[Senate Hearing 116-208]
[From the U.S. Government Publishing Office]
S. Hrg. 116-208
CONFRONTING EBOLA: ADDRESSING A
21st CENTURY GLOBAL HEALTH CRISIS
=======================================================================
HEARING
BEFORE THE
SUBCOMMITTEE ON AFRICA AND
GLOBAL HEALTH POLICY
OF THE
COMMITTEE ON FOREIGN RELATIONS
UNITED STATES SENATE
ONE HUNDRED SIXTEENTH CONGRESS
FIRST SESSION
__________
JULY 24, 2019
__________
Printed for the use of the Committee on Foreign Relations
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Available via the World Wide Web:
http://www.govinfo.gov
U.S. GOVERNMENT PUBLISHING OFFICE
40-600 PDF WASHINGTON : 2020
COMMITTEE ON FOREIGN RELATIONS
JAMES E. RISCH, Idaho, Chairman
MARCO RUBIO, Florida ROBERT MENENDEZ, New Jersey
RON JOHNSON, Wisconsin BENJAMIN L. CARDIN, Maryland
CORY GARDNER, Colorado JEANNE SHAHEEN, New Hampshire
MITT ROMNEY, Utah CHRISTOPHER A. COONS, Delaware
LINDSEY GRAHAM, South Carolina TOM UDALL, New Mexico
JOHNNY ISAKSON, Georgia CHRISTOPHER MURPHY, Connecticut
JOHN BARRASSO, Wyoming TIM KAINE, Virginia
ROB PORTMAN, Ohio EDWARD J. MARKEY, Massachusetts
RAND PAUL, Kentucky JEFF MERKLEY, Oregon
TODD, YOUNG, Indiana CORY A. BOOKER, New Jersey
TED CRUZ, Texas
Christopher M. Socha, Staff Director
Jessica Lewis, Democratic Staff Director
John Dutton, Chief Clerk
SUBCOMMITTEE ON AFRICA AND
GLOBAL HEALTH POLICY
LINDSEY GRAHAM, South Carolina, Chairman
JOHNNY ISAKSON, Georgia TIM KAINE, Virginia
ROB PORTMAN, Ohio CHRISTOPHER A. COONS, Delaware
RON JOHNSON, Wisconsin CORY A. BOOKER, New Jersey
TED CRUZ, Texas CHRISTOPHER MURPHY, Connecticut
(ii)
C O N T E N T S
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Page
Graham, Hon. Lindsey, U.S. Senator From South Carolina........... 1
Kaine, Hon. Tim, U.S. Senator From Virginia...................... 1
Wolfe, MD, Mitch, Chief Medical Officer, Centers for Disease
Control and Prevention, U.S. Department of Health and Human
Services, Washington, DC....................................... 3
Prepared statement........................................... 4
Ziemer, Rear Admiral Tim, USN, Retired, Senior Deputy Assistant
Administrator, Bureau for Democracy, Conflict, and Humanitarian
Assistance, U.S. Agency for International Development,
Washington, DC................................................. 11
Prepared statement........................................... 12
Bernicat, Hon. Marcia, Principal Deputy Assistant Secretary,
Bureau of Oceans and International Environmental and Scientific
Affairs, U.S. Department of State, Washington, DC.............. 16
Prepared statement........................................... 17
Nagy, Hon. Tibor, Assistant Secretary, Bureau of African Affairs,
U.S. Department of State, Washington, DC....................... 18
Prepared statement........................................... 20
Additional Material Submitted for the Record
Responses of Hon. Tibor Nagy to Questions Submitted by Senator
Robert Menendez................................................ 35
Responses of Hon. Tibor Nagy to Questions Submitted by Senator
Edward J. Markey............................................... 36
Responses of Hon. Marcia Bernicat to Questions Submitted by
Senator Robert Menendez........................................ 38
Responses of Hon. Marcia Bernicat to Questions Submitted by
Senator
Edward J. Markey............................................... 39
Responses of Rear Admiral Tim Ziemer, USN, Retired to Questions
Submitted by Senator Robert Menendez........................... 40
Responses of Rear Admiral Tim Ziemer, USN, Retired to Questions
Submitted by Senator Edward J. Markey.......................... 44
Responses of Dr. Mitch Wolfe to Questions Submitted by Senator
Edward J. Markey............................................... 46
(iii)
CONFRONTING EBOLA: ADDRESSING A
21st CENTURY GLOBAL HEALTH CRISIS
----------
WEDNESDAY, JULY 24, 2019
U.S. Senate,
Subcommittee on Africa and Global Health Policy,
Committee on Foreign Relations,
Washington, DC.
The subcommittee met, pursuant to notice, at 2:35 p.m. in
room SD-419, Dirksen Senate Office Building, Hon. Lindsey
Graham, chairman of the subcommittee, presiding.
Present: Senators Graham [presiding], Kaine, Menendez,
Coons, and Murphy.
OPENING STATEMENT OF HON. LINDSEY GRAHAM,
U.S. SENATOR FROM SOUTH CAROLINA
Senator Graham. Thank you. The hearing will come to order.
I apologize for being late. It is one of those days where you
start late and you wind up late.
Really an impressive panel. And what brings us here is we
had the 10th outbreak, the second largest in history, in the
Republic of Congo, in areas that have been, without a doubt,
have been conflict zones. This is sort of the worst case
situation. There is no governance in these places. It is a war
torn region. Thousands have been killed and displaced. In the
middle of all this mess, you have an Ebola outbreak without a
whole lot of governance to deliver relief. And this hearing is
going to focus on what we can do and should do and what are the
consequences of doing nothing.
I just appreciate Senator Kaine very much being a good
partner. And I will introduce the panel after your opening
statement.
STATEMENT OF HON. TIM KAINE,
U.S. SENATOR FROM VIRGINIA
Senator Kaine. Great. Thank you, Mr. Chair, and thanks to
all the witnesses.
The chair and I talked about doing this hearing after a
hearing 6 weeks or so ago with the USAID Administrator, Mark
Green. And it is very, very timely. He talked about the need
for us to focus more on this.
And 1 week ago today, the World Health Organization, after
an Ebola case was discovered in the City of Goma, declared this
outbreak of Ebola a public health emergency of international
concern. For those who do not follow the WHO terminology, they
have just done this five times in their history--has there been
an outbreak of such significance that they have declared a
public health emergency of international concern. The earlier
instances were a polio virus in 2014, swine flu in 2009, Ebola
in West Africa in 2014, and the Zika outbreak in 2016. So this
was an outbreak that started, I believe, in August of 2018 in
Uganda and the DRC, but it has now significantly affected 1,700
deaths, more than 1,700 deaths, 2,600 cases. And so the WHO has
now weighed in, and we have to decide what to do about it, what
the U.S. can do in tandem with other partners.
The chairman made a good point. This is a public health
emergency, but the solution is not just a health care solution
because we are dealing with conflict. We are dealing with
failed democracy. We are dealing with failed systems. And so
how do we end that situation to deal with this significant
health emergency. The answer will be broader than just narrow
health. Certainly health expertise and creativity can be part
of it, but it is going to have to be bigger than that.
And so the idea today is to hear from each of you in your
own areas of expertise and get your advice for what we can do
in Congress to be helpful.
So thank you, Mr. Chair. I look forward to the hearing
today.
Senator Graham. Thank you.
And to put a fine point on what Senator Kaine said, this is
a case study, exhibit A, as to why you cannot withdraw from the
world. To those who believe that things over there are not our
problem over here, you are going to learn pretty quickly that
when it comes to diseases like this, if you do not get ahead of
it, you are going to regret it. And this is not just about a
medical problem. This is a governance problem. This is a whole-
of-government problem.
So when you start cutting developmental budgets, you are
going to get more of this, not less. So every time I hear
somebody wanting to cut foreign assistance which is $30-
something billion of a $4 trillion dollar budget, I keep
thinking what world are you looking at. So that is my
commercial for our committee.
So to people who know what they are talking about far more
than I do when it comes to Ebola, we are going to start with
Dr. Mitch Wolfe, a medical doctor, Chief Medical Officer,
Centers for Disease Control and Prevention, U.S. Department of
Health and Human Services. He is the technical and medical lead
for the response.
We have Rear Admiral Tim Ziemer, USN, Retired, Senior
Deputy Assistant Administrator, Bureau for Democracy, Conflict,
and Humanitarian Assistance, USAID, providing assistance to the
U.N. and NGOs fighting Ebola.
The Honorable Marcia Bernicat, Principal Deputy Assistant
Secretary, Bureau of Oceans and International Environmental and
Scientific Affairs, U.S. Department of State. She is the lead
for the interagency in diplomatic response.
And finally, Assistant Secretary Tibor Nagy, Bureau of
African Affairs, U.S. Department of State, who will focus on
the regional political aspects of Ebola.
Let us start with Dr. Wolfe.
STATEMENT OF MITCH WOLFE, MD, CHIEF MEDICAL OFFICER, CENTERS
FOR DISEASE CONTROL AND PREVENTION, U.S. DEPARTMENT OF HEALTH
AND HUMAN SERVICES, WASHINGTON, DC
Dr. Wolfe. Good afternoon, Chairman Graham, Ranking Member
Kaine, and members of the subcommittee. I am Dr. Mitch Wolfe,
Chief Medical Officer of the Centers for Disease Control and
Prevention. I am a rear admiral in the U.S. Public Health
Service, and I have worked with the Department of Health and
Human Services for 21 years, 18 of those with CDC, including 10
years overseas in Vietnam and Thailand working on addressing
infectious disease threats and helping to build the capacity
for countries to address these threats at their source.
Thank you for the opportunity to update you on the Ebola
outbreak in the DRC and outline what CDC is doing to prevent,
detect, and respond to this and other emerging global health
threats. CDC's efforts are grounded in over 40 years of Ebola
research and more than 20 Ebola outbreak responses. I want to
emphasize our goal is to end this outbreak as soon as possible.
This Ebola outbreak, first reported in the DRC in August
2018, is continuing to spread. As of July 24th, there are a
total of 2,597 cases and 1,743 deaths, with recent cases in
Goma and Uganda. The outbreak now encompasses 25 health zones
in the DRC, and in the past 21 days, we have seen 253 active
cases in 19 health zones. Of these cases, about a third were
known and monitored contacts, and even more concerning, roughly
30 percent were cases identified as community deaths that
occurred outside of the health care system. A substantial
percentage of cases were acquired in health care settings, and
137 health care workers have been infected. In light of this
regional spread, last week WHO's Director General declared the
DRC Ebola outbreak a public health emergency of international
concern.
This is the first outbreak in DRC that is occurring in a
densely populated area that has also experienced decades of
continuing conflict and civil unrest. DRC has reported nine
previous outbreaks of Ebola, but the two currently affected
provinces have never experienced an Ebola outbreak and have
busy, porous borders with Uganda, Rwanda, and South Sudan.
These challenges make this outbreak extremely difficult to
contain, and it is not yet under control at this time.
Over the course of this outbreak, we have deployed 204
experts from CDC to the DRC and neighboring countries and WHO
headquarters. And for the past several months, CDC has deployed
staff to Goma in support of surveillance, vaccination, border
health, and risk communication. CDC scaled up efforts following
the announcement of the first Ebola case in Goma, and our staff
are working directly with responders on the ground there to
assist with core public health interventions.
Availability of an Ebola vaccine is a new development since
the West Africa outbreak. CDC is actively working with the WHO,
providing technical support for the vaccination program, and
over 165,000 people in DRC have been vaccinated.
While vaccine is important and has likely had a mitigating
effect on the outbreak, vaccination complements but does not
replace basic and critical public health response activities
such as contact tracing and rapid identification and isolation
of ill patients.
Based on experience from previous outbreaks, an effective
response depends on early case identification and effective
isolation of about 70 percent of all cases and sustaining this
for several months. The fact that we are seeing so many cases
discovered as community deaths means that we are missing
contacts and missing the chains of transmission that must be
identified to bend the curve of the outbreak.
CDC's work in this outbreak reflects our extensive
expertise in disease control to inform the response, and CDC
works in three main avenues organizationally in this outbreak:
providing direct assistance to the DRC Ministry of Health in
Kinshasa and in Goma where the incident command is located,
with the WHO in Geneva, and as the public health lead in the
disaster assistance response team, or DART. Our work with
border countries focuses on their ability to quickly identify,
isolate, and effectively respond to a possible case of Ebola.
The rapid Ugandan containment of three imported Ebola cases in
June of this year is a demonstration of the effectiveness of
these preparedness efforts, which also build on CDC's long-term
involvement in disease detection, response training, and
capacity development in Uganda, supported by global health
security investments.
While this outbreak continues to be an urgent situation in
the region, the current risk to America remains low. The most
effective way to protect America from emerging threats is to
stop outbreaks at their source before they reach our borders.
CDC continues to improve the public health workforce abroad,
having trained over 12,000 public health professionals now in
70 countries. More than 260 of these professionals are from the
DRC and many are responding to this outbreak.
CDC is committed to this response and will continue to
position our assets globally to quickly respond to emerging
threats and disease hotspots around the world.
Thank you for your continued commitment and support to CDC
and our critical global health security mission.
[The prepared statement of Dr. Wolfe follows:]
Prepared Statement of Dr. Mitch Wolfe
Good morning Chairman Graham, Ranking Member Kaine, and members of
the Subcommittee. I am Dr. Mitch Wolfe, Chief Medical Officer of the
Centers for Disease Control and Prevention (CDC). Thank you for the
opportunity to testify before you on the Ebola outbreak in the
Democratic Republic of the Congo (DRC), and thank you for your
continued commitment to supporting CDC's work in global health
security.
This is the tenth and largest outbreak in DRC, and the second
largest outbreak of Ebola ever recorded since the virus was discovered
in 1976 in DRC. On July 17, 2019, the World Health Organization
declared the outbreak a Public Health Emergency of International
Concern (PHEIC). CDC has worked since last summer, in collaboration
with interagency and international partners, to end this outbreak and
ensure the health and security of our country. On June 13, CDC
announced the activation of its Emergency Operations Center to support
the response to the ongoing Ebola outbreak in Eastern DRC, which allows
CDC to provide increased operational support to meet the outbreak's
evolving challenges, and provides strengthened functional continuity to
meet the long term commitment needed to end the outbreak. We have
comprehensive Ebola response capabilities developed over 40 years at
the forefront of Ebola virus research and further refined by direct
engagement in more than 20 Ebola outbreak responses globally. In the
wake of the worst Ebola outbreak in history, the 2014-2016 outbreak in
West Africa that claimed over 11,000 lives, CDC has made significant
advancements in Ebola science, surveillance, and response. For example,
we confirmed that live Ebola virus can persist in specific body fluids,
such as in seminal fluids, for over a year following infection. We have
also trained epidemiologists and laboratory scientists, and provided
testing materials for African countries at greatest risk of an Ebola
outbreak.
In addition, in June 2015, we established CDC's Global Rapid
Response Team, a cadre of over 500 highly-trained CDC responders ready
to deploy on short notice anywhere in the world to respond to global
health threats and emergencies.
As of July 17, CDC expert disease detectives and other staff had
completed 313 deployments to the DRC, neighboring countries, and the
World Health Organization (WHO) headquarters in Geneva to provide
leadership and expertise in surveillance, laboratory testing, data
analytics, vaccine implementation, emergency management, infection
prevention and control, behavioral sciences, health communications, and
border health. In addition, we support coordination of activities among
response leaders including the DRC Ministry of Health and WHO. Our
operational expertise allows us to quickly and efficiently identify the
unique scientific and social variables of outbreaks and address them
with proven interventions.
However, the unique challenges of this Ebola outbreak mean this
fight is even more difficult than past responses. The complex security
challenges in North Kivu and Ituri provinces have severely limited
CDC's direct participation at the outbreak's epicenter, which is
located far from the capital city of Kinshasa in an area threatened by
armed conflict, crime, and civil unrest, as well as heavy cross-border
movement into neighboring countries. Violence in the impacted
communities has hampered Ebola disease surveillance, contact tracing,
and vaccination efforts. The affected population has low levels of
trust in the government and the international community. The DRC is
also experiencing other serious infectious disease outbreaks, such as
cholera, measles, and malaria, further stressing its health system.
Additionally, disease control in the impacted area is challenging
because of weak healthcare and public health infrastructure.
status of the epidemic
On August 1, 2018, the DRC Ministry of Health and Population
reported an outbreak of Ebola virus disease (EVD) in North Kivu
Province. As of July 21, the number of cases reported was 2,592, with
1,737 deaths (a 67 percent fatality rate). Due to challenges in case
detection and reporting posed by the security situation, CDC suspects
that the true number of cases could be much larger. As of July 21,
cases have been reported in 25 health zones of North Kivu and Ituri
provinces. On June 11, the Ugandan Ministry of Health reported its
first confirmed case of Ebola; two additional cases, from the same
family who crossed into Uganda from DRC, were then confirmed on June
12. There are currently no additional confirmed cases in Uganda, and
contacts of these cases were closely monitored for 21 days (the
incubation period for Ebola). More than 3,000 people were vaccinated in
Uganda to help prevent disease spread from the cases in Kasese
District, as well as over 4,000 frontline healthcare workers vaccinated
across the country. To date, no cases of Ebola have been confirmed in
any other provinces in the DRC or in the other neighboring countries.
The current outbreak is, however, already the second-worst Ebola
outbreak ever recorded, with case counts continuing to increase and key
response indicators showing little improvement.
Past outbreaks of Ebola in the DRC typically occurred in sparsely-
populated, rural areas. The current outbreak--like the 2014-2016
outbreak in West Africa--includes densely-populated urban areas,
increasing the likelihood of human-to-human spread. The outbreak
initially affected the Mandima health zone and then spread to the town
of Beni, which has a municipal population of 340,000 and a greater area
population of about one million. More recently the outbreak has been
heavily affecting the adjacent North Kivu health zones of Katwa and
Butembo, which together also encompass an urban area with a population
of approximately one million. The highly mobile population in this area
of DRC poses challenges for Ebola responders' contact tracing efforts.
Affected health zones have experienced reintroduction of Ebola cases to
areas where disease transmission was previously halted or slowed. The
number of affected health zones is also increasing; on June 30 an Ebola
case was identified in a previously unaffected health zone of Ituri
Province, close to the South Sudan border. On July 14, an Ebola case
was confirmed for the first time in the city of Goma, which has a
population of approximately two million people and is on the border
with Rwanda. CDC staff already embedded in the Goma Emergency
Operations Center provided direct support to the case investigation,
including interviewing contacts to establish their level of risk,
performing an assessment at the health care facility visited by the
patient, and strengthening the screening process at the Goma airport.
In each instance, CDC experts were able to quickly identify and correct
weaknesses in the response, reducing the risk of onward disease
transmission.
Escalating violence in some areas has generated significant
population displacement within DRC as well as across borders. Ongoing
insecurity limits the effectiveness of public health interventions such
as case investigation, contact tracing, and vaccination efforts. Many
of the new cases that are reported each day are identified in later
stages of illness, meaning that they spent much of their infectious
period outside of isolation and potentially infected others. Moreover,
from June 27 to July 17, among the 245 new cases with contact-related
information, 61 percent were either unknown contacts (not known as
contacts of previous Ebola patients) or known contacts but not being
followed by responders at the time of symptom onset. This means that
contact tracers may be missing chains of transmission and Ebola cases
may not be identified by responders early enough to prevent further
transmission.
status of response efforts
The Government of the DRC is leading the response, with strong
assistance from WHO. CDC is providing technical guidance to the DRC
government, bordering country governments, WHO and partners, bringing
to bear decades of experience, global health investments, and lessons
learned in the West Africa Ebola response. For example, CDC is working
with WHO and DRC's Ministry of Health to standardize training materials
and operating procedures for triage and isolation, decontamination of
healthcare facilities, and routine patient care. All partners are
working together toward one goal: to end this outbreak as soon as
possible.
