[Senate Hearing 117-227]
[From the U.S. Government Publishing Office]


                                                       S. Hrg. 117-227

                VACCINE DIPLOMACY IN LATIN AMERICA AND
                 THE CARIBBEAN: THE IMPORTANCE OF U.S. 
                 ENGAGEMENT

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

                                HEARING

                               BEFORE THE

                        SUBCOMMITTEE ON WESTERN
                       HEMISPHERE, TRANSNATIONAL
                       CRIME, CIVILIAN SECURITY,
                        DEMOCRACY, HUMAN RIGHTS,
                       AND GLOBAL WOMEN'S ISSUES

                                 OF THE

                     COMMITTEE ON FOREIGN RELATIONS
                          UNITED STATES SENATE

                    ONE HUNDRED SEVENTEENTH CONGRESS


                             FIRST SESSION

                               __________

                           NOVEMBER 18, 2021

                               __________


       Printed for the use of the Committee on Foreign Relations
       
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                  Available via http://www.govinfo.gov

                                __________

                    U.S. GOVERNMENT PUBLISHING OFFICE                    
47-213 PDF                 WASHINGTON : 2022                     
          
-----------------------------------------------------------------------------------   

                 COMMITTEE ON FOREIGN RELATIONS        

             ROBERT MENENDEZ, New Jersey, Chairman        
BENJAMIN L. CARDIN, Maryland         JAMES E. RISCH, Idaho
JEANNE SHAHEEN, New Hampshire        MARCO RUBIO, Florida
CHRISTOPHER A. COONS, Delaware       RON JOHNSON, Wisconsin
CHRISTOPHER MURPHY, Connecticut      MITT ROMNEY, Utah
TIM KAINE, Virginia                  ROB PORTMAN, Ohio
EDWARD J. MARKEY, Massachusetts      RAND PAUL, Kentucky
JEFF MERKLEY, Oregon                 TODD YOUNG, Indiana
CORY A. BOOKER, New Jersey           JOHN BARRASSO, Wyoming
BRIAN SCHATZ, Hawaii                 TED CRUZ, Texas
CHRIS VAN HOLLEN, Maryland           MIKE ROUNDS, South Dakota
                                     BILL HAGERTY, Tennessee
                 Damian Murphy, Staff Director        
        Christopher M. Socha, Republican Staff Director        
                    John Dutton, Chief Clerk        



              SUBCOMMITTEE ON WESTERN HEMISPHERE,        
       TRANSNATIONAL CRIME, CIVILIAN SECURITY, DEMOCRACY,        
            HUMAN RIGHTS, AND GLOBAL WOMEN'S ISSUES        

                 TIM KAINE, Virginia, Chairman        
JEFF MERKLEY, Oregon                 MARCO RUBIO, Florida
BENJAMIN L. CARDIN, Maryland         ROB PORTMAN, Ohio
JEANNE SHAHEEN, New Hampshire        JOHN BARRASSO, Wyoming
EDWARD J. MARKEY, Massachusetts      BILL HAGERTY, Tennessee
                                     TED CRUZ, Texas


                              (ii)        

  
                         C  O  N  T  E  N  T  S

                              ----------                              
                                                                   Page

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

Rubio, Hon. Marco, U.S. Senator From Florida.....................     3

O'Reilly, Kevin, Deputy Assistant Secretary of State for Western 
  Hemisphere Affairs, U.S. Department of State, Washington, DC...     5
    Prepared Statement...........................................     6

Natiello, Peter, Acting Assistant Administrator, Bureau for Latin 
  America and the Caribbean, United States Agency for 
  International Development, Washington, DC......................     9
    Prepared Statement...........................................    10

Runde, Daniel F., Senior Vice President, Center for Strategic and 
  International Studies..........................................    22
    Prepared Statement...........................................    24

Restrepo, Dan, Senior Fellow, Center for American Progress, 
  Washington, DC.................................................    29
    Prepared Statement...........................................    31

Castro, Dr. Arachu, Director of the Collaborative Group for 
  Health Equity in Latin America [Chela], Tulane University, New 
  Orleans, LA....................................................    34
    Prepared Statement...........................................    35

                                 (iii)
 

 
               VACCINE DIPLOMACY IN LATIN AMERICA AND 
            THE CARIBBEAN: THE IMPORTANCE OF U.S. ENGAGEMENT

                              ----------                              

                                       THURSDAY, NOVEMBER 18, 2021

                           U.S. Senate,    
                 Subcommittee on Western Hemisphere,
               Transnational Crime, Civilian Security,
                       Democracy, Human Rights, and
                             Global Women's Issues;
                            Committee on Foreign Relations,
                                                    Washington, DC.
    The subcommittee met, pursuant to notice, at 10:02 a.m., in 
room SD-419, Dirksen Senate Office Building, Hon. Tim Kaine, 
chairman of the subcommittee, presiding.
    Present: Senators Kaine [presiding], Menendez, and Rubio.

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

    Senator Kaine. I would like to call the hearing to order. 
This is a hearing of the Senate Foreign Relations Subcommittee 
on Western Hemisphere, Transnational Crime, Civilian Security, 
Democracy, Human Rights, and Global Women's Issues.
    Senator Rubio, I think we have the honor of the 
subcommittee with the longest name of any in the Senate.
    The hearing will come to order, and it is a pleasure to 
welcome two distinguished panels of witnesses for this hearing 
on vaccine diplomacy in Latin America and the Caribbean, and 
the importance of U.S. engagement in the region.
    I want to thank Ranking Member Senator Rubio and his team 
for helping develop this hearing and for always advancing the 
important work of this subcommittee, and always having a 
passion for the region.
    Americans have learned a lot of hard lessons since the 
COVID-19 pandemic first reached our shores in early 2020: the 
importance of a strong public health system, the vulnerability 
of and the valuable work performed by our essential health 
workers, disparities in our economic system that can be 
exacerbated by unforeseen crises, the effectiveness of 
vaccines, and the difficulties of achieving political consensus 
even when faced with a common threat.
    Another lesson the pandemic has taught us is that we are 
inextricably linked to other nations, particularly our 
neighbors in the Americas. Disease does not stop at borders. 
Our health, to a degree, depends on the health of our brothers 
and sisters in Latin America and the Caribbean.
    Latin America and the Caribbean has suffered greatly during 
the pandemic. More than a million and a half dead, tens of 
millions of cases. Thirty percent of the deaths in the world 
attributed to the pandemic are in the Caribbean and the 
Americas with only 8 percent of the population. So this has 
been a region that has been hit particularly hard.
    I saw some of the effects of the pandemic firsthand in the 
region this summer when I joined Senator Portman and four other 
Senate colleagues in a bipartisan CODEL to visit Mexico, 
Ecuador, Colombia, and Guatemala.
    We talked in those nations about the effect of a pandemic, 
but we also heard the gratitude of these nations for U.S. 
vaccine diplomacy in the region, a common story, and we were 
arriving in capitals and talking to presidents at about the 
same time as significant American vaccines were arriving to be 
distributed in these countries.
    A common story that we heard was that when it comes to 
vaccines, we think the American vaccines are the best and you 
are giving them to us. We are getting vaccines from China and 
Russia that we are purchasing, and sometimes the shipment gets 
delayed, and in the instance of China, if we happen to say 
something about Taiwan the contract will mysteriously disappear 
and we will never get vaccines.
    So there was a real window that was opening, we viewed, in 
the Americas because there was gratitude for the U.S. role in 
delivering now, I believe, nearly 50 million vaccines into the 
Americas and the Caribbean.
    There is much more to do. We have stepped up to provide 
support to our southern neighbors. It is a little belated 
because we wanted to take care, obviously, of our own needs 
first, but distribution of vaccines and other humanitarian aid, 
most notably through sharp increase in funding through the 
American Rescue Plan, has started to flow. More needs to be 
done.
    While the U.S. initially focused on overcoming the public 
health crisis at home, outside actors like China and Russia 
have taken this opportunity to exert their influence--really, 
continue their influence in Latin America and the Caribbean, 
and that has potentially deleterious long-term effects on U.S. 
interests and values in the region.
    So after almost 2 years now of living with COVID, this 
hearing is an opportunity to consider our successes and 
failures in responding to the pandemic in the Americas and what 
we can do to continue to improve our efforts in the region.
    I am hopeful that testimony from our panels of witnesses 
both from the State Department and outside experts can help us 
better understand these vital issues and chart a path forward.
    I now want to turn it over to my ranking member, Senator 
Rubio, for his remarks before I introduce our first panel.

                STATEMENT OF HON. MARCO RUBIO, 
                   U.S. SENATOR FROM FLORIDA

    Senator Rubio. Thank you for holding this hearing, and as 
the former chairman of this committee who had to read that long 
title, we could never come up with an acronym. So if you can, 
that would be great, but I appreciate you both being here 
today.
    We are coming up on the 2-year anniversary of that day that 
patients in Wuhan, China, first publicly reported symptoms of a 
disease that we now know has swept and changed the world and no 
region has been hit harder, as the chairman said, than Latin 
America and the Caribbean, in particular. Not just in terms of 
the numbers of those that have been afflicted by the disease 
and, ultimately, killed by this virus, but also the effects 
that it has had on unemployment, on rising poverty, on 
political instability.
    It has been pretty dramatic, and what that has done is it 
has made the region ripe and vulnerable to malign actors to 
come in and try to leverage them.
    We have seen that, of course, from the Chinese Communist 
Party. We have seen it from Putin's Russia, and now even Cuba 
appears to be threatening to get into that game, basically, 
exploiting access to a vaccine in the absence of a better 
alternative to extract concessions from different countries in 
the region.
    They have, very frankly, made no effort to hide the fact 
that these vaccines come with strings attached. One example is 
Paraguay.
    In April of this year, Paraguay had its largest outbreak 
wave of COVID cases, and the Chinese Communist Party's 
diplomats made it very clear that they would only deliver 
vaccines to Paraguay if they severed ties with Taiwan.
    In Brazil, there seems to have been some success in 
convincing Brazilian officials to allow Huawei to compete to 
develop the 5G network. Strong evidence of that is the fact 
that 2 weeks after Brazil's communication minister went to 
Beijing to ask for vaccines, it reversed its decision to ban 
Huawei from competing.
    Then, of course, Putin's Russia has gotten into this as 
well, providing, really, millions of dubious Sputnik vaccines 
to countries around the region, and I say dubious because there 
has been cases now where what is in that little vial is 
actually not any vaccine, much less an effective one.
    After delivering vaccines to Bolivia, the President of 
Bolivia agreed to reactivate a Russian nuclear power plant 
project and to allow Russia access to Bolivia's lithium 
reserves and their natural gas.
    Now on top of all this, we face the Cuban regime with its 
fake Abdala vaccine, which we know nothing about in terms of 
its effectiveness or what long-term consequences it might have, 
and they are now talking about potentially exporting it to 
other countries, I imagine, in return for their silence and 
their support in the face of really brutal tactics to repress 
protests.
    The bottom line is that the lives of people across this 
region have become bargaining chips and exchanged in return for 
higher profits for Chinese tech companies and lucrative 
business deals for Russian oligarchs.
    So what I hope to learn from our witnesses today is why the 
U.S. has allowed for this to go on for so long in Latin 
America. Russia delivered its first vaccines in February of 
2021. China made its first delivery in March of '21.
    President Biden's administration did not deliver vaccines 
until June, a full month after Senator Kaine and Menendez, who 
chairs the full committee, and myself sent a letter 
highlighting the urgent need for vaccines in Latin America.
    Even now, more than 109 million Chinese vaccines have been 
delivered, far more than the 89 million American vaccines that 
so far have been delivered to the region.
    So I was glad to see the U.S. announce the donation of 
approximately 500 million vaccines to 92 countries, but only 10 
of those countries were in Latin America and the Caribbean.
    So I am very interested in how we came up with the list of 
who gets these vaccines. I imagine some of it has to do with 
the capacity to store and deliver and some of it--I am curious 
to see how we picked who got it and how much and so forth.
    So I appreciate you being here today because I think it 
will be insightful as we look forward to how we move forward on 
this issue.
    Thank you.
    Senator Kaine. Thank you, Senator Rubio. I am going to 
introduce our witnesses now.
    Kevin O'Reilly is the Deputy Assistant Secretary for 
Western Hemisphere Affairs at the Department of State. He 
became the Deputy Assistant Secretary after having served as 
the Director of the Office of Brazil and Southern Cone Affairs.
    He previously served as DCM at the U.S. Embassy in Panama 
City, Panama. He is a career member of the U.S. Foreign 
Service. He has held many other senior level positions, 
including the Director of the Office of Mexican Affairs.
    He has served as the White House National Security Council 
Director for North American Affairs from 2009 to 2011, served 
as a foreign policy fellow in Senator Durbin's office, and he 
is a native of Illinois with a Master's degree from the U.S. 
Naval War College and Johns Hopkins SAIS. Received his Bachelor 
of Arts degree from Loyola University.
    Peter Natiello serves as the Acting Assistant Administrator 
in the U.S. Agency for International Development's Latin 
American and Caribbean Bureau. Before that, he served as 
USAID's mission director in Kabul, Afghanistan.
    He has extensive experience in Latin America with USAID 
serving as Missions Director in El Salvador and Colombia, and 
from 2003 to 2009 he was in Bolivia where he was Deputy Mission 
Director and Director of the Alternative Development Program at 
USAID.
    He has also managed USAID's Democracy in Conflict 
Mitigation Portfolio in Ecuador where he served as a Peace 
Corps volunteer and subsequently as a research analyst with the 
Inter-American Development Bank.
    Fluent in Spanish and proficient in Portuguese, he has a 
Bachelor of Arts degree from Colorado College and a Master's of 
International Affairs from Columbia University.
    It is great to have both of you before us to discuss this 
important issue and I would like to have, first, Mr. O'Reilly 
and then Mr. Natiello do opening statements. Try to confine 
them to 5 minutes. Your full statements will be included in the 
record and then we will proceed to questions.
    I will just let you know we are a little bit uncertain 
about the voting schedule today. I think you may see members 
coming and going based on votes, but I think we should have 
good attendance over the course of the hearing. This is an 
important topic. We are glad to have you with us.
    Mr. O'Reilly.

  STATEMENT OF KEVIN O'REILLY, DEPUTY ASSISTANT SECRETARY OF 
STATE FOR WESTERN HEMISPHERE AFFAIRS, U.S. DEPARTMENT OF STATE, 
                         WASHINGTON, DC

    Mr. O'Reilly. Chairman Kaine, Ranking Member Rubio, thank 
you for this opportunity to discuss the Biden-Harris 
administration's efforts to support Latin America and the 
Caribbean as they respond to and recover from the COVID-19 
pandemic.
    They make up an important part of our efforts across the 
globe to save lives, end this pandemic in 2022, and prepare for 
the next pandemic. COVID-19 has hit the hemisphere hard and it 
has worsened long-standing problems, challenges to public 
security, confidence in democratic institutions, corruption, 
and inequality.
    Just 8.4 percent of humanity lives in Latin America and the 
Caribbean. Yet, as of the 1st of November, this region has had 
more than 46 million reported infections, 20 percent of cases 
worldwide, 31 percent of reported deaths, approximately 1.5 
million souls lost.
    The pandemic hit a continent weakened by anemic growth. The 
IMF estimated in October that the global economy contracted by 
3.1 percent in 2020, but the economies of Latin America and the 
Caribbean contracted by 7. Caribbean nations suffered declines 
of more than 15 percent.
    The IMF projects a return to growth of 5.8 percent this 
year, but the shock of the downturn remains. We have donated 
more vaccines globally than all other countries combined. That 
includes more than 49 million doses donated in partnership with 
COVAX or bilaterally to 29 countries in our hemisphere.
    In September, President Biden announced that the United 
States would donate an additional half a billion Pfizer 
BioNTech doses through the COVAX facility to low and middle 
income countries, bringing the total commitment to those 
countries to 1.2 billion. Beneficiaries include countries in 
Latin America and the Caribbean.
    We share these doses without political conditions or 
expectations with the purpose of saving lives. Beating back 
this pandemic requires full vaccination of 60 to 70 percent of 
each country's population.
    Now, the Pan American Health Organization estimates that 
Latin America and the Caribbean need about 720 million 
additional doses administered to reach that goal.
    Thirteen countries in the region now report over 60 percent 
partial vaccination with several others close behind, but 12 
have yet to reach 40 percent partial vaccination with about 
half of those below the 20 percent full vaccination rate, and 
we have to help close that gap and do more to ensure equitable 
vaccine distribution across the hemisphere.
    We support the rapid rollout of vaccines that meet 
internationally accepted standards of efficacy and safety 
because protecting the vulnerable demands rigor and high 
standards. Vaccines without sufficient clinical data to 
demonstrate safety and compelling evidence of efficacy put 
people at risk and undermine trust.
    At a time of global vaccine scarcity, some governments 
turned to suppliers from the People's Republic of China and the 
Russian Federation. We have seen PRC coercion ramping up or 
tapering off supplies based on a willingness to adopt policies 
favorable to Beijing, a less than admirable wolf at the door 
form of diplomacy.
    The PRC has even offered to trade vaccines for changes in 
political recognition from Taipei to Beijing, a particularly 
cruel tactic. Russia has struggled to provide contracted 
amounts of Sputnik V in a timely fashion to countries from 
Argentina to even Mr. Maduro's regime in Venezuela, and the 
Russians have yet to provide adequate documentation to secure 
an emergency use listing from the World Health Organization.
    Now, next year, when the United States hosts the ninth 
Summit of the Americas, the President intends to place health 
and the state of our health systems high on the agenda. We need 
to work together to do better on health security with 
transparency and accountability. As COVID has reminded us, 
people's lives depend on it.
    Congressional support for these donations has saved lives, 
prevented and reduced the severity of human suffering, and 
helped our hemisphere begin the long and arduous process of 
recovering from the worst of this pandemic, building back 
better than before.
    We look forward to working with you to promote health 
resilience, security, and equity in our hemisphere. I thank you 
for your time and I welcome your questions and comments.
    [The prepared statement of Mr. O'Reilly follows:]

