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






                     GLOBAL EFFORTS TO FIGHT EBOLA

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

                                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

                               __________

                           SEPTEMBER 17, 2014

                               __________

                           Serial No. 113-239

                               __________

        Printed for the use of the Committee on Foreign Affairs

[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]



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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
DOUG COLLINS, Georgia                GRACE MENG, New York
MARK MEADOWS, North Carolina         LOIS FRANKEL, Florida
TED S. YOHO, Florida                 TULSI GABBARD, Hawaii
SEAN DUFFY, Wisconsin                JOAQUIN CASTRO, Texas
CURT CLAWSON, Florida

     Amy Porter, Chief of Staff      Thomas Sheehy, Staff Director

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

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

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














                            C O N T E N T S

                              ----------                              
                                                                   Page

                               WITNESSES

The Honorable Nancy Lindborg, Assistant Administrator, Bureau for 
  Democracy, Conflict and Humanitarian Assistance, U.S. Agency 
  for International Development..................................    15
Anthony S. Fauci, M.D., Director, National Institute of Allergy 
  and Infectious Diseases, National Institutes of Health, U.S. 
  Department of Health and Human Services........................    24
Luciana Borio, M.D., Director, Office of Counterterrorism and 
  Emerging Threats, Office of the Chief Scientist, U.S. Food and 
  Drug Administration, U.S. Department of Health and Human 
  Services.......................................................    42
Beth P. Bell, M.D., Director, National Center for Emerging and 
  Zoonotic Infectious Diseases, Centers for Disease Control and 
  Prevention, U.S. Department of Health & Human Services.........    51
Kent Brantly, M.D., medical missionary, Samaritan's Purse 
  (survivor of Ebola)............................................    81
Chinua Akukwe, M.D., chair, Africa Working Group, National 
  Academy of Public Administration...............................    92
Mr. Ted Alemayhu, founder & executive chairman, US Doctors for 
  Africa.........................................................   101
Dougbeh Chris Nyan, M.D., director of the secretariat, Diaspora 
  Liberian Emergency Response Task Force on the Ebola Crisis.....   108

          LETTERS, STATEMENTS, ETC., SUBMITTED FOR THE HEARING

The Honorable Christopher H. Smith, a Representative in Congress 
  from the State of New Jersey, and chairman, Subcommittee on 
  Africa, Global Health, Global Human Rights, and International 
  Organizations: Prepared statement..............................     5
The Honorable Nancy Lindborg: Prepared statement.................    18
Anthony S. Fauci, M.D.: Prepared statement.......................    27
Luciana Borio, M.D.: Prepared statement..........................    44
Beth P. Bell, M.D.: Prepared statement...........................    54
Kent Brantly, M.D.: Prepared statement...........................    84
Chinua Akukwe, M.D.: Prepared statement..........................    94
Mr. Ted Alemayhu: Prepared statement.............................   103

                                APPENDIX

Hearing notice...................................................   118
Hearing minutes..................................................   119
Dougbeh Chris Nyan, M.D.: Material submitted for the record......   120
Questions submitted for the record by the Honorable Mark Meadows, 
  a Representative in Congress from the State of North Carolina..   124

 
                     GLOBAL EFFORTS TO FIGHT EBOLA

                              ----------                              


                     WEDNESDAY, SEPTEMBER 17, 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 10 o'clock 
a.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, or good morning, I should say, to everybody. We are 
here today to hold our second hearing in just 5 weeks on the 
Ebola crisis in west Africa to underscore just how serious a 
crisis they are facing and I would say we are facing--an 
international pandemic which threatens to balloon unless 
confronted head on.
    I spoke yesterday to Dr. Tom Frieden, director of the U.S. 
Centers for Disease Control and Prevention and the lead witness 
at our August 7 emergency hearing during recess on Ebola, and 
he said that this is the worst health crisis he had ever seen.
    He said, I have never seen anything like this in my life, 
and coming from the head of the CDC that was an extraordinarily 
powerful statement.
    Since our August emergency hearing, we are seeing a 
constant movement upwards in the number of actual cases as well 
as the predictions of how many people may contract the disease 
and what potentially the number of fatalities might indeed be.
    The numbers range. Yesterday the President was talking 
about hundreds of thousands. I read a German doctor who said 
something on the order of 5 million.
    That, hopefully, is way overinflated but it underscores 
that nobody really knows and we are talking about a pandemic 
that even if it stays contained in the west African countries 
is doing unbelievable damage and imposing unbelievable sorrow.
    The World Health Organization estimated we would see as 
many as 20,000 cases of Ebola before it has ended and, again, 
the numbers have now begun to exceed that in terms of 
estimates.
    We are holding this hearing to take stock of where our 
intervention efforts stand, particularly in light of the 
President's decision to commit U.S. Military personnel to 
Liberia to fight this disease.
    Liberian President Ellen Johnson Sirleaf, with whom I spoke 
yesterday, has conceded that the Ebola epidemic has overwhelmed 
her country, her ability to treat.
    She said this in a letter that she sent to the President: 
``The virus is spreading at an exponential rate and we a have 
limited time window to arrest it.'' She pointed out that well 
over 40 percent of the total cases have occurred in the last 18 
days alone.
    She said the treatment centers are overwhelmed and that at 
this rate we will never break the transmission chain and the 
virus will overwhelm us--an ominous statement from the 
distinguished President of Liberia.
    We are also holding this follow-up hearing this morning to 
determine if there is a reasonable hope for vaccines, 
treatments, or detection strategies in time to help with this 
health emergency.
    I hesitate to provide figures for the number of people who 
have died but I think the estimates are something on the order 
of 2,500 people who have passed away and that is probably an 
underestimation of the actual number.
    Ebola, which was mostly unknown in west Africa until now, 
presents itself early in the infection like usually non-fatal 
diseases such Lassa fever, malaria, or even the flu.
    The temperature seen in the early stages might even be 
brought down with regular medicines. Therefore, many people may 
not believe or may not want to believe that they have 
contracted this often fatal disease.
    If someone is in denial or unknowledgeable about this 
disease, they may not seek treatment until it is too late, both 
for them and for the people they unknowingly infect. Families 
in Africa tend to help each other in times of need, an 
admirable trait that unfortunately increases the risk of 
infection.
    The sicker a person gets with Ebola, the more contagious 
they are and never more so than when they die. So burials that 
don't involve strict precautions to avoid direct contact with 
highly contagious remains of victims make transmission of this 
deadly disease almost inevitable.
    Burial traditions make avoidance of infection problematic. 
The porous lightly-monitored borders in west Africa lend 
themselves to cross-border transmission as people go back and 
forth along well-traveled roads and into marketplaces where 
hundreds of people also travel and make contact with those who 
are infected.
    Patrick Sawyer, a Liberian-American, reportedly was caring 
for his dying sister a few weeks ago. After she died, 
apparently of Ebola, he left Liberia on his way to his 
daughter's birthday party in Minnesota. He collapsed at the 
Lagos airport in Nigeria and died within days.
    Had he left Liberia a week or even days earlier, he might 
have made it home to Minnesota but he likely would have 
infected people along the way, including his own family.
    We can say that because Sawyer infected several people in 
Nigeria, which led to Ebola being transmitted to health care 
workers and then to dozens of other people.
    We will never know now if Mr. Sawyer realized that he had 
contracted Ebola and just wanted to go home for treatment or 
whether he thought his symptoms were from some other illness.
    Many people are just like him, however, and they are 
spreading this disease even to places where they have been 
brought under control. For example, the Macenta region of 
Guinea on the Liberian border was one of the first places where 
this disease surfaced.
    But by early September, no new cases had been seen for 
weeks. Doctors Without Borders closed one of its Ebola 
treatment centers to focus on harder-hit areas. Infected people 
leaving Liberia for better treatment than Guinea have once 
again made Macenta a hot spot for the disease.
    The U.S. Centers for Disease Control and Prevention has 
established, as we know, teams in Guinea, Liberia, Sierra 
Leone, and Nigeria to help local staff do fever detection and 
to administer questionnaires on potential troublesome contacts. 
The agency also was helping to establish sites at airports for 
further testing and/or for treatment.
    Liberia and Sierra Leone are the hardest hit so far by this 
Ebola outbreak. This is undoubtedly partly because of the weak 
infrastructures of the two countries emerging from long 
conflicts.
    However, post-conflict countries also have significant 
segments of the population who don't trust the central 
government. The unfortunate mishandling by the Liberian 
Government of an attempted quarantine in the capital 
demonstrates why trust has been so difficult to come by.
    The Liberian Government, as we know, established barriers 
to block off the West Point slum area where, after a holding 
center for Ebola victims was ransacked and contaminated 
materials were taken.
    This quarantine was done without fully informing its 80,000 
inhabitants or consulting with the health care workers. Not 
only did this prevent people from pursuing their livelihoods or 
bringing in much-needed supplies, this move created great 
suspicions of the motives of the Liberian Government.
    This suspicion was heightened when the official in charge 
of the area was called to a meeting and was seen leaving just 
as everyone else was trapped behind barriers. The furor over 
the quarantine forced the government to abandon it 10 days into 
its planned 21-day term.
    Liberian officials assured us that they have learned from 
their mistakes, that of the quarantine, and has alerted 
Liberians of the reality of the Ebola epidemic. I read many of 
the newspapers from west Africa every single day and it is 
front-page headlines, sometimes a little bit exaggerated, but 
certainly front-page headlines, so people are becoming more 
aware through that medium.
    Despite the fact that the drug ZMapp appears to have saved 
some lives including Americans Nancy Writebol and Dr. Kent 
Brantly, who we will hear from in our second panel, there are 
no proven readily available treatments for Ebola.
    The death rate for this disease, once more than 90 percent, 
is now down to 53 percent despite the number of cases growing 
exponentially.
    In Africa, a few patients apparently have been successfully 
treated with ZMapp and Dr. Fauci, I am sure, will give us 
additional insights in this, and some others may have been 
saved using other treatment methods, especially when the 
disease was identified early.
    Yet there is not now nor will there be in the short term 
large quantities of this medicine or any others. There are 
other several Ebola therapeutics under development but if this 
outbreak cannot be brought under control soon, even the most 
optimistic timetable for the testing and production of these 
drugs will not be sufficient to meet the ever expanding need.
    ZMapp was used with the informed consent of those to whom 
it was given. But how can we guarantee that the many Ebola 
victims, whose most likely salvation would be to use an 
experimental drug, truly understand the risk of using a drug 
that has not been fully tested?
    Lack of faith in national and international systems 
fighting Ebola has impeded the replacement of many Africa 
health care workers who have died from this disease. That is 
one of the untold problems, that people on the front line are 
dying, as well as their families.
    I was talking to a friend who runs an NGO in Sierra Leone 
who works with obstetric fistula and a nurse at his clinic 
died, and so did her six children. So health care workers have 
borne a disproportionate share of this horrific disease.
    As of late August, 164 Liberian health care workers had 
contracted Ebola and 78 had died and that number no doubt has 
increased. African health care workers face an epidemic that 
threatens to defy control.
    The lack of diagnostic techniques and insufficient supplies 
of safety equipment have put these health care workers at 
extreme risk. These health care workers know that the lack of 
treatment centers and medicines means that those on the front 
lines of this epidemic are most at risk, as I indicated 
earlier.
    And finally, without objection will put my full statement 
into the record. I will just point out that yesterday's 
announcement that some 3,000 American service personnel will be 
deployed. Nancy will remember that I traveled right after the 
typhoon hit in the Philippines and if it wasn't for the 
military providing food, water, shelter, and medicines working 
with USAID and NGOs like Catholic Relief Services, many more 
Filipinos would have died as a result of Dengue fever and other 
terrible diseases might have manifested in large numbers.
    Same goes for the tsunami. I will never forget a number of 
us went and we saw what was being done in Banda Aceh. Again, 
USAID, working with CDC, NIH, and the military. But this is a 
little bit different and perhaps our witnesses could elaborate 
on this either during the Q and A or in their statements about 
what precautions might be provided to those service members.
    I know they will be likely building beds, which are 
unbelievably lacking, particularly in Liberia. People can't 
find a bed when they are sick to get treatment or at least to 
live in until they pass.
    And so it does raise the question of what kind of 
precautions those military personnel will take, whether they 
will be properly suited, what their mission will be, and when 
will they be deployed. A number of questions have arisen, I am 
sure, by many of us concerning it to ensure their safety.
    I would like to yield to Ms. Bass and then to the chairman 
of the full committee, Mr. Royce.
    [The prepared statement of Mr. Smith follows:]
    
