[Senate Hearing 116-208]
[From the U.S. Government Publishing Office]





                                                        S. Hrg. 116-208
 
                     CONFRONTING EBOLA: ADDRESSING A 
                   21st CENTURY GLOBAL HEALTH CRISIS

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

                                HEARING
                                
                               BEFORE THE

                       SUBCOMMITTEE ON AFRICA AND
                          GLOBAL HEALTH POLICY 
                          
                                 OF THE
                                 
                     COMMITTEE ON FOREIGN RELATIONS
                          UNITED STATES SENATE


                     ONE HUNDRED SIXTEENTH CONGRESS

                             FIRST SESSION



                               __________

                             JULY 24, 2019

                               __________



       Printed for the use of the Committee on Foreign Relations
       
       
       
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              U.S. GOVERNMENT PUBLISHING OFFICE 
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                 COMMITTEE ON FOREIGN RELATIONS        

                JAMES E. RISCH, Idaho, Chairman        
MARCO RUBIO, Florida                 ROBERT MENENDEZ, New Jersey
RON JOHNSON, Wisconsin               BENJAMIN L. CARDIN, Maryland
CORY GARDNER, Colorado               JEANNE SHAHEEN, New Hampshire
MITT ROMNEY, Utah                    CHRISTOPHER A. COONS, Delaware
LINDSEY GRAHAM, South Carolina       TOM UDALL, New Mexico
JOHNNY ISAKSON, Georgia              CHRISTOPHER MURPHY, Connecticut
JOHN BARRASSO, Wyoming               TIM KAINE, Virginia
ROB PORTMAN, Ohio                    EDWARD J. MARKEY, Massachusetts
RAND PAUL, Kentucky                  JEFF MERKLEY, Oregon
TODD, YOUNG, Indiana                 CORY A. BOOKER, New Jersey
TED CRUZ, Texas
              Christopher M. Socha, Staff Director        
            Jessica Lewis, Democratic Staff Director        
                    John Dutton, Chief Clerk        




                   SUBCOMMITTEE ON AFRICA AND        
                      GLOBAL HEALTH POLICY        

            LINDSEY GRAHAM, South Carolina, Chairman        
JOHNNY ISAKSON, Georgia              TIM KAINE, Virginia
ROB PORTMAN, Ohio                    CHRISTOPHER A. COONS, Delaware
RON JOHNSON, Wisconsin               CORY A. BOOKER, New Jersey
TED CRUZ, Texas                      CHRISTOPHER MURPHY, Connecticut

                              (ii)        

  


                            C O N T E N T S

                              ----------                              
                                                                   Page

Graham, Hon. Lindsey, U.S. Senator From South Carolina...........     1

Kaine, Hon. Tim, U.S. Senator From Virginia......................     1

Wolfe, MD, Mitch, Chief Medical Officer, Centers for Disease 
  Control and Prevention, U.S. Department of Health and Human 
  Services, Washington, DC.......................................     3
    Prepared statement...........................................     4

Ziemer, Rear Admiral Tim, USN, Retired, Senior Deputy Assistant 
  Administrator, Bureau for Democracy, Conflict, and Humanitarian 
  Assistance, U.S. Agency for International Development, 
  Washington, DC.................................................    11
    Prepared statement...........................................    12

Bernicat, Hon. Marcia, Principal Deputy Assistant Secretary, 
  Bureau of Oceans and International Environmental and Scientific 
  Affairs, U.S. Department of State, Washington, DC..............    16
    Prepared statement...........................................    17

Nagy, Hon. Tibor, Assistant Secretary, Bureau of African Affairs, 
  U.S. Department of State, Washington, DC.......................    18
    Prepared statement...........................................    20

              Additional Material Submitted for the Record

Responses of Hon. Tibor Nagy to Questions Submitted by Senator 
  Robert Menendez................................................    35

Responses of Hon. Tibor Nagy to Questions Submitted by Senator 
  Edward J. Markey...............................................    36

Responses of Hon. Marcia Bernicat to Questions Submitted by 
  Senator Robert Menendez........................................    38

Responses of Hon. Marcia Bernicat to Questions Submitted by 
  Senator 
  Edward J. Markey...............................................    39

Responses of Rear Admiral Tim Ziemer, USN, Retired to Questions 
  Submitted by Senator Robert Menendez...........................    40

Responses of Rear Admiral Tim Ziemer, USN, Retired to Questions 
  Submitted by Senator Edward J. Markey..........................    44

Responses of Dr. Mitch Wolfe to Questions Submitted by Senator 
  Edward J. Markey...............................................    46

                             (iii)        


                    CONFRONTING EBOLA: ADDRESSING A

                   21st CENTURY GLOBAL HEALTH CRISIS

                              ----------                              


                        WEDNESDAY, JULY 24, 2019

                               U.S. Senate,
   Subcommittee on Africa and Global Health Policy,
                            Committee on Foreign Relations,
                                                    Washington, DC.
    The subcommittee met, pursuant to notice, at 2:35 p.m. in 
room SD-419, Dirksen Senate Office Building, Hon. Lindsey 
Graham, chairman of the subcommittee, presiding.
    Present: Senators Graham [presiding], Kaine, Menendez, 
Coons, and Murphy.

           OPENING STATEMENT OF HON. LINDSEY GRAHAM, 
                U.S. SENATOR FROM SOUTH CAROLINA

    Senator Graham. Thank you. The hearing will come to order. 
I apologize for being late. It is one of those days where you 
start late and you wind up late.
    Really an impressive panel. And what brings us here is we 
had the 10th outbreak, the second largest in history, in the 
Republic of Congo, in areas that have been, without a doubt, 
have been conflict zones. This is sort of the worst case 
situation. There is no governance in these places. It is a war 
torn region. Thousands have been killed and displaced. In the 
middle of all this mess, you have an Ebola outbreak without a 
whole lot of governance to deliver relief. And this hearing is 
going to focus on what we can do and should do and what are the 
consequences of doing nothing.
    I just appreciate Senator Kaine very much being a good 
partner. And I will introduce the panel after your opening 
statement.

                 STATEMENT OF HON. TIM KAINE, 
                   U.S. SENATOR FROM VIRGINIA

    Senator Kaine. Great. Thank you, Mr. Chair, and thanks to 
all the witnesses.
    The chair and I talked about doing this hearing after a 
hearing 6 weeks or so ago with the USAID Administrator, Mark 
Green. And it is very, very timely. He talked about the need 
for us to focus more on this.
    And 1 week ago today, the World Health Organization, after 
an Ebola case was discovered in the City of Goma, declared this 
outbreak of Ebola a public health emergency of international 
concern. For those who do not follow the WHO terminology, they 
have just done this five times in their history--has there been 
an outbreak of such significance that they have declared a 
public health emergency of international concern. The earlier 
instances were a polio virus in 2014, swine flu in 2009, Ebola 
in West Africa in 2014, and the Zika outbreak in 2016. So this 
was an outbreak that started, I believe, in August of 2018 in 
Uganda and the DRC, but it has now significantly affected 1,700 
deaths, more than 1,700 deaths, 2,600 cases. And so the WHO has 
now weighed in, and we have to decide what to do about it, what 
the U.S. can do in tandem with other partners.
    The chairman made a good point. This is a public health 
emergency, but the solution is not just a health care solution 
because we are dealing with conflict. We are dealing with 
failed democracy. We are dealing with failed systems. And so 
how do we end that situation to deal with this significant 
health emergency. The answer will be broader than just narrow 
health. Certainly health expertise and creativity can be part 
of it, but it is going to have to be bigger than that.
    And so the idea today is to hear from each of you in your 
own areas of expertise and get your advice for what we can do 
in Congress to be helpful.
    So thank you, Mr. Chair. I look forward to the hearing 
today.
    Senator Graham. Thank you.
    And to put a fine point on what Senator Kaine said, this is 
a case study, exhibit A, as to why you cannot withdraw from the 
world. To those who believe that things over there are not our 
problem over here, you are going to learn pretty quickly that 
when it comes to diseases like this, if you do not get ahead of 
it, you are going to regret it. And this is not just about a 
medical problem. This is a governance problem. This is a whole-
of-government problem.
    So when you start cutting developmental budgets, you are 
going to get more of this, not less. So every time I hear 
somebody wanting to cut foreign assistance which is $30-
something billion of a $4 trillion dollar budget, I keep 
thinking what world are you looking at. So that is my 
commercial for our committee.
    So to people who know what they are talking about far more 
than I do when it comes to Ebola, we are going to start with 
Dr. Mitch Wolfe, a medical doctor, Chief Medical Officer, 
Centers for Disease Control and Prevention, U.S. Department of 
Health and Human Services. He is the technical and medical lead 
for the response.
    We have Rear Admiral Tim Ziemer, USN, Retired, Senior 
Deputy Assistant Administrator, Bureau for Democracy, Conflict, 
and Humanitarian Assistance, USAID, providing assistance to the 
U.N. and NGOs fighting Ebola.
    The Honorable Marcia Bernicat, Principal Deputy Assistant 
Secretary, Bureau of Oceans and International Environmental and 
Scientific Affairs, U.S. Department of State. She is the lead 
for the interagency in diplomatic response.
    And finally, Assistant Secretary Tibor Nagy, Bureau of 
African Affairs, U.S. Department of State, who will focus on 
the regional political aspects of Ebola.
    Let us start with Dr. Wolfe.

 STATEMENT OF MITCH WOLFE, MD, CHIEF MEDICAL OFFICER, CENTERS 
 FOR DISEASE CONTROL AND PREVENTION, U.S. DEPARTMENT OF HEALTH 
               AND HUMAN SERVICES, WASHINGTON, DC

    Dr. Wolfe. Good afternoon, Chairman Graham, Ranking Member 
Kaine, and members of the subcommittee. I am Dr. Mitch Wolfe, 
Chief Medical Officer of the Centers for Disease Control and 
Prevention. I am a rear admiral in the U.S. Public Health 
Service, and I have worked with the Department of Health and 
Human Services for 21 years, 18 of those with CDC, including 10 
years overseas in Vietnam and Thailand working on addressing 
infectious disease threats and helping to build the capacity 
for countries to address these threats at their source.
    Thank you for the opportunity to update you on the Ebola 
outbreak in the DRC and outline what CDC is doing to prevent, 
detect, and respond to this and other emerging global health 
threats. CDC's efforts are grounded in over 40 years of Ebola 
research and more than 20 Ebola outbreak responses. I want to 
emphasize our goal is to end this outbreak as soon as possible.
    This Ebola outbreak, first reported in the DRC in August 
2018, is continuing to spread. As of July 24th, there are a 
total of 2,597 cases and 1,743 deaths, with recent cases in 
Goma and Uganda. The outbreak now encompasses 25 health zones 
in the DRC, and in the past 21 days, we have seen 253 active 
cases in 19 health zones. Of these cases, about a third were 
known and monitored contacts, and even more concerning, roughly 
30 percent were cases identified as community deaths that 
occurred outside of the health care system. A substantial 
percentage of cases were acquired in health care settings, and 
137 health care workers have been infected. In light of this 
regional spread, last week WHO's Director General declared the 
DRC Ebola outbreak a public health emergency of international 
concern.
    This is the first outbreak in DRC that is occurring in a 
densely populated area that has also experienced decades of 
continuing conflict and civil unrest. DRC has reported nine 
previous outbreaks of Ebola, but the two currently affected 
provinces have never experienced an Ebola outbreak and have 
busy, porous borders with Uganda, Rwanda, and South Sudan. 
These challenges make this outbreak extremely difficult to 
contain, and it is not yet under control at this time.
    Over the course of this outbreak, we have deployed 204 
experts from CDC to the DRC and neighboring countries and WHO 
headquarters. And for the past several months, CDC has deployed 
staff to Goma in support of surveillance, vaccination, border 
health, and risk communication. CDC scaled up efforts following 
the announcement of the first Ebola case in Goma, and our staff 
are working directly with responders on the ground there to 
assist with core public health interventions.
    Availability of an Ebola vaccine is a new development since 
the West Africa outbreak. CDC is actively working with the WHO, 
providing technical support for the vaccination program, and 
over 165,000 people in DRC have been vaccinated.
    While vaccine is important and has likely had a mitigating 
effect on the outbreak, vaccination complements but does not 
replace basic and critical public health response activities 
such as contact tracing and rapid identification and isolation 
of ill patients.
    Based on experience from previous outbreaks, an effective 
response depends on early case identification and effective 
isolation of about 70 percent of all cases and sustaining this 
for several months. The fact that we are seeing so many cases 
discovered as community deaths means that we are missing 
contacts and missing the chains of transmission that must be 
identified to bend the curve of the outbreak.
    CDC's work in this outbreak reflects our extensive 
expertise in disease control to inform the response, and CDC 
works in three main avenues organizationally in this outbreak: 
providing direct assistance to the DRC Ministry of Health in 
Kinshasa and in Goma where the incident command is located, 
with the WHO in Geneva, and as the public health lead in the 
disaster assistance response team, or DART. Our work with 
border countries focuses on their ability to quickly identify, 
isolate, and effectively respond to a possible case of Ebola. 
The rapid Ugandan containment of three imported Ebola cases in 
June of this year is a demonstration of the effectiveness of 
these preparedness efforts, which also build on CDC's long-term 
involvement in disease detection, response training, and 
capacity development in Uganda, supported by global health 
security investments.
    While this outbreak continues to be an urgent situation in 
the region, the current risk to America remains low. The most 
effective way to protect America from emerging threats is to 
stop outbreaks at their source before they reach our borders. 
CDC continues to improve the public health workforce abroad, 
having trained over 12,000 public health professionals now in 
70 countries. More than 260 of these professionals are from the 
DRC and many are responding to this outbreak.
    CDC is committed to this response and will continue to 
position our assets globally to quickly respond to emerging 
threats and disease hotspots around the world.
    Thank you for your continued commitment and support to CDC 
and our critical global health security mission.
    [The prepared statement of Dr. Wolfe follows:]