                  Prepared Statement of Kevin O'Reilly

    Chairman Kaine, Ranking Member Rubio, Members of the Subcommittee, 
thank you for this opportunity to discuss the Biden-Harris 
administration's efforts to support Latin America and the Caribbean as 
they respond to, and recover from, the COVID-19 pandemic, and to work 
together with partners across the hemisphere to prepare for the future.
    Our efforts here in our own hemisphere make up an important part of 
our efforts to work with people of goodwill from across the globe to 
save lives, end this pandemic in 2022, and do what we need to do to 
prepare for the next pandemic.
    This pandemic has hit the Western Hemisphere hard, and the economic 
crisis that it has provoked worsened long-standing problems the region 
knows only too well--challenges to public security; confidence in 
democratic institutions; corruption; and inequality in all countries 
with economies deeply dependent on commodities exports for growth. The 
pandemic has spotlighted and exacerbated many real development 
challenges as well.
    Just 8.4 percent of the world's population lives in Latin America 
and the Caribbean, yet as of November 1, this region had more than 46 
million reported COVID-19 infections, an estimated 20 percent of cases 
worldwide; and 31 percent of reported deaths worldwide, approximately 
1.5 million souls lost.
    The region also suffered disproportionate economic losses, as the 
pandemic hit a continent already weakened by recession anemic growth. 
The International Monetary Fund estimated in its October World Economic 
Outlook that the global economy contracted by 3.1 percent in 2020, but 
the economies of Latin America and the Caribbean contracted by seven 
percent overall. Caribbean nations that depend heavily on tourism 
suffered declines of more than 15 percent. The IMF projects a return to 
growth of 5.8 percent in 2021, but the shock of the downturn sharply 
increased poverty and exacerbated pervasive income inequality.
    So, we see the scope of the challenge, we bring the same urgency to 
international response and recovery efforts that we have demonstrated 
at home, and we focus on spurring vaccinations worldwide and across our 
hemisphere, sharing pandemic response best practices, and countering 
vaccine disinformation and coercive diplomacy.
    To that end, the United States has donated more vaccines globally 
than all other countries combined, and as of last week that includes 
more than 50 million vaccine doses donated, in partnership with COVAX 
or bilaterally, to 29 countries in the Western Hemisphere. These 
contributions represent a large portion of our broader global 
commitment, which by late October reached over 243 million doses 
donated worldwide.
    The region will continue to benefit from our efforts to help 
vaccinate the world. At the Global COVID-19 Summit convened by 
President Biden on September 22, the President announced that the 
United States would donate an additional 500 million Pfizer-BioNTech 
vaccine doses through the COVAX facility to low- and middle-income 
countries and economies in need, bringing the total U.S. commitment to 
these countries to 1.2 billion doses. Beneficiaries include 10 
countries in Latin America and the Caribbean. The U.S. Government 
shares these vaccine doses, whether bilaterally or through COVAX, 
without political conditions or expectations, with the sole purpose of 
saving lives.
    Let's consider for a moment what we have helped achieve so far, and 
the work that remains. Beating back this pandemic, at least to the 
extent needed to allow people to resume everyday activities, requires 
full vaccination of 60 to 70 percent of each country's population. And 
we support the World Health Organization's global COVID-19 vaccination 
goal to reach that 70 percent target everywhere by September 2022. We 
can see our way to that objective now, far more clearly than we could a 
year ago, but we have work to do to get there. The Pan American Health 
Organization estimates that Latin America and the Caribbean need 720 
million additional COVID-19 vaccine doses administered to reach 70 
percent coverage. We must work closely with our counterparts across the 
region and the broader international community to support vaccine 
administration and uptake.
    As global vaccine supply increases, many countries in the region 
have approached or reached the 70 percent goal. Thirteen countries in 
the region report over 60 percent partial vaccination, with several 
others close behind. Larger and relatively prosperous countries in the 
region have vaccination rates that rival, and in some cases, surpass 
our own.
    Unfortunately, vaccination rates diverge greatly, with many lower-
income and smaller countries lagging. As of November 15, 12 countries 
in the region had yet to reach 40 percent partial vaccination, with 
half of these below 20 percent full vaccination, nearly all located in 
the Caribbean and Central America--traditionally areas with strong ties 
to the United States. Haiti, racked by insecurity, a fuel shortage, and 
the lingering effects of the 7.2 magnitude earthquake in August, has 
administered approximately 138,330 doses of COVID vaccines so far, 
which adds up to about 0.6 percent of its population vaccinated with 
two doses. To increase that vaccination rate, the U.S. Government has 
provided vaccines to Haiti and is organizing additional shipments this 
year.
    We must help close that gap and do more to ensure equitable vaccine 
distribution across the hemisphere to boost vaccination rates.
    Donations to five Caribbean Community (CARICOM) governments in 
early November provided needed support to governments that had 
exhausted their supplies of vaccine doses. These followed earlier 
donations to all CARICOM members, and of course our COVAX donations 
provide essential support to those who live in the region's eleven low 
and lower-middle-income countries, many of which still struggle with 
low vaccination rates.
    The Western Hemisphere remains a region of largely middle and 
upper-middle income countries that are not Advanced Market Commitment 
(AMC)-eligible, however, and those countries participate in COVAX as 
self-financing partners. They have struggled to purchase vaccines 
directly from manufacturers, and--as in so many other places across the 
world--even those that have completed purchase agreements saw delivery 
delays.
    This virus and its variants do not respect borders. This pandemic 
demands a global response to support worldwide efforts for effective 
and safe vaccine distribution, with no political strings attached. As 
part of global and national strategies to combat the pandemic, the U.S. 
Government supports the rapid rollout of vaccines that meet 
internationally accepted standards of efficacy and safety. We take no 
position on nations accepting vaccines authorized by their respective 
regulators; we respect the authorization processes of other 
governments.
    We support COVAX and the role it plays as a distributor for sharing 
vaccines authorized by the World Health Organization.
    Protecting people, and protecting the vulnerable, demands rigor and 
high standards. Distributing vaccines without sufficient clinical data 
to demonstrate safety and compelling evidence of efficacy puts people 
at risk, does not serve the public interest, and undermines trust and 
the integrity of the scientific process.
    We must also fight vaccine disinformation to build and sustain 
public trust in these lifesaving tools.
    At a time of global vaccine scarcity, many of our hemisphere's 
governments initially turned to suppliers from the People's Republic of 
China and the Russian Federation. Products manufactured in the PRC 
still comprise a large percentage of the vaccine mix for many 
countries.
    At times we have seen evidence of PRC coercion in making supplies 
available to governments in need--ramping up or tapering off supplies 
based on a government's willingness to adopt policies favorable to the 
Government in Beijing, a less-than-admirable wolf-at-the-door form of 
diplomacy. The PRC has even offered ready access to vaccines in 
exchange for changes in political recognition from Taipei to Beijing in 
those countries that recognize Taipei, a particularly harsh tactic in 
counties struggling to vaccinate their citizens.
    Deliveries from Russia of the Gamaleya Research Institute's Sputnik 
V vaccine have faltered as Russia has failed to provide the contracted 
amounts of Sputnik V in a timely fashion to Latin American countries 
such as Argentina and even Mr. Maduro's regime in Venezuela. Russia's 
Direct Investment Fund commercializes Sputnik V, but the Russians have 
yet to provide adequate documentation to secure an Emergency Use 
Listing from the World Health Organization.
    Beyond its direct impact, the COVID-19 pandemic revealed profound 
deficiencies in the world's ability to detect and appropriately respond 
to infectious diseases with pandemic potential. To do better in the 
future we need to improve regional cooperation and the effectiveness of 
the international institutions we all rely on. Next year, when the 
United States hosts the Ninth Summit of the Americas, the President 
intends to place health and the state of our health systems high on the 
agenda for leaders and for the multilateral organizations, civil 
society, academic institutions, and private sector players that 
participate in the Summit process. We need to work together to develop 
the region's health security capacity, and to do so with transparency 
and accountability. As COVID-19 has reminded us, people's lives depend 
on it.
    I would like to briefly expand on an issue that has gained 
attention in recent months: The expansion of vaccine manufacturing in 
the region.
    Latin America and the Caribbean trail other middle-income regions 
in COVID-19 vaccine production, and the pandemic has prompted some of 
the region's governments to look for ways to reduce their extreme 
dependence on vaccines, therapeutics, and other essential medical 
products produced outside of our hemisphere. Increasing vaccine 
manufacturing in Latin America would not take root in time to curb the 
current pandemic, but it remains a legitimate goal. Any government that 
able to invest adequately in education and professional development for 
its people and create an attractive regulatory framework that 
encourages intellectual property rights protections could help our 
hemisphere prepare for future health security threats, create good 
jobs, new technological capabilities, and new business opportunities, 
and promote scientific ties with the United States.
    Several Latin American countries are already producing or could 
potentially produce COVID-19 vaccines, therapeutics, diagnostics, and 
other essential medical products, including Argentina, Brazil, 
Colombia, Mexico, Panama, and perhaps Chile and Uruguay. This would 
increase access to these life-saving commodities in those nations and 
the region. Successful production will depend on solving supply chain, 
financing, technical capacity, and regulatory climate issues that 
countries in the region are working to address.
    Congressional generosity in support of these vaccine donations has 
saved lives, prevented and reduced the severity of human suffering, and 
helped the nations of our hemisphere begin the long and arduous process 
of recovering from the worst of this pandemic--building back, better 
than before. We look forward to working with you to promote resilience, 
health security, and health equity in the Western Hemisphere.
    I thank you for your time, and I welcome your questions and 
comments.

    Senator Kaine. Thank you.
    Mr. Natiello.

 STATEMENT OF PETER NATIELLO, ACTING ASSISTANT ADMINISTRATOR, 
   BUREAU FOR LATIN AMERICA AND THE CARIBBEAN, UNITED STATES 
      AGENCY FOR INTERNATIONAL DEVELOPMENT, WASHINGTON, DC

    Mr. Natiello. Chairman Kaine, Ranking Member Rubio, members 
of the subcommittee, thank you for the invitation to testify 
today. I am grateful for the committee's support for USAID's 
work particularly as we respond to COVID-19 in Latin America 
and the Caribbean.
    The countries of Latin America and the Caribbean have been 
hit hard by the pandemic, as we have heard this morning. 
Although it is home only to 8 percent of the world's 
population, the region is seeing 20 percent of all cases and 
just over 30 percent of all global deaths.
    The American people have demonstrated incredible generosity 
and solidarity with our neighbors, providing more than 500 
million for USAID's COVID-19 response in Latin America and the 
Caribbean since March 2020.
    Since the beginning of the pandemic, USAID has moved 
quickly to mobilize new health assistance, respond to emerging 
food and protection needs, adapt current programming, and plan 
for the long-term impacts that we know will plague the region 
for years to come.
    I commend our staff and our partners and all those on the 
front lines who are working relentlessly to help those most in 
need.
    On the health front, our efforts include working with 
health ministries to minimize the risk of transmission and 
prevent and control infections in health care facilities, 
training and equipping rapid response teams to better track and 
record cases, helping countries to provide the public with 
reliable verifiable information that keep citizens informed 
about how best to protect themselves and each other, and 
providing oxygen to treat patients in the most dire need.
    Of course, the availability and wider distribution of 
vaccines has been key to the region's significant strides this 
year. In the last 5 months, the United States provided more 
than 50 million vaccines throughout the region. These vaccines 
are being provided safely, equitably, and with no political 
strings attached.
    USAID is providing crucial assistance that has enabled 
countries to receive and distribute these life-saving vaccines. 
Our efforts to get shots in arms include support for cold chain 
management, training of vaccinators and establishment of 
vaccination sites, support for communications campaigns to help 
overcome vaccine hesitancy, and work with ministries of health 
to better track vaccination rates.
    Just last month, I saw progress on the health front 
firsthand when I visited Medellin, Colombia. The Department of 
Antioquia, of which Medellin is the capital, was severely 
impacted by COVID-19, seeing daily cases in excess of 4,000 and 
a 98 percent ICU occupancy rate in June 2021.
    Thanks to the Government of Colombia's concerted response, 
which included distribution of vaccines donated by the United 
States and others purchased by Colombia through COVAX, as well 
as USAID's support for vaccine distribution, Antioquia was able 
to significantly reduce infection prevalence and death rates, 
decreasing from 4,000 in June to 301 recorded infections a day 
in mid-October.
    Region wide, infection rates and death rates due to COVID-
19 have decreased by 84 percent over the past 5 months. The 
region's economy, as has been noted, is also improving with the 
International Monetary Fund projecting an economic rebound of 
6.3 percent in 2021, second only to emerging and developing 
economies in Asia. This is the kind of progress that USAID 
seeks to support throughout the region.
    As we have addressed the critical health situation, we have 
been keenly aware of the secondary impacts of the pandemic 
including job losses and kids out of the classroom, growing 
food insecurity, increases in gender-based violence, and 
contraction of civil liberties and rights.
    USAID continues to address long-term challenges in the 
region through programs that foster inclusive economic growth, 
address climate change, improve citizen security, promote 
respect for human rights, fight corruption and promote 
transparency, elevate the voices of civil society and other 
community leaders, and enable diversity and participation by 
historically marginalized groups.
    Our efforts have not gone unnoticed. Partner nations 
regularly recognize and thank the United States for our 
steadfast support in the face of this unprecedented emergency.
    The solidarity reminds us all that this pandemic affects 
the entire world. We must continue to be good neighbors, 
partners, and friends so that we can overcome this challenge 
together. We are safe when everyone is safe.
    Even as we maintain our vigilance and continue to respond 
to the virus, we remain committed to helping countries adapt to 
new realities presented by the pandemic and shore up hard-won 
development gains.
    Ultimately, we seek to help the people of the region live 
in peace and prosperity and realize a more healthy hopeful 
future.
    Mr. Chairman, Senator Rubio, thanks again for the 
opportunity to testify. I welcome your questions.
    [The prepared statement of Mr. Natiello follows:]

