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

                             THE WUHAN CORONAVIRUS:
                            ASSESSING THE OUTBREAK,
                           THE RESPONSE, AND REGIONAL
                                  IMPLICATIONS

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

                                    HEARING

                                   BEFORE THE

             SUBCOMMITTEE ON ASIA, THE PACIFIC AND NONPROLIFERATION

                                     OF THE

                          COMMITTEE ON FOREIGN AFFAIRS
                            HOUSE OF REPRESENTATIVES

                         ONE HUNDRED SIXTEENTH CONGRESS

                                 SECOND SESSION

                                   __________

                                FEBRUARY 5, 2020

                                   __________

                               Serial No. 116-100

                                   __________

            Printed for the use of the Committee on Foreign Affairs

     [GRAPHIC(S) 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
    39-674PDF           WASHINGTON : 2022

                          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 PHILLIPS, 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 Asia, the Pacific and Nonproliferation

                      BRAD SHERMAN, California, Chairman,

    DINA TITUS, Nevada                   TED YOHO, Florida, Ranking Member
    CHRISSY HOULAHAN, Pennsylvania       SCOTT PERRY, Pennsylvania
    GERALD CONNOLLY, Virginia            ANN WAGNER, Missouri
    AMI BERA, California                 BRIAN MAST, Florida
    ANDY LEVIN. Michigan                 JOHN CURTIS, Utah
    ABIGAIL SPANBERGER, Virginia

                         Don MacDonald, Staff Director

                                C O N T E N T S

                                  ----------
                                                                       Page

                                   WITNESSES

    Nuzzo, Dr. Jennifer, Associate Professor and Senior Scholar,
      Center For Health Security, Johns Hopkins University...........     8
    Bouey, Dr. Jennifer, Senior Policy Researcher and Tang Chair in
      China Policy Studies, Rand Corporation.........................    21
    Klain, Mr. Ron, Former White House Ebola Response Coordinator,
      2014-2015......................................................    39

                                    APPENDIX

    Hearing Notice...................................................    76
    Hearing Minutes..................................................    77
    Hearing Attendance...............................................    78

                      OPENING STATEMENT FROM CHAIRMAN BERA

    Opening statement from Chairman Bera.............................    79

       THE WUHAN CORONAVIRUS: ASSESSING THE OUTBREAK, THE RESPONSE, AND
                             REGIONAL IMPLICATIONS

                          Wednesday, February 5, 2020

                            House of Representatives

                     Subcommittee on Asia, the Pacific and

                                Nonproliferation

                          Committee on Foreign Affairs

                                         Washington, DC

        The subcommittee met, pursuant to notice, at 2:02 p.m., in
    room 2172 Rayburn House Office Building, Hon. Ami Bera
    (chairman of the subcommittee) presiding.
        Mr. Bera. The subcommittee will come to order.
        We meet today for Congress' first hearing on the 2019 novel
    coronavirus. Without objection, all members will have 5 days to
    submit statements, questions, extraneous materials for the
    record, subject to the length limitations in the rules.
        I will now make my opening statement and then turn it over
    to the ranking member for his opening statement.
        First-off, I want to thank the witnesses for joining us
    today. This is the first hearing on coronavirus, and for many
    Americans as well as Members of Congress, this is on our mind
    right now. Before kind of diving into things, I do want to make
    note that we did ask the Administration to come up and brief
    us. And, unfortunately, they did not send folks.
        This is not a partisan issue, this is an issue of how we
    work together as Democrats and Republicans, Congress along with
    the Administration, to get ahead of a public health emergency.
        I would note that they did give Members of Congress a
    bipartisan unclassified hearing earlier today with Acting Chief
    of Staff Mick Mulvaney, Secretary of HHS Alex Azar, Deputy
    Secretary of State Steve Biegun, Acting Deputy Secretary of
    Homeland Security Ken Cucinelli, the Director of the CDC Robert
    Redfield, the Director of National Institutes of Allergy and
    Infectious Disease Dr. Tony Fauci, and Assistant Secretary for
    Preparedness and Response, Dr. Robert Kadlec.
        That was not televised. That was not open to the public but
    it was unclassified. And I would make the request of the
    Administration to provide their opening statements to this
    committee so we can add that to the public record because we do
    believe the public's concerns here. The more the Administration
    can speak directly to the public and answer those questions,
    the better off we would all be.
        Again, the Administration has an open door to come before
    this committee or the full committee to show what they are
    learning in the rapidly fluid situation. We look to work with
    the Administration to support the response.
        You know, I look at this as a physician and someone who has
    worked in public health, was Chief Medical Officer for
    Sacramento County, and who has worked overseas internationally.
    This is quite concerning right now. We have many questions.
    When I think about the three objectives of this hearing, but
    also of how we respond as a nation but also a globe, how is the
    U.S. Government coordinating the response both domestically and
    internationally?
        Do we have the right tools and resources in place to help
    get ahead of this outbreak?
        And what I mean by that is if we think about one of the
    most urgent things we could do, CDC has the best
    epidemiologists in the world. We have some of the best
    personnel. I know we have been getting conflicting reports. We
    have had some folks in country that now would be a time for us
    to collaborate with the Chinese to get our best epidemiologists
    to the epicenter so we could actually answer some of the health
    questions that are there.
        How easily is this transmitted human to human?
        How are people infectious when they are asymptomatic?
        Are people infectious when they do not exhibit symptoms, or
    is it only when they are symptomatic?
        We have had conflicting reports of what the incubation
    period is. At times we are told it is up to 14 days. Then we
    were told it was 5 to 7 days. Then we were told it is 3 to 5
    days. All of these are incredibly important questions for our
    staff. So, we cannot just help the Chinese as well as the rest
    of the world internationally, but we can also plan our response
    here.
        A second important point that we learned post-Ebola and
    post-other pandemics is the importance of having an individual
    or small group of individuals who can coordinate across the
    interagency process. To date we do not have that single
    individual that has sole responsibility of that coordination.
        We have Secretary Azar, extremely capable individual, but
    he runs Health and Human Services. If this broadens here
    locally, Health and Human Services are going to have their
    hands full responding and supporting our public health efforts
    here.
        We have a great CDC director, but they have a specific
    role.
        The DoD can do logistics, and they have a specific role.
        Homeland Security, you know, has a specific role.
        One of the recommendations was at the national security
    level we really do need to have a single individual who can
    coordinate the whole interagency process. Mr. Klain, I know you
    were instrumental in that role, and certainly look forward to
    hearing your thoughts about why that is such an important role.
        No. 3, in the era that we live in the misinformation that
    is out there is going to be really important as the public, you
    know, should this spread in the United States. What is the
    right information that should get out to the public? And how do
    we combat disinformation? That is a very difficult scenario,
    but it is incredibly important, not just here but also, you
    know, internationally.
        I look forward to hearing from the witnesses on their
    thoughts and ideas.
        Out of an abundance of caution, we did see the
    Administration institute a travel ban and increase screening of
    folks that are returning from China and the region.
        You know, there are discussions taking place backward and
    forwards as to whether that actually will help us get a handle
    on this or if the travel ban will actually potentially make
    things worse. And, again, I would be curious for the
    perspective of some of the witnesses on how that is being
    implemented and the impact of that.
        Lastly, part of the reason why I really did want the
    Administration here is we do not see this as an adversarial
    role. A lot of things in Washington, DC. are partisan. This is
    not partisan. We, as Congress, understand how rapidly this is
    moving. We also understand that we want to make sure the
    Administration has all the tools and resources that they need.
        Right now, we are guessing at what they might need in the
    emergency supplemental. I would invite the Administration to
    work with us. Tell us what you need and then we will work to
    try to get that available to you as quickly as possible. We are
    on the same team here. This, you know, novel coronavirus does
    not see Republicans or Democrats, it sees human beings. And
    let's get ahead of this. Let's learn from this.
        And then let's also plan so we are not constantly
    responding to the latest outbreak but we are actually thinking
    about how to prevent the next pandemic.
        Those are a few things that I have on my mind. And, again,
    I want to thank the witnesses for being here. And we really do
    have great personnel at CDC, HHS, State Department. And they
    are working overtime. And, again, I commend those men and women
    that are spending quite a bit of time working on this just to
    keep us safe. We look forward to working with them.
        This is an open door if they ever want to come to this
    subcommittee. And I think any of the members here, we are here
    to help support the Administration.
        With that, let me turn it over to the ranking member for
    his opening statement.
        Mr. Yoho. Well, thank you, Mr. Chairman, and good morning.
    I would like to thank Chairman Bera for holding this hearing on
    global spread of novel coronavirus from China.
        And I want to comment on what you said, the hysteria and
    misinformation. We saw that when Zika happened. And it was--it
    turned into a political fight, it was politicized. And we do
    not want to do this. And I commend everybody that is working on
    this to this point; it hasn't happened. And I hope we go
    forward.
        And then you have an M.D. and a veterinarian, and so we are
    both used to having quarantines and dealing with outbreaks.
        I would like to welcome Dr. Jennifer Nuzzo from the Johns
    Hopkins University, Dr. Jennifer Bouey from RAND, and Mr. Ron
    Klain. I look forward to hearing from each of you about recent
    developments and paths forward to coronavirus and related
    global diseases.
        As of today, 20,630 people in 24 countries around the world
    have been infected with coronavirus that we know of. The virus
    has killed 425 people so far, as we know, or that is all we
    know of, the vast majority of which have occurred within China.
    I extend my sympathies to the people in China who have lost
    family members or remain quarantined by the Chinese authorities
    in an unprecedented look-down of millions of people. I do not
    think we have ever seen this before.
        However, despite the severity and infectiousness of this
    virus, the Chinese Government has so far refused to fully
    cooperate with the global community. And, again, this is
    something we hope does not become politicized. Viruses know no
    borders and they do not really care what your politics are.
        Although Chinese scientists were able to share the sequence
    of the strain with international partners, they were only able
    to do so after bypassing government censors. So far, China has
    spurned the help of CDC and refused to provide biological
    samples to the United States. And to date, if we look back,
    whether it was the MERS or SARS epidemic, that was a worldwide
    collaboration. And other countries, even Taiwan, needs to be
    involved in this because they were the ones that helped solve
    the SARS epidemic.
        The slow-walking of information and assessments not only
    hurts the credibility of China, but also hinders our ability as
    an international community to prevent the further loss of life
    and spread of the disease. Further, in the middle of the
    unprecedented crisis the CCP continues to endanger people
    through Asia by using the World Health Organization to advance
    its political agenda through the exclusion of Taiwan.
        Taiwan has also forbidden the evacuation of Taiwanese
    citizens from the mainland, directly threatening the safety and
    sovereignty of their citizens. This cannot stand. And, again,
    viruses really do not care what your politics are.
        The United States should be better prepared to face future
    threats as well, which is why I supported multiple efforts in
    Congress to promote the One Health framework which we are going
    to talk a little it about, because this coordinates
    departments, activities, and programs that will prepare to
    protect the U.S. food and feed supplies in the event of a
    zoonotic disease outbreak. So, this is a cooperation between
    USDA and HHS.
        As we know, six to seven out of ten diseases that we get
    originate in the animal world. And the coronavirus is a perfect
    example.
        The recent outbreak of coronavirus stemming from Wuhan,
    China, is a perfect example why managing the spread of the
    animal-to-person spread to prevent person-to-person spread is
    so important. Thankfully, the CDC has repeatedly assured the
    American people that the risk to our residents remains low.
    This, thanks in large part to the actions taken by the
    Administration in organizing targeted quarantines, travel
    advisories, research into treatments and vaccines, in addition
    to the daily calls our staffs get and Members of Congress get
    on this issue.
        However, questions remain regarding potential paths
    forward. What can we do in the future to prevent not just
    China, but China, any country from hiding the spread of a
    deadly virus, of which they are repeat offenders?
        How can we balance long-term pandemic preparedness with the
    billions of dollars our government spends in short-term
    responses to emerging threats?
        Congress must continue to enable our agencies to respond
    effectively to infectious diseases and encourage our Government
    to collaborate with all of our international partners in global
    health.
        I look forward to hearing from the panel on response to the
    spread of the coronavirus in the U.S., and what we can do
    better to prepare ourselves for the arrival of not just this
    one but future pandemics from foreign countries.
        Thank you, and I yield back.
        Mr. Bera. Thank you to the ranking member.
        And my staff was just updating numbers. It is now 492
    deaths. So, obviously, rapidly flowing and constantly being
    updated.
        I should have noted that it is my pleasure to have had the
    gavel passed over toward me from the former chair of this
    committee. And I would like to recognize you for a 1-minute
    opening statement, Mr. Sherman.
        Mr. Sherman. Thank you, Mr. Chairman. You are to be
    commended for having the first public hearing on this disease
    outbreak of either house of Congress.
        We did get a private briefing from the Administration. And
    let me say that I was impressed by the team that made that
    presentation to us. That is, I hope, particularly noteworthy
    because I am not a leader when it comes to complimenting the
    Trump administration. I am also not a leader in complimenting
    the government in Beijing.
        But, I think the entire world is impressed when they build
    a new hospital and put it in service in 8 days. Which is why I
    am surprised that the Chinese Government has taken offense that
    we have chosen to limit travel, because the Chinese Government
    has limited travel internally in China. And, of course, Hong
    Kong has limited travel from the Chinese mainland. What we do
    to protect our own citizens should not be regarded by the
    Chinese as an insult but, rather, as part of a collective
    effort to control this disease.
        We need Chinese cooperation to start clinical trials. There
    are a variety of possible medicines that might be helpful, but
    we will not know. One of the good things about this disease is
    that it looks like the mortality rate is 1 to 2 percent. That
    is much lower than other outbreaks. I realize some people may
    have slightly different definitions, but it is a lower
    mortality rate than, say, Ebola, that Mr. Klain is familiar
    with.
        And so it means that without a clinical trial you do not
    know whether a particular medicine is successful. Because if
    you take 20 people with Ebola and you try something out and
    they all live, that is a good treatment. If you take 20 people
    with this disease and give them a treatment and they all live,
    that may have proved nothing at all.
        So, we need double-blind clinical trials, we need
    cooperation with China. And I look forward to getting there.
        I yield back.
        Mr. Bera. Thank you, Mr. Sherman.
        Now I am very pleased to welcome our witnesses to today's
    hearing. We are joined by Dr. Jennifer Nuzzo, a Senior Scholar
    at the Johns Hopkins Center for Health Security.
        She will be followed by Dr. Jennifer Bouey, the Tang Chair
    in China Policy Studies at the RAND Corporation. Both are
    trained epidemiologists.
        And, finally, we are joined by Mr. Ron Klain, who
    coordinated the response to West African Ebola epidemic in 2014
    and 2015.
        Please summarize your written statements to 5 minutes. And
    without objection, your prepared written statements will be
    made a part of the record.
        Dr. Nuzzo, if you could begin.

