[Senate Hearing 113-625]
[From the U.S. Government Publishing Office]




                                                        S. Hrg. 113-625
 
           THE EBOLA EPIDEMIC: THE KEYS TO SUCCESS 
                FOR THE INTERNATIONAL RESPONSEa

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

                                HEARING

                               BEFORE THE

                    SUBCOMMITTEE ON AFRICAN AFFAIRS

                                 OF THE

                     COMMITTEE ON FOREIGN RELATIONS
                          UNITED STATES SENATE

                    ONE HUNDRED THIRTEENTH CONGRESS

                             SECOND SESSION

                               __________

                           DECEMBER 10, 2014

                               __________

       Printed for the use of the Committee on Foreign Relations


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


                                   ______
                                      
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                COMMITTEE ON FOREIGN RELATIONS         

             ROBERT MENENDEZ, New Jersey, Chairman        
BARBARA BOXER, California            BOB CORKER, Tennessee
BENJAMIN L. CARDIN, Maryland         JAMES E. RISCH, Idaho
JEANNE SHAHEEN, New Hampshire        MARCO RUBIO, Florida
CHRISTOPHER A. COONS, Delaware       RON JOHNSON, Wisconsin
RICHARD J. DURBIN, Illinois          JEFF FLAKE, Arizona
TOM UDALL, New Mexico                JOHN McCAIN, Arizona
CHRISTOPHER MURPHY, Connecticut      JOHN BARRASSO, Wyoming
TIM KAINE, Virginia                  RAND PAUL, Kentucky
EDWARD J. MARKEY, Massachusetts
               Daniel E. O'Brien, Staff Director        
        Lester E. Munson III, Republican Staff Director        

                         ------------          

                SUBCOMMITTEE ON AFRICAN AFFAIRS        

            CHRISTOPHER A. COONS, Delaware, Chairman        

RICHARD J. DURBIN, Illinois          JEFF FLAKE, Arizona
BENJAMIN L. CARDIN, Maryland         JOHN McCAIN, Arizona
JEANNE SHAHEEN, New Hampshire        JOHN BARRASSO, Wyoming
TOM UDALL, New Mexico                RAND PAUL, Kentucky

                              (ii)        

  

                            C O N T E N T S

                              ----------                              
                                                                   Page

Alvarez, Javier, senior team lead, Strategic Response and Global 
  Emergencies, Mercy Corps, Portland, OR.........................    31
    Prepared statement...........................................    33
Coons, Hon. Christopher A., U.S. Senator from Delaware, opening 
  statement......................................................     1
Farmer, Paul, M.D., cofounder, Partners in Health, Boston, MA....    12
    Prepared statement...........................................    14
Flake, Hon. Jeff, U.S. Senator from Arizona, opening statement...    11
Gaye, Pape, president and CEO, IntraHealth International, Chapel 
  Hill, NC.......................................................    25
    Prepared statement...........................................    27
Peterson, E Anne, M.D., vice dean, Public Health Program, Ponce 
  Health Sciences University, World Vision, Washington, DC.......    17
    Prepared statement...........................................    19
Sirleaf, Her Excellency Ellen Johnson, President, Republic of 
  Liberia, Monrovia..............................................     2
    Prepared statement...........................................     5

              Additional Material Submitted for the Record

Catholic Relief Services, prepared statement.....................    52
Menendez, Hon. Robert, U.S. Senator from New Jersey, prepared 
  statement......................................................    50
Save the Children, prepared statement............................    51

                                 (iii)

  


 THE EBOLA EPIDEMIC: THE KEYS TO SUCCESS FOR THE INTERNATIONAL RESPONSE

                              ----------                              


                      WEDNESDAY, DECEMBER 10, 2014

                               U.S. Senate,
                   Subcommittee on African Affairs,
                            Committee on Foreign Relations,
                                                    Washington, DC.
    The subcommittee met, pursuant to notice, at 10:35 a.m., in 
room SD-419, Dirksen Senate Office Building, Hon. Christopher 
Coons (chairman of the subcommittee) presiding.
    Present: Senators Coons, Durbin, Shaheen, and Flake.
    Also Present: Senators Markey and Murphy.

        OPENING STATEMENT OF HON. CHRISTOPHER A. COONS, 
                   U.S. SENATOR FROM DELAWARE

    Senator Coons. Good morning. This meeting of the Senate 
Foreign Relations Subcommittee on African Affairs will come to 
order.
    We are going to do things a little differently than usual 
today because of a rare honor for this subcommittee. Joining us 
from the Liberian capital of Monrovia today via video 
conference will be President Ellen Johnson Sirleaf, who will 
share with us her observations on the Ebola outbreak and its 
impact on her country.
    President Sirleaf is an extraordinary individual who has 
already once pulled her country back from the brink of collapse 
following Liberia's long and destructive civil war. Her 
certainty of purpose, coupled with a vigorous commitment to 
reconciliation and economic recovery, make her the single best 
person to be leading Liberia through this very difficult time.
    President Sirleaf has shown extraordinary leadership for 
her country in this time of crisis and continues to be an 
example for all in public service. Winner of the Nobel Peace 
Prize and Africa's first elected female head of state, 
President Sirleaf is an individual of exemplary character, 
fortitude, and compassion for her people.
    I would also like to take a moment to recognize Mr. 
Jeremiah Sulunteh, the Republic of Liberia's Ambassador to the 
United States, who, like Madam President, has played a key role 
as a long-time servant to the Republic.
    It is an honor and a privilege to have you with us today.
    President Sirleaf has also volunteered to answer a few 
questions from members of the subcommittee following her 
remarks. It is a rare honor and an extraordinary opportunity to 
be joined by video conference by a sitting head of state, one 
for which my colleagues and I are grateful.
    Madam President.

 STATEMENT OF HER EXCELLENCY ELLEN JOHNSON SIRLEAF, PRESIDENT, 
                 REPUBLIC OF LIBERIA, MONROVIA

    President Sirleaf. Good morning. Thank you for inviting me 
to offer remarks at this hearing.
    I would like to start by extending warm and profound 
gratitude on behalf of the people and Government of Liberia to 
the American people, the U.S. Government, the many American 
institutions and faith-based organizations for the leadership 
your country has taken by joining us on the frontline of this 
battle to turn the tide against this unknown disease that has 
threatened our very way of life.
    My colleagues from Guinea and Sierra Leone, also victims of 
this disease, join me in these sentiments.
    Allow me to recognize also the extraordinary work of U.S. 
Ambassador Deborah Malac and the Embassy team.
    Chairman Coons and Ranking Member Flake, I would like to 
express my heartfelt thanks for the personal commitment 
demonstrated by you and other Members of Congress through your 
numerous phone calls and messages of support.
    We express appreciation to President Obama for the bold 
steps, including the work of Dr. Tom Frieden, director of the 
Centers for Disease Control, and Rajiv Shah, the Administrator 
of USAID, in coming to our aid. It was the United States that 
awakened the world to the scope and magnitude of the Ebola 
disease's virulent spread in West Africa, that led to the 
extraordinary step to deploy the United States military to help 
Liberia. It was the leadership of the Obama administration, 
supported by Congress, that opened the space for the disease to 
stabilize in Liberia and encouraged the rest of the world to 
respond to this global crisis. It is a demonstration of 
leadership as important as the role to combat terrorism and 
other ills around the world.
    We applaud the construction of Ebola Treatment Units by the 
DOD and the establishment of the field hospital to treat health 
care personnel as a significant and timely response to our 
predicament.
    Today, our Armed Forces, which worked with the DOD, can 
boast of the capability to construct Treatment Units and other 
similar type of facilities. The Treatment Units send a powerful 
message to our people that Ebola is real, that it requires an 
overpowering response, and that the people of the United States 
stand by us. The units serve us well by ensuring that we can 
respond to continuing hotspots and possible recurrence.
    The fact that they are not full is a strong sign of their 
success and shows that by working together with overwhelming 
force, we have begun to push back on this unknown killer 
disease.
    Honorable Members of Congress, several of you may recall 
that on March 16, 2006, shortly after being elected President 
in Liberia's first post-conflict elections, I had the honor to 
address a joint meeting of the U.S. Congress and said that we 
will pay any price to lay the foundation for durable peace. In 
2013, we celebrated the 10th year of peace that enabled us to 
achieve over 7 percent average annual economic growth, a 50-
percent reduction in the infant mortality rate, 17 additional 
years in life expectancy, relief from a crippling external 
debt, and a restoration of economic and social infrastructure. 
Perhaps more importantly, we have established a free and 
democratic society, thus reversing the many decades of 
authoritarian rule.
    This year incredibly changed everything. Like the rest of 
the world, we knew nothing about this disease. It sprung on us 
at the worst of times. Our subregion had just begun to recover 
from years of instability and commenced the process of regional 
integration. The three most affected countries have embarked on 
a path of democratic governance. As natural resource-rich 
countries, we were in the process of attracting investors, 
creating the conditions to accelerate growth with development. 
This has all been unimaginably reversed.
    Today, we are fighting to keep people alive, facing a 
faceless but deadly enemy. As I speak to you, the Ebola virus 
has caused a serious disruption of Liberia's social, economic, 
and cultural fabric. It has destroyed many of our hard-fought 
development gains, wreaked havoc on our economy, exposed the 
weakness of our public health systems, interrupted our 
infrastructure development, closed schools, restrained travels, 
and shattered the lives of our people. The disease has 
subjected us to a stigma all over the world, creating a fear 
more destructive than Ebola itself.
    With the support of partners like you, we have made 
progress in containing the virus. Our 13 emergency treatment 
units, with a total of 840 beds, have only 136 patients. Our 70 
burial teams have buried 23 persons per day across the country, 
compared to hundreds months ago. We have seen a drop from 
around 100 new cases per day at the peak of the epidemic to 
only 10 confirmed new cases per day over the past week. Our six 
active laboratories have tested 60 samples a day but, on 
average, only find 8 new Ebola cases per day. The 4,000 contact 
tracers, which involve community workers, are following some 
7,000 persons. Doctors, nurses, and other health care workers, 
some 174 of the over 3,000 who have died, are no longer at risk 
because quality treatment facilities are available to them. We 
are happy to say that 1,312 persons, including 345 children, 
many of them orphans, have walked away free from the disease.
    Can I profoundly say I am excited about this progress? Yes, 
I am. But I also know that more has to be done, as we are now 
in the most critical stage of response. At 10 new cases a day, 
the crisis is now manageable, but experts tell us that 
traveling that last mile to zero new cases will be much more 
difficult because the disease has retreated and must now be 
chased down in every corner.
    To illustrate this, consider the challenge of contact 
tracing. For each of the patients in the United States, there 
were around 40 contacts that needed to be quarantined and 
monitored. The challenge in Liberia is greater, with thousands 
more contacts, often in villages which take hours to reach 
through densely forested terrain. This is one of the many 
reasons why your continued support and our joint collaboration 
is so important. Moreover, full eradication will not be secured 
until the whole region is freed from Ebola, until there is 
prevention against future possible outbreak, until we develop a 
medicine both preventive and curative to conquer this deadly 
disease.
    Yesterday, Liberia hosted a regional technical summit with 
Sierra Leone, Guinea, and Mali to share lessons and best 
practices. The summit drove home the point that Ebola is not a 
Liberian issue or a West African issue. It is a global issue 
that we must all continue to confront. This is why continuing 
your assistance to the combined effort with our neighbors 
remains a priority. This is why the United States has been 
right to tackle it at the front line, here in West Africa. This 
is why Dr. Margaret Chan, Director General of WHO, was right 
when she noted that this is the greatest peacetime challenge 
the United Nations and its agencies have ever faced.
    In Liberia and in Sierra Leone and in Guinea, we continue 
to live this challenge. As our response evolves, we ask that 
partners continue to support our efforts. This calls for 
strengthening community ownership and responsibility for 
awareness and immediate response action through the Community 
Care Centers that are being established with the support of 
USAID.
    Here are a few statistics in this regard. Liberia has 218 
medical doctors and 5,234 nurses to serve a 4.3 million 
population at 405 public and 253 private health facilities. 
This means we have 1 doctor for 100,000 people, compared with 4 
for 100,000 in Sierra Leone, 10 for 100,000 in Guinea, and 245 
for 100,000 in the United States. As we speak, there are more 
Liberian doctors and medical professionals in the United States 
than at home. Most of them left during the war, and we were in 
the process of trying to get them back home with incentives 
that measure up to their qualifications. This disease has upset 
that effort.
    Clearly, we are far behind and can only sustain the 
progress and prevent a recurrence through better trained and 
better equipped health facilities, better diagnosis facilities 
for infectious diseases, better hospitals, better clinics. We 
have asked the 137 partners from some 26 countries who are with 
us in this fight to join us in this expanded effort.
    Above all, Liberia must get back on the path to growth. My 
government is preparing a comprehensive plan for Liberia's 
post-Ebola economic recovery, accelerating our work in 
infrastructure, above all Roads to Health, electricity, and 
WATSAN operations. A major push in the agricultural sector, 
where most Liberians are employed, will enable us to generate 
jobs and restore livelihoods. The private sector will play a 
crucial role. In this regard, we commend the private sector 
organized under the Ebola Private Sector Mobilization Group 
with the efficacy of ECOWAS and the African Union for their 
support in making people and resources available to fight the 
disease. Their efforts will be even more critical in the 
building of post-Ebola economies, requiring from us commitment 
to create conducive conditions for private capital to succeed.
    Liberia is extremely proud that we achieved the MCC Compact 
eligibility in 2012 by passing 10 out of the 20 indicators, 
including control of corruption. Liberia again passed 
eligibility in 2014 by passing 10 of the 20 indicators. Liberia 
has surpassed the MCC's Control of Corruption standard for 
seven straight years, one of the few developing countries to do 
so. An MCC grant would be a game changer for Liberia. It would 
facilitate our post-Ebola economic recovery and put our 
development momentum back on track, leading to substantial 
transformation of our economy.
    I want to conclude by expressing our gratitude to you, the 
U.S. Congress, for the friendship and assistance, without which 
we would not have made the progress to date.
    There remains a lot to do to ensure the resources are 
properly deployed by the many institutions to which it is 
directly allocated to ensure that there is full accountability 
to you and to all our partners, and to the Liberian people. Our 
resolve to meet the challenge that confronts us is strong and 
unrelenting. We will win this battle.
    Once again, I want to thank you and the American people for 
the opportunity to be with you in this meeting today.
    [The prepared statement of President Sirleaf follows:]

       Prepared Statement of Her Excellency Ellen Johnson Sirleaf

    Chairman Coons, Ranking Member Flake, distinguished Members of the 
Senate Foreign Relations Subcommittee on African Affairs, Friends of 
Liberia, good morning. Thank you for inviting me to offer remarks at 
this hearing.
    I would like to start by extending warm greetings and profound 
gratitude of the people and Government of Liberia to the American 
people, the U.S. Government, the many American institutions, and faith-
based organizations for the leadership your country has taken by 
joining us on the front line of this battle to turn the tide against 
this unknown disease that has threatened our very way of life. My 
colleagues from Guinea and Sierra Leone, also victims of this disease, 
join me in these sentiments. Allow me to recognize also the 
extraordinary work of U.S. Ambassador Deborah Malac and the Embassy 
team.
    Chairman Coons and Ranking Member Flake, I would like to express my 
heartfelt thanks for the personal commitment demonstrated by you and 
other Members of Congress through your numerous phone calls and 
messages of support.
    We want to express appreciation to President Obama for the bold 
steps, including the work of Tom Frieden, Director of the Centers for 
Disease Control, and Rajiv Shah, the Administrator of USAID in coming 
to our aid. It was the U.S. administration that awakened the world to 
the scope and magnitude of the Ebola disease's virulent spread in West 
Africa; that took the extraordinary step to deploy the U.S. military to 
help Liberia. It was the leadership of the Obama administration 
supported by Congress that opened the space for the disease to 
stabilize in Liberia and encouraged the rest of the world to respond to 
this global crisis. It is a demonstration of leadership as important as 
the role to combat terrorism and other ills around the world.
    We applaud the construction of Treatment Units by the DOD and the 
establishment of the field hospital to treat health care personnel as a 
significant and timely response to our predicament. Today, our Armed 
Forces which worked with the DOD can boast of the capability to 
construct treatment units and other similar type of facilities. The 
treatment units send a powerful message to our people that Ebola is 
real that it requires an overpowering response and that the people of 
the United States stand by us. The units serve us well by ensuring that 
we can respond to continuing hotspots and possible recurrence. The fact 
that they are not full is a strong sign of their success and shows that 
by working together with overwhelming force we have begun to push back 
on this killer disease.
    Honorable Members of Congress: Several of you may recall that on 
March 16, 2006, shortly after being elected President in Liberia's 
first post-conflict elections, I had the honor to address a joint 
meeting of the U.S. Congress and said that we would pay any price to 
lay the foundation for durable peace. In 2013, we celebrated the 10th 
year of peace that enabled us to achieve over 7 percent average 
economic growth, a 50-percent reduction in the infant mortality rate; 
17 additional years in life expectancy, relief from a crippling 
external debt, and a restoration of economic and social infrastructure. 
Perhaps more importantly we have established a free and democratic 
society thus reversing the many decades of authoritarian rule.
    This year changed everything. As the rest of the world, we knew 
nothing about this disease. It sprung on us at the worst of times. Our 
subregion had just begun to recover from years of instability and 
commenced the process of regional integration. The three most affected 
countries had emerged from the days of instability and embarked on a 
path of democratic governance. As natural resource rich countries, we 
were in the process of attracting investors, creating the conditions to 
accelerate growth with development. This has all been reversed. Today, 
we are fighting to keep people alive, facing a faceless but deadly 
enemy.
    As I speak to you, the Ebola virus has caused a serious disruption 
of Liberia's social, economic, and cultural fabric. It has destroyed 
many of our hard fought development gains, wreaked havoc on our 
economy, exposed the weakness of our public health systems, interrupted 
our infrastructure development, closed schools, restrained travel, and 
shattered the lives of our people. The disease has subjected us to a 
stigma all over the world, creating a fear more destructive than Ebola 
itself.
    With the support of partners, we have made progress in containing 
the virus. Our 13 Emergency Treatment Units, with a total of 840 beds, 
has only 136 patients. Our 70 burial teams have buried 23 persons per 
day across the country compared to hundreds, months ago. We have seen a 
drop from around 100 new cases per day at the peak of the epidemic, to 
only 8 confirmed new cases per day over the past week. Our six active 
laboratories have tested 60 samples a day, but on average only find 8 
new Ebola cases per day. The 4,000 contact tracers which increasingly 
involve community workers are following some 7,000 persons. Doctors, 
nurses, and other health care workers, some 174 of whom died, are no 
longer at risk because quality treatment facilities are available to 
them. We are happy to say that 1,312 persons including 345 children, 
many of them orphaned, have walked away free from the disease.
    Am I excited about this progress? Yes, I am! But I also know that 
much more has to be done for we are now in the most critical stage of 
response.
    At 10 new cases a day, the crisis is now manageable; but experts 
tell us that traveling that last mile to zero new cases will be much 
more difficult, because the disease has retreated and must now be 
chased down in every corner. To illustrate this, consider the challenge 
of contact tracing. For each of the patients in the U.S., there were 
around 40 contacts that needed to be quarantined and monitored. The 
challenge in Liberia is greater, with thousands more contacts, often in 
villages which take hours to reach through dense bush. This is one of 
the many reasons why continuing support your support and our joint work 
together is so important.
    Moreover, full eradication will not be secured until the whole 
region is freed from Ebola; until there is prevention against future 
possible outbreak and until we develop a medicine, both preventive and 
curative to conquer this deadly disease. This is why securing our 
borders remains a priority requiring additional resources, as well as 
providing assistance to our neighbors. On yesterday, Liberia hosted a 
regional Technical summit with Sierra Leone, Guinea, and Mali to share 
lessons and best practices. The summit drove home the point that Ebola 
is not a Liberian issue or a West African issue. It is a global issue 
that we all must continue to confront. This is why the U.S. has been 
right to tackle it at the front line, here in West Africa. This is why 
Dr. Margaret Chan, Director General of WHO, was right when she noted 
that this is greatest peacetime challenge the United Nations and its 
agencies have ever faced.'' In Liberia, and our Mano River Union 
neighbors of Sierra Leone and Guinea, we continue to live this 
challenge.
    As our response evolves we ask that partners continue to support 
our efforts. This calls for strengthening community ownership and 
responsibility for awareness and immediate response action, through the 
Community Care Centers that are being established with the support of 
USAID. Here are a few statistics in this regard. Liberia has 218 
medical doctors and 5,234 nurses to serve 4.3 million population at 405 
public and 253 private health facilities. This means we have 1 doctor 
for 100,000 people, compared with 4 per 100,000 in Sierra Leone, 10 per 
100,000 in Guinea and 245 per 100,000 in the United States. As we 
speak, there are more Liberian doctors and medical professionals in the 
United States than at home. Most of them left during the war and we 
were in the process of trying to get them back home, with incentives 
that measure up to their qualifications. This disease has upset all of 
this effort.
    Clearly we are far behind and can only sustain the progress and 
prevent a recurrence through better training and better equipped health 
facilities. We have asked the 137 partners from some 26 countries who 
are with us in this fight to join us in this expanded effort.
    Above all, Liberia must get back on the path to growth. My 
government is preparing a comprehensive plan for Liberia's post-Ebola 
economic recovery, accelerating our work in infrastructure--above all 
Roads to Health, electricity and WATSAN operations. A major push in the 
agricultural sector, where most Liberians are employed, will enable us 
to generate jobs and restore livelihoods. The private sector will play 
a crucial role.
    In this regard, we commend the private sector organized under the 
Ebola Private Sector Mobilization Group (EPSMG), with the advocacy of 
ECOWAS and the African Union for their support in making people and 
resources available to fight the disease. Their efforts will be even 
more critical in the building of post-Ebola economies requiring from us 
commitment to create conducive conditions for private capital to 
succeed.
    Liberia is extremely proud that we achieved MCC compact eligibility 
in 2012 by passing 10 out of 20 indicators, including control of 
corruption. Liberia again passed eligibility in 2014 by passing 10 out 
of 20 indicators. Liberia has surpassed the MCC's control of corruption 
standard for 7 straight years, one of the few developing countries of 
the world to do so.
    An MCC grant would be a game changer for Liberia. It would 
facilitate our post-Ebola economic recovery and put our development 
momentum back on track leading to substantial transformation of our 
economy.
    I want to conclude by expressing our gratitude to you, the United 
States Congress, for the friendship and assistance, without which we 
would not have made the progress to date. There remains a lot to do--to 
ensure the resources are properly deployed by the many institutions to 
which it is directly allocated; to ensure that there is full 
accountability to you and all our partners and to the Liberian people. 
Our resolve to meet the challenge that confronts us is strong and 
unrelenting. We will win this battle. Once again, I want to thank you 
and the American people for the opportunity to address you today.