In August 2018, CDC and USAID briefly deployed Ebola experts to
Beni for a few days, but they were pulled back due to security
concerns. In the context of a December 2018 DRC presidential election,
where several areas of the country experienced a deterioration in the
overall security situation, U.S. Embassy Kinshasa went on Ordered
Departure of non-emergency U.S. Government staff and all eligible
family members on December 14, 2018. When this was lifted on Jan. 31,
CDC staff returned to DRC to directly support the DRC government, WHO,
and the integrated U.S. Disaster Assistance Response Team (DART), where
CDC serves as the public health lead for the DART. As of July 19, 15
CDC staff were working with Ministry of Health counterparts in DRC in
the capital of Kinshasa and especially in the North Kivu provincial
capital of Goma, which has become the DRC government's base of
operations to respond to the outbreak. Goma is about 300 kilometers
from the main outbreak areas, and is considered to be more secure. As
an example of how we work, in March, with U.S. Embassy Kinshasa
concurrence, two CDC staff deployed to the town of Bunia in Ituri
Province for 2 weeks to assist with the investigation of a newly
confirmed Ebola case. CDC made local responders aware that there may be
unrecognized chains of transmission in Bunia, and CDC advised local
Bunia staff to better standardize and share information across
vaccination and contact tracing teams. CDC works closely with the U.S.
Embassy in Kinshasa to ensure the safety of deployed personnel, and
routinely defers to the State Department to assess the security
situation and determine access to the outbreak areas. While not
currently operating within Beni, Butembo, and other outbreak areas, CDC
remains prepared to return when it is deemed safe to do so by the U.S.
Department of State.
CDC also has deployed staff to augment our existing country offices
in the neighboring countries of Uganda, Rwanda, and South Sudan. As
evidenced by the cross-border transmission in Uganda last month, these
countries are all vulnerable to the possibility of imported cases
arriving from the DRC. From August 6, 2018 through July 17, 2019, 199
CDC staff have participated in a combined 313 deployments in response
to the Ebola outbreak: 98 deployments to DRC; 91 to Geneva; 55 to
Uganda; 40 to Rwanda; and 29 to South Sudan.
risk communications and health education
While the context of the response still presents many challenges,
efforts to improve cooperation and engagement with local communities
remains a critical aspect of this Ebola response, and continues to be a
focus of our work. CDC social and behavioral scientists have deployed
to DRC, WHO headquarters, and several countries bordering the DRC to
guide risk communication and community engagement strategies. Experts
from CDC, WHO, the International Federation of Red Cross and Red
Crescent Societies (Red Cross), and ICEF continue to work toward
improving the quality of engagement activities by standardizing
approaches and developing and delivering communications training to all
implementing partners.
A key component of improving community engagement is fulfilling the
information needs of the community by answering and addressing their
questions and concerns. Since May, CDC deployers have worked with the
DRC Ministry of Health and UNICEF on message development and testing,
analyzing and promoting the use of community feedback data in content
and strategy development, and long-term risk communication and
community engagement planning. CDC has also posted multiple Ebola
prevention-oriented fact sheets, posters, and flip books translated
into French, Swahili, Kinande, and Kinyarwanda, and recently released a
video public service announcement (PSA) video featuring Congolese
native and former NBA star Dikembe Mutombo delivering Ebola prevention
messages.
contact tracing
Contact tracing is the effort to find everyone who comes in contact
with a sick Ebola patient, either directly or through contaminated
materials. The goals of this process are to monitor contacts daily for
signs of illness and to isolate ill persons before they can infect
others. One missed contact who develops disease can keep the outbreak
going. When a case is not known to be a contact, they are usually
identified in a late stage of illness and may have already spread the
infection to others. On July 21, a total of 17,253 out of 20,302 (85
percent) known contacts of people with Ebola were being followed.
However, as noted earlier, among the new cases with contact information
from June 27 to July 17, 61 percent were either unknown contacts or
known but not followed at the time of symptom onset. The high
proportion of cases that are not known contacts or that are lost to
follow-up indicates that the quality of contact tracing must improve if
the outbreak is to be contained; contact tracing efforts have been
hindered by the volatile security situation. To strengthen contact
tracing, CDC designed ``train-the-trainers'' courses for frontline
response workers, focusing on contact tracing methods. CDC also created
an Ebola ``Exposure Window Calculator'' smartphone app in use by case
investigators.
infection prevention and control in healthcare settings
Healthcare settings have played an important role in amplifying
transmission in this and many prior outbreaks. Implementing proper
infection control and prevention practices is critical to stopping the
spread of the virus within the healthcare delivery system and to the
community. Prompt identification and isolation of patients arriving at
healthcare facilities with possible Ebola virus infection is essential
so that they may be safely evaluated and, if necessary, transported to
an Ebola Treatment Unit for further care. Infected people who are not
initially recognized to have Ebola may receive care at multiple
facilities before Ebola is suspected, exposing numerous patients and
healthcare workers to the virus. As of July 21, 34 percent of cases
identified in the preceding 21 days had visited two or more health care
facilities before being confirmed with Ebola.
Unfortunately, patients often arrive at specialized Ebola Treatment
Units late in their illness, and other healthcare facilities in the
area are not necessarily prepared to effectively or safely care for
Ebola patients. Patients are more likely to infect others during this
time, and less likely to survive if treatment is started late. As of
July 21, 137 local healthcare workers have contracted Ebola in the DRC.
Within DRC, CDC is collaborating with WHO and the Ministry of Health to
improve the use of standard procedures for correct patient assessment,
triage, and infection prevention and control (IPC) practices across
health facilities and to strengthen the supportive supervision and
mentoring of healthcare workers.
In the bordering countries of Uganda and Rwanda, CDC is providing
assistance to response partners to improve the capacity of healthcare
facilities to rapidly identify and isolate suspected Ebola cases, train
personnel, and improve infection prevention and control. At least 150
healthcare personnel have been trained by CDC in Uganda and Rwanda
since October 2018. Using information from interviews conducted at
border crossings, refugee transit centers, and district health offices,
CDC identified clinics and hospitals in border districts of neighboring
countries that would be most likely to receive an imported case of
Ebola from the outbreak area.
CDC assessed triage practices at these facilities, interviewed and
informed staff about risks of imported Ebola, and prioritized
facilities for additional training and support.
border health
The two DRC provinces affected by this outbreak, North Kivu and
Ituri, both border Uganda. North Kivu also borders Rwanda, and Ituri
province has a relatively short border with South Sudan. There is
substantial population movement across these country borders. The
Mpondwe Border Crossing is the busiest official ground crossings on the
border between Uganda and the DRC, with a peak of 35,000 travelers
passing through each day. At the Rubavu District Point of Entry between
Goma, DRC and Gisenyi/Rubavu City, Rwanda, an estimated 50,000 people
cross daily. This high volume, which includes pedestrian, commercial
car, and truck traffic, poses significant concerns for potential cross-
border transmission of infectious diseases. The WHO assesses that there
is a very high risk of regional spread. Preparedness activities in
bordering countries are ongoing and CDC is providing technical
assistance on their border health security efforts. Building on long-
term in-country CDC presence as well as collaborations from the earlier
2018 outbreak, CDC is working with the DRC Ministry of Health and
Population and other partners to adapt and implement screening
protocols at country-prioritized airports and ground crossings, and to
map population movement into and out of the outbreak zone to determine
where surveillance and other public health interventions could be
enhanced. As of July 22, over 77 million travelers have been screened
at 80 priority ports and crossing points in the DRC since the outbreak
began.
vaccine implementation
CDC conducted a clinical vaccine trial in Sierra Leone during the
West Africa Ebola outbreak, enrolling and vaccinating nearly 8,000
healthcare and frontline workers. This and several other studies have
suggested that the rVSV-ZEBOV (Merck) investigational vaccine is safe
and protects against infection with the Ebola virus. While the vaccine
is not yet licensed, the vaccine is being used in the current outbreak
in expanded access trials, predominantly in a ring vaccination strategy
that targets contacts of Ebola case patients for vaccination as well as
secondary contacts. WHO and the DRC Ministry of Health co-lead the
vaccination effort, with CDC contributing expert advice. While security
concerns have prevented CDC from participating in field activities, CDC
staff are embedded in the DRC Vaccine Commissions in Kinshasa and Goma
and at WHO headquarters to analyze data and improve the quality of ring
vaccination efforts.
CDC has also collaborated with WHO colleagues in Rwanda, South
Sudan, and Uganda to implement preventative vaccination of health care
workers in geographic areas near the DRC border, and has provided
technical assistance to these countries. To date, over 9,000 healthcare
workers have been vaccinated in the border countries of Rwanda, Uganda
and South Sudan. In addition, we have applied our expertise to update
Ebola vaccination protocols, operating procedures, and training and
communications materials for use at national and local levels, and
facilitated trainings for national staff. Our work across multiple
countries has helped standardize procedures and facilitate the use of
best practices. As of July 17, over 164,000 individuals had been
vaccinated in DRC.
On May 7, the WHO Strategic Advisory Group of Experts (SAGE) on
Immunization published interim recommendations to expand Ebola
vaccination strategies and address security concerns. Their recommended
vaccination strategies include ring vaccination, using ``pop-up
vaccination'' sites at a distance from the residences of contacts, and
targeted geographic vaccination, where all individuals in a given
village or neighborhood are invited to receive vaccine. These SAGE
recommendations also include alternative dosing to help ensure vaccine
continues to be available. Following the SAGE recommendation, the DRC
ethical review board approved a protocol to implement vaccination for
new populations (pregnant women beyond the first trimester, lactating
women, and infants down to 6 months of age) and to implement
vaccination at half the previous DRC dosage, which provides a similar
potency to the vaccine used in the West African outbreak. These changes
have been implemented in the field since early June 2019.
With expanded vaccination efforts we continue to underscore that
strengthening implementation of basic public health measures,
especially effective engagement and comprehensive identification of
contacts, will be essential in conjunction with any vaccination
strategy.
outlook of the epidemic
Ebola transmission can be stopped and the outbreak terminated when
at least 70 percent of cases are effectively isolated; that is, moved
to an Ebola Treatment Unit before they have infected anyone else, or
have their contacts and secondary contacts fully vaccinated. This needs
to be sustained for at least two to three months in order to end the
outbreak. While we have the public health knowledge and tools to
complete this task, we have not been able to fully implement these
tools in the field. Neither the outbreak nor the security situation on
the ground has improved in recent months and it is difficult to predict
with certainty what will happen. Without substantial and continued
improvements, the DRC could soon be facing an epidemic that rapidly
increases; at that point, the possibility of the outbreak spreading to
neighboring countries--in numbers much higher than the three confirmed
cases in Uganda we have already seen--will increase. CDC is committed
to leveraging its resources and global health security expertise to
help end the outbreak.
risk to the united states
CDC understands that an international outbreak of Ebola puts the
United States at risk and we appreciate the trust placed in CDC to keep
Americans safe from public health threats both at home and abroad. At
this time, we believe the direct risk to the United States remains low
based on the travel volume and patterns from the outbreak areas to the
United States and the implementation of border screening measures at
key airports and ports in the DRC and neighboring countries. CDC helped
organize exit screening workshops in Kinshasa and Goma in DRC to
bolster screening efforts and prevent spread of disease. On average, of
the approximately 325,000 air travelers arriving in the United States
daily, about 43 travelers are from the DRC, largely from regions
unaffected by the Ebola outbreak.
CDC continues to implement routine border health security measures
at U.S. Ports of Entry and has issued a Level 2 (Practice Enhanced
Precautions) travel health notice for the DRC that informs travelers
and clinicians about the outbreak and what types of precautions they
should take if traveling to the affected areas of the DRC. CDC has been
in regular contact with the non-governmental organizations operating in
the outbreak areas, and we provide recommendations on monitoring and
pre-departure health assessments for healthcare workers. In addition,
the U.S. Department of State has identified the outbreak area as a ``do
not travel'' zone because of armed conflict, crime, and civil unrest.
Current CDC guidance for managing Ebola cases in U.S. healthcare
settings has been reviewed and communicated to healthcare facilities as
part of domestic preparedness efforts. CDC's Laboratory Response
Network stands ready to perform testing on Ebola specimens should any
need arise, with testing kits deployed across the United States.
big picture: global health security
The ongoing response to Ebola in DRC and surrounding countries
demonstrates CDC's continued commitment to strengthen global health
security. CDC has been engaged in global health security work for over
7 decades and is able to leverage the essential public health assets
developed by notable initiatives like the U.S. President's Emergency
Plan for AIDS Relief (PEPFAR), the President's Malaria Initiative, and
global polio eradication to support core global health security
programs and ensure the safety of Americans. With an understanding of
the increasing threats posed by infectious diseases globally and in the
context of the West Africa Ebola outbreak, CDC received $582 million in
supplemental funding for a five-year effort in support of the Global
Health Security Agenda (GHSA). GHSA was launched by a growing
partnership of nations, international organizations, and non-
governmental stakeholders in 2014 with a stated vision of a world safe
and secure from global health threats posed by infectious diseases.
Since GHSA's launch, CDC's global health security work has helped
partner countries build and improve their public health system
capacity. With CDC's support, partner countries were able to
effectively contain meningitis in Liberia, Marburg virus in Uganda,
multidrug-resistant tuberculosis in India, and vaccine-preventable
diseases including measles and pertussis in Pakistan and diphtheria in
Vietnam, among other threats across the globe. These outbreaks were
stopped at their source, saving lives and reducing the amount of time
it takes to effectively respond from months and weeks to days.
We appreciate the continued commitment of Congress to global heath
security. Support for global health security enables CDC to continue
protecting Americans by detecting and preventing infectious disease
threats before they reach our borders. We are seeing progress in the 17
priority countries where we have invested our global health security
resources: all 17 have improved rapid response to disease threats
through established or expanded public health workforce training of
field-based epidemiologists, 13 have improved prevention of vaccine-
preventable diseases through increased community immunization coverage,
15 have ensured effective public health emergency operation centers
through training of emergency management officials, and 9 have
increased their ability to identify country-prioritized pathogens
through improved national laboratory testing capacity.
The DRC serves as an example of a country where CDC investments
have built capacity since program operations began in 2002, including
activities specifically to prepare for an Ebola outbreak. These efforts
have also fostered strong relationships with the DRC and surrounding
countries' ministries of health that have proved critical in times of
crisis. The May-July 2018 outbreak of Ebola in the Equateur province of
the DRC raised international concern due to logistical challenges
caused by the large and remote area. That outbreak ultimately led to 53
cases and 29 deaths. The swift response, which included CDC and other
U.S. Government personnel in the field, ensured it was quickly
controlled. Without a doubt, our global health security activities in
the DRC enabled a faster, more effective and successful response to the
May-July 2018 outbreak, and provide an important foundation in the
current Ebola response, even considering the complex security situation
and special difficulties posed by this outbreak.
The DRC Field Epidemiology Training Program (FETP), developed with
assistance from CDC and modeled after CDC's own training programs, has
trained around 260 frontline and advanced disease detectives who are
crucial to accurately detecting and identifying outbreaks. The DRC
graduated its first cohort of FETP residents in 2015. These disease
detectives are supporting the current Ebola outbreak and serve as an
example of how CDC supports sustainable capacity development of
countries to respond to outbreaks within their own borders.
There are presently 42 FETP-trained staff deployed in nine outbreak
health zones. Training programs like these work effectively because
they are complemented by decades of field experience that CDC experts
bring, teaching new epidemiologists how to rapidly identify diseases
and respond effectively to prevent spread. CDC maintains long-standing
collaborations in the DRC for priority diseases, including monkeypox
virus response and prevention, building capacity and skills that have
been beneficial for Ebola response. Sustainable investments, such as
resources and expertise to train laboratory technicians, renovate and
upgrade two laboratories, and establish a National Emergency Operations
Center in the DRC, are all being leveraged in the current Ebola
response.
Our global health security work is enhancing the world's ability to
respond to other emerging health threats. More than 70 countries have
an FETP program, resulting in more than 12,000 graduates around the
world. In Liberia, improved laboratories, epidemiology training,
surveillance, and surge capacity resulted in the identification of an
April 2017 meningitis outbreak within one day of the first discovery of
a case. By comparison, it took 90 days for the country to recognize the
first Ebola case in 2014. The Uganda Virus Research Institute has
emerged as a regional reference laboratory for viral hemorrhagic fevers
thanks to collaboration with CDC and its subject matter experts. In
addition, Uganda's Public Health Emergency Operations Center,
established with CDC support in 2013, is a model for other global
health security program countries. This center has been activated for
over 75 outbreaks and public health events. With this improved
capacity, Uganda has detected 16 viral hemorrhagic fever outbreaks as
of July 2018, and responded quickly to keep outbreaks small and
contained, including the three Ebola cases identified in June 2019.
They also detected a yellow fever outbreak in spring of 2016 in only
four days, compared to over 40 days that it took to identify the yellow
fever outbreak of 2010.
Another important component of CDC's global health work is the
agency's ability to monitor threats globally and to provide rapid
response through deployment of staff from across the agency. CDC's
Global Emergency Alert and Response Service (GEARS) closely monitors 35
to 45 outbreaks a day through event-based surveillance and supports
emergency deployments to respond to selected outbreaks. GEARS brings
together the Global Disease Detection Operations Center (CDC's
electronic surveillance analysis and response system for global
threats) and the Global Rapid Response Team, which has trained over 500
CDC personnel who have provided nearly 22,000 person-days of response
support.
One way that CDC ensures our domestic preparedness is through
building global capacity in health security. As we saw during the West
Africa Ebola epidemic, the current measles outbreak, and the Middle
East Respiratory Syndrome (MERS) outbreak, infectious disease threats
do not respect borders. An outbreak that starts in another country
could reach us in a matter of hours; this is why CDC works globally to
stop health threats before they enter the United States.
conclusion
CDC's number one priority during any public health emergency is to
save lives. CDC never loses sight of its primary mission to protect the
health and safety of the American people, and we know that global
health security is national security. CDC works overseas to ensure that
health threats do not reach the U.S., most importantly by working to
stop these threats where they start. CDC works to protect the United
States from direct health threats, protect U.S. interests in global
economic security, and ensure that lessons learned overseas can be
applied here to increase the strength of the U.S. public health system.
While significant progress has been made, we know that we will continue
to see the emergence of both known and unknown threats that will
require the laboratory and surveillance infrastructure that CDC
continues to support. The current Ebola outbreak remains a particular
challenge for DRC and the global health community, and there are no
signs that the outbreak is slowing. However, CDC's global health
programs have allowed us to build strong working relationships with the
DRC and surrounding countries' ministries of health, and we will
continue to work with USAID and our sister agencies in the Department
of Health and Human Services, as well as WHO and other international
partners, until we stop this particularly challenging outbreak.
The ability to rapidly detect and effectively respond to threats to
the public's health is a top priority for CDC. CDC works around the
clock to not only ensure its readiness but the readiness of those on
the front lines. CDC remains vigilant, because at any given moment,
thousands of infectious diseases are circulating in the world. We don't
know exactly which outbreak or potential pandemic threat is coming
next, but we know it is coming. The work we do now ensures that, when
the next major outbreak or pandemic threat does arrive, we are able to
protect the health of Americans and save lives.
