Transcripts For CSPAN2 House Subcommittee Hearing On Coronavirus Response 20240713

[inaudible conversations] him him him. The hearing will come to order. Good morning welcome to the labor health and Human Services and education appropriations subcommittee todays hearing is with the ongoing response to the coronavirus. Like all other efforts of the supplemental package we have been bipartisan when we commend him my colleagues on both sides of the aisle. Before i began i went to extend they were to our witnesses tom friedman president and ceo and former director of cdc in prevention 2009 through sc 2016 doctor rivers senior scholar that hell security an assistant professor in the department of Environmental Health and engineering at the Johns Hopkins Bloomberg Schools of health. Doctor friedman will do is perspective of fighting epidemics including leading the cdc response of where we are and what we need to do to protect americans doctor rivers makes a case where the months and years to come we will need additional capacity heea with Contact Tracing to combat the virus. So glad to have my colleagues here this morning and on the republican side congressman andy harris i do hope we have the congresswoman butler we are all disappointed others could not be here due to flight and the Health Issues raised the chairwoman and Ranking Member and congresswoman barbara lee and lois frankel and congressman and tom graves. They could not attend but they did send questions which we will ask on their behalf. I want to underscore member should not be blocked from participating all Committee Members should bers heard that means moving as quickly as possible into the 21st century to conduct virtual hearings every member should be able to participate then yest donald trump told reporters that he would not permit dr. Anthony found you to testify before the Democratic House committee dr. Fauci, saying the house is a bunch of haters, who frankly want the situation to be unsuccessful or cold but they are allowing dr. Fauci to testify before the u. S. Senates week. This is a bipartisan panel. Dr. Fauci has appeared before our subcommittee dozens of times. He has testified, whether it was a democratic or republican chair. He has testified hundreds of times, working with democratic and republican president s, but now, the white house said no, leaving no doubt they are just frightened. The labor hhs subcommittee provided billions of dollars in funding for the cdc and the nih, the National Strategic stockpile , and hospitals per we have appropriated 175 billion for hospitals and other Health Care Providers. Most recently, 25 billion for testing and improve diagnostic, including 11 billion for states and localities Testing Capacity. The purpose of todays hearing eyed get a clear clear view of the path forward in response to covid19. As we work to mitigate the spread of the coronavirus, in the mediumterm as we develop the therapeutics to treat the disease and a vaccine to inoculate millions of americans against the coronavirus. Makee long term, as we investments to enhance our nationss Public Health and Global Health systems, better prepare for the next pandemic over the horizon. These are the three pillars we will look to build. Todays hearing, i would like to for the recommendations of our two Public Health experts on the necessary measures that must be put in place in the benchmarks that must be met to move forward on keeping americans safe. Science and facts prescriber policy, and hearing from doctors, scientists, researchers and experts to command those facts and drive the science of public policy. It is urgent that we do so, as these models predict or predictors according to the New York Times and washington post, that in the coming months, 3000 americans could die every day. There is no time to delay. Our Witnesses Today will give us the analysis, the facts of the science, and the strategy that will help us to make the right decisions. With that, i would like to recognize a good friend, the Ranking Member on the committee for any opening rep. Cole thank you, madam chair. First, i will have some extemporaneous remarks. I want to thank you for the hearing. It is a very important meeting to have, and i want to thank my colleagues for being here. We understand why they could not, but i appreciate you on both sides of the aisle for coming, and i want the record to show that i have joined the chairman in urging dr. Fauci be allowed to testify here. I think it would be a good testimony, useful to this committee and useful to the country, quite frankly. I think Going Forward, the subcommittee probably more than any other will need expert input as we make the important decisions in front of us, and while i am not naive enough to believe there is not a certain amount of partisanship on capitol hill, and some committees are more partisan than others, frankly, the Appropriations Committee and the subcommittee are not hyperpartisan committees in my view, and the record shows it. In the last five years, working on the subcommittee and with our friends in the United States senate, particularly senator blunt and senator murray, we have increased funding by 39 , increased cdc funded by 24 . We have increased the strategic stockpile funding by 34 . We establish the Infectious Disease Rapid Response fund. I think that is a bipartisan record of accomplishment to be proud of, and i think, in retrospect, we all wish we had done more. The reality is we are so much better off where we are at because of the actions taken in a bipartisan sense by this committee, so its record shows that it knows how we have increased thing by 30 percent or 20 percent and the strategic stockpile and Infectious Disease Rapid Response fund. That is the bipartisan record and in retrospect we wish we had done himge and that i could do the same thing with her. I hope thats the way we can continue to work Going Forward. We will be called upon to make some important decisions and having read the testimony the over t, spread of covid19 has caused unthinkable disruptions to life as usual and will continue to do so for some time, even as we flatten the curve. Following the hon strain on our Health Care Systems and the Health Care System as a direct result of this coronavirus, desire for normalcy to return is certainly a sentiment shared by us all, but as state and local economies cautiously begin to reopen, it is important to remember that getting back to business does not mean getting back to normal. Even though the fight against covid19 is far from over, keeping businesses closed and workers at home is not a sustainable option for the longterm. While the federal government has provided some shortterm relief to help individuals, households, businesses, and communities stay afloat during this period of social distancing, our economies need to get moving again, and americans need to get back to work. However, any such efforts to reopen must continue to keep the health and safety of americans at top of mind and not undo previous progress in slowing the spread of the coronavirus. This will, indeed, be a balancing act. Until they are working treatments, effective therapeutics, and ultimately a vaccine to control covid19, the risk and danger for disease remains. Returning to more regular functions and operations needs to be based on data. President trump the Coronavirus Task force recently recommended criteria for states and communities to achieve before moving into phases of reopening. This includes a consistent downward trend in reported symptoms, a consistent downward trend in document a cases, for positive tests as well as hospitals being able to treat all patients without crisis care , and robust testing in place for all Health Care Workers at risk. While this is a helpful reopening blueprint, states are not strictly bound to it, and indeed, just as there are 50 separate and unique states, there may be 50 approaches to reopening that carry the same spirit of caution in decisionmaking based on sound data. However, the idea behind these three phases is to gradually allow this mrs. And workplaces to open back up, not immediately, full speed ahead allow businesses and workplaces to open back up. Phases, this may include limiting the number of employees. Workplaces continuing telework practices, and vulnerable and Older Americans remain at home, and limiting the number of customers inside stores and restaurants. Clearly, life is going to be Going Forward that it was in our immediate past. Regardless of our reopening in our communities, we must remember not to abandon hygienic precautions, like thoroughly and frequent washing hands, not touching our faces, daily disinfecting of surfaces, keeping a safe distance from others, and staying at home when sick. It is quickly important that the federal government learns from this crisis, in order to face down another pandemic in the future. I am proud that congress is generally invested in were the tools and response resources to strengthen our readiness in recent years. It must be an even higher priority in days to come. You cannot be fully prepared for what you do not know what is coming. In this case, a mysterious virus originating in china only identified earlier this year for which a vaccine does not exist. I look forward to this, and i yield back the remainder of my time. To theelauro thank you Ranking Member, and i assure you that we will continue with the subcommittee. To Work Together in a collaborative spirit to do what is right in this area and in other areas that we have jurisdiction over on behalf of the American People. Let me also welcome our collie, Jaime Herrera beutler. You have come a long way from a state that has been hard hit. I appreciate that. And now, i would like to introduce our witnesses. Our first witness is dr. Tom , the president and ceo of resolve to save lives, part of the global Public Health association. Dr. Frieden was director of the centers for Disease Control and prevention, the cdc, from 2009 to 2016. Dr. Frieden is recognized as one of the worlds leading experts, currently assisting countries during this covid19 epidemic, as well as providing Technical Assistance to new york state and other jurisdictions here at home. During his time at cdc, many will recall that he led the response to the ebola outbreak, along with his colleagues at the state department. He also spearheaded many new Health Initiatives here in the u. S. , including initiatives to address the Opioid Epidemic and to reduce chronic disease. So pleased, we are to have you here today. Your full written statement will be entered into the record. You are now recognized for your opening remarks. Thank you very much, and good morning. Members ofber cole, the subcommittee, i appreciate the opportunity to testify. I will preside testimony based on three decades based on fighting disease globally. The bottom line is that covid is a terrible tragedy. Families have experienced devastating loss. Parents have lost their jobs, and all of our lives have been disrupted. Our war against covid will be long and difficult, and we must act strategically now to establish a new way of preventing future health disasters. At inappropriate time, we can assess what went well and what did not. I am acutely aware that hindsight is 20 20. Tois far too easy secondguess decisions others have made. We are just at the beginning of this pandemic and must focus on the future. There is only one enemy here, the dangerous microbe. It is us against them, humans against the virus. We will get through this best if we Work Together, learn from each other, and support each other. Here are 10 plain truths about covid19. First, it is really bad. Live, york city, where i i have heard for the past two months the sounds of ambulances day and night. In new york city, it is on the order of the 19181919 pandemic. More than 20,000 people when you look at all of the excess deaths killed in less than two months. That is as bad as the worst phase of the pandemic 100 years ago. Even now, with deaths decreasing substantially, there are twice as many deaths of covid in new york city as there are on a usual day from all other causes combined. And sadly, looking at the u. S. As a whole, just calculating forward from the number of people whose infections have already been documented, there will be tragically at least 100,000 deaths from covid by the end of this month. Been, as bad as this has it is just the beginning. Until we have an effective vaccine and unless something very unexpected happens, our viral enemy will be with us for many months and possibly many years. Very powerful a weapon against this virus. ,ealtime monitoring of trends finding cases before they become clusters, clusters before they become outbreaks, outbreaks before they become explosive epidemics that risk the lives of Health Care Workers and others. Fourth, we will be able to reopen as soon and safely as possible by basing decisions based on data and creating together a new normal. We are also impatient to restart our activities. Sheltering in place is a blunt but effective weapon. It suppresses the spread of the virus but inflict severe Economic Hardship on individuals and the economy. We need to deploy all of the effective weapons in our arsenal. After flattening the curve, the next step is what we call the box strategy. There are four corners to the box. Testing widely and strategically, i slitting people who test positive, isolating people who test positive, warning people who are exposed to the virus, and quarantining contacts, providing essential services so that they can be sure the infection stops with them. If any corner of that