda of the G8.3 It is an issue in the discussions of debt relief
by finance ministers at the World Bank and the International Monetary Fund.
HIV/AIDS in Africa was the subject of discussion in the U.N. Security Council in
early 2000, under the leadership of the United States, and will be the subject of a
special session of the U.N. General Assembly in May 2001. Health was a major
subject of the April 2000 Millennium Report of the U.N. Secretary-General and in his
August 2000 report to the U.N. General Assembly on the United Nations, he stated
that HIV/AIDS is “destroying the economic and social fabric in the countries most
affected, reversing years of declining death rates and causing dramatic rises in
mortality among young adults.”4 Reducing maternal mortality, reducing deaths of
children under five, and stopping the spread of infectious diseases were among the
goals set by the governments participating in the U.N. Millennium Summit, held at the
United Nations in New York in September 2000.
The Clinton Administration focused considerable attention on health in its last
years with particular attention to infectious disease. In various domestic and
international fora, the President stressed the need for greater attention to HIV/AIDS,
particularly in Africa. In his February 2000 State of the Union address, he announced
a Millennium Initiative, one part of which includes support for an international
initiative to combat infectious disease in developing countries through GAVI, the
Global Alliance for Vaccines and Immunization and other means. It also calls for
increased attention to immunization by the multilateral development banks, and for
Congress to assist in offering support and encouragement to pharmaceutical
companies to develop and market at a reasonable price the medicines needed to
control disease in developing countries.
Congress has long been interested in and supported international health
programs, especially those geared toward children. Like the Clinton Administration,
Congress has increasingly focused attention on infectious disease in recent years.
Congress has expressed frustration in congressional hearings over what it sees as the
slow USAID response to infectious disease, and disagreement over USAID’s
priorities in foreign health programs. For this reason, Congress has increasingly
earmarked specific amounts for specific health programs.
USAID has resisted earmarking funds for specific diseases because it sees health
as an integrated development problem with funds needing to flow between health
needs. The overlapping nature of health programs, where one health center may be
providing maternal care, vaccination against childhood diseases, and HIV/AIDS
counseling, often to the same people, makes separating funds spent on one disease
program from another nearly impossible, according to USAID. USAID also
3 The G-8 includes Canada, France, Germany, Great Britain, Japan, Italy, the United States
(known as the G-7) and Russia.
4 United Nations. Report of the Secretary-General on the work of the Organization. General
Assembly. Official records. Fifty-fifth session. Supplement No. 1 (A/55/1). pg. 28.
[http://www.un.org/news/ossg/sg].
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expresses concern that Congress identifies the dollar amount to be devoted to a
particular disease in appropriations legislation without increasing the overall health
account to compensate. This lowers the amount of money available to USAID for
other health needs which USAID deems essential to carrying out congressional
mandates. USAID cites as examples improving health infrastructure and disease
surveillance. The dispute between an administration wishing maximum flexibility in
foreign aid spending and a Congress wishing greater control over foreign aid spending
is long standing. It occurs in all areas of foreign aid, not just health programs.
Congress has increasingly pushed USAID toward specific, measurable programs with
dedicated funds and away from general purpose aid programs with hard to measure
results.
USAID Health Program Allocations
Table 1 shows the funding for all health assistance programs in USAID,
including the Child Survival and Disease Programs Fund and amounts coming from
regional or other programs, such as Economic Support Fund and funds for the former
Soviet Union and Eastern Europe. Because the Child Survival and Disease Programs
account also includes funding for U.S. programs to improve education in developing
countries, that amount, about $100 million per year in recent years, has been
subtracted in order to show actual bilateral health spending.
Table 1. USAID Health Spending from All Accounts
(in millions of dollars)
FY2001
FY1997
FY1998
FY1999
FY2000
(Est.)
Child Survival and Health*
360.9
338.3
400.7
464.5
383.0
HIV/AIDS
121.1
125.6
142.1
200.0
340.0
Infectious Disease Initiative
0.6
54.5
64.4
70.4
137.0
UNICEF
100.0
100.0
107.0
112.0
110.0
Total
582.6
618.4
714.2
846.9
970.0
Source: USAID. 2001 figures do not include a 0.22% recission from all discretionary accounts.
*Now called Child Survival and Maternal Health account by USAID.
Although P.L. 106-429 appropriates $860 million for Child Survival and Disease
programs after subtracting education programs, the funding breakdown provided in
the legislation is not comparable to the figures in Table 1 because they do not include
funds drawn from USAID regional and other programs and because there may be
duplications.
The line entitled Child Survival and Health includes U.S. funding for vaccination
programs to protect children from childhood diseases such as measles and polio. It
also includes programs to reduce maternal mortality and promote maternal health,
programs to address nutritional deficiencies in children, and U.S. efforts to eliminate
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micronutrient deficiencies (for example, Vitamin A). The USAID program focuses
on helping countries develop the capacity to provide these services to women and
children and is the primary source of funding for health infrastructure, according to
USAID. Table 2 shows funding for some of the programs within the Child Survival
and Health account which have been of particular interest to Congress.
Table 2. Selected USAID Child Survival and
Health Account Expenditures
(in thousands of dollars)
FY2000 Estimate
FY2001 Estimate
Polio
25,000
27,500
Guinea Worm
800
0
Vitamin A
16,832
not available
Other micronutrients
24,714
not available
Maternal health
50,000
50,000
Immunization
33,221
not available
Source: USAID 8/21/00.
Vaccination Against Childhood Diseases
The campaign to vaccinate children against six childhood diseases (measles,
pertussis, polio, diphtheria, TB, and tetanus) began in the 1970s and has been a major
U.S. and multilateral effort since the early 1980s. The UNICEF/WHO Child Survival
Initiative, started in 1982, had as one of its goals universal immunization of children
by 1990. Although the 80% immunization rate (the percent necessary to prevent
disease epidemics) was reached overall in many developing countries, children in
some areas were never vaccinated and in some countries the overall goal was reached
for only 4 or 5 of the 6 diseases. Vaccination coverage in the poorest countries,
particularly in urban slums and isolated areas, remains low. Low income countries
with conflict or political unrest tend to have the lowest immunization rates. During
the 1990s, vaccination programs in developing countries lagged for a variety of
reasons including internal conflict. In sub-Saharan Africa, for example, the overall
average for immunization is under 60% and has fallen in the last decade. An October
1999 GAO Report cited the low level of commitment from bilateral donors during the
1990s as one reason for falling vaccination rates.5 For example, UNICEF, a major
source of vaccines and funding for immunization programs, saw its contributions for
immunization programs fall from about $182 million in 1990 to about $51.5 million
in 1998. And attempts to add newly developed and sometimes more expensive
5 Factors Contributing to Low Vaccination Rates in Developing Countries (GAO/NSIAD-
00-4).
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vaccines against Hepatitis B, Yellow Fever, and Haemophilus influenzae type b (Hib)
have not been successful. According to the GAO Report, USAID funding for
vaccination programs declined from about $53 million between FY1990 and FY1993
to about $51 million from FY1994-97 and $47 million in FY1998. Administration
requests for vaccination programs continue to decline. Since FY1996, about half of
U.S. immunization spending has been devoted to eradicating polio.