    Senator Coons. Thank you, Madam President. Thank you for 
your remarks with us today, and thank you for the opportunity 
for several of our members to ask a few questions.
    I might just begin with one question, and I think we might 
restrict ourselves to one question each, if we might.
    I want to make sure, Madam President, that we are providing 
the right resources both to meet the emergency that you so 
correctly point out is not over and we need to remain engaged 
on as an international community, the pressing and current 
emergency of Ebola. But I also am wondering if we are providing 
the right resources to rebuild your public health 
infrastructure and to overcome what you referenced, a stigma 
that is in some ways a fear of Ebola that is greater than Ebola 
itself in terms of long-term challenges for your economic 
recovery.
    Are we providing the right assistance, and are we helping 
you rebuild for the future in the right ways?
    President Sirleaf. The resources to contain the virus are 
for the moment adequate to do so, as the progress has shown. 
However, there is always the chance of reoccurrence, as the 
history has shown in other countries that have been affected by 
the disease. This is why we must now move from containment, 
from treatment to prevention, and to do that means we will need 
the resources to rebuild, to strengthen our health care 
facilities, our hospitals, our clinics, through training, 
through better equipment, through better facilities. That way 
we can ensure that there will not be a reoccurrence, or in the 
event of a recurrence we will have the means to control it and 
to prevent its spread, not only within our country but as it 
spreads across borders.
    And that is why today we are working with our partners to 
get them to join us in this transition to prevention, working 
with our own people, our Community Care Workers, taking full 
responsibility by being trained to handle basic health care, 
particularly in our rural areas.
    Senator Coons. Thank you, Madam President.
    Senator Flake.
    Senator Flake. Thank you, Madam President. Thank you for 
appearing here today. I wanted to thank you for what you have 
done to rally the international community to join the effort 
to, as you say, stop the epidemic in West Africa.
    We are pleased to hear the progress that Liberia is making, 
and our concern that similar progress has not been made in 
Sierra Leone. You mentioned that you have come together with 
leaders in other countries and public health officials.
    What are you doing to make sure that best practices are 
shared and that the progress that has been made in Liberia is 
replicated elsewhere? Can you give us some idea of what is 
going on there?
    President Sirleaf. The coordinator of the President's 
Advisory Ebola Committee is today on his way to start 
discussion that will put him in the position to become a 
general coordinator for the three countries, working with 
UNMEER, the U.N. coordinating agency that is based in Accra. At 
the meeting held yesterday, Liberia offered, and I had already 
obtained President Roman's agreement to that, to send some of 
those nurses and doctors that we have over to Sierra Leone, 
with the agreement, of course, to be able to join the Sierra 
Leone forces in trying to expand their own capacity to deal 
with the disease. We expect that we will be looking at the 
results of yesterday's meeting to see what else Liberia can do 
to be able to join Sierra Leone particularly because they seem 
to be right now the ones in most serious trouble.
    But we will do everything that we can, share every capacity 
that we have, every resource we have, to be able to work with 
them so that they can get the same progress. Because, like I 
say, until the other two countries are free, Liberia cannot be 
truly free.
    Senator Coons. Thank you, Madam President.
    Senator Durbin.
    Senator Durbin. Madam President, thank you. Let me tell you 
that your statement about the number of doctors and medical 
professionals in Liberia is sobering and evidences a dramatic 
need for more medical resources in your country.
    Our immigration bill that we considered 2 years ago would 
have allowed, for example, Liberians practicing medicine in the 
United States to go back to Liberia and West Africa and to help 
on an emergency basis without jeopardizing their immigration 
status in the United States, and I hope we can return and pass 
something of that nature very quickly next year.
    But my specific question to you is this. The United States 
and President Obama are making substantial investments in West 
Africa to address Ebola. Many, many other countries are joining 
in that effort. I applaud all of their efforts.
    What is being done in Liberia to make certain that the 
investments that are being made are part of a transition in 
Liberia to a stronger public health system? The investments in 
equipment, in laboratories, in training of health care workers? 
Is Liberia working with these nations to make sure that there 
is a long-term commitment to strengthening the public health 
system in your country?
    President Sirleaf. Congressman, first of all, I am so glad 
about the immigration law, and I wish it would be reintroduced 
and would pass to enable our Liberian doctors to come and work 
with us.
    I am so pleased that with the support of the Clinton 
initiative we had before Ebola worked on and finalized a 10-
year health system improvement plan. That plan has in it the 
training of thousands of health care workers that would be 
placed throughout the country, in all areas. It also has the 
upgrading of facilities by better equipment, better facilities.
    So this is our plan. We are now discussing that plan with 
the partners who are here working with us on Ebola and engaging 
them to start the transition from working on Ebola to support 
for our health care system, because that is the most lasting 
way to contain Ebola and to contain similar diseases such as 
malaria, on which we have made substantial progress and which 
could be reversed if we do not have the infection control 
system through a better health care delivery system.
    Senator Durbin. Thank you.
    Senator Coons. Thank you, Madam President.
    Senator Shaheen.
    Senator Shaheen. Thank you very much, President Sirleaf, 
for your willingness to join us today and for your resolute 
leadership to address the Ebola crisis that has threatened not 
only Liberia but Guinea, Sierra Leone and other countries in 
Africa.
    As you know, one of the mandates of the U.N. mission for 
Ebola Emergency Response is to help work with the governments 
affected to reinforce the leadership of those countries, 
including Liberia, and I wonder if you could talk a little bit 
about how that part of the U.N. mission has been working and 
whether the cooperation is helpful, and are there other things 
that can be done to improve that cooperation.
    President Sirleaf. The support has been most helpful to us. 
The mission works with us as we plan our responses not only for 
Ebola but responses in all of our development initiatives. 
There could be more coordination because we do have many 
partners that join us in this, and what we are doing is trying 
to ensure that we set up the mechanism that will enable us to 
be able to continue to monitor the progress that is being made, 
to continue to revise plans and to upgrade them to meet 
extenuating circumstances.
    So at this stage we are very pleased with the support of 
the mission, and when it comes to the USAID mission, I have to 
say that I cannot start saying so much for the Administrator, 
Rajiv Shah, who has just worked with us through all of this in 
so much, and has worked with so many of the other missions in 
the other countries that enable us to coordinate that, not only 
on a national basis but on a regional basis.
    Senator Shaheen. Thank you.
    Senator Coons. Thank you, Senators.
    Madam President, thank you so much for your remarks to us 
today, thank you for your leadership, and thank you for the 
opportunity to continue to work in partnership as we invest in 
sustaining the recovery of your nation, lay the foundation for 
a strong public health system, and work tirelessly together to 
ensure that this outbreak of Ebola is brought to an end. Thank 
you very much.
    President Sirleaf. Chairman Coons, I thank you and all of 
you, the members of the subcommittee, for this opportunity, and 
thank you for the support that you continue to give to Liberia, 
not only in this fight but in our overall development effort.
    May I stay and listen to some of it? [Laughter.]
    Senator Coons. Absolutely, Madam President. You are the 
President. You can do what you want. [Laughter.]
    Technically, what we are doing from a parliamentary 
procedural perspective is that we are now going to conclude 
what was a meeting of the subcommittee, and I will now gavel in 
a formal hearing of the Senate Foreign Relations Subcommittee 
on African Affairs, which is the final hearing of this 
subcommittee for the 113th Congress.
    And without objection, at the outset I would like to 
request the testimony from Save the Children and Catholic 
Relief Services be entered into the record. Additionally, I 
will request that a statement from the chairman of our full 
committee, Chairman Bob Menendez, be entered into the record.

[Editor's note.--The articles mentioned above can be found in 
the ``Additional Material Submitted for the Record'' section at 
the end of this hearing.]

    Senator Coons. I would like to invite our four witnesses 
for our next panel to come forward while I make some brief 
opening remarks.
    We plan to focus today on the factors that made it so easy 
for the Ebola virus to spread in West Africa and so difficult 
for it to be contained. It is by learning how we got here that 
I think we will be better able to prevent flareups and future 
outbreaks of Ebola and other highly infectious deadly diseases 
and reduce the likelihood that American and international 
intervention will again be necessary.
    Ebola to date, in this outbreak in three countries in West 
Africa and several others, has claimed the lives of more than 
6,000 men, women and children that we know of, and has infected 
nearly three times that many, mostly in Guinea, Liberia, and 
Sierra Leone, and has claimed the lives of 330 health workers, 
who I was pleased to see earlier today were recognized by Time 
Magazine as person of the year. It is often the unsung, 
unheralded men and women who took to this challenge on the 
ground and from throughout the world who I think we should be 
lifting up and supporting in the weeks and months ahead.
    The international community, as we all know, was slow to 
respond to the outbreak and is still working to catch up, but 
the U.S. Government has already invested more than $780 million 
in the Ebola response effort, nearly twice the amount of the 
next largest donor, and I am grateful for the leadership 
actions of President Obama to ensure that members of our Armed 
Forces and the United States Uniform Public Health Service have 
been deployed and made available.
    My understanding is that as of this week, roughly 2,600 
U.S. Armed Forces and public health personnel are deployed in 
West Africa.
    Our contributions are having a marked impact, as you heard 
from President Sirleaf. U.S. support for the establishment of 
Ebola treatment units and safe burial teams have contributed to 
a significant reduction in the rate of growth of the disease. 
However, our work is indeed far from done. Sierra Leone has 
seen a sharp rise in recent cases, and as cases continue to 
grow, Sierra Leone has surpassed Liberia, which previously for 
months had had the highest caseload. As we have heard from 
President Sirleaf, Liberia is still wrestling with this virus 
but is making very hopeful progress. Mali also recently saw its 
first Ebola cases in October and now has eight.
    Ebola is a volatile virus with the potential to flare up at 
a moment's notice, and we need to be able to react as quickly 
as possible to contain it. So I hope we will talk about how we 
work together with our partners to ensure that we are prepared 
for future outbreaks and that we build at the ground level the 
public health resources that we need.
    The U.S. Government was the first international governance 
institution to step in when the NGO community, which had been 
on the ground for months and truly led the response to Ebola, 
called for our response. It is because the United States 
stepped in, and at the scale we did, that progress has been 
made in combating this terrible disease. This is, as others 
have said, not just a matter of our national security, it is a 
matter of fundamental humanity.
    We cannot as a country go back to the sidelines and watch 
these already impoverished and unstable countries fall apart 
when we as a nation have the resources and the calling to help 
turn this crisis around. I am elated to have heard from 
Appropriations Committee leadership that $5.4 billion in 
emergency funding is included in the appropriations package 
that will be taken up and voted on this week by the Senate of 
the United States to contribute to the pace and scale and 
investment required to not just control this outbreak but to 
invest in preventing future outbreaks.
    The four witnesses who join us here today represent 
organizations that were fighting this Ebola outbreak far before 
headlines appeared here in the United States and have done 
heroic work for which all of us should be grateful.
    Before I turn this over to my friend and distinguished 
ranking member, I just wanted to note what a pleasure it has 
been for me to chair this subcommittee these last 4 years. I 
have had the honor of sharing this dais over many hearings with 
two wonderful ranking members, Senator Isakson of Georgia and 
Senator Flake of Arizona, who care deeply and passionately 
about Africa and with whom it has been a true joy to work.
    Senator Flake.

             OPENING STATEMENT OF HON. JEFF FLAKE, 
                   U.S. SENATOR FROM ARIZONA

    Senator Flake. Thank you, Senator Coons, and let me just 
return the sentiment. It is wonderful to work with a chairman 
who not only cares deeply about the continent but has so much 
experience and firsthand knowledge and a desire to learn more 
all the time, and it has truly been a pleasure working with 
you, and I look forward to a long-time partnership on these 
issues. I want to thank you for calling this hearing as well, 
and for your response on this issue early on and encouraging a 
more robust response from the United States. I think the 
response that we have seen is, in large measure, due to your 
efforts. So, thank you for that, and thanks for this hearing.
    I appreciate the witnesses being here and look forward to 
hearing what you have to say. As Senator Coons mentioned, there 
is a significant investment that has been made by the United 
States and the taxpayers, and we represent them. We want to 
make sure that the hard-earned funds that are being spent here 
are done so wisely. So that is why we are so anxious to hear 
from you on what we need to do, one, for the current crisis, 
and moving ahead what we need to do to make sure that we do not 
have flareups as well.
    So, thank you for being here, look forward to the 
testimony.
    Senator Coons. Thank you, Senator Flake.
    I would now like to turn it over to our witnesses to make 
opening statements, and I will offer a brief introduction of 
each of you in turn.
    First is Dr. Paul Farmer, one of the founders of Partners 
in Health. Dr. Farmer has been a revolutionary voice in public 
health globally and in working to build and sustain community-
based health care institutions since the 1980s. He heads the 
Department of Global Health and Social Medicine at Harvard 
Medical School. Partners in Health had a footprint in West 
Africa prior to this outbreak, and Dr. Farmer has been on the 
front lines of soliciting international support for the Ebola 
response effort, and I am grateful for his passionate voice 
around the questions of equity and access to health care 
globally.
    Dr. Anne Peterson is the vice dean of the Public Health 
Program at Ponce Health Services University and is former 
director of Global Health for World Vision and former USAID 
Assistant Administrator for the Bureau of Global Health. Dr. 
Peterson recently returned from Liberia and Sierra Leone, where 
she was working through World Vision to identify gaps in 
response efforts and evaluating how stakeholders have been 
coordinating efforts on the ground.
    Mr. Pape Gaye is the president and CEO of IntraHealth 
International, which is focused on strengthening health systems 
by training health care workers in developing countries at the 
community level. A native of Senegal, Mr. Gaye has been a 
lifelong advocate of health systems strengthening in developing 
countries and now more than ever can speak to the needs in 
these crisis-stricken countries.
    And last but certainly not least, Javier Alvarez is the 
Liberia country director for Mercy Corps, with more than 15 
years of experience at UNDP and UNICEF, and he is an expert on 
humanitarian emergency response and wrote Mercy Corps' most 
recent report on the economic impact of Ebola in Liberia.
    Thank you, all of you, for your service, for your time, for 
your advice, and we look forward to your input.
    Dr. Farmer.

          STATEMENT OF PAUL FARMER, M.D., COFOUNDER, 
                 PARTNERS IN HEALTH, BOSTON, MA

    Dr. Farmer. Thank you, Mr. Chairman. Thank you, Senators. 
And greetings, Madam President. It is wonderful to see you, and 
thank you for the warm welcome that you have showed our teams 
in Liberia, and the leadership that you have shown in 
responding.
    I am making just very brief and illustrative comments and 
will submit a more extensive written comment to the record, if 
that is acceptable to you, Senator.
    Senator Coons. Without objection.
    Dr. Farmer. I just wanted to--and I apologize for 
obliterating it. I do not know if there is an image that comes 
up. I would rather look at the President myself. But just as a 
reminder, the matter of zoonoses--that is, diseases that leap 
from animals to humans--is an important one. It will remain 
important. In the 1960s and 1970s and 1980s, some of these 
hemorrhagic fevers were first described, and remember HIV 
shortly thereafter, also a zoonosis which spread into a global 
pandemic. I believe this is what we are here to avert with a 
much more rapid, clinically rapid pathogen, Ebola.
    Now, one of the questions that I was asked to address was 
how did this disease spread quickly. Every time there is an 
epidemic, there are explanatory voids where lots of assertions 
are made, and we heard in this example a great deal about bush 
meat and other exotic modes of transmission. We should be very 
clear that the rapid spread of Ebola is not due to 15,000 
episodes of bush meat eating frenzy but rather to person-to-
person transmission in a setting of weak health care 
infrastructure. So the diagnosis, speaking as a physician, is 
that it is critical that we understand that. So, weak health 
systems are responsible for the spread.
    In interviewing survivors--these are three young people 
from Sierra Leone, but it is not a different story elsewhere in 
the region--there are very few mysteries. These are people who 
are looking after members of their families--their family 
members--while they are sick or after they have died. As in 
every culture in the world, we respect the dead, we bury the 
dead. That is actually in my faith tradition one of the 
corporeal works of mercy, if I get my Sunday school memory 
back, bury the dead. Of course, this is not something that can 
be easily wished away, that people stop revering those who have 
passed away and honoring them. So these are, as has been said, 
in a way, the heroes of the epidemic.
    Now, what I hope we will be able to focus on in the hearing 
is what usually does not happen with emergency responses. The 
last time I was in this room was shortly after the earthquake 
in Haiti, making these very same points, and yet President 
Sirleaf has made them more effectively. We need to address the 
human resources for health crises. We need to build local 
capacity, local systems, and local health care infrastructure. 
That is how we will avert the next disaster.
    This has gone under the unglamorous name of health systems 
strengthening. I think we need a consultant to help us think of 
something--you know, we all of us talk that language, but we 
need a little help from you. These are substantial resources 
you have requested, and we are thrilled to see that many of 
them will go into health systems strengthening that has a 
significant component focused on building local capacity in 
places that include Liberia, Sierra Leone, and Guinea.
    I would like to just close by saying I personally am proud, 
as an American, of the CDC's role, the NIH, other American 
institutions that have stepped up. I think I am very grateful 
for my colleagues who are physicians and nurses from the states 
you represent and all across the country who have gone in to 
serve Partners in Health, who is proud to be part of this 
coalition. We will seek to promote health systems strengthening 
while we are looking for the new and sexier term and to open 
with our colleagues in the public health sector in Liberia and 
Sierra Leone--and we hope one day Guinea--many clinical units 
able to take care of people sick with Ebola.
    But also, as noted, and maybe I skipped over this, the 
largest number of Ebola victims will not have Ebola. They will 
have malaria, they will have obstructive labor, they will have 
minor injuries that, because there is no health care system, 
will fester and take their lives or maim them in other ways.
    So we are looking forward to responding over the course of 
the coming years and again are grateful to the President for 
being here with us today, but also for being such a welcoming 
host. Thank you.
    [The prepared statement in the form of slides of Dr. Farmer 
follows:]




    Senator Coons. Thank you, Dr. Farmer.
    For several members of the subcommittee who have joined us, 
the President of Liberia made remarks previously and has 
graciously agreed to stay and to hear from our witnesses.
    Dr. Anne Peterson.
    Dr. Peterson.