box is weak, the virus can escape and spread explosively again. Each is important. Fifth, find the balance between restarting our economy and letting the virus run rampant. We are conditioned to think in terms of dichotomies. A versus b. Versusthis case, open closed is not a dichotomy. It is more accurate to think of a dimmer switch or a dimmer dial than an on off switch to avoid undue risk. Even when we are closed, many essential activities continue, and when we reopen, our new normal will be different. With care and creativity, we can offer open sooner. It would change the way we travel, work, and go about our lives. The virus can create a new generation in minutes, in human populations, it takes weeks to see the result of repeated spread. As we reopen, if there is a lot of spread, it will take weeks before we actually see it. Another false dichotomy is between Public Health and Economic Security. In fact, the very best way to get our economy back is to control the virus, and economic stability is critically important to the Public Health. Sixth, we must protect the Health Care Workers and other essential staff who are the frontline heroes of this war. They should never have to put their lives at risk to care for us. Having safer Health Care Facilities is essential to more societal activity to resume. It is one thing to take risks for yourself, but if the risk you take for yourself and set up infecting a nurse or a doctor and then their mother or father or child, that is something quite different. Enth, we have to predict protect our most vulnerable people. Unless we take urgent action, there will be at least 100,000 deaths in Nursing Homes throughout this country. All congregate facilities and high risk settings require intensive protection. We must also act now to reduce the higher rates of both infection and death among africanamerican, native american, and hispanic people. Eighth, governments and private Companies Must join forces to make massive, continued investments in testing and distributing a vaccine as soon as possible, assuring rapid and put up access in this country and around the world. Nothing else will enable life to get back to a pree covid precovid normalcy. Must not neglect our focus on noncovid Health Issues. This is a very important lessons for around the world. Not only do underlying conditions increase the risk of severe illness from covid, but if we do not continue noncovid conditions, there will be many deaths that could have been avoided, not from people infected with covid but people affected by the disruption of services that covid causes. And when fall comes around, we will have to do the best we have ever done in getting people vaccinated against influenza, because that will make it easier in the next phase. 10th, never again. It is inevitable that there will be future outbreaks. It is not inevitable that we will be so unprepared. This is an interconnected world. A disease risk anywhere is a risk everywhere. It was very difficult, as you all know, to secure funding for Global Health security. It took years of effort, and funding was only allocated after the ebola hit, and that was only one time funding. Therefore, congress and the administration deserve congratulations for quickly passing comprehensive, Bipartisan Legislation with supplemental funding for the covid response. But supplemental funding is a temporary fix. It is a bandaid. Without sustained support, our health will be avoidable he at risk. One time funds are very problematic from the point of view of someone running an agency. You cannot hire the best staff. You cannot enter into partnerships with countries and organizations where you can keep up your end of the bargain, and you cannot hold contractors accountable for an ongoing contract. In congress, you have any unique opportunity to take strategic action to protect americans from another microbial sneak attack, and to protect us from Health Threats, we have to change the way we allocate funds. Have all been through this. His questionnaire he funding is subject to caps and sequestration. Even mandatory funding does not assure stable support, as we have seen. We propose a new approach for specific health programs. These are programs particularly to prevent, detect, and respond to threats, and we suggest calling this the health offense as the budgethdo designation. It would exempt only these Critical Health protection funds from budget control act caps, so our Public Health agencies can protect us. Hdo programs should be required to cement a bypass congressional judgment annually, just as nih does with hiv, alzheimers, and cancer. That way, congress and the American People can understand what is really needed for our Public Health defense, and congress can appropriate the resources needed to sustain the Public Health system we need to keep us safe. This investment can save millions of lives and potentially as we have seen, trillions of dollars. Good Public Health is good business. In my 30 years in global Public Health, i have never seen anything like this. It is scary. It is unprecedented. We are learning more each day. I have outlined some of the things we can do at home, business, and government right now to slow the spread of covid and rebuild our economy. We must make sure this never happens again by investing in systems defined to stop emerging Health Threats before they spread whenever and wherever that is possible. Thank you, and i look forward to answering your questions. Chair delauro thank you very much, dr. Frieden, and appreciative. I feel so personally about this issue. Died in theer spanish influenza of 1918 at age 36, leaving a widow and five children with one on the way. So it is it really brings it all home that we are now experiencing this and our families are experiencing all of this. Now, i would like to introduce our second witness, dr. Caitllin john hopkins, assistant professor at the department of Environmental Health and engineering at the Johns Hopkins limburg school of Public Health. Dr. Rivers has been a leading Public Health voice during the response to covid19. She coauthored a report along with dr. Scott gottlieb and their colleagues at the american aerprise institute, aei, aboutp to reopening, what states should need as they items. R easing dr. Rivers is also the lead author of a report Public Health principles for a phased reopening during covid19 guidance for governors, which is being used by the National Governors association as well as maryland and washington, d. C. , to guide their reopening plans. I would also note that dr. Rivers worked as an epidemiologist or the United States army Public Health center as a department of defense scholar. Dr. Rivers, we are so pleased to have you with us today. Again, your full written statement will be entered into the record. You now are recognized for your opening remarks. Dr. Rivers thank you. Rep. Cole, ando, distinguished members of the committee. I am epidemiologist at john hopkins for Health Security at the Johns Hopkins Bloomberg School of Public Health. I have coauthored a number of reports and guidance documents on reopening safely, and it is referenced from that work that i would like to share with you today. First about the situation. The United States still faces 25,000 to 30,000 new cases every day and approximately 2000 deaths, and many states are either moving towards reopening or looking ahead to those decisions and wondering, as we all are, how to do that safely. It is clear to me that we are at a critical moment in this fight. We risk complacency and preventable deaths of americans and risk complacency in accepting our Health Care Workers do not have what they need to do their job safely, and we risk complacency that without continued vigilance we will again contribute to the conditions that lead us to be the worst affected country in the world. With that, i want to highlight some capacities that i think we should be prioritizing. The first could go capacity is diagnostic testing. Last week, the first critical capacity is diagnostic testing. Gains are testament to the impressive biomedical enterprise that we have built through sustained investment in science and medicine. Estimates of the number of tests that we will need to gain control of this outbreak start at 3. 5 million per week and go up from there. We urgently need a National Plan for how we will close that gap. We need to understand National Capacities we can expect at the end of may, at the end of june, at the end of august. Where are the bottlenecks . Where are the untapped resources . It is also for consumable supplies needed for testing, ppe, viral transport media. There are a lot of components involved a diagnostic testing, and at various points, all of them have been implicated in interim shortages, and we urgently need to understand where we are going with diagnostic testing and how were are going to get there. If this work has been done, i have not seen it, and i have heard that neither have the governors and the mayors and the Business Leaders and University Leaders and school principal, all of whom are having to make decisions about how and when to reopen, so it is not just the federal government that needs this information. It is really all of us who needed to help navigate. The second capacity is Contact Tracing. You heard from dr. Frieden that Contact Tracing is really a key opponent an approach that will allow us to reopen safely. One thing that i do not hear a lot about about Contact Tracing that i want to bring to your attention is that it is also a key source of data that we badly need. We currently have very little understanding about where people are getting infected. Our most new cases in longterm facilities or correctional this lease, which we know are high risk settings, correctional facilities . We do not know whether people who are essential workers performing duties in the community are getting infected or whether most infections are happening at home. To get a better understanding of what that looks like will help us better guide intervention. If it is special settings, we know we need to be doing more to protect people there, and we may also assess the risks of the General Community to be lower. On the other hand, if most people are getting infected at home, at least to some central isolation capacity, by that i mean if people feel safer recovering in a hotel away from their families, for example, that should be an option made available to them. We would want to know which cases are originating in the household to understand whether that is an important investment. This information on where transmission is occurring is critical but not currently being prioritized, and it is Contact Tracing that allows us to collect this data, so in addition to it being a key tool for containment, it helps us with response. The third pillar is Health Care Capacity. We were able to secure enough Health Care Capacity to treat everyone with covid only through extra name measures, like canceling elective procedures and turning operating rooms into icus. Right when we are doing this, states are moving to reopen, so we have to be careful that we do not allow our Health Care Systems to become overwhelmed by drawing down our Surge Capacity as we increase items in the community. We have to be careful that we do not again create the conditions of new york or wuhan. We should plan now on how we would staff and fund medical teams to move from hotspot to hotspot, and i will point out that we are making these decisions as we face hurricane season, which will draw on many of the same resources, so i think we need to plan for the worst Case Scenario and understand he may be needing these Surge Capacity resources in the coming months, and we should also continue to fight for sufficient supplies for personal Protection Equipment to keep our workers safe. This has been a continuous problem and one we need to solve privately. It is not acceptable that our Health Care Workers do not have what they need to do their job safely. Contact tracing and health care will allow us to transition safely, and staying at home to slow the spread for a gradual reopen. We should be working to make sure we have the tools to do that successfully. And i want to touch briefly on a longerterm priority that i believe we should keep. We have seen in the white house briefings we have seen when many people dont realize is the expertise is that outstanding capacity and is a volunteer force ofst academics this is in stark contrast to weather forecasting the nation had invested in n for decades. We dont have anything like that h for outbreaks we should consider establishing ath national parity forecasting analytics and just briefly one other longterm parity is that we plan of risk resources for countermeasures what were previously identified. We dont have dedicated programs for the new pathogens we didnt know existed. So i think we should be thinking how we can and resources to develop the tools that we need to expand our capacity those pathogens we dont know anything about that could be facing at any point. Based on the house Appropriations Committee we must prioritize the capacity and diagnostic testing Contact Tracing in the Health System to combat the virus in the weeks and months and years to come. Thank you. O thank you doctor rivers i would love to talkat to about your idea of the center like the National Weather service go as in the past we will proceed fiveminute rounds we will be respectful of our witnesses and give them enough time to respond to questions. But provided recommendations about the state and local capacities to be in place before