The Centers for Disease Control and Prevention (CDC) is the historic U.S.
leader for international vaccination programs and has become a major source of U.S.
funds for vaccine purchase. Of its $226 million international activities expenditures
for FY2001, $102.5 million is directed to polio and measles elimination efforts.
A new vaccination campaign, the Global Alliance for Vaccines and
Immunizations (GAVI) which began in 1999, was formally launched at the January
2000 World Economic Forum. It is an alliance of business leaders, philanthropic
foundations, development banks, U.N. agencies, and national governments formed to
regain the momentum for immunizing children against preventable childhood diseases.
President Clinton requested a $50 million contribution for this program in the FY2001
budget. This amount was authorized in PL 106-264, the Global AIDS and
Tuberculosis Relief Act of 2000 and appropriated in P.L. 106-429.
Contributions to UNICEF
The annual U.S. contribution to the regular budget of UNICEF is included in the
Child Survival and Disease Programs account. It was moved into this account by
Congress. It had been appropriated as part of the International Organizations and
Programs account where most other U.N. voluntary programs are funded and
President Clinton continued to request it as part of that account. Only part of the U.S.
contribution to UNICEF is devoted to health assistance. UNICEF’s most recent
annual report states that 32 percent of its program budget is dedicated to health, 11%
to water and sanitation, and 6% to child nutrition. Community development,
women’s programs, education, and early childhood development are other areas
addressed by UNICEF. The U.S. contribution remained at $100 million for most of
the 1990s, but has increased recently. The FY2001 appropriation is $110 million.
Additional UNICEF funding, including funding for health programs, may be provided
from other USAID accounts in response to specific situations or programs. For
example, funding for refugee or other humanitarian health programs may be provided
to UNICEF from the Migration and Refugee Assistance account or from the Bureau
of Humanitarian Response.
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Infectious Diseases
Infectious diseases are among the leading causes of death worldwide as
estimated annually by the World Health Organization.6 For this reason, much of the
international effort in the health area involves monitoring, vaccination, and research
on infectious diseases. According to the World Health Organization (WHO),
infectious diseases are the world’s biggest killer of children and young adults. They
kill more than 13 million people a year, accounting for half of all deaths in developing
countries. Ninety percent of these deaths are caused by just six diseases: tuberculosis
(TB), malaria, HIV/AIDS, pneumonia, diarrheal diseases, and measles. (See Figure
1.)
Figure 1. Leading Infectious Killers
* Acute respiratory infections include pneumonia and influenza.
** HIV-positive people who died with TB have been included among AIDS deaths.
Source: World Health Organization, 1999.
Developing countries are doubly handicapped in addressing infectious disease
outbreaks. Many infectious diseases are endemic to the tropical areas where most
developing countries are located. Because of poverty, the health and sanitation
infrastructure is poorly equipped to address local health needs. WHO studies indicate
that infectious disease is spreading most rapidly in areas of conflict or political crisis.
In addition to deaths, frequent bouts of illness slow the rate of development overall
6 Although accurate health statistics are not available, particularly in developing countries,
U.N. agencies and many governmental agencies cooperate in providing estimates of the health
status of populations around the world. These statistics are used in many of the annual
publications of U.N. agencies such as the UNDP Human Development Report, the UNICEF
State of the World’s Children, the World Bank World Development Report, and the WHO
World Health Report. See the World Health Report: [http://www.who.int/whr].
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and the cost, in time and money, of caring for sick relatives can have a devastating
impact on the local economies in developing countries.
In 1995, the World Health Organization established a new division on emerging
and reemerging infectious diseases. The G8 began discussing the international
response to the problem of infectious disease in 1997 and, in its communique at the
end of the June 2000 summit, supported U.N. goals of reducing the number of HIV-
infected young people by 25% by 2010, reducing TB deaths and prevalence of the
disease by 50% by 2010, and reducing the burden of disease associated with malaria
by 50% by 2010.7
Concern about the spread of infectious diseases has been growing in the United
States for several years. Since the end of the Cold War, increased understanding of
U.S. vulnerability to infectious diseases endemic to developing countries, such as
West Nile virus, the growing threat from emerging and reemerging diseases like
HIV/AIDS and Ebola, and the renewed threat from drug resistance among diseases
such as TB, have pushed the Administration toward a greater interest in bilateral and
multilateral health assistance programs. Like the Administration, Congress has
increasingly focused attention on infectious disease. Extensive hearings have led to
increased appropriations for HIV/AIDS and other infectious disease programs.
Several studies by scientific panels reporting to the White House led to a 1996
Presidential Decision Directive calling for a more focused U.S. response to infectious
disease worldwide. In January 2000, the National Intelligence Council issued a report
on the security implications of infectious disease. This report, NIE99-17D, The
Global Infectious Disease Threat and Its Implications for the United States, outlined
the threat to national security posed by projected infectious disease over the next 20
years.8 The National Intelligence Council (NIC) report notes that of the seven main
diseases, four (TB, malaria, hepatitis, and HIV/AIDS) continue to surge and become
more drug resistant and that TB and HIV/AIDS would account for the overwhelming
majority of deaths from infectious diseases in developing countries by 2020. Acute
respiratory infections, diarrheal diseases, and measles, which have been the focus of
international child survival efforts since the early 1980s, appear to have peaked, at
least temporarily. The report notes that in the last 25 years, more than 30 new
infectious diseases have appeared around the world, many of them incurable. The
reemergence of infectious diseases once thought to be under control, such as TB,
Dengue and malaria, and the growth of drug resistant diseases have also increased the
threat to Americans. Under-Secretary of State Alan Larsen noted in a speech on
April 12, 2000, that with increased trade and travel, the spread of disease could undo
development abroad and threaten health and security at home.9 The NIC Report
stated that growing trade, travel and immigration, plus the large civilian and military
presence abroad, continues to place the United States at risk of infectious disease
outbreaks.
7 G-8 Kyushu-Okinawa Summit Communique (Issues include development, trade, info
technology) (7560) [http://pdq.state.gov/pdqhome.html]
8 [http://www.odci.gov/cia/publications/nie/report/nie99-17d.html]
9 [http://usinfo.state.gov/homepage.htm]
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The Infectious Disease Initiative was established in 1998 with strong support
from Congress. It includes activities to control TB and reduce deaths caused by
malaria and other diseases, to improve disease surveillance and response in developing
countries, and to reduce the growing threat of microbial resistance (diseases becoming
resistant to treatment with antibiotics). Table 3 shows USAID funding for some
infectious disease programs.
Table 3. Infectious Disease Initiative Appropriations
(in thousands of dollars)
FY2001 Preliminary
FY2000 Estimate
Estimate
TB
20,269
56,700
Malaria (excluding Child Survival)
15,971
50,000*
Malaria in Child Survival
11,579
Disease Surveillance
10,665
14,700
Antimicrobial Resistance
4,847
12,000
Other
18,649
6,000
Total Infectious Disease Initiative
70,401
138,900
Source: USAID
*All malaria funds are combined in the 2001 allocation.
The Clinton Administration’s Millennium Vaccine Initiative for FY2001 includes
increased spending for vaccine research at the National Institutes of Health and the
Department of Defense, a $50 million contribution to GAVI, a $1 billion tax credit
for sale of new vaccines, as well as pressures on multilateral development banks to
provide $400 to $900 million in low interest lending for health. Members of Congress
supported much of this initiative. P.L. 106-429 appropriated $50 million for GAVI,
$10 million for an International AIDS Vaccine Initiative and $20 million for a U.S.
contribution to an international HIV/AIDS fund which may also fund vaccine
research.
