[Senate Hearing 114-775]
[From the U.S. Government Publishing Office]


                                                        S. Hrg. 114-775

                       A PROGRESS REPORT ON THE
                       WEST AFRICA EBOLA EPIDEMIC

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

                                HEARING

                               BEFORE THE

                       SUBCOMMITTEE ON AFRICA AND 
                          GLOBAL HEALTH POLICY

                                OF THE

                     COMMITTEE ON FOREIGN RELATIONS
                          UNITED STATES SENATE

                    ONE HUNDRED FOURTEENTH CONGRESS

                             SECOND SESSION
                               __________

                             APRIL 7, 2016

                               __________

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                COMMITTEE ON FOREIGN RELATIONS         

                BOB CORKER, Tennessee, Chairman        
JAMES E. RISCH, Idaho                BENJAMIN L. CARDIN, Maryland
MARCO RUBIO, Florida                 BARBARA BOXER, California
RON JOHNSON, Wisconsin               ROBERT MENENDEZ, New Jersey
JEFF FLAKE, Arizona                  JEANNE SHAHEEN, New Hampshire
CORY GARDNER, Colorado               CHRISTOPHER A. COONS, Delaware
DAVID PERDUE, Georgia                TOM UDALL, New Mexico
JOHNNY ISAKSON, Georgia              CHRISTOPHER MURPHY, Connecticut
RAND PAUL, Kentucky                  TIM KAINE, Virginia
JOHN BARRASSO, Wyoming               EDWARD J. MARKEY, Massachusetts


                  Todd Womack, Staff Director        
            Jessica Lewis, Democratic Staff Director        
                    John Dutton, Chief Clerk        


                              (ii)        

  
                         C O N T E N T S

                              ----------                              
                                                                   Page

Flake, Hon. Jeff, U.S. Senator from Arizona......................     1


Markey, Hon. Edward J., U.S. Senator from Massachusetts..........     2


Knight, Alan, General Manager, Corporate Responsibility, 
  ArcelorMittal and Chairman of the Ebola Private Sector 
  Mobilization Group.............................................     5

    Prepared statement...........................................     7


Panjabi, Dr. Raj, CEO, Last Mile Health..........................    10

    Prepared statement...........................................    13


Glassman, Amanda, Vice President for Programs and Director of 
  Global Health Policy, Center for Global Development............    17

    Prepared statement...........................................    19


Delaunay, Sophie, Advisor, Doctors Without Borders/Medecins Sans 
  Frontieres (MSF) USA...........................................    21

    Prepared statement...........................................    23


                            (iii)  
                       
 
                        A PROGRESS REPORT ON THE 
                       WEST AFRICA EBOLA EPIDEMIC

                              ----------                              


                        THURSDAY, APRIL 7, 2016

                                       U.S. Senate,
 Subcommittee on Africa and Global Health Policy Committee 
                                      on Foreign Relations,
                                                    Washington, DC.
    The subcommittee met, pursuant to notice, at 10:04 a.m., in 
Room SD-419, Dirksen Senate Office Building, Hon. Jeff Flake, 
chairman of the subcommittee, presiding.
    Present: Senators Flake [presiding], Isakson, Markey, and 
Coons.

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

    Senator Flake. This hearing of the Senate Foreign Relations 
Committee, Subcommittee on Africa and Global Health, will come 
to order.
    Just last week, the World Health Organization declared the 
West Africa Ebola epidemic no longer constitutes an 
international public health emergency. However, this does not 
mean that the affected countries of Liberia, Sierra Leone, and 
Guinea have fully recovered from the epidemic.
    Today's hearing gives us an opportunity to examine West 
Africa's road to recovery from the deadly outbreak of Ebola 
that in--in 2004, that infected more than 28,000 people, took 
the lives of more than 11,000 individuals before the epidemic 
was brought under control. The epidemic decimated already weak 
healthcare systems in the three affected countries. It also has 
continued to wreak havoc on their economies, complicating 
recovery for governing institutions and hampering a return to 
normalcy for the citizens of those countries. There have been a 
number of so-called flareups of Ebola since the primary 
outbreak was brought under control, including one ongoing 
outbreak that has already claimed the lives of at least seven 
people.
    Now, the U.S. Government provided 5.4 billion in emergency 
appropriations at the end of 2014 to assist affected countries 
in their response. More than $2.5 billion of this funding falls 
under the oversight jurisdiction of this committee. Now, more 
than a million dollars of assistance remains unobligated, with 
some of it set to expire at the end of the fiscal year, and the 
remainder to be available until expended. This is a substantial 
amount of money.
    It is incumbent on this committee to examine the successes 
and the failures of U.S. efforts to assist in the Ebola 
recovery efforts. This hearing will especially--is especially 
timing--or timely, given the news reports that indicate that 
the White House will ask Congress to reprogram 589 million of 
existing unobligated balances to address the Zika virus. Some 
of this will come from funds appropriated to fight Ebola.
    At the height of the outbreak, this subcommittee heard 
testimony that called for the establishment of first-rate 
healthcare systems in the affected countries. I think we all 
share that goal, and it is important to remember that simply 
providing affected countries with the tools they need to stamp 
out diseases like Ebola is not an economically sustainable 
model. This kind of health infrastructure necessary to address 
these outbreaks while providing other health services can only 
be sustained by the affected countries, themselves.
    Is the U.S. helping these countries to put their healthcare 
systems on a path to self-sufficiency? Have we helped mitigate 
second-order impacts of the epidemic by focusing assistance in 
a way that helps facilitate economic recovery and development? 
The physical accessibility of health services was a problem 
before the Ebola outbreak, as was the access to clean water for 
drinking, handwashing, and other activities central to proper 
hygiene. Are we working to continue the kind--these kind of 
systemic--or to address these kind of systemic problems that 
will likely contribute to recovery and certainly contributed to 
the severity of the outbreak?
    We will examine whether our assistance to affected 
countries is complete enough to consider reprogramming Ebola 
money for other matters. Will that programming come at the 
expense of long-term efforts to help economic recovery in the 
affected countries and to ensure eventual self-sustainability 
of healthcare systems by the countries, themselves? These are 
questions that we want to answer.
    Lastly, it should be noted that the Ebola recovery funds 
were appropriated using a supplemental appropriations measure. 
These funds are not subject to spending caps established by 
Congress, and they are not part of any long-term strategic 
planning effort. As Congress prepares to potentially consider 
appropriation of another tranche of emergency supplemental 
appropriations, this time to combat the Zika virus here in the 
U.S., it is worth examining whether this method of 
appropriating is effective. Does it result in smart 
investments, or is there pressure to simply get the money out 
the door before it expires?
    I look forward to hearing from the witnesses today. I would 
like to thank them for taking the time to meet. I have met with 
each of you before--or three of you in my office before, and I 
appreciate the time and effort you have put into the testimony 
that you are going to give us today, and thank you.
    We will turn now to the Ranking Member, Senator Markey.

              STATEMENT OF HON. EDWARD J. MARKEY, 
                U.S. SENATOR FROM MASSACHUSETTS

    Senator Markey. Thank you, Mr. Chairman, very much. And 
thank you for your leadership and for scheduling this hearing 
on such an important topic.
    The West Africa Ebola epidemic devastated communities in 
Guinea, Liberia, and Sierra Leone. The virus sickened more than 
28,000 people and claimed the lives of more than 11,300. While 
new cases of Ebola have been dramatically reduced, Ebola is not 
over, and the conditions that made it an epidemic persist. Last 
week, a 30-year-old woman died of the disease in Liberia's 
capital, and her 5-year-old son has been diagnosed with the 
same disease. Our thoughts and prayers are with them and all 
the victims of Ebola. But, thoughts and prayers are not enough. 
We must continue to build up health systems in the most 
vulnerable places so that we can prevent an even worse epidemic 
from again rising up to threaten people in Africa and around 
the world.
    Through 2014 and much of 2015, people watched with a sense 
of helpless horror as the Ebola virus seemed to spread 
unchecked. Doctors and nurses unable to stem its deadly tide, 
fell mortally sick themselves. That fear took on a new 
dimension as Ebola began to spread. In September of 2014, a man 
checked into a Dallas hospital, sick with the disease, and many 
began to fear that the U.S. would suffer an outbreak, as well. 
Of course, the United States did not have an outbreak, neither 
did countries in Europe. The U.S. and European citizens are 
fortunate to have capable health systems that virtually 
eliminated the risk of an epidemic and saved 80 percent of 
those treated, a survival rate far above what anyone previously 
thought was possible.
    As Dr. Paul Farmer has explained, we in the developed world 
have the staff, the stuff, the space, and systems to deal with 
these things. Guinea, Liberia, and Sierra Leone are not so 
fortunate. Ebola infections there became a rampant, devastating 
epidemic. More people got the disease than should have, and 
more sick people died than should have.
    Beyond the immediate impact of Ebola, the story became even 
more tragic as the disease crippled weak healthcare systems and 
patients had nowhere to seek treatment for routine medical 
issues. Infant and maternal mortality rates soared, and the 
economy of each country was hobbled. Agricultural production 
was disrupted and food and work became increasingly scarce. The 
scale of Ebola's devastation may never be fully known.
    U.S. leadership under President Obama and the Congress was 
instrumental in stopping the spread of the disease. Thanks to 
$5.4 billion in emergency funding to combat Ebola, this type of 
leadership in the face of our severe threats is not only vital 
for our national security, but also an essential statement 
about America's commitment to humanity. Just yesterday, the 
administration once again demonstrated its commitment to 
protect the American people and strengthen global health 
security by temporarily redirecting $589 million from existing 
Ebola funds to combat the Zika virus, a mosquito-borne 
infection that has broken out in countries of Latin America and 
threatens to spread north.
    In February, the administration asked Congress for an 
emergency supplemental appropriation of $1.9 billion to fight 
Zika. We cannot look at a false choice between responding to 
Zika and continuing to build healthcare systems capable of 
preventing Ebola from again becoming an epidemic. I applaud the 
administration for making a good start on Zika. As has often 
been said, a stitch in time saves nine. But, we cannot stop 
there on Zika, and we cannot pull out the threads that we and 
our African partners are using to stitch together health 
systems capable of preventing Ebola from again becoming an 
epidemic threat. Congress must act to fight both of these 
threats or be prepared to answer for the consequences of 
inaction.
    On Zika, we must invest all of the resources needed to 
better understand how this disease is transmitted and the 
suffering which it causes, including babies born with stunted 
heads and brains. Zika is spreading rapidly in South and 
Central America, in Puerto Rico and the Pacific islands. And in 
a small part of Africa, you can see, on this startling map, the 
World Health Organization estimated the virus will infect up to 
4 million people by the end of this year. And health officials 
have warned of the spread of Zika in the United States, where 
its mosquito host is already endemic. This next map shows just 
how much of the U.S. is vulnerable to that mosquito and the 
diseases which it carries.
    While Zika presents a new challenge that America must face, 
we cannot become complacent about the gains we have achieved 
against Ebola. We must build upon the investments made during 
the epidemic and the wake-up call that it provided to the 
world. The health of the United States is intricately connected 
with the health of West Africa, Latin America, and other 
developed regions. As devastating as Ebola was, it is difficult 
to contract and relatively easy to trace. The next pandemic may 
not be so forgiving. Having strong health systems in place in 
vulnerable parts of the world will be crucial to isolate and 
stamp out the next inevitable threat.
    I want to thank each of our distinguished witnesses for 
being here today. All of your leadership and sacrifice in the 
face of the Ebola epidemic is nothing short of heroic, and we 
deeply appreciate your service. I should also note that several 
of you have connections to Massachusetts. And I am especially 
grateful that you are representing our great State here today.
    Thank you, Mr. Chairman.
    Senator Flake. Thank you, Senator Markey.
    We will now turn to our witnesses. Dr. Alan Knight is 
General Manager of Corporate Responsibility for ArcelorMittal, 
and--but, he also served as chairman of the Ebola Private 
Sector Mobilization effort, which--EPSMG, a group founded in 
July of 2014 to facilitate a mobilized and coordinated private-
sector response to the Ebola virus. Dr. Raj Panjabi is a Co-
Founder and CEO of Last Mile Health, a nonprofit organization 
working to save lives in the world's most remote villages, 
including in Liberia, where Dr. Panjabi was born. Ms. Amanda 
Glassman is the Vice President for Programs, Director of Global 
Health Policy, and Senior Fellow at the Center for Global 
Development, leading work on priority-setting, resource 
allocation, and value for money in global health. Lastly, we 
are joined by Ms. Sophie Delaunay, who serves as Advisor to 
Doctors Without Borders, an organization that was on the front 
lines of the Ebola epidemic.
    We ask you to keep your comments right around 5 minutes. 
Your full remarks will be submitted as part of the record. We 
just want to maximize time for Q&A thereafter.
    So, thank you. And, Dr. Knight.

   STATEMENT OF ALAN KNIGHT, CHAIRMAN, EBOLA PRIVATE SECTOR 
              MOBILIZATION GROUP, LONDON, ENGLAND

    Dr. Knight. Okay. Good morning. And thank you for the honor 
of speaking here.
    You have my paper, so I will just highlight what I think 
are the most important points in that paper.
    As you said, I come here wearing two hats. One, on behalf 
of ArcelorMittal, who are the largest investor in Liberia, an 
iron-ore mine; our investment, at the moment, of about 1.7 
billion, with an iron-ore mine railway and port facilities, but 
also as the, sort of, founder, the chairman of the Ebola 
Private Sector Mobilization Group, which was really, for 
several months, a hub where the private sector with operations 
within the whole of West Africa could get together to exchange 
notes, share information about how the private sector should be 
responding to this crisis. But, over time, that evolved to 
where we had a bit of a voice and an opinion on some of these 
key issues and, more importantly, with in-country groups, a hub 
where we could exchange resources and assets very quickly to 
NGOs and government partners who needed them--and so, trucks, 
medicines, and that sort of stuff.
    At the time, it was quite unique for such a large number of 
private sectors to get together and be actively involved in the 
operational side of fighting such a big issue. And I think that 
is why people sort of still remember it and we still talk about 
it, and many of us are obviously still so active.
    I know a lot of this conversation you want to have today is 
about recovery and ``What next?'' And so, that is what I really 
want to focus on.
    Firstly, so, what has been the impact on us, as a business? 
Well, it was hard. We were committed, and we succeeded in 
keeping our business running, and not forgetting that some 
businesses just packed up and left the country. We have done 
that, and we have succeeded. The impacts on us, commercially, 
was, we lost a scale-up project. Just as Ebola happened was 
when we had planned to build a lot of infrastructure to 
significantly grow the size of our operation. Our contractors 
went home, and we lost that project. Of course, we were 
distracted with management time, and we had to spend a lot of 
money on the interventions to prevent Ebola from happening in 
our concession area. And let us not forget, make a really 
strong point, we, like most of the private sector, can claim, 
rightly so, that nobody in our operations actually got Ebola. 
So, the interventions we did for their own staff clearly 
worked.
    What is been harder for us is the perfect storm that has 
all happened at the same time as the iron-ore prices collapsed, 
and probably we spend more time in the office now talking about 
the consequences of that as much as we talk about the 
consequences of Ebola. But, despite that, we are working very 
hard to keep our business functional, and our commitment to 
staying in Liberia is absolutely clear.
    So, I really sort of want to end with just making sort of 
four points about recovery and what we think we can do, and 
what we would like to suggest others help us do on this road to 
recovery.
    Firstly, this whole issue of travel. For a group of 
private-sector people at the time of the crisis, we spent a lot 
of time talking about travel restrictions. What happens if 
somebody from our--America or the U.K. goes over and catches 
Ebola? Can they come home? And that sort of--it took a lot of 
time. And it sort of--the observation was, it was not clear, 
there is no sort of international convention on the movement of 
people from these areas where this happens. And so, that became 
very distracting, and we lost a lot of time worrying about 
that, which we could have been devoted to actually being on the 
front line. So, I think that there is a space there which we 
can fill.
    There are still--and a lot about the investment--What is 
the role of the private sector? It is about confidence, giving 
them the confidence to invest in that country. And another 
conversation we are having a lot now is about the withdrawal of 
our mill, where we are--you know, we are nervous about the 
United Nations security support might actually create tensions 
in the ore and an inability to sort of fight some security 
issues. So, that is now--we talk about that as a commercial 
risk. What will happen when these people work out? What can we 
do together with other people to fill that space?
    I think we need to have an honest conversation about 
infrastructure. You know, you can build fantastic health 
services, but if you do not have roads to get them--get people 
to those health services, it does not actually work. We need 
roads to keep our business running, and the country needs roads 
to keep the country working.
    I am using roads as a bit of a metaphor, but infrastructure 
really matters. When our business is running really well, part 
of our contribution towards these countries is, we actually 
give money and we help build that--some of the infrastructure. 
But, at the moment, we are really having to focus on our core 
business. So, just at the moment when we need more 
infrastructure is just at the moment that some of the 
conventional sources of that infrastructure disappear. And I 
have got some photographs here to show that this is not sort 
of--issue. You know, the--roads--physical roads, if somebody 
could--you know, if somebody wants to have a look at them, they 
are great, but they are just mud tracks. And so, what is the 
road to recovery? Well, the road to recovery could actually be 
roads, you know, sort of--that sort of line.
    And finally, to save space to discuss this. You know, we 
have--there are a lot of very big issues--iron mill, Ebola, 
commodity prices, infrastructure. And I think what EPSMG did 
when it was just about Ebola was a safe space for different 
people from different sectors just to get together and discuss 
with government officials. And I think people are--just 
underestimate how much can be achieved with collaboration and 
dialogue.
    So, sort of, really, my headline, in my last 30 seconds, 
is, do not underestimate how important the road to recovery is. 
And a lot of that road to recovery will be infrastructure, like 
roads. And the vehicle being dialogue and collaboration. Where 
can we carry on with our EPSMG-type dialogue on these broader 
issues, where we can get together and talk to government 
officials in-country, NGOS, about what we all really need to 
move this forward? Where is that safe space?
    Thank you.
    [Dr. Knight's prepared statement follows:]