    STATEMENT OF DR. JENNIFER NUZZO, ASSOCIATE PROFESSOR AND SENIOR
     SCHOLAR, CENTER FOR HEALTH SECURITY, JOHNS HOPKINS UNIVERSITY

        Dr. Nuzzo. Good afternoon. Chairman Bera, Ranking Member
    Yoho, and members of the committee, thank you for allowing me
    to appear before you today to discuss the emerging global
    spread of the 2019 novel coronavirus.
        In the last 2 months since this virus was first identified
    we have learned several important things, such as its potential
    to spread between people, and its capacity to cause a spectrum
    of disease ranging from mild to severe. These discoveries have
    changed our perceptions of the global risks the virus poses,
    but there are still critical unknowns for which we urgently
    need more information.
        Though more and more cases are reported each day, we do not
    yet know the true size and geographic scope of this epidemic.
    And many countries are not capable of actively searching for
    cases. And most countries that have implemented surveillance
    are likely missing cases, perhaps large numbers of them.
        Severity of this disease is another key unknown. Because of
    biases in the way we look for cases, it is difficult for us to
    estimate from the case numbers how much severe illness and
    death we may expect to see as this epidemic grows. That said,
    even though we cannot get a precise estimate, there are some
    emerging signs that this virus may be less severe than we
    initially feared. If these trends continue we will ultimately--
    we may ultimately downgrade our concerns about this virus. But,
    for now these uncertainties leave important gaps in our
    response planning.
        Though the ultimate trajectory of this epidemic is hard to
    predict with certainty, evidence is mounting each day that it
    may not be possible to contain this virus. What this means is
    that if it is not possible to completely stop disease
    transmission, we must plan for how we will mitigate the impact
    of the virus as it spreads.
        To do this, I recommend three priority actions:
        First, we need to seriously reexamine the current policy of
    banning travel from China and quarantining returning travelers.
    All of the evidence we have indicates that travel restrictions
    and quarantines directed at individual countries are unlikely
    to keep the virus out of our borders. These measures may
    exacerbate the epidemic's social and economic tolls and can
    make us less safe.
        Simply put, this virus is spreading too quickly and too
    silently, and our surveillance is too limited for us to truly
    know which countries have active transmission and which do not.
    The virus could enter the U.S. from other parts of the world
    not on our restricted list, and it may already be circulating
    here.
        The U.S. was a target of travel bans and quarantines during
    the 2009 flu pandemic. It did not work to stop the spread and
    it hurt our country. I am concerned that by our singling out
    China for travel bans we are effectively penalizing it for
    reporting cases. This may diminish its willingness to further
    share data and chill other countries' willingness to be
    transparent about their own outbreaks.
        Travel bans and quarantines will make us less safe if they
    divert attention and resources from higher-priority disease
    mitigation approaches that we know are needed to respond to
    cases within the United States. Caring for and monitoring even
    a small number of quarantined individuals will be highly
    challenging for health departments and may siphon attention
    from other more important response work.
        And we are already hearing stories about chaos in the
    States as they are trying to implement these recent policies.
        Second, rather than penalize China, we should try to assist
    it in responding to the epidemic. Helping China is in our best
    interests. It is a risk of the drastic actions that China is
    taking to control the epidemic could lead to disruptions in
    U.S. supplies of essential medical resources such as personal
    protective equipment and critical medicines. We need to examine
    this possibility and identify ways to ensure that the epidemic
    or the U.S. response to it does not interrupt medical supply
    chains.
        Third, we should focus on health response efforts that we
    know will help to lessen the impacts of the virus within U.S.
    communities. We need to ensure that Federal, State, and local
    health agencies, and hospitals and health clinics have the
    resources they need to diagnose, isolate, and safely treat
    cases, and to promote feasible approaches to disease mitigation
    that are most likely to reduce disease spread, minimize
    disruption, and protect those most likely to experience severe
    illness and death.
        For this, we need leadership and additional investment,
    possibly in the form of emergency funding such as was
    appropriated during the 2009 pandemic.
        Government leadership is also needed to facilitate the
    development of medical countermeasures, including infectious
    disease diagnostics.
        The points I have raised today hopefully paint a picture of
    a epidemic that is in many ways complex and evolving, but for
    which we are increasingly gaining clarity. One thing is
    certain, international collaboration will be essential for us
    to monitor, for continued monitoring and learning about the
    virus and to inform our own response plans. That we know
    anything about this virus is due in large part to information
    contributed by China, Thailand, Vietnam, the other countries
    that have worked hard to improve their surveillance, in part
    with U.S. help. And we will likely need their help going
    forward.
        We should recognize these successes as they demonstrate the
    value of our investments and the need for continued
    international engagement. Though our instincts may be to
    isolate ourselves to try to keep the virus out of our borders,
    this approach may only weaken our preparedness.
        Thank you.
        [The prepared statement of Dr. Nuzzo follows:]

    [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

            Mr. Bera. Thank you, Dr. Nuzzo.
        Dr. Bouey.

     STATEMENT OF DR. JENNIFER BOUEY, SENIOR POLICY RESEARCHER AND
          TANG CHAIR IN CHINA POLICY STUDIES, RAND CORPORATION

        Dr. Bouey. Thank you. Chairman Bera, Ranking Member Yoho,
    and members of subcommittee, thank you for inviting me to
    testify for this coronavirus outbreak. My testimony will start
    with laying out the context of this outbreak by looking at
    China's public health development after SARS. Then I will
    examine China's current response to this outbreak. And I will
    end with some recommendations.
        Seventeen years ago SARS emerged from southern China and
    caused a global outbreak and infecting over 8,000 people, and
    killing more than 700. SARS prompted China to radically rethink
    its public health system. The country invested heavily in the
    Centers for Disease Control, surveillance networks, and a
    National Influenza Center. SARS also spurred China to
    strengthen its relationship with United States and the wider
    international community around public health concerns.
        The U.S. helped China in both public health infrastructure
    and capacity building. Public health professionals from both
    countries collaborated on HIV/AIDS, avian flu, swine flu, H7N9,
    and Ebola. In the last couple years, however, this relationship
    has faltered due to tensions between the U.S.-China
    relationship.
        Compared to SARS, the time taken for the Chinese Government
    and global health communities to respond to the first cases of
    coronavirus are much shorter. So, there were about 4 weeks from
    the first noticed case to the public announcement of the
    outbreak, and then 12 days to the time when virus was
    identified, and then 9 more days until the national case report
    system was triggered.
        The credit for this progress can be tied to the
    availability of the latest genomic sequencing technology and
    the global data networks. Because of the rapid identification
    of the virus, many countries, including U.S. and China, can now
    quickly develop a testing kit, monitor the genetic mutation,
    and have better understanding of the transmission. All
    countries can link their cases to the current outbreaks now.
        Further, the wide use of social media and China's progress
    on globalization has pushed the government to be more
    transparent. However, there are remaining similarities to the
    SARS response. Given the Chinese Government values stability
    most, an outbreak by its nature is disruptive. The government's
    hesitation to announce the public health threat was reflected
    in the long review process and the regulations that prohibited
    local officials and the members of the public to discuss the
    outbreak before the approval from the central government.
        The downplay of the severity of the outbreak also has
    happened again. From January 3d to the 20th, the expert
    investigation team assured the public that there was limited
    person-to-person transmission. And after closing the animal
    markets associated with the first group of cases, the epidemic
    was under control.
        It was not until cases outside China appeared and the
    second team was sent and they confirmed the communal
    transmission, then the government announced a public health
    emergency and triggered the national case reporting system.
        Finally, as with SARS, the government uses mass quarantine
    as the primary intervention. Resources have been mobilized
    nationally to support a health care system in the crisis areas,
    and even new hospitals were built for the outbreak. The
    quarantine and the health care system strengthening are
    important strategies, but we do not know, do not know yet if
    such intervention can contain this epidemic, nor do we know
    about the social, cultural, economic, and the political
    implication and impacts.
        I will highlight three recommendations here:
        First, USG should consider having a concerted and
    comprehensive plan to contain the domestic outbreak. In
    addition to the social distancing action we just mentioned, we
    should consider the strategies to reduce the spread of rumors
    and the stigma associated with the outbreak.
        Second, public health and humanitarian assistance should be
    sent at a time when China is bearing the principal burden of
    the outbreak. Currently, 99 percent of the cases are in China,
    and 97 percent of the deaths in Hubei province. Public health
    expertise, medical supplies, and even supporting language can
    help the people who are suffering there.
        And, last, given the continued spread of the outbreak, USG
    should consider working with WHO and China CDC to provide
    strategic and capacity building for other countries that are in
    danger of the epidemic.
        Thank you.
        [The prepared statement of Dr. Bouey follows:]

    [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

        Mr. Bera. Thank you, Dr. Bouey.
        Mr. Klain.

