[Senate Hearing 116-299]
[From the U.S. Government Publishing Office]




                                                        S. Hrg. 116-299
 
                  COVID	19 AND U.S. INTERNATIONAL PANDEMIC 
                   PREPAREDNESS, PREVENTION, AND RESPONSE

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

                                HEARINGS

                               BEFORE THE

                     COMMITTEE ON FOREIGN RELATIONS
                          UNITED STATES SENATE

                     ONE HUNDRED SIXTEENTH CONGRESS

                             SECOND SESSION



                               __________

                        JUNE 18 AND JUNE 30, 2020

                               __________



       Printed for the use of the Committee on Foreign Relations
       
       
       

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                   Available via the World Wide Web:
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            U.S. GOVERNMENT PUBLISHING OFFICE 
42-192 PDF           WASHINGTON : 2020                         
                         
                         


                 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
JOHN BARRASSO, Wyoming               CHRISTOPHER MURPHY, Connecticut
ROB PORTMAN, Ohio                    TIM KAINE, Virginia
RAND PAUL, Kentucky                  EDWARD J. MARKEY, Massachusetts
TODD YOUNG, Indiana                  JEFF MERKLEY, Oregon
TED CRUZ, Texas                      CORY A. BOOKER, New Jersey
DAVID PERDUE, Georgia
              Christopher M. Socha, Staff Director        
            Jessica Lewis, Democratic Staff Director        
                    John Dutton, Chief Clerk        



                               (ii)        

  


                            C O N T E N T S

                              ----------                              
                                                                   Page

COVID-19 AND U.S. INTERNATIONAL PANDEMIC PREPAREDNESS, PREVENTION, AND 
                                RESPONSE

Part 1: Covid-19 and U.S. International Pandemic Preparedness, 
  Prevention, and Response --

  June 18, 2020

Risch, Hon. James E., U.S. Senator From Idaho....................     1

    Prepared Statement...........................................     3

Menendez, Hon. Robert, U.S. Senator From New Jersey..............     4

    Prepared Statement...........................................     6

Richardson, James L., Director, Office of Foreign Assistance, 
  U.S. Department of State, Washington, DC.......................     8
    Prepared Statement...........................................    10

Milligan, Chris, Counselor, U.S. Agency for International 
  Development, Washington DC.....................................    13
    Prepared Statement...........................................    15

Grigsby, Garrett, Director, Office of Global Affairs, U.S. 
  Department of Health and Human Services, Washington, DC........    18
    Prepared Statement...........................................    19

              Additional Material Submitted for the Record

Responses of James L. Richardson to Questions Submitted by 
  Senator Robert Menendez........................................    47

Responses of Chris Milligan to Questions Submitted by Senator 
  Robert Menendez................................................    54

Responses of Mr. Garrett Grigsby to Questions Submitted by 
  Senator Robert Menendez........................................    62

Responses of James L. Richardson to Questions Submitted by 
  Senator Ben Cardin.............................................    64

Responses of Mr. Chris Milligan to Questions Submitted by Senator 
  Ben Cardin.....................................................    69

Responses of Mr. Garrett Grigsby to Questions Submitted by 
  Senator Ben Cardin.............................................    72

Responses of James L. Richardson to Questions Submitted by 
  Senator Chris Coons............................................    73

Responses of Mr. Chris Milligan to Questions Submitted by Senator 
  Chris Coons....................................................    74

Responses of Mr. Garrett Grigsby to Questions Submitted by 
  Senator Chris Coons............................................    74



                              ----------                              



                                 (iii)

  
Part 2: Covid-19 and U.S. International Pandemic Preparedness, 
  Prevention, and Response: Additional Perspectives --

  June 30, 2020

Risch, Hon. James E., U.S. Senator From Idaho....................    77

    Prepared Statement...........................................    80

Menendez, Hon. Robert, U.S. Senator From New Jersey..............    81

    Prepared Statement...........................................    83

Dybul, Hon. Mark, M.D., Co-Director of the Center for Global 
  Health Practice and Impact and Professor in the Department of 
  Medicine, Georgetown University Medical Center.................    85
    Prepared Statement...........................................    88

Kolker, Hon. Jimmy J., Former Assistant Secretary For Global 
  Affairs, U.S. Department of Health and Human Services..........    91
    Prepared Statement...........................................    93

Jha, Dr. Ashish K., M.D., Director, Harvard Global Health 
  Institute, Cambridge, MA.......................................    95
    Prepared Statement...........................................    97

Konyndyk, Jeremy, Senior Policy Fellow, Center For Global 
  Development, Washington, DC....................................   101
    Prepared Statement...........................................   104

              Additional Material Submitted for the Record

Responses of The Honorable Mark Dybul, M.D. to Questions 
  Submitted by Senator Robert Menendez...........................   133

Responses of The Honorable Jimmy J. Kolker to Questions Submitted 
  by Senator Robert Menendez.....................................   136

The Committee Received No Response From Dr. Ashish K. Jha, M.D. 
  for the Following Questions by Senator Robert Menendez.........   141

Responses of Jeremy Konyndyk to Questions Submitted by Senator 
  Robert Menendez................................................   143


                COVID-19 AND U.S. INTERNATIONAL PANDEMIC 
                 PREPAREDNESS, PREVENTION, AND RESPONSE



    PART 1: COVID-19 AND U.S. INTERNATIONAL PANDEMIC PREPAREDNESS, 
                        PREVENTION, AND RESPONSE

                              ----------                              


                   THURSDAY, JUNE 18, 2020

                                       U.S. Senate,
                            Committee on Foreign Relations,
                                                    Washington, DC.
    The committee met, pursuant to notice, at 9:33 a.m., in 
room SD-106, Dirksen Senate Office Building, Hon. James E. 
Risch, chairman of the committee, presiding.
    Present: Senators Risch [presiding], Johnson, Gardner, 
Barrasso, Young, Perdue, Menendez, Cardin, Shaheen, Murphy, 
Kaine, and Booker.

           OPENING STATEMENT OF HON. JAMES E. RISCH, 
                    U.S. SENATOR FROM IDAHO

    The Chairman. The committee will come to order.
    Morning, everyone. I want to thank all of you who are 
attending this important hearing.
    Today, we are going to discuss the international response 
to the COVID-19 pandemic as well as future pandemic 
preparedness, prevention, and response.
    The hearing will focus on Senate bill 3829, which Senator 
Murphy and I have introduced, the Global Health Security and 
Diplomacy Act. It is written on paper, not on stone, which we 
will talk about a little bit in the future here. This is an 
important endeavor that this committee is going to take up. 
Indeed, probably one of the weightiest matters that we will 
deal with as we attempt to create a new shield to prevent a 
COVID virus-type attack from happening again. The COVID-19 
global pandemic has reaffirmed what we have long known, and 
that is, infectious diseases, particularly those of viral 
nature, do not respect borders; they are a threat, and a threat 
anywhere is a threat everywhere. We have been right, here, to 
focus on our domestic response to this pandemic, but we ignore 
the spread overseas at our own peril, for obvious reasons.
    It is essential that we respond now to help our partners 
who are not yet experiencing significant spread to get testing, 
tracing, and quarantine procedures in place, and to help our 
partners who already are under siege avert a worst-case 
scenario. We also need to focus on protecting access to food, 
livelihoods, water, sanitation, and hygiene.
    Protecting existing investments in immunizations, maternal 
and child health, and other infectious diseases are important 
at this time, also. And we need to work with partner countries 
and organizations to ensure that our aid reaches those who need 
it most, without aiding and abetting corruption, human rights 
violations, and democratic backsliding, which we all know 
frequently happens in the world when we start focusing on 
something else.
    At the same time, we need to figure out how to get ahead of 
the next global pandemic. Indeed, that is what the focus of 
this hearing is going to be on. And again, the vehicle we are 
talking about is Senate bill 3829, but it is for discussion 
purposes, and we look for every possible improvement to that 
bill that we can make.
    This hearing is one of a number that I am going to 
undertake as we construct Senate bill 3829 going forward. And 
the purpose of it is to, as I said, construct a shield that is 
better than the shield that we have. I have repeatedly said 
that what we need is a fire station and a fire department ready 
and able to put out a fire before it burns the entire world. 
Over the years, we have come to expect that the World Health 
Organization would play a role. The World Health Organization 
has done great work in many respects. It does play a key role 
as the guardian of the international health regulations and as 
the clearinghouse of global health data and best practices, and 
it has done remarkable work in combating polio and eradicating 
smallpox. But, its response to fast-moving emergencies, such as 
Ebola and COVID-19, has exposed significant weaknesses that the 
WHO has. But, we are not here to demean or to criticize or 
condemn the WHO. Rather, what we are here to do is to have a 
fair analysis of what the response was, and how their structure 
is constructed that has caused the weaknesses we have.
    Dr. Tedros and his management team were very kind to spend 
some time with me early on, and they explained to me what their 
objectives were and how they were attempting to achieve them. 
They made some very fair points, and it truly is obvious that 
they did things that could have been done differently, and they 
will be the first to admit that.
    In addition to reforming WHO--and, truly, there is some 
reform that is needed--and it should be done, as I said, 
without demeaning, criticizing, or condemning--but, rather, in 
the kindest way possible, to make it work better. We need an 
international financing mechanism that will reenergize action 
under the Global Health Security Agenda so we can help 
countries with a high commitment but low capacity to improve 
their pandemic preparedness and response. And we need a long-
term fix to the coordination problems that have long plagued 
U.S. country teams operating overseas. We need a single 
accountable entity housed at the Department of State to lead 
diplomatic efforts and coordinate the efforts of the agencies 
implementing global health security assistance overseas. This 
accountable entity would not--I repeat, not--replace the 
central role of the NSC in coordinating global health security 
policy across the whole of government here in Washington. 
Alternatively, it would ensure the effectiveness of global 
health security programs at the mission level.
    We have put these ideas forward in this bipartisan bill, 
the Global Health Security and Diplomacy Act, and have invited 
all those who wish to participate to do so. This has to be a 
bipartisan effort.
    It is not too late to get back on track and to restore the 
longstanding tradition of bipartisanship that has characterized 
every successful U.S. global health program of the past 20 
years. It also is not too late to focus our efforts on 
addressing the current COVID-19 pandemic overseas in a manner 
that saves lives and protects the United States from future 
waves of infection. But, let there be no mistake about it, this 
bill is designed to look at the future.
    There is no doubt this is going to happen again. We have 
been told that the bat population, particularly in the Wuhan 
area in China, contains about 2,000 viruses. Of course, this 
pandemic was caused by one of these viruses jumping from one 
species to another, from a bat to a human being. What happened 
after that has been greatly debated, but we know what the 
result was, and we know that the result was not good, and we 
know that there were failures along the line. We know that we 
can do better.
    There is no other group more qualified than this committee, 
the United States Senate Committee on Foreign Relations, to 
undertake this proposition. This is something that we owe 
America, that we owe the world. We can do this. I am committed 
to do that. I would hope that every member on the committee 
will help focus on this as one of the most important things 
that we do. It will be a legacy that will be incredibly 
important for future generations. And we know that the world 
cannot withstand much more of what we have seen that we got 
from the COVID-19 infection that went through the world.
    So, with that, I hope that we, as a committee, do what we 
try to do, and that is focus with civility, kindness, 
understanding, and tolerance as we hear from everyone. We are 
going to have a lot of different ideas. There is going to be a 
lot of ideas that people have strong feelings about. I hope 
people will do their best to listen carefully to what others 
have to say, and listen to defenses that people make as to what 
has happened. But, more important, listen carefully to what 
people tell us that they have learned that will help us in the 
future. In a bipartisan fashion that is done with kindness and 
civility, I have every confidence we can develop a bill that 
can pass this Congress, be signed by the President, become law, 
and really be a tremendous benefit to our fellow human beings 
as we go forward.
    [The prepared statement of Senator Risch follows:]

              Prepared Statement of Senator James E. Risch

    Today we meet to discuss the international response to the COVID-19 
pandemic and the future of pandemic preparedness, prevention, and 
response.
    The COVID-19 global pandemic has reaffirmed what we've long known: 
infectious diseases do not respect borders. A threat anywhere is a 
threat everywhere.
    We have been right to focus on the domestic response to this 
pandemic. But we ignore the spread overseas at our own peril.
    It is essential that we respond now: to help our partners who are 
not yet experiencing significant spread to get testing, tracing, and 
quarantine procedures in place; and to help our partners who already 
are under siege avert worst-case scenarios.
    We need to also focus on protecting access to food, livelihoods, 
water, sanitation, and hygiene; protecting existing investments in 
immunizations, maternal and child health, and other infectious 
diseases.
    And we need to work with partner countries and organizations to 
ensure that our aid reaches those who need it most, without aiding and 
abetting corruption, human rights violations, and democratic 
backsliding.
    At the same time, we need to figure out a way to get ahead of the 
next global pandemic.
    I repeatedly have said we need a fire station, ready and able to 
put out a flame before it burns the whole world down. Over the years, 
we have come to expect the WHO to play that role. And we've been 
disappointed.
    The WHO does play a key role as the guardian of the International 
Health Regulations and as the clearinghouse of global health data and 
best practices. And it has done remarkable work in combatting polio and 
eradicating smallpox. But its response to emergencies, from Ebola to 
COVID-19, has exposed significant weaknesses. Reform is essential.
    In addition to reforming the WHO, we need an international 
financing mechanism that will re-energize action under the Global 
Health Security Agenda, so we can help countries with high commitment 
but low capacity improve their pandemic preparedness and response.
    And we need a long-term fix to the coordination problems that have 
long plagued U.S. country teams operating overseas. We need a single 
accountable entity, housed at the Department of State, to lead 
diplomatic efforts and coordinate the efforts of the agencies 
implementing global health security assistance overseas.
    This accountable entity would not replace the central role of the 
NSC in coordinating global health security policy across the whole-of-
government here in Washington. Alternatively, it would ensure the 
effectiveness of global health security programs at the mission-level.
    I have put these ideas forward in a bipartisan bill, the Global 
Health Security and Diplomacy Act.
    I share the frustration expressed by many of our committee members 
that it has taken so long to get us all here together, but I am glad 
for the opportunity today.
    It is not too late to get back on track and to restore the long-
standing tradition of bipartisanship that has characterized every 
successful U.S. global health program of the past 20 years.
    It is not too late to focus our efforts on addressing the current 
COVID-19 pandemic overseas in a manner that saves lives and protects 
the United States from future waves of infection.
    I thank our witnesses for their efforts to help us get there.
    With that, I will ask Ranking Member Menendez if he wishes to make 
any opening remarks.

    The Chairman. With that, I will turn the time to Senator 
Menendez.

              STATEMENT OF HON. ROBERT MENENDEZ, 
                  U.S. SENATOR FROM NEW JERSEY

    Senator Menendez. Thank you, Mr. Chairman, for convening 
today's hearing. As you know, I have been seeking a series of 
hearings on COVID for quite some time, and I am pleased that we 
are now having one. And I understand you intend to hold more. 
And I strongly support that.
    But, let me start by speaking to the larger concerns that 
the Democratic Minority recently wrote to you about. We must 
have serious and sustained focus on U.S. foreign policy, and a 
serious oversight agenda. And we want to work with you to make 
that happen.
    Mr. Chairman, we should be having more public hearings. We 
need to tackle some of the major challenges that confront us--
Afghanistan, Venezuela, North Korea, just to mention some. And 
we need to ensure the Secretary of State testifies before this 
committee. We should all be shocked and, frankly, offended that 
the Secretary is refusing to appear, refusing to defend the 
Administration's foreign affairs budget. And we should all be 
insisting on his appearance. This could be the first time in 
over 20 years that a Secretary of State has not testified 
before this committee to explain administration priorities. 
And, I guess, after Ambassador Bolton's book, we probably will 
never see him again.
    This lack of engagement fundamentally undermines our work. 
Not only does the Secretary of State feel comfortable in 
refusing to come before us, that refusal apparently extends to 
other Senate-confirmed officials. We have only heard from one 
Senate-confirmed official this entire year. And the 
Administration has repeatedly ignored oversight inquiries, many 
of them that are even bipartisan.
    We do not need to rehash the contentious vote on Michael 
Pack, but we should all be seriously concerned about what we 
have seen in the last 10 days and 24 hours at the U.S. Agency 
for Global Media. Mr. Pack has gone on a wholesale firing 
spree, removing the heads of the networks, dissolving their 
corporate boards, only to replace them with unqualified 
political people, fundamentally undermining the mission and 
work of the organization. It is now obvious why the White House 
wanted Pack so badly, so they can transform the agency into 
their own personal mouthpiece. This is a blow from which it may 
never recover. Once the credibility is gone, no one will ever 
trust a report from Radio Free Europe, Radio Marti, nor trust 
the tools of the Open Technology Fund.
    So, Mr. Chairman, I would just urge you to respond to the 
letter that we sent you and the spirit in which it was offered. 
On behalf of myself and all the Democratic members of the 
committee, I can tell you that we want to work with you, and we 
want to find common ground. We want the State Department to be 
successful. And we want this committee to take on serious and 
meaningful work that will make an impact on the national and 
global stage. So, let us work together to make that happen.
    Now, while I thank all of our witnesses for their service, 
it is disappointing that the White House would not send a 
member of the Coronavirus Task Force or any of the Senate-
confirmed individuals from the State Department, Health and 
Human Services, or the United States Agency for International 
Development responsible for Administration's response. The 
American people deserve to hear from members of the President's 
handpicked team to understand what it is doing to address the 
worst pandemic the world has faced in 100 years--more than 8 
million cases worldwide, more than 115,000 American lives lost. 
In my home state of New Jersey, which is the second-largest 
state in the nation, in terms of COVID deaths, I am vividly 
reminded of this consequence.
    This tragedy has assuredly been a wake-up call to those who 
question whether we should engage with, and invest in, the rest 
of the world. So, I would like to use this hearing to 
understand how we got here, what we knew about the virus, and 
when, and how we are leveraging our diplomatic relationships 
and leadership to best respond and protect the American people.
    So far, most of what we have seen is a lot of bluster, 
finger-pointing, and retrenchment. Yes, we should examine the 
World Health Organization's initial response. I wish we had 
someone from the State Department's Bureau of International 
Organizations here to do exactly that. But, we also know that 
the U.S. was regularly communicating with, and receiving 
information from, the WHO, including through U.S. Government 
employees embedded at WHO headquarters in Geneva. And, rather 
than seriously consider how to best leverage our leadership and 
contributions, the President abruptly announced the U.S. would 
simply pull out of the organization, threatening not just our 
ability to confront COVID-19, but risking decades of progress 
on other global health initiatives, including combating Polio 
and Ebola.
    And yes, China has a lot to answer for. But, the 
administration's use of racially stigmatizing language to 
describe COVID-19, in direct contradiction to guidance issued 
by the Centers for Disease Control and Prevention, has been 
deeply hurtful to Americans at home, and utterly 
counterproductive in leading an international response. The 
Secretary of State's insistence that the rest of the world 
agreed to use such language has prevented us from reaching 
consensus of the G7 and in the Security Council. And, while the 
White House engages in divisive rhetoric, the rest of the world 
is stepping up without us.
    When Chinese President Xi Jinping addressed the World 
Health Assembly in May, he pledged $2 billion over 2 years to 
combat COVID-19. In contrast, when Secretary Azar addressed the 
Assembly, he attacked the WHO and cast blame on China. The 
European Union held a pledging conference on vaccines last 
month, at which over $8 billion was raised. The White House 
declined the invitation to participate, for reasons that are 
beyond me. Is this what the Administration means by ``America 
First''? Well, if this EU consortium comes up with a vaccine 
before we do, it will mean ``America Last.'' This approach is 
not only isolationist, shortsighted, and foolish, it endangers 
American lives.
    Finally, as the old saying goes, ``An ounce of prevention 
is worth a pound of cure.'' I am all for ensuring the U.S. 
Government is better organized to prevent, detect, and respond 
to future pandemics both here and abroad, but some of the 
proposals coming out of the Administration, eerily similar to 
those coming from some Members of Congress, are ill-thought, 
destructive, and dangerous, insofar that they would cripple 
USAID and create a mechanism at the World Bank to which the 
Administration could channel all of the funding it is 
withholding from the WHO.
    So, I look forward to the first of what I hope are many 
thorough discussions.
    Thank you, Mr. Chairman.
    [The prepared statement of Senator Robert Menendez 
follows:]

             Prepared Statement of Senator Robert Menendez

    Mr. Chairman, thank you for convening today's hearing. As you know, 
I have been seeking a series of hearings on COVID for quite some time. 
I am pleased we are now having one. I understand you intend to hold 
more, and I strongly support that.
                 dem letter and committee prerogatives
    But let me start by speaking to the larger concerns that the 
Democratic minority recently wrote to you about. We must have serious 
and sustained focus on U.S. foreign policy and a serious oversight 
agenda . . . and we want to work with you to make that happen.
    Mr. Chairman, we should be having more public hearings . . . we 
need to tackle the major challenges that confront us . . . Afghanistan, 
Venezuela, and North Korea . . . and we need to ensure the Secretary of 
State testifies before this Committee.
    We should all be shocked and, frankly, offended, that Secretary is 
refusing to appear . . . refusing to defend the Administration's 
foreign affairs budget; we should all be insisting on his appearance. 
This could be the first time in over 20 years that a Secretary of State 
has not testified before this Committee to explain an administration's 
priorities.
    This lack of engagement fundamentally undermines our work. Not only 
does the Secretary of State feel comfortable in refusing to come before 
us, that refusal apparently extends to other Senate-confirmed 
officials--we have heard from only one Senate-confirmed official this 
entire year. And the Administration has repeatedly ignored oversight 
inquiries--many of them bipartisan.
    We do not need to rehash the contentious vote on Michael Pack. But 
we should all be seriously concerned about what we've seen in the last 
10 days and 24 hours at the U.S. Agency for Global Media.
    Mr. Pack has gone on a wholesale firing spree, removing the heads 
of the networks, and dissolving their corporate boards only to replace 
them with unqualified political people . . . fundamentally undermining 
the mission and work of the organization.
    It's now obvious why the White House wanted Pack so badly--so they 
could transform the Agency into their own personal mouthpiece. This is 
a blow from which it may never recover. Once the credibility is gone, 
nobody will ever trust a report from Radio Free Europe . . . or Radio 
Marti . . . nor trust the tools of the Open Technology Fund.
    So Mr. Chairman, I urge you to respond to the letter in the spirit 
in which it was offered. On behalf of myself and all of the Democratic 
members of the Committee, I can tell you that we want to work with you 
. . . we want to find common ground.
    We want the State Department to be successful . . . and we want 
this Committee to take on serious work and make a meaningful impact on 
the national and world stage. Let's work together to make this happen.
                            covid-19 hearing
    Now, while I thank all of our witnesses for their service . . . it 
is disappointing the White House would not send a member of the 
coronavirus task force, or any of the Senate confirmed individuals from 
the State Department, Health and Human Services, or the United States 
Agency for International Development responsible for the 
Administration's response.
    The American people deserve to hear from members of the President's 
hand-picked team to understand what it is doing to address the worst 
pandemic the world has faced in 100 years . . . more than 8 million 
cases worldwide, and more than 115,000 American lives lost.
    This tragedy has assuredly been a wake-up call to those who 
question whether we should engage with--and invest in--the rest of the 
world. So I would like to use this hearing to understand how we got 
here--what we knew about the virus and when, and how we are leveraging 
our diplomatic relations and leadership to best respond and protect the 
American people.
                               blame game
    So far most of what we have seen is a lot of bluster, finger 
pointing, and retrenchment.
    Yes, we should examine the World Health Organization's initial 
response--I wish we had someone from the State Department's Bureau of 
International Organizations here to do that--but we also know that the 
U.S. was regularly communicating with and receiving information from 
the WHO--including through U.S. Government employees embedded at WHO 
headquarters in Geneva.
    And rather than seriously consider how to best leverage our 
leadership and contributions, the President abruptly announced the U.S. 
would simply pull out of the organization; threatening not just our 
ability to confront COVID-19, but risking decades of progress on other 
global health initiatives including to combat Polio and Ebola.
    And yes, China has a lot to answer for, but the Administration's 
use of racially stigmatizing language to describe COVID-19 in direct 
contradiction to guidance issued by the Centers for Disease Control and 
Prevention has been deeply hurtful to Americans at home, and utterly 
counterproductive in leading an international response.
    The Secretary of State's insistence that the rest of the world 
agree to use such language has prevented us from reaching consensus at 
the G7 and in the Security Council.
                           loss of leadership
    While the White House engages in divisive rhetoric, the rest of the 
world is stepping up. Without us. When Chinese President Xi Jinping 
addressed the World Health Assembly in May, he pledged $2 billion over 
2 years to combat COVID-19.
    In contrast, when Secretary Azar addressed the Assembly, he 
attacked the WHO and cast blame on China.
    The European Union held a pledging conference on vaccines last 
month, at which $8.2 billion was raised. The White House declined the 
invitation to participate for reasons that are beyond me. Is this what 
the Administration means by ``America First''?
    Well, if this EU consortium comes up with a vaccine before we do, 
it will mean ``America Last.'' This approach is not only isolationist, 
shortsighted and foolish--it endangers American lives.
    Finally, as the old saying goes, an ounce of prevention is worth a 
pound of cure. I'm all for ensuring the U.S. government is better 
organized to prevent, detect and respond to future pandemics both here 
and abroad, but some of the proposals coming out of the 
Administration--eerily similar to those coming from some Members of 
Congress--are ill-thought, destructive and dangerous in so far as they 
would cripple USAID, and create a mechanism at the World Bank through 
which the Administration could channel all of the funding it's 
withholding from the WHO.
    So I look forward to the first of what I hope are many thorough 
discussions. Thank you, Mr. Chairman.

    The Chairman. Thank you very much.
    We will now proceed to do exactly what I said we were going 
to do, and that is examine this with an eye towards 
constructing a shield for the future. And, of course, that does 
require some discussion of what happened and how we got here. 
But, nonetheless, I am hoping we will continue to focus the 
discussion, just as Senator Murphy and my bill has done in 
Senate bill 3829, and that is: look forward.
    So, with that, we have a distinguished panel today, 
certainly people with outstanding knowledge in this area and 
who can help us understand the task at hand, and how we can 
accomplish that task.
    So, first of all, we have Mr. James Richardson, who serves 
as Director of the Office of Foreign Assistance, where he 
coordinates $35 billion in foreign assistance across the 
Department of State and the U.S. Agency for International 
Development. Prior to this, he coordinated USAID's 
Transformation Task Team and served as Assistant to the 
Administrator for Policy, Planning, and Learning. He has 20 
years of government experience and holds a bachelor's of 
science and government, a master's of science and defense and 
strategic studies, and is a graduate of the United States Air 
Force Command and Staff College.
    Mr. Richardson, thank you so much. Give us the benefit of 
your wisdom.

 STATEMENT OF JAMES L. RICHARDSON, DIRECTOR, OFFICE OF FOREIGN 
      ASSISTANCE, U.S. DEPARTMENT OF STATE, WASHINGTON, DC

    Mr. Richardson. Great. Thank you, Chairman Risch, Ranking 
Member Menendez, and members of this committee. Thank you for 
inviting me to testify on the international response to the 
COVID-19 pandemic.
    As a former staffer to a member on this committee, it is 
great to be back, and I look forward to having this opportunity 
to have a dialogue and answer any of your questions.
    First of all, I need to acknowledge the leadership of 
President Trump, Vice President Pence, Secretary Pompeo, and, 
really, the myriad of teams we have all around the world at 
State and USAID who are working together to defeat COVID-19.
    For those who may not be familiar, I am the Director of the 
Office of Foreign Assistance, which is a joint office between 
both State and USAID, and we coordinate foreign assistance on 
behalf of the Secretary.
    As the Chairman mentioned, prior to that I was at USAID, 
where I led the agency's historic transformation, looking for 
ways to strengthen the power of development and improve the 
institution. As such, I believe deeply in the power of both 
development and diplomacy. But, together, I think they can be 
unstoppable.
    The United States is the world's undisputed leader in 
foreign assistance. We have invested $500 billion over the past 
20 years; 140 of that in global health, alone. The United 
States has built and sustained health systems across the globe, 
trained millions of healthcare workers, and saved millions of 
lives. COVID has posed a unique challenge to the United States 
and the entire world, as you know, impacting both high-income 
and developing countries, alike. The numbers speak for 
themselves. The State Department has received nearly 1,000 
requests from almost every country in the world.
    In the face of COVID, the generosity of the American people 
has been on full display, with more than 12 billion in 
financial, humanitarian, scientific, and technical support to 
combat the crisis. Of that total, Congress has appropriated 
$1.6 billion to State and USAID for the international response. 
First, thank you for that. This money is being well spent. We 
have committed, so far, 1.3 billion of that, and our assistance 
has gone to 120 countries, and it is making true impact. Of 
note, we have obligated over 500 million of that, with a plan 
to quickly obligate the rest.
    We have provided much-needed ventilators in El Salvador. We 
have trained 20,000 front-line workers in India. We have funded 
public health service announcements on how to fight the virus 
in more than 50 languages. State and USAID has undertaken 
unprecedented coordination in the COVID response. That 
coordination has not slowed us down, but actually ensured 
alignment and effectiveness of our resources, for, when 
people's lives are at stake, we need to make sure we get this 
right. While the COVID-19 pandemic is certainly not over, I 
firmly believe that we need to start thinking about, today, 
what systems the U.S. and the world needs to lessen the 
likelihood of another outbreak becoming a global pandemic.
    When looking across both this pandemic and epidemics and 
pandemics of the past, I think we can pull some important 
lessons learned, but the bottom line is that, moving forward, I 
hope we can all agree that more data, more coordination, and 
more response functions are necessary to respond to future 
outbreaks and prevent pandemics.
    So, the first lesson learned is that pandemics are not just 
a development challenge or confined to the developing world. 
They are truly global in scope, with the risk of severe health 
and economic impact across the globe. For instance, of the 
countries with the highest percentage of COVID-related deaths, 
almost none of them have U.S. Government bilateral global 
health programs. As such, U.S. leadership needs to not just 
focus on the development piece, which is critically important, 
but has to have a broader scope, focusing on mobilizing 
countries' own resources, burden-sharing with like-minded 
donors, and building true accountability into the global 
system.
    The second lesson is that the U.S. Government and the 
global system must be prepared to respond internationally in 
strength and accountability. Coordination in the U.S. 
Government is key. We have to leverage the existing strengths 
of each department and agency for maximum impact. As I often 
say, true coordination is not about control, it is about 
empowerment. We have to unleash the power of our diplomacy, of 
our development, of our public health efforts in order to 
maximize our impact. We also need to ensure that global 
structures can effectively prevent and contain outbreaks from 
becoming epidemics and pandemics.
    The third lesson is, the world needs more effective early-
warning systems and data-tracking.
    And, lastly, we need to think holistically about 
preparedness, and be flexible.
    We understand that the challenges that we may face can come 
in many different forms, and that our response will ultimately 
be multifaceted, so we need to start thinking and planning for 
all of those inevitabilities today.
    In the age of globalization, I fear that the next outbreak 
will look more like this one than outbreaks that we have dealt 
with in the past, but we have an opportunity to save lives, 
promote accountability, and ensure that pandemics are prevented 
to the greatest extent possible. We need systems that are 
flexible, focused, and truly global. We need to fill the gaps 
in the system while coordinating and leveraging the respective 
comparative advantages and unique strengths of each aspect of 
the U.S. Government. Time and time again, when there is a 
global challenge, Americans lead. We are the world's greatest 
humanitarians that the world has ever seen, and I am committed 
to working with all of you to strengthen this fact.
    Thank you for having me today, and I look forward to your 
questions in this important conversation.
    [The prepared statement of James Richardson follows:]

                 Prepared Statement of James Richardson

    Chairman Risch, Ranking Member Menendez, and Members of the 
Committee--thank you for inviting me to testify today on the State 
Department and USAID international response to the COVID-19 pandemic. 
As a former staffer on this Committee at the beginning of my career, it 
is great to be back, and I'm grateful for the opportunity to have this 
dialogue and answer your questions. The United States has been a global 
leader in responding to the COVID-19 crisis, as we have been in 
numerous other health, humanitarian, and complex crises for decades.
    As you are fully aware, the COVID-19 pandemic is unique in that it 
is causing widespread health and economic devastation across the world: 
developed and developing countries alike. Unfortunately, scientists and 
the health security community have been clear that we should be 
prepared for another outbreak to rise to the level of a global 
pandemic. Therefore, even amid our significant response, we must begin 
to look to the future in order to analyze the lessons learned, adapt 
processes and structures accordingly, and act. Months into the 
pandemic, we already have important lessons learned that can help to 
inform our future response and ensure that our resources continue to be 
aligned with both our national security and international development 
goals.
    First, I want to acknowledge the leadership of President Trump, 
Vice President Pence, Secretary Pompeo, Dr. Birx, and our talented 
teams around the world as we work together to defeat COVID-19, both at 
home and abroad. The President knows that pandemics like COVID-19 do 
not respect national borders, and so our All-of-America response must 
also stretch beyond our borders. We can and must both fight pandemics 
at home and help our partners overseas.
    For those that may be unfamiliar, the Office of Foreign Assistance, 
which I lead, is a Bureau staffed with personnel from the State 
Department and U.S. Agency for International Development, responsible 
for coordinating foreign assistance policy, resources, performance and 
strategy across the State Department and USAID. My team has been deeply 
involved in the COVID-19 response effort, ensuring foreign assistance 
is prioritized and committed to countries in need.
    Previous to this role, I was at USAID, where I served as the 
Assistant to the Administrator for Policy, Planning and Learning and 
worked extensively with your staff as head of the Agency's historic 
Transformation. While at USAID, we built several new Bureaus, including 
the new Bureau for Humanitarian Assistance, which is operational as of 
this week, unifying and strengthening USAID's humanitarian response. We 
also created dozens of new policies and strategies, including the 
Private Sector Engagement Policy, and worked to empower the diverse and 
brilliant workforce, strengthening the Agency from the bottom to the 
top. I passionately believe in the power of development and diplomacy 
individually, but together they can be unstoppable. I am proud to have 
worked at both organizations during this Administration, now serving as 
the institutional link between the two.
    The United States is the world's undisputed leader in foreign 
assistance, with $500 billion invested by American taxpayers in the 
21st Century, including over $140 billion in global health, alone. The 
United States has built and sustained health systems across the globe, 
trained millions of healthcare workers, and saved millions of lives. It 
is no surprise that nearly every country in the world has requested 
assistance from the United States during this pandemic. They know we 
will deliver no-strings attached, high-quality interventions and 
equipment that addresses their greatest challenges.
    When it comes to COVID-19, it's important to remember, this is not 
the first time we've seen an outbreak, and it certainly won't be the 
last. The United States has led the global fight against HIV/AIDS, 
tuberculosis, malaria, polio, Ebola, and many other infectious disease 
health security threats. At nearly $10 billion dollars each year, the 
United States provides nearly 40% of worldwide global assistance for 
health--nearly five times the next highest donor. Without a doubt, our 
foreign assistance investments over time have laid the foundation for 
our COVID-19 response today.
    We have mobilized as a nation to combat this disease both at home 
and abroad. With unprecedented destruction, COVID-19 has posed a unique 
challenge to the United States and the entire world in a way that we 
haven't seen this generation, affecting both the developed and 
developing world alike. When we look at the effects of COVID-19, it's 
important to understand the true challenges not just today in this 
pandemic, but also for the next pandemic.
    In the face of COVID-19, the generosity of the American people has 
been on full display. Since the outbreak of COVID-19, the U.S. 
government alone has committed more than $12 billion in financial, 
humanitarian, technical, and scientific support across many federal 
agencies to combat the crisis. As part of this, the State Department, 
USAID, HHS, DoD, and others are working together to support health 
systems; humanitarian assistance; and economic, security, and 
stabilization efforts worldwide with nearly $2.4 billion in emergency 
supplemental program funding provided by Congress in March, including 
nearly $1.6 billion for State Department and USAID foreign assistance. 
The U.S. government has no higher priority than the protection of 
American citizens. On top of our foreign assistance efforts, the State 
Department has worked to bring more than 100,000 Americans home.
    Our efforts are guided by the SAFER package, a comprehensive 
interagency strategy to support our international partners in 
combatting COVID-19. The SAFER package is part of an All-of-America 
approach, leveraging the unique expertise, capacities, and mechanisms 
of various U.S. government departments and agencies to rapidly deploy 
and deliver essential support when, where, and to whom it is most 
critically needed. As part of this package, our foreign assistance 
funding is saving lives in more than 120 countries by bolstering 
countries' ability to prevent, detect and respond to the virus, support 
risk communications, funding water and sanitation services, and 
preparing healthcare facilities and staff. That coordination does not 
end at a shared strategy, but experts from USAID, State, and CDC are 
meeting regularly to ensure that we implement this strategy in a united 
way. In addition, thanks to the expertise of American manufacturing, 
this effort now includes ventilators, delivering on President Trump's 
generous commitment to meet requests from foreign governments now that 
we have met our domestic needs for this equipment.
    Importantly, our work has made a demonstrable impact, saving lives, 
with innovation leading the way. For example, in India, the United 
States has virtually trained more than 20,000 people on the frontlines 
of COVID-19, leveraging the power of digital technology to help state 
leaders prepare local COVID-19 response plans and train frontline 
health workers in strategic messaging, screening activities, counseling 
of patients, and basic clinical management. The United States has 
worked with Thailand to create a mobile application where 80,000 health 
volunteers can now track the location of suspected cases, manage home 
visits, and deliver relief kits with essential staples such as soap, 
rice, fish, and safe drinking water. And in many other places around 
the world, the United States has worked to pivot humanitarian 
assistance programs to respond to the pandemic, continuing to save 
lives through emergency food assistance and cash assistance while 
simultaneously providing access to water and soap for handwashing and 
critical information on how to stay safe.
    While our response has been unprecedented, the COVID-19 pandemic is 
far from over, and will certainly not be the last outbreak that 
threatens to become a pandemic. We have a moral obligation to lead and 
to build a safer system for the next generation. The stakes have never 
been higher. With a current death toll above 400,000 and increasing and 
estimated economic losses between $6 and $9 trillion, we must seize 
this opportunity to prepare for the future, and we know where to start. 
COVID-19 has provided the U.S. interagency and international community 
a harsh reminder of existing health security gaps and new challenges 
that we must face. There are lessons to be learned about the way that 
we've responded to this pandemic and about the way we've responded to 
previous global health challenges, with great research to pull from 
think tanks and oversight bodies. Building on lessons from COVID-19, as 
well as previous challenges--Ebola in West Africa, Zika, H1N1, and so 
on--various trends emerge time and again. The value of this learning 
should be clear--the U.S. government can and should do better. While 
the list is much longer, for the sake of brevity, I'll mention four key 
lessons learned today.
    First, as we have seen with COVID-19, the effects of pandemics are 
not limited to the developing world, and are truly global in scope, 
with the risk of severe health and economic impacts across the globe. 
U.S. leadership must have whole-of-globe reach that focuses on 
mobilizing partner countries' own resources and should demand 
transparency and accountability in the global system.
    Second, the U.S. government must continue to prevent, detect, and 
respond internationally to outbreaks. Our historic investments in 
global health security have been critical in helping partner countries 
respond to COVID-19, and we will continue those investments to build 
their national capacities to respond to a variety of disease outbreaks. 
However, COVID-19 has had a multifaceted impact, with catastrophic 
health, economic, and humanitarian consequences. Coordination is key, 
and we must leverage existing strengths of each U.S. government 
department and agency for maximum impact. It is clear that global 
health structures alone are not able to effectively prevent or contain 
outbreaks from becoming epidemics and pandemics.
    Third, the world does not have effective early warning systems and 
data tracking in-country in order to detect and prevent outbreaks from 
spreading. There is uncertainty on when and where outbreaks may occur 
at any given time. A robust multisectoral approach and transparent 
coordination with Health and other relevant Ministries will be critical 
for virus detection and demanding the accountability and transparency 
that is imperative to stopping a virus in its tracks. Pandemics don't 
know borders--we must take a close look at both domestic and 
international systems.
    Lastly, we need to think holistically about preparedness, and start 
preparing for the next serious outbreak that could turn into a 
pandemic, today. As COVID-19 has proven, an outbreak can strike 
anywhere at any time. We must ensure our systems are flexible, 
accountable and meet the challenge at hand.
    While there are many more lessons that could be identified, both 
large and small, these initial four provide a starting place. The 
question on the table is: how do we use these lessons learned to shape 
what do we do next? In the past, the world has faced serious infectious 
disease outbreaks such as HIV/AIDS, malaria, and Ebola. Over the past 
20 years, for each of these diseases, the United States has stepped up 
to lead in response. We have also worked with our allies and partners 
to prevent, detect, and respond to a wide variety of other disease 
outbreaks. We have a moral obligation and national security imperative 
to do the same when it comes to preventing dangerous future outbreaks. 
However, as I mentioned, the challenge with COVID-19 is that it's 
simply different than outbreaks and pandemics most of us have seen in 
our lifetimes. In this age of globalization, I fear the next outbreak 
will look more like this one than the ones of the recent past. With 
proactive thinking, together, we can prepare the U.S. government and 
international system to ensure the world is prepared for the next 
outbreak--and work together to prevent a future pandemic.
    As we look forward, with history as our guide, we have an 
opportunity to save lives, promote accountability, and ensure that 
pandemics of this size and scale are prevented to the greatest extent 
possible. We need systems that are flexible, focused, and truly global. 
We need U.S. Government and international systems organized in a way to 
prevent, detect, and respond to future outbreaks, with better tools and 
improved whole-of-government coordination. We need to fill the gaps in 
our systems, while coordinating, leveraging and respecting the 
comparative advantages and unique strengths of each U.S. Government 
agency involved in pandemic preparedness, prevention and response. This 
does not mean taking away funding or responsibilities from any single 
government agency but mobilizing the collective strengths of each in a 
way that is truly coordinated and impactful. Lastly, and importantly, 
out of respect for the lives and livelihoods of Americans, we need to 
ensure effective oversight, accountability and performance mechanisms 
to ensure each dollar spent advances our objectives, including 
protecting Americans at home and abroad, and meets the challenges at 
hand.
    Time and again, when there is a global challenge, Americans lead. 
We are the world's greatest humanitarians. And our international 
response does not detract from our ability to protect the homeland; 
rather, it bolsters it. Thank you for having me today for this 
important discussion, and I look forward to your questions.

    The Chairman. Thanks so much. Great comments.
    Mr. Milligan serves as Counselor to USAID. He previously 
served as the Acting Mission Director in Madagascar; Mission 
Director in Burma; Senior Development Advisor for the first 
Quadrennial Diplomatic and Development Review; a Senior Deputy 
Assistant Administrator for Policy, Planning, and Learning. He 
has a bachelor's degree from Georgetown School of Foreign 
Service, a master's degree from Johns Hopkins School of 
Advanced International Studies, and is a distinguished graduate 
of the National War College.
    With that, Mr. Milligan, thank you for coming. We would 
like to hear what you have to say.

    STATEMENT OF CHRIS MILLIGAN, COUNSELOR, U.S. AGENCY FOR 
            INTERNATIONAL DEVELOPMENT, WASHINGTON DC

    Mr. Milligan. Thank you. Chairman Risch, Ranking Member 
Menendez, members of the committee, it is really an honor to be 
here today.
    And let me begin, first, by thanking you for your 
generosity, which has allowed the United States Agency for 
International Development to mount a robust response to the 
COVID-19 pandemic.
    I have been a Foreign Service Officer at USAID for more 
than 30 years, and I currently serve as Agency Counselor, which 
is the senior-most career official at the agency. And, 
throughout my career, I have seen the United States respond to 
crises all over the world, and I have led some of those 
responses, such as the response to the Haiti earthquake.
    I have seen how the United States saves lives, how we 
support our partner countries, and how we stand with them when 
disaster strikes. The scale of COVID-19 response is 
unprecedented, but these core American values are constant. In 
the past 10 years, USAID has been on the front line to fight 
numerous complex health emergencies, including the outbreaks of 
Ebola in West Africa, Zika in Latin America and the Caribbean, 
and the pneumonic plague in Madagascar, one I know quite well. 
We are continuing to fight Ebola in the DRC, and we are in this 
fight for the long term, because that is what we do, and that 
is who we are as Americans.
    Through these experiences, USAID has developed deep 
operational and technical expertise to respond quickly, 
rapidly, and appropriately to complex health crises. The United 
States Government is strongest when we are agile and flexible 
and well-coordinated, particularly at the country level. I know 
from my own experience, out-of-control epidemics are a symptom 
of multiple complex causes, and health emergencies have 
consequences that can rapidly require broader development 
assistance to address those deeper root causes of instability 
and poor governance. Controlling epidemics requires more than a 
standalone effort, and we have seen that, when we do not 
address poor governance and conflict, we wipe out the 
investments in health and education and other basic social 
services.
    USAID has development experience to address these issues 
and prevent outbreaks from becoming epidemics, but we are 
hampered. We are hampered when countries such as the People's 
Republic of China and other malign actors do not disclose 
information transparently or share pathogen samples, and 
instead destroy samples and obfuscate facts, imprison medical 
personnel, and silence journalists. In stark contrast, USAID 
builds capacity and strengthens healthcare systems and 
democratic institutions to enable countries, themselves, to 
respond better to global health crises, and that protects us 
back home. We appreciate your support for retaining the 
independence to make these investments ourselves based on data 
and the best available evidence.
    Today, faced with COVID-19, the United States is again 
demonstrating clear and decisive leadership. USAID is investing 
$1.2 billion in emergency supplemental foreign assistance 
generously appropriated by Congress to finance healthcare, 
humanitarian assistance, economic security, and stabilization 
efforts worldwide. This funding is saving lives. It is also 
improving public health education and protecting health 
workers, strengthening laboratory systems, and supporting 
disease surveillance, and boosting rapid response capacity in 
over 100 countries around the world.
    We are leveraging our development programming to complement 
our global efforts, because we recognize that COVID-19 will 
have extensive secondary- and tertiary-order impacts. So, 
taking health out of a broader development approach and 
isolating it will not lead to success. We must empower our 
health and development experts to do what they do best in the 
field, to respond to dangerous infections, diseases. It is 
imperative that we act proactively and address the ways--the 
many ways this crisis has not only cost lives, but threatened 
development outcomes.
    We are very concerned about these secondary and tertiary 
impacts. We are concerned about the more than 113 million 
people who will need emergency foods assistance in the coming 
year, which would be a 25-percent increase. We are seeing a 
disturbing trend of a rolling back of democratic reform and 
democratic backsliding, closing space for civil society. We are 
investing not only in food security, but also in combating this 
democratic backsliding. These investments build responsive, 
transparent government.
    USAID's response to the COVID pandemic contributes to the 
United States remaining a trusted and preferred partner in 
countries around the world. No other country can match our 
unparalleled generosity, our open and collaborative approach, 
our long-term commitment to helping--the Journey to Self-
Reliance. So, that is why I greatly appreciate the ability to 
be here today and testify in front of this committee.
    Thank you very much.
    [The prepared statement of Chris Milligan follows:]

                  Prepared Statement of Chris Milligan

    Chairman Risch, Ranking Member Menendez, and Members of the 
Committee--Thank you for inviting me to testify today on the 
international response to the COVID-19 pandemic. It is an honor and 
privilege to testify in front of the Committee, and I look forward to 
your questions.
    Let me begin by first thanking you for your generosity, which has 
allowed the U.S. Agency for International Development (USAID) to mount 
a robust response to an unprecedented global crisis that has touched 
nearly every person around the world--both at home and overseas.
    I have served with USAID as a Foreign Service Officer for more than 
30 years in multiple countries, including Burma and the Republics of 
Iraq, Madagascar, Ecuador, and Zimbabwe. Throughout my career, I have 
seen how the United States rushes to help during times of disaster and 
crisis. We bring relief to the affected and hope to the afflicted. We 
save lives, support our partners to build systems, and stand with them 
if disaster strikes. The scale of the response to COVID-19 might be 
unprecedented, but these values--these core American values--are not. 
USAID is one of the faces of American compassion and generosity 
overseas, and I am proud to be here on behalf of the men and women who 
serve and carry out our mission all around the world.
    Of course, our assistance goes far beyond relief work. We work with 
our partners throughout the U.S. government to strengthen democracies, 
drive economic growth, help send children to school, and keep families 
healthy.
    Our response builds upon these decades of investments in global 
health. In just the 21st Century alone, the United States has 
contributed more than $140 billion in global health assistance. For 
example, over the past 20 years, USAID's funding has helped Gavi, the 
Vaccine Alliance, vaccinate more than 760 million children, which has 
prevented 13 million deaths. This month, the United States committed 
$1.16 billion to Gavi over the next 4 years, with the goal to immunize 
300 million additional children by 2025. Since 2005, the U.S. 
President's Malaria Initiative (PMI), led by USAID in partnership with 
the Centers for Disease Control and Prevention (CDC), has saved more 
than 7 million lives and prevented more than 1 billion cases of 
malaria. USAID also recognizes that viruses do not respect borders, as 
the current pandemic so clearly demonstrates. USAID invests in global 
health security to address existing and emerging zoonotic diseases--
which account for more than 70 percent of new infectious-disease 
outbreaks. USAID alone has invested $1.1 billion in this critical area 
since 2009, in close coordination with other U.S. Government agencies.
    In the past 10 years, USAID has been on the front lines to fight 
numerous complex health emergencies, including the outbreaks of Ebola 
in West Africa and Zika in Latin America and the Caribbean, and the 
outbreak of pneumonic plague in Madagascar. Today, even as we 
cautiously count down towards the end of the 10th outbreak of Ebola in 
the Eastern Democratic Republic of Congo (DRC), we are now scaling up a 
response to fight the confirmed 11th outbreak in Northwestern DRC. We 
are in this fight for the long term--because that is what we do, and 
that is who we are as Americans.
    We know that what happens around the world can affect us here at 
home. Until now, local authorities, often with U.S. Government support, 
brought most of these outbreaks of dangerous pathogens under control. 
Our success has come from the ability to act quickly, rapidly and 
appropriately. The U.S. Government is at its strongest when we are 
agile, flexible, and well-coordinated at the country level.
    Throughout the years, we have built up our operational and 
technical expertise and learned some hard lessons. Chief among them, is 
that we need close partnerships with communities, civil society, non-
governmental organizations (NGOs), and faith-based organizations to 
solicit the support and engagement of local communities to ensure an 
effective response, as well as the need to collaborate with researchers 
and the private sector.
    As we continue to learn from this pandemic, we must address the 
root causes of these outbreaks and apply the lessons learned from 
COVID-19 and epidemics past. We have also learned that outbreaks and 
epidemics are directly related to governance, transparency, and 
capacity considerations. For example, the robust international response 
to the ongoing Ebola outbreak in eastern DRC was notably challenged by 
a humanitarian crisis, weak institutions, marginalized and impoverished 
communities, and insecurity. Yet thanks to healthcare capacity and 
expertise--supported by millions in USAID and U.S. government long-term 
investments in the country, the DRC government and international 
community was able to contain outbreak spread within DRC borders and 
prevent a global pandemic.
    From my own experience, controlling epidemics requires more than a 
stand-alone effort. And we have seen that when we do not address poor 
governance and conflict, we wipe out investments in health, education, 
and other basic social services.
    More often than not, we have the tools to prevent outbreaks from 
becoming epidemics--but we are hampered when countries such as the 
People's Republic of China and other malign actors do not disclose 
information transparently or share pathogen samples, and instead 
destroy samples, obfuscate facts, imprison medical personnel, and 
silence journalists.
    And we recognize that health emergencies have consequences that can 
rapidly require broader development assistance--whether that is support 
for orphaned children, protection against sexual exploitation, gender-
based violence, and abuse, buttressing sustainable livelihoods or 
addressing the deeper root causes of instability and governance.
    When former Administrator Mark Green last testified before this 
Committee, he spoke of USAID's overarching mission of helping 
communities on their Journey to Self-Reliance. Our investments in 
global health throughout the decades are a cornerstone of this 
approach. Through USAID, our partners have built capacity and 
strengthened healthcare and democratic institutions to enable them to 
respond better to global health crises. We appreciate your support for 
retaining the independence to make these investments ourselves, based 
on data and the best available evidence.
    Today, faced with COVID-19, the United States is again 
demonstrating clear and decisive leadership. The United States has 
mobilized as a nation to combat the virus, both at home and abroad, by 
committing more than $12 billion to benefit the global COVID response 
overseas. USAID is working with the U.S. Departments of Defense, Health 
and Human Services, and State, as part of an All-of-America response. 
With $2.3 billion in emergency supplemental funding generously 
appropriated by Congress, including nearly $1.7 billion for foreign 
assistance implemented by USAID and the State Department, we are 
financing health care; humanitarian assistance; and economic, security, 
and stabilization efforts worldwide.
    This funding is saving lives by improving public health education, 
protecting healthcare workers, strengthening laboratory systems, 
supporting disease surveillance, and boosting rapid-response capacity 
in more than 120 countries around the world. We are providing high-
quality, transparent, and meaningful assistance to support communities 
affected by COVID-19 and equip them with the tools needed in their 
efforts to combat this pandemic. We are also using funding to support 
COVID responses in complex crisis countries and regions and providing 
health, water and sanitation, and logistics for humanitarian and crisis 
response.
    We are forging partnerships with the private sector, NGOs, and 
others to help respond. For example, in the State of Israel, USAID has 
a long partnership with Hadassah Hospital, and a new one with Pepsi and 
SodaStream is underway to invent a high-flow respirator for COVID-19 
patients, which would be available for medical centers in Jerusalem 
neighborhoods with an especially high incidence of the virus. The open-
source designs can be downloaded for free for assembly anywhere in the 
world, and have already been used in the Republics of El Salvador, 
Guatemala, and Turkey.
    In the Kingdom of Thailand, we have worked with the Thai Red Cross 
to create an application called Phonphai, which enables users to report 
locations of people infected with COVID-19 and in need of assistance. 
Village health volunteers in Thailand are using the app to locate 
people in quarantine, conduct basic health screening, and collect vital 
information. Working with Makro, Thailand's Costco equivalent and 
third-largest retailer, health volunteers have used the app to order 
and deliver emergency kits, including essential food and hygiene items, 
to more than 115,000 vulnerable people in quarantine throughout the 
country.
    In the Federal Republic of Nigeria, USAID launched a partnership 
with cellphone provider Airtel to reach 1 million citizens a day with 
critical information via voice and text messages on physical 
distancing, safe hygiene practices, and other preventive measures to 
contain the spread of the disease. Now we are able to distribute the 
latest public-health messaging instantly to millions.
    Looking long term, we understand that COVID-19 will continue to 
have an impact around the world in the months and years to come. We 
remain committed to helping communities in our partner countries 
through this pandemic, and its second- and third-order effects. The 
COVID-19 pandemic is not simply a health crisis, and our response 
cannot be just a health response. It is an economic one as well.
    Because of this reality, USAID is leveraging our development 
programming to complement our global health efforts. We are including 
other facets of our development programming to complement our health 
efforts to mitigate pandemics--because preventing pandemics requires 
functioning healthcare in the public and private sectors. And 
functioning health institutions require engagement beyond just the 
health sector. They require reforms in the gathering of local tax 
revenue, private-sector development, as well as engaging with patients 
and a broad set of actors. Taking health out of a broader development 
approach and isolating it will not lead to success. We recognize that 
diplomacy is a critical component of fighting epidemics, and we as a 
government should emphasize the importance of full compliance with the 
International Health Regulations (2005) in addition to coordinating and 
empowering our health and development experts to do what they do best 
in the field to respond to dangerous infectious diseases.
    Already, the spread of the novel coronavirus and actions to 
mitigate COVID-19 have had significant secondary impacts--perhaps none 
more devastating than in the areas of food security and nutrition. At 
the beginning of 2020, conflict, poor macroeconomic conditions, and 
weather shocks were already driving high food assistance needs across 
the globe. The Famine Early-Warning System Network (FEWS NET), led by 
USAID, estimates 113 million people will be in need of emergency 
humanitarian food assistance this year, which represents an increase of 
approximately 25 percent in the span of just 1 year. The onset and 
progression of the COVID-19 pandemic, and measures taken to suppress 
its spread, are likely to increase the magnitude and severity of acute 
food-insecurity.
    It is imperative that we proactively--and comprehensively--address 
the many ways that this crisis has eroded food security and driven 
malnutrition worldwide. To that end, USAID is working with the World 
Food Programme and NGOs to invest over $165 million of COVID-19 
supplemental humanitarian resources to address emergency food needs in 
21 countries, including countries such as Afghanistan, Bangladesh, 
Colombia, Ecuador, and Lebanon and 15 countries in Africa that already 
were experiencing high levels of hunger before the pandemic. In 
addition to emergency food assistance, we are addressing disruptions to 
agricultural production, trade, and local markets; the loss of 
livelihoods; and the deterioration of essential social services, like 
water and sanitation, while building longer-term resilience. Each of 
these plays an important role in strengthening food security and 
nutrition, as well as fostering long-term resilience.
    At the same time, we recognize how important democracy and citizen-
responsive governance are in responding to the outbreak, and we are 
investing funds accordingly. Unfortunately, we are seeing democratic 
backsliding, closing space for civil society, and crackdowns on media 
freedom as the pandemic continues to unfold. To counter this trend, 
through ongoing USAID programming and supplemental funding, we are 
supporting civil-society organizations and independent media outlets, 
strengthening the rule of law, working with national electoral 
commissions, and combatting disinformation--because we know responsive, 
transparent governments are better-equipped to help their populations 
address the crisis and eventually help to mitigate the pandemic.
    USAID also has begun to think about how we can successfully execute 
our mission in the post-COVID-19 world, in a way that is flexible and 
agile. To that end, Acting Administrator Barsa is establishing a 
temporary Agency Planning Cell and Executive Steering Committee to 
guide this effort. While the USAID COVID-19 Task Force manages near-
term challenges arising from the pandemic, the Agency Planning Cell 
will perform research, conduct outreach, and prepare analyses around 
key strategic questions to help USAID prepare for lasting challenges to 
the development and humanitarian landscape in the medium to long term. 
It will then provide this information to the Executive Steering 
Committee, composed of senior leaders from across the Agency, who will 
craft recommendations for the Acting Administrator's consideration.
    We are already planning for the medium- and long-term impacts of 
COVID-19 because we know the United States will remain a trusted 
partner, the preferred partner, in countries across the world. No other 
nation can match our unparalleled generosity, our open, collaborative 
approach, or our long-term commitment to helping communities on their 
Journey to Self-Reliance.
    Thank you for the opportunity to represent USAID. I welcome your 
questions.

