[House Hearing, 113 Congress]
[From the U.S. Government Publishing Office]



 
                       COMBATING THE EBOLA THREAT

=======================================================================

                                HEARING

                               BEFORE THE

                 SUBCOMMITTEE ON AFRICA, GLOBAL HEALTH,

                        GLOBAL HUMAN RIGHTS, AND

                      INTERNATIONAL ORGANIZATIONS

                                 OF THE

                      COMMITTEE ON FOREIGN AFFAIRS

                        HOUSE OF REPRESENTATIVES

                    ONE HUNDRED THIRTEENTH CONGRESS

                             SECOND SESSION

                               __________

                             AUGUST 7, 2014

                               __________

                           Serial No. 113-209

                               __________

        Printed for the use of the Committee on Foreign Affairs


Available via the World Wide Web: http://www.foreignaffairs.house.gov/ 
                                  or 
                       http://www.gpo.gov/fdsys/

                                 ______




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                      COMMITTEE ON FOREIGN AFFAIRS

                 EDWARD R. ROYCE, California, Chairman
CHRISTOPHER H. SMITH, New Jersey     ELIOT L. ENGEL, New York
ILEANA ROS-LEHTINEN, Florida         ENI F.H. FALEOMAVAEGA, American 
DANA ROHRABACHER, California             Samoa
STEVE CHABOT, Ohio                   BRAD SHERMAN, California
JOE WILSON, South Carolina           GREGORY W. MEEKS, New York
MICHAEL T. McCAUL, Texas             ALBIO SIRES, New Jersey
TED POE, Texas                       GERALD E. CONNOLLY, Virginia
MATT SALMON, Arizona                 THEODORE E. DEUTCH, Florida
TOM MARINO, Pennsylvania             BRIAN HIGGINS, New York
JEFF DUNCAN, South Carolina          KAREN BASS, California
ADAM KINZINGER, Illinois             WILLIAM KEATING, Massachusetts
MO BROOKS, Alabama                   DAVID CICILLINE, Rhode Island
TOM COTTON, Arkansas                 ALAN GRAYSON, Florida
PAUL COOK, California                JUAN VARGAS, California
GEORGE HOLDING, North Carolina       BRADLEY S. SCHNEIDER, Illinois
RANDY K. WEBER SR., Texas            JOSEPH P. KENNEDY III, 
SCOTT PERRY, Pennsylvania                Massachusetts
STEVE STOCKMAN, Texas                AMI BERA, California
RON DeSANTIS, Florida                ALAN S. LOWENTHAL, California
TREY RADEL, Florida--resigned 1/27/  GRACE MENG, New York
    14 deg.                          LOIS FRANKEL, Florida
DOUG COLLINS, Georgia                TULSI GABBARD, Hawaii
MARK MEADOWS, North Carolina         JOAQUIN CASTRO, Texas
TED S. YOHO, Florida
LUKE MESSER, Indiana--resigned 5/
    20/14 noon deg.
SEAN DUFFY, Wisconsin--
    added 5/29/14 
CURT CLAWSON, Florida--
    added 7/9/14 

     Amy Porter, Chief of Staff      Thomas Sheehy, Staff Director

               Jason Steinbaum, Democratic Staff Director
                                 ------                                

    Subcommittee on Africa, Global Health, Global Human Rights, and 
                      International Organizations

               CHRISTOPHER H. SMITH, New Jersey, Chairman
TOM MARINO, Pennsylvania             KAREN BASS, California
RANDY K. WEBER SR., Texas            DAVID CICILLINE, Rhode Island
STEVE STOCKMAN, Texas                AMI BERA, California
MARK MEADOWS, North Carolina


                            C O N T E N T S

                              ----------                              
                                                                   Page

                               WITNESSES

Tom Frieden, M.D., Director, Centers for Disease Control and 
  Prevention.....................................................     8
Ariel Pablos-Mendez, M.D., Assistant Administrator, Bureau for 
  Global Health, U.S. Agency for International Development.......    22
The Honorable Bisa Williams, Deputy Assistant Secretary, Bureau 
  of African Affairs, U.S. Department of State...................    30
Mr. Ken Isaacs, vice president of program and government 
  relations, Samaritan's Purse...................................    51
Frank Glover, M.D., missionary, SIM..............................    66

          LETTERS, STATEMENTS, ETC., SUBMITTED FOR THE HEARING

Tom Frieden, M.D.: Prepared statement............................    14
Ariel Pablos-Mendez, M.D.: Prepared statement....................    25
The Honorable Bisa Williams: Prepared statement..................    34
Mr. Ken Isaacs: Prepared statement...............................    57
Frank Glover: Prepared statement.................................    68

                                APPENDIX

Hearing notice...................................................    78
Hearing minutes..................................................    79
Written responses from the Honorable Bisa Williams to questions 
  submitted for the record by the Honorable Frank Wolf, a 
  Representative in Congress from the Commonwealth of Virginia...    80
The Honorable Edward R. Royce, a Representative in Congress from 
  the State of California, and chairman, Committee on Foreign 
  Affairs: Prepared statement....................................    83


                       COMBATING THE EBOLA THREAT

                              ----------                              


                        THURSDAY, AUGUST 7, 2014

                       House of Representatives,

                 Subcommittee on Africa, Global Health,

         Global Human Rights, and International Organizations,

                     Committee on Foreign Affairs,

                            Washington, DC.