                 Prepared Statement of Dr. Mitch Wolfe

    Good morning Chairman Graham, Ranking Member Kaine, and members of 
the Subcommittee. I am Dr. Mitch Wolfe, Chief Medical Officer of the 
Centers for Disease Control and Prevention (CDC). Thank you for the 
opportunity to testify before you on the Ebola outbreak in the 
Democratic Republic of the Congo (DRC), and thank you for your 
continued commitment to supporting CDC's work in global health 
security.
    This is the tenth and largest outbreak in DRC, and the second 
largest outbreak of Ebola ever recorded since the virus was discovered 
in 1976 in DRC. On July 17, 2019, the World Health Organization 
declared the outbreak a Public Health Emergency of International 
Concern (PHEIC). CDC has worked since last summer, in collaboration 
with interagency and international partners, to end this outbreak and 
ensure the health and security of our country. On June 13, CDC 
announced the activation of its Emergency Operations Center to support 
the response to the ongoing Ebola outbreak in Eastern DRC, which allows 
CDC to provide increased operational support to meet the outbreak's 
evolving challenges, and provides strengthened functional continuity to 
meet the long term commitment needed to end the outbreak. We have 
comprehensive Ebola response capabilities developed over 40 years at 
the forefront of Ebola virus research and further refined by direct 
engagement in more than 20 Ebola outbreak responses globally. In the 
wake of the worst Ebola outbreak in history, the 2014-2016 outbreak in 
West Africa that claimed over 11,000 lives, CDC has made significant 
advancements in Ebola science, surveillance, and response. For example, 
we confirmed that live Ebola virus can persist in specific body fluids, 
such as in seminal fluids, for over a year following infection. We have 
also trained epidemiologists and laboratory scientists, and provided 
testing materials for African countries at greatest risk of an Ebola 
outbreak.
    In addition, in June 2015, we established CDC's Global Rapid 
Response Team, a cadre of over 500 highly-trained CDC responders ready 
to deploy on short notice anywhere in the world to respond to global 
health threats and emergencies.
    As of July 17, CDC expert disease detectives and other staff had 
completed 313 deployments to the DRC, neighboring countries, and the 
World Health Organization (WHO) headquarters in Geneva to provide 
leadership and expertise in surveillance, laboratory testing, data 
analytics, vaccine implementation, emergency management, infection 
prevention and control, behavioral sciences, health communications, and 
border health. In addition, we support coordination of activities among 
response leaders including the DRC Ministry of Health and WHO. Our 
operational expertise allows us to quickly and efficiently identify the 
unique scientific and social variables of outbreaks and address them 
with proven interventions.
    However, the unique challenges of this Ebola outbreak mean this 
fight is even more difficult than past responses. The complex security 
challenges in North Kivu and Ituri provinces have severely limited 
CDC's direct participation at the outbreak's epicenter, which is 
located far from the capital city of Kinshasa in an area threatened by 
armed conflict, crime, and civil unrest, as well as heavy cross-border 
movement into neighboring countries. Violence in the impacted 
communities has hampered Ebola disease surveillance, contact tracing, 
and vaccination efforts. The affected population has low levels of 
trust in the government and the international community. The DRC is 
also experiencing other serious infectious disease outbreaks, such as 
cholera, measles, and malaria, further stressing its health system. 
Additionally, disease control in the impacted area is challenging 
because of weak healthcare and public health infrastructure.
                         status of the epidemic
    On August 1, 2018, the DRC Ministry of Health and Population 
reported an outbreak of Ebola virus disease (EVD) in North Kivu 
Province. As of July 21, the number of cases reported was 2,592, with 
1,737 deaths (a 67 percent fatality rate). Due to challenges in case 
detection and reporting posed by the security situation, CDC suspects 
that the true number of cases could be much larger. As of July 21, 
cases have been reported in 25 health zones of North Kivu and Ituri 
provinces. On June 11, the Ugandan Ministry of Health reported its 
first confirmed case of Ebola; two additional cases, from the same 
family who crossed into Uganda from DRC, were then confirmed on June 
12. There are currently no additional confirmed cases in Uganda, and 
contacts of these cases were closely monitored for 21 days (the 
incubation period for Ebola). More than 3,000 people were vaccinated in 
Uganda to help prevent disease spread from the cases in Kasese 
District, as well as over 4,000 frontline healthcare workers vaccinated 
across the country. To date, no cases of Ebola have been confirmed in 
any other provinces in the DRC or in the other neighboring countries. 
The current outbreak is, however, already the second-worst Ebola 
outbreak ever recorded, with case counts continuing to increase and key 
response indicators showing little improvement.
    Past outbreaks of Ebola in the DRC typically occurred in sparsely-
populated, rural areas. The current outbreak--like the 2014-2016 
outbreak in West Africa--includes densely-populated urban areas, 
increasing the likelihood of human-to-human spread. The outbreak 
initially affected the Mandima health zone and then spread to the town 
of Beni, which has a municipal population of 340,000 and a greater area 
population of about one million. More recently the outbreak has been 
heavily affecting the adjacent North Kivu health zones of Katwa and 
Butembo, which together also encompass an urban area with a population 
of approximately one million. The highly mobile population in this area 
of DRC poses challenges for Ebola responders' contact tracing efforts. 
Affected health zones have experienced reintroduction of Ebola cases to 
areas where disease transmission was previously halted or slowed. The 
number of affected health zones is also increasing; on June 30 an Ebola 
case was identified in a previously unaffected health zone of Ituri 
Province, close to the South Sudan border. On July 14, an Ebola case 
was confirmed for the first time in the city of Goma, which has a 
population of approximately two million people and is on the border 
with Rwanda. CDC staff already embedded in the Goma Emergency 
Operations Center provided direct support to the case investigation, 
including interviewing contacts to establish their level of risk, 
performing an assessment at the health care facility visited by the 
patient, and strengthening the screening process at the Goma airport. 
In each instance, CDC experts were able to quickly identify and correct 
weaknesses in the response, reducing the risk of onward disease 
transmission.
    Escalating violence in some areas has generated significant 
population displacement within DRC as well as across borders. Ongoing 
insecurity limits the effectiveness of public health interventions such 
as case investigation, contact tracing, and vaccination efforts. Many 
of the new cases that are reported each day are identified in later 
stages of illness, meaning that they spent much of their infectious 
period outside of isolation and potentially infected others. Moreover, 
from June 27 to July 17, among the 245 new cases with contact-related 
information, 61 percent were either unknown contacts (not known as 
contacts of previous Ebola patients) or known contacts but not being 
followed by responders at the time of symptom onset. This means that 
contact tracers may be missing chains of transmission and Ebola cases 
may not be identified by responders early enough to prevent further 
transmission.
                       status of response efforts
    The Government of the DRC is leading the response, with strong 
assistance from WHO. CDC is providing technical guidance to the DRC 
government, bordering country governments, WHO and partners, bringing 
to bear decades of experience, global health investments, and lessons 
learned in the West Africa Ebola response. For example, CDC is working 
with WHO and DRC's Ministry of Health to standardize training materials 
and operating procedures for triage and isolation, decontamination of 
healthcare facilities, and routine patient care. All partners are 
working together toward one goal: to end this outbreak as soon as 
possible.
    In August 2018, CDC and USAID briefly deployed Ebola experts to 
Beni for a few days, but they were pulled back due to security 
concerns. In the context of a December 2018 DRC presidential election, 
where several areas of the country experienced a deterioration in the 
overall security situation, U.S. Embassy Kinshasa went on Ordered 
Departure of non-emergency U.S. Government staff and all eligible 
family members on December 14, 2018. When this was lifted on Jan. 31, 
CDC staff returned to DRC to directly support the DRC government, WHO, 
and the integrated U.S. Disaster Assistance Response Team (DART), where 
CDC serves as the public health lead for the DART. As of July 19, 15 
CDC staff were working with Ministry of Health counterparts in DRC in 
the capital of Kinshasa and especially in the North Kivu provincial 
capital of Goma, which has become the DRC government's base of 
operations to respond to the outbreak. Goma is about 300 kilometers 
from the main outbreak areas, and is considered to be more secure. As 
an example of how we work, in March, with U.S. Embassy Kinshasa 
concurrence, two CDC staff deployed to the town of Bunia in Ituri 
Province for 2 weeks to assist with the investigation of a newly 
confirmed Ebola case. CDC made local responders aware that there may be 
unrecognized chains of transmission in Bunia, and CDC advised local 
Bunia staff to better standardize and share information across 
vaccination and contact tracing teams. CDC works closely with the U.S. 
Embassy in Kinshasa to ensure the safety of deployed personnel, and 
routinely defers to the State Department to assess the security 
situation and determine access to the outbreak areas. While not 
currently operating within Beni, Butembo, and other outbreak areas, CDC 
remains prepared to return when it is deemed safe to do so by the U.S. 
Department of State.
    CDC also has deployed staff to augment our existing country offices 
in the neighboring countries of Uganda, Rwanda, and South Sudan. As 
evidenced by the cross-border transmission in Uganda last month, these 
countries are all vulnerable to the possibility of imported cases 
arriving from the DRC. From August 6, 2018 through July 17, 2019, 199 
CDC staff have participated in a combined 313 deployments in response 
to the Ebola outbreak: 98 deployments to DRC; 91 to Geneva; 55 to 
Uganda; 40 to Rwanda; and 29 to South Sudan.
                risk communications and health education
    While the context of the response still presents many challenges, 
efforts to improve cooperation and engagement with local communities 
remains a critical aspect of this Ebola response, and continues to be a 
focus of our work. CDC social and behavioral scientists have deployed 
to DRC, WHO headquarters, and several countries bordering the DRC to 
guide risk communication and community engagement strategies. Experts 
from CDC, WHO, the International Federation of Red Cross and Red 
Crescent Societies (Red Cross), and ICEF continue to work toward 
improving the quality of engagement activities by standardizing 
approaches and developing and delivering communications training to all 
implementing partners.
    A key component of improving community engagement is fulfilling the 
information needs of the community by answering and addressing their 
questions and concerns. Since May, CDC deployers have worked with the 
DRC Ministry of Health and UNICEF on message development and testing, 
analyzing and promoting the use of community feedback data in content 
and strategy development, and long-term risk communication and 
community engagement planning. CDC has also posted multiple Ebola 
prevention-oriented fact sheets, posters, and flip books translated 
into French, Swahili, Kinande, and Kinyarwanda, and recently released a 
video public service announcement (PSA) video featuring Congolese 
native and former NBA star Dikembe Mutombo delivering Ebola prevention 
messages.
                            contact tracing
    Contact tracing is the effort to find everyone who comes in contact 
with a sick Ebola patient, either directly or through contaminated 
materials. The goals of this process are to monitor contacts daily for 
signs of illness and to isolate ill persons before they can infect 
others. One missed contact who develops disease can keep the outbreak 
going. When a case is not known to be a contact, they are usually 
identified in a late stage of illness and may have already spread the 
infection to others. On July 21, a total of 17,253 out of 20,302 (85 
percent) known contacts of people with Ebola were being followed. 
However, as noted earlier, among the new cases with contact information 
from June 27 to July 17, 61 percent were either unknown contacts or 
known but not followed at the time of symptom onset. The high 
proportion of cases that are not known contacts or that are lost to 
follow-up indicates that the quality of contact tracing must improve if 
the outbreak is to be contained; contact tracing efforts have been 
hindered by the volatile security situation. To strengthen contact 
tracing, CDC designed ``train-the-trainers'' courses for frontline 
response workers, focusing on contact tracing methods. CDC also created 
an Ebola ``Exposure Window Calculator'' smartphone app in use by case 
investigators.
        infection prevention and control in healthcare settings
    Healthcare settings have played an important role in amplifying 
transmission in this and many prior outbreaks. Implementing proper 
infection control and prevention practices is critical to stopping the 
spread of the virus within the healthcare delivery system and to the 
community. Prompt identification and isolation of patients arriving at 
healthcare facilities with possible Ebola virus infection is essential 
so that they may be safely evaluated and, if necessary, transported to 
an Ebola Treatment Unit for further care. Infected people who are not 
initially recognized to have Ebola may receive care at multiple 
facilities before Ebola is suspected, exposing numerous patients and 
healthcare workers to the virus. As of July 21, 34 percent of cases 
identified in the preceding 21 days had visited two or more health care 
facilities before being confirmed with Ebola.
    Unfortunately, patients often arrive at specialized Ebola Treatment 
Units late in their illness, and other healthcare facilities in the 
area are not necessarily prepared to effectively or safely care for 
Ebola patients. Patients are more likely to infect others during this 
time, and less likely to survive if treatment is started late. As of 
July 21, 137 local healthcare workers have contracted Ebola in the DRC. 
Within DRC, CDC is collaborating with WHO and the Ministry of Health to 
improve the use of standard procedures for correct patient assessment, 
triage, and infection prevention and control (IPC) practices across 
health facilities and to strengthen the supportive supervision and 
mentoring of healthcare workers.
    In the bordering countries of Uganda and Rwanda, CDC is providing 
assistance to response partners to improve the capacity of healthcare 
facilities to rapidly identify and isolate suspected Ebola cases, train 
personnel, and improve infection prevention and control. At least 150 
healthcare personnel have been trained by CDC in Uganda and Rwanda 
since October 2018. Using information from interviews conducted at 
border crossings, refugee transit centers, and district health offices, 
CDC identified clinics and hospitals in border districts of neighboring 
countries that would be most likely to receive an imported case of 
Ebola from the outbreak area.
    CDC assessed triage practices at these facilities, interviewed and 
informed staff about risks of imported Ebola, and prioritized 
facilities for additional training and support.
                             border health
    The two DRC provinces affected by this outbreak, North Kivu and 
Ituri, both border Uganda. North Kivu also borders Rwanda, and Ituri 
province has a relatively short border with South Sudan. There is 
substantial population movement across these country borders. The 
Mpondwe Border Crossing is the busiest official ground crossings on the 
border between Uganda and the DRC, with a peak of 35,000 travelers 
passing through each day. At the Rubavu District Point of Entry between 
Goma, DRC and Gisenyi/Rubavu City, Rwanda, an estimated 50,000 people 
cross daily. This high volume, which includes pedestrian, commercial 
car, and truck traffic, poses significant concerns for potential cross-
border transmission of infectious diseases. The WHO assesses that there 
is a very high risk of regional spread. Preparedness activities in 
bordering countries are ongoing and CDC is providing technical 
assistance on their border health security efforts. Building on long-
term in-country CDC presence as well as collaborations from the earlier 
2018 outbreak, CDC is working with the DRC Ministry of Health and 
Population and other partners to adapt and implement screening 
protocols at country-prioritized airports and ground crossings, and to 
map population movement into and out of the outbreak zone to determine 
where surveillance and other public health interventions could be 
enhanced. As of July 22, over 77 million travelers have been screened 
at 80 priority ports and crossing points in the DRC since the outbreak 
began.
                         vaccine implementation
    CDC conducted a clinical vaccine trial in Sierra Leone during the 
West Africa Ebola outbreak, enrolling and vaccinating nearly 8,000 
healthcare and frontline workers. This and several other studies have 
suggested that the rVSV-ZEBOV (Merck) investigational vaccine is safe 
and protects against infection with the Ebola virus. While the vaccine 
is not yet licensed, the vaccine is being used in the current outbreak 
in expanded access trials, predominantly in a ring vaccination strategy 
that targets contacts of Ebola case patients for vaccination as well as 
secondary contacts. WHO and the DRC Ministry of Health co-lead the 
vaccination effort, with CDC contributing expert advice. While security 
concerns have prevented CDC from participating in field activities, CDC 
staff are embedded in the DRC Vaccine Commissions in Kinshasa and Goma 
and at WHO headquarters to analyze data and improve the quality of ring 
vaccination efforts.
    CDC has also collaborated with WHO colleagues in Rwanda, South 
Sudan, and Uganda to implement preventative vaccination of health care 
workers in geographic areas near the DRC border, and has provided 
technical assistance to these countries. To date, over 9,000 healthcare 
workers have been vaccinated in the border countries of Rwanda, Uganda 
and South Sudan. In addition, we have applied our expertise to update 
Ebola vaccination protocols, operating procedures, and training and 
communications materials for use at national and local levels, and 
facilitated trainings for national staff. Our work across multiple 
countries has helped standardize procedures and facilitate the use of 
best practices. As of July 17, over 164,000 individuals had been 
vaccinated in DRC.
    On May 7, the WHO Strategic Advisory Group of Experts (SAGE) on 
Immunization published interim recommendations to expand Ebola 
vaccination strategies and address security concerns. Their recommended 
vaccination strategies include ring vaccination, using ``pop-up 
vaccination'' sites at a distance from the residences of contacts, and 
targeted geographic vaccination, where all individuals in a given 
village or neighborhood are invited to receive vaccine. These SAGE 
recommendations also include alternative dosing to help ensure vaccine 
continues to be available. Following the SAGE recommendation, the DRC 
ethical review board approved a protocol to implement vaccination for 
new populations (pregnant women beyond the first trimester, lactating 
women, and infants down to 6 months of age) and to implement 
vaccination at half the previous DRC dosage, which provides a similar 
potency to the vaccine used in the West African outbreak. These changes 
have been implemented in the field since early June 2019.
    With expanded vaccination efforts we continue to underscore that 
strengthening implementation of basic public health measures, 
especially effective engagement and comprehensive identification of 
contacts, will be essential in conjunction with any vaccination 
strategy.
                        outlook of the epidemic
    Ebola transmission can be stopped and the outbreak terminated when 
at least 70 percent of cases are effectively isolated; that is, moved 
to an Ebola Treatment Unit before they have infected anyone else, or 
have their contacts and secondary contacts fully vaccinated. This needs 
to be sustained for at least two to three months in order to end the 
outbreak. While we have the public health knowledge and tools to 
complete this task, we have not been able to fully implement these 
tools in the field. Neither the outbreak nor the security situation on 
the ground has improved in recent months and it is difficult to predict 
with certainty what will happen. Without substantial and continued 
improvements, the DRC could soon be facing an epidemic that rapidly 
increases; at that point, the possibility of the outbreak spreading to 
neighboring countries--in numbers much higher than the three confirmed 
cases in Uganda we have already seen--will increase. CDC is committed 
to leveraging its resources and global health security expertise to 
help end the outbreak.
                       risk to the united states
    CDC understands that an international outbreak of Ebola puts the 
United States at risk and we appreciate the trust placed in CDC to keep 
Americans safe from public health threats both at home and abroad. At 
this time, we believe the direct risk to the United States remains low 
based on the travel volume and patterns from the outbreak areas to the 
United States and the implementation of border screening measures at 
key airports and ports in the DRC and neighboring countries. CDC helped 
organize exit screening workshops in Kinshasa and Goma in DRC to 
bolster screening efforts and prevent spread of disease. On average, of 
the approximately 325,000 air travelers arriving in the United States 
daily, about 43 travelers are from the DRC, largely from regions 
unaffected by the Ebola outbreak.
    CDC continues to implement routine border health security measures 
at U.S. Ports of Entry and has issued a Level 2 (Practice Enhanced 
Precautions) travel health notice for the DRC that informs travelers 
and clinicians about the outbreak and what types of precautions they 
should take if traveling to the affected areas of the DRC. CDC has been 
in regular contact with the non-governmental organizations operating in 
the outbreak areas, and we provide recommendations on monitoring and 
pre-departure health assessments for healthcare workers. In addition, 
the U.S. Department of State has identified the outbreak area as a ``do 
not travel'' zone because of armed conflict, crime, and civil unrest. 
Current CDC guidance for managing Ebola cases in U.S. healthcare 
settings has been reviewed and communicated to healthcare facilities as 
part of domestic preparedness efforts. CDC's Laboratory Response 
Network stands ready to perform testing on Ebola specimens should any 
need arise, with testing kits deployed across the United States.
                  big picture: global health security
    The ongoing response to Ebola in DRC and surrounding countries 
demonstrates CDC's continued commitment to strengthen global health 
security. CDC has been engaged in global health security work for over 
7 decades and is able to leverage the essential public health assets 
developed by notable initiatives like the U.S. President's Emergency 
Plan for AIDS Relief (PEPFAR), the President's Malaria Initiative, and 
global polio eradication to support core global health security 
programs and ensure the safety of Americans. With an understanding of 
the increasing threats posed by infectious diseases globally and in the 
context of the West Africa Ebola outbreak, CDC received $582 million in 
supplemental funding for a five-year effort in support of the Global 
Health Security Agenda (GHSA). GHSA was launched by a growing 
partnership of nations, international organizations, and non-
governmental stakeholders in 2014 with a stated vision of a world safe 
and secure from global health threats posed by infectious diseases. 
Since GHSA's launch, CDC's global health security work has helped 
partner countries build and improve their public health system 
capacity. With CDC's support, partner countries were able to 
effectively contain meningitis in Liberia, Marburg virus in Uganda, 
multidrug-resistant tuberculosis in India, and vaccine-preventable 
diseases including measles and pertussis in Pakistan and diphtheria in 
Vietnam, among other threats across the globe. These outbreaks were 
stopped at their source, saving lives and reducing the amount of time 
it takes to effectively respond from months and weeks to days.
    We appreciate the continued commitment of Congress to global heath 
security. Support for global health security enables CDC to continue 
protecting Americans by detecting and preventing infectious disease 
threats before they reach our borders. We are seeing progress in the 17 
priority countries where we have invested our global health security 
resources: all 17 have improved rapid response to disease threats 
through established or expanded public health workforce training of 
field-based epidemiologists, 13 have improved prevention of vaccine-
preventable diseases through increased community immunization coverage, 
15 have ensured effective public health emergency operation centers 
through training of emergency management officials, and 9 have 
increased their ability to identify country-prioritized pathogens 
through improved national laboratory testing capacity.
    The DRC serves as an example of a country where CDC investments 
have built capacity since program operations began in 2002, including 
activities specifically to prepare for an Ebola outbreak. These efforts 
have also fostered strong relationships with the DRC and surrounding 
countries' ministries of health that have proved critical in times of 
crisis. The May-July 2018 outbreak of Ebola in the Equateur province of 
the DRC raised international concern due to logistical challenges 
caused by the large and remote area. That outbreak ultimately led to 53 
cases and 29 deaths. The swift response, which included CDC and other 
U.S. Government personnel in the field, ensured it was quickly 
controlled. Without a doubt, our global health security activities in 
the DRC enabled a faster, more effective and successful response to the 
May-July 2018 outbreak, and provide an important foundation in the 
current Ebola response, even considering the complex security situation 
and special difficulties posed by this outbreak.
    The DRC Field Epidemiology Training Program (FETP), developed with 
assistance from CDC and modeled after CDC's own training programs, has 
trained around 260 frontline and advanced disease detectives who are 
crucial to accurately detecting and identifying outbreaks. The DRC 
graduated its first cohort of FETP residents in 2015. These disease 
detectives are supporting the current Ebola outbreak and serve as an 
example of how CDC supports sustainable capacity development of 
countries to respond to outbreaks within their own borders.
    There are presently 42 FETP-trained staff deployed in nine outbreak 
health zones. Training programs like these work effectively because 
they are complemented by decades of field experience that CDC experts 
bring, teaching new epidemiologists how to rapidly identify diseases 
and respond effectively to prevent spread. CDC maintains long-standing 
collaborations in the DRC for priority diseases, including monkeypox 
virus response and prevention, building capacity and skills that have 
been beneficial for Ebola response. Sustainable investments, such as 
resources and expertise to train laboratory technicians, renovate and 
upgrade two laboratories, and establish a National Emergency Operations 
Center in the DRC, are all being leveraged in the current Ebola 
response.
    Our global health security work is enhancing the world's ability to 
respond to other emerging health threats. More than 70 countries have 
an FETP program, resulting in more than 12,000 graduates around the 
world. In Liberia, improved laboratories, epidemiology training, 
surveillance, and surge capacity resulted in the identification of an 
April 2017 meningitis outbreak within one day of the first discovery of 
a case. By comparison, it took 90 days for the country to recognize the 
first Ebola case in 2014. The Uganda Virus Research Institute has 
emerged as a regional reference laboratory for viral hemorrhagic fevers 
thanks to collaboration with CDC and its subject matter experts. In 
addition, Uganda's Public Health Emergency Operations Center, 
established with CDC support in 2013, is a model for other global 
health security program countries. This center has been activated for 
over 75 outbreaks and public health events. With this improved 
capacity, Uganda has detected 16 viral hemorrhagic fever outbreaks as 
of July 2018, and responded quickly to keep outbreaks small and 
contained, including the three Ebola cases identified in June 2019. 
They also detected a yellow fever outbreak in spring of 2016 in only 
four days, compared to over 40 days that it took to identify the yellow 
fever outbreak of 2010.
    Another important component of CDC's global health work is the 
agency's ability to monitor threats globally and to provide rapid 
response through deployment of staff from across the agency. CDC's 
Global Emergency Alert and Response Service (GEARS) closely monitors 35 
to 45 outbreaks a day through event-based surveillance and supports 
emergency deployments to respond to selected outbreaks. GEARS brings 
together the Global Disease Detection Operations Center (CDC's 
electronic surveillance analysis and response system for global 
threats) and the Global Rapid Response Team, which has trained over 500 
CDC personnel who have provided nearly 22,000 person-days of response 
support.
    One way that CDC ensures our domestic preparedness is through 
building global capacity in health security. As we saw during the West 
Africa Ebola epidemic, the current measles outbreak, and the Middle 
East Respiratory Syndrome (MERS) outbreak, infectious disease threats 
do not respect borders. An outbreak that starts in another country 
could reach us in a matter of hours; this is why CDC works globally to 
stop health threats before they enter the United States.
                               conclusion
    CDC's number one priority during any public health emergency is to 
save lives. CDC never loses sight of its primary mission to protect the 
health and safety of the American people, and we know that global 
health security is national security. CDC works overseas to ensure that 
health threats do not reach the U.S., most importantly by working to 
stop these threats where they start. CDC works to protect the United 
States from direct health threats, protect U.S. interests in global 
economic security, and ensure that lessons learned overseas can be 
applied here to increase the strength of the U.S. public health system. 
While significant progress has been made, we know that we will continue 
to see the emergence of both known and unknown threats that will 
require the laboratory and surveillance infrastructure that CDC 
continues to support. The current Ebola outbreak remains a particular 
challenge for DRC and the global health community, and there are no 
signs that the outbreak is slowing. However, CDC's global health 
programs have allowed us to build strong working relationships with the 
DRC and surrounding countries' ministries of health, and we will 
continue to work with USAID and our sister agencies in the Department 
of Health and Human Services, as well as WHO and other international 
partners, until we stop this particularly challenging outbreak.
    The ability to rapidly detect and effectively respond to threats to 
the public's health is a top priority for CDC. CDC works around the 
clock to not only ensure its readiness but the readiness of those on 
the front lines. CDC remains vigilant, because at any given moment, 
thousands of infectious diseases are circulating in the world. We don't 
know exactly which outbreak or potential pandemic threat is coming 
next, but we know it is coming. The work we do now ensures that, when 
the next major outbreak or pandemic threat does arrive, we are able to 
protect the health of Americans and save lives.