    The Chairman. Thank you. It is good information.
    Mr. Garrett Grigsby is the Director of the Office of Global 
Affairs at the Department of Health and Human Services, which 
leads U.S. engagement with the World Health Organization and 
its regional offices. He previously served as USAID's Deputy 
Assistant Administrator for Democracy, Conflict, and 
Humanitarian Assistance, as USAID's Director of Faith-Based and 
Community Initiatives, and as Deputy Staff Director for the 
Senate Foreign Relations Committee.
    With that, Mr. Grigsby, we are anxious to hear what you 
have to say about our relationship with the WHO and how we will 
move forward.

   STATEMENT OF GARRETT GRIGSBY, DIRECTOR, OFFICE OF GLOBAL 
    AFFAIRS, U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES, 
                         WASHINGTON, DC

    Mr. Grigsby. Thank you, sir.
    Mr. Chairman, Ranking Member Menendez, and members of the 
committee, it is an honor to be with you to discuss the World 
Health Organization and the Global Health Security Agenda, or 
GHSA.
    Last month, Secretary Azar addressed the World Health 
Assembly, the WHO's governing body, expressing concerns with 
the WHO and member-state response to the COVID-19 outbreak. The 
committee is aware of the President's statements and letter 
expressing his concerns and his May 29th statement that the 
United States is terminating its relationship with the WHO.
    With respect to the WHO, allow me to go back even before 
the first reporting of the outbreak in Wuhan, China, and 
highlight the concerns, and then I will address GHSA.
    After the SARS pandemic that also originated in China, the 
International Health Regulations, or IHRs, were revised in 2005 
to improve transparency and reinforce obligations of countries 
to provide accurate, timely, and complete information about 
outbreaks. After the 2014 West Africa Ebola crisis, the WHO 
Health Emergencies Program was created, and it has had some 
success on the ground responding to complex emergencies, but it 
has not met the goal, the global challenge of COVID-19. 
Fourteen years after SARS, China failed again to provide 
accurate, timely, and complete information to the WHO about its 
COVID-19 outbreak, and, in fact, withheld information that 
could have helped countries take actions earlier to protect 
public health. The WHO did not call out the Chinese government, 
which we believe exacerbated the pandemic. Early statements 
from WHO leadership praised the Chinese government while 
criticizing others. When missteps of China and the WHO became 
apparent, our team compiled information to identify gaps in the 
WHO's outbreak response toolkit. This led to discussions with 
partner countries about reform of the WHO.
    For example, the WHO's Director General must demand 
compliance with IHR obligations. The Director General and the 
WHO's Health Emergency Program must be insulated from malign 
political pressure. Improvements to the process for declaring a 
public health emergency of international concern are overdue, 
and linking travel and trade restrictions together must be 
reexamined so countries can take proactive measures, like the 
U.S. did to protect our citizens, without criticism or 
retaliation.
    Enacting these reforms, regardless of the United States 
relationship with the WHO, would be good for the world. The WHO 
will only live up to its mandate with increased transparency 
and accountability of all member states.
    Switching to the Global Health Security Agenda, 18 months 
into phase two, called GHSA 2024, the need for a multi-sectoral 
approach to pandemic preparedness is greater now than ever. 
GHSA was created in the midst of the 2014 West Africa Ebola 
crisis to help countries comply with the IHRs. GHSA is a group 
of 67 countries, international organizations, NGOs, and 
companies working together to prepare for infectious disease 
threats. Under GHSA, nations make concrete commitments to 
elevate health security and improve capacities to prevent, 
detect, and respond to infectious diseases as a national 
priority. GHSA members provide support for implementation 
through advocacy, collaboration, information-sharing, and 
technical advice.
    The U.S. is a leading voice on the GHSA 2024 Steering 
Group, as chair of the Accountability and Results Task Force, 
ensuring the focus on addressing gaps and challenges in 
countries' core capacities. The target is to have more than 100 
countries with improved capacities by 2024. It seeks to improve 
accountability and tracks partner commitments in a transparent 
manner. We also collaborate with partners as chair of the 
Sustainable Financing for Preparedness Action Package to 
mobilize resources for preparedness.
    HHS works with many countries to improve health security 
capacities pursuant to GHSA commitments. This includes helping 
complete a joint external evaluation to assess preparedness, 
developing national action plans, and mobilizing resources.
    As GHSA core capacities are based on the International 
Health Regulations, both efforts I have discussed, leading GHSA 
2024 and forging ahead on WHO reforms focused on strengthening 
the IHRs, are mutually reinforcing and will help bring about a 
safer world.
    Thank you, Mr. Chairman. We look forward to working with 
the committee on global health security.
    [The prepared statement of Mr. Garrett Grigsby follows:]

               Prepared Statement of Mr. Garrett Grigsby

    Mr. Chairman, Sen. Menendez, and members of the Committee, it's an 
honor to be with you to discuss the World Health Organization (WHO) and 
the Global Health Security Agenda, or GHSA.
    Last month, Secretary Azar addressed the World Health Assembly, 
which is WHO's governing body, expressing concerns with WHO and Member 
State response to the COVID-19 outbreak.
    The Committee is aware of the President's statements and letter 
expressing his concerns, as well as his May 29 statement that the 
United States is terminating its relationship with WHO.
    With respect to WHO, allow me to go back even before the first 
reporting of the outbreak in Wuhan, China and briefly highlight the 
concerns of the United States, and then address GHSA.
    After the SARS pandemic, which also originated in China, WHO Member 
States revised the International Health Regulations, or IHRs, in 2005 
to improve transparency and reinforce and expand obligations of 
countries to provide accurate, timely and sufficient information 
related to outbreaks.
    After the 2014 West Africa Ebola crisis, the WHO Health Emergencies 
Program was created. The program has had some success on the ground, 
responding to complex emergencies, like Ebola in the Democratic 
Republic of Congo, but it has not met the global challenge of COVID-19.
    Unfortunately, 14 years after SARS, China failed again. We have 
grave concerns that China did not provide accurate, timely and 
sufficiently detailed information to WHO in accordance with the IHRs 
about its COVID-19 outbreak and, in fact, withheld information that 
could have helped countries take actions earlier to protect global 
public health. China had a responsibility to share this information 
with the rest of the world as it was the first to know about the virus.
    WHO did not call out the Chinese government on its lack of 
transparency and timely information-sharing, and we believe that not 
doing so exacerbated the pandemic we are now experiencing. To the 
contrary, statements from WHO leadership praised the Chinese 
government. while criticizing other nations.
    As early as February, when missteps of China and WHO were becoming 
apparent, our team was compiling information about the lack of sharing 
accurate, timely and sufficiently detailed information for the purpose 
of identifying gaps in WHO's outbreak response toolkit. This led to an 
intense discussion with partner countries about reform of WHO relating 
to outbreak response tools and preparedness programs.
    For example, it is critical that WHO's Director-General use his 
platform to call for compliance with IHR obligations. The Director-
General and WHO's Health Emergencies Program must be insulated from 
political pressure. Improvements to the process for declaring a Public 
Health Emergency of International Concern are needed. And the practice 
of linking travel restrictions must be reexamined so countries can take 
proactive measures, as the U.S. did to protect our citizens, without 
criticism or retaliation.
    If these reforms are enacted, regardless of the United States' 
relationship with WHO, it would be good for the world by enabling WHO 
to fulfill its mandate, and increasing transparency and accountability 
of all Member States, in particular those with responsibility during 
infectious disease outbreaks in their territory.
    Switching to the Global Health Security Agenda--18 months into the 
second phase of GHSA--called GHSA 2024--the need for a strong, multi-
sectoral approach to pandemic preparedness is greater now than ever.
    GHSA was created in the midst of the 2014 West Africa Ebola crisis 
to help countries meet their obligations to comply with the 
International Health Regulations. GHSA is a voluntary group of 67 
countries, as well as international organizations, NGOs and companies 
working together to prepare for infectious disease threats. Under GHSA, 
nations make concrete commitments to elevate global health security and 
improve their capacity to prevent, detect and respond to infectious 
diseases as a national priority. GHSA members provide support for 
implementation through advocacy, collaboration, information sharing, 
and technical advice.
    The U.S. is a leading voice on the GHSA 2024 Steering Group, as the 
chair of the Accountability and Results Task Force, ensuring that GHSA 
continues to focus on addressing gaps and challenges in countries' core 
capacities. The GHSA 2024 target is to have more than 100 countries 
with improved capacities by 2024. It also seeks to sharpen the focus on 
accountability and tracking country and partner commitments in a 
transparent manner.
    We also collaborate with partners as the chair of the Sustainable 
Financing for Preparedness Action Package to use momentum from the 
COVID-19 response to mobilize resources to invest in preparedness.
    HHS, alongside U.S. Government partners at State Department, USAID, 
and beyond, works with many countries to improve their health security 
capacities pursuant to GHSA commitments. This includes helping complete 
a Joint External Evaluation to assess their current state of 
preparedness, developing National Action Plans for Health Security, and 
mobilizing resources. Since the launch of GHSA, the United States 
Government has invested over $3 billion to strengthen national capacity 
in partner countries to prevent, detect, and respond to existing and 
emerging-infectious disease threats.
    As GHSA core capacities are based on the International Health 
Regulations, the two efforts I have discussed--forging ahead on WHO 
reforms focused on strengthening the IHRs, and leading in GHSA 2024--
are mutually reinforcing and will help bring about a safer world.
    Thank you, Mr. Chairman, for your attention and interest. We look 
forward to working with the Committee on global health security in the 
future.

    The Chairman. Well, thanks, to all of you. It certainly 
looks like we have got the right panel here to give us the 
information we need to try to go forward.
    Mr. Richardson, let me say, first of all, thank you for 
reminding us of how critical and pivotal the role of the United 
States is in any kind of a global challenge, and, most 
importantly, how generous Americans are. The 330 million of us, 
compared to the 8 billion in the world, contribute an 
incredibly high percentage of need that is given to less 
fortunate people.
    You made one statement that I would like to focus on a 
little bit. And I am going to follow up on this with Mr. 
Grigsby, also. But, you said you fear that future pandemics are 
going to look a lot more like this COVID-19 than the ones that 
we have experienced in the past. Could you drill down on that a 
little bit, why you say that and what do you mean by that?
    Mr. Richardson. Yes. I appreciate the question, Senator.
    I think when we start looking at what is the real 
differences with this pandemic--whether it is Ebola or SARS, 
both of those were fairly localized in scope. The challenges 
that they presented were probably overwhelmingly focused on the 
developing world. This pandemic--and, I think, given the 
globalization realities that we find, the fact that we can 
easily travel around the world, and that is continuing to 
accelerate, I fear that that mobility will drive epidemics, the 
outbreaks somewhere, to then be able to spread more easily 
through the developed world, in addition to the developing 
world.
    The Chairman. You know, let me stop you there. As I look at 
these differences in the viruses--just take Ebola and compare 
it to COVID. The transmission mechanism is very different on 
the two, it seems. And the contagiousness of the disease seems 
to be very different. And with 2,000 viruses kicking around out 
there, they are probably all going to have idiosyncrasies that 
are different than others. Is that what you are making 
reference to?
    Mr. Richardson. Yes, absolutely. I think, when you really 
look at what the challenge we are presented, the likelihood of 
transmission, the globalization of this world, and the ability 
for viruses to quickly move outside of a containment area, that 
is a game-changer. And again, given the fact that it has been 
able to impact high-income countries, like the way it has, I 
think, really makes us want to rethink how we approach this.
    The Chairman. Yeah, that is what we are trying to do right 
here, and that is exactly the focus of what we are doing. And I 
think your identification there is important.
    In a minute, I am going to ask Mr. Grigsby a little bit 
more about that, because of the system we need to put in place. 
It seems to me that COVID-19, because of the way it transmitted 
and the rapidity at which it transmitted, it is so different 
from those other viruses that we have experienced in the past, 
and, in the defense of the systems that we are trying to 
respond to this, they were not ready for that. They did not 
expect it. They expected that it would behave like SARS or like 
Ebola or something like that. And what we found out is that it 
behaved very differently and required a very different 
response. And that did not happen. Is that a correct 
characterization?
    Mr. Richardson. Absolutely. We are not really sure what the 
next outbreak or next virus will look like, or what it will do. 
I will leave it to the scientists to talk about, you know, how 
it is transmitted or how much more easily it can move. But, I 
think our systems are not built for this type of outbreak. 
Clearly, it did not work, right? It did not stop the ability 
for this to become a global pandemic. So, we really need to 
think about what kind of flexible mechanisms, both in the 
international system and in the U.S. Government, that we can 
put into place now that allows us to be able to respond, both 
at an outbreak and at a pandemic level, that is to be able to 
say, you know, regardless of what the virus is, or regardless 
of where the outbreak starts and where it goes, we need to have 
an ability to respond. This idea of a worldwide ability to 
respond is incredibly critical.
    The Chairman. Well, and that is what Senator Murphy and I 
and this committee are focused on, as far as trying to develop 
the system, here. And thank you for being part of that.
    Mr. Grigsby, you know, in my conversations with Mr. Tedros 
and his team, they were defensive in one respect. I think it 
was legitimate. And that is, they said they did not have enough 
power. And, regardless of our criticism of them, we do have to 
realize that they are not a sovereign entity, and they cannot 
really tell a sovereign entity what to do. They can certainly 
encourage them and try to press them to do the right thing. 
But, it struck me that, going along with the conversation I was 
just having with Mr. Richardson, that they, as much as the rest 
of the world, were taken aback by how COVID-19 reacted, 
compared to their dealings with polio or AIDS or Ebola. Is that 
a fair assessment of where they were, as far as being taken 
aback by what happened?
    Mr. Grigsby. Thank you, Mr. Chairman.
    You know, it is fair to say, as Jim was alluding to, COVID-
19 is a novel virus, it is one that had not been seen in human 
beings before. There is still a lot that we are learning about 
it. And, by the way, we would be happy to come up and brief you 
or your staff--not myself, but we have leading scientists in 
the world at HHS, and they could answer some of these questions 
very specifically for you. They are still learning about this. 
I think that is a fair comment.
    And it is true, and it is a challenge, that the World 
Health Organization does not have a police force, it does not 
have a standing army to go in and enforce international health 
obligations, which is only one of two treaties that are in the 
WHO that countries have signed up for and are obliged to comply 
with.
    But, I think what we all know is that, rather than even 
calling China out, what was really going on is that the 
leadership of WHO was praising China. This has happened before. 
We have been in this movie before. If you go back to the SARS 
situation in the early 2000s, the leadership of the WHO was a 
little bolder when it was confronting China, in that it did 
call China out. There were significant problems that happened 
that led, as I mentioned in my statement, to a revision of the 
International Health Regulations in 2005. But, there is only so 
much that it can do. But, it did not even do the minimum it 
could have done, as in calling out what was really going on, 
the information that it needed that it was not receiving. That 
did not happen at all, unfortunately.
    The Chairman. Thank you.
    I am going to end here and turn it over to Senator 
Menendez.
    Before I do, what I want you to think about is. We have 
focused quite a bit on what did not happen, and why it did not. 
And what I would like to hear when I come back to you is your 
thoughts as to what a system would look like if we were 
designing it now, which we are, hopefully, for the next 
pandemic, whose transmission is rapid and easily as COVID-19. 
Because, as we have now, I think, all agreed, this is entirely 
different than what we have dealt with in the past. We need a 
system entirely different than what we have had in the past. We 
want your thoughts on that as to how we would go forward.
    Senator Menendez.
    Senator Menendez. Thank you, Mr. Chairman.
    Mr. Chairman, just a comment. I agree that we need to 
continue working on a bipartisan approach. Before the last 
business meeting, we were working well on a bipartisan 
manager's package. And I, along with all the other Democrats on 
the committee, introduced the COVID-19 International Response 
and Recovery Act. And I hope we can find a common ground and a 
productive path forward. And I look forward to that 
opportunity.
    Mr. Grigsby, I want to pick off, in your last set of 
comments here as well as your testimony, that China did not 
share sufficient information about the virus. And you just said 
that the WHO's words of praise for China actually exacerbated 
the pandemic because it did not pressure China to be more 
transparent. But, President Trump, himself, praised China's 
response multiple times, in speeches, public statements, in 
tweets, quite explicitly. In one tweet, on January 24th, he 
wrote, ``China has been working very hard to contain the 
coronavirus. The United States greatly appreciates their 
efforts on transparency. It will all work out well. In 
particular, on behalf of the American people, I want to thank 
President Xi,'' close quote.
    On February 6th, at the WHO executive board meeting, 
Ambassador Bremberg, who represented the United States, was 
similarly effusive, saying, quote, ``We deeply appreciate all 
that China is doing on behalf of its own people and the world, 
and we look forward to continuing to work together as we move 
ahead in response to the coronavirus,'' close quotes.
    Those are just some of the quotes.
    So, was the WHO's praise for China the fatal flaw which 
necessitated the U.S. withdrawal from the WHO? And, if so, why 
did the United States make similar statements of praise and 
support for China at the same time if this was detrimental to 
the global pandemic response?
    Mr. Grigsby. Thank you, Senator.
    The comments you made are absolutely correct. Early on, the 
information we were receiving was that China was being 
cooperative. We were getting those reports from the World 
Health Organization. I remember having conversations early on 
at my level and members of WHO telling me how unbelievably 
transparent China was being, particularly compared to the SARS 
problem in the early 2000s.
    What happened was, we received more information later, as 
we all have had, and information is going to continue to come 
out. And, as that information changed, the tone changed. And 
that is just a fair comment.
    Last month, the World Health Assembly approved a 
resolution. It is cosponsored by--in fact, because it was a 
virtual Assembly and much condensed, as opposed to the normal 
meetings, they were not able to do a lot of business. They had 
one item, and that was a resolution, cosponsored by 140 
countries, expressing concern, but also demanding that there be 
an independent review of what happened, including about the 
origins of the disease and its path to transmission to humans.
    So, a lot of countries were saying good things about 
China's response early on, but then as more information came 
out, and it will continue to come out with these independent 
reviews----
    Senator Menendez. Well, I look forward to the review, and I 
certainly believe it is important, but the President's praise 
continued even after the ones I mentioned.
    Let me ask you this. You listed several reforms the 
Administration would like to see at the WHO, including pressure 
for better compliance of international health regulation 
obligations and improving the process for declaring public 
health emergencies of international concern. That would be good 
for the world. But, the Director General is not the person who 
decides on those reforms. It is the WHO, which is a member 
organization. Member countries make those decisions. How does 
the United States expect to influence other members to achieve 
reforms of the WHO if it has relinquished its seat at the 
table?
    Mr. Grigsby. Senator, that is a good question, and I 
appreciate it.
    The fact of the matter is, the United States is a member of 
the World Health Organization now. The President has announced 
that that relationship is being terminated and----
    Senator Menendez. Well, if I said, ``I am terminating my 
relationship with you,'' why should I listen to you? Can you 
explain that to me? If you tell me you are terminating your 
relationship with me, why should I listen to you about anything 
you want to do with the organization that I no longer am going 
to have a relationship with?
    Mr. Grigsby. Why don't I tell you what we are actually 
doing?
    Senator Menendez. No, why don't you answer my question.
    Mr. Grigsby. I am doing that, sir.
    As you know, the United States has the presidency of the G7 
this year. That provides us an opportunity to speak with health 
ministries. In fact, Secretary Azar has, since early on in the 
pandemic, had once-a-week telephone conversations with all 
health ministers of the G7. As the situation with COVID-19 
became more apparent, there was a focus on reform of the WHO. 
Those conversations continue. And some of the countries have 
asked us the same question. It is in the interest of the United 
States, whether or not we are a member of the WHO, to have a 
WHO that performs better.
    Senator Menendez. Well, I appreciate your lengthy answer, 
which is a non-answer, as far as I am concerned. The reality 
is, you have not made it clear to me how you are going to 
effect change in the WHO when you have terminated your 
relationship.
    Let me ask you one other question. If we create a new 
Global Trust Fund at the World Bank--as I understand it from 
reading Senator Risch's bill that is what it would do--would we 
just be going it alone? The rest of the world, they may be 
seeking change at the WHO, but they are behind the WHO. So, 
help me understand why other countries would now support a new 
mechanism at the World Bank. Would this not just create a 
parallel mechanism to the World Health Organization?
    Mr. Grigsby. Senator, we just received a copy of the bill a 
couple of days ago, and I know our team is looking at that. I 
do not know that that would be the case. In terms of, for 
example, HIV/AIDS, there are multiple organizations that have 
been created, and I believe that they very much complement each 
other. I assume that the Senator's proposal would be in that 
same spirit.
    Senator Menendez. Well, we look forward to your further 
analysis of the bill, because that is what it seems to me.
    Let me close.
    Mr. Richardson, I know that you have talked about the 
generosity of the United States. I would just say that, if I 
look at the President's proposals for global health in fiscal 
year 2020, which is more than a 20-percent decrease in the 
foreign affairs budget, including a 28 percent cut to global 
health programs at AID and the Department of State, and, 
similarly, the proposal for FY-2021 includes, by some 
estimates, a 34 percent reduction to the State Department and 
USAID's global health funding, and the budgets of the President 
for the last 3 years, had they been enacted, the U.S. would 
have, by some accounts, $7 billion less to spend on 
humanitarian assistance in the last 3 years. So, to the extent 
that the American people have been generous--and they have--it 
has been because the Congress of the United States has put 
forward these funds, not because the Administration has 
proposed it. And I have serious concerns, which I will wait for 
the second round, as it relates to the actual delays in the 
obligation of critical humanitarian aid. We have heard, from 
many partners, that up to 10 weeks in delay. I do not think 
that there is a good reason for that. But, I look forward to 
exploring it with you.
    Senator Johnson.
    Senator Johnson. Thank you, Mr. Chairman.
    This is a crisis that is really driven by, and really 
defined by, certain data points, certain metrics. Moving 
forward, if we are really going to respond properly, I think 
there are certain metrics that I think we have to key in on. I 
just kind of want to ask some questions about that.
    If you look at recent past viruses, different outbreaks--
H1N1, I am not a doctor, but I view that as a flu. Numbers I 
have seen, about 60 million Americans were affected by that, 
200 million globally, but it was not particularly deadly. 
Ebola, I think, all told now, about less than 50,000 people 
have been infected with Ebola. It is about a 40-percent 
fatality rate. MERS was, I think, about 2500 people, about a 32 
percent fatality rate. SARS, less than 10,000 people, and about 
a 10 percent fatality rate. Is it safe to say, Mr. Grigsby, 
that early on, in December, when this first surfaced in China, 
the WHO was looking at this, Dr. Fauci was looking at this, we 
were hoping that this type of new virus would be something 
similar, on the order of MERS and SARS, where, you know, it 
might be pretty deadly, but it was not going to spread that 
much? And I think my main point is, is the main metric there 
the transmission rate? And how quickly can we really obtain 
information on transmission rate in a new virus that we have 
never even seen before?
    Mr. Grigsby. Well, Senator, I think you have hit upon the 
problem. And I sort of wish Dr. Fauci were here to answer your 
questions. He is a lot more knowledgeable than I am.
    But, again, the point is, is that it was a novel 
coronavirus. And there are other coronaviruses that we have 
dealt with. SARS is an example. So, that is really the only 
thing that you could go back to and look at.
    COVID-19 is not SARS. It behaves differently. But, you do 
not know that until you get into it. And, frankly, the 
scientists are still learning a lot more about it, and will be, 
I am sure, for years. That makes it very difficult to respond 
to.
    Ebola is a scary thing. The mortality rate is high. It is 
very difficult to deal with. But, at this point, there has been 
a lot of experience in dealing with that. There have been new 
tools that have been created, like a vaccine that is effective, 
and therapeutics that are effective. But, early on, that was 
not the case. But, once you deal with these things, you become 
better at it, you learn more about it, and that is what we are 
in the process of doing.
    Senator Johnson. We have obviously now seen the economic 
devastation caused by, you know, global and national shutdowns. 
I think we have to take that into effect, the human toll of 
that, as well. I think we are starting to understand that, the 
devastating human toll of what has happened to our economies.
    Early on in these models--for example, the Imperial College 
of London, I have read the reports, but the one that really 
drove so many of these shutdowns--in the first report, the 
introductory summary estimated, without mitigation, 7 billion 
people would contract coronavirus. Is that not an 
impossibility?
    Mr. Grigsby. I confess to you, sir, that I am not an expert 
on those models. We have people at CDC and NIH and other places 
that are. We would be happy to bring up those folks and talk 
with your staff. There is a whole industry that deals with 
these models.
    Senator Johnson. I guess, my point being is, what models 
are we relying on to drive policy? We need to take a serious 
look at that, and we need to take a serious look back at what 
drove so much of this economic devastation. And, you know, 
eventually we will find out what the infection fatality rate 
is. Right now, according to the Oxford Center for Evidence-
Based Medicine, they are saying it is going to be somewhere 
between 0.1 and 0.41 percent. A bad season of flu is about 
0.18. If we are moving forward, in terms of, you know, what our 
response is going to be, we need to identify these metrics that 
drive the type of policy--first of all, to address the health 
situation, but also understand what is happening with our 
economy as we employ these shutdowns.
    Mr. Grigsby. Right. You are right, Senator. And again, I 
would just go back to the fact that this is a novel 
coronavirus, something that had not been seen in humans before. 
So, some of it is educated guesswork. There is no doubt about 
it.
    Senator Johnson. Thank you, Mr. Chairman.
    Mr. Richardson. Senator, if I may, just----
    The Chairman. Go ahead.
    Mr. Richardson. I think your point is exactly right, sir, 
and I just want to sort of reemphasize that this idea of having 
an early-warning tracking system--we have early-warning 
tracking systems for families, right? That is an existing 
program. It is run out of USAID. It is phenomenal. But, we do 
not have effective early-warning systems and data-tracking 
systems for outbreaks going into a pandemic. This is a huge 
vulnerability and a gap in the strategic system, and it is not 
a gap currently filled by the WHO or any other system out 
there, and it is something, I think, we certainly need to look 
at.
    The Chairman. We will take note of that.
    Senator Johnson, thank you for bringing this into the area 
of the economics. It is certainly something that needs to be 
considered as we go forward with the bill and the metrics that 
need to be developed to look at that.
    Senator Kaine.
    Senator Kaine. Thank you, Mr. Chair.
    And thank you, to the witnesses.
    I want to follow up on Senator Johnson and ask you some 
questions about data.
    So, on January 21st, the United States and South Korea both 
had their first reported case of coronavirus. And, on that day, 
the unemployment rate in both nations was fairly similar. It 
was 4 percent in South Korea, and it was a 3-and-a-half percent 
in the United States. On March 3rd, we had a hearing in this 
room, I believe, a HELP Committee hearing, not a Foreign 
Relations Committee hearing--with a number of the political 
appointees dealing with coronavirus. And on that day, South 
Korea had experienced 28 deaths, and the U.S. had experienced 9 
deaths, the coronavirus, and the unemployment in both nations 
was also, essentially, similar.
    Today, South Korea has lost 280 people to coronavirus, and 
the United States has lost, now, more than 119,000. The South 
Korean unemployment rate has risen to 4.8 percent, while the 
U.S. unemployment rate has risen to 13.3 percent.
    South Korea has one-sixth of the population of the United 
States. Their GDP is one-twelfth that of the United States. 
South Korean per-capita income is less than two-thirds of U.S. 
per-capita income. South Korea is every bit as much affected by 
any missteps of the WHO and every bit--and possibly more 
affected by Chinese missteps because of their close proximity 
to China and the frequency of travel between China and South 
Korea.
    Even with vastly greater resources, the United States now 
has a COVID-19 death rate per 100,000 population that is 80 
times higher--80 times higher--than that in South Korea. I know 
four people who have died of coronavirus. And our economy has 
been devastated by this crisis in a way that South Korea's has 
not.
    In a hearing on international response, I think it is 
important to look at other nations and ask, what did they get 
right that we got so wrong? So, I would like to ask our panel, 
how can America and the entire world replicate the more 
successful strategy that South Korea or other nations--Japan, 
Canada, Germany, Australia, New Zealand, Vietnam--utilized, as 
we go forward in fighting COVID-19 and preparing for the next 
pandemic?
    Mr. Grigsby. Senator, I am happy to start out.
    I think that many years are going to be spent taking a look 
at lessons learned. The World Health Organization just approved 
a resolution to take the first steps to do the first one.
    Senator Kaine. Is that a good thing? Does the U.S. support 
that?
    Mr. Grigsby. Yes, we did. In fact, we negotiated--the EU 
sponsored it. We worked very closely with them to ensure that 
that language was, in fact, in there and was not weakened by 
other states that were seeking to weaken that language. And 
there were 140 other cosponsors.
    I have no doubt that, in our own country, there will be 
countless studies looking at this, and there will be lots of 
lessons----
    Senator Kaine. Can I ask you, are you guys looking at this? 
Are you guys analyzing the experience of nations whose death 
tolls are dramatically less than the United States, and asking 
yourselves, What do we need to do better right now--not years 
of analysis; we are still fighting COVID-19--what do we need to 
do better right now, and what do we need to do better to 
prepare for the likelihood of future pandemics?
    Mr. Grigsby. Yes, sir. I mean, we have folks at the CDC in 
Atlanta who do just that. As you mentioned, you know, South 
Korea is a very different country than the United States, and, 
in fact, even their laws allow the government to----
    Senator Kaine. They are also similar to the United States 
in a lot of ways.
    Mr. Grigsby. Sure.
    Senator Kaine. They are an ally; big, messy multiparty 
democracy, densely urban, but also fairly rural. Every country 
is different than the United States in some ways, but South 
Korea is a country that has a lot of similarities to the United 
States, including a very close working relationship.
    Mr. Grigsby. And I think that all of us are going to have a 
lot to learn from the successes and failures of many countries, 
including what we have done in the United States. So, that is 
going to be happening for years on something like this that has 
had this massive of an impact.
    Senator Kaine. My time is close to the end, and I do not 
want to go over, but, Mr. Chair, I think a hearing on best 
practices, in this committee, and maybe a combined hearing 
between this committee and HELP would make a lot of sense, 
because there are things we have done that we could teach 
others, but there is an awful lot of things that other nations 
have done that we should learn. To be true to what you say, we 
are having this hearing to prepare for the near-certainty of 
future epidemics. We should be trying to learn those lessons as 
quickly as we can.
    The Chairman. Yes. You know, Senator Kaine, I could not 
agree with you more. It seems to me, though, that the answer to 
the question is relatively straightforward, and that is, how 
tough does the government want to be, as far as locking people 
up so they cannot spread the disease? That is a debate that is 
probably going to be pretty heated, I would think, depending 
upon the culture of where you come from. But, it needs to be 
explored. There is no question about it. Because the question 
is, do you want to go ahead, as Senator Johnson and others have 
pointed out, that if you compare this to the flu, we go through 
this every year with the flu, and we take hits as a result of 
that. What are we willing to do in a pandemic like this? And 
that is a very fair discussion----
    Senator Kaine. And I think, Mr. Chair, just to respond, 
South Korea is not a China or a Vietnam, it is not an 
authoritarian state, but a democracy. And so, yes, the 
government did some things--early testing, and then, if people 
are sick, contact trace, isolate and treat those who are sick. 
But, by doing that--and that was heavy government action--they 
did not have to shut down the economy.
    The Chairman. Yes.
    Senator Kaine. So, that is why the unemployment rate went 
from 4 percent to 4.8 percent, where ours went from 3.5 to 
13.3. So, you have tough government action on the testing and 
contact tracing, meant that they needed to do less dramatic 
government action on shutting down the economy. And other 
nations are going to have other experiences. And then, we have 
done things that we can--in, especially, our research 
institutions, that we could share with others. But, it makes my 
skin crawl to think of--first case on the same day, similar 
tiny number of deaths in March, and now 280 deaths in South 
Korea--and 120,000 in the United States. And so, I know we can 
do better. And this committee, with the Global Health 
Subcommittee, together with the HELP Committee, are the places 
where we ought to be hashing that out, learning those lessons.
    The Chairman. Yes. Fair points, across the board. I think, 
also, a person pointed out to me the fact about how important 
wearing a mask is in social interaction. And this person also 
pointed out that, culturally, around the world, there are 
people that are very comfortable wearing a mask. In some 
countries--I was told by this person, who is an academic, as 
far as these things are concerned--that, in many countries, 
people will wear a mask if they have got a cold or if they have 
a cough. We never see that in our Western civilization here. 
But, yet, in other countries, that is the case. So, you are 
right. I mean, these things absolutely do need to be looked at 
further.
    Dr. Barrasso.
    Senator Barrasso. Thank you very much, Mr. Chairman.
    Mr. Grigsby, I believe the World Health Organization failed 
the American people, failed the world during the coronavirus 
crisis, refused to call out China for its disinformation 
campaign, lack of transparency, the cover-ups. You made 
reference to some of this. From the start, I believe the World 
Health Organization blindly accepted China's leaders' false 
reporting and understated the threat of the disease. They 
repeatedly praised China for transparency and spreading 
accurate and misleading information. January 14th, we know they 
pushed out a false information that there was no evidence, they 
said, of human-to-human transmission of the virus, despite 
clear evidence to the contrary.
    But, it continues. I mean, just last week, the World Health 
Organization announced that asymptomatic spread of the 
coronavirus was rare, and then that made the national and the 
international news for a day. And then, the next day, they had 
to walk back the claim, so they had to change things. Lots of 
inconsistencies. But, this is not the first instance of the 
World Health Organization's failure to prevent, detect, or 
respond to a severe infectious disease crisis. As a doctor, I 
always thought that the World Health Organization's 
mismanagement of Ebola and the delay in declaring it an 
international emergency--and I called them out publicly about 
it back in, I think it was 2014.
    So, due to the leadership failures and the repeated 
mistakes, I think it is time to reconsider the role that the 
WHO and its leadership play. I agree with the withdrawing of 
the funding. Reforms are needed. I agree that reforms are 
needed to ensure the accurate and transparent data-sharing to 
members.
    So, the question is, how do you do this? Another member of 
this committee said, what leverage do you have after you have 
withdrawn the funding? I think you have a lot of leverage, 
because if you say, ``You want the funding restored, you want 
us to come back and reengage, then give us the kind of 
credibility and engagement that is necessary.''
    Fundamentally, what do you see is the problem with the 
World Health Organization? Is it a lack of political 
commitment? Is it a lack of capacity or capabilities? Why are 
they continuing to fail to implement needed reforms?
    Mr. Grigsby. Thank you, Senator.
    Maybe if I could just talk a little bit about some of the 
reforms that we are discussing with other countries. And it 
goes beyond G7 health ministers, as well. As I mentioned 
before, this is not the first time. We have experienced this 
before with the World Health Organization. And, in fact, I made 
mention of the SARS earlier--when there were problems, again, 
in the West Africa Ebola crisis, that led to more reforms, the 
creation of the Emergencies Program at WHO. The Obama 
administration, at the time, actually had to redirect funding 
away from the WHO, because the WHO could not get its act 
together and even accept the money. So, that went for good work 
that was going on in those countries through private 
organizations.
    So, this sort of thing is not new. There is a big 
difference between the COVID-19 pandemic and how that has 
impacted the world and the West Africa Ebola crisis, which was 
more regionally focused. But, you know, we have had many 
encouraging conversations with other countries regarding the 
need for reform. I mentioned a few of those in my statement. 
And, really, you answered Senator Menendez's question better 
than I did. But, the fact remains that if WHO can get its act 
together, and can make the reforms, and can prove that it has 
independence from China, I am sure there is every possibility 
that the relationship that the United States has could be 
changed. But, the ball is in their court. And there are a 
number of reforms that they need to undertake. And we have, 
really, a remarkable amount of agreement and common ground with 
other health ministers that we are dealing with on the need for 
reform, notwithstanding our relationship with WHO. That is 
beside the point. So, the ball is in their court, and we hope 
that they will embrace these reform proposals.
    Senator Barrasso. Can I ask about the development of a 
vaccine? Can you please discuss the steps, Mr. Grigsby, that 
the Administration is taking to engage with our global partners 
to ensure that the vaccine can be developed and distributed as 
quickly as possible?
    Mr. Grigsby. Well, yes, sir. You know, we have our own 
projects that are going on, Operation Warp Speed, and we are 
investing a lot of resources in that. There are other efforts 
going on globally. We have collaborations and conversations, 
and share lessons learned, and provide technical assistance. 
So, really, we are rooting for all of the efforts. We are going 
to need more than one vaccine, and we are going to need more 
than one company, because we are going to really need 
vaccinations for everybody on Earth, ideally, and easy access 
to them.
    There are a lot of different things in play. We have folks 
whose job is to work on these. I am happy to bring up some 
folks, technical experts and scientists, who can speak with you 
and your staff. We are happy to do that anytime. But, there are 
a number of initiatives going on. And our Department and the 
White House, as well, they are in discussions with, I am 
assuming, all of them.
    Senator Barrasso. Thank you.
    Thank you, Mr. Chairman.
    The Chairman. Thank you.
    Senator Booker.
    Senator Booker. Thank you very much, Mr. Chairman.
    It goes without saying this pandemic has hit the United 
States of America pretty significantly, and, within that 
context, my State of New Jersey has seen the worst of this 
pandemic; and the lives lost, the families facing devastating 
grief, and the struggles that we have seen have been legion. I 
am grateful that it was already said in this committee that we 
have a serious problem--at a time that people were calling into 
question China's secrecy, we have a President that was praising 
China. At a time when people were demanding transparency from 
China, this President was coddling them and encouraging them in 
numerous public statements, in numerous tweets, and we were 
failing--as people in New Jersey were dying, we were failing to 
hold them to account for the challenges that were before them. 
And so, I continue to be concerned about our policies regarding 
China that go beyond tough talk, but to really working to get 
results. According to reporting, China appears, during this 
crisis, to have nationalized control of domestic production and 
international distribution of critical personal protective 
equipment. In early 2020, in response to this crisis, including 
that of the U.S. companies, such as 3M, which produce PPE, this 
is a significant challenge. Under their action of nationalizing 
their control, China required factories that make masks on 
behalf of American companies in China to produce masks for its 
own domestic use. Now, China is currently exporting more masks, 
and these exports seem to relate to political calculations, 
with the U.S. receiving less priority than other markets. 
China's mask diplomacy, or China's distribution of masks and 
medical equipment in order to curry favor, has been widely 
reported. I would like to really know, how is China, in your 
perspective--and maybe address this to Grigsby and Richardson--
how is China prioritizing their exports of PPE? And how is the 
U.S., in your view, benefiting or to the detriment of our 
country? And, really, the entire world saw the images of our 
healthcare professionals working without adequate PPE while we 
waited for China to release the supplies of PPE. What have we 
learned, as a nation, through the process, in the event that 
another surge of the coronavirus hits and we find ourselves 
with heightened demands and needs for PPE? I am very concerned 
that this problem still is ongoing and that the Chinese 
policies are still working at a detriment, at a significant 
detriment, to the United States of America, and we are not 
doing enough.
    So, I would like a response from Mr. Grigsby and Mr. 
Richardson, if possible.
    Mr. Grigsby. Thank you, Senator. I think your comments are 
spot-on. And I do not know that there are many silver linings 
to this terrible crisis. But, I think one of them is going to 
be, I can assure you, a reexamination of the supply chains. I 
believe that everything you mentioned is true, in terms of 
that. I can assure you--this is not my office that does this, 
but there are a lot of people, not only in HHS, but across our 
government, working very hard specifically on the supply-chain 
issue. It is a big issue. And thank you for raising that.
    Senator Booker. Thank you, Mr. Grigsby.
    Mr. Richardson.
    Mr. Richardson. Yes, thank you, Senator. I totally agree 
with you, and I agree with Garrett.
    When you look at China--and I would not just look at it in 
the context of COVID--but, if you look at their approach to 
foreign assistance generally, they have a really mercantilist, 
very strategic approach to what they do. They are looking at 
strategic medical--mineral rights. They are looking at 
strategic ports. They are looking at, you know, bribing 
officials in order to get their companies access to things. 
That is really the Chinese approach to foreign assistance, writ 
large. And I think it does set up a really great dichotomy 
between, you know, if you want to go with China and accept that 
type of assistance, you are going to go backsliding on your 
governance and your transparency, and it is not ultimately 
going to be the most successful for any of our partners.
    I think what the U.S. really offers with our donor 
partners--offers, really, a different solution of transparency, 
no-strings-attached assistance, and those types of things. It 
is a critical issue.
    Senator Booker. So, I am grateful. And I do not think we 
are sounding the alarm enough. We see the authoritarian regime 
of China working against our country, from currency 
manipulation to corporate espionage and stealing secrets. We 
have seen this behavior consistently in how they deal with 
foreign relations. But, now, in the nature of a pandemic, it is 
chilling to see that their actions and what they are doing is 
putting lives in our country at risk in the past, right now, 
and especially with the potential for a second wave. I am 
grateful you are echoing, Mr. Grigsby, what I have been saying 
in this committee, in the Small Business Committee, is the 
supply-chain issues are national security issues, and we need 
to be acting with bolder, far-greater action to protect our 
nation from this menace that seems to be the Chinese intention 
to undermine our safety, our health, and our well-being.
    I want to ask, very quickly, about wet markets, because I 
have great partnerships across the aisle. China CDC announced 
it found COVID-19 in samples collected in a wet market in 
Wuhan, China, in January. There is a new outbreak right now in 
Beijing, but China, yet again, in this outbreak, we see that it 
is still linking a lot of the challenges to wet markets. These 
live wildlife markets were also linked to the 2003 SARS 
outbreak. Scientists studying zoonotic diseases, diseases that 
jump between animals and humans, have pointed to the close 
proximity of shoppers, vendors in these markets, as they are 
being prime locations for the spread of these pathogens. And 
so, we know, from SARS, which I mentioned, Ebola, monkeypox, 
COVID-19, MERS, and more, jump from animals to humans. It is 
clear that wildlife markets that sell wildlife animals for 
human consumptions need to be shut down.
    Senator Graham and I sent a letter to the heads of 
international organizations, urging them to engage in efforts 
to shut down these markets. And so, very quickly, and then I 
will stop--and love to ask this question to Milligan and 
Richardson--is, how should the U.S. work through international 
organizations and the international wildlife community to 
increase the awareness of this risk and, really, to begin to 
take real measures to shut down and ban wildlife markets so 
that we do not see this challenge again? I am grateful to be 
working with Senator Cornyn, Senator Graham, and others, on 
legislation. But, to me, this has got to be an international 
priority. And I would love to get your thoughts on that.
    Mr. Richardson. Thank you, Senator. I appreciate those 
comments.
    State and USAID have really robust programs when it comes 
to preventing wildlife trafficking, environmental programs. And 
we have a fairly broad reach, although a lot of the countries 
that are the greatest offenders, like China--we do not have a 
lot of those types of programs in some of these countries. So, 
I do think we need to expand, not just in the development piece 
that Chris will have better insight in, but on the diplomatic 
side. I think that we have got to do a one-two punch here. But, 
working together, I think we can make real progress.
    Mr. Milligan. Thank you. And I think what this shows is 
that these issues are all interrelated. You cannot look with 
just a simple health focus. It is all interrelated. We have a 
tremendous opportunity now to build more commitment behind 
preventing wildlife trafficking, by action messaging on CITES, 
and by talking to many of the countries that enable this to 
happen about the consequences and the downstream effects. So, 
this is a tremendous opportunity.
    And going back to the whole sanitation issue that you 
raised, we are prioritizing many of our investments in water 
and sanitation hygiene, particularly for that reason, you know, 
that we can prevent the spread of this disease as it goes 
forward. So, Senator Booker, your point is well taken that 
these issues are all quite interrelated. But, we have an 
important ability now to message strongly and show these 
connections, which can help have a broader impact on these 
important issues, such as countering wildlife trafficking.
    Senator Booker. Thank you.
    Thank you.
    Thank you, Mr. Chairman.
    The Chairman. Thank you. Thank you, Senator Booker, for 
raising the supply-chain issue. That is certainly something 
that is critical.
    This ties in a little bit with what Senator Kaine was 
saying, and that is that one of the things that South Korea 
did, it had an all-of-government approach to this thing, and 
they shut down their supply chain out. They hung onto 
everything that they had. And what has happened in this is, 
there has been a real underscoring of the weaknesses that we 
have as a result of a lot of our manufacturing going overseas. 
And I think some of that manufacturing that is national 
security, and certainly a health challenge is a national 
security issue, like anything else. I have no doubt we are 
going to be looking at that as we go forward. So, thank you for 
that.
    Senator Murphy.
    Senator Murphy. Thank you very much, Mr. Chairman.
    In response to a question about global vaccine efforts, Mr. 
Grigsby said that we are ``rooting for these efforts.'' And I 
will, maybe, direct this question at Mr. Richardson, because it 
probably matters more what the Secretary of State thinks about 
this than the head of the CDC.
    Why should we just be ``rooting'' for these global vaccine 
efforts? In fact, we could be a part of these global vaccine 
efforts. In particular, there is one that is probably the most 
promising. It is CEPI, the Coalition for Epidemic Preparedness 
Innovations. All our allies are a part of it. It is, frankly, 
doing work, as we speak, with U.S. companies. The legislation 
that Senator Risch and I have would authorize the United States 
to become a partner with CEPI and put money behind that effort. 
So, what is the Administration's specific position on the 
wisdom of joining this particular global vaccine effort? It 
just seems to be a lot smarter for us to be at the table, so, 
if CEPI is the one that produces a vaccine, that we have 
something to say about where that vaccine goes and who gets it 
first.
    Mr. Richardson. Yeah, I appreciate that, Senator.
    You know, CEPI plays an important role, certainly. Gavi 
also plays an essential role. The Administration just made the 
largest pledge ever, for an American government, to Gavi, of 
$1.6 billion. So, I think our commitment to the international 
effort for vaccines is pretty strong.
    I would say that, if you look at what we have done--and a 
lot of this actually is on the HHS side--but, $4 and a half 
billion of--we have invested through BARDA. We have allocated 
$350 million for vaccine efforts, $1.8 billion for rapid 
acceleration of diagnostics. I think there is a lot of work 
that has already been happening in the U.S. Am I going to say 
that we should not coordinate more closely with our partners 
and allies around the world? Well, of course we should. That is 
a great commonsense approach.
    I will say--and I do not know if your question was leading 
to the EU Conference before--but, the U.S. has invested private 
sector and public dollars, over $12 billion so far into vaccine 
development and therapeutics.
    Senator Murphy. I do not deny we are spending a lot of 
money on vaccines. My question is not whether we are spending 
enough money. It is whether we are better off hedging our bets 
and making sure that we are not only doing that domestically, 
but we are also joining these international efforts. I hope 
that the Administration would be open to bipartisan 
congressional legislation pushing us towards joining CEPI. I 
think there is bipartisan support here.
    Mr. Richardson. Happy to look at that.
    Senator Murphy. Mr. Grigsby, I did want to turn back to 
this question of the WHO. I mean, I do think it is pretty 
stunning to hear from the Administration that the problem, 
early on, was that the WHO was giving cover for China to 
withhold information about the vaccine. And Senator Menendez 
covered this, and so we do not need to belabor the point. But, 
it was not that the President was simply saying nice things 
about China early on. On 40 different occasions, up to and 
including the month of April, the President of the United 
States was the primary global cheerleader for the Chinese 
response to COVID. He went out of his way, over and over and 
over again, to say great things about the Chinese response.
    Here he is on February 7th. This is far after we all 
recognized that China was withholding information. He gets a 
direct question at a gaggle, ``Are you concerned that China is 
covering up for the full extent of coronavirus?'' February 7th. 
He has an opportunity right here to say, ``Yes, I am concerned 
about it. They need to give us information.'' His answer is, 
``No. China is working very hard.'' And I have got 20 pages of 
this from the President.
    And so, it just belies reality to suggest that the problem 
was the WHO covering up China's response. The president of the 
WHO is not more power than the President of the United States. 
And we all need to acknowledge that.
    My question to you is this. The idea that we are going to 
try to affect WHO reform through the G7 is a new one. Can we at 
least just stipulate, for the time being, that it is harder for 
the United States to impact reform of the WHO if we are not a 
part of it, rather than a part of it? It might just be good for 
us to stipulate that. Whether or not you are going to try to 
pursue reform through the G7, or not, can we at least stipulate 
that it is more difficult for us to get the WHO to reform if we 
have withdrawn from it?
    Mr. Grigsby. Thank you, Senator.
    I think, as Senator Menendez or another Senator had 
mentioned, WHO is a member-state institution. Our conversations 
with the G7 are important, because it really represents the 
most significant and influential donors to the World Health 
Organization.
    I would say that if WHO and other countries do not want to 
see the United States leave WHO, there is no doubt about that--
it is important for WHO to embrace these reforms, and at the 
appropriate governing bodies, meaning for member states to take 
these reforms up and approve them.
    Senator Murphy. There is one country that is desperate for 
the United States to leave the WHO, and that is China. They are 
going to fill this vacuum. They are going to put in the money 
that we have withdrawn. And, even if we try to rejoin in 2021, 
it is going to be under fundamentally different terms, because 
China will be much more influential because of our even 
temporary absence from it. And any other construction of 
reality is just putting the United States in a very, very 
dangerous position.
    Thank you, Mr. Chairman.
    Mr. Grigsby. Well, I guess I would say to that, sir, that 
the U.S. has been the most generous donor to WHO, really, since 
the beginning. It has been remarkable, the increase in China's 
influence within WHO, really, over a long period of time. That 
has been with the United States in WHO and being the most 
generous contributor to WHO. So, the President made a bold 
decision. There is no doubt about that. Personally, I hope that 
it will get the attention of the leadership of the World Health 
Organization, and that the scenario you just described would 
not come about. That is at least my hope.
    Senator Murphy. I would just, finally, note, we were 
continuing to fund the WHO for the last 3 years, but we left 
our seat on the board vacant. So, it does not take a lot of 
imagination to figure out why China was able to get more 
influence if we were sending money but not sending anybody to 
sit on the governing board. So, we invited--listen, I am not 
defending the fact that WHO has gotten closer to China, but, we 
essentially invited the Chinese to step in and fill the shoes 
of the United States, given the fact that we were not sitting 
on that governing board.
    Mr. Grigsby. Senator, I actually have something to do with 
that, so I would like to respond to that.
    I am actually the alternate board member, and I am sure I 
do not do as nearly as good a job as a Senate-confirmed person, 
but that seat was not vacant, I assure you. And, in fact, 
Ambassador Bremberg or his predecessor, the Ambassador in 
Geneva, they are always there to fill that seat. And Dr. 
Giroir, who is the Assistant Secretary of Health, he was 
actually nominated--I think it was 2017. So, he was nominated a 
long time ago, and we sure do wish we could have had him 
confirmed sooner, but he was just confirmed a couple of weeks 
ago. He was nominated last year, and had to be re-nominated 
again this year.
    Senator Murphy. All right. Well, I will not get into an 
argument over whether it is more effective to have Senate-
confirmed positions, or not. I would, obviously, argue that it 
is.
    I am well over my time. Thank you, Mr. Chairman.
    The Chairman. Thank you, Senator Murphy.
    Mr. Grigsby, I can tell you that I have got contacts with 
the WHO, and your suggestion that our talk of withdrawing and 
withdrawing funds might get their attention. I can assure it 
has gotten their attention. And it has probably been your 
experience, too, but it is clearly my experience. So.
    In any event, we want to look forward, as opposed to 
backward. And we are going to talk about it in a few minutes. 
But, before we do that, Senator Cardin.
    Senator Cardin. Well, I hope I am looking forward.
    Mr. Chairman, thank you very much for holding this hearing.
    Let me thank all of our witnesses for their service to our 
country.
    On global challenges, U.S. leadership is indispensable if 
we are going to have the type of outcome that is in the 
interest of the United States, in our security interests. And 
this committee knows that best. So, that is why I was very 
pleased to see that we are holding this hearing.
    It is through U.S. leadership that we have a safer world, a 
more democratic world, and a healthier world. So, many of us 
are very concerned as to how the United States responded to 
this global pandemic. We have seen inconsistent information 
coming out from the White House--and that is being kind to the 
President--on a lot of the things that he has done in regards 
to this pandemic. We have not seen the type of preparation or 
response to the pandemic that would be used as a model for the 
world to respond. I think Senator Kaine pointed out that pretty 
clearly in his questioning.
    This is not an isolated example of the Trump administration 
in regards to global affairs. I could point to the immigration 
policy of this country. And I was very proud that the Supreme 
Court ruled the President's actions in trying to end the DACA 
program were, in their words, ``arbitrary and capricious.'' 
But, we also could talk about the President's trade agenda that 
initially put us at odds with our trading partners, our 
traditional trading partners, rather than trying to isolate 
China. Or the United States pulling out of the Paris Climate 
Agreement--the only country in the world, basically, to pull 
away from that. And now the pandemic.
    So, my question starts off with the effectiveness of U.S. 
global leadership on this pandemic. When other countries look 
at what is being done here in the United States, how much 
influence do we really have in the behavior of other countries? 
Because they look at what is happening in the United States, 
they see the President holding a political rally, bringing lots 
of people together, against the advice of the public health 
officials. So, how can we complain about what is going on in 
other countries--and my question is going to deal specifically 
with some of our largest countries in our hemisphere who have, 
at least publicly reported that their cases of COVID are very 
much underreported, and they have not taken the steps that 
public health officials believe are necessary in order to 
contain the spread of COVID-19? This is our hemisphere, and we 
know this is a global pandemic. How much influence do we really 
have? And how much are we concerned with what is happening in 
our own hemisphere, with other countries that are 
underreporting COVID-19 and have not taken the steps that 
public health officials believe are necessary in order to 
contain this virus?
    Mr. Richardson. Yes, Senator, I can start that. I 
appreciate that question.
    You know, we are really, truly committed to the western 
hemisphere. I think we just announced another $250 million to 
be turned on for the Northern Triangle countries. Our 
commitment to Colombia is unprecedented. Mexico----
    Senator Cardin. I am trying to limit this to COVID-19, if I 
can.
    Mr. Richardson. Sure. Yes.
    Senator Cardin. And you might want to also point out that 
Congress appropriated almost $2 billion of aid to deal with 
COVID-19. Can you tell me how much of that money has actually 
been spent, and where it has been spent?
    Mr. Richardson. We can go and look exactly at the 
obligations by country----
    Senator Cardin. Not obligations. How much has been spent?
    Mr. Richardson. That is how much has been spent.
    Senator Cardin. Spent.
    Mr. Richardson. Yes. So----
    Senator Cardin. Can you give me a range of that 2 billion, 
how much has been spent?
    Mr. Richardson. Yes. So, Congress has appropriated $1.6 
billion for State and USAID. So, I can speak to that piece. We 
have committed about 1.3 billion. Of that, we have committed 
almost 200 million for the western hemisphere----
    Senator Cardin. And you say ``committed.'' The money is 
actually out, and it is being spent?
    Mr. Richardson. We have identified which project----
    Senator Cardin. I understand you identified. How much of 
that has actually been spent?
    Mr. Richardson. So, it gets down to the obligation rates, 
which--USAID actually does their own obligations. I will turn 
to Chris to answer specifically. But, in general, we have 
obligated almost over 500----
    Senator Cardin. I am not interested--I want to know how 
much has been spent. This is a global emergency.
    Mr. Richardson. Right. So----
    Senator Cardin. Time is critical. How much has actually 
been spent?
    Mr. Richardson. So, obligation equals spending. It is when 
we actually hand over the money to the implementing partner to 
do the work. And so, that is the big picture. And then I can 
turn it over to Chris, if he has more details on, specifically 
for western hemisphere, what the obligation rate is.
    I will say, you know, one thing. So, each individual bureau 
and an agency handles their own obligations rate. So, I can 
speak for the State Department side. State Department has 
obligated every dollar that we have identified that we want to 
spend on COVID. So, that is happening. AID has a different 
mechanism and different approach to this, and so I can let 
Chris, sort of, elaborate. But, I think----
    Well, let me just do that. Chris, if you want to have this 
conversation.
    Mr. Milligan. Thank you, Senator.
    The easy answer, from our perspective, is that USAID has 
put over a billion dollars into the hands of people overseas to 
respond to the COVID-19. That includes the portion of the 
supplemental that we are still continuing to put in people's 
hands.
    Senator Cardin. How much of the supplemental has been 
spent?
    Mr. Milligan. More than 50 percent, sir. Of the portion 
that we control. But----
    Senator Cardin. And why has not all of it been allocated?
    Mr. Milligan. We have been allocating in tranches, because 
the virus moves very quickly, and if we--what we need to do is 
see where the virus is going, and then move ahead of it and 
prepare, and learn as we go.
    Senator Cardin. Do you need more money? Are you going to be 
requesting more money?
    Mr. Milligan. We are busy obligating the money that we 
have, and we are very thankful for the generosity of Congress 
in this. We are not through this pandemic, and we are learning 
a lot.
    One of the things I am most concerned about, sir, are the 
secondary and tertiary impacts. We are seeing a big rise in 
food insecurity. We are seeing a democratic backsliding. We see 
1.1 billion children out of school. We are alarmed about 
gender-based violence. So, there is a whole set of secondary 
and tertiary impacts that we will have to consider, going 
forward, sir.
    Senator Cardin. I just would ask that you would keep our 
committee informed as the money is actually spent, and the 
requests for additional funds, as you see the needs.
    Mr. Milligan. Yes.
    Mr. Richardson. No, absolutely, Senator.
    And just to pick up on what Chris mentioned. We have $35 
billion that is being spent every year on foreign assistance--
you know, much of it going to western hemisphere. We want to 
make sure that every dollar is spent in a COVID-sensitive way. 
Right? How do we make sure that our gender-based violence 
programming, our education programming, our health programming 
takes into effect of what is happening with the virus, right 
there, right then? And so, it is a really important 
conversation. So, as Chris mentioned, it is not just the 
supplemental. We are really trying to bring to bear all of our 
foreign assistance in order to help countries overcome this 
virus.
    Senator Cardin. Thank you.
    The Chairman. Let me follow up on Senator Cardin's 
question.
    On the 50 percent of the supplemental money that has been 
put out, has that been spent on the primary effects of COVID, 
or is some of it spent on the secondary and tertiary effects 
that you have quite properly and considerately brought up?
    Mr. Richardson. Yes, it is a mix. So, Congress has 
appropriated a certain amount of money for our Economic Support 
Fund, which is looking at that tertiary and secondary impacts. 
Primarily, most of our resources are coming in the form of both 
global health and humanitarian, which do focus more primarily 
on the actual virus and providing critical medical supplies, 
training healthcare workers, looking at best practices, those 
types of things.
    The Chairman. Thank you so much.
    Senator Shaheen.
    Senator Shaheen. Thank you, Mr. Chairman.
    And thank you, to our panelists.
    I would like to go back to China. There has been a lot of 
discussion about China and their role, in the hearing today. We 
have seen a concerted effort from China to counter any negative 
narrative that may develop in the international media and 
within countries on China's role in the pandemic. And I would 
say, given the discussion this morning, they have been pretty 
successful. They have demonstrated a clear willingness to use 
their resources, including the manufacturing of personal 
protective equipment, to realign national sentiments in 
countries that may otherwise be inclined to critically examine 
China's response to the coronavirus. In fact, the Center for 
Strategic and International Studies released a report earlier 
this month that surveyed political elites across Southeast Asia 
and found that China is gaining ground on political influence 
and far outstrips the U.S. on economic influence in that 
region.
    So, I have two questions for you, really. One is, how does 
the lack of U.S. leadership on the pandemic response create a 
vacuum that allows China to better develop that narrative, 
where they are the provider, helping countries with needed 
resources and expertise? And, secondly, how does the pandemic 
contribute to this dynamic in Southeast Asia in a way that has 
a negative impact on the United States and our role?
    Mr. Richardson. Yes, I appreciate----
    Senator Shaheen. I am happy to have whoever wants to answer 
it.
    Mr. Richardson. I can start, and then I can pass it on.
    I mean, I just totally agree with your premise of your 
question. I mean, the reality is, China has used this pandemic 
to advance their strategic interests around the world. As I 
mentioned earlier, it does need to be seen in the context of 
their larger efforts. I think we have a lot of work to do, 
especially on the public diplomacy side, to--one, to counter 
misinformation, and our Global Engagement Center does a great 
job of doing that, and also providing----
    Senator Shaheen. Well, let me--I am sorry to interrupt, 
but----
    Mr. Richardson. Of course.
    Senator Shaheen. --let me just ask you, Why do you think 
that is? Why have we been slow? Has it been some of the 
statements that were read, from the President, that suggest 
that we have been slow to recognize what was happening in 
China?
    Mr. Richardson. No. Actually, I think what you are seeing 
is that the United States has outspent China, time and time 
again, both in its everyday foreign assistance--right? China 
spends 400 million or so on foreign assistance, and we are at 
35 billion. I mean, they are just not a significant player when 
it comes to what we would consider to be effective foreign 
assistance. They spend all of their resources trying to build 
up strategic ports and to engage in bribery and other aspects. 
And so, I think it is an asymmetrical challenge, from a 
development perspective, and we need to develop asymmetrical 
responses, accordingly.
    And, you know, Congress was really smart in last year's 
appropriations bill. They established what is called the 
Countering China Incentive Fund, and we are going to be 
spending $300 million through a bottom-up process, trying to 
develop best practices across the world to say, How can we 
effectively counter China in Djibouti and in Malawi and in El 
Salvador? This is not a Southeast Asia problem, as you know. 
China's influence has dramatically shifted, and the next 
battlefield is Africa and western hemisphere. And we want to 
position ourselves in order to be able to be, one, the partner 
of choice, always; and two, remind people of the everyday 
commitment we have been making to countries over the past 40 
years. We have been there. We have stood with countries through 
thick and thin. As I said, we have invested $500 billion just 
over the past 20 years.
    Senator Shaheen. Well, I agree with that. But, a lot of 
that 500 billion has not been in humanitarian and economic 
development aid, is it? And when you are counting that 500 
billion, are you not counting the military aid in that, as 
well?
    Mr. Richardson. Yes. So, about 25 percent of--the way that 
our budgets work, about 25 percent of our foreign assistance is 
security assistance. And that is not just military, that is 
also law enforcement----
    Senator Shaheen. Right.
    Mr. Richardson. --and those types of things, 25 percent is 
global health, 25 percent is humanitarian, and 25 percent is 
everything else.
    Senator Shaheen. So, given that, why do you think we have 
not been more successful and China has been successful?
    Mr. Milligan. I would like to, please. I have been working 
in development for 30 years, and most of that time I have been 
overseas. And yes, we have seen the quick increase in Chinese 
influence. But, we are also seeing that China is not now as 
successful, in many ways. There is a lot of buyer's remorse and 
more understanding that Chinese investments come with strings 
attached. The supplemental that we are implementing has a very 
important public diplomacy side that really shows American 
leadership. And countries overseas are turning to us and to our 
embassies for leadership on this issue.
    Senator Shaheen. So, can I--I am sorry to interrupt again, 
but I am out of time, and I just want to get an answer to the--
what has the pandemic done to allow China to increase its 
influence, as opposed to our reaction globally to the pandemic, 
which does not seem to have produced a similar response to 
American aid?
    Mr. Richardson. Yes. I mean, that is a tough question to--
obviously, to answer. And we would have to go country-by-
country to really determine. Every country is unique in how 
they approach it and how they think about Chinese assistance. 
Most countries are willing to accept face masks, or whatever, 
from China. But, to Chris's point, they often then go around to 
us and say, ``Hey, is this financing deal from China any 
good?'' That we are the trusted partner in choice, even though 
we have seen China really accelerate. But, if you look at their 
investments, even in COVID, versus what the U.S. has invested, 
it pales in comparison. I think they have just really focused 
on getting those headlines.
    Senator Shaheen. Well, let me just point out that the State 
of New Hampshire was able to get personal protective equipment 
from China when we could not get it from the United States or 
from FEMA. So, I think we need to examine what is happening 
there and what we could be doing better in order to address the 
fallout from the pandemic.
    Thank you, Mr. Chairman.
    The Chairman. Thank you, Senator Shaheen.
    Now, the tough questions. If you guys were sitting here, 
each of you, one at a time, what would you do to construct a 
system for the future? Would it be to rehabilitate WHO, to 
reform WHO, to create a new division of WHO, to restructure its 
management? Would it be to create a new international agency? 
Would it be to use something else, like CDC, or what have you, 
to construct a system as we go forward?
    I want to say that Senator Menendez raised a very 
legitimate question about parallel spending in another 
organization. And I think the last thing anybody here wants to 
do is to create more bureaucracy, as opposed to an effective, 
nimble response to this in the future.
    And so, give me your thoughts. I guess we will go right 
down the line.
    Mr. Richardson, you are up.
    Mr. Richardson. Thank you, Chairman.
    You know, whenever you deal with these challenges, I always 
want to make sure we are thinking about what problem we are 
trying to solve and what results that we are looking for. The 
solution, and the specifics about the solution, will naturally 
come, and that is through the legislative process. The 
Administration has yet to finalize its own proposal in this 
space. But, let me say that--a couple of things.
    You know, first and foremost, having really clear 
leadership and coordination function is essential. And, as I 
said, coordination does not mean control, it means empowerment. 
We should not be--you know, the State Department should not be 
doing global health programming. That would be a terrible 
duplication of efforts, and really takes away from what CDC and 
USAID does. But, the State Department also has global reach, it 
has embassies in nearly every country in the world. And it has 
a natural coordination function that is essential.
    The other gaps into the system that we have seen in both 
the domestic and the international systems is data-tracking, is 
built-in accountability. How do we create true accountability 
into the international system to hold countries accountable for 
not meeting minimum standards? How do we make sure that we are 
encouraging countries to use their own resources in a 
coordinated and systematic way that allows us to better share 
data, to be able to create early-warning systems? And how do we 
bring the very best of our private sector and the U.S. 
Government to work together? So, those are a couple thoughts.
    The Chairman. Those are all good questions, but not much of 
an answer. What--who--when the fire alarm goes off, who 
responds?
    Mr. Richardson. The State Department is the functional lead 
for foreign policy for the United States.
    The Chairman. How about for the world?
    Mr. Richardson. For the world, sorry. The CDC is 
responsible for outbreaks or for public health emergencies. 
USAID leads on complex crises. So, each one of us has our 
natural roles or responsibilities. And so, I would guess I 
would encourage as how we can pull all of our expertise 
together in order to solve the problem.
    The Chairman. So, the criticism has been made both in this 
committee here, and for a long time, that the WHO fell down on 
the job when it was obvious that there was something 
developing. Should they be the ones to undertake this in a 
fast-moving pandemic like this, or should there be a different 
agency that does that, that shines light on it, that attacks 
it--that goes and gets it? Who should do that?
    Mr. Richardson. I appreciate that. I do not think that--
look, the WHO has failed the world on multiple occasions. The 
last Administration saw the same thing with the Ebola crisis. 
We have now seen this with the COVID crisis. You know, when 
this problem has been brought to us before--this is not the 
first time we have had to think about, can the WHO do HIV/AIDS 
response?--for instance. I think the world said, ``No.'' It 
does what it does, but it is not going to be nimble, dynamic, 
respect burden-sharing, bring in private-sector actors, and be 
able to respond appropriately, with the highest-levels 
accountability. So, last time, the U.S. led to create the 
Global Fund in order to do something on the HIV/AIDS side. And 
so, I think that looking at where are the strategic gaps in the 
multilateral space, and how the U.S. can lead with our friends 
and partners and folks around the world in order to 
strategically fill those gaps, that will be an essential part 
of that conversation.
    The Chairman. So, is the Global Fund a model?
    Mr. Richardson. I think the Global Fund is a tremendous 
model. I think Gavi is also a tremendous model. I think there 
are a lot of things to be learned from lots of different 
options out there. I think really the key here is having 
worldwide reach, focusing on burden-sharing. You know, right 
now, the U.S. spends--40 percent of the world's global public 
health work comes from the American people. You know, we do not 
want to back away from that, but, as we take on this new 
challenge, we really need to surge in both private-sector and 
other donors into this space. And both the Global Fund and Gavi 
have tremendous models about how to do that well.
    The Chairman. Do you agree, Mr. Milligan?
    Mr. Milligan. Thank you, Senator.
    When I think about the future, I think we need to think 
about, how do we respond to the next pandemic, and how do we 
prevent, also, as well, an epidemic from becoming a pandemic? 
And then, how do we structure ourselves to effectively engage 
in that effort?
    We know that, in order to respond, we have to maintain a 
nimble and effective means to do so. We cannot have an 
overarching, top-down, bureaucratic bureaucracy engaging in 
that.
    The Chairman. We have learned that the hard way.
    Mr. Milligan. And we need to empower our people in the 
field, at the country-team level, because that is where a lot 
of the true coordination and expertise comes due. In order----
    The Chairman. Do you agree with Mr. Richardson that good 
models for the vehicle are the Global Fund and Gavi?
    Mr. Milligan. That depends, sir, because it is a model for 
what? I do not mean to be cheeky, but a----
    The Chairman. No, no. No, I--fair enough.
    Mr. Milligan. Because we are--Preventing is very different 
than responding. And those are different skillsets and 
different attributes. So, when I consider prevention, we know 
that a pandemic is not really a health crisis, it is a 
governance crisis. We know, where we have epidemics today, we 
have them because of state fragility. Where is Ebola today? 
Eastern Congo. Why does polio still exist where it exists 
today? It exists in fragile states, like parts of Pakistan and 
South Sudan. So, many times, an epidemic is really a governance 
crisis masquerading as a health crisis. And we need to make 
sure that we have an integrated approach.
    Senator Booker talked about the link between wildlife 
trafficking and zoonotic crossovers. So, when we look at 
preventing, there is a level of coordination that needs to take 
place. We cannot have a stove-piped, health-alone approach that 
creates another layer of bureaucracy. It has to be something 
that brings everything together.
    When we look at the response side, we have to maintain our 
nimbleness and our ability to actually engage in that 
international effort at multiple levels.
    The Chairman. And what agency, or what system--what do you 
recommend in that regard? Again, this is a global--for that 
part--when the fire alarm goes off and the fire department 
goes, who is the fire department?
    Mr. Milligan. Correct. We do not really have the Global 
Fund or Gavi set up to be the fire department. The Global Fund 
is responding to slow-moving epidemics, not----
    The Chairman. So, is there no model, then, that exists for 
the fire department?
    Mr. Milligan. The only model we currently have is the one 
that we are suggesting needs to be reformed. Currently, when 
there is a humanitarian assistance crisis--and I have led many 
of our interactions in them--we work through the U.N. cluster 
system. The U.N. actually sets and organizes the international 
parts together. It works well on a--for a regional stage. But, 
now we do not have a model for the pandemic stage. But, we have 
principles that we need to incorporate: flexibility, 
responsiveness, integrated approach, and one that brings the 
U.S. Government core capabilities that we share at this table 
into that together.
    The Chairman. Mr. Grigsby.
    Mr. Grigsby. Yes, sir. Thank you.
    I think Jim and Chris have stated it quite well. And I just 
want to thank Jim and colleagues at U.S. Agency for 
International Development. We have worked very closely with 
them in the development of these ideas. We appreciate that.
    We do support the coordinator concept being in a non-
implementing agency. I would just point out that most of what 
we are talking about is sort of foreign-assistance-related. The 
CDC, which would be the agency in HHS that would have the most 
to do in this area, it is not a foreign-assistance agency. It 
really is a technical-assistance agency. It operates 
differently than USAID, and, in fact, in different places. It 
does have 50 or 60 offices in developing countries. But, it 
actually operates in every country on Earth. So, rich 
countries, poor countries. It has all sorts of collaborations.
    But, we----
    The Chairman. Are you suggesting CDC is the model for the 
fire department?
    Mr. Grigsby. No, not necessarily. It just depends on what 
kind of fire that the trucks are going out to address, I guess. 
I mean, CDC is on point when it comes to the pandemics and 
disease outbreaks. There is no doubt about that. It oftentimes 
works very closely with U.S. Agency for International 
Development, particularly in the case--in eastern DRC is a 
great example--where there is a disease outbreak, and it is 
happening in a part of the world where there is a war going on, 
and many other problems, and it is, by definition, a complex 
emergency. So, we work hand-in-glove with USAID on that.
    So, I do not know that there is a one-size-fits-all sort of 
answer. Kind of case-by-case.
    The Chairman. Well, thanks.
    I was hoping to get a clearer answer to the question of, 
``Who is the fire department?'' Because that is what we are 
trying to do here. I get all the moving parts. I understand 
that. But, it seems to me that if there was a telephone number 
that somebody could call and say, ``Come and put out the 
fire,'' we want that agency. But, right now, what you are 
suggesting is, we give them a list of phone numbers to call. 
And I am not sure that that response makes sense.
    Mr. Richardson. Well, Senator, if I could just be very 
clear. There already is a number that countries call when they 
have a problem. It is our Ambassador. And that is really where 
our worldwide reach is really essential. And then, our 
ambassadors and chiefs of mission around the world, they are 
naturally lean on the technical expertise, depending on the 
challenge. Right? And I think as we start thinking about what 
the next pandemic looks like--is it fast-moving? Is it slow-
moving? Does it hit the developing world? Does it hit the high-
income countries? How does it work? What are the responses that 
we need to do? We just do not know. And so, making sure that we 
have true coordination that can pull the right levers at the 
right time in order to get to results, I think is essential. 
But, I certainly would not want to move away from the fact that 
we do have a worldwide reach today. People know who to call. 
And that is our chief of mission at the State Department. And 
we want to just look to strengthen that capacity.
    Mr. Milligan. And if I could add briefly to that. I would 
say that our ambassadors, they are the mayors, and the fireman 
is the Office of Foreign Disaster Assistance, which mobilizes 
rapidly through DARTS around the world, but currently 
responding to very complex humanitarian assistance all around 
the world, and complex emergencies. So, from our U.S. point of 
view, we have firemen. But, I think your question, sir, is--
should there be, and will there be, an international 
fireperson?
    The Chairman. That is what we are looking for.
    Senator Kaine, anything for the good of the order?
    Senator Kaine. Just to follow up, Mr. Chair, on your 
comment, and then one additional question.
    I will put myself firmly in the camp on this, in that I 
think we ought to stay in the WHO and use our leverage to push 
reforms. An enormously frustrating organization, like every 
international organization. The U.S. chose not--the Senate 
actually chose not to put the U.S. into the League of Nations 
when President Wilson urged, after World War I, that we do so. 
And the organization was ineffective. It was more ineffective 
because the U.S. was not involved. But, it was interesting, 
during the 1930s, long before World War II, FDR could see the 
League of Nations collapse coming, and basically said, ``It has 
been ineffective, but if it collapses, we are going to have 
recreate it. The world needs it,'' and started planning for a 
U.N. Those plans were delayed by World War II, but eventually 
Presidents Roosevelt and then Truman carried forward on it, 
recognizing the frustrations. The U.S. pulled out of the U.N. 
Human Rights Council, for some very legitimate reasons--a 
history of anti-Israel bias, and also a more broad history of 
hypocrisy. The member nations, you know, were fulminating about 
human rights and doing bad things. But, what has happened as a 
result of us pulling out--has it gotten better for Israel? No. 
And things that the U.S. advocated on the Council that did 
become global priorities--for example, fighting against 
discrimination against LGBTQ people, that would not have been 
part of the global human rights agenda if it were not for the 
United States. Those have gone unaddressed or sort of dormant 
with the U.S. not there.
    I think these organizations are enormously frustrating, but 
I think it always goes worse for the world if the U.S. is not 
involved. And I think it generally goes worse for us, as well.
    And so, I, like the President--whether it is with NATO or 
the WHO, lean on them, demand more accountability, more strings 
have to be attached. But, it just goes worse for the world if 
we are not there. I am so confident that the U.S. always had 
such a value-add to any organization that when we back away 
from it, (a) they lose the expertise that we uniquely have, and 
then, worse actors elevate their profile in ways that is not 
good for us or anyone else.
    Here is the question I want to ask you quickly, and it 
follows up on a conversation I think you were having with 
Senator Cardin. There was a New York Times piece in the last 
week about on-the-ground agencies feeling frustrated about the 
slow pace of the delivery of the March CARES Act and other 
money, this 1.6 billion, out into the field. And you have given 
us, basically, ``An awful lot of it has been committed, a big 
chunk of it has been obligated.'' And I just want to understand 
this, and maybe we will follow up in writing. But, 
``obligation'' means you put it in the hands of the 
organization--you know, the U.S. is writing a check to an 
organization. Is that the same thing as getting to the field? 
Might some of the complaints of these ground-level--you know, 
Church World Services, Save the Children, World Vision--might 
their complaints be, the U.S. has written a check to somebody, 
but there is a middleman problem, and it is not getting down to 
the ground yet? Because this was a recent piece in the New York 
Times, with groups named that were really frustrated. What is 
the source of their frustration? How can we solve it?
    Mr. Milligan. Senator, I think that their source of their 
frustration is that they want to act as quickly as we want them 
to act, as well. Without getting very bureaucratic, our 
different accounts have different abilities to spend money. 
Here are these concerns from these NGOs, our important 
partners. With the humanitarian assistance funding that we 
have, as soon as it is available, they can begin spending it. 
We contract directly with them. We do not go through middlemen.
    Senator Kaine. Okay.
    Mr. Milligan. As soon as it is available--this is a unique 
ability we have with these funds. And so, of the $535 million 
in humanitarian assistance funding, they can currently spend 
267 million, and, by July 17th, they can spend all of it. So, 
that is in addition to the--that is part of the overall funding 
that we have made available, which is a billion dollars that we 
have made available, which it is in their hands to do work now. 
We are looking at ways of actually streamlining the process. We 
are committed to fully obligate all this humanitarian 
assistance by the end of July.
    I have to tell you, these are extraordinary times. Previous 
to the global pandemic, we were running very large-scale 
humanitarian assistance efforts in very difficult places, like 
Yemen, Iraq, South Sudan, and Syria. And the global pandemic 
has also affected our own workforce, as well. But, we are 
adapting, and we are streamlining, and we are meeting the 
challenge.
    Senator Kaine. Thank you. Appreciate that.
    Thanks, Mr. Chair.
    The Chairman. Thank you, Senator Kaine.
    To our witnesses, thank you so much. You have been very 
patient with us. And this is a part of the puzzle that we are 
trying to solve, here. We appreciate your thoughts on it. We 
hope to hold a number of these hearings to try to get as much 
input as we can and then, as a committee, sit down and try to 
construct a bill that is going to move us forward and that, 
when this happens again--and I think we are all under the 
belief that it is going to happen again, hopefully later rather 
than soon--that we will be more ready for it. And hopefully we 
will have some legislation that will address that.
    So, with that, thank you again for your service, and thank 
you for attending this hearing.
    The committee is adjourned.
    [Whereupon, at 11:41 a.m., the hearing was adjourned.]
                              ----------                              