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    Ms. Bass. Thank you, Mr. Chairman, as always for your 
leadership and for calling today's hearing to give us an 
opportunity to examine the scope of global efforts to address 
the ongoing Ebola crisis in west Africa.
    This is the subcommittee's second hearing on Ebola in the 
past 6 weeks and I look forward to getting updates from our 
witnesses today on how their agencies and organizations 
continue to combat this deadly outbreak, what trends they are 
seeing both positive and negative, and what additional support 
is needed as they coordinate with the governments of the 
impacted countries.
    I appreciate their efforts and outreach to help keep 
Congress informed on this evolving and devastating epidemic. 
Yesterday, I was very pleased to see President Obama's 
announcement at the CDC headquarters in Atlanta where he 
provided a comprehensive outline of the U.S. support for 
Liberia and other west African nations impacted by the crisis.
    The President's commitment totals, as I understand it, over 
$700 million over the next 6 months and will include sending 
3,000 American military personnel to the region, AFRICOM's 
establishment of a regional intermediary staging base to 
facilitate the transport of medical equipment, supplies and 
personnel to affected regions, and the command's establishment 
of a medical training site to train up to 500 health care 
providers per week.
    It has been an honor to work with the various U.S. agencies 
seeking sustainable solutions to the Ebola outbreak including 
the CDC, USAID, the Departments of State and Defense, 
respectively.
    I also want to commend the steps being taken by the 
Governments of Liberia, Sierra Leone, Guinea, and Nigeria 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 disease.
    The U.S. commitment will address the unique nature of this 
outbreak that has made combating the disease particularly 
difficult. West Africa has not faced this before and 
communities and governments and health professionals in Guinea, 
Sierra Leone, and Liberia don't have the expertise and capacity 
to address the scale, spread, and proper treatment of the 
outbreak alone.
    The crisis is not just about obvious health concerns, and 
this is a major concern to me and why I was happy with the 
President's announcement about military support because I am 
really concerned about the stability of the countries, with 
post-civil war conflicts.
    These countries have weak institutions and a crisis like 
this could actually lead to a complete destabilization. 
Although they have elected democracies right now, we know that 
in many of these countries, as I mentioned before, you could 
actually have a collapse of the governments.
    Yesterday, I also had the privilege to speak with Liberian 
President Johnson Sirleaf on the impact of the outbreak in her 
country and the work they have done to fight the spread of the 
diseases.
    She called to thank me and to express her deep gratitude 
for U.S. assistance and stated that with essential support from 
the U.S. Government, the World Bank, the African Development 
Bank, she actually feels confident now and she sees moving 
toward a health recovery, and I will say that this was markedly 
different than the telephone conversation I had with her a few 
weeks ago, and I am sure the chairman and ranking member and 
Mr. Smith had the same type of calls, where she seemed to be 
particularly desperate. So it was nice to have the call 
yesterday.
    It is in America's and the world's interest to continue to 
assist in this crisis and to continue to support nations as 
they fight this outbreak and work to develop and strengthen 
their health care systems.
    Health care is a human right. We must ensure that countries 
have the ability to address this outbreak and are able to move 
forward and prevent future health epidemics from occurring. In 
Congress, there has been consistent activity related to the 
recent crisis.
    Prior to the August recess, 100 bipartisan members 
introduced House Resolution 701 expressing the sense that the 
current outbreak is an international health crisis and is the 
largest and most widespread outbreak of the disease ever 
recorded.
    On August 7, the Foreign Affairs Committee's Africa 
Subcommittee held an emergency hearing on the crisis and 77 
members have signed a letter to the Committee on Appropriations 
to fulfill the President's $88 million funding request to fight 
the crisis.
    And there is also going to be a member meeting tomorrow 
that we are all doing together to brief members who don't have 
the opportunity to sit on this subcommittee or the full 
committee.
    I look forward to your testimony and I am interested in 
hearing from all of you about what more Congress can do to 
assist your efforts to combat the disease outbreak and support 
international efforts to improve health care systems around the 
world.
    Thank you, and I yield back.
    Mr. Smith. Ms. Bass, appreciate it.
    We are joined by the distinguished chairman of the full 
committee, Mr. Royce.
    Mr. Royce. Thank you, Mr. Chairman. I just guess I would 
start by thanking and welcoming Dr. Kent Brantly who is with us 
and to say that I am very glad that ZMapp is in trials and I am 
glad you are here.
    Our heart goes out to the families of your colleague who 
also tried the ZMapp and did not survive. But we are encouraged 
by the fact you are with us today. We have seen this pandemic 
in the past in the Philippines, in Uganda, in Congo, different 
strains, and over the past in each case the strain has burned 
itself out. I mean, we have had about 2,300 deaths worldwide 
since 1976 as, time after time, different strains of Ebola have 
been put to rest.
    But in this latest chapter in west Africa, primarily in 
Liberia and the neighboring states, we see a situation where we 
have already had 2,300 deaths, as many as in all the previous 
cases combined.
    And I spoke yesterday also to President Sirleaf, who 
contacted me about the situation in Liberia. She acknowledged 
that the health system of Liberia has virtually collapsed under 
the strain of this Ebola crisis and she correctly pointed out 
that this is not just a health catastrophe affecting her 
country.
    It affects the region. It affects the security of the 
region, threatens the economic growth and food security but, 
beyond that, affects the security of the United States.
    The entire global health community must come together and 
put in place a coherent strategy to stem the tide of new 
infections and my hope is that some of our effort here will 
encourage this in terms of the entirety of the world health 
community.
    We do not have the luxury of time. Infectious diseases like 
this one, they do not recognize borders, they do not 
discriminate, and the time to act is now.
    And I spoke recently with Raj Shah, the Administrator of 
USAID, who shares our concern on this subject. But I really 
want to thank the witnesses for appearing today and we look 
forward to working with them to ensure that the U.S. 
contribution to the global response to Ebola is robust and is 
effective. And thank you again, Mr. Chairman.
    Mr. Smith. Thank you very much, Chairman Royce. I would 
like to now yield to the ranking member of the full committee, 
Mr. Engel, of New York.
    Mr. Engel. Thank you, Mr. Chairman--Chairman Smith, Ranking 
Member Bass. Thank you for holding this important hearing on 
the devastating Ebola outbreak in west Africa.
    I want to say at the outset I am very happy that Betty 
McCollum, our colleague from Minnesota who is a former member 
of this committee is here with us as well.
    Without exception, the global health leaders from around 
the world continue to sound the alarm about the terrible threat 
posed by this Ebola outbreak. It is almost impossible to 
overstate how dire the situation has become in Liberia, Sierra 
Leone, and Guinea.
    The World Health Organization has called this outbreak 
unparallelled in modern times. Almost 2,500 of the 5,000 
individuals infected by Ebola have died. NGOs and humanitarian 
organizations have shouldered most of the burden in fighting 
this epidemic for months but their passion and dedication is no 
match for the speed with which this disease is spreading. More 
government involvement is desperately needed.
    The World Health Organization has also said that if the 
response is quickly scaled up, only tens of thousands of 
individuals will become infected by the time the outbreak is 
contained. That is the best case scenario, believe it or not. 
The alternative is simply unacceptable.
    The need for more well-trained health care personnel, 
personal protective equipment, and adequate health care 
facilities is immediate. So I am pleased to see the CDC, USAID, 
and Department of Defense are rapidly scaling up their efforts. 
I am also glad that President Obama has decided to send the 
U.S. Military to help.
    It is my belief that our response must be well coordinated, 
sustained, and nimble enough to meet the needs as they evolve. 
However, the United States cannot contain this disease alone. 
It is a threat to the entire international community and 
requires a truly global response.
    I will be interested to hear from our panelists about what 
our other partners around the world are doing to help with the 
response and what significant gaps remain to be filled.
    I would also like to take a moment to applaud the courage 
and selflessness of the health workers on the front lines 
trying to help those afflicted to survive.
    They put themselves at significant personal risk and are 
bearing the brunt of the infection's spread, as one of our 
witnesses, Dr. Kent Brantly, can attest to. Their bravery and 
dedication is simply appreciated and a true inspiration to all 
of us.
    So let me say as the ranking member of the House Foreign 
Affairs Committee, thank you, Chairman Smith and Ranking Member 
Bass, for convening this hearing and thank you to our witnesses 
for coming to talk about this urgent issue. I yield back.
    Mr. Smith. Thank you very much, Mr. Engel. Mr. Stockman.
    Mr. Stockman. I just want to say a brief note to those that 
are here in attendance today, I was in South Sudan and one of 
the organizations, Mr. Chairman, that I saw there, of all the 
other nongovernmental organizations that were there, was 
Samaritan's Purse, and wherever I travel around the world they 
are a shining light and example of true compassion and 
sacrifice and it is done in silence that most Americans aren't 
aware of.
    And Kent's sacrifice is not just in Africa, but your whole 
organization is to be commended for the compassion and the 
heart you have and I know Franklin Graham and others have 
worked tirelessly and has not broadcast that.
    But wherever I went Samaritan's Purse was there and it is 
really a testimony to the work that you and others have done on 
behalf of the United States and I just want to send a thank you 
for that.
    Mr. Smith. Thank you very much, Mr. Stockman.
    Mr. Cicilline.
    Mr. Cicilline. Thank you, Mr. Chairman. I want to thank you 
and Ranking Member Bass for holding today's hearing on this 
very serious outbreak of Ebola in west Africa.
    I also want to acknowledge and send thoughts and prayers to 
all of the families who have already been affected by this 
outbreak and I know in my home state of Rhode Island, which is 
the very proud home to a wonderful Liberian community, it has 
caused considerable heartache and concern.
    I want to particularly offer my gratitude to the witnesses 
today for your testimony and for the really important work that 
you are doing and to the government panel in particular for 
keeping Congress so well informed with regular updates on the 
situation on the ground.
    In particular, I also want to acknowledge and thank Dr. 
Kent Brantly for joining us on the second panel and for sharing 
with us the work that he has been doing in Africa to fight 
Ebola and, of course, his own personal experience surviving the 
virus.
    The United States has both a humanitarian responsibility 
and a national interest in doing all that we can to fight this 
outbreak, and in addition to obviously protecting against Ebola 
within our borders, we also have a responsibility to work to 
help save lives and strengthen the economies of our trading 
partners and maintain political stability in the region that 
has been affected by this outbreak.
    We must all be concerned about the serious issues of civil 
unrest, food insecurity, and the collapse of national health 
care systems in the African countries impacted by this 
outbreak, and I hope our witnesses will share with us ways that 
we can address this crisis more effectively and what are the 
things Congress might do to support an effective response to 
this crisis.
    And with that I, again, thank the witnesses and yield back, 
Mr. Chairman.
    Mr. Smith. Thank you, my friend. I would like to yield to 
Dr. Burgess.
    Mr. Burgess. Well, thank you, Mr. Chairman, and thank you 
and Ranking Member Bass for allowing me to be part of your 
committee's activities today and I am anxious to hear from the 
witnesses that you have assembled and to learn more.
    I am on the Energy and Commerce Committee and we do have a 
healthcare footprint. But, Mr. Chairman, let me just say you 
have taken an outsized role in providing leadership in the 
Congress in having the hearings on this very important 
outbreak.
    Certainly, Dr. Fauci, for the last 12 years you have been a 
resource for me whenever infectious disease threatens and, 
unfortunately, it does and I have always looked to you for your 
expertise and your leadership in this area.
    Dr. Brantly, I just had a chance to meet you for the first 
time today. You are from my part of the world in Fort Worth and 
I appreciate your service at Samaritan's Purse and certainly 
grateful that you are with us and I really mean that you are 
with us today.
    Others have said it so well but more people have died in 
this outbreak than all of the previous outbreaks of Ebola going 
back to 1976. No one expected the outbreak to reach the 
proportions that it did, but it did.
    No one expected it to last the length of time that it has, 
but it has. Now, certainly, whatever criticism there may be for 
lack of action in the past I am pleased that action is 
occurring now.
    Just also feel obligated to note that an obstetrician is 
recovering today in Omaha, Nebraska--Dr. Rick Sacra--who was 
not actually treating Ebola patients but was exposed through 
his work in labor and delivery, and it just underscores part of 
the risk--the accelerated risk that healthcare providers 
experience in this illness and in the countries that are so 
affected but also the fact that the rest of civil society and 
the healthcare infrastructure is really put under strain by 
this.
    And you can really scarcely devote the resources that are 
needed to treating malaria and accident victims and mothers in 
labor when everything else has to be diverted to taking care of 
people with Ebola.
    So, Mr. Chairman, I thank you for the opportunity to be 
with you today. Thank you for your leadership on this issue and 
I will yield back my time.
    Mr. Smith. Thank you very much, Dr. Burgess.
    I would like to yield now to the gentlelady from Minnesota, 
Ms. McCollum
    Ms. McCollum. Well, thank you, Mr. Chair. That is an 
unexpected surprise. Thank you very much.
    I would also like to extend my thanks to the panels that 
are here today who reflect all the healthcare workers around 
the world, especially those in Africa who are working so hard 
and the researchers who are trying to find ways in which to 
defeat this disease.
    Minnesota is my home state. We are a state that is blessed 
to have so many wonderful, wonderful people from all over the 
world who call Minnesota home including a large Liberian 
population, one who is mourning the loss of their own, as 
Chairman Smith pointed out.
    We are also the home to my first state epidemiologist, Mr. 
Osterholm, who sometimes gets accused of talking fire but he is 
saying look where the fire exits are.
    So in my work on the Appropriations Committee and the 
Department of Defense I am pleased that we are putting boots on 
the ground to fight this disease. Thank you, Mr. Chairman.
    Mr. Smith. Thank you very much, Ms. McCollum.
    I would like to now introduce our very distinguished panel, 
beginning first with the Honorable Nancy Lindborg, who is the 
Assistant Administrator for the Bureau for Democracy, Conflict 
and Humanitarian Assistance at USAID, and she has testified 
before our subcommittee several times and provided very 
valuable input and leadership for her respective portfolio but 
also great input to this subcommittee as to what we ought to be 
doing to be of assistance.
    Since assuming her office in October 2010, Ms. Lindborg has 
led DCHA teams in response to the ongoing Syria crisis, in the 
Horn of Africa in 2011, the Sahel 2012 droughts, the Arab 
Spring upheaval, in the aftermath of Typhoon Haiyan in the 
Phillippines, and numerous other global crises. Prior to 
joining USAID, Ms. Lindborg was the president of Mercy Corps 
where she spent 14 years.
    We will then hear from Dr. Anthony Fauci, who is Director 
of the National Institute of Allergy and Infectious Diseases at 
the NIH.
    Since his appointment as NIAID Director in 1984, Dr. Fauci 
has overseen an extensive research portfolio devoted to 
preventing, diagnosing, and treating infectious and immune-
mediated diseases. Dr. Fauci has made numerous discoveries 
related to HIV/AIDS and is one of the most cited scientists in 
the field.
    Dr. Fauci serves as one the key advisors to the White House 
and the Department of Health and Human Services on global AIDS 
issues and he was one of the principal architects of PEPFAR.
    We will then hear from Dr. Luciana Borio, who serves as 
Assistant Commissioner for Counterterrorism Policy and the 
Director of the Office of Counterterrorism and Emerging Threats 
in the Office of the Chief Scientist, U.S. Food and Drug 
Administration.
    In this capacity, Dr. Borio is responsible for providing 
leadership, coordination and oversight for FDA's national and 
global health security, counterterrorism, and emerging threat 
portfolios.
    She serves as FDA's point of entry on policy and planning 
matters concerning counterterrorism and emerging threats, 
collaborates across U.S. Government and internationally on 
actions to advance global health security and U.S. national 
security.
    And our fourth witness in Panel I will be Dr. Beth Bell, 
who is the Director of the National Center for Emerging and 
Zoononic Infectious Diseases.
    Most recently, Dr. Bell served as the Associate Director 
for Epidemiologic Science in the National Center for 
Immunization and Respiratory Diseases.
    Dr. Bell has served in leadership roles during CDC 
responses to several major public health events including the 
2001 anthrax attacks--and she will recall one of the post 
offices hit was my own in Hamilton Township where we had a 
number of people who contracted cutaneous anthrax--Hurricane 
Katrina, and the 2009 H1N1 influenza pandemic.
    As a member of the senior leadership team for the 2009 H1N1 
influenza pandemic response she provided oversight of policy 
and scientific direction. So four extraordinarily important 
and, I think, great leaders in the field.
    I would like to now go to Ms. Lindborg and then to Dr. 
Fauci.

     STATEMENT OF THE HONORABLE NANCY LINDBORG, ASSISTANT 
ADMINISTRATOR, BUREAU FOR DEMOCRACY, CONFLICT AND HUMANITARIAN 
     ASSISTANCE, U.S. AGENCY FOR INTERNATIONAL DEVELOPMENT

    Ms. Lindborg. Thank you. Thank you, Chairman Smith, Ranking 
Member Bass, members of the subcommittee and other members.
    Thank you for inviting me to testify today on the U.S. 
response to the really unprecedented Ebola epidemic in west 
Africa and special thanks for your continued support and vital 
interest in these issues.
    I think as a number of you have very articulately laid out, 
this is the largest and most protracted Ebola epidemic in 
history. Thousands have already been sickened or killed and for 
the first time ever it is being transmitted in densely 
populated urban areas.
    So we are now seeing a near exponential increase in the 
transmission of the virus with the potential for a regional 
spread beyond the primary countries of Guinea, Liberia, and 
Sierra Leone.
    The United States began combatting the epidemic when the 
first cases were reported in March and what began as a public 
health crisis began morphing into a multidimensional public 
health, humanitarian, and security crisis this summer.
    And so we then significantly expanded our efforts and on 
August 5 USAID deployed a Disaster Assistance Response Team, or 
a DART, to the region to oversee and coordinate the U.S. 
response, drawing on critical assets and resources from across 
the U.S. Government including CDC, USAID, HHS, DoD and the U.S. 
Forest Service.
    We developed a clear four-part government strategy that 
supports the U.N. and country-led responses. That was first and 
most urgently focused on controlling the epidemic. Next, we are 
working to mitigate the side effects of the crisis. This 
includes blunting the economic, social, and political tolls.
    Third, we are helping to coordinate with the U.N. and 
enable a broader effective global response, and finally, very 
importantly, we will work to fortify the global health 
infrastructure.
    So we had deployed 120 experts to the region and began 
airlifting urgent supplies, personal protective equipment for 
healthcare workers, disinfectant backpack sprayers, water 
treatment, chlorine, body bags, et cetera--the kinds of 
supplies that are absolutely critical.
    The team is providing technical guidance to strengthen the 
local response systems, do the contact tracing, and upgrade 
laboratory testing facilities. We have supported the U.N. 
humanitarian air service and we funded those organizations 
willing to step forward to run Ebola treatment units.
    However, we very quickly ran into the reality that there is 
simply not the global expertise or capacity in the humanitarian 
or health world to respond to this kind of crisis at this scale 
at the rate that it is continuing to increase.
    With the disease transmission rates nearly doubling each 
week there is little time to spare, and as President Obama 
announced yesterday, we are now significantly expanding the 
response with the deployment of the unique capabilities of our 
military to respond with the speed and the scale that is so 
essential to get ahead of this disease.
    So those efforts will essentially provide the backbone for 
an expanded regional effort that will enable the entire 
international community to contribute.
    It will include the establishment of a joint force command 
headquartered in Liberia, very importantly, a training facility 
in Liberia that will have a tent city and the training 
facilities to train 500 workers a week so that we can have a 
vital pipeline of health and management personnel.
    They will include a regional base with lift and logistical 
capacity to expedite a surge of urgently needed equipment, 
supplies and personnel, and include command engineers to help 
construct the Ebola treatment units.
    This is the critical infrastructure, coordination and 
logistics to provide the foundation for an ever greater 
response as needed so that we can bring all our resources to 
bear and set the lead for our international partners.
    The President also announced the launch of our community 
care campaign. This is focused on getting vital information and 
support to families and communities so they can protect 
themselves and their families.
    We will work with local communities and international 
partners to initially target 400,000 of the highest risk 
households with intensive outreach, information, and important 
tools for those unable to access a bed in a healthcare unit and 
we will simultaneously work on broad information campaigns to 
reach all of society and every household.
    We recognize that a significant number of people in this 
region don't seek formal healthcare which is why ultimately the 
virus will only be controlled if people have a better 
understanding of what this is and how to prevent transmission.
    We are hearing stories of ordinary west Africans who do not 
believe that Ebola is real. Show me Ebola, they say. So we are 
challenged to reverse deeply-ingrained cultural practices even 
as we help the affected communities.
    Cultural funeral traditions, such as washing the body where 
family members touch and clean the body of the deceased, are 
contributing to the spread and women are especially vulnerable 
as even those who sometimes know they shouldn't continue this 
practice are pressured to do so.
    Our partners are already saying thank you for the public 
messaging campaigns, that now people know that this is harmful 
and can spread the disease, even though it goes against their 
traditions.
    This is a region of fragile states just emerging from 
decades of conflict and poverty, so we are also looking at how 
to help with economic help, food support, and salaries for 
health workers. We know that tough months lie ahead.
    It will take a coordinated effort by the entire global 
community to stem this terrible crisis, but past outbreaks have 
been stopped and we are confident with this concerted effort we 
can stop this one.
    I want to just add my commendation for the extraordinary 
courage of the health workers, including Dr. Brantly and the 
many, many west Africans who have sacrificed to provide help 
for their families and their neighbors.
    We are remaining focused on outreach efforts to get 
additional medical workers willing and able to go to west 
Africa. So we encourage those who are interested in joining 
this historic response to go to our Web site at www.usaid.gov/
ebola and we will continue to work together and across the 
international community to stem the tide on this disease.
    Thank you very much.
    [The prepared statement of Ms. Lindborg follows:]
    
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    Mr. Smith. Thank you very much, Nancy.
    I would like to now ask Dr. Fauci if you would proceed.