 STATEMENT OF E ANNE PETERSON, M.D., VICE DEAN, PUBLIC HEALTH 
   PROGRAM, PONCE HEALTH SCIENCES UNIVERSITY, WORLD VISION, 
                         WASHINGTON, DC

    Dr. Peterson. Thank you, Chairman Coons and Ranking Member 
Flake, and subcommittee members as well; and thank you for 
having this hearing and for inviting me to be here.
    I went to Liberia and Sierra Leone not so much to look at 
what was being done well--and I will say many things are being 
done very well in all of the countries, and especially in the 
United States response--but my terms of reference as I went 
with World Vision was to look at what are the gaps, what are 
the gaps between what the faith communities are doing or could 
be doing and how well are they working together with the U.S. 
Government.
    So I will try to focus my remarks on six areas where I 
think we could do a little better than we have. Three of them 
are in areas of ongoing effort, and the first is in the need 
for cross-cutting coordination.
    If you talk to anyone who is working on the ground, they 
will tell you there is a lot of coordination happening. There 
are meetings and meetings and pillar meetings and coordination 
meetings. But they are all focused in their more narrow 
vertical programming. We have seen this all along in health 
development. Vertical programs, vertical efforts can be very, 
very effective. But when you do that, you do not build an 
intact health system. So as I went and looked across the 
pillars, across government agencies and NGOs and faith-based 
organizations, as I looked at the difference between what was 
happening in Liberia and Sierra Leone, in fact there were a 
number of places where it was clear that if we had had a bigger 
view, a cross-cutting collaboration and coordination, we would 
have had economies of scale, we would have had reduced 
duplication, and some of the gaps in what needs to have been 
done would not have been missed.
    So my first call was outlined in the Institute of Medicine 
report that was published this summer, ``Investing in Global 
Health Systems: Sustaining Gains and Transforming Lives,'' that 
I was honored to cochair with Ambassador John Lang. We talked 
about this need to go from vertical focus to a broad health 
systems approach, and the same thing is happening right now in 
Ebola response, and we can do better than that.
    The next is to invest sustainably. Very rightly, 
investments that the U.S. Government and others are putting in 
are focused on stopping Ebola. Stopping Ebola is absolutely 
essential. But we are also setting it up in such a way that the 
ground is being cleared, the tents are being put up, the labs 
are set, the foreign doctors and health care workers are coming 
in, and when Ebola is done, my desperate fear is that the tents 
will be rolled up and the expats will go home, and what will be 
left will be the previous health system that is only more 
broken than before Ebola came.
    So as we are doing just what we should be doing in 
addressing Ebola, if we could focus on investing it so that it 
will make permanent improvements in the health systems; to be, 
in fact, training and building health worker capacity even as 
we deal with the Ebola epidemic itself.
    My third ``do it better'' comment is in the area of 
listening to communities. Communities are part of the health 
system. If, in fact, we do not hear their needs and address 
their needs, they do not respond to our behavior change 
messages. So we heard from President Sirleaf that people heard 
messages that this is a terrible disease, it is a fatal 
disease. Well, if that is so, then why would you send your 
child to disappear into an Ebola treatment unit and never come 
home? Instead, we should be looking at what can be done, 
celebrating survivors, knowing that people can protect 
themselves, protect their families. By going in sooner when 
they have Ebola, they can prevent transmission to their 
families.
    So I would ask that all of the communities and the 
collaboration that is going on, do not just talk to one 
another. Remember to go in and talk to the people of 
communities. Some of the best messages I heard were talking to 
mothers in the slum communities in Monrovia and Freetown, and I 
will tell you I am not surprised that in Freetown, in Sierra 
Leone, cases are going up. It is exactly what I expected as I 
looked at both the economic issues and the behavioral issues 
and Ebola approaching those slum dwellings.
    So there are now three game changers, and I am almost out 
of time. You probably have not heard about rapid diagnostic 
tests as a major game changer. I will tell you that if we could 
distinguish between who has Ebola and who does not have Ebola, 
you would change how many people are in the Ebola units, and 
you would be able to remove those from risk who do not have 
Ebola, the malarias that look like Ebola. You would change the 
ability of health care workers to go in and man the regular 
outpatient departments so we could begin to address the 
indirect impacts and profound health impacts of other diseases, 
and we would change what happens in burials.
    Maybe up to 70 percent of community transmission is now 
happening in funerals and burials. If people knew when someone 
died whether they truly were an Ebola patient or not, we would 
then have fewer Ebola burials. We would not be doing Ebola 
burials with destruction of homes for those who are not Ebola 
patients. So for me, the rapid diagnostic test is a profound 
game changer in almost every aspect, and it would stop a lot of 
transmission.
    The last and probably most important, if we are going to 
listen to communities and learn from them, we need to work with 
the faith-based sector. They are the link between our 
governments, our NGOs, and the communities. They know where the 
orphans are, they know where the people in need are, and they 
are an incredible vehicle. There are starting to be quite a 
number of things. World Vision is doing safe burials, but 
dignified and safe burials, meeting the cultural needs of the 
people.
    In closing, I will just say that I would suggest that we 
need to focus on listening better, building back better, 
partnering with the communities and the faith-based 
organizations; and I, like Dr. Farmer, am very pleased and very 
proud of the work that the U.S. Government has been doing in 
West Africa.
    Thank you.
    [The prepared statement of Dr. Peterson follows:]

               Prepared Statement of Dr. E Anne Peterson

    Chairman Coons, Ranking Member Flake, and subcommittee members, 
thank you for conducting this hearing on what remains a critical issue 
to Americans and to the people of West Africa. Thank you also for the 
honor of being able to speak with you about Ebola. I have spoken before 
this committee previously when I was Assistant Administrator for Global 
Health at USAID, but now hopefully will bring a civil society and on 
the ground perspective on what is and could be done to address Ebola in 
the affected countries.
    Recently, I spent most of a month first in Liberia and then in 
Sierra Leone as a consultant to World Vision. My terms of reference for 
that consultancy were very similar to the questions to be discussed in 
this hearing. I was to assess what was being done, what could be done 
better and what additional capacity was needed to meet the gaps. The 
focus of the assessment was on what the faith sector was contributing 
to the response. My broad terms of reference connected me with a 
variety of government agencies (U.S. Ambassador in Liberia, CDC, USAID, 
DFID, and both national Ministry of Heath representatives) as well as a 
myriad of NGO, FBOs, and individual faith leaders. We were able to see 
an incredible amount of what was happening in response to Ebola could 
spend time with people in communities in both the countries we visited. 
This gave us a big picture view of the response but also gave us access 
to the community perspective that highlighted strengths, weaknesses, 
gaps and growing needs that had not been addressed yet.
    I would like to focus my testimony on three areas of current work 
that I believe could be enhanced, three ``game changers'' and then some 
suggestions about how future USG investments might be prioritized to 
speed ending the Ebola crisis, mitigate the suffering of the countries 
most impacted and help rebuild the health system so that Ebola or other 
similar crises never take hold again at this level. Let me say first 
and strongly, that the emphasis on stopping Ebola is the correct focus 
and there is a great effort to achieve that end, but there is room to 
work smarter and to greater effect. The international aid community is 
fully aware of the need for coordination, correct messaging and need to 
build health care capacity but the workload and vertical pillar 
approach have limited the perspective and effectiveness in each of 
these areas. With some new perspectives the current work could be 
significantly more effective. Some of these needed changes were 
beginning to happen as I left Africa but clarity and encouragement to 
continue those improvements will maximize impact and the usefulness of 
the U.S. investments in Ebola. The three game changers would be (1) 
engagement and mobilization of the faith community; (2) availability of 
a rapid Ebola test; and (3) addressing now the massive indirect impacts 
of Ebola on the economy, society, and health of the impacted countries. 
Each of these ``game changers'' would significantly help reduce 
transmission of Ebola and mitigate the immediate and long term harm of 
the epidemic, beginning to reestablish a stable, functional system.
            achieving greater impact in our current efforts
    There are several ways that the current Ebola epidemic response 
could be improved to achieve greater impact, both in the immediate and 
the long term.
    First, there is a need for cross-cutting coordination. Coordination 
of effort is essential and a great deal of time and energy is 
appropriately being expended on coordination with national government 
and collaborating aid agencies. While the current coordination is 
essential the intensity of the response work and the narrow focus of 
work within each of the coordinating pillars leaves little time for 
collaborating across pillars, agencies or even learning lessons from 
nearby affected countries. Opportunities for synergy are lost, 
unnecessary duplication of effort is inevitable. These are predictably 
inefficiencies and like vertical programming of the past measureable 
and laudable progress might be happening in a certain ``pillar'' of the 
response, but the disconnected pillars do not build a coherent health 
system. The gaps between the vertical pillars are no one's 
responsibility and go unnoticed until they reach harmful levels. The 
recent Institute of Medicine (IOM) report that I was honored to cochair 
with Ambassador John Lange, ``Investing in Global Health Systems: 
Sustaining Gains, Transforming Lives,'' speaks about the limitation of 
the piecemeal approach to health and cites this Ebola outbreak as an 
example of what happens without a strong and intact health system. Our 
Ebola response is falling into a similar vertical, piecemeal set of 
actions.
    Invest sustainably. The U.S. is investing heavily in the Ebola 
response and doing good Ebola control response with the invested funds. 
It is probably necessary, at least for patient care, that there is a 
parallel Ebola system in addition to the regular health care 
infrastructure. We do want to separate Ebola patients from other 
patients to prevent transmission. We are clearing land, putting up 
tents, and manning Ebola units primarily with foreign medical 
personnel. While this is due in part to an existing lack of health care 
workforce exacerbated by the epidemic, it is not an approach that will 
help build national capacity, either in health facilities or workforce. 
When Ebola has been halted, the tents will be rolled up and removed, 
the foreign workers will return home. The other preventable health 
problems that have been ignored and neglected by a health system either 
shut down or diverted to Ebola will be of far larger proportions than 
before Ebola emerged. And unless we do our current work differently, 
the health system which has lost so much manpower will be weaker than 
before Ebola while forced to address greater and ongoing health 
challenges. It is possible, to address the urgent Ebola scale-up needs 
in a way that contributes to a stronger and sustainable health system. 
If we plan and invest only in the short-term control of Ebola, we will 
miss a great opportunity to strengthen national health systems to build 
their capacity to address the already prevalent preventable maternal 
and child deaths or to avert or respond to the next major health 
crisis.
    Listen to the communities. There are so many meetings and long 
conversations among all the Ebola response agencies that it isn't 
obvious initially that conversations are primarily between foreign aid 
workers and the government officials and rarely do we hear the voice of 
community members. Decisions and activities in the Ebola response have 
in some cases led to distrust and anger in communities, messages on the 
seriousness of Ebola have been scoffed at as unreal by some and taken 
fatalistically by others. In many instances, well intentioned 
scientifically based messages just haven't elicited the behavioral 
responses from the communities that were desired and transmission of 
Ebola therefore continues. The only way to develop effective behavior 
change programs and messages is to know and address the issues of the 
community from their perspective, addressing the fears and beliefs that 
have hindered the response effort. Listening before messaging is the 
key. Listening to the concerns of community members, the mothers with 
young children as well as leaders who might be at the decision tables 
will lead to a better understanding of what is needed to change 
behaviors and reduce Ebola transmission.
            game changer: engaging with the faith community
    If most Ebola transmission is happening in communities, as it is, 
and if we acknowledge it is hard for foreign aid agencies to link 
directly to communities, then an interface or intervening organization 
is needed. Far better than secular NGOs, faith-based NGOs or FBOs and 
church or Muslim associations are deeply embedded and knowledgeable 
about their communities and can link the voices and views of the 
communities to the Ebola response.
    The U.S. Government has long worked with faith-based organizations. 
Engaging with FBOs was critical in the war against AIDS and rose to 
some prominence in the implementation of PEPFAR. Longer ago than 
PEPFAR, local churches were instrumental in the small pox eradication 
efforts in the same West African settings now beset by Ebola. Yet, USG 
engagement with FBOs or mobilization of the faith networks has not been 
a core part of the Ebola response to date.
    A core focus of my work in Liberia and Sierra Leone was to conduct 
a qualitative assessment for World Vision of the roles of faith-based 
organizations (FBOs), churches and faith leaders in the Ebola response; 
what were they doing, what could they be doing and how could they be 
better integrated with the U.S. Government Ebola response. Granted, 
there are fewer FBOs who work in disaster humanitarian operations type 
settings, but there are some FBOs experienced, willing or active, such 
as Samaritan's Purse work in Liberia that responded early and at great 
cost in establishing Ebola treatment centers. Medical Teams 
International is providing training in infection control. Catholic 
Relief Services, CAFOD (another Catholic FBO), Catholic Medical Mission 
Board, MAP international, IMA World Health and World Vision all are 
participating in different places and ways.
    I'll use World Vision as just one example of what FBOs can 
contribute to the fight against Ebola. World Vision works primarily in 
Sierra Leone and has taken on unusual leadership roles in addressing 
Ebola, such as efforts to improve safe and dignified burials, training 
pastors and imams on Ebola prevention and stigma reduction, and 
addressing the indirect consequences of Ebola (including food 
insecurity, livelihoods, care of orphans and survivors, and educating 
children while they are out of school).
    The first and perhaps most urgent FBO coalition activity was taking 
on safe and dignified burials. The World Vision coalition in Sierra 
Leone, with Catholic and Muslims partners, has taken on managing, 
training, and paying burial teams in 12 of the14 districts. They are 
making sure the Ministry of Health burial teams are actually paid for 
their gruesome work, using their financial management expertise. As 
result of this effort, there are fewer burial team strikes and great 
progress has been made toward responding and conducting all burials 
within 24 hours.
    The added value of the FBO rather than secular coalition is that 
they have added a strong emphasis on how to convert safe but offensive 
burial practices (mass unmarked graves, no markers, no prayers or 
family attendance) into safe but dignified burials acceptable to the 
communities. As burials become ``dignified'' and faithful to spiritual 
traditions, families will no longer need to conduct the high risk 
transmission secret burials of Ebola deaths that are occurring now.
    But the issue isn't just what are international FBOs doing but what 
are the faith leaders and local churches doing and what part could they 
play in the Ebola response in their communities. In Liberia, there was 
more vigorous infection control but less visible coordination among the 
faith community. The reverse was true in Sierra Leone, where infection 
control practices were more lax but there was more action and greater 
coordination among the local faith community.
    The church, as has been true in past epidemics like AIDS, has been 
mixed in their response. There are many examples of churches being 
helpful and others that spread messages and practices contrary to 
helping control the spread of infection and discourage stigma. The 
situation is improving over time as the stark reality of Ebola hits 
congregations directly. Most churches have stopped the practice of 
greeting one another with handshakes or kisses or ``laying on of 
hands'' in prayer for the sick. Many, but not all, churches and mosques 
now have chlorine and hand-washing stations set up before people enter 
the church though sometimes the chlorine is missing and the water 
bucket is dry. A brave few churches were venturing out from their 
church buildings to conduct services right outside the doors of Ebola 
treatment units so patients can hear that others are praying for them. 
Others are beginning to note and address the needs of widows and 
orphans, or provide trauma counseling for devastated families. Support 
and reassurance from faith leaders is essential also in helping the 
transition to safe and dignified burials be acceptable to their 
communities. If faith leaders are engaged and informed they can even 
pave the way for acceptance of new tools, like an Ebola vaccine or 
rapid diagnostic test once they are available.
    The faith community has a clear command to meet the needs of their 
people, but as the epidemic has spread, the desire for reliable 
information has grown but many churches and mosques do not have 
reliable ways to learn about Ebola to correctly guide their 
congregations. Some have welcomed scientists from the CDC to their 
services to learn about Ebola. In addition to information from the 
government and CDC, there is a need to frame the science of Ebola 
response into the more familiar faith language of the Christians and 
Muslims. World Vision is leading another consortium, working with CRS 
and the Muslim organization Focus 1000, on the production of a toolkit 
on Ebola messaging to be disseminated through the leaders of each faith 
group. World Vision is combining the available scientific information 
on Ebola with the faith oriented tool kit into a reflective and action 
oriented training for a wide array of faith leaders, Muslim and 
Christian, through its Channels of Hope program which had previously 
been developed and used for training in HIV/AIDS.
    Through this tool, faith leaders can reduce negative messages and 
enhance positive ones, such as that reporting in to Ebola centers as 
soon as the disease is suspected protects their families from harm. 
Rather than preaching fear, faith leaders can affirm that God works 
through His people to meet the needs of the sick, widows, and orphans. 
Framing the stigma being experienced by families of victims and 
survivors in parallel to biblical example of reaching out and caring 
for lepers and outcasts can be particularly helpful in reducing stigma 
faced by survivors. Correct information, in the hands of faith leaders, 
harmonized and expressed in their faith language, can overcome 
widespread mistrust of the government and by extension the Ebola 
response. FBOs and faith leaders can encourage the people of Liberia, 
Sierra Leone, and Guinea not only to respond more appropriately to 
Ebola but to be active agents to stop the spread of Ebola and mitigate 
the enormous personal, spiritual, and societal impacts of Ebola on 
their people.
    But the impact of Ebola and the opportunities for faith leaders and 
FBOs to mitigate the impact of Ebola goes far beyond stopping Ebola 
infections. Food insecurity is increasing as prices rise and farmers 
are not planting crops. Attention is also diverted from other health 
issues. Most deaths in Ebola-affected countries are not Ebola deaths. 
The even larger epidemic of deaths is from pneumonia, childbirth, 
malaria, and diarrhea due to the Ebola epidemic's impact on the health 
care system, lack of preventive services and broken societal and 
economic structures. Addressing these issues cannot wait for the end of 
the Ebola outbreak and the global health community, FBOs and faith 
leaders know how to prevent these deaths. It is the kind of work they 
are already called to do. They just need encouragement and resources to 
take on the daunting devastation of the impact of Ebola on these 
countries.
             game changer: rapid diagnostic test for ebola
    Ebola symptoms are similar initially to many other diseases. This 
nonspecificity of symptoms has profound impacts on health care worker 
risk and on patient care seeking behavior. I would argue that not being 
able to know promptly whether a patient (or body) has Ebola or not is a 
major driver of continued Ebola transmission and the cause of the 
collapse of almost all other health services, leading to unmeasured 
numbers of non-Ebola deaths indirectly caused by Ebola. A rapid 
diagnostic test would have a dramatic impact on both health care 
workers and patients
    Most of the recent health care worker infections have not occurred 
in Ebola treatment centers but in settings where they thought they were 
treating illnesses other than Ebola. A doctor was infected and died 
after delivering a baby. Forty-two health workers were infected by one 
Ebola patient, a friend who claimed initially only to have an ulcer. 
Twenty one of those health workers died. Each time a health care worker 
in a non-Ebola center is infected and diagnosed as an Ebola patient, 
all his or her health care worker colleagues become contacts, must be 
quarantined and often the care center closes until the 21-day 
quarantine is completed. Perhaps as much as two-thirds of the regular 
health system is closed and once closed, it is very hard for health 
care workers to return to take on again the risks of caring for 
patients who are not supposed to have Ebola but might.
    Patients, just like doctors, can't tell the initial Ebola symptoms 
apart from many other common diseases. Unless they have had significant 
exposure to a sick or dead Ebola patient, most of the symptoms will be 
due to malaria, diarrhea, typhoid fever, lassa fever or the number one 
child killer, pneumonia. These very common illnesses, have only become 
more common as the immunization programs, malaria prevention programs, 
outpatient treatment centers have closed in mass. Mothers, in poor slum 
areas have stated emphatically, that if they or their child was sick 
with a fever or a stomach ache or diarrhea they would not bring them in 
to a treatment center. They know these symptoms could be Ebola, but 
they believe sometimes rightly and sometimes with wishful thinking, 
that it is far more likely to not be Ebola than to be Ebola. They don't 
want to risk ``disappearing into an Ebola'' center never to return. 
When someone becomes sick they are rightly afraid to come in for care. 
If their symptoms could at all be like Ebola, as is true of many common 
illnesses, they know they will be held in Ebola observation until the 
test result is known 2-3 or more days later. They also know that 
staying in these holding centers with suspected Ebola cases puts them 
at high risk of being infected with Ebola while seeking care for 
another health problem. Very logically they stay home until it is clear 
they have Ebola. They would rather risk their child dying at home of 
malaria than risk getting Ebola and dying far away.
    But if in fact, the sick person has Ebola the delay in accessing 
care has impact on more than just that one individual. We have learned 
in this epidemic that Ebola is both more infectious as the disease 
progresses and that infectivity is dose dependent. The sicker and 
longer an Ebola patient stays in the home the greater the likelihood of 
transmission to family and friends.
    But if we had a rapid Ebola test at the triage of all non-Ebola 
centers and maybe even available for community health workers, all of 
these scenarios are changed. Health care workers could safely go back 
to work and families could safely bring their sick family members in 
for diagnosis and treatment. Communities, families, and patients would 
know only non-Ebola patients would be in the regular health centers and 
Ebola patients would be referred to now much less crowded Ebola 
centers. This would decrease transmission of Ebola in communities 
because families would be less likely to delay. It would decrease 
transmission within holding and quarantine centers. Patients could 
safely seek treatment for malaria and the increasing common diseases 
caused directly by the diversion of care to Ebola and halting of 
preventive and curative services other than Ebola. It would even reduce 
transmission in Ebola centers where uninfected suspect cases were 
previously being exposed to Ebola. Health care workers, both national 
and international volunteers, who are not ready to treat Ebola but do 
want to assist with the devastating health needs in the impacted 
countries could safely return to work. We could begin to rebuild the 
broken health system that allow the Ebola rampage to begin and continue 
unchecked.
    Community Ebola burials have been a source of anger and sometimes 
violence, especially if it turns out the death was not an Ebola death. 
A rapid test would contribute rebuilding of relationships with the 
community and to decreasing transmission since only the fewer and 
proven Ebola burials would need Ebola burials. If secret burials were 
thereby avoided, we would begin to get more accurate death reporting, 
surveillance, and referral. It would also help ensure when there is a 
non-Ebola death that homes and possessions aren't destroyed 
unnecessarily. A rapid diagnostic test would facilitate more rapid 
access to care for family contacts, less breaking of quarantine and 
fewer contacts lost to followup. All of these impacts will lead to 
better data on deaths, reduced burial transmission and better 
relationships with community members, which directly or indirectly 
enhances Ebola infection control.
          game changer: address the indirect impacts of ebola
    The massive indirect impacts of Ebola on the economy, education, 
social structures and health of the impacted countries are much greater 
and long-lasting than the impact of the Ebola epidemic itself. The 
plight of children demonstrates just a portion of this impact. WHO 
estimate of the number of orphans from October 29 for the three 
countries was 10,395 single orphans and 4,455 double orphans. These 
numbers corrected for underreporting (CDC uses 2.5 fold multiplier, 
which has been verified in an active surveillance activity in November) 
would make the estimated total orphans 25,986. Because of the previous 
civil war, there were many single parented homes in both Liberia and 
Sierra Leone. When Ebola hits these vulnerable homes, with perhaps 
greater adult vulnerability to Ebola than children, there are a 
disproportionate number of double orphans which is unprecedented even 
in Africa. In Sierra Leone, 42 percent of the orphans are double 
orphans and in some districts there were more double orphans (both 
parents dead) than single orphans. This was unheard of even in the 
height of the AIDS epidemic.
    Life is difficult in Sierra Leone and Liberia, even before Ebola. 
There are high child and maternal mortality rates and poverty in both 
countries, which was just beginning to improve after the civil war of a 
decade ago. Now, ALL children are impacted by Ebola. Most are out of 
school for the entire year, with some radio broadcast classes as their 
only educational input. About 50 percent of parents have been keeping 
their children home--all the time--no friends, no family gatherings, so 
they aren't exposed to Ebola. Most of the regular health care 
facilities are closed for any usual illnesses--malaria, diarrhea, 
pneumonia. Children (all children but even more so for orphans) are 
less well-nourished because of increasing poverty and food insecurity, 
they are also no longer receiving preventive services like Vitamin A or 
routine vaccinations. Therefore disease rates are escalating just as 
access to all health services, except Ebola services, are decreasing.
    Stigma is a debilitating reality for children, adult survivors, and 
families of Ebola victims even if they never had Ebola. People are 
afraid of the children as potential vectors of Ebola but also don't 
trust that the children won't bring Ebola into their home, even after a 
21 day quarantine. Unlike other orphan situations in Africa, the 
extended family is very reluctant to take the children in. Even those 
who would, usually can't afford to take in extra children. The economy 
is so hard hit with so many businesses and schools closed that there is 
little income. Families in poor urban areas have gone from two meals a 
day to one meal a day for their own children and just can't feed 
anymore. In rural areas, between stigma and lack of crops, orphaned 
children are abandoned in large numbers. People are also afraid of 
survivors, especially since even when a survivor is no longer 
infectious they often have continued symptoms of migratory joint and 
muscle pain--which people misinterpret as still sick with Ebola. 
Survivors often move across the country to avoid anyone knowing they 
were sick with Ebola even if they are fully recovered.
    Often survivors also have no home to return to or family members 
have no home to stay in. When a sick person or body is picked up the 
house must be decontaminated, this may destroy much of the household 
belongings and the house itself is stigmatized as an Ebola house. It 
may in fact be infectious for a few days so care and decontamination is 
needed. But the process leads to further impoverishment and 
stigmatizing of those who have just been through the horrific 
experience of being sick with Ebola.
    The indirect impacts of Ebola need immediate and long term 
response. Without food and financial support food insecurity now, is 
likely to evolve into something closer to famine in a few months. WFP, 
UNICEF, and some NGOs, like World Vision, are beginning to partner with 
faith leaders and communities to identify hard hit communities, orphans 
and other vulnerable children (OVC) and survivors to begin to provide 
child protection, food, and safe places to live.
    These devastating impacts of Ebola warrant attention in their own 
right. These are illnesses and deaths we know well how to prevent. But 
ignoring them also impacts Ebola prevention efforts. Sick and 
malnourished children maybe more vulnerable to Ebola but certainly will 
add to the case load of an already overburdened health system. Every 
malaria case prevented is one less diagnostic dilemma that complicates 
isolation of suspected Ebola patients. When hunger, illness, or 
economic necessity compel someone to break quarantine more Ebola 
transmission is possible. When these other concerns loom so large and 
compromise life and health, Ebola precautions fall in relative 
importance and increased transmission becomes more likely. We cannot 
wait until the end of the Ebola outbreak massive indirect impacts of 
Ebola on West African society. Again, in Sierra Leone World Vision is 
ahead of the game in commissioning a rapid assessment of these indirect 
impacts of Ebola. They will use the information to help them reprogram 
their own funds but I believe this information will also provide 
desperately needed data for advocacy and prioritization of the global 
efforts.
What could/should the USG do?
   Stop Ebola by enlisting the assistance of those who care 
        even more than we do--the people of Liberia, Sierra Leone, and 
        Guinea. Work with trusted faith leaders to empower communities: 
        listening to their concerns and potential solutions.
   Rebuild better not separate and temporary. The incredibly 
        weak heath system, lack of surveillance systems, labs, 
        inadequate workforce are the things that allowed the Ebola 
        outbreak to reach such epic proportions. Instead of building a 
        parallel system, in tents and manned by foreign health care 
        workers, we should be ``building back better'' in ways that 
        last; upgrading permanent facilities, building communications 
        systems, training all cadres of health workers in infection 
        control and disease treatment with a strong emphasis on 
        preventive medicine, public health and community-based 
        interventions and disease prevention. It would have been far 
        easier to identify the first cases of Ebola if they were not 
        lost among the many sick from diseases we know how to prevent.
   Don't wait. The indirect impacts of Ebola on the people of 
        each of these countries are enormous. As poverty, malnutrition, 
        lack of school and work and preventable diseases increase, 
        Ebola control will fall lower on the population's priority 
        list. If you can't feed your child, the ``far away'' risk of 
        getting Ebola becomes much less important.
   Listen well, address their fears, give messages of hope, 
        celebrate survivors, and empower parents, families and 
        communities to protect themselves and assist in the response.
   Message at home. Stopping Ebola in Africa is the best 
        protection for Americans and celebrate those willing to serve 
        in Africa. Healthy people don't transmit Ebola. Health care 
        workers are not a danger to Americans just because they have 
        worked in West Africa. We need to encourage American volunteers 
        who want to help to be able to go and to be able to return home 
        without stigma, shunning and exclusion from normal American 
        work and society. The inappropriate level of fear is hindering 
        the flow of aid workers needed to stop this Ebola epidemic 
        there and increasing the risk of spread here.
                               conclusion
    I am very proud of my country for its extraordinary efforts to 
address Ebola. The investments by the U.S. to address the Ebola 
outbreak in West Africa are critical and are the best way to protect 
the American people. We have learned an immense amount in this current 
epidemic, that we couldn't have learned from previous smaller 
outbreaks. But we must continue to learn and to apply the lessons 
learned, to improving our medical and the nonmedical programs, 
addressing the urgent demands of stemming the spread of Ebola and 
addressing the urgent life needs of communities devastated by the 
presence of Ebola in their country We are doing well but we can do even 
better by investing in the right interventions, focusing on long-term 
sustainability and engaging the right stakeholders. We can stop the 
Ebola epidemic and leave behind a health system and developed 
infrastructure well-positioned to respond to future crises.

