certainly, they can point to a lot of legal explanation that would say that they did. when it comes to labor issues, that becomes a sticking point politically, almost before you can have a rational conversation about it. host: harry in florida. caller: secretary lahood is correct in what he was saying. the republican party does not seem to care about working people. they would sacrifice 100,000 people for their own ideology. another thing. we should have a national labor party in the u.s., or union, so if the republicans are going to hurt people by putting them in the unemployment line because of issues like that, they cannot compromise if that is the case, maybe we

should close the nation down on a national not level instead of being divided by unions. it put us against each other. guest: the overwhelm thing to add with that is the fuel percentage of the work force that's unionized has gone down dramatically in the last 10, 20 years. i can't pull numbers completely out of my head here. we are talking half as many as before. so that's something that's been difficult for unions to cope with and in part because the labor work force is changing. the kinds ever jobs that labor unions made sense for 20, 30 years ago, particularly in the manufacturing sector, have been disappearing. so that's i think part of where this turn is coming from. that labor unions are feeling

the pinch. democrats and republicans, too, that the workers aren't quite getting what they deserve, but the work force has been changing enough that nobody has quite adapted to it yet. it is something that republicans feel very strongly about. they really -- they have felt like the labor unions have captured the democratic party for years and they don't want to see it happen. i don't know whether that's true and i don't know if it even matters because it's gotten to the point where if you have a labor issue, it can inflame people. the perfect -- politically. they have re-elections and things to worry about. makes it difficult. host: republican in suffolk, virginia. good morning, larry. caller: good morning, how are you this morning? i just wanted to say that i think we should just back the federal government out of it totally and let the airports own their own airports. let them make their

improvements, and let them hire their own air traffic controllers. host: all right. jefferson city, missouri. what are your thoughts caller: it's not what harry reid says, it's what he does. one of the airports that's targeted for -- in the house bill is in nevada. and that airport gets $1,000 subsidy per ticket. guest: that is correct. although harry reid did say multiple times yesterday he was willing to accept that cut. if it meant he could stop the shutdown. i don't think that he would said that a week ago, but when it became clear that was the only option -- he was very clear about it. he spent as far as -- from what i understand, i was sort of watching it and madly emailing people, he was working hard to try to make sure that his caucus would accept the house bill and ultimately it wasn't able to pull it across the finish line. host: one last phone call.

from la trobe, pennsylvania, anna is watching us. democratic line. caller: yeah. i think watching the people in this country, and it's time that we do something about it. with this airport, that should never have happened. i think that congress and the president is out of touch with the people and it's time we change that. host: that will have to be the final word. thanks for being here an talking to our viewers about the f.a.a. stalling in congress. issue comes back up in september when they return. here's a headline of the "l.a. times," u.n. declares famine in southern somalia. that's the topic next before the senate foreign relations subcommittee on african affairs. live coverage here on c-span. [captioning performed by national captioning institute] [captions copyright national cable satellite corp. 2011]

>> i'd like to call to order today's hearing focusing on one of the most critical issues in the world today, responding to the drought and famine in the horn of africa. as always, i'm privileged to serve with my friend, senator isakson, and want to thank him for staying with me here in washington after the senate has adjourned in order to help convene and preside over today's hearing. this is a children's crisis. there are hundreds of thousands of children on the verge of death suffering from severe malnutrition in the horn of africa, and senator isakson and i agreed this hearing could not wait. so even while many of our colleagues have understandably returned to their home states and districts, we both believed it was crucial we go ahead with this hearing today and not let another month go by. senator isakson has been a true and good partner in highlighting a range of compelling issues and shared concerns in africa and i greatly appreciate his leadership on this subcommittee. as everyone is well aware, the united states congress has been almost entirely focused on the

deficit and debt crisis in recent weeks. while that issue was rightfully at the top of the agenda of the united states, we must also consider global issues of greater humanitarian concern, especially when millions of lives are at risk and tens of thousands have already died. today we display in front of the hearing room images of the crisis in the horn of africa to demonstrate the rising human toll of the drought and famine, including children who are facing unspeakable depravation and hardship. in today's hearing we'll list numbers that quantify the impact of the drought, but it is these images that help convey powerfully the true impact on human lives. i want to thank at the outset unicef for its vital work on behalf of children worldwide and providing the photographs we have displayed at today's hearing. they have also submitted a statement detailing its efforts in the horn of a can that i will -- africa that i will submit. the crisis has been caused worst drought in the region in more than 60 years resulting in

malnutrition, rising levels of starvation and famine in somalia. it is the most severe humanitarian crisis in a generation. affecting food security for more than 12 million people across somalia, ethiopia, and surrounding areas as illustrated by a map i will also submit for the record. according to the unicef an estimated 2.3 million children in the region are acutely malnourished, half a million of whom are at risk of imminent death. unfortunately this crisis expected to worsen in the coming months, eclipsing the famine, that elicited first global outcry and a great response as demonstrated by memorable events such as live aid. the broad public awareness of that crisis in the 1980's appears to be absent today despite a worsening situation and increasing need for aid. the situation is the most severe in somalia where rising food prices and failures of governance and regional security have exacerbated an already dire situation given the ongoing

conflict, poor governance, and humanitarian access by the group al sha bad. aid organizations and u.s. government officials estimate more than 1,500 refugees every day are leaving somalia for kenya, flooding the world's largest refugee compound which is well over capacity nearly half a million refugees, or a population comparable to tucson, arizona. they are fleeing every day for the camp in ethiopia, also well over its capacity with more than 100,000 refugees. the international community and united states are working closely with the governments of kenya, ethiopia, and djibouti to address this massive transnational influx of refugees, and i praise their efforts to accommodate these displaced populations while their countries face severe challenges from the drought. the countries impacted by this drought and famine are among the world's poorest, suffering from high rates of poverty and unemployment. while the failure of two

competitive rainy seasons contributed to the scale of this disaster, the humanitarian crisis and famine that has resulted highlights broader capacity, governance, infrastructure, and security problems and needs in the region. this drought was not a surprise. usaid through its famine, early warning system predicted an impending crisis last year and worked closely with the kenyan and ethiopian governments as well as our own to enhance their ability to respond and preposition emergency reef leaf supplies. as thes us joins with its partners in the international community to provide emergency assistance, we must also consider the lessons learned in order to avert the next famine. to improve food security globely, to build sustainable capacity, and mitigate the impact of this crisis on future generations. in response to the crout the united states has been the largest international donor providing more than $450 million in food aid, critically needed treatment for malnourished children, health care, and other assistance. the responsibilities cannot rest on our shoulders alone.

especially in difficult budgetary times, the humanitarian response to this crisis must be a shared transnational obligation. according to the united nations, more than $2 billion will be needed to provide emergency assistance and only $1 billion has so far been committed. the international community must join the united states and many others in providing this critical aid in the near term to save lives, especially those of malnourished children and others in desperate need. as we consider the international response to this crisis, we must also examine restrictions on access given the volatile security environment in somalia where the united nations recently declared a famine in southern areas controlled by al shabab. just yesterday they announced an easing of restrictions on humanitarian organizations operating in somalia to facilitate the delivery of aid. i look forward to hearing from today's witnesses about this policy which aims to provide additional guidance and assurances to u.s. support organizations. to hear more about the scope, impact, and response to the

crisis we are privileged to be joined by two distinguished channels. first we'll hear from nancy lindborg, assistant administrator for the bureau of democracy conflict and humanitarian assistance for usaid, miss lindborg will also be joined on this panel by ambassador donald yamamoto, and former am bass core to ethiopia and djibouti. we'll hear from dr. reuben brigety, a former fellow at the council on foreign relations who has just returned for a visit to the region. on the second panel we will hear from jeremy konyndyk, who has led humanitarian and post conflict recovery operations throughout the region. next is dr. peter pham, director of the africa center of the atlantic council and former professor of justice studies at james madison university. finally we'll hear from mr. wouter schapp, assist ant

director for care international somalia based into nairobi' recently returned from a visit to drought infected areas. i am pleased to highlight this crisis. americans have demonstrated great leadership helping those in need domestically and abroad and i'm confident we can continue to partner with the international community. i appreciate each of the witnesses being here today and look forward to your testimony. senator isakson. >> thank you, chairman koonce -- coons. i want to particularly thank wouter schapp, headquarter in my hometown, as well as being so many of the care people that are here. i have had the privilege of being on site with care in kenya, tanzania, ethiopia, and darfur in the sudan. and seen first hand what our n.g.o.'s do to deliver humanitarian aid as well as in

the case of care, life sustaining techniques that people can learn to be self-sustaining among themselves which is so critical in the areas of bad poverty and not well educated. i appreciate care being here and testifying today. i'm always proud to have my home team here talking about the good things they do. dr. pham, also on the second panel, i'm particularly delighted he's here because he can provide insights as an informed observer of the regional and political and security dynamic without the constraints of an n.g.o. must maintain in describing the situation give the exposure of the staff. he will also be able to exam the extremist vain that runs through somalia and impact it has on the region and international donors. the severity of this crisis and complexity of the geopolitical situation of the region coupled with the u.n. and united states' own challenging history dealing with hunger and conflict in somalia make this a particularly challenging humanitarian

response. it is in such places that the principles of our policies are testifieded both our humanitarian impulse as well as our hard-nosed realism regarding the purveyors of a moral control. of the people and the region. i am delighted that the chairman called this hearing today. this is one of the main humanitarian crisis before the world today. we need to work together to see to it, bring humanitarian relief to a people struggling in a terrible part of the world. mr. chairman, thank you for calling this hearing today. i look forward to hearing the testimony of all of our witnesses. >> thank you, senator isakson. we'll begin with the opening statement of ambassador yamamoto and nancy lindborg and dr. brigety. and proceed to questions. >> i have a longer version for submission for the record. i'll read a short version, sir. >> i would encourage five-minute statements if that's possible. we'll submit your full. without objection, we'll submit your full statements for the record.

thank you. >> senator, chairman coons, and ranking member isakson, members of the committee, the worst humanitarian crisis in the horn of africa in 60 years has its roots in the brutal force of al shabab which has until now prevented humanitarian assistance from reaching those most in need. and changing regional climate patterns that impact vulnerable populations. we are working hard with our international and regional partners to deliver quickly the lifesaving short-term relief critical to those suffering the effects of this crisis. u.s. government and u.s. funded assistance has prevented the loss of millions of lives. at the same time, we cannot rely on emergency assistance alone to resolve the underlying long-term problems in the region. therefore we are working with the government, governments in the region to support lornl political and food security in the region.

let me be clear, the response to the drought has been complicated by the continued instability in somalia. especially due to the actions of al shabab. those most seriously affected by the current famine are more than two million somalis trapped in controlled areas in south central somalia. since january, 2010, they have largely prohibited international humanitarian workers and organizations from op plating in the areas it controls. they continue to refuse to grant humanitarian access and prevented the international community from responding quickly inside somali. as we seek to take advantage of any current openings to expand aid, we are also working with our partners and international community to counter their ability to turn our interest or continue to hold the people hostage. at the same time, we are taking necessary steps to support the flow of urgently needed humanitarian aid to those who need it in the south central

somalia. while working to minimize any risk of diversion to al shabab. we have worked closely with the department of treasury to ensure that aid workers who are partnering with u.s. government to help save lives under difficult and dangerous conditions are not in conflict with u.s. laws and regulations. however, the united states sanctions against al can shab do not and never have delivered the ability of assistance including to those areas under the de facto control of shabab. in a long-term regional security in the horn of africa requires political stability in somalia. the united states already has placed a long term process to stabilize somalia. last year we are now approach to broaden our efforts by taking into account the complex nature of somali society, politics, as well as more flexible and abantable to our engage. on track one, we continue to support the peace process, the

t.g.f.g., transitional government, as first line of efforts to stabilize somalia and expel shabab from mogadishu. stins 2011, the united states has supported efforts by obligating $258 million to support amazon training logistical need and approximately $85 million to support and build capacity to the t.f.g. forces. on track we are depending -- deepening our engagement with the regional government and administration throughout the central and south somali area. and those who are close to shabab but not affiliated with the t.f.g. and f.y.-11 the united states plans to provide approximately $21 million to support development efforts in our dual track polcy. -- polcy. we have further information as we go on to the k and a, i want to leave -- "q&a," i want to leave room for my colleagues to talk.

