    [House Hearing, 116 Congress]
    [From the U.S. Government Publishing Office]

          ERADICATING EBOLA: LESSONS LEARNED AND MEDICAL ADVANCEMENTS

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

                                    HEARING

                                   BEFORE THE

                     SUBCOMMITTEE ON AFRICA, GLOBAL HEALTH,
                            GLOBAL HUMAN RIGHTS, AND
                          INTERNATIONAL ORGANIZATIONS

                                     OF THE

                          COMMITTEE ON FOREIGN AFFAIRS
                            HOUSE OF REPRESENTATIVES

                         ONE HUNDRED SIXTEENTH CONGRESS

                                 FIRST SESSION

                                   __________

                                  JUNE 4, 2019

                                   __________

                               Serial No. 116-44

                                   __________

            Printed for the use of the Committee on Foreign Affairs

    [GRAPHIC NOT AVAILABLE IN TIFF FORMAT]

           Available:  http://www.foreignaffairs.house.gov/, http://
                                docs.house.gov,
                           or http://www.govinfo.gov

                                    __________

                        U.S. GOVERNMENT PUBLISHING OFFICE
    36-558PDF                 WASHINGTON : 2019

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

                          COMMITTEE ON FOREIGN AFFAIRS

                       ELIOT L. ENGEL, New York, Chairman

    BRAD SHERMAN, California             MICHAEL T. McCAUL, Texas, Ranking
    GREGORY W. MEEKS, New York               Member
    ALBIO SIRES, New Jersey		     CHRISTOPHER H. SMITH, New Jersey
    GERALD E. CONNOLLY, Virginia         STEVE CHABOT, Ohio
    THEODORE E. DEUTCH, Florida	     JOE WILSON, South Carolina
    KAREN BASS, California		     SCOTT PERRY, Pennsylvania
    WILLIAM KEATING, Massachusetts	     TED S. YOHO, Florida
    DAVID CICILLINE, Rhode Island	     ADAM KINZINGER, Illinois
    AMI BERA, California		     LEE ZELDIN, New York
    JOAQUIN CASTRO, Texas		     JIM SENSENBRENNER, Wisconsin
    DINA TITUS, Nevada		     ANN WAGNER, Missouri
    ADRIANO ESPAILLAT, New York          BRIAN MAST, Florida
    TED LIEU, California		     FRANCIS ROONEY, Florida
    SUSAN WILD, Pennsylvania	     BRIAN FITZPATRICK, Pennsylvania
    DEAN PHILLPS, Minnesota	             JOHN CURTIS, Utah
    ILHAN OMAR, Minnesota		     KEN BUCK, Colorado
    COLIN ALLRED, Texas		     RON WRIGHT, Texas
    ANDY LEVIN, Michigan		     GUY RESCHENTHALER, Pennsylvania
    ABIGAIL SPANBERGER, Virginia	     TIM BURCHETT, Tennessee
    CHRISSY HOULAHAN, Pennsylvania       GREG PENCE, Indiana
    TOM MALINOWSKI, New Jersey	     STEVE WATKINS, Kansas
    DAVID TRONE, Maryland		     MIKE GUEST, Mississippi
    JIM COSTA, California
    JUAN VARGAS, California
    VICENTE GONZALEZ, Texas

                     Jason Steinbaum, Staff Director
                  Brendan Shields,  Republican Staff Director
                                     ------

        Subcommittee on Africa, Global Health, Global Human Rights, and
                          International Organizations

                         KAREN BASS, California, Chair

    SUSAN WILD, Pennsylvania             CHRISTOPHER SMITH, New Jersey
    DEAN PHILLIPS, Minnesota             JIM SENSENBRENNER, Wisconsin
    ILHAN OMAR, Minnesota                RON WRIGHT, Texas
    CHRISSY HOULAHAN, Pennsylvania       TIM BURCHETT, Tennessee

                        Janette Yarwood, Staff Director

                               C O N T E N T S

                                  ----------
                                                                       Page

                               OPENING STATEMENT

    Opening statement for the record from Chair Bass.................     4

                                   WITNESSES

    Ziemer, Tim, Acting Assistant Administrator, United States Agency
      for International Development..................................    14
    Redfield, Robert, Director, Centers for Disease Control and
      Prevention.....................................................    23

                                    APPENDIX

    Hearing Notice...................................................    56
    Hearing Minutes..................................................    57
    Hearing Attendence...............................................    58

                 ADDITIONAL MATERIALS SUBMITTED FOR THE RECORD

    Ebola Hearing Memo submitted for the record......................    59

                               ERADICATING EBOLA:.
                    LESSONS LEARNED AND MEDICAL ADVANCEMENTS

                             Tuesday, June 4, 2019

                           House of Representatives,

                     Subcommittee on Africa, Global Health,

                     Global Human Rights, and International

                                 Organizations,

                         Committee on Foreign Affairs,

                                         Washington, DC

        The subcommittee met, pursuant to notice, at 2:40 p.m., in
    room 2172, Rayburn House Office Building, Hon. Karen Bass
    [chair of the subcommittee] presiding.
        Ms. Bass [presiding]. Good afternoon, everyone.
        This hearing for the Subcommittee on Africa, Global Health,
    Global Human Rights, and International Organizations will come
    to order.
        The subcommittee is meeting today to hear testimony on
    eradicating Ebola, building on lessons learned and medical
    advancements.
        I want to thank everyone, including our witnesses, for your
    patience. We had a series of votes, and other members will be
    joining us shortly, but we are joined by our ranking member,
    Mr. Smith.
        So, today we are here to discuss the eradication of Ebola
    and some of the medical advancements and lessons learned in
    trying to suppress this deadly disease. Ebola is one of the
    deadliest viral diseases in the world and has become a part of
    the global health landscape.
        The recent discovery of an Ebola vaccine and better
    healthcare employee training have helped improve response times
    to outbreaks and decrease the ability of the virus transmitting
    to remote areas. However, Ebola outbreaks are often complicated
    by regional conflict, lack of trust between local communities
    and practitioners, and armed groups attacking and burning down
    treatment centers. This hearing will address the challenges and
    opportunities to combat the transmission of Ebola and the
    effort and collaboration needed by appropriate stakeholders.
        I look forward to hearing more from our witnesses regarding
    the Ebola vaccines and how they are being used in this most
    recent outbreak.
        So, without objection, all members may have 5 days to
    submit statements, questions, extraneous materials for the
    record, subject to the length limitation in the rules.
        I recognize myself for the purpose of making an opening
    statement.
        I would also like to thank our distinguished witnesses who
    are here with us today.
        The current outbreak in the Democratic Republic of the
    Congo began in August of last year and is the second largest to
    date, and as of news reporting from today, may have reached up
    to over 2,000 cases and almost 1200 confirmed deaths. If we do
    not collaborate with all stakeholders to combat the outbreak
    and, ultimately, eradicate Ebola, the disease would surpass the
    2014-2016 outbreak, the deadliest in history, which had 11,000
    recorded deaths and 28,000 total cases. That outbreak started
    in Guinea, Liberia, and Sierra Leone, then spread to Mali,
    Nigeria, and Senegal, and even beyond the continent, with cases
    in Italy, Spain, the United Kingdom, and I think we all
    remember the cases in the United States.
        The Ebola epidemic has been heightened because it is in a
    conflict zone in the Democratic Republic of the Congo. The
    epicenter of the outbreak is in North Kivu, which happens to
    have more than 100 active armed groups in the region. North
    Kivu also shares a border with Uganda and is a hub for travel
    and trade, but also various other types of movement across the
    border.
        New cases are hard to determine because the violence and
    political unrest in the affected areas have further restricted
    the community's access to health care. The lack of security in
    the region is also hindering the Ebola response by making it
    difficult to trace context and organize crucial community
    outreach activities. Some health centers have been temporarily
    closed or damaged. Several of the health workers have been
    killed.
        I know that the people of the DRC are frustrated because of
    the lack of medicine, food, and foreign companies extracting
    the country's precious minerals, but that is no excuse to burn
    down facilities or attack or kill people that are there to help
    treat this deadly disease.
        What this indicates, though, is that we must work to do all
    that we can to keep these health practitioners safe. This means
    that we have to think beyond just providing humanitarian
    assistance for medical treatment. USAID Administrator Mark
    Green said in testimony before the Senate 2 weeks earlier that,
    when it comes to Ebola, the DRC setting is a labyrinth of
    challenges, poor governance, resentment toward community
    leaders. With a failed democracy in many, many ways, it will
    take more than simply a medical approach.
        Considering the dilemma of suppressing this outbreak, I
    look forward to hearing your views and suggestions in your
    testimony or in the Q&A. I am also very interested in hearing
    the pros and cons of identifying this outbreak as an
    international public health emergency. Why would not we declare
    that? Those are just a few concerns I want to pose to the
    witnesses.
        Finally, I am concerned that the Administration released a
    Presidential memo last November implementing aid restrictions
    to most of the Tier 3 countries found in the 2018 TIP report.
    It clearly states in Section 110, ``The President shall
    exercise the waiver authority when necessary to avoid
    significant adverse effects on vulnerable populations,
    including women and children.''
        Not focusing resources on health, education, and community
    outreach hinders the success of countering the Ebola outbreak
    in the DRC, and I urge the Administration to act more
    diligently now. This Administration has an opportunity and an
    obligation to try to stop the deadly outbreak, and that is why
    we are having this hearing and I am introducing the Ebola
    Eradication Act of 2019, which would authorize USAID to assist
    with the Ebola efforts in the DRC.
        Last, I believe that it is imperative that we not let Ebola
    reach Goma because, if it does, it is highly probable that it
    will reach Rwanda, Uganda, Ethiopia, and South Sudan--oh, my
    goodness--and that would have an effect on humanitarian
    efforts, peace and security, and economic trade.
        So, the Tier 3 status is something I know the ranking
    member is the author of the TIP report and has worked for many
    years on this. And it kind of presents a little bit of a
    dilemma where we certainly do not want to do anything to reward
    a country that is a Tier 3 status, but, on the other hand, we
    have this situation where have Ebola in a Tier 3 country. So,
    what do you do? Not provide aid, when this disease, obviously,
    has international impact?
        [The prepared statement of Ms. Omar follows:]