    The subcommittee met, pursuant to notice, at 2 o'clock 
p.m., in room 2172, Rayburn House Office Building, Hon. 
Christopher H. Smith (chairman of the subcommittee) presiding.
    Mr. Smith. The subcommittee will come to order, and good 
afternoon to everyone.
    I have called this emergency hearing today during recess to 
address a grave and serious health threat which has in recent 
weeks gripped the mass media and heightened public fears of an 
epidemic, the Ebola virus. What we hope to gain from today's 
hearing is a realistic understanding of what we are up against 
while avoiding sensationalism.
    Ebola is a severe, often fatal disease that first emerged 
or was discovered in 1976 and has killed 90 percent of its 
victims in some past outbreaks. Since March of this year there 
have been more than 1,700 cases of Ebola, including more than 
900 fatalities in Guinea, Liberia, Sierra Leone, and Nigeria. 
This time, the average fatality rate in this outbreak is 
estimated at 55 percent, ranging from 74 percent in Guinea to 
42 percent in Sierra Leone. The disparity in mortality rates is 
partially linked to the capacity of governments to treat and 
contain the disease and per capita health spending by affected 
governments.
    There is also concern that given modern air travel and the 
latency time of the disease, the virus will jump borders and 
threaten lives elsewhere in Africa and even here in the United 
States. In my own State of New Jersey, at CentraState Hospital 
in Freehold, just a few hundred yards from my district office, 
precautions were taken. A person who had traveled from west 
Africa began manifesting symptoms, including a high fever. He 
was put in isolation. Thankfully, it was not Ebola, and the 
patient has been released.
    New Jersey Health Commissioner Mary O'Dowd reiterated to me 
yesterday that New Jersey hospitals have infection control 
programs in which they train and are ready to deal with 
potentially infectious patients that come through their doors. 
She also told me that physicians and hospital workers follow 
very specific protocols prescribed by the CDC on how to protect 
themselves, as well as other patients, and how to observe a 
patient if they have any concerns, which includes protocols 
like managing a patient in isolation so that they are not 
around others who are not appropriately protected.
    The commissioner also underscored that the Federal 
Government has U.S. quarantine stations throughout the country 
to limit introduction of any disease that might come into the 
United States at ports of entry like New Jersey's Newark 
Liberty International Airport.
    I also hope our distinguished witnesses today will confirm 
whether sufficient resources are available and are being 
properly deployed to assist victims and contain the Ebola 
disease. Are there gaps in law and policy that Congress needs 
to address? To the government witnesses especially, my pledge 
to you is that, if legislation is needed, I will work, and I 
know I will be joined by colleagues on both sides of the aisle, 
with you to write those new policies.
    As you know, key symptoms of Ebola include fever, weakness, 
head, joint, muscle, throat, and stomach ache, and then 
vomiting and diarrhea, rashes and bleeding. These symptoms are 
also seen in other diseases besides Ebola, which make an 
accurate diagnosis early on uncertain.
    Earlier today I had a full briefing, a lengthy briefing 
with the deputy chief of staff of the President of Guinea, 
President Conde, Ibrahima Khalil Kaba, who said that the virus 
has masked many other diseases, including Lassa fever, so many 
of the doctors, especially those who have never seen Ebola in 
this part of the world before, it has been in other parts of 
Africa, but not in west Africa, just simply didn't think this 
would be Ebola. Many of them have died.
    Ebola punches holes in blood vessels by breaking down the 
vessel walls, causing massive bleeding and shock. The virus 
spreads quickly, before most people's bodies can fight the 
infection effectively, breaking down the development of 
antibodies. As a result, there is massive bleeding within 7 to 
10 days after infection that too often results in the death of 
the affected person.
    Fruit bats are suspected of being a primary transmitter of 
Ebola to humans in west Africa. The virus is transmitted to 
humans through close contact with the blood, secretions, 
organs, or other bodily fluids of infected animals. Some health 
workers, such as the heroic American missionary aid workers, 
Dr. Kent Brantly and nursing assistant Nancy Writebol, had 
contracted the disease despite taking every precaution while 
helping Ebola patients. Both of them are now being treated at 
Emory Hospital in Atlanta, Georgia, in an isolation unit after 
being flown to the U.S. in a specially equipped air ambulance.
    While there is no known cure for Ebola, both Dr. Brantly 
and Ms. Writebol have been given doses of an experimental 
antiviral drug cocktail called ZMapp developed by a San Diego 
company called MAP Biopharmaceutical. They are reportedly both 
feeling stronger after receiving the drug, but it is considered 
too early to tell whether the drug itself caused improvement in 
their conditions.
    MAP Biopharmaceutical has been working with the National 
Institutes of Health and the Defense Threat Reduction Agency, 
an arm of the military responsible for countering weapons of 
mass destruction, to develop an Ebola treatment for several 
years. The drug, which attaches to the virus cells, much like 
antibodies their compromised immune systems would have 
produced, has never been tested on humans before Dr. Brantly 
and Ms. Writebol, who gave their consent to be the first human 
trials.
    There will be hope, great hope if ZMapp works in the two 
Americans who bravely agreed to test it and it has a positive 
effect. Still, it won't mean that it will be produced in great 
quantities quickly and sent to affected people in west Africa. 
It is still an experimental drug. Those who use it might be 
given complete information on its use again, but that still is 
something that our experts I hope will address.
    There is also promising research being done by Tekmira 
Pharmaceuticals. They have come up with a drug, a process, and 
one of the comments that has been made, that it has never been 
tested on humans, that it has provided 100 percent protection 
from an otherwise lethal dose of Zaire ebolavirus, but again 
not in humans, it has been done in others, nonhumans.
    Unfortunately, there are other issues that impact the 
ability of the international community to assist the affected 
governments in meeting this grave health challenge. Some of the 
leading doctors in their countries have died treating Ebola 
victims. The nongovernmental and medical personnel who are 
there say they are besieged not only because they are among the 
only medical personnel treating this exponentially spreading 
disease, but also because they are under suspicion by some 
people in these countries who are unfamiliar with this disease 
and they fear that doctors who treat the disease may have 
brought it with them. Of course, it is not true, but again 
myths do abound.
    The current west African outbreak, as we all know and as 
Dr. Frieden has said, is unprecedented. Many people are not 
cooperating with efforts to contain the disease. There is an 
information gap. Despite the efforts through cell phones and 
radio to get the message out, of course there is still a 
learning curve.
    As we consider what to do to meet this health challenge, I 
do suggest we reconsider the funding levels for pandemic 
preparedness, and this message is to us in Congress and to the 
executive branch. In the restricted budget environment in which 
our Government operates, funding to meet these pandemics has 
fallen from $201 million in Fiscal Year 2010 to an estimated 
$72 million in 2014. The proposed budget for Fiscal Year 2015 
is $50 million, and we mustn't shortchange vital efforts to 
save the lives of people in these developing countries.
    Dr. Tom Frieden, one of today's expert witnesses, has tried 
to assure the American public that our Government is doing what 
we can do to address the Ebola crisis. He has announced the 
dispatch of at least 50, perhaps more, public health experts to 
the region within the next 30 days. USAID, WHO, the World Bank, 
the British Development Agency, African Development Bank, and 
many others are also joining in and trying to meet this crisis.
    To those who say we have no plan, I would say that planning 
is definitely underway, and it is being done so very 
aggressively. Still, there is much more that needs to be done.
    I would just say finally, I have introduced legislation 
that is known as the End Neglected Tropical Diseases Act, which 
establishes the policy of the U.S. to support a broad range of 
implementation of research and development activities to 
achieve cost-effective and sustainable treatment control and, 
where possible, elimination of the neglected tropical diseases.
    Ebola is not on WHO's list of the top 17 neglected tropical 
diseases, but it does fit the definition of an infection caused 
by pathogens that disproportionately impact individuals living 
in extreme poverty, especially in developing countries. Ebola 
had been thought to be limited to isolated areas where it could 
be contained. We now know that is no longer true. We need to 
take seriously the effort to devise more effective means of 
addressing this and all neglected tropical diseases.
    I now yield to my good friend and colleague, the ranking 
member, Ms. Bass.
    Ms. Bass. Mr. Chairman, thank you for your leadership and 
for calling today's emergency hearing to give us an opportunity 
to learn about and work to address the current Ebola outbreak 
in west Africa. I look forward to hearing directly from our 
witnesses today on the work their agencies and organizations 
are doing to combat the deadly outbreak and how they have 
coordinated with the governments of impacted countries. I 
appreciate their efforts and outreach to keep Congress informed 
on this ever-evolving and devastating situation.
    This outbreak comes as nearly 50 African heads of state 
join us here in Washington, DC, this week as part of the first 
in history U.S.-Africa Leaders Summit. I have been honored to 
join my African and American colleagues as we have worked 
together to reach the full capacity and promise of the African 
continent. We have had several productive sessions that further 
cemented the relationship between the U.S. and African nations 
and highlighted areas of opportunity for us to continue to work 
together.
    Despite the meaningful dialogue and collaboration that 
occurred this week, there is still work to be done. The 
development of healthcare capacity and global health security 
is just one area of collaboration for the U.S. and African 
nations. I do have to say that I was a little dismayed that 
with all of the activities that happened this week around the 
summit, obviously the crisis we are dealing with today is very, 
very important, but when it came to coverage on Africa, the 
coverage centered pretty much solely around Ebola.
    I want to commend the steps being taken by the Governments 
of Liberia, Sierra Leone, Guinea, Nigeria, and the U.S., and 
the great work of the many health professionals from throughout 
the world who are doing everything they can to help people who 
have contracted this awful disease. With over 1,700 suspected 
and confirmed cases and over 900 deaths since March, the 
current Ebola outbreak we know is the longest lasting, 
widestspread, and deadliest outbreak ever recorded. This is 
also the first Ebola outbreak ever in west Africa and the first 
outbreak to be spreading in both rural areas and capital 
cities.
    The unique nature of this outbreak has made combating the 
disease particularly difficult. West Africa has not faced this 
disease before, and communities, government, and health 
professionals in the nations do not have the expertise and 
capacity to address the scale, spread, and proper treatment of 
the Ebola outbreak.
    This lack of logistical expertise, healthcare workforce, 
and supplies has hindered the ability of governments to quickly 
identify, track, and isolate new cases and properly care for 
those infected. Officials have also had to fight against fear 
of the disease and cultural unfamiliarity with proper 
treatment, which have really contributed to the spread and kept 
people from seeking care.
    Yesterday, I had the privilege to speak to President Ellen 
Johnson Sirleaf on the impact of the outbreak on her country 
and the work they have done to fight the disease. I asked her 
what more we could be doing, and one of the things she talked 
about was the need for logistical support, the need for 
training of their healthcare workforce so that they would know 
how to prevent the disease. I am sure Dr. Frieden, and I spoke 
with him yesterday, also is going to say that we do know how to 
prevent the spread of the disease, but that is where our 
efforts need to be directed.
    The other thing that the President said was that the 
problem, of course, with the outbreak is all of the resources 
are centered toward the outbreak, and then just routine medical 
care has really suffered because there hasn't been the 
workforce to be able to handle both.
    So President Sirleaf called for increased international 
assistance to provide food and water to impacted communities. 
She said that the communities that were most heavily impacted 
were quarantined and that there needed to be food and water 
brought into the areas. Especially in situations like this you 
have a concern that civil unrest could be an outbreak, 
especially in areas that are quarantined that feel that they do 
not have access. And so she felt that that was one of the ways 
that the United States could help the best.
    It is obviously in our interest and in the world's interest 
to assist in the crisis and to continue to support nations as 
they fight this outbreak and work to develop and strengthen 
their healthcare systems. Healthcare is a human right, and we 
must ensure that countries have the ability to address this 
outbreak and we are able to move forward and prevent future 
health epidemics from occurring.
    Both the chairman and I have introduced legislation to 
respond to this crisis, and I look forward to your testimonies, 
and I am interested in hearing from all of you about what more 
Congress can do to assist your efforts to combat the disease 
outbreaks and support international efforts to improve 
healthcare systems around the world.
    Thank you.
    Mr. Smith. Thank you very much, Ms. Bass.
    I would just like to recognize in the audience, Zainab 
Bangura, who is the Special Representative to the Secretary 
General of the U.N. on Sexual Violence in Conflict. Thank you 
for joining us today.
    I would like to now yield to the distinguished chairman of 
the Commerce, Justice, Science, and Related Agencies 
Subcommittee of the Appropriations Committee, Congressman Frank 
Wolf, who has had a 34-year career of tremendous support for 
the weakest and the most vulnerable. As a matter of fact, the 
genesis of this hearing was a conversation with Ken Isaacs from 
Samaritan's Purse last week. We were planning on a hearing on 
the Ebola virus for September, and the sense of urgency--and 
Chairman Wolf was the one who set up that conference call--the 
sense of urgency was so great that the thought was that it is 
better now, and we can have more hearings in the future and 
more action plans and the like. So I want to thank the chairman 
for his tireless efforts on behalf of the weak and vulnerable.
    Chairman Wolf.
    Mr. Wolf. Thank you, Mr. Smith.
    I want to thank my good friend Chairman Chris Smith for 
pulling together today's hearings on such a short notice amid 
the escalating outbreak of Ebola across west Africa countries, 
including Liberia, Sierra Leone, Guinea, and now Nigeria. I 
also appreciate him inviting me to join today's hearing. 
Although not a member of the Foreign Affairs Committee, I do 
serve on the State and Foreign Operations Appropriations 
Subcommittee, which funds the State Department and foreign aid 
programs.
    I would also say to the witnesses, too, if you need extra 
money, you ought to ask for reprogramming. You ought not to be 
waiting until September, October, November, and December. You 
should ask for it immediately, and I am confident that the 
appropriate committees up here will allow it. But if in doubt, 
there should be the request for the reprogramming.
    The current Ebola epidemic has claimed over 900 people 
since it was first detected earlier this year. It has proven to 
be the world's worst outbreak of the virus ever recorded. It 
now appears that this alarming contagious disease could be on 
the verge of spreading.
    On July 28, I received a call from Ken Isaacs with 
Samaritan's Purse, one of the witnesses here today. Let me say, 
Samaritan's Purse and Doctors Without Borders have done more to 
help the poor and the suffering in many places than almost any 
other groups around, so I want to commend Samaritan's Purse, 
and I also want to commend Doctors Without Borders. Wherever 
you will go in Africa, they will be there when other groups 
have long, long gone.
    Samaritan's Purse was on the front line working to curtail 
the Ebola outbreak. The outlook, absent immediate action from 
the United States, was bleak. It appears that both the 
international health organizations and the Obama administration 
underestimated the magnitude and the scope of the epidemic. 
Despite well-intentioned efforts by local and international aid 
workers, doctors and nurses working on the ground, it seems the 
international community and the U.S. had been noticeably absent 
in helping these west African countries to get out in front of 
the spread of this epidemic. For the first part of the 
epidemic, the international community simply let three of the 
most impoverished countries in the world deal with the Ebola 
threat essentially on their own. It should be no surprise that 
the health systems in Liberia, Guinea, and Sierra Leone do not 
have the resources or the capacity to deal with this epidemic 
on their own.
    Despite early warnings from those NGOs working on the 
ground, there was little action taken to get out in front of 
this problem, and now we are seeing the consequences. Nothing 
can bring back the lives that were lost, and even the money and 
personnel deployed to help may not be enough to contain the 
epidemic.
    I spent much of last Monday, on July 28, on the phone with 
the White House, State Department, CDC, and HHS trying to 
understand just what, if anything, the U.S. was doing both to 
help contain the outbreak in west Africa and prevent the spread 
of Ebola to the U.S. I was concerned that no one could tell me 
who was in charge within the administration on this issue, and 
no one could explain what actions are being taken to ensure the 
U.S. was prepared to respond. Although more progress has been 
made over the last week since these conversations, it is clear 
that the government is still trying to catch up.
    This grave situation requires immediate and coordinated 
efforts across agencies and countries. France, Great Britain, 
and many of the countries in Europe who are very experienced in 
Africa should also be brought in.
    It also has come to my attention there needs to be an 
immediate response to the existing deficiencies in CDC 
planning, procedures, and protocols in response to the Ebola 
threat. As Mr. Isaacs will share today, and I have read his 
testimony, when its two healthcare workers were confirmed with 
Ebola, Samaritan's Purse struggled to get guidance on protocols 
for dealing with returning healthcare workers from the region. 
It soon became apparent that there were significant gaps in 
existing procedures for dealing with this. The CDC had no 
available registry of medical facilities capable of treating 
Ebola patients in the United States. There are no quarantines 
or travel restrictions in place. And there was concern about 
these gaps in the protocols and how you deal with them.
    I appreciate very much, and I want to thank Dr. Frieden, 
for taking the call, as he was getting on an airplane. I want 
to publicly thank you, Doctor, I am very appreciative that you 
are here today and hope you will talk about any deficiencies 
and how they can be addressed by the government and also by the 
Congress.
    In closing, I want to thank again Chairman Smith for 
calling this hearing during the August recess. I also want to 
recognize the men and women of the CDC and other international 
response groups who are on the ground and will soon be on the 
ground in Africa, as well as the doctors and nurses helping the 
two patients in Atlanta. I want to thank them because this is 
very dangerous, what they will be doing, and what people who we 
do not know their names will be doing. I think we should tell 
them that we are appreciative.
    I also want to thank the State Department and the 
Department of Defense for their invaluable assistance as this 
situation has taken place. This is important and serious work, 
and I know the American people, if they knew what these folks 
were doing and had been done, would appreciate their tireless 
efforts.
    This should be a very top priority of the White House, the 
political leadership of the Nation. We know the career people, 
what they are going to do, but of the White House because the 
American people deserve to know what their government 
leadership is doing to prevent the spread of this epidemic and 
keep the country safe.
    With that, Mr. Chairman, I again thank you and yield back.
    Mr. Smith. Chairman Wolf, thank you so very much.
    I would like to now introduce our first panel of two 
panels, beginning first with Dr. Tom Frieden, who has been 
Director of the Centers for Disease Control and Prevention, 
CDC, since June 2009, and has worked to control infectious and 
chronic diseases in the United States and globally. He led New 
York City's program that controlled tuberculosis and reduced 
multidrug resistance cases by 80 percent and worked in India 
for 5 years, helping to build a tuberculosis control program 
that has saved nearly 3 million lives. As the commissioner of 
New York City's Health Department, Dr. Frieden led programs 
that reduced illness and death and increased life expectancy 
substantially. He is the recipient of numerous awards and 
honors and has published more than 200 scientific articles and 
has previously testified before this subcommittee on drug-
resistant diseases, as well as other very important health 
topics.
    Thank you, Doctor, for being here.
    I then would like to introduce Dr. Ariel Pablos-Mendez, who 
is the Assistant Administrator for Global Health at USAID, a 
position he assumed in August 2011. Dr. Pablos-Mendez joined 
USAID's leadership team with a vision to shape the Bureau for 
Global Health's programmatic efforts to accomplish scaleable, 
sustainable, and measurable impact on the lives of people 
living in developing countries. Prior to joining USAID, he 
worked on global health strategy and transformation of health 
systems in Africa and Asia. He also served as Director of 
Knowledge Management at the World Health Organization. Dr. 
Pablos-Mendez is a board-certified internist and until recently 
was practicing as a professor of clinical medicine and 
epidemiology at Columbia University.
    And then we will hear from Ambassador Bisa Williams, a 
career member of the Senior Foreign Service with the rank of 
Minister Counselor and currently Deputy Assistant Secretary in 
the Bureau of African Affairs at the U.S. Department of State. 
Ambassador Williams has served as Ambassador to the Republic of 
Niger from 2010 to 2013. She has also served in U.S. Embassies 
in Mauritius, France, Panama, and Guinea. Ambassador Williams' 
postings have also included Director for International 
Organizations in the National Security Council at the White 
House and adviser at the U.S. Mission to the United Nations in 
New York.
    Dr. Frieden, the floor is yours.