>> miss lindborg. >> thank you. i appreciate your taking this time to hold the hearing and raise the level of attention. even as we meet today, the situation is deteriorating. and i think we all share the significant concerns. as you noted the horn of africa has long been plagued by cyclical drought. what we are seeing now is the worst in 60 years, what used to be 10-year drought cycles are happening literally every other year. and the current drought is now affecting $12.4 million people in somalia, kenya, ethiopia, and djibouti. the crisis is both humanitarian and security one. the famine as you noted has been declared in only the most difficult to access areas of somalia. we'll hear more from dr. brigety about the refugees pouring across the border into the already drought stressed areas of kenya and ethiopia.

internally, more than 1.5 million displaced somalis are crowding into the northern cities of somalia that are ill-equipped to handle this increased in population. the july 20 u.n. declaration of famine in the two regions of somalia was not made lightly. and truly reflects the dire conditions of the people in somali. it's based on nutrition and mortality surveys, data that's been verified by the c.k.c. and on the basis of that we estimate that in the last 90 days 29,000 somali children have died. this is nearly 4% of the children in southern somalia. our fear and the fear of the international community and governments in the horn of africa is that the famine conditions in those two regions of somalia will spread to encompass the entire eight regions of southern somalia. the next rains are september and october, even if they are good, we could bear witness to another

wave of mortality in the south due to watt earn-borne diseases -- water-borne diseases. in ethiopia and kenya the situation is grave but we do not expect it to deteriorate into famine or result in the level of needs as we are witnessing in the south. ethiopia and kenya have large areas of arid land. in partnership with local governments and international donors, usaid has worked extensively in both countries to increase the resilience and food security of these communities in drought affected areas. we strengthened early warning systems, we supported ongoing safety net and community protection programs, and work to increase productivity in arid lands. and just for example in partnership with the ethiopian government, with the world bank, and other donors, the u.s. government has supported the ethiopian productive safety net program. as a result, 7.6 million people

have been removed from the emergency caseload. in the drought of 2002, 2003, the government of ethiopia stated that 13.2 million people in ethiopia were drought affected. by contrast, today only 4.8 million are stated to be in need. the needs in ethiopia and kenya are serious. they will require sustained focus and attention, but the results of our preparedness and development programs are paying off. we are seeing results. as you noted, senator coons, the early warning system alerted us in august so the drought is on the horizon. we began prepositions food stocks, food aid, stockpiling food in djibouti, kenya, and south africa. we have sense just this fiscal year provided $459 million of aid in the horn. this includes food assistance, treatment for malnourished

children, water, sanitation, hygiene, education, and assistance in the refugee camps. we are now focused aggressively on working to abate the possession for mass starvation in southern somalia. we learned in the drought of 19962 in somalia that the leading cause of death for children under 5 was disease. we are focusing on three key areas, therefore. first the availability of food including those therapeutic foods so essential for children under 5. access to food. and integrated health programs. in terms of key challenges, we identify three. first time, it is not on our side. we have a small window to reach those in need. or risk the adigsal deaths of several 100,000. we are looking at about a six to eight week window. access, access is the -- in the worst affected areas of south somalia. remain the primary obstacle to relief efforts. as you noted the world food

program and most international organizations suspended operations in early 2010. and since 2008, the w. frges p. has lost 14 staff members. until now elshabab has restricted access and they have given mixed signals whether it will lift its ban. we along with the international community are working to explore all avenues to safely provide assistance where there is access. in the face of these extreme needs, we have issued new guidance on the provision f a-- of acyance to provide flexibility to a wider range of aid to those areas in need. and we have clarified that aid workers partners with the u.s. government to help save lives are not in conflict. the third challenge is scale. the emergency will outstrip the resources currently available in the international community. in the traditional donor community. so we are working aggressively to encourage all donors, all nations to step forward with

assistance. i'll conclude by saying we cannot stop drought from happening. specifically in this region, but we can do is strengthen communities and their ability to withstand these natural calamities. president obama's feed the future initiative is focused on addressing these root causes of hunger and under nutrition and working to strengthen the resilience of communities. it assures us the ability of these populations to withstand drought through commercial availability, access of staple foods, reducing the trade and transport barriers, that impede the movement and sale of livestock and harnessing science and technology. we are seeing right now how these investments in the future can make a critical difference. thank you, mr. chairman. thank you senator isakson. i'd like the testimony to signal to the people of the horn as well as the somali americans i recently met in minnesota and ohio, that the american people are very much with them in this

time of need. thank you. >> thank you. dr. brigety. >> chairman coons 8 -- coops, ranking member isakson -- coons, ranking member isakson, thank you for allowing me to testify today. let me also say we appreciate the sorns and attention that congress has given to this crisis in the midst of so many other issues you have been grappling with this summer. i will discuss today the current situation facing refugees, our immediate response, the challenges we face in meeting their needs as more splice reach the borders, and our plans to work with the world community to meet those challenges and save as many lives as we possibly can in the coming months ahead. i traveled to ethiopia and kenya in july to ehave wait the emerging refugee crisis in the region where hundreds of thousands of somalis have fled. during my trip, i visited refugee camps in each country

along with representatives from donor countries. i met with senior government officials. i talked with officials from u.n. agencies and nongovernmental organizations, and spoke with many refugees. it was clear that this situation is developing into the worst humanitarian emergency the region has seen in a generation. at least since the great famine of 1991 and 1992. we now must confront a refugee emergency within protracted refugee situation. years of hard work by the host governments and their international partners to address just the basic needs within established camps quickly are being overshadowed by the need to add new, broader border -- new border crossing facilities, new camps, and additional emergency services. both ethiopia and kenya are receiving record inflows of refugees from somalia and in both countries refugees are arriving in appalling physical health.

every refugee familiar with whom i spoke with both ethiopia and kenya said they had walked for days from somalia with virtually no food and water. free visits to the health clinics in the refugee camps revealed dozens of malnourished children, so emaciated and weak to the untrained eye they appeared close to death. among new arrivals in the camps in ethiopia we are seeing up to 50% global acute malnutrition. reflecting the even more grim state of affairs for children inside somalia. camps in ethiopia and kenya are strained far beyond their capacity in every way. with regard to space, staff, food, and essential services. as they try to cope with the record influx of refugees which continues unabated. somalis represent the largest refugee population in all of africa. according to unhcr, they now

host more than 620,000 somali refugees. some 159,000 somalis have sought refuge in ethiopia with over 75,000 arriving just since january. of this year. kenya hosts more than 448,000 somali refugees with nearly 100,000 arriving since the beginning of this year. even djibouti has seen an almost 20% increase in the number of refugees since the beginning of 2011. we commend the governments 6 kenya, djibouti, and ethiopia for their again russ support of refugee populations, even as they themselves are currently struggling with the drought that may be the worst in 60 years. while the current crisis is taxing an already stressed system, i'm confident that the governments of kenya, ethiopia, djibouti, and international partners to include the united states have the ability to confront this crisis head-on and will be able to find new solutions to address the needs not only within the camps, but

also for those within somalia. let me give you just two examples what i saw during my trip and how we are responding to those in need. first, the u.s. in our regional and international partners have helped ramp up emergency assistance. i traveled to the refugee camp complex on the ethiopian and somali border accompanied by u.s. ambassador to ethiopia, donnell booth, usaid deputy administrator, ethiopian government officials, country representatives, and senior representatives from several donor embassies. as we wandered through the refugee camp talking with people who had been there for several days or arrived only hours earlier, we heard versions of the same story over and over again. one man i met had come all the way from mogadishu, traveling nine days with his wife and six children with very little to eat along the way. i talked with him as he sat on

the hospital cot with his youngest child, a 3-year-old girl. as we spoke, isha nefrl stopped moaning. she could not get comfortable amiths the meet and flies as her tiny bones threatened to pierce her paper thin skin. we saw many families in the same desperate situation during a separate visit to a camp in kenya. i spoke to one mother who had carried her polio stricken 7-year-old daughter on her back for nine days with little food and water as her other six children trailed behind. it was clear that a number of recent interventions such as the provision of hot meals at the transit center are vital steps needed beyond just basic camp services to assist those making this heartbreaking journey. i commend antonio gutierrez, the u.n. high commissioner for refugees, for finding ways to add these additional programs after he visited the area a few days before i had. still, we know that more must be

done. the second example is how the united states has increased overall refugee assistance throughout the region. the u.s. has long been a partner to governments and people of the horn of africa as they host hundreds ever thousands of somali refugees, providing approximately $459 million in humanitarian assistance just this fiscal year to those in need. this funding supports refugees, internally displaced persons, and other drought affected populations. out of this overall funding, the u.s. is providing approximately $69 million specifically to refugees through the state department's bureau of population, refugee pop uelation -- population. this is critical to saving lives. the u.s. has previously supported the expansion of the camps and they are now moving refugees into the new space following the government of kenya's agreement to allow the opening of a new site.

we are also urging kenya to open quickly more reception center capacities so that incoming refugees can be properly screened and registered. we will continue to support the horn country's efforts to provide help. including through our support and international organizations and n.g.o.'s. representatives from other donor countries who accompanied me were also moved by the graphity of the situation and they said they would work with their own governments to support the efforts. rigorous and sustained diplomacy will be required both in the region and with other donor capitals to ensure that the under national community and host countries take necessary measures to save lives in the coming months. we are also committed to addressing the humanitarian needs inside somalia as my colleague spoke. there is an immediate need to reach vulnerable populations inside somalia so they don't have to travel long distances to

save lives. let me also say unless we find ways to provide assistance to people inside somalia, we will continue to see refugees arrive in in kenya and ethiopia and we'll continue to see more tality rates in the refugee camps rise unabated. this brings us to the security situation. the ack 50's have clearly made the current situation worse as the ambassador noted. we expect the situation in somalia to continue to decline especially in southern somalia where the u.n. had declared famine. there is not a single solution to this regional crisis. we are working to tackle it through a variety of means and mechanisms. including addressing underlying causes addressed by my colleague. mr. chairman, ranking member, thank you very much for your time and attention. i look forward to any questions you may have. thank you. >> thank you. ambassador yamamoto. if i might pick up, clearly

being able to deliver humanitarian assistance within somalia, particularly southern somalia is vital to preventing refugees from having to make day-long or week-long treks across the desert that are so difficult and so stressful on them and their children. my understanding is in the past day the administration has eased restrictions on humanitarian groups providing assistance in southern somalia. could you explain in more detail the modified policy, the extent to which it will increase the flow of aid. do you have confidence that there is enough time left for humanitarian assistance to be provided in southern somalia given the famine? >> that's really a kind of multifaceted answer. i'll refer to dr. lindborg for an answer. 60% of those in need are in al shabab-held territory. the question comes in whether or not this u.s. policy or not has prevented. no, it has not. the issue it has been extremely

difficult to deliver food into these held territories. the united states has taken has been to ease the licenses on n.g.o. groups. they are required a heightened due diligence, procedures to avoid a diversion -- essentially it is to allow n.g.o. groups and deliver to enter al sha bad held areas if they, even if it means paying fees or convoy fees. as long as they have done the due diligence, if there is no other alternative. the bottom line is even with these measures and easing of the licensing and procedures, is shabab going to allow the deliveries? right now as an example if you see the internally displaced people right now, you are having about 100,000 or so suffering in

mogadishu, at the rate of 1,000 a day going into those areas, you have shabab troops and shooters going into the areas and targeting refugees. and making it more difficult. amazon has done a preemptive measure to try to keep the corridors of feeding open to these i.d.p.'s. the question comes in, how are we going to stabilize the area? how are we going a lou free flow of food into these areas? i guess i refer to dr. lindborg for more information. >> if you would like to expand. >> thanks. i think time and access are the two critical challenges that we face. we are working closely with the international community to explore a number of options is that testify the possibility of having greater access. there are airlifts bringing food into mogadishu. we are hopeful that there will

be an opportunity to move more vigorously into areas where there is a willingness by al shabab and others to let assistance in. i think that the new guidance that was issued just over the last few days creates greater assurance and greater flexibility. but fundamentally this is a tough area to operate. it is probably one of the toughest operating environments globally right now. it will take seasoned, very seasoned humanitarian workers to be able to navigate through that environment. >> how would you assess the under national community's response to this crisis compared to the united states? and what are we doing and how successful are we being to encourage engagement by the african union, the e.u., g.c.c., arab league, and others, other multilateral entities and groups that might be engaged? >> first the response by the

united states has always been, there is not something that we have suddenly responded because of the effect of the famine. for the last several years the united states is the primary food supplier to the region. in fact, the horn of africa is probably our number one regionor for food recipient around the world. and ethiopia is our number one country for the last several years. the issue comes in, another example, just to give you the breadth, detcht of the problems, on a good day in ethiopia you have something like 300 kids under the age of 5 dying each and every day. from preventable diseases. under this situation the rates are much higher. so the response has been how to get more food into the pipelines, ensure deliveries, more important, is working with ethiopia and kenya to a, get better access, expand refugee camps. number three, to work with the amazon forces in mogadishu to

ensure there is more feeding capability to those i.d.p.'s. and also easing up of procedures to make it easier for n.g.o. groups to operate. finally, really to confront the shabab and how they can either we can contain them or open up more corridors for feeding. >> i would be interested, miss lindborg, you mentioned the important role of harnessing science and technology, the role that feed the future has played. in doing the background reading on this i was struck at the effectiveness of ready to use therapeutic foods that are being deployed and ref lutionized our ability to revive children who have come to the very edge of starvation. and also the investments usaid has made on water drilling in thrope and how it's allowed them to sustain their lifestyle but still provided them with more reliable water supplies.