        [GRAPHICS NOT AVAILABLE IN TIFF FORMAT]

        I now want to recognize the ranking member for the purpose
    of making an opening statement.
        Mr. Smith. Thank you very much, Madam Chair. Thank you for
    convening this very important and timely hearing.
        As she knows, the gentlelady from California and my good
    friend--and some of you may remember--this subcommittee was
    heavily engaged in the summer of 2014 in addressing Ebola when
    we were in the midst of an Ebola outbreak in Sierra Leone and
    in Liberia and the ensuing panic over the disease. We actually
    held three hearings during a 4-month span, a period when many
    around the world thought a new equivalent of the bubonic plague
    was about to jump borders and overwhelm the health systems,
    especially of Sub-Saharan Africa.
        Indeed, there was a period when we thought that Nigeria,
    particularly in Lagos--and Nigeria is the most populous country
    in Africa--would suffer from a pandemic outbreak. But, thanks
    to a largely unheralded work of a number of key actors,
    including and especially our own Centers for Disease Control,
    the outbreak was contained. And while we did have cases in the
    U.S., due to highly effective quarantine measures and state-of-
    the-art medical care, we were able to dodge that bullet as
    well.
        Perhaps our witnesses, Dr. Robert Redfield, can enlighten
    us further as to the critical role the CDC played with regard
    to global efforts and containing, and then, defeating, the 2014
    Ebola outbreak, particularly in Nigeria, and lessons that have
    been learned.
        Although in many ways today we are better equipped to
    address the Ebola outbreak, certainly in terms of vaccines that
    were not readily available in 2014, as a practical, boots-on-
    the-ground matter, we are in some ways worse off dealing with
    the current outbreak, which began in 2018. Last year's outbreak
    in the DRC has now spread in populated areas of the eastern
    DRC. What makes the situation more difficult this time is the
    security situation with attacks, vicious attacks, on healthcare
    workers.
        As reported by The Washington Post, according to the WHO,
    there have been some 119 attacks against health workers this
    year--and that was as of May--with some 85 wounded or killed.
    The presence of expatriates, in particular, among the
    healthcare workers appears to have increased the militants who
    have carried out the attacks.
        When one considers that these dedicated health workers put
    their lives on the line to help prevent and treat Ebola, the
    fact that they should be targeted boggles the mind. Recall the
    testimony of Dr. Kent Brantly at one of our 2014 hearings, how
    he contracted the disease, despite taking every precaution,
    while helping Ebola patients in Liberia.
        We hope to get an update from our witnesses today as to
    what is the security situation on the ground and whether we are
    putting our CDC and other personnel further in harm's way
    beyond the threat posed by the Ebola virus.
        Finally, I would like to address the issue--and it was just
    raised by my good friend and colleague, Chairwoman Bass--there
    is some concern that assistance to the DR Congo used to combat
    Ebola will be cut based on the fact that our State Department
    has designated the DRC as a Tier 3 country in terms of human
    trafficking. I certainly hope that this is not the case, as it
    does not comport with the intent behind the legislation.
        As the author of the Trafficking Victims Protection Act of
    2000, the TVPA requires that we withhold non-humanitarian, non-
    trade-related foreign assistance to the government of Tier 3
    countries, which means that the country does not fully comply
    with the minimum standards and is not making significant
    efforts to do so. I note that TVPA explicitly excludes
    humanitarian and trade-related assistance from any assistance
    cutoff. It further allows development assistance which directly
    addresses basic human needs which is not administered by the
    government. In other words, development assistance can flow via
    non-State entities to non-government organizations, including
    faith-based actors. Indeed, if one visits the eastern DRC--and
    I have visited it myself--one notices that health and education
    needs are met largely by faith-based entities, as the
    government and its institutions are viewed with a great deal of
    suspicion.
        Moreover, Section 110(d)(4) of the TVPA vests the President
    with waiver authority with respect to non-humanitarian, non-
    trade-related foreign assistance when such assistance is in the
    national interest of the United States, such as seen in the
    prevention of the spread of Ebola. Further, the TVPA mandates
    that the President exercise such waiver authority, quote,
    ``when necessary to avoid significant adverse effects on
    vulnerable populations, including women and children.''
        If there is any misunderstanding with respect to how this
    law should be interpreted or implemented, I know that the
    chairwoman and I would be very happy to meet with leaders of
    the Administration to discuss that.
        I do want to note that, since Fiscal Year 2018, the
    American taxpayers have provided approximately $330 million in
    humanitarian assistance to the Democratic Republic of Congo and
    some $87 million in response to the Ebola crisis. I am further
    told that additional congressional notifications for the DRC
    will be forthcoming and look forward to receiving and reviewing
    those as well.
        Thank you, Madam Chair, and I yield back.
        Ms. Bass. Thank you very much.
        Before I introduce the witnesses, I would just like to
    acknowledge a few people who are in the audience. This is a
    special day on the Hill when we acknowledge, celebrate, and
    lift up the hundreds of thousands of young people who are in
    the Nation's child welfare system. And so, for the first time--
    I have been doing this for years--but for the first time, three
    of our former foster youth are from the continent of Africa.
    One is from the Democratic Republic of the Congo, Ethiopia, and
    Kenya. And so, I want to acknowledge them for being here.
        Raise your hands or stand up.
        [Applause.]
        Yes, thank you.
        In support of the young people is a very famous actor who
    represents one of my favorite TV shows, Blackish, Marcus
    Scribner, who is here with his father, who is here supporting
    all of the foster youth.
        [Applause.]
        So, thank you very much for attending.
        And now, to our panel. Admiral Ziemer is the Acting
    Assistant Administrator for the Bureau of Democracy, Conflict,
    and Humanitarian Assistance, at USAID. From April 2017 to July
    2018, he was appointed by President Trump to be the Senior
    Director for Global Health Security and Biodefense at the
    National Security Council. And in June 2006, he was nominated
    by President Bush to lead the President's Malaria Initiative.
        Dr. Robert Redfield is the Director for the Centers for
    Disease Control and Prevention. He has been a public health
    leader actively engaged in clinical research and clinical care
    of chronic human viral infections and infectious diseases,
    especially HIV, for more than 30 years. He made several
    important early contributions to the scientific understanding
    of HIV, and in addition to his research, he oversees an
    extensive clinical program providing HIV care and treatment in
    the Baltimore-Washington, DC. community.
        Thank you very much today. And please, we would like to
    hear a summary of your testimony. We have your written
    testimony, but if you would present for 5 minutes, and then, we
    will have questions and answers by the panel.