              Additional Material Submitted for the Record


             Responses of James L. Richardson to Questions 
                  Submitted by Senator Robert Menendez

    Question. The Administration provided a shipment of ventilators to 
Russia under emergency authority. Does the Administration remain 
committed to sanctions imposed on Russia in response to its election 
interference and illegal occupation of Crimea and aggression in Donbas? 
Would the State Department be willing to put out a statement towards 
that end?

    Answer. Our actions have sent a clear message to those who take 
part in malign Russian activity: they are on notice. If they continue 
to pursue election interference efforts, aggression in Eastern Ukraine 
and Crimea, human rights abuses or other threatening activity, they 
will suffer consequences. More broadly, the U.S. government has 
sanctioned more than 350 individuals and entities for their involvement 
in Russia's malign activities since January 2017.
    Most recently, the United States Delegation to the Organization for 
Cooperation and Security in Europe (OSCE) reiterated on July 2 that the 
United States does not, nor will ever recognize Russia's purported 
annexation of Crimea and that sanctions will remain in place against 
Russia until it fully implements its Minsk commitments and returns full 
control of the Crimean peninsula to Ukraine. We will continue to impose 
costs until Russia changes course, and sanctions will remain a key part 
of that.

    Question. A study published in 2016 by Yale University researchers 
found that there may have been as many deaths from HIV AIDS, TB and 
Malaria during the 2014/2015 Ebola outbreak in Guinea, Liberia and 
Sierra Leone as there were from Ebola because the health systems in 
those countries were overwhelmed, limiting access to health services. 
Recent reports indicate that as the COVID-19 pandemic continues, there 
has been a rise in the number of illnesses from preventable illnesses 
including polio, cholera and diphtheria. Have we provided funding for 
the Global Fund's COVID-19 mechanism?

    Answer. One third of the total resources at the Global Fund were 
provided by the United States government, as part of our regular 
contribution. We have not provided additional resources for the Global 
Fund's COVID-19 Response Mechanism (C19RM) beyond our regularly planned 
Global Fund amounts. The Global Fund Board, including the United 
States, approved up to USD $1 billion originally intended for HIV, 
Malaria and TB programs for needed adaptations due to COVID-19 
disruptions and for mitigating the COVID-19 pandemic through C19RM. The 
mechanism currently has been approved to be funded for up to USD $500 
million at this time.

    Question. WHO plays a leading role in the provision of vaccines. It 
is one of the main partners of Gavi, the Vaccine Alliance, which is the 
critical funding agency supporting vaccine programs in the world's 
poorest countries where the majority of the world's unimmunized 
children live: How is our pulling out of WHO going to affect 
vaccinations, and what impact will disruption of vaccine campaigns have 
on under five mortality?

    Answer. The withdrawal of the United States from the World Health 
Organization (WHO) will not have a deleterious impact on the ability of 
Gavi, the Vaccine Alliance, to reach children in lower-income countries 
with life-saving vaccines. While the U.S. Government (USG) is the 
third-largest donor to Gavi, historically none of the USG's funding to 
Gavi has gone to the WHO. Under the terms of the funding agreement 
between the U.S. Agency for International Development (USAID) and Gavi, 
Gavi primarily uses the USG's funding for the procurement and delivery 
of vaccines. I refer you to USAID for further details on its financial 
and technical support to Gavi and immunization programs globally.

    Question. Do the Department and USAID have the resources to help 
countries bring the pandemic under control? What does Congress need to 
provide in the next supplemental appropriations bill?

    Answer. The pandemic of COVID-19 continues to have an extraordinary 
impact on the people, countries, and partners that benefit from U.S. 
foreign assistance. We are grateful to Congress for the emergency 
supplemental funding already appropriated to the U.S. Department of 
State and the U.S. Agency for International Development (USAID). The 
Department of State and USAID are investing these funds to respond to 
COVID-19 effectively. We look forward to working with Congress to 
address the significant needs we continue to have to respond to COVID-
19, including the secondary and tertiary impacts of the pandemic.

    Question. I would like to better understand whether and how the 
Department and USAID's many understandable COVID-related reprogramming 
requests are interacting with overall expenditures and obligations, 
including the possibility of the unintended creation of significant 
unobligated balances. Congress needs to know if and how certain 
decisions made by the Administration--such as its decision to withhold 
funds to the World Health Organization--may be affecting departmental 
budgeting and financial management for the remainder of the fiscal 
year. I am also concerned that unforeseen complications related to the 
pandemic may create situations in which funds expire at the end of the 
fiscal year before they can be obligated, especially FY19 funds, unless 
the Department and USAID take action to prevent this from happening. 
What is the status of obligations for FY 19 funds?

    Answer. The U.S. Department of State and the U.S. Agency for 
International Development (USAID) recognize that the pandemic of COVID-
19 currently is affecting, or could affect, the ability to obligate and 
expend funds appropriated by Congress for Fiscal Year 2019. Following 
normal practice, State and USAID are working with U.S. Embassies and 
Missions throughout the world, and Bureaus domestically, to take the 
steps necessary to obligate all unobligated expiring resources 
prudently prior to the end of the Fiscal Year. Consistent with 
statutory provisions, State and USAID are continuing to transmit all 
required Congressional Notifications for expiring funds, and are 
committed to working to resolve any questions and concerns that the 
relevant congressional Committees of jurisdiction raise.
    State and USAID both expect to obligate all expiring funds by the 
end of the Fiscal Year, and we are monitoring obligations closely.

    Question. I would like to better understand whether and how the 
Department and USAID's many understandable COVID-related reprogramming 
requests are interacting with overall expenditures and obligations, 
including the possibility of the unintended creation of significant 
unobligated balances. Congress needs to know if and how certain 
decisions made by the Administration--such as its decision to withhold 
funds to the World Health Organization--may be affecting departmental 
budgeting and financial management for the remainder of the fiscal 
year. I also concerned that unforeseen complications related to the 
pandemic may create situations in which funds expire at the end of the 
fiscal year before they can be obligated, especially FY19 funds, unless 
the Department and USAID take action to prevent this from happening: 
Can the State Department assure me that the Administration will not 
seek to pursue a rescission, either by intent or by mismanagement, as 
we approach the end of this fiscal year?

    Answer. State and USAID plan to prudently obligate expiring funds 
for programs that advance U.S. foreign policy objectives. Consistent 
with normal practice, State and USAID are working with posts throughout 
the world and bureaus domestically to take the steps necessary to 
prudently obligate all unobligated expiring resources prior to the end 
of the fiscal year.
    We remain concerned about being able to obligate expiring 
International Military Education and Training (IMET) account funds by 
the end of the fiscal year as those funds support in-person training 
sessions that likely will not be able to occur due to the threat of 
COVID-19. The Department is seeking Congress's support to extend the 
availability for expiring IMET funding to ensure they do not expire at 
the end of the fiscal year.
    Consistent with required congressional notification processes, 
State and USAID are continuing to transmit all required congressional 
notifications for expiring funds and are committed to working to 
resolve questions and concerns raised by the relevant congressional 
committees.

    Question. On April 7, the President declared he would like to put a 
``powerful hold'' on WHO funding and on May 29, the President said the 
Administration plans to ``terminate'' the relationship. On April 8, 
Sec. Pompeo stated that the World Health Organization has ``to get the 
data, they have to share that data with the world's best scientists--
many of which are often located right here in the United States--and 
allow that information to be transferred freely so that we can have a 
transparent response that will save lives.'' This is an essential 
aspect of WHO's work, which has received praise from health experts 
here and abroad but would be significantly harmed if the U.S. withheld 
funding: In light of this statement, can you explain the guidance you 
gave to Sec. Pompeo? Can you detail the implications beyond the COVID-
19 response this hold would have?

    Answer. The WHO failed to uphold its responsibilities and grossly 
mismanaged the COVID-19 pandemic response. Even after the President's 
many public statements and his May 18, 2020 letter, the WHO has done 
little to respond to the Administration's serious concerns and repeated 
calls for progress and reform. I shared those views and my concerns 
about WHO with the Secretary.
    The United States accounts for more than 40 percent of total global 
health funding, and we have given more than $142 billion since 2001. 
Only about 4 percent of our annual global health budget is spent 
through the WHO. Our work in global health does not stop because we 
have halted funding to the WHO, and we are confident that we will be 
able to find qualified implementers for any voluntary assistance that 
was planned for WHO programs. Beyond the WHO, we have an extensive 
cadre of faith-based organizations, NGOs, contractors, and multilateral 
organizations that have the ability to implement health programs--for 
COVID-19 response and beyond. The State Department is committed to 
ensuring that we find trustworthy, accountable, results-oriented 
implementing partners on behalf of the American people, whose taxpayer 
dollars fund our foreign assistance programs.

    Question. In an April 8 press conference, Sec. Pompeo stated the 
need for the World Health Organization to complete ``the work they were 
designed to do.'' And yet the Administration has consistently delayed 
tens of millions in funding each year that Congress has appropriated to 
WHO so it could complete its work. To take one example of many, in 
Yemen, these delays coupled with a funding cut-off will mean that over 
2 million people assisted by WHO, that no one else is able to do, will 
no longer receive essential care support. This represents 25% of the 
total population in need to whom WHO has delivered lifesaving services 
in the last 2 years:

    Answer. Since the 1980s, the U.S. Government has paid annual 
assessed contributions to the World Health Organization (WHO) and many 
other U.N. specialized and technical agencies for a given calendar year 
with funds appropriated to the Contributions to International 
Organizations (CIO) account in the subsequent U.S. government fiscal 
year. WHO and other U.N. agencies have long since adapted management of 
their finances to accommodate this delay. Assessed funding goes 
primarily to headquarters operations, not programs and activities in 
specific countries such as Yemen. I would refer you to our Bureau of 
International Organization Affairs for more information on how funding 
for assessed contributions is managed. Congress has not appropriated 
any foreign assistance funds specifically for WHO.
    The population of the Republic of Yemen is extremely vulnerable to 
health threats after years of conflict. As COVID-19 spreads rapidly and 
overwhelms the country's collapsing health institutions, we are using 
all of the tools and resources we have available to help. We have made 
available supplemental funding and resources from the International 
Disaster Assistance account from FY 2020 to support the response to 
COVID-19 in Yemen. In addition, the U.S. Agency for International 
Development (USAID) is financing robust, ongoing programming in health 
and nutrition in the country, including through other United Nations 
agencies that can adapt as necessary to the pandemic.
    The United States remains one of the largest donors of humanitarian 
assistance in the Republic of Yemen. For years, the United States has 
funded emergency health programs in Yemen, as well as made investments 
in water, sanitation, and hygiene that have lasting impacts and help 
keep people healthy, stave off disease, and build capacity in health 
care. In FY 2019, USAID provided more than $26 million in emergency 
health funding, along with nearly $14 million for water, sanitation, 
and hygiene in communities affected by Yemen's conflict. These efforts, 
which include training health care workers, supporting medical 
facilities, and teaching safe hygiene practices, continue to help 
communities in Yemen to prepare for disease outbreaks and other health 
threats.

    Question. Diseases do not recognize borders, so challenges like the 
COVID-19 pandemic necessitate a global, collective response. The WHO--
through its high level of technical expertise and international 
legitimacy--is uniquely positioned to lead the international response 
to public health emergencies like the COVID-19 pandemic. From the 
outset of the crisis, WHO has been a critical provider of supplies and 
tests, distributing 1.5 million diagnostic kits and millions of items 
of PPE to dozens of countries; designed, refined, and distributed 
technical guidance for communities, hospitals, frontline clinicians, 
private sector partners, and public health authorities around the 
world; carried out public awareness campaigns in dozens of languages in 
149 countries; and, through its ``Solidarity Trial,'' has been working 
to enable rapid and accurate research on the effectiveness of potential 
therapeutics. People around the world--including Americans--stand to 
benefit from these types of activities:
    What effect will ``terminating'' our relationship with the World 
Health Organization have on these efforts? How can we hope to protect 
Americans from pandemic disease and other health challenges without a 
multilateral coordinating authority like the WHO?

    Answer. As U.S. leadership demonstrated in the Ebola and MERS 
outbreaks, our diplomatic, health security capacity building, and 
development efforts enable countries to develop tools for addressing 
infectious disease. Through these efforts, we filled gaps created by 
the WHO's inaction to prevent, detect, and respond to outbreaks 
immediately. The Administration is examining ways to leverage the 
expertise of key U.S. Government departments and agencies and the 
American private sector to rapidly deploy and deliver this essential 
support to other countries to prevent, detect, and respond to 
infectious disease outbreaks at their source. During the President's 
May 29, 2020 announcement that the United States will be terminating 
its relationship with the WHO, President Trump announced that the 
United States will be redirecting funding planned for the WHO to other 
global health organizations and urgent needs around the world.
    While the United States was by far the leading donor to the WHO, 
that funding represented a small fraction--just 4 percent--of our total 
funding to global health assistance every year. This year, it will 
represent just 2 percent of the health assistance the United States 
provides worldwide. The United States leads the world in health and 
humanitarian aid in an ``All of America'' effort and is committed to 
ensuring our generosity directly reaches people around the world. We 
account for more than 40 percent of total global health funding. Since 
2001, we have given more than $142 billion. Every day, U.S. global 
health funding prevents, detects, and treats HIV/AIDS, malaria, 
tuberculosis, Ebola, and other diseases. We give an average of $10 
billion per year--and this year, it will be double that as we surge to 
fight the virus around the world. The United States has allocated more 
than $12 billion that will benefit the global COVID-19 pandemic 
response; more than $2 billion of this has already been committed.

    Question. WHO has been on the frontlines of nearly every global 
health challenge over the last 70 years, combatting, containing, and 
eradicating some of the planet's most deadly diseases, viruses, and 
infections. While the world is rightly focused on defeating COVID-19, 
other health challenges confronting the world have not disappeared, and 
it is not in our interest to neglect them. These include WHO-led 
efforts to control and eliminate malaria, implement global disease 
surveillance for the polio virus in areas where U.S. government 
agencies do not have the capacity to reach, support measles 
immunization campaigns, and strengthen the health sector's response to 
HIV/AIDS and Tuberculosis. The loss of more than $400 million in annual 
U.S. funding threatens to upend these critical activities: What does 
our withdrawal from these multilateral initiatives say to our allies 
and partners around the world? Given how far-reaching and complex these 
challenges are, how can bilateral efforts even hope to begin to make a 
dent?

    Answer. The President's decision to terminate our relationship with 
the WHO in no way diminishes U.S. leadership on global health and 
combatting the COVID-19 pandemic. While the United States was by far 
the leading contributor to the WHO, those contributions represented a 
small fraction of our total funding to global health assistance every 
year. This year, it will represent just 2 percent of the global health 
assistance the United States provides. We account for more than 40 
percent of total global health funding. The United States has allocated 
more than $12 billion that will benefit the global COVID-19 pandemic 
response; more than $2 billion of this has already been committed. To 
fill in gaps in the WHO's handling of the HIV/AIDS pandemic, the United 
States set up a far more effective framework for HIV/AIDS called 
``PEPFAR''--the program started by President George W. Bush two decades 
ago that has saved literally millions of lives across the African 
continent and beyond.

    Question. With regards to U.S. arrears in our payments to WHO, in a 
June report to Congress, the State Department noted a number of 
possible impacts, including: ``1. Loss of vote or inability to be a 
member of governing bodies; 2. Diminished U.S. standing and diminished 
ability to pursue U.S. priorities; 3. Reduced U.S. ability to promote 
increased oversight and accountability through reforms that promote 
efficiency, cost savings, and improved management practices; 4. Reduced 
standing needed to successfully promote qualified U.S. citizens to 
assume senior management roles; and 5. Impairments of peacekeeping 
missions to operate, including addressing objectives that may directly 
impact the national security of the United States:'' Given your 
experience working with international organizations like the WHO, do 
you stand by these conclusions from your own Department?

    Answer. The Administration is examining ways to leverage the 
expertise of key U.S. Government departments and agencies and the 
American private sector to rapidly deliver essential support to other 
countries to prevent, detect, and respond to infectious disease 
outbreaks at their source. As the World Health Organization's (WHO) 
failed response to COVID-19 has clearly demonstrated, we lack the 
international structures to prevent, detect, and respond to infectious 
disease outbreaks. Without U.S. global leadership on pandemic 
preparedness, prevention, and response, future pandemics will continue 
to severely impact public health and the world economy. As U.S. 
leadership demonstrated in the Ebola and MERS outbreaks, our efforts 
enable countries to develop tools for addressing infectious disease. 
Due to these efforts, we filled gaps created by the WHO's inaction to 
prevent, detect, and respond to outbreaks immediately.

    Question. The U.S. has so far provided only $5M to the West Bank 
and no money at all for some of the most COVID-19 vulnerable people 
living in Gaza. When will the Trump administration release the full 
amount of funding appropriated by Congress for Palestinians, including 
$75 M in aid?

    Answer. The $5 million is in support of immediate, life-saving 
needs for Palestinian hospitals and households in the West Bank. We are 
closely monitoring the global response to the U.N.-led Interagency 
Response Plan, which, along with Israel, is providing vital support to 
Gaza. We continue to engage with partners on the outstanding needs and 
ways in which the United States and global community can support.
    This decision does not prejudge future decisions about U.S. 
assistance in the West Bank and Gaza. We will continue to assess how 
U.S. assistance can best be used to advance U.S. foreign policy and 
provide value to U.S. taxpayers, consistent with applicable legal 
requirements.

    Question. How is the State Department prioritizing the needs of 
children and youth (access to education, nutrition, continued basic 
healthcare) during the pandemic?

    Answer. The pandemic of COVID-19 has created serious risks to the 
safety and well-being of children and young people on an unprecedented 
scale, including secondary health impacts such as worsening nutritional 
status; reduced vaccination rates; loss of education; and increased 
risks of violence, child marriage, inadequate care, income-insecurity, 
and psychosocial distress and trauma.
    To mitigate these impacts, the U.S. Government is prioritizing the 
well-being of children and youth throughout our response to COVID-19, 
which includes working with Ministries of Health and other key 
Ministries to provide basic social services to marginalized groups. For 
example, in the Republic of Ghana, the U.S. Agency for International 
Development (USAID) is working with the Ministry of Gender, Children, 
and Social Protection and the Ghana Health Service to develop targeted 
child-protection messages and provide referral information within 
health facilities for responding to violence against children. Making 
this information available during routine visits provides an 
opportunity for women and children to talk with trained staff privately 
in a safe space in COVID-19 hotspot areas, as well as in underserved 
and rural areas.
    Globally, the U.S. Department of State has provided $12.46 million 
to reduce the transmission of COVID-19 in affected countries and 
mitigate the impact of the pandemic on children, youth, and their care-
providers in refugee and migrant settings. This assistance will 
strengthen risk-communications and community engagement; provide 
critical medical, water, sanitation, and hygiene supplies to prevent 
and control infections; support continued access to essential health 
care for women, children, and young people; support access to 
continuous education, social protection, and resources on gender-based 
violence disrupted by the pandemic; and assist with the collection and 
analysis of data on the secondary impacts of the pandemic on children 
and women.
    USAID's Bureau for Global Health is prioritizing the continuity of 
essential maternal, newborn, and child health care in the pandemic 
context, including by supporting routine immunization and restarting 
measles vaccination campaigns; protecting providers to ensure ongoing 
health care for children in facilities and the community; increasing 
support to improve children's nutrition through community outreach; and 
promoting social and behavior-change communications.
    Additionally, school closures have affected the education sector 
profoundly, which has left nearly 1.2 billion children and young people 
out of school as of July 7, 2020.\1\ In response, the United States is 
demonstrating global leadership by mobilizing its existing human and 
financial resources to mitigate and address the negative education 
impacts of COVID-19, from pre-primary through higher education. The 
U.S. Government's work in this regard will help governments, faith-
based organizations, public and private educators, learners, parents, 
and communities in our partner countries stay safe and continue to 
learn during the COVID-19 pandemic and after the crisis subsides.

    Question. In what ways are you seeking to expand distance learning 
services to populations in need of assistance?

    Answer. The scope of the impact of the pandemic of COVID-19 on 
education requires rapid mobilization and a strategy to respond to the 
shifting needs. In response, the U.S. Government (USG) through the U.S. 
Agency for International Development (USAID) is leveraging existing 
resources and programs in 20 different countries, to help pivot our 
programming during school closures to meet the educational needs of 
children and youth. This includes supporting Ministries of Education to 
broadcast educational programs over radio and television, adapting 
teacher-led curricula to family- or self-led instruction, and 
encouraging safe and healthy routines that promote the social and 
emotional well-being of learners. For example, in the Democratic 
Republic of Congo, USAID has used COVID-19 supplemental funding to 
expand distance and alternative education for Congolese children and 
young people so they can continue to learn and maintain protective 
routines and social connections while schools remain closed across the 
country.
    The U.S. Government Action Plan to Support the International 
Response to COVID-19 addresses the evolving needs of education in the 
countries where we provide support and prioritizes that ``all children 
and youth access high-quality distance education.'' To do so we have 
curated distance-learning materials, which includes the development of 
an easy-to-use, centralized resource library for interactive radio and 
audio instruction. The library now contains materials for 12 countries, 
including in local languages. As we add more, the Inter-Agency Network 
for Education in Emergencies (INEE) will formally launch a Global 
Distance Learning Hub for our implementing partners. We have also 
published a Literature Review on Delivering Distance Learning in 
Emergencies, which presents the basic modalities for delivering 
learning through radio, television, cell phone, and online methods. It 
presents lessons-learned and recommendations for using these tools to 
ensure equitable and inclusive continuity of learning through distance 
formats even during crisis situations. To increase access to books and 
other reading materials, we created the Global Book Alliance, a cross 
platform search engine, called FreeLearning, to allow users to find 
high-quality books and other reading materials. The platform launched 
in June 2020 with more than 300 titles in 100 different languages.

    Question. In April of 2018, U.S. Global AIDS Coordinator Ambassador 
Deborah Birx announced that PEPFAR would transition 70% of prime awards 
to local partners by the end of FY2020. Notably, the definition of 
``local partner'' used by PEPFAR does not include locally registered 
offices of international non-governmental organizations (INGOs), even 
if the local INGO offices are predominantly governed and staffed by 
local citizens of that country. The end of FY2020 is just weeks away, 
which means that USAID is actively moving funding away from effective, 
high-performing international partners in country at a time when we 
need established partners--local and international--to quickly adapt 
and implement COVID-19 activities in HIV settings (which are often some 
of the strongest health care facilities in these countries). In 
particular, INGOs can coordinate approaches and share practices across 
countries, while also working closely with local partners to ensure 
that interventions tailored for specific communities and country 
contexts: Does the ``all hands on deck'' effort needed to address the 
COVID pandemic necessitate a re-evaluation of the pace and purpose of 
PEPFAR's rapid push towards localization? How are you utilizing INGOS 
and their decades of experience in HIV to help the U.S. global response 
to COVID?

    Answer. To sustain epidemic control of HIV, it is critical that the 
full range of HIV prevention and treatment services are owned and 
operated by local institutions, governments, and community-based and 
community-led organizations. The intent of the transitioning to local 
partners is to increase the delivery of direct HIV services, along with 
non-direct services provided at the site, and establish sufficient 
capacity, capability, and durability of these local partners to ensure 
successful, long-term, local partner engagement and impact. In line 
with USAID's ``Journey to Self-Reliance,'' PEPFAR has set a bold goal 
of 70 percent of agency funds directly to local prime partners by the 
end of FY 2020 and agencies are well on their way--at the start of FY 
2020 CDC had 63 percent of their funding portfolio awarded to local 
partners and USAID had 45 percent respectively. On this goal of 
localization, PEPFAR has always been somewhat flexible in agencies 
achieving this goal, and is especially so in the context of dual 
pandemics. However, PEPFAR is not re-evaluating this goal toward 
localization. The COVID-19 response has underscored even more how 
important local partners are on the ground in providing and continuing 
services to clients. International NGOs also continue to be important 
in the HIV and COVID responses.

    Question. The largest refugee camp in the world is hosting over a 
million Rohingya people in Bangladesh right now, where families live in 
cramped and squalid conditions, which makes social distancing during 
the COVID pandemic impossible. COVID-19 cases have already been 
confirmed in the camps despite limited testing. Problematically, the 
government of Bangladesh has also imposed telecommunications and mobile 
data ban in the camps since September 2019. The ban has hindered 
humanitarian response efforts and prevented the Rohingya from being 
able to more freely access information and communicate effectively with 
their family and friends, all of which are critical in a pandemic. The 
ban is a concern not only for the Rohingya, but it also negatively 
impacts and increases risks in the neighboring Bangladeshi communities: 
How is the State Department prioritizing its response to the dire needs 
of the Rohingya refugees in Bangladesh and working to reduce 
impediments to the response, including by ensuring that internet and 
telecommunications services are restored immediately?

    Answer. The Department has placed a high priority on responding to 
Rohingya refugees in Bangladesh. In the context of the COVID-19 
pandemic, the United States has provided nearly $44 million in 
assistance for Bangladesh to include more than $21 million for health 
and IDA humanitarian assistance to support case-management, 
surveillance activities, the prevention and control of infections in 
health facilities, risk communications, water, sanitation, hygiene, and 
emergency food assistance, and more than $22 million in MRA 
humanitarian assistance to support vulnerable people during the 
pandemic, including refugees and host communities. This is in addition 
to the nearly $926 million that the United States has contributed to 
relief efforts in the Rohingya/Rakhine State crisis since August 2017, 
of which more than $776 million has been used in Bangladesh.
    The importance of telecommunications to all residents and service 
providers in Cox's Bazar District has become more immediate due to the 
COVID-19 pandemic. While the Government of Bangladesh has restored 3G 
cellular service in the Cox's Bazar area, we share your concern that 4G 
service is not yet reliable. We continue to press the government to 
improve 4G. We also support the U.N.'s ongoing advocacy with the 
Government of Bangladesh to provide Rohingya refugees a means for 
legally purchasing SIM cards.

    Question. Conditions set up by the Government of Burma in IDP camps 
and camp-like settings are prime for rapid and uncontrolled spread of 
COVID-19 among vulnerable populations. These conditions include 
significant overcrowding, limited access to health care, severe 
movement restrictions, internet bans reducing dissemination of real 
time information about the virus, and the potential of camp lockdowns 
reducing the ability of humanitarians to provide essential services: 
What steps is the State Department taking to encourage rolling back 
these restrictions so Rohingya populations and other communities living 
throughout Rakhine State are adequately protected from COVID-19?

    Answer. The United States continues to push for the removal of 
restrictions on humanitarian access and freedom of movement in Rakhine 
and Chin States, as well as other regions affected by violence. We also 
continue to push for the removal of restrictions on mobile data 
services, which have curtailed communication and access to information, 
including about COVID-19, for as many as 1 million people. These 
restrictions cut communities off from life-saving humanitarian 
assistance and information. Humanitarian access, freedom of movement, 
and access to the Internet and media are fundamental for improving the 
lives of people in Rakhine and Chin States, particularly in the face of 
the pandemic.
    The United States is also working closely with the Burmese 
government, health professionals, and civil society actors to contain 
the spread of COVID-19 in Burma. We have provided $16.5 million in 
health and humanitarian assistance for a range of activities, including 
the prevention and control of infections in health facilities, improved 
case management, support for laboratories, risk-communications and 
community engagement, and water and sanitation supplies for internally 
displaced persons and other vulnerable communities.

    Question. Additionally, what is the State Department doing to 
ensure that COVID-19 is not used as a justification to further restrict 
freedom of movement throughout Burma for all ethnic and religious 
minorities, and that these marginalized minorities enjoy equitable 
access to testing, health care, and that humanitarian aid is maintained 
throughout this crisis?

    Answer. The State Department is coordinating efforts to deter human 
rights abuses in Burma under the pretext of responding to COVID-19. The 
Department also is working to ensure all citizens of Burma have access 
to COVID-19-related information. In response to Burma's ongoing 
Internet shutdown in Rakhine and Chin States, the United States issued 
a joint statement with 13 diplomatic missions in Burma and used its 
social media presence to call for the Government of Burma to end the 
shutdown. Ending the shutdown will give residents of Rakhine and Chin 
States easier and more reliable access to information about COVID-19.
    The United States continues to work closely with the Burmese 
government, health professionals, and civil society actors to contain 
the spread of COVID-19 in Burma. We have provided $16.5 million in 
health and humanitarian assistance for a range of activities, including 
the prevention and control of infections in health facilities, improved 
case management, and support for laboratories for internally displaced 
persons and other vulnerable ethnic and religious minority communities.

----------------
Notes

    \1\ United Nations Educational, Scientific, and Cultural 
Organization. COVID-19 Impact on Education. Accessed July 7, 2020.
                                 ______
                                 

               Responses of Chris Milligan to Questions 
                  Submitted by Senator Robert Menendez

    Question. In 2017, within 5 months of receiving nearly $1 billion 
in emergency appropriations for International Disaster Assistance, the 
Trump administration had effectively obligated the bulk of that 
funding, and leveraged an additional $1.5 billion from humanitarian 
funding accounts to respond to four famines, each of which occurred in 
differing, complex, and non-permissive environments. As of late May, 
little of $550 million in emergency appropriations from the same 
account had been obligated to respond to humanitarian needs related to 
COVID-19. These delays undoubtedly have cost lives in countries 
severely impacted by the pandemic. What constraints have led to the 
extended time to obligate funding in comparison to past crises?

    Answer. We are in unprecedented times right now, with a rapidly 
evolving situation on the ground in almost every country. We are 
working aggressively to obligate all of our resources for COVID-19 as 
swiftly and effectively as possible. At the same time, we want to 
ensure we are accountable for the effective use of funds for COVID-19 
and are good stewards of U.S. taxpayer dollars. USAID is resolving all 
the issues and the IDA funds are on track for being obligated by July 
30th, 2020.

    Question. How has the process within USAID to obligate supplemental 
International Disaster Assistance funding changed between this crisis 
and the 2017 famines?

    Answer. USAID is working to ensure that IDA funds are available to 
our partners on the ground as quickly as possible. For example, the 
USAID Bureau for Humanitarian Assistance (USAID/BHA) has expedited its 
proven systems and procedures to program humanitarian resources to 
frontline partners, with supplemental funding being obligated on 
average within 37 days from proposal receipt, approximately 40 percent 
faster than non-expedited obligation timelines.

    Question. When do you anticipate spending down supplemental funds 
that Congress has already appropriated for the crisis?

    Answer. We intend to obligate the entirety of the $558 million in 
COVID-IDA supplemental funds appropriated by Congress by July 31, 2020.

    Question. I have seen actions that actively undercuts international 
efforts to respond. Mr. Barsa, the Acting Administrator of USAID sent a 
letter to U.N. Secretary General Antonio Guterres that offers nothing 
by way of support to combat the most deadly pandemic of the last 
century, but does internationalize the Administration's ideologically 
driven attack on women's reproductive rights. What is USAID doing to 
contribute to and support the U.N.'s Global Humanitarian Response Plan?

    Answer. The United States is a top donor to the COVID-19 pandemic 
response, and has made available $558 million in COVID-19 International 
Disaster Assistance (IDA) supplemental funding directed to support 
humanitarian interventions. Much of this funding supports the U.N.'s 
Global Humanitarian Response Plan (GHRP) that addresses food, health, 
protection, and other critical humanitarian needs and has been provided 
to U.N. agencies such as the World Food Program and UNICEF.
    While some USAID funding goes toward projects not listed in the 
appeal, we work closely with in-country teams and partners to ensure 
that programming reaches the most vulnerable populations and addresses 
critical humanitarian gaps. USAID is also working with partners to 
adapt existing programs, as necessary, to address needs that have 
arisen due to the COVID-19 pandemic.
    USAID coordinates closely with the U.N. Office for the Coordination 
of Humanitarian Affairs (OCHA) to advance improvements in the GHRP, 
such as prioritizing response activities to address acute needs and 
better promoting linkages between humanitarian and development efforts.

    Question. In March, Congress appropriated $558 million to the 
International Disaster Assistance (IDA) account to address COVID-19 
overseas, which is managed by USAID, and $350M to the Migration and 
Refugee Assistance account (MRA), overseen by State's Bureau of 
Population, Refugees, and Migration (PRM). I understand that a large 
portion of these funds have yet to be obligated and expended due to 
unusual bureaucratic delays from senior levels. These funds, generally 
speaking, are the most nimble at our disposal. By comparison, during 
the Ebola response in 2014-15, it typically took between 30-45 days for 
humanitarian money to reach partner agencies. How many IDA and MRA 
dollars have you obligated to date from the additional appropriations 
we provided in March?

    Answer. As of June 18th, USAID had obligated $201 million in 
International Disaster Assistance to respond to the pandemic. USAID 
planned and obligated all $558 million of IDA funding by July 30th, 
2020. Regarding MRA funds, I would defer to the Department of State 
Bureau for Populations, Refugees, and Migration for the most recent 
update on the status of obligations of those funds, as they are 
responsible for programming that account.

    Question. Why is it taking longer than usual for life-saving 
humanitarian funds to reach the ground and prevent the spread of COVID-
19?

    Answer. USAID's ability to obligate COVID-19 supplemental funding 
effectively and quickly remains our highest priority. Providing our 
implementing partners with the necessary resources to support critical 
emergency health, WASH, protection, and food assistance programs on the 
frontline of the pandemics is at the core of our response strategy. 
Several unexpected challenges impacted the ability to obligate funding 
quickly.
    These challenges included the need to accurately address the policy 
on Personal Protective Equipment (PPE) as well as the relationship with 
the World Health Organization (WHO). In both cases, USAID worked to 
adapt operational responses and collaborate with partners to support 
these policies.
    In coordination with the Department of State, USAID issued 
additional PPE guidance on June 9 that allows USAID implementing 
partners to procure PPE for their staff, and to continue critical 
programs as long as the PPE is produced locally or regionally and not 
intended for the U.S. market.
    I assure you that we are working as hard as possible to ensure that 
IDA funds are available to our partners on the ground as quickly as 
possible.
    For example, the USAID Bureau for Humanitarian Assistance (USAID/
BHA) has expedited its proven systems and procedures to program 
humanitarian resources to frontline partners, with supplemental funding 
being obligated on average within 37 days from proposal receipt, 
approximately 40 percent faster than non-expedited obligation 
timelines.