     STATEMENT OF MR. RON KLAIN, FORMER WHITE HOUSE EBOLA RESPONSE
                         COORDINATOR, 2014-2015

        Mr. Klain. Chairman Bera, Ranking Member Yoho, other
    members of the subcommittee, thanks for having me. I move you--
    I commend you for moving quickly to hold this hearing.
        At the outset I want to make two preliminary points:
        First, while scientists are working at unprecedented speed
    to learn more about this virus, we still know less about the
    coronavirus today than we did about Ebola in 2014. There are
    many important gaps to be filled in.
        Second, I want to say a word about partisanship. I am a
    political partisan, that is well known, but I testify today the
    same way I approached serving as Ebola Response Coordinator,
    putting politics aside. Epidemic response should not be a
    partisan issue. The coronavirus will certainly not ask anyone's
    political affiliation before infecting them.
        With that introduction, I want to turn to the lessons from
    the Ebola response. That response was not without problems, and
    particularly early on. But, ultimately, President Obama
    launched a whole-of-government effort, he appointed me to lead
    a team at the White House to coordinate it. The president
    ordered the first ever deployment of U.S. troops to combat an
    epidemic. He implemented innovative policies and travel
    screening and monitoring, and worked with this body to pass a
    $5.4 billion bipartisan emergency response package.
        This response improved preparedness at home, and put over
    10,000 people, civilians and soldiers, government employees,
    contractors, and NGO members on the ground in Africa to help; a
    gargantuan effort. The epidemic was tragic, a loss of 11,000
    lives or more, but experts had forecast a death toll of more
    than 1 million. Thus, as part of a global response, with
    Africans playing the largest part, America helped save hundreds
    of thousand of lives.
        Here at home, after some initial missteps in Dallas, no one
    contracted Ebola on U.S. soil. And the evacuation of Americans
    from Africa with Ebola saved lives and resulted in no spread of
    the disease here.
        And the benefits of this response continues to this day.
    With Congress' support we stood up a national network of
    medical facilities that remain prepared now to respond to cases
    of dangerous infectious disease. Nothing like that existed
    before. The response helped develop an effective Ebola vaccine
    being used now in Central Africa. And new therapeutics have
    dramatically reduced the mortality rate of Ebola.
        Tom Friedman recently wrote that the Ebola response was
    ``President Obama's most significant foreign policy achievement
    for which he got little credit precisely because it worked,
    demonstrating that without America as quarterback, important
    things that save lives and advance freedom often do not
    happen.''
        Now, the challenges we face now from the novel coronavirus
    have many differences from those that Ebola posed, but also
    some key similarities. And I want to try to quickly run through
    seven lessons from the Ebola response that should be applied
    today.
        First, in a scenario like this one there is no substitute
    for White House leadership. There should be a single high-level
    official inside the National Security Counsel overseeing the
    response. At the end of my tenure as Ebola Response
    Coordinator, President Obama accepted my recommendation to
    create a permanent pandemic preparedness and response
    directorate inside the NSC.
        President Trump initially continued this structure. But,
    unfortunately, in July 2018 he disbanded this unit. The gap
    that created for this response is significant.
        Now, last week's decision to create a task force to oversee
    the coronavirus response is a valuable step, but I think it is
    insufficient. That is not a criticism of its chair, Secretary
    Azar, for whom I have a great respect, but reflects the
    fundamentals of bureaucratic behavior, the realities of the
    competing demands on a cabinet secretary's time, and the need
    to ensure foreign engagement at a high level. This response
    should be lead by a full-time senior appointee at the White
    House.
        Second, the U.S. must lean forward to fight this epidemic
    overseas. Unlike West Africa in 2014, China said they would not
    accept thousands of U.S. responders on the ground. But that
    does not mean our focus is limited to the homeland. Nations
    poorer than China may see outbreaks and need direct help. Our
    diplomats should be engaged around the globe.
        The best way to keep Americans safe is to eschew
    isolationism and help other nations combat the virus.
        Third, this Administration must ensure that science and
    expertise guide our actions. There are going to be many hard
    decisions in the days ahead. The American people are fortunate
    to have the world's leading experts on infectious disease
    working in this government, experts who have served Democratic
    and Republican presidents alike. This expertise should be
    paramount in decisionmaking.
        Fourth, the Administration should quickly transmit to
    Congress an emergency funding package to respond to the
    coronavirus challenge. Federal agencies, State and local
    governments, hospitals testing and treating patients will need
    assistance. Research and deployment of new therapeutics and
    vaccine need government support.
        While the response has benefited from the new emergency
    fund that Congress created on a bipartisan basis last year,
    that probably will not suffice. The Trump administration should
    send an appropriate funding request to this body.
        Fifth, the Congress must do its job in dealing with the
    coronavirus. It needs to act on any such request quickly and
    should, perhaps, work now to be ready for it.
        In addition, hearings like today's are very important. The
    emergency fund needs to be increased and paired with a fund to
    support the development of therapeutics and vaccines on public/
    private partnerships.
        And, finally, Congress must renew funding for the full
    network of Ebola and special pathogen hospitals created in 2014
    that is set to expire in May.
        Six, this should be a wake-up call to finish the work we
    need on pandemic preparedness. Recently we marked the 100th
    anniversary of the single largest mortality event in American
    history, the Spanish flu epidemic. At present it seems very
    unlikely that the coronavirus poses a similar threat. But even
    if this epidemic is not the big one, as Representative Yoho
    said, it is a reminder that the danger lurks and it will come.
        The global health security agenda, bipartisan commissions
    and reports, and my own writing have set forth detailed agendas
    of what we need to do to prepare for this event that have
    largely been ignored. The time to act is now.
        And seventh, finally, all of us need to be on the watch for
    discrimination against Chinese Americans and speak out strongly
    against it. The coronavirus strikes humans, not people of any
    particular race or ethnicity. Chinese Americans and Chinese
    immigrants in America are no more likely to get this disease or
    transmit it than anyone else. It is critical to speak out
    against discrimination. Americans need to pull together to
    fight the disease, not pull apart to fight one another.
        Thank you again for having. And I am ready to answer your
    questions.
        [The prepared statement of Mr. Klain follows:]

