Epidemics and disasters. We are so pleased to be here today with you. Ofare here for a discussion the urgent ebola crisis in west africa. There have been estimates in the last few days the project as many as 20,000 cases of ebola by november and as many as 1. 4 million cases of ebola by the end of january, without an immediate and massive response. In the affected countries, there is a terrible consequence and academic hardship on the ground and epidemic hardship on the ground. Ebola combines an extraordinary case fatality rate with the capacity to spread by contact, an inability to treat with medicines or prevent with vaccine, and dublin time as short as 20 days. Theres no other Infectious Disease like this. A disease once relegated to remote villages is now threatening to take hold in major cities in africa. But there are also major new efforts underway the u. S. Government and by the who, and other governments in the world. Cdc is making its Largest International response in history. More than 100 people on the ground in west africa. Hundreds of people in the cdc Emergency Operation center. Usaid is providing hundreds of thousands of Home Protection kits and training and information. Its people are moving 100,000 units of personal protective equipment to west africa. The u. S. To farming of defense is providing 3000 u. S. Forces for the response, establishing a regional staging base to facilitate the arrival of equipment and supplies and preparing to trains hundreds to train hundreds of health care providers. We know who has provided a roadmap for response and is providing expertise in africa and is seeking funding from governments around the world. Ngos like Doctors Without Borders are heroically leading the efforts on the ground. In our discussion today, we will hear about the situation on the ground in west africa by people who have been there quite recently and to our leading the effort. We will learn about what the u. S. Government is doing in more detail and, perhaps most important me, we can take to end this crisis perhaps most importantly, we will discuss what measures we can take to end this crisis. Our speakers today, who we are so fortunate to have, given all that they are doing in this response first, the director of the usaid office of u. S. Foreign disaster assistance. Tom frieden, director of the u. S. Center for disease control. Joseph, cofounder of the well known organization and the assistant secretary of defense for nuclear, chemical, and biological programs. We are sorry not to have keiji kejii fukada. His boss said she needed him in new york today. Feel free to make your comments from there or come to the podium. Thanks for the opportunity to speak. It is great to see this level of interest on the hill. This is a remarkable challenge. I think it will take it is taking the whole of government and it will take a whole of Society Response for us to fully support the liberians the liberian, sierra leone, and guinean governments. This is a crucial piece to our ultimate success. I will talk for just a few minutes about the over arching u. S. Strategy that the president laid out last tuesday and usaids specific pieces of that, then turn it over to my colleagues to go into more depth on their respective pieces. As the president laid out on tuesday, we have a fourpillar strategy that the u. S. Government is pursuing across all of its many capacities to try and control and ultimately defeat this outbreak, but also to look beyond the immediate outbreak at the longerterm needs of Health Systems and the resilience of these countries to what will be a likely future outbreak of this as well now that this is in the environment in other countries such as uganda and drc. We dont want this whole episode to result the next time that happens here we do know from those other countries that it can be controlled when there are measures in place to do so. The first pillar of the strategy is to focus on controlling the immediate epidemic and the immediate outbreak. The second pillar focuses on mitigating second order impact, things like food security, economic and political stability , and ensuring that as these countries struggle with the immediate outbreak, that we dont see second order impacts that are equal to if not greater than the outbreak itself in terms of human out human impact. The third pieces to coordinate an effective global and u. S. Government agency response. Coordination will be critical to the success of this, both at a country level and at a global level. There are many, many countries that are looking to play a role here, and in any major response that we undertake, there is a large coordination element, that hundreds and hundreds of ngos that famously showed up in haiti are a wellknown example of. In this case, its even more critical, because this is something that none of us have ever done on this scale before. Having cord did action is all the more important for that reason having coordinated action is all the more important for that reason. It is also critical because there is an ability to prevent future outbreaks of this magnitude. It is critical for the longterm future of these countries, but also critical in the immediate term that some of the neighbors do not see outbreaks on this scale. And i think the fact that cases have popped up in a few of the neighboring countries so far not triggering any major outbreaks is an indicator both of the risk but also of the potential to keep this managed with swift and decisive action. Just to speak briefly about usaids role. The office that i lead has the standing role in the federal government as the lead coordinator for International Disaster response. And so, in that capacity, we have sent a dart team to the region that has representation from across the interagency, works closely with the larger cdc team that is also there on the ground, also has cdc representation on the dart as well. The focus of the dart team is both to coordinate the agency input and also to deliver and execute