  STATEMENT OF REAR ADMIRAL TIM ZIEMER, USN, RETIRED, SENIOR 
DEPUTY ASSISTANT ADMINISTRATOR, BUREAU FOR DEMOCRACY, CONFLICT, 
  AND HUMANITARIAN ASSISTANCE, U.S. AGENCY FOR INTERNATIONAL 
                  DEVELOPMENT, WASHINGTON, DC

    Mr. Ziemer. Chairman Graham, Ranking Member Kaine, members 
of the subcommittee, thanks very much for this opportunity to 
speak to you about the U.S. response to this Ebola outbreak.
    Senator Graham, you have already summarized the challenge. 
This deadly virus has appeared in one of the most insecure 
areas of the world, endangering lives of people made vulnerable 
by deadly violence and contributing to the population's 
distrust of outsiders. It is really a perfect storm. Reaching 
affected communities with proven and tested health 
interventions has been undermined and interrupted by attacks on 
health care workers. Over the last couple days, 14 deaths were 
reported, not all on health care workers.
    While mostly contained in two provinces, the Ebola outbreak 
is now a regional issue, as punctuated by the World Health 
Organization's declaration of the public health emergency.
    USAID has been at the forefront of this response since the 
outbreak began. With the additional $38 million that we 
announced today, USAID's contribution to the Ebola response is 
$136 million. Our partners have strengthened infection 
prevention and control in over 360 health facilities and 
dispensaries, trained more than 19,000 health care workers, 
patient screening, isolation, and triage, and have reached over 
2.1 million people with key health messages.
    As the lead coordinator of the U.S. Government response in 
DRC supporting Ambassador Hammer, the DART team works very, 
very closely with CDC, the State Department, and our other 
government agencies.
    I traveled to DRC in May, followed quickly by the trip by 
Administrator Green that you mentioned. Our visits confirmed 
while a lot has happened, a shift in strategy was needed. And I 
am pleased to say that reset is underway. And it takes a more 
comprehensive humanitarian approach. With strong leadership 
from Ambassador Hammer and coordinated efforts across the 
entire interagency, the reset is supporting a greater cross-
border response, and it is also strengthening the health 
response and tightening financial accountability and 
transparency. Progress is being made. The emphasis on border 
surveillance and local capacity has helped quickly contain the 
virus, as illustrated by the cases that popped up in Uganda a 
couple weeks ago.
    So in the last several weeks, other significant adjustments 
have been made such as the assignment of Mr. David Gressly as 
the U.N. Emergency Ebola Response Coordinator to preside over 
the entire coordination and leadership of the response. We are 
expecting the release of the new strategy in a couple weeks 
that aligns the humanitarian objectives with the public health 
efforts. This strategy will set funding requirements which the 
U.S. Government will use to solicit increased funding and 
burden sharing from other governments.
    So in the near term, cases will likely increase, but we 
expect that the approaches outlined in the reset will help DRC 
turn the tide and contain this deadly virus.
    So in the long term, through the Global Health Security 
Agenda that Admiral Mitch Wolfe just mentioned, USAID will 
continue to work with CDC, as well as the Department of State 
and other agencies, to build the capacities of countries to 
prevent, detect, and respond to future outbreaks. A threat 
anywhere is a threat everywhere. And we are committed to 
containing this outbreak and other outbreaks at the source. So 
we are working closely with our interagency partners in a very 
coordinated effort to bring our funding, our technical 
assistance, and all the U.S. Government resources to bear. To 
bring this outbreak to an end is a challenge, but it is not 
insurmountable.
    So thanks for your time, most importantly for your interest 
in calling this hearing, and for your leadership. And we look 
forward to answering your questions.
    [The prepared statement of Mr. Ziemer follows:]

      Prepared Statement of Rear Admiral Tim Ziemer, USN, Retired

    Chairman Graham, Ranking Member Kaine, members of the subcommittee, 
thank you for the opportunity to speak with you today about the U.S. 
response to the ongoing Ebola outbreak in the Democratic Republic of 
the Congo (DRC), and for your interest in this important issue. Since 
August 2018, the DRC has been facing what is now an unprecedented Ebola 
outbreak in the country, with 2,578 confirmed and probable cases and 
1,737 deaths as of July 21, 2019. It is the world's second-largest 
recorded outbreak of the disease, eclipsed only by the 2014 West Africa 
outbreak that resulted in nearly 29,000 cases and killed more than 
11,000 people. On July 17, 2019, the World Health Organization (WHO) 
declared it a Public Health Emergency of International Concern, a 
status only announced when there is an ``extraordinary event'' that is 
determined ``to constitute a public health risk to other States through 
the international spread of disease'' and ``to potentially require a 
coordinated international response.'' This declaration is only the 
fifth one of its kind that the WHO has made since the adoption of the 
International Health Regulations in 2005.
    This ongoing Ebola outbreak is more than just a public health 
crisis--it is happening in the midst of a complex humanitarian crisis 
that has left 12.8 million people in need of assistance in the DRC. 
While the DRC has faced nine previous Ebola outbreaks, this is the 
first in Provinces that already suffer from chronic humanitarian 
needs--like the lack of food, safe drinking water, and shelter.
    In May, I traveled to Eastern DRC and saw the scale and complexity 
of this outbreak and the response firsthand. I have traveled 
extensively in my career, from my 3 decades with the U.S. Navy and in 
the roles I have held since. This trip to the DRC was one of the most 
important trips I have ever taken. I heard directly from local 
traditional and religious leaders, as well as our partners, about the 
ongoing violence and community distrust towards the response driven by 
years of corruption and political and governance failures in the 
region, which makes this outbreak more difficult to contain.
    This outbreak is far from controlled. In recent weeks, it has 
become clear that this could become a regional issue, as we have seen 
cases move dangerously close to neighboring Rwanda and South Sudan. In 
Uganda, three cases were detected in June 2019, although those cases 
were later recorded officially as DRC cases since that is the country 
where they originated. The U.S. Government is aggressively adapting our 
strategies, and working with our interagency and international 
partners, including the Government of the DRC the WHO, and the U.N. 
humanitarian agencies to help reset our approach to the response to 
stop the spread of the disease.
    USAID has contributed more than $98 million for the response 
efforts to date, and will continue to invest and provide vital support 
until this disease is contained. Bringing an end to this devastating 
outbreak is a top priority for the U.S. Government, because we are 
committed to reducing the suffering of those affected by Ebola, and 
because effective efforts to contain and end the outbreak can prevent 
it from reaching the broader region, as well as our borders.
                   update on the outbreak in the drc
    Next week, we will mark one year since the Government of the DRC 
declared the current Ebola outbreak in North Kivu Province in Eastern 
DRC. Within 2 weeks of that declaration, confirmed cases were reported 
in neighboring Ituri Province. By mid-October, increased transmission 
in hospitals and health facilities led to a spike in cases in Beni, 
which made it the epicenter of the outbreak at the time. Today, Beni is 
a hotspot for transmission, alongside Mabalako, Katwa, and Butembo, as 
the virus continues to spread in the region as a result of community 
deaths, high population mobility, and other factors, with 25 Health 
Zones throughout North Kivu and Ituri Provinces affected as of July 15.
    Regional spread remains a very serious concern. On July 14, the DRC 
confirmed its first case in Goma, a city of more than a million people 
near the border with Rwanda and a major transit hub in the region. In 
addition, a case was recently confirmed in the DRC's Ariwara Health 
Zone, in Northern Ituri Province, fewer than 45 miles from South Sudan 
and 7 miles from Uganda.
    Complicating an already difficult response to this deadly disease, 
this outbreak is occurring in areas with ongoing fighting between 
multiple armed groups, which leads to access constraints and the 
intermittent suspension or modification of ongoing activities, 
including those of USAID partners. A little more than a week ago, two 
health care workers were deliberately targeted and killed in Beni, 
which highlights how dangerous this outbreak has been for the brave 
people who are risking their lives in responding. In the week following 
my recent visit, the Katwa Ebola treatment unit (ETU) was attacked--not 
for the first time--killing one guard, and a militia attacked a hotel 
in Butembo housing Ebola responders, killing several people and halting 
response operations for several days. Every day that health teams are 
absent from an outbreak area because of a security incident is a lost 
day of critical response activities that can save lives.
    The outbreak is also spreading in an area with a long history of 
deeply-rooted community distrust--which at times has exploded into 
violence against frontline workers--of the central government, 
foreigners, and people from other regions in the DRC because of decades 
of neglect, corruption, exploitation, and violence. This deep mistrust 
has also fueled misconceptions that Ebola was created to wipe out 
populations or extort money from people. Faith and community leaders 
told me about feeling exploited by the ``Ebola economy'' and about 
their deep suspicion regarding the motives of the sudden and dramatic 
presence of outsiders. This was a sobering reminder for me that 
communities do not trust the response.
                           response and reset
    There is no question that our interventions thus far have saved 
lives and prevented a much larger outbreak. The more than $98 million 
USAID has provided for the Ebola response in the DRC to date has been 
supporting life-saving assistance, including activities to prevent and 
control infections, training for health care workers, community 
engagement, the promotion of safe and dignified burials, and food 
assistance for affected people, including Ebola contacts under 
monitoring and their families, patients in Ebola treatment centers, and 
discharged survivors.
    Last September, the U.S. Government deployed a Disaster Assistance 
Response Team, or DART, which built upon early assistance from USAID 
and the Centers for Disease Control and Prevention (CDC) within the 
U.S. Department of Health and Human Services (HHS). The DART is the 
lead coordinator of the United States' whole-of-government response to 
the Ebola outbreak in the DRC. This expert team--composed of disaster 
and health experts from USAID and HHS--is working tirelessly to 
identify needs and coordinate activities with partners on the ground. 
By augmenting ongoing efforts to prevent the spread of disease and by 
providing aid to help Ebola-affected communities, the DART provides a 
forward-leaning, flexible, efficient, and effective operational and 
coordination structure to mount the U.S. Government response.
    There has been clear progress because of their efforts and the work 
being done by our partners on the ground to stop the spread of Ebola. 
We have helped train 1,680 community health care workers to conduct 
surveillance, equipping them with knowledge and tools to track the 
disease and stop the chains of transmission. We have also trained more 
than 19,000 Congolese health care workers in patient screening, triage, 
isolation, appropriate waste-management, and other practices that 
prevent the transmission of disease. These practices are helping 
strengthen measures to prevent and control infections in at least 309 
health facilities across at least 18 Health Zones. Our partners 
continue to provide treatment and care that help increase the chance of 
survival for people with Ebola, and USAID is ensuring they have the 
supplies they need to operate, including by providing 53 metric tons of 
personal protective equipment at more than 100 health facilities. 
Additionally, USAID has funded the provision of enough food to meet the 
needs of 300,000 people--including Ebola patients, contacts, survivors, 
and their family members.
    Our experience with this outbreak so far, and the 2014 West Africa 
outbreak, has shown us that community acceptance and ownership is 
crucial to the success of this response. USAID is funding partners to 
dispel rumors about the disease through community outreach--including 
by working with trusted community leaders--to increase acceptance of 
public health response activities. Our partners are working to reach 
508,000 households, or 2.1 million people, with key health messages to 
engage communities in conversations about Ebola, debunk myths, and 
raise awareness about the transmission of Ebola.
    Despite all of our efforts, it became clear during my trip to the 
DRC that insecurity, poor coordination, the underutilization of key 
partners like non-governmental organizations (NGOs) and faith-based 
groups, and insufficient community engagement were hindering response 
efforts. This is in part why, soon after my return to Washington DC, 
the U.S. Government began to shift towards a complete reset of the U.S. 
response towards a more comprehensive humanitarian and development 
approach that responds to the broader needs of the community to help 
improve the community's perceptions and attitudes towards the public 
health interventions. Following my trip in June 2019, Administrator 
Green also travelled to Butembo to see the Ebola emergency first-hand, 
and it was very clear to him that this was a development emergency in 
the DRC.
    With this critical context in mind, the U.S. Government has four 
key strategies to achieve this reset: (1) enhancing response leadership 
and coordination; (2) strengthening community engagement; (3) 
addressing the complex security environment; and (4) strengthening 
preparedness, in both the DRC and the surrounding countries.
    First, strong leadership and coordination is critical to making 
this response more effective, which is why we are optimistic about the 
appointment of United Nations Emergency Ebola Response Coordinator 
David Gressly in May. USAID has emphasized the need for clear lines of 
leadership and accountability to strengthen his ability to oversee 
response functions to support the Government of the DRC's and the WHO's 
lead of the public-health response. Overall, leadership for this 
response must be more inclusive, and directly involve the local and 
international NGOs that are vital to the response. These organizations 
must be better engaged and active in coordination efforts, because they 
deliver assistance that complements efforts by the Government of the 
DRC and U.N. agencies and because they have the trust of the affected 
communities. The U.S. Government, along with other lead donors, also 
continues to advocate for strategic shifts, like including civil 
society, faith-based organizations, and NGOs in coordination 
structures. USAID is also closely collaborating with our interagency 
partners--like HHS and the HHS National Institutes of Health--along 
with the Government of the DRC, other donors, the WHO, the U.N., 
international partners, and civil society to battle this disease. For 
example, we worked with these key partners to provide input into the 
development of the latest Strategic Response Plan for the outbreak, the 
public-health portion of which was just released earlier this month, to 
guide efforts over the coming months. We are also continuing to 
encourage other donors to contribute resources to this Ebola response, 
including governments that have already provided modest assistance.
    Second, Congolese communities must be at the center of what we do, 
which is why we are working to shift the response from a top-down 
approach to one that elevates the communities' role and prioritizes 
their needs and feedback. As such, the U.S. Government is continuing to 
emphasize community engagement across the response--from the DRC 
Ministry of Health to the WHO and USAID partners, many of which have 
found innovative ways to connect with communities. One of our partners, 
for example, worked with a music festival in Goma to get Ebola-
prevention messages out, which reached more than 37,000 people with 
handouts and fliers; musicians even incorporated these messages into 
their sets. USAID's partners are also engaging with journalists, to get 
them to take to the airwaves, create mini movies, and organize groups 
on the WhatsApp social messaging platform to educate people about Ebola 
and stimulate discussions. We are increasing emphasis on community 
dialogue and actively looking to involve a wider cross-section of 
organizations, like local women's, youth, and faith-based groups. One 
of our partners is working with young people to change their 
perspectives on Ebola-related rumors, and has trained them to 
communicate about Ebola and mobilize their peers in the response. Our 
partners have also hired local people--including Ebola survivors--to be 
a part of the response in their own communities, and are reaching out 
to respected local leaders to deliver Ebola prevention messages in 
local languages. Ultimately, we are working to listen to local needs, 
incorporate feedback, and ensure we are doing all we can to foster 
positive changes in the relationship between communities and Ebola 
responders.
    Third, we must do more to address the complex security environment. 
This is imperative to fully earning the trust of communities and 
gaining their participation in the response. The affected communities 
have long experienced armed conflict, and have suffered for years prior 
to this outbreak. Our response must acknowledge how this insecurity has 
affected them and their beliefs about the disease. Given all that these 
communities have been through, we must be cautious of militarizing the 
response. We should energize leading responders to utilize common 
humanitarian techniques, including transparent information-sharing, 
negotiations on how to gain access to affected communities, and 
engaging local community leaders in discussions and tactics on security 
that benefit the entire community, not just responders.
    Fourth, with the continued threat of spread to countries that 
neighbor the DRC, we must do more to strengthen preparedness both in 
other high-risk areas in the DRC, as well as in Burundi, Rwanda, South 
Sudan, and Uganda. This is why we have been looking outside of the 
DRC's borders to provide the support and expertise needed to keep the 
disease from spreading. Part of this line of effort must be a more 
aggressive approach to vaccination, which should include the use of the 
second available vaccine to help build a firewall around the outbreak 
zone.
        preparedness and preventing ebola from crossing borders
    We are intensely concerned that this outbreak could soon become a 
regional issue, as it moves closer to the borders of countries that 
neighbor the DRC. We are continuing to strengthen health surveillance 
activities at borders, as well as train health workers and strengthen 
local capacity within the countries to respond efficiently and 
effectively to case alerts. In these neighboring countries, we are 
supporting Ebola preparedness efforts that strengthen local capacity to 
detect the disease; train screeners and screen travelers at key points 
of entry; track cases if they occur; maintain water, sanitation, and 
hygiene facilities; improve the prevention and control of infections in 
health facilities: vaccinate at-risk workers; and conduct public 
awareness and sensitization campaigns about Ebola.
    USAID is also funding Ebola preparedness efforts in Goma, as well 
as in Provinces adjacent to North Kivu and Ituri, to help ensure that 
the virus does not spread any further within the country. Our efforts 
also account for how the humanitarian situation in the DRC affects the 
movement of people. Factors such as poor infrastructure, forced 
recruitment into armed groups, and ongoing violence have contributed to 
the deterioration of humanitarian conditions and triggered mass 
internal displacement and refugee outflows.
    These efforts have never been more critical: With the confirmed 
case in Goma at the beginning of last week, the outbreak is now nearing 
the Rwanda border. Earlier this month, a confirmed case in Ariwara 
Health Zone brought the outbreak fewer than 45 miles from the South 
Sudan border. Most concerning, three confirmed cases of Ebola, in 
individuals all of whom later died, were detected in Uganda in June, 
which marked the first cases of the deadly disease detected outside DRC 
since the start of the outbreak in August 2018. These cases serve as a 
reminder that we must stay vigilant. USAID continues to monitor the 
situation closely, and we will continue to work with partners to 
support preparedness efforts in these neighboring countries.
    Preparing for disease requires a whole-of-society approach across 
multiple sectors to prevent, detect, and respond to infectious-disease 
threats as our national Biodefense and Global Health Security 
Strategies make clear. When crises happen--like the current Ebola 
outbreak--we work to ensure response groups have the tools and 
operational structures necessary to respond quickly and effectively.
    USAID is also working to promote global health security at the 
local level by helping at-risk communities develop preparedness plans 
and train community volunteers to detect and respond to infectious-
disease threats in their own neighborhoods. We have developed an 
emergency supply-chain playbook designed to build country capacity to 
quickly provide and manage essential emergency commodities, like 
personal protective equipment, that are critically needed during 
outbreaks. We are helping countries establish risk-communication 
programs that provide communities the information needed to reduce 
disease spread.
                               conclusion
    In conclusion, USAID and the rest of the U.S. Government are well-
equipped to help the DRC and neighboring countries respond to this 
disease, and have begun to reset our response to better adapt to these 
key challenges on the ground. We have been providing humanitarian and 
development assistance in the DRC for more than 3 decades, and are 
familiar with the operating environment and access challenges. While 
responding to this outbreak is complex, this is a whole-of-government 
response, which is making the most of each Department and Agency's 
knowledge and expertise. We are all united in the same goal of helping 
the people of the DRC to bring this outbreak under control as soon as 
possible while demonstrating our continued support for the people, 
families, and communities affected by this devastating disease.
    We know that this is more than just a public-health crisis: This is 
occurring on top of an extended, complex, and violent humanitarian 
crisis. By placing community needs at the forefront of the response, we 
can strengthen the relationship between communities and the so the 
public health interventions can be more effective. Thank you for your 
time. I look forward to answering your questions.

