    [Senate Hearing 113-760]
    [From the U.S. Government Publishing Office]

                                                           S. Hrg. 113-760

                     PREPAREDNESS AND RESPONSE TO PUBLIC
                       HEALTH THREATS: HOW READY ARE WE?

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

                                    HEARING

                                   BEFORE THE

                                  COMMITTEE ON
                   HOMELAND SECURITY AND GOVERNMENTAL AFFAIRS
                              UNITED STATES SENATE

                        ONE HUNDRED THIRTEENTH CONGRESS

                                 SECOND SESSION

                                   __________

                               NOVEMBER 19, 2014

                                   __________

            Available via the World Wide Web: http://www.fdsys.gov/

                           Printed for the use of the
            Committee on Homeland Security and Governmental Affairs

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            COMMITTEE ON HOMELAND SECURITY AND GOVERNMENTAL AFFAIRS

                      THOMAS R. CARPER, Delaware Chairman
    CARL LEVIN, Michigan                 TOM COBURN, Oklahoma
    MARK L. PRYOR, Arkansas              JOHN McCAIN, Arizona
    MARY L. LANDRIEU, Louisiana          RON JOHNSON, Wisconsin
    CLAIRE McCASKILL, Missouri           ROB PORTMAN, Ohio
    JON TESTER, Montana                  RAND PAUL, Kentucky
    MARK BEGICH, Alaska                  MICHAEL B. ENZI, Wyoming
    TAMMY BALDWIN, Wisconsin             KELLY AYOTTE, New Hampshire
    HEIDI HEITKAMP, North Dakota

                      Gabrielle A. Batkin. Staff Director
                   John P. Kilvington, Deputy Staff Director
              Stephen R. Vina, Chief Counsel for Homeland Security
         Susan B. Corbin, U.S. Department of Homeland Security Detailee
           Larry Small, U.S. Department of Homeland Security Detailee
                   Keith B. Ashdown, Minority Staff Director
             Daniel P. Lips, Minority Director of Homeland Security
              William H.W. McKenna, Minority Investigative Counsel
        Gabe S. Sudduth, Legislative Assistant, Office of Senator Coburn
                         Laura W. Kilbride, Chief Clerk
                       Lauren M. Corcoran, Hearing Clerk

                                C O N T E N T S

                                     ------
    Opening statements:
                                                                       Page
        Senator Carper...............................................     1
        Senator Coburn...............................................     3
        Senator McCaskill............................................    18
        Senator Johnson..............................................    20
        Senator Ayotte...............................................    23
        Senator Portman..............................................    25
        Senator Baldwin..............................................    29
    Prepared statements:
        Senator Carper...............................................    49

                                   WITNESSES
                            Thursday, June 12, 2014

    Nicole Lurie, M.D., Rear Admiral, U.S. Public Health Service, and
      Assistant Secretary for Preparedness and Response, U.S.
      Department of Health and Human Services........................     5
    Thomas Frieden, M.D., Director, Centers for Disease Control and
      Prevention.....................................................     7
    R. Gil Kerlikowske, Commissioner, U.S. Customs and Border
      Protection, U.S. Department of Homeland Security; accompanied
      by Kathryn Brinsfield, M.D., Chief Medical Officer, U.S.
      Department of Homeland Security................................     9
    Nancy E. Lindborg, Assistant Administrator, U.S. Agency for
      International Development......................................    10
    David L. Lakey, M.D., Commissioner, Texas Department of State
      Health Services................................................    12

                         Alphabetical List of Witnesses

    Frieden, Thomas M.D.:
        Testimony....................................................     7
        Prepared statement...........................................    65
    Kerlikowske, R. Gil:
        Testimony....................................................     9
        Prepared statement...........................................    77
    Lakey, David L.:
        Testimony....................................................    12
        Prepared statement...........................................    89
    Lindborg, Nancy E.:
        Testimony....................................................    10
        Prepared statement...........................................    82
    Lurie, Nicole M.D.:
        Testimony....................................................     5
        Prepared statement...........................................    51

                                    APPENDIX

    American Hospital Association statement for the record...........    96
    Responses to post-hearing questions for the Record:
        Ms. Lurie....................................................   102
        Mr. Frieden..................................................   140
        Mr. Kerlikowske and Ms. Brinsfield...........................   153
        Ms. Lindborg.................................................   170
        Mr. Lakey....................................................   180

     PREPAREDNESS AND RESPONSE TO PUBLIC HEALTH THREATS: HOW READY ARE WE?

                                  ----------

                          WEDNESDAY, NOVEMBER 19, 2014

                                         U.S. Senate,
                               Committee on Homeland Security
                                      and Governmental Affairs,
                                                        Washington, DC.
        The Committee met, pursuant to notice, at 10:08 a.m., in
    room SD-342, Dirksen Senate Office Building, Hon. Thomas R.
    Carper, Chairman of the Committee, presiding.
        Present: Senators Carper, McCaskill, Baldwin, Coburn,
    Johnson, Portman, and Ayotte.

                  OPENING STATEMENT OF CHAIRMAN CARPER

        Chairman Carper. Our hearing will come to order.
        To all of our witnesses, thank you very much for being
    here. I just want to say to our staffs, both on the majority
    and minority side, a big thank you for pulling together a
    terrific line-up here on a subject that is real important to
    our country, I think to our world, and for all of you for
    making time to prepare for it today and to present today and to
    respond to our questions.
        Normally, when Gil is here, we would put everybody under
    oath, but--no, we do not do that, only one time, when he was
    here for his confirmation. We are very pleased with the work
    that you are doing, pleased with the work that you are all
    doing.
        Today, we will examine, as you know, our Nation's response
    to the ongoing Ebola epidemic and our overall preparedness for
    other public health threats. We are very fortunate to have a
    great panel of witnesses with us today, and I want to thank
    each of you again for, not just for your presence, but for your
    public service at a very challenging time in our Nation's
    history and certainly in the history of the countries in West
    Africa.
        Since February, the public has watched an epidemic of Ebola
    virus grip the countries of Sierra Leone, Liberia, and Guinea,
    and now Mali. To date, roughly 5,200 people in West Africa, we
    are told, are believed to have died from the Ebola virus. The
    actual number of deaths may be significantly higher. The
    severity and the scale of this outbreak has challenged the
    worldwide public health community.
        And, when I think about the tragedy that is playing out in
    West Africa and what role we should play, I am reminded of the
    New Testament, and I am reminded in particular of an answer
    that Jesus once gave when the Pharisees asked Him, ``What are
    the two most important commandments?'' And He told them what
    the first one was, and then He said, ``The second one is to
    love thy neighbor as thyself.'' And the Pharisees then asked
    Him, ``Who is my neighbor?'' And, famously, he told them the
    one about the good Samaritan, and if you do not remember the
    story of the good Samaritan, it is a good one to read, be
    refreshed on, because the question that we need to ask
    ourselves from time to time, especially those of us who are
    privileged to serve in these positions, is who is our neighbor?
    And, in this case, the folks, I think, in West Africa are our
    neighbors, as well, and we are responding, I think, in a way
    that is reflective of our belief, our embrace of the Golden
    Rule.
        If we do not take care of our neighbors in West Africa,
    then we may see this deadly disease spread even faster across
    the world. And, that is why I believe it is vital that we,
    along with our international partners, continue to battle Ebola
    at its epicenter.
        Ebola, like all infectious diseases, knows no borders. It
    has even reached our shores. And, over the weekend, the United
    States began treating its tenth patient for Ebola, who, sadly,
    passed away on Monday. His death marks the second Ebola-related
    death here at home.
        In light of the Ebola virus epidemic, many Americans have
    asked this important question: How prepared is our Nation to
    handle a major public health threat? And, that is what we hope
    to help answer here at our hearing today.
        Our goal for this hearing is not to create needless
    confusion. Doing that would be counterproductive, potentially
    putting more people at risk and exacerbating the public's
    understandable fear of this disease. Instead, I hope, I think
    Dr. Coburn hopes, we are able to find some lessons learned from
    our Ebola response and use them to inform our future responses
    to this disease and to others that could threaten our Nation
    and its people.
        And, while I know the disease is far from being defeated
    and has even, as I mentioned earlier, it began to spread at
    least in Mali, it is my understanding that the number of cases
    in Liberia has substantially declined, and that is welcome
    news, although I know we could see a spike in cases with little
    notice there. We have seen in Nigeria the reporting of no new
    outbreaks, no new cases, I think since the end of August, and
    that is very welcome news. But, we must continue to pay close
    attention to the changing dynamics in Africa, and we must
    continually reassess the scales of the response needed overseas
    and here in the United States to end this epidemic.
        Whether it is Ebola, whether it is influenza, or a disease
    we have yet to hear about, the bottom line is the same. We need
    to be better prepared. We need to be ready to respond.
        To be most effective, of course, we must have a well-
    coordinated response at the Federal, State, and local level,
    and I might add, this is not all on America. We are a wealthy
    nation. We have a responsibility as a world leader to respond
    in situations like this, but it is not all on us. There are
    other nations out there that have some responsibilities, and I
    think in a number of these countries, and my staff are good,
    they are standing up and meeting their responsibilities and
    that is very reassuring.
        We must also have clear guidance and protocols from the
    Centers for Disease Control (CDC) and Prevention and other
    public health officials so that everyone knows exactly what to
    do and what not to do. We must also ensure that our State and
    local health and emergency response professionals have the
    training and tools they need to succeed. Finally, we must have
    a strong screening process in place at our ports of entry (POE)
    so we can better identify and monitor high-risk travelers.
        I also believe that a critical part of addressing any
    public health threat is the availability of antivirals,
    therapeutics, and other medical countermeasures (MCM). In the
    case of Ebola, I have been encouraged by the significant
    progress that we have made in the last few months on a vaccine
    for the virus as well as therapeutics to treat the disease, and
    I appreciated the opportunity to talk with Dr. Frieden about
    that just yesterday. We look forward to hearing about the
    status of these countermeasures and the plan for getting them
    quickly to people in need.
        To help meet the immediate and long-term needs of the Ebola
    epidemic, President Obama recently submitted an emergency
    funding request of nearly $6.2 billion, and we look forward to
    hearing more about that request, particularly in light of the
    changing situation on the ground in Africa. As we discuss this
    funding request, I believe we should keep in mind our moral
    obligation to help the least of these in our society. We
    believe that in this Committee. We also believe in trying to do
    that in a cost effective way.
        In closing, I just want to acknowledge the work of our
    witnesses and countless first responders and health
    professionals who are literally willing to risk their lives in
    order to help save people they do not even know. We are
    grateful for their courage and for their willingness to serve.
        And, I also want to recognize and thank the non-
    governmental organizations who are so critical in this
    worldwide effort to stem the epidemic of Ebola.
        And, with that in mind, I am going to turn it over to my
    compadre, Dr. Coburn, for any comments that he might have, and
    then we will come back to introduce the panel. Thank you. Dr.
    Coburn.

                  OPENING STATEMENT OF SENATOR COBURN

        Senator Coburn. Mr. Chairman, thank you, and I apologize
    for being late.
        I do not have a prepared statement other than to say I want
    to thank those presenting here today. I think we are very
    fortunate where we find ourselves today, whether that is
    because of our lack of knowledge or because of our knowledge.
    But, I think, overall, we have done a fairly effective job at
    each level. Even though we remain vigilant and worried, we
    appreciate the efforts on everybody's part.
        And, I really want to hear from our witnesses more than I
    want to hear us make statements that the public might want to
    hear. I want to hear the knowledge, the recommendations. I am
    somewhat concerned that the request may be a little bit high,
    but other than that, there are things we need to do and things
    that we need to be prepared for.
        So, personally, let me thank each of you for your efforts
    and your commitment and your service and I look forward to your
    testimonies.
        Chairman Carper. I want to take just a moment and introduce
    each of our witnesses.
        Our first witness is Dr. Nicole Lurie. She is the Assistant
    Secretary for Preparedness and Response (ASPR) at the U.S.
    Department of Health and Human Services (HHS), a position she
    has held since 2009. Dr. Lurie is also a Rear Admiral, out of
    uniform here today, in the U.S. Public Health Service (USPHS).
    I love it when you all wear those uniforms. I am an old Navy
    guy, so I like to salute our admirals.
        Previously, Dr. Lurie served as a Professor of Health
    Policy at the RAND Corporation and the University of Minnesota.
    She has also served in State Government as Medical Advisor to
    the Commissioner at the Minnesota Department of Health. Who was
    the Governor then?
        Dr. Lurie. It was Jesse Ventura.
        Chairman Carper. Jesse Ventura?
        Dr. Lurie. Jesse Ventura. I knew Jesse Ventura well and
    worked with him a lot.
        Chairman Carper. The only Governor I ever served with who
    wore snakeskin pants to work. [Laughter.]
        Dr. Lurie. With his pink boa, yes.
        Chairman Carper. There you go. [Laughter.]
        Next on our panel, we have Dr. Thomas Frieden, Director of
    the Centers for Disease Control and Prevention within the
    Department of Health and Human Services. Dr. Frieden has held
    this position since 2009. Previously, he served as Commissioner
    of the New York City Department of Health and Mental Hygiene
    from 2002 to 2009. He began his career at CDC in 1990 as an
    Epidemic Intelligence Service Officer. Nice to see you.
    Welcome.
        Next, and no stranger to this Committee, is Gil
    Kerlikowske, who heads up the Customs and Border Protection
    (CBP) operation in the Department of Homeland Security (DHS). I
    was kidding him earlier, Tom, about how many places he has been
    police chief, and I think they include Buffalo, I want to say
    Seattle, and a couple places in Florida. Which ones?
        Mr. Kerlikowske. Fort Pierce and Port St. Lucie.
        Chairman Carper. There you go. That is it, just four? That
    is a pretty good run. And also, as I recall, a couple of times,
    were you not the leader of the National Police Chief's
    Organization a couple of times?
        Mr. Kerlikowske. I was.
        Chairman Carper. That is pretty good credentials. You are
    accompanied today by Kathryn Brinsfield, who serves as the
    Chief Medical Officer for the Department of Homeland Security.
    Kathryn, would you raise your hand, please? Thank you. Nice to
    see you. Dr. Brinsfield is available for questions during the
    hearing. In case Gil slips up, she will just jump in and
    correct him.
        Our fourth witness is Nancy Lindborg, nice to see you--
    Assistant Administrator for the Bureau for Democracy,
    Conflicts, and Humanitarian Assistance at the U.S. Agency for
    International Development (USAID). And, in this role, she leads
    the efforts of more than 500 team members in the nine offices
    focused on crisis prevention, on the response, recovery, and
    transition. Before joining USAID, Ms. Lindborg was President of
    the Mercy Corps, where she spent 14 years with this
    organization.
        And our final witness, last but not least, Dr. David Lakey,
    who served as Commissioner of the Texas Department of State
    Health Services (DSHS) since 2007. Dr. Lakey has served in a
    number of positions at the University of Texas Health Center,
    including Associate Professor of Medicine and Medical Director
    of the Centers for Infectious Disease Control.
        Again, we thank you all for your service and for your
    testimony here.
        I do not want to chair this hearing today. I want Tom
    Coburn to chair it. So, I am going to pass this gavel over to
    him and put him in charge and I will try to be a good wingman.
    All right, Thomas, it is all yours.
        Senator Coburn. You want me to get the practice?
    [Laughter.]
        Chairman Carper. You might make a comeback. [Laughter.]
        Senator Coburn [presiding]. Well, we thank you. It is very
    doubtful. [Laughter.]
        Thank you all for being here. Dr. Lurie.

