[House Hearing, 116 Congress]
[From the U.S. Government Publishing Office]
ERADICATING EBOLA: LESSONS LEARNED AND MEDICAL ADVANCEMENTS
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HEARING
BEFORE THE
SUBCOMMITTEE ON AFRICA, GLOBAL HEALTH,
GLOBAL HUMAN RIGHTS, AND
INTERNATIONAL ORGANIZATIONS
OF THE
COMMITTEE ON FOREIGN AFFAIRS
HOUSE OF REPRESENTATIVES
ONE HUNDRED SIXTEENTH CONGRESS
FIRST SESSION
__________
JUNE 4, 2019
__________
Serial No. 116-44
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Printed for the use of the Committee on Foreign Affairs
[GRAPHIC NOT AVAILABLE IN TIFF FORMAT]
Available: http://www.foreignaffairs.house.gov/, http://
docs.house.gov,
or http://www.govinfo.gov
__________
U.S. GOVERNMENT PUBLISHING OFFICE
36-558PDF WASHINGTON : 2019
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COMMITTEE ON FOREIGN AFFAIRS
ELIOT L. ENGEL, New York, Chairman
BRAD SHERMAN, California MICHAEL T. McCAUL, Texas, Ranking
GREGORY W. MEEKS, New York Member
ALBIO SIRES, New Jersey CHRISTOPHER H. SMITH, New Jersey
GERALD E. CONNOLLY, Virginia STEVE CHABOT, Ohio
THEODORE E. DEUTCH, Florida JOE WILSON, South Carolina
KAREN BASS, California SCOTT PERRY, Pennsylvania
WILLIAM KEATING, Massachusetts TED S. YOHO, Florida
DAVID CICILLINE, Rhode Island ADAM KINZINGER, Illinois
AMI BERA, California LEE ZELDIN, New York
JOAQUIN CASTRO, Texas JIM SENSENBRENNER, Wisconsin
DINA TITUS, Nevada ANN WAGNER, Missouri
ADRIANO ESPAILLAT, New York BRIAN MAST, Florida
TED LIEU, California FRANCIS ROONEY, Florida
SUSAN WILD, Pennsylvania BRIAN FITZPATRICK, Pennsylvania
DEAN PHILLPS, Minnesota JOHN CURTIS, Utah
ILHAN OMAR, Minnesota KEN BUCK, Colorado
COLIN ALLRED, Texas RON WRIGHT, Texas
ANDY LEVIN, Michigan GUY RESCHENTHALER, Pennsylvania
ABIGAIL SPANBERGER, Virginia TIM BURCHETT, Tennessee
CHRISSY HOULAHAN, Pennsylvania GREG PENCE, Indiana
TOM MALINOWSKI, New Jersey STEVE WATKINS, Kansas
DAVID TRONE, Maryland MIKE GUEST, Mississippi
JIM COSTA, California
JUAN VARGAS, California
VICENTE GONZALEZ, Texas
Jason Steinbaum, Staff Director
Brendan Shields, Republican Staff Director
------
Subcommittee on Africa, Global Health, Global Human Rights, and
International Organizations
KAREN BASS, California, Chair
SUSAN WILD, Pennsylvania CHRISTOPHER SMITH, New Jersey
DEAN PHILLIPS, Minnesota JIM SENSENBRENNER, Wisconsin
ILHAN OMAR, Minnesota RON WRIGHT, Texas
CHRISSY HOULAHAN, Pennsylvania TIM BURCHETT, Tennessee
Janette Yarwood, Staff Director
C O N T E N T S
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Page
OPENING STATEMENT
Opening statement for the record from Chair Bass................. 4
WITNESSES
Ziemer, Tim, Acting Assistant Administrator, United States Agency
for International Development.................................. 14
Redfield, Robert, Director, Centers for Disease Control and
Prevention..................................................... 23
APPENDIX
Hearing Notice................................................... 56
Hearing Minutes.................................................. 57
Hearing Attendence............................................... 58
ADDITIONAL MATERIALS SUBMITTED FOR THE RECORD
Ebola Hearing Memo submitted for the record...................... 59
ERADICATING EBOLA:.
LESSONS LEARNED AND MEDICAL ADVANCEMENTS
Tuesday, June 4, 2019
House of Representatives,
Subcommittee on Africa, Global Health,
Global Human Rights, and International
Organizations,
Committee on Foreign Affairs,
Washington, DC
The subcommittee met, pursuant to notice, at 2:40 p.m., in
room 2172, Rayburn House Office Building, Hon. Karen Bass
[chair of the subcommittee] presiding.
Ms. Bass [presiding]. Good afternoon, everyone.
This hearing for the Subcommittee on Africa, Global Health,
Global Human Rights, and International Organizations will come
to order.
The subcommittee is meeting today to hear testimony on
eradicating Ebola, building on lessons learned and medical
advancements.
I want to thank everyone, including our witnesses, for your
patience. We had a series of votes, and other members will be
joining us shortly, but we are joined by our ranking member,
Mr. Smith.
So, today we are here to discuss the eradication of Ebola
and some of the medical advancements and lessons learned in
trying to suppress this deadly disease. Ebola is one of the
deadliest viral diseases in the world and has become a part of
the global health landscape.
The recent discovery of an Ebola vaccine and better
healthcare employee training have helped improve response times
to outbreaks and decrease the ability of the virus transmitting
to remote areas. However, Ebola outbreaks are often complicated
by regional conflict, lack of trust between local communities
and practitioners, and armed groups attacking and burning down
treatment centers. This hearing will address the challenges and
opportunities to combat the transmission of Ebola and the
effort and collaboration needed by appropriate stakeholders.
I look forward to hearing more from our witnesses regarding
the Ebola vaccines and how they are being used in this most
recent outbreak.
So, without objection, all members may have 5 days to
submit statements, questions, extraneous materials for the
record, subject to the length limitation in the rules.
I recognize myself for the purpose of making an opening
statement.
I would also like to thank our distinguished witnesses who
are here with us today.
The current outbreak in the Democratic Republic of the
Congo began in August of last year and is the second largest to
date, and as of news reporting from today, may have reached up
to over 2,000 cases and almost 1200 confirmed deaths. If we do
not collaborate with all stakeholders to combat the outbreak
and, ultimately, eradicate Ebola, the disease would surpass the
2014-2016 outbreak, the deadliest in history, which had 11,000
recorded deaths and 28,000 total cases. That outbreak started
in Guinea, Liberia, and Sierra Leone, then spread to Mali,
Nigeria, and Senegal, and even beyond the continent, with cases
in Italy, Spain, the United Kingdom, and I think we all
remember the cases in the United States.
The Ebola epidemic has been heightened because it is in a
conflict zone in the Democratic Republic of the Congo. The
epicenter of the outbreak is in North Kivu, which happens to
have more than 100 active armed groups in the region. North
Kivu also shares a border with Uganda and is a hub for travel
and trade, but also various other types of movement across the
border.
New cases are hard to determine because the violence and
political unrest in the affected areas have further restricted
the community's access to health care. The lack of security in
the region is also hindering the Ebola response by making it
difficult to trace context and organize crucial community
outreach activities. Some health centers have been temporarily
closed or damaged. Several of the health workers have been
killed.
I know that the people of the DRC are frustrated because of
the lack of medicine, food, and foreign companies extracting
the country's precious minerals, but that is no excuse to burn
down facilities or attack or kill people that are there to help
treat this deadly disease.
What this indicates, though, is that we must work to do all
that we can to keep these health practitioners safe. This means
that we have to think beyond just providing humanitarian
assistance for medical treatment. USAID Administrator Mark
Green said in testimony before the Senate 2 weeks earlier that,
when it comes to Ebola, the DRC setting is a labyrinth of
challenges, poor governance, resentment toward community
leaders. With a failed democracy in many, many ways, it will
take more than simply a medical approach.
Considering the dilemma of suppressing this outbreak, I
look forward to hearing your views and suggestions in your
testimony or in the Q&A. I am also very interested in hearing
the pros and cons of identifying this outbreak as an
international public health emergency. Why would not we declare
that? Those are just a few concerns I want to pose to the
witnesses.