STATEMENT OF REAR ADMIRAL TIM ZIEMER, USN, RETIRED, SENIOR
DEPUTY ASSISTANT ADMINISTRATOR, BUREAU FOR DEMOCRACY, CONFLICT,
AND HUMANITARIAN ASSISTANCE, U.S. AGENCY FOR INTERNATIONAL
DEVELOPMENT, WASHINGTON, DC
Mr. Ziemer. Chairman Graham, Ranking Member Kaine, members
of the subcommittee, thanks very much for this opportunity to
speak to you about the U.S. response to this Ebola outbreak.
Senator Graham, you have already summarized the challenge.
This deadly virus has appeared in one of the most insecure
areas of the world, endangering lives of people made vulnerable
by deadly violence and contributing to the population's
distrust of outsiders. It is really a perfect storm. Reaching
affected communities with proven and tested health
interventions has been undermined and interrupted by attacks on
health care workers. Over the last couple days, 14 deaths were
reported, not all on health care workers.
While mostly contained in two provinces, the Ebola outbreak
is now a regional issue, as punctuated by the World Health
Organization's declaration of the public health emergency.
USAID has been at the forefront of this response since the
outbreak began. With the additional $38 million that we
announced today, USAID's contribution to the Ebola response is
$136 million. Our partners have strengthened infection
prevention and control in over 360 health facilities and
dispensaries, trained more than 19,000 health care workers,
patient screening, isolation, and triage, and have reached over
2.1 million people with key health messages.
As the lead coordinator of the U.S. Government response in
DRC supporting Ambassador Hammer, the DART team works very,
very closely with CDC, the State Department, and our other
government agencies.
I traveled to DRC in May, followed quickly by the trip by
Administrator Green that you mentioned. Our visits confirmed
while a lot has happened, a shift in strategy was needed. And I
am pleased to say that reset is underway. And it takes a more
comprehensive humanitarian approach. With strong leadership
from Ambassador Hammer and coordinated efforts across the
entire interagency, the reset is supporting a greater cross-
border response, and it is also strengthening the health
response and tightening financial accountability and
transparency. Progress is being made. The emphasis on border
surveillance and local capacity has helped quickly contain the
virus, as illustrated by the cases that popped up in Uganda a
couple weeks ago.
So in the last several weeks, other significant adjustments
have been made such as the assignment of Mr. David Gressly as
the U.N. Emergency Ebola Response Coordinator to preside over
the entire coordination and leadership of the response. We are
expecting the release of the new strategy in a couple weeks
that aligns the humanitarian objectives with the public health
efforts. This strategy will set funding requirements which the
U.S. Government will use to solicit increased funding and
burden sharing from other governments.
So in the near term, cases will likely increase, but we
expect that the approaches outlined in the reset will help DRC
turn the tide and contain this deadly virus.
So in the long term, through the Global Health Security
Agenda that Admiral Mitch Wolfe just mentioned, USAID will
continue to work with CDC, as well as the Department of State
and other agencies, to build the capacities of countries to
prevent, detect, and respond to future outbreaks. A threat
anywhere is a threat everywhere. And we are committed to
containing this outbreak and other outbreaks at the source. So
we are working closely with our interagency partners in a very
coordinated effort to bring our funding, our technical
assistance, and all the U.S. Government resources to bear. To
bring this outbreak to an end is a challenge, but it is not
insurmountable.
So thanks for your time, most importantly for your interest
in calling this hearing, and for your leadership. And we look
forward to answering your questions.
[The prepared statement of Mr. Ziemer follows:]
Prepared Statement of Rear Admiral Tim Ziemer, USN, Retired
Chairman Graham, Ranking Member Kaine, members of the subcommittee,
thank you for the opportunity to speak with you today about the U.S.
response to the ongoing Ebola outbreak in the Democratic Republic of
the Congo (DRC), and for your interest in this important issue. Since
August 2018, the DRC has been facing what is now an unprecedented Ebola
outbreak in the country, with 2,578 confirmed and probable cases and
1,737 deaths as of July 21, 2019. It is the world's second-largest
recorded outbreak of the disease, eclipsed only by the 2014 West Africa
outbreak that resulted in nearly 29,000 cases and killed more than
11,000 people. On July 17, 2019, the World Health Organization (WHO)
declared it a Public Health Emergency of International Concern, a
status only announced when there is an ``extraordinary event'' that is
determined ``to constitute a public health risk to other States through
the international spread of disease'' and ``to potentially require a
coordinated international response.'' This declaration is only the
fifth one of its kind that the WHO has made since the adoption of the
International Health Regulations in 2005.
This ongoing Ebola outbreak is more than just a public health
crisis--it is happening in the midst of a complex humanitarian crisis
that has left 12.8 million people in need of assistance in the DRC.
While the DRC has faced nine previous Ebola outbreaks, this is the
first in Provinces that already suffer from chronic humanitarian
needs--like the lack of food, safe drinking water, and shelter.
In May, I traveled to Eastern DRC and saw the scale and complexity
of this outbreak and the response firsthand. I have traveled
extensively in my career, from my 3 decades with the U.S. Navy and in
the roles I have held since. This trip to the DRC was one of the most
important trips I have ever taken. I heard directly from local
traditional and religious leaders, as well as our partners, about the
ongoing violence and community distrust towards the response driven by
years of corruption and political and governance failures in the
region, which makes this outbreak more difficult to contain.
This outbreak is far from controlled. In recent weeks, it has
become clear that this could become a regional issue, as we have seen
cases move dangerously close to neighboring Rwanda and South Sudan. In
Uganda, three cases were detected in June 2019, although those cases
were later recorded officially as DRC cases since that is the country
where they originated. The U.S. Government is aggressively adapting our
strategies, and working with our interagency and international
partners, including the Government of the DRC the WHO, and the U.N.
humanitarian agencies to help reset our approach to the response to
stop the spread of the disease.
USAID has contributed more than $98 million for the response
efforts to date, and will continue to invest and provide vital support
until this disease is contained. Bringing an end to this devastating
outbreak is a top priority for the U.S. Government, because we are
committed to reducing the suffering of those affected by Ebola, and
because effective efforts to contain and end the outbreak can prevent
it from reaching the broader region, as well as our borders.
update on the outbreak in the drc
Next week, we will mark one year since the Government of the DRC
declared the current Ebola outbreak in North Kivu Province in Eastern
DRC. Within 2 weeks of that declaration, confirmed cases were reported
in neighboring Ituri Province. By mid-October, increased transmission
in hospitals and health facilities led to a spike in cases in Beni,
which made it the epicenter of the outbreak at the time. Today, Beni is
a hotspot for transmission, alongside Mabalako, Katwa, and Butembo, as
the virus continues to spread in the region as a result of community
deaths, high population mobility, and other factors, with 25 Health
Zones throughout North Kivu and Ituri Provinces affected as of July 15.
Regional spread remains a very serious concern. On July 14, the DRC
confirmed its first case in Goma, a city of more than a million people
near the border with Rwanda and a major transit hub in the region. In
addition, a case was recently confirmed in the DRC's Ariwara Health
Zone, in Northern Ituri Province, fewer than 45 miles from South Sudan
and 7 miles from Uganda.
Complicating an already difficult response to this deadly disease,
this outbreak is occurring in areas with ongoing fighting between
multiple armed groups, which leads to access constraints and the
intermittent suspension or modification of ongoing activities,
including those of USAID partners. A little more than a week ago, two
health care workers were deliberately targeted and killed in Beni,
which highlights how dangerous this outbreak has been for the brave
people who are risking their lives in responding. In the week following
my recent visit, the Katwa Ebola treatment unit (ETU) was attacked--not
for the first time--killing one guard, and a militia attacked a hotel
in Butembo housing Ebola responders, killing several people and halting
response operations for several days. Every day that health teams are
absent from an outbreak area because of a security incident is a lost
day of critical response activities that can save lives.
The outbreak is also spreading in an area with a long history of
deeply-rooted community distrust--which at times has exploded into
violence against frontline workers--of the central government,
foreigners, and people from other regions in the DRC because of decades
of neglect, corruption, exploitation, and violence. This deep mistrust
has also fueled misconceptions that Ebola was created to wipe out
populations or extort money from people. Faith and community leaders
told me about feeling exploited by the ``Ebola economy'' and about
their deep suspicion regarding the motives of the sudden and dramatic
presence of outsiders. This was a sobering reminder for me that
communities do not trust the response.
response and reset
There is no question that our interventions thus far have saved
lives and prevented a much larger outbreak. The more than $98 million
USAID has provided for the Ebola response in the DRC to date has been
supporting life-saving assistance, including activities to prevent and
control infections, training for health care workers, community
engagement, the promotion of safe and dignified burials, and food
assistance for affected people, including Ebola contacts under
monitoring and their families, patients in Ebola treatment centers, and
discharged survivors.
Last September, the U.S. Government deployed a Disaster Assistance
Response Team, or DART, which built upon early assistance from USAID
and the Centers for Disease Control and Prevention (CDC) within the
U.S. Department of Health and Human Services (HHS). The DART is the
lead coordinator of the United States' whole-of-government response to
the Ebola outbreak in the DRC. This expert team--composed of disaster
and health experts from USAID and HHS--is working tirelessly to
identify needs and coordinate activities with partners on the ground.
By augmenting ongoing efforts to prevent the spread of disease and by
providing aid to help Ebola-affected communities, the DART provides a
forward-leaning, flexible, efficient, and effective operational and
coordination structure to mount the U.S. Government response.
There has been clear progress because of their efforts and the work
being done by our partners on the ground to stop the spread of Ebola.
We have helped train 1,680 community health care workers to conduct
surveillance, equipping them with knowledge and tools to track the
disease and stop the chains of transmission. We have also trained more
than 19,000 Congolese health care workers in patient screening, triage,
isolation, appropriate waste-management, and other practices that
prevent the transmission of disease. These practices are helping
strengthen measures to prevent and control infections in at least 309
health facilities across at least 18 Health Zones. Our partners
continue to provide treatment and care that help increase the chance of
survival for people with Ebola, and USAID is ensuring they have the
supplies they need to operate, including by providing 53 metric tons of
personal protective equipment at more than 100 health facilities.
Additionally, USAID has funded the provision of enough food to meet the
needs of 300,000 people--including Ebola patients, contacts, survivors,
and their family members.
Our experience with this outbreak so far, and the 2014 West Africa
outbreak, has shown us that community acceptance and ownership is
crucial to the success of this response. USAID is funding partners to
dispel rumors about the disease through community outreach--including
by working with trusted community leaders--to increase acceptance of
public health response activities. Our partners are working to reach
508,000 households, or 2.1 million people, with key health messages to
engage communities in conversations about Ebola, debunk myths, and
raise awareness about the transmission of Ebola.
Despite all of our efforts, it became clear during my trip to the
DRC that insecurity, poor coordination, the underutilization of key
partners like non-governmental organizations (NGOs) and faith-based
groups, and insufficient community engagement were hindering response
efforts. This is in part why, soon after my return to Washington DC,
the U.S. Government began to shift towards a complete reset of the U.S.
response towards a more comprehensive humanitarian and development
approach that responds to the broader needs of the community to help
improve the community's perceptions and attitudes towards the public
health interventions. Following my trip in June 2019, Administrator
Green also travelled to Butembo to see the Ebola emergency first-hand,
and it was very clear to him that this was a development emergency in
the DRC.
With this critical context in mind, the U.S. Government has four
key strategies to achieve this reset: (1) enhancing response leadership
and coordination; (2) strengthening community engagement; (3)
addressing the complex security environment; and (4) strengthening
preparedness, in both the DRC and the surrounding countries.
First, strong leadership and coordination is critical to making
this response more effective, which is why we are optimistic about the
appointment of United Nations Emergency Ebola Response Coordinator
David Gressly in May. USAID has emphasized the need for clear lines of
leadership and accountability to strengthen his ability to oversee
response functions to support the Government of the DRC's and the WHO's
lead of the public-health response. Overall, leadership for this
response must be more inclusive, and directly involve the local and
international NGOs that are vital to the response. These organizations
must be better engaged and active in coordination efforts, because they
deliver assistance that complements efforts by the Government of the
DRC and U.N. agencies and because they have the trust of the affected
communities. The U.S. Government, along with other lead donors, also
continues to advocate for strategic shifts, like including civil
society, faith-based organizations, and NGOs in coordination
structures. USAID is also closely collaborating with our interagency
partners--like HHS and the HHS National Institutes of Health--along
with the Government of the DRC, other donors, the WHO, the U.N.,
international partners, and civil society to battle this disease. For
example, we worked with these key partners to provide input into the
development of the latest Strategic Response Plan for the outbreak, the
public-health portion of which was just released earlier this month, to
guide efforts over the coming months. We are also continuing to
encourage other donors to contribute resources to this Ebola response,
including governments that have already provided modest assistance.
Second, Congolese communities must be at the center of what we do,
which is why we are working to shift the response from a top-down
approach to one that elevates the communities' role and prioritizes
their needs and feedback. As such, the U.S. Government is continuing to
emphasize community engagement across the response--from the DRC
Ministry of Health to the WHO and USAID partners, many of which have
found innovative ways to connect with communities. One of our partners,
for example, worked with a music festival in Goma to get Ebola-
prevention messages out, which reached more than 37,000 people with
handouts and fliers; musicians even incorporated these messages into
their sets. USAID's partners are also engaging with journalists, to get
them to take to the airwaves, create mini movies, and organize groups
on the WhatsApp social messaging platform to educate people about Ebola
and stimulate discussions. We are increasing emphasis on community
dialogue and actively looking to involve a wider cross-section of
organizations, like local women's, youth, and faith-based groups. One
of our partners is working with young people to change their
perspectives on Ebola-related rumors, and has trained them to
communicate about Ebola and mobilize their peers in the response. Our
partners have also hired local people--including Ebola survivors--to be
a part of the response in their own communities, and are reaching out
to respected local leaders to deliver Ebola prevention messages in
local languages. Ultimately, we are working to listen to local needs,
incorporate feedback, and ensure we are doing all we can to foster
positive changes in the relationship between communities and Ebola
responders.
Third, we must do more to address the complex security environment.
This is imperative to fully earning the trust of communities and
gaining their participation in the response. The affected communities
have long experienced armed conflict, and have suffered for years prior
to this outbreak. Our response must acknowledge how this insecurity has
affected them and their beliefs about the disease. Given all that these
communities have been through, we must be cautious of militarizing the
response. We should energize leading responders to utilize common
humanitarian techniques, including transparent information-sharing,
negotiations on how to gain access to affected communities, and
engaging local community leaders in discussions and tactics on security
that benefit the entire community, not just responders.
Fourth, with the continued threat of spread to countries that
neighbor the DRC, we must do more to strengthen preparedness both in
other high-risk areas in the DRC, as well as in Burundi, Rwanda, South
Sudan, and Uganda. This is why we have been looking outside of the
DRC's borders to provide the support and expertise needed to keep the
disease from spreading. Part of this line of effort must be a more
aggressive approach to vaccination, which should include the use of the
second available vaccine to help build a firewall around the outbreak
zone.
preparedness and preventing ebola from crossing borders
We are intensely concerned that this outbreak could soon become a
regional issue, as it moves closer to the borders of countries that
neighbor the DRC. We are continuing to strengthen health surveillance
activities at borders, as well as train health workers and strengthen
local capacity within the countries to respond efficiently and
effectively to case alerts. In these neighboring countries, we are
supporting Ebola preparedness efforts that strengthen local capacity to
detect the disease; train screeners and screen travelers at key points
of entry; track cases if they occur; maintain water, sanitation, and
hygiene facilities; improve the prevention and control of infections in
health facilities: vaccinate at-risk workers; and conduct public
awareness and sensitization campaigns about Ebola.
USAID is also funding Ebola preparedness efforts in Goma, as well
as in Provinces adjacent to North Kivu and Ituri, to help ensure that
the virus does not spread any further within the country. Our efforts
also account for how the humanitarian situation in the DRC affects the
movement of people. Factors such as poor infrastructure, forced
recruitment into armed groups, and ongoing violence have contributed to
the deterioration of humanitarian conditions and triggered mass
internal displacement and refugee outflows.
These efforts have never been more critical: With the confirmed
case in Goma at the beginning of last week, the outbreak is now nearing
the Rwanda border. Earlier this month, a confirmed case in Ariwara
Health Zone brought the outbreak fewer than 45 miles from the South
Sudan border. Most concerning, three confirmed cases of Ebola, in
individuals all of whom later died, were detected in Uganda in June,
which marked the first cases of the deadly disease detected outside DRC
since the start of the outbreak in August 2018. These cases serve as a
reminder that we must stay vigilant. USAID continues to monitor the
situation closely, and we will continue to work with partners to
support preparedness efforts in these neighboring countries.
Preparing for disease requires a whole-of-society approach across
multiple sectors to prevent, detect, and respond to infectious-disease
threats as our national Biodefense and Global Health Security
Strategies make clear. When crises happen--like the current Ebola
outbreak--we work to ensure response groups have the tools and
operational structures necessary to respond quickly and effectively.
USAID is also working to promote global health security at the
local level by helping at-risk communities develop preparedness plans
and train community volunteers to detect and respond to infectious-
disease threats in their own neighborhoods. We have developed an
emergency supply-chain playbook designed to build country capacity to
quickly provide and manage essential emergency commodities, like
personal protective equipment, that are critically needed during
outbreaks. We are helping countries establish risk-communication
programs that provide communities the information needed to reduce
disease spread.
conclusion
In conclusion, USAID and the rest of the U.S. Government are well-
equipped to help the DRC and neighboring countries respond to this
disease, and have begun to reset our response to better adapt to these
key challenges on the ground. We have been providing humanitarian and
development assistance in the DRC for more than 3 decades, and are
familiar with the operating environment and access challenges. While
responding to this outbreak is complex, this is a whole-of-government
response, which is making the most of each Department and Agency's
knowledge and expertise. We are all united in the same goal of helping
the people of the DRC to bring this outbreak under control as soon as
possible while demonstrating our continued support for the people,
families, and communities affected by this devastating disease.
We know that this is more than just a public-health crisis: This is
occurring on top of an extended, complex, and violent humanitarian
crisis. By placing community needs at the forefront of the response, we
can strengthen the relationship between communities and the so the
public health interventions can be more effective. Thank you for your
time. I look forward to answering your questions.
STATEMENT OF HON. MARCIA BERNICAT, PRINCIPAL DEPUTY ASSISTANT
SECRETARY, BUREAU OF OCEANS AND INTERNATIONAL ENVIRONMENTAL AND
SCIENTIFIC AFFAIRS, U.S. DEPARTMENT OF STATE, WASHINGTON, DC
Ambassador Bernicat. Chairman Graham, Ranking Member Kaine,
distinguished members of the committee, thank you for inviting
me here to speak today. I am honored to appear as part of a
team of officials and colleagues who represent the whole-of-
government approach that the United States brings to the Ebola
response.
The ongoing Ebola outbreak in the Democratic Republic of
Congo is the second largest in human history. For nearly a
year, brave responders, with strong U.S. support, have been
working to stop Ebola's spread and treat the ill. Their efforts
have saved countless lives, but new cases continue to emerge.
We are now at a critical juncture. Ebola cases continue to
rise. Ebola patients continue to die, and local communities and
responders have not been taking all the necessary steps to end
the outbreak. And in some cases, as we have noted, communities
are actively, even violently, resisting Ebola response efforts.