any brief comments you would like to add about how our strategic investments in advance of this particular crisis have changed the ground and made this different than previous drought cycles? >> yes. thank you. i think the most striking is the -- is what i cited in my testimony in that because of the work with the world bank and other donors and ethiopian government on the community safety net we have enabled 7.5 million ethiopians to not go into a state of urgent need. and in addition, there has been significant work on increasing the ability of pastoralists to weather these kinds ever serious droughts to improving the health of their livestock, improving their ability to trade. as we look ahead to the feed the future initiative, that is really i think at the heart of president obama's vision for how to truly enable us to not have to mobilize large emergency

responses every time there is a drought, we want to couple that with the kind of trade reforms and policies that can enable vulnerable populations to have greater protection. for there to be greater productive capacity. and to use science and technology on issues like you drought resistant seeds or better productive techniques. >> senator isakson. >> thank you, mr. chairman. thanks to all of you for testifying. ambassador yamamoto, you said, i think i got this right, sanctions do not inhabit delivery of humanitarian aid. i think you were referring to somalia and al shabab. what do our sanctions say regarding humanitarian aid? >> this is the licensing? >> yes. >> when we debated the issue of

deliveries into shabab-held trts, debate was centered on the payment of convoy fees to the shabab in order to allow feeding into those areas. the second thing is what were they using those money and funding for. that became a major concern. is through this effort of feeding are we also contributing to greater instability? so that became a great debate. the problem comes in right now is that with the famine and -- the severe acute malnutrition, how do you open up the capabilities of n.g.o.'s and explore opportunities to allow them procedurally to get into those areas faster, quicker, and food deliveries. but the problem remains is that even with all the procedural openness, is that will the shababs allow them to enter. ethiopia and kenya have tried to open up corridors for feeding or they pushed into somalia, but even those are not sufficient

enough given that those still remain insecure areas and dangerous. it becomes a big problem, how do you engage, how do you open corridors, how do you begin to feed in those areas where really 50% of those in need are in shabab held territories. >> the problem is the corruption where the checkpoints that al shabab would issue they have payoff fees for safe passage and use those to help finance their organization, is that what you are referring to? >> yes, sir. >> the question is, is are we telling them -- are we telling n.g.o.'s willing to travel and deliver humanitarian aid it's ok to pay those fees? >> no. we are requiring through procedures that they do the due diligence to find any way possible to be able to feed and provide food to needed areas. without paying those fees. but if it becomes necessary, obviously -- >> is there any security for

n.g.o.'s providing either u.n.wise or african union in terms of getting the material in to somalia? >> i refer to you. >> miss lindborg. >> i know you have an n.g.o. panel following us. i know they'll have much no to say on this. i think most groups operating have a very principaled approach to not paying taxes or tolls. and many are able to accomplish this. the easing of the legal restrictions simply removes any concern that an accidentable or incidental payment will not jeopardize them with any legal action. so it's creating a greater sense of comfort with the partners that that is not a barrier to effective assistance delivery. >> in somalia, after that issue, still pretty dangerous place, and al shabab has used violence in many cases to carry out its

intent. do these n.g.o.'s have any degree of protection other than their own? >> i believe most of them choose not to have any other protection other than the protection of the communities welcoming them in and hosting them in the provision of assistance. ultimately we all need the kind of access that comes from the communities wanting and understanding the importance of the international effort to help them at this critical hour. >> i wanted to make a point, chairman coons and i traveled to africa together and see the scourge, the scruppingsquases throughout the continent. this is not related to this issue, but what the united states is doing to get democratic institutions to rid themselves of corruption in return for m.c.c. contracts and things of that nature is -- it's changing africa.

this region not necessarily because of al shabab and some of the other organizations that are there, but that is the single biggest problem i see, inhibitor i see to u.s. investment in businesses as well as u.s. foreign aid going there through n.g.o.'s. dr. brigety, let me ask you about the dam for a second. two years ago the kenyans were expressing the frustrations being applied to them with the refugees then. your flyer says they are getting 1,295 new one as day. and that camp has almost half a million people now. is that correct? other than providing the additional land for the expansion, what pressure is being put on the kenyans by this number of people to provide help? what cost and how is that cost being borne? >> thank you very much, senator. you are correct that the refugee camp is the largest in the world. it's been there since 1991. the issue of refugees inside

kenya frankly is very sensitive one politically for them. they have been very patient in dealing with this refugee crisis for two decades now. just to give you a sense of order of magnitude. earlier this year in january, they were getting about 1,arrivals a week. it's now a day. the international community has long asked them to open an additional camp, the three major cam nts, -- camps, there was an expansion to etho called etho 2. what i was in dabab three weeks ago, i was there on the ground with the prime minister who had a public press conference with the international media. at that press conference he gave his word that the government of kenya would allow the etho expansion to be opened and unhcr has begun to move refugees there. and we look forward to a continued commitment from kenya to support that.

the cost for the camp is largely born by the international community. the u.n. high commissioner for refugees is responsible for management. and the world food program is responsible for feeding. the government of kenya provides some financial support with regard to the provision of security forces around the borders. but the united states has long been the leader in terms of supporting unhcr. >> the reason i brought it up is i think when we talk about tragedies like what's going on with the famine on the horn, we also ought to give kudos to those countries trying to help. and the kenyan government and kenyan people have been supportive as you said for two decades and are bearing a tremendous amount of the brunt of the burden now and the cost of that security alone is significant contribution by kenya. we need to acknowledge and appreciate what they have done in that case. >> you are correct. we do, regularly. >> thank you, mr. chairman.

>> thank you, senator. if i could just follow up. the other largest refugee camp that is receiving somalis is dolo aldo in ethiopia. there were nearly ,000 refugees arriving a day up until two weeks ago. that has dropped significantly. do you have a sense of the cause of that and how do you assess the ethiopian government's willingness or capacity to provide support? >> thank you for the question, senator. you are correct. when i was there about three weeks ago, the arrival rate was about 2,000 a day. it's dropped to about 250 a day. we do not have a good answer for why that number has decreased. but we are continuing to work with our partners to try to understand what the nature of that dynamic is. when i was first there in february of this year, the two major camps there had about 50,000 refugees combined. that number is now doubled to about 100,000. at the rates we were receiving

in mid july, it is conceivable that rate could double again by the end of the year. the government of ethiopia frankly has been a very, very good partner in terms of supporting this refugee population. particularly since the onset of the current drought crisis elier this summer. they have responded with alacrity in terms of providing additional staff from their refugee agencies, they have allowed n.g.o.'s to operate at the transit center near there. we engage regularly and repeatedly with the government of ethiopia both in their ministry of foreign affairs and also in the refugee agency to ensure they know we are effective partners with them and we are very pleased with the extent to which they have extended their hospitality. . what the medical situation in these two camps? it's hard for a senator from the state the size of delaware to grasp half a million people. that's the size of kansas city. that would be five times larger than the largest city in my state.

how are they managing the health pressures and concerns in ensuring we don't have miss lindborg mentioned, with the onset of september rains, a follow-on humanitarian crisis from a rapid spread of disease. >> that's a very good question. to be frank in dabab, the health pressures are enormous. the refugee camp complex, just the camp, is the fourth largest population center in kenya. now, having said that, there are a number of partners that provide health services inside the camps. doctors without borders is one of the more important. frankly with the new refugees arriving, there are about 44,000 refugees that are simply on the outskirts of ethos 2 because they were not allowed to settled and the other three were full. those settling on the outskirts where there are no services to speak of, no significant health

services or others, were clearly suffering additional rates of all sorts of basically -- basic preventable diseases, to include respiratory diseases. these are very hot, dusty conditions. you are out without shelter. and it's very easy to develop those sorts of problems. we are hoping that the addition of the opening of this camp expansion will give people shelter, will give them access to established health clinics which are built but simply needed the perfect nergs of the government of ethiopia to support. we'll continue to support everyone to provide the essential medical services, especially to treat these horrible rates of malnutrition amongst children under 5 years old that we are seeing. >> question for ms. lindborg. we were talking science and technology earlier. these two nations, ethiopia and kenya, are bearing enormous burden in terms of the refugee commant. much of kenya's power is

delivered by hydroelectric power, which due to the record drought has dropped by more than half. what's usaid doing to help deploy alternative power whether solar or geothermal that might help provide electricity either in ethiopia or kenya to these camps or might represent reduce the strain on the rest of these host nations in terms of their electricity or anything they are doing to streamline the process of deploying alternative power that aren't so reliant on water? >> senator, i would like to get back to you with specifics on that answer. i know that there are a number of conversations with both kenya and ethiopia about ways in which we can work closely with them to mitigate the impact of future drought. and so there are conversations under way and we would be delighted to get back to you with details. >> thank you. let me ask just a final question any member of the panel wants to speak to.

what are we doing to avoid the significant security challenges facing somalia spilling over into kenya and ethiopia both of these nations have supported and sustained very large refugee population from somalia for a long time. and would have understandable concerns about the possibility of it destabilizing either of their nations and then last is the investment that's being made sufficient from the united states, from the international community, and what additional resources might be needed and how might we be more effective in engaging the n.g.o. community and the international communities on top commitments already made by the united states? >> answer quickly. the somali region is so complex. for example, if you think about one of every six somali is a ethiopian living in the area. the refugee flows.

the issue comes in on security and stability. for ethiopia and kenya, somalia is a strategic interest because of the security concerns. during the time i was there, for instance n. one year time we had 12 terrorist bombings in one year. from groups emanating out of somalia into ethiopia. it's a concern for the ethiopiaans. just as it is a concern for kenya that the concern for the regional states. how do you ease security concerns? i think the dual track approach is one approach that we have worked not just with the regional states but also with the transitional government to stabilize that region. that really is one area that -- to look at the security by the somalis themselves addressing the somali problems. and then the amazon troops from uganda and burundi have done a great job in taking back a lot of the parts of mogadishu, but, again, the bottom line problem

is that security will be a long-term problem. do we have enough finances? no. but it's an issue that will be in partnership with the regional states and also the somalis themselves. >> senator, if i may add one concrete example on the security aspect. one of the principal crossing points is an area called la boy where the united states has long encouraged the government of kenya to open a screening center. as you know the government of kenya has officially closed their border from kenya and ethiopia. kenya to somalia, has for some years. we encouraged the government of kenya to reopen the screening center and we have committed some funds, considerable funds, to help them pay for that opening. that will be a means for them to help them know who is coming into their country. in addition, it will be a means to providing assistance to refugees at the first point of crossing before they have to make the additional trek.

we hope the government of kenya will continue to consider this favorably and open the screening center in short order. >> i'll just wrap that up by saying we are very focused on ensuring that the host communities around the have a sinities of the camps also receive assistance. there are large drought affected areas as we have discussed in both ethiopia and kenya. and it's important that we work to meet those very grave needs as well. on the awareness issue, it is critically important i think that we mobilize the resources of the -- of very generous private citizens as well as donors, including nontraditional donors. there is a significant effort under way to do exactly that. >> thank you very much. senator. >> thank you, mr. chairman. just one question. i ask ambassador yamamoto.

in our briefing memo from the committee, there is a reference to ethnic somalis living in ethiopia. and access given the n.g.o.'s to be able to provide them with food and humanitarian assistance. the inference being it was somewhat restricted. what is the case with ethnic somalis in ethiopia? and is there restriction in getting food and aid to those somalis? . .

we'd like to thank our first panel. now to our second panel. we'll like to thank dr.