 STATEMENT OF TOM FRIEDEN, M.D., DIRECTOR, CENTERS FOR DISEASE 
                     CONTROL AND PREVENTION

    Dr. Frieden. Thank you so much, Chairman Smith, Ranking 
Member Bass, Congressman Wolf, for your interest in global 
health, for your interest in Ebola, and for calling this 
hearing at this really critical and pivotal time.
    I think, first, let's remember the lives and the faces of 
the men, women, and children who are affected by the Ebola 
outbreaks in the four countries currently affected, especially 
the healthcare workers, who account for a substantial 
proportion of cases. Those are the people who we must focus on, 
those are the people who we must support, and it is in Africa 
that we can stop this outbreak and protect not only these 
countries, but ourselves as well.
    We focus on what works, and I am incredibly proud of the 
staff of the Centers for Disease Control and Prevention, and I 
think every American who would know the expertise, dedication 
of the disease detectives, laboratory experts, disease 
intervention specialists who have been on the ground in the 
past few weeks and months and who are now surging for our 
response would be proud to know what we are doing there.
    I want to start with the bottom line, three basic facts. 
First, we can stop Ebola. We know how to do it. It will be a 
long and hard fight, and the situation in Lagos, Nigeria, is 
particularly concerning, but we can stop Ebola. Second, we have 
to stop it at the source in Africa. That is the only way to get 
control. And, third, that we have to stop it at the source 
through tried and true means, the core public health 
interventions that work and that I will go through in a few 
moments.
    By way of background, Ebola is one of several viral 
hemorrhagic fevers. There are others, but Ebola is the most 
feared in part because it had a movie made about it. There are 
others that are just as deadly. The first Ebola virus was 
identified in 1976 in what is now the Democratic Republic of 
the Congo, and there have been sporadic outbreaks since. The 
natural reservoir is not known but is believed to possibly be 
bats, which then pass it to primates and other forest-living 
mammals, and humans may come in contact with them by eating 
bush meat or contact with bats. That is a theory, there is 
increasing evidence for it, but we are not certain of it.
    What we are certain of is that when Ebola gets into human 
populations it spreads by two routes. First, to people who are 
giving care to individuals who are sick with Ebola. Ebola does 
not spread from people who have been infected but are not yet 
sick. So it is only the sick people who transmit it. And, 
second, it is transmitted only by close contact with exchange 
of body fluid, so a healthcare worker or a family caregiver who 
comes into contact with a patient who is very ill, may be 
bleeding or have other body fluids that get on to that 
individual.
    That is how Ebola spreads, and in the outbreaks in Africa 
there have been two main drivers: Healthcare settings and other 
caregiving settings, including the family, and burial 
practices, where there may be practices that involve contact 
with a recently deceased person. Those are the drivers of Ebola 
in Africa.
    Again, Ebola only spreads from people who are sick and only 
spreads through contact with infectious body fluids. It does 
not spread through casual contact, it is not an airborne 
disease that it spreads in nature, doesn't spread through water 
or food, and the incubation period is usually between 8 and 10 
days from exposure to onset of illness. It can be possibly as 
short as 2 days and possibly as long as 21 days, but in that 
period it is essential that any contact be very closely 
monitored to determine if they have developed the symptoms of 
Ebola, and if they have, are followed up.
    We do know how to stop Ebola: Meticulous case finding; 
isolation; and contact tracing and management. We, with our 
partners, have been able to stop every Ebola outbreak to date, 
and I am confident that if we do what works, we will stop this 
one also, but it won't be quick and it won't be easy. It 
requires meticulous attention to detail, because if you leave 
behind even a single burning ember, it is like a forest fire, 
it flares back up. One patient not isolated, one patient not 
diagnosed, one healthcare worker not protected, one contact not 
traced, each of those lapses can result in another chain of 
transmission and another flare of the outbreak.
    To control the outbreak, we have to work effectively. The 
challenge really isn't the strategy. The challenge is the 
implementation of that strategy. Mr. Chairman, we have provided 
to the committee this basic information on how Ebola can be 
controlled, and if you would permit me, I will just go very 
quickly through this because I think it is important to get the 
fundamentals out there.
    First, to find patients and diagnose them. That means fever 
or other symptoms. The only way to diagnose Ebola is with a 
laboratory test. That is generally done by a blood test in 
Africa, and we, working with partners from the Department of 
Defense, from the Pasteur Institute of France, from other 
countries, and the countries where the disease is present, are 
scaling up the ability to diagnose patients. So the first, that 
diagnosis, is suspect it with fever, test with blood, get it 
tested in the lab. That is a critical first step.
    The second step is to respond to those individual cases. We 
do that by putting patients in isolation, by interviewing them 
and eliciting their contacts, and then by following each and 
every contact every day for 21 days, and if a contact develops 
fever, begin that process all over again, interview them, 
isolate them, find out who their contacts are. It is laborious, 
it is hard, it requires local knowledge and local action, but 
it is how Ebola is stopped.
    And, third, prevent it. Prevent it through infection 
control in health care, safe burial practices, and reducing the 
consumption or unsafe consumption of bush meat and contact with 
bats.
    The current outbreak is a crisis. It is unprecedented, and 
it is unprecedented in five different ways. First, it is the 
largest outbreak ever. In fact, at the current trend within 
another few weeks there will have been more cases in this 
outbreak than in all previous recognized outbreaks of Ebola put 
together.
    Second, it is multicountry, and one of the biggest 
challenges is that one of the epicenters is on the confluence 
of three different countries. And cases have moved between 
countries. One country gets control and then patients come in 
from another country, so that tricountry area is a critical 
challenge.
    Third, this is the first outbreak in west Africa. This was 
a disease that was unknown, as far as we know, in that area 
before, and because of this, it has been a particular 
challenge, and the health systems in these countries are quite 
weak, and this also is a challenge.
    Fourth, many of the cases have been in urban areas, and 
there has been spread in urban areas, and this is something we 
have not seen to this extent before. From everything we know to 
date, this doesn't appear to be a change in the virus, but it 
is a new development in how and where the virus is spreading, 
and it makes control much more difficult.
    And, fifth, it is the first time we are having to deal with 
it here in the United States, and that is not merely because of 
the two people who became ill caring for Ebola patients and 
were brought back to the U.S. by their organization. That is 
primarily because we are all connected, and inevitably there 
will be travelers, American citizens and others, who go from 
these three countries, or from Lagos, if it doesn't get it 
under control, and are here with symptoms. Those symptoms might 
be Ebola or something else. So we are having to deal with Ebola 
in the U.S. in a way that we have never had to deal with it 
before.
    The U.S. is working in a coordinated way to support partner 
governments and the World Health Organization. I have activated 
the CDC Emergency Operations Center at Level 1 for this 
outbreak. This is our highest level of response. It doesn't 
mean that there is an increased risk to Americans, but it does 
mean that we are taking an extensive effort to do everything we 
can to stop the outbreaks.
    We can't do it alone. There are many partners throughout 
the U.S. Government who we are working with. The World Health 
Organization, the World Bank, partner governments around the 
world, as well as, most importantly, people in-country will be 
key to stopping the outbreak.
    We will send, as I have said, at least 50 staff to the 
region. Within the next week or two actually we will have 
reached that 50 number. But I think it is important to 
understand that the 50 in-country are supported at our home 
base in Atlanta by a much larger group. As of today, even 
before the full surge in activation, we have more than 200 
staff working on this outbreak response, and we will increase 
that number substantially in the coming days and weeks.
    You will hear more about the work we are doing with the 
U.S. Agency for International Development, where we are using 
an unprecedented model to work together in a collaborative way 
to rapidly identify and call in for reinforcements and 
assistance. When we finish this response, we are determined to 
not only stop the outbreak, but leave behind strong systems 
that will be better at finding the disease and other threats, 
at stopping it before it spreads, at preventing it in the first 
place. In fact, if those systems had been there in the first 
place, we wouldn't be here today. The outbreak would have been 
over already.
    We don't know how to treat Ebola, and we don't know how to 
vaccinate, we don't have medications that cure it, but we do 
know how to care for patients with Ebola. You may have seen a 
lot of press coverage about experimental treatment, and the 
plain fact is that we don't know whether that treatment is 
helpful, harmful, or doesn't have any impact, and we are 
unlikely to know from the experience of two or a handful of 
patients whether it works.
    We do know that supportive care for patients with Ebola 
makes a big difference. Supportive care saves people's lives, 
giving them fluid, making sure they are not over or under their 
fluid balance, giving them supplemental oxygen if it is needed, 
treating other infections that occur, providing good quality 
healthcare.
    We are currently coordinating with NIH, FDA, the Department 
of Defense, and others to see whether there can be new 
treatments and whether these treatments can be effective and 
available. But there is a lot we don't know about that yet. It 
is important that we keep in mind that we do know, even without 
medicines that are specific to Ebola or a vaccine, we do know 
how to control it, and we can stop it.
    I want to spend a moment on what we are doing to protect 
people in this country. First off, the single most important 
thing we can do is to stop the outbreaks, to stop it at the 
source. The second issue that we are working on is to help 
these countries do a better job screening people who are 
leaving their countries so that they will screen out people who 
are ill or who may be incubating Ebola. And, third, because we 
recognize that we are interconnected, we are working closely 
with State and local health departments and health providers 
throughout the United States so that they are aware that there 
could be people who come from these three countries who have 
been there in the last 3 weeks, if they come in with fever or 
other symptoms, they should think that it could be Ebola, 
immediately isolate them in the hospital, and get them tested 
at CDC.
    We have issued a Level 3 travel advisory against all 
nonessential travel to Guinea, Sierra Leone, and Liberia. We 
have issued a Level 2 travel advisory about enhanced 
precautions on Nigeria, and we will reassess the Nigerian 
situation daily or more frequently as needed.
    There is strict infection control possible in hospitals in 
the U.S., and there has been some misconception about this. 
Ebola is not as highly infectious as something like influenza 
or the common cold. What is so concerning about Ebola is that 
the stakes are so high, that a single lapse in standard 
infection control could be fatal. That is why the key is to 
identify rapidly and strictly follow infection control 
guidance.
    It is certainly possible that we could have ill people in 
the U.S. who develop Ebola while here after having been exposed 
elsewhere. It is possible that they could spread it to close 
family members or to healthcare workers if their infection is 
not rapidly identified. But we are confident that there will 
not be a large Ebola outbreak in the U.S. We are confident that 
we have the facilities here to isolate patients, not only at 
the highly advanced ones like the one at Emory, but really at 
virtually every major hospital in the U.S.
    What is needed is not fancy equipment. What is needed is 
standard infection control rigorously applied. We have released 
guidance for doctors and other healthcare providers in the U.S. 
on identifying, diagnosing, and treating patients, and guidance 
for airline flight crews, cleaning personnel, and cargo 
personnel.
    Fundamentally, to end here, we have three roads before us. 
We can do nothing and let the outbreak rage, and I don't think 
anyone wants to do that. We can focus on stopping these 
outbreaks, and that is something that we will certainly do. Or 
we can focus not only on stopping these outbreaks, but also on 
putting in place the laboratories, the disease detective, the 
emergency response systems that will find, stop, and prevent 
future outbreaks of Ebola and other threats.
    We do face in this country a perfect storm of vulnerability 
with emerging infections like Ebola, resistant infections like 
the ones we discussed in our last hearing, intentionally 
created infections, which remain a real threat. But we have 
unique opportunities to confront them with stronger technology, 
more political commitment, and success stories on real progress 
from around the world.
    Earlier this year the U.S. joined with the World Health 
Organization and more than two dozen other countries to launch 
a Global Health Security Agenda. That Global Health Security 
Agenda is exactly what we need to make progress not only in 
stopping Ebola, but in preventing the next outbreak.
    And the second document that we provided for you provides a 
summary of what the mapping is between what we launched back in 
February before this outbreak was known or reported to have 
started and what is needed to stop the Ebola outbreak, and they 
are closely aligned.
    The President's budget includes a request of $45 million to 
CDC to accelerate progress in the detection, prevention, and 
response.
    A former Under Secretary of State for Africa said to me, 
citing his decades of work, that CDC is the 911 for the world. 
And though I was happy to hear that, I realized that really 
what we want to make sure is that every country, or at least 
every region, has its own public health 911. That will be good 
for them, it will be good for us in terms of safety, it will 
improve economic and social stability, and expanding that type 
of work, strengthening global health security, will allow us to 
not only stop this outbreak, but also prevent future outbreaks 
and stop them faster if they do occur.
    Thank you so much for your interest in this topic.
    Mr. Smith. Dr. Frieden, thank you very much for that very 
comprehensive and incisive testimony.

    [The prepared statement of Dr. Frieden follows:]

    
    
                                  ----------                              

    Mr. Smith. I would like to now yield to Dr. Pablos-Mendez.

       STATEMENT OF ARIEL PABLOS-MENDEZ, M.D., ASSISTANT 
   ADMINISTRATOR, BUREAU FOR GLOBAL HEALTH, U.S. AGENCY FOR 
                   INTERNATIONAL DEVELOPMENT

    Dr. Pablos-Mendez. Thank you very much, Chairman Smith, 
Ranking Member Bass, Chairman Wolf. Thank you for this 
opportunity, very timely, to allow the U.S. Agency for 
International Development to present to you an update on where 
we are with the work on this tragic and alarming outbreak of 
Ebola in western Africa. You have been a longstanding supporter 
of this area, and Member Bass quite so for Africa, so we 
couldn't have better champions in this emergency.
    The epidemic of Ebola in western Africa is historic because 
both the magnitude is unprecedented, as well as because it has 
never really occurred in this region or, as we heard from Tom, 
spreading to cities and the risk of spread beyond the region.
    I am, like many of you, saddened to see the devastation of 
the loss of lives caused by this outbreak, but also the broader 
social-economic disruption that this is inflicting in the 
region, what is really a set of fledgling democracies in 
western Africa.
    The good news, as we have heard, is we know how to deal 
with Ebola. Since 1976 there have been about 30 or so outbreaks 
in central Africa, and each of those, of course, have been 
contained. The systems don't have to be perfect. The basics 
have to be in place. Systems have to be familiar.
    Uganda has a track record that is worth noting. In the year 
2000 they had about 425 cases during that outbreak. The support 
that we provided allowed that outbreak to be contained. 
Subsequent outbreaks in 2008 only saw 149 cases, a two-thirds 
reduction, and in the last outbreak in the region, 2011-2012, 
the number was only 32. So systems can learn, can prepare, can 
deal with this outbreak. We have done it many times, and as Tom 
has said, we know exactly what to do.
    USAID, with the support that you gave us all along, 
provides routine funding to both CDC, the World Health 
Organization in Geneva and in Africa to have preparedness 
planning and response, and indeed that has been part of the 
machinery that has been put in place here. We support about 22 
laboratories in 18 countries in Africa and Asia where almost 
500 new viruses have been detected just in the last 5 years. So 
there is a lot of activity going all the time.
    This particular virus of Ebola is, again, familiar to us, 
and as far as we can tell from a biological, genetic point of 
view, it is really the same virus. It is not that it is a new 
mutant virus that has taken on new powers. It is the same virus 
we are familiar with, but it has entered a new region and has 
entered perhaps, as we speculate, because bats that have been 
tested positive in central Africa are now also tested positive 
in western Africa.
    This ecological dimension of the work that we do has to be 
kept in mind, and because of the novelty of this, neither the 
new systems or the people in western Africa and other health 
systems were experienced in dealing with the outbreak, which 
has helped contribute to the dimensions of this.
    USAID has also targeted in this year the response in 
western Africa. We started earlier this year supporting with a 
$2.1 million investment to WHO, to UNICEF, and has been 
reinforced now with $12.4 million to support CDC, the WHO, and 
the like.
    Indeed, it is important to note, to Chairman Wolf's 
comments, that the outbreak in Sierra Leone and in Liberia 
probably started, in retrospect, we now with regard to verbal 
autopsies can see that earlier on, but the cases were 
identified in late March and for a couple of weeks we have had 
this outbreak that then went down. So that in the spring the 
initial outbreaks went down, as Tom Frieden has pointed out, 
but if you allow one case in these remote areas, one case can 
reignite the whole thing, and indeed that is what we have seen 
with a secondary spike that has been truly difficult to 
control.
    These investments have allowed us to work with WHO and 
UNICEF to allow to deploy 30 or so technical experts, provide 
additional operational support, including 35,000 sets of 
personal protective equipment and supplies. Also the basics, 
soap, water, that sort of thing is also very important in this 
type of situation, and it is taking place as we speak.
    USAID is closely coordinating its response to Ebola with 
the Departments of State, Health and Human Services, and 
Defense, as well as with WHO. The CDC has the lead in the 
response to the Ebola outbreak, but the coordination--and I 
have been part of many other interagency efforts--has been 
truly exemplary, and I want to really point that out. It has 
been something the last couple of weeks that that coordination 
has been working just to make sure that we actually support 
those countries to stop this outbreak.
    USAID, in addition, has activated a Disaster Assistance 
Response Team, a DART, something that you are familiar with 
that we have deployed in other emergencies, from Fukushima 
typhoons to Haiti earthquakes, and this provides the 
architecture for the response of the U.S. Government once the 
U.S. Ambassador on the ground has declared an emergency. And 
this has indeed occurred, and the DART is now deployed, and the 
team, the team leaders and the deputy team leaders are in 
place. CDC is responsible for the health and medical part of 
this response, but there is plenty of other activities in 
planning, in operations, in communications, engaging not only 
in the USG, but with the other local governments and with the 
other partners that I mentioned before.
    I spoke with our mission director in Liberia where we have 
a large platform for health work that works very closely with 
the Minister of Health. We have only one or so health staff in 
Sierra Leone regular in Guinea, and in Sierra Leone we did not 
have a mission. And so it has been we are building out of this 
DART and working with the CDC and others to have the required 
staff and experts on the ground to facilitate the report.
    I want to report that the morale is high in our teams. 
Although the family members have been ordered to leave the 
country, our teams are staying put, working with the CDC, 
working with MSF, working with others, taking all the 
precautions to ensure their safety, but also supporting them to 
work effectively against this outbreak.
    And this reminds us, of course, that an outbreak requires 
also prevention, not only in the acute setting to avoid the 
growth of this epidemic, but also the global vigilance that we 
must maintain since these viruses know no borders.
    In the short term it is a humanitarian imperative and a 
national security priority to contain this Ebola outbreak as 
quickly as possible. It will take probably months to end it, 
but I think we can turn around these tables in the next couple 
of weeks if the proposed response that has been mounted is 
deployed and executed as planned. The U.S. Government is fully 
engaged in the response, and we are confident that we can stop 
the epidemic. As I said, it will not be easy and it might take 
several months.
    In the long term we must assist developing countries in 
strengthening their own health systems, both those dedicated to 
infectious diseases like this, but also the overall capability 
of the systems to deal, because it is about the front line 
health workers in primary care settings, in communities, and 
this time is Ebola in western Africa. We have seen H1N1 coming 
from Mexico, we didn't expect that, or MERS coming from South 
Africa. These pathogens can jump anywhere, and health systems 
need to be prepared to deal with these things as they occur.
    With your support, USAID will continue to make this a 
priority in our global health investments in Africa, and as Tom 
Frieden has alluded also, the administration is working on the 
Global Health Security Agenda for which we look to work with 
you in the plans because they will require support in the 
future, and we look forward to working with you on that. Thank 
you very much for giving me this opportunity, and I look 
forward to your questions.
    Mr. Smith. Doctor, thank you very much for your testimony 
and for your leadership.