scaling back on social activity according to reports disease models are projecting the country is moving in the opposite direction. It could surge this month and some are projecting deaths could rise 3000 each day. Now asking a series of questions, to the best of your knowledge has a single statement the necessary parameters for a restriction . N we mentioned at the aei report there are four criteria the first is to see the number of cases decline for at least two weeks some have met the criteria but there are three others to be met the other is publiccrcr Health Capacity to do contactct tracing and diagnostic tracing tasting on testing everybody and then the capacity to treat everyonee safely. No space we all those. I have not looked at all of the data but i would make two comments there could be areas within states closer than others and as i said in opening testimony opened first on versus closed is not on off essential retail hospital emergency facilities and things that could be first to open outofdoors is way less risky than inside. Take out, outdoor recreation, even daycare if done carefully could be lower risk we have to think of this as a dimmer rather than the on off switch. And followup. T fo things open again will increase the risk to individuals contracting covid19, and there is no way to completely guard against that. Let me ask this of both of you. Should the any state testing 1 percent of the population every week. No any state or region reducing the basic number below one that the epidemic is no longer growing . The lead author of making recommendations to the governors there is no way to completely guard against that. Let me ask, should the country be reopening now . Are we ready . Is it irresponsible to the economy without adequate testings. I think there is an enormous need to balance political with the economic pressures and thats what we see so even as we move towards reopening we still need to focus on increasing capacity with Contact Tracing the window we have to implement that is open so its not either or. We need to ramp up the abilitytr Public Health professionals not just test that isolate and quarantine having all of those in place we come out safer and sooner and start the economy without risk of explosives read. Doctor fauci the last several days said how many deaths and how much suffering are we willing to accept to get back to a sense of normalcy . What is your sense of what is acceptable to get back to normalcycopr without help nationals advising us . We have seen several other countries have regained control of their outbreaks and we can do that will be difficult and take a lot of investment for that option remains open. We have to ensure we protect our Health Care Workers and other essential workers they are not making the choice they are doing their duty to provide essential services and we have to do Everything Possible to keep them safe and a particular attention to the most liberal such as Nursing Homes, homeless shelterses,eso , correctional facilities, large factories to see explosive spread not only causing suffering also seed infections elsewhere in the community. Is that the criteria that we are willing to accept quick. It isrid a balance we need o reopen to start important medical care for the economy in a way that is careful and doesnt risk an explosion of cases sending us back into our homes. I yield to my colleague thank you for your testimony in the papers submitted. I am very intrigued by the ideaea you presented about a special Health Defense budget the equivalent of the ceo spending and what it takes to win the war. And i think we have had this discussion that this particular accounts that need to be exempt. Could you go in more detail to talk about what specific accounts we need to set outside much, and i appreciate all of your commitment to this issue over the years. We have discussed it for many years. And what we have seen is if it is in discretionary, no matter how wellintentioned everybody is, there are going to be problems. If it is mandatory, no matter how fixed it is, it is not. What we have suggested is something similar to the overseas contingency account that the normal budget process with Public Health and those threats with me to spend what we need in these areas. We have seen that for many years if it is discretionary there will be problems. We have seen the overseas contingency accountld, by the fe majority leaders as well as myself and multiple other allowing for a rational judgment to enter into the record a letter sent to the senate and house leaders signed by those leaders and other cdc leaders. If we can do that for theol record. And that includes budget line examples which is included in the area of protecting americans. Chooset want to between the military radar defense in the same way we shouldnt choose between this kind of defense and another budget. Is that americans are far more likely to be killed by a pandemic than a terrorist attack. In the same way we have to recognize other than nuclear war nothing else can kill 10 million other than a biological event we have to ventfr judgment, give the actual professional judgment from what is needed so that in congress and in public, you can assess that, and then put in all of the accountability metrics for what we expect to see for moneys being spent. This is building up our National Defense. Rep. Cole madam chair, that is something we should work on together and maybe cement together with our colleagues, because it will take obviously an agreement with the executive branch. I think it is a very good idea. That from happening so you identify the budget lines to this mechanism and second you require a bypass session all judgment to do that for what is needed so congress can assess that. This is not a piggy bank for the specific investment to build that National Defense for the consideration of our colleagues i think its a very good idea. I enjoyed reading your paper in testimony you made. 2. That were striking Contact Tracing. Intensiveormously manpower type operation, with your concern we just appropriated 95 million for additional testing. Im not sure what we are doing the same point with Contact Tracing this is intensive ynpower especially the sizehi go up was to mark that is not clear to me. As an epidemiologist, i could say, sure, if we could test everyone every week, every two weeks, we would have these options, but it is not clear to me which of those plans is feasible, so it is important to go stepbystep to figure that out, and i think we need a National Plan and that it should not be left to be done independently. In terms of Contact Tracing, in addition to using that as an approach for containment, i think we should be prioritizing Data Collection. Cdc recently put out new guidance for so what do you recommend we do this would be an adequate Testing Program . We have are different plans for Testing Capacity we should have im suggesting to start at the other side where are the components that is not clear to me. Sure if we could test everybody once a week but it is not clear which of those plans is feasible so we have to go stepbystep to figure that out. We need a National Plan in terms of Contact Tracing to use that as an approach we should amortize Data Collection cdc put out new guidance of testing, and as you described, dr. Rivers, we are under testing right now if our goal, and i would be interested if you both could read the goal, is 1 of the United States population once a week, so that would be roughly 3. 8 million tests, and we are now at 1. 6 million. Isdo you agree that that 1 the right benchmark we should be aiming for . Dr. Rivers i think that is in the right ballpark, but i would make the point we do not want to test 1 of america evenly distributed breed we want to test symptomatic people and essential workers. Dr. Frieden i would add to that we have issued a briefing of who we think should be tested by priority level, because you can test 1 , exactly as dr. Rivers said. If you test the wrong 1 you have to look at those symptoms most likely to spread, those most likely to die in congregate facilities, Health Care Workers with symptoms, hospitalized patients, even without symptoms, because they can spread it widely, all people in a nursing home if there is a case there, because there can be explosive spread, essential workers if they are symptomatic. Our estimate is you would need at least two or three times current volume even if you only test of the highest priority people to do it, but that does not mean there is not a lot we cannot do at the same time to ramp up our other things, because it will not be one thing that gets us out of this except a vaccine. Rep. Clark that is right, and we have to do all of these things, but with the tests, to get to where we need to be, to be testing those essential workers, part of my understanding is that the tests we are using now are inefficient and expensive, and it requires a lot more of the swabs and other equipment that we, frankly, are just having shortages of. So where are we with point of contact testing, more instant testing, and even if their accuracy is not as good as the current tests we are using, is it worth it if it is more widely distributed and lets us test more of these essential workers and people at greatest risk . Dr. Frieden there are two broad ways of testing. For the virus itself, youre looking for the genetic particles, like the pcr that is done, testing for antibodies. I will leave antibodies aside, because there are many unknowns. There are some systems that are relatively rapid now, but they are low throughput, so youre only going to be testing a few people each hour or people over , so thatur period needs to be looked at. There are newer technologies and older technologies that may be helpful, but youre always going to have to take a good sample, and youre always going to have to be looking for a tiny amount of genetic material, so your idea of a test of what we would call a low sensitivity, still a high specificity in other words, some false negatives, it could rule someone in, it would be helpful. Rep. Clark what are some of the limiting factors for reaching just the sheer number of tests that we are going to need . And how can we address them as we look at putting together a develophat can really the data we need . Dr. Rivers i tried in earnest to find this out, and i was not able to determine what the apps are, and i think that, in itself, is a big problem. I think continuing to bring new platforms onto the market would be helpful, but what about the ppe that the Health Workers need to take the sample . That is something i think we can fix. Have just a few minutes left. I will just say at this point, i cannot underscore and agree with you more on the need for a National Plan and that states are too interconnected, and we need to be learning from each other and how this virus is being spread and how we can best do these things, test, isolate, trace, and quarantine, and safely bring our economy open. That is the goal of everybody here, but we need to support that in a national way. Thank you, madam chair. International way the thank you madam chair but effective. We do not really have Scientific Data on that for coronavirus, do we . Because if you plot what the states have done versus the severity or the measure that the states have gone versus their case counts, you actually find that the states with less restrictions in place sometimes have lowercase counts. An example of florida. We really have no specific, objective data about that, do we . Has that been looked at . For the coronavirus, covid19 . We frieden covid19, if look at information from around the world, it is very clear that when people stay home, it reduces the spread, that it is also clear, dr. , that there are countries, including singapore and south korea, that have been able to limit the amount of physical restrictions or physical distancing and still control the virus, and there are differences in different environments. Representative harris so florida, for instance, did not put in stayathome, but their caseload is lower than maryland. Dr. Frieden there are many factors that go into it. Rep. Harris shelterinplace might work, but it may just be the social distancing, the shelterinplace obviously implies. Rivers, i looked at the recommendations from aei. They are one month old. Is that right . Dr. Harris dr. Rivers yes. Rep. Harris the first criteria as we ramp up is that your case count has to go down. Well, as you ramp up testing, youre going to find cases that you would not have found. So, for instance, i am sure you are aware there is a michigan prison where they tested their so shelter in place might work but it could be social distancing that it implies. Doctor rivers there are more alums . We have learned a lot in the last month about this disease . If we testing the first criteria is the case count has to go down you have testing you find cases you have not found in michigan as and 50 percent tested positive but asymptomatic. The Health Care System, right, because we want a Health Care System to take care of people so they do not die, then why would not hospitalizations or icu occupancy, even more importantly, be the benchmark . Because in maryland, we have ,lateaued in icu utilizations but our case counts continue to go up as we go into a hotspot. For instance, the processing facilities, when you go in there, there are a lot of Healthy People. They may have coronavirus, but they are otherwise healthy. They are asymptomatic. Youre going the case count continue to go up with the processing facilities if you in their there are a lot