The risk of Ebola spreading to additional areas of the DRC or
neighboring countries remains high, as demonstrated by the
three confirmed cases in Uganda in early June and the case in
Goma last week.
At the same time, there is reason for hope. The DRC and
neighboring governments are taking action to prevent Ebola
cases, detect possible infections, and respond quickly to treat
patients. The World Health Organization and the United Nations
are improving coordination with nongovernmental organizations
and local communities. And the United States, as it has since
the first Ebola cases emerged, continues to take a leading role
to end the outbreak.
As you noted, Senator Graham, ending this outbreak is not
only a global health security priority--it is a U.S. national
security priority. And as my colleague said, an infectious
disease threat anywhere can be an infectious disease threat
everywhere, as we saw vividly in 2014. The United States
Government is firmly committed to stopping this pandemic. We
are the largest single country donor, and we have continuously
deployed staff to the DRC and neighboring countries to enable a
more effective response.
Our whole-of-government approach is critical to stopping
this outbreak, which is occurring in the midst of a complex
humanitarian crisis and tremendous security challenges from
local armed groups. The Government of the DRC and the WHO have
led the response since the first cases emerged nearly a year
ago. Government officials in Uganda, Rwanda, Burundi, and South
Sudan have also demonstrated leadership by increasing
preparedness efforts to prevent, detect, and respond to Ebola
cases. And the United Nations' designation of David Gressly as
U.N. Emergency Ebola Response Coordinator on May 23 is
enhancing the response coordination and addressing the broader
humanitarian and security conditions impacting the response.
The World Bank has provided significant resources and helped
ensure financial accountability of response efforts. Other core
donors include the United Kingdom and the European Union. And
NGO staff and the Congolese citizens themselves are the
backbone of the on-the-ground response efforts to identify and
treat Ebola patients and their contacts.
The State Department has also raised international
awareness of the DRC Ebola outbreak and is encouraging the
international community to fully fund the response. We convened
a meeting of the DC diplomatic corps on June 14 where USAID,
CDC, and State Department officials briefed on the outbreak's
trajectory and underlined the urgent need for funds. On July
14, the DRC Government and World Health Organization released a
partial new response plan requesting $287 million over the next
6 months to fund the public health response. Additional appeals
for support in other sectors beyond health are forthcoming.
The State Department and our embassies' country teams are
regularly engaging our foreign counterparts from the DRC to the
WHO to the DRC's neighbors at the highest levels to make the
Ebola response a priority and to enhance coordination across
governments and donors.
Thank you for your time, your consideration, and your
interest. I welcome the opportunity to respond to your
questions.
[The prepared statement of Ambassador Bernicat follows:]
Prepared Statement of Hon. Marcia Bernicat
Chairman Graham, Ranking Member Kaine, and distinguished members of
the Committee, I want to thank you for inviting me to speak today. I am
honored to appear as part of a team of officials who represent the
whole-of-government approach that the United States brings to the Ebola
response.
The ongoing Ebola outbreak in the Democratic Republic of the Congo
(DRC) is the second-largest in human history, with more than 2,500
cases and over 1,700 deaths since August 2018. For nearly a year, brave
responders--with strong U.S. support--have been working to stop Ebola's
spread and treat those infected. Their efforts have saved countless
lives, but new cases continue to emerge. We are now at a critical
juncture. Ebola cases continue to rise, Ebola patients continue to die,
and local communities and responders are not taking all necessary steps
to end the outbreak. In some cases, local communities are actively,
even violently, resisting Ebola response efforts. The risk of Ebola
spreading to additional areas of the DRC or neighboring countries
remains high, as demonstrated by the three confirmed cases in Uganda in
early June and the case in Goma last week.
At the same time, there is reason for hope. The DRC and neighboring
governments are taking action to prevent Ebola cases, detect possible
Ebola infections, and respond quickly to treat Ebola patients. The
World Health Organization (WHO) and the United Nations are facilitating
improved response coordination with nongovernmental organizations and
local communities, taking security and humanitarian needs into account.
And the United States--as it has since the first Ebola cases emerged in
eastern DRC--continues to take a leading role to end the outbreak.
At the outset of my testimony, I would like to make one point
clear. Ending this outbreak is not only a global health security
priority--it is a U.S. national security priority. An infectious
disease threat anywhere can be an infectious disease threat everywhere
as we saw vividly in the 2014 West Africa Ebola outbreak. The U.S.
Government is firmly committed to stopping Ebola's transmission,
supporting the treatment of those infected, and minimizing the loss of
life in this outbreak. The United States is the largest single-country
donor to response efforts, and we have deployed staff to the DRC and
neighboring countries to enable a more effective response.
We have seen time and again how critical a whole of government
approach is to stopping epidemics and pandemics. This is especially
true for this Ebola outbreak, which is occurring in the midst of a
complex humanitarian crisis and tremendous security challenges from
local armed groups. Stopping Ebola transmission in this case also
requires a multi-government approach. The Government of the DRC and the
World Health Organization (WHO) have led the response in the DRC since
the first cases emerged nearly a year ago. Government officials in
Uganda, Rwanda, Burundi, and South Sudan have also demonstrated
leadership by increasing preparedness efforts to prevent, detect, and
respond to Ebola cases. The United Nations designated David Gressly as
U.N. Emergency Ebola Response Coordinator on May 23 to enhance response
coordination and address broader humanitarian and security conditions
impacting the response. The World Bank has provided significant
resources and helped ensure financial accountability of response
efforts. Other core donors include the United Kingdom and the European
Union. And NGO staff and Congolese citizens themselves are the backbone
of on-the-ground response efforts to identify and treat Ebola patients
and their contacts.
The State Department has championed efforts to raise international
awareness of the DRC Ebola outbreak and encourage the international
community to fully fund the response. My bureau convened a meeting of
the DC diplomatic corps on June 14 where USAID, CDC, and State
Department officials provided a briefing on the outbreak's trajectory
and underlined the urgent need to fund response activities. On July 14,
the DRC government and World Health Organization released a partial new
response plan requesting $287 million over the next six months to fund
the public health response. Additional appeals for support in other
sectors beyond health are forthcoming, and it is imperative that we
diversify the donor pool to meet resource needs. On July 17, WHO
declared the outbreak a Public Health Emergency of International
Concern (PHEIC), which we hope will mobilize more resources. All
countries must contribute to ensure global health security.
The State Department has also been regularly engaging foreign
counterparts in the DRC, the United Nations, the WHO, and the DRC's
neighboring countries to enhance response coordination. Our embassies
and country teams are engaging foreign counterparts at the highest
levels to make the Ebola response a priority--and to enhance
coordination across government ministries and donors.
Thank you for your time and consideration of this important issue,
and I welcome the opportunity to answer any questions you may have.
STATEMENT OF HON. TIBOR NAGY, ASSISTANT SECRETARY, BUREAU OF
AFRICAN AFFAIRS, U.S. DEPARTMENT OF STATE, WASHINGTON, DC
Ambassador Nagy. Mr. Chairman, Ranking Member, and
distinguished members, thank you for the opportunity to testify
today on the State Department Bureau of African Affairs'
efforts to combat the ongoing Ebola outbreak in eastern
Democratic Republic of Congo.
This panel serves as a reminder that the Ebola response is
a whole-of-U.S. government effort, and I am grateful that my
colleagues and I are in this fight.
My remarks today briefly summarize the longer and more
detailed statement which was previously submitted for the
record.
The Ebola outbreak in eastern DRC, now declared by the
World Health Organization to be a public health emergency of
international concern, continues to devastate the region. The
DRC successfully handled nine previous Ebola outbreaks with
capacity and expertise built up over decades of close
cooperation with the United States. However, this 10th
outbreak, now the second longest in history, is different as it
is in a conflict zone.
Eastern DRC is not new to instability. Longstanding
regional and local tensions fueled wars that killed millions in
the 1990s and 2000s. Clashes persist to this day in Ituri and
North Kivu where the Ebola outbreak continues to spread. Local
populations have faced decades of armed group attacks, food in
security, poverty, outbreaks of measles, cholera, other
diseases.
The recent surge of international attention on the Ebola
response stands in stark contrast to a record of neglect on
these other problems. This glaring dichotomy has led local
militia and frustrated community members to lash out and target
health care facilities and workers. It underscores more than
ever the necessity of engaging communities and local leaders to
garner buy-in for the response.
The United States is working closely with the DRC
Government, U.N., and WHO on this response. The historic
transfer of power to President Felix Tshisekedi in January
opened a new chapter in the U.S.-DRC bilateral relationship.
With President Tshisekedi, we are optimistic that we have a
willing partner receptive to U.S. and international support to
contain the outbreak.
Embassy Kinshasa is fully engaged in supporting the entire
U.S. Government response in the DRC. The Kinshasa team has not
only kept up with increasing policy and logistical demands from
the Ebola outbreak, but also accelerated its diplomatic
overreach, oversight, and reporting. The embassy has expanded
its operations to support a surge of U.S. temporary duty
personnel to Kinshasa and Goma where we did not previously have
an established presence. Ambassador Hammer has proactively
supported a constant stream of high level U.S. and U.N.
visitors to the East, to increase attention and demonstrate
U.S. commitment to this response. From our embassy in Kinshasa,
we engage in diplomacy across the entire country, which in
distance stretches almost from my driveway in west Texas to
here in Washington, DC.
At the same time, our Embassies Bujumbura, Juba, Kampala,
and Kigali have consistently urged the most senior members of
their host governments to strengthen efforts to prevent the
outbreak's spread. Burundi, South Sudan, Uganda, and Rwanda are
vulnerable to the spread of Ebola and must remain vigilant,
evidenced by recent cases in Uganda and in Goma City, a major
transportation hub.
The existing humanitarian crisis and Ebola outbreak has
already caused tremendous harm to Congolese people and threats
to the broader region. Our response must address the complex,
underlying factors exacerbating the outbreak and impede its
spread. The Bureau of African Affairs is here to offer the full
suite of diplomatic tools to assist Congo and facilitate the
work of our partners.
Thank you for your time and consideration, and I look
forward to your questions.
[The prepared statement of Ambassador Nagy follows:]
Prepared Statement of Hon. Tibor Nagy
Mr. Chairman, ranking Member and distinguished Members, thank you
for the opportunity to testify today on the State Department Bureau of
African Affairs' efforts to combat the ongoing Ebola outbreak and
humanitarian crisis in eastern Democratic Republic of the Congo (DRC).
I am pleased to be here with my colleagues. This panel serves as a
reminder that the Ebola response is a whole-of-U.S.-government effort,
and I am grateful that my colleagues and I are in this fight.
The Ebola outbreak in eastern DRC, now declared by the World Health
Organization (WHO) to be a Public Health Emergency of International
Concern (PHEIC), continues to devastate the region, with tragic loss of
life and disruption of social and economic livelihoods. The DRC
successfully handled nine previous Ebola outbreaks, with capacity and
expertise built up over decades of close cooperation with the United
States, especially CDC. However, this 10th outbreak in eastern DRC--now
the second largest in history--is different, as it is in a conflict
zone. Health responders have been attacked and we mourn the loss of
heroic Congolese and WHO health workers who have been killed. This
insecure environment has challenged the international community's
standard operational response, strengthened after the 2014-2016 West
Africa outbreak, and hampered the U.S. Government's ability to stop the
outbreak at its source. As a result, the Africa Bureau and Embassy
Kinshasa have worked closely with technical and policy experts across
USAID, the Department of Health and Human Services, and the U.S.
interagency to demand a fresh start and ``reset'' of the response to
better address the unique context in which this outbreak is occurring.
eastern drc context
Eastern DRC is not new to instability. Longstanding regional and
local tensions with deep-rooted grievances have fueled wars that killed
millions in the 1990s-2000s and clashes persist to this day in Ituri
and North Kivu provinces, where the Ebola outbreak continues to spread.
Numerous armed groups operate in the region, conducting attacks that
have harmed and killed thousands of Congolese civilians over decades.
Despite the DRC being home to tremendous natural resource wealth, the
Congolese people have seen little economic benefit, particularly in the
mineral-rich and agriculturally fertile current outbreak zone.
Food insecurity plagues local populations, and outbreaks of
cholera, polio, and malaria continue to take the lives of innocent
Congolese throughout the country. Although not specific to the East,
the current measles outbreak in the DRC has sickened over 110,000
people and killed over 1,800 in 2019 alone. This overall humanitarian
crisis and intercommunal violence has led to significant internal
displacement as well as to Congolese fleeing to neighboring countries.
With poor infrastructure, rampant corruption, economic stagnation,
and years of governance failures in the East left unaddressed by the
previous DRC administration, local populations are disillusioned and
fed up. An ``Ebola economy'' is developing, where despite our best
intentions, the international response is exacerbating economic divides
in a historically impoverished area. The surge of international
attention on the Ebola response stands in stark contrast to a record of
neglect on other health, political, and social problems the East faces.
This glaring dichotomy has led local militia and frustrated
community members to lash out and target healthcare facilities and
workers. It underscores more than ever the necessity of engaging
communities and local leaders to garner buy-in for the response.
u.s. embassy engagement
The DRC government, alongside the U.N. and WHO, is leading this
response, building on their decades of experience. The historic
transfer of power to President Felix Tshisekedi in January 2019 has
opened a new chapter in the U.S.-DRC bilateral relationship, defined by
our statement announcing a Privileged Partnership for Peace and
Prosperity that elevates our bilateral relationship and strengthens
cooperation on issues ranging from anti-corruption to human rights to
institutional strengthening, among others, and including the Ebola
response. With President Tshisekedi, we are optimistic that we have a
willing partner and new administration receptive to U.S. and
international support to contain the outbreak.
I heard this commitment firsthand during President Tshisekedi's
visit to Washington in April and have seen it since demonstrated by his
recent travels to eastern DRC. There, he has personally advocated for
Ebola response efforts and encouraged popular local figures to lend a
voice in support of community acceptance and participation in response
and preparedness measures.
The U.S. Government will continue to work closely with new U.N.
Emergency Ebola Response Coordinator David Gressly, the WHO, the DRC
Presidential Steering Committee on Ebola led by Director Dr. Jean-
Jacques Muyembe, and the DRC Ministry of Health, to improve
communication and coordination across the public health and
humanitarian response. We are thankful to be working alongside
Congolese medical professionals who have for years navigated logistical
and bureaucratic obstacles, limited resources, community sensitization,
and other challenges to protect not only the Congolese people, but the
world as a whole, from the spread of Ebola.
Embassy Kinshasa is fully engaged in supporting the entire U.S.
Government response in the DRC. Amidst challenging circumstances, the
team in Kinshasa has not only kept up with increasing policy and
logistical demands from the Ebola outbreak, but also accelerated its
diplomatic outreach, oversight, and reporting on the issue. The Embassy
hosted permanent USAID and CDC missions prior to this outbreak. As part
of the response, it has expanded its operations to support a surge of
USAID, CDC, NIH, and other temporary duty personnel to Kinshasa and
Goma, where we did not previously have an established presence or
robust mission support. Ambassador Hammer has proactively supported a
constant stream of high-level U.S. and U.N. visitors to the East, to
increase attention on the outbreak and demonstrate U.S. commitment to
the response. Our team has leveraged its close ties with the Tshisekedi
administration to encourage the closest coordination possible for
information sharing, facilitate access to permissive outbreak zones,
and ensure smooth logistical processes from visas to equipment
turnover. From our Embassy in Kinshasa, we engage in diplomacy across
the entire country, which in distance stretches almost from my driveway
in Texas to here in Washington, DC.
While Embassy Kinshasa has carried much of this weight, our Embassy
teams in Bujumbura, Juba, Kampala, and Kigali have consistently urged
the most senior members of their host governments to strengthen efforts
to prevent the outbreak's spread. Burundi, South Sudan, Uganda, and
Rwanda are vulnerable to the spread of Ebola and must remain vigilant.
Our embassies are working at national, state, and local levels to
provide technical and strategic assistance, support preparedness
efforts, build trust in communities, improve information exchanges,
strengthen border screenings and entry points, and coordinate
leadership across ministries of health, elected officials, NGOs, the
U.N., and others. These neighbors are suffering from preparation
fatigue, despite the WHO's July 17 PHEIC declaration and the recent
cases in both Uganda and in Goma city, which shares the busiest
pedestrian border crossing in the world with Rwanda. Clearly, the Ebola
outbreak requires we redouble our efforts. Few countries are prepared
to handle a challenge like Ebola alone, so we call on all our partners
to join these efforts.
looking forward
The existing humanitarian crisis and Ebola outbreak has already
caused tremendous harm to Congolese lives and livelihoods and taken a
significant toll on economic, social, and healthcare services across
eastern DRC. Our response to this public health emergency must also
address the complex underlying factors exacerbating the outbreak and
impeding its control. The State Department's Bureau of African Affairs
is here to offer the diplomatic tools in our U.S. Government toolbox,
and work alongside host government, U.N., and U.S. interagency
colleagues for a unified and comprehensive Ebola outbreak response.
Thank you for your time and consideration. I welcome the
opportunity to answer any questions you may have.
Senator Graham. Well, thank you all very much.
This may be one of the hearings that they play the tape
back down the road, and I hope not.
Dr. Wolfe, give us sort of the ABCs of Ebola for those that
are not as informed as they should be, beginning with me. What
causes it? How deadly is it? And why does it keep recurring
here?
Dr. Wolfe. Sure. Ebola is endemic in many parts of Africa.
Scientists believe it may have reservoir in bats. It is very
difficult to predict when outbreaks will happen. It has an
incubation period of 2 to 21 days, normally between 8 and 10
days, and has severe symptoms with vomiting, diarrhea,
hemorrhagic symptoms, and has a very high mortality.
Senator Graham. Thank you.
Admiral, a national security issue is not much a leap here.
Tell us how the whole-of-government approach, the governance
part of it, is essential to solving this problem because as I
understand it, you got members of parliament basically telling
people not to be vaccinated and there is a real effort to chill
out health care here.
Mr. Ziemer. Senator, there are many complicating factors.
The role of the government in DRC in transition and their
ability to influence the work on the ground is questionable.
In terms of the U.S. approach, we do have a well
coordinated approach to that. As I have monitored this----
Senator Graham. But did you not say 35 health care
facilities were attacked?
Mr. Ziemer. More than that, sir, since the beginning of the
year.
Senator Graham. So who is doing the attacking?
Mr. Ziemer. There are an estimated 70 to 90 armed groups.
They vary from structure to gangs to just youth members. So
there is a variation of the type of activity that is imposing
threats.
Senator Graham. Are they looting the facilities or just----
Mr. Ziemer. Intimidating the health care workers. They have
gone in and damaged the Ebola treatment units.
Senator Graham. Are there any African Union forces present?
Mr. Ziemer. In many cases, there are, and local security as
well.
Senator Graham. So the security footprint has to be
enhanced. Right?
Mr. Ziemer. Yes, sir.
Senator Graham. What are we doing to enhance the security
footprint?
Mr. Ziemer. Part of the coordination effort that David
Gressly is overseeing is to leverage the existing security.
Senator Graham. What is it? What is the existing security?
Mr. Ziemer. It is the use of government troops, as well as
the MONUSCO troops.
Senator Graham. I mean, do they have a real army they use?
Mr. Nagy?
Ambassador Nagy. The security presence has provided several
different layers. First, we have the United Nations forces,
MONUSCO. They have about 20,000 forces throughout the DRC. In
the actual Ebola zone, they have about 3,000.
This gentleman we have been talking about, David Gressly--
his previous assignment was to head MONUSCO. Now he has gone
over as the chief U.N. coordinator.