Finally, I am concerned that the Administration released a
Presidential memo last November implementing aid restrictions
to most of the Tier 3 countries found in the 2018 TIP report.
It clearly states in Section 110, ``The President shall
exercise the waiver authority when necessary to avoid
significant adverse effects on vulnerable populations,
including women and children.''
Not focusing resources on health, education, and community
outreach hinders the success of countering the Ebola outbreak
in the DRC, and I urge the Administration to act more
diligently now. This Administration has an opportunity and an
obligation to try to stop the deadly outbreak, and that is why
we are having this hearing and I am introducing the Ebola
Eradication Act of 2019, which would authorize USAID to assist
with the Ebola efforts in the DRC.
Last, I believe that it is imperative that we not let Ebola
reach Goma because, if it does, it is highly probable that it
will reach Rwanda, Uganda, Ethiopia, and South Sudan--oh, my
goodness--and that would have an effect on humanitarian
efforts, peace and security, and economic trade.
So, the Tier 3 status is something I know the ranking
member is the author of the TIP report and has worked for many
years on this. And it kind of presents a little bit of a
dilemma where we certainly do not want to do anything to reward
a country that is a Tier 3 status, but, on the other hand, we
have this situation where have Ebola in a Tier 3 country. So,
what do you do? Not provide aid, when this disease, obviously,
has international impact?
[The prepared statement of Ms. Omar follows:]
[GRAPHICS NOT AVAILABLE IN TIFF FORMAT]
I now want to recognize the ranking member for the purpose
of making an opening statement.
Mr. Smith. Thank you very much, Madam Chair. Thank you for
convening this very important and timely hearing.
As she knows, the gentlelady from California and my good
friend--and some of you may remember--this subcommittee was
heavily engaged in the summer of 2014 in addressing Ebola when
we were in the midst of an Ebola outbreak in Sierra Leone and
in Liberia and the ensuing panic over the disease. We actually
held three hearings during a 4-month span, a period when many
around the world thought a new equivalent of the bubonic plague
was about to jump borders and overwhelm the health systems,
especially of Sub-Saharan Africa.
Indeed, there was a period when we thought that Nigeria,
particularly in Lagos--and Nigeria is the most populous country
in Africa--would suffer from a pandemic outbreak. But, thanks
to a largely unheralded work of a number of key actors,
including and especially our own Centers for Disease Control,
the outbreak was contained. And while we did have cases in the
U.S., due to highly effective quarantine measures and state-of-
the-art medical care, we were able to dodge that bullet as
well.
Perhaps our witnesses, Dr. Robert Redfield, can enlighten
us further as to the critical role the CDC played with regard
to global efforts and containing, and then, defeating, the 2014
Ebola outbreak, particularly in Nigeria, and lessons that have
been learned.
Although in many ways today we are better equipped to
address the Ebola outbreak, certainly in terms of vaccines that
were not readily available in 2014, as a practical, boots-on-
the-ground matter, we are in some ways worse off dealing with
the current outbreak, which began in 2018. Last year's outbreak
in the DRC has now spread in populated areas of the eastern
DRC. What makes the situation more difficult this time is the
security situation with attacks, vicious attacks, on healthcare
workers.
As reported by The Washington Post, according to the WHO,
there have been some 119 attacks against health workers this
year--and that was as of May--with some 85 wounded or killed.
The presence of expatriates, in particular, among the
healthcare workers appears to have increased the militants who
have carried out the attacks.
When one considers that these dedicated health workers put
their lives on the line to help prevent and treat Ebola, the
fact that they should be targeted boggles the mind. Recall the
testimony of Dr. Kent Brantly at one of our 2014 hearings, how
he contracted the disease, despite taking every precaution,
while helping Ebola patients in Liberia.
We hope to get an update from our witnesses today as to
what is the security situation on the ground and whether we are
putting our CDC and other personnel further in harm's way
beyond the threat posed by the Ebola virus.
Finally, I would like to address the issue--and it was just
raised by my good friend and colleague, Chairwoman Bass--there
is some concern that assistance to the DR Congo used to combat
Ebola will be cut based on the fact that our State Department
has designated the DRC as a Tier 3 country in terms of human
trafficking. I certainly hope that this is not the case, as it
does not comport with the intent behind the legislation.
As the author of the Trafficking Victims Protection Act of
2000, the TVPA requires that we withhold non-humanitarian, non-
trade-related foreign assistance to the government of Tier 3
countries, which means that the country does not fully comply
with the minimum standards and is not making significant
efforts to do so. I note that TVPA explicitly excludes
humanitarian and trade-related assistance from any assistance
cutoff. It further allows development assistance which directly
addresses basic human needs which is not administered by the
government. In other words, development assistance can flow via
non-State entities to non-government organizations, including
faith-based actors. Indeed, if one visits the eastern DRC--and
I have visited it myself--one notices that health and education
needs are met largely by faith-based entities, as the
government and its institutions are viewed with a great deal of
suspicion.
Moreover, Section 110(d)(4) of the TVPA vests the President
with waiver authority with respect to non-humanitarian, non-
trade-related foreign assistance when such assistance is in the
national interest of the United States, such as seen in the
prevention of the spread of Ebola. Further, the TVPA mandates
that the President exercise such waiver authority, quote,
``when necessary to avoid significant adverse effects on
vulnerable populations, including women and children.''
If there is any misunderstanding with respect to how this
law should be interpreted or implemented, I know that the
chairwoman and I would be very happy to meet with leaders of
the Administration to discuss that.
I do want to note that, since Fiscal Year 2018, the
American taxpayers have provided approximately $330 million in
humanitarian assistance to the Democratic Republic of Congo and
some $87 million in response to the Ebola crisis. I am further
told that additional congressional notifications for the DRC
will be forthcoming and look forward to receiving and reviewing
those as well.
Thank you, Madam Chair, and I yield back.
Ms. Bass. Thank you very much.
Before I introduce the witnesses, I would just like to
acknowledge a few people who are in the audience. This is a
special day on the Hill when we acknowledge, celebrate, and
lift up the hundreds of thousands of young people who are in
the Nation's child welfare system. And so, for the first time--
I have been doing this for years--but for the first time, three
of our former foster youth are from the continent of Africa.
One is from the Democratic Republic of the Congo, Ethiopia, and
Kenya. And so, I want to acknowledge them for being here.
Raise your hands or stand up.
[Applause.]
Yes, thank you.
In support of the young people is a very famous actor who
represents one of my favorite TV shows, Blackish, Marcus
Scribner, who is here with his father, who is here supporting
all of the foster youth.
[Applause.]
So, thank you very much for attending.
And now, to our panel. Admiral Ziemer is the Acting
Assistant Administrator for the Bureau of Democracy, Conflict,
and Humanitarian Assistance, at USAID. From April 2017 to July
2018, he was appointed by President Trump to be the Senior
Director for Global Health Security and Biodefense at the
National Security Council. And in June 2006, he was nominated
by President Bush to lead the President's Malaria Initiative.
Dr. Robert Redfield is the Director for the Centers for
Disease Control and Prevention. He has been a public health
leader actively engaged in clinical research and clinical care
of chronic human viral infections and infectious diseases,
especially HIV, for more than 30 years. He made several
important early contributions to the scientific understanding
of HIV, and in addition to his research, he oversees an
extensive clinical program providing HIV care and treatment in
the Baltimore-Washington, DC. community.
Thank you very much today. And please, we would like to
hear a summary of your testimony. We have your written
testimony, but if you would present for 5 minutes, and then, we
will have questions and answers by the panel.
STATEMENT OF TIM ZIEMER, ACTING ASSISTANT ADMINISTRATOR, UNITED
STATES AGENCY FOR INTERNATIONAL DEVELOPMENT
Mr. Ziemer. Chair Bass, Ranking Member Smith, members of
the subcommittee, thank you for the opportunity to speak with
you today about the United States Government's response to the
ongoing Ebola outbreak.
Chair, you referenced the 2014 West Africa outbreak and the
devastation and the impact that it had. The current outbreak in
North Kivu and Ituri Province has just surpassed 2,020 cases.
The situation is worsening and the numbers of cases will
continue to rise.