                  Prepared Statement of Peter Natiello

    Chairman Kaine, Ranking Member Rubio, and members of the 
Subcommittee, thank you for the invitation to testify today about the 
Biden-Harris administration's response to COVID-19 in Latin America and 
the Caribbean. I am grateful for the Committee's support for the United 
States Agency for International Development's work, particularly as we 
work as part of a larger U.S. Government effort to address the impacts 
of the pandemic in the region.
                                context
    The countries of Latin America and the Caribbean have been hit hard 
by COVID-19. In the last 18 months, the virus has swept through the 
region, infecting more than 46 million people and killing more than 1.5 
million; although it is home to only 8 percent of the world's 
population, the region has seen 20 percent of all cases, and just over 
30 percent of all global deaths. We mourn with the families of those 
impacted both at home and abroad.
    As is the case around the world, the pandemic has reverberated 
through all sectors of society and jeopardized important development 
gains made in recent decades. As countries went into a series of 
lockdowns and quarantines, many people worked significantly fewer hours 
or lost their sources of income entirely; in fact, the International 
Labor Organization estimates that the region lost 31 million jobs in 
2020 due to the pandemic, and its economies contracted by seven percent 
in 2020, according to International Monetary Fund estimates. Gender-
based violence, an issue that I know is of particular concern to this 
subcommittee, also has increased during the pandemic; in Argentina, 
Mexico, and Colombia, for example, calls to domestic violence hotlines 
rose by 40, 80, and more than 100 percent, respectively, in the first 
months after mandatory stay-at-home orders were issued. Children were 
unable to go to school, and many who do not have access to technology 
or reliable internet to continue their education at home are in danger 
of being left behind. Authoritarian leaders used COVID-19 as an excuse 
to consolidate power, take further anti-democratic actions, and imperil 
human rights and fundamental freedoms.
    That said, the region is in a much different position than it was 
even 6 months ago, and United States assistance has been pivotal to the 
progress that has been made. As we address the pandemic at home, the 
American people have demonstrated incredible generosity and solidarity 
with our neighbors around the world, providing more than $9 billion for 
USAID's global COVID-19 response, including more than $500 million in 
Latin America and the Caribbean since March 2020, in addition to 
support from other U.S. departments and agencies. Infection and death 
rates due to COVID-19 have decreased by 84 percent over the past 5 
months. The region's economy is also improving, with the International 
Monetary Fund projecting an economic rebound of 6.3 percent in 2021, 
second only to emerging and developing economies in Asia; the United 
States' support to the region has undoubtedly played a part in this 
encouraging progress.
                             usaid response
    USAID is supporting COVID-19 efforts in 29 countries in the region. 
We are working in close partnership with local governments, 
international organizations, the private sector both in the region and 
the United States, faith-based organizations, and other non-
governmental organizations to deliver urgent assistance to those most 
in need. Since the beginning of the pandemic, USAID personnel in 
Washington and our field missions have moved quickly to mobilize new 
health assistance, respond to emerging food and protection needs, adapt 
current programming, and plan for the long-term impacts that we know 
will plague the region for years to come. I commend our staff, 
partners, and all those on the front lines, who are working 
relentlessly to help those most in need.
    USAID mobilized from the earliest days of the pandemic to respond 
to the urgent health situation in Latin America and the Caribbean. As 
COVID-19 emerged, we began the work we continue to this day: partnering 
with countries to treat those affected and stop the virus from 
spreading. We are working with health ministries to minimize the risk 
of transmission and prevent and control infections in healthcare 
facilities, including through the donation of personal protective 
equipment for health care workers. We train and equip rapid-response 
teams to better track and record cases. We support the rehabilitation 
and repair of water systems to ensure that there is access to clean 
water at health facilities, promote healthy hand-washing behaviors, and 
partner with utilities and other service providers to maintain water 
and sanitation services so that businesses and markets can operate 
safely. We help countries to provide the public with reliable, 
verifiable information that keeps citizens informed about how best to 
protect themselves and each other. Along with training health 
professionals to ensure they are able and equipped to manage COVID-19 
cases, we have also provided both oxygen and ventilator support 
throughout the region to treat patients in the most dire need.
    For example, as part of our region-wide communications efforts, 
USAID funded a COVID-19 campaign in Santo Domingo, Dominican Republic 
to promote public awareness on preventive practices and counter 
misinformation, and targeted areas of the border with Haiti to raise 
awareness of the dangers of the disease. As with other countries in the 
region and the world, in Honduras, USAID provided training to help more 
than 2,600 health workers care for COVID-19 patients, including 
patients with severe COVID-19, improving the quality of care offered in 
hospitals, triage centers, and other health centers across the country. 
In Haiti, USAID donated oxygen supplies, including 50 oxygen 
concentrators in June and 250 oxygen-filled cylinders this month, to 
help ensure the uninterrupted availability of oxygen for critical 
COVID-19 patients receiving treatment.
    Of course, the availability and wider distribution of vaccines has 
been key to the region's significant strides this year. In the last 5 
months, the United States--bilaterally or in partnership with COVAX--
has provided more than 50 million vaccines to countries throughout the 
region, enabling millions of people to be fully vaccinated against the 
deadly virus. These vaccines are being provided safely, equitably, and 
with no political strings attached.
    USAID is providing crucial assistance that has enabled countries to 
receive and distribute these life-saving vaccines. Our efforts to get 
shots in arms include support for cold chain management to ensure that 
vaccines remain viable and effective, training of vaccinators and 
establishment of vaccination sites, support for communications 
campaigns to provide accurate information and help overcome vaccine 
hesitancy, and work with ministries of health to better track 
vaccination rates.
    For example, in Guatemala, we have supported the establishment and 
quality improvement of more than 690 vaccination sites across the 
country, including walk-up, drive-up, and hybrid walk-up/drive-up sites 
in public and private sector venues. In Peru, USAID is supporting the 
implementation of the Government of Peru's national COVID-19 
vaccination plan, including by training more than 1,750 (56 percent of 
whom are women) health workers in planning, conservation of vaccines in 
the cold chain, vaccination process, and handling and application of 
vaccines. And in Barbados, USAID supported public service announcements 
that reached more than 50,000 parents with messaging on COVID-19 
vaccination for children aged 12-18.
    Just last month, I saw this progress firsthand when I visited 
Medellin, Colombia. The Department of Antioquia, of which Medellin is 
the capital, was severely impacted by COVID-19, seeing daily cases in 
excess of 4,000 and a 98 percent ICU occupancy rate in June 2021. 
Thanks to the Government of Colombia's concerted response, which 
included distribution of vaccines donated by the United States and 
purchased by Colombia through COVAX, as well as USAID support for 
vaccine distribution planning, communications, and service delivery, 
Antioquia was able to significantly reduce infection prevalence and 
death rates, decreasing to 301 recorded infections a day in mid-October 
2021. This is the kind of progress that USAID seeks to replicate 
throughout the region.
    As a result of these concerted efforts by the United States and the 
people of the region, over the past 5 months, the region's death and 
infection rates have both dropped by 84 percent. USAID's widespread 
programs in support of our partner nations' COVID-19 response have been 
key to making that good news possible, and we remain committed to 
supporting our neighbors in their ongoing efforts.
    As we have addressed the critical health situation, we have been 
keenly aware of the secondary impacts of the pandemic, including job 
losses and kids out of the classroom, growing food insecurity, 
increases in gender-based violence, and contraction of civil liberties 
and rights. When the pandemic tore through the region, and even as our 
own staff was affected by infection and lockdowns, our field missions 
quickly pivoted programs to adapt, addressing both these emerging 
issues while also ensuring that the important work of development can 
advance. USAID continues to address long-term challenges in the region 
through programs that foster inclusive economic growth, address climate 
change, improve citizen security, promote respect for human rights 
(including freedom of expression, including for members of the press), 
fight corruption and promote transparency, elevate the voices of civil 
society and other community leaders, and enable diversity and 
participation by historically marginalized groups.
    For example, in Colombia, where COVID-19 disrupted traditional 
supply chains and markets nationwide, USAID worked with the U.S. 
Development Finance Corporation and seven local microfinance 
institutions to guarantee an additional $35 million in productive loans 
to micro businesses affected by COVID lockdowns. With USAID assistance, 
state and municipal authorities in Mexico developed new interventions 
during the initial phase of the pandemic to stop domestic violence 
against women before it potentially progressed to femicide; in the 
unique COVID context, new protection and victim response models tailor 
services to victims' needs while supporting state authorities to better 
prosecute these crimes. In the Dominican Republic, USAID's programs 
with the private sector are providing food assistance to more than 
270,000 people to supplement government relief efforts and reach 
targeted vulnerable populations affected by the pandemic. In Paraguay, 
USAID is helping 6,500 micro and small businesses overcome the economic 
consequences of the pandemic by improving housing structures and 
providing support such as training in entrepreneurship and business 
plan development so that vulnerable people can set up micro-businesses 
in their homes. In Jamaica, USAID provided laptops and tablets to keep 
children connected to school in the absence of face-to-face classes, in 
support of the Government of Jamaica's one tablet or laptop per child 
initiative. In Ecuador, where economic exclusion of vulnerable 
populations has been exacerbated by the pandemic, USAID programs 
enabled nearly 22,000 Ecuadorians and Venezuelans to access formal 
financial services by opening a savings account and/or obtaining a 
credit product or facility from a bank or other financial institution. 
And in El Salvador, USAID helped 4,370 small and medium-sized 
enterprises in fiscal year 2021, including more than 780 micro, small, 
and medium businesses that received direct support for economic 
recovery due to COVID-19.
    Our efforts have not gone unnoticed. Partner nations regularly 
recognize and thank the United States for our steadfast support in the 
face of this unprecedented emergency. We have seen expressions of 
gratitude on social media from everyday people in countries like 
Paraguay, where one recipient of U.S.-donated vaccines posted, ``Hope 
is what keeps us connected to life. Thank you, U.S.!'' Honduran 
officials have stated that their vaccination campaigns, which have 
raised the number of Hondurans who are fully vaccinated from less than 
one percent in July to 43 percent in early November, ``would not be 
possible'' without COVID-19 vaccine donations from the United States 
and USAID's assistance for vaccine distribution and administration to 
the people. The Government of Peru has repeatedly thanked the U.S. for 
life-saving COVID-19 support, including donation of 2 million doses of 
vaccine, eight mobile military hospitals, personal protective 
equipment, and other technical assistance. This kind of solidarity 
reminds us all that this pandemic affects the entire world and we must 
continue to be good neighbors, partners, and friends so that we can 
overcome this challenge together. We're safe when everyone is safe.
    We must remain vigilant to ensure that this kind of progress can 
continue. While conditions in the region have improved, and we are in a 
better place than we were only a few months ago, the pandemic has 
taught us that we cannot become complacent and must guard against 
future variants and surges. USAID programming continues, including with 
American Rescue Plan Act (ARPA) funding generously appropriated by this 
Congress. As part of our commitment to localization, a portion of 
USAID's programming in the region under ARPA will be managed by local 
partners. We will continue to work with countries to increase 
vaccination rates, including for marginalized or underserved 
populations, so that people can be better protected against severe 
illness. We will continue to support surveillance of and testing for 
COVID-19 so that we can stop the spread of the virus. We will continue 
to provide crucial training and medical supplies, including oxygen, so 
that the most critical patients can be treated and healed. And we will 
continue our support for longer-term development programs to help the 
region recover and emerge from the pandemic with as little disruption 
as possible.
                               conclusion
    As it is around the world, the COVID-19 situation in Latin America 
and the Caribbean remains dangerous. However, thanks to the generosity 
of the American people and the support of Congress, USAID has been able 
to help the countries of the region make real progress despite the 
unprecedented health and economic impacts of the pandemic. Even as we 
maintain our vigilance and continue to respond to the virus, we remain 
committed to helping countries adapt to new realities presented by the 
pandemic and shore up hard-won development gains.
    Ultimately, we seek to help the people of the region live in peace 
and prosperity and realize a more healthy, hopeful future.

    Senator Kaine. We will have a 5-minute round of questions 
for the witnesses and I would just like to begin by asking you 
both this question.
    The U.S. total delivery of vaccines to the region is about 
49 million and that is significantly behind Chinese vaccine 
delivery to the region. The three of us did join together in a 
letter to the Administration many months ago saying there are a 
lot of reasons to prioritize the Americas, one, because of 
family and other ties between the United States and folks in 
the Americas, a disease that knows no borders. If we prioritize 
the region, it will keep us healthier.
    Second, the follow-on consequences of this health pandemic 
in the region produce economic and other instabilities that can 
be a push factor for migration.
    We are dealing with tough migration issues. It would help 
us deal with those issues if we were more forward leaning in 
helping nations in the region access vaccines.
    Third, we pointed out and have been very aware of the 
efforts of China and Russia to use vaccines in the region and 
why would we want to be on our back foot while they are racing 
ahead.
    Even though we are the single biggest donor of vaccines in 
the world, what explains why our vaccine donations to the 
Americas, which has suffered so disproportionately, still are 
lagging behind China?
    Mr. O'Reilly. Mr. Chairman, one of the factors is the--as 
you mentioned in your own opening remarks was the priority that 
we had to give to domestic requirements.
    Secondly, that we went through rigorous procedures to make 
sure that anything that we donated was safe and reliable, and 
encompassed some of the sorts of the broader support elements 
that Mr. Natiello was just referring to.
    When you add these along with--there are also commercial 
deals that companies have and some of those are also American 
providers, we have tried to focus our donations on the areas 
most in need and we are taking a look at the hard numbers, at 
the facts--the case rates, the death rates, the current 
vaccination rates in particular countries--and to respond to 
surges in the most agile way that we can to make sure that the 
vaccines that we donate are safe, reliable, and are turned from 
vaccines into vaccinations because a vaccine is not any good to 
anyone until it gets into somebody's shoulder and gets into 
someone's arm.
    Senator Kaine. Let me push a little bit farther on that. I 
actually understand why we might have been slow out of the 
blocks to do deliveries in June when other nations were faster, 
because we were putting a priority, first, on making sure folks 
in the United States were vaccinated, and we also have quality 
standards about vaccines that are superior to what China and 
Russia have and that encompasses some delay that I understand.
    If I just look at the amount of vaccines delivered by the 
United States into the region, you would think one of the 
factors might be, well, if this is a region that is 
experiencing 30 percent of the deaths in the world then why 
would not 30 percent of American vaccines be going into the 
region?
    I have not done the math on it, but it seems to me that 
vastly less than 30 percent of American vaccines going abroad 
have gone into the region. So I sort of wonder about the--and 
Senator Rubio mentioned this in his opening comments--what are 
the allocation factors that the Administration is using and 
might we expect to see, particularly in the run-up to the 
Summit for the Americas, might we expect to see even a more 
aggressive approach from the United States in terms of 
delivering vaccines to the region?
    Mr. O'Reilly. I can say that as we prepare for the summit, 
as we look through 2022, the President has made a commitment to 
try to beat back this pandemic worldwide by the time the world 
next convenes at the U.N. General Assembly, and that we want to 
push through to the summit as well.
    Senator Kaine. My time is about up. I am going to yield to 
Senator Rubio.
    Senator Rubio. Again, I just want to continue to touch upon 
when we determine who gets what, when we make this big purchase 
of vaccines and we start sending them, what is the criteria we 
use to determine this country is going to get it, this country 
is not, this country is going to get X amount, this country is 
going to get that amount?
    Is there a criteria that is being used to determine how 
this is being distributed globally and, in particular, how that 
impacts this region?
    Mr. O'Reilly. I think that the goal is looking at capacity, 
how we can maximize the number of vaccine doses available in a 
country and do so equitably for the greatest number of 
countries and the greatest number of people at risk within 
those societies.
    Take a look at the data in terms of surges and how to 
mitigate potential surges, how to cut off surges when they have 
already appeared, and giving priority to protecting people in 
the healthcare sectors who need to care for those who are ill.
    So we try to base it on the best and most reliable public 
health data that we have available and we do try to give 
priority as well to areas at risk.
    Mr. Natiello. If I could just add to that, Senator.
    We look at a variety of factors including case rates, death 
rates, and hospitalizations, current vaccination rates in a 
country, again, responding to surges and a country's ability to 
receive vaccines and put shots into arms as well as U.S. 
national and economic security.
    Senator Rubio. So when you say--obviously, the case numbers 
are what they are. Everyone has had a surge, some bigger than 
others. Depends on how much they are testing, how much they are 
monitoring. The hospitalization rates are often dependent on 
whether there are hospitals or hospital availability.
    What I am hearing, though, potentially, is that part of it 
is if a country does not have, for example, a health care 
system that can actually organize people and get people 
vaccinated, if a country does not have the ability to store 
vaccines and get them to people fast enough before they expire, 
that, I would imagine, is a big factor in how we are 
determining this.
    Donating 10 million vaccines to a country that does not 
have health care infrastructure to distribute them and, 
therefore, they are going to go bad, they are going to expire, 
they are not going to get to people--is that a major factor in 
how this is being decided?
    Mr. Natiello. So those are important criteria, and that is 
precisely why USAID is focused on strengthening health systems 
in our partner nations, because we want them to be able to not 
only receive the vaccine but, clearly, to get shots in arms, 
which is why we do things like support the cold chain, support 
training of vaccinators, support communications campaigns to 
overcome vaccine hesitancy.
    In some countries, the level of readiness far exceeds that 
in other countries. So the challenge, for instance, in a 
country like Haiti is very, very different than a country like 
Brazil or Honduras.
    So these are the kind of things that we look at. These are 
the kind of things that we apply U.S. technical assistance to, 
to help get those vaccines in arms.
    Senator Rubio. Now, the other thing I wanted to ask is both 
the Kremlin and the Communist Party in China are engaged 
globally in a large-scale disinformation campaign trying to 
discredit the American-origin vaccines, particularly Moderna 
and Pfizer, and promote their own.
    So what are we doing in the region, in particular? I think 
there is a broader communication issue. We have seen the RT, 
Spanish version, has grown in audience, unfortunately, and it 
is a big challenge in the region that we have to confront as 
well.
    What are we doing to counter that, in particular, this sort 
of disinformation campaign about vaccines, specifically, in 
Latin America?
    Mr. O'Reilly. First off, sir, bringing light to exactly 
what you spoke about, you cannot play whack-a-mole on every bit 
of disinformation. What you have to do is make sure that you 
bring true facts, accurate information. You have to do it 
repetitively and you have to make sure that you work to get 
those messages out to communities. I think Peter could probably 
speak a little bit more on the details of how we do that, but 
the fundamental principle is you have to beat bad information, 
which is rife, and disinformation, which is rife and has been 
motivated from Russia, in particular, but also from China.
    You have to flood the zone with better, more reliable 
information and make sure that people who are trusted in the 
communities all over this hemisphere where their governments 
are having uptake problems bring that information to their 
publics so that they overcome this challenge.
    Senator Kaine. Senator Menendez.
    Senator Menendez. Thank you, Mr. Chairman, you and the 
ranking member. I appreciate you holding this hearing on a very 
important topic.
    Deputy Assistant Secretary O'Reilly, the pandemic exposed 
many of the region's weaknesses, including widening social 
inequalities, widespread informality, growing environmental 
risks, a gender-based violence epidemic, and weak healthcare 
and education institutions.
    When you pair that with massive population displacement and 
efforts by certain leaders to systematically dismantle 
democratic institutions, I am concerned that the next decade in 
the hemisphere will be a turbulent one unless the United 
States, the international communities, and our partners in the 
region are strategic in addressing these increasingly complex 
challenges.
    Now, from my own perspective, the Administration's vaccine 
diplomacy and policy in the Western Hemisphere has been a 
failure. Let me give you an example.
    I was talking to a president in the hemisphere and he said 
to me, I am pro-America, but in the midst of the pandemic I 
wanted to buy--I was not even looking for donations of 
vaccines--I wanted to buy vaccines for my people.
    I could not get anywhere with the U.S. Government. China 
sold them the vaccines. They may be less efficient, but if you 
have got nothing then you will take something, at the end of 
the day.
    I am privatizing, for the first time, our energy 
infrastructure. Tried to get America interested in the 
possibilities. China comes along and says, we will buy the 
bonds.
    We are having challenges with the IMF, which is a problem 
that is beyond this country that I am referring to. It is 
hemispheric. Because look at what we did as a government to, 
ultimately, deal with the economic challenges of the pandemic, 
how much money we pumped into the economy and to help families, 
but not every country has that wherewithal.
    Yet, the IMF is creating a series of conditions that they 
insist without creating a smoothing period so that these 
countries can get through this difficult time and the economic 
consequences of the COVID pandemic.
    So the Chinese come to this president and say, okay, we 
will lend to you at 1 percent. Now, we missed the boat on 
vaccines in the Western Hemisphere and all of us wrote to you--
to you, meaning the Administration--urging you to take a much 
different course.
    You can have all the calculuses you want. I can create the 
little boxes and checks to say that we systematically did it 
this way, but the reality is in our own hemisphere, in our own 
front yard, with all of the nexus of family and trade and 
migration, in our own interests--forget about being a good 
neighbor--in our own interests, it made eminent sense to 
significantly deploy the vaccine in the hemisphere.
    We failed. China was in there. They got the goodwill, and 
we failed. So now the question is how do we deal with the 
aftermath of that failure in the context of the economic 
challenges that are facing these countries?
    So can you tell us how you are working with the Treasury 
Department to ensure that the United States uses its voice and 
its vote at the IMF and the World Bank to ensure greater 
flexibility and increase access to resources for these 
developing countries as they pursue their post-COVID-19 
recovery?
    Mr. O'Reilly. Well, thank you. Thank you, Senator, for the 
question.
    I mean, one of the things that the Administration is doing 
is working with other members of the International Monetary 
Fund to develop the resilience and sustainability trust over at 
the IMF, and seeking also authorization to lend $21 billion to 
poor and low income countries and putting a focus, 
particularly, on areas which have been really walloped by this 
first year and a half to 2 years of the pandemic, small 
islands' economies, and there is a particular focus in doing so 
on the Caribbean, and I think that is going to be one 
significant process underway.
    We also work very closely with the Inter-American 
Development Bank and I also have responsibilities for preparing 
for the Summit of the Americas next year and we have a process 
underway of reviewing, I know, keen interest that you and other 
members of this committee have in the future of our----
    Senator Menendez. Mr. Chairman, if I may, just--so I 
appreciate all that, but here is the point. If we do not use 
our voice and our vote at the IMF and the World Bank, you will 
see more of what you saw in Colombia.
    Colombia is being squeezed by the IMF. The Duque 
administration responded by doing a series of fiscal issues 
that the IMF wanted to see and there was social unrest.
    I am not talking about people walking away from their 
obligations. I am talking about creating a smoothing period so 
that they can get through what we are getting through as a 
country, but they do not have the wherewithal to get through as 
a country, so that, in fact, they can then meet their 
obligations.
    If we do not do that, we are going to see enormous social 
unrest and we might as well turn the hemisphere over to 
authoritarian figures because they will say the way to solve 
your problems is not through this democratic process but 
through authoritarianism, which is, unfortunately, rampant.
    I am glad you raised the IDB. It is the last point I will 
make. All of us here have been advocating for a capital 
increase for the Inter-American Development Bank as part of the 
U.S. effort to support the region's economic recovery, and I 
thought this Administration would embrace our bipartisan effort 
to do exactly that because if you want to deal with China in 
terms of its pervasive presence in the hemisphere, you create 
the wherewithal to meet the challenge of what they are doing in 
the hemisphere by an institution like the IDB and by the DFC 
and others.
    At the end of the day, why is it that the Administration 
has not embraced a 10th capital increase?
    Mr. O'Reilly. My understanding, Senator, is that the issue 
remains under review, and we certainly have had discussions 
about this with our colleagues over at the Treasury Department, 
and we do recognize the absolutely essential role that the 
Inter-American Development Bank plays in this hemisphere and 
that it needs to be able to act in the most robust way possible 
within its authority.
    Senator Menendez. Well, while we are navel gazing about 
this issue, it seems to me it is rather straightforward. China 
is displacing our influence in the region and we have no tools 
to effectively deal with that.
    So maybe we can stop looking at our navel, figure out how 
we are going to support an increase and under what conditions, 
and then get the IDB with the U.S. representative there to 
start engaging in the hemisphere in a way that can turn the 
dynamics around.
    Because I am telling you, as someone who has spent 30 years 
not only in foreign affairs but most specifically focused on 
the hemisphere, we are losing and losing fast.
    This is not just this Administration, but nonetheless, it 
is this Administration that has the power to change it and it 
should.
    Thank you for your indulgence, Mr. Chair.
    Senator Kaine. Second round of questions. I have two topics 
that I would like to raise.
    Help the committee understand the decision makers on 
allocation of American vaccines. So there is criteria and there 
is factors, but we are the most generous in the world totally, 
but who is making the decisions about allocations to countries 
and regions?
    Ultimately, the decisions are the President's, but is this 
a State Department function? Is it a multi-agency roundtable? 
Help us understand this.
    Mr. Natiello. Thank you for the question, Mr. Chair. So the 
process to determine vaccine provision internationally is led 
by the National Security Council and the White House COVID-19 
teams. It does include inputs from USAID, from the State 
Department, HHS, and the CDC. That is my understanding of that 
process.
    Senator Kaine. Do you know who the leader at the NSC of 
this allocation decision-making process is?
    Mr. Natiello. Well, it is the NSC COVID team, but I cannot 
tell you exactly who the person is. I do not know if my 
colleague, Ambassador O'Reilly, has----
    Senator Kaine. Mr. O'Reilly, do you know who at the NSC has 
this billet?
    Mr. O'Reilly. I will confess that it is somewhere on the 
tip of the tongue. I cannot pull it up at this moment.
    Senator Kaine. I will ask it for the record, but if you 
think of it in the next couple of minutes, please let us know.