WHO lists six diseases as the cause of most deaths from infectious disease. The
National Intelligence Council adds a seventh. A description and discussion of each
of the seven follows.
Tuberculosis (TB)
In June 2000, Dr. David Heymann of WHO described TB before a congressional
committee as “a disease once thought to be under control, which has returned with
a vengeance to kill 1.5 million people a year” and another half million in combination
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with HIV/AIDS.10 He noted that nearly one third of the world’s population have
latent TB infection. In 1993, WHO declared TB a global emergency. WHO
estimates that between 2000 and 2020, nearly one billion more people will be infected,
200 million will get sick, and 35 million will die if control is not further strengthened.
TB is a contagious disease which spreads through the air. Only people who are sick
with pulmonary TB are infectious. Overall, one-third of the world’s population is
currently infected with TB, but only 5 to 10% of those become sick or infectious at
some time during their life, according to WHO. Among HIV infected persons who
are also infected with TB, the rate of conversion to active TB disease (and therefore
to becoming infectious) is considerably larger. The National Intelligence Council
report states that TB is especially prevalent in Russia, India, Southeast Asia, sub-
Saharan Africa, and parts of Latin America. Poorly supervised or incomplete
treatment threatens to make TB incurable as multidrug resistant TB cases rise.
Infection with HIV is accelerating the spread of TB. Increased global travel,
migration, and growing refugee numbers are also causes of the growing TB problem.
The Stop TB Initiative was established by WHO to bring together governmental and
non-governmental groups in a coordinated effort to control TB. The current WHO-
recommended approach to TB cure and prevention, called DOTS (Directly Observed
Treatment, Short Course), is 95% effective and may cost as little as $11 per patient
for the six month treatment. Twenty-two countries have 80% of TB cases, led by
India with an estimated 2 million cases, and China, with over 1 million estimated
cases.
Malaria
This mainly tropical disease kills over 1 million people a year, mostly children,
according to WHO. An estimated 300 to 400 million people are infected by the
mosquito borne malaria parasite each year. About 86 % of malaria deaths occur in
Africa and 71% of its victims are under 5 (accounting for 20% of all childhood deaths
in Africa). Women are especially vulnerable during pregnancy. Between 10% and
13% of maternal mortality is due to malaria. About 80% of regions undergoing major
political crises or conflicts suffer from high rates of malaria due to massive migration,
absence of sanitary infrastructure, malnutrition, and environmental deterioration.
WHO estimates that up to 30% of African malaria deaths each year occur in countries
affected by serious conflict or natural disaster. A campaign to curb the disease called
Roll Back Malaria was established in November 1998 by the World Bank, WHO,
UNICEF and UNDP with support from USAID. Its initial focus is on Africa.
Pneumonia
Acute respiratory infections (ARI) were the cause of 3.5 million deaths in 1998
(down from 4.1 million in 1993), according to NIE99-17D. Pneumonia is the
deadliest of these and kills more children than any other infectious disease. Ninety-
nine percent of deaths occur in developing countries. Pneumonia often affects
children with low birth weights or those whose immune systems are weakened by
10 Statement of Dr. David L. Heymann, Executive Director for Communicable Diseases,
World Health Organization, before the House International Relations Committee. June 29,
2000.
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malnutrition or other disease. Influenza is another cause of acute respiratory
infection.
Diarrheal Diseases
These diseases, mainly spread by contaminated food or water, kill nearly 2
million children under 5 per year, according to WHO. NIE99-17D estimated the total
number of deaths at 2.2 million in 1998, down from 3 million in 1993. Children die
because their bodies are weakened by rapid loss of fluids and undernourishment.
These diseases thrive in areas with poor sanitation, inadequate hygiene and unsafe
drinking water. In developing countries, children under 5 suffer about 1.5 billion
bouts of illness each year, a heavy burden on their families. Epidemics of cholera and
dysentery strike down adults and children alike. Other major diarrheal diseases
include typhoid fever and rotavirus, which is the main cause of severe dehydrating
diarrhea among children. Growing incidences of diarrheal diseases are occurring in
countries of the former Soviet Union.
Measles
Measles is the most contagious disease known to man, according to the
testimony of WHO Executive Director for Communicable Diseases Dr. Heymann.
It is a major childhood killer in developing countries, killing about 900,000 per year.
(This is down from 1.2 million in 1993, according to NIE99-17D.) Even more deaths
can be attributed to measles if one includes complications from pneumonia, diarrhea,
and malnutrition. Measles is the leading cause of death among refugees and internally
displaced persons. It will continue to be a major threat until vaccination rates are
substantially increased, according to NIE99-17D.
Hepatitis B and C
According to NIE99-17D, Hepatitis B caused some 600,000 deaths in 1997. It
is highly entrenched in the developing world and an estimated 350 million people
worldwide are chronic carriers. The less prevalent, but more lethal hepatitis C,
identified in 1989, has grown dramatically and is a significant contributor to cirrhosis
and liver cancer. WHO estimates that 170 million people worldwide were infected
with hepatitis C virus in 1997 and at risk of developing the diseases associated with
this virus. Various studies project that up to 25% of people with chronic hepatitis B
and C will die of cirrhosis of the liver and liver cancer over the next 20 to 30 years,
according to NIE99-17D.
HIV/AIDS
HIV/AIDS is the infectious disease receiving the most attention currently.
According to the December 2000 report of UNAIDS, the U.N. entity charged with
tracking and coordinating the multilateral response to the HIV/AIDS epidemic, an
estimated 36.1 million people are living with HIV/AIDS, of which 5.3 million were
infected in the last year. Since the epidemic began, 18.8 million people have died. Of
the 36.1 million suffering with HIV/AIDS, 25.3 million are in sub-Saharan Africa and
5.8 million are in South and Southeast Asia. Although the congressional and Clinton
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Administration focus has been on the devastation caused by AIDS in Africa, experts
are alarmed at the course of the epidemic in Asia, where several countries individually
have larger populations than all of sub-Saharan Africa and where government action
to prevent the spread of AIDS has been judged inadequate.
The United States began addressing AIDS in its foreign aid program and made
the first contribution to the newly established WHO AIDS program in FY1986.
AIDS was added to the G-8 summit discussion at the initiative of the United States
in 1996. The USAID HIV/AIDS program focuses on prevention and treatment,
addressing the needs of children with AIDS and improving infrastructure and capacity
in 46 countries (22 in Africa). This is a rapidly growing program, due in large part
to congressional support. In the last year, the devastating impact of HIV/AIDS on
Africa has led to a growing U.S. effort, including increased funding for AIDS
programs in Africa, a push to provide less costly access to AIDS drugs for Africa, and
a meeting of the U.N. Security Council dedicated to AIDS in Africa.11 Table 4 shows
USAID funding for HIV/AIDS from all foreign aid accounts.
Table 4. USAID Funding for HIV/AIDS from All Accounts
(in millions of dollars)
2001
FY:
1993
1994
1995
1996
1997
1998
1999
2000
(est.)