Last month, I traveled to eastern DRC with a core team from
USAID and CDC. I met with health teams, local community
leaders, and our implementing partners. I saw firsthand the
scale and complexity of this outbreak. I have traveled
extensively in my career, from my three decades in the U.S.
Navy and in the roles that I have had since. This trip to the
DRC was one of the most sobering trips I have ever taken.
The scope of this biosecurity threat is changing and the
risk of the virus leaping across the border to other countries
is very high. This will further destabilize the region
economically and heighten insecurity. In order to control this
Ebola outbreak at its source, a fundamental shift and an
immediate reset is necessary.
The ongoing violence and community distrust toward the
response has been summarized by both of the opening statements.
Armed group violence as well as deep-rooted community
resistance has really kept the health teams from doing their
critical health savings work and frequently results in the
suspension of the response efforts.
In February, community members set fire to and destroyed
the Katwa Ebola treatment unit. When I was there, we saw it
restored. The evening we left, one of the guards was killed in
another recurring attack.
There have been over 70 security incidents this year alone.
Cases have been accelerating in areas where the community
members exhibit deep-rooted distrust of the central government
and foreigners, as well as the people from other regions within
the DRC. This widespread distrust has fueled misconceptions
about the disease and deep suspicion regarding the motives of
this sudden and dramatic international presence responding to
Ebola. It is the feelings of the community that they are being
exploited by this injection of cash. They refer to it as ``the
Ebola economy''.
There is clear consensus among the stakeholders that we
need to listen better to the communities, listen to what they
are feeling, and that should and must inform the trajectory of
how we can shift our response to this accelerated increase in
cases. The outbreak is not just a public health crisis, it is
an outbreak in the midst of a complex emergency. In order to
contain this outbreak, a broader, more holistic humanitarian
approach is needed.
Toward this end, USAID, supported by CDC, as the technical
lead, is leading a whole-of-government response focusing on six
key areas in order to bring this Ebola outbreak to an end. Let
me just quickly review those six areas of focus.
First, we are working to improve coordination among the DRC
government, WHO, and our international partners. I am pleased
to say that over the last week to 10 days significant change is
underway to accomplish that objective.
Second, we are emphasizing and addressing the paramount
importance of community engagement and local ownership.
Third, we are working with the newly appointed U.N. Ebola
Response Coordinator, Mr. David Gressly, to bolster security
coordination through non-militarized humanitarian approaches.
Fourth, we are working with the CDC to implement
operational improvements in the public health response,
including a forward-leaning vaccine strategy.
Fifth, we are looking at enhancing the Ebola readiness in
Goma and along the Goma-Butembo corridor as well as the four
countries to the east.
Last, we are engaged in longer-term planning scenario for
stabilization and development to address the root causes of
fragility in the region.
This reset is building on the work of our USAID-funded
partners that have been implementing key aspects of this public
health response. Our partners have helped train 1,680 community
health workers to conduct surveillance, strengthen infection
prevention control measures in over 280 health facilities,
reached 1.5 million people with health messages, and provided
enough food to meet the needs of approximately 45,000
beneficiaries each month, and much more.
There is no silver bullet to end this outbreak, but I
believe that an adaptable, whole-of-government response that
capitalizes upon each agency's unique strengths and expertise
will be successful in containing, controlling, and ultimately
ending this outbreak.
I look forward to your questions.
[The prepared statement of Mr. Ziemer follows:]
[GRAPHICS NOT AVAILABLE IN TIFF FORMAT]
Ms. Bass. Dr. Redfield.
STATEMENT OF ROBERT REDFIELD, DIRECTOR, CENTERS FOR DISEASE
CONTROL AND PREVENTION
Dr. Redfield. Good afternoon, Chair Bass, Ranking Member
Smith, and members of the subcommittee. Thank you for the
opportunity to update you on the Ebola outbreak in the DRC and
outline what CDC is doing to prevent, detect, and respond to
this and other emerging global health threats.
CDC's efforts are grounded in over 40 years of Ebola
research and more than 20 Ebola outbreak responses. I want to
emphasize that our goal is to end this outbreak as soon as
possible.
When I visited Beni 2 weeks after the outbreak was declared
last August, I saw firsthand the complexity of this urban Ebola
outbreak. In March, I traveled back again to the outbreak zone,
where I met with responders on the front lines. These trips
further reinforced my understanding of the critical role that
experienced technical leadership plays in the field.
This is the first urban outbreak in the DRC, occurring in
densely populated areas that have experienced decades of
conflict and civil unrest which continue today. The two
currently affected provinces have never experienced an Ebola
outbreak. They have busy, porous borders with Uganda, Rwanda,
and South Sudan. These challenges make this outbreak extremely
difficult.
As of this week, we have surpassed the grim milestone with
now 2,020 cases, 1354 deaths occurring in 22 health zones. A
significant percentage of these cases have actually been
acquired in healthcare settings, including 109 healthcare
workers. In the past 42 days, we have seen 668 active cases in
18 different health zones. Of these cases, less than a quarter
were known contacts and monitored. Even more concerning,
roughly 40 percent were community deaths that occurred outside
the healthcare system.
Based on experience from previous outbreaks, an effective
response demands early ascertainment and effective isolation of
at least 70 percent of all cases and sustaining this for
several months. The fact that we are seeing so many community
deaths means that we are missing contacts. While no Ebola cases
have been confirmed outside the DRC, this outbreak is not under
control at this time.
CDC is working with the World Health Organization to
support vaccination. Over 130,000 people in the DRC and
surrounding countries have been vaccinated to date. Recently,
WHO has recommended the expansion of vaccination strategies and
an increase in vaccine supply to reach a greater number of
individuals at risk for Ebola.
Over the course of this outbreak, CDC has deployed 184
experts to the DRC, neighboring countries, and the World Health
Organization headquarters. Our work includes case recognition
and contact tracing, infection control in the healthcare
settings, safe burials, laboratory testing, border health,
vaccination, and real-time data analysis to inform the
response.
CDC also continues to provide direct assistance to the DRC
Ministry of Health, both in Kinshasa and Goma, where the
incident command is now located. The World Health Organization
in Geneva and the U.S. Government response in the DRC are also
enhancing preparedness efforts in the neighboring countries.
While this outbreak continues to be an urgent situation in
the region, the current risk to America is low. The most
effective way to protect America from emerging threats is to
stop disease at their source before they reach our borders.
We have seen tremendous progress in the rapid disease
detection and response. For example, this includes meningitis
in Liberia, multidrug-resistant tuberculosis in India, and the
rapid detection of yellow fever in Uganda, all a direct result
of CDC's global health security investment.
CDC continues to improve the technical public health work
force abroad. We have trained over 12,000 public health
professionals now in 70 countries. More than 200 of these CDC-
trained professionals are currently in the DRC. CDC continues
to position our assets globally to quickly respond to the
emerging health threats and disease hotspots.
Finally, I want to thank you for your continued commitment
and support to CDC and our critical global health security
mission. Thank you.
[The prepared statement of Dr. Redfield follows:]
[GRAPHICS NOT AVAILABLE IN TIFF FORMAT]
Ms. Bass. Thank you very much.
I wanted to know if you could elaborate and explain a
little bit about the differences in how people are responding
to the epidemic. You remember when it started in Liberia and
Guinea, there were challenges over traditional practices of how
you deal with the dead. And that was one of the reasons why the
outbreak was spreading, because it took a while to get people
to break with their traditional practices of washing and
preparing the body.
Here in the DRC you have the conflict where the workers are
being attacked, and it is believed as though the disease is
fake. And I just want to know if you can elaborate a little
more on what is going on. Why on earth would people be
attacking the facilities and the healthcare workers?
And then, I do not know if any of this is involved in the
broader political situation in terms of the election that
happened. The new President was here. He came and we met with
him. When was it, Mr. Smith? It was maybe a couple of months
ago that he was here.
And I was surprised because, when he was here, he requested
essentially security assistance. I understand that there are
security problems, but in the midst of an epidemic like this I
was surprised by that request.
So, could you please explain your perspectives on why are
the attacks happening? Why do not people understand that this
is a real deadly disease?
Mr. Ziemer. I think that is the question----
Ms. Bass. The microphone is not on. How about now?