    Senator Coons. Thank you, Dr. Peterson.
    Mr. Gaye.

    STATEMENT OF PAPE GAYE, PRESIDENT AND CEO, INTRAHEALTH 
                 INTERNATIONAL, CHAPEL HILL, NC

    Mr. Gaye. Chairman Coons, Ranking Member Flake, and other 
distinguished members of the subcommittee, on behalf of 
IntraHealth International, I thank you for inviting me to 
testify today on this issue of paramount importance to our 
friends in West Africa and to us here in the United States.
    I ask that my full written testimony be submitted for the 
record.
    Senator Coons. Without objection.
    Mr. Gaye. In my native Senegal, there is a Wolof proverb: 
``Nit, nit ay garabam.'' It means ``the best medicine for a 
person is another person.'' I am fortunate to lead an 
organization, IntraHealth International, that for 35 years has 
been a firsthand witness to this proverb in action through our 
support to frontline health workers in 100 countries around the 
world, including all the Ebola-affected countries.
    Tragically, however, far too many people in the West Africa 
region I hold dear did not have access to that person, that 
health worker, who could have prevented Ebola from decimating 
their communities and threatening the well-being and security 
of their countries, their region, and the world.
    As this Ebola outbreak has already started to fade from the 
consciousness of some, one of the crucial underlying conditions 
that helped the virus spread remains the absence of a 
sustainable and resilient health workforce in the region. Let 
there be no misunderstanding: if health workforce does not get 
the high-level political attention it sorely needs, workforce 
deficiencies will continue to threaten global health security, 
and threaten the tremendous progress made in saving women and 
children's lives, fighting diseases like HIV/AIDS, and all the 
great work accomplished by USAID.
    As shared by President Sirleaf, Liberia, Sierra Leone, and 
Guinea all had fewer than three doctors, nurses, and midwives 
per 10,000 people, even before the Ebola epidemic began. But 
these countries are hardly alone. The World Health Organization 
last year estimated that 83 countries in the world are below 
the minimum threshold of health workers needed to provide 
essential services to everyone.
    Last year, at a major conference in Brazil, Guinea and 
Liberia were among 57 countries that made health workforce 
commitments. Guinea's commitment highlighted two rural 
provinces where frontline health workers were largely absent, 
and one of those regions is where ``Patient Zero'' of the Ebola 
epidemic was believed to be infected less than a month later.
    Let me be clear: because of the generosity of the American 
people and the know-how and innovations of implementing 
partners like IntraHealth, the United States Government has 
maintained global health leadership, and no one on this Earth 
will dispute that the mantle of that leadership rests and will 
continue to rest on the shoulders of the United States.
    For example, IntraHealth and UNICEF are currently working 
with the Liberian government on a tool called mHero to allow 
the Ministry of Health and health workers to instantly 
communicate critical information. The USAID-supported, open-
source, online personnel management system, called iHRIS, will 
save low-income countries about $232 million, and data using 
the tool has already been used to drive additional domestic 
investment for health workers. In the next 5 years, iHRIS is 
expected to save the Liberian Government, the equivalent amount 
of money as the salaries of 317 Liberian nurses. That number of 
nurses could serve 634,000 Liberians.
    These innovations supported by American foreign assistance 
are critical to addressing some health workforce challenges, 
but certainly not all of them. The Frontline Health Workers 
Coalition, an alliance of 41 U.S.-based public and private 
organizations, with a Secretariat housed in our offices at 
IntraHealth, last month released recommendations for how the 
United States can lead 
on these issues. I have included them in an addendum to my 
testimony.
    In brief, there must be a more concerted effort to address 
the needs of local health workers in West Africa, such as 
ensuring timely delivery of hazard pay and personal protective 
equipment. This support to local health workers must be backed 
by an equally fervent political push for addressing the most 
critical health workforce gaps globally. A 2010 report 
estimated that by 2020, the United States needs to invest at 
least $5.5 billion in health workforce strengthening to achieve 
its global health goals. Investment must be guided by a cross-
agency strategy that sends an unequivocal message that America 
is committed to this issue, and we expect others to respond in 
kind. I also believe all global health procurements should be 
required to show how they will help strengthen the health 
workforce and systems.
    I would like to close by asking each of us to think about 
what it would be like to wake up tomorrow morning infected with 
Ebola and not have a single person in your community to turn to 
for care, or to have your infant child this evening show signs 
of malaria and have nowhere to take them. This is the reality 
for far too many, and it must be changed now. We would be doing 
a great disservice to the 346 health workers who, as of the end 
of November, have given their lives to help turn the tide on 
this Ebola epidemic if we did not focus on their colleagues' 
immediate needs, while working fervently to ensure we never 
again have a crisis of this scale in public health.
    I thank you very much, and I look forward to answering your 
questions.
    [The prepared statement of Mr. Gaye follows:]

                    Prepared Statement of Pape Gaye

    Chairman Coons, Ranking Member Flake, and other distinguished 
members of the subcommittee, on behalf of IntraHealth International, I 
would like to thank you for the honor of inviting me to testify today 
on this issue of paramount importance to the security and well-being of 
our friends in West Africa, as well as to us here in the United States. 
I ask that my full written testimony be submitted for the record.
    In my native Senegal, there is a Wolof proverb, ``Nit, nit ay 
garabam.'' It means ``the best medicine for a person is another 
person.''
    I am fortunate to lead an organization, IntraHealth International, 
which, for 35 years, has been a firsthand witness to this proverb in 
action through the awe-inspiring efforts of frontline health workers we 
have supported in 100 countries around the world, including all the 
Ebola-affected countries.
    Tragically, however, far too many people in my native West Africa 
have not had access to that person--that health worker--who has the 
training and support necessary to prevent the Ebola virus from 
desolating their communities and threatening the well-being and 
security of their countries, their region, and the world.
    Stories from this epidemic--such as the five Liberian children who 
were left at home with the corpses of their Ebola-infected parents for 
three days because of overwhelmed ambulance services--make us sick to 
our stomachs and heighten our resolve to end the crisis as soon as 
possible. The heroic efforts of health workers on the front lines of 
the epidemic have given us hope that, if our resolve to support them 
does not waiver, that day is coming soon.
    But as this Ebola epidemic has already started to fade from the 
consciousness of some, one of the crucial underlying conditions that 
helps the virus spread remains: the absence of a sustainable and 
resilient global health workforce to both stop threats like Ebola in 
their tracks and complete the daily work of saving and making lives 
healthier in every community.
    Let there be no misunderstanding: if health workforce deficiencies 
do not get the high-level political attention the issue sorely needs 
and it continues to languish as a global health policy afterthought, it 
will continue to threaten both global health security and the 
tremendous progress the United States has helped to lead in saving 
women's and children's lives and fighting diseases such as HIV/AIDS and 
tuberculosis.
    Liberia, Sierra Leone, and Guinea all had fewer than three doctors, 
nurses, and midwives per 10,000 people even before the Ebola outbreak 
began. More people could very well die due to Ebola's impact on such 
fragile workforces and systems than directly from the Ebola virus 
itself. Yet, these countries are hardly alone. The World Health 
Organization last year estimated 83 countries are below the minimum 
threshold of 22.8 doctors, nurses, and midwives per 10,000 people 
needed to provide essential services to a population.
    The countries that have the most acute workforce crises--the Ebola-
affected countries in West Africa among them--have long recognized the 
gravity of inaction on health workforce strengthening for their 
communities, and they have been committed to action. Unfortunately, 
chronic lack of attention and significant reduction of formal 
development assistance to the West Africa region as a whole has 
exacerbated the problem.
    Last year, I had the pleasure of speaking to government and civil 
society leaders and health workers at the Third Global Forum on Human 
Resources for Health in Recife, Brazil. At this forum, 57 countries--
including Liberia and Guinea--made specific health workforce 
commitments, for several of which IntraHealth provided technical 
guidance in crafting. Guinea's commitment focused on its desire to get 
more frontline health workers to two rural provinces where they were 
largely absent. One of those regions, N'Zerekore, is the same region 
where ``patient zero'' of the current Ebola epidemic was believed to be 
infected--less than a month after Guinea made this commitment. Yet as 
many African countries stood up to make their commitments clear in 
Recife, only one donor commitment to health workforce strengthening was 
made. That financial commitment was made by Ireland.
    Let me be clear: because of the generosity of the American people 
and the know-how and innovations of implementing partners such as 
IntraHealth, the United States government has made huge inroads in 
helping countries improve the numbers, the competencies, and the 
support for health workers in West Africa and around the world.
    For example, a major issue Liberia now faces is the need to quickly 
get the latest information to its health workers. IntraHealth and 
UNICEF are currently working with the Liberian Government on a tool 
called mHero to allow the Ministry of Health and health workers to 
instantly communicate critical information to one another. The USAID-
supported, open source, online personnel management system IntraHealth 
is using for this effort, called iHRIS, has already saved our low-
income country partners approximately $232 million in 20 countries 
around the world--and many of these countries are using iHRIS data to 
successfully drive more domestic investment in health workers.
    In Liberia, more than 8,000 health workers are registered in iHRIS. 
This open source system will save Liberia more than $3.1 million in 
proprietary fees over the next 5 years--equivalent to the annual 
salaries of 317 Liberian nurses for 5 years. These nurses could provide 
634,000 Liberians access to lifesaving services.
    Innovations such as iHRIS that are supported by American foreign 
assistance are critical to addressing some specific workforce 
challenges, but certainly not all of them. I believe if you asked any 
administration official to articulate the United States strategy or its 
cumulative results across agencies in assisting partner countries in 
strengthening their health workforce, they could not tell you.
    The Frontline Health Workers Coalition, an alliance of 41 U.S.-
based public- and private-sector organizations and of which IntraHealth 
is proud to host the Secretariat and help lead, last month released 
recommendations for how the United States can lead in helping the 
countries of West Africa and other low-income country partners build 
the resilient and sustainable workforce we need for the 21st century.
    I've included our full recommendations as an addendum to my 
testimony. In brief, there must be a more concerted effort to address 
the needs of local health workers in Liberia, Sierra Leone, and Guinea. 
This includes ensuring timely delivery of hazard pay, ensuring an 
effective and efficient supply chain management system that provides 
personal protective equipment and other necessary supplies with 
requisite training, creating supply outposts for local health workers, 
making psychosocial support available, addressing Ebola-related stigma 
that has arisen, and increasing the authority of local management of 
health workers.
    This support to local workers--a critical first step to rebuilding 
the health systems of these countries--must be backed by an equally 
fervent political push for global action to meaningfully address the 
most critical deficiencies of the global frontline health workforce. A 
2010 IntraHealth report estimated that by 2020, the United States needs 
to invest at least $5.5 billion in health workforce strengthening to 
achieve the global health goals and targets to which it has committed.
    The robust bipartisan support for global health must also continue 
to ensure Ebola does not set back the extraordinary progress we've made 
in the last decade. And I believe each procurement for those 
investments should be required to show how it will help strengthen 
health workforces and systems.
    U.S. health workforce investments must be guided by a multiyear, 
costed, cross-agency strategy with an implementation plan that sends an 
unequivocal message to our developing country partners: that America is 
committed to this issue and we expect others to respond in kind. This 
clear sign of commitment would go a long way in helping to ensure a 
serious and coordinated effort by all governments for a financed global 
health workforce strategy with specific timelines and targets.
    I would like to close by asking each of us to pause and think about 
what it would be like to wake up tomorrow morning infected with Ebola 
and not have a single person to turn to for health care. Or to have 
your infant child this evening show signs of malaria, and have nowhere 
to take her. This is reality for far too many--and it must be changed 
now.
    Frontline health workers have started to turn the tide on Ebola at 
great risk to their own lives--WHO reports as of November 30, 622 
health workers have been infected during the epidemic, 346 of whom have 
died. We would be doing a great disservice to health workers' 
sacrifices if we didn't focus on their immediate needs and at the same 
time work just as fervently to ensure we never again have a crisis of 
this scale in public health.
    Thank you very much, and I look forward to answering your 
questions.