    [The prepared statement of Dr. Pablos-Mendez follows:]

    
    
        
                              ----------                              

    Mr. Smith. I would like to note we have been joined by 
Augustine Ngafuan, who is the Foreign Minister of Liberia.
    Thank you for being with us today, Mr. Minister.
    And now I would like to yield to Ambassador Williams.

  STATEMENT OF THE HONORABLE BISA WILLIAMS, DEPUTY ASSISTANT 
 SECRETARY, BUREAU OF AFRICAN AFFAIRS, U.S. DEPARTMENT OF STATE

    Ambassador Williams. Thank you very much, Chairman Smith, 
Ranking Member Bass, Chairman Wolf, and members of this 
subcommittee, for the chance to testify before you on this very 
important topic.
    The evolving Ebola crisis in Guinea, Liberia, Sierra Leone, 
and now Nigeria is one of the most daunting challenges those 
countries and the region have faced in decades. To date, more 
than 1,600 suspected and confirmed cases of Ebola have been 
reported, including over 900 total deaths.
    Although these affected countries are home to many heroic 
and dedicated health workers, the rapid spread of the disease 
reflects the lack of national capacity, particularly in the 
three epicenter countries of Liberia, Guinea, and Sierra Leone, 
to limit the spread of the disease and to treat patients. The 
NGO community, which has played a significant role in the 
response effort by providing front line medical care to 
patients, is hard-pressed to continue to provide care in all 
affected regions.
    Compounding the issue, affected populations' lack of 
understanding of the virus and widespread mistrust of 
healthcare providers and treatment methods have further 
hampered response efforts. In significant portions of the 
affected regions, local traditions, such as public funerals and 
cultural mourning customs, including preparing bodies of the 
deceased for burial, have contributed to the spread of the 
virus and have led locals to block access to patients and in 
some places have led to attacks on healthcare workers. 
Following one such incident in Liberia, major care providers 
like Samaritan's Purse have begun pulling out of the region due 
to concerns for the safety of their staff.
    Thus, in addition to proper medical care, there is an 
urgent need for effective health messaging campaigns and public 
outreach as an integral and crucial component of these response 
efforts. We are reaching out to ensure our response is 
coordinated with the WHO and other countries that can assist 
both through our representatives at WHO headquarters in Geneva 
and through direct discussion with other governments.
    Guinea, Liberia, and Sierra Leone are still rebounding from 
lengthy conflict. These conflicts destroyed lives, 
institutions, and infrastructure. This was especially acute in 
Liberia and Sierra Leone, where the fighting went on for years. 
These countries have taken important steps to reverse the 
effects of deterioration and neglect and to build lasting 
security and stability. Border control and other factors key to 
checking Ebola's spread also are challenging for the countries 
in this region.
    Aside from our interest in making sure this Ebola virus 
does not spread to the United States or farther in Africa, we 
do not want the virus to erode the capacity of African 
countries to address other important national and regional 
challenges. We want to ensure these countries remain strong, 
strategic allies to the United States in a region facing 
serious development and security challenges. Sadly, this virus 
already has impacted peacekeeping in Somalia. The African Union 
cancelled a planned deployment of Sierra Leonean peacekeeping 
force due to fears that the virus could be introduced into the 
country.
    Given the critical importance of this issue, we are fully 
committed to doing everything possible to shore up each 
government's efforts to combat the viral outbreak and control 
its spread. We are confident that through the concerted and 
coordinated efforts of our Government and our international 
partners we can contain and stop this virus. In fact, Mr. 
Chairman, the Department has established a monitoring group on 
the humanitarian situation in west Africa to monitor and 
coordinate information. The task force may be reached at the 
following email address, that is [email protected].
    Since the beginning of the crisis the Department has 
maintained close contact and coordination with the governments 
of all of the affected countries and has closely monitored 
their operational plans to combat the viral outbreak. In Sierra 
Leone, President Koroma directed government officials to make 
containment of the virus their top priority and set up a 
Presidential task force to lead the government's efforts. In 
Guinea improved messaging to the populace helped healthcare 
providers gain access to infected regions. And in Liberia, 
President Johnson Sirleaf announced a national task force to 
combat the spread of the virus.
    On August 1, the three Presidents detailed their collective 
strategy for eradicating the virus in a joint communique 
following a meeting of them of the Mano River Union. We commend 
all three countries for taking this outbreak seriously and for 
taking concrete steps to address it.
    This week's news of new cases in Lagos, Nigeria, a city of 
over 20 million people, makes the need for an effective, well-
supported, and well-coordinated national plan and international 
response more important than ever. In fact, Mr. Chairman, I 
just met today with President Blaise Compaore of Burkina Faso 
and with Dr. Kadre Ouedraogo, who is president of the ECOWAS 
Commission, who told me that the health ministers of the three 
affected states will meet again, they will meet in Conakry at 
the end of this week on August 11 through 14, and that 
following that the health ministers of all of the ECOWAS states 
will meet in Accra, Ghana, on August 28. The intensified 
attention of the health ministers of the entire region is a 
good sign, and it demonstrates that the whole region is seized 
with this crisis.
    Assistant Secretary Linda Thomas-Greenfield has spoken to 
the Presidents of Guinea, Liberia, and Sierra Leone to express 
support and to assure them of our assistance to stop the spread 
of the virus. On August 4th, the Department hosted and 
moderated a meeting on Ebola on the sidelines of the U.S.-
Africa Leader Summit to discuss the next steps for controlling 
and ending the virus. HHS Secretary Sylvia Burwell, CDC 
Director, my colleague here, Dr. Tom Frieden, and NIH Director, 
Dr. Francis Collins, USAID Assistant Administrator for Global 
Health Dr. Ariel Pablos-Mendez, and President Alpha Conde of 
Guinea, the Liberian Minister for Foreign Affairs, Sierra 
Leone's Ambassador to the United States, and Professor Tomori 
Oyewale, the president of the Nigerian Academy of Science, 
participated in the meeting. Representatives from DOD, from the 
NSC, the World Bank, as well as private partners like the GE 
Foundation and Becton, Dickinson and Company, also joined. In 
addition to emphasizing the need to focus on detection, 
isolation, and adequate training for health workers in the 
field, we also emphasized our long-term commitment to building 
the health care capacities of individual west African nations 
beyond this immediate crisis intervention.
    We continue to work with our international partners and the 
WHO to assess what is needed to properly treat patients and to 
mount a sustainable response. Such support has included 
providing financial and technical assistance to properly equip 
treatment centers and supporting communication efforts to help 
healthcare workers access affected communities. The WHO Sub-
Regional Coordination Center opened in Conakry on July 23rd and 
is coordinating all surveillance efforts, harmonizing technical 
support, and mobilizing resources being provided to the 
affected countries. The organization has also launched a $100 
million emergency response plan to surge resources to mount a 
more effective response. We are in continuous discussions to 
find new ways to provide assistance.
    The Department of State has no higher priority than the 
protection of U.S. citizens. We extend our deep sympathies to 
the family of Patrick Sawyer, a U.S. citizen who died in 
Nigeria after contracting the virus in Liberia. At least two 
additional citizens affiliated with the response organizations 
have been infected in Liberia and are currently undergoing 
treatment. We are in close contact with the sponsoring 
organizations of those two individuals, and our thoughts and 
prayers go out to them and to their families.
    U.S. Embassies in the affected countries have disseminated 
security messages, including the CDC's warnings, to resident 
and traveling U.S. citizens. We continue to take steps to 
educate citizens about the virus, to dispel rumors, and to 
provide information on preventive measures.
    We also take the safety and well-being of our staff very 
seriously. To that end, the Department's Chief of Infectious 
Disease traveled to west Africa to provide Embassy staff with 
assistance regarding protection measures and case recognition. 
Additionally, Embassies in the affected region have organized 
regular town hall meetings to answer questions and concerns of 
mission personnel and U.S. citizens.
    Embassies in neighboring countries like Mali, Senegal, and 
Togo have also held meetings to assess the capabilities of 
their host governments and to make contingency plans for 
Embassy personnel and resident citizens in the event of an 
outbreak.
    In closing, Mr. Chairman, I would like to reiterate and 
assure this committee that the Department of State takes the 
Ebola threat very seriously and we are fully dedicated to 
working with our governmental and non-governmental allies, the 
interagency community and host governments in the affected 
countries to respond to this crisis, prevent its spread and to 
restore stability to the region.
    I thank you for your attention to this issue, and I look 
forward to answering your questions.

    [The prepared statement of Ambassador Williams follows:]

    
    