 STATEMENT OF HON. MARCIA BERNICAT, PRINCIPAL DEPUTY ASSISTANT 
SECRETARY, BUREAU OF OCEANS AND INTERNATIONAL ENVIRONMENTAL AND 
  SCIENTIFIC AFFAIRS, U.S. DEPARTMENT OF STATE, WASHINGTON, DC

    Ambassador Bernicat. Chairman Graham, Ranking Member Kaine, 
distinguished members of the committee, thank you for inviting 
me here to speak today. I am honored to appear as part of a 
team of officials and colleagues who represent the whole-of-
government approach that the United States brings to the Ebola 
response.
    The ongoing Ebola outbreak in the Democratic Republic of 
Congo is the second largest in human history. For nearly a 
year, brave responders, with strong U.S. support, have been 
working to stop Ebola's spread and treat the ill. Their efforts 
have saved countless lives, but new cases continue to emerge. 
We are now at a critical juncture. Ebola cases continue to 
rise. Ebola patients continue to die, and local communities and 
responders have not been taking all the necessary steps to end 
the outbreak. And in some cases, as we have noted, communities 
are actively, even violently, resisting Ebola response efforts. 
The risk of Ebola spreading to additional areas of the DRC or 
neighboring countries remains high, as demonstrated by the 
three confirmed cases in Uganda in early June and the case in 
Goma last week.
    At the same time, there is reason for hope. The DRC and 
neighboring governments are taking action to prevent Ebola 
cases, detect possible infections, and respond quickly to treat 
patients. The World Health Organization and the United Nations 
are improving coordination with nongovernmental organizations 
and local communities. And the United States, as it has since 
the first Ebola cases emerged, continues to take a leading role 
to end the outbreak.
    As you noted, Senator Graham, ending this outbreak is not 
only a global health security priority--it is a U.S. national 
security priority. And as my colleague said, an infectious 
disease threat anywhere can be an infectious disease threat 
everywhere, as we saw vividly in 2014. The United States 
Government is firmly committed to stopping this pandemic. We 
are the largest single country donor, and we have continuously 
deployed staff to the DRC and neighboring countries to enable a 
more effective response.
    Our whole-of-government approach is critical to stopping 
this outbreak, which is occurring in the midst of a complex 
humanitarian crisis and tremendous security challenges from 
local armed groups. The Government of the DRC and the WHO have 
led the response since the first cases emerged nearly a year 
ago. Government officials in Uganda, Rwanda, Burundi, and South 
Sudan have also demonstrated leadership by increasing 
preparedness efforts to prevent, detect, and respond to Ebola 
cases. And the United Nations' designation of David Gressly as 
U.N. Emergency Ebola Response Coordinator on May 23 is 
enhancing the response coordination and addressing the broader 
humanitarian and security conditions impacting the response. 
The World Bank has provided significant resources and helped 
ensure financial accountability of response efforts. Other core 
donors include the United Kingdom and the European Union. And 
NGO staff and the Congolese citizens themselves are the 
backbone of the on-the-ground response efforts to identify and 
treat Ebola patients and their contacts.
    The State Department has also raised international 
awareness of the DRC Ebola outbreak and is encouraging the 
international community to fully fund the response. We convened 
a meeting of the DC diplomatic corps on June 14 where USAID, 
CDC, and State Department officials briefed on the outbreak's 
trajectory and underlined the urgent need for funds. On July 
14, the DRC Government and World Health Organization released a 
partial new response plan requesting $287 million over the next 
6 months to fund the public health response. Additional appeals 
for support in other sectors beyond health are forthcoming.
    The State Department and our embassies' country teams are 
regularly engaging our foreign counterparts from the DRC to the 
WHO to the DRC's neighbors at the highest levels to make the 
Ebola response a priority and to enhance coordination across 
governments and donors.
    Thank you for your time, your consideration, and your 
interest. I welcome the opportunity to respond to your 
questions.
    [The prepared statement of Ambassador Bernicat follows:]

               Prepared Statement of Hon. Marcia Bernicat

    Chairman Graham, Ranking Member Kaine, and distinguished members of 
the Committee, I want to thank you for inviting me to speak today. I am 
honored to appear as part of a team of officials who represent the 
whole-of-government approach that the United States brings to the Ebola 
response.
    The ongoing Ebola outbreak in the Democratic Republic of the Congo 
(DRC) is the second-largest in human history, with more than 2,500 
cases and over 1,700 deaths since August 2018. For nearly a year, brave 
responders--with strong U.S. support--have been working to stop Ebola's 
spread and treat those infected. Their efforts have saved countless 
lives, but new cases continue to emerge. We are now at a critical 
juncture. Ebola cases continue to rise, Ebola patients continue to die, 
and local communities and responders are not taking all necessary steps 
to end the outbreak. In some cases, local communities are actively, 
even violently, resisting Ebola response efforts. The risk of Ebola 
spreading to additional areas of the DRC or neighboring countries 
remains high, as demonstrated by the three confirmed cases in Uganda in 
early June and the case in Goma last week.
    At the same time, there is reason for hope. The DRC and neighboring 
governments are taking action to prevent Ebola cases, detect possible 
Ebola infections, and respond quickly to treat Ebola patients. The 
World Health Organization (WHO) and the United Nations are facilitating 
improved response coordination with nongovernmental organizations and 
local communities, taking security and humanitarian needs into account. 
And the United States--as it has since the first Ebola cases emerged in 
eastern DRC--continues to take a leading role to end the outbreak.
    At the outset of my testimony, I would like to make one point 
clear. Ending this outbreak is not only a global health security 
priority--it is a U.S. national security priority. An infectious 
disease threat anywhere can be an infectious disease threat everywhere 
as we saw vividly in the 2014 West Africa Ebola outbreak. The U.S. 
Government is firmly committed to stopping Ebola's transmission, 
supporting the treatment of those infected, and minimizing the loss of 
life in this outbreak. The United States is the largest single-country 
donor to response efforts, and we have deployed staff to the DRC and 
neighboring countries to enable a more effective response.
    We have seen time and again how critical a whole of government 
approach is to stopping epidemics and pandemics. This is especially 
true for this Ebola outbreak, which is occurring in the midst of a 
complex humanitarian crisis and tremendous security challenges from 
local armed groups. Stopping Ebola transmission in this case also 
requires a multi-government approach. The Government of the DRC and the 
World Health Organization (WHO) have led the response in the DRC since 
the first cases emerged nearly a year ago. Government officials in 
Uganda, Rwanda, Burundi, and South Sudan have also demonstrated 
leadership by increasing preparedness efforts to prevent, detect, and 
respond to Ebola cases. The United Nations designated David Gressly as 
U.N. Emergency Ebola Response Coordinator on May 23 to enhance response 
coordination and address broader humanitarian and security conditions 
impacting the response. The World Bank has provided significant 
resources and helped ensure financial accountability of response 
efforts. Other core donors include the United Kingdom and the European 
Union. And NGO staff and Congolese citizens themselves are the backbone 
of on-the-ground response efforts to identify and treat Ebola patients 
and their contacts.
    The State Department has championed efforts to raise international 
awareness of the DRC Ebola outbreak and encourage the international 
community to fully fund the response. My bureau convened a meeting of 
the DC diplomatic corps on June 14 where USAID, CDC, and State 
Department officials provided a briefing on the outbreak's trajectory 
and underlined the urgent need to fund response activities. On July 14, 
the DRC government and World Health Organization released a partial new 
response plan requesting $287 million over the next six months to fund 
the public health response. Additional appeals for support in other 
sectors beyond health are forthcoming, and it is imperative that we 
diversify the donor pool to meet resource needs. On July 17, WHO 
declared the outbreak a Public Health Emergency of International 
Concern (PHEIC), which we hope will mobilize more resources. All 
countries must contribute to ensure global health security.
    The State Department has also been regularly engaging foreign 
counterparts in the DRC, the United Nations, the WHO, and the DRC's 
neighboring countries to enhance response coordination. Our embassies 
and country teams are engaging foreign counterparts at the highest 
levels to make the Ebola response a priority--and to enhance 
coordination across government ministries and donors.
    Thank you for your time and consideration of this important issue, 
and I welcome the opportunity to answer any questions you may have.

 STATEMENT OF HON. TIBOR NAGY, ASSISTANT SECRETARY, BUREAU OF 
   AFRICAN AFFAIRS, U.S. DEPARTMENT OF STATE, WASHINGTON, DC

    Ambassador Nagy. Mr. Chairman, Ranking Member, and 
distinguished members, thank you for the opportunity to testify 
today on the State Department Bureau of African Affairs' 
efforts to combat the ongoing Ebola outbreak in eastern 
Democratic Republic of Congo.
    This panel serves as a reminder that the Ebola response is 
a whole-of-U.S. government effort, and I am grateful that my 
colleagues and I are in this fight.
    My remarks today briefly summarize the longer and more 
detailed statement which was previously submitted for the 
record.
    The Ebola outbreak in eastern DRC, now declared by the 
World Health Organization to be a public health emergency of 
international concern, continues to devastate the region. The 
DRC successfully handled nine previous Ebola outbreaks with 
capacity and expertise built up over decades of close 
cooperation with the United States. However, this 10th 
outbreak, now the second longest in history, is different as it 
is in a conflict zone.
    Eastern DRC is not new to instability. Longstanding 
regional and local tensions fueled wars that killed millions in 
the 1990s and 2000s. Clashes persist to this day in Ituri and 
North Kivu where the Ebola outbreak continues to spread. Local 
populations have faced decades of armed group attacks, food in 
security, poverty, outbreaks of measles, cholera, other 
diseases.
    The recent surge of international attention on the Ebola 
response stands in stark contrast to a record of neglect on 
these other problems. This glaring dichotomy has led local 
militia and frustrated community members to lash out and target 
health care facilities and workers. It underscores more than 
ever the necessity of engaging communities and local leaders to 
garner buy-in for the response.
    The United States is working closely with the DRC 
Government, U.N., and WHO on this response. The historic 
transfer of power to President Felix Tshisekedi in January 
opened a new chapter in the U.S.-DRC bilateral relationship. 
With President Tshisekedi, we are optimistic that we have a 
willing partner receptive to U.S. and international support to 
contain the outbreak.
    Embassy Kinshasa is fully engaged in supporting the entire 
U.S. Government response in the DRC. The Kinshasa team has not 
only kept up with increasing policy and logistical demands from 
the Ebola outbreak, but also accelerated its diplomatic 
overreach, oversight, and reporting. The embassy has expanded 
its operations to support a surge of U.S. temporary duty 
personnel to Kinshasa and Goma where we did not previously have 
an established presence. Ambassador Hammer has proactively 
supported a constant stream of high level U.S. and U.N. 
visitors to the East, to increase attention and demonstrate 
U.S. commitment to this response. From our embassy in Kinshasa, 
we engage in diplomacy across the entire country, which in 
distance stretches almost from my driveway in west Texas to 
here in Washington, DC.
    At the same time, our Embassies Bujumbura, Juba, Kampala, 
and Kigali have consistently urged the most senior members of 
their host governments to strengthen efforts to prevent the 
outbreak's spread. Burundi, South Sudan, Uganda, and Rwanda are 
vulnerable to the spread of Ebola and must remain vigilant, 
evidenced by recent cases in Uganda and in Goma City, a major 
transportation hub.
    The existing humanitarian crisis and Ebola outbreak has 
already caused tremendous harm to Congolese people and threats 
to the broader region. Our response must address the complex, 
underlying factors exacerbating the outbreak and impede its 
spread. The Bureau of African Affairs is here to offer the full 
suite of diplomatic tools to assist Congo and facilitate the 
work of our partners.
    Thank you for your time and consideration, and I look 
forward to your questions.
    [The prepared statement of Ambassador Nagy follows:]

                 Prepared Statement of Hon. Tibor Nagy

    Mr. Chairman, ranking Member and distinguished Members, thank you 
for the opportunity to testify today on the State Department Bureau of 
African Affairs' efforts to combat the ongoing Ebola outbreak and 
humanitarian crisis in eastern Democratic Republic of the Congo (DRC). 
I am pleased to be here with my colleagues. This panel serves as a 
reminder that the Ebola response is a whole-of-U.S.-government effort, 
and I am grateful that my colleagues and I are in this fight.
    The Ebola outbreak in eastern DRC, now declared by the World Health 
Organization (WHO) to be a Public Health Emergency of International 
Concern (PHEIC), continues to devastate the region, with tragic loss of 
life and disruption of social and economic livelihoods. The DRC 
successfully handled nine previous Ebola outbreaks, with capacity and 
expertise built up over decades of close cooperation with the United 
States, especially CDC. However, this 10th outbreak in eastern DRC--now 
the second largest in history--is different, as it is in a conflict 
zone. Health responders have been attacked and we mourn the loss of 
heroic Congolese and WHO health workers who have been killed. This 
insecure environment has challenged the international community's 
standard operational response, strengthened after the 2014-2016 West 
Africa outbreak, and hampered the U.S. Government's ability to stop the 
outbreak at its source. As a result, the Africa Bureau and Embassy 
Kinshasa have worked closely with technical and policy experts across 
USAID, the Department of Health and Human Services, and the U.S. 
interagency to demand a fresh start and ``reset'' of the response to 
better address the unique context in which this outbreak is occurring.
                          eastern drc context
    Eastern DRC is not new to instability. Longstanding regional and 
local tensions with deep-rooted grievances have fueled wars that killed 
millions in the 1990s-2000s and clashes persist to this day in Ituri 
and North Kivu provinces, where the Ebola outbreak continues to spread. 
Numerous armed groups operate in the region, conducting attacks that 
have harmed and killed thousands of Congolese civilians over decades. 
Despite the DRC being home to tremendous natural resource wealth, the 
Congolese people have seen little economic benefit, particularly in the 
mineral-rich and agriculturally fertile current outbreak zone.
    Food insecurity plagues local populations, and outbreaks of 
cholera, polio, and malaria continue to take the lives of innocent 
Congolese throughout the country. Although not specific to the East, 
the current measles outbreak in the DRC has sickened over 110,000 
people and killed over 1,800 in 2019 alone. This overall humanitarian 
crisis and intercommunal violence has led to significant internal 
displacement as well as to Congolese fleeing to neighboring countries.
    With poor infrastructure, rampant corruption, economic stagnation, 
and years of governance failures in the East left unaddressed by the 
previous DRC administration, local populations are disillusioned and 
fed up. An ``Ebola economy'' is developing, where despite our best 
intentions, the international response is exacerbating economic divides 
in a historically impoverished area. The surge of international 
attention on the Ebola response stands in stark contrast to a record of 
neglect on other health, political, and social problems the East faces.
    This glaring dichotomy has led local militia and frustrated 
community members to lash out and target healthcare facilities and 
workers. It underscores more than ever the necessity of engaging 
communities and local leaders to garner buy-in for the response.
                        u.s. embassy engagement
    The DRC government, alongside the U.N. and WHO, is leading this 
response, building on their decades of experience. The historic 
transfer of power to President Felix Tshisekedi in January 2019 has 
opened a new chapter in the U.S.-DRC bilateral relationship, defined by 
our statement announcing a Privileged Partnership for Peace and 
Prosperity that elevates our bilateral relationship and strengthens 
cooperation on issues ranging from anti-corruption to human rights to 
institutional strengthening, among others, and including the Ebola 
response. With President Tshisekedi, we are optimistic that we have a 
willing partner and new administration receptive to U.S. and 
international support to contain the outbreak.
    I heard this commitment firsthand during President Tshisekedi's 
visit to Washington in April and have seen it since demonstrated by his 
recent travels to eastern DRC. There, he has personally advocated for 
Ebola response efforts and encouraged popular local figures to lend a 
voice in support of community acceptance and participation in response 
and preparedness measures.
    The U.S. Government will continue to work closely with new U.N. 
Emergency Ebola Response Coordinator David Gressly, the WHO, the DRC 
Presidential Steering Committee on Ebola led by Director Dr. Jean-
Jacques Muyembe, and the DRC Ministry of Health, to improve 
communication and coordination across the public health and 
humanitarian response. We are thankful to be working alongside 
Congolese medical professionals who have for years navigated logistical 
and bureaucratic obstacles, limited resources, community sensitization, 
and other challenges to protect not only the Congolese people, but the 
world as a whole, from the spread of Ebola.
    Embassy Kinshasa is fully engaged in supporting the entire U.S. 
Government response in the DRC. Amidst challenging circumstances, the 
team in Kinshasa has not only kept up with increasing policy and 
logistical demands from the Ebola outbreak, but also accelerated its 
diplomatic outreach, oversight, and reporting on the issue. The Embassy 
hosted permanent USAID and CDC missions prior to this outbreak. As part 
of the response, it has expanded its operations to support a surge of 
USAID, CDC, NIH, and other temporary duty personnel to Kinshasa and 
Goma, where we did not previously have an established presence or 
robust mission support. Ambassador Hammer has proactively supported a 
constant stream of high-level U.S. and U.N. visitors to the East, to 
increase attention on the outbreak and demonstrate U.S. commitment to 
the response. Our team has leveraged its close ties with the Tshisekedi 
administration to encourage the closest coordination possible for 
information sharing, facilitate access to permissive outbreak zones, 
and ensure smooth logistical processes from visas to equipment 
turnover. From our Embassy in Kinshasa, we engage in diplomacy across 
the entire country, which in distance stretches almost from my driveway 
in Texas to here in Washington, DC.
    While Embassy Kinshasa has carried much of this weight, our Embassy 
teams in Bujumbura, Juba, Kampala, and Kigali have consistently urged 
the most senior members of their host governments to strengthen efforts 
to prevent the outbreak's spread. Burundi, South Sudan, Uganda, and 
Rwanda are vulnerable to the spread of Ebola and must remain vigilant. 
Our embassies are working at national, state, and local levels to 
provide technical and strategic assistance, support preparedness 
efforts, build trust in communities, improve information exchanges, 
strengthen border screenings and entry points, and coordinate 
leadership across ministries of health, elected officials, NGOs, the 
U.N., and others. These neighbors are suffering from preparation 
fatigue, despite the WHO's July 17 PHEIC declaration and the recent 
cases in both Uganda and in Goma city, which shares the busiest 
pedestrian border crossing in the world with Rwanda. Clearly, the Ebola 
outbreak requires we redouble our efforts. Few countries are prepared 
to handle a challenge like Ebola alone, so we call on all our partners 
to join these efforts.
                            looking forward
    The existing humanitarian crisis and Ebola outbreak has already 
caused tremendous harm to Congolese lives and livelihoods and taken a 
significant toll on economic, social, and healthcare services across 
eastern DRC. Our response to this public health emergency must also 
address the complex underlying factors exacerbating the outbreak and 
impeding its control. The State Department's Bureau of African Affairs 
is here to offer the diplomatic tools in our U.S. Government toolbox, 
and work alongside host government, U.N., and U.S. interagency 
colleagues for a unified and comprehensive Ebola outbreak response.
    Thank you for your time and consideration. I welcome the 
opportunity to answer any questions you may have.