    STATEMENT OF TIM ZIEMER, ACTING ASSISTANT ADMINISTRATOR, UNITED
              STATES AGENCY FOR INTERNATIONAL DEVELOPMENT

        Mr. Ziemer. Chair Bass, Ranking Member Smith, members of
    the subcommittee, thank you for the opportunity to speak with
    you today about the United States Government's response to the
    ongoing Ebola outbreak.
        Chair, you referenced the 2014 West Africa outbreak and the
    devastation and the impact that it had. The current outbreak in
    North Kivu and Ituri Province has just surpassed 2,020 cases.
    The situation is worsening and the numbers of cases will
    continue to rise.
        Last month, I traveled to eastern DRC with a core team from
    USAID and CDC. I met with health teams, local community
    leaders, and our implementing partners. I saw firsthand the
    scale and complexity of this outbreak. I have traveled
    extensively in my career, from my three decades in the U.S.
    Navy and in the roles that I have had since. This trip to the
    DRC was one of the most sobering trips I have ever taken.
        The scope of this biosecurity threat is changing and the
    risk of the virus leaping across the border to other countries
    is very high. This will further destabilize the region
    economically and heighten insecurity. In order to control this
    Ebola outbreak at its source, a fundamental shift and an
    immediate reset is necessary.
        The ongoing violence and community distrust toward the
    response has been summarized by both of the opening statements.
    Armed group violence as well as deep-rooted community
    resistance has really kept the health teams from doing their
    critical health savings work and frequently results in the
    suspension of the response efforts.
        In February, community members set fire to and destroyed
    the Katwa Ebola treatment unit. When I was there, we saw it
    restored. The evening we left, one of the guards was killed in
    another recurring attack.
        There have been over 70 security incidents this year alone.
    Cases have been accelerating in areas where the community
    members exhibit deep-rooted distrust of the central government
    and foreigners, as well as the people from other regions within
    the DRC. This widespread distrust has fueled misconceptions
    about the disease and deep suspicion regarding the motives of
    this sudden and dramatic international presence responding to
    Ebola. It is the feelings of the community that they are being
    exploited by this injection of cash. They refer to it as ``the
    Ebola economy''.
        There is clear consensus among the stakeholders that we
    need to listen better to the communities, listen to what they
    are feeling, and that should and must inform the trajectory of
    how we can shift our response to this accelerated increase in
    cases. The outbreak is not just a public health crisis, it is
    an outbreak in the midst of a complex emergency. In order to
    contain this outbreak, a broader, more holistic humanitarian
    approach is needed.
        Toward this end, USAID, supported by CDC, as the technical
    lead, is leading a whole-of-government response focusing on six
    key areas in order to bring this Ebola outbreak to an end. Let
    me just quickly review those six areas of focus.
        First, we are working to improve coordination among the DRC
    government, WHO, and our international partners. I am pleased
    to say that over the last week to 10 days significant change is
    underway to accomplish that objective.
        Second, we are emphasizing and addressing the paramount
    importance of community engagement and local ownership.
        Third, we are working with the newly appointed U.N. Ebola
    Response Coordinator, Mr. David Gressly, to bolster security
    coordination through non-militarized humanitarian approaches.
        Fourth, we are working with the CDC to implement
    operational improvements in the public health response,
    including a forward-leaning vaccine strategy.
        Fifth, we are looking at enhancing the Ebola readiness in
    Goma and along the Goma-Butembo corridor as well as the four
    countries to the east.
        Last, we are engaged in longer-term planning scenario for
    stabilization and development to address the root causes of
    fragility in the region.
        This reset is building on the work of our USAID-funded
    partners that have been implementing key aspects of this public
    health response. Our partners have helped train 1,680 community
    health workers to conduct surveillance, strengthen infection
    prevention control measures in over 280 health facilities,
    reached 1.5 million people with health messages, and provided
    enough food to meet the needs of approximately 45,000
    beneficiaries each month, and much more.
        There is no silver bullet to end this outbreak, but I
    believe that an adaptable, whole-of-government response that
    capitalizes upon each agency's unique strengths and expertise
    will be successful in containing, controlling, and ultimately
    ending this outbreak.
        I look forward to your questions.
        [The prepared statement of Mr. Ziemer follows:]

        [GRAPHICS NOT AVAILABLE IN TIFF FORMAT]

        Ms. Bass. Dr. Redfield.

      STATEMENT OF ROBERT REDFIELD, DIRECTOR, CENTERS FOR DISEASE
                         CONTROL AND PREVENTION

        Dr. Redfield. Good afternoon, Chair Bass, Ranking Member
    Smith, and members of the subcommittee. Thank you for the
    opportunity to update you on the Ebola outbreak in the DRC and
    outline what CDC is doing to prevent, detect, and respond to
    this and other emerging global health threats.
        CDC's efforts are grounded in over 40 years of Ebola
    research and more than 20 Ebola outbreak responses. I want to
    emphasize that our goal is to end this outbreak as soon as
    possible.
        When I visited Beni 2 weeks after the outbreak was declared
    last August, I saw firsthand the complexity of this urban Ebola
    outbreak. In March, I traveled back again to the outbreak zone,
    where I met with responders on the front lines. These trips
    further reinforced my understanding of the critical role that
    experienced technical leadership plays in the field.
        This is the first urban outbreak in the DRC, occurring in
    densely populated areas that have experienced decades of
    conflict and civil unrest which continue today. The two
    currently affected provinces have never experienced an Ebola
    outbreak. They have busy, porous borders with Uganda, Rwanda,
    and South Sudan. These challenges make this outbreak extremely
    difficult.
        As of this week, we have surpassed the grim milestone with
    now 2,020 cases, 1354 deaths occurring in 22 health zones. A
    significant percentage of these cases have actually been
    acquired in healthcare settings, including 109 healthcare
    workers. In the past 42 days, we have seen 668 active cases in
    18 different health zones. Of these cases, less than a quarter
    were known contacts and monitored. Even more concerning,
    roughly 40 percent were community deaths that occurred outside
    the healthcare system.
        Based on experience from previous outbreaks, an effective
    response demands early ascertainment and effective isolation of
    at least 70 percent of all cases and sustaining this for
    several months. The fact that we are seeing so many community
    deaths means that we are missing contacts. While no Ebola cases
    have been confirmed outside the DRC, this outbreak is not under
    control at this time.
        CDC is working with the World Health Organization to
    support vaccination. Over 130,000 people in the DRC and
    surrounding countries have been vaccinated to date. Recently,
    WHO has recommended the expansion of vaccination strategies and
    an increase in vaccine supply to reach a greater number of
    individuals at risk for Ebola.
        Over the course of this outbreak, CDC has deployed 184
    experts to the DRC, neighboring countries, and the World Health
    Organization headquarters. Our work includes case recognition
    and contact tracing, infection control in the healthcare
    settings, safe burials, laboratory testing, border health,
    vaccination, and real-time data analysis to inform the
    response.
        CDC also continues to provide direct assistance to the DRC
    Ministry of Health, both in Kinshasa and Goma, where the
    incident command is now located. The World Health Organization
    in Geneva and the U.S. Government response in the DRC are also
    enhancing preparedness efforts in the neighboring countries.
        While this outbreak continues to be an urgent situation in
    the region, the current risk to America is low. The most
    effective way to protect America from emerging threats is to
    stop disease at their source before they reach our borders.
        We have seen tremendous progress in the rapid disease
    detection and response. For example, this includes meningitis
    in Liberia, multidrug-resistant tuberculosis in India, and the
    rapid detection of yellow fever in Uganda, all a direct result
    of CDC's global health security investment.
        CDC continues to improve the technical public health work
    force abroad. We have trained over 12,000 public health
    professionals now in 70 countries. More than 200 of these CDC-
    trained professionals are currently in the DRC. CDC continues
    to position our assets globally to quickly respond to the
    emerging health threats and disease hotspots.
        Finally, I want to thank you for your continued commitment
    and support to CDC and our critical global health security
    mission. Thank you.
        [The prepared statement of Dr. Redfield follows:]

        [GRAPHICS NOT AVAILABLE IN TIFF FORMAT]