    [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

        Mr. Bera. Thank you, Mr. Klain. And thank you to all the
    witnesses.
        I will now recognize myself for opening questions, and then
    I will recognize the ranking member and other members for 5
    minutes for the purpose of questioning our witnesses.
        Let's touch on a couple areas that I think each of you
    touched on in your opening statement. I understand the initial
    reaction to say, you know, let's try to contain this virus at
    the epicenter in China. That, you know, just given the
    worldwide spread of these cases how little we know about the
    transmission at this juncture.
        It seems as though, you know, we are beyond the point of,
    you know, trying to contain this at the epicenter.
        Maybe starting with you, Dr. Nuzzo, and, you know, just
    going down the line, how effective is this travel ban? And you
    touched on it that it actually may worsen, worsen things right
    now in concentrate.
        Dr. Nuzzo. Thank you, Chairman Bera.
        I, as I mentioned, am worried about the implications of the
    travel ban. We often see when we have emerging disease
    outbreaks out first instinct is to try to lock down travel to
    prevent the introduction of virus to our country. And that is a
    completely understandable instinct.
        I have never seen instances in which that has worked when
    we are talking about a virus at this scale. Respiratory viruses
    like this one, and like others, they just move quickly. They
    are hard to spot because they look like many other diseases. It
    is very difficult to interrupt them at borders. You would need
    to have complete surveillance in order to do that, and we
    simply do not have that.
        In China we are looking for largely sick people. I mean,
    other countries we are only looking for people from China. So,
    we are going to miss transmission elsewhere.
        So, for that and other reasons I do not believe that it
    will be able to keep the virus out of our border.
        I am, though, very worried about the potential diversion of
    resources because this was apparently, it was a decision that
    caught many public health folks off guard. And they are now
    trying to figure out what to do. And so, I talked to one health
    department who has 31 staff working around the clock supporting
    two quarantined individuals. And I just think, as this epidemic
    grows that is not likely to scale.
        So, I am worried about that. And then I am also worried
    about the chilling effect that attends the potential to erode,
    well, our relationship with China that we are critically
    dependent on right now for the supplies of the things that we
    need to be able to manage our own cases. But, also, we just
    need more information.
        And as you mentioned in your opening remarks, China will be
    the source for that information in large part.
        Mr. Bera. Right.
        You know, maybe, Mr. Klain, Dr. Nuzzo touched on the supply
    chains and the interconnectedness of it. How concerned should
    we be about those supply chains? And, you know, obviously they
    are global supply chains as well, and the medical supply
    potentially needed here but also in China?
        Mr. Klain. Yes, Congressman. We do not have a travel ban,
    we have a travel band-aid right now.
        First, before it was imposed, 300,000 people came here from
    China in the previous month. So, that horse is out of the barn.
        Second, what we have restricted is not travel to or from
    China but passports to and from China. There is no restriction
    on Americans going back and forth. There are warnings. People
    should abide by those warnings. But today 30 planes will land
    in Los Angeles that either originated in Beijing or came here
    on one stops. Thirty in San Francisco, 25 in New York City. OK?
        So, unless we think that the color of the passport someone
    carries is a meaningful public health restriction we have not
    placed a meaningful public health restriction.
        And then to get to your question, exempt from the
    President's travel restriction, of course, is the import of
    goods from China and, of course, the people who fly the planes
    and drive the boats that bring those goods from China. We
    couldn't ban that activity. We vitally need that. 90 percent of
    the antibiotics in this country come from China. All kinds of
    vital medical supplies. Dr. Nuzzo mentioned the PPP--PPE we
    will use to treat people.
        So, travel bans, even putting aside Dr. Nuzzo's concerns,
    that is not what we are imposing, that is not what exists. What
    we should be focused on is monitoring the people who are here
    who have been in China in the past 14 days. That is
    complicated. That is hard. We built a path-breaking system to
    do that in the Ebola response. This is much larger and more
    complicated.
        And I do not think we have heard answers--I hope Congress
    will get them--but what the Administration is doing on that,
    which really should be our public health priority.
        Mr. Bera. And maybe in the limited time I have left, Dr.
    Bouey, you have a unique perspective having trained in China.
    And, you know, from your perspective, how best can we assist
    the Chinese? And, again, from the congressional perspective we
    are not looking at this as adversarially, we are looking at
    this as collaboratively.
        Dr. Bouey. Thank you. I agree wholeheartedly with Dr. Nuzzo
    and Mr. Klain that the travel ban does not cause--does not help
    that much in this, the current situation.
        I want everyone to understand that China, Chinese
    scientists look up to the American scientists highly. The
    United States has helped China to build a public health system,
    and has helped with capacity building after SARS.
        So, they are always looking at the U.S. as a leader in this
    field and for U.S. to make this decision. So, I think that is
    why China is a little bit surprised and also feel hurt.
        And I also, my own feeling is that with the travel ban that
    should come with other policies. It should not be the only
    policy that U.S. announced to China. Humanitarian aid, the
    public health assistance should, and the other support should
    be in place at the same time as the travel ban.
        Mr. Bera. Great. I am out of time.
        Let me go and recognize Ranking Member Mr. Yoho from
    Florida.
        Mr. Yoho. Thank you, Mr. Chairman.
        Great testimony. I really, really appreciate it. I have a
    ton of questions let me go through.
        Dr. Nuzzo, you said we should look to help China versus
    blocking them out. What kind of help would you recommend other
    than what we have done?
        Keep in mind if China will not accept our offer to help
    with the CDC, what else can we do? I would like to hear from
    you.
        Dr. Nuzzo. Yes, thank you, Ranking Member Yoho, for that
    question.
        First of all, I want to make clear that I think one of the
    concerns that I have about our----
        Mr. Bera. Dr. Nuzzo, could you speak into the microphone,
    please.
        Dr. Nuzzo. Excuse me. Sorry.
        I want to make clear one of the concerns that I have
    pertains to not just our response to this virus but also how
    China is responding. And the disruptions that I spoke to
    earlier I believe will be exacerbated by the lock-downs that
    China is taking in an attempt to control the virus.
        Since those lock-downs have been announced, every single
    province in China is reporting cases. So, I am increasingly not
    convinced that those measures are helping. And I am really
    worried that they are going to cause disruptions.
        And so, I think it is essential that we encourage China,
    pressure China, whatever the negotiations that we do, to pursue
    strategies for controlling the virus that are not going to be
    disruptive, that will not suspend the production of critical
    medical supplies because people cannot get to their jobs.
        Mr. Yoho. Let me interrupt you right there because that is
    something I want to talk about.
        Dr. Nuzzo. Right.
        Mr. Yoho. You know, does the fact that China did a massive
    quarantine--our reports are 50 to 58 million people have been
    quarantined--does that concern you in addition to the rapid
    construction of the 1,000-bed hospital, which was a monumental
    feat, and they have another 1,500 going in--so China is putting
    a stellar effort into this--that alone would be a concern for
    all of us if they are that concerned about it, yet the
    information coming out is, well, we have it kind of under
    control. And then the furloughing of workers, I have heard up
    to some, they are told not to come back till sometime in March.
        I think this is a big concern that we need to look at. And
    I am all for quarantine if it is done properly but, as Dr.
    Bouey said, it cannot be the only thing. You have to have a
    systematic way of doing it. I mean, we do that with equines
    with influenza outbreaks in shows.
        And it is not--somebody asked me, well, do you care more
    about horses than people, or do you want to treat people like
    horses? I am, like, no. But do we put more emphasis on our
    animals than we do our people?
        This is a national security thing and we cannot afford it.
    And if the economic impact that China is going to feel I think
    that is something that we need to look at very seriously that
    this has the potential.
        And I want to bring up, does anybody know the duplication
    rate of this virus compared to the influenza or SARS?
        Dr. Nuzzo. I completely agree with your concerns about the
    internal response. I do not believe that the massive lock-downs
    in China will lead to a cessation of transmission of the virus.
    I think that it is already causing a tremendous amount of
    disruption.
        When you hear stories about people having to walk to the
    hospital, sick people having to walk to the hospital because
    transportation has been shut down, that is really what raises
    warning flags in terms of the public health benefits of these
    measures.
        Mr. Yoho. But does not that also show you the severe threat
    that the Chinese see themselves?
        Dr. Nuzzo. I think that everybody is viewing this severely.
    I will tell you that many of these tendencies we saw during
    SARS as well, and we often see when there is an emerging
    infectious disease outbreak like this.
        Mr. Yoho. All right. I want to go to Mr. Klain because he
    is jumping over there.
        Mr. Klain. Yes. Thank you. I appreciate that, Congressman.
        Look, I think that there are two points, or three. One, I
    agree that there are a lot of signs that this has been more
    severe in China than has been reported. And I have no doubt
    that the actionable cases is significantly higher.
        Mr. Yoho. Well, let me tell you what I heard yesterday from
    reliable sources. It is over 100,000 people have been exposed.
        Mr. Klain. Yes. Yes, I----
        Mr. Yoho. What we have heard. And the duplication rate with
    influenza was about 1.3 percent. That means one person can
    affect about 1.3 people. And that was the same with SARS, a
    little bit higher for SARS.
        This one they are estimating right now between 2.5 to 3.
    So, that means one person is affecting 2.5 to 3 people. And
    that is not being reported. And if that is true and the Chinese
    know that, they need to let that--us know because that shows
    you the virulence of that and the rapid spread.
        Mr. Klain. Yes, I agree. We do not really know what the R-
    nought is, we do not know a lot of these facts. We need to get
    this information, I agree.
        The last thing I want to say is about this Chinese internal
    quarantine. Just to put a finer point on what Dr. Nuzzo said, I
    am highly skeptical that this is effective.
        You know, I think we all saw that picture of all the
    bridges out of Wuhan with no one leaving. But if you look at
    that picture, on the other side were literally thousands of
    trucks on their way into Wuhan.
        Who drove those trucks? And what happened after they
    unloaded them?
        Think about trying to quarantine a city the size of New
    York City in the United States, and imagine that no one would
    come in and no one would go out. How would you feed those
    people? Who would run the power plants and all these things.
        Mr. Yoho. That is going to be found out in the future.
        Mr. Klain. Yes. And so what I am willing to bet right now
    is that people are coming and going from Wuhan every day. And
    it is just a practical reality of the size and the scope of
    what we are talking about.
        Mr. Yoho. I am out of time. Thank you.
        Mr. Bera. Thank you, Mr. Yoho.
        Mr. Sherman from California.
        Mr. Sherman. First, this outbreak shows the
    wrongheadedness, almost immorality of the Chinese Government
    excluding Taiwan from the World Health Organization. We have to
    be on Team Human, not on Team Disease.
        You know, whenever something new like this happens we
    react. Almost always it is an overreaction until there is that
    one case where the reaction is not an overreaction. We are in a
    race to develop vaccines and cures. And that can happen only
    with cooperation between the United States and China.
        We look back at November 2002 when it took months for the
    scale of Chinese SARS crisis to be exposed. This time, as the
    New York Times reported, at critical moments in the first 7
    weeks between the appearance of the first symptoms in early
    December and today, the government's decision--between when the
    first appearance and the government's decision to lock down the
    city officials chose to put secrecy and order ahead of openly
    confronting the growing crisis.
        So, I will ask each of our witnesses, are the Chinese being
    honest as to the extent of the epidemic?
        Does the World Health organization have sufficient access
    to facilities and to patients? Doctor?
        Dr. Nuzzo. I cannot speak to intention. I think there have
    been critical information gaps.
        Mr. Sherman. Uh-huh.
        Dr. Nuzzo. The one that I am particularly interested in
    learning more about and think we should have more information
    about is about the severity of cases.
        You know, to the point about how--is the situation more
    severe than they are letting us know? Are there more deaths or
    dying that we are not hearing about?
        Mr. Sherman. OK.
        Dr. Nuzzo. One puzzling feature so far is that the cases
    that we have seen outside of China have been far more mild than
    what is going on in China. So, we need to understand why that
    is. And for that we need access to more data.
        I have been encouraged that there have been a number of
    scientific publications that have come out already about this
    with Chinese and others, scientists from elsewhere on those
    publications. But I, as an academic, cannot even justify
    waiting for a publication to learn about these things.
        So, I absolutely believe that more information is critical.
        Mr. Sherman. OK. I do have limited time.
        The Chinese have reported 24,000 cases and 490 deaths. Dr.
    Bouey, what----
        Dr. Bouey. My observations----
        Mr. Sherman [continuing]. What do you think the number is?
        Dr. Bouey. Right. My observation is that there was delay of
    case reporting for sure before January 19th. After January
    19th, the government triggered a public health emergency. And
    that triggers the national case reporting system.
        That case system was implemented after SARS. And as we know
    SARS better, well, then you know that at the end of the SARS
    when they set up this system they said, they put in a law that
    if anyone cannot report accurate numbers then they will be
    punished.
        Mr. Sherman. I have to go to the other----
        Dr. Bouey. I think that is very well. But the problem is--
    --
        Mr. Sherman. Excuse me. I have limited time.
        The Chinese have not involved the United States' experts to
    the degree they should. Are they, do we have sufficient numbers
    of people from Europe, Japan, and the World Health Organization
    on the ground to get us the information and to see that we are
    doing all we can to look for cures and vaccines? Mr. Klain.
        Mr. Klain. I do not think so, Congressman. And, again, this
    is one reason why I think we need a high-level coordinator at
    the White House who can be in touch with foreign governments at
    other high levels. Again, Secretary Azar is competent and
    skilled, but this is an active diplomacy, not just health
    diplomacy but high-level diplomacy.
        Our President should be on the phone with President Xi. You