Senator Graham. Are these 3,000 troops effective?
Ambassador Nagy. Three thousand troops. They are about as
effective as they can be, given the circumstance. I had a
conversation this morning with our Ambassador, and he was
actually in the Ebola zone. And I asked him the very same
question, and he said that with the recent reset, he is much
more optimistic than he has been in the past because of the
whole new approach of engaging the villagers.
The fundamental problem in the past--I think we all alluded
to it, Senator--was this huge decades of mistrust that had been
built up between the communities and any outside government
force.
Senator Graham. That seems to me as big a problem as Ebola.
Ambassador Nagy. Absolutely. That is why the complexity
that everybody has been talking about--it is like a house of
cards. Everything impacts everything else, sir.
Senator Graham. Well, let us just talk about the security.
I want to know about this new government. We have hope. Is that
correct?
Ambassador Nagy. Yes. President Tshisekedi's new
government, yes, sir.
Senator Graham. Do you agree with that, Ms. Bernicat?
Ambassador Bernicat. Yes, I do, sir. He has visited
Washington, DC and met with Secretary Azar. He visited the
affected area. He has allowed for the return of one of the
political exiles from the region who actually came back to the
region, and very publicly received a vaccine. And so he has
begun to show leadership in ways that we had not seen----
Senator Graham. What can we do to help him that we are not
doing on the security front?
Ambassador Bernicat. One other aspect that I think is worth
pointing out on the security front is that there are any number
of people who have distrust of all individuals wearing military
or police uniforms.
Senator Graham. I understand that.
Ambassador Bernicat. Exactly. The government has a very
difficult dilemma of how to increase security without
increasing distrust. Putting more boots on the ground in many
cases is the answer. In this case, it can be a complicating
factor.
Senator Graham. Do we have any U.S. forces involved?
Ambassador Bernicat. No.
Senator Graham. Do we need U.S. forces involved?
Ambassador Bernicat. No.
Senator Graham. Everybody agrees with that? Okay.
So we have got a new partner. He is doing things that we
like. From the Congress' point of view, from the Senate's point
of view, I think everybody up here wants to help you. Give us a
very quick shopping list with the things we can do to help you
in this cause that we are not doing. Not all at once.
[Laughter.]
Senator Graham. Yes, Mr. Nagy.
Ambassador Nagy. I wish money could help in this regard,
but the truth is I think that more than anything else, time is
going to help. He is having to undo the tremendous damage done
by his predecessors. For the first time, we have had President
Tshisekedi come to us and say that he wants to engage with the
United States as partners for his security.
Senator Graham. We just need to thank him and encourage him
to keep doing what he is doing.
Ambassador Nagy. Pardon me, sir?
Senator Graham. We need to thank him and encourage him to
do what he is doing.
Ambassador Nagy. Absolutely.
Senator Graham. All right.
Dr. Wolfe, you said before it is not a threat to the United
States at this moment. What would make it a threat to the
United States?
Dr. Wolfe. Yes, Senator. Currently the risk to the U.S. is
low. We analyze transmission dynamics of the epidemic, and when
there is a change in the epidemic, we do a risk assessment and
look at the strategy that matches that risk assessment.
Currently we believe that addressing the outbreak at its source
is the best way to prevent spread, and we have many activities
to prevent the spread.
Senator Graham. My question is what would be the conditions
that would make it a threat to the United States. What are we
afraid of?
Dr. Wolfe. There are many different scenarios. And so the
best way to prevent spread is to assess the situation and do a
risk assessment and look at what strategy is necessary at that
time. We have a number of activities that are looking at
screening on the border, screening at airports.
Senator Graham. Will you tell this committee when it gets
to be a higher threat? How do we know? Will you all tell us?
Dr. Wolfe. Absolutely. So when we do the risk assessments
and look at the strategy, we will let you know what our
strategy is and what needs to be done.
Senator Graham. Senator Kaine?
Senator Kaine. Dr. Wolfe, I am going to stay with you. You
used a phrase in your testimony, ``community deaths,'' that I
am not familiar with. Are these deaths that occur not in health
care facilities so it is a little hard to track them? Or what
does ``community deaths'' mean?
Dr. Wolfe. That is correct, Senator. So these are deaths
that we identify Ebola in somebody who is dead. That means that
they were not identified when they were a case. And what is
going to control this outbreak is the rapid identification and
isolation of cases.
Senator Kaine. I hear you.
Let me ask about vaccination. Over 160,000 people have been
vaccinated against Ebola as of July 15, and that includes more
than 31,000 health workers. I gather that the vaccination is
somewhat experimental.
And I also understand that just in the last week, the
health minister of the DRC has resigned. Largely, as I gather,
there is sort of a dispute about which vaccine should be used,
should both vaccines be used. To have a health minister resign
in this situation obviously is a significant challenge. Talk a
little bit about what that means and what we are doing, if
anything, to help promote stability in the health ministry
there. That may be a question more for the State Department
side.
Ambassador Nagy. Sure, Senator. Yes, indeed, the minister
has resigned because the president was moving away from him.
The president had appointed a special Ebola coordinator
reporting directly to the president, a Dr. Muyembe, who has
himself been involved with these Ebola emergencies, going back
to the initial one in 1976. There is going to be a new health
minister anyway when the entire new government is announced
hopefully this next week, sir.
Senator Kaine. So you do not view that resignation as a
problem. In fact, it may actually be an improvement to the
situation. Is that----
Ambassador Nagy. Yes, sir. It may be an improvement to the
situation.
Senator Kaine. My understanding is that Rwanda and Burundi,
as neighboring nations--they have not dealt with an Ebola
outbreak before. So as we are looking at neighbors, some have
dealt with it, some have not. What is your assessment of the
capacity and preparation among neighboring nations to deal with
the outbreak?
Ambassador Nagy. My colleagues can also chime in on that.
But from our point of view, Uganda and Rwanda are in very good
shape to be able to deal with it. The disaster would be is if
it got to South Sudan. With the large refugee populations
there, the totally disorganized, dysfunctional, nonexistent
government, that could be a disaster.
Senator Kaine. And that goes back to the question the
chairman was asking Dr. Wolfe. The things we would need to
worry about are travel or people moving into other countries,
especially into places that are fairly chaotic, and then that
could lead to transmission to all kinds of places, including
the United States. Is that a fair concern?
Dr. Wolfe. Since the outbreak started, we have augmented
our presence in the neighboring countries to work on
preparedness activities with those countries. Some countries
are better prepared than others. In Uganda, we have worked
there for many years. It highlights the importance of work on
global health security and the Global Health Security Agenda,
which is a U.S. Government effort and a multinational effort to
build capacity of countries to prevent, detect, and respond to
infectious disease threats.
Senator Kaine. And this is sort of a sweet spot for this
committee because this committee is not just the Subcommittee
on Africa, it is also the Subcommittee on Global Health Policy.
So that is why this is sort of a little bit of a textbook
problem for us to resolve and then use as a template.
Tell us about the status of the vaccine. So there are
vaccines that are sort of experimental. I mean, are the
vaccines proven. Talk about the quality of the vaccine in terms
of dealing with this, and then talk about quantities. Is there
sufficient vaccine? Do we need dramatically more? Share that
with us.
Dr. Wolfe. So evidence suggests that the investigational
vaccine that is being used has efficacy to protect against
Ebola, and we feel that it has had a mitigating effect on this
outbreak.
Senator Kaine. And this is the vaccine that is a Merck
product?
Dr. Wolfe. Correct.
Senator Kaine. There is a second vaccine that is a Johnson
& Johnson product that has not yet been used in the DRC. Is
that correct?
Dr. Wolfe. Correct. We provide technical assistance to WHO
and ministry of health to look at all available resources, and
we have been pushing for an aggressive vaccination campaign. I
want to highlight that the ministry of health is in charge of
the epidemic, and they have decided that they are not ready to
use that vaccine.
Senator Kaine. Talk to us about the available quantity of
the vaccine in terms of trying to meet the challenge.
Dr. Wolfe. Our goal is to ensure that there is sufficient
vaccine to address this outbreak.
Senator Kaine. I know that is the goal, but give yourself a
grade on that one right now. Are we at a C minus, or are we at
an A? Do we have sufficient quantity?
Dr. Wolfe. We currently have sufficient quantity to address
the outbreak. I do not have the additional information on
numbers. We could get back with you on that.
Senator Kaine. Admiral Ziemer?
Mr. Ziemer. There are over 800,000 doses between now and
March of 2020 that are in the pipeline. So based on the use and
the scale-up strategy, we are watching that very closely. I do
know that HHS is working very closely on production schedules
and the production line to look at future requirements. When
this Ebola outbreak is ended, the use of a vaccine is clearly
going to be an essential tool. So Secretary Azar and his team
are looking at that.
Senator Kaine. Talk to us a little bit about the community
resistance. So I know that with political turmoil, contested
elections--is the community resistance connected to political
factions, political divides, or rumors that were spread about
what the vaccine does or does not do. Share that with us a
little bit.
Ambassador Nagy. Yes, sir. It is all of the above. Part of
it is historical because historically anytime you see somebody
in a uniform, they are there to kill you, rob you, or rape you.
The various different militias, the misery and the lack of
development that has been in that region now almost since
independence. And part of the community's thinking is, okay, we
have been through decades of malaria and poverty and abuse, and
all of a sudden, there is this new disease and we have all
these Westerners showing up with all their resources because
they tell us it is so important. We had the same thing in West
Africa partially, but it is so much more intense here because
of the horrendous abuse that that population has been through
and the succeeding governments of the DRC, which just did not
care at all about their population, especially that isolated
part of the DRC.
Senator Kaine. Thank you, Mr. Chair.
Senator Graham. I think the first vote is about to end. Do
you want to adjourn, vote, and come right back? Is that okay,
or do you want to keep going? I think we need to vote. What do
you want to do, Chris?
Senator Coons. We could have some more questions and then
go.
Senator Graham. Well, but the first vote is over. So they
are holding it for us. So why do we not vote and come right
back. So we will be back in about 15-20 minutes.
[Recess.]
Senator Kaine. We will get the hearing started up again.
Senator Graham is on his way back and said we could go ahead
and continue. Senator Menendez will question next.
Senator Menendez. Thank you, Mr. Chairman.
Thank you all for your testimony.
Doctor, disease knows no borders or boundaries. Is that
fair to say?
Dr. Wolfe. Yes, that is correct. That is how we use the
phrase that diseases know no boundaries, and a threat anywhere
could be a threat everywhere.
Senator Menendez. So even though, in answer to the
chairman's question, you said it is a low risk right now,
obviously a greater outbreak of the Ebola virus produces a
greater risk. It can be just one flight away--right--from
someone who is contaminated before they show the symptoms.
Dr. Wolfe. Yes, sir. Some of the things we look at are the
transmission dynamics in the area and what the response
capability is and also what the travel patterns are from the
areas in the outbreak. So that is something we are constantly--
--
Senator Menendez. My point in just raising that is that
this is about more than being a good global partner. We have
self-interests here as well.
It seems to me that the major obstacle to contain the Ebola
outbreak in the eastern Democratic Republic of Congo appears to
be the lack of adequate access to the affected communities and
the decades of insecurity, coupled with political
marginalization, has resulted in conditions where not only our
health care workers are unable to reach areas subject to
militia attack, the very communities that we are trying to have
access to have rejected health interventions, even attacking
and killing health care workers.
The U.S. intervention in West Africa during the Ebola
crisis of 2014 was, I think, instrumental in stopping its
spread.
However, in the DRC, the U.S. has to date been unable to
provide a full suite of interventions. The administration, for
example, refused for months to issue a waiver for sanctions
imposed on the DRC as a result of the DRC's tier 3 ranking
under the Trafficking Victims Protection Act. USAID briefed
committee staff in May on plans for engaging with communities
to assess basic needs they may have in addition to Ebola, both
in the health care sector and beyond as an improved strategy
for gaining access to these communities. It is no good to have
you go to a health care center. You may not have Ebola, but you
have some other significant disease and you cannot be treated.
People do not necessarily find that a reason then to go.
So actions that, until very recently, could not be fully
undertaken due to the Trafficking Victims Protection Act
sanctions, which were never really meant for that purpose, as
one of those who were fully engaged in the TVPA, which brings
me to my questions.
Admiral, is any of the fiscal year 2018 funding that was
being held by the administration now being used to fund USAID's
strategy to go beyond the health sector so as to provide health
workers with better access to these communities?
Mr. Ziemer. Senator, thanks for the question. And first of
all, I just want to thank you and the other members for your
strong support in this area. It is very much appreciated.
The current investment that has been made by the U.S.
Government and USAID, the $136 million, has not been affected
by TVPA. I believe you and your staff were aware of that.
The interagency is reviewing the implication of TVPA,
particularly as a result of this outbreak and the implications
not only in DRC but also in Burundi and South Sudan, which are
on the tier 3 list. And we expect to hear a resolution on that
very soon, and we will keep you and your staff----
Senator Menendez. So 2018 funding that was being held-- is
it being used now or not?
Mr. Ziemer. No, sir, not all of it.
Senator Menendez. Not all of it.
So how long is it going to take for money for those
activities to reach the ground?
Mr. Ziemer. As soon as we get the disposition on the
funding and the release of the funding, then----
Senator Menendez. And that is still being held up because
of determining whether or not the TVPA is going to continue to
affect them?
Mr. Ziemer. Yes, sir.
Senator Menendez. That is not acceptable.
Is there fiscal year 2018 money that is being reprogrammed
out of the DRC, to your knowledge, or Secretary Nagy?
Ambassador Nagy. I do not know, Senator. I can certainly
check on it, but I do not know.
Senator Menendez. Admiral, do you know if there is?
Mr. Ziemer. No, but we will double check the specifics and
get back to you.
Senator Menendez. Has fiscal 2019 money been approved for
Ebola response activities?
Mr. Ziemer. On the IDA account, we are continuing to expend
funding.
Senator Menendez. Well, I would like not to dwell on it
right now, but I would like to get the administration's
response to us about--the Trafficking Victims Protection Act
was meant to ensure that countries were doing the right things
in terms of making sure they were not trafficking in persons.
But it certainly was not meant to withhold money in a health
emergency like this. That was never envisioned by the Congress.
And I hope we can get to that. I know that some of us are
offering language to make that clear for now and in the future,
but in the interim, we cannot wait for the Ebola virus to break
out even more significantly before we respond to it.
Let me ask you, Mr. Secretary, what affect did the
cancellation of elections have in terms of further straining
relations between Kinshasa and the disenfranchised communities
in areas affected by Ebola?
Ambassador Nagy. The eastern DRC was not that significantly
affected by the elections. You are referring, sir, to the ones
that were won by Tshisekedi?
Senator Menendez. Yes.
Ambassador Nagy. There was not any serious election/ post-
election violence there. Unfortunately, that had always been a
disaffected region of the DRC. The population there for decades
has been very cynical about political developments. Luckily,
President Tshisekedi is the first president to have actually
visited now the Ebola region. He has been there several times
to get the local authorities dynamized to confront it. So his
image has really gone up since the inauguration and since his
presidency.
Senator Menendez. Is there any impact about our endorsement
of Mr. Tshisekedi's questionable victory had on the credibility
and our ability to undertake the full range of Ebola-related
activities in eastern Congo?
Ambassador Nagy. Senator, from my information and from
talking to Ambassador Hammer, it has been just the opposite.
The United States' image has actually been much improved
because post election, President Tshisekedi's popularity goes
up and up.
Senator Menendez. Let me ask you this. On July 2nd, the
DRC's minister of health, Oly Ilunga, resigned in protest over
President Tshisekedi's decision to take over the Ebola
response. By all accounts, he was an effective administrator, a
good interlocutor. How does the resignation affect the Ebola
response? You mentioned there will be a new health minister at
some point, but when do we expect that to happen and why is
this taking place when you have somebody who seemed to be
working well in the job?
Ambassador Nagy. Senator, my colleagues may be able to
chime in also on the technical parts of this, but the president
did not have confidence in the health minister. There was going
to be a new one anyway. So he brought the whole Ebola issue to
the presidency's office by appointing a coordinating committee,
I think I mentioned, headed by Dr. Muyembe, who has Ebola
expertise going back to 1976. So right now, the Ebola is still
being directed out of the presidency, and the truth be told, it
has been going on for over a year. So the previous health
minister has not been all that effective.
Senator Menendez. So we did not consider her effective or a
good interlocutor.
Ambassador Nagy. I think she was a good interlocutor, but
as far as the results, I think for the effectiveness speak for
themselves, sir.
Senator Menendez. Last question. So we are all in with
Tshisekedi then.
Ambassador Nagy. We are very guardedly optimistic, and if
you would like, I would be happy to submit a list of President
Tshisekedi's positive accomplishments since assuming office,
sir.
Senator Menendez. That is not my question. We are all in
with Tshisekedi.
Ambassador Nagy. For now, we are. Yes, sir.
Senator Menendez. All right. Thank you, Mr. Chairman.
Senator Graham. Senator Coons?
Senator Coons. Thank you, Chairman Graham, Ranking Member
Kaine, for holding this important hearing.
As we have all been discussing, the Ebola outbreak in
eastern DRC has now grown into the second worst such outbreak
in history, and this is not something we can afford to ignore.
The combination of disaffection from the central government,
poverty, under-development, chaos, and distrust makes this an
exceptionally dangerous area in which to have a disease of this
potential lethality spreading.
This is, I think, an opportunity for us to, again,
demonstrate the best of American leadership by helping support
and lead a multilateral effort to combat what is a potentially
global health and security threat. I do think it is a chance
for us to mobilize our traditional allies, as well as others,
like China who benefit from the international system, and to
strengthen our efforts to make the world more capable of
fighting global pandemics.
We have already seen this outbreak cross international
borders, and I think if we do not step up now and get ahead of
this outbreak, there is a chance it could spread into even more
countries, as our witnesses have testified.
I also think it is important we help the DRC and other
countries across the region build their resiliency and their
capacity to resist further outbreaks. I think the question is
not where and if, but when the next major Ebola outbreak will
occur.
In 2014, I traveled to Liberia and witnessed the suffering
caused by Ebola firsthand and saw a genuinely inspiring, well-
coordinated, multilateral effort where the United States played
an absolutely essential role, but the Liberian people and their
ministries and government did as well, as did many nonprofits
and arms of the United Nations.
Ultimately many of us here fought for an emergency spending
package which amounted to more than $5 billion, but those
costs, both human and fiscal, were well beyond what they could
have been had we really confronted it earlier as it grew. And
some of those funds, if I understand correctly, are still being
used today to combat the current outbreak.
As I said in 2014, that outbreak would not be the last and
certainly this will not either. There are very promising
developments, as you have said, in terms of two potential
effective, widely usable vaccines. But I think we need to
prioritize investments in resiliency that will reduce the risks
of the next outbreak.
So let me ask, if I could, just a few questions.
First, we have got real tensions with China across a wide
range of issues, but Assistant Secretary Nagy, I would be
interested in whether you think combating pandemics is an area
where we could actually cooperate. There was some Chinese
participation in the West African counter-Ebola efforts. Have
we encouraged or engaged with the Chinese? Their hesitancy to
step up and actually bear the costs and challenges of a world
leader I think we should call to question.
Ambassador Nagy. Senator, maybe some of my colleagues know
as to what extent if we have had any discussions on the Hill
side with the Chinese, but I absolutely support your
proposition because there is no reason why we cannot work
together with them in those areas where we can. Obviously, we
do have trade and other competition with them throughout the
world, especially in Africa, but there certainly can be areas
of cooperation like in health.