Total Prog.
124.5
112.8
120.7
117.8
121.1
125.6
142.1
200.0
340.*
-U.N.
35.0
29.5
26.9
18.0
16.0
16.0
15.2
15.0
17.2
-Africa Bur.
23.8
30.6
41.8
58.9
51.1
51.1
56.0
104.2
153.7
Source: USAID.
*Includes $10 million in food aid directed primarily to Africa.
The Centers for Disease Control and Prevention, which has always had a small
international program in HIV/AIDS, has also increased its spending in the last few
years. According to CDC, expenditures have risen from $11.6 million in FY1999,
to nearly $47.5 million in FY2000 and an estimated $116.5 million in FY2001.
Congress also added two new sources of HIV/AIDS funding in the Department of
Defense Appropriation and the Department of Labor Appropriation. Each agency
was directed to spend $10 million on HIV/AIDS prevention and education programs
in other countries in the military and in the workplace.
Congressional Action
Congress has long taken an interest in international health programs, particularly
those affecting children. In 1984, Congress consolidated most of the USAID child
11 For information on U.S. initiatives in response to the HIV/AIDS pandemic in Africa, see
CRS Issue Brief IB10050, Aids in Africa.
CRS-12
health programs into a single account, the Child Survival Account. Over time,
pressure mounted to use these funds for other pressing health needs and earmarks or
congressional directives were added to the legislation or accompanying committee
reports. During the 106th Congress, congressional attention focused on HIV/AIDS
in Africa, and to a lesser extent, the spread of infectious disease. Congress introduced
and considered many health bills during this session.
The major legislation passed in 2000 was the Foreign Operations Appropriation,
which was enacted by reference by P.L. 106-429 on November 7,2000. As it became
law, H.R. 5526 appropriates $963 million for Child Survival and Disease programs,
of which $103 million is for education, rather than health. Of the $860 million which
is dedicated to health programs, $300 million is earmarked for HIV/AIDS, and $125
million for other infectious diseases, $295 million for child survival and maternal
health, $30 million for vulnerable children, and $110 million for UNICEF. The law
allows a U.S. contribution to the Global Fund for Infectious Disease established by
GAVI of $50 million, $10 million for the International AIDS Vaccine Initiative and
$20 million for a U.S. contribution to the international HIV/AIDS fund authorized in
P.L. 106-264.
P.L. 106-264, Global AIDS and Tuberculosis Relief Act of 2000, which became
law on August 19, 2000, combined the provisions in two bills, H.R. 3519 and S.
2382. It authorizes the appropriation of $300 million for each of FY2001 and
FY2002 for USAID’s HIV/AIDS programs, with 20% dedicated to multilateral
programs for orphans in sub-Saharan Africa, 8.3% dedicated to programs to control
mother/child transmission, and 65% of the total to be provided through
nongovernmental organizations. The law authorizes $50 million for each year for a
U.S. contribution to the Global Alliance for Vaccines and Immunization (GAVI), and
$10 million for U.S. contribution to the International AIDS vaccine Initiative. The
law also requires the Secretary of the Treasury to negotiate the establishment of a
World Bank AIDS Trust Fund and authorizes a U.S. contribution of $150 million for
each of the 2 years. Finally, the law authorizes a U.S. contribution of $60 million for
each of the 2 years for tuberculosis programs.
P.L. 106-259, Department of Defense Appropriations, became law on August
9, 2000. Title VI of this law includes an earmark of $10 million to be used for HIV
prevention education activities undertaken as part of U.S. military training, exercises,
and humanitarian assistance activities in Africa.
P.L. 106-554, the Labor, Health and Human Services, and Education
Appropriation appropriates $10 million for international programs to control
HIV/AIDS through workplace based prevention and education programs.
P.L.106-570, the Assistance for International Malaria Control Act, authorizes
an appropriation of $50 million for each of FY2001 and FY2002 for the establishment
and conduct of activities to prevent, treat, control, and eliminate malaria in countries
with a high percentage of malaria cases.
CRS-13
Issues for the 107th Congress
It is not clear yet what priority the Bush Administration will place on
international health spending. Press coverage of early activities indicates that the
White House, the National Security Council, and the Department of State will place
less emphasis on infectious disease as a national security threat in the Bush
Administration. Nonetheless, international health assistance continues to have strong
bipartisan support in Congress. HIV/AIDS, which was addressed primarily as it
affects Africa during the 106th Congress, will continue to be a problem in Africa, and
likely a growing problem in other parts of the world during the 107th Congress. The
public health systems in the nations comprising the former Soviet Union have declined
precipitously in recent years, and there is growing evidence that those countries are
increasingly important in the spread of infectious disease around the world. Warfare
and political unrest continue to undermine vaccination efforts and disease control in
Africa and parts of Asia. Health programs are also likely to continue to be a priority
of the United Nations and other international organizations.
CRS Report for Congress
Received through the CRS Web
Health in Developing Countries:
The U.S. Response
Updated February 27, 2001
Lois B. McHugh
Analyst in International Relations
Foreign Affairs, Defense, and Trade Division
Congressional Research Service ˜ The Library of Congress
Health in Developing Countries: The U.S. Response
Summary
P.L. 106-429, the Foreign Operations, Export Financing, and Related Programs
appropriates $963 million for Child Survival and Disease program activities. Of this
amount, Congress directed $295 million for child survival and maternal health, $300
million for HIV/AIDS, $125 million for other infectious diseases, and $30 million for
vulnerable children. The sum also includes $110 million for UNICEF and $103
million for education. The law directs USAID to allocate up to $50 million for
GAVI, an international vaccine initiative, and up to $30 million for an international
AIDS Initiative and fund.
Health assistance spending has increased overall in recent years, but only in
some areas of the account. Both the Administration and Congress have devoted
growing amounts to programs to control HIV/AIDS and some infectious diseases, but
funding for other health programs has stayed the same or declined. An October 1999
GAO report stated that USAID funding for childhood vaccination programs, for
example, fell from about $53 million in the early 1990s to $47 million in FY98 and to
an estimated $33 million in FY2000. USAID has been concerned in recent years that
funding for such basics of health development programs as disease surveillance and
building health infrastructure has also fallen. Growing alarm at the spread of new
infectious diseases and the resurgence of many others due to the spread of antibiotic
resistant strains has put pressure on traditional health assistance programs. How to
address this situation with limited funds is the debate within Congress, the
Administration and among health professionals around the world.
Contents
Background . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
USAID Health Program Allocations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Vaccination Against Childhood Diseases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Contributions to UNICEF . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
Infectious Diseases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Tuberculosis (TB) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Malaria . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Pneumonia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Diarrheal Diseases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Measles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Hepatitis B and C . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
HIV/AIDS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Congressional Action . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Issues for the 107th Congress . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
List of Figures
Figure 1. Leading Infectious Killers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
List of Tables
Table 1. USAID Health Spending from All Accounts . . . . . . . . . . . . . . . . . . . . . 3
Table 2. Selected USAID Child Survival and Health Account Expenditures . . . . 4
Table 3. Infectious Disease Initiative Appropriations . . . . . . . . . . . . . . . . . . . . . 8
Table 4. USAID Funding for HIV/AIDS from All Accounts . . . . . . . . . . . . . . 11
Health in Developing Countries:
the U.S. Response
Background
P.L. 106-429, the FY2001 Foreign Operations Appropriation provides $963
million for the Child Survival and Disease Programs of the U.S. Agency for
International Development (USAID).1 Of this amount, $103 million is for educational
programs rather than health programs and $110 million for the regular U.S.
contribution to UNICEF, leaving $750 million for bilateral health programs. The
legislation earmarks $300 million for HIV/AIDS and $125 million for other infectious
diseases. Overall, $295 million is dedicated to child survival and maternal health
programs and an additional $30 million for vulnerable children (which includes
HIV/AIDS orphans).