    know, we should be engaging these other countries at a very
    high level. That is what we did during the Ebola response, very
    high level from the White House. And I think we need to do that
    here to get more American eyes on the ground there.
        Mr. Sherman. And, again, I was asking not just about the
    U.S. Do any of our witnesses know the level of WHO, European,
    and Japanese experts on the ground in China? And is that
    sufficient?
        Is China cooperating with any of the other advanced health
    organizations in the world?
        Dr. Bouey. My source is the news. And I know that the WHO
    has announced that they will--they have a team on ground. And I
    thought----
        Mr. Sherman. They have a what?
        Dr. Bouey. They have an emergency team in Beijing.
        Mr. Sherman. Uh-huh.
        Dr. Bouey. And I think the Director of the WHO was in
    Beijing I think since January 27th.
        Mr. Sherman. My time has expired.
        Mr. Bera. I recognize Mr. Perry for 5 minutes.
        Mr. Perry. I thank the Chairman, thank the witnesses.
        We have ample evidence that China has undue influence over
    many U.N. organizations, including the WHO. The WHO continues
    to exclude Taiwan, that is an important player in this and many
    other things.
        Do you, do all of you think that we can just unilaterally
    trust the World Health Organization to give an impartial
    assessment of China's response to the coronavirus?
        Mr. Klain. I will start. I certainly do not think so,
    Congressman Perry. I think the WHO is performing better now
    than it was during the Ebola response 5 years ago. I think new
    leadership has helped.
        But I think the delay in declaring a public health
    emergency international concern reflected Chinese influence
    there.
        And think that, you know, the WHO is just one aspect of
    this response. They aren't going to treat people. They aren't
    doing research. They are important. The U.S. should support the
    WHO. But we need to be involved directly on our own in China
    and with our allies.
        Mr. Perry. OK, so that is fair. They have been
    complimentary of China's response but critical of other
    nations. I mean, do you take pause when you hear that?
        Or, Mr. Klain, just for example, you are I guess a self-
    described expert having your involvement with Ebola, have you
    been critical of China's response?
        Mr. Klain. Yes, I have, sir. I have published. And
    everything I have written about this so far that the Chinese
    have failed the test of transparency and cooperation, and that
    they, they definitely need to do better.
        We should be very concerned about that. And we should be,
    as I just said a moment ago, engaging the Chinese Government at
    the highest levels to press the issue.
        Mr. Perry. Do you know----
        Mr. Klain. This should be at the top of our agenda----
        Mr. Perry. Mr. Klain.
        Mr. Perry [continuing]. In our relations with China, sir.
        Mr. Perry. I understand.
        Do you know if President Trump has or has not talked to the
    President of China about this?
        Mr. Klain. I do not, sir.
        Mr. Perry. You do not know?
        Mr. Klain. I do not.
        Mr. Perry. I mean, you would admit it is a little unfair to
    criticize it here when you just said you do not know if he--
    maybe he has, maybe he hasn't, I do not know. But you are
    making the claim here that he should have done it or should be
    doing it.
        Mr. Klain. My claim is that he should have done it or
    should be doing it. I will say he hasn't said that he has done
    it. And the officials reiterate that the Chinese aren't
    cooperating yet.
        Mr. Perry. Mr. Klain, you worked on the Ebola virus
    outbreak in Sierra Leone, Guinea, and Liberia, is that, West
    Africa; is that about right?
        Mr. Klain. Yes, sir.
        Mr. Perry. Yes. Are any of those nations communist nations?
        Mr. Klain. Not to the best of my knowledge, sir.
        Mr. Perry. No. Right.
        Are any of those nations seeking worldwide dominance over
    the United States of America, stealing somewhere between $300
    and $600 billion in intellectual property annually, including
    medical technology?
        Mr. Klain. No, sir. As I said, I am not here to defend
    China or its response to this virus. In fact, I have been
    critical of China and its response to this virus in virtually
    every answer I have given to the subcommittee today.
        Mr. Perry. So, in your view, what is the first
    responsibility of the U.S. Government regarding a pandemic, the
    coronavirus, Ebola? What is the first responsibility of the
    United States Government?
        Mr. Klain. The first responsibility of this government is
    to keep the American people safe. And the best way----
        Mr. Perry. To keep the American people safe. That is right.
        Mr. Klain. Yes, sir. And the best way to do that, as we did
    with Ebola, as we do with other things, is be engaged globally
    in helping nations fight these diseases overseas so they do not
    come here, sir.
        Mr. Perry. So, are you, are you advocating for a travel ban
    outright to China or from China? I am trying to get that from
    your initial testimony and I couldn't tell where you were. You
    were critical of the current situation but you did not offer
    your solution set as an expert, so to speak.
        Mr. Klain. Sir, I did offer my solution set. It was that we
    monitor carefully everyone who has come to this country from
    China recently.
        Mr. Perry. How many people travel from China to the United
    States every single day, sir?
        Mr. Klain. Well, before this outbreak it was about 8,000 a
    day.
        Mr. Perry. Eight thousand a day?
        Mr. Klain. Yes, sir.
        Mr. Perry. And it is your studied opinion that we should
    let that happen unencumbered, unimpeded, under all
    circumstances and monitor those 8,000 people a day's
    whereabouts should this continue to progress and we found an
    outbreak in the United States of America?
        Mr. Klain. Congressman, it is my studied opinion that we
    will never reduce that to zero due to trade and due to travel
    of Americans and Americans' family members. In fact, the
    President's order exempts 11 different categories of people
    from going back and forth to China, as well as hundreds of
    people a day bringing goods here.
        Mr. Perry. So, it is----
        Mr. Klain. And so given that hundreds----
        Mr. Perry [continuing]. Zero or all?
        Mr. Klain. No, sir. Given that hundreds of people,
    thousands of people will come here every day, I take it, sir,
    it is not your position that American citizens in China should
    be stranded there and unable to come back. And, given that,
    then the only practical thing we can do is to monitor those who
    are coming here to this country, who are bringing medicines to
    this country, who are bringing goods.
        Mr. Perry. May I close with the time I have, Mr. Chairman.
        Mr. Klain. That seems like the only practical solution.
        Mr. Perry. Mr. Klain, we appreciate your experience, we do,
    and your expertise because you have done this to a certain
    extent, but I do not think that you have operated in the same
    realm with the Chinese Communist Government and their actions
    toward the United States. So, things are a little different.
        And the other thing is, is that while you had a certain
    experience, it might not be the only way of doing things. And
    so while it is great to throw partisan shots, I mean, when you
    talk about bringing--I read your piece in The Atlantic, sir--I
    mean, you are talking about bringing countries and the United
    States together and not being paranoid. All you did was offer
    criticism and really no help. And that is not helpful at all.
        And I yield back.
        Mr. Klain. Well, Congressman, that piece included praise
    for Secretary Azar for the other aspects of the response,
    praise for the Administration's response, to a limited extent,
    in Congo to Ebola we have seen there.
        I opened by saying this isn't a partisan issue, and I
    reiterate that this is not a partisan issue. What I do believe,
    though, is that if we do not engage globally--and, again, I
    have been very critical of the Chinese--we cannot keep America
    safe, sir.
        Mr. Perry. And I would agree with you. But instead of
    blaming America, you ought to look more toward the Chinese.
        And I yield.
        Mr. Bera. Great. And, again, the goal here is we want to be
    supportive of the Administration. Congress wants to be on the
    same page with the Administration. And we want to work with the
    Chinese to get ahead of this because this is a global issue.
        With that, let me recognize Ms. Houlahan.
        Ms. Houlahan. Thank you, Mr. Chair. Thank you all for
    coming today.
        I am actually really intrigued by, Dr. Nuzzo and Dr. Bouey,
    your initial conversations about the fact that the travel bans
    and quarantines weren't necessarily the solution. I guess I am
    really struggling trying to understand, based on my limited
    understanding of biology, and I am a mere engineer, why is
    quarantining not appropriate? Why is it something that is not
    useful to this case?
        How do we know what cases it is useful?
        And because my limited understanding of biology is
    quarantining works, is there ever a situation where that would
    be something that would be useful? And when do we know when it
    is before it is too late?
        Dr. Nuzzo. Thank you so much. I will start with answering
    that question.
        The challenge here is that we are talking about a
    respiratory virus that potentially has--and I take the earlier
    points, there are still some uncertainties about the incubation
    period--but potentially can spread between people quite
    quickly. So, it is very difficult to know where the disease is
    spreading because we just simply cannot get a hold of it, ahead
    of it in terms of your surveillance.
        So, those sorts of circumstances makes quarantine
    challenging because we do not know who we should be
    quarantining fully. We may decide just based on the numbers of
    cases in China that we should quarantine travelers from China.
    But we do not actually know if travelers from other countries
    have the virus.
        We also do not know if it is already here because we are
    only testing people who have a connection to China. So that
    makes it challenging.
        Quarantine is actually not something that we routinely use
    in public health. Despite what you may have heard, it is
    actually something that we only use in very rare circumstances.
    We, in public health, when we talk about quarantine we mean
    restricting the movement of people that are not yet sick. We
    very frequently isolate people that we know are sick. It is a
    very routine and well-studied process. But quarantine is not
    something we routinely do. It is usually reserved for
    circumstances in which you have a small group of people,
    perhaps in a measles outbreak in a vaccine-hesitant community.
        Ms. Houlahan. So, is this a situation where you will know
    it when you see it? You will know that this is a quarantine
    situation and an effective one, and this just does not happen
    to be one? Or we are just speculating?
        Dr. Nuzzo. In this situation this definitely does not
    happen to be one.
        Ms. Houlahan. And, Dr. Bouey?
        Dr. Bouey. My sense of a quarantine it is a primary
    prevention. So it is basically separating those who are sick
    versus those who are not sick.
        So, without the vaccine, without the treatment usually we
    have to rely on quarantine on paper, on paperwork. But in
    reality, it often only slows the transmission, not prevents.
        Ms. Houlahan. So, I am sorry to interrupt, because I do
    have very limited time I just want to talk about the vaccine or
    treatment.
        Is there anything that we can do in the short-term with
    this particular situation with vaccinations or treatment from a
    congressional standpoint? Is there anything that we should be
    able to do for the forward-looking perspective because this may
    not be as bad as it seems to have been, at least initially. But
    at some point it will be, something will be.
        I guess this is probably for Mr. Klain. Can you talk to
    anything, you mentioned maybe emergency supplemental funding?
        Can you identify what programs specifically or what
    accounts would be useful, not just for this particular
    situation but for future situations as well?
        Mr. Klain. Yes, Congresswoman. I think it is very--I think
    Congress last year expanded the public health emergency fund,
    considered but did not adopt a proposal to create a special
    fund to help seed public/private partnerships to accelerate the
    development of vaccines and therapeutics. And I think while
    that would probably be too late to really help with this
    epidemic, it might not be. And certainly it will be very
    helpful going forward.
        I think, you know, that means putting more money also into
    BARDA, which plays an important part in turning this research
    and bringing it to the marketplace. We are always underfunded
    and always a little bit behind. But I think, you know, whatever
    Congress can do to supplement public/private partnerhips in
    this regard would be very useful for keeping the American
    people safe.
        Ms. Houlahan. Thank you. And with the last minute of my
    time, Dr. Bouey, I was wondering, you did comment on the fact
    that there would be potential social, cultural, political, and
    economic implications to our current strategy. But you kind of
    left it at that.
        Can you elaborate on what those--I know you said we do not
    know what they are--but could you speculate?
        Dr. Bouey. I was referring to the quarantine measures in
    China. Certainly economic concern is huge. And I think even
    China's government probably is considering, you know, how long
    this quarantine can actuate without harming the economy too
    much.
        And of course it has social and cultural issues. People who
    are being quarantined are worried. They are nervous. And
    especially for the hospitals within Wuhan, they are
    overwhelmed. Certainly the new hospital will help a little bit,
    and the mobilization of resources help a little bit. But for
    people under quarantine it is a tremendous stress.
        Politically, of course, there are lots of distrust, a lot
    of questions within China now. And, again, quarantine to lock
    down a whole city usually is not the best practice.
        Ms. Houlahan. Thank you. I have run out of time.
        I yield back.
        Mr. Bera. Great. Thank you.
        Let me recognize Mr. Mast from Florida for 5 minutes.
        Mr. Mast. Thank you, Mr. Chairman.
        I want to take a step back and ask that we all recall we
    have districts back home. And while we deal with national
    policy, the questions that we ask on this matter to
    individuals, individuals with children, individuals that go to
    work, individuals that are exposed to people that travel. We
    will all travel presumably Friday or Saturday back to our home
    districts. We are in a very international city here.
        And I think, I feel as though the sense that I am getting
    from you all about quarantine not being the right path does not
    pass the test of common sense. But I do not want to dwell on
    that right at this moment.
        What I want to ask first, No. 1, in the aim of speaking
    about people that we represent back home, if you were in Wuhan
    right now, any one of you, you all have experience with this,
    what would be your first or second or third line of defense?
        How would you protect your family? How would you protect
    yourself? Would you wear a mask? Would you wash your hands?
    Does that not work? Would you not touch your eyes or your nose?
    Would you prevent your kids from going to school? What would
    you do?
        Dr. Bouey. Can I start with I think there are many other
    primary prevention methods. Health education is one. I think if
    people understand what is going on, and they understand the
    severity of the issue, and you let them know that how can they
    protect themselves and their families and their children----
        Mr. Mast. That is the question I asked. If you could answer
    that for me it would be fantastic.
        Mr. Klain. That would be through social media, through any
    channel we can have.
        Mr. Mast. Social media is not protecting anybody in Wuhan.
        Dr. Bouey. The knowledge. The knowledge they can.
        Mr. Mast. What do they do to protect themselves?
        So, if there are people that come to our country because