konyndyk, peter pham and wouter schaap. we are grateful for you taking time out to add your testimony to the record and to the attention that's being paid by the senate and the international community to this concerning challenge in the horn of africa. mr. konyndyk, i'd invite to you give an opening statement. i'd encourage each of you to contain your comments to about five minutes and we'll submit to the record any additional statement you might have. please, sir. >> thank you, senator. thank you, chairman coons. thank you, senator isakson for the testimony today. it's an incredibly important issue and we'd appreciate the focus you and the subcommittee are dedicating to this. it's very timely and very urgent. my name is jeremy konyndyk. i'm director of policy and advocacy with mercy corps. i'm here today representing a

relief organization that works in over 40 countries but particularly for today's purposes in three of the most affected countries in the region, kenya, ethiopia and somalia where we are providing drought relief throughout that region. i think that everyone has been shocked by some of the photos that have been coming out of the region but particularly out of dadaab and mogadishu in recent days. there was a shocking photo in "the new york times." a child. as horrific as some of these images are, it's important we recognize for every image of a child to however unfortunate has at least made it to a treatment center in mogadishu or dadaab. there are many, many children and adults as well who have not made it that far and that is a growing tragedy. it's also critical to remember even as much of the attention so far has focused on somalia,

the situation in kenya, somalia is desperate as well. our teams are -- our teams are doing assessments right now throughout kenya and ethiopia and initiating programs and they are finding vast swabs that are in extreme humanitarian emergency. our teams are seeing landscapes full of dead and dying live stock which normally would form the basis of the ability of people living there to feed themselves and support their families. they're seeing villages completely emptied by the drought because people can't get water and they have to go elsewhere. they're seeing families to eat one meal a day. it's a truly desperate situation. the superlatives that are being described in the horn are not hyperbole. this does threaten to become one of the worst if not the worst humanitarian crisis we have seen in a generation. the good news, if there is even, the aid community has a pretty good understanding how to fight a crisis like this.

we learned a great deal since the famines of the 1980's and 1990's of how to respond effectively to hunger cries cisand i've described in detail to my written remarks that i submitted for the record. the big question is whether groups will have the opportunity to apply that understanding that we have developed. our entire sector is facing a massive shortfall in funding for the response. the u.s. in particular has been very generous so far. the rest of the world has also with some variants put up a good amount of money but it still falls far short of what we saw even a few years ago when the drought hit the region in 2008. we -- there doesn't seem to be yet a global recognition of how severe this crisis is. we're seeing just a fraction of the engagement in the level of resources after we saw after the haiti earthquake, for example, despite the number of people across the horn exceeds the total top lakes of haiti,

much less the people affected by the earthquake there. the u.s. government is working very, very hard to respond and to mobilize resources and we are desperately appreciative of that. at the usaid and the refugee bureau are the best in the business. we deeply appreciate their expertise, their professionalism. but they need resources in order to combat this crisis. so far this year the u.s. contribution, while extremely generous and we recognize it as such, remains under half of what the bush administration contributed in 2008 to a major crisis -- last major drought in the region. and we're very concerned as we look at the upcoming f.y. 2012 debate that there are proposals on the other side of the hill to slash the very accounts that are providing the assistance that the u.s. government is using for the response to this crisis, specifically the international disaster assistance count, food for peace.

particularly food for peace should be highlighted here because that is our food aid account and there's a proposed cut of 30% of that budget over f.y. 2011 levels that would be a 50% cut over what we had in 2008 during the last major crisis so that is a real concern. the other challenge to the u.s. response has been the legal restrictions which were discussed in the earlier panel. it does appear the u.s. government has waived or is moving to waive these. this is a very positive step. we recognize it and we commend the administration for taking it. we do nonetheless have some remaining concerns of how this will be implemented. i'd be happy to address those during questioning. but even as we hopefully move past this impasse it's important to recognize the fact that the administration issued this license only several weeks after a famine was declared and several months after we knew that something very, very bad was coming, represents a real systemic problem. i don't think it makes sense to

point to any particular part of the administration as bearing responsibility for this they were struggling to hash these things out the best that they could. but there is a systemic issue here that i think bears further exploration in terms of the interaction between some of our legal restrictions and our humanitarian priorities. very quickly, to the question of whether we can get into this and how this is going to work, i'd say we don't know yet. we are going to -- the waiving of the legal restrictions takes an obstacle out of the way. but there are a lot of questions about what can be achieved in the south, what kind of access we're going to see. i think dr. pham can talk a little bit more about the regional politics there. i think there are reasons for optimism in terms of unicef and the red cross' success so far in getting some shipments in without interference. that gives us hope. so i think we have a posture of hope and optimism.

thank you. >> thank you very much. dr. pham. >> mr. chairman, ranking member ice ackson, i want to thank you for this isackson, i want to thank you for this opportunity. as the other panelists told you earlier, it's especially grave. the u.n. refugee agency describes it as the worst humanitarian disaster in the world with nearly half the somali population facing starvation while at least another 11 million men, women and children across the horn are at risk. given this grim reality, the first concern of the international community is understandably focused where it should be, getting relief to the victims. however, in addressing immediate needs, attention should also be paid to the broader geopolitical context as well as the long-term implications of the challenges before us. since other witnesses testifying today are better positioned individually or institutionally to address the

technical questions relating to the humanitarian crisis, it's impact on vulnerable populations and the logistics of getting assistance to them, i'll concentrate on four key points which i believe policymakers in the united states and other responsible international actors shid bear in mind in assessing the current situation in determining adequate responses to it as well as planning longer term engagement with this region. first, that back has the responsibility for exacerbating the crisis. while the group cannot be plan for dessertification trends, climate change or meterological conditions, the violent conflict it has engaged in, the economic and political policies it has pursued have certainly worsened an already bad situation. although in the past, al that back has profited --ial shabab has profited, it represents a

small fraction of its broader stream. it's heartening to hear the administration is working to clarify or necessary ease the relevant restrictions in order to facilitate the work of humanitarian organizations. however, allow me to cite just one example of where -- the export of charcoal. it's estimated that between somewhere of 2/3 of the forest which used to cover 15% of somali territory have been reduced to chunks of black gold packed into 25 kilogram bags and shipped to countries in the persian gulf. one cannot underestimate the negative environmental impact of all this which earned shabab millions recycled into violence and terrorism. and if this were not all bad

enough, once the famine set in, al-shabaab leaders prevented effective people from moving in search of food. whether or not it's are a formal policy of the group, i have reports from sources on the ground in the last 24 hours of at least three holding areas in lower shabeli where al-shabaab are using force or the threat thereof to keep people from leaving the territory and finding help. we'll get into why they might be doing that. secondly, far from being part of the solution, somalia's transitional federal government, the t.f.g., is part of the problem. in fact, a not insignificant cause of the ongoing crisis. the regime's unelected officials may be preferable to al-shabaab insurgents but they represent at best the two of the lesser evils. the t.f.g.'s limited

helpfulness in the humanitarian emergency. t.f.g.'s are likelier to see the crisis as yet another opportunity to capture rents, especially since the already extended mandate expires in two weeks and is a already plan b that the international community is not taking issue with the t.f.g.'s leader arbitrary extension of their terms of office by another year. no wonder the official position of the government of the united states, notwithstanding its engagements with the regime, is not to recognize the t.f.g. or any other entity as the legal sovereign of somalia. we need to pursue a permanent resolution to the ongoing crisis of state failure in somalia if we want to avoid humanitarian emergencies in the future. the potential population shifts threaten to up end delicate

political balances as well as present new security challenges for the horn of africa and beyond. if they are not the cause -- to cause, however, unintentionally greater harm, responses to this mass migration need to be fractured into these considerations. finally, amid the crisis, there is nonetheless an opportunity to promote stability and security in somalia. in fact, there is a narrow window of opportunity during which it might be possible to seriously weaken and possibly even finishial-shabbab as a force of politics once and for all. it has divisions in the movement with some of the councils and militias not willing to accept help. the disaster has exposed divisions with some of -- groups within it and factions and there are ways the international community can get assistance to drought-affected populations and do so where

they are rather than requiring of these poor people, displace themselves and create additional challenges that will be dealt with down the road. i want to underscore there are local n.g.o.'s with a proven ability to both deliver aid in hard to reach to areas all the while avoiding diversion of aid to al-shabaab and other entities. thank you for your attention and i look forward to your questions. >> thank you, doctor. mr. schaap. >> thank you for the opportunity you have given to us to testify today on this horrible situation we are facing in the horn of africa. i spook on behalf of care fighting global poverty. with six decades of experience in helping prepare for and respond to natural disasters, providing life-saving assistance in crises and helping communities recover after an mare mrge.

we place special focus on women and children and yet again in this crisis they bear the brunt of what's happening. i see firsthand in my work the consequences that tens of thousands of people are facing today. i worked in the horn for seven years now traveling extensively within somalia both in the north and the south. i recently returned from a trip to refugee camps in the north and what besee there is probably less dramatic than what we see in some martz of the south, yet the stories we hear are horrible. a woman that i met in one of the i.d.p. camps with a severely malnourished child on her arm explained to me she didn't have any money to go to the health clinic to seek assistance for her child and that assistance was not available there. you could see in her eyes she was severely traumatized by the

experiences in the south. she thinks -- and the things she had seen there. i met her father who recently lost his wife and he was there nursing his five remaining cows. the cows were bleeding from their noses and he was trying to do about it but not knowing what to do. our staff said this is a lost cause. these kind of experiences my staff see on a very regular basis and there are stories that remain with you for the rest of your life. our response to the emergency in the horn began to scale up in 2011, the beginning of 2011 when the early signs were clearly that this was going to be a major crisis. today we're helping more than one million people in ethiopia, somalia and kenya with life-saving food, water, nutrition and other life-saving assistance. care is one of the largest agencies working in the horn. we also support longer term

activities that help people become more resilient to drought. the severity of the situation is extremely worrying and other speakers have spoken at length about that so i will keep my remarks on that quite short. but the worry is that the situation is not at its worst yet. the deepest part of the drought is normally the month before the rains come and then people are weakened and so by september we're going to see a significant increase number of deaths due to diseases that affect these already weakened populations. so as my colleagues have said, agencies know now how to deal with this kind of situation and we need to focus on a broad range of services of waters, sanitation, health, nutrition, food and address those multiple causes of deaths in a famine crisis. however, unfortunately, there's still a major funding gap in the region of about $1.4

billion for the appeal of the u.n. this is really a worry notwithstanding of the generous contributions from various donors and we really appreciate the support from the u.s. government for our work in industry countries where we've been supported by bprm and others and really appreciate that. however, it's not enough. the crisis is so massive it needs additional support. the issues have been discussed at length. the ongoing conflict in the south is making it much more difficult to get access to the south. and what we're seeing is that agencies already present there, local n.g.o.'s other international n.g.o.'s that work there have an ability to negotiate some level of access but it is limited. and unfortunately it risks of becoming very politicized in this environment. it's important for all sides of this conflict to let humanitarian principles,

neutrality, impartiality guide all of our discussions on humanitarian assistance. and we're determined to provide only assistance to those people that are most in need. we have assistance to ensure that only those people get it. we are urging local authorities in southern somalia to grant uninhibited and unconditional access. but the crisis is happening now and it needs a concerted, thoughtful, careful diplomatic work of u.n., donors and n.g.o.'s to give aid to the victims of famine wherever they are. now is really the time to have space and reach out to all parties of the conflict and work to save lives of tens of thousands of people and to avoid politicization of the issues. we have been speaking with colleagues in the u.s. government about the legal issues that have concerned us and we really appreciate the recent steps taken by the u.s. government, specifically for programs funded by usaid and

the department of state. questions, however, remaining on the ability of u.s. n.g.o.'s to program funding from non-u.s. government doaners. for instance, the u.s. public. n.g.o.'s gets large sums of money from the u.s. public but this funding doesn't fall under the licensing that is now being put in place by the n.g.o.'s. that will only be covered if you have funding from the u.s. government for south central somalia. other funding like echo, dfid that would not be covered for u.s.-based n.g.o.'s and those are major sources of funding for u.s.-based n.g.o.'s. the longer term implications, we need to start think about those as well. i'm sorry aim' running over time. these are very marginalized pop police stations. they are among the most vulnerable to the impact of changes in the weather patterns. when i started working in somalia we see a drought every

five years. now it's a continuous psycheled of missed seasons and things are changing. we know there are things we can do to help that. we need to invest in that in the years to come. our recommendations, just to sum up, the expansion and the speed of funding for the crisis is really important. the urgency is there but we're seeing that major donors take quite substantial time for funding to become available on the ground to support our work, and we urge donors to be faster in their processes and moving things forward. we need to start planning for long-term support for resiliencey in these areas, and we concerted, thoughtful, careful, diplomatic work of donors and n.g.o.'s to negotiate access on the ground and help to support a public

climate in which those efforts can actually take place by the agencies working there. and the efforts by the u.s. government to easily -- work is really appreciated but it's not enough. because we are at risk when we use other government -- other government's funding and u.s. public funding, for instance. so on that last item we really need some very urgent action forward. the n.g.o. community's ready to engage the u.s. appropriate agencies to alleviate the effects of famine while controlling the risk of diversion and there are precedents for this in gaza and that can be achieved in two different ways. first, issueans of a general license from ofac that would risk prosecution that may be