ATTACHMENT

  IntraHealth International--Building a Resilient, Sustainable Health 
         Workforce to Respond to Ebola and Other Future Threats

  frontline health workers coalition policy recommendations--november 
                                  2014
    The Ebola virus disease epidemic in West Africa has highlighted the 
urgent need for increased support for frontline health workers and the 
systems that support them in the region and around the world. The World 
Health Organization (WHO) reports that as of Nov. 2, 2014, 546 health 
workers have been infected with Ebola since the onset of the epidemic, 
and 310 of them have died caring for the more than 13,000 people 
confirmed or suspected to be infected with the virus.
    Nearly all of these lives have been lost in three countries--
Guinea, Liberia, and Sierra Leone--that have some of the lowest numbers 
of health workers per capita in the world. These three countries all 
had less than three doctors, nurses or midwives per every 10,000 people 
before the Ebola epidemic even took hold, far less than the 22.8 per 
10,000 ratio WHO says is the minimum needed to deliver basic health 
services.
    Access to competent and supported health workers can no longer be 
allowed to languish as a global health policy afterthought. The heroic 
sacrifices of frontline health workers must be met with honor, 
compassion, and support for their efforts. Investments must be made in 
equipment, supplies, training, effective management and financial 
support for the retention of health workers to ensure that every 
community has the workforce needed to save lives, and the robust 
systems to support those workers in detecting, analyzing and responding 
to new and emerging public health threats like Ebola.
    The Frontline Health Workers Coalition recommends that the U.S. 
Government and its partners address this public health emergency and 
help build a sustainable response to future emergencies by taking the 
following actions:
In Guinea, Liberia, and Sierra Leone
   Increase support for local health workers on the frontlines 
        of the Ebola fight: Working with health ministries, 
        professional associations, local governments and communities, 
        and nongovernmental organizations (NGOs), the U.S. can support 
        local health workers by:

        Supporting the financing and timely delivery of hazardous 
            duty pay and death and insurance benefits for local health 
            workers during the period of active crisis;
        Ensuring personal protective equipment (PPE) and infection 
            control supplies are provided to health workers with the 
            requisite training and supervision for safe and consistent 
            use;
        Ensuring the availability of psychosocial support for 
            health workers and specific treatment units or centers 
            dedicated to health workers who become infected with Ebola;
        Creating supply outposts for health workers to collect 
            food, clean water and basic supplies;
        Improving data collection and dissemination efforts about 
            the epidemic, including data on the health workforce, 
            patient tracking and supply chain;
        Supporting the recruitment of health workers from the 
            region to respond to the epidemic and assist in bringing 
            routine health services back to normal;
        Increasing capacity and authority for local management of 
            health workers.

   Build a responsive and sustainable supply-chain management 
        system: Health workers' ability to continue fighting Ebola 
        depends on having adequate equipment, supplies, and medicines. 
        The U.S. should work to ensure that both local and 
        international health workers have the supplies they need 
        through a responsive and sustainable supply chain management 
        system.
   Ensure a sustainable frontline health workforce by 
        supporting training programs: The World Bank estimates that at 
        least 5,000 additional health workers are needed to respond to 
        the current epidemic. Maintaining and scaling up educational 
        and training programs, such as medical and nursing schools for 
        new health workers, is critical to building a sustainable 
        response. The U.S. should:

        Support scale-up of enrollment of students from rural 
            communities into health professional schools and community 
            health worker training programs;
        Ensure educational programs for health workers are open 
            and adequately staffed and funded to meet local health 
            labor market demand. Liberia's health professional schools 
            are currently closed, and they must be assisted to reopen;
        Ensure all health worker training programs provide 
            adequate infection control information on Ebola and other 
            transmissible agents.

   Address stigma:

        Frontline health workers and their families have been 
            attacked, stigmatized and even thrown out of their homes 
            and communities while risking their lives to care for those 
            infected with Ebola. The U.S. should work with partners to 
            ensure health workers are protected and honored for their 
            work.
        The U.S. should work with partners and communities to 
            leverage media and communications channels to promote 
            messages about protecting health workers as a national and 
            community asset. Community members and health workers 
            should to be encouraged to share their stories to directly 
            address stigma and psychosocial issues.
Worldwide
   Provide new investments that could help:

        Jumpstart U.S. partner country efforts to strengthen their 
            health workforce's capacity to quell Ebola and other public 
            health emergencies as part of the Global Health Security 
            Agenda. The United Nations estimated that it will cost at 
            least $600 million to halt the current Ebola epidemic in 
            West Africa.
        Build a sustainable frontline health workforce in partner 
            countries to achieve the U.S. Government's core global 
            health priorities (ensuring global health security, ending 
            preventable child and maternal deaths, and achieving an 
            AIDS-free generation). A report from FHWC member 
            IntraHealth International estimated that the U.S. should 
            invest at least $5.5 billion by 2020 \1\ to help strengthen 
            the health workforce to achieve USG global health goals.

   Ensure through continued robust investments across global 
        health that Ebola does not set back the extraordinary progress 
        of recent decades in saving lives and preventing the spread of 
        diseases.
   Release a multiyear, costed, cross-agency health workforce 
        strategy with an implementation plan that sends an unequivocal 
        message about how the United States will support partner 
        countries to ensure that communities have access to health 
        workers who are supported and equipped to save lives and stop 
        public health threats. This strategy should include concrete 
        targets and benchmarks and have clear mechanisms for monitoring 
        progress.
   Provide specific targets that include key cadres of health 
        workers, necessary financing and an implementation timeline for 
        the following goal of the Global Health Security Agenda:

        ``The United States will also support countries in 
            substantially accomplishing: A workforce including 
            physicians, veterinarians, biostatisticians, laboratory 
            scientists, and at least 1 trained field epidemiologist per 
            200,000 population, who can systematically cooperate to 
            meet relevant IHR and PVS core competencies.''

   Advocate strongly for the World Health Organization to adopt 
        at the 2016 World Health Assembly a financed global health 
        workforce strategy that sets specific targets, timelines, and 
        commitments for ensuring that by 2030:

        All communities will have access to competent health 
            workers, trained and supported to save lives and improve 
            health;
        All countries will have the health workforce and systems 
            needed to stop Ebola and other existing and emerging public 
            health threats.

----------------
End Note

    \1\ The IntraHealth International report Saving Lives, Ensuring a 
Legacy (2010) recommends the U.S. Government invest at least $5.5 
billion by 2020 dedicated to strengthening health workforce in partner 
countries to address severe shortages and human resources for health 
(HRH) deficiencies in U.S. Government partner countries. As of November 
2014, the U.S. Government currently does not have mandated funding 
allocations for health workforce. A detailed explanation of the 
methodology used for this estimate is available in the report: http://
www.intrahealth.org/files/media/saving-lives-ensuring-a-legacy-a-
health-workforce-strategy-for-the-global-health-initiative/
IntraHealth_Policy_Paper_1.pdf.

    Senator Coons. Thank you, Mr. Gaye.
    Mr. Alvarez.

   STATEMENT OF JAVIER ALVAREZ, SENIOR TEAM LEAD, STRATEGIC 
   RESPONSE AND GLOBAL EMERGENCIES, MERCY CORPS, PORTLAND, OR

    Mr. Alvarez. Mr. Chairman Coons, Ranking Member Flake, and 
members of the committee, Your Excellency President, I would 
like to take the opportunity again to meet you. We met a couple 
of weeks ago in a social mobilization subcommittee, another 
subcommittee, and thank you very much for the support you are 
giving to the entire humanitarian community but also to Mercy 
Corps.
    Thank you for inviting me to testify today on this critical 
crisis. I speak today in my capacity as senior team leader of 
the Strategic Response and Global Emergencies Team for Mercy 
Corps, a global humanitarian and development organization. I 
have just returned from Liberia, where I served as Country 
Director for Mercy Corps Liberia.
    Mercy Corps has worked in Liberia since 2002, supporting 
its transition from civil war to sustainable economic and 
social development. While our core programs focus on reviving 
agricultural markets, job creation, and youth entrepreneurship, 
our Ebola response has focused on two pillars: reducing 
transmission through community education and mobilization 
campaigns, and to mitigate the socioeconomic impacts of the 
crisis on Liberian communities and the region.
    For the purpose of this hearing, I would like to focus on 
the second pillar, as my colleagues have covered already most 
of the health crisis.
    The Ebola outbreak has been largely approached as a health 
crisis. I am very glad to hear Madam President's announcement 
today of the launch of the possible comprehensive plan, 
economic plan. From Mercy Corps' perspective it is better 
understood as a system crisis, the failure of health governance 
humanitarian systems to prevent a disease from disrupting the 
socioeconomic order of communities and countries.
    Adopting a systems approach to the planning, management, 
and monetary needs are therefore critical, and the recovery 
efforts must right-size emergency efforts and work toward long-
term development goals so that future shocks are not as 
disastrously disruptive.
    In October, Mercy Corps conducted an economic assessment to 
better understand the economic impacts of the crisis in 
people's daily lives. We found three major findings now guiding 
our response.
    First, household incomes, food security, and food 
consumption have been greatly reduced by the Ebola crisis. 
Without targeted interventions and policy changes now, 
households could face a critical level of food insecurity by 
April-May 2015.
    Second, some of the protocols and policies associated with 
the Ebola crisis have put significant strain on the Liberian 
economy.
    And third, disproportionate economic impacts are being felt 
by youth, self-employed persons, and lower-wage workers. This 
threatens the stability of Liberia and the region.
    Food insecurity in Liberia was already widespread before 
the Ebola crisis, with 42 percent of the population considered 
food insecure and 32 percent of children stunted. As a result 
of the crisis, vulnerable households are reducing food consumed 
at each meal, purchasing lower quality meals or less expensive 
food, and eating fewer meals. At the same time, some of the 
protocols deemed necessary for Ebola containment are creating 
constraints and blockages in the market system. These include 
border closures, market closures, and increased transportation 
costs and time.
    In August, the Government of Liberia closed borders with 
Guinea, Sierra Leone and Ivory Coast, imposed a 12 a.m. to 6 
a.m. curfew, and recommended the closure of weekly markets. 
Goods that were previously sourced quickly and cheaply from 
Guinea and the Ivory Coast are no longer available. Traders 
cannot afford to move goods from Monrovia to northern markets 
due to increased costs, and a lot of agricultural goods spoil 
before reaching their destination due to the curfew.
    Traders currently cannot keep markets alive. Further 
compounding these economic stressors is the uncertainty of 
Liberian agriculture. Fortunately, weekly markets have been now 
reopened. This is welcome news. However, policies restricting 
movement are still putting downward pressure on the volume of 
goods moving between markets and households.
    Finally, the impacts of the Ebola crisis have had a 
disproportionate impact on low-wage workers and the self-
employed, who are mainly urban youth. Seventy percent of 
Liberia's population is under 35. Productive engagement of 
youth was a major priority and challenge before the crisis and 
will now be more difficult. It is thus critical that youth are 
at the center of early recovery planning, implementation and 
management, ensuring they gain the skills, opportunities and 
experience they need to become active drivers of Liberia's 
economy.
    There are several short- and medium-term actions that can 
be taken to support markets, prevent a food security crisis, 
and lay the foundations for early recovery. Within the United 
States, we thank you for robustly funding the Ebola supplement 
and the International Disaster Assistance Account in the fiscal 
year 2015 appropriations process. As you know, the humanitarian 
system is under extraordinary stress in the face of Ebola, 
Syria, Iraq, South Sudan, and the Central African Republic.
    We further urge that the administration should target 
short-term food security and income recovery interventions 
toward the worst affected communities, with the goal of 
increasing access to income through well-targeted cash 
programming with careful market monitoring.
    All relevant government entities plan and budget for a pro-
poor, market-based early recovery strategy in Liberia in the 
region now. Strategies should seek to address the root causes 
of chronic underdevelopment.
    In Monrovia, changes to government-imposed regulations, so 
long deemed appropriate from a public health standpoint, could 
decrease economic stress. This includes opening the borders or 
negotiating an economic corridor to allow essential goods to 
cross from neighboring countries, addressing constraints that 
policies are imposing on trade. Issuing permits allowing 
commercial vehicles to travel during curfew hours and pass more 
easily through checkpoints is one idea.
    Among donors and implementing partners, we recommend 
monitoring markets, prices, and systems constraints by 
investing financial resources and human capital in assessments; 
invest in learning and capacity-building; preventing regional 
economic decline by embedding market conflict and political 
economic analysts in regional responsive sectors; and ensuring 
close coordination between financial institutions, governments, 
NGOs, and civil society.
    Again, I wish to sincerely thank the subcommittee, and Your 
Excellency as well, for your leadership on this critical 
crisis, and the great honor of extending me the privilege of 
testifying today. I look forward to your questions.
    Thank you.
    [The prepared statement of Mr. Alvarez follows:]

                  Prepared Statement of Javier Alvarez

    Chairman Coons, Ranking Member Flake and members of the committee, 
thank you for inviting me to testify before this esteemed subcommittee 
on the critical issue of ensuring a sustained and strategic 
international response to the Ebola crisis. I speak today in my 
capacity as Senior Team Lead of the Strategic Response and Global 
Emergencies unit for Mercy Corps, a global humanitarian and development 
organization saving and improving lives in the world's toughest places. 
With a network of experienced professionals in more than 40 crisis-
affected countries worldwide, Mercy Corps partners with local 
communities to help people recover, overcome hardship and build 
resilience to future shocks.
    Mercy Corps has worked in Liberia since 2002, supporting its 
transition from civil war to sustainable economic and social 
development. Our programs focus on reviving agricultural markets and 
creating jobs, with a particular focus on youth entrepreneurship and 
leadership and access to financial services. Our Ebola response has 
focused on two pillars based on close monitoring and assessment of gaps 
in the response: (1) filling a gap in community education on how to 
reduce transmission by mobilizing a robust social mobilization 
campaign, and (2) mitigating the socioeconomic impacts of the crisis on 
Liberian communities, and the region. For the purposes of this hearing, 
I will focus on the second pillar.
    I have just returned from 2 months in Liberia where I served as 
Acting Country Director for Mercy Corps Liberia. My testimony will 
outline how Mercy Corps sees the crisis, highlight findings from our 
market assessment and gaps we see in the current response, and will 
conclude by suggesting a series of short- and medium-term solutions to 
ensure a successful international response.
              more than a health crisis, a systems crisis
    As my copanelists have detailed, Ebola has wreaked havoc across 
five West African nations since the outbreak began in February 2014. 
Liberia is the nation most severely affected by the crisis, suffering 
almost half of all cumulative confirmed, probable and suspected cases 
reported (7,690), with 3,161 deaths as of December 8, 2014.\1\ Having 
originally arrived through the porous border with neighboring Guinea, 
it has spread from the rural Lofa County to reach every one of 
Liberia's 15 counties including the capital city, Monrovia. This has 
created the most serious Ebola epidemic in history, which not only 
directly threatens the lives of tens of thousands of people, but 
jeopardizes the economic progress and stability Liberia has achieved 
since a protracted civil war ended a decade ago.
    The Ebola outbreak has been approached largely as a health crisis. 
From Mercy Corps' perspective, it is better understood as a systems 
crisis--the failure of health, governance, and humanitarian systems to 
mitigate the threat of a disease from disrupting the socioeconomic 
order of communities and multiple countries. And the longer the crisis 
continues, the greater potential it has to contribute to another 
systems failure--a failure of market systems.
    Fortunately, Liberians and all West Africans have shown 
extraordinary resilience and ingenuity in the face of this crisis, 
transmission rates have started to slow and some market activities have 
resumed. However, this is no means for pause. The Ebola epidemic 
continues to cripple the economies of Liberia, Sierra Leone, and 
Guinea; has left thousands of civilians unemployed and hundreds of 
thousands of households more vulnerable to food insecurity; and the 
social fabric of an already fragile nation--just before a tenuous 
election season--has been further eroded.
    Adopting a systems approach to the planning, management, and 
monitoring of this crisis--by broadening the set of analytical tools, 
planning strategies, and funding streams to address it--is critical to 
ensuring a successful crisis response and building more inclusive, 
responsive, and resilient communities and institutions along the way.
            major socioeconomic impacts of the ebola crisis
    To better understand the socioeconomic impacts of the Ebola crisis 
on households, vendors and markets in Liberia, Mercy Corps conducted an 
economic assessment in Lofa and Nimba counties and in parts of the 
capital, Monrovia, from Oct. 3-13, 2014. Findings from the assessment 
and our ongoing programs in Liberia point us to three major areas of 
focus for the response, and my testimony, moving forward:

          1. Household incomes, food security, and food consumption 
        have been greatly reduced by the Ebola crisis. Without targeted 
        interventions and policy changes now, households could face a 
        critical level of food insecurity by April/May of 2015;
          2. Some of the protocols and policies associated with the 
        Ebola crisis have put a significant strain on the Liberian 
        economy; and
          3. Disproportionate economic impacts are being felt by youth, 
        self-employed persons, and lower wage workers. This threatens 
        Liberia's, and the region's, stability.
1. Risk of a food security crisis by April/May 2015
    Food insecurity in Liberia was already widespread before the Ebola 
crisis, with 42 percent of the population considered food insecure, and 
32 percent of children classified as stunted.\2\ Still fighting to 
recover from years of civil war, Liberia continues to be one of the 
world's poorest countries, ranked 162 out of 169 countries in the 2010 
United Nations Development Program (UNDP) Human Development Index, with 
up to 84 percent of its population live below the national poverty 
line, on less than $1.25 day.\3\
    As a result of both the Ebola crisis and precrisis economic 
inequalities, vulnerable households started reducing the amount of food 
consumed at each meal (mentioned by over 90 percent of households 
interviewed in our assessment), purchasing lower quality or less 
expensive food, and eating fewer meals (mentioned by 90 percent and 85 
percent respectively). Seventy-seven percent of those interviewed cited 
borrowing money from friends and relatives as an additional coping 
mechanism. Households in general are spending most of their income on 
food products. These coping mechanisms could have lasting negative 
impacts on people's nutritional status and economic investments and may 
jeopardize their future ability to recover.
    Constraints on household food security caused by reduced incomes 
and increased prices may also be compounded by uncertain agricultural 
yields from the next harvest. Upland and lowland rice harvests in 
October/November and January/February may provide temporary relief for 
agricultural households in Lofa and Nimba counties, but it remains 
unclear. If the overall situation continues without changes and if the 
economy experiences production decreases, food insecurity would 
increase significantly by April/May 2015.
2. Constraints in the market system imposed by the Ebola response
    Some of the protocols deemed necessary for Ebola containment are 
creating additional constraints and blockages in the market system, 
namely:

   Border closures,
   Closure of markets, and
   Spiked transport costs and increased transportation time due 
        to the 12 a.m.-6 a.m. curfew, checkpoints, and other 
        regulations.

