Transcripts For CSPAN3 House Foreign Affairs Subcommittee Hearing On Ebola 20240714

Member mr. Smith. Today we are here to discuss the eradication of ebola, and the medical advancements and Lessons Learned in trying to suppress this deadly disease. Ebola is one of the deadliest viral disease in the world has become a part of the Global Health landscape. The recent discovery up in a bowl of vaccine and better healthcare employee training have helped improve response times to outbreaks and decrease the ability of the virus transmitting to rural areas. However evil outbreaks are often complicated by regional conflicts, lack of trust between local communities and practitioners, and armed groups attacking and burning down treatment centers. This hearing will address the challenges and opportunities to combat the transmission of ebola, and the effort and collaboration deeded by appropriate stakeholders. I look forward to hearing more from our witnesses regarding the ebola vaccines and how they are being used in this most recent outbreak. Without objection, all members may have five days to submit statements, questions, extraneous materials for the record, subject to the length limitation in the roles. I recognize myself for the purpose of making an opening statement. I would also like to thank our distinguished witnesses who are here with us today. The current outbreak in the Democratic Republic Of The Congo began in august of last year. It is the second largest today. As of news reporting from today, may have reached up to over 2000 cases. And almost 1200 confirmed deaths. If we do not collaborate with all stakeholders to combat the outbreak and ultimately eradicate ebola, the disease would surpass the 2014 2016 outbreak, the deadliest in history. Which had 11,000 recorded deaths in and 28,000 cases. That outbreak started in new guinea iberia and sierra leone, and spread to mali, nigeria and senegal and even beyond the continent with cases in italy, spain, the united kingdom, and i think we all remember the cases in the United States. Ebola epidemic has been heightened because it is in a comfort zone in the Democratic Republic Of The Congo. The epicenter of the outbreak is in north kivu which has more than 100 active armed groups in the region. North kivu also shares a border with uganda, and is a hub for travel and trade but also various other types of Movement Across the border. New cases are hard to determine because of the violence and political unrest in the affected areas, it is further restricted the communities access to healthcare. The lack of security in the region is also hindering the Ebola Response by making it difficult to trace context and organize Crucial Community outreach activities. Some Health Centers have been temporarily closed or damaged. Several of the Health Workers have been killed. I know that the people of the drc are frustrated because of the lack of medicine, food, and Foreign Companies extracting the countrys precious metal minerals. But that is no excuse to burn down facilities or attack and kill people who are there to help treat this deadly disease. What this indicates is that we must work to do all that we can to keep these Health Practitioners safe. These are things we have to think beyond providing humanitarian assistance, and medical treatment. Usaid administrator mark green said two weeks earlier that when it comes to ebola the drc is a labyrinth of challenges, government resistance to community leaders. A failed democracy in many ways, it will take more than simply a medical approach. Considering suppressing the outbreak, i look forward to hearing your views and suggestions in your testimony or in the q a and i am interested in hearing the pros and cons of identifying this outbreak as an International Public Health Emergency. Why wouldnt we declare that . Those are just a few concerns i want to pose to the witnesses. Finally i am concerned that the administration released a president ial memo last november implementing eight restrictions to most of the tier 3 countrys found in the 2018 report. It clearly states in section 110 the President Shall exercise a Waiver Authority when necessary to avoid significant adverse effects on vulnerable populations including women and children. Not focusing resources on health, education and community outreach, hinders the success of countering the Ebola Outbreak in the drc and i urge the administration to act more diligently now. This administration has an opportunity and obligation to try and stop the deadly outbreak. That is why we are having this hearing and im introducing the trend 19 which would authorize usaid to assist with the efforts in the drc. Lastly i believe it is imperative that we not let ebola reach, because if it does it is highly probable that it will reach rwanda, uganda, ethiopia and south sudan. Oh my goodness. And that would have an effect on humanitarian efforts, peace and security and economic trade. The tier 3 status is something i know the Ranking Member is the author of the report and has worked for many years on this. Presents a bit of a dilemma. Where we certainly do not want to do anything to reward a country that is a tier 3 status. On the other hand, we have the situation where we have ebola in a tier 3 country. So what do you do . Not provide aid . When this disease obviously has international impact. I now want to recognize the Ranking Member for the purpose of making an opening statement. Drug thank you very much madame chair. Its very important. The gentle lady from california is a good friend. This cup somebody was heavily engaged in the summer of 2014, in addressing ebola when we were in the midst of that outbreak. In sierra leone and liberia. And ensuing panic over the disease. We held three hearings, when many around the world thought the bubonic plague was about to jump borders. And overwhelm Health Systems especially of subsaharan africa. It was a. When we thought that nigeria, nigerias most populous country in africa, would suffer from a pandemic outbreak, thanks to a largely unheralded work of a number of key actors including and especially our own centers for Disease Control, the outbreak was contained. But we did have cases in the u. S. , due to highly effective quarantine measures, and state oftheart medical care, we were able to dodge that bullet as well. Perhaps our witnesses, dr. Robert redfield can enlighten us further, and the Critical Role of the cdc, played with regard to global efforts in containing and then defeating the 2014 Ebola Outbreak in nigeria and Lessons Learned. In many ways today we are better equipped to address Ebola Outbreak in terms of vaccines that were not available in 2014, as a practical boots on the ground matter we are worse off with the current outbreak which began in 2018. That outbreak, has now spread in Populated Areas of the eastern drc. It makes the situation more difficult this time, is the security situation. Vicious attacks on healthcare workers. As reported by the washington post, according to the who there been some 119 attacks against Health Workers this year. With some 85 wounded or killed. The presence of expatriots in particular, among healthcare workers appears to have increased the militants who have carried out the attacks. Centers, these dedicated Health Workers put their lives on the line to help prevent and treat ebola. The fact that they should be targeted boggles the mind. The testimony of of one of our 2014 hearings, how he contracted the disease despite taking every precaution. By helping a bowl of patience and liberia. We hope to get an update from Witnesses Today as to what is the security situation on the ground. And whether we are putting our cdc and other personnel further in harms way beyond the threat posed by the virus. Finally i would like to address the issue raised by my good friend and colleague, there is some concerned that assistance to the drc will be cut based on the fact that our state department has designated the drc as a tier 3 country. In terms of Human Trafficking. I certainly hope that this is