    Senator Graham. Well, thank you all very much.
    This may be one of the hearings that they play the tape 
back down the road, and I hope not.
    Dr. Wolfe, give us sort of the ABCs of Ebola for those that 
are not as informed as they should be, beginning with me. What 
causes it? How deadly is it? And why does it keep recurring 
here?
    Dr. Wolfe. Sure. Ebola is endemic in many parts of Africa. 
Scientists believe it may have reservoir in bats. It is very 
difficult to predict when outbreaks will happen. It has an 
incubation period of 2 to 21 days, normally between 8 and 10 
days, and has severe symptoms with vomiting, diarrhea, 
hemorrhagic symptoms, and has a very high mortality.
    Senator Graham. Thank you.
    Admiral, a national security issue is not much a leap here. 
Tell us how the whole-of-government approach, the governance 
part of it, is essential to solving this problem because as I 
understand it, you got members of parliament basically telling 
people not to be vaccinated and there is a real effort to chill 
out health care here.
    Mr. Ziemer. Senator, there are many complicating factors. 
The role of the government in DRC in transition and their 
ability to influence the work on the ground is questionable.
    In terms of the U.S. approach, we do have a well 
coordinated approach to that. As I have monitored this----
    Senator Graham. But did you not say 35 health care 
facilities were attacked?
    Mr. Ziemer. More than that, sir, since the beginning of the 
year.
    Senator Graham. So who is doing the attacking?
    Mr. Ziemer. There are an estimated 70 to 90 armed groups. 
They vary from structure to gangs to just youth members. So 
there is a variation of the type of activity that is imposing 
threats.
    Senator Graham. Are they looting the facilities or just----
    Mr. Ziemer. Intimidating the health care workers. They have 
gone in and damaged the Ebola treatment units.
    Senator Graham. Are there any African Union forces present?
    Mr. Ziemer. In many cases, there are, and local security as 
well.
    Senator Graham. So the security footprint has to be 
enhanced. Right?
    Mr. Ziemer. Yes, sir.
    Senator Graham. What are we doing to enhance the security 
footprint?
    Mr. Ziemer. Part of the coordination effort that David 
Gressly is overseeing is to leverage the existing security.
    Senator Graham. What is it? What is the existing security?
    Mr. Ziemer. It is the use of government troops, as well as 
the MONUSCO troops.
    Senator Graham. I mean, do they have a real army they use? 
Mr. Nagy?
    Ambassador Nagy. The security presence has provided several 
different layers. First, we have the United Nations forces, 
MONUSCO. They have about 20,000 forces throughout the DRC. In 
the actual Ebola zone, they have about 3,000.
    This gentleman we have been talking about, David Gressly--
his previous assignment was to head MONUSCO. Now he has gone 
over as the chief U.N. coordinator.
    Senator Graham. Are these 3,000 troops effective?
    Ambassador Nagy. Three thousand troops. They are about as 
effective as they can be, given the circumstance. I had a 
conversation this morning with our Ambassador, and he was 
actually in the Ebola zone. And I asked him the very same 
question, and he said that with the recent reset, he is much 
more optimistic than he has been in the past because of the 
whole new approach of engaging the villagers.
    The fundamental problem in the past--I think we all alluded 
to it, Senator--was this huge decades of mistrust that had been 
built up between the communities and any outside government 
force.
    Senator Graham. That seems to me as big a problem as Ebola.
    Ambassador Nagy. Absolutely. That is why the complexity 
that everybody has been talking about--it is like a house of 
cards. Everything impacts everything else, sir.
    Senator Graham. Well, let us just talk about the security. 
I want to know about this new government. We have hope. Is that 
correct?
    Ambassador Nagy. Yes. President Tshisekedi's new 
government, yes, sir.
    Senator Graham. Do you agree with that, Ms. Bernicat?
    Ambassador Bernicat. Yes, I do, sir. He has visited 
Washington, DC and met with Secretary Azar. He visited the 
affected area. He has allowed for the return of one of the 
political exiles from the region who actually came back to the 
region, and very publicly received a vaccine. And so he has 
begun to show leadership in ways that we had not seen----
    Senator Graham. What can we do to help him that we are not 
doing on the security front?
    Ambassador Bernicat. One other aspect that I think is worth 
pointing out on the security front is that there are any number 
of people who have distrust of all individuals wearing military 
or police uniforms.
    Senator Graham. I understand that.
    Ambassador Bernicat. Exactly. The government has a very 
difficult dilemma of how to increase security without 
increasing distrust. Putting more boots on the ground in many 
cases is the answer. In this case, it can be a complicating 
factor.
    Senator Graham. Do we have any U.S. forces involved?
    Ambassador Bernicat. No.
    Senator Graham. Do we need U.S. forces involved?
    Ambassador Bernicat. No.
    Senator Graham. Everybody agrees with that? Okay.
    So we have got a new partner. He is doing things that we 
like. From the Congress' point of view, from the Senate's point 
of view, I think everybody up here wants to help you. Give us a 
very quick shopping list with the things we can do to help you 
in this cause that we are not doing. Not all at once.
    [Laughter.]
    Senator Graham. Yes, Mr. Nagy.
    Ambassador Nagy. I wish money could help in this regard, 
but the truth is I think that more than anything else, time is 
going to help. He is having to undo the tremendous damage done 
by his predecessors. For the first time, we have had President 
Tshisekedi come to us and say that he wants to engage with the 
United States as partners for his security.
    Senator Graham. We just need to thank him and encourage him 
to keep doing what he is doing.
    Ambassador Nagy. Pardon me, sir?
    Senator Graham. We need to thank him and encourage him to 
do what he is doing.
    Ambassador Nagy. Absolutely.
    Senator Graham. All right.
    Dr. Wolfe, you said before it is not a threat to the United 
States at this moment. What would make it a threat to the 
United States?
    Dr. Wolfe. Yes, Senator. Currently the risk to the U.S. is 
low. We analyze transmission dynamics of the epidemic, and when 
there is a change in the epidemic, we do a risk assessment and 
look at the strategy that matches that risk assessment. 
Currently we believe that addressing the outbreak at its source 
is the best way to prevent spread, and we have many activities 
to prevent the spread.
    Senator Graham. My question is what would be the conditions 
that would make it a threat to the United States. What are we 
afraid of?
    Dr. Wolfe. There are many different scenarios. And so the 
best way to prevent spread is to assess the situation and do a 
risk assessment and look at what strategy is necessary at that 
time. We have a number of activities that are looking at 
screening on the border, screening at airports.
    Senator Graham. Will you tell this committee when it gets 
to be a higher threat? How do we know? Will you all tell us?
    Dr. Wolfe. Absolutely. So when we do the risk assessments 
and look at the strategy, we will let you know what our 
strategy is and what needs to be done.
    Senator Graham. Senator Kaine?
    Senator Kaine. Dr. Wolfe, I am going to stay with you. You 
used a phrase in your testimony, ``community deaths,'' that I 
am not familiar with. Are these deaths that occur not in health 
care facilities so it is a little hard to track them? Or what 
does ``community deaths'' mean?
    Dr. Wolfe. That is correct, Senator. So these are deaths 
that we identify Ebola in somebody who is dead. That means that 
they were not identified when they were a case. And what is 
going to control this outbreak is the rapid identification and 
isolation of cases.
    Senator Kaine. I hear you.
    Let me ask about vaccination. Over 160,000 people have been 
vaccinated against Ebola as of July 15, and that includes more 
than 31,000 health workers. I gather that the vaccination is 
somewhat experimental.
    And I also understand that just in the last week, the 
health minister of the DRC has resigned. Largely, as I gather, 
there is sort of a dispute about which vaccine should be used, 
should both vaccines be used. To have a health minister resign 
in this situation obviously is a significant challenge. Talk a 
little bit about what that means and what we are doing, if 
anything, to help promote stability in the health ministry 
there. That may be a question more for the State Department 
side.
    Ambassador Nagy. Sure, Senator. Yes, indeed, the minister 
has resigned because the president was moving away from him. 
The president had appointed a special Ebola coordinator 
reporting directly to the president, a Dr. Muyembe, who has 
himself been involved with these Ebola emergencies, going back 
to the initial one in 1976. There is going to be a new health 
minister anyway when the entire new government is announced 
hopefully this next week, sir.
    Senator Kaine. So you do not view that resignation as a 
problem. In fact, it may actually be an improvement to the 
situation. Is that----
    Ambassador Nagy. Yes, sir. It may be an improvement to the 
situation.
    Senator Kaine. My understanding is that Rwanda and Burundi, 
as neighboring nations--they have not dealt with an Ebola 
outbreak before. So as we are looking at neighbors, some have 
dealt with it, some have not. What is your assessment of the 
capacity and preparation among neighboring nations to deal with 
the outbreak?
    Ambassador Nagy. My colleagues can also chime in on that. 
But from our point of view, Uganda and Rwanda are in very good 
shape to be able to deal with it. The disaster would be is if 
it got to South Sudan. With the large refugee populations 
there, the totally disorganized, dysfunctional, nonexistent 
government, that could be a disaster.
    Senator Kaine. And that goes back to the question the 
chairman was asking Dr. Wolfe. The things we would need to 
worry about are travel or people moving into other countries, 
especially into places that are fairly chaotic, and then that 
could lead to transmission to all kinds of places, including 
the United States. Is that a fair concern?
    Dr. Wolfe. Since the outbreak started, we have augmented 
our presence in the neighboring countries to work on 
preparedness activities with those countries. Some countries 
are better prepared than others. In Uganda, we have worked 
there for many years. It highlights the importance of work on 
global health security and the Global Health Security Agenda, 
which is a U.S. Government effort and a multinational effort to 
build capacity of countries to prevent, detect, and respond to 
infectious disease threats.
    Senator Kaine. And this is sort of a sweet spot for this 
committee because this committee is not just the Subcommittee 
on Africa, it is also the Subcommittee on Global Health Policy. 
So that is why this is sort of a little bit of a textbook 
problem for us to resolve and then use as a template.
    Tell us about the status of the vaccine. So there are 
vaccines that are sort of experimental. I mean, are the 
vaccines proven. Talk about the quality of the vaccine in terms 
of dealing with this, and then talk about quantities. Is there 
sufficient vaccine? Do we need dramatically more? Share that 
with us.
    Dr. Wolfe. So evidence suggests that the investigational 
vaccine that is being used has efficacy to protect against 
Ebola, and we feel that it has had a mitigating effect on this 
outbreak.
    Senator Kaine. And this is the vaccine that is a Merck 
product?
    Dr. Wolfe. Correct.
    Senator Kaine. There is a second vaccine that is a Johnson 
& Johnson product that has not yet been used in the DRC. Is 
that correct?
    Dr. Wolfe. Correct. We provide technical assistance to WHO 
and ministry of health to look at all available resources, and 
we have been pushing for an aggressive vaccination campaign. I 
want to highlight that the ministry of health is in charge of 
the epidemic, and they have decided that they are not ready to 
use that vaccine.
    Senator Kaine. Talk to us about the available quantity of 
the vaccine in terms of trying to meet the challenge.
    Dr. Wolfe. Our goal is to ensure that there is sufficient 
vaccine to address this outbreak.
    Senator Kaine. I know that is the goal, but give yourself a 
grade on that one right now. Are we at a C minus, or are we at 
an A? Do we have sufficient quantity?
    Dr. Wolfe. We currently have sufficient quantity to address 
the outbreak. I do not have the additional information on 
numbers. We could get back with you on that.
    Senator Kaine. Admiral Ziemer?
    Mr. Ziemer. There are over 800,000 doses between now and 
March of 2020 that are in the pipeline. So based on the use and 
the scale-up strategy, we are watching that very closely. I do 
know that HHS is working very closely on production schedules 
and the production line to look at future requirements. When 
this Ebola outbreak is ended, the use of a vaccine is clearly 
going to be an essential tool. So Secretary Azar and his team 
are looking at that.
    Senator Kaine. Talk to us a little bit about the community 
resistance. So I know that with political turmoil, contested 
elections--is the community resistance connected to political 
factions, political divides, or rumors that were spread about 
what the vaccine does or does not do. Share that with us a 
little bit.
    Ambassador Nagy. Yes, sir. It is all of the above. Part of 
it is historical because historically anytime you see somebody 
in a uniform, they are there to kill you, rob you, or rape you. 
The various different militias, the misery and the lack of 
development that has been in that region now almost since 
independence. And part of the community's thinking is, okay, we 
have been through decades of malaria and poverty and abuse, and 
all of a sudden, there is this new disease and we have all 
these Westerners showing up with all their resources because 
they tell us it is so important. We had the same thing in West 
Africa partially, but it is so much more intense here because 
of the horrendous abuse that that population has been through 
and the succeeding governments of the DRC, which just did not 
care at all about their population, especially that isolated 
part of the DRC.
    Senator Kaine. Thank you, Mr. Chair.
    Senator Graham. I think the first vote is about to end. Do 
you want to adjourn, vote, and come right back? Is that okay, 
or do you want to keep going? I think we need to vote. What do 
you want to do, Chris?
    Senator Coons. We could have some more questions and then 
go.
    Senator Graham. Well, but the first vote is over. So they 
are holding it for us. So why do we not vote and come right 
back. So we will be back in about 15-20 minutes.

    [Recess.]