Senator Coons. I think the Global Health Security Agenda is
something that deserves a few minutes of focus. It is a
partnership of 64 countries. There are stakeholders across CDC,
USAID, NIH. Over the last 5 years, there was a billion dollars
in GHSA funding that has supported efforts to build global
health capacity to effectively combat infectious disease.
Admiral Ziemer, my understanding is that this pool of
funding expires in September. If funding for GHSA is not
maintained at current levels in fiscal year 2020, will all the
agencies you represent be able to maintain current global
health security programming, or will you be required to scale
back operations either at CDC, AID, or at State?
Mr. Ziemer. Senator, thanks for your recognition of the
significance of the Global Health Security Agenda. And, yes,
the funding that got that started, the $1 billion, came from
the original supplemental.
The Global Health Security Agenda is part of this
administration's priority. There is funding in the current
budget. While modest, it allows us to continue the program.
Senator Coons. How modest, and how does it align with the
need?
Mr. Ziemer. I will have to get back to you on the specific
budget.
Senator Coons. But I will take the fact that you described
it as modest to suggest that it is well below what may be
necessary to sustain robust investment and resiliency in the
face of a potential pandemic.
Mr. Ziemer. Yes, sir. And I think your other point that you
made earlier--there is an expectation of burden sharing, other
countries stepping up to the plate. In terms of contributions
to the current Ebola outbreak right now in DRC, the Government
of China has contributed $1 million.
Senator Coons. One.
Mr. Ziemer. One million, yes, sir.
Senator Coons. Has the WHO not said that funding for Ebola
response needs to triple, and that their most recent estimate
was there needs to be a total investment of about $320 million
to get ahead of the virus?
Mr. Ziemer. Yes. Senator, the good news is that we have a
plan coming together that has specifically identified $384
million--we can get you the figure--to move the health response
through the end of the year. The good news is it also is built
on four other components, pillars, if you will. The latter one
is a $70 million call for country preparedness. For the first
time, we are going to have a comprehensive picture of the
projected requirements in terms of funding this Ebola response.
The good news this morning, the World Bank made an
announcement that they are going to provide $300 million. So
with our $36 million, plus what the U.K. has committed, and we
are seeing a gradual uptick in some of the other countries,
there is an expectation that we will be able to move forward
with the current plan.
Senator Coons. That is very encouraging.
I will just say that the United States has now for decades
been the principal, the leading funder of public health
challenges on the continent at the same time that China has
eclipsed us as the largest trading partner, the largest
investor on the continent. They are present in literally every
country I have been to on the continent. They have expanded
their footprint and, frankly, their extractive relationships
with a number of countries. I will be pressing to see them step
up to some of this responsibility. The idea that they are
investing $1 million and we are investing tens, if not
hundreds, of millions strikes me as an opportunity for us to
partner.
Mr. Ziemer. Thank you for your support on that.
Senator Coons. Can I ask a last question, Dr. Wolfe and
Admiral Ziemer or Assistant Secretary Nagy, if have any, about
the decision to allow U.S. Government personnel either close to
or not close to the hot zones? One of the things that really
turned the tide in Ebola was the uniformed U.S. Public Health
Service setting up a facility right at the edge of the Monrovia
airport to guarantee that public health workers in Ebola
treatment units, if they contracted Ebola, would get prompt and
effective treatment. That was a key piece, the deployment of
U.S. military testing labs out into the field into remote areas
so that people did not have to come into the capital to confirm
whether they had Lassa fever, Ebola, or something else.
Where are we in terms of allowing either CDC or other U.S.
personnel to actually be engaged on the ground, and what, if
any, recommendation have you made and what do you think we
should be doing?
Dr. Wolfe. Yes, Senator. For the past year, we have
deployed 200 people to support the outbreak with the ministry
of health in Kinshasa, in Goma, in Geneva, and in surrounding
countries. So we do have extensive activities there. It is true
we have not been able to go directly into the outbreak zone
because of security concerns, and we defer to State. We are
under chief of mission authority in countries, and they
determine where we can deploy.
One thing I would like to highlight is in the recent case
in Goma, we were able to deploy directly into outbreak and we
were able to provide on-the-ground, real-time strengthening of
the response.
Senator Coons. And are you deployed in places like Burundi,
South Sudan, in the region that may not have the resiliency
that Uganda does where you previously described as if it gets
into South Sudan, given the chaos there----
Dr. Wolfe. Yes. We have country offices in South Sudan,
Uganda, and Rwanda, and we have augmented those to work on
preparation activities with those countries.
Senator Coons. Assistant Secretary, you look as if you
could add to this.
Ambassador Nagy. Yes, indeed.
The problem is not with Goma or Kinshasa, but it is with
Beni and Bunia. And given the dynamics of the situation and how
it changes day to day, we have a very careful policy under
chief of mission, under Ambassador Hammer, where the regional
security officer, diplomatic security, looks at the proposed
travel, evaluates the threats, and then gives their blessing or
recommends against it just like we were talking earlier about
the CDC person just receiving permission today to shadow the
U.N. overall coordinator. It was not an easy decision, and the
whole emergency action committee had to take a look at it
because of all the armed groups. There is one ISIS-linked
terrorist organization operating in North Kivu. So it really is
a case-by-case basis and how much has the situation changed.
Unfortunately, as you said, sir, the West Africa situation
was so different because of accessibility.
Senator Coons. Do you have any sense how many Americans are
in this immediate area who are there perhaps through
Samaritan's Purse or Save the Children or Doctors Without
Borders?
Ambassador Nagy. I do not have an exact number, but I can
certainly find out because I know that there are some that are
not under chief of mission authority.
Senator Coons. Because they certainly were in West Africa,
literally hundreds of Americans deployed.
Ambassador Nagy. Exactly.
Senator Coons. Admiral, did you have any closing thoughts
on what is the most important thing we are not doing that we
should be doing to get ahead of this?
Mr. Ziemer. The ideal situation would be to get the CDC
personnel on the deck. We all support that.
I just want to echo what the Ambassador has said, that we
are working very hard with the Ambassador and the RSO to look
at places that we can flex. The fact that we are in Goma today
with a robust CDC and USAID team reflects a forward-leaning
strategy. And just within the last couple weeks they have
extended the curfew so that teams can get out and operate. So
this is an ongoing issue. It is appreciated, and we are doing
everything we can to make the right assessment in terms of
getting our folks in the field.
Senator Coons. I just want to thank all of you. I really
appreciate your testimony, and I appreciate the patience of the
chairman and my colleagues on the committee. Thank you very
much.
Senator Graham. Thank you. It has been great.
One follow-up question and I will turn it over to my
colleagues.
Generally speaking, do you think, with the current
resources and engagement, that we got a handle on this? Dr.
Wolfe?
Dr. Wolfe. Well, currently the outbreak is not under
control, and what we need to do is increase the core public
interventions, you know, rapid case identification, rapid
isolation.
Senator Graham. So we do not have a handle.
Dr. Wolfe. So we need to improve these core public health
interventions. It continues to expand, and we continue to have
cases.
Mr. Ziemer. The current plan, focusing in on the health
response, has brought in aspects on how to improve our
community engagement, how to improve the political interaction
and the security, as well as perimeter support.
So the jury is still out on whether or not this new effort,
this international combined effort, will deliver the progress
that we need. Right now, I am optimistic that we have
mechanisms in place to move us forward, much improved over
where we were 6 months ago.
Senator Graham. Ms. Bernicat?
Ambassador Bernicat. I would say that the aspect we do have
a very firm handle on is our policymaking process back here and
the number and the quality of people we have deployed in the
field who are working not only on the response efforts, as best
we can under the conditions, but also to involve more of the
international community by broadening and diversifying the
funding sources going forward.
Ambassador Nagy. My perspective, Senator, is more on the
governance issue. What they desperately need is positive
governance and a professional military. And if Tshisekedi can
succeed in that, it will take years not months, but that would
flip the Democratic Republic of Congo from being a perennial
area of instability to actually exporting stability for a
change.
Senator Graham. Do you think that is remotely possible
without American leadership?
Ambassador Nagy. Sir, I guarantee you American leadership
is there. Our Ambassador is fully engaged with the president,
with his government. So I am guardedly optimistic, sir.
Senator Graham. Thank you.
Senator Kaine. If I could just ask one follow-up.
Ambassador Nagy, you mentioned the ISIS connection in one of
the regions just briefly and I want to get into it because from
the security standpoint, it is important. Senator Menendez and
Chairman Risch did a hearing in this room earlier this morning
about the current military authorizations against al Qaeda and
ISIS. We were talking a lot about it. There was an attack in
April. DRC soldiers were killed in parts of the country where
Ebola has been very widespread. I guess it was the Allied
Democratic Forces that claimed responsibility, but then ISIS
also claimed responsibility. And the ADF says, or at least are
saying, that they want to have more of an ISIS tie. So this,
obviously, is the security complicator of getting our people in
place. It is not just the health risk. It is now also the risk
of these groups with an ISIS connection.
Give us an assessment of ISIS activity. Is that a group in
name only that is not particularly effective? Is the ADF really
connected to ISIS? Share that with us.
Ambassador Nagy. Obviously, I think we could provide more
facts in a different setting. But in this setting, I can say
that the ADF is the single one of the many armed groups in that
area that has affiliated with ISIS. ISIS has embraced them.
There are potentials for exchanges with other ISIS groups,
individuals in the area receiving resources. But the ADF is a
rather bizarre group because they do not range much beyond
their territory because of the ethnic identity, and they do not
specifically target Ebola efforts. It just happens that if they
are undertaking a violent campaign, that people involved in the
Ebola campaign could get caught up in that. So it is definitely
a group worth watching. And as I said, I think we could provide
additional details in a different setting, sir.
Senator Kaine. Thank you.
Senator Graham. Thank you all. You represent our country
very well, and we are here to help. I appreciate your knowledge
and level of attention to this. If we are successful, it will
be because of your efforts. And if we are not successful, it
will not be because you did not try.
So we will hold the record open till Friday for any further
comments or questions. Thank you.
[Whereupon, at 4:10 p.m., the hearing was adjourned.]
----------
Additional Material Submitted for the Record
Responses of Hon. Tibor Nagy to Questions Submitted
by Senator Robert Menendez
22 U.S.C. Chapter 78, Section 4 of the Trafficking Victims
Protection Act provides for the continuation of assistance that would
otherwise be sanctioned for failing to meet the minimum standards on
trafficking when it is in the National Interest of the United States to
waive sanctions. Paragraph Section (d)(5)(B) of TVPA states: ``The
President shall exercise the authority under section (4) when necessary
to avoid significant adverse effects on vulnerable populations,
including women and children.'' According to the World Health
Organization, the Ebola virus disease has a mortality rate of 50
percent.
Question. Do we consider the people in eastern Democratic Republic
of Congo (DRC) living in Ebola affected regions, or living near those
infected with Ebola vulnerable? How many women have been infected with
Ebola in this outbreak, and how many have died as a result of the
infection? How many children have been infected with Ebola in this
outbreak? How many children have died as a result of being infected?
Answer. The current Ebola outbreak in an active conflict zone in
eastern DRC is affecting a vulnerable population that is extremely poor
and historically neglected and abused. The outbreak is
disproportionately affecting women due to their role as primary
caretakers. Community resistance and a large number of community deaths
further exacerbate the impact on women and children. According to the
WHO, as of July 31, 56 percent of the total 2,612 confirmed and
probable cases were women, and 29 percent were children under 18 years.
While we do not have data on the number of women fatalities, according
to Save the Children, over 500 children have died since the outbreak
began in August 2018.
Question. Do we consider the morbidity resulting from Ebola a
significant adverse effect?
Answer. Yes.
Question. Why hasn't the waiver cited above been exercised as
required by the law?
Answer. The United States is the largest single-country donor to
the current Ebola outbreak response, including support through the U.S.
Agency for International Development of more than $136 million since
August 2018. Most assistance to the Ebola response is not subject to
the TVPA restrictions. The U.S. Government is committed to global
health security as outlined in the National Security and National
Biodefense strategies, and is working with partners to provide the
assistance needed to contain this outbreak. The process of evaluating
assistance affected by restrictions for FY 2020 TVPA is ongoing.
Question. How effective will the international response be if we
are not able to engage in actions that will help lower community
resistance?
Answer. The current Ebola outbreak is the tenth in the DRC. Against
the backdrop of a complex humanitarian crisis, community resistance--
evidenced by the high number of community deaths--is complicating
response efforts. Community engagement and buy-in are critical to
containing this outbreak, and to preventing it from spreading to
populous regions and neighboring countries. We support broader
engagement by the United Nations and outreach to community leaders and
civil society, including faith-based groups and religious leaders, to
lower community resistance.
Question. What polling data exists to support claims that
Tshisekedi continues to grow in popularity in eastern Congo?
Answer. In June, the New York University-based Congo Research Group
(CRG) released new polling data that confirmed the optimism of the
Congolese people towards President Felix Tshisekedi. The data
highlighted that 61 percent of Congolese are optimistic about DRC's
future and 67 percent have a favorable view of the new president's
first 100 days in office. The CRG poll confirms average Congolese are
hopeful about the future for the first time in many years and suggests
that U.S. support is a key factor to ensure President Tshisekedi is
able to consolidate the democratic transition and enact reforms
encompassing human rights, accountability, anti-corruption, security
sector professionalization, and fiscal transparency. During insecurity-
driven protests this week in Beni territory, civil society called on
President Tshisekedi to travel again to the region to personally assess
the situation. This is notably different from the protests that
occurred frequently during the previous regime calling on Kabila to
step down.
Question. According to a fact sheet released by the Armed Conflict
Location & Event Data Project (ACLED), ``Six months into the new
presidency of Felix Tshisekedi, ACLED data show that overall political
violence is rising at even higher rates than last year, at the
conclusion of Joseph Kabila's nearly 20-year rule.'' To what do we
attribute this uptick in violence?
Answer. South Kivu and Ituri saw major escalations in longstanding
communal grievances in the last few months, which may account for some
of the uptick as ACLED does not seem to clearly distinguish between
purely political and ethnic violence, which are often intertwined in
local conflicts. In terms of the ACLED data set between January and
June, armed clashes and attacks dwarfed traditional political violence
by the state against peaceful opposition and demonstrators. The U.N.
reported that after the inauguration of President Tshisekedi in late
January a number of armed groups turned themselves in to MONUSCO and
the GDRC. More than 1,000 fighters requested demobilization, as they no
longer feel threatened by the national government. Our focus is on
ensuring MONUSCO and the GDRC have the personnel and funding resources
to leverage these gains by implementing sustainable options for
reintegrating former militia members into their communities.
MONUSCO's Joint Human Rights Office (JHRO) documented 9 percent
fewer human rights violations over the first six months of 2019
compared to same period in 2018. This is an encouraging sign of
improvement during President Felix Tshisekedi's first few months in
office. In particular, the JHRO noted state security forces were
responsible for notably fewer violations when compared to the same
period in 2018. Political violence in the Haut Uele and Bas Uele
provinces decreased due to military pressure by the FARDC. Violence has
been curbed in areas of North Kivu where MONUSCO supported local
authorities' efforts to facilitate dialogue between warring groups and
re-instituted a local conflict resolution mechanism. MONUSCO and the
GDRC also made strides in quelling ethno-political conflict and
displacement in South Kivu in June by brokering cease-fire agreements
and fostering dialogue between ethnic armed group leaders and the local
communities. In addition, MONUSCO and the FARDC recently addressed
longstanding violent conflict and significant displacement in Ituri by
fostering an agreement to turn an armed group (Ituri Patriotic Front
Resistance) into a political party.
__________
Responses of Hon. Tibor Nagy to Questions Submitted
by Senator Edward J. Markey
The ongoing Ebola outbreak and other Infectious disease threats,
such as measles and antibiotic resistance, help reinforce the
importance of the Global Health Security Agenda (GHSA)--a partnership
of over 64 nations and stakeholders to help create a world safe and
secure from infectious disease threats. Across CDC, USAID, and NIH, $1
billion in GHSA funding between 2014 and 2019 has supported efforts to
build global health capacity to effectively combat infectious diseases.
Question. As you know, this pool of funding expires in September.
Can you speak to the importance of maintaining adequate funding for the
GHSA?
Answer. Achieving global health security remains a foreign policy
priority for the Department of State. Agencies other than the
Department are the primary implementers of the funds made available for
U.S. Government Global Health Security Agenda (GHSA) activities. The
State Department regularly highlights U.S. Government investments in
the GHSA, and their lifesaving impact, in diplomatic engagements with
partner countries.
Question. If funding is not maintained at current levels in the FY
20 spending bill, will your agencies be able to maintain current global
health security programming, or will you be required to scale back
operations?
Answer. The Department of State is not a primary implementer of the
overseas capacity-building activities to prevent, detect, and respond
to infectious diseases. Department staff will continue to conduct
outreach, promote global health security, and coordinate implementation
of the interagency Global Health Security Agenda activities through
U.S. missions.
Question. Ongoing conflict, violence and community mistrust have
been identified as the main reasons complicating the current response
in a country that is no stranger to Ebola outbreaks. However, former
Minister of Health Dr. Oly Ilunga Kalenga identified additional
weaknesses in response efforts, including a lack of coordination and
communication among actors, lack of actionable data, and weak
operational plans. What are your agencies doing to help the Ministry of
Health address these weaknesses and strengthen the response from an
implementation standpoint?
Answer. The State Department, in coordination with USAID, CDC, and
other agencies, is working with the DRC Ministry of Health and the U.N.
system (including the WHO) to improve coordination among Ebola
responders and strengthen the response effort. Ambassador Hammer and
his team at Embassy Kinshasa and in Goma are in constant contact with
DRC and other actors, assessing the response effort and providing
guidance on how to improve it. A particular focus is to ensure the
transition of DRC leadership overseeing the response--from former
Minister of Health Ilunga to lead Ebola coordinator Dr. Jean-Jacques
Muyembe--is smooth and leads to a better-coordinated response.
Question. The World Health Organization has identified a funding
shortfall of $54 million for response efforts to control the outbreak
and prevent further spread. U.S. contributions thus far have come out
of existing Ebola emergency supplemental funding from the 2014
outbreak. Are there any plans for the U.S. to make an additional
contributions on par with increasing challenges?
Answer. The United States is the largest single-country donor to
the Democratic Republic of Congo, contributing approximately $500
million in development and humanitarian programming annually, and more
than $136 million to the current Ebola response. Working with the
international community, the U.S. Government is constantly assessing
the humanitarian needs and gaps in the response and may make further
contributions where we are best placed to fill a need. We continue to
engage members of the international community to fully fund the
response. We are also supporting Ebola preparedness efforts in
unaffected areas in the DRC and neighboring countries through the
Global Health Security Agenda and other mechanisms.
Question. As one the largest and longest-lasting U.N. peacekeeping
missions, the United Nations Organization Stabilization Mission in the
Democratic Republic of the Congo (MONUSCO) has been criticized for its
cost, effectiveness, and various allegations of misconduct on-the-
ground. In March, the United Nations Security Council called for a
security review of the mission, including a drawdown and exit strategy.
In April, the mission scaled back operations in various parts of the
country, due to budget cuts. At the moment, do you think that MONUSCO
is equipped to handle the on-going Ebola crisis, amid these on-going
and possible future changes? If so, how can the U.S. assist in this
regard?