In addition to the funds of the Child Survival and Disease Account, USAID
allocates money to health programs from its regional and other programs. Other
sources of health assistance funds, both in USAID and in other agencies, are also
available. Population programs, which are in a separate USAID account, have been
funded at about $400 million per year in recent years.2 Other funds used for
international health are in the annual budgets of the Department of Health and Human
Services, in the appropriation for the Center for Disease Control and Prevention
(CDC) and the National Institute of Health. The CDC focuses on epidemiology and
disease surveillance abroad as part of its role of preventing and controlling disease
outbreaks. CDC is also the historic leader of U.S. worldwide vaccination efforts,
working closely with USAID. The CDC estimate for international activities for
FY2000 is $158 million. The Fogarty International Center of NIH is also involved in
health programs. Its FY2001 budget is $50.5 million. The Department of Defense
budget supports research, prevention, and response to disease outbreaks as part of its
broader operations. U.S. contributions to the World Health Organization are
appropriated in the Department of State Appropriation. But for purposes of this
paper, health assistance is the funding identified by USAID.
Health has become an increasingly significant part of the world’s political agenda
as donors have become aware that health problems hinder development and limit
trade. Moreover, diseases in one country can and have led to health problems in other
countries. The current U.S. concern about West Nile Virus is just the latest example
1 P.L. 106-429 enacts by reference H.R. 5526 and this paper will refer to the provisions of
H.R. 5526 as P.L. 106-429.
2 For information on U.S. population programs, see CRS Issue Brief IB96026, Population
Assistance and Family Planning Programs: Issues for Congress. Updated regularly.
CRS-2
of a disease entering the United States from another continent. World Health
Organization (WHO) Director General Gro Brundtlund noted in her opening speech
to the delegates of the World Health Assembly in May 2000 that health has become
a regular part of the agenda of the G8.3 It is an issue in the discussions of debt relief
by finance ministers at the World Bank and the International Monetary Fund.
HIV/AIDS in Africa was the subject of discussion in the U.N. Security Council in
early 2000, under the leadership of the United States, and will be the subject of a
special session of the U.N. General Assembly in May 2001. Health was a major
subject of the April 2000 Millennium Report of the U.N. Secretary-General and in his
August 2000 report to the U.N. General Assembly on the United Nations, he stated
that HIV/AIDS is “destroying the economic and social fabric in the countries most
affected, reversing years of declining death rates and causing dramatic rises in
mortality among young adults.”4 Reducing maternal mortality, reducing deaths of
children under five, and stopping the spread of infectious diseases were among the
goals set by the governments participating in the U.N. Millennium Summit, held at the
United Nations in New York in September 2000.
The Clinton Administration focused considerable attention on health in its last
years with particular attention to infectious disease. In various domestic and
international fora, the President stressed the need for greater attention to HIV/AIDS,
particularly in Africa. In his February 2000 State of the Union address, he announced
a Millennium Initiative, one part of which includes support for an international
initiative to combat infectious disease in developing countries through GAVI, the
Global Alliance for Vaccines and Immunization and other means. It also calls for
increased attention to immunization by the multilateral development banks, and for
Congress to assist in offering support and encouragement to pharmaceutical
companies to develop and market at a reasonable price the medicines needed to
control disease in developing countries.
Congress has long been interested in and supported international health
programs, especially those geared toward children. Like the Clinton Administration,
Congress has increasingly focused attention on infectious disease in recent years.
Congress has expressed frustration in congressional hearings over what it sees as the
slow USAID response to infectious disease, and disagreement over USAID’s
priorities in foreign health programs. For this reason, Congress has increasingly
earmarked specific amounts for specific health programs.
USAID has resisted earmarking funds for specific diseases because it sees health
as an integrated development problem with funds needing to flow between health
needs. The overlapping nature of health programs, where one health center may be
providing maternal care, vaccination against childhood diseases, and HIV/AIDS
counseling, often to the same people, makes separating funds spent on one disease
program from another nearly impossible, according to USAID. USAID also
3 The G-8 includes Canada, France, Germany, Great Britain, Japan, Italy, the United States
(known as the G-7) and Russia.
4 United Nations. Report of the Secretary-General on the work of the Organization. General
Assembly. Official records. Fifty-fifth session. Supplement No. 1 (A/55/1). pg. 28.
[http://www.un.org/news/ossg/sg].
CRS-3
expresses concern that Congress identifies the dollar amount to be devoted to a
particular disease in appropriations legislation without increasing the overall health
account to compensate. This lowers the amount of money available to USAID for
other health needs which USAID deems essential to carrying out congressional
mandates. USAID cites as examples improving health infrastructure and disease
surveillance. The dispute between an administration wishing maximum flexibility in
foreign aid spending and a Congress wishing greater control over foreign aid spending
is long standing. It occurs in all areas of foreign aid, not just health programs.
Congress has increasingly pushed USAID toward specific, measurable programs with
dedicated funds and away from general purpose aid programs with hard to measure
results.
USAID Health Program Allocations
Table 1 shows the funding for all health assistance programs in USAID,
including the Child Survival and Disease Programs Fund and amounts coming from
regional or other programs, such as Economic Support Fund and funds for the former
Soviet Union and Eastern Europe. Because the Child Survival and Disease Programs
account also includes funding for U.S. programs to improve education in developing
countries, that amount, about $100 million per year in recent years, has been
subtracted in order to show actual bilateral health spending.
Table 1. USAID Health Spending from All Accounts
(in millions of dollars)
FY2001
FY1997
FY1998
FY1999
FY2000
(Est.)
Child Survival and Health*
360.9
338.3
400.7
464.5
383.0
HIV/AIDS
121.1
125.6
142.1
200.0
340.0
Infectious Disease Initiative
0.6
54.5
64.4
70.4
137.0
UNICEF
100.0
100.0
107.0
112.0
110.0
Total
582.6
618.4
714.2
846.9
970.0
Source: USAID. 2001 figures do not include a 0.22% recission from all discretionary accounts.
*Now called Child Survival and Maternal Health account by USAID.
Although P.L. 106-429 appropriates $860 million for Child Survival and Disease
programs after subtracting education programs, the funding breakdown provided in
the legislation is not comparable to the figures in Table 1 because they do not include
funds drawn from USAID regional and other programs and because there may be
duplications.
The line entitled Child Survival and Health includes U.S. funding for vaccination
programs to protect children from childhood diseases such as measles and polio. It
also includes programs to reduce maternal mortality and promote maternal health,
programs to address nutritional deficiencies in children, and U.S. efforts to eliminate
CRS-4
micronutrient deficiencies (for example, Vitamin A). The USAID program focuses
on helping countries develop the capacity to provide these services to women and
children and is the primary source of funding for health infrastructure, according to
USAID. Table 2 shows funding for some of the programs within the Child Survival
and Health account which have been of particular interest to Congress.
