[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/
        

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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.
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    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.]

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