     TESTIMONY OF NICOLE LURIE, M.D.,\1\ REAR ADMIRAL, U.S. PUBLIC
     HEALTH SERVICE, AND ASSISTANT SECRETARY FOR PREPAREDNESS AND
         RESPONSE, U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

        Dr. Lurie. Sure. Good morning, Chairman Carper, Ranking
    Member Coburn, and distinguished Members of the Committee. I am
    Dr. Nicole Lurie, the Assistant Secretary for Preparedness and
    Response at HHS. I very much appreciate the opportunity to talk
    to you today about the actions that ASPR has taken to enhance
    our national preparedness and strengthen our resilience to
    public health threats.
    ---------------------------------------------------------------------------
        \1\ The prepared statement of Ms. Lurie appears in the Appendix on
    page 51.
    ---------------------------------------------------------------------------
        While it is absolutely essential that we continue to focus
    on controlling the Ebola outbreak in West Africa, we also have
    a critical responsibility to protect our country from this
    disease. Today, I will highlight three areas in which ASPR's
    work is critical to our domestic as well as international
    response.
        First, the Biomedical Advance Research and Development
    Authority (BARDA), building on its previous success in medical
    countermeasure development, is speeding the development,
    testing, and manufacture of Ebola vaccines and treatments.
        Second, the Hospital Preparedness Program (HPP), as I will
    call it, has since the beginning of this outbreak been
    preparing hospitals and first responders to recognize and treat
    patients suspected with Ebola.
        And, third, our Federal resources and responders, whether
    the National Disaster Medical System (NDMS), the Medical
    Reserve Corps (MRC), or the U.S. Public Health Service, stand
    ready to support a comprehensive response, should it be needed
    in the coming months.
        BARDA, in coordination with other medical countermeasures
    partners, has a great track record in expanding the medical
    countermeasures pipeline and building needed infrastructure to
    do so. In addition to developing and procuring 12 products
    since Project BioShield's inception over a decade ago, BARDA
    Centers for Innovation and Advance Development and
    Manufacturing (CIADM) and its Fill-Finish Manufacturing Network
    are being used to produce, formulate, and fill vaccines and
    treatments for Ebola.
        Complementing our successes in medical countermeasure
    development, ASPR has made great strides in U.S. health care
    system preparedness, as well. HPP investments have fostered an
    increased level of preparedness throughout communities and
    decreased reliance on Federal aid following many disasters. In
    the last several years, HPP awardees have demonstrated their
    ability to respond to and quickly recover from disasters,
    including tornadoes, floods, hurricanes, and the fungal
    meningitis from contaminated steroids.
        Through HPP, ASPR has actively engaged in Ebola
    preparedness by developing and disseminating information,
    guidance and checklists, and serving as a clearinghouse for
    lessons learned. Together with CDC, we have launched an
    aggressive outreach and education campaign nationally that has
    now reached well over 360,000 people through webinars and
    national calls, including with public health officials,
    hospital executives, front line health care workers all over
    the country, and others across the United States.
        My office, along with CDC, continues to recruit hospitals
    willing and able to provide definitive care to patients with
    Ebola in the United States. Concurrently, we are working with
    Personal Protective Equipment (PPE) manufacturers to coordinate
    supply and distribution and are working with HPP-funded health
    care coalitions to collaboratively assess and share supplies
    across communities.
        The likelihood of an Ebola outbreak in the United States is
    quite small, but ASPR, HHS, and our interagency partners are,
    as you know, part of a coordinated whole-of-government
    response, a response that extends on the one hand to West
    Africa and on the other to State and local governments, to
    hospitals and communities throughout the United States.
        As is typical for other emergencies and disasters, ASPR is
    responsible for public health and medical services and
    coordinates Federal assistance to supplement State, local,
    Territorial, and Tribal resources and response to public health
    and medical care needs during emergencies.
        I would like to close with an overview of the recent
    emergency funding request from the Administration that includes
    $2.43 billion for HHS. ASPR's request supports two major
    components, BARDA's product development efforts and HPP's
    preparedness initiatives. Specifically, funding will support
    development of Ebola vaccine and therapeutic candidates,
    clinical trials, and commercial scale manufacturing. Funding
    will ensure that communities will be able to purchase
    additional Personal Protective Equipment, that health care
    workers will receive additional training on patient detection,
    isolation, and infection control, and that we further build our
    preparedness for the future by ensuring that all States have
    facilities that can handle a serious infectious disease like
    Ebola.
        Mr. Chairman and Members of the Committee, the top priority
    of my office is protecting the health of Americans. I can
    assure you that my team, the Department, and our partners have
    been working and continue to work to ensure our Nation is
    prepared to respond to threats like Ebola.
        I thank you again for this opportunity to address these
    issues and welcome your questions.
        Senator Coburn. Thank you for your testimony. We will come
    back to you for questions after we have had everybody testify.
    Dr. Frieden.

      TESTIMONY OF THOMAS FRIEDEN, M.D.,\1\ DIRECTOR, CENTERS FOR
                     DISEASE CONTROL AND PREVENTION

        Dr. Frieden. Thank you very much, Chairman Carper, Ranking
    Member Dr. Coburn, Members of the Committee. We really
    appreciate the opportunity to share with you what is going on
    with Ebola here in the United States and in West Africa.
    ---------------------------------------------------------------------------
        \1\ The prepared statement of Mr. Frieden appears in the Appendix
    on page 65.
    ---------------------------------------------------------------------------
        At CDC, we work 24/7 to protect Americans from threats,
    whether those threats are naturally occurring, like Ebola, or
    manmade, like anthrax, whether they are infectious, like Ebola
    and other infectious diseases, or non-infectious, whether they
    come from this country or anywhere in the world. CDC's work
    includes supporting States for preparedness and response. Also,
    we manage the Strategic National Stockpile and we support
    laboratory and epidemiologic capacity throughout the United
    States to detect and respond to threats.
        The bottom line with preparedness, as far as our experience
    has shown, is that everyday systems are critical to protect us.
    If we have a great system that is shrinkwrapped in a closet and
    we try to bring it out when there is an emergency, we are
    likely not to be able to respond as effectively as if we have
    an everyday system that can be scaled up for use on the front
    lines for a flexible response to a situation.
        Ebola is a real and present threat. It needs to be
    addressed not only in the United States, but most importantly,
    at its source. We cannot get the risk to Americans to zero
    until we control it at the source in Africa.
        The basics of Ebola are relatively well known, though we
    will always continue to learn more. Everything we have seen in
    four decades of fighting Ebola in Africa suggests that patients
    are only infectious when they are ill, and they become more and
    more infectious the more ill they become, and that they only
    infect others by direct contact with body fluids of someone who
    is ill or someone who has died. That means the two main ways
    that Ebola spreads are through caring, health care or in
    communities and families, or burial practices in Africa, where
    there may be contact with body fluids.
        The emergency funding request is really critical to protect
    Americans and to stop Ebola at the source. It is focused on
    speed, flexibility, and keeping the front lines first. Those, I
    believe, are the three most important principles in confronting
    Ebola.
        In the three epicenter countries, Guinea, Liberia, and
    Sierra Leone, we are seeing changes in the nature of the
    epidemic. In Liberia, we have seen now proof of principle, that
    it is possible to stop the exponential increase that we were
    seeing before. But, we are still seeing hundreds of new cases
    per week and we need to step back and remember that a year ago,
    even a dozen cases would be appropriately considered to be a
    major emergency. So, we are nowhere near out of the woods. We
    have much further to go. But, we do have proof of principle
    that our approach can work.
        In Sierra Leone, we are still seeing significant numbers of
    cases and possibly significant increases continuing.
        In Guinea, where the outbreak probably started, the forest
    region remains very challenging, difficult to access, difficult
    to get to each of the communities that is at risk.
        The emergency funding request for affected countries
    focuses on prevention through areas like screening and
    infection control, detection through laboratory and
    surveillance work and others, and response through core public
    health activities, such as contract tracing, rapid response
    teams, and support to ministries of health that will be able to
    respond flexibly and effectively. It is quite like a forest
    fire in the way that we have to both stop it at the source and
    protect the surrounding countries from sparks emerging and
    creating new fires.
        In Mali, our team is on the ground today helping the
    government to trace more than 400 contacts of a cluster there.
        In Cote d'Ivoire, we have been in place because we know
    that there is significant contact between two of the countries
    in Cote d'Ivoire.
        In addition, the emergency funding request addresses
    prevention through biosafety and biosecurity issues that are
    quite familiar to this Committee, more broadly; detection,
    which is about three-quarters of the CDC request for the global
    health security area, so we have an alerting system, an alarm
    system, and know when problems are emerging; and response,
    through emergency operation centers that can stop problems
    before they expand broadly.
        Within the United States component of the CDC ask in the
    emergency funding request, we would not only stop it at the
    source and deal with border protections, which we have worked
    very closely with CBP on, but strengthen State and local health
    departments, strengthen hospitals so that they will be better
    able to identify possible cases of Ebola, better able to
    prevent the spread of Ebola and other infectious diseases in
    health care facilities, and better able to respond, so that we
    can stop it at the source.
        In conclusion, we are able to stop Ebola, we were able by
    surging rapidly to Nigeria to work with Nigerians to end a
    cluster there. But, we cannot let our guard down. We have much
    further to go than we have already come and we will not be able
    to fully protect Americans until we control the threat at the
    source. We have to be there until the last spark is
    extinguished. We have to strengthen our systems here to protect
    health care workers and the public. And, we have to build the
    basic warning and preparedness systems in other countries so
    that we do not face this type of problem again, because the
    vulnerability of any other country is potentially our own
    vulnerability, as well.
        Thank you very much.
        Senator Coburn. Thank you. Mr. Kerlikowske.

    TESTIMONY OF R. GIL KERLIKOWSKE,\1\ COMMISSIONER, U.S. CUSTOMS
     AND BORDER PROTECTION, U.S. DEPARTMENT OF HOMELAND SECURITY;
    ACCOMPANIED BY KATHRYN BRINSFIELD, M.D., CHIEF MEDICAL OFFICER,
                  U.S. DEPARTMENT OF HOMELAND SECURITY

        Mr. Kerlikowske. Chairman Carper, Ranking Member Dr.
    Coburn, distinguished Members of the Committee, thanks for the
    opportunity to discuss the efforts of U.S. Customs and Border
    Protection as part of the whole of government response to the
    Ebola virus outbreak in West Africa. CBP, in carrying out our
    mission to secure and facilitate international travel to the
    United States, has an important role in minimizing the
    introduction and spread of communicable diseases such as Ebola.
    ---------------------------------------------------------------------------
        \1\ The prepared statement of Mr. Kerlikowske appears in the
    Appendix on page 77.
    ---------------------------------------------------------------------------
        As you know, CBP and the Centers for Disease Control and
    Prevention are conducting enhanced Ebola screening at five U.S.
    airports, Kennedy, O'Hare, Dulles, Atlanta, and Newark, which
    have been designated for the arrival of all passengers who have
    recently traveled through or from Liberia, Sierra Leone,
    Guinea, and as of Monday, Mali. CBP utilizes advance passenger
    information to identify the travelers, and we work with the
    airlines to reroute them, when necessary, to one of those five
    designated airports. I have visited each of the airports. I
    have met with our front-line personnel who are conducting that
    enhanced Ebola screening.
        CBP and CDC have worked closely on communicable disease
    outbreaks in the past--H1N1, the Severe Acute Respiratory
    Syndrome (SARS), the Middle East Respiratory Syndrome (MERS).
    We have developed policies, procedures, protocols to identify
    and respond to travelers who may present a threat to public
    health. For example, CDC or other appropriate medical authority
    provides a ``Do Not Board'' order to CBP for individuals who
    are considered to be infected with a highly contagious disease
    and should be prevented from traveling to the United States on
    commercial aircraft.
        Upon arrival at an airport designated for enhanced Ebola
    screening, identified travelers complete a health
    questionnaire. They provide contact information. They have
    their temperature checked. And, if there is a reason to believe
    that a traveler has been exposed to Ebola because of overt
    symptoms, a positive response to the targeted questions, or an
    elevated temperature, we refer that person to CDC immediately
    for evaluation on scene at that airport. All travelers who
    undergo enhanced Ebola screening are provided with information
    and instructions, and should he or she develop symptoms or have
    a possible concern of infection.
        While the vast majority of travelers who have traveled from
    or through an affected country will arrive at one of the
    designated airports, all U.S. ports of entry, land, air, and
    sea, are prepared to conduct enhanced screening. In addition to
    the standard procedure of visually screening all passengers for
    overt signs of illness, CBP officers continue to inspect visas,
    entry-exit stamps of all passports, and they ask travelers
    about their recent travel history. CBP officers at all the
    ports of entry are asking passport holders from Liberia, Sierra
    Leone, Guinea, and Mali, regardless of where they traveled
    from, if they had been in any of those countries in the last 21
    days, and if they have, they are also referred for secondary
    screening.
        Ensuring the health and safety of our employees is an
    absolute priority in responding to this outbreak, and all the
    CBP officers receive public health training to learn how to
    identify the symptoms of ill travelers, how to apply universal
    precaution procedures for infection control, and when
    encountering potentially ill individuals or when examining
    potentially contaminated luggage.
        CBP also provides officers operational training and
    guidance on how to respond to travelers with potential illness,
    including referring individuals who display signs of illness to
    CDC officials and assisting CDC with implementation of its
    isolation and quarantine procedures. The Department of Homeland
    Security and CBP are deploying additional Personal Protective
    Equipment to ensure the safety of those front-line personnel.
        And, the DHS Office of Health Affairs and the Centers for
    Disease Control and Prevention have provided guidance on the
    proper use of protective equipment. All CBP officers are
    required to complete a web-based video training. CBP and CDC
    are also providing onsite training at the five designated
    airports for our officers who are performing that enhanced
    screening.
        We will continue to monitor the Ebola outbreak, and in
    coordination with DHS and our partners in the Federal
    Government, provide the necessary equipment, the guidance to
    front-line personnel to prevent the spread of Ebola in the
    United States.
        Thank you for this opportunity and I look forward to your
    questions.
        Senator Coburn. Thank you. Ms. Lindborg.