    there is no quarantine on them because of this academic
    approach instead of common sense approach, what do people do to
    protect themselves when they are exposed to others?
        Dr. Nuzzo. I think what confused me about your question
    initially is the if you were in Wuhan. And I cannot speculate.
    I do not know what the situation is happening in Wuhan.
        As I mentioned before, one of the great unknowns about this
    virus is the apparent discrepancy in what we are hearing about
    in terms of severity and illness in China versus the more close
    to 150 cases that have been reported outside of China. The
    majority of the cases that have been reported outside of China
    have largely been mild disease, like other respiratory
    illnesses----
        Mr. Mast. I apologize for cutting you off. But none of you
    are answering a very straightforward question.
        Mr. Klain, you are presumably the expert on this panel. If
    you were there at ground zero, maybe you are not in a full-on
    TAP suit, but what would you do if your family was going to be
    in an area that was exposed to it? How would you protect your
    family from this? What is defense one?
        Mr. Klain. Yes. So, Congressman, I think this goes back to
    your initial point, which is defense one would be get out. And
    the problem I think for this issue of travel bans and
    quarantines is that probably hundreds of thousands or millions
    of people have.
        Mr. Mast. OK. No. 1, get out.
        Mr. Klain. Right.
        Mr. Mast. No. 2?
        Mr. Klain. No. 2 would be, would be----
        Mr. Mast. If you cannot get out of there, No. 2, what would
    you do?
        Mr. Klain. Would be social distancing. Would be trying to
    have fewer interactions with people, yes.
        But keeping your children home from school? We found in the
    past is when that happens, people's children leave the house
    and go to shopping malls and other places where they have
    contact with people.
        So, you know, it is a tricky thing.
        Mr. Mast. How would you physically protect yourself?
        Mr. Klain. The only real way I think to physically protect
    yourself is to try to stay away from other people. I think if
    you are going to have exposure to other people, as we all do,
    you know, washing your hands, doing things to minimize the
    spread of the virus is good.
        But, you know, get out of where the virus is, stay away
    from other people, and then engage in standard, you know,
    public health kind of practices, wash your hands, whatever.
        Mr. Mast. I mean, we do not say whatever, this is a serious
    question.
        Mr. Klain. Yes.
        Mr. Mast. I mean, washing your hands might be a simple act,
    but it is a very serious thing when you are looking at a
    pandemic like this.
        Dr. Bouey, one of your last comments that you made was
    about quarantine perhaps only slowing the transmission. Is
    there at this point a vaccine?
        Dr. Bouey. No.
        Mr. Mast. So, would slowing the transmission be a victory?
        Dr. Bouey. Well, it is a victory for other cities, other
    countries.
        Mr. Mast. Is it a victory for the United States of America?
        Dr. Bouey. It is a victory for human beings.
        Mr. Mast. So, it is a victory to slow that. That being
    something that comes from----
        Dr. Bouey. I think so.
        Mr. Mast [continuing]. Some point.
        Dr. Bouey. I am not all against the quarantine. I am just
    saying the quarantine policy should be evaluated very often.
    Now, every 7 days, every month, you know, it should be
    evaluated.
        Mr. Klain. Congressman, my concerns about the travel policy
    is not an academic concern, it is that as a practical matter
    people are coming here from China every day. Every day. And we
    couldn't stop that unless your district does not want
    antibiotics and protection, and all the things that come from
    China every single day.
        And so, we need to be honest about the American people,
    with the American people about the fact that we cannot keep
    people coming here from China. We are not going to keep
    Americans from coming home, for goodness' sakes, and there is
    no reason to think that a foreign national or an American
    anymore is likely to transmit the disease. In fact, we think
    they aren't.
        So, I think reducing the number of amount of travel from
    China here is a, is a good thing. But I also think we need to
    be honest with people about the fact that we will always be at
    risk for this disease coming here because we will never turn
    off the supply of people, and planes, and ships altogether
    coming here from China given the interconnectedness of our
    world, interconnectedness of vital traffic back and forth.
        Dr. Nuzzo. Can I----
        Mr. Mast. My time has expired.
        Dr. Nuzzo. I would just like to add that this has been
    worked out in a number of circumstances, including the lead-up
    prior to the 2009 influenza pandemic. And, essentially, the
    best evidence suggests that a lock-down of travel will at most
    prevent an introduction for perhaps weeks.
        That is not meaningful in the context of developing a
    vaccine. A vaccine could take a year or more. It is not like
    flu where we have an exiting platform that we can use toe
    create a new version of a flu vaccine for the use in a
    pandemic.
        So, I do not disagree that slowing is a good idea if it a
    meaningful amount of time that it can be slowed, and if the
    consequences do not, do not--aren't worse than the disease
    itself.
        Mr. Mast. Right.
        Mr. Bera. I appreciate the point that my colleague from
    Florida is making. I just want to emphasize one piece that, you
    know, we certainly have emphasized to the Administration is the
    best thing we can do right now is get the smartest people, our
    smartest epidemiologists and everyone working side-by-side with
    the Chinese and the global community to figure out as much as
    we can about infectiousness, incubation, transmission, et
    cetera.
        And, again, the best thing we can do is get those folks
    into China. And the President may be working on this every day
    with phone calls, et cetera. But, again, we are here to help.
    And I do think we can then better answer a lot of those
    questions if we can get our folks into China to help answer
    some of those questions.
        I am going to go to the chairman of the full committee, Mr.
    Engel. Mr. Engel, you are recognized for 5 minutes.
        The Chairman. Thank you, Mr. Chairman. Thank you for
    calling this important hearing on the coronavirus outbreak. It
    is one of the reasons why I love this committee, we are really
    right in the center of things, and quickly as well.
        So, I want to start by expressing my sympathy and
    condolences to everyone who has been impacted by the outbreak,
    including the people of China, other affected countries, and
    those here in the United States. It is hard to imagine how
    painful and scary these past weeks have been for these
    families.
        Here on the Foreign Affairs Committee we know that global
    health is critical to our national security. We held a hearing
    on women's health this morning. The rapid spread of the
    coronavirus over the past month shows this all too clearly. Our
    country needs substantial resources to strengthen our ability
    to prepare for and respond to public health crises like this.
    But instead of building up that capacity, the Trump
    administration has scaled down some of our most critical public
    health institutions.
        Over the past 3 years, the Administration has slashed the
    budget for the Centers for Disease Control and Prevention,
    known as CDC, National Center for Emerging and Zoonotic
    Infections Diseases, and the CDC's Global Health Security
    Agenda, making it much harder for the agency to respond to
    outbreaks overseas.
        And here in the U.S., our own response capabilities are
    diminished. State and local health departments, our first line
    of defense in public health emergencies, are short staffed,
    down tens of thousands of health workers compared to where we
    were just in 2008. This Fiscal Year President Trump is
    proposing a nearly 20 percent cut to the CDC's budget--and you
    heard that right. Just as we are confronting the coronavirus,
    the President wants to cut the very agency on the front lines
    of fighting the disease.
        I think Americans from all corners of the Nation will find
    that extremely unwise, if not crazy. And I hope all my
    colleagues will join me in opposing this dangerous plan and
    committing to support the CDC's important work.
        Rather, building up our institutions is critical. So is
    working hand-in-hand with other countries and investing in
    international bodies like the World Health Organization, WHO.
    In order for us to effectively fight this virus, we need to
    respond with evidence-based practices, transparency,
    collaboration, and communication.
        To that end, I am glad that the Chinese authorities have
    been more cooperative partners with the United States and
    others in the international community in handling the
    coronavirus than they were during 2003 SARS outbreak. Maybe we
    learned something from that.
        But the way the Chinese Communist Party has treated its
    citizens in response to this outbreak is horrifying: crackdowns
    on transparency and information, brave doctors and ordinary
    citizens facing draconian punishments merely for speaking about
    the outbreak. It is unacceptable and must come to an end.
        And in our own country we need to approach this outbreak
    with a scientific, fact-based approach. The United States and
    other countries around the world have put in place
    unprecedented travel restrictions in response to the virus.
    These measures are not proven to improve public health
    outcomes, rather, they tend to cause economic harm and to stoke
    racist and discriminatory responses to this epidemic.
        Now I will turn to ask questions of all witnesses. I must
    note I am profoundly disappointed that the Trump Administration
    would not agree to send any government officials to testify
    today. I understand that there was some kind of briefing today,
    but this hearing was set for a long time and we did not get any
    cooperation from the Administration. I personally asked the
    Administration to send a witness to the hearing. The American
    people deserve to hear firsthand what the Government is doing
    to protect them in this situation.
        Nonetheless, I am pleased that we have such a distinguished
    panel of experts before us today.
        So, thank you, Mr. Chairman, for holding this important
    hearing. And with that, I will move to my questions.
        Over the past 3 years we have seen reductions in funding
    for epidemic prevention efforts abroad, attempted cuts to
    foreign assistance, including global health security funding,
    as well as the elimination of the NSC Global Health Security
    and Biothreats Directorate. How would you assess our Nation's
    current capacity to address epidemics, both here in our own
    country and in terms of offering our expertise to help other
    countries around the world?
        Anyone who would care to answer that I would be happy.
        Dr. Nuzzo. Thank you. I would like to point out that this
    is not the only emergency that our scientists at the Centers
    for Disease Control are managing. They are also still trying to
    end an Ebola epidemic in the DRC. There are other important
    transmissions of polio in the world. This past year has been
    unprecedented in terms of measles cases.
        So, I think what this points to is the need for continued
    support and increased support for the CDC and for their other
    health partners.
        The Chairman. Anybody else?
        Dr. Bouey. Can I add?
        The Chairman. Yes.
        Dr. Bouey. In the last 17 years, U.S. CDC has been working
    with China CDC hand-in-hand in every single pandemic or
    epidemic in China. And the current difficulty I feel as relates
    to your comments is the reduction of collaborations in the last
    2, you know, 2 to 3 years.
        The NSF, National Science Foundation office was closed in
    Beijing last--in 2018. The GAP program, the Global AIDS Program
    was closed last year. The NIH and CDC programs all reduced in
    size in Beijing.
        So, when we talk about the influence, U.S. had a huge
    influence on Chinese public health a few years ago. But the
    problem is the interruption in the last few years.
        Mr. Klain. Congressman, I would just reiterate what I said
    before you arrived. The best way to keep the American people
    safe is to engage globally and to help fight diseases overseas.
    President Obama made a big point of creating a, helping to
    create a CDC in Africa so that we could help fight disease
    there.
        Global health security is American security, and we need to
    continue to support and invest in that.
        The Chairman. Let me--thank you very much--let me ask one
    final question. And if it was asked and answered, please let me
    know. And that is how would you rate the response to this
    epidemic by the Chinese Government and by WHO and other U.N.
    specialized agencies so far?
        What has been the impact of Taiwan's exclusion from the WHO
    and other U.N. specialized agencies given its proximity to the
    Chinese mainland, its status as a transit and trade hub, and
    the handful of cases reported there as well?
        Dr. Nuzzo. I study outbreaks, and epidemics, and pandemics
    in various different settings. And in every situation that we
    have looked at there have always been challenges, there have
    always been missteps, and there have always been mistakes.
        I have not personally seen yet a mistake that I haven't
    also seen in other places. And so, while I think that there is
    an important gap in our knowledge and for which I think it is
    incredibly urgent that we gain additional data in order to
    answer some of these questions that we still have, I also have
    to imagine that any country dealing with tens of thousands, or
    essentially tens of thousands of cases now would be hard
    pressed to handle all that it needs to do, including managing
    the patients, standing up enhanced laboratory surveillance,
    rolling it out to all of the hospital clinics, making sure the
    hospitals have all the personal protective equipment that they
    need.
        So, I am very reluctant to criticize anybody at this point.
        In terms of the World Health Organization, they are limited
    by their member States. The international health regulations
    were established to define the maximum efforts that countries
    should take in the name of disease control. They are inherently
    looking at international issues and not what individual
    countries do within their own borders so long as it does not
    spill across their borders.
        What we have seen from the WHO is that they have been very
    reluctant to call out countries, all countries, not just China.
    And there was questions earlier about whether they were unduly
    influenced by China.
        Just looking at the Ebola outbreak in the DRC, there was a
    long period for which many individuals thought that they should
    have declared a public health emergency of international
    concern, and they did not want to. And I believe, and the
    director-general said, and I believe him at his word, that one
    of his deep concerns was that in doing so it would encourage
    countries to take non-evidence based actions like banning
    travel and trade, et cetera. Very much mindful of what happened
    in Ebola in 2014.
        This was, again, reiterated as a concern about declaring a
    public health emergency of international concerns with this
    current outbreak. And what we saw was that countries even
    before the declaration, but certainly after the declaration did
    just that.
        So, I believe that WHO is in a very difficult position of,
    one, not having enough resources itself. It is still very much
    on the ground in essentially a war zone in the DRC, trying to
    stop the spread of Ebola, and now also managing this and many
    other outbreaks in insecure settings in the world.
        Mr. Bera. I want to be conscious of each of the member's
    times. If you have anything to add to that otherwise, go ahead.
        The Chairman. Thank you.
        Mr. Bera. With that, let me recognize Ms. Wagner from
    Missouri.
        Mrs. Wagner. I thank the Chair very much, certainly for
    organizing this timely hearing. I want to thank all of our
    witnesses for being here today.
        I represent the St. Louis area and greater metropolitan