not the case as it does not comport with the intent behind the legislation. As the author of the trafficking protection act of 2000, it requires that we withhold not humanitarian, foreign assistance to the government of tier 3 countrys. Which means that the country does not fully comply with the minimum standards and are not making significant efforts to do so. I know that the tvp at explicitly excludes humanitarian and trade related assistance from any assistance cut off. Further allows Development Assistance which directly addresses given needs which is not administered by the government. Development assistance can flow to nongovernment organizations, i visited myself, one notices that health and Education Needs are met largely by faithbased entities. As the government and its institutions are viewed with a great deal of suspicion. Moreover section 110 d for of the tvp a invest the president with Waiver Authority with respect to neon battalion non trade related assistance. When such assistance is in the National Interest of the United States. Such as the spread of ebola. Further, the tvp eight mandates, when necessary to avoid significant adverse effects on vulnerable populations, including women and children, if theres any misunderstanding with respect to how it should be interpreted, rental minute, i know the chairwoman and i would be very happy to meet with members of the administration to discuss it. I do want to note that in the fiscal year 2018, the american taxpayers had provided 330 million, humanitarian assistance to the democratic republic of congo, and some 87 million in response to the ebola crisis. We are told additional will be forthcoming. And we look forward to receiving those as well. Thank you madame chair. I yelled back. Truck before introduce the witnesses, i would like to acknowledge, who were in the audience, this is a special day on the hill, when we acknowledge, celebrate and lift up the hundreds of thousands of young people who are in the nations Child Welfare system. For the first time i have been doing this for years, for the first time three of our former foster youth are from the continent of africa. One is from the congo, ethiopia and kenya. I want to acknowledge them. [ applause ] in support of the young people, a very famous actor who is one of, who represents one of my favorite tv shows, blackish, who is here with his father. [ applause ] supporting all of the foster youth. Thank you very much for attending. And now to our panel. Admiral sieber is the acting assistant administrator for the bureau of democracy conflict and humanitarian assistance. And usaid. April 2017 to july 2018, he was appointed by President Trump to be the senior director for Global Health security and bio defense at the National Security council and in june 2006 he was nominated by president bush to lead the president s malaria initiative. Dr. Robert redfield is the director for the centers for Disease Control and prevention. He has been a Public Health leader actively engaged in Clinical Research and Clinical Care of chronic human viral infections and Infectious Diseases especially hiv for more than 30 years. He made several early contributions to the Scientific Understanding of hiv and in addition to his research, he oversees an extensive Clinical Program providing hiv care and treatment in the baltimore, washington dc community. Thank you very much today and we would like to hear a summary of your testimony, we have your written testimony. But if you would present for five minutes. And then we will have questions and answers by the panel. Ranking member smith, members of the subcommittee thank you for the opportunity to speak with you. About the United States government response to the ongoing Ebola Outbreak. You referenced the 2014 west african outbreak and the devastation and the impact it had. The current outbreak in north kivu and in the province has surpassed 2020 k cases the situation is worsening and the numbers of cases will continue to rise. Last month i traveled to the eastern drc. I met with health teams, local community leaders, implemented partners, and saw firsthand the scale and complexity of this outbreak. I traveled extensively in my career, in my three decades in the u. S. Navy and in the roles i have had since, this trip to the drc was one of the most sobering trips i have ever taken. The scope of this virus, Security Threat is changing. And the risk of the virus sleeping the border to other countries is very high. This will further destabilize the region economically and heighten insecurity. In order to control this Ebola Outbreak, and its source, a fundamental shift in a reset is necessary. And ongoing violence and Community Distress tort the response has been summarized by both of the opening statements. On group violence, as well as deeprooted Community Resistance has kept the health teams from doing their Critical Health saving work. And frequently results in the suspension of the response efforts. In february, Community Members and set fire and destroyed the ebola treatment unit, when i was there beside restored. The evening we left, one of the guards was killed and another recurring attack. There been over 70 security incidents this year alone. Cases have been accelerating in areas where the Community Members exhibit deeprooted distrust of the Central Government and foreigners as well as the people from other regions within drc. This widespread distrust has fueled misconceptions about the disease and deep suspicion regarding the motives of the sudden and dramatic International Presence responding to ebola. As well, the feelings of the community, that they are being exploited by this injection of cash. They refer to it as the ebola economy. There is clear consensus among stakeholders that we need to listen better, to the communities, listen to what they are doing, and that should and must inform the trajectory of how we can shift this accelerated increase in cases. The outbreak is not just a Public Health crisis, it is an outbreak in the midst of a complex emergency. In order to contain this outbreak, a more holistic humanitarian approach is needed. Towards this end, usa supported by cdc as the technical lead is leading a government response focusing on six key areas. In order to bring this Ebola Outbreak to an end. Let me quickly review those six areas of focus. First, we are working to improve coordination among the drc government who and our international partners. I am pleased to say that over the last week and 10 days significant change is underway to accomplish that objective. Secondly, we are emphasizing and addressing the paramount importance of Community Engagement in local ownership. Third, we are working with the newly appointed un a bowler response coordinator, mr. David grassley, nonhuman and we are working with the cdc to implement operational improvements in the Public Health response including a forward leaning vaccine strategy. Fifth, we are looking at the ebola readiness along the coma quarter as well as the four countries to the east. And lastly, we are engaged in a longerterm planning scenario for stabilization and development to address the root causes of fragility in the region. This reset is building on the work of our usa funded partners that have been implementing key aspects on this Public Health response. Are partners of help train 1600 community Health Workers and surveillance, prevention control measures, andover 280 health facilities, reached 1. 