    Question. What is the USG doing to ensure the money moves in an 
expeditious and transparent manner moving forward?

    Answer. We understand the concerns about delays in funding, and we 
are working to make resources available as quickly as possible. I 
assure you that we are working aggressively to obligate COVID-IDA as 
swiftly and effectively as we can. At the same time, we want to ensure 
we are accountable for the effective use of COVID-19 funds as stewards 
of U.S. taxpayer dollars.
    To accelerate the pace of processing awards and our obligations, 
USAID/BHA is taking concrete actions, including implementing the 
following measures:

  1.  Quicker Turnaround: Impose stricter deadlines on partners to 
        develop applications, and for USAID to provide technical 
        approval.

  2.  Prioritization: Fast-track all COVID-19 proposals for review over 
        non-COVID applications.

  3.  All Hands on Deck: Ensure Agency buy-in across the spectrum of 
        USAID business processes, from USAID/BHA field teams/
        headquarters staff, General Counsel, and M/OAA.

    Since implementing these measures in early July, obligations have 
increased significantly and we expect to obligate the entirety of 
COVID-IDA funds by July 31, 2020.

    Question. USAID has received explicit instruction from the NSC to 
expend funds provided in the CARES Act on ventilators destined for 
countries hand selected by the President based on conversations he has 
with foreign leaders. What analysis is informing the decisions about 
which countries are given ventilators? Are ventilators given to 
countries that most need them based on case load?

    Answer. President Trump has pledged ventilator assistance to 
countries in need across the world. The Head of State or Ministry of 
Health in each country that is receiving ventilators has requested this 
equipment, and the U.S. Government is offering it as an in-kind 
contribution. After pledges to partner countries, USAID mobilizes to 
fulfill pledges under direction from the NSC. For additional 
information on the decision-making process, we refer you to NSC.

    Question. Were health experts at USAID, other agencies or elsewhere 
consulted, and did they or do they agree that these are the countries 
in most need of ventilators?

    Answer. USAID is committed to supporting countries in need around 
the world and leading the global COVID-19 response through an All-of-
America approach. This includes coordinating closely as part of the 
U.S. Government interagency around all COVID-19 activities, including 
ventilators. USAID health experts are closely involved in this process 
and are consulted frequently.

    Question. What assurances is USAID seeking or requiring from 
countries receiving ventilators that they will provide equitable access 
to U.S. provided ventilators and that the country is in fact following 
proper protocols and implementing health security measures to prevent 
the spread of COVID-19?

    Answer. USAID is offering ventilators as an in-kind contribution. 
Once delivered, USAID transfers the title to the ventilators to the 
host government. The host government then distributes ventilators based 
on a number of factors including where it determines the greatest need 
is to care for the most critically ill patients affected by COVID-19 
and which facilities are best-suited to use ventilators. USAID is 
coordinating with host country Ministries of Health to assess overall 
capacity to provide respiratory care for critically ill patients 
suffering from COVID-19, as well as health facilities' capacity to 
provide critical care and use ventilators safely and appropriately. 
USAID health experts are providing regular input and guidance to 
promote the safe and effective use of ventilator donations in recipient 
countries. USAID offers targeted technical assistance where needed, 
using assessments conducted with ministries of health and implementing 
partners to guide this support. In addition, USAID is providing access 
to a global distance learning portal and a technical hotline for health 
providers to tap into subject matter expertise.

    Question. It is my understanding that USAID is procuring nearly all 
ventilators, and that the NSC is requiring them to purchase them from 
two companies (Zoll and Vyaire). Is USAID competitively bidding this 
procurement?

    Answer. NSC allocates recipient countries to specific vendors 
identified by the U.S. Department of Health and Human Services (HHS) 
and the Federal Emergency Management Agency (FEMA) within the U.S. 
Department of Homeland Security (DHS). These vendors include Vyaire, 
Zoll, and Medtronic. USAID then works with assigned vendors and 
countries to coordinate the necessary county-specific customizations 
and fulfil assigned ventilator orders. For more details on the bidding 
process for these vendors, we refer you to HHS and FEMA.

    Question. How many of these orders have been fulfilled?

    Answer. As of 18 June 2020, 800 of 8,482 ventilators have been 
delivered to El Salvador (250), India (200), Russia (200), and South 
Africa (50).

    Question. If the decisions on which countries are being given 
ventilators are being made by the White House weeks before the 
ventilators can be delivered, why is USAID using authorities that allow 
it to waive the regular 15 day Congressional notification process on 
these procurements?

    Answer. USAID has occasionally relied on emergency authority to 
obligate funds when we have identified an urgent need to obligate funds 
and when notifying these funds to Congress in accordance with the 
regular procedures would pose a substantial risk to human health and 
welfare. Specifically, funds are needed in advance for the 
manufacturers to start production on country-customized ventilators.

    Question. Does USAID have adequate resources to help countries 
bring the pandemic under control? What does Congress need to provide in 
the next supplemental appropriations bill?

    Answer. USAID is extremely grateful for the generous supplemental 
appropriations from Congress on behalf of the American people. Besides 
the immediate health impacts of COVID-19, many countries are also 
experiencing an increase in conflict, as well as humanitarian, 
economic, and social challenges.
    Countries with weak health systems are suffering from a lack of 
laboratory systems, infection prevention and control in health 
facilities, case management, contact tracing, surveillance, and 
behavior change and risk communications. USAID's other global health 
programs across areas such as maternal and child health, nutrition, 
HIV/AIDS, tuberculosis, malaria, global health security, population and 
reproductive health, and neglected tropical diseases are also seeing 
additional costs and challenges rise from supply chain delays and 
shutdowns, pauses in health services and immunization campaigns, 
inability to reach health facilities to pick up medicines, as well as 
due to misinformation.
    Food insecurity, unemployment, education, and economic shutdowns 
have left many already-vulnerable families even more at-risk. Countries 
with already volatile and conflict-ridden situations are experiencing 
increasing humanitarian challenges. Women, girls, and youth are 
particularly at risk from a rise in gender-based violence, and child 
abuse as a result of economic pressures, stress, and mental health 
challenges resulting from COVID-19.
    Malign actors are using the growing economic, social, and health 
challenges in many countries to spread disinformation and 
misinformation, reverse democratic gains, further violent extremism, 
and increase their influence.
    USAID is committed to addressing the aforementioned development 
challenges to the best of our ability with available resources.

    Question. The U.S. has suspended aid to northern Yemen amid a 
pandemic. While some ``life-saving'' activities are carved out from the 
suspension, other programs key to preventing and treating COVID-19, 
including hygiene promotion, public education, basic healthcare, 
epidemiological surveillance, and the provision of safe drinking water, 
are not. How can the U.S. lay claim to leading the global response when 
it is undercutting core prevention and treatment activities in the 
world's largest humanitarian crisis?

    Answer. The United States remains one of the largest donors of 
humanitarian assistance in Yemen despite severe access restraints and 
deliberate operational impediments imposed by the Houthis on U.S. 
humanitarian partners in northern Yemen. Ongoing interference in 
international aid operations by Houthi officials in northern Yemen has 
prevented millions of people from receiving the assistance they need to 
survive.
    Yemen is now confronting what the U.N. says is the country's 
``greatest threat in the past 100 years''--COVID-19. The pandemic is 
spreading rapidly through the country, where prolonged conflict has 
decimated the country's health system and left people malnourished and 
extremely vulnerable to disease. Despite this unprecedented crisis, the 
Houthis have not only failed to end their longstanding obstruction of 
aid, we are hearing reports that, in some cases, they have instituted 
even more brazen measures to seize control of international aid 
operations. Now more than ever, we need to ensure critical resources 
reach those who need them most.
    Our priority remains delivering life-saving aid to the most 
vulnerable populations in Yemen. While we have reduced certain NGO 
programs that have become untenable due to the Houthis' ongoing 
interference, we continue to support critical life-saving activities in 
northern Yemen, including COVID-19 response activities, and remain 
fully operational in the south. These activities--such as providing 
safe water at sites for displaced families and treating malnourished 
women and children--are helping to keep people healthy and prevent 
diseases, such as cholera and COVID-19.
    The United States remains one of the largest donors of humanitarian 
assistance in Yemen. Given the constrained operating environment in the 
north of Yemen, some of our partners have not been able to program at 
their anticipated levels. As a result, USAID currently has some Fiscal 
Year 20 humanitarian funding available to support new COVID-19 response 
efforts without needing to request additional COVID supplemental funds, 
and allowing these critical resources to be prioritized for other life-
saving responses. Our Yemen response also has robust ongoing 
programming that is able to adapt as necessary to respond to this 
outbreak.
    We are working to safely and responsibly program all funding in 
Yemen funding, and expect to announce new humanitarian assistance that 
will support COVID-19 response efforts in Yemen in the coming weeks. 
The United States continues to carefully monitor the situation in close 
coordination with Yemeni health officials, the United Nations, and 
other donors. We also continue to fully support the U.N.'s countrywide 
services that underpin the humanitarian response and are critical to 
COVID-19 response efforts, including the U.N. Humanitarian Air Service, 
Logistics Cluster, and coordination mechanisms. We are also working 
with our partners to adapt existing programs, as necessary, to address 
additional needs due to COVID-19. Longstanding U.S. health and water, 
sanitation, and hygiene programs--which include training healthcare 
workers, supporting medical facilities, and teaching safe hygiene 
practices--have and continue to help communities to be better prepared 
for disease outbreaks and other health threats.
    As COVID-19 threatens communities in Yemen that are already 
extremely vulnerable, the United States remains committed to providing 
humanitarian assistance whenever and wherever conditions permit.
    As a donor accountable to U.S. taxpayers, the U.S. cannot 
responsibly fund aid operations if our partners are prevented from 
monitoring and protecting the humanitarian integrity of these programs. 
We must be able to operate without interference in program operations, 
including the ability to assess actual needs on the ground and to 
protect resources being diverted from the most vulnerable; absent that, 
we cannot be sure resources will get to those who need them most. This 
suspension was thoughtfully planned with our partners to ensure they 
were ready to safely and responsibly adjust their programming. We are 
working closely with partners to ensure they resume operations as 
quickly as possible once we are confident that they can deliver U.S.-
supported assistance without undue interference.

    Question. NOAA's Climate Prediction Center predicts 2020 to have an 
above-average number of hurricanes. How is USAID increasing support for 
disaster risk reduction and preparing for a compound emergency like 
hurricanes during a pandemic?

    Answer. USAID's Bureau for Humanitarian Assistance (USAID/BHA) is 
actively planning and preparing for an above-normal hurricane season 
this year in the Atlantic and eastern Pacific. A key aspect of this 
preparation has been adapting USAID's standard operating procedures for 
responding to multiple hurricane scenarios, particularly in the Latin 
America and Caribbean (LAC) region, while also addressing the operating 
constraints of the COVID-19 pandemic.
    USAID/BHA and the interagency have conducted table-top exercises to 
review response procedures and the added challenges of responding in 
the COVID-19 environment. Consultations with U.S. embassies and USAID 
missions throughout the LAC region reviewing factors related to staff 
deployment, access restrictions, COVID-19 status, as well as 
coordination to expedite clearance processes, quarantine, and other 
anticipated changes are ongoing. USAID/BHA is also providing a Mission 
Disaster Preparedness six-session online learning series geared towards 
USAID staff and Mission Disaster Relief Officers (MDRO) and alternates 
(A/MDRO) in the Latin America and Caribbean (LAC) region. These 
trainings are designed to ensure effective coordination between 
Embassies and USAID/BHA during a disaster, and improve access the 
appropriate tools and resources.
    USAID has strategically pre-positioned disaster experts and 
emergency relief supplies throughout the LAC region in preparation for 
the 2020 hurricane season. Disaster experts in the region and in 
Washington, DC will assess needs and determine whether USAID should 
provide humanitarian assistance immediately following hurricanes and 
other disasters, even in the event that a Disaster Assistance Response 
Team (DART) is not required.
    Through its Regional Disaster Assistance Program, USAID/BHA has a 
network of disaster risk management specialists (DRMS) in the LAC 
region that have provided training and technical assistance to national 
disaster management organizations and first responders. There are 29 
DRMSs and more than 400 local surge capacity consultants located 
throughout the region. This capacity-building effort has increased the 
ability of countries in the region to manage disasters without U.S. 
assistance. Due to potential COVID-19 access restrictions, USAID/BHA is 
expanding communications capacity, including satellite phones, in order 
to enhance response efforts using this network.
    To facilitate any potential response, USAID/BHA has an email alert 
system that provides up-to-date information on entry protocols/
restrictions for response personnel, in addition to storm locations, 
development probabilities, and projected trajectories to MDROs and 
other relevant U.S. Government (USG) personnel.
    USAID/BHA will embed an advisor with Joint Task Force-Bravo (JTF-B) 
at Soto Cano Air Base in Honduras this year, from July-November, to 
ensure seamless coordination, communication, and information sharing 
between USAID/BHA and forward-deployed Department of Defense (DoD) 
teams in the LAC region. JTF-B has capacity for rapid response 
throughout the region and has responded to major events with USAID in 
the past, including Hurricane Matthew in 2016. Additionally, USAID/BHA 
has participated in hurricane response coordination activities and 
communications in the COVID-19 context with SOUTHCOM and Caribbean 
Disaster Management Agency (CDEMA).

    Question. Refugee populations, like the Rohingya communities that 
have settled in Bangladesh, who are restricted to living in densely 
populated internally displaced persons camps or camp-like settings that 
restrict health care, movement, access to hygiene materials and 
sanitation, do not allow for social distancing or self-isolation, and 
provide no clear mechanism for referrals of severe COVID cases. How 
does the U.S. COVID action plan account for this vulnerable population 
who are forced to live in conditions ripe for COVID to take root?

    Answer. According to the Inter-Sector Coordination Group--a Cox's 
Bazar coordination body that comprises U.N. agencies and NGOs--health 
partners have delivered Infection Prevention and Control (IPC) training 
to staff in all clinics and facilities serving the Rohingya camps. In 
addition, health partners have trained over 1,500 refugee community 
health work volunteers on COVID-19 to conduct household-level health 
screenings and referrals, and are working with Imams and local leaders 
to disseminate key messages on virus transmission, how refugees can 
protect themselves and their families, and symptoms and proper care-
seeking behavior.
    Since May, humanitarian organizations have established 14 Severe 
Acute Respiratory Infection Isolation and Treatment Centers near camps 
to treat both the refugee and host community populations, according to 
the Inter-Sector Coordination Group. In addition, all health 
organizations working in the camps ensure that water and soap are 
readily available by increasing the number of hand-washing facilities 
in distribution centers, health points, and nutrition centers. U.N. 
agencies and NGOs continue to clean and disinfect communal areas and 
neighborhoods throughout the camp, while physical distancing measures 
are now required at distribution points, as well as mandatory hand 
washing before entering distribution lines.
    USAID's Bureau of Humanitarian Assistance (USAID/BHA) continues to 
provide support in the camps in coordination with State/PRM. While food 
assistance has continued, USAID/BHA partners are adapting measures to 
minimize the spread of COVID-19 by providing a full month's food 
ration, rather than biweekly, and implementing social distancing 
measures at distribution sites. Each sponsored food vendor is required 
to have two months of food in stock to prevent shortages and keep 
refugees from congregating in markets. In April, IOM, with support from 
USAID/BHA, began using pre-positioned USAID plastic sheeting for the 
construction of temporary COVID-19 isolation and treatment centers and 
upgrades to existing health facilities in host communities and refugee 
camps, increasing local capacity to isolate and treat vulnerable 
patients exhibiting symptoms of COVID-19.
    In addition to ensuring existing programming is COVID-19 sensitive, 
USAID/BHA is programming $5 million in COVID-19 International Disaster 
Assistance supplemental funding to support vulnerable communities 
hosting Rohingya refugees with health; water supply and hygiene; and 
protection services. In host-community health facilities, USAID/BHA is 
providing critical inputs such as pharmaceuticals, personal protective 
equipment (PPE), and handwashing inputs. In addition, USAID/BHA 
partners support water, sanitation, and hygiene (WASH) infrastructure 
repairs, and training on IPC and case management. Following recent 
reports by the U.N. Children's Fund (UNICEF) and other protection 
actors, USAID/BHA is also scaling-up programs to combat harmful coping 
mechanisms, such as early marriage and domestic violence.

    Question. After years of eradicating extreme poverty, the World 
Bank is predicting that 71 million to 100 million people will be pushed 
into extreme poverty due to COVID-19. What is the U.S. strategy to 
mitigate the secondary impacts of COVID-19, especially in fragile and 
conflict-affected places?

    Answer. The COVID-19 pandemic starkly illustrates the linkage 
between public health outcomes and its impact on fragility and 
conflict. While immediate international responses are focusing on 
medical and humanitarian assistance, these alone will not be 
insufficient to meet needs and respond to this crisis.
    COVID-19 impacts are being felt across a range of sectors, 
including governance, the economy, civilian security, education, 
energy, tourism, agriculture, and food security, with both short-term 
and long-term repercussions. USAID is working to address urgent COVID-
related conflict prevention and stabilization challenges to preserve 
development gains and prevent backsliding in regions critical to U.S. 
national security. USAID has prioritized support for citizen-responsive 
governance, economic support, and peace and stability. Economic support 
funds from the COVID-19 supplemental funding have gone towards 
combating misinformation and disinformation, reducing the influence of 
malign actors, strengthening economic opportunities, improving 
workforce training and development, and enhancing private sector 
adaptability and productivity so that populations are better equipped 
to respond to the pandemic and not fall into deeper economic and social 
vulnerabilities. Funds have also gone towards improving good 
governance, ensuring the free flow of media and independent journalism, 
countering violent extremism, counter-narcotics efforts, and providing 
social support to the most vulnerable populations. These efforts will 
help improve stability and peace in conflict-ridden regions.
    Where and when violence and conflict do arise, USAID's programs 
will aim to not only address the immediate conflict, but also to 
prevent longer-term economic, governmental, and social effects of 
conflict.

    Question. What additional resources will be needed to ensure that 
USAID and the State Department can address the secondary impacts of the 
crisis?

    Answer. USAID is working in close coordination with the State 
Department on future programming needs and related budgeting priorities 
to ensure they align with U.S. strategic priorities, including our 
economic, security, and diplomatic interests.

    Question. How will implementation of the Global Fragility Act 
support these efforts?

    Answer. The Global Fragility Act and subsequent Strategy can serve 
as a framework for addressing second order impacts due to COVID. The 
Global Fragility Strategy (GFS) aims to strengthen U.S. efforts to 
stabilize conflict-affected areas, prevent violence, and address global 
fragility, in line with the Global Fragility Act of 2019. It reinforces 
the National Security Strategy commitment to strengthen the resilience 
of communities and states ``where state weakness or failure would 
magnify threats to the American homeland.'' America's prosperity and 
security depend on our ability to stabilize conflict-affected areas, 
prevent violence, and reduce fragility globally. The interagency sees 
the GFS as a framework any USAID mission can utilize to shape their 
programs to the changing environment amidst the COVID pandemic, even if 
they are not one of the countries selected as part of the GFS.
    USAID's transformation elevated many of the issues outlined in the 
Global Fragility Act and has begun building a new organizational 
structure designed to spearhead this very challenge. For example, the 
Bureau for Conflict Prevention and Stabilization (CPS) will engage 
dedicated senior leadership within USAID and the interagency for 
peacebuilding; preventing conflict and violence; and implementing 
programs in political transition and stabilization, while also 
conducting civilian-military coordination to support U.S. foreign- and 
national-security policy priorities in high-priority countries.

    Question. How is USAID prioritizing the needs of children and youth 
(access to education, nutrition, continued basic healthcare) during the 
pandemic? In what ways are you seeking to expand distance learning 
services to populations in need of assistance?

    Answer. As a result of the global pandemic, the education sector 
has been negatively affected by school closures, leaving more than 1.68 
billion children and youth out of school at the height of the pandemic, 
equaling more than 91 percent of enrolled learners worldwide. In 
response, and to prevent development backsliding, USAID is mobilizing 
its existing human and financial resources to mitigate and address the 
negative education impacts of COVID-19, from pre-primary through higher 
education. USAID's work will help our partner countries, learners, and 
communities to stay safe and continue to learn both during the COVID-19 
pandemic and once the crisis subsides.
    In 20 different countries, USAID is leveraging existing resources 
and programs to pivot programming during school closures to meet the 
educational needs of children and youth. This includes supporting 
ministries of education to broadcast USAID-funded educational programs 
over radio and television, adapting teacher-led curricula to family- or 
self-led instruction, and encouraging safe and healthy routines that 
promote social and emotional wellbeing of learners.
    For example, in the Democratic Republic of Congo COVID-19 
supplemental funding has enabled USAID to expand distance education and 
alternative education for Congolese children and youth so they can 
continue to learn and maintain protective routines and social 
connections while schools are closed across the country.
    USAID is also working with partner countries to adapt approaches to 
the context of each country's education system to ensure they are 
resilient during future crises. Specifically, USAID is coordinating and 
leveraging resources through partnerships with international education 
actors. For example:

   USAID's commitment to launch a Global Distance Learning Hub 
        supports governments, schools and parents to keep children and 
        youth learning during times of crisis.

   USAID's support to the Inter-Agency Network for Education in 
        Emergencies (INEE) enables the curation and global 
        dissemination of tools, resources, and guidance on education 
        and COVID-19.

   USAID's investment in Education Cannot Wait (ECW) supports 
        an immediate response to COVID-19 of about $1 million per 
        country in all 27 existing ECW partner countries. The specific 
        response will vary by country.

   USAID's investment in the Global Partnership for Education 
        (GPE) supports GPE's phased COVID-19 response, which includes 
        $8.8 million for contingency and response planning for all 87 
        GPE member countries and a second phase that includes a $250 
        million funding window for immediate COVID-19 response.

    Question. The Stop TB Partnership has reported a major decrease in 
the number of people accessing tuberculosis services globally, 
following the emergence of COVID-19, and this risks a major setback in 
our efforts to control the disease internationally--and ultimately to 
protect the U.S., since TB knows no borders. For instance in India, the 
country with the highest number of TB cases, the TB case notification 
rate has fallen 80%, indicating a massive drop in diagnosis and 
treatment. Similar figures have been reported by Indonesia and South 
Africa. How is USAID helping countries rapidly shore up and adapt their 
TB programs to help patients get rapidly and properly diagnosed and 
stay on their course of treatment, despite lockdown conditions?

    Answer. As the spread of COVID-19 was confirmed around the world, 
USAID/Washington quickly developed and distributed tuberculosis (TB) 
technical guidance on best practices for adapting TB programs and their 
platforms to combat COVID-19, especially for TB patients, who are at 
high risk. The technical guidance is being updated regularly as the 
pandemic evolves and shared with USAID Missions and Advisors embedded 
in country National TB Programs (NTP). USAID Missions are working with 
NTP and partners to adapt and adopt the guidance developed by USAID/
Washington on continuity of TB services during the COVID-19 pandemic. 
Missions are also supporting the NTP to rapidly assess the extent of TB 
service disruption and develop appropriate mitigation plans.
    For example, USAID/South Africa supported the NTP to conduct a data 
analysis and quantification of impact of COVID-19 on the TB program, 
including any disruptions in TB drug supply, case finding, and 
treatment support. As a result, the Mission is intensifying TB and 
COVID-19 case finding in communities and health facilities, including 
the development of integrated programs for TB and COVID-19 case 
finding, treatment, and infection prevention control. In Uganda, USAID 
supported the development of a TB-COVID-19 screening algorithm and the 
training of health care workers to screen for both COVID-19 and TB; 
developed a remote case finding mentorship for District TB programs to 
better support facilities and communities in continuing TB services; 
worked with partners and facilities to increase the number of TB 
medicines dispensed from weekly to monthly through the Family DOT 
practice; and extended the supply of TB medicines to lower-level 
facilities (Health Center Level II) to dispense first- and second-line 
medicines closer to patients. In Ukraine, USAID scaled-up video-
observed therapy options, allowing patients to stay home and reduce the 
number of contacts with medical and social staff.
    USAID also commissioned modeling from the STOP TB Partnership to 
quantify the impact COVID-19 mitigation efforts could have on TB 
activities.
    USAID is committed to continuing to monitor programs and adapt our 
strategies during the COVID-19 pandemic to address the challenges for 
TB program implementation.

    Question. USAID's Standards of Conduct state the Agency strives to 
foster a ``respectful, diverse, inclusive, and collaborative 
environment that promotes professional and personal growth for 
everyone,'' and requires employees to ``promote and support a 
respectful and inclusive work environment in which all individuals are 
treated with dignity at all times. Employees shall ensure that both 
their verbal and non-verbal communications comport with this 
standard.'' Please explain how publicly-reported comments by Mark Kevin 
Lloyd and Merritt Corrigan are consistent with those principles. For 
example, Mr. Lloyd has referred to Islam as a ``barbaric cult'' and Ms. 
Corrigan referred to the ``tyrannical LGBT agenda.'' As a career USAID 
foreign service officer, I understand that you may not be personally 
responsible for selecting political appointees for USAID or monitoring 
compliance with USAID's Standards of Conduct, but you are the official 
that the agency sent to testify before this Committee, so I appreciate 
your comments on this matter.

    Answer. USAID has long held our employees, regardless of hiring 
category, to the highest legal, moral, and ethical standards, and the 
Agency will continue to do so.

    Question. Given the difficult discussion about racial injustice 
taking place in our nation right now and across the world, along with 
reports of diplomats and foreign service officers abroad struggling to 
represent the United States to the world in the face of ongoing 
injustice, do you agree that our international development agencies, 
including USAID, have an important role to play in supporting 
diversity, speaking out against racial injustice, and supporting those 
serving around the world? Please provide all messages and guidance that 
senior USAID leadership and Acting Administrator Barsa have provided on 
these topics.

    Answer. Last year, USAID issued a policy statement on diversity and 
inclusion stating that, in accordance with USAID 's core values, we 
remain fully committed to the fundamental principles that underpin a 
workplace in which all employees are proud of their work; are 
encouraged to collaborate, innovate, and learn; are respected for their 
uniqueness; and are valued for their different perspectives. To achieve 
our mission, one that promotes and demonstrates democratic values 
abroad and advances a free, peaceful, and prosperous world, we must 
draw from the strength of a workforce that represents these American 
values. As such, we strictly prohibit discrimination, harassment, and 
retaliation in all employment-related decisions including recruitment, 
hiring, promotions, employee development, and retention. I work day in 
and day out with my fellow foreign service officers, as well as all 
USAID staff, to strengthen our core values as we remain mission focused 
and committed to these principles.
                                 ______
                                 

             Responses of Mr. Garrett Grigsby to Questions 
                  Submitted by Senator Robert Menendez

    Question. WHO plays a leading role in the provision of vaccines. It 
is one of the main partners of Gavi, the Vaccine Alliance which is the 
critical funding agency supporting vaccine programs in the world's 
poorest countries where the majority of the world's unimmunized 
children live. How is our pulling out of WHO going to affect 
vaccinations, and what impact will disruption of vaccine campaigns have 
on under five mortality?

    Answer. The United States continues to be a leader in promoting and 
providing vaccines, including through its support of GAVI and other 
international partners. The United States will focus on and strengthen 
other partnerships on vaccine issues. In addition, we are continuing to 
review all collaborations to discover if there are certain activities 
that only WHO can undertake and, if this is the case, decisions will be 
made about how to deal with this situation.

    Question. On April 7, the President declared he would like to put a 
``powerful hold'' on WHO funding and on May 29, the President said the 
Administration plans to ``terminate'' the relationship. On April 8, 
Sec. Pompeo stated that the World Health Organization has ``to get the 
data, they have to share that data with the world's best scientists--
many of which are often located right here in the United States--and 
allow that information to be transferred freely so that we can have a 
transparent response that will save lives.'' This is an essential 
aspect of WHO's work, which has received praise from health experts 
here and abroad but would be significantly harmed if the U.S. withheld 
funding. In light of this statement, can you explain the guidance you 
gave to Sec. Pompeo? Can you detail the implications beyond the COVID-
19 response this hold would have?

    Answer. HHS works closely with the Department of State and other 
interagency partners on global health policy and programs. We continue 
to provide input to the interagency and the impact of our activities on 
COVID-19.

    Question. Diseases do not recognize borders, so challenges like the 
COVID-19 pandemic necessitate a global, collective response. The WHO--
through its high level of technical expertise and international 
legitimacy--is uniquely positioned to lead the international response 
to public health emergencies like the COVID-19 pandemic. From the 
outset of the crisis, WHO has been a critical provider of supplies and 
tests, distributing 1.5 million diagnostic kits and millions of items 
of PPE to dozens of countries; designed, refined, and distributed 
technical guidance for communities, hospitals, frontline clinicians, 
private sector partners, and public health authorities around the 
world; carried out public awareness campaigns in dozens of languages in 
149 countries; and, through its ``Solidarity Trial,'' has been working 
to enable rapid and accurate research on the effectiveness of potential 
therapeutics. People around the world--including Americans--stand to 
benefit from these types of activities. What effect will 
``terminating'' our relationship with the World Health Organization 
have on these efforts? How can we hope to protect Americans from 
pandemic disease and other health challenges without a multilateral 
coordinating authority like the WHO?

    Answer. The United States is, and will continue to be, a leader on 
global health issues, whether or not we are a WHO Member State. The 
United States is leading on the research and development of vaccines, 
diagnostics and therapeutics to combat COVID-19 and will work with our 
partners to exchange information and understanding.
    Technical collaboration between the United States and WHO through 
the Global Influenza Surveillance and Response System (GISRS) has been 
used for global virus surveillance and selection of viruses for use in 
vaccines to protect Americans from seasonal and pandemic influenza. We 
are continuing to review all collaborations to discover if there are 
certain activities that only WHO can undertake and, if this is the 
case, decisions will be made about how to deal with this situation.

    Question. WHO has been on the frontlines of nearly every global 
health challenge over the last 70 years, combatting, containing, and 
eradicating some of the planet's most deadly diseases, viruses, and 
infections. While the world is rightly focused on defeating COVID-19, 
other health challenges confronting the world have not disappeared, and 
it is not in our interest to neglect them. These include WHO-led 
efforts to control and eliminate malaria, implement global disease 
surveillance for the polio virus in areas where U.S. government 
agencies do not have the capacity to reach, support measles 
immunization campaigns, and strengthen the health sector's response to 
HIV/AIDS and Tuberculosis. The loss of more than $400 million in annual 
U.S. funding threatens to upend these critical activities. What does 
our withdrawal from these multilateral initiatives say to our allies 
and partners around the world? Given how far-reaching and complex these 
challenges are, how can bilateral efforts even hope to begin to make a 
dent?

    Answer. While the United States was by far the leading contributor 
to the WHO, those contributions represented a small fraction--just 4 
percent--of our total funding of global health assistance every year.
    It is important to underscore that the United States continues to 
lead on global public health issues and provides generous funding to 
initiatives to eliminate malaria, global disease surveillance for 
polio, immunization and addressing HIV/AIDS and Tuberculosis. Since 
2001, the U.S. has provided more than $142 billion in global health 
funding, and an average of approximately $10 billion per year in recent 
years. Our global health efforts, whether in concert with the WHO, or 
with other partners will continue. There are many important partners 
working on global health in addition to the WHO. We plan to communicate 
and coordinate, as appropriate, with all stakeholders to continue the 
global response.

    Question. With regards to U.S. arrears in our payments to WHO, in a 
June report to Congress, the State Department noted a number of 
possible impacts, including: ``1. Loss of vote or inability to be a 
member of governing bodies; 2. Diminished U.S. standing and diminished 
ability to pursue U.S. priorities; 3. Reduced U.S. ability to promote 
increased oversight and accountability through reforms that promote 
efficiency, cost savings, and improved management practices; 4. Reduced 
standing needed to successfully promote qualified U.S. citizens to 
assume senior management roles; and 5. Impairments of peacekeeping 
missions to operate, including addressing objectives that may directly 
impact the national security of the United States.'' Given your 
experience working with international organizations like the WHO, do 
you stand by these conclusions from your own Department?

    Answer. We defer to Jim Richardson, the panelist from the 
Department of State, to answer the above question about a State 
Department report.
                                 ______
                                 

             Responses of James L. Richardson to Questions 
                    Submitted by Senator Ben Cardin

    Question. COVID-19 poses a significant threat to low and middle-
income countries. Recognizing this need, Congress appropriated almost 
$2 billion for foreign assistance in the emergency supplemental 
packages. Nonetheless, we are increasingly hearing from foreign aid 
implementers that very little of this assistance has been disbursed to 
those who need it most: What is causing these delays?

    Answer. Of the nearly $1.7 billion in foreign assistance, State and 
USAID have obligated more than $800 million across State and USAID, 
with that level increasing every day. The State Department's Bureau for 
Population, Refugees, and Migration confirms that nearly all of the 
committed State Department humanitarian assistance funding has been 
obligated to date. I have also personally committed to responding to 
funding allocations and proposals from State Department and USAID 
bureaus in 24 hours. We are committed to moving quickly, while still 
ensuring every dollar is used wisely, effectively, and strategically.

    Question. Of the $1 billion that USAID has pledged, how much has 
actually been obligated?

    Answer. Across the State Department and USAID, the Secretary has 
committed more than $1.3 billion for COVID-19 foreign assistance to 
date. Of this total, more than $800 million has been obligated across 
both agencies, with that level increasing every day. We refer you to 
USAID for further information on USAID obligations.

    Question. What are State and USAID doing to ensure funds get 
disbursed as quickly as possible?

    Answer. I have committed to responding to funding proposals from 
State Department and USAID bureaus in 24 hours. Budget should move at 
the speed of policy, which is why I've focused on speeding up our 
processes in the Office of Foreign Assistance, ensuring every dollar is 
coordinated, effective, and efficient.

    Question. Are State and USAID concerned with the potential long-
term impacts these delays could cause?

    Answer. We are in unprecedented times right now, with a rapidly 
evolving situation on the ground in almost every country. The State 
Department and USAID are working aggressively to obligate all of our 
resources for COVID-19 as swiftly and effectively as possible. At the 
same time, we recognize that our agencies are accountable for the 
effective use of funds for COVID-19 response, and must be good stewards 
of U.S. taxpayer dollars. We refer you to USAID for further information 
on obligations.

    Question. Is the State Department concerned that a U.S. withdrawal 
from the WHO will further strengthen China's role at the organization 
and other multilateral bodies?

    Answer. In May, Chinese President Xi pledged $2 billion over the 
next 2 years to help in the COVID-19 response--he did not say how much 
money will be given to the WHO. This pledge is less than what China 
borrows every year from the World Bank. China's pledge falls well short 
of the U.S. commitment of $10 billion to the COVID-19 response. The 
President's decision to terminate our relationship with the WHO in no 
way diminishes U.S. leadership on global health and combatting the 
COVID-19 pandemic. The United States leads the world in health and 
humanitarian aid in an ``All of America'' effort and is committed to 
ensuring our generosity directly reaches people around the world. We 
account for more than 40 percent of total global health funding. The 
United States has allocated more than $12 billion that will benefit the 
global COVID-19 pandemic response; more than $2 billion of this has 
already been committed.

    Question. How can we hope to protect Americans from pandemic 
disease and other health challenges without a multilateral coordinating 
authority like the WHO?

    Answer. As the COVID-19 pandemic and the WHO's failed response have 
clearly demonstrated, we lack the international structures to prevent, 
detect, and respond to infectious disease outbreaks. As U.S. leadership 
demonstrated in the Ebola and MERS outbreaks, our diplomatic and 
development efforts enable countries to develop tools for addressing 
infectious disease. Due to these efforts, we filled gaps created by the 
WHO's inaction to prevent, detect, and respond to outbreaks 
immediately. The Administration is examining ways to leverage the 
expertise of key U.S. Government departments and agencies and the 
American private sector to rapidly deploy and deliver this essential 
support to other countries to prevent, detect, and respond to 
infectious disease outbreaks at their source. In addition, President 
Trump announced on May 29 that the United States will be redirecting 
funding planned for the WHO to other global health organizations and 
urgent needs around the world.

    Question. Do you believe that a bilateral approach to complex and 
far-reaching global health crises is the most effective and efficient 
way to spend tax payer dollars?

    Answer. Achieving global health security remains a foreign policy 
priority for the U.S. Government. The U.S. Government implements many 
of its capacity building programs at the country level, including our 
coordinated whole of government investments in support of the Global 
Health Security Agenda (GHSA). U.S. Government investments have and 
continue to build foundations to prepare and respond to the current 
COVID-19 pandemic, and help countries more broadly prevent, detect, and 
respond to infectious disease threats. Building upon decades of 
investment in life-saving health and humanitarian assistance, the 
American people should be proud of the real results we are achieving 
through our help to nations around the world, which also helps protect 
the homeland. Stopping outbreaks at their source protects U.S. national 
security, and the lifesaving impact of our bilateral efforts remain 
fruitful components in our diplomatic relationships.

    Question. With the world experiencing the worst public health 
disaster in the last 100 years, it is difficult to understand why the 
Administration would decide now is the right time to suspend funding 
and withdraw from the World Health Organization. While China has been 
used as the pretext for this withdraw, this decision will play into 
China's hands and possibly strengthen their role at WHO: How does the 
Administration plan to allocate funding that would otherwise be 
obligated to WHO, particularly in countries like Venezuela and Yemen 
that are particularly difficult for U.S. implementers to operate?

    Answer. On May 29, 2020, the President announced that the United 
States will be terminating its relationship with the WHO and 
redirecting WHO-related funding to other deserving and urgent global 
health organizations and needs around the world. While the United 
States was by far the leading contributor to the WHO, those 
contributions represented a small fraction--just four percent--of total 
U.S. funding to global health assistance every year. There is a wide 
range of excellent implementing partners available to us, partners that 
value transparency and are better able to provide value for American 
taxpayers. In many cases, our teams in the field and here in Washington 
have already identified alternate implementers in challenging 
environments, such as World Vision in Afghanistan, the International 
Medical Corps in Iraq and the International Rescue Committee in Syria, 
and in environments where we do not discuss the names of our partners 
due to safety and operational considerations.

    Question. How do you assess the role of PAHO in providing support 
to Latin America and the Caribbean countries during the pandemic?

    Answer. PAHO plays a critical role in the Americas to prevent, 
detect, prepare and respond to a COVID-19 outbreak. PAHO has activated 
regional and country incident management system teams to provide direct 
emergency response to regional Ministries of Health and other national 
authorities for surveillance, laboratory capacity, support to health 
care services, infection prevention control, clinical management and 
risk communication; all aligning with priority lines of action. PAHO 
has developed, published, and disseminated evidence-based technical 
documents to help guide PAHO Member States' strategies and policies to 
manage this pandemic in their territories. PAHO has also been critical 
to advancing lab support and detection in the region, including inside 
Venezuela and throughout the Caribbean. PAHO is the only Organization 
in the region supplying COVID-19 testing kits and supplies.

    Question. In light of the pandemic, will the Administration 
reconsider its PAHO budget request that would cut funding so 
significantly?

    Answer. We remain committed to PAHO and understand it plays a 
critical role in the Americas to prevent, detect, prepare and respond 
to a COVID-19 outbreak. The United States is the largest funder of 
PAHO, providing 59.4 percent of assessed contributions to PAHO, in 
addition to voluntary funding from USAID and the HHS Centers for 
Disease Control (CDC). That said, the United States remains deeply 
troubled by the role PAHO played in facilitating the provision of Cuban 
doctors for Brazil's Mais Medicos program. This is the basis of a 
pending lawsuit filed by several Cuban doctors against PAHO in U.S. 
federal district court. The United States must ensure U.S. tax dollars 
are in no way contributing to any program that may have involved human 
trafficking, as alleged in the lawsuit. At the same time, Secretary of 
State Pompeo has approved the continuation of limited U.S. foreign-
assistance health-related funding to PAHO to implement critical health-
related activities in the region, including in Venezuela.

    Question. How would a U.S. withdrawal from the WHO impact our 
support for PAHO?

    Answer. A withdrawal from the WHO does not affect our relationship 
with PAHO. The United States remains a member state of PAHO and 
supports its unique and important role in the region as the oldest 
public health organization of its kind. While PAHO serves as a regional 
office of the World Health Organization (WHO), a U.N. Specialized 
Agency, PAHO is also an independent organization with its own 
Constitution, membership, and legal personality. PAHO is also 
recognized by the Organization of American States (OAS) as a 
specialized organization of the inter-American system.

    Question. I am particularly concerned about the impact of COVID-19 
on Venezuela, as the country's health care system was collapsing even 
prior to the pandemic. How much U.S. humanitarian assistance may be 
required for Venezuela beyond the $12.3 million announced, as of late 
May 2020, to address COVID-19?

    Answer. The COVID-19 crisis has exacerbated humanitarian needs 
among vulnerable populations in the Bolivarian Republic of Venezuela. 
As you noted, Senator, health care in Venezuela was already near 
collapse prior to the pandemic of COVID-19 because of the emigration of 
healthcare workers during the ongoing crisis, interruptions of 
electricity and water that have resulted in the deterioration of 
hospital infrastructure, and the acute shortage of medicines. Further, 
assessing the extent of the impact of COVID-19 in the country is 
challenging because of the lack of transparency from the illegitimate 
Maduro regime. Venezuelan health actors continue to express concern 
that the COVID-19 caseload and death rate are significantly higher than 
the numbers officially reported.
    A further strain on health care in Venezuela during the pandemic is 
the return of more than 80,000 Venezuelans from Colombia and other 
neighboring countries since March, many of whom require additional 
health, financial, and livelihood support. In addition, the Maduro 
regime has enforced mitigation measures on returnees who arrive through 
formal border crossings; they must quarantine in overcrowded, 
unsanitary makeshift shelters, often operated by the Venezuelan 
military, where they face heightened protection risks and cannot follow 
proper physical-distancing protocols.
    Not only are Venezuelan health institutions ill-equipped to manage 
the outbreak, but the ongoing nationwide restrictions imposed by the 
Maduro regime have reduced livelihood opportunities and the 
availability of food and fuel. Beyond providing direct humanitarian 
assistance, the U.S. Government (USG) continues to advocate for 
unfettered humanitarian access and improved coordination and 
information-sharing.
    Since Fiscal Year (FY) 2017, the USG has provided more than $856 
million in development and humanitarian assistance for programs inside 
Venezuela and across 17 neighboring countries. Since the beginning of 
FY 2020, the USG has provided more than $76 million in lifesaving 
humanitarian assistance and over $12.3 million in COVID-19 support 
inside Venezuela. This includes directly supporting the critical 
response to the pandemic, improving water and sanitation in schools and 
hospitals, distributing food for children and families, and protecting 
vulnerable groups inside Venezuela. The U.S. Agency for International 
Development is examining options for providing additional funding for 
health-related interventions against COVID-19 inside Venezuela.
    While the USG continues to be the largest humanitarian donor in 
Venezuela, a significant scale-up in funding and support is required to 
mitigate the impact of the pandemic of COVID-19 on the existing 
political and economic crisis. On May 26, 2020, the European Union and 
the Government of the Kingdom of Spain convened an international 
donors' conference to mobilize resources in support of Venezuelan 
migrants and refugees. The governments in attendance pledged nearly $3 
billion at the conference; the USG announced more than $200 million, 
the single largest commitment. The conference largely focused on how 
COVID-19 is exacerbating the ongoing humanitarian crisis caused by the 
corruption and tyranny of the Maduro regime. The USG continues to 
advocate for other donors to increase their financial contributions to 
respond to the crisis, especially inside Venezuela.

    Question. What is your assessment of the recent shipment of COVID-
19 aid that Iran sent to Venezuela?

    Answer. We see the increased Iranian shipments to Venezuela as Iran 
acting opportunistically to obtain desperately needed cash, while 
marketing the trade as primarily humanitarian in nature. However, 
recent shipments of food may have been accompanied by equipment for 
Venezuela's failing refinery infrastructure. To pay Iran for its 
assistance, the Maduro regime looted nine tons of gold, worth $500 
million.

    Question. How has COVID-19 impacted the obligation of other 
development, humanitarian, and global health funds? Please provide us 
with an update on the status of FY19 and FY20 funding.

    Answer. The State Department and the U.S. Agency for International 
Development (USAID) recognize that the COVID-19 pandemic is currently 
affecting, or could affect, the ability to obligate and expend funds 
appropriated by Congress for Fiscal Year (FY) 2019 and FY 2020. 
Following normal practice, State and USAID are working with posts 
throughout the world and Bureaus domestically to take the steps 
necessary to obligate all unobligated expiring resources prudently 
prior to the end of the Fiscal Year. Consistent with statutory 
provisions, State and USAID are continuing to transmit all required 
Congressional Notifications for expiring funds, and are committed to 
working to resolve any questions and concerns that the relevant 
Committees of jurisdiction raise.
    State and USAID both expect to obligate all expiring funds by the 
end of the Fiscal Year, and we are monitoring obligations closely.

    Question. What policy actions does the State Department intend to 
take to push back against negative trends in democracy and human rights 
that are tied to government responses to COVID-19?

    Answer. The United States is committed to the protection of 
democracy and human rights in the global response to the COVID-19 
pandemic. Strong respect for human rights is a necessary part of the 
solution to public health crises. Government responses to the COVID-19 
epidemic must focus on protecting public health, rather than using the 
disease as a pretext for repression of people or ideas.
    As a member of the Freedom Online Coalition, Media Freedom 
Coalition, Global Action on Disability network, Community of 
Democracies, and Open Government Partnership, the United States, with 
its partners, has called upon governments to respect democratic values 
and human rights in their responses to COVID-19. The State Department 
will continue to lead multi-stakeholder initiatives, as well as 
leverage bilateral and multilateral diplomacy and foreign assistance, 
to advance democratic norms and combat authoritarian responses to the 
COVID-19 pandemic.

    Question. Will you commit to the importance of equitable and 
affordable vaccines for the whole world regardless if it is developed 
for COVID-19?

    Answer. In February, the United States pledged $1.16 billion to 
Gavi, the Vaccine Alliance, over 4 years. This marks the largest U.S. 
commitment to Gavi to date, and reaffirms our commitment to 
strengthening global health security and combatting the spread of 
infectious diseases through the delivery of safe and effective vaccines 
to at-risk populations across the world. On top of investments in Gavi, 
the United States supports the work of UNICEF and has invested over $2 
billion towards Polio eradication, including through investments in the 
Global Polio Eradication Initiative, which seeks to end polio by 2023 
through delivery of routine and targeted vaccination campaigns in 
endemic and outbreak countries.
                             lgbtqi rights
    This month marks Pride Month--which recognizes people of varying 
sexual orientations and gender identities across the world. I am deeply 
concerned that the United States has abdicated its historic leadership 
role in upholding the human rights of all people. Already facing 
stigma, violence, and discrimination in their communities prior to the 
pandemic, there have been multiple reports that LGBTQI+ people are 
being scapegoated for the spread of the disease. Notably, last month 
for the International Day against Homophobia, Biphobia, Intersexism, 
and Transphobia, the United States did not sign onto U.N. statements 
about the unique risks that LGBTQI+ people face in the context of 
COVID-19:

    Question. Why did the United States fail to join these statements?

    Answer. U.S. policy on LGBTI human rights around the world is 
focused on mitigating violence and the decriminalization of LGBTI 
conduct. The statements issued by the Core Group included broad 
language that went beyond the scope of the Department's policy mandate. 
The United States' longstanding commitment to protecting the human 
rights and fundamental freedoms of all people, including LGBTI persons, 
is well-known. So too is its sovereign interest in ensuring that any 
statements it joins are consistent with U.S. law and policy.
    In this case, a virtual abbreviated negotiation process for a 
lengthy statement made it preferable to release our own statement, 
which was posted on the USUN Mission's website and social media 
accounts.

    Question. How is the United States promoting the human rights of 
LGBTQI+ people in the context of COVID-19?

    Answer. The State Department and USAID have been at the forefront 
of the U.S. Government's response to the impact of the global COVID-19 
crisis on democracy and human rights. The Department has established a 
COVID-19 Working Group spearheaded by the Bureau of Democracy, Human 
Rights, and Labor (DRL) to track foreign governments' autocratic and 
abusive responses to COVID and to coordinate and promote democratic and 
human rights-respecting responses instead.
    Since the launch of our COVID working group on April 9 at a large 
NGO virtual roundtable, DRL has hosted more than 50 additional external 
consultations with more than 100 NGOs. Our partners have highlighted 
COVID-19-related disinformation and other malign influence, growing 
authoritarianism, crackdowns on fundamental freedoms, expanded use of 
surveillance tools, and targeting of vulnerable groups, including LGBTI 
persons.
    These consultations have been instrumental in helping the 
Department adapt and implement programming in response to the crisis. 
We recognize that the LGBTI community is often a target of abuse where 
governments conveniently cloak crackdowns on fundamental freedoms as 
efforts to respond to the pandemic. The Department is working with our 
civil society partners to make current LGBTI programs flexible and 
responsive to the impact COVID-19 is having on the human rights of 
individuals in this community.
    In response to COVID-19, USAID has worked to ensure that existing 
funds--both from USAID and bilateral partners such as Canada and 
Sweden--can be used flexibly to address the most urgent challenges 
facing LGBTI people in developing countries. Additionally, USAID is 
working to incorporate LGBTI considerations into broader COVID-19 
emergency response efforts.

    Question. How is the United States monitoring human rights abuses 
against LGBTQI+ people in the context of COVID-19?

    Answer. The State Department has established a COVID-19 Working 
Group spearheaded by the Bureau of Democracy, Human Rights, and Labor 
(DRL) to track foreign governments' autocratic and abusive responses to 
COVID. DRL has hosted more than 50 external consultations with more 
than 100 NGOs and is documenting cases of COVID-19-related 
disinformation and other malign influence, growing authoritarianism, 
crackdowns on fundamental freedoms, expanded use of surveillance tools, 
and targeting of vulnerable groups, to include LGBTI persons. These 
consultations have been instrumental in helping the Department to adapt 
and implement LGBTI programs that are flexible and responsive to the 
impact COVID-19 is having on the human rights of individuals in this 
community.

    Question. What steps has the U.S. taken to ensure that our 
international assistance, especially with respect to global health 
programming, is being carried out in a non-discriminatory and inclusive 
manner when other governments may not have protections in place for 
vulnerable populations?

    Answer. USAID integrates inclusion and nondiscrimination principles 
into its policies and programming, and advances inclusion and 
nondiscrimination through programs that address the specific needs of 
marginalized and vulnerable populations. In all programs, USAID 
continues to enforce its nondiscrimination policies for access to 
services to beneficiaries, which ensure that no USAID contractor or 
grant recipient discriminates against any beneficiary for any reason.
                                 ______
                                 

             Responses of Mr. Chris Milligan to Questions 
                    Submitted by Senator Ben Cardin

                              ventilators
    The administration has touted the distribution of U.S.-made 
ventilators to countries overseas as a large success. However, many are 
concerned by a lack of details regarding USAID's distribution of 
ventilators and the strategy behind it.
    Question. To date, how much funding has been spent on these 
ventilators? How many countries have received ventilators? And how is 
the Administration deciding which countries receive them? Specifically, 
can you walk us through the decision to provide 200 ventilators to 
Russia? As you know, ventilators are complex medical machines that 
require training and maintenance to operate successfully. How are we 
ensuring that medical professionals in countries receiving these 
ventilators have the proper training to operate and maintain these 
machines?

    Answer. The total funding spent on ventilators is $195.7 million. 
USAID has delivered U.S. manufactured ventilators to ten countries as 
of June 18, 2020.
    The COVID-19 pandemic is worldwide: Nearly all countries are either 
experiencing the effects of the virus or are at risk of shortly 
experiencing transmission, morbidity and mortality. Up to 20 percent of 
all COVID-19 patients are expected to require at least supplemental 
oxygen; the most-critical patients require intensive care and assisted 
ventilation. The COVID-19 pandemic has been particularly acute in the 
Russian Federation.
    A total of 44 countries (with NATO) are receiving ventilator 
donations. USAID does not have visibility into the parameters for 
country selection within the larger USG ventilator donation program. We 
would advise engaging HHS and NSC for this status.
    In alignment with Pillar IV of the U.S. Government Action Plan to 
Support the International Response to COVID-19, USAID procured U.S. 
manufactured plans to use ESF resources to support the Russian 
Government to implement an immediate, critical, life-saving response to 
COVID-19 by providing 200 ventilators and related commodities and 
consumables. The recipient of the equipment is expected to be a Federal 
State Budgetary Institution, ``National Medical and Surgical Center 
named after N.I. Pirogov'' of the Ministry of Healthcare of the Russian 
Federation. In light of the urgent need for this assistance to address 
the pandemic in Russia, notifying these funds in accordance with the 
regular notification procedures would pose a substantial risk to human 
health and welfare.
    USAID is coordinating with host country Ministries of Health to 
assess overall capacity to provide respiratory care for critically ill 
patients suffering from COVID-19, as well as health facilities' 
capacity to provide critical care and use ventilators safely and 
effectively. USAID is facilitating setup and orientation support for 
ventilator deliveries led by manufacturers. USAID is also offering 
targeted technical assistance where needed, using assessments conducted 
with Ministries of Health and implementing partners to guide this 
support. In addition, USAID is providing access to a global distance 
learning portal and a technical hotline for health providers to tap 
into subject matter expertise.
                                  ppe
    I was pleased by the Administration's recent decision to re-allow 
U.S. international assistance to be used to purchase PPE, like masks 
and gloves, to protect healthcare workers on the frontlines of fighting 
COVID-19 overseas. However, the new policy only allows the purchase of 
PPE that is regionally produced.

    Question. Are essential PPE like N95 masks produced in sub-Saharan 
Africa, southern Asia, and the other resource-limited areas? Will 
healthcare workers be able to access the PPE they need to protect 
themselves and patients under the revised policy, or will they continue 
to face challenges?

    Answer. This guidance adheres to the White House's guidance to 
reduce competition for PPE with the U.S. market, while allowing our 
countries and staff a great degree of flexibility and freedom to 
protect themselves and continue to implement life-saving programs.
    A number of countries throughout the regions where USAID works have 
the manufacturing know-how and capacity to produce essential personal 
protective equipment, however, which country or region is producing 
what types of PPE is highly variable. Many regionally-produced types of 
PPE are emerging from countries such as the Middle East, South Asia, 
and East Asia, whereas the continent of Africa as a whole may have less 
experience in producing complex types of PPE such as respirators. For 
this reason, USAID's PPE guidance allows for exceptions on the regional 
and locally produced elements. For beneficiaries of USAID programs, 
Covered Materials should be procured from local or regionally-
manufactured sources. However, in the case where a country does not 
have access to local or regional suppliers, or if they find products 
with a better price or higher quality elsewhere, they are permitted to 
procure Covered Materials produced in regions other than the region in 
which the country itself is located, with written Agreement Officer/
Contracting Officer approval and the understanding that these products 
are not, and reasonably could not, be intended for the U.S. market.
    Anyone receiving financial compensation from a USAID implementing 
partner is considered to be staff, and can therefore procure and use 
Covered Materials from any source, not just regional or local sources. 
In many situations, government-employed healthcare workers and Ministry 
of Health employees are implementing partners of USAID and those 
healthcare workers are therefore able to procure and use Covered 
Materials from any source. This guidance enables healthcare workers to 
access the products and supplies they need to protect themselves and 
patients. Furthermore, only the items considered ``Covered Materials'' 
are under any type of procurement restrictions--other types of PPE, 
hand sanitizer, and cleaning suppliers are not under procurement 
restrictions.
                               ebola/who
    USAID and other U.S. agencies, including the CDC, worked closely 
with WHO in responding to the Ebola outbreak in the Democratic Republic 
of the Congo since 2018.

    Question. With reports of new cases in the western part of the 
country, how will the U.S. continue to provide assistance in the fight 
against Ebola outside the WHO framework?

    Answer. Historically, USAID's response to outbreaks of Ebola in the 
Democratic Republic of Congo (DRC) has been coordinated with WHO and 
U.N. leadership, but we always directly fund U.N. and NGO partners to 
ensure any gaps in critical response operations are filled.
    USAID has more than 20 active United Nations and non-governmental 
organization partners responding to Ebola in eastern DRC. These 
partners have the flexibility to respond country-wide, supporting 
activities to prevent and control infections in health facilities, 
enhance disease surveillance, train health-care workers, and educate 
and engage communities on health behaviors. Two USAID partners, the 
International Medical Corps and the Alliance for International Medical 
Action, have already leveraged the geographic flexibility and rapid 
response capabilities in their awards and are currently providing case 
management support in western Equateur province.
    DRC's Minister of Health is leading the response to the Ebola 
outbreak in Equateur, while the U.N.'s Humanitarian Coordinator and the 
Office for the Coordination of Humanitarian Affairs (OCHA) is providing 
critical coordination support to international response actors. USAID 
is closely tracking the situation unfolding in northwestern DRC and is 
assessing other potential areas of support. Additionally, USAID is 
coordinating closely with all response stakeholders, including other 
donors, to identify needs and ensure an efficient and effective 
response to this new outbreak.
                           program oversight
    In March, the State Department authorized the return to the United 
States of high-risk U.S. government personnel from diplomatic or 
consular posts abroad. USAID and the Millennium Challenge Corporation 
followed State Department guidance, while the Peace Corps suspended all 
operations worldwide.