incidental to the famine response. and specific licensing requests from ofec to the n.g.o.'s. it would place themselves in position for accessing aid on the ground. thank you. >> thank you very much, mr. schaap. i hear a common theme. obviously there are both naturally caused our occurring climate-driven causes for this regional drought and famine but also those that arise directly from al-shabaab and its control of a significant area. there are real concerns about the security and logistics of getting in the area but the pressing of the united states and our agencies and departments the opportunity now through ofac to get a license. mr. konyndyk, you also had raised some concerns or questions about the

implementation of the new license opportunity that mr. schaap reflected upon. we're grateful care and mercy play. some unresolved questions about the license. would you expand a little bit, as you suggested in your statement, you'd like concerns about implementation and clarity about the necessary path forward for to us deliver assistance appropriately and in a multilateral way? >> i associate myself with mrs. schaap's comments. as we understand it and we were only briefed on this yesterday afternoon so we're still digesting it and, you know, we all have our lawyers who are reviewing this and what not. our understanding at this point is that the license that has been issued would only apply to programs that are wholly or partly funded by the u.s. government. and so if our agencies are

working there doing discreet prosecutors prams that do not receive u.s. government funding or wishing to do that, that would not be covered by the license that was issued. apparently last friday. >> so your concern, if i understand correctly, from both of you on behalf of your organizations, relief efforts that are not directly funded by the united states government may still put your organizations at legal risk? >> that's correct. >> that are operating in south africa? >> that's correct. >> we hope that will be resolved promptly. >> at this point per our understanding you say it has all the authorities and clarences it needs and how they'll translate that into how it will be applied to their partners. that will be an issue we'll be addressing in the coming days. >> the time of the essence that there are literally tens of thousands of children who are starving and hundreds of thousands who are at risk or on the verge of starvation. would further bureaucratic delay strike you as cruel and

inappropriate? >> your words, not mine, senator. i certainly think that the administration is moving now with great urgency to try and clear these things out of the way. i think what we were told yesterday is an important step forward and a sign of sincere good faith on the part of the administration in resolving these things. i hope we're not to a point of detailed negotiations as well as big picture political will and i do think that's the case. as i said in my remarks and as i expand on in my written testimony, i do think there is a larger issue here that bears exploration going forward by the congress and the administration of how -- why it even got to this point. i mean, can we find some ways of reviewing the law on this so that we don't have to go through this long drawn up bureaucratic process in order to do what generally everyone agrees should be done in the

first place. >> doctor, let's turn to the question of al-shabaab. understandably they are subject to sanctions by the united states. we have done everything we can to restrict their opportunity to gain funding for the terrorist activity. you said in your written testimony and the testimony you just gave to us the real opportunity here because of some tensions within the organization. speak, if you would just a little bit further about whether it's appropriate for us to be issuing broad licenses and allowing humanitarian assistance in if it might further strengthen this terrorist organization. >> thank you. mr. chairman, the question of al-shabaab really is to understand that it's not a monolithic organization. at its core it's a radicalized extremist leadership with very close connections to some very dangerous people in other parts of the world and we need to be seriously concerned. they have operational reesm and

have shown themselves capable of carrying out attacks in neighboring countries as well. that being said, however, the organization itself is broken up. it's a marriage of convenience. some of the factions that are now in al-shabaab a year ago were possibly with the government. next year their clan factions and militias. this is an opportunity. some of them in places -- i can name some -- haradiri, state, bring us aid, we're willing to switch allegiance. so there is an opportunity. this is where it's important the secondary track two policy that assistant secretary carson announced last year, we need to get that going. it was announced a year ago but we still really haven't developed it. this is a type of program that would allow us to have the information and the partners on the ground who can distinguish, ok, which -- where are the areas we can work in. right now it's a theory, it's a concept, a very valid one but

we really haven't worked it out as we should have. >> like most groups, it's made up of a variety, different splintor groups, some hardcore jihadists bent on international terror. some are local clan or tribal groups that are aligned with al-shabaab sort of out of convenience. you mentioned in your testimony before there is reason to believe they might be holding by force or threat of force thousands of potential refugees who could find assistance elsewhere in kenya or ethiopia. would would you think they might be doing -- why would you think they might be doing it? >> several reasons. there have been several districts they didn't exercise that type of control and now they rule literally a desert. 100% of the people are gone. 100% of the livestock is dead. they have a desert to themselves. they canning enjoy it. if you're trying to seek control of territory you want a

population. secondly, this gets into some of the quandaries of aid delivery, i think they gambled as well eventually aid is going to flow and this is where we have to be careful how we let that flow. and therefore the more -- and we had this experience in somalia. was there in the 1990's when it happened. the more refugees you have, the more resources flow to those area. not so much the people. some of them may very well simply be holding people so they can increase head count and seek aid. >> and aratria, the most totalitarian regimes in the world there is little information about the conditions on the ground, the humanitarian needs. as i was looking at maps, it was blank in terms of data. any insight from any members of the panel about the likely humanitarian issue in this area, also a tension between the government situation, the

humanitarian situation is unresolved and with an unclear path. >> if i any begin, senator, just to give one index of how bad the situation probably is in aritria, somewhere around slightly under 50,000 people have crossed the border into ethiopia. it's a mine-laden trap and these people have risked everything, not just to walk across the desert but a mine field -- these are the survivors. that just says something about the level of desperation. i've met people who made that passage, who've become refugees, i've spoken with them and the situation is pretty dimplete >> thank you. i have further questions but i'll yield to senator isakson. >> i want to talk what you refer to as a systemic problem in the administration regarding licensing. is the problem there's too much bureaucracy?

>> there are different agencies that have different priorities and different angles on some these issues. the set up we have right now in terms of the legal restrictions, the ofac makes it very difficult for those different agencies that have a -- our suggestion would be to look at -- maybe as a first step, to our understanding the patriot act exempts medical supplies and religious materials from the definition of what would constitute material support. we would be interested in exploring whether that -- that carve out could be broaden to include other source and humanitarian assistance in situations like this so that it wouldn't require a long drawnout brewer catic process to enable aid agencies to have

the legal permissions they need to respond in these situations. >> on that, dr. pham, it's my understanding -- i know in fact in your testimony you said in many situationes that local n.g.o.'s are better equipped to deliver aid than might be a nonresident n.g.o. sighied is a group of somali women that deliver support within somalia because of this restriction. it will only be u.s.-delivered funds, is that correct? >> well, senator, sighied, to cite that specific n.g.o., one of their problems is they were fausely accused a year and a half ago in a u.n. report to have payoffs to al-shabaab. they were exonerated in the subsequent u.n. follow-up. that meant 18 months were they were cut off from the international funding and those were 18 months they lost.

they work very effectively by partnering with traditional clan elders, local community members and that's their protection. during the period of fighting in mogadishu, they were the only entity, governmental or not, that had operations in all 16 districts of the city. it's a tremendous organization. what the scale of what they're delivering is amazing. i want to pay tribute to them. if i could turn back -- i know my two colleagues are somewhat restrained on -- to comment -- >> that's why i asked you. >> although we focus a lot and we are americans, we focus a lot on perhaps obstacles in our own proceeses. we need to look at obstacles at the international level. the world food program works on a three-month cycle. i ask -- i ask myself -- how is it coming down the line they

didn't put more food in the region? over the weekend they had two flights that for all intents and purposes to dolo and mowing deeshy were for show. they too two tons of plumpy to mogadishu. syad in a month goes through 65 tons just in mogadishu alone. four tons is helpful but it really -- it was more for the cameras than anything else, frankly. >> one of the reasons for some of the restrictions is from them getting in the terrorist hands. when you do reach a crisis point in a humanitarian crisis like this there seems to be expedited procedures or else the people you are trying to help are going to be dead. and that's the comment that i was trying to get to because

many of them are affiliated with al qaeda and our nefarious groups around the world. we need to have an expedited procedure to the maximum extent as possible. i noted that bob was supposed to testify today but you are in his place. it causes me to make an observation for the people here today. mr. lapred with care international, he suffers from malaria. it reminded me that my first trip with care to ethiopia that the care representative that i worked with also had malaria. i want to thank you for the risk that you take in dangerous parts of the world to help. and care and many n.g.o.'s like it, some people don't equate

the risk and exposure of your own health that you put to help other people. so thank you for doing that. one last question for dr. pham. you talked in your remarks about al-shabaab, keeping people from getting help. they're actually stopping reue gees -- refugees from leaving the country to get help, is that correct? >> sources on the ground that i have spoken with within the last 24 hours, there appears in lower area in three different areas. one appears to be a camp of sorts where they're actually holding people. two are just areas where they created enough violence around them more or less to corral them in so it's not a guarded situation but it's a threatening one. and they're preventing people in -- it appears in two of those case fathers heading to mogadishu, crossing the lines over to the area controlled by

the african union peacekeepers so aid can get to them. hundreds of people have already crossed. the other area seems to prevent people from heading south toward kenya. >> and the goal of that is to strike fear in the population or what? >> i think it's seven-fold. it's hard to keep people but they can still rule. they aspire to rule and ruling on empty land is not what they were planning to do. and, two, i think some of it might be local interests of local al-shabaab commanders to have people as resources because people will attract aid which they hope they will be able to tax, divert or otherwise tap into. >> last quick question. one of the big problems in africa is a lot of the -- in a lot of indicateses organizations will use rape and violence against women as a tool of accomplishing their end goal.

do your people on the ground give you any indication al-shabaab is using that as a tool? >> not on a -- i'm not getting reports of that. there are cases of violence against women very clearly. those are -- some of those are being documented. not as a systematic attempt to exert control or terror unlike other tragic cases in africa. >> may i -- in various camps in the region sexual violence against women is a serious problem and not just within somalia but also outside. >> thank you very much for testifying. mr. chairman. >> i'd like to follow-up, if i could, mr. schaap on a comment you made earlier about the earthquake in 2003. there was an accept by the licensing that was granted more broadly that might be a useful example on that.

could you elaborate on that? >> i don't have the technical assessment but i'll get back to you on that. >> we're looking for a responsible, swift and appropriate path forward. i understand despite my comment earlier, i understand that different entities within the understand government are charged when forcing different legal obligations. and sometimes the desire for profert and effective humanitarian assistance runs up against the barriers that we put in place in order to prevent assistance from being provided wittingly or unwittingly to those who are also enemies of the united states and pose a real threat to international order. i'd be interested in your input, if i could -- my last three questions here -- first br future planning of how the united states can better assist with countries in the region, particularly here in the horn of africa where the climatic conditions seem to be worsening. how do we help them build

resilience, sustainable capacity to deal with these crises so we don't face them more periodically? second, several of you referenced threatened cuts to u.s. aid, the house has taken up the relevant budget and has proposed -- i think mr. konyndyk suggested it was a 30% cut from last year, 50% of the 2008 levels. how do you see our efforts to sustain american engagement with development, with assistance playing out and what suggestion us might you have for us in how to help the average american understand why there is value in doing this, not just from a humanitarian perspective but a strategic perspective? >> i think the need for recovery and resilience programming is extremely high and i think it's important to get that -- the planning for that started now even while we are in such crisis. there are a lot of things that

n.g.o.'s and others are doing in these areas, ensuring livestock health, ensuring improvement of natural resource management, vocational training to diversify the income streams that people have and with care they work to help ensure asset diversification so people have liquid assets during a drought. so there are a lot of things that can be done and this needs to be scaled up. in response to the drought because people have lost all of their assets. we want to avoid a situation where after this drought and after this massive crisis because it's going to be massive people are left for a long period of time while agencies are planning for recovery and resilience programming afterwards. if i may add a point on your earlier comment on bureaucratic obstacles and aid delivery coming through quickly, this is a serious concern. we -- we're looking at two or

three-month window of opportunity in which we can still save lives. with the pace we have seen, not just with the u.s. government donors but other donors as well, it takes multiple, multiple months to get through the process. and the added complications of u.s. regulations have added significant periods of time and that's worrying going forward since we have a short time frame to prevent more death. >> thank you, mr. schaap. mr. konyndyk. >> i'd say the need to build resiliencey, the sorts of program that the u.s. has funded in ethiopia and kenya are a really important reason why the impact of the drought there is not as severe as where we're seeing in southern somalia. i think it's important to note regardless of the political insecurity factors, the program going back years in somalia is

a significant factor in why it is so much worse there. looking forward we need to invest in a response right now that is not thinking just about the next three months but about the next five to 10 years in trying to rebuild people's resilience and livelihood as quickly as possible. in ferms of -- in terms of the u.s. government support, we've been very concerned so far that the -- this situation doesn't seem to have really broken through yet in terms of the american consciousness in the way the recent crisis and haiti did. i think there is a very clear link between the level of american public engagement in a crisis and the level of private donations and private support that the public provides but also then the level of support that the u.s. government is motivated to provide. so i think that obviously we

strongly support the accounts that i mentioned earlier and we any protecting those are critical. it's also important for u.s. political leaders to i think to signal to the american people just how serious this situation is. after the crisis in haiti, the president and the first lady were very vocal about the needs there, about the importance of providing aid there. we haven't seen that level of engagement out of the white house yet and i think that would be really important and really helpful. i understand the president has been dealing with some other issues lately but hopefully in the coming month we can see more engagement on that. i think as well, you know, for members of congress, all of them going back to the districts now for recess, i think this is an important issue to discuss with your constituents. and we would love to see, you know, joint calls from the congress and the administration for a greater american engagement on this. thank you. >> thank you. senator isakson.