     Prepared Statement of Alan Knight, General Manager, Corporate 
Responsibility, ArcelorMittal and Chairman of the Ebola Private Sector 
                           Mobilization Group

    Mr. Chairman, Ranking Member Markey, members of the subcommittee, 
thank you for giving me the privilege to testify today on the Ebola 
outbreak recovery efforts in West Africa and the lessons that we can 
draw from the response.
    It is an honor to represent my company, ArcelorMittal, one of 
Liberia's largest investors. I am also here in my capacity as a 
founding member of the Ebola Private Sector Mobilization Group (EPSMG).
    My testimony today will focus on two issues:


   Examining the role of the private sector in coordinating an 
        effective, rapid response during a crisis, and

   Looking beyond Ebola and lessons learned and considering the 
        challenges of economic recovery.


    As I sit here today, and as you consider my testimony, I would like 
to suggest that the private sector's largest contribution during the 
Ebola outbreak was simply to keep business running. This was achieved 
through rigorous risk-planning and through the development of health-
and-safety systems which minimized the risk of employees contracting 
the virus.
    Going forward, I would like to further suggest that the private 
sector's greatest contribution, post-Ebola, is to keep business going, 
not in the face of a health emergency, but in an environment of higher 
costs, higher risks, and low commodity prices.
    It is my hope that this hearing will examine not only lessons 
learned but what steps can be taken to ensure that the region's 
recovery is driven by a private-sector recovery.
From risk register to company level mobilization
    First, by way of background, ArcelorMittal operates an iron ore 
mine, a railway of 240 kilometers, and a port in Liberia. Our 
operations stretch from the border of Guinea to the shore of the 
Atlantic and through three of Liberia's fifteen provinces, Nimba, Bong, 
and Grand Bassa. We have been operating in the country for ten years. 
At the height of the Ebola outbreak we had nearly 3,000 direct and 
indirect employees. While many of our subcontractors declared force 
majeure because of the health emergency and departed, ArcelorMittal did 
not. We never left. We never stopped working. We stayed operational 
throughout the peak of the virus.
    As you can imagine, given our footprint and our direct and indirect 
employees, their families, their extended families, and their 
communities, ArcelorMittal touches the lives of tens of thousands of 
people in the region. During Ebola, that meant that our health and 
safety protocols did as well, and this saved untold lives.
    We monitored the Ebola outbreak carefully. We worked hard to 
understand the virus and make sure that our facilities were prepared to 
deal with it. We hired experts to advise the company, trained and 
counselled our staff, and mobilized protective and specialized medical 
equipment. We also reviewed and refined our emergency response and 
evacuation procedures, set up a management committee, and enacted the 
appropriate procedures and systems.
    In July 2014, cases of Ebola were reported in Monrovia, Liberia and 
the risk management triggers were pulled for ArcelorMittal. The company 
led the way in private sector support to the government with the total 
value of support to the government and individual counties estimated at 
US$1.3 million.
    Although we hoped that the outbreak would not spread any further 
and endanger more lives, we were prepared for it. However, we were not 
the only company operating in the region and knew that we would have to 
learn from others in order to share what we already knew and to drive a 
stronger response to the escalating crisis. That is why a call was made 
to companies we knew, inviting them to join an informal conversation in 
London to share information about the outbreak, compare best practices, 
and collaborate to limit impacts across West Africa.
EPSMG is born
    The ESPMG started in July 2014 as a one-off gathering of 11 London-
based companies who came together to share what they could contribute 
to help combat the growing threat of Ebola. These companies all had an 
operational footprint in the affected region.
    Awareness of the group spread by word of mouth and more companies 
asked to be involved. The number of companies dialing in for EPSMG 
calls quickly grew and we were soon joined by representatives of aid 
organizations, international institutions, and governments. At the peak 
there were over 100 companies and almost 50 public bodies and NGOs 
joining the calls. For one of our December 2014 calls, we believe we 
had over 400 individuals dialing in.
    I call the EPSMG a hub because it was never actually a legal entity 
with a board, budget or articles of association. Our initial focus was 
to exchange notes on what we were doing at our operations. We also 
decided to write to the Director General of the World Health 
Organization to ask advice on how we could strengthen our response.
    Through this all, we found a common voice. Despite the 
unprecedented nature of the outbreak, group members made a joint 
commitment to continue operating in those Ebola-affected economies and 
to carry out business as usual, as far as was possible. This was no 
easy feat in the face of emerging restrictions on national and 
international trade as well as travel restrictions. Falling commodity 
prices bought extra complexity to this operating environment.
    Looking after our own people was important but that alone was not 
going to ``bend the curve'' of the outbreak. What started as an inter-
company information exchange evolved to advocacy for a global response 
and a hub where the public and NGO sector had direct access to 
companies for bilateral collaboration.
    Although aid organizations had the humanitarian and health response 
expertise, we had heavy lifting equipment, transport, accommodation, 
and other needed resources. Perhaps most critically, we already had all 
of this in the affected countries and were ready to help. The ESPSMG 
provided a quick and simple hub to learn what needs were and helped 
facilitate bilateral arrangements between donors and recipients.
Country groups, the real success
    From the EPSMG came the EPSMG country groups which were on the 
ground, mobilizing skills and resources in Guinea, Liberia, Sierra 
Leone, as well as in the adjacent countries of Mali and Senegal, to 
increase preparedness and prevent the spread. Most of the EPSMG's 
success can be linked to these country groups; the umbrella 
organization created a sense of community and an environment which 
enabled an efficient exchange of information.
    We had a clear responsibility to foster stronger relationships with 
government and responders, ensuring that we had the information needed 
to fight the disease, which we could then share within our communities. 
However, this could only happen at country level and a great success of 
EPSMG was its ability to help get things done on the ground.
    So what did companies do? In some instances assistance meant giving 
cash, while in others it meant donating vehicles for use as ambulances, 
providing medical supplies, and providing access to logistics, 
infrastructure, and communications technology.
    People like numbers, but numbers with meaning can be hard to 
obtain. We believe that, at a minimum, the EPSMG companies gave away 
least 50,000 liters of chlorine, 4 million latex gloves, and 55 
vehicles. More importantly, we trained over 50,000 employees who we 
estimate reached 350,000 dependents. Another positive outcome was the 
low infection rates within member companies. Thanks to the rigorous 
planning and precautions taken by our Liberian colleagues, not one of 
our employees contracted the virus, a fact that most other companies 
could also report.
    The EPSMG never sought to replace or compete with the governments, 
donors, other coordination groups, or task forces. It was created to 
provide a simple access point into the private sector for joint 
mobilization. The EPSMG was about practical in-field action--not 
intellectual consensus building.
    By January 2015, the Ebola outbreak curve had been bent. While the 
numbers of new cases reported were still unacceptably high, there were 
fewer with each passing week. Discussions began on ``the road to 
zero.'' With the crisis over, we observed that many private sector 
companies began disengaging from the EPSMG, instead channeling their 
efforts into the daily operations of running a business in post-Ebola 
West Africa. By April 2015, EPSMG was no longer as active as was 
required at the height of the crisis.
Travel restrictions--our biggest distraction
    With people dying from a highly contagious disease, it was a shock 
to many of us that governments around the world had no formal policies 
or thoughts on what was the right approach to the movement of nationals 
to and from countries at risk.
    For example, if I, as a British national, flew to Liberia to help 
fight the Ebola outbreak and contracted the disease it was unclear 
whether I could come back to UK for treatment, or whether I would have 
to stay in Liberia. If so, what would happen to me? What if I broke my 
leg or suffered an illness or injury completely unrelated to Ebola 
while in an Ebola-affected area--would I be able to return to the UK? 
It was all unclear. Expatriate employees were concerned about the 
uncertainties surrounding routine return transport to their home 
countries and fears grew about the availability of medical evacuation 
for suspected or confirmed cases of Ebola.
    We also realized that blanket travel bans were of significant 
concern to humanitarian responders struggling to get personnel and 
supplies to the affected areas. We lobbied hard on this, as there was 
too much fear driving decisions.
    As we look at outcomes from this hearing I would ask that this 
committee considering asking for an international convention on the 
movement of nationals to and from countries suffering a pandemic. It is 
imperative that a protocol be negotiated and agreed before the next 
pandemic. This is an unnecessary distraction the private and public 
sectors can ill afford to see repeated.
What did we learn?

 1. The EPSMG's greatest contribution was preventative action

    The epidemic was rightly seen as a humanitarian disaster, but we 
observed that it is important not to put Ebola in the same box as 
event-based disasters like floods and earthquakes, where the worst 
outcomes occur suddenly, before businesses can intervene, placing the 
focus on rescue and recovery. While a death toll of 12,000 is a 
disaster, we should remember that the forecast number of cases exceeded 
250,000 in September 2014. Perhaps the forecasts were wrong, or even 
more likely, the joint effort with NGOs, the public sector, and the 
private sector were successful. Either way, this success story is about 
what was prevented.


 2. Business has been here before--parallels with HIV

    Parallels can be drawn with the long track record many businesses 
have in managing HIV in their workforces. Whilst the pace of the HIV 
outbreak was over months and years rather than hours and days, many 
companies in Africa proved to be highly effective in mobilizing their 
staff and resources to prevent HIV from spreading. The parallels are 
noteworthy: the need to change behaviors, the need to have the right 
medicines, the value of peer-to-peer education, and the issues of 
stigma are all similar. Perhaps most noteworthy was the need for an 
employer to engage in conversations with employees about topics that 
they normally would avoid. For HIV, this was about sexual behavior; for 
Ebola, it was about attitudes toward funeral rites and traditional care 
behaviors. Anyone studying the EPSMG contribution should, therefore, 
also draw lessons from HIV.


 3. Risk management works

    Business risk processes provide a good framework to plan for 
pandemic risks. Since SARS, contagious disease has become a theoretical 
business risk, but late-2013 and early-2014 Ebola cases in West Africa 
captured the attention of risk managers and their health and safety 
colleagues. During the worst moments of the outbreak, ArcelorMittal's 
top management reviewed the status of the outbreak and our actions. 
This model was replicated across the business network. It works.


 4. Businesses will look after their employees, which means they look 
        after citizens

    The most significant private-sector contribution was undoubtedly 
the training and care these companies offered their own employees and 
those individuals' families and neighbors. Employees are citizens, so a 
mass outreach by all the employers will reach a significant proportion 
of the population. I am confident the companies operating in Ebola-
affected regions would have done this regardless, but the EPSMG 
provided value as a hub for sharing best practices on how to approach 
this most effectively.


 5. Business interests are also human interests

    To protect a business from such a disease you need to protect your 
employees. Employees are citizens, so business interventions protect 
the human, as well as the economic need. The logic extends from the 
employee to their family and community. What is more, the public sector 
asked the private sector to stay in-country and remain economically 
active. The other choice would be to leave the country, which would 
have made matters worse. By staying in the affected countries the 
private sector helped keep economies active.


 6. Rewiring public-private partnerships

    Chairing the EPSMG gave me the rare privilege of getting closer to 
the workings of the public sector. While I deeply respected the 
individuals with whom I engaged, I saw that their desire to deliver 
results quickly and pragmatically was constrained by bureaucracy, 
process, and politics. Governance of the public sector is key but it 
can pay a price in moments of need.
    I was proud to see my business colleagues acting nimbly and 
quickly, but conscious that many public sector players saw business as 
merely a source of money. The EPSMG was special because it helped to 
unlock the real contribution from the private sector which was not 
cash, but skills, assets and awareness. The EPSMG helped the 
collaboration and coordination of goodwill, skills, and physical 
assets. It is now clear that the private sector has more to offer than 
donations and I hope the EPSMG (and the business response to HIV) are 
proof points. The challenge for the public and NGO sectors is figuring 
out how to best utilize this in the future.


 7. The value of simplicity

    It could be argued that the Ebola related events in West Africa 
were unique. The region simply did not have the means to contain the 
disease. An Ebola crisis would not happen in the UK, for example. Even 
airborne Ebola would be contained by measures implemented by the UK 
government since the SARS epidemic. But while this case was 
unprecedented, valuable lessons can be taken and applied in future 
global challenges. Today, for example, there is general recognition 
that the private sector has a valuable role to play in crisis and 
humanitarian response.
    But perhaps the most important lesson is the value of simplicity. 
With the EPSMG, a group of businesses saw value in collaborating to 
protect their people, companies, and entire communities from a terrible 
disease. Learning and resources were shared when they were needed. 
Practical action happened when it was needed. When these things were no 
longer needed the EPSMG was no longer needed and naturally, it fizzled 
out.
What now?
    We get to zero and stay at zero; we build resilient healthcare 
systems and delivery mechanisms. Beyond on-going collaborations, our 
group is making two unique contributions in this area. First, some 
EPSMG members, under Chevron's leadership, have set up the Center of 
Excellence for Infectious Disease Control at JFK Hospital in Liberia as 
an on-going platform for training and public-private collaboration. 
This project is now eligible for a USAID Global Development Alliance 
grant for Ebola recovery. Secondly, the No More Epidemics Campaign has 
offered to house lessons learned from Ebola and keep the EPSMG 
experience relevant.
    Recovery in West Africa is vital. At ArcelorMittal, we remain 
deeply committed to Liberia. While the combination of market conditions 
and Ebola posed a challenge to our operations, our company is proud 
that we were able to maintain production and contribute to the Liberian 
economy at a crucial time in the country's history. We continue 
supporting the country further, even though low iron ore prices 
required changes to our operating model. But sustaining a private 
sector recovery cannot be done by a single company, and in this 
environment, not just by the host-governments. All of Liberia's 
stakeholders need to take a look at helping to create conditions for a 
recovery where jobs are created by a vibrant private sector.
    Going forward, the United Nations and other response groups need to 
look at the private sector as equal partners and not just as donors. 
The UN Office for the Coordination of Humanitarian Affairs (OCHA) has a 
role to play here in leveraging new relationships and partnerships.
    Again, we need an international convention on the movement of 
people across borders during a pandemic. We need to address this now, 
before the next pandemic.
    The battle against Ebola is far from over and many obstacles lie 
ahead, particularly the fight to sustain the economies of the affected 
countries. The private sector has shown that it can rise to the 
challenge, working in partnership with other stakeholders to deliver 
the most effective response to the benefit of employees, their 
families, and their communities. It is my hope that the hard lessons 
from this outbreak can be applied to prevent the next.


    Senator Flake. Thank you, Dr. Knight.
    Dr. Panjabi.