                              ----------                              

    Mr. Smith. Thank you so very much, Ambassador Williams.
    I do have a few questions I would like to pose to our 
distinguished panel, beginning first with Dr. Frieden. As you 
said, supportive services are important. With no effective 
vaccine or drug treatment, you outlined how important those 
services are, including hydration and, I am sure, antibiotics 
to deal with some of the other co-infections.
    Now, I wonder if you could just tell us, is there any 
disproportionality in result when it comes to whether or not we 
are talking about a frail elderly person, a woman, a man, a 
child, a woman who happens to be pregnant, or any of the others 
who has a compromised immune system? What has been the MO of 
that, if you could?
    Secondly, I know that treatment centers, for example, in 
Guinea--there are some three to four treatment centers, but, 
again, it is very hard for people in that country as well as 
the others--Liberia and Sierra Leone as well--to get to those 
treatment centers. It is a long trek. Very often with the ride, 
the person is very sick, others could come in contact with him 
or her. There seems to be an overwhelming need.
    One of the points that I think needs to be underscored that 
is under-appreciated in many places is that, in dealing with 
someone who is dying, especially in those--that part of the 
world, there is a psychological trauma with being alone. So it 
almost exacerbates the spread of the disease because people 
want to be around, near, touching and, when that person is 
highly infectious, that is when family members and others might 
get it. If you could, speak to that.
    The lack of testing, testing areas, whether they be, you 
know, as part of the treatment centers where there is a testing 
lab--it is my understanding, especially since this masks and 
parallels what other--you know, it looks like other things, but 
it is Ebola--but unless you get that test back--how long does 
it take to do the test? And, again, is there any way of 
standing up labs?
    I know for a fact that--you know, especially through the 
work of Bush's PEPFAR program, which has been followed up with 
Obama doing the same thing--and, you know, the idea that 
building health capacity and labs in Africa is a very high 
priority, and now we are seeing where inadequate labs or lack 
of labs leads to people being sick and not even knowing it.
    The courage of the healthcare workers I think needs 
exclamation points. I know you are there as well and you go on 
the front line yourself and go into--all three of you--into 
contagious areas. But Dr. Brantly and Ms. Writebol and others 
who put their lives on the line, motivated so often by faith, 
in the case of Dr. Brantly and--I mean, I have read some of the 
things his wife has put out, the prayers that are being offered 
up not just for him, but for all of the victims.
    In Liberia, there have been 60 healthcare workers infected. 
35 are dead. In Guinea, 33 healthcare workers affected. 20 are 
dead.
    How does a country now attract or retain healthcare workers 
who say, ``If I go into that arena, the prospects of me getting 
this are very real''? Is there enough protective equipment, you 
know, the gowns, the plastic, to mitigate the possibility of 
transfer?
    And, finally--and I do have other questions, but I will 
yield to my colleagues--there are a number of, I said in my 
opening, promising drugs. ZMapp is one of them. TKM--Ebola, 
which was in Phase I trials; yet, the FDA has a hold on it. 
They were contracted by the Department of Defense.
    From what I have read--and it is only from what I have 
read, you know, the available data, it was showing promise. And 
I am wondering if there is any way to accelerate, knowing that 
you don't want to obviously put something out there that is 
risky--because Ebola is not 100 percent fatal, as we all know. 
We don't want to keep people getting sick from the remedy or 
supposed remedy.
    What about accelerating that? Is there an effort to do 
that?
    And my final question is about the safety of airline 
flight. Many people have contacted my office to ascertain, you 
know, how safe it is to fly perhaps next to somebody who has 
maybe changed flights en route to the United States coming from 
Liberia, for example.
    And are the efforts at the airports, particularly where 
there is a large diaspora population--I don't know if you have 
enhanced efforts there where people from west Africa are more 
likely to go. But, you know, are they up to the task of 
detecting at point of embarkation of passengers who might be 
sick from Ebola?
    Dr. Frieden. So let me try to quickly give you clear 
answers to all of those questions.
    The first is the relative case fatality rate of different 
groups. And in the current outbreak, the data is still too 
foggy for us to give you clear data. There is not the kind of 
robust data that we will have eventually, but don't have now to 
give you, what we would call a case fatality rate for different 
groups.
    But there is one very intriguing historical fact which I 
think is worth mentioning. In 1967, there was a laboratory 
accident in Marburg, Germany. The Marburg virus was then 
identified. Marburg has a similar fatality rate to Ebola, if 
anything, a little higher. It is around 80 percent. The 
outbreaks have been in the 80 percent range in Africa.
    The case fatality rate in Germany in the Marburg outbreak 
was 23 percent. Now, that might have been because of the better 
supportive care--there was no specific antiviral treatment--or 
it might have been because people were healthier going in. We 
don't know.
    But we do know that it was dramatically different, and I 
think that is an important point. Good supportive healthcare is 
a proven way of saving lives, and we should never lose sight of 
that.
    Second, in terms of treatment centers, you are absolutely 
correct that there is a challenge in getting to treatment 
centers. And that is one of--that is, in fact, the number one 
priority for the DART team, which USAID is convening and CDC is 
leading the medical public health aspects of, which is on the 
ground today in Liberia to assess.
    And the biggest challenge is both in the city of Monrovia, 
where there continue to be chains of transmission, and in that 
tri-country area. So looking at whether one facility or 
multiple facilities and where the facilities would be, that is 
a critical issue for us to determine in the coming days.
    Treatment centers, as you point out, are very important to 
support. I was speaking with the American Charge from Sierra 
Leone, who was speaking very movingly about the patients and 
their isolation in the treatment centers and simple things like 
giving them cell phones so they could talk to their family or 
things that they could do while there was very important. And 
if patients don't believe that they are going to be well-
treated in the treatment centers, they won't come in and they 
may continue to spread it in the community. So good quality 
care is very important.
    In terms of testing, you are absolutely correct. As you 
know, Mr. Chairman, with support from PEPFAR, the CDC has 
helped create the African Society for Laboratory Medicine, and 
that has for the first time ever had high-quality laboratories 
established all over Africa. These countries have not been 
PEPFAR-focused countries; so, they have limited activities in 
that area.
    But scaling up laboratory testing is important. We will do 
that in two ways, first, by finding laboratories--this isn't 
simple laboratory tests. This is a realtime PCR. The results 
come back within a day, but false contamination, false 
positives, are possible if you are not scrupulously careful. 
And that would be a real problem.
    So we will scale up the labs that can do testing. We are 
working with international partners on this, who are involved 
and with the Defense Department, which has a very active 
program, for example, in Sierra Leone and is providing services 
there, and with the National Institutes of Health, which has 
been very helpful.
    We will also establish safe specimen transport means. We 
have done this in Uganda, where we can very safely transport. 
Hard to get a lab out all over, but quite possible to get 
transport into the lab. And that is what we will establish in 
the coming days.
    In terms of the courage of healthcare workers, I certainly 
agree with you. And it is an issue not just for healthcare 
workers, it is an issue for patients. We have heard that, with 
healthcare systems less functional, problems like malaria may 
become more deadly.
    So the impacts of Ebola aren't just Ebola. There are the 
other conditions that aren't treated because of Ebola. So 
responding is so very important, and protecting the responders 
is so very important.
    So a key aspect that we are working on with the World 
Health Organization, with the countries, with USAID and others 
is making sure that there is effective personal protective 
equipment there for healthcare workers. We believe it is 
possible to take care of Ebola patients, even in Africa, 
safely, but it takes meticulous attention to detail.
    In terms of the promising drugs, I can assure you that the 
U.S. Government is looking at this very carefully and will look 
at any way to try to expedite development or production, but I 
don't want any false hopes out there. Right now we don't know 
if they work and we can't, as far as we know, have them in any 
significant numbers. We hope that that might change.
    But these medicines that have been used in the experimental 
cases, as far as I understand it, are not easy to use. They 
require infusion. They may have adverse events. And basic 
supportive care needs to be in place as a prerequisite to 
giving many of these treatments.
    So whatever else we do, we have to do the basics right. And 
we might or might not have effective and available treatment in 
3 months or 6 months or 1 year or 5 years, but we today have 
the means to stop the outbreaks.
    And, finally, in terms of airline flights, we do have teams 
in the affected countries who are working with the equivalent 
of their border protection services, helping them to do 
screening at the airports. It is not a simple measure. It is 
key first to reduce the number of cases. That is what is going 
to be the safest.
    And there are other things that can be done at airports in 
terms of questions to be asked or temperatures to be taken or 
lists to be cross-matched against known patients and known 
contacts, but all of those procedures do take time to set up. 
But we do have teams working on them now.
    Mr. Smith. Dr. Frieden, if I could ask you, if somebody is 
in proximity to a sneeze or a cough, is that a mode of 
transmission?
    Dr. Frieden. In medicine, we often say, ``Never say 
never.'' So, in general, the way we have seen the disease 
spread is by close contact with very ill people.
    As you know, the individual who traveled from Liberia to 
Lagos did become ill on the plane, and we have assisted those 
countries to track the travelers who traveled with him and, as 
of now, have not identified illness in any of them.
    But, in general, it is not from a sneeze or a cough. In 
general, it is from close contact with someone who is very ill, 
but we do have concerns that there could be transmission from 
someone who is very ill.
    Mr. Smith. So at the fever stage, if somebody is onboard, 
that wouldn't be construed to be very ill? You are not likely 
to get it from somebody who is at fever stage?
    Dr. Frieden. You are not going to get it from someone who 
is not sick with Ebola. So if they are just clearing their 
throat or sneezing or coughing, but they don't have a fever, 
they have not become ill with Ebola, they are not infectious to 
others. But if someone became ill on the plane and was having 
fever or started bleeding, then, for example, that might 
present a risk to those who came in contact with that and 
didn't take appropriate precautions.
    Mr. Smith. Is there a way of advising airline personnel, 
particularly flight attendants who, again, might be in very 
close proximity to the whole plane and there could be someone 
on there? Does CDC advise them and the airlines, like Delta, 
which flies numerous flights to the region?
    Dr. Frieden. Yes. We have provided detailed advice to the 
airlines.
    Mr. Smith. Let me just ask you, Ambassador Williams, very 
quickly.
    You spoke--and I think it was a very good insight--about 
the handling for funeral arrangements and just generally 
sensitivity to the culture.
    I know it is part of the public information campaign in 
Guinea--for example, some 9 million cell phones are being used 
and text messages are being sent with a number for the Red 
Cross, and one of the text messages says, ``The bodies of Ebola 
victims are very contagious. Do not manipulate. Call the Red 
Cross.''
    Now, I am wondering if there is any thought being given--I 
remember after Operation Provide Comfort, when the Kurds made 
their way fleeing Iraq after Saddam Hussein--I was there about 
5 or 6 days after that, and our military was on the ground and 
they were using PSYOPS to educate and leafleting that was done 
in a way that we would use in a not-so-benign situation. In 
this case, it was to get food out and Meals Ready to Eat, and 
it was amazing how that kind of information made the Kurds who 
were at great risk of the elements and starvation, very aware 
of what they needed to do.
    Is there any thought of helping the Liberians and the other 
countries with a benign PSYOPS effort to make people aware? I 
know that radio is being used, but it seems to me that more 
needs to be done. Any thoughts?
    Ambassador Williams. Thank you, Chairman.
    I can't say that we have moved to the point of PSYOPS, but 
I think you are hitting a very, very important issue, which is 
that culture makes a difference and you have to adjust your 
messaging and do the campaign according to the sensitivities 
and the routines and the practices per culture.
    What was extremely effective in Guinea was not only what 
you mentioned, Mr. Chairman, but the fact that they started 
talking about survivors and the survivors came on the radio. 
They went around and said: ``Look, I was sick, but this and 
this and this happened to me. I did such and such, and I am 
still alive. You should go get treatment. You should isolate. 
You should make sure people know you have this.'' So that is 
very, very important.
    Our military right now is helping in the ways that have 
already been described as far as with logistics and making sure 
that we can get in body bags, protective equipment for the 
healthcare providers. And that--that is where we are so far.
    But we are relying upon the host governments to help 
explain to us what is most effective, what the sensitivities 
are, and what messaging needs to get out. And then we were 
helping with the means of the communication, but not the actual 
message, because they know best what the people need.
    Mr. Smith. Thank you.
    I yield to Ms. Bass.
    Ms. Bass. Thank you very much, Mr. Chairman.
    This is for the doctors. I wanted to know if you could talk 
a little bit more about the disease. We all know about fevers, 
but having spent a number of years working in emergency rooms, 
I can imagine what is happening in our emergency rooms around 
the country. Everybody with a fever is running in, being 
concerned.
    And I was wondering if you could talk a little bit more 
about what are the other symptoms of the disease and maybe if 
you have any thoughts of why some folks are surviving, since my 
understanding of part of the disease is that it interferes and 
takes over with the immune system.
    Dr. Frieden. So the fevers can be one symptom, but chills, 
weakness, nausea, vomiting, diarrhea are other symptoms. In 
about 45 percent of cases, there is bleeding, both internal and 
external, and that is a feared complication. So these are 
symptoms which, as you both pointed out, are not specific to 
Ebola.
    And that is why the laboratory testing is so important. It 
is also why it is not the case that someone will know they have 
Ebola and go to a special Ebola unit and why it is so important 
that health facilities who are there think of the risk of Ebola 
and then rapidly isolate people.
    In this country, what we have told healthcare workers to do 
is take a travel history: Has the person been in one of these 
countries in the past 21 days? If yes and if they have fever or 
other symptoms, then do tests.
    We have already had five people in different parts of the 
U.S. who come in with a travel history to one of these 
countries in the past 21 days. All five have turned out not to 
have Ebola. Two had malaria, one had influenza, and two had 
something else.
    So we expect this to happen. In fact, we want there to be a 
high-level index of suspicion so that doctors will rapidly 
isolate the person and then rapidly test them.
    Ms. Bass. And how do you screen? Just as the chairman 
asked--and I know, you know, again, what is in the press is 
that, if someone on an airline sees someone with a fever--and I 
mentioned to you yesterday when we spoke there are these 
pictures in the news of the wands or they are doing some type 
of screen, and I think you pointed out--and maybe you could 
talk about that is really not effective.
    So how does one screen, short of a blood test in a medical 
facility, that like an airport worker might do?
    Dr. Frieden. There is no way to diagnose Ebola without a 
laboratory test. So if someone has fever and they may have been 
exposed, they have been in one of these countries, they need be 
isolated and tested.
    For people within the U.S., currently both we have a test 
that is accurate and relatively quick--a few hours once the 
specimen gets to our lab--and the Department of Defense also 
has a test.
    And we are working in collaboration with them to see if we 
can over the next couple of weeks get that test out to what is 
called the Laboratory Response Network, or LRN. This is a 
network that CDC coordinates of laboratories at mostly health 
departments around the country to test for dangerous pathogens.
    Ebola is not in their usual network; so, this would be a 
new procedure. But either through the Defense Department's 
assay or our own, we will look into getting that available so 
not all of the tests have to come to CDC Atlanta and they can 
be tested locally. We also have safe ways for specimens to be 
transported to CDC if they need to be transported.
    Ms. Bass. One of the other things that we have touched on a 
couple of times today is the ZMapp. I think that is what it is 
called. And I would like for you to talk a little bit about 
that because there is a lot of concern that maybe we have 
access to this and are not providing that access. And one of 
the things that I think was a mention that maybe you could 
elaborate is that there might only be just a couple of doses 
that--that were even made.
    Dr. Frieden. So, first, I really would need to refer you to 
the National Institutes of Health, which would be the lead on 
developing new treatments and vaccines against Ebola. The 
information I have on that medication is quite indirect.
    What I understand is that it is a combination of different 
monoclonal antibodies--this is part of what the body does to 
respond to an infection--and that there is some evidence from 
at least one animal study that it may have some effect on the 
illness.
    However, I think I would caution that we really don't know. 
I think that has to be emphasized. Even whatever happens with 
these two individuals--and we hope that they and every other 
person with Ebola will get better, as some people do. But we 
will not know from their experience whether these drugs work.
    Antibodies are only one part of our response to an illness. 
There are many different parts of the immune response. In some 
other conditions, antibodies can actually make the disease 
course worse. So we don't know until it is rigorously studied 
scientifically.
    I also cannot tell you definitively how many such courses 
there are. I have heard that there are a handful, fewer than 
the fingers of one hand, but I have no direct information on 
that. Other manufacturers are coming forward to say that they 
have some or could make some. We have heard from some companies 
that it would take months to make even a few dozen courses.
    So I think this is rapidly changing information. I don't 
have definitive information and would refer you to the National 
Institutes of Health.
    But let's always go back to the basics, that we know now 
how to stop Ebola and, if a person has Ebola, we know how to 
support them to reduce their risk of death in proven ways by 
treating and preventing other infections that they can get when 
they are sick by providing hydration, fluids, careful 
management of their health condition, blood transfusions if 
they need them. These are proven things.
    If there is a new treatment, we will do everything we can 
to help get it out to those who need it most. We would also be 
very interested in a vaccine. If there were an effective 
vaccine, we would offer it with full informed consent to 
healthcare workers as a way of helping them protect themselves.
    But right now we are months or at least a year away, from 
everything I have seen and heard, from significant quantities 
of either drugs or a vaccine, even if everything goes well and 
we are able to develop them. That could change, but that is the 
information as of now. What is available to us today right now 
is the means to stop the outbreaks in Africa.
    Ms. Bass. It is not helped when it is reported that the one 
individual had a miraculous turnaround and was able to walk out 
of the ambulance because he had gotten the treatment. You know, 
that leads to the belief that there is some kind of cure out 
there that we know about that we are not sharing.
    In looking at the death rates at the different countries, 
there is a difference. In Guinea, it is 74 percent; Sierra 
Leone, 42; and Liberia, 55.
    And I wanted to know from the panelists, what do you see as 