5 Million People with health messages, and provided enough food to meet the needs of approximately 45,000 beneficiaries each month and much more. There is no Silver Bullet to end this outbreak. But i believe that an adaptable, government response that capitalizes on each agencys unique strengths and expertise, will be successful in containing controlling and ultimately ending this outbreak. I look forward to your questions. Dr. Redfield . Good afternoon. Thank you for the opportunity to update you on the Ebola Outbreak in the drc and outlying what cdc is doing to prevent, protect in response to this and other emerging Global Health threats. Cdcs efforts are grounded in over 40 years of ebola research. And more than 20 Ebola Outbreak responses. I want to emphasize that our goal is to end the outbreak as soon as possible. When i visited two weeks after the outbreak was declared last august, i saw firsthand the complexity of this urban Ebola Outbreak. In march i traveled back again to the outbreak sown where i met with responders on the front lines. These trips further reinforced my understanding of the Critical Role that experienced technical leadership plays in the field. This is the first is back in the drc. Occurring in densely Populated Areas that experienced decades of conflict and civil unrest which continue today. The two currently affected provinces, have never experienced an Ebola Outbreak. They have busy porous borders with uganda, rwanda, and south sudan. These challenges make this outbreak extremely difficult. As of this week, we have surpassed a grim milestone with now 2020 cases, 1354 deaths, occurring in 22 health zones. A significant percentage of cases have been acquired in Healthcare Settings including 109 healthcare workers. In the past 42 days, we have seen 600, 668 active cases and 18 Different Health zones. Of these cases, less than one quarter were known contacts. We have seen 668 active cases. More concerning roughly 40 were Community Deaths that occurred outside the healthcare system. Based on experience from previous outbreaks, and Effective Response demands early ascertainment and effective isolation of at least 70 of all cases and sustaining this for several months. The fact that we are seeing so many Community Deaths means that we are missing contacts. Well know ebola have been confirmed outside the drc, this outbreak is not under control at this time. Cdc is working with the World Health Organization to support vaccination, over 130,000 people in the drc and surrounding countries have been vaccinated today. Recently w cho has recommended the expansion of vaccination strategies, and an increase in vaccine supply to reach a greater number of individuals at risk for ebola. Over the course of the outbreak, cdc has deployed 184 experts to the drc, neighboring countries, and the World Health Organization headquarters. Our work includes case recognition and conduct tracing, Infection Control in the healthcare setting, they barriers, laboratory testing, board of health vaccination, and Data Analysis to inform response. In real time. Cdc provides direct assistance to the drc ministry of health both in kinshasa and goma were the incident command is now located. The World Health Organization and the united in geneva and the u. S. Response to the rc are also enhancing their preparedness efforts in neighboring countries. While this outbreak continues to be an urgent situation in the region, the current rest to americas low. The most effective way to protect america from emerging threats is to stop the disease at the source. Before they reach our borders. We have seen tremendous progress in the rapid Disease Detection and response. For example, this includes meningitis in liberia, multi drugresistant tuberculosis in india, rapid detection of yellow fever in uganda. All a direct result of cdcs Global Health security investment. Cdc continues to improve the technical Public Health worse for work for us abroad, we trained over 12,000 Public Health professionals. Now in 70 countries. More than 200 of these trained professionals are currently in the drc. Cdc continues to position our assets globally. To quickly respond to the emerging Health Threats and disease hotspots. Finally, i want to thank you for your continued commitment, and support, and the Critical Health mission. Thank you. Thank you very much. I want to know if you could elaborate and explain about the differences in how people are responding to the epidemic. You remember when it started in liberia, and there were challenges over traditional practices. Of how you deal with the dead. And that was one of the reasons why the outbreak was spreading. It took a while to get people to break with their traditional practices of washing and preparing the body. Here in the drc, you have the conflict where the workers are being attacked, and it is believed that the disease is fake. I just want to know if you can elaborate a little more on what is going on . Why on earth would people be attacking the facilities and the healthcare workers . And i dont know if any of this is involved in the broader political situation, in terms of the election that happen, the new president was here. He came and we met with him. It was maybe a couple of months ago. That he was here. And i was surprised because when he was here, he requested essentially security systems. And i understand that there are security problems, but in the midst of an epidemic like this, i was surprised by that request. Can you explain your perspective on why are the attacks happening . Why dont people understand that this is a real deadly disease . I think that is the question. The microphone is not on. How about now . I think your question is exactly the question that we are trying to filter through. You look at the three vectors the virus, the security situation, and the community lack of cooperation, all three of those are going in the wrong direction. We know how to control the virus, we cant just cant we just cant get there. And do what is needed in order to bring this under control based on the previous experiences. The last outbreak was in the ecuadorian prophets, and with the drcs response complement it by cdc, it was brought to a close, what is different in this region . That would cause this deep rooted response in the negative . Human behavior. Is driven by many. I know theres a lot of armed groups. I dont know if the armed groups are ideologically based . Ethnically based . 60 to 70 armed groups with different motivations. And different intent. They have undermined the community, the communities intense and welfare over the years. My father knew a colleague who was killed in 1964 after paul carlson, not too far from this area, there is been deeprooted , issues, having to do with insecurity and. How is the new administration responding . How is the new administration in the drc . The new president . Based on feedback we are getting, the president represents a bright light, he has visited the area, was something that his predecessor never did, we are hopeful that with that type of political support, with the effort by the partners and the local responders that there might be an opportunity to start seeing a change in the activity. In terms of the waiver that our Administration Needs to provide, has that happened . Are you under the belief that we have to hold back a because of their involvement in Human Trafficking . The drc has been impacted by the tvpa restrictions. You get a sense that they are going to give a waiver to allow you to use the tools you have . We are waiting to hear. I would like to offer, that the current investment by usaid in this response has been unimpeded. We are using ida money, from the 2015 2015 appropriations to invest and respond to the outbreak. Okay thank you. Mr. Making number . Thank you madam chair. One of the ways the message got out during the crisis in liberia was with cell phones. Im wondering, i sought in the testimony. Is there generally speaking and effort to get to the public . Apparently that was one way of getting that message out about how to keep yourself from getting. Sick. What kind of security, is the president , past the best of the best . To make sure that situation, the workers and people, risk, is negated . I have other questions. You said 130,000 have been vaccinated. I wonder if you could enlighten us, elaborate on whether the vaccination, how long before production kicks in after they get the vaccine . Is there enough vaccine available . Is anybody including healthcare workers after vaccination, is it 100 . If you could speak to the faith community. A lot of church leaders, do wonderful