      TESTIMONY OF NANCY E. LINDBORG,\1\ ASSISTANT ADMINISTRATOR,
               U.S. AGENCY FOR INTERNATIONAL DEVELOPMENT

        Ms. Lindborg. Thank you, Chairman Carper, Ranking Member
    Coburn, and Members of the Committee. I very much appreciate
    your holding this hearing today.
    ---------------------------------------------------------------------------
        \1\ The prepared statement of Ms. Lindborg appears in the Appendix
    on page 82.
    ---------------------------------------------------------------------------
        And, as we have heard, the world faces the largest and most
    protracted Ebola epidemic in history, and it is a very sobering
    reminder of what happens when disease encounters weak health,
    economic, and governance systems, and reminds us that this
    rapid spread is happening in a region that is very affected by
    conflict, two of the countries emerging from decades of very
    bloody civil wars. And, it just underscores that we live in an
    ever more interconnected world, that we are all neighbors, that
    we must stop Ebola at its source in West Africa, and that we
    urgently need to build stronger and more resilient global
    health security systems so that we can prevent, detect, and
    rapidly respond to future outbreaks before they become
    epidemics.
        This is a national security priority for the United States.
    It is a security priority for the world. We have to have a
    safety net without these kinds of holes.
        So, today, I really want to underscore three key points.
    The first is that when Ebola jumped borders and migrated to the
    urban centers this summer, the United States mounted an
    aggressive whole of government effort that was governed by four
    key pillars. The first is controlling the epidemic.
        The second is mitigating second order impacts. We need to
    also blunt the very significant food security, economic, and
    social tolls that we are already seeing in these very weak
    States. These are countries where 58 percent already lived in
    extreme poverty, clean water was a luxury, and so today, on top
    of the epidemic, we also have a food and health crisis. We have
    countries where vaccination rates of measles have dropped
    precipitously. Women no longer have help at childbirth.
        The third pillar was coordinating the United States and the
    global response. This requires not just a whole of government
    response, it requires a whole of the world response, and we
    have, with aggressive U.S. leadership, been able to galvanize a
    response that now includes significant resources of both funds
    and personnel from around the world.
        The fourth is to fortify the global health security
    infrastructure.
        And, just a few comments on controlling the epidemic. We
    have surged both civil and military personnel into the region
    to isolate and treat Ebola patients, provide safe and dignified
    burials, conduct extensive community outreach so that people
    have the information they need to keep their families and loved
    ones safe, and to help stand up command and control centers at
    both the national and county levels of the affected countries.
        At USAID, we have deployed our Disaster Assistance Response
    Teams through the region and now into Mali, and with that team,
    we are coordinating with the State Department, CDC, the
    Department of Defense (DOD), HHS, the U.S. Forest Service, the
    United Nations, and our many Non-governmental organization
    (NGO) partners to ensure that we are all working against a
    coordinated strategy.
        I was in Liberia in early October and, it really
    underscored--this is a country that is in the grip of a
    crippling rainy season, very poor infrastructure, what roads
    are there are usually impassable during the rainy season, and
    an absolutely destroyed health system. So, the response has
    been extraordinary. However, the U.S. Government moved in
    critical supplies. Personal Protective Equipment, all the
    suits, the plastic sheeting, thermometer guns, chlorine, these
    have all surged into the region along with labs to provide
    critical diagnostics, engineering, logistics, and transport
    capabilities. All of these have made a substantial difference.
    And, as the crisis evolves and the virus moves, we are adapting
    our strategy to have a highly mobile, very scalable strategy
    that allows us to go where the virus is.
        In Sierra Leone, we have worked with the United Kingdom to
    adapt the Liberia strategy to Sierra Leone and learn the
    lessons. We saw in Liberia that we are having a decrease in
    average reported cases and we believe that some of the rapid
    scale-up of particularly the burial teams and the health
    outreach has been critical.
        However, with the Mali cases, we are also seeing it is
    absolutely critical to invest in a stronger global health and
    preparedness system, and the USAID Emerging Pandemics Program
    has particularly focused in those areas where increased
    population pressures are increasing the chances of a jump from
    animal to human disease transition.
        We have worked with CDC and the World Health Organization
    (WHO) to develop the Public Health Emergency Framework that is
    making a difference, and we are already seeing a decrease in
    the number of countries that are affected by H5N1, for example.
        And, now that the Ebola virus has emerged, it is going to
    reoccur periodically, and that is why President Obama launched
    the Global Health Security Agenda (GHSA) in February 2014,
    acknowledging that we need a global effort to advance a world
    safe and secure from infectious diseases.
        The request from President Obama for $6.18 billion in
    emergency funding includes $1.98 billion of urgently needed
    resources for USAID to continue to scale up the activities to
    control the outbreak, to support a critical recovery in West
    Africa, and to strengthen the capacity to address these threats
    immediately. It includes $278 million in support of the Global
    Health Security Agenda and to expand our Emerging Pandemics
    Threat Program. This is essential. We cannot accelerate our
    efforts without this. And, without these funds, we will also be
    ill equipped to address crises around the world, as we have an
    unprecedented number of global crises.
        I want to close just with a very special salute to the many
    good samaritans who have responded, to the health care workers
    and humanitarian workers who are on the front lines with great
    courage and great dedication helping us to address this
    pandemic, and I look forward to your questions.
        Senator Coburn. Thank you. Dr. Lakey.

       TESTIMONY OF DAVID L. LAKEY, M.D.,\1\ COMMISSIONER, TEXAS
                  DEPARTMENT OF STATE HEALTH SERVICES

        Dr. Lakey. Thank you, sir. Good morning, Chairman Carper,
    Ranking Member Coburn, and Members. Thank you for the
    opportunity to be here today.
    ---------------------------------------------------------------------------
        \1\ The prepared statement of Mr. Lakey appears in the Appendix on
    page 89.
    ---------------------------------------------------------------------------
        I have been the Commissioner of the Department of State
    Health Services for about 8 years. October of this year has
    been one of my most challenging months as Commissioner of the
    Department of State Health Services.
        On September 30, 2014, the Texas State Public Health
    Laboratory, a laboratory that is part of the Laboratory
    Response Network (LRN) family of laboratories, diagnosed the
    first case of Ebola in the United States. The diagnosis of Mr.
    Duncan with Ebola set in motion a process that we in public
    health have refined through continued use, tried and true
    public health principles and protocols, which include
    identification of those who have had contact with an individual
    that is infected with a disease, monitoring those individuals,
    isolating and providing compassionate care to those
    individuals, and using quarantine when needed.
        The magnitude of the situation really was unprecedented. We
    at the Department of State Health Services, along with our
    colleagues in Dallas and at the Centers for Disease Control and
    Prevention, took the responsibility to contain the spread of
    this disease extremely seriously.
        We organized a local incident command structure (ICS) to
    handle the event, and at the State level, we activated our
    Emergency Response Management Centers. While the core mission
    was simple in concept, to protect the public's health by
    limiting the number of individuals exposed to the virus, the
    challenges associated with carrying out that mission were
    enormous.
        The care of Mr. Duncan presented its own challenges: The
    identification of the first person with a novel disease in the
    United States; infection control; the management of waste and
    its transportation; the availability of experimental treatments
    and vaccines; the training of health care workers in how to
    care for this novel disease; the availability and guidance on
    how to use Personal Protective Equipment.
        And, when Mr. Duncan regretfully passed away, we handled
    issues such as how do you take care of the remains of this
    individual, which the remains have highly infectious Ebola, and
    it can be in that body for many, many months. And,
    unfortunately, during the care of Mr. Duncan, two nurses became
    infected.
        Concerns related to the handling of the three Ebola
    patients include questions about how do you decontaminate the
    home and how do you take care of their automobiles, decisions
    about how to handle personal effects, the monitoring of pets,
    patient transportation issues, and addressing the public's
    concerns.
        Additionally, identifying and locating potential contacts
    and monitoring those individuals who have had some risk of
    exposure also involved many challenges: Decisions about who to
    quarantine and at what level, balancing the public's health and
    the individual's rights; providing accommodations for those
    confined in one location for the 21-day monitoring period;
    quickly processing these control orders, and coordinating two
    symptom checks a day for each person under monitoring; and
    managing and transportation and testing of the laboratory
    specimens.
        Throughout all these specific challenges, our experience in
    Dallas exemplified common requirements for successfully
    responding to any emergency situation, to have clear roles and
    responsibilities among all levels of government and all the
    entities that are involved, to have strong lines of
    communication, to use an incident command structure staffed by
    trained emergency management and public health professionals,
    and to do this in partnership.
        The outcomes in Dallas prove up the strengths of the public
    health processes. Hundreds of individuals were monitored in the
    State. Two cases of Ebola resulted from direct care of the
    index case, and they were detected early in the disease onset
    and they recovered. No cases resulted from community exposure.
        At this time, like other States, Texas is providing active
    monitoring for individuals who arrive in the United States from
    one of the outbreak countries. Texas has monitored
    approximately 80 individuals under this airport screening
    process. Texas is also, like other States, working to ensure
    that the capacity exists inside the State of Texas to care for
    patients with high consequence infectious diseases like Ebola.
    Two centers currently are able to stand up on short notice to
    receive a patient, and Texas is working to identify additional
    capacity.
        As Ebola screening and monitoring transitions into our
    routine processes, our focus in Texas is shifting to include
    complete evaluation of the response in Dallas and a discussion
    of how to improve the public health response system in Texas as
    a whole and sharing these experiences and lessons learned.
        Governor Perry has put together a Task Force for Infectious
    Disease Preparedness and Response to evaluate Texas's system
    and to make recommendations for improvement, and I believe the
    discussion among governmental and non-governmental individuals,
    among varied stakeholders, and including experts that are
    pertinent fields will result in a Texas that is better prepared
    and a Nation that is better prepared.
        We do not know what the next form or the next event will
    take. We do know that there will be another event. I tell my
    colleagues that it is my expectation to have at least one major
    disaster, one unthinkable event per year in the State of Texas,
    working with our national partners. That is why the funding
    that you provide to States through the CDC is so critically
    important, and that is why the need for strong partnerships
    between the local health departments, the CDC, and our many
    other Federal partners.
        Finally, I want to thank our colleagues at both the Dallas
    County Health Department and our Federal partners for their
    support throughout this event, and I thank you for the
    opportunity to be here today. Thank you, sir.
        Senator Coburn. Well, thank you for your testimony.
        A couple of questions. Just so I get this straight, our
    inbound screening right now, Mr. Kerlikowske, covers 95 percent
    of the inbound from these countries, is that correct?
        Mr. Kerlikowske. It is 100 percent of the screening for
    everyone passing through those four countries at only those
    five airports.
        Senator Coburn. I know, but those five airports account for
    only 95 percent.
        Mr. Kerlikowske. Everyone has to go through those five
    airports. We rerouted, working with the airlines authority.
        Senator Coburn. So, nobody goes into Houston and nobody
    goes into DFW anymore?
        Mr. Kerlikowske. Correct, Doctor.
        Senator Coburn. OK. Thank you.
        Can you all explain your interaction with the President's
    Czar on Ebola and what the coordination is and what the
    communication is so we can get an understanding? I had asked
    that he testify today. They refused to have him testify. So, I
    would just like to know, this is the person that is working
    under the President that is coordinating what he knows, and
    information is going up to him and coming back down to you. Can
    you all please explain to me what your interactions are with
    this individual, Mr. Klain?
        Dr. Frieden. Well, I would say that Mr. Klain plays the
    policy coordination role. The response to Ebola requires many
    parts of the government to work together, both on the domestic
    aspect and on the global aspect. I can say that I have very
    frequent communications with him on a daily basis, multiple
    times, and that he has been very supportive and very focused on
    problem solving and identifying what we can do to make the
    response quicker, more effective, and more unified.
        Senator Coburn. OK.
        Dr. Lurie. Sure. I think I would reiterate Dr. Frieden's
    comments. I think most of us had the opportunity to meet with
    Mr. Klain the day or the day after he took office. We have had
    within the Department a very tight coordination structure
    within HHS, and that coordination structure, even before his
    arrival, really reached parts of the whole of government,
    because there were many other departments, as you know,
    involved in this that we had frequent communication with all
    the time.
        Since his arrival, there has been a tremendous amount of
    coordination, collaboration, discussion, problem solving. I
    think we all talk with him frequently in small and large groups
    and we very much appreciated and see the benefits of his being
    there.
        Senator Coburn. OK.
        Ms. Lindborg. I would just add that a number of us are
    going from here to our weekly strategy session with Mr. Klain.
        Senator Coburn. All right.
        Mr. Kerlikowske. Many people within the Department of
    Homeland Security, and certainly Dr. Brinsfield and others and
    myself, have had interaction with him. Most of mine has been by
    e-mail or attending a particular meeting, because as you know,
    Doctor, we have a little bit narrower role in CBP.
        Senator Coburn. OK.
        Dr. Lakey. I have had two interactions with Mr. Klain. A
    week ago, we had a meeting of the folks that do my job across
    the Southern part of the United States and with some of our
    Federal partners, and in that meeting, we had a 30-minute
    conversation by phone with Mr. Klain. And then last night, I
    had the opportunity to spend about 30 minutes with him to
    express some of our challenges in the State of Texas.
        Senator Coburn. OK. All right. Thank you.
        On ASPR, the request for your portion of this is $2.43
    billion, is that correct?
        Dr. Lurie. For HHS.
        Senator Coburn. For HHS.
        Dr. Lurie. For HHS, yes.
        Senator Coburn. And, what percentage of that is for BARDA?
        Dr. Lurie. For BARDA, it is $157 million to continue the
    development of vaccines and other therapeutics.
        Senator Coburn. So, what is the other $1.9 billion for?
        Dr. Lurie. So, within ASPR, there is $166 million for other
    aspects of domestic response, including within the Hospital
    Preparedness Program to provide additional training, in
    particular, Personal Protective Equipment, through health care
    coalitions, and other drills and exercises, and there is
    funding to establish the capability to treat Ebola patients
    diffused throughout the United States.
        Senator Coburn. Just a question. Should the Federal
    Government be providing the protective equipment for the
    hospitals rather than the hospitals provide that, the insurance
    companies paying for that?
        Dr. Lurie. So, what we are finding is that for both
    hospitals and other health care institutions to be prepared,
    they do not always have either the kind of the amount of
    Personal Protective Equipment that is required to safely care
    for an Ebola patient. And, as I think you know, there has been
    a pretty big hue and cry for people who are seeking that
    equipment.
        One of the things that we have done with the Hospital
    Preparedness Program is really focus on preparedness at a
    community level instead of an individual hospital level, to be
    more efficient at sharing resources that are scarce.
        Senator Coburn. Right.
        Dr. Lurie. And, so, the funding would actually provide for
    purchasing of Personal Protective Equipment at a community
    level, in fact, to be efficient, so that not every hospital or
    doctor's office or anything else needs to stash a large amount
    of it but you have enough in the community.
        Senator Coburn. And we have coordinated with DuPont on the
    increased manufacture of this?
        Dr. Lurie. I have personally had the opportunity to speak
    with the leadership at each of the manufacturers of different
    kinds of Personal Protective Equipment. They are all now gone
    to 24/7 manufacturing. Some of them have made a decision to
    start with greenfields and stand up additional capacity for
    manufacture of other scarce PPE.
        Also, we are coordinating with the manufacturers and
    distributors, to be sure that hospitals that need it, hospitals
    that are ready, EMS agencies that need it can get it on a
    priority basis. We have coordinated a lot with the Strategic
    National Stockpile that has purchased additional PPE to be sure
    that if an institution receives an Ebola patient, that we can
    get them sufficient PPE within a matter of hours. That is in
    addition to the Rapid Team from CDC that would be on the
    ground. And, then, we have been coordinating with USAID and
    others because the PPE needs are not only domestic, but
    international, and we want to be sure that we do not compromise
    the response in West Africa.
        Senator Coburn. Why such a small amount at BARDA? They seem
    to have done such great work in the past.
        Dr. Lurie. Thank you. They have done great work and we have
    appreciated the advance of that, of $58 million in the CR so
    that they could get moving with the scale-up and manufacturing
    of, both of vaccines and the therapeutics. We think that this
    additional funding will help us both get to the point where the
    current vaccines that are in testing can be tested in clinical
    trials and then procured, I imagine by others, for use in West
    Africa if, in fact, the vaccine proves effective. And, because
    we never put all of our eggs in one basket, we have invested in
    the development of a couple of other vaccines----
        Senator Coburn. Right.
        Dr. Lurie [continuing]. As well as therapeutics to get
    those moving.
        Senator Coburn. I have one question and then I will pass it
    on. Tom or Gil, answer this for me. When I go home to Oklahoma,
    people ask me these common sense questions. Somebody comes into
    this country and lies about whether or not they have been in
    one of these three countries and is taking antipyretics. So,
    therefore, they have no fever, they have been dishonest about
    where they have been, and they come into our country. Why
    should we not worry about that?
        Mr. Kerlikowske. So, I think there are a couple things that
    are very helpful. One is that Customs and Border Protection
    officers go through a lot of training. They are in uniform.
    They have a badge. They are armed. They know how to ask
    questions. They know how to look for signs of deception.
        We have a huge amount of passenger information in that
    manifest, which we get quite early. We look for things,
    particularly if there is broken travel, and that was the case
    with Dr. Spencer. So, the fallback positions are when you go to
    that Customs authority and that person is sitting there in the
    booth, plus we have the roving patrols, that person is asking
    questions. He or she is looking at that passport to see where
    they are from. They are looking for the stamps from any of
    those now four countries and they are looking at the visa
    applications.
        So, could someone lie and essentially be deceptive? But, I
    think it is much more difficult when you are faced with that
    kind of onslaught of questioning and scrutiny that people need
    to go through in order to enter our country safely.
        Dr. Frieden. And, if I can add, in terms of taking an
    antipyretic or something else, if someone is tracked through
    the system, and we have now tracked more than 2,000 people
    through the system, we are then in close collaboration with CBP
    and DHS, providing the information to State health departments
    like Dr. Lakey's within just a few hours of their arrival. We
    also provide to the individual information about Ebola so that
    they will understand that if they do not get prompt care, not
    only may they die, but they may spread it to their family.
        Senator Coburn. Yes.
        Dr. Frieden. We are providing them with a low-cost
    thermometer and with a wallet card to call the health
    department so that if they develop a fever, they can be safely
    and securely moved to a facility where they can be safely
    treated. That system is already in operation. We have already
    had multiple individuals who have had fevers, none of them from
    Ebola, call and be safely transported and cared for.
        Senator Coburn. Tom, what do we know about the infectivity?
    We know in terms of body fluids. What do we know about
    temperature and infectivity? What is actually known? What is
    our science right now?
        Dr. Frieden. What we know is that as you get sicker and
    sicker with Ebola, the quantity of virus in your body increases
    dramatically, so that, generally, fever will be one of the
    first, if not the first, signs of illness. And, what we have
    seen in this country is people with very low-grade fevers--Dr.
    Spencer's was 100.3--and perhaps with the more intensive
    monitoring here, we are finding people with lower temperature
    levels. But, what we are finding in Africans consistently is
    over the course of the illness, infectivity kind of increases
    exponentially.
        And, just as an indication of that, when we do the initial
    real time polymerase chain reaction (PCR) test to see if
    someone has Ebola, it cannot infrequently be negative
    initially, not because there is a problem with the test, but
    because there is virtually no virus in the blood. Within 72
    hours, it will become positive both in the test and the
    individual will get sicker.
        Senator Coburn. OK. Thank you. Senator McCaskill.