        Ms. Bass. Thank you very much.
        I wanted to know if you could elaborate and explain a
    little bit about the differences in how people are responding
    to the epidemic. You remember when it started in Liberia and
    Guinea, there were challenges over traditional practices of how
    you deal with the dead. And that was one of the reasons why the
    outbreak was spreading, because it took a while to get people
    to break with their traditional practices of washing and
    preparing the body.
        Here in the DRC you have the conflict where the workers are
    being attacked, and it is believed as though the disease is
    fake. And I just want to know if you can elaborate a little
    more on what is going on. Why on earth would people be
    attacking the facilities and the healthcare workers?
        And then, I do not know if any of this is involved in the
    broader political situation in terms of the election that
    happened. The new President was here. He came and we met with
    him. When was it, Mr. Smith? It was maybe a couple of months
    ago that he was here.
        And I was surprised because, when he was here, he requested
    essentially security assistance. I understand that there are
    security problems, but in the midst of an epidemic like this I
    was surprised by that request.
        So, could you please explain your perspectives on why are
    the attacks happening? Why do not people understand that this
    is a real deadly disease?
        Mr. Ziemer. I think that is the question----
        Ms. Bass. The microphone is not on. How about now?
        Mr. Ziemer. Yes, OK.
        I think your question is exactly the question that we are
    trying to filter through. If you look at the three vectors, the
    virus, the security situation, and the community lack of
    cooperation, all three of those are going in the wrong
    direction. We know how to control the virus. We just get there
    and do what is needed in order to bring this under control,
    based on the previous experiences.
        The last outbreak was in the Equateur Province. And with
    the DRC's response, complemented by the CDC, it was brought to
    a close. So, what is different in this region that would cause
    this deep-rooted response in the negative? Human behavior is
    driven by many----
        Ms. Bass. But, I mean, I know that there is a lot of armed
    groups. I do not know if the armed groups are ideologically
    based, if they are ethnically based, if they, you know----
        Mr. Ziemer. Yes, there are over 60 to 70 armed groups with
    different motivations and different intent. They have
    undermined the communities' intents and welfare over the years.
        My father knew a colleague who was killed in 1964, Dr. Paul
    Carlson, not too far from this area. There has been deep-rooted
    issues having to do with insecurity and lack of----
        Ms. Bass. How is the new administration responding? How is
    the new administration in the DRC----
        Mr. Ziemer. You mean the President?
        Ms. Bass. The new President, yes.
        Mr. Ziemer. Based on the feedback we are getting, President
    Tshisekedi represents a bright light. He has visited the area.
    It is something that his predecessor never did. We are hopeful
    that, with that type of political support, with the efforts by
    the partners and the local responders, there might be an
    opportunity to start seeing a change in the receptivity of the
    community.
        Ms. Bass. In terms of the waiver that our administration
    needs to provide, has that happened or are you under the belief
    that we have to hold back aid because of their involvement in
    human trafficking?
        Mr. Ziemer. Yes, the DRC has certainly been impacted by the
    TVPA restrictions, and we need to use all the tools.
        Ms. Bass. Do you get a sense from the Trump administration
    that they are going to give a waiver to allow you to use all
    the tools you have?
        Mr. Ziemer. Chair, we are waiting to hear that. I would
    like to offer, though, that the current investment by USAID in
    this response has been unimpeded. We are using IDA money from
    the 2015 appropriation to invest and respond to this outbreak.
        Ms. Bass. OK. Thank you.
        Mr. Ranking Member.
        Mr. Smith. Thank you very much, Madam Chair.
        If I could, one of the ways that the message got out during
    the crisis of Ebola in Sierra Leone and Liberia was with cell
    phones. And I am wondering, and I know we have an effort--I saw
    it in your testimony, Dr. Redfield--of getting that information
    out to key personnel.
        Is there, generally speaking, an effort to get it to the
    public? Because, apparently, that was one way of getting that
    message out about how to keep yourself from getting
    contaminated or sick.
        Second, what kind of security arrangements are being made
    for health workers? Is the President, for example--not ours; of
    course I am talking about the President of DRC--mustering a
    group of perhaps his best of the best to make sure that that
    situation, the risk to the workers and to the people, of
    course, is mitigated, if you could get to that as well?
        I do have other questions. But you said 130,000 have been
    vaccinated to date. I wonder if you could just enlighten us,
    elaborate on whether the vaccination--how long when somebody
    gets it before protection kicks in? Is there enough vaccine
    available? Has anybody, including healthcare workers, gotten
    the disease after vaccination? How efficacious is it? Is it 100
    percent, 90 percent?
        And then, if you could, speak to the faith community.
    Obviously, there are many. And I have, when I have been there,
    met with a lot of the church leaders. They do wonderful work,
    but I am wondering if they are being fully brought into the
    messaging and the protection strategy.
        You talked about training the trainers in your testimony,
    Dr. Redfield. Maybe you could elaborate a little bit on that as
    well. I think that is an excellent concept. Thank you for doing
    it. But maybe you could tell us a little more what you are
    doing.
        And finally--and I do have other questions--what tools are
    not available in the toolbox that the Trafficking Victims
    Protection Act sanctions are precluding? My sense is--and I
    have spoken to many--so far, I do not know of any, but there
    may be and I am missing it. Again, that is where the waiver
    authority would come in to help meet this crisis head-on. But I
    am just wondering what is not being done that would require an
    act of Congress or, again, a waiver by the President of the
    United States.
        Mr. Ziemer. On the security front, I think it is clear that
    the entire two-province area is insecure. I think what we are
    looking forward to is a positive shift with the appointment of
    David Gressly as the deputy for the U.N. Ebola response. He is
    being moved over from the MONUSCO, where he was the deputy
    responsible for the security forces. And so, his understanding
    of security in that area, as a very experienced African hand,
    will give us significant insight into how better to improve the
    security.
        When I was there, I asked WHO what they needed most. They
    said security. When I asked the community workers what they
    needed most, they said less security. So, somehow we have to
    get in there and understand the dynamics, what the security
    requirements are. It is counterintuitive to move forward in an
    area where there is such variation in demand and how to move
    forward to provide the health care.
        Let me just jump into what tools are in that toolkit to
    offset the TVPA. I would just say at this point it is clear
    that additional funding would complement the current outbreak
    response. It would be complementary. It would build capacity.
    Once we get a final ruling on that, we will see where we stand
    and we will press ahead.
        Dr. Redfield. I think I can start with maybe the vaccine
    questions. Clearly, this is a great addition to our toolbox. It
    is not this outbreak, the vaccines--there are currently both
    unlicensed vaccines. The one that is currently being used is
    the Merck Sharp & Dohme vaccine.
        As you have said, it has been to 130,000 individuals. The
    way it is being administered is, if you identify a case, then
    you find the contacts around that case. And then, you find the
    contacts of the contacts around that case, and you try to
    immunize everybody.
        Operationally, this is not really going as effectively as
    we would like. If you look at cases that present, and then, ask
    the question, were they previously identified as a case, were
    they previously monitored, and were they previously vaccinated,
    currently, it is less than 20 percent. All right. And as I
    mentioned in my testimony, we are not going to get anywhere
    near effective control until we get this over 70 percent.
        Vaccine supply is limited, and there is a need to
    accelerate that supply. Merck Sharp & Dohme is the current
    provider of it, and there is a need to increase that supply.
    There is an opportunity to do what we call split dosing to make
    the supply go further, which is currently being recommended.
    But we do need more vaccine for sure.
        Mr. Smith. Doctor, can you say how much more? I mean, how
    much more vaccine? How much are we lacking?
        Dr. Redfield. Right now, there is about 145,000 doses of
    vaccine. As I mentioned to you, if you realize that we are only
    vaccinating about 20 percent of the people that we want to be
    vaccinating right now, you can see that there is a need
    substantially for more vaccine.
        The other thing I would mention, that the new strategy is
    going to go beyond vaccinating contacts and contacts of
    contacts. We now actually want to vaccinate geographic areas
    where we cannot function because of the insecurity.
    Unfortunately, there is going to be a 6-to-12-month lag before
    there is adequate vaccine supply. So, we do project that we are
    going to run out of vaccine before we get adequate vaccine.
        Mr. Smith. If I could briefly on the vaccine issue, is it
    safe? Are there downsides to it?
        Dr. Redfield. Again, it is a non-licensed vaccine.
        Mr. Smith. How long a shelf life is it?
        Dr. Redfield. Yes. It is a non-licensed vaccine, but it
    should be licensed soon. The shelf life is fairly long,
    particularly in bulk. Clearly, the shelf life, once it is
    vialed, is also very reasonable, multiple years.
        The truth is, not everybody that has been vaccinated,
    though, has been protected. There are breakthroughs. The
    estimated efficacy of the vaccine is, say, over 85 percent,
    but, again, that is not through any controlled clinical trial.