    region, and many, many of my constituents do business, they
    study, and travel in China. And I appreciate the opportunity to
    learn more about the rapidly changing coronavirus outbreak so I
    can share best practices and up-to-date information with other
    St. Louisians in Missouri's 2d congressional District
    specifically.
        And I would like to just say this, contrary to some of the
    things that are being represented here today, I have had a
    number of briefings. I probably attended at least three myself.
    My staff has had daily briefings from the NIH, CDA--or CDC,
    Health and Human Services, the Administration. So, I want to
    applaud the Trump administration for an amazing amount of
    information, transparency, and trying to keep us up to date on
    things that are really very frightening I think globally, and
    certainly here at home.
        I also would like to thank Representatives Connolly and
    Chabot for introducing the bipartisan Global Health Security
    Act to establish a permanent official responsible for epidemic
    and pandemic preparedness. I am proud to be an original co-
    sponsor of the bill. And I urge my colleague to support it.
        Health systems across the developing world lack the
    capacity to control the spread of the novel coronavirus. Mr.
    Klain, how is--I will ask the question and then I want to put a
    context on it--I want to know how the U.S., and it sounds
    broad, but how is the U.S. helping these partners to prepare?
        I know for a fact that the CDC and the NIH here in the
    United States of America have been begging in very early
    January China to come in, help, be there on the ground. And it
    took them 3 weeks, it wasn't until about the 28th or 29th of
    January before they finally said, oh, please, rush on over. We
    could use the help and the assistance.
        And we are there on the ground in a very big presence and
    way.
        So, what else are we doing to help, help these partners
    prepare? What more needs to be done?
        Mr. Klain. Well, thank you, Congresswoman. And I was
    waiting for either Mr. Connolly or Mr. Chabot to show up here
    to praise their bill that you are the co-sponsor of.
        Mrs. Wagner. Yes.
        Mr. Klain. I think H.R. 2166----
        Mrs. Wagner. Yes.
        Mr. Klain [continuing]. Is vital legislation. I hope this
    committee and the Congress will act on it, bipartisan as well,
    as it should be.
        What I would say is, and this is why I have been a little
    perhaps more critical of the Chinese than Dr. Nuzzo, I think
    this delay of a month of getting our people on the ground there
    in China is hard to explain and hard to justify. And I think it
    is good that we have some people there. We should have more
    experts there.
        We have the best experts in the world here working for our
    government. Having them on the ground I think would be of use.
        Mrs. Wagner. And we were trying for over a month to get----
        Mr. Klain. Yes. Yes, ma'am.
        Mrs. Wagner [continuing]. Get there. And we will come up
    with a cure and the vaccine. Now, sadly, it will take months
    and months to probably do that, but.
        Mr. Klain. Yes, ma'am.
        The other thing I would say is we also needed to work with
    the nations around China; right? We are going to see spread of
    this virus certainly through the region, probably globally, but
    certainly first and foremost through the region. Other nations
    in the neighborhood have less advanced health care systems than
    China, less resources, less ability to manage this than even
    the Chinese do. So, we ought to be reaching out to them to see
    what we can do to help them. They may need more direct
    assistance from us in terms of the response.
        And, of course, we need to be beefing up our own
    preparedness for cases here.
        Mrs. Wagner. Well, I think we are doing that. I think we
    are very much on top of that. That is certainly what the
    briefings have been telling, telling me.
        Dr. Nuzzo, what challenges does the U.S. face in deploying
    testing services?
        Dr. Nuzzo. Thank you. That is an area that I am
    particularly concerned about. There seems to be a testing lag
    right now for individuals here in the United States. That is in
    part because the CDC has been doing all of the testing. And I
    know that they plan to roll test kits out to the State
    laboratories, which I think will be essentially important. And
    it is essential that States think about how they are going to
    be doing the testing and what the plan is for that.
        But we do not just need it at public health labs, we also
    need it at hospitals and health clinics so that doctors can use
    it to guide treatment and isolate patients.
        Mrs. Wagner. Well, and in addition, given that respirators
    and other medical equipment are largely produced and shipped
    from China, how can we best address supply chain issues--I keep
    hearing this over and over again--supply chain issues that
    could become critical if the coronavirus were to spread more
    widely in the U.S.?
        I mean, I talked about some of the medical equipment and
    respirators that are mainly sourced, being produced in China.
    But it is also masks, it is so many things. So, can you speak
    to that, please?
        Dr. Nuzzo. Yes. So, we need to assessing the medical supply
    chain and see where there are potential vulnerabilities. That
    is, I know, work that has been ongoing. And I have been
    encouraged to hear that the agencies have been working on that.
    But it also needs to be addressed at the political strategy
    level in China because the decisions that they are making
    internally could impact that beyond just our own assessment of
    what country is producing where, and can we get it from
    somewhere else.
        This summer, the U.S. experienced critical shortages in the
    drug Heparin, which is a blood thinner.
        Mrs. Wagner. Right.
        Dr. Nuzzo. This shortage was in part due to China's efforts
    to control the spread of African swine fever, which is not a
    human disease, it is a pig disease. They were culling pigs. You
    need the pigs to make the Heparin.
        So, we have already seen the impact of how decisions made
    in the name of controlling a disease can affect health and
    health care here in the U.S.
        Mrs. Wagner. I have a lot of other questions. I will go
    ahead and submit them.
        I appreciate the chair's indulgence. And I will yield back.
    Thank you, all, for being here.
        Mr. Bera. Great. Thank you. I appreciate my colleagues.
    And, again, a compliment to the Administration that the
    briefings that they have been giving us, their experts, et
    cetera, on a regular basis, as well as to our staff. That said,
    we would love for those experts to come before our committee in
    a public setting to answer those questions.
        And what we are really asking for is how can we be of
    assistance? You know, what do they need from Congress in terms
    of appropriations, et cetera? And, again, these experts ought
    to be talking to the public and not just Members of Congress.
        With that, let me recognize Ms. Spanberger from Virginia.
        Ms. Spanberger. Thank you very much, Mr. Chairman. And to
    our witnesses today, thank you very much for what has been a
    very interesting conversation focused on the epidemiology of
    this disease and how it is spreading, and also a policy
    discussion related to what we can do as Members of Congress.
        And, Mr. Klain, I would also like to thank you for your
    very specific 7-point plan and recommendations of things that
    we should see from a Federal perspective out of Washington to
    help with this and future, future viruses and future outbreaks.
        And you have talked about the need for high-level diplomacy
    to address threats on the ground. And so, I would like to
    briefly just talk about that from this committee's perspective.
    Looking long-term, I have deep concerns about the fact that we
    have vacancies at State Department and other agencies, we have
    individuals who continue to work in acting positions not fully
    confirmed.
        And reflecting back on your experiences working with other
    outbreaks, looking forward toward what we are dealing with now,
    could you just tell me briefly what your day to day experiences
    were, how much you were interacting with diplomats and with
    civil servants, and how some of these staffing challenges might
    be impacting our ability to react currently?
        Mr. Klain. Yes, thank you, Congresswoman.
        My job in coordinating the Ebola response was really to
    oversee the all-of-government response that President Obama
    summoned. And that means daily interactions with key people at
    the agencies at all levels, some at the cabinet level, some
    below that.
        I think the good news is many really high-quality people
    remain in key posts. Tony Fauci is a national icon and hero.
    Dr. Schuchat at the CDC, others throughout the government. We
    have great people, Ambassador Green at USAID for example.
        But I do worry about some of the gaps, particularly at DHS.
    You know, Congressman Perry was saying how could you possibly
    screen all these people coming here, and so on and so forth?
    That is a DHS function. It will require great skill and
    organization to do that. I worry about the vacancies there.
        I worry about the loss of institutional capacity for
    highest levels of the State Department, which has to manage so
    much of the logistics of an international response.
        So, there are gaps. We have some great people in our
    government. We have some gaps in our government. And we are
    going to need to manage all that.
        And last, as I said, I think someone at the White House
    really needs to be running this every day to help fill those
    gaps, but also to be interacting with other countries. I had
    daily calls with people in Liberia, Sierra Leone, Guinea,
    weekly calls with my counterparts in the U.K. and France. These
    are high-level interactions that really are needed to make a
    global response like this effective.
        Ms. Spanberger. Thank you very much.
        And, Dr. Nuzzo, as we are looking at contagious outbreaks,
    and in this case there is a contagious outbreak that is
    happening on the other side of the world. And all of us
    represent districts here in the United States. My question for
    you is how could or how should the Federal Government work in
    ensuring that medical providers across the United States can
    deal with some of the concerns, have the information they need,
    have the resources that they need? And that is one part of it.
        And then the other part of it would be how can we help as
    Members of Congress to ensure that the information is getting
    out there and that these physicians and hospitals have what
    they need?
        And do you anticipate that there are specific resources
    that will need to be mobilized to support clinicians across the
    country if we do see increased spread here at home?
        Dr. Nuzzo. Yes, thank you.
        I had said earlier that although we have a perception of
    this as an epidemic that is happening across the world, we
    actually do not have enough information to say for sure where
    it is happening. We are only testing around people's
    connections with China.
        Ms. Spanberger. Does that mean that are you asserting that
    it could be elsewhere and we are not yet attuned to that?
        Dr. Nuzzo. Yes.
        Ms. Spanberger. OK. Thank you.
        Dr. Nuzzo. And that is what other countries are doing as
    well. I mean, it could very well already be here.
        And I think an important thing for us to all consider in
    thinking about this is it is not just about how many cases we
    have in the world but our level of concern should be tiered to
    what our perception of the severity is. And I continue to be
    encouraged by the fact that we are seeing many, many more mild
    cases than we initially thought were possible, particularly
    outside of China.
        As I said earlier, we need to understand what is going on
    in China about those severe cases and deaths to know if they
    are in the people that we would expect to have severe illness
    and death regardless of what pathogen, what respiratory virus
    they have.
        It seems like some of the death reports that that is the
    case, the elderly and people with underlying medical
    conditions.
        Ms. Spanberger. Uh-huh.
        Dr. Nuzzo. And if you walk into any hospital in the United
    States and just look for people suffering from respiratory
    viruses you would see disturbing things.
        I think the critical thing that we need here in the United
    States is enhanced diagnostic capabilities. We are moving test
    kits to the State labs, which will be important for
    supplementing our understanding of the virus and where it is,
    and potentially to think about expanding the categories of
    people that we test. But we also need this in health care
    clinics so that they do not have to wait a day or more to get a
    test result for a patient to make a decision about whether or
    not to isolate somebody, how they should treat them, et cetera.
        And although we have heard a lot attention on medicines and
    vaccines, there is less attention to diagnostics. And so, I
    think that is where a funding opportunity as well as funding
    for State health departments and hospitals who are going to be
    on the front lines of this.
        Ms. Spanberger. And just a followup point quickly on that.
    So, in the absence of those diagnostic tools in clinics and
    with health providers across the country, the alternative then
    is what?
        Dr. Nuzzo. The alternative is you do not get tested for
    coronavirus. I mean, we are only at this point testing absent
    the people who are traveling. But in the United States you have
    to have a lower respiratory infection and have traveled to
    Wuhan specifically.
        Ms. Spanberger. Uh-huh.
        Dr. Nuzzo. Or, if you have traveled to China, broader China
    you have to be hospitalized for your infection.
        So, we are only looking at a very small number of people.
    And so your earlier point about people's level of concern, et
    cetera, I think having diagnostic tools to help know what
    people's illnesses are will be useful.
        Ms. Spanberger. And in the absence of that testing, from
    your perspective and your role, how does that contribute to the
    spread of disease at a faster, slower?
        Dr. Nuzzo. It absolutely contributes to the spread oft he
    disease because we do not know where it is. We do not know who
    to stop from coming, and we do not know who to isolate.
        But I continue to be encouraged by the appearance of mild
    symptoms because it is important to recognize that we live with
    a whole lot of respiratory viruses that do not, we do not have
    hearings about.
        Ms. Spanberger. Thank you. I have gone well over time.
    Thank you very much, Mr. Chairman. I yield back.
        Mr. Bera. Thank you.
        I recognize Ms. Titus from Nevada for 5 minutes.
        Ms. Titus. Thank you, Mr. Chairman.
        Dr. Bouey, do you need to finish that conversation?
        Dr. Bouey. If I could. I would, because Dr. Nuzzo mentioned
    several times that the cases outside China are milder, I, you
    know, no one--I agree with her question, but some hypotheses
    or, you know, potential answers are in China, especially in
    Wuhan, within China there are different, we see different
    percentage of fatality. Wuhan is the highest.
        So, I wonder if Wuhan they, only hospitals have noticed
    people who have the most symptoms. So there is a, it is a
    reflection of a lack of resources medically.
        Ms. Titus. Well, thank you.
        Ms. Spanberger, you got that? OK, thank you.
        Well, now I would like to ask you something. In your
    remarks you said that in 2003 the industries hurt most by SARS
    were tourism, retail, and entertainment. And at that point
    those industries made up 43 percent of China's GDP. They now
    account for 54 percent. And China contributes a much larger
    share to the world's economy.
        I serve as the co-chair of the Travel and Tourism Caucus,
    and I recognize the huge impact of tourism on local economies.
    Also, China has expressed concern about travel restrictions
    that have been announced by the White House and noted correctly
    that the World Health Organization advises against the
    application of restrictions of international traffic, based on
    the information that is currently available.
        Could you address how we might balance U.S. security
    precautions with the negative impact that these restrictions on
    travel have had on travel and tourism here in the U.S., and on
