[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://
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                                __________
               
               
                    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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