Answer. MONUSCO has successfully consolidated its activities from
electoral support throughout the country to focus eastward on
protection of civilians, provision of good offices to mitigate
conflict, and neutralizing the over 100 armed groups that operate in
the eastern DRC. MONUSCO has made notable strides in quelling ethno-
political conflict in South Kivu and Ituri by brokering cease-fire
agreements, fostering dialogue between agents of conflict and local
communities, as well as producing an agreement to turn an armed group
(Ituri Patriotic Front Resistance) into a political party. These
efforts complement the overall effort to control the current Ebola
outbreak.
MONUSCO also provides invaluable logistical, security, good offices
and leadership support to the Ebola response itself, including
providing escorts and securing road access for humanitarian operations
and personnel. In May, at the United States' suggestion, U.N. Secretary
General Guterres appointed former MONUSCO Deputy Special Representative
of the Secretary General David Gressly as the U.N.'s Ebola Emergency
Response Coordinator (EERC), responsible for coordinating the
international response including U.N. agencies, NGOs and donors, in
partnership with the government of the DRC. Gressly's professional
background and substantial DRC experience give him the tools and
expertise to navigate a complex response in an even more complex
environment. Since his appointment, Gressly has introduced
complementary, multi-sector humanitarian programs that aim to enhance
community acceptance of Ebola response activities. He formalized
political and security management protocols under what he describes as
a ``complex public health emergency.'' Gressly's proposed security
reforms for the response, while ambitious to implement quickly, mirror
USG priorities for de-militarizing the response by reducing security
escorts and shifting to long-range perimeter security. In response to
recent increases in Ebola-related insecurity in the Beni-Butembo
epicenter area, MONUSCO has also deployed additional peacekeepers
there.
Question. In 2019, the United Nations Refugee Agency estimated that
DRC has over 856, 043 refugees and the 4.5 million internally
displaced. How has the Ebola crisis further worsened the on-going
refugee and IDP situation in the Congo and its neighboring states? What
bilateral and multilateral efforts can the U.S. take to reduce the
migration of peoples both in and out of DRC?
Answer. The Ebola outbreak is occurring in eastern DRC, one of the
most geopolitically complex areas in Africa. A combination of decades
of neglect by the central government, socio-economic marginalization,
and political tensions has led to persistent conflict by armed groups
and spontaneous attacks between intercommunal groups and youth groups.
While the U.S. Government has not observed additional displacements due
to the Ebola outbreak, the response to it is complicated by insecurity
and large-scale population displacement. The U.S. Government continues
to respond to the complex emergency, supporting humanitarian protection
and the provision of basic services, such as food assistance, health
care, psychosocial support, and water and sanitation, which help reduce
some displacement.
We encourage all countries to follow the World Health Organization
(WHO) recommendations to address the Ebola outbreak, which is a Public
Health Emergency of International Concern. The WHO advises against
placing travel and trade restrictions on or closing borders with the
DRC.
The United States continues to call on other donors to increase
their support for humanitarian assistance in the DRC and for Congolese
refugees in the region. Ultimately, durable solutions for most
displacement in the country and region depend on resolution of the
political conflicts that are driving people from their homes in the
DRC, Burundi, Central African Republic, Rwanda, and South Sudan.
__________
Responses of Hon. Marcia Bernicat to Questions Submitted
by Senator Robert Menendez
22 U.S.C. Chapter 78, Section 4 of the Trafficking Victims
Protection Act provides for the continuation of assistance that would
otherwise be sanctioned for failing to meet the minimum standards on
trafficking when it is in the National Interest of the United States to
waive sanctions. Paragraph Section (d)(5)(B) of TVPA states: ``The
President shall exercise the authority under section (4) when necessary
to avoid significant adverse effects on vulnerable populations,
including women and children.'' According to the World Health
Organization, the Ebola virus disease has a mortality rate of 50
percent.
Question. Do we consider the people in eastern Democratic Republic
of Congo (DRC) living in Ebola affected regions, or living near those
infected with Ebola vulnerable? How many women have been infected with
Ebola in this outbreak, and how many have died as a result of the
infection? How many children have been infected with Ebola in this
outbreak? How many children have died as a result of being infected?
Answer. The current Ebola outbreak in an active conflict zone in
eastern DRC is affecting a vulnerable population that is extremely poor
and historically neglected and abused. The outbreak is
disproportionately affecting women due to their role as primary
caretakers. Community resistance and a large number of community deaths
further exacerbate the impact on women and children. According to the
WHO, as of July 31, 56 percent of the total 2,612 confirmed and
probable cases were women, and 29 percent were children under 18 years.
While we do not have data on the number of women fatalities, according
to Save the Children, over 500 children have died since the outbreak
began in August 2018.
Question. Do we consider the morbidity resulting from Ebola a
significant adverse effect?
Answer. Yes.
Question. Why hasn't the waiver cited above been exercised as
required by the law?
Answer. The United States is the largest single-country donor to
the current Ebola outbreak response, including support through the U.S.
Agency for International Development of more than $136 million since
August 2018. Most assistance to the Ebola response is not subject to
the TVPA restrictions. The U.S. Government is committed to global
health security as outlined in the National Security and National
Biodefense strategies, and is working with partners to provide the
assistance needed to contain this outbreak. The process of evaluating
assistance affected by restrictions for FY 2020 TVPA is ongoing.
Question. How effective will the international response be if we
are not able to engage in actions that will help lower community
resistance?
Answer. The current Ebola outbreak is the tenth in the DRC. Against
the backdrop of a complex humanitarian crisis, community resistance--
evidenced by the high number of community deaths--is complicating
response efforts. Community engagement and buy-in are critical to
containing this outbreak, and to preventing it from spreading to
populous regions and neighboring countries. We support broader
engagement by the United Nations and outreach to community leaders and
civil society, including faith-based groups and religious leaders, to
lower community resistance.
Question. What polling data exists to support claims that
Tshisekedi continues to grow in popularity in eastern Congo?
Answer. In June, the New York University-based Congo Research Group
(CRG) released new polling data that confirmed the optimism of the
Congolese people towards President Felix Tshisekedi. The data
highlighted that 61 percent of Congolese are optimistic about DRC's
future and 67 percent have a favorable view of the new president's
first 100 days in office. The CRG poll confirms average Congolese are
hopeful about the future for the first time in many years and suggests
that U.S. support is a key factor to ensure President Tshisekedi is
able to consolidate the democratic transition and enact reforms
encompassing human rights, accountability, anti-corruption, security
sector professionalization, and fiscal transparency. During insecurity-
driven protests this week in Beni territory, civil society called on
President Tshisekedi to travel again to the region to personally assess
the situation. This is notably different from the protests that
occurred frequently during the previous regime calling on Kabila to
step down.
Question. According to a fact sheet released by the Armed Conflict
Location & Event Data Project (ACLED), ``Six months into the new
presidency of Felix Tshisekedi, ACLED data show that overall political
violence is rising at even higher rates than last year, at the
conclusion of Joseph Kabila's nearly 20-year rule.'' To what do we
attribute this uptick in violence?
Answer. South Kivu and Ituri saw major escalations in longstanding
communal grievances in the last few months, which may account for some
of the uptick as ACLED does not seem to clearly distinguish between
purely political and ethnic violence, which are often intertwined in
local conflicts. In terms of the ACLED data set between January and
June, armed clashes and attacks dwarfed traditional political violence
by the state against peaceful opposition and demonstrators. The U.N.
reported that after the inauguration of President Tshisekedi in late
January a number of armed groups turned themselves in to MONUSCO and
the GDRC. More than 1,000 fighters requested demobilization, as they no
longer feel threatened by the national government. Our focus is on
ensuring MONUSCO and the GDRC have the personnel and funding resources
to leverage these gains by implementing sustainable options for
reintegrating former militia members into their communities.
MONUSCO's Joint Human Rights Office (JHRO) documented 9 percent
fewer human rights violations over the first six months of 2019
compared to same period in 2018. This is an encouraging sign of
improvement during President Felix Tshisekedi's first few months in
office. In particular, the JHRO noted state security forces were
responsible for notably fewer violations when compared to the same
period in 2018. Political violence in the Haut Uele and Bas Uele
provinces decreased due to military pressure by the FARDC. Violence has
been curbed in areas of North Kivu where MONUSCO supported local
authorities' efforts to facilitate dialogue between warring groups and
re-instituted a local conflict resolution mechanism. MONUSCO and the
GDRC also made strides in quelling ethno-political conflict and
displacement in South Kivu in June by brokering cease-fire agreements
and fostering dialogue between ethnic armed group leaders and the local
communities. In addition, MONUSCO and the FARDC recently addressed
longstanding violent conflict and significant displacement in Ituri by
fostering an agreement to turn an armed group (Ituri Patriotic Front
Resistance) into a political party.
__________
Responses of Hon. Marcia Bernicat to Questions Submitted
by Senator Edward J. Markey
The ongoing Ebola outbreak and other Infectious disease threats,
such as measles and antibiotic resistance, help reinforce the
importance of the Global Health Security Agenda (GHSA)--a partnership
of over 64 nations and stakeholders to help create a world safe and
secure from infectious disease threats. Across CDC, USAID, and NIH, $1
billion in GHSA funding between 2014 and 2019 has supported efforts to
build global health capacity to effectively combat infectious diseases.
Question. As you know, this pool of funding expires in September.
Can you speak to the importance of maintaining adequate funding for the
GHSA?
Answer. Achieving global health security remains a foreign policy
priority for the Department of State. Agencies other than the
Department are the primary implementers of the funds made available for
U.S. Government Global Health Security Agenda (GHSA) activities. The
State Department regularly highlights U.S. Government investments in
the GHSA, and their lifesaving impact, in diplomatic engagements with
partner countries.
Question. If funding is not maintained at current levels in the FY
20 spending bill, will your agencies be able to maintain current global
health security programming, or will you be required to scale back
operations?
Answer. The Department of State is not a primary implementer of the
overseas capacity-building activities to prevent, detect, and respond
to infectious diseases. Department staff will continue to conduct
outreach, promote global health security, and coordinate implementation
of the interagency Global Health Security Agenda activities through
U.S. missions.
Question. Ongoing conflict, violence and community mistrust have
been identified as the main reasons complicating the current response
in a country that is no stranger to Ebola outbreaks. However, former
Minister of Health Dr. Oly Ilunga Kalenga identified additional
weaknesses in response efforts, including a lack of coordination and
communication among actors, lack of actionable data, and weak
operational plans. What are your agencies doing to help the Ministry of
Health address these weaknesses and strengthen the response from an
implementation standpoint?
Answer. The State Department, in coordination with USAID, CDC, and
other agencies, is working with the DRC Ministry of Health and the U.N.
system (including the WHO) to improve coordination among Ebola
responders and strengthen the response effort. Ambassador Hammer and
his team at Embassy Kinshasa and in Goma are in constant contact with
DRC and other actors, assessing the response effort and providing
guidance on how to improve it. A particular focus is to ensure the
transition of DRC leadership overseeing the response--from former
Minister of Health Ilunga to lead Ebola coordinator Dr. Jean-Jacques
Muyembe--is smooth and leads to a better-coordinated response.
Question. The World Health Organization has identified a funding
shortfall of $54 million for response efforts to control the outbreak
and prevent further spread. U.S. contributions thus far have come out
of existing Ebola emergency supplemental funding from the 2014
outbreak. Are there any plans for the U.S. to make an additional
contributions on par with increasing challenges?
Answer. The United States is the largest single-country donor to
the Democratic Republic of Congo, contributing approximately $500
million in development and humanitarian programming annually, and more
than $136 million to the current Ebola response. Working with the
international community, the U.S. Government is constantly assessing
the humanitarian needs and gaps in the response and may make further
contributions where we are best placed to fill a need. We continue to
engage members of the international community to fully fund the
response. We are also supporting Ebola preparedness efforts in
unaffected areas in the DRC and neighboring countries through the
Global Health Security Agenda and other mechanisms.
__________
Responses of Rear Admiral Tim Ziemer, USN, Retired to Questions
Submitted
by Senator Robert Menendez
22 U.S.C. Chapter 78, Section 4 of the Trafficking Victims
Protection Act provides for the continuation of assistance that would
otherwise be sanctioned for failing to meet the minimum standards on
trafficking when it is in the National Interest of the United States to
waive sanctions. Paragraph Section (d)(5)(B) of TVPA states: ``The
President shall exercise the authority under section (4) when necessary
to avoid significant adverse effects on vulnerable populations,
including women and children.'' According to the World Health
Organization, the Ebola virus disease has a mortality rate of 50
percent.
Question. Do we consider the people in eastern Democratic Republic
of Congo (DRC) living in Ebola affected regions, or living near those
infected with Ebola vulnerable? How many women have been infected with
Ebola in this outbreak, and how many have died as a result of the
infection? How many children have been infected with Ebola in this
outbreak? How many children have died as a result of being infected?
Answer. Anyone living in proximity to a disease outbreak is
vulnerable to infection, including persons vulnerable to Ebola in at-
risk areas in the Democratic Republic of the Congo (DRC). USAID
continues to support Ebola response assistance to support vulnerable
populations in DRC. We defer to the Centers for Disease Control and
Prevention (CDC) on the latest case numbers for women and children.
Question. Do we consider the morbidity resulting from Ebola a
significant adverse effect?
Answer. Yes, the morbidity resulting from Ebola is a significant
adverse effect of infection. USAID continues to support the Ebola
response, providing assistance under available authorities, including
the exception to the TVPA restriction, as well as by relying on funding
not impacted by TVPA.
Question. Why hasn't the waiver cited above been exercised as
required by the law?
Answer. Ebola-related assistance is continuing through available
authorities and exceptions, and as such, the exercise of the TVPA
waiver is not necessary in order to avoid significant adverse effects
of the TVPA restriction on vulnerable populations.
Question. How effective will the international response be if we
are not able to engage in actions that will help lower community
resistance?
Answer. Effectively engaging communities remains integral to ending
the outbreak. USAID is engaging in actions that will help lower
community resistance along with international partners ECHO, DFID, and
the World Bank. For example, USAID has provided $5.3 million to support
UNICEF in engaging communities affected by the Ebola virus disease
(EVD). UNICEF is the co-lead for risk communication and community
engagement in the response and plans to strengthen community engagement
through social and behavioral change, local community participation,
and mental health and psychosocial support. UNICEF will work with
affected and at-risk communities and address community concerns and
rumors, among other activities. UNICEF will further conduct research
and implement evidence-based communication in the development of a
Communication Strategy.
Additionally, USAID is undertaking a number of actions to address
community resistance, such as supporting primary health care or
providing basic water, sanitation and hygiene. USAID emphasizes the
importance of an expanded community-based response strategy that
operationalizes community feedback, increases local ownership of Ebola
response activities, and helps address broader, community-prioritized
needs to improve community acceptance and access. Under this approach,
to build local ownership, USAID will support hiring more persons from
the local community, including Ebola survivors, as well as engage a
wide range of local stakeholders in core response strategies and
communications--from women's groups and faith leaders to traditional
leaders and youth. The goal is to change perspectives so that members
of the community themselves can spread messages related to the
response, which will help reinforce community acceptance and engagement
in the response.
USAID's Office of Inspector General released two reports in January
of 2018 assessing lessons learned and gaps in the last response. Two of
the reports pointed to challenges in filling staffing vacancies during
the last Ebola response. One report pointed to the ``lack of an Agency
wide system for capturing and sharing program and project data'' which
``challenged internal communication and coordination.''
Question. What are the major lessons learned from the 2014 Ebola
response in the areas of staffing, programming and planning, and how
are these lessons being incorporated in this response?
Answer. States must be prepared to quickly respond to infectious
disease outbreaks that could pose a global danger, in some cases even
before the World Health Organization (WHO) declares an official PHEIC.
USAID has committed to the continual strengthening of the Agency's
policies, practices, structures, and systems to prepare for, respond
to, and learn from global infectious disease outbreaks. For example, on
October 31, 2018, an Agency Notice was issued titled, ``USAID Response
to Global Infectious Disease Outbreaks''. The Agency Notice clearly
outlines the roles and responsibilities of USAID staff when preparing
for and responding to infectious disease outbreaks, including a
requirement to USAID Missions and Offices overseas to be aware of local
outbreaks and to notify [email protected] when there is an outbreak
that may require international or additional assistance. On July 26,
2019, an Agency Notice was issued titled ``Process for Programming
Resources during a declared Public Health Emergency of International
concern''. The notice outlines the process at the U.S. Agency for
International Development (USAID) for programming resources during a
Public Health Emergency of International Concern (PHEIC) declared by
the World Health Organization (WHO). USAID's broad-based and
multisectoral approach allows the Agency to leverage the technical
expertise to strengthen local capacity around the world to prevent,
detect, and respond to infectious diseases.
USAID has established partnerships across the U.S. Government, with
relevant international, non-governmental, and other organizations, to
strengthen preparedness and response efforts for potential disease
outbreaks that could require an international emergency response. While
we are applying lessons learned wherever possible, we are also
accounting for key differences in the outbreaks and responses,
including the fact that the current response is taking place in an
active conflict zone. Many personnel responding to this outbreak also
responded in 2014 and have leveraged their expertise in this response.
WHO has adopted emergency response reforms over the last several years,
with the strong backing of the United States, which have enabled the
organization to improve their operational capacity and more effectively
and rapidly respond to this and other outbreaks.
Question. Have USAID and the Interagency worked to develop an
overarching framework and strategy for improved leadership, staffing,
and coordination for this and future global health security responses?
If so, how has this improved framework and approach helped in this
current DRC outbreak?
Answer. USAID maintains several mechanisms, such as interagency
agreements, with key interagency partners to rapidly pull in and
leverage unique capabilities across the U.S. Government to support
response efforts. Additionally, we support the roles and
responsibilities of federal agencies for this kind of emergency, as
outlined in the 2019 U.S. Government Global Health Security Strategy.
USAID remains in an ongoing dialogue with Centers for Disease Control
and Prevention (CDC) to further formalize coordination for future
public health emergencies that become humanitarian crises.
Question. What do you see as remaining challenges in U.S.
Government preparation for improved coordination and implementation in
future international public health emergencies?
Answer. There are myriad challenges to effectively coordinating the
response to future public health emergencies. While USAID continues to
build up its staffing and systems for public health emergency
responses, including: having the right people with the necessary skills
(foreign language and previous outbreak experience) for immediate
assignments which may last for months or longer is a challenge. It is
even more difficult in light of the growing number of humanitarian
responses and increasing demands on USAID.
Question. Have all programs and activities currently underway using
International Development Assistance funds been shared with bureaus in
the Agency, such as the Africa and Global Health bureaus to better
support coordination with ongoing programs and inform planning for
future programs? Did those bureaus help plan the Office of Foreign
Disaster Assistance programs and activities currently underway in
eastern Congo? Are recovery activities being incorporated into our
disaster response activities?
Answer. Coordination within USAID is excellent, with both Global
Health and Africa bureau staff fully integrated into the Response
Management Team (RMT) led by the Bureau for Democracy, Conflict and
Humanitarian Assistance. Programs and activities currently underway in
eastern Democratic Republic of the Congo (DRC) using International
Disaster Assistance funds are shared with the Africa and Global Health
bureaus to better support coordination with ongoing programs and inform
planning for future programs. USAID is currently focusing its efforts
on response activities in the affected provinces of the DRC as well as
bolstering the preparedness capabilities of unaffected parts of the DRC
and neighboring at-risk countries (Uganda, South Sudan, Rwanda, and
Burundi).