>> following up, mr. konyndyk. what assurance that mercy corps give that the funding gets to those in need? >> we have arrangements in place for that. as with any private american charity there are laws and procedures that are in place. we get audited every year and we make those audit findings very public. those audits a very intensive. we are also part of the -- collaborate with various accountability networks within our sector. there is a group called interaction which is sort of the umbrella organization for all american international charities which has member standards that we adhere to, that get to exactly that. also as a partner of the u.s. government there are very, very rigorous standards that we have to adhere to in order to qualify for u.s. government funding. so there are a lot of kind of overlapping accountability standards and audits and all of those things that -- which help

to hold us to account. >> in those standards or in your own internally controlled standards, is there an acceptability amount of -- i understand we are dealing in very difficult areas of the world and very difficult circumstances. is there an acceptable of leakage and one which there is no tolerance? >> there is no -- you know, you never want to say here is our acceptable level of leakage because then you'll get that level of leakage. >> understand how that can work. >> our priority is absolutely to ensure that the aid gets to where it's supposed to go. i think we have a very low tolerance for leakage. it's always on a case-by-case basis. looking at somalia specifically and as i've written in earlier articles on this, one of the factors that caused us to scale back our operations in the south back in 2010 even before

we were formerly expelled was that we were sealing, you know, unacceptable levels of interference. so we -- no level of leakage is tolerable. i think what is -- what we are willing to -- what we are willing to work with is minimal but it can't be -- it is defined on a case-by-case basis. >> mr. schaap is nodding in agreement. i want you to express yourself. >> to add to that, with agencies working in somalia, constant dialogue of what mechanisms we have in place to severely limit the ability of diversion to happen. there is the leadership of the u.n. humanitarian coordinator has been quite strong in the last couple months to really push back on those initiatives that have been pushing for taxation, etc., etc., on the

ground. and our systems internally are very tight. whatever we pledge to beneficiaries are actually going to beneficiaries and not anywhere else. >> thank you, mr. chairman. >> senator isakson, thank you very much for joining me. i'd like to thank mr. konyndyk, dr. pham, mr. schaap, for your relief, for the leadership role your organizations have taken, for the insight you've given us and the world as folks have deliberated over this humanitarian crisis. as you've helped make clear today, this is the gravest humanitarian crisis facing the world today. it was foreseeable. it was one for which preparations were made and where there is investment that has made it less severe than it otherwise might have been but it's one that can be expected to occur again because of the combination of governance, climatic, regional, economic

and social factors in the horn of africa. and so it is my hope that we will be working together, the people of the united states, the nonprofit community, private citizens to heighten public concern, to strengthen international engagement, to not just respond to this immediate and very real crisis that will likely take tens of thousands if not hundreds of thousands of lives but to lay the groundwork for preventing a recurrence of this crisis. there were parts of this that were entirbleely preventable. africa is a continent of enormous promise and it is tragic to have this particular crisis be what most americans will be seeing about africa in the month ahead. it is my hope they will be seeing more of it and i'm grateful for your role in highlighting and addressing this very serious humanitarian crisis. thank you for your testimony. i will keep the record open for the senators who were not able to join us today to submit

statements until the close of business, august 5, and this hearing is adjourned. [captioning performed by natonal captioning institute] [captions copyright national cable satellite corp. 2011]

>> coming up in about two hours, 2:00 p.m., a senate banking committee hearing looking at the foulness of the banking economy. -- industry. that gets under way at 2:00 p.m. eastern.

we'll have it live here on c-span. coming up later, president obama will celebrate his 50th birthday. faund raising event in chicago. it includes jennifer hudson and herbie hascock. you'll see this live at 8:15 eastern tonight here on c-span. >> eight, nine. >> eight, seven, six, five, four, three, two, one. these are the stakes. to make a world in which all of god's children can live or to go into the dark. we must either love each other or we must die. >> look for president johnson on november 3.

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>> hydrocephalus is a buildup of fluid inside the skull which could lead to conany tif problems or death. it affects about 700,000 americans. well, tuesday the house global health subcommittee heard from a doctor behind a surgical procedure that reduced the number of hydrocephalus-related deaths in ugandan children. this is about 90 minutes. >> the committee will come to order. i want to thank you for joining us this afternoon for this hearing on a serious and seriously neglected health condition and a relatively sophisticated way of curing it. i had the opportunity to learn more about hydrocephalus when i was traveling in africa last march. children who suffer from it

characteristically have heads that are far out of proportion to the size of their small bodies. i was horrified to learn that in africa where superstitions still are widespread hydrocephalus is commonly perceived as a curse or caused through witchcraft. a child may be subjected to horrific abuse and killed as a result. it was therefore a real eye opener for me to see the cultural context of hydrocephalus in africa and the extraordinary efforts of a number of courageous, compassionate individuals who are addressing it. the human brain normally produces cerebral spinal fluid which surrounds and cushions it. it delivers knew recents and removes waste away from the brain -- nutrients and removes waste away from the brain. it is absorbed into blood vessels. hydroself will you occurs when this draining process no longer functions properly. the fluid levels inside the

skull rise causing increased pressure that compresses the brain and potentially enlarges the head. symptoms include headaches, vomiting, convulsions, brain damage and ultimately death. hydrocephalus can occur in adults but most commonly is present at birth. our witnesses will testify there are believed to be more than 4,000 new cases of infant hydrocephalus in uegonda and 100,000 to 375,000 new cases in subsaharan africa each year. by comparison in the united states, eyed row self luss occurs in one out of 500 births. another 6,000 children under the age of 2 develop hydrocephalus annually. the u.s. national institutes of health estimates that 700,000 americans have hydrocephalus and it is a leading cause of brain surgery -- it is the leading cause of brain surgery

for children in this country. a major difference between the united states and sub-saharan africa is the number of neurosurgeons available to treat this. the united states has 3,500 neurosurgeons where uganda has four. the doctor will say in his testimony the number is about one per 10 million africans. there is such a dirt of this very important and needed specialty. another major different teens the united states and sub-is a marianne africa is the methodology in order to treat hydrocephalus. in the western world, doctors insert a shunt into the brain in order to drain the fluid from the neck into the other parts of the body. is shunt is only a temporary solution and there is always a danger that any number of things can go wrong. for example, the two may become blocked, catheters may break or

malfunction due to calcification or the drain may drain too much or too little fluid. . in almost half of all cases, shunts fail in the first two years. when they do the patient must have immediate access to a medical facility and doctor who can fix the problem. this is a constant source of stress for people in the united states and their families in the united states however in subsaharan africa, shunts are not an option. they travel arduously and long even under the best of places. a child in uganda would have

little hope of living more than a couple of years. in march of this year, i had the privilege of meeting with one of the four neurosurgeons in uganda. with the help of a video such as we'll be doing in this hearing, he explained the fascinating surgical procedure that he's performing several times daily in uganda to cure small children of hydrocephalus. this is being provided at cure children's hospital of uganda and is not only overcoming a medical barrier, it is educating ewe began dan communities that it is not a curse and not a reason to kill a child. parents are helping other parents to identify the condition early in a child's life and know where to go for

treatment. one of the -- the doctor was one of the first to identify prenatal infection as a source of hydrocephalus. as he'll testify, hydrocephalus has never been a public health priority in developing countries. most infants in africa do not receive treatment and even when treated they succumb to premature death or suffer severe disabilities. therefore it's imperative we find the causes in order to develop a prevention strategy. i'm pleased to welcome our witnesses who will explain the procedures and the efforts being undertaken to find the causes of hydrocephalus and the

measures being take ton end this life threatening illness. i encourage all stake holders who care about the children of africa, including the african ministries of health and nongovernment organizations to provide tangible support for these efforts an initiatives. i'd like to yield to my good friend and colleague, mr. payne. >> thank you very much. let me begin by thanking chairman smith for calling this hearing and helping us to shine light on the terrible condition that we've heard him describe and that we will be discussing today. i certainly appreciate the experts who have given they time here today to enlighten us on this situation. chairman smith has mentioned hydrocephalus is a an -- is an excess i accumulation of the

cerebral spinal fluid in the brain and can be congenital or acquired. con jell tall hydrocephalus may be caused by parental factors or genetic abnormalities caused by infections, tumors, or head injuries. the disease can be fatal if left untreated. i'm hopeful that by providing prenate tall care to mothers, the president's global health initiative can help prevent the infection that causes the disease. the prevalence rate of hydrocephalus is not well known or not well documented. however, cure international estimates that there were roughly 400,000 new cases in 2010. i believe that the numbers of cases in east africa and the developing world is much greater -- greater due to a

high rate of neonatal infections. in that region, it's estimated that 6,500 new case os cur each year and more than 45,000 in subsaharan africa. the actual number of hydrocephalus cases in uganda is not known. conservative estimates put the number at 1,000 to 2,000 new cases each year occurring. roughly 60% of these are reportedly attributed to neonatal infections. while the doctor, and cure international, and others are making an impact in uganda, it is clear that innovative inventions are needed throughout africa. the resources to combat this disease are severely lacking in africa and the world. the lack of funding and access

to health facilities, the expertise needed to combat such a disease is rare. there's an estimated one neurosurgeon for every one million people in east africa and the number in uganda is one trained neurosurgeon per eight million -- 8.6 million, believe it or not, that's a little bit bet for the uganda than other east african countries. and really, if you take other countries in africa, it's even worse because it's documented that there are no trained neurosurgeons in a number of countries in africa. zero. not one. so we see that we have a very serious situation where in the u.s. we have 2.67 physician pers 100,000 people and for neurosurgeons we have one

neurosurgeon per 88,000 people in america. you see where we have one per 88,000 in the just and one for 10 million or zero for millions, we see why we have such a serious problem. in addition to the lack of -- of course the resources available to combat this disease are severely lacking as we can see by the number of physicians and in addition, the lack of funding and access to health facilities, the access needed to combat the disease is rare, as we mentioned with the lack of trained people to deal with this. i'm interested in hearing from our experts here today in how they can best promote the training of specialized doctors an surgeons to combat this disease. i'm also interested in learning

about what measures can be taken to prevent the disease over -- altogether. i think we need to work on prevention, it's going to be difficult to get people in to treat to and care for it but if we can deal with overall prevention, i think our dollars will go much further and really keep a lot of agony from people so i certainly look forward to hearing the witnesses and actually sort of kind of the fact that we lack the training, i just want to mention that i am co-sponsoring a bill on african higher education, we call it the african higher education advancement and development, we call it the head act of 2011, where we're trying to deal with higher education in africa regardless of whether it's medicine, or just basic education, teacher training, as we see africa

moving more toward universal elementary education, most countries now have decided there is universal free el mentry education, though there's still school fees, but minimal and now that the girl child has finally been recognized as an entity that ought to be included in elementary and secondary education, at least we're seeing a move for girls in elementary education and hopefully we'll see in it secondary education and of course getting into high education, i think we need to -- into -- into higher education, i think we need to move forward so doctors and neurosurgeons and people we need to have positioned in africa, africans themses will have the training to deal with this. mr. chairman, thank you. >> thank you very much. we're joined by the cheam of

the commerce, justice, since and related agencies, chairman of the appropriations committee, congressman frank wolf. >> i thank you. i want to welcome the witnesses. thank you, mr. smith, for having the hearing. we were talking about this issue on the floor. i don't serve on this committee, i have to go to another place but thank you for the invitation. >> thank you very much. i'd like to introduce our distinguished panel, dr. ben japan worf who was the first pediatric fellow in nur surgery, he and his family moved to uganda to help start a hospital for pediatric neurosurgery. he served as medical director and established the only neurosurgery pediatric hospital

in uganda. he remains involved to uncover pathogen -- pathogenesis. he developed a novel surgical technique known as etbtpc. he's investigated the role of etbccc in north american infants and continues to work in intever national neurosurgery and dwhofmente rejoined the team at children's hospital in boston in 2009 and was appointed director of nia no, i tall -- neo natal surgery. we will then hear from dr. steven j. schiff, rush chair professor of engineering and director of the penn state