work. I wonder if they are being fully brought into the messaging and the protection strategy. You talked about training the trainers. In your testimony. Maybe you can elaborate on that as well. I think thats an excellent concept. I thank you for being here. If you could tell us what you are doing. And finally, what is not available in the toolbox that the tvpa is precluding . My sense is, so far i dont know, thats where the authority would come in to meet that crisis headon, im wondering what is being done that would require an act of congress or a waiver by the president of the u. S. . On the security front, i think it is clear, the entire prophets area is insecure. What we are looking forward to is a positive shift with the appointment of David Gressly as the deputy for the un Ebola Response. He is being moved over from the neuse, where he was deputy as possible for the security forces, his understanding of security in that area is a very experience, it will give us, significant insight to better improve the security. When i was there i asked to bho what they needed and they said security. One asked the Community Workers what they needed most, they said less security. So somehow we have to get in there and understand the dynamics, what security requirements are. It is counterintuitive. To move forward in an area where there is such a variation in demand and how to move forward to provide the healthcare. Let me just jump in to what tools are in the toolkit. To offset the tvpa. I would say at this point, it is clear, that additional funding would complement the current outbreak response. It would be complementary, it would build capacity. Once we get a final ruling on that, we will see where we stand and press ahead. Maybe starting with the vaccine questions, clearly, this is a great addition to our toolbox, the vaccines, there are unlicensed vaccines, the merck vaccine, its been two 130,000 and if you identify a case, and you find the context around the case, then you find the context around the context around that case, and you try to immunize everybody. Operationally this is not going as effectively as we would like, if you look at cases that present and asked the question, where they previously identified as a case, are they monitored . Were they previously vaccinated . Currently its less than 20 . As i mentioned in my testimony we are not going to get anywhere near effective control until we get this over 70 . Vaccine supply . It is limited. There is a need to accelerate that supply. The current provider, there is a need to increase that supply. There is opportunity to do what we call split dosing to make the supply go further. Which is currently being recommended. But we do need more vaccine for sure. How much more . How much more vaccine . Right now theres about 145,000 doses. As i mentioned, if you realize we are only vaccinating about 20 of people we want to vaccinate, you can see theres a need, substantially for more vaccine. The other thing i would mention, the new strategy is going to go beyond vaccinated context and context of context, we want to vaccinate geographic areas where we cant function because of the insecurity. Unfortunately there is going to be a 6 to 12 month lack before there is adequate vaccine supply. We do project that we are going to run out of vaccine. Before we get adequate vaccine. The vaccine issue . Is it safe . Its an unlicensed. What is the shelf life . At unlicensed. But it should be licensed soon. The shelf life is fairly long. Particularly in bulk. And clearly the shelf life, once it is filed is also a very reasonable, multiple years. The truth is not everybody that has been vaccinated has been protected. There are breakthroughs, estimated efficacy is over 85 . But that is not to any controlled trial, thats just efficacy. We do have cases in individuals that have been vaccinated. Significant evidence, that this vaccine is impacting acquisition substantially. And there is a suggestion, its premature, data is ongoing but if you do get vaccinated, and that the you do that get affected, your course maybe more ameliorated. This is still in the absence of control data, this is what appears to be the observation. Thank you. Good afternoon, dr. Read phil, following up on what you were just talking about, what is split dosing, you made reference to that. What that means is there is a normal dose that is administered. And rather than give a full dose, they plan to give happy does. It turns out that half a dose has been shown in the application of the fda, to give adequate immune response. They have looked at that and do believe that will be efficacious. It is similar to the dose, even more than the dose that was used in west africa. We do need, there is substantial evidence that half a dose is going to be effective. Where is it manufactured . The initial lot was manufactured at west point, in a production plant. That plant was closed. And they have moved the facility to germany. That facility currently is going through what we call validation plots to make sure that it can make the product effectively. And one of the recent locks did not validate, so its another reason, there are discussions our secretaries had discussions about what can be done to try to look at ways that merck might accelerate. How close are we to authorization . We are just waiting for the validation of the new plants. The clinical efficacy data and safety data is there. It is just waiting to prove that the plant that is going to make the vaccine is validated to make it in a reliable way. I want to switch gears with you dr. Redfield, and written testimony, you indicate that in the last calendar year there were 1954 reported cases and 1314 deaths which by my calculations is a 67 fatality rate. And you indicate that the number of cases is continuing to increase. I assume that accurate reporting of cases and tracing of contacts is essential. Is that fair to say . To get control of the epidemic, for sure. One missed case or one missed opportunity to trace contacts can keep the outbreak going or cause it to spread, fair enough . Right. My question to you is threefold. How accurate do you think those numbers are that are in your written testimony . I will ask all questions and you can address them. How accurate you think the numbers are . Is there some kind of uniform infrastructure for which we count and the track these diagnoses . And our medical examiners or corners reluctant to record the cause of death . The first is, we are confident that the numbers underrepresent the outbreak. I think first and foremost, i tried to illustrate, this late in the outbreak, where you see up to 40 of the individuals presenting as Community Deaths, there was no way for us to do context the context of context, those people stayed in the community until they died. The problem with the bowl is the infectivity goes up and up and up, as you get sick, and finally one of the most infectious ways to transmit hiv as the chair mentioned in her comments, is to burial. You wonder why we are seeing that this late in the game. But this region never experienced ebola before. They dont understand it. How do we see this outbreak, 25 of the people who got a bullet got it because they were sick and went to a hospital or Something Else and got infected with ebola when they went to the hospital. So you argue we need Infection Control. In the last 21 days we had 11 Healthcare Professionals come down with ebola. We still dont have effective infectious control. This really underscores as you mentioned, we are not, we are not anywhere near getting 95 of those contacts identified and isolated. We are lucky to be 30 . I want to move on quickly before my time runs out. In 2015, after the Ebola Outbreak ended that president obama created a special National Security council team to oversee epidemic preparedness and response on a permanent basis. My understanding is you are the official leading that team until the summer of 2018, is that right . Does that Global Health security bio defense team exist today . Yes it does. The office has changed