Table 2. Selected USAID Child Survival and
Health Account Expenditures
(in thousands of dollars)
FY2000 Estimate
FY2001 Estimate
Polio
25,000
27,500
Guinea Worm
800
0
Vitamin A
16,832
not available
Other micronutrients
24,714
not available
Maternal health
50,000
50,000
Immunization
33,221
not available
Source: USAID 8/21/00.
Vaccination Against Childhood Diseases
The campaign to vaccinate children against six childhood diseases (measles,
pertussis, polio, diphtheria, TB, and tetanus) began in the 1970s and has been a major
U.S. and multilateral effort since the early 1980s. The UNICEF/WHO Child Survival
Initiative, started in 1982, had as one of its goals universal immunization of children
by 1990. Although the 80% immunization rate (the percent necessary to prevent
disease epidemics) was reached overall in many developing countries, children in
some areas were never vaccinated and in some countries the overall goal was reached
for only 4 or 5 of the 6 diseases. Vaccination coverage in the poorest countries,
particularly in urban slums and isolated areas, remains low. Low income countries
with conflict or political unrest tend to have the lowest immunization rates. During
the 1990s, vaccination programs in developing countries lagged for a variety of
reasons including internal conflict. In sub-Saharan Africa, for example, the overall
average for immunization is under 60% and has fallen in the last decade. An October
1999 GAO Report cited the low level of commitment from bilateral donors during the
1990s as one reason for falling vaccination rates.5 For example, UNICEF, a major
source of vaccines and funding for immunization programs, saw its contributions for
immunization programs fall from about $182 million in 1990 to about $51.5 million
in 1998. And attempts to add newly developed and sometimes more expensive
5 Factors Contributing to Low Vaccination Rates in Developing Countries (GAO/NSIAD-
00-4).
CRS-5
vaccines against Hepatitis B, Yellow Fever, and Haemophilus influenzae type b (Hib)
have not been successful. According to the GAO Report, USAID funding for
vaccination programs declined from about $53 million between FY1990 and FY1993
to about $51 million from FY1994-97 and $47 million in FY1998. Administration
requests for vaccination programs continue to decline. Since FY1996, about half of
U.S. immunization spending has been devoted to eradicating polio.
The Centers for Disease Control and Prevention (CDC) is the historic U.S.
leader for international vaccination programs and has become a major source of U.S.
funds for vaccine purchase. Of its $226 million international activities expenditures
for FY2001, $102.5 million is directed to polio and measles elimination efforts.
A new vaccination campaign, the Global Alliance for Vaccines and
Immunizations (GAVI) which began in 1999, was formally launched at the January
2000 World Economic Forum. It is an alliance of business leaders, philanthropic
foundations, development banks, U.N. agencies, and national governments formed to
regain the momentum for immunizing children against preventable childhood diseases.
President Clinton requested a $50 million contribution for this program in the FY2001
budget. This amount was authorized in PL 106-264, the Global AIDS and
Tuberculosis Relief Act of 2000 and appropriated in P.L. 106-429.
Contributions to UNICEF
The annual U.S. contribution to the regular budget of UNICEF is included in the
Child Survival and Disease Programs account. It was moved into this account by
Congress. It had been appropriated as part of the International Organizations and
Programs account where most other U.N. voluntary programs are funded and
President Clinton continued to request it as part of that account. Only part of the U.S.
contribution to UNICEF is devoted to health assistance. UNICEF’s most recent
annual report states that 32 percent of its program budget is dedicated to health, 11%
to water and sanitation, and 6% to child nutrition. Community development,
women’s programs, education, and early childhood development are other areas
addressed by UNICEF. The U.S. contribution remained at $100 million for most of
the 1990s, but has increased recently. The FY2001 appropriation is $110 million.
Additional UNICEF funding, including funding for health programs, may be provided
from other USAID accounts in response to specific situations or programs. For
example, funding for refugee or other humanitarian health programs may be provided
to UNICEF from the Migration and Refugee Assistance account or from the Bureau
of Humanitarian Response.
CRS-6
Infectious Diseases
Infectious diseases are among the leading causes of death worldwide as
estimated annually by the World Health Organization.6 For this reason, much of the
international effort in the health area involves monitoring, vaccination, and research
on infectious diseases. According to the World Health Organization (WHO),
infectious diseases are the world’s biggest killer of children and young adults. They
kill more than 13 million people a year, accounting for half of all deaths in developing
countries. Ninety percent of these deaths are caused by just six diseases: tuberculosis
(TB), malaria, HIV/AIDS, pneumonia, diarrheal diseases, and measles. (See Figure
1.)
Figure 1. Leading Infectious Killers
* Acute respiratory infections include pneumonia and influenza.
** HIV-positive people who died with TB have been included among AIDS deaths.
Source: World Health Organization, 1999.
Developing countries are doubly handicapped in addressing infectious disease
outbreaks. Many infectious diseases are endemic to the tropical areas where most
developing countries are located. Because of poverty, the health and sanitation
infrastructure is poorly equipped to address local health needs. WHO studies indicate
that infectious disease is spreading most rapidly in areas of conflict or political crisis.
In addition to deaths, frequent bouts of illness slow the rate of development overall
6 Although accurate health statistics are not available, particularly in developing countries,
U.N. agencies and many governmental agencies cooperate in providing estimates of the health
status of populations around the world. These statistics are used in many of the annual
publications of U.N. agencies such as the UNDP Human Development Report, the UNICEF
State of the World’s Children, the World Bank World Development Report, and the WHO
World Health Report. See the World Health Report: [http://www.who.int/whr].
CRS-7
and the cost, in time and money, of caring for sick relatives can have a devastating
impact on the local economies in developing countries.
In 1995, the World Health Organization established a new division on emerging
and reemerging infectious diseases. The G8 began discussing the international
response to the problem of infectious disease in 1997 and, in its communique at the
end of the June 2000 summit, supported U.N. goals of reducing the number of HIV-
infected young people by 25% by 2010, reducing TB deaths and prevalence of the
disease by 50% by 2010, and reducing the burden of disease associated with malaria
by 50% by 2010.7
Concern about the spread of infectious diseases has been growing in the United
States for several years. Since the end of the Cold War, increased understanding of
U.S. vulnerability to infectious diseases endemic to developing countries, such as
West Nile virus, the growing threat from emerging and reemerging diseases like
HIV/AIDS and Ebola, and the renewed threat from drug resistance among diseases
such as TB, have pushed the Administration toward a greater interest in bilateral and
multilateral health assistance programs. Like the Administration, Congress has
increasingly focused attention on infectious disease. Extensive hearings have led to
increased appropriations for HIV/AIDS and other infectious disease programs.