Mr. Ziemer. Yes, OK.
I think your question is exactly the question that we are
trying to filter through. If you look at the three vectors, the
virus, the security situation, and the community lack of
cooperation, all three of those are going in the wrong
direction. We know how to control the virus. We just get there
and do what is needed in order to bring this under control,
based on the previous experiences.
The last outbreak was in the Equateur Province. And with
the DRC's response, complemented by the CDC, it was brought to
a close. So, what is different in this region that would cause
this deep-rooted response in the negative? Human behavior is
driven by many----
Ms. Bass. But, I mean, I know that there is a lot of armed
groups. I do not know if the armed groups are ideologically
based, if they are ethnically based, if they, you know----
Mr. Ziemer. Yes, there are over 60 to 70 armed groups with
different motivations and different intent. They have
undermined the communities' intents and welfare over the years.
My father knew a colleague who was killed in 1964, Dr. Paul
Carlson, not too far from this area. There has been deep-rooted
issues having to do with insecurity and lack of----
Ms. Bass. How is the new administration responding? How is
the new administration in the DRC----
Mr. Ziemer. You mean the President?
Ms. Bass. The new President, yes.
Mr. Ziemer. Based on the feedback we are getting, President
Tshisekedi represents a bright light. He has visited the area.
It is something that his predecessor never did. We are hopeful
that, with that type of political support, with the efforts by
the partners and the local responders, there might be an
opportunity to start seeing a change in the receptivity of the
community.
Ms. Bass. In terms of the waiver that our administration
needs to provide, has that happened or are you under the belief
that we have to hold back aid because of their involvement in
human trafficking?
Mr. Ziemer. Yes, the DRC has certainly been impacted by the
TVPA restrictions, and we need to use all the tools.
Ms. Bass. Do you get a sense from the Trump administration
that they are going to give a waiver to allow you to use all
the tools you have?
Mr. Ziemer. Chair, we are waiting to hear that. I would
like to offer, though, that the current investment by USAID in
this response has been unimpeded. We are using IDA money from
the 2015 appropriation to invest and respond to this outbreak.
Ms. Bass. OK. Thank you.
Mr. Ranking Member.
Mr. Smith. Thank you very much, Madam Chair.
If I could, one of the ways that the message got out during
the crisis of Ebola in Sierra Leone and Liberia was with cell
phones. And I am wondering, and I know we have an effort--I saw
it in your testimony, Dr. Redfield--of getting that information
out to key personnel.
Is there, generally speaking, an effort to get it to the
public? Because, apparently, that was one way of getting that
message out about how to keep yourself from getting
contaminated or sick.
Second, what kind of security arrangements are being made
for health workers? Is the President, for example--not ours; of
course I am talking about the President of DRC--mustering a
group of perhaps his best of the best to make sure that that
situation, the risk to the workers and to the people, of
course, is mitigated, if you could get to that as well?
I do have other questions. But you said 130,000 have been
vaccinated to date. I wonder if you could just enlighten us,
elaborate on whether the vaccination--how long when somebody
gets it before protection kicks in? Is there enough vaccine
available? Has anybody, including healthcare workers, gotten
the disease after vaccination? How efficacious is it? Is it 100
percent, 90 percent?
And then, if you could, speak to the faith community.
Obviously, there are many. And I have, when I have been there,
met with a lot of the church leaders. They do wonderful work,
but I am wondering if they are being fully brought into the
messaging and the protection strategy.
You talked about training the trainers in your testimony,
Dr. Redfield. Maybe you could elaborate a little bit on that as
well. I think that is an excellent concept. Thank you for doing
it. But maybe you could tell us a little more what you are
doing.
And finally--and I do have other questions--what tools are
not available in the toolbox that the Trafficking Victims
Protection Act sanctions are precluding? My sense is--and I
have spoken to many--so far, I do not know of any, but there
may be and I am missing it. Again, that is where the waiver
authority would come in to help meet this crisis head-on. But I
am just wondering what is not being done that would require an
act of Congress or, again, a waiver by the President of the
United States.
Mr. Ziemer. On the security front, I think it is clear that
the entire two-province area is insecure. I think what we are
looking forward to is a positive shift with the appointment of
David Gressly as the deputy for the U.N. Ebola response. He is
being moved over from the MONUSCO, where he was the deputy
responsible for the security forces. And so, his understanding
of security in that area, as a very experienced African hand,
will give us significant insight into how better to improve the
security.
When I was there, I asked WHO what they needed most. They
said security. When I asked the community workers what they
needed most, they said less security. So, somehow we have to
get in there and understand the dynamics, what the security
requirements are. It is counterintuitive to move forward in an
area where there is such variation in demand and how to move
forward to provide the health care.
Let me just jump into what tools are in that toolkit to
offset the TVPA. I would just say at this point it is clear
that additional funding would complement the current outbreak
response. It would be complementary. It would build capacity.
Once we get a final ruling on that, we will see where we stand
and we will press ahead.
Dr. Redfield. I think I can start with maybe the vaccine
questions. Clearly, this is a great addition to our toolbox. It
is not this outbreak, the vaccines--there are currently both
unlicensed vaccines. The one that is currently being used is
the Merck Sharp & Dohme vaccine.
As you have said, it has been to 130,000 individuals. The
way it is being administered is, if you identify a case, then
you find the contacts around that case. And then, you find the
contacts of the contacts around that case, and you try to
immunize everybody.
Operationally, this is not really going as effectively as
we would like. If you look at cases that present, and then, ask
the question, were they previously identified as a case, were
they previously monitored, and were they previously vaccinated,
currently, it is less than 20 percent. All right. And as I
mentioned in my testimony, we are not going to get anywhere
near effective control until we get this over 70 percent.
Vaccine supply is limited, and there is a need to
accelerate that supply. Merck Sharp & Dohme is the current
provider of it, and there is a need to increase that supply.
There is an opportunity to do what we call split dosing to make
the supply go further, which is currently being recommended.
But we do need more vaccine for sure.
Mr. Smith. Doctor, can you say how much more? I mean, how
much more vaccine? How much are we lacking?
Dr. Redfield. Right now, there is about 145,000 doses of
vaccine. As I mentioned to you, if you realize that we are only
vaccinating about 20 percent of the people that we want to be
vaccinating right now, you can see that there is a need
substantially for more vaccine.
The other thing I would mention, that the new strategy is
going to go beyond vaccinating contacts and contacts of
contacts. We now actually want to vaccinate geographic areas
where we cannot function because of the insecurity.
Unfortunately, there is going to be a 6-to-12-month lag before
there is adequate vaccine supply. So, we do project that we are
going to run out of vaccine before we get adequate vaccine.
Mr. Smith. If I could briefly on the vaccine issue, is it
safe? Are there downsides to it?
Dr. Redfield. Again, it is a non-licensed vaccine.
Mr. Smith. How long a shelf life is it?
Dr. Redfield. Yes. It is a non-licensed vaccine, but it
should be licensed soon. The shelf life is fairly long,
particularly in bulk. Clearly, the shelf life, once it is
vialed, is also very reasonable, multiple years.
The truth is, not everybody that has been vaccinated,
though, has been protected. There are breakthroughs. The
estimated efficacy of the vaccine is, say, over 85 percent,
but, again, that is not through any controlled clinical trial.
That is just back-of-the-envelope efficacy. So, we do have
cases in individuals that have been vaccinated, but I think
there is significant evidence that this vaccine is impacting
acquisition substantially.
And there is a suggestion--again, it is premature; the data
is ongoing--that if you do get vaccinated and you, then, do get
infected, that your clinical course may be more ameliorated.
But, again, this is still, in the absence of controlled data,
this is just what appears to be the observation.
Ms. Bass. Thank you.
Representative Wild.
Ms. Wild. Thank you, Madam Chairman.
Good afternoon.
Dr. Redfield, just following up on what you were just
testifying about, what is split dosing? You made reference to
split dosing.
Dr. Redfield. So, what that means is there is a normal dose
that is currently administered. Rather than give a full dose,
they are planning to give half a dose. Now it turns out that
half a dose has been shown in the application to the FDA to
give an adequate immune response. So, the FDA has looked at
that. They do believe that that is going to be efficacious. And
it is similar to the dose, it is actually even more than the
dose that was used in West Africa in some of the efficacy
trials. So, we do think there is substantial evidence that half
of the dose is going to be effective.