on usaids pieces of the response. Our current focus, and i wont reiterate everything that president has already announced, but our current focus is along five lines of effort. The first being effective in country management and leadership of the response. We are very policed please to announce today that the Liberian NationalEmergency Operation center has opened officially. All of the elements of the liberian government coordination now sits under one roof after a great deal of u. S. Government support. The second element is to focus on scaling up isolation and treatment. So we are focusing heavily on getting etu set up and working closely with dod in that effort. The ebola treatment unit, excuse me if i use acronyms that you all dont recognize. Please just raise a hand. Its hard to think about. Fairly ingrained. The third piece of that is safe burial. We are on track to have we are on track i think thats one where weve seen the most rapid process. It is one of the more easily scalable pieces of this. We are on a good track there. The fourth element of this is Infection Control. More broadly within the country and a big piece of that will be the Community Care strategies that the president announced last tuesday. That will focus on beyond the etus, enabling communities and necessary households to safely isolate and provide care when etu treatment is not available, because that takes time to scale. The protective kits that tom referenced in the opening remarks are an important part of that approach and were happy to talk more about that. And then the fifth element is communications and social mobilization. This is a new disease in all of these countries. Theres a lot of misinformation and misunderstanding about it, and ensuring that theres accurate understanding, accurate information, and that people know the basics on how to protect themselves is a critical piece. Underpinning all of that is a huge logistical effort that both we and dod are working on very intensively to ensure both adequate procurement, adequate transport, as well as adequate supplies and supply Chain Management within the country, because the volume of personal protective equipment, chlorine and other supplies, that are required to run a medical operation on this scale is just enormous. So, thats a huge piece we are focusing on. Thanks. Tom . So, thanks very much for bringing us together and senator to senator coons office and to all of you for your interest. Ive been doing Public Health, running Public Health agencies for a few decades on a few continents and i became a doctor working in new york city in the 1980s where i cared for literally hundreds of people dying from aids with a limited ability to do much other than help them die comfortably. And that experience was searing for me personally, and ive never seen anything like that until i was in monrovia recently. And went during ebola treatment unit run by Doctors Without Borders who are working really with just incredible effort, their largest response ever, exceeding the capacity, stretching the limits of their operations. But we went into a treatment unit and we saw really a scene out of dante. It was patients who were in all stages of the disease, from those suspected but maybe didnt have it and maybe might get it there if they werent effectively separated from others. And our Lab Next Door was working more than 12 hours a day confirming within a few hours whether people had disease or not. People who were just getting in and being cared for and desperately needed rehydration to survive. Patients who were recovering, including one guy who was healthy enough to complain about the food. I thought he should probably be helping to make the food if he could complain about the food. [laughter] but also, tragically, three patients who had died in the past few hours, and the staff was so overwhelmed, they could not remove their bodies. And this is the facility in which there are 14 to 20 beds per tent. One person in one tent who had died was next to the other patients who were struggling to live. And that kind of situation is the real world example realworld exemplification of what it means to have an exponentially increasing outbreak. Its a very hard term for all of us, myself included, to get our minds around, that it is doubling in 20 to 30 days in the region. That facility had had 60 bodies removed that day. So, the situation right now in west africa is an absolute crisis. It is moving faster than it is easy to understand, particularly in liberia, and weve already seen exports to both senegal and nigeria. We now have a field team in rule cote divoire in rural cote divoire looking at cases there. If i were to just summarize for a minute, what we need is an Immediate Response that is sustained, and then make sure that this doesnt happen again. And if i can just outline those three concepts for a moment. Ive never seen a Public Health situation with this much need for immediacy. As ive explained to people, and an adequate response today is much better than a great response in a week. It is that urgent. And thats the case, really, in all three countries that are affected, even though liberia has, by far, the most out of control situation. But there are districts within liberia that are having relatively few cases. They have the opportunity to stop it before it spreads widely there. And where there are many cases, we are intensively trying to scale so we can reduce the spread. In sierra leone, where cases have not increased quite as quickly as in liberia, we have the opportunity to prevent a liberialike situation. In guinea, where cases have had three consecutive waves where it has expanded and been controlled, they have the potential of keeping it under control. The best analogy or the best metaphor is a forest fire. We see the forest fire raging in many districts of both sierra leone and liberia, especially that tricountry area. Theres a threeborder area where the three countries come together. It a deeply forest did deeply