   STATEMENT OF RAJ PANJABI, CO-FOUNDER AND CHIEF EXECUTIVE 
        OFFICER, LAST MILE HEALTH, BOSTON, MASSACHUSETTS

    Dr. Panjabi. Chairman Flake, Ranking Member Markey, 
distinguished members of the committee, thank you for having me 
here to testify today.
    I just returned from Liberia a couple of weeks ago, and 
people have not forgotten the leadership that all of you have 
shown, not only to mobilize resources, but also to actually 
come to the front lines, as members of this committee did 
during the height of the epidemic. So, I wanted to express and 
share that gratitude.
    I speak today as CEO of Last Mile Health and as a physician 
and teacher from Harvard, but also as an American citizen. I 
was born in Liberia, and fortunatley escaped the country's 
civil war as a child. Over a decade ago, I went back to 
Liberia, and, with my colleagues, created Last Mile Health, 
which, as Chairman Flake noted, partners with governments to 
create national networks of what we call community health 
workers. That is,we recruit people from their own villages, 
give them the equipment, the medicines, the training that they 
need to bring healthcare to the doorsteps of their neighbors.
    And today, I am going to make the case that investing in 
those community health workers, especially in rural areas, was 
one of the most effective measures taken by the United States 
in responding to Ebola. And I also want to make the case that 
increasing investment in community health workers in rural 
areas can help stop the next epidemic, build back health 
systems, and even help support and drive economic recovery.
    In West Africa, we lost over 500 of my fellow health 
workers. Many of them were community health workers. This kind 
of loss would be great for any country. It was especially so 
for mine, Liberia. We had very few health workers, to begin 
with. When I first returned to Liberia in 2005 after the war, 
we were left with just 51 doctors to serve a country of nearly 
4 million people. Now, to put that in perspective, just imagine 
for a moment all of Washington, D.C., the entire city, being 
cared for by only eight doctors. And you can imagine if you 
were sick in a city back then, you might stand a chance, but if 
you were sick way out in the remote villages, where there were 
no doctors, you could die anonymously.
    And I bring this up because it has something to do with 
Ebola. The massive shortage of health workers in remote 
villages has a lot to do with outbreaks of zoonotic origin, 
infectious diseases that move from animals to humans. Ebola has 
revealed that illness is universal but access to care is not in 
these places, and that fact places all of us--all of us from, 
Liberia's rainforests to American cities--at greater risk. 
Paradoxically, it is exactly in these hard-to-reach areas where 
defeating diseases like Ebola is most difficult. The problem is 
that remote communities, not unlike I imagine some very rural 
stretches of your own States, face what we call a triple bias. 
That is, that the public sector is unable to prioritize remote 
communities. The private sector often does not see the market 
potential. And even the nonprofit social sector thinks it is 
too expensive to serve them. Now, that set of conditions brewed 
a perfect storm to help escalate what was--could have been--a 
local outbreak into a global epidemic.
    And you only have to think of patient zero, little 2-year-
old Emile in the borderlands of rural Guinea, Sierra Leone, and 
Liberia, who fell sick with Ebola in December of 2013. A lot 
has been made of what happened from March 2014 and thereafter, 
what was too slow of an initial response. But, between December 
2013 and March 2014, not only did Emile die, but dozens of 
people in nearby villages also died. Partly because of a lack 
of well-supported health workers in those remote communities, 
we lost time. When minutes counted, we lost months. It took us 
months before we recognized the outbreak in March 2014. What 
more could have been stopped, in terms of loss of lives, in 
terms of billions of dollars lost, had we had those health 
workers in place? And so, Ebola and other emerging infectious 
diseases that start in regions that are in remote communities 
reminds us that the cost of inaction is greater than the cost 
of action.
    You know, the good news is, is that when the U.S. does 
invest in rural community health workers, their achievements 
can be dramatic. I have seen it firsthand. Over a year ago, I 
was sitting in a mud-walled hut, working with local rural 
community health workers, helping them respond to an outbreak. 
A woman, 42 years old, had come into the community, died of 
Ebola, and over a dozen people there had also died who had 
attended her funeral. Now, this community, deep in the rain 
forest, in an area called Rivercess, was cut off. It was cut 
off from electricity, from roads, from phones, and days away 
from the nearest hospital
    We were told back then, as you know, that we could see as 
many as 1.4 million cases of Ebola, that outbreaks like this 
would spread all across the region, and that many of those 
people could die. But, together, we fought back. And that was a 
major credit to the Liberian government, to the U.S. Government 
and other partners. With other NGOs and a coalition of U.S. 
agencies, including USAID and the CDC, we rallied behind the 
government to train several hundred front-line health workers. 
That included people like David, a 24-year-old who drove a 
motorbike 6 hours over mud tracks in the rain forest to go 
door-to-door to collect blood samples from people who had been 
exposed. And it included community health nurses, like Alice 
Johnson, who distributed thermometers, masks, gowns, and gloves 
to clinics to help put in place infection control measures. And 
they also included community health workers, like Zarkpa, who, 
while the health system was collapsing all around her, managed 
to keep all kids who had malaria on treatment and never miss a 
single date. These community health workers risked their lives 
to hunt down the virus, stop it in its tracks, and protect all 
of us.
    And, as you said, the fight is not over. We have seen 
flare-ups in Liberia and rural Guinea last week. There are 
other outbreaks of HIV/AIDS, malaria, tuberculosis. We have 
seen a spike in child and maternal deaths, in malnutrition. You 
know, Ebola has taught us that what works best in an emergency 
system is not actually an emergency system; it is an everyday 
system that reaches all people, that is robust, resilient, and 
can respond before these threats even emerge. If that is our 
goal, to build such a system, in partnership with our Liberian 
counterparts, to make a sustainable system, we must continue to 
invest in people, we must continue to invest in Liberia's 
health workforce.
    At this hearing, we heard that call echoed 15 months ago in 
this very chamber by Liberia's leader, President Ellen Johnson 
Sirleaf. Members of this committee asked her, What is one of 
your top priorities? She said--I quote--``At the time, we want 
to build capacity at all levels, especially at the lower levels 
of community healthcare workers.'' Her government has followed 
through on that vision. She is now launching a revolutionary 
health workforce program that, once fully financed, will train, 
equip, and pay over 4,000 community health workers, and train 
hundreds of Liberian nurses and doctors across the country. 
This community health workforce has the potential to be a 
front-line defense that can stop the next local outbreak from 
becoming the next global epidemic. It is also going to extend 
healthcare to all people. And it is going to be great for jobs, 
because it is going to create employment opportunities for 
young, unemployed, rural people.
    In closing, I will say that it is a single program that can 
save lives, create jobs, and stop the next outbreak. Investing 
in these kinds of programs, alongside labs, supply chains, and 
hospitals, can generate great returns, not only for Liberians, 
but the safety of Americans. A lot of U.S. Government agencies, 
including USAID, CDC, HHS, the Peace Corps, as well as 
international partners, are already mobilizing support for 
Liberia's health workforce program.
    And I would say, in the face of other global threats, U.S. 
funding towards programs like this must be preserved and 
sustained over the long term if we are going to have a 
healthcare system led by Liberians.
    Mr. Chairman, as Liberians and Americans have shown, those 
who fought Ebola taught us that we are not defined by the 
crises that strike our lives. We are defined by how we respond. 
Our response is not over. We must demand a health worker for 
everyone, everywhere. That is the only effective response, I 
believe, to the Ebola crisis and to the everyday crisis of 
premature death.
    Thank you.
    [Dr. Panjabi's prepared statement follows:]


      Prepared Statement of Dr. Raj Panjabi, CEO, Last Mile Health

    Chairman Flake, Ranking Member Markey and other distinguished 
members of the committee, thank you for inviting me to testify. We are 
grateful to members of this Committee not only for the resources you've 
mobilized in the fight against Ebola in West Africa, but also for your 
personal leadership. I just returned from caring for patients alongside 
community health workers and nurses in rural Liberia and my colleagues 
there have not forgotten that members of this Committee visited them on 
the frontlines of the Ebola epidemic while it was still very active.
    Today, I want to speak about the power of those local health 
workers. As you know, over 11,000 people and over 500 of my fellow 
health workers--nearly all West African--have lost their lives in this 
fight. I want to dedicate my testimony in honor of their sacrifices and 
the Americans who stood by their side. I will make the case that 
investing in Liberian health workers--especially in remote rural 
areas--was one of the most effective measures taken by the United 
States in responding to Ebola. And I will present the case that long-
term investments in rural health workers are more important now than 
ever to respond to public health threats and build resilient, 
sustainable health systems.
    Liberian health workers have shaped my life. As CEO of Last Mile 
Health and a physician and teacher from Harvard, I've had the privilege 
of working with my colleagues on the ground in Liberia for a decade to 
train and employ hundreds of community health workers to serve 
Liberia's most remote communities. But their mark on my life runs 
deeper than that. Today, I am a proud American citizen and I was 
fortunate to be born in Liberia where Liberian midwives helped my 
mother bring me into this world.
    I know first-hand how dire conditions can get in the absence of 
health workers. When I was 9 years old, Liberia erupted in civil war. I 
was one of the lucky few. My family was evacuated and eventually 
resettled in America. Here in America, I went from having my hopes 
crushed in a war to pursuing my dream of attending medical school. But 
I could not forget where I came from. So in 2005, I returned to Liberia 
as a medical student, to help serve the people I had left behind. What 
I found was utter destruction. After 14 years of civil war, Liberia was 
left with just 51 doctors to serve a country of over 4 million people. 
To put that in perspective, imagine the entire city of Washington, DC, 
having only 8 doctors available to care for it. If you fell sick in the 
city you might stand a chance, but if you fell sick in remote villages 
you could die anonymously. It was in response to this massive shortage 
of rural health workers that my colleagues and I began our work at Last 
Mile Health.
    What does this lack of health workers in remote areas have to do 
with the Ebola outbreak? While Ebola infections transmit primarily from 
person to person, Ebola and 75% of emerging infectious diseases first 
enter human populations from animals--that is they have a ``zoonotic 
origin'. Ebola and other epidemics with a zoonotic origin--like HIV/
AIDS--often first emerge in the world's most remote communities. We all 
know that ``patient zero', two-year old Emile from rural Guinea likely 
first fell sick in this way with Ebola and died in remote communities 
in the rainforest borderlands connecting Guinea, Sierra Leone and 
Liberia. In large part due to the lack of trained and equipped health 
workers in rural areas, it took three months before an Ebola outbreak 
was identified. This time lapse allowed the epidemic to spread and as 
we know, it eventually reached 10 countries, including this one.
    Paradoxically, the hardest-to-reach communities are also where 
zoonotic infections--amongst other diseases--are the hardest to defeat. 
The problem is that remote communities, not unlike the most rural 
reaches of your own states, face a triple bias. The public sector, 
which favors areas that are easier to reach to maximize limited 
resources, is often unable to prioritize remote populations. The 
private sector, which favors areas with high concentrations of 
customers, doesn't see market potential. The social sector, which 
favors reaching more people in fewer areas at less cost, deems it too 
expensive to serve them.
    The good news is U.S. investments in local health workers in remote 
communities can have dramatic results. A little over a year ago, I 
stood in a mud-walled building in one of these isolated, hard-to-reach 
rainforest communities. I was there to help train a group of Liberian 
health workers in an area called Rivercess. Nearby, an outbreak had 
erupted in a village days from the nearest hospital and cut-off from 
roads, electricity and phones. A young woman there had just died of 
Ebola, and so had over a dozen people who attended her funeral. We 
partnered with a coalition of U.S. agencies, other NGOs, to support the 
Liberian Government to train and equip brave local health workers to 
respond.
    Investments like these, complemented investments in Ebola Treatment 
Units, and were made across Liberia, with the support of the USAID, 
NIH, CDC, HHS, the DOD and other agencies. With that and other 
international support, the Government of Liberia and its partners 
trained and equipped thousands of Liberian health workers in remote 
areas. They included lab technicians like David Sumo, a 24-year-old who 
drove a motorbike more than six hours over mud tracks in the rainforest 
to collect blood samples from the hundreds of people at risk. Nurses 
like Alice Johnson distributed digital thermometers, masks, gloves and 
gowns to clinics to ensure infection prevention and control measures 
were in place. And community health workers like Zarkpa Yeoh ensured no 
child with malaria in her village missed a day of treatment even as the 
rest of the country's health system was collapsing. It's these rural 
health workers--alongside American health workers--who have helped hunt 
down Ebola, who are best positioned to help prevent flare-ups, and who 
can help rebuild a health system led by Liberians themselves.
    Last week, the World Health Organization declared the West Africa 
Ebola epidemic no longer an international public health emergency. But, 
let U.S. make no mistake. The response is not over. The Ebola threat 
remains real and it has been persistent. Counter to conventional 
wisdom, this epidemic isn't West Africa's first encounter with Ebola. 
Medical studies document antibodies to Ebola in the region as far back 
the late 1970s--suggesting the virus has been present and has gone 
undetected in remote villages in West Africa at least since then. 
Infectious diseases can also act with speed. We have seen already seen 
flare-ups of Ebola and other outbreaks. In the last week alone, new 
Ebola cases and deaths occurred in both Liberia and rural Guinea. Ebola 
shut down other health services and we've seen an increase in other 
infectious diseases like measles, malaria and pertussis, as well as 
child and maternal deaths. We must sustain a defense that exceeds the 
persistence and speed of these threats. We must help West Africa 
maintain a high level of capacity to rapidly prevent, detect and 
respond to flare-ups of Ebola and other public health crises.
    Ebola has taught U.S. what works best in an emergency is not an 
emergency system--it is an everyday system that is robust, resilient, 
and functioning before the crisis begins. If our collective goal, 
looking forward, is to work with Liberians and other affected countries 
to build such health systems--then we must continue to make smart 
investments. We must continue to invest in people. We must invest in 
Liberia's rural health workforce. We've heard this call echoed by 
Liberia's leaders. Mr. Chairman, at another hearing on Ebola hosted by 
this committee only 15 months ago in December 2014 in this very room 
Committee members asked Liberia's President Ellen Johnson Sirleaf about 
her priorities. She responded clearly, ``we seek to build capacity at 
all levels, especially at the lower levels of community health care 
workers.''
    Her Excellency's Government has followed through on this vision. 
The Government is working to launch a revolutionary National Health 
Workforce Program. This program, once fully financed, will train 
hundreds of Liberian doctors and nurses in line with President 
Sirleaf's priorities, employ and equip over 4,000 community health 
workers nationally. This rural community health workforce will bring 
disease surveillance for Ebola and other threats each and every at-risk 
remote corner of Liberia. They are a frontline defense that can stop 
the next outbreak from becoming an epidemic. It will also build health 
systems by extending health care to the over 1 million rural Liberians 
who've never had health care before. President Sirleaf has already 
called for 2000 rural community health workers to be deployed by the 
end of next year.
    Investing in training, equipping and paying rural community health 
workers not only saves lives in remote areas, but they are also a great 
economic bet. Recent reports show that by creating jobs, providing 
``insurance''for countries against catastrophes like Ebola, and by 
extending productive life, rural community health workforce investments 
in can yield an economic return of up to $10 for every $1 spent.
    Of course, rural community health workers are not a panacea. 
Investments in these workers must be complemented with broader 
investments in publicly financed health systems that include well 
equipped clinics and hospitals, robust laboratories and supply chain 
systems. We must target these investments not just in cities, but also 
in rural areas. And these investments must align with and reinforce 
government-led plans. One example includes the recent re-signing of the 
results-based five-year Fixed Amount Reimbursement Agreement (FARA) 
between USAID and the Liberian Government that invests directly in the 
Government's National Health Plan.17 Such mechanisms should be expanded 
because they directly build country capacity and help improve the 
effectiveness and sustainability of U.S. foreign assistance to Liberia.
    As we look forward, we must not forget that illness is universal 
but access to care is not, and as Ebola has taught us, this places all 
of U.S. at greater risk. The cost of inaction on closing this access 
gap is greater than the cost of action. Mr. Chairman, as Liberians and 
Americans have shown, we are not defined by the crises that strike our 
lives. We are defined by how we respond. Our response is not over. We 
must demand a health worker for everyone, everywhere. That is the only 
effective response to the Ebola crisis--and the everyday crisis of 
premature death.
                                 ______
                                 