Ms. Wild. And where is it being manufactured?
Dr. Redfield. Right now, the initial lot was manufactured
at West Point in a production plant by Merck Sharp & Dohme.
That plant was closed, and they have moved the production
facility to Germany. That production facility currently is
going through what we call validation lots to make sure that
they can make the product effectively. And one of the recent
validation lots did not validate. So, that is another reason.
So, there are discussions about, our Secretary has had
discussions about what can be done to try to look at ways that
Merck might be able to accelerate vaccine availability.
Ms. Wild. And how close are we to having this vaccine ready
for license and broad administration, would you say?
Dr. Redfield. My understanding from the FDA meetings that
we have listened to their presentation, that we are just
waiting for the validation of the new plant. In other words,
the clinical efficacy data, safety data, is there. It is just
waiting to prove that the plant that is going to make the
vaccine is validated to make it in a reliable way.
Ms. Wild. OK. And I want to switch gears with you, Dr.
Redfield. In your written testimony, you indicate that in the
last calendar year there were 1,954 reported cases and 1,314
deaths, which by my calculations is a 67 percent fatality rate.
And you indicate that the number of cases is continuing to
increase. I assume that accurate reporting of cases and tracing
of contacts is essential. Is that fair to say?
Dr. Redfield. To get control of the epidemic, for sure.
Ms. Wild. OK. And one missed case or one missed opportunity
to trace contacts can keep the outbreak going or cause it to
spread. Fair enough, right?
Dr. Redfield. Right. Right.
Ms. Wild. So, my question to you is threefold. How accurate
do you think those numbers are that are in your written
testimony? I will ask all the questions, and then, you can
address it. How accurate do you think those numbers are? Is
there some kind of uniform infrastructure through which we
count and track these diagnoses? And are medical examiners or
coroners reluctant to report the cause of death?
Dr. Redfield. So, first is we are confident that the
numbers underrepresent the outbreak. I think, first and
foremost, I have tried to illustrate this late in the outbreak,
where you see up to 40 percent of the individuals presenting as
community deaths, there was no way for us to do contacts,
contacts of contacts. Those people stayed in the community
until they died.
The problem with Ebola is the infectivity goes up and up
and up and up and up, as you get sick toward death. And
probably one of the most infectious ways to transmit Ebola, as
the chair mentioned in her comments, is through burial. And you
wonder why we are seeing that this late in the game. Well, this
region never experienced Ebola before. They do not understand
Ebola.
How do we see this outbreak? Twenty-five percent of the
people who got Ebola got it because they were sick and went to
a hospital with something else, and then, got infected with
Ebola when they went to the hospital. So, you argue we need
infection control. In the last 21 days, we had 11 healthcare
professionals come down with Ebola. So, we still do not have
effective infectious control.
This really underscores, as you mentioned, we are not
anywhere near getting 95 percent of those contacts identified
and cases isolated. We are lucky to be 30 percent.
Ms. Wild. OK. I want to move on to one other thing real
quickly before my time runs out, Admiral Ziemer. In 2015, after
the Ebola outbreak ended in West Africa, then-President Obama
created a Special National Security Council Team to oversee
epidemic preparedness and response on a permanent basis. My
understanding is you were the official lead in that team until
the summer of 2018, is that right?
Mr. Ziemer. Yes.
Ms. Wild. And does that Global Health Security and
Biodefense Team even still exist today?
Mr. Ziemer. Yes, it does. The office has changed at the
NSC. The initiative is led by the State Department and
supported by CDC and USAID. So, the mechanism, the strategy,
and the commitment still exist.
Ms. Wild. And who leads it now?
Mr. Ziemer. It is led through the NSC, but the State
Department is the interagency lead.
Ms. Wild. Thank you.
Ms. Bass. Representative Wright.
Mr. Wright. Thank you, Madam Chair.
And thank you, gentlemen, for being here.
As all of us know, Ebola and its potential for an
international epidemic is very real for my home State of Texas
and my home county of Tarrant County, which borders Dallas.
Back in 2014, Thomas Eric Duncan died from Ebola in Dallas
after traveling there from Liberia. All of you know that story.
And two of the nurses who provided treatment, Nina Pham and
Amber Vinson, in Dallas were later diagnosed with Ebola and,
thank God, survived.
Earlier in 2014, Dr. Kent Brantly, who completed his
residency and fellowship in Fort Worth at John Peter Smith, our
public hospital, contracted Ebola while serving as a medical
missionary. You know that story as well. I got to visit with
him in December 2014. He is a remarkable man, remarkable
doctor.
So, the point is, we in the Dallas-Fort Worth area know
probably better than any community that what happens in the
DRC, what happens overseas, can happen here, and it can happen
very quickly. When this happened back in 2014, it was like a
bomb going off in the Dallas-Fort Worth area. My question is,
what were the biggest lessons learned from that--and I will go
with Dr. Redfield first--that are benefiting us now?
Dr. Redfield. Congressman, I think probably the most
important lesson that we are operationalizing now is to really
prepare particularly the bordering countries. We have been very
fortunate, if there is any ``fortunate'' in this outbreak, in
that it is a very remote area without significant air travel,
without significant roads. This is why, as was discussed
already by the chair, if or when this outbreak extends to Goma,
which is the place of an airport, this could offer greater
challenge.
Currently, we have really prepared South Sudan, Uganda, and
Rwanda, and the Goma area, to be able to recognize these cases
quickly, like we saw in Nigeria in the 2014 outbreak, and, if
you will, shut them down, so there is not a lot of secondary
transmission.
So, this border screening is really important. I think many
people will be shocked when I say this. In this outbreak to
date, we have screened over 58 million people. And you say to
yourself, wait a minute, how did we screen 58 million people
and we do not have cross-border or cross-region transmission
yet? You know, you can think about that. I think it is really
remarkable, to say the least.
But I do think that really recognizing how important
preparedness is and border screening is at the source--this one
comes back to my testimony for America. The best thing we can
do is stop these epidemics at their source and to really focus
on doing that. So, I think that is the lesson I know we have
all taken home. Preparedness is just not something to do
casually. It is something to do very seriously.
Mr. Wright. All right. And, Admiral, I had a followup for
you. A while ago, you mentioned how people there feel
exploited. Can you elaborate on that, exactly what that means,
that they feel exploited by the Ebola economy, if you will?
Mr. Ziemer. Congressman, I want to quote one of the
community leaders that I interviewed. He said, ``for years, we
have been abandoned by our government. We have not been cared
for. We have seen people die of malaria, cholera. Thousands of
people have been killed, and we have been left on our own. And
now, Ebola happens and you show up.''
That point of communication spoke volumes to me. Ebola to
them was more important to us than it was to them. We are there
to contain it, to keep it from spreading, and we are rolling in
with sophisticated interventions, committed people, and a
significant amount of funding. They feel as though they have
not benefited and that they are going to be abandoned as soon
as the Ebola outbreak is contained. That is the message that we
have got to listen to and move and try to encapsulate as we
look at this very unstable area that borders some fairly
significant countries.
Mr. Wright. Right. Thank you very much.
I yield back.
Ms. Wild [presiding]. Representative Houlahan.
Ms. Houlahan. Thank you, Madam Chair.
Thank you very much for coming today.
I have a bit of a preamble before my question, so maybe a
minute or so.
Women and girls are the two groups that are
disproportionately affected by this outbreak. Women and women's
groups also have the capacity to advance response activities
through socialization and education in their communities. Yet,
little outreach seems to be being done to this critical group.
According to a rapid assessment by the International Rescue
Committee from March 2019, which is responding directly to this
outbreak, preexisting gender norms expose women and girls to
specific and increased risks during disease outbreaks. And
during the current outbreak of Ebola in North Kivu in the DRC,
health actors have seen a similar pattern to that that they saw
in West Africa in 2014, with infection rates for women and
girls fluctuating between 57 and 62 percent.