    STATEMENT OF ANTHONY S. FAUCI, M.D., DIRECTOR, NATIONAL 
    INSTITUTE OF ALLERGY AND INFECTIOUS DISEASES, NATIONAL 
   INSTITUTES OF HEALTH, U.S. DEPARTMENT OF HEALTH AND HUMAN 
                            SERVICES

    Dr. Fauci. Ranking Member Bass, members of the committee, I 
appreciate the opportunity to discuss with you today the role 
of the National Institute of Allergy and Infectious Diseases in 
the research that addresses the Ebola epidemic.
    There are some visuals, I believe, on your screen in front 
of you and I will speak from them if you see them, if we can do 
that.
    It is very interesting that we became involved in this in 
an unusual way dating back to the tragic events of 9/11 
followed by the attacks by mail of anthrax to United States 
Senators and to the press because that triggered a multi agency 
effort in what we call biodefense involving the CDC, the FDA, 
the NIH, a variety of other agencies--including Homeland 
Security--to develop an agenda to be able to be prepared not 
only against deliberate attacks but against natural emerging 
and reemerging infectious diseases.
    We developed a research agenda against what we call 
Category A agents, which is shown on this visual, including 
anthrax, botulism, plague, smallpox, tularemia, and notice on 
the last bullet is what we call the viral hemorrhagic fever 
viruses including Ebola, Marburg, Lassa and others.
    These were of particular concern because, as we are 
painfully witnessing now, these viruses have a high degree of 
lethality and infectivity. Unfortunately, therapy consists 
mainly of supportive therapy with no specific anti-viral drugs, 
and a vaccine, as I will get to in a moment, is not yet 
available.
    This is an electron micrograph of the Ebola virus, a 
particular deadly character, as you know, as we are 
experiencing. It is a member of the filovirus family because of 
the filamentous look that you see on this image.
    Just a very brief word as to what we were referring to as 
the kinetics or dynamics of the epidemic. This visually shows 
you the 22 previous outbreaks, some of which were so small that 
they don't even fit on the scale.
    If you will look at the far right, the current outbreak, as 
we have all mentioned several times, is more than all of the 
others combined both in numbers and in deaths. And if you look 
at the map of west Africa, this is a few days outdated but, 
indeed, even the underestimated numbers show about 5,000 
infections and about 2,500 deaths in the countries involved.
    Now, without a doubt, the approach to this is an 
intensification of the effort of infection control. This next 
slide is a bit frightening because if you look at the red line 
under Liberia that is a mathematical manifestation of what we 
call exponential increase.
    Linear and incremental is not a steep slope. When you go up 
like that what you have is an exponential increase at the same 
time that we might be incrementally increasing our response. As 
we know in public health when you put incremental against 
exponential, exponential always wins and that is really the 
problem and why we are so gratified and excited about the 
President's initiative about really ratcheting up the response 
in infection control.
    But also supplementing and complementing that is the 
development of countermeasures and let me just take a minute to 
outline this because we at NIH and NIAID are involved in 
everything from basic to clinical research and also supplying 
the research resources for academic as well as industrial 
partners to develop the three main interventions--diagnostics, 
therapeutics, and vaccines.
    So a moment on therapeutics. You have heard a lot about 
ZMapp. It is a combination of three artificially-produced 
antibodies directed against the Ebola virus.
    The results in an animal--in this case, monkey model--have 
been really quite striking, and as I will get to in a moment it 
has been given to seven humans, the first time it has been in 
human.
    It is the responsibility and the mandate of the NIH when 
more of this becomes available to strike the delicate balance 
of getting it to people who need it and at the same time 
proving that it is safe, that it really does work and if it 
does, how well does it work and does it, in fact, hopefully not 
have any paradoxical harm.
    Also shown on this slide are a couple of other 
interventions that you will be hearing about or have heard 
about again. All did well in an animal model and now are either 
in or getting ready to go into Phase I trials--things like 
novel drugs that interfere with the reproductive process of the 
virus or small molecules that interfere with the replication of 
the virus.
    This is a series of press releases regarding the ZMapp and 
you know there have been anecdotal data that it works. We are 
very, very pleased and gratified to have our colleague, Dr. 
Kent Brantly, with us today who received this.
    Whether or not that was the deciding factor, we hope so and 
we hope to be able to prove it, but we don't know that right 
now and that is why a clinical trial is important.
    And then, finally, the issue of vaccines. We have been 
working on vaccines for Ebola for several years and 
incrementally have done better and better in an animal model 
and even gone into Phase I. The most recent one is shown on 
this first bullet. It is referred to as the NIAID/
GlaxoSmithKline candidate.
    It is not the only vaccine candidate but it is the one that 
we have actually just started now, and as I know I have 
mentioned to this committee before, you go from an animal 
preclinical to a Phase I in human. If it is safe and it proves 
to be immunogenic, you then expand the trial to be able to find 
the important information--A, is it safe, B, does it work, and 
C, does it do no harm.
    And, again, it will be the delicate balance of determining 
that at the same time that we actually make it available to the 
best extent that we can, and in this regard on September the 
first human received this at the NIH in Bethesda, Maryland in a 
20-volunteer study. This is a little bit outdated.
    We injected the 13th volunteer about 1 hour and 45 minutes 
ago up at the NIH, and we are hoping to get to 20, and the data 
will be available by the end of November or the beginning of 
December.
    So in summary, members of the committee, the NIAID research 
has a dual mandate. For years and years, we continually do 
robust and basic clinical research to be able to fulfill and 
determine pathogenic mechanisms and microbiology in infectious 
diseases.
    Despite this effort every day, every week, every month, we 
still stand prepared at a moment's notice to respond to 
surprising emerging and reemerging infectious diseases and this 
is exactly what happened with the reemergence of Ebola in west 
Africa.
    So we stand prepared for this pandemic and, hopefully, for 
anything in the future. Thank you.
    [The prepared statement of Dr. Fauci follows:]
    
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    Mr. Smith. Dr. Fauci, thank you so very much for your 
testimony and your leadership.
    Dr. Borio.

     STATEMENT OF LUCIANA BORIO, M.D., DIRECTOR, OFFICE OF 
  COUNTERTERRORISM AND EMERGING THREATS, OFFICE OF THE CHIEF 
 SCIENTIST, U.S. FOOD AND DRUG ADMINISTRATION, U.S. DEPARTMENT 
                  OF HEALTH AND HUMAN SERVICES

    Dr. Borio. Good morning, Chairman Smith, Ranking Member 
Bass and members of the subcommittee. Thank you for the 
opportunity to appear before you today to discuss FDA's actions 
to respond to the Ebola epidemic in west Africa.
    This epidemic, with so many lives lost, is heartbreaking 
and tragic. My colleagues and I at the FDA are fully dedicated 
to doing all we can to help end it as quickly as possible.
    The primary approach to containing this epidemic remains 
standard, tried and true public health measures, but 
effectively implementing such measures on a broad scale has 
proven challenging, and I know the professionals caring for 
patients with Ebola are doing all they can under very difficult 
conditions.
    They are operating in a setting of very limited healthcare 
infrastructure which has made it almost impossible for them to 
provide supportive medical care, such as intravenous fluids and 
electrolytes, for the large number of patients who need them, 
and this response is further complicated by the lack of 
specific treatments or vaccines that have been shown to be safe 
and effective for Ebola.
    In situations like this, the FDA plays a very critical 
role. We have one of the most flexible regulatory frameworks in 
the world and we are working diligently to facilitate and speed 
the development, manufacturing, and availability of 
investigational products such as vaccines, therapies, and 
diagnostic tests.
    We are providing FDA's unique scientific and regulatory 
expertise to U.S. Government agencies that support medical 
product development, agencies such as Dr. Fauci's at NIAID, 
BARDA, and the Department of Defense.
    We are working interactively with companies to clarify 
regulatory requirements to help expand manufacturing capacity 
and we expedite the review of data as it is received so there 
is no lag between receiving data and reviewing data.
    As a result, the vaccine candidate being co-developed by 
the NIAID and GlaxoSmithKline began Phase I testing on 
September 2 and a second vaccine candidate is expected to begin 
clinical testing very soon.
    We will continue to work closely with all of these 
companies, again, to speed development of their products. In 
addition, we are collaborating with the WHO and working with 
several of our international counterparts, including the 
European Medicine Agencies and Health Canada, to exchange 
information about investigational products for Ebola and 
considerations for their deployment in west Africa.
    It is important to note, though, that these investigational 
products are in the earliest stages of development. For most, 
only small amounts have been manufactured for early testing. 
This constrains options for assessing their safety and efficacy 
in clinical trials and for wider distribution and use.
    Access to limited the supplies of investigational products 
during an epidemic like this should be through clinical trials 
when possible because they provide an ethical means for access 
while also allowing us to learn about product safety and 
efficacy.
    FDA is working with developers to encourage the conduct of 
practical, ethical, and informative trials so the global 
community can know for sure the risks and clinical benefits of 
these products.
    But until such trials are established, we will continue to 
facilitate access to these products when available and when 
requested by clinicians.
    We have mechanisms such as compassionate use which allow 
patients to access investigational products outside of clinical 
trials when we assess that the expected benefits outweigh the 
potential risks for the patient.
    This epidemic has posed incredible demands on FDA. There 
are more than 200 staff at FDA involved in this response and 
without exception everyone involved has been proactive, 
thoughtful, and adaptive to a complex range of issues that have 
emerged.
    Developing these products for Ebola is highly complex and 
will, unfortunately, take time. I once again stress that public 
health measures remain the cornerstone of curbing this epidemic 
and improving the medical infrastructure in the affected 
countries is critical to save lives.
    Such infrastructure is also essential for advancing product 
development to meet the global access to vaccines and cures. 
FDA is fully committed to sustaining our deep engagement and 
aggressive response activities.
    Thank you so much.
    [The prepared statement of Dr. Borio follows:]
        
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    Mr. Smith. Thank you very much for your testimony.
    Dr. Bell.

STATEMENT OF BETH P. BELL, M.D., DIRECTOR, NATIONAL CENTER FOR 
EMERGING AND ZOONOTIC INFECTIOUS DISEASES, CENTERS FOR DISEASE 
   CONTROL AND PREVENTION, U.S. DEPARTMENT OF HEALTH & HUMAN 
                            SERVICES

    Dr. Bell. Good morning, Chairman Smith, Ranking Member 
Bass, members of the subcommittee and members of other 
committees.
    I am Dr. Beth Bell. I am the director of the National 
Center for Emerging and Zoonotic Infectious Diseases at the 
CDC. I appreciate the opportunity to be here today to discuss 
the current epidemic of Ebola in west Africa, which illustrates 
in a tragic way the need to strengthen global health security.
    I will be updating you on testimony that CDC Director Tom 
Frieden gave before this subcommittee in August when you played 
an important role in calling attention to this emerging 
epidemic.
    The Ebola epidemic in Guinea, Liberia, and Sierra Leone is 
ferocious and it is spreading exponentially. The current 
outbreak is the first that has been recognized in west Africa 
and the biggest and most complex Ebola epidemic ever 
documented.
    As of early September, there were more than 4,500 confirmed 
and suspected cases and over 2,500 deaths, though we believe 
the actual numbers could be at least two or three times higher.
    We have now also seen cases imported into Nigeria and 
Senegal from the initially affected areas and other countries 
are at risk of similar exportations as the outbreak grows. 
There is an urgent need to help bordering countries to better 
prepare for cases now and to strengthen detection and response 
capabilities throughout Africa.
    The secondary effects of this outbreak now include the 
collapse of the underlying healthcare systems resulting, for 
example, in an inability to treat malaria or to safely deliver 
an infant as well as non-health impacts such as economic and 
political instability and increased isolation of this area of 
Africa.
    These impacts are intensifying and not only signal a 
growing humanitarian crisis but also have direct impacts on our 
ability to respond to the Ebola epidemic itself. There is a 
window of opportunity to control the spread of this disease but 
that window is closing.
    If we do not act now to stop Ebola, we could be dealing 
with it for years to come, affecting larger areas of Africa. 
Ebola is currently an epidemic, the worst Ebola outbreak in 
history, but we have the tools to stop it and an accelerated 
global response is urgently needed and underway, as the 
President announced yesterday.
    It is important to note that we do not view Ebola as a 
significant public health threat to the United States. The best 
way to protect the U.S. is to stop the outbreak in west Africa. 
But it is possible that an infected traveler might arrive in 
the U.S.
    Should this occur, we are confident that our public health 
and healthcare systems can prevent an Ebola outbreak here and 
recognize that the authorities and investments provided by the 
Congress have put us in this strong position.
    Many challenges remain, particularly since there is 
currently no therapy or vaccine shown to be safe and effective 
against Ebola. We need to strengthen the global response which 
requires close collaboration with WHO, additional assistance 
from international partners and a strong and coordinated United 
States Government response.
    CDC has over 100 staff in west Africa and hundreds of 
additional staff are supporting this effort from Atlanta. CDC 
will continue to work with our partners across United States 
Government and elsewhere to focus on five key strategies to 
stop the outbreak: Establishing effective emergency operations 
centers in countries, rapidly ramping up isolation and 
treatment facilities, helping promote safe burial practices, 
strengthening infection control and other elements of 
healthcare systems, and improving communication about the 
disease and how it can be contained.
    Controlling the outbreak will be costly and require a 
sustained effort by the U.S. and the world community. Within 
HHS the administration recently proposed that the Congress 
provide $30 million for CDC's response during the continuing 
resolution period and for efforts to develop countermeasures.
    Yesterday the President was briefed at CDC on the epidemic 
and announced that the unique logistics and materiel 
capabilities of the U.S. Military will be engaged as part of an 
urgent and intensified U.S. Government response.
    As my colleagues can attest, we are working across United 
States Government to assess the full range of resources that 
can be leveraged to change the trajectory of this epidemic.
    Working with our partners, we have been able to stop every 
previous Ebola outbreak and we are determined to stop this one. 
It will take meticulous work and we cannot take shortcuts.
    As CDC Director Tom Frieden has noted, fighting Ebola is 
like fighting a forest fire--leave behind one burning ember, 
one case undetected, and the epidemic could reignite. Ending 
this epidemic will take time and continued intensified effort.
    The tragedy also highlights the need for stronger public 
health systems around the world. There is worldwide agreement 
on the importance of global health security but the Ebola 
epidemic demonstrates that there is much more that needs to be 
done.
    In Dr. Frieden's previous testimony, he outlined new 
investments we are seeking to strengthen fundamental public 
health capabilities around the globe. If these people, 
facilities, and labs had been in place in the three countries 
currently battling Ebola, the early outbreaks would not have 
gotten to what we are facing now.
    Stopping outbreaks where they occur is the most effective 
and least expensive way to protect people's health. I know many 
of you have travelled to Africa to see our work in global 
health, as have I, and we all come away with an appreciation 
for the enormous challenges many people and countries face.
    These may never have been more evident than in the current 
Ebola epidemic. Each day for the past months I have been in 
personal contact with our teams in the field. Their experiences 
reinforce the dire need and put real stories and faces on a 
tragedy that can't simply be reduced to numbers and charts.
    But these stories from the field also reinforce the unique 
and indispensable role that CDC and our many partners are 
playing and the sense that with an intensified global focus we 
can make a real difference.
    Thank you again for the opportunity to appear before you 
today and for making CDC's work on this epidemic and other 
global threats possible.
    [The prepared statement of Dr. Bell follows:]
       
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    Mr. Smith. Thank you very much, Dr. Bell.
    Let me just begin the questioning and then I will yield to 
my colleagues for their questions. I will throw out a few 
questions and if you wouldn't mind jotting them down because I 
do have about 100. I exaggerate a little bit.
    There has been a lot of criticism about who is in charge. 
Is it the health ministers in country? WHO puts out a lot of 
press releases.
    Dr. Brantly made an observation, and I think it is a very 
good one, that

        ``Agencies like the World Health Organization remain 
        bound up by bureaucracy. Their speeches, proposals, and 
        plans--though noble--have not resulted in any 
        significant action to stop the spread of Ebola. The 
        U.S. Government must take the lead immediately to save 
        precious African lives and protect our national 
        security.''