[Editor's note.--Senator Kaine chose not to submit the question 
for the record.]

    Mr. O'Reilly. Absolutely.
    Senator Kaine. Because, again, I mean, there are many 
factors that you would use, but if you just look at the 
critical nature of the Americas, the connection between the 
Americas and the United States and the death toll in the 
Americas as a percentage of the global death toll, it just 
still seems like the allocation of vaccines is pretty out of 
whack with what the threat in the region and the threat to the 
United States is.
    Second question. One of the things that we can do to really 
help any region is inspire local production of vaccines. So the 
Pan American Health Organization in September announced that it 
had selected two biomedical centers in Argentina and Brazil to 
develop and produce COVID vaccines and China's Sinovac biotech 
also announced in August that they would open a manufacturing 
facility in Chile in the first half of 2022. What is the U.S. 
doing, if anything, to support local development of vaccines in 
the Americas?
    Mr. O'Reilly. I have certainly seen and I have heard 
directly from colleagues, counterparts, in governments from 
Argentina to Colombia, I know also expressions of interest in 
Mexico and elsewhere that they have taken a look at the 
circumstances in which our hemisphere has found itself, and 
these long and sometimes politically unreliable supply chains 
concern them deeply.
    So we have, certainly, entered into discussions. Just 
recently we sent down--actually, the Administration sent down a 
team led by our colleagues from HHS and CDC to dive deep into 
the topic in Colombia, for example, and take a look at the 
kinds of regulatory frameworks, the types of protections of 
intellectual property, the types of technical training, the 
standards that they would need.
    We have had similar discussions with--perhaps not at the 
same depth, but we have had similar discussions over the course 
of this pandemic, elsewhere in South America, I know, and to 
try to figure out or help people figure out how they need to 
adapt their policies and their investment environments to 
attract those kinds of investments, and it is a priority, also, 
because it is a good way to create good reliable jobs and 
strengthen connections and ties with the U.S. and the United 
States industry.
    Senator Kaine. Senator Rubio.
    Senator Rubio. Mr. O'Reilly, just while we have you here 
today. I want to take this opportunity to talk about the Summit 
of Democracies that is coming up in December.
    The Government of interim President Juan Guaido, we 
recognize that. The official U.S. policy remains that that is 
the legitimate government in Venezuela. Is that correct?
    Mr. O'Reilly. That is correct.
    Senator Rubio. Why is not Venezuela on the list and his 
government on the list of countries that are being invited to 
the Summit of Democracies? Or has that changed?
    Mr. O'Reilly. The White House makes the final calls as to 
how to organize this White House scheduled and structured 
event. I am not aware that the final list of participants and 
speakers has been completed. We, certainly, have not invited 
every government in the hemisphere around the globe to this 
event.
    It will be a representative group of government and 
nongovernmental officials and representatives, and it is the 
first phase of a two-set phase summit process, which will end 
in an in-person event next year. Its principles are a 
fundamental through-line as well for our Summit of the Americas 
preparations.
    Senator Rubio. No. No. I understand all that. My point is 
if the U.S. policy is that the interim Government of President 
Guaido is a legitimate government and we are trying to 
strengthen both the leverage and credibility of the pro-
democracy movement in Venezuela, not inviting them even in the 
initial list to a Summit of Democracies is, certainly, not 
helpful to that and, I would argue, is quite damaging.
    So I guess my point is, I get that the White House makes 
the final decision, but I am curious, what is the State 
Department's position on it or what--if you could share with 
us--is the State Department against them being included in the 
list?
    Are you involved in the formation of the list? I would 
imagine that they are talking to you as the Deputy Assistant 
Secretary of State for the Western Hemisphere about who should 
be on that list.
    Mr. O'Reilly. Yes. We have been in consultations with the 
organizers within the Administration of the event pretty much 
from the get-go, Senator. And, first, to the fundamental 
question, look, we recognize the National Assembly, and the 
National Assembly decided to elect Juan Guaido as its 
President, given that Nicolas Maduro stole the presidential 
election, manipulated the prior election for--election, we 
could call it, last year for the National Assembly, and has 
skewed the table so rawly that Sunday's event will in no way 
represent anything that is free and fair.
    We understand where democratic principles rest in terms of 
our relationship with Venezuela and we understand who is 
blunting the democratic aspirations of the Venezuelan people.
    Senator Rubio. So then why are not they on the--that is all 
great. Why is that not reflected? I would imagine in the first 
iteration of the list that has been put out there you would 
think that it would be at the top of the list, not an 
afterthought, or we will wait and see what we are going to do.
    My question--I mean, do you favor them being on the list? 
Is there anybody in the State Department that is against them 
being on the list? That is what I am trying to get at.
    Why are not they on there? I mean, I do not--I cannot 
imagine, given everything you have just said, that we have 
forgotten about how important this would be for them to be 
included.
    Mr. O'Reilly. Senator, I must say in terms of the regional 
focus of my portfolio, it is my highest priority to work to 
support the democratic aspirations of the Venezuelan people.
    It is, I think, exceptionally important that Mr. Maduro 
accept the reality of what he has done to his country and to 
come back to the table to negotiate a fairer, a more 
democratic, and a more open system.
    Senator Rubio. No, I understand, but that does not explain 
why Guaido is not--or whoever they choose as their--whether it 
is him or somebody else to be the speaker of the National 
Assembly, why they are not on the list, given everything you 
have just said.
    Mr. O'Reilly. I understand the concern, and I will bring it 
back with me, Senator.
    Senator Rubio. Okay. I think my time is up on this.
    Senator Kaine. I want to thank both witnesses on this first 
panel for your questions. We may have questions for the record 
to submit as well. I will make an announcement about that at 
the end of the hearing.
    Should there be questions for the record we would encourage 
you to be prompt in responses. Thank you so much for your 
service and for appearing today.
    With that, let us get the witnesses from the second panel 
to come out and we will proceed with them. Thank you very much.
    Mr. O'Reilly. Thank you.
    [Pause.]
    Senator Kaine. We want to welcome the witnesses on Panel 
II. Very important hearing. Let me now introduce you. I am 
going to begin with Mr. Runde.
    Daniel Runde is the Senior Vice President of the Project on 
Prosperity and Development in Americas program and holds the 
William Schreyer Chair on Global Analysis at the Center for 
Strategic and International Studies.
    Previously, he held senior leadership roles at the 
International Finance Corporation and from 2005 to 2007 he was 
the director of the Office of Global Development Alliances at 
USAID. Lifetime member of the Council on Foreign Relations and 
a graduate of both Dartmouth College and Harvard University's 
Kennedy School of Government. Mr. Runde, welcome. Glad to have 
you with us today.
    Dan Restrepo, senior fellow at the Center for American 
Progress for nearly 6 years and through two presidential 
campaigns served as the Principal Advisor to President Obama on 
issues related to Latin America, the Caribbean, and Canada, and 
then served as Special Assistant to the President and senior 
director for Western Hemisphere Affairs at the National 
Security Council.
    Previously, he created and directed the Americas Project, 
which focused on Latin America and the role of Hispanics in the 
United States at the Center for American Progress.
    He served as a judicial clerk on the U.S. Court of Appeals 
for the Third Circuit and worked for former Representative Lee 
Hamilton on the staff of the House Foreign Affairs Committee. 
He is a graduate of the University of Virginia and University 
of Pennsylvania School of Law.
    Finally, Dr. Arachu Castro, who is the Samuel Z. Stone 
Chair of Public Health in Latin America and director of the 
Collaborative Group for Health Equity in Latin America at 
Tulane School of Public Health and Tropical Medicine.
    Prior to joining Tulane in 2013, she was the Associate 
Professor of global health and social medicine at Harvard 
Medical School. She is a member of the World Health 
Organization's Strategic and Technical Advisory Group of 
Experts for maternal, newborn, child, adolescent health and 
nutrition, and has also worked as a consultant for numerous 
intergovernmental public health organizations including Pan 
American Health Organization, the WHO, and UNICEF.
    Dr. Castro has a Ph.D. from the School for Advanced Studies 
in Social Sciences in Paris, a Ph.D. in Social Sciences from 
the University of Barcelona, and a Master of Public Health from 
the Harvard School of Public Health.
    I want to thank all the witnesses. Beginning in the order 
that I introduced you, if you would each testify. Confine your 
comments to about 5 minutes. Your full comments will be 
included in the record, and then we will look forward to 
engaging in dialogue with you.
    Mr. Runde.

STATEMENT OF DANIEL F. RUNDE, SENIOR VICE PRESIDENT, CENTER FOR 
              STRATEGIC AND INTERNATIONAL STUDIES

    Mr. Runde. Thank you, Senator Kaine. Thank you, Senator 
Rubio. It is a privilege to be here before this committee.
    In addition to being a moral and the right thing to do from 
a public health standpoint, whichever country is seen as 
solving the COVID-19 vaccine challenge is going to reap 
enormous public diplomacy benefits.
    The United States must play a more prominent, more decisive 
role in leading distribution of safe and effective vaccines, 
particularly in the Western Hemisphere. Vaccine delays in the 
Americas will mean economic stagnation in the region, likely 
resulting in more migration to our southern border.
    The Chinese and Russian governments took advantage of a 9-
month window when the United States and the West could not 
provide vaccines to the developing world because of a mix of 
vaccine nationalism, lack of coordination, and disagreement 
over how to distribute the vaccines.
    China has used its global vaccine campaign to advance long-
term foreign policy objectives. The following examples are 
anecdotal but highly believable, and the committee should 
remain vigilant.
    China has allegedly tied its vaccine manufacturing capacity 
and distribution to pushing Huawei-driven ICT solutions in 
countries like Brazil and the Dominican Republic, two allies of 
the United States.
    On the issue of Taiwan, China is accused of pressuring 
Paraguay to recognize the mainland in return for vaccines. 
Similarly, China assured El Salvador of a higher level of 
vaccines, highly likely related to its non-recognition of 
Taiwan.
    The other two countries that comprise the Northern 
Triangle, Guatemala and Honduras, recognize Taiwan and have not 
received the same levels of vaccines from China and, as a 
result, there are credible reports in Honduras and Guatemala 
that if we had only recognized the mainland we would get more 
vaccines and there also seems to be, for some reason, a series 
of vaccine campaigns on border towns bordering El Salvador and 
Guatemala with El Salvador. They seem to be awash in Chinese 
vaccines.
    The good news is that the U.S. has made substantial but 
incomplete progress in reversing the narrative by aggressively 
ramping up its distribution of COVID-19 vaccines globally. We 
have an opportunity because the Chinese- and Russian-funded 
vaccines are just not as good as Western vaccines, so we have a 
chance to close the gap.
    We need to do several things. The first is we need to 
strengthen a coherent interagency response to addressing the 
COVID-19 pandemic in the region. This response should include a 
comprehensive vaccination plan with clear strategies regarding 
vaccine supply logistics, communication, monitoring, and 
evaluation impact.
    Second, the U.S. should move to a 50/50 strategy, where 50 
percent of vaccines are delivered bilaterally and the other 50 
percent of vaccines are delivered multilaterally. Currently, 
the Biden-Harris administration has said we are going to 
deliver 75 percent multilaterally and 25 percent bilaterally. I 
would suggest 50/50, not 75/25.
    Also, the Biden-Harris administration should prioritize 
countries in Latin America and the Caribbean that have not yet 
reached 70 percent national vaccination rates. We still have a 
long way to go in a number of countries.
    Third, the U.S. should directly assist governments in the 
region that still require preparing for national level 
vaccination campaigns.
    Fourth, we need to develop for the future capable regional 
manufacturing platforms so that other countries can help us 
answer the mail on vaccine production in the future.
    Any democratic government is going to prioritize 
Pennsylvania over Paraguay--no offense to Paraguay--just 
because of the political realities and so we are going to just 
need to have more production capacity to respond to this. The 
iron laws of vaccine nationalism are going to be really hard to 
break.
    So, ultimately, we need to find partners. It could be 
Uruguay, it could be Costa Rica--countries that have strong 
rule of law, a respect for democracy, a capable workforce. We 
need additional surge capacity to make vaccines because that 
is, ultimately, the long-term answer to this.
    We need, fifth, public-private partnerships to assist on 
things like pandemic early warning systems. We have a number of 
ways of dealing with early warning, but frankly, we could do 
more. There are new technologies and we should be leveraging 
the private sector.
    Finally, we should be thinking about how we are working 
with partners. That could include Taiwan. That can include 
Canada. That can include Brazil, and we should absolutely be 
leveraging the multilateral institutions that are part of how 
we respond.
    Finally, the U.S. has an opportunity to finish strong on 
solving the COVID-19 pandemic. If countries do not receive 
vaccines from America or our allies they will seek vaccines 
from our strategic competitors.
    Great power competition has come to global health. We 
should commit to achieving widespread immunity in the region 
and prepare for future pandemics. Thank you.
    [The prepared statement of Mr. Runde follows:]