                                 ANNEX

    new report shows that investing in community health workers is 
 essential for improving health, strengthening economy, and preventing 
                             the next ebola

                  by Jeffrey Walker and Rajesh Panjabi

        CHWs play the most important and effective role in our fight 
        against disease; it is they who have reached the most 
        vulnerable, they who have been able to be the contract tracer, 
        they who have been able without much training to take the risk 
        to go out into the community and bring care. We need to 
        urgently invest in the training and building of capacity of 
        healthcare workers at the community level.--President Ellen 
        Johnson Sirleaf of Liberia at the Third International Financing 
        for Development Conference in Addis Ababa on July 13, 2015


    In May, the World Health Organization declared Liberia ``Ebola 
free''after forty-two days without new cases. While thiswas a 
remarkable milestone, none of U.S. can forget that Ebola killed 4,800 
people in Liberia and has already left more than 11,000 dead across 
West Africa. While the fight against Ebola continues in Liberia and 
neighboring Sierra Leone and Guinea, one vital measure for epidemic 
preparedness has emerged: a robust community health system. As 
President Ellen Johnson Sirleaf stated on Monday at the UN's Third 
International Financing for Development Conference: ``We need to 
urgently invest in healthcare workers at the community level.''
    For the past year, we have been asking ourselves how the Ebola 
outbreak spread so quickly and what steps should be taken to prevent 
such future disasters. A year after the epidemic took hold, we know 
that stronger, integrated community-based delivery systems are 
necessary to help prevent such outbreaks and support progress against 
the top killers of women and children--especially malaria, pneumonia, 
and diarrhea. At the core of such delivery systems are highly-trained, 
supervised, equipped and paid professional Community Health Workers 
(CHWs), who work in teams with other primary health workers (e.g. 
nurses) to extend care to the most vulnerable.
    Unfortunately, financing for community health systems is relatively 
low compared to other health system areas and to priority diseases. 
Consequently, countries struggle to raise the funding necessary to 
train, supervise, and pay CHWs. Today, there is an estimated shortage 
of more than 700,000 community health workers across sub-Saharan Africa 
and it will require at least $3 billion each year to address this gap. 
In Ebola's deadly wake, a number of leaders from African countries and 
the global health community came together to explore how to address 
this funding problem. We released our initial thinking on Monday at the 
Financing for Development Conference in Addis Ababa through a report 
titled, ``Strengthening Primary Health Care through Community Health 
Workers: Investment Case and Financing Recommendations.''The report 
calls for urgent action by all global stakeholders, including African 
governments, major funders, and our partners to address funding 
challenges of CHWs, and provides the following key findings:


   Supporting Community Health Workers is a game-changing investment: 
        CHWs are critical for increasing access to health care and, if 
        scaled up, could save up to 3 million more lives each year. 
        They are also a great economic bet, returning up to $10 for 
        every $1 spent through productivity gains from a healthier 
        population, from the ``insurance'' they provide against 
        catastrophes like Ebola, and from expanding employment 
        opportunities.

   Not all Community Health Worker systems are created equal: What we 
        need are highly trained and skilled community health workers 
        integrated into the primary health system. While each national 
        context will be different, when building CHW programs policy 
        makers should focus on core factors such as measurement and 
        management of community health program performance, integration 
        with the rest of the primary health system, leadership from 
        within Ministries of Health, and community engagement in 
        program design. It's also important that CHWs not be construed 
        as ``stand-alone'' agents of change, but instead are 
        effectively linked to broader teams of clinic-based health 
        workers.

   Countries need to be proactive in developing a financing pathway: 
        When developing a CHW program, countries need to take the 
        initiative to determine program scale, cost the plan, set 
        funding targets and identify specific financing mechanisms to 
        reach targets. Countries are used to doing this for other 
        disease areas and should apply the same methodology to 
        community health. Support from international donors through 
        mechanisms like the World Bank's recently launched Global 
        Financing Facility, will create new avenues for long-term 
        country-led investments for CHW programs, but additional start-
        up funding remains vital.


    In addition to these findings, we went on to make a set of 
recommendations to national goverments, donors, and the broader 
community.


   First, we encouraged governments in sub-Saharan Africa to 
        prioritize CHW programs for investment and to create teams to 
        focus on community health financing;

   Second, we asked international donors and funders to make more 
        grants and low-cost financing available to countries wishing to 
        build CHW programs;

   Next, we urged funders that currently support specific diseases to 
        make more of that funding available to support CHW programs, 
        since CHWs are absolutely essential for diagnosing and treating 
        diseases like malaria, HIV, and TB and preventing epidemics;

   Finally, we encouraged the broader health community to consider 
        establishing teams to work alongside existing initiatives to 
        assess available financing options and develop metrics and 
        scorecards to track progress in community health.


    On the last day of June, when the body of a dead seventeen year old 
boy tested positive for Ebola, Liberia reported its first new case 
since it was declared ``Ebola-free'' in May. While the country now has 
much stronger health capabilities than it did at the start of the Ebola 
epidemic, this sad death is a clear reminder that we must remain 
vigilant and move urgently to make much larger investments in community 
health systems. Such investments will not only help prevent the 
resurgence of Ebola and achieve our global health goals, but may also 
help prevent the next epidemic. This is crucial as the World Bank 
estimates that a severe pandemic flu is ``virtually inevitable'' and 
could cost the global economy up to $3 trillion. The time for action is 
now.


    Senator Flake. Thank you.
    Ms. Glassman.

STATEMENT OF AMANDA GLASSMAN, DIRECTOR OF GLOBAL HEALTH POLICY, 
        CENTER FOR GLOBAL DEVELOPMENT, WASHINGTON, D.C.

    Ms. Glassman. Chairman Flake, Ranking Member Markey, 
members of the subcommittee, thank you very much for the 
opportunity to testify today.
    My comments will focus on three U.S. actions that might 
accelerate progress in the Ebola response: first, a 
recommitment to recovery; second, an enhancement of efforts to 
promote global health security; and, third, a call to track the 
money better.
    First, on recommitment to recovery. The Ebola outbreak took 
a serious toll on the affected countries' economies. Businesses 
suffered, jobs disappeared. A fifth of Monrovia businesses 
closed as a result of the outbreak. And almost half of jobs 
were lost.
    Economic recovery is gradual and at risk, due to commodity 
price drops that affect Liberia's biggest employers, like those 
of my colleague on this panel. And estimates suggest it could 
take until after 2020 for Liberia to achieve the rate of GDP 
growth that it experienced prior to the epidemic.
    Ebola was also a shock to the health system. Overwhelmed 
health facilities were unable to provide services. Delayed 
immunization campaigns led to Liberia's worst measles outbreak 
in years. And, as we have seen, days after the WHO declared the 
end of Ebola last week, new cases were confirmed.
    After being out for months, from mid 2015, families did 
send their kids back to school and increased use of basic 
services, but two-thirds of households are food insecure in 
Sierra Leone, and almost 70 percent of the Liberian population 
lives on less than $1.90 a day.
    To counteract these effects and ensure continued protection 
against health threats, the U.S. should recommit to recovery in 
ways that will make a measurable difference for firms and 
economic growth, health system effectiveness, and family well-
being.
    In support of firms and economic growth, the U.S. should 
continue to work to improve the investment climate, address 
infrastructure deficits, and encourage business support 
services as well as regional investments. These steps are 
critical to maintaining foreign investments and reviving local 
firms needed to ensure recovery and sustainability.
    The U.S. must continue its work to strengthen health 
systems, but our efforts have to go beyond capacity-building. 
More training and numbers of people trained are not, 
themselves, signs of health system preparedness. Instead, the 
U.S. should ensure that countries structure their healthcare 
funding to reward improved performance. Increases in children 
fully vaccinated, reductions in hospital infections, and 
improvements in child survival are what we must seek to achieve 
with our investments. And to aid families, keep kids in school, 
reduce food insecurity, and get markets working again, USAID 
should extend its support to cash transfer programs in Ebola-
affected, ultra-poor populations. Evidence shows that cash is 
the most efficient way to help families and can counteract the 
widespread distrust in government that actually contributed to 
the epidemic's spread.
    Second, on the issues related to global health security. 
The next outbreak is a matter of when, and not if. Our health 
and the health of our economies depend on modern and flexible 
response. And to get to that kind of response, the U.S. must 
ensure that the WHO is fit for purpose. We should incentivize 
our partner countries to step up their own global health 
security, and we should invest permanently in disease outbreak 
preparedness and response.
    The WHO has been rightly criticized for its response to 
Ebola, but its role remains critical. With the change in WHO 
leadership later this year, the U.S. must ensure that the next 
Director-General has the full confidence of our Congress and 
the credibility, financing, and support needed to implement 
much-needed reforms and execute its mission. The U.S. should 
develop stronger incentives for countries to adopt best 
practices in outbreak preparedness. Perhaps financial and 
reputational incentives to low-income countries that make 
measurable progress in strengthening their disease surveillance 
should be rewarded.
    Finally, we need to ditch the ad hoc interagency task 
forces and emergency budget requests. To understand the full 
range of alternatives, Congress should ask the Government 
Accountability Office to explore potential budget instruments 
that would ensure the availability of contingency funding and 
risk management in the event of a major outbreak.
    Finally, we need to track the money better. No existing 
platforms are up to this task. USAID's regular factsheets offer 
only snapshots of the work underway. Quarterly progress reports 
from the Offices of the Inspectors General only hint at what we 
might expect as results from our program. And a search on 
ForeignAssistance.gov yields an incomplete record. And, worst 
of all, there is no way--no easy way--to match the reported 
expenditures across these documents and platforms.
    More than a year ago, the Center for Global Development 
hosted Liberia's Minister of Public Works, Gyude Moore. We were 
greatly honored to have you, as well, Chairman Flake. At that 
time, Moore asked that the organizations responding to Ebola 
provide an account of money received and report on how it was 
spent in the public domain. Our response to his very sensible 
request has fallen short. I believe it is appropriate to hold 
this off-budget emergency supplemental funding to a higher 
standard. That means not only reporting on spending, but 
linking it to performance. In the absence of such reporting, we 
lose the opportunity to know what we have accomplished and 
where our next dollar is going to have the biggest impact. And 
we should start now by improving our accounting for any 
remaining unobligated funds.
    Thank you. And I look forward to your questions.
    [Ms. Glassman's prepared statement follows:]


  Prepared Statement Amanda Glassman, Vice President for Programs and 
    Director of Global Health Policy, Center for Global Development

    Chairman Flake, Ranking Member Markey, and members of the 
Subcommittee, thank you for the opportunity to testify on West Africa's 
recovery from a devastating Ebola outbreak and the lessons we can learn 
from the U.S. response to the crisis.
    My name is Amanda Glassman and I am the vice president for programs 
and director of global health policy at the Center for Global 
Development, an independent, non-partisan think tank headquartered in 
Washington, DC. CGD conducts policy research aimed at improving the 
policies and actions of rich countries, including the United States, 
that affect developing countries.
    Along with my colleagues at the Center, I have been watching the 
Ebola epidemic unfold in West Africa and keeping a close eye on the 
world's response. As you know, this outbreak was unprecedented in scale 
and impact. Liberia, Sierra Leone, and Guinea endured a total of more 
than 28,600 cases of the virus and 11,300 deaths.\1\ The disease took a 
heavy toll not only on families, but also on the health systems and 
economies of the afflicted countries.
---------------------------------------------------------------------------
    \1\ World Health Organization. (2016). Ebola Situation Report--30 
March 2016. Retrieved from http://apps.who.int/ebola/current-situation/
ebola-situation-report-30-march-2016
---------------------------------------------------------------------------
    By the time the World Health Organization (WHO) declared Ebola a 
public health emergency in August 2014, it was clear additional 
resources were urgently needed to help West Africa contain the disease. 
Congress stepped up to the plate, appropriating $5.4 billion in 
emergency funding, including nearly $2.5 billion to the U.S. Agency for 
International Development (USAID) for international response, recovery, 
and preparedness.\2\
---------------------------------------------------------------------------
    \2\ P.L. 113-235
---------------------------------------------------------------------------
    My testimony will focus on three areas, providing specific 
recommendations to Congress to help West Africa heal and regain lost 
ground, and to ensure that the United States is better protected and 
prepared to face future global health threats.


 1. Remain committed to recovery with an approach that addresses the 
        needs of households, health systems, and firms.

 2. Enhance efforts to promote global health security by improving 
        coordination, developing clearer incentives, and exploring new 
        ways to manage risk.