    Question. What has been the impact of these evacuations on program 
operations, both for existing and new programs? How has reduced staff 
capacity in the field affected oversight of programming?

    Answer. Following the State Department's Global Authorized 
Departure, U.S. employees at high-risk were evacuated to the United 
States, where they immediately continued their normal duties by 
teleworking. Even with staff evacuating on Global Authorized Departure, 
all operating units had U.S. employees, including supervisors, 
remaining, with the exception of one small country office. Under the 
in-country leadership of these remaining U.S. and host country staff, 
and with the support of employees teleworking from the United States, 
USAID continues program operations.
    USAID has been able to continue operations without reducing program 
oversight by using available technology. However, restrictions on 
movement imposed by overseas public health authorities have, in some 
posts, reduced our ability to engage in-person with beneficiaries, 
implementers, and host-government officials. USAID has worked to 
overcome these restrictions by advising our Missions on how to 
effectively use remote monitoring techniques, including cell-phone 
monitoring, accessing data from institutional monitoring systems, and 
direct monitoring through satellite data and geospatial information. 
USAID has also created an online forum to share monitoring and 
evaluation best practices as well as lessons learned during COVID-19.
                       covid-19 in latin america
    The leaders of Brazil, Mexico, and Nicaragua have played down the 
threat of COVID-19 and failed to take adequate actions to stem its 
spread. There are also concerns that several countries in the region 
are undercounting their COVID-19 death tolls.

    Question. To what extent do you share these concerns? How might the 
United States play a role in convincing governments to adequately 
address the spread of COVID-19 and be transparent in reporting COVID-19 
cases and deaths?

    Answer. Combating the COVID-19 pandemic will require an 
unprecedented level of global trust, transparency, and accountability, 
particularly in the areas of accurate case and death reporting. With 
the generous support of Congress, through the COVID-19 supplemental 
funding, USAID has been able to promote these best practices in many 
countries around the world. For example, with COVID-19 Supplemental 
funding in many conflict-ridden and vulnerable countries, USAID is 
supporting activities to counter misinformation and disinformation, 
bolster the independent and free flow of media, journalism, and 
information, and support citizen-led governance, civil society, and 
good governance efforts. Additionally, USAID has advanced efforts to 
disseminate in local languages scientific-based risk and behavior 
change materials, and supports surveillance, digital methods of 
tracking cases, points-of-entry screening, case reporting, and contact 
tracing, all of which lead to increased visibility and transparency 
into the accurate numbers of COVID-19 cases. By working with Ministries 
of Health and other local leaders in our partner countries, USAID can 
play a key role in convincing governments and leaders that accurate and 
timely reporting of COVID-19 cases is a strength that will allow for 
quicker assistance, better communication and messaging to their people, 
a reduction in caseload, earlier preparation for infection prevention 
and control in facilities, and most importantly, a reduction in 
livelihoods and lives lost due to the pandemic.
                             immunizations
    The WHO has reported that the pandemic has disrupted routine 
immunization services in at least 68 countries, putting more than 80 
million children at risk of becoming infected with polio, measles, 
diphtheria and other diseases. The resulting disease burden from 
outbreaks of vaccine-preventable illnesses may be devastating for 
already weak and stretched healthcare systems in developing countries.

    Question. How has the pandemic impacted USAID's immunization 
programs, and how will USAID help restore and strengthen immunization 
services globally?

    Answer. COVID-19 and its global spread has resulted in the 
disruption of immunization services worldwide, including the suspension 
of campaigns against epidemic-prone diseases, such as polio and 
measles. Among the 25 high-burden countries prioritized for USAID 
maternal and child health (MCH) efforts, since March 2020, 20 have 
experienced or are projected to experience disruptions in campaign 
activities for polio, measles, yellow fever, and other vaccine-
preventable diseases. In addition, USAID partners report reduced demand 
for immunizations in 14 of 22 MCH priority countries.
    To address these challenges, USAID--in partnership with Gavi, the 
Vaccine Alliance, and others--is supporting country governments to plan 
for catch-up vaccination campaigns and to promote improved infection 
prevention and control efforts by immunization service providers to 
prevent the spread of COVID-19. USAID and partners are adapting 
immunization delivery strategies, developing strategies to track and 
follow-up with individuals who missed vaccinations, monitoring 
reductions in vaccine coverage, and re-establishing community trust and 
demand for vaccination. USAID is committed to continuing support to 
minimize the effects of immunization service disruptions, respond 
rapidly to outbreaks of vaccine preventable diseases, and protect 
health workforces, even as we address the direct effects of the COVID-
19 pandemic.
                                 ______
                                 

             Responses of Mr. Garrett Grigsby to Questions 
                    Submitted by Senator Ben Cardin

                                  who
    I believe freezing aid to the WHO and withdrawing the U.S. is 
short-sighted and dangerous.
    Question. What reforms was the Administration seeking from the WHO?

    Answer. The United States is working with other likeminded WHO 
member states on a number of areas of concern with WHO's preparedness 
and response that have come to light due to the outbreak of COVID-19. 
These proposals focus on member state compliance with the International 
Health Regulations as well as strengthening WHO's leadership, allowing 
them to be more independent and empowered to call out concerns about 
member states' failure to comply with the IHRs. Reforming the process 
for declaring a Public Health Emergency of International Concern 
(PHEIC) is being discussed, as well as delinking travel from trade 
restrictions. The President also articulated the specific concerns of 
the United States in his May 18, 2020 letter to WHO Director-General 
Tedros.

    Question. Why did the administration announce the withdraw from the 
WHO 10 days after telling the organization it had 30 days to make these 
reforms?

    Answer. The President announced on May 29, 2020 his determination 
that it was in the best interest of the United States to ``terminate 
its relationship'' with the WHO. On July 6, the United States deposited 
its notice of withdrawal from the WHO with the U.N. Secretary General, 
the depositary of the WHO Constitution, effective July 6, 2021.

    Question. Which alternative implementers has the interagency review 
panel found who can step into the gap while assistance to the WHO is 
suspended? Are you worried about a lack of coordination and decreased 
effectiveness through using non-WHO implementers?

    Answer. The United States collaborates with many partners on global 
health. Funding that was previously provided to WHO will, to the extent 
permitted by law, be redirected to these partners. We will work to 
ensure coordination and effectiveness with these partners, as 
appropriate and feasible. The interagency is reviewing all 
collaborations to discover if there are certain activities that only 
WHO can undertake and, if this is the case, decisions will be made 
about how to deal with this situation.

    Question. How does the U.S. plan to partner with other countries on 
global health initiatives without being a WHO member?

    Answer. The United States' partnership with many countries on 
global health is not dependent upon our membership in WHO. U.S. 
leadership on global health has been uncontested for decades and that 
will remain so. In fact, several signature U.S.-led global health 
initiatives, such as the President's Emergency Plan for AIDS Relief and 
the President's Malaria Initiative , were created, in part, because the 
international community, including WHO, were not able to put sufficient 
resources toward fighting HIV/AIDS or malaria. The United States 
Government is committed to maintaining and even strengthening our 
leadership in the field of global health, notwithstanding our 
relationship with WHO.

    Question. The U.S. has invested heavily in WHO-led polio 
eradication efforts, as the WHO is the only global entity with safe 
access to polio hotspots in places experiencing conflicts, including 
Afghanistan. How will the U.S. continue to be a global leader in polio 
eradication efforts without the support WHO provides?

    Answer. The interagency is reviewing all collaborations to discover 
if there are certain activities that only WHO can undertake and, if 
this is the case, decisions will be made about how to deal with this 
situation.
                            solidarity trial
    Among other activities, WHO is leveraging its global reach and 
convening power to support an unprecedented effort to identify 
effective treatments and vaccines for COVID-19. The organization's 
``Solidarity Trial,'' in which more than 100 countries are now 
participating, could--due to its wide geographic breadth and inclusion 
of diverse demographic groups under one umbrella--reduce the time 
needed to evaluate the effectiveness of specific treatment regimens by 
80%.

    Question. Do you think it is important for the U.S. to support 
these types of global trials? Why is the United States not joining this 
effort when it could help Americans and American companies?

    Answer. The United States has contributed significantly to the 
establishment of the Solidarity Trial by writing the master clinical 
trial protocol used. This is critical because the majority of on- going 
clinical trials globally are observational or under-powered and will 
not result in data that can be used to support safety and efficacy of 
investigational therapeutics. The United States, through leadership at 
HHS' National Institutes of Health, has launched a series of robust 
clinical trials targeting: (1) the re-purposing of products licensed 
for another indication for activity against SARS-CoV-2; (2) novel 
therapeutics; (3) convalescent plasma; and (4) neutralizing monoclonal 
antibodies targeting the virus. In undertaking these studies directly, 
the U.S. has moved out significantly faster in enrolling patients in 
robust clinical trials, making determination of investigational 
products' efficacy, and sharing these results with the global 
community.
                          operation warp speed
    The U.S. is focused on developing a safe and effective COVID-19 
vaccine through Operation Warp Speed.

    Question. In addition to securing a vaccine for domestic 
distribution, will the U.S. also be a partner in the global effort to 
develop and distribute a COVID-19 vaccine?

    Answer. Although Operation Warp Speed's primary mission is to 
advance medical countermeasure development to accelerate the 
availability of products for use by Americans, we believe that such 
work advances global efforts to develop critical tools to combat COVID-
19 and would expect that our commercial partners would ultimately make 
any approved COVID-19 vaccines available globally as well. Moreover, 
the Administration is examining ways to leverage the expertise of key 
U.S. Government departments and agencies and the American private 
sector to rapidly deploy and deliver essential support to other 
countries to prevent, detect, and respond to infectious disease 
outbreaks at their source.
                                 ______
                                 

             Responses of James L. Richardson to Questions 
                    Submitted by Senator Chris Coons

    Question. In December 2019, the U.S. Congress passed the bipartisan 
Global Fragility Act (GFA), which calls for a new strategy to address 
the root causes of violence fragility around the world. The GFA 
requires a dramatic shift from the status quo and requires a 
coordinated, proactive, multi-sectoral, locally-driven, and evidence-
based approach.
    The Trump administration's current strategy to address to global 
consequences of the COVID-19 pandemic prioritizes four pillars, 
including: protecting American interests, bolstering health systems, 
and addressing complex humanitarian crises. The fourth pillar calls for 
preparing for, mitigating, and addressing second-order economic, 
civilian security, stabilization, and governance. I am concerned that 
this strategy does not adequately address the issues of fragility and 
focuses instead on the emergent needs of the pandemic.
    Will you advocate for a U.S. Government strategy to combat COVID-19 
that includes a focus on fragility and adequately addressing the issues 
that will be exacerbated by the global pandemic and contribute to the 
increased spread of violence and violent extremism?

    Answer. Since the outbreak of COVID-19, the State Department and 
USAID have committed more than $1.3 billion in emergency health, 
humanitarian, economic and development assistance to help fight the 
pandemic. A portion of this assistance helps governments, civil 
society, and the private sector to prepare for, mitigate, and address 
the second-order economic, civilian-security, stabilization, and 
governance effects in fragile states caused by COVID-19. This includes 
over $13 million dollars committed thus far to Pillar IV programming in 
fragile states and an additional $11 million to peace and security 
programming. This work will promote democracy in Libya, support media 
and civil society organization-led awareness campaigns in the DRC and 
the Central African Republic (CAR), and improve the capacity of host 
country governments in the Sahel to communicate COVID-19 prevention, 
management, and response messages. The Global Fragility Act and its 
associated strategies and plans will be a crucial tool in successfully 
addressing COVID-19's impact on conflict and fragility.

    Question. How will the State Department seek to develop a Global 
Fragility Strategy that addresses the increased risk that COVID-19 
presents in fragile states?

    Answer. The White House is coordinating an interagency process to 
implement the GFA and corresponding Global Fragility Strategy. The 
Department of State leads the drafting and execution of the GFS, with a 
five-phase approach that includes initial scoping, consultation, 
drafting, country and region selection, and country plan development. 
The GFS will help identify the underlying causes of fragility, 
violence, and conflict; articulate more effectively how to use U.S. 
taxpayer dollars; foster greater transparency, accountability, adaptive 
and locally-based approaches; and demand measurable and meaningful 
outcomes. Underpinning the development of the GFS is a dynamic analytic 
approach that can take into account new and evolving developments, 
including the impact and risks that COVID-19 will have on fragility and 
conflict. By pursuing an innovative, data-driven, consultative approach 
through the GFA, the U.S. Government can better mitigate threats to its 
core national security interests and more effectively address the 
drivers of global conflicts and fragility.
                                 ______
                                 

             Responses of Mr. Chris Milligan to Questions 
                    Submitted by Senator Chris Coons

    Question. On April 28, Acting Administrator Barsa released a press 
statement on the New Partnerships Initiative where he focused on the 
COVID-19 response, saying that ``USAID is pursuing all options for an 
effective response, including by working with new or underutilized 
partners that can provide innovative, scalable solutions to address the 
pandemic.'' What results has the agency achieved in utilizing new and 
underutilized partners to date in combatting the consequences of the 
global pandemic around the world?

    Answer. Throughout our response to the COVID-19 pandemic, USAID is 
committed to working with new, underutilized, local, and locally 
established partners as defined by our New Partnerships Initiative. 
Thus far, just over 4 percent of our total obligations for COVID-19 
funds have gone to new and underutilized partners, totaling over $26.4 
million. Additionally, many of USAID's prime partners are expanding 
their association with local sub-partners to effectively respond to 
COVID-19.
                                 ______
                                 

             Responses of Mr. Garrett Grigsby to Questions 
                    Submitted by Senator Chris Coons

    Question. Do you believe U.S. based, multinational companies will 
be adversely impacted by WHO policy recommendations once the Trump 
administration terminates its relationship with the WHO?

    Answer. The United States will continue to advocate for U.S. 
companies, as appropriate, in multilateral fora directly or in 
collaboration with allies. We will work together to ensure that policy 
recommendations are based on science and the best available evidence 
and do not disadvantage American interests.

    Question. Do you believe that the United States has more or less 
leverage to advocate for the interests of U.S. based, multinational 
companies in the WHO after termination of the U.S. relationship with 
the WHO?

    Answer. The United States will participate actively and advocate 
effectively for its interests, including, as appropriate, the interests 
of the U.S. private sector. This is also why the WHO reform package the 
U.S. Government is leading on is necessary and why we have proposed 
that trade and travel restrictions be delinked when responding to 
health emergencies. This particular reform would seek to ensure that 
private sector partners can continue to deliver products and produce 
needed health supplies and get these goods into the hands of those who 
need them.



COVID-19 AND U.S. INTERNATIONAL PANDEMIC PREPAREDNESS, PREVENTION, AND 
                                RESPONSE



    PART 2: COVID-19 AND U.S. INTERNATIONAL PANDEMIC PREPAREDNESS, 
           PREVENTION, AND RESPONSE: ADDITIONAL PERSPECTIVES

                              ----------                              


                         TUESDAY, JUNE 30, 2020

                                       U.S. Senate,
                            Committee on Foreign Relations,
                                                    Washington, DC.
    The committee met, pursuant to notice, at 10:05 a.m. by 
videoconference, Hon. James E. Risch, chairman of the 
committee, presiding.
    Present: Senators Risch [presiding], Menendez, Cardin, 
Shaheen, Gardner, Udall, Murphy, Merkley, Perdue, and Booker.

           OPENING STATEMENT OF HON. JAMES E. RISCH, 
                    U.S. SENATOR FROM IDAHO

    The Chairman. Well, good morning, everyone. The hour of 
10:00 a.m. having arrived, I am going to call this meeting of 
the Foreign Relations Committee to order.
    And I want to thank all of you for participating. We have 
very important business for the committee today, and this is 
the second in a series on the international response to the 
COVID-19 pandemic and what we can do about it in the future of 
prevention, preparedness, and response.
    Let me take just a moment to talk about what we are 
attempting to do here. You know, around here in the Senate, 
exaggeration and hyperbole is kind of the order of the day, and 
so I am always reluctant to say this truly could be one of the 
most important things we, as members of this committee, do.
    What the world is experiencing today, what the United 
States of America is facing today, is one of the most 
significant challenges that a lot of us will face in our 
lifetime.
    The bad news, the really bad news, is that it is entirely 
possible that it will happen again, and I say this, of course, 
because the experts tell us that this virus that made the leap 
from one species to another, from bat species to human species, 
can very easily happen again and that there are 2,000 of these 
viruses out there. We have no idea what they can do when they 
get into a human being.
    The bat populations, the experts and scientists tell us, 
have had identified within their ranks about 2,000 different 
viruses.
    So having said that, we need to look forward, and I want to 
stress what I am trying to do with this and what I hope all of 
us will be joining and trying to do is to look forward.
    I believe there is a lot of hearings going on. There is a 
lot of hyperbole going on. There is a lot of finger pointing 
and a lot of blame assignment.
    But that is not what I am trying to focus on here and I 
hope we would all avoid that. Certainly, a person cannot help 
but think about how this happened, who is responsible for this, 
who could have done things better.
    We do want to see how we could do things better. But I 
would hope, I would sincerely hope, that all of us are 
committed to the idea that what we are trying to do is to keep 
from happening--keep this from happening again, not trying to 
tar and feather somebody that should have done things better in 
the past.
    I mean, there has been a number of criticisms levied 
against the World Health Organization. I have spent a 
considerable period of time talking to the people at WHO. I 
have been impressed with the fact that they themselves 
recognize that things should be looked at, and they, like us, 
are--would really like to see that things work better in the 
future. Heaven help us if this happens again.
    In any event, to that end, there has been legislation 
prepared. There has been a number of pieces of legislation, and 
I am going to urge the committee in the strongest way possible 
for everyone to get together and pull the wagon on this to get 
to the place where we can have a piece of legislation that will 
actually help in the future.
    As I said, there is--this future is so important when it 
comes to how we react next time. It is going to be very 
important, particularly if it turns out to be a worse virus 
than what--the world is not going to know probably what we did, 
and if we fail they probably will not even know that we made an 
effort at it.
    But all of us run for these offices because we want to make 
a difference, particularly into the future, and this is our 
opportunity to do this.
    This is my 40th year in a Senate body. I led a Senate body 
over two decades. I know good-faith effort when I see it, and I 
have seen a lot of good-faith effort here on a bipartisan basis 
to develop something as we go forward in the future.
    There is--of the 22 members on this committee, there is a 
tremendous pool of talent here on both sides of the aisle.
    Ranking Member Senator Menendez has spent many, many years 
in the service of the United States, dealing with the 
challenges, and they are challenges that we face with other 
countries. He brings that to the table, and much more.
    Across this committee, we have people who are--have been 
deeply involved in Committees on Health and Human Services, on 
Homeland Security, on Armed Services, Intelligence, and other 
committees. Everybody brings something to the table.
    What I am hoping is we have a product that will reflect the 
best of all of us in bringing the matter into a bill. As I have 
said over and over again, the bill that myself and Senator 
Murphy have introduced is written on paper. It is not written 
on stone.
    We want the best possible ideas and the best possible 
outcomes as we move forward. And everything is on the table and 
there is no pride of authorship here, and I hope everyone can 
set aside preconceived notions and move forward when we need, 
obviously, a more innovative approach to be brought to this 
problem, as it, hopefully, but probably will exist in the 
future. Hopefully, it will not, but probably will, exist in the 
future.
    We are fortunate to have with us a panel of experts with an 
impressive range of expertise today for infectious disease 
detection and treatment, diplomatic engagement, and emergency 
response, and we know that all of these are incredibly 
important as we put together a holistic approach to this 
problem.
    Each of you bring something unique to the table. Thank you 
for sharing your insights today. In our last hearing, we 
focused on a number of key issues including the need for World 
Health Organization reform.
    Again, simply because we talk about the World Health 
Organization reform we do not want to demonize people who have 
made incredible efforts to try to address the problems we have 
today.
    I am aware of the challenges and differences that several 
of our panelists faced when they worked with World Health 
Organization during the Ebola outbreak in West Africa, which, 
ultimately, led to a number of things that bring us to where we 
are here today.
    While some structural improvements have been made to the 
World Health Organization since the Ebola situation, it appears 
we may be repeating history today, though on a much grander and 
deadlier scale. After Ebola, of course, the Global Health 
Security Agenda was formed and it did not get us where we need 
to be either.
    Some have suggested that the World Health Organization has 
neither the mandate nor the capacity to hold countries 
accountable for failing to uphold obligations under the 
international health regulations, and that probably can be 
fixed.
    Indeed, as I talked with the World Health Organization, 
they made credible cases as to why they could not do some of 
the things that they really wanted to do. Those are things that 
we really need to--others have suggested that the World Health 
Organization does not have the will. That is a harder fix. But, 
again, we need to focus on what we could do about it.
    And so it is only appropriate for us to recognize what the 
World Health Organization is. It is a convening mechanism, a 
guardian of things, and a clearinghouse of norms and best 
practices, and we probably out to examine our own consciences 
and ask us if we are asking the World Health Organization to be 
something that it is not.
    I have repeatedly asked what entity to call when an 
outbreak begins before it gets out of control. What entity is 
the fire department?
    Again, I want to especially say that we should avoid 
condemning what happened in the past and look forward to the 
future. I have repeatedly been disappointed by the response as 
to who is the fire department.
    One thing is clear. It is not the World Health 
Organization, at least not as it exists today. That does not 
mean it cannot be fixed.
    So what entity is it and what entity responds to the alarm? 
The mandate capacity and will do not yet exist to whom and 
where should that be vested.
    That question is wide open and the answer that we need and 
the right answer is not an answer that is dictated by 
politically taking sides.
    What entity raises the alarm? How can we approve and expand 
early warning at a global level so we can get ahead of an 
outbreak before it gets out of control?
    The Global Health Security Agenda provides a useful and 
only a framework for addressing these issues. How can we more 
effectively operationalize it?
    As I said, our suggestions to point is only for discussion 
and written on paper, not stone. And how can we incentivize 
countries to prioritize global health security, strengthen 
preparedness and response, and share critical global health 
data? Is there a way we can better support countries that have 
demonstrated will but a low capacity to operationalize?
    More importantly, how do we incentivize innovation 
including from development, manufacturing, and equitable 
deployment of vaccines are a couple of the issues.
    These are difficult challenges that require serious 
solutions. Though we are rightly focused on the immediate 
COVID-19 response, particularly as the Southern Hemisphere 
moves into the winter months, we cannot afford to wait.
    This is not our first pandemic, and unless we can figure 
out some solutions, it will not be our last. We have put a 
number of ideas forward in a bipartisan bill, the Global Health 
Security and Diplomacy Act.
    It is a bill that we hope everyone will take as a starting 
point and as a discussion point. I am hopeful that our 
discussions today will help us further refine the ideas in that 
bill so we can answer these questions, chart a responsible path 
forward, save lives, and ultimately protect America from future 
waves of infection.
    I have been impressed by the way the committee had been 
working together. We are taking ideas from everyone. Senator 
Murphy and I continue to meet to try to--to try to 
operationalize the ideas that we are getting from other members 
of the committee.
    I thank our witnesses for their contributions to this 
inquiry. Yet, I strongly urge that if we are to succeed, and we 
must succeed for the future of America and the future of the 
world. We work on solutions and not necessarily on focusing of 
the failures of the most recent response.
    [The prepared statement of Senator James E. Risch follows:]

              Prepared Statement of Senator James E. Risch

    We will now convene the second hearing in a series on the 
international response to the COVID-19 pandemic, and the future of 
preparedness, prevention, and response.
    We are fortunate to have with us a panel of experts with an 
impressive range of expertise--from infectious disease detection and 
treatment, to diplomatic engagement and emergency response.
    You each bring something unique to the table. Thank you for sharing 
your insights today.
    During our last hearing, we focused on a number of key issues, 
including the need for WHO reform.
    I am aware of the difficulties several of our panelists faced when 
working with the WHO during the Ebola outbreak in West Africa--which 
ultimately led to a decision not to fund the WHO appeal, to request an 
interim review of the WHO's performance, and to advance a broader WHO 
reform agenda.
    While some structural improvements have been made since, it appears 
we may be repeating history--though on a much grander and deadlier 
scale.
    Some have suggested that the WHO has neither the mandate nor the 
capacity to hold countries accountable for failing to uphold 
obligations under the International Health Regulations. That can 
probably be fixed.
    Others have suggested that it does not have the will. That's a much 
harder fix. And so perhaps it's time for us to recognize what the WHO 
is--a convening mechanism, a guardian of the IHR, and a clearinghouse 
of norms and best practices--and stop asking it to be something it's 
not.
    I've repeatedly asked, ``Who do we call when an outbreak begins, 
before it gets out of control? Who is the fire department?''
    I've repeatedly been disappointed by the response.
    One thing is clear--it's not the WHO. At least not today.
    So who is it? Who responds to the alarm? If the mandate, capacity, 
and will do not yet exist, to whom and where should they be vested?
    Who raises the alarm? How can we improve and expand early warning 
at a global level, so we can get ahead of an outbreak before it spins 
out of control?
    The Global Health Security Agenda provides a useful framework for 
addressing these issues. How can we more effectively operationalize it?
    And how can we incentivize countries to prioritize global health 
security, strengthen preparedness and response, and share critical 
global health data?
    Is there a way we can better support countries with demonstrated 
will but low capacity?
    And, importantly, how do we incentivize innovation, including for 
the development, manufacturing, and equitable deployment of vaccines 
and counter-measures?
    These are serious challenges that require serious solutions.
    While we are rightly focused on the immediate COVID-19 response--
particularly as our friends in the Southern Hemisphere move into the 
winter months, and infections accelerate in places like Brazil, India, 
and across Africa--we cannot afford to wait.
    This is not our first pandemic and, unless we can figure out some 
solutions, it won't be the last.
    I've put a number of ideas forward in a bipartisan bill, the Global 
Health Security and Diplomacy Act. It's a bill that is written on paper 
and not on stone, and it continues to evolve.
    I am hopeful that our discussion today will help us further refine 
the ideas in that bill, so we can answer these questions, chart a 
responsible path forward, save lives, and, ultimately, protect America 
from future waves of infection.
    I thank our witnesses for their contributions to this important 
effort.
    With that, I will ask Ranking Member Menendez if he wishes to make 
any opening remarks.

    The Chairman. With that, I thank everyone again for joining 
us today. I will urge everyone to work in good faith to try to 
actually reach some conclusion. With that said, it is, I think, 
one of the most important things we will probably do with our 
service here in the United States Senate.
    With that, I want to recognize Senator Menendez for his 
remarks.

              STATEMENT OF HON. ROBERT MENENDEZ, 
                  U.S. SENATOR FROM NEW JERSEY

    Senator Menendez. Thank you, Mr. Chairman. Thank you for 
convening another hearing on the ongoing COVID-19 pandemic.
    As of June 26, 2020, the World Health Organization had 
recorded just under 9.5 million confirmed cases of COVID-19 and 
more than 484,000 deaths worldwide. More than 2 million of 
those cases are right here in the United States.
    This disease has claimed more than 120,000 American lives 
in the span of 5 months. I know it well because, unfortunately, 
at least 14,000 to 15,000 of those are from my home state of 
New Jersey.
    And it has proven resilient and pernicious, with new spikes 
across the United States and China, and alarming increases in 
the number of cases in South Africa, India, and Brazil.
    This pandemic presents one of the most complex and novel 
threats the United States, indeed, the world has faced in 
several generations and it is clear that even if we stop the 
spread of the disease here, which we certainly have not, 
without a serious global effort to understand and confront it, 
COVID-19 can and will return to our shores.
    If ever there was a need for the United States to be an 
active leader in an international coalition to respond to a 
common threat, it is now. We simply cannot safeguard American 
lives without one.
    Unfortunately, the United States has not yet risen to meet 
this challenge. We have seen a haphazard response, going so far 
as to effectively withdrawing from the very international 
institution best poised to respond to this crisis.
    We have alienated critical partners and have been absent at 
critical convening meetings, all of this at the expense of the 
health and safety of the American people.
    I believe there is more America can and must do, and that 
Congress has a critical role to play. In good faith, as you 
referred to, Mr. Chairman, in May all the Democratic members of 
this committee introduced comprehensive legislation laying out 
concrete actions the United States could take to lead in the 
global response.
    The COVID-19 International Response and Recovery Act, or 
CIRRA, presents a clear strategy to confront the ongoing 
pandemic and prepare the United States to deal with the next 
and compels the Trump administration to constructively engage 
with other countries, international organizations, and 
multilateral fora to stop the spread of this deadly pandemic.
    Specifically, our bill authorizes an additional $9 billion 
in funding to fight the COVID-19 pandemic through contributions 
towards vaccine research at the Coalition for Preparedness and 
Innovations; a contribution to the Global Fund for AIDS, 
Tuberculosis, and Malaria for its COVID-19 response mechanism; 
additional funding for emergency overseas humanitarian 
assistance in response to the pandemic, ensuring that these 
funds are provided both to the U.N. for its global response 
plan as well as directly to NGOs working on the front lines; 
and a new surge-financing authority at the U.S. International 
Development Finance Corporation that would allow the DFC to 
expedite decisions and make strategic investments quickly to 
aid in COVID-19 reconstruction efforts.
    CIRRA also puts in place mechanisms to help us better 
prepare for the next pandemic. It requires an annual 
intelligence estimate on pandemic threats and establishes a 
White House advisor for global health security to coordinate a 
whole of government U.S. response to global health security 
emergencies aimed at improving both domestic and international 
capacity to prevent, respond, and detect epidemic and pandemic 
threats.
    It clearly delineates the role for the State Department, 
USAID, and the Centers for Disease Control and Prevention in 
responding to pandemic threats, and it directs the U.S. 
executive director to the World Bank to begin negotiations to 
establish a trust fund at the World Bank designed not to 
compete with or supplant the World Health Organization, but to 
work in tandem with the World Health Organization on 
incentivizing countries to mobilize their own resources for 
epidemic and pandemic preparedness.
    Mr. Chairman, more than 700 Americans are dying each day. 
Neither the finger pointing blame game, race-baiting statements 
linked to the origins of the disease, nor a strategy centered 
on denial will win the battle against COVID-19.
    It is painfully apparent that Congress will have to lead in 
this effort, just as it led in domestic relief and recovery 
efforts.
    I enjoy, appreciate, and embrace your call for us to 
develop a proposal in the committee that boldly and robustly 
addresses the current crisis, ensures that we are adequately 
prepared for the next one, and aids countries across the globe 
with recovery.
    Anything less falls short of the legacy created through 
initiatives such as the president's emergency plan for AIDS 
relief and the Marshall Plan.
    So I welcome our witnesses as well and look forward to our 
discussion.
    [The prepared statement of Senator Robert Menendez 
follows:]

             Prepared Statement of Senator Robert Menendez

    Mr. Chairman, thank you for convening another hearing on the 
ongoing COVID-19 pandemic. As of June 26, 2020, the WHO had recorded 
just under 9.5 million confirmed cases of COVID-19, and more than 
484,000 deaths worldwide. More than 2 million of those cases are right 
here in the United States. This disease has claimed more than 120,000 
American lives in the span of 5 months. And it has proven resilient and 
pernicious, with new spikes across the United States and China, and 
alarming increases in the number of cases in South Africa, India and 
Brazil.
    This pandemic presents one of the most complex and novel threats 
the United States--indeed the world--has faced in a generation. And 
it's clear that even if we stop the spread of the disease here--which 
we certainly have not--without a serious global effort to understand 
and confront it--COVID-19 can and will return to our shores. If ever 
there was a need for the United States to be an active leader in an 
international coalition to respond to a common threat, it is now. We 
simply cannot safeguard American lives without one.
    Unfortunately, the United States has not yet risen to meeting this 
challenge. We have seen a haphazard response . . . going so far as to 
effectively withdrawing from the very international institution best 
poised to respond to this crisis. We have alienated critical partners, 
and have been absent at critical convening meetings. All this at the 
expense of the health and safety of the American people.
    I believe there is more America can--must--do, and that Congress 
has a critical role to play. In May, all the Democratic members of this 
Committee introduced comprehensive legislation laying out concrete 
actions the United States could take to lead in the global response. 
The COVID-19 International Response and Recovery Act, or CIRRA [SEAR-
Ah], presents a clear strategy to confront the ongoing pandemic and 
prepare the United States to deal with the next; and compels the Trump 
administration to constructively engage with other countries, 
international organizations, and multilateral fora to stop the spread 
of this deadly pandemic.
    Specifically, our bill authorizes:

   An additional $9 billion in funding to fight the COVID-19 
        pandemic through contributions towards vaccine research at the 
        Coalition for Preparedness and Innovations;

   A contribution to the Global Fund for AIDS, Tuberculosis and 
        Malaria for its COVID-19 response mechanism;

   Additional funding for emergency overseas humanitarian 
        assistance in response to the pandemic, ensuring that these 
        funds are provided both to the U.N. for its global response 
        plan as well as directly to NGOs working on the front-lines;

   And a new surge financing authority at the U.S. 
        International Development Finance Corporation (DFC) that would 
        allow the DFC to expedite decisions and make strategic 
        investments quickly to aid in COVID-19 reconstruction efforts.

    CIRRA [SEAR-ah] also puts in place mechanisms to help us better 
prepare for the next pandemic. It requires an annual National 
Intelligence Estimate on pandemic threats, and establishes a White 
House advisor for global health security to coordinate a whole of 
government U.S. response to global health security emergencies, aimed 
at improving both domestic and international capacity to prevent, 
respond and detect epidemic and pandemic threats.
    It clearly delineates the roles for the State Department, USAID and 
the Centers for Disease Control and Prevention in responding to 
pandemic threats. And it directs the U.S. Executive Director to the 
World Bank to begin negotiations to establish a trust fund at the World 
Bank designed not to compete with or supplant the World Health 
Organization, but to work in tandem with the WHO on incentivizing 
countries to mobilize their own resources for epidemic and pandemic 
preparedness.
    Mr. Chairman, more than 700 Americans a day are dying. Neither the 
finger pointing blame game, race-baiting statements linked to the 
origins of the disease, nor a strategy centered on denial will win the 
battle against COVID-19. It is painfully apparent that Congress will 
have to lead in this effort, just as it's led domestic relief and 
recovery efforts.
    I encourage us to develop a proposal in this Committee that boldly 
and robustly addresses the current crisis, ensures that we are 
adequately prepared for the next one, and aids countries around the 
globe with recovery. Anything less falls short of the legacy created 
through initiatives such as the President's Emergency Plan for AIDS 
Relief, and the Marshall Plan.
    I welcome our witnesses, and look forward to our discussion.

    The Chairman. Thank you, Senator Menendez. Well spoken. I 
think that your reference to the success that we have in 
addressing the AIDS pandemic is appropriate.
    When I started out to construct the bill, it was, as I 
said, a starting point. I used the successes that PEPFAR had. 
Certainly, if we can replicate that for future pandemics, I 
think we will all be given a great credit--that is another 
issue.
    Your remarks about the United States being the leader in 
this are absolutely right. We have a moral obligation based on 
our standing in the world and we should come together to do 
that.
    Those ideas--some of the ideas that you have had are novel 
to me. Your discussion about an annual threat assessment of the 
pandemic I think is appropriate. We have that every year on the 
Intelligence Committee.
    But, unfortunately, it is mixed with every other threat to 
the United States and they are regional, and it gets a nod that 
there is a threat of a pandemic it frequently takes the form of 
assessing what terrorists would do or malign influences would 
do and do not really focus on what a pandemic might look like.
    And I think that part of that may be due to the fact that 
these pandemics are different. Each one is different. It has 
things that they are the same. But each virus has a different 
way of acting and reacting in the world.
    So it gets short shrift in the Intelligence Committee it 
probably ought to be undertaken by either Health and Human 
Services or by us or by someone who could spend a little bit of 
time with it. So that is a great idea.
    So with that, let us move to our panel. We have a very 
impressive panel here today, and I must say that the last 
panel, I thought, was good. It helped clear up my thinking on 
this.
    One of the things I learned, I think, from the last panel 
about how there just is not a silver bullet, that it is going 
to take a coordinated effort by many, many different agencies 
and countries, and today we are going to take a little 
different approach on that.
    But these people have great experience. If we were to go 
through each of their accomplishments, we would be here all 
day. So with each of their forgiveness I am going to give just 
very brief introductions first.
    Our first witness is Ambassador Mark Dybul. He is an 
accomplished diplomat physician and medical researcher. He 
currently serves as a professor in the Department of Medicine 
and as co-director of the Center for Global Health Practice and 
Impact at Georgetown University.
    He previously served as the executive director of the 
Global Fund to Fight AIDS, Tuberculosis, and Malaria, and as 
the U.S. Global AIDS Coordinator. Certainly an impressive 
resume as he joins us today.
    So with that, Ambassador Dybul, the floor is yours.

 STATEMENT OF HON. MARK DYBUL, M.D., CO-DIRECTOR OF THE CENTER 
  FOR GLOBAL HEALTH PRACTICE AND IMPACT AND PROFESSOR IN THE 
  DEPARTMENT OF MEDICINE, GEORGETOWN UNIVERSITY MEDICAL CENTER

    Dr. Dybul. Thank you, Chairman Risch, Ranking Member 
Menendez, members of the committee. It is a great privilege to 
be back before this important body.
    I would like to thank the committee, the entire Congress, 
for its steadfast bipartisan efforts to ensure the U.S. has 
been the ongoing leader in global health for decades.
    COVID-19 has made clear that a global pandemic requires a 
global response and we are not quite there yet. But there is 
good news. What is needed is not rocket scientists.
    A number of countries who did well in the early stages of 
COVID-19 were not faster at setting up systems. They already 
had them. They were prepared. Therefore, they never had to 
enforce total lockdowns.
    Other countries rapidly put in place test, trace, and 
quarantine systems, and as a result they were able to safely 
begin reopening within 6 weeks, identifying and containing 
additional outbreaks as they occur.
    I am very grateful to the chairman as bipartisan co-
sponsors as well as to the ranking member for putting forward 
proposals to help ensure the U.S. coordinates international 
bilateral programs and to ensure non-duplicative multilateral 
institutions.
    I listened with great interest to the hearing the committee 
held on June 18th. From my experience, I would like to offer 
with all humility one perspective on the chairman's question, 
who is the fire department; who may we call.
    From a bilateral perspective, the proposal to create a 
coordinator at the State Department resonates. From the 
perspective of legislative oversight, the coordinator would 
seem to be the fire department for bilateral engagement.
    When PEPFAR was developed, and I was fortunate to be 
involved in the creation of the small group that put together 
the plan, we struggled with where to house it.
    A coordinator at State was, to paraphrase Churchill's quip 
on democracy, the worst approach except for everything else. 
Multiple parts of the U.S. government must be engaged in global 
health, as you noted, including pandemics.
    USAID is deeply involved in many aspects of health as well 
as those that impact health and, of course, USAID leads on 
humanitarian responses.
    CDC is the premier government health organization in the 
world. It is the only agency in the U.S. government 
armamentarium that spans domestic and global engagement, 
including pandemics, and is involved with, provides technical 
support to, and is looked to and respected by governments and 
institutions in high, middle, and low income countries. And as 
we know from this pandemic, we must be involved with every 
country.
    CDC is built for what is most needed for; global and 
national pandemic preparedness and response. However, more than 
with PEPFAR, the national security apparatus is needed, as you 
both noted.
    That requirement complicates full coordination from the 
Department of State. In that regard, it is important to note 
that both of the proposals identify the essential role of the 
National Security Council, as has been noted.
    Perhaps there is also an opportunity for cross-committee 
authorization and preparation legislation, which is now without 
some precedent.
    From a multilateral perspective, the world has come 
together and created the Global Health Security Agenda, or 
GHSA, as has been noted.
    However, GHSA is not the fire department. GHSA provides an 
action plan for every country to have an Emergency Operation 
Center, or EOC, capable of mounting a response to an outbreak 
within 2 hours.
    At least in my view, the EOC must also be responsible for 
continual surveillance down to the community level with 
systematic reporting to rapidly detect an outbreak.
    We need a global EOC as the fire department. The global EOC 
should be multi-sectoral and the principal functions of it 
would be to learn from the past what has worked and not worked 
during previous epidemics and pandemics to conduct regular 
simulations of local outbreaks with national, regional, and 
global responses to them, rigorously interrogating gaps and 
weaknesses, to support regional and national EOCs to be fully 
operational, and coordinate with a financing mechanism, what we 
will call the fire hydrant, to help ensure optimal use of 
resources.
    A global effort on pandemics and a global EOC cannot be 
effective without the deep engagement of WHO. It is a necessary 
although not sufficient player. In my view, WHO has done a good 
job under the circumstances and has vastly improved from Ebola.
    I have known the director general, Dr. Tedros, since 2004 
when he was the newly-installed junior administrator. I watched 
him systematically transform one of the worst-performing 
ministries of health in the world to one of the best.
    He has been a steadfast partner and ally of the U.S. and 
global health, and he has taken on a difficult vast task of 
reforming WHO and has made significant strides.
    As the first African director general, he also has the 
unwavering support of African countries, and as the second most 
populous continent, Africa's total engagement is essential for 
pandemic detection and control.
    Finally, I know from experience that the U.S. can best 
drive reform when we are fully engaged. You cannot place a bet 
if you are not at the table, and if we are not at the table 
others are ready to step in and take our place, including China 
and Russia.
    In my view, a financing facility, the fire hydrant, related 
to but organizationally separate from a global EOC, would 
create the optimal conditions for success.
    One already exists to procure vaccines for low- and middle-
income countries, Gavi, the Vaccine Alliance. However, there is 
a great deal of preparedness, detection, and response that 
needs to be funded before and after a vaccine becomes available 
and for future pandemics.
    The principal function of the fire hydrant would be to 
finance the priorities identified by the global, regional, and 
national EOCs, the fire departments.
    I appreciate the discussion of Gavi and the Global Fund 
models during the government panel hearing. Of course, the 
World Bank houses catalytic and trust funds, as the ranking 
member noted, and something could be created new.
    All have pros and cons. It seems to me the best approach 
would be for the Administration to play a leadership role, 
working with key governments and stakeholders in a time bound 
way with parameters set by Congress to identify the most likely 
mechanism to succeed, now and for the future; succeed in the 
tracking funds and implementing pandemic preparedness, 
detection, and response.
    In the short term, Congress has an important opportunity. 
This committee has a long history of supporting both U.S. 
leadership and the commitment of significant resources.
    Including at least $12 billion in the HEROES Act will save 
lives, help protect the U.S. from additional waves of this 
pandemic and send an important message abroad as well as here 
at home.
    And there is no time to lose. You might have seen the 
troubling report today of a new swine flu. While there is yet 
no reported human-to-human contact, there is reason for concern 
the next pandemic might be upon us.
    Mr. Chairman, Ranking Member, members of the committee, no 
country is safe and no one is safe until everyone is safe.
    The good news is that this is one of the most solvable 
problems facing the world. Throughout history we have seen that 
when we come together and look forward, outward, and with hope, 
there is no problem we cannot solve and, in particular, the 
U.S. has shown that when we take a leadership role, it is in a 
blessing of enlightened self-interest, serving others while 
protecting and promoting our interests and our lives.
    I thank the committee for what you are doing to lead again.
    [The prepared statement of Dr. Dybul follows:]

           Prepared Statement of the Honorable Mark Dybul, MD

    Chairman Risch, Ranking Member Menendez and members of the 
Committee: It is a privilege to be back before this important body. I 
would be remiss if I did not thank this Committee and the entire 
Congress for its steadfast, bipartisan efforts to ensure that the USA 
has been the unquestioned leader in global health for decades.
    Most people living in the USA, Europe and many other countries are 
experiencing for the first time the devastating impact of a rapidly 
spreading and deadly global pandemic. There have been scares--SARS, 
MERS, H1N1 Influenza and Zika, among others. Fortunately, those 
epidemics were limited in their scope and scale.
    COVID-19 has made clear that a global pandemic requires a global 
response. While we have the outlines of a global response, it needs to 
be strengthened by reforming existing structures and identifying 
financing mechanisms that will build on the uneven response to this 
crisis. Thank you for taking up the remarkably important issue of 
controlling this pandemic and focusing on preparedness for the next 
one.
    Unfortunately, it is likely this will not be the last pandemic we 
will experience. Changes in climate and weather patterns, population 
growth, increased contact with animals and a highly mobile global 
population create the conditions conducive to pandemics.
    The task before the world is to work to ensure that all countries 
can respond to the current threat, but also to be ready for the next 
one.
    But there is good news: what is needed is not rocket science. A 
number of countries that did well in the early stages of COVID-19 were 
not faster at setting up systems to respond--they already had them.
    From the relatively high-tech South Korean to the relatively low-
tech Taiwanese approaches taken, the devastating experiences from SARS 
and/or MERS propelled them to develop, establish and maintain effective 
systems for sentinel surveillance, testing, contact tracing and 
quarantine. They performed simulations of outbreaks to identify and 
fill gaps and to stay alert. They stockpiled key commodities. They were 
prepared. Therefore, they never had to enforce total lockdowns.
    Other countries, for example Germany, rapidly put test, trace and 
quarantine systems in place. As a result, they were able to safely 
begin reopening within 6 weeks, identifying and containing additional 
outbreaks as they occurred--and continue to occur.
    I am grateful to the Chairman and his bipartisan co-sponsors, as 
well as to the Ranking Member for putting forward proposals to help 
ensure the U.S.A. coordinates its international bilateral programs and 
to ensure complementary, non-duplicative multilateral institutions so 
the world can be prepared and rapidly detect and respond to continued 
and new waves of COVID-19, and to future pandemics.
    I listened with great interest to the hearing the Committee held on 
June 18 with Government witnesses, all good people working hard in 
challenging times.
    From my experience as one of the principal architects, and then as 
the head, of the President's Emergency Plan for AIDS Relief (PEPFAR) 
under President George W. Bush, and as someone who has been involved 
deeply in multilateral organizations, including as the Executive 
Director who led the transformation of the Global Fund to Fight AIDS, 
Tuberculosis and Malaria, I would like to offer, with all humility, one 
perspective on the Chairman's question: ``Who is the fire department? 
Whom do we call?''
    For those interested in more detail, please refer to a White Paper 
on the need for a Global Response to COVID-19 published with colleagues 
from Georgetown University and Dr. Peter Piot.\1\ Please also refer to 
the Report of the CSIS Commission on Strengthening America's Health 
Security--co-chaired by a former member of this chamber and former 
Director of CDC--on which both Ambassador Kolker and I served.\2\
                         bilateral perspective
    Proposals to create a Coordinator at the Department of State 
resonate. Perhaps that is not surprising since I served as the U.S. 
Global AIDS Coordinator in the State Department. From the perspective 
of Legislative oversight, the Coordinator would be the fire department 
for bilateral engagement.
    When PEPFAR was developed, we struggled with where to house it. A 
Coordinator at State was, to paraphrase Churchill's quip on democracy: 
the worst approach--except for everything else.
    Like COVID-19, the HIV pandemic is caused by a virus that jumped 
from animals to humans. Fortunately, unlike HIV, COVID-19 is not yet 
wiping out a generation in Sub-Saharan Africa. We knew what this 
Committee knows, and what the Government panel verified a few weeks 
ago: to be prepared for and combat a global pandemic, multiple parts of 
the U.S. Government must be engaged. We also knew from reviewing past 
experiences that selecting one implementing agency to receive all of 
the funds and then fully embrace, engage and fund other implementing 
agencies stretches beyond the bureaucratic breaking point.
    USAID is deeply engaged in many aspects of health as well as 
overall development efforts that impact health, such as education, 
economic security, agriculture and nutrition, water, sanitation and 
hygiene (WASH) required for hand-washing to prevent COVID-19 and many 
deadly diseases. And of course, USAID leads on humanitarian responses.
    CDC is the premier government health organization in the world. It 
is the only agency in the U.S. Government armamentarium that spans 
domestic and global health and that is engaged with, provides technical 
support to and is looked to, and respected by, governments and 
institutions in high-, middle- and low-income countries. These unique 
characteristics are essential in pandemic preparedness and response. It 
leads in sentinel surveillance, testing, laboratory capacity and public 
health capacity. It has already supported countries to implement GHSA 
that resulted in strong responses to COVID-19. CDC is built for what is 
most needed for global and national pandemic preparedness and response.
    More than with PEPFAR, the national security apparatus is needed 
for other pandemics. While the Department of Defense is a key part of 
PEPFAR, it is a relatively small piece of the budget and relates mostly 
to work with HIV prevention, care and treatment in foreign militaries. 
For global health security, there is a much bigger role including 
identification of outbreaks, potential in emergency responses, such as 
transportation, logistics and deployment of field hospitals as was done 
with Ebola. The need for significant engagement of the national 
security departments and agencies complicates full coordination from 
the Department of State. In that regard, it is important to note that 
both proposed bills identify the essential role of the National 
Security Council. Perhaps there is also an opportunity for cross-
Committee Authorization and Appropriation legislation, which is not 
without some precedent.
                        multilateral perspective
    The world has come together and created the Global Health Security 
Agenda (GSHA), including 67 countries, international organizations, the 
private sector, communities and others. It provides a good framework 
and sensible ``action packages''. However, GHSA it is not the fire 
department.
    In the limited time available, I would like to focus on two 
organizations that I believe are needed: the fire department and the 
fire hydrant.
The Fire Department: A Global Emergency Operations Center
    GHSA provides an action plan for every country to have an Emergency 
Operations Center (EOC) capable of mounting a multi-sectoral response 
to an outbreak within 2 hours. At least in my view, the EOC must also 
be responsible for continual surveillance down to the community level 
with systematic reporting to rapidly detect an outbreak at the earliest 
possible stage.
    We need a global EOC as the fire department. This is not a new 
concept. Bill Gates, myself and others have been calling for some 
version of this--often called a Task-Force--for a number of years. Of 
course, there is a lot involved in a global EOC. Managing the many 
viewpoints and equities will not be easy. But neither was creating 
PEPFAR, Gavi (the Vaccine Alliance) or the Global Fund. It is time to 
exert the energy to get it done.
    The global EOC should be multi-sectoral, including key 
organizations for health, economics, security and include the private 
sector and civil society communities, including the faith community. In 
the end, everything will work or fall apart at the community level. The 
principal functions of the EOC would be similar to national EOCs:

   Learn from the past: what has worked and not worked at the 
        global, regional and national levels during previous epidemics 
        and pandemics (as South Korea, Taiwan and others did after 
        their SARS and/or MERS epidemics);

   Conduct regular simulations of local outbreaks with 
        national, regional and global responses to them, rigorously 
        interrogating gaps and weakness;

   Use the knowledge gained from the past and regular 
        simulations to evolve the global EOC to be maximally effective 
        and to support regional and national EOCs to be fully 
        operational; and

   Coordinate with a financing mechanism, the fire hydrant, to 
        help ensure optimal use of resources.

The Central Role OF WHO
    It has been said ``If WHO didn't exist, we would create it.'' 
Perhaps as with the PEPFAR coordinator it is the worst approach--except 
for every other option. But a global effort on pandemics, and a global 
EOC, cannot be effective without the deep engagement of WHO. It is a 
necessary, although not sufficient, player.
    In my view, WHO has done a good job under the circumstances. And it 
has significantly improved. There is no real comparison between the 
deeply flawed response to Ebola and the initially flawed, but overall 
improved performance of WHO during COVID-19.
    The current Director General, Dr. Tedros Adhanom Ghebreyesus, is a 
committed public health servant and diplomat. I have known Tedros since 
2004 when he was the newly installed junior Minister of Health and I 
was the U.S. Deputy Global AIDS Coordinator. I watched him 
systematically transform one of the worst performing ministries of 
health in the world to one of the best performers. He has been a 
steadfast partner and ally of the U.S.A. in global health. He has taken 
on the difficult task of reforming WHO and, only a few years in, has 
made significant strides, including reorienting an institution 
resistant to change from headquarters to the countries.
    As the first African Director General, he also has the unwavering 
support of African countries, who for the first time voted in a block 
to elect him. As the second most populous continent, Africa's total 
engagement is essential for pandemic detection and control.
    Finally, as an official of the Bush administration, including 
preparation for G7 Summits, and then as Executive Director of the 
Global Fund, I know that the U.S.A. can be most effective in reforming 
institutions when it is fully engaged. In part because we bring deep 
expertise and financial resources, and in part because I know from 
experience that you can't place a bet if you aren't in the game. And if 
we are not at the table, others are ready to step in and take our seat: 
China and Russia.
The Fire Hydrant: A Financing Mechanism
    The significant progress on childhood vaccinations, HIV, 
Tuberculosis and Malaria has demonstrated that a financing mechanism 
separated from normative and deep-bench technical functions can be 
highly valuable. In my view, a financing facility related to, buy 
organizationally separate from, a global EOC would create the optimal 
conditions for success. One already exists to procure vaccines for low- 
and low-middle income countries: Gavi, the Vaccine Alliance. It was 
wonderful to see the significant pledge made by the U.S.A. at the 
recent Gavi replenishment conference.
    However, there is a great deal of preparedness, detection and 
response that needs to be funded before and after a vaccine becomes 
available.
    The principal function of the financing mechanism--the fire 
hydrant--would be to finance the priorities identified by the global, 
regional and national EOCs--the fire departments.
    I appreciated the discussion of the Gavi and Global Fund models 
during the Government panel hearing. Of course, the World Bank houses 
catalytic and trust funds. And something new could be created. All have 
pros and cons. Again, similar to the PEPFAR Coordinator, and for that 
matter the structure of many organizations, we might have to settle for 
the least bad option.
    It seems to me that the best approach would be for the 
Administration to play a leadership role working with key governments 
and stakeholders in a time-bound way and with direction and parameters 
set by Congress, to identify the most likely mechanism to succeed now 
and for the future in attracting funds and implementing pandemic 
preparedness, detection and response. This was the approach taken with 
the creation of the Global Fund, in which the U.S. Government was 
deeply involved, and Gavi.
                         short-term opportunity
    Global and American partners are looking for a sign that the U.S. 
will, once again, demonstrate its commitment to a comprehensive global 
response. It is in our national security interest to do so. Investing 
in the immediate response now and laying the foundation for the future 
will require leadership and resources. This Committee has a long 
history of supporting both. Including at least $12 billion in the 
Heroes Act before Congress will save lives, help protect the U.S. from 
additional waves of the pandemic and send an important message abroad 
as well as here at home. A recent poll conducted by the U.S. Global 
Leadership Coalition found that 72 percent of Americans support 
including $10 to $15 billion for international assistance in the next 
emergency package.
                               conclusion
    We know from the massively destructive global pandemics of history 
what, sadly, we needed to learn again from COVID-19. No country, and no 
one is safe until everyone is safe.
    But there is good news. This is one of the most solvable problems 
facing the world--as countries who activated systems they built after 
their SARS and MERS epidemics, and those who rapidly built those 
systems and controlled the outbreak in 6-10 weeks and are now safely 
reopening have shown.
    Throughout history, we have seen that when we come together and 
look forward, outward and with hope there is no problem we cannot 
solve. And in particular, the U.S.A. has shown that when we take a 
leadership role, it is a blessing of enlightened self-interest serving 
others while protecting and promoting our interests--and our lives. I 
thank the committee for what you are doing to lead--again.

----------------
Notes

    \1\ See https://georgetown.app.box.com/s/
5snwu87gg0szfreu5oaqqdm21qwbs2ty
    \2\ See https://healthsecurity.csis.org/final-report/

    The Chairman. Well, thank you very much.
    First of all, it is good to hear that when you--when 
PEPFAR's structure was put together that you struggled with 
where to house it because that has certainly been one of the 
vexing issues that we have struggled with here and, of course, 
have not reached a conclusion on that yet.
    You also--I appreciate your remarks about the importance 
that we have a place at the table. I think not only have a 
place at the table but I think it--because of our unique 
standing in the world, we need a very significant voice in how 
to construct that.
    Thank you. Thank you so much for your remarks.
    We are now going to turn to Ambassador Kolker. Before 
retiring in 2017, Ambassador Kolker served 30 years in the U.S. 
diplomatic service, including as ambassador to Burkina Faso and 
Uganda, and as deputy chief of mission in Denmark and Botswana.
    He completed his government service as assistant secretary 
for global affairs at the U.S. Department of Health and Human 
Services where he represented the United States at WHO meetings 
and as alternate board member of the Global Fund to Fight AIDS, 
Tuberculosis, and Malaria.
    With that, Ambassador Kolker, the time is yours.