                 Prepared Statement of Daniel F. Runde

    Chairman Kaine, Ranking Member Rubio, and distinguished members of 
the Senate Subcommittee on Western Hemisphere, Transnational Crime, 
Civilian Security, Democracy, Human Rights, and Global Women's Issues, 
thank you for the opportunity to appear before you today to discuss the 
importance of U.S.-led vaccine diplomacy in Latin America and the 
Caribbean.
   brief overview of the impact of covid-19 on latin america and the 
                               caribbean
    The Covid-19 pandemic is arguably the most significant economic and 
social disruption since World War II. In addition to being the moral 
and right thing to do from a public health standpoint, whichever 
country is seen as ``solving'' the Covid-19 vaccine challenge will reap 
enormous public diplomacy benefits. The United States should play a 
more prominent, more decisive role in leading distribution of safe and 
effective vaccines, particularly in Latin America and the Caribbean. 
Given the rise of strategic competitors--China and Russia--the United 
States needs to address global health challenges more effectively. 
Latin America and the Caribbean (LAC) is the most devastated region 
(https://news.harvard.edu/gazette/story/2021/07/how-the-pandemic-has-
affected-latin-america/) by the pandemic in terms of fatality rates and 
negative economic impacts. Latin America and the Caribbean represent 
(https://crsreports.congress.gov/product/pdf/R/R46336) 18.2 percent of 
Covid-19 cases contracted and 31 percent of fatalities globally, both 
far above the region's share of the world's population. Countries 
(https://crsreports.congress.gov/product/pdf/IF/IF11581) with the 
highest number of deaths in the region include Brazil, Mexico, Peru, 
Colombia, and Argentina. Covid-19 has impacted politics (e.g., 
Argentina, Brazil, and Haiti), drastically set back education, and put 
pressure on democratic governance in the region. Critically, vaccine 
delays in the Americas will mean economic stagnation in the region, 
which very likely means more migration to our Southern border.
    The Chinese and Russian governments took advantage (https://
www.economist.com/graphic-detail/2021/04/29/vaccine-diplomacy-boosts-
russias-and-chinas-global-standing) of a 9-month window when the United 
States and the West could not provide vaccines for the developing world 
because of a mix of vaccine nationalism, a lack of coordination, and 
disagreement over how to distribute the vaccines. China sought and 
achieved significant geopolitical benefits from this vacuum. If Russia 
and China can fill a void, they will.
    China, in particular, has used its global vaccine campaigns to 
advance long-term foreign policy objectives, including pushing Huawei-
driven information and communications technology (ICT), coercing 
countries to reduce recognition of Taiwan, and tamping down criticism 
of Uighurs in Xinjiang. The following examples are ``anecdotal but 
highly believable,'' nonetheless this committee should remain vigilant 
of them.
    China has allegedly pressured various governments in Latin America 
and the Caribbean including in Brazil, the Dominican Republic, and 
Paraguay. In the Western Hemisphere, where eight countries still 
recognize Taiwan, China only offers vaccines to those governments that 
recognize the mainland.
    In Brazil, China allegedly tied its vaccine manufacturing capacity 
to the allowance of Huawei to participate in Brazil's 5G network 
(https://www.nytimes.com/2021/03/15/world/americas/brazil-vaccine-
china.html), something that the pro-U.S. Bolsonaro Government had 
assured the Trump administration would not happen. Likewise, after 
initial plans to exclude Huawei from its telecom system, and after 
receiving 20 million doses from China, the Dominican Republic (https://
wng.org/roundups/china-peddles-influence-with-vaccines-1630687161) 
suddenly reversed its position allowed Huawei to participate in its 
telecommunications market.
    On the issue of Taiwan, China is accused of pressuring Paraguay in 
return (https://www.nytimes.com/2021/04/16/world/americas/paraguay-
china-vaccine-diplomacy.html) for vaccines. Similarly, China assured El 
Salvador of a higher level of vaccines, possibly related to its 
position on Taiwan (https://www.as-coa.org/articles/vaccines-reignite-
china-vs-taiwan-debate-latin-america). Guatemala and Honduras (https://
www.ft.com/content/c0717932-0d88-4cea-b55c-ff561ed1f70e), the other 
countries that compose the Northern Triangle, which do recognize 
Taiwan, have not received vaccines from China and do not have the same 
levels of vaccination as El Salvador. Honduras has requested (https://
apnews.com/article/latin-america-honduras-el-salvador-coronavirus-
pandemic-health-ed1e04523bc501a847e8de700d141bdd) that El Salvador 
share surplus Chinese-funded vaccines. It seems that Salvadoran border 
towns are flush with Chinese vaccines sending the signal that ``if 
Guatemala or Honduras would only recognize Mainland China, then 
Guatemala and Honduras would not have such low vaccination rates.'' 
Taiwan, it should be noted, is supporting the development of a new 
vaccine, Medigen, and hopes to share it with the world soon.
    Ensuring the delivery and administration of safe and effective 
vaccines across Latin America and the Caribbean will help solve a 
global pandemic and pay diplomatic dividends for the United States. 
Increasing vaccine efforts in our Hemisphere is a necessary 
demonstration of U.S. leadership and is both a moral and foreign policy 
imperative essential to global health security.
    Over the last 2 years, the United States has made substantial but 
incomplete progress in reversing the narrative by aggressively ramping 
up its distribution of Covid-19 vaccines in partner countries. Chinese-
funded vaccines are seen as less desirable and perceived as less 
effective than Western vaccines, including in the Americas. In 
addition, the World Health Organization has not accepted the Sputnik V 
vaccine due to the Russian Government's refusal to provide data across 
trials and reported side effects.
    However, The U.S. cannot take its foot off the gas and must 
accelerate its efforts to help respond to the pandemic swiftly and 
effectively. This likely means moving from ``75/25'' ``COVAX/bilateral 
distribution'' to ``50/50 ``COVAX/bilateral distribution.'' COVAX's 
efforts to supply and distribute vaccines to the developing world are 
essential but have faced various obstacles (https://www.pmi.org/
learning/publications/pm-network/digital-exclusives/vaccine-rollout). 
COVAX planned to provide 2 billion doses (https://www.gavi.org/
vaccineswork/covax-explained) the end of 2021, but as of November 14, 
it had only delivered 435 million doses. Challenges include supply 
bottlenecks distribution and transportation, infrastructure, and 
meeting timetables and needs of cold chains. The United States should 
ensure that it remains at the forefront of Covid-19 assistance and 
vaccine delivery and that it gets proper ``credit,'' including and 
especially when COVAX delivers U.S. donated vaccines in a country.
    To effectively deliver vaccines, the United States will need to 
work closely with partners such as the private sector, regional 
partners such as Canada and Brazil, allies operating in the region such 
as Taiwan, and multilateral partners (e.g., the Pan-American Health 
Organization (PAHO), the regional office of the WHO, the Inter-American 
Development Bank (IADB), and the World Bank). Covid-19 will require 
multilateral and bilateral actions and significant public-private 
partnerships that respond to the current crisis and endeavor to improve 
global preparedness for future pandemics. The current Covid-19 pandemic 
will likely require routine booster vaccines and continued support in 
delivery efforts, manufacturing, and local healthcare to administer 
vaccines.
     covid-19 pandemic impact and vaccine diplomacy in the western 
                               hemisphere
    Despite significant rates of Covid-19 deaths and cases, the region 
is making positive strides. As of November 13, PAHO reports that 44 
percent of the population of Latin America and the Caribbean is 
vaccinated. Vaccination rates are steadily increasing (https://www.as-
coa.org/articles/timeline-tracking-latin-americas-road-vaccination); 
however, distribution is much higher in some countries compared to 
others. Those who are unvaccinated or have only received one dose of a 
vaccine remain increasingly vulnerable to variants and new waves of the 
virus.
    Countries leading in vaccinations include Chile and Uruguay, which 
have vaccinated 75 percent (https://crsreports.congress.gov/product/
pdf/IF/IF11581) of their populations, and Brazil, which has vaccinated 
close to 60 percent of its population. Meanwhile, Argentina, Ecuador, 
and Panama are not far behind with 50 percent (https://www.cnbc.com/
2021/10/06/latin-america-and-caribbean-islands-have-vaccinated-just-
37percent-of-populations-against-covid-who-officials-say.html) 
vaccination rates. However, there is a significant disparity between 
countries, as Guatemala, Haiti, Jamaica, Nicaragua, and St. Vincent and 
the Grenadines have fully vaccinated less than 20 percent (https://
crsreports.congress.gov/product/pdf/IF/IF11581) of their populations. 
However, Haiti is most concerning in the region, having vaccinated less 
than 1 percent (https://www.cnbc.com/2021/10/06/latin-america-and-
caribbean-islands-have-vaccinated-just-37percent-of-populations-
against-covid-who-officials-say.html) of its population. We will not 
have widespread vaccination, particularly in some Central American 
countries and small Caribbean Island states, such as Jamaica and Haiti, 
until 2022 or even 2023. The U.S. needs to help close this gap.
    Covid-19 has markedly impacted economic and political conditions in 
the region. For example, the IMF reported that 2020 saw a 7 percent 
(https://crsreports.congress.gov/product/pdf/IF/IF11581) economic 
contraction in LAC, the region's largest recorded economic contraction 
in history. This contraction impacted the financial resources available 
to regional countries' governments and, thus, their ability to 
purchase/distribute vaccines and respond to pressing social needs 
aggravated by Covid-19. Economic declines were even more severe for 
Caribbean countries heavily dependent on tourism, some of which saw 
more than 15 percent (https://crsreports.congress.gov/product/pdf/IF/
IF11581) economic declines in 2020. A report from March 2021 by the 
U.N. Economic Commission for Latin America and the Caribbean found that 
in 2020: approximately 22 million (https://crsreports.congress.gov/
product/pdf/IF/IF11581) people in Latin America moved below the poverty 
line, and the poverty rate rose 3.2 percent (https://
crsreports.congress.gov/product/pdf/IF/IF11581) from levels recorded in 
2019. In addition, losses in education will likely result in an 
economic loss of 16 percent of regional GDP (https://
blogs.worldbank.org/education/covid-19-and-learning-crisis-latin-
america-and-caribbean-how-can-we-prevent-tragedy) or $1.7 trillion. 
Covid-19 also exacerbated existing political unrest (https://
crsreports.congress.gov/product/pdf/IF/IF11581). Any vaccination 
strategy should complement economic initiatives that will help the 
region to recover from the pandemic. This economic plan must include 
the digitalization of the region's countries to help reduce the digital 
divide that Covid-19 accelerated. The U.S. should ensure that it helps 
close the digital divide before others close that divide.
                   vaccine initiatives: united states
    The U.S. is currently outpacing China (https://
www.atlanticcouncil.org/content-series/aviso-latam-covid-19/aviso-
latam-covid-19-october-29-2021/) regarding Covid-19 vaccine donations 
to LAC and must continue this momentum. On June 21, 2021, the Biden 
administration announced (https://www.whitehouse.gov/briefing-room/
statements-releases/2021/06/21/fact-sheet-biden-harris-administration-
announces-allocation-plan-for-55-million-doses-to-be-shared-globally/) 
the distribution of 80 million vaccine doses to developing countries, 
75 percent via COVAX, co-led by the Coalition for Epidemic Preparedness 
Innovations (CEPI), the Global Vaccine Alliance (GAVI), WHO, and United 
Nations Children's Fund (UNICEF), and 25 percent to be distributed 
bilaterally from the U.S. Government to partner countries.
    As of October 2021, the U.S. Agency for International Development 
has distributed over $482 million (https://www.usaid.gov/sites/default/
files/documents/USAID_COVID-19_LAC_Response_Fact_Sheet_2_FINAL.pdf) of 
total funding for Covid-19 response in Latin America and the Caribbean. 
This is part of a larger $9.3 billion in FY 2021 used in over 120 
countries to fight against Covid-19.
    The State Department reports that since mid-October 2021, the U.S. 
has delivered more than 44 million (https://crsreports.congress.gov/
product/pdf/IF/IF11581) doses of Covid-19 vaccines to countries in the 
Western Hemisphere (Canada included). Countries that have received the 
most doses include Mexico with 7.5 million (https://
crsreports.congress.gov/product/pdf/IF/IF11581), Colombia with 6 
million (https://crsreports.congress.gov/product/pdf/IF/IF11581), 
Guatemala with 4.5 million (https://crsreports.congress.gov/product/
pdf/IF/IF11581), and Argentina with 3.5 million (https://
crsreports.congress.gov/product/pdf/IF/IF11581). Other U.S. vaccine 
initiatives in LAC include President Biden's pledge in April 2021 of 60 
million (https://www.as-coa.org/articles/tracker-us-vaccine-donations-
latin-america) vaccines to be donated through COVAX, 20 million 
(https://www.as-coa.org/articles/tracker-us-vaccine-donations-latin-
america) of which were designated for LAC. Furthermore, in June 2021, 
Biden expanded these efforts by pledging to purchase and donate 500 
million (https://www.as-coa.org/articles/tracker-us-vaccine-donations-
latin-america) Pfizer doses for low- and lower-middle-income countries 
(such as Bolivia, El Salvador, Honduras, and Nicaragua). Over the next 
2 years, these doses will be distributed via COVAX (https://www.as-
coa.org/articles/tracker-us-vaccine-donations-latin-america).
      vaccine initiatives: multilateral organizations (non-covax)
PAHO
    PAHO has helped countries in LAC gain access to Covid-19 vaccines 
through the COVAX Facility, with 22 countries (https://
crsreports.congress.gov/product/pdf/IF/IF11581) in the region having 
signed agreements to receive vaccines via the facility.
World Bank
    The World Bank has provided $725 million (https://
www.worldbank.org/en/who-we-are/news/coronavirus-covid19/world-bank-
support-for-country-access-to-covid-19-vaccines) in operations to 
support the rollout of Covid-19 vaccines in Latin America and the 
Caribbean. Since April 2021, the World Bank has provided $4.6 billion 
(https://www.worldbank.org/en/news/factsheet/2020/04/02/world-bank-
response-to-covid-19-coronavirus-latin-america-and-caribbean) in Covid-
related IBRD/IDA operations. These funds will be crucial in helping 
resolve problems that inhibit or complicate access to and distribution 
of vaccines, such as supply chain and delivery issues (https://
www.worldbank.org/en/news/factsheet/2020/04/02/world-bank-response-to-
covid-19-coronavirus-latin-america-and-caribbean).
Inter-American Development Bank
    In December 2020, the IDB announced the allocation of $1 billion 
(https://www.iadb.org/en/news/idb-mobilizes-1-billion-covid-19-vaccine-
financing-latin-america-and-caribbean) to countries in LAC to 
facilitate the acquisition and distribution of Covid-19 vaccines. IDB 
support will occur primarily in three areas (https://www.iadb.org/en/
news/idb-mobilizes-1-billion-covid-19-vaccine-financing-latin-america-
and-caribbean): acquisition of vaccines via multilateral collaboration 
or singular country efforts; strengthening of institutions to bolster 
the development of vaccine deployment mechanisms; investment to build 
capacity for immunization/fund operational costs. In March 2021, the 
IDB introduced an instrument (https://www.iadb.org/en/news/idb-support-
latin-america-and-caribbean-negotiate-faster-access-vaccines) to 
facilitate LAC countries' access to Covid-19 vaccines, allowing them to 
better compete for vaccines. The instrument helps resolve indemnity 
obligations (https://www.iadb.org/en/news/idb-support-latin-america-
and-caribbean-negotiate-faster-access-vaccines)--a pivotal barrier to 
reaching consensus in many vaccine contract negotiations--and introduce 
regulatory (https://www.iadb.org/en/news/idb-support-latin-america-and-
caribbean-negotiate-faster-access-vaccines) reforms to simplify the 
purchase and delivery of vaccines.
                 vaccine initiatives: russia and china
    China and Russia developed vaccines that were available earlier 
internationally and advertised as ``cheaper'' and easier to transport 
and store than Western mRNA vaccines that require ultra-cold storage. 
Although first to launch global vaccine campaigns, China and Russia 
vaccine diplomacy efforts have not been entirely successful (https://
time.com/6086028/chinese-russian-covid-19-vaccines-geopolitics/) and 
allow an opportunity for the U.S. to retake the vaccine diplomacy lead.
Russia
    Russia initially approved the Sputnik V vaccine (https://
www.nature.com/articles/d41586-021-01813-2), a two-dose viral vaccine, 
in August 2020. Currently, Russia has overpromised, and underdelivered 
(https://www.as-coa.org/articles/vaccine-manufacturing-race-russia-
trips) Sputnik V contracted to Latin America. For example, due to 
production delays, Russia is not completing contracts, notably in 
Argentina, Mexico, and Peru, which together are waiting on 
approximately 20 million doses. Additionally, many of the shipments of 
the Russian vaccines delivered have only been able to provide one of 
the two doses required, leaving people with limited immunity. 
Nonetheless, Russia is still moving its vaccination campaign forward--
on October 14, the Russian Direct Investment Fund signed an agreement 
with the (https://www.elfinanciero.com.mx/nacional/2021/10/14/cerrado-
la-vacuna-sputnik-v-se-envasara-en-mexico/) Mexican Government.
China
    China has pledged to deliver 2 billion vaccine doses (https://
apnews.com/article/2020-tokyo-olympics-joe-biden-health-coronavirus-
pandemic-coronavirus-vaccine-c2712b56c0464ec0b95c41cd18cc38dd) 
worldwide by the end of 2021--China has currently sold 1.4 billion 
doses, donated 99 million, and delivered 1.1 billion doses (https://
bridgebeijing.com/our-publications/our-publications-1/china-covid-19-
vaccines-tracker/). With moderate success, China has reworked its image 
from being the origin of the pandemic to helping other countries 
respond and recover with a significant effort in Latin America and the 
Caribbean. For example, Brazil has contracted 160 million vaccines from 
China. However, Chinese-funded vaccines have much lower efficacy rates 
than western vaccines like Moderna and Pfizer. Chinese-funded vaccines 
ranged from 51 to 79 percent effective (https://www.nature.com/
articles/d41586-021-02796-w) compared to 90 percent and higher efficacy 
ratings of Moderna and Pfizer. However, when there is no other option, 
countries will accept Chinese-funded vaccines to ensure that people 
have some immunity rather than none. Chinese-funded vaccines are stored 
at standard refrigeration, which is much easier for developing 
countries to manage in supply chain infrastructure. China is leading 
vaccination campaigns in Chile, the Dominican Republic, and Ecuador and 
boasts a significant presence in Argentina.
              recommendations for continued and increased 
                u.s. engagement in lac vaccine diplomacy
    The United States has an opportunity to ``finish'' strong on 
``solving'' Covid-19. The U.S. should create partnerships to fix 
longer-term systemic problems in the region related to global 
pandemics. Even countries that accept non-U.S. vaccines will need 
continued funding and technical assistance (https://www.nytimes.com/
2021/03/16/world/brazil-needs-vaccines-and-china-is-benefiting.html) in 
delivering and administering vaccines and booster shots to populations.
    First, the U.S. should increase donations to Latin America and the 
Caribbean. The U.S. should also make arrangements for the hundreds of 
thousands of private U.S. citizens abroad to access vaccines.
    Second, the United States should strengthen a coherent interagency 
response to address the Covid-19 pandemic. This response should include 
a comprehensive vaccination plan, with clear strategies regarding 
vaccine supply logistics, communication, monitoring and evaluation, and 
impact. All distribution, progress, and impact data should be defined, 
transparent and available. USAID would be in charge in partnership with 
the Department of State and HHS. The U.S. can build on existing 
strategies and supply chain operations associated with existing U.S. 
global health programs such as PEPFAR (https://www.state.gov/pepfar/), 
PMI, and other vaccination programs.
    Third, the U.S. should move to a 50/50 strategy where 50 percent of 
vaccines are delivered bilaterally, and the other 50 percent of 
vaccines are delivered multilaterally. Multilateral initiatives like 
COVAX are a necessary component of the Covid-19 response, but it is not 
the most efficient mechanism available. Within the bilateral 
allocation, the Biden administration and Congress should prioritize 
countries in Latin America and the Caribbean that have not reached 70 
percent national vaccination rates, provide more funding towards the 
region, and monitor and make sure doses are procured, delivered, and 
administered on the promised timelines. There could also be an 
opportunity to offer U.S. mRNA booster shots to bolster less effective 
Sputnik V and Chinese government-funded vaccines. We should take full 
advantage of Russia's supply chain challenges.
    Fourth, the U.S. should directly assist those LAC governments that 
still require it with preparing for national-level vaccination 
campaigns. This includes:

   Helping determine what steps each government can take to 
        expand access to personal protective equipment (PPE), treatment 
        protocols, contact tracing, access to vaccines, and public 
        health measure to reduce further transmission;

   Identifying the requirements of each country to execute 
        necessary cold chains, and if possible, enable manufacturing 
        capacity. This includes following vaccines through the ``last 
        mile'' and avoiding scenarios where doses may expire. For 
        example, preventing situations such as what happened in Haiti, 
        where the Haitian Government announced they would return 
        thousands of Moderna vaccine doses to the United States 
        (https://www.bloomberg.com/news/articles/2021-10-13/haiti-to-
        send-back-expiring-u-s-donated-moderna-vaccines?sref=VEVHJ4cS) 
        that were close to expiring; and

   Working with civil society actors (community organizations, 
        health focused organizations) to engage with local perspectives 
        that are essential to understand in-county health systems and 
        optimize vaccine distribution campaigns.