    Regarding border closures, the Government of Liberia closed borders 
with Guinea, Sierra Leone, and Ivory Coast and at the same time 
recommended the closure of weekly markets as Ebola prevention measures 
in August 2014. As a result, goods that were previously sourced quickly 
and cheaply from Guinea and Ivory Coast are no longer available due to 
border closures, causing vendors to source replacement goods at higher 
prices with longer transportation times.
    One vendor we spoke with previously spent 2,000LD on a trip to 
Guinea to purchase goods for her shop. Now with borders closed, she 
must travel further to Monrovia to purchase goods and the trip costs 
her 5,000LD. She passes this cost increase along to her customers 
through increased prices at her shop in the market.
    Weekly market days have been reopened to allow for increased trade 
between counties. This is great news. However, policies restricting 
internal movement are still puting downward pressure on the volume of 
goods moving between markets and households.
    The impact of Ebola policies on transport prices has also been 
significant. Border closures and reduced consumer demand have 
contributed to an increase in transport costs and a reduction in the 
number of vehicles transporting goods. Checkpoints and regulations 
limiting the number of passengers in vehicles, the inability of 
vehicles to travel during curfew hours, and delays due to road blocks 
have also contributed to the increase in transportation prices. A rapid 
assessment of the transportation market is needed to help inform a 
short- and medium-term program to increase access to transportation for 
economic purposes. A more robust transportation system can reduce 
market costs for consumers, including for food items, increasing 
households' food security.
3. Disproportionate economic impacts on workers and self-employed, 
        including youth
    The economic impacts of the Ebola crisis have had a particular 
impact on workers and those who are self-employed--particularly youth 
in urban areas. A cell phone survey commissioned by the World Bank 
throughout October and November indicates generally lower incomes and 
jobs being shed in both the wage-earning and the self-employed 
sectors--sectors largely composed of youth.\4\
    Liberian youth, defined as 15-35-year-olds, represent a third of 
the country's population, with 70 percent of its total population under 
35. Productive engagement of youth a priority and major challenge for 
economic development efforts even before the crisis, as social ties 
between youth and their communities were severely damaged by the 
country's long civil war, the resulting displacement, and rural-to-
urban migration making.
    Many of these youth have been frustrated by the international 
community's post-conflict response to Liberia for over a decade, 
feeling that their opinions have marginalized from planning processes 
and their capacities for productive engagement in society disregarded. 
In this capacity, youth are key to reducing risks of future instability 
in Liberia.
    It is thus critical that youth are at the center of early recovery 
planning, implementation and management, ensuring they gain the skills, 
opportunities and experience they need to become active drivers of 
Liberia's economy.
            recommendations for immediate and future action
    There are several short- and medium-term actions that can be taken 
in the U.S., in Monrovia, and within the humanitarian response to 
mitigate the cascading socioeconomic impacts of the crisis on 
households and the region, prevent a food security crisis in April/May 
2015 and lay the foundations for early recovery.
    Within the U.S., we recommend that:
    1. Congress robustly fund the International Disaster Assistance 
Account in the FY15 appropriations process at $3.5 billion given the 
extraordinary demands on the global humanitarian system in the face of 
Ebola, Syria, Iraq, South Sudan, and the Central African Republic. As 
you surely know, the United Nations appealed Monday for a record $16.4 
billion global appeal in order to address unprecedented global 
humanitarian needs in 2015.
    2. The administration should target short-term food security and 
income recovery interventions toward the worst affected communities, 
with the goal of increasing access to income through well-targeted cash 
programming with careful market monitoring to ensure food supplies are 
available.
    3. All relevant government entities should simultaneously and 
jointly plan and budget for a pro-poor market-based early recovery 
strategy in Liberia that addresses the root causes of underdevelopment. 
U.S. strategies should be aligned with those of Liberian youth and 
civil society, the Government of Liberia, U.N., World Bank, and other 
major actors, and must seek to lay the foundations for an economic 
recovery agenda that addresses the root causes of economic inequality, 
stagnation and chronic underdevelopment.
    In Monrovia, changes to government-imposed regulations, so long as 
deemed appropriate from a public health standpoint, could lessen the 
spikes in transportation costs that are reducing economic activity and 
increasing household vulnerability. These include:
    1. Open the borders or negotiate an economic corridor to allow 
essential goods to cross from neighboring countries by traders screened 
at the border.
    2. Address constraints that the curfew is imposing on trade. 
Issuing permit to commercial vehicles to travel during curfew hours and 
facilitate their passage at checkpoints could immediately address some 
of the time burdens that traders currently face.
    Within the donor and implementing partner community:
    1. Monitor markets, prices and systems constraints iteratively by 
investing financial resources and human capital in sustained 
multisector assessments. Pay close attention to any shortages or 
adverse economic effects and take corrective actions, as necessary.
    2. Invest in learning and capacity-building throughout the 
response. We have a responsibility to learn from this crisis, capture 
and utilize transferable knowledge, and support local leadership of 
Liberians at every level of the response.
    For example, Mercy Corps' current USAID-funded social mobilization 
Ebola prevention program, the Ebola Community Action Platform, has a 
major learning component focused on real-time information gathering to 
understand how communities respond to information in this crisis, to 
inform feedback on immediate improvements to programming and lessons 
for strategic planning to disaster risk reduction and crisis prevention 
in the future. While I did not focus on this program during my 
testimony, I am happy to discuss it in Q&A.
    3. Stay ahead of the potential for regional economic decline by 
embedding market, conflict and political economy analysts in the UNMEER 
structure, and ensuring close coordination between financial 
institutions such as the World Bank and African Development Bank, 
government actors and NGOs.
    Again, I wish to sincerely thank the subcommittee for its 
leadership on this critical crisis, and the great honor of extending me 
the privilege of testifying today. I look forward to answering any 
questions.

----------------
End Notes

    \1\ http://www.cdc.gov/vhf/ebola/outbreaks/2014-west-africa/case-
counts.html.
    \2\ DHS , Republic of Liberia--2013.
    \3\ World Bank, Liberia--poverty headcount ratio. http://
data.worldbank.org/Country/Liberia.
    \4\ World Bank, Update on the Economic Impact of the 2014 Ebola 
Epidemic on Liberia, Sierra Leone, and Guinea, December 2, 2014. http:/
/www.worldbank.org/en/topic/growth/publication/economic-update-ebola-
december.