at the nsc. The initiative is led by the state department. And supported by cdc and the usa. The mechanism got the strategy and the commitment still exists. Who leads it now . Is led through the nsc. At the state department is the agency lead. Thank you. Representative right. Thank you madam chair. Thank you gentlemen for being here. As all of us know, ebola and his potential for an International Epidemic is very real for my own state of texas. In my home county. Which borders dallas. Back in 2014 Thomas Eric Duncan died from ebola in dallas after traveling from liberia. You know that story. Two of the nurses who provided treatment, in dallas, were later diagnosed with ebola and thank god survived. Earlier in 2014 dr. Kent brantley who completed his residency and fellowship in fort worth at John Peterson public hospital, contracted ebola while serving as a medical missionary. You know that story as well. I got to visit with him in december 2014. He is a remarkable doctor. The point is, we in the Dallas Fort Worth area probably know better than any community, that what happens in the drc, what happens overseas, and happened here and it can happen very quickly. My question is, because when this happened in 2014 it was like a bomb went off. In the dallasfort worth area. My question is, what were the biggest Lessons Learned from that . I will go with dr. Redfield first. That are benefiting us now. Congressman i think probably the most important lesson is to prepare, particularly countries, weve been very fortunate if there is any fortunate in that outbreak and that it is a very remote area without significant air travel, without significant roads, this is why as was discussed already by the chair, if or when this outbreak extends to goma which is a place with an airport, this could offer a greater challenge. Currently we have prepared south sudan, uganda and rwanda, and the goma area to recognize these cases quickly like we saw in nigeria in the 2014 outbreak. And if you will, shut them down so there is not a lot of secondary transmission. So this border screening is really important. I think many people will be shocked when i say this, and this outbreak today we have screened over 58 Million People. And you say to yourself, wait a minute . How do we screen 58 Million People . And we dont have crossborder, cross region, transmission yet. You can think about that. I think it is remarkable. To say the least. But i do think that to recognize how important preparedness is an border screening, at the source. This goes back to my testimony for america. The best thing we can do is stop these epidemics at their source. And focus on doing that. I think that is the lesson, we have all taken home. Preparedness is not something to do casually. It is something to do very seriously. I had a followup. A while ago you mentioned how people there feel exploited. Can you elaborate on that exactly what that means . That they feel exploited by the ebola economy . One of the community leaders, i interviewed, he said, for years we have been abandoned by our government. We have not been cared for. We have seen people die of malaria. Cholera. Thousands of people have been killed and we have been left on our own. And now ebola happens, and you show up. And so, that point of communication, spoke volumes to me. Ebola to them was more important to us than it was to them. We are there to contain it, and keep it from spreading. And we are rolling in with sophisticated interventions, committed people, and a significant amount of funding. And they feel as though they have not benefited and that they are going to be abandoned as soon as the Ebola Outbreak is contained. That is the message we have got to listen to. And move and try to encapsulate as we look at this very unstable world. That borders significant countries. Thank you very much. I yield back. Senator chrissy houlahan. I have a bit of a preamble before my question so it will be a minute or so. Are women and girls are the two groups that are disproportionately affected by this outbreak. Women and women groups also have the capacity to advance response activities. Through socialization and education in the communities yet little outreach seems to be being done to this critical group. According to a Rapid Assessment by the International Rescue committee from march 2019 which is responding directly to this outbreak pre existing gender norms expose women and girls to specific and increased risks during disease outbreaks. During the current outbreak of ebola in north kivu in the drc how factors have seen a similar pattern that they saw and west with fluctuating between 62 . Carry permit this means that women and girls in particularly adolescent girls must increase the number of times by foot each day to fetch water. Here are my questions, what is being done to ensure that women and girls have access to both services and sexual and gender based violence related during this out . If you can comment on that. Thank you for the question. I can say clearly that the interventions in the treatment is focused for all. There clearly is a significant increase in children and women and so that is being noted and factored in to our interventions. Is there any sort of coordinated activity that is specifically relating to the Sexual Violence of women and girls as it relates to their exposure to the evil or as it relates to treating ebola in that particular population . Is there any coordinated effort on that that you are aware of and should there be . Yes there should be. I know our partners are looking at that specifically and i will get back to you with specifics on that. That would be wonderful. My next question is for either of you gentlemen, what lessons did you each for your organizations learn from the west africa outbreak and how have they been applied to the drc outbreak and maybe specific to women and girls if you are able to dive deeper into that . I would say the Lessons Learned from west africa are significant. The ability to take all of those lessons and apply them have been interrupted by the Community Resistance in the can security reality. Unfortunately there is not a direct benefit from that although we have learned a lot, the other significant tool that has been brought in is the vaccine. The situation would look a lot worse if it had not been for the vaccine that doctor redfield was just summarizing in terms of the programs Lessons Learned, dealing with women and girls in west africa and they transfer into province, i will get back to you. Thank you i would appreciate that. Are there any efforts to be made right now to codify or think about Lessons Learned as we learn them now in the field to be able to apply them in the future or are we in the process of having weekly conversations about what we have learned in this particular so that we can use them in the future . Yes i can commit to you that we will make sure that that is ongoing. Finally what kind of cultural barriers to educating the impacted communities have you encountered and how are you experiencing the opportunity to apply best practices to the congolese people . I know you spoke a lot about the resisted that i completely but tyson understand the situation but have we found anything that is working to be able to convey to the women and girls particularly who are the caregivers and largely explosive this. What lesson the could be used to be able to make them safer . One of our primary partners as unicef and i know they focus on that is a priority. That we will follow up on that just to give you specifics on how unicef and our other partners are applying the ongoing Lessons Learned so that we improve that particular issue. I really appreciate your efforts on this. This is something that literally keeps me up at night, biology and its been the concerns that are for all of us. Thank you for much. I yield back. Was i being called on for talking or called on to speak . Either. [ laughter ] i will go speak. I was the current conflict that is currently ongoing in the center of the outbreak affect the chances