                 OPENING STATEMENT OF SENATOR MCCASKILL

        Senator McCaskill. Dr. Lurie, I would like to talk about
    BioShield. BioShield was passed in 2004 to protect the United
    States against chemical, biological, radiological, and nuclear
    (CBRN) threats to national security. We have spent $3.3
    billion, and I am really worried about how it has been spent,
    especially in light of what we have seen with the Ebola crisis.
        Eight of the 13 BioShield contracts were signed in
    September 2013, the last month that the funds were available to
    spend. Five of those were related to anthrax. Obviously,
    BioShield is an organization that combines both DHS and HHS, as
    you are well aware, but I want to make sure the record is
    clear. I am asking you this because the Office of Science and
    Technology (S&T) is not here from DHS. So, you are going to get
    all of my attention this morning, but I want to make sure
    everyone understands that this is not just HHS that I think has
    made mistakes in this area. I think it is also the DHS Office
    of Science and Technology.
        You have produced material threat determinations for 21
    different chemical, biological, radiological, or nuclear
    agents. However, as of December 2013, you have contracts to
    procure countermeasures for only six of the 21 threats
    identified as high priorities. And, by the way, Ebola was
    identified as a material threat in 2006.
        So, since 2006, there have only been two material threat
    determinations issued. So, we have gone now years and years and
    years without any significant additional material threats. Does
    this mean that these decisions are being made on an almost
    decade-old analysis?
        Dr. Lurie. No, I appreciate very much your questions, and
    let me start by explaining a couple of things. First of all, I
    think when BARDA and BioShield were created, these were brand
    new systems and brand new programs, and I do not think that
    there is any question but that some of this got off to a rocky
    start. As I think you know, in 2010, after our experience with
    H1N1, the Secretary requested and we did an end-to-end review
    of the medical countermeasure enterprise and did a significant
    amount of retooling. We did this in concert with our colleagues
    at DHS and DOD and USDA, as well as all of the HHS components.
        And, I will say, we now have procured 12 medical
    countermeasures. They are in the stockpile. When BARDA and
    BioShield started, there was almost nothing in the pipeline.
    There are now about 90 chemical, biological, radiological, and
    nuclear products in the pipeline and another huge host for
    pandemic flu. So, I think from those perspectives, they have
    been tremendously effective.
        Two other things to keep in mind. One of the things that I
    did as Chair of the Public Health Emergency Medical
    Countermeasures Enterprise (PHEMCE), was to ask that we go back
    over looking at the set of processes that we use to make
    material threat determinations and to set requirements, and we
    have been working very closely with DHS to do that. It has
    borne a lot of fruit and we are continuing on that path.
        I think the other thing to keep in mind with regard to
    Project BioShield is Project BioShield itself cannot spend
    money on procurement until a product is far enough along in
    development to be within a certain amount of time--8 years--of
    being able to be licensed by the Food and Drug Administration
    (FDA).
        Senator McCaskill. Well, what about Abthrax?
        Dr. Lurie. What about what?
        Senator McCaskill. When you bought Abthrax, one of the
    multiple anthrax countermeasures you have bought, and when it
    was first looked at, it was a boutique product that the exact
    use of which was unclear. But, you spent $722 million on it. It
    was also an additional product beyond the vaccine and three
    antibiotics that we already had to treat anthrax.
        And, by the way, 44 percent of the money that has been
    spent in this program has been on anthrax. I mean, almost half.
    We have got 21 threats and almost half of the money has been
    spent on just one of them. How can that be justified?
        Dr. Lurie. So, let me, again, take a step back and make a
    couple of comments. First of all, DHS has continued to assess
    that the No. 1 threat in terms of biothreats to our country,
    other than those produced by Mother Nature, which are
    significant, is anthrax.
        Second, the anthrax products have been much further along
    in the stages of development and so those are the ones that
    have been first been ready for procurement.
        This past year or two, we have taken a look at all of our
    requirements again. We have also taken a really careful look at
    what is in the Strategic National Stockpile and we have done
    some adjustment, both based on the threat, based on what we
    know about the disease, based on what those countermeasures
    are.
        There is now a strategy, an implementation plan, that lays
    out for the next 5 years what it is that the PHEMCE will invest
    in and spend money on, and as we took a look at that, we,
    again, did some readjusting so that we were able to cover
    threat areas that were not covered well at the beginning of
    this program, including, by the way, viral hemorrhagic fevers.
        Senator McCaskill. Well, I understand that anthrax is a
    threat, although I am worried about the fact that a dose was
    $2.26 in 1999 and we issued a contract to procure doses for
    $24.50 6 years later. That worries me, that we are spending
    more than we need to on some of this and that we have done
    overkill on anthrax. But, anthrax does not spread. I mean,
    anthrax is not something that is highly contagious.
        I look at the way you develop what the threats are. I look
    at the way the money has been spent. All of us get suspicious
    around here when a bunch of contracts are signed the month
    before the money expires. It always makes us believe that
    someone is rushing to spend the money, because if they do not,
    they are not going to have it anymore, as opposed to
    judiciously looking as to whether or not they are just buying
    what is available and easy as opposed to doing the hard work of
    figuring out whether we have put too many eggs in the basket of
    anthrax and not enough in the basket of highly contagious
    diseases like the pandemic flu or others that have been
    identified as material threats for years and years and years,
    including Ebola.
        Dr. Lurie. I appreciate your concerns, and that is, in
    fact, why we have been making so many adjustments in the
    program. In addition, we have been very much trying to move
    away from this idea of ``one bug, one drug,'' and moving much
    more toward the development of platform technologies that are
    nimble and flexible and, in fact, when confronted with a new
    disease like Ebola, can make either vaccines or other
    countermeasures much more quickly. And, in fact, it is those
    flexible platforms that you are seeing now in the development
    of the Ebola therapeutics.
        So, we have shifted considerably in this program since
    1999. We have certainly shifted considerably since 2006. And,
    since the review in 2010, I think we have been on a really
    terrific path targeting----
        Senator McCaskill. Well, the 2013 contracts do not indicate
    that. It still indicates a huge proclivity toward anthrax and
    anthrax domination in terms of this. The frustrating part from
    here is that this program was supposed to be identifying things
    like Ebola so that we are not rushing to fund after a crisis,
    but, rather, prepared when the crisis occurs. It looks like
    there was a rush to spend before the funds expired, but not a
    rush to truly identify additional threats that had developed
    and the severity of some of the threats that have not been
    addressed.
        So, I am going to continue to follow up on this. As I say,
    S&T deserves a lot of these questions, and, hopefully, we will
    have other hearings in the next Congress that we can get to
    this. The fact that this happened in 2013 kind of swims
    upstream against your argument that everything has been
    retooled.
        Dr. Lurie. We look forward to coming and briefing you and
    updating you about the program and where it has been.
        Senator McCaskill. Thank you.
        Senator Coburn. Perhaps it would be great to have a
    Subcommittee hearing just on this.
        Senator McCaskill. As do I----
        Senator Coburn. Yes. Also, could we have a direct answer on
    the differences in the cost of ciprofloxacin, which originally
    was purchased and why the differential in the price? I would
    like to know why we are paying such an exorbitant amount for
    the same drug to treat the same thing. So, can we have an
    answer, a written answer from you back on that contract and why
    we are paying those kind of prices?
        Dr. Lurie. Absolutely.
        Senator Coburn. Thank you.
        The Senator from Wisconsin.

                  OPENING STATEMENT OF SENATOR JOHNSON

        Senator Johnson. Dr. Lakey, have you in Texas put any kind
    of cost estimate on what it did cost your public health system
    to treat those three patients?
        Dr. Lakey. I can partially answer that question. If I look
    at the cost that we incurred as a State agency, including time
    of my staff, the cost to do the decontamination, waste, the
    control, transportation, et cetera, that is about a million
    dollars. The monitoring of the individuals that have come back
    from overseas, that cost right now is a little shy of $20,000
    right now. The costs that Presbyterian incurred, I cannot tell
    you what that number is.
        Senator Johnson. OK. But, the cost has been over a million
    dollars for a couple patients.
        Dr. Lakey. Yes.
        Senator Johnson. Dr. Frieden, do you have any cost estimate
    of what it cost to cure some of these heroes? I mean, what does
    it cost?
        Dr. Frieden. The care of patients with Ebola can be quite
    expensive because it requires intensive care. It needs to be
    done in a place where you may have to actually not admit other
    patients----
        Senator Johnson. Do you have a number, though? I have
    limited time.
        Dr. Frieden. No, nothing other than what I have read in the
    media.
        Senator Johnson. Hundreds of thousands or millions of
    dollars per case, correct? In terms of the incubation period,
    at what point--how many days does it take to exhibit a fever?
        Dr. Frieden. The incubation period is between 2 and 21 days
    after exposure until illness, usually around 8 to 10, or 12
    days.
        Senator Johnson. So, in general, somebody could be infected
    and then really not exhibit any signs of illness or fever for
    about 8 days?
        Dr. Frieden. That is correct.
        Senator Johnson. That is a real possibility. What are the
    current projections in terms of this outbreak as it progresses?
    Right now, I have about 14,000 cases in my briefing packet
    here. I do not know how many there were when we first admitted
    Mr. Duncan. What are we looking at 2, 3, 4 months down the
    road, because we have some pretty scary numbers.
        Dr. Frieden. That will depend entirely on our response and
    how rapidly we intervene. Currently, we think there may be
    between 1,000 and 2,000 new cases per week in West Africa, but
    we have seen areas of West Africa achieve very rapid reductions
    when they implement the comprehensive strategy such as that
    that we would be able to support through the emergency funding
    request.
        Senator Johnson. So, we had heard estimates of this thing
    growing exponentially to over a million people by 2015. Are we
    past that point? Are we getting a handle on this that we are
    not looking at that kind of exponential growth?
        Dr. Frieden. In Liberia, we are no longer seeing
    exponential growth. I think that is a reflection of the proof
    of principle of the strategy. However, we are still seeing
    growth in Sierra Leone, and Guinea is a cautionary note because
    we have seen it come and go in waves whenever we have relaxed
    our efforts.
        Senator Johnson. So, it still is possible to have tens of
    thousands, hundreds of thousands of cases with this current
    situation?
        Dr. Frieden. We do not think the projections from over the
    summer will come to pass. Those were projections of what would
    have happened if prior trends continued with no intervention.
    There has been very effective intervention with USAID,
    ourselves, the global community, and most importantly, the
    countries and the communities most affected.
        Senator Johnson. OK. Well, that is good news. My point
    being, if this really does grow either exponentially or
    geometrically, we are going to have a whole lot more cases
    throughout the world, in West Africa. When we had about 10,000
    or 12,000 cases, one individual got into this country, and we
    are seeing the cost of just treating one or two cases in the
    millions of dollars. I do not know how many cases of Ebola
    would utterly overwhelm our health care system.
        So, from my standpoint, I think the goal we should really
    have would be to keep Ebola out of the United States. Now, we
    obviously have to treat these heroes, these health care workers
    that are going down there, and nobody is talking about
    isolating West African nations, but we really ought to set as
    an achievable goal, let us not let it spread out of there. Let
    us keep it in West Africa.
        So, Mr. Kerlikowske, through our Customs and Border
    Protection process here, through the airlines, we cannot
    identify 100 percent of people that had been in West Africa in
    the last 21 days, correct?
        Mr. Kerlikowske. Probably not identify 100 percent, but we
    have come very close. We look for all the things----
        Senator Johnson. Well, why would it not be 100 percent,
    because you have to fly here, right, I mean, and people have to
    have passports and those things are stamped. Why can it not be
    100 percent?
        Mr. Kerlikowske. Well, there are people that can use broken
    travel, and that is why we have those secondary layered
    approach of looking for stamps, looking at their passport,
    asking them questions, what other countries they have traveled
    in.
        Senator Johnson. But, again, people will lie, so we have to
    rely on documents and thorough evaluation of those documents to
    try and protect people from coming here, correct?
        Mr. Kerlikowske. Yes.
        Senator Johnson. So, I was a little surprised at your
    answer to Senator Coburn. You said that we are funneling 100
    percent of people into those five--because it did not sound
    like that from your testimony.
        Mr. Kerlikowske. Well, he was specific about the people
    coming into the airports that we have that information on, and
    that is why in my opening statement I also mentioned that all
    of our ports, including sea and land ports, also have the
    information and also have the ability to do any screening.
        Senator Johnson. So, my point being is if we can screen,
    using passports, using stamps, understanding that people, when
    they were in West Africa, at a pretty high percentage, 95 to
    100 percent, in light of the fact that treating just one case
    of Ebola could be more than a million dollars, why would we not
    set the achievable goal of saying, let us not let people into
    America other than the health care workers? Why not control
    that and let the world know that you are not going to come into
    America until you have been out of West Africa for at least 21
    days? I mean, would that not be a reasonable restriction so
    that we do not overwhelm our health care system? Why would we
    not do that?
        Mr. Kerlikowske. So, Senator Johnson, I do not think I am
    probably the best person to answer that from that medical
    viewpoint, but I do know a couple things that have been
    expressed, and one is that when we do a level of restriction
    and isolate those three particular countries, other countries
    may follow.
        Senator Johnson. They already are doing that, are they not?
        Mr. Kerlikowske. Other countries could follow our lead.
        Senator Johnson. Let me just interrupt. Would that not be a
    good thing? Why would we want it to spread out of those three
    countries into any other country? Why do we not have a world
    effort to keep the disease in those three countries, flood
    resources, flood heroes to treat them, but why are we not
    really taking a look at let us keep it isolated in those three
    countries? It makes no sense to me. I do not think it makes
    sense to the American public that we do not really double our
    efforts to keep it contained in those countries and get it
    stamped out in those countries, do not let it spread.
        Mr. Kerlikowske. Well, restricting or isolating those
    countries, I do not think, and has been explained to me, would
    be the best answer. The other is that I think it could drive
    people underground. You could easily leave any of those three
    countries without getting on an airplane and easily go
    somewhere else and surreptitiously or through deceit attempt
    then to enter the United States.
        Senator Johnson. But why make it easier? I am out of time.
    Thank you.
        Senator Coburn. Senator Ayotte.