    Senator Coons. Thank you very much, Mr. Alvarez.
    I would like to thank the entire panel.
    We have a relatively brief period, so I will have us go to 
5-minute rounds, and I am just going to ask one question of 
each of the four of you. If I could ask for a relatively 
concise answer, that will allow my colleagues a chance to 
question as well.
    You have said, Dr. Farmer, this is a caretaker disease in 
the context of very weak health systems. I will carry the 
phrase ``zoonoses'' with me from this hearing, something I will 
drop casually in social settings in Delaware and impress people 
with my great knowledge of zoonoses, something I was previously 
unfamiliar with.
    The challenge of having a clear term for what it means to 
do public health systems strengthening I think can best be 
summarized this way. As Senator Durbin said to me, when we roll 
up a major intervention that includes DOD and the Public Health 
Service and then leave, sometimes we look at what are we 
leaving behind. And I hope we would instead look at what are we 
doing to build health forward.
    What are we doing, as you put it, Dr. Peterson, to invest 
in building sustainably? Are we, as we respond to this 
emergency, building sustainable public health systems for 
Liberia, Sierra Leone, Guinea, and the region?
    So, Dr. Farmer, my question for you: What is the one thing 
in your view that we would do that would most contribute to 
building forward a meaningful public health system?
    To Dr. Peterson, one of your points was that we need to 
more effectively listen to the faith community on the ground. 
What is the number one thing you would urge us to do to 
incorporate that into our responses?
    To Mr. Gaye, how do we engage the African diaspora better 
and mobilize the resources that the President referred to of 
the many doctors and health care workers who have fled the 
region during conflict and could possibly be returned back? And 
how does health worker safety play into that?
    And if we have any time left, Mr. Alvarez, what role does 
stigma play in the economic impact? My concern is that the 
regional economies, as you pointed out in great detail, are 
heading south rapidly, and if we do not open borders and reduce 
stigma, we will not return to economic growth and thus real 
recovery from this Ebola outbreak.
    Thank you to all four witnesses. I would urge you to 
endeavor to give brief replies.
    Dr. Farmer. Concision is not my strong suit, Senator, but I 
will skip ahead from the obvious point that we need these four 
S's: staff, stuff, space, and systems. It is a point that has 
been made by the President, by everyone here.
    I think, to take a critical look at the legacy of our 
investments, we should just use some examples. When we say we 
need to build local capacity, that term can be distorted and 
perverted in many ways. It could end up meaning, as it often 
does, 2-day workshops on infection control, say, or clinical 
management of Ebola. That is not really what our colleagues and 
partners need.
    They need the same things that we have, formal credentialed 
training programs in medicine, in nursing, in public health, 
and in health care management. Those take years to build. That 
is why I think the President mentioned the Human Resources for 
Health program that the Clinton Foundation had been working on 
with the Ministry of Health for many months before the crisis. 
That is a program that deserves to be supported, and it is what 
our partners are asking for.
    So the differences between a workshop, fine, but not what 
we need, which is long-term training programs. It took me 8 
years to train as an infectious disease doctor. It takes a 
surgeon even more. And there is so much human capital in this 
part of the world, there is so much talent. Give them a chance 
to have formal training.
    The second point I will just pass on is look at the 
infrastructure that we are building. I actually had a picture--
I am sorry I do not know how to resurrect it on the screen--
comparing an Ebola treatment unit that I saw in rural Liberia 
with the hospital that we built in rural Haiti, also an 
unelectrified region. It is the largest solar-powered hospital 
in the developing world today. It is the largest training 
center for Haitian doctors and nurses. It is the kind of 
investment that we need to link to our emergency response in 
West Africa.
    Thank you.
    Senator Coons. Thank you, Dr. Farmer, and thank you for 
being with us.
    Dr. Peterson.
    Dr. Peterson. Thank you for your question. I think that the 
best way to explain how we can listen better to communities and 
link to faith-based organizations is to talk about some of the 
things that are actually happening and happening well in Sierra 
Leone, and I saw it more in Sierra Leone than in Liberia.
    World Vision is leading a number of coalitions. The 
coalitions include Christians, Catholics, and Muslims together. 
One coalition is pulling together burials, safe and dignified 
burials in 12 of the 14 districts, allowing families to have 
someone to pray for their loved ones, to meet the cultural 
traditions. They are also trusted by the donor, in this case 
DFID, because the Ministry of Health money did not actually pay 
the burial teams, but World Vision as an organization that 
knows how to do fiscal management can manage logistics, can do 
fiscal management, and is beginning to do that very critical 
service to the community in a way that both meets donor needs 
and meets the people's cultural needs.
    Similarly, there is another coalition, again Muslim and 
Christian and Catholic, that is looking at what are the 
important messages that the community needs to hear, what are 
their fears, how do we frame the science that we have from CDC 
and NIH in a way that it is understandable in a faith language. 
They are putting together training for faith leaders--Muslim, 
Christian, pastors, priests--and beginning to reach through 
that whole network of faith leaders into the communities, which 
will begin to transform behavior. I think that is how we can do 
it.
    Thank you.
    Senator Coons. Thank you.
    Mr. Gaye, briefly.
    Mr. Gaye. Yes. Thank you for the question on how to better 
engage African diaspora. There is a lot of talent sitting in 
this country, and in these phases of crisis there are a lot of 
people who want to help.
    I think there are only two very simple things we need to 
do, and they are both about information. A lot of people want 
to help. They do not know where to go. If we manage to create 
good information flows and collect a repository of groups that 
are doing this, I think that we will go a long way.
    The second thing we need to do is to build on the platforms 
that already exist. There are some very good examples of 
practices that I would certainly encourage. The Global Health 
Corps is one of these. I think the young Barbara Bush is 
leading that. It is very clever in pairing up young American 
and young foreigners to engage in an internship. In fact, 
IntraHealth is hosting two of them. They might even be in the 
room. So programs like that need to be replicated because I 
think they expand the idea that you could serve Africa by being 
here.
    Then we can look into examples in the private sector. 
Pfizer, for example, has a great global health program where 
they encourage their employees to go overseas. For the majority 
of companies that have these programs, it would be fantastic 
for the diaspora that works with these companies to know these 
programs exist. So I think we need to publicize more of this.
    It is all about information and providing the right 
information.
    Senator Coons. Thank you, Mr. Gaye.
    Mr. Alvarez, in one sentence, how do we deal with economic 
stigma?
    Mr. Alvarez. So, yes, I think it is part of an equation. 
The stigma of the survivors returning back to their communities 
is becoming a huge issue, as the representative already 
mentioned. There are more and more survivors. So the ones that 
want to come back are sometimes ostracized and sidelined. So 
those people, if we see them as engines of change in the 
economic recovery, we are losing a huge opportunity.
    Again, it all comes down to information, misinformation, 
community involvement. And, of course, you know, the movement 
of goods has been reduced, and we see that as affecting the 
livelihoods of households. There will be more food insecurity.
    So stigma is going to become the next big issue. Messaging 
so far has been focusing on ``Ebola Kills,'' ``Ebola is Real.'' 
It has been more promoting the negative. Now we are at a 
juncture that that messaging needs to change, and we have to 
offer people the hope and the forward looking that we are 
seeing from the fears.
    Thank you, Mr. Chairman.
    Senator Coons. Thank you, and I would like to thank our 
whole panel.
    Senator Flake.
    Senator Flake. Thank you.
    I appreciate the testimony, and I know it must be 
intimidating speaking with the President of Liberia literally 
looking over your shoulder here. [Laughter.]
    It speaks well for her that she wants to hear what is going 
on here.
    I just have one, in my limited time here, one question that 
I hope all of you can address very briefly, and I hope that we 
can follow up with you.
    We have a phenomenon here often when we fund operations 
overseas--just take Afghanistan, for example. We are finding 
many examples now of appropriating a lot of money that builds a 
facility that was right and proper for an occupying force but 
does not serve those who are left behind. We have talked with 
some of you saying we need to address the concerns of health 
workers that will be there afterward, after the expats leave.
    What would you caution us in terms of how we appropriate, 
and procurement rules, and whatever we have to deal with here 
to make sure that we can respond nimbly to the changes that are 
being made? I would think that we may not have thought a couple 
of months ago that Liberia would be in the situation that they 
are right now with just 10 new cases per day. We want to make 
sure that the funding we provide, the resources we provide are 
addressing the needs now and in the future rather than 
addressing needs in the past. The last thing we want are 
facilities that we built that were fine for a lot of expats 
there or the response that we have had in the past rather than 
public health centers that we need in the future.
    What cautions would you give us or what advice in terms of 
our role here in terms of oversight now that can help for the 
long term?
    Dr. Farmer, any thoughts?
    Dr. Farmer. Thank you very much, Senator. That is a 
terrific question, and I think if I were to signal the biggest 
trap I think for us--for you and for us--is the trap of double 
standards, which is very common, I fear, in development work in 
public health, international health.
    Example: If we build a facility, one of the things that we 
should be pushing for as a metric is very low case fatality 
rates. So, in other words, people who are diagnosed with Ebola, 
what is the harm of saying, as people who are supporting this, 
we want to see less than 10 percent die? We want 90 percent 
survival rate. What is the harm of that? There is no harm.
    No American has died from Ebola because when they get into 
the embrace of our--granted--dysfunctional health care system, 
they get good critical care, and you cannot take care of people 
with Ebola who are losing up to 10 liters of fluid a day from 
vomiting and diarrhea without good medical care, with an 
intravenous line and a nurse or a physician administering it.
    So I think we should reject the double standards. What is 
appropriate for the physiology of a Liberian or a Sierra 
Leonean or a Guinean with Ebola is the same as what is 
appropriate for us. It is just that they do not have the 
systems, and we should help them build them.
    I think the other big trap is related; the trap of the 
contractual, the trap of thinking there is a beginning and an 
end to this accompaniment process. This is going to be a long 
term. We are making significant investments in West Africa. We 
should be thinking long term, just as the President said. We 
have to link our emergency response to rebuilding systems, and 
that is going to take a long time.
    Senator Flake. Thank you.
    Dr. Farmer. Thank you, sir.
    Senator Flake. Dr. Peterson, briefly.
    Dr. Peterson. Yes, thank you. I spent a lot of time in 
Afghanistan, so I actually really appreciate that question. The 
rebuilding of the health system within Afghanistan, I think, is 
very appropriate for this issue because, in fact, they did it 
fairly systematically.
    I will also repeat my earlier comment that listening is 
very helpful. The Minister of Health of Afghanistan said no-
thank-you to a great big clinic hospital in the center of 
Kabul. What she wanted for her country were rural centers, 
training of midwives and community health workers. And that, in 
fact, built the long-term sustainability.
    The other thing that Afghanistan did that I think would 
make a difference in this Ebola response is they focused on 
management training for the health system, for the provincial 
and medical and district directors. How do they actually do 
fiscal accountability? How do they do supply logistics? Some of 
our NGOs provided that kind of expertise for health systems 
management, and I think that was really key.
    The other piece in the management rebuilding that helped 
there and could make a big difference in Africa is the whole 
health management information system, another not very sexy 
acronym, but set up data that provided transparency so that it 
was harder for money to go astray and easier to know whether 
you were truly making the difference in improving the health 
system.
    If we took some of those experiences that worked well in 
Afghanistan, not everything worked well, but those things that 
did work well and applied it to rebuilding the health system in 
the West African context, I think we would do better.
    Thank you.
    Senator Flake. Well, thank you.
    My time is up. But if you can briefly, very briefly, 
respond?
    Mr. Gaye. So, just a couple of points. One: is it is a 
different type of mind-set to get into building these systems 
because it does take a little longer. I know that the issue of 
the health workforce is not new. Senator Durbin, I know for a 
fact that in 2008 you supported legislation to support the 
health workforce. So that is the first mind-shift we need to 
make.
    Second, we do need to have a good strategy to guide this 
investment, a strategy that is going to do one thing, make sure 
that at the country level we have checks and balances. The way 
you are going to do this is by investing more with civil 
society. There are a lot more actors in the countries that are 
ready to jump in, and we just need to create a safe space and a 
good space for them to engage and support the government work.
    Mr. Alvarez. Thank you. Just one very quick point. I think 
one of the more intelligent approaches to funding of partners 
in Liberia, agencies like Mercy Corps, we would like to see 
very flexible approaches to funding. I mean, the situation is 
evolving. There are a lot of moving pieces. So moving from an 
emergency standpoint that we are close to coming to an early 
economic development phase that will allow us to be able to be 
responding to the reality on the ground.
    I think another very important piece of advice, very humble 
advice to give the committee, would be that partners have 
continuity on the ground. When we saw that the outbreak was 
there, a lot of partners left the country. I mean, agencies 
like Mercy Corps and other agencies stayed put, and we have to 
stay put. There was a fear of the unknown, but we stayed put, 
and we continue doing our business.
    So I think that will be another piece of advice. Thank you.
    Senator Coons. Thank you, Senator Flake.
    Senator Durbin.
    Senator Durbin. Let me address--and I invite President 
Sirleaf. Perhaps she can join in responding. Let me address the 
economics that I found in some parts of Africa. I do not know 
West Africa as well. Here is what I found when it came to the 
health care staff and people engaged in this field.
    I found that there was a limited capacity for training and 
education. There was a long-term commitment necessary so that 
they would develop the skills and training necessary to become 
doctors, nurses, even health care workers. There was a limited 
capacity in terms of what training was available, teaching was 
available, colleges were available.
    I found that those that did graduate many times became 
employees not in the private sector but in the public sector, 
working for the government of their countries.
    I found that they were paid, by Western standards, a very 
small amount of money each month, and that many times went 
unpaid for months when the countries would get into budgetary 
problems.
    I found that these skilled health workers, whether they are 
doctors or nurses in particular, were often poached by England, 
Europe, and the United States, which could offer them multiples 
of their promised salaries in Africa, and they took the 
invitation and left.
    How do we stop that from happening? We are talking about an 
investment here in a bill we are about to vote on of $5.4 
billion, according to the Chair, into these countries. I would 
imagine whether it is Liberia, Sierra Leone, or Guinea, that 
this is a dramatic increase over the usual public health budget 
in each country. This is going to fall like manna from the 
heavens, and the question is how do we translate that into 
long-term growth of the workers, the health workers that create 
public health systems, when there is always the lure of leaving 
and making a lot more money?
    Dr. Farmer. Well, I am sure the President has something to 
say on this. She comes to mind in the exchange we had, Senator. 
As you all know, the nursing and medical schools are closed in 
the course of the epidemic. So the training is not happening.
    Going back to this experience in Rwanda with the Human 
Resources for Health program that we have been proposing 
through the Clinton Foundation and working with our Liberian 
colleagues, but also in Haiti, to say when have we succeeded in 
stopping the brain drain? Is it by limiting the free movement 
of the professionals? No. It is by drawing them back into 
better health care systems, including public systems. If I were 
to name a third trap, in response to Senator Flake, it is that 
if we avoid the public sector, that will be a mistake, the 
Liberian institutions for example, or Sierra Leonean 
institutions.
    The hospital I mentioned in rural Haiti may have been built 
by Partners in Health, but it was built by Partners in Health 
with people from your city, in fact, as you know, very rapidly, 
18 months after the earthquake, as a public facility, a 
teaching facility, and that is why the head of surgery came 
back after 20 years at Harlem Hospital. That is why the head of 
medicine came back, Haitian, 15 years in France. That is why 
the chief of nursing, raised in the United States but a 
Haitian-American, is there. They have good facilities, and that 
is a metric we can use if we are putting in billions of 
dollars.
    Senator Durbin. Can I invite President Sirleaf? Could you 
address how much is a doctor or nurse or health care worker 
paid in Liberia, and can you put it in the context of the 
average wage and whether they are above that?
    President Sirleaf. Let me say that I was a little bit 
disappointed in ourselves that we were not paying our doctors 
as much as they should get. Yes, they get much of what the 
average wage is, but they do get less than, say, some of our 
high-level officials, and that is something that we are going 
to correct. Doctors were getting anywhere between $1,500 and 
$3,000 U.S. dollars, and we do have certain high-level 
officials that get well over that, somewhere between $5,000 and 
$6,000. So we are going to have a policy decision that says 
that they are going to earn as much as our highest officials 
earn because they make a great investment to get to where they 
are, and they certainly give great service to our country. So 
that is going to be corrected.
    Senator Durbin. Thank you.
    President Sirleaf. I do agree generally with all the 
testimony that has been made, and I would just like to make 
three quick points.
    First, our plan is an evolving one. It is an evolving one 
that makes the transition from containing Ebola to improving 
our health care systems to going on to economic recovery. And 
that evolving plan will ensure that we will have permanence in 
trying to ensure that we are able to respond to any such 
breakdown, whether it is through Ebola or a recurrence, or 
whether it is through other types of diseases.
    It will also enable us to have personal capacity through 
increased per capita incomes that will enable people to live 
better and to respond to their own health needs in a much more 
effective way on a personal basis.
    The second thing is capacity. I could not agree more with 
Dr. Farmer that capacity is the key. In our 10-year plan for 
improving the health care workforce is to build that capacity 
at all levels, particularly at the bottom--it is like a 
pyramid--training over 30,000 health care workers at the 
community level to provide basic health services, and then 
moving on up to ensure that we then have the physician 
assistants, the midwives, the nurses, and then finally at the 
apex, the doctors who are very specialized. So we want to see 
that plan implemented. It is a long-term plan, but we want to 
get it started, and we want to make enough progress within the 
next 2 to 3 years.
    Finally, the involvement of the communities. Our success in 
Ebola has been the active participation and ownership of our 
communities. As long as we got them involved where they took 
responsibility to go there and find the sick, to call and have 
them taken to treatment centers, to be able to respond to those 
quarantined in the communities, to work with us, we began to 
get success. So we are going to, in this final push, make sure 
that the community workers take the lead role and we provide 
them with the support they need for us to get this job done.
    Thank you again for this great hearing.
    Senator Coons. Thank you, Madam President. Thank you for 
your remarks today.
    Senator Shaheen.
    Senator Shaheen. Thank you. I do not have anyone in 
particular to direct my question to, but as we look at the 
outbreak in Mali and the potential for other countries, 
neighboring countries in Africa to be affected, how concerned 
should we be about that? What kind of lessons have we learned 
that will help us address those outbreaks, and why was Nigeria 
able to respond so quickly and address the outbreak there?
    And finally, are there any lessons from our involvement 
with the AIDS virus and the PEPFAR program that should have 
translated here or that we should be looking at as we think 
about the current outbreak of Ebola?
    Whoever wants to take it.
    Dr. Farmer. We are dying to take it.
    Dr. Peterson. All of us. [Laughter.]
    I do not think I can speak for Nigeria except it certainly 
had a more intact health system, which helped enormously. For 
Mali and the other countries where the health system is weak, 
it is a danger. One of the things that I think we could do much 
more quickly and much better is take what we have learned in 
Liberia and Sierra Leone and bring it there.
    I went from Liberia for 10 days and then to Sierra Leone, 
and both countries were frantically working on their burial 
protocols and their case management protocols and their 
logistics protocols, and they were both doing it at the same 
time. Well, we now have them, both countries have them. We 
could take that learning and bring it to those countries.
    Senator Shaheen. Could I just interrupt for a minute? I 
apologize, but when you say ``we,'' who are we talking about as 
``we''? Is this something that we are hopeful that all of the 
organizations that have been working in the currently affected 
countries will do? Is this something that the U.N. mission 
should do? Is this something that the United States, that all 
of us--who is the ``we''?
    Dr. Peterson. A brilliant question, because in each of 
these places it is the combination of the aid agencies and the 
local governments that are heading every single one of these 
committees, pillars, et cetera. I found that there was not any 
communication going on between Sierra Leone and Liberia. In 
fact, because I had sat in both of those meetings and I was on 
their email list, I started getting all of the case management 
protocols from Liberia and said could I send these to Sierra 
Leone, and I was a complete outsider.
    So this is that cross-cutting collaboration. If there was 
somebody who would take that broad view and say here are all 
the things that we have learned--maybe it is UNMEER--and bring 
it to the next country so that they do not have to go through, 
actually which was what was several months of very good and 
very hard work, in order to do that collaboration.
    As far as learning from the AIDS, I will give an example 
again from the faith community. World Vision had put together a 
platform they called Channels of Hope for HIV/AIDS. It was 
designed to train pastors, imams, other clerics in that 
sensitive HIV issue, how do we talk to these faith leaders 
about AIDS and sex, and how do they talk to their 
congregations. World Vision is using that very same platform 
for training on Ebola to imams, priests, and others. So those 
are the kinds of uses of AIDS platforms that I see going on 
that we should continue.
    Thank you.
    Dr. Farmer. Can I just say, Senator, that this is the 
pertinent question in global health, because prior to PEPFAR, 
there were no major huge programs in global health. They were 
post-colonial projects. They were public sector engagement 
inside one's own country. So this was the big game changer.
    There is kind of an ugly secret that preceded it that is 
worth remembering, in the spirit of your question, and that is 
socialized for scarcity. What our colleagues, what we did in 
public health was to pit prevention against care.
    Of course, that is why the epidemic continued unfettered, 
because these arguments about managing scarce resources, they 
really lacked any kind of intellectual depth. They were really 
all just about funding and scarcity.
    What turned that around and made this a success story, 
especially in the most heavily affected areas? Easing the 
scarcity with substantial investment, of the level you are 
talking about for Ebola, and then integrating prevention and 
care. Then guess what happened? People who were told--and this 
point was made already by the President and by several of us. 
If you are told that you are going to die if you get Ebola, 
then why not stay home? But if you are told we can help you, we 
can take care of you, we can help you survive, we can make sure 
you get treatment, people come in for screening, and then we 
can find out who does not have Ebola and get them treated for 
malaria or whatever else, or get them back on therapy, 
including treatment for AIDS. But we need to avoid, this time 
around, that debate, pitting prevention against care.
    Senator Shaheen. Thank you.
    Mr. Gaye.
    Mr. Gaye. Yes, a couple of quick points on lessons from 
HIV/AIDS. Of course, we see great results when there is rapid 
mobilization and engagement of everybody that needs to be 
engaged. We saw the tremendous impact of engaging religious 
leaders in the HIV/AIDS fight. So with Ebola we have a lot of 
similarities with stigma and rumors and so forth. So, I think 
that we can apply these lessons immediately.
    On the question of should we worry: yes, we should worry, 
because the health systems of these countries are extremely 
weak. This is the time when you say I wish we had invested more 
in frontline health workers and health workers that were closer 
to their communities, because in the end they are the ones who 
are delivering the services. They are the ones. I mean, we have 
seen it. Study after study has shown that we can reduce these 
people leaving if we recruit at the community level, at the 
local level, because when people are recruited and trained 
where they are from, they tend to go back, and they tend to 
stay there.
    So those are some of the things that I think we could do.
    Senator Shaheen. Thank you.
    Mr. Alvarez.
    Mr. Alvarez. Thank you very much. So, what I saw there when 
I was in Liberia was that the numbers started to go down and 
there was a trend identified that was stable between 10 and 20 
cases that the person had mentioned, and in my view it has been 
a lot about information. The system, the health system has been 
able to produce detailed information, where these contacts 
were, which countries, what contact tracing they had, and that 
information has been able to feed back into the response and be 
able to track down the disease.
    So it has been a reverse trend. Whereas before the disease 
was hunting us, now the Liberian Government and other health 
authorities are hunting the disease because they know where 
they are.
    So, how worried should we be about all of this? Very 
worried. But we think that closing down the borders, if we have 
that information, should not be one of the measures, or at 
least the borders are porous anyway, so we should be able to 
let people cross. I mean, in the north, food insecurity is 
becoming a big, big issue. Markets are closed. There were 
traditional border crossings, and we should still put in the 
systems to monitor people crossing those borders, to be able to 
first sell their goods, and second get their goods.
    So it is very important data and how these data are being 
produced to respond locally to this disease. Thank you.
    Senator Shaheen. Thank you all very much for being here 
today and for your great work.
    Senator Coons. Thank you, Senator Shaheen. And thank you, 
Senator, for focusing us on what are some of the basic 
questions here. Having invested billions of dollars through 
PEPFAR in what is understood as the fight against HIV/AIDS, we 
have also strengthened health systems in dozens of countries. 
And the progress in fighting polio, for example, has largely 
been made possible by the health system investments made 
through PEPFAR. It is our hope that we will focus our response 
to Ebola in also strengthening systems regionally.
    Senator Markey.
    Senator Markey. Thank you, Mr. Chairman. Thank you for 
having this very important hearing.
    Dr. Farmer, could you talk a little bit about the different 
cultures in Liberia as opposed to Sierra Leone and Guinea?
    And we congratulate you, Madam President, for your 
tremendous leadership and work in helping to really focus in 
and isolate this problem in your country.
    But just generally speaking, could you just explain why it 
is so successful in Liberia and not so much in the other two 
countries?
    Dr. Farmer. Thank you, Senator.
    He is setting me up, Madam President, because he knows I 
also have a Ph.D. in anthropology, which makes me cautious in 
answering.
    I have heard, and read as well, about differences in those 
two countries that are fundamentally cultural, linguistic, 
historical differences that would determine the pace at which 
there has been uptake, for example, of safe burials or improved 
infection control practices. You have heard those claims made 
as well.
    I am not sure that it is a good idea to put too much faith 
in those claims yet because we have failed so far in Sierra 
Leone to have a real collision between modern medicine, 
including prevention, and Ebola, and that is true as far as 
safe burials goes as well.
    So, the focus for us, as Anne said, should be on listening 
to people, on talking to religious leaders, and that has been 
done perhaps more successfully in Liberia than elsewhere, and I 
wish I knew more about Guinea. But in each of these places, the 
response needs to do that better, to listen more carefully, to 
engage with religious leaders and families in their homes, and 
to have frontline workers be our other bridge, as well as 
religious communities, to the household.
    It is not that that is an a-cultural process, right? But 
that is something that is--working with community health 
workers, in my experience, has worked in Haiti, in Boston, in 
Rwanda. It is a structural intervention that needs to be shaped 
to local cultural practice but can give a very big return, I 
think, regardless of which part of West Africa we are.
    Senator Markey. Do you think it would be helpful if there 
was a larger U.S. presence in the other two countries given 
what has now happened in Liberia, that if we ramped up a larger 
U.S. presence in the other two countries, that it could make a 
big difference in telescoping the timeframe that it would take 
in order to successfully replicate what has happened in 
Liberia?
    Dr. Farmer. You know, I would just say having a larger 
expatriot presence is a good thing if those expatriots, 
regardless of their origin, have the skills that are needed, 
and some of those skills are clinical skills, as was noted. 
That is, delivery is a big problem, Senator. We have the right 
ideas, we have the information, but we are not delivering, 
especially that last mile, in rural areas.
    So logisticians we still lack. President Sirleaf said 
before that there is more electricity generated to power the 
Dallas Cowboys stadium than the entire country of Liberia.
    So there are things that we need, and I would say bring it 
on. I think the United States, as Pape Gaye said, we have had 
this mantle of leadership in global health for the last dozen 
years, if not 15, and I think we would be welcome. So are the 
Cubans welcome because they are bringing delivery capacity, and 
so are those who can bring laboratory capacity and logistic 
capacity.
    We have a long way to go, it seems to me, especially out in 
the rural areas.
    Senator Markey. Dr. Peterson.
    Dr. Peterson. Thank you. I went from Liberia to Sierra 
Leone, so I got to see a little bit of the comparison, and when 
I look at the epidemiology of what happened, the Ebola epidemic 
made a round, a very fast, fierce round through Liberia, and we 
saw a lot more cases there early on than we saw in Sierra 
Leone. Sierra Leone is doing the same round, started in one 
part of the country and moving from hot spot to hot spot, but 
it has done it more slowly.
    I think what we are seeing now is completely predictable 
because the place it had not yet reached was Freetown. It had 
not reached Freetown with its slums that have no running water, 
that have no sanitation, where people are very close together. 
It was just arriving there as I left a month ago. So Sierra 
Leone has a larger population.
    In the end, are the epidemics going to be really different? 
I do not know. We can and should roll up a much stronger 
response in the urban and peri-urban areas, especially of 
Sierra Leone. It is possible in each of the countries they 
could do another round because it has been hot spot to hot 
spot. I think we are now ready to jump on and stop each one of 
those new satellites from expanding, and that should be our 
focus. So, back to the communities and identifying every 
patient.
    Senator Markey. Thank you.
    Senator Coons. Thank you, Senator Markey.
    Senator Murphy.
    Senator Murphy. Thank you very much, Mr. Chairman, and 
thank you, Senator Flake, for convening this hearing.
    Very impressive, Madam President, your testimony and your 
willingness to continue to be part of this hearing.
    Senator Markey really asked the questions that I wanted to 
ask, and so I saw, Mr. Gaye, you nodding your head. So I am 
just going to extend the question to you, and I will really 
focus on the second half of Senator Markey's question, which is 
this query of where the United States should be and whether 
there is a role for us in Sierra Leone commensurate to the role 
that we have been playing in Liberia.
    The British are there, but there have been criticisms of 
their ability to put together the kind of coordinated effort 
that we have helped, along with the President and her team, in 
Liberia. So, I would just love your thoughts on this question 
as well.
    Mr. Gaye. Sure. Yes, I think there is a great role, a 
critical role, a strategic role for the United States to play. 
I am not sure that the answer would be to send more people from 
here. I think we should strive to foster local solutions. I 
think we should recruit President Sirleaf, who has taken great 
leadership here and who has really demonstrated what we need to 
hear more and see more from the African leadership: a high 
level commitment to the issue of the health workforce.
    This is the human part of the health system. This is the 
entry point. Without the person, without the people, without 
the health workforce, we just cannot do anything. So we need to 
embrace this idea of a people-centered health system. When 
people think about health systems they usually think about 
infrastructure, the supply chain, or the costing. Economists 
come and give you a lot of the studies.
    Paradoxically, we do not think about the most important 
element: the people we are trying to serve and the people who 
do the serving. This is why I think we need to, again, 
reelevate the importance of the health workforce, get the local 
commitment and look for local, national, and regional solutions 
in the long term. The United States is better placed than 
anybody to orchestrate that because of this leadership that we 
have been talking about.
    Senator Murphy. The quickest way that the United States can 
deploy more personnel is through the military. Have we reached 
the limit of what military personnel can do inside--we are 
talking about Liberia, but the British have people, other 
places--or is there a utility to increase the numbers 
throughout the region from the one sole source that we have 
that is quickly deployed, being our military?
    Mr. Gaye. We need to win this fight quickly, so I think we 
need to bring all the forces we can to do that; as long as we 
also take the opportunity to reengage and recommit to really 
building the systems that are going to make sure this does not 
happen again.
    Senator Murphy. Dr. Peterson, I am going to ask a version 
of the same question that has been asked a number of times, 
which is how do we sustain this effort, and I want to just 
maybe ask you the question in this frame. We talked about the 
fact that there is a lot of money all at one time, and anyone 
else can answer this as well.
    How do we think about time-releasing this money? Should we 
be thinking about mechanisms by which this money is spent over 
a longer period of time rather than all at once? If we think 
about how we actually make this be impactful 5 years from now, 
is this not just about what we choose to fund at the here-and-
now moment? Should we consider reserving portions of it, or 
should we just spend it all now on the crisis and then come 
back to Congress and fight for more later on? As this might be 
our only bite at the apple, and if you have this kind of money 
and this kind of leverage, how do you spend it?
    Dr. Peterson. Thank you very much. I think perhaps both. We 
clearly have an urgent task that needs to be done now. But if 
we only address it from the urgent standpoint, if we do not 
reach out and deal with the economic issues, the drivers that 
are leading food insecurity and breaking quarantine, all these 
other issues are both important for the society itself and they 
are also part of the driver in the people's and the 
communities' response for infectious disease.
    Our emergency response teams are not used to doing 
development. They are not used to working in community and 
talking in community. So I actually think we need a mix. We 
need OFDA in there saying, okay, what is the most important 
thing to do in the next 3 months, and we need the other side of 
the foreign aid that is looking at what are the systems, how do 
we build it, how do we build the capacity locally, and that 
will mean not one-year funding a bunch of times, which will 
always be urgent responses, but some longer term funding that 
says this rebuilding, as the President has said, is a long-term 
endeavor.
    If I could also just speak to the DOD?
    Senator Murphy. Sure.
    Dr. Peterson. I think there is a role. I had a number of 
the faith organizations say please would we get DOD to help 
bring our stuff to us, home protection kits, PPEs, that they 
cannot get from one side of the country to the other side of 
the country. Our military is brilliant at that.
    So there are roles, again, for our military, our aid 
organizations to work with communities and locals to get the 
most needed resources out to the places where it will make the 
most difference.
    Senator Murphy. This is a hearing happening in an amazing 
week in which this committee is grappling with a question of 
how we authorize force in the Middle East and whether there are 
ways in which we exert military influence and power that do us 
more harm than good. My hope is, especially with this new 
allocation of significant resources in the omnibus, that this 
is going to be maybe the pinnacle of success stories in terms 
of how the United States exerts influence around the world. 
This is a combination of humanitarian aid, public health 
dollars, and military support that can, at the end, be able to 
paint a way out of a crisis that a few months ago seemed to 
many in the short term to be unsolvable.
    So as we all on this committee try to figure out what 
America's footprint moving forward in the world is, this is 
going to be a source of, I think, some very positive lessons 
learned.
    Thank you, Mr. Chairman, for focusing us on this today.
    Senator Coons. Thank you, Senator Murphy. And I would like 
to thank all the members of the subcommittee who have joined us 
today. Thank you, Senator Flake, for a strong and good working 
partnership through the course of this Congress.
    I would like to thank all of the four folks who have 
provided testimony today, to Mr. Alvarez, to Mr. Gaye, to Dr. 
Peterson, to Dr. Farmer. Thank you for your service, for your 
example, and for your tireless dedication to improving public 
health. It is indeed our hope and our prayer that in our 
emergency response we are focused on building sustainably very 
strong public health systems in the three most directly 
affected countries and across the region, and that we will 
continue to work together in very real and meaningful 
partnership.
    And to Madam President, thank you for being our very 
special guest today, thank you for providing remarks, and thank 
you for showing an unusual interest in what actually is done by 
Members of the U.S. Senate. It is not a common experience for 
us----
    [Laughter.]
    Senator Coons [continuing]. To have a President as 
interested in the deliberations of the Senate as you have been 
today. We are grateful for your tireless leadership of your 
nation, of the region, and of our world as we continue to try 
and find ways to stand up to the challenges of inequity and 
inequality, and as we try to believe a better future into being 
for the Republic of Liberia and the United States. Ours is a 
long and positive friendship between our nations, and I am 
grateful for your time with us today.
    President Sirleaf. Thank you.
    Senator Coons. Thank you all very much.
    We will hold the record open until the 11th for any members 
of the committee who might have questions for the four 
witnesses who testified today. Thank you.
    With that, this meeting is adjourned.
    [Whereupon, at 12:32 p.m., the hearing was adjourned.]
                              ----------                              