of the disease spreading across the border and of those that are involved in the conflict do they understand about and are they concerned with the spread of the disease because a lot of times it seems like education is the key and there always seems to be a disconnect. My Immediate Response is the Armed Conflict is characterized by armed resistance with armed individuals to neighborhood gangs to basically the thugs on higher. Than we have Community Resistance that manifests itself in insecurity. All of that together is undermining our ability to do good health work. What are we doing about it . I think we are continuing to talk to the community, get the Community Involved in determining what their perspective is that our recommendations but clearly the security environment has been unstable and continues to destabilize the approach. Is one of the priorities that we are looking at. Doctor. The, and i wanted to make, i have a slight i would like to show you about the impact of the Armed Conflict. If you look at this second half of the slide, that redline, thats the current outbreak. All the lines you see before that, those are all the other outbreaks besides west africa. The insecurity is causing the lack of our ability to bring this outbreak to the end. You can see these out rex are over in four months. This outbreak now if you go back to this time of initial symptoms is actually now over a year old even though it was recognized in august some of them. I want to emphasize the magnitude of this outbreak is getting to the point that one has to anticipate that we are going to see spread outside of the outbreak area and that the direct result of the conflict blocking the ability for the Public Health response to take place. That is truly scary. This is not in my notes but after seeing that willie get to the point where i guess the folks that carry will die would decrease or just keep spreading . The problem is that in the absence of the Public Health response you get a case in that case leads to multiple other cases. You can see the curve is changing its no longer linear. It is starting to get an arch to it where it is you see all the other cases, the curve plateaus and then the outbreak stops. This is a direct result of not having the ability to operationalize what we know how to do, that is a Public Health response that we have outlined in our testimony and its blocked because of the insecurity in the area. I would like to follow up with one comment. That is the reality and its very sobering. All the more reason that our prevention initiatives in south sudan, burundi, uganda and miranda are scaled up as doctor said. Prevention order security, airport security, is very very important. The fact that we are focusing and scaling up prevention in goma which is 120 miles south of this outbreak is a critical part of this strategy. So to keep it from leaving the border and to keep it from going in to goma is part of the strategy while the Health Responders are working day in and day out to continue to address what is happening in these areas. Next question, it might have 40 been answered but i would like a little clarification. The administration, how is there calibrating a response efforts in fiscal year 20 request get a continued spread of the outbreak . Congressman i would say that that is being factored in to the request. We just met recently with they know the requirements and we will keep you updated how that goes. Thank you. I yield back the rest of my time, cheerleading, thank you. Mister phillips. Give it to chair. My district minnesotas Third District is home to one of the largest liberian communities in the country as you might know. In 2014, 2015 of course ebola hit their country and one of my extraordinary staffers in minnesota is a liberian and her husband patrick is one of the very First Americans to actually die of ebola. I dedicate my questions today in his memory. It is sometimes difficult to connect Foreign Affairs to dinner tables in america but there is no question that if we dont help african nations stem the tide of ebola it truly will appear on our doorstep so i am grateful to both of you for the extraordinary work you do. I believe chairwoman asked some similar questions earlier but my first question is about the distressed of International Workers in the drc. Some of course in the drc believe that the ebola heartbreak was deliberately created and wont go to facilities to seek care when they show symptoms. What specifically very specifically relative to Community Engagement education is being done to educate and try to overcome the challenge . As we look at this reset that we are supporting as part of the Us Government whole of government response, the folks on the community specifically being targeted. In addition to engaging more effectively with the communities themselves, certain projects are being identified, some to do with increasing opportunities for them to earn Small Projects in the community, via infrastructure, wealth, just to see if we could benefit and benefit them with smallscale Infrastructure Projects that will end up at the individuals as well as the community. That is step one as we look at other opportunities to engage, its going to be a challenge to continue to build first of all to understand but then to build credibility so that the community itself can begin to own and collaborate with the Health Responders for if it is very specifically, who are the gatekeepers in these communities and how is information conveyed. Is it through, here it would be through social media is it through families and faceto face, is it through advertising, is it through places of gathering . How do we try to communicate and overcome this . Congressman is all of the above, media direct contact facetoface meetings unicef is involved, cdc is involved with some of their community programs. Our partners are involved, that information is being collated and applied to improving Community Relations and building trust. Anything you wish to add . I think the complexity congressman is that this is an area where distrust is really deep. When we went there with that will maybe we could meet with the leaders. What what leaders . There is actually well over 100 different small rebel groups. One thing to deal with the adf, you can find a leader and talk to him. But this mahimahi is a bunch of small groups with small leaders and disinformation going back and forth so you get one group to have the right message but then the other groups dont agree with the message because they dont trust that group. Its going to be a long haul to get trust in that area. We reached out to the religious community to do that the bishop and again they had a priest that was killed another bishops are being intimidated so its a very very complicated environment right now. How to really build trust in the community thats been at war for 25 years is going to be very complicated and it will take a long time. That is one of the reasons we are concerned. This reset is credible we have to get the Community Involved and we have to figure out something on security side. Both of those are not easy answers how we would get either one of them done. A quick question, is the government of the drc problem part of the problem or part of the solution . I cannot comment, i will at the admiral comment. Historically this is an area that does not trust their own government. Whether its different with the new president time will tell but historically they did not trust their own government. I would just concur with what dr. Redfield said. This Community Feels abandoned in has been abandoned and it will take a long time for them to trust the government. The good news, is that we have a different government that is in transition remains to be seen once the cabinet is appointed how they will appropriately respond. If adjusted, would you are they might trust something from us with the american brand on it as a source of information more than their own government right now relative to overcoming this . Pretty hard to speculate who they might