Several studies by scientific panels reporting to the White House led to a 1996
Presidential Decision Directive calling for a more focused U.S. response to infectious
disease worldwide. In January 2000, the National Intelligence Council issued a report
on the security implications of infectious disease. This report, NIE99-17D, The
Global Infectious Disease Threat and Its Implications for the United States, outlined
the threat to national security posed by projected infectious disease over the next 20
years.8 The National Intelligence Council (NIC) report notes that of the seven main
diseases, four (TB, malaria, hepatitis, and HIV/AIDS) continue to surge and become
more drug resistant and that TB and HIV/AIDS would account for the overwhelming
majority of deaths from infectious diseases in developing countries by 2020. Acute
respiratory infections, diarrheal diseases, and measles, which have been the focus of
international child survival efforts since the early 1980s, appear to have peaked, at
least temporarily. The report notes that in the last 25 years, more than 30 new
infectious diseases have appeared around the world, many of them incurable. The
reemergence of infectious diseases once thought to be under control, such as TB,
Dengue and malaria, and the growth of drug resistant diseases have also increased the
threat to Americans. Under-Secretary of State Alan Larsen noted in a speech on
April 12, 2000, that with increased trade and travel, the spread of disease could undo
development abroad and threaten health and security at home.9 The NIC Report
stated that growing trade, travel and immigration, plus the large civilian and military
presence abroad, continues to place the United States at risk of infectious disease
outbreaks.
7 G-8 Kyushu-Okinawa Summit Communique (Issues include development, trade, info
technology) (7560) [http://pdq.state.gov/pdqhome.html]
8 [http://www.odci.gov/cia/publications/nie/report/nie99-17d.html]
9 [http://usinfo.state.gov/homepage.htm]
CRS-8
The Infectious Disease Initiative was established in 1998 with strong support
from Congress. It includes activities to control TB and reduce deaths caused by
malaria and other diseases, to improve disease surveillance and response in developing
countries, and to reduce the growing threat of microbial resistance (diseases becoming
resistant to treatment with antibiotics). Table 3 shows USAID funding for some
infectious disease programs.
Table 3. Infectious Disease Initiative Appropriations
(in thousands of dollars)
FY2001 Preliminary
FY2000 Estimate
Estimate
TB
20,269
56,700
Malaria (excluding Child Survival)
15,971
50,000*
Malaria in Child Survival
11,579
Disease Surveillance
10,665
14,700
Antimicrobial Resistance
4,847
12,000
Other
18,649
6,000
Total Infectious Disease Initiative
70,401
138,900
Source: USAID
*All malaria funds are combined in the 2001 allocation.
The Clinton Administration’s Millennium Vaccine Initiative for FY2001 includes
increased spending for vaccine research at the National Institutes of Health and the
Department of Defense, a $50 million contribution to GAVI, a $1 billion tax credit
for sale of new vaccines, as well as pressures on multilateral development banks to
provide $400 to $900 million in low interest lending for health. Members of Congress
supported much of this initiative. P.L. 106-429 appropriated $50 million for GAVI,
$10 million for an International AIDS Vaccine Initiative and $20 million for a U.S.
contribution to an international HIV/AIDS fund which may also fund vaccine
research.
WHO lists six diseases as the cause of most deaths from infectious disease. The
National Intelligence Council adds a seventh. A description and discussion of each
of the seven follows.
Tuberculosis (TB)
In June 2000, Dr. David Heymann of WHO described TB before a congressional
committee as “a disease once thought to be under control, which has returned with
a vengeance to kill 1.5 million people a year” and another half million in combination
CRS-9
with HIV/AIDS.10 He noted that nearly one third of the world’s population have
latent TB infection. In 1993, WHO declared TB a global emergency. WHO
estimates that between 2000 and 2020, nearly one billion more people will be infected,
200 million will get sick, and 35 million will die if control is not further strengthened.
TB is a contagious disease which spreads through the air. Only people who are sick
with pulmonary TB are infectious. Overall, one-third of the world’s population is
currently infected with TB, but only 5 to 10% of those become sick or infectious at
some time during their life, according to WHO. Among HIV infected persons who
are also infected with TB, the rate of conversion to active TB disease (and therefore
to becoming infectious) is considerably larger. The National Intelligence Council
report states that TB is especially prevalent in Russia, India, Southeast Asia, sub-
Saharan Africa, and parts of Latin America. Poorly supervised or incomplete
treatment threatens to make TB incurable as multidrug resistant TB cases rise.
Infection with HIV is accelerating the spread of TB. Increased global travel,
migration, and growing refugee numbers are also causes of the growing TB problem.
The Stop TB Initiative was established by WHO to bring together governmental and
non-governmental groups in a coordinated effort to control TB. The current WHO-
recommended approach to TB cure and prevention, called DOTS (Directly Observed
Treatment, Short Course), is 95% effective and may cost as little as $11 per patient
for the six month treatment. Twenty-two countries have 80% of TB cases, led by
India with an estimated 2 million cases, and China, with over 1 million estimated
cases.
Malaria
This mainly tropical disease kills over 1 million people a year, mostly children,
according to WHO. An estimated 300 to 400 million people are infected by the
mosquito borne malaria parasite each year. About 86 % of malaria deaths occur in
Africa and 71% of its victims are under 5 (accounting for 20% of all childhood deaths
in Africa). Women are especially vulnerable during pregnancy. Between 10% and
13% of maternal mortality is due to malaria. About 80% of regions undergoing major
political crises or conflicts suffer from high rates of malaria due to massive migration,
absence of sanitary infrastructure, malnutrition, and environmental deterioration.
WHO estimates that up to 30% of African malaria deaths each year occur in countries
affected by serious conflict or natural disaster. A campaign to curb the disease called
Roll Back Malaria was established in November 1998 by the World Bank, WHO,
UNICEF and UNDP with support from USAID. Its initial focus is on Africa.
Pneumonia
Acute respiratory infections (ARI) were the cause of 3.5 million deaths in 1998
(down from 4.1 million in 1993), according to NIE99-17D. Pneumonia is the
deadliest of these and kills more children than any other infectious disease. Ninety-
nine percent of deaths occur in developing countries. Pneumonia often affects
children with low birth weights or those whose immune systems are weakened by
10 Statement of Dr. David L. Heymann, Executive Director for Communicable Diseases,
World Health Organization, before the House International Relations Committee. June 29,
2000.
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malnutrition or other disease. Influenza is another cause of acute respiratory
infection.
Diarrheal Diseases
These diseases, mainly spread by contaminated food or water, kill nearly 2
million children under 5 per year, according to WHO. NIE99-17D estimated the total
number of deaths at 2.2 million in 1998, down from 3 million in 1993. Children die
because their bodies are weakened by rapid loss of fluids and undernourishment.
These diseases thrive in areas with poor sanitation, inadequate hygiene and unsafe
drinking water. In developing countries, children under 5 suffer about 1.5 billion
bouts of illness each year, a heavy burden on their families. Epidemics of cholera and
dysentery strike down adults and children alike. Other major diarrheal diseases
include typhoid fever and rotavirus, which is the main cause of severe dehydrating
diarrhea among children. Growing incidences of diarrheal diseases are occurring in
countries of the former Soviet Union.
Measles
Measles is the most contagious disease known to man, according to the
testimony of WHO Executive Director for Communicable Diseases Dr. Heymann.
It is a major childhood killer in developing countries, killing about 900,000 per year.
(This is down from 1.2 million in 1993, according to NIE99-17D.) Even more deaths
can be attributed to measles if one includes complications from pneumonia, diarrhea,
and malnutrition. Measles is the leading cause of death among refugees and internally
displaced persons. It will continue to be a major threat until vaccination rates are
substantially increased, according to NIE99-17D.