                  OPENING STATEMENT OF SENATOR AYOTTE

        Senator Ayotte. I want to thank the Chair.
        I want to thank all of you for what you are doing. This is
    very important to the country.
        I want to also thank two of my constituents, Brigadier
    General Peter Corey, who is Deputy Commander of U.S. Army in
    Africa, who was deployed to Liberia in September and is helping
    to lead the U.S. military effort to halt the spread of Ebola in
    Africa. I know General Corey personally and I really appreciate
    his leadership. Also, our State Deputy Epidemiologist, Dr.
    Elizabeth Talbot, who is helping train humanitarian workers in
    Africa. I want to thank everyone who is trying and working very
    hard to combat Ebola and the spread of this deadly disease.
        I wanted to follow up on the issue--Dartmouth Hitchcock in
    New Hampshire has been designated as a location where, if we
    were to receive an Ebola patient in New Hampshire, it would be
    our designated health facility. They have raised issues with me
    about the Personal Protective Equipment that Senator Coburn had
    asked about including concerns about not having access to that
    protective equipment if they were to receive a patient now.
    They also want to ensure that they train properly and prepare,
    should they receive a patient.
        So, I know that we have discussed some of the manufacturing
    challenges, to some extent, of the availability of this
    equipment, but I wanted to delve into that a little bit further
    to understand if there are hospitals like the one in my State
    that are not able to have this protective equipment. What are
    they supposed to do in the interim?
        Dr. Lurie. I appreciate your question. I think it is a very
    good one and it is one that we have heard about from other
    places. So, let me line a couple of things.
        First of all, as I think you know, when a hospital
    determines that it might want to be in a position to treat
    Ebola patients and the State health officer agrees, one of the
    first things that happens is that they receive a checklist of
    things to start getting ready for, and when they feel that they
    are ready for a visit, the CDC will send out a Rapid Ebola
    Preparedness Team to do an assessment with them.
        Senator Ayotte. Mm-hmm.
        Dr. Lurie. One of the things, ultimately, on that list that
    is required for them to be ready is to have a 7-day supply of
    Personal Protective Equipment on hand. We have been working,
    obviously, with CDC, with the States, with the hospitals, and
    if a hospital would like us to, we are in a position to give
    the name of that institution to the manufacturers and
    distributors of PPE so, in fact, they can be on a priority list
    to get what it is that they need, both to get ready and in the
    event that they have a patient.
        As I indicated in my previous answer, the Strategic
    National Stockpile at the CDC has also bought Personal
    Protective Equipment, and in the event that a hospital were to
    receive a patient, they would, if needed, send additional PPE
    to that hospital.
        One of the things that the manufacturers and distributors
    have told us--and we have been working quite a bit with them--
    is that for hospitals that want to train on equipment, that
    they will actually come out to a hospital with training
    equipment, not the stuff that is in short supply. The front-
    line health workers who would be in a position to need to use
    that equipment can practice and can drill and can be ready for
    that.
        They have also told us, interestingly, that it is their
    perspective that many hospitals, because they are frightened,
    have been double and triple ordering equipment from various
    distributors and manufacturers. And, so, one of the things that
    we have been doing is working with front-line health workers
    all over the country to be clear about two points, No. 1, there
    are options on what you can buy, and that is in the CDC
    guidance, and No. 2, get a little clearer about, really, who
    needs what and how much you need so that we can cut down on the
    fear and the panic and be sure equipment gets to those who need
    it.
        Senator Ayotte. I appreciate that, and I think there needs
    to be, perhaps, better communication, because this is an issue
    where, Dartmouth Hitchcock, which is a great hospital in New
    Hampshire, and part of a research facility connected with
    Dartmouth College--probably needs increased communication on
    this issue so that there is a better understanding from the
    hospitals' perspective. So, I hope that will follow from this.
        I wanted to followup, Mr. Kerlikowske, in terms of what
    Senator Johnson had asked you about. As I understand it, there
    have been other countries that have restricted travel in terms
    of the West African nations. Do you have a sense of what some
    of our partners have done in that regard and what their
    thinking is?
        Mr. Kerlikowske. Senator, the only country I know that has
    restricted travel has been Canada, and I am actually a little
    bit unsure as to what they actually have decided. As you know,
    from any of those four countries, there are no direct flights
    into the United States, so everybody leaving those four
    countries goes to Morocco, to France, to Belgium, et cetera,
    and they all fly into those countries.
        Senator Ayotte. So, Canada is the only country? So, I would
    think we would want to followup and understand, since they are
    such an important ally and, our neighbor--what their thinking
    was versus our difference in policy on that issue. I hope we
    will do that.
        Mr. Kerlikowske. We will.
        Senator Ayotte. I appreciate that.
        I also wanted to ask about some of the agreements that are
    in place, regarding the intake at the airports where the
    enhanced screening is taking place. Are there already
    established areas of quarantine, if that is necessary, in those
    airports?
        Mr. Kerlikowske. All of those airports already have CDC
    personnel that have been there for many years, and at first--
    and I have to give a shout out to the United States Coast
    Guard, who actually stepped up with medical corpsmen before our
    contracts went into place, with Emergency Medical Technicians
    (EMT) and other local health care people to do the temperature
    screening. So, it has been a really good effort. And, of
    course, the key has been the relationships that our port
    directors have with those airports, with the CDC and others,
    who have all worked together.
        Senator Ayotte. So, my time is expiring but I had a
    specific question as to whether there are actual agreements
    between the five airports and the area hospitals. In other
    words, do we have direct memorandum of understanding (MOU) so
    there is clarity if we do have to act?
        Dr. Frieden. We have a detailed planning process so that
    for each of the five entry airports we have hospitals on the
    ready that we have visited with our Rapid Ebola Preparedness
    Teams that we have ensured are ready, and we have a mechanism
    to transport patients safely. So, for all of those, we have
    procedures in place that would allow us to do that. We have had
    a handful of people with fever or other symptoms coming in.
    They have been safely transported. None of them have turned out
    to have Ebola on the way in, but that is something that we have
    made sure is in place to the greatest extent possible.
        Senator Ayotte. Thank you.
        Senator Coburn. Senator Portman.

                  OPENING STATEMENT OF SENATOR PORTMAN

        Senator Portman. Thank you, and I thank you all for not
    just being here today with us, but for the work you are doing
    every day to try to address this problem.
        As some of you know, I have been critical of the response,
    mostly the timeliness of it, and I think it took us way too
    long to get a coordinator and I think it took us way too long
    to respond to the World Health Organization's very clear
    message to the world that this was going to be a crisis, and so
    we are behind. And, particularly in these countries and in West
    Africa, it is now much more difficult to address the issue.
        I do continue to have concerns, as I expressed to Mr.
    Kerlikowske, as you know, early on about more screenings. I
    viewed active screenings as being necessary. You now have them,
    I think, at five of the airports, and I am glad we have that
    now. I think it could have avoided some of the problems that we
    have had in this country.
        I will say in response to your question to Senator Ayotte,
    there are a lot of countries that have suspended visas. We have
    not. I think there are 40. So, short of a travel ban, doing
    some things to, as many African countries have done, to
    discourage people from leaving these countries at this point. A
    temporary suspension until we get our act together, I think,
    makes sense.
        But, if I could switch to the hospital side for a moment,
    and again thanking you for the actions that have been taken
    more recently and some of the work, including the President's
    funding request, you have $166 million in there for public
    health and social service emergency fund to immediately respond
    to patients with high infectious diseases. That $166 million, I
    would like to ask you about for a second, and I am not sure who
    to direct this to, probably you, Dr. Frieden, from the CDC
    perspective.
        But, as you know, in our State of Ohio, we were one of
    those States that was affected. We have over 100 individuals
    who were possibly exposed to Ebola, and because of this,
    hospitals around the State of Ohio rapidly prepared for the
    possibility of an individual coming through their doors.
    Fortunately, that has not been the problem that many had
    feared. But, my question for you is, will any of this $166
    million for emergency funding be allocated to those hospitals
    to help offset the costs of the preparedness efforts,
    particularly those in Northeast Ohio, in our case, but also in
    Texas and elsewhere who had to quickly respond to the concerns
    of those who had been affected?
        Dr. Frieden. So, I will start, and Dr. Lurie may want to
    comment further because hospital preparedness is a joint effort
    between CDC and ASPR.
        Also, on timeliness, I would comment that CDC was on the
    ground in West Africa sending staff in March of this year, and
    again, we activated our emergency operations center in early
    July of this year. So, we are surging as quickly as we can and
    working throughout the U.S. Government and in the global
    community to respond. The emergency funding request is critical
    to our ability to continue to do that and extend that.
        For hospitals, we see this as critically important, both to
    support State and local health departments so that they can
    have a community-wide approach of improving infection control
    and addressing Ebola and other severe infectious disease
    threats and hospital preparedness, ensuring that they are ready
    and improving their infection control program. CDC has had
    highly effective programs through State health departments to
    improve infection control in hospitals, and one of the things
    that we would do with the emergency funding request is extend
    that and expand the support available to hospitals and to
    public health to improve infection control.
        Senator Portman. Just quickly, would any of these funds be
    available for the hospitals that I talked about that had to
    quickly prepare?
        Dr. Frieden. In terms of the reimbursement for past
    expenditures up until now, that is something which the
    Administration has indicated it is quite willing to work out
    wording with Congress on.
        Senator Portman. Let me switch to, if I could, these
    hospitals, following on what, again, Senator Ayotte talked
    about, in her case with Dartmouth Hitchcock. As you probably
    know, I am introducing legislation today with Mr. Markey, and
    Senator Markey and I have been working on this for the last
    several weeks about ensuring that some hospitals on a regional
    basis have this expertise. We call it Centers of Excellence. We
    base it on the 10 Medicare regions around the country.
        The legislation, which we worked with some of your folks on
    to ensure that it met the criteria that you might be looking
    for, would ensure that you have certain hospitals that do have
    not just the medical expertise, but the equipment to be able to
    respond, and not just to Ebola, but to other infectious
    diseases. It seems to me that is a much more efficient way to
    do it than to have every hospital in America be expected to
    have that expertise, and even to have the isolation rooms and
    the other necessary equipment. So, have you all thought about
    that issue further, and what would your response be to that
    kind of legislation?
        Dr. Frieden. Let me start, and then Dr. Lurie has important
    information to add. One of the components of our domestic ask
    within the $621 million for the immediate part of the emergency
    response would be to expand programs like Prevention
    Epicenters, which we have had around the country, so that we
    can advance the science and preparedness in different regions
    of the country. It is, however, the case that every hospital
    needs to consider that someone might come in and have that
    thought through and that each State needs to work. We have
    worked very closely with public health and hospitals in Ohio.
    We have had visits to the hospitals to help them through our
    Rapid Ebola Preparedness teams, and Dr. Lurie can address the
    other hospital-based issues.
        Dr. Lurie. Sure, and maybe I will just, to amplify on Dr.
    Frieden's comments here, our strategy for getting hospitals
    ready has been to build from the three biocontainment units
    that now exist at the National Institutes of Health (NIH),
    Nebraska, and Emory to be sure, first of all, that hospitals in
    those airport funneling cities are the first group that are
    prepared with training, with identified staff, with Personal
    Protective Equipment, with the physical infrastructure in
    place.
        Building out from there, we are now working in States that
    receive large numbers of travelers back from West Africa or
    have large diaspora populations, and those are the States that
    we are now actively working to identify hospitals in, again, so
    that they can be prepared should an Ebola patient present in
    their State and need end-to-end care.
        One of the things about this, though, is we are not
    entirely sure, No. 1, whether and where one of these patients
    would show up, and No. 2, I think one of the things that Ebola
    has shown us very clearly is Mother Nature always has the upper
    hand and that there will be diseases after this for which we
    need to be prepared with high containment facilities and
    training and equipment. We do not know where that is going to
    strike, but it is clear to us that an additional component of
    our preparedness has to be to build out that capability. No,
    not every hospital in America needs to or could take care of
    patients that are this sick or are this contagious, but we do
    need to have capability across the Nation to be able to do
    that.
        Chairman Carper [presiding]. Dr. Lurie, I am going to ask
    you to hold it right there, before Dr. Coburn leaves. I do not
    know if it was my last year in the U.S. House of
    Representatives, but I had served in the U.S. House for a
    number of years. Maybe you remember Bob Michel. He had been the
    Republican Leader in the House for many years. Tip O'Neill was
    then the Speaker of the House. And, Bob Michel had never had a
    chance to--all those years in the House, he never had a chance
    to preside over the House, and he had served there for, like,
    several decades.
        Tom Coburn has presided many times over Subcommittee
    hearings, but in the 2-years that we have been privileged to
    lead this Committee together, I do not believe, and although we
    have taken a couple of times when I run off to take a call or
    something and he is good enough to take over and run the show.
    But, I just want to say, as he prepares to weigh anchor, as we
    say in the Navy, weigh anchor and sail off into the sunrise,
    how much I appreciate the partnership that we have known for
    these 10 years and to say we have a lot to be proud of in this
    Committee this year. We have a lot more that we are working on
    and trying to get across the finish line. I want us to finish
    strong, and we are. Thank you, Tom.
        Senator Coburn. Thank you.
        Senator Portman. My time was already expired, so he is
    indulging me, and I will be very brief, but just to say, first
    of all, thank you for the way you conducted this Subcommittee,
    my Subcommittees and the full Committee, Mr. Chairman, and the
    same with our Ranking Member. You are nice to give him the
    proper farewell.
        In 2013, we passed this Preparedness Reauthorization Act
    and we spent $255 million in grants in fiscal year 2014 and yet
    we found significant gaps, obviously, in our ability to
    respond. And, so, I am not disagreeing with what you said. As a
    matter of fact, I think what you said is consistent with what
    Senator Markey and I are trying to get at, which is the fact,
    of course, as Dr. Frieden says, every hospital has to be
    prepared for people to come through their doors. Every clinic
    does. You have done a good job, I think, in making them more
    aware, because in my home State of Ohio, as I have talked to
    people, they now ask the questions, have you been to West
    Africa and so on, that they never would have thought about
    before.
        But, to have that expertise, as you say, is impractical at
    every hospital and every clinic, and that level of commitment
    of resources for the containment and isolation and so on. So, I
    hope you will look at this legislation and be willing to work
    with us to try to figure out the most effective and efficient
    way to deal with potential problems in the future.
        Thank you, Mr. Chairman.
        Dr. Lurie. That is one of the things that I think we have
    always appreciated, is the bipartisan spirit around
    preparedness. It has been really important, and I think
    everybody really understands that that is something important
    to our country and that we all take really seriously. And, we
    all understand a chain is as strong as its weakest link.
        Chairman Carper. Senator Baldwin, good morning.