 3. Track money and progress to ensure accountability and learn what 
        works.


    First, the United States must remain committed to West Africa's 
recovery from Ebola, addressing the needs of households, health 
systems, and firms.
    The Ebola virus and the fear it generated took a serious toll on 
the affected countries' economies, which lost an estimated $2.2 billion 
in 2015.\3\ During the crisis, borders and markets were closed and 
plans to invest in West Africa were put on hold. Economic recovery has 
been gradual. Estimates suggest it could take until after 2020 for 
Liberia to achieve the rate of GDP growth it experienced prior to the 
epidemic.\4\
---------------------------------------------------------------------------
    \3\ World Bank Group. (2016). World Bank Group Ebola Response Fact 
Sheet. Retrieved from http://www.worldbank.org/en/topic/health/brief/
world-bank-group-ebola-fact-sheet
    \4\ International Monetary Fund. (2016). IMF Country Report No. 16/
8: Liberia. Retrieved from http://www.imf.org/external/pubs/ft/scr/
2016/cr1608.pdf
---------------------------------------------------------------------------
    Further, Ebola was a shock to already fragile health systems in 
West Africa. During the epidemic, overwhelmed health facilities were 
unable to provide services, while the fear of contracting Ebola 
prevented residents from seeking care. Delayed immunization campaigns 
led to Liberia's worst measles outbreak in years.\5\ The system also 
lost healthcare workers, which may have long-term effects on health and 
service delivery. Analysts predict that maternal mortality rates could 
increase by 74 percent in Sierra Leone and by a staggering 111 percent 
in Liberia relative to pre-Ebola rates.\6\
---------------------------------------------------------------------------
    \5\ World Health Organization. (2015). Liberia tackles measles as 
the Ebola epidemic comes to end. Retrieved from http://www.who.int/
features/2015/measles-vaccination-liberia/en/
    \6\ Evans, D. K., Goldstein, M., & Popova, A. (2015). The Next Wave 
of Deaths from Ebola? The Impact of Health Care Worker Mortality. World 
Bank Group. Retrieved from http://www-wds.worldbank.org/external/
default/WDSContentServer/WDSP/IB/2015/06/26/090224b082f92f94/2--0/
Rendered/PDF/The0next0wave00are0worker0mortality.pdf
---------------------------------------------------------------------------
    To counteract these effects and ensure sustained protection against 
existing and new disease threats, the United States should invest in 
ways that will make a measurable difference for household well-being, 
health system effectiveness, and economic growth.
    When it comes to aiding households, USAID should extend cash 
transfer programs in Ebola-affected communities to help the poorest 
families pay for food, medical costs, and school fees. Evidence shows 
that cash is often a better way to help people meet their basic needs, 
can counteract the damage to young children's nutrition, get kids back 
to school, and stimulate local markets.\7\ USAID supports small-scale 
cash transfer programs in Liberia and Sierra Leone, and these should be 
scaled up.\8\
---------------------------------------------------------------------------
    \7\ Center for Global Development & Overseas Development Institute. 
(2015). Doing Cash Differently: How Cash Transfers Can Transform 
Humanitarian Aid. Report of the High Level Panel on Humanitarian Cash 
Transfers. Retrieved from http://www.cgdev.org/sites/default/files/HLP-
Humanitarian-Cash-Transfers-Report.pdf
    \8\ USAID & HHS Offices of Inspectors General. (2015). Quarterly 
Progress Report on U.S. Government International Ebola Response and 
Preparedness Activities: Fiscal Year 2016, First Quarter. Retrieved 
from https://oig.usaid.gov/sites/default/files/other-reports/oig--
ebola--quarterly--fy16--021720126.pdf
---------------------------------------------------------------------------
    On health systems, U.S. efforts must go beyond capacity building. 
More training and number of people trained are not sufficient 
indicators of health system readiness or performance. Instead, the 
United States must ensure that countries structure their healthcare 
financing and payments so that they reward improved performance in 
health facilities and on health itself. Increases in children who are 
fully vaccinated, reductions in maternal mortality and morbidity, 
improvements in child survival are what the United States must seek to 
achieve with its investments. More money should be tied to improved 
results instead of specific inputs or staffing models.
    In support of economic growth, the U.S. government, in coordination 
with other donors, should work to improve investment climates, address 
infrastructure deficits, encourage business support services, and look 
for opportunities to strengthen regional ties. These steps are critical 
to attracting foreign investment and reviving local firms. A new 
Millennium Challenge Corporation compact to address roads and 
electricity in Liberia and a threshold program in Sierra Leone to 
improve water and electricity service delivery are complementary steps 
in the right direction.\9\ \10\
---------------------------------------------------------------------------
    \9\ MCC. (2015). Liberia Compact. Retrieved from https://
www.mcc.gov/where-we-work/program/liberia-compact
    \10\ MCC. (2015). Sierra Leone Threshold Program. Retrieved from 
https://www.mcc.gov/where-we-work/program/sierra-leone-threshold-
program
---------------------------------------------------------------------------
    Next, we must enhance our efforts to promote global health security 
by improving coordination, developing clearer incentives, and managing 
risk.
    The next outbreak is a matter of when, not if. Our health and our 
economies increasingly depend on modern, flexible responses to these 
imminent threats. The U.S. government must take steps to (1) ensure the 
WHO is fit for purpose; (2) incentivize countries around the world to 
step up their health security; and (3) invest permanently in disease 
outbreak preparedness and response.
    The WHO has been rightly criticized for its slow response to the 
Ebola outbreak. But the role of the WHO remains critical. It is in a 
unique position to set standards, initiate and coordinate incidence and 
pathogen tracking, and strengthen health-system responses. With a 
change in WHO leadership later this year, it is incumbent upon the 
United States and the global community to ensure the next leader of the 
institution has the credibility, support, and respect needed to govern 
effectively and implement much-needed reforms.
    The U.S. government, through USAID or the Centers for Disease 
Control and Prevention, should develop incentives for countries to 
adopt best practices in disease response and preparedness. By rewarding 
countries on the basis of progress toward strengthening disease 
surveillance and preparedness, the United States could more effectively 
leverage limited resources and ensure results.
    Lastly, we need to ditch the ad hoc interagency task forces and 
emergency budget requests. To understand the full range of 
alternatives, Congress should ask the Government Accountability Office 
to explore potential budget instruments for ensuring permanent 
preparedness and protection in a way that manages risk. One option is 
to contribute to the World Bank's Pandemic Emergency Financing 
Facility. Another, complementary option would be to develop our own 
global health emergency fund that would allow for faster release of 
financing to assist countries in need and provide coordinated funding 
at each stage of pandemic preparedness, response, and recovery.
    Finally, Congress should require U.S. agencies to report data on 
Ebola spending and progress to a consistent, integrated and publicly 
available platform.
    No existing platforms are currently up to the task. USAID's regular 
fact sheets offer snapshots of the work underway, but lack the detail 
to determine how most money is being used. Quarterly progress reports 
from the Offices of the Inspectors General provide a more comprehensive 
outline of the U.S. response, but program descriptions only hint at 
expected outputs and outcomes. A search of the term Ebola on 
ForeignAssistance.gov yields some results, but it is unclear how much 
of this incomplete record is related to the supplemental funding. Worst 
of all, there is no easy way to match the reported expenditures across 
these documents and platforms.
    More than a year ago, the Center for Global Development hosted 
Liberia's Minister of Public Works Gyude Moore. At the time, Moore 
stressed the need for accountability when it came to the money being 
provided to fight Ebola in Liberia. He asked that the organizations 
responding to Ebola provide an account of the money they received and 
how it was spent. Our response to this sensible request has fallen 
short.
    While all U.S. assistance should strive for greater transparency, I 
believe it is appropriate to hold this off-budget, emergency, 
supplemental funding to a higher standard. Crises of this scale and 
novelty complicate procurement and data collection, especially when 
there are multiple agencies involved in the response. This makes it all 
the more critical that we are vigilant when it comes to recording how 
much has been spent and where, and what we are getting for our dollars. 
That means not only reporting on spending but linking it to performance 
indicators and targets. In the absence of such reporting we lose the 
opportunity to determine what we have accomplished and where our next 
dollar would have the greatest impact. We should start now by improving 
our accounting for the remaining unobligated funds.
    The WHO's recent declaration of the end to the public health 
emergency in West Africa was good news, but there is more to be done to 
address flare-ups and realize full recovery in Liberia, Sierra Leone, 
and Guinea.
    The devastating epidemic should serve as a wake-up call. Congress 
can ensure a stronger U.S. response to health threats and guard against 
future ones by supporting recovery focused on households, health 
systems, and firms; promoting global health security through 
coordination, incentives, and risk management; and encouraging improved 
aid transparency in crisis response.


    Senator Flake. Ms. Delaunay.

     STATEMENT OF SOPHIE DELAUNAY, ADVISOR, MEDECINS SANS 
                 FRONTIERES, NEW YORK, NEW YORK

    Ms. Delaunay. Thank you, Chairman Flake, Ranking Member 
Markey, and members of the subcommittee, for providing me the 
opportunity to address you today.
    This outbreak prompted one of MSF's biggest emergency ever, 
and valuable lessons were learned from this strategy, and it is 
vital that they be acted upon. Needless to say, we also learned 
our own lessons in this process.
    But, today I am going to share with you MSF's perspective 
regarding one specific issue, the state of biomedical research 
and development, R&D, because Ebola not only revealed existing 
challenges in the current R&D system, but teaches us lessons 
that are also applicable to other public health emergencies 
priorities, from tuberculosis to antibiotic resistance to Zika.
    So, today, where do we stand when it comes to preventing, 
diagnosing, or treating Ebola? As we speak, we are still 
lacking an accurate and rapid point-of-care Ebola test that 
caregivers could use in the triage area to find out immediately 
whether a patient has Ebola or not. The few therapeutic options 
identified as effective, such as ZMapp, also present severe 
limitations in terms of availability and cost. On the vaccine 
side, there is one promising candidate, but, again, its use 
will be made more complex by cold-chain requirements or its 
perceived side effects. So, this is to say that current 
solutions are not ideal. And a number of key questions remain 
about the disease, and more research is needed on it.
    But, based on our lessons learned, MSF would like to see 
changes in the way biomedical R&D is conducted, and would like 
emphasize four priorities. One is to invest in needs-driven R&D 
before the next epidemic. The second is to start clinical 
trials as early as possible once an outbreak is identified. The 
third priority is really to maximize existing knowledge about 
the disease by sharing data and biomaterial among scientists. 
And the fourth priority should be to ensure that, once research 
is done, the products are indeed available and affordable to 
the population it needs.
    So, let me go back to my first point about investing in 
research before the next outbreak. We know that R&D takes time 
and that we cannot wait for another outbreak before initiating 
research on lethal disease. So, we need to continue investing 
in research on Ebola, for Zika, and other neglected disease. 
And incentives for innovations are essential, but they need to 
work as intended and for the patients they claim to support.
    And, to this point, in 2007, Congress created an incentive 
program for research on neglected diseased called the FDA 
Priority Review Voucher Program, the PRV. This program rewards 
a research institution which successfully registers a product 
for neglected disease with a voucher allowing this institution 
to actually fast-track any other project in its portfolio 
through the FDA regulatory process.
    So, this is a very valuable programs, but two changes must 
be made to it. First, it should include a novelty requirement 
to ensure it actually induces new investments in R&D and is not 
awarded to already-existing drugs or vaccines. Second, the PRV 
should also require an access strategy to ensure that patients 
which the PRV intends to benefit will have affordable and 
appropriate access to the products.
    These recommendations are not just rhetorical. They result 
from our own experience in dealing with leishmaniasis, 
tuberculosis, and malaria, where PRVs were granted for drugs 
that had been available in other countries for years, and also 
from our persistent struggle to access affordable medicine and 
medical innovations.
    So, my second point is about implementing trials early in 
the emergency response. The lesson is that we started the 
trials much too late, and, as a result, the trials could not be 
deemed conclusive. So, we recommend that product calls and 
ethical guidelines for clinical trials during emergency be 
predefined in the interepidemic period.
    My third priority is maximizing access to available 
knowledge, because collaborative research involving a timely 
sharing of data and specimen is being increasingly recognized 
by the scientific community as an essential means to 
incentivize research. MSF, which has cared for more patients 
with Ebola than any other organization, in terms of treatment, 
has collected valuable data that we would like to share, and we 
would like to see it used ethically for research priorities by 
the scientific community. The CDC, itself, certainly holds the 
largest collection of EVD-specimen library from this 
experience. Nevertheless, our attempt to support the WHO in 
establishing networks of biobanks and data-sharing platform is 
very poorly supported by actors, including the U.S. 
counterparts. And there is still a very significant gap between 
the rhetoric and action.
    I would like to go to my fourth and final point, ensuring 
that the final products when research is done are available and 
affordable to population in need, because innovation without 
access is actually meaningless. And we hope that, you know, 
improvements to the Priority Review Voucher Program to ensure 
medical products are available would be an important step, but 
there is still an urgent need also to address the global crisis 
on raising drugs and vaccine prices.
    So, in conclusion, I would like to say that significant 
scientific advances are still required against Ebola and other 
deadly neglected disease. Ebola shocked and shook the world, 
giving us another opportunity to reflect on how we approach 
R&D. And as Zika has most recently demonstrated, it is in the 
interest in--of all countries, including the United States, to 
guarantee that appropriate mechanisms are in place to maximize 
the benefit of research and improve our response to future 
outbreaks.
    Thank you.
    [Ms. Delaunay's prepared statement follows:]


        Prepared Statement of Sophie Delaunay, Advisor, Doctors 
           Without Borders/Medecins Sans Frontieres (MSF) USA

    Thank you Chairman Jeff Flake, Ranking Member Edward Markey, and 
members of the subcommittee for providing Doctors Without Borders/
Medecins Sans Frontieres--also known as MSF--the opportunity to share 
our perspective regarding the Ebola outbreak in West Africa, and some 
of the lessons MSF has garnered in its wake.
    The Ebola Virus Disease (EVD) outbreak in West Africa was the most 
significant global medical challenge MSF faced between 2014 and 2015. 
As we speak, recent cases declared in Guinea and Liberia attest to the 
continued challenges posed by the virus.MSF's response to this outbreak 
has been unprecedented, and prompted one of our biggest emergency 
interventions in the 40 years MSF has been operational internationally. 
MSF responded across the region in Guinea, Sierra Leone and Liberia, 
but also in Mali, Senegal, and in Nigeria, and cared for one third of 
all infected patients throughout this outbreak. From March 2014 to 
December 2015--MSF set up and managed 15 Ebola management centers, with 
40 to 250 beds in each facility, and also provided Ebola management 
training to national governments, international responding agencies--
including the CDC, U.S. Public Health Service and the 101st Airborne 
Division--and other non-governmental organizations.
    Across many sectors, valuable lessons were learned in the past two 
years, and it is vital that these lessons be acted upon. Needless to 
say, we also learned many of our own lessons in this process. Today, I 
am going to share with you MSF's perspective regarding one specific 
issue: the state of biomedical research and development (R&D). Notably, 
Ebola not only revealed existing challenges in the current R&D system; 
but allowed us to learn lessons that we think are also applicable to a 
large number of other public health priorities, from tuberculosis, to 
antibiotic resistance to Zika.
    Ebola starkly illustrated how critically important it is to develop 
tools for infectious diseases before an outbreak occurs, as well as how 
challenging it can be to respond when adequate tools aren't available. 
This was not just an Ebola problem, though; it's an R&D problem, a 
systemic problem. And the consequences should really come as no 
surprise. Ebola was discovered nearly 40 years ago, but only after the 
outbreak devastated thousands of lives across West Africa and reached 
the U.S. and Europe, were significant R&D efforts launched to deliver 
tools to prevent and treat the disease.
    Historically, Ebola has primarily affected rural populations in 
sub-Saharan Africa, and therefore the development of tools to prevent, 
diagnose, or treat the disease has not been a priority. Almost no R&D 
efforts were focused on Ebola until the mid-2000s, when the virus was 
identified as a potential bioterrorism threat in several countries. 
Thereafter, the U.S., Canada, and a few other governments began 
supporting some basic research projects for Ebola.
    However, the primary objective was to protect citizens of the 
countries sponsoring the research, not necessarily to address the needs 
of people affected by the disease where it occurs, in Africa. 
Therefore, crucial characteristics, such as product affordability or 
user-friendliness in resource-poor settings, were not really taken into 
consideration. Moreover, some of the public funding for this research 
dried up due to national level budget cuts, and several potentially 
promising treatments and vaccines stalled in the early stages of 
development without a sponsor to take them forward.
    When the current outbreak started, research was incomplete and 
products had not been developed, despite the earlier public 
investments. Following the introduction of Ebola cases on U.S. and 
European soil, a number of trials for new vaccines and treatments were 
initiated. The beginning of these trials, however, also coincided with 
decreasing numbers of new cases.
    Today, where do we stand when it comes to preventing, diagnosing or 
treating Ebola? Should there be another Ebola outbreak tomorrow, or an 
outbreak of another deadly and neglected pathogen, will we be better 
equipped to provide relief and treatment to the people affected by the 
disease? How can the R&D efforts be improved upon?
    I would like to address a few of these questions now:
    Firstly, in the area of diagnostics: the traditional Lab-based 
polymerase chain reaction (PCR) test used to diagnose EVD is very 
accurate, but the time taken between obtaining a blood sample and 
getting a result can be considerable,\1\ and can take several days in 
some cases when samples need to be shipped from remote areas, as we 
have seen in West Africa. By using other types of accurate tests that 
can be positioned in more peripheral settings (such as the GeneXpert 
assay), our teams were able to reduce the time needed between sampling 
and result notification by 50%. Considering that the earlier a patient 
is treated, the more likely they are to survive, this is significant 
progress. The diagnostic process, however, is still time consuming and 
labor intensive. What is still lacking today is an accurate and rapid 
point of care Ebola diagnostic test that caregivers could use in the 
triage area to find out immediately whether a patient has Ebola or not.
---------------------------------------------------------------------------
    \1\ Van den Bergh R, Chaillet P, Sow MS, Amand M, van Vyve C, 
Jonckheere S, et al. Feasibility of Xpert Ebola Assay in Medecins Sans 
Frontieres Ebola Program, Guinea. Emerg Infect Dis. 2016;22(2):210-2106
---------------------------------------------------------------------------
    Secondly, regarding therapeutics, three main types of products were 
tested or used in the treatment of patients: antibody-based products 
(i.e. ZMapp, convalescent serum), antiviral products (i.e. favipiravir, 
brincidofovir), and to a lesser extent, commercially available drugs 
repurposed for Ebola due to demonstrated in vitro activity (i.e. 
amodiaquine). None of the trials have been fully conclusive. In many 
cases, due to the decreasing numbers of infected individuals available 
to participate in trials, the sample size was just too small to lead to 
definitive conclusions.
    The most promising results were found with ZMapp (licensed to Mapp 
Biopharmaceutical). There are on-going discussions in the United States 
to offer ZMapp under an ``expanded access protocol'' until it reaches 
licensure. However, other limitations for its use remain--including the 
potential high price of ZMapp and the limited production capacity. 
MIL77, a biosimilar of ZMapp which is produced in China is more likely 
to be available in large quantities and potentially at a lower cost. We 
are also now seeing many second generation drugs in the pipeline, but 
these products are unlikely to pass through the necessary trials before 
the next outbreak. One question, in this case, is whether it could be 
possible to rely exclusively on data in animals and in healthy 
volunteers to approve new treatments for Ebola.
    Regarding vaccines, the good news is that there are now many more 
vaccine candidates in the pipeline. One of them--rVSV-ZEBOV acquired by 
Merck--is currently the most advanced candidate. Yet, even if 
scientists are able to confirm its efficacy and safety, it still will 
not be the perfect vaccine for Ebola due to several significant 
limitations. The vaccine currently needs to be stored at -80 C (-112 
Fahrenheit); it protects only against Zaire Ebola virus and not for 
other Ebola species or other filoviruses such as Marburg; the duration 
of its immunity is unknown; and the management of recorded side-
effects--such as post-vaccination fever--will constitute a challenge 
during an epidemic.
    As you can see, and despite a remarkable mobilization in 
accelerating Ebola research and development, current solutions are not 
a panacea. From my preceding assessments, we can conclude that, if 
there were another outbreak of EVD tomorrow, the tools will surely help 
but we cannot ascertain that we will contain the virus or save the 
lives of most patients.
    Lastly, there are still a number of crucial questions related to 
the course of the disease itself. For example, how long does the virus 
linger in body fluids? This question leads to complications in a 
significant number of survivors and to the potential risk of sexual 
transmission several months after a patient could be otherwise 
confirmed as Ebola-free. More research is needed. There are other 
sequelae for Ebola survivors that require further research, including 
post-traumatic stress disorder.
    MSF would like to see changes in the way biomedical R&D is 
conducted, including by pursuing the following:


 1. Invest in patient and needs-driven R&D before the next epidemic;

 2. Test these candidates and start clinical trials as early as 
        possible once the outbreak is identified;

 3. Maximize existing data and knowledge about the disease--by sharing 
        it among scientists;

 4. Ensure final products are available and affordable to populations 
        in need.

1. Investing in research before the next outbreak
    Research and development can be a lengthy and laborious process and 
years can pass before it delivers the right drug or vaccine. We should 
not wait for another outbreak before initiating research on lethal 
diseases. Due to biosafety considerations, Ebola benefited from public 
research in the past decade, but this early stage research was never 
translated into biomedical breakthroughs for at-risk populations. 
Despite representing more than 10% of the global disease burden, only 
4% of new drugs and vaccines approved across the world were indicated 
for neglected diseases between 2000 and 2011. It takes vision and 
needs-driven priority setting to invest in R&D for neglected diseases, 
and such vision could save lives when outbreaks like Ebola occur. We 
need to continue investing in research for Ebola, Zika, and other 
neglected diseases or epidemic-prone emerging pathogens.
    When incentives for innovation exist, especially if paid with 
public funding, they should benefit those most in need. For example, in 
2007, Congress created an incentive program for research on neglected 
diseases called the FDA PRV program. The program works as follows: if a 
company, research institution or organization successfully registers a 
product with the FDA from a list of eligible neglected diseases, it is 
rewarded with a voucher, known as an FDA priority review voucher (PRV), 
allowing it to fast-track any other product in its portfolio through 
the FDA regulatory process. The voucher can also be sold to another 
company. The PRV program was recently improved, by lifting limits on 
transfers of the PRV for neglected diseases, increasing the potential 
appeal and value to prospective PRV recipients. The latest PRV has been 
sold for US$350 Million--a considerable amount of funding for R&D in 
the field of neglected diseases.
    However, two changes must be made to ensure the FDA PRV program 
works as intended and for the patients it claims to support. First, the 
PRV program should have a novelty requirement to ensure it induces new 
investments in R&D and is not awarded to already existing drugs or 
vaccines. Secondly, the PRV should require an access strategy to ensure 
that patients and treatment providers which the PRV intends to benefit 
will have affordable and appropriate access to products. These 
recommendations are a direct result from our experience in dealing with 
leishmaniasis, tuberculosis and malaria, where PRVs were granted for 
drugs that had been available in other countries for years, or from our 
persistent struggle to access affordable medical innovations.
2. Implementing clinical trials early in the emergency response
    Prior to the EVD outbreak, MSF had never been involved in clinical 
trials in the midst of an emergency intervention. Yet, even though the 
trials were fast-tracked, relative to traditional timeframes, they 
started too late. When the number of Ebola-infected cases started to 
dwindle, as a result, trials could not be deemed conclusive.
    Clinical trials pose formidable logistical, technical and ethical 
challenges in an emergency situation. Yet, they are feasible and 
accepted by local communities when all information is shared openly. 
With adapted and transparent trial designs in place, medical 
organizations could promptly experiment candidates and augment the 
chances of expeditiously finding new medical solutions. MSF recommends 
that protocols and ethical guidelines for clinical trials during 
emergencies be pre-defined and agreed upon during the inter-epidemic 
period so when the next emergency occurs, trials can commence much 
sooner. The United States has, and continues to invest millions in the 
response and containment of epidemics. It is well placed to ensure that 
such mechanisms are in place to improve the response to future 
outbreaks
3. Maximizing access to available knowledge
    Outbreaks, be they of Zika, Ebola or influenza, are always 
contained through a combination of community, national and 
international efforts. Science is no exception to this rule; there, 
unity is also strength.
    Collaborative research, involving timely sharing of data and 
specimens is being increasingly recognized as an essential means to 
incentivize research and leverage our understanding of diseases. 
Despite having learned a great deal about Ebola, many unanswered 
questions remain which will continue to hamper our ability to fight 
against the disease.
    More than two years after the first case was confirmed in Guinea, 
responding country agencies, international organizations and NGOs 
involved in the response are still unable to draw a complete picture of 
the data, nor of the biological samples collected during the outbreak. 
Each of us holds a piece of the puzzle.
    MSF, which has cared for more patients with Ebola than any other 
organization,\2\ has collected valuable data that we would like to 
share and see used ethically for research priorities by the scientific 
community. The CDC certainly holds the largest EVD specimen library 
ever collected. Nevertheless, our attempt to support the WHO in 
establishing networks of biobanks and data sharing platforms for EVD 
and emerging pathogens is poorly supported by the many actors 
involved--starting with the U.S. counterparts. A significant gap 
remains between rhetoric and action. Knowledge sharing and 
collaborative research are often acknowledged in principle but they 
face tremendous resistance when it comes to implementing them. And too 
often, they come too late, once the outbreak has begun.
---------------------------------------------------------------------------
    \2\ MSF Ebola Treatment Centers admitted over 5,200 confirmed Ebola 
cases, of which almost 2,500 have survived
---------------------------------------------------------------------------
    Collaborative science should be an integral part of the culture and 
the response to outbreaks, with clear standards and frameworks in place 
beforehand to optimize the limited knowledge available. I regret to say 
that should another outbreak hit tomorrow, there is no ethical or 
organizational framework in place to ensure the collection and sharing 
of biospecimens or the standardization of accurately collecting routine 
data.
    As Zika has most recently demonstrated, it is in the interest of 
all countries, including the United States, to guarantee a culture of 
knowledge and data sharing in biomedical research.
4. Ensure final products are available and affordable to populations in 
        need
    Innovation without access is meaningless. Improvements to the FDA 
PRV program to ensure medical products are made available to patients 
and treatment providers will be one important step toward broader 
changes that are urgently needed to ensure the R&D system delivers 
appropriate and affordable health technologies. There is an urgent need 
to address the global crisis of pharmaceutical companies raising drug 
and vaccine prices. MSF is advocating for changes in the way biomedical 
R&D is financed by separating cost of research and development from the 
price of final products.
    Likewise, global quantities of available products may not be 
sufficient to meet all needs. There may be a need to ration them at the 
global level. Member States of the World Health Organization should 
agree on a code of conduct on stockpiling of strategic drugs and 
vaccines. In order to make the best and most equitable use of those 
products, a collective stockpiling mechanism needs to be discussed 
under the auspices of the WHO.
                              conclusion:
    Significant scientific advances are still required against Ebola 
and other deadly neglected diseases. Once a disease is known and starts 
being documented, the lack of adapted and affordable medicine is rarely 
unavoidable. This is often caused by our inability or unwillingness to 
implement lessons learned and a needs-driven approach. Ebola shocked 
and shook the world. It gave us another opportunity to reflect on how 
we approach R&D.
    The multiple health crises that patients are facing, including 
those treated by MSF, must be addressed. Every day, patients go without 
access to critical medical tools because such products are either not 
affordable, not suited to the conditions in which patients live, or 
simply do not exist because patients suffer from a disease not seen as 
a commercially attractive market.
    These are challenges we have faced for decades but in 2016 several 
government-driven processes will take place that seek to address 
different aspects of the failures of the R&D system and to create 
global norms and efforts to deliver appropriate and affordable medical 
tools, including negotiations at the World Health Organization, the 
United Nations General Assembly and the G7/G20. This a critical and 
historic opportunity to make a political choice to sustain improved 
medical outcomes.
    Being a major contributor to both the responses to global health 
emergencies and to research and development, the United States 
government can and should lead by example by boosting collaborative and 
open research, including but not limited to neglected diseases and 
emerging pathogens, ensure global investments in R&D are coordinated, 
target priority health needs and deliver medical tools that are 
available and affordable to patients and medical treatment providers by 
de-linking the price of drugs from their R&D cost.