Question. How many team members are there on the Disaster
Assistance Response Team (DART)? Which agencies are the team members
from? How many DART members are in each of the locations where USG
personnel are assigned? How long have each of the team members been
deployed and what is the length of their deployment? Is turnover of
deployed members at all affecting the response? Did any of the current
DART team members participate in the 2014 response?
Answer. There are currently 17 DART members deployed in the DRC,
including 7 in Kinshasa and 11 in Goma. In addition, the Disaster
Assistance Response Team (DART) has consultants supporting the local
surveillance and IPC commissions and reporting to the DART. Members of
the team include USAID and CDC staff. Average rotations of DART team
members are two to three months. The turnover does not affect the
response. A number of DRC Ebola DART team members also participated in
the 2014 West Africa response.
Question. Has USAID made changes or taken specific steps to better
coordinate, track, and execute financial and human capital resources
among the Office of U.S. Foreign Disaster Assistance, Global Health,
and regional bureaus? How has the availability (on unavailability) of
the appropriate resources--both funds and human capital--from these
bureaus and various accounts helped, or hindered, USAID's response to
the outbreak in DRC?
Answer. Coordination across different bureaus occurs through
regular meetings with the intra-agency technical working group, regular
discussions on high level policy issues, mission collaboration with the
mission liaison position to the DART, and through the Global Health and
Africa Bureau liaisons to the RMT. The Bureau for Global Health, Africa
Bureau, and USAID's Office of Foreign Disaster Assistance (USAID/OFDA)
budget offices regularly coordinate with each other, and the Bureau for
Resource Management and State/F to execute accurate financial tracking
across the entire response architecture.
To date, USAID has sufficient funding to adequately support the
response, thanks in part to the Congressional Ebola supplemental
funding provided during the West Africa Ebola outbreak. Specifically,
the availability of these funds has supported technical expertise to
partners for disease surveillance, case investigation, contact tracing,
emergency health care, patient management in Ebola treatment units,
water, sanitation, and hygiene, infection prevention and control,
border health, community engagement, risk communication, the promotion
of safe and dignified burials, and other technical support. We continue
to evaluate requests for assistance and are coordinating with the
Government of the DRC and other international partners to ensure the
disease is contained. Our goal is to provide the most efficient and
effective support possible to our partners to bring this outbreak to an
end as soon as possible.
Since the 2014 West Africa Ebola outbreak, USAID/OFDA has
undertaken multiple steps to ensure USAID staff receive training on
USAID's Response Management System (RMS), which codifies authorities,
structures and responsibilities for the Disaster Assistance Response
Team and Response Management Team. In July 2017, OFDA launched the On-
Ramp Program, which prepares qualified USAID staff to become a part of
USAID/OFDA's emergency staffing pool to broaden the number of available
surge personnel. USAID/OFDA now also regularly offers humanitarian
assistance and disaster response training to orient USAID staff to the
broader humanitarian architecture and interagency structures. In
addition to the additional training and On-Ramp program, USAID/OFDA is
developing and launching the Personnel, Experience, and Training,
Equipment, and Readiness (PETER) system. PETER is a readiness and
deployment database which supports the unique qualification,
activation, and human resource requirements of both USAID/OFDA and
USAID's Office of Food for Peace. PETER will assist managers in
identifying and tracking the qualifications, experience, and
availability of personnel for all types of disasters and complex
emergencies.
Question. USG personnel are not currently authorized to deploy to
the epicenter of the outbreak in DRC due to insecurity. Given that
security constraints prevent U.S. personnel from being deployed the
affected regions, how are we ensuring that we effectively monitor
activities undertaken with USG funds?
Answer. With the Emergency Operations Center relocated to Goma,
most of the Disaster Assistance Response Team (DART) staff are now
based there as well. The response reset also recommends the continued
use of Goma, given that it is the optimal location to continue to
support response efforts in Eastern Congo. U.S. staff in Kinshasa and
Goma continue working closely with the Democratic Republic of the Congo
Ministry of Health, WHO, and key response agencies providing daily
support and technical recommendations for improving the response.
Additionally, they remain in constant contact with partners and
responders located in the affected areas. USAID partners with many
entities that are able to access affected areas and implement key
response activities. The DART in Goma meets regularly with partners and
receives weekly reports on implementation.
__________
Responses of Rear Admiral Tim Ziemer, USN, Retired to Questions
Submitted by Senator Edward J. Markey
The ongoing Ebola outbreak and other Infectious disease threats,
such as measles and antibiotic resistance, help reinforce the
importance of the Global Health Security Agenda (GHSA)--a partnership
of over 64 nations and stakeholders to help create a world safe and
secure from infectious disease threats. Across CDC, USAID, and NIH, $1
billion in GHSA funding between 2014 and 2019 has supported efforts to
build global health capacity to effectively combat infectious diseases.
Question. As you know, this pool of funding expires in September.
Can you speak to the importance of maintaining adequate funding for the
GHSA?
Answer. Maintaining adequate funding for the GHSA is important to
help prevent avoidable outbreaks, quickly detect new ones, and rapidly
and effectively respond to infectious disease outbreaks. The U.S.
Global Health Security Strategy, released in May 2019, provides
guidance and an operational framework for current and future USAID
global health security engagement.
Question. If funding is not maintained at current levels in the FY
20 spending bill, will your agencies be able to maintain current global
health security programming, or will you be required to scale back
operations?
Answer. Should Congress not maintain current appropriated levels
for GHSA, USAID will adapt and focus efforts to strengthen global
health security in priority countries.
Question. Ongoing conflict, violence and community mistrust have
been identified as the main reasons complicating the current response
in a country that is no stranger to Ebola outbreaks. However, former
Minister of Health Dr. Oly Ilunga Kalenga identified additional
weaknesses in response efforts, including a lack of coordination and
communication among actors, lack of actionable data, and weak
operational plans. What are your agencies doing to help the Ministry of
Health address these weaknesses and strengthen the response from an
implementation standpoint?
Answer. USAID understands that an effective response to the Ebola
outbreak requires enhanced coordination between the Government of DRC
(GDRC), including its Ministry of Health (MoH), World Health
Organization (WHO), non-governmental organizations (NGOs), and other
humanitarian stakeholders. April 30, 2019, the U.S., with other lead
donors to the response, sent a letter to the WHO Director General and
U.N. Under-Secretary General for Humanitarian Affairs/Emergency
Response Coordinator (ERC) citing the severity of the outbreak and gaps
in leadership and coordination and requesting urgent action, including
the appointment of an empowered senior leader for the international
response. In May 2019, a delegation from USAID and the Centers for
Disease Control and Prevention (CDC) travelled with Ambassador Michael
A. Hammer to eastern DRC and met with civil society, traditional and
faith-based leaders, and representatives of the GDRC, United Nations
(U.N.), NGOs, and donors. The visit confirmed analysis that security
issues, leadership challenges, poor coordination, underutilization of
NGOs and faith-based groups, and insufficient community engagement were
hindering response effectiveness.
As a result of a whole of U.S. Government engagement pressing for
changes with the U.N. and WHO, in coordination with other lead donors,
the U.N. Secretary General appointed David Gressly as the U.N. Ebola
Emergency Response Coordinator (EERC) to oversee the coordination of
international support for all Ebola Virus Disease (EVD) response-
related and enabling operations, and on May 30, 2019 the ERC activated
a System-Wide Scale-Up for the Control of Infectious Disease Events.
The activation targets health zones in the DRC in which transmission is
occurring and likely to occur, with the possibility of including other
geographical areas should the disease spread. The scale-up has five
strategic priorities: (i) strengthened political engagement to create
an enabling environment for the response; (ii) strengthened multi-
sectoral humanitarian coordination that fosters greater community
engagement; (iii) timely and sustainable financing, monitoring and
reporting on the use of funds in collaboration with the World Bank and
key donors; (iv) enhancing the public health response, working with the
Ministry of Health; and (v) leadership for a contingency cell in Goma
and redouble preparedness efforts in other countries (Burundi, South
Sudan, Rwanda and Uganda).
The USAID Disaster Assistance Response Team (DART) is working
closely with EERC Gressly to improve coordination and communication
among response actors and the GDRC. This includes pressing for a
unified international and national response, currently led by the MoH
out of the Emergency Operations Center in Goma. The DART meets
regularly with the EERC and WHO leadership, bilaterally and weekly with
other lead donors, to monitor this response ``reset'' and ensure
improved leadership and coordination progresses to improve the
trajectory of the outbreak. This includes close tracking of the
development of Strategic Response Plan 4.0.
On July 20, President of the DRC Felix Tshisekedi announced the DRC
MoH is no longer the lead response entity and the creation of
multisectoral Ebola committee led by the Director of the National
Institute for Biomedical Research that will oversee day-to-day response
activities. On July 22, the DRC Minister of Health Dr. Oly Ilunga
resigned. The U.S. continues to press for appointment of a Minister of
Health, while supporting the EERC in bringing about an effective
response with the GDRC and current leadership in place.
USAID is collaborating with the CDC to provide community engagement
assistance to the MoH-led and WHO-coordinated response based on
previous Ebola responses, as well as community feedback to tailor
community engagement approaches based on unique community dynamics
across the response. USAID has also contracted private health sector
experts to serve as our eyes and ears on the ground, to provide
technical support to the DRC MoH, and reinforce response efforts in the
outbreak zone. USAID staff in Kinshasa and Goma continue to work
closely with the MoH, WHO, and key response agencies providing daily
support and technical recommendations for improving the response.
Since arriving in May, EERC Gressly has established the Ebola
Emergency Response Team (EERT), which will implement the U.N.'s scale-
up strategy and bridge the public health response with multi-sector
humanitarian activities. EERC Gressly and WHO Assistant Director-
General Dr. Ibrahim Soce Fall co-chair the EERT, which meets on a
weekly basis. As a result of USAID advocacy, many NGOs are
participating on the EERT, ensuring a broad representation of
perspectives and bringing a different set of knowledge and expertise to
the response.
USAID has also been working with EERC Gressly, the U.N., and the
GDRC to release a comprehensive response plan, the aforementioned SRP
4.0, which includes the cost requirements for both public health
interventions and multi-sector humanitarian activities to end the
outbreak. We expect the GDRC to release a revised comprehensive plan
that will include input from various response actors and present a
financial appeal for strengthened public health response, political
engagement, security support, complementary humanitarian assistance,
community engagement activities, and financial planning and monitoring
in the coming days.
Question. The World Health Organization has identified a funding
shortfall of $54 million for response efforts to control the outbreak
and prevent further spread. U.S. contributions thus far have come out
of existing Ebola emergency supplemental funding from the 2014
outbreak. Are there any plans for the U.S. to make an additional
contributions on par with increasing challenges?
Answer. On July 24, the U.S. Government (USG), through USAID,
announced an additional $38 million in assistance to help end the
ongoing Ebola outbreak in Eastern Democratic Republic of the Congo,
including $15 million in new funding to the World Health Organization.
Since the beginning of the outbreak in August 2018, USAID has provided
more than $136 million to the Ebola response, making the USG the
largest single country donor to the response. We look forward to
reviewing the revised comprehensive strategic plan and stand prepared
to provide additional contributions as necessary.
Question. As one the largest and longest-lasting U.N. peacekeeping
missions, the United Nations Organization Stabilization Mission in the
Democratic Republic of the Congo (MONUSCO) has been criticized for its
cost, effectiveness, and various allegations of misconduct on-the-
ground. In March, the United Nations Security Council called for a
security review of the mission, including a drawdown and exit strategy.
In April, the mission scaled back operations in various parts of the
country, due to budget cuts. At the moment, do you think that MONUSCO
is equipped to handle the on-going Ebola crisis, amid these on-going
and possible future changes? If so, how can the U.S. assist in this
regard?
Answer. USAID believes that MONUSCO's ongoing support to the Ebola
response efforts is sufficient, based on the current mandate language
related to humanitarian access and logistical support. However, even
the perception of the militarization of the Ebola response through the
provision of security by MONUSCO could aggravate the situation. We
defer to the Department of State on how the U.S. can assist amidst
these challenges.
Question. In 2019, the United Nations Refugee Agency estimated that
DRC has over 856, 043 refugees and the 4.5 million internally
displaced. How has the Ebola crisis further worsened the on-going
refugee and IDP situation in the Congo and its neighboring states? What
bilateral and multilateral efforts can the U.S. take to reduce the
migration of peoples both in and out of DRC?
Answer. The Ebola outbreak is occurring in eastern DRC, one of the
most geopolitically complex areas in Africa. A combination of decades
of neglect by the central government, socio-economic marginalization,
and political tensions has led to persistent conflict by armed groups
and spontaneous attacks between intercommunal groups and youth groups.
While the U.S. Government has not observed additional displacements due
to the Ebola outbreak, the response to it is complicated by the
insecure environment and large-scale population displacement. The U.S.
Government continues to respond to the complex emergency, supporting
humanitarian protection and the provision of basic services, such as
food assistance, health care, psychosocial support, and water and
sanitation, which help reduce some displacement.
We encourage all countries to follow World Health Organization
(WHO) recommendations to address the Ebola outbreak, which is a Public
Health Emergency of International Concern. The WHO advises against
placing travel and trade restrictions or closing borders with the DRC.
The United States continues to call on other donors to increase
their support for humanitarian assistance in the DRC and for Congolese
refugees in the region. Ultimately, durable solutions for most
displacement in the country and region depend on resolution of the
political conflicts that are driving people from their homes in the
DRC, Burundi, Central African Republic, Rwanda, and South Sudan.
__________
Responses of Dr. Mitch Wolfe to Questions Submitted
by Senator Edward J. Markey
The ongoing Ebola outbreak and other Infectious disease threats,
such as measles and antibiotic resistance, help reinforce the
importance of the Global Health Security Agenda (GHSA)--a partnership
of over 64 nations and stakeholders to help create a world safe and
secure from infectious disease threats. Across CDC, USAID, and NIH, $1
billion in GHSA funding between 2014 and 2019 has supported efforts to
build global health capacity to effectively combat infectious diseases.
Question. As you know, this pool of funding expires in September.
Can you speak to the importance of maintaining adequate funding for the
GHSA?
Answer. The FY 2015 emergency appropriation for implementation of
the Global Health Security Agenda and National Public Health Institute
Development ($597M) was a substantial investment towards CDC's global
health security efforts. Those resources have been put to use as
intended--to address an urgent need for accelerating progress towards a
world more prepared to stop infectious diseases at their source before
they pose a threat to us here at home. The five-year supplemental will
be fully obligated, as planned, by the end of this year (FY 2019).
Although we have made considerable progress through the investment of
these funds, most of the world is still under-prepared to effectively
prevent, detect, and respond to infectious disease health threats.
Building health security capacity, particularly sustainable capacity
over which partner countries exhibit ownership without significant
decrease in quality, can take years of effort. [Please note that the
NIH was not a recipient of GHSA-designated funding.]
CDC's FY2020 request includes $99.762 million, an increase of $49.8
million above FY2019 Enacted for Global Health Security activities that
will protect Americans through partnerships and other activities that
support public health capacity improvements in countries at risk from
uncontrolled outbreaks of infectious diseases. CDC will implement an
approach to global health security investments that is informed by
lessons learned over the last 5 years. CDC is proactively planning its
future global health strategy to strengthen our ability to respond more
rapidly and effectively to health threats wherever they occur and
balance our commitment to our core mission of protecting Americans.
Ultimately, this plan strikes a balance between responsible
sustainability and maximum impact through CDC presence overseas.
Question. If funding is not maintained at current levels in the FY
20 spending bill, will your agencies be able to maintain current global
health security programming, or will you be required to scale back
operations?
Answer. CDC has primarily supported these activities using
supplemental funding received in FY 2015, which will expire at the end
of FY 2019. Congress has also provided CDC with $50 million in global
health security funding in both FY 2018 and FY 2019. The FY 2020
President's Budget request for CDC includes $99.762 million for global
health security activities, an increase of $49.8 million above the FY
2019 enacted level. In FY 2020, CDC's GHS funding will be directed
towards activities in countries receiving intensive and targeted
support, as defined in the Global Health Security Strategy. Funding
will also be directed towards the most pressing, cross-cutting disease
threats and global capacity requirements that will maximize outcomes
for these countries. CDC will maintain its focus on building capacity
in these core areas in alignment with the Global Health Security
Strategy's objective of sustainability and transition to country
ownership. It is also important to note that CDC is planning for FY
2020 while also playing a key role in the USG response to a persistent
Ebola outbreak in DRC that is likely to extend into FY 2020.
Question. Ongoing conflict, violence and community mistrust have
been identified as the main reasons complicating the current response
in a country that is no stranger to Ebola outbreaks. However, former
Minister of Health Dr. Oly Ilunga Kalenga identified additional
weaknesses in response efforts, including a lack of coordination and
communication among actors, lack of actionable data, and weak
operational plans. What are your agencies doing to help the Ministry of
Health address these weaknesses and strengthen the response from an
implementation standpoint?
Answer. As part of the administration's whole-of-government effort,
CDC experts are supporting the DRC government, neighboring country
governments, WHO, and other partners by providing technical guidance
and expertise in contact tracing, surveillance, laboratory testing,
data analytics, vaccine implementation, emergency management, infection
prevention and control, behavioral sciences, health communications, and
border health. CDC continues to deploy staff who are embedded with the
DRC Ministry of Health in both Goma and Kinshasa, and at WHO
headquarters, to strengthen these activities and support coordination
among response leaders. In addition, CDC and USAID are supporting
community engagement activities based on lessons learned from previous
Ebola outbreaks, including incorporating feedback from affected
populations and tailoring the response approach based on unique
dynamics within Ebola-affected communities.
CDC's operational expertise allows us to quickly and efficiently
identify the unique scientific and social variables of outbreaks and
address them with proven interventions. Working directly with partners
on the ground, CDC has been providing guidance to standardize response
actions, streamline implementation of public health measures, improve
the effectiveness of training and educational materials, and assist
with coordination and communication across the public health response.
For example, CDC continues to provide technical assistance to the
Ministry of Health and WHO in the implementation of vaccination
strategies, including assistance with protocols, operating procedures,
data analysis, and training and communications material for use at
national and local levels in DRC and neighboring countries. CDC is
collaborating with WHO and Ministry of Health colleagues in Rwanda,
South Sudan, Uganda, and Burundi to implement preventative vaccination
of health care workers in geographic areas near the DRC border. CDC
staff have embedded into teams with the DRC Ministry of Health and at
WHO headquarters, to analyze data and to help improve the quality of
vaccination efforts.
Over the course of the response, CDC has also been working with
U.S. Government partners, the DRC Ministry of Health, WHO, and others
to identify gaps in infection prevention and control (IPC) systems,
assess healthcare provider IPC knowledge and skills, and improve IPC
practice. CDC is helping DRC Ministry of Health and WHO to finalize a
standardized set of infection prevention and control resources for use
across the response, which includes training modules, standard
operating procedures, and job aids. CDC is also designing and preparing
to implement a training course for IPC partners and DRC Ministry of
Health infection prevention and control supervisors. Where security
conditions have allowed, as demonstrated with recent confirmed cases in
Goma, CDC experts have been able to work directly with local case
investigation teams on the ground to identify areas for improvement in
surveillance, vaccination, and other aspects of case management.
Question. The World Health Organization has identified a funding
shortfall of $54 million for response efforts to control the outbreak
and prevent further spread. U.S. contributions thus far have come out
of existing Ebola emergency supplemental funding from the 2014
outbreak. Are there any plans for the U.S. to make an additional
contributions on par with increasing challenges?
Answer. CDC defers to USAID for this response.