    Fifth, the United States needs to help create regional 
manufacturing platforms for future pandemics in LAC countries with a 
strong rule of law, a commitment to democracy, and an educated 
workforce, such as Costa Rica and Uruguay. Any democratically elected 
leader in the United States will prioritize vaccine distribution to 
Pennsylvania over Paraguay. Therefore, we need small, capable countries 
who can quickly ``answer the mail'' on meeting their vaccine 
requirements and then export to the region and burden share. We need a 
broader ``culture of immunization'' in the region for such 
manufacturing platforms to work.
    Sixth, the United States should leverage existing multilateral 
architecture, namely COVAX and PAHO, to reinforce vaccine supply 
chains. While not sufficient on their own, the efforts of COVAX, the 
World Bank, the IDB, and PAHO are necessary aspects of the global 
vaccination effort. The U.S. should play a decisive leadership role in 
these multilateral organizations. It ought to strengthen coordination 
amongst multilateral actors and help facilitate an implementation plan 
to coordinate both the USG and the multilateral system.
    The United States should leverage PAHO's technical support and the 
PAHO Revolving Fund for vaccines and Strategic Fund. The U.S. should 
provide $100 million to cover the costs of implementing those measures. 
It should also use PAHO and COVAX vaccine facilities (https://
www.reuters.com/business/healthcare-pharmaceuticals/brazil-argentina-
tapped-make-mrna-vaccines-latin-america-2021-09-21/) to ensure the 
fastest possible acquisition of vaccines.
    Seventh, as part of an expanded bilateral effort, the United States 
must engage more robustly with the private sector, universities, city 
governments (especially mayors) and people to people networks (e.g. 
networks of trained emergency personnel throughout the region) through 
public-private partnerships (PPPs) (https://www.csis.org/analysis/
beyond-covax-importance-public-private-partnerships-covid-19-vaccine-
delivery-developing) to amplify reach and execution, complement 
multilateral efforts, and demonstrate additional U.S. leadership in 
vaccine distribution and administration in Latin America and the 
Caribbean. Organizations such as the Pan-American Development 
Foundation are well positioned to broker such partnerships across the 
hemisphere. Operation Warp Speed (https://www.gao.gov/products/gao-21-
319) proved what can be accomplished to create and manufacture safe and 
effective vaccines. We need an ``Operation Warp Speed'' focused on the 
distribution of vaccines in developing countries. U.S. agencies, 
specifically, USAID should identify priority local gaps for vaccination 
and build in-country and local vaccination public-private partnerships.
    More immediately, the Administration should partner with U.S. 
companies with significant workforces throughout Latin America to 
protect their employees as a safeguard against more economic 
devastation. The U.S. should also work with Pfizer and Moderna to 
increase procurement for Latin America and the Caribbean. For example, 
facilitate partnerships such as Pfizer's recent commitment (https://
www.mcclatchydc.com/news/coronavirus/article253746158.html) to partner 
with a Brazilian biopharmaceutical company, Eurofarma Laboratorios SA, 
to mass-produce doses in the region.
    In the long-term, public-private partnerships can assist with the 
supply and equitable distribution of vaccinations. The United States 
should also encourage and implement private-sector innovations to 
update outdated systems regarding the supply and distribution of 
vaccines. For example, applying better cold chain and storage 
technologies to strengthen transport and storage capacity in places 
that lack adequate infrastructure. PPP's are needed to bolster existing 
early-warning systems (https://www.foreignaffairs.com/articles/united-
states/2020-07-14/predicting-next-pandemic) through innovative data 
collection mechanisms (https://www.medicalnewstoday.com/articles/how-
google-search-data-can-predict-covid-19-outbreaks).
    To conclude, we cannot fight something with nothing. If countries 
do not have vaccines from the U.S. or our allies, they will seek 
vaccines from our strategic competitors. Great power competition has 
come to global health, and we should commit to achieving widespread 
immunity in the region and prepare for future pandemics.

    Senator Kaine. Thank you very much.
    Mr. Restrepo.

 STATEMENT OF DAN RESTREPO, SENIOR FELLOW, CENTER FOR AMERICAN 
                    PROGRESS, WASHINGTON, DC

    Mr. Restrepo. Chairman Kaine, Senator Rubio, thank you very 
much for this opportunity.
    As has been well established so far in this hearing, it is 
difficult to overstate the importance of U.S. vaccine diplomacy 
in Latin America and the Caribbean. In fact, one can argue that 
through its vaccine diplomacy the Biden administration has 
engaged in the most important U.S. strategic initiative in the 
Americas in decades.
    To understand why, it is critical to step back and examine 
the cascading crises that faced Latin America and the Caribbean 
before COVID-19, how the pandemic exacerbated them, and what it 
all means for U.S. interests.
    In early 2020, the countries of Latin America and the 
Caribbean were amidst a historic dislocation of vulnerable 
populations, home to some of the highest levels of citizen 
insecurity in the world, awash in mis- and disinformation, both 
homegrown and state actor generated, undermining the region's 
basic social fabric, buffeted by the intensifying effects of 
the climate crisis, plagued by multiple governance failures 
and, worse, characterized by corruption, populism, and 
authoritarianism.
    Perhaps most fundamentally concerning, the region was 
suffering a profound crisis in confidence in democracies' 
ability to deliver at scale for the people of the Americas. In 
2018, fewer than half of all Latin Americans viewed democracy 
as the preferred form of government and only 24 percent 
reported being satisfied with their democracy, and then COVID-
19 hit.
    To date, the pandemic has claimed at least a million and a 
half lives across the region, representing more than 30 percent 
of all worldwide reported deaths in a region with 8 percent of 
the world's population, triggered the most severe regional 
economic contraction in the world and the slowest economic 
recovery.
    It plunged 22 million people into poverty and 8 million 
into extreme poverty, and that was only in the last 9 months of 
2020. It exacerbated the irregular movement of people 
throughout the hemisphere.
    So the nearly 50 million doses of U.S.-manufactured COVID-
19 vaccines distributed to date by the United States is sound 
policy on numerous levels. It is a vital component of any 
effective strategy to mitigate the unprecedented movement of 
people that I just mentioned.
    It is an investment in the U.S. economy and, particularly, 
our export sector, given that fully a third of U.S. exports are 
to countries in the Western Hemisphere.
    It is also pretty sound basic public health policy, given 
that most foreign visitors to the United States, particularly 
relevant as we open up international travel, are from our 
closest neighbors.
    Above all else, it is better application of U.S. power for 
geopolitical benefit. It is the best possible demonstration 
project that democracy can deliver for the people of the 
Americas.
    It draws a stark contrast with China's attempts, which we 
have been discussing this morning, to use vaccine diplomacy for 
its own ends, particularly because the superior efficacy of 
U.S.-manufactured vaccines has made the U.S. the increasingly 
sought after partner of choice, including by countries that 
were high-profile recipients of initial Chinese and, to a 
lesser extent, Russian largesse.
    Because they are delivered without strings, U.S.-
manufactured vaccines also underscore a steady confidence in 
the power of innovation and collaboration, two characteristics 
that made those vaccines possible, but also they draw a 
critical distinction between what is great about the United 
States and what fuels China's rise.
    In short, helping end the COVID-19 pandemic, making 
economic recovery more possible, and instilling greater faith 
in the promise of democracy across the Americas amounts to an 
essential historic demonstration of U.S. leadership in the face 
of a region and regional tumult likely to continue for years to 
come.
    Thank you very much. I look forward to your questions.
    [The prepared statement of Mr. Restrepo follows:]

              Prepared Statement of Daniel A. Restrepo \1\

    It is difficult to overstate the importance of U.S. vaccine 
diplomacy across Latin America and the Caribbean. To understand why 
this is true, it is important to take a step back and understand the 
broader context of the cascading set of crises affecting the region.
    Front of mind among these, of course, is the unprecedented COVID-19 
pandemic. Since it arrived in Latin America and the Caribbean, the 
pandemic has claimed at least 1.5 million lives, representing more than 
30 percent of all reported deaths world-wide for a region with 8 
percent of the world's population.\2\ At various points in the past 20 
months, multiple countries throughout the region have laid claim to the 
dubious distinction of leading the world in infection and mortality 
rates. We will not soon forget scenes of bodies piling up on the 
streets of Guayaquil, Ecuador nor forget stories of entire cities in 
Brazil running out of bottled oxygen.
    The pandemic's economic fallout has, in many ways, been even more 
severe. In 2020, Latin America and the Caribbean endured, according to 
the World Bank, the most significant economic contraction of any region 
in the world, with regional GDP contracting by 7 percent.\3\ The first 
9 months of the pandemic saw 22 million people fall into poverty, 
including 8 million into extreme poverty--whipping out, respectively, 
12 and 20 years of progress, on these fronts.\4\ Latin America and the 
Caribbean has also been among the slowest regions of the world to 
bounce back for its COVID-onset economic contraction. Economic growth 
in 2021 is expected to be 6.3 percent but regional GDP is not expected 
to be above pre-pandemic levels until 2023 at the earliest.\5\ Given 
the pandemic's persistence, the economic wreckage continues to pile up 
and millions more will have slipped into poverty and extreme poverty 
during this calendar year.
    Although the region's overall COVID profile has begun to improve 
markedly, the region is also being buffeted by the accelerating effects 
of the climate crisis and by multiple governance failures--and worse--
fueled by a plague of corruption, populism, and authoritarianism. The 
region is also seeing an historic displacement of vulnerable 
populations both within and across international borders, including:

   100,000s of Haitians dislocated by the 2010 earthquake; \6\

   More than 5.9 million Venezuelans driven from their country 
        since 2015; \7\

   Nicaraguans fleeing an authoritarian regime; \8\

   Haitians dislocated by 2021 earthquake and post-Moise 
        assassination political tumult; \9\

   Central Americans uprooted by Ida and Iota that befell them 
        on top of COVID and the historically predatory conditions under 
        which they live; \10\ and

   Mexicans subject to spiraling violence and loss of economic 
        opportunity.\11\

    COVID's impact, however, is perhaps most troubling for U.S. 
interests in the Western hemisphere because it hit at a time when 
democracy was under its most significant strain since the region's 
post-Cold War democratic transformation and its 2001 embrace, through 
the Inter-American Democratic Charter, of a shared responsibility to 
protect it.
    In 2020, less than half of all Latin Americans, 49 percent, 
according to Latinobarometro, the region's leading public opinion 
survey, viewed democracy as the preferred form of government and only 
25 percent report being satisfied with their democracy.\12\ Although 
some take solace in the fact that those levels were virtually unchanged 
from 2018, which saw 48 percent preference for democracy and 24 percent 
satisfaction with democracy, such ``stability'' should be cold 
comfort.\13\ A steady downward trend has perhaps temporarily been 
arrested, but a fundamental crisis of confidence in democracy still 
prevails, opening up ample space for populists--of the Left and the 
Right--to fill with divisive rhetoric, empty promises, and nostalgia 
for oftentimes illusory, by-gone, golden eras.
    The reasons behind this loss of faith are multi-factor, but a clear 
thread is a belief that democracy is incapable of addressing people's 
basic needs with pronounced majorities believing basics like education 
(58 percent), healthcare (64 percent) and justice (77 percent) are not 
equitably available.\14\ Only majorities in the curious trio of Costa 
Rica, Uruguay, and Nicaragua view these three basic services as being 
equitably available.\15\
    It is in the context of this complex backdrop that, in my 
estimation, it is no exaggeration to say that for the past several 
months, away from the glare of camera lights, the Biden administration 
through its vaccine diplomacy has been executing the most important 
U.S. geostrategic initiative in the Americas in decades with lasting 
implications for democracy in the region--and for U.S. democracy here 
at home.
    Since President Biden first prioritized our closest neighbors for 
distribution of U.S.-manufactured COVID-19 vaccines, the United States 
has distributed nearly 50 million vaccine doses throughout the 
Americas,\16\ including more than 10 million via COVAX.\17\
    This clear prioritization of the Western hemisphere is sound policy 
on numerous levels. It is a vital component of any effective strategy 
to mitigate the unprecedented irregular movement of people throughout 
the region triggered, in no small measure, by the impacts of COVID-19. 
It is good for our economy and for export-supported sectors, in 
particular, given that one-third of all U.S. exports go to countries in 
the Western hemisphere.\18\ It has been an excellent, basic public 
health policy given that most foreign visitors to the United States 
originate in our closest neighbors.
    It has, however, been an even better application of U.S. power with 
clear geopolitical benefits.
    It demonstrates the U.S. competitive advantages compared to China 
and unquestionably advances U.S. interests, as helping governments put 
vaccines in arms, turn the tide on COVID-19, and bolster economic 
recovery is the best possible demonstration project that democracy can 
deliver for the people of the Americas.
    The efficacy of U.S.-manufactured vaccines--made possible by 
international and public-private collaboration--also provides a stark 
contrast with China's much-touted vaccine diplomacy. Although China--
and to a lesser extent Russia--enjoyed ``first-mover'' advantages 
distributing vaccines across the region before the United States and 
doing so with more emphasis on making headlines than delivering impact, 
Chinese and Russian vaccines have proven far less effective than their 
U.S.-manufactured counterparts.\19\ As a result, they have been 
increasingly less sought-after with countries that were high-profile 
recipients of Chinese and/or Russian largesse earlier this year turning 
to the United States as the partner of choice.
    That U.S. vaccines are delivered with no strings also sends a 
powerful, albeit indirect, message. It underscores a confidence in the 
power of innovation and openness to collaboration, two characteristics 
that not only made the highly effective, U.S.-manufactured vaccines 
possible, but which also draw perhaps the most critical distinction 
between the power of the American experiment writ large and that which 
fuels China's rise.
    Finally, shoring up faith in democracy in the Americas is not just 
good for the above stated reasons. Nor does it simply advance abstract 
U.S. interests abroad. It is also important for what it portends for 
the interplay between a crisis of faith in democracy across the 
Americas and its effects on U.S. democracy considering the deep 
interconnection that binds the United States to the rest of the 
countries of the Americas.
    As it has done with so many other pre-existing conditions, COVID-19 
has laid bare a dark underside of interconnection in the Americas. Over 
the course of the past 9 months lies and distortions--communicated in 
Spanish and emanating from Latin America--have fueled vaccine hesitancy 
among U.S. Latinos.\20\ A similar, robust, negative feedback loop 
exists around mis- and disinformation campaigns in and from the region 
fueling skepticism in democracy--there and here--via platforms like 
WhatsApp \21\ and YouTube.\22\ Platforms on which U.S. Latinos over-
index and which are falling short in countering Spanish-language 
propaganda.\23\ As a result, the more the United States can do to shore 
up democracy across Latin America and the Caribbean, the more it will 
do to shore up democracy at home as well.
    Aligning the United States with the democratic aspirations of the 
approximately 600 million individuals with whom we share the Americas, 
of course, does not end with vaccines. It requires using the full range 
of U.S. policy tools to support peaceful, prosperous, and resilient 
communities throughout the Americas. But helping end the COVID-19 
pandemic, making economic recovery more possible, and instilling 
greater faith in the promise of democracy across the Americas 
nonetheless amounts to an essential, historic step forward in the face 
of regional tumult likely to continue for years to come.