    Senator Flake. Thank you, Ms. Delaunay.
    Start with a round of questions now.
    Dr. Knight, can you give some assessment of U.S. programs 
in our aid, our 5.4 billions, most of which was used initially, 
some left over. But, how could we have better utilized the 
private sector in Liberia? In what ways did we fully leverage 
the resources that were there, and what could we have done 
better to utilize those resources?
    Dr. Knight. I think it boils down to a very simple sort of 
attitude, which is historically--and we saw it in the beginning 
of the Ebola outbreak--that the private sector was often sort 
of seen as just remote, ``Just give us a check and let us get 
on with it.'' And they underestimated just how much physical 
resource we had in the way of assets, expertise, way around the 
country. And sometimes the really basic stuff, which sometimes 
gets in the way, like just somewhere to sleep that night, 
access to a Land Rover, access to a bulldozer, and somebody to 
drive it. And so it sort of goes to that sort of almost closing 
remark I made in my more formal entry about just dialogue and 
collaboration.
    And so, treat the private sector as an operational tactical 
partner, and start the dialogue with them as quickly as 
possible.
    I mean, we were lucky with the EPSMG, because we had the 
idea, and people came to it. What if we had not had the idea? 
Yes. Who else could have that idea. And just make it a 
prerequisite, when you go into these types of operational 
places, fields, Who are the big private sector? Who is having a 
conversation with their big boss in their big corporate office? 
And who is going to have a conversation with them in the 
country? And I think you will be shocked. If you take the 
conversation away from the check to, ``How can you physically 
help us with assets, skills, and expertise?''--people want to 
help. So, very simple answer. Treat them as an operational 
partner.
    Senator Flake. Right. I have seen the pictures that you 
have----
    Dr. Knight. Yes.
    Senator Flake.--of the roads around Liberia. Give--can you 
give some outline of how much of the country is inaccessible 
during much of the year? Just--you have operations in various 
parts of the country. How difficult is it, in terms of 
infrastructure that would relate to healthcare centers as well 
as businesses?
    Dr. Knight. Well, I will give you an example which I am 
familiar with. You know, to go from Monrovia to our mine, when 
everything is right--you know, the sun is shining, the road is 
dry--it can take 3 hours. When we get to these conditions, it 
can take 10-12 hours. So, imagine trying to run a business, 
just getting assets, let alone people, to and from that site. 
We used to have a helicopter, but we have now grounded that as 
part of our cost-cutting messages. So, imagine if somebody gets 
hurt. Imagine if we break a leg and we need to get somebody to 
Monrovia. We have got to move them on those types of roads. You 
know, who would want to work in that environment? You know, I 
mean, sort of saying things such as, ``We want to create 
confidence and incentives for people to invest in these 
countries.'' You know, these really basic things get in the 
way. So, a muddy, destroyed road really makes businesses 
suffer.
    You asked me what percentage. I do not actually know the 
number, but it is a lot, and it is making a noticeable 
difference.
    Senator Flake. All right. Thank you. In Arizona, we dream 
of muddy roads like that. But--[Laughter.]
    Senator Flake. Dr. Panjabi, it was touch-and-go for a while 
during the height of the outbreak, when--there was a case here 
in the U.S., someone who had traveled from West Africa. And 
there was a real push for a travel ban that would have affected 
those countries and cut off airline service. Fortunately, we 
avoided that. What would that have done, in your view? How 
would that affected--have affected your operations and others?
    Dr. Panjabi. Thank you, Mr. Chairman.
    You know, I was in Liberia at the moment that traveler was 
here, and, you know, to be very honest with you, it would have 
felt like an infected wound was being cut off. But, besides the 
moral dilemma there, and leaving people behind, it would not 
have been very strategic. The most important thing that the 
U.S. did was to keep those doors open to allow health workers 
to go there and help stop the infection at its source. So, from 
a strategic perspective, it was wise to keep the doors of this 
country open.
    Senator Flake. Thank you. As far as lessons learned, I 
think that is one that we have to learn again and again, not to 
overreact on some of these epidemics that make the matters 
worse. And, frankly, that would have been a big blunder on our 
part, I think, had we pushed through and allowed that to 
happen.
    Give us an idea what these local health centers--President 
Sirleaf has talked about, in the next--before she leaves 
office, to have, I think, 2,000 or so in rural areas. Is that 
achievable? And how can we help? And are we helping in that 
effort?
    Dr. Panjabi. Well, the good--what President Sirleaf--
amongst her priorities in the health system, in addition to 
labs and clinics and hospitals that need to be refurbished and 
equipped, she has focused in on the health workers. The number 
you mention is around the community health workers. In one 
effort, she has seen that you can extend healthcare to the most 
remote communities, there are about 1.2 million people out of 4 
and a half [million] in the country--that do not have any 
physical access to healthcare. So, this will bring healthcare 
to those regions. Those are exactly the places where Ebola is 
likely to reemerge. And it also is going to create jobs. We 
know that rural unemployed people, men and women, is not--is a 
big issue for the country. It always has been, from all 
perspectives, economically and securitywise. This is a chance 
to give employment to 4,000 people out there.
    She [President Sirleaf] has asked for 2,000 of these 
workers to be deployed for the sake of healthcare and jobs by 
the time she transitions office at the end of the next calendar 
year. The U.S. is already stepping up to mobilize this kind of 
support, and a number of agencies I mentioned in my testimony 
have been designing this program, along with the Liberian 
government. It will be government-led. Private groups will also 
be involved in helping roll it out. Speed is of the essence, I 
think, to help stop the next Ebola, but also to make sure we 
take advantage of the fact that there is phenomenal leadership 
from the country itself that is being asked to push forward.
    So, I think what can be done, from the Congress's 
perspective in the U.S., is to make sure that that momentum is 
preserved, the funding is preserved for that kind of initiative 
that is so important as a priority to her, and that it is 
amplified and there are commitments made to the long term. This 
is something that is not going to be built back in a year or 
even in the next 18 months. It will give us a big headstart, 
but it took years to start to rebuild the health system after 
our war, and it is going to take years to put this in place. 
But, it will have a high return on investment.
    Senator Flake. All right.
    Before I turn it to Senator Markey, let me just say--
dealing with Liberia with an epidemic like this, I cannot 
imagine having done that with the prior administration or 
others that did not work directly with us. And also, on the 
back end, to have the President of Liberia come back and thank 
us, and thank the American people for the resources and the 
taxpayer monies that were spent is something that perhaps is 
not heard often enough by the taxpayers out there who fund 
these kind of efforts. But, there was genuine gratitude and a 
willingness to work with us to make sure that we can prevent 
this kind of outbreak in the future.
    So, with that, turn it over to Senator Markey.
    Senator Markey. Thank you, Mr. Chairman, very much.
    Without the United States and international community 
moving in to help and build the structures and help the 
healthcare system, how capable would these countries have been 
to deal with this issue? How indispensable is the United 
States, in other words, in dealing with this issue?
    Ms. Glassman. The U.S. has obviously had an indispensable 
role. And, most importantly, is helping with the logistical 
response, funding the many nongovernmental organizations who 
deployed healthcare workers to meet the need. But, even more 
importantly, as a signal of commitment to the rest of the 
nations of the world that this was an important problem that 
needed to be solved, because we cannot go it alone. This is 
obviously something that affects the world community.
    Senator Markey. So, if there are, which there will be, 
additional Ebola flareups, Lassa fever flareups, what is the 
capacity for these countries to deal with it in the absence of 
the United States being there to provide assistance?
    Ms. Glassman. Well, I mean, you have seen how poor the West 
African countries are. Other countries have more resources to 
be able to mobilize on their own. But, unless we, as the United 
States Government, are creating better incentives for 
governments to put their own money towards basic public health 
programs, disease surveillance, healthcare workers, infection 
control, results in health, I do not think we will get to 
sustainability anytime soon. So, I think that is something that 
we need to think about, going forward.
    Senator Markey. So, we will have to be there in order to 
ensure that, when these flareups occur, that the problem is 
contained quickly. Is that what you are saying?
    Ms. Glassman. So far, the United States seems to have been 
the first responder in many cases----
    Senator Markey. And that will have to continue, in your 
opinion?
    Ms. Glassman. In low-income countries, I think that will 
have to continue.
    Senator Markey. Yes, thank you.
    And what about the survivors? They are particularly 
vulnerable. What kind of additional assistance will they need 
in order to be able to deal with the aftermath of their 
families being afflicted with this disease?
    Dr. Panjabi. I can take that.
    You know, Senator Markey, I--what is needed is good 
healthcare. I mean, you brought up, in your opening remarks, 
that the survival rate for people with Ebola in West Africa was 
dramatically lower than it was for people that were brought 
here. They had the same disease, but they had different 
healthcare systems. So, what we need for Ebola survivors is 
ongoing care. A number of them have ophthalmological/eye 
problems. Of course, there is the potential for the disease to 
be retransmitted through sexual transmission. So, focusing 
there [on strengthening healthcare] will also help care for 
those people and help, from a public health perspective----
    Senator Markey. How high is the threat for reinfection?
    Dr. Panjabi. Well, you know, I am not an expert in 
reinfection, itself, but we do know, for instance, that our 
initial estimates of how long the Ebola virus exists in semen 
was an underestimate; it is actually much longer. And we are 
still learning exactly how long it can last. But, certainly 
beyond the 90 days we initially thought, and several more 
months after that. So, you know, continued monitoring is also 
going to need to happen. And that is not going to come from 
anything but actually providing healthcare to these Ebola 
survivors.
    Senator Markey. Okay. What are the lessons that you think 
we can take from Ebola and now apply to Zika, in terms of 
protecting those countries that are already infected and the 
United States as we head into the warm-weather months? And----
    Dr. Panjabi. Yes.
    Senator Markey.--at least 200 million people are 
potentially in areas that could have Zika outbreaks before the 
end of this year. What are the lessons that you would have us 
take from that? And what kind of actions should the United 
States take in order to deal with that potential threat?
    Dr. Panjabi. Yes. Well, I think that the effort to bring in 
capacity to detect early, respond quickly, and then prevent 
these things from coming back is critical. So, health 
workforces are important. The training is important. You know, 
the lab systems are important. Vaccine delivery and creation is 
important.
    We need to also remember that 75 percent of emerging human 
infections are of zoonotic origin. That means that they are 
coming from animals to humans. They may spread human-to-human 
in some cases, as Ebola does primarily, but they are happening 
in remote parts of the world. Zika itself was discovered 
initially in a forest in Uganda in the '50s. So, you know, can 
we detect these earlier in those remote parts of the world to 
identify the next threat that we do not even know about yet? I 
mean, that----
    Senator Markey. Just going back to what you said earlier 
about how we had to move in minutes and we were moving in 
months and years.
    Dr. Panjabi. Yes.
    Senator Markey. Do you feel that there is a sense of 
urgency here?
    Dr. Knight, could you talk about that, in terms of the 
lessons of Ebola, given the fact that Zika is on our border.
    Dr. Knight. I think, you know, the lesson is, How would you 
work with the private sector? I mean, this sort of reducing the 
response time from months to minutes. The private sector is 
already established in those places. You know, it is an email. 
It is a phone call. And it is a request. And we can mobilize, 
because we have got systems and logistics there.
    You know, what can the private sector do? It can talk to 
everybody who works for them. It can talk to everybody who 
supplies them. It can talk to their neighbors. And if every 
single big-, medium-sized company in those infected countries 
was doing that, it makes a big difference. You know, you have a 
very special relationship in an employer-employee relationship.
    Senator Markey. Well, how do you feel about this transfer 
of funding out of Ebola and over to Zika at this time, Dr. 
Knight?
    Dr. Knight. It is hard, because, as you sort of said, it is 
sort--it is a big of a moral maze. But, if the question is, 
Have we done enough to stop Ebola happening in Liberia? Have we 
done enough to create the right momentum towards economic 
recovery in Liberia?--the answer is no.
    Senator Markey. Have we done enough to put in place the 
protections that we need against Zika, from that perspective?
    Dr. Knight. Well, I--I am not close to Zika, so it is not 
fair to----
    Senator Markey. Dr. Delaunay, how do you feel about that?
    Ms. Delaunay. MSF is not working in the countries where--
affected by Zika either, so I am not really able to answer your 
question. But, I can just say that, indeed, there is still a 
lot to be done for Ebola, both in terms of system strengthening 
and research to understand this disease. And if it is about 
shifting from one priority to another, then it is worrying, 
because this is one of the lessons that we learned from Ebola, 
that we need to be prepared. It is going to come back, and 
science needs to goes on.
    Senator Markey. Yes. So, your basic message is to fund Zika 
at the levels that it should be funded, but do not underfund 
Ebola as a result of making that choice--almost a ``Sophie's 
choice'' between the two diseases and the impact it can have on 
families?
    Ms. Delaunay. Absolutely. Absolutely, yes. There is still a 
lot to be done on Ebola. And our big concern is that, when the 
cameras have left these countries and the--there are still lots 
of lessons can--that can be implemented, especially in terms 
of--because it is not just about funding, it is also, as Amanda 
was saying, you know, trying to be more effective with the 
funding that we do. And in the field of science, it is clear 
that one big lesson is being prepared and being organized to 
gather that data, to share knowledge, is going to improve the 
scientific advances.
    Senator Markey. Okay.
    Thank you so much.
    Senator Flake. Thank you.
    Senator Isakson.
    Senator Isakson. Thank you, Chairman Flake.
    Being a Senator from the State of Georgia, I am very proud 
of what the CDC and Emory University did in the contribution 
toward the terrible Ebola outbreak. And I have a few questions 
regarding the CDC on that line.
    And, Dr. Panjabi, I would really like to ask you, if I 
could for just a minute. We have--in our supplemental 
appropriation, we talked about a goal of establishing many CDCs 
around the world, maybe as many as 20 of them. And Bill and 
Melinda Gates and International Association of Public 
Institutes and others are working on that goal. Would it be 
helpful to disperse that type of delivery system around the 
world? And would there be enough countries who would be willing 
to make the financial contribution to help make that happen?
    Dr. Panjabi. Thank you, Senator Isakson.
    A short answer is yes, that it would make a big difference. 
In the middle of this crisis, at the beginning of it, the 
Liberian government and Ministry of Health, we were sitting in 
these rooms. There was--it is not that there were not any 
actions taken at that level. There were 30-40 people meeting 
every day, including the Minister of Health, trying to respond 
to the initial outbreak. One of the most effective things the 
CDC helped with was putting in an emergency operations center 
and helping--organized even the decisionmaking around that, 
called an incident management system. So, whether it is the 
field epidemiology training programs that the CDC wants to put 
in place or an initiative like that, I think the--efforts like 
that will be critical. As long as we are trying to transfer and 
support the skills of local health workers, we need to build 
that capacity in those countries.
    A question of whether other groups will be behind this, I 
know that the African Union and others are looking to try to 
focus on that. The idea of an African CDC or a CDC based in 
Africa, is something that I know a lot of groups, both specific 
governments, but also as a community of African states, for 
instance, and I imagine other parts of the world will be 
interested in.
    Senator Isakson. I was interested in Dr. Knight's comments 
about engaging the private sector early on in the effort, and 
what you did, yourself, to recognize what needed to be done to 
protect your people and your assets. Is there a catalyst 
anywhere in Africa to take best practices and lessons learned 
from this Ebola outbreak and try and train countries so they 
are better able to respond on their own? Is anybody 
synthesizing that?
    Dr. Knight. The World Economic Forum took a lot of interest 
in Ebola, and they took a lot of interest in, obviously, what 
we did as the private sector, being the World Economic Forum. 
So, they have codified and written down everything we did. And 
in Turkey, U.N. are hosting the humanitarian sort of big 
convention. And again, it is clear that they have now sort of--
they are beginning to look at the private sector in a different 
way.
    The tough thing about what we did was that it was in--it 
worked because it was quite informal, and it was not wrapped up 
in process and governance. So, it is actually quite hard to 
sort of codify something which works when it is quite informal. 
So--but, my message to people at World Economic Forum, the 
United Nations--it goes back to the earlier comment. It is--the 
moment you need to mobilize on any humanitarian crisis, one of 
the questions in that, sort of, first page should be, ``Who are 
the private-sector players out there? Let us get them together 
and talk to them.''
    Senator Isakson. Right.
    Dr. Knight. And if you start to overinstitutionalize 
something, people sort of--the private sector sort of go, ``Oh, 
this is going to be membership fees. This is going to be 
governance. I am going to have to commit something politically. 
I am not quite sure.'' But, the moment there is a crisis, they 
are eager and keenly enthusiastic help. So, it is just how 
quickly you engage, the moment you need players on the ground 
with equipment and assets.
    Senator Isakson. Yes, do not overbureaucratize the 
response, or it will take entirely too long. I think that is 
what I hear you saying.
    Dr. Knight. Yes. Yes.
    Senator Isakson. Because time----
    Dr. Knight. Do not overbureaucratize, but jump on the 
opportunity as soon as you need it. And--you know, and all of 
us are saying what the big lessons from Ebola was: We all could 
done more, quicker. And that is the other thing, you know. And 
I think what worked for the private sector, as well, was the 
fact that we had a risk-management system. You know, it is very 
textbook, it is very business school. But, when it works, it 
really works. You know, we were testing what would happen if 
Ebola became serious back in about February.
    Senator Isakson. Right.
    Dr. Knight. We had everything in place. All our staff were 
trying to--when we had the big outbreak in Monrovia, the first 
deaths in Monrovia, we literally just turned on a switch and we 
were there. We were testing people. We were communicating with 
people. Because we had planned it. We had rehearsed it. And we 
were ready.
    Senator Isakson. Yes, I was really proud of Dr. Frieden, at 
the CDC, and also our military. A lot of people have forgotten, 
we deployed military assets in West Africa to build some of the 
temporary facilities so we could isolate those that had the 
infection, keep them from spreading it to others. So, it takes 
a multiple set of efforts.
    Dr. Knight. Yes.
    Senator Isakson. And a private-sector partnership with 
governments that are prepared to respond and have a best-
practices plan, if we have another one, God forbid, will be an 
improvement on the lessons we learned from this one.
    Dr. Knight. And to go back to the private-sector 
contribution, many of the foundations and the ground-clearing 
for that was actually done by our equipment and our bulldozer 
drivers. You know, you cannot build a medical center without 
foundations. And we just turned up and did it. So, all that 
extra bit of complication for real mobilization, we just did. 
You know, and it is just very--it is very--we underestimate the 
power of these very simple, straightforward support. Very easy 
for us to drive bulldozers----
    Senator Isakson. And we are also--we have some----
    Dr. Knight. But, we just got to it quicker.
    Senator Isakson. We had a lot of private sector, like 
Samaritan's Purse and religious-based organizations did a 
tremendous--deliver healthcare services. In fact, one of the 
people who was transferred from West Africa to the United 
States at Emory University was a Samaritan's Purse physician 
who was infected in Africa. And that was the first big 
controversial issue about bringing somebody into the country. 
But, because we did that, I think it was a--it was a good 
thing, obviously, for the patient, but it was a good thing for 
the entire epidemic and the----
    Dr. Knight. Yes.
    Senator Isakson. Thank you very much for your efforts.
    Senator Flake. Thank you.
    Senator Coons.
    Senator Coons. Thank you, Chairman Flake, Ranking Member 
Markey, to Senator Isakson, my good friend, to all of you for 
your remarkable work in this field and for your testimony 
today.
    The principal point you are making is that Ebola is not 
over and that the significant amount of resources that the 
United States has appropriated to try and address Ebola should 
not be redirected elsewhere, that, frankly, we should also be 
investing, simultaneously, in a response to Zika, and that all 
the conditions that led Ebola to go from largely unknown to a 
significant challenge to a global concern are still there.
    When you say, Dr. Panjabi, it is a zoonotic illness, there 
is an animal reservoir of Ebola that has probably been active 
in West Africa 40 years, that we have now discovered. There 
have probably been a whole series of small outbreaks in remote 
villages that the rest of the world never knew about. And there 
is, of course, the possibility, that this virus will mutate and 
become more lethal.
    What we see on the ground in Liberia, in Guinea, in Sierra 
Leone, economies that have not yet fully recovered, may not 
recover for a number of years. Grassroots healthcare systems 
that need to be fully built out. And, of course, we commend 
President Sirleaf for her terrific work in leading the effort 