center for neuroengineering. he's a faculty member in neurosurgery, engineering, science, mechanics and physics, he has a particular interest in hydrocephalus, ep accept -- epilepsy and parkinson's disease. he's perhaps the only fellow of both the american physical -- american society of college of surgeons and served as associate editor of physical review letters. he's been listed in the consumer research council guide to top physicians and surgeons and the plays the viola. no time for that today, though. we hear from james co-hick who serves as health care

professional since 1983. for 16 years he served in field and corporate administration with u.s. based specialty hospital networks and for the past dozen plus year he is has been mart of an internationally foe cutted pediatric specialty hospitals and organizations. in 1997, mr. cook and his family moved to kenya to start and run the first cure international hospital. first of its kind on the african continent. in addition to serving as executive director of the hospital, he directed regional operations in east caffer can -- africa of the cure, which involved development of the two other facilities. he continued to provide oversight of the growing network of hospitals and initiated a cure global clubfoot program. after completing his m.b.a. and studies at kellogg school of management he served as hospital administrator for shriner's hospital for children

in chicago. he continues to be a fellow at the american college of health care executives. now as senior vice president of specialty programs at cure international, he provides executive leadership to cure clubfoot worldwide and hydrocephalus. dr. warf, if you could proceed. >> thank you very much, chairman smith, congressman payne, members of the committee. it's a great honor to be here today. i appreciate the opportunity to testify about this devastating condition affecting millions of babies in africa and across the developing world. i'm currently at children's hospital, boston, an associate professor of surgery at harvard medical school. but from 2000 to 2006, my family lived in uganda as medical missionaries to help start a specialty hospital for mediate rick neurosurgery. from its opening, our hospital

was inundated with a steady stream of mothers seeking treatment for their enfants with hydrocephalus, a condition in which the fluid is unable to circulate out of the brain and be absorbed normally. this leads to rapid expansion of the infant's head, damage to the infant's brain and death if untreated. astonished by the staggering volume of patients we were presented with two questions. one, what were the chief causes and burden of disease in this part of the world? and two, what was the best way to treat this condition in the context of rural subsaharan africa? the burden of hydrocephalus in africa is arresting. we estimate there are between 100,000 and 375,000 new cases of infant hydrocephalus each year with an annual economic burden of untreated hydrocephalus from $1 billion to tens of billions of dollars

depending on the economic analysis use. this is comparable to published estimates of other conditions in africa, such as malignancies, cataract and glaucoma, yet we're the first to highlight hydrocephalus as a problem. in the u.s., most hydrocephalus is related to hemorrhage in babies. 60% of ewe began dan cases were caused by infections mostly within the first month of life, the neonatal period. these were characterized by a february rile illness, usually accompanied by seizures, followed by rapid enlargement of the infant's head. in addition, the brains of these children contained pus, blood and substantial

destruction of tissue. we could successfully save the vast majority of these children by treating the hydrocephalus but the primary brain injury from the original infection was often devastating. in a study now in press, we found that a third of these children had died by five years and a third of the survivors had severe disabilities. the importance of prevention or early treatment of these infections was obvious. but we were unable to isolate any bacteria from the fluid at the time of the surgical treatment. this is where my invaluable colleague dr. schiff here and his team at penn state have come to the rescue, as he will give testimony. infant hydrocephalus is almost always treated by implanting a tube called a shunt which drains the fluid from the brain into the abdomen. in the u.s. the average patient requires two to three operations for shunt failure during their childhood. shunt failure is a

life-threatening emergency in children. but in rural africa, abscessing emergency neurosurgical care is impossible. we developed a novel way to treat hydrocephalus using a scope that avoided shunt dependence in more than half of these babies overall, including those with post-infection hydrocephalus. it provides a new pathway for the fluid to escape and cauterizes the place that makes the fluid, slowing its rate of production. we've learned to predict which patients are most likely to be treated successfully in this way and trained other surgeons in this technique, which will be demonstrated in a short video. we estimate the lifetime cost of $90 per year averted using a paradigm we created at children's hospital of uganda.

this compares favorably to the other surgical interventions studied in developing countries. hydrocephalus has never been a public heath priority in developing countries. most enfants in africa receive no treatment. training and equiping centers and an evidence-based treatment paradigm is essential and it's imperative we identify the causes of these cases. these are the challenges that lie before us. thank you very much and we have a video now that i would like to show. the man you'll hear talking is a ewe began dan neurosurgeon who i -- the ugandan neurosurgeon who i trained before i came back to the u.s.

>> they think the biggest problem comes from witchcraft to god's curses. they may have visual impairment and ultimately they do die if they're not crippled. i have great joy from treating children. when they see their child playing, i feel so happy. >> this is a scene in our operating room in uganda. just takes about a minute and a half or so to demonstrate. the setup in the operating theater, there's the doctor making the small incision in the infant's scalp just over the soft spot, the anterior

font nell, and in a few moments he'll insert a small, flexible, fiberoptic endo scope into the cavity in the brain, the ventricle of the brain and you'll see where he makes the opening to allow the fluid to escape. that's a view from inside the brain. on the left side is where the pituitary gland is. to the right offscreen is the brain stem. s the floor of the third ventricle. he's making an opening in the floor of the third ventricle where the fluid is trapped now the fluid will be able to exit through this opening and allow it to escape to the outside of the brain into the spaces where it can normally circulate and be absorbed. this part of the procedure is called the cauterization, this

is the tissue that is being caughtized, the tissue that makes the spinal fluid. we found that in infants, the success rate suzz greatly increased by addition of this procedure at the time of the surgery. the innovation was combining the two techniques, which hadn't been try before. >> thank you so very much. dr. schiff. >> chairman smith and congressman payne, thank you for the invitation to testify today. i'm a pediatric neurosurgeon who started my career practicing at the children's hospital here in washington, d.c. i now direct the center for neural engineering at penn state university seeking solutions to problems that lie at the intersection of medicine, engineering and science. i've known dr. warf for many years and hearing of his efforts to address childhood

illnesses in ewe began darks i visited him in 2006 to see how our engineering center might help his patients. it was readily apparent that he and his colleagues were inundated with cases of post infectious hydrocephalus. at that time, they'd treated over 1,000 patients without being able to culture any of the causative organisms in their laboratory. i asked dr. war of what the single -- dr. warf what the single most important thing he faced at the hospital and he said finding what caused this. i began my effort seeking those answers. we threw the book at them in terms of advanced way to grow organisms. we grew nothing. we turned to d.n.a. collection tools police use at crime scenes and set up a little forensics lab at the cure hospital.

we gathered d.n.a. from the brain fluid of enfants at the time of surgery to sequence the bacterial genes that might be present my penn state colleagues and i found evidence of bacteria within the brain fluid in nearly every one of these children. the bacterial types appeared consistent with those found on a farm with animals. the bacterial spectrum also was noted to change with the various seasons and with the rainy seasons in uganda. the most prevalent back tier wasa was one that has caused terrible problems in wounds in our military in afghanistan. we took environmental samples in huts, dung and water

supplies that yielded close matches for the organisms refreeved. our findings were significant but did not determine what initially made think infants sick. most of them developed serious enphoenixes within the first month of life, nia natal accept sis. the world health organization estimates that infections lead to the death of 1.6 million newborn infants each year. the majority in subsaharan africa and southern asia. the bacteria in the developing world appear different from those in the u.s. and most of the cultured results from septic african neonates have failed to grow out organisms in any lab rah tir. we began a study last yore of neonatal accept sis at one of the -- uganda's major referral hospitals. last year we recruited 8 0 mother-infant pairs in a

partnership with their head pediatrician correcting -- collecting spinal fluid and blood if the babies and birth canal specimens from the mothers. we're now collaborating with the venter institute near washington, d.c. to perform an exhaustive sequencing of the bacterial and viral content of these samples. since cure treats all the hydrocephalus that develops in patients, once we studied a sufficient numb of patients with neonatal accept sit we will know which infections lead to hydrocephalus treated at the cure hospital. recently, by fusing dr. warf's case data with u.s.-noaa satellite data, we demonstrated a link between climate and post infectious hydrocephalus. infants get sick at intermediate levels of rain fall, emphasizes -- emphasizing

the role of the environment in this condition. our work demonstrates that we're benefiting from united states technology in ways we never anticipated. we are committed to optimally surgically treat the large numbers of children who have hydrocephalus, however, we will never operate our way out of this problem. a critical long-term goal is more effective treatment of children with neonatal accept sis to decrease brain complications in survivors and most important, once we understand the root causes, we need public health measures to prevent these infections. hydrocephalus is a global health issue well beyond the specifics raised by small, very fine african hospital, a great u.s. charitable organization that brings the highest quality of medical care and compassion to children around the world, and the finest physician i've ever met, dr. warf. of the 130 million children

born around the world each year, we are inadequately addressing the million and a half who die of preventable newborn infection. as a physician and scientist and as a father, i'm struck by how much we don't know about new bonch infections in developing countries. i am concerned that one reason is that the newborn infants who die there have no political voice. i will offer three conclusions in closing. first, we have not paid sufficient attention to the massive loss of human life from newborn infections in the developing world. second, we now have the technology to shed new light on the causes of a substantial fraction of these deaths. and third, we can now develop sustainable strategies and scaleable technologies to more effectively prevent the deaths and tragic survivals from these devastating illnesses. the fate of millions of lives

depends on our actions. thank you. >> dr. schiff, thank you so very much. >> chairman smith, congressman payne, members of the committee, thank you for inviting me to talk about this issue and what cure international is doing to help cure children with these condition. it's an honor to be here with dr.s warf and schiff who have been on the leading edge of calling attention to this. as the executive director of the first cure international hospital in kenya, i ran the hospital for a numb of years. i now serve as the vice president for specialty programs for cure international. our mission is to heal disabled

children. we operate hospitals throughout the developing world from afghanistan to zambia. cure hydrocephalus is perhaps our most ambitious and innovative initiative. our unique work at cure children's hospital of uganda is the endo scaupic treatment of children with hydrocephalus, more commonly known as water on the brain, which can be presented at birth or caused later by infection. the cure hydrocephalus initiative was born at the cure ewe dwan da hospital buzz of the work of dr. warf during his tenure as medical director there. he also trained dr. john mugamba, the medical director there now. we stirment that in 2010, there

were more than 4,000 new cases of infant hydrocephalus in uganda, nearly 3,000 in the developing world using a ratio of three per 1,000 births. virtually all these children, if left untreated, die. over the next five years, that means as many as 1.5 million infants in the developing world could guy from hydrocephalus. the majority of hydrocephalus cases treated at our hospitals when medically appropriate involve the novel combination of two surgical procedures described by dr. warf known as etbcpc. the technique truly is a cure for children suffering from hydrocephalus as it eliminates the need for a shunt in the brain, the standard hydrocephalus treatment which can need a replacement two to three times, even up to five times over a child he's

lifetime. as you can imagine,s that huge logistical and economic challenge in developing world locations like uganda. too many children with hydrocephalus are never treated and die. many treated with a shunt live only a short time before their shunt fails and their families are unable to access further medical care. mr. chairman, hydroreceive sluss a global concern that is widespread in poor countries and vastly underreported. with new techniques like etbcpc we have the opportunity to save thousands of children and end the suffering of their families. what's needed is to scale up proven treatment by increasing training of national surgeons and creating the proper infrastructure to support their ongoing work. to give you a sense of the scale of the problem, there are four trained neurosurgeons in uganda, a country of 33.6 million people. there's approximately one trained neurosurgeon for every

10 million in east africa. in the united states we have 3,500 board certified neurosurgeons, meaning we have 110 times the access to treatment of those in east africa. our efforts is summed up in four initiatives that make up cure hydrocephalus. first, strengthening national health systems through training and equiping national surgeons from the developing world in advanced surgical treatment methods for hydrocephalus. second, enabling the surgeons to use their new skills by providing them the appropriate operative equipment. third, developing the i.t. infrastructure to capture patient care data to facilitate research with our strategic partners to advance the understanding of causes, the understanding of best practices and the effective methods of prevention of post infectious hydrocephalus. finally, demonstrating compassionate care and concern for the world east most vulnerable children and their

parents and their families by ongoing followup. training, treatment, research and prevention, and compassionate care will change how hydrocephalus is treated. it will translate into significant cost savings for tradge ill developing world health systems. mr. chairman, thank you again for your personal interest in this life threatening medical condition and your leadership in helping toest cab learn -- establish creative and effective ways to save more lives and end the suffering of thousands of children. my colleagues and i at cure international and our partners are excited and confident to go forward as we are called upon to do so. mr. chairman, i'm not -- this may have already been handled but i do have a document to submit as part of the record. >> without objection, it will be made part of the record and any additional materials any of

our three distinguished witnesses would like to add. thank you. mr. wolf, do you have any questions for our panel? >> let me begin with some opening questions -- >> let me say it needs to be treated -- shouted from the rooftops that hydrocephalus is a preventable tragedy and the work you have done remain the best kept secret in washington. there are many people, after can -- who have raised these issues who are shocked, they have no idea the prevalence of the 375,000 as dr. warf you testified, new cases per year. and in idea frankly that there is a an ongoing and very effective solution that you are employing every day but you need more people, more

resources to expand the solution. so again, on behalf -- i know mr. payne and i and all members of our subcommittee, we thank you for the pioneering humanitarian work you have done. it is absolutely extraordinary. if you could, perhaps warf, describe the life cycle of a child with hydrocephalus, you know, as the pressure builds, the pain perhaps that he or she may experience, and what is the ultimate consequence if untreated. >> yes, sir. well, as the fluid is trapped in the spaces in the brain, as the brain continues to make more fluid at the rate of about an ounce every hour, the head begins to expand, sometimes to enormous sizes. the soft spot on the baby's head begins to bulge.