In addition, the IRC found that women and girls carry
primary responsibility for caring for the sick and for managing
household prevention. And this means that women and girls, and
particularly adolescent girls, must increase the number of
times they travel long distances by foot each day to fetch
water. And this results in elevated risks of sexual violence
and harassment.
So, here are my questions: Admiral Ziemer, what is being
done to ensure that women and girls have access to services,
both health, but also sexual and gender-based violence-related
during this outbreak, if you can comment on that?
Mr. Ziemer. Thanks for the question. I can say clearly that
the interventions and the treatment are focused for all. There
clearly is a significant increase in children and women, and
that is being noted and factored into our interventions.
Ms. Houlahan. And so, is there any sort of coordinated
activity that specifically relates to the sexual violence of
women and girls as it relates to exposure to the Ebola or as it
relates to treating Ebola in that particular population? Is
there any coordinated effort on that, that you are aware of,
and should there be?
Mr. Ziemer. Yes, there should be. I know our partners are
looking at that specifically, and I will get back to you with
specifics on that.
Ms. Houlahan. That would be wonderful.
And my next question is for either of you gentlemen. What
lessons did you each or your organizations learn from the West
Africa outbreak and how have they been applied to the DRC
outbreak? And maybe specific to women and girls, if you are
able to dive deeper into that.
Mr. Ziemer. I will say the lessons learned from West Africa
are significant. The ability to take all of those lessons and
apply them has been interrupted by the community resistance and
the security reality. OK? So, unfortunately, there is not a
direct benefit from that, although we have learned a lot.
The other significant tool that has been brought in is the
vaccine. The situation would look a lot worse if it had not
been for the vaccine that Dr. Redfield has just summarized.
In terms of the programs' lessons learned, and dealing with
women and girls in West Africa, and the transfer into the
current two provinces, again, I will get back to you.
Ms. Houlahan. Thank you. I would really appreciate that.
And are there any efforts being made right now to codify or
to think about lessons learned as we learn them now in the
field, to be able to apply them in the future? Are we in the
process of sort of having weekly conversations about what we
have learned in this particular instance, so that we can use
them in the future?
Mr. Ziemer. Yes. I can commit to you that we will make sure
that that is ongoing.
Ms. Houlahan. And finally, what kind of cultural barriers
to educating the impacted communities have you encountered, and
how are you experiencing the opportunity to apply best
practices to the Congolese people? I know that you have spoken
a lot about the resistance, and I completely can empathize and
understand the situation. But have we found anything that is
working to be able to convey to particularly women and girls,
who are the caregivers and who are largely exposed to this,
what lessons could be used to be able to make them safer?
Mr. Ziemer. Yes, one of our primary partners is UNICEF. And
I know they focus on that as a priority. We will followup on
that, too, just to give you specifics on how UNICEF and our
other partners are continuing to applying lessons learned so
that we improve upon that particular issue.
Ms. Houlahan. I really appreciate your efforts on this.
This is something that literally keeps me up at night. Biology
and the concerns that come out of Africa and Asia are something
that are very, very concerning, I think, and should be for all
of us. So, thank you very much for your care.
I yield back.
Ms. Wild. Mr. Burchett.
Mr. Burchett. Thank you, Madam. Was I being called down for
talking or was I being called on to speak?
[Laughter.]
Ms. Wild. Either.
Mr. Burchett. All right. I will go speak then. How about
that?
Thank you all for being here.
How does the armed conflict that is currently ongoing in
the center of the outbreak affect the chance of the disease
spreading across the border? And are those that are involved in
this conflict, do they understand about and are they concerned
with the spread of the disease? Because a lot of times it seems
like education is the key and there always seems to be a
disconnect.
Mr. Ziemer. Yes, well, my immediate response is the armed
conflict is characterized by armed resistance with armed
individuals: the neighborhood gangs, basically the Mai-Mai
which are thugs on hire. Then, we have community resistance
that manifests itself in insecurity. All of this together is
undermining our ability to do good health work.
What are we doing about it? I think we are continuing to
talk to the community, get the community involved in
determining what their perspective is, and their
recommendations. But, clearly, the security environment has
been unstable. It continues to destabilize the approach, and it
is one of the priorities that we are looking at.
Mr. Burchett. Doctor?
Dr. Redfield. The comment I wanted to make, I have a slide
I would like to just show you about what the impact of the
armed conflict is, if she puts up the second slide. If you look
at this second half of the slide, that red line, that is the
current outbreak. All the lines you see before that, those are
all the other outbreaks besides West Africa.
The insecurity has caused a lack of our ability to bring
this outbreak to an end. You can see that most of these
outbreaks are over in 4 months. All right. This outbreak now,
if you go back to the time of initial symptoms, is really
actually now over a year old, even though it was recognized in
August, some of this.
And so, I want to emphasize, the magnitude of this outbreak
is getting to the point that one has to anticipate that we are
going to see spread outside of the outbreak area. And that is a
direct result of the conflict blocking the ability for the
public health response to take place.
Mr. Burchett. That is truly scary. This is not in my notes,
but after seeing that, will it get to a point where it will
just, because the host, I guess the folks that carry it would
die, will it then decrease or will it just keep spreading?
Dr. Redfield. The problem is that, in the absence of
effective public health response, you get a case. And then,
that case leads to multiple other cases. And you can see the
curve is changing. It is no longer linear. It is starting to
get an arch to it.
Mr. Burchett. Yes.
Dr. Redfield. Whereas, you see all those other cases, the
curve plateaus, and then, the outbreak stops. Right? This is a
direct result of not having the ability to operationalize what
we know how to do; that is, a public health response that we
have outlined in our testimony. And it is blocked because of
the insecurity in the area.
Mr. Ziemer. I would like to followup with one comment. That
is the reality and it is very sobering. All the more reason
that our prevention initiatives in South Sudan, Burundi,
Uganda, and Rwanda are scaled up. As Dr. Redfield said,
infection prevention, border security, and airport security are
very, very important. The fact that we are focusing and scaling
up prevention in Goma, which is 120 miles south of this
outbreak, is a critical part of the strategy. To keep it from
leaping the border and to keep it from going into Goma is part
of this strategy while the health responders are working day-in
and day-out to continue to address what is happening in Butembo
and Katwa, and some of the other areas.
Mr. Burchett. This next question might have already been
answered, but I would like a little clarification. The
administration, how is their calibrating our response efforts
in Fiscal Year 2020 request, given the continued spread of the
outbreak?
Mr. Ziemer. Congressman, I would say that that is being
factored into the requests. We have just met recently with OMB.
They know the requirements. I will keep you updated on how that
goes.
Mr. Burchett. Thank you, Admiral.
I yield back the rest of my time, Chairlady. Thank you.
Ms. Wild. Mr. Phillips.
Mr. Phillips. Thank you, Madam Chair.
My district, Minnesota's 3d District, is home to one of the
largest Liberian communities in the country, as you might know.
And in 2014-2015, of course, Ebola hit their country. And one
of my extraordinary staffers in Minnesota, Decontee Sawyer, is
a Liberian and her husband Patrick is one of the very first
Americans to actually die of Ebola. So, I dedicate my questions
today in his memory.
And it is sometimes difficult to connect foreign affairs,
of course, to dinner tables in America, but there is no
question that, if we do not help African nations stem the tide
of Ebola, it surely will appear on our doorstep. So, I am
grateful to both of you for the extraordinary work you do.
I believe Chairwoman Bass asked some similar questions
earlier. But my first question is about the distrust of the
international workers in the DRC. Some, of course, in the DRC
believe that the Ebola outbreak was deliberately created and
won't go to health facilities to seek care when they show
symptoms. So, what specifically, very specifically relative to
community engagement/education, is being done to educate and
try to overcome that challenge?
Mr. Ziemer. As we look at this reset that we are supporting
as part of the U.S. Government whole-of-government response,
the focus on the community is specifically being targeted. In
addition to engaging more effectively with the communities
themselves, certain projects are being identified. Some have to
do with increasing opportunities for them to earn small
projects in the community, be it infrastructure, be it wealth,
just to see if we can benefit, and benefit them with small-
scale infrastructure projects that will benefit the individuals
as well as the community. That is step one.