causing the difference? And is it a situation where each of the 
countries have addressed the outbreak differently? Capacity? 
Commitment? What is the difference?
    Dr. Frieden. I think, in terms of the death rates, the data 
is still very fluid and it is not clear that each of those 
rates is actually comparable, given the different ways cases 
are diagnosed and counted and reported.
    What is the case is that, for each of the countries, they 
have their own challenges. I would say that the country of 
Guinea is probably furthest along in responding. They have 
reduced their number of cases. But there, too, they have 
continued spread in healthcare facilities.
    And that tri-border area, that area seems to be a core 
epicenter. And security problems in Liberia, for example, have 
led to treatment facilities not being available in Liberia, 
patients moving over to Guinea and then re-importing the 
disease there.
    So it really is a regional response that is needed for the 
three countries, and that also will be a core first deliverable 
of the DART team that USAID is leading and CDC is leading the 
public health healthcare medical aspects of to identify in that 
region what can be provided rapidly to assist with caring for 
patients to allow us to reverse the outbreak.
    Dr. Pablos-Mendez. Just, if I may add, in addition to the 
difficulty in establishing the denominator to calculate the 
percentages that Tom is referring to, the fact is that across, 
nonetheless, even if there were more cases that we have not 
recognized, that is more likely to be recognize the cases. And 
so the percentage can vary in that.
    But, on the whole, we are seeing that the disease is indeed 
quite deadly, but not universally fatal. And that is very 
important.
    And, in Guinea, it has been a very important part of the 
study of educating the public because, if people think that you 
are going to get it, you are going to die, then there is no 
motivation to go to the services, to protect the families. And 
so the education has been paramount.
    And, in Guinea, we have seen a plateau of the outbreak. In 
the last month or two, there is still some, especially because 
of the border area. But, on the whole, the response that Guinea 
has implemented and the education in this case has been very 
important both for the patients, again, and for the health 
workers.
    We are now doubling up to 70,000 the personal protective 
equipment will be available. We had already in storage in 
Ouagadougou in the region, and that is what we got going 
through the spring. We are having more now equipment that is to 
be prepared to protect those health workers.
    And it was raised before and I want to emphasize, health 
workers are trying to do their best to save lives of other 
people. And so the 120-plus of them who have already died in 
this outbreak are true heroes. And I think that support for the 
health workers is really paramount, and I think that we are 
very committed to doing that.
    When we mentioned earlier the State Department has advised 
the families of our staff to leave the countries, it is not so 
much because they are in immediate risk, but because the health 
system's already so overwhelmed that, if you had anything else, 
there is nowhere for you to go to.
    And, in addition, for many of those, if I may add, also, is 
that kids who will start school soon, the schools may not be 
opening. So asking the family members to leave is wise, not 
because they are in immediate danger.
    Ms. Bass. You know, Dr. Pablos-Mendez, I think you have 
mentioned a couple of different figures, and maybe I have 
confused them.
    I think you said 70,000 and 35,000 pieces of protective 
gear. And I was wondering if those have reached the affected--
well, number one, what was the difference? Did I get them mixed 
up? Or maybe it was at different times.
    And then, two, has it reached the area? Because I mentioned 
yesterday earlier speaking to President Johnson and she was 
very concerned and expressed the need for additional units of 
protective gear.
    Dr. Pablos-Mendez. Thank you.
    The 35,000 units were indeed part of the first batch that 
we mobilized early on in the epidemic. We already had some of 
them in strategic storage locations, one in the region, in 
Ouagadougou, that has been made available now.
    The question is the logistics of distribution, and that is 
where our DART team now deployed will support the countries to 
make sure that they reach all the front line workers that would 
require it. But with the additional resources we are mobilizing 
now, we will reach 70,000 of such; these are spacesuits that 
you have seen.
    Ms. Bass. Right.
    Dr. Pablos-Mendez. It is the production part, and they have 
to be prepared. They don't come just ready to use. And that is 
where we are right now. But we expect to reach 70,000 of such 
PPEs, as we call them, to reach where important.
    We have also in every countries some of this training. We 
have some of those available to them just at least to become 
familiar in case that we need to scale up.
    And we have all along model how this could spread. Indeed, 
as Nigeria has been one of the nodes, Ghana has been another 
that we are paying attention because, in our models, that 
suggest that that could be a route where the airlines flights 
could allow this to escape the countries that we have even 
today. So we are preparing and we have trainings and we have 
some of the equipment already available there.
    Ms. Bass. Thank you.
    Ambassador Williams.
    Ambassador Williams. Yes. Thank you.
    I just wanted to clarify. As I said earlier, we are 
continuously monitoring the situation in all of the affected 
countries. And our primary responsibility, our primary concern 
is the health and welfare of American citizens abroad, our 
Embassy staff as well as residents.
    We have not, in fact, ordered the departure of our family 
members from any of our places, although we are--it is--of 
course, it is one of the things that occurs to people. It is 
one of the things under consideration. But at this time we 
haven't.
    And I know that, since we do have an interagency 
coordinating committee that has been talking about a number of 
things, it has been among the things we have been considering, 
but----
    Ms. Bass. So USAID has had the----
    Ambassador Williams. No American personnel. No American 
official personnel or their families have been ordered. It is 
one of the--it is one of the options under consideration, but 
we are continuing to look.
    As was stated, you know, our families, our dependents, 
follow the government officers all over. We are on the front 
lines every day all over in very dangerous places.
    And bearing in mind the stresses in the various countries 
now and the concerns, the anxiety levels, among some of our 
families, it is something that has been discussed.
    But at this point we have not ordered the departure of any 
of our family members. I just wanted to make sure you 
understand.
    Ms. Bass. Okay. And the last question is--I think it might 
have been--one of the panelists referred to the security issues 
in Liberia, and, you know, when I spoke to President Johnson 
yesterday, she didn't mention that.
    But when I was watching the news this morning, there were--
you know, the text messages that come across the news said that 
she was very concerned about it.
    And I wanted to know if maybe you could address--what are 
the security--what is happening? Is this something new? What 
are we talking about?
    Ambassador Williams. What I was trying to stress is putting 
it in a framework. You know, these things happen in a context. 
And it is one thing to have this health crisis, but, in fact, 
the country was already still trying to build itself up from a 
rather torturous past.
    Ms. Bass. Okay.
    Ambassador Williams. So the President of Liberia did 
declare a disaster in her country as a result of this crisis 
because she really wants the international community to pay 
attention and she is trying to also explain to her people why 
she is mobilizing an intensified force to specifically focus on 
Ebola, but there is no new security external threats.
    Ms. Bass. Okay. Thank you.
    Thank you, Mr. Chairman.
    Mr. Smith. Chairman Wolf.
    Mr. Wolf. I thank you, Mr. Chairman.
    In what country did this first begin?
    Dr. Frieden. The first cases were reported from Guinea, but 
it is really possibly--we don't really know at this point--or I 
don't know at this point the history of it. But the epicenter 
is that forested area that has the confluence of the three 
countries.
    Mr. Wolf. Ambassador Williams, over the years, we have 
heard from Ambassadors and Embassy staff that Washington does 
not take cables from them seriously.
    When did the State Department in the District of Columbia 
in Washington first get a cable notification from the Embassies 
of Sierra Leone, Guinea and Liberia about the Ebola crisis?
    Ambassador Williams. Chairman Wolf, if you don't mind, I am 
going to look through my notebook to see if I have the exact 
date. I am not sure I have the exact date. So if you could just 
give me a second.
    Mr. Wolf. Sure.
    Ambassador Williams. Mr. Chairman, I am going to have to 
look up the cable. I don't have the cable traffic.
    I will say, however, we are in daily communication with our 
Embassies and, if not through cables, through emails, through 
telephone. We are in constant control. But I will find the 
specific answer to your question and get it back to you.
    Mr. Wolf. You were an Ambassador. It is often we hear--and, 
as you know, my district in northern Virginia, we have many.
    They say that sometimes the cable gets sent and they wonder 
if they are taken seriously. I would like to know when the 
cables were sent. And, secondly, how high in the State 
Department were the concerns raised, at what level and what 
time?
    Ambassador Williams. Thank you.
    And I will take the question. I have to find the exact 
date. We have been aware of this for a while now and we are 
working on it.
    And as having come out of the region as an Ambassador--as 
it was stated, I was our Ambassador to Niger up until the end 
of 2010.
    In covering west Africa in the Bureau of African Affairs, I 
am seized with this. I am paying close attention to what the 
Embassies are saying. I know what Ambassadors and the people 
there are going through. And I will get the answer to your 
question as soon as possible.
    Mr. Wolf. You mentioned the work in response of USAID and 
State and others.
    What other donor nations have gotten involved in the 
efforts? And what exactly are they doing? Can you give us a 
list of the countries?
    You said, Dr. Frieden, you have 40 to 50 people coming.
    Can you tell us what Great Britain is doing and what France 
is doing. Can you give us some specification as to numbers and 
how they are cooperating. It all cannot be the United States. 
What are our European allies and others doing, in numbers, if 
you can?
    Dr. Frieden. I think it would probably be best if we got 
back to you with details. It is something of a moving target.
    I can tell you that the French, through the Institut 
Pasteur, have been very active. They have laboratory services 
and other services there.
    The British have also been very active and have provided 
both resources and people on the ground. We had an announcement 
earlier this week from the World Bank of a commitment of $60 
million to $70 million for emergencies as well as the emergency 
response as well as a longer-term response.
    The World Health Organization, as you may be aware, issued 
an appeal recently for $100 million to respond to the 
outbreaks. And we have been in close coordination with many of 
our colleagues around the world.
    Mr. Wolf. Has the White House asked them to be involved? 
For instance, the Germans have a history in Africa. The French 
have a history in Africa. The British have a history in Africa. 
Has there been a formal request by the White House to the heads 
of those governments that they participate to help your effort?
    Dr. Frieden. We have had intensive conversations with 
multiple other countries.
    Were you going to say something, Dr. Pablos-Mendez?
    Dr. Pablos-Mendez. The answer is yes. The Ambassadors in 
Geneva had met from the various countries.
    And, as you pointed out, there are many historical 
linkages, the British Government particularly supporting the 
response in Sierra Leone, France supporting the response in 
Guinea.
    We have a strong presence, really, hand-in-glove, with the 
Ministry of Health in Liberia. So our response has been 
particularly important there, as Tom has mentioned.
    The emergency plan that WHO put forward just over a week 
ago is for $103 million. They originally got about $30 million 
of that covered to begin moving, including some of the support 
that we have been providing.
    With the World Bank coming through, also, just this week 
with an announcement of $200 million, that will allow us to 
fill the gap in the WHO plan for the immediate response, but, 
in addition, will invest in the months to come in strengthening 
the systems in that part of the world.
    So many of these pieces and, as we speak, many of these 
things are moving very fast. So we are trying to continue that 
conversation. But in Geneva it has been a focus for the various 
donor countries to be having periodic updates as to how much 
more resources.
    But that geographical location of division of labor, if I 
can put it that way, is already underway, even though CDC's 
presence is in all of these countries.
    Mr. Wolf. Is the African Union engaged?
    Dr. Pablos-Mendez. The African Union has been engaged. The 
African Regional Office of the World Health Organization, in 
particular, has been engaged.
    And to your earlier question, in Liberia, March 27 was when 
the first cases were reported. There was only a dozen or so of 
cases and then the outbreak fizzled. And this is typical of 
these outbreaks in central Africa. And for a month, there were 
not many new cases.
    So, in fact, the early behavior of the outbreaks was light 
to begin, as we have seen in previous outbreaks, and it was 
only as it was rekindled again in this three-border area that 
we have seen the expansion, particularly in Sierra Leone and 
Liberia, whereas, in Guinea, it has been after the initial 
outbreak more a sense of containment.
    Mr. Wolf. Are the Chinese involved? The Chinese Government 
has historically invested in soccer stadiums in Africa? Are 
they involved?
    Dr. Frieden. We would have to get back to you about their 
involvement.
    Mr. Wolf. Madam Ambassador, can you tell us? You are with 
the State Department.
    Ambassador Williams. Yes. I will have to look into that. I 
haven't heard about the Chinese involvement at this point, but 
I will check.
    But I would like to reiterate--you were asking about the 
African Union--as I mentioned earlier, the ECOWAS states, the 
subset of the regional governments, are very seized with this 
and they are meeting this week and then again in 10 days after 
that.
    Mr. Wolf. The last question, Mr. Chairman.
    If someone wanted to raise a question or call somebody, do 
something, had a great idea, who do they call? Is there one 
person? Is it the CDC? Is it the Secretary of State? Is it 
USAID?
    For our friends here in the United States, but abroad, is 
there one person and one place and one number that someone can 
call? Because on the 28th, it was very difficult, bouncing from 
here to there.
    And let me just say again to Dr. Frieden. Thank you for 
taking the call, even as you were traveling.
    Is there one place that we would go to or someone would go 
to?
    Dr. Frieden. For response to any potential case or problem 
here, that is the CDC. That is the----
    Mr. Wolf. And what about if a nation abroad wanted to 
contribute, wanted to be involved, had an idea? Who do they 
contact?
    Dr. Frieden. In terms of the global collaboration, the key 
there is to support the World Health Organization, which really 
is the lead for the overall response.
    Mr. Wolf. And is there an individual there at the World 
Health Organization who is responsible, that is your person to 
contact?
    Dr. Frieden. Yeah. That would be Dr. Keiji Fakuda.
    Mr. Wolf. Okay. Good.
    Thank you, Mr. Chairman.
    Mr. Smith. Before we go to the our next panel, if Ms. Bass 
has any additional questions, I will recognize her for that.
    How accurate is the data? Data in even the best and most 
pristine of situations often is very hard to obtain. But here 
we are talking about proximity issues, difficulty of 
ascertaining what is really going on.
    There was a report on CBS News that suggested that there 
may be as much as a 50 percent higher prevalence of Ebola. And 
I am wondering if you might want to comment on that. Is there 
any underreporting? And that is both of cases as well as 
fatalities.
    And then, secondly, I know that the FDA is notoriously slow 
and notoriously comprehensive. And I don't want to either 
exaggerate or understate. But, ZMapp, TKM-Ebola and that one, 
again, was contracted by our own Department of Defense to work 
on that, and, yet, those clinical trials have been halted, 
Phase I.
    And I am just wondering if there is any effort to rethink 
that. Because this could take off--you know, those who have 
lost their lives and are sick is a tragedy beyond words, but 
many more could become sick and die as a result.
    Is there an interagency effort to say, ``Let's relook at 
that''? There might be some reason to lift that Phase I trial's 
halt to see if we ought to get at it.
    And, finally, in his testimony today, Mr. Isaacs of 
Samaritan's Purse, again, the man with whom I and Congressman 
Wolf spoke to last week who had a profound sense of urgency and 
thought that we needed all to be doing more--he said it took 
two Americans getting the disease in order for the 
international community and the United States to take serious 
notice of the largest outbreak of the disease in history. 
Yesterday the President of Liberia declared a state of 
emergency in the nation. This declaration, he goes on, is at 
least a month late.
    And I am wondering, not only with the countries that are 
already now affected, the four of them, what might be the fifth 
or the sixth? Is there a sense that there is a heightened 
concern about another nation, particularly one that might be 
contiguous with these four?
    Dr. Frieden. So in answer to your first question, yes, we 
think that the data are not as accurate as we would like. There 
may be cases counted as Ebola that are not, and there may well 
be many cases not counted that are.
    The lack of treatment facilities, lack of laboratory 
facilities, make it so that the data coming out--it is kind of 
a fog of war situation, if you will. And that is one thing that 
we want to try to resolve quickly by getting laboratory, 
epidemiologic. But if there aren't treatment facilities, the 
patients won't come forward and we won't be able to do the 
control activities.
    In terms of the FDA, there are calls at least once, 
sometimes four or five times a day on coordination. I can tell 
you that they are leaning very far forward on this and they are 
quite willing and quite constructive and productive in thinking 
of how to get things out there sooner if there is anything 
available.
    I think, on the one hand, we have to do everything we can 
to try to find new tools. On the other hand, we have to 
recognize that we have the tools today to save lives and stop 
the outbreak.
    And in terms of future countries, we can't predict where 
that might be, but we do know that an outbreak anywhere is a 
threat everywhere.
    And one of the reasons we have focused on the global health 
security program is that we have the international health 
regulations, which require countries to report outbreaks and 
new diseases so that we can all, as a global community, work 
together because it is in all of our best interests not only to 
protect health, but to protect the economy, to strengthen our 
work in this area.
    Mr. Smith. I want to thank our very distinguished panelists 
for your extraordinary service for the sick and at risk and for 
being here today and helping to enlighten our subcommittee and, 
by extension, many other Americans who are tuning in and 
watching this. Thank you so very, very much.
    Dr. Frieden. Thank you.
    Ambassador Williams. Thank you.
    Mr. Smith. I would like to now introduce our second 
panelists, beginning first with Mr. Ken Isaacs, who serves as 
the vice president of programs and government relations for 
Samaritan's Purse.
    Ken Isaacs has served as the director of the Office of 
Foreign Disaster Assistance within USAID. He coordinated the 
U.S. Government's response to the Indonesian tsunami, the 
Pakistani earthquake, humanitarian relief efforts in both 
Darfur and South Sudan, as well as the Niger and Ethiopian 
emergency responses.
    Mr. Isaacs has more than 27 years experience working in the 
relief and disaster response fields and has led major efforts 
in dozens of countries, including the ones I just mentioned. He 
is currently leading the Samaritan's Purse organization's 
efforts in Liberia in response to the Ebola epidemic.
    We will then hear from Dr. Frank Glover, who is the 
director of the Urology Institute and Continence Center in the 
Urology Institute Ambulatory Surgery Center.
    His discovery of the world's highest rate of prostate 
cancer in Jamaica has been internationally recognized and 
published in numerous journals and textbooks. He and his wife 
founded SHIELD, or Strategic Healthcare Initiative Emphasizing 
Local Development, which is dedicated to building a medical 
school in Liberia, training resident doctors in various medical 
and surgical specialties, and providing loan forgiveness for 
Liberian doctors that have trained in the United States and who 
would like to go back and be involved in teaching doctors and 
serving patients in Liberia. Dr. Glover has been involved in 
efforts to treat Ebola in Africa since the early 1990s.
    Mr. Isaacs, please proceed.