    That is just back-of-the-envelope efficacy. So, we do have
    cases in individuals that have been vaccinated, but I think
    there is significant evidence that this vaccine is impacting
    acquisition substantially.
        And there is a suggestion--again, it is premature; the data
    is ongoing--that if you do get vaccinated and you, then, do get
    infected, that your clinical course may be more ameliorated.
    But, again, this is still, in the absence of controlled data,
    this is just what appears to be the observation.
        Ms. Bass. Thank you.
        Representative Wild.
        Ms. Wild. Thank you, Madam Chairman.
        Good afternoon.
        Dr. Redfield, just following up on what you were just
    testifying about, what is split dosing? You made reference to
    split dosing.
        Dr. Redfield. So, what that means is there is a normal dose
    that is currently administered. Rather than give a full dose,
    they are planning to give half a dose. Now it turns out that
    half a dose has been shown in the application to the FDA to
    give an adequate immune response. So, the FDA has looked at
    that. They do believe that that is going to be efficacious. And
    it is similar to the dose, it is actually even more than the
    dose that was used in West Africa in some of the efficacy
    trials. So, we do think there is substantial evidence that half
    of the dose is going to be effective.
        Ms. Wild. And where is it being manufactured?
        Dr. Redfield. Right now, the initial lot was manufactured
    at West Point in a production plant by Merck Sharp & Dohme.
    That plant was closed, and they have moved the production
    facility to Germany. That production facility currently is
    going through what we call validation lots to make sure that
    they can make the product effectively. And one of the recent
    validation lots did not validate. So, that is another reason.
    So, there are discussions about, our Secretary has had
    discussions about what can be done to try to look at ways that
    Merck might be able to accelerate vaccine availability.
        Ms. Wild. And how close are we to having this vaccine ready
    for license and broad administration, would you say?
        Dr. Redfield. My understanding from the FDA meetings that
    we have listened to their presentation, that we are just
    waiting for the validation of the new plant. In other words,
    the clinical efficacy data, safety data, is there. It is just
    waiting to prove that the plant that is going to make the
    vaccine is validated to make it in a reliable way.
        Ms. Wild. OK. And I want to switch gears with you, Dr.
    Redfield. In your written testimony, you indicate that in the
    last calendar year there were 1,954 reported cases and 1,314
    deaths, which by my calculations is a 67 percent fatality rate.
    And you indicate that the number of cases is continuing to
    increase. I assume that accurate reporting of cases and tracing
    of contacts is essential. Is that fair to say?
        Dr. Redfield. To get control of the epidemic, for sure.
        Ms. Wild. OK. And one missed case or one missed opportunity
    to trace contacts can keep the outbreak going or cause it to
    spread. Fair enough, right?
        Dr. Redfield. Right. Right.
        Ms. Wild. So, my question to you is threefold. How accurate
    do you think those numbers are that are in your written
    testimony? I will ask all the questions, and then, you can
    address it. How accurate do you think those numbers are? Is
    there some kind of uniform infrastructure through which we
    count and track these diagnoses? And are medical examiners or
    coroners reluctant to report the cause of death?
        Dr. Redfield. So, first is we are confident that the
    numbers underrepresent the outbreak. I think, first and
    foremost, I have tried to illustrate this late in the outbreak,
    where you see up to 40 percent of the individuals presenting as
    community deaths, there was no way for us to do contacts,
    contacts of contacts. Those people stayed in the community
    until they died.
        The problem with Ebola is the infectivity goes up and up
    and up and up and up, as you get sick toward death. And
    probably one of the most infectious ways to transmit Ebola, as
    the chair mentioned in her comments, is through burial. And you
    wonder why we are seeing that this late in the game. Well, this
    region never experienced Ebola before. They do not understand
    Ebola.
        How do we see this outbreak? Twenty-five percent of the
    people who got Ebola got it because they were sick and went to
    a hospital with something else, and then, got infected with
    Ebola when they went to the hospital. So, you argue we need
    infection control. In the last 21 days, we had 11 healthcare
    professionals come down with Ebola. So, we still do not have
    effective infectious control.
        This really underscores, as you mentioned, we are not
    anywhere near getting 95 percent of those contacts identified
    and cases isolated. We are lucky to be 30 percent.
        Ms. Wild. OK. I want to move on to one other thing real
    quickly before my time runs out, Admiral Ziemer. In 2015, after
    the Ebola outbreak ended in West Africa, then-President Obama
    created a Special National Security Council Team to oversee
    epidemic preparedness and response on a permanent basis. My
    understanding is you were the official lead in that team until
    the summer of 2018, is that right?
        Mr. Ziemer. Yes.
        Ms. Wild. And does that Global Health Security and
    Biodefense Team even still exist today?
        Mr. Ziemer. Yes, it does. The office has changed at the
    NSC. The initiative is led by the State Department and
    supported by CDC and USAID. So, the mechanism, the strategy,
    and the commitment still exist.
        Ms. Wild. And who leads it now?
        Mr. Ziemer. It is led through the NSC, but the State
    Department is the interagency lead.
        Ms. Wild. Thank you.
        Ms. Bass. Representative Wright.
        Mr. Wright. Thank you, Madam Chair.
        And thank you, gentlemen, for being here.
        As all of us know, Ebola and its potential for an
    international epidemic is very real for my home State of Texas
    and my home county of Tarrant County, which borders Dallas.
        Back in 2014, Thomas Eric Duncan died from Ebola in Dallas
    after traveling there from Liberia. All of you know that story.
    And two of the nurses who provided treatment, Nina Pham and
    Amber Vinson, in Dallas were later diagnosed with Ebola and,
    thank God, survived.
        Earlier in 2014, Dr. Kent Brantly, who completed his
    residency and fellowship in Fort Worth at John Peter Smith, our
    public hospital, contracted Ebola while serving as a medical
    missionary. You know that story as well. I got to visit with
    him in December 2014. He is a remarkable man, remarkable
    doctor.
        So, the point is, we in the Dallas-Fort Worth area know
    probably better than any community that what happens in the
    DRC, what happens overseas, can happen here, and it can happen
    very quickly. When this happened back in 2014, it was like a
    bomb going off in the Dallas-Fort Worth area. My question is,
    what were the biggest lessons learned from that--and I will go
    with Dr. Redfield first--that are benefiting us now?
        Dr. Redfield. Congressman, I think probably the most
    important lesson that we are operationalizing now is to really
    prepare particularly the bordering countries. We have been very
    fortunate, if there is any ``fortunate'' in this outbreak, in
    that it is a very remote area without significant air travel,
    without significant roads. This is why, as was discussed
    already by the chair, if or when this outbreak extends to Goma,
    which is the place of an airport, this could offer greater
    challenge.
        Currently, we have really prepared South Sudan, Uganda, and
    Rwanda, and the Goma area, to be able to recognize these cases
    quickly, like we saw in Nigeria in the 2014 outbreak, and, if
    you will, shut them down, so there is not a lot of secondary
    transmission.
        So, this border screening is really important. I think many
    people will be shocked when I say this. In this outbreak to
    date, we have screened over 58 million people. And you say to
    yourself, wait a minute, how did we screen 58 million people
    and we do not have cross-border or cross-region transmission
    yet? You know, you can think about that. I think it is really
    remarkable, to say the least.
        But I do think that really recognizing how important
    preparedness is and border screening is at the source--this one
    comes back to my testimony for America. The best thing we can
    do is stop these epidemics at their source and to really focus
    on doing that. So, I think that is the lesson I know we have
    all taken home. Preparedness is just not something to do
    casually. It is something to do very seriously.
        Mr. Wright. All right. And, Admiral, I had a followup for
    you. A while ago, you mentioned how people there feel
    exploited. Can you elaborate on that, exactly what that means,
    that they feel exploited by the Ebola economy, if you will?
        Mr. Ziemer. Congressman, I want to quote one of the
    community leaders that I interviewed. He said, ``for years, we
    have been abandoned by our government. We have not been cared
    for. We have seen people die of malaria, cholera. Thousands of
    people have been killed, and we have been left on our own. And
    now, Ebola happens and you show up.''
        That point of communication spoke volumes to me. Ebola to
    them was more important to us than it was to them. We are there
    to contain it, to keep it from spreading, and we are rolling in
    with sophisticated interventions, committed people, and a
    significant amount of funding. They feel as though they have
    not benefited and that they are going to be abandoned as soon
    as the Ebola outbreak is contained. That is the message that we
    have got to listen to and move and try to encapsulate as we
    look at this very unstable area that borders some fairly
    significant countries.
        Mr. Wright. Right. Thank you very much.
        I yield back.
        Ms. Wild [presiding]. Representative Houlahan.
        Ms. Houlahan. Thank you, Madam Chair.
        Thank you very much for coming today.
        I have a bit of a preamble before my question, so maybe a
    minute or so.
        Women and girls are the two groups that are
    disproportionately affected by this outbreak. Women and women's
    groups also have the capacity to advance response activities
    through socialization and education in their communities. Yet,
    little outreach seems to be being done to this critical group.