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

    \1\ The views reflected in this testimony are my personal views and 
do not represent the views of any institution with which I am or have 
been affiliated.
    \2\ In Focus, ``Latin America and the Caribbean: Impact of COVID-
19,'' Congressional Research Service, November 15, 2021 available at 
IF11581.pdf (fas.org) (https://sgp.fas.org/crs/row/IF11581.pdf).
    \3\ International Monetary Fund, Regional Economic Outlook Western 
Hemisphere: A Long and Winding Road to Recovery, October 2021, 
available at Regional Economic Outlook for Western Hemisphere, October 
2021 (imf.org) (https://www.imf.org/en/Publications/REO/WH/Issues/2021/
10/21/Regional-Economic-Outlook-October-2021-Western-Hemisphere).
    \4\ U.N. Economic Commission for Latin America and the Caribbean, 
``Social Panorama of Latin America,'' March 2021, available at Pandemic 
Prompts Rise in Poverty to Levels Unprecedented in Recent Decades and 
Sharply Affects Inequality and Employment--Press Release--Economic 
Commission for Latin America and the Caribbean (cepal.org) (https://
www.cepal.org/en/pressreleases/pandemic-prompts-rise-poverty-levels-
unprecedented-recent-decades-and-sharply-affects).
    \5\ U.N. Economic Commission for Latin America and the Caribbean, 
``The recovery paradox in Latin America and the Caribbean. Growth amid 
persisting structural problems: inequality, poverty and low investment 
and productivity,'' July 8, 2021 available at Growth in Latin America 
and the Caribbean in 2021 Will Not Manage to Reverse the Adverse 
Effects of the Pandemic--Press Release--Economic Commission for Latin 
America and the Caribbean (cepal.org) (https://www.cepal.org/en/
pressreleases/growth-latin-america-and-caribbean-2021-will-not-manage-
reverse-adverse-effects).
    \6\ Jacqueline Charles, ``In aftermath of Haiti's 2010 earthquake, 
many still face immigration uncertainty,'' Miami Herald, January 13, 
2021 available at Haitian immigrants who fled 2010 earthquake face 
uncertainty--Miami Herald (https://www.miamiherald.com/news/nation-
world/world/americas/haiti/article248450275.html).
    \7\ Inter-Agency Coordination Platform for Refugees and Migrants 
from Venezuela available at Home--R4V (https://www.r4v.info/en).
    \8\ Alvaro Murillo, ``Soaring numbers of Nicaraguans seek refuge in 
Costa Rica amid domestic crackdown,'' Reuters, August 10, 2021 
available at Soaring number of Nicaraguans seek refuge in Costa Rica 
amid domestic crackdown--Reuters (https://www.reuters.com/world/
americas/soaring-number-nicaraguans-seek-refuge-costa-rica-amid-
domestic-crackdown-2021-08-11/).
    \9\ Lisa Deaderick, ``A perfect storm of crises and instability 
leading Haitian migrants to seek U.S. asylum,'' San Diego Tribune, 
September 26, 2021 available at A perfect storm of crises and 
instability leading Haitian migrants to seek U.S. asylum--The San Diego 
Union-Tribune (sandiegouniontribune.com) (https://
www.sandiegouniontribune.com/columnists/story/2021-09-26/a-perfect-
storm-of-crises-and-instability-leading-haitian-migrants-to-seek-u-s-
asylum).
    \10\ Dan Restrepo, ``Central Americans Are Fleeing Bad 
Governments,'' Foreign Affairs, March 5, 2021 available at Central 
Americans Are Fleeing Bad Governments--Foreign Affairs (https://
www.foreignaffairs.com/articles/central-america-caribbean/2021-03-05/
central-americans-are-fleeing-bad-governments).
    \11\ Kirk Semple, ``Violence Drives Swell in Mexican Migration,'' 
New York Times, December 7, 2019 available at Violence Drives a Swell 
in Mexican Migration--The New York Times (nytimes.com) (https://
www.nytimes.com/2019/12/07/world/americas/mexico-border-migration-
asylum.html).
    \12\ Latinobarometro, Latinobarometro Report 2021, available at 
Latinobarometro (https://www.latinobarometro.org/lat.jsp).
    \13\ Latinobarometro, Latinobarometro Report 2021, available at 
Latinobarometro (https://www.latinobarometro.org/lat.jsp).
    \14\ Latinobarometro, Latinobarometro Report 2021, available at 
Latinobarometro (https://www.latinobarometro.org/lat.jsp).
    \15\ Latinobarometro, Latinobarometro Report 2021, available at 
Latinobarometro (https://www.latinobarometro.org/lat.jsp).
    \16\ Chase Harrison, ``Tracker: U.S. Vaccine Donations to Latin 
America,'' AS/COA, November 3, 2021 available at Tracker: U.S. Vaccine 
Donations to Latin America--AS/COA (as-coa.org) (https://www.as-
coa.org/articles/tracker-us-vaccine-donations-latin-america).
    \17\ Chase Harrison, ``Tracker: U.S. Vaccine Donations to Latin 
America,'' AS/COA, November 3, 2021 available at Tracker: U.S. Vaccine 
Donations to Latin Americ--AS/COA (as-coa.org) (https://www.as-coa.org/
articles/tracker-us-vaccine-donations-latin-america).
    \18\ Office of the United States Trade Representative, Countries & 
Regions, available at Countries & Regions--United States Trade 
Representative (ustr.gov) (https://ustr.gov/countries-regions).
    \19\ Sui-Lee Wee, ``They Relied on Chinese Vaccines. Now They're 
Battling Outbreaks.,'' New York Times, June 22, 2021 available at They 
Relied on Chinese Vaccines. Now They're Battling Outbreaks--The New 
York Times (nytimes.com) (https://www.nytimes.com/2021/06/22/business/
economy/china-vaccines-covid-outbreak.html).
    \20\ Nada Hassanein, ``'You can't trust the government': Spanish-
speaking social media spreads COVID-19 vaccine disinformation, adds to 
hesitancy,'' USA Today, March 29, 2021 available at COVID-19 
'infodemic': Social media in Spanish spreads myths, hoaxes 
(usatoday.com) (https://www.usatoday.com/story/news/health/2021/03/29/
covid-19-vaccine-infodemic-social-media-spanish-disinformation-
coronavirus/4592379001/).
    \21\ Sam Sabin, ``Hispanic Adults Use WhatsApp More Than the 
General Public. Disinformation Campaigns Are Targeting That 
Vulnerability,'' Morning Consult, October 30, 2020 available at 
Hispanic Adults Use WhatsApp More Than the General Public. 
Disinformation Campaigns Are Targeting That Vulnerability--Morning 
Consult (https://morningconsult.com/2020/10/30/hispanic-adults-use-
whatsapp-more-than-the-general-public-disinformation-campaigns-are-
targeting-that-vulnerability/).
    \22\ ``2021 Hispanic Digital Fact Pact,'' H Code available at 
DocSend (https://hcode.docsend.com/view/ni6ftqnh4uwtbwkj/d/
azgd6a593i9nkqca).
    \23\ Stephanie Valencia, ``Misinformation online is bad in English. 
But it's far worse in Spanish,'' Washington Post, October 28, 2021 
available at Social media misinformation is bad in English. But it's 
far worse in Spanish.--The Washington Post (https://
www.washingtonpost.com/outlook/2021/10/28/misinformation-spanish-
facebook-social
-media/).

    Senator Kaine. Thank you so much.
    Dr. Castro.

 STATEMENT OF DR. ARACHU CASTRO, DIRECTOR OF THE COLLABORATIVE 
   GROUP FOR HEALTH EQUITY IN LATIN AMERICA [CHELA], TULANE 
                  UNIVERSITY, NEW ORLEANS, LA

    Dr. Castro. Thank you, Mr. Chairman, Tim Kaine, and Ranking 
Member Marco Rubio for inviting me to testify today. My 
comments complement the written statement that I submitted 
yesterday.
    The pandemic continues to create great human suffering in 
Latin America and the Caribbean, where an estimated 2.2 million 
people have died of COVID-19. This includes both reported and 
an estimate of under reported deaths.
    Although more men than women have died of COVID, not 
included in these mortality statistics are the thousands who 
have died due to the disruption of essential health services 
such as women of reproductive age, children, and adolescents.
    Additionally, last year the pandemic caused the worst 
economic contraction in more than a century, deepening social 
and economic inequalities and increasing poverty. The 
underfunding of scientific and technological research and 
development in most countries in the region is at the root of 
the limited capacity to develop novel vaccines and the uneven 
rollout of vaccines.
    Despite a regional vaccine procurement mechanism since 
1979, the Pan American Health Organization's Revolving Fund for 
Vaccine Procurement, most countries negotiated access to COVID-
19 vaccines last year through bilateral agreements with vaccine 
developers from the United States, Europe, Russia, and China.
    At the same time, most also participated in the COVAX 
mechanism whose procurement agent in the Americas is the 
Revolving Fund. Although half of the population is fully 
vaccinated, significant differences exist between countries.
    The inequity behind the distribution of vaccines is 
primarily explained by the type of participation in the COVAX 
mechanism, which has been severely affected by the 
concentration of doses in high income countries and the 
interruption of vaccine export from the largest manufacturer of 
vaccines in the world, located in India.
    As of last Friday, among the 10 countries that participate 
in COVAX as donor dependent, only 26 percent of the population 
is fully vaccinated. Coverage ranges from less than 1 percent 
in Haiti to 61 percent in El Salvador.
    On the other hand, among the self-financing participants in 
COVAX, twice as many--51 percent--of the population is fully 
vaccinated. Coverage ranges from 16 percent in Jamaica to 81 
percent in Chile.
    Cuba, which did not participate in COVAX and is the only 
country in the region that has developed its own COVID 
vaccines, has fully vaccinated 70 percent of its population.
    The divide reflected by these data can undermine all 
efforts to bring the pandemic to an end in the Americas, where 
it continues to have a devastating impact due to the uneven 
deployment of vaccines, the lack of a regional systematic 
vaccination strategy, the limited capacity to develop novel 
vaccines, and the reliance on imported vaccines.
    Consequently, 2 months ago, the Community of Latin American 
and Caribbean States approved the plan for self-sufficiency in 
health matters in Latin America and the Caribbean, prepared by 
the Economic Commission for Latin America and the Caribbean, 
ECLAC.
    The United States has the opportunity to help support this 
regional plan by: number one, facilitating technology transfer 
and the development of manufacturing capacity for mRNA 
vaccines; two, training and qualifying specialized human 
resources; three, equipping national and regional laboratories; 
and four, leveraging regional supply chains to help increase 
production capacity in a region of 660 million and insufficient 
vaccine development.
    Latin America and the Caribbean has, however, research 
capacity, scientific development, and technological innovation 
centers that are underfunded and that should be strengthened to 
discover and manufacture vaccines.
    Thank you for your attention.
    [The prepared statement of Dr. Castro follows:]

                Prepared Statement of Dr. Arachu Castro

    In Latin America and the Caribbean, a region inhabited by 8.5 
percent of the world's population, 46.7 million people have been 
diagnosed with COVID-19 (18 percent of world cases), and more than 1.5 
million deaths have been reported (30 percent of world deaths) as of 
November 15, 2021.\1\ Including underreported deaths, it is estimated 
that the actual figure as of this date is 2.2 million deaths.\2\ Figure 
1 shows the reported and underreported deaths per 100,000 population in 
27 countries and the Commonwealth of Puerto Rico, as well as the 
projected additional deaths in the next three and a half months. 
According to these estimates, Bolivia, Peru, and Venezuela will surpass 
500 deaths per 100,000 population by March 1, 2022, followed closely by 
Ecuador and Mexico.\2\ Nicaragua, Venezuela, and Haiti have the 
greatest underreporting of deaths.\2\ Table 1 provides the number of 
reported cases and deaths and the projected deaths per country or 
territory.
    Mortality among males has been greater than among females.\3\ 
However, not included in these statistics are the thousands--including 
women of reproductive age, adolescents, and children--who are estimated 
to have died due to the disruption of essential health services, the 
decrease in the use of these services for fear of acquiring COVID-19, 
and other indirect effects of lockdown-related measures that affect 
women disproportionately.\4\ \5\ \6\ Several studies have found a 
higher prevalence of COVID-19 infection among indigenous, 
Afrodescendant, and migrant populations compared to other groups and 
among those in the lower socioeconomic positions, further increasing 
health equity gaps in the region.\7\ \8\ \9\
    In Latin America and the Caribbean, in 2020, the pandemic caused 
the worse economic contraction in more than a century.\9\ The sharp 
increase in unemployment and loss of income has particularly affected 
informal workers, deepening social and economic inequalities and 
increasing poverty.\10\ \11\
    Governments have allocated resources to strengthen the capacity of 
the health sector to face the pandemic.\12\ Still, the response has 
been insufficient in most of the region due to the chronic underfunding 
and pre-existing weaknesses of public health systems. In most 
countries, segmentation between public services, social security 
services, and private medicine, the concentration of human resources 
and medical technology in some urban hospitals, the under-financing of 
primary health care (PHC) and epidemiological surveillance, and the 
lack of articulation between the different levels of care have weakened 
the coordinated actions of the national response.\5\ \10\

[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]



Source: Institute for Health Metrics and Evaluation, COVID-19 
Projections (https://covid19.healthdata.org/global?view=cumulative-
deaths&tab=trend), 2021.\2\


[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]



Source: World Health Organization, Coronavirus Dashboard (https://
covid19.who.int/), 2021; \1\ Institute for Health Metrics and 
Evaluation, COVID-19 Projections (https://covid19.healthdata.org/
global?view=cumulative-deaths&tab=trend), 2021.\2\

Note: n/a = not available.

    The underfunding of scientific and technological research and 
development in most Latin American and Caribbean countries is at the 
root of the limited capacity to develop novel vaccines in the region. 
Despite the existence of a regional vaccine procurement mechanism since 
1979--the Pan American Health Organization's Revolving Fund for Vaccine 
Procurement \13\--most countries negotiated access to COVID-19 vaccines 
in 2020 through bilateral agreements with vaccine developers from the 
United States, Europe, Russia, and China.\14\ At the same time, most 
also participated in the COVID-19 Vaccines Global Access (COVAX) 
facility, whose procurement agent in the Americas is the Revolving 
Fund.\15\ As a result, the roll-out of vaccines in the region has been 
highly uneven. Table 2 shows the COVID-19 vaccination coverage as of 
November 12, 2021. Although half of the population in the region is 
fully vaccinated, large differences exist between countries.

[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]



Source: Pan American Health Organization, COVID-19 Vaccination in the 
Americas (https://ais.paho.org/imm/IM_DosisAdmin-Vacunacion.asp), 
2021.\16\

    The inequity behind the distribution of COVID vaccines in Latin 
American and the Caribbean is primarily explained by the type of 
participation in the COVAX mechanism, which has been severely affected 
by the concentration of doses in high-income countries and the 
interruption of vaccine exports from the largest manufacturer of 
vaccines, located in India.\9\ As of November 12, 2021, among the 10 
countries that participate as donor-dependant--Bolivia, Dominica, El 
Salvador, Guyana, Grenada, Haiti, Honduras, Nicaragua, Saint Lucia, and 
Saint Vincent and the Grenadines--, 26.1 percent of the population is 
fully vaccinated. Coverage ranges from less than 1 percent in Haiti to 
60.8 percent in El Salvador, shown in Figure 2.\16\ On the other hand, 
among the self-financing participants in COVAX--Antigua and Barbuda, 
Argentina, Bahamas, Barbados, Belize, Brazil, Chile, Colombia, Costa 
Rica, Dominican Republic, Ecuador, Guatemala, Jamaica, Mexico, Panama, 
Paraguay, Peru, Saint Kitts and Nevis, Suriname, Trinidad and Tobago, 
Uruguay, and Venezuela--, 51.1 percent of the population is fully 
vaccinated. Coverage ranges from 15.8 percent in Jamaica to 81.2 
percent in Chile.\16\ Cuba, which did not participate in COVAX and is 
the only country in the region that has developed its own vaccines, has 
fully vaccinated 69.6 percent of its population.\16\

[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]



Source: Pan American Health Organization, COVID-19 Vaccination in the 
Americas (https://ais.paho.org/imm/IM_DosisAdmin-Vacunacion.asp), 
2021.\16\

    The divide reflected by these data can undermine all efforts to 
bring the pandemic to an end in the Americas, where the COVID-19 
pandemic continues to have a devastating impact in part due to the 
uneven deployment of vaccines, the lack of a regional systematic 
vaccination strategy, the limited capacity to develop novel vaccines, 
and the reliance on imported vaccines. Consequently, in September 2021, 
the Community of Latin American and Caribbean States (CELAC) approved 
the Plan for self-sufficiency in health matters in Latin America and 
the Caribbean,\17\ which includes seven priorities:

  1.  Strengthen mechanisms for pooled international procurement of 
        vaccines and essential medicines.

  2.  Use public procurement mechanisms for medicines to develop 
        regional markets.

  3.  Create consortiums for the development and production of 
        vaccines.

  4.  Implement a regional clinical trials platform.

  5.  Take advantage of regulatory flexibilities to gain access to 
        intellectual property.

  6.  Strengthen regulatory convergence and recognition mechanisms.

  7.  Strengthen primary health systems for equitable distribution of 
        vaccines and universal access to them.

    The United States has the opportunity to help support this regional 
plan by facilitating technology transfer and the development of 
manufacturing capacity for mRNA vaccines, training and qualification of 
specialized human resources, the equipment of national and regional 
laboratories, and leveraging regional supply chains to help increase 
production capacity in a region with a population of 660 million and 
insufficient vaccine development.\18\ Latin America and the Caribbean 
is a region with research capacity, scientific development, and 
technological innovation centers that should be strengthened to 
discover and manufacture vaccines.

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

    \1\ WHO. Coronavirus Dashboard. Available at: https://
covid19.who.int. Geneva: World Health Organization; 2021.
    \2\ IHME. COVID-19 Projections. Available at https://
covid19.healthdata.org. Seattle: University of Washington; 2021.
    \3\ PAHO. COVID-19 Health Outcomes by Sex in the Americas. From 
January 2020 to January 2021, https://iris.paho.org/handle/10665.2/
53372. Washington, DC: Pan American Health Organization; 2021.
    \4\ Castro A. Maternal and child mortality worsens in Latin America 
and the Caribbean. Lancet 2020;396:e85.
    \5\ Castro A. Challenges posed by the COVID-19 pandemic in the 
health of women, children, and adolescents in Latin America and the 
Caribbean. UNDP Latin American and the Caribbean, COVID-19 Policy 
Documents Series Number 19, September 2020. Available at: https://
www.latinamerica.undp.org/content/rblac/en/home/library/
crisis_prevention_and_recovery/desafios-de-la-pandemia-de-covid-19-en-
la-salud-de-la-mujer--de-.html. New York: United Nations Development 
Programme; 2020.
    \6\ Villalobos Dintrans P, Maddaleno M, Granizo Roman Y, et al. 
Interrupcion de servicios de salud para embarazadas, recien nacidos, 
ninos y ninas, adolescentes y mujeres durante la pandemia de COVID-19: 
proyecto ISLAC 2020 [Disruption of health services for pregnant women, 
newborns, children, adolescents, and women during the COVID-19 
pandemic: ISLAC 2020 Project]. Rev Panam Salud Publica 2021;45:e140.
    \7\ Coates A, Castro A, Marmot M, Mujica OJ, Eijkemans G, Victora 
CG. Just societies: A new vision for health equity in the Americas 
after COVID-19. Rev Panam Salud Publica 2020;44:e137.
    \8\ Castro MC, Gurzenda S, Macario EM, Franca GVA. Characteristics, 
outcomes and risk factors for mortality of 522 167 patients 
hospitalised with COVID-19 in Brazil: a retrospective cohort study. BMJ 
Open 2021;11:e049089.
    \9\ ECLAC, PAHO. The prolongation of the health crisis and its 
impact on health, the economy and social development. Available at 
https://hdl.handle.net/11362/47302. Santiago, Chile: Economic 
Commission for Latin America and the Caribbean; 2021.
    \10\ ECLAC, PAHO. Health and the economy: A convergence needed to 
address COVID-19 and retake the path of sustainable development in 
Latin America and the Caribbean. Available at: https://www.cepal.org/
en/publications/45841-health-and-economy-convergence-needed-address-
covid-19-and-retake-path. Santiago: Economic Commission for Latin 
America and the Caribbean and Pan American Health Organization.; 2020.
    \11\ ECLAC. Employment Situation in Latin America and the 
Caribbean. Employment trends in an unprecedented crisis: policy 
challenges. Available at: https://www.cepal.org/en/publications/46309-
employment-situation-latin-america-and-caribbean-employment-trends-
unprecedented. Santiago, Chile: Economic Commission for Latin America 
and the Caribbean; 2020.
    \12\ ECLAC. Measuring the impact of COVID-19 with a view to 
reactivation. Available at: https://www.cepal.org/en/publications/
45477-measuring-impact-covid-19-view-reactivation. Santiago, Chile: 
Economic Commission for Latin America and the Caribbean; 2020.
    \13\ PAHO. PAHO Revolving Fund, https://www.paho.org/en/
revolvingfund. Washington, DC: Pan American Health Organization.
    \14\ Castro A. A Race Against Time: Deploying Vaccines and 
Addressing the Disproportionate Impacts of COVID-19 in Latin America 
and the Caribbean. Available at Hearing before the Subcommittee on the 
Western Hemisphere, Civilian Security, Migration, and International 
Economic Policy, May 13. Washington DC: United States Congress; 2021.
    \15\ PAHO. COVAX vaccines COVID-19 deliveries in the Americas, 
https://app.powerbi.com/
view?r=eyJrIjoiMjA5ZDAxMmEtYTljNC00M2I0LWE5MjUtYWQzZGQxNDc4OThhI
iwidCI6ImU2MTBlNzljLTJlYzAtNGUwZi04YTE0LTFlNGIxMDE1
MTlmNyIsImMiOjR9. Washington, DC: Pan American Health Organization; 
2021.
    \16\ PAHO. COVID-19 vaccinations in the Americas. Available at: 
https://ais.paho.org/imm/IM_DosisAdmin-Vacunacion.asp. Washington, DC: 
Pan American Health Organization; 2021.
    \17\ ECLAC. Plan for self-sufficiency in health matters in Latin 
America and the Caribbean: Lines of action and proposals. Available at 
https://repositorio.cepal.org/bitstream/handle/11362/47253/1/
S2100556_en.pdf. Santiago, Chile: Economic Commission for Latin America 
and the Caribbean; 2021.
    \18\ Saenz R, Castro A. Can Latin America Develop New Ways to 
Procure Vaccines? Latin America Advisor 2021;August 11:pp. 4-5.