Hepatitis B and C
According to NIE99-17D, Hepatitis B caused some 600,000 deaths in 1997. It
is highly entrenched in the developing world and an estimated 350 million people
worldwide are chronic carriers. The less prevalent, but more lethal hepatitis C,
identified in 1989, has grown dramatically and is a significant contributor to cirrhosis
and liver cancer. WHO estimates that 170 million people worldwide were infected
with hepatitis C virus in 1997 and at risk of developing the diseases associated with
this virus. Various studies project that up to 25% of people with chronic hepatitis B
and C will die of cirrhosis of the liver and liver cancer over the next 20 to 30 years,
according to NIE99-17D.
HIV/AIDS
HIV/AIDS is the infectious disease receiving the most attention currently.
According to the December 2000 report of UNAIDS, the U.N. entity charged with
tracking and coordinating the multilateral response to the HIV/AIDS epidemic, an
estimated 36.1 million people are living with HIV/AIDS, of which 5.3 million were
infected in the last year. Since the epidemic began, 18.8 million people have died. Of
the 36.1 million suffering with HIV/AIDS, 25.3 million are in sub-Saharan Africa and
5.8 million are in South and Southeast Asia. Although the congressional and Clinton
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Administration focus has been on the devastation caused by AIDS in Africa, experts
are alarmed at the course of the epidemic in Asia, where several countries individually
have larger populations than all of sub-Saharan Africa and where government action
to prevent the spread of AIDS has been judged inadequate.
The United States began addressing AIDS in its foreign aid program and made
the first contribution to the newly established WHO AIDS program in FY1986.
AIDS was added to the G-8 summit discussion at the initiative of the United States
in 1996. The USAID HIV/AIDS program focuses on prevention and treatment,
addressing the needs of children with AIDS and improving infrastructure and capacity
in 46 countries (22 in Africa). This is a rapidly growing program, due in large part
to congressional support. In the last year, the devastating impact of HIV/AIDS on
Africa has led to a growing U.S. effort, including increased funding for AIDS
programs in Africa, a push to provide less costly access to AIDS drugs for Africa, and
a meeting of the U.N. Security Council dedicated to AIDS in Africa.11 Table 4 shows
USAID funding for HIV/AIDS from all foreign aid accounts.
Table 4. USAID Funding for HIV/AIDS from All Accounts
(in millions of dollars)
2001
FY:
1993
1994
1995
1996
1997
1998
1999
2000
(est.)
Total Prog.
124.5
112.8
120.7
117.8
121.1
125.6
142.1
200.0
340.*
-U.N.
35.0
29.5
26.9
18.0
16.0
16.0
15.2
15.0
17.2
-Africa Bur.
23.8
30.6
41.8
58.9
51.1
51.1
56.0
104.2
153.7
Source: USAID.
*Includes $10 million in food aid directed primarily to Africa.
The Centers for Disease Control and Prevention, which has always had a small
international program in HIV/AIDS, has also increased its spending in the last few
years. According to CDC, expenditures have risen from $11.6 million in FY1999,
to nearly $47.5 million in FY2000 and an estimated $116.5 million in FY2001.
Congress also added two new sources of HIV/AIDS funding in the Department of
Defense Appropriation and the Department of Labor Appropriation. Each agency
was directed to spend $10 million on HIV/AIDS prevention and education programs
in other countries in the military and in the workplace.
Congressional Action
Congress has long taken an interest in international health programs, particularly
those affecting children. In 1984, Congress consolidated most of the USAID child
11 For information on U.S. initiatives in response to the HIV/AIDS pandemic in Africa, see
CRS Issue Brief IB10050, Aids in Africa.
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health programs into a single account, the Child Survival Account. Over time,
pressure mounted to use these funds for other pressing health needs and earmarks or
congressional directives were added to the legislation or accompanying committee
reports. During the 106th Congress, congressional attention focused on HIV/AIDS
in Africa, and to a lesser extent, the spread of infectious disease. Congress introduced
and considered many health bills during this session.
The major legislation passed in 2000 was the Foreign Operations Appropriation,
which was enacted by reference by P.L. 106-429 on November 7,2000. As it became
law, H.R. 5526 appropriates $963 million for Child Survival and Disease programs,
of which $103 million is for education, rather than health. Of the $860 million which
is dedicated to health programs, $300 million is earmarked for HIV/AIDS, and $125
million for other infectious diseases, $295 million for child survival and maternal
health, $30 million for vulnerable children, and $110 million for UNICEF. The law
allows a U.S. contribution to the Global Fund for Infectious Disease established by
GAVI of $50 million, $10 million for the International AIDS Vaccine Initiative and
$20 million for a U.S. contribution to the international HIV/AIDS fund authorized in
P.L. 106-264.
P.L. 106-264, Global AIDS and Tuberculosis Relief Act of 2000, which became
law on August 19, 2000, combined the provisions in two bills, H.R. 3519 and S.
2382. It authorizes the appropriation of $300 million for each of FY2001 and
FY2002 for USAID’s HIV/AIDS programs, with 20% dedicated to multilateral
programs for orphans in sub-Saharan Africa, 8.3% dedicated to programs to control
mother/child transmission, and 65% of the total to be provided through
nongovernmental organizations. The law authorizes $50 million for each year for a
U.S. contribution to the Global Alliance for Vaccines and Immunization (GAVI), and
$10 million for U.S. contribution to the International AIDS vaccine Initiative. The
law also requires the Secretary of the Treasury to negotiate the establishment of a
World Bank AIDS Trust Fund and authorizes a U.S. contribution of $150 million for
each of the 2 years. Finally, the law authorizes a U.S. contribution of $60 million for
each of the 2 years for tuberculosis programs.
P.L. 106-259, Department of Defense Appropriations, became law on August
9, 2000. Title VI of this law includes an earmark of $10 million to be used for HIV
prevention education activities undertaken as part of U.S. military training, exercises,
and humanitarian assistance activities in Africa.
P.L. 106-554, the Labor, Health and Human Services, and Education
Appropriation appropriates $10 million for international programs to control
HIV/AIDS through workplace based prevention and education programs.
P.L.106-570, the Assistance for International Malaria Control Act, authorizes
an appropriation of $50 million for each of FY2001 and FY2002 for the establishment
and conduct of activities to prevent, treat, control, and eliminate malaria in countries
with a high percentage of malaria cases.
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Issues for the 107th Congress
It is not clear yet what priority the Bush Administration will place on
international health spending. Press coverage of early activities indicates that the
White House, the National Security Council, and the Department of State will place
less emphasis on infectious disease as a national security threat in the Bush
Administration. Nonetheless, international health assistance continues to have strong
bipartisan support in Congress. HIV/AIDS, which was addressed primarily as it
affects Africa during the 106th Congress, will continue to be a problem in Africa, and
likely a growing problem in other parts of the world during the 107th Congress. The
public health systems in the nations comprising the former Soviet Union have declined
precipitously in recent years, and there is growing evidence that those countries are
increasingly important in the spread of infectious disease around the world. Warfare
and political unrest continue to undermine vaccination efforts and disease control in
Africa and parts of Asia. Health programs are also likely to continue to be a priority
of the United Nations and other international organizations.