trust. I would say they would trust their local presented his more than anybody else. I think it did mentioned earlier that the president did take a trip out. Its the first time a president had been in the area for years. That is a step. Good thank you i yield back. In just a moment i will yield additional time to mister smith but before i do i just want to ask a quick followup question to doctor redfield. Its my understanding that the World Health Organization has twice decided against declaring this outbreak is an International Public Health Emergency as it did for the ebola epidemic in liberia. First of all is that correct . Yes congresswoman. And if the World Health Organization did declare this in International Emergency would it help to increase the production of vaccine or other measures that could be taken that would help to get this under control . I think that who has made it clear we were just that the World Health Assembly and they may direct request that we need to stimulate more vaccine production. The decision to do an International Significance is really a who decision, a committee decision. Historically they have stayed to pretty strong guidelines that they do that when there is crossborder transmission. I will say that nothing about their decision to declare it or not declare is impacting the United States ability to respond. Its basically a consequence of their arbitrary guidelines that the committee has about calling it. Thank you with that i yield additional time to mister smith. You very much. This is drcs tent outbreak of ebola, is there any evidence that anywhere else in the congo this hideous disease is manifesting . Let me also ask you in your testimony you talk about training some 1600 community Health Workers to conduct surveillance equipping them with knowledge and tools to gather information and track the disease and then you go on to say that you have trained nearly 3000 healthcare workers in patient screening isolation appropriate Waste Management and other practices to prevent disease transmission as well as handling triage and isolation infrastructure. First of all, let me just say how grateful members of the committee, i am certainly, for that at the herculean response. Its amazing. We are taking the lead as we do so often as we have in the past. So thank you for stepping up and doing it so robustly. That is a lot of training and maybe you could explain a little bit with that training entails but i want to thank you for that first and foremost and you might want to speak a little bit further. Doctor redfield you talk about cdc has designed the trainers course for frontline response workers on tracing and also that there is an ebola exposure window calculator Smart Phone App for case investigators. If you could provide us with some details on that again talking about innovations Lessons Learned, the title of your testimony. The cdc i think is really responding very aggressively in a very effective way as well. I think the good news story for every american, they know their taxpayer dollars are being very aggressively deployed in a way that most likely will mitigate this terrible outbreak and as you said doctor redfield, the congregating factor of insecurity has so exacerbated what could have been maybe even stopped months ago so i think thank you. Break great big thank you. I did ask earlier about the use of cell phones maybe you could speak to that. We know in liberia and sierra leone that cell phone messages were everywhere about what to do and that really helped get the message out which helped to contain the contagion. Let me start the last questions on the cell phones. I know Cell Phone Technology and use is being brought in too many many Different Development and health programs. How its specifically being applied during these two provinces i will have to get back to you on that. On the training thank you. U. S. A in the u. S. Government usaid recognize the need for training on all levels, basic education and health training. We look at the security agenda with a good capacity and Health Systems training. Its all about the investment in training healthcare workers so thank you for that recognition. A couple of comments to talk about what you brought out, am trying to read my notes for the first one i cant read my own writing that is a good. Its because youre a physician. I am a doctor. I will start with the idea of the mitigation. The challenge we have is not that people dont know that there is an Ebola Outbreak but i am telling you people who got sick with ebola, a lot of them are deciding to stay home and hide. 40 die. So is not just them that there hiding its their family members citing. So this distrust issue is beyond knowledge. Its really something when you know youre sick you likely have a bullet you know your wife has a bola and you know theres a Health Facility there and you dont maybe trust that are not in as i tell you you basically stay home until you die. That the big problem. I think that is important and thats why i said it would take a long time. We are hopeful that we can get the word out because there is now for experimental therapeutics with Clinical Trials with promising therapeutics that ebola is not the same death sentence as it was in the west outbreak but how can we start to get that information out to the community. Its actually an advantage for you to come forwarding it treated both in our ability to hydrate you properly because we have learned how to do this better and now that theres an opportunity to get some very new promising experimental therapeutics. Thats really a key issue. I will say our training or Field Epidemiology Training Program which we have in over 70 countries as i said in the drc its our lifeline. Weve got almost 200 individuals that have gone through what we call a twoyear epidemic Investigator Program like we have in the United States. When the eastern when the western outbreak happened in the early spring when it first became cdc director we were able to mobilize about 40 or 50 of those people along with cdc and that outbreak shut down unless and 60 days. Now you have the eastern outbreak, we were able to utilize a lot of those individuals that without the technical stewardship of the leadership of cdc to provide some ability to make sure what we said needed to be practiced is actually being practiced and reinforced in the field as driven by the insecurity. We have started a center of excellence with the minister of health in goma for a bola so we are trying to really enhance accelerating training the trainers so that if we can be in the field at least we can be training the people that can go in the field and make sure increase in their skill set more and more and more. That is currently ongoing in goma and will continue but i will say our Overall Concept here is we are not planning a threemonth strategy or a sixmonth strategy. We need to dig in and realize that this is going to be a 12, 18, 24 month strategy and make investments in the 24 month interventions like holding the center to train people how to deal better with mobile ebola. You said 43 travelers that you mentioned per day that come to United States from the deer congo and largely from the infected areas that you said, how much of a risk is that and not just to us but also the other african country due to travel. How well screened are they before they hop on an airplane or use some other mode of transportation . Right now for the congo we do level ii screening. We have our ports of entry alerted and as you mentioned these individuals are not from areas where there is active transmission at this point. That said, we are still alerted to being able to start looking at travelers that are coming from the dsa. As you mentioned of the hundreds of thousands of travelers we are very fortunate that not too many are coming from the congo. I can tell you from the north kiva region its probably almost reportable in terms of having travelers and their. Is not in an area that has travel, travel is not part of their culture. I think if we do get into