        According to a rapid assessment by the International Rescue
    Committee from March 2019, which is responding directly to this
    outbreak, preexisting gender norms expose women and girls to
    specific and increased risks during disease outbreaks. And
    during the current outbreak of Ebola in North Kivu in the DRC,
    health actors have seen a similar pattern to that that they saw
    in West Africa in 2014, with infection rates for women and
    girls fluctuating between 57 and 62 percent.
        In addition, the IRC found that women and girls carry
    primary responsibility for caring for the sick and for managing
    household prevention. And this means that women and girls, and
    particularly adolescent girls, must increase the number of
    times they travel long distances by foot each day to fetch
    water. And this results in elevated risks of sexual violence
    and harassment.
        So, here are my questions: Admiral Ziemer, what is being
    done to ensure that women and girls have access to services,
    both health, but also sexual and gender-based violence-related
    during this outbreak, if you can comment on that?
        Mr. Ziemer. Thanks for the question. I can say clearly that
    the interventions and the treatment are focused for all. There
    clearly is a significant increase in children and women, and
    that is being noted and factored into our interventions.
        Ms. Houlahan. And so, is there any sort of coordinated
    activity that specifically relates to the sexual violence of
    women and girls as it relates to exposure to the Ebola or as it
    relates to treating Ebola in that particular population? Is
    there any coordinated effort on that, that you are aware of,
    and should there be?
        Mr. Ziemer. Yes, there should be. I know our partners are
    looking at that specifically, and I will get back to you with
    specifics on that.
        Ms. Houlahan. That would be wonderful.
        And my next question is for either of you gentlemen. What
    lessons did you each or your organizations learn from the West
    Africa outbreak and how have they been applied to the DRC
    outbreak? And maybe specific to women and girls, if you are
    able to dive deeper into that.
        Mr. Ziemer. I will say the lessons learned from West Africa
    are significant. The ability to take all of those lessons and
    apply them has been interrupted by the community resistance and
    the security reality. OK? So, unfortunately, there is not a
    direct benefit from that, although we have learned a lot.
        The other significant tool that has been brought in is the
    vaccine. The situation would look a lot worse if it had not
    been for the vaccine that Dr. Redfield has just summarized.
        In terms of the programs' lessons learned, and dealing with
    women and girls in West Africa, and the transfer into the
    current two provinces, again, I will get back to you.
        Ms. Houlahan. Thank you. I would really appreciate that.
        And are there any efforts being made right now to codify or
    to think about lessons learned as we learn them now in the
    field, to be able to apply them in the future? Are we in the
    process of sort of having weekly conversations about what we
    have learned in this particular instance, so that we can use
    them in the future?
        Mr. Ziemer. Yes. I can commit to you that we will make sure
    that that is ongoing.
        Ms. Houlahan. And finally, what kind of cultural barriers
    to educating the impacted communities have you encountered, and
    how are you experiencing the opportunity to apply best
    practices to the Congolese people? I know that you have spoken
    a lot about the resistance, and I completely can empathize and
    understand the situation. But have we found anything that is
    working to be able to convey to particularly women and girls,
    who are the caregivers and who are largely exposed to this,
    what lessons could be used to be able to make them safer?
        Mr. Ziemer. Yes, one of our primary partners is UNICEF. And
    I know they focus on that as a priority. We will followup on
    that, too, just to give you specifics on how UNICEF and our
    other partners are continuing to applying lessons learned so
    that we improve upon that particular issue.
        Ms. Houlahan. I really appreciate your efforts on this.
    This is something that literally keeps me up at night. Biology
    and the concerns that come out of Africa and Asia are something
    that are very, very concerning, I think, and should be for all
    of us. So, thank you very much for your care.
        I yield back.
        Ms. Wild. Mr. Burchett.
        Mr. Burchett. Thank you, Madam. Was I being called down for
    talking or was I being called on to speak?
        [Laughter.]
        Ms. Wild. Either.
        Mr. Burchett. All right. I will go speak then. How about
    that?
        Thank you all for being here.
        How does the armed conflict that is currently ongoing in
    the center of the outbreak affect the chance of the disease
    spreading across the border? And are those that are involved in
    this conflict, do they understand about and are they concerned
    with the spread of the disease? Because a lot of times it seems
    like education is the key and there always seems to be a
    disconnect.
        Mr. Ziemer. Yes, well, my immediate response is the armed
    conflict is characterized by armed resistance with armed
    individuals: the neighborhood gangs, basically the Mai-Mai
    which are thugs on hire. Then, we have community resistance
    that manifests itself in insecurity. All of this together is
    undermining our ability to do good health work.
        What are we doing about it? I think we are continuing to
    talk to the community, get the community involved in
    determining what their perspective is, and their
    recommendations. But, clearly, the security environment has
    been unstable. It continues to destabilize the approach, and it
    is one of the priorities that we are looking at.
        Mr. Burchett. Doctor?
        Dr. Redfield. The comment I wanted to make, I have a slide
    I would like to just show you about what the impact of the
    armed conflict is, if she puts up the second slide. If you look
    at this second half of the slide, that red line, that is the
    current outbreak. All the lines you see before that, those are
    all the other outbreaks besides West Africa.
        The insecurity has caused a lack of our ability to bring
    this outbreak to an end. You can see that most of these
    outbreaks are over in 4 months. All right. This outbreak now,
    if you go back to the time of initial symptoms, is really
    actually now over a year old, even though it was recognized in
    August, some of this.
        And so, I want to emphasize, the magnitude of this outbreak
    is getting to the point that one has to anticipate that we are
    going to see spread outside of the outbreak area. And that is a
    direct result of the conflict blocking the ability for the
    public health response to take place.
        Mr. Burchett. That is truly scary. This is not in my notes,
    but after seeing that, will it get to a point where it will
    just, because the host, I guess the folks that carry it would
    die, will it then decrease or will it just keep spreading?
        Dr. Redfield. The problem is that, in the absence of
    effective public health response, you get a case. And then,
    that case leads to multiple other cases. And you can see the
    curve is changing. It is no longer linear. It is starting to
    get an arch to it.
        Mr. Burchett. Yes.
        Dr. Redfield. Whereas, you see all those other cases, the
    curve plateaus, and then, the outbreak stops. Right? This is a
    direct result of not having the ability to operationalize what
    we know how to do; that is, a public health response that we
    have outlined in our testimony. And it is blocked because of
    the insecurity in the area.
        Mr. Ziemer. I would like to followup with one comment. That
    is the reality and it is very sobering. All the more reason
    that our prevention initiatives in South Sudan, Burundi,
    Uganda, and Rwanda are scaled up. As Dr. Redfield said,
    infection prevention, border security, and airport security are
    very, very important. The fact that we are focusing and scaling
    up prevention in Goma, which is 120 miles south of this
    outbreak, is a critical part of the strategy. To keep it from
    leaping the border and to keep it from going into Goma is part
    of this strategy while the health responders are working day-in
    and day-out to continue to address what is happening in Butembo
    and Katwa, and some of the other areas.
        Mr. Burchett. This next question might have already been
    answered, but I would like a little clarification. The
    administration, how is their calibrating our response efforts
    in Fiscal Year 2020 request, given the continued spread of the
    outbreak?
        Mr. Ziemer. Congressman, I would say that that is being
    factored into the requests. We have just met recently with OMB.
    They know the requirements. I will keep you updated on how that
    goes.
        Mr. Burchett. Thank you, Admiral.
        I yield back the rest of my time, Chairlady. Thank you.
        Ms. Wild. Mr. Phillips.
        Mr. Phillips. Thank you, Madam Chair.
        My district, Minnesota's 3d District, is home to one of the
    largest Liberian communities in the country, as you might know.
    And in 2014-2015, of course, Ebola hit their country. And one
    of my extraordinary staffers in Minnesota, Decontee Sawyer, is
    a Liberian and her husband Patrick is one of the very first
    Americans to actually die of Ebola. So, I dedicate my questions
    today in his memory.
        And it is sometimes difficult to connect foreign affairs,
    of course, to dinner tables in America, but there is no
    question that, if we do not help African nations stem the tide
    of Ebola, it surely will appear on our doorstep. So, I am
    grateful to both of you for the extraordinary work you do.
        I believe Chairwoman Bass asked some similar questions
    earlier. But my first question is about the distrust of the
    international workers in the DRC. Some, of course, in the DRC
    believe that the Ebola outbreak was deliberately created and
    won't go to health facilities to seek care when they show
    symptoms. So, what specifically, very specifically relative to
    community engagement/education, is being done to educate and
    try to overcome that challenge?
        Mr. Ziemer. As we look at this reset that we are supporting
    as part of the U.S. Government whole-of-government response,
    the focus on the community is specifically being targeted. In
    addition to engaging more effectively with the communities
    themselves, certain projects are being identified. Some have to
