[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/
______
U.S. GOVERNMENT PUBLISHING OFFICE
94-193 PDF WASHINGTON : 2015
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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]