    international commercial activities? And then either one of you
    could also weigh in.
        Dr. Bouey. So, if I can say quickly, that I think both
    quarantines and travel bans, all of these social distancing
    measures can harm the economy. So, it is always a--so, often I
    tell people, I am a public health researcher, a public health
    worker, then I am all for social distancing. But usually it is
    not just me talking, it is the economy is also talking.
        So, as you mentioned that in my report I provided some
    statistics that it is going to harm China's GDP. And how much,
    it depends how long the quarantine will be on, how long the
    travel ban will be on. So, I urge all the policymakers to think
    about these measures as temporary measures and certainly
    balance the economic loss versus health care concerns.
        Ms. Titus. Mr. Klain?
        Mr. Klain. Congresswoman, I would just add we live in a
    global economy, interconnected economy. It is impossible,
    impossible to cutoff the flow of people from China to the
    United States. They are needed to bring vital goods to the
    United States by boat and by plane.
        We have Americans coming back, to and from, back from
    China, family members, so on and so forth.
        So, my point about travel bans is beyond the effectiveness
    issue that Dr. Nuzzo has raised, as a practical matter we do
    not have one, we will never have one. And, therefore, what we
    need to do is to monitor the people who have been in China
    recently who are here in the U.S. and pose public health
    measures on a very large scale. This is a complicated, it is a
    hard problem to detect if those people get sick, to isolate
    them, and to treat them.
        This isn't about academics, it is the only practical
    solution on the facts we face here.
        Ms. Titus. Dr. Nuzzo?
        Dr. Nuzzo. I was just reacting to the notion of monitoring.
    And I agree that it is a preferable approach than the
    restriction of travel and the quarantine. I am less optimistic
    about the impact of those measures. And just reflecting on
    Ebola, that we monitored 30,000 individuals and found not a
    single case of Ebola. And, yet, those programs that were
    essentially necessarily set up overnight, in many respects
    diverted resources from, I think, more important work.
        So, I, I used to be a public health practitioner, so I am
    thinking from the field and what it means for them. You know,
    these measures are only as effective as people believe in their
    utility. There was an important paper where a bunch of
    clinicians were monitored for their symptoms for Ebola upon
    returning. And a large, surprisingly large percentage of them
    reported that they lied about their temperatures because they
    did not believe that they should be monitored.
        So, nothing is perfect. And if that is where we need to go
    I, truthfully, from an epidemiological perspective think that
    those approaches are more about politics than public health.
    But if that is what is needed to be done to provide assurances
    and to make people feel better, then I, in my view it is
    potentially less resource intensive than some of what I have
    also heard proposed.
        Ms. Titus. Well, not only does a travel ban, or
    restrictions, or monitoring impact the economy, does not it
    also make it more difficult to share information so that we can
    address the outbreaks quickly or get international cooperation
    from others addressing the problem?
        Dr. Nuzzo. So, I am deeply concerned about penalizing
    countries that report cases. And when you implement travel bans
    and trade restrictions, that is a penalty.
        China may be able to handle it, but other countries around
    the world are watching who haven't yet reported any cases. And
    I can imagine they are seeing what is playing out and thinking
    is it in their best interest to tell, to even look for cases
    first of all. So, that is something that I am particularly
    concerned about.
        I also agree with all the statements that have been made
    about the importance of gaining access to data in China. I
    particularly think China understands that severity is a matter
    of priority. And I do not truthfully understand what the rate-
    limiting step is. I am not sure that they do not have the right
    epidemiologists or scientists. I think China is actually quite
    capable, the fact that they have pumped out many Lancet and New
    England Journal of Medicine papers does not signal to me a lack
    of expertise.
        I wouldn't be surprised if we see a paper next week that
    tells us more than we already know. But I think that this is
    critically important, and we should do everything in our power
    to make sure we continue to incentivize the flow of
    information.
        Ms. Titus. So, it affects, negatively affects the economy,
    travel and tourism; negatively affects our ability to get
    information; negatively affects our ability to cooperate with
    other countries. And, finally, we have in the past sent health
    care workers to other countries where these outbreaks occur,
    like Ebola. But now with this new approach of bringing people
    home, that cuts off that assistance as well, does not it?
        Dr. Nuzzo. And just to add to that, what happened in Ebola,
    even with threats of quarantine for health care workers,
    actually put a chilling effect on the number of doctors and
    nurses who were willing to go volunteer, essentially put their
    lives on the line to fight a deadly virus. Just the prospect of
    coming back and having to, in addition to the time away from
    their families and their jobs, then we put into quarantine,
    that is another concern that I have.
        Mr. Klain. If I could just very quickly. I think it is
    important that public health and scientific analysis drive
    these decisions, not politics. So, the same day that we
    quarantined a charter plane of Americans coming from Wuhan,
    that same day planes landed at airports all over this country
    bringing people from China to airports all over this country.
    OK?
        And so, you know, I just think that these policies on
    travel restrictions and quarantines, which I understand why
    they are politically compelling, I understand why one of the
    members earlier said it kind of, like, passes the common sense
    test. But policies that are kind of filled with Swiss cheese
    and exceptions and unevenly applied do not keep us safe, and
    raise the kinds of concerns about cooperation and effectiveness
    that Dr. Nuzzo raised.
        So, whatever we do, I think we need to be candid about what
    we are doing and what we are not doing, and let science drive
    those decisions.
        Mr. Bera. Great. Let me take the chair's liberty here and
    give each of the witnesses a minute or two, if there is
    anything we did not ask that we should have been asking or
    thinking about, or that would be in the public's interest of
    asking. Maybe we will start with you, Mr. Klain. Again, a
    minute or two just.
        Mr. Klain. Yes. What I would say just very briefly is
    Congressman Sherman said before he left that we have a tendency
    to overreact to these things. And what I would say is it is
    actually more complicated than that.
        We have a tendency to overreact in the short term and then
    underreact in the long term. After the 2001 anthrax attacks
    this body appropriated billions of dollars to prepare for a
    potential pandemic. And most of those investments were
    frittered away because they weren't followed up. Most of that
    was gone when I took over the Ebola response in 2014.
        This body then put billions of dollars into responding to
    Ebola very effectively. And, yet, before the coronavirus
    outbreak we were set to see the national hospital network that
    protects us from these infectious diseases expire in May
    without being renewed.
        So, what I would say is we should address this crisis or
    this challenge immediately, but also make the consistent long-
    term investments in pandemic preparedness and response that are
    vital to keep this Nation safe over the long run. Again, I
    think the Connolly Chabot bill is a good start on that. There
    are many other proposals. But I think it is consistent focus
    that really keeps this country safe.
        Mr. Bera. Great.
        Dr. Bouey, if there is anything that you would like to add
    or we should have asked?
        Dr. Bouey. I will focus, I will emphasize that it is a
    battle between human and the virus. It is not between persons
    to person, and it is not between party to party, it is not
    between country to country.
        I really hope that global health should be a area for
    research for health care collaborations that is beyond all the
    conflict. It think it needs a long-term investment, not only in
    the infrastructure but also in collaboration, in capacity
    building.
        And I hope, no matter what happens between the two
    countries, between the two parties, that this area can be
    protected because this is critical for every country, for all
    the human beings. So, this should be more than just pointing
    fingers. But this is a time for collaboration.
        Mr. Bera. Thank you, Dr. Bouey.
        Dr. Nuzzo.
        Dr. Nuzzo. As I mentioned in my remarks, I am increasingly
    of the belief that this virus is not something that we can stop
    at borders, that we cannot contain it, that we should be
    probably shifting our focus to one more of trying to mitigate
    its spread and mitigate the impacts. And as I look at th
    situation it is, of course, evolving and complex, but it is
    increasing to me--increasingly to me looking like what we saw
    in 2009 with the influenza pandemic.
        And we have a number of things that we learned during 2009.
    So, we learned that the travel restrictions and the quarantines
    did not stop the spread. Within months the virus was
    everywhere. And that is because we had more capability to do
    surveillance for flu than we have for novel coronavirus right
    now. So, I wouldn't be surprised if we had those capabilities
    if we saw a very similar map to what we saw in 2009.
        So, I really think we should be thinking about it in the
    context of that and asking, if this were flu would we be doing
    these things?
        Obviously, there are still questions about severity. But
    increasingly, and my, my perspective is that we will find more
    cases and our perception of severity will decline.
        The other thing I want to point out is that I actually see
    some optimism here. Just looking at what we have learned in the
    amount of time that we have learned from countries who have
    previously had difficulties, like for instance South Korea, in
    2015 it had a very bad MERS outbreak that caught it off guard,
    they really struggled with, and their information and their
    ability to do surveillance. And an epi investigation of the
    case, the novel coronavirus cases to me is the symbol of what
    our goals are when we make investments and we work with
    countries to improve their capacities. And we are the direct
    benefits of that.
        So, I just want to stress that it is we need more
    information from other countries. The fact that they are able
    to get this information is likely because of our help and
    assistance in many places. We should continue those efforts,
    not just as I mentioned in China, but in other countries that
    we expect to struggle. And I think that we should continue to
    assess our plans based on the information that we have coming
    in and, crucially, in my mind not so much the number of cases
    but the severity.
        Mr. Bera. Great. Thank you.
        Let me allow the ranking member to make a closing statement
    and I will make one myself.
        Mr. Yoho. Well, I appreciate everybody being here. And, Mr.
    Klain, I have this article here and you are saying we need to
    keep politics out of it and need to be factual based. But just
    the title of this, ``Coronavirus Is Coming and Trump Isn't
    Ready.`` And I read it, and there is a lot of politics in that
    article. That is all I am going to say.
        Dr. Nuzzo and Dr. Bouey, you are both epidemiologists. We
    know that the epicenter is supposedly the Wuhan area, the fish
    market and the wet market. Correct?
        Dr. Bouey. Yes.
        Mr. Yoho. Do you feel it was sufficiently studied to get
    the possible original outbreak of where it came from? Do you
    feel that? Do you have any indication?
        Dr. Nuzzo. The answer is no. One of the concerns----
        Mr. Yoho. You said no, you do not think it was?
        Dr. Nuzzo. No, I do not think it was sufficiently studied.
        Mr. Yoho. OK.
        Dr. Nuzzo. And I know that I have heard not just WHO, but
    also some of the major philanthropies are putting money toward
    enhancing the study of that, trying----
        Mr. Yoho. Yet the Chinese Government destroyed it
    completely, the way I understand it. Is that correct?
        Dr. Nuzzo. I do not, I do not have any information about
    that.
        Mr. Yoho. Dr. Bouey, do you know?
        Dr. Bouey. I know they, after they announced the outbreak
    they closed the animal, the wet market the next day. They
    thought it was the sources. We do not know.
        We do not know whether there is a person working there had
    the first case and transmitted to other people or the animal
    source was there. We do not know that.
        Mr. Yoho. But that supposedly was where it was reported
    where it came from. But then we have heard it was completely
    demolished and destroyed. And that, there again that creates a
    cloud of confusion. You know, what is their intent.
        And if we are going to work on this collaboratively
    together between countries, politics needs to go away and it
    needs to be based on science because this is something that we
    are all in threat of. And I think you brought up over and over
    again how it does not seem to be as virulent in other
    countries. And let's hope it maintains that way.
        But I worry about countries like in Africa where there is
    large Chinese population in the Belt Road Initiative, and their
    inability to check with diagnostic equipment.
        So, this is something that is going to be fluid, we are
    going to watch, and we want to make----
        Dr. Bouey. I think it is to everyone's advantage to know
    where it comes from.
        Mr. Yoho. Right.
        Dr. Bouey. So, I do not think it is Americans or Chinese,
    it is everyone wants to know that.
        Mr. Yoho. Sure. We are all here together.
        Thank you all. Appreciate it. Mr. Chairman, thank you.
        Mr. Bera. Great. Thank you.
        And just in close, first-off I want to thank each of you
    for taking the time to come here as well as your service to
    both science as well as to our country and the global
    community.
        You know, again, the message to the Administration here is
    we are here to work as Congress. We are all on the same page
    here. And to the global community and to the Chinese, you know,
    let's get ahead of this. And it will take all of our resources
    to learn as much as we can.
        You know, I think I cannot speak for the CDC, but in my
    conversations with the CDC, with Dr. Fauci and others, we want
    to get there and work with you side by side. And if there is
    one thing that we can do it is that second thing is really put
    someone in control of this.
        This isn't the last time we are going to see a pandemic.
    This isn't the last time we are going to be dealing with a
    viral outbreak. And as we get ahead of this let's not--Mr.
    Klain, you talked about this as let's stop just responding to
    crisis after crisis, let's actually make this part of our
    national security agenda.
        And I had the privilege of being a commission member for
    CSIS. They just came out with a recommendation on what we could
    be doing with regards to global health security. And in a
    bipartisan way it was a great commission, great Members of
    Congress on there, but also, you know, working closely with the
    Administration and others to come up with recommendations.
        And I would say let's deal with the situation that we have
    in front of us right now, but then let's take some of those
    recommendations and act on them.
        So, you know, again I thank the witnesses and all the
    members for being here today. And with that, the committee is
    adjourned.
        [Whereupon, at 3:54 p.m., the subcommittee was adjourned.]

                                    APPENDIX

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                      OPENING STATEMENT FROM CHAIRMAN BERA

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