                  OPENING STATEMENT OF SENATOR BALDWIN

        Senator Baldwin. Good morning. Thank you for holding this
    vital hearing and I will tell Senator Coburn later that I
    appreciate it. Thank you to all our witnesses.
        I want to inquire and get an update on maintaining a
    resolute response in West Africa on Ebola. I think there is
    growing consensus that in order to safeguard the United States,
    we have to take the fight there. And, I am interested in
    hearing an update from you, Dr. Frieden, but also from Ms.
    Lindborg on secondary impacts, economic impacts that we are
    seeing in the region that could also lead to chaos or
    additional economic crisis.
        We had a time for which we could receive information 24/7
    on Ebola. It has subsided a bit, and with that media spotlight
    only slightly diminished, I would like to hear directly from
    you, starting with you, Dr. Frieden.
        Dr. Frieden. Thank you. I will address the epidemic and
    Nancy Lindborg the secondary effects.
        We continue to be in the midst of an epidemic of Ebola in
    West Africa. The three countries are hard hit. The most cases
    are still in Sierra Leone and Liberia. We are seeing it through
    many parts of each of those countries. In Liberia, it is in at
    least 13 out of the 15 counties. We continue to have diagnosed
    roughly a thousand--and reported--roughly a thousand cases per
    week. We think there may be as many as twice that many in the
    region overall per week.
        We have, however, seen proof of principle that it can be
    controlled in individual communities, but we have also seen
    from Guinea that it comes back any time we let up our guard. We
    are also now surging to assist the Malian government in
    responding to the cluster there. There are already multiple
    cases from both household transmission and health care
    transmission.
        So, what we are going to have to do over the next period is
    be ready for a long, hard fight against Ebola. We are going to
    have to trace every single chain of transmission, identify the
    contacts, rapidly isolate them, and do what we know works in
    Ebola very well in very many different places. That way, we can
    stop it from spreading. But, there is the risk that if we fail
    to do that, if we do not have the resources through the
    emergency funding request, if we cannot accelerate our control
    efforts, it could spread to other countries in the region and
    it could become a threat for years to come.
        Senator Baldwin. Ms. Lindborg, in the last hearing that I
    attended on this issue in, I think it was late September, one
    of our witnesses who was visiting from Sierra Leone talked
    about the economic impacts, hotels with nobody traveling for
    tourism, even business reasons, laying off their entire work
    force, schools being closed for public health reasons, so
    teachers are not drawing salaries. That has to have an
    incredible ripple effect. I am wondering how it is impacting
    issues like hunger and food security, and please tell us what
    our efforts are in that regard.
        Ms. Lindborg. Sure, and thank you very much for the
    question. Even as we maintain a very high tempo and rapid
    response to controlling the outbreak, which has to be an
    ongoing priority, as Dr. Frieden has said, and we have a very
    aggressive all of government effort working through the region
    to do that, at the same time, these were weak economies to
    begin with and we are seeing that the disease has further
    devastated food security systems, health systems. And, so, on
    top of the virus, we have health and food crises.
        We are working rapidly to look at food security solutions
    and we want to do so in a way that both meets immediate needs,
    but is sensitive to rebuilding the markets. What we are finding
    is that many communities are affected not by the disease at
    all, but by the secondary effects of closed markets, missed
    planting, inability to travel about. And, so, you have
    communities that are in a very precarious situation without
    livelihoods, particularly women farmers throughout the region
    as they are unable to access seeds, they are unable to do the
    planting, they are unable to get to markets.
        So, that is a significant effort, and in the emergency
    funding request, we do have critical funding not just to
    continue and accelerate the response, but also to meet food
    security needs as well as strengthening and restarting,
    essentially, the health system for non-Ebola health threats. We
    are seeing that the vaccination rates for measles in these
    countries is dropping to precipitously low rates. Women are no
    longer having access to assistance at childbirth. A whole host
    of diseases that were starting to get under control in these
    fragile States are slipping back. So, we have a significant
    effort to go in alongside the response to this virus and
    rebuild those systems and underscore those issues.
        I want to also add that we are seeing in other parts of the
    world the importance and the positive impact of the
    preparedness agenda, and as we look at DR Congo and Uganda,
    they have both had Ebola and Marburg outbreaks in the last few
    months. Because of the important work that USAID, CDC, WHO has
    done in the past several years, those outbreaks were contained.
    They did not spread. They did not have this devastating impact.
    So, just to underscore the preparedness, it is critical around
    the world as we look at the need for strengthened global health
    security.
        Senator Baldwin. If I have time to put in one more
    question, I want to observe that during the time that this
    really was 24/7 in the media, there was misinformation as well
    as accurate information that was dispensed at that time. And,
    we have seen in prior epidemics the potential for the real
    medical epidemic and the epidemic of fear circulating amongst
    people. Tell me the components that you are looking at to make
    sure that there is constant accurate public information
    available for people who are anxious, have questions, need real
    information, both in the public health and medical community,
    but at the general public level, too.
        Dr. Frieden. We are committed to providing the most up-to-
    date and accurate information that is available as promptly and
    effectively and in as plain language as possible, and we do
    that through multiple means. We do that through communication
    with the health professionals, through our Health Alert Network
    (HAN), through our website and other measures, through a series
    of webinars that we have had with other parts of HHS, in-person
    meetings and briefings, and we do that through a partnership
    with the media to convey the information on how Ebola spreads
    from everything that we know and how it does not spread and
    what really is most important to stop the outbreak and protect
    Americans, and getting back to the, I think, sometimes
    challenging but fundamental truth that we cannot make the risk
    zero in this country until we stop it in West Africa.
        Chairman Carper. From one side of Wisconsin to another.
    Senator Johnson, please.
        Senator Johnson. Thank you Mr. Chairman. Dr. Lurie, you are
    with HHS. You are looking for about $3 billion of funding. How
    detailed is that request? I have a sheet here. We have about
    five different areas. I mean, how have you drilled down and
    just really detailed out that budget request? And, if you have
    it in much greater detail, can you provide that just for my
    staff? I mean, is this pages and pages of detail, or is this a
    couple categories and we were kind of estimating we were going
    to throw a half-million here, half-billion there?
        Dr. Lurie. Well, I have a couple pages even here of top-
    line issues, and we would be more than happy to provide it to
    your staff. I think we have really gone through it really very
    carefully, largely because we all appreciate the need to both
    respond to this epidemic with urgency and speed, but also
    really be responsible stewards of our society's resources.
        Senator Johnson. Great. So, being an accountant, I would
    like that detail. And, Ms. Lindborg, the same from USAID and
    the State Department. It looks like it is about $2 billion.
        A question I do have is I know we are sending, what, about
    4,000 of our military personnel there. I see very little in
    terms of funding from the military. Who can really speak to the
    military's role in West Africa?
        Ms. Lindborg. I can do that. They have funding that they
    reprogrammed from last year that they notified and got approval
    to spend about $750 million. That is separate from this.
    President Obama mobilized the military to be a part of the
    response in mid-September when it became clear that the scale
    and size and the complexity really needed the unique
    capabilities of the U.S. military.
        Senator Johnson. So, do you know how much the military will
    spend on their efforts? Any estimate?
        Ms. Lindborg. I do not know that we have that final, but
    they expect to be within that envelope.
        Senator Johnson. I believe in your testimony, you were
    talking about what the role of the military would be. Can you
    describe that----
        Ms. Lindborg. Yes.
        Senator Johnson [continuing]. In greater detail?
        Ms. Lindborg. Yes. So, they have played a critical role of,
    first of all, providing engineering and logistics capabilities.
    They built a 25-bed medical unit in Monrovia that is
    specifically for health care workers.
        Senator Johnson. OK.
        Ms. Lindborg. They have provided engineering capabilities
    and have built or, will build a total of 10 Ebola treatment
    units (ETUs).
        Senator Johnson. And, how many beds in each one of those
    treatment units?
        Ms. Lindborg. So, each of these are built initially--the
    plan is that they are built for about 10 to 20 initially with
    the possibility to scale up to 100. This is part of the need to
    be very modular.
        Senator Johnson. Are they on the ground now? Do we have
    4,000 members of the military in West Africa?
        Ms. Lindborg. No. They do not currently anticipate that
    they will need all 4,000----
        Senator Johnson. How many are on the ground right now, and
    in which countries?
        Ms. Lindborg. They are in Senegal and Liberia, and the
    exact figure changes because they flow capabilities in and out,
    and we can get you that----
        Senator Johnson. So, nobody in Guinea? Nobody in Sierra
    Leone?
        Ms. Lindborg. Correct.
        Senator Johnson. Are they going to be coming in contact,
    because I thought you said----
        Ms. Lindborg. No.
        Senator Johnson. I thought you said something about
    treatment of patients. I misheard that?
        Ms. Lindborg. We are supporting the treatment--USAID is
    funding the partners who are providing the management and the
    treatment inside the Ebola treatment units. Army personnel, or
    military personnel will not come into any contact with what we
    call hot zones.
        Senator Johnson. Who is planning the foreign medical worker
    plan, the logistics of that? How many medical professionals
    need to be surged into there, and is it on a rotating basis, 30
    days--I mean, can anybody speak to that plan?
        Ms. Lindborg. Yes. So, you are exactly right. There is an
    enormous need for a pipeline of trained and equipped health
    care workers. This has been one of the logistical challenges.
    In addition to the medical unit that provides the confidence
    for health care workers, that if they come in, they will get
    that American standard treatment, and that is for both Liberian
    and international health care workers, the military, U.S.
    military, has also stood up a training facility so that it can
    train up to 500 health care workers a week so they have that
    special training----
        Senator Johnson. In those countries?
        Ms. Lindborg. In those countries.
        Senator Johnson. OK.
        Ms. Lindborg. It is in Monrovia and outside of Monrovia. We
    work very closely with WHO, who runs a foreign medical team
    coordinating center, and those teams get deployed against the
    needs within these Ebola treatment units. Very importantly, the
    U.S. military is also helping with some of the critical
    transport of commodities and personnel. There is a base in
    Senegal that enables them to move from Senegal through the
    region with transport.
        Senator Johnson. OK. Dr. Frieden, just for my last couple
    minutes here, I really want to ask some of those common sense
    questions that people just have on their minds. If we can get
    the answers to them, maybe we can alleviate some of the fears.
        I know protocol was not, apparently, followed, but just
    specifically, how did those two nurses catch Ebola? Did they
    simply not have proper clothing? I mean, was their skin
    exposed? I mean, were they in just at the very height of Mr.
    Duncan's illness and all kinds of medical waste and fluids and
    stuff? Can you tell us what happened there?
        Dr. Frieden. We do not know definitively how the infections
    occurred. We believe from the investigation and the evidence
    that it is likely that they were infected actually prior to Mr.
    Duncan's diagnosis, from the 28th to the 30th of September,
    when he was very ill. He had a lot of body fluids, a lot of
    diarrhea, a lot of vomiting, and they were caring for him with
    protective equipment that they were trying to beef up so that
    they would be safer. But, in doing that, they may have
    inadvertently increased their risk. And that is why,
    immediately, we strengthened the level of safety and went to a
    new set of Personal Protective Equipment guidelines. Two of the
    essential components of those guidelines are that health care
    workers practice and practice and practice----
        Senator Johnson. OK.
        Dr. Frieden [continuing]. So they are comfortable with
    doing, and that they are observed to put on and take off the
    equipment.
        Senator Johnson. Can we talk a little bit about the
    survivability of the virus. We are talking about this, really,
    because of the burial practices in Africa, the virus is
    obviously present in those bodies and it, obviously, survives.
    If, it remains moist. Is that really all it takes, is just the
    virus to be in a moist environment and it will continue to
    survive?
        Dr. Frieden. The virus cannot live indefinitely outside of
    the body, as far as we know, but it will depend on the
    environmental conditions. We know that it is produced more by
    people as they are sicker.
        Senator Johnson. Mm-hmm.
        Dr. Frieden. But, all of what we have seen in Africa has
    suggested that it takes direct contact with someone who is ill.
    Even one study we did showed that even family members who
    shared meals, lived in the same household with patients, if
    they did not have direct contact, they did not----
        Senator Johnson. What is the theory of how it jumps from
    animals to humans? Is that through diet?
        Dr. Frieden. We do not know in particular. It has not been
    proven in Ebola. Our work has shown that in Marburg, a similar
    virus, bats are an important reservoir, and then contact,
    hunting and cleaning bush meat can bring people into contact
    with infected animals and their body fluids.
        Senator Johnson. A quick question for Texas. We know Mr.
    Duncan got ill in a parking lot. What happened to the result of
    that illness?
        Dr. Lakey. What happened----
        Senator Johnson. We heard it sat around for a couple days
    and then was just washed down a drain.
        Dr. Lakey. For the cleaning of the environment? Is that
    your question, sir?
        Senator Johnson. Yes. Apparently, he vomited in a parking
    lot.
        Dr. Lakey. We brought in a crew to do cleaning, cleaning of
    the apartment. They went to several lengths to clean the
    apartment, clean all the environment around--there was a
    contractor that came in to do all that cleaning.
        Senator Johnson. OK. Well, thank you, Mr. Chairman.
        Dr. Frieden. If I may, just the Ebola virus itself is
    relatively easy to decontaminate. It has an envelope, so soap
    and water, an alcohol-based wipe, bleach readily decontaminates
    it, but we want to make sure that is done thoroughly and
    completely any time there may be exposure.
        Ms. Lindborg. And, if I may, Senator Johnson, just to add,
    the funding request that is before you includes as a part of
    the two--the $1.89 billion--funds that will enable the military
    to transition out so that there will be civilian capabilities
    coming in behind the military, which is why they do not
    anticipate exceeding their current funding envelope.
        Senator Johnson. Thank you.
        Chairman Carper. Yes. I want to thank Senator Johnson for
    calling me during the, I guess it was at the time of the run-up
    to the election when we were not in session actually
    encouraging us to hold a hearing. He actually encouraged Dr.
    Coburn and I to hold a hearing a couple of weeks before the
    election, and we talked it over and decided that this might be
    a better time to do it. I thank him for raising the idea and
    certainly for being here again today to be with all of you and
    ask these questions, including the ones that are common sense
    questions.
        Senator Rob Portman from Cincinnati, Ohio.
        Senator Portman. Thank you, Mr. Chairman.
        So, we talked earlier about timeliness, and Dr. Frieden and
    I can probably have a debate over that. CDC was on the ground
    with a relatively small number of people relatively early, but
    it also got out of control, and I hope no one on the panel
    would disagree with that. Look at it as compared to, for
    instance, the severe acute respiratory syndrome (SARS) epidemic
    in China and how we reacted. And, I say ``we.'' I mean the
    global community. And, we are now paying the price. So, there
    have been over 14,000 people infected. That is probably a low
    number. Over 5,000 people have died. It sounds like we are
    beginning to get it under control in Liberia, but not
    necessarily in Sierra Leone and Guinea. I think it just speaks
    to the need to respond more quickly because of the way it
    spreads, as Dr. Frieden was talking about.
        So, two questions. One, World Health Organization. I
    mentioned SARS because I think they responded appropriately and
    quickly there. I do not think they responded quickly here. Yes,
    they sent out a report saying this was a problem, but they did
    not send those treatment teams that you talked about as quickly
    as they could have, nor in the numbers that were needed, and I
    think the World Health Organization did not mobilize the donor
    community, meaning countries, as quickly as they could have,
    and have in other instances. So, what is happening? And, I do
    not know who wants to answer this question, who has the
    expertise on World Health Organization, but it seems to me we
    have to learn a lesson here, which is that the global response
    needs to be both more rapid and more concerted, but also there
    needs to be more effort in funding early on.
        Ms. Lindborg. So, if I could just start, and then I will
    pass it to Dr. Frieden.
        Senator Portman. You guys are fighting for the microphone
    here.
        Ms. Lindborg. It speaks, really, to two things. One is the
    response and how quickly and how thoroughly we need to be able
    to respond. But, even more importantly, it speaks to the
    preparedness agenda and being able to understand how we help
    countries detect and respond effectively to these kinds of
    diseases much more quickly.
        And, I will just say once again that even this year, these
    last few months, because of work that USAID, CDC, and WHO have
    done with the Democratic Republic of Congo and Uganda, they
    have both experienced outbreaks of Ebola and Marburg this year
    that were successfully contained. And, it is because of the