forested region. It has very poor infrastructure, has very poor relations with the rest of each of the countries but is the crucible of this epidemic. And other Capital Cities of freetown and monrovia which are the worlds first Extensive Urban spread of ebola in the context of the worlds ebola epidemic. So an Immediate Response is critically important and thats why president obamas announcement at the cdc last week is of critical importance that the department of defense is already on the ground. Usaid and the dart process is there. And the needs are extraordinarily large. And thats whats really hard to get our minds around because not only are the needs large today but they will be twice as large in less than one month. And if were going to be successful we have to build to where theyre going to be in a month. And were going to have to sustain this, because once we tamp it down controlling ebola is something that cdc has done for decades with who, with other countries. In 2012, in uganda where work on ebola many times, tragically a 12 Year Old Girl died from ebola. What was striking was that she was the only one who got ebola. Thats the only time in history weve seen a situation like that that im aware of, other than a laboratory incident, where there is someone who got it but people thought immediately, this might be ebola, they immediately isolated her, tested, and confirmed it was ebola. They confirmed that when she died she was safely buried and they ensure that any contacts were tracked. If they had gotten ill, they would not have spread it further. If that kind of core Public Health service, finding problems quickly, responding and preventing were possible, if that had been in place a year ago in these three countries, the world would be a very different place today. But the fact is we now have an outbreak that is likely to continue for a significant amount of time, and to protect other countries, we need to surge. So, when one individual went to lagos, city of 21 million people, about the same as the three cities in west africa the three countries in west africa, we got on the phone with the governor of lagos and Health Minister of nigeria. We sent a team of experts within 48 hours to be there. We brought in 40 people who we who were trained in the polio eradication effort and working effectively now they are not completely out of the woods but it does look like they have controlled the outbreak in both lagos and port harcourt. That involved more than 1000 Health Care Workers doing among other things more than 19,000 home visits to measure temperature of nearly 1000 made named contacts. That was to address one case of ebola. So, we need to have a response that is immediate, that is sustained, and that prevents future events like this. Because we could have prevented this in the first place. Sars cost the world 30 billion in just about three months. The economic implications of ebola in west africa, not just west africa, not just for africa, but for the world are quite substantial. Who, in the publication yesterday, raised the possibility of ebola becoming endemic in africa, and that would mean, for those of you who are not in the Public Health world, that it would continue on an ongoing low or medium level indefinitely. We think thats not inevitable. We think if that were to happen, it would be an enormous problem, not just for west africa and africa, but for the world, because we would always have to be thinking about the possibility of ebola. Anyone who had been in any region that might have a case of ebola i would reiterate the approach that president obama has outlined is exactly what we need , and we need to get to scale and speed that will match the exponential growth of the outbreak to ensure that we have an Immediate Response, sustained , and prevent this from happening both where it is not happening now and from happening again anywhere, whether it is ebola or any other health threat. Thank you. Thank you for the invitation to talk today. Let me start sorry. Let me start by saying i completely echo director friedens comments. We happened to see each other in sierra leone while he was there. Id like to preface my remarks with the fact with the understanding that i am mostly speaking from my experience in sierra leone and liberia. By remarks tend to be skewed towards those countries which are currently experiencing the worst parts of the outbreak. And when we say the situation is dire in sierra leone and liberia, we just cant emphasize that strongly enough. What we are facing is an end ofdays scenario locally, of biblical proportions. And the people of those countries largely feel abandoned by the International Community. However, that response is now starting to trickle in and there is hope, there is a light at the end of the tunnel, hopefully, although it is going to get worse before the its better. Id like you to keep in mind when were talking about at least those two countries, we are talking about two countries that have endured almost a decade of civil conflict. We are approximate 11 years out from the end of the civil conflict and considering build a Public Health care infrastructure in just 11 years is an enormous task. We were dealing with regions which are almost on the brink of not being able to offer sufficient health care on a normal day. What weve seen since the onset of the outbreak is a complete breakdown in the Public Health and the health care infrastructure. Schools are closed. Hospitals that havent even experienced ebola are closed. And i think from that we may never know the toll of deaths that resulted from nonebola cases, from very normative infections that occur every day in sierra leone. There was a headline today on cnn that you have ebola unless proven otherwise, and that is indeed the case. Before this outbreak i could argue the case would be you have malaria unless proven otherwise. We have complicating this factor that ebola is now occurring in the highly mobile environment, that is well connected by roa