of Healthy People there asymptomatic you will find a lot of cases that doesnt mean the Healthcare System is a restrained. Why would you choose cases and not hospitalization or icu utilization as your benchmark . I would add the this is a stay at home orders is to prevent overwhelming the Healthcare System but also give time to build up our space your estimate of the numbef cases that are asymptomatic . People are asymptomatic, never had symptoms, so they never would be detected with Contact Tracing. Dr. Rivers those people would still be affected by quarantine. Rep. Harris you do know in stockholm, the estimate is for every case that is identified, there are 73 cases that have not been identified. Is that right . Are you aware of that statistic . Have not shared that. Rep. Harris you can google it. Contactncentrate on tracing, and that is our Gold Standard is that we have to have Contact Tracing, for every patient we contact trace, we could have 10, 20 people who are out there not contact trace, and the description of Contact Tracings we are going to educate the people infected in the people they could have come in contact with about what the good Public Health measures are. Wouldnt it be more effective if we just educated everybody, because we really do not know who is an asymptomatic carrier . That is educate everyone. Wear a mask when you got in public to make sure you do not spread the disease. Make sure you wash your hands i do not touch her face or nose. These are things we have known for years. We know how to prevent the spread of respiratory illness. What we are not doing is educating. To say to do this through Contact Tracing and not very broad education, that means we are going to set a standard to train 100,000 people nationwide in Contact Tracing it could take weeks. I have Small Business owners in my state who in my district tell me they cannot last weeks. They are going to go out of business. So you tell me, dr. Rivers, why a Business Owner in my district who sees five customers in a store for an entire day cannot safely operating with social distancing and masks and hygiene . Dr. Rivers i do not think the economy will be able to recover if people are worried about being infected. Rep. Harris so you think it is dangerous for that store owner to open up their store using cdc guidelines . And we will not even get into, because i was going to ask, and maybe in the second round i will, why the who guidelines are so much different from the cdc guidelines. You think it is dangerous for that store to open . Dr. Rivers i think customers will not want to visit. Rep. Harris that is their choice. Thank you. I yield back. Chair, andu, madam dr. Rivers and dr. Frieden, thank you for taking the time to be with us today. I want to ask you about covid19 in rural communities. The district that i represent in the northwest corner of the state of illinois, 85 of the towns are thousand people or fewer. Over 60 art 1000 people or fewer, so that gives you an idea of the district i represent. There are people who think that covid19 is less serious in notl areas, outside of highly populated, not highdensity population. And so a couple of examples i want to share with you that we are seeing in this Congressional District, we have 102 counties in the state of illinois. Two of those counties, one is called Warren County in the district i served with a population of about 17,000 people, so not a large population. It now has the fifth highest number of cases per capita in the state of illinois. Another county, stephenson county, on the wisconsin state line has a population of about 44,000 people. The number of covid19 cases there are doubling every five days, right . So that is the third fastest rate in the state of illinois, so i just want to give you a little perspective. So i know like if you look nationally, we have many, many governors now who are pushing for our country to reopen, and certainly in their own states looking at reopening, and there are also these ideas that we can where any state in tiers, it is less populated versus where it is more populated, so i am wondering if you can address that along the lines of what resources and practices do we need to know in more of these rural areas . Level ofd a certain testing . Maybe if you can just drill down how it is different in Rural America versus towns like cities like chicago or new york, and this is addressed to both of you. I would like to hear from both of you. Dr. Frieden well, first, i would say, in general, the challenge in urban areas may be more severe. What to do about crowded subway systems, bus systems, very close quarters in the u. S. And globally. That is something we have not yet figured out and is an enormous challenge, but no area is immune. We do not have immunity to this virus. In each community, there may be Nursing Homes. There may be factories. There may be other facilities where there is a potential for a lot of spread, and there may be less access to the kind of intensive care that is needed in some rural areas of the country. I think something dr. Rivers said is really important to highlight, and that is the importance of data. The are learning more about this virus every day. The famous Nobel Laureate used to say that microbes outnumber us. It is their numbers against our brains. And we have to use intelligence to figure out what the weaknesses of the virus are, to understand, for example, where it is spreading, what are the highest risks, and i talked about two dichotomies in my testimony, open versus closed. It really is a question of degree. The second was Public Health versus the economy. Together, we can resolve them. Another false dichotomy is safe and risky. It is really safer and riskier. We can make as much of our environment by design by changing the way we go about our business as safe as possible, reduce risk, and we will do that by understanding through things like Contact Tracing where the disease is spreading and how to reduce the spread most effectively. Dr. Rivers i would say that rural areas have seen less explosive growth, which is encouraging, but they also tend to have less capacities, so i worry that there might be a congregant setting like a nursing home that becomes infected, and then suddenly, the local hospital might have 25 patients that need to be admitted, and the hospital might not be able to accommodate that, so i think that is the kind of Surge Capacity we have to be preparing for, for rural communities. Quick speaking of correctional facilities, we have two in the Congressional District i serve, and i do not know if you have been following this case or this topic very closely, but the Marshals Service has turned over inmates to the bureau of prisons to go to 11 different prisons throughout the country, a transfer of patients that are not tested for covid19. One of those prisons is in thompson, illinois. This is in a county, zero hospitals there. You would have to travel across the Mississippi River to iowa to go to the hospital or to a county to the north or to the south. Wondering about screening, the proper screening, that should happen before the transfer of any patients or, i am sorry, any inmates to another prison. If you can talk about what would best practices look like for transferring prisoners from one facility to another . Dr. Frieden the best practice would be to minimize transfers, first and foremost, because anytime you are mixing more people, you are creating the possibility of explosive spread. You would certainly want to ensure that nobody who is symptomatic is transferred. The challenge is that we recognize there are a lot of a sum to medic people, some of them presymptomatic a lot of asymptomatic people. They do appear to be able to spread the infection. Even symptom screening is a problem, and in every copper good facility, we need a comprehensive approach to reduce the risk in every congregant facility, we need a copper has been approached to reduce the risk and to stop it from spreading widely. Place one misstep that people sometimes make us to think that just because you have a negative diagnostic test, it means you are not infected. The situation you want to avoid is when you test somebody early in the incubation period, so there is not enough for the test to pick up, so it builds over a coming days. Coupling the timing of the testing with the quarantine period would be important. Thank you. i yield back. Representative thank you, madam chair. So one thing, and this is probably for both of you all, one thing we have learned in this pandemic is the importance of Domestic Production. Of essential medicine and medical supplies. I could add to it many other things, but that is obviously what is being highlighted, especially an overreliance on china. However, knowing how many tests we need, what we just talked about, and how money vaccines, 300 million plus, etc. , i worry there is no way to produce that in the United States at present, possibly even with our jason allies. This presents a serious threat to our security and our Public Health even with our adjacent allies. How would you rate our current Domestic Production capability, and what steps do we need to be taking today, right now, to do that . Dr. Frieden i think that this pandemic has emphasized the interconnectedness of the world, including both the ability of virus and other infectious agents to spread and the fragility of some of the supply chains for a variety of products including the active pharmaceutical components of many of our medications. When it comes to personal protective equipment, there are means to increase production of n95ly reusable ppe, such as respirators. This was an Important Technology that is, not new it has been around for a while, but it allows a Health Care Worker to have a n95 be safely disinfected between uses. For months at a time. So, there are some technological improvements that can improve the supply chain. In terms of vaccines and therapeutics, we dont yet have any, so we dont know how difficult it will be to manufacture when we do. I believe there will be to ensuring there is essentially open source, that once we know how to make it, anyone can make it. Even companies that had strongly opposed this for many years agree. I think there is a recognition, but the manufacturing capacity i apologize. I have a couple more questions. I appreciate that very much. Flew verytioned, i far to get here and want to try to get through as many of these as i can, because this is so important and i appreciate your time. What we have seen thus far, it appears Underlying Health othersons, diabetes, impact likelihood a covid19 patient will require hospitalization. Additionally, concerns about laying medical care and pursuing alternative care sites such as homes. I think about people waiting for transplants, perhaps a kidney transplant, being told they have a donor, a living donor, but that is elective. I dont know if you have ever been on lifesupport waiting for a kidney, essentially what dialysis is, it doesnt feel very elective. Can you speak to the impact of the virus on those communities and what you anticipate Going Forward . Perhaps they are not in this arediate fear, but they certainly impacted. Can either of you speak to that . Dr. Rivers to acknowledge the importance of the question, there are so many secondary impacts of the pandemic and those with Underlying Health conditions are not only more likely to get severe disease when infected with covid, but are struggling with managing their conditions. I think this needs to be a priority both for this response and Going Forward. Thank you. Lucille here now, roybalallard and i chair the maternity caucus. While they are taking upper cautions, patients are still giving birth. It doesnt stop just because we say it should. We are seeing mothers often forced to go into labor without partners or midwives. I have known of one lady who could potentially lose her baby, because of a preexisting condition. She had her miracle and the baby lived, but this is what mothers are facing now. You recommendations would give to providers and the Maternal Health community to protect new and expectant mothers . Dr. Rivers an area somewhat outside my expertise. Our Strategic National stockpile was not able to support all the needs for this pandemic and that is a lesson we can look at Going Forward that would benefit the maternity can unity and Health Care Workers more broadly. Thank you. I yield back. If i might just tell my colleagues what we do in terms of manufacturing efforts, two billion is certainly not enough to support advanced research and development of vaccines, therapeutics, diagnostics, prioritizing platformbased technology with u. S. Based manufacturing capabilities. In the cares act there was at least 3. 