You know, I know that you might be loathe to criticize WHO but 
we need to know who is actually in charge on the ground.
    Secondly, if I could, the deployment of 3,000 members of 
the U.S. Military obviously, that was weeks, certainly, days in 
preparation. Interagency coordination had to have been a part 
of that for that announcement to be made. I am just wondering 
if you could tell us who will be deployed.
    I will never forget making a trip to the border of Iraq and 
Turkey immediately after the Kurds flocked to that border, and 
many were dying from exposure and disease and Operation Provide 
Comfort was established.
    Within about 5 days a group of us went over there to take a 
look at it and to talk to people, and if it wasn't for the 
Special Forces and the work they did, and they handed the baton 
eventually to NGOs and others who helped those individual 
Kurds, but for about a month had it not been for the Special 
Forces, particularly the military doctors and others that were 
there, hundreds if not thousands would have died. So my 
question is how that force will be configured.
    Will it be made up of a significant portion of MDs, nurses, 
and others? I know that we have heard that they will be 
constructing or, I believe, that is one thing they are going to 
do in Liberia, you know, hospital beds or at least places where 
people can find refuge and get help.
    But what will that configuration look like? Dr. Brantly, 
again, in his testimony makes an excellent point, ``For too 
long, private aid group have been confronting this Ebola 
epidemic without adequate international support.'' Then he says 
these organizations cannot go it alone.
    ``A significant surge in medical boots on the ground must 
happen immediately to support those already working in west 
Africa'' . . . and he goes on in his testimony. How many 
medical personnel are needed?
    How many have been deployed and will this deployment of 
3,000 of our service members be significantly made up of 
medical personnel? On force protection--and Dr. Fauci, you 
might want to speak to this as well--obviously, when you are 
dealing with an epidemic and people can contract this disease 
it gives new meaning to force protection, you know, all the 
usual. How many protective suits will be needed?
    Do you have adequate access to those suits and gear? You 
know, as Dr. Brantly points out, he took every precaution and 
he still got Ebola. So the question would arise, and I am sure 
for the individual service members being deployed and their 
families: Will there will be adequate protections?
    Is more money needed? You know, as my friend and colleague 
pointed out at the Rules Committee the other day, $88 million 
is in the supplemental: Is that enough?
    You know, we should leave no stone unturned to make sure 
that people are protected and hopefully safe from this hideous 
disease but when putting many more Americans into harm's way, 
no stone should be left unturned in making sure they are 
protected as well.
    If there are any gaps there, please speak to that. Let me 
also ask you: How do you attract medical personnel to be 
deployed? You know, if they are ordered by way of military, 
that is one thing.
    But how do you incentivize it? Many of the faith-based 
groups go there and risk their lives, as do the non-faith 
based, out of pure love of African people or wherever it is 
that they are deployed.
    But now they are dealing with a pandemic. How do you 
incentivize and are people coming forward to go? The range of 
the estimates of infections and, Dr. Fauci, I want you to speak 
to this, is there a possibility or probability that this could 
mutate into an airborne, you know, infection?
    Right now we are told that is not the case but is that a 
possibility and, again, if you could put any kind of number on 
how many medical personnel are needed to be deployed. You know, 
I have been trying--I read everything I can on Ebola, talk to 
people nonstop about it.
    I still don't know how many people--because so much of the 
infrastructure, as we all know, in west Africa for healthcare 
has been decimated as well as the NGOs that were there early on 
where their personnel have been hurt as well.
    And finally, to Dr. Borio, if you could, at our last 
hearing I raised the issue of TKM-Ebola and the FDA's 
suspension of the trials. Has that changed?
    I remember reading the company's information and they were 
kind of surprised. But has that been reversed on that 
particular drug? Ms. Lindborg.
    Ms. Lindborg. Yes.
    Mr. Smith. Okay. Dr. Fauci, if you could.
    Dr. Fauci. No. Actually, Ms. Lindborg was going to, I 
think, take the first question. There were several you asked me 
for which I will be happy to answer but I think Ms. Lindborg is 
going to take the first question.
    Ms. Lindborg. Let me also offer, Chairman Smith, that it 
might be helpful to come and do a more--even more detailed 
walk-through since that seems to be something that is of great 
interest.
    What I will say is that there is a two-star, General 
Williams, from AFRICOM who arrived in Monrovia yesterday and is 
already beginning to work closely with the DART on detailing 
out the exact configuration of the mission. It will come out of 
the African Command.
    There will be a large contingent of logisticians and 
engineers, medical planners, planners, that will be setting up 
the fundamental nerve center that will be able to support this 
overall response.
    There will also be 60 medical trainers who will be 
operating the training facility and critical barriers in moving 
forward a more robust response have been several key 
constraints.
    First is there has not been confidence that people could 
get in and out of the region. Therefore, we are looking at 
laying down the significant lift capacity that will serve the 
entire region.
    Secondly, people are worried because they have been 
uncertain about Medevac in the event that they are ill, and so 
we are working to increase the reliability and availability of 
Medevac services for health workers.
    Thirdly, they have been concerned about lack of healthcare 
for the health workers, which is why the military is bringing 
in a 25-bed hospital for healthcare workers.
    It will be staffed by public health workers, teams of 65 at 
a time out of HHS, and the first of the 13 plane loads bringing 
that hospital in arrive on Friday in Monrovia. So that will be 
set up.
    Then finally is the lack of training. It is not so much 
that you need high-level medical expertise so much as there 
needs to be rigorous, very disciplined infection control.
    Most urgently is a large cadre of basic care workers and 
part of what this training will seek to do is create a pipeline 
of healthcare workers who understand how to minimize the 
infection and how to run a clinic that is absolutely rigorous 
in following the right kind of procedures, and we will be 
working with MSF to adopt their training so that that is 
available to a larger cadre.
    Finally, there are doctors needed both for the Ebola 
treatment units but also for the larger revitalization of the 
health systems.
    As Dr. Bell mentioned, this is a problem throughout the 
country and it is training those healthcare providers and those 
clinics also on rigorous infection control because of the 
stories that we have heard of people coming in and being 
treated for other problems and end up you have transmission of 
the Ebola virus.
    So there is that whole package of issues that when we 
address those, the goal is to unlock greater capacity of 
organizations and healthcare workers who can come in, augmented 
by this extraordinary capability that the U.S. Military is 
bringing.
    Mr. Smith. And we do have sufficient moneys allocated? I 
mean, is there----
    Ms. Lindborg. DoD has requested a $500 million----
    Mr. Smith. Reprogramming?
    Ms. Lindborg [continuing]. Reprogramming previously and I 
believe today they will be submitting an additional $500 
million.
    Mr. Smith. Now, is that request being based on what they 
think can be gotten or is it to really get the job done?
    You know, we know that U.N. agencies notoriously 
underestimate what the cost will be because they think when 
they put out their request to other nations--donor nations--
they think that is all they are going to get rather that what 
is the need and then we fight like the devil to get that money 
allocated.
    I have had that argument with them for 30 years in Geneva. 
Ask for what is really needed even if we don't reach it so we 
know the true need. Is what you are asking for what is needed?
    Ms. Lindborg. Well, that is for the military's budget.
    Mr. Smith. Yes, I mean--but also, like, the $88 million----
    Ms. Lindborg. The $88 million, and USAID has allocated $100 
million from our budgets. We think so for at least the initial 
response but this is unprecedented. This is new territory for 
all of us.
    And so as we lay down this urgent scaled response we will 
be closely monitoring to see what impact it makes and what else 
we might need.
    Mr. Smith. Gotcha. Dr. Fauci.
    Dr. Fauci. So let me answer the question about this 
potential scope, which is important because there is a lot of 
confusion about that.
    So the issue is--the question that is asked and that 
sometimes frightens people: Is it possible that this virus 
would mutate and then by the mutation completely change its 
modality of transmission, mainly going from a virus that you 
get by direct contact with bodily fluids to a virus that is 
aerosolized, so if I am talking like this I can give it to Ms. 
Lindborg or to Dr. Borio? So let me explain to you how that 
possibly could happen and why I think it is unlikely, but not 
impossible.
    Ebola is an RNA virus and when it replicates it replicates 
in a sloppy way. It makes a lot of mistakes when it starts 
trying to duplicate itself. Those mistakes are referred to as 
mutations.
    Most mutations in this particular situation are irrelevant. 
Namely, they don't--they are not associated with a biological 
function that changes anything.
    They just mutate and it is meaningless. Every once in a 
while, rarely, a mutation, which is called a nonsynonymous 
mutation--that is what scientists call it--does have a change 
in biological function.
    That change, if it occurs--if you historically look at 
viruses that mutate, it generally, if it changes the function, 
modifies an already existing function. It makes it either a bit 
more virulent or a bit less virulent.
    It makes it a little bit more efficient in spreading the 
way it usually spreads or a little less efficient. What it 
very, very rarely does is completely change the way it is 
transmitted. So although this is something that is possible, 
and I need to emphasize because whenever I try to explain it 
people might think I am pooh-poohing it.
    I am not. It is something we look at very carefully and we 
actually have grants and contracts with organizations like the 
Broad Institute in Boston which very carefully follow the 
sequential evolution of the virus to alert us if in fact this 
is happening.
    So A, we take it very seriously, B, it is something that we 
look at and that we follow closely. But we don't think it is 
likely to happen. So I would rather that I lose sleep and Dr. 
Borio and Ms. Lindberg and Dr. Bell lose sleep over that, but 
not the American public lose sleep over that because we are 
watching it very carefully.
    Having said that, what is likely, and this gets to 
everything we are talking about, is that if this virus keeps 
replicating and keeps infecting more and more people, you are 
going to give it more of a chance to mutate.
    So the best possible way that we can take that off the 
table is to actually shut down this epidemic and if we do, as I 
always say, a virus that doesn't replicate doesn't mutate. So 
if you shut it down then that thing is off the table. I hope 
that was clear.
    Mr. Smith. And your best case estimate on September 17th, 
what this could evolve into? I mean, exponential was used 
several times during your statement.
    Dr. Fauci. Well, Mr. Chairman, the estimate is going to be 
directly related to our response because it is kind of a race.
    If our response is like this and Ebola is going like that, 
as I said, this is going to win all the time and that is the 
reason why we are excited and pleased to hear that the 
President came out and said what he did and we are going to see 
the things that Ms. Lindborg and others have been talking about 
because once you get over that curve then you start to see the 
epidemic coming down.
    Now, that could be within a period of a few months if we 
really put a full court press on. If we fall behind, it could 
go on and on. So it is almost impossible to predict without 
relating it to the degree of your response.
    Mr. Smith. Dr. Brantly calls for a surge of medical boots 
on the ground. How many U.S. medical personnel are now in the 
impacted areas and how many do you think will be there in the 
next month, how many the next several months? I have been 
trying to get a handle on that for some time.
    Ms. Lindborg. So one of the things we are doing is 
supporting a worldwide call, this is really going to be an all 
hands on deck response.
    The African Union has mobilized 100 health keepers, which 
is doctors, nurses, and other health clinicians, and the U.S. 
is supporting their mobilization. Their advance team is on the 
ground right now led by a Ugandan doctor who led the Ebola 
response in Uganda.
    The Chinese have mobilized medical personnel and the U.K. 
and EU are both contributing facilities, labs and funding. So 
we will continue to mobilize. One of the questions is how many 
of these Ebola treatment units we will need.
    Each Ebola treatment unit, according to the MSF model, 
takes about 216 people, the majority of whom are basic 
healthcare providers, basic care providers, augmented by, you 
know, a chief medical officer, a lot of infection control 
logistics, water sanitation--those kinds of management 
capabilities.
    So what we are seeking to do is to create a pipeline of the 
trained medical care providers with this 500-a-week training 
facility augmented by additional support, training and direct 
provision of that management infection control piece because 
ultimately the most important thing is it is rigorous, 
disciplined, almost command and control of the----
    Mr. Smith. All right. If I could just get back to that. How 
many medical boots on the ground do we have as of today--U.S.?
    Ms. Lindborg. We have--we are focused right now not on the 
direct care but rather on providing the system that can enable 
a full-throated response.
    We have supported organizations like International Medical 
Care and we are in discussions with several other organizations 
that will bring--International Medical Care has a 60-bed unit 
that they have stood up and it is a combination of medical and 
other personnel that are needed to make each one of these Ebola 
treatment units functioning.
    Mr. Smith. But we do have doctors and nurses on the ground?
    Ms. Lindborg. Correct.
    Mr. Smith. Could you get back to us if you can find that 
number? Because, you know, I understand the training component 
and that is extraordinarily important.
    But we know that there must be, including in the military 
deployment, a number of doctors and nurses that will be a part 
of that. Just to know what our commitment is on that side of 
it.
    Ms. Lindborg. Yes. And it is part of a much larger number. 
We will get you--we will get you the break out of what the 25 
percent are, the 115 people already in the region and the 3,000 
who are being mobilized.
    Mr. Smith. And anyone else? Yes, Dr. Bell.
    Dr. Bell. I was--thank you, Chairman Smith, and I actually 
just wanted to mention that I led the field team in New Jersey 
during the 2001 anthrax attack so I know your district, 
actually, quite well from the old days.
    I just wanted to say a couple of other things about this 
training pipeline, to build on what Nancy was saying and to 
make a couple of these important points--that the majority of 
the workers are local workers but there is a need for some 
nurses and doctors and more higher-trained healthcare workers 
and we have at CDC, working with MSF, established a training 
program which will be held in Anniston, Alabama, every week.
    It is a 3-day program which is meant to build a pipeline of 
U.S. healthcare workers that are getting ready to deploy to the 
region. Our first training, will begin next week and is already 
full at something like 40 healthcare providers.
    So, as Nancy says, we need sort of a very multifaceted and 
multi disciplinary approach to addressing the problem and at 
our end here at CDC we have had the--we will have these series 
of classes every week for the foreseeable future to help build 
that pipeline.
    Mr. Smith. Just two final questions. The deployment of 
3,000, when will the full contingent be actually in theater 
and, again, to reassure not only those who will be deployed but 
their families, will they have the protective gear in adequate 
numbers from masks and the like to ensure that they do not 
contract the disease?
    And, Dr. Borio, if you could, speak to the issue of the 
TKM-Ebola and whether or not the suspension has been lifted so 
that the trial can continue.
    Dr. Borio. So, Mr. Chairman, I am unable to discuss the 
specific product today but what I can tell you is that clinical 
hold issues it is based on our assessment of the benefit risk 
profile for a proposed clinical study.
    So whereas a product may be on clinical hold for a specific 
study, it may not be on hold for different types of studies.
    For example, sometimes the dose or frequency proposed in a 
study does not allow us to believe the benefits will outweigh 
the risks. In addition, sometimes we put a study on hold 
because of adverse events that are identified immediately 
after, you know, using the drug in the first few volunteers.
    Another reason for a study to be on hold has to do with the 
patient population that is being studied on that particular 
proposed study. So there are many reasons for a study to be on 
hold.
    It is rare that we are not--well, in situations where a 
study is on hold we will work the company very closely, 
especially in a situation like this with Ebola, to be able to 
make sure that we can design the studies where the benefit-risk 
balance would be more appropriate.
    Mr. Smith. Again, are there cross conversations? You 
mentioned how flexible FDA is, like with NIH and others. I was 
shocked when that hold was placed because I read a lot about 
the drug.
    It doesn't make me an expert, but there were some 
encouraging signs and when you only have three or so drugs in 
the pipeline that is not a large universe.
    Dr. Borio. We are working very closely with our colleagues 
at the NIH, at BARDA, DoD, as well as all the different 
companies that have products of interest to the U.S. Government 
to do all we can to move the development programs forward as 
fast as we can.
    Mr. Smith. Okay. Again, Ms. Lindborg, do we know when the 
3,000 will actually be there? You know, I know they will be 
going in components but when fully will they be deployed?
    Ms. Lindborg. They are going in components and I will just 
quote General Dempsey, who said they will move as fast as they 
possibly can until they hit the laws of gravity.
    Mr. Smith. Okay.
    Ms. Lindborg. So they are fully seized and deployed.
    Mr. Smith. And fully protected?
    Ms. Lindborg. Yes, and if--I just want to underscore one 
other point in response to your questions and that is we are 
continuing to conduct outreach efforts so that we can find 
other medical workers--doctors, nurses, and physicians 
assistants--who are interested in working with organizations 
who are responding and that is the Web site, usaid.gov/ebola, 
and with the training that is available and the pipelines of 
this critical gear that the response will provide of PPE, et 
cetera.
    Mr. Smith. Thank you. Dr. Bell.
    Dr. Bell. Mr. Chairman, just to your point about will the 
force be adequately protected, I just wanted to say that, you 
know, at CDC we have over 100 young trainees, many of them in 
the field, and so we have worked very hard on the sort of 
information people need ahead of time--very, very clear 
delineation of the sorts of protective equipment, things to do 
to protect yourself, and what to do when you are in a situation 
that you think is perhaps not as safe and secure as it should 
be.
    And so this is the sort of information that I think we have 
spent--actually, quite a while now we have had people in the 
field sort of perfecting and it is the sort of thing, I think, 
that can be used with the military.
    We all want to make sure that people are as safe as humanly 
possible. The other thing I see off of my list of questions I 
just wanted to address your question about the funding and to 
just say from the CDC perspective that the $30 million is 
enough to get us through the continuing resolution and allow us 
to keep our people in the field but that we are going to be 
considering during the period of the CR, what additional 
funding we might need for the rest of the year.
    Mr. Smith. Thank you, Dr. Bell. You know, in a conversation 
I had with the President of Guinea, who has deployed his 
military, I was concerned about how well-protected they were, 
you know, when they rush in to be of assistance and then all of 
a sudden they find themselves contracting the disease.
    So and I am very concerned about our military as well. I 
would like to yield to Ms. Bass.
    Ms. Bass. Thank you, Mr. Chair, and I would like to begin 
by asking a question on behalf of my colleague, Mr. Cicilline, 
who had to leave and in his opening statement he mentioned that 
many of his constituents are from Liberia.
    So his question is the current extension of deferred 
enforced departure for Liberians living legally in the U.S. is 
scheduled to expire at the end of the month and apparently this 
summer several Senators sent a letter to President Obama asking 
him to end the uncertainty, especially given the current 
crisis.
    And so even though this is an issue under the jurisdiction 
of USCIS, he was wondering if you know whether the 
administration is really taking into account the health crisis 
if many of these individuals would have to return home.
    Dr. Bell. Thank you, Congresswoman Bass. As I testified 
yesterday before the Senate HELP Committee and Senator Reed 
asked a similar question, as you say, this is an important 
issue in Rhode Island and other parts of the country as well, 
and actually my deputy participated in a number of briefings 
and town hall meetings on this topic.
    This is a humanitarian issue, we agree, but we don't have 
any further information about what is happening from the 
perspective of the Immigration Service on this topic. Do you 
have any information, Nancy?
    Ms. Lindborg. We will take that question. We are 
coordinating closely across the interagency that is a State 
Department question. We will take it and get back to you.
    Ms. Bass. Okay. All right. Thank you. And then I, in 
speaking to a number of my colleagues yesterday as we were 
preparing for this member briefing tomorrow, several of them 
mentioned to me their concerns about the virus mutating and 
becoming airborne, and I am not sure if those came up in the 
questions before. Oh, they did?
    Mr. Smith. They did.
    Ms. Bass. Yes. You raised it? Okay. Well, maybe you could 
explain why that is not a concern.
    Dr. Fauci. Well, I wouldn't say it is not a concern but it 
is not an overwhelming concern.
    Ms. Bass. Okay.
    Dr. Fauci. As I mentioned, and I will just very briefly 
summarize what I said when you were out, Ms. Bass, that this is 
a virus that continually replicates and makes a lot of 
mistakes.
    It mutates, and the overwhelming majority of the mutations 
are irrelevant. They are not associated with any change in 
function of the virus. Rarely, occasionally, you will get a 
mutation that actually does have a biological function.
    Now, that could be that it evades the diagnostic or the 
mutation makes it a little bit more virulent or a little bit 
less virulent. It makes it a little bit more efficient in being 
transmitted or a little bit less efficient. But it would be 
distinctly unusual, underline, not impossible----
    Ms. Bass. Right.
    Dr. Fauci [continuing]. For it to completely change the way 
it is transmitted. In fact, of the many, many viruses like HIV 
that replicate in millions and millions of people and mutate a 
lot, you don't see a change in the way it is transmitted.
    Now, having said that, we have contracts and grants with 
organizations that do continuing phylogenetic sequencing which 
means they trace the evolution.
    So we are looking at that very, very carefully and thus far 
with all of the infections and all the mutations we have not 
seen any indication of any modification of biological function 
associated with the mutations.
    So, again, although it is not something you can completely 
rule out, it is not something that I would put at the very top 
of the radar screen and say this is something that is occupying 
all of my concern. Having said that, the easiest way to avoid 
that is to stop the infections which will then stop the 
mutations and then you won't have to have the discussion we are 
having right now.
    Ms. Bass. So it is safe to say that in previous outbreaks 
that has never happened?
    Dr. Fauci. Right. Right.
    Ms. Bass. Okay. Thank you very much. I yield back my time.
    Mr. Smith. Dr. Burgess.
    Mr. Burgess. Thank you, Mr. Chairman. And Dr. Fauci, along 
those lines, now 10 years ago in the language of avian flu I 
remember the discussion was genetic drift and genetic shift--
genetic drift being why we have to have a new flu shot every 
year because there are little changes that occur and then 
genetic shift would be one of those major changes that would 
occur in--say avian flu, the transmissability from human to 
human where it hadn't been occurring before.
    Is that the same sort of thing you are talking about here?
    Dr. Fauci. A bit different, Dr. Burgess. It is a bit 
different because when we talk about a drift we are talking 
about the immune response that the body has made to previous 
viruses and when it drifts a bit it doesn't change much in its 
fundamental way that it is transmitted.
    How it changes is that it evades your already existing 