  STATEMENT OF MR. KEN ISAACS, VICE PRESIDENT OF PROGRAM AND 
            GOVERNMENT RELATIONS, SAMARITAN'S PURSE

    Mr. Isaacs. Thank you.
    Chairman Smith, esteemed members of the council and fellow 
guests of this subcommittee, I am privileged to testify before 
you today on the developments of the Ebola outbreak in west 
Africa and Samaritan's Purse experience in response there.
    I am going to read this first page so I don't overlook any 
of the things that I really want to say, and then I am going to 
put the script away and I am going to say the things that I 
feel like need to be said.
    Samaritan's Purse is an international NGO with 38 years of 
experience, dedicated to humanitarian relief. We have worked in 
over 100 countries, including Afghanistan, North Korea, South 
Sudan, Sudan, Syria, and Liberia.
    As an organization, we have responded to medical 
emergencies, such as the cholera epidemic in Haiti, and we have 
provided medical care to the people of Bosnia, Rwanda, and 
Sudan during the genocides in those countries.
    The Ebola outbreak has had a profound impact on our 
organization, and I would like to share with you about our 
experience in Liberia. I want to take this opportunity to thank 
the United States Government, particularly the Department of 
State and the Department of Defense, for assisting Samaritan's 
Purse in the evacuation of our sick personnel from Liberia. We 
could not have done it without them.
    And we would especially like to call to attention and thank 
Kathleen Austin-Ferguson of the Department of State, Dr. 
William Walters of the Department of State, Phil Skotte of the 
State Department, Mr. Dent Thompson, and Congressman Wolf and 
yourself.
    We would also like to thank certain staff members of the 
CDC and the National Institutes of Health for bringing to our 
attention and obtaining the experimental medication as a 
treatment option for our two infected staff members.
    As an organization, we have worked to contain the growing 
Ebola crisis in Liberia and we were devastated to discover that 
two of our personnel had contracted the deadly virus while 
trying to assist others.
    The support that the U.S. Government has shown to our 
organization is tremendous, and Samaritan's Purse thanks you 
for helping us bring the two of them home in the face of 
incredible challenges.
    The Ebola crisis was not a surprise to us at Samaritan's 
Purse. We saw it coming back in April. Our epidemiologists 
predicted it. By the middle of June, I was having private 
conversations with senior government leaders and, by July, I 
was writing editorials in the New York Times saying that this 
was out of control.
    In the 32 years since the disease was discovered, as I 
believe Dr. Frieden said a moment ago, there were a total of 
2,232 known infections, which killed 1,503 people. Easily, this 
present outbreak is going to surpass that in fatalities as well 
as overall cases.
    It is clear to say that the disease is uncontained and it 
is out of control in west Africa. The international response to 
the disease has been a failure, and it is important to 
understand that.
    A broader coordinated intervention of the international 
community is the only thing that will slow the size and the 
speed of the disease. Currently, WHO is reporting 1,711 Ebola 
diagnoses and 932 deaths in west Africa. Our epidemiologists 
and medical personnel believe that these numbers represent 25 
to 50 percent of what is happening.
    The Ministries of Health in Guinea, Liberia, and Sierra 
Leone simply do not have the capacity to handle the crisis in 
their countries. If a mechanism is not found to create an 
acceptable paradigm for the international community to become 
directly involved, then the world will be effectively 
relegating the containment of this disease that threatens 
Africa and other countries to three of the poorest nations in 
the world.
    I know that a part of community and development philosophy 
is to work with your local partner and build capacity. The 
capacity that is needed in the nations that are fighting Ebola 
should have been built 3 to 5 years ago. But in the times of 
crisis, I believe that the attention needs to be put on the 
crisis and the building of the capacity should be a secondary 
function.
    We undertook a massive public awareness campaign in Liberia 
starting in April and we have had over 435,000 people go 
through that training, but there are 3.6 million people there 
and the majority of them are illiterate. It is not going to be 
easy to change the way that people think and what their 
cultural mores are.
    In the first months, we were able to provide support to the 
World Health Organization, the CDC, the Ministry of Health and 
Doctors Without Borders, also known as MSF, with our two 
aircraft, the only two aircraft in Monrovia, in Liberia, that 
were flying support.
    We flew personnel, supplies, and specimens back and forth 
across the country. It makes a difference from the 
triangulation area that Dr. Frieden was talking about, also 
known as Foya, to Monrovia. It reduces it from a 16-hour road 
trip to a 40-minute helicopter flight.
    I do want to take this moment to recognize and thank our 
co-workers in Doctors Without Borders for standing in the 
trenches with us. They are still in Sierra Leone. They are in 
Guinea. And they are now filling the gap for us in Liberia, as 
we have had to pull back while we re-plan what we are going to 
do next.
    If there was any one thing that needed to demonstrate a 
lack of attention of the international community on this 
crisis, which has now become an epidemic, it was the fact that 
the international community was comfortable in allowing two 
relief agencies to provide all of the clinical care for the 
Ebola victims in three countries, two relief agencies, 
Samaritan's Purse and Doctors Without Borders.
    It was not until July 26, when Ken Brantly and Nancy 
Writebol were confirmed positive that the world sat up and paid 
attention. Today we are seeing headlines every day of Ebola 
fears. There is a man who has bled to death, evidently, in 
Saudi Arabia. And the Saudi Government has confirmed it was a 
hemorrhagic fever, and he came from Sierra Leone.
    There was a man, a Liberian-American, who came to ELWA 
Hospital with one of the most prominent physicians in Liberia, 
and that physician openly mocked the existence of Ebola. He 
tried to go into our isolation ward with no gloves, no 
protective gear. It is not an issue of gloves and a mask. It is 
an issue of no millimeter of your skin can be exposed or you 
will get sick and most likely die. That is sort of the reality 
of it.
    Those two men left our hospital. They went to the JFK 
Hospital in downtown Monrovia, where the doctor did examine 
Ebola patients, and he was dead 4 days later. The other man was 
dead 5 days later, but not before he went to Nigeria. And now 
there are cases of death from Ebola in Nigeria and there are 
eight more people in isolation.
    Our epidemiologists believe that what we are going to see 
is a spike in the disease in Nigeria and then it will go quiet 
for about 3 weeks and then, when it comes out, it will come out 
with a fury. As I am talking to you today, we are making 
preparations for a hospital that we support 263 miles north of 
Lagos on what they are going to do when Ebola comes to them.
    To fight Ebola, I have identified four levels of society 
that need intensive instruction because they simply do not 
understand what is going on. One is the general public. The 
custom that they have of venerating the dead by washing the 
body--I am going to be graphic because I think people need to 
know--a part of that is kissing the corpse.
    In the hours after death of Ebola, that is when the body is 
the most infectious because the body is loaded with the virus. 
Everybody that touches the corpse is another infection.
    We have encountered violence against us on numerous 
occasions by people in the general public when we have gone out 
at the request of the Ministry of Health to sanitize a body for 
a proper burial. This is going to be a tough thing to do. So 
you have got this general awareness in the general public.
    The number two area that needs to be addressed is community 
health workers. The entire international community has built a 
medical system around community health workers, which is 
essentially a moderately educated person who is given a few 
simple medical supplies, an algorithm chart, ``If it hurts 
here--,'' ``Are you passing blood?,'' ``Do you have a 
temperature?,'' ``Give them this color pills,'' ``The doctor 
can talk about this more than I, but I think generally I am 
getting this right.'' They do not have the information to 
understand what Ebola is.
    Friday--3 weeks ago this Friday at ELWA we had 12 patients 
with Ebola present. Eight of them were community health 
workers. Every one of those health workers had seen a patient, 
had diagnosed them for whatever they thought they had, and then 
they saw other patients. We have no way of knowing how many 
other people they have come in contact with.
    The third level of society is actually medical 
professionals. Something needs to be done with a focused 
attention on medical professionals because, when I hear reports 
that prominent physicians who are educated and credentialed and 
respected denied the disease, I think they need a little bit 
more education.
    And then the fourth level is leadership and politics, 
academics and religion. I don't know how to make those things 
happen, but those are the four stratas that I see to turn the 
disease back.
    I think the entire fight on the disease has to be focused 
on containment. To contain it means you need to identify it. 
The previous panel up here was saying that it could be 
contained, that we have the information. Okay.
    Liberia, Sierra Leone, and Guinea are poor. Like all 
countries, they have their problems with pointless bureaucracy, 
disfunction, and corruption. I know for a fact that, in Foya, 
the second largest center where Ebola is manifesting in 
Liberia, the workers at the Ministry of Health clinic were not 
paid for 5 months, even after the European Union had put money 
forward. The money just didn't get downstream.
    Again, I will say that Ebola is out of control in west 
Africa, and we are starting to see panic now around the world. 
People want to know. I don't know about you folks. I look at 
the Drudge Report. It can drive a lot of panic.
    And, you know, there is a guy in New York, there is a woman 
in England, there is--six people have been tested in the United 
States. There are reports that there are 340 Peace Corps 
workers coming back.
    I greatly appreciate the help of the CDC. They have, in 
fact--Dr. Frieden and I personally have spoken, and they have, 
in fact, helped articulate their procedures and protocols for 
Americans returning into this country, and we are grateful for 
that.
    While our Liberian office remains open doing public 
awareness campaigns, we have, in fact, suspended all other 
program activity. I would say that we are in the process right 
now of backing up, re-planning, and reloading. We intend to 
come back and we intend to fight the disease more, but we have 
found some things that are needed.
    One of the things that I recognized during the evacuation 
of our staff is that there is only one airplane in the world 
with one chamber to carry a Level 4 pathogenic disease victim. 
That plane is in the United States. There is no other aircraft 
in the world that I could find. That means that the United 
States does not have the capacity to evacuate its citizens back 
in any significant mass unless the Defense Department has 
something, the DoD has something that I am not aware of.
    It was not easy to get the plane back, but one thing that 
is important is that if the United States, and I believe the 
United States is going to have to take the lead on this. It may 
not be popular for us to take the lead today, but I think that 
we need to take the lead. If we are going to expect people, 
including the CDC people, to go abroad and put their life on 
the line, there has to be some assurance that we are able to 
care for them if they are sick. That may be a regional 
healthcare facility that is exclusive to those citizens, and 
those workers, or that may be a demonstrated capacity to get 
them home. But one airplane with one chamber to get them back 
is a bit of a slow process.
    Lastly, I think I want to say, it is a necessary thing that 
more laboratories be set up just in Liberia. The one laboratory 
now is at JFK Hospital. There is another one up over in Guinea 
in Gueckedou, and it can take us sometimes 30 hours to get a 
sample back. I have had discussion with the CDC about this. I 
think that is under consideration, but I would ask you if you 
could lean into that and question that, that would be very 
helpful.
    The problem is, if you have six people that come in and 
three of them or four of them are suspected, you have to put 
them in a semi-quarantine area and you are holding that area of 
your case management center until you get a positive or a 
negative back on them and it takes time.
    I understand that the World Bank has just committed $200 
million to fight the disease. That is fine. That is good. It is 
a little late. It is good. As somebody with 26 years of 
experience, including being the director of OFDA running many 
DARTs around the world, interacting with governments on 
multiple levels, I have some practical questions. I would like 
to know where the money will go. I would like to know what it 
will actually produce and I would like to know what it will 
actually buy. I fear that money alone cannot solve this 
problem.
    I disagree with earlier testimony that there is PPE in 
Liberia. That is inaccurate. I have an email that I have just 
received in the last 90 minutes from our hospital, the hospital 
that--the SIM hospital at ELWA. They are asking us for more 
personal protection gear. This is a problem everywhere. I am in 
touch daily with the headquarters of MSF, and Brussels. We are 
working hand-in-glove. I appreciate them so much for the way 
that they are stepping in and fighting this. The biggest 
challenge that we all have is the logistical support to get the 
materials and the supplies on the ground to fight this disease. 
As one of you quoted something that I said earlier, if we do 
not fight and contain this disease in west Africa, we will be 
fighting this disease and containing it in multiple other 
countries around the world, and the truth is, the cat is most 
likely already out of the bag.
    I want to thank my staff, and recognize them for who have 
been there, and have done a valiant job at great risk to their 
own lives and I want to let you know that the reintegration 
back into their country is awkward, people are afraid to get 
around them. Their husbands and their wives don't know if it is 
safe to hug them. Their communities may ostracize them. We are 
doing everything that we can in the staff care way to give them 
a safe place to be, to protect their privacy, but I just want 
you to know how difficult it is for American citizens, and in 
fact citizens of all countries we have people on that team that 
came from more than six countries maybe seven countries. They 
all suffer these issues.
    I believe that this is a very nasty bloody disease. I could 
give you descriptions of people dying that you cannot even 
believe. But I think that we have to fight this disease and we 
have to fight it now. We are going to fight it here or we are 
going to fight it somewhere else. I am talking about here in 
west Africa, but I do believe that an international coordinated 
response something significantly more is needed.
    Thank you.
    Mr. Smith. Thank you very much, Mr. Isaacs, for that 
testimony.
    [The prepared statement of Mr. Isaacs follows:]

    
    
        
                              ----------                              

    Mr. Smith. And again, I think, underscoring your experience 
as head of the Office of Foreign Disaster Assistance, I mean, 
you have lived it and I don't think your resume tells the full 
story, all of those years of dedication.
    So, again, thank you, and we will take extraordinarily 
serious your recommendations and the questions you have posed. 
And I thank you for it.
    Dr. Glover.