the veins in the scalp begin to bulks this eyes are deafuated downward in something called the subset sign. the chern become listless they feed poorly, they are irtable and in pain they vomit, about half of them will be dead by the age of two, the other half will be severely devastated. sometimes hydrocephalus, after it becomes quite advanced, can sort of accommodate or spontaneously arrest itself, that's why some of them survive. the bad news is that they all virtually either die or are badly disabled. the good news is that it's an imminently treatable condition. if hydrocephalus is the only problem, for instance, a congenital cause of hydrocephalus and you treat the hydrocephalus early, those children can be quite normal. in a case where the hydrocephalus is secondary to

another event such as an infection or hemorrhage there is sometimes varying degrees of primary brain injury like we described in the children with post infectious hydrocephalus. also, children that are shunt dependent, even in developed countries, in our own practices here in the u.s., are fortunate to have access to a safety net such that when their shunt malfunctions, they almost always have emergency access to neurosurgical care and we fix those shunts at 2:00 in the morning or whatever it takes because it is an emergency. but one of the things that drove me to look for other treatments was knowing when i put a shunt in these children and they went back to the bush,

that when the shunt failed later in life, when the soft spot had closed up, they would almost certainly die before they found their way to a hospital where anybody could do anything about it. >> dr. schiff you talked about the discovery of -- you said the most common bacteria was one that causes injuries to our military personnel in vietnam, iraq and afghanistan. were there other bugs or infections? and secondly, dr. mugamba, when we met with him in africa, he said a likely major cause of hydrocephalus and i think it's based on work you've done as well is the use of cow dung which is cheap and plentiful to cauterize the umbilical court following birth which normally occurs at the mother's home. i wonder if that's one way some

chern are contracting hydrocephalus, infection-borne, and whether or not the ministries of health, for example, of uganda have shown any interest in better birthing practices to mitigate the passage of this terrible infection. >> i hope that in a few years, we can come back and be very clear that we truly have worked all these mysteries out. we find a great deal of evidence for that bacteria and related organisms in the brains of these children. that doesn't tell us if it's what caused the initial devastating infection that may have destroyed a great deal of brain and leaving them in a devastated state. so we're conducting several

different clinical trials, trying to untangle this. we have a trial at the cure hospital where we're comparing children with hydrocephalus who have a history of serious newborn infection with those who don't. it's entirely possible you and i brush our teeth in the morning, we shower our bodies with bacteria, it may be that these children are exhibiting for us a great deal of the environmental bacteria that they encounter as newborn infants. in field work, i must say, it is rather an eye opener for one of us to go to the rural settings and understand the conditions that these newborn infants need to survive. the huts are actually lined with dung, purposefully. it's a very good insulator against both rain and it keeps out ants, which are unpleasant. the patios around the huts are

stripped of vegetation and dung is pounded in to keep the dust down and vegetation away. granaries are lined with dung for ants and rats system of this tremendous exposure, in addition to cultural practices of certain peoples using dung on umbilical stumps. so infants are exposed to a greet deal of this. one of the other things we need to do is nail down what causes the very common scenario that dr. war of -- warf mentioned not just high fevers and serious infection in the newborn period but almost all of these children had epileptic seizures to go along with it. we have what appears to be organisms that have a predlix to get into the brain -- a predielection to get into the brain. they're very able to show you

what they're exposed to in the environment because we sequence it if the cure hospital. this is a -- an example of the kind of complexity that we face. being able to work all this out now is straightforward. we fortunately have the ability to go, even in burned out infections, go back and find the fragments of the organisms and use new techniques to do this. i think one of the challenges will be how do we bring this to the next country? you can't have major science institutes in the united states running very expensive sequencing and sampling on every site in the developing world but i really do think that in the coming years, being able to understand how to go into another country, whether it's east africa, southern asia and the other sites that seem to have many, many of these cases, learn how to uncover the organisms, learn how to keep

surveillance in these countries, and so we can do two things. learn how to better treat the enfants when they're sick and most important, be able to institute rational public helicopter strategies to cut down the numbers of these infections. >> goal number four seeks to drastically reduce the number of children who die, childhood mortality and i would add morbidity as well. has unicef and other u.n. agencies, n.g.o.'s in general that deal with health issues, includingist aud -- including usaid and the european union and its organizations in africa, have they addressed the hydrocephalus epidemic that's occurring which very preventable and treatmentable? if you stop the enphoenix in

the first place, the children don't get sick and you have a solution if they do get sick. are they interested in this? >> to my knowledge, no, sir. there's not been much focus on this at all. there are many overwhelming problems, obviously. i think hydrocephalus has been below the radar screen. i was recently -- i recently attended the world health organization rollout of their report on disability and many things were mentioned in that report but hydrocephalus and the infection of these children were not among the things that are talked about in that report. so i think it is something that just needs to be brought to the attention of the kind of bodies that are able to fund work in this area. >> which is precisely what you're doing. i think you're doing an enormous service to those children and their parents and

siblings. if i could, has the fwates foundation or the one campaign or any of the other very laudable and noble chairties, have they joined in, as far as you know? >> not yet. >> well put. with regards to evpcpc, what is the acceptance of that domestically here in the united states? could you compare the cost of shunt interventions versus that procedure that you've perfected and created? >> that's sort of a multianswer here. so first of all, i should make it clear that e.t.v. has been been being done for quite some time. it was found to be not very successful in babies under a year of age or even under 2 years of age and it was rarely done and still isn't done that

often. in an effort to find a way to make it more successful and be able to avoid shunt dependence in babies from the beginning, what we did was added an old idea, which had been practiced a number of years ago, before shunts, actually, as an idea of how to treat hydrocephalus, to reduce the tissue that makes the fluid. that had been largely abeen donned, it was not effective by itself. the idea of combining the two procedures was to address both the obstructive problems with the hydrocephalus, bypassing the fluid obstruction to getting out of the brean and also addressing what some people call a communicating hydrocephalus which is left over sometimes in babies after the e.t.v. they can't handle absorbing the fluid once it gets out. by reducing the tissue somewhat and reducing the rate of

production, we found in a fairly large study that there was a significantly increased success rate with the e.t.v. there is a growing acceptance of this in the u.s. it's hour -- it's our preferred primary treatment of infant hydrocephalus at children's hospital in boston. there are others that have begun to use the technique and i think the main shift in culture has been a shift away from simply placing a shunt in a baby to thinking, could this be avoided by a bit more sophisticated of a technique that takes some different skills, but it's very often well worth doing. for instance, a common cause of hydrocephalus in the u.s. is that which is associated with spina diff -- spina bifida. about 2/3 of those children have hydrocephalus that needs to be treated. those chern were all treated with shunts up until fairly

recently. what we have found is that the etv by itself was only successful in 35% of those babies but with the combined procedure it's successful more than 75% of the time. that's not only the ewe began dan data but now as the numbers grow, we're matching those same success rates in the u.s. there's a growing interest in that, especially in the spina bifida community. it's a matter of practice change and those things can happen fairly slowly. >> dr. schiff, you talked about how the data from dr. warf's cases and u.s. noaa satellite data showed a correlation between climate and hydrocephalus and that infants get sick at intermediate levels of rainfall. why is that? do we know? >> we don't know for sure yet but it's very substantial and

points to an environmental component to this which we'll need to understand and then take into account to know how to rationally reduce the numbers of infections. there are other serious infections in the world where this type of rainfall link has been shown. the one that's most famous is called melioadosis, a terrible skin infection in southeast asia and northern australia. the bacteria is so nasty it's on our select agent list now. in speaking to doctors who worked that out, they had to learn how the soil temperature and soil moisture allowed that bacteria to get to the surface at certain times of year and infolk people directly. those are the kinds of things, if we need to do that here, it's straightforward and will

give us the answers to design good preventive measures. >> has c.d.c. worked with you on that? it seem this is this is a strategy that will reduce the number of hydrose phallic children. >> not yet but this is relatively new findings and we will be in the process of raising the resources we need to get to the bottom of this. >> thank you very much. appreciate your testimony and just sort of on this whole question of water, water borne diseases, even though it's off the specific topic here, in injure opinions, how much -- in your opinions, how much preventable diseases are caused by impure water, water borne diseases?

things like, i don't know, diarrhea, you know, just diseases in general especially for newborns and infants and children. in your opinion, investment in clean water, do you think that probably would be one of the greatest preventive methods to preventing many childhood diseases and 9/11 particular what you're talking about although you're talking about rainfall which is a -- which is a little different than the question of clean water and things of that nature. >> congressman payne, there's nothing i think i've seen more shocking in my work than unprotected wells in rural villages in africa. and what people need to drink and to bathe their children in.

and there's no question that you're right. that the availability of potable drinking water that's safe is an enormous factor of public hell around the world. when i started this work, i thought that would be the likely answer to these chern but we see cases in villages with excellent government-drilled water holes, very good water supplies, and in villages with terrible water supplies. i'm not going to discount that there may not be an important role from water supplies, and if that's what we find, then the answers are going to be straightforward. but my suspicion is that it's going to be as everything else in this story more complicated than we had hoped. >> although it's not well documented, it's noted that the

developing world has a significantly higher prevalence of hydrocephalus than the developed world. is there one form of hydrocephalus that is more common in the developed world versus the developing world? and in your opinion, what accounts for such differences? >> if i can answer that, congressman payne, there's a huge difference. so what we showed in uganda was that 60% of our cases, and this is continued on as we've gone into the thousands of cases and we keep looking back, it persists, 60% of the cases we see of infant hydrocephalus are secondary to these infections. we rarely see hydrocephalus from that cause in north america, for instance. a common cause of hydrocephalus here is one that we never see in africa, and that is

hydrocephalus secondary to hemorrhage in the brain of prematurely born infants which obviously don't survive in africa because they don't have neonatal intensive care units to keep them alive. i'd like to say that post infectious hydrocephalus is a disease of poverty and post hemorrhagic hydrocephalus is a disease of prosperity. there are other causes in the u.s. which are common, congenital causes, congenital obstruction of one of the pathways that the fluid has to get out, the hydrocephalus associated with spina bifida and so forth. but what we don't see very much of ever are these post-infectious cases. so what i suspect is that with the high birth rates in africa, we probably see the same incidents of the other causes of hydrocephalus that we see in developed countries and then on

top of that, another 60% from the infections that we don't see at all here. >> actually, we would be sort of -- with the sort of health care costs in uganda and the developing world, of course we know it's much higher than in other places due to lack of the resources and the ability of the average income of people, no level of consumer income, what does the u.s. and international community need to do to make freement more accessible for patients and families in the developing world? what are the differences in terms of cost and technical barriers in using stents versus the etv or to combine etvcpc and can more be done to prevent the disease and what preventable -- and would

preventable measures be more costesquive? >> i think preventable measures are certainly more cost effective. if we could eliminate the neonatal infection that causes not quite 2/3 of the cases that would be almost certainly more cost effective. however, there will always be hydrocephalus and fairly large numbers of it in populations with high birth rates because it's not an uncommon disease of childhood from congenital causes. in regard to the endo scaupic treatment versus shunt, we've done fairly detailed, people that i work with that are economists, i should say, have done fairly detailed analyst of costs and what we have found is that the more patients, hydrocephalus patients you have in your population with shunts, the less costesquive the treatment, the more cost burden there is because those shunts require maintenance. the numbers that we used for

determining this was based on the type of shunt we were using in uganda which was a very inexpensive shunt that cost $35 made in india. i did a randomized trial in 2005 that showed that the outcomes at a year for using that shunt for no different than the outcomes for using one of the commonly used american shunts which costs $650 and the shunts that we typically use now in my practice cost around $1,000 which is impossible for children in africa. so even at the cheap shunt numbers, the more children you can spare shunt dependence and treat indo scaupically, the more cost effect i have it is. we also looked at the initial cost of treatment in our hospital, including everything, keeping the lights on, salaries, depreciations all salaries, depreciations all those kinds of