      
    Senator Kaine. We will move to questions now.
    Just to let you know, there is a voting schedule that is a 
little bit up in the air. There is no vote called now. That is 
great. If there is a vote, you could see us coming and going, 
but we will jump right in.
    I think we are all on the same page in terms of realizing 
the importance of American vaccine diplomacy in the Americas. 
They are our neighbors. Travel and family connections and 
connections of commerce are intense.
    The pandemic has hurt neighboring countries in such a way 
that it creates migration pressures that we feel here and our 
chief strategic adversary, China, is very engaged in trying to 
grab the mantle of leadership in the Americas from the United 
States.
    All those things are true and, yet, I am puzzled about the 
American deployment of vaccines to the region because it does 
not seem to match up with the things that I have just stated, 
which I think are kind of consensus positions.
    We have donated about 49 million vaccines to the region. I 
traveled to the region in July. They like the quality of the 
American vaccines. They like that there is no strings attached. 
They like that they are donated rather than sold, but if I look 
overall at what the United States is doing, and I believe we 
are the most generous donor of vaccines in the world, but the 
percentage of our vaccines that are going into the Americas, 
which is disproportionately suffering and disproportionately 
connected to us, seems very, very small.
    Those decisions are made by a process and, ultimately, made 
at the National Security Council, but let me put the 
proposition on the table, and I would love to hear you respond 
to it, that we should be allocating a percentage of the 
American vaccines into the Americas that is more equivalent to 
the suffering level in the Americas.
    If it is 30 percent of deaths with 8 percent of the 
population, I do not think we should be giving 8 percent of 
vaccines to the Americas. I think we should be giving 
significantly more, both because of the extent of suffering and 
because of the direct connection between conditions in the 
Americas and conditions here.
    What do any of you think of that proposition I put on the 
table?
    Mr. Runde. Senator, if I may.
    We have been very generous, but we could be doing more. I 
would propose that we might consider thinking about our health 
border going all the way to Panama and prioritizing at least 
North America plus Central America in a special way in the 
future in terms of future pandemics.
    I know that the world is crying out for vaccines, but in 
some ways, as I said earlier, in a democracy we are always 
going to prioritize Pennsylvania over Paraguay, but if we 
consider the entire Western Hemisphere our health border 
because microbes do not respect walls, then we would, perhaps, 
think differently about how we are allocating vaccines in that 
construct. There have been suggestions by serious public health 
professionals to do something like that.
    So I do think that is something for us to consider. It is 
good news that we produce far higher quality vaccines and they 
are in demand. I have spoken to a number of embassies in 
preparation for this hearing, and a number of countries that 
have taken Sinovac, the Chinese vaccines, are adding Pfizer as 
boosters because they know what China is offering is not very 
good. I could use other words, but I will go with not very 
good, Senator.
    So I would just say that we have an opportunity to finish 
strong. It has been unfortunate that they took advantage of a 
tactical window and they have pressed other geostrategic 
priorities--Huawei, Taiwan recognition.
    A friend of mine who is a prominent political consultant in 
the region is friends with the President of Paraguay and he 
said, tell your friends in America I am not going to flip to 
the mainland, but tell them the Americans are offering me 
nothing.
    Now, this was at one point. I think we need to think about 
we cannot fight something with nothing. So I do think, 
ultimately, we are going to have other funny name diseases 
happen like clockwork for a whole series of reasons.
    So I do not want to sit in my basement again for 18 months 
and I do not think anyone else in the Western Hemisphere does, 
and so I think we need to prepare differently and one of the 
things is we need to have surge capacity to manufacture not 
just in the United States but in places.
    It could be Uruguay. It could because Costa Rica. We could 
partner with Argentina. We could partner with Brazil, but in 
the meantime, we have a job to do. We need to finish the job 
strong.
    Senator Kaine. Mr. Restrepo.
    Yes, finish strong. I got that from your testimony. I like 
that idea.
    Mr. Restrepo.
    Then I have a second question for you, Dr. Castro.
    Mr. Restrepo. Certainly. Senator, if I may.
    I think two things are important here. One is COVID-19 
exposed preexisting conditions of all shapes and sizes, one of 
which is a lack of strategic attention to the Americas that has 
been long-standing by the United States in terms of our 
geostrategic balance in the world, and I think this is a result 
of kind of hardwired structural biases towards time and 
attention to the national security space to other parts of the 
world ahead of the Americas.
    I think your recommendation is a very solid one, that given 
the deep interconnection and the deep strategic interests the 
United States does have in the Americas and given the level of 
devastation wrought by this pandemic in this region, our 
response should be proportionate to that and not proportionate 
to our preexisting lack of attention, and, again, over decades. 
This is not a preexisting just with this Administration or even 
the Administration under which I served.
    Senator Kaine. Dr. Castro, you mentioned something in your 
testimony that I think is really important and that is U.S. 
participation in local manufacturing of vaccines and trying to 
play a leadership role there.
    The Caribbean and Latin American nations are exploring 
that, and I think there is a lot of good that we can do. Even 
better than donating would be the U.S. playing a significant 
role in the development of local capacity and I am, certainly, 
going to urge that on the Administration.
    We asked the panel before what the U.S. is doing, and there 
was a nice answer, but it was, basically, well, we are thinking 
about it. We are kind of talking to them and seeing what we 
might be able to do.
    We need to be doing better than that because Sinovac is 
committed to doing vaccine production in Chile. There is other 
local vaccine production initiatives. The U.S. should be using 
our innovation and our technical expertise to try to help those 
initiatives, and I really appreciate you putting that on the 
table.
    I have gone over my time and I want to yield now to Senator 
Rubio.
    Senator Rubio. Thank you. I could probably ask this of the 
entire panel. I will start with you, Mr. Runde.
    One of the things I am fascinated by, in general, is supply 
chains, right, and the fact that our supply chains in this 
country are deeply dependent on locations in the Asia Pacific 
region for a lot of different reasons.
    It strikes me that if we had some of these supply chains, 
obviously, in the United States, preferably, but if not in the 
U.S. in the Western Hemisphere, it would have a dual purpose.
    First, it would create some diversity and, therefore, we 
would not see some of the container backlogs and there would be 
other ports that would be available to take some of this, and 
second, it would solve a lot of the socioeconomic issues in 
some of these countries.
    In essence, I am not--I know the answer, okay, but I am not 
sure--but I imagine a world in which Guatemala, Honduras, El 
Salvador, Haiti, were countries that had vibrant manufacturing 
sectors, downscale on the production, but that created stable 
employment for young people so they would not have to leave 
their countries.
    I get rule of law and other things of that nature become a 
problem in many of these places. In particular, as I look at 
Pfizer designating factories in China as the main manufacturer 
of vaccines for the greater region that includes Taiwan, you 
can only imagine how that would be used, and third, because I 
think we are entering an era that I think there is going to 
be--the best way to say it is biomedical nationalism.
    There are plenty of countries around the world that have 
gone through this and said, never again will we not have the 
inability to make oxygen, the inability to make PPE, the 
inability to make medicine, the inability to manufacture 
vaccine and our basic goods because pandemics disrupt supply 
chains but so, potentially, can geopolitical conflict.
    So in specific and then in general, in specific, why have 
we not seen and what can we do to make it more so that places 
like Pfizer, Moderna, and other pharmaceutical companies return 
or enter the Western Hemisphere as a place to manufacture?
    Obviously, it is a U.S. territory, but Puerto Rico is a 
logical place and it is one that I deeply believe that we 
should reinstate and everything we can in tax policy. What more 
can we do to encourage that, specifically when it comes to the 
pandemic and then, more broadly, in general in the region on 
other topics?
    I know these countries have to do a lot, but what can we do 
to make the region more attractive in both the short and long 
term for this?
    I will start with you, Mr. Runde, but I open it up to the 
whole panel.
    Mr. Runde. Thank you, Senator. This is one of the key 
questions of the COVID pandemic. I have done 1,500 Zoom calls 
since March 12, 2020, and so have you, Senator, and one of my 
deep thoughts is that we are going to get a partial economic 
divorce from China.
    Maybe they can visit with their spouse and come--they can 
bring their new spouse to Thanksgiving and maybe we can sit 
together at graduation for the kids, but we are going to have a 
very different kind of relationship with mainland China, going 
forward. So I think that is--I will not call it the silver 
lining, but perhaps it is a----
    Senator Rubio. By the way, that is not just us.
    Mr. Runde. Yes. Oh, everybody.
    Senator Rubio. Everyone in the world.
    Mr. Runde. I think everyone is going to get a partial 
economic divorce from China.
    Senator Rubio. China plus one. Yes, they are going to look 
for some----
    Mr. Runde. Yes. China--right. They can bring--right, to the 
blended family a holiday picture. You get the idea, Senator.
    I think--the point is, is I think that there are a number 
of steps at--we are going to move from a just in time supply 
chain world to a just in case supply chain world.
    I do not think anybody in this room ever wants to depend on 
mainland China ever again for PPEs, pills, ventilators. When 
they started making threats about we are going to cut you off, 
those are fighting words. So I think that was a wakeup call.
    So I think there are several things we could do 
specifically and you, the senators, could do. Ecuador wants a 
free trade agreement. We ought to do it.
    Uruguay wants a free trade agreement. We ought to do it. 
Brazil would like a free trade agreement. We ought to do it. We 
ought to also fulfill the promise of CAFTA-DR. We have not 
fully seen that happen.
    I think we have an opportunity to some of the Americas to 
put some concrete things on the table. So I think one of the 
opportunities will be to ask the Biden-Harris administration 
what are you doing in the aspects of trade to enable some of 
these things.
    I also think we ought to be using our foreign aid to grease 
the skids of some of these shifts in global supply chains. 
Japan is doing this. They are providing a billion dollars to 
have Japanese companies move their factories from mainland 
China to, say, Southeast Asia.
    In theory, Mexico and Central America and the Caribbean 
could be--and Colombia and Brazil could be net winners of sort 
of these global shifts in supply chains.
    So some of it are trade agreements. Some of it is about 
foreign aid. I think we ought to continue to have a 
constructive dialogue with the Government of Mexico. I think, 
in theory, Mexico ought to be a net winner of some of these 
shifts in global supply chains.
    Then finally, on Puerto Rico, I absolutely agree with you, 
Senator. We ought to revisit some of those tax agreements that, 
I guess, went away in the 1990s. We ought to look at that. I 
know Governor Fortuno is someone who is very knowledgeable 
about these issues and would be someone who I would be 
consulting about the details of that.
    I think you put your finger on something very important, 
Senator. Thank you.
    Dr. Castro. Senator Rubio, helping Latin American and 
Caribbean countries strengthen their manufacturing capacity and 
helping transfer mRNA technology, which definitely the mRNA 
vaccines are the superior vaccines, and those are U.S.--the 
U.S. Government can do so much to facilitate that technology 
transfer from Pfizer and Moderna.
    Those--strengthening also local laboratories could have a 
great impact for the current pandemic and also for preparedness 
for future pandemics, and definitely would answer a lot of your 
concerns regarding the lack of employment opportunities and all 
the factors that trigger migration to the United States.
    So, definitely, strengthening the local production, 
strengthening public health systems, and because what has 
happened throughout the region in most countries, not in all, 
is that essential health services have been disrupted because 
of the covidization, as they say in Latin America, la 
covidizacion, and of the health systems.
    So everything else--for example, people give birth every 
day and a lot of women have been unable to give birth in a good 
quality setting because of the way that COVID has overtaken a 
lot of their health services.
    So definitely strengthening local capacity to be able to 
respond better now and in the future is the best thing that the 
United States Government can do. Thank you.
    Senator Kaine. I have one additional question that I would 
like to just put on the table. Senator Rubio, thank you. This 
is an important hearing and I think you have given us a lot we 
want to follow up on.
    Here is my last question. Without repeating anything you 
have already said, for example, in your opening testimony, if 
the White House were to call you tomorrow and say, hey, the 
Summit for the Americas, the primary focus of it is going to be 
public health--and that is in fact the case--so what should the 
United States be putting on the table at that summit in terms 
of a commitment in the public health space to deal with this 
covidizacion and the next chapter? What would your advice to 
the White House in prepping for the Summit for the Americas be?
    Dr. Castro. Well, certainly, getting prepared--thank you--
getting prepared for the next epidemic. Hopefully, we do not 
have another pandemic, but there will be----
    Senator Kaine. Yes.
    Dr. Castro. --and we need to look into the future because 
the present has been so dire with the crisis that COVID has 
created throughout the entire--all of the Americas and 
strengthening health systems and looking at the future and 
improve the ties between the United States and the region could 
be what I would, certainly, hope that is discussed at the 
Summit.
    Thank you.
    Senator Kaine. Mr. Restrepo.
    Mr. Restrepo. Senator, along those lines, the--we have an 
antiquated set of inter-American institutions, right. The 
inter-American institutions were built primarily in the 
forties, they were revamped in the sixties, and they correspond 
to issues of the forties and the sixties much more than they do 
to the dawn or--not even the dawn of the 21st century, and one 
of these areas is public health and pandemic response.
    There is an interesting model to build off in terms of 
pandemic response mechanisms in North America that can be--
through the North American Leaders Summit several summits ago 
that is being held again today here in Washington, to build off 
of that platform to be ready for the next one and to be--and to 
deepen public health cooperation in the region.
    PAHO is an organization with its challenges and it needs to 
be modernized and brought so it is a more effective mechanism 
within the inter-American system to deal with very much 21st 
century challenges.
    Unfortunately, none of us want to be relegated to our 
basements. I think all of us are going to be facing future 
pandemics and we need the international infrastructure in place 
now, and the Summit of the Americas provides a very good 
opportunity to begin the work of building that architecture.
    Senator Kaine. Thank you.
    Mr. Runde, finally.
    Mr. Runde. Thank you. There has been more digital payments, 
digital commerce, and distance learning in the last 80 weeks 
than in the last 80 years. So one of the things is thinking 
about how--and it has not just been in Fairfax County, but it 
has been all over the Western Hemisphere.
    So the digital pipes of the future should not be Huawei and 
ZTE. It ought to be somebody other than that. So one of the 
things we ought to have at the Summit of the Americas is 
digitize the hemisphere and make sure that it is the good stuff 
and it is not mainland Chinese digital.
    Second, I think we need to get real about a capital 
increase for the Inter-American Development Bank. I understand 
what the issues are and there is some hesitancy in the 
Administration and some folks in the Congress about this.
    Frankly, the main solution--collective action vehicle for 
the Americas is the Inter-American Development Bank. I believe 
it is going to be very difficult for those who dislike the 
current president of the Inter-American Development Bank to 
dislodge him. So we should work with him.
    So my view is we should announce at the Summit of the 
Americas a capital increase and as part of it we should say we 
are going to make Taiwan a member, we are going to add 
Australia and the Quad as members of the Inter-American 
Development Bank and as part of the ask we are going to say we 
want to use some of that money to help set up new manufacturing 
capacities for vaccines in places like Costa Rica and Uruguay 
and put that on steroids.
    I would also use some of that money for things like early 
warning systems. So that would be another thing I would be 
asking for. So digital--a capital increase for the IDB. I have 
said, finish the job on vaccines, early warning systems.
    On PAHO and the WHO, the WHO was born in the mid-1940s and 
in some ways born in sin because we had set up PAHO 50 years 
before and was sort of the--it is a very well regarded 
organization in the hemisphere, PAHO. It has got some 
understandable criticisms here in the Senate and the Congress 
about some of its relations with Cuba, but overall, it is a 
very good organization. However, we get to pick the head of 
PAHO and we did not want to stop picking the head of PAHO. So 
when we set up the WHO, the WHO head is sort of like the Holy 
Roman Emperor.
    It is neither holy nor Roman nor an emperor, and so they do 
not get to pick the head of PAHO. So we said, well, we will set 
up a whole bunch of PAHOs in Asia and Africa and the Middle 
East.
    So it is the same model. The regional folks get to pick. So 
the one employee of PAHO who is an employee of WHO is the head 
of PAHO. So it creates all sorts of weird distortions, and I 
think one of the problems with this pandemic and perhaps in 
Ebola as well in Africa was that the regional heads are very 
responsive and sometimes, perhaps, too responsive to regional 
folks.
    So I think one of the problems with the WHO is they took 
too darn long to go to, you know, DEFCON 5 in terms of this 
pandemic. I would disagree with the Administration's decision 
to re-up the head of WHO. I thought we ought to find--and there 
are plenty of other excellent candidates in Africa. We could 
have gone to the African Union and said we could find somebody 
else.
    So, anyway, so I think one of the things at the Summit of 
the Americas would be to look at this issue of the PAHO and the 
WHO relationship because I think anyone who has looked at it 
seriously will say it is a screwy arrangement that has been--
that ought to be looked at.
    Senator Kaine. Well, I want to thank the witnesses for your 
work and for being here today and your testimony. I am going to 
ask colleagues if they would like to submit questions for the 
record to try to do that by--let us see, today is Thursday, so 
we will say by the close of business tomorrow, Friday, November 
19, and I would ask that members submit those questions and if 
there are questions that are directed to any of you we would 
appreciate prompt and thorough responses.
    Again, we thank you for your willingness to appear today, 
your public service. You have given us a lot to think about and 
a lot to follow up on.
    With that, the hearing is adjourned.
    [Whereupon, at 11:22 a.m., the hearing was adjourned.]

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