 STATEMENT OF HON. JIMMY J. KOLKER, FORMER ASSISTANT SECRETARY 
    FOR GLOBAL AFFAIRS, U.S. DEPARTMENT OF HEALTH AND HUMAN 
                            SERVICES

    Mr. Kolker. Thank you. Thank you very much, Chairman Risch, 
Ranking Member Menendez, distinguished senators.
    I am Jimmy Kolker and am honored to be with you today. I am 
very proud to have been a State Department Foreign Service 
Officer and with the Department of HHS for 5 years, as you 
said.
    And in those jobs I help develop and implement both the 
President's emergency plan for AIDS relief and the Global 
Health Security Agenda in the Obama administration.
    These are two exceptional examples of global leadership, 
which all Americans should be proud of. Starting with the 
Global Health Security Agenda, some people have dismissed its 
work because we did not prevent or adequately respond to the 
novel coronavirus outbreak.
    But five countries took actions because of GHSA with 
extraordinary results in combating the novel coronavirus.
    After mishandling the MERS outbreak in 2015, South Korea 
became one of the most active members of GHSA, reviewing its 
own procedures, and when COVID-19 hit it was ready with 
surveillance and crisis management capacity developed through 
GHSA efforts.
    Uganda and Vietnam were the two pilot countries where the 
U.S. Centers for Disease Control and Prevention helped develop 
comprehensive prevention, detection, and response capacity.
    Both have been positive examples in their regions of 
controlling coronavirus and did so without extensive outside 
help.
    Likewise, the Republic of Georgia, through the involvement 
of CDC and of the Department of Defense through the Lugar 
Center managed coronavirus better than any other country in the 
former Soviet Union.
    And within the European Union, Finland, the first chair of 
GHSA and its most enthusiastic initial backer, did an 
exceptional job of preventing and controlling COVID-19.
    So GHSA has some solid successes, and despite some 
justified criticism, so does the World Health Organization. Its 
Health Emergencies Program responded immediately to validate 
and distribute a good diagnostic test for COVID-19.
    The World Health Organization was the only organization 
that could get Chinese approval for independent scientists to 
enter China, and WHO, as they always would, included American 
government experts in their delegation.
    And the WHO also convened the first multi-stakeholder 
meeting to look at access to eventual vaccines, treatments, and 
countermeasures.
    You asked, Mr. Chairman, who is the fire department; who 
responds when there is an outbreak that threatens to become an 
epidemic. My reply for that question is that there is no 
alternative to WHO.
    Others will be mobile, such as the CDC through the GOARN, 
the Global Outbreak and Response Network, CEPI, the Coalition 
for Epidemic Preparedness Innovation, and GISAID, a laboratory 
network.
    But WHO has to be at the core. After Ebola, with U.S. 
leadership I was involved personally and we helped make WHO 
more effective and we can do so again. The reforms that need to 
be made, I can enumerate some of them later if senators wish.
    But let me turn also to strengthening U.S. government's 
leadership and capacity. I mentioned my experience with PEPFAR, 
initially as ambassador to Uganda.
    PEPFAR worked. It worked because it had, one, presidential 
engagement and leadership; two, bipartisan support; three, 
implementation organized country by country; four, significant 
new money, initially, $15 billion over 5 years; and not least, 
number five, a State Department coordinator but, I emphasize, 
who was empowered because of that new money.
    I support the establishment of a senior Global Health 
Security and Diplomacy coordinator at State. But I support that 
if and only if there is significant new money. Simply 
redirecting USAID and CDC appropriations to STATE will result 
in gridlock.
    Additional new appropriations through State, on the other 
hand, can foster innovation and can incentivize both USAID and 
CDC to up their game, as PEPFAR did.
    So how can experience make U.S. global health leadership 
more effective? Here is some criteria I would use to evaluate 
any new proposal.
    One, as both proposals of Senator Risch and Senator 
Menendez do, it should restore White House whole of government 
expert leadership through a health security senior director at 
the National Security Council.
    It should be bipartisan. It should define responsibility 
and division of labor for implementation, not just at 
headquarters level.
    It should recognize the unique role that embassy teams play 
in allocating resources to build on the comparative advantages 
of USAID, of CDC, and of other parts of the Department of 
Health and Human Services.
    And most important, any new proposal must request, 
authorize, and appropriate through the appropriate committees 
enough money for these agencies to do their work.
    The proposal of $3 billion over 5 years is not enough. It 
is less than the CSIS commission I was a member of 
recommended--and I will put the cover there, give an 
advertisement--recommended for preparedness even before COVID 
hit.
    The HELP Committee and HHS appropriators will have to come 
up with billions more. And global health money in the HEROES 
Act, as Mark mentioned, will--is likely also to be required to 
reach health security goals.
    Funding should also include more money for the World Health 
Organization, a U.S. contribution to the Coalition for Epidemic 
Preparedness Innovation, and an incentive fund for low-interest 
countries--low-income countries, I am sorry, possibly through 
the already created Health Emergency Preparedness Fund at the 
World Bank.
    I thank you for your attention and I welcome your 
questions.
    [The prepared statement of Mr. Kolker follows:]

                   Prepared Statement of Jimmy Kolker

    Chairman Risch, Ranking Member Menendez, Distinguished Senators: I 
am Jimmy Kolker, honored to be with you today and very proud to have 
been a State Department Foreign Service Officer for 30 years and at the 
Department of Health and Human Services for 5.
    In those jobs, I helped develop and implement both President Bush's 
Emergency Plan for AIDS Relief (PEPFAR) and the Global Health Security 
Agenda in the Obama administration.
    These are two exceptional examples of U.S. global leadership of 
which all Americans should be proud.
                the global health security agenda (ghsa)
    Starting with the Global Health Security Agenda, I have heard 
people dismiss its work because we did not prevent or adequately 
respond to the novel coronavirus outbreak.
    Five countries, however, took actions because of GHSA with 
extraordinary results in combatting the novel coronavirus.

   After mishandling the MERS outbreak in 2015, South Korea 
        became one of the most active members of GHSA, reviewing its 
        own procedures. When COVID-19 hit, it was ready with 
        surveillance and crisis management capacity developed through 
        GHSA efforts.

   Uganda and Vietnam were the two pilot countries where the 
        U.S. Centers for Disease Control and Prevention helped develop 
        comprehensive prevention, detection and response capacity. Both 
        have been positive examples in their regions of controlling 
        coronavirus and did so without extensive outside help.

   Likewise, the Republic of Georgia, through the involvement 
        of CDC and of DoD through the Lugar Center, managed coronavirus 
        better than any other country in the former Soviet Union

   And within the European Union, Finland, the first chair of 
        GHSA and its most enthusiastic initial backer, did an 
        exceptional job of preventing and controlling COVID-19.

    So GHSA has some solid successes.
                     the world health organization
    And despite some justified criticism, so does the World Health 
Organization.
    Its Health Emergencies Program responded immediately to validate 
and distribute a good diagnostic test for COVID 19.
    The WHO was the only organization that could get Chinese approval 
for independent scientists to enter China, and WHO, as they always 
would, included American government experts in their delegation.
    The WHO also convened the first multi-stakeholder meeting to look 
at access to eventual vaccines, treatments and countermeasures.
                           who's the fireman
    You asked, Mr. Chairman, at the previous hearing ``Who's the Fire 
Department?'' Who responds when there is an outbreak that becomes an 
epidemic?
    My reply to that question is that there is no alternative to the 
WHO.
    Others will mobilize, such as the CDC through GOARN, the Global 
Outbreak and Response Network, CEPI, the Coalition for Epidemic 
Preparedness Innovation, and GISAID, a laboratory network. But WHO is 
at the core.
    After Ebola, with U.S. leadership, we helped make WHO more 
effective and we can do so again. There are reforms that need to be 
made, and I can enumerate some of them later if Senators wish.
      strengthening the u.s. government's leadership and capacity
    But let me turn to strengthening the U.S. Government's leadership 
and capacity I mentioned my experience with PEPFAR, initially as 
Ambassador to Uganda.
    PEPFAR worked because it had:

   presidential engagement and leadership;

   bipartisan support;

   implementation country-by-country;

   significant new money, $15 Billion over 5 years; and, not 
        least

   a State Department coordinator empowered because of the new 
        money.

    I support the establishment of a senior Global Health Security and 
Diplomacy coordinator at State. But if and only if there is significant 
new money.
    Simply redirecting USAID and CDC appropriations to State will 
result in gridlock. Additional new appropriations through State can 
foster innovation and incentivize both USAID and CDC to up their game, 
as PEPFAR did.
                   what to look for in new proposals
    How can experience make U.S. global health leadership more 
effective? Here are some criteria I would use to evaluate any new 
proposal.

   It should restore White House whole-of-government expert 
        leadership through a health security senior director at NSC.

   It should be bipartisan.

   It should define responsibility and division of labor for 
        implementation.

   It should recognize the unique role of embassy teams in 
        allocating resources to build on the comparative advantages of 
        USAID, CDC and other parts of HHS.

   Most important, it requests, authorizes and appropriates 
        enough money for them to do the work.

    The proposal of $3 Billion over 5 years is not enough. It is less 
than the CSIS commission I was a member of recommended for preparedness 
even before COVID hit. The HELP committee and the HHS appropriators 
will have to come up with billions more. Global Health money in the 
HEROES Act will be required to reach health security goals.
    Funding should also include more money for WHO, the Coalition for 
Epidemic Preparedness Innovation and an incentive fund for low income 
countries, possibly through the Health Emergencies Preparedness Fund of 
the World Bank.
    Thanks for your attention and I welcome your questions.

    The Chairman. Ambassador, thank you very much.
    I think I appreciate your focus on the structure. That is, 
although, not the most exciting thing in the world, it 
certainly is one that is absolutely critical here. I think 
without a structure we really are going to be lost.
    I really appreciate all the other suggestions that you have 
made and I would hope that you put those in writing and get 
them to us so that as we are discussing this amongst ourselves 
we can have this in front of us.
    Again, thank you for your--thank you for your experience in 
that regard.
    Next, we have Dr. Jha. He is a physician, researcher, and 
data enthusiast. I am not exactly sure what a data enthusiast 
is. I have never met one before. But I am glad to hear we have 
one here.
    He is the K.T. Li Professor of Global Health at Harvard, 
T.H. Chan School of Public Health, and the faculty director of 
the Harvard Global Health Institute.
    He is a practicing general internist and a professor of 
medicine at Harvard Medical School. He holds an M.D. from 
Harvard Medical School and an M.P.H. from the Harvard T.H. Chan 
School of Public Health.
    With that, Dr. Jha, we welcome you and maybe you can start 
off by telling us what a data enthusiast is. So thank you for 
joining us.

STATEMENT OF DR. ASHISH K. JHA, M.D., DIRECTOR, HARVARD GLOBAL 
                HEALTH INSTITUTE, CAMBRIDGE, MA

    Dr. Jha. Chairman Risch and Ranking Member Menendez, and 
members of the committee, it is indeed an honor to be here this 
morning.
    I do not think I have described myself as a data 
enthusiast, but I do believe that data and evidence should 
drive our decision making. So maybe that is--maybe that is the 
idea.
    But let me get to my testimony. We are in the middle of the 
greatest global public health crisis in a century. Millions of 
people around the world have gotten sick and hundreds of 
thousands have died from this disease.
    Despite this, our best estimates are that less than 2 
percent of the world's population has been infected with this 
virus. The global pandemic is just getting started.
    And the single biggest obligation that I believe we all 
have is to protect the lives and well-being of the American 
people and the people around the globe, and this is why I 
believe that the Administration's decision to withdraw from WHO 
is so deeply unwise.
    You know, Chairman Risch, there is some irony in my 
testifying today in defense of WHO. You see, for years I have 
been widely seen as a critic of WHO and rightly so.
    I was one of WHO's harshest critics of its disastrous 
handling of the Ebola outbreak in West Africa, and coming out 
of that outbreak I co-chaired an international panel that 
recommended major changes at WHO.
    So did WHO change? In some ways, yes, and in other ways, 
no. And WHO's response to COVID-19 has been better but no 
perfect. After China informed WHO of a viral pneumonia outbreak 
in Wuhan, WHO acted quickly and alerted the world.
    And because both Ambassadors Dybul and Kolker have talked 
about what the WHO has done well, let me focus for a minute on 
what WHO has done poorly.
    To me, the single biggest failure of WHO in this outbreak 
has been the excessive praise for the Chinese government and 
its handling of the outbreak.
    The Chinese government's response is not worthy of praise. 
They, clearly, hid the virus and silenced doctors and 
scientists for weeks if not months. They delayed notifying the 
world.
    China is a major world power and we should expect better. 
So I was disappointed to see WHO's lavish praise for China. 
Disappointed, but not surprised, because WHO is a membership 
organization and, as such, it has had a long tradition of 
showering praise on governments even when those governments are 
behaving poorly.
    One of the criticisms of WHO has been that it did not stand 
up to China, and I have to say I find this puzzling. I have 
never understood what that could possibly mean.
    WHO has no authority to compel China to do anything, any 
more than it has authority to compel our government to act in a 
certain way. WHO is a membership organization. It can only be 
as effective as its members allow it to be.
    And let me be clear in my testimony. I believe WHO can be 
more effective. One of the areas where I think WHO can be more 
effective is that its mission is too broad. It literally works 
on every health-related issue in the world, and I believe WHO 
should only do those things that only WHO can do.
    So let us come back to how that might apply in this 
pandemic. Walking away from WHO at this moment is an 
extraordinarily bad idea. It will weaken WHO, which will harm 
the world and harm Americans because WHO does critical work 
that we all benefit from.
    WHO is running the solidarity trial, which has patients 
enrolled from 35 countries to find new treatments for COVID-19. 
WHO is coordinating the procurement and delivery of vaccines 
once they become available, and WHO is working closely with 
ministries of health in nearly every low- and middle-income 
country around the globe.
    It takes visiting any ministry of health to realize the 
integral role that WHO plays. WHO is a trusted partner to 
ministries around the world, and if other countries struggle to 
control the outbreak, it will be bad not just for people of 
those nations but for all of us because the one thing we have 
learned over and over again is that an outbreak anywhere can 
quickly become an outbreak everywhere.
    So during this pandemic when we have many, many difficult 
months ahead of us, walking away from WHO, I believe, makes 
controlling the virus globally harder and makes it harder to 
manage the virus here at home.
    Walking away from WHO leaves us without a voice at the 
table to better manage the disease globally and walking away 
from WHO means we will have little influence on how WHO is 
shaped and improved when this pandemic eventually comes to an 
end.
    I believe WHO can and should be more effective. But the 
bottom line is WHO is essential, as you have already heard this 
morning. There is no substitute.
    So for the sake of the health and the well-being of the 
world and particularly for the health and well-being of the 
American people, I believe it is critical to use America's 
leadership to improve WHO's performance in this pandemic and 
for future ones.
    Thank you very much.
    [The prepared statement of Dr. Jha follows:]

             Prepared Statement of Dr. Ashish K. Jha, M.D.

    We are the middle of the greatest global public health crisis in a 
century. The COVID-19 pandemic has wreaked havoc on lives, healthcare 
systems, and economies around the globe. In most countries around the 
world, cases and deaths are still rising, and an effective, widely 
deployed vaccine is likely at least a year away. Yet at this critical 
moment in global public health, U.S. leadership is lacking. The most 
striking example of this lack of leadership is our Administration's 
decision to withdraw the U.S. from the World Health Organization (WHO). 
This is a decision that will harm not only the health of people around 
the world, but also U.S. leadership and scientific prowess. And 
ultimately, the withdrawal from WHO, if it is to be finalized, will 
harm the health of the American people at a time when Americans are 
getting sick and dying at an unprecedent rate.
    WHO has a unique and incomparable ability to coordinate and support 
international pandemic response. Now more than ever, we should be 
investing in and supporting this organization that is uniquely poised 
to tackle COVID-19.
                        the pandemic is not over
    The COVID-19 pandemic is still accelerating. We are continuing to 
see record-breaking daily increases in COVID-19 cases, and deaths are 
also rising worldwide. The pandemic is still in its early stages in 
most parts of the world, with cases still on their first uphill climb 
in Latin America, Africa, and large parts of Asia, as well as a 
resurgence of cases right here in the U.S.
    The Latin American region recently reached 2.2 million cases after 
infections doubled over the past 2 months, and its combined death toll 
passed 100,000 last week.\1\ Brazil has been described as a ``worst-
case scenario,'' with overflowing hospitals and morgues; \2\ last week, 
they saw their largest rise in daily infections and passed 50,000 
deaths.\3\ India is now recording record numbers of single-day cases 
after easing the strict national lockdown that had been imposed.\4\ 
Reports of overwhelmed hospitals and lack of access to tests or 
treatment reveal the dire state of the pandemic there.\5\ South Africa 
is also seeing an uphill trend and new daily records of confirmed 
cases.\6\ They are now reporting about 7,000 new cases per day, about 
four times the number of daily new cases from a month ago.\7\ Israel 
has seen a rise in cases since easing restrictions at the end of May. 
During the month of May, they were seeing only dozens of new cases each 
day; now, daily cases counts hit 400 and 500.\8\
    And these are just a few examples. Globally, we are still early in 
the crisis. Most nations are in the middle of an uphill climb in cases, 
and some countries that did have some success in battling the virus 
early are now seeing second peaks after lifting their lockdowns. While 
the scientific community has made remarkable progress on diagnostics, 
vaccines, and therapeutics, the disease remains deadly for many. The 
pandemic is far from over.
                        the critical role of who
    The World Health Organization's response to the COVID-19 pandemic 
has been highly visible and at times, less than ideal. WHO is not 
perfect, by any means. I have historically criticized WHO a number of 
times, particularly following their leadership failures during the 2014 
Ebola outbreak in West Africa.\9\ Then, WHO's response was slow and 
diffuse and contributed directly to several thousand preventable 
deaths. Indeed, the United Nations even created a new entity to 
coordinate the response, typically WHO's prerogative, when it created 
the U.N. Mission for Ebola Emergency Response. I co-chaired a 
commission that examined the failures of the global community to 
respond effectively to Ebola, and our report specifically called out 
WHO's shortcomings and failures as a major contributor to the poor 
outcomes we saw in West Africa.
    While the shortcomings of the global Ebola response went far beyond 
WHO, its poor performance was one critical element. To that end, our 
commission made a series of recommendations about WHO reforms, many of 
which have indeed been taken up and implemented, while others have not. 
As a result, WHO's response to the COVID-19 pandemic has been much 
stronger than its Ebola response.
    But that is still not enough. WHO has made important mistakes in 
its response to the COVID-19 pandemic. WHO excessively praised China's 
early response to its outbreak, calling it ``transparent'' and 
``responsible'' despite early clues that China's response was anything 
but that.\10\
    Some have argued that WHO should have refused to take China's 
claims at face value and done more to independently investigate the 
early outbreak. For example, WHO probably should have considered it a 
greater possibility that human transmission was already occurring, even 
when officials in Wuhan said otherwise.\11\ Although WHO does not have 
the power to forcibly investigate their own member states, it may have 
been beneficial for them to not have so quickly accepted China's data 
and statements as truth.
    Furthermore, WHO remained opposed to implementing travel 
restrictions until late February. While travel restrictions have not 
been proven to stop the spread of disease, some studies have found that 
they may delay its spread,\12\ and some have argued that countries 
could have bought more time to prepare their response if they had not 
been encouraged to keep their borders open.
    So yes, WHO's response has been imperfect, but that doesn't mean it 
is in our interest--or the world's interest--for the U.S. to leave WHO. 
Instead, we should stay involved to encourage improvement of the 
organization as an active member. After WHO's failures during the Ebola 
crisis--which were far more dismal than any failures related to COVID-
19--the U.S. Government engaged deeply with the organization and helped 
implement necessary changes. These changes included establishing a 
unified WHO platform for outbreaks and emergencies, creating the WHO 
Health Emergencies Programme, and implementing a framework for R&D 
preparedness and capacity.\13\ WHO also worked to address shortages in 
funding that limited its ability to respond to the outbreak, including 
through the establishment of a Contingency Fund for Emergencies.
    WHO's role in helping countries, particularly low- and middle-
income countries (LMICs), cannot be overstated. These nations' 
ministries of health are heavily dependent on WHO for technical 
expertise and guidance on pandemic response. WHO is deeply embedded in 
LMICs--whereas local health officials in the U.S. turn to the CDC for 
help, health officials in most other countries turn to WHO during an 
outbreak. For example, WHO has distributed tests to 126 countries 
around the world,\14\ many of which lack the capacity to develop their 
own test kit quickly enough and thus rely on WHO's technical expertise. 
When countries receive help from non-governmental organizations (NGOs), 
it is WHO that helps provide coordination. When countries need access 
to scientific expertise to inform policies, conduct disease 
surveillance, and acquire necessary resources and supplies, they turn 
to WHO. And given the longstanding relationship that local WHO offices 
have in many LMICs, they are uniquely able to collect and collate new 
data coming out of these countries. WHO is the primary hub of the 
knowledge and skills needed to prevent cross-national infectious 
disease outbreaks. Now is a time when LMICs are relying on WHO the 
most.
    The U.S.'s partnership plays an important role in ensuring that WHO 
has the capacity to do these things. The U.S. provides about 15% of 
WHO's funding.\15\ Ten percent of WHO's collaborating centers for 
research and development are hosted in the U.S.\16\ And the U.S. CDC 
has played a critical role in facilitating public health emergency 
management training events and supporting the deployment of staff and 
resources to respond to crises. It's clear that cutting U.S. ties with 
WHO significantly hampers WHO's ability to execute on its mission.
                       leaving who harms the u.s.
    The decision to leave WHO doesn't just harm the rest of the world--
it hurts the United States, as well. By ending our relationship with 
WHO at this critical moment, the U.S. is removing itself from the most 
important decisions surrounding this virus. We are sending a message 
that the U.S. is an undependable partner, that we cannot be counted on 
for collaboration in a global crisis. And we are leaving a leadership 
vacuum within WHO for other countries to fill. Some European countries 
are already starting to step up to fill the space the U.S. has left 
behind--last week, Germany pledged $560 million and France pledged $100 
million to support WHO's work.\17\ And China may also seize the 
opportunity to exert more influence over WHO.
    Leaving WHO also separates the U.S. from much of the leading 
research and development around COVID-19. Scientists from countries 
around the world turn to WHO to share samples and collaborate on 
quickly building an evidence base. A notable example of this is WHO's 
SOLIDARITY Trial, the world's largest clinical trial of COVID-19 
therapies.\18\ Over 3,500 patients have already been recruited into 
this trial, and WHO is actively supporting 60 countries with ethical 
and regulatory approvals, identification of participating hospitals, 
training on usage of the online data system, and procurement of 
necessary medications. The SOLIDARITY Trial is believed to reduce the 
time needed to design and conduct a randomized controlled drug trial by 
80%.
    WHO is also playing a key role in COVID-19 vaccine development and 
manufacturing.\19\ They have created a coalition of 300 scientists, 
developers, and funders with the goal of expediting exchange of 
scientific results and reducing duplication of research efforts. They 
are designing a large international vaccine trial that would ensure 
faster turnaround of results--around 3-6 months to determine the 
efficacy of each vaccine candidate. An expert group convened by WHO is 
working to prioritize the vaccine candidates with the most potential 
and develop a protocol for later trial phases that can be used around 
the world. WHO also played a role in creating the ACT-Accelerator, 
which, in addition to several other goals, is working to ensure that a 
vaccine will be manufactured and distributed quickly and equitably once 
it is developed.\20\ This level of international scientific cooperation 
is critical to allowing us to rapidly develop tools to fight this 
virus--but the U.S. will no longer be able to shape or participate in 
this work.
    In addition to hindering U.S. scientific and global health 
leadership, the decision to leave WHO threatens the health of 
Americans. As we have so clearly seen during this pandemic, diseases do 
not respect borders. We can't keep travel restrictions in place 
forever, and until this pandemic is under control globally, we will 
continue to be at risk of spread in the U.S. If low- and middle-income 
countries continue to have large outbreaks, they will become the 
sources of spread of the disease globally. No level of fortified 
borders will prevent disease spread from other nations. Unless we shut 
off all travel and trade from every other nation in the world, a 
physical impossibility, we will continue to import cases from other 
countries (and export cases as long as our outbreak remains large). 
Importing more cases of COVID-19 from other nations puts Americans' 
health at greater risk. If we really want to protect the health of the 
American people, a central feature is to control the disease in the 
U.S. and help other countries control their outbreaks as well.
    These implications don't only apply to this current outbreak, but 
also future ones. WHO provides critical information on most major 
public health threats, including influenza season and emerging 
diseases, and we will no longer have the same access to that 
information. We will no longer be able to inform the global scientific 
and political response to those outbreaks. Collaborating with other 
countries to keep future diseases from entering our own borders will be 
more difficult. While COVID-19 is our major concern currently, the 
harms to the U.S. of pulling out of WHO are far-reaching.
                         there is no substitute
    There is no substitute for WHO. Its unique position as an 
international agency made up of 194 member states gives it an 
unparalleled legitimacy and capacity to facilitate collective action 
and political will. Because of its international leverage, WHO is 
uniquely positioned to set and communicate public health norms and 
coordinate critical research and development across countries. It also 
has the ability to coordinate with international institutions from 
other sectors, like the World Trade Organization or the World Bank--an 
important asset for an interdisciplinary field like global health.
    The leadership of WHO is chosen by member states. The deep 
relationship between individual nations and WHO, as I have outlined 
above, makes the organization essential for many countries around the 
world. If we were to get rid of WHO today, we would have to recreate a 
WHO tomorrow with many of the same features. There is no substitute for 
the essential work that WHO does.
    A U.S.-based global health organization, or even other 
international organizations like the World Bank, are no substitutes for 
WHO. There are no other organizations with the same reach into 
ministries of health. No other organizations have earned the same level 
of trust from healthcare organizations and frontline health workers 
here in the U.S. and around the world. WHO's role as a membership 
organization made up of nearly every nation in the world makes its 
presence accepted and welcomed in many countries in a way that the 
presence of a U.S. government organization or even World Bank would not 
be, at least not in the health sector. And for global issues, you need 
truly global collaboration.
                               conclusion
    The U.S. potentially leaving WHO has dire consequences for both 
global health and for the health and well-being of the American people. 
WHO plays a critical role in providing support during health 
emergencies and accelerating scientific research. It is irreplaceable. 
During this pandemic, its response has been extraordinary, although not 
without some missteps. Some of the urgent reform efforts laid out in 
the post-Ebola period have yet to be completed. But there is no 
substitute for WHO. If we were to leave WHO, we would have no 
legitimacy or ability to make WHO a stronger organization. Instead, we 
should engage with WHO, support its important mission, and work to 
improve and strengthen it. Our ability to beat this pandemic--and to 
improve the health of people in the U.S. and around world--depends on 
it.

----------------
Notes

    \1\ Henley J. Global report: India has highest rise in Covid-19 
cases as Latin America toll passes 100,000. The Guardian. https://
www.theguardian.com/world/2020/jun/24/global-report-india-has-highest-
rise-in-covid-19-cases-as-latin-america-toll-passes-100000
    \2\ Leite J, Preissler Iglesias S, Viotti Beck M, Bronner E. The 
pandemic's worst-case scenario is unfolding in Brazil. Bloomberg 
Businessweek. https://www.bloomberg.com/news/features/2020-06-24/
coronavirus-pandemic-brazil-faces-worst-case-scenario
    \3\ Otte J, Gayle D, Quinn B, Perraudin F, Sullivan H. Bolsonaro 
silent as Brazil passes 50,000 deaths; global cases reach 9 million--as 
it happened. The Guardian. https://www.theguardian.com/world/live/2020/
jun/22/coronavirus-live-news-covid-19-update-china-us-uk-brazil-latest-
updates
    \4\ Henley J. Global report: India has highest rise in Covid-19 
cases as Latin America toll passes 100,000. The Guardian. https://
www.theguardian.com/world/2020/jun/24/global-report-india-has-highest-
rise-in-covid-19-cases-as-latin-america-toll-passes-100000
    \5\ Dewan A, Woodyatt A. A surge in cases shows the coronavirus 
won't go away soon. CNN. https://www.cnn.com/2020/06/23/world/
coronavirus-spikes-after-lockdown-intl/index.html
    \6\ Coronavirus in South Africa: Restrictions ease as Covid-19 
cases rise rapidly. BBC News. https://www.bbc.com/news/world-africa-
53093832
    \7\ Johns Hopkins University Coronavirus Resource Center. https://
coronavirus.jhu.edu/map.html
    \8\ Johns Hopkins University Coronavirus Resource Center. https://
coronavirus.jhu.edu/map.html
    \9\ Jha AK. A race to restore confidence in the World Health 
Organization. Health Affairs Blog. https://www.healthaffairs.org/do/
10.1377/hblog20170406.059519/full/
    \10\ Rauhala E. Chinese officials note serious problems in 
coronavirus response. The World Health Organization keeps praising 
them. Washington Post. https://www.washingtonpost.com/world/asia--
pacific/chinese-officials-note-serious-problems-in-coronavirus-
response-the-world-health-organization-keeps-praising-them/2020/02/08/
b663dd7c-4834-11ea-91ab-ce439aa5c7c1_story.html
    \11\ Perez-Pena R, McNeil DG. WHO, now Trump's Scapegoat, warned 
about coronavirus early and often. New York Times. https://
www.nytimes.com/2020/04/16/health/WHO-Trump-coronavirus.html
    \12\ Narea N. Coronavirus is already here. Blocking travelers won't 
prevent its spread. Vox. https://www.vox.com/2020/3/12/21176669/travel-
ban-trump-coronavirus-china-italy-europe
    \13\ Chan M. Learning from Ebola: readiness for outbreaks and 
emergencies. Bulletin of the World Health Organization. https://
www.who.int/bulletin/volumes/93/12/15-165720/en/
    \14\ Rolling updates on coronavirus disease (COVID-19). World 
Health Organization. https://www.who.int/emergencies/diseases/novel-
coronavirus-2019/events-as-they-happen
    \15\ Joseph A, Branswell H. Trump: U.S. will terminate relationship 
with the World Health Organization in wake of Covid-19 pandemic. STAT. 
https://www.statnews.com/2020/05/29/trump-us-terminate-who-
relationship/
    \16\ The United States of America: Partner in global health. World 
Health Organization. https://www.who.int/about/planning-finance-and-
accountability/financing-campaign/us-impact
    \17\ Schmitz R. Germany and France promise new financial support to 
World Health Organization. NPR. https://www.npr.org/sections/
coronavirus-live-updates/2020/06/25/883302474/germany-and-france-
promise-new-financial-support-to-world-health-organization
    \18\ ``Solidarity'' clinical trial for COVID-19 treatments. World 
Health Organization. https://www.who.int/emergencies/diseases/novel-
coronavirus-2019/global-research-on-novel-coronavirus-2019-ncov/
solidarity-clinical-trial-for-covid-19-treatments
    \19\ Accelerating a safe and effective COVID-19 vaccine. World 
Health Organization. https://www.who.int/emergencies/diseases/novel-
coronavirus-2019/global-research-on-novel-coronavirus-2019-ncov/
accelerating-a-safe-and-effective-covid-19-vaccine
    \20\ Access to COVID-19 Tools (ACT) Accelerator. World Health 
Organization. https://www.who.int/publications/m/item/access-to-covid-
19-tools-(act)-accelerator

    The Chairman. Thank you for those candid and, I think, very 
helpful remarks. You, I think, quite clearly and correctly 
noted that WHO has no authority over other countries, and as I 
discuss this in a robust fashion with Dr. Tedros and with his 
management team, they stress that over and over again, wishing 
they had that authority.
    I think the criticism perhaps is more correctly directed at 
the fact that they do have a bully pulpit and, as we all know, 
the bully pulpit can be as effective and, indeed, sometimes 
more effective than having actual authority over someone.
    And I think, from my own personal standpoint, I was 
disappointed that--but at the same time understanding--that the 
minute you step up on the bully pulpit you are going to find 
yourself in an adversarial position with someone or some 
country that you are trying to get to cooperate with you. But 
that may dissipate. It is a fine line. There is absolutely no 
question about that. I thank you for your remarks and I thank 
you so much.
    We now have Mr. Jeremy Konyndyk and he is a senior policy 
fellow at the Center for Global Development. He previously 
served as director of USAID's Office of Foreign Disaster 
Assistance during which time he led the U.S. humanitarian 
response to the 2015-2016 outbreak in West Africa, among other 
complex emergencies.
    He is a member of WHO's Independent Oversight and Advisory 
Committee and previously served on the Independent Advisory 
Group and helped design WHO's post-Ebola reports.
    Mr. Konyndyk, the floor is yours. I am told that they are 
having a little technical difficulty with your--with the audio. 
So I hope this works. In any event, the floors is yours.

STATEMENT OF JEREMY KONYNDYK, SENIOR POLICY FELLOW, CENTER FOR 
               GLOBAL DEVELOPMENT, WASHINGTON, DC

    Mr. Konyndyk. Yes. Thank you. Thank you, Chairman Risch 
and, thank you, Ranking Member Menendez for the opportunity to 
testify.
    I apologize that you cannot see me. I had logged in and 
then mid-way through Chairman Risch's opening statement, my 
internet completely went down and it seems the provider is not 
working. But at least we have the phone as a backup.
    The Chairman. Would you like me to repeat the second half 
of my opening statement?
    [Laughter.]
    Mr. Konyndyk. No, I heard it--I heard it perfectly clearly 
on my phone.
    The Chairman. Okay. Thank you.
    Mr. Konyndyk. So and I greatly appreciated your remarks, 
Senator.
    The Chairman. Thank you.
    Mr. Konyndyk. I thought you set a wonderful tone.
    I want to thank the committee for the opportunity to 
testify today on this--on this important topic. The COVID-19 
pandemic has made incredibly clear the importance of expanding 
U.S. government investments in global pandemic preparedness and 
also the linkage between that and our own domestic 
preparedness, you know, within our own borders.
    Investments like this in global outbreak cooperation are 
not just altruistic. They also serve to keep us safe here at 
home, and so I commend the many thoughtful ideas that have been 
put forward by members of this committee, by some of your 
colleagues in the House, and I am encouraged by some aspects of 
the plans that are reportedly being developed by the 
Administration as well.
    Because it is clear that the U.S. now needs to take 
advantage of this moment to go really big on a global 
partnership for pandemic preparedness, and this means focusing 
on a number of things.
    It means investing more in surveillance diagnostics and 
early warnings so that we can build the same kind of early 
warning capacity for infectious disease risks that we currently 
have for things like hurricanes, famines, or tsunamis.
    It means creating--using that risk awareness to create 
clearer triggers for global and country-level action so that we 
never again have to see the kind of inconsistent patchwork of 
country responses that we have seen in response to COVID-19 and 
I think one of the things that the current pandemic really 
shows clearly is that that kind of early action is just as 
important as the baseline national capacity.
    The countries that acted early have done better whether or 
not they have the full capacity we might--that they might want 
and countries that have waited, even if they had good capacity 
on paper, have really struggled. So both capacity and early 
action are incredibly important.
    It also means things like investing in the readiness and 
resilience of medical and public health systems in weak and 
low-income countries. It means reinforcing supply chains and 
reserves of PPE and essential drugs.
    It means collaborating towards the development of 
innovative diagnostics, vaccines, and therapeutics on a global 
level, and I was encouraged to see in Senator Risch's bill the 
U.S. support for CEPI, which I think is incredibly important.
    And, of course, all of these things will require robust 
U.S. funding behind these priorities, and so I urge Congress to 
include pandemic response and preparedness funding in the 
HEROES Act and continue supporting this on a more ongoing 
reliable basis over time as we have done with things like 
PEPFAR.
    But that, of course, if we are to do all those things it 
raises the natural question of how should we organize ourselves 
and how should we organize the global system to deliver on 
that, and so I want to lay out a few ideas on that, based on my 
own experience with this over the years.
    First, within the U.S. government it is incredibly 
important to establish a clear interagency division of labor 
that is built on each agency's comparative advantages, and this 
is something that has been a struggle in PEPFAR. It has been--
it has produced a lot of turf battles over the years between 
USAID and CDC.
    It is something we did not struggle with so much on Ebola 
because we laid out a clear division of labor right at the 
outset of the Ebola response and then we budgeted and allocated 
funding based on that. So there was, simply, less to fight over 
between the agencies. Our roles were clear from the beginning.
    And so something like an international response framework 
to parallel what we have domestically with the national 
response framework could help to clarify and enshrine some of 
those roles for institutions like the State Department, USAID, 
CDC, DoD, and others.
    I was encouraged to see that Senator Menendez's bill 
contains some similar language.
    Second, the State Department has an incredibly important 
role in building diplomatic support for pandemic readiness and 
can play a role also in coordinating broader overseas U.S. 
engagement.
    But I do not believe a heavy PEPFAR style centralized 
authority at the State Department over programs and budgets of 
interagency partners is the right template for this particular 
role.
    I believe a lighter approach modeled more on the counter-
ISIL envoy would be more effective. That approach was tasked 
similarly with building a global coalition of allies towards, 
of course, in that case fighting ISIL, in this case fighting 
pandemics.
    That is a sweet spot role for the State Department and the 
coordination function that the counter-ISIL envoy used was 
shared with a senior director at the NSC who could more 
effectively coordinate with the interagency and I believe that 
that sort of model would be a better partnership here, hinging, 
of course, on restoring the White House senior director and 
accompanying team for global health security, which is as 
crucially important, as some of the other witnesses have 
already noted.
    Third, as several of these proposals do acknowledge, any 
new U.S. initiative must be robustly resourced. The pandemic 
has cost trillions of dollars in emergency economic stimulus 
and lost productivity and other spending.
    So investing in pandemic preparedness on a PEPFAR like 
scale, which is to say billions of dollars a year, is an 
extremely good return on investment if it can prevent that kind 
of economic damage in future pandemics.
    Fourth, it is impossible to envision the U.S. succeeding in 
this kind of ambitious pandemic preparedness agenda without the 
full engagement of the World Health Organization and, frankly, 
it is hard to envision the rest of the world working together 
with us on this effort if they view it as a U.S. alternative or 
competitor rather than a complement and a supporter and partner 
to the World Health Organization.
    Withdrawing the U.S. from the World Health Organization 
will be tragic and it is entirely unjustified. In an earlier 
hearing, Senator Risch, you asked a group of administration 
witnesses to identify the fire department for global health 
emergencies.
    I agree with the other witnesses who have noted that such a 
thing already exists. It is called the Health Emergencies 
Program at the World Health Organization. It was established--
and I and Ambassador Kolker both had a hand in helping to stand 
it up--it was established following the failures of the 2014 
Ebola outbreak.
    It is not perfect. It is still a work in progress. But it 
is making great progress and has succeeded in recent years in 
addressing several outbreaks like Ebola in the Congo as well as 
other outbreaks like cholera in Yemen.
    There is no question that WHO continues to need further 
reform, and I would echo what Senator Risch said about the 
challenges within the limitations that the international health 
regulations currently put on WHO.
    But we should then focus on those problems. We should not 
abandon the organization and our best chance to focus on those 
problems is by staying part of the organization despite its 
flaws and working to improve it.
    Finally, it is a bit painful to say this but I think we 
also have to acknowledge that the U.S.'s credibility to lead a 
global coalition on pandemic preparedness will really hinge on 
our ability to contain our domestic outbreak here at home.
    Our credibility globally starts with our competence within 
our own borders, and so to rectify this we need to take the 
advice that we have given to other countries for many years: 
depoliticizing public health, following the evidence, 
communicating risk effectively, building public trust, and 
deploying competent management structures.
    And I think we have to show a degree of humility as well, 
recognizing that even a country as well prepared and powerful 
and wealthy as the United States can falter when it departs 
from these sort of sound public health principles.
    With that, I look forward to your questions, and thank you.
    [The prepared statement of Mr. Konyndyk follows:]

                 Prepared Statement of Jeremy Konyndyk

    Dear Chairman Risch, Ranking Member Menendez, and distinguished 
Senators, thank you for inviting me to testify before you today. This 
hearing comes as the COVID-19 pandemic is proving what public health 
experts have warned for years: no country in the world is adequately 
prepared for a lethal pandemic. Many countries today are failing to 
contain the virus, whether through poor management, weak systems, late 
action, or all of the above. There is an aphorism that one must never 
waste a crisis. So even as we work to defeat the current pandemic, we 
must begin learning from the failures to contain it, and prepare 
ourselves to be more ready the next time around. We are fortunate that 
COVID, while highly transmissible, has a lethality far lower than past 
threats like SARS-1, Ebola, or the Spanish flu. A comparably 
transmissible virus with a much higher lethality is plausible, and over 
time even probable. So we must use this moment to marshal the political 
will to be ready for that.
    Being ready for the next pandemic must be a global effort: U.S. 
readiness at home will be compromised if there are vulnerabilities 
overseas. As COVID is teaching us, a lethal pathogen will take 
advantage of any weakness in the world's defenses. The Pandemic All 
Hazards Preparedness Act, which was reauthorized a year ago, focuses on 
domestic pandemic readiness but is nearly silent on international 
aspects. This is a moment to rectify that, for our global and our 
domestic efforts must be well aligned. We must understand that our 
investments in global cooperation are not purely altruistic; the also 
keep us safe. And we must connect those efforts directly into our 
domestic efforts.
                           the global outlook
    In an earlier hearing of this Committee, Chairman Risch asked a 
group of administration witnesses to identify the ``fire department'' 
for global health emergencies. While none acknowledged it, the world 
already has such an institution: the Health Emergencies Programme of 
the World Health Organization, guided by the WHO's mandate under the 
International Health Regulations to ``prevent, protect against, control 
and provide a public health response to the international spread of 
disease.'' While WHO is not a perfect institution, it has improved 
dramatically since its failings during the 2014 Ebola outbreak, and has 
largely served the world well during the present pandemic. U.S. 
involvement with WHO is a critical pillar of American and global 
pandemic preparedness. Withdrawing the United States from the WHO will 
weaken both the WHO and the United States, and put at risk the health 
of millions around the world and here at home.
    There have been assertions by the Administration, and by some in 
Congress, that WHO's performance on COVID has been a repeat of mistakes 
it made during the West Africa Ebola outbreak, and that the U.S. is 
therefore justified in abandoning the organization as hopeless. This 
mis-diagnoses both what went wrong in 2014, and what constrained the 
organization during the early phase of this pandemic.
    There is no question that the organization badly mishandled the 
Ebola outbreak in 2014 during the critical May-August period when the 
outbreak accelerated across West Africa. The WHO country offices were 
slow to take the risk seriously, WHO HQ in Geneva was slow to sound the 
global alarm, and the organization lacked the operational wherewithal 
to mount a rapid and effective response. The independent panel tasked 
with evaluating WHO's response to that outbreak concluded that the 
organization did not ``currently possess the capacity or organizational 
culture to deliver a full emergency public health response.'' \1\ And 
this glaring gap in the global readiness for complex outbreaks allowed 
a virus that had never previously produced more than 425 cases in any 
single outbreak to infect 28,616 people and kill 11,310. It forced the 
U.S. and other nations to deploy massive civilian and military 
operations to contain the outbreak, at a cost of billions of dollars.
    At the time, I served at USAID as the director of foreign disaster 
assistance, and my team served as the backbone coordinating the U.S. 
response in West Africa. Following the outbreak, I was closely involved 
in U.S. deliberations over what to do with WHO. The interagency debated 
a range of options, up to and including the creation of a new, separate 
agency responsible for health emergencies. But we concluded ultimately 
that that was neither feasible nor advisable, and that the best 
approach was to press for a fundamental overhaul of WHO's role in 
health emergencies.
    We also recognized, as did other prominent WHO member states, that 
part of the responsibility for the failure rested with us. WHO is a 
member state-based organization, and its policies and priorities are 
not determined in a vacuum: they reflect the guidance and direction 
that the WHO secretariat receives from WHO members. And for too long, 
member states had pushed WHO leaders to prioritize non-emergency 
missions while ignoring the erosion of the organization's emergency 
response capacity.
    So rather than abandon the organization, the U.S. set out to 
strengthen it. We worked with WHO leadership to develop a plan for a 
major organizational overhaul; I and a CDC representative sat on the 
advisory group that helped design the proposed reforms. We also 
mobilized diplomatic efforts to build support among member states for 
the emergency reform package, which was passed by the WHO's governing 
body in May 2016 with broad support. We provided targeted funding to 
help kickstart the reform process, tied to rigorous accountability 
requirements to ensure that the organization followed through on reform 
implementation. And since 2016 I have had a unique vantage point on the 
implementation of these reforms from another perspective, as a member 
of the independent oversight board that monitors WHO's Health 
Emergencies Programme and reports back to the member states on the 
organization's implementation of the post-Ebola reforms.
    These reforms have had a real impact. There is perhaps no clearer 
contrast between the WHO of 2014 and the WHO of today than the 
organization's handling of the extremely complex Ebola outbreak that 
finally concluded last week in Eastern Congo. An agency that had been 
unable, in 2014, to mobilize a rapid or robust operational Ebola 
response in three stable and peaceful countries was able, by 2018, to 
mount a massive field operation in one of the most complex conflict 
zones on earth. And furthermore, WHO did this without anything like the 
kind of massive U.S. and UK personnel deployments that had rolled out 
in West Africa. In fact, WHO received far less technical support and 
cooperation from CDC and USAID than it customarily would, due to the 
State Department's fears about security risks to U.S. personnel. WHO 
meanwhile deployed more than 700 personnel, at significant risk, and 
lost staff to armed violence. Over the course of the outbreak, WHO and 
the Congolese government partnered to build an operation that 
vaccinated more than 300,000 people and at its high-water mark was 
tracing and monitoring more contacts (in a war zone!) than most U.S. 
states are today.\2\
    And that in turn is a useful backdrop to understanding WHO's 
performance during the ongoing COVID pandemic. The organization today 
remains far from perfect but has made huge strides since its nadir in 
2014. And while the Trump administration has criticized the WHO for 
supposed failures on COVID-19, the main charges do not hold up to 
scrutiny--and certainly do not justify withdrawing from the 
institution.
    The Administration has made three main accusations: that the WHO is 
uniquely close and credulous toward China; that it was late to warn the 
world about the dangers of the virus, particularly its potential for 
human-to-human transmission; and that it opposed President Trump's 
imposition of a travel ban on China. Collectively, the Administration 
has suggested that different behavior from WHO on these fronts would 
have spared the U.S. and the world from the catastrophe that this virus 
has wrought.
    These accusations are false.
    With respect to WHO's supposed closeness to China, it is certainly 
true that WHO is highly deferential toward member states--but this is 
not unique to China. Like any multilateral, member-state based 
organization, WHO is loath to criticize its members in public. This is 
by design; WHO's members (the U.S. included) have traditionally steered 
it to be highly deferential toward member state prerogatives. WHO also 
avoided criticizing shortcomings by the Congolese government, or the 
governments of West Africa, during Ebola outbreaks there; all of those 
members states have far less global power than China.
    This kind of deference is formally enshrined in the International 
Health Regulations, the binding treaty negotiated by WHO member states 
that guides WHO's authorities in major outbreaks. The IHRs make 
explicitly clear that WHO has virtually no authority to second-guess 
outbreak reporting by a member state, and can only investigate new 
outbreaks with the state's cooperation and consent. Furthermore, the 
IHRs grant WHO no authority to sanction or punish states for 
inaccurate, late, or incomplete reporting. Again, it is important to 
emphasize that this situation was created by the choices of the member 
states that negotiated and adopted the IHRs. As for the notion that 
China has outsized influence in the WHO, U.S. citizens occupy two 
senior leadership positions in the organization while only one is 
occupied by a Chinese national.
    The idea that WHO was unjustifiably late in warning the world about 
COVID-19 also ignores the evidence. China confirmed the outbreak to WHO 
on December 31 2019. Within days, WHO had released an extensive set of 
resources and technical guidance on the virus, and on January 12 
(unprecedentedly fast compared to previous outbreaks) WHO shared the 
virus' genetic sequence with the world, with detailed guidance for 
diagnostic testing released on January 13.\3\ With respect to human-to-
human transmission, WHO stated in a press conference on January 14 that 
human-to-human spread was a possibility (albeit yet unproven).\4\ WHO 
subsequently confirmed human-to-human spread was occurring on January 
22, a day after WHO staff returned from the first trip that the Chinese 
government had permitted them to make to Wuhan. Another day later, on 
January 23, Director General Tedros convened the WHO Emergency 
Committee (and advisory body composed of outside experts, including a 
senior U.S. CDC official) to review emerging information from China and 
advise on declaration of a public health emergency of international 
concern. The PHEIC is the highest level of alert that WHO is authorized 
to sound under the IHRs.
    The emergency committee was split at that time on declaring a 
PHEIC; there were fewer than 600 cases officially reported. Nonetheless 
the WHO's summary of the committee deliberations provided a picture of 
the virus that was deeply alarming: a novel respiratory coronavirus 
that was spreading uncontained in the community; had a severity rate of 
25% and a preliminary fatality rate of 4%; and had a reproduction 
number of up to 2.5 \5\, making it significantly more transmissible 
than seasonal flu. In the infectious disease world, this is a highly 
worrying collection of characteristics. A week later, after China had 
begun shutting down Wuhan and other major cities, the Emergency 
Committee reconvened and advised declaring a PHEIC, which Director 
General Tedros did. At the time, fewer than 100 cases had been detected 
outside China, and only 5 in the United States.
    With respect to on the travel ban controversy, WHO's posture was 
grounded in the widely held view in public health literature that 
travel bans are a highly disruptive measure that provides limited real 
protection against the spread of a respiratory virus. Most research on 
travel bans has found that in a large and open country like the United 
States, such bans can at best modestly delay the acceleration of an 
outbreak by a few weeks. They cannot shield a country from the eventual 
arrival of a virus, as is now obvious. There was good reason to 
therefore be wary of such bans, for fear that they foster a false sense 
of complacency that deters emphasis on true readiness for the arrival 
of the outbreak--which indeed is precisely what happened here. And in 
fact WHO did not actively oppose such bans; it sent a circular notice 
to member states on February 6 noting that such bans could be justified 
if they were used to allow time for countries to implement sustained 
preparedness and response measures.
    Put together then, these accusations have little merit and there is 
no reason to believe that different behavior from WHO would have 
produced a different readiness posture by the U.S. Government. The 
failure of the U.S. to be ready for the pandemic now battering our 
country is not result of listening to WHO, but rather a result of not 
listening. China was slow to release information on the virus; but WHO 
had no authority under the IHRs to compel different behavior. Once WHO 
verified updated and more accurate information it relayed that evidence 
to the world, at a time when there was still a sufficient window for 
preparedness. And it noted that travel bans, if implemented, should be 
used to buy time for domestic preparedness, advice that the U.S. 
ignored.
    The U.S. withdrawal from WHO is absurd on the merits and will be 
tragic in its consequences. WHO is a crucial reporting hub for every 
country in the world, and there are numerous USG secondees working for 
the organization. Membership provides access to important policy and 
research bodies; walking away from WHO leaves the U.S. less informed in 
COVID-19 and future pandemics. The U.S. has also invested heavily over 
the years in WHO's ability to lead the fight against infectious 
diseases so that we don't need to carry that burden alone. Global 
polio, for example, is close to full eradication due to WHO's U.S.-
backed vaccination efforts. Withdrawing from WHO will leave the U.S. 
isolated in global health efforts and unilaterally surrender U.S. 
influence.
    Instead of withdrawing, the United States should focus its efforts 
on continuing to advance WHO reform. While great progress has been 
made, much more is needed. The United States' ability to promote those 
reforms will evaporate with our departure from the institution. The 
U.S. should focus as well on the bigger weakness that this pandemic has 
revealed: glaring shortcomings in the International Health Regulations. 
If we want to see greater country transparency and accountability in 
outbreaks, the IHRs' tepid handling of those dimensions is the place to 
start. We should also explore updating the PHEIC mechanism, whose 
binary structure undermines its usefulness as a true alarm bell for 
health emergencies. A far better approach would be to rethink the PHEIC 
as an escalating scale of pandemic risks, with different global and 
national readiness triggers tied to gradations of risk. These kinds of 
reforms would make the U.S. and world meaningfully safer in future 
emergencies; by leaving WHO, we lose the ability to accomplish this.
                     organizing the u.s. government
    As the U.S. focuses on adapting the international system to the 
lesson of COVID-19, we must also rethink how the U.S. Government itself 
works to advance global pandemic readiness. I am very heartened to see 
a flurry of proposals to bolster U.S. Government focus, operations, and 
financing toward this critically important objective. We must seize 
this moment to begin building a stronger U.S. and global architecture 
for health security, just as we did after 9-11 for counter-terror 
cooperation (although hopefully with greater regard for human rights 
and civil liberties).
    And so I welcome and commend the spirit of the proposals that have 
emerged--the Risch/Murphy/Cardin bill and the Menendez bill in the 
Senate; the Connolly bill in the House; and elements of the emerging 
proposals being formulated by the Administration. However, I have real 
concerns about the design of some of these proposals. Global health 
security and pandemic preparedness are whole-of-government functions 
that must be effectively organized within the U.S. Government and well 
aligned with our multilateral partners, particularly the WHO. I do not 
believe that modeling the new initiatives on PEPFAR, as some of these 
proposals envision, is the best approach. While PEPFAR's robust budget 
and long-term political commitment are both characteristics we want to 
emulate here, other aspects of that initiative are poorly suited to 
pandemic preparedness. I will outline several elements that I believe 
USG-focused reforms must incorporate.
    First, it is important to establish a clear division of labor 
across the interagency, building on each agency's comparative 
advantages.
    This was not enough of a focus during PEPFAR's inception, and that 
lay the groundwork for years of interagency friction that continues to 
plague the USAID-CDC relationship. Due to initial ambiguity over the 
division of tasks and expertise, each agency built parallel capacities 
and programs in different countries. Even now it is not uncommon for 
CDC to lead program areas in one country that USAID leads next door, 
and vice versa.
    In developing the Ebola response in West Africa, my team at USAID 
and our counterparts at CDC instead sought to explicitly avoid this 
kind of ambiguity. We defined each agency's roles clearly at the 
outset, based on our respective comparative advantages--and then OMB 
developed budget proposals that reflected that pre-arranged division of 
labor. This led to a much smoother partnership, because we each 
obtained the resources we needed and had little reason to compete with 
the other agency for turf. I would urge that as Congress considers how 
best to authorize a new USG initiative, it establishes up front the 
respective roles of CDC, USAID, State, and other USG institutions (I 
was encouraged to see this reflected in the Menendez bill). This will 
reduce the potential for interagency friction and the need for a heavy 
coordination infrastructure.
    Second, the coordinator role at the State Department should 
accordingly be a lighter structure modeled on the Counter-ISIL envoy, 
rather than the heavy and directive model of the PEPFAR Coordinator.
    The PEPFAR Coordinator role centers expansive authority over 
program priorities, evaluation, and most importantly budgetary 
oversight at the State Department. This centering of interagency 
authority at State was arguably necessary for two reasons; the 
Coordinator's role in refereeing the aforementioned interagency turf 
battles, and to give the Coordinator leverage for interagency 
coordination. Repeating that model for pandemic readiness would have 
real downsides. It would prompt resistance from USAID and CDC, who are 
skeptical of the need for an added budgetary and program layer for 
initiatives that in many cases they have been investing in for years. 
And it would put a huge amount of program control in a Department that, 
outside of the PEPFAR office, has a weak institutional track record on 
global health.
    While PEPFAR has worked well overall, the State Department has 
struggled with other global health efforts over the years. The Obama-
era ``Global Health Initiative'' launched in 2009 was an earlier 
attempt by the State Department to improve interagency coherence across 
the U.S. Government's global health programs. But, as my CGD colleagues 
wrote at the time, it was ``plagued by infighting, leadership 
questions, and general confusion since its launch'' and was quietly 
shuttered in 2012.\6\ A few years later, during the Ebola outbreak, the 
State Department performed some tasks extremely well--such as 
organizing medevac services and providing Embassy-level support to 
outbreak response in the affected countries. But Main State in 
Washington struggled with interagency coordination, because the issue 
had no clear institutional home in the department. Eventually the 
Secretary recalled retired ambassadors to manage an ad-hoc Ebola 
Coordination Unit to manage State's contributions and represent in 
interagency deliberations. It is quite a leap to go from this track 
record to overseeing and leading the full range of programmatic, 
strategic, diplomatic, and budgetary functions envisioned in some of 
these proposals, and in the reported State Department vision.
    A lighter approach modeled on the Counter-ISIL envoy would have a 
higher chance of success. The Counter-ISIL envoy role has numerous 
parallels to what is needed for pandemics. It emerged from a 
recognition that protecting the U.S. homeland from ISIL would depend on 
both a well-aligned U.S. interagency response, and a major global 
diplomatic mobilization. The U.S. Special Envoy role was established in 
the State Department and tasked with building a coalition of allies--a 
classic State Department function. The Envoy's office also co-led the 
U.S. interagency planning, in close partnership with the National 
Security Council at the White House. This produced an effective and 
expansive coordination model, that gave government departments and 
agencies appropriate space to manage their operations while ensuring 
alignment and mutual visibility. Like the counter-ISIL campaign, a 
pandemic readiness initiative must mobilize a surge in global 
diplomatic outreach alongside agency-level programs and operations. The 
same kind of decentralized alignment--rather than concentrated 
bureaucratic power--is what the U.S. government needs for its global 
pandemic readiness efforts. Lastly, there is simply no substitute for 
White House leadership. A signature U.S. pandemic initiative needs 
visible Presidential backing and White House coordination in order to 
deliver on the ambitious scale that this challenge requires.
    Third, as many of the proposals have acknowledged, any new U.S. 
initiative must be robustly resourced. The pandemic has stripped 
trillions of dollars from global economic productivity, and cost 
trillions more in emergency economic stimulus and safety net spending. 
Investing on a PEPFAR-like scale--which is to say several billion 
dollars a year--to build the capacity to prevent a recurrence of this 
kind of catastrophe is an extremely good return on investment.
    Whatever the bureaucratic shape of this initiative, its priorities 
are clear. It must build a global partnership that advances the world's 
ability rapidly detect and contain future pandemic threats. This means 
investing in surveillance, diagnostics, and early warning--building the 
same capacities for infectious disease risks that we have built for 
hurricanes, droughts, and tsunamis. It means creating clearer triggers 
for global and country-level preparedness, so that we never again see 
the kind of inconsistent patchwork of country response that we have 
seen on COVID-19. It means investing in the readiness and resilience of 
medical and public health systems in weak and low-income countries, so 
that those states can contain disease threats that might reach us here. 
It means reinforcing critical supply chains of PPE and drugs. It means 
collaborating toward development of innovative diagnostics, vaccines, 
and therapeutics as global public goods.
                               conclusion
    All of these priorities will cost money, and all will require 
multilateral cooperation. To state it plainly, it is impossible to 
envision the U.S. advancing this kind of agenda without the full 
engagement of the World Health Organization. And it is hard to envision 
the rest of the world collaborating with us in this effort if they 
perceive it as an alternative--rather than a complement--to the WHO.
    Finally, it is painful to say this but it must be candidly said: 
the U.S.' credibility to lead a global coalition on pandemic 
preparedness will also fall short unless and until we also get serious 
about containing our domestic outbreak. Our credibility globally starts 
with our competence at home, yet we are presently a prime example of 
how not to handle this pandemic. To rectify this, and to be able to 
credibly reassert our global health leadership, we must start taking 
the advice we have long provided to other countries: depoliticizing 
public health, following the evidence, communicating risk effectively, 
building public trust, and deploying competent management structures. 
And as we engage with the world going forward, we must show a degree of 
humility, in recognition that even a country as nominally well-prepared 
as the United States can falter when it departs from sound public 
health principles.