As we look at other opportunities to engage, it is going to
be a challenge first of all, to understand, but then to build
credibility so that the community itself can begin to own and
collaborate with the health responders.
Mr. Phillips. And if I can ask very specifically about it,
so who are the gatekeepers in these communities and how is
information conveyed? I mean, here it would be through social
media. Is it through families and face-to-face? Is it through
advertising? Is it through places of gathering? How do we try
to communicate and overcome the disinformation?
Mr. Ziemer. Yes, Congressman, it is all of the above:
media, direct contact, face-to-face meetings. UNICEF is
involved. CDC is involved with some of their community
programs. Our partners are involved. That information is being
collated and applied to improving community relations and
building trust.
Mr. Phillips. OK. Doctor, anything? Anything you wish to
add?
Dr. Redfield. I think the complexity, Congressman, is that
this is an area where distrust is really deep. When we went
there, we thought, well, maybe we could meet with the leaders.
Mr. Phillips. Right.
Dr. Redfield. Well, what leaders?
Mr. Phillips. Exactly.
Dr. Redfield. There is actually well over 100 different
small rebel groups. It is one thing to deal with the ADF. You
can find their leader and you can talk to them. But this Mai-
Mai is just a bunch of small groups with small leaders, and
disinformation going back and forth. So, you get one group to
have the right message, but, then, the other groups do not
agree with the message because they do not trust that group.
So, it is going to be a long haul to get trust in that area. We
reached out to the religious community to do it, the bishop,
and, again, they had a priest that was killed. And now, the
bishops are being intimidated. So, this is a very, very
complicated environment right now.
How to really build trust in that community that has been
at war for 25 years is going to be very complicated, and it is
going to take a long time. That is one of the reasons we are
concerned. This reset is critical. We have got to get the
community involved. We have got to figure out something on the
security side. Both of those are not easy answers, how we are
going to get either of them done.
Mr. Phillips. And just a quick final question. Is the
government in the DRC part of the problem or part of the
solution?
Dr. Redfield. Well, I cannot comment, and I will go to the
admiral to comment. Now, historically, this is an area that
does not trust their own government. Now whether it is
different with the new President, time will tell. But,
historically, they did not trust their own government.
Mr. Phillips. Right.
Admiral?
Mr. Ziemer. I will just concur with what Dr. Redfield said.
This community feels abandoned and has been abandoned, and it
is going to take a long time for them to trust the government.
The good news is that we have a different government. It is in
transition. It remains to be seen, once the cabinet is
appointed, how they will appropriately respond.
Mr. Phillips. If I could just add, would you argue they
might trust something from us, you know, with the American
brand on it, as a source of information, more than their own
government right now, relative to overcoming this?
Mr. Ziemer. It is pretty hard to speculate who they might
trust. I would say they would trust their local representatives
more than anybody else.
Mr. Phillips. OK.
Mr. Ziemer. I think I did mention earlier that President
Tshisekedi did take a trip out. This is the first time the
President had been in that area for years.
Mr. Phillips. Yes.
Mr. Ziemer. That is a step.
Mr. Phillips. Good. All right.
Thank you. I yield back.
Ms. Wild. In just a moment, I am going to yield additional
time to Mr. Smith. But, before I do, I just want to ask a quick
followup question to Dr. Redfield. It is my understanding that
the World Health Organization has twice decided against
declaring this outbreak as an international public health
emergency, as it did for the Ebola epidemic in Liberia. First
of all, is that correct?
Dr. Redfield. Yes, Congresswoman.
Ms. Wild. And if the World Health Organization did declare
this an international emergency, would it help to increase the
production of vaccine or other measures that could be taken
that would help to get this under control?
Dr. Redfield. I think the WHO has made it clear--we were
just at the World Health Assembly, and they made direct
requests that we need to stimulate more vaccine production. The
decision to do an international significance is really a WHO
decision, a committee decision. Historically, they have stayed
the pretty strong guidelines that they do that when there is
cross-border transmission.
I will say that nothing about their decision to declare it
or not declare it is impacting the United States' ability to
respond. And it really, basically, is a consequence of their
arbitrary guidelines that the committee has about calling it.
Ms. Wild. OK. Thank you.
With that, I yield additional time to Mr. Smith.
Mr. Smith. Thank you very much, Madam Chair.
Admiral Ziemer, this is DRC's 10th outbreak of Ebola. Is
there any evidence that anywhere else in DR Congo this hideous
disease is manifesting?
Let me also ask you, in your testimony you talk about
training some 1,680 community health workers to conduct
surveillance, equipping them with knowledge and tools to gather
information to track the disease. And then, you go on to say
that we have trained nearly 3,000 healthcare workers in patient
screening, isolation, appropriate waste management, and other
practices to prevent disease transmission as well as enhancing
triage and isolation infrastructure.
First of all, let me just say how grateful members of this
committee are--I am certainly--for that Herculean response. It
is amazing. I mean, we are taking the lead, as we do so often,
as we have in the past. So, thank you for stepping up and doing
it so robustly. That is a lot of training, and maybe you could
explain a little bit what that training entails. But I want to
thank you for that, first and foremost, and you might want to
speak a little bit further.
And, Dr. Redfield, you talk about CDC has designed a train-
the-trainers course for front-line response workers on contact
tracing methods; and, also, you have created an Ebola exposure
window calculator smartphone app for case investigators. If you
could provide us with some details on that? Again, we are
talking about innovations, lessons learned, you know, the title
of your testimony. CDC I think is really responding very
aggressively and very effectively as well.
So, I think the good news story for every American, they
know their taxpayers' dollars are being very aggressively
deployed in a way that is most likely to mitigate this terrible
outbreak. And as you said, Dr. Redfield, this complicating
factor of insecurity has so exacerbated what could have been
maybe even stopped months ago.
So, I think we would thank you, you know, a great big thank
you for that work.
And if you could delve into some of those answers?
I did ask earlier about the use of cell phones. Maybe you
wanted to speak to that, because we know in Liberia and Sierra
Leona that cell phone messages were everywhere about what to
do, and that really helped get the message out, which helped to
contain the contagion.
Mr. Ziemer. I am going to start with your last question on
the cell phones. I know the cell phone technology in use is
being brought into many, many different development and health
programs. How it is specifically being applied here in these
provinces, I will have to get back to you on that.
Mr. Smith. All right.
Mr. Ziemer. On the training, thanks. USAID and the U.S.
Government recognize the need for training at all levels, basic
education and health training. When we look at the global
health security agenda, we look at capacity-building and health
systems strengthening. It is all about the investment in
training the healthcare workers. So, thanks for that
recognition.
Mr. Smith. Thank you.
Dr. Redfield. A couple of comments to talk about what you
brought out. I am trying to read my note for the first one. I
cannot read my own writing. That is not so good.
Ms. Wild. It is because you are a physician.
Dr. Redfield. But I am a doctor, OK? Yes, so I have some
pass.
[Laughter.]
But I will start with the idea of communication. The
challenge we have is not that people do not know that there is
an Ebola outbreak. But I am telling you, people who get sick
with Ebola, a lot of them are deciding to stay home and hide. I
told you, 40 percent die. So, it is not just them that are
hiding; it is their family members that are hiding. So, this
distrust issue is beyond knowledge. It is really pretty
something when you know you are sick, you likely have Ebola,
you know your wife has Ebola, and you know there is a health
facility there. You maybe trust it or not. And as I tell you,
you basically stay home until you die. That is a big problem.
So, I think that is important. That is why I said it is
going to take a long time. We are hopeful that we are going to
get the word out because there is now four experimental
therapeutics that NIH is doing in the clinical trial there of
promising therapeutics, that Ebola is not the same death
sentence as it was in the West Africa outbreak. But how can we
start to get that information out to the community? It is
actually an advantage for you to come forward and get treated,
both in our ability to hydrate you properly, because we have
learned how to do this better, and now that there is an
opportunity to get some very new, promising, experimental
therapeutics. So, that is really a key issue to do.
I will say, on training, our Field Epidemiology Training
Program, which we have now over in seven countries, 70
countries, as I said, in the DRC it is our lifeline. We have
got almost 200 individuals that have gone through what we call
a 2-year epidemic investigator program, like we have in the
United States.