immune response or the immune response that a particular 
vaccine might induce. A little bit it drifts. It doesn't 
change.
    A shift is that it is so different than the previous virus 
that you don't have any background immunity to it. So when you 
have a new pandemic like the H1N1 2009 influenza, except for 
people who were alive and well back in the late 1960s, early 
1970s, mid-1970s, most of the young people never had seen a 
virus like that.
    So they didn't have any background immunity. Did that mean 
it changed the way it was transmitted? No. Flu is a 
respiratory-borne virus whether it is a pandemic flu or a 
seasonal flu.
    The actual shift means that it was so different than 
anything else that you experienced that you don't have any 
background immunity which makes it much easier for it to turn 
into a pandemic.
    Mr. Burgess. Okay. Thank you for the clarification.
    Now, we have got CDC, FDA, NIH, and USAID today because we 
understand from yesterday's speech by the President, Department 
of Defense is involved and we have heard Department of State 
mentioned today.
    So I guess my question is, and this may be fundamentally 
naive as far as the function of government, but who is in 
charge? Who is in charge of our response to what is happening 
in Western Africa?
    Is it the CDC? Is it the State Department? Is it now going 
to be Department of Defense? Who is our go-to agency as far as 
who is in charge?
    Ms. Lindborg. So the U.S. Military is working in support of 
USAID on the ground. This is very similar to the approach that 
Chairman Smith noted. We worked in the Philippines just 
recently.
    There are task forces in each of the critical agencies that 
are enabling CDC, HHS, State Department, USAID to organize 
across our agencies to mobilize for the best response.
    USAID is leading the U.S. interagency response as part of 
the worldwide efforts led by the U.N. in support of sovereign 
nations--Liberia, Guinea, and Sierra Leone--working very 
closely across those task forces and with the NSC.
    Mr. Burgess. So things are already--things are already 
tough. If they get a lot tougher USAID is who we call? If 
things go really bad, who do we pick up the phone and call?
    Ms. Lindborg. Yes.
    Mr. Burgess. USAID? All right. So noted. I will put you on 
speed dial.
    You know, we heard through some of the discussion--I guess, 
Dr. Fauci, this will be to you is that, you know, previous 
episodes this virus has burned itself out. Is there still a 
possibility, even with your rather frightening exponential 
graph that you showed us, is it still possible that at some 
point this episode will burn itself out?
    Dr. Fauci. It is more than possible. That is what we are 
all striving for. The escalation--it was very clear that the 
rate of increases of cases that we were seeing, particularly in 
the densely populated areas where instead of two or three 
contacts you have 30, 40, 50, 70 or 100 contacts, that the 
growth of it was outstripping even our ability to increase it 
at incremental levels.
    So that is the reason why, as I mentioned, Dr. Burgess, 
when the President made this announcement that it is going to 
be a sea change. It is not going to be an increment, it is 
going to be a major change in how we approach this with a 
considerable amount of resources--not only direct resources of 
healthcare but home kits, home care components, education 
components.
    It is a very comprehensive package that the President 
announced at the CDC yesterday. So if we implement that, which 
I believe we will--I hope we will--I think there is a very good 
chance that it is not going to happen tomorrow and it is not 
going to happen next month but that we are going to turn this 
around. But it is going to require that really accelerated 
effort that the President spoke about yesterday.
    Mr. Burgess. Well, Dr. Fauci and Dr. Borio, let me ask you 
as well, being representatives for the Food and Drug 
Administration, Dr. Fauci, I have been to the Galveston 
National Laboratory.
    I remember right after Hurricane Ike going down there to 
make certain they were okay and hearing about the work they 
were doing on Ebola. Then I was down there I think it was less 
than a year ago.
    So there has been ongoing work. I mean, this--you have 
known of the risk and there has been ongoing work. I guess I am 
just a little disappointed, Dr. Borio, to hear about a clinical 
hold--I don't know that I had heard that term before.
    I mean, we knew this was out there. We knew this was 
percolating. U.S. taxpayer resources were being put toward the 
research and development and I guess my question is what does 
it take to get us over that obstacle to where we can put these 
things in the field and begin--and begin clinical trials. 
Instead of talking about clinical holds let us talk about 
clinical trials. Let us talk about breakthrough designation. 
Let us talk about making things available. Can either of you 
speak to that?
    Dr. Borio. Absolutely, Dr. Burgess. So for the vaccines, 
for example--I will give an example--you know, even though they 
have been in development for a number of years when this 
outbreak--epidemic began we did not have any of the INDs filed 
with the FDA for the vaccines.
    So I think what you are hearing is really an unprecedented 
level of engagement by the FDA to facilitate the applications 
for these vaccines and to be able to begin clinical trials in 
record time.
    I can tell the reviewers review the applications in a 
matter of a few days and in addition prior to the application 
being received we work intensely with the sponsors to be able 
to get them ready for this--for the submission.
    So I hope that I conveyed that, you know, so that there is 
no doubt that we are doing all we can to be--to exert not only 
maximum flexibility but also to speed development and to engage 
very actively with all the developers, government partners, and 
the companies.
    So the clinical hold that--the clinical hold situation that 
I was asked, again, all of our decisions are based on the 
science we have available and with the interest of public 
health in mind and we are working with every one of the 
developers to move their programs forward.
    But there are situations where if the risk is believed to 
outweigh the benefits based on the available science we--it is 
called a clinical hold. We basically tell the sponsor that the 
study cannot proceed in volunteers at this moment until some 
adjustments are made and the benefit-risk profile is more 
favorable.
    Mr. Burgess. There is a broad understanding at the Food and 
Drug Administration that this is no ordinary time, correct?
    Dr. Borio. Absolutely. I think, as I mentioned in my 
testimony, there are more than 200 people at the FDA who are 
engaged in this response and working very actively with the 
developers. There is no question in my mind that it is all 
hands on deck and everybody is very aware of the gravity of the 
situation and very determined to do all they can to help 
mitigate it. There is no question about that.
    Mr. Burgess. Mr. Chairman, I realize that I am a guest on 
your committee and I wasn't going to bring this up but you 
did--you said you were loathe to criticize the World Health 
Organization but then you went ahead.
    So, Dr. Bell, not really a criticism but observation and 
then, of course, this goes back several years--if it were not 
for the CDC the global outreach and response network of the 
World Health Organization would be pretty thin.
    Now, I talked to the folks at the CDC right at the end of 
July. Someone there told me you had 30 people that were getting 
ready to deploy to western Africa.
    I believe I have that number correct. And Chris Smith 
talked about, you know, the surge of people that are needed in 
the healthcare field. But we also recognize healthcare 
personnel are under special risk in this outbreak.
    Are you all the go-to people for that preliminary training 
for people who are going to western Africa to mitigate that 
risk somewhat and to minimize that risk to the extent that it 
can be minimized?
    Does that fall to CDC or is that actually a World Health 
Organization jurisdiction?
    Dr. Bell. Thank you, Dr. Burgess. I think, as Nancy 
mentioned, the scale of this problem is such that we are going 
to need many, many different partners assisting.
    On the topic of training and infection control, I think, 
first of all, the good news is I think because of the 
leadership of MSF we have actually a very clear and very tried 
and true protocol or method for minimizing risk to healthcare 
workers when they are treating Ebola patients.
    I believe that there is something like 450 MSF workers who 
have been working in west Africa and we have seen no infections 
so far, thank goodness, in those healthcare workers.
    So it is impossible to drive the risk to zero, obviously. 
There are extremely difficult conditions but we do have, I 
think, a good framework for training. As I mentioned, we at CDC 
we sort of have the public health lead, as you well know, in 
this response and in many others and given the importance of 
infection control as part of the public health response we have 
been ramping up our efforts in many spheres around infection 
control as we work to stop the outbreak and one of them is to 
have taken a leadership role among others to build this 
pipeline of training in safe--how to work safely in an Ebola 
treatment unit.
    As I mentioned, we have this course that we have put 
together in collaboration with MSF which we think will help 
with building a pipeline of U.S. healthcare workers who are 
going to be deploying to the region.
    But as Nancy said, there are many other groups that I think 
will be helping to gather people together to sort of bring to 
bear the resources that we need to bring to bear in the region.
    I do think that we have the sort of training that is 
necessary in order to minimize that risk and that is a training 
that can actually be sort of spread and propagated in any other 
venues where training might occur.
    The same is true in-country. As Nancy mentioned, there is a 
very large need for basic infection control in healthcare 
facilities. As I mentioned, the healthcare system is really 
completely collapsed and this was largely because healthcare 
workers were seeing patients who turned out to have Ebola. They 
didn't realize that. They have no protective equipment.
    They have no understanding of infection control. They don't 
know what safe triage means and therefore, tragically, many of 
them got infected and the facilities closed. So this is another 
large priority on the topic of infection control that we and 
many other groups are working together.
    We would like to see an infection control practitioner in 
every facility in Liberia, for example, similar to the way we 
deal with infection control here in U.S. hospitals.
    Mr. Burgess. Mr. Chairman, fascinating panel. You have been 
most courteous. I will yield back.
    Mr. Smith. Thank you very much, Doc. Ms. McCollum.
    Ms. McCollum. Thank you. We hopefully will have someone 
from the Department of Defense who can maybe inform members 
more at the co-briefing we are doing with the Global Health 
Caucus along with you and Ms. Bass to have maybe some of those 
questions answered.
    But my understanding is, first and foremost, we need 
staging areas. We need, you know, places where people can be 
treated and so the DoD is bringing in a wave of engineers and 
those engineers for the most part will not be coming into 
contact with patients or people who are ill, and the DoD has a 
great medical staff.
    I mean, infectious disease is something that they are--they 
have their own research. They collaborate with the CDC, the 
NIH, everybody--the Department of Health. They all work 
together on this.
    So I am fairly confident that AFRICOM has a good handle on 
the first wave that is going to come in because if we don't 
have the infrastructure, and that is the boots on the ground--
it is building, the framing up the hospitals and all that will 
be really, really important and then our soldiers will get 
really excellent training before going in.
    But the first wave going in for a lot of what we are 
talking about they are not going to be coming in contact, and 
you are all kind of shaking your heads yes. So I just wanted to 
kind of say that DoD knows when it is trained to this.
    And so one of the things that I think you pointed out as, 
you know, you all kind of have a hierarchy. You have your own 
special responsibilities. You are getting together. This is an 
emergency and you are talking amongst yourselves quite a bit.
    But I want to just kind of talk about some secondary 
impacts. We touched on a little bit about what is, you know, 
happening with maternal-child health, what is happening with 
people who maybe have been diagnosed with cancer, tuberculosis, 
HIV/AIDS--all of those critical resources in healthcare systems 
that we have been working to make better in these countries.
    Now people are not being able to access that kind of a 
treatment especially in some of the countries where the Ebola 
has gone. So, for example, in Guinea, Sierra Leone, and Liberia 
are large poor populations, limited access to clean drinking 
water, basic infrastructure, other public health services.
    One of the things that has come up time and time again--how 
farmers are not out in the field, how we are expecting a major 
food crisis--this is already--many countries, as I pointed out, 
with some of the very poor people whose health is fragile as it 
is what are some of the things we should be looking from the 
international community to supplement the work that you are 
doing from the World Bank, from the African Development Bank, 
from the, you know, World Food Programme? What are some of the 
things that we should be thinking of next step?
    Ms. Lindborg. Great. Thank you. And I would just fully 
agree with you and reiterate that what DoD is fundamentally 
bringing is their unique capability of having a scaled, fast 
response that sets that framework up, as you said.
    On the second order impacts, this is very important to pay 
attention to and we are coordinating closely with the World 
Bank, IMF, African Development Bank, all of which are preparing 
economic support packages.
    We are also looking at ensuring that health workers' 
salaries are paid during this critical period where you need 
people to continue to come to work at a time where there is the 
threat of total collapse. We are working throughout the region 
on preparedness.
    Countries that border throughout west Africa are 
increasingly concerned and so we have teams working to help 
them strengthen their health systems and be more prepared in 
the event that there is a case that appears.
    Malaria, especially as we come into the rainy season, is a 
particular threat so there is an increased effort among all of 
the agencies--UNICEF, USAID, CDC--who participate--WHO--who 
participate in the stop malaria efforts to ensure that there is 
a redoubled effort and a coordinated effort to get bed nets 
into the most affected areas.
    One of the most important issues is, first of all, 
controlling the outbreak and as a part of that enabling people 
to have the kind of information that can reduce the fear level 
because they are better equipped to protect themselves.
    Since it isn't an airborne disease, there are measures that 
families and communities can take to protect themselves so that 
commerce and regular activities can resume, borders can stay 
open, and economic activity is not brought to a standstill.
    So these are all part of that secondary impact piece of the 
strategy that we are very focused on, working with these global 
partners.
    Ms. McCollum. Thank you.
    Mr. Chair, much has been said about vaccines and having a 
vaccine is critically important. But making sure that we go 
through the same clinical trials that we would for anyone in 
the United States or in Europe, for that matter, before a 
vaccine is widely disbursed is critically important.
    To rush into this and not have it tested by sex, age, 
health condition, and blanketly using a vaccine that is not 
ready to go will discredit and make people more fearful of some 
of the vaccines and preventions that we currently have in the 
field and there is--there is grave concern from some in Africa, 
and I have heard it from some of the population here, that 
Africa not be a testing ground, that their African brothers and 
sisters and relatives have stuff that has been safely vetted to 
the best of scientific ability.
    There is always going to be, you know, human error and 
things that don't go the way we quite planned. So I know that 
there is a lot of pressure but I, for one, think it is really 
important that we follow the science and that we do this safely 
so it could be done effectively. Thank you, Mr. Chair.
    Mr. Smith. Thank you very much. Before yielding to Mr. 
Wolf, I would just point out that TKM-Ebola is a treatment and 
we have such a limited universe of treatments available. Even 
Dr. Brantly took a risk in taking ZMapp. I am not suggesting 
that we bypass the safety, and the efficacy remains an open 
question, but I am still bewildered as to why TKM-Ebola has 
this hold. I would like to yield to the distinguished chairman 
of the Subcommittee on Commerce, Justice, Science, and Related 
Agencies Congressman Frank Wolf.
    Mr. Wolf. Thank you, Chairman Smith.
    One, I want to thank Mr. Smith for having this hearing and 
being really one of the first here in Congress doing it at the 
end before the Congress went away. The other thing I just felt 
like saying as I was listening at the other hearing too, two 
groups--MSF, every time they travel everywhere you go they are 
there.
    They are in little villages, they are in places and 
Samaritan's Purse, which is a Christian group run by Franklin 
Graham who, quite frankly, I think at one time was even 
disinvited from an event that this administration had somewhere 
because he might have wanted to pray at a prayer breakfast--I 
forget what it was--two groups, MSF and the Samaritan's Purse, 
have been out in the front before our Government was and I want 
to personally thank MSF, all of their people.
    They--and I think we should be thanking them, all of them, 
and also Samaritan's Purse and all of their people for what 
they have done because they have been out in front of everyone 
and, Mr. Smith, and Samaritan's Purse people calling and having 
a hearing back in the summer and I think we should recognize 
them.
    I know you kept referencing MSF. Thank God for MSF. Thank 
God for Samaritan's Purse. I think Dr. Burgess made an 
interesting point. I think you need one person--I want to thank 
all of you for what you do--I think you need one person in the 
administration so that there is a central point.
    You have the State Department. You have the Health 
Department. You have the Defense Department. I think Ms. 
McCollum was right--Agriculture would be involved. It would be 
very difficult if you don't have one person who is the person 
that they can--not that they will do it all, but one place to 
go to call.
    I also think, and that leads me to the question, you 
probably need someone to travel the world the same way that 
Secretary Kerry is, to his credit, asking for people to support 
the effort that is going to be taking place with regard to ISIL 
and Syria and places like that. When I listen to the testimony 
and read all the articles, I only have America and reference 
periodically to one or two other countries.
    Are the other countries giving commensurate with what we 
are giving based on their size and population? China, the 
Saudis, Qatar, Germany, France, England--are they stepping up 
the same way that President Obama stepped up the other day?
    Is Cameron stepping up in England doing that? Is the French 
Government stepping up? Are the Scandinavians stepping up? Are 
the Saudi princes stepping up? Is the Chinese Government 
stepping up?
    Are they stepping up to the same degree, and I am not going 
to try and embarrass each and every country but are they all 
cooperating and have they all been asked to do as much as we 
are?
    Ms. Lindborg. This is a very important point and what we 
know is that when America leads it sets the frame for others to 
make a bolder and more aggressive response as well. So on the 
heels of yesterday's announcement there are calls this morning.
    Secretary Kerry has been having meetings as a part of his 
Paris conversations. There will be a U.N. meeting tomorrow on 
Thursday and during the U.N. General Assembly next Thursday 
there will also be a meeting on Ebola. The hope and the goal is 
that, inspired by the response that the U.S. announced 
yesterday, there will be a ramped up response from a large 
number of international actors.
    We are already seeing some additional more forward leaning 
responses from the UK. We expect them to make an announcement 
any day now that is quite larger.
    As I mentioned earlier, the African Union has mobilized 
what they call health keepers of 100 health workers who will be 
travelling to Liberia and we are supporting that effort. The 
European Union has pledged $180 million and there will be more.
    There will be more efforts as a part of the mobilization. 
So over the next week watch for the global response, which we 
anticipate will continue to ramp up.
    Mr. Wolf. Okay. And I would assume, unless you differ with 
me, that you all agree with me with regard to MSF and 
Samaritan's Purse.
    Ms. Lindborg. Absolutely, and, you know, we support 
Samaritan's Purse in many countries around the globe and are 
very aware of the heroic efforts of Samaritan's Purse and of 
MSF, who are on the front lines of so many crises globally.
    What is particular about this outbreak is that Ebola has 
not been this kind of a challenge before. There have been 
small, relatively contained outbreaks so there hasn't been a 
requirement for large-scale global capacity to address Ebola 
and that has been one of the challenges as this particular 
outbreak jumped borders and went into urban areas in countries 
that were absolutely ill equipped to deal with that level of 
transmission.
    So this will--this will be a sea change in how the global 
community understands and responds to Ebola.
    Mr. Wolf. Thank you, and I want to thank all of you and 
your people, too, the CDC that are on the front lines, and 
thank all of your people for what they are doing and what I 
know they will be doing.
    With that, Mr. Chairman, I yield back. Thank you very much.
    Mr. Smith. Thank you very much, Chairman Wolf. Just one 
final very brief question. Whose idea was it for this surge? 
Did it come in from an interagency recommendation or was there 
one person who said this is what has to be done?
    Dr. Fauci. There have been intensive discussions going on 
at various levels and it became apparent to us all that we 
really needed to have a sea change and that is how it evolved.
    Ms. Lindborg. So I would say that, as I mentioned earlier, 
USAID through our DART and our Office of Foreign Disaster 
Assistance is responsible for coordinating the U.S. Government 
response to disasters overseas.
    Each of the critical agencies here in Washington has a task 
force and we are using that whole of government approach to 
draw from critical resources from across the government and 
there has been a concerted effort working together to identify 
both the need and then the kind of response that is necessary 
to get ahead of the transmission, which has resulted in 
yesterday's announcement.
    Mr. Smith. Thank you for your leadership. Thank you for 
spending time this morning with us, now afternoon, and we look 
forward to work with you going forward. Thank you.
    I would like to now welcome our second panel, beginning 
with Dr. Kent Brantly, who is a family medicine physician who 
has served since October 2013 as a medical missionary at a 
hospital in Monrovia, Liberia.
    In the spring of 2014, Dr. Brantly found himself fighting 
on the front lines in the battle against the deadliest Ebola 
outbreak ever to occur and was appointed as medical director 
for what would become the only Ebola treatment unit in all of 
southern Liberia.
    On July 26, he was diagnosed with Ebola, became the first 
person to receive the experimental drug ZMapp and the first 
person with Ebola to be treated in the United States. Thank 
you, Doctor, for being here.
    We will then hear from Dr. Chinua Akukwe, who is an Academy 
Fellow and chair of the Africa Working Group of the National 
Academy of Public Administration.
    The Africa Working Group is the leading NAPA's effort to 
forge lasting partnerships in governance and public 
administration reform efforts in Africa with the U.S. and 
African stakeholders. Dr. Akukwe was the technical advisor in 
the design of two continent-wide initiatives in Africa, the 
Communicable Disease Guidelines for the Africa Development Bank 
and the Framework for Achieving Universal Access to HIV/AIDS, 
Tuberculosis and Malaria Services for the African Union. He has 
written extensively on health and development issues and we 
welcome Dr. Akukwe to the subcommittee.
    We will then hear from Mr. Ted Alemayhu, who is the founder 
and executive chairman of U.S. Doctors for Africa, a non-profit 
organization that is dedicated to providing support to the 
continent of Africa with regard to volunteer healthcare 
professionals, donations of medical supplies and equipment, as 
well as hosting high-level healthcare seminars involving 
African First Ladies and pan-African medical doctors. He is 
also founder of the African First Ladies Health Summit as well 
as a key contributor to the formation of the African Union 
Foundation.
    Then we will hear from Dr. Dougbeh Chris Nyan, who is a 
medical doctor and a biomedical research scientist of Liberian 
origin.
    He specializes in infectious disease diagnostics and his 
expertise focuses on developing simple and rapid diagnostic 
tests for detecting blood-borne infections and pathogens. Dr. 
Nyan is currently a scientist at the FDA but he is testifying 
here in this capacity as the head of the Diaspora Liberian 
Emergency Response Task Force on the Ebola Crisis, a 
conglomeration of Liberian professionals and Diaspora 
organizations in the fight against the Ebola outbreak in 
Liberia and in the region.
    If you could begin, Dr. Brantly, and then we will go to 
each of the distinguished physicians.