----------------
Notes

    \1\ https://www.who.int/csr/resources/publications/ebola/report-by-
panel.pdf?ua=1
    \2\ https://www.who.int/news-room/detail/25-06-2020-10th-ebola-
outbreak-in-the-democratic-republic-of-the-congo-declared-over-
vigilance-against-flare-ups-and-support-for-survivors-must-continue
    \3\ https://www.who.int/news-room/detail/29-06-2020-covidtimeline
    \4\ https://twitter.com/UNGeneva/status/1217146107957932032
    \5\ https://www.who.int/news-room/detail/23-01-2020-statement-on-
the-meeting-of-the-international-health-regulations-(2005)-emergency-
committee-regarding-the-outbreak-of-novel-coronavirus-(2019-ncov)
    \6\ https://www.cgdev.org/blog/failure-launch-post-mortem-ghi-10

    The Chairman. Well, thank you very much. First of all, that 
is a good point, the last point made about if we are going to 
be the leader in this we need to have things at home covered.
    I want to say I have sat through a lot of panels on the 
Foreign Relations Committee over the years. This is probably 
the best one that has been put together.
    I would like to take full credit for it but, unfortunately, 
I am going to have to concede that the staff, both the majority 
staff and the minority staff, had a great hand in this and, 
clearly, picked out the best possible people on this topic.
    I really appreciate the tone of the panel as far as trying 
to move forward and not being in a condemning mode. I think 
that one thing that has come clear to all of us and has been 
evident by all of you is the fact that this is going to take 
more dollars.
    For those of us that are--have a difficult time spending 
money, other people's money, this is a real challenge. But, 
obviously, there are things--you do not have any trouble with 
us most of the time but when it comes to defense spending.
    But this is going to fall in the category of defense 
spending because without it, the consequences are phenomenal. 
All you have to do is look at what we just do with the wall at 
$2.8 trillion, half of the annual budget, to address this one 
single problem.
    And that indicates that we are going to have to be spending 
more to avoid having to do this again in the future. So I think 
coming to that realization is difficult. It is painful. But it 
is the reality.
    The Emergency Health Program within the WHO is probably one 
we are going to have to take a really serious look at. I think 
if--one thing that has come clear here is as I have tried to 
identify the fire department there is no fire department, but 
if there is one it is the Emergency Health Program but they act 
more like a volunteer fire department than the real deal when 
you pick up the phone and want the fire department.
    Maybe we could go around, just very quickly, and get each 
of you, give me your brief thoughts on the Emergency Health 
Program, how we ought to look at it, what it needs to be, and 
if you would go, please, in the same order from where we 
started. Then I am going to turn it over to others for comment 
and questions.
    With that, we will start with Mark Dybul. Mark, are you 
there?
    Dr. Dybul. I am. Thank you, Mr. Chairman.
    So within that response there is something called the 
Strategic Health Operation Center, or SHOC, which is similar to 
what an EOC, which I put forward in the testimony, we need.
    However, it is not funded sufficiently and there will be 
limitations for some of the reasons that have been discussed 
that WHO does not have authority to compel countries to act 
nor, really, would anyone else.
    There are limitations that are involved in the private 
sector. And so, I think, you know, WHO absolutely needs to be 
involved, likely should host, and SHOC could be the central 
point of that.
    But we would need to supplement the authorities. I think 
you need to involve heads of state, the private sector, civil 
society including faith communities, so that we are ready to 
go.
    And then a key piece, and this worked in South Korea, 
Taiwan, and other countries, they have to do regular 
simulations, and the national security apparatus, the 
apparatuses of the world.
    The private sector is exquisitely good at these 
simulations. You identify where your gaps are. So, for example, 
that SHOC or whatever the EOC would be would literally pick up 
the phone and call a country and say, you have an outbreak, and 
then the whole system would kick in and you would see how it 
worked, whether it worked.
    You would have stockpiles, and then you would start to see 
how to support regional and national EOCs so that they can be 
ready at the same time.
    So I totally agree that WHO has to be central to that and 
would be a driving force. But I think there is some 
supplemental things that would need to be done to make it 
totally effective with national security, private sector, civil 
society, and other groups, and to have those simulations, which 
WHO can manage and should run.
    But and this would be, I think, a conversation we have to 
have globally to put together the right pieces.
    The Chairman. Thank you.
    Let us see. Ambassador Kolker.
    Mr. Kolker. Thank you very much. I agree with Mark, and 
there does need--the WHO's budget for the entire operation with 
all of the mandates that they have is one-third of the state of 
Maryland Department of Health budget every year. So we need 
to--we need to go quantum levels more to let them be anything 
but a volunteer fire department.
    And in that regard, the dependence of the Health 
Emergencies Program on the overall budget of WHO, the small 
amount of assessed contributions for which the U.S. is 
traditionally in arrears--not just now but we are now more than 
ever in arrears--and the voluntary contributions makes it 
always dependent on an aspirational budget to do its work.
    It has to respond and then raise the money to pay for what 
it just did, borrowing from other WHO programs.
    So I used to work for UNICEF, which has a tremendous 
ability to raise money from individuals, from foundations, from 
the private sector, in a way that the WHO does not.
    The Red Cross also takes huge advantage of emergencies when 
people, Americans in particular, really want to respond and 
donate money.
    WHO has just set up a foundation that can scratch that 
surface. But I think we really need to look at the UNICEF and 
World Food Program models and look at a way that the World 
Health Organization can raise money widely from individuals and 
from organizations that now do not contribute because it is a 
number of state organizations with assessed contributions, not 
a funded program like UNICEF and WFPR.
    In addition, I think we need to look at the international 
health regulations, which are the basis on which countries need 
to cooperate with the Health Emergencies Program.
    I think they need to be strengthened maybe through a review 
conference or through member state effort like we reviewed the 
Health Outbreaks and Emergencies Program after the Ebola 
outbreak at WHO.
    But there should be a stronger right of international 
inspection. The International Atomic Energy Agency can require 
that countries let them inspect facilities if they think 
something has gone wrong. This will be harder in the health 
context but I think it is something we need to look at.
    And we need more options for declaring levels of public 
health emergency. We need to be able to prepare a proportionate 
response, for instance, having to do with travel regulations, 
for instance, having to do with laboratory requirements so that 
right now it is either an outbreak or it is a Public Health 
Emergency of International Concern, which triggers a number of 
different other requirements for states.
    We need to have a traffic light system in which there are 
more moderate levels of public health emergency that would 
galvanize states to take action earlier before this Public 
Health Emergency of International Concern take place.
    And I fully endorse what Mark said and others have, that 
WHO's inability to deal effectively with the private sector, 
which civil society, and even with finding a way in which 
other--many other multilateral organizations have to engage 
Taiwan, all of these are factors that can be addressed and need 
to be addressed by WHO in order to make the multilateral 
response more effective.
    The Chairman. Thank you very much. I appreciate those 
remarks and I am particularly interested in your comparison 
to--on inspections to the nuclear inspections.
    I would respectfully disagree that these may be more 
difficult than the nuclear inspections would be. You have a 
lot--you have a lot of experience with that, particularly with 
Iran and North Korea are probably the poster children for that.
    But what we have found is an international agency can use 
the bully pulpit really to shame countries into doing what 
needs to be done.
    And so I am not so sure that it is more of a challenge. But 
that is an interesting idea and a novel idea that I had not 
heard. That is one of the biggest complaints WHO has about 
their lack of authority is that they cannot go in on these 
things.
    That is really worth taking a look at. Excellent thoughts.
    Let us see. Dr. Jha.
    Dr. Jha. Yeah. So, Chairman Risch, I am going to just be 
very brief and echo a few of the points that Ambassadors Dybul 
and Kolker have made because I agree, largely, with their 
points, and let me emphasize maybe three.
    So, first of all, I do think the Health Emergencies Program 
is, clearly, underfunded. One of the reasons why it feels like 
a volunteer fire department is because in some ways it is. It 
is a little bit of a ragtag.
    They do not have--they are always out there asking for 
money, and if we are going to use them as one of the key 
pillars of our global response they need sustained and adequate 
financing.
    So I think whatever mechanism we use, that, I think, has to 
be essential.
    Second is on the public health emergency declaration. One 
of the calls that we had from our report in 2014 was that you 
do need a graded system because it cannot be an all or none 
because what that does is it raises the threshold for calling 
out a problem until it becomes much worse than it needs to be.
    And so we called for essentially a version of what the 
Department of Homeland Security does--you know, kind of green, 
yellow, orange, red--and I think that would be very, very 
helpful. It will probably require some looking at IHR and what 
can be done there.
    Last is one of my broader frustrations with WHO, which does 
come up here again and has been mentioned both by Ambassadors 
Dybul and Kolker but let me emphasize because I think this is 
extraordinarily important, is the difficulty WHO has engaging 
with nongovernment actors, nonstate actors.
    It has a framework that it uses. But, largely, WHO really 
struggles and one of the things that we have learned is that a 
global response to a pandemic is not just about government 
action. It is about private sector. It is about civil society 
organizations.
    And so that is a broader and, I think, deeper discussion 
with WHO, not just about the Health Emergencies Program.
    But I would like to see a WHO that is more deeply engaged, 
that is more favorable, that is more welcoming of nonstate 
actors, because I think that is something that hinders WHO's 
effectiveness.
    [Pause.]
    The Chairman. Excuse me. Great thoughts.
    Lastly, Mr. Konyndyk, you are up.
    Mr. Konyndyk. Thank you, and hopefully you can all see me 
again. My internet has returned.
    So I agree with--I agree with everything that my other 
colleagues here have said. I think that, Senator Risch, you are 
framing that it is a fire department but it is a volunteer fire 
department is a really nice shorthand for the challenges that 
the World Health Organization's emergency program continues to 
face.
    They have made great strides. They are now at a point where 
I think the proof of concepts has been demonstrated and now we 
need to really invest in strengthening and institutionalizing 
their emergency capacity, and that means more consistent 
funding.
    I have watched them from my perch on their Independent 
Oversight Committee for the last few years. I have watched them 
struggle constantly with tradeoffs, of trying to cover all the 
things that they have to cover within their mandate despite not 
receiving enough resources to do so. And, you know, they are--
they are trying to contend with everything the world throws at 
them with a budget smaller than most U.S. hospital systems.
    Tied to that, they need greater staffing but they also, as 
other witnesses have said, they need to invest more in 
partnerships.
    And so, you know, WHO should not have to do everything 
alone and they have made progress, I think, overcoming some of 
the cultural challenges within WHO around partnership with 
nongovernmental actors. I think that is an area that needs to--
that needs to continue.
    And then, finally, it is very, very important to take a 
look, as Ambassador Kolker said, at the international health 
regulations and some of the authorities that WHO has to operate 
under that really do tie their hands and their ability to be 
more forward leaning and more assertive.
    And, in particular, looking fresh at the Public Health 
Emergency of International Concern mechanism, which right now 
is a binary mechanism--it either is or it is not--we need to 
build in more gradations because there is a huge difference 
between something like the COVID-19 pandemic and the Ebola 
outbreak that has just finished in eastern Congo.
    But within the existing construct of the emergency 
declaration mechanism that cannot be acknowledged, so a more 
gradated mechanism that looks perhaps more like what we do 
within the humanitarian sector with famine declarations and 
famine prediction I think could be very helpful in triggering 
early action and differentiating between different levels of 
risk.
    Thank you.
    The Chairman. Thank you very much for those remarks, and 
just let me close. I am going to turn it over to Senator 
Menendez.
    Again, I want to stress that for every member of this 
committee, the Foreign Relations Committee, and their staffs we 
are going to be meeting as we have been regularly and talking 
about ways of moving forward and getting things into the bill 
that people can embrace so everyone--there is no closed secret 
meetings.
    Everyone is invited to these. Senator Murphy are going to 
meet with our staffs briefly at noon today to talk about next 
steps forward. So I want to invite everyone to participate and 
so we can try to pull this wagon together.
    With that, Senator Menendez.
    Senator Menendez. Thank you, Mr. Chairman, and thank you 
all for some very thoughtful testimony.
    Dr. Dybul, in your written statement you mention that, 
quote, ``Global and American partners are looking for a sign 
that the United States will once again demonstrate its 
commitment to a comprehensive global response. Investing in the 
immediate response now, laying the foundation for the future, 
will require leadership and resources.''
    So do you or any of the witnesses testifying today believe 
that the Administration's response has been commensurate with 
the scope and nature of the COVID-19 pandemic, domestically or 
abroad?
    Dr. Dybul. Thank you, Senator Menendez.
    I think the only honest answer to that is no, we are not 
quite there yet. I would say we have some of the best people, 
and I think we all know all of them, in the Administration and 
in our civil service capable of mounting a strong engagement 
internationally, as you saw from the government panel a few 
weeks ago.
    But we do have room to make up in terms of being engaged, 
our leadership, joining CEPI, which both of your bills called 
for, and participating there, engaging with WHO, supporting 
WHO's reform and engaging with international partners which, as 
I point out, I think is necessary to establish that fire 
hydrant.
    I know you have put the World Bank trust fund in and maybe 
that is the best mechanism. But until we talk to the rest of 
the world and know where they would put money, it is difficult 
to know that.
    So I do think we have the right people. We have got a great 
team that can do the work. But we have some ground to make up 
and I really thank the Congress and this committee for the 
leadership and stressing it because people do look to Congress, 
not just the Administration, and when they see leadership 
coming from--and I know this from PEPFAR and the Global Fund--
leadership from Congress actually makes a big difference in the 
world, took and I think we are positioned well to be able to 
engage and to see this through.
    And I would just point out, again, that swine flu report 
today is very disturbing. I mean, if we have at the same time 
new waves of the coronavirus, the potential for a bad flu 
season or swine flu, it is a catastrophic future we could face, 
and I really thank all of you and the people in the 
Administration doing the work. But we have some work to do.
    Senator Menendez. So let me ask you all, what lessons 
should we learn from watching other countries who have 
successfully responded to the COVID-19 pandemic?
    I open that up to anyone who wants to give any insights.
    Dr. Jha. Well, Senator Menendez, maybe I can--this is 
Ashish Jha. Maybe I can begin.
    There are lots of lessons, but the single most important 
one is countries that have taken the virus seriously and have 
moved aggressively have done better. This is a virus that is 
unforgiving if you fall behind and, unfortunately, for much of 
the time that we have been battling this virus I think we have 
been behind and we have been playing catch up.
    But, certainly, South Korea, New Zealand, Germany, and 
Taiwan, Hong Kong, Singapore, there is a list of countries. 
They have not all done the exact same thing. Some of them have 
pushed more in testing and tracing, others sort of more 
aggressive lock down.
    But they all took it much more seriously than we have and 
that has been the single biggest difference, in my opinion, 
between countries that have done well and countries like ours 
that have really struggled.
    Mr. Konyndyk. Senator, this is Jeremy Konyndyk. Quick 
thoughts on those two questions.
    First, I would agree with Dr. Jha. The countries that have 
done the best are the countries that have acted the earliest 
had have been the most robust in using public health 
engagement, that they have used upstream public health 
capacity, testing, tracing, and strong public health systems to 
prevent overwhelming their hospitals.
    We have a weak public health system in the United States 
compared to most other developed countries and that is an area 
that needs more focus. But we also just have to act early and 
be guided by evidence and I think it is clear we waited too 
long and that has really hurt us.
    On the international scene, you know, you asked if it has 
been commensurate to the scope of the pandemic. I do not think 
our engagement has.
    We have been uncharacteristically absent from international 
leadership on this pandemic and I look at the contrast with the 
Ebola outbreak a few years ago or past outbreaks under the Bush 
administration where, you know, the U.S. is really showing 
leadership, engaging with the world, trying to convene and 
bring the world along with us around a common vision.
    We do not see anything like that here. Instead, we see the 
Administration attacking WHO, moving very slowly to disburse 
the aid funds that Congress has appropriated to it and going it 
alone on things like vaccine development where the rest of the 
world is collaborating.
    So I think we really do need to step up into the customary 
leadership role that we have shown in past outbreaks.
    Senator Menendez. Well, thank you.
    Now, moving into what this should look like then, recent 
articles in Devex and Politico reported that the Trump 
administration is proposing an initiative as called the 
President's Response to Outbreaks, which would consolidate 
international pandemic preparedness under a new State 
Department coordinator and establish a new central fund to 
fight pandemics, using money out of the COVID supplemental.
    And let me go back to you, Mr. Konyndyk. You state clearly 
in your testimony that you do not believe that modeling a new 
initiative on PEPFAR as proposed by the Administration or as 
the chairman's bill envisions is a good approach.
    Would taking budgetary authority and programs from USAID 
and moving them to the State Department at all improve the 
ability of USAID or the U.S. in general to respond to epidemics 
and pandemics?
    What impact would further stove piping pandemic response 
funding for prevention and response efforts have on global 
health programs and the relief to development continuum?
    Mr. Konyndyk. Thanks for that question, Senator.
    Yeah, I do not think that creating a PEPFAR style highly 
empowered centralized coordinator at the State Department is 
the right model for what we need to do here.
    I think that the--something like the counter-ISIL 
coordinator is more the sort of function that we need here, and 
that was a lighter touch structure.
    It has some coordination authority but it led that in close 
conjunction with the White House and it left the budgetary and 
program decision making and line management to the agency 
themselves, and I think that that is a much better way to go as 
long as right from the outset we clearly define who is on the 
hook to do what across the interagency.
    And that was one of the challenges within PEPFAR and one of 
the reasons the PEPFAR coordinator has had to be so empowered 
is because that was kind of a free for all in the early years 
of PEPFAR between USAID and CDC and it set the foundation for a 
long--many years of turf battles between those two agencies and 
forced the PEPFAR coordinator role to be more of kind of 
referee for some of those interagency fights.
    But if we design it well up front, I do not think we need 
quite that heavy structure and that will be--you know, in the 
Ebola outbreak when we did that it worked very well and we got 
along because we did not have that much to fight over.
    If we leave them a lot to fight over by not outlining roles 
clearly, that is when you need that kind of heavy-handed 
coordination function.
    Senator Menendez. Very good.
    And then, finally, Dr. Jha, on May 18th, President Trump 
called for WHO reform within 30 days. Eleven days later he 
announced that the United States withdraw from the WHO.
    Former Deputy Secretary of State Bill Burns, one of 
America's preeminent diplomats who served for 33 years, 
commented that, quote, ``You do not reform the fire brigade 
when the fire is raging out of control.''
    So as someone who has both been a severe critic of the WHO 
but today's testimony balances with some of the realities, what 
is your assessment of the Trump administration's efforts to 
reform the WHO, have they been effective, and what lessons can 
we learn now from the United States efforts to work with and 
reform the WHO during and following the 2014 Ebola outbreak?
    Dr. Jha. So, Senator Menendez, thank you for that question.
    To stick with Chairman Risch's analogy of a fire brigade, a 
fire department--a fire department that, let us say, is 
struggling to manage a blaze that is engulfing our 
neighborhood, it is important to look at how that fire brigade 
is doing and assess its performance. But to distract it in the 
middle of fighting the fire is probably not ideal.
    And so I believe that we have to do a very thorough and 
careful examination of what did WHO do well, what did it do 
badly, and how we make it better.
    Interim assessments as have been proposed may be reasonable 
as long as they are not hugely distracting. I believe at this 
moment all of us have one job and one job only, which is to try 
to manage this pandemic and try to bring it to a close as 
quickly as possible. Anything that helps is a good thing to do 
and anything that distracts is a bad thing to do.
    I believe at the end of this pandemic, which I hope will be 
within a year with vaccines that are widely available or at 
least, let us say, controlling the pandemic by then, I think 
there will be plenty of opportunity to do a very deep dive on 
what WHO did well, badly, what reforms are needed.
    Again, after Ebola it took both independent commissions and 
U.S. leadership to make those changes, and I suspect that we 
will need both of those, both independent assessments as well 
as U.S. leadership to make the necessary reforms to make WHO a 
more effective organization yet.
    Senator Menendez. All right. Thank you. I have a lot of 
questions I am going to submit for the record. I would love to 
have your expertise on it, all of you.
    And with that, Mr. Chairman, I turn it back to you.
    The Chairman. Thank you, Senator Menendez. I think we all 
have questions we will be submitting for the record and I think 
those will be helpful as we try to put a path forward.
    Unfortunately, technology has not helped me know who is on 
the line here. So I am just going to go--I am going to do this 
on seniority and I am going to move as quickly as I can through 
these until we--so we can get through these.
    Senator Rubio, are you on?
    [No response.]
    The Chairman. Senator Johnson.
    [No response.]
    The Chairman. Senator Gardner.
    [No response.]
    The Chairman. Senator Romney.
    [No response.]
    The Chairman. Senator Graham.
    [No response.]
    The Chairman. Senator Barrasso.
    [No response.]
    The Chairman. Senator Portman.
    [No response.]
    The Chairman. Senator Paul.
    [No response.]
    The Chairman. Senator Young.
    [No response.]
    The Chairman. Senator Cruz.
    [No response.]
    The Chairman. Senator Perdue.
    [No response.]
    The Chairman. Senator Cardin.
    Senator Cardin. I am here, Mr. Chairman.
    The Chairman. Oh, thank you. Senator Cardin, thank you for 
being on, number one. Number two, thank you for your work on 
this. Your work has been very helpful, very instrumental in 
moving the entire issue forward.
    Both yours and Senator Portman's work in that regard is 
greatly appreciated and, again, on a bipartisan fashion I hope 
we could all move forward to get a bill, whatever that bill may 
look like, that would move the ball downfield.
    So thank you, Senator Cardin. The floor is yours.
    Senator Cardin. Thank you, Mr. Chairman, and I agree with 
your assessment. I think this panel has been an excellent panel 
and I thank each of them for their contribution.
    A couple of observations, then I am going to ask a specific 
question on what we should be doing in the United States 
Congress.
    Observations, as you have all said, that if you are in a 
country, you are not going to be safe unless all countries are 
safe to be in because it will spread; that U.S. leadership is 
indispensable; and that the United States pulling out of WHO 
during the middle of this pandemic made no sense whatsoever, 
recognizing that the WHO definitely needed to be reformed.
    We also recognize that the United States must lead by 
example, and when we live in a country where we have the 
continuation of the first wave and the escalating number of 
cases, we are not the example that the world is going to look 
to as the best way to handle this pandemic.
    All of that are facts we have to deal with. The Senate 
Foreign Relations Committee has a strong record of the 
independence of the Congress in leading our nation. And yes, 
you have all mentioned the fact that we need to provide greater 
resources and I could not agree with you more. We do need to 
provide the resources and Congress has the responsibility to 
provide the resources.
    But we can do more than just provide resources, and that is 
my question to you, is what should the United States Congress 
do? By example, during the previous Administration, we 
disagreed with the policies in regards to Iran. We passed the 
bill to be much stronger against the regime of Iran.
    In this Administration, we disagreed with the 
Administration's policy in regards to Russia. We passed a 
strong bill to stand up to Russian aggression.
    We acted independently. Now, we may have some different 
views, but I believe that the President has been very 
inconsistent--that is being kind--but has not given the 
leadership we need for the global community in order to 
effectively deal with this pandemic.
    What should Congress do? What concrete steps should we take 
in order to exercise U.S. global leadership to protect the 
health of not just the global community but, clearly, the 
health of Americans?
    What action would you like to see come out of Congress?
    Mr. Kolker. Senator, this is Jimmy Kolker. I would like to 
take a first stab at that. Is that----
    Senator Cardin. Sure.
    Mr. Kolker. Okay. Sure. First of all, many people said, oh, 
the U.S. was the best prepared country in the world, and in 
another book, the Nuclear Threat Initiative, Johns Hopkins, and 
the Economist published a study in which we did get the highest 
score, 83 out of 100, which is not an A grade.
    But if you look at the--if you look at the areas in which 
we failed, we got a grade of 60 or less in three of the 34 
indicators in that study, Global Health Security Index.
    One was in the preparedness of our clinics and hospitals 
for a pandemic outbreak in terms of supplies, training, 
personnel, and all those things. We got a score of 60.
    We got a score of 23 out of 100, a phenomenally bad grade, 
in terms of health care access; how easy is it for the most 
vulnerable populations to get access to health care in the 
United States. A low score.
    And we got an even lower score in exercising our team, and 
we have seen that all three of these that we did not have a 
team in place that was used to working with each other on 
outbreaks and emergencies.
    We did not have access for the most vulnerable populations 
and our hospitals have been struggling to meet the demands that 
had been placed on them.
    So, domestically, Congress needs to look at this 
holistically. But I also want to make one other point about 
China. It is absolutely true China was not wholly transparent 
or cooperative in the way they looked at this.
    But, historically, the United States is not reliant and has 
not been reliant on Chinese government official statements or 
even on World Health Organization information about China.
    After the SARS outbreak in 2003, China systematically set 
up the CDC model on their own CDC. We had CDC people co-located 
in China and in 2016 there were 47 of them on the campus of the 
Chinese CDC in daily contact with their counterparts about 
outbreaks and epidemics training, sharing information.
    In 2013, with H7N9, bird flu outbreak, which many people 
thought was going to be an epidemic, we surged 40 CDC people to 
China to help the Chinese epidemiologists control that epidemic 
and they did.
    But two things happened. One is the post-Benghazi move of 
all U.S. government personnel onto embassy compounds, which at 
HHS or during the Obama administration I actually fought saying 
this was not in the interests of our public health 
preparedness, and indeed, in China we have moved all of CDC off 
of the Chinese CDC campus into the embassy compound.
    Then the Trump administration talked about reducing our 
footprint of health presence in China and those 47 people have 
been reduced to 14, of who only three are Americans.
    So when we had this outbreak, we had--we had none of the 
three protocols. We did not use any of the three protocols that 
we could have used to engage China in direct bilateral 
collaboration, and the last one of those three, I have to say, 
which is an emerging infectious disease protocol, expires 
today.
    June 2020 is the expiration date. But emerging infectious 
disease protocol, we have not convened a meeting under that 
protocol since 2017.
    So we have a protocol which would have facilitated the 
sharing of information directly to us. We have not used those 
authorities.
    Senator Cardin. I have limited time. Let me just see if any 
of the others want to respond.
    Dr. Dybul. Senator Cardin, if I could.
    As a constituent, I live in Kent County.
    Senator Cardin. Sure--you first.
    [Laughter.]
    Dr. Dybul. I would say your direct question on what can 
Congress do is very pointed and I would say what you are doing. 
One is to link domestic and global much more clearly, which 
would mean working across committees.
    And that is one thing I would emphasize because this 
crosses CDC in our domestic response. It crosses, you know, our 
international activity, both at the State Department and in 
Defense. It becomes complicated and it is very important to 
work across those committees as I know you have begun to do.
    The second thing is to do precisely what you are doing with 
the legislation that has been proposed. Put forward how the 
U.S. government can lead in both a bilateral and a multilateral 
way, and open that up for discussion and then ultimately pass 
the legislation and work with the appropriators to ensure it 
gets funded.
    But I do believe this committee is actually taking the 
steps that are necessary and, again, there are people in the 
Administration who can work with what you can do.
    But if it is clear that Congress is acting I can tell you 
that matters both here but abroad because people understand our 
system of government, and clear action from Congress on 
financing structure, activity, what you want to see done, makes 
a big difference in terms of how the rest of the world views 
the U.S. response.
    So I thank this committee for initiating that process. The 
key is to drive it forward, get it done, and then it can make a 
big difference.
    Senator Cardin. Considering you just complimented the 
committee, I am sure the chairman did not mind I ran over a 
little bit of time.
    Thank you, Mr. Chairman.
    The Chairman. If that had not been so complimentary I would 
be very angry about your going over time. But thank you for 
those remarks and I want to underscore again this is a--this is 
a full committee response to this.
    With that, Senator Shaheen, are you on?
    [No response.]
    The Chairman. I know she was with us earlier.
    Senator Coons.
    [No response.]
    The Chairman. Well, Senator Coons is not here but I can see 
Senator Udall sitting in front of a beautiful New Mexico state 
flag and the mountains behind him reminds me of home.
    Senator Udall. --you can hear me, I take it, right?
    The Chairman. I can.
    Senator Udall. Great.
    Ambassador Kolker, first, I would like to thank you for 
your previous work as HHS's chief health diplomat. The COVID-19 
pandemic demonstrates how crucial it is for us to engage early 
on with our international allies and neighbors to address 
emerging public health issues. Only with open communication and 
focused coordination can we effectively take on this virus.
    The U.S.-Mexico Border Health Commission has a tradition of 
working bilaterally to tackle shared public health challenges. 
That is why I introduced bipartisan legislation with Senator 
Cornyn and others, the Border Health Security Act, to better 
coordinate our public health response along the northern and 
southern borders by increasing emergency preparedness, 
developing stronger health surveillance, and strengthening our 
public health infrastructure by providing additional resources, 
as the chairman has talked about.
    Our bill uses the recommendations of the commission to help 
effectively guide resources along with input from the 
Administration.
    Ambassador Kolker, in your opinion, will providing 
additional resources to build public health infrastructure or 
better coordinate early warning infectious disease surveillance 
at our borders, which my bill does, improve our ability to 
combat COVID-19 and future pandemics?
    Mr. Kolker. Senator, thanks for your question and, of 
course, the answer is yes. I did represent the secretary of 
Health and Human Services and was co-chair with the Mexican 
minister of health to lead these sessions of the U.S.-Mexico 
Border Health Commission when I worked at HHS.
    And it is a little known operation but it--when we think 
about border security it is really important also to think 
about border cooperation, and this is a great example of where 
the four U.S. border states and the five Mexican border states 
meet regularly to exchange information about health threats 
with a direct involvement of the populations that live across 
the border and the state departments of health.
    And in that capacity we were able in the past to give small 
grants, a total of only about $2 million a year, to state 
health departments to enable them to leverage state support and 
to support state and local efforts to do things like 
surveillance, TB control, which is especially difficult across 
the border, and looking for infections and outbreaks.
    And this, unfortunately, with the reduction in budget for 
the secretary's office at HHS, these grants to the states have 
ended. So your efforts to--earmarks of money to do something 
that I really saw good results from, especially in this time 
when health security is national security, I really appreciate.
    Senator Udall. Great. Well, I hope I can persuade Chairman 
Risch and Senator Menendez to put this border health security 
package into the next COVID relief package that we are going to 
be working on because I think it would make a real difference, 
as you have said, on all of the issues that impact us on the 
northern border and the southern border.
    Dr. Jha, in your opening remarks you said that the Latin 
American region recently reached 2.2 million cases after 
infections doubled over the last 2 months and its combined 
death toll passed 100,000 last week.
    Yet, the Trump administration has repeatedly cut funding to 
the Latin American region. Furthermore, instead of helping our 
neighbors in Cuba, the Administration has cut off communication 
to family support networks. These cuts simply were not prudent 
in light of the current pandemic.
    What impact will these cuts have on our effectiveness in 
dealing with the pandemic here at home and across Latin 
America?
    Dr. Jha. So, Senator, thank you for your question and your 
comment.
    You know, Latin America is our neighbor. These are our 
neighbors, in Mexico and Cuba and, certainly, across the entire 
Americas.
    And when I look across the entire globe, Senator, I see 
what is happening in Mexico and Peru and Brazil and Chile but 
other countries as well as incredibly concerning. These have 
really become, along with the United States, the hotspots of 
the world.
    And so if you think of this as a fire raging across an 
entire city, and these are our neighbors, we have got to work 
with our neighbors to put the fire out, because if there is a 
fire, a raging fire, in our neighbor's home, there is nothing 
we can do to protect our home that will not require us also 
working with our neighbor.
    So I believe deeply in American engagement globally but I 
believe particularly in our engagement locally in our own 
neighborhood. It is a good thing to do. It is in tradition with 
what America has always done and it helps protect the American 
people.
    Senator Udall. Thank you, Chairman Risch, very much for 
this hearing.
    The Chairman. Thank you, Senator Udall. Appreciate that.
    Senator Murphy, are you with us?
    Senator Merkley. Yes, I sure am.
    The Chairman. Senator Merkley, the floor is yours.
    Senator Merkley. Mr. Chairman, were you calling on Chris 
Murphy or Senator Merkley?
    The Chairman. I am sorry. Chris Murphy.
    Senator Merkley. That is not me. This is Senator Merkley 
speaking.
    The Chairman. I am sorry.
    Senator Murphy, are you with us?
    [No response.]
    The Chairman. Senator Kaine.
    [No response.]
    The Chairman. Senator Markey.
    [No response.]
    The Chairman. Looks like you are going to get your chance 
after all, Senator Merkley. You are up.
    Senator Merkley. Okay. Very good, Mr. Chairman. Thank you 
very much.
    I want to start by asking for some thoughts on some of the 
secondary impacts that we are facing, and perhaps Mr. Konyndyk, 
I will address this to you at the Center for Global 
Development.
    One of the secondary impacts is a potential massive 
increase in food insecurity, an estimated doubling of severe 
food insecurity, an estimated 150 million more people driven 
into extreme poverty.
    Is this an area where America could really show some 
international leadership and take that on?
    Mr. Konyndyk. Thank you, Senator, for that question.
    I think you raised a really important point, which is that 
the--you know, the full impact of a pandemic like this is not 
simply the infections that it causes. It is also the second 
order impact so things like the economic damage, the food 
security damage.
    And, you know, we are seeing increasing reports of food 
security impacts, particularly, you know, in countries that 
have resorted to lockdown tactics without having the ability to 
cushion the economic impact of that the way that a wealthy 
country like the U.S. or the European countries have been able 
to.
    So I am particularly concerned about what that will mean 
for much of the developing world as they try to contain this 
virus and we need to then--we need to support them not just 
with--not just with fighting the pandemic but we also need to 
provide more comprehensive support.
    And, you know, one of the areas where I have been 
concerned, and I wrote a piece about this last week, is that 
not much aid funding, whether from the U.S. or from other 
donors, is reaching NGOs and front line local organizations in 
developing countries and they have a very important role in 
cushioning those impacts.
    So, you know, I would urge the U.S. and other global donors 
to focus on getting money really as expeditiously as possible 
to those front line local partners who play such an important 
role while also supporting organizations like the World Food 
Program, which have an enormously important responsibility on 
the kind of macro side of the food impact.
    Senator Merkley. Thank you.
    I wanted to turn to another aspect, and Dr. Jha, perhaps I 
will direct this your way, which is there was reports that 
international refugee camps are starting to show the signs of 
outbreaks that could move very quickly.
    I have been in some of those refugee camps around the world 
where people are densely populated, most recently in Cox's 
Bazar, and is that an area where the United States could really 
help focus world attention and resources on the refugee camps?
    Dr. Jha. Yes. So, Senator Merkley, thank you for that 
question, and absolutely. You know, refugee camps--we have more 
people displaced in the world right now than we have ever had 
since World War II, about 70 million around the world, and 
refugee camps are breeding grounds for large outbreaks of this 
virus because it is, obviously, very difficult to socially 
distance.
    They do not have strong health infrastructure and you have 
a very mobile population, often people with a lot of chronic 
illness.
    So I think this is an area of extreme concern to me as a 
public health person and an area that I think has gotten very 
little attention globally. And so U.S. leadership in this area, 
I think, would be very helpful.
    We are not talking about a small group of individuals--70 
million people around the world who are internally or 
externally displaced--and we really do need a concerted effort 
to make sure that we manage disease outbreaks in those 
communities.
    Senator Merkley. Thank you. I think about how in Oregon we 
are looking at the high-risk areas--farm worker camps, old 
folks centers, prisons, and so forth, and how our committee--
our Foreign Relations Committee could be looking at those high-
risk areas around the--around the globe.
    Let me turn to another piece of the puzzle, and perhaps, 
Mr. Dybul, I will ask you to respond to this, and that is 
vaccine strategy.
    There is some hundred groups pursuing a vaccine. There has 
been a conversation about if a United States organization 
develops a vaccine that is approved whether we should insist 
on, essentially, all the vaccine being available in the United 
States first before it can be exported, or whether it should be 
available to be developed or reproduced in, I guess, in 
factories--drug factories around the world to quickly spread 
it.
    And so in terms of vaccine strategy, what is the--assuming 
we get an effective approved vaccine what is the best way to 
pursue the production and distribution of that vaccine?
    Dr. Dybul. That is an excellent question, Senator Merkley, 
and I do not think any of us would agree that we should just 
give it to the U.S. first before we give it to anyone else 
because that does not make us safe. If other countries have 
widespread virus worst and we do not, we are stuck here. You 
need vaccination across the world.
    What is happening actually here is very exciting. In the 
research world, the international collaboration is very strong 
across the private sector.
    We have three candidates that are moving, and there is a 
significant investment both by the United States government 
through NIH, BARDA, and other mechanisms, and also through the 
Gates Foundation, through CEPI, which, unfortunately, the U.S. 
did not participate in, to actually basically put bets on seven 
vaccines, and we do not know if they are going to work but 
begin creating the production facilities now.
    The hope is that we would have more than one approach. For 
example, there is about three major approaches that are being 
taken to vaccine development.
    You cannot just switch one factory from one type to other, 
and so people are investing billions of dollars, including the 
Gates Foundation, and Bill said, ``I am going to lose a couple 
billion dollars'' because he is going to actually create the 
production capacity now for those vaccines should they become 
available so he can mass produce.
    So there is great work being done there and I think support 
from the U.S. Government, including financially, in addition to 
NIH, which is hugely important, but to CEPI and others, which 
both bills call for, will be important.
    And secondly, to understand that just waiting until we get 
to every last person in the United States is not the best way 
to protect us from the virus. We actually need the world to 
have the vaccinations so that we can have the open global 
economy that we need if our economies are going to grow.
    And the last thing I would say to that, which is something 
I actually said to Senator Cardin, it is important that the WHO 
be at the table, and so something Congress can do is make sure 
we do not withdraw from WHO.
    Senator Merkley. Thank you very much. Thank you, Mr. 
Chairman.
    The Chairman. Thank you, Senator Merkley.
    We have got less than 15 minutes left but we have had a 
couple of members join us who want to participate.
    And we will do that starting with Senator Shaheen.
    Senator Shaheen, you are up.
    Senator Shaheen. --but I had to leave for a few minutes, 
and I very much appreciate the thoughtful discussion and all of 
our panelists' testimony this morning.
    Dr. Jha, I want to begin with you because one of the things 
you talked about was that you have been critical of the World 
Health Organization for the way they praised China's response 
to the coronavirus.
    Given what has been said about the lack of carrots and 
sticks that the WHO actually has, what do you think they should 
have done in response to the way China behaved?
    Dr. Jha. Yeah. Senator Shaheen, this is a very difficult 
question because WHO--you know, people have often said, well, 
WHO should have chastised China, and I think, well, I am sure 
that would have worked out well in terms of WHO's ability to 
get in and do things.
    So I think the balancing act, as Chairman Risch brought up, 
would have been, one, to acknowledge the information, demand 
that China let WHO investigators in. But they did not have to 
go as far as to praise China as the model.
    I remember listening to those early WHO press conferences 
and being struck by what I thought was an excessive level of 
praise.
    I suspect it was done with the motivation of getting the 
Chinese government to then be more open to WHO's engagement, 
and so I think the motivation was probably good.
    But it also, I think, led a lot of people to be less 
suspicious of the data coming out of China than probably should 
have been. So I think it had costs, and it is always easy to 
armchair quarterback but I do think they went too far and I 
wish they had not.
    Senator Shaheen. And could the international community, 
could the United States, have done more at the time to 
criticize and demand that China provide accurate data?
    Dr. Jha. Yeah. You know, I always believe that direct 
engagement by global leaders on issues like this and moments 
like this is really important.
    Harsh criticism may not work so well with the Chinese 
government, just as it would not work with our government if 
another government or WHO criticized us harshly. I am not sure 
we would be amenable to working closely.
    But I think direct engagement and more of a demand for 
accountability and sharing of information coming from the 
United States, coming from other European leaders, would have 
been helpful.
    The Chinese government, I think, responds to pressure when 
it is done respectfully, as I think most organizations and 
governments do, and I think that could have been done more 
effectively than it was.
    Senator Shaheen. Thank you.
    One of the questions that I asked at the last hearing that 
we had about the current pandemic was what opening the United 
States withdrawal from the global stage has provided to China 
to extend their influence in other parts of the world as they 
respond as the country that is there to provide materials, to 
provide medicine, to provide guidance based on their 
experience.
    Can any of you comment on the opening that you see that 
that has given China and what the United States has sacrificed 
in our not being the leader on the global stage right now?
    Dr. Dybul. Well, Senator Shaheen, this is Mark Dybul, and 
having run an international organization I can tell you it is 
significant. And it is not just China. It is actually Russia, 
too.
    They have both been, over the last 3 or 4 years, been 
increasing their footprint in global health significantly and 
particularly in Africa.
    And this is a real risk, I think, to the United States. 
There should be a balance. We need China involved. They have 
got lots of resources and they have got a lot to offer.
    We cannot just open up the door to them, and wherever we 
have stepped back, they have stepped in, and not just in the 
WHO but in other areas.
    And so we are at great risk around the world if we do not 
stay actively engaged and at the table, and I would just 
emphasize it is not just China. Russia has also been increasing 
their footprint in the multilateral and in specific countries 
in terms of health because they know countries value health, 
and the U.S. has been the preeminent leader unquestioned in 
global health and we need to maintain that role for many 
reasons, including who are going to be our trading partners in 
the future, and we need--we want to have those relationships 
maintained not only for health but for many reasons that are 
important to our security and our economic strength.
    Mr. Kolker. This is Jimmy Kolker. If I can just reinforce 
what Mark said.
    You know, I was in the Foreign Service for 30 years, and 
the U.S. is the aspirational nation. People in many, many 
countries, especially in Africa, where I served for 14 years, 
look to the U.S.
    How do you solve that problem in the U.S.? How can we get 
U.S. partners, U.S. expertise, and U.S. energy, involved in our 
projects? And that is especially true with health.
    And it seems to me that if we see this as mercantilist, if 
it is zero sum, we miss opportunities that we took advantage of 
working with China, for instance, on the Ebola response in 
Liberia where there is a Chinese facility and ours worked 
together with the African CDC, which was set up after Ebola and 
has responded well.
    So there are opportunities bilaterally with China but, 
particularly, in the WHO and the rest of the world. People look 
to us for expertise, guidance. We are the best prepared 
delegation. We have the resources they want. If we are not 
there, they are going to find somebody else and China, 
certainly, is eager to play that role.
    Senator Shaheen. Well, thank you very much.
    Mr. Konyndyk, do you want to add to that?
    Mr. Konyndyk. Yeah. I agree with everything the other 
witnesses have said. I would just say as well I think that the 
U.S. posture globally has been a real coup for China on this 
because, you know, what the world has seen over the past few 
months is China, because they controlled their outbreak 
fairly--you know, relatively quickly, has been able to go 
around the world distributing PPE and other supplies to 
developing countries while for most of that period the U.S., 
rather than providing aid as we customarily would, has actually 
been competing with a lot of these same countries for scarce 
supplies or testing materials and PPE, and it is only recently 
that that has begun to reverse.
    You know, so what the world has seen is they are competing 
with the U.S. that they are usually accustomed to partnering 
with and instead they are getting help from China, and China 
has been very happy to step into that gap and they have made a 
lot of hay in terms of the public diplomacy, about really 
playing that up.
    I think that, you know, that is something we need to be 
very wary of and the sooner we get our outbreak domestically 
under control the sooner we can return to that customary role 
of supporting the rest of the world.
    Senator Shaheen. Well, thank you all very much. It seems to 
me that as we talk about the importance of health around the 
world, it is something that some of us in Congress seem to have 
missed because it is also a huge issue here at home, and we 
need to make sure that we are also looking towards the health 
of the American people as well as globally.
    Thank you all very much.
    The Chairman. Thank you, Senator Shaheen.
    We are down to about 5 minutes, and I have Senator Kaine 
and Senator Booker, particularly Senator Booker, who has been 
with us the entire meeting.
    But, Senator Kaine, you are first in seniority so have at 
it.
    Senator Booker. Seniority and looks, by the way.
    The Chairman. Yeah. Right.
    Senator Kaine, are you with us?
    [No response.]
    The Chairman. Looks like, Senator Booker, you are up.
    Senator Booker. I am grateful. Make sure somebody tells 
Senator Kaine that I was saying nice things about him behind 
his back.
    The Chairman. Oh, I will. Believe me.
    [Laughter.]
    Senator Booker. All right.
    I want to thank everyone on the panel for being here. It 
has been a really substantive discussion and dialogue. I want 
to get real quick to Mr. Konyndyk, and just ask you, you were 
also a member of the CSIS Task Force that Senator Young and I 
co-chaired just last year, and your expertise in producing the 
report was really invaluable, frankly, and I just thank you for 
your engagement and your commitment to easing suffering around 
the world. It was a great experience for me and my team, quite 
frankly.
    I would like to ask you just some quick questions and, 
hopefully, getting succinct answers, knowing that we have a 
time limit.
    Understanding that we really need global coordination and 
information sharing to bring COVID-19 and other pandemics under 
control, what would be less costly to the American taxpayer? 
And that is something, I think, is a good lens with which to 
look for.
    Is it less costly to remain in the WHO, in your opinion, or 
setting up a whole new international global health 
organization?
    Mr. Konyndyk. Thanks. That is a very easy question that I 
can answer quickly. It is much cheaper and easier to stay in 
the WHO and try to fix it than to set up something new.
    And we--you know, when I served in the last Administration 
we looked very hard at this question, as Ambassador Kolker will 
remember, trying to figure out what to do with WHO after it 
really dropped the ball badly on Ebola in 2014.
    And we gave serious consideration to a range of options and 
what we came back to was both the--kind of the least expensive 
but also the most effective solution was to try and make WHO 
work and that prompted the creation of the Health Emergencies 
Program, which over the last 2 years, I think, has proven--has 
proven the concept.
    I would point most to the Ebola outbreak in Congo over the 
last 2 years, an incredibly complex outbreak which WHO was able 
to handle, you know, largely, without the kind of intensive 
support it got from the U.S. and UK during the West Africa 
outbreak.
    You know, there was no deployment of 3,000 U.S. military 
personnel. There was no deployment of hundreds of CDC and USAID 
civilian personnel, and WHO still got the job done and the U.S. 
spent far less--contributed far less to the Congo outbreak than 
we had to do in the billions of dollars that we spent 
containing the West Africa outbreak.
    So I think there is very good return on investment in 
working to make WHO work.
    Senator Booker. Well, let me ask you the same kind of 
balance sheet cost benefit analysis. What would demand less 
resources from the State Department, working through the 
existing system to reform the WHO or corralling the entire 
international community to join a new organization to do what 
the WHO already does?
    Mr. Konyndyk. Yeah, of course, it is the same answer, and I 
would add I think the rest of the world is not as upset with 
WHO as the Trump administration is. You know, we are not seeing 
other countries threaten to abandon WHO or even lodge criticism 
towards WHO the way the U.S. has.
    So I do not think there is any appetite for that. The U.S. 
would really be, you know, banging its head against a brick 
wall if we are trying to create a new organization without 
consensus from the rest of the world on that.
    Senator Booker. But it is more than just banging your head 
against the wall. You know, it is so resource intensive, 
correct, to try to go out and develop relationships----
    Mr. Konyndyk. Absolutely.
    Senator Booker. --with every health minister in every 
country in the world as opposed to just tapping into the 
relationships that the WHO has already developed over decades 
and where its presence, frankly, is already accepted and 
welcomed when some of the countries our presence, 
understandably, with a lot of state of the globe right now 
would not be welcomed. Is that correct?
    Mr. Konyndyk. That is very well stated. You know, one thing 
I have seen in my years doing this work is that the WHO is 
almost an extension of the health ministry in many developing 
countries, and that is not a--you know, that is not a role that 
a new organization could just take over.
    We need to capitalize--that is a huge advantage for WHO. It 
is one that they could capitalize on better with their 
emergency work and they are beginning to do so.
    But I do not think you could just create something new and 
expect to have that same sort of deep relationship and trust 
that WHO has with the health ministries that need to be 
partners on it.
    Senator Booker. And in terms of just making America less 
safe, is it--you know, trying to replicate the WHO's solidarity 
trial, which is, you know, the world's largest clinical trial 
of COVID-19 therapies, coalition of 300 scientists exchanging 
scientific results as they test vaccines, we are really being 
sort of isolating going at it to determine the efficacy of 
vaccines ourselves. That does not seem a wise way to go.
    Mr. Konyndyk. Yeah. We should be spreading our bets when it 
comes to vaccines. I mean, I am glad to see the Warp Speed 
program that the Administration has launched. We need that.
    But we should not be putting all our eggs just in that 
basket, and if there are other mechanisms that might pay off 
sooner, you know, we do not know which of these things 
ultimately is going to hit first. So we want to have a hand in 
all of them.
    Senator Booker. Yeah, and that is the challenges. I hear 
this idea of using taxpayer dollars wisely, and it just seems 
on a lot of levels just so deeply unwise, not to mention wildly 
fiscally irresponsible to try to remove ourselves from the WHO 
and then think that we are going to be able to replicate that 
without extreme expense, putting ourselves in jeopardy, putting 
American health and well-being at risk.
    And so I just, really quickly, in the last seconds I have 
remaining I want to go to Dr. Jha. I do not--I am not sure if 
Americans really know the role that WHO plays in just the 
seasonal flu vaccine, for example, and ending our involvement 
in the WHO will, for the first time, cut the government--U.S. 
government, rather--out of the development of the seasonal 
influenza vaccine from the Southern Hemisphere, which is a 
process that is actually coordinated by the WHO in partnership 
with the United States.
    So just really quickly, do we know for sure how or if U.S. 
would maintain access to the most up-to-date information needed 
to develop a vaccine?
    How important it is--is it for the U.S. and for Americans, 
in your opinion, to take the flu shot every year and what would 
be the consequences for the world of not sharing and 
coordinating information and the processes themselves for the 
development of the seasonal flu vaccine?
    If you could just give me a window on that and then I will 
yield back to the chairman.
    Dr. Jha. Senator Booker, thank you.
    A couple of very quick remarks on that. Yes, we develop a 
new flu vaccine, the world does, every year. Ten institutions 
from around the world come together to collaborate, including 
American institutions, and it is all done under the aegis of 
the WHO.
    I have no idea whether we would continue to be able to be 
engaged and have a hand. But what I know is that if we could 
not access that information and if we had to go it alone, our 
ability to make the right bets, create the right vaccine every 
year would be substantially diminished.
    And that would--as you know, the flu, while, you know, 
nothing like the current coronavirus, is still a deadly virus 
and especially affects older Americans, and a vaccine is 
incredibly helpful.
    And if our vaccines became far less effective the main 
people who would suffer from that are the American people.
    So there are a lot of questions about what we would be able 
to continue to engage in. Walking away from WHO, in my mind, it 
is a no-brainer. It would leave the American people much worse 
off and the influenza vaccine is just one example of how the 
American people would be hurt by this decision.
    Senator Booker. I am grateful for that, and thank you, Mr. 
Chairman. I will yield back.
    The Chairman. Thank you. Thank you, Senator Booker, and 
thank you for being with us for this entire hearing.
    We are past time, but Senator Murphy has joined us. I know 
he is supposed to be in a very important meeting with a 
distinguished member of the body right now. But we will 
certainly welcome him and give him a shot at this.
    So, Senator Murphy?
    Senator Murphy. Thank you very much, Mr. Chairman, and I 
will just ask one question. I know I am a little late to the 
party here.
    But there is one topic that we have not covered that I 
think might be important to hear from at least Ambassador Dybul 
on, and that is the status of global health infrastructure.
    What we learned in combating viruses in West Africa is that 
fragile local public health infrastructure makes it very, very 
difficult to respond to new and evolving diseases.
    And I know, Ambassador, you were involved in the creation 
of the Global Fund for AIDS, Tuberculosis, and Malaria, which 
has been a huge success in tackling those diseases. But the 
mandate of the fund is really limited to those diseases.
    Right now, there is not a robust global financing mechanism 
by which we can muster partners together to go and just help 
build and rebuild local public health infrastructure and then 
also partner with nations to try to prompt reforms in the way 
that they govern their public health infrastructure space.
    So one of the things we have talked about across the aisle 
is whether there is a need for the United States to stand up 
that kind of capacity with other partners and on a nondisease-
specific basis go in and work with nations where we know there 
is vulnerabilities and we know there is likely going to be 
future viruses and pandemics and just use some basic building 
block work of public health infrastructure where it is lacking.
    So I just wanted your thoughts, quickly, on, you know, how 
we go about doing that work, whether that can be done at the 
Global Fund or whether we need to do that kind of work through 
another entity, the WHO, new authority prompted by 
congressional action.
    Your thoughts?
    Dr. Dybul. Thank you, Senator Murphy, and it is an 
extraordinarily important question, especially right now.
    A couple of quick points. From a technical perspective, 
technical support, WHO plays a critical role. As was mentioned, 
often the WHO is an extension of the ministries of health in 
countries.
    So they do play a critical role on the technical side, but 
not on the financing side and so the financing piece is a 
little bit different.
    The Global Fund would have the capacity, certainly, with 
new money now to scale up support to countries for 
infrastructure, for procurement, for the pieces that are 
necessary to respond to COVID right now.
    I think for the longer term, it would be an open question 
where the best international facility is, and we had a little 
discussion about that a little bit earlier.
    I would also point out that, you know, there are different 
approaches, and we saw this, right. Taiwan had a relatively 
low-tech approach versus South Korea's relatively high-tech 
approach.
    Because of the investments the U.S. and others have made in 
HIV, TB, malaria vaccination, maternal and child health, South 
Africa has fielded 28,000 community health workers to go out 
and do contact tracing. Sierra Leone has 9,000.
    In the Ebola crisis, it was those workers that went around, 
that were repurposed, in a sense, from what had gone into the 
institution building.
    But we absolutely need more laboratory capacity. We need 
more structure, and this is where the complementary 
opportunities for CDC and which does this all the time, and 
GHSA, USAID, bilaterally but then multilaterally.
    Without a financing institution to complement the technical 
institutions, we will not be able to get there, and I believe--
and I am a little biased, having run the Global Fund, but I 
also ran PEPFAR so I have both perspectives--they could do--
they could absorb money now while the conversation is going on 
for what it would do for the future.
    Senator Murphy. Thank you, Mr. Chairman. I appreciate the 
time.
    The Chairman. Thank you, Senator Murphy.
    That pretty much runs us out of time.
    But, Senator Menendez, did you want to--first of all, let 
me thank the panelists. This has been an incredibly frank and 
good-faith honest broker exchange of ideas, and we really 
appreciate that.
    On behalf of the committee, I want to thank each and every 
one of you for spending----
    Senator Menendez, did you want to add anything----
    Senator Menendez. Mr. Chairman, with your indulgence, if I 
could ask Mr. Konyndyk one quick question just so I could----
    The Chairman. Sure.
    Senator Menendez. --devise responses to what you are trying 
to do, and then with my thanks to everybody because it has 
been--I echo the chairman's remarks--been extraordinarily 
helpful and insightful.
    Mr. Konyndyk, you mentioned in your testimony that your 
team at USAID and the counterparts at CDC define each agency's 
roles clearly at the outset of the response to the Ebola 
outbreak in West Africa based on each institution's respective 
comparative advantages.
    A provision that we have in the legislation that we drafted 
clearly spells out the roles of State, USAID, and CDC in the 
pandemic response.
    Is such a provision useful, in your view, and if so, why? 
And, secondly, another provision creates a special advisor at 
the White House rather than the State Department.
    What is your view on having a coordination function at the 
White House?
    Mr. Konyndyk. Thank you, Senator. I will be very brief.
    I would say that defining----
    Senator Menendez. Unmute yourself because I cannot hear 
you.
    Mr. Konyndyk. How about now? Are you able to hear me now?
    The Chairman. This is Jim Risch. I can hear you. Go ahead.
    Mr. Konyndyk. Okay. I will try this again.
    So I think that it is not just helpful, I think it is 
essential to define each agency's comparative advantages up 
front and I think the provision in your bill is--you know, it 
is on the right path there.
    You know, when it is clear what each agency is supposed to 
do there is far less to fight over. There is far less turf 
battling that I saw during the Ebola outbreak.
    On the--on the White House piece, I would not say that you 
need the White House coordinating instead of the State 
Department. I think, you know, one of the helpful things with 
the counter-ISIL model was the--it was a sort of partnership.
    I spoke earlier this week with Brett McGurk, who served in 
the envoy role, just to pick his brain a little bit on how that 
worked in preparing for this hearing.
    You know, and he talked about the partnership he had in his 
team with the NSC, because the NSC has coordination leverage 
that, frankly, the State Department just does not have vis-a-
vis other agencies.
    So I think that you need both. I think a coordinator based 
at the State Department synced with a restored global health 
security director and an empowered senior director at the White 
House is probably the best structure.
    Senator Menendez. Well, thank you. Thank you, Mr. Chairman.
    The Chairman. Thank you, Senator Menendez, and again, thank 
you to our panel. I think we have all learned a lot that is 
going to help us move the ball down the field and try to get to 
a place that will make the world a better place and America a 
better place.
    Thank you all, and with that, the hearing is adjourned.
    [Whereupon, at 12:10 p.m., the hearing was adjourned.]
                              ----------                              


              Additional Material Submitted for the Record


       Responses of The Honorable Mark Dybul, M.D. to Questions 
                  Submitted by Senator Robert Menendez

                    the u.s. international response
    On June 7, The New York Times published an article which revealed 
weeks of delays in getting emergency funding appropriated in the CARES 
Act to fund our international response out the door to our partners. 
Implementing partners themselves report waiting up to 10 weeks as 
opposed to our usual 3 and a half weeks. And more than $200 million in 
COVID aid is being spent on ventilators for countries handpicked by the 
President with little to no examination as to whether this was the best 
use of funds, and whether countries have the facilities and medical 
personnel to put the ventilators to use.
    Question. Did these types of funding delays happen while you were 
in government? To your knowledge, what accounts for the current delays 
in pushing funding out the door?