goma that will change. If we get into a some other parts of the drc, that will change. Again thank you for your leadership, thank you for the risk you take when you go there, and all the personnel that are deployed there from the United States and other places but for those who do it we all are very very grateful. To yield back. I think someone has additional questions lets i have had the opportunity in a Different Committee thy servant to be doing a little bit more of a deep dive on the Mueller Report on election interference also on a test report that i am participating on. As a result of that deeper dive i have had the opportunity to understand just how involved russia was in the disinformation and misinformation with the eighth outbreak in south africa in the 80s and deliberately pointing the finger at the us and hour involvement or lack thereof in that particularly outbreak. I guess my question to you is as russia and china are really rising on the continent of africa and they are influenced clearly rising again in that particular area, have you any concern, have you seen anything that would indicate that there is any sort of campaign of disinformation against the United States specific about the rise of ebola, is that something that concerns you . You for the question. At this point we have not seen any indication that there is any direct strategy or attempt to undermine the issue. That has not been an issue for trying to get the Ebola Outbreak under control. Are you concerned at all about that given the rise of russias strength . In the 80s they were consistent it significantly weekend and that was a weak attempt at disinformation but do you have any concerned that at this point in time it might become more strong . I think the awareness is very high. I think the concern is there and there are a number of agencies looking at that. The positioning, the influence of china is a priority to any extent that it might be involving or undermining our ability to respond better to this outbreak, well get back to you on that but i dont let that. Thank you i appreciate it, youll back. Mister phillips. Thank you madam chair. Doctor, on a scale from 1 to 10 how well prepared is the United States, god forbid, if we face in a bola outbreak or for that matter any other contagion on a National Basis . The domestic footprint or dealing with crossborder cases coming into the United States is one of the great benefits of the 2014 is that we really have established a system. Multiple hospitals now across the country have been firmly prepared ahead of time how to do this in an effective way so we dont repeat some of the situations that happened in 2000. I think as i said in my testimony at present the risk to our nation directly is extremely low just because apprentices. That may change if we get outbreaks and if it spreads into goma or compile or Something Like that if this goes on. We do have a very effective Screening Program now that we have developed in the sense of the consequence of the 2014 experience. I think we are very prepared here. This is why i come back and say and i will say to you in general for our Health Security the best thing this nation can do to protect itself security is to detect respond and prevent these outbreaks where they start. A grade. Is there anything you would like to see us provide resources for or improve strategically in the country . I think that as we do these emergency responses from cdcs perspective on like save my colleagues at usaid, there are some things that would be able to make us more effective and more efficient. Particularly the ability to have direct hiring authorities for these emergencies, usaid has that we dont have that. Same things in terms of our ability to procure different items that we need to secure so that we could have what we call other transactional authority so that we can actually procure we need when we need it. Those two things will be very helpful for supplies and not go out to 1 million different people to try to get Competitive Bidding when we need an emergency response. This would allow us to be much more effective, much more efficient, and these responses. It is something that cdc director we would like to see that we have that ability for these emergency responses. Thank you. I yield back. Leslie, i guess i get the last word, i am still highly concerned and i think we all are about the potential for travel to the United States. I understand we are fortunate that at this point we have a low rate of travelers from the drc and that they are screened before they come here but my understanding from i think it was your written testimony is the incubation period could be as long as 21 days. Presumably somebody could be screened and not be showing any symptoms, is that right . They could be screened and not show symptoms at the time they are screened but if they were from a highrisk area than they would be put into a system to self monitor for the development of a fever. So like what we did in the present and 14 outbreak where the Health Departments were bringing them into a system, let them self monitor, if they do develop a symptom favor then basically they would get Laboratory Diagnosis and then be handled appropriately. That is dependent on accurate reporting . The self Monitoring System . I think the advantage we have, some of it is self monitoring. We do have the point of exit so we know individuals that are coming from the exit. Its not like for example if we are dealing with middle eastern respiratory virus where the real introduction might be someone shared a smoking lounge in london. We would not have any understanding of that. Here at least we know the areas that are at risk where there is active transmission. Those individuals would be identified and strained as they came into this country and then they would be set up with the Health Department depending on Different Health departments we do it different ways but most of the individuals do self temperature assessments they call them. To have a temperature yes or no and followup there. It worked pretty effectively in the 2014 outbreak once they got operationalized. Having said all of that the need for containment is very much recognized by all of us here today. I would like to think thank those of you for your time on this very important subject and also to everyone who attended this hearing as well of the members who attended and asked very good questions, with that this meeting is adjourned. Tank you. Thank you. Sunday night on afterward, in his latest book the conservative sensibility pulitzer prizewinning columnist george will offers his thoughts on american conservatism. He is interviewed by National Review Senior Editor jonah goldberg. I believe our country is spurious to that extent i am a nationalist. Superior in the sense that it embodies as Margaret Thatcher said is made by a philosophy that is right and that is not suitable for all people at all times but everyone ought to aspire to it. I dont want to export it at bayonet point, i want to make it available to people. I want to help them where we can and we have a lot of experience with the Civil Society of the democratic society. So i am a mild nationalist. Watch afterwards sunday at 9 pm eastern on book tv on cspan number two. Intelligence analyst testify wednesday and invocations of Climate Change on National Security. Watch that House Intelligence Committee hearing live at 8 30 am eastern on cspan3 or online at cspan. Org. For 40 years cspan has been providing america unfiltered coverage of the White House Supreme Court and congress and Public Policy events in washington d. C. Around the country so you can make up your own mind. Created by cable in 1979 cspan is brought to you by your local cable or provider. Cspan, your unfiltered view of government. Panelists of the Hudson Institute discussed the role of a rocket as tensions build between the u. S. A and iran. This came after President Trumps recent announcement that he was deploying more troops and military resources to the middle east to deter threats from iran