              Additional Material Submitted for the Record


             Prepared Statement of Senator Robert Menendez

    I'd like to thank Senator Coons for convening the subcommittee to 
examine efforts to halt the spread of Ebola in West Africa. I'd also 
like to thank our esteemed guest, President Ellen Johnson Sirleaf, for 
consenting to join us, as well as witnesses from the NGO community. I 
would also like to take a moment to not only thank, but to commend, the 
many brave volunteers who are and have been on the front lines on the 
battle to stop Ebola.
    Madam President, our sympathies are with you and all the people of 
Liberia who have been affected by the outbreak. We stand resolute in 
our commitment to help end this very clear threat to international 
health.
    We all know the figures associated with Ebola: over 17,000 people 
infected. More than 6,000 lives lost. What we must also keep in mind is 
the enormous toll this is taking on survivors and those in the broader 
community. Over 3,000 children have been orphaned. Livelihoods have 
been disrupted with a potentially devastating economic impact. Children 
have been out of school for months. Thousands of people are unable to 
obtain lifesaving interventions such as immunizations, prenatal care 
and malaria treatment because poor, already overtaxed medical systems 
cannot cope with the dual demands of crisis response and routine care.
    The United States Government has led the way among donors, working 
with the Government of Liberia to halt the spread of Ebola before it 
becomes a pandemic, building treatment centers, sending thousands of 
units of personal protective equipment and laboratory materials to the 
subregion, and helping health officials with contact tracing, airport 
screening, training in safe burials, and medical testing and treatment. 
The U.N. has stepped up in an unprecedented way, with the establishment 
of the U.N. Mission for the Ebola Emergency Response. However reports 
from Sierra Leone about a rise in infections, and concerns about lack 
of accurate information about the widespread nature of the threat is 
troubling. We must work to ensure that we are sharing lessons learned 
from efforts in Liberia with our U.K. and French partners who have 
taken the lead in working with the governments of Sierra Leone and 
Guinea to bring infection rates under control. We can do more to share 
best practices on the health care response and social messaging 
efforts, and to coordinate our efforts on the ground.
    While we may have seen progress in Liberia, the danger posed by 
Ebola is far from over. Congress is working now to act on President 
Obama's request for $2 billion in emergency funding for continued U.S. 
assistance to the beleaguered countries in West Africa. The money will 
be used to fund critical efforts by the U.S. Agency for International 
Development, the Centers for Disease Control and Prevention, and the 
U.S. military to contain and end the outbreak and to mitigate its 
secondary effects. Once the outbreak ends, we must look at ways to 
support improved global health systems in order to prevent another 
health crisis like Ebola from emerging.
    Today I hope our guest and witnesses will address--among other 
things--whether and how we need to change the approach we are taking in 
the three most heavily impacted countries so that mitigation efforts 
are carried out in disease hot spots, and what we are doing to ensure 
non-Ebola patients can obtain care. I'd also like your views on what we 
need to do in the long-term to strengthen health care systems so that 
countries in the subregion--and beyond--to better respond to this type 
of crisis in the future.
    Again, I offer many thanks to all of our panelists today. Welcome 
to the committee. We look forward to hearing from you.
                                 ______
                                 

                Prepared Statement of Save the Children

    West Africa is now battling the deadliest Ebola outbreak the world 
has ever seen. The scale of the crisis is unprecedented in terms of 
geographic distribution, infection rate and the number of people killed 
by the disease. Save the Children is working urgently in Liberia, 
Sierra Leone, and Guinea to halt the epidemic before it spirals further 
out of control. Serious steps must be taken now to relieve the 
suffering of children and families affected by the outbreak. To this 
end, we urge policymakers to take the following actions:

    1. Fund the Administration's proposed Ebola emergency funding 
package. In particular, we urge Congress to fund the International 
Disaster Assistance (IDA) account at a total of $3.5 billion for FY 
2015 to make sure that as we address Ebola, we are not neglecting to 
fund critical responses to other crises such as those in Syria, Iraq, 
and South Sudan. This $3.5 billion includes:

   $1.4 billion requested by the administration for the 
        International Disaster Account in the emergency Ebola funding 
        package,
   $2.1 billion requested by the NGO community for the 
        International Disaster Account for FY2015.

    2. Immediately strengthen public health systems in affected 
countries to address not only treatment of Ebola, but also the delivery 
of other essential health services. One of the main causes of the Ebola 
outbreak getting out of control was weak, underfunded, and understaffed 
health services. It is therefore crucial to build strong local health 
systems to enable communities to prevent and respond to future 
outbreaks of Ebola and other infectious diseases.
    3. Invest in Education. Children are losing out on critical months 
of learning as school year start-dates are delayed and schools in 
affected areas are closed. The postponement of primary exams and closed 
schools significantly increase the risk of permanent dropout and the 
loss of learning gains achieved in recent years by investments made by 
USAID in education. To ensure children receive a quality education, 
funding must be provided for quality home-learning programs, teacher 
training programs, home-based instructional materials, radio-programs, 
and text messaging that cover the national curricula.
    4. Meet the needs of vulnerable children. Many children living in 
affected countries are traumatized by the loss of a parent or death of 
a family member and may be left without appropriate care. Stigma and 
fear may further contribute to isolation or rejection of children 
affected by Ebola. Efforts must be made to locate, identify, and 
register unaccompanied children to ensure that adequate alternative 
family-based care is provided. This care must be in line with the 
International Guidelines for the Alternative Care of Children. 
Moreover, children accompanying their family members to health 
facilities but who are not accepted into the health facility for 
treatment of Ebola should be cared for, monitored, provided with access 
to basic services and receive appropriate psychosocial support.
    5. Address the Impact of Ebola on household food security and 
livelihood activity. In Liberia and Sierra Leone the price of food has 
increased in some markets since the start of the crisis, threatening to 
deepen the vulnerabilities of already poor and food insecure 
households. Some reports indicate that lower productivity also 
threatens the flows of production from the affected areas to main 
markets, with implications for wider food security in the West and 
Central Africa regions. The U.S. Government should invest in a thorough 
food security and livelihoods assessment in countries affected by Ebola 
to assess the impact that Ebola has had on income and food sources. In 
addition, targeted food assistance should be provided to isolation 
units, Ebola-affected families, and communities under quarantine and at 
risk of Ebola. Care should be taken that food assistance modality and 
distribution procedures align and support larger public efforts to 
prevent the spread of Ebola. Finally, trade must continue to and from 
affected countries to maintain economic activity and ensure adequate 
food and nonfood supplies.

    We welcome the committee's attention to the Ebola crisis and 
appreciate U.S. Government efforts to address the threat of this crisis 
for the over 2.5 million children under the age of 5 living in areas 
affected by Ebola. As the needs in the region continue to escalate, so 
too must our humanitarian commitment. We sincerely appreciate your 
attention to these important issues, and look to both the 
administration and Congress to marshal the necessary support, including 
in appropriations legislation, to reduce the suffering and improve the 
outlook for the children and families of West Africa.
                                 ______
                                 

             Prepared Statement of Catholic Relief Services

    Catholic Relief Services (CRS) is the official international 
humanitarian agency of the U.S. Conference of Catholic Bishops (USCCB), 
assisting poor and vulnerable people in 100 countries on five 
continents. Without regard to race, creed, or nationality, CRS programs 
address food security, agriculture, health, education, emergency 
relief, and peace-building.
    As part of our integrated, multisectoral approach, CRS supports 
more than 180 health programs in nearly 50 countries across Africa, 
Asia, and Latin America. In partnership with the local Catholic Church 
and other faith-based and nongovernmental organizations, CRS health 
programs directly support more than 26 million people. These 
partnerships often connect us to communities inaccessible to government 
and provide the kind of local knowledge that builds sustainable 
solutions.
    The West Africa Ebola outbreak is the largest since the virus was 
discovered in 1976. The first case was documented in Guinea in December 
2013; since then, there have been more than 17,000 reported cases of 
Ebola virus disease (EVD), with just over 5,689 reported deaths in 
eight countries in Africa, the United States and Europe. The World 
Health Organization (WHO) has indicated that the outbreak may be 
stabilizing in some areas. Case incidence is stable in Guinea, stable 
or declining in Liberia, but may still be increasing in Sierra Leone.
    Stopping Ebola transmission requires behavior change (people must 
understand what puts them at risk and take action to protect 
themselves), strong case management (prompt identification, isolation, 
and treatment of those who are infected), contact tracing 
(identification, isolation, and surveillance of those who have had 
contact with infected people) and safe and dignified handling of 
deceased bodies. Despite aggressive containment efforts, the World 
Health Organization (WHO) predicts that transmission will continue for 
at least 9 more months.
    CRS has been active in the response since the outbreak began to 
spiral out of control, capitalizing on our existing programming 
capacity in the region and our extensive experience with natural and 
man-made disasters throughout the world. CRS has been working in West 
Africa for more than five decades (51 years in Sierra Leone, 24 years 
in Liberia, and 12 years in Guinea). In addition to committing more 
than $1.5 million in private resources, CRS has leveraged our health, 
food security, education, and other programs to rapidly and effectively 
respond to the Ebola outbreak. In addition, CRS has to date been 
awarded $5 million from the U.S. Government, through the generous 
support of USAID and CDC.
    Though primarily a health emergency, the Ebola outbreak has wide 
ranging effects. It is setting back a full decade of development 
progress in fragile states emerging from civil conflict. The ripple 
effects of this crisis include the following:

   Routine health care: Prior to the crisis, the affected 
        health systems suffered from inadequate personnel, low quality 
        services, poor public confidence and poor health outcomes. 
        Ebola is increasingly straining these already weak systems. 
        Nearly 600 health care workers have been infected with Ebola, 
        of whom 380 have died. Essential health services such as 
        routine childhood immunization have ceased in many areas, and 
        most health experts predict a surge in deaths from preventable 
        illnesses such as measles, malaria, and diarrhea. Prenatal and 
        obstetric care have also been compromised, and thousands of 
        women are being forced to deliver at home without a skilled 
        birth attendant, placing them and their babies at risk. In 
        addition, Ebola survivors face stigma that can negatively 
        affect their physical or psychosocial well-being. Many more 
        people will die from lack of routine health care than will die 
        from Ebola.
   Livelihoods and food security: Agricultural activities, 
        including this year's harvest, will be heavily impacted. Many 
        families have lost productive members and in some instances 
        have been unable to access their farms due to travel 
        restrictions and quarantines. There are indications that market 
        disruptions and fears related to Ebola may result in price 
        increases, limited produce in the market, and decreased income 
        from cross-border trade with neighboring Mali and Senegal. 
        Agricultural production is expected to be lower than usual, 
        leading to an earlier and more pronounced lean season and 
        negative coping strategies such as eating seed; FEWS NET 
        predicts a ``stressed'' situation in heavily affected areas of 
        Sierra Leone and Liberia.
   Education: Schools In Guinea, Liberia, and Sierra Leone have 
        been closed since last summer, with potential far-reaching 
        negative implications for children, who are losing valuable 
        education time and may be at increased risk for child labor and 
        early marriage. Universities and technical training 
        institutions are also closed, which will make it difficult for 
        countries to replace their skilled labor force (particularly 
        health care workers).
   Vulnerable children: In Guinea, Liberia, and Sierra Leone, 
        we are seeing a rise in street-children, in violence against 
        girls and early marriage, pregnancies; hazardous under-age 
        labor, and rising stress. We must be careful about hasty 
        interventions that are not evidence-based and about ``creeping 
        orphanages'' that devolve from interim care centers.

    In response, CRS teams are setting up and supporting five community 
care centers to quickly triage and isolate possible Ebola patients. We 
are training 3,000 health workers and providing personal protection 
equipment in Guinea and Liberia to help provide access to routine 
health care for an estimated 3 million people. In addition, CRS was 
instrumental in the reopening of St. Joseph's Catholic hospital in 
Liberia's capital, Monrovia. The oldest hospital in Liberia, it serves 
as a referral facility for all other health facilities in the country, 
public and private. Now open, St. Joseph's is not only treating Ebola 
patients, but also offers routine health care, which has largely become 
unavailable due to stress on the local health system.
    In addition, CRS is working to curb transmission of Ebola through 
programs that aim to educate and change behavior, with particular 
emphasis on using mass media, including radio and text messages, to 
promote awareness and increase knowledge. We have also capitalized on 
our strong connection to local communities, training religious leaders 
and volunteers to raise awareness and promote behavior change. CRS and 
our partners have already reached more than 2 million people with these 
messages.
    The WHO estimates that 70 percent of Ebola transmission occurs 
through exposure to dead bodies. In Sierra Leone, CRS manages 19 burial 
teams (9 in Port Loko, 6 in Bombali, and 4 in Koinadugu) that conduct 
hundreds of safe and dignified burials in order to prevent further 
infections and respect families' religious practices. CRS is also 
collaborating with religious and traditional leaders to ensure access 
to and acceptance of safe and dignified burials.
    Historically, outbreaks of EVD have been limited in scale and 
duration. The current outbreak is the largest and most complex in 
history, with more cases and deaths than all other outbreaks combined. 
Why has this particular outbreak evolved into a regional crisis? One 
reason is the location. In the past, Ebola has appeared in isolated, 
remote villages that had limited contact with outsiders; the virus was 
geographically contained until the outbreak quickly ran its course. In 
contrast, the current outbreak emerged for the first time at the 
intersection of three countries, spreading along porous borders and 
well-traveled roads until it arrived in the densely populated capital 
cities of Monrovia, Freetown, and Conakry where it claimed the majority 
of its victims.
    Misconceptions, fear and distrust have also facilitated the spread 
of Ebola. Many sick people are not seeking care due to unfamiliar and 
sometimes frightening isolation procedures, low trust in health 
services, and perceived poor quality of care at treatment centers, 
helping to propagate the virus at an alarming rate. Traditional burial 
practices are another factor. Throughout the region, it is customary 
for relatives to wash and prepare bodies at home. While these practices 
are an important part of West African cultures, they expose family 
members to infectious bodily fluids.
    And the slow international response allowed the outbreak to gain 
momentum while local authorities and NGOs struggled to respond.
    But by far the largest contributor to the spread of Ebola has been 
weak health systems. Guinea, Liberia, and Sierra Leone all face a 
critical shortage of health workers, inadequate health financing, poor 
access to data for decision making, and weak supply chains. The virus 
appeared and spread for 3 months before health structures were able to 
identify its presence. None of the three countries had enough health 
professionals to trace the virus to its origins and isolate all those 
who had been infected. When tracing procedures identified infected 
people, many treatment centers quickly reached full capacity and many 
observation units were not fully staffed. Country health institutions 
also lacked the trained staff and volunteers needed to run education 
and awareness programs that would help people avoid infection and bury 
loved ones in a safe yet culturally acceptable manner. Those health 
centers that were up and running often lacked the necessary and life-
saving equipment to treat Ebola patients and prevent the spread of 
infection. Personal protective equipment (PPE) is only effective if 
used properly but overworked health workers and improper training have 
resulted in nearly 600 health workers contracting the disease.
    Furthermore, Guinea, Liberia and Sierra Leone are among 83 
countries that do not meet the WHO's minimum recommended number of 
health care providers needed to provide basic health services (22.8 per 
10,000 people). In most of these countries few, if any, local partners 
have the existing capacity in all areas (including clinical skills, 
strategic information, laboratory services, finance, health supply 
chain) that are required to sustain routine and emergency health 
services.
    For this reason on September 23, 2014, the USCCB and CRS sent a 
letter to National Security Advisor Susan Rice to urge the U.S. 
Government to implement a multipronged approach: continue emergency 
response (case detection, treatment, contact tracing, safe burial) 
until the outbreak is contained, restore essential services (such as 
preventative and routine care) and focus on health systems 
strengthening to prevent future disease outbreaks from overwhelming 
local and regional health networks.
    Strengthening health systems is critical to ensuring 
sustainability, equity, effectiveness and efficiency, all of which 
contribute to positive health outcomes. Building strong health systems 
will require expert technical assistance to all key stakeholders--
including Ministries of Health, local technical organizations, civil 
society organizations and faith-based health networks--until regular 
monitoring demonstrates successful outcomes. An abrupt end to expert 
technical assistance will jeopardize programs and patients.
    A successful effort will require a number of partners with varied 
expertise. The HIV epidemic has taught us that sustainable health care 
is multidimensional and all interested stakeholders must be engaged to 
bring their knowledge to the table. In particular, the role of civil 
society organizations (CSOs), especially faith-based organizations 
(FBOs), cannot be understated. Faith-based institutions are often the 
most trusted organizations. They play a vital role in the health 
systems located in resource limited settings. FBOs support national 
efforts; they offer complementary services, in many places assisting 
those the government does not reach; they help ensure accountability; 
and they advocate for strategies that match needs on the ground. As we 
assist countries in building resilient, high quality care delivery 
systems, we must ensure continued synergy between faith-based and civil 
society actors and local governments. The effectiveness of faith-based 
health system strengthening was demonstrated, in part, by CRS' 
AIDSRelief project. With support from PEPFAR, the 9-year program 
provided lifesaving HIV care and treatment services to more than 
700,000 people through 276 health facilities in 10 countries. Working 
largely through rural and faith-based facilities, AIDSRelief 
established basic packages of care and treatment that exceeded what 
many thought possible in a resource-constrained environment. Instead of 
merely offering HIV tests and dispensing medicine, AIDSRelief helped 
our partners to build strong supply chains, operate high-quality 
pharmacies, manage state-of-the-art laboratories, and use timely-
accurate data for decision making. More than 30,000 participants--
doctors, nurses, pharmacists, and other health care workers--attended 
training sessions that built and strengthened their skills to provide 
high-quality medical, laboratory, pharmaceutical, and other services.
    We urge the U.S. Government to lead other donor nations in 
developing and funding a coordinated, long-term humanitarian and 
development strategy for the affected region that rivals that of PEPFAR 
in its scale and scope. This new program for Africa should include 
immediate humanitarian assistance and health systems strengthening 
through ongoing technical support to build laboratory capacity, train 
and retain health workers, strengthen supply chains for medicines and 
commodities, and ensure sustainable financing for the future.
    USCCB and CRS deeply appreciate U.S. leadership in West Africa, 
without which this crisis on top of so many other crises might have 
spun totally out of control. Our Nation's Ebola response will require a 
long-term strategy, sustained funding, and continued sacrifice from 
brave men and women willing to act out of love and concern for those 
less fortunate.

                                  [all]