    Answer. There can be delays following appropriation of funds even 
when the executive functions are fully staffed. COVID itself could be 
slowing use of funds.

    Question. Based on your knowledge of the capacity constraints of 
healthcare systems in developing countries, would healthcare facilities 
serving rural or underserved communities in a given develop country 
have the technical capacity or medical staff to safely and successfully 
employ a ventilator?

    Answer. Rural communities would not likely be able to manage 
ventilators. However, this is true for many more advanced services, 
e.g. c-sections, drugs needed to treat women during complications 
during pregnancy, PCR for HIV or drug resistant TB, etc. For this 
reason, health services in low income settings--including in the 
U.S.A.--are designed with a ``hub and spoke'' approach. Several 
countries in Africa have fewer than 10 ventilators. There is no 
question they are desperately needed. However, many other less 
expensive commodities and services are also needed. Oxygen, which can 
save many lives and prevent progression requiring ventilators, is 
relatively inexpensive and can be provided in many settings. It is 
important to prioritize in a pandemic crisis and to ensure that 
countries with the highest risk of an explosive epidemic and most in 
need rapidly receive support for commodities and services, e.g. support 
for testing, contact tracing and quarantine. In addition, there has 
been a long standing, bipartisan agreement that politics and political 
issues should not come into play for humanitarian relief.

    Question. Is the expenditure of more than $200 million on a few 
thousand ventilators for a select set of countries the best investment 
for protecting the most lives and preventing the spread of COVID-19?

    Answer. As noted above, ventilators are definitely needed. As are 
many other commodities and services. The prices per unit of a 
ventilator, and any other commodity or service, should, of course, be 
reasonable and within standards and procurement procedures.

    Question. What assurances on equitable access to care, when it 
comes to U.S. supported response activities, should USAID seek from 
host country governments?

    Answer. In general, because much of the programming by USG 
bilateral funding, and in particular USAID funding, is performed 
through implementing organizations, e.g. non-governmental organizations 
(NGOs), the USG can directly set standards and requirements for equity, 
including where and to whom services should be provided. International 
organizations, e.g. the U.N. family, the Global Fund to Fight AIDS, 
Tuberculosis and Malaria (the Global Fund), Gavi (the Vaccine Alliance) 
have strong equity provisions as part of their mission. Regarding 
direct support to governments, the U.S. is often successful at 
negotiating agreement on funding to ensure equity consistent with 
national priorities and plans. CDC works closely with ministries of 
health around the world and is a trusted partner and source of 
technical support welcomed by countries. CDC also plays an important 
role in ensuring equitable access to care.
    It is important that U.S. support through NGOs and international 
organizations also fit within national priorities and plans wherever 
feasible.

    Question. What else should we be doing to help end the pandemic--
are there programs and activities that the Administration should be 
funding that it currently is not?

    Answer. The legislation introduced by the Chairman with his 
bipartisan co-sponsors and the Ranking member advance the two areas 
that require coordination and funding--better coordination for U.S. 
bilateral support and for international efforts. The Administration 
seems to have similar approaches. The Center for Strategic and 
International Studies Commission on Strengthening America's Global 
Health Security, for which Ambassador Kolker and I serve as 
Commissioners, issued and important report with additional 
recommendations which can be accessed at: https://
healthsecurity.csis.org/final-report/.
    More specifically, an effective pandemic response requires 
coordinated and effective efforts to: 1) control spread, including 
testing, tracing and quarantine and implementation of social distancing 
and masks, and; 2) care and treatment for those who progress with 
symptoms. Both control and care and treatment requires trained 
personnel and varying degrees of personal protective equipment. In 
addition, because it is likely that the pandemic will continue, 
potentially with a second large wave beginning between August and 
October, it is important for the U.S. to support efforts to understand 
the global movement of the virus and genetic drift so that we, and the 
rest of the world can be better prepared for the future. For a more 
complete analysis, please see the White Paper published by Georgetown 
University: https://gumc.georgetown.edu/covid-19-a-global-pandemic-
demands-a-global-response/
                        global reach of the who
    The WHO has been on the frontlines of nearly every global health 
challenge over the past 70 years, combatting, containing, and 
eradicating some of the planet's most deadly diseases. The WHO serves 
as both a repository of global expertise as well as a critical 
implementation partner for local health ministries and organizations on 
the ground. In many places with weak health systems, the WHO's role is 
indispensable in ensuring the delivery of adequate health services and 
responses.

    Question. From your perspective, what makes the WHO a critical, or 
even indispensable, partner?

    Answer. There is remarkably wide agreement on the indispensable 
role of WHO in pandemic preparedness, detection and response. Many have 
come together to summarize the key strategic values of WHO as 
summarized below:

    Preeminent Technical Guidance--With a presence in over 150 
countries and the trust of governments around the world, WHO is 
uniquely positioned to both collect new evidence emerging from anywhere 
in the world and use it to develop, refine and disseminate technical 
and normative guidance essential to battling COVID-19.
    Global Clinical Trials--WHO is the only agency in the world capable 
of coordinating unprecedented global trials on therapeutics and 
vaccines, including the groundbreaking scope of the ``Solidarity Trial 
(https://www.who.int/emergencies/diseases/novel-coronavirus-2019/
global-research-on-novel-coronavirus-2019-ncov/solidarity-clinical-
trial-for-covid-19-treatments),'' with more than 100 countries 
participating. As important, the Solidarity trial will reduce the 
amount of time it normally takes for a drug trial to determine 
effectiveness by 80%.
    Communication--WHO is the only organization with the technical 
expertise and capacity, global membership, credibility, access and--
most important of all--trust, to launch pandemic awareness campaigns 
throughout the world. Billions of people have access to WHO's evidence-
based information in dozens of languages.
    Distribution--At least 133 countries are relying on WHO to globally 
procure millions of pieces of personal protective equipment (PPE) and 
other vital health commodities like tests and testing supplies, 
including more than 4.5 million items of vital PPE.
    Equity and Access--Only WHO is working to pre-position 
manufacturing capacity and distribution channels to ensure countries 
will have access to COVID-19 vaccines and treatments as quickly as 
possible and at a fair price.
    Developing world engagement--The WHO has a particularly important 
role to play in helping poorer countries fight COVID-19. Out-of-control 
outbreaks in the developing world will threaten the United States and 
could spark second waves of disease.

    Question. What challenges do we face in responding to a global 
pandemic without the WHO as a partner?

    Answer. The challenges would be insurmountable given the key roles 
WHO plays, and must play, as noted in the previous question. In 
addition, the risk to the world--and the U.S.--for future pandemic 
preparedness and response would be significant.
    Every agency can always do better, and no doubt mistakes have been 
made by WHO and every organization involved in COVID-19. However, 
overall the WHO has done a very good job in challenging circumstances. 
Action was taken from January 1 onward. And WHO has significantly 
improved under the leadership of the Director General, who was elected 
on a reform platform. The responses to the recent Ebola outbreak in the 
Democratic Republic of Congo and to COVID-19 have been substantially 
better than the response to the Ebola epidemic in West Africa several 
years ago.

    Question. What barriers will the United States face in trying to 
set up an effective alternative to the WHO?

    Answer. There is no effective alternative to WHO as a global 
normative, guidance, technical agency. No other organization would have 
the credibility, access, network of country offices or authority 
needed.
    I have not seen any proposals by the Administration to establish an 
alternative, perhaps understanding that any attempt to create an 
alternative would be technically and politically impossible. However, 
WHO is not ordinarily an implementing or financing agency (In unusual 
circumstances it can fill a vacuum, for example during Ebola Congo when 
it got too dangerous and the NGO's left Butembo). Those key pieces must 
be established as discussed in the hearing and as noted in the 
legislation put forward.
                       international cooperation
    In addition to efforts to combat COVID-19 at the WHO, there have 
been a number of other international efforts to combat the virus, 
including the European Commission's Coronavirus Global Response Summit 
on vaccines, which the United States conspicuously did not join. In 
fact, since the start of the pandemic the United States has failed to 
lead the international efforts to respond. We blocked consensus on a 
statement from the Security Council, and from the G7 by insisting on 
using divisive racially inflammatory rhetoric to describe the 
infection. The President himself used offensive terms to describe the 
disease at a political rally in Tulsa.

    Question. What kind of international engagement is necessary for 
the United States to be best prepared to combat COVID-19?

    Answer. As discussed at the hearing, and addressed in proposed 
legislation and, it seems, being considered by the Administration, a 
coordinated U.S. Government bilateral effort combined with a global 
fire department--a multi-sectoral global Task Force or Emergency 
Operations Center--and a separate financing agency (the fire hydrant) 
are needed. The U.S. has been the unquestioned leader in global health 
with strong bipartisan support for two decades. It is important that 
the U.S. play a strong leadership role again.
    For more detail, please refer to the White Paper released by 
Georgetown University: https://gumc.georgetown.edu/covid-19-a-global-
pandemic-demands-a-global-response/.

    Question. How can we use our international relationships to improve 
the situation for U.S. citizens as well as our partners?

    [No Response Received]
                           western hemisphere
    Over the past few months, there have been multiple reports 
documenting that the Trump administration has deported dozens of 
Guatemalan, Mexican, and Haitian nationals who tested positive for 
COVID-19 upon arrival in their home countries. Just this week, it was 
reported that despite an agreement to deport only those with medical 
certificates showing a negative test, Guatemalan authorities say that 
at least 28 deportees have tested positive since early May. Thirteen of 
my colleagues and I sent a letter to the State Department and 
Department of Homeland Security highlighting this very issue, though we 
have yet to receive a response. This question is for any of our 
panelists:

    Question. How, in your view, does deporting COVID-19 positive 
individuals to countries with weak or limited health system capacity 
affect our strategic interests in the hemisphere?

    Answer. The most sound scientific and medical approach is to 
quarantine and care for and treat anyone who is positive for SARS-CoV-
2, and to conduct rigorous contact tracing and testing related to the 
sentinel person. Deportation of someone who is actively positive for 
the virus risks further spread in the region and damages our 
reputation.

    Question. What policy approach would you recommend regarding 
removals during a pandemic? How have U.S. Government policies relating 
to deportation addressed previous epidemics, such as the Ebola crisis?

    Answer. There is no scientific or medical basis for deportations of 
any kind.

    Question. What is the scientific or medical evidence supporting the 
Trump administration's closure of U.S. borders to asylum seekers, but 
not other ``essential'' travelers such as truck drivers and family 
members?

    Answer. There is no scientific or medical basis for such a 
restriction.
                impact on other global health priorities
    A study published in 2016 by Yale University researchers found that 
there may have been as many deaths from HIV AIDS, TB and Malaria during 
the 2014/2015 Ebola outbreak in Guinea, Liberia and Sierra Leone as 
there were from Ebola because the health systems in those countries 
were overwhelmed, limiting access to health services. Recent reports 
indicate that as the COVID-19 pandemic continues, there has been a rise 
in the number of illnesses from preventable illnesses including polio, 
cholera and diphtheria. This question is for any of our panelists:

    Question. What should we be doing to prevent the disruption of 
health services, including service for those affected by HIV/AIDS, TB 
and Malaria?

    Answer. The reality is that until there is pandemic control, other 
health services will suffer. As during the Ebola crisis, pandemics can 
lead to significant disruptions to health services including HIV, TB 
and malaria, vaccinations, etc. There is fear among health providers 
and those at risk, leading to decreased availability of health 
services. There are reports of 70 percent declines in, for example, 
identification of new cases of tuberculosis. Because virtually every 
country has been effected by COVID-19, it has also been reported that 
COVID-19 could wipe out the significant gains the world has made 
against the HIV, TB and malaria pandemics, with strong leadership and 
bipartisan support of the U.S.
    However, it is also important that the U.S. do what she can to 
minimize the collateral damage by supporting bilateral and multilateral 
organizations and efforts to ensure as many HIV, tuberculosis and 
malaria services are provided, including through PEPFAR, PMI, other 
health programs supported by USAID, the Global Fund to Fight HIV, 
Tuberculosis and Malaria, Stop TB, Roll Back Malaria, Gavi, and 
importantly, as noted above, WHO.
    The most important and effective approach the U.S. can take is lead 
global efforts to control the global pandemic and to lead in preparing 
for the next one. With population growth, changes in climate and 
temperature patterns, and increased proximity to animals, another 
pandemic in the near- to mid-term is highly likely.

    Question. Should the U.S., provide funding for the Global Fund to 
Fight AIDS Tuberculosis and Malaria's COVID-19 mechanism?

    Answer. Yes. The Global Fund consistently receives high marks for 
results, transparency and accountability. It has the capacity and 
mechanisms to rapidly support national responses including procurement 
and supply chain, laboratory and human capacity, data collection and 
analysis and other key aspects of efforts to control the pandemic and 
provide care and treatment to those who become infected. It also can 
support countries to maintain and even strengthen their HIV, 
tuberculosis and malaria responses, helping to protect massive and 
highly successful U.S. investments over the past two decades. In that 
regard, during the West African Ebola epidemic, the Global Fund 
supported a community-led national malaria bed net campaign in Liberia 
and, with WHO leading the normative, guidance and technical aspects, 
the presumptive treatment of malaria at the height of the epidemic.
                                 ______
                                 

        Responses of The Honorable Jimmy J. Kolker to Questions 
                  Submitted by Senator Robert Menendez

                    the u.s. international response
    On June 7, The New York Times published an article which revealed 
weeks of delays in getting emergency funding appropriated in the CARES 
Act to fund our international response out the door to our partners. 
Implementing partners themselves report waiting up to 10 weeks as 
opposed to our usual 3 and a half weeks. And more than $200 million in 
COVID aid is being spent on ventilators for countries handpicked by the 
President with little to no examination as to whether this was the best 
use of funds, and whether countries have the facilities and medical 
personnel to put the ventilators to use.

    Question. Did these types of funding delays happen while you were 
in government? To your knowledge, what accounts for the current delays 
in pushing funding out the door?

    Answer. The June 7 NYT article refers mostly to USAID, where I did 
not personally work, and, needless to say, every crisis and every 
appropriation has some unique features which make comparison difficult. 
I nonetheless understand the frustration that urgently needed funds are 
not getting to their intended beneficiaries.
    In the current case, the differences include that we are facing the 
same public health crisis at home as other countries are experiencing, 
that most U.S. government employees and most NGO partner staff are 
working from home, that embassies overseas are working with reduced 
staff, including the local staff who are essential in the response, and 
that the demands are truly global, not centered on one country or 
region, thus requiring more clearances and trade-offs in setting 
priorities. Each of these factors probably resulted in some delays in 
moving funds to many overseas partners and American implementers 
working overseas.
    In addition, I have a concern, maybe specific to my time as 
ambassador and with HHS, when I hear ``pushing funds out the door.'' 
The emergency supplemental Ebola funds, that were appropriated for a 5 
year period, are an example. USAID was able to obligate a large 
percentage of those funds during the first weeks and months because 1) 
OFDA has lots of ``notwithstanding'' authority which CDC, for instance, 
does not have, and 2) USAID works primarily through grants and 
contracts, where all of the money is ``obligated'' and thus ``out the 
door'' up front, but expenditure and implementation may not start 
immediately and is phased over many months or years. HHS, by contrast, 
does most of its work through USG employees. The salaries and expenses 
of these people cannot be sent ``out the door'' all at once, but we had 
a very accurate idea of what the multi-year costs would be. and this 
was in a clear multi-year budget. However, when Congress (and some in 
the Administration) looked at 2014 Ebola emergency funds as a source 
for reducing the Administration's request for Zika funds in 2016, the 
USAID 5-year money was mostly ``spent'' while the HHS money was deemed 
``unspent'' even though progress on actual programs in the field was 
comparable.
    That said, the groups quoted in the article, Catholic Relief 
Services and International Rescue Committee, are essential partners and 
responsible actors in emergency situations. If they experienced 
procedures, timetables or motivations different from the imperfect 
systems we had in past USG administrations for ``moving money out the 
door,'' the comparison is instructive--and disappointing if harmful to 
getting results.

    Question. Is the expenditure of more than $200 million on a few 
thousand ventilators for a select set of countries the best investment 
for protecting the most lives and preventing the spread of COVID-19?

    Answer. Not in my opinion.
    It is hard to recognize any public health strategy, needs 
assessment or realistic logistics plan in selection of partner 
countries and ventilator destinations within those countries. Equipment 
that can only be used in tertiary hospitals with specialist medical 
supervision raises questions of access for the poorest, most vulnerable 
and the greatest numbers, who rightly are the target beneficiaries of 
most U.S. global health programs.

    Question. What assurances on equitable access to care, when it 
comes to U.S. supported response activities, should USAID seek from 
host country governments?

    Answer. Such assurances, naturally, depend on the circumstances, 
partner and resources provided. My experience is that we sometimes 
worked through non-government, including faith-based, organizations or 
multilaterals, such as UNICEF or UNHCR, because they could reach target 
populations more directly than governments could, so the analysis needs 
to extend beyond host country government ``assurances.''
    Nonetheless, with the novel coronavirus affecting everyone, 
everywhere, serious thought at all levels of government and among non-
government actors to allocation of supplies, access to prevention, 
testing and treatment and to disparities is essential. We in the U.S. 
are in a precarious position to make demands on others because our 
domestic response has been so weak in this area. Tellingly, the 
indicator for access to care and treatment in the 2019 Global Health 
Security Index for the United States was 23 out of 100, a poorer score 
than many African countries. The consequence has been dramatic racial, 
ethnic, income and social disparities in our own outbreak and the 
outcomes for patients.
    The message both at home and abroad needs to be: collect the data 
on who has access and who does not, look at what it tells you; address 
inequities and keep in mind that social determinants of health are not 
abstract. They determine how well the health system can respond. This 
is a role the World Health Organization often plays well in countries. 
We might not need to do this work bilaterally if we cooperate with the 
WHO to see that it is done.

    Question. What else should we be doing to help end the pandemic--
are there programs and activities that the Administration should be 
funding that it currently is not?

    Answer. As Jeremy Konyndyk said in the hearing, we are recommending 
that others around the world listen to experts whose advice we are not 
following at home. Paying closer attention to the science and 
scientists in our response at home will help end the pandemic.
    We should contribute to the Coalition for Epidemic Preparedness 
Innovation and look at setting some better guidelines for public 
benefits in terms of cost, availability or other benefit from USG 
investment in research which leads to blockbuster drug development by 
private sector firms which develop, patent, manufacture and market 
these discoveries.
    I also support Senator Udall's effort to fund Covid-relevant 
activities through the U.S.-Mexico Border Health Commission. The 
Administration has discontinued using discretionary funds to support 
the border areas' health needs.
                        global reach of the who
    The WHO has been on the frontlines of nearly every global health 
challenge over the past 70 years, combatting, containing, and 
eradicating some of the planet's most deadly diseases. The WHO serves 
as both a repository of global expertise as well as a critical 
implementation partner for local health ministries and organizations on 
the ground. In many places with weak health systems, the WHO's role is 
indispensable in ensuring the delivery of adequate health services and 
responses.

    Question. From your perspective, what makes the WHO a critical, or 
even indispensable, partner?

    Answer. It is the pre-eminent global health normative and 
consultative agency, with a broad mandate and near universal 
membership. It has been effective in getting countries to work together 
on priorities (smallpox, polio, childhood immunization) and has helped 
the United States leverage our resources, expertise and soft power to 
make health a priority and to base interventions on evidence.
    WHO processes are cumbersome, its budget far below what is needed 
to cover its responsibilities and its structure, antiquated, But these 
are solvable problems, and considerable progress was made 2015-16 
improving processes that proved problematic in the Ebola response.
    WHO's was the first specialized agency of the United Nations and 
the premier example of how the U.S. helped create a rules-based, 
science-based order for addressing trans-national problems. That should 
remain the cornerstone of our international engagement, even as the 
structures of WHO are updated and the funding increased to meet 21st 
century challenges, including health issues far beyond infectious 
diseases.

    Question. What challenges do we face in responding to a global 
pandemic without the WHO as a partner?

    Answer. There are many, but I will highlight three.
    The biggest challenge in my view is that we are not working with 
WHO and the broad international community that it convened to consider 
equitable access to and allocation of vaccines, treatments and cures 
for COVID-19 that are under development.
    The U.S. public and private sector systems for research do not 
align with the WHO's focus on global health equity priorities. Market 
forces can be at odds with WHO's desire to assure vaccine and treatment 
affordability for low and middle income countries. In the past, the 
U.S. has taken a ``problem-solving'' approach to discussing these 
situations and working together to share information, define roles and 
reach accommodations, so that divergent interests are recognized, even 
if never fully satisfied.
    By boycotting the WHO meeting that set up the Access to Coronavirus 
Tools (ACT) Accelerator and the subsequent European Commission and UK-
led conference to collaborate on practical solutions, we missed the 
chance to have our priorities taken into account as well as to benefit 
from the conclusions reached for vaccine deployment. If the U.S. is the 
first to develop a safe and effective vaccine, our monopolization of 
the supply will be seen as illegitimate by other nations. If we are not 
the first, we will have reduced leverage to meet our domestic needs 
equitably, as we were not at the table.
    Second, experts from the U.S. have always in the past been included 
in WHO panels and delegations, reviewing public health emergency 
responses, gathering key data or recommending remedial actions. Not 
being included in these groups will inhibit our ability to gather and 
analyze the data, bring our perspective to the discussion and influence 
the recommendations. An example is the expert group that will go to 
China to review their handling of the novel coronavirus outbreak. The 
WHO has the authority to organize the delegation and report on results. 
This knowledge is important, but we may be getting it second-hand.
    Third and related, is that there are many collaborative activities, 
such as development of a seasonal flu vaccine (cited by Senator Booker 
in the hearing) that are jointly convened and acted upon by the WHO and 
by, in this case, the U.S. CDC. Relinquishing our role as co-convener 
and lead vaccine developer may severely handicap our deploying the most 
effective possible flu vaccine at exactly the time the dual threat of 
seasonal flu and COVID-19 may have the most devastating effect on our 
population and health systems.

    Question. What barriers will the United States face in trying to 
set up an effective alternative to the WHO?

    Answer. We have a lot of allies wanting to improve the World Health 
Organization. We have no allies on abandoning it. There is no support 
by other major countries for an alternative to WHO, although it is 
clear to all that WHO alone is not adequate to address the world's 
response to a pandemic, given its social, economic and political 
facets.
    As we look at existing and potentially new structures that can add 
value and impact to the domestic and international capacity, it is 
essential that these be seen as supplements to or reinforcing WHO, not 
as alternatives. Numerous studies looking into WHO's weaknesses and 
missteps, for instance in the initial Ebola response, all concluded 
that there is no multilateral alternative that could assume or 
duplicate the WHO's mandate, reach and embedded collaborations. Their 
conclusion, which I think is even more pertinent today, is that trying 
to create a global health structure as a replacement for WHO would be 
politically impossible to negotiate. It is especially important to 
recognize that any alternative proposed unilaterally by the U.S. 
Government has no chance of winning wide support.
    I advocated in my testimony for a review conference or revision 
meeting to update the International Health Regulations. I think this 
would be the best place to start if we are looking for more effective 
multilateral platforms for dealing with outbreaks, epidemics and member 
state obligations when they occur. Any new or improved arrangements 
would also depend on robust and sustainable financing, with the U.S. 
government as a core guarantor.
                       international cooperation
    In addition to efforts to combat COVID-19 at the WHO, there have 
been a number of other international efforts to combat the virus, 
including the European Commission's Coronavirus Global Response Summit 
on vaccines, which the United States conspicuously did not join. In 
fact, since the start of the pandemic the United States has failed to 
lead the international efforts to respond. We blocked consensus on a 
statement from the Security Council, and from the G7 by insisting on 
using divisive racially inflammatory rhetoric to describe the 
infection. The President himself used offensive terms to describe the 
disease at a political rally in Tulsa.

    Question. What kind of international engagement is necessary for 
the United States to be best prepared to combat COVID-19?

    [See response to next question below.]

    Question. How can we use our international relationships to improve 
the situation for U.S. citizens as well as our partners?

    Answer. I will reply to the two questions together.
    COVID-19 struck first and has had its most widespread consequences 
in countries with advanced health systems. This reality reinforces my 
belief that we must approach global health and international health 
engagement as a technical partner and not as a ``donor''. I mentioned 
in a previous reply the importance of U.S. participation in discussions 
and decisions about vaccine access, and I am in favor of pro-active 
U.S. leadership on health in the U.N. Security Council, G7, G20 and the 
many other fora that can shape world opinion and national action.
    But I also advocated in my testimony a stronger role for the State 
Department, with a permanent senior coordinator for health security and 
diplomacy. My foreign service experience is that we have phenomenal 
resources in our embassies and missions overseas, which are often under 
appreciated and underused for health goals.
    This is not a suggestion that State should take over health work 
done by USAID or anyone else. It is a recognition that traditional 
diplomatic skills and attention can greatly expand our influence and 
ability to deal with health challenges. We have underappreciated the 
value of health and scientific partnerships as a priority in bilateral 
relations as well as multilateral. Our ambassadors and embassy teams 
can gather information, alert our own and foreign governments to health 
conditions and needs, find counterparts in civil society, academia and 
the private sector, recognize best practices and build coalitions to 
respond, nationally, regionally and globally.
    It was of course important to address the needs of American 
citizens in our initial coronavirus response activity around the world, 
But as we devoted priority embassy resources to evacuations of American 
employees and their families and of private citizens, I don't believe 
we paid enough attention to the diplomatic priority Coronavirus had 
become and remains. In China, for example, the health attache and all 
American FDA and NIH staff were evacuated. Shouldn't these have been 
considered essential, even ``emergency'' employees to protect our 
national security? Where was the Office of Global Health Diplomacy in 
instructing embassies, analyzing information and leading the diplomatic 
response to coronavirus? Lodging this Office within the Office of the 
Global AIDS Coordinator has severely limited its responsibility and 
potential influence.
    Furthermore, cutbacks in funding and staff required CDC and, to a 
lesser extent, USAID, to cut back health security staff and programs in 
partner countries. This now seems very short-sighted, and we need to 
look holistically at health diplomacy as a component of U.S. interests 
in most countries around the world and reinforce both traditional 
diplomacy and soft-power expeditionary diplomacy to promote and protect 
those interests.
                           western hemisphere
    Over the past few months, there have been multiple reports 
documenting that the Trump administration has deported dozens of 
Guatemalan, Mexican, and Haitian nationals who tested positive for 
COVID-19 upon arrival in their home countries. Just this week, it was 
reported that despite an agreement to deport only those with medical 
certificates showing a negative test, Guatemalan authorities say that 
at least 28 deportees have tested positive since early May. Thirteen of 
my colleagues and I sent a letter to the State Department and 
Department of Homeland Security highlighting this very issue, though we 
have yet to receive a response. This question is for any of our 
panelists:

    Question. How, in your view, does deporting COVID-19 positive 
individuals to countries with weak or limited health system capacity 
affect our strategic interests in the hemisphere?

    Answer. Any non-emergency, non-therapeutic transport of people who 
have an active contagious disease is a questionable public health 
practice and almost inevitably a source of tension between sending and 
receiving countries. Even if the deportation legality and mechanisms 
are established and mutually agreed (which may or may not be the case 
here), these need to be re-examined in the current circumstances of 
high U.S. infection levels and many international travel restrictions.

    Question. What policy approach would you recommend regarding 
removals during a pandemic? How have U.S. government policies relating 
to deportation addressed previous epidemics, such as the Ebola crisis?

    Answer. The precedents of the Ebola crisis are not very relevant 
because travelers from the affected countries could not reach the U.S. 
overland, and the transmissibility of the pathogen was different. To my 
knowledge, there were no Ebola-specific deportations or instances of 
individuals who contracted Ebola in or en route to the U.S. who were 
deported, nor any deportations to the three West African countries 
during the Ebola epidemic. (We strongly advised Nigeria not to put the 
arriving Ebola-stricken Liberian airline passenger back on a flight to 
Liberia, which was their original intention). The system of screening 
passengers for fever and visible symptoms at airports of departure in 
Liberia, Sierra Leone and Guinea and then monitoring arrivals through 
state health department check-ins when they reached the U.S. worked 
well--better, in fact, than we had anticipated within the 
Administration.

    Question. What is the scientific or medical evidence supporting the 
Trump administration's closure of U.S. borders to asylum seekers, but 
not other ``essential'' travelers such as truck drivers and family 
members?

    [No Response Received]
                impact on other global health priorities
    A study published in 2016 by Yale University researchers found that 
there may have been as many deaths from HIV AIDS, TB and Malaria during 
the 2014/2015 Ebola outbreak in Guinea, Liberia and Sierra Leone as 
there were from Ebola because the health systems in those countries 
were overwhelmed, limiting access to health services. Recent reports 
indicate that as the COVID-19 pandemic continues, there has been a rise 
in the number of illnesses from preventable illnesses including polio, 
cholera and diphtheria. This question is for any of our panelists:

    Question. What should we be doing to prevent the disruption of 
health services, including service for those affected by HIV/AIDS, TB 
and Malaria?

    Answer. One of the advantages of the standing, funding and track 
record of the U.S. PEPFAR program and the Global Fund to Fight AIDS, TB 
and Malaria is that we have resources and partnerships that can be and 
are being directed to this priority.
    U.S. leadership, through financial commitment, consultation with 
front-line partners and UNAIDS and WHO guidance and policies, can 
contribute substantially to keeping these diseases on governments' and 
communities' agendas and assuring the supply chain and health facility 
capacity to minimize disruptions due to COVID-19. The AIDS 2020 
conference this month provided a broad platform for innovative ideas 
toward this goal.
    The increase in illness and death due to other causes while West 
African states were fighting Ebola in 2014-15 is well documented, but 
it is not evident that we learned the necessary lessons. It was because 
of the Ebola outbreak that I recognized the success of Last Mile 
Health, an organization supporting community health workers in some 
parts of Liberia, which uniformly had better Ebola and non-Ebola health 
outcomes than the rest of the country. That model is being used in 
Liberia and some nations now to maintain routine health services, and 
should be expanded. [Disclaimer: I am a member of the Last Mile Health 
Advisory Board].

    Question. Should the U.S., provide funding for the Global Fund to 
Fight AIDS Tuberculosis and Malaria's COVID-19 mechanism?

    Answer. Yes.
                                 ______
                                 

The Committee Received No Response From Dr. Ashish K. Jha, M.D. for the 
             Following Questions by Senator Robert Menendez

                    the u.s. international response
    On June 7, The New York Times published an article which revealed 
weeks of delays in getting emergency funding appropriated in the CARES 
Act to fund our international response out the door to our partners. 
Implementing partners themselves report waiting up to 10 weeks as 
opposed to our usual 3 and a half weeks. And more than $200 million in 
COVID aid is being spent on ventilators for countries handpicked by the 
President with little to no examination as to whether this was the best 
use of funds, and whether countries have the facilities and medical 
personnel to put the ventilators to use.

    Question. Based on your knowledge of the capacity constraints of 
healthcare systems in developing countries, would healthcare facilities 
serving rural or underserved communities in a given develop country 
have the technical capacity or medical staff to safely and successfully 
employ a ventilator?

    [No Response Received]

    Question. Is the expenditure of more than $200 million on a few 
thousand ventilators for a select set of countries the best investment 
for protecting the most lives and preventing the spread of COVID-19?

    [No Response Received]

    Question. What assurances on equitable access to care, when it 
comes to U.S. supported response activities, should USAID seek from 
host country governments?

    [No Response Received]

    Question. What else should we be doing to help end the pandemic--
are there programs and activities that the Administration should be 
funding that it currently is not?

    [No Response Received]
                        global reach of the who
    The WHO has been on the frontlines of nearly every global health 
challenge over the past 70 years, combatting, containing, and 
eradicating some of the planet's most deadly diseases. The WHO serves 
as both a repository of global expertise as well as a critical 
implementation partner for local health ministries and organizations on 
the ground. In many places with weak health systems, the WHO's role is 
indispensable in ensuring the delivery of adequate health services and 
responses.

    Question. From your perspective, what makes the WHO a critical, or 
even indispensable, partner?

    [No Response Received]

    Question. What challenges do we face in responding to a global 
pandemic without the WHO as a partner?

    [No Response Received]

    Question. What barriers will the United States face in trying to 
set up an effective alternative to the WHO?

    [No Response Received]
                       international cooperation
    In addition to efforts to combat COVID-19 at the WHO, there have 
been a number of other international efforts to combat the virus, 
including the European Commission's Coronavirus Global Response Summit 
on vaccines, which the United States conspicuously did not join. In 
fact, since the start of the pandemic the United States has failed to 
lead the international efforts to respond. We blocked consensus on a 
statement from the Security Council, and from the G7 by insisting on 
using divisive racially inflammatory rhetoric to describe the 
infection. The President himself used offensive terms to describe the 
disease at a political rally in Tulsa.

    Question. What kind of international engagement is necessary for 
the United States to be best prepared to combat COVID-19?

    [No Response Received]

    Question. How can we use our international relationships to improve 
the situation for U.S. citizens as well as our partners?

    [No Response Received]
                           western hemisphere
    Over the past few months, there have been multiple reports 
documenting that the Trump administration has deported dozens of 
Guatemalan, Mexican, and Haitian nationals who tested positive for 
COVID-19 upon arrival in their home countries. Just this week, it was 
reported that despite an agreement to deport only those with medical 
certificates showing a negative test, Guatemalan authorities say that 
at least 28 deportees have tested positive since early May. Thirteen of 
my colleagues and I sent a letter to the State Department and 
Department of Homeland Security highlighting this very issue, though we 
have yet to receive a response. This question is for any of our 
panelists:

    Question. How, in your view, does deporting COVID-19 positive 
individuals to countries with weak or limited health system capacity 
affect our strategic interests in the hemisphere?

    [No Response Received]

    Question. What policy approach would you recommend regarding 
removals during a pandemic? How have U.S. government policies relating 
to deportation addressed previous epidemics, such as the Ebola crisis?

    [No Response Received]

    Question. What is the scientific or medical evidence supporting the 
Trump administration's closure of U.S. borders to asylum seekers, but 
not other ``essential'' travelers such as truck drivers and family 
members?

    [No Response Received]
                impact on other global health priorities
    A study published in 2016 by Yale University researchers found that 
there may have been as many deaths from HIV AIDS, TB and Malaria during 
the 2014/2015 Ebola outbreak in Guinea, Liberia and Sierra Leone as 
there were from Ebola because the health systems in those countries 
were overwhelmed, limiting access to health services. Recent reports 
indicate that as the COVID-19 pandemic continues, there has been a rise 
in the number of illnesses from preventable illnesses including polio, 
cholera and diphtheria. This question is for any of our panelists:

    Question. What should we be doing to prevent the disruption of 
health services, including service for those affected by HIV/AIDS, TB 
and Malaria?

    [No Response Received]

    Question. Should the U.S., provide funding for the Global Fund to 
Fight AIDS Tuberculosis and Malaria's COVID-19 mechanism?

    [No Response Received]
                                 ______
                                 

               Responses of Jeremy Konyndyk to Questions 
                  Submitted by Senator Robert Menendez

                       state usaid reorganization
    Question. How will doing taking budgetary authority and programs 
from USAID and moving them to State Department impact development 
outcomes in global health? Will doing so at all assist with health 
systems strengthening?

    Answer. I have grave reservations about shifting program and budget 
authority from USAID (and potentially CDC) into the State Department. 
As I noted in my testimony, the State Department does have an important 
role in promoting global health security and pandemic preparedness, but 
it is mainly centered on diplomatic engagement to mobilized aligned 
global action around these issues. That is quite different from 
asserting State as the overall lead for the initiative; a role that 
would require greater subject matter expertise at the institutional 
level than the State Department possesses.
    I fear that this approach would increase friction between State, 
USAID, and CDC, thus weakening programs and undermining health security 
outcomes. It would also be inimical to health system strengthening, 
which would be better supported by keeping these programs housed at 
USAID and CDC, both of which support broader health system 
interventions. Shifting pandemic authorities to State would turn those 
into more of a vertical intervention (similar to the PEPFAR model) that 
can be narrowly useful toward a specific disease or threat but will 
struggle to align with horizontal system strengthening interventions. A 
vertical structure would be, in my view, a poor design for this 
initiative because pandemic preparedness is inherently cross-cutting--
it touches on many different structures and capacities across a 
government, health system, and society.
                    the u.s. international response
    On June 7, The New York Times published an article which revealed 
weeks of delays in getting emergency funding appropriated in the CARES 
Act to fund our international response out the door to our partners. 
Implementing partners themselves report waiting up to 10 weeks as 
opposed to our usual 3 and a half weeks. And more than $200 million in 
COVID aid is being spent on ventilators for countries handpicked by the 
President with little to no examination as to whether this was the best 
use of funds, and whether countries have the facilities and medical 
personnel to put the ventilators to use.

    Question. Did these types of funding delays happen while you were 
at USAID? To your knowledge, what accounts for the current delays in 
pushing funding out the door?

    Answer. These kinds of delays in funding emergency appropriations 
did not happen during my tenure at USAID. In fact, during the 2014 
Ebola outbreak, we did nearly the inverse of what the Trump 
administration has done on COVID. We felt an extreme sense of urgency 
to roll out programs and interventions quickly that we began doing so 
using regular annual appropriation money even before the emergency 
supplemental funds cam through. We knew that waiting to roll out 
programs until we had a special appropriation would mean letting the 
outbreak spread exponentially further before we acted. So at the 
direction of the Administrator, my office spent down nearly the 
totality of our non-OCO appropriation to cover our cash flow needs for 
Ebola even before the supplemental came through. We then used the 
supplemental funding to backfill our normal budget and to continue 
extending our Ebola programs.
    By the time the Ebola emergency appropriation passed in December 
2014, the U.S. government had spent over $750 million on Ebola efforts, 
of which 362.8 million had been spent through my team in the USAID 
Office of U.S. Foreign Disaster Assistance (OFDA).\1\ This was roughly 
4 months after the deployment of the Disaster Assistance Response Team 
(DART) and corresponding activation of USAID's Response Management Team 
(RMT) and Agency Task Force. During the COVID-19 response, USAID 
activated their agency Task Force in early March and their RMT in mid-
March, likewise roughly 4 months ago. Over that period, they have 
announced public obligations of only $214 million, of which only $8 
million is through the Disaster Assistance account.\2\ They have 
announced over $1 billion in ``pledged'' funding, with few details 
provided. Pledged funding typically means funding that remains on the 
agency's books and has not yet determined a specific intended recipient 
(``committed'') or been disbursed to that recipient (obligated).
    I do not have full awareness of the reasons for these delays. 
However, my understanding both from public report and from 
conversations with USAID partners is that politicization of PPE funding 
has been among the major bottlenecks between USAID and the White House. 
The White House was reportedly very wary of allowing aid partners to 
use U.S. fund to supply PPE to low-income countries while U.S. 
hospitals remained under-supplied, and so issued a soft prohibition on 
such usage of funds. However this made it functionally impossible for 
partners to move ahead with responsible programs, because PPE is a 
vital component of such interventions (during my time at USAID I 
directed my team to develop a USAID PPE reserve stock for situations 
like this; my understanding is that those reserves were diverted for 
domestic use).

    Question. Is the expenditure of more than $200 million on a few 
thousand ventilators for a select set of countries the best investment 
for protecting the most lives and preventing the spread of COVID-19?

    Answer. With respect to ventilator donations, I find a number of 
puzzling dimensions. It is difficult to assess whether USAID has 
applied consistent criteria to distributing these because there does 
not appear to be a publicly stated set of criteria for the selection of 
countries or the proposed volumes of ventilators to each recipient. 
Meanwhile, USAID documents (as reported by ProPublica) make explicit 
that some of these donations to middle and high income countries are 
being made for political purposes. It is not otherwise clear to me why 
a wealthy country like Malaysia needs 250 U.S.-donated ventilators.

    Question. What assurances on equitable access to care, when it 
comes to U.S. supported response activities, should USAID seek from 
host country governments?

    Answer. The U.S. should allocate its COVID funding based on an 
evaluation of the degree of need, and of the gaps in country capacity 
and preparedness. This should include an analysis of whether U.S. aid 
and health resources more generally are accessible to the population in 
an equitable manner. In some countries--such as conflict affected 
states--this may be particularly difficult, and the U.S. should seek to 
work through partners that can complement or work around government 
obstructions, where those may exist.

    Question. What else should we be doing to help end the pandemic--
are there programs and activities that the Administration should be 
funding that it currently is not?

    Answer. This is a challenging question to answer given how little 
funding has so far been disbursed. But I would broadly see several 
priorities for U.S. global aid funding on COVID-19:

   Reinforcing fragile health systems.

   Community engagement, communication, and behavior change.

   Logistics and supplies.

   Macroeconomic support to countries taking major economic 
        hits.

   Safety net and livelihood support at household level.

   Supporting frontline aid and civil society organizations.
                        global reach of the who
    The WHO has been on the frontlines of nearly every global health 
challenge over the past 70 years, combatting, containing, and 
eradicating some of the planet's most deadly diseases. The WHO serves 
as both a repository of global expertise as well as a critical 
implementation partner for local health ministries and organizations on 
the ground. In many places with weak health systems, the WHO's role is 
indispensable in ensuring the delivery of adequate health services and 
responses.

    Question. What makes the WHO a critical, or even indispensable, 
partner?

    Answer. The Trump administration's decision to withdraw the United 
States from the World Health Organization is reckless and entirely 
unjustified. The Administration's accusations against WHO do not stand 
up to scrutiny, and certainly do not rise to the level of abandoning 
the organization as the worst pandemic in a century sweeps around the 
world and hammers the United States. WHO's handling of the pandemic has 
not been perfect, but has been more than good enough to provide ample 
early warning and actionable guidance to countries that were paying 
attention.
    The U.S. withdrawal will have damaging consequences both for the 
U.S. and the world at large. WHO makes vital contributions to the 
health of Americans, including through vaccine and therapeutic research 
and coordinating annual flu vaccines. It advances U.S. interests by 
countering global health threats like Ebola and cholera, carrying the 
frontline burden in places like Eastern Congo and Yemen where USG 
personnel cannot safely operate. It has partnered successfully with the 
U.S. on global vaccine programs and disease eradication efforts. Global 
polio eradication, which has for years been a U.S. priority, will be 
imperiled by this decision, as will numerous other longstanding U.S. 
health investments. And weakening WHO will also reverberate across the 
developing world, where health ministries rely heavily on WHO technical 
guidance. WHO covers these and numerous other functions on a budget 
that is less than the annual budget of a U.S. hospital system, and just 
a fraction of the annual spending of the CDC and NIH.

    Question. What challenges do we face in responding to a global 
pandemic without the WHO as a partner?

    Answer. Despite the Trump administration's claim that it can easily 
route WHO funds to other equally capable partners, the reality is that 
WHO's role is unique and there are no viable substitutes for many of 
its functions. WHO has the ability to mobilize and deploy large teams 
of public health experts to any country in the world, usually with the 
eager consent of the host government. That is a critical capability in 
a global pandemic, and not one that exists within the NGO community or 
elsewhere in the U.N. WHO's longstanding relationships with health 
ministries enable its personnel, in many countries, to function as de 
facto extensions of the health ministry and play a central role in 
shaping policy and strategy. Again, there is no other institution in 
the world that could readily step into such a role--and in any case, 
those national ministries would continue looking to WHO rather than to 
a U.S. contractor or non-profit.

    Question. What barriers will the United States face in trying to 
set up an effective alternative to the WHO?

    Answer. The best way to rectify weaknesses in WHO and in wider 
global health governance is by remaining engaged and outlining a 
constructive vision for reform. Past Administrations have responded to 
previous outbreaks by doing exactly that: after SARS the Bush 
administration worked to develop the 2005 International Health 
Regulations, and after Ebola in West Africa the Obama administration 
led member states to approve sweeping reform and reorganization of 
WHO's emergency programs. Withdrawing now, particularly on such 
specious grounds, will destroy U.S. credibility and diminish U.S. 
influence over the reforms that will inevitably follow the present 
outbreak.
    Withdrawing will also likely sound a death knell for the emerging 
U.S. proposals for new global pandemic response mechanisms. It will be 
hard for other countries to align with U.S. efforts if those efforts 
serve as an alternative or competitor to WHO. Plainly put, other 
countries expect WHO to play a central role in any future pandemic 
architecture, and U.S. efforts will fail if they ignore this reality.
                       international cooperation
    In addition to efforts to combat COVID-19 at the WHO, there have 
been a number of other international efforts to combat the virus, 
including the European Commission's Coronavirus Global Response Summit 
on vaccines, which the United States conspicuously did not join. In 
fact, since the start of the pandemic the United States has failed to 
lead the international efforts to respond. We blocked consensus on a 
statement from the Security Council, and from the G7 by insisting on 
using divisive racially inflammatory rhetoric to describe the 
infection. The President himself used offensive terms to describe the 
disease at a political rally in Tulsa.

    Question. What kind of international engagement is necessary for 
the United States to be best prepared to combat COVID-19?

    Answer. To fully protect Americans, this virus must be contained 
both within the United States and well beyond our borders. As every 
country has learned, travel restrictions are not an effective long-term 
protection against the virus. And in any case, the U.S. and global 
economies will suffer greatly if long-term travel disruption remains in 
effect. The fight against the virus in the U.S. cannot be siloed from 
the global fight.
    A globally engaged U.S. COVID policy should cover multiple 
dimensions:

   Leadership and convening: The absence of U.S. presence and 
        leadership in global fora has been palpable throughout this 
        response. Where past Presidents like Obama and Bush put the 
        U.S. at the forefront of global efforts against threats like 
        Ebola and pandemic influenza, the U.S. has been largely absent 
        under President Trump. It makes it hard for global institutions 
        to function effectively when the U.S. is absent from or opposed 
        to efforts to drive international collaboration on the 
        pandemic.

   Support to poor and fragile countries: The impact of COVID-
        19 on low-income and fragile countries will be devastating and 
        will resonate for years. The U.S. should be helping to organize 
        and lead global support, both financial and technical, to 
        enable low-income countries to fight the virus without 
        jeopardizing decades of development progress.

   Research collaboration: The U.S. ``Warp Speed'' vaccine 
        initiative is prioritizing only 5 vaccine candidates. Meanwhile 
        there are currently more than 140 coronavirus vaccine 
        candidates (see https://www.who.int/publications/m/item/draft-
        landscape-of-covid-19-candidate-vaccines ) being tracked by 
        WHO. There is no way to predict which of these will first prove 
        effective, nor which will eventually prove most effective. It 
        is strongly in the U.S. interest to spread our bets--pursuing 
        our own vaccine candidates while collaborating with a wide 
        range of other vaccine options, so that we are positioned to 
        benefit from whichever one(s) prove effective. The global 
        vaccine trial partnership--led by WHO--may also prove more 
        effective and efficient in identifying a safe and effective 
        vaccine. A large multi-country, multi-population trial can 
        evaluate a large number of vaccines against a common placebo 
        group, enabling a wide range of candidates to be simultaneously 
        evaluated, increasing the prospects of rapidly identifying a 
        viable vaccine.

   Supply chain: U.S. supply chains for items like PPE, 
        pharmaceuticals, and testing supplies all depend on global 
        producers and suppliers. This will likely hold for vaccine 
        production as well. The U.S. will need cooperation on vaccine 
        production--as we've seen with PPE, we cannot produce 
        everything that is needed solely within our own borders. The 
        U.S. drug supply chain is heavily dependent on global 
        suppliers, and an antagonistic or uncooperative posture towards 
        other countries could harm U.S. access to needed materials.

    Question. How can we use our international relationships to improve 
the situation for U.S. citizens as well as our partners?

    Answer. The United States' global reputation as taken a heavy hit. 
Perceptions of American competence have eroded as the U.S. struggles to 
control the virus as well as other high-income and even middle-income 
countries. But perceptions of U.S. benevolence have suffered as well. 
Much of the developing world has encountered the U.S. not as a partner 
on COVID, but as a competitor. The failure to contain case counts in 
the U.S., combined with the lack of PPE production capacity 
domestically and the failure to mandate it under the DPA, put the U.S. 
in a position of outbidding other nations for global PPE supply. The 
image of the U.S. pricing developing countries out of the PPE market, 
while China happily provided PPE donations to those same countries, 
will not soon be forgotten. The U.S. must begin to rebuild credibility 
by:

   Controlling our domestic outbreak.

   Providing rapid and effective support to nations being hit 
        hard by COVID.

   Re-engaging in global collaboration around COVID 
        containment, including the joint vaccine initiative.

   Revoking our withdrawal from the World Health Organization.
                           western hemisphere
    Over the past few months, there have been multiple reports 
documenting that the Trump administration has deported dozens of 
Guatemalan, Mexican, and Haitian nationals who tested positive for 
COVID-19 upon arrival in their home countries. Just this week, it was 
reported that despite an agreement to deport only those with medical 
certificates showing a negative test, Guatemalan authorities say that 
at least 28 deportees have tested positive since early May. Thirteen of 
my colleagues and I sent a letter to the State Department and 
Department of Homeland Security highlighting this very issue, though we 
have yet to receive a response. This question is for any of our 
panelists:

    Question. How, in your view, does deporting COVID-19 positive 
individuals to countries with weak or limited health system capacity 
affect our strategic interests in the hemisphere?

    Answer. Deporting COVID-positive individuals to countries with weak 
health systems will place further strain on those systems; a particular 
concern as the outbreaks in South and Central America worsen.

    Question. What policy approach would you recommend regarding 
removals during a pandemic? How have U.S. government policies relating 
to deportation addressed previous epidemics, such as the Ebola crisis?

    Answer. During the Ebola outbreak in West Africa, the Department of 
Homeland Security authorized Temporary Protected Status (TPS) for 
citizens of the three principally affected countries. I believe that a 
similar measure would be appropriate for COVID, in instances where the 
individual's home country is suffering a major outbreak of COVID-19 
and/or lacks the domestic capacity to appropriately quarantine, 
isolate, and treat cases of the virus.

    Question. What is the scientific or medical evidence supporting the 
Trump administration's closure of U.S. borders to asylum seekers, but 
not other ``essential'' travelers such as truck drivers and family 
members?

    Answer. To my knowledge there are no scientific grounds for 
considering asylum seekers to pose higher risks of the virus than other 
categories of migrants or travelers.
                             food security
    USAID has determine that in addition to the pandemic's exacerbation 
of economic decline across the developing world, the pandemic also 
stands to drastically increase food insecurity and risk major 
backsliding in countries that the U.S. has worked hard and invested 
significantly to improve food security and agricultural based economic 
opportunities.

    Question. USAID's analysis on food insecurity risks is incredibly 
important and informative, and USAID has a model food security program 
in Feed the Future, but in light of the pandemic's compounding effects 
on food security and nutrition, does USAID have adequate resources to 
prevent food insecurity backsliding related to the impacts of the 
pandemic?

    Answer. We are still formulating an accurate picture of how the 
pandemic will affected global food insecurity. I find the projections 
by FEWSNET to be broadly credible, and consistent with the wider 
picture of economic damage that the pandemic will cause in the 
developing world. It is impossible to separate the food insecurity 
challenge from the wider economic impact, and I believe USAID and other 
aid donors should be focusing heavily on broad-based livelihoods 
support to enable vulnerable populations to continue to afford 
sufficient food. Per FEWSNET, global food supply remains around normal 
levels, although prices have risen somewhat. The combination of 
sufficient supply with increased prices and reduced household income is 
concerning, and would indicate that household cash grants and 
government safety net programs are likely the best tool to use, rather 
than provision of in-kind food aid. But without question, substantial 
further resources--both through USAID and the World Bank--will be 
needed to avert damaging impacts on food security.

    Question. Feed the Future is great, but are there additional 
programmatic needs and considerations USAID should make as it related 
to preserving food security in regions, countries and communities 
hardest hit by the pandemic? Are there modifications that USAID needs 
to make to its food security programs to address pandemic specific 
impacts on food security (like, strengthening supply chains)?

    Answer. As noted above traditional in-kind food aid programs are 
not likely to be the most appropriate tool. Instead--somewhat as we 
have done domestically in the U.S.--aid programs should focus on 
shoring up livelihood support among vulnerable populations to ensure 
that they can continue meeting their own needs through market 
mechanisms.
                impact on other global health priorities
    A study published in 2016 by Yale University researchers found that 
there may have been as many deaths from HIV AIDS, TB and Malaria during 
the 2014/2015 Ebola outbreak in Guinea, Liberia and Sierra Leone as 
there were from Ebola because the health systems in those countries 
were overwhelmed, limiting access to health services. Recent reports 
indicate that as the COVID-19 pandemic continues, there has been a rise 
in the number of illnesses from preventable illnesses including polio, 
cholera and diphtheria. This question is for any of our panelists:

    Question. What should we be doing to prevent the disruption of 
health services, including service for those affected by HIV/AIDS, TB 
and Malaria?

    Answer. It will be critically important to ensure that health 
systems in low-income countries remain solvent, have the technical 
support that they need, and can provide sufficient protection to their 
frontline personnel. Most COVID services will be delivered through 
health ministries and health systems, not through aid organizations. 
The U.S. should work with the World Bank to ensure that health 
ministries can access the resources needed to maintain adequate health 
budgets, and provide top-up funding where needed (the U.S. provided 
salary support to the Liberian health ministry during the Ebola 
outbreak, for example). U.S. support to WHO is critical to ensure that 
health ministries in low-income countries can draw on technical support 
related to COVID while also managing other health priorities. And U.S. 
aid funds should prioritize supply of PPE and sanitation support to 
frontline health facilities, to prevent outbreaks among health 
personnel and ensure continuity of normal health services.

    Question. Should the U.S., provide funding for the Global Fund to 
Fight AIDS Tuberculosis and Malaria's COVID-19 mechanism?

    Answer. The U.S. should consider support to any funding mechanism 
that demonstrates it can quickly route money to frontline needs.

----------------
Notes

    \1\ https://www.usaid.gov/sites/default/files/documents/1864/
12.10.14%20-
%20USG%20West%20Africa%20Ebola%20Outbreak%20Fact%20Sheet%20%2311.pdf
    \2\ https://www.usaid.gov/sites/default/files/documents/1860/
05.05.20_-_USAID_COVID-19_Global_Response_Fact_Sheet_2.pdf