[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/
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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
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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
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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.]
A P P E N D I X
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