    do with increasing opportunities for them to earn small
    projects in the community, be it infrastructure, be it wealth,
    just to see if we can benefit, and benefit them with small-
    scale infrastructure projects that will benefit the individuals
    as well as the community. That is step one.
        As we look at other opportunities to engage, it is going to
    be a challenge first of all, to understand, but then to build
    credibility so that the community itself can begin to own and
    collaborate with the health responders.
        Mr. Phillips. And if I can ask very specifically about it,
    so who are the gatekeepers in these communities and how is
    information conveyed? I mean, here it would be through social
    media. Is it through families and face-to-face? Is it through
    advertising? Is it through places of gathering? How do we try
    to communicate and overcome the disinformation?
        Mr. Ziemer. Yes, Congressman, it is all of the above:
    media, direct contact, face-to-face meetings. UNICEF is
    involved. CDC is involved with some of their community
    programs. Our partners are involved. That information is being
    collated and applied to improving community relations and
    building trust.
        Mr. Phillips. OK. Doctor, anything? Anything you wish to
    add?
        Dr. Redfield. I think the complexity, Congressman, is that
    this is an area where distrust is really deep. When we went
    there, we thought, well, maybe we could meet with the leaders.
        Mr. Phillips. Right.
        Dr. Redfield. Well, what leaders?
        Mr. Phillips. Exactly.
        Dr. Redfield. There is actually well over 100 different
    small rebel groups. It is one thing to deal with the ADF. You
    can find their leader and you can talk to them. But this Mai-
    Mai is just a bunch of small groups with small leaders, and
    disinformation going back and forth. So, you get one group to
    have the right message, but, then, the other groups do not
    agree with the message because they do not trust that group.
    So, it is going to be a long haul to get trust in that area. We
    reached out to the religious community to do it, the bishop,
    and, again, they had a priest that was killed. And now, the
    bishops are being intimidated. So, this is a very, very
    complicated environment right now.
        How to really build trust in that community that has been
    at war for 25 years is going to be very complicated, and it is
    going to take a long time. That is one of the reasons we are
    concerned. This reset is critical. We have got to get the
    community involved. We have got to figure out something on the
    security side. Both of those are not easy answers, how we are
    going to get either of them done.
        Mr. Phillips. And just a quick final question. Is the
    government in the DRC part of the problem or part of the
    solution?
        Dr. Redfield. Well, I cannot comment, and I will go to the
    admiral to comment. Now, historically, this is an area that
    does not trust their own government. Now whether it is
    different with the new President, time will tell. But,
    historically, they did not trust their own government.
        Mr. Phillips. Right.
        Admiral?
        Mr. Ziemer. I will just concur with what Dr. Redfield said.
    This community feels abandoned and has been abandoned, and it
    is going to take a long time for them to trust the government.
    The good news is that we have a different government. It is in
    transition. It remains to be seen, once the cabinet is
    appointed, how they will appropriately respond.
        Mr. Phillips. If I could just add, would you argue they
    might trust something from us, you know, with the American
    brand on it, as a source of information, more than their own
    government right now, relative to overcoming this?
        Mr. Ziemer. It is pretty hard to speculate who they might
    trust. I would say they would trust their local representatives
    more than anybody else.
        Mr. Phillips. OK.
        Mr. Ziemer. I think I did mention earlier that President
    Tshisekedi did take a trip out. This is the first time the
    President had been in that area for years.
        Mr. Phillips. Yes.
        Mr. Ziemer. That is a step.
        Mr. Phillips. Good. All right.
        Thank you. I yield back.
        Ms. Wild. In just a moment, I am going to yield additional
    time to Mr. Smith. But, before I do, I just want to ask a quick
    followup question to Dr. Redfield. It is my understanding that
    the World Health Organization has twice decided against
    declaring this outbreak as an international public health
    emergency, as it did for the Ebola epidemic in Liberia. First
    of all, is that correct?
        Dr. Redfield. Yes, Congresswoman.
        Ms. Wild. And if the World Health Organization did declare
    this an international emergency, would it help to increase the
    production of vaccine or other measures that could be taken
    that would help to get this under control?
        Dr. Redfield. I think the WHO has made it clear--we were
    just at the World Health Assembly, and they made direct
    requests that we need to stimulate more vaccine production. The
    decision to do an international significance is really a WHO
    decision, a committee decision. Historically, they have stayed
    the pretty strong guidelines that they do that when there is
    cross-border transmission.
        I will say that nothing about their decision to declare it
    or not declare it is impacting the United States' ability to
    respond. And it really, basically, is a consequence of their
    arbitrary guidelines that the committee has about calling it.
        Ms. Wild. OK. Thank you.
        With that, I yield additional time to Mr. Smith.
        Mr. Smith. Thank you very much, Madam Chair.
        Admiral Ziemer, this is DRC's 10th outbreak of Ebola. Is
    there any evidence that anywhere else in DR Congo this hideous
    disease is manifesting?
        Let me also ask you, in your testimony you talk about
    training some 1,680 community health workers to conduct
    surveillance, equipping them with knowledge and tools to gather
    information to track the disease. And then, you go on to say
    that we have trained nearly 3,000 healthcare workers in patient
    screening, isolation, appropriate waste management, and other
    practices to prevent disease transmission as well as enhancing
    triage and isolation infrastructure.
        First of all, let me just say how grateful members of this
    committee are--I am certainly--for that Herculean response. It
    is amazing. I mean, we are taking the lead, as we do so often,
    as we have in the past. So, thank you for stepping up and doing
    it so robustly. That is a lot of training, and maybe you could
    explain a little bit what that training entails. But I want to
    thank you for that, first and foremost, and you might want to
    speak a little bit further.
        And, Dr. Redfield, you talk about CDC has designed a train-
    the-trainers course for front-line response workers on contact
    tracing methods; and, also, you have created an Ebola exposure
    window calculator smartphone app for case investigators. If you
    could provide us with some details on that? Again, we are
    talking about innovations, lessons learned, you know, the title
    of your testimony. CDC I think is really responding very
    aggressively and very effectively as well.
        So, I think the good news story for every American, they
    know their taxpayers' dollars are being very aggressively
    deployed in a way that is most likely to mitigate this terrible
    outbreak. And as you said, Dr. Redfield, this complicating
    factor of insecurity has so exacerbated what could have been
    maybe even stopped months ago.
        So, I think we would thank you, you know, a great big thank
    you for that work.
        And if you could delve into some of those answers?
        I did ask earlier about the use of cell phones. Maybe you
    wanted to speak to that, because we know in Liberia and Sierra
    Leona that cell phone messages were everywhere about what to
    do, and that really helped get the message out, which helped to
    contain the contagion.
        Mr. Ziemer. I am going to start with your last question on
    the cell phones. I know the cell phone technology in use is
    being brought into many, many different development and health
    programs. How it is specifically being applied here in these
    provinces, I will have to get back to you on that.
        Mr. Smith. All right.
        Mr. Ziemer. On the training, thanks. USAID and the U.S.
    Government recognize the need for training at all levels, basic
    education and health training. When we look at the global
    health security agenda, we look at capacity-building and health
    systems strengthening. It is all about the investment in
    training the healthcare workers. So, thanks for that
    recognition.
        Mr. Smith. Thank you.
        Dr. Redfield. A couple of comments to talk about what you
    brought out. I am trying to read my note for the first one. I
    cannot read my own writing. That is not so good.
        Ms. Wild. It is because you are a physician.
        Dr. Redfield. But I am a doctor, OK? Yes, so I have some
    pass.
        [Laughter.]
        But I will start with the idea of communication. The
    challenge we have is not that people do not know that there is
    an Ebola outbreak. But I am telling you, people who get sick
    with Ebola, a lot of them are deciding to stay home and hide. I
    told you, 40 percent die. So, it is not just them that are
    hiding; it is their family members that are hiding. So, this
    distrust issue is beyond knowledge. It is really pretty
    something when you know you are sick, you likely have Ebola,
    you know your wife has Ebola, and you know there is a health
    facility there. You maybe trust it or not. And as I tell you,
    you basically stay home until you die. That is a big problem.
        So, I think that is important. That is why I said it is
    going to take a long time. We are hopeful that we are going to
    get the word out because there is now four experimental
    therapeutics that NIH is doing in the clinical trial there of
    promising therapeutics, that Ebola is not the same death
    sentence as it was in the West Africa outbreak. But how can we
    start to get that information out to the community? It is
    actually an advantage for you to come forward and get treated,
    both in our ability to hydrate you properly, because we have
    learned how to do this better, and now that there is an
    opportunity to get some very new, promising, experimental
    therapeutics. So, that is really a key issue to do.
        I will say, on training, our Field Epidemiology Training