    Senator Kaine. We will get the hearing started up again. 
Senator Graham is on his way back and said we could go ahead 
and continue. Senator Menendez will question next.
    Senator Menendez. Thank you, Mr. Chairman.
    Thank you all for your testimony.
    Doctor, disease knows no borders or boundaries. Is that 
fair to say?
    Dr. Wolfe. Yes, that is correct. That is how we use the 
phrase that diseases know no boundaries, and a threat anywhere 
could be a threat everywhere.
    Senator Menendez. So even though, in answer to the 
chairman's question, you said it is a low risk right now, 
obviously a greater outbreak of the Ebola virus produces a 
greater risk. It can be just one flight away--right--from 
someone who is contaminated before they show the symptoms.
    Dr. Wolfe. Yes, sir. Some of the things we look at are the 
transmission dynamics in the area and what the response 
capability is and also what the travel patterns are from the 
areas in the outbreak. So that is something we are constantly--
--
    Senator Menendez. My point in just raising that is that 
this is about more than being a good global partner. We have 
self-interests here as well.
    It seems to me that the major obstacle to contain the Ebola 
outbreak in the eastern Democratic Republic of Congo appears to 
be the lack of adequate access to the affected communities and 
the decades of insecurity, coupled with political 
marginalization, has resulted in conditions where not only our 
health care workers are unable to reach areas subject to 
militia attack, the very communities that we are trying to have 
access to have rejected health interventions, even attacking 
and killing health care workers.
    The U.S. intervention in West Africa during the Ebola 
crisis of 2014 was, I think, instrumental in stopping its 
spread.
    However, in the DRC, the U.S. has to date been unable to 
provide a full suite of interventions. The administration, for 
example, refused for months to issue a waiver for sanctions 
imposed on the DRC as a result of the DRC's tier 3 ranking 
under the Trafficking Victims Protection Act. USAID briefed 
committee staff in May on plans for engaging with communities 
to assess basic needs they may have in addition to Ebola, both 
in the health care sector and beyond as an improved strategy 
for gaining access to these communities. It is no good to have 
you go to a health care center. You may not have Ebola, but you 
have some other significant disease and you cannot be treated. 
People do not necessarily find that a reason then to go.
    So actions that, until very recently, could not be fully 
undertaken due to the Trafficking Victims Protection Act 
sanctions, which were never really meant for that purpose, as 
one of those who were fully engaged in the TVPA, which brings 
me to my questions.
    Admiral, is any of the fiscal year 2018 funding that was 
being held by the administration now being used to fund USAID's 
strategy to go beyond the health sector so as to provide health 
workers with better access to these communities?
    Mr. Ziemer. Senator, thanks for the question. And first of 
all, I just want to thank you and the other members for your 
strong support in this area. It is very much appreciated.
    The current investment that has been made by the U.S. 
Government and USAID, the $136 million, has not been affected 
by TVPA. I believe you and your staff were aware of that.
    The interagency is reviewing the implication of TVPA, 
particularly as a result of this outbreak and the implications 
not only in DRC but also in Burundi and South Sudan, which are 
on the tier 3 list. And we expect to hear a resolution on that 
very soon, and we will keep you and your staff----
    Senator Menendez. So 2018 funding that was being held-- is 
it being used now or not?
    Mr. Ziemer. No, sir, not all of it.
    Senator Menendez. Not all of it.
    So how long is it going to take for money for those 
activities to reach the ground?
    Mr. Ziemer. As soon as we get the disposition on the 
funding and the release of the funding, then----
    Senator Menendez. And that is still being held up because 
of determining whether or not the TVPA is going to continue to 
affect them?
    Mr. Ziemer. Yes, sir.
    Senator Menendez. That is not acceptable.
    Is there fiscal year 2018 money that is being reprogrammed 
out of the DRC, to your knowledge, or Secretary Nagy?
    Ambassador Nagy. I do not know, Senator. I can certainly 
check on it, but I do not know.
    Senator Menendez. Admiral, do you know if there is?
    Mr. Ziemer. No, but we will double check the specifics and 
get back to you.
    Senator Menendez. Has fiscal 2019 money been approved for 
Ebola response activities?
    Mr. Ziemer. On the IDA account, we are continuing to expend 
funding.
    Senator Menendez. Well, I would like not to dwell on it 
right now, but I would like to get the administration's 
response to us about--the Trafficking Victims Protection Act 
was meant to ensure that countries were doing the right things 
in terms of making sure they were not trafficking in persons. 
But it certainly was not meant to withhold money in a health 
emergency like this. That was never envisioned by the Congress. 
And I hope we can get to that. I know that some of us are 
offering language to make that clear for now and in the future, 
but in the interim, we cannot wait for the Ebola virus to break 
out even more significantly before we respond to it.
    Let me ask you, Mr. Secretary, what affect did the 
cancellation of elections have in terms of further straining 
relations between Kinshasa and the disenfranchised communities 
in areas affected by Ebola?
    Ambassador Nagy. The eastern DRC was not that significantly 
affected by the elections. You are referring, sir, to the ones 
that were won by Tshisekedi?
    Senator Menendez. Yes.
    Ambassador Nagy. There was not any serious election/ post-
election violence there. Unfortunately, that had always been a 
disaffected region of the DRC. The population there for decades 
has been very cynical about political developments. Luckily, 
President Tshisekedi is the first president to have actually 
visited now the Ebola region. He has been there several times 
to get the local authorities dynamized to confront it. So his 
image has really gone up since the inauguration and since his 
presidency.
    Senator Menendez. Is there any impact about our endorsement 
of Mr. Tshisekedi's questionable victory had on the credibility 
and our ability to undertake the full range of Ebola-related 
activities in eastern Congo?
    Ambassador Nagy. Senator, from my information and from 
talking to Ambassador Hammer, it has been just the opposite. 
The United States' image has actually been much improved 
because post election, President Tshisekedi's popularity goes 
up and up.
    Senator Menendez. Let me ask you this. On July 2nd, the 
DRC's minister of health, Oly Ilunga, resigned in protest over 
President Tshisekedi's decision to take over the Ebola 
response. By all accounts, he was an effective administrator, a 
good interlocutor. How does the resignation affect the Ebola 
response? You mentioned there will be a new health minister at 
some point, but when do we expect that to happen and why is 
this taking place when you have somebody who seemed to be 
working well in the job?
    Ambassador Nagy. Senator, my colleagues may be able to 
chime in also on the technical parts of this, but the president 
did not have confidence in the health minister. There was going 
to be a new one anyway. So he brought the whole Ebola issue to 
the presidency's office by appointing a coordinating committee, 
I think I mentioned, headed by Dr. Muyembe, who has Ebola 
expertise going back to 1976. So right now, the Ebola is still 
being directed out of the presidency, and the truth be told, it 
has been going on for over a year. So the previous health 
minister has not been all that effective.
    Senator Menendez. So we did not consider her effective or a 
good interlocutor.
    Ambassador Nagy. I think she was a good interlocutor, but 
as far as the results, I think for the effectiveness speak for 
themselves, sir.
    Senator Menendez. Last question. So we are all in with 
Tshisekedi then.
    Ambassador Nagy. We are very guardedly optimistic, and if 
you would like, I would be happy to submit a list of President 
Tshisekedi's positive accomplishments since assuming office, 
sir.
    Senator Menendez. That is not my question. We are all in 
with Tshisekedi.
    Ambassador Nagy. For now, we are. Yes, sir.
    Senator Menendez. All right. Thank you, Mr. Chairman.
    Senator Graham. Senator Coons?
    Senator Coons. Thank you, Chairman Graham, Ranking Member 
Kaine, for holding this important hearing.
    As we have all been discussing, the Ebola outbreak in 
eastern DRC has now grown into the second worst such outbreak 
in history, and this is not something we can afford to ignore. 
The combination of disaffection from the central government, 
poverty, under-development, chaos, and distrust makes this an 
exceptionally dangerous area in which to have a disease of this 
potential lethality spreading.
    This is, I think, an opportunity for us to, again, 
demonstrate the best of American leadership by helping support 
and lead a multilateral effort to combat what is a potentially 
global health and security threat. I do think it is a chance 
for us to mobilize our traditional allies, as well as others, 
like China who benefit from the international system, and to 
strengthen our efforts to make the world more capable of 
fighting global pandemics.
    We have already seen this outbreak cross international 
borders, and I think if we do not step up now and get ahead of 
this outbreak, there is a chance it could spread into even more 
countries, as our witnesses have testified.
    I also think it is important we help the DRC and other 
countries across the region build their resiliency and their 
capacity to resist further outbreaks. I think the question is 
not where and if, but when the next major Ebola outbreak will 
occur.
    In 2014, I traveled to Liberia and witnessed the suffering 
caused by Ebola firsthand and saw a genuinely inspiring, well-
coordinated, multilateral effort where the United States played 
an absolutely essential role, but the Liberian people and their 
ministries and government did as well, as did many nonprofits 
and arms of the United Nations.
    Ultimately many of us here fought for an emergency spending 
package which amounted to more than $5 billion, but those 
costs, both human and fiscal, were well beyond what they could 
have been had we really confronted it earlier as it grew. And 
some of those funds, if I understand correctly, are still being 
used today to combat the current outbreak.
    As I said in 2014, that outbreak would not be the last and 
certainly this will not either. There are very promising 
developments, as you have said, in terms of two potential 
effective, widely usable vaccines. But I think we need to 
prioritize investments in resiliency that will reduce the risks 
of the next outbreak.
    So let me ask, if I could, just a few questions.
    First, we have got real tensions with China across a wide 
range of issues, but Assistant Secretary Nagy, I would be 
interested in whether you think combating pandemics is an area 
where we could actually cooperate. There was some Chinese 
participation in the West African counter-Ebola efforts. Have 
we encouraged or engaged with the Chinese? Their hesitancy to 
step up and actually bear the costs and challenges of a world 
leader I think we should call to question.
    Ambassador Nagy. Senator, maybe some of my colleagues know 
as to what extent if we have had any discussions on the Hill 
side with the Chinese, but I absolutely support your 
proposition because there is no reason why we cannot work 
together with them in those areas where we can. Obviously, we 
do have trade and other competition with them throughout the 
world, especially in Africa, but there certainly can be areas 
of cooperation like in health.
    Senator Coons. I think the Global Health Security Agenda is 
something that deserves a few minutes of focus. It is a 
partnership of 64 countries. There are stakeholders across CDC, 
USAID, NIH. Over the last 5 years, there was a billion dollars 
in GHSA funding that has supported efforts to build global 
health capacity to effectively combat infectious disease.
    Admiral Ziemer, my understanding is that this pool of 
funding expires in September. If funding for GHSA is not 
maintained at current levels in fiscal year 2020, will all the 
agencies you represent be able to maintain current global 
health security programming, or will you be required to scale 
back operations either at CDC, AID, or at State?
    Mr. Ziemer. Senator, thanks for your recognition of the 
significance of the Global Health Security Agenda. And, yes, 
the funding that got that started, the $1 billion, came from 
the original supplemental.
    The Global Health Security Agenda is part of this 
administration's priority. There is funding in the current 
budget. While modest, it allows us to continue the program.
    Senator Coons. How modest, and how does it align with the 
need?
    Mr. Ziemer. I will have to get back to you on the specific 
budget.
    Senator Coons. But I will take the fact that you described 
it as modest to suggest that it is well below what may be 
necessary to sustain robust investment and resiliency in the 
face of a potential pandemic.
    Mr. Ziemer. Yes, sir. And I think your other point that you 
made earlier--there is an expectation of burden sharing, other 
countries stepping up to the plate. In terms of contributions 
to the current Ebola outbreak right now in DRC, the Government 
of China has contributed $1 million.
    Senator Coons. One.
    Mr. Ziemer. One million, yes, sir.
    Senator Coons. Has the WHO not said that funding for Ebola 
response needs to triple, and that their most recent estimate 
was there needs to be a total investment of about $320 million 
to get ahead of the virus?
    Mr. Ziemer. Yes. Senator, the good news is that we have a 
plan coming together that has specifically identified $384 
million--we can get you the figure--to move the health response 
through the end of the year. The good news is it also is built 
on four other components, pillars, if you will. The latter one 
is a $70 million call for country preparedness. For the first 
time, we are going to have a comprehensive picture of the 
projected requirements in terms of funding this Ebola response.
    The good news this morning, the World Bank made an 
announcement that they are going to provide $300 million. So 
with our $36 million, plus what the U.K. has committed, and we 
are seeing a gradual uptick in some of the other countries, 
there is an expectation that we will be able to move forward 
with the current plan.
    Senator Coons. That is very encouraging.
    I will just say that the United States has now for decades 
been the principal, the leading funder of public health 
challenges on the continent at the same time that China has 
eclipsed us as the largest trading partner, the largest 
investor on the continent. They are present in literally every 
country I have been to on the continent. They have expanded 
their footprint and, frankly, their extractive relationships 
with a number of countries. I will be pressing to see them step 
up to some of this responsibility. The idea that they are 
investing $1 million and we are investing tens, if not 
hundreds, of millions strikes me as an opportunity for us to 
partner.
    Mr. Ziemer. Thank you for your support on that.
    Senator Coons. Can I ask a last question, Dr. Wolfe and 
Admiral Ziemer or Assistant Secretary Nagy, if have any, about 
the decision to allow U.S. Government personnel either close to 
or not close to the hot zones? One of the things that really 
turned the tide in Ebola was the uniformed U.S. Public Health 
Service setting up a facility right at the edge of the Monrovia 
airport to guarantee that public health workers in Ebola 
treatment units, if they contracted Ebola, would get prompt and 
effective treatment. That was a key piece, the deployment of 
U.S. military testing labs out into the field into remote areas 
so that people did not have to come into the capital to confirm 
whether they had Lassa fever, Ebola, or something else.
    Where are we in terms of allowing either CDC or other U.S. 
personnel to actually be engaged on the ground, and what, if 
any, recommendation have you made and what do you think we 
should be doing?
    Dr. Wolfe. Yes, Senator. For the past year, we have 
deployed 200 people to support the outbreak with the ministry 
of health in Kinshasa, in Goma, in Geneva, and in surrounding 
countries. So we do have extensive activities there. It is true 
we have not been able to go directly into the outbreak zone 
because of security concerns, and we defer to State. We are 
under chief of mission authority in countries, and they 
determine where we can deploy.
    One thing I would like to highlight is in the recent case 
in Goma, we were able to deploy directly into outbreak and we 
were able to provide on-the-ground, real-time strengthening of 
the response.
    Senator Coons. And are you deployed in places like Burundi, 
South Sudan, in the region that may not have the resiliency 
that Uganda does where you previously described as if it gets 
into South Sudan, given the chaos there----
    Dr. Wolfe. Yes. We have country offices in South Sudan, 
Uganda, and Rwanda, and we have augmented those to work on 
preparation activities with those countries.
    Senator Coons. Assistant Secretary, you look as if you 
could add to this.
    Ambassador Nagy. Yes, indeed.
    The problem is not with Goma or Kinshasa, but it is with 
Beni and Bunia. And given the dynamics of the situation and how 
it changes day to day, we have a very careful policy under 
chief of mission, under Ambassador Hammer, where the regional 
security officer, diplomatic security, looks at the proposed 
travel, evaluates the threats, and then gives their blessing or 
recommends against it just like we were talking earlier about 
the CDC person just receiving permission today to shadow the 
U.N. overall coordinator. It was not an easy decision, and the 
whole emergency action committee had to take a look at it 
because of all the armed groups. There is one ISIS-linked 
terrorist organization operating in North Kivu. So it really is 
a case-by-case basis and how much has the situation changed.
    Unfortunately, as you said, sir, the West Africa situation 
was so different because of accessibility.
    Senator Coons. Do you have any sense how many Americans are 
in this immediate area who are there perhaps through 
Samaritan's Purse or Save the Children or Doctors Without 
Borders?
    Ambassador Nagy. I do not have an exact number, but I can 
certainly find out because I know that there are some that are 
not under chief of mission authority.
    Senator Coons. Because they certainly were in West Africa, 
literally hundreds of Americans deployed.
    Ambassador Nagy. Exactly.
    Senator Coons. Admiral, did you have any closing thoughts 
on what is the most important thing we are not doing that we 
should be doing to get ahead of this?
    Mr. Ziemer. The ideal situation would be to get the CDC 
personnel on the deck. We all support that.
    I just want to echo what the Ambassador has said, that we 
are working very hard with the Ambassador and the RSO to look 
at places that we can flex. The fact that we are in Goma today 
with a robust CDC and USAID team reflects a forward-leaning 
strategy. And just within the last couple weeks they have 
extended the curfew so that teams can get out and operate. So 
this is an ongoing issue. It is appreciated, and we are doing 
everything we can to make the right assessment in terms of 
getting our folks in the field.
    Senator Coons. I just want to thank all of you. I really 
appreciate your testimony, and I appreciate the patience of the 
chairman and my colleagues on the committee. Thank you very 
much.
    Senator Graham. Thank you. It has been great.
    One follow-up question and I will turn it over to my 
colleagues.
    Generally speaking, do you think, with the current 
resources and engagement, that we got a handle on this? Dr. 
Wolfe?
    Dr. Wolfe. Well, currently the outbreak is not under 
control, and what we need to do is increase the core public 
interventions, you know, rapid case identification, rapid 
isolation.
    Senator Graham. So we do not have a handle.
    Dr. Wolfe. So we need to improve these core public health 
interventions. It continues to expand, and we continue to have 
cases.
    Mr. Ziemer. The current plan, focusing in on the health 
response, has brought in aspects on how to improve our 
community engagement, how to improve the political interaction 
and the security, as well as perimeter support.
    So the jury is still out on whether or not this new effort, 
this international combined effort, will deliver the progress 
that we need. Right now, I am optimistic that we have 
mechanisms in place to move us forward, much improved over 
where we were 6 months ago.
    Senator Graham. Ms. Bernicat?
    Ambassador Bernicat. I would say that the aspect we do have 
a very firm handle on is our policymaking process back here and 
the number and the quality of people we have deployed in the 
field who are working not only on the response efforts, as best 
we can under the conditions, but also to involve more of the 
international community by broadening and diversifying the 
funding sources going forward.
    Ambassador Nagy. My perspective, Senator, is more on the 
governance issue. What they desperately need is positive 
governance and a professional military. And if Tshisekedi can 
succeed in that, it will take years not months, but that would 
flip the Democratic Republic of Congo from being a perennial 
area of instability to actually exporting stability for a 
change.
    Senator Graham. Do you think that is remotely possible 
without American leadership?
    Ambassador Nagy. Sir, I guarantee you American leadership 
is there. Our Ambassador is fully engaged with the president, 
with his government. So I am guardedly optimistic, sir.
    Senator Graham. Thank you.
    Senator Kaine. If I could just ask one follow-up. 
Ambassador Nagy, you mentioned the ISIS connection in one of 
the regions just briefly and I want to get into it because from 
the security standpoint, it is important. Senator Menendez and 
Chairman Risch did a hearing in this room earlier this morning 
about the current military authorizations against al Qaeda and 
ISIS. We were talking a lot about it. There was an attack in 
April. DRC soldiers were killed in parts of the country where 
Ebola has been very widespread. I guess it was the Allied 
Democratic Forces that claimed responsibility, but then ISIS 
also claimed responsibility. And the ADF says, or at least are 
saying, that they want to have more of an ISIS tie. So this, 
obviously, is the security complicator of getting our people in 
place. It is not just the health risk. It is now also the risk 
of these groups with an ISIS connection.
    Give us an assessment of ISIS activity. Is that a group in 
name only that is not particularly effective? Is the ADF really 
connected to ISIS? Share that with us.
    Ambassador Nagy. Obviously, I think we could provide more 
facts in a different setting. But in this setting, I can say 
that the ADF is the single one of the many armed groups in that 
area that has affiliated with ISIS. ISIS has embraced them. 
There are potentials for exchanges with other ISIS groups, 
individuals in the area receiving resources. But the ADF is a 
rather bizarre group because they do not range much beyond 
their territory because of the ethnic identity, and they do not 
specifically target Ebola efforts. It just happens that if they 
are undertaking a violent campaign, that people involved in the 
Ebola campaign could get caught up in that. So it is definitely 
a group worth watching. And as I said, I think we could provide 
additional details in a different setting, sir.
    Senator Kaine. Thank you.
    Senator Graham. Thank you all. You represent our country 
very well, and we are here to help. I appreciate your knowledge 
and level of attention to this. If we are successful, it will 
be because of your efforts. And if we are not successful, it 
will not be because you did not try.
    So we will hold the record open till Friday for any further 
comments or questions. Thank you.
    [Whereupon, at 4:10 p.m., the hearing was adjourned.]

                              ----------                              


              Additional Material Submitted for the Record


          Responses of Hon. Tibor Nagy to Questions Submitted 
                       by Senator Robert Menendez

    22 U.S.C. Chapter 78, Section 4 of the Trafficking Victims 
Protection Act provides for the continuation of assistance that would 
otherwise be sanctioned for failing to meet the minimum standards on 
trafficking when it is in the National Interest of the United States to 
waive sanctions. Paragraph Section (d)(5)(B) of TVPA states: ``The 
President shall exercise the authority under section (4) when necessary 
to avoid significant adverse effects on vulnerable populations, 
including women and children.'' According to the World Health 
Organization, the Ebola virus disease has a mortality rate of 50 
percent.

    Question. Do we consider the people in eastern Democratic Republic 
of Congo (DRC) living in Ebola affected regions, or living near those 
infected with Ebola vulnerable? How many women have been infected with 
Ebola in this outbreak, and how many have died as a result of the 
infection? How many children have been infected with Ebola in this 
outbreak? How many children have died as a result of being infected?

    Answer. The current Ebola outbreak in an active conflict zone in 
eastern DRC is affecting a vulnerable population that is extremely poor 
and historically neglected and abused. The outbreak is 
disproportionately affecting women due to their role as primary 
caretakers. Community resistance and a large number of community deaths 
further exacerbate the impact on women and children. According to the 
WHO, as of July 31, 56 percent of the total 2,612 confirmed and 
probable cases were women, and 29 percent were children under 18 years. 
While we do not have data on the number of women fatalities, according 
to Save the Children, over 500 children have died since the outbreak 
began in August 2018.

    Question. Do we consider the morbidity resulting from Ebola a 
significant adverse effect?

    Answer. Yes.

    Question. Why hasn't the waiver cited above been exercised as 
required by the law?

    Answer. The United States is the largest single-country donor to 
the current Ebola outbreak response, including support through the U.S. 
Agency for International Development of more than $136 million since 
August 2018. Most assistance to the Ebola response is not subject to 
the TVPA restrictions. The U.S. Government is committed to global 
health security as outlined in the National Security and National 
Biodefense strategies, and is working with partners to provide the 
assistance needed to contain this outbreak. The process of evaluating 
assistance affected by restrictions for FY 2020 TVPA is ongoing.

    Question. How effective will the international response be if we 
are not able to engage in actions that will help lower community 
resistance?

    Answer. The current Ebola outbreak is the tenth in the DRC. Against 
the backdrop of a complex humanitarian crisis, community resistance--
evidenced by the high number of community deaths--is complicating 
response efforts. Community engagement and buy-in are critical to 
containing this outbreak, and to preventing it from spreading to 
populous regions and neighboring countries. We support broader 
engagement by the United Nations and outreach to community leaders and 
civil society, including faith-based groups and religious leaders, to 
lower community resistance.

    Question. What polling data exists to support claims that 
Tshisekedi continues to grow in popularity in eastern Congo?

    Answer. In June, the New York University-based Congo Research Group 
(CRG) released new polling data that confirmed the optimism of the 
Congolese people towards President Felix Tshisekedi. The data 
highlighted that 61 percent of Congolese are optimistic about DRC's 
future and 67 percent have a favorable view of the new president's 
first 100 days in office. The CRG poll confirms average Congolese are 
hopeful about the future for the first time in many years and suggests 
that U.S. support is a key factor to ensure President Tshisekedi is 
able to consolidate the democratic transition and enact reforms 
encompassing human rights, accountability, anti-corruption, security 
sector professionalization, and fiscal transparency. During insecurity-
driven protests this week in Beni territory, civil society called on 
President Tshisekedi to travel again to the region to personally assess 
the situation. This is notably different from the protests that 
occurred frequently during the previous regime calling on Kabila to 
step down.

    Question. According to a fact sheet released by the Armed Conflict 
Location & Event Data Project (ACLED), ``Six months into the new 
presidency of Felix Tshisekedi, ACLED data show that overall political 
violence is rising at even higher rates than last year, at the 
conclusion of Joseph Kabila's nearly 20-year rule.'' To what do we 
attribute this uptick in violence?

    Answer. South Kivu and Ituri saw major escalations in longstanding 
communal grievances in the last few months, which may account for some 
of the uptick as ACLED does not seem to clearly distinguish between 
purely political and ethnic violence, which are often intertwined in 
local conflicts. In terms of the ACLED data set between January and 
June, armed clashes and attacks dwarfed traditional political violence 
by the state against peaceful opposition and demonstrators. The U.N. 
reported that after the inauguration of President Tshisekedi in late 
January a number of armed groups turned themselves in to MONUSCO and 
the GDRC. More than 1,000 fighters requested demobilization, as they no 
longer feel threatened by the national government. Our focus is on 
ensuring MONUSCO and the GDRC have the personnel and funding resources 
to leverage these gains by implementing sustainable options for 
reintegrating former militia members into their communities.
    MONUSCO's Joint Human Rights Office (JHRO) documented 9 percent 
fewer human rights violations over the first six months of 2019 
compared to same period in 2018. This is an encouraging sign of 
improvement during President Felix Tshisekedi's first few months in 
office. In particular, the JHRO noted state security forces were 
responsible for notably fewer violations when compared to the same 
period in 2018. Political violence in the Haut Uele and Bas Uele 
provinces decreased due to military pressure by the FARDC. Violence has 
been curbed in areas of North Kivu where MONUSCO supported local 
authorities' efforts to facilitate dialogue between warring groups and 
re-instituted a local conflict resolution mechanism. MONUSCO and the 
GDRC also made strides in quelling ethno-political conflict and 
displacement in South Kivu in June by brokering cease-fire agreements 
and fostering dialogue between ethnic armed group leaders and the local 
communities. In addition, MONUSCO and the FARDC recently addressed 
longstanding violent conflict and significant displacement in Ituri by 
fostering an agreement to turn an armed group (Ituri Patriotic Front 
Resistance) into a political party.
                               __________

          Responses of Hon. Tibor Nagy to Questions Submitted 
                      by Senator Edward J. Markey

    The ongoing Ebola outbreak and other Infectious disease threats, 
such as measles and antibiotic resistance, help reinforce the 
importance of the Global Health Security Agenda (GHSA)--a partnership 
of over 64 nations and stakeholders to help create a world safe and 
secure from infectious disease threats. Across CDC, USAID, and NIH, $1 
billion in GHSA funding between 2014 and 2019 has supported efforts to 
build global health capacity to effectively combat infectious diseases.

    Question. As you know, this pool of funding expires in September. 
Can you speak to the importance of maintaining adequate funding for the 
GHSA?

    Answer. Achieving global health security remains a foreign policy 
priority for the Department of State. Agencies other than the 
Department are the primary implementers of the funds made available for 
U.S. Government Global Health Security Agenda (GHSA) activities. The 
State Department regularly highlights U.S. Government investments in 
the GHSA, and their lifesaving impact, in diplomatic engagements with 
partner countries.

    Question. If funding is not maintained at current levels in the FY 
20 spending bill, will your agencies be able to maintain current global 
health security programming, or will you be required to scale back 
operations?

    Answer. The Department of State is not a primary implementer of the 
overseas capacity-building activities to prevent, detect, and respond 
to infectious diseases. Department staff will continue to conduct 
outreach, promote global health security, and coordinate implementation 
of the interagency Global Health Security Agenda activities through 
U.S. missions.

    Question. Ongoing conflict, violence and community mistrust have 
been identified as the main reasons complicating the current response 
in a country that is no stranger to Ebola outbreaks. However, former 
Minister of Health Dr. Oly Ilunga Kalenga identified additional 
weaknesses in response efforts, including a lack of coordination and 
communication among actors, lack of actionable data, and weak 
operational plans. What are your agencies doing to help the Ministry of 
Health address these weaknesses and strengthen the response from an 
implementation standpoint?

    Answer. The State Department, in coordination with USAID, CDC, and 
other agencies, is working with the DRC Ministry of Health and the U.N. 
system (including the WHO) to improve coordination among Ebola 
responders and strengthen the response effort. Ambassador Hammer and 
his team at Embassy Kinshasa and in Goma are in constant contact with 
DRC and other actors, assessing the response effort and providing 
guidance on how to improve it. A particular focus is to ensure the 
transition of DRC leadership overseeing the response--from former 
Minister of Health Ilunga to lead Ebola coordinator Dr. Jean-Jacques 
Muyembe--is smooth and leads to a better-coordinated response.

    Question. The World Health Organization has identified a funding 
shortfall of $54 million for response efforts to control the outbreak 
and prevent further spread. U.S. contributions thus far have come out 
of existing Ebola emergency supplemental funding from the 2014 
outbreak. Are there any plans for the U.S. to make an additional 
contributions on par with increasing challenges?

    Answer. The United States is the largest single-country donor to 
the Democratic Republic of Congo, contributing approximately $500 
million in development and humanitarian programming annually, and more 
than $136 million to the current Ebola response. Working with the 
international community, the U.S. Government is constantly assessing 
the humanitarian needs and gaps in the response and may make further 
contributions where we are best placed to fill a need. We continue to 
engage members of the international community to fully fund the 
response. We are also supporting Ebola preparedness efforts in 
unaffected areas in the DRC and neighboring countries through the 
Global Health Security Agenda and other mechanisms.

    Question. As one the largest and longest-lasting U.N. peacekeeping 
missions, the United Nations Organization Stabilization Mission in the 
Democratic Republic of the Congo (MONUSCO) has been criticized for its 
cost, effectiveness, and various allegations of misconduct on-the-
ground. In March, the United Nations Security Council called for a 
security review of the mission, including a drawdown and exit strategy. 
In April, the mission scaled back operations in various parts of the 
country, due to budget cuts. At the moment, do you think that MONUSCO 
is equipped to handle the on-going Ebola crisis, amid these on-going 
and possible future changes? If so, how can the U.S. assist in this 
regard?