5 billion for barda, for the same efforts. Conversations are trying to move in the direction of having more independence in that area. Thank you, chairwoman. I want to thank both of you for coming here today, and your testimony, and the work you have been doing in this area. Were going to be safest when there is a vaccine. I know were going to have dustups when there is a vaccine as to whether or not everyone will take it. My understanding of the development of a vaccine and its testing, it takes a while and that it could be years. Is there any substitution in the efficacy of a vaccine, developing a vaccine, that will countermeasure years . Frieden, dr. Rivers . Dr. Frieden there is nothing more important in the fight against virus than developing a vaccine. The quickest Vaccine Development so far historically has been about four years. Dr. Anthony fauci suggested 1218 months would be possible, and all of us would like to see a vaccine as soon as possible. There are many, many vaccine candidates being considered, and different models of assessing vaccine efficacy being developed. Already, some of them are in phase one trials. Fundamentally, we need on the one hand to do Everything Possible to get a vaccine as soon as possible. On the other hand, we need to recognize Vaccine Development is uncertain, and it may be a long time, and it may not be as effective as we would like, so we need to do Everything Possible to make a vaccine, but we cannot assume we will have one, and need to act accordingly with all the other measures we can. Do you want to say something, dr. Rivers . Add,ivers i would identifying a safe and effective vaccine is just the first step, and we need to think about manufacturing, production, distribution, which can take a long time, but if we think and plan we can speed up the timeline on that. Under what circumstances are asymptomatic people being tested now in this country . Dr. Frieden there is different situations. Most important is when there is an outbreak in a congregate facility. If theres a case in a nursing home, we would think everyone in that nursing home has to be tested. What about outside of a facility . Somerieden were seeing testing done to release people from isolation. We dont really know what a positive test means in that contacts of, but cases could ideally be tested to see if they are infected, because if they are, Contact Tracing needs to be done with them also. Dr. Rivers i agree. Testing people without symptoms is not currently one of the higher priorities on the cdc priority list. That is a concern to someone like me. Im over 65 years old. I have some of those conditions that have been raised as potential issues. I cant just stay home. So i need people to be tested in general, so that i know that im in a more safe environment than a less safe environment. How long do you think it would take us to get there, and isnt it reasonable, if not feasible, isnt it necessary to get there . Dr. Rivers universal testing is a strategy that is not clear to me if we will ever have the capacity to carry out, and i mean that, it is not clear to me, it could be that we do, but im not sure. An alternate approach would be Contact Tracing, which would enable us to regain control if done at the level and scale necessary. Youve outlined a series of conditions that are more optimum for us to be able to open up and come out and do things. Where are we exactly, right now, this week . Right now, where are we on that sort of spectrum of enough testing and Contact Tracing and isolating, enough alternative facilities for quarantine . Where are we, right now . Both can answer. Dr. Rivers i can start us off. Right now, most states and communities are still staying home to slowly spread. As we start to move into phase two, gradual reopening, some communities do have sufficient diagnostic testing. Many communities do not. States, thanks to the appropriation of this committee, have funding to hire more contact tracers, but that capacity is still in progress. So are we like in phase one and a half . Dr. Rivers were looking to phase two. Dr. Frieden the way we think about it, three things you want to look at. One, what is happening with the virus, are severe infections coming down, and are estimated numbers of cases going down controlling for amount of testing . Healthcare systems robust so that healthcare workers are not getting infected on the job and we have the capacity to treat a surge and manage ongoing conditions like pregnancy safely. Three, is our Public Health system ready with Contact Tracing and isolation . I would say there are some communities in parts of the u. S. Getting ready to do that, but all of us need to have vigilance. Its not about relaxing. Its about increasing vigilance to prevent explosive spread, save lives and restore our economy. Im confused as to where we are, and when we do allow states, when the governors allow them to reopen, id like to know what kind of indicators of Public Health professionals are willing to say or should say that you need to shut it back down, or if it is ok to continue in that direction, and i just am not knowledgeable about that, and i dont get the impression that in general we are. Dr. Frieden we have looked at that specifically, when to loosen and when to tighten again, looking at increasing case counts in what is called syndromic surveillance, early and a Public Health system that cant do the boxing in well, so we dont know where cases are coming from. That is the optimal way, but i think we recognize that part of the state at home may be able to be changed without undue risk, for example Outdoor Activities and other things with physical distancing. When we go out, it isnt going normal. Ck to it will be a new normal with Hand Sanitizer and perhaps face masks where it is spreading widely. Notouch doors and Elevator Buttons and lots of ways to engineer risk out of our lives. Thank you. I yield back. I forgot i had my mask on. Thank you. I yield back. Follow up, for a sec ond, for a question. E themerican people deserv truth. The American People, one the one hand it is here, and on the one hand it is that. Where . Know . Erstand, you we hear on tv, the ordinary person, we have access to other kinds of information, but vaccine, how many are being reviewed, what are the different lines of reviews, what are the main ones . Are there 40, and of those are the only two that are real . Is there a National Testing plan . I believe you said no, we do not have a National Testing plan. We do not have a national Contact Tracing plan. Have ppe. Control of what that is and where it is going, and the American People are scared, they are scared. They dont know what to believe, and they may not go into that mentioned. Harris so what do we get to. Dc guidelines on testing being followed, yes or no, because i want to be mindful of my colleagues time as well, are those cdc guidelines being followed about who gets tested, and who doesnt . Or is it just a jump ball . Thats the way it appears to me, that we do not have kind of a Central Control of what is happeneinging, as you have poind out. In the worst pandemic going back to 1918. The American People going to get the answers that they need . How are we . Us, whatto tell need policy initiatives to be put in place. You have a subcommittee here. It is bipartisan, it is sotically important, and many pieces are within our jurisdiction, and we need to understand. We are not fully enough to know possibility ofe clarity, but give us more clarity than we have now, in wherewithalvide the for those who are in charge to carry out their mission. Testing, quick question, should the cdc be in charge of that effort . Should the states be in charge of that effort . And again, i need quick answers because im going to run out of time. Dr. Frieden the federal government needs to establish guidelines, provide the resources. The implementation is done at the state and local level. Ok. Our state and local level does not have the resources today that it needs to do its job, yes . Dr. Frieden there are not enough tests currently. Circumstances, the Public Health infrastructure in this country is weak, and its being overrun. Not that it hasnt wanted to do the job. Its being overrun. As your point earlier, we need to do something about that. Plan,you know, is there a , if we have a vaccine . Get manufactured . How does it get prioritized . Are there people sitting down as far as you know now, and i am looking to the scientists, im l knowg to you, because we what havoc politics can play, and just put that aside. You are the guideposts. Give us the plan, and let us thew absolutely, and American Public and say, its not going to happen for 18 months. Theyre not dumb. We need truth, and facts at this time. Goas not prepared to just in this direction, but we cannot say on the one hand this and on the one hand that, if we are going to get out of this. Give us the posts to get us out of this, the pillars that help us gain that control. So that we can move forward, as a country. I went over my time. I apologize. You are the chairman. You never go out of your time. And i respect that and respect the concerns you went through. Let me get, because i think the chair is right, we are looking for specifics, so that me ask a very specific question to both of you. I think one of the early lessons from this is that we certainly didnt happy public lab testing capabilities, lets say, that we needed to respond as quickly as all of us would like to respond. So i ask your professional opinion, is it true, and number two, how would you go about remedying that . Number two, and i could be wrong about this, and would be happy to be corrected. I also thought we were a little slow getting our private sector partners into the fight, for whatever reason. I dont know if theres a barrier there, if we have to assure the market. Forprofithese are companies, they have to make money, but i dont think we mobilized them nearly as rapidly as we should have. So what do we need to do to get Public Health labs up to where they need to be, what mechanisms do we need to have in place so that if we find ourselves in a allout war with a microbe that we have everyone on the field as quickly as we can get them there . Dr. Rivers just to tie together your two questions, we spent a lot of money and time on hospital preparedness and making sure that our private medical facilities are able to respond to a mass casualty event. We dont have some thing like that for diagnostics, and i think we should. It is not just Public Health labs, although we should work to increase capacity, but also the private sector as you mentioned, so we should have a unified Preparedness Program on how to make sure we are not caught in this position again when it comes to diagnostics. Dr. Frieden it is certainly the truth that the Public Libraries at National Laboratories at national, state and local levels antiquated. Not using the latest technologies, still using fax machines. The testing methodologies, information technology, that is something that needs to be upgraded. It is also the case that we need to look at new platforms and newer diagnostic technologies. There are innovations coming, and they are not cheap. They will be expensive, but you want to keep your Fire Department there in case theres a fire, the same way you want to keep your lab healthy. Unfortunately, the lab is often the poor relation, and it is a three legged stool. PublicHealth System doing publichealth testing, hospital laboratories developing their own tests, and the private sector coming in with large volumes. In this case, all three had problems. We delta little with that in one of our last hearings dealt a little with that in one of our last hearings. The cdc was talking about a plan, developing technological updates. Id hope, they have obviously been dealing with a lot but i hope that has not slipped through the cracks, because we will need Something Like that Going Forward. Thats a very specific investment we could make. Let me ask a very different question, if i may. We talked a lot about vulnerable groups, and we certainly have Health Disparities in minority groups, lower income groups, a lot of people who find themselves with a higher degree of vulnerability and much worse foromes further populate the population in general. I want to talk about that maybe later, but i also want to ask about children. I was mentioning to dr. Harris, talking to the ambassador of a friendly european country during this. What do you do . One of the things we are doing in terms of getting back, opening schools a lot faster than you are, because our children are not particularly of theire, and a lot parents are in their 30s or 40s, the workers that we actually need to get the economy going again, and they are not as vulnerable obviously as others. Any thoughts in terms of number one, what is happening with younger people in this, and number two, not asking for master blueprint of what we should do, but would you have concerns about the School System and getting kids back up and operational, parents able to get in the workplace . Dr. Rivers thankfully, we are able to observe that children are at lower risk of severe illness. That is something we have seen in other countries and the United States, so that is encouraging. What we dont know is what role that Children Play in transmission. We know from influenza generally that children are really central for transmission in the community, not just in schools but the community broadly. We havent been able to pin down the science yet of what exactly the role is of children in transmission, so that is where you see a lot of the uncertainty. These factors weigh against each other and make it difficult to come to a decision, so i would suggest as other countries move toward reopening, some countries going back to school, they will be collecting data and doing analyses that will let us understand the role of children, and that will be helpful for informing our decision. Dr. Frieden i would agree with all that. I would say, we dont know why children and women are less likely to get severe illness from covid19. It is a clue for something about the virus. But as we reopen, we want to prioritize societal benefit, for example daycares. If we keep out from daycare kids with underlying condition or staff who are older or underlying conditions that may be a way to start reopening. Staff kids get infected, get infected and come home to the grandparents, are they a risk . We dont know. I do think there