    Program, which we have now over in seven countries, 70
    countries, as I said, in the DRC it is our lifeline. We have
    got almost 200 individuals that have gone through what we call
    a 2-year epidemic investigator program, like we have in the
    United States.
        When the western outbreak happened in the early spring,
    when I first became CDC Director, we were able to mobilize
    about 40 to 50 of those people, along with CDC, and that
    outbreak shut down in less than 60 days.
        Now you have got the eastern outbreak. We were able to
    mobilize a lot of those individuals, but without the technical
    stewardship of the leadership of CDC to provide some ability to
    make sure what we said needed to be practiced is actually being
    practiced and reinforce it in the field, as driven by the
    insecurity.
        We have started a Center of Excellence with the Minister of
    Health in Goma for Ebola. So, we are trying to really enhance
    and accelerate training the trainers, so that if we cannot be
    in the field, at least we can be training the people that can
    go in the field, and make sure we are increasing their skill
    sets more and more, and more and more. And that is currently
    ongoing in Goma. We will continue.
        But I will say, our overall concept here is we are not
    planning a 3-month strategy or a 6-month strategy. We need to
    dig in and realize that this is going to be a 12-, 18-, 24-
    month strategy, and make the investment in those 12-, 24-month
    interventions, like building the center to train people how to
    really do better at Ebola in the North Kivu Province, like we
    are doing in Goma.
        Mr. Smith. Can I just ask you one final question? The 43
    travelers that you mentioned per day that come to the United
    States from the DR Congo, and largely not from the affected
    areas, as you indicate, how much of a risk is that, and not
    just to us, but also to the African countries due to travel?
    How well-screened are they before they hop on an airplane or
    use some other mode of transportation?
        Dr. Redfield. Right now, for the Congo, we do what we call
    Level 2 screening. We have our ports of entries alerted. As you
    mentioned, these individuals are not from areas where there is
    active transmission at this point. That said, we are still
    alerted to be able to start looking at travelers that are
    coming from the DRC.
        As you mentioned, of the hundreds of thousands of
    travelers, we are very fortunate that not too many are coming
    from the Congo. I can tell you, from the North Kivu region, it
    is probably almost reportable, you know, in terms of having
    travelers from there. It is just not in an area that has--
    travel is not part of their culture.
        But I think if we do get into Goma, that is going to
    change. If we do get into some other parts of the DRC,
    Kinshasa, that is going to change.
        Mr. Smith. Again, thank you for your leadership. Thank you
    for the risks you take when you go there, and all the personnel
    that are deployed there from the United States, and other
    places. But, for those who do it, we all are very, very
    grateful.
        I yield back.
        Ms. Wild. Ms. Houlahan, I understand you have additional
    questions.
        Ms. Houlahan. I do, and thank you, Madam Chair.
        I just have had the opportunity on a different committee
    that I serve on to be doing a little bit more of a deep dive on
    the Mueller report on election interference; also, on a task
    force that I am participating on. And as a result of that
    deeper dive, I have had the opportunity to understand just how
    involved Russia was in the disinformation/misinformation with
    the AIDS outbreak in South Africa in the eighties, and
    deliberately sort of pointing the finger at the U.S. and our
    involvement, or lack thereof, in that particular outbreak.
        And so, I guess my question to you is, as Russia and China
    are clearly rising on the continent of Africa and their
    influence is clearly rising again in that particular area, have
    you any concern? Have you seen anything that would indicate
    that there is any sort of campaign of disinformation against
    the United States specific about the rise of Ebola? Is that
    something that concerns you?
        Mr. Ziemer. Thanks for the question.
        At this point, we have not seen any indication that there
    is any direct strategy or intent to undermine the issue. So,
    that has not been an issue for trying to get the Ebola outbreak
    under control.
        Ms. Houlahan. Are you concerned at all about that, given
    the rise of Russia's strength? I think in the eighties they
    were significantly weakened, and that was a pretty weak attempt
    at disinformation. But do you have any concern that at this
    point in time it may become more strong?
        Mr. Ziemer. I think the awareness is very high. I think the
    concern is there. There are a number of agencies looking at
    that. The positioning, and the influence of China are
    priorities. To any extent that it might be involving or
    undermining our ability to respond better to this outbreak, we
    will get back to you on that.
        Ms. Houlahan. Thank you.
        Mr. Ziemer. But I do not sense it.
        Ms. Houlahan. Thank you. I appreciate it.
        I yield back.
        Ms. Wild. Mr. Phillips.
        Mr. Phillips. Thank you, Madam Chair.
        Doctor, on a scale from 1 to 10, how well-prepared is the
    United States, God forbid, if we faced an Ebola outbreak or,
    for that matter, any other contagion on a national basis?
        Dr. Redfield. The domestic footprint for dealing with
    cross-border cases that would come into the United States is
    one of the great benefits of the 2014. It is that we really
    have established a system. Multiple hospitals now across the
    country have been firmly prepared ahead of time how to do this
    in an effective way, so we do not repeat some of the situations
    that happened in 2014.
        I think, as I said in my testimony, at present the risk to
    our Nation directly is extremely low, just because of where
    this is. That may change if we get outbreaks, if it spreads
    into Goma or into Kinshasa or into Kampala, or something like
    that, if this sort of dwells on.
        But we do have a very effective screening program now that
    we have developed, in a sense as a consequence of that 2014
    experience. So, I do think we are very prepared here. This is
    why I come back and say--and I will say to you in general for
    our health security--the best thing this Nation can do to
    protect its self-security is detect, respond, and prevent these
    outbreaks where they start.
        Mr. Ziemer. Agree.
        Mr. Phillips. Is there anything that you would like to see
    us either provide resources for or improve strategically in the
    country?
        Dr. Redfield. Well, I think that, as we do these emergency
    responses from CDC's perspective, unlike, say, my colleagues at
    USAID, there are some things that would enable us to be more
    efficient, more effective, more timely, you know, particularly
    the ability to have direct hiring authority for these
    emergencies. USAID has that. We do not have that.
        Mr. Phillips. OK.
        Dr. Redfield. The same thing in terms of our ability to
    procure different items that we need to procure, so that we
    could have what we call our transactional authority, so that we
    can actually procure what we need when we need it.
        Mr. Phillips. OK.
        Dr. Redfield. Those two things would be very helpful to
    CDC.
        Mr. Phillips. For supplies and----
        Dr. Redfield. Yes, for supplies, and not go out to a
    million different people to try to get competitive bidding,
    when we need an emergency response. This would allow us to be
    much more effective, much more efficient in these responses.
    And it is something, as CDC Director, we would like to see that
    we have that ability for these emergency responses.
        Mr. Phillips. OK. Thank you.
        Dr. Redfield. Yes.
        Mr. Phillips. I yield back.
        Ms. Wild. The last area, I guess I get the last word.
    Actually, you get the last word on this. I am still highly
    concerned--and I think we all are--about the potential for
    travel to the United States. And I understand we are fortunate
    that at this point we have a low rate of travelers from the
    DRC, and that they are screened before they come here. But my
    understanding from, I think it was your written testimony, is
    that the incubation period can be as long as 21 days. So,
    presumably, somebody could be screened and not be showing any
    symptoms, is that right?
        Dr. Redfield. They could be screened and not show symptoms
    at the time they are screened. But if they were from a high-
    risk area, then they would be put into a system to self-monitor
    for the development of a fever, similar to what we did in the
    2014 outbreak----
        Ms. Wild. OK.
        Dr. Redfield [continuing]. Where the health departments
    will bring them into a system, let them self-monitor. If they
    do develop a symptom/fever, then, basically, they would get
    laboratory diagnosis, and then, be handled appropriately.
        Ms. Wild. But that is dependent on accurate reporting, this
    self-monitoring system?
        Dr. Redfield. Yes, I think the advantage we have, some of
    it is self-monitoring. The initial advantage is we do have the
    point of exit. So, we know individuals that are coming from the
    exit. It is not like, for example, if we were dealing with
    Middle East respiratory syndrome, where the real introduction
    might be someone shared a smoking lounge in London, but we
    would not have any understanding of that.
        Here at least we know the areas that are at risk for their
    active transmission. Those individuals would be identified and
    screened as they came into this country. And then, they would
    be set up with the health department. Depending on different
    health departments would do it different ways, but most of the
    individuals do self-temperature assessment. They call them.
    They do have a temperature, yes/no, and followup there. I mean,
    it worked pretty effectively in the 2014 outbreak once it got
    operationalized.
        Ms. Wild. Having said all of that, the need for containment
    is very much recognized by all of us here today.
        I would like to thank both of you for your time on this
    very important subject, and also, to everyone who attended this
    hearing, as well as the members who attended and asked very
    good questions.
        With that, this meeting is adjourned. Thank you.
        [Whereupon, at 4:02 p.m., the subcommittee was adjourned.]

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