    Answer. MONUSCO has successfully consolidated its activities from 
electoral support throughout the country to focus eastward on 
protection of civilians, provision of good offices to mitigate 
conflict, and neutralizing the over 100 armed groups that operate in 
the eastern DRC. MONUSCO has made notable strides in quelling ethno-
political conflict in South Kivu and Ituri by brokering cease-fire 
agreements, fostering dialogue between agents of conflict and local 
communities, as well as producing an agreement to turn an armed group 
(Ituri Patriotic Front Resistance) into a political party. These 
efforts complement the overall effort to control the current Ebola 
outbreak.
    MONUSCO also provides invaluable logistical, security, good offices 
and leadership support to the Ebola response itself, including 
providing escorts and securing road access for humanitarian operations 
and personnel. In May, at the United States' suggestion, U.N. Secretary 
General Guterres appointed former MONUSCO Deputy Special Representative 
of the Secretary General David Gressly as the U.N.'s Ebola Emergency 
Response Coordinator (EERC), responsible for coordinating the 
international response including U.N. agencies, NGOs and donors, in 
partnership with the government of the DRC. Gressly's professional 
background and substantial DRC experience give him the tools and 
expertise to navigate a complex response in an even more complex 
environment. Since his appointment, Gressly has introduced 
complementary, multi-sector humanitarian programs that aim to enhance 
community acceptance of Ebola response activities. He formalized 
political and security management protocols under what he describes as 
a ``complex public health emergency.'' Gressly's proposed security 
reforms for the response, while ambitious to implement quickly, mirror 
USG priorities for de-militarizing the response by reducing security 
escorts and shifting to long-range perimeter security. In response to 
recent increases in Ebola-related insecurity in the Beni-Butembo 
epicenter area, MONUSCO has also deployed additional peacekeepers 
there.

    Question. In 2019, the United Nations Refugee Agency estimated that 
DRC has over 856, 043 refugees and the 4.5 million internally 
displaced. How has the Ebola crisis further worsened the on-going 
refugee and IDP situation in the Congo and its neighboring states? What 
bilateral and multilateral efforts can the U.S. take to reduce the 
migration of peoples both in and out of DRC?

    Answer. The Ebola outbreak is occurring in eastern DRC, one of the 
most geopolitically complex areas in Africa. A combination of decades 
of neglect by the central government, socio-economic marginalization, 
and political tensions has led to persistent conflict by armed groups 
and spontaneous attacks between intercommunal groups and youth groups. 
While the U.S. Government has not observed additional displacements due 
to the Ebola outbreak, the response to it is complicated by insecurity 
and large-scale population displacement. The U.S. Government continues 
to respond to the complex emergency, supporting humanitarian protection 
and the provision of basic services, such as food assistance, health 
care, psychosocial support, and water and sanitation, which help reduce 
some displacement.
    We encourage all countries to follow the World Health Organization 
(WHO) recommendations to address the Ebola outbreak, which is a Public 
Health Emergency of International Concern. The WHO advises against 
placing travel and trade restrictions on or closing borders with the 
DRC.
    The United States continues to call on other donors to increase 
their support for humanitarian assistance in the DRC and for Congolese 
refugees in the region. Ultimately, durable solutions for most 
displacement in the country and region depend on resolution of the 
political conflicts that are driving people from their homes in the 
DRC, Burundi, Central African Republic, Rwanda, and South Sudan.
                               __________

       Responses of Hon. Marcia Bernicat to Questions Submitted 
                       by Senator Robert Menendez

    22 U.S.C. Chapter 78, Section 4 of the Trafficking Victims 
Protection Act provides for the continuation of assistance that would 
otherwise be sanctioned for failing to meet the minimum standards on 
trafficking when it is in the National Interest of the United States to 
waive sanctions. Paragraph Section (d)(5)(B) of TVPA states: ``The 
President shall exercise the authority under section (4) when necessary 
to avoid significant adverse effects on vulnerable populations, 
including women and children.'' According to the World Health 
Organization, the Ebola virus disease has a mortality rate of 50 
percent.

    Question. Do we consider the people in eastern Democratic Republic 
of Congo (DRC) living in Ebola affected regions, or living near those 
infected with Ebola vulnerable? How many women have been infected with 
Ebola in this outbreak, and how many have died as a result of the 
infection? How many children have been infected with Ebola in this 
outbreak? How many children have died as a result of being infected?
    Answer. The current Ebola outbreak in an active conflict zone in 
eastern DRC is affecting a vulnerable population that is extremely poor 
and historically neglected and abused. The outbreak is 
disproportionately affecting women due to their role as primary 
caretakers. Community resistance and a large number of community deaths 
further exacerbate the impact on women and children. According to the 
WHO, as of July 31, 56 percent of the total 2,612 confirmed and 
probable cases were women, and 29 percent were children under 18 years. 
While we do not have data on the number of women fatalities, according 
to Save the Children, over 500 children have died since the outbreak 
began in August 2018.

    Question. Do we consider the morbidity resulting from Ebola a 
significant adverse effect?

    Answer. Yes.

    Question. Why hasn't the waiver cited above been exercised as 
required by the law?

    Answer. The United States is the largest single-country donor to 
the current Ebola outbreak response, including support through the U.S. 
Agency for International Development of more than $136 million since 
August 2018. Most assistance to the Ebola response is not subject to 
the TVPA restrictions. The U.S. Government is committed to global 
health security as outlined in the National Security and National 
Biodefense strategies, and is working with partners to provide the 
assistance needed to contain this outbreak. The process of evaluating 
assistance affected by restrictions for FY 2020 TVPA is ongoing.

    Question. How effective will the international response be if we 
are not able to engage in actions that will help lower community 
resistance?

    Answer. The current Ebola outbreak is the tenth in the DRC. Against 
the backdrop of a complex humanitarian crisis, community resistance--
evidenced by the high number of community deaths--is complicating 
response efforts. Community engagement and buy-in are critical to 
containing this outbreak, and to preventing it from spreading to 
populous regions and neighboring countries. We support broader 
engagement by the United Nations and outreach to community leaders and 
civil society, including faith-based groups and religious leaders, to 
lower community resistance.

    Question. What polling data exists to support claims that 
Tshisekedi continues to grow in popularity in eastern Congo?

    Answer. In June, the New York University-based Congo Research Group 
(CRG) released new polling data that confirmed the optimism of the 
Congolese people towards President Felix Tshisekedi. The data 
highlighted that 61 percent of Congolese are optimistic about DRC's 
future and 67 percent have a favorable view of the new president's 
first 100 days in office. The CRG poll confirms average Congolese are 
hopeful about the future for the first time in many years and suggests 
that U.S. support is a key factor to ensure President Tshisekedi is 
able to consolidate the democratic transition and enact reforms 
encompassing human rights, accountability, anti-corruption, security 
sector professionalization, and fiscal transparency. During insecurity-
driven protests this week in Beni territory, civil society called on 
President Tshisekedi to travel again to the region to personally assess 
the situation. This is notably different from the protests that 
occurred frequently during the previous regime calling on Kabila to 
step down.

    Question. According to a fact sheet released by the Armed Conflict 
Location & Event Data Project (ACLED), ``Six months into the new 
presidency of Felix Tshisekedi, ACLED data show that overall political 
violence is rising at even higher rates than last year, at the 
conclusion of Joseph Kabila's nearly 20-year rule.'' To what do we 
attribute this uptick in violence?

    Answer. South Kivu and Ituri saw major escalations in longstanding 
communal grievances in the last few months, which may account for some 
of the uptick as ACLED does not seem to clearly distinguish between 
purely political and ethnic violence, which are often intertwined in 
local conflicts. In terms of the ACLED data set between January and 
June, armed clashes and attacks dwarfed traditional political violence 
by the state against peaceful opposition and demonstrators. The U.N. 
reported that after the inauguration of President Tshisekedi in late 
January a number of armed groups turned themselves in to MONUSCO and 
the GDRC. More than 1,000 fighters requested demobilization, as they no 
longer feel threatened by the national government. Our focus is on 
ensuring MONUSCO and the GDRC have the personnel and funding resources 
to leverage these gains by implementing sustainable options for 
reintegrating former militia members into their communities.
    MONUSCO's Joint Human Rights Office (JHRO) documented 9 percent 
fewer human rights violations over the first six months of 2019 
compared to same period in 2018. This is an encouraging sign of 
improvement during President Felix Tshisekedi's first few months in 
office. In particular, the JHRO noted state security forces were 
responsible for notably fewer violations when compared to the same 
period in 2018. Political violence in the Haut Uele and Bas Uele 
provinces decreased due to military pressure by the FARDC. Violence has 
been curbed in areas of North Kivu where MONUSCO supported local 
authorities' efforts to facilitate dialogue between warring groups and 
re-instituted a local conflict resolution mechanism. MONUSCO and the 
GDRC also made strides in quelling ethno-political conflict and 
displacement in South Kivu in June by brokering cease-fire agreements 
and fostering dialogue between ethnic armed group leaders and the local 
communities. In addition, MONUSCO and the FARDC recently addressed 
longstanding violent conflict and significant displacement in Ituri by 
fostering an agreement to turn an armed group (Ituri Patriotic Front 
Resistance) into a political party.
                               __________

       Responses of Hon. Marcia Bernicat to Questions Submitted 
                      by Senator Edward J. Markey

    The ongoing Ebola outbreak and other Infectious disease threats, 
such as measles and antibiotic resistance, help reinforce the 
importance of the Global Health Security Agenda (GHSA)--a partnership 
of over 64 nations and stakeholders to help create a world safe and 
secure from infectious disease threats. Across CDC, USAID, and NIH, $1 
billion in GHSA funding between 2014 and 2019 has supported efforts to 
build global health capacity to effectively combat infectious diseases.

    Question. As you know, this pool of funding expires in September. 
Can you speak to the importance of maintaining adequate funding for the 
GHSA?

    Answer. Achieving global health security remains a foreign policy 
priority for the Department of State. Agencies other than the 
Department are the primary implementers of the funds made available for 
U.S. Government Global Health Security Agenda (GHSA) activities. The 
State Department regularly highlights U.S. Government investments in 
the GHSA, and their lifesaving impact, in diplomatic engagements with 
partner countries.

    Question. If funding is not maintained at current levels in the FY 
20 spending bill, will your agencies be able to maintain current global 
health security programming, or will you be required to scale back 
operations?

    Answer. The Department of State is not a primary implementer of the 
overseas capacity-building activities to prevent, detect, and respond 
to infectious diseases. Department staff will continue to conduct 
outreach, promote global health security, and coordinate implementation 
of the interagency Global Health Security Agenda activities through 
U.S. missions.

    Question. Ongoing conflict, violence and community mistrust have 
been identified as the main reasons complicating the current response 
in a country that is no stranger to Ebola outbreaks. However, former 
Minister of Health Dr. Oly Ilunga Kalenga identified additional 
weaknesses in response efforts, including a lack of coordination and 
communication among actors, lack of actionable data, and weak 
operational plans. What are your agencies doing to help the Ministry of 
Health address these weaknesses and strengthen the response from an 
implementation standpoint?

    Answer. The State Department, in coordination with USAID, CDC, and 
other agencies, is working with the DRC Ministry of Health and the U.N. 
system (including the WHO) to improve coordination among Ebola 
responders and strengthen the response effort. Ambassador Hammer and 
his team at Embassy Kinshasa and in Goma are in constant contact with 
DRC and other actors, assessing the response effort and providing 
guidance on how to improve it. A particular focus is to ensure the 
transition of DRC leadership overseeing the response--from former 
Minister of Health Ilunga to lead Ebola coordinator Dr. Jean-Jacques 
Muyembe--is smooth and leads to a better-coordinated response.

    Question. The World Health Organization has identified a funding 
shortfall of $54 million for response efforts to control the outbreak 
and prevent further spread. U.S. contributions thus far have come out 
of existing Ebola emergency supplemental funding from the 2014 
outbreak. Are there any plans for the U.S. to make an additional 
contributions on par with increasing challenges?

    Answer. The United States is the largest single-country donor to 
the Democratic Republic of Congo, contributing approximately $500 
million in development and humanitarian programming annually, and more 
than $136 million to the current Ebola response. Working with the 
international community, the U.S. Government is constantly assessing 
the humanitarian needs and gaps in the response and may make further 
contributions where we are best placed to fill a need. We continue to 
engage members of the international community to fully fund the 
response. We are also supporting Ebola preparedness efforts in 
unaffected areas in the DRC and neighboring countries through the 
Global Health Security Agenda and other mechanisms.
                               __________

    Responses of Rear Admiral Tim Ziemer, USN, Retired to Questions 
                               Submitted 
                       by Senator Robert Menendez

    22 U.S.C. Chapter 78, Section 4 of the Trafficking Victims 
Protection Act provides for the continuation of assistance that would 
otherwise be sanctioned for failing to meet the minimum standards on 
trafficking when it is in the National Interest of the United States to 
waive sanctions. Paragraph Section (d)(5)(B) of TVPA states: ``The 
President shall exercise the authority under section (4) when necessary 
to avoid significant adverse effects on vulnerable populations, 
including women and children.'' According to the World Health 
Organization, the Ebola virus disease has a mortality rate of 50 
percent.

    Question. Do we consider the people in eastern Democratic Republic 
of Congo (DRC) living in Ebola affected regions, or living near those 
infected with Ebola vulnerable? How many women have been infected with 
Ebola in this outbreak, and how many have died as a result of the 
infection? How many children have been infected with Ebola in this 
outbreak? How many children have died as a result of being infected?

    Answer. Anyone living in proximity to a disease outbreak is 
vulnerable to infection, including persons vulnerable to Ebola in at-
risk areas in the Democratic Republic of the Congo (DRC). USAID 
continues to support Ebola response assistance to support vulnerable 
populations in DRC. We defer to the Centers for Disease Control and 
Prevention (CDC) on the latest case numbers for women and children.

    Question. Do we consider the morbidity resulting from Ebola a 
significant adverse effect?

    Answer. Yes, the morbidity resulting from Ebola is a significant 
adverse effect of infection. USAID continues to support the Ebola 
response, providing assistance under available authorities, including 
the exception to the TVPA restriction, as well as by relying on funding 
not impacted by TVPA.

    Question. Why hasn't the waiver cited above been exercised as 
required by the law?

    Answer. Ebola-related assistance is continuing through available 
authorities and exceptions, and as such, the exercise of the TVPA 
waiver is not necessary in order to avoid significant adverse effects 
of the TVPA restriction on vulnerable populations.

    Question. How effective will the international response be if we 
are not able to engage in actions that will help lower community 
resistance?

    Answer. Effectively engaging communities remains integral to ending 
the outbreak. USAID is engaging in actions that will help lower 
community resistance along with international partners ECHO, DFID, and 
the World Bank. For example, USAID has provided $5.3 million to support 
UNICEF in engaging communities affected by the Ebola virus disease 
(EVD). UNICEF is the co-lead for risk communication and community 
engagement in the response and plans to strengthen community engagement 
through social and behavioral change, local community participation, 
and mental health and psychosocial support. UNICEF will work with 
affected and at-risk communities and address community concerns and 
rumors, among other activities. UNICEF will further conduct research 
and implement evidence-based communication in the development of a 
Communication Strategy.
    Additionally, USAID is undertaking a number of actions to address 
community resistance, such as supporting primary health care or 
providing basic water, sanitation and hygiene. USAID emphasizes the 
importance of an expanded community-based response strategy that 
operationalizes community feedback, increases local ownership of Ebola 
response activities, and helps address broader, community-prioritized 
needs to improve community acceptance and access. Under this approach, 
to build local ownership, USAID will support hiring more persons from 
the local community, including Ebola survivors, as well as engage a 
wide range of local stakeholders in core response strategies and 
communications--from women's groups and faith leaders to traditional 
leaders and youth. The goal is to change perspectives so that members 
of the community themselves can spread messages related to the 
response, which will help reinforce community acceptance and engagement 
in the response.
    USAID's Office of Inspector General released two reports in January 
of 2018 assessing lessons learned and gaps in the last response. Two of 
the reports pointed to challenges in filling staffing vacancies during 
the last Ebola response. One report pointed to the ``lack of an Agency 
wide system for capturing and sharing program and project data'' which 
``challenged internal communication and coordination.''

    Question. What are the major lessons learned from the 2014 Ebola 
response in the areas of staffing, programming and planning, and how 
are these lessons being incorporated in this response?

    Answer. States must be prepared to quickly respond to infectious 
disease outbreaks that could pose a global danger, in some cases even 
before the World Health Organization (WHO) declares an official PHEIC. 
USAID has committed to the continual strengthening of the Agency's 
policies, practices, structures, and systems to prepare for, respond 
to, and learn from global infectious disease outbreaks. For example, on 
October 31, 2018, an Agency Notice was issued titled, ``USAID Response 
to Global Infectious Disease Outbreaks''. The Agency Notice clearly 
outlines the roles and responsibilities of USAID staff when preparing 
for and responding to infectious disease outbreaks, including a 
requirement to USAID Missions and Offices overseas to be aware of local 
outbreaks and to notify [email protected] when there is an outbreak 
that may require international or additional assistance. On July 26, 
2019, an Agency Notice was issued titled ``Process for Programming 
Resources during a declared Public Health Emergency of International 
concern''. The notice outlines the process at the U.S. Agency for 
International Development (USAID) for programming resources during a 
Public Health Emergency of International Concern (PHEIC) declared by 
the World Health Organization (WHO). USAID's broad-based and 
multisectoral approach allows the Agency to leverage the technical 
expertise to strengthen local capacity around the world to prevent, 
detect, and respond to infectious diseases.
    USAID has established partnerships across the U.S. Government, with 
relevant international, non-governmental, and other organizations, to 
strengthen preparedness and response efforts for potential disease 
outbreaks that could require an international emergency response. While 
we are applying lessons learned wherever possible, we are also 
accounting for key differences in the outbreaks and responses, 
including the fact that the current response is taking place in an 
active conflict zone. Many personnel responding to this outbreak also 
responded in 2014 and have leveraged their expertise in this response. 
WHO has adopted emergency response reforms over the last several years, 
with the strong backing of the United States, which have enabled the 
organization to improve their operational capacity and more effectively 
and rapidly respond to this and other outbreaks.

    Question. Have USAID and the Interagency worked to develop an 
overarching framework and strategy for improved leadership, staffing, 
and coordination for this and future global health security responses? 
If so, how has this improved framework and approach helped in this 
current DRC outbreak?

    Answer. USAID maintains several mechanisms, such as interagency 
agreements, with key interagency partners to rapidly pull in and 
leverage unique capabilities across the U.S. Government to support 
response efforts. Additionally, we support the roles and 
responsibilities of federal agencies for this kind of emergency, as 
outlined in the 2019 U.S. Government Global Health Security Strategy. 
USAID remains in an ongoing dialogue with Centers for Disease Control 
and Prevention (CDC) to further formalize coordination for future 
public health emergencies that become humanitarian crises.

    Question. What do you see as remaining challenges in U.S. 
Government preparation for improved coordination and implementation in 
future international public health emergencies?

    Answer. There are myriad challenges to effectively coordinating the 
response to future public health emergencies. While USAID continues to 
build up its staffing and systems for public health emergency 
responses, including: having the right people with the necessary skills 
(foreign language and previous outbreak experience) for immediate 
assignments which may last for months or longer is a challenge. It is 
even more difficult in light of the growing number of humanitarian 
responses and increasing demands on USAID.

    Question. Have all programs and activities currently underway using 
International Development Assistance funds been shared with bureaus in 
the Agency, such as the Africa and Global Health bureaus to better 
support coordination with ongoing programs and inform planning for 
future programs? Did those bureaus help plan the Office of Foreign 
Disaster Assistance programs and activities currently underway in 
eastern Congo? Are recovery activities being incorporated into our 
disaster response activities?

    Answer. Coordination within USAID is excellent, with both Global 
Health and Africa bureau staff fully integrated into the Response 
Management Team (RMT) led by the Bureau for Democracy, Conflict and 
Humanitarian Assistance. Programs and activities currently underway in 
eastern Democratic Republic of the Congo (DRC) using International 
Disaster Assistance funds are shared with the Africa and Global Health 
bureaus to better support coordination with ongoing programs and inform 
planning for future programs. USAID is currently focusing its efforts 
on response activities in the affected provinces of the DRC as well as 
bolstering the preparedness capabilities of unaffected parts of the DRC 
and neighboring at-risk countries (Uganda, South Sudan, Rwanda, and 
Burundi).
    Question. How many team members are there on the Disaster 
Assistance Response Team (DART)? Which agencies are the team members 
from? How many DART members are in each of the locations where USG 
personnel are assigned? How long have each of the team members been 
deployed and what is the length of their deployment? Is turnover of 
deployed members at all affecting the response? Did any of the current 
DART team members participate in the 2014 response?