     STATEMENT OF KENT BRANTLY, M.D., MEDICAL MISSIONARY, 
             SAMARITAN'S PURSE (SURVIVOR OF EBOLA)

    Dr. Brantly. Thank you very much, Mr. Chairman. Chairman 
Smith, Ranking Member Bass and fellow guests of this committee 
and fellow witnesses, thank you for allowing me to testify here 
today on behalf of those suffering in west Africa as a result 
of the Ebola outbreak there.
    I would also like to take this opportunity to express my 
deep gratitude to the U.S. Government, particularly to the 
State Department, and everyone else involved in my evacuation. 
Thank you for bringing me home when I was sick.
    I am a little torn because I have this prepared testimony 
and my personal story and there are so many questions and 
issues that were just raised in the previous panel that I want 
to address. But let me first present my prepared testimony here 
for you today.
    I began work as a medical missionary, a missionary doctor 
at ELWA Hospital in Monrovia, Liberia in October 2013, as you 
said. Even before Ebola came to our area we worked long hours 
in challenging conditions to provide quality healthcare to 
support the country's struggling medical infrastructure.
    Missionary facilities like ours provide between 40 and 70 
percent of healthcare in sub-Saharan Africa. So it is easy to 
see why we were one of the first to join in the fight against 
Ebola as it made its deadly march into Monrovia.
    In June, we received our first Ebola patients and the 
numbers quickly and steadily increased from that time on. My 
organization, Samaritan's Purse, took over responsibility for 
direct clinical care of Ebola patients for all of Liberia the 
following month.
    MSF had been present in Liberia but because of the growth 
of the outbreak in Guinea and Sierra Leone their resources had 
been stretched and they were unable to provide personnel at 
that time for the outbreak in Liberia.
    Ebola is a scourge that does not even allow its victims to 
die with dignity. Most of them suffer a lonely horrifying 
death. I came to understand the extreme physical and emotional 
toll that Ebola inflicts in an even more personal way when I 
was diagnosed with Ebola virus disease on July 26.
    I had isolated myself 3 days earlier when I first felt ill. 
I had a dedicated team of medical professionals who cared for 
me in Liberia. But even their best efforts could not prevent 
the virus from racking my body with sustained fever, 
excruciating pain, and vomit and diarrhea filled with blood.
    Like the dozens of Ebola patients I had treated, I found 
myself suffering alone, and the men and women who cared for me 
were wearing protective personal equipment that looked like 
space suits and all I could see were their eyes through their 
protective goggles.
    The only human contact I had came through double layers of 
medical gloves. While in Liberia I became the first human being 
to receive the experimental drug ZMapp. Shortly after receiving 
ZMapp, I was evacuated to Emory University Hospital in Atlanta.
    As a survivor of Ebola, it is not only my privilege but my 
duty to be a voice for those who continue to suffer devastation 
from this horrible disease in west Africa.
    When Nancy Writebol and I were diagnosed with Ebola at the 
end of July 2014, the global media began feverishly reporting 
on the grave situation in west Africa.
    I am grateful for that coverage but it is unfortunate that 
thousands of African lives and deaths did not warrant the same 
global attention as two infected Americans. Even after this 
attention, when my colleague, Rick Sacra, arrived in Liberia 2 
weeks after my diagnosis, it was impossible to buy a box of 
medical gloves in the city of Monrovia.
    Agencies like the World Health Organization, as has been 
mentioned, remained bound up by bureaucracy. Their speeches, 
proposals and plans, though noble, have not resulted in any 
significant action to stop this Ebola outbreak.
    I was honored to meet with President Obama yesterday and I 
am pleased that the U.S. has now committed to take the lead and 
provide military and medical resources to fight against Ebola.
    Now we must make those promises a reality if we are to 
accurately represent the compassion and generosity of the 
American people and reduce the suffering and death in west 
Africa.
    Just this week, I saw a report that the 160-bed isolation 
unit at my hospital in Liberia is turning away an average of 30 
infectious patients every day because they don't have beds.
    Those with other life-threatening diseases are also 
suffering, as Liberia's already substandard healthcare 
infrastructure continues to collapse under the weight of this 
epidemic.
    The military assets that have been committed must be 
mobilized as quickly as possible to set up larger treatment 
facilities, to send in skilled personnel and provide logistical 
support.
    It is also imperative that our Government response be 
conducted in close partnership with nongovernmental 
organizations that have been on the front lines of this 
epidemic as well as other governmental organizations like the 
health ministries of the countries that are affected and other 
countries who wish to join in the fight.
    These NGOs that have been involved in the fight, as was 
mentioned by the Congressman earlier, specifically MSF and 
Samaritan's Purse, are now taking the lead in finding creative 
interventions to halt the spread of Ebola.
    Past outbreaks have been contained through the 
identification and isolation of infected patients and the 
tracing of their contacts. But the rate of transmission for 
this current outbreak has rendered this approach nearly 
impossible.
    A large part of the problem is that Ebola-infected people 
are choosing to stay at home because of overwhelming fear and 
superstition. Family members are caring for these sick 
individuals at home and therefore contracting the disease 
themselves.
    We now have to educate and equip these home caregivers for 
their own protection. They must be trained in safety measures 
and supplied with basic equipment to protect themselves.
    Ebola survivors can be instrumental in reaching their 
communities with critical information and resources. As the 
number of survivors increases, employing them as educators and 
community health workers can make them champions in this fight 
and help restore their dignity while tearing down the walls of 
fear and stigma attached to this disease.
    Admittedly, home-based care is less ideal than treatment 
provided in an isolation unit. However, Ebola treatment units 
are overcrowded and unable to take new patients at this time.
    If we do not provide education and protective equipment to 
caregivers now, we will be condemning countless numbers of 
mothers and fathers and brothers and sisters to death simply 
because they don't want to let their loved ones die alone.
    There is no time to waste in implementing this home-based 
care strategy in addition to the deployment of the resources 
the President has promised.
    As the current outbreak is on the verge and maybe already 
over the edge of becoming a significant threat to our national 
security, in societies where fear and distrust of authority are 
the norm many still deny that Ebola is real and they actively 
seek other explanations for the deaths of their loved ones.
    I had one patient in early July who died after 2 days in 
our isolation unit. As we tried to explain to the family the 
cause of her death, some of her family members, with the help 
of a witch doctor, determined that her death was caused by a 
curse placed on her by her best friend. The family was bent on 
getting revenge and that meant the death of the person they 
believed had caused the curse on their loved one.
    There is a palpable sense of tension on the streets that is 
priming the pump of society for skirmishes that could quickly 
lead to war. The world cannot afford to allow more conflict in 
this region that is home to dictators-in-hiding and terrorist 
groups.
    This epidemic must be brought to a halt as soon as possible 
to regain order and reestablish confidence in local 
governments. This is a global problem and the U.S. must take 
the lead immediately. The longer we wait the greater the cost 
of the battle both in dollars and in lives.
    We must act immediately and decisively to bring healing and 
stability to the people of west Africa, the African continent, 
the United States and the world.
    Thank you, Mr. Chairman, for allowing me to testify today.
    [The prepared statement of Dr. Brantly follows:]
    