is a valid argument to be made for a sooner reopening of areas with younger people because of the lower risk, but you have to do it in a way that minimizes risk and recognizes that the vulnerable population need to be protected, as well as the risk of transmission. Rep. Cole thank you very much. Andhank you, madam chair, thank you again for all this. I want to start with a broad question, if you could name a country that you think is doing a good job and if they have a national and . Dr. Rivers sick National Plan . Dr. Rivers singapore has done a very good job and they have a National Plan. Any others come to mind . Dr. Frieden many countries. Do any of them not have a National Plan . Do any countries who have who havelly done this, said we will do it regionally or by city . Dr. Frieden there is a varying degree of centralization and decentralization in different countries. Even germany, which has had a very Effective Response, has a decentralized form of government but with Strong National guidance and regional implementation of that guidance, as far as i understand. They certainly have a more unified Health Care System. Dr. Frieden yes. As we look at testing essential workers, i think it is to think about Health Care Workers, but how do you look at one area im very interested in to followup on the Ranking Members question, child care. Childcare is critical to reopening our economy. We are not going to have success if we dont have a childcare system which has been so underfunded and teetering at the brink. Would you see employerbased testing . Is that how, would a Childcare Center that is maybe smaller, would you test every teacher within those . Would you look at auto manufacturing plants, would you test everyone coming onto the floor, or what you do something more like what dr. Gottlieb suggested, testing everybody who shows up at a doctors office, whether for a sprained ankle or for symptoms of coronavirus . Dr. Frieden i completely agree that daycare, childcare is particularly important, and we highlighted that in the materials from day one, that can may be an area that open sooner as long as we do it safer, meaning that if theres a kid with an underlying condition, they shouldnt go in. Staff with an underlying condition shouldnt go in. We should use Hand Sanitizer frequently. Of massthe potential testing is just that, a potential. In order to do that kind of testing, wer talkinge about tens of millions of tests per day, and as dr. Rivers said, we dont know whether that will be feasible, but we dont think it is realistic to wait to reopen some of the most critical aspects of society until theres that kind of capacity. Dr. Rivers i agree with that. Back to not having clarity about what capacity we can expect, i also think we need to understand more about logistics of how that would work, if you had a point of care test that can only test five people per hour, how would that work with an entire Daycare Center that needs to be tested . There are probably ways around that, but it hasnt been worked out. My point is i dont think we should rely on having that capacity. I think we will have to be prepared to move forward without it. So how would you see getting 1 , isting done for the understand it will vary in regions in the country. Do you see Something Like dr. Gottlieb suggested, where it would be people who come into areors offices, so you getting a random sample . Dr. Rivers starting with people with symptoms. The nice thing about Contact Tracing, once you get in the network and are connected to people who are infected and who might get infected because they have been exposed, you can continue to follow the network outward, so you dont have to be as concerned about checking everywhere, because you start to get a handle on transmission in the community. So this brings us back to where we started, that to even open something essential like childcare we are going to need open quickly and support as we look at tremendous instability in a critical underpinning of our economy, we cant begin to do that until we have robust testing and tracing and quarantining. Dr. Frieden the sooner we establish the box it in strategy of test, isolate, quarantine, the sooner we can. Thank you. Thank you. So, let me ask about the box it in strategy. Dr. Frieden, how many people do you think there are asymptomatic for every one weve diagnosed . We talk about the number of cases, but to be very specific, we mean the number of cases confirmed by testing, and of course, what is your impression . How many cases are there that arent confirmed by testing, asymptomatic . Dr. Frieden there are two different questions there. One, how many were symptomatically and not tested and how many were asymptomatic and not tested . The number we have documented is a small fraction. What fraction do you think that is . Dr. Frieden it depends on the area of country and level of testing. It could be high, right . So how do you box in something when you arent recommending testing asymptomatic people but you know they are out there . Whyomes to my question, wouldnt we just have very intensive education processes so that every american follows social distancing, wearing a mask, hand hygiene, so that we kind of hammer this in . Because these are the principles, and get a test if you are symptomatic . Dr. Frieden i think thats correct. We can do both, and we have to do both, because this is a very infectious virus and very deadly. But the criteria for nd iveng include the, a seen this, dont reopen until you have contact testing in place. Dr. Frieden what we can say, you will be safer if you are able to open with Contact Tracing. We are safer from death if we arent bored, right . The bottom line, there is some element of risk. Homeng this back, stay at might work in new york, because if you leave your home in new york you will get on a train, a subway, a crowded street. But if you are in parts of my district, you will leave home, getting your car or truck, drive to a store that has almost no customers in it, conduct your business and go back home, because that is normally the way you live. So, why would you insist that, or why is there insistence broade, t hom the home, the broad blanket statement it is effective because i dont think it adds anymore in the example i gave you in a rural area . Why do we have a onesizefitsall approach, when we could be much more nuanced about it . Dr. Frieden the concept of physical distancing is an important one. In the scenario you outlined, if the individual goes to the store and for example calls in advance and picks up the order at the front, thats a very lowrisk interaction. If you go out and work outdoors, thats a very lowrisk interaction. I would suggest, i visited, a couple of the stay at home things that dont make sense to me. Recreational boating is prohibited in my state, so a family that stays at home and needs at home, they dont wear masks at home, they cant go out on their boat in the outdoors. Golf courses, as you know, outdoor. There are guidelines in place that would absolutely physically separate you from other people. These things that, again, nuanced approaches. Stay at home, onesizefitsall, everybody has to stay at home no matter what you are going outside to do. Cant we get more nuanced, given that we know that social distancing, wearing a mask, hand hygiene will likely be the major in to stop spread of this some circumstances . Dr. Frieden that is generally correct. One other factor to consider is environmental contamination. Covid is spreading like a supersars. We know sars spread through Elevator Buttons and door handles and other ways, so we have to think about reengineering some of our environments, so we have no touch doors and reduce the number of contaminated surfaces and cleaned them more reliably. This is about adjusting to a new normal, and as soon as we do that the sooner we can get our economies back without unduly stressing our Health Care Systems. Two additional things. Kind of novel ideas coming forward. One, the ability to test, because nasal swabs are a problem, i understand there are tests that work on sputum, salivary tests. And what do you think the effect of that will be unavailable at the of testing . The other one, the new antivirals being spoken about, obviously remdesivir, made by money ithich took made from hepatitis c drugs and reinvested to help us care that, as well as the mono tunnel monotonal antibody discovery in i believe israel. Will these change the Playing Field . Dr. Frieden we will have to see. We are learning more everything a day, and the more we learn, the more we can do. Sputum testing, is it likely it will work, and you can test sensitively enough so you dont need a nasal swab . Dr. Frieden i would need to see the data on that. Ok. Thank you. I yield back. Thank you, madam chair. I wonder if you can share with us the patient experience, a patient who has covid19 goes to the hospital, whats the, how long is it taking there, what is the treatment, and what is the hospital bill like, if you can talk through that . Thatrieden one thing is for many patients it does not require hospitalization, and in areas of the country like new york city with an overwhelming number of patients, what has been set for the last couple months, if you are just mildly ill, stay home, because you will come in and use of scarce resources. If you dont have it, you might get infected, if you do have it, you might give it to someone else, and if you do have it, you might just be told to go home. That might not be the right answer. The right answer, if you cannot be safely cared for at home because maybe you have a grandmother or someone who has cancer, come to this facility and we will care for you until you are no longer infectious, and that is something we need to think of Going Forward. For someone who comes into the hospital, what we see is very low levels of oxygen in their blood, and that is a big concern. Oxygenation is a major component , probably the most important part of Supportive Care of someone with covid, and doctors in intensive care units are figuring out ways to support oxygenation without intubation and use of ventilators. That is a new finding, reducing the number of ventilators we thought would be needed. What is that care, if you dont need a ventilator . Dr. Frieden there are a variety of ways to position patients and give oxygen through other means they dont require insertion of a breathing tube. And general Supportive Care for the individual. Making sure they are well caredfor. Weve seen very severely ill patients in cities that have been hardhit having a very low survival rate, partly because they are so severely ill, partly because systems are somewhat overwhelmed. Were learning more about how to care for patients all the time. There is potentially good news with remdesivir, the antiviral. It appeared to shorten the time to recovery in a welldone study that has not yet been released by the data has been shared. Can you talk a little about that . Reduce it by . Dr. Frieden 15 days to 11 days. Ok. Dr. Frieden and it reduced the mortality rate by about 30 , although that difference was not statistically significant given the size of the sample. So a nonsignificant trend toward a lower death rate. I am guessing, if you are hospitalized, this is going to result in probably thousands of dollars in hospital bills . Dr. Frieden intensive care is extremely expensive. And do we have any hard numbers associated with what an average stay is going to look like, for patients . Dr. Rivers no, i am sorry. All right. I want to make an editorial comment, in that congressman lloyd doggett, congresswoman susan wild and i have a bill that would call for the opening up of the reenrollment for the Affordable Care act right now. And when we have 30 million uninsured americans, and in the state of illinois we have 800,000 uninsured americans, i actually partially wanted you to go through that. We know this will be very costly. We know it, by the economic recovery bill we are looking at. But it is quickly important. The Trump Administration has pushed back on reopening, reenrollment and we call for an eight week period where people can be reenrolled in the Affordable Care act. Dr. Frieden, you have obviously been in the Obama Administration very involved in the Affordable Care act. That is important to note. What you just talk through, it is a long process. Im glad we are seeing some encouraging news out of treatment in hospitals. I want to ask you also about Behavioral Health. If you can talk a little about that, from a Public Health perspective, what we see as far as happening with Behavioral Health, what we need to prepare for Going Forward and what we can do as members of the labor, health and Human Services subcommittee of appropriations as we look at that . Dr. Rivers . Dr. Rivers yes. I think this is an important area. Going back to our previous discussions about the secondary consequences of this pandemic and the support and treatment and continuity of care that people have had. Behavioral health is one area that is chronically underserved and under supported, and i think contextssible in the constan of this pandemic that those disparities will intensify. Dr. Frieden i would outline four areas of concern. The first, interruption of needed care, either ongoing care or need for new care,in the Behavioral Health area. Second, Substance Abuse and chemical dependency, need for treatment and potential increased need for treatment and care. Acute trauma of grieving and losing family members, family numbers getting severely ill, and also the responders. First responders, healthcare workers. I was