        STATEMENT OF FRANK GLOVER, M.D., MISSIONARY, SIM

    Dr. Glover. Thank you, Mr. Chairman, and Members of 
Congress, for the opportunity to share with you.
    My name is Dr. Frank Glover and I am a board certified 
urologist. I earned my M.D. degree at Johns Hopkins and also a 
Doctor of Public Health in International Health (Health 
Systems). I have also done some work as a research fellow at 
Johns Hopkins in epidemiology. I am also a medical missionary 
working with SIM, which is a Christian missions organization 
with works in over 60 countries.
    In addition to working with SIM, I am the President of 
SHIELD In Africa, a U.S.-based NGO working in Liberia. My first 
experience in Liberia was in 1988, when as a medical student, I 
spent 2 months doing medical missionary work in an SIM hospital 
called ELWA (Eternal Love Winning Africa). For the past 3 
years, I have spent 4 months per year working in various 
hospitals throughout Liberia. I have taken teams of up to 50 
doctors and nurses several times per year. During this time 
period, we have taken care of thousands of medical and surgical 
patients. I have spent time rendering services of teaching, 
training, and patient care in most of the counties in Liberia. 
I have, therefore, had the opportunity to assess many of the 
hospitals and clinics throughout Liberia.
    In every case, the hospitals were understaffed and lacking 
in many basic essentials and pharmaceuticals. This Ebola 
outbreak in Liberia has exposed the country's inherently weak 
health system. Less than 200 doctors existed in this country of 
4 million prior to this epidemic. After the outbreak in March 
of this year, that number plummeted to only 50 doctors. This 
occurred as a result of the exodus of 95 percent of the 
expatriate doctors.
    Prior to the Ebola outbreak, the nurses went on strike or 
slowed down work throughout the country due to work grievances. 
This was true in Lofa, Bong, Bomi, and Montserrado Counties, 
which have been hit hardest by the epidemic. These nurses 
returned to work after negotiations with the Ministry of Health 
just before Ebola entered the country. After the outbreak began 
claiming the lives of the nurses who did not have protective 
gear, the nurses fled the hospitals.
    After a second Liberian doctor died of Ebola, all of the 
government hospitals shut down. The patients are too terrified 
to enter the buildings. The nurses have stated they will not 
return to work unless they are issued adequate protection 
including gloves, gowns, and goggles. At the ELW hospital in 
conjunction with Samaritans Purse, doctors and nurses continue 
to treat Ebola patients. There are 5 doctors and 77 nurses and 
aides. This is the only place in Monrovia where treatment for 
Ebola takes place. Currently, there is only enough space for 25 
patients in the isolation center. Initial attempts to expand 
the unit were met with protests from the local community which 
did not want Ebola patients coming from all over Liberia into 
their community. Having allayed the fears of the community, 
Samaritan's Purse will complete an 80-bed unit in the next 2 
weeks.
    The only other treatment center in Liberia is a 40-bed unit 
in Lofa County. The case fatality rates range from 80 to 90 
percent at both facilities, owing in part to the delays in 
people seeking treatment. Many patients die within 24 hours of 
presentation. ELWA is the only functioning hospital in 
Montserrado County, a population of nearly 1 million people 
where Monrovia is located. Many patients are dying with Ebola 
in their communities in part because there is simply no open 
health facilities.
    This creates problems because whole families are getting 
infected and dying. There is no way to count all of the people 
dying of Ebola in the villages and in the remote areas. The 
cause of death is often unknown and there exists a lot of 
suspicion toward Western and government health workers. As a 
result, information is often withheld from health workers. 
Advice on safe burial practices or abstaining from eating bats 
and monkeys is oftentimes met with resistance and even violence 
against health workers.
    To complicate matters further, usual illnesses such as 
malaria, typhoid, pneumonia, and surgical emergencies result in 
death as there are no functioning facilities at this time. The 
death toll will undoubtedly reach into the tens of thousands in 
Liberia unless immediate actions are taken to: 1) Increase the 
capacity to treat patients in isolation. 2) Create an effective 
means of quarantine for those suspected of having been exposed 
to Ebola. 3) Provide protective gear to all healthcare workers, 
and those involved in disposing of the bodies of patients that 
have expired.
    Given the episodic nature of Ebola, we must begin investing 
in healthcare system strengthening as we prepare to deal with 
future outbreaks. SIM and SHIELD stand ready to assist in the 
building of capacity of west Africans by training and producing 
more African healthcare professionals. Thank you.
    Mr. Smith. Thank you so very much for your life-long 
commitment and for building up capacity and doing it yourself, 
and working with others at SIM.

    [The prepared statement of Dr. Glover follows:]

    
    
                              ----------                              

    Mr. Smith. Let me ask you a just a few questions because 
your testimonies I think were very comprehensive.
    You said, Mr. Isaacs, that the international response you 
deemed it a failure and of course, no failure need be a failure 
in perpetuity. And I am wondering if there has been a turn of 
the corner; again, inspired by the tragedy of two of your 
workers being affected by the Ebola virus.
    And secondly, could you tell us how are they doing; how are 
their spirits; whether or not there is a sense, even if it is 
not fully backed by science yet that the drug ZMapp may have 
had an impact? I think, you know, one of the things, one of the 
questions I asked of the earlier panel, if some of these 
interventions proved to be efficacious, delay is denial if you 
have Ebola and since this seems to be ramping up and not 
ramping down currently, your thoughts on an aggressive FDA 
working in cohort with and in conjunction with the other 
agencies of Government to get, based on an opt-in, certainly 
recognizing the risks as Dr. Brantly certainly did, and Ms. 
Writebol?
    Mr. Isaacs. So on the failure aspect, I would say that I 
think the full international impact of Ebola has not been 
realized. I believe that Ebola threatens the stability of the 
three countries where it is effected right now. My staff met 
with the President of Liberia for almost 6 hours last 
Wednesday. They described to me that the atmosphere in the room 
was somber because she realized the full gravity of it.
    If you read the Ministry of Health status reports that come 
out every day from Liberia, I don't mean to be dramatic, but it 
has an atmosphere of ``Apocalypse Now'' in it. There are bodies 
lying in the street. It is on the front page of the Wall Street 
Journal, and today, there are gangs threatening to burn down 
hospitals, and this is essentially a society that is, let us 
say, a generation from everybody had Posttraumatic Stress 
Disorder from a horrible war. They can go from a normal 
conversation to a fistfight, to sticks in the flash of an eye. 
So they have a lot of temperament and they have a lot of 
investment in what is going on. There is a lot of emotion. But 
it isn't just Liberia. It is Sierra Leone, it is all of these 
countries.
    What would happen, you know, I don't want to, I mean, you 
can use your own imagination in Nigeria, Lagos, what could 
happen there? And I believe that this disease has the potential 
to be a national security risk for many nations. And I think it 
will have an impact even on our national security. It has been 
a failure because it is now jumped another country because the 
epidemiologists have totally misread the magnitude of the 
disease and because there are not resources on the ground.
    The status of the two patients, I can say that I hear from 
Emory the same thing everybody does. They seem to be getting a 
little better every day. I do not think this will be a fast 
process. After that medicine was administered, after it was 
brought to us by the NIH people, and Dr. Brantly was very much 
involved in giving his informed consent to it. He understood as 
did Nancy Writebol. There was improvement, and I think as the 
doctors were saying here, I am not a doctor, you know, I don't 
want to guess at science, but I will say that they seem to have 
gotten better. They got home, they are at Emory. We appreciate 
Emory, they are getting good treatment there and we just pray 
that they survive and can recover their health.
    Mr. Smith. Let me ask you, you pointed out four different 
areas: Kissing the corpse, community health workers, medical 
professionals, as three of those.
    Now let me ask you about the community health workers. You 
have pointed out that in one cluster of infected individuals 8 
out of 12 were community health workers. Now, doctors obviously 
have a higher degree of training, they understand the essential 
importance of protective garb, and community health workers 
might not have that same level of indoctrination about how 
important that is.
    In your view, are they much more at risk because they are 
more rudimentary in what they do and therefore they are not 
taking the precautions?
    Mr. Isaacs. So in my view, yes, they are more at risk. It 
is not just to do with the personal protective gear, but it is 
also due to the lack of education. If you look at the symptoms 
of the disease, fever, joint pain, vomiting, and diarrhea, I am 
going to guess that probably covers 50 percent of all the 
diseases that present to them. That puts them in an untenable 
and weak position of being exposed to the disease, and not 
exactly knowing what it is.
    I just am saying that I think that there needs to be 
focused education efforts on these four levels of society: 
General public awareness, community health workers, medical 
professional, and national leaders. I don't think putting a 
poster up on the wall saying ``Ebola kills'' is going to do it. 
I think that there has to be a programmatic approach to each 
one of these stratums of society to get the essential 
information that they need to encourage people from their 
position and to deal with the things that come to them.
    Mr. Smith. Doctor, please.
    Dr. Glover. I would have a slightly different take on it. I 
believe that community health workers, if properly trained, can 
get the same outcome of coverage as physicians. What we have to 
understand is that people, health workers, don't get Ebola 
because of carelessness, necessarily, or because of lapses in 
sterile technique.
    In the case of these workers, for example, it is very 
likely that they contracted Ebola from other workers who were 
at the hospital who may have gotten the disease from the 
community. So if you are working alongside someone and they 
happen to have Ebola, then you get it from the staff and so 
there are a number of documented cases of staff infecting 
staff. In fact, just yesterday there was a report in the 
Kakata, in Margibi County where four nurses died and 11 more 
were infected. And so there is a lot about the infectivity that 
we don't realize in terms of how it happens.
    Mr. Smith. Let me just, in terms of getting the message out 
in a way that will be most likely received so that people 
understand the catastrophic nature of the disease, my 
understanding is that Guinea today is recruiting retired 
doctors, nurses, and midwives, authority figures, older rather 
than younger, to convey this message.
    Have you heard that and are the other countries, the other 
two countries and perhaps even Nigeria, too, looking to do that 
so that authority figures convey, again, the paramount 
importance of, for example, burial practices and the like?
    Dr. Glover. One of the challenges we have in Liberia is 
after this 14-year brutal civil war, during that period of time 
people did not go to school. So you have a large population of 
illiterate people and many of the languages in Liberia are not 
scripted, so you can't write something. So there needs to be 
language-appropriate messaging in each dialect in a way that 
each community can understand it, so they can get the message.
    So it requires people that are seen as authority figures, 
but also people that are able to communicate in the person's 
spoken language so they are able to get the message. So as he 
says, putting a poster up is not going to help someone when you 
have got an illiteracy rate of 75 percent.
    Mr. Smith. Finally, just let me ask, Mr. Isaacs, if you 
could, you said that the President of Liberia was a month late. 
Is it too late? And what would have happened had that state of 
emergency been declared a month ago?
    Mr. Isaacs. The month statement was not a scientific 
statement. It is just an opinionated statement, and when I 
don't have knowledge, I always have opinions, rightly or 
wrongly. But I do think that Liberia would have been better 
served had a status of emergency been declared earlier.
    Now, I don't know all of the actual mechanisms that will go 
along with that declaration, but it is clear to me that Liberia 
is in a severe crisis that I believe threatens the stability of 
the society as it exists today and I think that as you see the 
disease spread in Freetown and in Conakry, hopefully it has 
peaked there, and in Monrovia you are going to see more 
instability and insecurity.
    Mr. Smith. Then we do ask about the question of testing and 
you heard the exchange earlier with Dr. Frieden and other 
members of the panel about the lack of labs, lack of testing 
capability. You might want to comment on that. But even in the 
best of circumstances, say in New York, or New Jersey, how long 
does it take to get a test back? Because this does move very 
fast.
    Dr. Glover. Well, we have special tests in the U.S. so in 
just a matter of a few hours.
    Mr. Smith. Hours.
    Dr. Glover. But logistically, when you look at the 
infrastructure of these countries, to go from one point to the 
other on a map, it may look like, ``Oh, it is just 50 miles.'' 
That 50 miles could take you 8 hours because you can only drive 
3 miles an hour through roads that are impassable.
    So a lot of logistical problems exist here, but I believe 
the number one cause of healthcare worker infections in Liberia 
is the lack of the protective gear. You are asking people to go 
to work, to take care of patients, and they don't have simple 
gloves. And to me this is unconscionable. So if we are going to 
put people on the line, the brightest and the best people in 
the country on the line, we owe it to them to give them a 
fighting chance.
    Even in this country, no matter how well-trained a doctor 
is, if an Ebola patient comes up to him before he or she knows 
what he has, he has already been infected.
    Mr. Smith. Mr. Isaacs, you asked the question earlier, 
where will the money go? What will it buy? Where in your 
opinion should the money go and what should it buy?
    Mr. Isaacs. I think that international personnel are 
needed. I frankly do not think that the Ministry of Health of 
Liberia can fight this. They do not have the case investigation 
capacity. I talked with a senior person in CDC, I won't name 
her, but she is a well-known person. She told me that in the 
United States if there was one person that had a Level 4 
infectious disease, they would have many hundreds of contacts 
to run down. There are no contacts being run down in Liberia.
    I don't believe that the Liberian Government, as well 
intentioned as they are, and I do believe that they are well 
intentioned, I just do not think that they have the capacity. I 
am all for building the capacity, but I think there needs to be 
something to augment their capacity. I think that there needs 
to be some kind of a coordination unit. I have heard here today 
that the World Health Organization has the lead; maybe, maybe 
not. I think that probably something perhaps with a bit more of 
an operational edge to it is called for. I don't know what that 
could be, but more is needed.
    And I think that if we leave this situation up to the 
Ministries of Health, I mean, you have a unique situation where 
you have three poor countries that have a communicable, 
infectious, and lethal disease, that clearly don't have the 
capacity to contain it, and is the world willing to allow the 
public health of the world to be in their hands while they try 
to contain the disease? I think that is the essential question.
    Mr. Smith. Thank you. And finally, Dr. Glover, you had 
worked on the DRC outbreak of Ebola, what, some 20 years ago?
    Dr. Glover. Actually, I was, at that time I was working in 
Zaire. I was in Zaire, in Kinshasa, but the outbreak was in 
Kikwit, so I was there during the outbreak, but I wasn't 
actually working with Ebola.
    Mr. Smith. How does this compare to that outbreak?
    Dr. Glover. There is no comparison because back then it was 
a very sparsely populated rural area, where it could 
essentially burn itself out.
    But you have so many people in Liberia that have moved to 
the city, so that they are living in very close spaces--if you 
look at a taxicab or a bus, you wonder how could they get so 
many people jam packed in there or how many people live in a 
house, for example. At the Phebe Hospital, the administrator 
came down with the virus, and he infected his 8 children, and 
his wife and all 10 of them died.
    So the close proximity in which the people are living, the 
concentration of the population, means that as this epidemic, 
no matter what we do, unfortunately, there is going to be 
tremendous loss of life just by the nature of this disease.
    Mr. Smith. Well, I thank you both.
    Is there anything you would like to add before we conclude 
the hearing?
    Mr. Isaacs. I would just say that I think much more--I am 
certain there is much more than I know of, but this concept of 
research and development for a vaccine and a cure is very 
important. I agree with Dr. Glover. I think we are going to see 
death tolls in numbers that we can't imagine right now. That is 
potential and also, I will tell you that we are now at 
Samaritan's Purse in the process of distributing Ebola-
readiness information to all missionary hospitals across 
Africa.
    Mr. Smith. Dr. Glover, any final words?
    Dr. Glover. No final words.
    Mr. Smith. Thank you.
    I want to thank both of you, again, for your extraordinary 
service to mankind and especially to the sick, and at risk, and 
disabled, and those who are suffering this terrible outbreak of 
Ebola.
    And we look forward if you could stay in touch with our 
subcommittee, this is the first of a series of hearings. We are 
looking to make sure that whatever we need to do as a Congress, 
and as a subcommittee, and me personally, and my colleagues, we 
want to do and again, your guidance is absolutely essential.
    Thank you for sharing your wisdom and insights, and 
incisive commentary to the subcommittee. The hearing is 
adjourned.
    Mr. Isaacs. Thank you.
    Dr. Glover. Thank you.
    [Whereupon, at 4:23 p.m., the subcommittee was adjourned.]
                                     

                                     

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