    Answer. There are currently 17 DART members deployed in the DRC, 
including 7 in Kinshasa and 11 in Goma. In addition, the Disaster 
Assistance Response Team (DART) has consultants supporting the local 
surveillance and IPC commissions and reporting to the DART. Members of 
the team include USAID and CDC staff. Average rotations of DART team 
members are two to three months. The turnover does not affect the 
response. A number of DRC Ebola DART team members also participated in 
the 2014 West Africa response.

    Question. Has USAID made changes or taken specific steps to better 
coordinate, track, and execute financial and human capital resources 
among the Office of U.S. Foreign Disaster Assistance, Global Health, 
and regional bureaus? How has the availability (on unavailability) of 
the appropriate resources--both funds and human capital--from these 
bureaus and various accounts helped, or hindered, USAID's response to 
the outbreak in DRC?

    Answer. Coordination across different bureaus occurs through 
regular meetings with the intra-agency technical working group, regular 
discussions on high level policy issues, mission collaboration with the 
mission liaison position to the DART, and through the Global Health and 
Africa Bureau liaisons to the RMT. The Bureau for Global Health, Africa 
Bureau, and USAID's Office of Foreign Disaster Assistance (USAID/OFDA) 
budget offices regularly coordinate with each other, and the Bureau for 
Resource Management and State/F to execute accurate financial tracking 
across the entire response architecture.
    To date, USAID has sufficient funding to adequately support the 
response, thanks in part to the Congressional Ebola supplemental 
funding provided during the West Africa Ebola outbreak. Specifically, 
the availability of these funds has supported technical expertise to 
partners for disease surveillance, case investigation, contact tracing, 
emergency health care, patient management in Ebola treatment units, 
water, sanitation, and hygiene, infection prevention and control, 
border health, community engagement, risk communication, the promotion 
of safe and dignified burials, and other technical support. We continue 
to evaluate requests for assistance and are coordinating with the 
Government of the DRC and other international partners to ensure the 
disease is contained. Our goal is to provide the most efficient and 
effective support possible to our partners to bring this outbreak to an 
end as soon as possible.
    Since the 2014 West Africa Ebola outbreak, USAID/OFDA has 
undertaken multiple steps to ensure USAID staff receive training on 
USAID's Response Management System (RMS), which codifies authorities, 
structures and responsibilities for the Disaster Assistance Response 
Team and Response Management Team. In July 2017, OFDA launched the On-
Ramp Program, which prepares qualified USAID staff to become a part of 
USAID/OFDA's emergency staffing pool to broaden the number of available 
surge personnel. USAID/OFDA now also regularly offers humanitarian 
assistance and disaster response training to orient USAID staff to the 
broader humanitarian architecture and interagency structures. In 
addition to the additional training and On-Ramp program, USAID/OFDA is 
developing and launching the Personnel, Experience, and Training, 
Equipment, and Readiness (PETER) system. PETER is a readiness and 
deployment database which supports the unique qualification, 
activation, and human resource requirements of both USAID/OFDA and 
USAID's Office of Food for Peace. PETER will assist managers in 
identifying and tracking the qualifications, experience, and 
availability of personnel for all types of disasters and complex 
emergencies.

    Question. USG personnel are not currently authorized to deploy to 
the epicenter of the outbreak in DRC due to insecurity. Given that 
security constraints prevent U.S. personnel from being deployed the 
affected regions, how are we ensuring that we effectively monitor 
activities undertaken with USG funds?

    Answer. With the Emergency Operations Center relocated to Goma, 
most of the Disaster Assistance Response Team (DART) staff are now 
based there as well. The response reset also recommends the continued 
use of Goma, given that it is the optimal location to continue to 
support response efforts in Eastern Congo. U.S. staff in Kinshasa and 
Goma continue working closely with the Democratic Republic of the Congo 
Ministry of Health, WHO, and key response agencies providing daily 
support and technical recommendations for improving the response. 
Additionally, they remain in constant contact with partners and 
responders located in the affected areas. USAID partners with many 
entities that are able to access affected areas and implement key 
response activities. The DART in Goma meets regularly with partners and 
receives weekly reports on implementation.
                               __________

    Responses of Rear Admiral Tim Ziemer, USN, Retired to Questions 
                 Submitted by Senator Edward J. Markey

    The ongoing Ebola outbreak and other Infectious disease threats, 
such as measles and antibiotic resistance, help reinforce the 
importance of the Global Health Security Agenda (GHSA)--a partnership 
of over 64 nations and stakeholders to help create a world safe and 
secure from infectious disease threats. Across CDC, USAID, and NIH, $1 
billion in GHSA funding between 2014 and 2019 has supported efforts to 
build global health capacity to effectively combat infectious diseases.

    Question. As you know, this pool of funding expires in September. 
Can you speak to the importance of maintaining adequate funding for the 
GHSA?

    Answer. Maintaining adequate funding for the GHSA is important to 
help prevent avoidable outbreaks, quickly detect new ones, and rapidly 
and effectively respond to infectious disease outbreaks. The U.S. 
Global Health Security Strategy, released in May 2019, provides 
guidance and an operational framework for current and future USAID 
global health security engagement.

    Question. If funding is not maintained at current levels in the FY 
20 spending bill, will your agencies be able to maintain current global 
health security programming, or will you be required to scale back 
operations?

    Answer. Should Congress not maintain current appropriated levels 
for GHSA, USAID will adapt and focus efforts to strengthen global 
health security in priority countries.

    Question. Ongoing conflict, violence and community mistrust have 
been identified as the main reasons complicating the current response 
in a country that is no stranger to Ebola outbreaks. However, former 
Minister of Health Dr. Oly Ilunga Kalenga identified additional 
weaknesses in response efforts, including a lack of coordination and 
communication among actors, lack of actionable data, and weak 
operational plans. What are your agencies doing to help the Ministry of 
Health address these weaknesses and strengthen the response from an 
implementation standpoint?

    Answer. USAID understands that an effective response to the Ebola 
outbreak requires enhanced coordination between the Government of DRC 
(GDRC), including its Ministry of Health (MoH), World Health 
Organization (WHO), non-governmental organizations (NGOs), and other 
humanitarian stakeholders. April 30, 2019, the U.S., with other lead 
donors to the response, sent a letter to the WHO Director General and 
U.N. Under-Secretary General for Humanitarian Affairs/Emergency 
Response Coordinator (ERC) citing the severity of the outbreak and gaps 
in leadership and coordination and requesting urgent action, including 
the appointment of an empowered senior leader for the international 
response. In May 2019, a delegation from USAID and the Centers for 
Disease Control and Prevention (CDC) travelled with Ambassador Michael 
A. Hammer to eastern DRC and met with civil society, traditional and 
faith-based leaders, and representatives of the GDRC, United Nations 
(U.N.), NGOs, and donors. The visit confirmed analysis that security 
issues, leadership challenges, poor coordination, underutilization of 
NGOs and faith-based groups, and insufficient community engagement were 
hindering response effectiveness.
    As a result of a whole of U.S. Government engagement pressing for 
changes with the U.N. and WHO, in coordination with other lead donors, 
the U.N. Secretary General appointed David Gressly as the U.N. Ebola 
Emergency Response Coordinator (EERC) to oversee the coordination of 
international support for all Ebola Virus Disease (EVD) response-
related and enabling operations, and on May 30, 2019 the ERC activated 
a System-Wide Scale-Up for the Control of Infectious Disease Events. 
The activation targets health zones in the DRC in which transmission is 
occurring and likely to occur, with the possibility of including other 
geographical areas should the disease spread. The scale-up has five 
strategic priorities: (i) strengthened political engagement to create 
an enabling environment for the response; (ii) strengthened multi-
sectoral humanitarian coordination that fosters greater community 
engagement; (iii) timely and sustainable financing, monitoring and 
reporting on the use of funds in collaboration with the World Bank and 
key donors; (iv) enhancing the public health response, working with the 
Ministry of Health; and (v) leadership for a contingency cell in Goma 
and redouble preparedness efforts in other countries (Burundi, South 
Sudan, Rwanda and Uganda).
    The USAID Disaster Assistance Response Team (DART) is working 
closely with EERC Gressly to improve coordination and communication 
among response actors and the GDRC. This includes pressing for a 
unified international and national response, currently led by the MoH 
out of the Emergency Operations Center in Goma. The DART meets 
regularly with the EERC and WHO leadership, bilaterally and weekly with 
other lead donors, to monitor this response ``reset'' and ensure 
improved leadership and coordination progresses to improve the 
trajectory of the outbreak. This includes close tracking of the 
development of Strategic Response Plan 4.0.
    On July 20, President of the DRC Felix Tshisekedi announced the DRC 
MoH is no longer the lead response entity and the creation of 
multisectoral Ebola committee led by the Director of the National 
Institute for Biomedical Research that will oversee day-to-day response 
activities. On July 22, the DRC Minister of Health Dr. Oly Ilunga 
resigned. The U.S. continues to press for appointment of a Minister of 
Health, while supporting the EERC in bringing about an effective 
response with the GDRC and current leadership in place.
    USAID is collaborating with the CDC to provide community engagement 
assistance to the MoH-led and WHO-coordinated response based on 
previous Ebola responses, as well as community feedback to tailor 
community engagement approaches based on unique community dynamics 
across the response. USAID has also contracted private health sector 
experts to serve as our eyes and ears on the ground, to provide 
technical support to the DRC MoH, and reinforce response efforts in the 
outbreak zone. USAID staff in Kinshasa and Goma continue to work 
closely with the MoH, WHO, and key response agencies providing daily 
support and technical recommendations for improving the response.
    Since arriving in May, EERC Gressly has established the Ebola 
Emergency Response Team (EERT), which will implement the U.N.'s scale-
up strategy and bridge the public health response with multi-sector 
humanitarian activities. EERC Gressly and WHO Assistant Director-
General Dr. Ibrahim Soce Fall co-chair the EERT, which meets on a 
weekly basis. As a result of USAID advocacy, many NGOs are 
participating on the EERT, ensuring a broad representation of 
perspectives and bringing a different set of knowledge and expertise to 
the response.
    USAID has also been working with EERC Gressly, the U.N., and the 
GDRC to release a comprehensive response plan, the aforementioned SRP 
4.0, which includes the cost requirements for both public health 
interventions and multi-sector humanitarian activities to end the 
outbreak. We expect the GDRC to release a revised comprehensive plan 
that will include input from various response actors and present a 
financial appeal for strengthened public health response, political 
engagement, security support, complementary humanitarian assistance, 
community engagement activities, and financial planning and monitoring 
in the coming days.

    Question. The World Health Organization has identified a funding 
shortfall of $54 million for response efforts to control the outbreak 
and prevent further spread. U.S. contributions thus far have come out 
of existing Ebola emergency supplemental funding from the 2014 
outbreak. Are there any plans for the U.S. to make an additional 
contributions on par with increasing challenges?

    Answer. On July 24, the U.S. Government (USG), through USAID, 
announced an additional $38 million in assistance to help end the 
ongoing Ebola outbreak in Eastern Democratic Republic of the Congo, 
including $15 million in new funding to the World Health Organization. 
Since the beginning of the outbreak in August 2018, USAID has provided 
more than $136 million to the Ebola response, making the USG the 
largest single country donor to the response. We look forward to 
reviewing the revised comprehensive strategic plan and stand prepared 
to provide additional contributions as necessary.

    Question. As one the largest and longest-lasting U.N. peacekeeping 
missions, the United Nations Organization Stabilization Mission in the 
Democratic Republic of the Congo (MONUSCO) has been criticized for its 
cost, effectiveness, and various allegations of misconduct on-the-
ground. In March, the United Nations Security Council called for a 
security review of the mission, including a drawdown and exit strategy. 
In April, the mission scaled back operations in various parts of the 
country, due to budget cuts. At the moment, do you think that MONUSCO 
is equipped to handle the on-going Ebola crisis, amid these on-going 
and possible future changes? If so, how can the U.S. assist in this 
regard?

    Answer. USAID believes that MONUSCO's ongoing support to the Ebola 
response efforts is sufficient, based on the current mandate language 
related to humanitarian access and logistical support. However, even 
the perception of the militarization of the Ebola response through the 
provision of security by MONUSCO could aggravate the situation. We 
defer to the Department of State on how the U.S. can assist amidst 
these challenges.

    Question. In 2019, the United Nations Refugee Agency estimated that 
DRC has over 856, 043 refugees and the 4.5 million internally 
displaced. How has the Ebola crisis further worsened the on-going 
refugee and IDP situation in the Congo and its neighboring states? What 
bilateral and multilateral efforts can the U.S. take to reduce the 
migration of peoples both in and out of DRC?

    Answer. The Ebola outbreak is occurring in eastern DRC, one of the 
most geopolitically complex areas in Africa. A combination of decades 
of neglect by the central government, socio-economic marginalization, 
and political tensions has led to persistent conflict by armed groups 
and spontaneous attacks between intercommunal groups and youth groups. 
While the U.S. Government has not observed additional displacements due 
to the Ebola outbreak, the response to it is complicated by the 
insecure environment and large-scale population displacement. The U.S. 
Government continues to respond to the complex emergency, supporting 
humanitarian protection and the provision of basic services, such as 
food assistance, health care, psychosocial support, and water and 
sanitation, which help reduce some displacement.
    We encourage all countries to follow World Health Organization 
(WHO) recommendations to address the Ebola outbreak, which is a Public 
Health Emergency of International Concern. The WHO advises against 
placing travel and trade restrictions or closing borders with the DRC.
    The United States continues to call on other donors to increase 
their support for humanitarian assistance in the DRC and for Congolese 
refugees in the region. Ultimately, durable solutions for most 
displacement in the country and region depend on resolution of the 
political conflicts that are driving people from their homes in the 
DRC, Burundi, Central African Republic, Rwanda, and South Sudan.
                               __________

          Responses of Dr. Mitch Wolfe to Questions Submitted 
                      by Senator Edward J. Markey

    The ongoing Ebola outbreak and other Infectious disease threats, 
such as measles and antibiotic resistance, help reinforce the 
importance of the Global Health Security Agenda (GHSA)--a partnership 
of over 64 nations and stakeholders to help create a world safe and 
secure from infectious disease threats. Across CDC, USAID, and NIH, $1 
billion in GHSA funding between 2014 and 2019 has supported efforts to 
build global health capacity to effectively combat infectious diseases.

    Question. As you know, this pool of funding expires in September. 
Can you speak to the importance of maintaining adequate funding for the 
GHSA?

    Answer. The FY 2015 emergency appropriation for implementation of 
the Global Health Security Agenda and National Public Health Institute 
Development ($597M) was a substantial investment towards CDC's global 
health security efforts. Those resources have been put to use as 
intended--to address an urgent need for accelerating progress towards a 
world more prepared to stop infectious diseases at their source before 
they pose a threat to us here at home. The five-year supplemental will 
be fully obligated, as planned, by the end of this year (FY 2019). 
Although we have made considerable progress through the investment of 
these funds, most of the world is still under-prepared to effectively 
prevent, detect, and respond to infectious disease health threats. 
Building health security capacity, particularly sustainable capacity 
over which partner countries exhibit ownership without significant 
decrease in quality, can take years of effort. [Please note that the 
NIH was not a recipient of GHSA-designated funding.]
    CDC's FY2020 request includes $99.762 million, an increase of $49.8 
million above FY2019 Enacted for Global Health Security activities that 
will protect Americans through partnerships and other activities that 
support public health capacity improvements in countries at risk from 
uncontrolled outbreaks of infectious diseases. CDC will implement an 
approach to global health security investments that is informed by 
lessons learned over the last 5 years. CDC is proactively planning its 
future global health strategy to strengthen our ability to respond more 
rapidly and effectively to health threats wherever they occur and 
balance our commitment to our core mission of protecting Americans. 
Ultimately, this plan strikes a balance between responsible 
sustainability and maximum impact through CDC presence overseas.

    Question. If funding is not maintained at current levels in the FY 
20 spending bill, will your agencies be able to maintain current global 
health security programming, or will you be required to scale back 
operations?

    Answer. CDC has primarily supported these activities using 
supplemental funding received in FY 2015, which will expire at the end 
of FY 2019. Congress has also provided CDC with $50 million in global 
health security funding in both FY 2018 and FY 2019. The FY 2020 
President's Budget request for CDC includes $99.762 million for global 
health security activities, an increase of $49.8 million above the FY 
2019 enacted level. In FY 2020, CDC's GHS funding will be directed 
towards activities in countries receiving intensive and targeted 
support, as defined in the Global Health Security Strategy. Funding 
will also be directed towards the most pressing, cross-cutting disease 
threats and global capacity requirements that will maximize outcomes 
for these countries. CDC will maintain its focus on building capacity 
in these core areas in alignment with the Global Health Security 
Strategy's objective of sustainability and transition to country 
ownership. It is also important to note that CDC is planning for FY 
2020 while also playing a key role in the USG response to a persistent 
Ebola outbreak in DRC that is likely to extend into FY 2020.

    Question. Ongoing conflict, violence and community mistrust have 
been identified as the main reasons complicating the current response 
in a country that is no stranger to Ebola outbreaks. However, former 
Minister of Health Dr. Oly Ilunga Kalenga identified additional 
weaknesses in response efforts, including a lack of coordination and 
communication among actors, lack of actionable data, and weak 
operational plans. What are your agencies doing to help the Ministry of 
Health address these weaknesses and strengthen the response from an 
implementation standpoint?

    Answer. As part of the administration's whole-of-government effort, 
CDC experts are supporting the DRC government, neighboring country 
governments, WHO, and other partners by providing technical guidance 
and expertise in contact tracing, surveillance, laboratory testing, 
data analytics, vaccine implementation, emergency management, infection 
prevention and control, behavioral sciences, health communications, and 
border health. CDC continues to deploy staff who are embedded with the 
DRC Ministry of Health in both Goma and Kinshasa, and at WHO 
headquarters, to strengthen these activities and support coordination 
among response leaders. In addition, CDC and USAID are supporting 
community engagement activities based on lessons learned from previous 
Ebola outbreaks, including incorporating feedback from affected 
populations and tailoring the response approach based on unique 
dynamics within Ebola-affected communities.
    CDC's operational expertise allows us to quickly and efficiently 
identify the unique scientific and social variables of outbreaks and 
address them with proven interventions. Working directly with partners 
on the ground, CDC has been providing guidance to standardize response 
actions, streamline implementation of public health measures, improve 
the effectiveness of training and educational materials, and assist 
with coordination and communication across the public health response.
    For example, CDC continues to provide technical assistance to the 
Ministry of Health and WHO in the implementation of vaccination 
strategies, including assistance with protocols, operating procedures, 
data analysis, and training and communications material for use at 
national and local levels in DRC and neighboring countries. CDC is 
collaborating with WHO and Ministry of Health colleagues in Rwanda, 
South Sudan, Uganda, and Burundi to implement preventative vaccination 
of health care workers in geographic areas near the DRC border. CDC 
staff have embedded into teams with the DRC Ministry of Health and at 
WHO headquarters, to analyze data and to help improve the quality of 
vaccination efforts.
    Over the course of the response, CDC has also been working with 
U.S. Government partners, the DRC Ministry of Health, WHO, and others 
to identify gaps in infection prevention and control (IPC) systems, 
assess healthcare provider IPC knowledge and skills, and improve IPC 
practice. CDC is helping DRC Ministry of Health and WHO to finalize a 
standardized set of infection prevention and control resources for use 
across the response, which includes training modules, standard 
operating procedures, and job aids. CDC is also designing and preparing 
to implement a training course for IPC partners and DRC Ministry of 
Health infection prevention and control supervisors. Where security 
conditions have allowed, as demonstrated with recent confirmed cases in 
Goma, CDC experts have been able to work directly with local case 
investigation teams on the ground to identify areas for improvement in 
surveillance, vaccination, and other aspects of case management.
    Question. The World Health Organization has identified a funding 
shortfall of $54 million for response efforts to control the outbreak 
and prevent further spread. U.S. contributions thus far have come out 
of existing Ebola emergency supplemental funding from the 2014 
outbreak. Are there any plans for the U.S. to make an additional 
contributions on par with increasing challenges?

    Answer. CDC defers to USAID for this response.