Health Commissioner in new york city after 9 11, and we studied the impact of the World Trade Center attacks, and found that as severe as the respiratory impacts were on people caught in the dust cloud, in terms of the amount of disability, posttraumatic stress disorder, depression and anxiety caused even more disability. So we have to take care of our responders and this time, and limit their hours to the extent possible, and provide good care and support. Thank you to both of you. I yield back. Rep. Delauro congresswoman herrera beutler. Thank you, madam chair. Part withon that last regard to Mental Health, and the impact that is having not just on our first responders, although they are constantly in our hearts and minds because they are the ones taking it in the things i think with regard to congressman harris comment about a nuanced approach to reopening. I recently called on the federal government to reopen. Washington state, we dialed back, we are starting to dial back open, and the governor has reopened state parks, or at least is doing them in a phased approach so people are able to leave their house and go to a safe place that has a lot of space and distance. But it has an impact, especially if you have kids. They are all in the house together, and it lets them release a little. I recently asked the feds reopen area,l land in our because they closed off in cooperation with the state and now i think it is time to start opening those things up. Id like to know on the recreational side, what types of things you see as, nothing is 100 safe, lets throw that out there, but that could help balance out the Mental Health piece . Ive been very concerned about Domestic Violence and violence with regard to children. The reports have gone way down, because they are not in school and educators are not able to see things and make calls, not that they are not happening. So could you please speak to the health piece with regard to reopening some of these things . Dr. Rivers i agree that outdoor areas are lowrisk for transmission and play a really Important Role in Mental Health and overall wellbeing, so i do support reopening of those areas. Dr. Frieden complete agreement. I would encourage that. The only thing you want to be careful about, where do people go after they go outdoors, congregating inside, and other things like doorknobs, places that can be easily reengineered to be safer . Addition, as the public is more educated, most people carry around Hand Sanitizer, right . You use it before you eat. You take your own lunch, sit out there, gather your garbage, put on the Hand Sanitizer before you eat. I think we need to begin to show areAmerican People that we seeing and hearing their stress. Not just the folks in the middle fight, but those who are in rural areas, who are held back. We are almost a victim of our success in certain ways. Im so grateful, we worked very hard to not allow our local Health Systems in my district to be overwhelmed, but because that isnt happening, people arent seeing the immediacy of the crisis, and we have to respond to that. Nuance, especially coming from our Public Health experts, is going to help us i think, in the long term with legard to adherence, but itl gain some trust. The other thing i want to bring up and ask about, Nursing Homes. Obviously that is a hotspot, and they continue to be a significant portion of covid including d deaths, a high number of those patients who travel three times a week to dialysis are nursing home residents, and figures increased during the pandemic. What special protections can we look at for these individuals, for them and for the staff . A lot of how these viruses could have originally been spread were visitors, but now it is Health Care Providers and or staff. Dr. Rivers we talk a lot about testing, when we should test, where we should test. For me, this is a really appropriate opportunity to do that universal testing. I think all staff working in care settings should have access to tests regularly. We know nursing home residents are at a very high risk of severe illness and the virus spreads easily in those settings, so that is the perfect opportunity to intervene. Dr. Frieden i completely agree. Im deeply concerned about Nursing Homes. Two months ago, i said Nursing Homes were ground zero for covid19 in the u. S. , and as i said in my opening statement, unless urgent action is taken, they will be at least 100,000 deaths in Nursing Homes. That means taking a comprehensive approach, making sure there is leadership in the nursing home at every level, every unit, every shift. Making sure we take a hierarchy of controls, including source controls, administrative engineering and personal controls. Cohorting staff and patients, coming up with novel ways to try to keep staff and patients safe. Some Nursing Homes are paying staff extra tuesday there, so they are not exposing others. That is very costly and difficult to do. If it turns out antibodies reflect immunity, maybe we can have people who have immunity care for others in Nursing Homes. We have to do something so we dont have that kind of terrible devastation. Thank you. I yield back. Thank you. Thank you both. This has been a tremendous learning experience for me. I wanted to ask a couple questions about our connectivity. O the rest of the world what do you think for instance is the true impact of the decision that our president made to withhold funding to the World Health Organization . Shortterm,being midterm or even longerterm implications . Dr. Frieden we are in the midst of the most severe Public Health pandemic in a century. Our Global Health organization, and we need to make it stronger. Approach, a different a supplemental approach . What are ways it could be more effective . I think every organization will need to look back and see how it could have been more effective, but the w. H. O. Has a Critical Role to play and we hope it will be able to play that with ever increasing effectiveness in the weeks months and years to come. I dont know if you wanted to weigh in, dr. Rivers . Dr. Rivers i will just add, from this experience and everything we know about Infectious Diseases, a threat anywhere in the world is a threat to the United States. It is in our National Interest to make sure the rest of the world is able to respond effectively, and w. H. O. Is the tool we have to do that and ensure that. Thank you. Another question that i have, all my colleagues have spoken to the need for a National Plan looking into this, and how we approach it, how we deal with the various phases and how we can create hopefully more dependability by having a National Plan. What is your reaction to the proposal to shut down the task force, the Coronavirus Task force . Is it an ok thing . Is it problematic . What should we be thinking about that . Dr. Frieden i would say that it depends what comes next. Initiative, we advise governments all over the world in how to prepare for and respond to an epidemic. And one of the essential components of an Effective Response is a clear, what is called incident management system, where there is an Incident Manager in charge, there is transparent information. The Incident Manager reports to the highest authority, and raises policy decisions that need to be made, which are then made and implemented through the incident management system. That is the best practice in how to handle an emergency like this. So whatever structure is there, i would hope it would follow that best practice. One of our challenges is that we have had so many people on the same base at the same time, pieces,out little sometimes colliding with one another as they try to get to home plate. To me, it is very important we have a cohesive plan of action, one voice, and agreement among all of the agencies inputing in to that. My other question has to do with the minority communities, the black community, the native american, hispanic communities. A lot of their access to health care has been damaged because of the Health Care Facilities not operating to par, if at all. What do we need to do to ensure they are not deprived of either the therapy or the vaccine, once it becomes available, to the hasee that the infection disproportionately impacted those communities . Dr. Frieden weve seen three problems. One, a larger proportion of essential workers in some underrepresented communities. Two, higher proportion of diabetes, uncontrolled diabetes and other underlying conditions. Three lesser access to health care services. If and when we have vaccine, it needs to be provided to those who need it most first. That would be healthcare workers and other essential workers, and then that is rolled out to everyone in society, because that will protect all of us. Dr. Rivers i would just add, although we do not have a safe and effective vaccine yet, that is the kind of thinking and planning we can and should be doing now so we can really take our time to identify the best way forward. Thank you. Finally, i just want to say i am really impressed with the discussion you both have approached about looking forward, not waiting for disease x that will come along. I think we are very fortunate no, were not fortunate with what we are experiencing now, although i suspect it could be worse, but this is pretty dog are the, and we smartest, most amazing country in the whole wide world as far as im concerned and we ought to be betterpositioned should and when there be another incident of this nature. Thank you, and i yield back. Rep. Delauro thank you. With agreement of the Ranking Member, what i would like to do, i mentioned we have members who and inot be here, so, know that there are three members on our side of the aisle. A question i would like to pose on their behalf. Thank you. You the senseive of the question. Congressman mark pocan of wisconsin, his question is, in order to safely reopen our communities, experts like dr. Gottlieb recommend being able to consistently test 1 of our population every week. In wisconsin that means 50,000 tests per week. Do you feel the federal government should play a role in helping states secure testing supplies and so they can safely reopen . What should we in the federal ourrnment do to ensure communities have testing and Contact Tracing capacity they need to safely address the pandemic . Are the guidelines from cdc on who should be prioritized accurate, in your view . Are they missing anyone . Workers, essential folks working at factories, our first responders, and i would add to that list i am sure mark would not mind, one of the questions i wanted to ask is about our folks in the meat and poultry processing plants. The president is designating meat and poultry processing plants as essential infrastructure that must stay open. I dont know about everyone here, but i have been to a poultry processing place and a Meat Processing place, and watch how those people are standing right next to each other as the chicken or beef goes by, so how do we deal with them as well . So let me lay that one out. Dr. Rivers i do think the federal government should play a role in obtaining testing supplies for the state. What we dont want is a situation where all 50 states have to devise their own strategies, pitted against each other. We need a central coordinating function to make that run smoothly. I think the same goes largely tracing, in that the federal government plays an Important Role in issuing guidance and supporting state and local Health Departments doing this work. But our Public Health in the United States happens at the state and local level, so it is appropriate those functions be carried out at that level. The cdc testing priorities largely revolve around people who are hospitalized first and foremost, with covidlike symptoms, those with symptoms who dont require hospitalization and Health Care Workers. I think those are appropriate given our limited resources, but that is not to say that people in essential roles like working in manufacturing and meatpacking should not become essential. It is just a matter of getting Testing Capacity to the point that we are able to support that. Dr. Frieden i would agree with all of that, and just request, we issued a brief on exactly this question, two pages about who should be tested, how many in each group and what level of prioritization, if we can enter that into the record, generally includes the cdc recommendations. Rep. Delauro you also, besides meat and poultry processing plants, prisons have become a place we really need to look at. Thank you. On behalf of our colleague lucille roybalallard, this is about cdc authority. The cdc has been an authoritative voice in the country to prevent the spread of Infectious Disease. When wery, february were learning about the novel coronavirus, cdc leadership, particularly dr. Messonnier and dr. Redfield were present several days a week, testifying and providing guidance. However, once the stay at home efforts began to cdc became disturbingly absent invisibility and silent in recommendations. To paraphrase, do you consider it problematic that the task force contained one cdc representative, and for the most dr. The briefings, redfield was not invited to be part of the presentation. Given your own experience, is it normal that cdc not be more directive in response to the outbreaks in Meat Processing plants . With federal directives that demand they stay open even if they dont have protocols in place to protect workers, should cdc mandate the use of face masks in public, insist they be available to all people entering stores and public places, and what role should cdc play in addressing this tragic epidemic of covid in our Nursing Homes . ,ll about the cdc, dr. Frieden about which you know. Dr. Frieden first to say, cdc has 20,000 Health Professionals who dedicate their lives to protecting americans. The National Center for immunization and respiratory disease has over 700 staff who are experts in this area who have spent decades working on the Public Health goal of respiratory viruses. The director was the former director for that center, in addition to being a deputy. Dr. Messonnier is the current director. Others in the center are deeply experienced and deeply committed to this, and many parts of cdc also have deep expertise in infection control, for example, in nursing home care. Cdc does not have the authority to mandate. Cdc provides guidance. What i will say, even as i am an Infectious Disease specialist, ive spent 30 years on Infectious Disease control, ive run two large Public Health agencies, i would not take action without detailed input from the experts at cdc, because they are the worlds top experts in this, and i will feel safer when we are hearing from them regularly. I would also say, the American People have voted with clicks. The cdc website has had Something Like 1. 