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                              ----------                              

    Mr. Smith. Dr. Brantly, thank you for providing this 
committee the honor of hearing your testimony and for your very 
significant recommendations, particularly in the home 
healthcare, which has not been focused upon enough.
    During Q and A hopefully you will elaborate on some of your 
answers to some of the questions raised early.
    Dr. Akukwe, thank you for being here.

STATEMENT OF CHINUA AKUKWE, M.D., CHAIR, AFRICA WORKING GROUP, 
           NATIONAL ACADEMY OF PUBLIC ADMINISTRATION

    Dr. Akukwe. Thank you, Chairman Smith, and Ranking Member 
Bass and other members of the subcommittee. I think that this 
is a great honor and a privilege to be part of this hearing in 
the global fight against Ebola, and I must say that it is also 
a honor to share this podium with Dr. Kent because when I saw 
him walk out of that ambulance and into the hospital, I knew 
that he had sent a very powerful message that you can actually 
survive from Ebola. So thank you, Dr. Kent, for all your 
wonderful efforts.
    While I listened to the first panel I think a lot of what I 
had intended to discuss have been touched in various ways 
because my discussion is around the idea that we can use this 
threat of Ebola, the global outbreak of Ebola, to strengthen 
health systems in Africa.
    I think for many of us who spent more than 20 years working 
on HIV/AIDS in Africa, one of the things we learned within the 
first decade is that you cannot really make any dent in the 
effort against HIV/AIDS without addressing some parts of the 
healthcare system and the thing about Ebola, as I have already 
mentioned, is that if you look at the three main countries, two 
of them just came out of war.
    But if you look at all indices of health, Liberia, Sierra 
Leone, and Guinea are always dominate the laggards. They are 
always among the worst ranked for the past two decades, even 
before the wars started, and it is getting worse since the 
onset of civil war and now they are trying to emerge from the 
civil war.
    And if you look at other indices of human development, 
Liberia, Sierra Leone, and Guinea also have very poor rankings 
and if you look at indices of health systems, Africa really has 
multiple challenges.
    Liberia, Guinea, and Sierra Leone have very difficult 
challenges, always coming up among the worst ranked, and we do 
know that WHO about 5 years ago indicated that Africa has 24 
percent of the global burden of disease with only 3 percent of 
the global workforce.
    So we are dealing with 25 percent disease burden and you 
only have 3 percent of the global workforce. So what you have 
in the situation in Africa is that we have Ebola today. We have 
HIV/AIDS.
    Tomorrow we are going to have another outbreak. So no 
matter what you are doing now, you know, send in people, boots 
on the ground, trying to contain the epidemic, if you don't 
address some of the lingering issues of a poor health system 
then you are going to come back again with this kind of 
emergency response within the next few years as other epidemics 
come up.
    And we do know that in the late 1970s and 1980s the global 
coalition that included USAID, U.N. agencies, World Bank, they 
came together and from that infrastructure development had a 
primary healthcare system.
    In many African countries, physically, the only existing 
health systems that you find are those health systems that were 
built as primary healthcare centers, medical centers in the 
1970s.
    Not much has changed, and I think what I am calling for is 
to use the opportunity of the Ebola outbreak to reevaluate how 
we can assist Africa to become part of this global health 
architecture that both the Obama administration and the Bush 
administration have actually spent significant amounts of money 
trying to have a situation where all regions in the world are 
part of this global health architecture taking care of emerging 
diseases and other outbreaks.
    And I agree with what has been expressed today that we need 
to go beyond WHO. We need to make sure that we put together a 
coalition that includes African governments, multilateral 
agencies, global foundations, the academia, organized private 
sector to look at the best ways to address healthcare systems 
in Africa.
    In my book on healthcare services we did find out that it 
is not easy for Africans on their own to deal with this 
problem. You probably need a lot of technical assistance--not 
just money but technical assistance to change the sort of 
health systems.
    Let me use an example. Technical capacity at continental 
and regional level--we are happy that the Africa Union set up 
the health keepers program.
    But we do know that Africa needs a lot of leadership at the 
continental and the regional economic levels to provide 
technical assistance for some of these very poor African 
countries that will never have the capacity to manage some of 
these outbreaks like we are seeing in Sierra Leone, Guinea and 
Liberia.
    And in closing, I think that in 2000 the U.S. Congress, the 
106th Congress, when we were all paralyzed by the response to 
HIV/AIDS, came up with the Global AIDS Trust Fund that 
jumpstarted the global response to HIV/AIDS. It wasn't a lot of 
money, about $50 million.
    But what it did was that it now allowed the World Bank and 
other multilateral agencies and other stakeholders to begin the 
process of looking at HIV/AIDS from a totally different 
perspective from the regular way of doing things.
    And I think that this is what we probably need at this time 
from the Congress in order to help African health systems be 
rebuilt in such a way that they could become part of the global 
health architecture.
    Thank you so much.
    [The prepared statement of Dr. Akukwe follows:]
    
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    Mr. Smith. Dr. Akukwe, thank you very much for your 
testimony and your leadership.
    Dr. Alemayhu.

STATEMENT OF MR. TED ALEMAYHU, FOUNDER & EXECUTIVE CHAIRMAN, US 
                       DOCTORS FOR AFRICA

    Dr. Alemayhu. Thank you, Mr. Chairman. First and foremost, 
I would like to thank you and Congressmember Bass. You both 
have been the true soldiers for the continent of Africa.
    Every time there has been a pressing need you have been on 
the forefront calling for hearings and showing mutual 
leadership. So I am truly grateful for that. Also, I want to 
thank my colleagues here at the table. Let me read my 
statement, Mr. Chairman, if you don't mind.
    Members of the United States Congress, it is my deepest 
honor and privilege to come before you this morning in order to 
show, in order to share what I know and what should be done to 
assist Ebola-affected nations in west Africa.
    I, first, wanted to express my sincere gratitude to you, 
Members of Congress, and to the entire Government of the United 
States for giving your fullest attention for this deadly 
crisis. I would also like to thank Dr. Kent Brantly for his 
extraordinary service for the people of Africa. We are 
delighted to see him well and alive.
    Mr. Chairman, Members of Congress, I have come before you 
this morning as a son of Africa and a proud citizen of the 
United States. As a son of Africa, I am deeply concerned and 
heartbroken to see my people once again suffer from another 
deadly virus.
    As you may recall, the HIV/AIDS virus has murdered millions 
of Africans across the continent. I am terribly scared and 
terrified as to what could happen now if we do not act rapidly 
and decisively to stop this deadly virus.
    Mr. Chairman, the Ebola virus does not discriminate. It is 
killing babies. It is killing mothers. It is killing fathers, 
doctors, and nurses and anyone else that is in its way.
    The World Health Organization reports that over 2,400 of my 
fellow Africans have been murdered by this disease. If we do 
not act rapidly and decisively we could potentially witness 
tens of thousands of dead bodies across west Africa and 
possibly even beyond.
    What is happening on the ground, particularly in the 
Republic of Liberia, Sierra Leone, and Guinea is simply 
heartbreaking. The governments of these nations are screaming 
for help and we must respond to their call immediately.
    We must still deploy some of our basis healthcare resources 
and accessories, medical supplies, and equipment immediately 
because they are needed and needed badly on the ground. Items 
such as protective gears, hospital beds, gloves, and masks and 
gowns are in dire need.
    Local healthcare workers are threatened to quit their 
service if their safety is not ensured with the delivery of 
these items. And who really can blame them? According to the 
World Health Organization, approximately 301 healthcare workers 
were infected by this virus and half of them are dead.
    There is a severe shortage of healthcare professionals in 
most African nations and particularly those nations that have 
been affected by this virus. I am speaking averaging one doctor 
per 50,000 people or more. This is what I call a perfect remedy 
for massive disaster.
    Once again, the World Health Organization has called for an 
additional 500 healthcare professionals to be deployed on the 
ground in order to assist effectively with this crisis.
    Mr. Chairman, I can tell you that U.S. Doctors For Africa 
and our partners are ready to help. In partnership with the 
AFYA Foundation of America--the president and chairman is right 
behind me--and many other strategic partners we are able to 
mobilize medical supplies and equipment worth tens of thousands 
of dollars and ready for shipment.
    We are also looking into actively recruiting medical 
doctors and nurses to be deployed to Africa. U.S. Doctors for 
Africa has access to medical clinics, telemedicine technology, 
emergency care units, and other personnel. They look to do all 
of this and can deploy them to Africa.
    Mr. Chairman, we need strategic assistance and the sponsors 
to deliver these units on the ground. Thank you, sir.
    [The prepared statement of Dr. Alemayhu follows:]
    
    
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    Mr. Smith. Dr. Alemayhu, thank you very much for your 
leadership as well and later on I will ask you about actively 
recruiting doctors and how well that is going.
    I would like to now ask Dr. Nyan if you could present your 
testimony.

    STATEMENT OF DOUGBEH CHRIS NYAN, M.D., DIRECTOR OF THE 
SECRETARIAT, DIASPORA LIBERIAN EMERGENCY RESPONSE TASK FORCE ON 
                        THE EBOLA CRISIS