    under-investment in West Africa that we saw the Ebola virus
    just take fire the way we have seen. So, it is very important
    about the preparedness agenda.
        Senator Portman. OK.
        Dr. Frieden. That was actually one of the two points I
    wanted to make, and it is critically important and it is part
    of the emerging funding request, both for the countries around
    these three heavily affected countries so that they can have
    the detection, response, and prevention capacity so that it
    does not get out of hand there, and more broadly, so we have an
    alarm system globally so that we do not have something that
    festers for weeks or months and then spreads widely before we
    can respond.
        Senator Portman. Dr. Frieden, here is my question to both
    of you. What happened? I mean, why did we not have that in
    effect? I mean, are you defending the World Health Organization
    today? Do you think they did the right thing? Do you think they
    were ready? I mean, why was West Africa left off the map? Why
    did they not have the preparedness and why did they not respond
    more quickly? And, I do not mean just WHO, because there are a
    lot of great NGO's involved, also, and others. But, why was the
    response so slow and what role should the WHO have played and
    what has been learned?
        Dr. Frieden. First, the countries themselves have very weak
    public health systems, so they did not have in place the basic
    laboratory, surveillance and tracking, response capacity, and
    emergency response and prevention capacity that are not very
    expensive to get in place, but would potentially have prevented
    this from becoming epidemic there. And, in fact, if you look at
    what the World Bank has estimated, more than $30 billion of
    costs in those countries, it would be a tiny fraction--less
    than a half a percent--to put in that kind of simple early
    warning and response system.
        In terms of the World Health Organization, I think they
    themselves would say that the response has not been optimal,
    that both within the countries, the WHO offices and the
    Regional Office of Africa did not respond effectively. They
    have terrific people in the WHO and they have a critically
    important role to play, and one of the aspects of the emergency
    funding request is to provide resources with accountability to
    WHO, because they need to have both a framework of providing
    guidelines globally, but also the ability to support response
    within capacity more than they have done so far.
        Senator Portman. Some experts I have talked to on this use
    the word ``bureaucracy,'' that there was a bureaucratic issue
    here in responding, and more money will not solve that problem.
    Maybe more accountability will.
        Dr. Frieden. I think we need to ensure that WHO has the
    resources to do the job that it needs to do and it also has the
    accountability to be held accountable for actually doing it.
        Senator Portman. Could we switch to the NGO's for a second.
    One thing that I have been asking about, and I have talked to--
    you mentioned the World Bank, so I will mention Dr. Jim Kim,
    who is not only the President of the World Bank, but happens to
    be an expert on infectious diseases and had a lot of successes
    through Partners in Health over the years with Dr. Farmer and
    others, but I have also talked to Dr. Bill Frist, who, as you
    know, was a former colleague of ours, and others about why we
    are not putting together an effective private sector response
    to channel the generosity and the support of the American
    people through something like we did after Katrina, or after
    the earthquake in Haiti, which had an enormous impact on
    Haiti's ability to get on its feet, and people were happy to
    help, or after the tsunami, where, you know, at a Presidential
    level, we put together an opportunity for people to give.
        In some cases, the Red Cross has provided some of the
    infrastructure for that. I know the U.N. has its own fund, and
    I know that there are other NGO's that are fundraising
    directly. I personally have contributed to Partners in Health,
    because I think they do a great job. The research I did showed
    that they probably put 96 percent of their money straight into
    service, which I was very impressed with.
        But, my question is, should there not be a national
    response here, and I think a lot of people would be willing to
    help, but there has not been that kind of an organized effort
    as we have seen in these other either health care or natural
    disasters, and I wonder why and what could be done now.
        Ms. Lindborg. So, that is an important question and there
    are new efforts to galvanize some of the fundraising that you
    mentioned through using social media and working very closely
    with the NGO's, and there are more campaigns that are coming
    online in the next few weeks to do exactly that. We have also
    worked very closely with the communications companies, that we
    are involved with them right now in using some of their
    technologies and expertise to improve data collection, data
    transmission, data analysis, and they have been very important
    partners with us on that.
        Just yesterday, I followed Ron Klain to speak at a meeting
    of foundation and private sector individuals who are very
    interested in increasing their response in a very strategic way
    to how they can provide assistance. So, there is a lot of
    effort out there, both in terms of tapping into technologies,
    into products, and into fundraising possibilities, and you will
    see that continue over the weeks ahead.
        Dr. Frieden. And, if I may, two additional points. CDC has
    a foundation created by Congress in 1993. That foundation has
    raised more than $45 million for the response, and that has
    been immediately deployed to accelerate the response in West
    Africa.
        And, second, I have to give a lot of credit to Doctors
    Without Borders (MSF). They have been there on the front lines,
    on the ground at all times, and they have been right about
    their concerns and the alarms that they have raised.
        Senator Portman. Yes. And the CDC fund has attracted some
    major donors, and that is terrific. I guess my question is, and
    to Ms. Lindborg talking about all the efforts that are going
    on, people who are watching today--thank you if anybody on C-
    SPAN is actually watching--they do not know about any of this.
        In the past, as I say, recent past, even, with regard to
    the earthquake in Haiti, the Presidential involvement in that,
    and also former Presidential involvement with regard to the
    tsunami, people knew about it and all of these media companies
    you are talking about were able to focus on one effort, one
    fund. It seems to me that makes sense. I just wonder if you are
    moving toward that.
        In addition to the CDC work, which is very important, this
    could be a broader fund that deals with not just Liberia, but
    all the countries of West Africa and trying to do what Dr.
    Frieden said earlier, which is he said, and I quote, ``You
    cannot remove the risk to the United States until we stop Ebola
    in West Africa,'' and I think people get that, want to help.
    They have compassion, and I do not think they know where to
    channel their generosity.
        Ms. Lindborg. We could not agree with you more. Watch this
    space and we will be happy to keep you briefed as efforts
    evolve. And, I would add that about $850 million has been
    raised from the private sector thus far, so they have already
    been significantly engaged, including some very strategic
    contributions from organizations like the Paul Allen Family
    Foundation, who provided transport and have been engaged with
    us on the medevac solutions. But, there is a need for more
    campaigns and we look forward to talking to you more about that
    in the coming weeks.
        Senator Portman. Well, I think, not speaking for all my
    colleagues, but a lot of us would be happy to be involved in
    that to help spread the word, but I think there needs to be an
    effort that is concerted, one effort that people understand and
    has accountability so that those generous Americans who want to
    help know their dollars are being well spent.
        Thank you, Mr. Chairman.
        Chairman Carper. You bet. Thank you. Senator Portman, I
    know you spend a lot of time, have a lot of personal interest
    in these matters, and I applaud you for that. It shows.
        Normally, the Chairman of the Committee leads off in the
    questioning here, as Gil knows and some others may recall, and
    I wanted others to go first today and I wanted to go last, and
    for about the next hour or two--it will not be that long. It
    may seem that long, but it will not be that long. [Laughter.]
        I have a couple questions, if I could. I am reminded of
    something that Lincoln once said. He used to say, ``The role of
    government is to do for the people what they cannot do for
    themselves.'' That is what he would say.
        Just a short question, and I invite a short answer. What is
    the role of government here, particularly our government? I am
    going to ask, is it Dr. Brinsfield, is that your name? Would
    you come to the table, please. You can be thinking about this.
    We will let you answer that one last. But, you are nice enough
    to come. I want to make sure we get our money's worth out of
    your appearance. [Laughter.]
        But, what is the role of government, Dr. Lakey, very
    briefly?
        Dr. Lakey. I think government had a very important role in
    the response. I cannot speak to fighting on the front lines in
    Africa, obviously, a very important role, to make sure that we
    prevent it from coming to the United States. But, an individual
    person cannot do the things that the government, local, State,
    Federal Government did together. You cannot test for an
    individual, to have that system in place to test that somebody
    has this disease or not. It cannot do the epidemiology to
    figure out, who have you been in contact with? That is a role
    of government. It cannot decide that somebody has had enough of
    an exposure that you might have to do a quarantine, et cetera.
    That is a role of government. To plan ahead, to make sure you
    know what facilities are ready, to train those individuals, I
    think there is a very important role of government providing
    for that common defense----
        Chairman Carper. OK. Hold it right there. That is good. I
    want to give these others a chance to respond. That is very
    good. Thank you. Ms. Lindborg.
        Ms. Lindborg. A very critical role for the U.S. Government
    has been to provide the global leadership that helped galvanize
    a kind of response that was commensurate with the level of the
    threat. And, in addition, as we see with the Global Health
    Security Agenda that was launched actually in February, create
    the global conversation about the policies and the actions that
    are critical for all of us to have greater safety from emerging
    threats.
        Chairman Carper. Thank you. Gil.
        Mr. Kerlikowske. Mr. Chairman, it is, I do not think, any
    different than when I was a police chief. It is to protect
    people, not only by the actions of government, but by equipping
    them with information and the steps that they can take
    themselves to be safer.
        Chairman Carper. All right. Thank you.
        Dr. Frieden. I would reiterate that. It is about getting
    information to people on what is happening with the disease and
    what they can do. It is about working to protect people from
    threats that they cannot protect themselves from because of the
    outbreak. And, it is working as a community to stop an outbreak
    in order to protect people in a way that we, as individuals,
    cannot do that. We cannot have the detection systems, response
    systems, and prevention systems that will be so effective.
        Chairman Carper. Good. Thanks. Dr. Lurie.
        Dr. Lurie. Great. The perils of going last on this one
    here, but----
        Chairman Carper. No, next to last. We are saving the best
    for last. [Laughter.]
        Dr. Lurie. Oh, OK. There you go. But, certainly to protect
    the public and to give people the information that they need to
    protect themselves. It is to lead. It is to educate. It is to
    be sure that an infrastructure is in place so that people can
    be protected and educated. It is to support funding when
    funding is not available. And, it is ultimately to hold
    together with the public all the components accountable for
    outcomes. So, in some sense, it is to be sure that there is a
    system in place that knits all of the moving parts of this
    together so that it can work seamlessly and accountable to
    drive to outcome.
        Chairman Carper. Good. Thanks. Dr. Brinsfield.
        Dr. Brinsfield. Thank you, sir, and thank you for inviting
    me. I think, in particular, it is our role to protect the
    homeland, and specifically our role to give the best advice
    possible to Mr. Kerlikowske, to our Secretary, to make sure
    that they are able to make the decisions necessary to protect
    both our workforce and the country. And, it is also our role in
    some sense to make sure the information is out there and
    available and that the response is equitable.
        Chairman Carper. All right. Thank you. Is he a pretty good
    listener?
        Dr. Brinsfield. Very much, sir.
        Chairman Carper. All right. Good.
        Each of you are going to be given about a minute to give
    just a brief closing statement--not yet, but just be thinking
    about that. We always ask our witnesses to give an opening
    statement, 5 minutes or so, and you will all be given a chance
    to offer just a brief closing statement, as well, so you might
    want to think about what you would say there.
        I am a recovering Governor, as my colleagues know, and as
    Governor, I did hundreds of customer calls to businesses across
    Delaware, outside of Delaware, maybe outside the country, a lot
    of whom would have operations in Delaware. So, we are always
    interested in job creation, job preservation in those roles,
    and in this role, too. But, when I would do customer calls on
    businesses--I still do them--I ask, how are you doing, ``you''
    being your business. How are we doing, ``we'' being the State
    of Delaware, Senate, Congress, Federal Government, and what can
    we do to help.
        So, I am going to just--this is not a customer call as
    such, but we will just use those questions anyway. How are we
    doing? We have been pretty much asking that question all
    morning, and I am encouraged by how we are doing. I am
    encouraged by the sense of team and I am encouraged by the
    sense of not just the Federal Government, not just the State
    Government, not just public health, not just non-governmental
    entities, it is not just other countries, but it is all this
    writ large, a lot of volunteers, very good people.
        But, in my sense, we are doing better, and in this country,
    I think we have done remarkably well when you actually look at
    the numbers. I am told that more people die of malaria in a
    week in this world than have died of Ebola maybe since we had
    our first fatality. It has been pretty remarkable, and yet we
    do not focus as much on malaria, nearly as much as we do, and
    yet the loss of life every day is so substantial.
        OK. How are we doing? We have talked about that. How are
    you doing? For those you represent, how are we doing? And, most
    importantly, how can we help? I would just like to ask each of
    you, and I am going to start with you, Dr. Lurie, how can we
    help? What are we doing right now that is really helpful? And,
    maybe one example of what do we need to do more of, or maybe
    even less of? Please, and just real briefly.
        Dr. Lurie. Great. Well, I would say one of the things that
    I think we have done very well is the preparedness has been
    built on the back of strong day-to-day systems. And, in fact,
    in this country, we have strong day-to-day systems that have
    let us detect, that have let us respond. We cannot take our
    foot off the gas here and we have to continue to build that,
    maintain it, and be sure it is in place, and I think we have to
    continue to look toward the future. We need to look at, as we
    do with any event, what are the lessons learned, what are the
    things that went well, and where do we need to build toward our
    future preparedness both in this country and globally.
    Obviously, there are lessons in that for both.
        Chairman Carper. We are going to come back and ask about
    lessons learned, but thank you for that.
        Dr. Frieden, what can we do to help, maybe that we are
    already doing or not doing enough of, or too much of?
        Dr. Frieden. I think the basic principles of moving fast
    and flexibly and keeping the front lines first are the critical
    components here. And right now, we are very focused on the
    emergency funding request, because that is going to be in a
    critical pathway for our being able to stop it in West Africa,
    being able to protect the homeland by strengthening systems
    here, and being able to anticipate and set the alarm earlier if
    Ebola or another deadly threat spreads elsewhere through the
    global health security work.
        Chairman Carper. All right. Thank you. Gil.
        Mr. Kerlikowske. Mr. Chairman, I think what is interesting
    to me is during the 6-years in the Administration, I have had
    two wonderful interactions with Senator Portman. So, as Drug
    Policy Advisor, it was all about enforcement. United States
    Customs and Border Protection is all about enforcement. My two
    interactions with Senator Portman, and, frankly, a number of
    other Members of Congress, have been about disease, have been
    about public health, and my work with Dr. Frieden on overdoses
    and prescription drugs and now on Ebola. And, what I think it
    clearly shows is that there is not a division. There is a true
    intersection of where public safety and public health come
    together.
        Chairman Carper. Thank you. Ms. Lindborg.
        Ms. Lindborg. So, even before the Ebola outbreak, we----
        Chairman Carper. Again, what I am really drilling down is
    what can we do to help, but please.
        Ms. Lindborg. Yes. Even before the Ebola outbreak, we had a
    record level of global crises around the world. Because of the
    fast-moving nature of Ebola, we had to push out hard and fast
    with all of our emergency responses, all of our resources. What
    you can most do to help is help us ensure that those mortgaged
    responses are still able to go forward. The emergency funding
    request is critical, both for maintaining our continual
    accelerated rapid response in West Africa, but also to ensuring
    that we are able to replenish some of our contingency accounts
    that were so critical for getting out fast.
        Chairman Carper. All right. Thanks.
        Ms. Lindborg. And then the second thing I would just say is
    the attention and the interest and the support from both the
    House and the Senate have been, I think, indispensable, both in
    terms of getting information out to the American public, but
    also just ensuring that there is this important ongoing
    dialogue. So, thank you for that.
        Chairman Carper. Thomas Jefferson used to say, ``If the
    people know the truth, they will not make a mistake,'' and part
    of the reason for this hearing today for Dr. Coburn and myself
    and, I think, others, is to get to the truth, make sure that
    people in this country know the truth.
        For me, a big piece of that was when the gentleman who died
    in Dallas, and we learned that the woman with whom he shared a
    bed, same sheets, same bedroom, the kids that were there, the
    adults who were there, none of them came down with the disease,
    that was just an eye-opener for me in what we were facing. And,
    it does not minimize the threat of what we were facing, but it
    was something that was, for me, really helped me understand the
    truth.