4 billion clicks, and is still the best place to go for information, advice, guidance and recommendations to keep you, your family, workplace, school safer. Rep. Delauro cdc cannot mandate, we understand that. But in regard to the meat and processing plants, you worked closely with osha and usda on these issues, as well as state Health Departments, in effect leading the way is the point, that cdc took a major role in this effort. And that is with guidelines as well, which is why i ask, are we this, but aredate we implementing everywhere in this country the cdc guidelines with regards to testing . I think the answer to that is no, but in any case. I dont know if you want to comment on the cdc, dr. Rivers . Dr. Rivers no thank you. Rep. Delauro congresswoman lois frankel, of florida. Again, this is similar. Testing is the key. There is inconsistency on how much testing needs to be done. Hundreds of thousands, and we are currently less than 200. Give us again the benchmark for the number of tests we should be doing. 3. 5 million per week and go up from there. Rep. Delauro do we have the capacity to provide this . Yet. T rep. Delauro what will we have to do to achieve the capacity . The steps are clear to me, but that should be a priority. Rep. Delauro who should determine the steps . Federal government. Rep. Delauro she asked based on your knowledge of the timeline of the response, she talked about november, officials began warning about the virus sweeping through wu hand, china, more than 70 days before the first confirmed case in the u. S. Paste on your knowledge of the timeline of the response, was there anything more that could be done to contain the spread . In may 20 18, the administration expanded the white house response team, later received a report warning the u. S. Was not prepared to respond to a severe influenzalike pandemic. Do you have an opinion as to the standing if the response was appropriate, and is there anything more that could have been done . Dr. Frieden this is exactly why we need a Health Defense appropriation. So whatever the status in the budget, americans can be safer because we have a stable source of funding to protect us from Health Threats at home or abroad. Just thinking about the first question. It is always true in Public Health that we prefer prevention. It is easier to prevent something then regain control. But we are in the midst of the pandemic and we need to be forwardlooking and focused. Ok. Delauro im going to ask congressman cole if he has closing comments, e andi willrep. Col then i will close. Le i appreciate you both. Chair, for, Madam Holding this. I think it is a very important hearing to hold and i think you asked a lot of your members because this has been a reason why we are in town, and im very pleased with all the members of the committee that were able to come here. Certainly very understanding of the ones who were not, but took time to submit questions. I thought i might win the prize for coming the furthest, but my colleague butler once again showed me up. Exceptional that she came with Young Children to this hearing, and all of you need to be commended, but i want to point out my friend who came the furthest for what she did. Theres a lot of good information in this hearing, and i think it really shows the reason why we need to be meeting as regularly as possible, particularly on this issue. I want to think again both of you. Eden, aside from the Health Defense fund, i think it bears considerable merit. Sharon and i have talked about Something Like this, have talked about the accounts that you would want to have, trying to open up the budget or cracked the budget cap. In january 1,dget 1942 was a lot difference then december 1, 1941. You have to look at what you planned and see if what is necessary to go forward. I think honestly spending billions to save trillions is a nobrainer to me and that is where we are at. We could never go through what we have gone through here before in terms of the disruption of lives of the American People and in terms of the catastrophic loss imposed on the federal treasury. A classic stitch in time saves nine argument. Think it is incontestable i think it is also clear this is den and id dr. Frie have talked about this before, this is not a one and done supplemental problem. We will have to adjust the baseline Going Forward in light of the information we have not all those in this committee as i talk to our chairman, we of nih,e focused on the cdc, the strategic stockpile and the Infectious Disease fund, but as she quickly pointed out, food Inspection Network and the fda, neither of which are under our jurisdiction, are also something you would want to look at. And i know i have talked to the Ranking Member about this and to our staff about looking across all the budget categories that might fit in and have some appropriate response to begin a enstem like dr. Fried recommended. I know having this discussion, madam chair, it has already popped up on politico, so it shows the virtue of being at work and doing your business. I think it stimulates a discussion farther beyond here. And i think its a very important discussion for us to have. We should be caught up and we are focused on dealing with the immediate problem that the coronavirus and ive been very proud of the congress. We have our differences of opinion and i noted there are some partisan elbows thrown along the way, fair enough, but for supplemental but four supplementals in a row with virtually no partisan dissent i think is a good indication people are very, very serious about this, are anxious to work about working together on this and can Work Together on this. While we respond to the immediate and will be responding for some time, we ought to build on the work this community this committee has been engaged in in a bipartisan way, because it cannot happen without our good friends in the senate. And move toward some sort of more realistic and systemic systematic i should say and systemic changes to accommodate those. The kind we build on of capability and sustain it over time. I think that will be the real toge, the real test as whether or not we have learned the lesson. Im not very im very understanding of people caught up in a crisis that they probably could not envision literally 16, 17 weeks ago. So there will be valuable lessons to learn. But again, we have not had a lot of time to do with this, so not going to get everything right. Where i would be more critical is if we lost the opportunity to make the basic changes we all know we need to make, the basic investments we need to make, and both of you have laid those out for us to consider today. , madamn, thank you chair, for what i thought was a very thoughtful and productive hearing. I call on my colleagues, thought everyone one of them had important points to make and questions to ask, and i look forward to working with you, madam chair, and all our colleagues on this committee and the full Appropriations Committee to see that we draw the lessons and make the investments the American People need us to make Going Forward so that while we are going to deal with this not just in the short term, probably as both dr. Rieden and dr. Fei indicated this is not going away by the end of this year or next year, it will be with us a considerable time, to develop therapeutics and ultimately a vaccine to deal with it, but it has taught an important lesson we ought to learn about the biosphere in general and the number of challenges. We have had quite a few in the last few years in regards to and ebola ands now this. That ought to tell us this is just a fact of life we have to do with and we have to deal with it more effectively than we have. In this hearing, madam chair, has made it very apparent. With that i thank you and i yelled back. I yield back. Rep. Delauro thank you very, very much. The thoughts process on this was a special subcommittee that we are at the programming, the portfolio include so many of the in thishat we face pandemic. And so i want to thank both of you for your willingness to be here this morning. I dont know what kind of difficulty that was in your own concerns. I know when your lives, but also your own concerns about your health and your safety, at a particular thank you to my colleagues who have come from all over to be here today. Know, many traveled far. I could think the bottle of Hand Sanitizer today. But it is a testament to every Single Member on the committee who spoke with who wanted to be here, and for one reason or another could not. And thats why in the opening of my remarks i talked about these conversations are so critical to the health, safety, and the Economic Health and safety of the country. And we ought to be discussing those now in real time as we are putting together the public oficy, the commitment serious resources, which is what we are doing and will continue to try to do as we are working to think about where we go with the cares package. A couple of the things we have talked about, i would just say , imy colleague, dr. Harris wrote down the education piece of this, very, very important. But then i watch the news and i people beaches and i see who are bright people, smart people, and it doesnt make any difference. And then i see honestly, i see people in various places around the country storming the bastille, if you will, storming no, city halls, saying, this is not what we should be doing. Even with the education that is out there at the moment. And what the scope of the number of cases and what the scope of deaths. I mean, that in and of itself should make you think about your own behavior ought to be in this kind of crisis. I also set of at the outset of my comments why . I was or i am angry, and you have helped a lot here with, can we get our arms around the testing and the federal government and its role in laying that out for the states. And the collaborative effort in taking on the response. Because i see it at the federal level. There was an accident in new , a writerth katrina named michael who wrote a piece that it was when the levee broke. Andpoke about government citizens as there being a covenant. And that when you reach a place where the circumstances in your life, in your environment are overwhelming, when the challenges are so overwhelming that you cannot do anything about it. That is the role of the federal government to step in, to take sure that we can build those bridges that allow for us to move forward. And he talked about when the levees broke, the covenant broke at that time. Well, i think we have a very similar situation here. The levees broke. And the federal government is not at the center of the determination of how we gain control. You will have written very substantial plants. A National Plan, etc. The roadmap to reopening lays out very specifically the kind of things we ought to do, phase i one, phase two, phase three, how we rebuild. You have laid out a roadmap of the agencies that can move us forward, where we go any forward way. There are going to be people looking backward. Im anticipating to look forward to, the kinds of things that we can do to make sure that we can prevent this. Again,m asking here test, isolate, find, and treat. This is a roadmap. And at the federal level what we ought to be doing is speaking with one voice, giving simple to theon to our states, agencies of our states, and most confidenceegain the of the American People. And letting them know how difficult this road is. As i said earlier, they are looking for the truth, no matter how hard it is. Tell people straight. Give them the sense that while we do not have all the answers, we do have the focus and the direction forward. To safeguard themselves, their families, their health, loved s, and to save card safeguard their Economic Future and their Economic Security in the future. So i cannot thank you enough for doing this, and you have written it out, laid it out. We need to work very closely with you. You need to keep speaking about standing the kind of that you will have. We believe in doctors and researchers and science. We believe in data. That is the foundation on which we will need to build to regain scourge, which is what it is. So i know you are not afraid, but dont be afraid to speak out. You have people who will listen, who will work with you. To where we us get want to go. And with that, this hearing is concluded. Thank you very, very much. 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