    Dr. Nyan. Thank you, Mr. Chairman, and members of this 
august committee, distinguished panelists, specifically Dr. 
Kent Brantly, to whom on behalf of the people of Liberia and 
also Sierra Leone and Guinea we pay you our deepest respect and 
to other healthcare workers who did not make it through as a 
result of the infection.
    Members of the fourth estate, ladies and gentlemen, I would 
like to thank the organizers of this hearing for the invitation 
extended to Diaspora Liberia Emergency Response Task Force on 
the Ebola crisis to testify on the situation of the current 
Ebola epidemic in Liberia and the subregion.
    We in the Liberia task force from the Diaspora believe that 
through this medium U.S. policymakers will have the first 
opportunity of hearing about the outbreak from the Liberian 
perspective primarily.
    The Diaspora task force is an umbrella organization which 
conglomerates Liberian healthcare professional organizations, 
community organizations, individuals of varying professional 
expertise including medical doctors, nurses, public health 
practitioners, pharmacists, biomedical research scientists and 
engineers, journalists, et cetera.
    From the inception of its nationhood in 1847, Liberia has 
always maintained a very special link to the United States of 
America and have always played a major role on the world stage. 
Also, Liberia was always a trusted Cold War ally of the United 
States.
    Cognizant of this relationship, Liberians have always 
turned to the United States for rescue in times of problems be 
it economic, social or political, now medical. Today, Liberia, 
along with countries of the Mano River subregion find itself in 
a situation that is occasioned by the current Ebola outbreak.
    This epidemic is dissipating lives, breaking up families as 
well as stigmatizing and traumatizing the country and its 
people. It is no secret that the Liberian healthcare system, as 
has been discussed over and over, completely collapsed under 
the pressure of the Ebola outbreak while also the leadership 
and local health authorities demonstrated an incapability of 
dealing with the outbreak.
    Most hospitals are still closed due to the lack of basic 
medical supplies. Healthcare workers lack the necessary 
protective gear to go in the field to perform their duties.
    Although there have been massive input of medical support 
and supplies from countries of the global community like China 
and India and the United States, we have yet to see a logistic 
plan put in place for the proper distribution and delivery of 
materials to intended clinics and hospitals.
    There is also the issue of mistrust and confidence between 
citizens and government authorities, as have been discussed 
over and over, and a total breach of confidence. The crisis 
have been deepened also by the appointment of unqualified 
personnel, particularly nonmedical personnel, as spokespeople 
to lead government's fight against the Ebola outbreak.
    And this has led to wrong decisions of government grossly 
contradicting public health disease control measures. Also, the 
unprofessional utterances from some nonmedical officials have 
engendered widescale disbelief in the general population that 
the Ebola virus is not real.
    Additional challenges include the lack of trained medical 
personnel in specialized areas of epidemiological infectious 
disease control.
    On the side of the Diaspora efforts, coordination of 
logistics across the United States has been difficult due the 
lack of financial resources. In Liberia, reduction of air 
flights into the country and the lack of clear policy on duty-
free process for Ebola equipment and supplies have hampered 
anti-Ebola efforts from the Diaspora community.
    These are among a few examples of the looming challenges in 
the fight against Ebola in Liberia and the subregion as a 
whole.
    Notwithstanding, Diaspora Liberians and, as we have met 
with others from the subregion, Guineans and Sierra Leonians, 
have since embarked on massive mobilizations of medical 
supplies and materials as well as food, and continue to send 
these items to Liberia and the other countries on a revolving 
basis.
    For example, partnering with other organizations and 
foundations, the Diaspora Liberia Emergency Response Task Force 
recently airlifted about 4,000 pounds of medical supplies to 
Liberia on August 27, 2014, set up its own distribution 
mechanism that was very much independent of government's 
control, and effectively delivered directly to healthcare 
facilities that were serving impoverished communities.
    One of those communities was the West Point community which 
was locked down, and in this service we utilized organized 
community involvement. It is important to note that Guinea, 
Liberia, and Sierra Leone were ravished by civil wars and this 
damaged the little infrastructure that these countries had.
    Yet, at the onset of the prevailing crisis there were some 
miscalculations also on the part of the international 
community. First, the international community should have had 
the inclination that these three Mano River Union countries of 
Guinea, Sierra Leone, and Liberia did not have the professional 
and technical capacity to control the outbreak of Ebola virus, 
a WHO-classified risk group four or biosafety level four or 
category A virus.
    Second, the international community failed to understand 
the cultural and traditional ties that exist among the people 
living in the common geographic region that connects Guinea, 
Sierra Leone, and Liberia.
    In that geographic triangle resides common ethnic groups, 
example the Kissi and Mandingo, that cannot be separated by 
political or colonial boundaries.
    Third, the response of the international community was 
seemingly uncoordinated. After looking for a while, the French 
Government quickly went into Guinea with scientists, doctors 
and medical supplies to help out.
    Then the British Government followed suit, helping Sierra 
Leone alone. Liberia was left alone for a little while, left 
alone, and by the mercy of Samaritan's Purse and Doctors 
Without Borders--we take our hats off to you again--Liberia was 
being cared for.
    As if British and the French Government were saying to 
Liberia, well, you have got America--let America come to your 
aid. True to this, in the last several days the U.S. Government 
has begun taking significant steps toward helping Liberia fight 
the Ebola crisis.
    As the WHO has since declared the Ebola outbreak as a 
humanitarian crisis and called for a coordinated response, in 
this regard the Diaspora Liberia Emergency Response Task Force 
on the Ebola Crisis will kindly call for the following.
    One, that Britain, France, and the United States create a 
triangular coordination of their assistance to the region for 
Guinea, Sierra Leone, Liberia, and Nigeria.
    Two, that the international community, mainly the United 
States of America, with the WHO should take immediate control 
of the healthcare system of Liberia and the subregion in order 
to resuscitate its capacity building.
    Three, that the fight against Ebola be conducted through a 
community-based approach and community empowerment through 
nongovernmental institutions as civic groups, churches, and 
community organizations have demonstrated competence and 
experience in service delivery during the war crisis at a time.
    An example will be the Catholic Church through the Catholic 
Relief Services and now we can make the Diaspora task force as 
an example and civic society groups that have already organized 
themselves in Liberia presently. Their acronym is called CASE. 
These will be viable partners for U.S. Government and 
international donors.
    Four, that the U.S. Government actively and practically 
supports the proposal of the Diaspora Liberia Emergency 
Response Task Force for the establishment of a national 
institute of disease control and prevention in Liberia to 
conduct disease surveillance and prevent future outbreaks of 
Ebola and other related diseases and establish a west African 
institute for disease control and prevention so as to create a 
network of infectious disease professionals again in Liberia, 
Nigeria, and Sierra Leone as well as the subregion to conduct 
disease surveillance and prevent future outbreak of Ebola and 
other related diseases.
    Six, that the United States Government or its aid agencies 
kindly provide assistance to the Diaspora Liberian, Guinean, 
and Sierra Leonian initiatives that are aimed at sending 
Diaspora healthcare professionals among whom are doctors, 
nurses, public health practitioners, et cetera, to their 
respective countries on a revolving 6-week basis.
    Seven, that the United States Government kindly increase 
its civilian medical expertise at about 1,000 in the region in 
Liberia to augment the 3,000 soldiers that will be sent. And 
this we are currently requesting should come from the Centers 
for Disease Control, the National Institute of Health, and the 
Food and Drug Administration.
    On this note, we would like to thank the Government of the 
United States of America and the Obama administration for the 
concrete steps it is taking in fighting against Ebola outbreak 
in Liberia and the subregion.
    Thank you, Mr. Chairman.
    [A prepared statement was not submitted by Dr. Nyan.]
    Mr. Smith. Dr. Nyan, thank you very much and for your very 
specific recommendations to the subcommittee and hopefully by 
extension to the administration and to the rest of Congress.
    Just a few questions and, Dr. Akukwe, when you talked about 
watching Dr. Brantly walking on his own and what a sense of 
hope that sent to you, that sense of hope is felt here on 
Capitol Hill in a huge way that Ebola isn't necessarily a death 
sentence, that some intervention may work.
    And my first question to all of you and to Dr. Brantly 
maybe in particular since he was on the ground dealing with 
Ebola patients: How do you incentivize doctors and healthcare 
personnel, other than those who might be ordered to be there as 
part of a military deployment, how do you incentivize people to 
take up that huge, not only responsibility, but to incur that 
risk that comes with it? I know for you, and I watched your 
press conference when you were with the doctors who had 
assisted in your recovery, and I was awed by your statement of 
faith in Jesus Christ, your sense of that motivating you to do 
what you did in helping those who were suffering so immensely, 
especially when the Ebola crisis hit, and you might want to 
elaborate on that because I think it goes unrecognized that 
even people in governments, even people who are a part of a 
military deployment, very often it is their faith that is the 
prime motivator for their tremendous acts of love, compassion, 
and altruism. If you could maybe elaborate on that.
    Dr. Brantly. Thank you, Mr. Chairman. I think there are a 
lot of practical things that people want if they are going to 
respond to a situation like this.
    They want to know that they are going to be safe, that they 
are going to have the support they need, they will have all the 
protective equipment they need. But none of that provides 
motivation.
    I think the only way to get volunteers to go serve in these 
situations, to go serve the people of Liberia and Guinea and 
Sierra Leone in the midst of this terrible Ebola outbreak, is 
for people to have some internal motivation and for a lot of us 
that is our religious faith.
    You know, Jesus instructed us, taught us to love your 
neighbor as yourself, and he told ``The Parable of the Good 
Samaritan'' and when he was asked the question: ``Who is your 
neighbor?'' the answer is ``Whoever is in need; that is who 
your neighbor is.''
    So for a lot of people that is and could be and should be 
their motivation. But even for people who don't hold a close 
religious faith, for medical professionals--I spoke to the 
Senate yesterday and said healthcare workers take oaths such as 
the Hippocratic Oath and all of us from the time we write our 
application essays for medical school we want to save the 
world, we want to help people, we want to serve people--
everybody's application essay says that--but it has to be true.
    You have to have a sense of compassion on your fellow man 
and an internal urge to serve your neighbor, to serve people in 
need, and I think healthcare workers in this country and other 
countries need to remember that that was their motivation for 
getting into the practice of medicine in the first place, and 
when they have that assurance that they will be supported and 
provided with the necessary protective equipment that they--
many people don't want to make a personal sacrifice--so if they 
can be compensated for their lost work or they can have someone 
fill in in their practice to be sure that their patients don't 
suffer because of their service to others, those things are all 
helpful. But people have to be motivated from their hearts to 
go serve.
    Mr. Smith. In your service would you, others--yes, Doctor.
    Dr. Akukwe. Thank you, Chairman Smith. I agree with what 
Kent said. But there are a couple of other things that we have 
learned because I served as the first executive chairman of the 
Africa Diaspora Health Initiative is that there are a series of 
things that are very critical when you are talking of 
professionals going into ``what they may consider hardship.''
    First one is about, in addition to faith and commitment, is 
logistics. They want to be sure that they are going to be safe 
and that there is an organizing platform. You were asking this 
morning who is in charge. That is one of the first questions 
that a typical professional will ask.
    Who is, what is the coordinating authority or coordinating 
body and then while they are in the host country the issue of 
safety and then, are they going to have basic supplies in order 
to do their work?
    We found out a lot of people, when they do not receive very 
specific assurances of that, they will not like to deploy. And 
then, of course, the issue of compensation. Not necessarily 
getting paid for what they are earning in United States but 
some form of compensation so they can take care of their 
families.
    And I think also the issue of nonprofits MSF and 
Samaritan's Purse. The more people get to know what they are 
doing and they are successful in deploying people in some of 
these countries, the more you are going to get volunteers.
    And then finally, with respect to Africa, the issue of 
Africans and the Diaspora, when we see what the Indians are 
doing, what the Chinese are doing in China, the issue of 
Africans and Diaspora, there are thousands of healthcare 
professionals.
    The National Medical Association has over 25,000 medical 
doctors. I know they have a program on the Diaspora but that is 
not well funded. So you do have to help prepare professionals 
within the Diaspora who with some kind of incentives, perhaps 
they will be more inclined to deploy to Africa.
    Mr. Smith. Excellent point. Yes, Doctor.
    Dr. Alemayhu. Thank you, Mr. Chairman. I guess the short 
answer to your question is really what is the mission of being 
a medical professional.
    I think most doctors and healthcare providers that I know 
of their mission is very simple. It is to save lives. It may 
have been in different very, very difficult situations in the 
past with the war zones, floods, earthquake disasters, you name 
it, and every step of the way they go they take a huge risk.
    And this is just another challenge and it is not so much of 
what is in it for them but I think it is so much of what they 
can do for others and that is--actually that is their mission.
    With regards to Africa for a moment, just 1 second, Mr. 
Chairman, the African Union is doing its best, you know, 
despite all these tremendous challenges and a lack of resources 
and everything else.
    Currently, they are assembling volunteer medical 
professionals from across the continent. Apparently, there are 
about 100 of them are being mobilized and being trained in 
Ethiopia at the African Union headquarters and supposedly they 
will be deployed in the next 48 hours or so.
    So the African Union does need a lot of help because 
ultimately I certainly don't want to come before you, and I am 
sure none of us want to come before this subcommittee, 5 years 
or 10 years from now.
    What we would like to see is hopefully an Africa taking 
care of Africa's business and challenges, and I think the work 
could be done as despite what we think about the situation on 
the ground, the African Union and the African governments 
should be supported in every effort they are out to accomplish.
    And so such as the African CDC is something that the 
President of the United States mentioned and the African Union 
is pursuing and the Ethiopian Government introduced this, and I 
think they are doing fantastic work but they do require a lot 
of supports. Thank you, sir.
    Mr. Smith. Let me just ask--we are going to have to leave 
at 1 o'clock because there is another hearing that will have to 
be convened. But let me just ask the question--Dr. Brantly, you 
pointed out that a significant surge of medical boots on the 
ground must happen immediately and I asked that question and it 
was right from your testimony to our distinguished witnesses in 
Panel I and I, frankly--I still don't have a sense--the 
subcommittee members don't have a sense: What is the critical 
mass that is necessary?
    It is hard to build up and build out capacity if you don't 
know what is needed. You also make an excellent point. I read a 
couple of articles about how people are getting in taxis and 
they can't find a bed anywhere and the taxis are actually 
getting hot--at least that is the way the author of the article 
put it--you know, potentially putting people at risk who get 
into the taxi.
    And you mentioned that your 120-bed isolation unit in ELWA 
is turning away as many as 30 infectious disease individuals 
every day. Where do they go? And again, this idea of home 
healthcare--can that be set up?
    Do you think that is part of the plan? I wish I would have 
asked that of the earlier panel but I didn't but I will because 
that ought to be incorporated and integrated, I would think, to 
a response.
    Dr. Brantly. Thank you. Let me answer this in an orderly 
way. The Ebola treatment units are absolutely necessary for 
handling this outbreak but right now they are insufficient. 
That is where the home care comes in.
    People are staying at home. There are not enough beds and 
it takes time to construct new units and put beds in them and 
provide adequate staff.
    A unit with beds but without the staff is just a place for 
people to die and that is more incentive for people to stay 
home where at least they are with their family. So we have--
also have to have the staff, which is--goes to your question as 
well.
    The home healthcare strategy, I believe, has been addressed 
by the President in his plan when he--I think he committed 
400,000 home care kits to be delivered and they have to be 
delivered without delay and those kits--I am not sure what is 
contained in them but it has to be not only things like oral 
rehydration solution and Tylenol to help treat the patient with 
that supportive care--and there are other types of supportive 
care that are not possible at home like intravenous fluids and 
other more technical medical interventions--but we can do some 
basic things like try to keep people hydrated with oral 
rehydration and ease their pain or their fever with small doses 
of Tylenol.
    But the more important part of that kit is the equipment to 
protect the caregiver and that is going to require education of 
those caregivers as well and that is where I think 
implementing, employing survivors to help reach their own 
communities.
    You know, survivors are stigmatized and many times can't 
return to their communities safely. But if they can return to 
their communities with the support of the authorities with some 
safety and security to be able to do this lifesaving work of 
educating their communities, of helping those caregivers 
provide good care to their patients, their family members in a 
safe way, I think that is very important and that can be 
mobilized more quickly than we can build new units. The two 
have to happen together. But I think the home healthcare needs 
to start immediately.
    As for numbers of medical boots on the ground, Mr. 
Chairman, obviously I can't give you an exact number but let me 
give you an idea of what is required to run a unit.
    The treatment team is made up of a doctor, two or three 
nurses or PAs or paramedics and two or three what we call 
hygienists. The hygienist does not have to be a medical 
professional.
    They have to be safety conscious people who are able to 
follow instructions and who are willing to do dangerous and 
difficult work. Those are the people who spray the unit with 
the chlorine to keep everything sanitized. They take care of 
the bodily waste of the patients and they deal with the dead 
bodies when patients pass away.
    So if you have this team of five or six individuals it 
would be one doctor, two or three other healthcare 
professionals which can be nurses, physician's assistants, 
paramedics, and then two or three of the hygienists, those 
people can care for maybe ten patients before--maybe not even 
that many--maybe five patients before they have to leave the 
unit because of the difficulty of wearing the personal 
protective equipment in the heat and you can't drink when you 
are wearing that equipment; there is a time limitation for how 
long you can stay in the unit.
    I think MSF has or WHO has estimated that for a 100-bed 
unit you have to have 200 personnel with that breakdown of, you 
know, six nurses, PAs, and paramedics for every three 
hygienists for every one doctor.
    So if you had 1,000 patients that needed to be cared for 
you would need roughly 600 healthcare workers, 100 physicians, 
and 300 hygienists and that is for people that work 12-hour 
shifts with no days off.
    It requires half of that again to work 12-hours shifts and 
give people a day off every once in a while. So we are talking 
about for every 100 patients, 200 personnel or 300, if you want 
people to be able to take a break and not be burned out after a 
few days of working.
    So it is large numbers but it is not that we need 10,000 
doctors. It is that we would need 1,200 nurses, 600 hygienists, 
and 200 doctors for 2,000 patients. Those are roughly the kinds 
of numbers we are looking at.
    So if we are looking at 10,000 patients in the next few 
weeks you can see the numbers of healthcare professionals and 
other volunteers that we would need to treat them.
    Dr. Akukwe. Let me say--in Guinea, Liberia, and Sierra 
Leone there are lots of trained community health workers who 
are either out of work, have retired, or have left the 
healthcare industry.
    So as part of work Kent is talking about on home health. It 
is easy to remobilize these individuals who benefited from very 
rigorous training 10, 15, 20 years ago--hundreds of them.
    Dr. Brantly. And Mr. Chairman, may I also say I am not 
suggesting that all of these people would have to be deployed 
from the United States of America. There are lots of Liberians 
in Liberia who can help in this response and in fact there are 
units--isolation units, Ebola treatment units--that are being 
run entirely by Liberians.
    There is one on the ELWA campus, which we refer to as ELWA 
II, being headed up by Dr. Jerry Brown and they are having 
phenomenal success by providing supportive care to patients, 
nutritional supplementation, vitamins, and providing 
compassionate care to them, and just in the last couple of days 
they had 50 patients and they have released 19 survivors.
    In the month of August they released 51 survivors. So 
supportive care works but you just have to have the personnel 
to provide it.
    Mr. Smith. Before we conclude, is there anything else you 
would like to add? Any answers to the questions that might have 
been posed earlier to Panel I that you think you would like to 
address? Anybody? Yes, Doctor.
    Dr. Alemaywu. Just quickly, Mr. Chairman. What one key 
piece that I have not heard us talking about is the 
psychological part of this whole thing. I am delighted to be 
joined by Dr. Judy Kuriansky from Columbia University--she is 
also a board member--it is unthinkable what is going on now 
with regards to the psychological challenge and the fear, and, 
of course, we have forgotten one huge piece in this which is 
the traditional healers--the traditional doctors, if you can 
call them that--because the locals, whether we like it or not, 
they believe who they know and who they trust, not so much of 
the outside forces coming to save them.
    And I think getting those elements in place and letting 
them be a part of the solution making process is absolutely 
key. Thank you, sir.
    Dr. Akukwe. And you need to know, from the earlier 
discussion--the problem is that I think in long term beyond the 
immediate response to Ebola, the next few years you are going 
to have another outbreak. So what is the best way to assist 
African countries and manage these outbreaks on their own in 
the future?
    Mr. Smith. I would like to thank all four of our 
distinguished panelists for your tremendous insight, your 
recommendations. I think it will help not only Congress but it 
will help the administration with your guidance and your 
wisdom.
    And, again, thank you for your leadership. It is 
extraordinary. The hearing is adjourned.
    [Whereupon, at 1:01 p.m., the committee was adjourned.]
                                     

                                     

                            A P P E N D I X

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                   Material Submitted for the Record


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Material submitted for the record by Dougbeh Chris Nyan, M.D., director 
of the secretariat, Diaspora Liberian Emergency Response Task Force on 
                            the Ebola Crisis

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