When the western outbreak happened in the early spring,
when I first became CDC Director, we were able to mobilize
about 40 to 50 of those people, along with CDC, and that
outbreak shut down in less than 60 days.
Now you have got the eastern outbreak. We were able to
mobilize a lot of those individuals, but without the technical
stewardship of the leadership of CDC to provide some ability to
make sure what we said needed to be practiced is actually being
practiced and reinforce it in the field, as driven by the
insecurity.
We have started a Center of Excellence with the Minister of
Health in Goma for Ebola. So, we are trying to really enhance
and accelerate training the trainers, so that if we cannot be
in the field, at least we can be training the people that can
go in the field, and make sure we are increasing their skill
sets more and more, and more and more. And that is currently
ongoing in Goma. We will continue.
But I will say, our overall concept here is we are not
planning a 3-month strategy or a 6-month strategy. We need to
dig in and realize that this is going to be a 12-, 18-, 24-
month strategy, and make the investment in those 12-, 24-month
interventions, like building the center to train people how to
really do better at Ebola in the North Kivu Province, like we
are doing in Goma.
Mr. Smith. Can I just ask you one final question? The 43
travelers that you mentioned per day that come to the United
States from the DR Congo, and largely not from the affected
areas, as you indicate, how much of a risk is that, and not
just to us, but also to the African countries due to travel?
How well-screened are they before they hop on an airplane or
use some other mode of transportation?
Dr. Redfield. Right now, for the Congo, we do what we call
Level 2 screening. We have our ports of entries alerted. As you
mentioned, these individuals are not from areas where there is
active transmission at this point. That said, we are still
alerted to be able to start looking at travelers that are
coming from the DRC.
As you mentioned, of the hundreds of thousands of
travelers, we are very fortunate that not too many are coming
from the Congo. I can tell you, from the North Kivu region, it
is probably almost reportable, you know, in terms of having
travelers from there. It is just not in an area that has--
travel is not part of their culture.
But I think if we do get into Goma, that is going to
change. If we do get into some other parts of the DRC,
Kinshasa, that is going to change.
Mr. Smith. Again, thank you for your leadership. Thank you
for the risks you take when you go there, and all the personnel
that are deployed there from the United States, and other
places. But, for those who do it, we all are very, very
grateful.
I yield back.
Ms. Wild. Ms. Houlahan, I understand you have additional
questions.
Ms. Houlahan. I do, and thank you, Madam Chair.
I just have had the opportunity on a different committee
that I serve on to be doing a little bit more of a deep dive on
the Mueller report on election interference; also, on a task
force that I am participating on. And as a result of that
deeper dive, I have had the opportunity to understand just how
involved Russia was in the disinformation/misinformation with
the AIDS outbreak in South Africa in the eighties, and
deliberately sort of pointing the finger at the U.S. and our
involvement, or lack thereof, in that particular outbreak.
And so, I guess my question to you is, as Russia and China
are clearly rising on the continent of Africa and their
influence is clearly rising again in that particular area, have
you any concern? Have you seen anything that would indicate
that there is any sort of campaign of disinformation against
the United States specific about the rise of Ebola? Is that
something that concerns you?
Mr. Ziemer. Thanks for the question.
At this point, we have not seen any indication that there
is any direct strategy or intent to undermine the issue. So,
that has not been an issue for trying to get the Ebola outbreak
under control.
Ms. Houlahan. Are you concerned at all about that, given
the rise of Russia's strength? I think in the eighties they
were significantly weakened, and that was a pretty weak attempt
at disinformation. But do you have any concern that at this
point in time it may become more strong?
Mr. Ziemer. I think the awareness is very high. I think the
concern is there. There are a number of agencies looking at
that. The positioning, and the influence of China are
priorities. To any extent that it might be involving or
undermining our ability to respond better to this outbreak, we
will get back to you on that.
Ms. Houlahan. Thank you.
Mr. Ziemer. But I do not sense it.
Ms. Houlahan. Thank you. I appreciate it.
I yield back.
Ms. Wild. Mr. Phillips.
Mr. Phillips. Thank you, Madam Chair.
Doctor, on a scale from 1 to 10, how well-prepared is the
United States, God forbid, if we faced an Ebola outbreak or,
for that matter, any other contagion on a national basis?
Dr. Redfield. The domestic footprint for dealing with
cross-border cases that would come into the United States is
one of the great benefits of the 2014. It is that we really
have established a system. Multiple hospitals now across the
country have been firmly prepared ahead of time how to do this
in an effective way, so we do not repeat some of the situations
that happened in 2014.
I think, as I said in my testimony, at present the risk to
our Nation directly is extremely low, just because of where
this is. That may change if we get outbreaks, if it spreads
into Goma or into Kinshasa or into Kampala, or something like
that, if this sort of dwells on.
But we do have a very effective screening program now that
we have developed, in a sense as a consequence of that 2014
experience. So, I do think we are very prepared here. This is
why I come back and say--and I will say to you in general for
our health security--the best thing this Nation can do to
protect its self-security is detect, respond, and prevent these
outbreaks where they start.
Mr. Ziemer. Agree.
Mr. Phillips. Is there anything that you would like to see
us either provide resources for or improve strategically in the
country?
Dr. Redfield. Well, I think that, as we do these emergency
responses from CDC's perspective, unlike, say, my colleagues at
USAID, there are some things that would enable us to be more
efficient, more effective, more timely, you know, particularly
the ability to have direct hiring authority for these
emergencies. USAID has that. We do not have that.
Mr. Phillips. OK.
Dr. Redfield. The same thing in terms of our ability to
procure different items that we need to procure, so that we
could have what we call our transactional authority, so that we
can actually procure what we need when we need it.
Mr. Phillips. OK.
Dr. Redfield. Those two things would be very helpful to
CDC.
Mr. Phillips. For supplies and----
Dr. Redfield. Yes, for supplies, and not go out to a
million different people to try to get competitive bidding,
when we need an emergency response. This would allow us to be
much more effective, much more efficient in these responses.
And it is something, as CDC Director, we would like to see that
we have that ability for these emergency responses.
Mr. Phillips. OK. Thank you.
Dr. Redfield. Yes.
Mr. Phillips. I yield back.
Ms. Wild. The last area, I guess I get the last word.
Actually, you get the last word on this. I am still highly
concerned--and I think we all are--about the potential for
travel to the United States. And I understand we are fortunate
that at this point we have a low rate of travelers from the
DRC, and that they are screened before they come here. But my
understanding from, I think it was your written testimony, is
that the incubation period can be as long as 21 days. So,
presumably, somebody could be screened and not be showing any
symptoms, is that right?
Dr. Redfield. They could be screened and not show symptoms
at the time they are screened. But if they were from a high-
risk area, then they would be put into a system to self-monitor
for the development of a fever, similar to what we did in the
2014 outbreak----
Ms. Wild. OK.
Dr. Redfield [continuing]. Where the health departments
will bring them into a system, let them self-monitor. If they
do develop a symptom/fever, then, basically, they would get
laboratory diagnosis, and then, be handled appropriately.
Ms. Wild. But that is dependent on accurate reporting, this
self-monitoring system?
Dr. Redfield. Yes, I think the advantage we have, some of
it is self-monitoring. The initial advantage is we do have the
point of exit. So, we know individuals that are coming from the
exit. It is not like, for example, if we were dealing with
Middle East respiratory syndrome, where the real introduction
might be someone shared a smoking lounge in London, but we
would not have any understanding of that.
Here at least we know the areas that are at risk for their
active transmission. Those individuals would be identified and
screened as they came into this country. And then, they would
be set up with the health department. Depending on different
health departments would do it different ways, but most of the
individuals do self-temperature assessment. They call them.
They do have a temperature, yes/no, and followup there. I mean,
it worked pretty effectively in the 2014 outbreak once it got
operationalized.
Ms. Wild. Having said all of that, the need for containment
is very much recognized by all of us here today.
I would like to thank both of you for your time on this
very important subject, and also, to everyone who attended this
hearing, as well as the members who attended and asked very
good questions.
With that, this meeting is adjourned. Thank you.
[Whereupon, at 4:02 p.m., the subcommittee was adjourned.]
APPENDIX
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