the deploy community health workers across the country. But, 
there is so much more to be done. Porous borders and a lack of 
any sort of a modern healthcare infrastructure in the remote 
places in these three affected countries led to the outbreak.
    One lesson, I think, that was most poignant at the time was 
that, at the moment when Ebola broke out into Nigeria, in the 
Port Harcourt area, I think there was a global collective gasp 
at the real prospect that Ebola would get loose into major 
metropolitan areas into the international travel community and 
metastasize globally. And it did not. It was contained, quickly 
and well, and in no small part because of, of course, the brave 
public health workers in Nigeria, volunteers, and the 
infrastructure. Investments made by the United States through 
our PEPFAR program, and through our efforts against polio built 
some of the labs and the communications and the infrastructure 
and the public health systems used to prevent an outbreak.
    So, if I hear you right, your central message to us across 
many concerns is this: To the U.S.--do not stop investing in 
making sure that we have addressed all the things that, because 
they were not addressed, led Ebola to be so lethal so quickly, 
so broadly. Have a clear path forward on vaccine testing and 
development. Have a clearly developed ethical structure and 
incentive structures. Medecins San Frontieres, you have shared 
with us that concern, and, I think, a very powerful and 
important one. We need to have a framework for data-sharing and 
for vaccine development that is proactive, not reactive. It is 
very hard to do effective field trials in the middle of 
disaster response. As Dr. Panjabi has said, continue to build 
out grassroots community health worker networks across the 
region in the country. And, as Dr. Knight has said, we have 
private-sector partners all over the continent and the world 
who can and should be proactively engaged in planning for the 
next pandemic.
    Zika, which is a challenge, is not what I think we are most 
concerned about as a group, which is a truly lethal global 
pandemic. Ron Klain, who I think served admirably as the 
President's Ebola coordinator, has recently published a piece 
in which he raises the specter of a truly global pandemic that 
would be faster-moving, more lethal, and more readily shared 
than Ebola was. And he makes a number of suggestions. So, let 
me move to asking what you see about both lessons learned, the 
need for our continued investment, and the suggestions that you 
and he have made.
    And let me not close my opening without saying that it was 
the people of Liberia, in my experience there in December of 
2014, volunteers from around the world, who were really on the 
front lines in making the lifesaving difference, and, in 500 
cases, giving their lives as health workers. But it was, as 
Senator Markey said, the United States that was the 
indispensable nation that brought to bear, at a critical 
moment, in the rainy season, when there was a near collapse of 
the nation of Liberia, absolutely essential logistical 
supplies, resources, funding, trained personnel that helped 
Liberians turn the corner. This was, I think, a moment of great 
partnership and of great leadership by the United States, the 
international community, and by thousands of volunteers from 
around the world.
    But, there are critical lessons learned about how to reform 
the WHO, about how to reform the accountability and 
transparency of data, about how to improve the grassroots 
healthcare networks of fragile nations, and about how to plan 
for the next outbreak.
    So, let me turn, if I might, to the issues raised by Ron 
Klain. He has suggested that, within the United States, we 
should have a--an identified National Security Council 
coordinator to manage interagency responses. He suggested 
investment in just the sort of CDC that Senator Isakson was 
asking about, regional CDCs--Africa first, but in other 
geographies--that have the capacity to mobilize cutting-edge 
analytical capabilities, field tests, and to coordinate field 
trials. He suggests that the global health security agenda, 
Global Health Security Act and the agenda that it would 
authorize, needs to move forward, that we need to continue, as 
a country, to invest at the grassroots. And he suggests a 
parallel to FEMA that would be essentially a public health 
emergency management agency.
    As was mentioned in passing, one of the things that most 
impressed me about the response I was able to see in December 
of 2014 was its coordination. There were dozens and dozens of 
nonprofits, of government ministries, of U.N. agencies, of U.S. 
entities, and there was a regular, clear, weekly meeting, with 
a public agenda, with everybody in the same room at the same 
place at the same time, using the National Incident Management 
System that has been built out in the United States by FEMA to 
coordinate response, to identify and prioritize investment. 
That was truly encouraging. And a number of the folks from the 
DART team at USAID, who I met with, said, across a half-dozen 
other disasters, they had never seen that work so well. That 
was partly due to private-sector engagement and leadership, in 
terms of skills and capability. It was partly the U.S. But, it 
also was a reflection of the very strong Liberian-American 
community. There were dozens and dozens of Liberian-Americans 
who had returned to help lead the government and ministry 
responses.
    So, please, if you would, respond to a number of those 
proposals. I know that was a long survey of the different 
issues. Each of you have spoken to them in your testimony, but 
if you would focus and sharpen. What are we missing? What do we 
most need to do next? And I assume you agree that Ebola is not 
over, the conditions that create it have not gone away, and, if 
anything, we need to double down on the investments we are 
making, and make them count.
    If you would, in order. Dr. Knight, please.
    Dr. Knight. I agree with everything you said. You know, 
Ebola is not over. But, I might put a slightly different 
context in it, that, in such a globalized world, the risks of 
pandemics is more severe. You know, and that might help some of 
this conversation about, How much do we appropriate funds? It 
is actually--this is an emerging and growing problem. Very 
mobile world, et cetera.
    The other question, What do I think of the recommendations? 
They all seem--I support them all, obviously, but the missing 
one, I think--and I mentioned it in my opening comment--is, in 
a world where there was a serious pandemic and an infectious 
pandemic, what are the conventions, protocols of people 
traveling from one country another? You know, if I was to send 
10 people to a country to help fight a pandemic, what do I do 
with them if one of them gets the disease? Can I fly them home 
to treat them in my hospital in my country? Or they then have--
they have to stay in that country? Because it changes who I ask 
and what I ask of them. It--if it is clear somewhere, it was 
not clear at the time. And it almost feels like--I do not 
understand how international systems work, but it almost feels 
like there should be an international convention on the 
movement of people across borders during the time of a 
pandemic. And maybe with different trigger levels. When it is 
beginning to happen, it is more accessible. When it is really 
severe, borders might have to shut. I do not know. But, do not 
let us work it out during the next one. Let us have it written 
whilst we enjoy not having one.
    Senator Coons. I do think, Dr. Knight, the establishment by 
the U.S. Public Health Service, which has been sort of an 
unsung hero of this, of the treatment facility out at Robertson 
Airport, was especially critical, because it allowed 
international volunteers, public health professionals to have 
some confidence that, when they contracted Ebola, they would 
get world-class care without having to be repatriated. I met 
with a number of the Liberians and foreign nationals who had 
survived Ebola because of their treatment there. We have no 
plan or convention around that----
    Dr. Knight. Let us, Yes, codify, write it, and say that is 
how we will deal with that scenario.
    Senator Coons. Excellent.
    Dr. Knight. Otherwise, it interferes with decisions 
sometimes.
    Senator Coons. Dr. Panjabi?
    Dr. Panjabi. Thank you, Senator Coons.
    You are right, Ebola is not over. The conditions, as you 
said so eloquently, that created it are still there. And it is 
true that the medical literature reports that we were warned 
about this. We just did not see it. As late as--as far back as 
the 1970s, there was literature from West Africa that reported 
antibodies--meaning that people were exposed to Ebola. It just 
was not caught. And so, there are these blindspots--and that is 
what I would say is missing--in global health. We ask, in 
making investments in global health, what disease to focus on. 
Is it HIV and AIDS? Is it Ebola? We have started to ask more of 
the question of how to do it. Amanda brought up great 
suggestions about focusing on performance, focusing on the 
health workforce. We have not asked enough about who and where 
the distribution of those resources have gone.
    Take the State of Alaska, for instance--a homegrown 
example--600,000 square miles, 600,000 people. Instead of 
deciding to allocate resources just on a dollar-per-capita 
basis, which would have left every small remote community out 
of that calculus, they asked the question, How far are people 
from healthcare? If there are 50 people in a village or a 
community, if there are 100 people, how far are they from a C-
section? If they are 60 minutes or more from a C-section, 
regardless of population size, you are going to be designated a 
``frontier community,'' which means you are going to get a 
higher earmark in the budget. This is the Office of Rural 
Health Policy here at HHS.
    Those kinds of policies and financing innovations need to 
come to global health if we are going to focus on the 
blindspots that lead to the hotspots of disease. And to get 
there, that first has to start with tracking conditions in 
those areas. So, we need to be asking about distribution. Who 
and where? If it is medicines, is it getting to the last mile, 
is it getting to all people? And can we prove that? Can you 
hold people accountable to cover each and every person? Great 
agendas are already been put forward. The Global Health 
Security Agenda, you mentioned one of them. There is no way you 
can stop emerging infectious diseases if they are zoonotic if 
you do not go to places where they first emerge. But, there is 
also broader agendas and synergies with the investments you all 
have already made in HIV and AIDS, in tuberculosis and malaria, 
in strengthening health systems. There is a grand agenda to get 
universal health coverage out to all parts of the world that do 
not have it. These are synergistic.
    And I think that is just the second point I would make that 
is more subtle, perhaps, is, we cannot pit different diseases 
against each other, but we also cannot pit different strategies 
against each other. Last week, a bunch of community health 
workers who were delivering care for mothers and children 
discovered a pertussis, a whooping cough, outbreak in that 
region. You know, you could have said, ``Well, those community 
health workers are not disease responders, they are not 
focusing on disease surveillance, so let us not fund primary 
healthcare.'' When, in fact, now they are the front lines of a 
disease response.
    So, these are synergies. It is not either/or. And I think 
there is a lot of leverage yet to be had in linking these 
agendas together. But, the goal, I think, again, the big 
blindspot, is, we are not reaching the last mile. There are 400 
million to one billion people on the planet who live out of 
complete reach of healthcare, even in the 21st century. And if 
we do not reckon with that, we are not going to, I think, be 
able to stop these outbreaks from happening.
    Senator Coons. Well, thank you, Doctor. And thank you for 
your particularly brave and persistent and powerful work, along 
with Paul Farmer and the Partners in Health. The model that you 
have been advancing is a huge ``aha'' moment, I think, for all 
of us.
    If you could, briefly, Amanda and Sophie.
    Ms. Glassman. Yes. Thank you, Senator.
    I agree totally, there should be a global health czar that 
has power over the interagency and the budgetary tools needed 
to assure that all the agencies are moving in the same 
direction. But, that said, I think we also need to structure 
our financing of response to infectious disease, whether they 
are outbreaks or whether they are protracted issues, in a way 
that avoids repeat disease earmarks and repeat emergency 
funding. As we have said, it is not if, it is when.
    So, you know, can we change? We have been doing this since 
the time of PEPFAR. And we seem to like disease-specific 
earmarks. It is great to know you can talk more specifically 
about what is happening, but we can still have that 
accountability and, you know, the impact on people's lives 
without having to name money by disease-specific intervention.
    And finally, the Global Health Security Agenda, very 
important. We have been doing a lot of training, meeting, and 
capacity-building. I worry that we are not creating enough 
incentives for outcomes on disease preparedness. So, we know 
what a good disease surveillance system looks like, but did we 
know whether Brazil's disease surveillance system was working 
well? Did it have complete coverage? Were they able to respond? 
Brazil is a big federal country like our own. They face a lot 
of the same issues. How do we get subnational entities to be 
prepared for public-health outbreaks? Are they really recording 
all the deaths? Do they have the capacity to do that?
    And I will end there. Thank you very much.
    Senator Coons. Sophie?
    Ms. Delaunay. Thank you, Senator, for your eloquent summary 
of our recommendations.
    I would like to make a comment about the Global Health 
Security Agenda and the CDC.
    On the Global Health Security Agenda, of course we see a 
lot of value in the U.S. taking a leading role in trying to 
address the response to outbreak. And one of the value is 
actually that you have been able to get onboard a number of 
countries. And the response to an outbreak never takes only one 
actor; it takes a whole range of actors. So, that is a very 
valuable issue.
    Our only concern with the Global Health Security Agenda is 
that--is hoping that the agenda is not just driven by security 
concerns, because what we have learned, and what we learn 
repeatedly in humanitarian and medical situations, is that the 
best way to actually address health issue is to be patient-
driven, is to try to respond to the needs of the patients 
first, and not necessarily when we feel a threat. There were 
some research about Ebola in the beginning of the 2000, when 
there was a fear of bioterrorism, and then it was abandoned. 
And so, the--you see the risk of actually attaching an agenda 
to security issue, as opposed to health consideration and needs 
of the population.
    Regarding the CDC, I would just like to share a very recent 
experience. We are--first, we have been working very, very well 
with the U.S. CDC in Liberia, as you may know, hand-in-hand 
during several--during 2 years. We also recognize that there is 
a major need for better surveillance. And we have engaged in 
talked with WAHO, the West African Health Organization, on 
data-sharing. And it was interesting to see that actually they 
wanted every discussion were going back to the African CDC. So, 
they want the African CDC. They want this to happen. And 
provided that the United States is able to actually help them 
set this up and help them develop the ownership and the 
capacity to run such a initiative, it will definitely be a 
game-changer in the region.
    Senator Coons. Well, thank you.
    Thank you all. Thank you for your service.
    And thank you, Chairman Flake and Ranking Member Markey, 
for convening this important hearing and for staying engaged 
and being such leaders on this important issue.
    Thank you.
    Senator Flake. You bet. And thank you, Senator Coons, for 
actually traveling to Liberia in the height of the epidemic. 
That was a gesture that was much appreciated by all, and 
certainly courageous on your part.
    Let me just say, in the form of kind of a question, but a 
statement--Ms. Glassman, you talked about the perils of 
supplemental funding. I think a lot of the discussion today is 
around--you know, we have disease-specific funding that we 
appropriate. It is, frankly, far easier to appropriate, from a 
standpoint of an elected official, when there is an issue like 
Ebola or like--or HIV/AIDS in Africa. With an epidemic level, 
it is just--it is easier to move money. That is why we do it. 
But, it does not serve us very well in the long term.
    And if I look at our global health budget, the request for 
2017 is $8.5 billion; enacted, 8.1 billion for last year. When 
are we going to actually bite the bullet and say, ``All right. 
We need to increase that, and decrease the likelihood of a 
supplemental needed later?'' Or do we go another direction?
    Ms. Glassman, do you have any thoughts on that? You have 
shared some in your testimony, certainly, but I would like to 
have you detail that a little more.
    Ms. Glassman. Thank you, Senator Flake.
    Well, it is a very difficult political task to do, but I 
think the idea of trying to increase funding and still hold 
ourselves accountable for results in specific disease areas is 
a good combination. That way, we can use our funding 
rationally, but we are still accountable for the outcomes in 
the diseases that we care about, the infectious diseases, and 
the preparedness that we care about. So, I think maybe that is 
a compromise that would be politically feasible.
    Thanks.
    Senator Flake. Well, certainly from our point of providing 
oversight, and a lot of the funding is through this committee, 
if we have a regular appropriation cycle that includes this 
money, it gives us opportunities through the hearing process, 
budget committee hearing processes, to actually scrutinize and 
scrub and see, you know, what worked and what did not. So, I 
hope that we can move more in that direction.
    Senator Markey, did you have any followup----
    Senator Markey. Yes, if I may, please. Thank you, Mr. 
Chairman, very much.
    I would like to, again, come back to this Zika question. I 
think it is very important, because there is clearly a dynamic 
tension now that is opening up, in terms of the willingness of 
Congress to appropriate the monies that are going to be needed 
to deal with both of these diseases. And maybe you--Dr. 
Panjabi, maybe you could talk about this issue again, in terms 
of the need to ensure that there is funding for the Zika 
epidemic as it moves throughout that region and towards the 
United States at an ever-accelerating pace. What would you 
recommend that we put in place, given the lessons that we have 
learned from Ebola? And would you recommend to Congress that 
they replenish the money that they are taking, that we could 
reprogram out of Ebola, and ensure that there is, at the same 
time, full funding for Zika so that we do not, unfortunately, 
lose the lessons of the Ebola crisis, lose all of the--you 
know, the basic hard-won human tragedy that had to be suffered 
through because we did not act quickly enough, because the 
world did not respond quickly enough, because the WHO did not 
respond quickly enough? What would you recommend to us, as an 
institution, in terms of the funding and how we should proceed?
    Dr. Panjabi. Well, you know, the way I think about this is, 
these are not separate battles in a single war. You cannot win 
one or the other and win the war. These are two different wars 
to fight. And we have to be able to maintain our defenses in--
on both fronts, whether it is in West Africa or in Latin and 
South America now, in the Americas. So, I do think whatever can 
be done, from the Congress perspective, to both provide the 
support that is needed to respond to Zika and, where needed, 
replenish, if that is what is needed, the funds that are being 
moved away from Ebola, but also actually--and again, tie that 
to performance. I mean, there are clear targets here of what is 
needed to be done. These are--you know, the--we need to get 
kids vaccinated in West Africa. We need to make sure that 
community health workers are paid and supported. Lab systems 
need to be strengthened. Health-worker readiness needs to be 
there. They need to have protective gear, gloves, and gowns. If 
we continue to do that in West Africa, we will help stop the 
next threat there.
    Some of those same lessons and interventions are what is 
needed in Zika, whether it is training health workers, 
equipping them appropriately. And, you know, I think that the 
Global Health Security Agenda, what the CDC has put forward, is 
very straightforward: prevent, detect, respond. That kind of 
agenda, of investing in that, will be very helpful.
    You know, we also know that Zika has been present--as I 
mentioned earlier, the first cases were in West Africa and 
Nigeria, of human infections. Right? So, by investing now, 
post-Ebola--or while we are trying to fight Ebola, still, and 
also recover, but also set it up to be resilient against Ebola 
in West Africa, we are also setting it up to be resilient 
against other kinds of diseases, if we do it the right way, 
whether that be Zika, if it reemerges there, or whether it is 
other infections. So----
    Senator Markey. So, as you look at WHO and what just 
happened with Ebola, have they learned the lessons, in your 
opinion, Doctor, of what just occurred in West Africa?
    Dr. Panjabi. I do think the WHO--a well-supported, fit-for-
purpose WHO--is going to be important to helping stop and 
respond to these outbreaks. I think they play an essential 
role. Have the lessons been learned? I think they are still 
being learned. I think that----
    Senator Markey. What do you think the big problem was, 
Doctor? Why did they not see it? Why was it not--why was the 
alarm bell not ringing so loudly that they did not respond? And 
why, in your opinion, should we have any confidence that any 
reforms are going to change that attitude?
    Dr. Panjabi. I think the central primary reason is that 
this went undetected? Right? As I mentioned in the testimony, 
you have an Ebola infection that moves from an animal reservoir 
into a human reservoir--a human population, initially, in 
really remote areas. Health workers are not supported there. 
They are unpaid or they are underpaid, they are unequipped or 
underequipped. And if you do not have a health system in these 
remote areas, you are going to miss--it took 3 months; when 
minutes counted--every minute counted, we lost months. So, by 
the time March rolled around, of 2014, to catch up with that 
response was--we were already behind several steps from the 
epidemic. So, I think that still is the central issue, is 
making sure surveillance in primary healthcare services in the 
most remote areas are there. That includes good data and 
monitoring. Had those pieces been in place earlier on, any 
institution, whether it was the governments in those three 
countries, the WHO, the U.S. Government, they all would have 
been better prepared to respond. And again, I think that is the 
focus now that needs to be there for all of us, is to make 
sure, where we know there are disease hotspots likely to 
happen, and there are blindspots in healthcare reaching those 
areas, we need to double down on investments in those places.
    Senator Markey. Thank you, Doctor.
    Thank you, Mr. Chairman.
    Senator Flake. Well, thank you.
    Thank you all for sharing your time and your experience and 
your expertise. This has been very enlightening to all of us. 
Appreciate the preparation that went into this.
    The hearing record will remain open through Friday. And so, 
as you receive questions, if you could respond promptly, then 
your responses will be part of the record.
    So, with the thanks of the committee, this hearing is 
adjourned.
    [Whereupon, at 11:31 a.m., the hearing was adjourned.]

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