        Dr. Lakey, just very briefly. What can we do, what more or
    less of?
        Dr. Lakey. Well, first, thank you for allowing me to be
    here today. I think it is important to have a State voice in
    these conversations, and as policies are put into place, that
    there are individuals from the State and local level that can
    have input into how those policies are going to be played out
    on a local level.
        Chairman Carper. As a former Governor, I know how important
    those States are.
        Dr. Lakey. Well, thank you. I think what we are incumbent
    to learn from this experience and make sure that we are
    quicker, faster, and smarter in our ability to respond, things
    like permitting and cutting some of those bureaucracies so that
    we can move quicker the next time. And, I would ask you to
    remember that that public health--we do not like the word
    ``infrastructure,'' but there is a capacity that needs to be in
    place to be able to do the detection, respond quickly, and that
    is a very important ability for us to respond to these events.
    Thank you, sir.
        Chairman Carper. Thank you. Dr. Brinsfield.
        Dr. Brinsfield. Thank you, sir. So, to echo Mr.
    Kerlikowske, we clearly every day see the intersection of
    public health and security, and this is something that we felt
    very supported by this Committee and look forward to working
    with you further to codify some of those areas.
        Chairman Carper. OK. Thanks.
        Dr. Lurie, you mentioned best practices. Let me just ask
    you each to name one, just something you have seen and you say,
    oh, that is a best practice. I always like to say, find out
    what works, do more of that. Find out what does not work, do
    less of that. And, maybe give us a good example of what works
    that we ought to do a lot more of. A best practice, please.
    Just one.
        Dr. Lurie. Certainly, one best practice is having day-to-
    day systems that have people drill and exercise for emergencies
    that might happen.
        Chairman Carper. Thank you.
        Dr. Lurie. So, I will just take a moment to respond to your
    other question, because it is all a best practice. I know that
    you are all going home for the holidays.
        Chairman Carper. Maybe.
        Dr. Lurie. You are going to have opportunities to meet with
    your constituents, and I want to be sure before you leave that
    you have all the information you need to help your constituents
    understand what is going on with Ebola in West Africa and here,
    and to help them stay educated and help them stay calm.
        Chairman Carper. That is a great point. Yes. Thanks so
    much.
        Dr. Frieden. Lagos, Nigeria, experienced a traveler arrive,
    caused a cluster of Ebola. CDC and the Nigerian government and
    the Lagos government were able to respond to that very
    intensively. It required 19,000 home visits, creating an Ebola
    treatment unit, and moving out very rapidly, and with that
    intensive effort, they have made Nigeria Ebola-free. That kind
    of intensive effort is what we need to devote to every single
    case of Ebola that occurs anywhere in the world so we can push
    it back and get it out of these countries where it is spreading
    so widely.
        Chairman Carper. Thank you. I mentioned the incident in
    Dallas, the death of the gentleman, and the fact that those
    right around him, even in the same bed with him, never
    contracted it. For me, that was a moment of truth. And the
    other moment of truth was what you just pointed out in Nigeria,
    a country that successfully addressed this and basically
    stopped it in its tracks. Thanks.
        Mr. Kerlikowski I almost called you ``Doctor,'' so, Chief,
    go ahead.
        Mr. Kerlikowske. I am with quite a few. After the laws,
    after the MOUs, after the agreements, after the policies, it
    really all comes down to those individual relationships. And,
    if you look at the complexity of an airport and to suddenly
    very quickly and very adaptively put in the type of screening
    that required the cooperation of the airlines, the airport
    authorities, the Chicago Public Health, or the State of New
    York Public Health, the relationships with CDC, all of these
    things to be--the United States Coast Guard--all of these
    things to be done very quickly so we can have great policies
    and MOUs, those relationships at the State and local level, as
    Dr. Lakey said, are critical.
        Chairman Carper. All right. Thank you, sir. Ms. Lindborg.
        Ms. Lindborg. Two things. One is having early on a joint
    strategy that was very clear and governed not just our
    response, but was closely aligned with the United Nations and
    with the affected countries made a difference. We were all able
    to move forward in the same direction.
        And then, second, is applying a lot of hard lessons learned
    of how to be very organized in the heat of a crisis response
    and having the systems and the authorities so that when we send
    in our Disaster Assistance Response Team, we can call forward,
    whether it is from DOD or the U.S. Forest Service, the
    capabilities from across the U.S. Government that are most
    appropriate, and it is a much more seamless relationship now
    than it was in the past.
        Chairman Carper. All right. Thank you. Dr. Lakey.
        Dr. Lakey. I think one of the things that was helpful to us
    was to have an outside entity, an advisory board, to be able to
    hand off, ask hard questions to, a board of prominent
    scientists from the State of Texas, individuals that run major
    agencies, have meetings that were public and so that we could
    have that outside entity advise us and be able to get the best
    scientific information as we devised our critical policies.
    Thank you.
        Chairman Carper. Thank you. Dr. Brinsfield.
        Dr. Brinsfield. So, I also believe that the interagency
    dialogue, the coordination that has gone, we have improved
    greatly, and I think it is one of the real strengths of this
    response.
        Chairman Carper. OK. Thank you.
        We have touched on the funding. You have, in some cases,
    responded in terms of what we can do to help, is to make sure
    that we are responsive to the Presidential request for
    supplemental funding. I am going to ask you to answer this
    question on the record, but before I ask the question, I will
    just try to draw a parallel here.
        Earlier this summer, we had tens of thousands of people,
    mostly young people, sometimes, as Gil knows, very young people
    who were coming up from Honduras, Guatemala, El Salvador,
    trying to get into our country and to escape the wretched lives
    that they are living down in those three countries in
    particular. We spent a fair amount of time trying to figure out
    what we could do to strengthen the borders, stop people at the
    borders, and we spent about a quarter-of-a-trillion dollars in
    the last 10 years to do that. We really were trying to address
    the symptoms of a problem, the underlying problem and
    underlying cause is lack of economic hope, lack of opportunity,
    lack of safety in those countries, and that is why these people
    are getting out of there.
        One of the questions I am going to ask you for the record
    is for some thoughts on underlying root causes. I always like
    to focus on root causes. We are so good at thinking about
    symptoms, how do we address the symptoms of problems, and for
    me, what I always like, what is the root cause of this
    particular problem? Let us make sure that we are dealing with
    that at the same time that we deal with the symptoms. So, I am
    going to be asking one question about the root cause.
        The second question I will ask you is a somewhat different
    kind of question. It goes back to the Administration's funding
    request, but it relates to the border. The Administration came
    in, as Gil will recall, with a very substantial supplemental
    appropriations request back in mid-summer, remember, and I
    think it was about, I want to say, $3.7 billion. It was then
    knocked down to $2.7 billion. And, the flow of particularly
    young people to our borders slowed dramatically. We did a bunch
    of things. The Mexicans did a number of things. We launched
    this truth campaign down in those three countries in Central
    America to try to make sure the people there knew what they are
    actually facing, trying to get through Mexico, trying to get
    into this country, and I think that helped, as well. The
    weather slowed some people down.
        But, we want to make sure that we are addressing root
    causes. We also want to make sure that the President's request,
    which 3.7--we never funded the 3.7. He knocked it down to 2.7.
    We did not fund 2.7. And, in the end, we asked the
    Administration to figure out and, like, literally take it out
    of their own hide, about $400 million to try to address the
    challenges at the border and everything that flows from that.
        You are going to get a lot of questions about a $6.5
    billion supplemental request, and I thought we had a good
    discussion about that today, but my question for the record
    will be, if we do not get it, if you do not get that kind of
    money, what does it mean? What does it mean if we do not
    respond in the way that the Administration is asking?
        Ron, do you have any more questions? No?
        I did say I was going to ask each of you to give one last
    parting comment, and no more than a minute, but, Dr.
    Brinsfield, again, thanks so much for joining us, and you get
    the last word.
        Dr. Brinsfield. Thank you, sir, and thank you for inviting
    me. I have nothing further to add except to say that we have
    appreciated greatly the ability to work with our colleagues. We
    have certainly learned a lot of lessons about how we can better
    move and transfer data, how we can work together in a more
    efficient manner, and particularly want to thank our colleagues
    from Texas and State and local public health because it really
    is where the rubber meets the road and we have great support
    and faith in their ability to do the job that we have been
    asking them to do.
        Chairman Carper. All right. Thank you. Dr. Lakey.
        Dr. Lakey. Again, I want to thank you for the privilege of
    being here today to be able to share our experiences. I think
    it is incumbent on us to make sure we learn from those
    experiences so that we can protect our health care workers, we
    are able to be able to respond quickly. The infrastructure at
    States and the local level really is critical in that ability
    to respond quickly, and so, again, I want to emphasize that
    infrastructure is very important. It is also very important
    that we know each other. We have worked together on many events
    before and it really is a team effort in order to respond to a
    novel event like this. Thank you, sir.
        Chairman Carper. No, ``I'' in the word ``team.'' It is a
    team and a good one. Ms. Lindborg.
        Ms. Lindborg. OK. So, this is the closing----
        Chairman Carper. This is your last minute----
        Ms. Lindborg. OK.
        Chairman Carper. Closing thoughts.
        Ms. Lindborg. So, Ebola preys on weak systems. We have seen
    what happens when it goes into countries that are ill prepared,
    especially countries that are recovering from conflict and just
    do not have the means. More than anything, this underscores
    that if we get upstream, if we pay attention to fragile States,
    if we work on strengthening the global health system, we are in
    the best position to keep this country safe and to avoid having
    to mount these very, very expensive, difficult responses. So,
    it is the root causes and the root causes are often fragility,
    poverty, repressive countries.
        Chairman Carper. All right. Thank you. Gil.
        Mr. Kerlikowske. As a police chief, it was important to
    arrest criminals. It was important to solve crimes. But, it was
    just as important to give people in Seattle the sense of
    confidence that their police department knew what the problems
    were, that they were action oriented, and that their first and
    primary task was to protect them. And, I think the opportunity
    to have this hearing and let people know that government
    actually is very much involved, and even though, as Tom said,
    we will never reduce the risk to absolutely zero, we are much
    better ahead of the game because of the cooperation and the
    support that we all have.
        Chairman Carper. Thank you. Dr. Frieden.
        Dr. Frieden. Ebola is a serious threat. It is one of
    several serious threats, and unless we move out quickly, get
    the resources needed, the risk is that it will spread
    throughout other countries in Africa and be a threat for a long
    time to come.
        The emergency response request for CDC, the funding is
    largely fixed, not dependent on the number of cases. It is to
    protect our systems here in the U.S. It is to prevent similar
    outbreaks of Ebola and other deadly diseases elsewhere and it
    is to surge into the three countries and the 11 countries
    around them to create the systems that will help them be safer
    and help us be safer by addressing some of those root causes of
    weak systems, weak public health systems, and establish the
    rapid response capacity that can end this epidemic and prevent
    the next one.
        Chairman Carper. All right. Thank you. Dr. Lurie.
        Dr. Lurie. We have been hearing a lot about root causes,
    and preparedness, as I said, is really built on the back of
    strong day-to-day systems. We have seen weak systems in West
    Africa. Those are some of the root causes of what happened
    there. We need to keep our systems here strong. We cannot let
    them degrade.
        We also have seen, with every investment in preparedness,
    there has been a peacetime return on investment. Our systems
    have gotten stronger. We have gotten better about preventing or
    detecting the next episode. And, we have been able to shorten
    the period between an event and, in some sense, recovery. One
    of the things that we really need to do with this emergency
    funding request is to deal with the acute situation in West
    Africa. I also anticipate that we will want to see the returns
    on investment, both in West Africa and around the ring
    countries, as Tom said, and around the globe, as well as the
    returns here from a strengthened public health and health care
    system that can deal with really deadly infectious diseases in
    the future.
        Chairman Carper. OK. Thank you.
        I will give a short, maybe, closing statement of my own
    now, and I, too, again thank you all for coming today. Thanks
    for working together, and thanks for doing important work.
        I often tell the story about listening to the National
    Public Radio (NPR) going to catch the train last year, one day
    last year--I go back and forth to my home State of Delaware
    almost every night from here and like to listen to NPR driving
    into the train station after I have worked out at the Y, catch
    that 7:15 train and come on down. And, one of my favorite
    recollections of listening to the news at the top of the hour,
    seven o'clock, is a question was asked about a year ago in an
    international survey, what do you like about your work, and it
    was a question asked of thousands of people all over the world.
    What do you like about your work?
        And, the people had different answers. Some said they liked
    getting paid. Some said they liked health care as a benefit.
    Some said they liked to have a pension. Some people said they
    liked having their vacations. Some people said they liked the
    folks they work with. Some people said they liked the
    environment in which they worked.
        But, the thing that most people liked most, that gave them
    real satisfaction in their work, is that they knew the work
    they were doing was important and they knew they were making
    progress. Think about that. The work they were doing was
    important and they knew they were making progress.
        There are few things more important than saving the lives
    of other people, whether in this country or other countries.
    Who is my neighbor? And, so I say to you, you are doing
    important work, and I am encouraged that we are making real
    progress here and starting to see some in Africa, as well.
        I love to ask people who have been married a long time, 50,
    60, 70 years, I love to ask them, what is the secret for being
    married 50 or 60 or 70 years. I get some hilarious answers. One
    of those is last month or so, I talked to a couple. They had
    been married 54 years. I asked the wife, what is the secret for
    being married to this guy for 54 years and she said of her
    husband, she said, ``He can be right or he can be happy'',
    ``but he cannot be both.'' [Laughter.]
        I get answers like this all the time. One of my favorite
    answers, and I have gotten this one a number of times, is the
    two Cs. The two Cs. The first time somebody said the two Cs, I
    said, what are those? The answer is, communicate and
    compromise. And, I have concluded over the years that that is
    not only the secret for a vibrant marriage between two people,
    but also the secret for a vibrant democracy, to communicate and
    compromise. And, I have added a third C, and the third C is
    collaborate. To communicate, compromise, to collaborate. Again,
    that third C stands up large as we explore this issue before us
    here today.
        I have had the privilege of leading this Committee for the
    last 2 years with Dr. Coburn, and I said earlier he and I have
    worked very closely together. We took turns being Chair and
    Ranking Member of the Financial Services Subcommittee within
    this Committee, so we had a great time working together then
    and we have had, I think, just a lot of challenges this
    Congress, but some real satisfying moments, as well, and we are
    not done yet.
        But, when he and I took over our leadership roles 2 years
    ago after Senators Lieberman and Collins had fled, at least
    this Committee, Lieberman into retirement and Susan to take on
    other responsibilities, but 2 years ago when Tom and I were
    talking about what lay ahead for the Committee and this
    Congress, the word ``Ebola'' never came up. The word Islamic
    State of Iraq and Syria (ISIS) never came up. The word
    ``Sandy'' was not something that we related to the kind of
    disaster that came to visit us on the East Coast. And, as it
    turns out, the nature of the challenges that we face to our
    homeland, to our people, evolves, continues to evolve.
        One of the best ways we can deal with the threats, whatever
    they might be, is to communicate, maybe some compromise, and a
    whole lot of collaboration, and that is what we have an
    obligation to do on our side, so, clearly, you have that
    obligation, as well, and my hope is that we are meeting our
    obligation and we will in the future, as well, as you have met
    your obligation to do those, to be faithful to those three Cs.
        And, in closing, I would say to the members of our staff,
    Committee staff, who are here how much I appreciate the great
    work that they have done, not for me, not for Dr. Coburn, but
    really for our country. As they know, it is very important
    work. What Tom and I have tried to do is just to work together,
    to demonstrate by not do as I say but actually do as I do, and
    hope that it will trickle down, and I really think that it has
    and I hope we have set an example for other Committees, as
    well.
        And, I think, with that having been said, I think it is a
    wrap. We want to again thank you all for joining us, and I am
    supposed to say these last words. The hearing record will
    remain open for 15 days--that is until December 4, 5 p.m., for
    the submission of statements and questions for the record.
        And, with that, this hearing is adjourned. Thank you all.
        [Whereupon, at 12:32 p.m., the Committee was adjourned.]

                                A P P E N D I X

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